Hyperandrogenaemia and the ovary

Basal serum level of Δ4-androstenedione reflects the ovaries' ability to respond to stimulation in IVF cycles: setting up a new reliable index of both ovarian reserve and response

PURPOSE

Adequate androgen levels are necessary for regular follicular growth, progression beyond the pre-antral stage, and prevention of follicular atresia. The main purpose of this study was to investigate whether baseline androgen levels had a predictive value on stimulation outcomes in IVF cycles. The secondary purpose was to compare the possible predictive value of androgens with that of already known markers.

METHODS

The study included 91 infertile patients aged 30-45 years awaiting the first IVF cycle. All women underwent the same stimulation protocol and the same starting dose of recombinant FSH. As stimulation outcomes, the number of follicles recruited, estradiol and progesterone levels on the day of trigger, the total dose of gonadotropins administered, and the number of oocytes collected were recorded. Multiple linear regression and multivariate logistic regression were used to evaluate the significant predictive value of the variables for response to controlled ovarian stimulation (COS). By studying the reliability of different markers, an attempt was made to develop a single index with the highest predictive value.

RESULTS

Pearson's correlation revealed a statistically significant inverse correlation between oocytes collected and age (r =  - 0.333, p < 0.001) and a positive correlation with AMH (anti-müllerian hormone) (r = 0.360, p < 0.001), antral follicle count (AFC) (r = 0.639, p < 0.001), and androstenedione (Δ4-A) (r = 0.359, p < 0.001). No significant correlation was reported with FSH (r =  - 0.133, p = 0.207) and total testosterone (r = 0.180, p = 0.088). In COS good responders, the G-index (= AMH ng/mL*AFC/Δ4-A ng/dL) revealed a significantly higher level (p < 0.001) than AMH, AFC, and Δ4-A alone.

CONCLUSION

Baseline serum Δ4-A, presumably crucial for ensuring a regular follicular growth, is a reliable marker of ovarian response to stimulation. Since the ovarian capacity to respond to gonadotropins does not depend exclusively on the presence of follicles, we suggest a new index, the G-index, able to contemplate both the ovarian reserve and the Δ4-A level.

Comparison of GnRH agonist versus luteal estradiol GnRH antagonist protocol using transdermal testosterone in poor responders

Objective:

Transdermal testosterone has been used in different doses and in different stimulation protocols in poor responders. The aim of the present study is to compare the luteal estradiol/GnRH antagonists protocol versus long GnRH agonists in poor responder patients according to the Bologna criteria, in which transdermal testosterone has been used prior to the stimulation with gonadotropins.

Methods:

In this retrospective analysis, a total of 141 poor responder patients according to the Bologna criteria were recruited. All patients were treated with transdermal testosterone preceding ovarian stimulation with gonadotropins during 5 days. In 53 patients we used the conventional antagonist protocol (Group 1). In 88 patients (GrH pituitary suppression was achieved by leuprolide acetate according to the conventional long protocol (Group 2). We analyzed the ovarian stimulation parameters and IVF outcomes.

Results:

Comparing groups 1 and 2, there were no significant differences between cancellation rates and number of oocytes retrieved. However the total gonadotropin dose used and the mean length of stimulation were significantly lower in group 1 when compared to group 2. There were no significant differences in pregnancy outcomes; however, there was a slight increase in the implantation rate in group 1 vis-a-vis group 2, although statistical significance was not achieved.

Conclusion:

TT in poor responder patients can be effective both with the conventional agonist's long protocol and with the conventional antagonist's protocol. However, short regimes with previous estradiol antagonists in the luteal phase facilitate ovarian stimulation by shortening the days of treatment and the consumption of gonadotropins

Androgens and poor responders: are we ready to take the plunge into clinical therapy?

OBJECTIVE

To review and summarize data from the scientific literature on the use of androgens to improve ovarian function.

DESIGN

Review of pertinent literature.

SETTING

University hospital.

PATIENT(S)

Women exposed to androgens.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Critical review of the literature.

RESULT(S)

The artificial increase of intra-ovarian androgen concentrations constitutes an attractive concept for improving the deficient ovarian function of poor responders. Data from studies conducted in animals treated with high-dose androgens, together with observations made in hyperandrogenic women or female-to-male transsexuals receiving virilizing androgen doses, indicate that androgens may increase follicle responsiveness to FSH and/or the number of growing follicles in the ovary. Yet, definite clinical demonstration of such a concept still is not available.

