Dados do Trabalho

Title

Full-term pregnancy in a patient with panhypopituitarism using in vitro fertilization techniques: a case report.

Objective

Description of a case report about a 24-year-old female previously diagnosed with panhypopituitarism (PHP), who was referred to the Gynecology and Obstetrics department at the General Clinical Hospital in Porto Alegre - Rio Grande do Sul, Brazil, for treatment of secondary infertility. She expressed her desire to become pregnant and was included in our Public Health Program in Assisted Reproduction. The patient had already been under periodic endocrinological follow-up since childhood at the same hospital to treat the PHP condition, which was a consequence of pituitary stalk agenesis.

Methods

When started in the Assisted Reproduction Program, the patient was receiving continuous treatment with levothyroxine (Euthyrox® - 125 mcg/day), estradiol (System® 25 - 1 patch every 2 days), medroxyprogesterone (Provera® 2.5 mg - (from day 13-23 of menstrual cycle), and prednisone 2.5 mg/day. Her endocrinologist recommended increasing the Provera® dosage to 5 mg (from day 13-23). However, she had stopped taking GH replacement four months before starting the procedure, on her own.
The patient's spouse provided a semen sample for a spermogram, and all parameters were within normal limits. Despite this, the first ovulation induction cycle for fertilization in the laboratory was unsuccessful.
A year later the patient attempted another ovulation induction. This time, human menopausal gonadotropin (HMG) was used at a dose of 150 IU/day, starting two days after the initial menstrual bleeding. HMG treatment continued for six days. The patient's Somatomedin C (IGF-1) levels were measured at 155 ng/mL, falling outside the recommended reference levels for her age. As a result, the patient was advised to discontinue GH replacement. Moreover, the ultrasound revealed another poor response to ovulation induction, leading to the termination of the induction cycle.
Three months later, the patient made a third attempt at ovulation induction. This time, the HMG dose was increased to 225 IU/day, starting three days after the onset of menstrual bleeding. The HMG treatment continued for six days, and ovulation control ultrasound was performed on the sixth day. Additionally, IGF-1 levels were determined again and resulted in 205 ng/mL, within the reference value.
Ultrasounds were performed every two days from the ninth day of the cycle to monitor follicular growth until the seventeenth day, with the same medication dose.

Results

The follicles were punctured on the twentieth day of the cycle, resulting in 15 collected oocytes. Among them, 13 were mature, and 2 degenerated.
Considering that the seminal parameters of the spouse were within normal limits, with a total motility of 90% and a concentration of 150x106 spermatozoa, classic in vitro fertilization (IVF) was used for oocyte fertilization. From the 13 inseminated oocytes, 11 embryos were obtained on D3, with four having embryonic classification B and seven having embryonic classification C. Two healthy embryos (classification B) were freshly transferred to the patient, and the remaining nine embryos were cryopreserved. After 15 days, Beta HCG levels were determined, confirming a single embryo pregnancy.
Given the high-risk pathology, the patient was referred to a specialized obstetric center for careful follow-up throughout the entire gestational period. The birth occurred at 38 weeks' gestational age, through cesarean delivery.

Conclusion

In women with PHP, spontaneous pregnancy, even if rare or exceptional, is associated with a high risk of miscarriages or fetal and maternal mortality. Thus, IVF techniques may be the only option for PHP patients to have a safe full-term pregnancy.

Keywords

Panhypopituarism; in vitro fertilization; pregnancy.