Usefulness of Finasteride to induce ovulation in a non responder hyperandrogenic woman: birth of a healthy male infant

Abstract

We report a case for the first time describing a new use of Finasteride. A 33-year-old woman participated with other hyperandrogenic anovulatory volunteers in our study on the efficacy of Finasteride in inducing ovulation [1]. She consulted her gynaecologist, because she was hoping to become pregnant. She reported oligomenorrhea, since menarche. Body mass index and a hirsutism score were evaluated according to the modified Ferriman–Gallway scoring system of 21 and 22, respectively. Pelvic examination showed micropolycystic enlarged ovaries. Serum levels of FSH, LH, T, DHT, androstenedione (A) and estradiol (E2)were measured on the 1st day of menses, using a recombinant immunoassay; T, DHT, A and E2 were repeated on the HCG day and DHT even on the 12th day after Finasteride discontinuance. Initial hormone levels were: FSH 4.1 mIU, LH 16.2 mIU, T 77 ng/dL, DHT 43 ng/dL, E2 55.9 pg/mL, and A 3.68 ng/mL. Initially, the patient underwent three consecutive cycles of controlled gonadotropin ovarian stimulation with recombinant FSH (b FSH, Organon, The Netherlands) starting at a daily dose of 150 IU on the 3rd day of cycle. Ovulation did not occur and after 21 days of stimulation, the cycles discontinued. On the 4th cycle, Finasteride was added. The patient was treated with recombinant FSH as described above for precedent stimulation cycles, plus 5 mg of Finasteride (Finastid; Neopharmed, Rome, Italy) daily, from day 1. On the 16th day of treatment, ultrasound examination showed one follicle of 20 mm; E2 was 180 pg/ml, human chorionic gonadotropin (HCG 10.000 UI; Gonasi; Amsa, Rome, Italy) was administered and Finasteride discontinued. On the same day, a significant decrease in DHT was achieved. After 14 days from Finasteride discontinuance, DHT was above basal level. Ultrasound examination revealed an intrauterine pregnancy. On the 6th week of amenorrhea, b hCG was 12.250 m UI/ml. The pregnancy evolved physiologically and after 40 weeks, a normal male infant of 3,600 g was delivered. Although follicular development is a complex interplay between many autocrine and paracrine factors, an important role is claimed by the competition between the enzymes aromatase and 5aR and their respective products E2 and DHT [2]. In PCOS, there is a raised activity of 5aR, responsible of higher level of intrafollicular DHT. The majority of ovarian follicles, in this syndrome, undergo atresia. Raised intrafollicular DHT concentrations are able to lead to follicular atresia that occurs at all stages of follicle development. Intrafollicular production of estrogens is indispensable for the growth of follicles. Atresic follicles exhibit decreased estrogen production and a lower estrogen/androgen ratio in the follicular fluid. In this case, sufficient exposure of antral follicles to FSH, increasing aromatase activity joined with low intrafollicular DHT level, due to Finasteride effect could be the critical stimulus for the follicle to escape atresia and reach the preovulatory follicle stage [3, 4]. In our patient, Finasteride not only favoured follicular growth (failure to achieved ovulation in 3 previous cycles), but also did not affect male genitalia differentiation. Finasteride seems not M. Tartagni G. R. Damiani (&) M. V. Tartagni G. Loverro Department of Obstetric and Gynecology, University of Bari, Policlinico, Piazza Giulio Cesare, 70124 Bari, Italy e-mail: damiani14@alice.it