Absent biologically relevant associations between serum inhibin B concentrations and characteristics of polycystic ovary syndrome in normogonadotrophic anovulatory infertility

Mesenchymal stem cells-derived exosomes as a promising new approach for the treatment of infertility caused by polycystic ovary syndrome

Polycystic ovary syndrome (PCOS) is a multifactorial metabolic and most common endocrine disorder that its prevalence, depending on different methods of evaluating PCOS traits, varies from 4% to 21%. Chronic low-grade inflammation and irregular apoptosis of granulosa cells play a crucial role in the pathogenesis of PCOS infertility. Mesenchymal stem cells (MSCs)-derived exosomes and extracellular vesicles (EVs) are lipid bilayer complexes that act as a means of intercellular transferring of proteins, lipids, DNA and different types of RNAs. It seems that this nanoparticles have therapeutic effects on the PCOS ovary such as regulating immunity response, anti-inflammatory (local and systemic) and suppress of granulosa cells (GCs) apoptosis. Although there are few studies demonstrating the effects of exosomes on PCOS and their exact mechanisms is still unknown, in the present study we reviewed the available studies of the functions of MSC-derived exosome, EVs and secretome on apoptosis of granulosa cells and inflammation in the ovary. Therefore, the novel cell-free therapeutic approaches for PCOS were suggested in this study.

Differentiating Polycystic Ovary Syndrome from Adrenal Disorders

Although polycystic ovary syndrome (PCOS) is primarily considered a hyperandrogenic disorder in women characterized by hirsutism, menstrual irregularity, and polycystic ovarian morphology, an endocrinological investigation should be performed to rule out other hyperandrogenic disorders (e.g., virilizing tumors, non-classical congenital adrenal hyperplasia (NCAH), hyperprolactinemia, and Cushing’s syndrome) to make a certain diagnosis. PCOS and androgen excess disorders share clinical features such as findings due to hyperandrogenism, findings of metabolic syndrome, and menstrual abnormalities. The diagnosis of a woman with these symptoms is generally determined based on the patient’s history and rigorous clinical examination. Therefore, distinguishing PCOS from adrenal-originated androgen excess is an indispensable step in diagnosis. In addition to an appropriate medical history and physical examination, the measurement of relevant basal hormone levels and dynamic tests are required. A dexamethasone suppression test is used routinely to make a differential diagnosis between Cushing’s syndrome and PCOS. The most important parameter for differentiating PCOS from NCAH is the measurement of basal and ACTH-stimulated 17-OH progesterone (17-OHP) when required in the early follicular period. It should be kept in mind that rapidly progressive hyperandrogenic manifestations such as hirsutism may be due to an androgen-secreting adrenocortical carcinoma. This review discusses the pathophysiology of androgen excess of both adrenal and ovarian origins; outlines the conditions which lead to androgen excess; and aims to facilitate the differential diagnosis of PCOS from certain adrenal disorders.

Ovulation induction techniques in women with polycystic ovary syndrome

Anovulation is very common and has several different clinical manifestations, including amenorrhea, oligomenorrhea and abnormal uterine bleeding. Various mechanisms can cause anovulation. The clinical consequences and commonest chronic anovulatory disorder, polycystic ovary syndrome (PCOS), has a prevalence that ranges between 6 to 10% of the global population. While multiple causes can eventually result in PCOS, various methods have been described in the literature for its management, often without ascertaining the underlying cause. Ovulation Induction (OI) is a group of techniques that is used in women with PCOS who are looking to conceive and are unbale to do so with natural means. This narrative review presents a summary of the current evidence and available techniques for OI in women with PCOS, highlighting their performance and applicability.

Anti-Müllerian Hormone and Inhibin-A, but not Inhibin-B or Insulin-Like Peptide-3, may be Used as Surrogates in the Diagnosis of Polycystic Ovary Syndrome in Adolescents: Preliminary Results

OBJECTIVE

Polycystic ovary syndrome (PCOS) is a common endocrine problem in adolescents with an increasing prevalence of 30%. Pursuing new biomarkers with high specificity and sensitivity in the diagnosis of PCOS in adolescents is currently an active area of research. We aimed to investigate the diagnostic value of anti-Müllerian hormone (AMH), insulin-like peptide-3 (INSL3), inhibin-A (INH-A), and inhibin-B (INH-B) in adolescents with PCOS and also to determine the association, if any, between these hormones and clinical/laboratory findings related with hyperandrogenism.

METHODS

The study group comprised 53 adolescent girls aged between 14.5 and 20 years who were admitted to our outpatient clinic with symptoms of hirsutism and/or irregular menses and diagnosed as having PCOS in accordance with the Rotterdam criteria. Twenty-six healthy peers, eumenorrheic for at least two years and body mass index-matched, constituted the controls. Fasting blood samples for hormones [luteinizing hormone (LH), follicle-stimulating hormone (FSH), dehydroepiandrosterone-sulfate (DHEAS), androstenedione (D4-A), total/free testosterone (T/fT), sex hormone binding globulin (SHBG), AMH, INSL3, INH-A, INH-B] were drawn after an overnight fast.

RESULTS

In the PCOS group, 83% of the subjects were oligomenorrheic/amenorrheic and 87% had hirsutism. The LH, LH/FSH ratio, total T, fT, free androgen-index (FAI), DHEAS levels were significantly higher (p=0.005, p=0.042, p=0.047, p<0.001, p=0.007, p=0.014, respectively) and SHBG was significantly lower (p=0.004) in PCOS patients as compared to the controls. Although the INSL-3 and INH-B levels showed no difference between the groups (p>0.05), AMH and INH-A levels were found to be significantly higher in the PCOS group compared to the controls (p<0.001, p<0.001, respectively). In multiple linear regression analysis, WC SDS (p=0.028), logD4-A (p=0.033), logSHBG (p=0.031), and total ovarian volume (p=0.045) had significant effects on AMH levels, and LH (p=0.003) on INH-A levels. In receiver-operating characteristic analysis, the cut-off values for AMH and INH-A were 6.1 ng/mL (sensitivity 81.1%) and 12.8 pg/mL (sensitivity 86.8%), respectively, to diagnose PCOS. When AMH and INH-A were used in combination, the sensitivity (96.2%) increased.

