Generic selectors
Exact matches only
Search in title
Search in content
Post Type Selectors
Search in posts
Search in pages
Filter by Categories
Abstract
Abstract Fertivision 2017
Case Report
Clinical Practice Guideline
Commentary
Edirorial
Editor's view point
Editorial
Editorial View Point
Fertivision 2015 - Abstracts
Guest Editorial
IFS pages
Letter to the Editor
Original Article
Original Research
PCOS Guideline
Point of View
Review Article
Generic selectors
Exact matches only
Search in title
Search in content
Post Type Selectors
Search in posts
Search in pages
Filter by Categories
Abstract
Abstract Fertivision 2017
Case Report
Clinical Practice Guideline
Commentary
Edirorial
Editor's view point
Editorial
Editorial View Point
Fertivision 2015 - Abstracts
Guest Editorial
IFS pages
Letter to the Editor
Original Article
Original Research
PCOS Guideline
Point of View
Review Article
View/Download PDF

Translate this page into:

Case Report
1 (
2
); 112-113
doi:
10.4103/2394-4285.162788

IUI in hypogonadotropic hypogonadism: Do not give up

Consultant and ART Specialist, ART Centre, Army Hospital (R&R), Delhi Cantt, New Delhi, India
HOD and ART Specialist, ART Centre, Army Hospital (R&R), Delhi Cantt, New Delhi, India
Address for correspondence: Dr. Seema Rai, Consultant and ART Specialist, ART Centre, Army Hospital (R&R), Delhi Cantt, New Delhi - 110010, India. E-mail: Seema73rai@hotmail.com
Licence

This is an open access journal, and articles are distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as appropriate credit is given and the new creations are licensed under the identical terms.

Disclaimer:
This article was originally published by Wolters Kluwer - Medknow and was migrated to Scientific Scholar after the change of Publisher.

Abstract

Ovulation is dependent on the presence of a functioning hypothalamic-pituitary-ovarian (HPO) axis. Estimates of chronic anovulation rates range from 6-15% of women during the reproductive years. Potential causes of anovulation are PCOS, hyperprolactinemia, thyroid dysfunction, stress etc. Idiopathic hypogonadotropichypogonadism (IHH) is rare cause of anovulation. Idiopathic hypogonadotropichypogonadism (IHH) is a collection of genetic mutations that result in delay of puberty, infertility, and low gonadotropins. Women with IHH have hypoestrogenism, amenorrhea, and low gonadotropin levels. Ovulation induction is the method for treating anovulatory infertility. For patients with hypogonadotrophichypogonadism, the treatment involves administration of both FSH and LH, while HCG is injected for follicle rupture. Such patients need high dosage and longer duration of stimulation than other patients.

Keywords

Hypogonadotropic hypogonadism (HH)
intrauterine insemination (IUI)
ovulation induction

INTRODUCTION

Hypogonadotropic hypogonadism (HH) has been classified by the World Health Organization (WHO) as a group 1 anovulation disorder.[1] HH is usually idiopathic with no anatomical lesions in the hypothalamo-pituitary tract[2] and is characterized by amenorrhea, hypoestrogenism, low serum gonadotropins, and a broad spectrum of abnormal secretion patterns of hypothalamic gonadotropin-releasing hormone (GnRH).[3,4]

Several etiologic factors have been described for idiopathic HH including intense or frequent exercise, weight loss, psychological stress, and psychological disturbances.[5,6,7,8]

In addition to being infertile, women with HH suffer from conditions associated with a low estrogenic milieu, including osteopenia.

Of all the causes of infertility, HH is the least common etiology. Patients in whom fertility is desired, induction of gonadotropin secretion by pulsatile GnRH or treatment with exogenous gonadotropin is the current treatment of choice.[9,10,11] The average treatment duration and the number of ampules used are higher compared with patients with other etiologies of infertility. This may be explained by the "dormant" ovaries that need to be primed before follicular response is achieved. Hence, the question arises about the dose from which to start stimulation and about when the lack of potential response can be defined.

We present a case that illustrates the concept that using a high human menopausal gonadotropin (hMG) dose for an unusually long time may be rewarding.

CASE REPORT

A 28-year-old lady was referred as a case of primary infertility with secondary amenorrhea for assisted reproductive technology (ART). Hypogonadotropic hypogonadism (HH) was diagnosed during the evaluation of secondary amenorrhea. Investigations revealed a small uterus with normal ovaries on laparoscopy, follicle-stimulating hormone (FSH) of 0.39 mIU/mL and luteinizing hormone (LH) of 0.74 mIU/mL and her serum prolactin and thyroid-stimulating hormone (TSH) to be within normal limits. Karyotype analysis revealed a pericentric inversion of chromosome 2 (estimated to occur in up to 1% of the population, probably without clinical relevance to HH). The patient was completely evaluated for the cause of adult-onset idiopathic HH but we could not come to any conclusion. Her body mass index (BMI) was low (weight: 36 kg; BMI: 15.2 kg/m2) and psychogenic stress could not be ruled out. Before her referral, repeated attempts of ovulation induction were attempted in the last 5 years. All inductions were cancelled due to nonresponsiveness of the ovaries. The patient's husband had a sperm concentration of 60 million/mL with a progressive motility (PR) of 50%. The patient was started on human menopausal gonadotropin (hMG) injection at a dosage of 75 IU/day on the second day of her menstrual cycle and the dose was gradually increased to a maximum of 225 IU/day. She received a total dose of 3,750 IU over 18 days. A single follicle of 1.9 cm developed on the right side and the endometrial thickness was 8 mm. Ovulation was triggered with 10,000 IU of human chorionic gonadotropin (hCG) and intrauterine insemination (IUI) was done 36 h later. IUI resulted in a singleton clinical pregnancy.

