ERß Regulation of Indian Hedgehog Expression in the First Wave of Ovarian Follicles.

Increased activation of ovarian primordial follicles in Erß knockout (ErßKO) rats becomes evident as early as postnatal day 8.5. To identify the ERß-regulated genes that may control ovarian primordial follicle activation, we analyzed the transcriptome profiles of ErßKO rat ovaries collected on postnatal days 4.5, 6.5, and 8.5. Compared to wildtype ovaries, ErßKO ovaries displayed dramatic downregulation of Indian hedgehog (Ihh) expression. IHH-regulated genes, including Hhip, Gli1, and Ptch1, were also downregulated in ErßKO ovaries. This was associated with a downregulation of steroidogenic enzymes Cyp11a1, Cyp19a1, and Hsd17b1. The expression of Ihh remained very low in ErßKO ovaries despite the high levels of Gdf9 and Bmp15, which are known upregulators of Ihh expression in the granulosa cells of activated ovarian follicles. Strikingly, the downregulation of the Ihh gene in ErßKO ovaries began to disappear on postnatal day 16.5 and recovered on postnatal day 21.5. In rat ovaries, the first wave of primordial follicles is rapidly activated after their formation, whereas the second wave of primordial follicles remains dormant in the ovarian cortex and slowly starts activating after postnatal day 12.5. We localized the expression of Ihh mRNA in postnatal day 8.5 wildtype rat ovaries but not in the age-matched ErßKO ovaries. In postnatal day 21.5 ErßKO rat ovaries, we detected Ihh mRNA mainly in the activated follicles in the ovaries' peripheral regions. Our findings indicate that the expression of Ihh in the granulosa cells of the activated first wave of ovarian follicles depends on ERß.

Loss of ERß Disrupts Gene Regulation in Primordial and Primary Follicles.

Loss of ERß increases primordial follicle growth activation (PFGA), leading to premature ovarian follicle reserve depletion. We determined the expression and gene regulatory functions of ERß in dormant primordial follicles (PdFs) and activated primary follicles (PrFs) using mouse models. PdFs and PrFs were isolated from 3-week-old Erß knockout (Erßnull) mouse ovaries, and their transcriptomes were compared with those of control Erßfl/fl mice. We observed a significant (≥2-fold change; FDR p-value ≤ 0.05) deregulation of approximately 5% of genes (866 out of 16,940 genes, TPM ≥ 5) in Erßnull PdFs; ~60% (521 out of 866) of the differentially expressed genes (DEGs) were upregulated, and 40% were downregulated, indicating that ERß has both transcriptional enhancing as well as repressing roles in dormant PdFs. Such deregulation of genes may make the Erßnull PdFs more susceptible to increased PFGA. When the PdFs undergo PFGA and form PrFs, many new genes are activated. During PFGA of Erßfl/fl follicles, we detected a differential expression of ~24% genes (4909 out of 20,743; ≥2-fold change; FDR p-value ≤ 0.05; TPM ≥ 5); 56% upregulated and 44% downregulated, indicating the gene enhancing and repressing roles of Erß-activated PrFs. In contrast, we detected a differential expression of only 824 genes in Erßnull follicles during PFGA (≥2-fold change; FDR p-value ≤ 0.05; TPM ≥ 5). Moreover, most (~93%; 770 out of 824) of these DEGs in activated Erßnull PrFs were downregulated. Such deregulation of genes in Erßnull activated follicles may impair their inhibitory role on PFGA. Notably, in both Erßnull PdFs and PrFs, we detected a significant number of epigenetic regulators and transcription factors to be differentially expressed, which suggests that lack of ERß either directly or indirectly deregulates the gene expression in PdFs and PrFs, leading to increased PFGA.

The impact of a group based, remotely delivered weight loss intervention in women with polycystic ovary syndrome on ovulation, quality of life and body composition.

