Mechanism and management of ovulatory failure in women with polycystic ovary syndrome

Growth Factors in Human Ovarian Follicle Fluid and Growth Factor Receptors in Granulosa-Luteal Cells

The levels of oestradiol (E2), progesterone (P4), transforming growth factor a (TGFa), transforming growth factor β2 (TGFβ2), insulin-like growth factor I (IGF-I), platelet-derived growth factor AB (PDGF-AB) and epidermal growth factor (EGF) were measured in follicular fluids obtained from patients undergoing ovarian stimulation as part of an in vitro fertilisation program. Each of the substances was detected in all of the fluid samples tested, except TGFα (which was detected in 90% of samples tested), PDGF-AB (70%) and EGF (2%). Comparisons were made between each of these factors, follicular maturity, successful oocyte recovery and the outcome of fertilisation and embryo transfer. No statistically significant correlations were found. The presence of receptors for EGF, IGF-I and PDGF in extracts from granulosa-luteal cells isolated from follicular fluids was detected by means of Western blotting. The co-localisation of these growth factors and their receptors within the ovarian follicle suggests a likely role in control of follicular development.

Impact of unilateral versus bilateral laparoscopic ovarian drilling on ovarian reserve and pregnancy rate: a randomized clinical trial

OBJECTIVE

To assess the impact of unilateral dose adjusted ovarian drilling (ULOD) compared to bilateral ovarian drilling (BLOD) on ovarian reserve and pregnancy rate.

METHODS

This randomized clinical study included 105 patients with polycystic ovary syndrome. Patients were assigned to two groups; group 1 (n = 52) underwent dose adjusted ULOD using 60 Joules/cm(3) applied to the larger ovary, while group 2 (n = 53) underwent BLOD with fixed doses of 1200 J. Ovulation rate, anti-Mullerian hormone (AMH), antral follicle count (AFC), and pregnancy rates were assessed at 3 and 6 months of follow-up.

RESULTS

Ovulation and pregnancy rates at 3 months periods were comparable (p > 0.05), but was significantly higher in BLOD at 6 months period (p < 0.05). There was a highly significant difference between the two groups regarding the AMH level at 3- and 6-month follow-up periods (p < 0.001) with lower levels in the BLOD group. The AFC was comparable in the two groups after 3 months (p > 0.05) but became higher in the ULOD at 6-month follow-up period (p < 0.001).

CONCLUSION

Dose-adjusted ULOD applied to the larger ovary has comparable ovulation and pregnancy rates to fixed dose BLOD at 3-month follow-up periods with decrease in its effectiveness after 6 months.

The role of intraovarian regulators in the aetiology of polycystic ovarian syndrome

The present review demonstrates that the availability of bioactive FSH and LH in PCOS is normal and that granulosa cells of PCO are not apoptotic and instead hyperexpress functional FSH receptors and may possess intact aromatase activity. Consequently, these cells respond excessively to exogenous FSH stimulation and produce high amounts of oestradiol bothin vivoandin vitro. The altered developmental capacity of follicles from PCOin vivois most likely due to the abnormal follicular milieu of PCO and the culminating effects of intrafollicular inhibitors and stimulators. The failure of ovarian oestradiol production and follicular maturation to dominancein vivomay be due to a mechanism that interferes with the function of FSH, such as intraovarian steroids and growth factors. It has previously been shown that EGF and TGFα have inhibitory actions on follicular development, aromatization and LH receptor formation. In contrast, EGF enhances early follicular recruitment and growth. Therefore, it is hypothesized that EGF/TGFα may have a causal relationship in the mechanisms of anovulatory infertility in women with PCOS. Thus, an aberration in the regulation of follicular fluid EGF and/or TGFα may result in reduced numbers of granulosa cells, cessation of follicle selection and ultimately in the creation and maintenance of PCOS. The exact mechanism by which the hyperfunction of EGF/TGFα occurs and the trigger for this hyperactivity in the ovary remain to be determined. An experimental animal model may be required to assist such investigations in the future.

Unilateral ovarian drilling in polycystic ovarian syndrome: a prospective randomized study

Ovarian drilling is a well-accepted intervention for ovulation induction in clomiphene citrate-resistant polycystic ovarian syndrome (PCOS) patients. The aim of this study was to evaluate the effect of unilateral and bilateral ovarian drilling by electrocautery in PCOS women. In this prospective randomized clinical study, 87 patients with ovulation failure as a result of PCOS were randomly allocated to either unilateral (group A; n = 43 patients) or bilateral (group B; n = 44 patients) laparoscopic ovarian drilling by electrocautery. The average time required for unilateral ovarian drilling was shorter than for bilateral drilling. In patients who ovulated after drilling, there was a significant fall in serum LH concentration (group A, P < 0.05, group B, P < 0.05). Ovulation, pregnancy and miscarriage rates were similar in both groups. It seems that unilateral ovarian drilling in PCOS is effective, less time-consuming and probably associated with fewer complications.

Hyperprolactinemia after laparoscopic ovarian drilling: an unknown phenomenon

BACKGROUND

The effects of ovarian drilling on the serum levels of gonadotropins and androgens have been studied previously. The aim of this study is to evaluate the effects of ovarian drilling on the serum prolactin levels and its relation to ovulation in women with polycystic ovary syndrome.

METHODS

This is a prospective controlled study. Thirty-six women with PCOS underwent ovarian electrocauterization in university hospitals. Control group consisted of 35 ovulatory women with unexplained infertility. Hormonal assessment performed in early follicular phase of spontaneous or induced cycle before operation in the two groups and repeated one week after operation. Hormonal assay was also performed in the early follicular phase of the first post-operative menstruation, folliculometry and progesterone assay were also performed in the same cycle. Data were analyzed by "repeated measurement design, discriminant analysis, correlation coefficient, and Fisher exact test".

