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Induction of ovulation with purified urinary follicle-stimulating hormone in patients with polycystic ovarian syndrome
Nutrition and cervical cancer. II
Volume 151 Number 5
2. Vitamin deficiencies. In: Paige DM, ed. Manual of clinical nutrition. Pleasantville, New Jersey: Nutrition Publications, 1984. 3. Devereux DF. Nutrition, malnutrition and the surgical wound. Infect Surg 1984;April:273-87. 4. Grobstein C, Chairman, Committee on Diet, Nutrition and Cancer. Assembly of Life Sciences, National Academy of Sciences. Washington DC: National Academy Press, 1982. 5. Orr JW Jr, Wilson K, Bodiford C, et al. Nutritiorial status of patients with untreated cervical cancer. AM J OBSTET GVNECOL 1985; 151 :625-31. 6. Nixon DW, Heymafield AE, Cohen MH, et al. Protein calorie malnutrition in hospitalized cancer patients. Am J Med 1980;68:683-90. 7. Basu TK, Dickerson JWT. The thiamine status of early cancer patients with particular reference to those with breast and bronchial carcinoma. Oncology 1976;33: 250-2. 8. Kummet T, Meyskens FL. Vitamin A: Potential inhibitor of human cancer. Semin Oncol 1983;10:281-9. 9. Mellow MH, Layne EA, Lipman TO, et al. Plasma zinc and vitamin A in human squamous carcinoma of the esophagus. Cancer 1983;51: 1615-20.
10. Ibrahim K,Jafarey NA, Zukeri SJ. Plasma vitamin A and carotene levels in squamous cell carcinoma of oral cavity and oral pharynx. Clin Oncol 1977;3:203-7. 11. Willett WC, Polk BF, Underwood BA, et al. Relation of serum vitamins A and E and carotenoids to the risk of cancer. N Engl J Med 1984;310:430-4. 12. Lambert B, Brisson G, Bielman P. Plasma vitamin A and precancerous lesions of cervix uteri: a preliminary report. Gynecol Oncol 1981; 11: 136-9. 13. Bernstein A, Harris B. The relationship of dietary and serum vitamin A to the occurrence of cervical intraepithelial neoplasia in sexually active women. AM J OBSTET GVNECOL 1984;148:309-12. 14. Goodman DS. Vitamin A and retinoids in health and disease. N Engl J Med 1984;310: 1023-31. 15. Wassertheil-Smoller S, Romney SL, Wylie-Rose H, et al. Dietary vitamin C and uterine cervical dysplasia. Am J Epidemiol 1981;114:714-24. 16. Brightsee E. Vitamin C and cancer prevention. Semin Oncol 1983; 10:294-8. 17. Butterworth CE, Hatch KD, Gore H, et al. Improvement in cervical dysplasia associated with folic acid therapy in users of oral contraceptives. Am J Clin Nutr 1982;35: 73-82.
Induction of ovulation with purified urinary follicle-stimulating hormone in patients with polycystic ovarian syndrome N. Garcea, M.D., S. Campo, M.D., V. Panetta, M.D., M. Venneri, M.D., P. Siccardi, M.D., R. Dargenio, M.D., and F. De Tomasi, M.D. Rome, Italy Purified urinary follicle-stimulating hormone was used to induce ovulation in 18 patients with polycystic ovarian syndrome. Each ampule contained 75 IU of follicle-stimulating hormone and <0.11 IU of luteinizing hormone. Initial doses were 150 to 225 IU/day, later increased to a maximum of 375 IU, according to daily clinical controls and estradiol values. After 12 to 16 days, follicle-stimulating hormone treatment was suspended. Within 36 to 48 hours each patient received 5000 or 10,000 IU of human chorionic gonadotropin, rarely more. Ovulation occurred in 39 of 43 treatment cycles and hyperstimulation in nine. Seven patients had normal pregnancies with viable fetuses, including one pair of twins. Two had abortions. Analysis of the endocrine situation during therapy does not permit either pregnancy or hyperstimulation to be predicted. However, hyperstimulation is frequently accompanied by endogenous luteinizing hormone peaks and greater estradiol increases during the final phase of induction. Purified follicle-stimulating hormone has thus demonstrated its validity in inducing ovulation in patients with polycystic ovarian syndrome, apparently with equal or lower risks of hyperstimulation than with other gonadotropin preparations. (AM J OaSTET GVNECOL 1985;151 :635-40.)
Key words: Ovulation induction, purified follicle-stimulating hormone The pharmacologic induction of ovulation in patients with polycystic ovarian syndrome depends almost exclusively on centrally acting drugs such as clomiphene or other antiestrogens. I From the Istituto di Glinica Ostetrica e Ginecologica della Universita Gattolica del Sacro Guore, and Farmacologia Glinica, Istituto Farmacologico Serono. Receivedfor publication April 1 , 1984; revised September 20,1984; accepted October 15, 1984. Reprint requests: Professor Nicola Garcea, lstituto di Glinica Ostetrica e Ginecologica della Universita Gattolica del Sacro Guore, Largo Agostino Gemelli 8,00168 Rome, Italy.
The high levels of endogenous luteinizing hormone in patients with polycystic ovarian syndrome increase the risk of hyperstimulation associated with use of the gonadotropins currently available. 2·8 Cases ofhyperstimulation can be reduced by careful monitorint or by the use of a preparation containing for the most part follicle-stimulating hormone. 10.14 For this reason we selected patients with polycystic ovarian syndrome, diagnosed by repeated hormone assays according to previous authors 3 . 15 and confirmed by laparoscopy.16 These patients were treated with a new gonadotropin prep-
635
636
Garcea et al.
March I, 1985 Am J Obstet Gynecol
Table I. Data for the case studies No.
