Immunological disturbances in patients with premature ovarian failure

Immunophenotypic profiles and inflammatory markers in Premature Ovarian Insufficiency

Premature Ovarian Insufficiency (POI), also known as Premature Ovarian Failure (POF), is a heterogeneous disorder characterized by the cessation of ovarian function before age 40. Clinical symptoms include menstrual disorders: amenorrhea/oligomenorrhea or symptoms of estrogen deficiency. This review aims to provide the most important summary of the immunophenotypic profile of premature ovarian failure syndrome, along with a review of the latest reports on the usefulness of inflammatory markers. The inflammatory microenvironment in POI applies to many levels. Concomitants of autoimmune ovarian inflammation and impaired cellular immune response may be a picture of impaired regulation in autoimmune ovarian disease. The serum concentration of pro-inflammatory cytokines, like IL-6, IL-8, IL-17, tumor necrosis factor α (TNF-α), and interferon-gamma (IFN-γ), tend to increase, whereas levels of the anti-inflammatory cytokine, IL-10, tend to decrease. In our review, we focus on whether the measured immunological parameters could help in the diagnosis and prognosis of the syndrome. Among the inflammatory markers, neutrophil-to-lymphocyte ratio (NLR) is noteworthy, as it is decreased in patients with POI. It is important to stress that besides case series, we need properly powered studies with randomization to answer which treatment is effective, and how to deal with concurrent autoimmunity. In this review, we emphasize the importance of the premature ovarian failure syndrome immunoprofile for a proper understanding of the complexity of this syndrome, potential diagnostic points, and therapeutic targets.

Premature ovarian insufficiency (POI) and autoimmunity-an update appraisal

PURPOSE

Primary ovarian insufficiency (POI) represents ovarian dysfunction related to very early aging of the ovaries. While the cause of POI in a majority of clinical cases remains undefined, autoimmunity is responsible for approximately 4-30% of POI cases. In the present paper, we aim to provide a critical appraisal and update review on the role of autoimmunity in POI patients.

METHODS

A literature review was conducted for all relevant articles reporting on POI and autoimmunity. PubMed/MEDLINE and the Cochrane library were searched for the best available evidence on this topic.

RESULTS

Patients with POI and coexisting autoimmunity are indistinguishable from those with negative autoimmune screen with regard to age of onset, prevalence of primary amenorrhea, or their endocrine profiles. A specific noninvasive reliable diagnostic test for the diagnosis of an autoimmune etiology is lacking; therefore, patients should be screened for the most common autoantibodies, i.e., steroid cell antibodies, anti-ovarian antibodies, and anti-thyroid antibodies. Moreover, treatment strategies to POI infertility are lacking and controversial.

CONCLUSIONS

Nowadays, guidelines for the treatment of autoimmune POI are not available. Moreover, since diagnostic and treatment strategies to POI infertility are still lacking and controversial, further large clinical studies are needed to investigate the true impact of autoimmunity on POI and to identify the selected groups of patients who are most likely to benefit from immunossuprresive treatment.

Prevalence of premature ovarian failure in patients with systemic lupus erythematosus

OBJECTIVE

To estimate the prevalence of premature ovarian failure (POF) and its associated factors in patients with systemic lupus erythematosus (SLE).

METHODS

Cross-sectional study including consecutive SLE women <60 years of age attending a rheumatology clinic. A face-to-face interview was undertaken to obtain demographic, gynaecological and lupus characteristics. Additional rheumatologic and endocrine data were retrieved from patients' medical records. POF prevalence was estimated in the study sample and in a subgroup of patients aged <40 years at interview. Associations between POF and selected variables were assessed by logistic regression analyses.

RESULTS

A total of 961 patients were analysed. Prevalence of POF, secondary amenorrhea of known cause, menopause and hysterectomy were 5.4%, 0.8%, 7.8% and 4.4%, respectively. In 674 (70%) patients who had not been exposed to cyclophosphamide (CYC) the prevalence of POF was 0.6%. Disease activity over time (OR 1.4 (CI 95% 1.0-1.8, p < 0.05)) and CYC treatment (OR 5.9 (CI 95% 1.8-18.8, p < 0.01)) were associated with higher prevalence. Association between POF and endocrine autoimmune diseases was not found.

CONCLUSIONS

In the absence of CYC treatment, the prevalence of POF in lupus patients is consistent with that reported in the general population. The existence of autoimmune processes at the ovary seems unlikely in most lupus patients.

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.