CONCLUSION(S)

Current clinical approaches aiming at increasing androgen availability in the ovary showed conflicting results. Therefore, additional studies using proper strategies to achieving higher intra-ovarian androgen concentrations for longer intervals are required to define the clinical efficiency of androgens in poor responders.

Incidence of polycystic ovaries and androgen serum levels in women with borderline personality disorder

Obesity, increased visceral fat and disturbed glucose metabolism have been found in borderline personality disorder (BPD) patients. These conditions are often associated with disturbed androgen metabolism. Elevated androgens in women are related to polycystic ovaries (PCO) and might have an impact on psychopathology. Thus, higher prevalence of PCO and elevated androgen levels are suspected in BPD. In the study, we examined 31 BPD patients and 30 healthy controls ultrasonographically for PCO and measured their serum levels of androgens and interacting hormones. Furthermore, influence on psychopathology of free testosterone (FT) serum level was assessed. PCO was significantly more prevalent in BPD patients (30.4%) compared to healthy controls (6.9%). Testosterone, FT, androstenedione (A), and 17alpha-hydroxyprogesterone (17-OHP) were significantly elevated in the BPD group independently of BMI. FT serum level significantly correlated with depressive symptoms. In summary, our data suggest a disturbed androgen metabolism in BPD patients.

Androgen receptor functions in male and female physiology

The biological actions of androgens are mediated by transcriptional control of target genes through binding to the androgen receptor (AR). The AR belongs to the nuclear receptor superfamily and acts as a ligand-inducible transcriptional factor. Androgens/AR system is thought to be central to male physiology and behaviors to the development of clinical pathology. The physiological importance of AR function currently recognized in female reproduction also has been verified in mouse genetic model. Here we review functions of AR in male and female physiology as revealed by mice lacking AR.

Anatomical evidence for in utero androgen exposure in women with polycystic ovary syndrome

OBJECTIVE

To determine whether women with polycystic ovary syndrome (PCOS) have masculinized finger length patterns compared to women without PCOS.

DESIGN

A case control study.

SETTING

University teaching hospital and in vitro fertilization unit.

PATIENT(S)

Seventy women aged between 18 and 40 years with PCOS were compared to 70 women without PCOS.

INTERVENTION(S)

Measurement of the second to fourth finger length ratio on the ventral surface of the left and right hand from the basal crease of the digit to the tip was made using Vernier calipers.

MAIN OUTCOME MEASURE(S)

The second to fourth finger length ratio.

RESULT(S)

We found a significantly reduced ratio in the right hand of the women with PCOS compared to the controls. The geometric mean right finger length ratio in the PCOS group was 98.3% that of the controls (95% confidence interval, 99.3%-97.3%).

CONCLUSION(S)

Here we show a subtle difference in the finger length pattern of women with PCOS. This may constitute anatomical evidence of in utero androgen exposure in PCOS.

Premature ovarian failure in androgen receptor-deficient mice

Premature ovarian failure (POF) syndrome, an early decline of ovarian function in women, is frequently associated with X chromosome abnormalities ranging from various Xq deletions to complete loss of one of the X chromosomes. However, the genetic locus responsible for the POF remains unknown, and no candidate gene has been identified. Using the Cre/LoxP system, we have disrupted the mouse X chromosome androgen receptor (Ar) gene. Female AR(-/-) mice appeared normal but developed the POF phenotype with aberrant ovarian gene expression. Eight-week-old female AR(-/-) mice are fertile, but they have lower follicle numbers and impaired mammary development, and they produce only half of the normal number of pups per litter. Forty-week-old AR(-/-) mice are infertile because of complete loss of follicles. Genome-wide microarray analysis of mRNA from AR(-/-) ovaries revealed that a number of major regulators of folliculogenesis were under transcriptional control by AR. Our findings suggest that AR function is required for normal female reproduction, particularly folliculogenesis, and that AR is a potential therapeutic target in POF syndrome.

