Induction of endometrial cycles and ovulation in a woman with combined 17α-hydroxylase/17,20-lyase deficiency due to compound heterozygous mutations on the P45017α gene

Objective: To describe the case of a Japanese woman with combined 17α-hydroxylase/17,20-lyase deficiency (congenital adrenal hyperplasia type V) and to discuss possible therapeutic procedures in such patients.Design: Case report.Setting: University hospital.Patient(s): A 26-year-old woman with secondary amenorrhea and primary sterility.Intervention(s): Nucleotide sequencing of the P45017α gene (CYP17), induction of endometrial maturation with steroid hormone replacement, and ovulation induction with gonadotropin.Main Outcome Measure(s): Nucleotide sequence of CYP17, endometrial thickness and follicle diameter measured by transvaginal ultrasonography, and histologic evaluation of the endometrium.Result(s): Two different mutations were detected on CYP17: One was a deletion of the phenylalanine codon (TTC) at either amino acid 53 or 54 in exon 1, and the other was a missense mutation with the substitution of histidine (CAC) by leucine (CTC) at position 373 in exon 6. Repeated histologic evaluations performed during treatment with P consistently revealed an unripe endometrium with glands of the early secretory phase and markedly scanty stroma. Ultrasound examination revealed follicular growth and ovulation after gonadotropin administration, but insufficient thickness of the endometrium.Conclusion(s): Ovulation induction was possible in this patient with 17α-hydroxylase/17,20-lyase deficiency, but the endometrial response to steroid hormone replacement was extremely poor.     

Seventeen alpha-hydroxylase deficiency.

Seventeen alpha-hydroxylase deficiency (17OHD) is a rare form of congenital adrenal hyperplasia in which defects in the biosynthesis of cortisol and sex steroid result in mineralocorticoid excess, hypokalemic hypertension and sexual abnormalities such as pseudohermaphroditism in males, and sexual infantilism in females. The disease is inherited in an autosomal recessive pattern, and is caused by mutations in the gene encoding cytochrome P450c17 (CYP17), which is the single polypeptide that mediates both 17alpha-hydroxylase and 17,20-lyase activities. We report the case of a 15-year-old patient with 17OHD who had a female phenotype but male karyotype (46,XY). The diagnosis was made based on classical clinical features, biochemical data and molecular genetic study. Two mutations were identified by polymerase chain reaction amplification and sequencing, including a S106P point mutation in exon 2 and a 9-bp (GACTCTTTC) deletion from nucleotide position 1519 in exon 8 of CYP17. The first of these mutations was found in the father and the second in the mother, and both have been previously reported in Asia. The patient's hypertension and hypokalemia resolved after glucocorticoid replacement and treatment with potassium-sparing diuretics. Sex hormone replacement was prescribed for induction of sexual development and reduction of the final height. Prophylactic gonadectomy was scheduled. In summary, 17OHD should be suspected in patients with hypokalemic hypertension and lack of secondary sexual development so that appropriate therapy can be implemented.     

Homozygous CYP17A1 mutation (H373L) identified in a 46,XX female with combined 17α-hydroxylase/17,20-lyase deficiency

Background: Defects in cytochrome P450c17 are uncommon forms of congenital adrenal hyperplasia caused by CYP17A1 mutations. An H373L mutation in the CYP17A1 gene has been identified in Japanese and Chinese patients. This mutation impairs 17α-hydroxylase and 17,20-lyase activity. Case: A 23-year-old Korean female (46,XX) presented with absent spontaneous puberty and hypertension. Hormonal findings were consistent with combined 17α-hydroxylase/17,20-lyase deficiency. Very high levels of progesterone and 11-deoxycorticosterone were detected, coincident with normal 17-hydroxysteroid levels. Plasma levels of dehydroepiandrosterone, androstenedione and testosterone were extremely low. Mutation analysis of the CYP17A1 gene identified a homozygous missense mutation changing His (CAC) to Leu (CTC) at codon 373. This mutation is known to completely abolish both 17α-hydroxylase and 17,20-lyase activity. The patient’s nonconsanguineous parents were heterozygous for this mutation. Of note, her serum steroid levels indicated decreased, but still present, 17α-hydroxylase activity in vivo. Conclusion: We detected a homozygous H373L mutation in a patient with combined 17α-hydroxylase/17,20-lyase deficiency. Our findings demonstrate minimally preserved 17α-hydroxylase activity in vivo and contribute to our knowledge of the regional prevalence of this mutation in Northeast Asia.     

