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Geographic border studies are relatively scare, but have the potential to inform bilateral health policies that affect the well-being of female sex workers (FSWs) who work at these borders as well as those individuals who solicit their services, both groups being at high risk for human immunodeficiency virus (HIV). We applied bivariate and multivariate techniques to examine FSWs' HIV knowledge and condom use across three partner types, at the Haiti Dominican Republic border, using data from the Study on Sex Workers (n = 241, 2014). Condom use was significantly lower among FSWs on the Haitian side of the border compared to the Dominican side, yet levels of HIV knowledge were similar; specifically, 81% of respondents on the Dominican side reported using condoms every time they had sex with a client, compared to 38% of peers in Haiti (p

STUDY QUESTION Do women with polycystic ovary syndrome (PCOS) seeking fertility treatment report smoking accurately and does participation in infertility treatment alter smoking? SUMMARY ANSWER Self-report of smoking in infertile women with PCOS is accurate (based on serum cotinine levels) and smoking is unlikely to change over time with infertility treatment. WHAT IS KNOWN ALREADY Women with PCOS have high rates of smoking and it is associated with worse insulin resistance and metabolic dysfunction. STUDY DESIGN, SIZE, DURATION Secondary study of smoking history from a large randomized controlled trial of infertility treatments in women with PCOS (N = 626) including a nested case-control study (N = 148) of serum cotinine levels within this cohort to validate self-report of smoking. PARTICIPANTS/MATERIALS, SETTING, METHODS Women with PCOS, age 18-40, seeking fertility who participated in a multi-center clinical trial testing first-line ovulation induction agents conducted at academic health centers in the USA. MAIN RESULTS AND THE ROLE OF CHANCE Overall, self-report of smoking in the nested case-control study agreed well with smoking status as determined by measure of serum cotinine levels, at 90% or better for each of the groups at baseline (98% of never smokers had cotinine levels

The aim of this study is to examine rates of magnesium sulfate utilization by emergency obstetric care trainees to treat preeclampsia-eclampsia in India. Secondarily, structural barriers are identified which limit the use of magnesium sulfate, highlighting limitations of emergency obstetric care training, which is a commonly implemented intervention in resource-poor settings.Trainees' curriculum specified magnesium sulfate treatment for eclampsia and severe preeclampsia. Case records were analyzed for preeclampsia-eclampsia diagnosis, magnesium sulfate utilization, delivery route, and maternal and neonatal outcomes from 13,238 reported deliveries between 2006 and 2012 across 75 district hospitals in 12 Indian states.Of 1320 cases of preeclampsia-eclampsia, 322 (24.4%) had eclampsia. Magnesium sulfate was given to 12.9% of preeclamptic and 54.3% of eclamptic women, with lower usage rates in rural communities. Among the 1308 women with preeclampsia-eclampsia, only 24 deaths occurred (1.8%). In contrast, among the 17,179 women without preeclampsia-eclampsia, there were 95 reported deaths (0.6%). Both maternal mortality ratios were found to be much higher than the Millennium Development Goal target of 0.15%. Magnesium sulfate administration was associated with a higher death rate in preeclamptic but not eclamptic women, representing possible confounding by severity.To optimize resources spent on emergency obstetric care training, the consistent availability of magnesium sulfate should be improved in India. Increasing drug availability, implementing clinical guidelines around its administration, and training health-care providers on the identification and treatment of preeclampsia-eclampsia could lead to notable improvements in maternal and infant mortality.

Experimental evidence supports a relevance of vitamin D (VitD) for reproduction; however, data in humans are sparse and inconsistent.To assess the relationship of VitD status with ovulation induction (OI) outcomes in women with polycystic ovary syndrome (PCOS).A retrospective cohort.Secondary analysis of randomized controlled trial data.Participants in the Pregnancy in PCOS I (PPCOS I) randomized controlled trial (n = 540) met the National Institutes of Health diagnostic criteria for PCOS.Serum 25OHD levels were measured in stored sera.Primary, live birth (LB); secondary, ovulation and pregnancy loss after OI.Likelihood for LB was reduced by 44% for women if the 25OHD level was30 ng/mL (75 nmol/L; odds ratio [OR], 0.58 [0.35-0.92]). Progressive improvement in the odds for LB was noted at thresholds of ≥38 ng/mL (≥95 nmol/L; OR, 1.42 [1.08-1.8]), ≥40 ng/mL (≥100 nmol/L; OR, 1.51 [1.05-2.17]), and ≥45 ng/mL (≥112.5 nmol/L; OR, 4.46 [1.27-15.72]). On adjusted analyses, VitD status was an independent predictor of LB and ovulation after OI.In women with PCOS, serum 25OHD was an independent predictor of measures of reproductive success after OI. Our data identify reproductive thresholds for serum 25OHD that are higher than recommended for the nonpregnant population.

Many women with polycystic ovary syndrome (PCOS) experience infertility and hirsutism and often seek treatment for both concurrently. We investigated whether women who ovulate in response to treatment with clomiphene citrate, metformin, or both would have greater improvement in hirsutism compared with those who did not ovulate.This is a secondary analysis evaluating the change in Ferriman-Gallwey score for the hirsute women (n=505 [80.7%]) from the Pregnancy in Polycystic Ovary Syndrome I study. This was a prospective, randomized, doubled-blind trial of 626 women with PCOS and infertility recruited from 12 university sites. They were treated with clomiphene citrate, metformin, or both (combination) for up to six cycles, and hirsutism evaluators were blinded to group assignment.There was a significant decrease in the Ferriman-Gallwey score between baseline and completion of the study in each of the three individual groups (clomiphene citrate, P=.024; metformin, P=.005; combination, P.001). There was no significant difference in the degree to which the hirsutism score changed when comparing the three groups (P=.44). The change in hirsutism was not associated with the duration of treatment or with the presence or absence of ovulation.In infertile hirsute women with PCOS, treatment with clomiphene citrate, metformin, or both for up to six cycles does not alter hirsutism.ClinicalTrials.gov, www.clinicaltrials.gov, NCT00068861.II.

