#331 CASE SUMMARY

Privacy Protected Case Summary

Understanding Secondary Infertility in a 23-Year-Old Woman — Irregular Cycles and Prior Missed Abortion

About the Couple

Patient Age:

23 Y/F years

Location:

Bangalore, Karnataka

Duration of Infertility:

<no_data>

Key Clinical Finding:

Discharge summary notes secondary infertility for DHL with irregular cycles (LMP 8/02/2025) and BP 130/98 mmhg, PR 86 bpm.

Report Type:

Discharge Summary

Comparison of Treatment Recommendations

What you were told

<no_data>

What we recommend

<no_data>

What you were told

<no_data>

What we recommend

<no_data>

Expert Interpretation

This discharge summary describes secondary infertility for “DHL” along with an irregular menstrual cycle (bleeding 3–5 days; last menstrual period LMP 8/02/2025). It also records BP 130/98 mmHg and pulse 86 bpm. The available information does not include a detailed fertility workup, hormone or imaging results, or specific treatment plan beyond prior noted history. In general, irregular cycles can make ovulation less predictable, which may contribute to difficulty conceiving; clinicians typically evaluate cycle patterns and underlying causes and may adjust treatment accordingly.

Previous Consultation

Treating Surgeon and Hospital

Dr Humerunisa,
OB/GYN

Medical Background

The Patien's records document the following relevant history:

  • Menstrual history: Irregular cycle with bleeding lasting for 3–5 days; LMP-8/02/2025.
  • Pregnancy history: ML-3yrs, NCM; A1-Nov-2022 missed abortion; medical MTP done; OI conception; Tab Novelon 0-0-1 x 21 days from D3(10/2/2025); Tab D rise weekly twice.
  • Existing/surgical history: <no_data>.

Key Findings From the Report

Diagnosis / Fertility concern:

PARAMETER

FINDING

Diagnosis

Secondary infertility for DHL

Secondary infertility for DHL is documented in the discharge summary.

Symptoms and reproductive history:

PARAMETER

FINDING

Chief Complaint

Anxious to conceive

Obstetric History

ML-3yrs, NCM; A1-Nov-2022 missed abortion; medical MTP done; OI conception

Treatment/Medication History (as stated in obstetric history)

Taken Tab Novelon 0-0-1 x 21 days from D3(10/2/2025); Tab D rise weekly twice

Chief complaint and obstetric history describe desire to conceive and prior pregnancy outcomes.

Menstrual pattern:

PARAMETER

FINDING

Menstrual History

Irregular cycle with bleeding lasting for 3-5 days; LMP-8/02/2025

Menstrual history shows irregular cycles with a specified last menstrual period.

Vital signs at discharge:

PARAMETER

FINDING

General Physical Examination

Afeverile

Blood Pressure (BP)

130/98 mmhg

Pulse Rate (PR)

86 bpm

General physical exam notes the patient was afebrile; BP and pulse are recorded.

Allergies and family/past history:

PARAMETER

FINDING

Allergies

NIL

Past History

NS

Family History

NS

Allergies are nil and family/past history are recorded as not significant or not specified.

Treatment and Procedures Performed

Medical MTP

<no_data>

<no_data>

Tab Novelon (as part of treatment history)

<no_data>

<no_data>

Tab D rise (as stated)

<no_data>

<no_data>

Questions Patients Often Ask

What does “secondary infertility” mean?

Secondary infertility means difficulty getting pregnant again after a prior pregnancy. In this summary, the diagnosis is documented as secondary infertility for DHL.

How can irregular periods affect fertility?

Irregular cycles can make ovulation less predictable. This discharge summary notes an irregular cycle with bleeding lasting 3–5 days and an LMP of 8/02/2025.

Is there information about a specific fertility treatment plan?

The document includes treatment/medication history (e.g., medical MTP for a missed abortion and prior use of Tab Novelon and Tab D rise), but it does not provide a detailed current fertility workup or an explicit treatment plan.

What were the recorded vital signs in the discharge summary?

The summary records BP 130/98 mmHg and pulse 86 bpm, and notes the patient was afebrile.

Who was consulted for this case?

The discharge summary lists consultation with Dr Humerunisa (OB/GYN).

What This Means for the Patient

  • You are documented as having secondary infertility for DHL, along with irregular menstrual cycles.
  • Your recorded last menstrual period (LMP) is 8/02/2025, and bleeding lasted 3–5 days—this irregular pattern can affect the timing of ovulation.
  • The summary records BP 130/98 mmHg and pulse 86 bpm, which may be important for overall health while pursuing fertility care.
  • The available document does not include detailed test results (hormones/imaging) or a full current infertility treatment plan, so further evaluation may be needed.

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