Human chorionic gonadotropin reduces aromatizable androgens and aromatase activity in women stimulated by clomiphene citrate and human menopausal gonadotropin

Periovulatory steroidal dynamics in women undergoing ovulation induction with clomiphene citrate and human menopausal gonadotropin were studied in 31 women with tubal blockage. Serum estradiol levels were significantly reduced 36 hours after human chorionic gonadotropin administration (from 1792 +/- 162 to 926 +/- 132 pg/ml, p less than 0.001). Peripheral levels of testosterone and androstenedione did not change during this periovulatory time. Progesterone and 17 alpha-hydroxyprogesterone, as anticipated, significantly increased with an early rise noted within the first 8 hours of human chorionic gonadotropin administration (p less than 0.001). A significant reduction of the ratios of the steroidal pairs 17 alpha-hydroxyprogesterone-progesterone (17 alpha-hydroxylase) and androstenedione-17 alpha-hydroxyprogesterone (17,20-desmolase) was observed after human chorionic gonadotropin injection (p less than 0.001). Aromatase activity appeared to be inhibited because of a significant reduction in the estradiol/testosterone ratio 34 to 36 hours after human chorionic gonadotropin administration. Thus human chorionic gonadotropin, which triggers ovulation in women treated by clomiphene citrate-human menopausal gonadotropin, appears to partially reduce aromatizable substrate as well as inhibit aromatase activity.     

A rare enzymatic defect,true isolated 17,20-lyase deficiency leading to endocrine disorders and infertility: case report

Abstract

The cytochrome P450 17A1 catalyzes the formation of 17-hydroxysteroids and 17-ketosteroid. Most defects in CYP17A1 impair both enzymatic activities and cause a combined 17α-hydroxylase/17,20-lyase deficiency, which impairs hormone production (cortisol and sex steroids), sexual development, and puberty. Isolated 17,20-lyase deficiency is usually defined by evidently normal activity of 17α-hydroxylase with a dramatic decline of 17,20-lyase activity or complete inactivity. The changes in enzyme activity lead to a lack in the production of sex steroids with normal levels of glucocorticoid and mineralocorticoid hormones. A 24-years-old married woman, as a product of a consanguineous marriage, presented with infertility and a background marked by primary amenorrhea. Laboratory data showed low normal serum cortisol levels and low levels of 17-hydroxyprogesterone. Also, her adrenal androgens were low but estradiol was normal. The chromosomal investigation uncovered a male karyotype of 46, XY. These clinical and laboratory evidence confirm the determination of an isolated 17,20-lyase deficiency in a genotypic male.     

Induction of luteal phase defect with clomiphene citrate

The effect of clomiphene citrate and progesterone on luteal function in infertile women was studied. Endometrial biopsies were performed in 103 women immediately prior to menstruation. Group 1 (n = 62) had secretory endometrium with a histologic lag time of ≥48 hours with respect to the subsequent menses, that is, luteal phase defect. Group 2 (n = 10) had normal histologic characteristics of the secretory phase. Group 3 (n = 31) had anovulatory endometrium. The last group was subdivided into those with polycystic ovary syndrome (n = 9) and those without the characteristic gonadotropin pattern of polycystic ovary syndrome (n = 22). Clomiphene citrate at doses of 50 to 250 mg daily for 5 days was administered for induction of ovulation, timing of ovulation, or treatment of luteal phase defect. An endometrial biopsy was obtained after three ovulatory treatment cycles. Only one fourth of the women with prior luteal phase defect had normalization of the biopsy specimen with clomiphene citrate, while one half of those treated with progesterone had normal specimens. Half of the normally ovulating women had induction of a luteal phase defect with clomiphene citrate. Only women with polycystic ovary syndrome had consistently well-timed endometrial histologic features with clomiphene citrate therapy. Despite successful induction of ovulation, 16 of the other 22 previously anovulatory women had endometrial histologic findings compatible with luteal phase defect. Increasing the clomiphene citrate dosage was unsuccessful in improving endometrial maturation. These results suggest that the use of clomiphene citrate may be associated with a high rate of luteal phase defect induction, except among women with polycystic ovary syndrome. Clomiphene citrate, even at high doses, appears to be ineffective therapy for luteal phase defect.     

