reatment of
anovulation as per cause ?? Once the diag of anovulation is confirmed then next
step will be the lab diag of class / type of anovulation- Then only one should
formulate Tr plan. A) WHO Group I:- (Hypogonadotrophic Hypogonadism) loosely
called in conferences or CME as HH disorders: This is diag by very low
gonadotrophins. Causes are A) Hypothalamic:-stress, Wt related, Kallmann’s syn
with anosmia, debilitating systemic diseases. Few cases are idiopathic. B)
Pit:-Sheehan’s syndrome, Pit radiation. Treatment will be Pulsatile GnRH if
Hypothalamus is the cause of Hypogonadotrophic Hypogonadism, but conventional
HMG will be equally effective in both Pit/ Hypo cases of Hypogonadotrophic
Hypogonadism.
B) WHO Group II:-
Dysfunction :- PCI is the chief cause of Class II anovulatory disorders. What
is PCOS ?? It (PCOS) comprises about 75% of women suffering from infertility
due to anovulation. Oligo-ameno (35-180days) is usual. Rarefy ameno. Treatment
ovulation induction by is 1) Life style modifications 2) Letrozole / CC/ rarely
. Anastrazole 3) insulin lowering agents, 4) LOD 5) Gonadotrophins.
The diag of PCOS may
be done without blood sampling but traditionally / or I may be permitted to say
that customarily one estimates LH, FSH, T4 (Total) and FPG: Insulin ratio.
But FSH & E2 will
be usually normal. Biochemical (Raised total Test, androstenedione &
FAI-Free androgen Index / Clinical Hyperandrogenism (Acne, Hirsutism, alopecia)
& USG E/O PCOS. = (> 12 follicles per ov measuring 2-9 main dia, or
increased Ov vol). But CAH, Cushing’s & Virilizing ov tumours have to be
eliminated before one really confirms PCO . But admittedly, that is never done
in clinical practice c.
WHO Group III:-
Primary Ov failure. POF, Nat menopause , Turners syn. Ameno, Low E2, High FSH-A
better marker will be low AMH than low FSH... Hot flushes. Primary Ov failure.
POF,. Quite often in cases of WHO Group III-the cause remains uncertain. Ov
induction will be futile, Donor egg may be considered and one can counsel for
adoption in WHO class III anovulation, Very rarely spont resumption of
ovulation have been recorded but that is few and far between .
WHO Group IV: -
Hyperprolactinaemia. In 30 % of cases raised PRL may not be documented(transient
hyperprolactinaemia) . Not Bromocriptin / Cabergolin if PRL is < 50(few
consider < 40) , But if associated with Galactorrhoea with normal TSH then
Cabergolin/ Bromocriptin have to be supplemented otherwise anovulation. / poor
oocyte dev i.e. Ovulatory disorders and thin ET will persist. When to Treat
raised PRL?? Not to treat if PRL is below > 50. Exclude Hypothyroidism,
phenothiazine intake, MRI as 50% will have microadenoma (< 10 mm).
Flow Chart after
confirming anovulatory cause of subfertility.- Step 1:- PRL- Go for
Bromocriptine/ Cabergolin. then estimate.
Step 2:- A) Normal
PRL-but Oestradiol low Hypothalamic Pit Failure. B)àLowàFSH butàNormal PRL-but
Oestradiol low Primary Ovarian Failure.à HighàFSH is Therefore diag of cause of
anovulation is easy and can be pinpointed by couple of days. Then estimate PRL
if PCT is +ve.àthen (sufficient E2 is present and excludes G P disorders)àThe
other way of diagnosing cause of anovulation:- Modified plan with minimum Lab
cost: Plan is if there is mod oligomenorrhoea -Prog Challenge Test- If
withdrawal bleed is +ve But if no PCT is –Ve then possibilities are 1)
Hypergonadotropic Hypogonadism (high FSH), 2) Hypogonadotropic Hypogonadism.
But if the sec ameno is > à6 months to follow the above scheme & investigation
for outflow tract Obstruction. By definition amenorrhoea implies absence of
mens >6 months. cc+inj r-FSH ,do follicular monitoring and accordingly add
r-FSH/ primary infertility wad pcod. Did not respond to 100mg of clomiphene.
Before going for HMG is there any other protocol. She is also taking tab.
Metformin and syrup m2 tone. What is her age, baseline FSH, LH, e2? For how
long she is taking metformin and what dose C) For pcod FSH is better then HMG
A) Cc+metformin or B) cc+steroids As she is already taking cc+metformin, start
with D) cc+inj r-FSH ,do follicular monitoring and accordingly add r-FSH/HMG
Don't forget to get AMH E) Try Myoinosital+Nacetylcystine combination for 2-3
months and then try induction with 200 mg of cc.
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