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Atila C, Refardt J, Christ-Crain M. Arginine vasopressin deficiency: diagnosis, management and the relevance of oxytocin deficiency. Nat Rev Endocrinol 2024; 20:487-500. [PMID: 38693275 DOI: 10.1038/s41574-024-00985-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/26/2024] [Indexed: 05/03/2024]
Abstract
Polyuria-polydipsia syndrome can be caused by central diabetes insipidus, nephrogenic diabetes insipidus or primary polydipsia. To avoid confusion with diabetes mellitus, the name 'central diabetes insipidus' was changed in 2022 to arginine vasopressin (AVP) deficiency and 'nephrogenic diabetes insipidus' was renamed as AVP resistance. To differentiate the three entities, various osmotic and non-osmotic copeptin-based stimulation tests have been introduced in the past decade. The hypertonic saline test plus plasma copeptin measurement emerged as the test with highest diagnostic accuracy, replacing the water deprivation test as the gold standard in differential diagnosis of the polyuria-polydipsia syndrome. The mainstay of treatment for AVP deficiency is AVP replacement with desmopressin, a synthetic analogue of AVP specific for AVP receptor 2 (AVPR2), which usually leads to rapid improvements in polyuria and polydipsia. The main adverse effect of desmopressin is dilutional hyponatraemia, which can be reduced by regularly performing the so-called desmopressin escape method. Evidence from the past few years suggests an additional oxytocin deficiency in patients with AVP deficiency. This potential deficiency should be further evaluated in future studies, including feasible provocation tests for clinical practice and interventional trials with oxytocin substitution.
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Affiliation(s)
- Cihan Atila
- Department of Endocrinology, Diabetology and Metabolism, University Hospital Basel, Basel, Switzerland
- Department of Clinical Research University of Basel, University Hospital Basel, Basel, Switzerland
| | - Julie Refardt
- Department of Endocrinology, Diabetology and Metabolism, University Hospital Basel, Basel, Switzerland
- Department of Clinical Research University of Basel, University Hospital Basel, Basel, Switzerland
- Department of Internal Medicine, Section of Endocrinology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Mirjam Christ-Crain
- Department of Endocrinology, Diabetology and Metabolism, University Hospital Basel, Basel, Switzerland.
- Department of Clinical Research University of Basel, University Hospital Basel, Basel, Switzerland.
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Terray A, Baussart B, Zins M, Goldberg M, Kab S, Cazabat L, Brière M, Brue T, Barraud S, Reznik Y, Christin-Maitre S, Illouz F, Raverot G, Young J, Raffin-Sanson ML, Hage M. Gonadotropic status in adult women with pituitary stalk interruption syndrome. Eur J Endocrinol 2024; 190:501-508. [PMID: 38857190 DOI: 10.1093/ejendo/lvae064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2024] [Revised: 05/06/2024] [Accepted: 06/08/2024] [Indexed: 06/12/2024]
Abstract
OBJECTIVE Pituitary stalk interruption syndrome (PSIS) is a rare cause of congenital hypopituitarism. Limited data exist on the gonadotropic status and fertility of adult women with PSIS. Our study aims to describe pubertal development and the evolution of gonadotropic function and fertility in adult women with PSIS. DESIGN A retrospective multicentric French study. METHODS We described gonadotropic function in 56 adult women with PSIS from puberty onward. We compared live birth rates per woman with PSIS with age-matched controls from the large French epidemiological cohort (CONSTANCES). Additionally, we assessed height, body mass index (BMI), blood pressure, other metabolic parameters, and socioeconomic status. RESULTS AND CONCLUSIONS Among 56 women with PSIS, 36 did not experience spontaneous puberty. Of these, 13 underwent ovarian stimulation, resulting in 7 women having a total of 11 children. In the subgroup with spontaneous puberty (n = 20), 4 had a total of 8 pregnancies, while 6 developed secondary gonadotropic deficiency. Women with PSIS had fewer children than controls (0.33 vs 0.63, P = .04). Median height was also lower (160.5 vs 165.0 cm, P < .0001). Although mean blood pressure was lower in women with PSIS compared with controls (111.3/65.9 ± 11.2/8.1 vs 118.7/72.1 ± 10.1/7.7 mmHg, P < .001), there were no significant differences in other metabolic parameters, notably BMI and lipid profile. Employment/academic status was not different in the 2 groups, but fewer women with PSIS were in relationships (42% vs 57.6% in controls, P = .02). The fertility prognosis in patients with PSIS needs optimization. Patients should be informed about the likelihood of declining gonadotropic function over time.
