The hormonal response of patients with polycystic ovarian disease to subcutaneous low frequency pulsatile administration of luteinizing hormone-releasing hormone

FERTILITY AND STERILITY Copyright c 1986 The American Fertility Society

Vol. 46, No.3, September 1986 Printed in U.8A.

The hormonal response of patients with polycystic ovarian disease to subcutaneous low frequency pulsatile administration of luteinizing hormone-releasing hormone

Arye Hurwitz, M.D. *t Barak Rosenn, M.D. * Zvi Palti, M.D. * Bonney Ebstein, Ph.D.+ Rooth Har-Nir* Moshe Ron, M.D.* Hadassah University Hospital, Mount Scopus, and The Central Laboratories of Kupat-Holim, Jerusalem, Israel

Four patients with oligoamenorrhea manifesting hormonal and clinical features of polycystic ovarian disease (peOD) were selected for treatment. All patients had high luteinizing hormone (LH) levels and a basal LHlfollicle-stimulating hormone (FSH) ratio of> 3. Three of them had high androgen levels with normal adrenal cortical function. The four patients were treated for 12 cycles by pulsatile LH -releasing hormone (LH-RH) subcutaneously. Frequency of pulses varied between once in every 120 to once in every 400 minutes in consecutive cycles, in an attempt to reverse LHI FSH ratio. The dose of LH -RH varied between 20 and 40 fLglpulse. Treatment was monitored hormonally by the determinations of LH, FSH, 17r>-estradiol, prolactin, progesterone, testosterone (T) (total and free), androstenedione (.:l4A), dehydroepiandrosterone sulfate (DHEA-S), and sex hormone-binding globulin (SHBG) every 2 days. The most striking change was the lowering of the LHIFSH ratio to the normal range, due to LH decrease and FSH increase with a pulse frequency of 180 to 240 minutes. DHEA-S levels reversed to normal in two patients and were reduced in one patient. T and .:l4A levels returned to normal with elevation to normal of SHBG. These hormonal improvements did not result in ovulation as expected (2 of 12 cycles). It may be assumed that either subcutaneous administration is inadequate in peOD patients or that the frequency of pulses needed to correct the hormonal disturbances in peOD patients differs from that needed for ovum maturation and ovulation. Fertil Steril 46:378, 1986

Received January 10, 1986; revised and accepted May 23, 1986. *Department of Obstetrics and Gynecology, Hadassah University Hospital, Mount Scopus. tReprint requests: A. Hurwitz, M.D., Department ofObstetrics and Gynecology, Hadassah University Hospital, Mount Scopus, P.O. Box 24035, Jerusalem 91240, Israel. :j:The Central Laboratories of Kupat-Holim.

378

Hurwitz et aI. Treatment ofPCOD with LH-RH

Pulsatile luteinizing hormone-releasing hormone (LH-RH) administration for induction of ovulation in women with hypothalamic amenorrhea is becoming a widespread method of treatment. I -a Treatment by this modality for ovulatory disorders of other etiologies has been dealt with by only a few authors reporting relatively low rates of success. 4 , 5 Fertility and Sterility

Table 1. Average Basal Hormonal Levels in the Four Patients From 3 Consecutive Determinations Taken 10 Days Apart Patient

LH

FSH

LHlFSH

mIUlml

mIUlml

1 2 3 4

20.6 23 25 17

4.0 7.0 6.0 4

5.9 3.2 4.1 3.7

Normal values

2-15

2-10

1-2

E.

