Hyper – Prolactinemiea in Subfertile Women

Hyper – Prolactinemiea in Subfertile Women

Shazia Rafiq

Classified Gynaecologist, PPAF Hospital, Rafiqui Base, Shorekot Cantt, Jhang

ABSTRACT

Objective:To determine the frequency of Hyperprolactinemia in subfertile women presenting to Nishtar Hospital Multan.

Study Design: Case series study.

Place and Duration of Study:This study was carried out in Gynae and Obst.Outpatient Department and Gynae and Obst.Units of NishtarHospital, Multan from Oct. 2009 to March 2010.

Materialand Methods:- A total of 111 Patients with subfertility were selected which were fulfilling inclusion criteria.

Results: The prevalence of HPR in subfertile women at Nishtar Hospital Multan is 31.53%,and it is more common in women with primary subfertility i.e. 23.42% than in secondary subfertility where it is 8.10%.

Conclusion:- It is concluded that hyperprolactinemia(HPR )leads to anovulation which is a main cause of subfertility, more common among women with primary subfertility than secondary subfertility.

KeyWords: Hyperprolactinemia, Female Subfertility, Prolactin, Anovulation

Citation of article: Rafiq S,. Hyper – Prolactinemiea in Subfertile Women. Med Foeum 2015;26(1):18-20.

 

INTRODUCTION

Subfertility is the failure of conception after at least 12 months of regular, unprotected intercourse1. Based on this 60-80 millions couples all over the world can be labelled as suffering from subfertility2.

The prevalence of subfertility in industrialized countries has been quoted as 20% and seems to be on the rise3,. About 84% couples who have regular sexual intercourse and who do not use contraception, conceive within a year, while about 92% couples that are trying to conceive will do so within 02 years4. Couples with primary subfertility have never been able to conceive5.

Correspondence: Dr. Shazia Rafiq

Classified Gynaecologist, PPAF Hospital, Rafiqui Base, Shorekot Cantt, Jhang

Cell No.:0324-6827042

Email:This email address is being protected from spambots. You need JavaScript enabled to view it.

 Subfertility because of its medical, social and psychological implications, is a serious problem. Recent advancements have increased the possibility of success in the treatment of subfertility. But the peak human fertility i.e. the chance of pregnancy per menstrual cycle in the most fertile couples, is no higher than 33%, so it is unrealistic to expect a higher chance of pregnancy than this from any fertility treatment6. However prediction models for spontaneous pregnancy have been developed which can select subfertile couples that have good prospects, who can be expectantly managed7. Delay in child bearing and the adverse effect of the age on women’s fertility have increased referrals for sub-fertility investigations and treatment. In the past 25years, the percentage of births to women age 30 years or above in England and Wales have doubled8. About one in six couples in the U.K require referral for investigation and treatment for subfertility9.

There are many biological causes of subfertility some of which may be bypassed with medical intervention10. Latest  figures on subfertility causes in couples in which the women is under 25 years of age, are 40% female, 23% male, 17% combined and 10% unexplained11. About 15% couples actually have more than one causes of subfertility12.

As a result of public awareness about subfertility and its treatment options available, more and more couples are expected to seek treatment for the condition13.

MATERIALS AND METHODS

This case series study was conducted in Gyn/obs outpatient department and Units of NistarHospital, Multanfrom March2008 to September2008. A total of 111 Patients with subfertility were selected which were fulfilling inclusion criteria, from the Gynae Outpatient Department or Gynae Units of Nishtar Hospital Multan. Relevant data of cases including personal data, presenting complaints, type of subfertility and mode of admission were recorded. We measured serum prolactin level of all selected women.

 RESULTS

This study determines the frequency of HPR in subfertile women presenting to Nishtar Hospital Multan. A total of 111 women were included in this study,out of these 72 women were with primary subfertility and 39 with secondary subfertility. All cases have age limit of 19-39 years, with majority aged 20-35 years(80%). 88 women presented in Gynae Outpatient Department and 23 women were admitted in Gynae Units of Nishtar Hospital Multan. Serum prolactin level were more than 25µg/L in 35women (31.5%), 26 women with primary subfertility (23.4%) and 9 women with secondary subfertility (8.1%).Among women with HPR,7 women had regular menstrual cycle( 20%), while 28women presented with menstrual irregularities (80%), 22 women had oligomenorrhea (65%) and 4 women had galactorrhea (12%). The prevalence of HPR in subfertile women at Nishtar Hospital Multan is 31.53%,and it is more common in women with primary subfertility i.e. 23.42% than in secondary subfertility where it is 8.10%.

TableNo.1: Age Distribution  (n=111)

Age (years)

No. of patients

%age

19-25

27

24.3

26-30

34

30.5

31-35

28

25.2

36-39

22

20.0

TableNo.2: Frequency of hyperprolactinemia in primary and  secondary subfertility  (n=111)

 

Subfertile women

Primary

Secondary

No.  

