Premature Ovarian Failure in 38 Year Old - What Are Her Options?

Question:

Dear Dr. Ramirez, I am a 38 year old from Birmingham, UK. After experiencing irregular periods and sometimes having 3 to 4 month absences, my hormone levels were tested and showed my level as 20. I was told that either I was experiencing premature ovarian failure (POF) or an early menopause. The course of action I was given at that time to determine which I had was to take a months supply of hormone replacement therapy. Obviously the bleed at the end would not have accounted for anything but the idea was to see if my periods came back after that. My gyno told me was that sometimes the ovaries can shut down for whatever reason and because of this the pituitary gland is desperately sending out more and more fsh to try and spur the ovaries into action and they are not responding hence the high FSH.

I was told that by taking a month of HRT it will switch off the pituitary gland and give the ovaries a rest from this constant hammering and that sometimes after this rest the ovaries start working again on their own. They did come back for about 3 months and a day 21 progesterone test showed my level as 20 suggesting some kind of ovarian activity.

I was told if I was in POF or menopause the ovaries would not respond to this but because I did get my periods back after the hrt for about 3 months it showed that I had POF, not menopause. I was also told that if I didn't get my periods back then they would be able to confirm menopause with a laparoscopy. My gyno said that because the HRT brought back my periods it showed that I have eggs so I am not in menopause.

Does this make any more sense to you at all? I have now been advised to stay off HRT for 2 months and then just go and get my hormone levels tested again and if my levels show menopausal then go on hrt permanently. I sort of feel as though I was given false hope. Can I still get pregnant?

Answer:

Hello,

The elevated FSH level is definitely concerning. It needs to be confirmed and should have been done on cycle day #2 or 3 of the first available menstrual cycle. If you are not having periods any more, then a random FSH can be done (done at any time in the cycle). If that level is greater than 20, then your ovaries have shut down and you are menopausal. The only difference between that and premature ovarian failure, is POF occurs in women under the age of 40 (as in your case). Otherwise, the net effect is the same. The ovaries have shut down. In that case, you cannot conceive naturally. Having a period is not a sign of the lack of menopause. You can have breakthrough bleeding or dysfunctional bleeding, which are caused by a lack of hormones, not the result of ovulation.

The exact cause of POF is unknown. Most think that it is an autoimmune problem, whereby somehow the body is shutting down the ovary. However, pregnancies have occurred in POF patients from random spontaneous ovulation. The problem is that the ovary is not picking up the FSH so the levels are increased. Fertility medications work by "bombarding" the ovary with increased FSH. The pituitary does not do that. The pituitary sends FSH to the ovary to stimulate ovulation. If the ovary does not pick up the hormone from the blood stream, the level is increased. I tell my patients to think of the ovary as a ball with lots of holes in it. If the holes are plugged up, the FSH can't get into the ovary and hence the FSH levels in the blood stream are elevated. POF is NOT due to the lack of eggs. It is due to the lack of ovarian stimulation/function. In addition, laparoscopy CANNOT diagnose menopause. It is a purely clinical and hormonal diagnosis.

In order to have a period on HRT, you need to be cycled i.e. take estrogen and then progesterone. In a young woman, the best method for HRT and cycling is the birth control pill. DO NOT USE menopausal hormone replacement drugs. It is too low for a young woman and you won't get adequate estrogen replacement. If you are indeed in premature ovarian failure, then you need to take estrogen and progesterone because your ovaries are not making them. The lack of these hormones will have long term detrimental effects. Since you want to get pregnant, then you need to see a reproductive specialist as soon as possible. Sometimes, in the early evolution of POF, the ovary can still be stimulated with HIGH dose FSH, which can lead to pregnancy. You want to be doing the optimal treatment method for pregnancy to ensue if either of these occur. That optimal treatment method is IVF because it performs 7 of the 9 steps required to get pregnant and has the highest chances of pregnancy.

For that reason, I would definitely recommend that you proceed to IVF as soon as possible. As long as your ovaries stimulate and eggs can be obtained (you only need one or two good quality embryos), you would have a 50-70% chance of pregnancy per IVF cycle. There are some IVF programs that will not allow a patient to try with her own ovaries if the FSH level is above 12. I do not have that policy. I don't make decisions for my patients, I only counsel them thoroughly and let them decide what they want to do. In your case, I would encourage you to try with your own eggs as long as the ovaries can be stimulated.

I counsel patients who are POF to also consider freezing some of thier eggs. Egg freezing techniques have greatly improved over the years and can be an alternative method of extending your fertility. It takes approximately four to six weeks to complete the egg freezing cycle, which follows the same protocol as IVF. Two to four weeks of self-administered hormone injections along with birth control pills to temporarily turn off natural hormones. This is followed by ten to fourteen days of hormone injections to stimulate the ovaries and ripen multiple eggs. Once the eggs are retrieved they can be frozen using a slow-freeze method or the flash-freeze method known as vitrification. They then can be thawed, ICSI'd, and the resulting embryos transferred into the uterus. The egg freezing process should be carefully considered, as it is still classified as an experimental technique by the American Society for Reproductive Medicine (ASRM). We have begun to offer this as a service at our clinic.

If the ovaries don't stimulate well, that means your ovaries have shut down or are shutting down. Then your next alternative would be donor eggs, but I would recommend you give it the best try that you can right away. Make sure you choose an IVF clinic that has good pregnancy rates. You don't want to waste your eggs! Good Luck!

Edward J. Ramirez, M.D., FACOG
Executive Medical Director
The Fertility and Gynecology Center
Monterey Bay IVF Program
www.montereybayivf.com