The human menopausal gonadotropin (hMG) dose in in vitro fertilization (IVF): What is the optimal dose?

Conclusion Evaluating clinical studies on ovarian response, the initial hMG dose should be 150 IU hMG/day in IVF programs without GnRH cotreatment and 225 IU hMG/day in IVF programs with cotreatment with GnRH-a. Age (>35 years), basal FSH level, and body weight are variables known to affect ovarian response and, therefore, reasons to consider an increase in the initial hMG dose. In addition to a good ovarian response, ovarian stimulation with 150 IU/hMG may restrict possible adverse effects of high-dose hMG treatment on the endometrium and on the oocyte (1,12,13). Let us hope that in the future prospective randomized studies will be available to answer questions on the optimal hMG dose in different stimulation protocols.     

Clinical and hormonal features of selective follicle-stimulating hormone (FSH) deficiency due to FSH beta-subunit gene mutations in both sexes

OBJECTIVE: To report the clinical, hormonal, and molecular features of a female adolescent with selective FSH deficiency. In addition, a complete review of previous cases is provided, focusing on hormonal aspects. DESIGN: Clinical study. SETTING: University hospital. PATIENT(S): A 16-year-old girl with primary amenorrhea and poor breast development due to isolated FSH deficiency. INTERVENTION(S): Blood drawing before and after GnRH stimulation and pelvic ultrasound examination. MAIN OUTCOME MEASURE(S): Gonadotropin and E(2) measurements and sequencing of the FSH beta-subunit gene. RESULT(S): The patient was referred for primary amenorrhea and partial breast development (Tanner III). Her basal and GnRH-stimulated LH levels were elevated (31 IU/L and 98 IU/L, respectively), whereas her FSH levels were undetectable (<1 IU/L) in both conditions. Estradiol levels were low (<13 pg/mL). Automatic sequencing showed a nucleotide substitution of C for A in exon 3, resulting in a homozygous nonsense mutation in amino acid position 76 (Tyr76X) of the FSH beta-subunit. CONCLUSION(S): The Tyr76X mutation of the FSH beta-subunit was associated with a partial phenotype of FSH deficiency. To date, only four loss-of-function mutations of the FSH beta-subunit have been described in eight patients with undetectable serum FSH and high serum LH levels. Therefore, this unusual hormonal profile strongly suggests a defect in the FSH beta-subunit in both sexes.     

Endocrine evaluation of induction of ovulation with pulsatile and continuous administration of human menopausal gonadotropin (hMG) in anovulatory women

To evaluate the endocrine profiles during induction of ovulation with pulsatile and continuous administration of hMG (Pergonal), 3 patients with polycystic ovarian disease (PCO) and 4 patients with hypothalamic amenorrhea were selected as the subjects. The total dose of hMG per day was 150 IU in each patient. hMG pulse was administered intravenously via a portable infusion pump every 90 min in 4 patients including 3 PCO cases (9.375 IU/pulse) and every 18 min in one patient (1.875 IU/pulse). The remaining 2 patients received continuous subcutaneous infusion of hMG (150 IU/day). Following hMG treatment, 8,000 to 10,000 IU of hCG was used to induce ovulation. All 7 patients ovulated and 4 of them conceived. Pregnancy resulted in 2 patients following pulsatile (every 90 min) administration and in 2 patients after continuous infusion. The duration of hMG treatment needed to induce ovulation was similar among the three modes of administration and within the range of 7 to 10 days. A sustained elevation of circulating FSH levels was observed in all patients and serum estradiol increased more than 3,000 pg/ml in 6 of 7 patients during the course of treatment. Mean (+/- SE) midluteal progesterone level was 107.1 +/- 20.9 ng/ml. Moderate to severe ovarian hyperstimulation occurred in all patients. These results indicate that both pulsatile and continuous administration of hMG are similarly effective in inducing ovulation. They also appear to indicate that the hMG-induced follicular development is profoundly affected by the maintenance of high levels of FSH in the circulation rather than by the mode of administering hMG, whether pulsatile or continuous.     

