Obgyn · Year 3 · from Obgyn

Case 1: Polycystic Ovary Syndrome and Anovulatory Infertility

Patient Demographics

  • Age: 28 years
  • Sex: Female
  • Occupation: Marketing manager

Chief Complaint

"My husband and I have been trying to get pregnant for 18 months without success."

History of Present Illness

The patient reports irregular menstrual cycles since menarche, occurring every 35 to 90 days. She has never been pregnant. She notes gradual weight gain over the past 5 years and increasing facial hair requiring weekly removal. Her last menstrual period was 8 weeks ago. She denies hot flashes, vaginal dryness, or galactorrhea. Her husband is 30 years old and healthy with no known fertility issues. They have been having unprotected intercourse 2-3 times weekly for 18 months.

Past Medical History

  • Obesity (BMI 34 kg/m2)
  • Acne vulgaris treated with topical retinoids

Physical Examination Findings

  • Vital Signs: BP 128/82 mmHg, HR 76 bpm, BMI 34 kg/m2
  • General: Obese female, android body habitus
  • Skin: Hirsutism on upper lip, chin, and chest; acanthosis nigricans at posterior neck and axillae
  • Thyroid: Normal size, no nodules
  • Breast: No galactorrhea expressed
  • Abdomen: Soft, non-tender, obese
  • Pelvic: Normal external genitalia, cervix appears normal, uterus normal size, no adnexal masses palpable

Diagnostic Workup

  • Serum beta-hCG: Negative
  • Day 3 FSH: 6.2 IU/L (normal)
  • Day 3 Estradiol: 42 pg/mL (normal)
  • Anti-Mullerian Hormone (AMH): 8.2 ng/mL (elevated, consistent with PCOS)
  • Total Testosterone: 68 ng/dL (elevated)
  • Free Testosterone: 2.1 ng/dL (elevated)
  • DHEA-S: 320 mcg/dL (upper normal)
  • TSH: 2.1 mIU/L (normal)
  • Prolactin: 12 ng/mL (normal)
  • Fasting Glucose: 102 mg/dL (impaired fasting glucose)
  • Fasting Insulin: 22 mIU/mL (elevated)
  • HbA1c: 5.8%
  • Mid-luteal Progesterone: 1.2 ng/mL (consistent with anovulation)
  • Transvaginal Ultrasound: Bilateral enlarged ovaries (12 mL and 14 mL) with more than 20 small peripheral follicles (2-9 mm) in each ovary; normal uterus with 8 mm endometrial thickness
  • Hysterosalpingogram: Normal uterine cavity; bilateral tubal patency with free peritoneal spill
  • Semen Analysis (partner): Volume 3.2 mL, concentration 45 million/mL, motility 58%, morphology 6% normal forms (all within WHO reference values)

Diagnosis

Polycystic Ovary Syndrome (PCOS) meeting Rotterdam criteria (2 of 3):

  1. Oligo-ovulation/anovulation (irregular cycles, low luteal progesterone)
  2. Clinical and biochemical hyperandrogenism (hirsutism, elevated testosterone)
  3. Polycystic ovarian morphology on ultrasound

Associated findings: Insulin resistance, impaired fasting glucose

Management Plan

Lifestyle Modification (First-Line):

  1. Weight loss goal of 5-10% body weight (target loss of 15-20 lbs)
  2. Mediterranean-style diet with reduced refined carbohydrates
  3. Regular aerobic exercise 150 minutes per week
  4. Referral to registered dietitian

Medical Treatment:

  1. Letrozole 2.5 mg daily for days 3-7 of menstrual cycle (first-line ovulation induction for PCOS per PPCOS II trial)
  2. Ovulation monitoring with urinary LH kits starting cycle day 10
  3. Timed intercourse every 1-2 days during fertile window
  4. Consider metformin 500 mg twice daily as adjunct for insulin resistance

Follow-up:

  1. Mid-luteal progesterone to confirm ovulation
  2. If no ovulation at 2.5 mg, increase letrozole to 5 mg then 7.5 mg in subsequent cycles
  3. If no conception after 3-4 cycles of letrozole with confirmed ovulation, proceed to IUI
  4. Reassess after 6 months; consider referral for IVF if unsuccessful

Counseling Points:

  • 80% of women with PCOS will ovulate with ovulation induction agents
  • 30-40% conception rate expected within 6 ovulatory cycles
  • Weight loss of 5-10% can restore spontaneous ovulation in many patients
  • Multiple pregnancy risk approximately 5-7% with letrozole (lower than clomiphene)
  • Long-term health counseling regarding diabetes, cardiovascular disease, and endometrial cancer risk

Clinical Image

Image Description: Transvaginal ultrasound image demonstrating a polycystic ovary with characteristic peripheral arrangement of multiple small follicles (2-9 mm), creating the classic "string of pearls" appearance. The central ovarian stroma appears increased in echogenicity. The ovarian volume exceeds 10 mL.

Attribution: Image from Wikimedia Commons. Licensed under CC BY-SA 4.0. Source: https://commons.wikimedia.org/wiki/File:Polycystic_Ovaries.jpg

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