A
37-year-old woman is seen in the clinic
because of infertility. She is gravida
3 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 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.
There are no abnormal features on
examination of either partner.
·
What is the cause
of the infertility?
·
What are the further
investigation and management options?
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
visual- ized at ultrasound scan. This is suggestive of anovulation from
premature failure of ovar-
ian 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.
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.
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
com- monly with progesterone pessaries.
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