A Randomized Double-Blind Controlled Proof-of-Concept Study of Alanyl-Glutamine for Reduction of Post-Myomectomy Adhesions

STUDY OBJECTIVE

To test the hypothesis that intraperitoneal instillation of a single bolus dose of l-alanyl-l-glutamine (AG) will reduce the incidence, extent and/or severity of adhesions following myomectomy and establish preliminary safety and tolerability of AG in humans.

DESIGN

Phase 1,2 Randomized, double-blind, placebo-controlled study (DBRCT).

SETTING

Tertiary care gynecology surgical centre.

PATIENTS

Thirty-eight women who underwent myomectomies by laparoscopy (N = 38; AG-19 vs Placebo-19) or laparotomy (N = 10; AG-5 vs Placebo-5) with a scheduled second-look laparoscopy (SLL) 6-8 weeks later. Thirty-two patients in the laparoscopy arm completed SLL.

INTERVENTIONS

Bolus dose of AG or normal saline solution control (0.9% NaCl) administered intraperitoneally immediately prior to suture closure of the laparoscopic ports. The average dose was 170 mL of AG or control based on a dosing scheme of 1 g/kg bodyweight.

MEASUREMENTS

Digital recordings obtained for all procedures. The primary endpoint was reduction in the incidence, severity and extent of post-operative adhesions analyzed by intention-to-treat (ITT) approach. Three independent, blinded reviewers evaluated all operative video recordings to assess presence of adhesions. Post-hoc analysis assessed presence or absence of adhesions in the peritoneal cavity. Secondary endpoints assessed safety and tolerability of AG.

MAIN RESULTS

Administration of AG reduced the incidence, severity and/or extent of post-operative adhesions (p = 0.046). The presence of adhesions in the AG group was lower than in the Control group (p = 0.041). Adhesion improvement was achieved in 15 of 15 (100%) in the AG group versus 5 of 17 (29.6%) in the placebo group. No serious adverse events were reported. No differences in safety parameters were observed.

CONCLUSIONS

Intraperitoneal l-alanyl-l-glutamine reduced adhesion formation in all patients following laparoscopic myomectomy. Complete absence of adhesions was achieved at all abdominal sites in 93% of patients. Results confirm AG's known effects on cellular mechanisms of adhesiogenesis and lay the foundation for new adhesion prophylaxis research and treatment.

A randomized controlled trial of a lifestyle intervention with longitudinal follow-up on ovarian dysmorphology in women with polycystic ovary syndrome

OBJECTIVE

Effects of lifestyle modification on reproductive function in polycystic ovary syndrome (PCOS) remain poorly elucidated. We compared the effects of a pulse-based diet (lentils, beans, split peas and chickpeas) with Therapeutic Lifestyle Changes (TLC) diet on ultrasonographic markers of ovarian morphology, hyperandrogenism and menstrual irregularity in PCOS.

DESIGN

Randomized controlled trial.

PATIENTS

Women with PCOS (18-35 years).

MEASUREMENTS

Thirty women randomized to the pulse-based and 31 to TLC groups completed a 16-week intervention without energy restriction. Groups performed aerobic exercise (minimum of 5 days/wk; 45 minutes/d) and received health counselling (monthly) and longitudinal follow-up. Follicle numbers per ovary (FNPO, 2-9 mm), ovarian volume (OV), free androgen index (FAI) and menstrual cycle length were measured pre- and postintervention.

RESULTS

Follicle numbers per ovary (mean change ± SD, -10 ± 15), OV (-2.7 ± 4.8 mL), FAI (-3 ± 2) and menstrual cycle length (-13 ± 47 days) decreased over time in both groups (All: P < .01), without group-by-time interactions (All: P ≥ .13). Attrition rate was 33.7% and comparable between groups (P = .94). Adherence to diet intervention negatively correlated with changes in FNPO (r=-0.54), OV (r=-0.35) and FAI (r = -.29) in pooled groups (All: P ≤ .04). Groups maintained reduced OV, FNPO, FAI and menstrual cycles 6 months postintervention; however, decreased FNPO and FAI at 16 weeks tended to revert to baseline levels 12 months postintervention in both groups (All: P ≤ .05).

CONCLUSIONS

Both interventions improved ovarian dysmorphology, hyperandrogenism and menstrual irregularity in PCOS, and no diet appeared to be superior at improving reproductive outcomes. Our observations highlight the importance of longitudinal surveillance for sustainable adherence to newly adopted healthy lifestyle behaviours and reproductive health in PCOS (ClinicalTrials.gov identifier, NCT01288638).