P

PRL

T

a'A

DHEA-S

SHBG

FreeT

pglml

nglml

nglml

nglml

nglml

fJ-g/ml

".gldl

pglml

73 52 96 40

0.4 1.0 0.6 0.4

11.8 8.0 12 10.6

0.5 0.9 1.5 0.8

2.1 2.2 5.0 3.0

1.5 4.6 7.0 4.5

1.3 1.0 3.2 1.8

1.1 3.8 5.0 3.2

5-15

<1

0.8-4.0

0.~.6

1.1-3.4

0.7-3.6

Ovulatory >6

One of the common ovulatory disorders is polycystic ovarian disease (PCOD), in which high levels of LH, low to normal levels of follicle-stimulating hormone (FSH), an abnormal LH/FSH ratio, and sometimes high androgen levels make treatment with LH-RH more complex. Nevertheless, these patients have a tendency to develop hyperstimulation with gonadotropin treatment when treatment with clomiphene citrate fails and therefore are in greater need of a low-risk treatment, which might be offered by LH-RH. This study deals with the trial of treatment with pulsatile LH-RH in patients with PCOD. The mode of treatment in this study was based on the work of Wildt et al.,6 who showed that a lower pulse frequency ofLH-RH favors secretion ofFSH over that of LH in monkeys bearing arcuate lesions. In view of the typical hormonal disturbances in PCOD, we have tried to alter the disturbed LH/FSH ratio by decreasing the LH-RH pulse frequency and changing the pulse dose. Monitoring the androgenic response during this treatment may offer deeper insight into the response of these patients to treatment. MATERIALS AND METHODS PATIENTS

Four patients were selected for treatment. Ages ranged from 25 to 33 years, with an average of 7 years of infertility. Two patients had oligoamenorrhea and were obese (patients 1 and 2), and two had secondary amenorrhea (patients 3 and 4). They had no mechanical factor based on hysterosalpingography and laparoscopy and had normospermic husbands. Patient 2 had classic polycystic ovaries on laparoscopy. All four had an adequate response to an LH-RH stimulation test (150 j-Lg). An adrenocorticotropin (ACTH) stimulation test (Cortrysin, Organon, Oss, The Netherlands) was normal, revealing no partial adrenal hydroxVol. 46, No.3, September 1986

ylase deficiencies. All four patients failed to conceive with clomiphene citrate and reacted with hyperstimulation to gonadotropin treatment. They gave informed consent before treatment with LH-RH was begun. Table 1 summarizes the patients' basal hormone levels comprising the average values of three blood samples taken 10 days apart. It is apparent from this table that the patients were normoprolactinemic and that all four had elevated LH levels and LH/FSH ratios. Additionally, patients 2 and 4 had increased dehydroepiandrosterone sulfate (DHEA-S) levels, and patient 3 had increased levels of all androgens: DHEA-S, androstenedione (a4 A), and total and free testosterone (T). The sex hormone-binding globulin (SHBG) level was decreased in patient 2, who had high levels of free T. LUTEINIZING HORMONE-RELEASING HORMONE TREATMENT PROTOCOL

LH-RH (Lutrelef, Ferring Arzneimittel GmbH, Kiel, FRG) was administered by means of the small computerized Zyklomat infusion pump (Ferring Arzneimittel, GmbH), connected to a chronic indwelling catheter inserted in the subcutaneous fat tissue of the lower abdominal wall. Initially, 50 j-LI of LH-RH (20 j-Lg) was infused subcutaneously every 180 minutes for 1 minute. Thereafter, LH-RH concentrations and pulse intervals were changed every 2, 3, or 4 weeks, according to the individual estradiol (E 2) response. For this reason, the E2 level was determined during treatment on the day of examination. When no satisfactory response in E2 was observed for 2 to 4 weeks, either the dose ofLH-RH or the interval between pulses, or both, was increased. Treatment was monitored by clinical examination, namely, cervical mucus, basal body temperature recordings, ultrasonic imaging, and peripheral venous blood sampling every 2 to 3 days for Hurwitz et aI. Treatment ofPCOD with LH-RH

379

course of treatment. LH and FSH levels were determined with the commercial kit (Amerlex, Amersham International, Amersham, UK) with the use of the radioimmunoassay (RIA) technique with double-antibody (solid phase second antibody). The LH code was IM.2081; the FSH code was IM.2071. E2 levels were determined with a commercial kit (Pantex, Santa Monica, CA) RIA double-antibody with extraction code 047. P, PRL, and T were determined by the commercial kit (Sorin, International CIS, Cedex, France), RIA direct double-antibody. The P code was DIRIA-PROGK; the PRL code was SB-PROL; and the T code was SB-TESTO. DHEA-S and a 4 A were assayed with the commercial kit (Biodata, Serono Diagnostic SA, Milano, Italy) with tritium labeling. The DHEA-S code was 10034; the a4 A code 10024. SHBG was assayed with a commercial kit (Serono Diagnostic SA, Switzerland) in which the residual binding sites of SHBG are occupied by 3H-dihydrotestosterone, and separation of bound and free isotope is achieved by ammonium sulfate precipitation, code 10651. Free T was assayed by the commercial kit (Coat-Count; Diagnostic Products Corporation, Los Angeles, CA) with antibody-coated tubes, using 125I_Ia_ beled T analog to compete with the free T in the patient's sample.

