Infertility : History and Examination –How ?? How to elicit history and what to examine clinically in primarily subfertile women??

 

A)     History. Age at menarche, Cycle regularity, Menst—Loss / .pain, ,Hirsutism, Galactorrhoea, Problems with sexual activity, Occupation, previous pregnancies. Duration of subfertility, operations, Drug/ alcohol./ smoking/ medical disorders/ contraceptive use/ Previous Tr of subfertility, Oligomenorrhoea implies-periods occurring between35-180 days: But Ameno implies no period continuously for 6 months. In cases of secondary subfertility  one have to enquire about MTP., previous marriage if any, consanguinity, birth of abnormal baby in the family .  H/O. STI ,,  H/O/ CS or complicated delivery any surgery for  Endometriosis  H/O Ectopic operation / App open., Ko’chs in articular .

B)     Examine:- 1) Wt, measure Height, BMI- Wt in Kg ÷ Ht in meter ². Normal  BMI will be 20-25; Overweight is 25.1 to 30 & Obesity is >  signify clinical IR-insist on wt loss 30.1 2) Any acanthosis 3) what is the waist circumference?- if above 88 cm & later metformin.

C)     Gynaecological examination ; T examine Cx for any inflammation , to assess the size, texture consistency of uterine corpus, its mobility, nodularity at U S ligament, adnexal tenderness.

C) Pre-induction Investigations:- 1) H semen analysis* , Basal Scan-day 3 scan ? any PCO, residual cyst & others as imaged  * PRL*, TSH* IgG rubella*, STI screen *,Viral screen * 2) What’s the tubal status? HSG is best and can pick up PID, Cavitary disorders, 3) baseline FSH, 4) day  LH 5)  Serum E 2 on day 3  6) Testosterone T4 (Total) and 7) FPG :Insulin ratio(in suspected PCOS only  Even peritubal adhesions may be picked up by good quality HSG. (as discussed on 14-08-20) 7) Role of PCT: is debatable, but have an important role when man can’t produce semen at Lab AMH ,  .( * Must  be done before any treatment  is initiated) 

D) Basic general treatment : 1) To

consider a) wt reduction b)  Regular brisk Exercise, Yoga ,To stop alcohol, smoking  c) Suppl of Vitamins may act as decreasing the load of  ROS  d) Relaxation e) one can add Metformin to lower the hyperinsulinaemia if there is clinical reason to believe that there is presence of IR (But most add Metformin after few cycles of CC resistant is established and women concerned is obese, thug lean women can have PCO too  f)  add Dexamethasone 0.5 mg only when DHEASO4 is high -> to curtail adrenal androgens g) where if LH is very high &   is the possible cause one can  choose for pretreatment with micronised progesterone in previous cycle.

D)     In proposed CC cycles:-better to use micro Prog in previous cycle. If Primolut-N os used to suppress LH in following cycle than  there can be embryonic loss in that cycle.

 

E)     Common Causes if anovulation ?? If no response with letrozole /CC  one should always think of- five common causes of anovulation- obesity, LH hyper function / excess Insulin/ Excess Androgen/ hyperprolactinaemia.