Autoimmune Diseases in Patients with Premature Ovarian Insufficiency-Our Current State of Knowledge

Premature ovarian insufficiency (POI), previously known as premature ovarian failure or premature menopause, is defined as loss of ovarian function before the age of 40 years. The risk of POI before the age of 40 is 1%. Clinical symptoms develop as a result of estrogen deficiency and may include amenorrhea, oligomenorrhea, vasomotor instability (hot flushes, night sweats), sleep disturbances, vulvovaginal atrophy, altered urinary frequency, dyspareunia, low libido, and lack of energy. Most causes of POI remain undefined, however, it is estimated that anywhere from 4-30% of cases are autoimmune in origin. As the ovaries are a common target for autoimmune attacks, an autoimmune etiology of POI should always be considered, especially in the presence of anti-oocyte antibodies (AOAs), autoimmune diseases, or lymphocytic oophoritis in biopsy. POI can occur in isolation, but is often associated with other autoimmune conditions. Concordant thyroid disorders such as hypothyroidism, Hashimoto thyroiditis, and Grave's disease are most commonly seen. Adrenal autoimmune disorders are the second most common disorders associated with POI. Among women with diabetes mellitus, POI develops in roughly 2.5%. Additionally, autoimmune-related POI can also present as part of autoimmune polyglandular syndrome (APS), a condition in which autoimmune activity causes specific endocrine organ damage. In its most common presentation (type-3), APS is associated with Hashomoto's type thyroid antibodies and has a prevalence of 10-40%. 21OH-Antibodies in Addison's disease (AD) can develop in association to APS-2.

Streptococcal toxic shock syndrome following group A streptococcal vulvovaginitis in a breastfeeding woman

Streptococcal toxic shock syndrome (STSS) is a systemic, life-threatening illness usually caused by invasive respiratory tract or skin and soft tissue infections of Streptococcus pyogenes (group A streptococcus, GAS). We report the case of an adult woman with lactational amenorrhea and GAS vulvovaginitis progressing to STSS. She was admitted to our hospital because of fever, lethargy, and a 2-week history of vaginal discharge; she also had hypotension and multiple organ failure. Blood and urine cultures yielded gram-positive cocci and GAS. After 14 days of antimicrobial therapy, she fully recovered without any complications. The vulvovaginitis was most likely the portal of entry for GAS, which is rarely recognized as a causative pathogen of vulvovaginitis. Lactational amenorrhea is thought to be a risk factor for GAS vulvovaginitis. It is important for clinicians to recognize the possibility of GAS vulvovaginitis in breastfeeding women with vaginal symptoms and consider the necessity of prompt antibiotic treatment.

Menstrual function, menstrual suppression, and the immunology of the human female reproductive tract

Analyses of menstrual function are important to our understanding of human evolution and can help to assess the risks of menstrual suppression, a practice increasingly recommended for women. Two evolutionary issues, however, are insufficiently appreciated in these analyses: the selection pressure infections pose to the human female reproductive system, and the variety of different-and possibly conflicting-immunological functions in the healthy human female reproductive and genital tract. Part of the reason why these issues are inadequately addressed is that reproduction is not sufficiently contextualized in evolutionary and immunological accounts. I argue that expanding the immunological context for menstrual function reinvigorates Margie Profet's (1993a) hypothesis that menstruation defends against sperm-borne pathogens. This expanded context also suggests that menstruation may have more than one function. Thus, until more is known about menstruation, we should proceed cautiously with regard to menstrual suppression.

Interferon-gamma-producing T cells, pregnancy, and postpartum relapses of multiple sclerosis

OBJECTIVE

To determine whether fluctuations in functional T-cell subsets can explain why multiple sclerosis (MS) relapses decline during pregnancy and increase in the postpartum period.

DESIGN

Case-control study.

SETTING

Kaiser Permanente Northern California and Stanford University.

