Idiopathic Premature Ovarian Failure Research Articles

P-210: Cryopreservation of whole sheep ovaries: Comparisons of different freezing protocols and assessment of functionality

Cryopreservation of ovarian tissue is a way to preserve fertility in cancer patients undergoing gonadotoxic chemotherapy or radiation, as well as in patients with idiopathic premature ovarian failure. Pregnancies have been reported after thawing and retransplantation of previously cryopreserved ovarian fragments. Following retransplantation of ovarian fragments, a large pool of viable ovarian tissue is lost. This is most likely due to vascular failure and tissue necrosis during the period of angiogenesis, leading to a relatively short survival time of the ovarian tissue graft.

Oogenesis from Human Somatic Stem Cells and a Role of Immune Adaptation in Premature Ovarian Failure

The central thesis is that, while embryonic oocytes originate from extra-ovarian sources, those generated during fetal period and in postnatal life are derived from the ovarian surface epithelium (OSE). With the assistance of immune system-related cells, primitive granulosa and germ cells appear to originate from OSE stem cells in the fetal and adult human gonads. Fetal primary follicles are formed during the second trimester of intrauterine life, prior to the end of immune adaptation, possibly in order to be recognized as self and renewed later. With the onset of menarche, a periodical follicular renewal emerges to replace aging primary follicles and ensure that fresh eggs are always available during the prime reproductive period. The periodical follicular renewal ceases between 35-40 years of age, and the remaining primary follicles are utilized during the premenopausal period until exhausted. However, the persisting oocytes accumulate genetic alterations and may become unsuitable for ovulation and fertilization. Premature ovarian failure (POF) may result from premature termination of follicular renewal during adulthood, possibly due to the alteration of fetal follicular development during immune adaptation (idiopathic POF), or due to the alteration of the adult immune system by cytostatic chemotherapy. Factors responsible for the diminution of follicular renewal may be responsible for the aging of other tissues and the whole body in general. However, our recent research shows that OSE stem cells may produce new eggs in vitro, even when derived from ovaries lacking primary follicles. Consequently, their in vitro fertilization (IVF) and subsequent utilization of embryos for intrauterine implantation may represent a novel IVF approach for providing genetically related children to women with ovarian infertility, which is worthy of consideration and further exploration.

Undetectable salivary testosterone in young women with premature ovarian failure

The extent of androgen deficiency in young women with premature ovarian failure (POF) is unclear. Cross-sectional study of androgen status in young women with POF. Twenty women with POF: six had Turner syndrome (group A); eight had iatrogenic POF either secondary to bilateral oophorectomy or treatment of malignancy (group B); and six had idiopathic POF (group C). The median age was 30.5 years (range 19-39); in groups B and C the median duration of ovarian failure was 10.0 years (range 1-35). After a 2-month wash-out period without sex steroid replacement (SSR), serum testosterone (T), androstenedione (A4), dehydroepiandrosterone (DHEAS), SHBG, salivary testosterone (SalT) and the free androgen index [FAI = (serum T/SHBG) x 100] were measured. Median serum A4 was 4.6 nmol/l (10th, 90th centiles, 3.6, 5.1) and DHEAS was 3.2 micromol/l (10th, 90th centiles, 2.3, 9.3). Although median serum T was relatively low at 1.4 nmol/l (10th, 90th centiles, 1.1, 1.7), median SHBG was also low at 34 nmol/l (10th, 90th centiles 22.2, 67.5) and the median calculated FAI was within the normal range at 3.7 (10th, 90th centiles, 2.3, 7.0). However, SalT was undetectable in almost all subjects in the three groups of POF. Serum T and SHBG are relatively low in young women with POF and their FAI is therefore within the normal range. However, SalT, which measures free testosterone, is consistently low to undetectable in these young women with POF. The reliability of the FAI as a marker of androgen deficiency remains questionable.