Effect of a pulse-based diet and aerobic exercise on bone measures and body composition in women with polycystic ovary syndrome: A randomized controlled trial

Polycystic ovary syndrome (PCOS) is the most common endocrine disorder in women of reproductive age, with clinical symptoms including menstrual dysfunction and hyperandrogenemia, as well as insulin resistance which is thought to be a key contributing factor to symptoms. Insulin is also thought to positively affect bone while oligo- and amenorrhea are known to negatively affect bone. Lifestyle modification is the first recommendation to treat symptoms of PCOS; however, little is known about the effect of lifestyle interventions on bone measures in this population. Pulses (e.g., chickpeas, beans, split peas, lentils) have been shown to lower fasting insulin, and the objective of this study was to determine the effect of a pulse-based diet compared to the therapeutic lifestyle changes (TLC) diet on bone measures and body composition in women with PCOS. Women aged 18-35 years with PCOS were randomized to either a pulse-based diet or the TLC diet for 16-weeks while following an aerobic exercise program. Thirty-one in the TLC group and 29 in the pulse group completed dual-energy X-ray absorptiometry analysis following the intervention. After 16-weeks, both groups had a lower BMI, whole body fat mass, and % fat (p < 0.005), with no difference in lean mass. In both groups, lumbar spine bone mineral content (BMC) and density were higher following the intervention (p < 0.05) while femoral neck bone mineral density (BMD) was lower (p < 0.05). Intertrochanteric section modulus improved in both groups while there was a group x time interaction in femoral shaft subperiosteal width which was more favorable in the pulse group (p < 0.05). This study demonstrates that the femoral neck may be compromised during a lifestyle intervention in women with PCOS. Research is warranted to preserve bone health during lifestyle change in women with PCOS.

A pulse-based diet and the Therapeutic Lifestyle Changes diet in combination with health counseling and exercise improve health-related quality of life in women with polycystic ovary syndrome: secondary analysis of a randomized controlled trial

Objective: A favorable dietary composition to increase health-related quality of life (HRQoL) in PCOS remains unclear. We compared changes in HRQoL of women with PCOS who participated in a low-glycemic-index pulse-based (lentils, beans, split peas, and chickpeas) or the Therapeutic Lifestyle Changes (TLC) diet intervention.Methods: Thirty women in the pulse-based and 31 in the TLC groups (18-35 years) completed a 16-week intervention without energy-restriction. Groups participated in health counseling (monthly) and aerobic exercise (5 days/week; 45 minutes/day).Results: Fifty-five (90.2%) women completed a PCOS-specific HRQoL survey. Greatest mean increases in time-effects occurred in the domains of healthy eating, PCOS knowledge, active living, healthcare satisfaction, feelings and experiences about intervention, and health concerns, respectively (p ≤ 0.02), without group-by-time interactions (p ≥ 0.13). Decreased weight (r = -0.35) and homeostatic model assessment of insulin resistance (r = -0.18) correlated with increased scores of PCOS knowledge; adherence to intervention correlated with increased scores of active living (r = 0.39) and healthy eating (r = 0.53; p ≤ 0.03).Conclusions: Both interventions improved HRQoL scores in women with PCOS without prescribed energy-restriction. Our observations add novel insights into current evidence and elucidate the need for future psychological research to target lifestyle modifications for improving HRQoL and unique psychological complications of PCOS in this high-risk population (CinicalTrials.gov identifier:NCT01288638).

OR31-01 A Randomized Controlled Trial of a Lifestyle Intervention with Longitudinal Follow up on Ovarian Dysmorphology, Hyperandrogenism, and Menstrual Irregularity in Women with Polycystic Ovary Syndrome

