Mutation in the follicle-stimulating hormone receptor gene causes hereditary hypergonadotropic ovarian failure

Significance of a common single nucleotide polymorphism in exon 10 of the follicle-stimulating hormone (FSH) receptor gene for the ovarian response to FSH: a pharmacogenetic approach to controlled ovarian hyperstimulation

The p.N680S sequence variation of the follicle-stimulating hormone (FSH) receptor gene was previously shown to influence the ovarian response to FSH in normo-ovulatory women undergoing controlled ovarian hyperstimulation. In this prospective, randomized, controlled study, we tested whether the same daily dose of FSH results in lower levels of oestradiol in women homozygous for the p.N680S sequence variation, and whether the difference can be overcome by higher FSH doses. Women undergoing controlled ovarian hyperstimulation for in vitro fertilization or intracytoplasmic sperm injection and homozygous for the wild-type or for the p.N680S FSH receptor were randomly assigned to group I (Ser/Ser, n=24), receiving an FSH dose of 150 U/day, or group II (Ser/Ser, n=25), receiving an FSH dose of 225 U/day. In group III (Asn/Asn, n=44), the FSH dose was 150 U/day. Age and basal FSH levels were not different between groups. At ovulation induction, total FSH doses were comparable in group I (1631+/-96 U) and group III (1640+/-57 U) but significantly higher in group II (2421+/-112 U) (P<0.001). Peak oestradiol levels on the day of human chorionic gonadotrophin (hCG) administration were significantly lower in group I (5680+/-675 pmol/l) compared to group III (8679+/-804 pmol/l) (P=0.028). Increasing the FSH dose from 150 to 225 U/day overcame the lower oestradiol response in women with Ser/Ser (group II, 7804+/-983 pmol/l). In women undergoing controlled ovarian hyperstimulation, the p.N680S sequence variation results in lower oestradiol levels following FSH stimulation. This lower FSH receptor sensitivity can be overcome by higher FSH doses.

Follicle-stimulating hormone receptor gene mutations are not evident in Greek women with premature ovarian failure and poor responders

BACKGROUND/AIMS

This clinical and molecular study aimed to investigate the presence of follicle-stimulating hormone (FSH) receptor gene mutations in women with premature ovarian failure (POF) and poor responders to in vitro fertilization treatment.

METHODS

DNA was extracted from blood samples for subsequent polymerase chain reaction (PCR). PCR was followed by restriction fragment length polymorphism and direct sequencing.

RESULTS

No inactivating mutations reported so far were identified in exons 6, 7, and 10 in women with POF and poor responders.

CONCLUSION

FSH receptor gene mutations are not frequent in Greek patients with POF as is the case in the rest of the world except for cases with ovarian dysgenesis in Finland.

Transcriptional regulation of early oogenesis: in search of masters

Transcription factors in the germline play important roles in ovary formation and folliculogenesis, and control both oocyte development and somatic cell function. Factor in the germline (Figla) and newborn ovary homeobox gene (Nobox) represent a growing number of oocyte-specific transcription factors that regulate genes unique to oocytes. Studies on oocyte-specific transcription factors are important in understanding the genetic pathways essential for oogenesis, pluripotency, and embryonic development. Likely, these genes regulate reproductive life span and represent candidate genes for reproductive disorders, such as premature ovarian failure, and infertility. Therefore, oocyte-specific transcription factors, and oocyte-specific genes regulated by such factors, are attractive tissue-specific pharmacological targets to regulate human fertility.

Pharmacogenetics of controlled ovarian hyperstimulation

Controlled ovarian hyperstimulation (COH) is a routine treatment employed in most assisted reproductive techniques (ARTs). The existence of genetic factors involved in COH has been suspected. The main challenge for clinicians involved in ART is COH cycle cancellation, which usually occurs due to two opposing situations. On the one hand, there is the presence of a poor response during COH treatment, and on the other there is the presentation of a side effect related to gonadotropin hypersensitivity (ovarian hyperstimulation syndrome [OHSS]). Evidence for an association between single nucleotide polymorphisms and COH outcome has been obtained during the last decade. The genetic dissection of both extreme phenotypes of COH will be the main objective of this review. The development of predictive panels useful for the clinical management of COH is currently underway, and will improve the clinical management of patients undergoing ART.

An update of the pathophysiology of human gonadotrophin subunit and receptor gene mutations and polymorphisms

New information about mutations and polymorphisms in the genes for the gonadotrophins and their receptors has become available in the last few years. In this short review mutations and polymorphisms in gonadotrophins, their receptors and their pathophysiological effects and implications are discussed. An increasingly clear picture about the structure–function relationships of gonadotrophin action is emerging from the combining the types and the locations of the mutations with their phenotypic effects and the information about the crystal structure of these molecules.

Human FSH beta subunit gene is highly conserved

FSH is a pituitary gonadotropin that along with LH plays a key role in the regulation of gonadal function. The gonadotropic hormones are composed of two subunits, the common alpha subunit and the hormone-specific beta subunit, which determines the binding to specific receptors and induction of biological response. Unlike the LHbeta gene, shown in earlier studies to harbour several amino acid-altering polymorphisms and mutations, information about the eventual sequence variation of the human FSHbeta subunit is not available. In this study, we made sequence analysis and comparison of polymorphisms found in FSHbeta in two Caucasian populations, the Finns and the Danes. It was found that FSHbeta subunit is highly conserved in these populations. Compared with the published sequences, only three silent polymorphisms were detected in the coding regions of the gene, and the promoter sequence was completely identical with the reported sequence. Two of the polymorphisms found were novel, one in the Finnish and one in the Danish population. The results of the sequence analysis show that the human FSHbeta gene is highly conserved and amino acid changing mutations are apparently extremely rare, at least in the samples collected randomly from control populations. This may be due to the crucial role of normal FSH function in the regulation of fertility.

Macroorchidism in two unrelated prepubertal boys with a normal FSH receptor

BACKGROUND

Macroorchidism in prepuberty is an uncommon condition which we hypothesised might reflect constitutive activation of the FSH receptor (FSHR).

PATIENTS AND METHODS

Patient 1 was found to have macroorchidism (15 ml testicular volume) at the time of orchidopexy when 3.7 years of age. A gonadal biopsy was obtained at the time of surgery. Patient 2 developed macroorchidism (5 ml) when 8.8 years old. Despite a testicular volume >4 ml, morning testosterone levels were unrecordable with no measurable gonadotrophin production in either patient. Patient 2 had prepubertal gonadotrophin levels 3 years later despite a testicular volume that was 8 ml bilaterally. Inhibin B was measured and the FSHR sequenced in both patients.

RESULTS

Inhibin B levels were age and pubertal stage appropriate. Gonadal biopsy (patient 1) demonstrated areas of Sertoli cell hyperplasia. Sequence analysis of all 10 exons of the FSHR was normal. There was significant, presumed gonadotrophin-dependent testosterone production in both boys by 15 years of age.

CONCLUSIONS

The cause of prepubertal macroorchidism in our patients is unclear but the pronounced difference in phenotype suggests that there may be more than one underlying mechanism. This mechanism was not constitutive activation of a mutated FSHR.

