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Old 07-22-2011
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ObGyn How would you treat this 35 Y/O Female with infertility?

A 32 y/o G3P3 woman presents to her obstetrician for help conceiving. She states her menstrual cycles have not been regular since the birth of her third child 3 years ago. Furthermore, although she readily became pregnant with her other 3 children, she has failed to become pregnant despite trying over the past 2 years. She has no significant past medical history and takes only prenatal vitamins. Although she says she has not been ill lately, she reports feeling "tired and cold all the time". She also reports she has had trouble sleeping over the past several months. Her physical is normal. Lab test show:

WBC: 9,000/mm3
Hemoglobin: 8.0 g/dL
Platelet : 300,000
Thyroid-stimulating hormone level 0.5
Free thyroxine : 2.0
Luteinizing hormone: 0.5
Follicle-stimulating hormone: 0.5

Which of the following will this woman likely need to take to conceive?

A. Levothyroxine
B. Prednisone
C. Progesterone
D. Clomiphene
E. Propylthiouracil
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Old 07-22-2011
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Levothyroxine
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Old 07-22-2011
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A.levothyroxine
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Old 07-22-2011
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Clinical features suggest hypothyroidism. Hypothyroidism cause disturbance in harmone balance and level-->disturbence in ovulation-->irregular menstruation-->infertility.

sometimes hypothyroidism is associated with pcod and ovarian cyst also. If not treated and if she become pregnant -->chances of miscarriage are there....

So its A...Levothyroxine......
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Old 07-23-2011
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feeling cold all the time shows hypothyroidism so i m with A
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Old 07-23-2011
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I think this is Sheehan syndrome. This causes hypothyroidism but also hypogonadism(Low LH and FSH). The patient's symptoms have started after birth. So the answer is progestron.
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Old 07-23-2011
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The correct answer is D. Clomiphene. This patient has Shehaan sx which is a consequence of reduced blood flow to the pituitary during delivery or post partum. The patient is exhibiting signs of hypothyroidism (low TSH and T4) and will likely need levothyroxine treatment. However she is likely not ovulating secondary to her pituitary difx (low FSH and low LH). In such cases ovulation has to be induced with Clomiphene.
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Old 07-23-2011
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Quote:
Originally Posted by aksyonez View Post
The correct answer is D. Clomiphene. This patient has Shehaan sx which is a consequence of reduced blood flow to the pituitary during delivery or post partum. The patient is exhibiting signs of hypothyroidism (low TSH and T4) and will likely need levothyroxine treatment. However she is likely not ovulating secondary to her pituitary difx (low FSH and low LH). In such cases ovulation has to be induced with Clomiphene.


a decrease (LH-FSH )means anovulation problem and decrease free t4 mans hypothyroidism so need L-thyroxine and induction of ovulation clomphen

but if it is sheehan y didnt menntion failure of lactation or APH OR PPH hx in q so that we can conclude it is shehan
y it is not hypothyroidism cause her anovulation so y we start by l thyroxine initially then induction ?????
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Old 07-23-2011
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Quote:
Originally Posted by miss patho View Post
a decrease (LH-FSH )means anovulation problem and decrease free t4 mans hypothyroidism so need L-thyroxine and induction of ovulation clomphen

but if it is sheehan y didnt menntion failure of lactation or APH OR PPH hx in q so that we can conclude it is shehan
y it is not hypothyroidism cause her anovulation so y we start by l thyroxine initially then induction ?????
but it's mentioned that there are menstrual problems since the last delivery, which is a clue instead of lactation, etc.. We can't expect the classic presentation always, u know.
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