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  #1  
Old 09-19-2012
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Question Help this woman to conceive

A 32-year-old 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 three children, she has failed to become pregnant despite trying over the past 2 years. She has no signifi cant 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 examination is normal.
Laboratory tests show:
WBC count: 9000/mm³
Hemoglobin: 8.0 g/dL
Platelet count: 300,000/³
Hematocrit: 40%
Thyroid-stimulating hormone level: 0.5 μU/mL
Free thyroxine: 2.0 ng/dL
Luteinizing hormone: 0.5 mU/mL
Follicle-stimulating hormone: 0.5 mU/mL

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

(A) Clomiphene
(B) Levothyroxine
(C) Prednisone
(D) Progesterone
(E) Propylthiouracil
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Answer B

Her hypothyroidism is causing infertility and the hypogonadism(low FSH and low LH), treating her with thyroid replacement may restore balance
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Help the woman to conceive.

I just really like the name of this thread ; )
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Originally Posted by DocSikorski View Post
Help the woman to conceive.

I just really like the name of this thread ; )
we can make the woman conceive without the pill too
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Quote:
Originally Posted by step_enhancer View Post
we can make the woman conceive without the pill too
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Quote:
Originally Posted by step_enhancer View Post
Answer B

Her hypothyroidism is causing infertility and the hypogonadism(low FSH and low LH), treating her with thyroid replacement may restore balance
Think again......B is incorrect
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Quote:
Originally Posted by step_enhancer View Post
we can make the woman conceive without the pill too
I think it should be clomiphene...

if the old school method does not work =)))
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Quote:
Originally Posted by DocSikorski View Post
I think it should be clomiphene...

if the old school method does not work =)))
What is the MOA of clomiphene ??????
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Quote:
Originally Posted by K06100 View Post
What is the MOA of clomiphene ??????
seriously, do not remember... Female endocrinology is my least favorite topic...
But there was a great scheme in FA'12 for step 1 with clomiphene arrowing somewhere in the area between hypophysis and folicles...
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Quote:
Originally Posted by K06100 View Post
A 32-year-old 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 three children, she has failed to become pregnant despite trying over the past 2 years. She has no signifi cant 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 examination is normal. aboratory tests show:
WBC count: 9000/mm³
Hemoglobin: 8.0 g/dL
Platelet count: 300,000/³
Hematocrit: 40%
Thyroid-stimulating hormone level: 0.5 μU/mL
Free thyroxine: 2.0 ng/dL

Luteinizing hormone: 0.5 mU/mL
Follicle-stimulating hormone: 0.5 mU/mL

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

(A) Clomiphene
(B) Levothyroxine
(C) Prednisone
(D) Progesterone
(E) Propylthiouracil
(A) Clomiphene
She has most of the features of hypopituitarism following the birth of her last child which points to Sheehan syndrome.

But, I will first find out what is causing her low Hb of 8 g/dL before prescribing her clomiphene since she is not in any shape to become pregnant which will be disaster.

Quote:
Clomifene appears to inhibit estrogen receptors in hypothalamus, thereby inhibiting negative feedback of estrogen on gonadotropin production.[1] It may also result in direct stimulation of the hypothalamic–pituitary–adrenal axis.[1]

In normal physiologic female hormonal cycling, at 7 days past ovulation, high levels of estrogen and progesterone produced from the corpus luteum inhibit GnRH, FSH and LH at the hypothalamus and anterior pituitary. If fertilization does not occur in the post-ovulation period the corpus luteum disintegrates due to a lack of beta-hCG. This would normally be produced by the embryo in the effort of maintaining progesterone and estrogen levels during pregnancy.
Therapeutically, clomifene is given early in the menstrual cycle. It is typically prescribed beginning on day 3 or 5 and continuing for 5 days. By that time, FSH level is rising steadily, causing development of a few follicles. Follicles in turn produce the estrogen, which circulates in serum. In the presence of clomifene, the body perceives a low level of estrogen, similar to day 22 in the previous cycle. Since estrogen can no longer effectively exert negative feedback on the hypothalamus, GnRH secretion becomes more rapidly pulsatile, which results in increased pituitary gonadotropin (FSH, LH) release. .......... Increased FSH level causes growth of more ovarian follicles, and subsequently rupture of follicles resulting in ovulation.
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Originally Posted by Novobiocin View Post
(A) Clomiphene
She has most of the features of hypopituitarism following the birth of her last child which points to Sheehan syndrome.
Sir , tell me what is the fate of pituitary gland after the sheehan's syndrome ??Does it recover its functions ??????

