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Interesting cases 2021 by Dr Aruna Ashok
The document presents a series of infertility cases managed by Dr. Aruna Ashok, highlighting various challenges and treatment methods including hypogonadotropic hypogonadism, resistant PCOS, and ectopic pregnancies. It details specific patient histories, hormonal evaluations, treatment protocols like IUI and IVF, and surgical interventions such as laparoscopic procedures and hysteroscopy. The document emphasizes the complexity of infertility treatments and innovations like ovarian stem cell instillation aimed at improving outcomes.
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Interesting cases 2021 by Dr Aruna Ashok
- 1. INTERESTING CASES 2021 Dr.Aruna Ashok Clinical Director
- 2. WHO Group I-Hypo hypo ● Mrs. V , 34y/F came with primary infertility h/o only withdrawal bleed for fertility treatment ● Her FSH was 1.65 and LH was less than 0.30 and prolactin was 6.8, TSH was 1.94, FT4 was 1.24, AMH was 0.81, Testosterone was 0.1, E2 was <5, Progesterone was 0.3. ● So this indicated that she is having hypogonadotropic hypogonadism with low ovarian reserve. ● Her AMH was low and FSH and LH was also low contrary to premature ovarian failure, where FSH and LH will be high. CASE 1
- 3. ● In thefertility centre the diagnosis of premature ovarian failure was made and Diagnostic Hystero Laparoscopy, Hysteroscopy and endometrial biopsy was done suspecting Asherman syndrome. ● The patient underwent histopathological examination it shows late proliferative endometrium, however empirically ATT was started for the patient and given for 6 months. Then also she didn’t have menstrual cycle, only it was an induced cycle. ● Then karyotyping also done, it was 46XX. First consultation with us on 2020 feb. CASE 1
- 4. Small uterus andOvaries CASE 1
- 5. ● Underwent 2cycle of IUI with HMG(human menopausal Gonadotropins 150 4 doses, 225 9 doses, 375 5 doses) - which was unsuccessful ● Planned for ICSI-Self ● Started on Menotas XP 450 IU for 12 days, triggered with Inj.Ovitrelle 250mcg ● OR-8, MII-5, Fert-4, Frozen 1D5, 2D6(BC) CASE 1
- 6. • FET wasdone a month later with 2D6 embryos • Beta HCG was positive with confirmed clinical pregnancy at 6 weeks with SLIUG • Done cervical cerclage with pessary insertion in view of short cervix at 26 weeks of gestation • Continued pregnancy with no complication till term • Delivered healthy female baby of 2.7kg by Elective LSCS CASE 1
- 7. WHO Group II-Resistant PCO ● Mrs.R 32yrs married for 14yrs, ● Underwent laparoscopy and drilling done in 2012, ● Wt 105 kg BMI 40, hypertensive and diabetic ,AMH was 4.64 OI done with letrozole and 5 doses of HMG 150 outside, but no DF. ● In the next cycle induced with Letrozole 5mg BD and HMG 150IU 4 doses D10 scan showed no DF dose increased to 225IU for 3 days, developed follicle on D15, trigger was given and IUI done which was negative. ● IUI 2nd cycle started with Letrozole 5mg BD and HMG 150 IU 3 doses, D11 scan showed MSF , dose increased to 225IU for 5 doses, D21 scan showed 22mm DF on rt ovary, inj. HCG 10000 given and IUI done... ● UPT positive with scan showing SLIUG CASE 2
- 9. WHO GROUP 3 ●Group III constitutes hypergonadotropic hypogonadism secondary to depleted ovarian function. ● Most difficult group to manage ● DHEA, Androgen Gels, IVF with Dual stimulation Ovarian Stem Cells CASE 3
- 10. Ovarian stem cells •Mrs.D, 27yrs, Married for 2 years, with primary infertility/ low ovarian reserve(AMH-0.6), with previous two failed IUI, planned for ICSI • Stimulated for 10 days with Gonal F 225IU and Menotas 150IU for 10 days • Retrieved only 3 oocytes, of which there was only one MII and formed 1D3 ‘B’ grade embryo • Planned for laparoscopic ovarian stemcells and dual stimulation • Ovarian stem cells was instilled in May 2021, AMH was improved to 0.9, AFC 4/3 (July) • Started stimulation with Inj.Pergoveris 300IU in July 2021 for 10 days • 4OR/ 2MII/ 2D3 embryos were frozen • Transferred all 3D5 and beta hcg was positive with singleton pregnancy ongoing 15 weeks