Identification of New Variants of HumanBMP15Gene in a Large Cohort of Women with Premature Ovarian Failure

Premature ovarian failure (POF) is a cause of female infertility characterized by primary (PA) or secondary amenorrhea (SA) and elevated gonadotropins. The pathogenesis is unknown in most cases. We recently reported two sisters with PA carrying a heterozygous mutation of BMP15 gene (locus Xp11.2), but the prevalence of BMP15 variations in the POF population is unknown. The objective of the study was to verify the involvement of BMP15 variations in a large POF population. Genetic screening of 166 unrelated patients with idiopathic POF (25 PA, 141 SA) and controls (group A: 95 women with menopause beyond 50 yr of age; group B: 86 women and 30 men from the general population) of Caucasian origin. Investigation revealed four heterozygous variations affecting the proregion of BMP15. The previously reported p.Y235C mutation occurred in one and three novel variants in eight patients: two missense alterations (p.R68W in one case, p.A180T in five) and one insertion (p.262insLeu) in two cases. The p.262insLeu was found in five controls of group A, thus diminishing its potential biological impact, whereas the other three variants were not present in any of the controls. All new mutations were found in SA cases. We describe the significant association of heterozygous BMP15 gene variants with the POF phenotype in humans (seven of 166 patients: 4.2%; P < 0.003 vs. controls). These findings are consistent with the critical role played by BMP15 in human folliculogenesis.

Idiopathic Premature Ovarian Failure in 63 Young Women

Background: Premature ovarian failure (POF) in adolescents is defined as primary or secondary amenorrhea associated with high follicle-stimulating hormone (FSH) levels. In normal 46,XX patients, its etiology is most often unknown. We have evaluated the clinical, hormonal and ovarian phenotypes in patients with a normal karyotype who were diagnosed with POF before the age of 18. Methods: Sixty-three patients were included in this retrospective study. Results: The mean patient age was 20.4 years. The patients presented with three clinical patterns: lack of pubertal development (n = 23), primary amenorrhea with interrupted puberty (n = 18), and secondary amenorrhea with normal puberty (n = 22). Ten patients had a familial history of POF and 6 presented with hypothyroidism. The FSH, estradiol and inhibin B levels were not statistically different in the three clinical groups. Fifty percent of the patients presented small ovaries (length <2 cm) at ultrasonography. The presence of follicles was found at histology in only 7 of the 27 patients who underwent an ovarian biopsy. Conclusion: 46,XX patients presenting with early POF rarely presented a specific, identifiable disorder. We discuss the clinical management and different diagnosis strategies to improve our current knowledge of this syndrome.

Controversial role of inhibin α-subunit gene in the aetiology of premature ovarian failure

Premature ovarian failure (POF) is characterized by hypergonadotropic amenorrhoea before the age of 40. Inhibin alpha-subunit (INHalpha) gene is proposed as a candidate gene due to its role in negative feedback control of FSH. Polymorphism -16C>T of INHalpha gene was studied in 61 POF patients and 82 controls above 40 years old (C > 40). Substitution 769G>A was studied in 59 POF patients, 76 C > 40 and 73 controls below 40 years old (C < 40). No significant difference in risk of POF development for -16T allele was found when comparing idiopathic POF (I-POF) with C > 40 (Odds ratio = 1.46; 95% confidence interval = 0.63-3.19). Implication of -16C>T polymorphism in serum inhibin levels was analysed in 46 controls, and no significant differences (P > 0.05) were found between CC and CT + TT genotype groups when comparing either mid-follicular phase Pro-alphaC and inhibin B values or mid-luteal phase Pro-alphaC and inhibin A values. Heterozygosity for substitution 769G>A was found in 1 of 59 POF woman, 2 of 76 C > 40 and 6 of 73 C < 40. Presence of this substitution in a relevant number of control subjects is herein described for the first time. Our results indicate that -16C>T and 769G>A variants in INHalpha gene may not be associated to POF disease.

The FMR1 premutation as a cause of premature ovarian failure in Brazilian women

The loss-of-function mutation of the FMR1 gene due to expansion of the 5' UTR CGG repeat causes the fragile X syndrome, the most frequent form of inherited mental retardation. On the other hand, the FMR1 premutation, which is transcriptionally active and produces the protein, confers an increased risk for premature ovarian failure (POF) to carrier females. Among 41 unrelated Brazilian women with idiopathic POF, we found three carriers of premutations (CGG expansionse > 59 repeats) and two carriers of high-intermediate alleles (50-55 repeats). Two premutations and two intermediate alleles were detected among the 16 familial POF cases, and one premutated woman, among the 25 sporadic cases. The premutation frequency among the familial cases (12.5%) differed significantly from that found in a control group of 96 unrelated Brazilian women aged > 47 years, who had not experience POF and in which no premutations or high-intermediate alleles were detected. In the search for factors influencing the probability of a premutation carrier presenting POF, another 20 unrelated premutated women with POF, from fragile X families, were included in the study. The analysis of the FMR1-linked loci DXS548 and FRAXAC1 did not indicate any association of a particular haplotype with the occurrence of POF. An effect of X-inactivation skewing was not apparent in blood cells, and POF-associated premutations showed a wide range of repeat sizes, from 59, the smallest known to expand to full mutations upon transmission to offspring, to approximately 200.