CONCLUSION

INSL3 and INH-B were not found to have diagnostic value in adolescents with PCOS. On the other hand, it was shown that INH-A could be used as a new diagnostic biomarker in addition to AMH.

Decreased inhibin B responses following recombinant human chorionic gonadotropin administration in normal women and women with polycystic ovary syndrome

OBJECTIVE

To determine whether granulosa cells contribute to excess androgen production, by assessing inhibin B (Inh B) responses to hCG in women with polycystic ovary syndrome (PCOS) and in normal women.

DESIGN

Prospective study.

SETTING

Academic medical center.

PATIENT(S)

Twenty women with PCOS and 16 normal women.

INTERVENTION(S)

Blood samples obtained before and 24 hours after injection of 25 μg recombinant hCG (r-hCG).

MAIN OUTCOME MEASURE(S)

Basal and stimulated Inh B, E2, androstenedione (A), and T responses after r-hCG administration.

RESULT(S)

In normal and PCOS women, r-hCG induced a significant reduction of Inh B levels. Lowered Inh B responses were not related to body mass index, PCOS status, or age by multivariate regression. Recombinant hCG significantly increased serum A and E2 in both normal and PCOS women.

CONCLUSION(S)

In normal and PCOS women, Inh B production was decreased following r-hCG administration. These findings strongly suggest that in PCOS women androgen excess is not enhanced by LH-stimulated Inh B production.

CLINICAL TRIAL REGISTRATION NUMBER

NCT00747617.

Disordered follicle development

Alterations of ovarian follicle morphology and function have been well documented in women with PCOS. These include increased numbers of growing preantral follicles, failure of follicle growth beyond the mid-antral stage, evidence of granulosa call degeneration, and theca cell hyperplasia. Functional abnormalities include paradoxical granulosa cell hyperresponsiveness to FSH which is clinically linked to ovarian hyperstimulation during ovulation induction. In addition, there is likely a primary theca cell defect that accounts for the majority of excess androgen production in this disorder. The precise mechanisms responsible for altered follicle function are not completely clear. However, several factors appear to influence normal advancement of follicle development as well as impair ovarian steroidogenesis. These include intra- as well as extraovarian influences that distort normal ovarian growth and disrupt steroid production by follicle cells.

Polycystic Ovary-Like Abnormalities (PCO-L) in women with functional hypothalamic amenorrhea

CONTEXT

In the general population, about 30% of asymptomatic women have polycystic ovary-like abnormalities (PCO-L), i.e. polycystic ovarian morphology (PCOM) at ultrasound and/or increased anti-Müllerian hormone (AMH) serum level. PCOM has also been reported in 30-50% of women with functional hypothalamic amenorrhea (FHA).

OBJECTIVE

The aim of this study was to verify whether both PCOM and excessive AMH level indicate PCO-L in FHA and to elucidate its significance.

DESIGN

We conducted a retrospective analysis using a database and comparison with a control population.

SETTING

Subjects received ambulatory care in an academic hospital.

PATIENTS

Fifty-eight patients with FHA were compared to 217 control women with nonendocrine infertility and body mass index of less than 25 kg/m(2).

INTERVENTIONS

There were no interventions.

MAIN OUTCOME MEASURES

We measured serum testosterone, androstenedione, FSH, LH, AMH, and ovarian area values. The antral follicle count (AFC) was used as a binary variable (i.e. negative or positive) because of the evolution of its sensitivity over the time of this study. The ability of these variables (except AFC) to detect PCO-L in both populations was tested by cluster analysis.

RESULTS

One cluster (cluster 2) suggesting PCO-L was detected in the control population (n = 52; 24%), whereas two such clusters were observed in the FHA population (n = 22 and n = 6; 38 and 10%; clusters 2 and 3, respectively). Cluster 2 in FHA had similar features of PCO-L as cluster 2 in controls, with higher prevalence of positive AFC (70%) and PCOM (70%), higher values of ovarian area and higher serum AMH (P < 0.0001 for all), and testosterone levels (P < 0.01) than in cluster 1. Cluster 3 in FHA was peculiar, with frankly elevated AMH levels. In the whole population (controls + FHA), PCO-L was significantly associated with lower FSH values (P < 0.0001).

CONCLUSION

PCO-L in FHA is a frequent and usually incidental finding of unclear significance, as in controls. The association of PCO-L with hypothalamic amenorrhea should not lead to a mistaken diagnosis of PCOS.

Endometrium in women with polycystic ovary syndrome during the window of implantation

The human endometrium undergoes to a complex series of proliferative and secretory changes in each menstrual cycle and displays only a short period of receptivity, known as the "window of implantation", necessary for the implantation of the blastocyst in the uterus. The implantation process occurs in a sequential manner, leading to the establishment of pregnancy. Morphofunctional changes during this period may prevent or hinder the implantation. For this reason, the study of the endometrium at this stage is important for the improvement of therapies that may interfere with the mechanisms involved in maternal-embryonic interaction. Several gynecological disorders, including polycystic ovary syndrome (PCOS), are associated with decreased fertility and uterine receptivity. In spite of recent advances in assisted reproduction techniques, allowing the selection of high quality embryos, the implantation rate remains low and has not increased enough in recent decades. This article aims at reviewing the endometrial aspects of the "window of implantation" in women with polycystic ovary syndrome, focusing mainly on adhesion molecules. For that purpose, we analyzed 105 articles published in journals indexed in PubMed in the last 50 years (up to May 2011). In conclusion, the endometrial receptivity seems to be the major limiting factor for the establishment of pregnancy in a large number of gynecological diseases, including PCOS, and treatment to improve implantation rates is likely to be taken towards this direction.