- 12. Tubes ● Blocked -Cannulation ● Hydrosalpinx - Clipping or Salpingectomy ● Non Functioning - Diagnosed after Ectopic ● Altered Tubo Ovarian Relation _ Diagnosed only with Laparoscopy
- 13. Tubal- Heterotopic Pregnancy(Endometriosis with SOAT) ● Primary infertility, married for 10 years with SOAT came for ICSI ● Stimulated for 10 days with GF225IU + Menotas 225IU, triggered with Deca 0.2mg - obtained 14 oocyte- 10MII- 2D5 & 2D6 were frozen ● Done for Laparoscopy which showed stage IV endometriosis and B/L tubal clipping done for B/L hydrosalpinx and hysteroscopy showed fibrosed Rt ostia otherwise normal hysteroscopy
- 14. ● Following cycle,FET was done with 2D5 embryos, beta hcg was positive ● Viability scan at 6 weeks showed intrauterine gestation with ? Rt interstitial pregnancy
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- 16. ● Confirmed diagnosiswith 3D USG ● Taken up for laparoscopy ● Intra-op: 2x2cm POC buldge with impending rupture at right cornua, vasopressin injected at cornua, POC scooped out
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- 18. ● Post operatively,intrauterine pregnancy continued to grow ● Reached term without complication and delivered a live healthy baby by LSCS CASE 4
- 19. Cornual Pregnancy ● Primigravida,married for 3 yrs, well educated , working as project manager. ● confirmed pregnancy at home, done scan elsewhere a week ago showing no e/o intrauterine sac/ ? Ectopic pregnancy ● Waited for one week as beta hcg doubling was positive ● TVS done at 7 weeks with us showed SLIUG at 6+5 weeks toward left cornua, advised to follow up after 2 weeks CASE 5
- 20. Early scan –6.5 weeks CASE 5
- 21. Follow up scanat 10 weeks ● At 10 weeks follow up, ● TVS showed missed miscarriage – hence planned for D& E under anaesthesia ● Any other consent or procedures you will be ready with ? CASE 5
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- 23. ● Intra-op :cervix dilated and suction and evacuation tried with karman’s cannula ● USG showed intact sac at left cornua ● Proceeded to hysteroscopy, found a intact sac at left cornua, same removed with grasper and uterine cavity found to be subseptate and cut with scissors after getting consent for the same. CASE 5
- 24. Hysteroscopy of CornualPregnancy CASE 5
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- 26. Recommendations on terminologyfor ectopic pregnancy - ESHRE ● Ectopic pregnancies should be classified as uterine and extra uterine(tubal/non tubal/angular pregnancy are abandoned) ● Partial or complete ectopic pregnancies— implanted in cervical, previous LSCS scar, Intramural, interstitial portion ● Intramural ectopic---pregnancy located within the uterus but breaches the endo- myometrial junction and invades the myometrium of the uterine corpus above the internal os ● Cervical ectopic pregnancy----pregnancies which invade the myometrium in the vicinity or below the level of internal os ,It could be located either anteriorly or posteriorly. ● Caesaren scar pregnancy--- which invade the myometrium implanted anteriorly at the visible or presumed site of transverse lower uterine scar CASE 5
- 27. TUBAL PREGNANCY SHOULDBE DESCRIBED AS ● INTERSTITIAL ECTOPIC PREGNANCY---uterine part of fallopian tube 5% ● ISTHIMIC ECTOPIC PREGNANCY---rare5% %-15% ● AMPULLARY ECTOPIC PREGNANCY--- 70% common type of tubal ectopic) ● RUDIMENTARY HORN ECTOPIC PREGNANCIES—in case of uterine anomalus the pregnancy located in a rudimentary horn of the uterus ● Residual ectopic pregnancy---ectopic pregnancy which presents as a discrete mass on USG with negative pregnancy test and B HCG ● (In this type clinically to ellicite the history of previous month menstrual date and flow and onset of pain ) CASE 5
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- 29. Uterus - Submucousfibroid ● Mrs.X, 30 yrs taken MTP pills for missed miscarriage came to us with continuos bleeding and scan done outside as RPOC for further management ● When patient came to us, TVS showed CASE 6