Treated patients Cycles of therapy Ovulatory cycles Ovulations without pregnancies H yperstimulations Pregnancies Abortions Deliveries
%
l8
43 39 2l 9 9 2
7*
22 78
*One bigeminal pregnancy at term and one bigeminal pregnancy with reabsorption of one twin and normal spontaneous delivery of a live and viable fetus. Therefore total number of viable fetuses was 8.
man chorionic gonadotropin in two doses (10,000 and 5000) on two consecutive days, while one patient, whose estradiol value was below 500 pglml on the day folliclestimulating hormone was suspended, received 20,000 IU of human chorionic gonadotropin in three doses over 3 days (10,000 + 5000 + 5000). Serum samples were collected daily and stored at - 20° C. Follicle-stimulating hormone, luteinizing hormone, prolactin, progesterone, estrone, testosterone, and androstenedione were all assayed. All assays for a single patient were carried out simultaneously with the use of radioimmunoassay kits (Biodata, Milan, Italy). Results
aration obtained from the urine of menopausal women, supplied by the Istituto Farmacologico Serono of Rome and containing 75 IU of follicle-stimulating hormone and <0.11 IU of luteinizing hormone. The aim of our study was to verify the efficacy of the preparation in inducing ovulation and to investigate whether its therapeutic effect was greater than that of other available gonadotropins. Finally, we wish to establish endocrine criteria for the selection of patients in the hope of predicting their response to the drug. Material and methods
Eighteen patients between 25 and 36 years of age with polycystic ovarian syndrome and desirous of having children were treated with purified urinary folliclestimulating hormone. Fourteen patients had previously been treated with clomiphene (50 or 100 mglday for 5 to 10 days) plus human chorionic gonadotropin. None had achieved pregnancy. Three patients had been treated with cycles of human menopausal gonadotropin plus human chorionic gonadotropin, which had resulted in hyperstimulation (Lunenfeld grade II)5 in spite of careful monitoring (see below). For these three patients the treatment protocol followed for human menopausal gonadotropin was imitated during the first cycle of treatment with purified follicle-stimulating hormone. A total of 43 treatment cycles were administered, with the use (except in the three cycles just mentioned) of personalized protocols in order to achieve ovulation within 12 to 16 days. Treatment was initiated with 150 to 225 IU of follicle-stimulating hormone daily and increased in accordance with the ovarian response, which was monitored daily by means of clinical examination, basal body temperature, cervical score, and plasma estradiol levels. The maximum daily dose of follicle-stimulating hormone administered was 375 IU. Human chorionic gonadotropin was given in a single intramuscular injection of doses of between 5000 and 10,000 IU to all patients, generally 36 to 48 hours after suspension of treatment with follicle-stimulating hormone. Five cycles were treated with 15,000 IV of hu-
Table I shows the data from our survey. Forty-three treatment cycles were administered and ovulation was achieved in 39 (91 %) cycles and mild hyperstimulation (Lunenfeld II) in 9 (23%) ovulatory cycles. There were nine pregnancies (50% of patients), two of which were interrupted spontaneously at weeks 8 and 21. Two of the seven normal pregnancies were bigeminal: one, after early reabsorption of one fetus (echographically documented), concluded with the birth of a term fetus. All eight fetuses at birth appeared healthy, with normal infant weights. We divided the ovulatory cycles into 3 groups for the purposes of analyzing our results: ovulatory cycles not resulting in pregnancy, cycles resulting in pregnancy, and cycles resulting in hyperstimulation. We included in the first group those cycles in which the estradiol values were ,,;;2000 pglml on the day following suspension of the treatment and following which no ovarian cysts developed. The follicle-stimulating hormone profile in Fig. 1 shows no significant variations in the different groups under consideration; differences may, however, be noted with regard to luteinizing hormone. The patients who conceived show constantly low values of luteinizing hormone in the first phase of stimulation. The ovulatory but nonpregnant patients show the same pattern but with greater standard deviation, which becomes excessive during the final days of treatment, thus manifesting the appearance of endogenous luteinizing hormone peaks. The hyperstimulated patients show more numerous and pronounced endogenous luteinizing hormone peaks during and after stimulation with purified follicle-stimulating hormone. The presence of an endogenous luteinizing hormone peak is not constant in all the cycles of a single patient. When it is present, the treatment frequently results in hyperstimulation, whereas when it is absent, pregnancy is more likely to result. Endogenous luteinizing hormone peaks were in fact present in 48% (10/21) of ovulatory cycles without pregnancy, in 56% (5/9) of hyperstimulated patients, and in 11 % (1/9) of ovulatory cycles followed by pregnancy.
Induction of ovulation
Volume 151 Number 5
OVULATION WITHOUT PREQNANCY
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Fig. 1. Follicle-stimulating hormone (FSH), luteinizing hormone (LH), and prolactin (PRL) values in the three groups of patients. The patterns of follicle-stimulating hormone are similar in all groups. The luteinizing hormone levels are higher in the nonpregnant patients and especially in those with hyperstimulation (probably because of the presence of high basal values or endogenous peaks). The prolactin pattern is always the same in the three groups of patients. Each point corresponds to a number of hormone doses equal to or greater than 16 for ovulation without pregnancy and equal to or greater than six for hyperstimulations and pregnancies.
