Endocrine Abstracts

We present a case of a 29-year-old lady who presented with subfertility. She had had a 2 years history of oligomenorrhoea with highly irregular menses. She had symptoms of depression and described tunnel vision. Clinically, she was euendocrine with no features of hormonal excess or deficiency. She was not hirsute. Visual field testing demonstrated a severe left superior temporal quadrantopia.

Laboratory investigations demonstrated an oestriadol level ranging between 5000 and 6000 pmol/l, in the context of a FSH of 15 U/l. Her prolactin was mildly elevated at 600 mU/l. A short synacthen test was consistent with pituitary adrenal failure (0 min 219, 30 min 411, 60 min 444). Her free T₄ was 10.3. A MRI of the pituitary gland revealed a large homogenous adenoma with chiasmal compression.

A diagnosis of a pituitary adenoma secreting FSH with ovarian hyperstimulation was made. She was commenced on hydrocortisone 30mg daily. It was felt that any tissue secreting FSH should be removed through surgery in order improve her chances of fertility. She elected to have her pituitary surgery abroad. She had a successful transphenoidal resection of the pituitary tumour, which was complicated by a post-operative CSF leak. Following her surgery, her FSH had dropped to 4.9 U/l with an undetectable oestradiol level. An insulin stress test showed good hypoglycaemia with a peak cortisol of 472 nmol/l at 90 min and peak growth hormone of 1.5 mU/l at 60 min.

She did not have a return of her menses, which was consistent with her hypopituitary status. She is still trying to conceive and is being considered for fertility treatment with GnRH treatment, however there are several factors which have made this problematic. Firstly, her BMI is over 35 and secondly her partner lives abroad.

In summary, this is a 29-year-old lady with a FSH secreting pituitary tumour, who presents as an unusual cause of primary infertility.