1 / 13

CASE #1

CASE #1 .

bathsheba
Download Presentation

CASE #1

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. CASE #1 • A 39 year old woman with a history of four pregnancies (1 full-term and 3 first trimester miscarriages), irregular periods (every 6-12 weeks) and long-standing and progressive hirsutism presents because of 3 years of infertility. She weighs 220 pounds (100 kg), has normal blood pressure and no known systemic diseases.

  2. CASE #1 • Her husband has a normal semen analysis and she had a normal hystero-salpingogram 4 years ago (which was prior to her last pregnancy). • Three years ago she conceived and miscarried after taking 150 mg clomiphene citrate a day for 5 days. • She has required clomiphene to conceive two of her other three pregnancies.

  3. CASE #1 • WHAT TESTS WOULD YOU ORDER NEXT? • Serum Testosterone and DHEAS? • Lupus anticoagulant and anti-phospholipid antibodies? • Lipid profile? • Day 3: TSH? LH? FSH? Estradiol?

  4. CASE #1 • Antral Follicle Count? • Other tests?_________________ • Glucose tolerance test? 2 Hr. Post Prandial Blood Sugar? Fasting Insulin and Glucose? • Karyotype • Thrombophilia workup

  5. CASE #1 • WHAT WOULD YOU RECOMMEND AS THE NEXT STEP(s)? • Laparoscopy? • Post Coital Test? • Endometrial Biopsy? • Sperm Function Tests? • Anti-sperm Antibody Tests? • Other tests? G. No additional tests?

  6. CASE #1 • WHAT TREATMENT(s) WOULD YOU RECOMMEND? • Clomiphene • Dexamethasone • Metformin • Menotropins (hMG) or FSH • Recombinant FSH • Intra-uterine insemination

  7. CASE #1 • Her day 3 FSH was 9.8 and the E2 was 45pg/ml • She decided to take clomiphene, 150 mg/ day, from days 5-9 for three months with sonographic evidence of 2-3 follicles greater than 18 mm and mid-luteal progesterone values consistent with ovulation. • She was given 10,000 IU of hCG each month and instructed to have intercourse each of the next two days. She did not conceive.

  8. CASE #1 • WHAT WOULD YOU RECOMMEND SHE DO NEXT? • Continue the clomiphene • Add intra-uterine insemination (IUI) • Perform a surgical procedure on the ovary? • Use gonadotropins(which ones?) and IUI • Do IVF • Do IVF with PGD

  9. CASE #1 • She decided to try urinary FSH(Fostimon) and IUI. • She took Fostimon 150 IU/day for ovulation induction on 4 occasions. On each occasion she had estradiol levels between 500-1000 pg/ml and 3-5 follicles over 12mm on the day of hCG.

  10. CASE #1 • She was inseminated with 10-35 million motile sperm approximately 36 hours after the hCG each month. She did not conceive.

  11. CASE #1 • She decided to try one more month of FSH and IUI before stopping her attempts to conceive. • She took Fostimon 225 IU/day for 5 days and 150 IU/day for 6 days.

  12. CASE #1 • On the 11th day of medication she had an estradiol level of 625 pg/ml and 5 follicles between 12 and 18 mm mean diameter. Right ovary *Left ovary has similar appearance

  13. CASE #1 • WHAT WOULD YOU DO NOW? • Continue Fostimon and repeat the estradiol level and sonogram the next day • Cancel the cycle because she is at too great a risk for a high-order multiple pregnancy? • Administer hCG? Today? (or) Tomorrow?

More Related