Poster Presentation ESA-SRB-ANZBMS 2024 in conjunction with ENSA

Isolated growth hormone deficiency due to chronic Sheehan syndrome presenting with secondary infertility four years after post-partum haemorrhage (#619)

Yeung-Ae Park 1 2 , Alon Talmor 3 4 5 , Rita Upreti 1 2 3 5
  1. Endocrinology Unit, Monash Health, Clayton, Victoria, Australia
  2. Hudson Centre for Endocrinology and Metabolism, Melbourne, Victoria, Australia
  3. Obstetrics and Gynaecology, Monash Health, Clayton, Victoria, Australia
  4. Monash IVF, Melbourne, Victoria, Australia
  5. Obstetrics and Gynaecology, Monash University, Melbourne, Victoria, Australia

Background: Sheehan syndrome is a rare condition of pituitary necrosis following post-partum haemorrhage, hypovolaemia and shock,1 typically presenting with lactation failure immediately post-partum,2 but hypopituitarism can manifest months to years later.1 The anterior pituitary gland is more susceptible to ischaemia, and growth hormone (GH) and prolactin are classically affected first.1 We present a case of isolated GH deficiency secondary to chronic Sheehan syndrome presenting with secondary infertility. 

Case: A 38-year-old female was referred for secondary infertility on a background of postpartum haemorrhage and inability to breastfeed postpartum four years ago. During workup for secondary infertility, her biochemistry revealed low insulin-like growth factor 1 (IGF-1) and GH deficiency was confirmed with a glucagon stimulation test. The rest of the pituitary panel was unremarkable, other than autoimmune primary hypothyroidism, which was corrected with thyroxine. Magnetic resonance imaging (MRI) of the pituitary revealed a partially empty sella and a thin 1.6 mm pituitary gland supportive of chronic Sheehan syndrome.3

Other fertility investigations, including partner’s semen analysis, were unremarkable. Given the history of postpartum haemorrhage, GH deficiency, and partial empty sella, a diagnosis was made of isolated adult-onset GH deficiency likely secondary to Sheehan syndrome. The patient was commenced on GH replacement and is awaiting the response of GH treatment for potential natural conception; otherwise is planning further in vitro fertilisation (IVF).

Discussions: GH and IGF-1 have been associated with signalling for reproductive function, ranging from folliculogenesis, ovarian steroidogenesis, oocyte maturation, and embryo implantation.4 GH upregulates the expression of follicle stimulating hormone and luteinising hormone receptors5 and has been associated with promoting endometrial receptivity.6 In individuals with GH deficiency and infertility, GH replacement is likely to enhance fertility outcomes.7 In pituitary pathology, not only hypothalamic-pituitary-gonadal and adrenal axes dysfunction but also GH deficiency should be considered as potential contributors to subfertility or infertility.

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