Elevated Serum FSH Levels Research Articles

OVULATION INDUCTION AND SUCCESSFUL LIVE DELIVERY IN A 46.5-YEAR-OLD WOMAN IN OVERT MENOPAUSE BY RESTORING FOLLICULAR SENSITIVITY TO FOLLICLE STIMULATING HORMONE (FSH)

To try to up-regulate FSH receptors on granulosa-theca cells in a woman of very advanced reproductive age in overt menopause whose FSH receptors had been internalized related to elevated serum FSH levels, by inhibiting release of FSH from the pituitary by negative feedback of estrogen. The overall objective was to deliver a live healthy baby. Ethinyl estradiol (EE) 20 micrograms was given to a woman age 46.5 who had amenorrhea for 9 months and who was in overt menopause, as evidenced by failure to have menses following 10mg medroxyprogesterone acetate x 13 days. In addition, the patient had a serum estradiol (E2) of <15 pg/mL, a serum FSH of 117 mIU/mL, and a serum anti-Mullerian level of <0.09 ng/mL. She was treated with EE to lower serum FSH levels rather than E2 because the former does not contribute to the total serum E2 level, and thus allows the treating physician to detect when a follicle has been recruited by rising serum E2 levels. A rising E2 would dictate the addition of pelvic sonography to help determine when a mature dominant follicle was achieved (18mm average diameter with serum E2 ≥200pg/mL). If a mature follicle was achieved, 1mg granulocyte colony stimulating factor (G-CSF) would be given the day before an injection of 10,000 units human chorionic gonadotropin (hCG) to help the oocyte release. At age 42 she had been treated for infertility and was found to have the luteinized unruptured follicle syndrome. She failed to release the oocyte with either hCG or leuprolide acetate but was successful with hCG when G-CSF was added (and delivered a healthy baby despite a day 3 serum FSH of 47 mIU/mL). Progesterone vaginal suppositories 200mg twice daily was supplemented in the luteal phase. After 44 days of EE she was able to attain a mature follicle (E2 273 pg/mL, follicular size 18.8mm average diameter). She released the oocyte, conceived and successfully delivered a full-term healthy baby. A previous case was reported in Human Reproduction in 2000 of a 45-year-old in overt menopause. Successful reversal of menopause was achieved, and she delivered a live baby utilizing this same technique of restoration of FSH sensitivity by using EE without any exogenous FSH stimulation. Precedents are important for patient-physician decisions regarding treatment options. This case shows a live delivery is possible even in a 46.5-year-old menopausal woman using her own oocytes.

Retrospective outcome in women aged 45 years and older undergoing natural cycle IVF treatment

Research questionIs natural cycle IVF treatment beneficial to middle-aged women with poor ovarian response? DesignRetrospective investigation of outcomes in women aged 45 years and older, who underwent natural cycle IVF treatment between 2009 and 2018 in a single assisted reproduction clinic with the aim of reporting several successful outcomes. ResultsIn total, 2408 IVF retrievals in women aged 45 years and older were included in this study. Mean serum FSH level on day 3 was 21.4 ± 12.5 (range: 0.3–93.7) IU/ml. One fresh cleavage-stage embryo was transferred in 37.4% (900/2408) of the initiated cycles. The overall clinical pregnancy rate and live birth rate per fresh embryo transfer were 2.8% (25/900) and 0.8% (7/900), respectively. Natural cycle IVF treatment led to seven successful deliveries during the period. All seven women who successfully delivered were poor ovarian responders who met the diagnostic Bologna criteria and, among them, three had elevated serum FSH levels on day 3 (range: 39.0–47.1 mIU/ml). All seven had full-term delivery, and no congenital abnormalities were observed in their infants. No significant difference was found in serum FSH level on day 3 between those with and without positive beta-HCG test results. ConclusionsThese findings suggest that natural cycle IVF treatment could be an option for older poor responders in countries that do not permit egg donation. Careful counselling is required, however, because of the low probability of live births after IVF in middle-aged women.

OR08-4 A Novel Mutation in the Follicle-Stimulating Hormone Receptor (Ile423Thr) in a Woman with Normal Pubertal Development and Primary Amenorrhea: In Vivo, In Vitro, and In Silico Studies

