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Menstrual Cyclicity in Women With Polycystic Ovary Syndrome
cells (TCs) from anovulatory women with polycystic ovary syndrome (PCOS). DESIGN: Experimentrial in vitro study. MATERIALS AND METHODS: The follicles were obtained from 12 women with PCOS and 15 women with normal menstrual cycle who underwent surgeries after the withdraw-bleeding or their menstrual cycles day 7 -10 respectively. The accumulations of estrogen (E2), progesterone (P), androstenediol (A), LH, FSH and insulin in follicular fluid were measured . LH receptor (LHR) mRNA was detected in GCs and TCs by RT-PCR using -actin as intra-control simultaneously. The co-culture of GCs and TCs was done under different ratios of LH: FSH and high insulin in Twelve-well Transwell with polymembrane. RESULTS: The steroid hormones in the culture medium were analyzed . the secretion of A was stimulated significantly both in PCOS and the control group (8.4⫾4.4 vs 5.5⫾3.4 ng/ml, P⬍0.05; 4.7⫾2.8 vs 2.4⫾1.4 ng/ml, P⬍0.05, respectively) by addition of insulin into medium containing LH and FSH, and the ratio of LH: FSH was 5: 1.And such culture condition also promoted P to be produced higher significantly in the control group (21.2⫾11.0 vs 16.1⫾8.7 ng/ml, P⬍0.01), and it was not reaching significant in PCOS ( 27.7⫾24.9 vs 24.4⫾19.1 ng/ml, P⬎0.05). The production of E2 in PCOS and the control group was generally affected by adding LH and insulin (1200.8⫾833.6 vs 587.1⫾145.7 pg/ml, P⬍0.01; 898.7⫾700.6 vs 557.1⫾111.3 pg/ml, P⬍0.01, respectively). LHR mRNA was not detected in GCs of the control group until the follicle reached 7.4mm in diameter, and it was strongly expressed when the follicle of 9.8mm was present. While it could be detected in GCs of PCOS as the diameter of the follicle was as small as 4mm only. It was over expressed in GCs and TCs from PCOS than those from control group (0.29⫾0.16 vs. 0.12⫾0.13, p⫽0.001; 0.46⫾0.14 vs. 0.34⫾0.09,P⫽0.012) when there is no significance in diameter of these follicles between PCOS and control group(6.9⫾1.5 mm vs.7.5⫾2.2 mm, P⫽0.34). LHR mRNA expressed in the GCs was not detected in follicles of the control in vivo which diameter were less than 7.4 mm, while it became to appear in vitro. LHR mRNA expressed in GCs was significantly induced by insulin and high level of LH under co- culture in both PCOS and the control group (Fig ) . Fig. Expression of LHR mRNA from granulosa cells (A) and theca cells (B) under stimulation of insulin and different ratio of LH/FSH after co-culture. Medium containing 50ng/ml insulin; 25mIU/ml LH and 5mIU/ml FSH; 25mIU/ml LH and 5mIU/ml FSH; 25mIU/ml LH,5mIU/ml FSH and 50ng/ml insulin, were in group 1,group2,group 3 and group 4, respectively. An asterisk indicates a significant difference between treatment groups (P⬍0.05). Values are mean⫾SEM CONCLUSION: These data here suggested that high level of insulin or LH may promote GCs to premature and also lead to the differentiation of GCs; It also is proposed that hyperinsulinmia, by increasing the response of GCs and TCs to LH, amplifies the effect of LH on GCs which leads to be premature. The abnormal differentiation of GC may be responsible for the ceasing growth of follicles in anovulatory PCOS women. Supported by: This research was funded by the NSFC (No. 30271367, 30300372); Guandong Natural Science Fundation (No. 31690;21874) and GZST (No.2004J-C0111).
