Corticosteroids do not influence ovarian responsiveness to gonadotropins in patients with premature ovarian failure: a randomized, placebo-controlled trial

Immunophenotypic profiles and inflammatory markers in Premature Ovarian Insufficiency

Premature Ovarian Insufficiency (POI), also known as Premature Ovarian Failure (POF), is a heterogeneous disorder characterized by the cessation of ovarian function before age 40. Clinical symptoms include menstrual disorders: amenorrhea/oligomenorrhea or symptoms of estrogen deficiency. This review aims to provide the most important summary of the immunophenotypic profile of premature ovarian failure syndrome, along with a review of the latest reports on the usefulness of inflammatory markers. The inflammatory microenvironment in POI applies to many levels. Concomitants of autoimmune ovarian inflammation and impaired cellular immune response may be a picture of impaired regulation in autoimmune ovarian disease. The serum concentration of pro-inflammatory cytokines, like IL-6, IL-8, IL-17, tumor necrosis factor α (TNF-α), and interferon-gamma (IFN-γ), tend to increase, whereas levels of the anti-inflammatory cytokine, IL-10, tend to decrease. In our review, we focus on whether the measured immunological parameters could help in the diagnosis and prognosis of the syndrome. Among the inflammatory markers, neutrophil-to-lymphocyte ratio (NLR) is noteworthy, as it is decreased in patients with POI. It is important to stress that besides case series, we need properly powered studies with randomization to answer which treatment is effective, and how to deal with concurrent autoimmunity. In this review, we emphasize the importance of the premature ovarian failure syndrome immunoprofile for a proper understanding of the complexity of this syndrome, potential diagnostic points, and therapeutic targets.

Evidence for the effectiveness of immunologic therapies in women with subfertility and/or undergoing assisted reproduction

Implantation is a critical step in the establishment of a successful pregnancy, depending on a complex immune-endocrine dialogue between the developing embryo and maternal endometrium. Research suggests that altered immunity in the maternal decidua results in implantation impairment and failure. Immunomodulatory drugs have, thus, been widely used in assisted conception to aid embryo implantation, despite an absence of consensus on their effectiveness and safety. We conducted a systematic review and meta-analysis of interventional studies investigating the use of immunomodulators in women undergoing assisted reproduction. Evidence was uncertain of an effect for most of the included interventions, owing to heterogeneous findings and a paucity of high-quality studies. For certain patient subgroups, however, the use of specific immunomodulatory therapies may offer some benefit. There is a need for further large randomized controlled trials to corroborate these findings.

Successful live birth after in vitro maturation treatment in a patient with autoimmune premature ovarian failure: a case report and review of the literature

OBJECTIVE

We report a successful live birth after oocytes in vitro maturation (IVM) and fresh embryo transfer in a patient with autoimmune premature ovarian failure (POF) and performed a review of the literature of livebirths obtained after oocytes IVM treatment in this indication.

METHODS

The patient was a 24-year-old woman with autoimmune POF diagnosed post-partum, who developed autoimmune polyglandular syndrome with serum anti-ovarian and anti-21-hydroxylase antibodies. The patient had typical symptoms of POF: secondary amenorrhea with hypoestrogenism, elevated gonadotropins and infertility; however, the serum anti-Müllerian hormone level and total antral follicle count remained normal. IVM of immature oocytes was performed after the administration of 150 IU highly purified human menopausal gonadotropin for three consecutive days and an injection of 10,000 IU human chorionic gonadotropin to trigger ovulation.

RESULTS

The six oocyte-cumulus complexes collected matured in vitro. After intracytoplasmic sperm injection (ICSI), five embryos were obtained. Pregnancy was achieved after the fresh transfer of two embryos and appropriate endometrial preparation. A normal female child was delivered following a 37-weeks pregnancy characterized by the onset of adrenal insufficiency and unstable diabetes.

CONCLUSIONS

We report a successful livebirth after IVM treatment in a patient with autoimmune premature ovarian failure (POF). Management of reproductive age women with autoimmune pathology requires fertility counseling. Early diagnosis of autoimmune POF is important for early conception and oocyte preservation, because the only other option at present is ovum donation.

