Long-term efficacy and safety of asenapine or olanzapine in patients with schizophrenia or schizoaffective disorder: an extension study

INTRODUCTION

Safety and efficacy results, collected in schizophrenia and schizoaffective disorder patients treated for up to nearly 3 years, are presented for asenapine and olanzapine.

RESULTS

Patients completing a 52-week randomized double-blind core study on flexible-dose asenapine (5 or 10 mg BID) or olanzapine (10 or 20 mg QD) could continue treatment until study blind was broken.290 patients on asenapine and 150 on olanzapine continued treatment for variable lengths of time [mean ± SD (range) 311.0 ± 146.1 (10 - 653) d and 327.4 ± 139.6 (15 - 631) d, respectively]. Adverse event (AE) incidence was lower during the extension (asenapine, 62%; olanzapine, 55%) than during the core study (78%, 80%). In both groups, body weight increase and incidence of extrapyramidal AEs were negligible during the extension. Mean PANSS total score changes during first year of treatment were - 37.0 for asenapine and - 35.3 for olanzapine, with further changes of 1.6 for asenapine and - 0.8 for olanzapine at the extension study endpoint.

CONCLUSIONS

Clinical stability on asenapine as well as olanzapine was maintained, with few recurrent or newly emerging AEs beyond 1 year of treatment.

P01-249-Weight change and metabolic effects of asenapine in placebo- or olanzapine-controlled studies

Introduction

Weight change and metabolic effects of atypical antipsychotics vary considerably.

Objective

Assess weight and metabolic effects of asenapine in adults.

Aim

Demonstrate that asenapine marketed doses are well tolerated compared with placebo or olanzapine.

Methods

Data were from pooled asenapine trials that used placebo (1748 patients; duration: 1−6 wk) and/or olanzapine (3430 patients; duration, 3−>100 wk) controls. Asenapine doses were 5 or 10 mg BID (2–20 mg BID in 2 studies); olanzapine doses were 5–20 mg QD. Post hoc inferential analyses based on ANOVA assessed change from baseline weight, body mass index, and fasting lipid and glucose levels.

Results

Table 1 summarizes the results.

Discussion

These post hoc pooled analyses support published reports and suggest asenapine was associated with moderate weight gain and increased fasting triglyceride and glucose levels vs placebo, but lower propensity for weight gain or increased serum lipids (ie, triglycerides, low-density lipoprotein, and cholesterol) vs olanzapine.

Predictive value of menstrual cycle pattern, body mass index, hormone levels and polycystic ovaries at age 15 years for oligo-amenorrhoea at age 18 years

BACKGROUND

On the question of how to counsel adolescents with irregular menstrual cycles or oligomenorrhoea, no clear answer has been given. Adolescents with oligomenorrhoea especially show endocrine abnormalities and may be at risk for ovulatory dysfunction and the polycystic ovary syndrome in adulthood.

METHODS

We followed a cohort of adolescents to document changes in menstrual cycle pattern between ages 15 and 18 years in the general population.

RESULTS

Two per cent (2/128) of adolescents with regular menstrual cycles developed oligomenorrhoea, and 12% (17/148) of those with irregular menstrual cycles did so. Fifty-one per cent (34/67) of the oligomenorrhoeic adolescents remained oligomenorrhoeic. Increase in body mass index (BMI), concentration of LH, androstenedione or testosterone, and polycystic ovaries (PCO) were associated with persistence of oligomenorrhoea. In multivariate analysis only a normal to high BMI (>19.6 kg/m(2)) consistently contributed significantly to predict persistent oligomenorrhoea. Glucose:insulin ratio as a marker for insulin resistance was not associated with an increased risk for oligomenorrhoea.

CONCLUSIONS

Oligomenorrhoea at age 18 years is better predicted by menstrual cycle pattern at age 15 years than by LH or androgen concentrations or PCO at this age. Not only obese, but also normal weight oligomenorrhoeic, adolescents have a high risk of remaining oligomenorrhoeic.

Intercycle variability of ovarian reserve tests: results of a prospective randomized study

BACKGROUND

This study was designed to assess prospectively the intercycle variability (ICV) of basal FSH (bFSH), clomiphene citrate challenge test (CCCT) (analysis of the CCCT was performed by the parameter: sum bFSH + sFSH) and exogenous FSH ovarian reserve test (EFORT) (analysis of the EFORT included the following parameters: estradiol (E(2)) increment and inhibin B increment 24 h after administration of FSH), and secondarily to assess the influence of the variability of these ovarian reserve tests.

METHODS

Eighty-five regularly menstruating patients, aged 18-39 years, participated in this prospective study, randomized, by a computer-designed four-blocks system into two groups. Forty-three patients underwent a CCCT, and 42 patients underwent an EFORT. Each test was performed 1-4 times in subsequent cycles, one test per cycle. During the first three cycles, patients were treated with intrauterine insemination (IUI). Follicle number and oocyte yield during IVF ovarian stimulation in the fourth cycle were taken as measures for ovarian reserve.

RESULTS

The per cycle variance of bFSH ranged from 1.8 to 4.4 (maximum to minimum ratio of 2.44, P < 0.0001), while that of CCCT ranged from 21.3 to 70.6 (3.31, P < 0.0001). No significant change in per cycle variance was found for the E(2) increment (1.25, P > 0.2) and inhibin B increment (1.31, P > 0.2), which were the EFORT parameters. A large ICV of CCCT and bFSH test results was strongly associated with lower ovarian reserve.

CONCLUSIONS

Our study shows that the ICV of the inhibin B increment and the E(2) increment in the EFORT is stable in consecutive cycles, which indicates that this reproducible test is a more reliable tool for determination of ovarian reserve than bFSH and CCCT. Women with limited ovarian reserve show a strong ICV of bFSH and FSH response to clomiphene citrate.

Comparison of endocrine tests with respect to their predictive value on the outcome of ovarian hyperstimulation in IVF treatment: results of a prospective randomized study

BACKGROUND

This study was designed to compare endocrine tests [clomiphene citrate challenge test (CCT), exogenous FSH ovarian reserve test (EFORT) and basal FSH, basal estradiol (E(2)) and basal inhibin B as an integral part of all CCT and EFORT], with respect to their ability to estimate the stimulable cohort of follicles in the ovaries (ovarian capacity) and to analyse which test or combination of tests would give the best prediction of ovarian capacity.

METHODS

A total of 110 regularly menstruating patients, aged 18-39 years, participated in this prospective study, randomized by a computer-designed 4-block system study into two groups. Fifty-six patients underwent a CCT, and 54 patients underwent an EFORT. In all patients, the test was followed by an IVF treatment. The result of ovarian hyperstimulation during IVF treatment, expressed by the total number of follicles, was used as gold standard.

RESULTS

Univariate linear regression analysis showed that the best correlation with the number of follicles after ovarian hyperstimulation (Y) is found by the inhibin B increment (InhB incr.) in the EFORT (Y = 3.957 + 0.081 x InhB incr. (95% CI 0.061-0.101); r = 0.751; P < 0.001). Multiple linear regression analysis showed a significant contributing value of the variables basal FSH, E(2) increment of the EFORT and inhibin B increment to the basic model with the variable age. The best prediction of ovarian capacity (Y) was seen when E(2) increment and inhibin B increment were used simultaneously in a stepforward multiple regression prediction model [Y = 2.659 + 0.052 x InhB incr. (0.026-0.078) + 0.027 x E(2) incr. (95% CI 0.012-0.054); r = 0.796; P < 0.001]. The CCT could not be used in a prediction model.

CONCLUSIONS

The EFORT is the endocrine test which gives the best prediction of ovarian capacity.

Obesity, rather than menstrual cycle pattern or follicle cohort size, determines hyperinsulinaemia, dyslipidaemia and hypertension in ageing women with polycystic ovary syndrome

OBJECTIVE

The aim of this study was to investigate if ageing women with polycystic ovary syndrome (PCOS) who gained regular menstrual cycles differed from women who continued to menstruate irregularly with regard to risk factors for developing diabetes mellitus and atherosclerosis.