卵泡刺激素受体基因的点突变和单核苷酸多态性

卵泡刺激素受体(FSHR)是由FSHR基因编码的G蛋白耦联受体蛋白,由胞外区、跨膜区及胞内区3部分构成。胞外区与FSH特异性结合组成FSH/FSHR系统,在人类生殖过程中发挥着重要作用。FSHR基因上突变基因分为活性突变和失活突变2种,失活突变可能导致原发或继发性闭经、高促性腺激素性功能障碍、卵巢早衰及生精功能障碍等生殖疾病,活性突变主要与卵巢过度刺激综合征(OHSS)关系密切。FSHR基因的点突变出现概率非常小,大部分仅有1次报道,而大多数FSHR基因突变为单核苷酸多态性。卵巢和睾丸的正常发育及发挥功能均依赖于完整的FSHR介导,FSHR突变对两性生殖表型的影响存在着差异。     

No Activating Mutations of FSH Receptor in Four Children with Ovarian Juvenile Granulosa Cell Tumors and the Association of These Tumors with Central Precocious Puberty

Study ObjectiveThe stimulation of the follicle-stimulating hormone receptor (FSHR) by circulating FSH or some activating mutations of the FSHR may play a causal role in the development of granulosa cell tumors of ovaries.Study designWe evaluated four patients with ovarian juvenile granulosa cell tumors (age range, 2.4 to 7.2; median, 2.9 years) and five healthy pubertal girls (age range, 16 to 18.5; median, 16.8 years) for activating mutations in exon 10 of the FSHR. The patients were followed and evaluated clinically. Genomic DNA was extracted from the peripheral blood. Exon10 of the FSHR was evaluated for mutations.ResultsAll four patients presented with signs of precocious puberty. One patient, who had markedly accelerated growth velocity and advanced bone age, developed central precocious puberty after the removal of her tumor. Another patient was diagnosed to have a left ovarian cyst without tumor recurrence approximately 3.3 years after the removal of the tumor. Activating mutations were not found, but previously reported polymorphisms (Ser680Asn and Ala307Thr) of the FSHR were detected in three of four patients and in three of five controls. The follow-up period of these four patients ranged from 4.5 to 8.8 years, with a median value of 6.7 years.ConclusionsWe did not find any activating mutation in exon 10 of the FSHR in our patients, and one patient developed precocious puberty after removal of her tumor. The development of ovarian tumors in these patients may have been caused by mutations at other exons of the FSHR and G protein subunits, so the association noted between central precocious puberty and granulosa cell tumors might not be coincidental.     

Genetic defect of a combined 17 α-hydroxylase/17,20-lyase deficiency patient with adrenal crisis

Combined 17 α-hydroxylase/17,20-lyase deficiency (17OHD) is a rare autosomal recessive disease that is a type of congenital adrenal hyperplasia, which results in hypertension, hypokalemia, sexual infantilism, primary amenorrhea in females (46,XX), or pseudohermaphroditism in males (46,XY). It is mainly caused by mutation in the CYP17A1 gene, which encodes a key enzyme in the steroidogenic pathway. However, these patients rarely experience adrenal crisis, due to abnormally high corticosterone levels. Here, we report a 17OHD patient who experienced clinical adrenal crisis on day 1 after gonadectomy. Her (46,XY) genetic defect was c0.715?C?>?T p.Arg239-stop in exon 4 of CYP17A1, which was confirmed by targeted sequence capture/high-throughput sequencing and Sanger sequencing technology. To the best of our knowledge, 17OHD with adrenal crisis has not been reported previously, and the reason why it arose in this patient might have been inappropriate glucocorticoid administration during the perioperative period.     

Ovarian failure without gonadotropin elevation in a patient with post-traumatic isolated hypogonadotropic hypogonadism

A woman with secondary amenorrhea following head trauma showing isolated gonadotropin deficiency of hypothalamic origin did not respond to massive doses of hMG therapy (11 250 IU daily dose). Ovarian biopsy showed the absence of follicles, despite persistently low FSH levels. In this case the occurrence of premature ovarian failure was only suspected from the lack of response to hMG and diagnosed by ovarian histology.     

New mutation causing androgen insensitivity syndrome – a case report and review of literature

Androgen insensitivity syndrome (AIS) is a congenital disorder in which a defect in the androgen receptor (AR) gene leads to cellular resistance to androgens. Defects in the AR gene, located on the X chromosome, result in the development of a feminine phenotype in chromosomally male (46, XY) individuals. In this case report, we present a 44?years old patient with complete androgen insensitivity syndrome (CAIS) initially presenting with primary amenorrhea. The patient underwent a full clinical evaluation, revealing hypoplastic vagina and a lack of uterus and ovaries. Hormonal evaluation revealed markedly elevated testosterone, FSH, and LH serum concentrations. Diagnostic imaging, including pelvic MRI, confirmed the presence of two solid masses in the inguinal canals (right 26?×?13?mm, left 25?×?15?mm). The patient underwent genetic testing, revealing a 46 XY karyotype and an as of yet unprecedented androgen receptor mutation. The type of the mutation was a single-base exchange – the substitution from cytosine to thymine in chromosome X:66942710 position (referred to human reference genome GRCh37), which has resulted in an amino acid changes from leucine (CTT) to phenyloalanine (TTT) in ligand-binding domain.     

