Association of severity of menstrual dysfunction with hyperinsulinemia and dysglycemia in polycystic ovary syndrome.

STUDY QUESTION: Is the severity of menstrual cyclicity related to hyperinsulinemia and dysglycemia in women with hyperandrogenic polycystic ovary syndrome (PCOS)? SUMMARY ANSWER: Hyperandrogenic PCOS women with amenorrhea, compared to those with oligomenorrhea or eumenorrhea, had a greater risk of post-challenge hyperinsulinemia, which may explain their higher prevalence of dysglycemia. WHAT IS KNOWN ALREADY: PCOS is associated with metabolic dysregulation including insulin resistance (IR) and hyperinsulinemia, risk factors for type 2 diabetes mellitus (T2DM) and other vascular-metabolic morbidities. Although the severity of menstrual cyclicity is associated with IR in PCOS, it is unclear whether, and to what extent, it is related to hyperinsulinemia and glycemic abnormalities. STUDY DESIGN, SIZE, DURATION: We prospectively compared the degree of menstrual cyclicity with the presence of dysglycemia (elevated 1-h plasma glucose ≥155 mg/dl; abnormal glucose tolerance [AGT], including prediabetes and T2DM; and AUC for glucose [G-AUC]) or dynamic state hyperinsulinemia (peak insulin levels either at 1 or 2 h of the oral glucose tolerance test (oGTT) and AUC for insulin [I-AUC]) in 333 hyperandrogenic PCOS women. PARTICIPANTS/MATERIALS, SETTING, METHODS: In a tertiary care setting, hyperandrogenic PCOS participants with ovulatory eumenorrhea (Ov-Eumeno, n = 25), anovulatory eumenorrhea (Anov-Eumeno, n = 33), oligomenorrhea (Oligo, n = 150) and amenorrhea (Ameno, n = 125) underwent comprehensive phenotyping and a 2-h 75 g oGTT. MAIN RESULTS AND THE ROLE OF CHANCE: Mean BMI was greater among Ameno women than among Oligo, Anov-Eumeno or Ov-Eumeno women. Adjusting for BMI, the Ameno group demonstrated higher mean 1- and 2-h insulin and glucose, peak insulin and I-AUC and G-AUC, and either had a higher, or tended toward having a higher, prevalence of elevated 1-h glucose level and prevalence of AGT than the Oligo, Anov-Eumeno or Ov-Eumeno groups. In logistic regression, adjusting for BMI, Ameno women were more likely to have: AGT than Oligo women (odds ratio [OR]: 2.3; 95% CI: 1.3 to 4.2); elevated 1-h glucose (OR: 10.2; CI: 1.3-79.7) than those with Ov-Eumeno; and both AGT (OR: 1.7; CI: 1.1-2.6) and elevated 1-h glucose (OR: 1.8; CI: 1.1-2.8) than those with Anov-Eumeno or Ov-Eumeno when combined. Race/ethnicity, age, waist-to-hip ratio, fasting insulin and glucose, and biochemical or clinical measures of hyperandrogenism were similar across the four menstrual categories. LIMITATIONS, REASONS FOR CAUTION: Our study was limited by its cross-sectional nature and by studying women affected by PCOS as defined by the Androgen Excess & PCOS Society criteria (i.e. Rotterdam Phenotypes A, B and C) who were identified in the clinical setting. Consequently, extrapolation of the present data to other PCOS phenotypes (e.g. PCOS Phenotype D) should be made with caution. WIDER IMPLICATIONS OF THE FINDINGS: In hyperandrogenic PCOS phenotypes, a history of amenorrhea, compared to oligomenorrhea or eumenorrhea, suggests a more severe cardiometabolic risk, including a higher degree of hyperinsulinemia and greater prevalence of glycemic abnormalities. These findings may assist in refining the treatment and screening guidelines for glycemic abnormalities in PCOS. STUDY FUNDING/COMPETING INTEREST(S): This work was supported in part by grants R01-DK073632 and R01-HD29364 from the NIH and an endowment of the Helping Hand of Los Angeles, Inc. (to R.A.). M.D.P. has no competing interests to declare. U.E. is an investor in Concentric Analgesics, Inc. R.A. serves as a consultant for Spruce Biosciences and Fortress Biotech and an advisor for Aurora Forge. TRIAL REGISTRATION NUMBER: N/A.

