Insuficiencia ovárica primaria en adolescentes: revisión de la literatura a propósito de un caso clínico / Primary ovarian insufficiency in adolescents: review of the literature regarding a clinical case

El objetivo de este manuscrito es realizar una revisión y actualización de la literatura de la insuficiencia ovárica primaria (IOP) en población adolescente, a partir del diagnóstico, manejo y seguimiento de un caso clínico. La insuficiencia ovárica primaria se define como la menopausia en una mujer antes de los 40 años, acompañada de amenorrea, hipogonadismo hipergonadotrópico e infertilidad. Su prevalencia varía entre 1 a 2%, y en mujeres menores de 20 años su prevalencia es un caso de cada 10,000. Aunque se sabe que muchas afecciones pueden llevar a una IOP, la más común es la causa idiopática. La presentación clínica es diversa, y varios trastornos diferentes pueden también, llevar a esta condición. CASO CLÍNICO: Se presenta el caso de una adolescente de 17 años, previamente sana, con historia de amenorrea secundaria, no embarazada, con examen físico general y ginecológico normal. Se solicita estudio analítico complementario resultando con niveles de hormona folículo estimulante (FHS), estradiol (E2) y hormona antimülleriana (AMH) compatibles con una insuficiencia ovárica como la observada en la posmenopausia. Se inicia terapia hormonal (TH) clásica con estradiol y progesterona, siendo posteriormente reemplazada por anticoncepción hormonal combinada (AHC) oral, coincidente con el inicio de vida sexual, con respuesta favorable y sangrados regulares. La IOP tiene graves consecuencias para la salud incluyendo trastornos psicológicos como angustia, síntomas depresivos o depresión, infertilidad, osteoporosis, trastornos autoinmunes, cardiopatía isquémica, y un mayor riesgo de mortalidad. La enfermedad de Hashimoto es el trastorno autoinmune más frecuente asociado a la IOP. Su tratamiento y diagnóstico deben establecerse de forma precoz para evitar consecuencias a largo plazo. La terapia con estrógenos es la base del tratamiento para eliminar los síntomas de la deficiencia de estrógenos, además de evitar las consecuencias futuras del hipogonadismo no tratado. También el manejo debe incluir los siguientes dominios: fertilidad y anticoncepción, salud ósea, problemas cardiovasculares, función psicosexual, psicológica y neurológica, informando a los familiares y a la paciente sobre la dimensión real de la IOP y la necesidad de tratamiento multidisciplinario en muchos casos. CONCLUSIÓN: El caso presentado, pese a ser infrecuente, permite abordar de manera sistematizada el diagnostico de IOP y evaluar alternativas de manejo plausibles para evitar graves consecuencias en la salud, así como conocer respuesta clínica y de satisfacción de la adolescente.

The objective of this manuscript is to review and update the literature on primary ovarian insufficiency (POI) in an adolescent population, based on the diagnosis, management and follow-up of a clinical case. Primary ovarian insufficiency is defined as menopause in a woman before the age of 40, accompanied by amenorrhea, hypergonadotropic hypogonadism, and infertility. Its prevalence varies between 1 to 2%, and in women under 20 years of age its prevalence is one case in every 10,000. Although it is known that many conditions can lead to POI, the most common is the idiopathic cause. The clinical presentation is diverse, and several different disorders can also lead to this condition. CLINICAL CASE: The case of a 17-year-old adolescent, previously healthy, with a history of secondary amenorrhea, not pregnant, with a normal general physical and gynecological examination is presented. A complementary analytical study is requested, resulting in levels of follicle stimulating hormone (FHS), estradiol (E2) and anti-müllerian hormone (AMH) compatible with ovarian insufficiency such as that observed in postmenopause. Classic hormonal therapy (HT) with estradiol and progesterone was started, later being replaced by combined hormonal contraception (CHC), coinciding with the beginning of sexual life, with a favorable response and regular bleeding. POI has serious health consequences including psychological disorders such as distress, depressive symptoms or depression, infertility, osteoporosis, autoimmune disorders, ischemic heart disease, and an increased risk of mortality. Hashimoto's disease is the most common autoimmune disorder associated with POI. Its treatment and diagnosis must be established early to avoid long-term consequences. Estrogen therapy is the mainstay of treatment to eliminate the symptoms of estrogen deficiency, in addition to avoiding the future consequences of untreated hypogonadism. Management should also include the following domains: fertility and contraception, bone health, cardiovascular problems, psychosexual, psychological and neurological function, informing family members and the patient about the real dimension of POI and the need for multidisciplinary treatment in many cases. CONCLUSION: The case, although infrequent, allows a systematic approach to the diagnosis of POI and evaluate plausible management alternatives to avoid serious health consequences, as well as to know the clinical response and satisfaction of the adolescent.

