Treatment of female causes


Treatment of type 11 anovulation:

Clomiphene citrate (CC):

Clomiphene citrate is an antioestrogen, which blocks the oestrogen receptors and reduce the oestrogenic activity in the body. As a result pituitary secretes FSH to stimulate ovaries to produce eggs and oestrogen.

It is the first line drug for ovulation induction. Usually given at a dose of 50 -150 mg  per day  from D3 to D7 of the regular or progesterone withdrawal cycle. It can be started at any day from D2 to D5 of the cycle. Cycles are monitored by transvaginal ultrasosnogram for assessing development of follicles which contain eggs. Monitoring usually started from D12 of menstrual cycle. Dose of the drug is adjusted according to response of the drug. Satisfactory response is development of follicle size of at least up-to18 mm and development of trilaminar endometrium. After getting satisfactory response couple are advised to have sexual intercourse at this phase and to continue this treatment at least for six cycles. Multiple follicles may develop causing multiple pregnancy. Chances of development of hyperstimualtion syndrome is less.

Some patients do not develop any eggs in spite of high dose of CC ( 150 mg per day) and they are called CC resistant. In other cases in spite of developing mature eggs some patients do not get pregnant and they are called CC failure. Ovulation rate is 75% to 80% and pregnancy rate is 40% to 50%. This disparity is due to some negative effects of CC on endometrium.

Tamoxephene:

Another antioestrogen can be used for ovulation induction in the same manner from D2 to D6 of the cycle. Usual dose is 20 mg to 40 mg per day. Cycles are monitored to see the response.

Aromatase inhibitors:

Aromatase inhibitor (Letrozole) is also an antioestrogen, which blocks the synthesis of oestrogen by inhibiting the enzyme aromatase. It is also given at any day from D2 to D5 of the cycle for 5 days. Usual dose is 2.5 mg to 7.5 mg per day. Cycles are monitored to see the response. Chances of development of multiple follicles are less. Usually single follicle is developed.

Gonadotropins:

rFSH is used if previous drugs fail to produce eggs. Step up or step down protocol is used to produce less number of follicles ( One to three). Usual dose is 50 IU to 75 IU per day or every other day. Cycles are monitored extensively to avoid hyperstimulation syndrome. PCOS are more prone to develop ovarian hyperstimulation syndrome. More

Metformin:

In CC resistant patients it is used to sensitise the ovaries to ovulation inducing drugs. Usual dose is 1500 mg per day. Starting dose is 500 mg daily after meal and is to be increased 500 mg weekly to adjust the drug. More

2. Laparoscopic adhesiolysis ( in PID and endometriosis) and Laparoscopic
“drilling” (in PCOS) of the ovarian capsule.

In pelvic inflammatory diseases (PID) and in endometriosis there may be adhesion in the pelvic organs causing anatomical derangement, which interferes the ovarian and tubal activity and causes infertility. By laparoscopy adhesions removed called adhesioslyis and restores the normal anatomy of pelvis as much as possible, which helps the ovaries and tubes to function properly. In PCOS when ovulation inducing drugs fail to produce eggs laparoscopic ovarian drilling causes spontaneous ovulation or increases ovarian response to drugs.

3. Tubal reconstructive surgery in some cases.

Tubal reconstructive surgery can be done where damage is not so severe. After tuboplasty  at least 4 cm functioning tube should be retained. Success rate is 20%.

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