DESIGN AND PATIENTS

In the original study of a population of 346 PCOS patients, defined in the past as having oligo- or amenorrhoea and elevated LH concentrations, we had sent out a questionnaire to investigate changes in the pattern of their menstrual cycles while ageing. From this cohort of patients, a significantly older group of 53 women (mean age: 41.3 years, range: 33.3-49.4) who were not using oral contraceptives or other hormones visited the outpatient clinic. These women did not differ from the non-participating group in BMI, ethnic origin, the proportion with regular menstrual cycles by age group, parity or the use of clomiphene citrate or gonadotrophins in the past.

MEASUREMENTS

A physical examination and a transvaginal ultrasound were performed. The size of the follicle cohort was determined by counting the number of small follicles in the ovaries. Thirty-four women were also willing to give two fasting blood samples for measuring their glucose, insulin and lipid status.

RESULTS

Forty-one of the 53 (77.4%) women had a regular menstrual cycle (shorter than 6 weeks) and 12 (22.6%) had an irregular cycle (longer than 6 weeks). The body mass index (BMI), waist: hip ratio (WHR), systolic blood pressure (SBP), diastolic blood pressure (DBP) and prevalence of diabetes (1-9%) and hypertension (11.3%) did not differ between the two menstrual cycle groups. Also, the fasting glucose, insulin, glucose/insulin ratio, total cholesterol, HDL-c, and LDL-c concentrations did not show any significant difference between the two groups. Instead, these parameters all were significantly higher in women with a BMI > 27 kg/M2 compared to women with a BMI < or = 27 kg/m2. Regularly menstruating PCOS women were older (P < 0.01), showed less follicles in their ovaries (n = 48, P < 0.01) and had lower androgens (n = 34, P < 0.05) than the irregularly menstruating women. Logistic regression analysis showed a second significant influence, after age, of the BMI on the menstrual cycle pattern (age, P < 0.01; BMI, P < 0.05). If age was excluded from the analysis, only the follicle count significantly predicted the menstrual cycle pattern (P < 0.02).

CONCLUSIONS

We conclude that hyperinsulinaemia, dyslipidaemia and hypertension in our population of ageing women with polycystic ovary syndrome are not related to the menstrual cycle pattern but rather to obesity. Age and the size of the follicle cohort are the main factors determining the menstrual cycle pattern in ageing women with polycystic ovary syndrome, although an association with the BMI was also found.

The postwash total progressively motile sperm cell count is a reliable predictor of total fertilization failure during in vitro fertilization treatment

OBJECTIVE

To predict the chance of total fertilization failure (TFF) before the day of ovum pickup with known semen and female variables.

DESIGN

A statistical model was constructed to predict TFF by retrospective analysis (2,366 couples) and subsequently tested on a new IVF population (917 couples).

SETTING

Academic tertiary referral center.

PATIENT(S)

Three thousand three hundred eighty-three couples who underwent an IVF-ET treatment.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

The ability to predict the probability of TFF in IVF.

RESULT(S)

Two variables-postwash total progressively motile sperm cell count (postwash TPMC) and number of follicles-were found to be significant. Taking a probability of 25% as an acceptable risk of TFF, we calculated that a postwash TPMC of <1.1 x 10(6) cells results in a risk of TFF of >25%. Low responders (<4 follicles) needed a postwash TPMC of >2.2 x 10(6) cells to reduce the risk of TFF to <25%. High responders (>15 follicles) needed only 0.35 x 10(6) postwash progressively motile spermatozoa.

CONCLUSION(S)

When postwash TPMC and number of follicles are known and an unacceptable TFF outcome is expected, one can propose an ICSI procedure a few days before the day of ovum pickup.

Determination of endometrial prolactin in vivo as a marker for endometrial development in spontaneous ovulatory cycles and in vitro fertilization cycles

Decidual prolactin was directly determined in endometrial tissue in order to assess its potential role in improving the accuracy of the diagnosis of luteal-phase defect (LPD). Endometrial biopsies of 124 women with regular cycles (group 1) and 13 women with controlled ovarian hyperstimulation and progesterone-supported cycles (group 2) were evaluated in the secretory phase. In addition, decidual prolactin was measured in the luteal phase of the in vitro fertilization (IVF) cycles. The biopsies dated on or after day 25 showed a significant increase in the slope of the regression line of the cycle day versus decidual prolactin content (p < 0.05). Delayed endometrium was not characterized by a lower amount of decidual prolactin compared with biopsies with the same histological dating. On day 27 of the cycle, less prolactin was measured in the out-of-phase biopsies (p < 0.05). A large inter-individual variation in endometrial prolactin tissue content was noticed. In group 2 all biopsies but one were in phase. Compared to the in-phase biopsies of group 1, a significantly higher amount of prolactin was found in group 2. Production of endometrial prolactin in vivo is associated with decidualization of the stromal cells. However, because of the large inter-individual variation, determination of prolactin is not of adjuvant diagnostic value for clinical assessment of LPD. Three factors might explain the higher amount of decidual prolactin in group 2 compared to group 1: (1) a higher serum progesterone concentration owing to an increased production by multiple corpora lutea, or because of the administered progesterone; (2) increased estradiol levels and thus progesterone receptors; and (3) direct stimulation of decidualization by gonadotropins.

The rise of estradiol and inhibin B after acute stimulation with follicle-stimulating hormone predict the follicle cohort size in women with polycystic ovary syndrome, regularly menstruating women with polycystic ovaries, and regularly menstruating women with normal ovaries

Polycystic ovaries contain a larger number of antral follicles than control ovaries. The aim of this study was to test whether the increase in estradiol (E(2)) and inhibin B after stimulation with 300 IU recombinant FSH in the early follicular phase and the ovarian volume can predict the size of the follicle cohort in polycystic ovary syndrome (PCOS) patients (n = 10), patients with polycystic ovaries detected by ultrasound but with regular menstrual cycles (PCO; n = 10), and regularly menstruating patients with normal ovaries (n = 10). The follicle cohort size was measured as the FSH-sensitive follicles growing during a standardized in vitro fertilization stimulation. Linear regression analysis showed that the slopes of the regression lines of the E(2) increment and the inhibin B increment in relation to the number of follicles were not significantly different among the three groups, meaning that an increased sensitivity for FSH of the granulosa cells of polycystic ovaries was not found. For the total group (n = 30) we calculated that an E(2) increment of 100 pmol/L predicts 5.5 follicles (95% confidence interval, 2.8--8.2; r = 0.617; P < 0.001), and an inhibin B increment of 100 ng/L predicts 6.2 follicles (95% confidence interval, 3.5--9.0; r = 0.665; P < 0.001). The ovarian volume could not be used in a prediction model because the association with the number of follicles was different in the PCO group compared with the PCOS and the control group. Women with PCO and women with PCOS both had a follicle cohort twice as big as the cohort in control women (P < 0.01). The differences in menstrual cycle pattern between the PCO and PCOS groups cannot be explained by differences in cohort size.