When used for ovulation induction, higher doses of clomiphene may lead to antiestrogenic side effects that reduce fecundity. It has been suggested that metformin in combination with clomiphene can restore ovulation to some clomiphene-resistant anovulators with polycystic ovary syndrome (PCOS).Our objective was to determine if cotreatment with extended-release metformin (metformin XR) can lower the threshold dose of clomiphene needed to induce ovulation in women with PCOS.A secondary analysis of data from the National Institute of Child Health and Human Development Cooperative Multicenter Reproductive Medicine Network prospective, double-blind, placebo-controlled multicenter clinical trial, Pregnancy in Polycystic Ovary Syndrome, was performed.Study volunteers at multiple academic medical centers were included.Women with PCOS and elevated serum testosterone who were randomized to clomiphene alone or with metformin (n = 209 in each group) were included in the study.Clomiphene citrate, 50 mg daily for 5 d, was increased to 100 and 150 mg in subsequent cycles if ovulation was not achieved; half also received metformin XR, 1000 mg twice daily. Treatment was for up to 30 wk or six cycles, or until first pregnancy.Ovulation was confirmed by a serum progesterone more than or equal to 5 ng/ml, drawn prospectively every 1-2 wk.The overall prevalence of at least one ovulation after clomiphene was 75 and 83% (P = 0.04) for the clomiphene-only and clomiphene plus metformin groups, respectively. Using available data from 314 ovulators, the frequency distribution of the lowest clomiphene dose (50, 100, or 150 mg daily) resulting in ovulation was indistinguishable between the two treatment groups.Metformin XR does not reduce the lowest dose of clomiphene that induces ovulation in women with PCOS.

Context: Clomiphene and insulin sensitizers such as metformin are used to induce ovulation in polycystic ovary syndrome (PCOS), but the ovulatory response is variable, and the causes of this variation are poorly understood. Objective: Our objective was to identify predictive genetic polymorphisms and other determinants of ovulatory response. Design: This was a substudy of a multicenter randomized clinical trial. Setting: This study was performed at academic medical centers and their affiliates. Participants: A total of 312 women with PCOS were included in the study. Main Outcome Measures: Historical, biometric, biochemical, and genetic parameters were performed. Results: We found that the C allele of a single nucleotide polymorphism in the STK11 gene (expressed in liver; also known as LKB1) was associated with a significantly decreased chance of ovulation in PCOS women treated with metformin. In an analysis of ovulation per cycle, the adjusted odds ratio (OR) comparing the C/C genotype to the G/G genotype was 0.30 [95% confidence interval (CI) 0.14, 0.66], and the OR for the C/G genotype vs. the G/G genotype was also 0.30 (95% CI 0.14, 0.66). In an analysis of metformin-treated subjects, we found that the percentage of women who ovulated increased with the number of G alleles present: 48% (10 of 21) of C/C women, 67% (32 of 48) of C/G women, and 79% (15 of 19) of G/G women ovulated. We also found that increased frequency of ovulation was associated with lower body mass index (BMI) [adjusted OR of 2.36 (95% CI 1.65, 3.36) and 2.05 (95% CI 1.46, 2.88), respectively, for comparisons of BMI less than 30 vs. BMI equal to or more than 35, BMI 30–34 vs. BMI equal to or more than 35, in the analysis of ovulation per cycle], a lower free androgen index (FAI) [adjusted OR of 1.59 (95% CI 1.17, 2.18) for FAI < 10 vs. FAI ≥ 10], and a shorter duration of attempting conception [adjusted OR of 1.63 (95% CI 1.20, 2.21) for < 1.5 vs. ≥ 1.5 yr]. Conclusions: We have demonstrated that a polymorphism in STK11, a kinase gene expressed in liver and implicated in metformin action, is associated with ovulatory response to treatment with metformin alone in a prospective randomized trial. The interaction with the effects of changes in modifiable factors (e.g. BMI or FAI) requires further study.

Polycystic ovary syndrome (PCOS) may be the commonest cause of female infertility. In addition to anovulation, early pregnancy loss, and later complications of pregnancy, obesity-which is common in women with PCOS-has been implicated. Small-scale trials suggest that treatment with an insulin sensitizer such as metformin, alone or combined with clomiphene citrate, is at least equal to, and possibly superior to clomiphene alone as treatment for infertility. This randomized, placebo-controlled trial evaluated both of these agents, alone and combined, in 626 infertile women diagnosed as having PCOS. Extended-release metformin was given in a maximum dose of 1 gm daily, and clomiphene concurrently in a dose of 50 mg daily, starting on menstrual day 3. The dose of clomiphene was doubled if necessary. Treatment continued for up to six cycles over 30 weeks. Baseline variables were similar in all treatment groups. Rates of live birth were 22.5% in clomiphene-treated patients, 7.2% with metformin therapy, and 26.8% with combination therapy. The differences between the metformin group and the clomiphene and combined treatment groups were significant. Combined therapy was not significantly more effective than clomiphene alone. Similar results were obtained when adjusting for body mass index. Among secondary outcomes, ovulation rates were significantly higher with combined treatment than in either of the single-drug groups, but this did not translate into increased live births. Rates of conception and of live births per ovulatory cycle were significantly higher in the clomiphene and combined drug groups than with metformin alone. There were no multiple pregnancies in the metformin group. There were no notable group differences in rates of first-trimester pregnancy loss. Compared to metformin-treated women, those given clomiphene or combined therapy had significant increases in sex hormone-binding globulin levels and decreased free androgen indices. Serious adverse events-mostly pregnancy complications-were most frequent in the clomiphene and combined treatment groups. Gastrointestinal side effects were more frequent, and vasomotor and ovulatory symptoms less frequent, in the metformin group than in the clomiphene group. These findings fail to support the view that extended-release metformin, alone or combined with clomiphene citrate, improves live birth rates in previously infertile women with PCOS. Clomiphene alone seems preferable as first-line treatment for these patients despite a risk of multiple births. Combining the two drugs does not further increase the chances of a live birth.