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Affiliation(s)
- Aglaé Terray
- Department of Endocrinology, Diabetology and Nutrition, Ambroise Paré University Hospital, Assistance Publique-Hôpitaux de Paris, F-92100 Boulogne Billancourt, France
- EA4340, Université de Versailles Saint-Quentin-en-Yvelines, UFR des Sciences de la Santé Simone Veil, F-78423 Montigny-le-Bretonneux, France
| | - Bertrand Baussart
- Department of Neurosurgery, Assistance Publique-Hôpitaux de Paris, La Pitié-Salpêtrière University Hospital, F-75013 Paris, France
- Université Paris Cité, CNRS, INSERM, Institut Cochin, F-75014 Paris, France
| | - Marie Zins
- UMS 011, Population-based Cohorts Unit, Université Paris Cité, Paris Saclay University, Université de Versailles Saint-Quentin-en-Yvelines, INSERM, F-94800 Villejuif, France
| | - Marcel Goldberg
- UMS 011, Population-based Cohorts Unit, Université Paris Cité, Paris Saclay University, Université de Versailles Saint-Quentin-en-Yvelines, INSERM, F-94800 Villejuif, France
| | - Sofiane Kab
- UMS 011, Population-based Cohorts Unit, Université Paris Cité, Paris Saclay University, Université de Versailles Saint-Quentin-en-Yvelines, INSERM, F-94800 Villejuif, France
| | - Laure Cazabat
- UMR 1198 BREED, équipe RHuMA, UFR Simone Veil Santé, Université Versailles Saint Quentin en Yvelines, F-78423 Montigny-le-Bretonneux, France
- Service de Neurochirurgie, Hôpital Foch, F-92150 Suresnes, France
| | - Mathilde Brière
- Department of Endocrinology, Diabetology and Nutrition, Ambroise Paré University Hospital, Assistance Publique-Hôpitaux de Paris, F-92100 Boulogne Billancourt, France
| | - Thierry Brue
- Aix Marseille Université, APHM, INSERM, MMG, MarMaRa, F-13305 Marseille, France
- Department of Endocrinology, Reference Center for Rare Pituitary Diseases HYPO, La Conception University Hospital, AP-HM, F-13305 Marseille, France
| | - Sara Barraud
- Department of Endocrinology Diabetes Nutrition, University of Reims Champagne-Ardenne, Reims University Hospital, CRESTIC, F-51092 Reims, France
| | - Yves Reznik
- Department of Endocrinology, Côte de Nacre University Hospital, F 14033 Caen, France
| | - Sophie Christin-Maitre
- Department of Endocrinology, Saint-Antoine Hospital, Centre de Référence des Maladies Endocriniennes Rares de la Croissance, Assistance Publique-Hôpitaux de Paris, ER9 University Pierre et Marie Curie, F-75005 Paris, France
| | - Frédéric Illouz
- Department of Endocrinology, Reference Center for Rare Pituitary Diseases HYPO, Angers University Hospital, F-49000 Angers, France
| | - Gérald Raverot
- Department of Endocrinology, "Groupement Hospitalier Est" Hospices Civils de Lyon, Reference Center for Rare Pituitary Diseases HYPO, F-69500 Bron, France
| | - Jacques Young
- Department of Endocrinology, Bicêtre Hospital, Assistance Publique-Hôpitaux de Paris, Reference Center for Rare Pituitary Diseases HYPO, F-94270 Le Kremlin-Bicêtre, France
- Université Paris-Saclay, Inserm, Physiologie et Physiopathologie Endocriniennes, F-94270 Le Kremlin-Bicêtre, France
| | - Marie-Laure Raffin-Sanson
- Department of Endocrinology, Diabetology and Nutrition, Ambroise Paré University Hospital, Assistance Publique-Hôpitaux de Paris, F-92100 Boulogne Billancourt, France
- EA4340, Université de Versailles Saint-Quentin-en-Yvelines, UFR des Sciences de la Santé Simone Veil, F-78423 Montigny-le-Bretonneux, France
| | - Mirella Hage
- Department of Endocrinology, Diabetology and Nutrition, Ambroise Paré University Hospital, Assistance Publique-Hôpitaux de Paris, F-92100 Boulogne Billancourt, France
- EA4340, Université de Versailles Saint-Quentin-en-Yvelines, UFR des Sciences de la Santé Simone Veil, F-78423 Montigny-le-Bretonneux, France
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Chen J, Chang JJ, Chung EH, Lathi RB, Aghajanova L, Katznelson L. Fertility issues in hypopituitarism. Rev Endocr Metab Disord 2024; 25:467-477. [PMID: 38095806 DOI: 10.1007/s11154-023-09863-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/05/2023] [Indexed: 06/09/2024]
Abstract
Women with hypopituitarism have lower fertility rates and worse pregnancy outcomes than women with normal pituitary function. These disparities exist despite the use of assisted reproductive technologies and hormone replacement. In women with hypogonadotropic hypogonadism, administration of exogenous gonadotropins can be used to successfully induce ovulation. Growth hormone replacement in the setting of growth hormone deficiency has been suggested to potentiate reproductive function, but its routine use in hypopituitary women remains unclear and warrants further study. In this review, we will discuss the clinical approach to fertility in a woman with hypopituitarism.