The recent International Evidence-based Guideline for the Assessment and Management of Polycystic Ovary Syndrome (PCOS) recommended healthy lifestyle interventions (dietary, exercise, behavioral modification, or combined) as the first-line therapy to mediate favorable metabolic outcomes in PCOS. However, the relationship between lifestyle modifications and reproductive health in PCOS is less clear. Specifically, a favorable dietary composition to facilitate reproductive changes in women with PCOS remains unknown. Further, the longitudinal impacts of lifestyle change programs in women with PCOS is poorly elucidated. We hypothesized that a low glycemic index pulse-based diet containing lentils, beans, split peas, and chickpeas would be more effective than the Therapeutic Lifestyle Changes (TLC) diet at improving insulin sensitivity without an energy-restricted protocol and would improve reproductive health outcomes in women with PCOS after a 16-week intervention. Our objective was to compare the effects of a nutritionally balanced pulse-based diet with the TLC diet on ultrasonographic markers of ovarian morphology, hyperandrogenism, and menstrual irregularity. Women (n=30) randomized to the pulse-based and TLC (n=31) groups completed a 16-week intervention. All women participated in aerobic exercise (minimum 5 days/week; 45 minutes/day) and received health counseling (monthly) about PCOS and the benefits of lifestyle modification. Additionally, we evaluated the effects of the intervention on the reproductive outcomes by longitudinal follow-up of all participants. Follicle numbers per ovary (FNPO, 2-9 mm), ovarian volume (OV), free androgen index (FAI), intermenstrual intervals, and insulin sensitivity (Matsuda index and homeostasis model assessment of insulin resistance [HOMA-IR] were evaluated at baseline, 16-week post-intervention, and 6- and 12-month post-intervention follow up visits. Follicle numbers per ovary (mean change ± SD, -10 ± 15), OV (-2.7 ± 4.8 mL), FAI (-3 ± 2), intermenstrual interval (-13 ± 47 days), and body mass index (BMI, -1.6 ± 4.2 kg/m²) decreased, and Matsuda index (1.1 ± 3.1) increased over time in both groups (All: P ≤ 0.01), without group-by-time interactions (All: P ≥ 0.27). Groups maintained reduced OV, FNPO, FAI, and menstrual cycles 6 months post-intervention, despite a propensity for weight regain as evidenced by increased BMI (1.0 ± 4.8 kg/m²; P < 0.01). Decreased FNPO, FAI, and HOMA-IR at 16-week tended to revert to baseline levels 12 months post-intervention in both groups (All: P ≤ 0.05). Both interventions improved ovarian dysmorphology, hyperandrogenism, and menstrual irregularity in women with PCOS. Our observations elucidate the importance of longitudinal surveillance for sustainable adherence to newly adopted healthy lifestyle behaviors and reproductive health in PCOS (ClinicalTrials.gov identifier, NCT01288638).

Dysglycemia, Not Altered Sex Steroid Hormones, Affects Cognitive Function in Polycystic Ovary Syndrome

Context

Polycystic ovary syndrome (PCOS) is a complex endocrine condition characterized by multiple reproductive and metabolic abnormalities. Because individual reproductive and metabolic abnormalities modulate working memory in the general population, there is growing interest in whether cognitive function is dually and negatively affected in PCOS.

Objective

To examine the association of reproductive and metabolic features with cognitive function in women with and without PCOS.

Design

An observational, cross-sectional study was conducted at an academic clinical research center in North America between 2006 and 2009. Common tests of working memory (i.e., manual dexterity, perceptual speed, and visuospatial ability) were performed by women with PCOS (n = 40) and control subjects (n = 40). Markers of sex steroid hormones, ovulatory function, and cardiometabolic health were also assessed.

Results

Reduced visuospatial ability was observed in women with PCOS compared with control subjects (P < 0.01). Reduced visuospatial ability was linked to higher levels of hemoglobin A1c in the entire study cohort, independent of body mass index or PCOS status. No associations were observed between visuospatial ability and reproductive features, after controlling for confounding variables.

Conclusion

Our findings support a role for glycemic control, and not PCOS per se, in cognitive dysfunction in women of reproductive age. Additional studies are needed to understand the short- and long-term effects of dysglycemia on brain health in women with PCOS, given their increased propensity for metabolic comorbidities, compared with control subjects.

Polycystic ovary syndrome is a risk factor for sarcopenic obesity: a case control study

BACKGROUND

Polycystic ovary syndrome (PCOS) is the most common endocrine disorder in young women and increases risk of cardiovascular and metabolic disease, and infertility. Women with PCOS share many characteristics commonly associated with aging including chronic inflammation and insulin resistance, which may be associated with "sarcopenic obesity", a term used to describe low appendicular skeletal muscle mass relative to total body mass. The purpose of this work was to determine the prevalence of sarcopenic obesity in women with PCOS. We hypothesized there would be a high prevalence of sarcopenic obesity, and that % appendicular skeletal muscle mass and markers of inflammation and insulin resistance would be inversely correlated in this population.

METHODS

Dual energy X-ray absorptiometry was used to assess body composition in 68 women with PCOS aged 18-35y and 60 healthy age-matched women from the same geographic area. Sarcopenic obesity was defined as having % appendicular skeletal muscle mass 2 standard deviations below the mean for the healthy age-matched controls and a % body fat above 35%. Data were analyzed with Mann-Whitney U-tests and Spearman correlations.

