ovulation case scenarios Panelists DrRama krishna hanumanchirala DrVaniEluru DrKarunavijayawada DrAnithavijayawada Moderators ID: 1046858
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1. Panel discussion on Induction of ovulation- case scenarios
2. Panelists Dr.Rama krishna hanuman,chirala Dr.Vani,Eluru Dr.Karuna,vijayawada Dr.Anitha,vijayawada Moderators, Dr.kavitha.v Dr.Chandana.V
3. 1961,milestone in ovulation inductionHopelessness-hopefullness
4. Ovulation induction -definitionDevelopment of one more follicles to reach maturity,culminating in the release of on eor more mature oocytes ready for fertilizationCOH-cohort of follicles
5. Case 1Mrs.X age 29yrs,Mr.Y age 30 yrsML-2yrs,NCMOccupation-IT jobs in a metroMenstural history-3 days/45-60 days, mild dysmenorrhoeaNo family history of infertilityO/E- Female-wt 140lbs ,Ht 5 ft, BMI 27 Vitals normal TVS –Normal Semen analysis -Normal
6. History??investigationsTreatment
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9. WHO Group I Hypogonadotrophic hypogonadismWHO Group II Normogonadotrophic Normogonadism WHO Group III Hypergonadotrophic hypergonadism
10. IndicationsAnovulationOligo-ovulationPCOSEndometriosispofUnexplained infertilityIn certain cases of male factor infertility for timing of ovulation
11. Pre-requisites Evaluation of male partnerHistory and physical examinationAge and duration of infertilityCause of infertilityGalactorrhoea and Prolactin levels.Thyroid functionPituitary function by baseline hormonal evaluation
12. Start with base line scan on day 2 or threeLook for AFC,any cysts,endometrial lining
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14. Case PresentationPatient Name : XAge : 33Husband age : 35History : primary infertility married life 3 YrsMenstrual history : regular menstrual cycles 3/30 days, normal flow spasmodic dysmenorrhoea pain starts on day 1 of cycle, lasts for 2 days not associated with vomitings or giddiness
15. Past medical history:Not a known hypertensive, diabetic, hypothyroid, asthmaticPast surgical history:Nil significantFamily history:Nil significantPast infertility record:Tried a few cycles of CC 100mg – unmonitored cyclesCase Presentation
16. Husband history:No significant medical problemsNot a smoker/alcoholicNo coital problemsCoital frequency: 2-3/weekOn examination: general examination is normal height - 160 cm weight - 62 kgs BMI - 24.2Case Presentation
17. P/A – soft, no mass palpableP/S – cervix is healthy, no dischargeP/V – uterus is retroverted, restricted mobility, no fornicial masses, no tendernessBreasts – normal, no galactorrhoea Case Presentation
18. Investigations CBP - normal S.TSH - 1.3 miu/ml S.PRL - 7.6 ng/ml GTT - 98/195/135 mg/dl HBA1c - 6.0%Viral markers - NegativeAny other routine investigations you would like to advice Case Presentation
19. Ultrasound Report Uterus - retroverted, normal sized Endometrium - 4 mm Right ovary - AFC is 8 Left ovary - AFC is 5 evidence of a large cyst with internal echoes and ground glass appearance measuring 4cm Case Presentation
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21. Any other investigations you would like to adviceCase Presentation
22. CA 125 - 60.4 U/mlFSH - 7.94 mIu/mlLH - 5.48 mIu/mlAMH - 4.7 ng/ml Husband semen analysis - volume - 1.4mlpH - alkalineTotal count - 100M/mlMotility - 53 - 30 - 17 Morphology - normal 10%Case Presentation
23. How do we proceed with this case?? Case Presentation
24. Role of MRI in the diagnosis of endometriosisAt present, there is insufficient evidence to indicate that magnetic resonance imaging (MRI) is a useful test to diagnose or exclude endometriosis compared to laparoscopy.MRI reserved for equivocal ultrasound results in cases of rectovaginal or bladder endometriosis.