Inhibin secretion in women with the polycystic ovary syndrome before and after treatment with progesterone

OBJECTIVES

It has been suggested that inhibin secretion is altered in women with the polycystic ovary syndrome (PCOS). However, the contribution of a preceding luteal phase has not been taken into account. The aim of the present study was to investigate whether progesterone in the context of a simulated luteal phase affects basal and FSH-induced inhibin secretion in women with PCOS and elevated LH.

METHODS

Ten women with PCOS and 8 normally cycling women participated in an experimental procedure (Exp) involving the administration of a single injection of recombinant FSH (450 IU sc). In the women with PCOS, the procedure was performed before (Exp 1) and after a 20-day treatment with progesterone (Exp 2), while in the normal women on day 2 of the cycle (Exp 3). Inhibin A and B levels were measured in blood samples taken before and 24 hours after the FSH injection.

RESULTS

Basal LH levels were significantly higher and inhibin A levels were significantly lower in the PCOS group compared to the control group, while inhibin B levels were comparable in the two groups. In the PCOS group, after treatment with progesterone inhibin A and LH but not inhibin B levels decreased significantly (p < 0.05). After the FSH injection, inhibin A and B levels increased significantly in the women with PCOS (Exp 1 and Exp 2) but not in the control women (Exp 3).

CONCLUSIONS

In women with PCOS, as compared to control women, the dissimilar pattern of inhibin A and inhibin B secretion in response to FSH appears to be independent of a preceding simulated luteal phase. It is possible that compared to normal ovaries, the PCOS ovaries are less sensitive to endogenous LH regarding inhibin A secretion and more sensitive to exogenous FSH stimulation in terms of inhibin A and inhibin B secretion.

Downregulation of both gene expression and activity of Hsp27 improved maturation of mouse oocyte in vitro

BACKGROUND

Heat shock protein 27 (Hsp27), a member of the small heat shock protein family, is an apoptosis regulator. Our previous proteomic study showed that Hsp27 mainly expressed in human oocyte, and that Hsp27 expression was downregulated in the ovaries derived from women with the polycystic ovary syndrome (PCOS), a well known endocrinal disorder with abnormal apoptotic activity and folliculogenesis. However, the exact effects of Hsp27 downregulation on oocyte development have not yet been clarified.

METHODS

The expression of Hsp27 gene was downregulated in the mouse oocytes cultured in vitro using siRNA adenovirus infection, while the activity of Hsp27 was decreased by microinjection of polyclonal Hsp27 antibody into the cytoplasm of germinal vesicle (GV) oocytes. Oocyte maturation rate was evaluated by morphological observation. Early stage of apoptosis was determined using Annexin-V staining analysis and some critical apoptotic factors and cytokines were also monitored at both mRNA level by real time RT-PCR and protein expression level by immunofluorescence and western blot.

RESULTS

Hsp27 expressed at high level in maturing oocytes. Infection with AdshHsp27, and microinjection of Hsp27 antibody into GV oocytes, resulted in the improved oocyte development and maturation. Germinal vesicle breakdown (GVBD) rates were significantly increased in two AdshHsp27-treated groups (88.7%, 86.0%) and Hsp27 antibody-injected group (77.0%) when compared with control (76.2% in AdGFP, 64.4% in IgG-injected), respectively. In addition, the rates of metaphase II (MII) development in two AdshHsp27-treated groups (73.8%, 76.4%) and Hsp27 antibody-injected group (67.3%) were higher than that in the controls (59.6% in AdGFP, 55.1% in IgG-injected). We also found that the rates of early stage of apoptosis in Hsp27 downregulated groups (46.5% and 45.6%) were higher than that in control group (34.1%) after 8 h of IVM. Similarly, downregulation of Hsp27 caused a significantly enhanced the expression of apoptotic factors (caspase 8, caspase 3) and cytokines (bmp 15 and gdf 9).

CONCLUSIONS

Downregulation of Hsp27 improved the maturation of mouse oocytes, while increased early stage of apoptosis in oocytes by inducing the activation of extrinsic, caspase 8-mediated pathway.

[Serum inhibin B in polycystic ovary syndrome as a potential marker of ovarian dysfunction]

INTRODUCTION

Polycystic ovary syndrome (PCOS) is one of the most common causes of anovulation, infertility and hyperandrogenism, and the prevalence of this condition in women of reproductive is 5-10%. The growth of early ovarian antral follicles is arrested and dominant follicle selection is disturbed in this syndrome.

OBJECTIVE

The aim of this study is to investigate whether inhibin B serum concentrations represent the extent of ovarian abnormalities in patients with PCOS.

METHOD

Inhibin B serum concentrations on the third day of spontaneous menstrual cycle and other endocrine characteristics were compared between 20 patients with PCOS and 19 healthy women in the control group.

RESULTS

Inhibin B concentrations were not significantly different between women with PCOS and women in the control group. In patients with PCOS there was statistically significant correlation between serum inhibin B and LH (r = 0.514; p = 0.021).There were no positive correlations between inhibin B and others endocrine parameters in patients with PCOS (FSH, E2,T, androstenedione).

CONCLUSION

Inhibin B serum concentrations on the third day of spontaneous menstrual cycle in women with PCOS are not different from the concentrations in healthy women. Serum Inhibin B levels in patients with PCOS are only slightly correlated with the endocrine markers of the disease so it could not represent the magnitude of ovarian dysfunction in this syndrome.

