Thursday, September 16, 2010

Woman With Hypogonadotropic Hypogonadism Needs FSH, LH and Hormones To Get Pregnant With IUI



Question:

Dear Sir, I have hypogonadotropic hypogonadism. I am trying to get pregnant and did IUI twice, but did not succeed. I was injected with GMH 150. I had to take around 26 injection to develop my follicles and then had to be injected with HCG for ovulation. My E2 level was 2250 and 4 big follicle. After IUI my doctor gave me only progestrone support. My question is that " is there no need of any other hormone medication as my body don't produce any hormone"? After fertilization can egg produce enough hormone which need for proper implantation. Can taking so many injections for stimulating the ovary affect the ovary or uterus in future? M. from India

Answer:

Hello M. from India,

In order to get you pregnant, you need to take supplemental FSH and LH (such a Menopur) and then when the follicle is appropriate size (18-22 mms), HCG is given to trigger ovulation. Progesterone supplementation is then started 3-4 days after the HCG to support implantation. You also have to consider that since this is a "natural" treatment, and most normal women don't get pregnant immediately when they begin trying for pregnancy (it usually takes 8-12 months of trying), this treatment is just making you into a normal ovulatory woman and so it may take several tries as well.

Finally, you have to make sure that you are taking thyroid hormone and adrenal hormone (cortisol), as well so that all your hormones are normal. If you don't, that could affect your ability to become pregnant. It sounds like your doc is doing the proper thing so you should trust in him/her, and ask him/her the same question.

Follow-Up Question:

Hello Dr., Good news. After HMG therapy and IUI, now I'm pregnant. 3rd month is going on, right now I am taking progestrone support only. I want to know in future will breast milk produce naturally or I have to take any hormone replacement for that. Will my baby affect because of my diseases? Thank you!

Follow-Up Answer:

Hello Again,

The pregnancy takes over hormone production, so you should not have problems producing breast milk. Your disease should not affect your baby unless it is due to some sort of congenital/genetic disease that is passed to your child.

Congratulations!

Edward J. Ramirez, M.D., FACOG
Executive Medical Director
The Fertility and Gynecology Center
Monterey Bay IVF Program
Monterey, California, U.S.A.


34 comments:

  1. Dear Sir, I have hypogonadotropic hypogonadism. I am trying to get pregnant and did IUI three times, but did not succeed. I was injected with GMH 150. I had to take around 8/month injection to develop my follicles and then had to be injected with HCG for ovulation. my doctor said that uterus is weak . My question is that " is there no need of any other hormone medication as my body don't produce any hormone"? After fertilization can egg produce enough hormone which need for proper implantation. Can taking so many injections for stimulating the ovary affect the ovary or uterus in future? iwant some suggestion to get pregnant. jhansi from India

    ReplyDelete
  2. Hello Jhansi from India,

    You are correct that there are other hormones required to allow for implantation and support an early pregnancy since the ovaries are not functioning correctly.

    With Hypo- Hypo-, the ovary is not being stimulated with FSh and Lh. For this reason, you require these hormones and the ideal formulation is a medication called Menopur or Repronex which have both hormones in it. In addition, to this, you may need progesterone supplementation once ovulation has occurred. This is usually given by vaginal suppository or injection. Usually the ovary will produce a corpus luteum cyst which secretes the progesterone required for implantation and support of the early pregnancy. But, with infertility treatments, we never take the chance that there is not enough progeterone so we always supplement it.

    You have to also bear in mind that all that is being done is to make you normal i.e. ovulatory like every other woman. It takes the average woman 8-12 months of trying for pregnancy to be successful. It may take that many tries for you as well.

    Good Luck

    ReplyDelete
  3. Dear Dr,
    I am a 37 year old female and was diagnosed with hypogonadotropic hypogonadotropism when I was 18 years. At that time I had presented with delayed puberty.I have been maintained on a drug called Climen for for the last 14 years. However I began fertility treatment (timed intercourse monitoring)with Repronex a few months ago which was successful, but unfortunately ended in a miscarriage at 10 weeks of gestation. I understand that this could have been due to a genetic abnormality with the fetus, but I also wonder if it could have been due to my stopping Prometrium support at 7 weeks gestation.
    I now completed my second time cycle and again I am pregnant on Prometrium support. My fertility doctor doesn't think taking Prometrium beyond week 7 or so will be beneficial and believes that I won't need any further hormonal supplimentation as the pregnancy will take over such functions. She however is willing to extend the Prometrium to possibly week 12 to appease me. My question to you therefore is, given my underlying diagnosis, do you think that I will need any additional hormonal support to maintain this pregnancy (my baseline thyroid and cortisol levels were normal)?
    Thank you.
    K.E from Canada