Overview of dehydroepiandrosterone biosynthesis

The biosynthesis of dehydroepiandrosterone (DHEA) from cholesterol involves only two enzymes, both cytochrome P450s. The conversion of cholesterol to pregnenolone is mediated by cholesterol side-chain cleavage enzyme (CYP11A1), which is found in the mitochondria. The cleavage of pregnenolone to DHEA requires both the 17alpha-hydroxylase and 17,20-lyase activities of CYP17, which is found in the endoplasmic reticulum. These conversions require pairs of electron transfer proteins or redox partners, which are adrenodoxin and adrenodoxin reductase for CYP11A1 and cytochrome P450-oxidoreductase and cytochrome b5 for CYP17. In addition, the steroidogenic acute regulatory (StAR) protein regulates the flux of cholesterol into the biosynthetic pathway and represents the mechanism of acute regulation. Finally, in addition to possessing CYP11A1 and CYP17, it is equally important that a steroidogenic cell not contain other enzymes that drain the flux of pregnenolone to DHEA. These characteristics are illustrated by the fetal adrenal cortex and the zona reticularis, which are dedicated to the synthesis of DHEA and DHEA-sulfate.     

Pubertal delay, hypokalemia, and hypertension caused by a rare form of congenital adrenal hyperplasia

A 17-year-old female presented with diffuse muscle weakness secondary to severe hypokalemia, metabolic alkalosis, and hypertension. Additional findings included delayed puberty with primary amenorrhea. Laboratory evaluation led to a diagnosis of 17 alpha-hydroxylase/17,20-lyase (P450c17) deficiency, a form of congenital adrenal hyperplasia (CAH). Her symptoms and metabolic derangements improved with glucocorticoid replacement to suppress ACTH production and mineralocorticoid excess, although she continues to require antihypertensive therapy. Estrogen replacement was initiated due to sex hormone insufficiency. This rare disorder should be considered when evaluating patients with pubertal delay and hypertension, particularly if there is associated hypokalemia.     

Ovulation induction in a woman with premature ovarian failure resulting from a partial deletion of the X chromosome long arm, 46,X,del(X)(q22)

Objective: To report successful ovulation induction in a woman with premature ovarian failure (POF) resulting from a partial Xq deletion.Design: An uncontrolled study. Setting: University hospital.Patient(s): A 27-year-old woman with 46,X,del(X)(q22) who had hypergonadotropic secondary amenorrhea.Intervention(s): Injections of hMG (225 IU/d) for 8 consecutive days after endogenous gonadotropin suppression with a long-acting GnRH agonist (900 μg/d) for 12 weeks, together with cyclic sex steroid replacement therapy.Main Outcome Measures: Serum concentrations of E₂ and P as well as ultrasonography.Result(s): Folliculogenesis and ovulation.Conclusion(s): Ovulation induction is possible in patients with POF caused by X chromosome aberrations.     

促排卵周期PCOS妇女子宫内膜纤维粘连蛋白及层粘连蛋白的表达

目的:了解促排卵药物氯米酚(CC)、hMG及GnRH-a对黄体中期子宫内膜内膜纤维粘连 蛋白(FN)及层粘连蛋白(LN)表达的影响。方法:应用单克隆抗体,采用免疫组织化学技术检测50 例正常妇女自然周期以及50例正常妇女,45例多囊卵巢综合征妇女应用CC／hCG,CC／hMG／hCG 及GnRH-a／hMG／hCG方案促排卵治疗后黄体中期子宫内膜FN和LN的表达。结果:子宫内膜FN 和LN表达在正常妇女自然周期着床窗口时呈现强阳性;而CC、hMG抑制FN和LN的表达,使 其阳性强度减弱,有显著性统计学差异P<0．01;GnRH-a对FN和LN抑制不明显。同时妊娠者较 未妊娠者FN和LN表达强度高。结论:CC／hCG及CC／hMG／hCG方案促排卵后黄体中期子宫内膜 中FN和LN表达下降或缺失,内膜容受性下降,妊娠率降低。     