Aetiology of premature ovarian failure

Premature ovarian failure (POF) is the occurrence of hypergonadotropic hypoestrogenic amenorrhoea in women under the age of 40 years. POF is idiopathic in 74–90% of cases but can be familial (4–33%) or sporadic. The known causes are: genetic aberrations; autoimmune ovarian damage; iatrogenic following surgery, radiotherapy or chemotherapy; environmental factors (viruses, toxins, etc.); and metabolic (galactosaemia, 17 OH deficiency, etc.) Genetic aberrations could involve the X chromosome (monosomy, trisomy or translocations) or be autosomal. Genetic mechanisms include reduced gene dosage and non-specific chromosome effect impairing meiosis, decreasing the pool of primordial follicles and increasing atresia due to apoptosis or failure of follicle maturation. The genes for POF-1 are localized to Xq 21.3–Xq27 and for POF-2 to Xq13.3–21.1. The FMR1 gene is responsible for the fragile X syndrome. It occurs due to CGG expansion of more than 55 repeats at the 5′UTR (Xq 27.3), which is associated with gene silence resulting in mental retardation in males, and POF in female carriers. Autoimmune ovarian damage is caused by the alteration of T-cell subsets and T-cell-mediated injury, increase of autoantibody producing B-cells and a low number of effector supressor/cytotoxic lymphocyte and a decrease of number and activity of natural killer cells. POF can be associated with other non-endocrine and endocrine diseases. The mutations of AIRE gene are responsible for polyendocrinopathies (APS I–III). As the cause of POF is unknown in the majority of cases and the number of women with POF is increasing, the primary goal of scientific groups worldwide should be focused on the study of the aetiology of POF.

Detection of antizona pellucida antibodies in the sera from premature ovarian failure patients by a highly specific test

OBJECTIVE

To develop a highly specific test for the detection of antizona pellucida (ZP) antibodies in the sera from premature ovarian failure (POF) patients.

DESIGN

Laboratory study.

SETTING

University hospital.

PATIENT(S)

Twenty-seven idiopathic POF patients, 30 control women, and 30 healthy males.

INTERVENTION(S)

Anti-ZP antibodies were detected by the microdot assay using a very small amount of human ZP or porcine ZP. The effect of anti-ZP antibodies on sperm-ZP binding was examined by hemizona assay.

MAIN OUTCOME MEASURE(S)

Results from the microdot assay and hemizona assay.

RESULT(S)

By the microdot assay using human ZP, the sera from POF patients reacted significantly stronger than those of control women and healthy males. However, no obvious difference could be found by the same assay using porcine ZP among these three groups. Anti-ZP antibodies against sera from some POF patients showed significant blocking effects on sperm-ZP binding assessed by hemizona assay. Anti-ZP antibodies were detected in 7 of 27 POF patients, while none were detected in control women and healthy males.

CONCLUSION(S)

Some idiopathic POF patients have anti-ZP antibodies in their sera, which were detected with high specificity by a newly developed microdot assay using a very small amount of human ZP.

Antiovarian antibodies in primary Sjogren's syndrome

Our study aimed at screening patients with primary Sjogren's syndrome (pSs) for the presence of antiovarian antibodies (AOAs). Detection of AOAs in patients' sera was achieved by ELISA, using bovine ovarian extract for coating. Western blot analysis and immunohistochemistry were used to characterize the antibody targets in the extract and to determine their locus on the bovine ovary, respectively. Specific AOAs were detected in 27% of 37 patients (two with premature menopause) and in none of the controls. Immunoreactivity mainly resided in five proteins of the extract with molecular masses 42, 49, 55, 64 and 72 kDa, and it might be attributed to their carbohydrate components. The antibody targets were mainly located in the granulosa and theca interna cells of the follicle, and in the endothelial cells and fibroblasts of corpus luteum. The detection, for the first time, of AOAs in a significant percentage of patients with pSs may suggest autoimmune oophoritis, clinical or subclinical.

