Interesting cases 2021 by Dr Aruna Ashok, Clinical director A4 Hospital and Fertility Centre, Chennai. #a4fertility #a4hospital #chennai

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 the fertility 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 and Ovaries
CASE 1

5. ● Underwent 2 cycle 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 was done 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

15. USG images

16. ● Confirmed diagnosis with 3D USG
● Taken up for laparoscopy
● Intra-op: 2x2cm POC buldge with impending rupture at right cornua,
vasopressin injected at cornua, POC scooped out

17. LAPAROSCOPY
CASE 4

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 scan at 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

22. CASE 5

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 Cornual Pregnancy
CASE 5

25. CASE 5

26. Recommendations on terminology for 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 SHOULD BE 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

28. CASE 5

29. Uterus - Submucous fibroid
● 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
before procedure
showing
submucous
fibroid
CASE 6

32. Hysteroscopic Myomectomy Video
CASE 6

33. USG after myomectomy
CASE 6

34. OVARIAN DETORSION ON THE 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 –Deca 0.1 + HCG 5000 IU
● Pt had pain abdomen and vomiting one day after trigger USG showed intact follicles .
CASE 6

36. ● With a working 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 with Stem Cells

40. SOAT with IUI Pooled 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 fibroid with ectopic
Right Ectopic Left broad ligament fibroid

42. OPENING CEREMONY
of our new branch
Welcome you all to

43. THANK YOU
A4 Fertility Centre
Address:
87, Arcot Rd, Udhayam Colony, AVM Avenue,
Virugambakkam, Chennai, Tamil Nadu 600092
Find us on:
aruna@a4fertility.com
www.a4hospital.com
/a4hospital