A new compound heterozygous mutation in the CYP17A1 gene in a female with 17α-hydroxylase/17,20-lyase deficiency

Abstract

Background: Congenital adrenal hyperplasia due to 17α-hydroxylase/17,20-lyase deficiency (OMIM #202110) is a rare autosomal recessive disorder, which is caused by mutations of the CYP17A1 gene located on chromosome 10q24.3. It has been reported that the type of mutation of the CYP17A1 gene was associated with the extent of 17α-hydroxylase/17,20-lyase deficiency, and the prevalence of common mutation was different among ethnic groups.

Case: A 21-year-old Korean female presented with primary amenorrhea and sexual infantilism, and intermittent hypokalemic episodes. Laboratory test was consistent with hypergonadotropic hypogonadism. The karyotype was 46,XX[20]. Genomic DNA was extracted from peripheral blood leukocytes. All the eight exons of the CYP17A1 gene including flanking regions of introns were amplified by PCR. The mutations of the CYP17A1 gene were detected by direct sequencing. A compound heterozygous mutation was identified; one allele had a missense mutation of c.1118A>T (p.His373Leu), which was reported previously and induced the complete loss of both 17α-hydroxylase/17,20-lyase activity. This mutation has been known to be one of the common mutation types in East Asia. The other allele had a novel 1-bp deletion c.1148delA causing frameshift, premature termination codon (p.Glu383fs) and induced truncated enzymes.

Conclusion: Our experience for stepwise clinical, laboratory and molecular approach would be helpful to diagnose these patients accurately and understand the genetic events in 17α-hydroxylase/17,20-lyase deficiency patients.     

Villous papyraceous: an unusual cause of tamoxifen-induced postmenopausal bleeding.

OBJECTIVE: We describe an unusual histological finding in a woman with postmenopausal bleeding who was being treated with tamoxifen for breast cancer. METHOD: This patient presented with a history of postmenopausal bleeding, 4 years after her last period. Pelvic ultrasound showed a thickened cystic endometrium and bulky uterus. A diagnostic endometrial aspiration biopsy by Pipelle was performed; at this time, urinary beta-human chorionic gonadotropin was negative. RESULTS: Histology showed villous papyraceous (sclerosed and mummified chorionic villi) in a background of scanty atrophic endometrium. CONCLUSION: Tamoxifen has dual estrogenic and antiestrogenic effects; the estrogenic effects have been associated with ovulation induction in premenopausal women. This effect, however, has not been documented in postmenopausal women. We conclude that the presence of chorionic villi is, in this instance, likely to be a tamoxifen-mediated effect.     

Histology of midluteal corpus luteum and endometrium from clomiphene citrate-induced cycles.

OBJECTIVE: To determine the histologic development of midluteal corpus luteum (CL) and endometrium in normal fertile women after induction of ovulation with clomiphene citrate (CC). DESIGN, PATIENTS, INTERVENTIONS: Twelve normally cycling women planning to undergo an elective tubal ligation were treated with 50 to 150 mg of CC daily on days 5 through 9 of the cycle. Luteectomy and endometrial biopsy were performed simultaneously 7 days after the urinary luteinizing hormone surge. RESULTS: Because polyovulation occurred in 10 of the 12 women, 22 CL and 12 endometrial biopsies were studied. Ten women had luteal and endometrial histology that were within 2 days of the ovulation to biopsy interval. The 2 remaining women had endometrial histology that lagged 3 days behind the chronological postovulatory date. In these women, out-of-phase endometrium occurred despite polyovulatory cycles in which two and three histologically normal CL lutea were present and associated with elevated progesterone concentrations. CONCLUSIONS: In CC-induced ovulatory cycles: (1) midluteal CL histology is normal and (2) apparently out-of-phase preimplantation endometrium occurs in midluteal phase.     

Investigations on the genetic polymorphism in the region of CYP17 gene encoding 5'-UTR in patients with polycystic ovarian syndrome.