Follicle stimulating hormone receptor gene variants in women with primary and secondary amenorrhea

Purpose  

This retrospective study was designed to analyze the FSHR gene variants in subjects with primary and secondary amenorrhea with hypergonadotropic hypogonadism.     

A novel androgen receptor gene mutation in a Chinese patient with complete androgen insensitivity syndrome

Objective

To identify the underlying androgen receptor gene mutation in a Chinese patient with typical symptoms of complete androgen insensitivity syndrome.

Study design

A Chinese female phenotype with 46, XY karyotype was diagnosed because of primary amenorrhea. Mutations were determined by polymerase chain reaction followed by DNA sequencing.

Results

DNA sequencing of the androgen receptor gene showed a G2439T transition causing E442X mutation in exon 1 in the patient with complete androgen insensitivity syndrome. The E442X mutation was a new de novo non-sense mutation in exon 1 of the androgen receptor gene. This non-sense mutation is located in the N-terminal transactivation domain and leads to a predicted truncated protein of 441 amino acids with loss of the end part of the N-terminal transactivation domain, and the DNA-binding and ligand-binding domain.

Conclusion

This E442X non-sense point mutation has not been described previously in cases of androgen insensitivity syndrome, and could lead to the synthesis of a short truncated non-functional androgen receptor probably responsible for the phenotype of complete androgen insensitivity syndrome in the affected individual. Gonadectomy should be planned to eliminate the risk of gonadal malignancy.     

Efficacy of low-dose hCG in late follicular phase in controlled ovarian stimulation using GnRH agonist protocol

Objective

Safe, simple and cost-effective protocol is an important goal in ART cycles. The aim of this prospective study was whether administration of low-dose hCG in late follicular phase can be used clinically to replace gonadotropin administration in GnRH long protocol.

Materials and methods

122 patients who were candidates for ART enrolled the study and randomly divided into two groups. The control group (n?=?62) received standard long protocol and gonadotropin administration continued until the day of hCG injection (10,000?IU) for final follicular maturation. The study group (n?=?60) received GnRH long protocol and when at least ??6 follicles with mean diameter ??12?mm were observed in both ovaries, hMG was displaced by 200?IU per day of hCG until final follicular maturation.

Results

There were no significant differences in age, basal FSH, infertility duration and infertility etiology between two groups. There were no statistically significant differences between two groups regarding chemical pregnancy, clinical pregnancy, ongoing pregnancy, and abortion per cycle (50, 40, 40, and 20?% in study group vs. 45.2, 35.5, 35.5, and 21.4?% in control group, respectively). Mean dose of used gonadotropins was significantly higher in control group than that in the study group (2,524?±?893?IU in control group and 1,439?±?433?IU in study group) (p?=?0.000).

Conclusion

According to our data, we recommend the use of low-dose hCG in GnRH long protocol because of lower doses of used gonadotropins.     

Germline study of AR gene of Indian women with ovarian failure

Objective.?Present study was designed for carrying out the mutational analysis of the entire Androgen receptor (AR) gene including two microsatellite (CAG)n, (GGN)n, promoter region in cases of premature ovarian failure (POF) and primary amenorrhea (PA).

Design.?Previous reports of AR knockout mice model showed POF phenotype, this draws an attention on the role of AR gene in the aetiology of POF for the case–control association studies in POF samples (n?=?133), PA samples (n?=?63) and control samples (n?=?200).

Results.?We identified six mutations including four novel mutations, i.e. c.636G?>?A, c.1885?+?9C?>?A, c.1948A?>?G, c.1972C?>?A, and two previously reported mutations, i.e. c.639G?>?A, c.2319?78T?>?G. Repeat length variation was noted in the two microsatellite regions CAG and GGN, located in the coding region of exon 1 at the N-terminal region of the AR gene. The CAG repeat length was homogenously distributed with the same frequency and no association among all cases and controls. The GGN repeat showed a significant association among the SS and SL allele with p?=?0.0231 and p?=?0.0476, respectively, among the POF/control samples.

