Premature ovarian insufficiency - fertility challenge.

Premature ovarian insufficiency, defined as amenorrhea with estrogen deficiency in a woman younger than 40 associated with a serum follicle stimulating hormone (FSH) >35 mIU/mL, can be temporarily reversed with ovulation achieved resulting in live delivered pregnancies. Though this may occur spontaneously the frequency of ovulation can be considerably increased by various techniques of lowering the elevated serum FSH level and thus up-regulate down-regulated FSH receptors in the granulosa-theca cells. This can be accomplished by either suppressing FSH release from the pituitary by negative feedback through high dose estrogen or by suppressing FSH production by inhibiting the gonadotropin releasing hormone (GnRH) by either using GnRH agonists or antagonists. The estrogen method is the technique of choice because it is much less expensive than GnRH analogues, and helps stimulate cervical mucus and endometrial development. Ethinyl estradiol is the preferred estrogen because it does not contribute to the measurement of serum estradiol and thus allows proper monitoring of follicular maturation. Sometimes exogenous gonadotropins are needed as a boost but the dosage should be low so as not to down-regulate FSH receptors again. The technique is referred to as the FSH receptor restoration technique. Progesterone should be supplemented in the luteal phase. Physicians should be cognizant of trying to help prevent premature ovarian insufficiency by judiciously choosing less gonadotoxic cancer treatment alternatives that are equally efficacious. Also surgery for ovarian endometriomas should be performed only when absolutely necessary.