Polycystic ovarian syndrome (PCOS) is a prevalent endocrine disorder, which is the most common cause of anovulatory infertility and hirsutism. It is caused by an overproduction of androgens in theca cells. In the ovary, androgen synthesis is regulated by 17 alpha-hydroxylase/17,20-lyase enzyme complex containing P450c17 (CYP17). In some individuals, the promoter region of CYP17 gene contains a T-->C substitution that creates an Sp1 site at position-34. This polymorphism generates a recognition site for the MspA1 restriction enzyme. The objective of the study was to investigate the frequency of T-->C substitution of CYP17 gene promoter in women with PCOS and elucidate its role in the pathogenesis of the syndrome. Another aim of the study was to compare the results with the levels of the hormones luteinizing hormone, follicle-stimulating hormone, testosterone and estradiol. The present investigation involved a group of 55 women with PCOS and 56 healthy women without symptoms of PCOS. Following digestion with restriction enzyme MspA1, it was demonstrated that the polymorphic A2 allele is no more frequent in women with PCOS than in healthy women. In the PCOS group, the hormonal profiles were not significantly different in the carriers of a normal allele A1A1 from the carriers of A1A2 and A2A2 alleles. It is concluded that T-->C polymorphism of CYP17 gene is not associated with steroid hormone synthesis in PCOS and is not the primary genetic defect in this disease.     

促排卵治疗对多囊卵巢综合征患者子宫内膜整合素αv,β3表？…

目的 了解促排卵药物对多囊卵巢综合征（ＰＣＯＳ）患者黄体中期子宫内膜整合素αｖ、β３表达的影响。方法 应用单克隆抗体,采用免疫组织化学技术对２２例正常妇女、４０例无排卵ＰＣＯＳ患者促排卵治疗后黄体中期的子宫内膜整合素αｖ、β３进行测定。结果正常妇女子宫内膜整合素αｖ、β３表达在“着床窗口期”呈现强阳性;而氯米芬（ＣＣ）及绝经期促性腺激素（ｈＭＧ）抑制αｖ、βｂ的表达,使其表达呈弱阳性;而促性腺素释     

Endometrial morphology after 6 months of continuous treatment with a new gonadotropin-releasing hormone superagonist for contraception

Light and electron microscopic studies were performed on endometrial curettage specimens from 27 women after 6 months of contraceptive treatment with continuous intranasal gonadotropin hormone-releasing hormone (GnRH) superagonist. The GnRH superagonist nafarelin acetate (D-Nal[2]6-GnRH) was used in single daily doses of 125 or 250 micrograms. Ovulation was inhibited during all but one of the 159 treatment months. No pregnancies occurred. In 6 women with fairly regular bleedings, the endometrium displayed weak to normal proliferation. Twenty women developed oligomenorrhea or amenorrhea, 16 of them had inactive endometrium, 1 had weakly proliferative endometrium, and 3 endometrial biopsies were too sparse for adequate evaluation. One woman reported repeated episodes of heavy uterine bleedings. The endometrial biopsy from this woman showed weak proliferation. No signs of endometrial hyperplasia were observed. Generally, the electron microscopy showed signs of low metabolic activity and weak protein synthesis. Thus, long-term continuous treatment with nafarelin acetate for inhibition of ovulation does not appear to have untoward effects on the endometrium.     

自然及促排卵周期子宫内膜整合素α4β1的表达

目的 了解氯米芬（CC）、绝经期促性腺激素（hMG）对黄体中期子宫内膜整合素α4β1表达的影响。方法 应用单克隆抗体,采用免疫组织化学技术检测48例正常妇女自然周期以及48例正常妇女、30例多囊卵巢综合征患者应用CC／绒毛膜促性腺激素（hCG）及CC／hMG/hCG方案促卵治疗后黄体中期子宫内膜整合素α4β1的表达。结果 子宫内膜整合素α4β1在正常妇女自然周期着床窗口期呈现强阳性表达,而CC、hMG抑制整合率α4β1的表达,两者比较,差异有极显著性（P＜0．01）;妊娠者较妊娠者整合素α4β1表达强度高。结论 促排卵周期黄体中期整合素α4β1表达下降或缺失,子宫内膜容受性下降,妊娠率降低。     

A new compound heterozygous mutation in a female with 17α-hydroxylase/17,20-lyase deficiency,slipped capital femoral epiphysis,and adrenal myelolipoma