Prevalence of diabetes mellitus, hypertension and cardiac complaints in a follow-up study of a Dutch PCOS population

The aim of this study was to investigate the prevalence of diabetes mellitus, hypertension and cardiac complaints in a Dutch population with polycystic ovarian syndrome (PCOS) and to compare the results with the prevalence of these conditions in the Dutch female population, as retrieved from the Netherlands Health Interview Survey of Statistics Netherlands. A total of 346 PCOS patients were interviewed by telephone, with a mean age of 38.7 years (range 30.3--55.7) and a mean body mass index of 24.4 (range 17.5--55.8). Diabetes occurred in eight (2.3%), hypertension in 31 (9%) and cardiac complaints in three (0.9%) of the women. The prevalence of diabetes and hypertension differed significantly from the prevalence of these conditions in the Dutch female population (both P < 0.05). In PCOS women aged 45--54 years (n = 32) the prevalence of diabetes was four times higher (P < 0.05) and of hypertension 2.5 times higher (P < 0.01) than the prevalence of these conditions in the corresponding age group of the Dutch female population. Hypertension also occurred significantly (P < 0.05) more in the younger (35--44 years) PCOS group (n = 233), but this age group was significantly more obese (P < 0.01) when compared with figures of obesity of the Dutch female population. In conclusion, our data show that in a follow-up study of a relatively lean PCOS population, the prevalence of diabetes mellitus and hypertension was increased when compared with the Dutch female population, especially in women aged 45--54 years.

Dose-finding study of triptorelin acetate for prevention of a premature LH surge in IVF: a prospective, randomized, double-blind, placebo-controlled study

Gonadotrophin-releasing hormone agonists (GnRHa) are routinely used in IVF programmes to prevent an unwanted LH surge and consequent ovulation. Despite its widespread use in IVF, a convincing dose recommendation for GnRHa in IVF does not exist. In our opinion, the lowest possible dose of GnRHa should be used. Thus, we performed a prospective, randomized, double-blind, placebo-controlled study to determine the minimal daily dose of triptorelin acetate needed to suppress a premature LH surge during IVF treatment in a long protocol. A total of 240 women (60 in each group) was randomized to either placebo or to one of three doses of triptorelin, i.e. 15, 50 or 100 microg daily. Ovarian stimulation was performed with two or three ampoules of FSH daily. A premature LH surge occurred in 23% of placebo-treated patients, but in none of the triptorelin acetate-treated patients. There were significantly more oocytes and embryos in the 50 and 100 microg triptorelin groups. There was no dose relationship in rates of either implantation, pregnancy, ongoing pregnancy, live birth or baby take-home. In this study we showed that daily administration of 15 microg triptorelin is sufficient to prevent a premature LH surge, and that 50 microg is equivalent to 100 microg in terms of IVF results.

Predictive value of serum follicle-stimulating hormone levels in the differentiation between hypogonadotropic hypogonadism and constitutional delay of puberty

OBJECTIVE

Gonadotropin secretion was evaluated to predict hypogonadotropic hypogonadism (HH) in 36 children suspected of having HH.

METHODS

LH was measured for 24 h at 10-min intervals, and FSH and estradiol or testosterone at 1-hour intervals. Twenty boys (age 15.7, range 13.2-19.3 years) and 16 girls (age 16.1, range 13.0-20.6 years) were studied.

RESULTS

LH pulses were detected in 9 boys and 5 girls. HH was confirmed in all 11 LH apulsatile boys and in 8 of 11 LH apulsatile girls. Random FSH values of < or =1.11 and < or =2.86 IU/l in boys and girls, respectively, discriminated patients with LH pulses from patients without (sensitivity for lack of LH pulses 97 and 100%, respectively). In boys testicular volume was not discriminatory. In 1 girl LH pulses were observed without estradiol production, suggesting LH neurosecretory dysfunction.

CONCLUSIONS

Low FSH levels in adolescence are strongly related to a lack of LH pulses. Lack of LH pulses is highly suspect for HH. FSH may be a tool in the differentiation between HH and delayed puberty.

Direct ovarian effects and safety aspects of GnRH agonists and antagonists

In in-vitro fertilization programmes, gonadotrophin releasing hormone (GnRH) agonists are now routinely used in order to prevent the undesired pre-ovulatory spontaneous luteinizing hormone surge. The first publications are now appearing in which GnRH antagonists are used with the same purpose. More attention should be addressed to the safety aspects of these drugs. This review aims to summarize studies on direct ovarian effects of GnRH agonists and GnRH antagonists in non-primates and primates with respect to the functional and morphological aspects in-vitro as well as in-vivo. We conclude that there is a wide variety of functional and morphological effects of GnRH analogues on the ovary. The sometimes paradoxical effects indicate that a variety of factors may be involved in the various processes. Those factors are: (i) the type and dose of the analogue, (ii) the different regimens of administration, (iii) ovarian status at the time of exposure, (iv) ovarian cell types in in-vitro systems, (v) hormonal pre-treatment of these cultures, (vi) the type of hormonal stimulation added to the in-vitro culture, (vii) further methodological differences in the experiments and finally (viii) physiological variations in GnRH receptor abundance which depends on species and/or timing in the cycle. With the increasing number of patients using GnRH analogues in assisted reproduction treatments, there will be an increasing number of pregnancies exposed to these drugs. So far, there does not appear to be an increased risk of birth defects or pregnancy wastage in human pregnancies exposed to daily low-dose GnRH agonist therapy in the first weeks of gestation.

Measuring apoptosis in human spermatozoa: a biological assay for semen quality?

OBJECTIVE

[1] To determine whether apoptosis can be measured in ejaculated spermatozoa by flow cytometry using the Annexin V assay, which measures expression of phosphatidylserine on the outer leaflet of the cell membrane, or the TUNEL (terminal deoxynucleotidyl transferase-mediated dUTP [deoxy-uridine triphosphate] nick end labeling) assay, which measures occurrence of DNA strand breaks and [2] to correlate the outcome with routine semen variables and the hypoosmotic swelling (HOS) test.

DESIGN

Pilot study and clinical trial.

SETTING

Large teaching hospital and fertility center.

PATIENT(S)

Men whose semen was studied for various reasons.

MAIN OUTCOME MEASURE(S)

Percentage of apoptotic spermatozoa by two different assays, percentage of necrotic spermatozoa, concentration and motility of spermatozoa, and outcome of the HOS test.

RESULT(S)

Apoptosis can be measured in spermatozoa by flow cytometry using the Annexin V assay and the TUNEL assay. Twenty percent of spermatozoa were apoptotic according to both assays. A significant inverse correlation was seen between phosphatidylserine expression (Annexin V assay) and sperm concentration (r = -0.389; P<.05) and motility (r = -0.289; P<.05). A highly significant inverse correlation was seen between DNA double-strand breaks (TUNEL assay) and sperm concentration (r = -0.629; P<.0001).

CONCLUSION(S)

Flow cytometry can easily and reliably detect phosphatidylserine expression on the outer leaflet of the cell membrane and DNA strand breaks, both of which are hallmarks of apoptosis. About 20% of ejaculated spermatozoa are apoptotic, and the concentration of spermatozoa is lower in men with more apoptotic spermatozoa.

Polycystic ovaries in adolescents and the relationship with menstrual cycle patterns, luteinizing hormone, androgens, and insulin

STUDY OBJECTIVE

To evaluate the possible role of inappropriate LH secretion, hyperandrogenism, and hyperinsulinemia in the development of polycystic ovaries (PCO) and the polycystic ovary syndrome.

DESIGN

Observational.

SETTING

General population samples.

PARTICIPANTS

58 adolescents with regular menstrual cycles, 50 with irregular menstrual cycles, and 29 with oligomenorrhea (age 16.7+/-0.9 years).

INTERVENTIONS

Transabdominal pelvic ultrasonography and vena puncture.

MAIN OUTCOME MEASURES

PCO; LH, androstenedione, and testosterone levels; overnight fasting insulin concentrations; and oligomenorrhea.

RESULTS

The prevalence of PCO increased significantly with the irregularity of the menstrual cycle pattern, as illustrated by the study, finding PCO in 9% of the girls with regular menstrual cycles, 28% of those with irregular menstrual cycles, and 45% of oligomenorrheic girls. The LH and androgen concentrations were significantly higher in girls with PCO; the insulin levels and the glucose-insulin ratio did not differ when the girls with PCO were compared with girls with normal ovaries. Oligomenorrheic girls with PCO had the highest androgen and LH concentrations; their insulin concentrations and glucose-insulin ratio were in the same range as girls with regular menstrual cycles and normal ovaries; and both their hip and waist girths were wider, although their waist-hip ratio was normal.

