Secondary Infertility Due To Premature Ovarian Failure..

History
A 37-year-old woman is seen in the clinic because of  secondary infertility. She had a daughter 13 years ago and a miscarriage 2 years later. She separated from her former husband and has now married again and is keen to conceive, especially as her new partner has no children.
Her last period started 45 days ago. She says that her periods are sometimes regular but at other times she has missed a period for up to 3 months. The bleeding is moderate and lasts up to 4 days. There is no history of pelvic pain or dyspareunia, and no irregular bleeding or discharge.
There is no medical history of note and she takes no regular medication.
Her partner is 34 years old and is also fit and healthy with no significant history of ill-health or medications.

Examination
There are no abnormal features on examination of either partner.

Investigations:
Day 3 follicle-stimulating hormone (FSH) = 11.1 IU/L ( normal on day 2-5 = 1–11 IU/L)
Prolactin = 305 mu/L (normal = 90–520 mu/L)
Day 21 progesterone = 23 nmol/L ( >30nmol/L if ovulation occurs)

Semen analysis report: normal volume, count, normal forms and motility.

Hysterosalpingogram report: the uterine cavity is of normal shape with a smooth regular outline. Contrast medium is seen to fill both uterine tubes symmetrically and free spill of dye is confirmed bilaterally.

Transvaginal ultrasound scan report: the uterus is anteverted with no congenital abnormalities, uterine fibroids or polyps visualized. Both ovaries are of normal morphology, volume and mobility. No follicles are noted.

Questions
• What is the cause of the infertility?
• What are the further investigation and management options?

Answers And Discussion


Women with irregular periods often do not ovulate. Anovulation in this case is confirmed by the low day 21 progesterone level. The commonest cause of anovulation is polycystic ovaries, but in this case the ovaries show normal morphology and the androgen levels are normal.
The noticeable abnormality is the high FSH level and the fact that no follicles are visualized at ultrasound scan. This is suggestive of anovulation from premature failure of ovarian function. The woman is not menopausal because she still has periods although irregular, and the FSH is only marginally raised. However it is known that FSH levels above 10 IU/L are associated with a poor prognosis for conception using the woman’s own ova.

Further investigation.
The FSH should be repeated, as it is possible that this could be a sporadic result or poorly timed sample, and therefore confirmation is needed before continuing on to treatment.

Management
As there is such a poor prognosis for conception either naturally or with in vitro fertilization using the woman’s own ova, she should be counselled and if acceptable may be given an option of donor eggs, or adoption .

Counselling issues for this couple
• Psychological:
• the woman may feel that her ovaries are ‘ageing’ prematurely and this may have an affect on her self-esteem and sexuality
• the stress associated with assisted conception is significant and many couples find that this in itself puts a large burden on their relationship.
• Funding: public funding may not be available as the woman already has one child.
• Consideration of alternative options: adoption, surrogacy and accepting childlessness should be explored with the couple.

Key Points In This Case:
• FSH above 10 IU/L is associated with poor prognosis for fertility.
• Infertile couples should be encouraged to explore all options, including accepting childlessness and adoption as well as assisted conception techniques.