Insulin-like growth factor (IGF)-binding proteins (IGFBPs) antagonize IGF and gonadotropin actions on granulosa cells. Human atretic follicles express IGFBP-2 in granulosa cells more strongly and contain higher levels of IGFBP-2 and IGFBP-4 than healthy follicles. We studied the effects of interferon-γ (IFNγ) and activin A, which decrease progesterone accumulation, on granulosa cell IGFBP production and apoptosis. Conditioned media from luteinizing granulosa cells cultured with IFNγ or activin A and/or LH were subjected to ligand blotting; northern blots of total ribonucleic acid (RNA) from these cells were probed for IGFBP-2 and -4. Apoptosis was measured by in situ DNA end labeling. LH decreased medium IGFBP-2 to 21% of the control value. Although IFNγ did not alter basal medium IGFBP-2, in the presence of LH it increased IGFBP-2 3.4-fold, with parallel changes in messenger RNA levels. Activin A also tended to increase medium IGFBP-2 in LH-treated cultures. In conditioned medium, IGFBP-4 was consistently decreased by LH, whereas both IFNγ and activin A increased IGFBP-4 and decreased IGFBP-4 protease activity. Both LH and IFNγ modestly stimulated IGFBP-4 messenger RNA levels. Follistatin antagonized the action of activin A, but not that of IFNγ. IFNγ, but not activin A, increased granulosa cell apoptosis. In conclusion, IFNγ produced by activated lymphocytes may decrease endogenous IGF activity through stimulation of IGFBPs and may promote apoptosis of granulosa-lutein cells in vivo and, thus, luteal regression. Activin A similarly promotes IGFBP accumulation, but it does not promote apoptosis. (J Clin Endocrinol Metab 83: 179–186, 1998)

Insulin-like growth factor (IGF) binding proteins are produced by ovarian follicular cells and can oppose the effects of the IGFs and gonadotropins on these cells. Since polycystic ovarian syndrome (PCOS) is characterized by disordered follicular development, with the accumulation of antral follicles within the ovary which fail to respond appropriately to endogenous FSH, it has been hypothesized that one or more IGFBPs, which can act as FSH antagonists in vitro, could play a role in inhibiting follicular development in this syndrome. Follicular fluid IGFBP levels, however, do not differ between PCOS follicles and the androgenic, presumably atretic follicles of cycling women without PCOS. Serum IGFBP-1 levels are lower in PCOS, likely because of hyperinsulinemia, and serum free IGF-1 levels are raised. This alternation may drive the excess thecal androgen production characteristic of PCOS follicles. Alterations in IGFBPs may sustain the anovulatory steady state in PCOS but are unlikely to initiate development of the syndrome.

GH increases circulating insulin-like growth factor I (IGF-I), which can promote the growth and differentiated function of ovarian granulosa and theca cells. Reported studies of GH as an adjunct to menotropin stimulation in women, largely those with ovarian dysfunction, have not consistently shown a benefit of GH, despite increases in serum and follicular fluid IGF-I. We hypothesized that changes in intrafollicular IGF-binding proteins (IGFBPs), which can antagonize IGF actions on granulosa cells, may underlie the inconsistent effects of GH. In the present study of GH, administered in double-blind, placebo-controlled, cross-over fashion to regularly cycling women undergoing in vitro fertilization, we found that follicular fluid levels of IGFBP-1, -3, and -4 and serum levels of IGFBP-3, as well as follicular fluid and serum IGF-I, were significantly increased in the GH-treated cycles, when compared with the placebo cycle of the same patient. We suggest that the net increase in intrafollicular IGFBPs in GH cycles may mitigate the potential beneficial effect of increased IGF-I.

To estimate whether progestin-induced endometrial shedding, before ovulation induction with clomiphene citrate, metformin, or a combination of both, affects ovulation, conception, and live birth rates in women with polycystic ovary syndrome (PCOS).A secondary analysis of the data from 626 women with PCOS from the Eunice Kennedy Shriver National Institute of Child Health and Human Development Cooperative Reproductive Medicine Network trial was performed. Women had been randomized to up to six cycles of clomiphene citrate alone, metformin alone, or clomiphene citrate plus metformin. Women were assessed for occurrence of ovulation, conception, and live birth in relation to prior bleeding episodes (after either ovulation or exogenous progestin-induced withdrawal bleed).Although ovulation rates were higher in cycles preceded by spontaneous endometrial shedding than after anovulatory cycles (with or without prior progestin withdrawal), both conception and live birth rates were significantly higher after anovulatory cycles without progestin-induced withdrawal bleeding (live births per cycle: spontaneous menses 2.2%; anovulatory with progestin withdrawal 1.6%; anovulatory without progestin withdrawal 5.3%; P.001). The difference was more marked when rate was calculated per ovulation (live births per ovulation: spontaneous menses 3.0%; anovulatory with progestin withdrawal 5.4%; anovulatory without progestin withdrawal 19.7%; P.001).Conception and live birth rates are lower in women with PCOS after a spontaneous menses or progestin-induced withdrawal bleeding as compared with anovulatory cycles without progestin withdrawal. The common clinical practice of inducing endometrial shedding with progestin before ovarian stimulation may have an adverse effect on rates of conception and live birth in anovulatory women with PCOS.II.

