Gyn - Primary infertility And PCOS

Question 1

28-year-old lady, married for 2 years; referred because of oligomenorrhoea and primary infertility; menstrual cycles 3 to 6 months long; husband is healthy and normal on physical exam. Physical exam of patient: acne and increased body hair; body weight 80kg, BMI 30.
What is the diagnosis?

Answer 1

Primary infertility due to PCOS (Oligomenorrhea and clinical hyperandrogenism).

Question 2

How would you investigate?

Answer 2

Diagnosis of PCOS: USG pelvis for polycystic ovary, androgen profile

Infertility:
Hormone profile: FSH, LH, E2, TSH, prolactin
Tubal patency: HSG/lap + dye
Semen analysis

Complication of PCOS: LFT, FBG, lipid, BP

Question 3

Lab results
FSH low, LH high, testosterone high
Estrogen, prolactin, TSH normal
Multiple cyst in ovary on USG

Answer 3

High LH:FSH ratio, and high testosterone: biochemical hydroandrogenism
USG polycystic ovaries
History of oligomenorrhea
Fulfils are three of rotterdam criteria for diagnosis of PCOS

Question 4

Management plan?

Answer 4

Counsel on PCOS, including infertility, CA and metabolic risks

PCOS: lifestyle modification, weight reduction, smoking cessation
Anti-androgens, progesterone for withdrawal bleeding every 3 months

infertility: weight reduction > clomiphene > ovarian drilling / IVF

arrange for regular metabolic screen and prescribe metformin

Question 5

Husband's semen analysis report shown
How to interpret this report and how to manage?
pH 7.2 
Conc 5M/ml 
motility 25% 
morphology 2%

Answer 5

Suggests severe male factor, but should repeat again in 3 months

Conc <15, morphology <40, motility <4

If confirmed, can proceed to IVF, + ICSI if failed