Background: Obesity and visceral adiposity are associated with anovulation. The most common cause of anovulatory infertility in women of reproductive age is polycystic ovary syndrome (PCOS). We conducted this formative study to examine the effects of a remotely delivered, group-based lifestyle program for women with overweight/obesity and PCOS on ovulation, PCOS related quality of life (PCOSQ) and body composition. Methods: Women with anovulatory infertility caused by PCOS (N = 12) were enrolled in a 6-month high-intensity weight management intervention. Participants were asked to attend 45 min., group behavioral lifestyle sessions, delivered remotely by a registered dietitian weekly across the 6-mo. study and comply with a reduced energy diet, increased physical activity (225 min/wk.), and self-monitoring of weight, physical activity and diet. Diets consisted of five portion-controlled meals (three shakes + two entrees), at least five servings of fruits/vegetables, and ad libitum non-caloric beverages daily. Wilcoxon signed-rank tests were used to assess changes in outcomes across the intervention. Results: Twelve women received the weight loss intervention (mean age = 32.7 ± 4.2 yrs., BMI = 36.8 ± 4.5 kg/m2, 92% college educated), and 8 completed the intervention. Eight (67%) women reported ovulating during the intervention with an average time to ovulation of 57 ± 45 days. Women lost an average of 3.85 ± 5.94 kg (p = 0.02), decreased their BMI (-1.61 ± 1.09 kg/m2; p = 0.04), and waist circumference (-4.54 ± 3.03 cm; p = 0.04) over the 6-mo. intervention. Additionally, self-reported menstrual problems measured by PCOSQ significantly improved over the study (p = 0.03). Conclusion: A multicomponent group-based, remotely delivered, lifestyle intervention delivered remotely is a feasible and potentially scalable option to achieve clinically relevant (>3%) weight loss in women with PCOS. Clinical trial registration: www.clinicaltrials.gov, identifier: NCT03677362.

Sexual Dimorphism in Kisspeptin Signaling.

Kisspeptin (KP) and kisspeptin receptor (KPR) are essential for the onset of puberty, development of gonads, and maintenance of gonadal function in both males and females. Hypothalamic KPs and KPR display a high degree of sexual dimorphism in expression and function. KPs act on KPR in gonadotropin releasing hormone (GnRH) neurons and induce distinct patterns of GnRH secretion in males and females. GnRH acts on the anterior pituitary to secrete gonadotropins, which are required for steroidogenesis and gametogenesis in testes and ovaries. Gonadal steroid hormones in turn regulate the KP neurons. Gonadal hormones inhibit the KP neurons within the arcuate nucleus and generate pulsatile GnRH mediated gonadotropin (GPN) secretion in both sexes. However, the numbers of KP neurons in the anteroventral periventricular nucleus and preoptic area are greater in females, which release a large amount of KPs in response to a high estrogen level and induce the preovulatory GPN surge. In addition to the hypothalamus, KPs and KPR are also expressed in various extrahypothalamic tissues including the liver, pancreas, fat, and gonads. There is a remarkable difference in circulating KP levels between males and females. An increased level of KPs in females can be linked to increased numbers of KP neurons in female hypothalamus and more KP production in the ovaries and adipose tissues. Although the sexually dimorphic features are well characterized for hypothalamic KPs, very little is known about the extrahypothalamic KPs. This review article summarizes current knowledge regarding the sexual dimorphism in hypothalamic as well as extrahypothalamic KP and KPR system in primates and rodents.

Occurrence of Gonadoblastoma in Patients with 45,X/46,XY Mosaicism.

STUDY OBJECTIVE: To estimate the overall frequency of gonadal tumors in patients with 45,X/46,XY mosaicism who underwent gonadectomy and to determine whether the degree of external masculinization or the location of gonads were associated with the presence of gonadal tumor. DESIGN: Retrospective study of patients with karyotype of 45,X/46,XY or variant who received care at the study institution between 1995 and 2012. SETTING: University of Michigan Health System (Ann Arbor, Michigan), a tertiary care academic center. PARTICIPANTS: Sixteen patients with karyotype of 45,X/46,XY who underwent gonadectomy. INTERVENTIONS: None. MAIN OUTCOME MEASURE: Presence of pathology-confirmed gonadal tumor. RESULTS: In patients who underwent bilateral gonadectomy, gonadoblastomas were detected in 36.4% (4 of 11), and all were identified in patients with normal female external genitalia (4 of 8 [50.0%]). Abdominal gonads were associated with a nonsignificant increase in rate of gonadal tumor compared with inguinal or scrotal gonads. No malignant tumors were identified. CONCLUSION: The overall rate of gonadoblastoma was higher than previously reported. The high rate of gonadoblastoma in patients with female external genitalia and the lack of gonadal function support continuing the standard of care of practice of prophylactic gonadectomy in this patient population.

Primary amenorrhea: diagnosis and management.

Puberty is a defining time of many adolescents' lives. It is a series of events that includes thelarche, pubarche, and menarche. Primary amenorrhea is the absence of menarche. There are numerous etiologies including outflow tract obstructions, gonadal dysgenesis, and anomalies of the hypothalamic axis. This review's aims are to define primary amenorrhea and describe the various causes, their workups, associated comorbidities, and treatment options. At the end, a generalist should be able to perform an assessment of an adolescent who presents with primary amenorrhea and, if warranted, begin initial treatment.