CONCLUSIONS

PCO in adolescents is associated with irregular menstrual cycles, oligomenorrhea, and/or high androgen and LH levels; but no relationship was found with the insulin level or glucose-insulin ratio. Thus, it is doubtful that hyperinsulinemia is an important factor in the development of PCO or polycystic ovary syndrome.

Elevated FSH concentrations in imminent ovarian failure are associated with higher FSH and LH pulse amplitude and response to GnRH

Imminent ovarian failure (IOF) in women is characterized by regular menstrual cycles and elevated early follicular phase FSH. This study explored underlying neuroendocrine causes of elevated FSH concentrations on day 3 of the menstrual cycle. The characteristics of episodic secretion of FSH and LH, the pituitary response to gonadotrophin-releasing hormone (GnRH), plasma oestradiol, and dimeric inhibin A and inhibin B on day 3 were compared in 13 women with elevated FSH concentrations (>10 IU/l) and 16 controls. FSH amplitudes were higher in the IOF group than in the controls (P < 0. 0001). The FSH pulse frequency did not differ between groups. The FSH response to GnRH was higher in the IOF patients than in the controls (P < 0.0001). Mean LH, LH amplitude and LH response to GnRH were higher in the IOF group, but LH pulse frequency did not differ between the groups. Concentrations of inhibin A and inhibin B were lower in the IOF group, while oestradiol showed no differences. We concluded that in women with IOF, the pituitary is more sensitive to GnRH. This leads to higher FSH and LH pulse amplitudes which underlie the elevated FSH concentrations in the early follicular phase.

Incipient ovarian failure and premature ovarian failure show the same immunological profile

PROBLEM

Incipient ovarian failure (IOF) is characterized by regular menstrual cycles, infertility and a raised early-follicular FSH in women under 40. IOF might be a precursor or a mitigated form of premature ovarian failure (POF). Disturbances in the immune system may play a role in ovarian failure.

METHOD OF STUDY

Autoantibodies and lymphocyte subsets were determined in 63 POF patients, 50 IOF patients, and 27 controls.

RESULTS

The prevalence of autoantibodies did not differ between the groups. There was a statistically significant difference in lymphocyte subsets between the control group and the POF group, with the IOF group taking an intermediate position. We found a decrease in percentage of T-suppressor cells with a rise in T-helper/T-suppressor cell ratio, a decrease in natural killer cells, and an increase in B lymphocytes and HLA-DR positive T cells.

CONCLUSIONS

These data support the concept that IOF is a mitigated form of POF. The question remains whether these changes are the cause or the consequence of the ovarian failure.

Insulin, androgen, and gonadotropin concentrations, body mass index, and waist to hip ratio in the first years after menarche in girls with regular menstrual cycles, irregular menstrual cycles, or oligomenorrhea

Data on changes in hormone concentrations during the first years after menarche are scarce. We studied the relation between gynecological age (age minus age at menarche), hormone concentrations, and body measurements from the lst to the 6th yr after menarche in 229 observations of girls with regular menstrual cycles, 157 observations of girls with irregular menstrual cycles, and 104 observations of girls with oligomenorrhea. Body Mass Index, waist circumference, hip circumference, LH, androstenedione, testosterone, and dehydro-epiandrosterone sulphate increased significantly (linear regression, P < 0.05) by gynecological age in all menstrual cycle pattern groups. For PRL and estradiol a significant increase with gynecological age was only documented in the regular menstrual cycle group and for waist to hip ratio only in the irregular menstrual cycle group. No significant correlation could be documented between gynecological age and overnight fasting insulin concentrations or glucose to insulin ratio. We found no significant correlation between insulin concentrations or glucose to insulin ratio and androgen concentrations. Significant positive correlations were found between LH and androgens. LH and androgen levels increase during the first years after menarche, and reference values should be adjusted for gynecological age. In these years, no significant correlation between hyperinsulinemia and hyperandrogenemia could be documented.

In-vitro fertilization in a spontaneous cycle: easy, cheap and realistic

The results of in-vitro fertilization in natural cycles (NIVF) in women with tubal infertility at our department are presented. The study had a prospective design. We needed 75 cycles in 50 patients to obtain one oocyte from each patient. Successful oocyte recovery rate was 67% per started cycle and 82% per oocyte retrieval. Thirty-five embryos were transferred and resulted in four ongoing pregnancies (5.3% per cycle, 6.5% per oocyte retrieval, 11.4% per embryo transfer and 11.4% per embryo). Six patients who participated in the study made a second attempt at NIVF. Five of them conceived of which four were ongoing. Cumulative ongoing pregnancy rates are 9. 8% per cycle, 11.9% per oocyte retrieval, 19.5% per embryo transfer and 19.5% per embryo. We conclude that NIVF is an easy, cheap and realistic method to obtain a pregnancy for patients with tubal infertility.

Intrauterine insemination or in-vitro fertilisation in idiopathic subfertility and male subfertility: a randomised trial and cost-effectiveness analysis

BACKGROUND

Couples affected by idiopathic subfertility or male subfertility have an estimated spontaneous conception rate of about 2% per cycle. Although various infertility treatments are available, counselling of a couple in their choice of treatment is difficult because of the lack of consistent data from good-quality comparative studies. We compared the results of treatment with intrauterine insemination (IUI) with those of in-vitro fertilisation (IVF), and did a cost-effectiveness analysis.

METHODS

In a prospective, randomised, parallel trial, 258 couples with idiopathic subfertility or male subfertility were treated for a maximum of six cycles of either IUI in the spontaneous cycle (IUI alone), IUI after mild ovarian hyperstimulation, or IVF. The primary endpoint was a pregnancy resulting in at least one livebirth after treatment. Cost-effectiveness based on real costs was studied by Markov chain analysis.

FINDINGS

86 couples were assigned IUI alone, 85 IUI plus ovarian hyperstimulation, and 87 IVF. Ten couples dropped out before treatment began. Although the pregnancy rate per cycle was higher in the IVF group than in the IUI groups (12.2% vs 7.4% and 8.7%, respectively; p=0.09), the cumulative pregnancy rate for IVF was not significantly better than that for IUI. Couples in the IVF group were more likely than those in the IUI groups to give up treatment before their maximum of six attempts (37 [42%] drop-outs vs 13 [15%] and 14 [16%], respectively; p<0.01). The woman's age was the only factor that influenced a couple's chance of success. IUI was a more cost-effective treatment than IVF (costs per pregnancy resulting in at least one livebirth 8423-10661 Dutch guilders [US$4511-5710] for IUI vs 27409 Dutch guilders [US$14679] for IVF).

INTERPRETATION

Couples with idiopathic or male subfertility should be counselled that IUI offers the same likelihood of successful pregnancy as IVF, and is a more cost-effective approach. IUI in the spontaneous cycle carries fewer health risks than does IUI after mild hormonal stimulation and is therefore the first-choice treatment.

Women with polycystic ovary syndrome gain regular menstrual cycles when ageing

The aim of this study was to investigate if previously oligo- or amenorrhoeic polycystic ovary syndrome (PCOS) patients gain regular menstrual cycles when ageing. Women registered as having PCOS, based on the combination of oligo- or amenorrhoea and an increased LH concentration, were invited by letter to participate in a questionnaire by telephone. In this questionnaire we asked for the prevalent menstrual cycle pattern, which we scored in regular cycles (persistently shorter than 6 weeks) or irregular cycles (longer than 6 weeks). We interviewed 346 patients of 30 years and older, and excluded 141 from analysis mainly because of the use of oral contraceptives. The remaining 205 patients showed a highly significant linear trend (P < 0.001) for a shorter menstrual cycle length with increasing age. Logistic regression analysis for body mass index, weight loss, hirsutism, previous treatment with clomiphene citrate or gonadotrophins, previous pregnancy, ethnic origin and smoking showed no influence on the effect of age on the regularity of the menstrual cycle. We conclude that the development of a new balance in the polycystic ovary, solely caused by follicle loss through the process of ovarian ageing, can explain the occurrence of regular cycles in older patients with PCOS.

