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Primary Metformin (MTF) ovulation induction in Polycystic Ovarian Syndrome (PCOS); the spectrum of insulin resistance and follicular response
excess is per se the main culprit for the follicular arrest. Despite its normal serum level, the effect exerted by FSH on the excessively large cohort would not be sufficient. In particular, it would unleash AMH, whom circulating levels correlated negatively to those of FSH (p⬍0.007), exerting its inhibiting effect on FSH-induced aromatase activity. Hyperinsulinism would also be involved in the follicular arrest, independently from the small follicle excess.
study was abandoned prematurely due to the overwhelming popularity of this visual aid. Ironically, this tool not only improved patient understanding but it actually shortened office visit length as well. This same tool is now being investigated for a possible role in fostering the education of resident physicians as well.
P-470 Primary Metformin (MTF) ovulation induction in Polycystic Ovarian Syndrome (PCOS); the spectrum of insulin resistance and follicular response. Jonathan W. T. Ayers, L Witthoeft, F. N. Shamma, K. Podorsek. IVF Michigan, Ypsilanti, MI; St Joseph Mercy Hosp, Ann Arbor, MI. Objective: To determine the actual ovarian folliculogenesis response of women primarily treated with MTF ovulation induction; and to characterize the clinical profiles of PCOS patients successfully treated with Insulin Sensitizers. Design: 71 Anovulatory women with normal: anatomy, male factor, endocrine profiles, and PCOS by sonographic (U/S) Adam’s criteria were treated with 1000 mg BID of MTF alone, and evaluated by ultrasound for ovarian follicular response. Materials and Methods: 12-14 days after a spontaneous menses on MTF treatment, U/S assessment of ovarian folliculogenesis was performed. Patients were categorized as: Group I-spontaneous menses with greater than or equal to 1 follicle over 18 mm; Group II-spontaneous menses with persistant PCO-no dominant follicle; Group III-no spontaneous menses within 40 days of MTF, persistant PCO. Results: Group I (31)
Group II (18)
Group III (22)
28.1 31.4 20.2 6.2 16/31
29.3 32.7 24.9 5.8 0
31.4 38.0* 32.3* 3.7* 0
Age (yrs) BMI (kg/m2) I (units) G/I Pregnant *p⬍.05 Group I
Conclusion: 1. MTF as primary ovulation induction for PCOS improves folliculogenesis in 70% of PCOS patients. 2. Initiation of regular menses does not necessarily equate to ovulatory normalcy-37% still PCOS by ultrasound. 3. In group II patients prompty addition of standard ovulation inducing agents may be warranted. 4. Insulin resistantance PCOS is a spectrum of Insulin/Androgen Dysfunction from the MTF sensitive to the morbidly obese, hyperinsulinemic, MTF insensitive PCOS.
P-471 Use of a novel visual analogy to facilitate patient understanding of the goals of hormonal therapy. Robert A. Greene, Brian Curtis. Specialty Care for Women, Redding, CA; MC2 Design, Chico, CA. Objective: Recent media coverage has heightened patient’s fears of hormone-based therapy. The goal of this study was to create a simple visual aid to improve patient adherence through education of treatment goals as well as possible side effects. Design: Patient’s presenting at a private reproductive endocrinology clinic completed a survey before and after the use of new educational tool. Materials and Methods: Various metaphors were investigated in order to create a widely understood literal reference to serve as an analogy to be used in explaining hormone related disturbances. This initial work found the mobile, a kinetic art structure, popularized in the sixties, achieved this goal. This symbol can appropriately represent the relationship between various hormones as well as their dynamic changes over time. Therefore, a graphic aid (see below) was tested in an office-based setting. A survey was initially given before and after consultation for every other patient referred to a reproductive endocrinology practice. Results: The goal of the study was to compare 50 office visits employing this educational tool and compare them to 50 traditional office visits. The
S276
Abstracts
Conclusion: The use of an appropriate educational tool can improve patient satisfaction as well as patient care while providing the clinician with more efficient use of their time.
