How to treat anovulatory disorders

 Flow Chart about etiology on Oligomenorrhoea.

Estimate  LH, FSH,TT, Free Test, 17-OH P, FBS Then  firstly try to exclude PCOS by signs of hyperandrogenism, Clinical/ biochemical hyperandrogenism. If clinically it seems that : HP Dysfunction is likely cause –

à Step-1:- PRL, Second Step 2:-Normal &  Impending Ov failure.  Insulin(LH estimation is  not necessary)

 

,B) No PCOS—estimate FSH—High When to stop CC and proceed for r-FSH (r-FSH is better in PCOS cases than HMG? 1) If no response with 150 mg CC- CC resistance. 2) ET persistently <  proceed for HMG in third cycle. Don’t push on such thin ET more than two cycles. 3) No conception after six ov cycles.

7mm in mid cycle-more than one cycle When to add met as well? - When profound CC resistant. including those related to stress, exercise and eating disorders, treatment with gonadotropins is effective in patients with low FSH levels, but it must be started at a low dose because of the possibility that ovaries unaccustomed to FSH. In cases of obese PCOS as many as 80% will have hyperinsulinaemia, and in normal wt PCOS the prevalence of hyperinsulinaemia will be about 30-40%. But insulin testing is usually not done due too complicated Lab procedures. LH Value in PCOS?? About 50% will have LH value > 10 IU/Lit. In such cases OI will not be successful and miscarriage rate will be high. Better IVF. One can use Micro Prog / OCP in previous cycle. When to do Total Testos & 17-OH P? If rapidly progressing hyperandrogenic symptoms then these two tests may be done. Other Rare Lab Tests? Lipid profile, Homocysteine, Plasminogen Activator Inhibitor-1

A) Clomiphene: Starting Dose: - Better start with 100mg as in many cases 50mg will not work, Initiate with 100 mg but if too many follicles or cyst formation than back to CC of dose of 50mg. better on day 3 as by the time ovulation occurs the adverse effect of Endo passes off. Clinical Indications of CC:- 1) WHO type II anovulation:- PCOS type. 2) LPD as P levels are typically higher in CC induced cycles ->which raises improved preovulatory follicle and good functioning CL development.3) Unexplained infertility.

What are The causes of CC failure/ resistance? CC failure/ resistance have many causes which have to be assessed before embarking on another Ovulogens- oral/ parental. Examples of such tests are, 1 PRL, 2 Metabolic disorders, Day 3 LH, FSH, E2, high day 9 LH, PCOS OF SEVERAL phenotypes, dose of cc employed, The chance of conception is poor if ET s < 8 mm. Why there is thinning of ET is not clearly known but appears to be unrelated to dosage & duration of Ry. Maybe it is idiosyncratic in nature. Metabolic syndrome prevalence was 41.4% in CC resistant’s, in 23.1% of CC responders, in 11.3% of PCOS fertile and 0% of controls. In case of CC failure it invites possibility of host of anatomical diseases in the form of minimal endometriosis, Tubo-peritoneal causes, uterine factors, BMI, Kochs, and coital factor too. When to ask for refraining from intercourse? If two follicles are above 14 mm then asking them to use condom-otherwise multiple gestation will follow. The most important benefit of USG monitoring that by careful monitoring one can quickly move on to other modalities of Ry. This will reduce the total cost  of infertility Ry. What about triggering with HCG? Roy Homburg considers that it is beneficial even in CC cycles as it ensures definite LH surrogate surge if administered after the follicle attains the size of 19-24 mm. What can be done that one can proceed for LH surge is delayed

Hypothalamic-PIT diseases are rare possibility. DHEASO4 for establishing Adrenal androgen excess and planning for corticosteroid Ry. Similarly review of semen other reputed Lab /PCT under your control may be thought of. 11 AFC, AMH

Got good results with Enclomiphene dosage schedule from day 2 to day 6 one tab at ID basis  50mg. Got good results with enclomiphene dosage schedule from day 2 to day 6 one tab od 50mg .For PCOS FSH is better than HMG..; Cc+metformin or cc+ steroids Enclomiphene citrate day 2 to 6 Gonadotropins +CC can start on CC 100mg (D2-5) +hMG 75 IU on day 5, 7, 9. Follicular monitoring from day 10.if required repeat hMG. Once DF is 18mm or more give HCG 10000units. IUI after 36 hrs Enclomiphene citrate day 2 to 6 and then Gonadotropins +CC. can start on CC 100mg (D2-5) +hMG 75 IU on day 5, 7, 9. Follicular monitoring from day 10.if required repeat hMG. Once DF is 18mm or more give HCG 10000units. IUI after 36 hrs How to curtail / minimise superfluous cycle??

Confirm that she is really a case of eu oestrogenic WHO Group II anovulation and not Group I (HH cases with low oestrogen) 2) Confirm that it is not group III anovulation (PRL. CAH/ Cushing’s). 2) Insist on Wt loss (three monthly BMI calculation-maintain a chart) and then only commence OI drugs. 3) Regular Exercise even in lean women. Improves hypothalamic hormones/ Pit hormones/ growth factors- Stress is partly relieved-diminution of cortisol. 4) Micronised Progesterone s pretreatment in midluteal phase 5) May add insulin sensitizers as pre-testament before initiating OI 6) Not to use CC in unexplained infertility cases 5) Not to use CC more than three documented Ovulatory cycles-rather proceed for alternative OV induction methods. This will cut down superfluous cycles and avoid disappointment amongst couples. Better proceed for gonadotrophins –because of all CC induced pregnancies as many as 75% pregnancies do occur with first three ovulatory 7) Once documented thin endometrium it will be always judicious to move to gonadotrophin  move to gonadotrophin cycle or to IUI. 10) Commence with 100mg though 50mg will be enough in fair number of cases. Very Important Points in CC