Bromocriptine-induced premature oestrus is associated with changes in the pulsatile secretion pattern of follicle-stimulating hormone in beagle bitches

The secretory profiles of LH and FSH were investigated before and during the administration of bromocriptine in six beagle bitches. Plasma samples were obtained via jugular venepuncture at 10 min intervals for 6 h every 2 weeks until the next ovulation. Bromocriptine treatment was started 100 days after ovulation. Both before and after bromocriptine treatment, LH and FSH pulses occurred together. The mean duration of the FSH pulse (120 min) was significantly longer than that of the LH pulse (80 min). The interoestrous interval in the bitches treated with bromocriptine was significantly shorter than that of the preceding cycle (160 +/- 3 versus 206 +/- 24 days). The mean basal plasma FSH concentration (7.4 +/- 0.6 versus 6.1 +/- 0.7 iu l-1) and the mean area under the curve for FSH (46.6 +/- 4.7 versus 40.4 +/- 4.4 iu l-1 in 6 h) increased significantly after the start of the bromocriptine treatment. In contrast, the differences in mean basal plasma LH concentration (2.1 +/- 0.2 versus 2.0 +/- 0.2 micrograms l-1) and the mean area under the curve for LH (19.0 +/- 3.1 versus 19.5 +/- 2.5 micrograms l-1 in 6 h) between the day before and 14 days after the start of the bromocriptine treatment were not significant. Bromocriptine administration also lowered the mean amplitude of the FSH pulse and shortened the mean duration of the FSH pulse, without influencing the LH pulse. In addition to demonstrating the concurrent pulsatile secretion of LH and FSH, the results of the present study demonstrate that the bromocriptine-induced shortening of the interoestrous interval in the bitch is associated with an increase in plasma FSH concentration without a concomitant increase in plasma LH concentration. This finding indicates that treatment with the dopamine agonist bromocriptine increase plasma FSH to a concentration that results in the enhancement of follicle development.

Successful in-vitro fertilization in a natural cycle after four previously failed attempts in stimulated cycles: case report

A case is reported of successful in-vitro fertilization (IVF) and pregnancy in a natural cycle after four previously failed attempts with stimulated cycles. The patient began treatment at the age of 36 years and underwent four stimulated IVF cycles, each time with three embryos of good quality transferred. In one attempt, three cryopreserved embryos were transferred in a natural cycle. The patient failed to conceive. At the age of 38 years, the patient was entered into a natural cycle IVF programme. The patient conceived twice in each of her first two attempts but unfortunately aborted. In her third natural cycle of IVF, again with one oocyte obtained and one embryo transferred, the patient conceived and had a full term gestation. It is concluded that IVF in a natural cycle is a viable option for infertile women with blocked Fallopian tubes who have normal ovulatory menstrual cycles.

GH substitution does not alter the pulsatile pattern of LH in amenorrhoeic growth hormone deficient women

OBJECTIVE

GH substitution in GH-deficient (GHD) children promotes pubertal development. In some GHD women, secondary amenorrhoea occurs after discontinuation of GH treatment. This study was designed to investigate whether GH substitution directly influences the GnRH pulse generator. For this reason, the pulsatile release of LH was studied in amenorrhoeic GHD women before and during GH substitution.

DESIGN

GH deficiency was confirmed by an insulin tolerance test. During a 24-h period, blood samples were drawn every 10 min for determination of LH, FSH and GH levels. Oestradiol and IGF-1 were determined at 1000 h and 2200 h. After the first test day, patients started with GH substitution, 0.25 IU/kg/week. During month 6 of GH treatment, the 24 h blood sampling was repeated.

SUBJECTS

Ten amenorrhoeic GH-deficient women participated in the trial. All were diagnosed as GH deficient during childhood or adolescence. Eight of them had been treated with GH during childhood. Seven women suffered from primary amenorrhoea and three from secondary amenorrhoea. Six women were started with GH substitution after the first test day (according to randomization in a larger study).

MEASUREMENTS

LH and GH were determined every 10 min and FSH every 60 min. LH pulse detection was conducted using a validated statistical method.

RESULTS

Prior to GH treatment, the LH pulse interval did not show a diurnal pattern as found during normal pubertal development. During GH treatment, IGF-1 levels rose significantly. No differences were found in mean LH, LH pulse amplitude and LH pulse interval before and during GH treatment. Oestradiol levels did not change either.

CONCLUSIONS

GH substitution in amenorrhoeic GH-deficient women does not alter the pulsatile pattern of LH. This may suggest that GH treatment does not influence central nervous system control of gonadotropin secretion in GHD patients.

Premature ovarian failure: a systematic review on therapeutic interventions to restore ovarian function and achieve pregnancy

Infertility is an important issue for patients with premature ovarian failure (POF). Although oocyte donation offers an alternative method to achieve a pregnancy, many patients seek to reproduce with their own gametes. We performed a literature search to evaluate the possibility of pregnancy following diagnosis, and the additional value of treatment strategies. We found 52 case reports, eight observational studies, nine uncontrolled studies and seven controlled trials. Due to a strong variability in study design, patient selection and mode of intervention, it was not possible to combine the data of the seven studies to perform a meta-analysis. None of the studies showed a statistically significant difference between both (or more) study groups. Due to a lack of incorporation of a placebo group, preference of any treatment over no treatment could not be established. Importantly, the collected data of observational, uncontrolled and controlled studies indicate that POF patients still have a 5-10% chance to conceive following diagnosis. Approximately 80% of the reported pregnancies resulted in the birth of a healthy child. There is no evidence that any treatment can enhance this pregnancy rate.

Endocrine features of polycystic ovary syndrome in a random population sample of 14-16 year old adolescents

Hospital based studies have shown that oligomenorrhoeic adolescents have high luteinizing hormone (LH) and androgen concentrations, endocrine signs of polycystic ovary syndrome (PCOS). The prevalence of these abnormalities in an unselected population of adolescents is not known. We determined LH, follicle stimulating hormone (FSH), androstenedione, testosterone, dehydroepiandrosterone sulphate (DHEAS), oestradiol and prolactin concentrations in unselected population samples of adolescents with oligomenorrhoea, secondary amenorrhoea and regular menstrual cycles. A total of 2248 white, west European adolescents, aged 15.3 +/- 0.6 (mean +/- SD) years, participated. Blood was taken from 107 adolescents with regular menstrual cycles, 52 with oligomenorrhoea and four with secondary amenorrhoea. Oligomenorrhoeic adolescents had higher mean LH, androstenedione, testosterone, DHEAS and oestradiol concentrations compared with girls with regular menstrual cycles; 57% of the oligomenorrhoeic girls had LH or androgen concentrations above the 95th centile of adolescents with regular menstrual cycles. None of the 52 oligomenorrhoeic girls and only one of four girls with secondary amenorrhoea had a hypogonadotrophic endocrine pattern. The present study and available literature support the view that oligomenorrhoea in adolescents is not a stage in the physiological maturation of the hypothalamic pituitary-ovarian axis but an early sign of PCOS associated with subfertility. Physicians should consider endocrine evaluation before reassuring oligomenorrhoeic girls or prescribing oral contraceptives to these girls.

