Question

A 37-year-old G2P1 comes to the clinic with her husband due to the inability to conceive for the last year. She reports being in good health and not having problems with her prior pregnancy two years ago, except for some postpartum depression for which she was placed on Imipramine and which she continues to take. She took birth control pills after her pregnancy and stopped one year ago, when she began trying to conceive. Her periods were regular on the pills, but have been irregular since she stopped taking them. She has no history of sexually transmitted infections or abnormal Pap smears. Her husband is also healthy and he fathered their first child. Her physical examination is completely normal. Laboratory tests show: Results Normal Values TSH 2.1 mIU/ml 0.5-4.0 mIU/ml Free T4 1.1 ng/dl 0.8-1.8 ng/dl Prolactin 60 ng/ml <20 ng/ml FSH 6 mIU/ml 5-25 mIU/ml LH 4 mIU/ml 5-25 mIU/ml What is the most appropriate next step in the management of this patient's subfertility?

A. Begin bromocriptine
B. Ovulation induction with clomiphene citrate (Clomid)
C. Wean off imipramine
D. Perform a visual field examination
E. Obtain a brain MRI

Answer 1

The elevated prolactin level suggests that the most appropriate next step in managing the patient's subfertility is to begin bromocriptine, which is a medication that can lower prolactin levels and potentially restore ovulation.

Step-by-step explanation:

The case of a 37-year-old G2P1 experiencing subfertility points out a key abnormality in her laboratory results: her prolactin level is elevated at 60 ng/ml, which is above the normal value of less than 20 ng/ml. This high level of prolactin can inhibit ovulation, leading to irregular menstrual cycles and subfertility. Considering the patient's symptoms and lab results, the most appropriate next step in managing this patient's subfertility would be A. Begin bromocriptine. Bromocriptine is a dopamine agonist that can help to lower prolactin levels, thus potentially restoring normal ovulatory cycles and improving chances of conception.

It is important to note that while imipramine, a tricyclic antidepressant that the patient continues to take, may cause side effects, there's no indication from the question that this medication is contributing to the subfertility, hence C. Wean off imipramine is not the immediate step. Moreover, there is no mention of symptoms that would indicate a visual field defect, so D. Perform a visual field examination, and E. Obtain a brain MRI would be less likely next steps without such evidence. The use of ovulation induction with clomiphene citrate (Clomid) might be an option if the prolactin levels were normal and if there was evidence of anovulation, but that is not the case here based on the abnormal prolactin levels.