|CASE SCENARIOS: ISSUE IN FOCUS
|Year : 2016 | Volume
| Issue : 4 | Page : 101-103
Evidence-based management of infertility: Clinical scenarios
Mohan S Kamath, Anurekha Janaki Periyasamy
Department of Reproductive Medicine, Christian Medical College, Vellore, Tamilnadu, India
|Date of Web Publication||22-Nov-2016|
Mohan S Kamath
Reproductive Medicine Unit, Christian Medical College, Vellore - 632 004, Tamil Nadu
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Kamath MS, Periyasamy AJ. Evidence-based management of infertility: Clinical scenarios. Curr Med Issues 2016;14:101-3
| Introduction|| |
The management of infertility is complex, and there are several treatment options available today. However, not all options are supported by adequate evidence and therapy must be tailored to each couple, accounting for factors such as age, efficacy of the treatment, adverse effects, and cost. A few clinical scenarios and questions are discussed to highlight these issues and help guide a general practitioner or postgraduate student in the management of infertility. The answers to the questions are discussed after the case scenarios.
| Question 1|| |
At what size of dominant follicle in a clomiphene cycle should one consider administering human chorionic gonadotropin (hCG) as an ovulation trigger?
- 18 mm
- 20 mm
- 22 mm
- Not at all.
| Question 2|| |
A 30-year-old woman, married for 3 years, with irregular menstrual cycles presented with primary infertility. A baseline ultrasound scan showed bilateral polycystic ovaries. Husband's semen analysis is normal. She was given clomiphene citrate and there was an ovulatory response to a dose of 100 mg and yet she did not conceive despite three cycles (clomiphene failure).
A diagnostic laparoscopy was performed for tubal evaluation. During laparoscopy, both ovaries appear enlarged with smooth, pearly, white surface.
Is laparoscopic ovarian drilling (LOD) a good option in this woman?
| Question 3|| |
A 19-year-old female, married for 2 years, with regular menstrual cycles had primary infertility.
The baseline ultrasound scan was normal. Husband's semen analysis shows azoospermia, and his endocrine profile was normal (follicle-stimulating hormone-5 IU/L). The couple insisted on autologous treatment, and sperms were obtained using testicular sperm aspiration.
What is the best fertility treatment option in this scenario and when should it be offered?
- Assisted reproductive technology (ART) as soon as possible
- Donor insemination as soon as possible
- ART after a reasonable time period
- None of the above.
| Question 4|| |
A 36-year-old woman, married for 5 years, presented with primary infertility. Her husband's semen analysis showed subnormal parameters (concentration - 5 mil/ml and motility - 10%).
Which combination of drugs for the patient's husband will be the most effective to achieve pregnancy?
- L-carnitine + coenzyme-Q for at least 1 year
- L-carnitine + Vitamin E + coenzyme-Q for at least 2 years
- None of the above
| Question 5|| |
A 26-year-old female with primary infertility for 2 years was diagnosed with bilateral ovarian endometriotic cysts measuring 4 cm × 4 cm in the right ovary and 2 cm × 2cm cyst in the left ovary. She underwent laparoscopic right endometriotic cystectomy and drainage of the cyst on the left side. Both fallopian tubes were patent. Semen analysis of her husband was normal.
What is the next best modality of treatment?
- Injection leuprolide depot 3.75 mg I/M once in 28 days for 6 doses
- Immediate ART/in vitro fertilization (IVF)
- Fertile period for 4-6 months followed by ART
- Cyclic oral contraceptive pills.
| Question 6|| |
The patient in the case scenario 5 was lost to follow-up and comes back after 4 years with an ultrasound scan suggestive of recurrence of the cyst in the left ovary (measuring 4 cm × 4 cm).
What is the best modality of treatment now?
- Laparoscopy and cystectomy
- Injection leupride depot 3.75 mg I/M
- Cyclic oral contraceptive pills.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
George K, Kamath MS, Nair R, Tharyan P. Ovulation triggers in anovulatory women undergoing ovulation induction. Cochrane Database of Systematic Reviews 2014, Issue 1. Art. No.: CD006900. doi: 10.1002/14651858.
Farquhar C, Brown J, Marjoribanks J. Laparoscopic drilling by diathermy or laser for ovulation induction in anovulatory polycystic ovary syndrome. Cochrane Database Syst Rev 2012;(6):CD001122. doi: 10.1002/14651858.CD001122.pub4.
Showell MG, Mackenzie-Proctor R, Brown J, Yazdani A, Stankiewicz MT, Hart RJ. Antioxidants for male subfertility. Cochrane Database Syst Rev 2014;(12):CD007411. doi: 10.1002/14651858.