Maternal obesity and adverse reproductive outcomes: reducing the risk.

Obesity is associated with multiple adverse reproductive outcomes such as infertility, ovulation dysfunction, miscarriage, preeclampsia, gestational diabetes mellitus, preterm delivery, operative delivery, and fetal growth disorders. Although the prevalence of maternal obesity is increasing, it is unclear which method of weight loss is most effective before conception to improve reproductive outcomes. This article reviews the amount of weight loss needed to improve ovulation and fertility, behavioral methods for optimal weight loss, as well as medical and surgical interventions to promote weight loss with the intention of providing a tool to promote weight loss in the preconception period. Behavioral modification that includes motivational interviewing, energy intake restriction, and increased energy expenditure is first-line therapy. Behavioral therapy has been shown to improve menstrual cyclicity, ovulation, conception rates, hormone profile, and amount of weight loss. Bariatric surgery and drug therapy may be used in overweight or obese patients who fail behavioral modification. However, women who undergo bariatric surgery or drug therapy must be cautioned about safety profiles, nutritional requirements, and some adverse pregnancy outcomes such as intrauterine growth restriction. There are several areas for further investigation including amount of weight loss needed to resume ovulation by obesity class and improve reproductive outcomes, safety and efficacy of very low energy diets in the preconception period, as well as safety of obesity medications in the preconception period.

Advanced stage endometriosis in adolescents and young women.

STUDY OBJECTIVE: To describe the prevalence and characteristics of advanced stage endometriosis in adolescents and young women treated in a tertiary referral center. DESIGN: Retrospective cohort. SETTING: Tertiary referral center. PATIENTS AND INTERVENTIONS: 86 adolescents and young women (≤22 y) who underwent surgery for endometriosis. The operative reports were reviewed for endometriosis stage, surgical findings, surgical procedures, and pathology. MAIN OUTCOME MEASURES: Endometriosis stage reported according to the revised American Fertility Society classification. RESULTS: Early stage endometriosis (stage I or II) was found in 66 (76%) and advanced stage endometriosis (stage III or IV) in 20 (23%). The surgical findings in the 20 patients with advanced stage endometriosis included ovarian endometriomas in 14 cases, rectovaginal nodule in 1 case, and diaphragmatic and pulmonary endometriosis in 1 case. Women with advanced stage endometriosis were found to be slightly older at time of diagnosis than those with early stage disease (mean age 20.4 ± 1.4 y vs 18.7 ± 2.2 y respectively, P < .001). CONCLUSION: In adolescents and young women with endometriosis, advanced stage disease is not uncommon. The main presentation of advanced stage endometriosis in this age group is ovarian endometriomas rather than extensive peritoneal or adhesive disease.

Case-control analysis of maternal prenatal analgesic use and cardiovascular malformations: Baltimore-Washington Infant Study.

OBJECTIVE: We sought to assess maternal prenatal use of analgesics and risk of cardiovascular malformations (CVM) in the offspring. STUDY DESIGN: Data from the Baltimore-Washington Infant Study, a population-based case-control investigation of CVM, were used to examine selected isolated CVM diagnoses and maternal analgesic use during the periconceptional period (3 months before and after conception). We compared case and control infants on frequency of maternal use of analgesics and estimated adjusted odds ratios (adjORs) and 95% confidence intervals (CI) with logistic regression models for specific CVM phenotypes. RESULTS: Frequency of periconceptional use of any analgesic was 52% among control mothers and 53% among case mothers. Analyses by CVM diagnoses identified an association of tetralogy of Fallot with maternal acetaminophen use (adjOR, 1.6; 95% CI, 1.1-2.3) and dextrotransposition of the great arteries with intact ventricular septum with maternal nonsteroidal antiinflammatory drug use (adjOR, 3.2; 95% CI, 1.2-8.7). CONCLUSION: Analgesic use during the periconceptional period was not associated with CVM in the aggregate or with most phenotypes of CVM examined. Associations with 2 phenotypes of CVM may have occurred by chance. These findings warrant corroboration and further study, including further evaluation of the observed associations, the dose of analgesic taken, more specific timing of analgesic use, and indications for use.

Fertility in patients with genetic deficiencies of cytochrome P450c17 (CYP17A1): combined 17-hydroxylase/17,20-lyase deficiency and isolated 17,20-lyase deficiency.