RESULTS

53% of women with PCOS were classified as sarcopenic obese. Women with PCOS had a median (interquartile range) appendicular skeletal muscle mass of 23.8 (22.3-25.8)% which was lower than the control median of 30.4 (28.6-32.4)% (p < 0.0001). Among women with PCOS, there were negative correlations between % appendicular skeletal muscle mass and the homeostasis model assessment insulin resistance index (r = - 0.409; p < 0.01), high sensitivity C-reactive protein (r = - 0.608; p < 0.0001) and glycosylated hemoglobin (r = - 0.430; p < 0.0001). Furthermore, % appendicular skeletal muscle mass correlated positively with vitamin D (r = 0.398; p < 0.0001) in women with PCOS, which is thought to positively affect skeletal muscle mass.

CONCLUSIONS

Women with PCOS have a high prevalence of sarcopenic obesity, which is correlated to insulin resistance and inflammation.

A Comparison of a Pulse-Based Diet and the Therapeutic Lifestyle Changes Diet in Combination with Exercise and Health Counselling on the Cardio-Metabolic Risk Profile in Women with Polycystic Ovary Syndrome: A Randomized Controlled Trial

We compared the effects of a low-glycemic index pulse-based diet, containing lentils, beans, split peas, and chickpeas, to the Therapeutic Lifestyle Changes (TLC) diet on cardio-metabolic measures in women with polycystic ovary syndrome (PCOS). Ninety-five women (18⁻35 years) enrolled in a 16-week intervention; 30 women in the pulse-based and 31 in the TLC groups completed the study. Women participated in aerobic exercise training (minimum 5 days/week for 45 min/day) and were counselled (monthly) about PCOS and lifestyle modification. Women underwent longitudinal follow-up post-intervention. The pulse-based group had a greater reduction in total area under the curve for insulin response to a 75-g oral glucose tolerance test (mean change ± SD: -121.0 ± 229.9 vs. -27.4 ± 110.2 µIU/mL × min; p = 0.05); diastolic blood pressure (-3.6 ± 6.7 vs. -0.2 ± 6.7 mmHg, p = 0.05); triglyceride (-0.2 ± 0.6 vs. 0.0 ± 0.5 mmol/L, p = 0.04); low-density lipoprotein cholesterol (-0.2 ± 0.4 vs. -0.1 ± 0.4 mmol/L, p = 0.05); total cholesterol/high-density lipoprotein cholesterol (TC/HDL-C; -0.4 ± 0.4 vs. 0.1 ± 0.4, p < 0.001); and a greater increase in HDL-C (0.1 ± 0.2 vs. -0.1 ± 0.2 mmol/L, p < 0.01) than the TLC group. Decreased TC/HDL-C (p = 0.02) at six-month and increased HDL-C and decreased TC/HDL-C (p ≤ 0.02) at 12-month post-intervention were maintained in the pulse-based group. A pulse-based diet may be more effective than the TLC diet at improving cardio-metabolic disease risk factors in women with PCOS.

TRIAL REGISTRATION

CinicalTrials.gov identifier, NCT01288638.

Women With Polycystic Ovary Syndrome Have Comparable Hip Bone Geometry to Age-Matched Control Women

Polycystic ovary syndrome (PCOS) is an endocrine disorder affecting women of reproductive age manifesting with polycystic ovaries, menstrual irregularities, hyperandrogenism, hirsutism, and insulin resistance. The oligomenorrhea and amenorrhea characteristic to PCOS are associated with low bone mineral density (BMD); conversely, the hyperandrogenism and hyperinsulinemia may elicit a protective effect on BMD. As bone geometric properties provide additional information about bone strength, the objective of this study was to compare measures of hip geometry in women with PCOS to a healthy female population. Using dual-energy X-ray absorptiometry, BMD and measures of hip geometry were determined in women with PCOS (n = 60) and healthy controls (n = 60) aged 18-35 years. Clinical biochemical measures were also determined in women with PCOS. Measures of hip geometry, including cross-sectional area, cross-sectional moment of inertia, subperiosteal width (SPW), and section modulus, were similar between groups following correction for body mass index (BMI) (all p > 0.05) with intertrochanter SPW significantly lower in women with PCOS (p < 0.05). BMI-corrected whole body BMD as well as the lumbar spine and regions of proximal femur were also comparable between groups. In women with PCOS, BMI-corrected correlations were found between insulin and femoral shaft SPW (r = 0.322, p < 0.05), glucose and femoral neck (r = 0.301, p < 0.05), and trochanter BMD (0.348, p < 0.05), as well as between testosterone and femoral neck BMD (0.376, p < 0.05) and narrow neck cross-sectional area (0.306, p < 0.05). This study demonstrates that women with PCOS may have compromised intertrochanter SPW while oligomenorrhea appears to have no detrimental effect on bone density or geometry in women with PCOS.