Women with inactivating mutations in the FSHR may exhibit an array of phenotypes, from lack of pubertal development, primary amenorrhea, and complete insensitivity to FSH, to secondary amenorrhea and premature ovarian failure. In contrast to the LHCGR, only 19 inactivating mutations in the FSHR have been described to date. We report herein the case of a 22 year old women who presented with normal pubertal development but primary amenorrhea, associated with elevated serum FSH and LH levels (27-30 IU/L), low serum estradiol (E2) (21-40 pg/ml) and normal serum AMH (2.2-2.5 ng/ml) levels. After administration of recombinant FSH (total dose 1425 IU/9 days) serum E2 levels rose from 20 to 65 pg/ml with a parallel increase in number (from 5 to 17 follicles) and size (from 3 to 10 mm diameter) of follicles, and ovarian volumes (from 4 to 10 cm3). Sequencing of the FSHR revealed a new homozygous mutation in codon 423, where ATC was changed to ACC, generating the Ile423Thr substitution at the junction of the transmembrane domain (TM) 2 and the exo-loop (EL) 1 of the FSHR. The mother and two half-brothers were heterozygous for the same mutation. The molecular physiopathogenesis of the novel Ile423Thr mutation was analyzed by a series of in silico and in vitro biochemical studies in HEK293 cells transiently expressing either the wild-type (Wt) FSHR or the Ile423Thr mutant cloned into the pSG5 vector, and the results were compared with those obtained in cells transfected with the expression-deficient Asp408Tyr mutant, which leads to a more severe form of hypergonadotropic hypogonadism (1). Compared with the Wt FSHR, the plasma membrane expression of the mature (~80 kDa) form of the Ile423Thr mutant was slightly reduced, while that of the Asp408Tyr mutant was remarkably low, as disclosed by immunoblotting. A dissociation in the responses to FSH-stimulated signaling between the mutant receptors was found: compared with the Wt FSHR, FSH-stimulated cAMP production and ERK phosphorylation were reduced by 67% and 27% in the Ile423Thr mutant and by 52% and 43% in the Asp408Tyr FSHR, respectively. In silico molecular dynamics simulations of the FSHRs in an explicit membrane environment unveiled important differences in the behavior of both mutants vs the Wt receptor, particularly in the interhelical interactions of Thr423 with TM7 and EL2, and Tyr408 with TMs 5 and 7. Concurrently, these data suggest that conformational differences during the inactive (particularly during trafficking of the receptor proteins from the endoplasmic reticulum to the plasma membrane) and active (agonist-occupied receptor) states, account for the distinct expression levels and differential signaling exhibited by the Ile423Thr and Asp408Tyr mutant FSHRs. (1) Bramble MS, et al. A novel follicle-stimulating hormone receptor mutation causing primary ovarian failure: a fertility application of whole exome sequencing. Hum. Reprod. 2016; 31;905-914.

SAT-240 Type B Insulin Resistance Resulting in Hyperthecosis in a Postmenopausal Woman

Type B insulin resistance is characterized by autoantibodies to the insulin receptor, inducing severe insulin resistance requiring administration of suprapharmacologic doses of exogenous insulin for treatment. A case report by Declue, Shah, Marchese and Malone (1) described a young woman who carried a presumptive diagnosis of ovarian hyperthecosis and was subsequently found to have type B insulin resistance. However, once she was treated with antibody depletion therapy and circulating insulin levels normalized, the serum testosterone level normalized, indicating that the presumed diagnosis of hyperthecosis was incorrect. We present the case of a 49 year old African American woman who developed type B insulin resistance at the age of 45, requiring upwards of 1800 units of insulin daily. Simultaneously, she developed oligomenorrhea; excessive hair growth on the chin, chest, upper abdomen and upper thighs; and biochemical androgen excess with a serum total testosterone level of 275 ng/dL. At the age of 46, the type B insulin resistance was treated with two infusions of rituximab, dexamethasone, and cyclophosphamide. Her insulin requirements dropped precipitously, to the point where she currently requires only oral metformin; her current HbA1c is 6.1%. Her serum testosterone level, however, has remained elevated at 67 ng/dL, indicating a persistent hyperandrogenic state. Symptoms of a postmenopausal state were confirmed by a highly elevated serum FSH level of 44.1 mIu/mL; she is presently amenorrheic. A transvaginal ultrasound revealed a right ovarian volume of 19.3 mL and a left ovarian volume of 12.4 mL; 3 anechoic follicles were noted on the left, the largest of which measured 14.5 x 14.0 x 15.0 mm; 2 anechoic follicles were noted on the right, the largest of which measured 18.9 x 21.5 x 16.8 mm; bilateral hydrosalpinges were identified. A CT scan of the adrenals was normal. A presumptive diagnosis of hyperthecosis has been made, and the patient has been referred for bilateral oophorectomy. We postulate that, in this patient, the exposure of the ovaries to extremely high circulating insulin resulted in stimulation of the ovarian thecal cells and, ultimately, in autonomous function, yielding a clinical state of hyperthecosis. Reference: (1) Brown RJ, Joseph J, Cochran E, Gewert C, Semple R, Gorden P. Type B Insulin Resistance Masquerading as Ovarian Hyperthecosis. J Clin Endocrinol Metab. 2016;102(6):1789-1791.

Successful fertility preservation following ovarian tissue vitrification in patients with primary ovarian insufficiency.