The prolactin pattern (Fig. 1) did not differ much from one group of patients to another. Individual values did, however, oscillate, tending to be higher in the hyperstimulated patients. Fig. 2 shows the plasma estradiol values. During stimulation there were no significant differences between the different groups; in fact, the profile seems identical, although the hyperstimulated women reached higher values on the last day of follicle-stimulating hormone administration. These average values were 531 ± 215 pglml for the nonpregnant patients, 552 ± 259 pglml for the pregnant women, and 1145 ± 835 pglml for the hyperstimulated patients. The progesterone increase precedes the end of follicle-stimulating hormone treatment and the administration of human chorionic gonadotropin in the hyperstimulated and ovulatory cycles without pregnancy. This early progesterone increase could be the result of endogenous peaks of luteinizing hormone, which, as we have seen, are more frequent in these two groups. The association between early progesterone increase and endogenous luteinizing hormone peaks is evident from analysis of the single cases. Endogenous luteinizing hormone peaks were accompanied by progesterone increases in 30% of ovu-
latory cycles without pregnancy (2/5). In cycles resulting in hyperstimulation this figure is 40% (4/10). We found only one luteinizing hormone peak not followed by an increase in progesterone in the treatment cycles followed by pregnancy. We never found a progesterone increase without a luteinizing hormone peak. Fig. 3 gives the profile of estradiol for the three patients to whom we administered first a cycle of stimulation with human menopausal gonadotropin and later a cycle of follicle-stimulating hormone at the same dosage. The pattern of estradiol increase shows no difference between the two types of stimulation. Fig. 4 shows the marked increase in the standard deviation for estrone in the nonpregnant patients after suspension of the therapy and even earlier in the hyperstimulated patients. The testosterone and androstenedione values, shown in Fig. 4, were unchanged by the therapy in the different groups of patients.
Comment Patients with polycystic ovarian syndrome present oligoamenorrhea and anovulation. The endocrine profile is marked by persistently high levds of luteinizing hormone with normal or low follicle-stimulating hor-
638 Garcea et al.
March I, 1985 Am J Obstet Gynecol
OVULATION WITHOUT ,.,•• GNANCY
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Fig. 2. Estradiol and progesterone levels in the three groups of patients. In the final phase of stimulation estradiol and progesterone levels tend to be higher in the hyperstimulated patients.
mone and high levels of androgens and estrone. The excess amount of luteinizing hormone stimulates ovarian production of androgens, which are converted into estrogens; these increase hypophyseal sensitivity to luteinizing hormone releasing factor, with consequent liberation of more luteinizing hormone. The comparative deficiency of follicle-stimulating hormone has been attributed either to an inhibitory effect of the intraovarian androgens or to the high levels of inhibin produced by the numerous follicles present in the ovaries of these patients. 17-19 The induction of ovulation by pharmacologic means in these patients uses centrally acting drugs, such as clomiphene, which, by interrupting the estrogen feedback, restores a normal luteinizing hormone cycle. The use of the common human gonadotropin preparations in patients who do not respond to clomiphene treatment can be associated with a high percentage of hyperstimulation, because of the presence in the preparations of large quantities of luteinizing hormone. Careful monitoring during this therapy can mitigate this problem. It has been shown that the use of purified folliclestimulating hormone from human pituitaries is unable to induce follicular maturation in hypogonadotropic patients, since adequate levels of luteinizing hormone must be present. 12. 20, 21 The use of preparations of purified follicle-stimulating hormone for patients with polycystic ovarian syndrome can, on the other hand, give satisfactory results, given the high levels of endogenous luteinizing hormone present in this type of functional condition.
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Fig. 3. 17j3-Estradiol values in the three patients who first received a cycle of human menopausal gonadotropin (HMG) and later a cycle of follicle-stimulating hormone (FSH) at the same dosage. The pattern of estradiol increase shows no difference between the two types of stimulation.
In 1972 Berger et al. 12 reported the efficacy of a preparation of purified pituitary follicle-stimulating hormone in inducing follicular maturation in patients with polycystic ovarian syndrome. In 1977 Raj et al. I3 achieved 77% ovulation in 18 cycles of treatment with purified pituitary follicle-stimulating hormone in 10 patients with polycystic ovarian syndrome, with a 27% incidence of moderate hyperstimulation. In 1982 Kamrava et al.I< achieved two pregnancies in two patients with polycystic ovarian syndrome who were treated with purified pituitary follicle-stimulating hormone without the addition of human chorionic gonadotropin. Our own data confirm the efficacy in women with polycystic ovarian syndrome of treatment with purified follicle-stimulating hormone extracted from the urine of menopausal women and virtually lacking in luteinizing hormone. In fact, this efficacy is emphasized by the following results: 91 % of treatment cycles were ovulatory and nine cycles, equal to 50% of the patients, resulted in pregnancy. Because of the low number of hyperstimulations (23%), these results seem to be as valid as those obtained by us in patients with hypo pi-
Induction of ovulation
Volume 151 Number 5
tuitarism after treatment with human menopausal gonadotropin plus human chorionic gonadotropin"· 6 The incidence of abortions was 22%, as in hypogonadotropic patients stimulated with human menopausal gonadotropin. 22 These results are more optimistic than those obtained by Venturoli et al.,23 who did not get any pregnancy at term in five patients affected with polycystic ovarian syndrome and treated with Pergonal and subsequently with follicle-stimulating hormone. The estradiol levels on suspension of treatment were not reliable parameters for predicting the results of stimulation. For example, average estradiol values in the nonpregnant and pregnant patients were fairly similar on the suspension of stimulation (531 ± 215 and 552 ± 259 pg/ml). It is probable that in many women of the former group this value is obtained by the simultaneous maturation of several follicles, as our occasional ultrasound examinations suggested. In the hyperstimulated women, on the other hand, the average estradiol values on suspension of follicle-stimulating hormone were decidedly greater (1145 ± 835 pg/ml), but the difference was not statistically significant. In some of these cases this would have been avoided by interrupting the administration of follicle-stimulating hormone earlier or by not administering human chorionic gonadotropin. In many cases, however, it was the spontaneous appearance of endogenous luteinizing hormone peaks that caused hyperstimulation. Maybe the basal androgenic situation of the ovary, and certainly the reactivity of the hypothalamic-pituitary axis in terms of luteinizing hormone production, could be a decisive element for the outcome of therapy. When this activation fails to assume any physiologic aspect, whether for reasons intrinsic to the ovary or because of high basal levels of androstenedione, the outcome of stimulation is jeopardized. Another decisive factor influencing the outcome of stimulation is the occurrence of an endogenous luteinizing hormone peak. The increase in estradiol induced by follicle-stimulating hormone often causes a positive estrogen feedback for luteinizing hormone in these patients. This endogenous peak, especially when induced by estrogens from the simultaneous maturation of more than one follicle, may occur when the ovary is not ready for ovulation and may thus provoke follicular luteinization or ineffective ovulation. In other situations this endogenous peak, when added to exogenous administration of human chorionic gonadotropin, could induce hyperstimulation. In our patients, in whom the assays of luteinizing hormone were carried out later, we often found endogenous peaks of luteinizing hormone, both in hyperstimulated and normostimulated but nonpregnant patients. This phenomenon may be one of the possible causes for the lack of
pregnancy in the latter group. Purified follicle-stimulating hormone was shown in
639
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Fig. 4. Estrone, testosterone, and androstenedione patterns in the three groups. Estrone is higher in the periovulatory phase in the hyperstimulated and ovulatory but nonpregnant women. Testosterone and androstenedione are not modified by the therapy.