Activin-A decreases progesterone secretion and aromatase activity in cultured human luteinizing granulosa cells. Follistatin is a binding protein for activin and inhibin produced by granulosa cells and present in follicular fluid. The present study examines the hypothesis that follistatin reverses the actions of activin-A on human granulosa cells. Granulosa cells from women undergoing ovarian stimulation for in vitro fertilization were cultured in defined medium with recombinant human (rh) activin-A and purified porcine follistatin. Follistatin completely reversed the inhibition of basal progesterone production by rh-activin-A, but only when added in a greater than 2:1 molar ratio to activin-A. Although variable effects of activin-A on aromatase activity were observed in these studies, follistatin also antagonized these effects. Follistatin had no effect in the absence of added activin-A. rh-Inhibin-A did not alter steroidogenesis by granulosa cells either with or without added activin-A. Even when added in a 45-fold molar excess, inhibin-A did not displace sufficient activin-A from follistatin to inhibit progesterone secretion. This suggests that the affinity of inhibin-A for follistatin is much lower than that of activin-A, and/or that activin-A bound to follistatin dissociates slowly. alpha 2-Macroglobulin, another activin-binding protein, did not alter the inhibition of progesterone production by activin-A. We conclude that in human granulosa cells, follistatin, but not alpha 2-macroglobulin or inhibin-A, acts to modulate the actions of activin-A. Follistatin and activin may be viewed as components of an autocrine/paracrine system within the human follicle that regulate the differentiated functions of granulosa cells.

Nonalcoholic fatty liver disease is common to insulin-resistant states such as polycystic ovary syndrome (PCOS). Metformin (MET) is often used to treat PCOS but information is limited as to its effects on liver function.We sought to determine the effects of MET on serum hepatic parameters in PCOS patients.This was a secondary analysis of a randomized, doubled-blind trial from 2002-2004.This multi-center clinical trial was conducted in academic centers.Six hundred twenty-six infertile women with PCOS with serum liver function parameters less than twice the upper limit of normal were included.Clomiphene citrate (n = 209), MET (n = 208), or combined (n = 209) were given for up to 6 months.The percent change from baseline in renal and liver function between- and within-treatment arms was assessed.Renal function improved in all treatment arms with significant decreases in serum blood urea nitrogen levels (range, -14.7 to -21.3%) as well as creatinine (-4.2 to -6.9%). There were similar decreases in liver transaminase levels in the clomiphene citrate and combined arms (-10% in bilirubin, -9 to -11% in transaminases) without significant changes in the MET arm. When categorizing baseline bilirubin, aspartate aminotransferase, and alanine aminotransferase into tertiles, there were significant within-treatment arm differences between the tertiles with the highest tertile having the largest decrease from baseline regardless of treatment arm.Women with PCOS can safely use metformin and clomiphene even in the setting of mildly abnormal liver function parameters, and both result in improved renal function.

Data obtained from a wide variety of mammalian species indicate that feeding behavior can be influenced by changes in endogenous estrogens and by exogenous estrogenic treatments. The present experiment represents an initial investigation of the hypothesis that the suppression of food intake by estradiol is mediated by an enhancement of the satiety effect of cholecystokinin (CCK). Twenty-four female rats were ovariectomized and implanted either with a 5% estradiol silastic capsule or an empty capsule on the day of surgery. Three weeks later, animals received IP injections of CCK-octapeptide (5.0 or 10.0 μg/kg) or saline after 24-h food deprivation. Food and water intake were measured 60 min after treatment. Although CCK suppressed feeding in all subjects, the effects on food intake were greater in estradiol-treated females. CCK injections also reduced water intake, but there was no interaction between estradiol and CCK on drinking. These findings indicate that the inhibitory effect of CCK on food intake is enhanced in females treated with a physiological dose of estradiol, and suggest that the effects of estradiol on feeding behavior may be mediated by a potentiation of the satiety effect of CCK.

A serum-free medium has been developed which supports in vitro function by ovarian cells derived from rat, monkey, and human tissue. This granulosa cell medium (GCM) consists of Dulbecco's Modified Eagle's Medium: Ham's F-12 medium (1:1, v:v) supplemented with insulin, transferrin, aprotinin, selenium, fibronectin, penicillin, and streptomycin. Ovarian cells from three species were compared: rat, macaque, and human. Four types of ovarian cultures were examined: 1) purified granulosa cell cultures and 2) co-cultures containing granulosa-theca-stroma cells, 3) luteal cells, and 4) granulosa-lutein (harvested from in vitro fertilization cultures) cells. Each cell type was characterized by its response to FSH or hCG when cultured in GCM. Morphologic responses to FSH were observed in GCM in rat granulosa and granulosa-theca-stroma cell cultures, macaque and human granulosa-lutein cells, and human granulosa-theca-stroma cell cultures. The FSH-stimulated cells retracted and became rounded, leaving long intercellular connections. Luteal cells did not retract in response to FSH, and the cells remained firmly attached to the fibronectin matrix. Steroidogenic regulation of the GCM-cultured ovarian cells was monitored following stimulation of the cultures with FSH. The ability of the cells to aromatize testosterone was first examined. Rat granulosa cell cultures and granulosa-theca-stroma cell cultures, macaque granulosa-lutein cell cultures, and human granulosa-theca-stroma cell cultures all accumulated estradiol when given FSH and testosterone for 48 h. Moreover, these cell types as well as human luteal cells were able to metabolize 25-hydroxy [1,2-3H]cholesterol to various steroid metabolites. The data indicate that GCM supports normal granulosa cell morphologic response to FSH.(ABSTRACT TRUNCATED AT 250 WORDS)

The production of insulin-like growth factor (IGF) binding proteins (IGFBPs) by human luteinizing granulosa cells obtained at oocyte harvest for in vitro fertilization was studied in defined medium. Three species of IGFBP were noted on Western ligand blotting of conditioned medium. A 31-33 kilodalton (kDa) doublet identified as IGFBP-2 by immunoprecipitation was consistently seen and was shown by metabolic labeling to be synthesized de novo. IGFBP-2 production was inhibited by hCG (100 ng/mL) to 32 +/- 8% of levels in control cultures; a similar inhibition was seen with dibutyryl cAMP and forskolin, but not with FSH. IGFBP-2 production was also inhibited by IGF-II and [Leu27]IGF-II (ED50 for both 3 ng/mL) but not by IGF-I at up to 30 ng/mL. In addition to IGFBP-2, a 35-45 kDa IGFBP identified by immunoprecipitation as IGFBP-3 was variably present on ligand blots of control conditioned medium and was consistently found in medium from cells treated with IGF-I or IGF-II (ED50 3 ng/mL) but not with insulin at 2 mg/mL. No de novo synthesis of IGFBP-3 was noted, suggesting that IGFBP-3 may be released from the cell surface by ligand. A 24-kDa IGFBP consistent with IGFBP-4 was also variably noted in basal cultures. Since IGFBPs are believed to sequester IGF peptides and inhibit their action on the granulosa, control of IGFBP production may be an important step in regulating gonadotropin and IGF action in the human granulosa cell.