25. Treatment modalities you would like to offer
26. Role of laparoscopy in the primary management of endometriosis
27. The patient underwent operative hyterolaparoscopy Uterus – normalRight adnexa – tube normal, tuboovarian relation normal, chromotubation -- positiveRight Ovary -- surface endometriosis fulguratedLeft adnexa – tube densely adherent to ovarian fossa, adhesiolysis done, patency establishedLeft ovary – large endometrioma adherent to the uterus, endometrioma excisedUterosacrals - endometriosis fulguratedPOD – POD completely obliterated with dense adhessionsCase Presentation
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30. Biologic Mechanisms That Might LinkEndometriosis and InfertilityDistorted pelvic anatomyAltered peritoneal functionAltered hormonal & cell-mediated functionEndocrine and ovulatory abnormalitiesImpaired implantationOocyte and embryo qualityAbnormal uterotubal transport
31. When To Do Laparoscopy?Younger women (?<37 years of age)Short duration of infertility (<4 years)Normal male factorNormal or treatable uterusNormal ovulation, orEasily treatable ovulation disorderLimited prior treatmentAppropriate candidate for laparoscopy “Treatable” disease reasonably suspected (NNT) OR= 1.66 (1) No contraindications to laparoscopy Patient accepts 9-15 months attempting before IVF
32. Endometriomectomy:Surgical PrinciplesRecommendations: In infertile women with ovarian endometrioma undergoing surgery, clinicians should perform excision of the endometrioma capsule, instead of drainage and electrocoagulation of the endometrioma wall, to increase spontaneous pregnancy rates (Hart et al., 2008). The GDG recommends that clinicians counsel women with endometrioma regarding the risks of reduced ovarian function after surgery and the possible loss of the ovary. The decision to proceed with surgery should be considered carefully if the woman has had previous ovarian surgery.
33. Role of hormone therapy Recommendation: In infertile women with endometriosis, clinicians should not prescribe hormonal treatment for suppression of ovarian function to improve fertility (Hughes, et al., 2007)
34. Recommendations: In infertile women with endometriosis, the GDG recommends clinicians not to prescribe adjunctive hormonal treatment before surgery to improve spontaneous pregnancy rates, as suitable evidence is lacking. In infertile women with endometriosis, clinicians should not prescribe adjunctive hormonal treatment after surgery to improve spontaneous pregnancy rates (Furness, et al., 2004).Role of hormone therapy
35. How to proceed next with the case ???
36. How to proceed next with the case ??? Patient underwent 3 cycles of COH + FI + IUI
37. Recommendations for treatment following laparoscopy in patients with endometriosis In infertile women with AFS/ASRM stage I/II endometriosis, clinicians may perform intrauterine insemination with controlled ovarian stimulation, instead of expectant management, as it increases live birth rates (Tummon, et al., 1997). In infertile women with AFS/ASRM stage I/II endometriosis, clinicians may perform intrauterine insemination with controlled ovarian stimulation, instead of intrauterine insemination alone, as it increases pregnancy rates (Nulsen, et al., 1993).
38. Recommendations for treatment following laparoscopy in patients with endometriosis In infertile women with AFS/ASRM stage I/II endometriosis, clinicians may consider performing intrauterine insemination with controlled ovarian stimulation within 6 months after surgical treatment, since pregnancy rates are similar to those achieved in unexplained infertility (Werbrouck, et al., 2006). The GDG recommends the use of assisted reproductive technologies for infertility associated with endometriosis, especially if tubal function is compromised or if there is male factor infertility, and/or other treatments have failed.