our experience to be capable of producing normal follicular maturation followed by a normal pregnancy in women affected with polycystic ovarian syndrome. The percentage of pregnancies we obtained was high. The number and severity of cases of hyperstimulation were similar to those obtained with other gonadotropic preparations. REFERENCES 1. Garcea N, PorceJluzzi L, Campo S, Siccardi P. Antiestro-
2. 3. 4.
5.
6.
7.
geni. Presented at XI Congresso Nazionale Societa Italiana Fertilita e Sterilita, Lucca, Italy, October 2-3, 1981 (in press). Yen SSC. Polycystic ovary (PCO) syndrome. In Yen SSC, Jaffe RB, eds. Reproductive endocrinology. Philadelphia: W.B. Saunders, 1979:306. Yen SSC. The polycystic ovary syndrome. Clin Endocrinol 1980;22:117. Garcea N. Induzione dell'ovulazione con gonadotropine umane e con c10mifene citrato. In: Maneschi M, Cittadini E, Quartararo P, eds. Fertilita e sterilita, Palermo, Italy: Cofese, 1977:289. Lunenfeld B: La therapeutique par les gonadotrophines humaines extraites des urines de femmes menopausees (HMG): indications, techniques, resultats. Gynecol Obstet 1966;65:553. Caruso A, Garcea N, Campo S, Siccardi P, Sgreccia M. Criteri di valutazione della terapia con HMG + HCG. In: Bompiani A, Garcea N, eds. Argomenti di sterilita, irsutismo, infertilita, sterilita di origine endocrina. Rome: Gruppo Editoriale Medico, 1980:297. Campo S, Garcea N, Caruso A, Siccardi P, Lenci M. Terapia con clomifene nelle pazienti affette da sterilita da PCO. In: Bompiani A, Garcea N, eds. Argomenti di ster-
640 Garcea et al.
8.
9.
10.
11.
12.
13. 14.
15.
i!ita, irsutismo, infertilita, sterilita di origine endocrina. Rome: Gruppo Editoriale Medico, 1980:286. Moneta E, Marana R, Garcea N, Caruso A. Iatrogenic hyperstimulation of the ovary with ascites: report of a case and considerations and management. Acta Eur Fertil 1977;8: 155. Kammann E, Tavakoli F, Shelden RM, Jones JR: Induction of ovulation with menotropins in women with polycystic ovary syndrome. AM J OBSTET GYNECOL 1981; 141:58. Garcea N, Campo S, Siccardi P, Panetta V, Martino G. Experiences with FSH about the induction of ovulation in women with PCO: preliminary reports. Presented at Third World Congress of Human Reproduction, Berlin, March 22-26, 1981, p. 188. Flamigni C, Venturoli S, Paradisi R, Fabbri R. Role of urinary purified FSH in treatment of chronic anovulation. Presented at Third World Congress of Human Reproduction, Berlin, March 22-26, 1981, p. 17. Berger MJ, Taymor ML, Karam K, Nudemberg F. The relative roles of exogenous and endogenous follicle-stimulating hormone (FSH) and luteinizing hormone (LH) in human follicular maturation and ovulation induction. Fertil Steril 1972;23:783. Raj SG, Berger MJ, Grimes EM, Taymor ML. The use of gonadotropins for the induction of ovulation in women with polycystic ovarian disease. Fertil SteriI1977;28: 1280. Kamrava MM, Seibel MM, Berger MJ, Thompson I, Taymor ML. Reversal of persistent anovulation in polycystic ovarian disease by administration of chronic low-dose follicle stimulating hormone. Fertil Steril 1982;37:520. Goldzier Jw. Polycystic ovarian disease. Fertil Steril 1981 ;35:371.
March 1, 1985 Am J Obstet Gyneco1
16. Garcea N, Bompiani A. La 1aparoscopia nello studio della sterilita di origine endocrina. In: Albano V, Cittadini E, Quartararo P, eds. Endoscopia gineco1ogica. Palermo, Italy: Cofese, 1981:55. 17. Serio M, Dell'Acqua S, Calabresi E, Borrelli D. Androgen secretion by the human ovary. In: James VHT, Serio M, Giusti G, eds. The endocrine function of the huran ovary. New York: Academic Press, 1976:471. 18. Chappel SC, Holt JA, Spies HG. Inhibin: differences in bio-activity within human follicular fluid in the follicular and luteal stages of the menstrual cycle. Proc Soc Exp Bioi Med 1980;163:310. 19. Channing CP, Gagliano P, Hoover DJ, et al. Relationship between human follicular fluid inhibin F activity and steroid content. J Clin Endocrinol Metab 1981 ;52: 1193. 20. Berger MJ, Taymor ML. The role of LH in human follicular maturation and function. AM J OBSTET GYNECOL 1971;111:708. 21. Jacobson A, Marshall JR. Ovulatory response rate with human menopausal gonadotropins of varying FSH-LH ratios. Ferti! Steril 1969;20: 171. 22. Oelsner G, Serr DM, Mashiach S, Blankstein J, Snyder M, Lunenfeld B. The study of ind uction of ovulation with menotropins: analysis of results of 1897 treatment cycles. Ferti! Steril 1978;30:538. 23. Venturoli S, Paradisi R, Fabbri R, Magrini 0, Porcu E, Flamigni C. Comparison between human urinary folliclestimulating hormone and human menopausal gonadotropin treatment in polycystic ovary. Obstet Gynecol 1984;63:6.
