Development of the gonadotrophic resistant ovary syndrome in myasthenia gravis: suggestion of similar autoimmune mechanisms

Resistant ovary syndrome: Pathogenesis and management strategies

Resistant ovary syndrome (ROS) is a rare and difficult gynecological endocrine disorder that poses a serious risk to women’s reproductive health. The clinical features are normal sex characteristics, regular female karyotype, and usual ovarian reserve, but elevated endogenous gonadotropin levels and low estrogen levels with primary or secondary amenorrhea. Although there have been many case reports of the disease over the past 50 years, the pathogenesis of the disease is still poorly understood, and there are still no effective clinical management strategies. In this review, we have collected all the current reports on ROS and summarized the pathogenesis and treatment strategies for this disease, intending to provide some clinical references for the management and treatment of this group of patients and provide the foothold for future studies.

Case report: Birth achieved after effective ovarian stimulation combined with dexamethasone in a patient with resistant ovary syndrome

BACKGROUND

Resistant ovary syndrome (ROS) is a rare endocrine disorder and there have been few reports of live births by affected patients. As gonadotropin resistance leads immature oocytes, some researchers reported few live births with in vitro maturation (IVM) of oocytes, but IVM is not always successful in ROS patients. Here, we report an original case of ROS, associated with Ig-FSHR in the serum, who achieved a live birth following ovarian stimulation combined with dexamethasone treatment.

CASE PRESENTATION

The 30-year-old woman presented with secondary amenorrhea and infertility. Her serum FSH levels were found to be higher than normal, but in discordance with a normal anti-Müllerian hormone (AMH) level and antral follicle count. Genetic investigation found no mutations potentially affecting FSHR. With reference of previous ROS studies, the patient's serum was analyzed for antibodies directed against FSHR and dot blot analysis showed strong reactivity with FSHR. Then, dexamethasone was proposed to the patient, and she successfully became pregnant, finally delivering a healthy girl by caesarean section.

CONCLUSION

To our best knowledge, this is the first report of the successful treatment of ROS using ovarian stimulation combined with dexamethasone. In some cases of ROS, high doses of exogenous gonadotropins in combination with immunosuppressive therapy could be an effective approach.

Follicle-stimulating hormone receptor autoantibody associated primary ovarian insufficiency successfully treated with corticosteroids: a case report

OBJECTIVE

To report a case of successful controlled ovarian stimulation (COH) for oocyte cryopreservation in a patient with autoimmune primary ovarian insufficiency (POI) and polyglandular autoimmune syndrome (PGAS) type 2.

DESIGN

Case report.

SETTING

Private in vitro fertilization clinic.

PATIENTS

25-Year-old woman, G0, with autoimmune POI and PGAS type 2.

INTERVENTIONS

Diagnosis of autoimmune interference with FSH signaling, with subsequent high-dose corticosteroid immune suppression and successful oocyte cryopreservation.

MAIN OUTCOMES MEASURES

Successful stimulation with exogenous gonadotropins, oocyte retrieval, and cryopreservation.

RESULTS

Retrieval and cryopreservation of 36 metaphase-II (MII) oocytes.

CONCLUSIONS

Scrutiny of POI cases will facilitate identification of a subset of patients in whom immune suppression with short-term, high-dose corticosteroids may enable successful COH.

Resolution of autoimmune oophoritis after thymectomy in a myasthenia gravis patient

Myasthenia gravis (MG) is an autoimmune disorder characterized by autoantibodies against acetylcholine receptors. MG is generally an isolated disorder but may occur concomitantly with other autoimmune diseases. We describe an eighteen-year-old girl with MG who was admitted to our clinic with secondary amenorrhea and diagnosed as autoimmune oophoritis. Since her myasthenic symptoms did not resolve with anticholinesterase therapy, thymectomy was performed. After thymectomy, her menses have been regular without any hormonal replacement therapy. To our knowledge, this is the first report on a patient with autoimmune ovarian insufficiency and MG in whom premature ovarian insufficiency resolved after thymectomy, without hormonal therapy.

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

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

Circulating immunoglobulins that inhibit the binding of follicle-stimulating hormone to its receptor: a putative diagnostic role in resistant ovary syndrome?

OBJECTIVE

To evaluate the presence of circulating immunoglobulins that inhibit FSH binding to its receptor (Ig-FSHR) in patients with premature ovarian failure (POF).