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Affiliation(s)
- Julie Chen
- Department of Medicine, Division of Endocrinology, Stanford University Medical Center, 300 Pasteur Drive, Grant-S025, Stanford, Palo Alto, CA, 94305-5103, USA.
| | - Julia J Chang
- Department of Medicine, Division of Endocrinology, Stanford University Medical Center, 300 Pasteur Drive, Grant-S025, Stanford, Palo Alto, CA, 94305-5103, USA
| | - Esther H Chung
- Department of Obstetrics and Gynecology, Division of Reproductive Endocrinology and Infertility, Stanford University, Palo Alto, CA, USA
| | - Ruth B Lathi
- Department of Obstetrics and Gynecology, Division of Reproductive Endocrinology and Infertility, Stanford University, Palo Alto, CA, USA
| | - Lusine Aghajanova
- Department of Obstetrics and Gynecology, Division of Reproductive Endocrinology and Infertility, Stanford University, Palo Alto, CA, USA
| | - Laurence Katznelson
- Department of Medicine, Division of Endocrinology, Stanford University Medical Center, 300 Pasteur Drive, Grant-S025, Stanford, Palo Alto, CA, 94305-5103, USA
- Department of Neurosurgery, Stanford University, Palo Alto, CA, USA
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Horibe Y, Nakabayashi A, Murata S, Hashimoto T, Tabata T. Outcomes of Ovulation Induction Aimed to Pregnancy in Eight Hypopituitarism Patients. Cureus 2024; 16:e58819. [PMID: 38784333 PMCID: PMC11113090 DOI: 10.7759/cureus.58819] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/23/2024] [Indexed: 05/25/2024] Open
Abstract
BACKGROUND Female sex hormones work in concert. Gonadotropin-releasing hormone and ovulation-inducing agents are required in female patients with infertility owing to hormone dysregulation. Although drug-induced follicular development can be expected in patients with endogenous female hormone deficiency, data are lacking on the protocols and drugs used. METHODS We retrospectively examined the success rates of ovulation induction, assisted reproductive technology, and pregnancy outcomes in 66 cycles of eight patients with pituitary insufficiency at our hospital. RESULTS Ovulation occurred in 75.4% (49/66); 82.6% (38/46) of patients <40 years and 57.9% (11/19) of patients ≥40 years of age. Five of the eight patients became pregnant, and three delivered babies. The fertilization rate was 78% with in vitro fertilization, and the recombinant follicle-stimulating hormone usage was 3,717.1 ± 1,528.9 International Unit in hypopituitarism patients. CONCLUSION Hypopituitarism patients can achieve ovulation, pregnancy, and delivery after optimal gonadotropin administration. Further studies are needed to determine the effects of gonadotropins on other pituitary hormones, such as growth hormones.
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Affiliation(s)
- Yu Horibe
- Gynecology, Tokyo Women's Medical University, Tokyo, JPN
| | - Akira Nakabayashi
- Obstetrics and Gynecology, Tokyo Women's Medical University, Tokyo, JPN
| | - Shuko Murata
- Obstetrics and Gynecology, Tokyo Women's Medical University, Tokyo, JPN
| | - Tomomi Hashimoto
- Obstetrics and Gynecology, Tokyo Women's Medical University, Tokyo, JPN
| | - Tsutomu Tabata
- Obstetrics and Gynecology, Tokyo Women's Medical University, Tokyo, JPN
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Ly N, Dubreuil S, Touraine P. Normal-high IGF-1 level improves pregnancy rate after ovarian stimulation in women treated with growth hormone replacement therapy. Endocr Connect 2022; 11:e220241. [PMID: 36219843 PMCID: PMC9641773 DOI: 10.1530/ec-22-0241] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Accepted: 10/11/2022] [Indexed: 12/04/2022]
Abstract
Objective Growth hormone (GH) and insulin-like growth factors (IGFs) are not mandatory for reproductive life, but data suggest their synergistic action with follicle-stimulating hormone throughout ovarian folliculogenesis. We aimed to evaluate the association of IGF-1 level on clinical pregnancy rate after ovarian stimulation, with or without intrauterine insemination, in women with GH deficiency (GHD) treated with GH replacement therapy (GHRT) at conception. Design and methods Data from 19 women with both GHD and hypogonadotropic hypogonadism referred to our reproductive medicine department were retrospectively collected. IGF-1 levels were assessed in a single laboratory, and values were expressed in s.d. from the mean. Results Amongst the seven patients receiving GHRT during ovarian stimulation, higher IGF-1 levels were significantly associated with clinical pregnancy (+0.4 s.d. vs-1.6 s.d., P = 0.03). Amongst the 24 pregnancies obtained by the 19 infertile patients, pregnancy loss was less frequent with the addition of GHRT than without (1 miscarriage out of 8 total pregnancies vs 4 miscarriages out of 16 total pregnancies). Conclusions This is the first study evaluating the association of IGF-1 level on clinical pregnancy rate in GH-treated women at conception. When taking care of female infertility due to hypogonadotropic hypogonadism, practitioners should enquire about the associated GHD and IGF-1 levels. To ensure higher clinical pregnancy chances, practitioners should aim for IGF-1 values at conception, ranging from 0 s.d. to +2 s.d., and, if necessary, could discuss initiation or increase GH treatment. Prospective studies should help strengthen our results.
