Infertility - Clinical Case

Question 1

30 year old, BMI 19 kg/m2, amenorrhoea for 6/12, runs daily to help with stress at work, training for London Marathon:
* Oestradiol: < 70pmol/L (undetectable)
* LH: 0.5 U/L (2 – 14)
* FSH: 0.8 U/L (1.5 – 10)
* Prolactin: 300mU/L (100 – 500)

What is the diagnosis?

Answer 1

• Acquired hypogonadotrophic hypogonadism (not prolactinoma) -> probably low BMI / XS exercise / stress induced

Question 2

30 year old, BMI 19 kg/m2, amenorrhoea for 6/12, runs daily to help with stress at work, training for London Marathon:
* Oestradiol: < 70pmol/L (undetectable)
* LH: 0.5 U/L (2 – 14)
* FSH: 0.8 U/L (1.5 – 10)
* Prolactin: 300mU/L (100 – 500)

What treatment would you suggest to improve fertility?

Answer 2

Behavioural changes:
* Reduce exercise
* Increase body weight
* Cognitive behavioural therapy
Pulsative GnRH pump
LH & FSH injections

Question 3

30 year old, BMI 30kg/m2, has gained weight over last 3 years. Oligomenorrhoea for 1 year. Acne and hirsutism particularly problematic over the last year too:
* Oestradiol: 150pmol/L (50-800)
* LH: 6 U/L (2 – 14)
* FSH: 3 U/L (1.5 – 10)
* Testosterone: 3 nmol/L (< 1.8)

What is the diagnosis?

Answer 3

Polycistic Ovary Syndrome (PCOS)

Question 4

30 year old, BMI 30kg/m2, has gained weight over last 3 years. Oligomenorrhoea for 1 year. Acne and hirsutism particularly problematic over the last year too:
* Oestradiol: 150pmol/L (50-800)
* LH: 6 U/L (2 – 14)
* FSH: 3 U/L (1.5 – 10)
* Testosterone: 3 nmol/L (< 1.8)

What treatment would you suggest to aid fertility?

Answer 4

Give:
* Lose weight / Exercise to promote fertility
* Metformin - insulin stimulates androgens in the ovaries

Cannot give:
* Anti-androgens (Spironolactone) cannot be used bcs it is contrraindicated with pregnancy

Question 5

40 y old, BMI 24kg/m2, amenorrhoea for 6/12, previously regular periods, no acne, hirsutism, galactorrhoea:
* Oestradiol: < 70pmol/L (undetectable
* LH: 30 U/L (2 – 14)
* FSH: 24 U/L (1.5 – 10)
* Prolactin: 300mU/L (100 – 500)

What is the diagnosis?

Answer 5

Premature ovarian insufficiency (POI)

Question 6

40 y old, BMI 24kg/m2, amenorrhoea for 6/12, previously regular periods, no acne, hirsutism, galactorrhoea:
* Oestradiol: < 70pmol/L (undetectable
* LH: 30 U/L (2 – 14)
* FSH: 24 U/L (1.5 – 10)
* Prolactin: 300mU/L (100 – 500)

What treatment would you suggest to improve fertility?

Answer 6

• IVF could be a solution, but very unlikely
• Check anti mullerian hormone level to see egg reserve

Treat symptoms:
* Progesterone if the womb is still intact, to avoid cancer
* Oestrogen to treat symptoms, such as oesteoporosis

Question 7

30 yearold, BMI 24kg/m2. Amenorrhoea for 6/12. Previously regular periods. Galactorrhoea. Recent visual disturbance:
* Oestradiol: < 70pmol/L (undetectable)
* LH: 0.5 U/L (2 – 14)
* FSH: 0.5 U/L (1.5 – 10)
* Prolactin: 30, 000mU/L (100 – 500)

What is the diagnosis?

Answer 7

Prolactinoma

Question 8

30 yearold, BMI 24kg/m2. Amenorrhoea for 6/12. Previously regular periods. Galactorrhoea. Recent visual disturbance:
* Oestradiol: < 70pmol/L (undetectable)
* LH: 0.5 U/L (2 – 14)
* FSH: 0.5 U/L (1.5 – 10)
* Prolactin: 30, 000mU/L (100 – 500)

What treatment would you suggest to aid fertility?

Answer 8

• Dopamine receptor agonists (Cabergoline) -> dopamine inhibits prolactin secretion (pramipexole, ropinirole)

Question 9

30 year old, BMI 24kg/m2. Regular periods:
* Oestradiol: 150pmol/L (50-800)
* LH: 3 U/L (2 – 14)
* FSH: 3 U/L (1.5 – 10)
* Prolactin: 300mU/L (100 – 500)

What is the diagnosis?

Answer 9

• Male factor infertility (sperm sample)
• Fibroids within the endometrium
• Womb (hostile womb) or fellopian tube (ectopic pregnancy) related -> ultrasound with bubble water (hycosi)

Question 10

30 year old, BMI 24kg/m2. Regular periods:
* Oestradiol: 150pmol/L (50-800)
* LH: 3 U/L (2 – 14)
* FSH: 3 U/L (1.5 – 10)
* Prolactin: 300mU/L (100 – 500)

What treatment would you suggest to aid fertility?

Answer 10

• Locate the cause
• Try IVF
• Adoption