Bilateral oophorectomy and premature menopause

The ovary is a complex metabolic organ. The follicles produce both androgens and estrogens, whereas the stromal tissue synthesizes androgens only. When menopause occurs, both androgen and estrogen levels decrease. The postmenopausal ovary remains a source of endogenous androgens that are converted to estrogen. The consequences of premature removal of the ovaries are not well known. The risks and benefits of menopausal hormone therapy (HT) in women with premature menopause have not been studied. Women who have had surgical menopause experience more severe symptoms and will need to stop estrogen therapy at some point in their lives. Intense symptoms such as hot flashes, night sweats, and insomnia will redevelop, so women should be given informed consent about the need for long-term use of HT and the greater difficulty in discontinuing therapy.

Galactose-1-phosphate uridyl transferase gene mutations in women with premature ovarian failure

We determined the frequency of galactose-1-phosphate uridyl transferase gene mutations: Q188R, K285N, and the Duarte allelle in 86 patients with idiopathic premature ovarian failure (POF) and 95 controls. No association of the mutations with POF was found.

FMR1 repeat sizes in the gray zone and high end of the normal range are associated with premature ovarian failure

Premature ovarian failure (POF) is the occurrence of menopause before the age of 40 and affects 1% of the female population. Whereas the etiology of POF is largely unexplained, FMR1 premutation carriers are known to be at increased risk of POF compared with the general population. The FMR1 premutation alleles have 55-200 copies of a CGG repeat in the 5' untranslated region of the FMR1 gene. However, functional effects on gene expression may occur even for repeat sizes in what has been considered the "normal" range. To evaluate the role of the FMR1 repeat in POF, repeat sizes were examined in 53 women with idiopathic POF, 161 control women from the general population, and 21 women with proven fertility at an advanced maternal age. A significant increase in the number of FMR1 alleles between and including 35 and 54 CGG repeats was found in the POF patient population; 15 of 106 (14.2%) POF alleles were between and including 35 and 54 repeats, whereas only 21 of 322 (6.5%) alleles in the general population (P=0.02) and 2 of 42 (4.8%) alleles from women with proven late fertility (P=0.09) were of this size (P=0.01 versus combined controls). The effect was also significant for comparisons of genotype repeat size (repeat size weighted by the relative activity of the two FMR1 alleles) and biallelic mean (average size of the two alleles). These results are clinically relevant and suggest that the FMR1 gene plays a more significant role in the incidence of POF than has previously been thought.

Serum inhibin A, inhibin B, pro-αC, and activin A levels in women with idiopathic premature ovarian failure

Serum inhibin A, inhibin B, pro-alphaC, and activin A levels in 30 women with idiopathic premature ovarian failure (POF), 30 postmenopausal women, and 30 age-matched fertile women were determined. Women with POF showed low levels of inhibin A and inhibin B, but not of activin A, whereas the levels of pro-alphaC were significantly higher than in postmenopausal women. Thus, the circulating level of pro-alphaC could be a marker for assessing residual ovarian function in women with POF.

Mutations in the coding region of the FOXL2 gene are not a major cause of idiopathic premature ovarian failure.

Premature ovarian failure (POF) is a heterogeneous disorder whose aetiology is still unknown. Recently, the autosomal FOXL2 gene, highly expressed in the adult ovary, has been correlated with the disorder. FOXL2 mutations, causing a truncation of the FOXL2 protein in the forkhead domain or in the poly-Ala tract lead to blepharophimosis-ptosis-epicanthus-inversus syndrome associated with POF (BPES I). Interestingly, in two out of 70 idiopathic POF patients, a 30 bp deletion (898-927del) and a missense mutation (1009T-->A) were identified. To further evaluate the correlation between POF and FOXL2 mutations, 120 phenotypically normal women affected by POF were analysed by direct sequencing of the FOXL2 coding region. The analysis did not reveal any mutation in the 240 analysed chromosomes, indicating that mutations in the FOXL2 coding region are rarely associated with non-syndromic POF.

