Acute ovarian responses to a long-acting agonist of gonadotropin-releasing hormone in ovulatory women and women with polycystic ovarian disease

Ovarian response to follicle-stimulating hormone in women with polycystic ovary syndrome is diminished compared to ovulatory controls

OBJECTIVE

The mechanisms underlying ovarian dysfunction in polycystic ovary syndrome (PCOS) have not been definitively established. Our objective was to perform a detailed examination of ovarian responses to recombinant follicle-stimulating hormone (rFSH) in women with PCOS and controls.

DESIGN

This prospective, crossover, dose-response study included three rFSH stimulation periods. Each stimulation period involved three consecutive, daily, subcutaneous injections of rFSH administered at a single dose. Low, medium and high rFSH doses were weight-adjusted, corresponding to 0.5, 1.1 and 2.2 IU/kg/d, respectively. Stimulation periods occurred in randomized order and were separated by 8-week washouts.

PATIENTS

Thirty participants (8 PCOS and 22 controls) were studied. PCOS was defined by oligomenorrhea and clinical or biochemical androgen excess, excluding other aetiologies of ovulatory dysfunction.

MEASUREMENTS

Blood samples were obtained for hormone measurements before and 24 h after each rFSH injection.

RESULTS

Participants with PCOS had significantly greater body mass index, antral follicle count and circulating testosterone, anti-mullerian hormone (AMH) and luteinizing hormone concentrations compared with controls participants. Baseline estradiol (E2) concentrations were similar in both groups. At the lowest dose of rFSH, PCOS participants did not demonstrate E2 increments, whereas a significant increase occurred in controls. rFSH-induced E2 production per follicle was significantly reduced in PCOS participants compared with controls at all rFSH doses. Increasing T and decreasing AMH concentrations were associated with augmented E2 production per follicle.

COONCLUSIONS

Women with PCOS exhibited diminished initial E2 responses to rFSH compared with controls. These findings suggest that the mechanism of anovulation in PCOS may involve altered ovarian response to gonadotropins.

The effect of estradiol on granulosa cell responses to FSH in women with polycystic ovary syndrome

BACKGROUND

The influence of estradiol (E₂) on granulosa cell (GC) function has not been tested clinically in women with polycystic ovary syndrome (PCOS). The objective of this study is to determine if E₂ influences GC responses to FSH in women with PCOS.

METHODS

This is a two phase, single cohort study conducted over a 2-year period at a single academic center. Nine women with PCOS according to NIH criteria. In Phase 1, FSH stimulation of GC responses as measured by E₂ and Inhibin B (Inh B) were assessed before and at 5 and 6 weeks after GnRH agonist administration. In Phase 2, the same protocol was employed with the addition of an aromatase inhibitor (letrozole, LET) administered daily beginning at week 4 for 2 weeks.

RESULTS

In Phase 1, recovery of FSH, E₂ and Inh B from ovarian suppression occurred at 5 and 6 weeks after GnRH agonist injection and preceded resumption of LH and androgen secretion. In Phase 2, hormone recovery after GnRH agonist was characterized by elevated FSH and suppressed E₂ levels whereas recovery of LH and androgen levels were unchanged. In Phase 1, FSH stimulated E₂ and Inh B responses were unaltered during recovery from ovarian suppression. In Phase 2, E₂ and Inh B fold changes after FSH were significantly reduced at weeks 5 (p < 0.04) and 6 (p < 0.01), respectively.

CONCLUSION

In anovulatory women with PCOS, chronic, unopposed E₂ secretion may contribute, at least in part, to enhanced ovarian responsiveness to FSH.

TRIAL REGISTRATION

NCT02389088.

Thiazolinedione treatment in PCOS--an update

Polycystic ovary syndrome (PCOS) is characterised by anovulation, hyperandrogenism, and polycystic ovaries. Fifty percent of patients fulfil the criteria for the metabolic syndrome. The pathogenesis of PCOS may be looked as a vicious cycle involving hyperandrogenemia, central obesity, and insulin resistance and medical treatment should aim at breaking this cycle. Lifestyle intervention, oral contraceptives, and insulin sensitises such as metformin are the most commonly used treatment modalities. The thiazolidinediones rosiglitazone and pioglitazone were recently applied as insulin sensitising treatment in patients with PCOS. Thiazolidinediones activate the transcription of genes that affect glucose and lipid metabolism mediating decreased free fatty acid levels and decreased visceral fat mass. In the present article, we give an overview of the diverse effects of glitazone treatment in patients with PCOS. We review the studies comparing glitazone versus metformin and oral contraceptive treatment and recommend which patients should be treated with glitazones in daily praxis.