Is ovarian tissue cryopreservation using vitrification followed by in vitro activation (IVA) of dormant follicles a potential approach for infertility treatment of patients with primary ovarian insufficiency (POI)? Our vitrification approach followed by IVA treatment is a potential infertility therapy for POI patients whose ovaries contain residual follicles. Akt (protein kinase B) stimulators [PTEN (phosphatase with TENsin homology deleted in chromosome 10) inhibitor and phosphatidyinositol-3-kinase (PI3 kinase) stimulator] activate dormant primordial follicles in vitro and ovarian fragmentation disrupts the Hippo signaling pathway, leading to the promotion of follicle growth. We treated POI patients with a combination of ovarian vitrification, fragmentation and drug treatment, followed by auto-transplantation, and reported successful follicle growth and pregnancies. Prospective clinical study of 37 infertile women with POI between 12 August 2011 and 1 November 2013. We enrolled 10 new patients since the previous publication. POI patients were originally selected based on a history of amenorrhea for more than 1 year and elevated serum FSH levels of >40 mIU/ml (n = 31) but this was later changed to >4 months, age <40 years and serum FSH levels of >35 mIU/ml (n = 6) (mean 71.8 ± 30.8, range 35.5-197.6) so as to include patients with a shorter duration of amenorrhea. Under laparoscopic surgery, ovariectomy was performed and ovarian cortices were dissected into strips for vitrification. Some pieces were examined histologically. After warming, two to three strips were fragmented into smaller cubes before culturing with Akt stimulators for 2 days. After washing, ovarian cubes were transplanted beneath the serosa of Fallopian tubes under laparoscopic surgery. Follicle growth was monitored by ultrasound and serum estrogen levels. After oocyte retrieval from mature follicles, IVF was performed. Among 37 patients, 54% had residual follicles based on histology. Among patients with follicles, 9 out of 20 showed follicle growth in auto-grafts with 24 oocytes retrieved from six patients. Following IVF and embryo transfer into four patients, three pregnancies were detected based on serum hCG, followed by one miscarriage and two successful deliveries. For predicting IVA success, we found that routine histological analyses of ovarian cortices and shorter duration from initial POI diagnosis to ovariectomy are valid parameters. Although our findings suggest that the present vitrification protocol is effective for ovarian tissue cryopreservation, we have not compared the potential of vitrification and slow freezing in follicle growth after grafting. We chose the serosa of Fallopian tubes as the auto-grating site due to its high vascularity and the ease to monitor follicle growth. Future studies are needed to evaluate the best auto-grafting sites for ovarian tissues. Also, future studies are needed to identify biological markers to indicate the presence of residual follicles in POI to predict IVA treatment outcome. In POI patients, ovarian reserve, namely the pool of residual follicles, continues to diminish with age. If one ovary is cryopreserved at an earlier stage of POI, patients could undergo additional non-invasive infertility treatments before the final decision for the IVA treatment. Furthermore, in the cases of unmarried POI patients, cryopreservation of ovarian tissues allows their fertility preservation until they desire to bear children. This work was supported by Grant-In-Aid for Scientific Research (Research B: 24390376, Challenging Exploratory Research: 24659722, and Innovative Areas, Mechanisms regulating gamete formation in animals: 26114510) and by research funds from the Smoking Research Foundation, and the Takeda Science Foundation. None of the authors has a conflict of interest. UMIN000010828.

Random anti-Müllerian hormone (AMH) is a predictor of ovarian response in women with elevated baseline early follicular follicle-stimulating hormone levels

To investigate the utility of random anti-Müllerian hormone (AMH) in assessing ovarian response among women with diminished ovarian reserve (DOR) diagnosed by elevated early follicular-phase FSH levels. Retrospective study. Academic and academically affiliated assisted reproductive technology (ART) programs. Seventy-three women undergoing ART with elevated early follicular FSH levels. None. Number of oocytes retrieved during ART cycle, number of day 3 embryos, and cycle cancellation and clinical pregnancy rates. Random AMH levels were strongly correlated with the number of oocytes retrieved during an ART cycle among women with elevated FSH (r=0.55). Women with elevated FSH who had a random serum AMH level of 0.6 ng/mL or higher had twice the number of oocytes retrieved (11±1.3 vs. 5.6±0.6), a greater number of day 3 embryos (5.7±0.9 vs. 3±0.5), and approximately a third of the cycle cancellation rate (14% vs. 41%) compared with women with a random serum AMH below 0.6 ng/mL. The clinical pregnancy rate was also higher among women with a random serum AMH≥0.6 ng/mL (28% vs. 14%), however, the difference was not statistically significant. A random serum AMH level is useful in setting expectations for ART prognosis in women with elevated early follicular-phase serum FSH levels.