RESULTS

Six to ten weeks after operation the serum mean +/- SD prolactin levels increased from 284.41 +/- 114.32 mIU/ml to 354.06 +/- 204.42 mIU/ml (P = 0.011). The same values for the control group were 277.73 +/- 114.65 to 277.4 +/- 111.4 (P = 0.981) respectively. Approximately 45% of subjects in PCOS group remained anovulatory in spite of decreased level of LH and testosterone. Prolactin level remained elevated in 73.2% of women who did not ovulate 6-10 weeks after the procedure.

CONCLUSION

Hyperprolactinemia after ovarian cauterization may be considered as a possible cause of anovulation in women with polycystic ovaries and improved gonadotropin and androgen levels. The cause of hyperprolactinemia is unknown. Hormonal assay particularly PRL in anovulatory patients after ovarian cauterization is recommended.

Gonadotrophins in ovulation induction

For anovulatory women who fail to ovulate or conceive with clomiphene citrate, gonadotrophin ovulation induction has been the conventional second-line therapy. The aim of treatment is to achieve monofollicular development and ovulation. This differs fundamentally from the aim of ovarian stimulation for IVF, in which multiple follicular development is the goal. The small therapeutic window of ovulation induction requires a rigorous approach to monitoring, and willingness to cancel the cycle when multiple follicle development occurs. The two most widely used approaches are the low-dose step-up and the step-down protocols. While the latter more closely mimics the normo-ovulatory cycle, outcomes are similar. For safety reasons, the step-down protocol has not been widely adopted. The principle risks of ovulation induction are ovarian hyperstimulation syndrome and multiple pregnancy. There is a need to individualize treatment if outcomes are to be optimized. The role of adjuvant therapies remains unclear. However, prediction models based on initial screening parameters enable the optimal dose of FSH to be determined, and the identification of patients with a poor prognosis for successful treatment.

Impact of medically assisted fertility on preterm birth

Preterm birth is a frequent problem in women who undergo treatment for infertility. Many factors appear to contribute to the occurrence of this complication. Infertile women seem to have a predisposition to giving birth preterm and to having low birthweight babies. These complications also occur in women with a history of infertility who achieve pregnancy without treatment and who have singleton pregnancies. Assisted reproduction patients treated with in vitro fertilisation (IVF) and intracytoplasmic sperm injection (ICSI) have a disproportionately high occurrence of preterm births even with singleton pregnancies. Spontaneous preterm labour may be related to underlying medical conditions of the female partner, as its occurrence is not increased in subjects treated with ICSI (i.e. when the infertility problem is associated with male reproductive dysfunction in normal female partners). Multiple pregnancy is the factor most likely to be related to preterm birth in infertile women. The administration of drugs to induce ovulation either alone or combined with intrauterine insemination causes a significant increase in multiple pregnancies. The occurrence of higher order multiple pregnancy is also increased. Multiple pregnancy in women undergoing IVF or ICSI is related to the number of embryos transferred at the end of treatment. The transfer of more than two embryos in women under 35 is not associated with an increased chance of conception, while the occurrence of multiple pregnancy is significantly increased. Women over 40 may benefit from the transfer of more than two embryos, with fewer risks of multiple pregnancy. Single embryo transfer is increasingly considered a workable clinical option, particularly in young women. Hopefully, a more cautious approach to infertility management will reduce the occurrence of multiple pregnancy, spontaneous preterm labour and the high number of low birthweight infants born after treating these women.

Naltrexone effect on pulsatile GnRH therapy for ovulation induction in polycystic ovary syndrome: a pilot prospective study

The aim of the present study was to analyze the opioid influence on LH pulsatility in polycystic ovary syndrome (PCOS) patients and to evaluate the effectiveness of a long-term opioid antagonist (naltrexone) treatment in improving the pulsatile GnRH therapy which is successful in this syndrome. Ten obese women affected by PCOS participated in the study. Patients were hospitalized during the early follicular phase and underwent an oral glucose tolerance test (OGTT) with 75 g of glucose and a pulse pattern study followed by a GnRH test (100 pg i.v.). All patients were then treated for ovulation induction with pulsatile administration of GnRH (5 microg/bolus every 90 min). Since pregnancies did not occurr in any patient, after spontaneous or progestin-induced menstrual cycles, all patients received naltrexone at a dose of 50 mg/day orally for 8 weeks and during treatment repeated the basal protocol study and the ovulation induction cycle with the same modalities. The naltrexone treatment significantly reduced the insulin response to OGTT and the LH response to GnRH bolus, whereas it did not affect the FSH and LH pulsatility patterns. Concerning the ovulation induction by pulsatile GnRH, naltrexone treatment was able to improve, although not significantly, the ovulation rate (60% pre-treatment vs 90% post-treatment). Furthermore, the maximum diameter of the dominant follicle and the pre-ovulatory estradiol concentration were higher after long-term opioid blockade (follicular diameter 19.5+/-1.76 mm pre-treatment vs 21.6+/-2.19 mm post-treatment, p<0.001; maximum estradiol level 728.7+/-288.5 pmol/l pre-treatment vs 986.4+/-382.1 pmol/l post-treatment, p<0.05). During the naltrexone-pulsatile GnRH co-treatment two pregnancies occurred. In conclusion, our data show that naltrexone-pulsatile GnRH co-treatment is able to improve the ovarian responsiveness to ovulation induction in obese PCOS patients when compared to pulsatile GnRH alone. This action seems to be related to a decrease of insulin secretion. Further randomized studies should be performed in order to obtain significant conclusions on the possible clinical application.

