Live Delivery in a 46.5-Year-Old Woman in Overt Menopause by Restoring Follicular Sensitivity to Follicle Stimulating Hormone (FSH)

Abstract

For almost 40 years, there have been several publications where ovulation induction has occurred by lowering elevated serum follicle stimulating hormone (FSH) to up-regulate down-regulated FSH receptors on granulosa theca cells thus restoring follicular sensitivity to endogenous gonadotropins resulting in live deliveries. The majority of case reports used ethinyl estradiol to lower FSH. The advantage of ethinyl estradiol is that it does not add to the serum estradiol and thus allows the physician to better determine follicular maturation. To date the oldest woman to have ovulation induction and live delivery despite menopause was aged 45. A 46.5-year-old woman with 9 months of amenorrhea with a serum estradiol <15 pg/mL and a serum FSH of 117 mIU/mL was given ethinyl estradiol 20 micrograms daily. She attained a mature follicle on day 44 and conceived with natural intercourse with vaginal progesterone supplementation in the luteal phase. She delivered a full-term healthy chromosomally normal baby. Interestingly, she also had a successful live delivery when we treated her with progesterone in the luteal phase at age 42 when her day 3 serum FSH was 47 mIU/mL. Besides a luteal phase defect, she failed to release the egg from the follicle first naturally then with 10,000 units of human chorionic gonadotropin (hCG) but finally did release and conceived with the novel use of granulocyte colony stimulating factor, which was used again at age 46.5. Live deliveries are uncommon in women aged 46 even with regular menses and normal egg reserve. Precedents are important in medicine. Thus, this case represents the oldest woman with documented menopause to conceive naturally.