Avaliação da reserva ovariana na predição do mau prognóstico reprodutivo: quando e como investigar / Ovarian reserve evaluation in the prediction of poor reproductive prognosis: when and how to investigate?

Muitas vezes, torna-se um grande desafio para o ginecologista a identificação daquelas com maior ou menor chance de concepção. Vários marcadores laboratoriais e ultrassonográficos, conhecidos conjuntamente como testes de avaliação da reserva ovariana, são estudados há décadas com a intenção de se buscar uma ferramenta para a predição do potencial reprodutivo. E, embora ainda se busquem os marcadores ideais para aplicação clínica, mais difícil do que os definir é definir quando eles estão indicados. Este artigo de atualização, assinado pela Comissão Nacional Especializada em Ginecologia Endócrina da Febrasgo, pretende oferecer ao leitor as ferramentas necessárias para o uso racional dos testes de avaliação da reserva ovariana no cotidiano.(AU)

Often, it becomes a great challenge for the gynecologist to identify women with a greater or lesser chance of conception. Several laboratory and ultrasound markers, known jointly as ovarian reserve evaluation tests, have been studied for decades with the intention of seeking a tool for the prediction of reproductive potential. And, while the ideal markers for clinical application are still sought, defining them is as harder as defining when they are indicated. This update article, signed by the National Specialized Committee on Gynecologic Endocrinology, Febrasgo, intends to offer the reader the necessary tools for the rational use of ovarian reserve evaluation tests in daily practice.(AU)

Utilidad de la determinación de la reserva ovárica como predictor de la posibilidad de embarazo espontáneo: revisión sistemática / Usefulness of determining ovarian reserve as a predictor of the possibility of spontaneous pregnancy: a systematic review

ANTECEDENTES: En la actualidad, muchos especialistas determinan la reserva ovárica para aconsejar a sus pacientes acerca de su futuro reproductivo. OBJETIVO: Definir, a través de una revisión sistemática, si existe evidencia que justifique la determinación de la reserva ovárica como predictor de la posibilidad de embarazo espontáneo. MÉTODO: Realizamos una revisión sistemática usando las palabras claves "ovarian reserve" y "spontaneous pregnancy" en las bases MEDLINE y EMBASE, entre los años 2000 y 2015. RESULTADOS: Sólo tres artículos cumplieron con los criterios de selección. Si bien difieren en la forma de determinar la reserva ovárica y la población analizada, ninguno de los estudios encontró que la determinación de la reserva ovárica tuviera utilidad clínica en predecir la posibilidad de un embarazo espontáneo. CONCLUSIÓN: No existe evidencia que justifique la determinación de reserva ovárica, en forma rutinaria, para aconsejar a las parejas acerca de sus posibilidades de embarazo espontáneo.

BACKGROUND: Many specialists use ovarian reserve tests to determine their patient's reproductive potential. OBJECTIVE: To determine whether the ovarian reserve determine the possibility of spontaneous pregnancy. METHOD: We searched in MEDLINE and EMBASE, articles published between 2000 and 2015, with the keywords "spontaneous pregnancy" and "ovarian reserve". RESULTS: Only three articles complied with the selection criteria. Although the studies have different approaches to evaluate ovarian reserve and study subjects, none of them found that that ovarian-reserve testing have clinical utility in predicting the chance of a spontaneous pregnancy. CONCLUSION: There is no utility to assess ovarian reserve routinely in order to predict chances of spontaneous pregnancy.

