Idiopathic gonadotrophin deficiency: genetic questions addressed through phenotypic characterization.

OBJECTIVE: The association of idiopathic hypogonadotrophic hypogonadism (IHH) with congenital olfactory deficit defines Kallmann's syndrome (KS). Although a small proportion of IHH patients have been found to harbour defined genetic lesions, the genetic basis of most IHH cases remains to be elucidated. Genes currently recognized to be involved comprise KAL (associated with X-linked-KS), the GnRH receptor (associated with resistance to GnRH therapy), DAX 1 (associated with adrenohypoplasia congenita) and three loci also associated with obesity, leptin (OB), leptin receptor (DB) and prohormone convertase (PC1). Because of the rarity of the condition and the observation that patients are almost universally infertile without assistance, familial transmission of IHH is encountered infrequently and pedigrees tend to be small. This has constrained the ability of conventional linkage studies to identify other candidate loci for genetic IHH. We hypothesized that a systematic clinical evaluation of a large patient sample might provide new insights into the genetics of this rare disorder. Specifically, we wished to examine the following propositions. First, whether normosmic (nIHH) and anosmic (KS) forms of IHH were likely to be genetically discrete entities, on the basis of quantitative olfactory testing, analysis of autosomal pedigrees and the prevalence of developmental defects such as cryptorchidism and cleft palate. Second, whether mirror movements and/or unilateral renal agenesis were specific phenotypic markers for X-linked-KS. DESIGN AND PATIENTS: We conducted a clinical study of 170 male and 45 female IHH patients attending the endocrinology departments of three London University teaching hospitals. Approximately 80% of data were obtained from case records and 20% collected prospectively. Parameters assessed included olfaction, testicular volume, family history of hypogonadism, anosmia or pubertal delay, and history or presence of testicular maldescent, neurological, renal or craniofacial anomalies. Where possible, the clinical information was correlated with published data on genetic analysis of the KAL locus. RESULTS: Olfactory acuity was bimodally distributed with no evidence for a spectrum of olfactory deficit. Testicular volume, a marker of integrated gonadotrophin secretion, did not differ significantly between anosmic and normosmic patients, at 2.0 ml and 2.2 ml, respectively. Nevertheless, the prevalence of cryptorchidism was nearly three times greater in anosmic (70.3%, of which 75.0% bilateral) than in normosmic (23.2%, of which 43.8% bilateral) patients. Individuals with nIHH, eugonadal isolated anosmia and/or KS were observed to coexist within 6/13 autosomal IHH pedigrees. On three occasions, fertility treatment given to an IHH patient had resulted in the condition being transmitted to the resulting offspring. Mirror movements and unilateral renal agenesis were observed in 24/98 and 9/87 IHH patients, respectively, all of whom were identifiable as X-KS males on the basis of pedigree analysis and/or defective KAL coding sequence. Abnormalities of eye movement and unilateral sensorineural deafness were observed in 10/21 and 6/111 KS patients, respectively, but not in nIHH patients. DISCUSSION: Patients with IHH are almost invariably either anosmic (KS) or normosmic (nIHH), rather than exhibiting intermediate degrees of olfactory deficit. Moreover, the prevalence of cryptorchidism is nearly three times greater in KS than in nIHH despite comparable testicular volumes, suggesting a primary defect of testicular descent in KS independent of gonadotrophin deficiency. Disorders of eye movement and hearing appear only to occur in association with KS. Taken together, these findings indicate a clear phenotypic separation between KS and nIHH. However, pedigree studies suggest that autosomal KS is an heterogeneous condition, with incomplete phenotypic penetrance within pedigrees, and that some cases of autosomal KS, nIHH and even isolated anosmia are likely to have a common genetic basis. The prevalences of anosmia, mirror movements and unilateral renal agenesis among X-KS men are estimated to be 100, 85 and 31%, respectively. In sporadic IHH, mirror movements and unilateral renal agenesis are 100% specific phenotypic markers of de novo X-KS. By comparison, only 7/10 X-KS families harboured KAL coding defects. Clinical ascertainment, using mirror movements, renal agenesis and ichthyosis as X-KS-specific phenotypic markers, suggested that de novo X-KS was unlikely to comprise more than 11% of sporadic cases. The majority of sporadic KS cases are therefore presumed to have an autosomal basis and, hence, the preponderance of affected KS males over females remains unexplained, though reduced penetrance in women would be a possibility.