P-750 Comparison of Clomiphene Citrate (CC), Metformin or the Combination for First Line Ovulation Induction and Achievement of Pregnancy in 154 Women With Polycystic Ovary Syndrome (PCOS). N. Neveu, L. Granger, P. St Michel, H. Lavoie. Centre Hospitalier de l’Universite de Montreal, Montreal, PQ, Canada; Procrea Cliniques, Montreal, PQ, Canada. OBJECTIVE: PCOS is one of the most common causes of infertility. Response to lifestyle and medical treatment is often challenging. There is no clear evidence as to which first line treatment intervention is more effective for restoring fertility. CC has been the standard medication for ovulation induction in these patients for many years. But as insulin resistance has been shown to be overwhelmingly important in this syndrome, metformin has gained more popularity and is being used before CC in many patients. But there is no head to head trial comparing metformin to CC for ovulation induction and pregnancy achievement. As well, all the published series so far comprise of a few patients or are meta-analyses . Follow up exceeding 6 months is also lacking. The objectives of this study are first, to determine which medication is more effective first line in PCOS patients for ovulation and pregnancy achievement. Second, to verify if any patient characteristic is
FERTILITY & STERILITY威
associated with a better response to therapy, to guide initial medication selection. DESIGN: This is a retrospective study of 154 consecutive women referred to our fertility clinic for PCOS and infertility. They were assigned to 3 groups according to which treatment they were initially prescribed for induction of ovulation. Group 1 (56 patients) received CC 50 mg from day 5 to 9 of the cycle. Group 2 (57 patients) received 500 mg tid of metformin. Group 3 (41 patients) received both medications. Doses were adjusted to tolerance and to successful ovulation induction. MATERIALS AND METHODS: All women fit the 1990 NIH consensus criteria and had a thorough medical evaluation including a metabolic and hormonal profile, a hysterosalpingogram and a spouse sperm analysis. Statistical analysis was done by ANOVA, 2 x 2 comparison by Tuckey test and Chi square tests. Regression analysis was used to correct for time. RESULTS: Mean overall follow up was : 9.4 months (range : 2 to 78). Among the baseline characteristics, BMI was higher in groups 2 and 3 compared to 1 (34.3 ⫾ 1 and 32.1 ⫾ 1.2 vs 27.4 ⫾ 1.3 kg/m2; mean ⫾ SEM, Group 2,3,1; p⬍0.001). Despite this, patients receiving metformin alone had an increased ovulation rate compared to the ones receiving CC (75.4% vs 50%, p⫽0.005). There was no benefit to the combination for ovulation induction. When excluding patients with morbid obesity (BMI⬎40), the difference in BMI for the 3 groups was no longer significant (p⫽0.111). The ovulation rate between groups 1 and 2 remained statistically different (p⫽0.029). Pregnancy rates were equivalent in the 3 groups (35.7%, 45.6% and 31.7%, Group 1,2,3; p⫽0.332). Interestingly, patients taking 0.5 g to 1 g / day of metformin ovulated just as well as patients taking 1.5 to 2g / day. Finally, non smoking is associated with better ovulatory response overall (p⫽0.013), as well as lower systolic blood pressure and fasting glucose for CC and lower total testosterone and androstenedione for metformin. CONCLUSION: Our study shows that metformin is better for ovulation induction than clomiphene citrate and equivalent for pregnancy achievement. We propose that metformin should be offered first line in all women with PCOS considering its efficacy and better safety profile than CC (no increased multiple births, ovarian cysts or miscarriage rate) and its known beneficial effect on the overall metabolic profile. Finally, non smoking and a lower systolic blood pressure, fasting glucose, total testosterone and androstenedione are associated with a better ovulatory response. Supported by: None
P-751 The Effect of Chromium Supplementation on Insulin Resistance and Ovarian/Menstrual Cyclicity in Women With Polycystic Ovary Syndrome. R. S. Lucidi, A. C. Thyer, T. M. Siler-Khodr, A. E. Holden, R. S. Schenken, R. G. Brzyski. University of Texas HSC San Antonio, San Antonio, TX. OBJECTIVE: To determine if chromium supplementation in women with PCOS improves insulin sensitivity and restores cyclic ovulation. DESIGN: Randomized, prospective, double blind, placebo-controlled trial. MATERIALS AND METHODS: Patients: Reproductive age women with established PCOS according to the 1990 NIH criteria. Interventions: Patients were randomly allocated to treatment with oral chromium picolinate 200 g/d or placebo for four months. Main Outcome Measures: Ovulation rates were assessed through analysis of basal body temperature charting and confirmed with serum progesterone levels. Insulin sensitivity was assessed before and after treatment using the frequently sampled intravenous glucose tolerance test (FSIGT). A 75-gram oral glucose tolerance test (OGTT) was performed before and after treatment. Serum measurements of metabolic parameters (insulin sensitivity, fasting glucose, fasting insulin, OGTT, triglycerides, cholesterol) and hormonal parameters (total testosterone, free testosterone, dehydroepiandrostenedione sulfate, follicle stimulating hormone, luteinizing hormone) were also obtained before and after treatment. RESULTS: Table 1 summarizes the results. After four months treatment with chromium picolinate, there were no significant differences in the primary outcome measures of ovulation rates and insulin sensitivity. There was, however, a significant improvement in one and two hour glucose tolerance. Although the plasma glucose after treatment did not change significantly from baseline within treatment groups, there were significant differences when comparing chromium vs. placebo. This
S427
observation may reflect a worsening of insulin resistance in the placebo group.