The validity of testicular catch-up growth and serum FSH levels in the long-term postoperative assessment of laparoscopic varicocele correction in adolescents

Background:Postoperative assessment after varicocele surgery in adolescence is commonly centred around catch-up growth of the testis. There is paucity of evidence on the correlation of catch-up growth with underlying testicular function in these patients.Aims:To assess the reliability of catch-up growth of the testis as an indicator of normalization of testicular function and the utility of serum FSH levels in the long-term postoperative assessment of varicocele surgery in adolescence.Materials and Methods:Prospective cohort study of young adults (18-27 years) who had laparoscopic varicocele correction in adolescence (11-16 years). Evaluation included serum FSH levels, scrotal ultrasonography and semen analysis.Analysis:Anatomical and functional parameters of participants with equal and normal testicular size were compared to those of participants with persistent testicular hypotrophy or hypertrophy. Sensitivity and positive predictive value of postoperative serum FSH levels were estimated and elevated levels of serum FSH were checked for association with suboptimal outcomes of varicocele correction.Results:The serum FSH levels of participants with unequal testicular sizes (n=6, median 6.65 IU/l), which included testicular hypertrophy (n=3, median 7.2 IU/l) and persistent testicular hypotrophy (n=3, median 6.1 IU/l), were significantly higher than the group with equal testicular sizes (n=8, median 3.5 IU/l; P=0.014, Mann-Whitney U test). Postoperative elevated serum FSH levels were significantly associated with suboptimal outcomes of varicocele surgery (P=0.015, Fisher's exact test). The test also had a high positive predictive value.Conclusions:Testicular catch-up growth may not be a reliable postoperative assessment criterion by itself. Serum FSH levels may be of value in detecting suboptimal outcomes of varicocele surgery in adolescents.

Pcsk6 mutant mice exhibit progressive loss of ovarian function, altered gene expression, and formation of ovarian pathology

Bioactivation of precursor proteins by members of the proprotein convertase (PC) family is essential for normal reproduction. The Pcsk6 gene is a member of the PC family that is expressed in numerous ovarian cell types including granulosa cells and oocytes. We hypothesized that loss of PCSK6 would produce adverse effects in the mouse ovary. Mice incapable of expressing PCSK6 (Pcsk6(tm1Rob)) were obtained, and reproductive parameters (serum hormones, whelping interval, estrus cyclicity, and fertility) were compared to Pcsk6(+/+) mice. While Pcsk6(tm1Rob) female mice are fertile, they manifest reduced reproductive capacity at an accelerated rate relative to Pcsk6(+/+) mice. Reproductive senescence is typically reached by 9 months of age and is correlated with loss of estrus cyclicity, elevated serum FSH levels, and gross alterations in ovarian morphology. A wide range of ovarian morphologies were identified encompassing mild, such as an apparent reduction in follicle number, to moderate--ovarian atrophy with a complete absence of follicles--to severe, manifesting as normal ovarian structures replaced by benign ovarian tumors, including tubulostromal adenomas. Targeted gene expression profiling highlighted changes in RNA expression of molecules involved in processes such as steroidogenesis, gonadotropin signaling, transcriptional regulation, autocrine/paracrine signaling, cholesterol handling, and proprotein bioactivation. These results show that PCSK6 activity plays a role in maintaining normal cellular and tissue homeostasis in the ovary.

Androgen insensitivity suspected by estimation of serum hormone levels in oligozoospermic and azoospermic men.

According to higher androgen insensitivity index than in fertile men, the group of 83 men, with high serum LH and high or normal testosterone levels, was separated from 800 infertile men. These patients with high androgen insensitivity index had oligozoospermia (6.38 +/- 3.18 X 10(6)/ml) or azoospermia. They had significantly higher serum LH and testosterone levels than compared groups of infertile and fertile men. Elevated serum FSH levels in infertile men with high androgen insensitivity index showed damage of spermatogenesis. There was completely disturbed hypothalamo-pituitary-testicular axis as the serum prolactin levels were significantly elevated too. There was no significant difference in serum estradiol levels among investigated groups. Using androgen insensitivity index we could identify those men whose infertility is not treatable.

Toward gene therapy of primary ovarian failure: adenovirus expressing human FSH receptor corrects the Finnish C566T mutation

Resistance ovarian syndrome is a heterogeneous disorder inherited as a Mendelian recessive trait and characterized by infertility, primary amenorrhea, normal karyotype and elevated serum FSH and LH levels. An inactivating mutation, C566T, in FSH receptor gene (FSHR) has been identified initially in Finland. We investigated if an adenovirus expressing a normal copy of human FSHR (Ad-hFSHR) has the ability to: (i) transfect granulosa cell lines, (ii) render the transfected cell lines responsive to FSH stimulation and (iii) transcomplement the malfunctioning form of human FSHR gene with C566T mutation. COS-7, JC-410, JC-410-P450-scc-luc and JC-410-StAR-luc cell lines were infected by Ad-hFSHR followed by treatment with FSH. Functional activity of the Ad-hFSHR was tested by measuring cyclic adenosine monophosphate (cAMP) or luciferase activity in response to FSH stimulation, and showed 2-4.6-fold increases in Ad-hFSHR transfected cells compared with untransfected or Ad-LacZ transfected cells, indicating that Ad-hFSHR is functionally active and expressing hFSHR. Generation of cAMP in cells expressing only mutated hFSHR-T566 showed minimal increase after FSH stimulation. Co-transfection of Ad-hFSHR in these cells carrying the malfunction form of human FSHR caused significant increases of 2.2-7.4-fold in FSH dependent cAMP generation (P = 0.0007). We concluded that adenovirus expressing a normal human FSHR can compensate the inactivating human FSHR-C566T mutation and restore FSH responsiveness.