Premature ovarian failure and fragile X premutation: a study on 45 women.

The aim of this study was to test for the presence of the fragile X (FRAXA) premutation a group of women with early menopause. 45 women with idiopathic premature ovarian failure (POF), five with a familial and 40 with a sporadic form, were screened for the presence of FRAXA premutation. A control group of 28 women >45 years, with one or more children and no signs of POF, was also studied. We found three cases of fragile X premutations in women all belonging to the group with sporadic POF. Our results seems to confirm previous observations on the non random association between POF and FRAXA premutation.

Characterization of early presentation idiopathic ovarian failure in girls and adolescents.

This study focused retrospectively on a selected cohort of 20 adolescents with early onset premature ovarian failure (POF) and no apparent underlying cause, in order to characterize the idiopathic ovarian failure at pediatric age. This characterization was based on medical history, pedigree analysis, phenotypical and audiological evaluation, final and target heights, pelvic ultrasonography, endocrine assessment, routine hematochemical analyses and complete autoimmune screening. We found that: a) idiopathic POF presented either before or after puberty onset and also with secondary amenorrhea; b) final height prognosis was impaired only in patients with prepubertal presentation of POF; c) ovarian pattern at ultrasonography and endocrine picture were similar those previously reported in patients with adult onset POF; d) clinical history and pedigree analysis, phenotypical and audiological examination and complete autoimmune screening failed to highlight the existence of any possible cause for POF in 15/20 patients; e) no alterations of total cholesterol, low-density lipoprotein cholesterol and high-density lipoprotein cholesterol serum levels were detected in any patient. On the basis of these results we concluded that: a) final height of the adolescents with POF may be impaired only in patients in whom POF presents as a pubertal delay; b) other parameters do not generally differ from those described by previous reports on young adults with POF, except for serum lipid levels which were normal in the present cohort.

Autoimmune premature ovarian failure

Autoimmune premature ovarian failure (POF) is a large category that requires better definition and characterization. It is not known whether it involves a single antibody-mediated process or multiple processes. No accurate serum marker is available to identify patients who have POF caused by autoimmunity, and specific antigens that are involved in the development of autoimmune POF have not been found. Ovarian biopsy is the only way to diagnose autoimmune POF with certainty, although the procedure is not indicated clinically unless it is included in an approved protocol for a clinical trial. Although some patients' POF undoubtly is caused by autoimmunity, such as in patients with Addison's disease, clear proof of autoimmunity is lacking in most cases of idiopathic POF. Autoimmunity remains a candidate for the cause of POF, but better approaches and solid data are needed to define its exact role. The use of immunosuppressive therapy for POF currently is not supported by properly designed, prospective, randomized trials.

Steroid-cell autoantibodies are preferentially expressed in women with premature ovarian failure who have adrenal autoimmunity

Objective: To determine the prevalence of steroid-cell autoantibodies, 3β-hydroxysteroid dehydrogenase (3β-HSD) antibodies, 17α-hydroxylase (17α-OH) antibodies, and P450 side-chain cleavage antibodies in premature ovarian failure. Design: Cross-sectional, observational study. Setting: Academic research hospitals. Patient(s): Eighty-one women with premature ovarian failure, 20 women with Addison disease not associated with premature ovarian failure, 42 women with type 1 diabetes mellitus, and 90 healthy women. Main Outcome Measure(s): Serum levels of steroid-cell autoantibodies, 17α-OH antibodies, P450 side-chain cleavage antibodies, and 3β-HSD antibodies. Result(s): Steroid-cell autoantibodies were present in none of 57 women with isolated premature ovarian failure or premature ovarian failure plus nonadrenal autoimmune disease and in 21 of 24 (87%) women with Addison disease-related premature ovarian failure. 17α-Hydroxylase antibodies and P450 side-chain cleavage antibodies were significantly more frequent in women positive for adrenal autoantibodies than in those negative for adrenal autoantibodies (50% vs. 0% and 71% vs. 2%, respectively). The presence of 17α-OH antibodies or P450 side-chain cleavage antibodies was strongly associated with presence of steroid-cell autoantibodies. Two of 24 (8%) women with Addison disease-related premature ovarian failure and 1 of 57 (2%) women with isolated premature ovarian failure or premature ovarian failure plus nonadrenal autoimmune disease were positive for 3β-HSD antibodies. None of 20 adult women with autoimmune Addison disease and none of 42 adult women with type 1 diabetes mellitus not associated with premature ovarian failure was positive for 3β-HSD antibodies. Conclusion(s): Markers of steroid-cell autoimmunity are found only rarely in idiopathic premature ovarian failure not associated with Addison disease. Most women with Addison disease-related premature ovarian failure were positive for steroid-cell autoantibodies, 17α-OH antibodies, or P450 side-chain cleavage antibodies. 3β-Hydroxysteroid dehydrogenase antibodies do not appear to be a major marker of steroid-cell autoimmunity.