Context: There is no standardized assay of testosterone in women. Liquid chromatography mass spectrometry (LC/MS) has been proposed as the preferable assay by an Endocrine Society Position Statement. Objective: The aim was to compare assay results from a direct RIA with two LC/MS. Design and Setting: We conducted a blinded laboratory study including masked duplicate samples at three laboratories—two academic (University of Virginia, RIA; and Mayo Clinic, LC/MS) and one commercial (Quest, LC/MS). Participants and Interventions: Baseline testosterone levels from 596 women with PCOS who participated in a large, multicenter, randomized controlled infertility trial performed at academic health centers in the United States were run by varying assays, and results were compared. Main Outcome Measure: We measured assay precision and correlation and baseline Ferriman-Gallwey hirsutism scores. Results: Median testosterone levels were highest with RIA. The correlations between the blinded samples that were run in duplicate were comparable. The correlation coefficient (CC) between LC/MS at Quest and Mayo was 0.83 [95% confidence interval (CI), 0.80–0.85], between RIA and LC/MS at Mayo was 0.79 (95% CI, 0.76–0.82), and between RIA and LC/MS at Quest was 0.67 (95% CI, 0.63–0.72). Interassay variation was highest at the lower levels of total testosterone (≤50 ng/dl). The CC for Quest LC/MS was significantly different from those derived from the other assays. We found similar correlations between total testosterone levels and hirsutism score with the RIA (CC = 0.24), LC/MS at Mayo (CC = 0.15), or Quest (CC = 0.17). Conclusions: A testosterone RIA is comparable to LC/MS assays. There is significant variability between LC/MS assays and poor precision with all assays at low testosterone levels.

Objective To investigate the relationship between body mass index and intercourse compliance in the Reproductive Medicine Network's Pregnancy in Polycystic Ovary Syndrome (RMN PPCOS) Trial. Design Post hoc data analysis of subjects in the RMN PPCOS Trial. Setting Academic medical centers. Intervention(s) None. Patient(s) Six hundred twenty-six infertile women with polycystic ovary syndrome (PCOS) with a mean age of 28.1 ± 4 years and mean body mass index (BMI) of 35.2 ± 8.7 kg/m 2 . Main Outcome Measure(s) Intercourse compliance and BMI. Result(s) Overall, body mass index was not associated with increased intercourse compliance. However, although patients with BMI ≥35 were less likely to ovulate than patients with BMI Conclusion(s) BMI was not associated with intercourse compliance or noncompliance. An elevated BMI in infertile women with PCOS is not associated with poor intercourse compliance.

Context: Polycystic ovary syndrome (PCOS) is the most common cause of anovulatory infertility. The selection of first-line therapies for ovulation induction is empiric. Objective: The aim of the study was to develop a clinically useful predictive model of live birth with varying ovulation induction methods. Design, Setting, and Participants: We built four prognostic models from a large multicenter randomized controlled infertility trial of 626 women with PCOS performed at academic health centers in the United States to predict success of ovulation, conception, pregnancy, and live birth, evaluating the influence of patients’ baseline characteristics. Interventions: Ovulation was induced with clomiphene, metformin, or the combination of both for up to six cycles or conception. Main Outcome Measure: The primary outcome of the trial was the rate of live births. Results: Baseline free androgen index, baseline proinsulin level, interaction of treatment arm with body mass index, and duration of attempting conception were significant predictors in all four models. History of a prior loss predicted ovulation and conception, but not pregnancy or live birth. A modified Ferriman Gallwey hirsutism score of less than 8 was predictive of conception, pregnancy, and live birth (although it did not predict ovulation success). Age was a divergent predictor based on outcome; age greater than 34 predicted ovulation, whereas age less than 35 was a predictive factor for a successful pregnancy and live birth. Smoking history had no predictive value. Conclusions: A live birth prediction chart developed from basic clinical parameters (body mass index, age, hirsutism score, and duration of attempting conception) may help physicians counsel and select infertility treatments for women with PCOS. The probability of a live birth after ovulation induction in PCOS women can be estimated based on their age, body mass index, hirsutism, and duration of attempted conception.

Objective To investigate the relationship among intercourse compliance, ovulation, and the occurrence of pregnancy in the Reproductive Medicine Network's Pregnancy in Polycystic Ovary Syndrome (RMNPPCOS) Trial. Design Post hoc data analysis of subjects in the Reproductive Medicine Network PPCOS Trial. Setting Academic medical centers. Intervention(s) None. Patient(s) Six hundred twenty-six infertile women with polycystic ovary syndrome with a mean age of 28.1 ± 4 years and mean body mass index of 35.2 ± 8.7 kg/m 2 . Main Outcome Measure(s) Intercourse compliance, ovulation, and pregnancy. Result(s) Data on 2925 cycles were included in the analysis, of which 1340 were ovulatory cycles and 1585 were nonovulatory cycles. The rates of intercourse compliance in the PPCOS trial were similar across all treatment groups at all cycles except cycle 4. Among cycles with known ovulation status, 81.2% of patients were compliant with intercourse instructions. Patients were more intercourse compliant in those cycles during which ovulation occurred (83.2% vs. 79.4%). With regard to ovulatory cycles, there was no difference in the occurrence of pregnancy when comparing intercourse compliant versus intercourse noncompliant cycles. Conclusion(s) Intercourse compliance was not associated with the occurrence of pregnancy in ovulatory cycles in the PPCOS Trial. The occurrence of ovulation still remains a critical predictor for the occurrence of pregnancy.