PARTICIPANTS

Twenty-six pregnant women with MS and 24 age-matched, pregnant controls. Intervention We prospectively followed up the pregnant women with MS and the age-matched, pregnant controls; conducted structured interviews; and collected peripheral blood mononuclear cells during each trimester and 2, 4, 6, 9, and 12 months post partum.

MAIN OUTCOME MEASURES

Sixteen functional cell types, including interferon-gamma (IFN-gamma)- and tumor necrosis factor-producing T-cell subsets, were measured using multicolor flow cytometry. Since these cell types may also fluctuate with pregnancy, lactational amenorrhea, or MS treatment, the data were analyzed taking into account these factors.

RESULTS

Fifteen women with MS (58%) had relapses during the postpartum year. CD4(+)IFN-gamma-producing cells fluctuated with MS relapses, declining during pregnancy in women with MS (P < .001) and continuing to decline after parturition in women with relapses (P = .001), yet rising or remaining stable in women with nonrelapsing MS or healthy pregnant women. Lactational amenorrhea was associated with a rise in CD4(+)IFN-gamma-producing cells in women with MS (P = .009). In contrast, CD4(+) tumor necrosis factor-producing cells decreased during lactational amenorrhea in all groups of women and, once this was taken into account, obscured any relationship to MS relapses. CD8(+)IFN-gamma-producing cells were elevated in women with MS throughout the study (P < .001) but did not fluctuate with relapses.

CONCLUSIONS

Our findings suggest that a decline in circulating CD4(+)IFN-gamma-producing cells leads to postpartum MS relapses. Our findings also suggest that the decline in these cells may begin during late pregnancy and that lactational amenorrhea induced by exclusive breastfeeding may be able to interrupt this process.

Primary ovarian insufficiency due to steroidogenic cell autoimmunity is associated with a preserved pool of functioning follicles

CONTEXT

Primary ovarian insufficiency (POI) is defined as hypergonadotropic amenorrhea before the age of 40 yr. In 4-5% of patients with POI, an ovarian autoimmune process is present.

DESIGN

Serum concentrations of antimüllerian hormone (AMH) have been determined in 26 women with POI due to steroidogenic cell autoimmunity (SCA-POI), 66 with nonautoimmune idiopathic POI (iPOI), 40 postmenopausal women (PMW), and 44 healthy fertile women (HW). SCA-POI was diagnosed according to presence of steroidogenic enzyme autoantibodies (17alpha-hydroxylase, side chain cleavage, and 21-hydroxylase autoantibodies).

RESULTS

AMH concentrations were significantly higher in women with SCA-POI than women with iPOI (P = 0.018) or PMW (P = 0.03) but significantly lower than HW (P < 0.0001). AMH was detected in 11 of 26 women with SCA-POI (42%) and seven of 66 with iPOI (11%) (P = 0.002). Serum concentrations above the fifth percentile of the normal range (0.6 ng/ml) were detected in nine of 26 women with SCA-POI (35%) and four of 66 with iPOI (6%) (P = 0.001). Eight of 12 women with SCA-POI with less than 5 yr (67%) and one of 14 with longer disease duration (7%) had AMH concentrations within the normal range (P = 0.003). AMH concentrations correlated inversely with disease duration in women with SCA-POI (rho = -0.563, P = 0.003) but not women with iPOI. AMH correlated inversely with FSH serum concentrations in HW (rho = -0.584, P < 0.001) but not PMW or women with POI.

CONCLUSIONS

Two thirds of women with recent-onset SCA-POI had normal AMH concentrations. Women with SCA-POI, differently from those with iPOI, present a preserved ovarian follicle pool for several years after diagnosis of ovarian insufficiency.

