The patient suffered from a rare syndrome of Panhypopituitarism: Sheehan Syndrome, due to prolonged low blood volume and lack of blood supply to Pituitary gland, resulting in necrosis. In developing nations, there are two Sheehan Syndrome cases for every 100,000 live births. The patient’s survival depended on a carefully calculated replenishment of all her vital hormones, including thyroid, cortisol, and growth hormone. According to Dr. Basu, this effort has helped to evaluate and analyse an issue that is supposedly extremely rare in the country.
It was in 2011 that patient Ruplekha (name changed to protect the patient’s privacy) first consulted infertility specialist Dr. Sudip Basu, who holds 36 years of expertise for irregular periods and trouble conceiving. Hailing from Halisahar town, regularly commuting to Kolkata for treatment was not an easy task for her and her working husband. She was subsequently diagnosed with Polycystic ovaries, a very prevalent ovarian dysfunction in recent times, which results in failure to release the egg at the right time.
The ensuing imbalance in hormone levels results in changes to the skin, fatty liver, and carbohydrate metabolism issues. Although many patients experience trouble getting pregnant with this condition, Ruplekha conceived within three months after her first visit with Dr. Basu. She was over the moon when a urine pregnancy test revealed that she was pregnant. However, what awaited her in the upcoming months was nothing short of a nightmare that no one could have foreseen. As her blood hormone levels (serum beta HCG) were rising satisfactorily, there was no need for concern, and she decided to stay with her parents during Durga Puja, 2012. On the eventful night of Durga Ashtami, she experienced excruciating abdominal pain. Following the advice of her consultant in Kolkata over the phone, she decided to go to the local hospital to exclude tubal pregnancy, a potentially fatal condition that is still one of the leading causes of maternal death.
Her condition had rapidly worsened by the time she arrived at the local hospital, as evidenced by her low blood pressure and rapid heartbeat. She was then directed back to Burdwan Medical College out of concern for a backlash in case something unpleasant transpired. Ruplekha was starting to get unconscious at this point, and her husband and parents were becoming very concerned. They called Dr. Basu, this time informing him of the lengthy wait times for any emergencies at the busy Medical College. Dr. Basu then made some frantic phone calls, pulled all of his contacts, and managed to rapidly get her admitted and operated on at the Medical College.
She required four units blood transfusions over the course of six days in the hospital due to a rupture ectopic pregnancy in her right Fallopian tube, which was removed through an emergency laparotomy along with two litres of blood. When she fully recovered, she went back to see Dr. Basu about her infertility. She had stopped menstruating by that point, but she suspected polycystic ovaries might be to blame.
After a comprehensive investigation, it was discovered that this time, rather than PCOD, her missed period was caused by her non-functioning pituitary gland (a rare syndrome of Panhypopituitarism: Sheehan Syndrome, due to prolonged low blood volume and lack of blood supply to Pituitary gland, resulting in necrosis). She was referred to Dr. Sujoy Ghosh, a prominent endocrinologist at SSKM hospital, because her survival depended on a carefully calculated replenishment of all her vital hormones, including thyroid, cortisol, and growth hormone.
The lowest levels of all the gonadotropin hormones at that time caused the uterus and endometrium, the lining of the endometrium, to shrink, making conceiving again seem far-fetched. Once stabilised, the couple refused to travel to higher centres in Vellore or South India because long-term care required meticulous monitoring, numerous visits, and a sizable budget. They then asked Dr. Sudip Basu and Dr. Sujoy Ghosh to take on the matter and do everything they could to complete her family.
She underwent cyclical oestrogen and progesterone treatment to get her shrunken uterus back in shape and functioning after her critical hormones were replenished and levels were adjusted. Once satisfied with the results, Dr. Basu began administering human menopausal gonadotropin at precisely determined levels for ovarian stimulation and in vitro fertilisation. She successfully transferred a frozen embryo from two IVF cycles into her body four times in total. She became pregnant after each embryo transfers but unfortunately suffered three miscarriages as well. Fourth time she got lucky and Ultrasound confirmed live intra uterine Pregnancy.
Although she required hospitalisation on a few occasions for high blood pressure and pregnancy bleeding, she gave birth to a healthy baby by Caesarean section early this month at a Multi-Specialty Hospital off Bypass under the supervision of a competent team of Anaesthetists, Endocrinologists, and Intensivists, and certainly Dr. Basu and his team. Both mother and child are doing well right now. Ruplekha and her husband expressed their gratitude and respect for Dr. Sudip Basu and the team of doctors in Kolkata, saying that “it was nothing short of a miracle.”