Postmenopausal hormone replacement therapy and breast cancer.

The concern that postmenopausal hormone replacement therapy (HRT) may cause cancer of the breast has generated much research in epidemiology, endocrinology, and tumor cell biology. The recognition that naturally occurring 17beta-estradiol is a weak genotoxic and mutagenic carcinogen provides a plausible background for the association of breast cancer with HRT. However, because of the small anticipated effect and several confounding factors, the epidemiology of this association is complex. The consensus at this writing is that long-term HRT (>10 years) is associated with an increased risk of breast cancer, which, on average, is equivalent to the risk associated with delaying menopause for the same period of time. The particular risk depends on the duration and probably the dose to which the individual woman is exposed, as well as on a number of predisposing environmental and genetic factors. One clinical implication of the data reviewed here is that the dosage of HRT chosen should be the lowest that produces the desired effect. The use of HRT in women with a history of breast cancer is also addressed. Low-dose estrogen together with a selective estrogen receptor modulator to protect the breast may be a treatment option for women with severe symptoms of estrogen deficiency.

Effects of laparoscopic ovarian drilling on serum vascular endothelial growth factor and on insulin responses to the oral glucose tolerance test in women with polycystic ovary syndrome.

OBJECTIVE: To evaluate the serum vascular endothelial growth factor concentrations and insulin responses to the oral glucose tolerance test before and after laparoscopic ovarian drilling in women with PCOS. DESIGN: Prospective study. SETTING: University teaching center. PATIENT(S): Twenty-seven women with clomiphene citrate-resistant polycystic ovary syndrome. INTERVENTION(S): Laparoscopic ovarian drilling. MAIN OUTCOME MEASURE(S): VEGF levels and insulin responses to OGTT before and after ovarian drilling. RESULT(S): No difference was found in VEGF levels in women with PCOS before (6.0 +/- 1.2 ng/mL) and after ovarian drilling (5.5 +/- 1.2 ng/mL). VEGF levels before and after ovarian drilling in women who conceived were, respectively, 5.9 +/- 1.0 and 5.1 +/- 0.9 ng/mL and in those who did not conceive were 6.0 +/- 1.3 and 5.7 +/- 1.2 ng/mL. No correlation was found between baseline serum insulin and VEGF levels. VEGF concentrations in women with normal ovaries (4.5 +/- 1.7 ng/mL) were significantly lower than in women with PCOS. There was no difference in glucose and insulin responses to OGTT before and after ovarian drilling. CONCLUSION(S): VEGF levels in women with PCOS are higher than in normal women, and ovarian drilling does not affect these levels. The procedure does not change insulin responses to OGTT.

Hormone replacement therapy and breast cancer.

The concern that postmenopausal hormone replacement therapy (HRT) may cause cancer of the breast has lead to an enormous volume of research in epidemiology, endocrinology and tumour cell biology. The epidemiology has become extremely sophisticated because the anticipated effect is small and there are several confounding factors. The consensus today is that long-term HRT (>10 years) is associated with an increase in the risk of breast cancer which, on average, is equivalent to delaying menopause for the same period of time that the patient is on treatment. The risk is related to endogenous and exogenous oestrogen levels. Studies that have investigated individual susceptibility are reviewed, as are environmental factors such as the interaction of HRT with alcohol intake. The clinical implication of these data is that the dosage of HRT should be the smallest that is efficacious. Subcutaneous implants of oestrogen typically cause very high oestrogen levels and, in the opinion of this reviewer, should be restricted to women unable to take or absorb oestrogen by mouth or percutaneously. Finally, the issue of HRT for women with a history of breast cancer is considered. The potential is discussed for treatment of women with severe symptoms of oestrogen deficiency with a low dose of oestrogen, together with a selective oestrogen receptor modulator to protect the breast.

Follicle-stimulating hormone or human menopausal gonadotropin for ovarian stimulation in in vitro fertilization cycles: a meta-analysis.