Live Birth Rate in Patients With Premature Ovarian Insufficiency During Long-Term Follow-Up Under Hormone Replacement With or Without Ovarian Stimulation

We analyzed data from 466 patients with premature ovarian insufficiency (POI) who wished to have a biological child and were followed up while undergoing hormone replacement (HR) therapy with or without ovarian stimulation (OS) between April 2014 and December 2020. OS was conducted in 6891 cycles in 429 patients (Group OS), whereas only HR (Group HR) was conducted in 1117 cycles in 37 patients. The follicle growth rate was 48.3% (207/429) per patient in Group OS and 5.4% (2/37) in Group HR (p<0.01). There were 51 live births (LBs) in 50 patients during follow-up. In Group OS, the LB rate was 5.8% (47/807) in cycles where in vitro fertilization (IVF) and embryo transfer were attempted (Group IVF), and 1.3% (3/236) in cycles where intrauterine insemination/timed intercourse was attempted (p<0.01). No pregnancies occurred in Group HR. Among the patients in Group IVF, the LB rate was significantly higher in patients aged <35 years at the initiation of follow-up than in patients who started at later ages (p<0.01). Among the cases who achieved an LB, 39 were patients with idiopathic POI (Group IVF-1, n=297) and seven were patients who had undergone surgical treatment for benign ovarian tumors (Group IVF-2, n=50); however, no LBs occurred in patients who had undergone treatment for malignancy (n=17), and only one in patients with chromosomal abnormalities (n=22). The LB rate per case in the patients in Group IVF-1 and those aged <35 years at the start of follow-up (Group IVF-1-a) was 24.1% (26/108), which was higher than those of the other age groups. The LB rate per case in the patients in Group IVF-1-a with <4 years of amenorrhea was 37.3% (19/51), and that in the patients in Group IVF-2 with <4 years of amenorrhea was 21.2% (7/33). These results suggest that infertility treatment is possible in some patients with POI, especially those that can be classified in Group IVF-1-a and Group IVF-2 with <4 years of amenorrhea. Therefore, OS combined with HR therapy should be considered for such patients before attempts at oocyte donation.

Fertility and pregnancy in women with primary adrenal insufficiency

Primary adrenal insufficiency (PAI) occurs in ~1/5000-1/7000 individuals and is in most cases caused by autoimmune Addison's disease (AAD). Around 10-20% of women with AAD develop premature ovarian insufficiency (POI) before the age of 40 years. 21-Hydroxylase autoantibodies (21OHAb) are the best single immune marker to classify AAD among PAI patients and autoimmune POI in hypergonadotropic hypogonadic women. In AAD, detection of steroid-cell autoantibodies (StCA) predicts future development of POI. AAD-related autoimmune POI is characterized by a selective destruction of theca cells with preservation of primary follicles and granulosa cells of secondary and tertiary follicles. Women with AAD show reduced fertility and parity. Patients with well-managed disease are generally expected to have uneventful pregnancies with favorable outcome, but increased risk of maternal and neonatal complications has been reported. Hence, AAD pregnant women must be carefully monitored by skilled staff which is familiar with the disorder and specific attention must be given to the substitutive therapy.

Decreased effector regulatory T cells and increased activated CD4+ T cells in premature ovarian insufficiency

PROBLEM

Premature ovarian insufficiency (POI) is a clinical syndrome defined by the loss of ovarian activity before 40 years old. An autoimmune mechanism is suggested to be involved in the development of POI. Therefore, we examined the relationship between peripheral blood regulatory T (Treg) cells and autoantibodies in POI.

METHOD OF STUDY

Thirty POI patients and 23 control women were enrolled in the study. Using flow cytometry, we measured the abundance of CD4⁺ T, CD4⁺ CD69⁺ T, CD8⁺ T, CD8⁺ CD69⁺ T, naive Treg, effector Treg, and FOXP3⁺ effector T cells in peripheral blood. Antinuclear and anti-thyroglobulin antibody (Tg-Ab) titers were measured in POI patients.

RESULTS

The number of CD4⁺ T or CD4⁺ CD69⁺ T cells was significantly higher in POI patients (P = 0.045, and P = 0.030), and there were significantly fewer effector Treg cells in POI patients (P = 0.016) than in the controls. There were significant negative correlations between effector Treg cells and Tg-Abs (r = -0.584, P = 0.0282), and between effector Treg cells and CD4⁺ CD69⁺ T cells (r = -0.415, P = 0.0226) in POI patients.

CONCLUSION

This is the first report of decreased numbers of effector Treg cells and increased CD4⁺ CD69⁺ activated T cells in peripheral blood in POI, suggesting that POI is an autoimmune disease.