Volume 151 Number 5
2. Vitamin deficiencies. In: Paige DM, ed. Manual of clinical nutrition. Pleasantville, New Jersey: Nutrition Publications, 1984. 3. Devereux DF. Nutrition, malnutrition and the surgical wound. Infect Surg 1984;April:273-87. 4. Grobstein C, Chairman, Committee on Diet, Nutrition and Cancer. Assembly of Life Sciences, National Academy of Sciences. Washington DC: National Academy Press, 1982. 5. Orr JW Jr, Wilson K, Bodiford C, et al. Nutritiorial status of patients with untreated cervical cancer. AM J OBSTET GVNECOL 1985; 151 :625-31. 6. Nixon DW, Heymafield AE, Cohen MH, et al. Protein calorie malnutrition in hospitalized cancer patients. Am J Med 1980;68:683-90. 7. Basu TK, Dickerson JWT. The thiamine status of early cancer patients with particular reference to those with breast and bronchial carcinoma. Oncology 1976;33: 250-2. 8. Kummet T, Meyskens FL. Vitamin A: Potential inhibitor of human cancer. Semin Oncol 1983;10:281-9. 9. Mellow MH, Layne EA, Lipman TO, et al. Plasma zinc and vitamin A in human squamous carcinoma of the esophagus. Cancer 1983;51: 1615-20.
10. Ibrahim K,Jafarey NA, Zukeri SJ. Plasma vitamin A and carotene levels in squamous cell carcinoma of oral cavity and oral pharynx. Clin Oncol 1977;3:203-7. 11. Willett WC, Polk BF, Underwood BA, et al. Relation of serum vitamins A and E and carotenoids to the risk of cancer. N Engl J Med 1984;310:430-4. 12. Lambert B, Brisson G, Bielman P. Plasma vitamin A and precancerous lesions of cervix uteri: a preliminary report. Gynecol Oncol 1981; 11: 136-9. 13. Bernstein A, Harris B. The relationship of dietary and serum vitamin A to the occurrence of cervical intraepithelial neoplasia in sexually active women. AM J OBSTET GVNECOL 1984;148:309-12. 14. Goodman DS. Vitamin A and retinoids in health and disease. N Engl J Med 1984;310: 1023-31. 15. Wassertheil-Smoller S, Romney SL, Wylie-Rose H, et al. Dietary vitamin C and uterine cervical dysplasia. Am J Epidemiol 1981;114:714-24. 16. Brightsee E. Vitamin C and cancer prevention. Semin Oncol 1983; 10:294-8. 17. Butterworth CE, Hatch KD, Gore H, et al. Improvement in cervical dysplasia associated with folic acid therapy in users of oral contraceptives. Am J Clin Nutr 1982;35: 73-82.
Induction of ovulation with purified urinary follicle-stimulating hormone in patients with polycystic ovarian syndrome N. Garcea, M.D., S. Campo, M.D., V. Panetta, M.D., M. Venneri, M.D., P. Siccardi, M.D., R. Dargenio, M.D., and F. De Tomasi, M.D. Rome, Italy Purified urinary follicle-stimulating hormone was used to induce ovulation in 18 patients with polycystic ovarian syndrome. Each ampule contained 75 IU of follicle-stimulating hormone and <0.11 IU of luteinizing hormone. Initial doses were 150 to 225 IU/day, later increased to a maximum of 375 IU, according to daily clinical controls and estradiol values. After 12 to 16 days, follicle-stimulating hormone treatment was suspended. Within 36 to 48 hours each patient received 5000 or 10,000 IU of human chorionic gonadotropin, rarely more. Ovulation occurred in 39 of 43 treatment cycles and hyperstimulation in nine. Seven patients had normal pregnancies with viable fetuses, including one pair of twins. Two had abortions. Analysis of the endocrine situation during therapy does not permit either pregnancy or hyperstimulation to be predicted. However, hyperstimulation is frequently accompanied by endogenous luteinizing hormone peaks and greater estradiol increases during the final phase of induction. Purified follicle-stimulating hormone has thus demonstrated its validity in inducing ovulation in patients with polycystic ovarian syndrome, apparently with equal or lower risks of hyperstimulation than with other gonadotropin preparations. (AM J OaSTET GVNECOL 1985;151 :635-40.)
Key words: Ovulation induction, purified follicle-stimulating hormone The pharmacologic induction of ovulation in patients with polycystic ovarian syndrome depends almost exclusively on centrally acting drugs such as clomiphene or other antiestrogens. I From the Istituto di Glinica Ostetrica e Ginecologica della Universita Gattolica del Sacro Guore, and Farmacologia Glinica, Istituto Farmacologico Serono. Receivedfor publication April 1 , 1984; revised September 20,1984; accepted October 15, 1984. Reprint requests: Professor Nicola Garcea, lstituto di Glinica Ostetrica e Ginecologica della Universita Gattolica del Sacro Guore, Largo Agostino Gemelli 8,00168 Rome, Italy.
The high levels of endogenous luteinizing hormone in patients with polycystic ovarian syndrome increase the risk of hyperstimulation associated with use of the gonadotropins currently available. 2·8 Cases ofhyperstimulation can be reduced by careful monitorint or by the use of a preparation containing for the most part follicle-stimulating hormone. 10.14 For this reason we selected patients with polycystic ovarian syndrome, diagnosed by repeated hormone assays according to previous authors 3 . 15 and confirmed by laparoscopy.16 These patients were treated with a new gonadotropin prep-
635
636
Garcea et al.
March I, 1985 Am J Obstet Gynecol
Table I. Data for the case studies No.