Values are the mean ⫾ SEM. No comparison is significant except as noted. a No significant difference, baseline vs. after treatment b p⬍ 0.05, chromium vs. placebo (by repeated measures ANOVA).
CONCLUSION: Chromium picolinate 200 g/d appears to improve glucose tolerance but not ovulatory frequency in women with polycystic ovary syndrome. Additional larger studies are recommended, since the current pilot study was underpowered to detect potentially significant differences between groups in a number of important study parameters. Supported by: Supported by a grant from the Endocrine Fellows Foundation. Supported by the Frederic C. Bartter General Clinical Research Center, Grant Number M01-RR01346 from the National Center for Research Resources, National Institutes of Health.
P-752 Irregular Periods as a Marker of Increased Insulin and Testosterone Levels in the Gestational Diabetic Patient. P. S. Uzelac, J. Lee, X. Zhang, R. Mirzaei, R. J. Paulson, F. Z. Stanczyk. University of Southern California, Los Angeles, CA. OBJECTIVE: Gestational diabetes (GDM) is associated with increased androgen levels in the third trimester of pregnancy. This finding is supported by observations in the nonpregnant state that hyperinsulinemia/ insulin resistance leads to hyperandrogenemia. Polycystic ovary syndrome (PCOS), a disease characterized by irregular menses and hyperandrogenemia, is also associated with insulin resistance. Women with a history of irregular periods often present with GDM early in pregnancy (mid-second trimester) suggesting a degree of insulin resistance greater than that which can be attributed to pregnancy alone. The purpose of this study was to utilize insulin levels and androgen profiles to test the hypothesis that women with GDM and irregular periods have greater insulin and androgen levels compared to women with GDM and regular periods. DESIGN: Two groups of patients were studied. Group I (N⫽10) had a history of irregular periods (⬍ 6 periods/year) and a diagnosis of gestational diabetes (GDM) based upon two or more elevated values on a 100-g 3-hour glucose tolerance test (GTT). Group II (N⫽8) had a history of regular periods and a diagnosis of GDM as described above. MATERIALS AND METHODS: Fasting blood samples were obtained from all subjects. Serum levels of testosterone (T), dihydrotestosterone (DHT) and androstenedione (A) were quantified by RIA following organic solvent extraction and Celite column partition chromatography. Sex hormone-binding globulin (SHBG), dehydroepiandrosterone sulfate (DHEAS), 3␣-androstanediol glucorinide (3␣-diol G) and insulin were quantified by direct specific immunoassays. Free T values were calculated. Student’s T test was used for statistical analysis. RESULTS: Patient weight (97 kg ⫹/- 17 kg, mean ⫹/- SD, vs. 82 kg ⫹/19 kg, p ⬎ .05) and gestational age (21 wk ⫹/- 5.3 wk, mean ⫹/- SD, vs. 19 wk ⫹/- 3.3 wk, p ⬎ .05) were similar between groups. Mean levels of SHBG, A, 3␣-diol G, DHEAS and DHT were similar between groups, whereas total T and insulin were significantly elevated in the GDM with irregular periods group. Free T values were nonsignificantly elevated in the GDM with irregular periods group. CONCLUSION: Women with GDM and a history of irregular periods
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Abstracts
have higher levels of insulin and total T compared to women with GDM and regular periods. Since GDM itself is associated with insulin resistance, the increased levels of insulin and testosterone in women with a history of irregular periods suggest that these women may have an underlying component of insulin resistance that is worsened by pregnancy. Therefore irregular periods may be used as a marker for greater degrees of insulin resistance and increased androgens in pregnancy. Supported by: None P-753 Reproductive Functions in Hydrocephalic Females Treated With Endoscopic Third Ventriculostomy. M. A. Bedaiwy, M. M. Fathalla, M. H. Ragab, S. Elbaba, M. Luciano, T. Falcone. Mount Sinai Hospital, Toronto, ON, Canada; Assuit