P-472 Elevated serum level of Anti-Mu¨ llerian Hormone (AMH) in Polycystic Ovary Syndrome (PCOS): Relationship to the ovarian follicle excess and to the serum FSH and to the follicular arrest. Didier Dewailly Sr., Pascal Pigny, Christine Decanter, Yann Robert. LILLE Univ Hosp, Lille, France. Objective: Since the serum level of AMH correlates tightly to the small antral follicle number (FN) at ultrasonography (U/S), we investigated whether an increased AMH serum level is a pertinent marker for PCOS. Design: Serum AMH has been assayed in 104 women (59 symptomatic PCOS, 45 Controls) between days 2 and 7 after the last either spontaneous or progestin-induced (in PCOS) menstrual period. Materials and Methods: In PCOS and Controls groups, mean age was similar (range: 17 to 37). BMI ranged from 16.4 to 45.7 (mean: 27.9) and from 17.1 to 42.9 (mean: 24.7), respectively (p⬍0.0001). Results: Mean serum AMH level was markedly increased in the PCOS group (47.1 ⫹ 22.9 vs 20.8 ⫹ 11.6 pmol/L in Controls, p⬍0.0001). Simple regression analysis indicated in PCOS and Controls a positive relationship between AMH and the 2-5mm FN at U/S (p⬍0.0001 and p⬍0.02, respectively), but not to the 6-9mm FN. In PCOS and Controls, the serum FSH level correlated negatively to the 2-5mm FN (p⬍0.007 and p⬍0.04, respectively), and negatively to AMH (p⬍0.003 and p⬍0.04, respectively). AMH was also positively related to the serum Testosterone (T) and Androstenedione (A) levels in PCOS exclusively (p⬍0.002 and ⬍0.008, respectively). Lastly, AMH was negatively related to BMI and fasting Insulin (I) serum level in Controls (p⬍0.02 and p⬍0.03, respectively), but not in PCOS (p⫽0.88 and p⫽0.76, respectively). No relationship was found between AMH and age, serum estradiol, inhibin B and LH levels, in both groups. After stepwise regression, only the 2-5mm FN remained significantly related to AMH in PCOS and Controls, while T (or A) and FSH in PCOS, and BMI (or I) and FSH in Controls, were rejected from the model. Conclusions: Our data confirms that AMH is a strong marker of the small antral FN both in normal and PCOS women and suggests that AMH could reflect the positive effect of androgens on the small antral FN in PCOS. This effect could explain why the negative effect of overweight and hyperinsulinism was not found in PCOS. Lastly, the available data suggest that AMH could be a new candidate to explain the follicular arrest of PCOS. Because of the increased FN leading to an exaggerated AMH tone in PCO, the negative effect exerted by FSH on AMH would not be sufficient, despite its normal serum level, and this would unleash AMH exerting its inhibiting effect on FSH-induced aromatase activity. This fits with the rationale for ovulation induction in PCOS, which implies that the FSH serum level needs to be increased at the time of selection.
Vol. 80, Suppl. 3, September 2003
study was abandoned prematurely due to the overwhelming popularity of this visual aid. Ironically, this tool not only improved patient understanding but it actually shortened office visit length as well. This same tool is now being investigated for a possible role in fostering the education of resident physicians as well.
P-470 Primary Metformin (MTF) ovulation induction in Polycystic Ovarian Syndrome (PCOS); the spectrum of insulin resistance and follicular response. Jonathan W. T. Ayers, L Witthoeft, F. N. Shamma, K. Podorsek. IVF Michigan, Ypsilanti, MI; St Joseph Mercy Hosp, Ann Arbor, MI. Objective: To determine the actual ovarian folliculogenesis response of women primarily treated with MTF ovulation induction; and to characterize the clinical profiles of PCOS patients successfully treated with Insulin Sensitizers. Design: 71 Anovulatory women with normal: anatomy, male factor, endocrine profiles, and PCOS by sonographic (U/S) Adam’s criteria were treated with 1000 mg BID of MTF alone, and evaluated by ultrasound for ovarian follicular response. Materials and Methods: 12-14 days after a spontaneous menses on MTF treatment, U/S assessment of ovarian folliculogenesis was performed. Patients were categorized as: Group I-spontaneous menses with greater than or equal to 1 follicle over 18 mm; Group II-spontaneous menses with persistant PCO-no dominant follicle; Group III-no spontaneous menses within 40 days of MTF, persistant PCO. Results: Group I (31)
Group II (18)
Group III (22)
28.1 31.4 20.2 6.2 16/31
29.3 32.7 24.9 5.8 0
31.4 38.0* 32.3* 3.7* 0
Age (yrs) BMI (kg/m2) I (units) G/I Pregnant *p⬍.05 Group I
Conclusion: 1. MTF as primary ovulation induction for PCOS improves folliculogenesis in 70% of PCOS patients. 2. Initiation of regular menses does not necessarily equate to ovulatory normalcy-37% still PCOS by ultrasound. 3. In group II patients prompty addition of standard ovulation inducing agents may be warranted. 4. Insulin resistantance PCOS is a spectrum of Insulin/Androgen Dysfunction from the MTF sensitive to the morbidly obese, hyperinsulinemic, MTF insensitive PCOS.
