Androgenic effects on ventricular repolarization: A translational study from the international pharmacovigilance database to iPSC-cardiomyocytes.

BACKGROUND: Male hypogonadism, arising from a range of etiologies including androgen-deprivation therapies (ADTs), has been reported as a risk factor for acquired long-QT syndrome (aLQTS) and torsades de pointes (TdP). A full description of the clinical features of aLQTS associated with ADT and of underlying mechanisms is lacking. METHODS: We searched the international pharmacovigilance database VigiBase for men (n=6 560 565 individual case safety reports) presenting with aLQTS, TdP, or sudden death associated with ADT. In cardiomyocytes derived from induced pluripotent stem cells from men, we studied electrophysiological effects of ADT and dihydrotestosterone. RESULTS: Among subjects receiving ADT in VigiBase, we identified 184 cases of aLQTS (n=168) and/or TdP (n=68; 11% fatal), and 99 with sudden death. Of the 10 ADT drugs examined, 7 had a disproportional association (reporting odds ratio=1.4-4.7; P<0.05) with aLQTS, TdP, or sudden death. The minimum and median times to sudden death were 0.25 and 92 days, respectively. The androgen receptor antagonist enzalutamide was associated with more deaths (5430/31 896 [17%]; P<0.0001) than other ADT used for prostate cancer (4208/52 089 [8.1%]). In induced pluripotent stem cells, acute and chronic enzalutamide (25µM) significantly prolonged action potential durations (action potential duration at 90% when paced at 0.5Hz; 429.7±27.1 (control) versus 982.4±33.2 (acute, P<0.001) and 1062.3±28.9ms (chronic; P<0.001), and generated afterdepolarizations and/or triggered activity in drug-treated cells (11/20 acutely and 8/15 chronically). Enzalutamide acutely and chronically inhibited delayed rectifier potassium current, and chronically enhanced late sodium current. Dihydrotestosterone (30nM) reversed enzalutamide electrophysiological effects on induced pluripotent stem cells. CONCLUSION: QT prolongation and TdP are a risk in men receiving enzalutamide and other ADTs. CLINICAL TRIAL REGISTRATION: URL: https://www.clinicaltrials.gov. Unique identifier: NCT03193138.

Detection and management of late-onset 21-hydroxylase deficiency in women with hyperandrogenism.

Moderate forms of 21-hydroxylase deficiency (D21OH-NC), the so-called non-classical or late-onset forms are a frequently reported cause of hyperandrogenism in women [1-5]. The purpose of this collective and synthetic work was to provide the endocrinologist, gynecologist and dermatologist with consensual information so as to detect the maximum cases with acceptable cost-benefit ratio and to define the main lines of optimal patient management, given the data currently available in medical literature.

Molecular pathology of the FSH receptor: new insights into FSH physiology.

Manipulations of mouse genome have helped to elucidate gonadotrophin function but important differences subsist between rodent and human reproduction. Studies of patients with mutations of gonadotrophins or gonadotrophin receptors genes allow understanding their physiological effects in humans. The correlation of the clinical phenotypes of patients with in vitro studies of the mutated receptor residual function and histological and immunohistological studies of the ovarian biopsies permits to understand which stages of follicular development are under FSH control. Total FSH receptor (FSHR) inactivation causes infertility with an early block of follicular maturation remarkably associated with abundant small follicles as in prepubertal ovaries and demonstrates the absolute requirement of FSH for follicular development starting from the primary stage. Partial FSHR inactivation, characterized by normal-sized ovaries, can sustain follicular development up to the early antral stages but incremental levels of FSH stimulation seem to be required for antral follicular growth before selection. These findings contrast with the traditional view of an initial gonadotrophin-independent follicular growth prior to the preantral-early antral stages. The presence of numerous reserve follicles in the ovaries of these patients may permit a future treatment of their infertility. The study of reduced FSHbeta or FSHR activity in genetically modified male mice models and in men suggests a minor impact of the FSHR on masculine fertility. Further studies on patients with a demonstrated total FSHbeta or FSHR inactivation are required to elucidate reported differences in spermatogenesis impairment. Finally, the studies of mutations of gonadotrophins and their receptors demonstrate differences in gonadotrophin function between genetically modified rodents and humans which suggest prudence in extrapolating observations in rodents to human reproduction. Ovarian hyperstimulation syndrome (OHSS) can infrequently arise spontaneously during pregnancy, but most often it is an iatrogenic complication of ovarian stimulation treatments with ovulation drugs for in vitro fertilization. The first genetic cause of familial recurrent spontaneous OHSS was identified as a broadening specificity of the FSHR for hCG due to naturally occurring heterozygous mutations located unexpectedly in the transmembrane domain of the FSHR. Broadening specificity of a G protein-coupled receptor is extremely rare. These observations led to the identification of the etiology of this previously unexplained syndrome and permitted to conceive novel models of FSHR activation. Susceptibility to iatrogenic OHSS or its clinical severity may be associated with FSHR polymorphisms with slightly different activities in vivo as suggested by several studies. The study of larger cohorts is needed to evaluate the clinical impact of these observations in the management of patients undergoing IVF protocols.