Mean anti-Mullerian hormone levels; comparison in fertile and infertile women of reproductive age

To compare the means of Anti-Mullerian hormone levels in both fertile and infertile women.Case-Control study. This study was conducted at infertility clinic of Gynecology and Obstetrics Unit-II, Civil Hospital, Karachi. The total duration of the study was approximately 1 year from October 2011 to October 2012. A total of 52 infertile women attending the Gynae-Unit-II out-patient clinic at Civil Hospital, Karachi and 48 fertile non-pregnant females of reproductive age group i.e. 20-35 years who met the inclusion criteria were included in the study. The serum Anti-Mullerian hormone levels were measured in both the infertile and fertile groups. Blood samples to determine AntiMullerian hormone levels were obtained irrespective of their menstrual cycle days. Independent sample t-test showed decreased mean serum Anti-Mullerian hormone levels in infertile group [cases] than the fertile controls. Mean concentration of serum AntiMullerian hormone in infertile women was significantly lower than that in fertile control women

Anti-Mullerian Hormone Levels in the Follicular Fluid of the Preovulatory Follicle: A Predictor for Oocyte Fertilization and Quality of Embryo

This prospective study investigated the relationship between anti-Mullerian hormone (AMH) level in the follicular fluid (FF) and the quality of the oocyte and embryo. A total of 65 FF samples from 54 women were included in this study. FF was collected from the largest preovulatory follicle sized> or =20 mm of mean diameter from each ovary. Samples were divided into 3 groups according to the FF AMH levels: below the 33th percentile (low group, FF AMH3.6 ng/mL, n=22). The quality of the ensuing oocytes and embryos was evaluated by fertilization rate and embryo score. FF AMH levels correlated positively with the matched embryo score on day 3 after fertilization (r=0.331, P=0.015). The normal fertilization rate was significantly lower in the low group than in the intermediate group (61.9% vs. 95.5% vs. 77.3%, respectively, P=0.028). Our results suggest that the FF AMH level could be a predictor of the ensuing oocyte and embryo quality.

Protocolo largo con análogos de GnRH versus protocolo corto con antagonistas: ¿existen diferencias en cuanto a los resultados de los ciclos de FIV-ICSI? / Protocol with GnRH analogues vs antagonists of GnRH: exist differences in the results of the IVF-ICSI cycles?

Objetivo: Valorar si existen diferencias en los resultados de los ciclos de FIV-ICSI en función del protocolo de estimulación empleado. Método: Estudio retrospectivo descriptivo de pacientes infértiles que fueron sometidas a ciclos de FIV-ICSI en el Hospital Universitario La Paz, entre los meses de enero y septiembre de 2010, comparando un protocolo largo de estimulación con análogos de GnRH vs un protocolo corto con antagonistas de GnRH. Las variables analizadas fueron: tasa de gestación, necesidad de cancelación del ciclo, dosis total de gonadotropinas requerida durante la estimulación, niveles de estradiol sérico el día de la administración de la hCG, número de folículos puncionados, complejos obtenidos, número de ovocitos maduros y de embriones conseguidos. Resultados: No hubo diferencias estadísticamente significativas en los resultados de los ciclos en función del protocolo de estimulación empleado, en ninguna de las variables analizadas. Conclusiones: Este estudio no encontró diferencias en los resultados de los ciclos de FIV-ICSI con relación al uso de análogos o antagonistas de GnRH. Es necesarios más estudios con mayores tamaños muestrales para definir qué tipo de pacientes serían subsidiarias de recibir cada tratamiento para conseguir resultados óptimos.

Aims: To assess if there exist any differences in the results of the IVF-ICSI cycles depending on the stimulation protocol employed. Methods: Retrospective descriptive study of infertile patients who underwent IVF-ICSI cycles at La Paz University Hospital, between January and September 2010, comparing sitmulation protocol with GnRH agonists vs antagonists of GnRH. The variables analyzed were pregnancy rate, cancellation rate, total dose of gonadotropin required for stimulation, serum estradiol levels on the day of hCG administration, number of follicles punctured, complexes obtained, number of mature oocytes and of embryos obtained. Results: No statistically significant differences where found in the results of cycles depending on the protocol of stimulation used in any of the variables analyzed. Conclusions: This study didn't find any difference in the outcome of IVF-ICSI cycles in relation to the use of GnRH agonists or antagonists. We need more studies with larger sample sizes to determine which is the best treatment to each patient in order to achieve optimal results.