AZFc partial deletions in Chilean men with severe spermatogenic failure

To determine the prevalence of AZFc subdeletions in infertile Chilean men with severe spermatogenic impairment. Prospective analysis. University infertility clinic. Ninety-five secretory azo/oligozoospermic men without AZFc Y chromosome microdeletions: 71 whose testicular histology showed severe spermatogenic impairment and 24 who exhibited reduced testicular volume and elevated serum FSH levels. As controls, we studied 77 men (50 fertile and/or normozoospermic, and 27 with azoospermia and normal spermatogenesis). Peripheral blood was drawn to obtain genomic DNA for polymerase chain reaction (PCR) digestion assays of DAZ-sequence nucleotide variants and for AZFc-STS PCR after a complete testicular characterization (biopsy, hormonal, and physical evaluation). DAZ genes and AZFc subdeletion types. In cases we observed two "gr/gr" subdeletions (2.1%), one with absence of DAZ1/DAZ2 (g1/g2 subtype), and the other with absence of DAZ3/DAZ4 (r2/r4 subtype). Additionally, we found a g1/g3 subdeletion in a patient with Sertoli-cell-only syndrome. In controls, we observed two gr/gr subdeletions with absence of DAZ1/DAZ2 (2.6%) in a fertile/normozoospermic and in an obstructive azoospermic man. AZFc subdeletions do not seem to cause severe impairment of spermatogenesis. Moreover, gr/gr-DAZ1/DAZ2 subdeletions do not appear to affect fertility in Chilean men.

Are Adolescent Boys with Klinefelter Syndrome Androgen Deficient? A Longitudinal Study of Finnish 47,XXY Boys

Testosterone (T)-substitution therapy is widely used in adult patients with Klinefelter syndrome (KS) to prevent symptoms and sequels of androgen deficiency, but it is currently unknown if adolescent boys with KS benefit from early T therapy. To evaluate the optimal age to start T substitution, we searched for signs of androgen deficiency in pubertal boys with KS. 14 nonmosaic 47,XXY boys, aged 10-13.9 y, were followed up for 4-37 mo with staging of puberty and frequent reproductive hormone measurements. Furthermore, indices reflecting androgen action (serum SHBG, leptin, and prostate-specific antigen (PSA) levels) were studied. Both onset and progression of puberty according to Tanner stages were normal in boys with KS. Consistently, serum T concentrations increased as expected and remained normal throughout follow-up. Changes in the indices of androgen action (decreases in serum SHBG and leptin, and increase in serum PSA concentrations) occurred normally, except that average leptin levels were higher in the boys with KS (KS boys 11.8 +/- 7.0 microg/L; controls 7.6 +/- 4.7 microg/L; p = 0.033). Despite normal T concentrations, the KS boys displayed from the age of 13 y elevated serum FSH and LH levels, and exaggerated gonadotropin responses to gonadotropin-releasing hormone. These data do not demonstrate an unequivocal androgen deficiency in adolescent boys with KS that would necessitate androgen supplementation therapy during early puberty.

Bioactive FSH May Have Value as a Marker for Ovarian Reserve in Patients With Elevated Serum FSH and Normal Basal Antral Follicle Counts