Premature ovarian insufficiency: how to improve reproductive outcome?

Premature ovarian insufficiency (POI) is a life-changing condition that affects women in their reproductive age. The condition is not necessarily permanent but is associated with intermittent and unpredictable ovarian activity. Hence, spontaneous pregnancies have been reported to be 5-10%. However, pregnancy in patients with POI is still unlikely and rare. Although, there are reviews on POI in the literature, there is a lack of reports which focus on how to improve the reproductive outcome of these women who wish to conceive spontaneously or use assisted conception with their own oocytes. We found that there is no conclusive evidence of which treatment is optimal for women with POI who wish to conceive using their own gametes. However, one could surmise that it is important to lower gonadotropin levels into the physiological range before embarking on any treatment, even if natural conception is the only choice for the woman/couple. In the future, multi-center, randomized, double-blind, placebo-controlled trials should be carried out, which may entail recruitment of patients from various centers nationally and internationally to increase the sample size and therefore achieve a powered study. This may standardize the treatment of women with POI who wish to conceive and ultimately have their biological child.

Medical alternatives to oocyte donation in women with premature ovarian failure: a systematic review

Oocyte donation can satisfy the desire to have children in women with premature ovarian failure (POF) but little progress has been made to improve reproduction using the patients' own gametes. The aim of this study was to assess the effectiveness of alternative treatments to oocyte donation in patients with POF. A systematic search of MEDLINE, EMBASE and Cochrane databases from January 1988 to January 2012 using descriptors related to POF, ovulation induction, and pregnancy was made. Randomized clinical trials of women with POF undergoing various treatments to achieve ovulation induction, often compared with alternative treatment and placebo groups, were only selected. Outcomes of interest were those related to pregnancy (biochemical and live birth). Twelve trials were included and analysed for methodology, inclusion and exclusion criteria, number of patients included, characteristics and type of intervention, and results in terms of ovulation rate, pregnancy rate and ongoing pregnancy rate. The large methodological variability among studies prevented to combined data for a meta-analysis. None of the studies showed statistically significant differences between the study groups. The lack of case-control studies with a placebo group makes it impossible to establish differences between a treatment and no treatment.

Resumption of ovarian function after 4 years of estro-progestin treatment in a young woman with Crohn's disease and premature ovarian insufficiency: a case report

PURPOSE

To report the long-term management of a case of premature ovarian insufficiency of unknown origin in a young woman with Crohn's disease.

METHOD

Here is reported the case of a 20 years old woman with Crohn's disease presenting with two years amenorrhea and FSH and LH levels of 255 mIU/ml and 182 mIU/ml respectively, who received 10 months corticosteroid treatment followed by 7 years of estro-progestin treatment.

RESULTS

Corticosteroid treatment was ineffective in restoring patients gonadotropin levels as well as ovarian volume, while estro-progestins promoted a prompt reduction in gonadotrophin levels, which returned in the normal range after two years of treatment, as well as restoration of ovarian function, which occurred after four years of estrogens administration, as demonstrated by normal ovarian volume and ovulatory follicles at ultrasound, and by the re-establishment of regular menses after estroprogestin discontinuation.

CONCLUSIONS

Long-term suppression of the endogenous gonadotropins using estroprogestins may be suggested as a treatment able to restore ovarian responsiveness even in patients with premature ovarian insufficiency showing highly elevated gonadotropin levels.

Can anti-ovarian antibody testing be useful in an IVF-ET clinic?

OBJECTIVE

To establish importance of anti-ovarian antibodies (AOA) testing in infertile women.

DESIGN

A clinical reproductive outcome comparative study between two groups of women undergoing IVF-ET. Group 1 consists of women tested positive for AOA, put on corticosteroid therapy, reverted to AOA negative and then taken up for IVF-ET. Group 2 were seronegative for AOA.

SETTING

Major urban infertility reference centre and National research institute.

PATIENT(S)

Five hundred seventy infertile women enrolled for IVF-ET.

INTERVENTION(S)

AOA testing, corticosteroid therapy and IVF-ET/ICSI.

MAIN OUTCOME MEASURE(S)

Comparable clinical outcome and significance of AOA testing established.