Microdose gonadotropin-releasing hormone agonist in the absence of exogenous gonadotropins is not sufficient to induce multiple follicle development

Because the effectiveness of the "microdose flare" stimulation protocol often is attributed to the dramatic endogenous gonadotropin release induced by the GnRH agonist, the aim of this study was to determine whether use of microdose GnRH agonist alone could induce multiple ovarian follicle development in normal responders. Based on these data, the duration of gonadotropin rise is approximately 24 to 48 hours and is too brief to sustain continued multiple follicle growth.

The reproductive phenotype in polycystic ovary syndrome

The symptoms of women with polycystic ovary syndrome (PCOS) include hirsutism and irregular menstrual bleeding due to ovarian androgen excess and chronic anovulation. Typically, these features emerge late in puberty or shortly thereafter. The proposed mechanism(s) responsible for increased ovarian androgen production include heightened theca cell responsiveness to gonadotropin stimulation, increased pituitary secretion of luteinizing hormone, and hyperinsulinemia. The cause of ovulatory dysfunction is not well understood, but is linked to abnormal follicle growth and development within the ovary. As a result, infertility is common among women with PCOS and, in many instances, is the initial presenting complaint. Insulin resistance and obesity are frequently associated with PCOS and probably contribute to the severity of symptoms. The polycystic ovary that accompanies the syndrome has recently been defined as having 12 or more follicles per ovary or an ovarian volume greater than 10 ml as determined by ultrasonography. In addition, there is an increased number of growing follicles in the polycystic ovary. Despite this distinctive appearance, the cause and development of the polycystic ovary are completely unknown.

Enhanced granulosa cell responsiveness to follicle-stimulating hormone during insulin infusion in women with polycystic ovary syndrome treated with pioglitazone

Women with polycystic ovary syndrome (PCOS) are known to exhibit insulin resistance with compensatory hyperinsulinemia. To determine the role of hyperinsulinemia on follicle function in PCOS, we examined 24-h estradiol (E(2)) responses to recombinant human FSH (r-hFSH), 75 IU, before and during insulin infusion both before and after administration of pioglitazone (30 mg/d) in seven PCOS women. Each subject underwent two 10-h hyperinsulinemic-euglycemic clamps at rates of 30 (low dose) and 200 (high dose) mU/m(2).min, respectively. During both low- and high-dose insulin infusions, E(2) responses to r-hFSH were unaltered compared with that observed in the absence of insulin. Pioglitazone administration for 5 months improved insulin sensitivity as indicated by significantly (P < 0.05) increased glucose infusion rates during the clamp studies. At 3 months of treatment, r-hFSH-stimulated E(2) responses were not different from those observed before treatment. With pioglitazone treatment, E(2) responses to r-hFSH remained unchanged during low-dose insulin infusion, whereas a highly significant (P < 0.02) increased response was noted with the high-dose hyperinsulinemic-euglycemic clamp. In addition to a greater magnitude of response, peak levels of E(2) were sustained longer compared with that seen before treatment. The data indicate that granulosa cell responsiveness to FSH was enhanced by insulin after improved insulin sensitivity induced by pioglitazone. These findings are consistent with the possibility that PCOS granulosa cells are insulin resistant.

Flare-up of endometriosis induced by gonadotropin-releasing hormone agonist leading to bowel obstruction

OBJECTIVE

To report a case of intestinal obstruction that developed shortly after preoperative administration of a GnRH analogue (GnRH-a) that caused flare-up and rapid progression of enteric endometriosis.

DESIGN

Case report.

SETTING

University tertiary reproductive endocrinology practice.

PATIENT

A 34-year-old nulligravid female with progressive severe symptomatic endometriosis.

INTERVENTIONS

Planned preoperative administration of GnRH-a for 3 months followed by extirpative surgery and hormone replacement therapy. Instead, total abdominal hysterectomy, bilateral salpingoophorectomy, resection of the obstructed ileocecal junction, and side-to-side ileo-ascending enterocolostomy was performed.

RESULTS

Preoperative GnRH-a administered in the midfollicular phase resulted in flare-up of preexisting ileocecal endometriosis that rapidly progressed, resulting in partial small bowel obstruction.