The Androgen Excess and PCOS Society criteria for the polycystic ovary syndrome: the complete task force report

OBJECTIVE

To review all available data and recommend a definition for polycystic ovary syndrome (PCOS) based on published peer-reviewed data, whether already in use or not, to guide clinical diagnosis and future research.

DESIGN

Literature review and expert consensus.

SETTING

Professional society.

PATIENTS

None.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

A systematic review of the published peer-reviewed medical literature, by querying MEDLINE databases, to identify studies evaluating the epidemiology or phenotypic aspects of PCOS.

RESULT(S)

The Task Force drafted the initial report, following a consensus process via electronic communication, which was then reviewed and critiqued by the Androgen Excess and PCOS (AE-PCOS) Society AE-PCOS Board of Directors. No section was finalized until all members were satisfied with the contents, and minority opinions noted. Statements were not included that were not supported by peer-reviewed evidence.

CONCLUSION(S)

Based on the available data, it is the view of the AE-PCOS Society Task Force that PCOS should be defined by the presence of hyperandrogenism (clinical and/or biochemical), ovarian dysfunction (oligo-anovulation and/or polycystic ovaries), and the exclusion of related disorders. However, a minority considered the possibility that there may be forms of PCOS without overt evidence of hyperandrogenism, but recognized that more data are required before validating this supposition. Finally, the Task Force recognized and fully expects that the definition of this syndrome will evolve over time to incorporate new research findings.

Inhibins as diagnostic markers in human reproduction

Over the past 75 years, many publications have focused on measurement of inhibin concentration and/or activity in biological samples in order to understand its role in physiology and disease. This chapter highlights the accomplishments within this area of research over the past decade including development of specific inhibin assays. Inhibin A is a marker of dominant follicle and corpus luteum activity and decreases in polycystic ovary syndrome (PCOS). Inhibin A increases in gestational diseases such as pre-eclampsia and fetal Down's syndrome, and this increase in inhibin A improves early diagnosis of both conditions. The measurement of inhibin A in women with threatened abortion provides useful information about the likelihood of pregnancy loss. Inhibin B increases markedly in women with granulosa cell tumor and appears closely related to gametogenesis in men, that is, reflecting Sertoli cell activity. On the contrary, Inhibin B decreases in women with declining ovarian function and correlates with female response to ovulation induction. This review evaluates the biochemical significance ofinhibins including their use in clinical practice.

Hormonal profile in women with polycystic ovarian syndrome with or without type 1 diabetes mellitus

CONTEXT

Anti-Müllerian hormone (AMH) levels are increased in polycystic ovarian syndrome (PCOS), but it is not known whether other forms of hyperandrogenism, such as PCOS observed in women with type 1 diabetes mellitus (DM1), are also associated with elevated AMH levels.

OBJECTIVE

Our objective was to compare AMH and steroid levels in women with PCOS with and without DM1.

DESIGN

We compared the clinical, hormonal, and ultrasonographic characteristics of 17 women with PCOS and DM1 (DM1+PCOS), 20 women with PCOS without DM1 (PCOS), and 35 normal women (control) in a cross-sectional study.

RESULTS

The Ferriman-Gallwey score, serum testosterone, free androgen index, 17OH-progesterone, and ovarian volume were elevated in both groups of PCOS women compared with controls. Serum androstenedione, LH/FSH ratio, and follicle number, however, were higher and SHBG was lower in PCOS compared with DM1+PCOS and controls. AMH levels were higher in PCOS (76.0 +/- 36.3 pmol/liter) than in DM1+PCOS (18.8 +/- 7.4 pmol/liter) and controls (13.9 +/- 8.3 pmol/liter). AMH levels correlated with follicle number in the three groups. Serum AMH/follicle number ratio was higher in PCOS than in DM1+PCOS and controls.

CONCLUSIONS

Women with DM1+PCOS have normal levels of AMH, inhibin B, estradiol, SHBG, and LH/FSH, suggesting that the pathophysiology of hyperandrogenism in PCOS patients with DM1 appears to be different from that in PCOS without DM1. However, hirsutism score and androgen levels were similar in both groups of women with PCOS. We postulate that insulin treatment acts as a co-gonadotropin increasing follicle recruitment, hence not increasing AMH levels.

Proteomic analysis of human ovaries from normal and polycystic ovarian syndrome

Polycystic ovary syndrome (PCOS) is the most common cause of anovulatory infertility, affecting 5-10% of females of reproductive age. Currently, little is known about the changes in whole proteins between PCOS and normal ovaries. In the present study, a proteomic approach comprised two-dimensional gel electrophoresis (2DE) analysis and mass spectroscopy was used to identify proteins and examine expression patterns in three PCOS and normal ovaries. One hundred and ten protein spots were separated and showed different intensities between PCOS and normal ovaries. Sixty-nine proteins associated with cellular metabolism and physiological process were identified from 72 spots. Fifty-four proteins were up-regulated in PCOS ovaries and 15 other proteins were up-regulated in normal ovaries. These data demonstrate, for the first time, the complexity in the regulation of ovarian protein expression in human PCOS, and will provide important insight for a better understanding of the pathogenetic mechanisms underlying this clinical disorder.

Acute effects of metformin therapy include improvement of insulin resistance and ovarian morphology

OBJECTIVE

To evaluate the acute effects of metformin therapy on biochemical markers and polycystic ovarian morphology among insulin-resistant (IR) and noninsulin-resistant (NIR) patients with polycystic ovary syndrome (PCOS).

DESIGN

Prospective interventional study.

SETTING

Reproductive endocrinology clinic in a university hospital.

PATIENT(S)

Five IR and five NIR patients with PCOS. The mean age of patients was 29.5 +/- 4.8 years (range, 23-36 years).

INTERVENTION

Metformin therapy, using 850 mg orally per day for 1 week.

