Ovulation disorders

 

after six ov cycles.

 

 

 When to add metformin  as well? - When profound CC resistant. What to do if in first cycle there is thinning of ET < 8 mm? It is unlikely that in next cycles there will be improvement of ET. It is better to switch over to gonadotrophins in second cycle .

 Prevalence of Cyst formation? In most cases the cyst formation after CC is due to hyper response has to be halved. In such cases of extreme sensitivity at  the dosage may have to be halved.

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. 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, 3. Day 3 LH, FSH, E2, high day 9 LH, PCOS OF SEVERAL phenotypes, dose of cc employed.

 

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.

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 o.d 50mg. Got good results with enclomiphene dosage schedule from day 2 to day 6 one tab od 50mg Enclomiphene citrate day 2 to 6 Gonadotropins +CC.can start on CC 100mg (D2-5) +hMG 75iu 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 cycles-because receptor per end in rat woman will always yield poor ET .9) In first cycle do PCT---if poor mucusà move to gonadotrophin cycle or to IUI. 10) Commence with 100mg though 50mg will be enough in fair number of cases.