Effective ovarian stimulation in a patient with resistant ovary syndrome and antigonadotrophin antibodies.

PROBLEM: We report on a successful ovarian stimulation and pregnancy in a patient with 'resistant ovary syndrome' (ROS) and antigonadotrophin antibodies. ROS is characterized by high endogenous gonadotrophins, low estradiol, normal ovarian antral follicle counts and normal antimuellerian hormone values. METHOD OF STUDY: After cyclical hormone treatment, downregulation with GnRH analogue and ICSI procedure followed. Granulosa cells were treated with LH, FSH or hMG and expression of receptors for FSH, LH, oestrogen receptor beta (ERb) and progesterone receptor A (PR-A) was determined. Serum of the patient was analysed for antibodies directed against hMG. RESULTS: After fertilization of ten metaphase II oocytes and transfer of two blastocysts, a singleton pregnancy was established. Stimulation of granulosa cells with FSH, LH and hMG upregulated ERb and PR-A. Dot blot analysis showed strong reactivity with hMG but not with recFSH. CONCLUSION: This patient with normal expression of gonadotrophin receptors showed antibodies directed to hMG but not to recFSH.

Primary Ovarian Insufficiency: X chromosome defects and autoimmunity.

Premature ovarian failure (POF) is a primary ovarian defect characterized by absent menarche or premature depletion of ovarian follicles before the age of 40 years. However, in several instances the distinction between definitive or intermittent POF may be difficult on clinical bases, therefore the more appropriate term Primary Ovarian Insufficiency (POI) has been recently proposed and will be used in this review. POI is a heterogeneous disorder affecting approximately 1% of women <40 years. The most severe forms present with absent pubertal development and primary amenorrhea, whereas forms with post-pubertal onset are characterized by disappearance of menstrual cycles (secondary amenorrhea) associated with a defective folliculogenesis. POI is generally characterized by low levels of gonadal hormones (estrogens and inhibins) and high levels of gonadotropins (LH and FSH) (hypergonadotropic amenorrhea). Heterogeneity of POI is reflected by the variety of possible causes, including autoimmunity, toxics, drugs, as well as genetic defects. Several data indicate that POI has a strong genetic component. In this manuscript we discuss the X chromosome abnormalities that are associated with POI.

Allergic reaction to a highly purified urinary follicle stimulating hormone preparation in controlled ovarian hyperstimulation for in vitro fertilization.

We report a case of general hypersensitivity-like allergic reactions to intramuscular injections of highly purified urinary follicle stimulating hormone (uFSH-HP) successfully managed by using intramuscular recombinant FSH (rFSH). The patient underwent a first cycle of in vitro fertilization (IVF) and controlled ovarian hyperstimulation (COH) was achieved with a combination of gonadotropin releasing hormone against (GnRH-a) and uFSH-HP. Because, after oocyte recovery, no fertilization occurred, the couple subsequently entered an intracytoplasmic sperm injection (ICSI) program. During the COH, the woman developed general hypersensitivity-like allergic reactions with itching, redness and swelling. Although there was regular follicular growth, the allergic symptoms worsened and, on day 8 of COH, the stimulation cycle was suspended. A few months later, the patient entered a new ICSI cycle. COH was achieved by using a combination of GnRH-a and rFSH. The cycle was completed and the patient did not report any allergic reaction. To avoid allergic reaction to the protein components of the urine-derived FSH preparations, the use of rFSH is suggested in those patients who present local and/or general hypersensitivity-like allergic reactions.

Pregnancy and birth in an in-vitro fertilization cycle after controlled ovarian stimulation in a woman with a history of allergic reaction to human menopausal gonadotrophin.