The success seemed to make Dr. Basu “more relieved than satisfied”. He remembers her patience, tenacity, and desire to become a mother despite all odds, and the love and support of the couple, standing beside each other during such challenging times in life. He believes that Ruplekha’s positive outlook and the extraordinary journey will serve as an inspiration to many others. He is full of admiration for Dr. Sujoy Ghosh and believes that he is an exceptional physician with great talent who has elevated the standard of care for endocrinology in the public sector. Dr. Sudip Basu hopes that these kinds of inspiring tales would restore patients’ faith in their neighbourhood physicians and curtail their propensity to seek care elsewhere at the drop of a hat.
Dr. Atanu Jana, who was taking care of the new-born and was previously in charge of Vellore’s neonatology unit, can’t recall any such case during his long-standing career. According to the literature search, it is, in fact, extremely unusual.
👉🏻 Medical Significance:
It is the success tale of a highly complex medical patient using a multidisciplinary approach. The pituitary gland, a very complex and important hormone secretory organ, is located in the brain and secretes several hormones, including the gonadotropins (FSH and LH), the prolactin hormone, and the growth hormone-releasing hormone. These hormones are crucial for a person’s overall health. Therefore, if it is lacking and not properly replenished, the patient risks dying. Infertility becomes more prevalent. This acquired Panhypopituitarism can occur with any significant blood loss, although it is more likely in cases of postpartum haemorrhage where lost blood is not promptly restored.
Pituitary avascular necrosis affects 1 to 5 new-borns per 100,000. Though very seldom observed in industrialised nations, it is common in underdeveloped nations. It is probably unheard of that the same issue emerged after an ectopic pregnancy ruptured. Once diagnosed, they require careful replenishment of the following hormones: growth hormone, thyroid hormone, gonadotropin hormone, and stress hormone (cortisol). Otherwise, the patient’s life is in danger, especially during stressful situations. Due to the low levels of gonadotropin, a perfectly balanced replacement is required for follicular growth, ovulation, and pregnancy. Since cortisol levels constantly fluctuate during pregnancy, careful monitoring and calculated replacement are required to avoid serious risks to the unborn child and the mother.
Here, a multidisciplinary strategy (public-private collaboration) in an uncharted area was implemented, and on the fourth attempt, it was successful. The first three embryo transfers resulted in miscarriages, most likely as a result of inadequate hormone replacement adequacy. A study of the literature turned up relatively few case reports, most of which were from Europe and none from Eastern India.
👉🏻 How rare it is
In developing nations, there are two Sheehan Syndrome cases for every 100,000 live births. In other words, out of 10,00,000 cases, 20 will be found. The majority of them happens after childbirth. So, Sheehan syndrome in the infertile group is very rare. Therefore, if we consider only five women in every 10,00,000 of reproductive age group need infertility treatment and 15% of them can afford IVF treatment and 30% manage deliver healthy baby, the exact prevalence of such case will be in the range of 1 in 1,80,00,000 (one crore eighty lakhs).
👉🏻 About Dr. Sudip Basu:
Dr. Sudip Basu is a trustworthy, well-known, and one of the best IVF specialists in Kolkata and a top gynaecologist in South Kolkata. He has delivered more than 2000 IVF babies in last twenty years. He has 36 years of expertise and specialises in gynaecology, in vitro fertilisation, and infertility. He practises at Srishti Infertility Clinic – East Kolkata township. All his centres are well equipped with the latest technology and capable of handling multiple advanced procedures related to Obstetrics, Gynaecology, and infertility-related issues. Dr. Basu provides services like IVF (In Vitro Fertilisation) or IUI (Intrauterine Insemination) & other Artificial Reproductive techniques (ARTs), Maternity related services like Ante-Natal Care (ANC), Normal Delivery or C-Section or High-risk pregnancy care, periods-related issues like PCOD or PCOS, PMS, no periods or irregular periods and uterus-related problems like fibroids, polyps, ovarian cysts removal. The success rate of IVF treatments by Dr. Basu is 55% in IVF, 15% in IUI, and 70% in surrogacy. He has completed FRCPI, FRCOG, and MD and is trained and experienced in handling many complicated cases with success.