University Hospitals, Assuit, Egypt; The Cleveland Clinic Foundation, Cleveland, OH. OBJECTIVE: Hydrocehalus has been long associated with reproductive abnormalities. An increasing number of women with hydrocephalus are surviving to the childbearing age after being treated with the appropriate cerbrospinal fluid shunting procedures. Endoscopic third ventriculostomy (3rd vs) has been introduced as a minimally invasive approach for the treatment of hydrocephalus. Inserting the surgical instruments through the floor of the third ventricle could disrupt the neurons bringing the higher control impulses controlling the reproductive functions. Nothing is known about the reproductive functions treated with 3rd vs. The aim of this study was the evaluation of the reproductive functions of hydrocephalic females in the child bearing period before and after cerebrospinal fluid shunting procedures involving 3rd vs and conventional ventriculoperitoneal (VP) shunts. DESIGN: Case control study. MATERIALS AND METHODS: 69 women with hydrocephalus during the reproductive age period (12-45 years) were included. Endoscopic 3rd ventriculostomy was performed in 52 (75.4%; group I) and ventriculoperitoneal shunt was performed in 17 (24.6%, group II). All patients who underwent 3rd vs stayed for 2 days after surgery. The median follow up
Vol. 84, Suppl 1, September 2005
P-750 Comparison of Clomiphene Citrate (CC), Metformin or the Combination for First Line Ovulation Induction and Achievement of Pregnancy in 154 Women With Polycystic Ovary Syndrome (PCOS). N. Neveu, L. Granger, P. St Michel, H. Lavoie. Centre Hospitalier de l’Universite de Montreal, Montreal, PQ, Canada; Procrea Cliniques, Montreal, PQ, Canada. OBJECTIVE: PCOS is one of the most common causes of infertility. Response to lifestyle and medical treatment is often challenging. There is no clear evidence as to which first line treatment intervention is more effective for restoring fertility. CC has been the standard medication for ovulation induction in these patients for many years. But as insulin resistance has been shown to be overwhelmingly important in this syndrome, metformin has gained more popularity and is being used before CC in many patients. But there is no head to head trial comparing metformin to CC for ovulation induction and pregnancy achievement. As well, all the published series so far comprise of a few patients or are meta-analyses . Follow up exceeding 6 months is also lacking. The objectives of this study are first, to determine which medication is more effective first line in PCOS patients for ovulation and pregnancy achievement. Second, to verify if any patient characteristic is
FERTILITY & STERILITY威
associated with a better response to therapy, to guide initial medication selection. DESIGN: This is a retrospective study of 154 consecutive women referred to our fertility clinic for PCOS and infertility. They were assigned to 3 groups according to which treatment they were initially prescribed for induction of ovulation. Group 1 (56 patients) received CC 50 mg from day 5 to 9 of the cycle. Group 2 (57 patients) received 500 mg tid of metformin. Group 3 (41 patients) received both medications. Doses were adjusted to tolerance and to successful ovulation induction. MATERIALS AND METHODS: All women fit the 1990 NIH consensus criteria and had a thorough medical evaluation including a metabolic and hormonal profile, a hysterosalpingogram and a spouse sperm analysis. Statistical analysis was done by ANOVA, 2 x 2 comparison by Tuckey test and Chi square tests. Regression analysis was used to correct for time. RESULTS: Mean overall follow up was : 9.4 months (range : 2 to 78). Among the baseline characteristics, BMI was higher in groups 2 and 3 compared to 1 (34.3 ⫾ 1 and 32.1 ⫾ 1.2 vs 27.4 ⫾ 1.3 kg/m2; mean ⫾ SEM, Group 2,3,1; p⬍0.001). Despite this, patients receiving metformin alone had an increased ovulation rate compared to the ones receiving CC (75.4% vs 50%, p⫽0.005). There was no benefit to the combination for