Childhood cognitive ability and age at menopause: evidence from two cohort studies

OBJECTIVE

To investigate whether poorer cognitive ability in childhood is associated with an earlier menopause.

DESIGN

Two cohorts were included: a nationally representative British birth cohort study of 1,350 women born in March 1946 and followed up to age 54 years, and an Aberdeen cohort study of 3,465 women born in Aberdeen from 1950 to 1956 and followed up to age 44 to 50 years. Both cohorts had prospective information on childhood cognitive ability at age 7 or 8 years.

RESULTS

In both cohorts, women with lower cognitive scores in childhood reached menopause earlier than women with higher scores. With follow-up of menopause to 49 years, the hazard ratio (HR) for one standard deviation of the cognitive score was 0.80 (95% CI, 0.72-0.90) in the Aberdeen cohort and 0.84 (95% CI, 0.73-0.97) in the older 1946 birth cohort. The effect was still evident in the 1946 birth cohort with follow-up of menopause to 53 years (HR = 0.87; 95% CI, 0.79-0.95). These ratios were weakly attenuated by adjustment for potential confounding effects of lifetime socioeconomic circumstances, parity, and smoking.

CONCLUSIONS

The association between early cognitive ability and timing of menopause only partially reflects common risk factors, although residual confounding remains a possibility. Alternatively, early environmental or genetic programming may explain this association, perhaps through setting lifelong patterns of hormone release or causing transient hormonal changes at sensitive periods of development. These findings have implications for the interpretation of studies investigating an association between age at menopause and adult cognitive function.

Genetic studies to identify genes underlying menopausal age

Menopausal age is important as a retrospective marker for ovarian senescence, an early menopausal age is associated with an increased risk of cardiovascular diseases and osteoporosis, whereas a later menopausal age has been associated with an increased risk of breast cancer. The worldwide average for age at natural menopause is approximately 51 years and is more or less normally distributed with a range roughly between 40 and 60 years. Environmental factors explain only a small part of the variance and it has been proposed that genetic factors are the main source of variation. Menopausal age may be considered a continuous complex trait. Complex traits are defined as traits that are influenced by both multiple genetic and environmental factors. A category of complex traits comprises those that are measured on a continuous scale. The genomic loci that make up the genetic component are called 'quantitative trait loci' or QTLs. The first linkage study on menopausal age suggests that the involvement of the X-chromosome may not be limited to premature ovarian failure (POF), but may influence the broader spectrum of menopausal age. A potentially new locus for variation in menopausal age was allocated to chromosome 9. Further studies need to identify new candidate genes to help unravel the pathophysiology of menopausal age. It is becoming increasingly clear that, in any speciality, it should be acknowledged that genetic factors are involved in many traits and that uncovering these factors may provide insight into pathogenesis and ultimately advance prevention and treatment of disease. In this review we discuss methods and basic principles of gene finding for such traits, exemplified by menopausal age as phenotype. Furthermore, we give an overview of the state of the art of candidate gene studies and linkage studies.

Follicle-stimulating hormone receptor polymorphisms in a population of infertile women

BACKGROUND

There are two known polymorphisms of clinical relevance in the follicle-stimulating hormone (FSH) receptor exon 10, alanine or threonine at position 307, and asparagine or serine at position 680, giving rise to two discrete allelic variants: Thr307/Asn680 and Ala307/Ser680. At position 680, three FSH receptor variants are possible: Asn/Asn, Asn/Ser, and Ser/Ser. We hypothesized an association between FSH receptor polymorphisms and ovarian reserve.

METHODS

FSH receptor polymorphisms at position 680 were studied in a population of 68 infertile women. We used serum FSH level at cycle day 3 as a screening for ovarian reserve. DNA was extracted from peripheral leukocytes in whole blood by using PCR and DNA sequencing in order to determine the type of FSH receptor.

RESULTS

The distribution of FSH receptor variants was Asn/Asn (AA) 35%, Asn/Ser (AS) 24%, and Ser/Ser (SS) 41%. In women with normal ovarian reserve, FSH levels at cycle day 3 were 5.6 +/- 1.9 (AA group), 6.7 +/- 1.3 (AS group), and 5.7 +/- 1.7 (SS group) (non-significant). Corresponding FSH levels at cycle day 10 were 6.9 +/- 1.9, 6.3 +/- 1.7, and 8.3 +/- 2.8 (P < 0.01, AA and AS vs. SS group). In the SS group, FSH levels at cycle day 10 were significantly higher than they were at cycle day 3 (P < 0.05).

CONCLUSIONS

The results show that Ser/Ser-680 predominates in the studied infertile population. Furthermore, women with normal ovarian reserve and the Ser/Ser FSH receptor variant had significantly higher FSH levels, compared to women with Asn/Asn and Asn/Ser variants. FSH receptor genotyping may, thus, be interesting as an adjunct indicator of ovarian reserve for infertile women undergoing assisted reproduction, and may be helpful in the determination of the starting dosage of FSH in in vitro fertilization.

Galactose-1-phosphate uridyl transferase gene mutations in women with premature ovarian failure

We determined the frequency of galactose-1-phosphate uridyl transferase gene mutations: Q188R, K285N, and the Duarte allelle in 86 patients with idiopathic premature ovarian failure (POF) and 95 controls. No association of the mutations with POF was found.

Mutational analysis of the homeobox region of the human NOBOX gene in Japanese women who exhibit premature ovarian failure

To determine whether mutations of the homeobox region of the human NOBOX gene are present in Japanese women with premature ovarian failure (POF), genomic DNA of blood samples from 30 women with POF and 20 normal controls were extracted for polymerase chain reaction (PCR) and analyzed by direct sequencing. No mutations in exons 2-6 of the NOBOX gene, including the homeobox region, could be identified in Japanese women with POF. Our data suggest that mutations of the homeobox region of the NOBOX gene are uncommon in Japanese patients with POF.

Premature ovarian failure

Premature ovarian failure (POF) causing hypergonadotrophic hypogonadism occurs in 1% of women. In majority of cases the underlying cause is not identified. The known causes include: (a) Genetic aberrations, which could involve the X chromosome or autosomes. A large number of genes have been screened as candidates for causing POF; however, few clear causal mutations have been identified. (b) Autoimmune ovarian damage, as suggested by the observed association of POF with other autoimmune disorders. Anti-ovarian antibodies are reported in POF by several studies, but their specificity and pathogenic role are questionable. (c) Iatrogenic following surgical, radiotherapeutic or chemotherapeutic interventions as in malignancies. (d) Environmental factors like viral infections and toxins for whom no clear mechanism is known. The diagnosis is based on finding of amenorrhoea before age 40 associated with FSH levels in the menopausal range. Screening for associated autoimmune disorders and karyotyping, particularly in early onset disease, constitute part of the diagnostic work-up. There is no role of ovarian biopsy or ultrasound in making the diagnosis. Management essentially involves hormone replacement and infertility treatment, the only proven means for the latter being assisted conception with donated oocytes. Embryo cryopreservation, ovarian tissue cryopreservation and oocyte cryopreservation hold promise in cases where ovarian failure is foreseeable as in women undergoing cancer treatments.

