OVULATION INDUCTION AND SUCCESSFUL LIVE DELIVERY IN A 46.5-YEAR-OLD WOMAN IN OVERT MENOPAUSE BY RESTORING FOLLICULAR SENSITIVITY TO FOLLICLE STIMULATING HORMONE (FSH)

Abstract

To try to up-regulate FSH receptors on granulosa-theca cells in a woman of very advanced reproductive age in overt menopause whose FSH receptors had been internalized related to elevated serum FSH levels, by inhibiting release of FSH from the pituitary by negative feedback of estrogen. The overall objective was to deliver a live healthy baby. Ethinyl estradiol (EE) 20 micrograms was given to a woman age 46.5 who had amenorrhea for 9 months and who was in overt menopause, as evidenced by failure to have menses following 10mg medroxyprogesterone acetate x 13 days. In addition, the patient had a serum estradiol (E2) of <15 pg/mL, a serum FSH of 117 mIU/mL, and a serum anti-Mullerian level of <0.09 ng/mL. She was treated with EE to lower serum FSH levels rather than E2 because the former does not contribute to the total serum E2 level, and thus allows the treating physician to detect when a follicle has been recruited by rising serum E2 levels. A rising E2 would dictate the addition of pelvic sonography to help determine when a mature dominant follicle was achieved (18mm average diameter with serum E2 ≥200pg/mL). If a mature follicle was achieved, 1mg granulocyte colony stimulating factor (G-CSF) would be given the day before an injection of 10,000 units human chorionic gonadotropin (hCG) to help the oocyte release. At age 42 she had been treated for infertility and was found to have the luteinized unruptured follicle syndrome. She failed to release the oocyte with either hCG or leuprolide acetate but was successful with hCG when G-CSF was added (and delivered a healthy baby despite a day 3 serum FSH of 47 mIU/mL). Progesterone vaginal suppositories 200mg twice daily was supplemented in the luteal phase. After 44 days of EE she was able to attain a mature follicle (E2 273 pg/mL, follicular size 18.8mm average diameter). She released the oocyte, conceived and successfully delivered a full-term healthy baby. A previous case was reported in Human Reproduction in 2000 of a 45-year-old in overt menopause. Successful reversal of menopause was achieved, and she delivered a live baby utilizing this same technique of restoration of FSH sensitivity by using EE without any exogenous FSH stimulation. Precedents are important for patient-physician decisions regarding treatment options. This case shows a live delivery is possible even in a 46.5-year-old menopausal woman using her own oocytes.