MAIN OUTCOME MEASURE(S)

Serum levels of T, FSH, and LH, fasting glucose/insulin ratio, levels of anti-Müllerian hormone (AMH) and inhibin B, and antral follicle count.

RESULT(S)

Levels of AMH and inhibin B were statistically significantly higher in patients with PCOS compared to controls (2.81 +/- 1.79 ng/mL versus 0.95 +/- 1.17 ng/mL, and 56.24 +/- 29.39 pg/mL versus 17.89 +/- 12.87 pg/mL, respectively). Levels of AMH and inhibin B were similar among IR and NIR patients with PCOS (2.77 +/- 1.92 ng/mL versus 2.85 +/- 1.89 ng/mL, and 53.96 +/- 28.58 pg/mL versus 58.51 +/- 33.28 pg/mL, respectively). One week of metformin therapy did not alter either AMH or inhibin B levels. However, there was a statistically significant increase in glucose/insulin ratios (4.59 +/- 1.57 versus 6.35 +/- 3.6), and a significant decrease in the number of antral follicles after 1 week of metformin therapy (38.8 +/- 19.3 versus 23.1 +/- 7.4).

CONCLUSION(S)

Levels of AMH and inhibin B are significantly increased in patients with PCOS compared to controls, but are not associated with insulin resistance. Low-dose metformin therapy improves IR and polycystic ovary morphology, even though levels of T, AMH, and inhibin B remain unchanged.

Positions statement: criteria for defining polycystic ovary syndrome as a predominantly hyperandrogenic syndrome: an Androgen Excess Society guideline

OBJECTIVE

The Androgen Excess Society (AES) charged a task force to review all available data and recommend an evidence-based definition for polycystic ovary syndrome (PCOS), whether already in use or not, to guide clinical diagnosis and future research.

PARTICIPANTS

Participants included expert investigators in the field.

EVIDENCE

Based on a systematic review of the published peer-reviewed medical literature, by querying MEDLINE databases, we tried to identify studies evaluating the epidemiology or phenotypic aspects of PCOS.

CONSENSUS PROCESS

The task force drafted the initial report, following a consensus process via electronic communication, which was then reviewed and critiqued by the AES Board of Directors. No section was finalized until all members were satisfied with the contents and minority opinions noted. Statements that were not supported by peer-reviewed evidence were not included.

CONCLUSIONS

Based on the available data, it is the view of the AES Task Force on the Phenotype of PCOS that there should be acceptance of the original 1990 National Institutes of Health criteria with some modifications, taking into consideration the concerns expressed in the proceedings of the 2003 Rotterdam conference. A principal conclusion was that PCOS should be first considered a disorder of androgen excess or hyperandrogenism, although a minority considered the possibility that there may be forms of PCOS without overt evidence of hyperandrogenism but recognized that more data are required before validating this supposition. Finally, the task force recognized, and fully expects, that the definition of this syndrome will evolve over time to incorporate new research findings.

Effect of laparoscopic ovarian diathermy on circulating inhibin B in women with anovulatory polycystic ovary syndrome

BACKGROUND

Laparoscopic ovarian diathermy (LOD) frequently induces ovulation in patients with polycystic ovary syndrome (PCOS). The mechanism by which this effect occurs remains largely unexplained. The aim of this study was to measure changes in inhibin B production in response to LOD to see whether this could explain the mechanism of action of LOD.

METHODS

This prospective study included 50 anovulatory women with PCOS. All women underwent LOD. Blood samples were collected before and after LOD to measure plasma concentrations of inhibin B, gonadotrophins and androgens.

RESULTS

The pre-operative median plasma concentration of inhibin B was 110.0 pg/ml (range 19.0-567.0 pg/ml). There was a statistically significant inverse correlation (r= -0.286; P < 0.05) between body mass index (BMI) and inhibin B. Non-obese women with PCOS (BMI <or= 30 kg/m2; n=37) displayed significantly (P < 0.05) higher plasma inhibin B concentrations [122.0 pg/ml (range 19.0-567.0 pg/ml)] compared with those [51.0 pg/ml (range 27.0-201.0 pg/ml)] of obese PCOS women (BMI > 30 kg/m2; n=13). Following LOD, 39 women ovulated. No statistically significant change of inhibin B after LOD was observed in the overall group of women with PCOS or in the subgroup of non-obese PCOS women with higher pre-operative inhibin B.

CONCLUSIONS

The lack of any change of inhibin B after LOD makes it unlikely that this hormone has any role to play in the mechanism of action of LOD.

Comparison of follicle-stimulating-hormone-stimulated dimeric inhibin and estradiol responses as indicators of granulosa cell function in polycystic ovary syndrome and normal women

CONTEXT

Follicular phase secretion of inhibin B, like that of estradiol (E(2)), correlates with the quantity and quality of developing follicles. However, it has not been established whether inhibin B responses to gonadotropin stimulation parallel those of E(2) as a reflection of granulosa cell functional capacity.

OBJECTIVE

Our objective was to determine whether inhibin B responses to FSH stimulation are similar to those of E(2) in women with polycystic ovary syndrome (PCOS) and normal women.

DESIGN AND SETTING

We conducted a prospective study to compare ovarian responses in two groups of women at a general clinical research center in a tertiary academic medical center.

PATIENTS

Women with PCOS, 18-35 yr (n = 19), and normal ovulatory controls, 18-35 yr (n = 7), were recruited for study.

INTERVENTIONS

Serum samples were measured over a 24-h period after an iv injection of recombinant human FSH, 150 IU.

MAIN OUTCOME MEASURES

Serum E(2), inhibin A, and inhibin B responses after FSH administration were assessed.