ObjectiveTo evaluate the bioactivity of FSH in women with paradoxically high serum immunoactive basal FSH levels and otherwise “normal” ovarian reserve as determined by ultrasound screening and response to gonadotropin stimulation.DesignCase Series at a large academic reproductive center.Materials and methodsWe compared immunoactive basal FSH levels (immulite assay (DPC)) and bioactive FSH levels in CHO cells transfected with the FSH receptor in two groups of women. Group 1 consisted of two patients with an elevated basal serum immunoactive FSH (> 13 mIU/mL), a normal basal antral follicle count (bAFC >8), and a robust response to gonadotropin stimulation (> 10 follicles) during IVF-ET therapy. Group 2 consisted of five patients with elevated basal serum FSH levels and either abnormal bAFC (< 6 total in both ovaries) or poor response to gonadotropin stimulation (< 5 mature follicles).ResultsTabled 1Tabled 1ConclusionsFSH with disproportionately lower bioactivity compared with immunoactivity on assay testing may account for some paradoxically abnormal basal FSH assessments in women with otherwise normal ovarian reserve and response to fertility therapy. Patients with normal antral follicle counts and elevated serum FSH by immunoassays can be candidates for a trial of IVF-ET, and based on our small series, can anticipate a reasonable reproductive outcome. Larger trials are required to assess if a basal bioactive FSH assessment can prospectively predict which of these patients are good IVF-ET candidates, and what cutoff (if any) of FSH bioactivity is most appropriate to use clinically. Presented with an abnormal FSH, but a normal bAFC, bioactivity testing may reassure that ovarian reserve is intact. ObjectiveTo evaluate the bioactivity of FSH in women with paradoxically high serum immunoactive basal FSH levels and otherwise “normal” ovarian reserve as determined by ultrasound screening and response to gonadotropin stimulation. To evaluate the bioactivity of FSH in women with paradoxically high serum immunoactive basal FSH levels and otherwise “normal” ovarian reserve as determined by ultrasound screening and response to gonadotropin stimulation. DesignCase Series at a large academic reproductive center. Case Series at a large academic reproductive center. Materials and methodsWe compared immunoactive basal FSH levels (immulite assay (DPC)) and bioactive FSH levels in CHO cells transfected with the FSH receptor in two groups of women. Group 1 consisted of two patients with an elevated basal serum immunoactive FSH (> 13 mIU/mL), a normal basal antral follicle count (bAFC >8), and a robust response to gonadotropin stimulation (> 10 follicles) during IVF-ET therapy. Group 2 consisted of five patients with elevated basal serum FSH levels and either abnormal bAFC (< 6 total in both ovaries) or poor response to gonadotropin stimulation (< 5 mature follicles). We compared immunoactive basal FSH levels (immulite assay (DPC)) and bioactive FSH levels in CHO cells transfected with the FSH receptor in two groups of women. Group 1 consisted of two patients with an elevated basal serum immunoactive FSH (> 13 mIU/mL), a normal basal antral follicle count (bAFC >8), and a robust response to gonadotropin stimulation (> 10 follicles) during IVF-ET therapy. Group 2 consisted of five patients with elevated basal serum FSH levels and either abnormal bAFC (< 6 total in both ovaries) or poor response to gonadotropin stimulation (< 5 mature follicles). ResultsTabled 1Tabled 1 ConclusionsFSH with disproportionately lower bioactivity compared with immunoactivity on assay testing may account for some paradoxically abnormal basal FSH assessments in women with otherwise normal ovarian reserve and response to fertility therapy. Patients with normal antral follicle counts and elevated serum FSH by immunoassays can be candidates for a trial of IVF-ET, and based on our small series, can anticipate a reasonable reproductive outcome. Larger trials are required to assess if a basal bioactive FSH assessment can prospectively predict which of these patients are good IVF-ET candidates, and what cutoff (if any) of FSH bioactivity is most appropriate to use clinically. Presented with an abnormal FSH, but a normal bAFC, bioactivity testing may reassure that ovarian reserve is intact. FSH with disproportionately lower bioactivity compared with immunoactivity on assay testing may account for some paradoxically abnormal basal FSH assessments in women with otherwise normal ovarian reserve and response to fertility therapy. Patients with normal antral follicle counts and elevated serum FSH by immunoassays can be candidates for a trial of IVF-ET, and based on our small series, can anticipate a reasonable reproductive outcome. Larger trials are required to assess if a basal bioactive FSH assessment can prospectively predict which of these patients are good IVF-ET candidates, and what cutoff (if any) of FSH bioactivity is most appropriate to use clinically. Presented with an abnormal FSH, but a normal bAFC, bioactivity testing may reassure that ovarian reserve is intact.

Hypospadias in a Cohort of 1072 Danish Newborn Boys: Prevalence and Relationship to Placental Weight, Anthropometrical Measurements at Birth, and Reproductive Hormone Levels at Three Months of Age

Hypospadias is one of the most frequent male congenital malformations and may be part of the testicular dysgenesis syndrome. The aim of the study was to investigate the prevalence of hypospadias in Denmark and evaluate the relationship to anthropometrical measurements at birth and reproductive hormone levels at 3 months of age. A prospective cohort study was conducted with 3-yr follow-up (1997-2004). The population-based study was conducted at the University Hospital of Copenhagen. A total of 1072 Danish boys were consecutively recruited antenatally, with 74.4% completing the study. The study examined the position of the urethral meatus, anthropometrical measurements, placental weight, and reproductive hormone levels. The Danish birth prevalence of hypospadias was significantly higher than in a concomitant Finnish study (1.03 vs. 0.27%; P = 0.012). At 3 yr, the true prevalence was found to be 4.64% because additional mild cases were detected when physiological phimosis dissolved. Weight for gestational age (percentage deviation from expected mean) (-5.00 vs. -0.59%; P = 0.030) and placental weight (567 vs. 658 g; P = 0.023) were significantly lower, and FSH was significantly higher (1.48 vs. 1.15 IU/liter; P = 0.007) in boys with hypospadias, compared with healthy boys. We found a surprisingly high total rate of hypospadias of 4.6% in this large prospective cohort study. Seventy-two percent of the cases were apparent only after the prepuce could be retracted. Hypospadias were associated with elevated serum FSH levels at 3 months. We also confirmed an association between fetal growth impairment and hypospadias; however, it is yet unknown whether this indicates a causal relationship or a shared pathogenic factor.