CYP17A1 catalyzes the 17-hydroxylase and 17,20-lyase reactions, regulating the steroid hormones produced by the adrenal glands and gonads. Mutations that compromise all CYP17A1 activities are extremely rare and cause combined 17-hydroxylase/17,20-lyase deficiency. Clinically, combined 17-hydroxylase/17,20-lyase deficiency presents with hypertension, hypokalemia, primary amenorrhea, and sexual infantilism. A few mutations selectively impair 17,20-lyase activity, and some mutations in cofactor proteins cytochrome P450-oxidoreductase and cytochrome b5 also selectively disrupt 17,20-lyase activity. The defect in sex steroid synthesis impairs fertility in both male and female patients when the deficiency is severe. This paper reviews the genetics, steroidogenesis, and fertility impairments associated with these disorders.

Surgical pearls: laparoscopic removal of uterine remnants in patients with Mayer-Rokitansky-Küster-Hauser syndrome.

BACKGROUND: Females with Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome may require surgical removal of uterine remnant(s) which can be accomplished with a laparoscopic approach, described in this case series. CASES: Nine females with MRKH and pelvic pain were treated with laparoscopic resection of uterine remnants without major complication. The following management recommendations are offered: (1) preoperative evaluation for urinary tract anomalies and postoperative cystoscopy; (2) medial traction of the remnant to allow adequate exposure of the pelvic sidewall; (3) awareness of possible anomalous vascular supply to uterine remnant; (4) individualized management of associated endometriosis; (5) careful use of surgical terminology, avoiding use of the word hysterectomy. SUMMARY AND CONCLUSION: Laparoscopic removal of uterine remnant(s) is safe and effective.

Uterine remnants and pelvic pain in females with Mayer-Rokitansky-Küster-Hauser syndrome.

OBJECTIVE: To assess the association between pelvic pain and uterine remnants and review the management of pelvic pain in females with Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome. DESIGN: Retrospective cohort. SETTING: Department of Obstetrics and Gynecology at a tertiary referring medical center. PATIENTS: Forty-eight females with MRKH presenting from 1997 to 2011 with anatomy confirmed by magnetic resonance imaging (MRI). INTERVENTIONS: None. MAIN OUTCOME MEASURE: Prevalence Of uterine remnants and the association of uterine remnants with pelvic pain in females with MRKH. RESULTS: Of the 48 females with MRKH, 23 (48%) had uterine remnants and 22 (46%) had pelvic pain. Presence of endometrium was associated with pelvic pain (RR = 2.3; 95% CI = 1.2-4.7) in females with MRKH. Of the females with MKRH and pain, 9/22 had laparoscopy, with endometriosis seen in 5/9 of the uterine remnants at stages higher than are usually seen in teenagers (56%). Nine patients with pain and uterine remnants (8 with endometrium, 1 without) had laparoscopic removal of uterine remnants with resolution of pain. CONCLUSIONS: Given the high prevalence of uterine remnants in females with MRKH, anatomic evaluation with MRI should be considered when assessing the etiology of pelvic pain. Presence of endometrium within uterine remnants, and subsequent endometriosis, in females with MRKH may be associated with pelvic pain necessitating surgical or medical management.

Functional neuroimaging of emotional processing in women with polycystic ovary syndrome: a case-control pilot study.

OBJECTIVE: To evaluate emotional processing in women with insulin-resistant polycystic ovary syndrome (IR-PCOS) and its relationship to glucose regulation and the mu-opioid system. DESIGN: Case-control pilot. SETTING: Tertiary referring medical center. PATIENT(S): Seven women with IR-PCOS and five non-insulin-resistant controls, aged 21-40 years, recruited from the general population. INTERVENTION(S): Sixteen weeks of metformin (1,500 mg/day) in women with IR-PCOS. MAIN OUTCOME MEASURE(S): Assessment of mood, metabolic function, and neuronal activation during an emotional task using functional magnetic resonance imaging (fMRI), and mu-opioid receptor availability using positive emission tomography (PET). RESULT(S): We found that insulin-resistant PCOS patients [1] had greater limbic activation during an emotion task than controls (n = 5); [2] trended toward decreased positive affect and increased trait anxiety; [3] after metformin treatment, had limbic activation that no longer differed from controls; and [4] had positive correlations between fMRI limbic activation during emotional processing and mu-opioid binding potential. CONCLUSION(S): Patients with IR-PCOS had greater regional activation during an emotion task than the controls, although this resolved with metformin therapy. Alterations in mu-opioid neurotransmission may underlie limbic system activity and mood disorders in IR-PCOS.