Premature ovarian failure

Premature ovarian failure (POF) causing hypergonadotrophic hypogonadism occurs in 1% of women. In majority of cases the underlying cause is not identified. The known causes include: (a) Genetic aberrations, which could involve the X chromosome or autosomes. A large number of genes have been screened as candidates for causing POF; however, few clear causal mutations have been identified. (b) Autoimmune ovarian damage, as suggested by the observed association of POF with other autoimmune disorders. Anti-ovarian antibodies are reported in POF by several studies, but their specificity and pathogenic role are questionable. (c) Iatrogenic following surgical, radiotherapeutic or chemotherapeutic interventions as in malignancies. (d) Environmental factors like viral infections and toxins for whom no clear mechanism is known. The diagnosis is based on finding of amenorrhoea before age 40 associated with FSH levels in the menopausal range. Screening for associated autoimmune disorders and karyotyping, particularly in early onset disease, constitute part of the diagnostic work-up. There is no role of ovarian biopsy or ultrasound in making the diagnosis. Management essentially involves hormone replacement and infertility treatment, the only proven means for the latter being assisted conception with donated oocytes. Embryo cryopreservation, ovarian tissue cryopreservation and oocyte cryopreservation hold promise in cases where ovarian failure is foreseeable as in women undergoing cancer treatments.

Immune effects of surgical menopause and estrogen replacement therapy in peri-menopausal women

The complex relationship between sex hormones and immune function suggests that sex hormone deficiency and estrogen replacement therapy (ERT) in post-menopausal women may have pleiotropic effects on immune function. For this reason, we aimed to investigate short-term effects of surgical menopause and ERT on immunity profile in peri-menopausal women. Seventeen healthy peri-menopausal women who were to undergo total abdominal hysterectomy and bilateral salpingo-oopherectomy (TAH + BSO) for uterine myoma were enrolled into this study. Three blood samples were collected from each patient: 1-day prior to surgery, 30 days after the operation (before ERT) and 30 days after transdermal ERT. The percentages of peripheral blood lymphocyte subpopulations, serum interleukin-4 (IL-4) and interferon-gamma (IFN-gamma) concentrations were determined by flow-cytometry and ELISA, respectively. Following TAH + BSO, the percentage of CD8+ cells was increased ( P < 0.001 ) while the percentage of CD19+ cells, serum IL-4, and IFN-gamma concentration and the ratio of CD4+ to CD8+ cells were decreased ( P < 0.001, P < 0.001, P < 0.002, and P < 0.05 respectively). After ERT, this trend reversed and a decrease in the CD8+ cells ( P < 0.001 ), increase in the CD19+ cells percentages ( P < 0.02 ) and increase in serum IFN-gamma concentration ( P < 0.002 ) were observed. Although an increasing trend in the CD4+ to CD8+ ratio occurred by ERT, this was not significant. However, the decrease in the serum IL-4 concentration after TAH + BSO was not reversed by ERT. Hormone deficiency in post-menopausal women may cause an impaired immune response, and ERT can restore this phenomenon. Estrogen seems to have an important role in the regulation of immune function.

Menstrual disturbances in patients with systemic lupus erythematosus without alkylating therapy: clinical, hormonal and therapeutic associations

We have evaluated 36 consecutive systemic lupus erythematosus (SLE) female patients, age 18-39 years, without current or previous alkylating therapy, in order to determine the prevalence of the menstrual disturbances and their clinical, hormonal and therapeutic associations. Seventeen patients presented normal cycles, whereas menstrual alterations were observed in 19. Ovarian function was generally preserved in these groups. Sub-clinical thyroid disease (normal free T4 and elevated TSH) and slightly increased prolactin levels were detected in 8% of patients, with comparable frequencies in both groups. Similarly, the current use of azathioprine was not associated with menstrual disturbances. Percentages of prednisone current use (P = 0.3), mean dose (P = 0.062), and percentages of patients on high doses (> or = 30 mg/day; P = 0.09) were comparable in patients with or without menstrual alterations. In contrast, the mean SLEDAI levels (P = 0.02) and the frequency of patients with SLEDAI > or = 8 (P = 0.008) were higher in patients with irregular cycles. Interestingly, 5/7 (71%) of the patients with menstrual disturbances and a new significant flare (SLEDAI > or = 8) were evaluated before the introduction of high dose steroid, supporting the idea that disease activity is a major factor in menstrual disorders in SLE patients without alkylating therapy.

Premature ovarian failure: etiology and prospects

A search of past and current articles on ovarian physiology and premature ovarian failure (POF) using MEDLINE was performed in order to present an overview of clinical manifestations, necessary laboratory investigations, possible etiologies and treatments for POF. POF is defined as gonadal failure before the age of 40 years. Initially, POF was thought to be permanent, but it is now believed that spontaneous remissions and even pregnancies are possible in affected women. In most cases, the etiology of POF remains elusive, but several rare specific causes have been identified. Although the etiology of POF is heterogenic, the treatment principles are the same. Hormone replacement therapy (HRT) is still the cornerstone of treatment. The only proven method of obtaining a pregnancy in patients with POF is fertilization of a donor oocyte. Cryopreservation of oocytes has worked well in animals but awaits refinement before it can be applied routinely to humans with prodromal POF, or to patients before chemotherapy or irradiation in order to save their oocytes for future fertilization. New alternatives to traditional HRT and methods of fertility preservation are under development, but understanding of the basic pathophysiology of POF is necessary for the development and use of innovative treatments.