The role of a pulse-based diet on infertility measures and metabolic syndrome risk: protocol of a randomized clinical trial in women with polycystic ovary syndrome

Background

Polycystic Ovary Syndrome (PCOS) is an endocrine disorder in women of reproductive age with an estimated prevalence of 5–20% of premenopausal women. The clinical symptoms common to PCOS include menstrual dysfunction, hyperandrogenemia, hirsutism, polycystic ovaries, insulin resistance, and hyperinsulinemia. Women with PCOS are at an increased risk of infertility, obesity and type 2 diabetes mellitus. Insulin resistance and hyperinsulinemia are believed to be key contributing factors to the pathogenesis of PCOS; excessive amounts of insulin are directly associated with the increased ovarian production of androgens and metabolic features of PCOS. Pulse-based diets (e.g., beans, chickpeas) are associated with improved glycemic control and have insulin lowering effects. The purpose of this study is to determine whether a pulse-based diet is more effective than the diet recommended by the National Cholesterol Education Program. The primary outcomes of this study are disease measures related to PCOS, with secondary outcomes including measures related to metabolic syndrome.

Methods

Women with symptoms of PCOS will be recruited for the study and a diagnosis of PCOS will be determined by an obstetrician-gynecologist. Women with PCOS will be randomly assigned to receive either a pulse-based diet or the National Cholesterol Education Program therapeutic lifestyle changes (TLC) diet for 16 weeks while participating in an aerobic exercise program. One hundred participants will be required (drop-out rate of 32%) for recruitment to provide 80% power for detecting a significant difference in fasting glucose (p < 0.05). Measures related to infertility, metabolic syndrome, quality of life, dietary intake and physical activity will be assessed pre- and post-intervention with follow up assessment at 6- and 12-months post-intervention.

Discussion

Polycystic ovary syndrome is the most common endocrine disorder in women of reproductive age and there is currently no recommended diet for this population of women. The multidisciplinary nature of this study, including determination of measures related to metabolic syndrome, infertility and physical activity provide a comprehensive assessment of any benefits associated with a pulse-based diet in women with PCOS. The results of this study will help in providing evidence-based recommendations for the optimum diet to reduce symptoms associated with PCOS.

Trial registration

NCT01288638. Trial registered January 13, 2011.

Recombinant human luteinizing hormone to trigger ovulation: randomized, controlled, dose-finding pilot study in ovulation induction

OBJECTIVE

To evaluate recombinant human luteinizing hormone (r-hLH) versus urine-derived human chorionic gonadotropin (u-hCG) to trigger ovulation in women (aged 20-40 years) with WHO Group II anovulatory infertility undergoing ovulation induction (OI) with recombinant human follicle-stimulating hormone (r-hFSH) (150 IU/day starting dose).

STUDY DESIGN

For this Phase II, open-label, dose-finding pilot study, patients were randomized to doses of 825, 2,750, 5,500, 11,000, or 22,000 IU r-hLH or u-hCG (5,000 IU). Primary endpoints were ovulation and ratio of ruptured follicles/follicle > or = 15 mm (day of r-hLH/ u-hCG administration). Secondary endpoints included monofollicular ovulation and clinical pregnancy rates.

RESULTS

All 67 randomized patients completed treatment. All patients in the r-hLH 2,750 (13/13), 5,500 (12/ 12), 11,000 IU (13/13), and u-hCG 5,000 IU (12/ 12) groups ovulated; 3/5 patients in the r-hLH 825 IU and 2/12 in the r-hLH 22,000 IU group failed to ovulate (p = 0.105 between evaluable groups). The mean ratio of ruptured follicles/ follicle > or = 15 mm was 1.1 (p = 0.675 between groups). The monofollicular ovulation rate was 15/60 (25%). Two cases of ovarian hyperstimulation syndrome were reported.

CONCLUSION

This open-label, pilot study (conducted in 1999-2001) suggests that the minimal effective dose of r-hLH to trigger ovulation in women with WHO Group II anovulatory infertility undergoing OI with r-hFSH (150 IU starting dose) was 2,750 IU.

