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Case History

image A 28-year-old woman presented to a Reproductive Medicine clinic with her male partner to discuss their wish to undergo fertility treatment. She had a past medical history of acute lymphoblastic leukaemia (ALL) aged 8 years old treated with chemotherapy. She then relapsed aged 11 and her treatment was escalated. She received conditioning chemotherapy with busulfan and cyclophosphamide followed by total body irradiation (TBI) total dose of 14 Gy in 8 fractions, and proceeded to matched sibling stem cell transplant (SCT). Following this, she suffered delayed puberty, and investigations showed she had developed primary ovarian insufficiency (POI) secondary to her anticancer treatment. Her induction of puberty began at 14 years old using oestrogen patches with incremental dosage increases at 6-month intervals, reaching menarche aged 17. Her current hormone replacement was the combined oral contraceptive pill (COCP).

Investigations were performed to assess her ovarian reserve and uterine anatomy. Blood tests for follicle stimulating hormone (FSH), luteinizing hormone (LH), oestradiol (E2) and anti-müllerian hormone (AMH) were requested (Table 14.1).Transvaginal ultrasound showed a small anteverted uterus with a thin endometrium. The endometrial cavity was regular. Both ovaries were small and no antral follicles were seen.

At her follow-up appointment, the option of in vitro fertilization (IVF) with donor oocytes was discussed as her best option to achieve pregnancy. Prior to fertility treatment she was referred to a maternal medicine pre-conception clinic for baseline tests. Cardiac echo, respiratory function tests, and assessment of renal function and thyroid function were all normal and a plan for surveillance during pregnancy was made.

Her first cycle of IVF using donor oocytes resulted in pregnancy. At 16 weeks of pregnancy she suffered rupture of membranes and a spontaneous miscarriage. Karyotype of the products of conception showed a chromosomally normal pregnancy. Her second cycle of IVF with donor oocytes resulted again in pregnancy. She took aspirin 75 mg once a day to reduce the risk of hypertensive disorders of pregnancy (including pre-eclampsia). She had cervical length surveillance during the second trimester and serial growth scans from 24 weeks of pregnancy. She had regular cardiology review and normal echocardiograms at 20 weeks and 30 weeks of pregnancy. At 33 weeks her waters broke, and she was admitted to hospital. She received steroids for fetal lung maturation and magnesium sulphate for fetal neural protection before labour started spontaneously the next day. She delivered a baby girl weighing 1750 g, who was admitted to the neonatal intensive care unit and subsequently discharged with no complications.

What was the chance of spontaneous pregnancy for this patient?

What dose of pelvic radiation causes POI in a young girl?

What fertility assistance does she require?

What risks would pregnancy pose to this patient?

What obstetric risks are increased following anticancer treatment?

Table 14.1Results of hormonal blood tests.

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