The effect of seizures and kindling on reproductive hormones in the rat

Reproductive dysfunction and endocrine disorders are common among both women and men with epilepsy, and, in particular, with temporal lobe epilepsy. In clinical studies, it is hard to separate the effects of seizures from the effects of medication and life style. Studies in rodents, however, suggest that seizures per se can contribute to reproductive dysfunction. In female rats, generalized seizures disrupt normal ovarian cyclicity in adults, and repeated electroshock seizures delay the onset of puberty in juveniles. Right amygdala kindling in adult female rats causes acyclicity, the development of polycystic ovaries and premature aging of the hypothalamic-pituitary neuroendocrine axis, leading to chronic anovulation and continuous estrogen exposure. In adult male rats, repeated electroshock seizures result in transient hypogonadism, characterized by decreased serum testosterone levels and lowered gonadal tissue weight. In contrast, right amygdala kindling increases serum testosterone, estradiol levels and gonadal weight. These findings suggest that reproductive dysfunction in women and men with epilepsy may result from recurrent seizure activity, due to seizure-related interference with the normal functions of the hypothalamic-pituitary-gonadal axis.

Follicular dynamics in the polycystic ovary syndrome

Anovulation in women with polycystic ovary syndrome (PCOS) is characterised by arrested growth of antral follicles. A relative lack of FSH may contribute to the persistence of anovulation but is unlikely, by itself, to be a major cause of it. Granulosa cells from anovulatory women with polycystic ovaries hypersecrete oestradiol, compared with size-matched follicles from normal ovaries or polycystic ovaries from ovulatory women. This phenomenon appears to reflect a condition of advanced maturation of medium-sized antral follicles. The underlying basis for the abnormalities in anovulatory PCOS remains uncertain, but it is possible that there are intrinsic differences in folliculogenesis between polycystic and normal ovaries which affect preantral as well as antral follicles. An alternative - but not mutually exclusive - explanation of this disorder is the abnormal endocrine environment. Hypersecretion of both LH and insulin are typical of anovulatory women with PCOS. Studies in isolated granulosa cells, have shown, that insulin greatly augments the action of LH on steroidogenesis but this interaction may compromise further growth of medium-sized antral follicles by generation of 'preovulatory' concentrations of cAMP within the granulosa cell and thereby leading, prematurely, to terminal differentiation of granulosa cells.

Limbic seizures alter reproductive function in the female rat

PURPOSE

Reproductive dysfunction and endocrine disorders are common among women with temporal lobe epilepsy. This study used the kindled rat model to test the hypothesis that limbic seizures directly contribute to reproductive dysfunction.

METHODS

Kindling electrodes were implanted in the basolateral amygdala in adult female rats. Females were kindled by either brief, daily, suprathreshold stimulations with a bipolar electrode or sham-kindled (controls). Electrographic and behavioral seizures were monitored. Estrous cycles also were monitored with daily vaginal smears.

RESULTS

Seizures arrested ovarian cyclicity in all (n = 42) kindled animals, the rats exhibiting persistent vaginal cornification (PVC). In these animals PVC was associated with high serum estradiol, increased pituitary weight, and polyfollicular ovaries consisting of many cystic follicles, as well as follicles in various stages of growth and atresia. In 93% of females, this effect occurred after the development of stage 5 motor seizures, when focal seizures had secondarily generalized. In contrast, only five (21%) of 24 sham-kindled controls exhibited PVC. A single injection of progesterone (P4) temporarily restored cyclicity in five (18%) of 28 kindled females exhibiting PVC. In contrast, P4 administration restored cyclicity in all five sham-kindled controls that had spontaneously stopped cycling. P4 treatment to kindled females in PVC resulted in a different endocrine profile than that in non-P4-treated, kindled rats in PVC. P4-treated rats had high serum estradiol, testosterone, and prolactin levels; they showed an increase in pituitary weight; and their ovaries contained numerous corpora lutea and cystic follicles surrounded by markedly overdeveloped thecal cell layers.

CONCLUSIONS

Seizures initiated in the amygdala result in impairment of the hypothalamic-pituitary axis, resulting in loss of ovarian cyclicity.

Growth factor action on ovarian function in polycystic ovary syndrome

Insulin-like growth factors, their receptors, binding proteins, and binding protein proteases are important in normal and abnormal ovarian follicle development. IGFs stimulate ovarian cellular mitosis and steroidogenesis and inhibit apoptosis. Patterns of expression of IGF family members are characteristic of whether follicles are estrogen- or androgen-dominant. The PCOS follicle is androgen-dominant but does not appear to be atretic and has characteristic IGF family expression. Available data strongly support an intraovarian, as opposed to endocrine, role for this growth factor family in ovarian follicle growth, steroidogenesis, and atresia.

Adhesion formation after microlaparoscopic and laparoscopic ovarian coagulation for polycystic ovary disease

STUDY OBJECTIVE

To compare the effects of microlaparoscopy and decreased CO2 exposure on peritoneal microcirculation and potential adhesion formation after ovarian surgery with those of conventional operative laparoscopy.

DESIGN

Prospective, randomized study (Canadian Task Force classification I).

SETTING

Teaching hospital.

PATIENTS

Eighteen women with polycystic ovary disease.

INTERVENTIONS

Microlaparoscopic or laparoscopic ovarian coagulation of the ovaries.

MEASUREMENTS AND MAIN RESULTS

Approximately 10 to 12 coagulation points were applied to each ovary. Two to 3 weeks after the initial surgery second-look microlaparoscopy was performed to determine the extent of adhesions in both groups. The frequency of adhesion formation and changes in glutathione peroxidase (GSH-Px), superoxide dismutase (SOD), catalase (CAT), and glutathione (GSH) levels were studied in homogenized peritoneal tissues obtained during surgery in each group.

RESULTS

Clinical profiles were similar between groups. Mean exposure, amount, and pressure of CO2 were significantly less in the microlaparoscopy group (p <0.05). The laparoscopy group had significantly more adhesions than the microlaproscopy group (24% vs 48%, p <0.05). The GSH-Px, SOD, CAT, and GSH levels were significantly lower in the laparoscopy group (0. 425 micromol, 1.2 ng, 37.55 micromol, and 0.9 nmol vs 0.755 micromol, 2.l ng, 625 micromol, and 2.6 nmol, respectively).