OBJECTIVE: To reanalyze the results of using FSH alone and hMG during IVF treatment, taking into account the different protocols of administration of superactive GnRH agonist analogs. DESIGN: Meta-analysis. SETTING: The London Women's Clinic. PATIENT(S): Women undergoing IVF treatment. INTERVENTION(S): A meta-analysis of published randomized controlled trials from 1985 to 1999 of the use of FSH versus hMG for ovarian stimulation during IVF treatment. The common Peto odds ratio was calculated with use of a fixed effect model. The overall log odds ratio was estimated after demonstrating the consistency or homogeneity of the study results. MAIN OUTCOME MEASURE(S): Clinical pregnancy rate per cycle of IVF. RESULT(S): The results suggested that in the "long and short GnRH agonists protocol" of IVF, FSH, and hMG were equally effective in achieving ovarian stimulation, and there were no differences in the clinical pregnancy rates per cycle of IVF. However, in protocols where no pituitary desensitization was used, FSH alone was more efficacious. CONCLUSION(S): The optimum choice of gonadotropin preparation for ovarian stimulation during IVF treatment is influenced by the regimen of pituitary desensitization used. The optimum gonadotropin to be used when GnRH antagonists are used has yet to be determined.

Serum vascular endothelial growth factor concentrations in postmenopausal women: the effect of hormone replacement therapy.

OBJECTIVE: To assess serum vascular endothelial growth factor (VEGF) concentrations in healthy postmenopausal women in relation to hormone replacement therapy (HRT) and the presence or absence of a uterus. DESIGN: Cross-sectional study. SETTING: The Middlesex Hospital. PATIENT(S): A total of 199 postmenopausal women were enrolled: 132 had uterus in situ and 67 had had hysterectomies. Of the 67 women who had had hysterectomies, 6 received no HRT, 20 received tibolone, 25 received transdermal E2, and 16 received conjugated equine estrogens. Of the 132 women with uteri in situ, 34 received no HRT, 56 received tibolone, 24 received transdermal E2 with sequential norethisterone acetate, and 18 received conjugated equine estrogens with sequential levonorgestrel. INTERVENTION(S): Serum VEGF level measurement. MAIN OUTCOME MEASURE(S): Serum VEGF concentrations. RESULT(S): Women who received HRT had higher VEGF concentrations than those not receiving HRT. Among women who received no HRT, those with uterus in situ had higher VEGF levels than did those who had had hysterectomies. Among women who had had hysterectomies, VEGF concentrations were higher in those who received conjugated equine estrogens than in those who did not receive HRT and those who received tibolone or transdermal E2. Among women with uterus in situ, no difference was found between subgroups. CONCLUSION(S): Postmenopausal women with uterus in situ and those who received HRT had higher VEGF concentrations than did those who had had hysterectomies and who did not receive HRT. Among women receiving HRT, those who received conjugated equine estrogens alone had higher VEGF concentrations. This estrogen-mediated increase in serum VEGF concentrations may be a mechanism by which HRT benefits the cardiovascular system.

The prevalence of polycystic ovaries in women with type 2 diabetes mellitus.

OBJECTIVE: Polycystic ovary syndrome (PCOS) and type 2 diabetes mellitus are both common conditions associated with insulin resistance and compensatory hyperinsulinaemia. Previous reports have noted that impaired glucose tolerance and diabetes are common in women with PCOS. In this report we present the results of the converse study: the prevalence of polycystic ovaries in premenopausal women presenting with type 2 diabetes mellitus. SUBJECTS: Subjects were recruited from a hospital Diabetes Clinic. A search of computerized records identified 49 premenopausal women with type 2 diabetes mellitus being treated with diet alone or oral hypoglycaemic agents of whom 38 (76%) patients agreed to be studied. DESIGN: A cross-sectional study recording clinical, demographic and anthropometric data. Measurements of fasting metabolic parameters, reproductive endocrine profiles and ovarian dimensions were taken. RESULTS: Eighty-two percent of women with type 2 diabetes mellitus had polycystic ovaries on ultrasound. Of these women, 52% had clinical evidence of cutaneous hyperandrogenism and/or menstrual disturbance. Correlations between metabolic and reproductive parameters were consistent with a stimulatory action of insulin on the ovary. There was no significant difference between the PCO and non-PCO groups with respect to metabolic profiles. CONCLUSIONS: Women with type 2 diabetes mellitus have a higher prevalence of polycystic ovaries than that reported in the general population. Not all women with hyperinsulinaemia due to type 2 diabetes mellitus, however, develop PCO suggesting that hyperinsulinaemia alone is not sufficient for the expression of this ovarian morphology.