Treated patients Cycles of therapy Ovulatory cycles Ovulations without pregnancies H yperstimulations Pregnancies Abortions Deliveries
%
l8
43 39 2l 9 9 2
7*
22 78
*One bigeminal pregnancy at term and one bigeminal pregnancy with reabsorption of one twin and normal spontaneous delivery of a live and viable fetus. Therefore total number of viable fetuses was 8.
man chorionic gonadotropin in two doses (10,000 and 5000) on two consecutive days, while one patient, whose estradiol value was below 500 pglml on the day folliclestimulating hormone was suspended, received 20,000 IU of human chorionic gonadotropin in three doses over 3 days (10,000 + 5000 + 5000). Serum samples were collected daily and stored at - 20° C. Follicle-stimulating hormone, luteinizing hormone, prolactin, progesterone, estrone, testosterone, and androstenedione were all assayed. All assays for a single patient were carried out simultaneously with the use of radioimmunoassay kits (Biodata, Milan, Italy). Results
aration obtained from the urine of menopausal women, supplied by the Istituto Farmacologico Serono of Rome and containing 75 IU of follicle-stimulating hormone and <0.11 IU of luteinizing hormone. The aim of our study was to verify the efficacy of the preparation in inducing ovulation and to investigate whether its therapeutic effect was greater than that of other available gonadotropins. Finally, we wish to establish endocrine criteria for the selection of patients in the hope of predicting their response to the drug. Material and methods
Eighteen patients between 25 and 36 years of age with polycystic ovarian syndrome and desirous of having children were treated with purified urinary folliclestimulating hormone. Fourteen patients had previously been treated with clomiphene (50 or 100 mglday for 5 to 10 days) plus human chorionic gonadotropin. None had achieved pregnancy. Three patients had been treated with cycles of human menopausal gonadotropin plus human chorionic gonadotropin, which had resulted in hyperstimulation (Lunenfeld grade II)5 in spite of careful monitoring (see below). For these three patients the treatment protocol followed for human menopausal gonadotropin was imitated during the first cycle of treatment with purified follicle-stimulating hormone. A total of 43 treatment cycles were administered, with the use (except in the three cycles just mentioned) of personalized protocols in order to achieve ovulation within 12 to 16 days. Treatment was initiated with 150 to 225 IU of follicle-stimulating hormone daily and increased in accordance with the ovarian response, which was monitored daily by means of clinical examination, basal body temperature, cervical score, and plasma estradiol levels. The maximum daily dose of follicle-stimulating hormone administered was 375 IU. Human chorionic gonadotropin was given in a single intramuscular injection of doses of between 5000 and 10,000 IU to all patients, generally 36 to 48 hours after suspension of treatment with follicle-stimulating hormone. Five cycles were treated with 15,000 IV of hu-
Table I shows the data from our survey. Forty-three treatment cycles were administered and ovulation was achieved in 39 (91 %) cycles and mild hyperstimulation (Lunenfeld II) in 9 (23%) ovulatory cycles. There were nine pregnancies (50% of patients), two of which were interrupted spontaneously at weeks 8 and 21. Two of the seven normal pregnancies were bigeminal: one, after early reabsorption of one fetus (echographically documented), concluded with the birth of a term fetus. All eight fetuses at birth appeared healthy, with normal infant weights. We divided the ovulatory cycles into 3 groups for the purposes of analyzing our results: ovulatory cycles not resulting in pregnancy, cycles resulting in pregnancy, and cycles resulting in hyperstimulation. We included in the first group those cycles in which the estradiol values were ,,;;2000 pglml on the day following suspension of the treatment and following which no ovarian cysts developed. The follicle-stimulating hormone profile in Fig. 1 shows no significant variations in the different groups under consideration; differences may, however, be noted with regard to luteinizing hormone. The patients who conceived show constantly low values of luteinizing hormone in the first phase of stimulation. The ovulatory but nonpregnant patients show the same pattern but with greater standard deviation, which becomes excessive during the final days of treatment, thus manifesting the appearance of endogenous luteinizing hormone peaks. The hyperstimulated patients show more numerous and pronounced endogenous luteinizing hormone peaks during and after stimulation with purified follicle-stimulating hormone. The presence of an endogenous luteinizing hormone peak is not constant in all the cycles of a single patient. When it is present, the treatment frequently results in hyperstimulation, whereas when it is absent, pregnancy is more likely to result. Endogenous luteinizing hormone peaks were in fact present in 48% (10/21) of ovulatory cycles without pregnancy, in 56% (5/9) of hyperstimulated patients, and in 11 % (1/9) of ovulatory cycles followed by pregnancy.
Induction of ovulation
Volume 151 Number 5
OVULATION WITHOUT PREQNANCY
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Fig. 1. Follicle-stimulating hormone (FSH), luteinizing hormone (LH), and prolactin (PRL) values in the three groups of patients. The patterns of follicle-stimulating hormone are similar in all groups. The luteinizing hormone levels are higher in the nonpregnant patients and especially in those with hyperstimulation (probably because of the presence of high basal values or endogenous peaks). The prolactin pattern is always the same in the three groups of patients. Each point corresponds to a number of hormone doses equal to or greater than 16 for ovulation without pregnancy and equal to or greater than six for hyperstimulations and pregnancies.