Evaluation of different markers of the ovarian reserve in patients presenting with premature ovarian failure.

Premature ovarian failure (POF) is a heterogeneous syndrome, possibly due to mutations of genes involved in the normal development of the ovary and/or the follicles. Based essentially on animal models, these mutations are associated with various ovarian histological phenotypes, from a complete absence of to a partial follicular maturation. The aims of our work were in one hand to determine if ovarian histology, compared to pelvic ultrasonography, would be helpful either in identifying which patients display an impaired follicular growth or in the orientation of the POF etiology; on the other hand, since developing follicles up to the antral stage are reported in POF and that Anti-Müllerian hormone (AMH) might be a good indicator of follicular presence, we decided to determine whether AMH should be a better marker to determine the presence of an ovarian reserve in POF patients. To try to answer to the first question, we studied first 166 patients suffering from POF with a normal karyotype. Vaginal ultrasonography (US) was performed in 134 patients and an ovarian biopsy was obtained in 67 women. The presence of follicles suggested at US was confirmed at histology in only 56% of the patients. Ovarian histology led to the distinction of two phenotypes (a) small-sized ovaries, deprived of follicles, and (b) normal-sized ovaries with partial follicular maturation. To confirm the value of ovarian biopsies, samples from 20 normal women have been studied, confirming that ovarian biopsy at random allow reliable assessment of follicular activity. To try to answer to the second question of our work, a cross sectional study analyzing serum AMH, ovarian histology and AMH immunoexpression in 48 POF patients, was performed. Serum AMH was significantly higher in women with more than 5 follicles at ovarian histology. Ovarian AMH immunostaining revealed a normal AMH expression in POF preantral follicles but a decrease expression at the early antral stages. In conclusion, ovarian histology appears to be a reliable tool to appreciate the follicular reserve, and helpful and complementary to clinical and hormonal phenotyping in order to orient the search for various genetic causes of POF syndrome. Finally, AMH levels in POF patients could identify women with persistent follicles.

Luteinizing hormone pulsatility in patients with major ovarian hyperandrogenism.

Hyperandrogenism and ovulatory dysfunction are common in women with either polycystic ovary (PCOS) or ovarian virilizing tumor. However, contrasting with the numerous studies that have extensively described gonadotropin secretory abnormalities, principally increased LH pulse amplitude and frequency, few studies have concerned gonadotropin secretion in patients with ovarian virilizing tumors; low gonadotropin levels have occasionally been reported, but never extensively studied. The goal of the present study was to further evaluate the pulsatility of LH secretion in women with ovarian virilizing tumor compared with that of PCOS patients. Eighteen women with major hyperandrogenism (plasma testosterone level >1.2 ng/ml) were studied (5 women with ovarian virilizing tumor, 13 women with PCOS, and 10 control women). Mean plasma LH level, LH pulse number and amplitude were dramatically low in patients with ovarian tumors when compared to both PCOS (p<0.001) and controls (p<0.001). In case of major hyperandrogenism, LH pulse pattern differs markedly between women with ovarian virilizing tumor or PCOS, suggesting different mechanisms of hypothalamic or pituitary feedback.