SHBG (p%)

Free Testo (pg/mll

LH FSH (mIU/ml) 2 ~------+---r---~--~IO

8

:€ l

: i1 1ii

RESULTS Patients' responses to the various schedules of treatment are shown in Figures 1 to 4.

2 ~

co

~~~~~~~~~~~ O~

o0

10 20 30 40 50 60 70 80

Days

Figure 1 The hormonal response of patient 1 to the varying schedules of LH-RH administration.

radioimmunologic determinations of FSH, LH, E 2, prolactin (PRL), progesterone (P), total and free T, a4 A, DHEA-S, and SHBG levels. HORMONAL ASSAY

Blood was drawn every 2 to 3 days at 8:00 A.M., and the serum was separated after clotting and stored at - 40°C until assayed. All serum samples were assayed with the same kits in one batch so that the interassay variability would be reduced, excluding E 2, which was determined during the 380

Hurwitz et aI. Treatment of peon with LH -RH

PATIENT 1

This patient (Fig. 1) responded only to treatment with 30 j.Lg LH-RH/pulse every 240 minutes. LH/FSH ratio dropped to within the normal range by decrease in LH levels and an increase in FSH levels. Ovulation was achieved, but menses appeared 7 days after P peaked at 10 ng/ml. The patient decided to stop treatment a few days later. PATIENT 2

This patient (Fig. 2) responded to treatment with a schedule of 30 j.Lg LH-RH/pulse every 180 minutes, by showing a tendency toward lowering ofT levels. Administration of 30 j.Lg LH-RH/pulse every 240 minutes resulted in a further decrease in T and free T levels, with a slight increase in SHBG levels. FSH levels showed a tendency to rise, but there was no rise in E2 levels. DHEA-S Fertility and Sterility

LHRHI (}.JQ)

20/180' 11301180'11 301240' 1140/300'1

lH/FSH 4

Testo (ng/ml)

Andro (ng/ml)

was continued with 20 f..Lg LH-RH/pulse every 90 minutes, as recommended by most authors. Ovulation occurred in spite of the high androgen levels, but the patient menstruated 11 days after the LH surge, with a peak P level of 6.7 ng/ml. Continuing treatment with 20 f..Lg LH-RH/pulse every 180 minutes brought the LH/FSH ratio to within the normal range, but androgen levels remained high. The levels of T, free T, and DHEA-S remained high when pulse frequency was decreased to every 240 minutes. In view ofthe patient's good DEXAMETHASONE

OHEAS

Pati.n t no. 3

(~g/ml)

20 111'

SHBG (p"l.)

U/FSII

Free

(nglml)

20/240'

20/180 '

Test.

Testo

Aldro (ng/ml )

lH TlIU/ml

.IIUS (,..gml)

FS H SIlIG

TlIUI ml

( J,I'f.)

E2

Free Testo

pg/ml

(pg/ml)

10

20 30

40 50 60 70 80 90

Days Figure 2 The hormonal response of patient 2 to the varying schedules of LH-RH administration.

LH

FSII (mIU/mI)

levels remained high. Only when 40 f..Lg LH-RHI pulse were given every 300 minutes did DHEA-S levels return to the normal range; yet there was no follicular maturation. After 95 days of treatment, the patient elected to stop further treatment.

E2 (pg/ml)

Days

PATIENT 3

Under the initial schedule of 20 f..Lg LH-RHI pulse every 180 minutes, this patient (Fig. 3) showed a rise in E2 levels. Therefore, treatment Vol. 46, No.3, September 1986

Figure 3 The hormonal response of patient 3 to the varying schedules of LH-RH administration. Hurwitz et aI.

Treatment of peon with LH -RH

381

7~:r 20/1BO' 201240'30/240' LHfFSH

8

lesto

1

(ng/ml l

PATIENT 4

This patient (Fig. 4) showed a decrease in DHEA-S levels to normal with a schedule of20 I-Lg LH-RH/pulse every 240 minutes. There was no other positive response to the various schedules, as· apparent by the constantly elevated LH/FSH ratio.

Andro (ng/mll

Free lesto

DISCUSSION

. ~~~~~~~~~~

(pg/ml l 2

LH

FSH

(mIU/ml l 4 ~'{ffI;~~~~~W;;

E2 (pg/mll 20 00

10' 20 30 40 50 60 70

Days

Figure 4 The hormonal response of patient 4 to the varying schedules of LH-RH administration.

response to the schedule of 20 I-Lg LH-RH/pulse every ISO minutes and corpus luteum insufficiency, due probably to the high androgen levels, the patient received dexamethasone (DEX), 0.25 mg/day by mouth, with the same schedule ofLHRH.Androgen levels returned to normal, an elevation in E2 up to 450 pg/ml was observed, and a l.S-cm follicle was demonstrated on sonographic imaging, but no ovulation was achieved. 382

Hurwitz et aI. Treatment of PCOD with LH-RH