The prolactin pattern (Fig. 1) did not differ much from one group of patients to another. Individual values did, however, oscillate, tending to be higher in the hyperstimulated patients. Fig. 2 shows the plasma estradiol values. During stimulation there were no significant differences between the different groups; in fact, the profile seems identical, although the hyperstimulated women reached higher values on the last day of follicle-stimulating hormone administration. These average values were 531 ± 215 pglml for the nonpregnant patients, 552 ± 259 pglml for the pregnant women, and 1145 ± 835 pglml for the hyperstimulated patients. The progesterone increase precedes the end of follicle-stimulating hormone treatment and the administration of human chorionic gonadotropin in the hyperstimulated and ovulatory cycles without pregnancy. This early progesterone increase could be the result of endogenous peaks of luteinizing hormone, which, as we have seen, are more frequent in these two groups. The association between early progesterone increase and endogenous luteinizing hormone peaks is evident from analysis of the single cases. Endogenous luteinizing hormone peaks were accompanied by progesterone increases in 30% of ovu-
latory cycles without pregnancy (2/5). In cycles resulting in hyperstimulation this figure is 40% (4/10). We found only one luteinizing hormone peak not followed by an increase in progesterone in the treatment cycles followed by pregnancy. We never found a progesterone increase without a luteinizing hormone peak. Fig. 3 gives the profile of estradiol for the three patients to whom we administered first a cycle of stimulation with human menopausal gonadotropin and later a cycle of follicle-stimulating hormone at the same dosage. The pattern of estradiol increase shows no difference between the two types of stimulation. Fig. 4 shows the marked increase in the standard deviation for estrone in the nonpregnant patients after suspension of the therapy and even earlier in the hyperstimulated patients. The testosterone and androstenedione values, shown in Fig. 4, were unchanged by the therapy in the different groups of patients.
Comment Patients with polycystic ovarian syndrome present oligoamenorrhea and anovulation. The endocrine profile is marked by persistently high levds of luteinizing hormone with normal or low follicle-stimulating hor-
638 Garcea et al.
March I, 1985 Am J Obstet Gynecol
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mone and high levels of androgens and estrone. The excess amount of luteinizing hormone stimulates ovarian production of androgens, which are converted into estrogens; these increase hypophyseal sensitivity to luteinizing hormone releasing factor, with consequent liberation of more luteinizing hormone. The comparative deficiency of follicle-stimulating hormone has been attributed either to an inhibitory effect of the intraovarian androgens or to the high levels of inhibin produced by the numerous follicles present in the ovaries of these patients. 17-19 The induction of ovulation by pharmacologic means in these patients uses centrally acting drugs, such as clomiphene, which, by interrupting the estrogen feedback, restores a normal luteinizing hormone cycle. The use of the common human gonadotropin preparations in patients who do not respond to clomiphene treatment can be associated with a high percentage of hyperstimulation, because of the presence in the preparations of large quantities of luteinizing hormone. Careful monitoring during this therapy can mitigate this problem. It has been shown that the use of purified folliclestimulating hormone from human pituitaries is unable to induce follicular maturation in hypogonadotropic patients, since adequate levels of luteinizing hormone must be present. 12. 20, 21 The use of preparations of purified follicle-stimulating hormone for patients with polycystic ovarian syndrome can, on the other hand, give satisfactory results, given the high levels of endogenous luteinizing hormone present in this type of functional condition.
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In 1972 Berger et al. 12 reported the efficacy of a preparation of purified pituitary follicle-stimulating hormone in inducing follicular maturation in patients with polycystic ovarian syndrome. In 1977 Raj et al. I3 achieved 77% ovulation in 18 cycles of treatment with purified pituitary follicle-stimulating hormone in 10 patients with polycystic ovarian syndrome, with a 27% incidence of moderate hyperstimulation. In 1982 Kamrava et al.I< achieved two pregnancies in two patients with polycystic ovarian syndrome who were treated with purified pituitary follicle-stimulating hormone without the addition of human chorionic gonadotropin. Our own data confirm the efficacy in women with polycystic ovarian syndrome of treatment with purified follicle-stimulating hormone extracted from the urine of menopausal women and virtually lacking in luteinizing hormone. In fact, this efficacy is emphasized by the following results: 91 % of treatment cycles were ovulatory and nine cycles, equal to 50% of the patients, resulted in pregnancy. Because of the low number of hyperstimulations (23%), these results seem to be as valid as those obtained by us in patients with hypo pi-
Induction of ovulation
Volume 151 Number 5
tuitarism after treatment with human menopausal gonadotropin plus human chorionic gonadotropin"· 6 The incidence of abortions was 22%, as in hypogonadotropic patients stimulated with human menopausal gonadotropin. 22 These results are more optimistic than those obtained by Venturoli et al.,23 who did not get any pregnancy at term in five patients affected with polycystic ovarian syndrome and treated with Pergonal and subsequently with follicle-stimulating hormone. The estradiol levels on suspension of treatment were not reliable parameters for predicting the results of stimulation. For example, average estradiol values in the nonpregnant and pregnant patients were fairly similar on the suspension of stimulation (531 ± 215 and 552 ± 259 pg/ml). It is probable that in many women of the former group this value is obtained by the simultaneous maturation of several follicles, as our occasional ultrasound examinations suggested. In the hyperstimulated women, on the other hand, the average estradiol values on suspension of follicle-stimulating hormone were decidedly greater (1145 ± 835 pg/ml), but the difference was not statistically significant. In some of these cases this would have been avoided by interrupting the administration of follicle-stimulating hormone earlier or by not administering human chorionic gonadotropin. In many cases, however, it was the spontaneous appearance of endogenous luteinizing hormone peaks that caused hyperstimulation. Maybe the basal androgenic situation of the ovary, and certainly the reactivity of the hypothalamic-pituitary axis in terms of luteinizing hormone production, could be a decisive element for the outcome of therapy. When this activation fails to assume any physiologic aspect, whether for reasons intrinsic to the ovary or because of high basal levels of androstenedione, the outcome of stimulation is jeopardized. Another decisive factor influencing the outcome of stimulation is the occurrence of an endogenous luteinizing hormone peak. The increase in estradiol induced by follicle-stimulating hormone often causes a positive estrogen feedback for luteinizing hormone in these patients. This endogenous peak, especially when induced by estrogens from the simultaneous maturation of more than one follicle, may occur when the ovary is not ready for ovulation and may thus provoke follicular luteinization or ineffective ovulation. In other situations this endogenous peak, when added to exogenous administration of human chorionic gonadotropin, could induce hyperstimulation. In our patients, in whom the assays of luteinizing hormone were carried out later, we often found endogenous peaks of luteinizing hormone, both in hyperstimulated and normostimulated but nonpregnant patients. This phenomenon may be one of the possible causes for the lack of
pregnancy in the latter group. Purified follicle-stimulating hormone was shown in
639
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Fig. 4. Estrone, testosterone, and androstenedione patterns in the three groups. Estrone is higher in the periovulatory phase in the hyperstimulated and ovulatory but nonpregnant women. Testosterone and androstenedione are not modified by the therapy.