Hormonal treatment of congenital adrenal hyperplasia due to 21-hydroxylase deficiency.

During childhood, the main aims of the medical treatment of congenital adrenal hyperplasia (CAH) secondary to 21-hydroxylase deficiency, are to prevent salt loss and virilization and to achieve normal stature and normal puberty. As such, there is a narrow therapeutic window through which the intended results can be achieved. In adulthood, the clinical management has received little attention, but recent studies have shown the relevance of long-term follow-up of these patients. Indeed, long-term evaluation of adult CAH patients enables the identification of multiple clinical, hormonal and metabolic abnormalities as bone mineral density alteration, overweight and disturbed reproductive functions. In women with classic CAH, low fertility rate is reported, and is probably the consequence of multiple factors, including neuroendocrine and hormonal factors, feminizing surgery, and psychological factors. Men with CAH may present hypogonadism either through the effect of adrenal rests or from suppression of gonadotropins resulting in infertility. These patients should therefore be carefully followed-up, from childhood through to adulthood, to avoid these complications and to ensure treatment compliance and tight control of the adrenal androgens, by multidisciplinary teams who have knowledge of CAH.

[Semen characteristics and quality of the conceptus in fertilization in vitro]. / Caractéristiques du sperme et qualité du conceptus en fécondation in vitro.

OBJECTIVE: Assisted reproductive technology (ART) is associated with increased risks for the neonate, compared to natural fertility, mainly because of multiple pregnancies and increased maternal age. On the opposite, the impact of paternal factors has been scarcely studied, except for the relationship between surgically retrieved sperms and genetic abnormalities. PATIENTS AND METHODS: This study has been realized using the large French register on in vitro fertilization (FIVNAT) that collects information on 80% of French ART activity. For the study, all the pregnancies obtained from oocyte recoveries between January 1996 and December 2003, for which information on cycles could be linked to the pregnancy were included, i.e. 34223 pregnancies, resulting in 27025 deliveries and 33945 neonates. Sperm quality was defined either according to the semen origin (spouse's ejaculate, epididymis, testis, or donor), or according to the spermiogramme values for concentration, motility and morphology. The statistical analysis included the use of multivariate logistic models, with the main prognostic factors. RESULTS: The delivery, spontaneous abortion and ectopic pregnancy rates were not influenced by semen origin nor by quality, all the 95% confidence intervals including 1. The neonates conceived through surgically retrieved sperms were at a slightly increased risk of hypotrophy (weight under the 10% centile of reference curves) and of malformation (OR=1.18, 95CI: 1.03-1.36 and OR=1.30 [0,95-1,84], respectively). On the opposite, when analysis was restrained to ejaculated semen, no risk was demonstrated. DISCUSSION AND CONCLUSION: The semen quality has little impact on pregnancy issue. Only the semen origin seems to act on hypotrophy and malformation, but these results deserve to be further analyzed for confirmation.

Serum anti-Müllerian hormone expression in women with premature ovarian failure.

BACKGROUND: Premature ovarian failure (POF) is generally irreversible. However, developing follicles up to the antral stage are reported in POF and anti-Müllerian hormone (AMH) might be a good indicator of follicular presence. This study analysed serum AMH, ovarian histology and AMH immunoexpression in POF patients. METHODS: A cross-sectional study of 48 POF patients in an Endocrinology Department setting. Patients had an ovarian biopsy simultaneously with serum AMH sampling and/or ovarian AMH immunostaining. RESULTS: Mean serum AMH was 1.04 +/- 1.66 ng/ml. Serum AMH was significantly higher in women with 15 or more follicles at ovarian histology (P = 0.001). Comparison of ovarian AMH immunostaining from POF patients and 10 normal controls revealed a normal AMH expression in POF pre-antral follicles, but a decreased expression at the early antral stages. Serum AMH was undetectable in 77% of the patients with 0-5 AMH immunopositive follicles and detectable in 100% of the patients with more than 15 AMH immunopositive follicles. CONCLUSIONS: AMH levels in POF patients could identify women with persistent follicles. The decrease of AMH immunoexpression in POF antral follicles could suggest a defect of antral development.