Bone density in a population of long term oral contraceptive pill users does not differ from that in menstruating women.

Prevention of osteoporosis is a major public health issue. Amenorrhoeic women have lower bone density than normally menstruating women, which is related to the duration of amenorrhoea and the severity of oestrogen deficiency. Bone mineral density (BMD) in amenorrhoeic women can be improved by oestrogen replacement in the form of the combined oral contraceptive pill (COCP), so increased BMD might be an important non-contraceptive benefit of the COCP in menstruating women. Previous studies have been variably reported, but have used different methodologies for measurement of BMD. We measured BMD using the DEXA technique in long term COCP users and compared this with menstruating women who had never used the COCP. No differences in bone density were found, suggesting that the COCP does not improve bone mass in menstruating women who are adequately oestrogenised by their own ovaries.

Kallmann's syndrome: is it always for life?

OBJECTIVE: Kallmann's syndrome (KS) is defined by the association of olfactory deficit with irreversible, congenital gonadotrophin deficiency (IHH). We present evidence for the existence of a variant form of KS, in which endogenous gonadotrophin secretion recovers spontaneously in later life. DESIGN: Longitudinal clinical study. PATIENTS: Five men with anosmia or severe hyposmia, who originally presented in their late teens or early twenties as a result of severe pubertal delay and were thus presumed to have KS. RESULTS: Spontaneous onset of endogenous gonadotrophin secretion, evidenced by progressive normalization of testicular volume and of serum testosterone concentration, occurred in these men over a period of years following the initial diagnosis. CONCLUSIONS: This variant form of Kallman's syndrome is not well recognized and may well be under-diagnosed. Once full virilization has been induced, males with congenital gonadotrophin deficiency whose testes have significantly increased in size should be reassessed, off androgen replacement therapy, to identify those who no longer require treatment.

Cumulative probability of clinical pregnancy and live birth after a multiple cycle IVF package: a more realistic assessment of overall and age-specific success rates?

OBJECTIVE: To provide an assessment of pregnancy and live birth probabilities for women presenting for in vitro fertilisation treatment for the first time, when committed in advance to have up to three cycles of treatment in one year. DESIGN: Up to three cycles of in vitro fertilisation within one year, committed in advance. SETTING: A tertiary referral centre for assisted reproduction. PARTICIPANTS: Two hundred and thirty-two women, undergoing a total of 536 cycles of in vitro fertilisation or intracytoplasmic sperm injection between August 1993 and December 1995. METHODS: Analysis of cumulative clinical pregnancy and live birth rates for women having IVF treatment for the first time and undertaking a three-cycle package, using the life-table approach. MAIN OUTCOME MEASURES: Cumulative clinical pregnancy and live birth rates. RESULTS: The cumulative probabilities of clinical pregnancy and live birth after two cycles of treatment were 38.2% and 33.2%, respectively, compared with 54.2% and 48.2%, respectively, after three cycles of treatment. Cumulative clinical pregnancy and live birth rates after three cycles of treatment for women up to the age of 40 years were 57.8% and 51.3%, respectively. Cumulative clinical pregnancy and live birth rates declined with increasing age (P = 0.02 and P= 0.01, respectively). CONCLUSION: The three-cycle package encourages couples to have multiple treatment cycles, thereby improving their ultimate chances of a live birth. The cumulative clinical pregnancy and live birth rates after such a package provide a more realistic assessment of overall and age-specific success rates after multiple treatment cycles.

Serum vascular endothelial growth factor (VEGF) in the normal menstrual cycle: association with changes in ovarian and uterine Doppler blood flow.