our experience to be capable of producing normal follicular maturation followed by a normal pregnancy in women affected with polycystic ovarian syndrome. The percentage of pregnancies we obtained was high. The number and severity of cases of hyperstimulation were similar to those obtained with other gonadotropic preparations. REFERENCES 1. Garcea N, PorceJluzzi L, Campo S, Siccardi P. Antiestro-
2. 3. 4.
5.
6.
7.
geni. Presented at XI Congresso Nazionale Societa Italiana Fertilita e Sterilita, Lucca, Italy, October 2-3, 1981 (in press). Yen SSC. Polycystic ovary (PCO) syndrome. In Yen SSC, Jaffe RB, eds. Reproductive endocrinology. Philadelphia: W.B. Saunders, 1979:306. Yen SSC. The polycystic ovary syndrome. Clin Endocrinol 1980;22:117. Garcea N. Induzione dell'ovulazione con gonadotropine umane e con c10mifene citrato. In: Maneschi M, Cittadini E, Quartararo P, eds. Fertilita e sterilita, Palermo, Italy: Cofese, 1977:289. Lunenfeld B: La therapeutique par les gonadotrophines humaines extraites des urines de femmes menopausees (HMG): indications, techniques, resultats. Gynecol Obstet 1966;65:553. Caruso A, Garcea N, Campo S, Siccardi P, Sgreccia M. Criteri di valutazione della terapia con HMG + HCG. In: Bompiani A, Garcea N, eds. Argomenti di sterilita, irsutismo, infertilita, sterilita di origine endocrina. Rome: Gruppo Editoriale Medico, 1980:297. Campo S, Garcea N, Caruso A, Siccardi P, Lenci M. Terapia con clomifene nelle pazienti affette da sterilita da PCO. In: Bompiani A, Garcea N, eds. Argomenti di ster-
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8.
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i!ita, irsutismo, infertilita, sterilita di origine endocrina. Rome: Gruppo Editoriale Medico, 1980:286. Moneta E, Marana R, Garcea N, Caruso A. Iatrogenic hyperstimulation of the ovary with ascites: report of a case and considerations and management. Acta Eur Fertil 1977;8: 155. Kammann E, Tavakoli F, Shelden RM, Jones JR: Induction of ovulation with menotropins in women with polycystic ovary syndrome. AM J OBSTET GYNECOL 1981; 141:58. Garcea N, Campo S, Siccardi P, Panetta V, Martino G. Experiences with FSH about the induction of ovulation in women with PCO: preliminary reports. Presented at Third World Congress of Human Reproduction, Berlin, March 22-26, 1981, p. 188. Flamigni C, Venturoli S, Paradisi R, Fabbri R. Role of urinary purified FSH in treatment of chronic anovulation. Presented at Third World Congress of Human Reproduction, Berlin, March 22-26, 1981, p. 17. Berger MJ, Taymor ML, Karam K, Nudemberg F. The relative roles of exogenous and endogenous follicle-stimulating hormone (FSH) and luteinizing hormone (LH) in human follicular maturation and ovulation induction. Fertil Steril 1972;23:783. Raj SG, Berger MJ, Grimes EM, Taymor ML. The use of gonadotropins for the induction of ovulation in women with polycystic ovarian disease. Fertil SteriI1977;28: 1280. Kamrava MM, Seibel MM, Berger MJ, Thompson I, Taymor ML. Reversal of persistent anovulation in polycystic ovarian disease by administration of chronic low-dose follicle stimulating hormone. Fertil Steril 1982;37:520. Goldzier Jw. Polycystic ovarian disease. Fertil Steril 1981 ;35:371.
March 1, 1985 Am J Obstet Gyneco1
16. Garcea N, Bompiani A. La 1aparoscopia nello studio della sterilita di origine endocrina. In: Albano V, Cittadini E, Quartararo P, eds. Endoscopia gineco1ogica. Palermo, Italy: Cofese, 1981:55. 17. Serio M, Dell'Acqua S, Calabresi E, Borrelli D. Androgen secretion by the human ovary. In: James VHT, Serio M, Giusti G, eds. The endocrine function of the huran ovary. New York: Academic Press, 1976:471. 18. Chappel SC, Holt JA, Spies HG. Inhibin: differences in bio-activity within human follicular fluid in the follicular and luteal stages of the menstrual cycle. Proc Soc Exp Bioi Med 1980;163:310. 19. Channing CP, Gagliano P, Hoover DJ, et al. Relationship between human follicular fluid inhibin F activity and steroid content. J Clin Endocrinol Metab 1981 ;52: 1193. 20. Berger MJ, Taymor ML. The role of LH in human follicular maturation and function. AM J OBSTET GYNECOL 1971;111:708. 21. Jacobson A, Marshall JR. Ovulatory response rate with human menopausal gonadotropins of varying FSH-LH ratios. Ferti! Steril 1969;20: 171. 22. Oelsner G, Serr DM, Mashiach S, Blankstein J, Snyder M, Lunenfeld B. The study of ind uction of ovulation with menotropins: analysis of results of 1897 treatment cycles. Ferti! Steril 1978;30:538. 23. Venturoli S, Paradisi R, Fabbri R, Magrini 0, Porcu E, Flamigni C. Comparison between human urinary folliclestimulating hormone and human menopausal gonadotropin treatment in polycystic ovary. Obstet Gynecol 1984;63:6.