CASE

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?