[Biological effects of GnRH antagonists]. / Les antagonistes du GnRH: effets biologiques.

Numerous questions about the efficacy of GnRH antagonists, known for the prevention of undesirable LH surge, have been raised. Al-Inany in 2002 in a meta-analysis, IVF Germany Register and FIVNAT the French data base in 2003, have shown a decrease of the pregnancy rate after antagonists treatment. Among 20761 ART attempts for good prognosis women (<35 years, i.v.f. range 1 or 2) we have compared the clinical and biological parameters after agonists' long protocol versus antagonist treatment. The characteristics of the responses to the stimulation treatment were similar for both groups, whereas the duration of the stimulation and the doses of gonadotrophin used in the antagonist group was lower. The fertilization and embryo development rates were not modified. But we observed a decrease in the number of oocytes retrieved, of embryos obtained and of the pregnancy rate (P < 0.001). These results could be explained by endometrial modifications induced by antagonists but we cannot exclude an impact of oestradiol and LH levels. GnRH antagonists could be an inhibitor of the cell cycle by decreasing the synthesis of growth factors. The interaction of GnRH antagonists and GnRH receptors may compromise the mitotic programme of the cells and induce an alteration of folliculogenesis, embryo quality and implantation. More studies are necessary to understand these results. Using of GnRH antagonists involves specific patient information on the benefits and drawbacks of such treatment before ART.

[Comparison of agonists versus antagonists for i.v.f. stimulation: the French FIVNAT survey 2001-2002]. / Comparaison agonistes / antagonistes dans les stimulations pour FIV: les données de FIVNAT 2001-2002.

In 2002, FIVNAT has continued its study on the use and the results of the ovarian stimulation protocols using GnRH antagonist for i.v.f. and i.c.s.i. The first part of this study demonstrates that the antagonist protocols were still used in more pejorative cases than the long agonist protocols but with a smaller difference compared to 2001. So far, the frequency of the antagonist protocols has jumped from 13% to 19% from 2001 to 2002. This increase was mainly at the expense of the long agonist protocols. In the overall population, the lower pregnancy rate per ovum pick-up with antagonists, demonstrated in 2001, has been confirmed. In the second part of the study, FIVNAT has selected a good prognosis group (women's age less than 35 years and attempts rank lower than 3). This group includes 17,532 cycles with agonists and 3229 cycles with antagonists. A comparison of all the biological and clinical data was made. Finally, the pregnancy rate per ovum pick-up was significantly reduced when the stimulation was done with an antagonist protocol (Anta) rather than with a long agonist protocol (Ago). In i.v.f. these rates were 20.8% (Anta) versus 25.8% (Ago) (P < 0.001). In i.c.s.i. they were 21.9% (Anta) versus 29.4% (Ago) (P < 0.001). Moreover, the absolute and relative differences were the same in 2001 and 2002, suggesting that the learning curve effect does not explain the differences.

Use of a topoisomerase I inhibitor (irinotecan, CPT-11) in metastatic adrenocortical carcinoma.

BACKGROUND: Complete responses are rare after medical treatment of adrenocortical tumors. We performed a single center prospective study of the antitumor effect of irinotecan (CPT-11) in patients with metastatic adrenocortical cancer. PATIENTS AND METHODS: Since 1999, all patients with advanced progressive adrenocortical carcinoma, referred to the Institut Gustave-Roussy, have been enrolled prospectively in this study. CPT-11 (250 mg/m(2)) was administered intravenously on day 1 in a 2-h infusion, every 14 days. World Health Organization (WHO) criteria were used to evaluate tumor response and toxicity. RESULTS: During treatment, no dose or schedule modifications were made. A median of three courses were given (range 1-8), and all but two patients received at least three complete chemotherapy courses. No objective or complete responses were observed. The best response achieved was stabilization in three patients, lasting from 1.5 to 4 months. Significant toxicity occurred in two patients. CONCLUSIONS: Our results do not support a major role of CPT-11 in adrenocortical carcinoma.

Impact of chromogranin A measurement in the work-up of neuroendocrine tumors.

