A 34-year-old nulligravid woman comes to clinic complaining of difficulty getting pregnant for the past 15 months. The woman reports that her menses have always been irregular. The woman has a BMI of 31 and hirsutism on physical exam. What is the most likely cause of infertility in this patient?

24 year old married obese girl with this classical finding on USG. patient is planning a child. lets discuss management and diagnosis

Associated Conditions Obesity (See Diet: Obesity.) Infertility (see topic) Hirsutism (see topic) Acne Endometrial hyperplasia and cancer (See Endometrial Hyperplasia and Endometrial Cancer.) Depression Sleep disorders (see topic) Hypertension (see topic) Insulin resistance DM Type 2 Metabolic syndrome (see topic) Cardiovascular disease ------------------------------------------ Diagnosis Signs and Symptoms History Oligo-ovulation: Amenorrhea (see chapter) Oligomenorrhea (See Bleeding, Abnormal Uterine: Oligomenorrhea.) Menorrhagia/Heavy bleeding (See Bleeding, Abnormal Uterine: Heavy Menstrual Bleeding.) Midline hair growth, acne, hair thinning or loss, voice changes Infertility, desire for fertility History of gestational DM or HTN Overweight/Obesity/Weight gain Family history DM or cardiovascular disease Individual goals for treatment Review of Systems Mood, appetite, energy, sleep Weight and diet ------------------------------------------ Physical Exam BP, pulse, height, weight, BMI, waist circumference, hip circumference, waist:hip ratio Thyroid: Nodules, enlargement Skin: Acanthosis nigricans, acne, hirsutism, balding, skin tags Breast: Galactorrhea Abdomen: Masses or organomegaly Extremities: Edema, DTRs GU: Clitoromegaly, adnexal masses Tests Rotterdam Criteria (2/3 with other causes of hyperandrogenism excluded): Oligo- or anovulation Clinical and/or biochemical signs of hyperandrogenism PCO (on US) Labs Pregnancy test Clinical criteria may be sufficient, with labs to rule out other causes TSH, Free T4, prolactin, DHEAS, total testosterone, 17-hydroxyprogesterone Fasting lipids, glucose and 2-hour GTT after 75-gm load No longer considered useful: LH:FSH ratio (pulsatile, can be normal in PCOS) Fasting glucose:insulin ratio (can miss glucose tolerance aberrations) Imaging TVU: >12 antral (<10 mm) follicles on a single ovary or ovarian volume >10 cm3 Endometrial thickness Differential Diagnosis Pregnancy Prolactinoma Thyroid dysfunction (See Thyroid Disease.) Androgen-secreting tumor (See Ovarian Tumors, Virilizing.) Adrenal enzyme defect: Late onset CAH (See Congenital Adrenal Hyperplasia.) Cushing's disease Metabolic/Endocrine Impaired fasting glucose (IFG): >100 mg/dL Impaired glucose tolerance (IGT): 2-hour glucose >140 mg/dL DM: Glucose fasting >126 mg/dL or 2-hour >200 mg/dL Metabolic syndrome (3 or more of): WC >85 cm (35 in) IGT or IFG SBP ≥140 mm Hg or DBP ≥85 mm Hg Triglycerides ≥150 mg/dL HDL cholesterol <50 mg/dL Tumor/Malignancy Risk of endometrial hyperplasia and malignancy Consider endometrial biopsy: US EC >9 mm <2 menses/year ========================== Treatment General Measures If overweight or obese: 5–10% weight loss to improve ovulation, hirsutism, fertility, pregnancy safety Calorie restriction, 30 minutes of vigorous exercise 5 times a week If IGT, lifestyle modification better than medication at preventing DM and metabolic syndrome Medication (Drugs) Endometrial protection: OCPs (monitor lipids and BP) or progestin withdrawal every 3–4 months Hirsutism control (try modalities for 6 months) OCPs Antiandrogens (use contraception) Spironolactone 100–200 mg/d (monitor electrolytes) Flutamide 130–500 mg/d (hepatotoxicity) Eflornithine cream (Vaniqa): b.i.d. only on face Rosiglitazone (4–8 mg/d): Mild improvement: Monitor electrolytes, kidney, liver function ± Weight gain (water retention) P.159 Metabolic (controversial for adolescents): Metformin HCl 1,500 mg–2,000 mg/d for prevention of DM and metabolic syndrome if IGT: Nausea, diarrhea, fatigue, ± weight loss; start 500 mg and increase slowly Rare-lactic acidosis; Monitor electrolytes, liver, kidney every 6–12 months Hold drug for surgery or contrast dye Pregnancy Considerations Ovulation Induction with timed intercourse, intrauterine insemination, or IVF Insulin sensitizers, alone or with clomiphene: Metformin 1,500 mg/d (Category B): May improve miscarriage rate if continued during pregnancy (but studies are small) Rosiglitazone 4–8 mg/d (Category C) Clomiphene citrate, 50–200 mg/d, 4–6 cycles: Cycle days 3–7 or 5–9 Alone or with insulin sensitizer 8–10% multiple pregnancy rate Vasomotor effects, visual symptoms (d/c) Aromatase inhibitors (Letrozole): 5 mg/d, 4–6 cycles (use instead of clomiphene controversial) Gonadotropin injections, FSH or LH: 20–30% multiple pregnancy rate Higher risk of ovarian hyperstimulation syndrome Surgery Ovarian drilling/diathermy via laparoscopy: Similar live birth rates to gonadotropin injections Temporary (6 months) spontaneous ovulation Risk of adhesion formation