The primary lesion causing hormonal disturbances in PCOD is not known. Among the causes implicated are a primary central disturbance in gonadotropin-releasing hormone (GnRH) puIs atility, probably mediated by dopamine 7 ; primary excessive ovarian androgen production, directly affecting hypophyseal production or release of gonadotropins8 or affecting GnRH hypothalamic release. Thus, it is most prudent to regard PCOD as the end result of multifactorial abnormalities in folliculogenesisand ovulation at the various levels, rather than a single disease entity. Therefore, the treatment of these patients may sometimes be complicated by these various interplaying factors. The idea of changing pulse frequencies in order to alter the LH/FSH ratio was derived from the study of Wildt et al.,6 which was later corroborated by others in the human. 9 We tried in this study to give low frequency pulses of LH-RH in the hope of lowering the LHIFSH ratio, thus diminishing ovarian androgen overproduction and enabling folliculogenesis. It is well understood that our cases differ from those of both latter authors because of the presence of endogenous LHRH as opposed to its absence in monkeys with arcuate lesions6 and isolated gonadotropin deftciency.9 The subcutaneous route of LH-RH administration has been shown to· be successful by some authors,10-12 though less effective by others. 5 , 13, 14 Loucopoulos et al. 5 have shown that the pattern of LH~RH levels in venous blood after subcutaneous administration resembles those obtained after intravenous administration, though peak levels achieved were lower. The four patients studied have shown a wide diversity in response to treatment. Three patients exhibited the expected change in LH/FSH ratio because of a mild decrease in LH and a moderate increase in FSH levels, with treatment schedules varying between 20 I-Lg LH-RH/pulse every lS0 minutes and 30 I-Lg LH-RH/pulseevery 240 minFertility and Sterility

utes. The lack of response in patient 4 emphasizes the diversity of responses in these patients and may be due to failure in reaching the right schedule for this individual. Three of our patients had high levels of DHEAS with no recognizable adrenal hydroxylase deficiency, as proved by ACTH test. 15 It has been found that some PCOD patients have elevated levels of DHEA-S due to a mild deficiency in adrenal 3f3-0l-dehydrogenase. 16 There was a positive response of DHEA-S reduction in patients 2 and 4, which was not related to a decrease in LH levels in these patients. A possible direct effect of LH-RH on the ovaries cannot, therefore, be excluded. l7 , 18 Patient 3, in whom all androgens were elevated, showed no consistent positive response, though the LH/FSH ratio decreased to within the normal range. 44A reached normal levels for most of the treatment period; yet T and DHEA-S remained basically high throughout this period. It is possible to argue that because of a long-standing hyperplasia of theca cells in this patient, our treatment was too short to affect these hormones. The dramatic effect of DEX in this patient cannot exclude a prominent adrenal contribution to T and DHEA-S levels, although the ACTH test results were normal. The poor follicular response in these patients, namely, only two ovulatory cycles, one at the beginning of treatment in patient 3 and the other toward the end of treatment in patient 1, projects the overall failure of these treatment schedules. This lack of response was not dependent on improvement in LH/FSH ratio and in androgen levels, and was mainly connected with the lack of an adequate increase in FSH levels. Diversity of response patterns in these patients may well be due to the multiplicity of underlying pathologies in PCOD patients. Loucopoulos et al. 5 recently reported their experience with pulsatile normal and low frequency of LH-RH in four patients with PCOD, and only in one patient did they lower the LH/FSH ratio. They recommended further investigation into this interesting area. Ory et al. 19 have reported a good ovulatory response to intravenous administration of LH-RH in PCOD patients, though their four patients had only slightly elevated LH/FSH ratios and normal androgen levels. An explanation for the marked discrepancy shown in this study between the improvement in LH/FSH ratio and androgen levels and the poor follicular response should be sought. Reid et al. 13 Vol. 46, No.3, September 1986