    ReplyDelete
  4. Dear Dr,
    May I invite your attention to a subject of great importance for me and my family and I would like to kindly ask you for your professional opinion on the following case. I am desperately seeking help for my daughter who has been ill for the past 3 years in hope that there is a treatment for her condition. I am very determined to find a cure and this is why I am contacting you.

    Let me briefly introduce some facts and examination results.
    Four years ago (2009) my 19-year-old daughter was diagnosed with Hypogonadotropic Hypogonadism-Hypothalamus, Secondary Amenorrhea.

    1. Hormone levels LH 0.38 mul/ml
    FSH 0.24 mul/ml
    Estradiol 18.36 pmol/l
    Prolactin 71.38 mul/ml
    Anti Muller 2.9 mg/l

    2.Karyotype 46,XX

    3.LHRH test LH mlu/ml FSH mlu/ml
    0 min 0.33 0.53
    30 min 3.75 5.84
    60 min 4.94 9.73
    90 min 4.14 10.95

    4. NMR Spectroscopy, head – NAD
    5. NMR Spectroscopy, lesser pelvis – underdeveloped uterus and ovaries
    6. Antibodies – NA
    7. Thyroid gland - NAD
    8. Bone age - 19 years, biological age – 19 years
    9. Pubertal Development – Tanner III
    10. Clomiphene test
    - 1st test - 50mg/5 days – no reaction
    - 2nd test - 100mg/5 days – reaction detected

    LH mlu/ml FSH mlu/ml Estradiol

    Day 1 0.10 0.98 283,9
    Day 6 11,6 33,30 311,4




    Menstruation didn’t start and currently absent.
    A year after the Clomiphene test, current hormone levels:
    LH 0,1 u/l
    FSH 0.84 u/l
    Estradiol 5.0 pg/ml

    Recommended Hormone Replacement Therapy, Oral Contraceptives.

    I did a web search for this diagnosis and I found information that patients diagnosed with Hypogonadotropic Hypogonadism-Hypothalamus, Secondary Amenorrhea undergo treatment and can complete puberty. I am in desperate search for the right treatment for my daughter. I’m particularly interested in Kisspeptin treatment and whether it can be applied in our case?

    Thank you very much and I really hope for an answer from you.

    ReplyDelete
    Replies
    1. "Hypogonadotropic hypogonadism" is a condition where the Pituitary is not producing the hormones FSH and LH. Therefore, the treatment is to replace these hormones when trying to get pregnant or to treat with theEstrogen and progesterone the ovaries are not producing as a result of the lack of these hormones. FSH/LH go to the ovaries and are what induce the ovaries to ovulate. In the process of ovulation, the ovaries produce the female hormones Estrogen and Progesterone. If the woman is trying to get pregnant we use medications such as Menopur that is FSH and LH to induce the ovaries to ovulate. If not trying for pregnancy, the birth control pill is used.

      If your daughter has not been see by a qualified endocrinologist or reproductive endocrinologist, that is the specialist she needs to see to manage this condition. Appropriate treatment will easily take care of this.

      Delete
  5. helo
    i am preety from nepal. i was did not get my period at the age of 15 so i was taken to gynocolgist by my parent at the age of 16. i was given provera first and still i did not responded to period. again i was given conjucate estrogen medicine and after taking for a month i got my meansuration. after taking that medicine for 5 month i stopped that medicine and got my period for about 3 years. after 3 years i stopped my period and my period started inrregular. now i am 25 and married. i want to conceive i want to get pregnant. i have noticed that my breat is underdeveloped its of little smaller than normal size. i do have little larger clitoris than normal. i went through all those AIS and PIAS from internet. but finnaly read about hypogonadism and i think i am the victim of hypogonadism as i notice that my height is only 4:10'' and i look younger than other of my ages. my question is i want to give birth to a baby so is that possible ? i am now in u.s an if there is possible treatment here than please please inform me.