Prevalence of Polycystic Ovary Syndrome Phenotypes Using Updated Criteria for Polycystic Ovarian Morphology: An Assessment of Over 100 Consecutive Women Self-reporting Features of Polycystic Ovary Syndrome

The prevalence of polycystic ovary syndrome (PCOS) and its distinct clinical phenotypes were assessed using 3 sets of international diagnostic criteria in women self-reporting concerns over outward features of PCOS. Revised ultrasonographic criteria for polycystic ovaries (PCO) based on modern ultrasound technology were used. Of the participants, 53%, 62%, and 70% were diagnosed with PCOS using National Institutes of Health, Androgen Excess and PCOS Society, and Rotterdam criteria, respectively. Prevalence of Frank, Ovulatory, Normoandrogenic, and Non-PCO PCOS were 66%, 13%, 11%, and 9%, respectively. Frank PCOS was associated with the severest metabolic disturbances whereas metabolic profiles in Normoandrogenic PCOS did not differ from controls, supporting reduced health risks in women without androgen excess. Metabolic disturbances and hyperandrogenism were linked to excess adiposity across all the groups. Using updated criteria for PCO, the prevalence of Non-PCO PCOS and PCO alone in healthy women recruited from the general population was reduced compared to the previous reports.

Digit ratios by computer-assisted analysis confirm lack of anatomical evidence of prenatal androgen exposure in clinical phenotypes of polycystic ovary syndrome

BACKGROUND

We recently showed that women with four clinical phenotypes of polycystic ovary syndrome (PCOS) do not demonstrate anatomical evidence of elevated prenatal androgen exposure as judged by a lower ratio of the index (2D) to ring (4D) finger. However, those findings conflicted with a previous study where women with PCOS had lower right hand 2D:4D compared to healthy female controls. Both these studies used Vernier calipers to measure finger lengths--a method recently shown to be less reliable at obtaining finger length measurements than computer-assisted analysis.

METHODS

Ninety-six women diagnosed with PCOS according to the 2003 Rotterdam criteria had their finger lengths measured with computer-assisted analysis. Participants were categorized into four recognized phenotypes of PCOS and their 2D:4D compared to healthy female controls (n = 48) and men (n = 50).

RESULTS

Digit ratios assessed by computer-assisted analysis in women with PCOS did not differ from female controls, but were significantly lower in men. When subjects were stratified by PCOS phenotype, 2D:4D did not differ among phenotypes or when compared to female controls.

CONCLUSION

Computer-assisted measurements validated that digit ratios of women with PCOS do not show anatomical evidence of increased prenatal androgen exposure.

Development of morphologically dominant follicles is associated with fewer metabolic disturbances in amenorrheic women with polycystic ovary syndrome: a pilot study

OBJECTIVES

To determine if amenorrheic women with polycystic ovary syndrome (PCOS) demonstrate ultrasonographically detectable changes in follicle population.

METHODS

Sixteen women with PCOS reporting the absence of menses for more than 3 months were enrolled in the study. Subjects had a physical examination, fasting blood tests and two transvaginal ultrasound scans spaced 1 month apart. In cases where evidence of a morphologically dominant follicle (≥ 10 mm in diameter) occurred, subsequent ultrasound scans were performed to determine the fate of the dominant follicle. Differences in total follicle population, maximum follicle diameter and clinical, hormonal and metabolic features were determined.

RESULTS

Forty-four percent of subjects showed changes in follicle population of 6-10 follicles and 37% showed changes in follicle population of > 10. Maximum follicle diameters ranged between 5.4 and 33.0 mm. Four subjects demonstrated follicle diameters ≥ 10 mm. Of those who developed dominant follicles, two subjects ovulated, one subject developed a persistent anovulatory follicle and the dominant follicle regressed in the remaining subject. Diagnostic criteria for PCOS were similar among women that did or did not develop dominant follicles (menstrual cycle length, P = 0.880; hirsutism score, P = 0.809; free androgen index, P = 0.991; total follicle count, P = 0.199). However, lower glycosylated hemoglobin (P = 0.047) and insulin levels (P = 0.049) and better insulin sensitivity (P = 0.048) were noted in women who attained dominant follicles.

CONCLUSION

Amenorrheic women with PCOS demonstrate changes in follicle population that are consistent with active follicle growth and regression despite prolonged periods of anovulation. Morphologic selection occurs in amenorrheic women and attainment of dominant follicles is associated with improved metabolic status.

Grid analysis improves reliability in follicle counts made by ultrasonography in women with polycystic ovary syndrome

Poor reliability has been reported when counting the total number of follicles in polycystic ovaries using conventional two-dimensional (2-D) ultrasound viewing methods. In the current study, we report good reliability in follicle counts when observers imposed a programmable grid system over the viewing window. Four observers estimated total follicle counts in 45 ovarian ultrasound scans by compartmentalizing the ovary into 9 to 12 grid sections and performing focused follicle counts per section. The mean number of follicles counted per ovary was 44.6 +/- 2.3. The level of inter-observer agreement when making follicle counts was 0.82 and total follicle counts did not differ among observers. The level of intra-observer agreement was 0.93 which further corroborated the utility of this method for making dependable follicle counts. In summary, the ability to obtain reproducible follicle counts will help to establish reliable diagnostic criteria for polycystic ovarian morphology.