RESULTS

In PCOS women, the 24-h production of inhibin B and E(2) after FSH was significantly greater than that of normal controls. Within the PCOS group, the fold change in inhibin B was significantly greater than that of E(2). Inhibin A responses between groups were similar and of markedly lower magnitude.

CONCLUSIONS

FSH-stimulated inhibin B responses may be employed to assess the functional capacity of granulosa cells in PCOS and normal women.

Increased anti-Müllerian hormone serum concentrations in prepubertal daughters of women with polycystic ovary syndrome

CONTEXT

Anti-Müllerian hormone (AMH) is produced by the granulosa cells and reflects follicular development. Adult women with polycystic ovary syndrome (PCOS) have increased levels of AMH associated with an excessive number of growing follicles. However, it is not known whether these abnormalities are present before the clinical onset of PCOS.

OBJECTIVE

Our objective was to investigate whether prepubertal daughters of women with PCOS have increased AMH levels.

DESIGN

Fourteen female infants (2-3 months old) and 25 prepubertal girls (4-7 yr old) born to PCOS mothers were studied. As a control group, we studied 21 female infants and 24 prepubertal girls born to mothers with regular menses and without hyperandrogenism. The group with PCOS mothers and the control group had normal birth weight and were born from spontaneous singleton pregnancies. Circulating concentrations of gonadotropins, testosterone, androstenedione, estradiol, 17-OH-progesterone, SHBG, inhibin B, and AMH were determined by specific assays.

RESULTS

Serum concentrations of AMH were significantly higher in the PCOS group compared with the control group during early infancy (20.4 +/- 15.6 vs. 9.16 +/- 8.6 pmol/liter; P = 0.024) and during childhood (14.8 +/- 7.7 vs. 9.61 +/- 4.4 pmol/liter; P = 0.007). Gonadotropin and serum sex steroid concentrations were similar in both groups during the two study periods, except for FSH, which was lower during childhood in girls born to PCOS mothers.

CONCLUSIONS

We conclude that serum AMH concentrations are increased in prepubertal daughters of PCOS women, suggesting that these girls appear to show evidence of an altered follicular development during infancy and childhood.

Luteal-phase inhibin A and follicular-phase inhibin B levels are not characteristic of patients with an elevated LH-to-FSH ratio

PURPOSE

To test whether serum inhibin levels are related to differences in gonadotropin concentrations between patients with an elevated LH-to-FSH ratio (ELF patients) and controls.

METHODS

32 ELF patients were matched with controls by age, body mass index (BMI), and cycle length.

RESULTS

No statistically significant difference was found in follicular-phase inhibin B levels or midluteal inhibin A levels between cases and controls. Significant negative correlation was observed between follicular-phase inhibin B concentrations and BMI in ELF patients but not among controls. LH and FSH were positively related to inhibin B levels in ELF patients. Midluteal inhibin A correlated with sex hormone-binding globulin in controls but not in ELF patients.

CONCLUSIONS

Neither follicular-phase inhibin B levels nor midluteal inhibin A levels are characteristic of patients with an elevated LH-to-FSH ratio. Opposite correlations with LH and BMI suggest dysregulation of inhibin secretion rather than dimeric inhibins having a central role to the endocrinological imbalance observed in polycystic ovary syndrome.

Müllerian-inhibiting substance reflects ovarian findings in women with polycystic ovary syndrome better than does inhibin B

OBJECTIVE

To investigate Müllerian-inhibiting substance (MIS) levels in women with polycystic ovary syndrome (PCOS), as well as relationships to ovarian morphology, levels of inhibin B, and other reproductive hormones.

DESIGN

Prospective clinical study.

SETTING

Academic endocrinology centers in Palermo, Italy and New York.

PATIENT(S)

Forty-six women with PCOS, recruited on the basis of the classic criteria of chronic anovulation and hyperandrogenism, and 25 age-matched ovulatory controls.

INTERVENTION(S)

Fasting blood was obtained in all subjects in the early follicular phase (days 5-6) after spontaneous or induced menses (in PCOS), and transvaginal ultrasounds were performed.

MAIN OUTCOME MEASURE(S)

Assessment of values for luteinizing hormone (LH), testosterone (T), androstenedione (A), estradiol (E2), inhibin B, MIS, fasting insulin, and the calculated quantitative sensitivity check index (QUICKI), as well as assessments of ovarian volume and blood flow.

RESULT(S)

Women with PCOS had higher LH, T, and A; higher insulin and lower QUICKI; and higher ovarian volume and lower pulsatility index. Inhibin B concentrations were statistically significantly higher in PCOS patients (70 +/- 8.0 vs. 40 +/- 3.4 pg/mL), as was MIS (6.7 +/- 0.9 vs. 4.6 +/- 0.5 ng/mL). Inhibin B had a statistically significant direct correlation with levels of MIS (r = 0.351). However, MIS, but not inhibin B, had a statistically significant positive correlation with ovarian size (r = 0.350); the reproductive hormones LH, T, A, and E2; and insulin (r = 0.249), independent of body mass index. Women with PCOS with the highest levels of MIS had higher ovarian volumes and values of LH, T, A, and insulin.

CONCLUSION(S)

Measurements of MIS reflect ovarian findings in PCOS better than levels of inhibin B and are more frequently elevated. However, MIS lacks sensitivity for use as a diagnostic tool in PCOS.