    ReplyDelete
    Replies
    1. First, you need to see a "Reproductive Endocrinologist" who can do an evaluation and then recommend an appropriate treatment for you. This will help you to get pregnant.

      Delete
  6. hi, i am 34, trying to conceive for last 2 yrs bt no success. all my reports have been absolutely normal till date,HSG, lapro everything done and no abnormalities found. Husband report has positive agglutination factor ,does it affect chances of conceiving?? M Ag, Delhi, INdia

    ReplyDelete
    Replies
    1. Agglutination of the sperm can lower the chances of natural pregnancy. The treatment of choice might be IUI or IVF so that the sperm is washed and the non-agglutinated sperm allow to get to the egg.

      Delete
  7. Hello,
    i am african and was diagnosed with hypogonadtropic hypogonadism. I didnt see my period till i was diagnosed 3 years ago. I have been on the evorel 100mg (estradiol) patch and progesterone. At what point an i stop this medication as i heard that HRT could cause heart diseases and cancer. i used to live in England but now i moved back to Africa. The doctors here are clueles about my medication. A bit confused. Please heeelp. I am 29 already

    ReplyDelete
    Replies
    1. "Hypogonadotropic hypogonadism" means that your hypothalamus is not working and so you are not producing estrogen and progesterone. You cannot continue with this condition so it needs to be replaced, hence the estradiol (estrogen) and progesterone. Estrogen is an essential hormone for a woman's body but it causes the uterine lining to grow so that has to be sloughed at least every three months to prevent it from growing into endometrial cancer. That is why the progesterone is used.

      These hormones are required for your body and do not cause heart disease or cancer. In fact, the lack of estrogen can lead to increased incidence of heart disease, hence heart attack is the number one cause of death in women after menopause. As mentioned, estrogen that is not opposed with progesterone can cause endometrial cancer, but there is no other cancer that it causes. If you are not trying for pregnancy, you need to be on estrogen and progesterone.

      Delete
    2. Hello, I am from nagpur, we are planning for baby from about 1 year, after done several ovolution study I done laparoscopy in Feb month. But my period will came little late my doctor give me tablet for that. My period came within 8 days and I were not experience any pain. But in that cycle my follicles were not rupture after taking hcg Inj, this is my second month after laparoscopy, this time my doctor suggested me to take gmh 150 Inj from 3rd day to every alternate day of cycle, my weight is 62 kg doctor told me to reduce some weight. I just want to ask is my treatment in right direction? And how much it needs to get pregnant, pls reply.

      Delete
    3. Hello Sumeet,

      I'm afraid I can't answer your question because your medical history doesn't quite make sense to me. I would have to review your medical records to give you specific advice.

      Good Luck.

      Delete
  8. Thank you for your quick response. I am the same person, the african female in question. I am trying to have a baby but my doctors in my country are confused about my condition. How do i go about getting pregnant. I am still on my oestrogen patches. Also i think i have been having some side effects with the patches i am taking.

    ReplyDelete
    Replies
    1. With your condition "hypogonadotropic hypogonadism" you need to be on a medication that has both FSH and LH to stimulate the ovary to ovulate. These are known in the U.S. as Menopur, Repronex, Pergonal, but may have a different name in your country.

      Delete
  9. Sir,
    i am 34 years hypo hypo patient, never had period without tabs
    went through 5 painful IVF cycles in last three years,
    need 450-600 u inj for follicle to develop followed by hmg.
    last cycle got pregnant but baby did not showed heartbeats after 9th week.baby's karyotype showed no abnormalities, so my worry is that since my system is not naturally functional - not my ovaries / uterus or the fertilized egg is capable of sustaining
    hence full term pregnancy and healthy baby is too much to ask, i am severely depressed.
    is one more cycle advisable, is this gamble worth for my type acute hypo condition
    from india

    ReplyDelete
    Replies
    1. All that IVF can do is help you get pregnant,. Once the pregnancy occurs then your body takes ovary the process, so in fact, it is a natural process from that point. I can't tell you why the fetus did not develop, but I would definitely recommend that you continue trying. It is more that likely that the fetus was abnormal. Just a suggestion, because you are a hypo hypo. you need the HMG more than the follicstim or gonal-f (FSH). Since you don't produce either FSH or LH, you need them both and HMG has both FSH and LH. That will probably help your ovaries to respond. I recently had a hypo hypo patient that I used FSH + a small amount of HMG and she did not stimulate. In the second cycle I used ONLY HMG and she did great! She is currently pregnant.