DESIGN

Non-randomized study. Blood sampling for determination of circulating immunoglobulins. patients Two hundred and forty-seven patients with POF and 60 normally menstruating women (controls). measurements Circulating immunoglobulins that inhibit FSH binding to its receptor were assessed by FSH-binding inhibition assay.

RESULTS

Twenty-three out of 247 women with POF presented circulating immunoglobulins that inhibit FSH binding to its receptor. These patients had been previously diagnosed as ROS. Sixty control subjects proved negative.

CONCLUSION

Determination of the presence of circulating immunoglobulins that inhibit FSH binding to its receptor could be instrumental in diagnosing the gonadotropin resistance ovary syndrome.

Autoimmune adrenal insufficiency and autoimmune polyendocrine syndromes: autoantibodies, autoantigens, and their applicability in diagnosis and disease prediction

Recent progress in the understanding of autoimmune adrenal disease, including a detailed analysis of a group of patients with Addison's disease (AD), has been reviewed. Criteria for defining an autoimmune disease and the main features of autoimmune AD (history, prevalence, etiology, histopathology, clinical and laboratory findings, cell-mediated andhumoral immunity, autoantigens and their autoepitopes, genetics, animal models, associated autoimmune diseases, pathogenesis, natural history, therapy) have been described. Furthermore, the autoimmune polyglandular syndromes (APS) associated with AD (revised classification, animal models, genetics, natural history) have been discussed. Of Italian patients with primary AD (n = 317), 83% had autoimmune AD. At the onset, all patients with autoimmune AD (100%) had detectable adrenal cortex and/or steroid 21-hydroxylase autoantibodies. In the course of natural history of autoimmune AD, the presence of adrenal cortex and/or steroid 21-hydroxylase autoantibodies identified patients at risk to develop AD. Different risks of progression to clinical AD were found in children and adults, and three stages of subclinical hypoadrenalism have been defined. Normal or atrophic adrenal glands have been demonstrated by imaging in patients with clinical or subclinical AD. Autoimmune AD presented in four forms: as APS type 1 (13% of the patients), APS type 2 (41%), APS type 4 (5%), and isolated AD (41%). There were differences in genetics, age at onset, prevalence of adrenal cortex/21-hydroxylase autoantibodies, and associated autoimmune diseases in these groups. "Incomplete" forms of APS have been identified demonstrating that APS are more prevalent than previously reported. A varied prevalence of hypergonadotropic hypogonadism in patients with AD and value of steroid-producing cells autoantibodies reactive with steroid 17alpha-hydroxylase or P450 side-chain cleavage enzyme as markers of this disease has been discussed. In addition, the prevalence, characteristic autoantigens, and autoantibodies of minor autoimmune diseases associated with AD have been described. Imaging of adrenal glands, genetic tests, and biochemical analysis have been shown to contribute to early and correct diagnosis of primary non-autoimmune AD in the cases of hypoadrenalism with undetectable adrenal autoantibodies. An original flow chart for the diagnosis of AD has been proposed.

Factors associated with early menopause

OBJECTIVE

An understanding of why certain factors contribute to a more rapid decline in ovarian function may, for some women, help prevent premature loss of fecundity and the subsequent impact of health problems secondary to long-term estrogen deficiency such as osteoporosis, cardiovascular disease, and possibly Alzheimer's disease.

METHODS

A summary of the evidence regarding factors that have been proposed to contribute to an early onset of natural menopause is presented. These factors include cigarette smoking, race, education, parity, menstrual cycle length, the use of oral contraceptives, age at menarche, major depression, anthropometry, and handedness.

RESULTS

Cigarette smoking has been found to hasten the onset of menopause by as much as one year. Lifetime number of ovulatory cycles (indicative of oocyte depletion) is also predictive of the age at natural menopause (ANP). This is consistent with the many studies that have reported early ANP among women with shorter menstrual cycles, and a later ANP among multigravid women or those who used oral contraceptives. The relationship between depressive disorder and ovarian failure is complex, involving consideration of the pharmacological effects of treatment, and is currently unclear. The findings regarding an effect of body mass index on ANP are also mixed. At this time, there is little persuasive evidence that handedness or demographic characteristics (independent of their relationship with behavioral factors like smoking) influence the ANP to any substantial degree.

CONCLUSIONS

Some factors that could potentially influence ANP have been identified, but these and other avenues of investigation warrant further study.