[Activity of succinate dehydrogenase from peripheral blood lymphocytes in girls with sexual maturation disturbance of chromosome genesis]

We carried out a comparative analysis of activity of enzymes characterizing metabolic (SDG) and catabolic (KF) processes in immune system cells of 195 girls with sexual maturation disturbance of chromosome (Shereshevsky-Terner syndrome--STS) and non-chromosome genesis. KF activity was similar in the compared groups and 14 control girls, while SDG activity and FSH levels were much higher in STS girls compared to control girls and girls with amenorrhea of non-chromosome genesis. Thus, FSH has a considerable influence upon metabolic parameters of immune system cells.

[Autoimmune ovarian failure in adolescent girls]

BACKGROUND

The aim of the study was to map the incidence of antiovarian antibodies (AOA) in adolescent girls with ovarian cycle irregularities in comparison with girls with the regular cycle. The relation between the AOA positivity and structural changes in the bioptic samples of ovaria was examined.

MATERIAL AND RESULTS

The studied cohort included 39 girls with primary amenorrhea (N = 18) and oligo/secondary amenorrhea (N = 21). All patients were tested for the presence of antiovarian antibodies (AOA) in the serum and levels of FSH and LH. The examination was done at the beginning of the study and after six months of therapy, in most of the cases by the hormone substitution treatment. In indicated cases the laparoscopic ovarian biopsy was done. A patients with serious failure of ovarian cycle the positivity of antibodies against various components of ovaria was found. Significantly higher levels of FSH was also found, LH levels were not higher. In our patients the depletion and alteration of the follicular apparatus in the cortex of ovaria belonged to the common findings. The control examination after the six month of hormonal substitution brought about lower levels of AOA, in some patients AOA fully disappeared.

CONCLUSIONS

Incidence mapping of antiovarian antibodies in patients with ovarian cycle irregularities correlate with findings of elevated atresia. Ovarian cycle irregularities can later or earlier turn into the extinction of the follicular apparatus and fibrotization of the ovarian cortex.

Anti-nuclear antibodies in patients with premature ovarian failure

We examined the prevalence of anti-nuclear antibodies (ANA) in 32 consecutive patients with premature ovarian failure with and without chromosomal abnormalities. Blood samples were taken for karyotype determination as well as detection of autoantibodies, X-terminal microdeletions and spontaneous follicular growth. The correlation between ANA positivity and the age at onset of amenorrhoea, as well as the presence of karyotype abnormalities, X-terminal microdeletions and follicular growth was determined. Ten of the 24 patients with normal karyotype and none of the 8 patients with karyotype abnormalities were ANA positive. ANA were found more frequently in patients with premature ovarian failure with normal karyotypes than in control amenorrhoeic patients (42 versus 6, P < 0.01). ANA were found in 77% (10/13) of premature ovarian failure patients with normal karyotypes who developed amenorrhoea at or under the age of 30 years, but not in the patients who developed amenorrhoea later in life. Follicular growth was evident in 50% (5/10) of karyotypically normal patients with ANA, 71% (10/14) of karyotypically normal patients without ANA and 38% (3/8) of patients with karyotype abnormalities. X-terminal microdeletions were not found in any of the patients studied. These results suggest that patients with premature ovarian failure and ANA are an aetiologically and clinically distinct group.

Prevalence, specificity and significance of ovarian antibodies during spontaneous premature ovarian failure