      Delete
    2. Thank you very much sir!

      Thank you for clearing out the reason of fetus development failure, becoz as patients we are so vulnerable that we either blame ourselves or the doctor

      I will try one more cycle as per your suggestion!

      I would try convincing my gynac about hmg , i think she would agree
      which HMG medicine you would suggest and at what dosage, currently i need 600 units that's the highest possible one so i am worried

      Sir, while reading through lit i came across Kallmann syndrome symptoms and have all of them - i am 34 yrs old, never had period without pills, absolutely no sense of smell, extremely underdeveloped breasts, no secondary hair growth (exception- normal height 5'3")
      Please comment/ suggest treatment measures in addition to hypo hypo situation ; especially ability to conceive or even breast feeding!


      Sir, one more favor , is your research team or any other would be willing to take me up as a subject for kallmann syndrome or hypo hypo study!

      Thanks once again for answering my questions , it means a lot to me as it gives me hope to be a mother!

      D from india

      Delete
    3. Hello,

      I would strongly recommend that you see a very good endocrinologist or a university based endocrine clinic for further evaluation based on the lack of secondary sex characteristics. This may have an influence on your ability to become pregnancy.

      I am not currently involved in any research projects.

      Good Luck

      Delete
  10. Which hmg Sir and at what dosages?

    ReplyDelete
    Replies
    1. HMG is the generic name for a class of medication. It is not a specific company name. Any competent endocrinologist will understand what this drug is. There are many "names" available worldwide for this drug. It is basically a combination of FSH and LH hormones. Dosage is highly variable. In general we start with the lowest dose and work upward to the point of ovarian stimulation and subsequent ovulation. This is NOT something you can do on your own if that is what you were thinking. It requires a specialist, NOT a general doctor and definitely not a non-Physician.

      Delete
  11. Hello Sir! I m from india...looking for Endocrinologist for my wife, could you suggest any one whose work you have come across with...and can place your faith on.

    ReplyDelete
    Replies
    1. Hello,

      I'm sorry, I am not familiar with any clinics or doctors in India. I do know that you have to be very careful, however, because there is quite a variation in quality.

      Delete
  12. Hello Dr. Ramirez,

    I was diagnosed with Hypogonadotrophic Hypogonadism when I was 18 I was told at the time when I was ready to conceive I would need to begin fertility treatment. I am now 27 and just this past Wednesday 9/9 I was seen by a reproductive endocrinologist at CA IVF in Davis CA. He performed an u/s where he states "ovsaries are very small that of a 13 yr old girl" also that he could not locate my "egg sac" given my history and the results from my u/s he is "certain I was born with no eggs due to my condition" hes not even open to trying hormones on me because he "can't make me have eggs either I have them or I don't" I understand this but given my diagnoses can't this be the reason he couldnt locate them? He's pretty adiment that I just need to take the route of IVF with an egg doner. I am not willing to accept this as I feel he is skipping so many possible steps.

    Any information you can give me would be greatly appreciated I am at a loss for words and have little hope.

    ReplyDelete
    Replies
    1. Hello. Hypogonadotropic hypogonadism is a hormonal disorder so the anatomy should not be affected. However, another reason for not having periods is if there is a genetic abnormality that caused the anatomy to not fully develop. The best way to check this is do to an MRI looking at the anatomy. The fact that the ovaries are small is not a good sign. I think that if the MRI were normal (all parts present and accounted for), the next step would be a trial of stimulation to see if there would be some type of response. This could be done on its own or in conjunction with a possible IVF cycle. If there is no ovarian response, then donor eggs would be your only choice.

      In most Hypo Hypo patients, because the only problem is that the ovaries do not go through an ovulatory cycle, treatment with FSH/LH (Menopur, Repronex, Pergonal) will stimulate the ovaries to ovulate and therefore the woman can get pregnant naturally if there are no other problems. That would be the first line of treatment I would recommend. I know CA IVF and the doctor there, but if he is not helping you, there are LOTS of IVF clinics in northern California for you to seek a second opinion from.