OC148: Reduced ovarian stromal blood flow and elevated serum FSH level after abdominal hysterectomy for benign conditions

OC148: Reduced ovarian stromal blood flow and elevated serum FSH level after abdominal hysterectomy for benign conditions

Pregnancy rates (prs) per cycle similar for the first four transfers despite improved prs

A study was performed to use life-table analysis to evaluate the cumulative probability of pregnancy following ET and to determine whether there is any decrease in PRs for the first four ETs now that PRs with IVF have improved so much. The study presented here evaluated the first four cycles of ET in our IVF center from 1/1/97 through 6/30/98. Since PRs/ET are equal in our center regardless of whether they are fresh or frozen, the first four ETs were assessed regardless of whether they were cryopreserved-thawed. All patients were evaluated, including women with elevated baseline serum FSH levels, previous poor responders, or patients with failed IVF cycles in other centers. Oocyte recipients, gestational carriers, and women receiving donor embryos were excluded. The patients were stratified into four age groups. The mean number of oocytes retrieved significantly decreased with advancing age20.4 for <30, 17.8 for 30–34, 12.7 for 35–39, and 7.5 for 40–44. Fertilization rates were similar. The respective number of embryos formed also significantly decreased with advancing age: 12.3, 10.9, 8.0, and 4.7. The mean number of embryos transferred in each age group was 3.0, 3.1, 3.1, and 3.5. For group 1, the probability of clinical pregnancy per transfer for the four cycles was 0.45, 0.49, 0.44, and 0.50 and the cumulative probability rates were 0.45, 0.72, 0.84, and 0.92. These rates were 0.40, 0.45, 0.40, and 0.33 and 0.40, 0.67, 0.80, and 0.87 in group 2, 0.40, 0.36, 0.29, and 0.38 and 0.40, 0.62, 0.73, and 0.83 in group 3, and 0.17, 0.27, 0.32, 0.23 and 0.17, 0.40, 0.59, and 0.68 in group 4. The probability of viable pregnancy per transfer was also similar in all four cycles in all four groups, and the cumulative probability of viable pregnancy after four cycles was 0.88, 0.82, 0.69, and 0.52 for the four groups. The majority of first cycle transfers were not frozen—31.0%, 30.3%, 20.5%, and 20.4%—but thereafter represented the majority of transfers for the three younger groups (ranging from 68.6% to 88.9%) and was 49.2%, 72.0%, and 38.4% for group 4. Thus, despite improved PRs per transfer, no other interventions seem necessary for at least the first four transfers.

A follicle-stimulating hormone–secreting gonadotroph adenoma with ovarian enlargement in a 10-year-old girl

Objective: To report a rare case of gonadotroph adenoma accompanied by ovarian enlargement in a child. Design: Case report. Setting: A university hospital. Patient(s): A 10-year-old Japanese girl with multiple cysts of both ovaries. Intervention(s): Endocrinologic assays, immunohistochemical staining, ultrastructural observations, and in vitro analysis. Main Outcome Measure(s): The endocrinologic assays showed an elevated serum FSH level. The tumor cells excised from the gonadotroph adenoma were immunohistochemically positive for antihuman FSH monoclonal antibody. When cultured in vitro, the tumor cells secreted FSH in the primary culture. Result(s): The gonadotroph adenoma produced FSH. After transsphenoidal surgery, both ovaries decreased in size. Conclusion(s): The ovarian enlargement was induced by endogenous FSH from the gonadotroph adenoma. To our knowledge, this is the first reported case of gonadotroph adenoma accompanied by ovarian enlargement in childhood or adolescence.

Antiprogestins suppress basal and activin-stimulated follicle-stimulating hormone secretion in an estrogen-dependent manner.

Previous studies from our laboratory, demonstrating that suppression of serum FSH by RU486 requires a high estrogen (E) background, suggested that E-inducible progesterone receptors play a role in the regulation of FSH secretion. We demonstrated further that the type II antiprogestin RU486 and the type I antiprogestin ZK98299 both suppressed the elevated serum FSH and FSHbeta messenger RNA levels similarly on the evening of proestrus, but had divergent effects on the morning of estrus, when only RU486, but not ZK98299, lowered the elevated serum FSH level (secondary FSH surge). In the present work we used primary anterior pituitary cell culture to examine whether RU486 caused direct, E-dependent suppression of basal and recombinant human activin A (activin)-induced FSH secretion in the gonadotrope and to compare this direct effect, if any, with that of ZK98299. Primary cell cultures were prepared from anterior pituitaries collected from cycling female rats either on metestrous or proestrous morning and cultured in DMEM, supplemented with charcoal-stripped serum without or with 10 nM estradiol (E2) for 96 h; exposure to test agents occurred during the last 48 h of culture. FSH released into the medium and intracellular FSH content were determined by RIA. In cells from the anterior pituitary of metestrous rats cultured in E2-free medium, neither antiprogestin (10 nM) affected FSH release; in contrast, when cells were cultured in medium to which E2 had been added, both antiprogestins caused profound suppression of both basal and activin (10 ng/ml)-stimulated FSH release. In cell cultures from proestrous rats, both antiprogestins caused a slight, but significant, suppression of basal FSH release even in the absence of added E2; activin-stimulated FSH release, however, was not affected. Upon exposure of the cells from proestrous rats to E2, the antiprogestins potently suppressed both basal and activin-stimulated FSH secretion. Because the foregoing incubations were performed in culture medium devoid of progesterone (P4), the actions of the antiprogestins on FSH secretion were independent of the natural ligand. Addition of P4 (10 nM) to the cell cultures stimulated basal and activin-induced FSH release more in the presence than in the absence of E2. The FSH response to P4 was completely blocked by both antiprogestins in both the absence and presence of E2. Finally, both RU486 and ZK98299 blocked the stimulatory effect of corticosterone (1 microM) on FSH secretion. The observed effects of P4 and antiprogestins were specific for FSH secretion; LH secretion was not similarly suppressed by either antiprogestin, but was, in fact, stimulated by ZK98299 in E2-treated cells. We conclude that 1) E2-inducible progesterone receptors interact with activin-mediated signal transduction to regulate FSH secretion, and 2) unlike on the morning of estrus in vivo, RU486 and ZK98299 affect FSH secretion similarly in the gonadotrope in vitro.