have argued that subcutaneous administration of LH-RH may mimic chronic LH-RH administration because of slow absorption from the subcutaneous tissue, exerting an inhibitory hypophyseal effect .. In contrast with this theory is the success of subcutaneous treatment in hypothalamic amenorrheic women. 10- 12 Another possible explanation for failure of treatment in our patients may be the relatively short period of treatment (up to 90 days), which may not be sufficient to permit "escape" of the ovaries and hypophysis from the long period of suppression. In conclusion, it seems to us that although some hormonal parameters in these patients may be improved by subcutaneous low-frequency administration of LH-RH, follicular response is at present unsatisfactory, and the two ovulations achieved in this study were unpredictable and perhaps merely episodic events. The great difficulty in establishing a better experimental design, which should extend over years, in women with infertility of long duration makes the drawing of definite conclusions impossible. It is therefore mainly the hormonal changes observed in this study, rather than the achievement of ovulation, that are interesting. REFERENCES 1. Leyendecker G, Wildt L, Hansman M: Pregnancies fol-

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lowing chronic intermittent (pulsatile) administration of GnRH by means of a portable pump (Zyklomat): a new approach to the treatment of infertility in hypothalamic amenorrhea. J Clin Endocrinol Metab 51:1214, 1980 Schoemaker J, Simons AHM, Van Osnabrugge GJC, Lugtenburg C, Van Kessel H: Pregnancy after prolonged pulsatile administration of luteinizing hormone-releasing hormone in a patient with clomiphene-resistant secondary amenorrhea. J Clin Endocrinol Metab 52:882, 1981 Miller DS, Reid RL, Cetel NS, Rebar R, Yen SSC: Pulsatile administration of low doses of gonadotropin releasing hormone for the induction of ovulation and pregnancy in women with hypothalamic amenorrhea. JAMA 250:2937, 1983 Burger CW, Van Kessel H, Schoemaker J: Induction of ovulation by prolonged pulsatile administration ofluteinizing hormone-releasing hormone (LRH) in patients with clomiphene resistant polycystic ovary-like disease. Acta Endocrinol (Copenh) 104:357, 1983 Loucopoulos A, Ferin M, Vande Wiele RL, Dyrenfurth J, Linkie D, Yen M, Jewelewicz R: Pulsatile administration of gonadotropin-releasing hormone for induction of ovulation. Am J Obstet Gynecol 148:895, 1984 Wildt L, Hausler A, Marshall G, Hutchinson JS, Plant TMI, Belchetz PL, Knobil E: Frequency and amplitude of gonadotropin-releasing hormone stimulation and gonadotropin secretion in the rhesus monkey. Endocrinology 109:376, 1981

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13. Reid RL, Leopold GR, Yen SSC: Induction of ovulation and pregnancy with pulsatile luteinizing hormone re· leasing factor: dosage and mode of delivery. Fertil Steril 36:553, 1981 14. Reid RL, Sauerbrei E: Evaluation of techniques for induc· tion of ovulation in outpatients employing pulsatile go· nadotropin releasing hormone. Am J Obstet Gynecol 148:648, 1984 15. Lobo RA, Goebelsman U: Adult manifestation of congeni· tal adrenal hyperplasia due to incomplete 21·hydroxylase deficiency mimicking polycystic ovarian disease. Am J Obstet Gynecol 138:720, 1980 16. Hoffman DI, Klove K, Lobo RA: The prevalence and sig· nificance of elevated dehydroepiandrosterone sulfate lev· els in anovulatory women. Fertil Steril 42:76, 1984 17. Jones PBC, Conn PM, Marian J, Hsueh AJW: Binding of gonadotropin releasing hormone agonist to rat ovarian granulosa cells. Life Sci 27:2125, 1980 18. Cusan L, Auclair C, Belanger A, Ferland L, Kelly P A, Seguin L, Babyic F: Inhibitory effects on long·term treat· ment of luteinizing hormone releasing hormone agonists on the pituitary gonadal axis in male and female rats. Endocrinology 104:1369, 1979 19. Ory SJ, London SN, Tyrey L, Hammond CB: Ovulation induction with pulsatile gonadotropin·releasing hormone administration in patients with polycystic ovarian syn· drome. Fertil Steril 43:20, 1985

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