Autoimmunity may be involved in idiopathic premature ovarian failure (POF). However, the frequency, physiopathology and potential reversibility of autoimmune oophoritis needs clarification. Using an ELISA against whole tissue homogenate as antigen, from human ovaries at different ages, positive circulating ovarian antibodies (AOA) were found in 59% of patients with primitive idiopathic POF (27/46); 20/27 were positive for IgG isotype, 9/27 for IgM and 8/27 for IgA. Specificity of AOA was examined (i) by comparison to different control groups; mean values of the three subclasses of immunoglobins were significantly higher in POF women than in normally cycling fertile young women (n = 23) and fertile young men (n = 17), in untreated Grave's disease (n = 35) or in women with positive antinuclear factor (n = 25); and (ii) by assessing possible cross-reaction; only six out of the 27 positive sera reacted with other tissues (thyroid, pancreas, adrenal), including four clinical polyendocrinopathies. Significance of AOA was explored (i) by comparison with postmenopausal women (n = 40) and older women (n = 15), who did not have enhanced ratios of AOA, thereby excluding a potential role of high FSH values; (ii) by analysing the factors time and surgery; no relation could be found either with the duration of amenorrhoea (6 months to 21 years) or with the history of an ovarian biopsy (12/47) in the absence of any associated pelvic surgery; and (iii) by screening for other immunological factors; familial or personal autoimmune disease (8/46), HLA DR3 (10/42), HLA DR4 (11/42), associated autoantibodies (thyroperoxidase, adrenal, beta islets, parathyroid, DNA, smooth muscles) (12/42). If one positive AOA isotype was present, a second immunological factor was found in 45% of cases. Spontaneous pregnancies during oestrogen therapy occurred in four cases, including three women with positive AOA. Circulating AOA detected by an ELISA may represent a practical and suitable marker for diagnosis of POF. Its use for prognosis and rational treatment needs further evaluation.

Circulating ovarian autoantibodies and FSH and LH levels in adolescent girls with primary menstrual cycle disorders

Seventy three adolescent patients with primary menstrual disturbances were studied by immunofluorescent methods for prevalence of ovarian autoantibodies (O-Ab), the enzyme immunoassay (EIA) method for examination of follicle-stimulating hormone (FSH) and luteinizing hormone (LH) hormonal levels was used. Clinically healthy girls (40) served as controls. Patients were divided into a group of 13 girls with primary amenorrhea (PA) and a group of 60 girls with oligo and/or secondary amenorrhea (OSA). In the PA group 38.5% positivity linked to ooplasm (OO), zona pellucida (ZP), and membrana granulosa cells (MG), as well as 46.2% to theca folliculi interna (TI) and 53.8% to lutein cells (LC), was detected. Statistically significant differences (p < .05) of LH levels between OO immunopositive and negative girls (19.0 and 9.4 mU/ml) were found, while FSH values were not different. In the OSA group a 16.7% positivity linked to OO, 23.3% to ZP and MG, 38.3% to TI, and 58.3% to LC were detected. Significant linkage between MG immunopositive and negative girls and FSH:LH ratio values were estimated. FSH values were significantly different (p < .05) for PA and OSA groups (23.7 and 6.7 IU/l) which corresponded particularly with higher findings of Ab in germ line-cells (OO-, ZP-, and MG-Ab). A striking correlation between evidence of O-Ab and menstrual cycle irregularities was found. It could support a possible coincidence of autoimmune mechanism in these dysfunctions. Localization of O-Ab-binding was verified at the electron microscopic level.

Detection of antibodies to ovarian antigens in women with premature ovarian failure

Premature ovarian failure is a common condition of uncertain aetiology in most cases, although autoimmunity is thought to play a role in a proportion of cases. The frequency of ovarian antibodies, which may be markers for an autoimmune aetiology in this condition, remains unclear. To define this further, we have examined the sera of 45 women with premature ovarian failure (five with iatrogenic ovarian failure, nine with an associated autoimmune disease, and 27 with idiopathic ovarian failure), as well as four women with infertility due to Turner's syndrome and 41 pre- and post-menopausal controls. Using two human ovarian antigen preparations, 24% and 60% of the ovarian failure patients reacted in an ELISA (P < 0.05 and P < 0.001 compared with controls), but frequent cross-reactivity was found with fallopian tube antigens. The apparent aetiology of ovarian failure did not correlate with the presence of ovarian antibodies. Using bovine ovary as an antigen, there was a significant overall increase in binding by the ovarian failure patients, but this was almost identical to binding in an ELISA with bovine fallopian tube. In contrast to a previous report, there was no significant increase of binding to soluble or Triton-extracted membrane fractions of bovine corpora lutea containing the LH/hCG receptor by the patients with ovarian failure. These results suggest that ovarian antibodies are common in premature ovarian failure, but their specificity and pathogenic role are questionable.