CONCLUSION

Reduced exposure to and amount of CO2 during microlaparoscopy may result in decreased adhesion formation compared with conventional laparoscopy. This effect may possibly be due to lack of or minimal adverse effects on peritoneal microcirculation and cell-protective systems, which are proposed mechanisms for adhesion formation and closely related to peritoneal injury. In addition, microlaparoscopy may be a cost-effective alternative to conventional laparoscopy. (J Am Assoc Gynecol Laparosc 6(2):159-163, 1999)

The use of gonadotrophin-releasing hormone antagonists in polycystic ovarian disease

Polycystic ovarian disease (PCOD) is characterized by anovulation, eventually high luteinizing hormone (LH) levels, with increased LH pulse frequency, and hyperandrogenism. As the aetiology of the disease is still unknown, gonadotrophin-releasing hormone (GnRH) antagonists, competitive inhibitors of GnRH for its receptor, are interesting tools in order to study and treat the role of increased LH levels and pulse frequency in this disease. Their administration provokes a rapid decrease in bioactive and immunoactive LH followed by a slower decrease in follicle-stimulating hormone (FSH). In patients with PCOD, the suppression of gonadotrophin secretion eradicates the symptoms of the disease as long as the treatment lasts. Several authors have suggested that increased plasma LH levels have deleterious effects on the fertility of women with PCOD. Indeed, fewer spontaneous pregnancies with more miscarriages are observed when plasma LH levels are high. Assisted reproduction techniques such as in vitro fertilization (IVF) have provided other clues to the role of the LH secretory pattern in women with PCOD. The number of oocytes retrieved, the fertilization rate and the cleavage rate are lower in PCOD patients undergoing IVF and this is inversely correlated with FSH:LH ratio. These abnormalities are corrected when endogenous secretion of LH is suppressed. On the other hand, implantation and pregnancy rates after IVF are similar to those observed in control women. New GnRH antagonists are devoid of side effects and suppress LH secretion within a few hours without a flare-up effect. This action lasts for 10-100 hours. When GnRH antagonists are associated with i.v. pulsatile GnRH, this combination both suppresses the effect of endogenous GnRH and because of the competition for GnRH receptors restores a normal frequency of LH secretion. We have studied two women with PCOD, administering first 10 mg s.c. every 72 hours for 7 days of the GnRH antagonist Nal-Glu, then adding on top i.v. pulsatile GnRH: 10 micrograms/pulse every 90 minutes for 15 days. We thus succeeded in normalizing LH secretion pattern and observed a significant decline in testosterone levels. We failed to induce appropriate ovarian response and ovulation. In conclusion, the combination of GnRH antagonist and GnRH pulsatile treatment can re-establish normal LH secretory pattern in patients with PCOD. The failure to induce ovulation with this regimen suggests the existence of an inherent ovarian defect in women with PCOD.

Hyperexpression of epidermal growth factor receptors in granulosa cells from women with polycystic ovary syndrome

OBJECTIVE

To compare the localization and quantitation of epidermal growth factor (EGF) receptor in granulosa cells from women with normal and polycystic ovaries.

DESIGN

Controlled, comparative study.

SETTING

Academic research laboratory.

PATIENT(S)

Forty-two women with normal or polycystic ovaries who attended our facility for the recovery of their immature or mature oocytes or for therapeutic purposes.

INTERVENTION(S)

Patients underwent intravaginal ultrasound-guided oocyte retrieval or laparoscopic follicular aspiration with or without prior stimulation.

MAIN OUTCOME MEASURE(S)

Quantitation of EGF receptor in granulosa cells.

RESULT(S)

Granulosa cells from polycystic ovaries expressed significantly higher levels of EGF receptor than granulosa cells from normal ovaries. In contrast with patients who were treated with clomiphene citrate, those who were treated with gonadotropins showed low levels of the receptor. However, the levels of the receptor in granulosa cells were not correlated with circulating levels of LH, FSH, progesterone, or E2. Immunolabeling of EGF receptor was confined to the cell membrane of granulosa cells. This receptor was fully functional, mediating the ligand-induced inhibition of E2 production in culture.

CONCLUSION(S)

These results provide further evidence supporting a possible role of EGF/transforming growth factor-alpha in the aberration of ovarian function in polycystic ovary syndrome.

Etiology of anovulation in polycystic ovary syndrome

Various endocrine factors may contribute to the phenomenon of arrested follicular development, which is the hallmark of anovulatory infertility in polycystic ovary syndrome. Hypersecretion of luteinizing hormone and/or insulin, together with high intrafollicular concentrations of androgens, can interact to produce supraphysiological levels of cyclic AMP in granulosa cells, resulting in premature activation of terminal differentiation and, hence, arrest of follicle growth.

Comparison of the effects of ovarian cauterization and gonadotropin-releasing hormone agonist and oral contraceptive therapy combination on endocrine changes in women with polycystic ovary disease

OBJECTIVE

To study the effects of laparoscopic ovarian cauterization and combination of long-acting GnRH agonist (GnRH-a) and oral contraceptive (OC) therapy on endocrine changes in women with clomiphene citrate (CC)- resistant polycystic ovary disease (PCOD).

DESIGN

Prospective, randomized.

SETTING

University-based infertility clinic.

PATIENTS

Seventeen women with CC-resistant PCOD were included randomly in the study to either laparoscopic ovarian cautery or GnRH-a and OC therapy for 3 months.

MAIN OUTCOME MEASURES

Serum concentrations of LH, FSH, androstenedione (A), T, and sex hormone-binding globulin (SHBG) were determined before each therapeutic approach and during the follicular phase of first menstrual cycle after the cessation of each treatment.

RESULTS

The mean serum concentrations and the clinical profiles were similar in both groups. Both groups showed significant changes in LH, FSH, A, T, and SHBG compared with pretreatment levels. There were no significant differences in the final concentrations of LH, FSH, and A between the two study groups after each treatment, whereas T and SHBG levels were significantly different in the goserelin and OC group. The decrease in LH and increase in SHBG serum concentrations were greater in the goserelin and OC-treated women [-59% and + 5.9% versus - 70% and + 13.5%, respectively]. Although the SHBG concentration increased in both groups, the serum SHBG concentration of the goserelin and OC group was significantly higher than the other group.