To determine the proportion of euthyroid women attending a fertility practice who develop hypothyroidism in very early pregnancy (gestational hypothyroidism [GHT]), and to examine the association of GHT with exogenous gonadotropin treatment.Retrospective cohort study.A private reproductive medicine practice.All healthy women (N = 94) with infertility or recurrent pregnancy loss, TSH level2.5 mIU/L, negative thyroid peroxidase antibodies at initial evaluation, and not taking thyroid medication, who conceived during an 18-month period.Usual fertility care; 30 women who had received exogenous gonadotropins.Serum TSH level at the time of pregnancy detection.Gestational hypothyroidism (TSH ≥ 2.5 mIU/L) developed in 23 of 94 women (24%). The mean increase in serum TSH level from initial evaluation to early pregnancy was 0.45 ± 0.08 [SE] mIU/L. There was a trend toward the association of GHT with use of exogenous gonadotropins. Gestational hypothyroidism was positively associated with initial prepregnancy TSH level.Euthyroid women may develop mild hypothyroidism in early pregnancy, especially after exogenous gonadotropin treatment. Appropriate vigilance will allow for timely levothyroxine treatment.

Objective To report the baseline characteristics and racial differences in the polycystic ovary syndrome (PCOS) phenotype from a large multicenter clinical trial (PPCOS). Design Double-blind, randomized trial of three treatment regimens (with extended release metformin or clomiphene citrate). Setting Academic medical centers. Patient(s) Six hundred twenty-six infertile women with PCOS, aged 18–39 years, with elevated T levels and oligomenorrhea (exclusion of secondary causes), seeking pregnancy, with ≥1 patent fallopian tube, normal uterine cavity, and a partner with sperm concentration ≥20 × 10 6 /mL in ≥1 ejaculate. Intervention(s) Baseline characterization. Main Outcome Measure(s) Historical, biometric, and biochemical measures of PCOS. Result(s) There were no significant differences in baseline variables between treatment groups. The overall mean (±SD) age of the subjects was 28.1 ± 4.0 years, and the mean body mass index was 35.2 kg/m 2 (±8.7). Polycystic ovaries (PCOs) were present in 90.3% of the subjects, and the mean volume of each ovary was 10 cm 3 or more. Of the subjects, 7% had ovaries that were discordant for PCO morphology. At baseline, 18.3% of the subjects had an abnormal fasting glucose level (>100 mg/dL). Asians tended to have a milder phenotype, and whites and African Americans were similar in these measures. Conclusion(s) The treatment groups were well matched for baseline parameters, and we have added further information to the PCOS phenotype.

Background Insulin sensitizers have favourable metabolic and ovarian effects in polycystic ovary syndrome (PCOS). This study examined rosiglitazone, a thiazolidinedione, in PCOS. Methods In a prospective, open-label study, the effects of rosiglitazone on metabolism and ovarian function were examined in 42 non-diabetic women with PCOS classified according to the National Institute of Child Health and Human Development criteria and insulin resistance (IR) by steady-state plasma glucose (SSPG) > or =10 mmol/l on octreotide-modified insulin suppression testing. Participants were randomized to rosiglitazone 2, 4 or 8 mg daily for 12 weeks. Endpoints included ovulation and menstrual pattern; serum testosterone, sex hormone-binding globulin (SHBG), and LH; and changes in IR and glucose-insulin responses on 8 h mixed-meal profile. Results After rosiglitazone 8 mg daily for 12 weeks, SSPG declined and insulinaemia fell by 46%; lower doses gave lesser effects. Serum LH, total and free testosterone were unchanged; SHBG increased. With rosiglitazone, ovulation occurred in 23/42 women (55%), without significant dose dependence. Both before and during treatment, ovulators on rosiglitazone had lower circulating insulin and free testosterone and higher SHBG than non-ovulators. Testosterone declined only in a subgroup of ovulators with early vaginal bleeding after starting rosiglitazone. Conclusions Rosiglitazone in insulin-resistant PCOS promoted ovulation and dose-dependently decreased IR and insulinaemia; ovulators had lower circulating insulin and testosterone.

Study objectives To evaluate the impact of estrogen and estrogen plus progesterone hormone-replacement therapy (HRT) on mild-to-moderate sleep-disordered breathing (SDB) in postmenopausal women. Design and setting Within-subjects, progesterone placebo-controlled prospective HRT trial in a clinical laboratory. Participants Six postmenopausal women, diagnosed with mild-moderate SDB. Intervention Transdermal estradiol and oral micronized progesterone. Measurements and results Subjects underwent polysomnography (PSG) on four occasions: a screening/adaptation night; a baseline night on no HRT; and two nights on HRT: one night after 7 to 12 days on estrogen plus placebo followed by a second night after 7-13 days on estrogen plus progesterone. The PSG was performed with a Sandman computerized PSG system using a standard clinical montage. Modified sleep diaries were used in the baseline week and throughout the study period. Mood was measured with the 20-item version of the Positive and Negalive Affect Schedule (PANAS). Estrogen monotherapy was associated with a significant reduction in the overall apnea-hypopnea index (AHI) (from a mean of 22.7 events per hour at baseline to a mean of 12.2 events per hour), but the AHI reduction on estradiol plus progesterone relative to baseline was not statistically significant (AHI=16.2 events per hour). Similar results were found for the percentages of total sleep time and of total non-rapid eye movement sleep time with oxygen saturation less than 90%. Estrogen, neither alone nor in combination with progesterone, significantly altered PSG- or diary-based measures of total sleep time, time to sleep onset, or time awake after sleep onset. Conclusions While the data are preliminary and based on a small number of subjects, estrogen appeared to have a substantial beneficial effect on measures of SDB in postmenopausal women. Overall, no additional benefit was seen with the addition of progesterone. In fact, progesterone attenuated the beneficial effects of estrogen in 4 out of the 6 participants.

