Suggest Treatment For Difficulty In Conceiving

Brief Answer:
Detailed information and reports needed.

Detailed Answer:
Dear XXXXXXX

I have gone through your brief history. I do agree, your situation is indeed confusing for you and naturally you are in dilemma. Let us discuss the issue step by step.

Yes, whenever any woman in a child-bearing age group, having otherwise regular menses and who is sexually active misses her period, the first in the list of differential diagnosis is Pregnancy. So is your situation. You fulfil all the criteria; hence the possibility of pregnancy has to be investigated keeping in mind the odds of this diagnosis.

Your age is 40 years. This is not the age in the 21st century, particularly in an advanced country like UK where a woman will attain her natural menopause at such an early age. You have at least 6-7 more years of your reproductory life. Moreover, your reproductive hormonal profile has been reported to be normal. So let us rule out menopause. When in menopause, Oestrogen levels are very low while FSH levels are very high.

Your doctor has advised you to reduce your weight. That is true, particularly in Polycystic Ovarian Syndrome. However, in PCOS, the FSH:LH ratio gets reversed which has not happened in your case. Still, to reduce weight, particularly by reducing waistline is a good option.

At this stage, I would advise you to find out the status of the pregnancy. Please do not be excited nor nervous about the results of the test. Be prepared for the worse results - non pregnant state. Since your menstrual cycles have been delayed up to 35 days also, I would advise you to get pregnancy test on overnight first morning urine sample done after 45 days of missed period. Done earlier, this test may give false negative results. The best option would be to go for Beta hCG test on your blood. This test will give you reliable results even now also.

If you are not pregnant, I would like you to consider certain issues before you go for pregnancy. After the age of 35, the chances of congenital abnormalities in the baby go on increasing. After the age of 40 years, the eggs remaining in the ovaries are more of substandard quality hence the incidence of abortions and abnormal babies go on increasing. Hence, please seek for a full prenatal counselling and take an informed decision.

If your attempts to become pregnant are in vain for many years, you should have undergone a battery of investigations to ascertain:
1. Egg release (ovulation)
2. Patency of the complete genital tract
3. Hormonal assays
4. Semen examination

Your history does not mention much about this, except some hormones normal and the values of FSH on second day. Would you please upload all the reports in details for my review. If the assessment of the above mentioned has been done, please upload all the reports and images also, else get them done.

I feel instead of hitting around the bushes, I would prefer to have a clear picture through all your reports when I can give you further advice (and may be ask for some more investigations). Also please let me know about your physique: Height, weight, BMI, waist:hip ratio, hair distribution, etc.. Please inform me your full marital history also. You have got a limited reproductory span of life left. So please get all this work up done at the earliest.

At this stage, let me take a break here to await for the requested information and the reports. Then we will further continue our discussion.

I would definitely like to guide you the most scientific way for your motherhood, XXXXXXX

Dr. Nishikant Shrotri

PS: I have seen the battery of reports you have posted just few minutes ago. They are not sufficient to assess your infertility problem. Please refer to the requirements as mentioned above and get the remaining reports done.

Dr. Nishikant Shrotri

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Brief Answer:
Some more work up needed

Detailed Answer:
Dear XXXXXXX

Very nicely provided information. Prima facae, there does not seem to be any problem in conception for you, provided on missing factors are assessed normal. All these investigations do not give me any information about the patency of the tubes, inside of the uterine cavity and the condition of the pelvic cavity & genital organs.

May request you to evaluate these aspects by:

1. Hysterosalpingography: X-ray of the uterus and tubes after pushing in a radio-opaque XXXXXXX through the uterus. This will inform us about the patency of the tubes and condition of uterine cavity.

2. Laparoscopy: This will inform us about the patency of the tubes, external appearance and condition of the genital organs and condition of pelvic cavity (any tumour, infections, adhesions, endometriosis, etc.)

Regarding the evidence of ovulation: If the home kit has given you evidence of ovulation, that should help you to plan your intercourse in the fertile period. Try to utilize the day of ovulation to increase the chance of success.

However, this kit has shown you that the ovulation is not that regular. It is expected at this age. Hence I would suggest you to monitor the ovulation regularly and plan the intercourse accordingly.

Moreover, with ultrasonography ovulation monitoring, you will get more information about the size of follicle when it ruptured and the thickness of uterine lining (endometrium) at the time of ovulation.

A follicle between 18 mm to 21 mm at the time of ovulation gives best results as far as conception and continuation of pregnancy is considered. Larger follicles do not have good success rate. Smaller follicles may have immature egg.

Endometrial thickness of at least 10 mm is needed at the time of ovulation for successful implantation of the fertilized ovum (zygote). Thinner endometrium may prove to be deficient.

I would definitely like to have the reports of blood FSH, LH, Oestrogen, Progesterone, Prolactin, T3, T4 & TSH. Please get them done and upload them for my review.

And now regarding your weight! Yes XXXXXXX your BMI is definitely considerably high and needs a thorough care. I do not like the weight reduction by medicines. Follow a proper diet control with the help of a dietician. Along with, exercise is absolutely necessary. In addition to the static exercises in the Gymnasium, aerobic exercises are necessary. Please walk in open air briskly at a pace of 90 steps per minute for 40 minutes minimum in the morning and evening. This should help you reducing weight. Even though you do not have PCOS, this weight may pose problem in your conception and even during pregnancy and delivery.

At this age, you may give a trial for natural conception (after all the investigations are completed and the barrier factors are taken care of) for six months to one year. If you do not conceive within that time, you may think of going for artificial reproductory technique since you have limited period of your Reproductory life left at your disposal.

Currently with whatever reports you have provided me, I have given you guidelines for further steps. Please upload all the other required reports and images to equip me further for scientific advice.

You may post your review with 5 stars rating for me if you find my advice useful; of course, for any more information, please feel free to get back to me any time and any number of times.

Dr. Nishikant Shrotri

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Brief Answer:
You are loosing limited available time

Detailed Answer:
Dear XXXXXXX

Well I do not agree to this view of delaying the further investigations till your BMI is within normal limits. This is wasting a time. As I had already expressed that you have got limited reproductory years at your disposal. In postponing these investigations, you are loosing the time. If after loosing few years, some ailment is found which calls for correction, again some more time lost. With every month or year passing, the chances of conception go on diminishing.

Anyway, I have expressed my views to you, conveyed the different options and informed you the pros and cons of the varied options. Now you have to take an informed decision.

Regarding the possibility of natural conception, I have already opined my view. However, more the time you loose, the chances of natural conception, pregnancy and even the delivery go on diminishing.

I hope I have given you sufficient clarification and the messages. If you feel you want some more information or my opinions, I am always available for you, XXXXXXX

Dr. Nishikant Shrotri

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