Manic Reaction After Induction of Ovulation With Gonadotropins

Ms. A, a 34-year-old married woman with no significant psychiatric history or family psychiatric history, was undergoing ovulation induction for secondary infertility. Her obstetric history included two first-trimester spontaneous abortions. After complete evaluation by a gynecologist, she had been diagnosed with secondary infertility and had received clomiphene, with no response. Several months later she embarked on ovulation induction that used urofollitropin and human chorionic gonadotropin. Urofollitropin, a follicle-stimulating hormone (FSH) preparation, was given intramuscularly daily from day 8 to day 12 of the patient's regular 4/24-day menstrual cycle. Estradiol levels were monitored and on day 12 attained the concentration of 2,171 pmol/liter (normal range=110–2,202 pmol/liter), indicating ripe follicles. On days 13 and 14 of her cycle, chorionic gonadotropin, a luteinizing hormone (LH) preparation, was given to induce ovulation.

Approximately midway through the course of ovulation induction, Ms. A experienced a rapid and dramatic heightening in mood. She described feeling “high and energized,” while friends observed that she was inappropriately happy, very talkative, and somewhat bizarre. Ms. A also described symptoms of reduced sleep, racing thoughts, and overactivity. In addition, she became hypersexual and preoccupied with sexual thoughts. She eventually had an extramarital affair with a man she met 1 week after her last hormone injection, and this led to the breakup of her 5-year marriage. After 2 months, the manic symptoms began to subside, and she recovered insight into her uncharacteristic behavior. She subsequently became clinically depressed and was hospitalized with suicidal ideation. She was treated with sertraline, 50 mg/day, with good response.