1. Treatment history
Patient Chen, 33 years old, was seen in February 2005 because she had been infertile without contraception for 7 years after marriage. The patient has been living together as a couple for 7 years after marriage, with a normal sexual life and no contraception and no pregnancy. 14 years old, she had her first menstruation, which has been irregular since the first menstruation. After marriage, her menstrual cycle gradually lengthened from 2-3 months to 6 months, and she sometimes used progesterone to have menstrual flow. She was treated with etidol and progesterone in an outside hospital, and she took clomiphene to induce ovulation for several cycles, and was unsuccessful in trying to conceive with coitus. Last menstruation: November 6, 2004. Physical examination at the time of consultation: height 155 cm, weight 65
Kg, body mass index 27, blood pressure 120/80mmHg. Both breasts were normally developed, with no nipple overflow and no hair growth above the nipples. Gynecological examination: normal vulva development, female pubic hair distribution, vaginal patency, smooth cervix, anterior uterus, normal size, movable, no pressure pain, no abnormalities in both adnexa. Vaginal ultrasound: uterus size.
4.5×3.7×3.4cm with uniform myometrial echogenicity. The right ovary was 4.2×3.1×2.3cm with 0.3-0.5cm small follicles and 14 ovarian medullary echogenicity, while the left ovary was 3.9×3.2×2.3cm with 0.3-0.5cm small follicles and 16 ovarian medullary echogenicity. Reproductive endocrine examination: follicle stimulating hormone (FSH) 5.7IU/L, luteinizing hormone (LH): 10.4IU/L, estradiol (E2): 112pg/ml, prolactin (PRL): 21.3ng/ml, thyroid stimulating hormone (TSH): 2.3uIU/l, testosterone (T) 0.55ng/dl, insulin (INS fasting): 23.4 uIU/L (normal value 7-15
uIU/L), hysterosalpingography suggested normal uterine cavity morphology, bilateral patent fallopian tubes, and the male partner’s semen routine suggested mild weak spermatozoa. Preliminary diagnosis: primary infertility, polycystic ovary syndrome, insulin resistance. The male partner had weak spermatozoa. Diagnostic scraping was performed on the first day of withdrawal bleeding, and the endometrial pathology was changed in the secretory phase. The patient was given desogestrel ethinyl estradiol tablets in combination with metformin cycle, and was also advised to have a low-calorie diet and exercise. After 3 months, the patient’s weight decreased to 62 Kg, and the repeat endocrine follicle stimulating hormone (FSH) was 5.4 IU/L, luteinizing hormone (LH): 5.8 IU/L, estradiol (E2): 42.3 pg/ml, prolactin (PRL): 20.3 ng/ml, testosterone (T) 0.43 ng/dl, insulin (INS fasting): 12.3 uIU/L. Sun Xiuqin, Reproductive Medicine Center, Jining First People’s Hospital, Jining, China Administered clomiphene 50mg, 1 capsule per day for 5 days, and took the drug on 3-7 days of menstruation. She continued to take metformin and added metroxyprogesterone acetate tablets 4mg twice daily for 7 days in the second half of the cycle. In the second cycle, the amount of clomiphene was increased to 100 mg once daily for 5 days; until it was increased to 150 mg daily for 5 days, but still no dominant follicle growth. CC tolerance was present, and after communication with the patient and family, the urinary follicle stimulating hormone combined with urotropic hormone regimen was switched to cycle 4. On the 5th day of menstruation, the patient was first given mafloquine 1 tablet daily for 21 tablets, and on the 21st day of menstruation, she was given albuterol 150ug intramuscularly, 1 tablet daily, for 10 days. If there is a dominant follicle, the dose should be maintained. If there is no dominant follicle, the dose should be increased by 37.5 IU every 7 days until the dominant follicle reaches 1.75 cm, then 10,000 IU of chorionic gonadotropin should be injected intramuscularly. The patient switched to the above regimen for the 1st cycle, and the ovulation promotion medication was administered until the 20th day of menstruation, and the medication cost more than 2000 RMB. In the second cycle, 7 urinary follicle stimulating hormone and 30 urinary sex stimulating hormone were applied. On the 26th day of menstruation, the left dominant follicle finally developed, and 10,000 IU of chorionic gonadotropin was administered intramuscularly. The following afternoon, IUI was performed, and the A+B sperm count was 20×106 after semen washing. After the insemination, a positive urine HCG and blood β-HCG: 342.5 IU/L, suggesting a biochemical pregnancy, was performed 35 days after the insemination. After regular antenatal checkups, a male baby was delivered by cesarean section at 39 weeks of gestation, weighing 3350 grams, with normal developmental appearance, and was followed up to 6 years old with normal development. 2. Discussion: The patient was married for 7 years and had menstrual cycles of variable length, sometimes as long as 6 months or even 1 year, requiring progesterone to induce menstruation. Her body mass index was 27 and she had insulin resistance, so she was given metformin and Daing 35 to correct the endocrine disorder. The patient had a long menstrual cycle and therefore a long medication duration. The use of incremental regimens to promote ovulation to mature the follicles is a long medication duration, with many monitoring sessions and high costs, which often cannot be adhered to without adequate communication with the patient and informing her of the treatment process. Since LH is at a high level and FSH is relatively deficient in this group of patients, the selection process of antral follicle recruitment is done under the influence of estrogen and FSH. The use of pure FSH (including Metrodin-HP and Gonal-F) during the recruitment phase of the dominant follicle is closer to the physiological process. In this study, u-FSH was used to avoid the simultaneous recruitment of multiple follicles and to mimic the secretion profile of FSH in the body during the natural cycle as much as possible, a low-dose initiation regimen was used. follicle to develop into a preovulatory follicle. Since the FSH threshold window for single follicle development is extremely narrow, in order to find the lowest effective dose of FSH for each PCOS patient, it must be slowly increased and patiently fumbled to achieve single follicle development. The switch to HMG after 4 applications of u-FSH reduced medical costs and made it easy for patients to receive without overstimulation occurring. Due to the emphasis on pre-treatment, no abandonment of cycle therapy occurred and wasted drug supply was avoided. Emphasis on pre-treatment: The key to the success of the FSH sequential HMG small-dose incremental regimen lies in the normalization of the body’s reproductive endocrine indexes. Since PCOS patients mostly have hormone disorders such as FSH, LH, T, PRL, INS, etc., the indicators should be regulated to normal range. In this case, all patients had LH/FSH ratio imbalance, hyperandrogenemia and hyperinsulinemia, which were regulated to normal with the combination of various drugs, and then ovulation was promoted. In conclusion, FSH sequential HMG in small incremental doses is a safe, effective and economical method of ovulation promotion in refractory PCOS patients with normal uterine morphology and bilateral patent fallopian tubes and basically normal husband’s semen as the treatment of choice.