ovulation induction. When excluding patients with morbid obesity (BMI⬎40), the difference in BMI for the 3 groups was no longer significant (p⫽0.111). The ovulation rate between groups 1 and 2 remained statistically different (p⫽0.029). Pregnancy rates were equivalent in the 3 groups (35.7%, 45.6% and 31.7%, Group 1,2,3; p⫽0.332). Interestingly, patients taking 0.5 g to 1 g / day of metformin ovulated just as well as patients taking 1.5 to 2g / day. Finally, non smoking is associated with better ovulatory response overall (p⫽0.013), as well as lower systolic blood pressure and fasting glucose for CC and lower total testosterone and androstenedione for metformin. CONCLUSION: Our study shows that metformin is better for ovulation induction than clomiphene citrate and equivalent for pregnancy achievement. We propose that metformin should be offered first line in all women with PCOS considering its efficacy and better safety profile than CC (no increased multiple births, ovarian cysts or miscarriage rate) and its known beneficial effect on the overall metabolic profile. Finally, non smoking and a lower systolic blood pressure, fasting glucose, total testosterone and androstenedione are associated with a better ovulatory response. Supported by: None
P-751 The Effect of Chromium Supplementation on Insulin Resistance and Ovarian/Menstrual Cyclicity in Women With Polycystic Ovary Syndrome. R. S. Lucidi, A. C. Thyer, T. M. Siler-Khodr, A. E. Holden, R. S. Schenken, R. G. Brzyski. University of Texas HSC San Antonio, San Antonio, TX. OBJECTIVE: To determine if chromium supplementation in women with PCOS improves insulin sensitivity and restores cyclic ovulation. DESIGN: Randomized, prospective, double blind, placebo-controlled trial. MATERIALS AND METHODS: Patients: Reproductive age women with established PCOS according to the 1990 NIH criteria. Interventions: Patients were randomly allocated to treatment with oral chromium picolinate 200 g/d or placebo for four months. Main Outcome Measures: Ovulation rates were assessed through analysis of basal body temperature charting and confirmed with serum progesterone levels. Insulin sensitivity was assessed before and after treatment using the frequently sampled intravenous glucose tolerance test (FSIGT). A 75-gram oral glucose tolerance test (OGTT) was performed before and after treatment. Serum measurements of metabolic parameters (insulin sensitivity, fasting glucose, fasting insulin, OGTT, triglycerides, cholesterol) and hormonal parameters (total testosterone, free testosterone, dehydroepiandrostenedione sulfate, follicle stimulating hormone, luteinizing hormone) were also obtained before and after treatment. RESULTS: Table 1 summarizes the results. After four months treatment with chromium picolinate, there were no significant differences in the primary outcome measures of ovulation rates and insulin sensitivity. There was, however, a significant improvement in one and two hour glucose tolerance. Although the plasma glucose after treatment did not change significantly from baseline within treatment groups, there were significant differences when comparing chromium vs. placebo. This
S427
observation may reflect a worsening of insulin resistance in the placebo group.
Values are the mean ⫾ SEM. No comparison is significant except as noted. a No significant difference, baseline vs. after treatment b p⬍ 0.05, chromium vs. placebo (by repeated measures ANOVA).
CONCLUSION: Chromium picolinate 200 g/d appears to improve glucose tolerance but not ovulatory frequency in women with polycystic ovary syndrome. Additional larger studies are recommended, since the current pilot study was underpowered to detect potentially significant differences between groups in a number of important study parameters. Supported by: Supported by a grant from the Endocrine Fellows Foundation. Supported by the Frederic C. Bartter General Clinical Research Center, Grant Number M01-RR01346 from the National Center for Research Resources, National Institutes of Health.