What I gathered from the question is that she's having hypothyroidism ,also her gonadotropins r low so it means her pituitary is failing...how will clomiphene be able to release gonadotropins from a failing gland ?????
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Quote:
Originally Posted by K06100 View Post
Sir , tell me what is the fate of pituitary gland after the sheehan's syndrome ??Does it recover its functions ??????

What I gathered from the question is that she's having hypothyroidism ,also her gonadotropins r low so it means her pituitary is failing...how will clomiphene be able to release gonadotropins from a failing gland ?????
You are right that it is the pituitary which secretes FSH/LH but in her case it is not a total pituitary failure. Otherwise she should also have had lactation failure, addison's etc.
Among the choices given Clomiphene is the only one which fits since it is the only one among the choices which can provide FSH.
Also, the question is not asking that which one will definately make her conceive but "Which of the following will this woman likely need to take to conceive?"

Quote:
Clomifene appears to inhibit estrogen receptors in hypothalamus, thereby inhibiting negative feedback of estrogen on gonadotropin production.[1] It may also result in direct stimulation of the hypothalamic–pituitary–adrenal axis.
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Quote:
Originally Posted by Novobiocin View Post
You are right that it is the pituitary which secretes FSH/LH but in her case it is not a total pituitary failure. Otherwise she should also have had lactation failure, addison's etc.
Among the choices given Clomiphene is the only one which fits since it is the only one among the choices which can provide FSH.
Also, the question is not asking that which one will definately make her conceive but "Which of the following will this woman likely need to take to conceive?"
hmmmm......ok.....thnx
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Originally Posted by step_enhancer View Post
we can make the woman conceive without the pill too
Dude that's the problem no matter how hard to try to help her conceive with treating her hypothyroidism it won't help. ;-)


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Man ! she has Sheehan syndrome
After birth of the third child ,her pituatary got fried -hypothtyroidism and hypogonadism .Very nice Qs Thanks K06100

I hope this time i am thinking right :sorry:

Answer would be Clomiphene .
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Found this http://emedicine.medscape.com/articl...view#aw2aab6b7

Quote:
Treatment includes hormone replacement with physiologic doses of glucocorticoids (before levothyroxine is given), levothyroxine, and sex steroids, with appropriate increases in glucocorticoid doses for stress. Sex steroids are given through various formulations and routes. Ovulation induction with pulsatile GnRH or exogenous gonadotropins may be needed for subsequent pregnancies. Some women with low libido may require androgen replacement. GH replacement is decided on a case-by-case basis, but the decision is made only after all other deficient hormones have been replaced.
and also http://www.ncbi.nlm.nih.gov/pubmed/6999398

Quote:
Detailed endocrinological studies were performed during and after the eighth pregnancy of a 38-year-old woman who had eight spontaneous pregnancies after the onset of hypopituitarism secondary to massive postpartum hemorrhage. Hormonal replacement therapy was not provided during seven pregnancies and all terminated in spontaneous abortions. Studies of pituitary function during and after the eighth pregnancy demonstrated that the patient had measurable amounts of growth hormone, follicle-stimulating hormone (FSH), luteinizing hormone (LH), thyrotropin (TSH), adrenocorticotropin (ACTH), and prolactin in her plasma under basal conditions but that these hormones did not increase approximately in response to pregnancy, stress, and specific stimuli. Evaluation of placental function at 26 weeks gestation by measurement of estradiol, progesterone, human placental lactogen, and chorionic gonadotropin revealed no abnormality. Hormone replacement therapy during the eighth pregnancy was associated with the delivery of normal premature infant at 32 weeks gestation. In addition to these studies, a critical review of the literature was undertaken to more clearly define the clinical and laboratory features of pregnancy in Sheehan's syndrome.
So where does this take us .....
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hmmmm......ok.....thnx
If HMG (human menopausal gonadotropin) was among the answer choices the it is the right answer. But, always try Clomiphene first since HMG use has complications like hyperstimulation.
Remember, the ideal answer may not be among the answer choices so you have to pick the most likely among the answer choices.

So many people have found out recently (based on posted exam experiences) that they look for the ideal answer among the choices and it isn't there! That's why this is a very good question.
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So where does this take us .....
It means that in real world you replace whatever is missing.
But this question specifically asks "Which of the following will this woman likely need to take to conceive?"
Anyway, Infertility treatment is a minefield. I am just going to stick with the basics.
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Quote:
Originally Posted by Novobiocin View Post
If HMG (human menopausal gonadotropin) was among the answer choices the it is the right answer. But, always try Clomiphene first since HMG use has complications like hyperstimulation.
Remember, the ideal answer may not be among the answer choices so you have to pick the most likely among the answer choices.
Thats exactly what I was thinking at the time of doing the question.....I was wondering how will clomiphene be able to release gonadotropins from the damaged pituitary gland.......
thank u sir......
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