Hormone replacement therapy reverses the decrease in natural killer cytotoxicity but does not reverse the decreases in the T-cell subpopulation or interferon-gamma production in postmenopausal women

OBJECTIVE

To investigate the immunologic deviations of postmenopausal women before and after hormone replacement therapy (HRT).

DESIGN

Prospective study.

SETTING

University teaching hospital.

PATIENT(S)

Seventeen postmenopausal women (study group) and 17 women of reproductive age (control group).

INTERVENTION(S)

Continuous usage of E(2) valerate 2 mg/d and medroxyprogesterone acetate 5 mg/d in postmenopausal women in the study group.

MAIN OUTCOME MEASURE(S)

Immunophenotyping with flow cytometry, cytokine production with and without mitogen stimulation of the peripheral mononuclear cells, and a natural killer (NK) cell cytotoxicity test against K562 target cells by the (51)Cr-release assay were performed in the control group and in the study group before, 1 month after, and 6 months after HRT.

RESULT(S)

NK cytotoxicity, interferon-gamma production, and the T-cell subpopulation were significantly decreased, and the subpopulations of CD3(+)CD25(+) and CD3(+)HLA-DR(+) were increased in the study group before HRT when compared with those in the control group. After HRT was given for 6 months, however, the NK cytotoxicity increased significantly in the postmenopausal women to a value similar to that of the control group.

CONCLUSION(S)

Women after menopause are prone to impaired immune responses. Nevertheless, some of the impairment can be restored after HRT.

Treatment of autoimmune premature ovarian failure

There is no known immunosuppressive therapy for autoimmune premature ovarian failure that has been proven safe and effective by prospective randomized placebo-controlled study. Nevertheless, immunosuppression using corticosteroids has been used on an empirical basis for this condition. Here we present two cases of young women with premature ovarian failure who were treated with glucocorticoids in the hopes of restoring fertility. The first case illustrates the potential benefit of such therapy, and the second case illustrates a potential risk. The first patient with histologically proven autoimmune oophoritis was treated with alternate day glucocorticoid treatment. She had return of menstrual bleeding six times and ovulatory progesterone concentrations four times over a 16 week period. The second patient with presumed but unconfirmed autoimmune ovarian failure was referred to us after having been treated with a 9 month course of corticosteroids. During that treatment her menses did not resume. The corticosteroid treatment was complicated by iatrogenic Cushing syndrome and osteonecrosis of the knee. Identifying patients with autoimmune premature ovarian failure presents the opportunity to restore ovarian function by treating these patients with the proper immune modulation therapy. On the other hand, potent immune modulation therapy can have major complications. Corticosteroid therapy for autoimmune premature ovarian failure should be limited to use in placebo-controlled trials designed to evaluate the safety and efficacy of such treatment.

Premature ovarian failure: an update

OBJECTIVE

To present an overview of potential etiologies, clinical manifestations, and treatment modalities of premature ovarian failure (POF).

DESIGN

A search of past and current articles on basic ovarian physiology and POF with use of MEDLINE. Additional information was obtained from an active study section on POF at the National Institutes of Health. Specific sections of this manuscript summarize the strengths and weaknesses of the possible pathophysiologic processes and management options of POF as they appear in the literature.

RESULT(S)

POF is not an uncommon disorder. Although the etiology remains elusive in most cases, several rare specific causes have been discovered. Although POF was once thought to be permanent, a substantial number of patients experience spontaneous remissions. Because of the association with other autoimmune diseases, close follow-up is recommended in patients with POF. Hormone replacement therapy remains the cornerstone of treatment, and the best chance of achieving a pregnancy is through oocyte donation.

CONCLUSION(S)

An understanding of basic ovarian embryology and physiology will allow clinicians to apply current treatments and develop new innovative therapies for their patients with POF.