CONCLUSION

Both therapeutic modalities revealed similar effects on the endocrine profiles in women with CC-resistant PCOD. Considering the invasiveness, cost, and potential complications of laparoscopic ovarian cauterization, noninvasive medical treatment with GnRH-a and OC combination may be more effective in restoring the optimal follicular environment in women with PCOD.

Intrafollicular insulin-like growth factor-II levels in normally ovulating women and in patients with polycystic ovary syndrome

OBJECTIVE

To investigate intrafollicular insulin-like growth factor II (IGF-II) in patients affected with polycystic ovary syndrome (PCOS) in comparison with normal women.

DESIGN

Insulin-like growth factor-II was determined in 103 follicular fluids (FF) from normally ovulating women and in 102 FF from patients with PCOS. Ribonucleic acid was extracted from granulosa cells of follicles obtained from control and PCOS patients and from tissue from polycystic ovaries.

SETTING

Procedures were performed in a university laboratory.

PATIENTS

Twenty-nine normally ovulating women and 19 patients with PCOS underwent ovulation induction for IVF-ET with LH-releasing hormone (LH-RH) analog and gonadotropins. Eleven of them, 4 to 8 months later, underwent ovulation induction with approximately the same dosage of gonadotropins plus a standard dosage of GH.

MAIN OUTCOME MEASURES

Intrafollicular IGF-II, IGF-I, epidermal growth factor (EGF), transforming growth factor beta 2, (TGF-beta 2), inhibin, and steroids were evaluated by appropriate RIA, immunoenzymatic assay (EIA), and ELISA assays. The expression of the gene encoding IGF-II was analyzed by Northern blot.

RESULTS

Intrafollicular IGF-II was lower in PCOS than in controls. Accordingly, IGF-II messenger RNA expression was lower in PCO than in normal granulosa cells. Several differences in FF IGF-I, EGF, inhibin, and TGF-beta 2 concentrations were observed between PCOS and controls.

CONCLUSIONS

Both IGF-II and IGF-I were reduced in PCOS, confirming a possible role of an IGF imbalance in the development of this disease.

Functional, long-term human theca and granulosa cell cultures from polycystic ovaries

Reproducible culture conditions for obtaining large numbers of functional PCOS theca interna and granulosalutein cells will be indispensable in studies focussing on the molecular basis for androgen overproduction by ovarian cells of patients with polycystic ovarian syndrome (PCOS). The objective of the present study was to determine if granuiosa and theca interna cells obtained from ovarian follicles of patients with PCOS could be passaged with maintenance of inducible steroidogenic activity. PCOS theca interna and granuiosa cells were obtained from individual follicles of polycystic ovaries containing multiple cystic follicles with characteristic hypertrophied theca interna. Utilizing conditions for growing normal ovarian cells, both cell types were passaged successively and conditions for cell freezing, storing and thawing were established. In granulosa-lutein cultures grown and passed for successive passages, and transferred into serum-free medium, forskolin stimulated aromatase activity increased 3-10-fold over control non-stimulated values. Concurrent treatment with IGF-I (50 ng/mL) enhanced forskolin-stimulated aromatase activity in PCOS granulosa-lutein cultures. In passaged PCOS theca interna cells, forskolinstimulated 17α-hydroxyprogesterone production was increased 4-25-fold over control values. Treatment of PCOS theca interna cells with insulin (50 ng/mL) enhanced forskolin-stimulated 17α-hydroxyprogesterone biosynthesis. The effects of various growth factors and phorbol esters on 17α-hydroxylase activity in cultured PCOS theca interna cells was also investigated. Treatment of PCOS theca cells with EGF, FGF, TGFβ and TPA resulted in the inhibition of forskolin-stimulated 17α-hydroxyprogesterone production. These data suggest that PCOS theca interna and granuiosa cells respond to insulin and to the growth factors similarly to cells obtained from normal cycling ovaries.

Insulin-like growth factors: clinical experience in ovarian function

Insulin, insulin-like growth factor, and insulin-like growth factor binding proteins have been shown to play major roles in the modulation of both normal and disturbed ovarian physiology. Identification of many of the actions of these peptides was initially characterized using animal models. However, an increasing body of evidence has emerged to clarify their contributions in human reproductive function. It is clear that at various stages of folliculogenesis, local steroid production acts in concert with intraovarian peptides to promote dominant follicle development. This review will discuss the physiologic role(s) of the insulin-insulin-like growth factor-insulin-like growth factor binding protein family in reproductive function and disorders of androgen excess.

The insulin-like growth factor system in normal and abnormal human ovarian follicle development

Intraovarian peptides synergize with and potentiate gonadotropin actions in ovarian follicular development. The insulin-like growth factor system is one of several growth factor systems that regulate a variety of processes in ovarian granulosa and theca cells. Insulin-like growth factor binding proteins, which generally inhibit insulin-like growth factor action, are high in androgen-dominant but not estrogen-dominant follicles, and these insulin-like growth factor binding proteins may limit the co-gonadotropic actions of insulin-like growth factors within the follicle. Evidence is accumulating that insulin-like growth factor binding proteins within estrogen-dominant follicles are regulated by decreased production and by increased degradation. In polycystic ovary syndrome, in which follicles are at an arrested stage of maturation, insulin-like growth factor I and follicle stimulating hormone levels are normal and yet there is an accumulation of androstenedione substrate. Aromatase activity can be activated when granulosa are isolated from the polycystic ovary syndrome follicle but is not active in the follicle in situ. High levels of insulin-like growth factor binding proteins are present and likely inhibit insulin-like growth factor action in this arrested stage of development. Whether they contribute to it directly or reflect the androgen-dominant state of the follicle is not known at this time. Insulin resistance in polycystic ovary syndrome may result from insulin acting on surrogate receptors, like the insulin-like growth factor receptor, although the precise roles of insulin and the insulin-like growth factor system in the pathogenesis of polycystic ovary syndrome and associated states of hyperandrogenism remain to be defined.