A randomized, controlled trial of estradiol replacement therapy in women with hypergonadotropic amenorrhea.

Premature ovarian failure is classically defined as menopause occurring before age 40 and is associated with elevated serum FSH levels. If elevated FSH levels indicate lack of ovarian feedback and depletion of primordial follicles, women with prematurely elevated FSH levels should have infertility. However, there are many reports of pregnancies in affected women occurring during estrogen therapy leading to the hypothesis that estrogen may have a salutary effect on folliculogenesis and conception. This randomized, controlled trial was designed to investigate whether estrogen replacement therapy offered a significant therapeutic benefit in hypergonadotropic amenorrhea and to evaluate the potential pathophysiologic mechanisms that would explain the reported pregnancies. Thirty seven women, aged 16 to 40, with menstrual dysfunction and documented FSH levels elevated above the 95% confidence limits of the mid-cycle gonadotropin peak of the normal menstrual cycle (> 40 IU/L 2nd IRP hMG in our RIA) on at least two occasions, entered the study. The average duration of their amenorrhea was 15.9 months (range 2-96 months). Subjects were randomized to begin estradiol replacement (micronized estradiol [Estrace TM], 2 mg orally each day) or no therapy for 6 weeks in a 12-week, cross-over design with weekly monitoring by both pelvic ultrasonography and serum hormone levels. Thirty-one women completed the entire randomized study. As expected, estradiol therapy increased mean serum estradiol levels by 98 pg/mL and was associated with a significant decrease in mean LH and FSH levels (LH: 45.4 IU/L 2nd IRP hMG vs. 37.1 IU/L, FSH: 63.4 IU/L vs. 40.6 IU/L, geometric means). However, there was no effect of estradiol replacement on mean ovarian volume, the number or size of new follicles, or the ovulation rate in all subjects or in the subset with no identified cause for their hypergonadotropic hypogonadism (n = 20). Two pregnancies occurred during the randomized trial, one on and one off estradiol. In both arms of the study, the majority of subjects developed cystic ovarian structures by ultrasound that were temporally associated with increasing serum estradiol levels, indicating functional ovarian follicles. Seventy-eight percent of all subjects grew at least one new follicle over 10 mm in diameter and 46% ovulated at least once, as determined by a serum progesterone level more than 4 ng/mL. Although ovulations were significantly more common in the 10 women subjects who had less than 3 months of amenorrhea (all of whom ovulated) than in the 27 with greater than 3 months of amenorrhea (only 7 of whom ovulated (26%), P < 0.001), there was no significant difference in eventual pregnancies (2 of the 10 women with less than 3 months of amenorrhea vs. 3 of the 27 with greater than 3 months of amenorrhea, P = 0.47). We conclude that in hypergonadotropic women with amenorrhea: 1) folliculogenesis occurs often but is less frequently followed by ovulation and rarely by pregnancy, suggesting that elevated FSH is a marker of oocyte dysfunction occurring distinct from and earlier than granulosa cell or follicular dysfunction; and 2) estrogen therapy does not improve the rate of folliculogenesis or ovulation.

Pregnancy in an azoospermic patient with markedly elevated serum follicle-stimulating hormone levels

To assess the possibility of achieving a pregnancy in an azoospermic patient with markedly elevated serum FSH level. A case report. In vitro fertilization program at the Instituto Valenciano de Infertilidad. An azoospermic patient with small testes and serum FSH level (38.7 mIU/mL) higher than three times normal. Testicular biopsy revealed Sertoli cell-only syndrome with focal spermatogenesis. Intracytoplasmic microinjection of testicular tissue-extracted spermatozoa. Fertilization rate, cleavage rate, clinical pregnancy. Eight of 11 (73%) intact oocytes showed two pronuclei. All of them cleaved normally. Four embryos were replaced into the uterine cavity and the other four were cryopreserved. A twin clinical pregnancy was achieved. Spermatozoa may be present in testicular biopsy specimens of azoospermic patients with severe spermatogenic failure despite markedly elevated serum FSH level. These patients can be fertile after intracytoplasmic testicular sperm microinjection.