Premature ovarian failure: steroid synthesis and autoimmunity

The androgen biosynthesis and autoimmunity of 25 patients with premature ovarian failure (POF) and 18 control subjects with normal cycles were examined. Serum levels of dehydroepiandrosterone sulfate (DHEAS), 17-hydroxyprogesterone (17-OHP), androstenedione, and testosterone were analyzed in POF patients with or without organ-specific autoimmunity, and the results compared with those of women with normal ovarian function. The comparative analysis of DHEAS, 17-OHP, androstenedione and testosterone showed that POF patients had significantly lower values than normal women (DHEAS, androstenedione and testosterone p < 0.01, 17-OHP p < 0.05). Furthermore, we found one or more organ-specific autoantibodies in 11 patients with POF (44%), while only one woman in the control group showed autoimmunity (antithyroid microsome) (5.5%). Only one patient had both anti-ovarian and anti-adrenal antibodies (4%). The comparison of androgen levels in POF patients with or without autoimmunity revealed a statistically significant reduction of DHEAS levels in POF patients with organ-specific autoimmunity (p < 0.01). These data reveal the reduction in androgen synthesis in POF patients, particularly in those with organ-specific autoimmunity.

High frequency of IgG antagonizing follicle-stimulating hormone-stimulated steroidogenesis in infertile women with a good response to exogenous gonadotropins

OBJECTIVE

To investigate the presence of FSH-blocking IgG in infertile women.

DESIGN

Retrospective study. Sera from patients and controls were processed for IgG purification, and purified IgG were tested at various concentrations for their ability to inhibit the recombinant human FSH-induced P production in vitro by human granulosa cells.

SETTING

Departments of Endocrinology, and Obstetrics and Gynecology, University of Caen.

PATIENT(S)

Fifty-seven infertile women including 14 women with premature ovarian failure (POF), 29 women with a poor response to IVF-ET, and 14 women with a good response to IVF-ET. Controls consisted of 22 healthy age-matched women.

INTERVENTION(S)

IVF-ET allowed human granulosa cell pooling and culture for FSH bioassay.

MAIN OUTCOME MEASURE(S)

Inhibition by purified IgG of the in vitro recombinant human FSH-induced P production by human granulosa cells.

RESULT(S)

Blocking IgG were identified in only 3 of 14 POF and in 2 of 29 women with a poor response to IVF-ET. In contrast, IgG from women with a good response to IVF-ET inhibited significantly P production, and blocking IgG were detected in 85% women with a good response to IVF-ET.

CONCLUSION(S)

This study identified FSH-blocking IgG in a high proportion of women with a good response to IVF-ET. The significance of this remains questionable.

Post-thymectomy murine experimental autoimmune oophoritis is associated with reduced natural killer cell activity

PROBLEM

Natural killer (NK) cells can influence the immune response by secreting potent lymphokines. It has been suggested that NK cells have a suppressive action on B cells, and that impaired NK cell activity may play a role in some types of autoimmunity. NK cell abnormalities have been reported in women with premature ovarian failure. We therefore examined NK cell activity during the development of murine experimental autoimmune oophoritis, which serves as a model for autoimmune ovarian failure in women.

METHOD OF STUDY

Neonatally thymectomized and sham-operated C57B1/6 x A/J (B6A) mice were prepared and sacrificed at 4, 6, 8, and 10 weeks after surgery. Splenic NK cell activity was determined in groups of five or more mice by measuring the percent specific lysis of target YAC-1 lymphoma cells using a standard 4-hr chromium release cytotoxicity assay. The number of splenic NK cells in neonatally thymectomized and sham-operated animals was also compared using flow cytometry. In a subsequent experiment, interleukin 12 (IL-12; NK cell-stimulating factor) was administered to neonatal mice before neonatal thymectomy.

RESULTS

Neonatally thymectomized mice with associated autoimmune oophoritis had a 75% reduction in the number of splenic NK cells, and 50% or greater reduction in splenic NK cell activity at 4, 6, and 8 weeks after surgery. IL-12 treatment before neonatal thymectomy maintained NK cell activity and was shown to ameliorate the associated autoimmune oophoritis.

CONCLUSION

Murine post-thymectomy autoimmune oophoritis is associated with reduced NK cell number and impaired NK cell activity, and in these respects the model is similar to premature ovarian failure in women. Research to define the relationship between NK cell abnormalities and the mechanism of ovarian failure in this model might lend insight into the pathogenesis of premature ovarian failure in women.