Genetics and assisted reproduction technology

In the past 20 years, a significant improvement has been shown in the treatment for infertility in both women and men through the development of in vitro fertilization (IVF) and intracytoplasmic sperm injection (ICSI). Only donated sperm could be previously used for treatment; now oocytes can also be donated. Furthermore, the combination of IVF and ICSI with advanced genetic methods has made preimplantation genetic diagnosis possible for many genetic conditions. These methods enable genetic testing of the early human embryo by using only a single cell, one blastomere biopsied from the embryo, as the sample from which the diagnosis of many chromosome rearrangements and other inherited diseases can be made. It has also been established that a considerable proportion of infertility is caused by genetic defects, which have several implications for infertility treatment. The purpose of this review is to give a concise introduction on how genetics is involved in assisted reproduction technology to specialists who may not be working in this particular field of gynecology, but who would need some knowledge of this for proper care of their patients.

Silencing of Fshr occurs through a conserved, hypersensitive site in the first intron

Expression of the FSH receptor (Fshr) is restricted to testicular Sertoli cells and ovarian granulosa cells, thereby limiting the direct targets of FSH action to these somatic cells of the gonads. Earlier studies indicate that transcription of Fshr in the gonads requires elements outside the gene's immediate 5' flanking sequence. To help uncover candidate regulatory sequences, comparative genomics and deoxyribonuclease I hypersensitivity mapping were employed. A total of 156 evolutionarily conserved sequences were found, and partial deoxyribonuclease I hypersensitivity mapping across 45 kb of 5' flanking sequence and the first intron identified four hypersensitive sites, DHS1-4. Notably, DHS1 and DHS2 localized to conserved sites in the promoter region and exon 1 and correlated with the active state of the gene. DHS3 also corresponded to a conserved site (site 7) but was more pronounced in nonexpressing myoid cells, suggesting a role in gene silencing. Transient transfection analysis of DHS3 confirmed its role in gene silencing, a function that was promoter, cell type, and position dependent. Protein-DNA binding studies on DHS3 revealed that octamer transcription factor 1 (OCT-1) and GATA-4 bound site 7, in vitro, and transient transfection analysis showed that their binding sites were required for silencing activity. Furthermore, chromatin immunoprecipitation revealed that OCT-1 bound to site 7 in the endogenous gene, but only in myoid cells. In contrast, GATA-1 bound site 7 predominantly in Sertoli cells, suggesting that it attenuates silencer activity. The findings reveal that OCT-1 binds within DHS3 to silence Fshr transcription and implicate members of the GATA family in the modulation of this activity.

Gonadotropin gene targeting and biological implications

Pituitary gonadotropins FSH and LH are heterodimeric glycoproteins consisting of a common alpha and a hormone-specific beta subunit that are non-covalently linked. These hormones orchestrate gonadal growth, differentiation, and function by regulating both steroid-ogenesis and gametogenesis. Advances in the past two decades in manipulating the mouse genome by site-specific mutagenesis have heralded a new dimension to our understanding of the biology of gonadotropins. Using these gene-targeting approaches, knockout mice lacking the hormone-specific gonadotropin subunits, and hence the functional dimeric hormones, have been generated. These individual gonadotropin-deficient mice are useful to delineate the distinct in vivo biological roles of FSH and LH. These mice also serve as valuable genetic tools to study the signaling mechanisms within the gonads and help a better understanding of some forms of human infertility.

Experimentally induced androgen depletion accentuates ethnicity-related contrasts in luteinizing hormone secretion in asian and caucasian men

The basis for ethnicity-related distinctions in gonadotropin secretion are unknown but may have important populational and physiological implications. In male contraceptive trials, exogenous testosterone and progestins suppress spermatogenesis to a greater degree in Asian than Caucasian men. In addition, iv infusion of testosterone inhibits LH release more in Asian than Caucasian volunteers. We test the converse postulate that experimental reduction of androgen-dependent negative feedback by way of the steroidogenic inhibitor combination ketoconazole/dexamethasone will unveil ethnicity-related mechanisms of regulated LH secretion in young men. LH release was monitored by sampling blood every 10 min for 24 h followed by immunoradiometric assay, model-free pulse detection, an entropy (regulatory) statistic, and cosine regression. Statistical comparisons revealed that healthy young Asian and Caucasian men maintain comparable baseline concentrations of LH, testosterone, estradiol, SHBG, and molar testosterone to SHBG ratios. In contrast, the two ethnic groups differ prominently in each of basal, pulsatile, entropic, and 24-h rhythmic LH adaptations to short-term androgen withdrawal. Therefore, we postulate that physiological nonuniformity of sex steroid-dependent negative feedback in particular may contribute to populational diversity in LH regulation.

No association of estrogen receptor α and cytochrome P450c17α polymorphisms with age at menopause in a Dutch cohort

BACKGROUND

Age at menopause is under strong genetic control. So far, genetic variations of only one gene, the PvuII polymorphism of the estrogen receptor alpha (ERalpha) gene, have been shown to be associated with age at onset of menopause. This study aims to investigate whether PvuII, XbaI and B-variant polymorphisms of the ERalpha gene, and the MspAI polymorphism of the cytochrome P450c17alpha (CYP17) gene are associated with age at menopause in a Dutch cohort.

METHODS

DNA was isolated from urine samples of 385 Caucasian women with natural menopause and the genotypes of the four polymorphisms were determined. A questionnaire was used for background characteristics. The genotypes of PvuII, XbaI, MspAI were obtained by PCR restriction fragment length polymorphism analysis. The B-variant was determined with an allele-specific oligonucleotide hybridization method. Two-sided t-tests were performed to assess the association between the four polymorphisms and menopausal age. The PvuII and XbaI polymorphisms were analysed separately as well as in a combined score.

RESULTS

The results show that none of the polymorphisms independently, nor the combined genotypes for PvuII and XbaI, were associated with age at natural menopause.

CONCLUSION

No evidence was found for a relationship between common variants of the ERalpha gene and the CYP17 gene with age at natural menopause.

Mutant G-protein-coupled receptors as a cause of human diseases

G-protein-coupled receptors (GPCR) are involved in directly and indirectly controlling an extraordinary variety of physiological functions. Their key roles in cellular communication have made them the target for more than 60% of all currently prescribed drugs. Mutations in GPCR can cause acquired and inherited diseases such as retinitis pigmentosa (RP), hypo- and hyperthyroidism, nephrogenic diabetes insipidus, several fertility disorders, and even carcinomas. To date, over 600 inactivating and almost 100 activating mutations in GPCR have been identified which are responsible for more than 30 different human diseases. The number of human disorders is expected to increase given the fact that over 160 GPCR have been targeted in mice. Herein, we summarize the current knowledge relevant to understanding the molecular basis of GPCR function, with primary emphasis on the mechanisms underlying GPCR malfunction responsible for different human diseases.

