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A. Toth, M.D.
Obstetrician, Gynecologist, & Pathologist
A Case of POF Associated With Actinomyces
Attila Toth, MD.
Clinical Associate Professor,
New York Hospital – Presbyterian Medical Center
Prior to seeing Ms. J. E., the only bacterium we conclusively associated with premature ovarian failure was Chlamydia trachomatis. In several cases, successful antibiotic therapy led to negative post therapy Chlamydia culture with full recovery of ovarian function and subsequent pregnancies.
In Ms. E. case, Chlamydia trachomatis was never isolated either by our center or by several centers she visited before. The only isolate our culture studies revealed was the anaerobic bacterium, Actinomyces. Her endometrial biopsy yielded an extremely heavy growth of this bacterium. Her history indicated that all of her troubles started after a boyfriend impregnated her in 1998 and she underwent an abortion. Her first symptoms were one or two missed periods in the first year after the abortion. Then she missed periods for six months straight. In 2000 her periods stopped altogether and hot flashes followed. She became concerned and visited her local physician, who in February 2000 ordered an FSH that was 82. She was told that nothing could be done and was advised to stay on birth control pills to reassure regular bleeding. Other physicians tried Provera challenge test, which repeatedly failed. By March 2002, it was the general consensus that Ms. E. should go on a cyclical Premarin/Provera hormone replacement therapy course in order to save as much bone structure as possible. A bone density study by that time showed about 25 percent bone loss in her femur and in her spinal column.
Normal menstruation was established under hormone replacement therapy, FSH and LH were suppressed, and she had menstrual periods in April, May and June when she heard about our clinic and came for consultation on July 1, 2002. She was still on hormone replacement therapy and serum hormones determined through our laboratory read as follows: FSH 7.1 mIU, LH 6.0 mIU and Estradiol 237.5 pg/ml.
Ms. E.’ family history revealed that there was no way of ignoring the potential of a vertically - transmitted infection due to her complicated family medical history. She was the younger of two sisters and her parents needed three years to produce her older sister, who suffered severe ear infections, severe allergies, asthma and was born one month prematurely. There are four years unaccounted for between the two sisters and when Ms. E was born, she only weighed 5 pounds 10 ounces, and was considered intrauterine growth retarded. One more pregnancy followed her, a stillborn child at 8 months.
Ms. E. underwent a full ten-day IV Clindamycin therapy combined with simultaneous intrauterine lavage using Ampicillin and Gentamicin. Following the completion of this treatment regimen, next month, she reported a spontaneous period with complete normalization of day 3 FSH, LH and Estradiol. I had a lengthy telephone conference with her explaining that it is unpredictable how many more follicles she has left. My advice was not to postpone childbearing for a lengthy period of time.
J’s last menstrual period was in October, just before she left for a European vacation. She reported pregnancy in early November of 2002.
For summary, Ms. J’s case documents a secondary ovarian failure that responded favorably to intravenous antibiotic therapy combined with intrauterine lavages with prompt restoration of her menstrual flow and a prompt pregnancy. The only isolated bacterium was Actinomyces known to cause pelvic damage. Due to the exceptionally heavy growth of this bacterium in the endometrium, it is a fair conclusion that this organism was the cause of her ovarian failure.