3 beta hydroxysteroid dehydrogenase autoantibodies in patients with idiopathic premature ovarian failure target N- and C-terminal epitopes.

The steroid cell enzyme 3 beta hydroxysteroid dehydrogenase (3 beta HSD) has been identified as a target of steroid cell autoantibodies, and autoantibodies to this enzyme are present in patients with premature ovarian failure and patients with autoimmune polyendocrine syndrome 1. The aim of the present study was to develop a radioligand binding assay for 3 beta HSD autoantibodies and to exploit this to examine regions of the molecule targeted by autoantibodies. We generated a construct of 3 beta HSD coupled to a luciferase fusion partner in order to maximize the yield of (35)S-radiolabeled protein. Labeled 3 beta HSD was then immunoprecipitated and the autoantibodies quantified by phosphoimaging. Autoantibodies to 3 beta HSD were detected in 12 of 100 (12%) idiopathic premature ovarian failure patients and 0 of 103 (0%) healthy age-matched controls (P < 0.0001). Three overlapping fragments of 3 beta HSD cDNA were cloned downstream of luciferase to examine autoantibody binding sites. Two of nine sera with 3 beta HSD autoantibodies (22%) displayed reactivity to the N terminus of 3 beta HSD, and seven (77%) showed reactivity to the C terminal; no sera reacted with the middle region. Our study demonstrates a markedly enhanced disease specificity of autoantibodies to 3 beta HSD detected using this novel assay and shows that distinct regions of the molecule are targeted.

3 Hydroxysteroid Dehydrogenase Autoantibodies in Patients with Idiopathic Premature Ovarian Failure Target N- and C-Terminal Epitopes

3 Hydroxysteroid Dehydrogenase Autoantibodies in Patients with Idiopathic Premature Ovarian Failure Target N- and C-Terminal Epitopes

The Lived Experience of Premature Ovarian Failure

To describe the lived experience of women who have been diagnosed with idiopathic premature ovarian failure (POF). Phenomenology was used to achieve the purpose. Women were asked to share their experiences in living with premature ovarian failure during an approximately 1-hour interview. The interviews were tape-recorded, transcribed, and analyzed for emergent themes. Interviews were conducted in the participants' homes and in a conference room in a hospital. The six participants were drawn from a multicultural sample of women with idiopathic POF. The women in this study expressed anger at their health care providers for their perceived lack of quality care they had experienced and at the insurance industry for its lack of reimbursement for fertility interventions; they expressed depression and sadness at the prospective outcome of the diagnosis, mixed emotions regarding their significant others, and sadness and resignation about their menopausal symptoms. Health care providers who create an environment in which women and their significant others will feel supported in asking questions, be assured that their concerns are taken seriously, and be provided with the physical and emotional resources they need can help these women to continue to build and live their lives.

A fork in the road to fertility.

Haploinsufficiency of FOXL2, a new forkhead transcription factor, causes blepharophimosis/ptosis/epicanthus inversus syndrome (BPES), a rare developmental disorder affecting the eyelid and sometimes the ovary. A new study implicates FOXL2 as the first human gene required for the maintenance of ovarian follicles. The discovery of FOXL2 may provide insight into the causes of idiopathic premature ovarian failure, a disease that burdens many infertile couples.