Therapeutic strategies for ovulation induction in infertile women with polycystic ovary syndrome

Polycystic ovary syndrome (PCOS) is a heterogeneous disorder characterized by hirsutism, obesity, hyperandrogenism and insulin resistance. The syndrome is often accompanied by infertility because of anovulation. Many approaches have been proposed to solve this problem, with the most commonly used therapies being ovarian drilling and pharmacological ovulation induction. Ovarian drilling is a procedure in which a laser fiber or electro-surgical needle punctures the ovary four to ten times. Side-effects are rare and often related to surgery itself. Pharmacological strategies include administration of metformin and insulin-sensitizing agents, clomiphene citrate (CC), gonadotropins and aromatase inhibitors. Metformin appears valuable in increasing ovulation rate, menstrual cyclicity and pregnancy rate. CC is an oral estrogen antagonist that raises circulating concentrations of follicle-stimulating hormone (FSH) and induces follicular growth in most women with PCOS and anovulation. Failure to respond is associated with high body mass index and high androgen levels. Aromatase inhibitors mimic the central reduction of negative feedback through which CC works. Ovulation induction with recombinant FSH has proved successful, but treatment requires skill and experience to avoid multiple pregnancies and ovarian hyperstimulation syndrome. The hypothetical deleterious effects of the high luteinizing hormone concentrations observed in PCOS patients seem to be related to the concomitant hyperinsulinemia (and/or insulin resistance). A thorough understanding of the syndrome and a careful assessment of each patient are the mainstays for choosing an appropriate treatment regimen.

Ovarian theca cell

Theca cells are the endocrine cells associated with ovarian follicles that play an essential role in fertility by producing the androgen substrate required for ovarian estrogen biosynthesis. Theca cells differentiate from the interfollicular stroma in response to proteins secreted from growing follicles. The most common endocrine cause of infertility is associated with excessive proliferation of theca cells and ovarian hyperandrogenism. Cell facts: -ovarian androgen-producing cells; -are associated only with developing follicles; -over-activity of theca cells causes infertility due to hyperandrogenism; -under-activity of theca cells causes infertility due to lack of estrogen. Theca cells: androgen-producing cells in the ovary.

Troglitazone regulates peroxisome proliferator-activated receptors and inducible nitric oxide synthase in murine ovarian macrophages

Peroxisome proliferator-activated receptor-gamma (PPARG) and PPAR-alpha (PPARA) control metabolic processes in many cell types and act as anti-inflammatory regulators in macrophages. PPAR-activating ligands include thiazolidinediones (TZDs), such as troglitazone, once frequently used to treat insulin resistance as well as symptoms of polycystic ovary syndrome (PCOS). Since macrophages within the ovary mediate optimal follicle development, TZD actions to improve PCOS symptoms are likely to be partly mediated through these specifically localized immune cells. In mouse ovary, PPARG protein was expressed in granulosa cells and in isolated cells localized to theca, stroma, and corpora lutea, consistent with EMR1+ macrophages. Isolation of immune cells (EMR1+ or H2+) showed that Pparg and Ppara were expressed in ovarian macrophages at much higher levels than in peritoneal macrophages. Ovulatory human chorionic gonadotropin downregulated expression of Pparg and Ppara in EMR1+ ovarian macrophages, but no hormonal responsiveness was observed in H2+ cells. Downstream anti-inflammatory effects of PPARG activation were analyzed by in vitro treatment of isolated macrophages with troglitazone. Interleukin-1 beta (Il1b) expression was not altered, and tumor necrosis factor-alpha (Tnf) expression was affected in peritoneal macrophages only. In ovarian macrophages, inducible nitric oxide synthase (Nos2), an important proinflammatory enzyme that regulates ovulation, was significantly reduced by troglitazone treatment, an effect that was restricted to cells from the preovulatory ovary. Thus, expression of PPARs within ovarian macrophages is hormonally regulated, reflecting the changing roles of these cells during the ovulatory cycle. Additionally, ovarian macrophages respond directly to troglitazone to downregulate expression of proinflammatory Nos2, providing mechanistic information about ovarian effects of TZD treatment.

4: Polycystic ovary syndrome

Polycystic ovary syndrome (PCOS) is a common condition characterised by menstrual abnormalities and clinical or biochemical features of hyperandrogenism. Features of PCOS may manifest at any age, ranging from childhood (premature puberty), teenage years (hirsutism, menstrual abnormalities), early adulthood and middle life (infertility, glucose intolerance) to later life (diabetes mellitus and cardiovascular disease). While pelvic ultrasound examination is useful, many women without PCOS have polycystic ovaries; ultrasound evidence is not necessary for the diagnosis. Testing for glucose intolerance and hyperlipidaemia is wise, especially in obese women, as diabetes mellitus is common in PCOS. Lifestyle changes as recommended in diabetes are fundamental for treatment; addition of insulin-sensitising agents (eg, metformin) may be valuable in circumstances such as anovulatory infertility. Infertility can be treated successfully in most women by diet and exercise, clomiphene citrate with or without metformin, ovarian drilling, or ovulation induction with gonadotrophins; in-vitro fertilisation should be avoided unless there are other indications.