OBJECTIVE: To investigate whether changes in circulating serum vascular endothelial growth factor (VEGF) concentrations during the menstrual cycle are associated with changes in blood flow within the ovaries and uterus. PATIENTS AND MEASUREMENTS: Serum VEGF concentrations were measured and pulsed and colour Doppler blood flow waveforms recorded within the ovarian stroma and uterine arteries during the early follicular, the immediate preovulatory and the mid-luteal phases of the menstrual cycle of 14 healthy women. RESULTS: Mean (+/- SD) serum VEGF concentrations rose from 2.44 +/- 0.1 ng/ml in the early follicular phase to 3 +/- 0.8 ng/ml in the pre-ovulatory phase and to 4.4 +/- 0.9 ng/ml in the mid-luteal phase (P < 0.0001) of the menstrual cycle. Mean peak systolic blood flow velocity (PSV) and time-averaged maximum flow velocity (TAMXV) were higher within the ovarian stroma of the ovary bearing the dominant follicle and the uterine arteries in the pre-ovulatory and mid-luteal phase than in the same sites during the early follicular phase of the menstrual cycle. PSV rose significantly from the early follicular phase (11 +/- 6 cm/s) to 14 +/- 4 cm/s in the pre-ovulatory phase and further in the mid-luteal phase (26 +/- 7 cm/s, P = 0.0001). Within the uterine arteries, mean PSV rose significantly from 28 +/- 9 cm/s in the early follicular phase to 31 +/- 8 cm/s in the pre-ovulatory phase and further in the mid-luteal phase (44 +/- 11 cm/s, P < 0.005). Serum VEGF correlated with serum progesterone concentrations in the luteal phase (r = 0.85, P < 0.001), with serum oestradiol concentrations in the early follicular (r = 0.67, P = 0.009), pre-ovulatory (r = 0.57, P = 0.03) and luteal phases (r = 0.68, P < 0.005) and with serum testosterone in the early follicular phase (r = 0.63, P = 0.01). CONCLUSIONS: Cyclical changes in serum vascular endothelial growth factor concentrations are associated with coincident changes in ovarian and uterine blood flow.

Leptin, polycystic ovaries and polycystic ovary syndrome.

As soon as leptin was discovered four years ago, its potential as a player in the polycystic ovary syndrome (PCOS) was explored in a primitive way, though little light was shed on the enigma that is PCOS. As a second wave of leptin research is now available, we review how the expanded role of the cytokine in reproduction might yet impact upon our understanding of PCOS.

Relationship of ovarian stromal volume to serum androgen concentrations in patients with polycystic ovary syndrome.

The aim of this study was to investigate of the relationship of ovarian stromal volume, measured using three-dimensional ultrasound, to serum androgen concentrations in patients with polycystic ovaries. Serum gonadotrophin, oestradiol and androgen concentrations and ovarian volume measurements were obtained in the early follicular phase from 100 women undergoing assisted conception treatment cycles. Group 1 contained 50 women with regular menstrual cycles and normal ovarian morphology, group 2 contained 24 women with regular menstrual cycles and polycystic ovaries seen on ultrasound scan and group 3 contained 26 women with polycystic ovary syndrome. Statistical analysis included analysis of variance, Scheffé's procedure and Pearson's correlation. Total ovarian volume (15.7-16.1 versus 11 ml, P < 0.05), stromal volume (14.5 versus 9.4 ml, P < 0.05) and thecal steroid concentrations were significantly greater in groups 2 and 3. Stromal volume was positively correlated with serum androstenedione concentrations (r = 0.45, P = 0.0019 in group 3) but was not correlated with any other endocrine parameter. It was concluded that polycystic ovaries are characterized by increased ovarian stroma with associated overproduction of theca-derived steroids, particularly androstenedione.

Reproductive endocrinology.

The theme running through the articles in this issue on reproductive medicine is that of the safety of the medical treatments we use in this specialty. Two of the articles focus on familiar medications, such as the oral contraceptive pill and the drugs used to induce ovulation, and two focus on the benefits and potential hazards of new approaches to treatment, viz the reduction of insulin drive in women with polycystic ovary syndrome and the use of selective modulators of estrogen receptors in postmenopausal women with osteoporosis.

Mortality of women with polycystic ovary syndrome at long-term follow-up.