111

72

39

Serum prolactin >25µg/L

35

26

09

TableNo.3: Percentage of hyperprolactinemia in primary and  secondary subfertility  (n=111)

Type of Subfertility

Cases

Women with serum prolactin >25µg/L

%age

Primary

72

26

23.4

Secondary

39

09

08.1

Total

111

35

31.5

TableNo.4: Mean age at presentation among women with primary and secondary subfertility

Type of subfertility

Mean age at presentation (Years)

Primary

26.1

Secondary

32.1

DISCUSSION

Subfertility is a socio-medical problem faced by 15-25% of married population varying in different areas of world.Female factors as well as male factors play a significant role and their treatment accordingly is more successful and cost effective14.

Evaluation of serum prolactin level is useful in the management of female subfertility15. Exess prolactin level decreases secretion of GnRH from hypothalamus and FSH, LH from the pituitary gland resulting in decrease secretion of estrogen and progesterone in the ovary which may manifest clinically as oligomenorhea, amenorrhoea, galactorrhea or subfertility.

During present study period total number of 111 women with history of subfertility, either primary or secondary, were included  and their serum prolactin levels measured.Serum prolactin  level were more than 25µg/L in 35women (31.5%), 26 women with primary subfertility (23.4%) and 9 women with secondary subfertility (8.1%).Among women with HPR ,7 women had regular menstrual cycle (20%), while 28women presented with menstrual irregularities (80%), 22 women had oligomenorrhea (65%) and 4 women had galactorrhea (12%). This study has illustrated that HPR is one of the causes of anovulatory subfertility. Majority of women in present study were with primary subfertility and with menstrual disorders. HPR adversely affects fertility potential by impairing GnRH pulsatility and thereby ovarian function.

A comparatively high prevalence of irregular menstruation, acne and polycystic ovarian syndrome may reflect higher prevalence of HPR in primary subfertility. High concentrations of FSH have been observed to be associated with subfertility. It is reported that decrease in the level of gonadotrophins in women with HPR16, which leads to anovulatory subfertility. Another study also showed that women with hyperprolactinemia have decreased levels of FSH and LH due to decrease secretion of GnRH from hypothalamus, which in turn leads to decrease secretion of estrogen and progesterone in the ovary, manifesting clinically as oligomenorrhea, amenorrhea, galactorrhea or subfertility17.

Bevan et al suggest that decline in gonadotrophins in hyperprolactinemic women indicates an association between gonadotrophin deficiency and hyper-prolactinemia18. Their view is that this may be an indirect sign of functional hypothalamic pituitary interruption due to inhibitory effect of prolactin on gonadotrophins release.

Rolland et al also observed low estradiol secretion in hyperprolactinemic women which in turn leads to impaired follicular growth and results in subfertility19.

Morris et alreported 24% infertility yperprolactinemic women and 27% quoted  in an Indian study20.

According to a study, it has been suggested that hypogonadism seen in hyperprolactinemic women is due to the high circulating levels of prolactin interfering with the action of the gonadotrophins at the ovarian level and impairing normal gonadal steroid secretion, which in turn alters positive feedback at the hypothalamic and pituitary levels21. This leads to lack of gonadotrophin cyclicity  and to infertility.

Yamaguchi et al found decreased LH secretion in hyperprolactinemic women22. Uilenbroek and Linden reported that prolactin can have a direct inhibitory effect on follicular estradiol production23. This might contribute to the reduced fertility seen in women with hyperprolactinemia.

Ben-David and Schenker reported that transient hyperprolactinemia at midcycle might disturb fertilization and embryo implantation24.

It is suggested from all above studies that any alteration in HPG-Axis contributes to abnormal prolactin secretion and hyperprolactinemia due to any cause leads to altered gonadotrophins secretion, affecting ovarian function and resulting in subfertility.

In a prospective study, serum prolactin level were checked in women at the time of  the couple initial consultation for subfertility25. There were 1.77% (15 out of 844 women) with elevated levels of prolactin. In our study the prevalence of HPR was 31.5% which is higher than the study in USA. In a study conducted at California in July 2005, 48% women with hyper-prolactinemia had subfertility26.

Results of a study showed that HPR is found in 64.91% of women with primary subfertility and 35.09% of women with secondary subfertility27.

The prevalence of HPR in subfertile women were studied in different parts of world, it was higher in Iraq i.e.  60%28, while in Hyderabad, India have prevalence of HPR 41% in subfertile women.

CONCLUSION

On the basis of this study, it is concluded that hyperprolactinemia leads to anovulation which is a main cause of subfertility, more common among women with primary subfertility than secondary subfertility. As fertility can be restored in these women by treating them with dopamine agonist which can normalize prolactin level and permit ovulation. So, serum prolactin level should be checked in all women presenting with subfertility.

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