A twenty-two years infertile patient was referred to us from west of Sudan as a case of primary amenorrhea and infertility. She was married to a 30 years-old healthy Sudanese man, a farmer, for 5 years and they have normal marital relationship. Examination revealed that the patient was obese, a well feminized female with normal secondary sex characters, hirsutism, and acne. Her Body Mass Index (BMI) was 30 kg/m2.No abnormalities were detected in abdominal as well as breast examination. Per vaginal (PV) examination revealed normal vagina, anteverted uterus, and free adnexae. Seminal analysis was normal, hormonal profile revealed normal level of LH and FSH and high prolactin level. Fasting blood sugar was within the normal range (85 mg/dl).Ultrasound revealed normal empty anteverted uterus, and polcystic ovaries(PCO) . PCO., which is commonly diagnosed by means of 12 or more 2-9mm follicles, or increased ovarian volume (> 10 cm
3)as shown in Figure 1.So we advised the patient to reduce her weight and change her life style.6months later there was no menstruation or pregnancy. Laparoscopywas performed. The laparoscopic findings revealed a normal sized anteverted uterus. and PCO, Pelvic adhesions, per tubal, per ovarian, massive pelvic adhesions, frozen pelvis, per portal adhesions and endometriosis were not found, her tubes were patent, confirmed with free spillage of methylene blue dye from the fimbrial ends. At laparoscopy, PCO look. The white capsules of the ovaries are thickened and the ovaries are often very rounded. The ovaries were punctured on 4 points with electro cautery (as shown in Figure 2) and then clomifene and metformin were prescribed for 6 months, with follow-up regarding her cycle and pregnancy. After 3 months of follow-up no menstruation or pregnancy wasreported.3 months after that the patient was proved to be pregnant. Her pregnancy was passed uneventful and she delivered a full term male baby alive and well vaginally. 6 weeks after delivery, she experienced her first menstrual cycle. PCOS is one of the most common female endocrine disorders. PCOS is a complex, heterogeneous disorder of uncertain etiology. Its symptoms occur in approximately 5% to 10% of women of reproductive age (12-45 years old) ranging from anovulation, obesity, biochemical or clinical hyper androgenism and insulin resistance. The World Health Organization criteria for classification of anovulation include the determination of oligomenorrhea (menstrual cycle > 35 days) or amenorrhea (menstrual cycle > 6 months) in combination with concentration of prolactin, FSH and estradiol. PCOS is the most common cause of anovulation in women with normal serum FSH and estradiol levels ( 10). Despite the heterogeneity in symptoms associated with PCOS, the essential feature is arrested follicular development at the stage when selection of the dominant follicle should normally occur ( 11). In a normal menstrual cycle, one egg is released from a dominant follicle-essentially a cyst that bursts to release the egg. After ovulation the remnantfollicle is transformed into a progesterone-producing corpus luteum, which shrinks and disappears after approximately 12-14 days. In PCOS, there is a so-called "follicular arrest", i.e., several follicles develop to a size of 5-7 mm, but not further. No single follicle reaches the preovulatory size (16 mm or more). The small ovarian follicles are believed to be the result of disturbed ovarian function resulting in failed ovulation, reflected by the infrequent or absent menstruation that is typical of the condition with normal LH level.
Figure 1. Ultrasound Picture of PCO
Figure 2. Laparoscopic Picture of PCO and Drilling
The principal features of PCOS are anovulation, resulting in irregular menstruation, amenorrhea, ovulation-related infertility, and polycystic ovaries. The main features of our patient, including primary amenorrhea, infertility and ultrasound (U/S) report, as well as laparoscopy confirmed the diagnosis of PCO. The patient had alsoacne and hirsutism; resulting from excessive amounts of androgenic hormones. Women with PCOS have an increased risk of developing type 2diabetes. However, before the onset of diabetes, the blood sugar is usually under control. Our case had also normal fasting blood sugar (85mg/dl). As such, it is normal for a woman with PCOS to have a fasting blood sugar of 85 to 100 mg/dL, which lies within the normal range of less than 100 mg/dL (
The chance of becoming pregnant depends on how often the patient ovulates. Some women with PCOS ovulate now and then, others not at all. Metformin is a drug that is commonly used to treat type 2 diabetes. It makes the body's cells more sensitive to insulin (
10). This may result in a decrease in the blood level of insulin which may help to counteract the underlying cause of PCOS and then increase the chance of ovulation. The United Kingdom's National Institute for Health and Clinical Excellence recommended in 2004 that women suffering from PCOS with a BMI above 25 be given metformin when other therapy has failed to produce preferable results ( 13). The patient was not menstruate or conceived after diet, lifestyle and clomiphene therapy; so she underwent laparoscopy and ovarian drilling followed by clomiphene and metformin.by means of this treatment, the patient usually regains their cycle and ovulation as the drilling decreases the level of androgen( 9).Our patient also conceived and regained her cycle after her delivery.
Clinicians in Sudan must consider PCOS as an important cause of primary amenorrhea & a common cause of primary infertility.