Murine postthymectomy autoimmune oophoritis develops in association with a persistent neonatal-like Th2 response

Autoimmune oophoritis develops in some patients despite evidence of impaired cellular immunity. Here, using the murine postthymectomy model of autoimmune oophoritis, we investigate the hypothesis that neonatal thymectomy induces autoimmune oophoritis by disrupting the normal postnatal balance of T helper cell regulation. Stimulated CD4+ splenic lymphocytes from adult mice sham-operated as neonates produced the expected T helper type 1 (Th1) predominant response normally seen in adult mice (low levels of interleukin-4 and high levels of interferon gamma). In contrast, cells from adult mice thymectomized as neonates produced an inappropriate neonatal-like Th2-predominant response (high levels of interleukin-4 and low levels of interferon-gamma). Manipulations that restored the postnatal shift to an adult Th1-dominant pattern ameliorated the autoimmune oophoritis. Thus, neonatal thymectomy abrogates the postnatal shift to a Th1-dominant pattern, and the resulting persistent neonatal-like Th2-dominant response is tightly associated with the development of postthymectomy autoimmune oophoritis. These results (i) suggest that the postnatal shift to the normal adult Th1/Th2 balance is established by a thymus-dependent process and (ii) raise the possibility that specific genetic defects, as yet to be determined, might mimic the effect of neonatal thymectomy in this model, impair the development of normal Th1/Th2 balance, and be a cause autoimmunity. These results hold implications for the pathogenesis and possibly for the therapy of autoimmune polyglandular failure in humans.

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).

Characterization of idiopathic premature ovarian failure

OBJECTIVE

To characterize women with idiopathic premature ovarian failure (POF) by their ovarian ultrasonographic appearances to establish the prevalence of follicular activity and relationship to autoimmunity, estrogen status, and historical background.

DESIGN

Retrospective analysis of clinical, endocrine, autoimmune, ultrasonographic, and bone densitometry parameters.

SETTING

Reproductive Endrocrinology Clinics of The Middlesex Hospital, London, United Kingdom.

PATIENTS

Data from 135 women with idiopathic POF were analyzed. A reference group of 18 women with normal ovarian function, studied in their follicular phase, was used for comparison of endocrine and ultrasound data. A reference group of 57 women with normal ovarian function was used for comparison of bone densitometry measurements.

MAIN OUTCOME MEASURES

Serum E2 concentrations, autoantibody screen, ultrasonographic measures of ovarian volume, uterine cross-sectional area and endometrial thickness and dual roentgenogram bone mineral densitometry of the lumbar spine.

RESULTS

The detection of ovaries by ultrasound (in 76%) and follicular activity (in 60% of patients) was associated with higher bone mineral density compared with women in whom ovaries could not be identified. Of 13 patients presenting with primary amenorrhea, ultrasonography identified ovaries in 62% and follicles in 38% whereas 38% had positive autoimmunity. Evidence of autoimmunity was found in 31% of patients overall and these were indistinguishable from the nonautoimmune remainder in every respect.

CONCLUSIONS

Ovarian follicular activity, previously considered to be rare, as in the "resistant ovary syndrome," is found in the majority of women with POF using pelvic ultrasonography. Patients presenting with primary amenorrhea have a similar degree of ovarian function, determined by ultrasound, and autoimmunity as those presenting with secondary amenorrhea. The role of autoimmunity in the pathogenesis of POF is not distinguished from nonautoimmune ovarian damage by the measurements made in this study.

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.

A new endocrinological and immunological syndrome in SLE: elevation of human chorionic gonadotropin and of antibodies directed against ovary and endometrium antigens

We have analysed the levels of gonadotropins in male and female patients with systemic lupus erythematosus (SLE). Human chorionic gonadotropin hCG was elevated in 23.8% of patients compared with 12.7% of controls. hCG isolated from the serum of SLE patients was bioactive in vitro. Levels of hCG were significantly correlated with those of its beta-subunit but not with the levels of follicle stimulating hormone, luteinizing hormone, prolactin alphafetoprotein or carcino embryonic antigen. A high percentage of patients presented an organ-specific humoral immune response against ovarian (26.7%) and endometrial (40%) antigens compared with controls (8% and 7.6%, respectively). Endometrial antibodies were significantly correlated to the levels of prolactin. The ovarian tumour marker CA-125 was elevated in 32.5% of patients, including two males. As a whole, these elements delineate a new endocrine and immunological syndrome in SLE in which the elevation of hCG could provide a central physiological explanation for a series of endocrine alterations that characterize this disease.