Metabolic consequences of polycystic ovary syndrome.

Polycystic ovary syndrome (PCOS) is the most common endocrine disorder in women and the leading cause of anovulatory infertility. The prevalence of the syndrome ranges between 6 to 15% based on broader Rotterdam diagnostic criteria verses strict NIH diagnostic criteria.1 The condition is characterized by a combination of ovulatory dysfunction, hyperandrogenism and the presence of polycystic ovaries. PCOS has been associated with multiple metabolic alterations and consequences including impaired glucose tolerance, insulin resistance, hyperinsulinemia, type II diabetes, dyslipidemia, metabolic syndrome, obesity and subclinical cardiovascular disease. It remains unclear however if these associations lead to an increased risk of clinically significant long-term cardiovascular disease. Large prospective studies to date have not detected significant differences in overall cardiovascular morbidity and mortality in PCOS. The phenotypical variability in PCOS has made researching each of these associations challenging as different aspects of the syndrome may be contributing, opposing or confounding factors. The ability to detect significant differences in long-term cardiovascular outcomes may also be due to the variable nature of the syndrome. In this review, we attempt to describe a summary of the current literature concerning the metabolic alterations and cardiovascular consequences of polycystic ovary syndrome.

DNA array analysis of changes in preovulatory gene expression in the rat ovary.

During the periovulatory period, the mammalian ovary is the site of dramatic functional and structural changes, leading to oocyte maturation, follicle rupture, and corpus luteum formation. To a large extent, these processes result from changes in the transcriptome of various ovarian cell types. To develop a broader view of periovulatory changes in gene expression in the ovary and to identify further genes involved in periovulatory events, we used the recently developed DNA array technology. Immature female eCG-primed rats were killed either immediately before or 6 h after ovulation induction with hCG. Total ovarian RNA was isolated and used to prepare radiolabeled cDNA probes, which were hybridized to DNA arrays representing approximately 600 rat genes. Quantitative analysis identified a multitude of regulated gene messages, including several genes involved in extracellular matrix degradation and lipid/steroid metabolism previously reported to be induced by hCG. This screening also identified a group of candidate genes whose ovarian expression and gonadotropin regulation was hitherto unknown. The induction of three of these genes, encoding cutaneous fatty acid-binding protein, the interleukin-4 receptor alpha chain, and prepronociceptin, was confirmed and further characterized by Northern blot analysis. In addition, in situ hybridization analysis showed that hCG administration resulted in exclusive or predominant expression of all three genes in theca cells. These results demonstrate that DNA arrays can be used to identify genes regulated during the periovulatory period, thus contributing to a more detailed understanding of the molecular mechanisms of ovulation.

Dehydroepiandrosterone supplementation augments ovarian stimulation in poor responders: a case series.