Left-handed women have earlier age of menopause

Association between handedness and age of menopause was assessed. A significant difference in the mean age of menopause was found between left-handed and right-handed women. There was a significant correlation between age at menopause and hand preference in right-handed women. These findings suggest that earlier age of menopause in left-handed women may be due to a more active and effective immune system in left-handers.

Identification of allelic variants in the follicle-stimulating hormone receptor genes of females with or without hypergonadotropic amenorrhea

OBJECTIVE

To determine whether women with idiopathic hypergonadotropic amenorrhea have unique alterations in the FSH receptor gene that could account for reduced activity.

DESIGN

Compare FSH receptor genes of affected women with normally menstruating control subjects.

SETTING

Center for Reproductive Health and university departments.

PATIENT(S)

Fourteen female subjects, including four normally menstruating controls; four sibling sisters, two of whom developed premature ovarian failure (POF); four patients with POF; one patient with 46,XX gonadal dysgenesis (GD); and one patient with hypogonadotropic hypogonadism.

INTERVENTION(S)

Blood samples were collected.

MAIN OUTCOME MEASURE(S)

Restriction fragment length polymorphism (RFLP) analysis, single-stranded conformation polymorphism analysis, gel electrophoretic mobility of amplified genomic DNA, and FSH receptor gene sequence.

RESULT(S)

The DNA sequencing revealed allelic variants in one RFLP-positive control. There were two silent variants and one missense variant that resulted in a change from Asp to Gly at position 334 from the start Met in the amino acid sequence. Six of 10 subjects, including controls and patients with POF and GD, had an allelic variant in which A was changed to G at position 919 which caused Thr307 to be changed to Ala.

CONCLUSION(S)

Allelic variants in the FSH receptor gene occur commonly in control subjects and affected patients.

Premature ovarian failure and ovarian autoimmunity

Premature ovarian failure (POF) is defined as a syndrome characterized by menopause before the age of 40 yr. The patients suffer from anovulation and hypoestrogenism. Approximately 1% of women will experience menopause before the age of 40 yr. POF is a heterogeneous disorder with a multicausal pathogenesis involving chromosomal, genetic, enzymatic, infectious, and iatrogenic causes. There remains, however, a group of POF patients without a known etiology, the so-called "idiopathic" form. An autoimmune etiology is hypothesized for the POF cases with a concomitant Addison's disease and/or oöphoritis. It is concluded in this review that POF in association with adrenal autoimmunity and/or Addison's disease (2-10% of the idiopathic POF patients) is indeed an autoimmune disease. The following evidence warrants this view: 1) The presence of autoantibodies to steroid-producing cells in these patients; 2) The characterization of shared autoantigens between adrenal and ovarian steroid-producing cells; 3) The histological picture of the ovaries of such cases (lymphoplasmacellular infiltrate around steroid-producing cells); 4) The existence of various autoimmune animal models for this syndrome, which underlines the autoimmune nature of the disease. There is some circumstantial evidence for an autoimmune pathogenesis in idiopathic POF patients in the absence of adrenal autoimmunity or Addison's disease. Arguments in support of this are: 1) The presence of cellular immune abnormalities in this POF patient group reminiscent of endocrine autoimmune diseases such as IDDM, Graves' disease, and Addison's disease; 2) The more than normal association with IDDM and myasthenia gravis. Data on the presence of various ovarian autoantibodies and anti-receptor antibodies in these patients are, however, inconclusive and need further evaluation. A strong argument against an autoimmune pathogenesis of POF in these patients is the nearly absent histological confirmation (the presence of an oöphoritis) in these cases (< 3%). However, in animal models using ZP immunization, similar follicular depletion and fibrosis (as in the POF women) can be detected. Accepting the concept that POF is a heterogenous disorder in which some of the idiopathic forms are based on an abnormal self-recognition by the immune system will lead to new approaches in the treatment of infertility of these patients. There are already a few reports on a successful ovulation-inducing treatment of selected POF patients (those with other autoimmune phenomena) with immunomodulating therapies, such as high dosages of corticosteroids (288-292).

Analysis of peripheral blood lymphocyte subsets, NK cells, and delayed type hypersensitivity skin test in patients with premature ovarian failure

PROBLEM

Premature ovarian failure (POF) probably belongs to the group of autoimmune endocrinopathies. Cell-mediated immune parameters were investigated. Sex steroids have a profound effect on the immune system. POF patients and postmenopausal control women (PM) were tested with or without estrogen substitution.