Menopause before 40--premature, but not always permanent

Seventy-five women with premature menopause presented to a reproductive endocrinologist over a 3-year interval. Thirty-five had an identifiable cause, usually a chromosomal defect, autoantibodies or cytotoxic chemotherapy. Forty had no apparent cause and of this group 5 conceived on hormone replacement therapy (HRT). Overall, this group of oestrogen deficient women had spent nearly half of their menopausal years to date, not on HRT.

Autoimmune oophoritis: a clinicopathologic assessment of 12 cases

Twelve cases of histologically confirmed autoimmune oophoritis are described. Eight presented with symptoms and laboratory evidence of premature ovarian failure (POF). Four were diagnosed unexpectedly after hysterectomy for endometrial pathology or for sequelae of cystic enlargement of the ovaries. Two of eight patients tested had serum anti-ovarian autoantibodies (Aab), while five of seven had anti-adrenal Aab. Two women had, or subsequently developed, Addison's disease, and two patients had Hashimoto's disease at presentation. All women with this disease risk the development of adrenal failure and hypothyroidism. Microscopically, 11 cases showed a lymphoplasmacytic infiltrate that spared primordial follicles but involved, with progressive intensity, early and late preovulatory follicles and corpora lutea. Sparse perivascular and perineural inflammatory infiltrates were also present. The twelfth case appeared to be a unique case of granulomatous oophoritis, considered autoimmune because of the folliculotropic nature of the inflammatory process. Three cases showed evidence of follicular dysplasia.

Immunochemical and biological characteristics of a human autoantibody to human chorionic gonadotropin and luteinizing hormone

Anti-hCG/LH autoantibodies were found in the serum of an infertile woman a few days after an abortion which occurred after 46 days of amenorrhea. The antibody titer increased for approximately 4 more weeks, and then declined to low levels during a 14-month anovulatory period, after which regular menses resumed. Immunoglobulins isolated from a pool of serum obtained during the postabortion period neutralized the activity of both hCG and LH in an in vivo bioassay, and the binding affinity of the antibodies toward both hormones was high. When menses were resumed, there was a considerable reduction of the affinity toward LH. The variations in antibody titers and/or affinities can explain the sequence of fertilization, abortion, anovulatory period, and normalization of menses.

Implications of circulating autoantibodies and peripheral blood lymphocyte subsets for the genesis of premature ovarian failure

Several kinds of circulating autoantibodies and peripheral blood lymphocyte subsets were studied in 20 patients with secondary amenorrhea manifesting hormonal and clinical features of premature ovarian failure (POF). More than one kind of autoantibody was detected in 14 patients (70%). Seven patients (35%) had anti-thyroglobulin antibody, 6 (30%) had anti-parietal cell antibody, 8 (40%) had anti-nuclear antibody, and one patient with chronic thyroiditis had anti-TSH receptor antibody. Anti-adrenal cortex antibody and RA test were negative in all patients. Two patients had clinically evident autoimmune disease; one had myasthenia gravis and the other had chronic thyroiditis. Examination of peripheral blood lymphocyte subsets of 19 patients by flow cytometry revealed an increase in the percentage of OKT3+ cells and OKT4+ cells and a decrease in OKT8+ cells in POF patients compared with age-matched controls, but these differences were not significant. An increase in the OKT4/OKT8 ratio was, however, significant. It has been suggested that an autoimmune mechanism may participate in the genesis of POF, at least in patients with autoimmune diseases; however, the findings in this study support the hypothesis that some pure POF may also be caused by an autoimmune process resulting from a subclinical imbalance in the immunoregulatory system before manifestation of the autoimmune disease.

