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Polycystic ovary syndrome (PCOS) is a gynecological disorder associated with a complexendocrinopathy and multiple metabolic co-morbidities.
Polycystic ovary syndrome (PCOS) is a gynecological disorder associated with a complexendocrinopathy and multiple metabolic co-morbidities. In the reproductive age, it’s commonly associated with infertility due to anovulation.
In this article, I would like to discuss a case where there was an atypical presentation of the disease when the patient presented with infertility.
Mrs. B aged 21 years was undergoing treatment for abnormal uterine bleeding for the past 6 years which she was suffering from menarche. She suffered from irregular menstrual cycles. She had only withdrawal bleed. She was put on progesterone therapy.
She came for treatment of infertility after one year of marriage. She was having irregular menstrual cycles. On evaluation, she had the following findings:
A diagnosis of lean polycystic ovarian syndrome was made and she was started on ovulation induction. She had clomiphene resistance and did not respond to higher doses and longer duration therapy. She did not respond to letrozole therapy. She was started on low dose long duration gonadotropin therapy. She did not respond at low doses of gonadotropins and had a hyper response with increasing doses of gonadotropins. She had mild ovarian hyperstimulation once and was treated on an OPD basis. She had evidence of ovulation in only two cycles after undergoing treatment for almost 1.5 years. Intrauterine insemination was carried out in her ovulatory cycles but she did not conceive.
A decision for diagnostic laparoscopy and ovarian drilling was made as she was not responding to standard ovulation induction therapy. In laparoscopy, she was found to have evidence of severe endometriosis in the form of severe thick pelvic adhesions, deep endometriosis in the pouch of Douglas and utero sacral ligaments. The adhesions were released and the endometriotic deposits were fulgurated. The ovaries were not punctured due to a fear of deposition of endometriotic tissue into the ovaries. She was given gonadotropin releasing hormone (GnRh) agonistdepot therapy for three months.
After surgery and agonist depot therapy, ovulation induction was tried with gonadotropins but she did not respond.
After counselling the couple, she was posted for in-vitro fertilisation (IVF) and embryo transfer. The following protocol was used for the cycle:
Agonist injection was given for trigger.10 MII oocytes were aspirated and subjected to in-vitro fertilization. 7 embryos fertilized and all were frozen. She was started on Cabergoline, GnRh agonists as prophylaxis against ovarian hyperstimulation syndrome (OHSS). In spite of all precautions, she developed OHSS. She had evidence of hemoconcentration and oliguria. She was given plenty of oral fluids and was put on a high protein diet. IV fluids and human albumin were given. Maintenance of intake and output was done. Cabergoline and GnRh agonists were continued. Symptoms settled after 10 days and she menstruated after 15 days. In the subsequent cycle, endometrial preparation was done and 3 grade A embryos were transferred. She conceived and delivered a male baby.
She came for treatment for secondary infertility one year back and was posted for IVF again as she did not respond to conventional therapy. She had only 6 oocytes aspirated and 3 embryos fertilized. This time, she had evidence of adenomyosis and persistent endometrial fluid collection during endometrial preparation for frozen embryo transfer (FET). She was treated with long-acting GnRh agonist depot for 3 months and then FET was done. Now, she has an ongoing twin pregnancy at 24 weeks of gestation.
This case is relatively rare for the following reasons:
Dr. Charmila Ayyavoo
MD DGO DFP FICOG PGDCR, Director, Aditi hospital & Parvathy Ayyavoo Fertility Center, Trichy.