Circulating and ovarian IGF binding proteins: potential roles in normo-ovulatory cycles and in polycystic ovarian syndrome

IGFs function as co-gonadotropins in the ovary, facilitating steroidogenesis and follicle growth. IGFBP-1 to -5 are expressed in human ovary and mostly inhibit IGF action in in vitro ovarian cell culture systems. In the clinical disorder of polycystic ovarian syndrome (PCOS), which is characterized by hyperandrogenemia, polycystic ovaries and anovulation, follicles have a higher androgen: estradiol (A : E2) content and growth is arrested at the small antral stage. In the PCOS follicle, follicle stimulating hormone (FSH) and IGF levels are in the physiologic range, and even in the face of abundant androstenedione (AD) substrate, aromatase activity and E2 production are low. When PCOS granulosa are removed from their ovarian environment, they respond normally or hyperrespond to FSH. It has been postulated that an inhibitor of IGF's synergistic actions with FSH on aromatase activity may be one (or more) of the IGFBPs, which contributes to the arrested state of follicular development commonly observed in this disorder. High levels of IGFBP-2 and IGFBP-4 are present in follicular fluid (FF) from androgen-dominant follicles (FFa) from normally cycling women and in women with PCOS. This is in marked contrast to the near absence of these IGFBPs in estrogen-dominant FF (FFe), determined by Western ligand blotting. Regulation of granulosa-derived IGFBPs is effected by gonadotropins and insulin-like peptides. In addition, an IGFBP-4 metallo-serine protease is present in FFe, but not in FFa in ovaries from normally cycling women and those with PCOS, although the IGFBP-4 protease is present in PCOS follicles hyperstimulated for in vitro fertilization. Recent studies demonstrate that IGF-II in FFe is higher than in FFa' whereas IGF-I, IGFBP-3 and IGFBP-1 levels do not differ, underscoring the importance of local IGF-II production by the granulosa and the importance of IGFBP-4 and IGFBP-2 in regulation of IGF-II action within the follicle during its developmental pathway as an E2- or A-dominant follicle. In the androgen-treated female-to-male transsexual (TSX) model for PCOS, IGF-I, IGF-II, IGFBP-3 and IGFBP-1 levels do not differ.

Effect of gonadotropins, insulin and IGF I on granulosa luteal cells from polycystic ovaries

The aim of this work is to evaluate the gonadotropin and growth factor effects in vitro on steroidal response in human granulosa luteal cells from polycystic ovaries compared with normal granulosa luteal cells in humans. The granulosa cells from polycystic (polycystic ovarian granulosa cells, POGC) and normo-ovulating women (normal cells, NC) were collected in the preovulatory phase after oocyte retrieval during the GIFT program. The cells were cultured serum-free for 24, 48 and 96 h. Estradiol and progesterone production was determined with or without HCG (1-200 ng/ml), FSH (10-300 ng/ml), insulin (1-50 micrograms/ml) and IGF I (1-50 ng/ml) addition. All treatments significantly induced a 2-3 fold estradiol increase at the 48-h and 96-h time points in POGC. The progesterone production was unaffected by HCG, FSH, insulin and IGF I addition, respectively, in POGC, whereas the NC were responsive at the 48-h and 96-h time points. FSH did not stimulate progesterone production in granulosa cells either from polycystic or normovulating subjects. Our findings indicate that POGC are hypersensitive to all substances in terms of estradiol production, whereas they show a reduced capacity of progesterone production with some treatments.

Transvaginal ultrasonic assessment of the response to clomiphene citrate in polycystic ovarian syndrome

OBJECTIVE

To study the relationship between some ovarian morphological findings based on transvaginal ultrasound (US) and the clomiphene citrate (CC) responsiveness in patients with polycystic ovarian syndrome (PCOS).

DESIGN

A comparative study of ovarian US features between the CC responders and the CC nonresponders.

SETTING

Infertility and Endocrine Clinic, Department of Obstetrics Gynecology, Shimane Medical University Hospital, Izumo, Japan.

PATIENTS

Forty-seven infertile patients with PCOS and 30 healthy volunteers.

INTERVENTIONS

A dose of 50 to 200 mg/d CC was given for ovulation induction in patients with PCOS.

MAIN OUTCOME MEASURES

Ovarian volume and number of follicles; serum LH, FSH, T, delta 4 androstenedione, and DHEAS.

RESULTS

The mean ovarian volume (11.9 mL) and the number of small follicles (13.0) were significantly larger in the CC nonresponders compared with those of the CC responders (7.9 mL and 7.0, respectively). Only 47% of the CC responders and 79% of the CC nonresponders had bilaterally enlarged ovaries (> 6.2 mL). Considerable overlap existed between the different groups. However, 96% of the CC nonresponders had a significantly increased number of follicles (> or = 10 follicles) in each ovary compared with that (16%) of the CC responders. Furthermore, with the combination of these parameters, none of the CC nonresponders had bilaterally normal ovaries, and 96% of patients with PCOS with bilaterally abnormal ovaries were CC nonresponsive.

CONCLUSIONS

Small multiple follicles (> or = 10) and enlarged ovarian volume (> 6.2 mL) were the most prominent transvaginal US features of ovaries in patients with PCOS with CC nonresponsiveness. These US features could be clinically useful for distinguishing clearly a CC nonresponder from a CC responder.

Serum levels of insulin-like growth factor binding protein-1 and ovulatory responses to clomiphene citrate in women with polycystic ovarian disease

OBJECTIVE

To study the serum levels of insulin, insulin-like growth factor I (IGF-I), and insulin-like growth factor binding protein-1 (IGFBP-1) in relation to clomiphene citrate (CC) responsiveness in women with polycystic ovarian disease (PCOD).

DESIGN

Prospective. PATIENTS, SETTING: Twenty-three women with PCOD admitted consecutively to the University Infertility Clinic, a tertiary referral center.