RESULTS

AOA positive serum samples were sent periodically to re-investigate presence of AOA after corticosteroid therapy and women turned AOA negative were taken up for IVF-ET. Of the 70/138 women in group 1 who were treated with corticosteroids and turned seronegative for AOA, 22/70 were poor responders and needed donor oocyte-recipient cycles. Results demonstrated that fertilization and clinical pregnancy rates between both groups are comparable. Nevertheless, it is also observed that there is poor response to stimulation protocol, smaller number of oocytes retrieved and more spontaneous abortions in group 1 women. Hence not all outcomes following the treatment are comparable between the two groups. Usefulness of the test was established in two case studies.

CONCLUSIONS

AOA testing could be included in the battery of tests investigating and treating infertility.

[Premature ovarian failure: which approaches?]

Premature ovarian failure (POF) occurs in one case of 10,000 in women below the age of 20, one case of 1000 below 30 and 1% in women before the age of 40. In 80% of POF cases, the etiology is unknown, except for Turner syndrome. Spontaneous fertility is very weak, only 3 to 10% of the patients will have natural conception. If the diagnosis is confirmed, ovarian stimulation usually fails. When fertility is desired, the alternative treatments are oocyte and/or embryo donation or adoption and "learn to be happy just in couple". Psychological management is always necessary.

Induction of ovulation in idiopathic premature ovarian failure: a randomized double-blind trial

In this prospective randomized study, women with idiopathic karyotypically normal premature ovarian failure (POF) were treated with gonadotrophin-releasing hormone (GnRH) agonist and gonadotrophins with and without the addition of corticosteroids in an attempt to restore ovarian function. The study comprised 58 women with idiopathic POF randomly allocated to either GnRH agonists (GnRHa) plus gonadotrophin therapy with the addition of corticosteroids (29 patients) or GnRHa plus gonadotrophin therapy with placebo (29 patients). Ovulation occurred in six cases (20.7%) in the dexamethasone group versus three cases (10.3%) in the placebo group. There were two singleton pregnancies in the dexamethasone group. There were no reported complications from the use of dexamethasone apart from a sense of sleepiness and fatigue. The combination of corticosteroids with pituitary suppression followed by ovarian stimulation with gonadotrophin appeared to be beneficial in restoring ovarian function in patients with idiopathic POF and normal karyotype.

Premature ovarian failure associated with autoimmune polyglandular syndrome: pathophysiological mechanisms and future fertility

BACKGROUND

Autoimmune polyglandular syndromes (APS) are a series of disorders characterized by autoimmunity against two or more endocrine organs. Premature ovarian failure (POF) may also have an autoimmune origin and, when accompanied by other autoimmune endocrinopathies, may be part of the APSs. Onset of autoimmune ovarian failure usually occurs in childhood, adolescence, or adulthood, and as a result, fertility may be severely compromised.

CASE REPORT

A 26-year-old women with secondary amenorrhea, Addison's disease, and autoimmune hypothyroidism requested infertility evaluation. Examination, transvaginal ultrasonography, endocrine evaluation, and ovarian biopsy were performed. 21-Hydroxylase and antithyroid antibodies were demonstrated, but ovarian steroid cell antibodies (StCA) were absent at the time of her infertility evaluation. Transvaginal sonography demonstrated only a few ovarian follicles. An ovarian biopsy revealed lymphocytic infiltration of the ovary. This presentation is consistent with APS type II accompanied by autoimmune POF.

DISCUSSION

Unlike APS types I and III, autoimmune POF is more commonly encountered with APS types I and III than with APS type II. An autoimmune response to steroidogenic enzymes and ovarian steroid cells appears to mediate destruction of ovarian function. Although immunotherapy with corticosteroids (with or without in vitro fertilization [IVF]) may be successful in limited cases where several follicles are present, oocyte donation with IVF may be the best option for the patient seeking fertility, particularly in the absence of ovarian follicles.

CONCLUSIONS

Advances in molecular genetics may be valuable in predicting and counseling women at risk for APS and POF, and cryopreservation of ovarian tissue may offer hope to affected unmarried young women. It is reasonable to suggest that children and reproductive aged women with one autoimmune disorder should be periodically screened for other autoimmune disorders.

Successful pregnancy after transient ovarian failure following treatment of symptomatic leiomyomata

OBJECTIVE

To report a case of transient ovarian failure after treatment of symptomatic leiomyomata and review other iatrogenic causes of transient ovarian failure.

DESIGN

Case report and literature review.

SETTING

University-affiliated private practice.