In patients with poor response to ovarian stimulation with gonadotrophins, growth hormone (GH) is sometimes used to increase paracrine insulin-like growth factor-1 (IGF-1) effect. We postulated that dehydroepiandrosterone (DHEA) administration to poor responders would augment gonado-trophin effect via a similar mechanism. Baseline ovarian stimulation response to a cycle with DHEA in five healthy non-smoking women <41 years old was compared with day 3 FSH <20 mIU/ml. All had documented poor response to vigorous gonadotrophin administration. After day 2 ultrasounds, DHEA-sulphate (DHEA-S), FSH, human chorionic gonadotrophin (HCG), and testosterone were measured, and the women were given 80 mg/day of oral micronized DHEA for 2 months. While still on DHEA, they underwent ovarian stimulation with FSH given i.m. twice a day, and HCG (10 000 IU) at follicular maturity, followed by intrauterine insemination. Cycle parameters assessed were peak oestradiol, and peak oestradiol/ampoule. The DHEA/ovarian stimulation cycles occurred between 4 and 24 months after the control cycles. After 2 months DHEA treatment, DHEA-S increased to 544 +/- 55 microg/dl, and testosterone increased to 67.3 +/- 6.1 ng/dl. All five subjects (six cycles; one subject had two DHEA cycles) had increased responsiveness; peak oestradiol concentrations increased from 266.3 +/- 69.4 pg/ml to 939.8 +/- 418.9 pg/ml. The oestradiol/ampoule ratio increased in all six cycles, by a mean of 2.94 +/- 0.50 fold (P = 0.012). One of the cycles resulted in a delivered twin pregnancy. In this small series, DHEA improved response to ovarian stimulation even after controlling for gonadotrophin dose. Supplemental DHEA treatment during ovarian stimulation may represent a novel way to maximize ovarian response.

Expression and function of estrogen receptor subtypes in granulosa cells: regulation by estradiol and forskolin.

The expression and function of estrogen receptor ERalpha/beta subtypes and ERbeta variants in granulosa cells have been determined using several integrated approaches:, Western blotting, indirect immunofluorescence, RT-PCR, and transient transfection assays. Each of these approaches has provided specific details concerning the dynamics of ER expression, ER functional activity, and estradiol (E) regulation of target genes in granulosa cells. Specifically, the studies presented herein document that messenger RNAs (mRNAs) encoding ERbeta and its splice variants, as well as mRNA encoding ERalpha, are expressed in granulosa cells of immature rats before and during culture in serum-free medium. The results also provide the first documentation that functional (DNA binding and transcriptionally active) ER is present in cultured granulosa cells and that its ability to bind consensus estrogen response element (ERE) oligonucleotide and to transactivate an ERE promoter-reporter construct is associated with the level (type?) of receptor protein as well as the stage of granulosa cell differentiation. Using a labeled ERE consensus oligonucleotide and antibodies specific for ERbeta and ERalpha, we show that ERbeta but not ERalpha was detected (supershifted in electrophoretic mobility shift assays) in extracts of granulosa cells cultured overnight (0 h) in defined medium alone. When the cells were cultured with FSH and testosterone (T) to stimulate their differentiation, ERbeta binding activity, as well as immunoreactive ERbeta as determined by Western blot analyses, decreased progressively from 24 to 48 h and was undetectable by 72 h. ERbeta mRNA was low, and ERbeta binding activity was not observed in luteinized granulosa cells. ERalpha DNA binding activity was not observed in any of the granulosa cell cultures, although low levels of immunoreactive ERalpha were detected by Western blot analyses. Immunofluorescent analyses documented that ERbeta, as well as ERalpha, were localized to granulosa cell nuclei and that the intensity of nuclear staining was related to agonist stimulation and differentiation: forskolin increased, whereas E decreased immunostaining for ERbeta and ERalpha at 48 h. When an ERE-E1b-luciferase vector was transfected into granulosa cells of unprimed rats, basal luciferase activity was low but increased by forskolin (3-4x) and by E (2x), responses to both agonists being blocked by the ER antagonist, ICI. When the same vector was transfected into differentiated granulosa cells (cultured for 48 h with FSH/T), forskolin alone increased activity. Collectively, these results show that ERbeta protein is preferentially expressed in immature granulosa cells, is functionally active (binds DNA), can transactivate (either as a homodimer or heterodimer with ERalpha) ERE-containing promoter constructs, and might be associated with increased expression of the endogenous gene encoding c-Jun.

Fertilization after standard in vitro fertilization versus intracytoplasmic sperm injection in subfertile males using sibling oocytes.