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Affiliation(s)
- Nathalie Ly
- Department of Endocrinology and Reproductive Medicine, Reference Center for Rare Endocrine Diseases of Growth and Development, Reference Center for Gynecological Rare Diseases, Hôpitaux Universitaires Pitié Salpêtrière-Charles Foix, Paris, France
- EndoERN, APHP Consortium Pitie Salpetriere Hospital, Necker Hospital, Paris, France
| | - Sophie Dubreuil
- Department of Endocrinology and Reproductive Medicine, Reference Center for Rare Endocrine Diseases of Growth and Development, Reference Center for Gynecological Rare Diseases, Hôpitaux Universitaires Pitié Salpêtrière-Charles Foix, Paris, France
- EndoERN, APHP Consortium Pitie Salpetriere Hospital, Necker Hospital, Paris, France
| | - Philippe Touraine
- Department of Endocrinology and Reproductive Medicine, Reference Center for Rare Endocrine Diseases of Growth and Development, Reference Center for Gynecological Rare Diseases, Hôpitaux Universitaires Pitié Salpêtrière-Charles Foix, Paris, France
- EndoERN, APHP Consortium Pitie Salpetriere Hospital, Necker Hospital, Paris, France
- Sorbonne University, Paris, France
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Aulinas A, Stantonyonge N, García-Patterson A, Adelantado JM, Medina C, Espinós JJ, López E, Webb SM, Corcoy R. Hypopituitarism and pregnancy: clinical characteristics, management and pregnancy outcome. Pituitary 2022; 25:275-284. [PMID: 34846622 PMCID: PMC8894301 DOI: 10.1007/s11102-021-01196-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/16/2021] [Indexed: 11/21/2022]
Abstract
PURPOSE To describe the clinical characteristics, management and pregnancy outcome of women with prepregnancy hypopituitarism (HYPO) that received care at our center. METHODS Retrospective study describing 12 pregnancies in women with prepregnancy HYPO (two or more pituitary hormonal deficiencies under replacement treatment) that received care during pregnancy at Hospital Santa Creu i Sant Pau. Clinical characteristics, management and pregnancy outcome were systematically collected. RESULTS Average patients' age was 35 years and HYPO duration at the beginning of pregnancy was 19 years. The most frequent cause of HYPO was surgical treatment of a sellar mass (8 pregnancies). Eight pregnancies were in primigravid women and 10 required assisted reproductive techniques. The hormonal deficits before pregnancy were as follows: GH in 12 women, TSH in 10, gonadotropin in 9, ACTH in 5 and ADH in 2. All deficits were under hormonal substitution except for GH deficit in 4 pregnancies. During pregnancy, 4 new deficits were diagnosed. The dosage of replacement treatment for TSH, ACTH and ADH deficits was increased and GH was stopped. Average gestational age at birth was 40 weeks, gestational weight gain was excessive in 9 women, 8 patients required induction/elective delivery and cesarean section was performed in 6. Average birthweight was 3227 g. No major complications were observed. Five women were breastfeeding at discharge. CONCLUSIONS In this group of women with long-standing HYPO, with careful clinical management (including treatment of new-onset hormonal deficits) pregnancy outcome was satisfactory but with a high rate of excessive gestational weight gain and cesarean section.
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Affiliation(s)
- Anna Aulinas
- Department of Endocrinology and Nutrition, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER Unidad 747), ISCIII, Barcelona, Spain
- Department of Medicine, University of Vic - Central University of Catalonia, Vic, Barcelona, Spain
- Institut de Recerca, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Nicole Stantonyonge
- Department of Endocrinology and Nutrition, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
- Department of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain
| | | | - Juan M Adelantado
- Department of Gynecology and Obstetrics, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Carmen Medina
- Department of Gynecology and Obstetrics, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Juan José Espinós
- Department of Gynecology and Obstetrics, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Esther López
- Department of Pediatrics, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Susan M Webb
- Department of Endocrinology and Nutrition, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER Unidad 747), ISCIII, Barcelona, Spain
- Institut de Recerca, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
- Department of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Rosa Corcoy
- Department of Endocrinology and Nutrition, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain.
- Institut de Recerca, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain.
- Department of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain.
- Centro de Investigación Biomédica en Red de Bioingeniería, Biomateriales y Nanomedicina (CIBERBBN), ISCIII, Madrid, Spain.
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Chen J, Katznelson L. The role of growth hormone for fertility in women with hypopituitarism. Growth Horm IGF Res 2022; 63:101458. [PMID: 35398725 DOI: 10.1016/j.ghir.2022.101458] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Revised: 03/25/2022] [Accepted: 03/27/2022] [Indexed: 11/04/2022]
Abstract
Growth hormone (GH) is an important regulator of the female reproductive system. In vitro and non-human in vivo studies demonstrate a role of GH in steroidogenesis, folliculogenesis, and post-fertilization development. Given its ability to modulate the reproductive system and potentiate the effects of gonadotropins, a beneficial role of GH replacement therapy to optimize fertility has been suggested. Women with hypopituitarism have lower pregnancy and live birth rates. Limited data suggest a role of GH in enhancing fertility management in women with hypopituitarism. GH replacement therapy may be especially relevant in women with hypopituitarism as well as in women considered poor ovarian responders and require assisted reproductive techniques.