PATIENT(S)

A 35-year-old woman with symptomatic leiomyomata.

INTERVENTION(S)

Bilateral uterine artery embolization with subsequent abdominal myomectomy to treat unchanged regular heavy menstrual flow.

MAIN OUTCOME MEASURE(S)

Ovarian function.

RESULT(S)

Because medical therapy failed to control her menorrhagia, the patient proceeded with uterine artery embolization. She had persistent menorrhagia after bilateral uterine artery embolization and underwent exploratory laparotomy and myomectomy. After surgery, she had amenorrhea, hot flushes, and elevated FSH levels for 3 months. Ovarian function recovered after a short course of oral contraceptives, and the patient conceived without assistance.

CONCLUSION(S)

Several interventions can affect normal ovarian function and can lead to permanent or transient ovarian failure. Possible causes of transient ovarian failure are radioactive iodine treatment, radiation, chemotherapy, pelvic surgery, stress, and uterine artery embolization. Before these interventions are applied, the possibility of ovarian failure and available preventive measures should be discussed with the patient.

[From pathological diagnosis to ovulation induction. The case of ovarian insufficiency]

The incidence of premature ovarian failure (POF) is around 1 to 3%. This pathology occurs in young women, who often wish to become pregnant. Theoretically, two mechanisms could be involved: initial follicle depletion and follicle dysfunction. However, in some cases, mixed mechanisms are involved. Initially, PFO was considered irreversible. In fact, signs of intermittent ovarian function in normal karyotypically women have been described, but predicting the probability of spontaneous remission in a specific woman is impossible. Therefore, various treatments for ovulation induction have been proposed to these patients. Most of the pregnancies occur after hormone replacement therapy. The action of this treatment is unclear and the cause-and-effect relation has not been proven by prospective, randomized studies. The benefit of suppressing endogen gonadotropins by GnRH agonists is not proven either. Estrogen supplementation and high-dose gonadotropin ovarian stimulation protocols have been proposed. Even so, this therapy cannot be recommended because of the lack of controlled studies. Finally, numerous case reports have described the return of ovarian function after using immunosuppressive therapies. The lack of particular criteria for the diagnosis of autoimmune mechanisms have lead to treat heterogeneous groups of patients. No randomized controlled studies with immunologic monitorage have been performed that could establish the success of this therapy. Therefore, in order to find effective treatments, basic pathophysiologic mechanisms must be better understood. For those women who want to become pregnant, the lack of prospective, randomized studies cannot lead to formal conclusions. Depending on the patients' age and history, it appears reasonable to attempt a corrective therapy based on defined etiology, before entering in a donor oocyte program.

Premature ovarian failure: etiology and prospects

A search of past and current articles on ovarian physiology and premature ovarian failure (POF) using MEDLINE was performed in order to present an overview of clinical manifestations, necessary laboratory investigations, possible etiologies and treatments for POF. POF is defined as gonadal failure before the age of 40 years. Initially, POF was thought to be permanent, but it is now believed that spontaneous remissions and even pregnancies are possible in affected women. In most cases, the etiology of POF remains elusive, but several rare specific causes have been identified. Although the etiology of POF is heterogenic, the treatment principles are the same. Hormone replacement therapy (HRT) is still the cornerstone of treatment. The only proven method of obtaining a pregnancy in patients with POF is fertilization of a donor oocyte. Cryopreservation of oocytes has worked well in animals but awaits refinement before it can be applied routinely to humans with prodromal POF, or to patients before chemotherapy or irradiation in order to save their oocytes for future fertilization. New alternatives to traditional HRT and methods of fertility preservation are under development, but understanding of the basic pathophysiology of POF is necessary for the development and use of innovative treatments.

Familial idiopathic premature ovarian failure: an overrated and underestimated genetic disease?

The incidence of familial cases of premature ovarian failure varies from 4 to 31%. Recall bias may explain part of the variance. Thorough evaluation of alleged affected relatives showed a lower incidence than the original family history suggested. In the present study the incidence of familial cases was 12.7%. Pedigree studies on affected families showed a mode of inheritance suggestive of autosomal dominant sex-limited transmission or X-linked inheritance with incomplete penetrance. An adequate family history can distinguish between familial or sporadic premature ovarian failure. The risk of female relatives developing premature ovarian failure may be as high as 100% in familial premature ovarian failure, or as low as 1% in sporadic cases.