Digit ratios do not serve as anatomical evidence of prenatal androgen exposure in clinical phenotypes of polycystic ovary syndrome

BACKGROUND

Polycystic ovary syndrome (PCOS) is heterogeneous in its clinical presentation and four major phenotypes have been identified. The precise etiology of PCOS is unknown; however, variable exposure to prenatal androgens may be responsible for the spectrum of endocrine and metabolic disturbances characteristic of this syndrome. Since prenatal testosterone exposure is known to decrease the ratio of the second to fourth finger lengths (2D:4D), we characterized the left and right hand 2D:4D in women with clinical variants of PCOS. We hypothesized that if prenatal androgens were involved in the development of the phenotypic spectrum of PCOS, then lower 2D:4D would be differentially expressed among clinical variants of the syndrome.

METHODS

Digit ratios were determined in 98 women diagnosed with PCOS by the 2003 international consensus guidelines and in 51 women with regular menstrual cycles, no clinical or biochemical signs of hyperandrogenism and normal ovarian morphology. Women with PCOS were categorized into four clinical phenotypes (i.e. Frank, Non-PCO, Ovulatory and Mild) and 2D:4D among groups were compared by Tukey-Kramer multiple comparisons tests.

RESULTS

Left (P = 0.77) and right (P = 0.68) hand 2D:4D were similar among the four clinical phenotypes and no phenotype of PCOS demonstrated a 2D:4D that differed from controls (Left Hand, P = 0.44 and Right Hand, P = 0.75).

CONCLUSIONS

Women with PCOS do not demonstrate finger length patterns that are consistent with increased prenatal androgen exposure. These findings do not preclude a role for prenatal androgens in the development of PCOS; however, low 2D:4D are not a characteristic of PCOS.

Assessment of ultrasonographic features of polycystic ovaries is associated with modest levels of inter-observer agreement

Background

There is growing acceptance that polycystic ovaries are an important marker of polycystic ovary syndrome (PCOS) despite significant variability when making the ultrasound diagnosis. To better understand the nature of this variability, we proposed to evaluate the level of inter-observer agreement when identifying and quantifying individual ultrasonographic features of polycystic ovaries.

Methods

Digital recordings of transvaginal ultrasound scans performed in thirty women with PCOS were assessed by four observers with training in Radiology or Reproductive Endocrinology. Observers evaluated the scans for: 1) number of follicles ≥ 2 mm per ovary, 2) largest follicle diameter, 3) ovarian volume, 4) follicle distribution pattern and 5) presence of a corpus luteum (CL). Lin's concordance correlation coefficients and kappa statistics for multiple raters were used to assess inter-observer agreement.

Results

Agreement between observers ranged from 0.08 to 0.63 for follicle counts, 0.27 to 0.88 for largest follicle diameter, 0.63 to 0.86 for ovarian volume, 0.51 to 0.76 for follicle distribution pattern and 0.76 to 0.90 for presence of a CL. Overall, reproductive endocrinologists demonstrated better agreement when evaluating ultrasonographic features of polycystic ovaries compared to radiologists (0.71 versus 0.53; p = 0.04).

Conclusion

Inter-observer agreement for assessing ultrasonographic features of polycystic ovaries was moderate to poor. These findings support the need for standardized training modules to characterize polycystic ovarian morphology on ultrasonography.

Diagnostic criteria for polycystic ovary syndrome: pitfalls and controversies

It is estimated that as many as 1.4 million Canadian women may be afflicted with polycystic ovary syndrome (PCOS). Although PCOS is heralded as one of the most common endocrine disorders occurring in women, its diagnosis, management, and associated long-term health risks remain controversial. Historically, the combination of androgen excess and anovulation has been considered the hallmark of PCOS. To date, while these symptoms remain the most prevalent among PCOS patients, neither is considered an absolute requisite for the syndrome. Inclusion of ultrasonographic evidence of polycystic ovaries as a diagnostic marker has substantially broadened the phenotypic spectrum of PCOS, yet much debate surrounds the validity of these newly identified milder variants of the syndrome. Difficulty in resolving the spectrum of PCOS stems from the continued use of inconsistent and inaccurate methods of evaluating androgen excess, anovulation, and polycystic ovaries on ultrasound. At present, there is no clear-cut definition of biochemical hyperandrogenemia, particularly since we depend on poor laboratory standards for measuring androgens in women. Clinical signs of hyperandrogenism are ill-defined in women with PCOS, and the diagnosis of both hirsutism and polycystic ovarian morphology remains alarmingly subjective. Lastly, there is an inappropriate tendency to assign ovulatory status solely on the basis of menstrual cycle history or poorly timed endocrine measurements. In this review, we elaborate on these limitations and propose possible resolutions for clinical and research settings. By stimulating awareness of these limitations, we hope to generate a dialogue aimed at solidifying the evaluation of PCOS in Canadian women.