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Affiliation(s)
- Julie Chen
- Department of Medicine, Division of Endocrinology & Metabolism, Stanford University School of Medicine, 300 Pasteur Drive, Grant-S025, Stanford, CA 94305-5103, United States of America.
| | - Laurence Katznelson
- Neurosurgery and Medicine (Endocrinology and Metabolism), Stanford University School of Medicine, 300 Pasteur Drive, Grant-S025, Stanford, CA 94305-5103, United States of America
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8
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Biller BMK, Höybye C, Carroll P, Gordon MB, Birkegård AC, Kelepouris N, Nedjatian N, Weber MM. Pregnancy outcomes in women receiving growth hormone replacement therapy enrolled in the NordiNet® International Outcome Study (IOS) and the American Norditropin® Studies: Web-Enabled Research (ANSWER) Program. Pituitary 2021; 24:611-621. [PMID: 33709288 PMCID: PMC8270875 DOI: 10.1007/s11102-021-01138-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/23/2021] [Indexed: 12/23/2022]
Abstract
PURPOSE Data on the safety of growth hormone (GH) replacement therapy during pregnancy are limited. We report a combined analysis of data from pregnant women treated with GH while enrolled in two non-interventional, multicenter studies: NordiNet® International Outcome Study (IOS) and the American Norditropin® Studies: Web-Enabled Research (ANSWER) Program. METHODS Pregnancy data were pooled from NordiNet® IOS and the ANSWER Program. Data were collected during routine clinic visits by participating physicians using a web-based system. Patients exposed to GH replacement therapy during pregnancy were included in the analysis. RESULTS The study population included 40 female patients with typical causes of adult GH deficiency (GHD). Overall, there were 54 pregnancies. Of these, 47 were exposed to GH between conception and delivery. In 48.9% of pregnancies exposed to GH, the dose was > 0.6 mg/day. GH was continued past conception and then stopped during the first, second, and third trimester, in 27.7%, 17.0%, and 2.1% of pregnancies, respectively. In 29.8%, GH was continued throughout pregnancy, with an unchanged dose in most cases. Of the 47 GH-exposed pregnancies, 37 (78.7%) progressed to normal delivery. There were three adverse events reported in two pregnancies. CONCLUSION These real-world data suggest that there were no new safety signals related to GH exposure in women with GHD during pregnancy. These results are consistent with findings from previous studies reporting data in pregnancies exposed to GH at conception or throughout pregnancy. This observational study in additional pregnancies provides further evidence that GH exposure does not adversely affect pregnancy outcome. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov NCT00960128 (date of registration: August 13, 2009) and NCT01009905 (date of registration: November 5, 2009).
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Affiliation(s)
- Beverly M K Biller
- Neuroendocrine Unit, Massachusetts General Hospital, Bulfinch 457B, Fruit St., Boston, MA, 02114, USA.
| | - Charlotte Höybye
- Department of Endocrinology, and Department of Molecular Medicine and Surgery, Karolinska University Hospital and Karolinska Institute, Stockholm, Sweden
| | - Paul Carroll
- Department of Endocrinology, Guy's & St. Thomas' NHS Foundation Trust, London, UK
| | - Murray B Gordon
- Allegheny Neuroendocrinology Center, Division of Endocrinology, Allegheny General Hospital, Pittsburgh, PA, USA
| | | | | | - Navid Nedjatian
- Global Medical Affairs - Rare Endocrine Disorders, Novo Nordisk Health Care AG, Zurich, Switzerland
| | - Matthias M Weber
- Unit of Endocrinology, Universitätsmedizin der Johannes Gutenberg-Universität Mainz, Mainz, Germany
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Abstract
The management of aggressive pituitary adenomas represents a special clinical challenge, and usually involves a combination of surgery, radiotherapy and pharmacological agents to control tumor growth and hormone abnormalities. Fertility is commonly affected in these patients due to compressive effects of the tumor, pituitary hormone dysfunction or as a result of the multiple therapies. The initial approach to restore fertility involves the reduction of tumor volume by the use of dopamine agonists in prolactinomas and by surgery in other pituitary adenomas. Somatostatin analogues are alternative options for GH, ACTH and TSH-secreting tumors. When present, pituitary deficiencies should be appropriately treated, particularly GH deficiency that has been associated with poor pregnancy rates in hypopituitary patients. Other therapies for aggressive pituitary tumors, such as invasive surgery, radiotherapy and temozolamide, may lead to infertility. In such cases, fertility preservation strategies might be considered and discussed with the patient desiring conception before or during treatment. In men and women with hypogonadotropic hypogonadism, administration of gonadotropins or pulse GnRH has resulted in satisfactory pregnancy rates. If spontaneous gestation is not achieved, assisted reproduction techniques can be employed as the last line of treatment. In any context, pre-conception counseling and care are essential as pregnancies in women with aggressive pituitary tumors should always be considered high risk.
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Affiliation(s)
- Júlia Vieira Oberger Marques
- SEMPR, Serviço de Endocrinologia e Metabologia, Departamento de Clínica Médica, Hospital de Clínicas da Universidade Federal do Paraná, Agostinho Leão Junior 285, Curitiba, PR, 80030-110, Brazil
| | - Cesar Luiz Boguszewski
- SEMPR, Serviço de Endocrinologia e Metabologia, Departamento de Clínica Médica, Hospital de Clínicas da Universidade Federal do Paraná, Agostinho Leão Junior 285, Curitiba, PR, 80030-110, Brazil.