Conclusions.?Thus, AR gene mutations may play a role in the genetic cause of POF. Identification of the underlying genetic alteration of the AR gene is important for a proper diagnosis of POF subjects.     

Cotreatment with human growth hormone and gonadotropins for induction of ovulation: a controlled clinical trial

A randomized, double-blind, placebo-controlled trial of cotreatment with biosynthetic, human sequence, growth hormone (GH), and human menopausal gonadotropins (hMG) for induction of ovulation was performed in 16 women with amenorrhea and anovulatory infertility. Patients were randomly allocated to treatment with hMG + GH (24 IU on alternate days, total dose 144 IU) or hMG + placebo. Those who received placebo were given GH in a subsequent course of treatment. On cotreatment with GH compared with placebo, there was a significant reduction in the required dose of hMG, duration of treatment, and the daily effective dose of gonadotropins. Serum insulin-like growth factor-I (IGF-I) rose during treatment with GH but not with placebo. We conclude that growth hormone augments the response of the human ovary to stimulation by gonadotropins. These results suggest a role for the use of GH in induction of ovulation.     

Genotyping of a Chinese family with 46,XX and 46,XY 17-hydroxylase deficiency

Background.?17-Hydroxylase deficiency is a rare form of congenital adrenal hyperplasia caused by CYP17A1 gene mutations.

Method.?A 46,XY and a 46,XX Chinese patients with 17-hydroxylase deficiency in a family and their four generations family members were genotyped by PCR-sequencing method.

Results.?Two CYP17 gene mutations were identified from these patients. Among them, IVS1-1G > A was a novel splicing mutation which disrupted the acceptor signal of exon 2 and might create a new exon after exon 1. The indel mutation of TAC329AA was a one-base deletion mutation and one-base change at codon 329 in exon 6.

Conclusion.?The results confirmed the diagnosis of 17-hydroxylase deficiency in these two patients and their autosome recessive heritage mode. The TAC329AA indel mutation had been identified in several reports of Chinese and Asian, suggesting that codon 329 was an unstable point of the CYP17 gene and this mutation was a prevalent CYP17 mutation in the Asian population. Although the noval mutation IVS1-1G > A founded in this family need more study to know its machinism of interrupting P450c17 function.     

用人绝经期尿促性腺激素治疗无排卵性不孕症110例分析

１９９０年１１月至１９９２年３月上海四家医院用国产人绝经期尿促性腺激素（ｈＭＧ）治疗无排卵性不孕症１１０例。患者平均３１．２岁，平均闭经时间５．９年，原发不孕症者占７９％。用ｈＭＧ－ｈＣＧ序贯法治疗１９８个周期，平均每个周期用药３３针。结果：１００例排卵率１００％，周期排卵率９４％，妊娠率５０％，周期妊娠率２７％。卵巢过度刺激综合征发生率３４．３％（轻度１０．９％，中度１９％，重度４．５％），双胎发生率１４．５％。表明国产ｈＭＧ对低促性腺激素性团经和无排卵性稀发月经的治疗效果令人满意。     

Ovarian hyperstimulation in polycystic ovary syndrome during therapy with leuprolide acetate

Continuous exposure to GnRH eliminates the pituitary as a source of gonadotropins and may have direct suppressive effects on the ovary. A woman with PCO syndrome received leuprolide acetate (1 mg/d SC) for 4 weeks before and simultaneously with hMG stimulation. Human chorionic gonadotropin (5,000 IU) was administered IM on the 8th day of hMG therapy. There were 10 follicles greater than 15 mm and a polycystic appearance to the ovaries with 25 follicles measuring less than 10 mm. The serum E2 concentration was 2,280 pg/mL. She developed severe ovarian hyperstimulation and required hospitalization for 12 days for fluid management. A viable intrauterine pregnancy was present. Four weeks of pretreatment with leuprolide did not prevent hyperstimulation in the presence of an intrauterine pregnancy.     