A novel 30 bp deletion in the FOXL2 gene in a phenotypically normal woman with primary amenorrhoea: Case report

In a Slovene patient with primary amenorrhoea without an association with blepharophimosis/ptosis/epicanthus inversus syndrome (BPES), a novel 30 bp deletion was identified in the FOXL2 gene. We report the clinical features of this woman who has spontaneously conceived and delivered two live healthy babies. The novel deletion was predicted to remove 10 out of 14 alanines (A221_A230del), from the polyalanine tract downstream of the winged helix/forkhead domain of the FOXL2 protein. The patient's parents and sister were shown not to carry this deletion. Despite seeing an anovulatory secretory pattern of FSH, follicles developed spontaneously. Persistent and consistent monitoring have practical implications for genetic and fertility counselling in the era when women with premature ovarian failure usually seek ovum donation. The role of FOXL2 in the development of infertility is still unclear, but several lines of evidence suggest that it plays a central role in follicle development.

Targeted disruption of luteinizing hormone beta-subunit leads to hypogonadism, defects in gonadal steroidogenesis, and infertility

Luteinizing hormone (LH) and follicle-stimulating hormone (FSH) act on gonadal cells to promote steroidogenesis and gametogenesis. Clarifying the in vivo roles of LH and FSH permits a feasible approach to contraception involving selective blockade of gonadotropin action. One way to address these physiologically important problems is to generate mice with an isolated LH deficiency and compare them with existing FSH loss-of-function mice. To model human reproductive disorders involving loss of LH function and to define LH-responsive genes, we produced knockout mice lacking the hormone-specific LHbeta-subunit. LHbeta-null mice are viable but demonstrate postnatal defects in gonadal growth and function resulting in infertility. Mutant males have decreased testes size, prominent Leydig cell hypoplasia, defects in expression of genes encoding steroid biosynthesis pathway enzymes, and reduced testosterone levels. Furthermore, spermatogenesis is blocked at the round spermatid stage, causing a total absence of the elongated spermatids. Mutant female mice are hypogonadal and demonstrate decreased levels of serum estradiol and progesterone. Ovarian histology demonstrates normal thecal layer, defects in folliculogenesis including many degenerating antral follicles, and absence of corpora lutea. The defects in both sexes are not secondary to aberrant FSH regulation, because FSH levels were unaffected in null mice. Finally, both male and female null mice can be pharmacologically rescued by exogenous human chorionic gonadotropin, indicating that LH-responsiveness of the target cells is not irreversibly lost. Thus, LHbeta null mice represent a model to study the consequences of an isolated deficiency of LH ligand in reproduction, while retaining normal LH-responsiveness in target cells.

Current evaluation of amenorrhea

Amenorrhea is the absence or abnormal cessation of the menses. Primary and secondary amenorrhea describe the occurrence of amenorrhea before and after menarche, respectively.

Novel expression of gonadotropin subunit genes in oocytes of the gilthead seabream (Sparus aurata)

It is widely believed that FSH and LH, which are known to play key roles in controlling the production of functional oocytes in vertebrates, are synthesized and secreted exclusively by the anterior pituitary. Here we present evidence for the novel expression of FSHbeta, LHbeta, and the common glycoprotein-alpha (Cgalpha) in the gilthead seabream ovary. Using in situ hybridization and immunocytochemistry, FSHbeta was detected in primary-growth and secondary-growth-I oocytes, LHbeta was found in secondary-growth oocytes, and Cgalpha was observed in both primary and secondary-growth oocytes. Northern blot analyses demonstrated that Fshbeta transcript is 0.6 kb in both pituitary and ovary, whereas the ovarian Lhbeta transcript (1.1 kb), unexpectedly, is longer than the known pituitary Lhbeta transcript (0.6 kb). Sequence analyses revealed that ovarian Lhbeta is driven by a different promoter than pituitary Lhbeta, which generates an additional 459 bases at the distal portion of the 5'-untranslated region of the ovarian Lhbeta. Furthermore, using in vitro ovarian fragment incubation, we demonstrated that mammalian GnRH analog agonist enhanced the expression of ovarian Fshbeta (up to 2.7-fold), Lhbeta (up to 1.4-fold), Cgalpha (up to 1.8-fold), and the secretion of ovarian LH (up to 2.2-fold). In contrast, GnRH antagonist, analog E, suppressed the secretion of ovarian LH. Our findings suggest that a GnRH-gonadotropin axis is present in the gilthead seabream ovary and that FSH and LH, the well-characterized pituitary hormones, may have prominent novel roles in teleost intraovarian communication between oocytes and ovarian follicle cells.

Perspectives on reproductive senescence and biological aging: studies in genetically altered follitropin receptor knockout [FORKO] mice

Increased life expectancy leads to increased age-associated health issues in both sexes. For menopausal women the most important of these appear to result from the severe estrogen deficiency caused by ovarian dysfunction. The consequences among others include hot flashes, osteoporosis, obesity, impaired memory, higher incidence of Alzheimer's disease and cardiovascular disease. Ovarian function and steroidogenesis are influenced by pituitary gonadotropins, including follicle-stimulating hormone (FSH), whose actions are mediated through ovarian receptors. This article highlights our recent data pertinent to aging as derived from a novel genetically modified animal model [the FORKO mouse (FOllitropin Receptor KnockOut) lacking the FSH receptor. FORKO female mice experience a chronic depletion of estrogen (E2) from early development, and have phenotypes similar to aging women, with ovarian failure, obesity, skeletal changes, and ovarian tumors. A variety of findings support the conclusion that E2 deficiency in FORKO mice is responsible for their neural impairments associated with glial cell hypertrophy, region-specific brain cells loss, and abnormal behavior. Findings from mice with FSH receptor haploinsufficiency mice ('menopausal mice') are also shedding light on the molecular basis of menopausal conditions that include degeneration of the hippocampus. Many phenotypes noted in the null condition also occur in +/- females but in an age related manner. Thus, the FORKO mouse becomes an excellent model to investigate mechanisms underlying age-related changes especially when these events are accelerated, as in menopausal women. Opportunities abound to assess the potential benefits/adverse effects of hormone replacement regimen on various targets.

Screening for known mutations in EIF2B genes in a large panel of patients with premature ovarian failure

BACKGROUND: Premature Ovarian Failure (POF), defined as the development of hypergonadotropic amenorrhea before the age of 40 years, occurs in about 1% of all women. Other than karyotype abnormalities, very few genes are known to be associated with this ovarian dysfunction. Recently, in seven patients who presented with POF and white matter abnormalities on MRI (ovarioleukodystrophy) eight mutationswere found in EIF2B2, 4 and 5. METHODS: To further test the involvement of known mutations of EIF2B genes in POF, we screened 93 patients with POF who did not have identified leukodystrophy or neurological symptoms. We evaluated these eight mutations and two additional mutations that had been found in patients with milder forms of eIF2B-related disorders. We used restriction enzymes and direct sequencing. RESULTS: None of the known mutations in EIF2B genes, either homozygous or heterozygous, were identified in our 93 patients with pure 46,XX POF. The upper 95 % confidence limit of the proportion 0/93 is 3.2%. CONCLUSIONS: We conclude that eIF2B mutations, already described in cases of POF associated with white matter abnormalities, are an uncommon cause of pure spontaneous premature ovarian failure.