We report a case of allergic reaction to i.m. injections of urinary human menopausal gonadotrophin (HMG) and a successful management of the problem by using recombinant follicle stimulating hormone (rFSH) administered i.m. The patient underwent two zygote intra-Fallopian transfer (ZIFT) cycles, in which ovarian stimulation was carried out by a combination of gonadotrophin-releasing hormone agonist (GnRHa) and HMG. A twin pregnancy was achieved after the first cycle. The patient delivered two premature boys at 28 weeks one of whom died after 25 days from severe respiratory distress. During the second ZIFT cycle the patient developed an allergic reaction with redness and swelling in many parts of her body 30 min after every HMG injection. Despite the allergic reaction, the cycle was completed with a second ZIFT. No pregnancy was achieved in this cycle. The patient came back to our centre for a third attempt during which ovarian stimulation was accomplished with a combination of GnRHa and rFSH. Adverse reaction as well as general discomfort were not reported by the patient during ovarian stimulation with rFSH. A successful singleton pregnancy was achieved after intrauterine embryo transfer with the birth of a healthy girl after 38 weeks. If any allergic reaction is present after injection of HMG it is advisable to stimulate a subsequent cycle with rFSH.

Delayed-type hypersensitivity to human gonadotropin: case report.

OBJECTIVE: To investigate adverse reactions to hMG preparations in two women in IVF programs. DESIGN: Two case reports with skin tests for delayed hypersensitivity (DH) to hMG and a biopsy of one delayed reaction. SETTING: Allergy and infertility clinics in university medical center. PATIENTS: Two affected patents with a history of local reactions to the injected hMG, one of whom also had fever, and nine control subjects. INTERVENTIONS: Skin tests and biopsy. MAIN OUTCOME MEASURES: Delayed hypersensitivity skin response to hMG in affected patients indicated by timing and biopsy results. Negative skin test with the purified hFSH, which was also used in treatment with no adverse effects. CONCLUSION: Use of the purified preparation avoids DH reaction.

Allergenic potential of gonadotrophic preparations in experimental animals: relevance of purity.

Local reactions have been frequently reported following repeated injections of human menopausal gonadotrophins (HMG) for the treatment of infertility. Also immunoglobulin (Ig) E-mediated systemic reactions have sporadically been observed. Since most HMG preparations contain significant amounts of non-hormonal urine-derived proteins, it was suggested that these contaminating proteins are responsible for the various allergic reactions. In order to verify this hypothesis, different human follicle stimulating hormone (HFSH) and HMG preparations (Metrodin and Pergonal from Ares-Serono, and Humegon from Organon), were compared with a highly purified preparation (Metrodin HP from Ares-Serono) for the frequency and severity of allergic reactions induced in laboratory animals. The occurrence of anaphylactic shock or related symptoms was studied in sensitized guinea-pigs. The production of specific IgE was evaluated in serum from mice sensitized with the test drugs by the induction of passive cutaneous anaphylaxis in rats. In both models, two different schedules of sensitization were used. Severe allergic reactions were found in 20 of 7% of the guinea-pigs receiving highly purified FSH (Metrodin HP) in the two schedules, respectively, compared to 90 and 88% with the other preparations. Similarly significantly lower IgE titres were induced by highly purified FSH in respect to the other preparations. It can be concluded that the elimination of contaminating proteins significantly reduces the allergenicity of urine-derived HFSH preparations.

Molecular composition of luteinizing hormone and follicle-stimulating hormone in commercial gonadotropin preparations.

The biologic (B) and immunologic (I) properties of luteinizing hormone (LH) and follicle-stimulating hormone (FSH) were studied in three commercial urinary gonadotropin preparations and in the first international standard preparation of human urinary gonadotropins before and after fractionation by isoelectrofocusing (IEF). Significant differences were found in the IEF profiles of both bioactive and immunoreactive LH and FSH and in the B/I ratios of the preparations studied. The observed differences in the molecular composition of LH and FSH seem to be attributable to the purification procedures employed. The possible influence of these differences on the in vivo potencies, circulating half-lives, and clinical effects of gonadotropin preparations are discussed.