Since the development of the first immunoassay for circulating chromogranin A in 1984, a lot of studies have evaluated its clinical impact in neuroendocrine tumors. Initially studied in pheochromocytoma patients, the clinical impact of chromogranin A has rapidly extended to most neuroendocrine tumours, sometimes in combination with other eutopic or ectopic secretions. In our experience, CgA demonstrates a variable sensitivity between NET primary and a high specificity. Our results suggest that CgA should be routinely screened in foregut-derived NET and abandoned in the routine screening of medullary thyroid carcinoma. In addition, in phaeochromocytoma and ileum-NET patients, CgA demonstrates a comparable sensitivity with urinary reference markers and its impact on the follow-up will form a key point when recommending routine screening. Both tumor burden and secretory activity should be taken into account when interpreting CgA results.

[1997 FIVNAT general balance]. / Bilan général FIVNAT 1997.

In 1997, the French National Register on in vitro fertilization, FIVNAT, has collected information on 3,854 initiated cycles and 36,583 oocyte recoveries, from which 61.2% were conventional IVF cycles and 38.6% were ICSI. For conventional IVF, the percentage of infertilities of tubal origin was 49.7%, whereas 45% of the recoveries involved a male factor. The stimulation regimen involved a GnRH in 95% of the cases mostly with a long blockage period (82.6%) which was associated to the highest pregnancy rate. The mean number of transferred embryos significantly decreased to 2.50 +/- 0.95 per transfer. Only 9.2% of the transfers involved more than 3 embryos, and were associated to a relatively poor pregnancy rate, confirming that they were preferently realised in couples with poor chances of pregnancy. Finally, the pregnancy rate per recovery (20.5%) and per transfer (26.0%) remained at the same level as in 1996.

[Ovulation stimulation]. / Stimulation de l'ovulation.

In 1997, 2 new recombinant FSH were available. The analysis of the first 11,000 attempts IVF and ICSI received by FIVNAT for 1997 shows that recombinant FSH was used in about 20% of cases. Pregnancy rates were similar with urinary and recombinant FSH but the number of ampoulles was significantly lower with recombinant FSH.

FIVNAT. Influence of attempt rank in in vitro fertilization. / FIVNAT. Influence du rang de la tentative en FIV.

The French national register on in vitro fertilization (IVF) FIVNAT, which has collected most of the oocyte pick-ups realised in France since 1986 has allowed us to build a cohort of 35,714 couples, of which the first recovery took place between 1990 and 1994 and followed up to a pregnancy or to the 31st of december, 1996. The per recovery clinical pregnancy rate decreased from 20.2% on the first attempt to 17.4% on the second, and to less than 13% after the sixth. This evolution existed whatever the women's age class or the infertility diagnosis. The women's age remained the most important factor, since the cumulative pregnancy rate decreased from 60% for women aged less than 35 years to 17% for those aged more than 41 years. Among the indications, male infertility using spouse's semen had the poorest prognosis, especially for women aged more than 41 years (9.6%) whereas male infertility using donor's semen among women aged less than 35 years was associated to the best results (68%). It must be noticed than a high percentage of unpregnant women did not come again for a further recovery (40% to 50%). Then, the crude cumulative birth rate (24.4%) was far below the theoretical cumulative one(54.2%).

[Experience of ectopic pregnancy]. / Vécu de la grossesse extra-utérine.

This survey relates to the experience and the management of women who have received a treatment for an ectopic pregnancy. It is based on 31 clinical interviews, conducted a month after the end of surgical or medical treatment. Among these women, 42% had had previous treatment for sterility. The main results show that 16% had never previously heard of ectopic pregnancy, and 29% do not see any reason why they had had one. For the patients, the diagnosis had not been made early enough: 45% feel that the consequences could have been serious if they had not taken the matter seriously themselves. Women clearly express some strong feeling against the health professionals (74%) who were responsible for their medical care, in spite of the attention they received, which reveals the psychological trauma they suffered. Although 55% of women felt depressed, for some of them the ectopic pregnancy seemed to operate as an exorcism from a previous more serious situation. They place their hope in a future pregnancy under close medical supervision. When it appears necessary, psychological support should be offered to these patients.