Adenomyosis, Endometriosis, Poor ovarian reserve and finally pregnancy.

Patient: Mrs. NC, 34 years old
Marital Status: Married for 8 years
Infertility: Secondary infertility, no living children
Previous History:

• Biochemical pregnancy with self IVF
• Failed IVF cycle with ovum donation at another center
• Laparoscopy performed previously for removal of bilateral chocolate cysts and adhesiolysis
• No living issues

Clinical Presentation:

• Normal BMI
• Vitals: Stable
• Per abdominal examination: Soft and non-tender
• P/S examination: Hypertrophied cervix with severe erosion (history of spotting and severe white discharge post-transfer in previous cycles)

Investigations:

• First USG: Adenomyotic uterus with recurrent bilateral endometriomas, nil antral follicle count
• AMH level: 0.32 ng/ml
• Husband’s semen analysis: Normal

Management:

• The patient was counselled regarding adenomyosis and recurrent endometriomas.
• Treatment options given:
  1. Ovum donation
  2. Self IVF
• The patient opted for ovum donation and declined self IVF.

Treatment Protocol:

1. Leuprolide Depot: First dose of 3.75 mg given; followed by two more doses at monthly intervals.
2. Hysteroscopic Evaluation: TBPCR testing and PAP smear with HPV DNA were done, all reports came back normal.
3. Donor Recruitment: A donor was recruited, and embryos were frozen.
4. Cervical Erosion Treatment: Treated for cervical erosion.
5. Endometrial Preparation: After the third dose of Leuprolide, endometrial preparation was done.
6. Embryo Transfer: Two good blastocysts were transferred. Luteal phase support was provided using injectables, avoiding vaginal medicines.

Outcome:

• HCG (10 days after transfer): 590 mIU/ml
• The patient had an uneventful pregnancy and delivered a 3.01 kg baby boy via LUCS (lower uterine caesarean section).

Summary:

She opted for a donor cycle again and, after transferring two good blastocysts, she had an uneventful pregnancy and delivered a healthy 3.01 kg baby boy via LUCS.

The patient had severe adenomyosis with grade 4 endometriosis, with normal reports from her husband.

She had poor ovarian reserve, with previous failed self and donor cycles.