27 year old female presented with infertility and amenorrhea. She has undergone a pelvic ultrasound scan. Images are shown below.

MY RESEARCH ARTICLE PUBLISHED IN INTERNATIONAL JOURNAL OF MEDICAL SCIENCES.. HAIR-AN SYNDROME WITH PCOS AND HASHIMOTOS THYROIDITIS: (CITE FULL ARTICLE : Kulkarni A, Srivastav SK, Susarla S, Kulkarni U, Ashok Kumar C, Chikkala S, Tabassum SM. Hyperandrogenism-insulin resistance- acanthosis nigricans syndrome with PCOS and Hashimoto’s thyroiditis: case report. Int J Res Med Sci 2015;3:2514-23.) Female hyperandrogenism is a frequent motive of consultation. It is revealed by hirsutism, acne or seborrhea, and disorders in menstruation cycle combined or not with virilisation signs. Several etiologies are incriminated but the hyperandrogenism-insulin resistance-acanthosis nigricans syndrome is rare. A 21-year female, having had a three- year-old secondary amenorrhea, known case of hypothyroidism since 4 years on medication. The exam revealed a patient, hypertensive with blood pressure at 170/110 mmHg with a Body Mass Index (BMI) at 40.08 (Obese Class-3, as per WHO 2004) and a waist measurement of 106cm, a severe hirsutism assessed to be 27 according to Ferriman and Gallwey scale, acanthosis nigricans behind the neck and elbows. The assessment carried out revealed testosteronemia at 1.07 ng/mL, which is more than twice the upper normal of the laboratory. Imaging studies revealed enlarged right adrenal gland, hepatomegaly with fatty infiltration of grade-1 also bilateral polycystic ovaries. The retained diagnosis is HAIR-AN syndrome with polycystic ovaries, hypertension, type-II diabetes mellitus, hypothyroidism since last 4-years and dyslipidemia and was provided with metformin 500 mg thrice daily, spironolactone 25 mg twice daily, atorvastatin 20 mg once daily, telmisartan 20 mg once daily with continuation of eltroxin 50 Mcg for hypothyroidism. To our knowledge this is the first case report of HAIR-AN syndrome in 21 year old female associated with Hashimoto’s thyroiditis, dyslipidaemia, hypertension and type-2-diabetes and this case also highlights about early diagnosis and management of HAIR-AN Syndrome with PCOS and Hashimoto’s thyroiditis which could help prevent long-term sequalae such as cardiovascular disease and endometrial cancer and with the advent of knowledge and availability of health resources we can prevent long-term adverse effects (threefold) on health of women. This woman should be observed for these ailments in later life.