Case 5
Mrs. H, a
30 year old nulligravida underwent ovulation induction and intrauterine
insemination for unexplained infertility. She had been married
for 7 years. During the monitoring for ovulation induction she
had 4 mature follicles. She conceived triplets. There was no family
history of twins/triplets.
At 11 weeks of pregnancy she underwent
fetal reduction by the transabdominal route. She opted for
a twin pregnancy. The pregnancy was closely monitored. Cervical
stitch was inserted at 14 weeks. She received prophylactic steroids
at 29+ weeks. She did not develop any pregnancy complications.
The growth of the twins was monitored b y ultrasound. At 37 weeks
she underwent an elective cesarean section. Both babies were extracted
by vertex and weighed 2.4 kgs and 2.5 kgs respectively. Both the
babies had good apgar scores. Their neonatal period was uneventful.
The mother did well postoperatively and in the puerperium.
Case 4
Mrs. S aged 31 years, approached our center for secondary infertility.
She had been married for 6 years. She had undergone three 1st
trimester spontaneous abortions, for which evacuation had been
done all the 3 times. Her menstrual cycles were regular and normal.
There was nothing significant in her past or family history. There
were no male factor problems as evidenced by a clinical and laboratory
examination.
Mrs. S underwent investigations, which revealed the following:
Hormonal profile was normal. Tests for antiphospholipid antibodies
were negative. She was not a diabetic. We do not do TORCH tests
as routine.
A pelvic ultrasound revealed multiple fibroids in the uterus,
and an endometriotic cyst in the right ovary measuring 3 cms.
On scan 6 fibroids were seen, all of which were more than 2 cms.
The fibroids were located in the fundus, posterior wall, and anteriorly
impinging on the uterine cavity.
Patient was counseled to undergo an operative laparosocpy and
a hysteroscopy, to which she consented. A 3 cms submucous fibroid
was removed via the hysteroscope. At laparoscopy 4 intramural
fibroids, one anterior and three posterior were enucleated. The
chocolate cyst in the right ovary was drained. Pelvic adhesions
were released. Patient did well postoperatvely. She received 3
doses of Zoladex postoperatively at monthly intervals.
After this patient underwent ovulation induction with CC+HMG which
was followed by intrauterine insemination at the appropriate time.
She conceived in the first cycle of IUI. She is in the 9th month
of her pregnancy. Her antenatal period has been uneventful. She
is carrying a live normal single fetus.
Comment:
Recurrent
spontaneous abortion (RSA) has many causes, one of which is anatomical
i.e. uterine fibroids. The role of fibroids in infertility is
not clear. Many women with fibroids have normal fertility and
pregnancies with no complications. Spontaneous abortion related
to a fibroid may be due to the following.
-
Submucous
fibroid may be a barrier to implantation or may occupy space
in the uterine cavity.
-
An intramural fibroid may interfere with the blood supply to
an embryo implanting near it.
-
A large sub serous fibroid may undergo degeneration or become
infected. These may result in uterine irritability, uterine
contractions, and a possible pregnancy loss.
Treatment
may be indicated if:
In the above
patient since all other investigations were normal, it seemed
logical to postulate the fibroids as a probable cause for the
RSA. Hence a myomectomy was decided upon. Laparoscopy myomectomy
was the option. The cavity was not entered into, during the laparocopic
procedure. The chocolate cyst was also removed. Patents first
line of treatment was ovulation induction with intrauterine insemination.
Fortunately she conceived in the first cycle.
Case 3
A 39 year
old lady presented with secondary infertility of 9 years duration.
Husband was diagnosed to have azoospermia. Nine years ago she
underwent a left salpingectomy for a left tubal pregnancy following
an AID (artificial insemination donor). She had undergone antituberculous
treatment 4 years ago elsewhere (no reports available indicating
reason).
Following
this she had undergone several cycles of AID, which were unsuccessful.
Her tubal status showed a patent right tube. She had had an unsuccessful
IVF elsewhere, 2 years ago. Following a detailed evaluation IVF-ICSI
with laser assisted hatching (LAH) was undertaken. Outcome was
a successful pregnancy. Antenatal period was uneventful. A live
healthy baby was delivered by caesarean section at term, the obstetric
indication being cephalopelvic disproportion. Postoperative period
was uneventful. Laser
assisted hatching is a fairly new technique in assisted reproduction.
In this patient LAH was the preferred option in view of her age
and previous failed attempts at assisted reproduction.
Case 2
A 36 year
old primigravida presented with a history of missed period (D36)
following intrauterine insemination after ovulation induction
with Letroz and HMG. She was asymptomatic. She had undergone a
thyroidectomy in 1996 and an ovarian drilling in 2000. Her previous
cycles were regular.
Clinical and ultrasonographic evaluation did not reveal a pregnancy
either intrauterine or extrauterine. ßhCG showed a value of >
1000 IU. She was sent for a second ultrasonographic opinion, which
also revealed negative results for a pregnancy. ßhCG on D38 was
2616 IU. An USS at this stage did not show a pregnancy at any
site.
In view of the positive and rising ßhCG values she was counseled
for a diagnostic SOS operative laparosocpy to which she consented.
Findings at laparoscopy revealed a left ampullary unruptured tubal
pregnancy. A linear salpingostomy was done and products of conception
were flushed out. Histopathological examination of the specimen
revealed products of conception. She was discharged one day later
in satisfactory general condition. Repeat ßhCG evaluation showed
falling titers.
Comment:
Any patient presenting with a history of a missed period after assisted
reproduction is considered to be pregnant unless proved otherwise.
Moreover, patients in this category present very early and hence
are asymptomatic in a great majority of cases. A laboratory diagnosis
of a pregnancy is made by ultrasound or serum ßhCG estimation. Of
the two, ßhCG is more sensitive as diagnoses by an ultrasound requires
a certain discriminatory level of ßhCG. This level is 1500-1800
IU with a high-resolution transvaginal scan and 6000-6500 IU for
a transabdominal scan. Below these levels a scan may fail to recognize
a pregnancy whether intra or extrauterine. Apart from a single value,
it is the rising levels which are diagnostic of an intra or an extrauterine
pregnancy. In a normal intrauterine pregnancy ßhCG levels double
or rise by 66% at least. Failure to do so is highly suspicious of
an extrauterine pregnancy. However studies have shown that in 64%
of cases of early ectopic pregnancies the ßhCG levels may show a
normal rise.
The point concluded is that if a discriminatory level of ßhCG is
reached without an ultrasound evidence of a pregnancy at any site
the patient requires intervention in the form a laparoscopy which
will be diagnostic as well as operative. By following the above
protocol one large study involving 1200 patients reported 100% sensitivity
and 99.9% specificity.
|