Amenorrhea after immunosuppressive treatment of multiple sclerosis

Interviews on changes in the menstrual cycle were taken from 38 women of fertile age, several years after immunosuppressive treatment (IS) with prednisone and cyclophosphamide (CP) for definite multiple sclerosis (MS). Serum FSH, LH and 17-beta-oestradiol levels were determined at the time of interview. MS in itself did not change the experience of menstrual cycles; 17 patients developed hypergonadotrophic amenorrhea during or after IS. Symptoms related to climacterium (c. q. flushing) were present in 15 of these patients. The onset of amenorrhea depended on the age at the time of IS and on the cumulative dose of CP. Older patients developed amenorrhea at a lower cumulative dose of CP than did younger patients. High estrogen oral contraceptives are advocated in oncology to prevent disturbance of ovarian function by anti-mitotic treatment. This policy is advisable in female MS patients treated with drugs like CP or azathioprine.

Hypergonadotropic amenorrhea--etiology and outcome in 93 young women

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

Persistent progesterone production associated with autoimmune oophoritis. A case report

A woman with autoimmune oophoritis was found to have luteal phase progesterone levels throughout a six-month period of amenorrhea. The common presentation of amenorrhea or metrorrhagia, despite the presence of a corpus luteum, in women with autoimmune oophoritis might result from this chronic progesterone production. A clinical picture consistent with a persistent corpus luteum may be a very early sign of autoimmune oophoritis.

Urticaria associated with antigonadotropin-releasing hormone antibody in a female Kallman's syndrome patient being treated with long-term pulsatile gonadotropin-releasing hormone

The administration of pulsatile gonadotropin-releasing hormone (GnRH) has received increasing attention as a method of inducing ovulation or initiating puberty. Few side effects have been reported, although urticarial allergic reactions have been reported in the male. An 18-year-old female with hypogonadotropic hypogonadism and anosmia due to lack of endogenous GnRH was treated for 230 days using subcutaneous GnRH in an attempt to induce physiologic puberty. Just before anticipated menarche, therapy was discontinued because of the appearance of an urticarial reaction at the injection site as well as at previous injection sites. The presence of immunoglobulin G (IgG) antibodies against GnRH were subsequently identified in the patient's serum. These results further confirm the potential for antibody production to this small natural peptide in the female not previously exposed to GnRH. Some practical considerations for this form of therapy are highlighted.

Elevation of plasma immunoreactive luteinizing hormone releasing hormone in hyperprolactinemic-amenorrheic women on bromocriptine therapy

There is evidence to suggest that abnormalities in the secretion of prolactin (PRL) in patients with the hyperprolactinemia-amenorrhea syndrome are due to hypothalamic dysfunction. In an attempt to further define the inhibitory effect of excessive PRL release on luteinizing hormone releasing hormone (LHRH) and luteinizing hormone (LH) secretory patterns in human plasma, four amenorrheic women with known hyperprolactinemia were studied before and during bromocriptine (BRCR) therapy. Ten-minute blood samples collected with a continuous withdrawal pump for two hours were analyzed for immunoreactive LHRH (IR-LHRH), LH and PRL using previously established radioimmunoassay procedures. Three patients showed a significant rise in mean IR-LHRH plasma levels coincident with a significant decrease in mean PRL concentrations five days to two weeks following BRCR therapy, whereas mean LH titers increased significantly in only one patient. One patient showed no increase in IR-LHRH or LH with BRCR therapy and failed to show a decrease in serum PRL to normal levels after five days of this treatment. A defect in the control of PRL release in these patients seemed to result from the inability of dopaminergic inhibition to be mediated effectively and seemed to be associated with altered secretion of LHRH.