Genetic polymorphisms of <Emphasis Type="Italic">FSHR,CYP17, CYP1A1, CAPN10, INSR,SERPINE1</Emphasis> genes in adolescent girls with polycystic ovary syndrome

Background  Polycystic ovary syndrome (PCOS), whose genetic basis is not completely well understood, is the most common endocrine disorder in women and it typically develops during adolescence. The aim of this study is to investigate the possible association between single nucleotide polymorphisms (SNPs) of FSHR, CYP17, CYP1A1, CAPN10, INSR, SERPINE1 genes and PCOS in adolescent girls. Methods  DNA samples from forty-four adolescent girls with PCOS and 50 healthy controls were analyzed by PCR-RFLP and direct DNA sequencing to determine the genotypic frequency of 17 different polymorphic loci on the FSHR (A307T, N680S), CYP17 (−34 T/C), CYP1A1 (T6235C), CAPN10 (44, 43, 19, 63), INSR (exon 17 C/T), SERPINE1 (4G/5G) genes. Genotyping of exon 12 (six polymorphisms) and intron 12 (one polymorphism) of INSR gene by direct DNA sequencing was performed for the first time in this study. Results  No significant differences were observed in the genotype and allele distributions of above mentioned polymorphisms between cases and control groups. Conclusion  Our data does not support an association between SNPs of FSHR, CYP17, CYP1A1, CAPN10, INSR, SERPINE1 genes and susceptibility to PCOS or related traits in Turkish adolescent girls.     

FSH β-subunit mutations in two sisters: the first report from the Indian sub-continent and review of previous cases

Isolated FSH deficiency due to mutations in the gene for β-subunit of FSH is an extremely rare autosomal recessive disease of which only eleven cases have been reported so far. The clinical features include absent breast development and primary amenorrhea in females and azoospermia with normal testosterone levels in males. In this study we report two Kashmiri sisters born to native Kashmiri consanguineous parents with failure of onset of puberty. Hormonal evaluation revealed undetectable serum FSH and estradiol and high LH. Genetic analysis of FSH β-gene identified one nonsense mutation (c.343C?>?T:p. Arg115Stop) in exon 3. The two sisters were homozygous for this nonsense mutation while the parents were heterozygous. Incorporation of a stop codon at 115 codon position is predicted to result in the formation of truncated FSH β protein, lacking 14 amino acid from the carboxy-terminus (p.Arg115Stop). Very recently, this same mutation was reported for the first time in a Chinese male. Ours is the first ever report of any FSH β-subunit mutation from the Indian sub-continent and this particular mutation in any female from anywhere in the world. We conclude and emphasize that this diagnosis should be considered in girls with delayed puberty and selective deficiency of FSH.     

卵泡刺激素受体与卵巢癌

卵巢癌是女性生殖系统最常见恶性肿瘤之一,以高复发率、高死亡率为特点。卵巢癌病因至今尚不明。大量研究显示,卵泡刺激素（FSH）与卵巢癌的发生密切相关。FSH对卵巢的作用主要是通过与卵泡刺激素受体（FSH Receptor,FSHR）特异性结合而介导。近年研究发现,在FSHR基因第10外显子及启动子序列的单核苷酸多态性,以及外显子不同剪接机制所致的异构体,可能对FSHR表达及其与FSH的结合产生影响。 而FSHR缺失或过度表达都可能影响正常的信号转导,从而促进肿瘤发生。     

Induction of ovulation with pulsatile subcutaneous administration of human menopausal gonadotropin in anovulatory infertile women

Pulsatile administration of human menopausal gonadotropin (hMG) via the subcutaneous route was evaluated in 15 patients with various ovulatory disorders. Administration of hMG was started at a dose of 4.6875 IU (75 IU/day) or 9.375 IU (150 IU/day) per pulse every 90 minutes. Ovulation was observed in 26 (92.9%) of 28 treatment cycles, and two singleton pregnancies were confirmed. Ovarian hyperstimulation was observed in 1 to 26 ovulatory cycles; however, no other side effects were observed during treatment. A regimen of 75 IU/day resulted in a significant increase (P less than 0.0001) of the total dose and prolongation of the treatment period for induction of ovulation, as compared with that of 150 IU/day. Shortened luteal phases occurred in ovulatory cycles induced by pulsatile subcutaneous treatment. Human chorionic gonadotropin administration given every other day until the midluteal phase significantly prolonged the duration of the luteal phase (P less than 0.05). This treatment in patients with the polycystic ovary syndrome was followed by a normalization of luteinizing hormone/follicle-stimulating hormone ratio and resulted in a successful induction of ovulation in 8 to 10 cycles. The present data demonstrated that pulsatile subcutaneous administration of hMG was effective in inducing follicular maturation and ovulation in patients with various types of anovulatory infertility.