Mutation analysis of two candidate genes for premature ovarian failure, DACH2 and POF1B

BACKGROUND

Balanced X;autosome translocations interrupting the 'critical region' of the long arm of the human X chromosome are often associated with premature ovarian failure (POF). However, the mechanisms leading to X-linked ovarian dysfunction are largely unknown, as the majority of the X chromosome breakpoints have been mapped to gene-free genomic regions. A few genes have been found to be interrupted, but their role has never been clarified.

METHODS AND RESULTS

By fine mapping of the X chromosome breakpoint of an X;autosome balanced translocation, we identified a new interrupted gene, POF1B. We performed a mutation analysis of POF1B and of another gene previously identified, DACH2, localized approximately 700 kb distal in Xq21, in a cohort of >200 Italian POF patients. Rare mutations were found in patients in both genes.

CONCLUSIONS

Our findings could not demonstrate any involvement of POF1B, but suggest that rare mutations in the DACH2 gene may have a role in the POF phenotype.

Mutations affecting gonadotropin secretion and action

A number of mutations are known to disturb the development and function of the hypothalamic-pituitary-gonadal axis. They affect hypothalamic-pituitary-gonadal function at multiple levels, from the migration of gonadotropin releasing hormone neurons to the hypothalamus right through to gonadotropin action in the ovary and testis. Most of the mutations are inactivating, causing various forms of hypogonadism. Exceptions are the activating mutations of the luteinizing hormone receptor, causing male-limited gonadotropin-independent precocious puberty. The human mutations and genetically modified animal models have clarified the molecular pathogenesis of hypogonadism and such disorders can now be diagnosed using molecular biological techniques, enabling selection of specific treatments and appropriate counselling of patients and their families.

Significance of ovarian histology in the management of patients presenting a premature ovarian failure

BACKGROUND

Premature ovarian failure (POF) is a heterogeneous syndrome, possibly due to mutations of genes involved in the normal development of the ovary and/or follicles. Based essentially on animal models, these mutations are associated with various ovarian phenotypes, from a complete absence of follicles to a partial follicular maturation. The aim of the present study was to determine whether ovarian histology, compared to pelvic ultrasonography, would be helpful in identifying which patients display an impaired follicular reserve and/or growth, and in orientating the search for POF aetiology.

METHODS AND RESULTS

We studied a cohort of 61 patients suffering from POF with a normal karyotype. Their median age (range) at diagnosis was 26 years (15-39). The FSH plasma level was high, 67.0 IU/l (13-155). Estradiol and inhibin B plasma levels were low: 18.5 pmol/l (18.5-555) and 5 pg/ml (5-105) respectively. Both pelvic ultrasonography and ovarian biopsies were performed in each patient. The presence of follicles suggested at ultrasonography was confirmed at histology in 56% of the patients. Ovarian histology led to the distinction of two phenotypes: (i) small-sized ovaries, deprived of follicles; and (ii) normal-sized ovaries with partial follicular maturation. To confirm the value of ovarian biopsies, samples from 20 normal women were studied. These demonstrated that ovarian biopsy at random enables reliable assessment of follicular presence, especially when their size is <2 mm.

CONCLUSION

Ovarian histology appears to be a reliable tool in evaluating the follicular reserve, and helpful and complementary to clinical and hormonal phenotyping in orienting the search for the various genetic causes of POF syndrome.

Screening of FSH receptor gene in Argentine women with premature ovarian failure (POF)

Diverse mutations in FSH-receptor (FSHR) gene have been described as possible cause of premature ovarian failure (POF). To investigate the presence of mutations and/or polymorphisms in FSHR gene, DNA from 20 POF, 5 of which were diagnosed as resistant ovary syndrome (ROS), and from 44 controls was isolated from peripheral lymphocytes. The complete coding sequence was analysed by PCR followed by SSCP, direct sequencing or restriction enzyme analysis. No mutations in FSHR gene were identified in the patients studied. The two already described polymorphisms in exon 10, A919G and A2039G, cosegregated in all the homozygous individuals, indicating that FSHR presents two isoforms: Ala307-Ser680 and Thr307-Asn680. OR results suggest that the 919G-2039G allelic variant or the homozygous genotype is not associated to disease risk. In addition, a heterozygous substitution T1022C (Val341Ala) was found in two control subjects. We suggest that mutations in FSHR gene are rare in women with POF in Argentine. Presence of a particular FSHR isoform does not appear to be associated with this disease.

Current evaluation of amenorrhea

Amenorrhea is the absence or abnormal cessation of the menses. Primary and secondary amenorrhea describe the occurrence of amenorrhea before and after menarche, respectively.

Hypergonadotropic ovarian failure associated with an inherited mutation of human bone morphogenetic protein-15 (BMP15) gene

Hypergonadotropic ovarian failure is a common cause of female infertility. It is a heterogeneous disorder that, in the most severe forms, is a result of ovarian dysgenesis (OD). Most OD cases are associated with major X-chromosome abnormalities, but the pathogenesis of this disorder is still largely undefined in patients with a normal karyotype. Animal models showed the important role in female reproduction played by the product of a gene located at Xp11.2 in humans (BMP15). BMP15 is an oocyte-specific growth/differentiation factor that stimulates folliculogenesis and granulosa cell (GC) growth. We report two sisters with a normal karyotype who are affected with hypergonadotropic ovarian failure due to OD. The familial presentation suggested a genetic origin, and candidate genes were screened for mutations. A heterozygous nonconservative substitution in the pro region of BMP15 (Y235C) was identified in both sisters but not in 210 control alleles. This mutation was inherited from the father. Mutant BMP15 appears to be processed abnormally, is associated with reduced GC growth, and antagonizes the stimulatory activity of wild-type protein on GC proliferation. In conclusion, the first natural mutation in human BMP15 is associated with familial OD, indicating that the action of BMP15 is required for the progression of human folliculogenesis. This condition represents an exceptional example of X-linked human disease exclusively affecting heterozygous females who inherited the genetic alteration from the unaffected father. BMP15 defects are involved in the pathogenesis of hypergonadotropic ovarian failure in humans.

Molecular mechanisms of end-organ resistance

Hormone resistance is caused by mutations in hormone receptors or by functional desensitization of hormone signaling pathways. Mutations that cause hormone resistance have been described for most classes of hormones, including peptides like growth-hormone releasing hormone (GHRH); large proteins such as insulin and the glycoprotein hormones; steroid hormones; and even ions such as calcium. In the case of proteins, many of these receptors include seven transmembrane, G-protein-coupled receptors such as those for thyroid-stimulating hormone (TSH), luteinizing hormone (LH), follicle-stimulating hormone (FSH), adrenocorticotrophic hormone (ACTH), GHRH and vasopressin. However, other classes of membrane receptors can also be affected. For example, the insulin receptor is a tyrosine kinase receptor, the growth hormone (GH) and leptin receptors belong to the cytokine family of receptors, and the Müllerian inhibiting substance (MIS, also known as anti-Müllerian hormone [AMH]) receptor is related to the transforming growth factor beta (TGFbeta) serine kinase group of receptors. G-protein mutations cause Albright's hereditary osteodystrophy, and, as might be expected, there is resistance to many different hormones that act through G-protein-coupled receptors. A variety of resistance syndromes involve members of the nuclear receptor superfamily, including resistance to androgens, vitamin D, thyroid hormone, glucocorticoids and estrogen. Mutations in orphan nuclear receptors such as steroidogenic factor-1 (SF-1) or DAX-1 result in defective glandular development, thereby indirectly causing hormone resistance. Another form of resistance, sometimes referred to as "post-receptor" resistance, is typified by acquired forms of insulin or leptin resistance, and the pathophysiology remains elusive. Studies of naturally occurring mutations have provided important insights into the structure and function of receptors. By definition, the mutations that cause disease identify important functional domains in the proteins. Although therapy is straightforward in some disorders, it is challenging or incompletely studied in others.