The pathogenesis of infertility and early pregnancy loss in polycystic ovary syndrome

Women with polycystic ovary syndrome (PCOS) frequently present with reproductive dysfunction. Ovarian function might be disturbed, with resultant abnormal folliculogenesis and steroidogenesis and, although it is difficult to define the exact pathogenesis of anovulation, many possible mechanisms have been postulated. Folliculogenesis in anovulatory women with PCOS is characterized by failure of dominance and the ovary has multiple small follicles, which are arrested but capable of steroidogenesis. Abnormalities in gonadotrophin and insulin secretion and disordered paracrine function have been identified. Women with PCOS have an increased prevalence of miscarriage, both after spontaneous and induced ovulation. Hypersecretion of LH, hyperandrogenaemia and hyperinsulinaemia have all been investigated as possible causes of PCOS. It is likely that these factors are interlinked and together might result in disordered ovarian and endometrial function. Multiple other possible abnormalities have been postulated as contributory factors in the reproductive failure. These include decreased plasminogen activator inhibitor activity, endothelial dysfunction and obesity. Ideally, therapy should target the underlying disorders but at present data are inadequate and further investigations are essential before therapeutic recommendations are truly based on an understanding of the pathophysiology.

PCOS: an ovarian disorder that leads to dysregulation in the hypothalamic–pituitary–adrenal axis?

This review focuses on the role of the ovaries in the pathogenesis of the polycystic ovarian syndrome. In particular, the failure of follicular development, hypothalamo-pituitary dysregulation, alterations in adrenal steroid output and derangement of intermediary metabolism are discussed in the context of the ovaries. It is concluded that the central and adrenal alterations associated with PCOS are unlikely to be primary but rather are secondary to the events within the ovary.

Inhibins and adult ovarian function

Inhibin B is predominantly produced by early healthy antral follicles during the luteo-follicular transition of the menstrual cycle. High inhibin B concentrations during the early follicular phase are responsible for the decline in FSH serum levels closing the FSH window and assuring single dominant follicle selection in the human. Early follicular phase inhibin B levels decrease over time, reflecting the recruitment of a diminished cohort of follicles with ovarian ageing. Hence, inhibin B is a predictor of poor response in IVF. In patients with PCOS inhibin B levels (potentially representing the number of healthy, early antral follicles) may be associated with the severity of ovarian dysfunction and consequently may predict ovulation induction outcome. However, inhibin B levels are normal in most PCOS patients suggesting a normal number of healthy follicles despite an increase in overall follicle number. Recent findings indicate that initial inhibin B concentrations can not predict the outcome of ovulation induction by either clomiphene citrate or FSH. Finally, inhibin B levels decrease over time in PCOS.

Abnormal gene expression profiles in human ovaries from polycystic ovary syndrome patients

Polycystic ovary syndrome (PCOS) represents the most common cause of anovulatory infertility and affects 5-10% of women of reproductive age. The etiology of PCOS is still unknown. The current study is the first to describe consistent differences in gene expression profiles in human ovaries comparing PCOS patients vs. healthy normoovulatory individuals. The microarray analysis of PCOS vs. normal ovaries identifies dysregulated expression of genes encoding components of several biological pathways or systems such as Wnt signaling, extracellular matrix components, and immunological factors. Resulting data may provide novel clues for ovarian dysfunction in PCOS. Intriguingly, the gene expression profiles of ovaries from (long-term) androgen-treated female-to-male transsexuals (TSX) show considerable overlap with PCOS. This observation provides supportive evidence that androgens play a key role in the pathogenesis of PCOS. Presented data may contribute to a better understanding of dysregulated pathways in PCOS, which might ultimately reveal novel leads for therapeutic intervention.

Anti-Müllerian hormone serum concentrations in normoovulatory and anovulatory women of reproductive age

Anti-Müllerian hormone (AMH) concentrations correlate with the number of antral follicles as well as age and constitute an endocrine marker for ovarian aging. In normogonadotropic anovulatory infertile women [World Health Organization (WHO) class 2], the number of early antral follicles is usually increased. To investigate whether AMH concentrations are increased, serum levels in 128 WHO 2 women were compared with those in 41 normoovulatory premenopausal women of similar age. Serum AMH concentrations are significantly (P < 0.001) elevated in WHO 2 patients [median, 7.6 micro g/liter (range, 0.1-40.0)], compared with controls [median, 2.1 micro g/liter (0.1-7.4)]. In 106 patients presenting with polycystic ovaries (PCOs) (>/==" BORDER="0">12 follicles/ovary measuring 2-9 mm and/or an ovarian volume > 10 ml), AMH levels were elevated [9.3 micro g/liter (1.8-40.0)], compared with 22 patients without PCOs [6.4 micro g/liter (0.1-22.1)] (P < 0.0001). In WHO 2 patients, AMH concentrations correlated with features characteristic for polycystic ovary syndrome such as LH concentrations (r = 0.331; P = 0.0001), testosterone levels (r = 0.477, P = 0.0001), mean ovarian volume (r = 0.421; P = 0.0001), and the number of ovarian follicles (r = 0.308; P = 0.0001). AMH levels correlated well with age in WHO 2 patients (r = -0.248; P = 0.002) as well as in controls (r = -0.465; P = 0.005). However, the relative decline in AMH with age is less pronounced in WHO 2 patients. In a subset of patients no significant correlation was found between AMH serum concentrations and the FSH response dose, the duration of stimulation, and the total number of ampoules of FSH used. In conclusion, serum AMH concentrations are elevated in WHO 2 women, especially in those patients exhibiting PCOs. Because AMH concentrations correlated well with other clinical, endocrine, and ultrasound markers associated with polycystic ovary syndrome, AMH may be used as a marker for the extent of the disease. A less pronounced AMH decrease over time in these women may suggest retarded ovarian aging. The latter hypothesis, however, should be confirmed by longitudinal studies.

Inhibin B levels on cycle day 3 to predict the ovulatory response in women with PCOS undergoing ovulation induction via low dose step-up gonadotropin protocol

BACKGROUND

In this prospective clinical single blind study, we aimed to investigate whether day 3 serum inhibin B levels in women with polycystic ovarian syndrome(PCOS) are of predictive value for the estimation of the ovarian response to gonadotropins.