METHOD

A novel FACS analysis system (using double labeling techniques) was used in 30 patients with POF to enumerate the subjects of peripheral blood lymphocytes and NK cells. Eighteen PM women and 30 healthy men and women served as controls. We also tested the delayed type hypersensitivity skin test (DTH) toward Candida in the POF patient group to be informed on their cell-mediated immune function.

RESULTS

The numbers of blood lymphocytes, CD3+, CD4+ and CD8+T cells, were not abnormal in POF patients. However, HLA-DR+T cells were increased in POF patients and in PM women (P < 0.05). These elevated numbers were partially reversible by estrogen substitution. The number of CD19+ cells (B cells) was elevated, whereas CD3-/CD16+/CD56+ cells (NK cells) were decreased in POF patients (P < 0.05), irrespective of estrogen substitution. DTH skin tests toward 0.1% Candidin (0.1 ml intradermal injection) were negative in 11 out of 20 tested POF patients, compared to only 2 out of 10 tested controls (P < 0.05).

CONCLUSION

POF patients show numerous immune cell abnormalities. These abnormalities were only partially due to estrogen deficiency. We hypothesize that these abnormalities either lead to ovarian autoimmunity or may have direct effects on the ovarian function.

Dysfunction of monocytes and dendritic cells in patients with premature ovarian failure

PROBLEM

Due to the presence of ovarian antibodies it has been suggested that premature ovarian failure (POF) belongs to the autoimmune endocrinopathies. Monocytes and the monocyte-derived dendritic cells play a prominent role in the initial stages of endocrine autoimmune reactions: the accumulation of monocytes/dendritic cells and the clustering of dendritic cells in endocrine organs is one of the first phenomena of an autoimmune endocrinopathy.

METHOD

This report describes a study on (1) the chemotactic responsiveness of blood monocytes, and (2) the cluster capability of blood dendritic cells in POF patients. The monocyte chemotaxis was determined using the cell's capability to polarize (changes in shape determined by light microscopy) under the influence of the chemoattractant, N-formyl-methionyl-leucyl-phenylalanine (fMLP). The cluster capability of dendritic cells was tested by allowing the dendritic cells to form aggregates with allogenic lymphocytes in vitro.

RESULTS

The blood monocytes of 46% of a total of 28 POF patients showed a decreased fMLP induced monocyte polarization in comparison to healthy control values. None of the young female controls (N = 28) and postmenopausal women (N = 17), showed such a defective monocyte polarization. The blood dendritic cells of 36% of the POF patients showed a decreased cluster capability. Defects in monocyte polarization and dendritic cell clustering were not affected by therapies aimed at changes in the estrogen levels or gonadotropin levels of the patients [using estrogen substitution therapy, gonadotropin-releasing hormone (GnRH) analog, follicle-stimulating hormone (FSH)].

CONCLUSIONS

A redistribution of active monocytes and of active dendritic cells from the peripheral blood to the ovaries may be the cause of the described abnormalities. Since similar abnormalities in monocyte function and dendritic cell function have been described in Graves' disease and type I diabetes, the data strengthen the view that POF is one of the endocrine autoimmune diseases.

Premature ovarian failure--the prognostic application of autoimmunity on conception after ovulation induction

OBJECTIVE

To assess whether the presence of autoimmune activity in patients with premature ovarian failure (POF) can predict the response to ovulation induction and conception.

DESIGN

Assessment of autoimmune activity in patients with POF, correlating the response to ovulation induction with this autoreactivity.

SETTING

Tertiary care academic center.

PATIENTS

Forty women with POF, 15 of them treated by ovulation induction because of infertility.

INTERVENTIONS

All patients were tested for the presence of autoimmune activity, antibodies against various tissues, and 15 of them were treated with combinations of hMG/hCG, glucocorticosteroids as immunosuppressant, and some of them also with a long-acting GnRH agonist. Those patients not interested in infertility were put on hormone replacement therapy (HRT).

MAIN OUTCOME MEASURES

Serum E2 and P were measured during ovulation induction as well as follicular diameter monitoring by transvaginal sonography. Achievement of gestations and their outcome were monitored in the group in which ovulation induction was accomplished.