Age at natural menopause is not linked with the follicle-stimulating hormone receptor region: a sib-pair study

OBJECTIVE

Studies have shown that age at natural menopause is heritable. Mutations in the FSH-receptor have been identified in women with premature ovarian failure (POF) and the FSH-receptor gene may, therefore, be considered a candidate gene for (early) menopausal age. This study investigates whether there is linkage between genetic markers in the FSH-receptor region and (early) age at menopause using a sib-pair design.

DESIGN

Sib-pair based linkage analysis.

SETTING

Sister pairs and their first-degree family members from The Netherlands.

PATIENT(S)

The inclusion criteria for a family were natural menopause in upper or lower tail of the distribution of menopausal age in at least two sisters. A total of 126 families with at least one sib-pair were included in this study. Six polymorphic markers encompassing the FSH-receptor gene were genotyped.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Single point and multipoint logarithm of the odds (LOD) scores.

RESULT(S)

None of the markers showed evidence in favor of linkage with overall age at natural menopause or early age at natural menopause.

CONCLUSION(S)

Possibly, age at natural menopause in the more or less normal range is not part of the spectrum of phenotypes determined by mutations in the FSH-receptor gene. Alternatively, our results might be explained by genetic heterogeneity in the left tail of the distribution of menopausal age. This can limit the chance of finding a genetic locus, especially if this factor has a modest contribution to the phenotype.

Foxl2 disruption causes mouse ovarian failure by pervasive blockage of follicle development

FOXL2 mutations cause gonadal dysgenesis or premature ovarian failure (POF) in women, as well as eyelid/forehead dysmorphology in both sexes (the 'blepharophimosis-ptosis-epicanthus inversus syndrome', BPES). Here we report that mice lacking Foxl2 recapitulate relevant features of human BPES: males and females are small and show distinctive craniofacial morphology with upper eyelids absent. Furthermore, in mice as in humans, sterility is confined to females. Features of Foxl2 null animals point toward a new mechanism of POF, with all major somatic cell lineages failing to develop around growing oocytes from the time of primordial follicle formation. Foxl2 disruption thus provides a model for histogenesis and reproductive competence of the ovary.

Clinical and molecular analysis of human reproductive disorders in Brazilian patients

Several genes that influence the development and function of the hypothalamic-pituitary-gonadal-axis (HPG) have been identified. These genes encode an array of transcription factors, matrix proteins, hormones, receptors, and enzymes that are expressed at multiple levels of the HPG. We report the experience of a single Endocrinology Unit in the identification and characterization of naturally occurring mutations in families affected by HPG disorders, including forms of precocious puberty, hypogonadism and abnormal sexual development due to impaired gonadotropin function. Eight distinct genes implicated in HPG function were studied: KAL, SF1, DAX1, GnRH, GnRHR, FSHbeta, FSHR, and LHR. Most mutations identified in our cohort are described for the first time in literature. New mutations in SF1, DAX1 and GnRHR genes were identified in three Brazilian patients with hypogonadism. Eight boys with luteinizing hormone- (LH) independent precocious puberty due to testotoxicosis were studied, and all have their LH receptor (LHR) defects elucidated. Among the identified LHR molecular defects, three were new activating mutations. In addition, these mutations were frequently associated with new clinical and hormonal aspects, contributing significantly to the knowledge of the molecular basis of reproductive disorders. In conclusion, the naturally occurring genetic mutations described in the Brazilian families studied provide important insights into the regulation of the HPG.

Re-evaluation of Secondary Amenorrheic Patients One Year after Initial Diagnosis: A Prospective Study

OBJECTIVES

The aim of the study was to re-evaluate women with secondary amenorrhea one year after the first visit evaluation.

STUDY METHODS

One hundred and seventy-five women with secondary amenorrhea were evaluated on the first visit. Their ages ranged from 18 to 29. Secondary amenorrhea was defined by the absence of menses for more than 3 months after excluding pregnancy. Women who were attempting to conceive were excluded from the study. 1) One hundred and two women were anovulatory (2) 36 had hypogonadotropic hypogonadism, 3) 11 had hypergonadotropic hypogonadism, and 4) 21 had hyperprolactinemia, 5) and five fell into other categories. The one hundred and forty-nine women in categories 1) to 3) were followed up for one year after the first diagnosis was made. A monthly progestational agent or HRT (hormone replacement therapy) was given to women with anovulation or hypogonadism, respectively.

RESULTS

Of the 149 women in categories 1) to 3), 100 could be evaluated one year after the first diagnosis. There were 31 women whose diagnosis was changed. Anovulation changed to hypogonadotropic hypogonadism in 11 women, oligomenorrhea in four, and normal ovulatory cycle in two. Hypogonadotropic hypogonadism changed to anovulation in nine women, and to normal ovulatory cycle in one. Hypergonadotropic hypogonadism changed to normal ovulatory cycle in two women.

CONCLUSIONS

A significant finding is that approximately one third of the women initially diagnosed with secondary amenorrhea, upon re-evaluation within one year had their diagnosis changed. Therefore evaluation of amenorrhea at an appropriate time is critical for proper management.

Molecular abnormalities of FSH and LH action

The identification of naturally occurring genetic mutations in individuals with disorders of reproductive function is the first logical step to therapy. To date, diagnostic investigations have been assisted by polymerase chain reaction and the development of an increasing number of effective screening techniques to scan genomic DNA (deoxyribonucleic acid) for causative mutations. The continued expansion of these technologies, coupled with high throughput gene sequencing, will ultimately result in automated DNA diagnosis for the practicing clinician at the point of care. At that time, the direct examination of a patient's DNA will be the definitive means of establishing the presence of specific genetic changes that cause or increase one's susceptibility to disease. This presentation selects important candidate genes in the human hypothalamic-pituitary-ovarian axis (HPG), reviews our knowledge of the spontaneously occurring human mutations that affect these genes, and reviews the biological implications of this information. To date, causative mutations in candidate genes have provided important insights into the transcription factors, receptors, and hormones that regulate the HPG axis at many levels. A major challenge in this field is that mutations in many of these genes and others remaining to be identified lead to infertility. The reduction in reproductive fitness due to these mutations limits the ability of investigators to use traditional genetic linkage and association studies to identify and clone important unidentified reproductive genes. Fortunately analysis of human gametes and new strategies that are being developed for the identification and mapping of complex human diseases will become increasingly important in continuing studies of idiopathic human infertility. At this time, it is helpful for the reader to become acquainted with some of the prototype mutations in candidate genes, their phenotypic consequences, and their prevalence. This presentation is designed to describe the known mutations in the gonadotropin genes and the genes encoding their respective receptors. The phenotypic effects of these mutations is compared, and evidence for causation is reviewed.