METHODS

Ovulation induction with low dose step-up gonadotropin protocol, starting with 75 IU/day, was performed for 30 cycles on 25 patients with PCOS. Day 3 serum inhibin B, follicle-stimulating hormone(FSH) and estradiol, and midluteal serum progesterone levels were measured during each cycle. The correlations between day 3 inhibin B levels and day 3 FSH, day 3 estradiol and midluteal progesterone measurements, as well as the amount of gonadotropin required to provide an ovulatory cycle were investigated.

RESULTS

Five (27.8%) out of 18 cycles with day 3 inhibin levels <50.0 pg/ml; and 11 (91.7%) out of 12 cycles with levels > or = 50.0 pg/ml were ovulatory (chi(2)=9.38, p<0.01). Moreover, day 3 inhibin B levels had statistically significant negative correlation with the gonadotropin used; and significant positive correlation with the midluteal progesterone levels (p<0.05). There wasn't any significant relation between day 3 FSH and estradiol levels with the gonadotropin used and progesterone levels.

CONCLUSIONS

It has been observed that as day 3 serum inhibin B levels increased in women with PCOS, the ovulatory response to gonadotropins and the rate of ovulatory cycles increased significantly.

IVF outcome in anovulatory infertility (WHO group 2)--including polycystic ovary syndrome--following previous unsuccessful ovulation induction

This follow-up study represents IVF treatment characteristics and outcomes in women with World Health Organization (WHO) group 2 anovulatory infertility after previous unsuccessful ovulation induction compared with controls. Furthermore, the possibility of initial screening parameters of these anovulatory women to predict IVF outcome was examined. Twenty-six patients with WHO 2 anovulatory infertility who failed to achieve a live birth following previous induction of ovulation (using clomiphene citrate as first line and exogenous FSH as second line) were compared with 26 IVF patients with tubal infertility matched for age, treatment period and treatment regimen. The WHO 2 patients underwent 49 IVF cycles, whereas the normo-ovulatory controls underwent 46 cycles. In WHO 2 patients 15 cycles were cancelled compared with six cycles in controls (P = 0.04). Cycles were predominantly cancelled due to insufficient response (P = 0.04). In cases in whom the cycle was cancelled, body mass index (BMI) was significantly higher (P < 0.001) in WHO 2 women compared with controls. Overall live birth rates were comparable (P = 0.9). Obese women suffering from WHO 2 anovulatory infertility are at an increased risk of having their IVF cycle cancelled due to insufficient response. Once oocyte retrieval is achieved, live birth rates are comparable with controls.

The physiology and pathophysiology of inhibin, activin and follistatin in female reproduction

In the last 2 years, major advances have been made in the understanding of inhibin physiology. Discovery of an inhibin receptor and binding protein has expanded our knowledge of the mechanism whereby inhibin antagonizes activin action. Controlled experimental studies have clarified the regulation and physiology of inhibin A and inhibin B, providing evidence for their use as markers of ovarian function. Clinical studies continue to uphold the use of inhibin as a marker for ovarian cancer, but have not generally supported its use over standard prognostic markers in assisted reproductive technologies. Finally, ongoing work suggests alterations in inhibin and follistatin that may be linked to the pathophysiology of polycystic ovary syndrome. Thus, the mechanism of inhibin action and its role in normal and abnormal ovarian function continues to emerge.

Obesity and serum luteinizing hormone level have an independent and opposite effect on the serum inhibin B level in patients with polycystic ovary syndrome

OBJECTIVE

To elucidate whether the negative effect of obesity on the serum inhibin B level that we previously reported is specific or not to polycystic ovary syndrome (PCOS) and whether it may explain the wide interindividual variability in serum inhibin B levels found in patients with PCOS.

DESIGN

Prospective study.

SETTING

Reproductive endocrinology unit of an academic medical center.

PATIENT(S)

One hundred thirty-four consecutive patients with PCOS (mean age, 27.4 +/- 4.7 years; mean body mass index [BMI], 28.3 +/- 7.6 kg/m(2); BMI > 25, 53%) and in 78 control women (mean age, 30.1 +/- 4.1 years; mean BMI, 24.3 +/- 4.9; BMI > 25, 34%).

INTERVENTION

Blood sampling was performed in the early follicular phase in patients and in control women.

MAIN OUTCOME MEASURE(S)

BMI and waist circumference (WC), serum levels of inhibin B, LH, FSH, E(2), androstenedione, T, fasting insulin, and leptin were assessed in all subjects.

RESULT(S)

No difference was observed in the mean inhibin B level between patients and controls. The BMI and WC correlated negatively with inhibin B in patients with PCOS and in controls, with similar regression slopes, thus indicating that the influence of obesity on inhibin B is not specific to PCOS. In addition, we found a positive relationship between serum LH and inhibin B levels in PCOS. There was no significant interaction between the effects of BMI and LH on the serum inhibin B levels by analysis of variance (ANOVA). The mean serum inhibin B level in patients with PCOS with high serum LH (i.e., >the 90th percentile of LH in controls) was significantly higher than in those patients with normal LH or in controls. The highest mean inhibin B level was noted in nonobese patients with PCOS with high LH levels (121.0 +/- 51.2 pg/mL), while nonobese patients with PCOS with normal LH levels and obese patients with normal LH or high LH levels had similar mean levels (94.5 +/- 40.0, 84.9 +/- 34 and 91.6 +/- 51.7 pg/mL, respectively).

CONCLUSION(S)

We confirm that obesity has a negative effect on inhibin B serum level, which is not specific to PCOS. Obesity and excess LH, acting oppositely and independently on inhibin B production, may explain the discrepancies between the previous reports studying serum inhibin B level in patients with PCOS. Further work is required to elucidate the mechanisms underlying the antagonistic effects of LH and obesity on inhibin B production in patients with PCOS.