Case 5: Infertility

 

Case 5: Infertility

CASE 5: INFERTILITY

History

A 37-year-old woman is seen in the clinic because of infertility. She is gravida 2 para 1 having 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

for up to 4 days. There is no history of pelvic pain or dyspareunia, and no irregular bleeding

or discharge. Alcohol intake is minimal and she does not smoke or take other drugs. 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 (DURING THE NEXT MENSTRUAL CYCLE)

Normal range

Day 3 follicle-stimulating hormone (FSH) 11.1 IU/L Day 2–5

1–11 IU/L

Day 3 luteinizing hormone 6.8 IU/L Day 2–5

0.5–14.5 IU/L

Prolactin 305 mu/L 90–520 mu/L

Testosterone 1.3 nmol/L 0.8–3.1 nmol/L

Day 21 progesterone 23 nmol/L

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?100 Cases in Obstetrics and Gynaecology

12

ANSWER 5

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.

Anti-Mullerian hormone (AMH) is a further test of ovarian reserve and ovarian responsiveness in women with infertility. It decreases with number of ovarian antral follicles and it can

be used to predict likelihood of ovarian response and pregnancy with assisted conception.

Optimal fertility is associated with AMH levels of 28–48 pmol/L, whereas levels less than 5

pmol/L are suggestive of poor success rates with natural or assisted conception.

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 about assisted conception using donor

eggs. Donated oocytes are fertilized with the partner’s sperm and then implanted into the

uterus. The woman needs appropriate luteal phase support, most commonly with progesterone pessaries.

! Counselling issues for this couple

• Psychological:

• the woman may feel that her ovaries are ‘ageing’ prematurely and this may

have an effect 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 acceptance of not

being able to have a child together should be explored with the couple.

KEY POINTS

• 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.

• Low AMH is associated with poor fertility. Values less than 5 pmol/L are associated

with a very poor chance of IVF success.