[Demonstration of gonadotropic cells in the adenohypophysis (pars distalis and pars tuberalis) of the monkey Macacus irus. Immunofluorescence study using human anti-beta-FSH and ovine anti-beta-LH antibodies]. / Mise en évidence de cellules gonadotropes dans l'adénohypophyse (pars distalis et pars tuberalis) du singe Macacus irus, Etude en immunofluorescence à l'aide d'anticorps anti bêta FSH humaine et anti bêta LH ovine.

Indirect immunofluorescence technique with anti-beta FSH and anti-beta oLH antisera has allowed us to detect "gonadotropic cells" in the pars distalis and in the pars tuberalis of the adenohypophysis of the monkey Macacus irus. In the pars distalis, 85-90 % of the "gonadotropic cells" react simultaneously with these two antisera ; 10-15 % of these cells react only either with anti-beta hFSH or anti-beta oLH antisera. The gonadotropic cells are dispersed in the whole pars distalis, amid the other cellular types ; indeed, in the female, there is a "gonadotropic zone" in the median zone of the lateral lobes of the gland. In the pars tuberalis, we have observed "gonadotropic cells" which react only with anti-beta oLH antiserum. These results are compared with observations of some authors.

Subunits of human chorionic gonadotrophin: immunological and biological studies.

The alpha and beta subunits of human chorionic gonadotrophin (hCG) were prepared by incubation in 8 M urea, pH 4.5. The separation of the two subunits was obtained by DEAE-Sephadex A-25 chromatography and purification was carried out by gel filtration on Sephadex G-100. The beta subunit obtained was biologically active and was therefore further purified by affinity chromatography using as immuno-adsorbent the alpha antibodies coupled to Sepharose 4B. The beta subunit so purified showed a biological activity less than 1 IU/mg. The immunological and biological properties of the hCG subunits have been studied. It was found that the anti HCG beta serum can discriminate between hCG and hLH and that in the 125I-hCG + anti-beta serum radioimmunoassay, the cross-reactivity of pituitary hLH was lower than that of urinary hLH. Moreover, it was observed that the less purified was the urinary LH preparation, the higher was the cross-reactivity. Therefore we considered the hypothesis that during the purification of human menopausal gonadotrophin (hMG) some LH subunits or smaller immunoreactive fragments could have been discarded with the waste fractions. In order to test the validity of this hypophysis, all the protein fractions obtained during the purification of the hMG were gel-filtered on Sephadex G-100. The immunoreactivity of the effluents from the gel filtration was tested by hCG, hCG-beta, hCG-alpha and hLH radioimmunoassays. While the alpha reactive material was found in some fractions as a peak having the same Ve/Vo value as hCG-alpha, the beta reactive material presenude hMG fractions was not observed in other fractions. The cross-reactivity with the anti beta serum was very low and was found in the LH region of the gel chromatogram. Furthermore, the neutralization of the biological activity of hCG and of urinary and pituitary LH by the anti hCG beta serum was studied by incubating a fixed amount of the three hormones with increasing volumes of antiserum and measuring the LH ACTIVITY AFTER INCUBATION BY THE OADD test. It was observed that the anti hCG beta serum inhibits hCG more than urinary or pituitary LH.

The effect of pH on radioimmunoassay of LH and FSH.

Freezing and thawing of human serum produces alkaline changes in the pH. Weak buffers were of insufficient capacity to compensate for these pH changes. Thus the effect of serum pH on modified solid-phase and double-antibody radioimmunoassay (RIA) of LH and FSH was studied. Pooled postmenopausal serum standardized against the Second International Reference Preparation of Human Menopausal Urinary Gonadotropon was used as a laboratory standard. In the solid phase RIA for LH and FSH, slopes with the greatest maximum binding were obtained at pH 6.4, whereas for the double-antibody method best results were obtained at pH 8.0. Since there is individual variation in the pH of various serum samples, different values will be obtained from samples containing the same amount of hormone. It is sum samples be standardized by the use of buffers with the capacity to keep the pH of the serum constant and that serum standards be dialyzed.