Abstract

17α-Hydroxylase/17,20-lyase deficiency (17-OHD) is a rare disease caused by mutations of the CYP17A1 gene. Slipped capital femoral epiphysis (SCFE) rarely occurs in adults. There are occasional reports of adrenal myelolipoma (AML) in 17-OHD. A 27-year-old Chinese female (46, XX) visited the hospital for SCFE and presented with continuous hypokalemia, absent spontaneous puberty, and hypertension. Hypergonadotropic hypogonadism was detected. The laboratory tests were consistent with 17-OHD. AML was considered based on the imaging examinations. A mutation analysis of the CYP17A1 gene identified the following compound heterozygous mutation: a frame-shift mutation, i.e. c.985_987delTACinsAA (p.Tyr329fs), that had been reported to be a common mutation in the Chinese population was found in exon 6. Another new nonsense mutation, i.e. c.1270C?>?T (p.Gln424*), that causes a premature termination codon was found in exon 8. Treatment with prednisone had poor efficacy. The administration of 0.75?mg dexamethasone and estradiol/dydrogesterone cyclic treatment significantly improved the patient’s symptoms. For the first time, we report a 17-OHD case accompanied by SCFE, AML, and a novel mutation site in the CYP17A1 gene. We provide insight into the clinical manifestations, genetic analysis, and treatment options of 17-OHD.     

Is it possible to run a successful ovulation induction program based solely on ultrasound monitoring? The importance of endometrial measurements

OBJECTIVE: To attempt the monitoring of ovulation induction solely with ultrasound (US). DESIGN: Using serial US measurements to monitor ovulation induction using human menopausal gonadotropin and human chorionic gonadotropin (hCG), in comparison with estradiol (E2) concentrations that became available at the end of each cycle. SETTING: Specialist Reproductive Endocrine Unit. PATIENTS, PARTICIPANTS: Twenty hypogonadotropic and 29 ultrasonically diagnosed polycystic ovary patients. MAIN OUTCOME MEASURE: Follicular growth, uterine measurements, endometrial thickness, and serum E2 concentrations. RESULTS: Follicular growth, uterine measurements, and endometrial thickness correlated strongly with E2 concentrations (P less than 0.0001). The endometrium on the day of hCG administration was significantly thicker (P less than 0.01) in the conception (n = 27) compared with the nonconception cycles (n = 87), whereas no significant difference were observed in serum E2 concentrations. No pregnancy was observed when hCG had been administered when the endometrial thickness was less than or equal to 7 mm. Midluteal endometrial thickness of greater than or equal to 11 mm was found to be a good prognostic factor for detecting early pregnancy (P less than 0.008). CONCLUSIONS: Serial US examinations used alone have proven to be safe and highly efficient. It also has a unique ability to detect pregnancy in the midluteal phase.     

Unusual presentation of a woman with polycystic ovaries and complex endometrial pathology

A 28-year-old woman with polycystic ovarian syndrome (PCOS) had attempted four assisted conception treatments, all of which were complicated by lack of response of the endometrium to the hypo-oestrogenic state induced with gonadotrophin releasing hormone analogue (GnRHa). Consequently, two treatment cycles were abandoned, one prior to the ovulation induction of a fresh IVF treatment and the other prior to oestrogen replacement for a frozen-thawed embryo transfer treatment cycle. Extended down-regulation eventually resulted in endometrial thinning and allowed completion of the other two treatments, but the outcome was negative. A targeted mid-cycle ultrasound scan in a natural cycle at follow-up showed thick, non-homogenous endometrium. A repeat hysteroscopy on this occasion showed abnormal endometrium with chalk-like deposits. Histological diagnosis was chronic endometritis and endometrial hyperplasia with focal atypia. Microbiological tests, including those for Mycobacterium tuberculosis, were negative. Because of atypical endometrial hyperplasia, this patient is currently under close follow-up by the original referring team. This case highlights inherent endometrial pathology presenting as non-responding endometrium to hormonal down-regulation, the limitations of conventional ultrasound scans, and the complimentary role of concomitant hysteroscopy in the correct identification of endometrial lesions that may negatively affect the assisted conception treatments.