INTERVENTIONS

Blood samples were taken at fasting state and during oral glucose tolerance test (OGTT) for the determination of insulin, IGF-I, and IGFBP-1. A dose of 50 to 200 mg/d CC was given for ovulation induction.

RESULTS

With CC treatment, ovulation was achieved in 13 of 23 PCOD patients. The IGFBP-1 concentration was lower in CC nonresponders than in CC responders (20.5 +/- 4.0 ng/mL versus 41.0 +/- 8.5 ng/mL) (P < 0.05). This difference was accentuated in 13 lean PCOD patients. Lean CC nonresponders (n = 7) had almost threefold lower serum IGFBP-1 levels than lean CC responders (n = 6) (24.0 +/- 3.1 ng/mL versus 61.8 +/- 8.6 ng/mL) (P < 0.01). By contrast, among 10 obese PCOD patients, the IGFBP-1 levels were low irrespective of CC responsiveness (14.8 +/- 8.0 ng/mL versus 16.7 +/- 7.2 ng/mL). The differences remained during OGTT. The concentrations of IGF-I, insulin, sex hormone-binding globulin, LH, FSH, and androgens showed no significant differences between CC responders and nonresponders. There was an inverse correlation between serum insulin and IGFBP-1 levels in obese PCOD patients, whereas this was not seen in lean patients.

CONCLUSION

In lean PCOD patients, low serum IGFBP-1 concentration is related to CC unresponsiveness by a mechanism unrelated to insulin.

Serum FSH bioactivity and response to acute gonadotrophin releasing hormone (GnRH) agonist stimulation in patients with polycystic ovary syndrome (PCOS) as compared to control groups

OBJECTIVE

We evaluated the biological activity of FSH in the serum of women with polycystic ovary syndrome before and after acute administration of a GnRH agonist as compared to control groups.

DESIGN

FSH, oestradiol and androstenedione response to buserelin (100 micrograms s.c.) comparing seven polycystic ovary patients, six idiopathic hirsute women, 11 normal women in the follicular phase and nine normal men.

MEASUREMENTS

Rat granulosa cell aromatase bioassay in the presence or absence of polyethyleneglycol (PEG) pretreated 2% serum. Serum biological FSH (B-FSH), immunological FSH (I-FSH) and B/I ratio at times 0, 1, 2, 3, 4, 8, 12 and 24 hours. Serum androstenedione and oestradiol at times 0 and 24 hours.

RESULTS

Human gonadotrophin-free (oral contraceptive user and after FSH immunoabsorption) and PEG-pretreated serum increases the aromatase activity in response to increasing doses of purified FSH. The maximum enzymatic activity is however higher with 2% serum than with 4% serum. The amplitude of the B-FSH response to the GnRH agonist is markedly decreased in the polycystic group as compared to the group of normal women. There is also a small decrease in the I-FSH response in the polycystic women. When compared to that of normal women, the area under the curve in the polycystic ovary patients is reduced by 71% for B-FSH (P < 0.01) and by 23% for I-FSH (P < 0.05). The B-FSH and I-FSH responses in men are very small. After an initial decrease the B/I ratio returns to baseline level in normal women but remains low in the other groups. At time 24 hours, there is no significant change in the serum concentration of androstenedione but serum oestradiol, the baseline of which is significantly higher in the polycystic patients than in normal women, is also significantly higher at 24 hours (P < 0.05) in response to the pharmacological release of FSH.

CONCLUSION

The gonadotrophin-free and PEG-pretreated human serum has an inherent stimulatory effect on the rat granulosa aromatase bioassay with a higher activity at 2% serum. Acute GnRH agonist stimulation reveals a deficiency in the FSH response in polycystic ovary patients. The greater deficit in B-FSH than in I-FSH would indicate a possible modification in the FSH isoforms in this syndrome. The meaning of this observation for the understanding of the physiopathology of the polycystic ovary syndrome remains to be evaluated.

Follicular fluid steroid and epidermal growth factor content, and in vitro estrogen release by granulosa-luteal cells from patients with polycystic ovaries in an IVF/ET program

The follicular fluid (FF) content of androgens, estrogens and epidermal growth factor (EGF) has been evaluated in a group of patients with policystic ovary disease (PCO) and in one of normally-ovulating infertile women (NOW) in an IVF/ET program. The in vitro response to follicle-stimulating hormone (FSH) has been also evaluated in granulosa luteal cells from the same patients. PCO patients showed significantly higher FF androstenedione (delta 4) and testosterone (T) and similar FF estrone (E1) and 17 beta-estradiol (E2) levels compared to controls. In vitro production of E1 and E2 by granulosa luteal cells from PCO patients and from controls were overlapping and their response to FSH was similar. These data indicate a normal intrinsic potential aromatase activity in ovaries from PCO patients stimulated with gonadotropins and suggest that PCOs do not derive from inherent ovarian aromatase deficiency. Increased FF androgen content following gonadotropin stimulation may result from theca cell hyperactivity and androgen accumulation in the follicular antrum of rescued hyperandrogenic follicles as well as from inhibitory factors that may inhibit aromatase activation in vivo, partially counteracting the effect of gonadotropins. FF EGF levels were significantly higher in the group of PCO patients compared to those of NOW. EGF may play a role in blunting the in vivo response of granulosa cells to gonadotropins.

Polycystic ovary syndrome: interaction of follicle stimulating hormone and polypeptide growth factors in oestradiol production by human granulosa cells

The mechanism of the ovarian dysfunction in polycystic ovary syndrome, the most common cause of anovulatory infertility, remains obscure. Clinical data suggest that follicle stimulating hormone (FSH) action may be inhibited at the ovarian level by paracrine factors derived, presumably, from interstitial cells. The greater responsiveness to FSH of granulosa cells isolated from polycystic ovaries (PCO) compared with that seen in cells derived from normal ovaries, provides some support for this hypothesis and we present data which suggests that epidermal growth factor, or more likely transforming growth factor alpha, could be a candidate for this inhibitor. It should be emphasized, however, that the cardinal biochemical feature of the PCO is hypersecretion of androgens by interstitial cells. Stromal tissue from the PCO will secrete significant quantities of androstenedione in response to LH, whereas there is a negligible response in stroma from normal ovaries. It remains to be determined whether androgens have a direct inhibitory effect on FSH-induced oestradiol production in the human follicle, or whether they might exert an indirect effect by activating inhibitory polypeptide growth factors.