OBJECTIVE: To compare conventional IVF with ICSI in the subfertile male population using sibling oocytes. Results from males with isolated severe teratozoospermia also are analyzed. DESIGN: Prospective experimental study. SETTING: University based IVF clinic. PATIENT(S): Group A: 18 patients with one or more abnormalities in count, motility, or morphology. Group B: 20 patients with isolated severe teratozoospermia (< or = 4% Kruger Strict Criteria). INTERVENTION(S): Ovulation induction, random allocation of sibling oocytes, and IVF or ICSI. MAIN OUTCOME MEASURE(S): Fertilization rates (fertilization per cycle, fertilization per oocytes, and fertilization per couple) and embryo quality. RESULT(S): In group A, fertilization occurred in 13 of 18 (72%) of IVF cycles and 17 of 18 (94%) of ICSI cycles. Overall, 69 of 120 (58%) oocytes fertilized after IVF, whereas 80 of 131 (61%) fertilized after ICSI. The mean (+/-SEM) percent of oocytes fertilized per couple was 44.6%+/-9.0% with IVF and 62.7%+/-5.6% with ICSI (not statistically significant). In group B, fertilization occurred in 18 of 20 (90%) cycles after IVF and 20 of 20 (100%) cycles with ICSI. Overall, 54 of 113 (48%) of the oocytes fertilized after IVF, whereas 82 of 124 (66%) fertilized with ICSI. The mean (+/-SEM) percent of oocytes fertilized per couple was 50.9%+/-7.1 % with IVF and 66.6%+/-4.7% with ICSI. No statistically significant difference in embryo quality after IVF versus ICSI was demonstrated. CONCLUSION(S): With severe teratozoospermia, ICSI results in higher fertilization rates than conventional IVF, without altering embryo quality. In our subfertile male population, there is a trend toward improved fertilization with ICSI, with less failed fertilization.

Heterotopic abdominal pregnancy treated at laparoscopy.

OBJECTIVE: To report a case of laparoscopic treatment of a heterotopic primary abdominal pregnancy after IVF with preservation of the concurrent intrauterine pregnancy. DESIGN: Case report. SETTING: University-based IVF program. PATIENT(S): A woman with a heterotopic abdominal pregnancy after IVF-ET. INTERVENTION(S): Pituitary down-regulation with luteal leuprolide acetate, ovulation induction with menotropins, IVF-ET, progesterone in oil for luteal support, laparoscopy, and resection of the abdominal gestation. MAIN OUTCOME MEASURE(S): Human chorionic gonadotropin levels, pelvic ultrasound examinations, and laparoscopic and pathologic findings. RESULT(S): A heterotopic abdominal pregnancy occurred after IVF-ET and was treated successfully with laparoscopy. The concurrent intrauterine pregnancy was delivered at term. CONCLUSION(S): Early diagnosis of an ectopic abdominal pregnancy allowed successful laparoscopic treatment, without sequelae to the intrauterine gestation.

Congenital hypopituitarism as part of suprasellar dysplasia. A case report.

Congenital hypopituitarism may be due to hypothalamic failure. The case presented below belonged to this category. In addition, the demonstration of absent septum pellucidum placed this case in the category of suprasellar dysplasia. The patient was 21 years old, with primary amenorrhea and lack of development of secondary sex characteristics. The laboratory findings confirmed the diagnosis of hypothyroidism, hypocortisolism, hypogonadotropism, hyperprolactinemia and normal growth hormone. Stimulation studies revealed a subnormal response of cortisol to adrenocorticotrophic hormone stimulation, subnormal response of follicle stimulating hormone and luteinizing hormone to gonadotropin releasing hormone stimulation, normal response of prolactin to thyrotropin releasing hormone stimulation and exaggerated response of thyroid stimulating hormone to thyrotropin releasing hormone stimulation. The patient was treated with thyroid supplementation. Magnetic resonance imaging showed a hypoplastic infundibulum, ectopic neurohypophysis, small anterior pituitary gland and absent septum pellucidum. Congenital hypopituitarism may be part of a large spectrum of midline brain abnormalities.