Objective: To determine the metabolic and reproductive effectiveness of rosiglitazone in polycystic ovary syndrome (PCOS). Design: Case report. Setting: Academic clinical practice and General Clinical Research Center. Patient(s): A 25-year-old woman with PCOS. Intervention(s): Rosiglitazone maleate, 4 mg daily for 5 months until conception. Main Outcome Measure(s): Insulin sensitivity by steady-state plasma glucose technique; serum androgens, progesterone, and hCG; and pelvic ultrasound images. Result(s): Rosiglitazone treatment for 5 months improved insulin sensitivity, lowered serum free testosterone, and resulted in spontaneous ovulation and conception. Conclusion(s): Rosiglitazone is a promising insulin sensitizer for treatment of PCOS. Clinical trials are warranted.

Insulin-like growth factor binding proteins (IGFBPs) are believed to modulate the actions of IGF-I and IGF-II at the cellular level. We have examined, by Western ligand blot analysis, the IGFBP profiles in follicular fluid (FF) from patients with polycystic ovarian syndrome (a disorder of ovarian folliculogenesis), compared to FF from atretic and developing (estrogenic) follicles from normally cycling women. IGFBPs with apparent mol wts (Mr) of 41.5, 38.5, 31, 28, and 24kDa were detected in PCOS FF. The profile of IGFBPs in PCOS FF was indistinguishable from that seen in atretic follicles in cycling women. However, higher levels of the 31, 28, and 24kDa IGFBPs were observed in PCOS FF, compared to healthy, estrogenic follicles. Using specific antisera, the 41.5 and 38.5kDa IGFBPs were identified as IGFBP-3, and the 31kDa IGFBP as IGFBP-2. IGFBP-1, however, was not appreciably detectable in PCOS FF, by Western ligand blotting. Endoglycosidase F treatment of FF decreased the Mr of the 28kDa IGFBP to 24kDa, and neither the 28kDa nor the 24kDa IGFBP was immunoprecipitated by antibodies to IGFBP-1, -2, or -3. Elevated levels of 28kDa and 24kDa IGFBPs in PCOS FF may represent glycosylated and core forms of IGFBP-4. The data presented herein show that in PCOS FF, as well as in FF from atretic follicles from normally cycling women, IGFBP-2 and 28 and 24kDa IGFBPs are present in greater amounts, compared to levels in FF from healthy, developing, estrogenic follicles. One or more of the IGFBP species elevated in atretic and PCOS follicles may bind IGFs in FF, thereby inhibiting IGF action on the granulosa during normal folliculogenesis.

I. Introduction II. Insulin and Insulin Receptor A. Structures of insulin and insulin receptor B. Presence of insulin and insulin receptor in the ovary C. Insulin action and the ovary D. Summary III. IGFs and Their Receptors A. IGF peptides and receptors B. Expression of IGFs and IGF receptors in the ovary C. Role of IGFs in ovulatory function and steroidogenesis D. Summary IV. IGF-Binding Proteins (IGFBPs) and Proteases A. Structural relationships among IGFBPs B. IGFBP expression in the ovary C. IGFBP proteases in the ovary D. IGFBP actions in the ovary E. Role of IGFBPs in follicular development and atresia F. Summary V. Polycystic Ovary Syndrome (PCOS) A. Clinical features B. Theories of pathogenesis C. Insulin resistance in PCOS D. Alterations of IGFs and IGFBPs in PCOS E. Summary VI. The Insulin-Related Ovarian Regulatory System: Implications for Therapy A. Treatment of PCOS B. Therapeutic use of IGF-I and IGF-II C. Use of GH in ovulation induction VII. Summary and Conclusions

The remarkably coordinated changes that occur in the female reproductive system during the menstrual cycle are unparalleled by any other integrated organ system in the body. The predictable and precise cyclic changes in this system set the stage for ovulation of generally a single oocyte from the ovary, its fertilization, nourishment, and transport in the oviduct, and implantation in the endometrium (Figure 1). In the absence of implantation, the ovarian corpus luteum undergoes regression, and the endometrium is shed as the menses. These events occur prior to a repeat performance in each organ in a subsequent cycle, with the single-minded goal of successfully establishing a pregnancy. In women, dysfunctions in ovarian follicle development, oocyte maturation, the process of ovulation, ovum pickup by and transport of gametes and an embryo through the Fallopian tubes, and nonreceptivity of the endometrium to implantation all have a common endpoint of unsuccessfully establishing a pregnancy. Seekers of contraception have exploited several of these possibilities, however, to couples desiring fertility, abnormalities in one or more of these processes (as well as in the male partner) can pose formidable barriers to achieving their goals. In addition to an impact on fertility, dysfunction in the female reproductive system can lead to other sequelae. Anovulation, resulting in no progesterone to oppose the effects of estradiol, predisposes women to dysfunctional uterine bleeding, endometrial hyperplasia, and/or endometrial cancer. Blocked Fallopian tubes can result in severe lower abdominal pain, and poorly developed endometrium can result in abnormal uterine bleeding and repetitive miscarriage. Endometriosis is a benign gynecologic condition in which endometrial tissue is found outside of its normal location, mainly on the ovaries and in the cul de sac. It responds to changes in circulating steroids and is associated with severe dysmenorrhea (pain with menses) and infertility. Another member of the system, the uterine myometrium (Figure 1), is most commonly thought of as an active participant in the process of labor and as a structural bystander in the nonpregnant state, aside from its potential contributions to dysmenorrhea. However, benign smooth muscle tumors of this compartment of the female reproductive tract, called leiomyomas or “fibroids,” often impair fertility and have other side-effects that are detrimental to women's health, including discomfort, excessive uterine bleeding and repetitive miscarriage. These unwelcome intruders comprise a leading cause of hysterectomy in women of reproductive age. Clearly, mechanisms regulating the processes at work for normal reproductive function are critical to continuation of the species and for the well-being of women. These processes involve auto- para- and/or juxtacrine interactions of growth modulators. This chapter reviews what is currently known about growth factors and cytokines in normal ovarian follicle development as well as in abnormal development (in polycystic ovarian syndrome [PCOS]), in oviductal function, in endometrial development, implantation, and endometrial shedding, in endometriosis, and in the growth of uterine leiomyomas. Our information is at best incomplete, which prompts us to propose models for the potential roles of growth factors and related peptides in the pathogenesis of these processes. Some systems have been more extensively studied than others due to tissue availability. Most systems have also been extensively studied in animal models, although some do not have natural homologues in most animals (e.g., PCOS, endometriosis, and uterine fibroids). Where appropriate we have made reference to animal models, although the primary focus of the chapter is on growth modulators in the human female reproductive system in health and disease.