Autoimmunity to steroid-producing cells and familial polyendocrine autoimmunity

New insights into the autoimmune basis for Addison's disease have come from identification of at least three P450 cytochrome enzymes as autoantigens, each having distinct associations with Addison's disease as part of the APS type 1 or 2 syndrome. Enzymes are tissue-restricted proteins which are the frequent targets of autoimmunity in other organ-specific diseases (Editorial, 1992), and it seems likely that further P450 enzymes could be involved in the pathogenesis of other components of these syndromes. How adrenal damage is initiated remains unclear. Adrenal autoantibodies may have a pathogenic role, as yet obscure, or could arise secondary to T cell-mediated tissue damage, although it seems highly likely that the same autoantigen provokes cell-mediated and humoral autoimmunity. Sharing of autoantigens between ovary and adrenal glands, particularly the side-chain cleavage enzyme, is one explanation for the close association of ovarian failure and Addison's disease, but other, more common forms of ovarian autoimmune disease exist. Their further definition will come from identification of the autoantigens involved. By analogy with animal models, T cell-mediated injury is likely to be central to pathogenesis. The evidence for antibodies blocking hormone receptors in premature ovarian failure is meagre at present, but the availability of recombinant LH and FSH receptors should clarify this issue. HLA-DR3 is associated with almost all autoimmune endocrinopathies, and this is particularly striking in APS type 2. However, there is no such association with APS type 1; the most likely genetic candidate in this condition is at a locus controlling T cell development. Although the adrenal and ovarian autoimmune processes in APS type 1 and 2 may be distinct, the characterization of the gene involved in APS type 1 will have major implications for our understanding of autoimmune endocrine disease.

Determination of the steroidogenic capacity in premature ovarian failure

OBJECTIVE

To determine the secretion of precursors, intermediate and final products of androgen biosynthesis in women with premature ovarian failure (POF).

PATIENTS

Seven patients 20 to 34 years of age with idiopathic POF and a control group of six women 27 to 29 years of age with normal ovarian function studied during the early follicular phase were included. DESIGN, INTERVENTIONS: In all patients an adrenal stimulation test was performed as follows: a short dexamethasone (DEX) inhibition was carried out the night before the corticotropin (ACTH, 0.25 mg, Cortrosyn; Organon, Orangeburg, NY) stimulation test, obtaining blood samples in basal conditions, post-DEX inhibition as well as at 60, 120, and 180 minutes after the ACTH bolus.

MAIN OUTCOME MEASURES

Using specific RIA serum concentrations of delta 5 precursors (pregnenolone, 17-hydroxypregnenolone, DHEA), delta 4 intermediates (P, 17-hydroxyprogesterone, androstenedione) and the final products T and cortisol (F) were measured.

RESULTS

Adrenal inhibition and stimulation responses in both groups of patients showed no differences for delta 5 precursors and F. On the other hand, delta 4 intermediates and androgens exhibited significant differences at the level of response to ACTH stimulation. Patients with POF had significantly lower values than those of control group.

CONCLUSION

An important decrement in the steroidogenesis was noticed in POF, particularly in androgen synthesis, revealing the selective participation of the adrenal gland in steroid production.

Case report: spontaneous pregnancy following thymectomy for myasthenia gravis associated with premature ovarian failure

We report the case of a 29-year-old woman who was diagnosed to have premature ovarian failure (POF) and myasthenia gravis at the age of 27 years. She was treated by thymectomy and pyridostigmine. Hormone replacement was started after the operation and she subsequently conceived spontaneously. We believe this is the first report of a spontaneous pregnancy after the diagnosis of POF associated with myasthenia gravis.

Premature ovarian failure: autoimmunity and natural history

OBJECTIVE

We studied the association of clinical and latent autoimmune diseases with circulating steroid-producing cells autoantibodies (SCA) in patients with premature ovarian failure (Group I). We investigated the presence of SCA in patients with organ-specific autoimmune diseases but without hypogonadism (Group II). We assessed whether SCA can be considered markers of hypergonadotrophic hypogonadism.

DESIGN

In Groups I and II blood samples were taken at diagnosis. In a subset of patients with SCA without hypogonadism blood samples were taken at least yearly for 6 years for immunological and functional tests.

PATIENTS

Group I included 50 females, aged 16-39 years; Group II included 3677 patients, aged 6-79 years, divided into Subgroup IIA (99 with Addison's disease alone or associated with other endocrinopathies or with hypoparathyroidism) and Subgroup IIB (3578 with insulin-dependent diabetes mellitus or thyroid autoimmune diseases). The follow-up group included nine subjects, aged 5-31 years (seven females and two males).