- 30. ● TVS :Submucous fibroid with minimal RPOC. ● Hence, PLANNED FOR HYSTEROSCOPIC MYOMECTOMY after MRI CASE 6
- 31. USG on table beforeprocedure showing submucous fibroid CASE 6
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- 34. OVARIAN DETORSION ONTHE DAY OF OPU ● A case of secondary infertility with previous miscarriage due to septate uterus came to us for further management ● Diagnostic laparoscopy with septal resection was done ● ICSI was planned due to failed IUI ● Ovarian stimulation was done using Gonal F 225 IU and menotas HP 225 IU for 10 days CASE 6
- 35. ● Trigger –Deca0.1 + HCG 5000 IU ● Pt had pain abdomen and vomiting one day after trigger USG showed intact follicles . CASE 6
- 36. ● With aworking diagnosis of ?premature rupture / torsion ,early OPU was done 2 hrs before scheduled ovum pick up. Pt consent was taken up for diagnostic laparoscopy in v/o of persistant symptoms. ● OPU- OR-18,M2-9, 2D3 & 2D5 frozen. ● Laparoscopy findings: Right ovarian torsion ,double time twisted around the pedicle, Detorsion done. CASE 6
- 37. 2 cycles later– FET ● FET done with 2D5 embryos ● Pt is now 25 weeks ongoing pregnancy with twin gestation on follow up. CASE 6
- 38. Asherman Syndrome- RIF ●Mrs. P 36yrs, MS 10yrs, h/o OD-ICSI done thrice in 2013, 2016, 2019... 2016 ET was positive with right ectopic for which Rt salphingectomy was done... ● -In 2016, hysteroscopy was done outside in which cervix was dilated with difficulty, uterus retroverted, arcuate, HPE - late proloferative endometrium. ● In 2019 ERA was done which was early receptive (128+/- 3hrs)-We planned for OD ICSI, diagnostic hysteroscopy and embryo transfer ● -Through OD ICSI we got 6 embryos( 4D5 &2D6) ● -Diagnostic hysteroscopy was done on 11/12/2020- endocervical canal stenosed, multiple false passage, cervix widened with scissors, os dilated, cx shaving done, endometrium fluffy. ● -Following hysteroscopy, HRT was attempted twice in jan/feb ● - cancelled due to thin endometrium(5.5mm) ● -Planned for hysteroscopy with stem cell instillation on 11/3/2021 on day 5 of periods preceeded by three days of gcsf injection... following which ET was 7mm on day 17 of same cycle... FET was done same month with 2D5 ● - but was negative. -Again in the following month HRT started from D2, patient received three PRP(2 fresh and 1 frozen), on D18, ET was 7.6mm three line good, 2D5 embryos transferred, post transfer patient received LMWH, IL, BG... betahcg on 25/5/2021 was 1234... positive
- 39. Unicornuate Uterus withStem Cells
- 40. SOAT with IUIPooled Sample ● Mrs.Reddy Rani Prashanth, 27yrs, married for 2 years, k/c/o hypothyroidism on Rx came to us with Primary infertility with male factor ● In the first visit, basic investigations were done which showed normal female factor with AMH – 4.28, B/L Tubes were patent in HSG. Initial SA showed Volume-1.5ml, 7M/1% motile/ 1% normal forms. Hormone profile – FSH-3.67, LH-1.39, Prolactin- 29.06, E2-<10, Total Testosterone – 166.9,TSH – 5.2 ● Patient was started on T.Anastrazole 1mg 0-0-1 (alternate days), Inj.HCG and Inj.HMG weekly once ● Gradually his SA improved. His subsequent analysis was 8.5M/5%/1% and improved upto 20M/8%/2% ● Planned for IUI. Done first cycle IUI with 2 fresh sample with TMSC – 5.8milliom sperms – Negative ● Second IUI done in following month with 2 fresh and 2 frozen sample with TMSC -2.4million sperm was also negative ● As the patient was reluctant for ICSI, as a last try third IUI was done with fresh and frozen sample containing TMSC of 2 million sperms – resulted in positive pregnancy ● Now patient is continuing her 8 weeks pregnant with good fetal heart rate
- 41. Broad ligament fibroidwith ectopic Right Ectopic Left broad ligament fibroid
- 42. OPENING CEREMONY of ournew branch Welcome you all to
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