CONCLUSION

Gonadotropin-releasing hormone agonist should be used with caution when there is known or suspected enteric endometriosis. Consideration should be given to blocking the agonistic effect of GnRH-a in this setting by the prior or concomitant use of progestins or danazol.

The poor-responder patient in an in vitro fertilization-embryo transfer (IVF-ET) program

The purpose of this article is to review the methods and evaluate the 'avenues' that are open to patients and physicians in their search for improvement of in vitro fertilization-embryo transfer (IVF-ET) treatment results. The option of egg donation, although very important and viable in the treatment of poor responders, is not described here.

17-Hydroxyprogesterone response to buserelin testing in the polycystic ovary syndrome

OBJECTIVE

We determined the 17-hydroxyprogesterone (17-OH P) response to buserelin, a GnRH agonist, and its relation to ovarian volume in the patients with polycystic ovary syndrome (PCOS).

DESIGN

We compared 17-OH P response to buserelin in a large group of patients with that in a control group of healthy women. We also investigated whether there is any relation between LH-induced 17-OH P production in response to buserelin and ovarian volume.

PATIENTS

Ten normal women and 31 women with PCOS were included in the study.

MEASUREMENT

Pelvic ultrasound examination by abdominal or vaginal transducer was performed. Serum basal levels of LH, FSH, free testosterone and 17-OH P were measured by radioimmunoassay. 17-OH P responses to both ACTH and buserelin were detected. Cortisol levels were measured before and after dexamethasone suppression.

RESULTS

The subcutaneous administration of 1 mg buserelin produced an increase in serum 17-OH P, which peaked within 24 hours in all groups. The mean +/- SEM level of 17-OH P, 24 hours after buserelin stimulation in the women with PCOS (15.94 +/- 1.31 nmol/l) was significantly higher (P < 0.001) than in the control group (6.75 +/- 0.69 nmol/l). The women with PCOS had increases in 17-OH P levels exceeding 10.15 nmol/l 24 hours after buserelin testing. The increased 17-OH P responses to buserelin were unchanged by pretreatment with dexamethasone to suppress adrenal function. The 17-OH P response was significantly related to ovarian volume (r = 0.53, P < 0.01).

CONCLUSIONS

Our findings suggest that the serum 17-OH P response to a 1-mg subcutaneous test dose of buserelin may be a diagnostic and practical test for PCOS. increased ovarian volume in PCOS may be responsible for the elevated 17-OH P response to buserelin, a GnRH agonist, at least in some patients.

Potential utility of gonadotropin-releasing hormone agonists in the management of ovarian hyperandrogenism

Gonadotropin-releasing hormone agonists are potent suppressors of ovarian androgen biosynthesis even in the face of severe hyperandrogenism (e.g., hyperinsulinemia, hyperthecosis). Gonadotropin-releasing hormone agonists are clinically useful in the context of hirsutism. The use of Gn-RH-a in the context of hirsutism is not duration-limited in that the induced hypoestrogenism and its consequent complications are likely to be effectively managed by the concurrent provision of estrogen replacement therapy.

Ovarian hyperstimulation associated with the sole use of leuprolide for ovarian suppression

An IVF patient who was placed on leuprolide therapy prior to ovulation induction to improve ovarian response developed moderate ovarian hyperstimulation from the sole use of the GnRH agonist. Clinicians should be aware of this possible outcome.

Improved pregnancy outcome with the addition of leuprolide acetate to gonadotropins for in vitro fertilization

In vitro fertilization treatment outcomes were compared prospectively in unselected patients with and without the addition of leuprolide acetate to gonadotropins for ovarian hyperstimulation. While the leuprolide patients required greater quantities of exogenous gonadotropins to achieve ovarian stimulation, significant improvements in the fertilization, implantation, and spontaneous abortion rates were observed compared with patients not receiving leuprolide. The ongoing pregnancy ("take home baby") rates per aspiration with and without leuprolide were 29% and 12%, respectively. Furthermore, the multiple pregnancy rate was markedly increased in the leuprolide group (44% versus 8%), suggesting that the improved pregnancy outcome with pituitary suppression was due primarily to higher oocyte and embryo quality.