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10
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Vila G, Fleseriu M. Fertility and Pregnancy in Women With Hypopituitarism: A Systematic Literature Review. J Clin Endocrinol Metab 2020; 105:5607346. [PMID: 31652320 DOI: 10.1210/clinem/dgz112] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Accepted: 10/08/2019] [Indexed: 12/21/2022]
Abstract
CONTEXT Human reproduction is mainly governed from the hypothalamic-adrenal-gonadal (HPG) axis, which controls both ovarian morphology and function. Disturbances in the secretion of other anterior pituitary hormones (and their respective endocrine axes) interfere with HPG activity and have been linked to fertility problems. In normal pregnancy, maintenance of homeostasis is associated with continuous changes in pituitary morphology and function, which need to be considered during hormone replacement in patients with hypopituitarism. DESIGN We conducted a systematic PubMed literature review from 1969 to 2019, with the following keywords: fertility and hypopituitarism, pregnancy and hypopituitarism, and ovulation induction and hypopituitarism. Case reports or single-case series of up to 2 patients/4 pregnancies were excluded. RESULTS Eleven publications described data on fertility (n = 6) and/or pregnancy (n = 7) in women with hypopituitarism. Women with hypopituitarism often need assisted reproductive treatment, with pregnancy rates ranging from 47% to 100%. In patients achieving pregnancy, live birth rate ranged from 61% to 100%. While glucocorticoids, levothyroxine, and desmopressin are safely prescribed during pregnancy, growth hormone treatment regimens vary significantly between countries, and several publications support a positive effect in women seeking fertility. CONCLUSIONS In this first systematic review on fertility, ovulation induction, and pregnancy in patients with hypopituitarism, we show that while literature is scarce, birth rates are high in patients achieving pregnancy. However, prospective studies are needed for evaluating outcomes in relationship to treatment patterns. Replacement therapy in hypopituitarism should always mimic normal physiology, and this becomes challenging with changing demands during pregnancy evolution.
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Affiliation(s)
- Greisa Vila
- Clinical Division of Endocrinology and Metabolism, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Maria Fleseriu
- Department of Neurological Surgery, Oregon Health & Science University, Portland, Oregon 97239
- Department of Medicine (Endocrinology), Oregon Health & Science University, Portland, Oregon 97239
- Northwest Pituitary Center, Oregon Health & Science University, Portland, Oregon 97239
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Sbardella E, Minnetti M, Pofi R, Cozzolino A, Greco E, Gianfrilli D, Isidori AM. Late Effects of Parasellar Lesion Treatment: Hypogonadism and Infertility. Neuroendocrinology 2020; 110:868-881. [PMID: 32335548 DOI: 10.1159/000508107] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2020] [Accepted: 04/21/2020] [Indexed: 11/19/2022]
Abstract
Central hypogonadism, also defined as hypogonadotropic hypogonadism, is a recognized complication of hypothalamic-pituitary-gonadal axis damage following treatment of sellar and parasellar masses. In addition to radiotherapy and surgery, CTLA4-blocking antibodies and alkylating agents such as temozolomide can also lead to hypogonadism, through different mechanisms. Central hypogonadism in boys and girls may lead to pubertal delay or arrest, impairing full development of the genitalia and secondary sexual characteristics. Alternatively, cranial irradiation or ectopic hormone production may instead cause early puberty, affecting hypothalamic control of the gonadostat. Given the reproductive risks, discussion of fertility preservation options and referral to reproductive specialists before treatment is essential. Steroid hormone replacement can interfere with other replacement therapies and may require specific dose adjustments. Adequate gonadotropin stimulation therapy may enable patients to restore gametogenesis and conceive spontaneously. When assisted reproductive technology is needed, protocols must be tailored to account for possible long-term gonadotropin insufficiency prior to stimulation. The aim of this review was to provide an overview of the risk factors for hypogonadism and infertility in patients treated for parasellar lesions and to give a summary of the current recommendations for management and follow-up of these dysfunctions in such patients. We have also briefly summarized evidence on the physiological role of pituitary hormones during pregnancy, focusing on the management of pituitary deficiencies.
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Affiliation(s)
- Emilia Sbardella
- Department of Experimental Medicine, Sapienza University of Rome, Policlinico Umberto I Hospital, Rome, Italy
| | - Marianna Minnetti
- Department of Experimental Medicine, Sapienza University of Rome, Policlinico Umberto I Hospital, Rome, Italy
| | - Riccardo Pofi
- Department of Experimental Medicine, Sapienza University of Rome, Policlinico Umberto I Hospital, Rome, Italy
| | - Alessia Cozzolino
- Department of Experimental Medicine, Sapienza University of Rome, Policlinico Umberto I Hospital, Rome, Italy
| | - Ermanno Greco
- Center for Reproductive Medicine, European Hospital, Rome, Italy
| | - Daniele Gianfrilli
- Department of Experimental Medicine, Sapienza University of Rome, Policlinico Umberto I Hospital, Rome, Italy
| | - Andrea M Isidori
- Department of Experimental Medicine, Sapienza University of Rome, Policlinico Umberto I Hospital, Rome, Italy,
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Alexandraki KI, Grossman AB. Management of Hypopituitarism. J Clin Med 2019; 8:jcm8122153. [PMID: 31817511 PMCID: PMC6947162 DOI: 10.3390/jcm8122153] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Revised: 12/01/2019] [Accepted: 12/02/2019] [Indexed: 12/14/2022] Open
Abstract
Hypopituitarism includes all clinical conditions that result in partial or complete failure of the anterior and posterior lobe of the pituitary gland’s ability to secrete hormones. The aim of management is usually to replace the target-hormone of hypothalamo-pituitary-endocrine gland axis with the exceptions of secondary hypogonadism when fertility is required, and growth hormone deficiency (GHD), and to safely minimise both symptoms and clinical signs. Adrenocorticotropic hormone deficiency replacement is best performed with the immediate-release oral glucocorticoid hydrocortisone (HC) in 2–3 divided doses. However, novel once-daily modified-release HC targets a more physiological exposure of glucocorticoids. GHD is treated currently with daily subcutaneous GH, but current research is focusing on the development of once-weekly administration of recombinant GH. Hypogonadism is targeted with testosterone replacement in men and on estrogen replacement therapy in women; when fertility is wanted, replacement targets secondary or tertiary levels of hormonal settings. Thyroid-stimulating hormone replacement therapy follows the rules of primary thyroid gland failure with L-thyroxine replacement. Central diabetes insipidus is nowadays replaced by desmopressin. Certain clinical scenarios may have to be promptly managed to avoid short-term or long-term sequelae such as pregnancy in patients with hypopituitarism, pituitary apoplexy, adrenal crisis, and pituitary metastases.