Improving inter-observer variability in the evaluation of ultrasonographic features of polycystic ovaries

BACKGROUND

We recently reported poor inter-observer agreement in identifying and quantifying individual ultrasonographic features of polycystic ovaries. Our objective was to determine the effect of a training workshop on reducing inter-observer variation in the ultrasonographic evaluation of polycystic ovaries.

METHODS

Transvaginal ultrasound recordings from thirty women with polycystic ovary syndrome (PCOS) were evaluated by three radiologists and three reproductive endocrinologists both before and after an ultrasound workshop. The following endpoints were assessed: 1) follicle number per ovary (FNPO), 2) follicle number per single cross-section (FNPS), 3) largest follicle diameter, 4) ovarian volume, 5) follicle distribution pattern and 6) presence of a corpus luteum (CL). Lin's concordance correlation coefficients (rho) and kappa statistics for multiple raters (kappa) were used to assess level of inter-observer agreement (>0.80 good, 0.60 - 0.80 moderate/fair, <0.60 poor).

RESULTS

Following the workshop, inter-observer agreement improved for the evaluation of FNPS (rho = 0.70, delta rho = +0.11), largest follicle diameter (rho = 0.77, delta rho = +0.10), ovarian volume (rho = 0.84, delta rho = +0.12), follicle distribution pattern (kappa = 0.80, delta kappa = +0.21) and presence of a CL (kappa = 0.87, delta kappa = +0.05). No improvement was evident for FNPO (rho = 0.54, delta rho = -0.01). Both radiologists and reproductive endocrinologists demonstrated improvement in scores (p < 0.001).

CONCLUSION

Reliability in evaluating ultrasonographic features of polycystic ovaries can be significantly improved following participation in a training workshop. If ultrasonographic evidence of polycystic ovaries is to be used as an objective measure in the diagnosis of PCOS, then standardized training modules should be implemented to unify the approach to evaluating polycystic ovarian morphology.

Screening of potential semen donors for sexual transmitted diseases

BACKGROUND AND OBJECTIVES

The risk of infection with sexually transmitted diseases (STDs) is of great concern to couples undergoing therapeutic donor insemination.

GOAL OF STUDY

We sought to determine the prevalence of STDs in potential semen donors and assess the rate of acquisition of new infection during the follow-up period.

STUDY DESIGN

29 potential semen donors were screened for common STDs.

RESULTS

The study population had a prevalence of the following STDs: 27.5% ureaplasma, 13.8% mycoplasma, 6.9% cytomegalovirus 6.9% group B streptococcus, and 3.4% human papillomavirus infection. No participant tested positive for gonoccoccal or HIV infection. Over all, evidence of STD was present in 10 of 29 (34.5%) prospective donors. A follow-up infection rate of 22.2% (6 of 27 enrolled donors) was found and 3 (11.1%) of these were excluded from semen donation.

CONCLUSION

A high prevalence of sexually transmissible infections is present in potential semen donors. New infections are also common during the follow-up period.

Characteristics of follicular evacuation during human ovulation

Our objectives were to determine the rate and extent of follicular evacuation during human ovulation. Female volunteers were given 5000 or 10,000 IU human chorionic gonadotropin to induce ovulation when a follicle reached 18-20 mm. Ovulations were observed via transvaginal ultrasonography and recorded. Images were digitized for computer-assisted analysis. Areas of the follicles, taken to reflect follicular volume, were measured at specific time intervals from the moment of the first leakage of fluid until complete follicular evacuation. Twenty-five ovulations were visualized. In 23 cases (92%) all of the follicular fluid was expelled, but in two cases the follicle failed to empty completely. In all complete ovulations the initial fluid loss was rapid. The time to reach 70% evacuation was 0.9 +/- 0.3 min (+/- SEM). The remaining fluid leaked out more slowly; the mean time to complete follicular evacuation was 6.1 +/- 1.1 min. There was considerable variability in the rates of ovulation (range 6 s to 18.5 min). An association was observed between the type of stigma formed prior to ovulation and the initial rate of fluid loss. The data provide evidence of variability during follicular evacuation, which may in turn influence the successful expulsion of the oocyte from the follicle.