Variation of luteinizing hormone and androgens in oligomenorrhoea and its implications for the study of polycystic ovary syndrome

We measured luteinizing hormone (LH) and androgen concentrations in patients at different phases of the oligomenorrhoeic cycle and compared the results with those of patients with normogonadotrophic amenorrhoea. Several blood samples separated by >/=7 days were obtained from each of 72 patients with oligomenorrhoea and 18 with normogonadotrophic amenorrhoea. The oligomenorrhoeic cycle was divided into five phases: the postmenstrual phase week 1 (day 1-7) and week 2 (day 8-14), the specific oligomenorrhoeic phase (SOP, day 15 after a menstruation to day 21 before the next menstruation), the possibly peri-ovulatory phase (days 21-11 before menstruation) and the premenstrual phase (days 10-1 before menstruation). Samples obtained in the possibly peri-ovulatory phase were excluded. Within individuals LH concentrations were significantly higher during the SOP than during all other phases of the oligomenorrhoeic cycle (paired t-test, P = 0.0001-0.03). In contrast to the other phases of the oligomenorrhoeic cycle, no significant differences in gonadotrophins, androgen or oestradiol concentrations were found between the SOP and normogonadotrophic amenorrhoea. In oligomenorrhoea timing of blood sampling influences the measurement of LH and androgen concentrations, and the accurate interpretation of these measurements requires that the dates of menstruation both before and after the sample is taken should be known. In patients with oligomenorrhoea blood samples should be obtained during the SOP, when the endocrinology is comparable with that of normogonadotrophic amenorrhoea.

Growth hormone (GH) substitution in hypogonadotropic, GH-deficient women decreases the follicle-stimulating hormone threshold for monofollicular growth

The FSH threshold concept for monofollicular growth (which means that at the time the largest follicle reaches 18 mm there are no other follicles with a diameter of 13-18 mm also present) was used during ovulation induction in hypogonadotropic women, who appeared to be GH deficient. This concept was used to investigate whether 1) GH influences the FSH threshold for monofollicular growth and 2) whether such an influence would depend upon the endogenous GH/insulin-like growth factor I (IGF-I)/IGF-binding protein-3 (IGFBP-3) levels. In six hypogonadotropic women the GH response after an insulin challenge did not exceed 6 microg/L. Patients underwent ovulation induction according to a low dose step-up protocol by hMG during two consecutive cycles. GH substitution was provided only during the second cycle. Except for one GH treated cycle, all cycles were ovulatory. IGF-I levels as well as IGFBP-3 levels significantly increased (P < 0.01) during GH substitution. Monofollicular growth was not achieved in the first cycles. In five of six GH-substituted cycles, monofollicular growth was obtained. FSH threshold levels decreased in all patients during GH substitution. The FSH area under the curve was negatively correlated to IGF-I (r = -0.6; P < 0.05) and IGFBP-3 (r = -0.6; P < 0.05). The results of this study indicate that GH may play a role in the physiological growth of the follicle; most likely this occurs by influencing the IGF-I or IGFBP-3 levels. GH appears to selectively increase the sensitivity of the dominant follicle to FSH, facilitating monofollicular growth.

Fluctuations in CA 125 and CA 15-3 serum concentrations during spontaneous ovulatory cycles

The aim of this study was to investigate cycle dependent changes of serum CA 125 and CA 15-3 concentrations during spontaneous ovulatory cycles. Twenty apparently healthy women with spontaneous menstrual cycles attending our infertility clinic were included. Of these women, 18 had occluded tubes as a result of sterilization. Ovulation was confirmed by luteinizing hormone test and ultrasonography and, to exclude endometriosis, a laparoscopy was performed. Serum samples for CA 125, CA 15-3, 17 beta-oestradiol and progesterone determinations were taken every second day starting on the 2nd day of the cycle until the 7th day of the next cycle. After correction for inter-individual variation in serum concentrations, highest CA 125 concentrations were found during the menstruation. During the follicular and peri-ovulatory phase CA 125 serum concentrations were lowest. For CA 15-3, serum concentrations were not statistically different throughout the cycle. CA 125 and oestradiol concentrations were negatively correlated, CA 15-3 and oestradiol concentrations were positively correlated. Absolute serum concentrations of both CA 125 and CA 15-3 vary among females. Within the female, fluctuations of CA 125 are phase related. In the population studied most of the patients had tubal obstruction and high CA 125 serum concentrations during menstruation, which revokes the theory that the menstrual rise of CA 125 is due only to retrograde menstruation.

Concurrent pulsatile secretion of luteinizing hormone and follicle-stimulating hormone during different phases of the estrous cycle and anestrus in beagle bitches

The 6-h secretory profiles of LH and FSH and the possible concordance between the episodic release of LH and FSH were studied in 6 beagle bitches during early, mid-, and late anestrus and during the follicular and luteal phases of the estrous cycle. Plasma samples were obtained at 10-min intervals via jugular venipuncture. In all stages of anestrus and in the luteal phase, FSH and LH secretion was pulsatile. All FSH pulses coincided with LH pulses. However, the mean duration of the FSH pulse (115 min) was significantly longer than that of the LH pulse (72 min). The basal plasma LH concentration was low compared with the maximum peak levels, whereas FSH pulses were characterized by relatively low peaks compared with the basal levels. In contrast to the basal plasma LH levels and the area under the curve (AUC) for LH, the basal plasma FSH levels and the AUC for FSH increased significantly as anestrus progressed. During the follicular phase, the secretory pattern of LH was characterized by frequent increases of short duration. During this phase, the basal plasma FSH concentration was relatively low, whereas the basal plasma LH level was high in comparison with that in the other phases of the estrous cycle. The luteal phase was characterized by an increased frequency of LH pulses, a shorter duration of the LH peaks, and a tendency to a lower amplitude of both LH and FSH peaks compared with values observed during anestrus. It is concluded that in the bitch, FSH and LH pulses are released in concordance and that progression from early to late anestrus is associated with an increase in basal plasma FSH concentration without a concomitant rise in basal plasma LH concentrations. The latter suggests that in the bitch an increase in circulating FSH should be considered to be a critical event required for the initiation of ovarian folliculogenesis and consequently for the termination of anestrus.

Corticosteroids do not influence ovarian responsiveness to gonadotropins in patients with premature ovarian failure: a randomized, placebo-controlled trial

OBJECTIVE

To determine the effect of corticosteroids on ovarian responsiveness to exogenous gonadotropins in patients with idiopathic premature ovarian failure (POF).

DESIGN

Placebo-controlled, randomized, double-blind, multicenter study.

SETTING

Two tertiary care academic centers for reproductive endocrinology and fertility and two general teaching hospitals.

PATIENT(S)

One hundred patients with idiopathic POF intended to enter the study. The study was discontinued after 36 patients failed to ovulate.

INTERVENTION(S)

Endocrine and immune parameters were tested on days 1 and 15. On day 1, subjects were randomized to receive either 9 mg of dexamethasone daily or placebo. From day 5 onward, 300 IU of hMG daily was added for 10 days in both groups. The dosage of dexamethasone was decreased stepwise in the second week and discontinued after day 15. Patients were monitored by transvaginal ultrasonography and by determining serum E2 levels.

MAIN OUTCOME MEASURE(S)

Ovulation rate. Fifty patients would have to be included in each study group to detect a statistically significant difference of 20% in the ovulation rate between the two groups with alpha = 0.05 and beta = 0.1 (one-tailed test).

RESULT(S)

No ovulation was recorded in the first 36 patients. Interim analysis showed that the 95% confidence intervals of an ovulation rate of 0 were 0-17% for the dexamethasone arm (n = 19) and 0-19% for the placebo arm (n = 17). Because the preset objective (a difference of 20%) would never be reached, the study was discontinued.

CONCLUSION(S)

Corticosteroids do not influence ovarian responsiveness to gonadotropins in patients with idiopathic POF.

The use of oral contraceptives by adolescents for contraception, menstrual cycle problems or acne

BACKGROUND

Oral contraceptives are prescribed as contraception but also as therapy for menstrual cycle disturbances and acne. We studied the prevalence of oral contraceptive (OC) use and the indications to start OC use among adolescents.

