Gyn - Infertility And OHSS

Question 1

Madam Leung is a 35-year-old clerk who is married for 4 years. She is referred because of secondary infertility. She is a Para 0+2 lady with two previous surgical terminations of pregnancies, and both
pregnancies belonged to her ex-boyfriend. She has a history of acute pelvic inflammatory disease in 2005 after surgical termination of pregnancy. Her menstrual cycle is 28 days cycle, but she suffers from severe dysmenorrhea. Her husband has been in good health and his physical examination is normal. Physical examination of Madam Leung is unremarkable.

What is the most likely diagnosis and what investigation will you perform to confirm your suspicion?

Answer 1

Secondary infertility due to tubo-peritoneal factor (PID)
Uterine factor due to STOP also possible

Triple swab to look for PID
STD screening for couple
Male semen analysis x 2
Ovulation assessment: BBT, mid luteal progesterone, urinary LH surge
Hormonal profile: FSH/LH/E2
Ovarian reserve: AMH/early follicular phase FSH
MSU for UTI 
\+/- hormone profile

*Laparoscopic chromotubation to diagnose peritubal adhesions & for adhesiolysis + hysteroscopy to assess uterine factor

Question 2

OT record: both fallopian tube adhesion + peri hepatic adjesiom

What does this show and how would you manage?

Answer 2

Confirms tubo peritoneal factor, and perihepatic adhesion suggests history of chlamydia infection. This is fitz high curtis syndrome

Refer patient to IVF.

Question 3

After IVF procedure, patient complains of abdominal distension. How to interpret and management plan?

Answer 3

This is ovarian hyperstimulation syndrome.

Admit
Check vitals
Physical exam for abdominal distension/ascites, pleural effusion, LL edema
Ix for CBC/clotting, RFT, LFT; USG pelvia + CXR

Management: supportive
Pain relief (not nsaid)
Fluid balance: Chart I/O, give orally, no diuretics
Thrombroprophylaxis with ambulation, elastic stocking, LMWH
Paracentesis or thoracentesis if needed