DISCUSSION

The prognosis of inducing ovulation in patients of HH is favorable though they require high doses of hMG. The baseline FSH and LH values do not predict an individual patient's response to hMG. The patient's response can be judged only after the patient is subjected to stimulation by ultrasonography (USG).

An unfavorable response to hMG stimulation was achieved in our patient prior to ovulation induction protocol due to the low dose of hMG.

We should know how high a dose of hMG to give and for how long to give this dose before we give up. In a patient of HH after head trauma, Ferrari and Crosignani[12] used massive doses of hMG therapy before giving up. Our current case report clearly illustrates that in these specific groups of patients, it is worthwhile to go to extremes with regard to treatment duration and dose. In patients with HH, the threshold for ovarian response may differ substantially from one patient to another.

In one case report by Dragojevic et al.,[13] hMG injection was used for follicular development in a 38-year-old patient of HH with empty sella syndrome that led to the formation of two follicles and after IUI, resulted in a successful singleton pregnancy and subsequent live birth.

In another case report, successful twin pregnancy was achieved in a 36-year-old patient of primary HH with empty sella syndrome after using recombinant FSH and LH.[14]

We conclude that patients with HH undergoing ovarian stimulation for in vitro fertilization (IVF) should be carefully assessed, on a trial and error basis, for ovarian response before we give up.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

REFERENCES

  1. . Induction of Ovarian Follicle Development and Ovulation with Exogenous Gonadotropins. Practice Committee Report. In: A Technical Bulletin. Birmingham, Alabama, USA: American Society for Reproductive Medicine; . p. :1-12.
    [Google Scholar]
  2. , , . Hypogonadotropic hypogonadism. Semin Reprod Med. 2002;20:327-38.
    [Google Scholar]
  3. , , , , . Pulsatile gonadotropin secretion in women with hypothalamic amenorrhea: Evidence that reduced frequency of gonadotropin-releasing hormone secretion is the mechanism of persistent anovulation. J Clin Endocrinol Metab. 1985;61:851-8.
    [Google Scholar]
  4. , , . Neuroendocrine abnormalities in hypothalamic amenorrhea: Spectrum, stability, and response to neurotransmitter modulation. J Clin Endocrinol Metab. 1999;84:1905-11.
    [Google Scholar]
  5. . Sex steroid metabolism and menstrual irregularities in the exercising female. A review. Sports Med. 1988;25:369-406.
    [Google Scholar]
  6. , , , . Alternate-day GnRH therapy for ovarian hypofunction induced by weight loss: Treatment of six patients who remained amenorrhoeic after weight gain. Clin Endocrinol (Oxf). 1993;39:641-8.
    [Google Scholar]
  7. , , , . Adult-onset amenorrhea: A study of 262 patients. Am J Obstet Gynecol. 1986;155:531-43.
    [Google Scholar]
  8. , , , . Psychological, hormonal, and weight disturbances in functional amenorrhea. Can J Psychiatry. 1983;28:624-8.
    [Google Scholar]
  9. , , . Pregnancy in women with Kallmann′s syndrome. Fertil Steril. 1995;63:494-9.
    [Google Scholar]
  10. , , , , , . Isolated hypogonadotropic hypogonadism: Induction of ovulation with exogenous gonadotropins. Fertil Steril. 1977;28:535-40.
    [Google Scholar]
  11. , , , . Results of ovulation induction using human menopausal gonadotropin or purified follicle-stimulating hormone in hypogonadotropic hypogonadism patients. Fertil Steril. 1991;56:1048-53.
    [Google Scholar]
  12. , . Ovarian failure without gonadotropin elevation in patient with post-traumatic isolated hypogonadotropic hypogonadism. Eur J Obstet Gynecol Reprod Biol. 1986;21:241-4.
    [Google Scholar]
  13. , , , , . Pregnancy using gonadotropins and performing intrauterine insemination in a woman with hypogonadotropic hypogonadism. Am J Reprod Immunol. 2006;55:164-7.
    [Google Scholar]
  14. , , . Twin pregnancy using recombinant gonadotropins in a woman with hypogonadotropic hypogonadism. Gynecol Endocrinol. 2002;16:27-32.
    [Google Scholar]
Show Sections