Intended for healthcare professionals

Endgames Case Report

Investigating infertility

BMJ 2009; 339 doi: (Published 09 September 2009) Cite this as: BMJ 2009;339:b3390
  1. Vaidyanathan Gowri, assistant professor, obstetrics and gynaecology,
  2. Rajeev Jain, associate professor, radiology
  1. 1Sultan Qaboos University, PO Box 35, 123, Muscat, Oman
  1. Correspondence to: V Gowri gowrie61{at}

    A 23 year old woman was referred to the infertility clinic for subfertility and an ovarian tumour. She had been married for two years and reported having irregular periods every two or three months. She also had a history of mild dysmenorrhoea. She reported having gained 16 kg after marriage and developing excess growth of fine hair all over her body and face. She did not have galactorrhoea, acne, altered appetite, or thyroid symptoms. Apart from treatment for infertility (ovulation induction with clomifene citrate) her medical history was unremarkable. There was no family history of diabetes or hypertension.

    On examination she was moderately built with a body mass of index of 26 and normal secondary sexual characters. She had a slight excess of fine hair on her face and abdomen. Examination of the breasts and thyroid was normal. No masses were found on examination of the abdomen, and on bimanual examination the uterus was normal with no adnexal masses.

    A routine transvaginal scan in the outpatient clinic showed bilateral polycystic ovaries with a 4 cm complex cystic lesion in the left ovary (possibly a dermoid cyst) and minimal free fluid in the pouch of Douglas.


    • 1 How would you approach this consultation?

    • 2 What imaging investigations would be useful?

    • 3 Would metformin help improve her fertility?


    Short answers

    • 1 Investigate infertility by taking a detailed history for both partners and performing semen analysis in the man. In the woman, irregular menstrual cycles, hirsutism, and suspected polycystic ovaries warrant hormonal investigations. Measure follicle stimulating hormone, luteinising hormone, testosterone, thyroid function, and prolactin to establish the cause of irregular periods. …

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