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Affiliation(s)
- Krystallenia I. Alexandraki
- Endocrine Unit, 1st Department of Propaedeutic Medicine, School of Medicine, National and Kapodistrian University of Athens, 115 27 Athens, Greece;
| | - Ashley B. Grossman
- Department of Endocrinology, Oxford Centre for Diabetes, Endocrinology and Metabolism, Churchill Hospital, University of Oxford, Oxford OX3 7LE, UK
- Centre for Endocrinology, Barts and the London School of Medicine, London EC1M 6BQ, UK
- Correspondence:
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Yuen KCJ, Biller BMK, Radovick S, Carmichael JD, Jasim S, Pantalone KM, Hoffman AR. AMERICAN ASSOCIATION OF CLINICAL ENDOCRINOLOGISTS AND AMERICAN COLLEGE OF ENDOCRINOLOGY GUIDELINES FOR MANAGEMENT OF GROWTH HORMONE DEFICIENCY IN ADULTS AND PATIENTS TRANSITIONING FROM PEDIATRIC TO ADULT CARE. Endocr Pract 2019; 25:1191-1232. [PMID: 31760824 DOI: 10.4158/gl-2019-0405] [Citation(s) in RCA: 138] [Impact Index Per Article: 27.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Objective: The development of these guidelines is sponsored by the American Association of Clinical Endocrinologists (AACE) Board of Directors and American College of Endocrinology (ACE) Board of Trustees and adheres with published AACE protocols for the standardized production of clinical practice guidelines (CPG). Methods: Recommendations are based on diligent reviews of clinical evidence with transparent incorporation of subjective factors, according to established AACE/ACE guidelines for guidelines protocols. Results: The Executive Summary of this 2019 updated guideline contains 58 numbered recommendations: 12 are Grade A (21%), 19 are Grade B (33%), 21 are Grade C (36%), and 6 are Grade D (10%). These detailed, evidence-based recommendations allow for nuance-based clinical decision-making that addresses multiple aspects of real-world care of patients. The evidence base presented in the subsequent Appendix provides relevant supporting information for the Executive Summary recommendations. This update contains 357 citations of which 51 (14%) are evidence level (EL) 1 (strong), 168 (47%) are EL 2 (intermediate), 61 (17%) are EL 3 (weak), and 77 (22%) are EL 4 (no clinical evidence). Conclusion: This CPG is a practical tool that practicing endocrinologists and regulatory bodies can refer to regarding the identification, diagnosis, and treatment of adults and patients transitioning from pediatric to adult-care services with growth hormone deficiency (GHD). It provides guidelines on assessment, screening, diagnostic testing, and treatment recommendations for a range of individuals with various causes of adult GHD. The recommendations emphasize the importance of considering testing patients with a reasonable level of clinical suspicion of GHD using appropriate growth hormone (GH) cut-points for various GH-stimulation tests to accurately diagnose adult GHD, and to exercise caution interpreting serum GH and insulin-like growth factor-1 (IGF-1) levels, as various GH and IGF-1 assays are used to support treatment decisions. The intention to treat often requires sound clinical judgment and careful assessment of the benefits and risks specific to each individual patient. Unapproved uses of GH, long-term safety, and the current status of long-acting GH preparations are also discussed in this document. LAY ABSTRACT This updated guideline provides evidence-based recommendations regarding the identification, screening, assessment, diagnosis, and treatment for a range of individuals with various causes of adult growth-hormone deficiency (GHD) and patients with childhood-onset GHD transitioning to adult care. The update summarizes the most current knowledge about the accuracy of available GH-stimulation tests, safety of recombinant human GH (rhGH) replacement, unapproved uses of rhGH related to sports and aging, and new developments such as long-acting GH preparations that use a variety of technologies to prolong GH action. Recommendations offer a framework for physicians to manage patients with GHD effectively during transition to adult care and adulthood. Establishing a correct diagnosis is essential before consideration of replacement therapy with rhGH. Since the diagnosis of GHD in adults can be challenging, GH-stimulation tests are recommended based on individual patient circumstances and use of appropriate GH cut-points. Available GH-stimulation tests are discussed regarding variability, accuracy, reproducibility, safety, and contraindications, among other factors. The regimen for starting and maintaining rhGH treatment now uses individualized dose adjustments, which has improved effectiveness and reduced reported side effects, dependent on age, gender, body mass index, and various other individual characteristics. With careful dosing of rhGH replacement, many