A 32-year-old woman with a POI diagnosis presented to our fertility clinic on August 2021 because of the desire to get pregnant but with repeated failures of IVF. The patient denied a family history of POI, infertility, autoimmune disease, or a history of chemotherapy or radiation therapy. The patient had menarche at the age of 13, with regular menstruation until the age of 30. The couple's chromosomes were both normal.
The patient had one natural pregnancy in 2018 at the age of 28 before the POI occurred; however, the embryo stopped developing in week 8 because of chromosome 16 trisomy. At that time, her menstrual cycle was regular (cycle length of about 28-30 days). After this miscarriage, the patient received 1-year treatment of traditional Chinese medicine to activate blood, remove stasis, and promote circulation (which does not affect ovarian function) but did not experience a successful pregnancy.
On May 2020, at the age of 30, the patient's menstruation started getting irregular without expectation. Her menstrual cycle length was shortened to 20-22 days, and her menstrual volume was reduced significantly. The blood testing showed that serum follicle-stimulating hormone (FSH) was 40.00 IU/L, estrogen was 114.50 pmol/L, progesterone was 1.31 ng/ml, and anti-Mullerian hormone (AMH) was 0.18 ng/ml. The transvaginal ultrasound (TVS) indicated that the bilateral ovarian volume was significantly smaller than normal ovaries with few antral follicles. The diagnosis of POI was made. The couple then went to a fertility clinic in Shanghai (China) seeking infertility treatment by IVF. A total of five times ovulation induction with four IVF were conducted from 2020 to 2021 with either micro-stimulation or natural cycle protocol. For each IVF cycle, the patient got one or two oocytes. Finally, five oocytes and two embryos were received. However, the two transplantations failed.
On August 2021, the patient visited our fertility center for consultation. We asked the patient to have estradiol valerate and progesterone treatment (hormone replacement therapy) for 2 months. If menstruation happens during the treatment, she should revisit us to check the ovarian reserve.
On 8 September 2021, the patient revisited our center on the 3rd day of menstruation. The TVS indicated a 20*20-mm cyst on the left ovary, and the thickness of the endometrium was 5.7 mm (Supplementary Table 1 and Supplementary Figure 1). The hormone test showed that the serum estrogen was 1,316 pmol/L and the FSH was 5.23 IU/L. All these suggested that this cyst should be a matured follicle. Therefore, we strongly suggested to the patient that they should seize this chance to get pregnant naturally. A guided sexual intercourse was scheduled on 9 September 2021 (day 4 of the menstruation) and 11 September 2021 (day 6 of the menstruation). The oral estradiol valerate (2 mg twice daily; Progynova, Baye) was given to help increase the thickness of the endometrium. On day 7 of the menstruation, the re-checked TVS indicated that the cyst disappeared and the thickness of the endometrium was 7.4 mm (Supplementary Table 1 and Supplementary Figure 2). The ovulation was inferred to occur between day 4 and day 6 of the menstruation. The estradiol valerate was continuously used (2 mg twice daily; Progynova, Baye). Luteal phase support was provided with the dydrogesterone tablets (10 mg twice daily; Duphaston, Abbott) for 14 days to prevent luteal phase defect.
Two weeks later, the blood testing indicated an increased level of human chorionic gonadotropin (HCG) (208.44IU/L) and progesterone (111.53IU/L), and a clinical pregnancy was diagnosed. Because of the slight bleeding, HCG (2,000 iu, every other day, 30 days) was applied, and dydrogesterone (10 mg twice daily, 60 days) and estradiol valerate (2 mg twice daily, 15 days) were continued.
One month later, on 21 October 2021, TVS confirmed the intra-uterine pregnancy with a gestational sac of 36*26 mm, a yolk sac of 3 mm, and a crown-hip length of 15.7 mm with a visible heartbeat (Figure 1).
On 21 May 2022, a healthy baby girl weighing 3,345 grams was born by the cesarean section at 39 weeks and 1 day of the pregnancy, and the APGAR score for the baby was 10.
Written informed consent for the publication of this case report was obtained. The non-identifiable ultrasound image is included in the case report; however, approval for publication was still obtained.