Staci Smith is a 31 –year-old female patient seen by her OB/GYN, Dr. Tibbet, for her annual exam. This is her first appointment with a doctor since moving to Louisville 8 months ago from California.
Staci’s main concern at this visit is her inability to get pregnant despite stopping taking the birth control pill 2 years ago. She reports that she and her husband have had sex at least three times a week during that time period, and that she has taken multiple pregnancy tests in the hopes that she would become pregnant but they were all negative. Her husband and she have been married for 8 years, and he has no other children.
She first got her period at age 12 and had been on the pill since age 16 for very painful and irregular periods and had been switched from a monthly form to a type that is taken 3 months at a time by her previous OB/GYN in California several years prior. Since coming off the pill, she has taken prenatal vitamins and does not take any other medications. She drinks about 4 alcoholic drinks a week, has never smoked, and does not take any illegal drugs although she did smoke pot in college occasionally.
She noticed her periods have been very unpredictable since coming off the pill—that was why she had taken so many pregnancy tests—and reports that when she does have periods they are very painful with heavy flow that can go on for weeks at a time.
Infertility does run in the family—Staci’s older sister had to have fertility treatments and was then able to carry twin girls to term. Staci is not sure which fertility interventions her sister underwent. In addition, Staci’s mom and a couple of maternal aunts have “the kind of diabetes that people take pills for” as well as high blood pressure.
Staci was an athlete in college (swimming) and still tries to exercise strenuously at least 3 times a week in the gym, but has gained about 20 pounds over the last couple of years.
Dr. Tibbett counsels Staci about doing additional laboratory workup to evaluate for the cause of her infertility. She gives urine and blood samples and makes an appointment for a uterine and ovarian ultrasound a few days later. At her ultrasound, samples of endometrial lining are taken for review by pathology.
|Lab||Patient value||Normal value|
|LH||25 mIU/ml||1-20 mIU/ml|
|FSH||10 mIU/ml||3-20 mIU/ml|
|Prolactin||20 ng/ml||<24 ng/ml|
|Fasting insulin||36 mIU/ml||<30 mIU/ml|
|Fasting Glucose||130mg/dL||70-120 mg/dL|
|Progesterone||1.0 ng/ml||<1.5 ng/ml|
|TSH||1.7 uIU/ml||0.4-4.0 uIU/ml|
|DHEAS 420 ug/dl||35-430 ug/dl|
|Androstenedione||1.5 ng/ml||0.7-3.1 ng/ml|
|17 Hydroxyprogesterone||50 ng/dl||20-100 ng/dl|
|SHBG||25 nmol/l||18-114 nmol/l|
|Testosterone(total)||40 ng/dl||6-86 ng/dl|
|Estradiol||27 pg/ml||25-75 pg/ml|
|Fasting Lipid Panel:|
|Triglycerides||230 mg/dl||30-150 mg/dl|
|Total Cholesterol||250 mg/dl||135-200 mg/dl|
|HDL||22 mg/dl||30-59 mg/dl|
|LDL||200 mg/dl||<200 mg/dl|
Two Hour Glucose Tolerance Test—serum glucose was 233 mg/dl
Random finger stick glucose in the office was 190 mg/dL
Transvaginal Ovarian Ultrasound: Bilateral ovarian enlargement with the left ovarian volume measured 30 milliliters and the right ovarian volume measuring 25 milliliters. Numerous (greater than 10) simple cysts are seen on both ovaries, ranging in size from 2 millimeters to 8 millimeters in diameter.
Pathologic examination of uterine biopsy: Proliferative endometrial lining is seen with some areas of endometrial hyperplasia is seen without atypia.
At follow-up, Dr. Tibbett explains the new diagnosis to Staci and recommends starting metformin, a diabetes medicine that can help with infertility related to this problem, daily to increase her chances of conception. She also recommends attempting modest weight loss of around 10 pounds total, recommending Weight Watchers as a supportive program to effect long-term weight loss and encourage continued healthy activity. She asks Staci to keep a diary of her menses and to follow up in three months. If Staci has not menstruated at that time, additional treatments will be tried to establish ovulatory cycles and increase the chances of conception.