Dynamics of ovarian development in the FORKO immature mouse: structural and functional implications for ovarian reserve

Adult Follitropin Receptor Knockout (FORKO) female mice are infertile and estrogen deficient. In order to understand the peri/postnatal developmental changes, we have now characterized the structural and molecular aberrations by comparing several markers of follicular development in 2-, 10-, and 24-day-old wild-type and FORKO females. By Day 24, FORKO mice have 40%-50% smaller uteri and vaginas. Estradiol is undetectable but testosterone and LH levels are already elevated at this age. FORKO ovaries are 45% smaller, indicating a postnatal or perinatal deficit consequent to FSH receptor ablation. This is attributable to decreased numbers of growing follicles and reduced diameter. Developmental markers, such as Müllerian inhibiting substance, GATA-4, estrogen receptor beta, and androgen receptor, were differentially expressed in granulosa cells. In the 2-day-old mutant neonates, a faster recruitment process was noted that later slowed down, impeding development of follicles. This is noteworthy in light of the controversy regarding the direct role of FSH/receptor system as a determinant of small and preantral follicle development in rodents. As the pool of nongrowing primordial follicles specifies the duration of female fertility and timing of reproductive senescence, we believe that the postnatal FORKO female mouse could help in exploring the signals that impact on early folliculogenesis. In addition, our data suggest that the FSH/receptor system is a major contributor to the formation and recruitment of the nongrowing pool of follicles as early as Postnatal Day 2 in the mouse.

Follicle-stimulating hormone receptor polymorphisms in women with normogonadotropic anovulatory infertility

OBJECTIVE

To assess the incidence of different FSH receptor genotypes in normogonadotropic anovulatory infertile women (World Health Organization class II) and normo-ovulatory controls and to correlate these genotypes with baseline characteristics and ovarian responsiveness during ovulation induction.

DESIGN

Cross-sectional study.

SETTING

University hospital.

PATIENT(S)

Thirty normo-ovulatory controls and 148 normogonadotropic anovulatory infertile women.

INTERVENTION(S)

All participants underwent a standardized evaluation that included cycle history, body mass index measurement, and transvaginal ultrasonography of ovaries. Fasting blood samples were obtained for endocrine evaluation. Ovarian responsiveness to FSH in normogonadotropic anovulatory infertile women was assessed during ovulation induction, and DNA was analyzed to determine the FSH receptor genotype.

MAIN OUTCOME MEASURE(S)

Prevalence of FSH receptor polymorphisms, baseline serum FSH levels, amount of FSH administered, duration of stimulation, and ovarian response dose.

RESULT(S)

The Thr/Thr 307 genotype was significantly less prevalent (52% vs. 23%) and the Ser/Ser 680 polymorphism was significantly more prevalent (40% vs. 16%) in patients compared with controls. Normogonadotropic anovulatory infertile women with the Ser/Ser 680 polymorphism presented with higher median FSH serum levels (5.2 IU/L [range, 2.4-9.7 IU/L]) than did those with the Asn/Asn 680 (4.6 IU/L [range, 1.4-5.8 IU/L) and Asn/Ser 680 (4.5 IU/L [range, 1.8-9.7 IU/L) variants. However, ovarian responsiveness to FSH was similar among anovulatory women with the various polymorphisms.

CONCLUSION(S)

Normogonadotropic anovulatory infertile patients have a different FSH receptor genotype than do normo-ovulatory controls. Although this characteristic is associated with increased baseline FSH serum levels, altered ovarian sensitivity to exogenous FSH during ovulation induction could not be established.

Mechanisms of follicular dysfunction in 46,XX spontaneous premature ovarian failure

Approximately one half of young women who have 46,XX spontaneous premature ovarian failure have ovarian follicles remaining in the ovary. These follicles function intermittently and unpredictably, and pregnancies can occur in these women without intervention, even many years after the diagnosis. Clearly, the term "premature menopause" is an inaccurate term for this condition. At present, there are no proven therapies that will improve follicular function for these women. Inappropriate luteinization related to low follicle number seems to be a major mechanism of follicular dysfunction. Autoimmune oophoritis, although apparently an uncommon cause of follicular dysfunction in these women, nonetheless presents the opportunity to develop an effective therapy to restore fertility. Young women with 46,XX spontaneous premature ovarian failure benefit from the care of a sensitive clinician, one who is willing to spend a little more time informing them about the diagnosis and referring them to other sources of information. With appropriate medical management and emotional support provided by a sensitive clinician, most young women with 46,XX spontaneous premature ovarian failure will lead happy, healthy, and fulfilling lives.

Role of follicle-stimulating hormone receptor Ser680Asn polymorphism in the efficacy of follicle-stimulating hormone

OBJECTIVE

To evaluate the association between FSH efficacy and FSHR alleles.

DESIGN

Retrospective study.

SETTING

University-based fertility unit and a private center for biomedical research.

PATIENT(S)

One hundred two women with ovarian function who were undergoing controlled ovarian stimulation (COS). Women were categorized as poor responders (< or =3 ovarian follicles at the end of the cycle) or normal responders (>3 follicles).

INTERVENTION(S)

Daily administration of exogenous FSH.

MAIN OUTCOME MEASURE(S)

Number of good or poor responders.

RESULT(S)

The allele frequency and genotype distribution of the Ser680Asn marker differed significantly between groups. Cycle cancellations were increased (21%) among women who were homozygous for Ser680 compared with Ser/Asn and Asn/Asn patients, and 36% of poor-responders were homozygous for Ser680.

CONCLUSION(S)

The results support a role for FSHR gene in COS outcome. However, the weight of this factor is probably low. The Ser680 allele may act in concert with other environmental and genetic factors that contribute to FSH efficacy.

Genetic causes of human infertility

The currently characterized chromosomal disorders and gene mutations that cause infertility in humans were reviewed. Of the four arbitrary compartments, genes expressed in the gonad comprise the most common site affected by mutations causing infertility. Clinicians should be aware of the most common causes that have clinical implications: (1) women with a 45,X cell line commonly have cardiac anomalies that may pose a risk for maternal death in pregnancies achieved by donor egg IVF; (2) men with Y-chromosome deletions may produce male offspring with the same deletion, rendering them infertile; (3) CBAVD must be ascertained in men with azoospermia because of the risk for having a child with CF; and (4) some women with premature ovarian failure may be fragile X syndrome carriers, so other family members may be at risk for the full syndrome. In the future, more genes will be identified to cause infertility in humans, which will translate into clinical significance. In select cases, in which the genetic defect is known, it may be possible to use preimplantation genetic diagnosis to screen embryos prior to uterine transfer.