Metabolic disturbances associated with insulin resistance are present in most women with polycystic ovary syndrome. This has led to suggestions that women with polycystic ovary syndrome may be at increased risk of cardiovascular disease in later life. We undertook a long-term follow-up study to test whether cardiovascular mortality is increased in these women. A total of 786 women diagnosed with polycystic ovary syndrome in the United Kingdom between 1930 and 1979 were traced from hospital records and followed for an average of 30 years. Standardized mortality ratios (SMRs) were calculated to compare the death rates of these women with national rates. The SMR for all causes was 0.90 (95% CI, 0.69-1.17), based on 59 deaths. There were 15 deaths from circulatory disease, yielding an SMR of 0.83 (95% CI, 0.46-1.37). Of these 15 deaths, 13 were from ischemic heart disease (SMR 1.40; 95% CI, 0.75-2.40) and two were from other circulatory disease (SMR 0.23; 95% CI, 0.03-0.85). There were six deaths from diabetes mellitus as underlying or contributory cause, compared with 1.7 expected (odds ratio 3.6; 95% CI, 1.5-8.4). Breast cancer was the commonest cause of death (SMR 1.48 based on 13 deaths; 95% CI, 0.79-2.54). We conclude that women with polycystic ovary syndrome do not have markedly higher than average mortality from circulatory disease, even though the condition is strongly associated with diabetes, lipid abnormalities, and other cardiovascular risk factors. The characteristic endocrine profile of women with polycystic ovary syndrome may protect against circulatory disease in this condition.

A prospective randomized study to assess the clinical efficacy of gonadotrophins administered subcutaneously and intramuscularly.

The purpose of this study was to compare the clinical efficacy of gonadotrophins administered s.c. or i.m., in a prospective randomized study of women undergoing in-vitro fertilization (IVF) treatment at a tertiary referral centre. In all, 71 patients undergoing a total of 162 IVF treatment cycles were randomized to receive either s.c. (n = 41) or i.m. (n = 30) administration of gonadotrophins. Up to three cycles of IVF were assessed for each patient. The main outcome measures were the number of oocytes retrieved, the total amount of gonadotrophins used, the number of follicles recruited and the cumulative pregnancy and live birth rates. The mean number of oocytes retrieved was 10.5 for each group. The number of days of stimulation was significantly shorter for the s.c. group (11.7 +/- 1.9 days, mean +/- SD) than the i.m. group (12.6 +/- 2.3 days). The cumulative conception and live birth rates after three cycles of treatment were similar between the two groups. Our results suggest that the clinical efficacy of s.c. and i.m. administration of gonadotrophins is comparable. Both routes are well tolerated by patients.

Serum vascular endothelial growth factor concentrations and ovarian stromal blood flow are increased in women with polycystic ovaries.

The aim of this study was to determine basal serum vascular endothelial growth factor (VEGF) concentrations and Doppler blood flow changes within the ovarian stroma of women with polycystic ovaries (PCO) and women with normal ovaries. Pulsed and colour Doppler blood flows within the ovarian stroma were recorded, and serum VEGF concentrations measured, in the early follicular phase (days 2-3 of a menstrual cycle) in 60 women undergoing ovarian stimulation for in-vitro fertilization. 36 women had normal ovaries, 14 women had PCO as seen on pelvic ultrasound examination and 10 had polycystic ovarian syndrome (PCOS). Mean+/-SD serum VEGF concentrations were significantly higher (P < 0.001) in women with PCO and PCOS (3.4+/-0.7 and 3.2+/-0.66 ng/ml respectively) compared with women with normal ovaries (2.3+/-0.5 ng/ml). Mean peak systolic blood flow velocity (PSV) and time-averaged maximum flow velocity (TAMXV) were significantly higher (P < 0.001) in women with PCO and PCOS compared with women with normal ovaries. The mean PSV were 15+/-4 and 16+/-4 cm/s in women with PCO and PCOS respectively, compared with 9+/-2 cm/s in women with normal ovaries. The TAMXV were 9+/-3 and 11+/-3 cm/s in women with PCO and PCOS respectively compared with women with normal ovaries (5.8+/-1.5 cm/s). Serum VEGF concentrations were positively correlated with PSV (r=0.44, P=0.001) and TAMXV (r=0.45, P < 0.000) in all three groups of women. Higher serum concentrations of VEGF in women with PCO and PCOS may relate to the increased vascularity that underlies the increased blood flow demonstrated by Doppler blood flow velocity measurements in these women. The results may explain the higher risk of ovarian hyperstimulation syndrome in programmes of ovarian stimulation in patients with PCO compared with those with normal ovaries.