39. What to do next ???
40. Now the patient age is 35 AMH is repeated – 0.90ng/ml
41. ART in endometriosis
42. Does Surgery prior to IVF improve IVF Success ???
43. Case 3Mrs Z,aged 23 yrsML-5 yrs ,came in august 2017,Menstural history-2-3/3-4 monthsBMI 27Past ,personel and family history nothing sinificantIntercourse-no coital problems,2-3/weekOccupation –home maker,husband own businessTreatment history10 cycles of ovulation induction
44. Clomiphine citrate ,added metformin,Added gonadotropins,OHSS,one IUI,10 cycles in total Documentation of ovulation?6/7/2014 FSH-4.8 PRL-10 serum fasting insulin -14.42 LH-16.6 DHEA 81
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46. Ovulation induction/LEOS and then ovulation inductionCriteria for LEOS in a case of pcos
47. 15/5/2018 investigations- TSH -1.0 FSH-6.1 on day 3 of periods LH -10.8 PRL- 13 AMH -17 fasting insulin 14
48. DHL with LEOS done ,no evidence of endomeriosis,bilateral tubes patent
49. First cycle letrazole 2.5 bd d2-d6,monofollicular growth,hcg 5000 iu ,Et 9.1Second –let 2.5bd,fsh 75iu 5 doses,single follicle,iuiThird-fsh 150 ,4 doses,4 DF one ruptured,iui fsh 150(2),d3 d5,75 d7,day9 37.5,37.5,cc 100,metformin,37.5 iu for 7 days.Monofollicular growth hcg trigger,iui ,UPT +In april 2019
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71. Case PresentationPatient Name : XAge : 29Husband age : 31History : primary infertility married life 1 ½ YrsMenstrual history : regular menstrual cycles 3/28 days, normal flow no complaints of dysmenorrhoea
72. Past medical history:Not a known hypertensive, diabetic, hypothyroid, asthmaticPast surgical history:Nil significantFamily history:Nil significantPast infertility record:Underwent infertility evaluation, reports told to be normalCase Presentation
73. Husband history:No significant medical problemsNot a smoker/alcoholicNo coital problemsCoital frequency : 2-3/weekOn examination: general examination is normal height - 154 cm weight - 69.8 kgs BMI - 29.4Case Presentation
74. P/A – soft, no mass palpableP/S – cervix is healthy, no dischargeP/V – uterus is anteverted, no fornicial masses, no tendernessBreasts – normal, no galactorrhoea Case Presentation
75. Investigations CBP - normal S.TSH - 0.29 miu/ml S.PRL - 14.71 ng/ml GTT - normal HBA1c - 6.5 %Viral markers - Negative Case Presentation
76. Ultrasound Report Uterus - anteverted, normal sized Endometrium - 3 mm Right ovary - 30.6*24.7mm, AFC is 2 Left ovary - 31.9*27.6mm, AFC is 4 Case Presentation
77. Count of total follicles measuring 2 to 5mm in both ovaries on Day 2/3 of periods.Some correlation with ovarian response but only at low thresholdIf AFC < 5 - significantly worse outcome.Inter observer variation is a limitation.Antral Follicular Count
78. So far, assessment of the number of antral follicles by ultrasonography, the antral follicle count (AFC), best predicts the quantitative aspect of ovarian reserveAntral Follicular Count
79. Oral contraceptive use (decreases)Polycystic ovary syndrome (PCOS) (increases).Drawbacks of AFC:Accurate assessment of AFC requires an experienced sonographer and can be limited in patients who have had pelvic surgery or uterine fibroids and in those who are obeseModerate interobserver and intercycle variability of AFC determinations limits its reproducibilityAs with basal FSH measurement, the intercycle variability of AFC does not correlate well with IVF outcome in individual patients.AFC can only tell of number, not quality of oocytesFactors affecting AFC measuremets
80. Husband semen analysis - volume - 1.6 mlpH - alkalineTotal count - 50 M/mlMotility - 60 - 30 - 10 Morphology - normal 12%Case Presentation
81. How do we proceed with this case?? Case Presentation
82. Any other investigations you would like to adviceCase Presentation
83. FSH - 7.68 mIu/mlLH - 4.32 mIu/mlAMH - 2.63 ng/ml Case Presentation
84. High (often PCOS) - Over 6.0 ng/mlNormal - Over 1.0 ng/mlLow normal range - 0.7 - 0.9 ng/mlLow - 0.3 – 0.6 ng/mlVery Low - Less than 0.3 ng/mlAMH Blood Level
85. Patient underwent 3 cycles of COH with Letrozole + FI + TI2 cycles of COH with Letrozole + Gn + FT + IUI Patient failed to conceiveCase Presentation
86. What next???Case Presentation
87. Laparoscopy / ARTCase Presentation
88. Patient wanted to go for ARTRepeat AMH – 0.95ng/mlCase Presentation
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91. ART which protocolDose of gonadotropins AdjuvantsSuccess of ART
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