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Monday, February 20, 2012

An Infertility Case Study

Mrs. K. P. aged 46 visited Infertility Centre with the complaints no living issue for 21 yrs. married life. They were referred to infertility centre by a Senior Gynaecologist for their complicated infertility problem.
They had two abortions at three to four months gestation. The last abortion took place six years ago. Since then she could not conceive but the details of the previous treatment was kept confidential within the doctor & the husband. Their past treatment record showed that she had artificial insemination of donor sperm because the husband had no sperm in his semen. She did not know that she got pregnant by donor insemination. During our counselling, the lady did not show any interest in treatment for herself because her menstrual cycle was already getting late & she lost hope of getting pregnant.
On examination, her physical built was good with her body weight of 65 Kg. Her cycle interval was 23-43 days with flow of 1-2 days scanty flow.
On the second visit however she was ready only for Hysterosalpingography (HSG) which revealed normal looking uterus with patent both fallopian tubes.
On third visit she brought her sister & wanted us to examine her whom the lady forced to marry with her husband for the sake of a child in their family.
 The second wife Mrs. S. Paudel 31 yrs. married five years ago & she also could not conceive. She was thin built with short height but her general physical condition looked quite fair with body weight of 39 Kg. Her menstrual cycle was 28-30 days with 5-9 days of flow. On pelvic examination the use of speculum could not clearly distinguish the cervix from vagina. In addition, the vaginal cavity was also narrow. The outline of cervix looked rather rudimentary. Careful surgical excision was done to separate the vaginal flaps which covered the cervix. She was then asked not to try conception for at least three months.
After surgical correction she was properly investigated for conception.
Her D2 hormone profile: FSH=7.4mIU/ml; LH=1.1mIU/ml; Estradiol=40.5pg/ml; Prolactin=30.8ng/ml; TSH=3.3mIU/ml.
Hyperprolactinemia was corrected with bromocriptin therapy.                                                                                           
This time, it was easy to access the cervix to perform HSG. Her HSG showed normal uterine cavity with patency of both tubes.
Semen was analysed which had no sperm. Thus, the conception was only possible with donor insemination. With written consent of the couple, Intra Uterine Insemination (IUI) of donor sperm was planned. Ovulation was stimulated for recruitment of more follicles with cyclic clomiphen citrate 50-150 mg. Development of follicles was serially monitored by transvaginal ultrasound. When at least one follicle reached 18mm, Human Chorionic Gonadotropin was injected & IUI was done within 30-48 hrs. Since they lived far away, their treatment was not regular. However, she finally conceived after total six months of IUI treatment.  She was followed up by us till 30 wks of gestational period & referred back to the same doctor for the delivery. She delivered a healthy baby boy.