MEASUREMENTS

SCA and other organ-specific autoantibodies were detected by standard indirect immunofluorescence using normal human tissues or passive haemagglutination tests. Gonadal functional tests included evaluation of FSH and LH levels by a RIA method; adrenocortical function included evaluation of cortisol and ACTH plasma levels by a RIA method.

RESULTS

Three subgroups were identified in Group I on the basis of clinical autoimmune disease. 9/50 (18%) patients were found to have an Addison's disease (Subgroup IA) and in this subgroup SCA were present in 7/9 (78%); 10/50 (20%) had other autoimmune diseases (Subgroup IB) and SCA were found in 1/10 (10%); 31/50 (62%) did not have other clinical autoimmune diseases (Subgroup IC) and 1/31 (3%) had SCA. SCA were significantly increased in Subgroup IA vs IB (P = 0.017) and vs IC (P = 0.00002). In Group II, SCA were found in 20/3677 (0.5%); in particular, SCA were detected in 18/99 (18%) of the patients in Subgroup IIA and in 2/3578 (0.06%) of the patients in Subgroup IIB. The frequency of SCA in Subgroup IIA was found to be significantly increased with respect to that found in Subgroup IIB (P = 0.001 x 10(-5)). During follow-up, 3/7 females (42.8%) but 0/2 males developed hypergonadotrophic hypogonadism with a latency period of 10, 13 and 15 years, respectively. Three females and two males lacked clinical Addison's disease at the beginning of the study, but during follow-up 1/3 female and 2/2 males developed clinical Addison's disease with a mean latency period of 13 months.

CONCLUSIONS

The results confirm the strong relationship between premature ovarian failure and other clinical autoimmune diseases, as well as the strong link existing between primary ovarian failure, Addison's disease and antibodies to steroid-producing cells. The study also suggests that in females antibodies to steroid-producing cells are serological markers of both potential hypergonadotrophic hypogonadism, and Addison's disease; however, in males these antibodies may be considered only as markers of potential Addison's disease.

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.

Increased peripheral T lymphocyte activation in patients with karyotypically normal spontaneous premature ovarian failure

OBJECTIVE

To determine if soluble interleukin 2 (IL-2) receptor measured in serum by an enzyme-linked immunosorbent assay (ELISA) might be useful in managing patients with karyotypically normal spontaneous premature ovarian failure.

DESIGN

Prospective, controlled observation.

SETTING

Tertiary care research institution.

INTERVENTIONS

None.

PATIENTS, PARTICIPANTS

Twenty-four patients with karyotypically normal spontaneous premature ovarian failure comprised the study group. Forty-two healthy men and women comprised the normal reference group.

MAIN OUTCOME MEASURES

We measured peripheral T lymphocyte human leukocyte antigen locus-DR (HLA-DR) expression and IL-2 receptor expression using monoclonal antibodies and flow cytometry. We measured soluble IL-2 receptor levels in serum using an ELISA.

RESULTS

Consistent with previous findings, our patients had significantly higher HLA-DR expression on peripheral T lymphocytes (5.3 +/- 0.46) as compared with controls (3.5 +/- 0.34) (mean +/- SEM, P less than 0.01). Seven patients also had elevated IL-2 receptor expression on peripheral T lymphocytes (P less than 0.05). However, soluble IL-2 receptor levels in the serum did not differ significantly from normals.

CONCLUSIONS

Patients with karyotypically normal spontaneous premature ovarian failure have a modest increase in peripheral T lymphocyte activation measured by flow cytometry. This degree of activation does not result in increased soluble IL-2 receptor release measured by ELISA.

Immunology of ovarian failure

Ovarian failure is the result of depletion of ovarian follicles. Naturally occurring ovarian failure usually takes place around 50 years of age in the human. Premature ovarian failure occurs in 1% of women and is the result of acceleration of rate of ovarian follicular depletion in the majority of cases. Cytokines are involved in the mechanisms of ovarian follicular atresia, whether it occurs at a normal or accelerated rate. It is the balance between the actions of TGF alpha and TGF beta upon the granulosa cell that determines the fate of a nonluteinized follicle and between LH and INF gamma that determines destiny of a luteinized follicle. When granulosa cells express MHC antigens in response to IFN gamma or genetic stimulus, an autoimmune reaction ensures resulting in follicular atresia. If the immune processes proceed continuously rather than cyclically, premature ovarian failure occurs. Thus, not only do the immunologic and endocrinologic systems need to communicate to allow normal ovarian function, evidence exists to support the concept that they interact in the pathophysiology of ovarian failure.