P-471 Use of a novel visual analogy to facilitate patient understanding of the goals of hormonal therapy. Robert A. Greene, Brian Curtis. Specialty Care for Women, Redding, CA; MC2 Design, Chico, CA. Objective: Recent media coverage has heightened patient’s fears of hormone-based therapy. The goal of this study was to create a simple visual aid to improve patient adherence through education of treatment goals as well as possible side effects. Design: Patient’s presenting at a private reproductive endocrinology clinic completed a survey before and after the use of new educational tool. Materials and Methods: Various metaphors were investigated in order to create a widely understood literal reference to serve as an analogy to be used in explaining hormone related disturbances. This initial work found the mobile, a kinetic art structure, popularized in the sixties, achieved this goal. This symbol can appropriately represent the relationship between various hormones as well as their dynamic changes over time. Therefore, a graphic aid (see below) was tested in an office-based setting. A survey was initially given before and after consultation for every other patient referred to a reproductive endocrinology practice. Results: The goal of the study was to compare 50 office visits employing this educational tool and compare them to 50 traditional office visits. The
S276
Abstracts
Conclusion: The use of an appropriate educational tool can improve patient satisfaction as well as patient care while providing the clinician with more efficient use of their time.
P-472 Elevated serum level of Anti-Mu¨ llerian Hormone (AMH) in Polycystic Ovary Syndrome (PCOS): Relationship to the ovarian follicle excess and to the serum FSH and to the follicular arrest. Didier Dewailly Sr., Pascal Pigny, Christine Decanter, Yann Robert. LILLE Univ Hosp, Lille, France. Objective: Since the serum level of AMH correlates tightly to the small antral follicle number (FN) at ultrasonography (U/S), we investigated whether an increased AMH serum level is a pertinent marker for PCOS. Design: Serum AMH has been assayed in 104 women (59 symptomatic PCOS, 45 Controls) between days 2 and 7 after the last either spontaneous or progestin-induced (in PCOS) menstrual period. Materials and Methods: In PCOS and Controls groups, mean age was similar (range: 17 to 37). BMI ranged from 16.4 to 45.7 (mean: 27.9) and from 17.1 to 42.9 (mean: 24.7), respectively (p⬍0.0001). Results: Mean serum AMH level was markedly increased in the PCOS group (47.1 ⫹ 22.9 vs 20.8 ⫹ 11.6 pmol/L in Controls, p⬍0.0001). Simple regression analysis indicated in PCOS and Controls a positive relationship between AMH and the 2-5mm FN at U/S (p⬍0.0001 and p⬍0.02, respectively), but not to the 6-9mm FN. In PCOS and Controls, the serum FSH level correlated negatively to the 2-5mm FN (p⬍0.007 and p⬍0.04, respectively), and negatively to AMH (p⬍0.003 and p⬍0.04, respectively). AMH was also positively related to the serum Testosterone (T) and Androstenedione (A) levels in PCOS exclusively (p⬍0.002 and ⬍0.008, respectively). Lastly, AMH was negatively related to BMI and fasting Insulin (I) serum level in Controls (p⬍0.02 and p⬍0.03, respectively), but not in PCOS (p⫽0.88 and p⫽0.76, respectively). No relationship was found between AMH and age, serum estradiol, inhibin B and LH levels, in both groups. After stepwise regression, only the 2-5mm FN remained significantly related to AMH in PCOS and Controls, while T (or A) and FSH in PCOS, and BMI (or I) and FSH in Controls, were rejected from the model. Conclusions: Our data confirms that AMH is a strong marker of the small antral FN both in normal and PCOS women and suggests that AMH could reflect the positive effect of androgens on the small antral FN in PCOS. This effect could explain why the negative effect of overweight and hyperinsulinism was not found in PCOS. Lastly, the available data suggest that AMH could be a new candidate to explain the follicular arrest of PCOS. Because of the increased FN leading to an exaggerated AMH tone in PCO, the negative effect exerted by FSH on AMH would not be sufficient, despite its normal serum level, and this would unleash AMH exerting its inhibiting effect on FSH-induced aromatase activity. This fits with the rationale for ovulation induction in PCOS, which implies that the FSH serum level needs to be increased at the time of selection.
Vol. 80, Suppl. 3, September 2003