Inhibition of follicle-stimulating hormone receptor binding by circulating immunoglobulins

We have characterized a circulating inhibitor of FSH receptor binding found in two patients with hypergonadotropic amenorrhea and myasthenia gravis. The inhibitor behaves as an immunoglobulin according to several criteria, including precipitation by 30% ammonium sulfate, migration on DEAE-cellulose chromatography, specific binding to protein A-Sepharose, characterization as a 7S protein in sucrose density gradients, and immunoprecipitation with specific antihuman immunoglobulin G. Evidence suggests that these antibodies are directed at determinants on or near the FSH receptor, and they may be responsible for the observed clinical FSH resistance.

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

A woman with myasthenia gravis who developed hypergonadotrophic amenorrhoea was studied. This patient fulfilled all accepted criteria for the diagnosis of the gonadotrophin resistant ovary syndrome: high levels of serum LH and FSH by radioimmunoassay and urinary gonadotrophin excretion by bioassay, low serum oestradiol, lack of response to exogenous gonadotrophin and ovaries with multiple non-stimulated primordial follicles. The serum of this patient contained a substance which behaving like a gamma globulin, inhibited FSH specific binding to receptors in an in vitro system. This inhibitor was looked for in further patients with hypergonadotrophic amenorrhoea, other immunological diseases or myasthenia gravis with normal menses. Ovarian biopsy was not available in these patients. In all except one who also had the association of myasthenia gravis and hypergonadotrophic amenorrhoea, the inhibitor was not detected. It is suggested that development of antibodies directed against gonadotrophin receptors or a receptor related membrane domain may play a role in the mechanism of failure of gonadotrophin stimulation in some patients with the gonadotrophin resistant ovary syndrome.

Secondary amenorrhoea due to autoimmune ovarian failure

A case of spontaneous premature menopause due to autoimmune ovarian failure is described. This report emphasises that this uncommon condition is important to diagnose because of its association with other autoimmune endocrine disorders including Addison's disease. In addition, in the present case, the marked increase in luteinizing hormone with relatively normal follicle stimulating hormone raises the possibility of a non-steroidal inhibitory feedback of follicle stimulating hormone.

Immunofluorescence studies on autoantibodies to steroid-producing cells, and to germline cells in endocrine disease and infertility

This study was aimed at comparing the clinical significance of antibodies to steroid-producing cells with reactions to gonadal germline cells in patients with autoimmune polyendocrine diseases and isolated infertility or amenorrhoea respectively. Indirect immunofluorescence was used on human adrenal, ovary and testis. The gonad substrates were compared with rat, rabbit and monkey glands.

152 adrenal-positive sera were selected from 1030 that had been tested on adrenal cortex. Antibodies to steroid-producing cells in the gonads were found in fifty of these 152 selected cases and were studied in detail. When using human gonads as substrates, steroid-producing-cell antibodies were never detected in the absence of adrenal cortical immunofluorescence, though false-positive reactions were sometimes obtained on rat or rabbit gonads.

Adrenal antibodies as well as those to steroid-producing cells were most frequent in Addisonian cases having one or more additional endocrine disease. The frequency of both types of antibody was lower in patients with Addison's disease and no other disorder but showing evidence of `polyendocrine serology'. Both antibodies were found least frequently when adrenalitis was unassociated with clinical or subclinical autoimmunity in other organs.

We were able to confirm the immunofluorescence patterns described by other authors on adrenal gland and gonads, as well as the independent rise or fall in titre of these two types of antibodies in individual cases with time. Prolonged follow-up of forty-two Addisonian patients showed that adrenal antibodies disappeared in seven instances (17%).

Ovum and sperm antibodies were found in about 25% of infertility cases and a smaller proportion of polyendocrine patients. Germline cell antibodies were rarely associated with other organ-specific reactions. In two cases, amenorrhoea was due to partial pituitary deficiency and the sera of the patients contained antibodies to pituitary prolactin-cells.

Testicular `basement membrane' or `Sertoli-cell' immunofluorescence were each observed in isolated cases and are discussed in relation to known non-organ-specific and heterophile patterns. The significance of zona pellucida fluorescence in relation to blood group substances requires further study on human ova obtained by aspiration from mature Graafian follicles.