METHODS

A cohort consisting of ninth grade secondary school girls (mean age 15.3+/-0.6 (s.d.) years) answered a questionnaire on their menstrual cycle. OC users were asked about duration and reasons for OC-use and the name of the preparation they used. The influence of calendar age, gynecological age and level of education on the prevalence of OC was studied by multiple logistic regression analysis.

RESULTS

The response on the questionnaire was 92%. Of 2248 responders 248 (11%) used oral contraceptives: 74% used low dose 'sub 50' preparations, 3% pills with 50 microg estrogen, 3% tri-phase preparations and 17% pills with antiandrogens. Of girls aged 14, 15 and 16 years 4%, 12% and 28% respectively, used OC. Of the 15-year-olds 31% mentioned contraception as most important reason for OC use, 18% menstrual cycle irregularity, 26% dysmenorrhea, 10% acne and 5% other reasons. Calendar age, gynecological age and level of education were independent variables for OC use in general and for OC use for contraception or dysmenorrhea, but less so for OC use for menstrual cycle irregularity or acne.

CONCLUSIONS

During adolescence low dose OC's were frequently used. In The Netherlands OC use among girls aged 15 and 16 years doubled in comparison with 1982. One third of the adolescent OC-users mentioned contraception as most important reason to start OC. Gynecological age (a determinant of biological maturation), calendar age (a determinant of biological maturation and lifestyle in peer groups), and level of education (a determinant of lifestyle in peer groups) were associated with OC use.

Apoptotic cell death in human granulosa-lutein cells: a possible indicator of in vitro fertilization outcome

OBJECTIVE

To determine whether women who do not conceive during an IVF treatment despite normal FSH levels have a higher rate of apoptosis in their granulosa-lutein cells than women who do conceive.

DESIGN

Prospective.

SETTING

Large teaching hospital and fertility center.

PATIENT(S)

Patients with normal FSH levels undergoing an IVF treatment.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Outcome of the IVF treatment and percentage of apoptotic granulosa-lutein cells.

RESULT(S)

A significantly lower percentage of granulosa-lutein cells were apoptotic in patients who became pregnant compared with those who did not become pregnant. A higher basal FSH level was significantly correlated with the duration of the stimulation, and the number of follicles was significantly inversely correlated with the number of ampules of FSH used and the duration of the treatment. The number of embryos was significantly correlated with the number of oocytes, and significantly inversely correlated with the number of apoptotic granulosa-lutein cells.

CONCLUSION(S)

Fewer granulosa-lutein cells are apoptotic in women who have an ongoing pregnancy after IVF treatment than in women who do not conceive.

Follicle-stimulating hormone measured in unextracted urine: a reliable tool for easy assessment of ovarian capacity

OBJECTIVE

To determine the presence of FSH in unextracted urine of perimenopausal women using a microparticle enzyme immunoassay kit on an AxSYM random access immunoassay analyzer.

DESIGN

Controlled descriptive study.

SETTING

A large teaching hospital and infertility clinic.

PATIENT(S)

Forty perimenopausal women aged 32-55 years admitted to our clinic for a gynecological operation.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Mean serum FSH level and urinary FSH in early-morning urine, in a random void urine sample, and in 24-hour urine on the same day. FSH in urine on the day of excretion and 1 and 4 weeks thereafter, stored under various conditions. FSH in urine before and after extraction.

RESULT(S)

The Pearson's correlation coefficient between mean serum FSH levels and urinary FSH in early morning urine was 0.904, in a random void 0.915, and in 24-hour urine 0.857. Determination of optimal storage conditions revealed that urine was best kept at 4 degrees C without any additive. The correlation between FSH in extracted and unextracted urine was 98.9%.

CONCLUSION(S)

In perimenopausal women, FSH can be reliably measured in unextracted urine. The correlation between urinary FSH and a random void urine sample and mean FSH from a serial serum sample is very high. Urine can be stored for 4 weeks at 4 degrees C without loss of FSH immunoreactivity.

Serological detection of heat shock protein hsp27 in normal and breast cancer patients

Heat shock protein Mr 27,000 (hsp27) is found in many human breast cancer cells and tissues; its expression is associated with the presence of estrogen receptors, lower cell proliferation, and resistance to certain chemotherapies. The purpose of this study was to assess whether hsp27 may be present in sera from women with primary breast cancer and to know whether autoantibodies to hsp27 may be found in these patients. The study was performed by Western blot analyzing sera from 42 normal premenopausal women, 20 normal postmenopausal women, and 36 breast cancer patients. hsp27 was clearly detected in sera by immunoblotting but only after immunoprecipitation. The mean hsp27 levels in cancer patients were higher than in the control patients; however, 66% of the breast cancer patients showed hsp27 within the normal range, indicating low sensitivity. Moreover, cancer patients with metastatic disease did not show significantly higher hsp27 levels than cancer patients without metastases. Serum hsp27 levels did not correlate with the hsp27 levels in tumor tissues detected by immunohistochemistry. Elevated CA 15-3 levels were not associated with high hsp27 values. Autoantibodies against hsp27 were not detected by immunoblotting in normal sera and in sera from breast cancer patients. As a consequence, serological determination of this biomarker is unlikely to be of utility in the detection and follow-up of breast cancer patients.

Gonadotrophin-releasing hormone agonist dose-dependency of pituitary desensitization during controlled ovarian hyperstimulation in IVF

The aim of this study was to find the minimal effective daily s.c. dose of the gonadotrophin-releasing hormone (GnRH) agonist, triptorelin acetate, that suppresses the GnRH-induced release of luteinizing hormone (LH) at time of human chorionic gonadotrophin (HCG) injection and thereby prevents spontaneous LH surges during in-vitro fertilization (IVF) stimulation cycles. Therefore, a double-blind, prospective and randomized titration study was performed. A total of 48 IVF patients were divided into four groups of 12 patients. Each group received a different dose of triptorelin acetate, namely 5, 15, 50 or 100 microg s.c. daily. Standard ovarian stimulation was carried out using urinary follicle stimulating hormone (FSH) preparations. A 500 microg GnRH test was performed 90 min before the HCG injection in order to measure the degree of pituitary desensitization. Spontaneous LH surges were not detected in any of the groups, although three patients in the 5 microg group had ovulated at the time of ovum retrieval. The pituitary LH response to the GnRH test at time of HCG, expressed as area under the curve (AUC), appeared to be dose-dependent. Thus, a daily s.c. dose of 100 microg triptorelin acetate appears to be too high, since adequate desensitization of the pituitary (i.e. no spontaneous LH surge) can be achieved with doses as low as 15 and 50 microg.

Relationship of the menstrual cycle pattern in 14-17 year old old adolescents with gynaecological age, body mass index and historical parameters

In a cross-sectional population-based study the association between the menstrual pattern in ninth grade schoolgirls and calendar age, gynaecological age, body mass index (BMI) and historical parameters was investigated. The survey was held in a combined urban and rural region, south of Amsterdam. A total of 2480 adolescents, mean age 15.3 +/- 0.6 (SD) years, answered a questionnaire: response 92%. The menstrual cycle patterns were categorized to regular menstrual cycles (RMC), irregular menstrual cycles (IMC), oligomenorrhoea, polymenorrhoea, pre-menarche, <6 months after menarche, and oral contraceptive use. Gynaecological age was strongly associated with the prevalence of IMC but only weakly with the prevalence of oligomenorrhoea. In a logistic regression analysis gynaecological age, subjective acne and intellectual performance were independently associated with oligomenorrhoea. Gynaecological age, low BMI, chronic non-specific lung disease (CNSLD) or allergic disease, stress and strain, weight loss of >5 kg were independently associated with IMC. More than 8 h sports per week was associated with not having experienced menarche in the ninth grade but not with menstrual cycle disturbances. The association between CNSLD or allergic disease and IMC has not previously been described. The associations between weight loss, low body weight, stress, physical exercise or signs of hyperandrogenism and menstrual cycle patterns in adolescents are weak when studied on a population basis. The value of these parameters to explain abnormal menstrual cycle patterns is limited.