features of adult GHD are reversible and side effects of therapy can be minimized. Scientific studies have consistently shown rhGH therapy to be beneficial for adults with GHD, including improvements in body composition and quality of life, and have demonstrated the safety of short- and long-term rhGH replacement. Abbreviations: AACE = American Association of Clinical Endocrinologists; ACE = American College of Endocrinology; AHSG = alpha-2-HS-glycoprotein; AO-GHD = adult-onset growth hormone deficiency; ARG = arginine; BEL = best evidence level; BMD = bone mineral density; BMI = body mass index; CI = confidence interval; CO-GHD = childhood-onset growth hormone deficiency; CPG = clinical practice guideline; CRP = C-reactive protein; DM = diabetes mellitus; DXA = dual-energy X-ray absorptiometry; EL = evidence level; FDA = Food and Drug Administration; FD-GST = fixed-dose glucagon stimulation test; GeNeSIS = Genetics and Neuroendocrinology of Short Stature International Study; GH = growth hormone; GHD = growth hormone deficiency; GHRH = growth hormone-releasing hormone; GST = glucagon stimulation test; HDL = high-density lipoprotein; HypoCCS = Hypopituitary Control and Complications Study; IGF-1 = insulin-like growth factor-1; IGFBP = insulin-like growth factor-binding protein; IGHD = isolated growth hormone deficiency; ITT = insulin tolerance test; KIMS = Kabi International Metabolic Surveillance; LAGH = long-acting growth hormone; LDL = low-density lipoprotein; LIF = leukemia inhibitory factor; MPHD = multiple pituitary hormone deficiencies; MRI = magnetic resonance imaging; P-III-NP = procollagen type-III amino-terminal pro-peptide; PHD = pituitary hormone deficiencies; QoL = quality of life; rhGH = recombinant human growth hormone; ROC = receiver operating characteristic; RR = relative risk; SAH = subarachnoid hemorrhage; SDS = standard deviation score; SIR = standardized incidence ratio; SN = secondary neoplasms; T3 = triiodothyronine; TBI = traumatic brain injury; VDBP = vitamin D-binding protein; WADA = World Anti-Doping Agency; WB-GST = weight-based glucagon stimulation test.
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Dosouto C, Calaf J, Polo A, Haahr T, Humaidan P. Growth Hormone and Reproduction: Lessons Learned From Animal Models and Clinical Trials. Front Endocrinol (Lausanne) 2019; 10:404. [PMID: 31297089 PMCID: PMC6607366 DOI: 10.3389/fendo.2019.00404] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2019] [Accepted: 06/06/2019] [Indexed: 01/13/2023] Open
Abstract
Growth Hormone (GH) has been considered as a therapeutic option to increase the number of growing follicles during Assisted Reproductive Technology (ART) for more than 30 years. In this review the biological rationale for therapeutic GH usage is explained through evidence in animal models, aiming to put this into a clinical context. First, we explain the GH-Insulin like Growth Factor (IGF)-1-gonadal axis and its role in reproduction. Evidence suggests that GH can stimulate the secretion of IGF1 not only in the liver but also in the peripheral target structures, including the ovary. Moreover, IGF-1 can be secreted locally under the influence of stimuli other than GH. In the case of the ovary, steroid hormones, gonadotropins or the combination of both seems to be involved. Even more interesting, the ovary itself can secret GH locally and exert a paracrine action modulating the intracellular signaling pathway of GH, i.e., not by the systemic pathway where GH binds to the extracellular domain of the GH receptor. Finally, these aspects from animal models are put into clinical perspective by discussing results and shortcomings of studies and meta-analyses in order to put forth the state-of-the-art rationale for therapeutic GH usage in modern ART.
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Affiliation(s)
- Carlos Dosouto
- Obstetrics, Gynecology and Reproductive Medicine, Hospital de la Santa Creu I Sant Pau- Fundació Puigvert, Barcelona, Spain
- Faculty of Medicine, Autonomous University of Barcelona, Barcelona, Spain
- *Correspondence: Carlos Dosouto
| | - Joaquim Calaf
- Obstetrics, Gynecology and Reproductive Medicine, Hospital de la Santa Creu I Sant Pau- Fundació Puigvert, Barcelona, Spain
- Faculty of Medicine, Autonomous University of Barcelona, Barcelona, Spain
| | - Ana Polo
- Obstetrics, Gynecology and Reproductive Medicine, Hospital de la Santa Creu I Sant Pau- Fundació Puigvert, Barcelona, Spain
- Faculty of Medicine, Autonomous University of Barcelona, Barcelona, Spain
| | - Thor Haahr
- The Fertility Clinic Skive Regional Hospital, Skive, Denmark
- Faculty of Health, Aarhus University, Aarhus, Denmark
| | - Peter Humaidan
- The Fertility Clinic Skive Regional Hospital, Skive, Denmark
- Faculty of Health, Aarhus University, Aarhus, Denmark
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