RESULTS

Antibodies against thyroglobulin, nuclear antigens, heart, tissue gluten, or increased levels of immunoglobulin (Ig)M, or decreased levels of complement C3 and C4 were significantly different in the patients with POF than in the control population. Autoreactivity of at least one class of the tested antibodies was found in 31 of 40 patients (77%). In 15 patients with autoimmune activity who have undergone ovulation induction using hMG/hCG, 14 pregnancies were achieved in 8 patients. Two of the pregnancies were spontaneous, and 12 were generated by hMG/hCG and fluocortolone, with or without pretreatment with GnRH-a. Twelve healthy babies were generated by 10 gestations, 3 ended in spontaneous abortions (23%), and 1 is ongoing. All the nonspontaneous pregnancies were achieved in the first three cycles of ovulation induction.

CONCLUSIONS

Patients with POF and autoimmune activity, suggesting an autoimmune etiology to the ovarian failure, may respond to ovulation induction and have a conception rate of approximately 40% in three cycles. Those who do not conceive in three treatment cycles have a very low probability to conceive; therefore, further attempts of ovulation induction should be discouraged. However, some patients may spontaneously conceive in association with HRT.

Hypergonadotropic amenorrhea--etiology and outcome in 93 young women

Ninety-three cases of amenorrheic women aged 40 years or less in whom serum FSH concentrations were found to be greater than 20 units/l have been reviewed. The etiology and diagnosis of this uncommon but serious condition and the potential for spontaneous recovery of ovarian follicular activity (17.1%) are discussed. Management is reviewed in the light of ultrasonic, karyotypic and immunological findings.

Organ-specific autoimmunity: a 1986 overview

The normally functioning immune system is subject to intricate networks of regulatory mechanisms: it is therefore not surprising to find that autoimmune diseases present a complex pathogenic picture in which the relative contributions of various factors probably determine the precise nature and course of disease. This is particularly evident in the effector mechanisms of organ-specific autoimmunity which are described in this chapter. These ultimately give rise to the disease symptoms, and can be directly cytotoxic, or may either stimulate or block functional activity or growth of the target cells. Their various contributions to human diseases are becoming more firmly established, as in Type I diabetes, or are only now being described, as in the case of EC-Ab in protracted diarrhea of infancy and as evidenced by the growing lists of receptor-stimulating or -blocking antibodies. The nature and precise location of relevant autoantigens is also coming under closer scrutiny. The answers to the question of why these diseases arise in the first place remain more elusive. However, it is again likely that a variety of factors can contribute. The attractive possibility of a role for idiotypic interactions is gaining ground, particularly within the context of antibodies to hormones and their receptors. Another potential mechanism which we believe may be of central importance, particularly in the development of organ-specific destructive autoimmunity, and which we have discussed here in detail, is the aberrant expression of HLA Class II molecules by target cells. Whether this is actually an initiating factor is presently not known, but its potential for promoting pathogenesis both early and late in the process is clear. Furthermore, the complex nature of the regulation of epithelial Class II expression may help to explain the heterogeneity of features and course of disease in different patients with the same underlying pathology. All these advances in our basic understanding of the disease processes should ultimately lead to more effective and specific means of therapeutic intervention.

Autoimmune premature ovarian failure with polyendocrinopathy and spontaneous recovery of ovarian follicular activity

Premature ovarian failure accounts for 10% of cases of secondary amenorrhea, and in most cases its cause remains unknown. One mechanism by which it occurs is autoimmune destruction. A 21-year-old patient is described in whom autoimmune ovarian failure occurred in association with Addison's disease and primary hypothyroidism. Although premature ovarian failure is generally considered irreversible, the patient subsequently resumed spontaneous ovarian follicular activity.

Endocrine and immunologic studies in a patient with resistant ovary syndrome

A patient with the resistant ovary syndrome is reported. To evaluate the hypothesis that the hypogonadism might be the result of circulating antibodies to gonadotropin receptors or to an abnormal gonadotropin molecule, a series of clinical and laboratory studies was carried out. Administration of human menopausal gonadotropin had no effect on the serum estradiol level. The patient's serum did not affect follicle-stimulating hormone binding to a membrane preparation of monkey testes, suggesting the absence of antibodies to follicle-stimulating hormone receptors, nor did the patient's serum affect in vitro responsiveness of human granulosa cells to human menopausal gonadotropin. Unresponsiveness to exogenous gonadotropins, combined with anatomically normal follicular apparatus and the absence of serum antibodies to gonadotropin receptors, supports the concept of a gonadotropin receptor or a postreceptor defect.