Comparison of Ovarian Stimulation Protocols in Hypogonadotropic Hypogonadism: Case Series and Review of Literature.

INTRODUCTION

Hypogonadotropic hypogonadism (HH) is one of the least common etiologies for female infertility and needs different approach when dealing with this condition, especially in the presence of low ovarian reserve. Standard measures are unlikely to be of use and therefore personalized and customized ovarian stimulation must be employed for this patient because the threshold of response to stimulation may differ substantially from that of normal patient. Moreover age-dependent decline in ovarian response for this subset of patients has not been established. Facing with this situation, the question arises at what regimens and at what appropriate dose to start stimulation as previous studies reported a higher dose of gonadotrophins and longer day of injections are needed than other IVF patients because of "dormant" ovaries that need to be primed before follicular response is achieved.

CASE ILLUSTRATION: We present two cases of infertile women who had hypogonadotropic hypogonadism and underwent In Vitro Fertilization (IVF) procedures with different stimulation protocols. Both patient exhibit clinical and biochemical features of hypogonadotropic hypogonadism and underwent individualized ovarian stimulation protocol. The first patient had diminished ovarian reserve and concomitant male factor infertility, received combination of follitropin delta, menotropin, and adjuvant of growth hormone during stimulation and subsequent intrauterine pregnancy was achieved. While in the second patient, despite a relatively more favorable ovarian reserve and normal semen parameters, underwent stimulation with recombinant FSH and LH but failed to achieve clinical pregnancy.

CONCLUSION

Hypogonadotropic hypogonadism remains a challenging cause of infertility requiring individualized ovarian stimulation strategies. This case series demonstrated heterogenous reproductive outcomes following different stimulation protocols, suggesting that tailored gonadotropin-based therapy may be effective in selected patients with HH. The potential benefit of adjunctive growth hormone requires further evaluation in larger prospective studies.