Comparative analysis of the FOXL2 gene and characterization of mutations in BPES patients

Bleparophimosis ptosis epicanthus inversus syndrome (BPES) is a rare disorder characterized by eyelid malformation and in some cases associated with premature ovarian failure. Although the familial form is autosomal dominant, many cases are also sporadic. The mutations causing this disorder were found in a winged/forkhead transcription factor gene named FOXL2. We have sequenced the mouse homolog for the FOXL2 gene and identified the Fugu rubripes (pufferfish) ortholog from the database. By alignment of the three sequences, we found an almost complete conservation of the forkhead domain in the three species. There is 95% and 61% conservation at the protein level between human-mouse and human-pufferfish, respectively. The polyalanine and polyproline tracts within the gene are absent in Fugu rubripes. An overview identifies four breaks in the conservation of the gene within these species. Using a direct sequencing approach, we performed mutation analysis from DNA of nine affected individuals from familial and sporadic cases. The mutations are distributed throughout the coding region of the FOXL2 gene. We identified five novel mutations: g.292delG (E19fsX149); g.530G>A (W98X); g.548A>G (H104R); g.652G>T (E139X); and g.1178_1185del8 (A314fsX530). In addition we also identified two known mutations g.823C>T (Q196X) and g.1092_1108dup17, the latter in individuals from three unrelated pedigrees.

Selected enquiries into the causation of premature ovarian failure

In most species, reproductive senescence can be explained in the same general terms as physiological senescence. In fact, in some species rapid physiological senescence occurs on the completion of reproduction. The programme in women is unusual in that ovarian function comes to a relatively abrupt halt at 45-50 years of age, when the impact of somatic senescence on most other functions is minimal. Early reproductive senescence has been reported in other species (chimpanzees, macaques and toothed whales) but it is more attenuated and less abrupt. The proximate cause of physiological menopause seems to be oocyte depletion, but less obvious neuroendocrine changes precede or result from the gradual loss of oocytes. This is not surprising as many age-specific processes are controlled by hormones. Hormones provide a way for an animal to co-ordinate the ageing of different tissues. The failure to comprehend completely the reasons for the biological uniqueness of women makes the study of the more extreme examples of premature ovarian failure an important exercise. The premature loss of ovarian function in certain eukaryotic women highlights the role of those special maintenance and repair systems that must be functional in the selection process for healthy germ cells. The purpose of this article is to indicate selected areas of clinical and basic investigation that may provide clues to the mechanisms of untimely ageing of the human ovary. Studies of those human extremes with premature loss, or extended ovarian function, may provide critical insights into the unique discordance between somatic and reproductive senescence that is characteristic of normal women.

Characterization of early presentation idiopathic ovarian failure in girls and adolescents

This study focused retrospectively on a selected cohort of 20 adolescents with early onset premature ovarian failure (POF) and no apparent underlying cause, in order to characterize the idiopathic ovarian failure at pediatric age. This characterization was based on medical history, pedigree analysis, phenotypical and audiological evaluation, final and target heights, pelvic ultrasonography, endocrine assessment, routine hematochemical analyses and complete autoimmune screening. We found that: a) idiopathic POF presented either before or after puberty onset and also with secondary amenorrhea; b) final height prognosis was impaired only in patients with prepubertal presentation of POF; c) ovarian pattern at ultrasonography and endocrine picture were similar those previously reported in patients with adult onset POF; d) clinical history and pedigree analysis, phenotypical and audiological examination and complete autoimmune screening failed to highlight the existence of any possible cause for POF in 15/20 patients; e) no alterations of total cholesterol, low-density lipoprotein cholesterol and high-density lipoprotein cholesterol serum levels were detected in any patient. On the basis of these results we concluded that: a) final height of the adolescents with POF may be impaired only in patients in whom POF presents as a pubertal delay; b) other parameters do not generally differ from those described by previous reports on young adults with POF, except for serum lipid levels which were normal in the present cohort.

CATSPER2, a human autosomal nonsyndromic male infertility gene

In the course of positional cloning of the Congenital Dyserythropoietic Anemia type I (CDAI) [MIM 224120] gene on 15q15.1-15.3, we examined a family of French origin, in which the propositus suffered from asthenoteratozoospermia and nonsyndromic deafness in addition to CDAI. Two of his brothers had a similar phenotype. All three siblings were homozygous carriers of the CDA1 mutation as well as of a distally located approximately 70 kb deletion of the proximal copy of a 106 kb tandem repeat on chromosome 15q15. These repeats encode four genes whose distal copies may be considered pseudogenes. Lack of functional stereocilin and CATSPER2 (a voltage-gate cation channel expressed specifically in spermatozoa) may explain the observed deafness and male infertility phenotypes. To the best of our knowledge, the involvement of CATSPER2 in asthenoteratozoospermia is the first description of a human autosomal gene defect associated with nonsyndromic male infertility.

Molecular basis of pubertal abnormalities

The causes of abnormal pubertal development are numerous. Recent molecular investigation has increased our understanding of the genetic basis of pubertal disorders. Investigators have identified some of the genes that are critical for normal puberty and have begun to elucidate the genes and pathogenesis of genetic disorders associated with abnormal pubertal development. Identification of specific chromosomal abnormalities and gene mutations allows for diagnostic testing and enables the clinician to provide accurate counseling of the recurrence risk for relatives. In the future, knowledge of the genetic basis of these disorders will facilitate the development of novel therapies and approaches to the fertility assessment and treatment of individuals with pubertal disorders. Although great strides have been made in identifying these genes, questions remain. Why do some genetic mutations affect puberty differentially in males and females? What is the long-term impact in terms of future fertility, and what is the risk to the offspring of such patients? Further research is needed to address these issues and to identify additional genetic loci involved in pubertal development.

[Genetic origin of spermatogenesis impairments: clinical aspects and relationships with mouse models of infertility]

Human spermatogenesis failures appear frequently as idiopathic and may be due to genetic causes. Mutations of genes involved in the hypothalamic/pituitary control of spermatogenesis have been described and account for several types of hypogonadotropic hypogonadism. Chromosomal abnormalities found in infertile patients are either gonosomal aneuploidies or structural anomalies which interfere with the normal chromosome behaviour at meiosis and lead to germ cell breakdown. Microdeletions of the Y chromosome are often undetectable at karyotype and are responsible for the loss of genes which compose the AZF factor. The increase in the number of mouse models of infertility will allow the description of many human genes involved in the spermatogenesis process provided that a detailed analysis of their genotype-phenotype relationships is performed.

Ovarian failure related to eukaryotic initiation factor 2B mutations

Ovarian failure (OF) at age <40 years occurs in approximately 1% of all women. Other than karyotype abnormalities, very few genes are known to be associated with this ovarian dysfunction. We studied eight patients who presented with premature OF and white-matter abnormalities on magnetic resonance imaging. Neurological signs may be absent or present after OF. In seven patients, we report for the first time mutations in three of the five EIF2B genes (EIF2B2, -4, and -5) that were recently shown to cause childhood ataxia with central nervous system hypomyelination/vanishing white-matter disease leukodystrophy. The correlation we observed between the age at onset of the neurological deterioration and the severity of OF suggests a common pathophysiological pathway.