Inhibition of oestradiol production by epidermal growth factor in human granulosa cells of normal and polycystic ovaries

Anovulation in women with polycystic ovary syndrome results from a disorder of FSH-mediated follicular maturation which may involve paracrine modulation of FSH action by intra-ovarian factors. Epidermal growth factor (EGF) is a potent inhibitor of FSH-stimulated oestradiol production in the rat and has also been shown to inhibit aromatase activity in human granulosa cells obtained after superovulation. The purpose of this study was to investigate the action of EGF on granulosa cell function in human ovaries which had not been previously exposed to treatment with exogenous gonadotrophins and to compare the responses in tissue obtained from normal and from polycystic ovaries. Granulosa cells were obtained from antral follicles less than 10 mm in diameter after dissection of unstimulated normal or polycystic ovaries (PCO). Cells were pooled, washed, plated and incubated for 48h in the presence of 10(-7) M testosterone and various doses of human FSH. FSH dose responses were obtained with or without the addition of purified EGF (50 pg/ml). Testosterone in the absence of FSH resulted in a fourfold (range 2-7.5) increase in oestradiol accumulation in the medium after incubation of granulosa cells from both normal and polycystic ovaries. This increase was reversed by addition of EGF. FSH treatment stimulated a dose-related increase in oestradiol regardless of the origin of the granulosa cells. The peak E2 response to FSH, obtained at a dose of 1-2.5 ng/ml was a 20-fold increase above testosterone alone (range 4-55) in cells from PCO compared to sixfold (2.5-13) in cells from normal ovaries.(ABSTRACT TRUNCATED AT 250 WORDS)

Accidental hyperstimulation during ovulation induction

Clinical hyperstimulation is the most serious complication of ovulation induction, occurring in approximately 3% of cases (0.8% in the severe form). Paradoxically, it seems to be rare following in vitro fertilization, probably because all the follicles are aspirated. High-risk patients are those with polycystic ovarian disease, hyperprolactinaemia and hypothyroidism. All forms of ovulation induction have been implicated. Use of LHRH agonists have not reduced the incidence of hyperstimulation and they may even have increased it. An ongoing pregnancy seems to predispose to the occurrence of hyperstimulation, due to the secretion of hCG. Clinically, three stages of hyperstimulation have been described by the WHO (mild, moderate and severe). The pathophysiology is not completely understood, although prostaglandins, histamines and, especially, the ovarian renin-angiotensin system may be involved. Local ovarian complications and thromboembolic complications have also occurred. The treatment of severe hyperstimulation is both symptomatic (fluid replacement, aspiration of effusions, moderate sodium and water restriction, small doses of diuretics) and specific (corticosteroids, aspiration of ovarian cysts, even voluntary interruption of pregnancy in the most serious forms). If the hyperstimulation occurs in the absence of pregnancy, antihistamines or antiprostaglandins can be given. Prevention is exceedingly important. This can be helped by recognition of polycystic ovarian disease and stimulation of these cases by clomiphene citrate or pure FSH associated, for use in in vitro fertilization, with prolonged desensitization using LHRH agonists. Daily ultrasound and hormonal monitoring of ovulation induction is required. When there is excessive response to stimulation, it is prudent not to induce ovulation with hCG or, alternatively, to aspirate all the follicles and freeze the embryos obtained without giving further injections of hCG in the luteal phase. Clinical ovarian hyperstimulation is the classic form of iatrogenic disorder and is the most important complication of ovulation induction treatments, since it can be life-threatening in its most severe form. In this chapter we review current knowledge concerning the frequency, factors associated with its occurrence, clinical aspects, physiopathological mechanisms and, finally, the possibilities for treatment and prevention.

Follicular fluid concentrations of insulin-like growth factor 1, epidermal growth factor, transforming growth factor-alpha and sex-steroids in volume matched normal and polycystic human follicles

Thirty-three samples of follicular fluid (FF) were collected from 14 patients with the polycystic ovary (PCO) syndrome and matched for FF-volume with small follicles collected from subjects with normal ovaries. The median (range) FF concentration of insulin-like growth factor 1 (IGF1) in the group with PCO, 0.42 (0.13-1.20) U/ml was significantly higher than that of the controls, 0.33 (0.04-0.59) U/ml. All samples tested had less than 1 ng/ml of FF-epidermal growth factor (EGF) and transforming growth factor-alpha (TGF-alpha). The patients with PCO syndrome (PCOS) had similar FF-testosterone (T) and FF-progesterone (P) concentrations to volume matched controls, but significantly higher levels of FF-androstenedione (AD) and lower FF-oestradiol (E2). These results suggest that the granulosa cells within the polycystic follicle have a functional defect in their aromatase enzyme complex.

Induction of ovulation with clomiphene citrate in women with polycystic ovary syndrome: the difference between responders and nonresponders

To identify why some women with polycystic ovary syndrome (PCO) fail to respond to clomiphene citrate (CC), the authors have monitored the endocrine and ovarian response to CC 100 mg/day given for 5 days. Of 40 cycles studied in 27 women, 73% were ovulatory. In 8 of 9 anovulatory women, there was no follicular development despite a significant rise in serum gonadotrophin concentrations within 3 to 5 days of starting CC. There were no significant differences between the ovulatory and anovulatory groups in the peak response of either luteinizing hormone (LH) or follicle-stimulating hormone (FSH). The authors conclude that, in women with polycystic ovaries, the most common reason for the failure to ovulate is an absent ovarian response to an appropriate rise in serum FSH.