Octreotide, a somatostatin analogue, alters ovarian sensitivity to gonadotrophin stimulation as measured by the follicle stimulating hormone threshold in polycystic ovary syndrome

The aim of the present study was to determine the effect of octreotide, a somatostatin analogue, on ovarian sensitivity for follicle stimulating hormone (FSH) in patients with polycystic ovary syndrome (PCOS). As the measure of ovarian sensitivity, the FSH threshold was determined in a case-control set-up. Eleven patients with PCOS were treated with FSH in a low dose step-up manner and subsequently received treatment with FSH combined with octreotide. The FSH threshold was found to be significantly higher during combined treatment. This increase was associated with a decrease in insulin-like growth factor-I (IGF-I) and IGF binding protein-3 (IGFBP-3) concentrations during treatment with octreotide, but not with a decrease in insulin concentrations. No differences were found between the two regimens, in number of follicles, in oestradiol concentrations on the day of human chorionic gonadotrophin (HCG) administration or in ovulation rate. With both treatments, there was a very low rate of multifollicular development. It can be concluded that octreotide lowers ovarian sensitivity for FSH through suppression of IGF-I/IGFBP-3 in patients with PCOS. However, this does not appear to affect follicular development during gonadotrophin stimulation, because the latter is controlled to a high degree by the use of a low dose step-up treatment schedule in these patients.

Insulin-like growth factor (IGF)-I and IGF binding protein-3 concentrations in fluid from human stimulated follicles

Insulin-like growth factor-I (IGF-I) and IGF binding protein-3 (IGFBP-3) play an important role in regulating follicle growth and maturation. We have evaluated whether responsiveness to gonadotrophins during an in-vitro fertilization (IVF) treatment is related to follicular fluid IGF-I and IGFBP-3 concentrations. We also investigated if a difference is present in IGF-I and IGFBP-3 concentrations between patients treated with human menopausal gonadotrophin (HMG) and patients treated with highly purified follicle stimulating hormone (FSH). We have measured IGF-I and IGFBP-3 in follicular fluid from pre-ovulatory follicles in an IVF programme. All 70 patients were stimulated after being down-regulated with a gonadotrophin-releasing hormone (GnRH) analogue. IGF-I concentrations in follicular fluid were significantly inversely correlated with the number of ampoules FSH administered and number of days of FSH administration, and significantly correlated with the number of follicles aspirated. IGFBP-3 concentrations were not correlated with any other parameter measured nor were IGF-I and IGFBP-3 concentrations correlated. IGFBP-3 concentrations were significantly higher in patients receiving highly purified FSH compared with patients receiving HMG (P < 0.005). These results are new evidence that IGF-I concentration in follicular fluid is higher in women who respond better to follicular stimulation, i.e. women who grow many follicles, women who need a shorter duration of stimulation and women who need fewer ampoules FSH before oocyte retrieval.

Cohort size rather than follicle-stimulating hormone threshold level determines ovarian sensitivity in polycystic ovary syndrome

The aim of the presented study was to compare FSH threshold levels and ovarian response to stimulation with one of two standard increments of exogenous FSH above the threshold in patients with polycystic ovary syndrome (PCOS) (n = 12) and eumenorrheic women (n = 11). The individual FSH threshold was determined by treatment according to a low-dose, step-up protocol with urinary FSH (Metrodin; Ares Serono, Geneva, Switzerland). In a subsequent treatment cycle, six PCOS patients and six eumenorrheic women were randomly assigned to double-blind treatment with the threshold dose plus 1/2 ampoule; the other six PCOS patients and five eumenorrheic women were treated with 1 ampoule above the threshold dose. Determination of threshold levels showed no significant differences in median and range between PCOS patients and eumenorrheic women. The number of follicles on the day of human chorionic gonadotropin administration showed no significant correlation with the increase in FSH level above the threshold level. Irrespective of the dose given, the number of follicles in the PCOS group was significantly higher than in eumenorrheic women. The higher sensitivity for gonadotropin stimulation in patients with PCOS compared with women with regular menstrual cycles therefore appears not to be dependent on differences in FSH threshold level, but rather on the larger size of the FSH sensitive cohort of small antral follicles.

Increased levels and pulsatility of follicle-stimulating hormone in mothers of hereditary dizygotic twins

According to the endocrine model of hereditary dizygotic twinning, high FSH is responsible for multiple ovulation and pregnancy. Our study explored the underlying neuroendocrine causes. In a prospective clinical study, we compared the third day of menses parameters of episodic secretion of LH and FSH, the pituitary response to LHRH, plasma estradiol, and dimeric inhibin A and B in 16 regularly menstruating and 9 postmenopausal mothers of dizygotic twins with a family history of twinning and 14 premenopausal and 9 postmenopausal controls. Seven of 16 premenopausal mothers of twins had abnormally high FSH levels of more than 10 IU/L compared with 1/14 in controls (P = 0.024). In the premenopausal mothers of twins, mean FSH concentrations (P = 0.025) and FSH pulse frequency (P = 0.003) were significantly elevated, whereas FSH pulse amplitude and FSH response to LHRH were unaltered. For LH, neither the secretory parameters nor the response to LHRH was different. There were no differences between estradiol and inhibin A and B levels. Postmenopausal mothers of twin and controls did not differ with respect to the secretory pattern of LH and FSH. We conclude that under equal ovarian feedback conditions, premenopausal mothers of a dizygotic twin have hyper stimulation by endogenous FSH caused by neuroendocrine, hypothalamic, or pituitary mechanisms. This is the result of altered responsiveness to ovarian feedback and/or pituitary or suprapituitary, non-LHRH-like mechanisms that stimulate pulsatile FSH.

Higher risk of preeclampsia in the polycystic ovary syndrome. A case control study

OBJECTIVE

To determine whether the risk of pregnancy-induced hypertensive disorders (PIHD) is higher in patients with the polycystic ovary syndrome (PCOS) than in non-PCOS controls, matched for age and parity.

STUDY DESIGN

Retrospective analysis of eighty-one patients with PCOS, consecutively becoming pregnant during a seven-year period. Each PCOS-patient was matched for age and parity with one control patient. Chi-squared, Mann-Whitney or Fisher's exact-tests were used for statistical analysis.

RESULTS

Overall incidence of PIHD was similar in both study groups. However, incidence of preeclampsia was significantly higher in patients with PCOS than in controls (P = 0.02). This higher incidence can not be explained by body mass index, endocrine profile before pregnancy, induction of ovulation or treatment regimens.

CONCLUSIONS

PCOS-patients are at a significantly higher risk for preeclampsia than non-PCOS controls.

Hypothetical risks of twinning in the natural menstrual cycle

Dizygotic (DZ) twinning is likely the result of multiple ovulation upon multiple ongoing follicle growth. Well known conditions with an increased incidence of DZ twinning are a hereditary trait, high maternal age and ovulation induction treatments. These conditions are clearly related to elevation of Follicle Stimulating Hormone (FSH) at the time of peri-menstrual follicle recruitment. In this contribution, we summarize certain other circumstances that may occur in normal women that could increase twinning rate based on the assumption that the elevation of FSH levels is the principal underlying mechanism in DZ twinning. It is hypothesized that recovery from prolonged hypothalamic amenorrhea in part mimics hormonal sequelae of puberty characterized by temporary overshoot of FSH levels. By deduction, such conditions are recovery from lactational amenorrhea, recovery from use of oral contraceptives and recovery of weight loss amenorrhea. According to the literature, these conditions indeed carry the risk of DZ twinning and all show temporary elevated FSH levels. However, prospective experiments will be needed to prove the relation between this type of DZ twinning and possible patterns of serum FSH that mimic puberty under these circumstances.