Case Presentation Patient Name Age Husband age History

Case Presentation Patient Name Age Husband age History : : X 29 31 primary infertility married life 1 ½ Yrs Menstrual history : regular menstrual cycles 3/28 days, normal flow no complaints of dysmenorrhoea

Case Presentation • Past medical history: • Not a known hypertensive, diabetic, hypothyroid, asthmatic • Past surgical history: • Nil significant • Family history: • Nil significant • Past infertility record: • Underwent infertility evaluation, reports told to be normal

Case Presentation • Husband history: • No significant medical problems • Not a smoker/alcoholic • No coital problems • Coital frequency : 2 -3/week • On examination: general examination is normal height - 154 cm weight - 69. 8 kgs BMI - 29. 4

Case Presentation • P/A – soft, no mass palpable • P/S – cervix is healthy, no discharge • P/V – uterus is anteverted, no fornicial masses, no tenderness • Breasts – normal, no galactorrhoea

Case Presentation • Investigations CBP S. TSH S. PRL GTT HBA 1 c Viral markers - normal 0. 29 miu/ml 14. 71 ng/ml normal 6. 5 % Negative

Case Presentation • Ultrasound Report Uterus Endometrium Right ovary Left ovary - anteverted, normal sized 3 mm 30. 6*24. 7 mm, AFC is 2 31. 9*27. 6 mm, AFC is 4

Antral Follicular Count • Count of total follicles measuring 2 to 5 mm in both ovaries on Day 2/3 of periods. • Some correlation with ovarian response but only at low threshold • If AFC < 5 - significantly worse outcome. • Inter observer variation is a limitation.

Antral Follicular Count • So far, assessment of the number of antral follicles by ultrasonography, the antral follicle count (AFC), best predicts the quantitative aspect of ovarian reserve

Factors affecting AFC measuremets • Oral contraceptive use (decreases) • Polycystic ovary syndrome (PCOS) (increases). Drawbacks of AFC: • Accurate assessment of AFC requires an experienced sonographer and can be limited in patients who have had pelvic surgery or uterine fibroids and in those who are obese • Moderate interobserver and intercycle variability of AFC determinations limits reproducibility • As with basal FSH measurement, the intercycle variability of AFC does not correlate well with IVF outcome in individual patients. AFC can only tell of number, not quality of oocytes

Case Presentation • Husband semen analysis • volume - 1. 6 ml • p. H - alkaline • Total count - 50 M/ml • Motility - 60 - 30 - 10 • Morphology - normal 12%

Case Presentation How do we proceed with this case? ?

Case Presentation Any other investigations you would like to advice

Case Presentation • FSH • LH • AMH - 7. 68 m. Iu/ml 4. 32 m. Iu/ml 2. 63 ng/ml

AMH Blood Level High (often PCOS) - Over 6. 0 ng/ml Normal - Over 1. 0 ng/ml Low normal range - 0. 7 - 0. 9 ng/ml Low - 0. 3 – 0. 6 ng/ml Very Low - Less than 0. 3 ng/ml

Case Presentation • Patient underwent • 3 cycles of COH with Letrozole + FI + TI • 2 cycles of COH with Letrozole + Gn + FT + IUI Patient failed to conceive

Case Presentation • What next? ? ?

Case Presentation Laparoscopy / ART

Case Presentation Patient wanted to go for ART • Repeat AMH – 0. 95 ng/ml

• ART which protocol – Dose of gonadotropins – Adjuvants – Success of ART

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