      Delete
  13. Hi,

    My name is Andreea, i live in Romania. I was diagnosed with hipo hipo when i was 16 and took treatment every month since then.
    At 29 years old i obtained a natural pregnancy with 150Ui gonal-f and one shot of pregnyl.
    I only write this to give hope to other girls. Now my beautiful and perfectly healthy 2,5 months old son is sleeping near me. I exclusively breastfeed him since birth. Girls, there is hope for hipo hipo to. Keep trying.

    ReplyDelete
    Replies
    1. Thank you very much for your comment. Yes, hypogonadotropic hypogonadism is NOT an insurmountable problem. The hormones that these patients don't make are available in injection form and can be given to induce the ovary to ovulate (the lack of which is why they don't get pregnant) so that you can achieve a pregnancy. All it takes is seeing a well qualified and competent physician to treat one appropriately.

      Delete
  14. Hi Sir
    I am 30 yes old an was diagnosed with an underdeveloped uterus my gynecologist said it will be impossible for me to fall pregnant, but everything was normal except for the uterus and I never got periods in my life. I read about iui I don't know if that might help.
    Mrs ll

    ReplyDelete
    Replies
    1. Hello,

      I'm sorry but your are mistaken. IUI (intrauterine insemination) does not work if you do not have a uterus that where an embryo can implant and grow. Since "underdeveloped" is a vague term, I can't say for sure whether or not your uterus would be capable of getting pregnant. If the uterus is formed correctly, despite being smaller than normal, it can still carry a pregnancy. On the other hand, if it is not formed correctly, then you cannot carry a pregnancy. In that case, you could have a genetic child by doing IVF with a gestational surrogate (someone who carries the baby for you).

      Delete
    2. I forgot to mention that the reason IUI will not work if the uterus is not normal is because IUI is basically a "natural" treatment. It requires that everything in the body related to getting pregnant, work appropriately. All IUI does is put the sperm into the reproductive tract to be closer to where the egg is. There are 10 steps your body goes through to achieve a pregnancy. IUI helps with three steps. Therefore the remaining seven steps happen naturally on their own, so the anatomy and physiology have to be normal.

      Delete
  15. Jessica if you're still following... I have hypogonadotropic hypogonadism, at age 19 I still hadn't gone through puberty and no period. I had almost no breast development, and undersized uterus and ovaries like you. I met a miracle doctor at UVM Medical Center in Burlington, VT who put me on a special course of hormone replacement therapy that basically completed puberty for me, increasing my breast, uterus and ovaries size. And low and behold, I have plenty of eggs! I'm a vegan since 2005, and in 2014 I went gluten-free and spontaneously ovulated! So don't give up hope, get a good doctor that is familiar with the condition and has faith in you.

    ReplyDelete
    Replies
    1. Thank you for your comment. Yes, special conditions like hypo hypo require a specialized physician who knows what the problem is, makes the diagnosis correctly and prescribes the correct treatment. It is absolutely treatable!

      Delete
  16. Anonymous, I would love to hear more about your treatment .... my daughter did not go through puberty until seeing a dr and starting taking pills at 18.... the small uterus, no period, and delayed breast development were only part of it, feeling left out socially was also very difficult for her during those years. It seems that you had to deal with that as well. Now she's concerned about future fertility and she hopes to have a period without being on medicines. (spontaneously?) Also it would be so nice for her to talk with someone else with this.... it is so rare, and she doesn't talk about it with anyone. I have looked online for a support group or some one else dealing with this. I remember the first gynecologist dr who said cruel things to her... we both cried when we got home. Finally after asking her pediatrician for years, we found a nice endocrinologist who started her on birth control pills. Still I feel there must be a dr who is more of an expert in this, and we are willing to travel to find one. I know she hopes to have a baby at some point in time. Thank you for posting, it is so nice to have "hope". I hope that you see this message, please reply if you do. Best wishes. Dr Ramirez, thank you for your work in this field. We do not know why my daughter has HH, idiopathic I believe.

    ReplyDelete
  17. Dear Dr. Ramirez, I have been diagnosed by my endocrinologist that I have hypogonadatropic hypogonadism. Mine is caused by my pituitary gland that is quite smaller than it should be and possibly goes as high up as the hypothalamus. I'm 22. Although this is not a fertility question, maybe you can help me. I'm trying to find numbers on this condition, such as its commonality or rarity. If you could help me or point me in the right direction, I'd be very appreciative. Thank you for your time, kt

    ReplyDelete

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