P-752 Irregular Periods as a Marker of Increased Insulin and Testosterone Levels in the Gestational Diabetic Patient. P. S. Uzelac, J. Lee, X. Zhang, R. Mirzaei, R. J. Paulson, F. Z. Stanczyk. University of Southern California, Los Angeles, CA. OBJECTIVE: Gestational diabetes (GDM) is associated with increased androgen levels in the third trimester of pregnancy. This finding is supported by observations in the nonpregnant state that hyperinsulinemia/ insulin resistance leads to hyperandrogenemia. Polycystic ovary syndrome (PCOS), a disease characterized by irregular menses and hyperandrogenemia, is also associated with insulin resistance. Women with a history of irregular periods often present with GDM early in pregnancy (mid-second trimester) suggesting a degree of insulin resistance greater than that which can be attributed to pregnancy alone. The purpose of this study was to utilize insulin levels and androgen profiles to test the hypothesis that women with GDM and irregular periods have greater insulin and androgen levels compared to women with GDM and regular periods. DESIGN: Two groups of patients were studied. Group I (N⫽10) had a history of irregular periods (⬍ 6 periods/year) and a diagnosis of gestational diabetes (GDM) based upon two or more elevated values on a 100-g 3-hour glucose tolerance test (GTT). Group II (N⫽8) had a history of regular periods and a diagnosis of GDM as described above. MATERIALS AND METHODS: Fasting blood samples were obtained from all subjects. Serum levels of testosterone (T), dihydrotestosterone (DHT) and androstenedione (A) were quantified by RIA following organic solvent extraction and Celite column partition chromatography. Sex hormone-binding globulin (SHBG), dehydroepiandrosterone sulfate (DHEAS), 3␣-androstanediol glucorinide (3␣-diol G) and insulin were quantified by direct specific immunoassays. Free T values were calculated. Student’s T test was used for statistical analysis. RESULTS: Patient weight (97 kg ⫹/- 17 kg, mean ⫹/- SD, vs. 82 kg ⫹/19 kg, p ⬎ .05) and gestational age (21 wk ⫹/- 5.3 wk, mean ⫹/- SD, vs. 19 wk ⫹/- 3.3 wk, p ⬎ .05) were similar between groups. Mean levels of SHBG, A, 3␣-diol G, DHEAS and DHT were similar between groups, whereas total T and insulin were significantly elevated in the GDM with irregular periods group. Free T values were nonsignificantly elevated in the GDM with irregular periods group. CONCLUSION: Women with GDM and a history of irregular periods
S428
Abstracts
have higher levels of insulin and total T compared to women with GDM and regular periods. Since GDM itself is associated with insulin resistance, the increased levels of insulin and testosterone in women with a history of irregular periods suggest that these women may have an underlying component of insulin resistance that is worsened by pregnancy. Therefore irregular periods may be used as a marker for greater degrees of insulin resistance and increased androgens in pregnancy. Supported by: None P-753 Reproductive Functions in Hydrocephalic Females Treated With Endoscopic Third Ventriculostomy. M. A. Bedaiwy, M. M. Fathalla, M. H. Ragab, S. Elbaba, M. Luciano, T. Falcone. Mount Sinai Hospital, Toronto, ON, Canada; Assuit University Hospitals, Assuit, Egypt; The Cleveland Clinic Foundation, Cleveland, OH. OBJECTIVE: Hydrocehalus has been long associated with reproductive abnormalities. An increasing number of women with hydrocephalus are surviving to the childbearing age after being treated with the appropriate cerbrospinal fluid shunting procedures. Endoscopic third ventriculostomy (3rd vs) has been introduced as a minimally invasive approach for the treatment of hydrocephalus. Inserting the surgical instruments through the floor of the third ventricle could disrupt the neurons bringing the higher control impulses controlling the reproductive functions. Nothing is known about the reproductive functions treated with 3rd vs. The aim of this study was the evaluation of the reproductive functions of hydrocephalic females in the child bearing period before and after cerebrospinal fluid shunting procedures involving 3rd vs and conventional ventriculoperitoneal (VP) shunts. DESIGN: Case control study. MATERIALS AND METHODS: 69 women with hydrocephalus during the reproductive age period (12-45 years) were included. Endoscopic 3rd ventriculostomy was performed in 52 (75.4%; group I) and ventriculoperitoneal shunt was performed in 17 (24.6%, group II). All patients who underwent 3rd vs stayed for 2 days after surgery. The median follow up
Vol. 84, Suppl 1, September 2005