Question:
Dear Doctor, I am a single, white female, aged 42. I have high prolactin and started having no periods at age 26 following cessation of pill. There has been no return of periods despite shrinking of prolactinoma found. Many consultants scratched their heads over the years. I am now using HRT (hormone replacement therapy) to guard against osteoporosis.
I have been told I would just need a little help conceiving, clomide maybe. I went off HRT for 6 months whilst exploring potential IVF (in vitro fertilization) clinics using donor sperm. I looked at adoption but did not proceed as few babies for single white people in the UK. Had ORT (ovarian reserve test) at clinic. FSH at 0.8. e2 under 44. AMH low at 0.83. tsh normal/borderline at 4.36. It was suggested that I get tested for response with gonatrophins, then if follicles appear I can try with donor eggs. Donor eggs and sperm may be a bit too far for me.
Any thoughts? Feels like end of road for me. But as clinic is going to seek advice from endocrinologists, I thought I would start to ask wider. Thank you! J. from the U.K.
Answer:
Hello J.from the U.K.,
There are several problems that you report. Let me take them one at a time.
You mentioned that you hve not had periods since the age of 26 and now your are 42 years old. There must be some explanation for that and the only explanation I can see is that your FSH level is very very low (0.8). I presume the LH (lutenizing hormone) level is similarly low. We call that "hypogonadotrophic hypogonadism". It means that your hypothalamus is dysfunctioning and not producing adequate FSH (follicle stimulating hormone) to stimulate the ovaries to work. The treatment for a woman that wants pregnancy is to give FSH and LH (Menopur or Repronex) to stimulate the ovaries to work. This can be done with a reproductive endocrinologist, not a medical endocrinologist, also known as an infertility subspecialist.
Secondly, I noticed that your TSH (thyroid stimulating hormone) level, albeit is within the normal limits, is higher than we like to see it. In general, and U.S. endocrinologists have now adjusted their tolerances as well, we like to see the TSH at less than 2.2. So your thyroid is functioning but it is a little hypothyroid. A little thryoid replacement hormone (synthroid) would probably help to bring that down.
Thirdly, I presume that your prolactin levels are normal now? If not, then need to be treated to get them down to less than 20.
Now, let's talk about your options to get pregnant assuming all the above findings. The one very significant problem that you have, in addition to those above, is your age. At 42 years old, your natural chances for pregnancy have diminished significantly. For example, a 26 year old would have an 85% chance of pregnancy per year. A 42 year old has a 1% chance of pregnancy per year. Therefore, as a single, white female, you need to think outside the envelope of getting pregnant by natural means i.e. just having intercourse or injecting sperm (IUI). IVF will be the treatment of choice, and the medications used to stimulate your eggs will be FSH and LH so that covers the hypothalamic problem.
You might want to consider a gonadotropin stimulation test (trial of using the meds to see if your ovaries respond), but that is not necessary. If you enter the IVF cycle path and your ovaries don't stimulate, then you just cancel the cycle, so the IVF cycle will be test enough. At 42 years old, in my clinic, your chances of pregnancy would be 44% per cycle. That's significantly better than your natural chances. You certainly have the option of using donor eggs. Because donor eggs are taken from a younger woman, and pregnancy rates are dependent on the age of the eggs, you will have a greater chance of pregnancy no matter what age you are as long as your uterus is normal. That means the chances of pregnancy would be the same at 42 as at 45 years old. So that is a backup option that you will always have. If you wanted the best chances for pregnancy, then donor eggs would give you a 60-79% chance of pregnancy per attempt. In the U.S., we do allow donor egg cycles in single women.
So I hope that gives you some food for thought. I have written more extensively on this subject in my blog so you might want to use the search bar to look up more information.
Good Luck,
Edward J. Ramirez, M.D., FACOG
Executive Medical Director
The Fertility and Gynecology Center
Monterey Bay IVF Program
Monterey, California, U.S.A.