Prevalence of pain syndromes, mood conditions, and asthma in adolescents and young women with endometriosis.

STUDY OBJECTIVE: Adult women with endometriosis are often diagnosed with comorbid pain, mood, and autoimmune conditions. This study aims to describe the occurrence of pain syndromes, mood conditions, and asthma in adolescents and young women with endometriosis evaluated at our medical center. DESIGN: Retrospective review of medical records. SETTING: Department of Obstetrics and Gynecology at a tertiary referral center. PARTICIPANTS: 138 adolescents/young women who were less than age 24 years at the time of their initial visit at our medical center, and whose surgical diagnosis of endometriosis was made at our institution or by outside institutions by the age of 21. INTERVENTIONS: None. MAIN OUTCOME MEASURES: Prevalence of comorbid pain syndromes (defined as interstitial cystitis, irritable bowel syndrome, chronic headaches, chronic low back pain, vulvodynia, fibromyalgia, temporomandibular joint disease, and chronic fatigue syndrome), mood conditions (defined as depression and anxiety), and asthma. RESULTS: Comorbid pain syndromes were found in 77 (56%) women, mood conditions in 66 (48%) women, and asthma in 31 (26%) women. Comparing endometriosis patients with and without comorbid pain syndromes, no differences were found in age at time of diagnosis, endometriosis symptoms, and endometriosis stage. Patients with comorbid pain syndromes were more likely to report mood conditions (62% vs 30% respectively, P < .001) and smoking (31% vs 10% respectively, P = .003), underwent more surgeries for endometriosis (median of 2 [range, 1-7] vs 1 [range, 1-5], P < .005), and were more likely to undergo appendectomy or cholecystectomy (30% vs 13%, P = .02). CONCLUSIONS: Comorbid pain syndromes, mood conditions and asthma are common in adolescents and young women with endometriosis.

Trends and factors associated with the Day 5 embryo transfer, assisted reproductive technology surveillance, USA, 2001-2009.

STUDY QUESTION: What characteristics are associated with a Day 5 embryo transfer? SUMMARY ANSWER: The use of the Day 5 embryo transfer has increased over time, with clinicians allowing women with typically 'poorer' prognostic characteristics to undergo a Day 5 embryo transfer. The mean number of embryos per Day 5 transfer decreased from 2001 to 2009, although the prevalence of the Day 5 single embryo transfer remains low and the rate of multiple births remains substantial. WHAT IS KNOWN AND WHAT THIS PAPER ADDS: Day 5 embryo transfer may reduce the rate of multiple gestation pregnancy. US trends over time in the prevalence of the Day 5 transfer, changes in characteristics of patients receiving Day 5 transfer, and number of embryos transferred are unknown. DESIGN: We used 2001-2009 US National assisted reproductive technology (ART) Surveillance System (NASS) data on 620,295 fresh IVF cycles derived from autologous oocytes with a Day 3 or 5 embryo transfer. Trends in the mean number of embryos transferred from 2001 to 2009 were assessed by the day of transfer. For 349,947 cycles from clinics performing both Days 3 and 5 embryo transfers, multivariable logistic regression was used to determine the characteristics associated with the Day 5 embryo transfer. We also compared the characteristics of the Day 5 embryo cycles in 2001 and 2009. MAIN RESULTS AND THE ROLE OF CHANCE: Overall, the proportion of ART cycles using the Day 5 embryo transfer increased from 12% in 2001 to 36% in 2009 (P<0.0001), while the mean number of embryos transferred decreased from 2.4 to 2.1 (P<0.0001). Among Day 5 transfers, the rate of the single embryo transfer tripled from 4.5% in 2001 to 14.8% in 2009 (P<0.0001); and the rate of multiple births decreased from 44.8 to 41.1% (P<0.0001). In cycles initiated after 2001, maternal age<35 years, no prior ART cycles, ≥1 prior pregnancies, baseline follicle stimulating hormone<10 international units and ≥10 oocytes retrieved were associated with the Day 5 embryo transfer. Compared with 2001, in 2009, a broader range of candidates received the Day 5 transfer. BIAS Women undergoing multiple ART cycles over time are not linked. CONFOUNDING FACTORS AND OTHER REASONS FOR CAUTION: We ran multivariable logistic regression to lessen the effects of the confounding factors. Cycle cancelation rates by the day of embryo transfer are unknown. GENERALIZABILITY TO OTHER POPULATIONS: Generalizable to ART clinics included in NASS. STUDY FUNDING/COMPETING INTERESTS: This study was funded by the Centres for Disease Control. The authors have no competing interests to declare.