Pituitary-ovarian responses to nafarelin testing in the polycystic ovary syndrome

To investigate the basis of polycystic ovary syndrome, we examined the responses of patients to nafarelin, a specific gonadotropin-releasing-hormone agonist, given to stimulate pituitary and gonadal secretion. We compared 16 normal women in the follicular phase, 5 normal men, 8 women with polycystic ovary syndrome, and 1 woman with polycystic ovary syndrome caused by a 3 beta-hydroxysteroid dehydrogenase deficiency. After 100 micrograms of nafarelin was given subcutaneously, serum follicle-stimulating hormone and luteinizing hormone increased rapidly to peak levels within four hours. The women with polycystic ovary syndrome had a pattern similar to that of the men, with greater early luteinizing-hormone responses (30 minutes to 1 hour) and lower peak follicle-stimulating-hormone responses than normal women (P less than 0.05). Patients with polycystic ovary syndrome responded to gonadotropin stimulation with normal to increased production of plasma estrogens and increased levels of androstenedione at 16 to 24 hours (P less than 0.05). Elevated production of 17 alpha-hydroxyprogesterone was found in all the women with polycystic ovary syndrome and in the men. These abnormal responses were unchanged by pretreatment with dexamethasone to suppress adrenal function. In the patient with the 3 beta-hydroxysteroid dehydrogenase deficiency, both basal and stimulated plasma levels of delta 5-3 beta-hydroxysteroids before the enzymatic block were elevated, whereas plasma levels of 17 alpha-hydroxyprogesterone and androstenedione--the steroids immediately beyond the block--were low. We conclude that women with polycystic ovary syndrome have masculinized pituitary and ovarian responses to stimulation by nafarelin. Our findings suggest that the regulation of the ovarian 17-hydroxylase and C-17,20-lyase activities is abnormal in such women.

Acute pituitary-ovarian response during chronic luteinizing hormone-releasing hormone agonist administration in polycystic ovarian syndrome

The purpose of the study was to evaluate the acute effect of daily subcutaneous injections of the GnRH agonist Buserelin on serum concentration of LH (evaluated by radioimmunoassay (iLH), and by bioassay (bioLH], FSH, oestradiol and testosterone in 20 women with a diagnosis of polycystic ovarian disease (PCO). Buserelin was administered subcutaneously at the dose of 200 micrograms three times daily for 7 days followed by 500 micrograms once daily for a total treatment period of 6 months. Blood samples were drawn immediately before and 2, 4 and 6 h after the injection on the first day of treatment as well as after 1, 2, 3, 4, 12 and 24 weeks. The first injection of Buserelin induced statistically significant rises of iLH, bioLH and FSH as well as of 17 beta-oestradiol. The acute response of gonadotrophins was suppressed after 1 week but a partial recuperation of FSH and iLH responses was observed starting after 2 and 4 weeks of treatment. No significant acute changes of bioLH or of 17 beta-oestradiol and testosterone could be seen. The persistence of a small but statistically significant pituitary response in the first hours following the daily injection of the peptide suggests a hyper-reactive state of the gonadotrophs in PCO patients. Such acute pituitary responses are not seen when a similar treatment is administered to endocrinologically normal women. This observation could be an argument in favour of an initial central defect in the pathogenesis of the syndrome.

Timing of initiation and dose schedule of leuprolide influence the time course of ovarian suppression

The time course of suppression of ovarian estrogen production and follicular development with leuprolide was examined in 40 normal women before ovarian stimulation for in vitro fertilization (IVF). Initiation of leuprolide during the midluteal phase caused a significantly more prompt suppression than when treatment was started during the early follicular phase (day 1). Injection of the same total amount of leuprolide in two divided doses also caused a significantly more prompt suppression. These two methods were consistent enough to make routine use of leuprolide practical before ovarian stimulation for IVF.

Suppression of the ovary using a gonadotropin releasing-hormone agonist prior to stimulation for oocyte retrieval

Five women with prior suboptimal ovarian stimulation for in vitro fertilization and embryo transfer (IVF-ET) were pretreated with a long-acting gonadotropin-releasing hormone (GnRH) agonist beginning in the midluteal phase of the preceding menstrual cycle. The four women with normal luteal function had castrate estrogen levels following regression of the corpus luteum, whereas one woman with an abnormal luteal phase and perimenopausal levels of gonadotropins had an agonistic response. In the three women with adequate stimulation, 20 oocytes were obtained and one women became pregnant. Initiation of GnRH agonist therapy during the luteal phase of a normal menstrual cycle may be an efficient way of obtaining ovarian suppression without an agonistic response.