OBJECTIVE: To learn about the current practice and utilization of oocyte cryopreservation (OC) among US ART programs. DESIGN: Cross-sectional survey. MATERIALS AND METHODS: A national conference on third-party reproduction in early 2013, a 1-page survey questionnaire was offered to all attendees. Descriptive statistics were compiled. RESULTS: Of the 74 ART programs with representatives attending the conference, 32 (43%) completed the survey, from 19 states with broad geographic and program size representation. 24 (75%) of these programs currently offer OC; 5 plan to do so in the next year. Over 90% stated they offer OC for elective fertility preservation and for cancer patients; 58% offer OC for donor eggs and at retrieval for IVF. The majority had no age limits for OC in cancer patients; for elective OC, 88% had no upper age limit or a limit of 40 yr or older. Most programs reported very low OC volume, with interquartile ranges of 0-10 annual retrievals with OC and 0-2 embryo transfers (ET) after prior OC. Only 3 programs had experience of bothR 25 retrievals with OC andR 10 ETafter OC. 87% of programs have onsite cryostorage for oocytes; only 12% reported that their storage consents are time-limited. Only 36% reported a pregnancy with ET after non-donor cryopreserved oocytes; 85% had a pregnancy with cryopreserved donor oocytes. The majority have contracted with an outside donor egg bank. 72% (100% of responses) stated they require STD screening before non-donor OC. 50% of programs advertise elective OC on their website. Insurance plans in mandated states do not cover OC even for cancer patients. CONCLUSION: Declared no longer experimental by ASRM in 2012, OC practice and utilization in the USA are still in their infancy despite high adoption rate. Common age limits set by programs for elective OC do not appropriately reflect oocyte biology.

Follicular development within the ovary (Fig. 15.1) is independent of gonadotropin action until the early antral stage. after which growth and steroidogenesis are dependent upon the presence of follicle-stimulating hormone (FSH) and luteinizing hormone (LH) (1, 2). During the luteal-follicular transition and under FSH action, follicular recruitment occurs. In the early follicular phase, as FSH levels increase, follicles grow to about the 4- to 6-mm stage, and, in the mid-follicular phase as FSH levels fall, one follicle gains dominance and the remainder of the cohort begins to undergo atresia (2, 3). It has been suggested that production of estradiol (E2) in sufficient amounts is essential for further follicle development and the prevention of atresia (4), and only in the follicle that has gained dominance is a substantial increase in granulosa aromatase gene expression and estradiol production observed (5). Enhancement of FSH action by local growth modulators is believed to be crucial for the major increase in aromatase activity in the follicle gaining dominance and for its growth, during declining serum levels of FSH. Mechanisms underlying follicular selection remain unknown, although atresia of the remaining cohort is effected by apoptotic mechanisms, which may also be under the control of growth factors and related peptides (3). In polycystic ovarian syndrome (PCOS), a disorder of anovulation, the initial stages of follicular development (i.e., recruitment and growth to the small antral stage) are not impaired, although selection of a dominant preovulatory follicle does not occur (Fig. 15.1).

IGFs function as co-gonadotropins in the ovary, facilitating steroidogenesis and follicle growth. IGFBP-1 to -5 are expressed in human ovary and mostly inhibit IGF action in in vitro ovarian cell culture systems. In the clinical disorder of polycystic ovarian syndrome (PCOS), which is characterized by hyperandrogenemia, polycystic ovaries and anovulation, follicles have a higher androgen: estradiol (A : E2) content and growth is arrested at the small antral stage. In the PCOS follicle, follicle stimulating hormone (FSH) and IGF levels are in the physiologic range, and even in the face of abundant androstenedione (AD) substrate, aromatase activity and E2 production are low. When PCOS granulosa are removed from their ovarian environment, they respond normally or hyperrespond to FSH. It has been postulated that an inhibitor of IGF's synergistic actions with FSH on aromatase activity may be one (or more) of the IGFBPs, which contributes to the arrested state of follicular development commonly observed in this disorder. High levels of IGFBP-2 and IGFBP-4 are present in follicular fluid (FF) from androgen-dominant follicles (FFa) from normally cycling women and in women with PCOS. This is in marked contrast to the near absence of these IGFBPs in estrogen-dominant FF (FFe), determined by Western ligand blotting. Regulation of granulosa-derived IGFBPs is effected by gonadotropins and insulin-like peptides. In addition, an IGFBP-4 metallo-serine protease is present in FFe, but not in FFa in ovaries from normally cycling women and those with PCOS, although the IGFBP-4 protease is present in PCOS follicles hyperstimulated for in vitro fertilization. Recent studies demonstrate that IGF-II in FFe is higher than in FFa' whereas IGF-I, IGFBP-3 and IGFBP-1 levels do not differ, underscoring the importance of local IGF-II production by the granulosa and the importance of IGFBP-4 and IGFBP-2 in regulation of IGF-II action within the follicle during its developmental pathway as an E2- or A-dominant follicle. In the androgen-treated female-to-male transsexual (TSX) model for PCOS, IGF-I, IGF-II, IGFBP-3 and IGFBP-1 levels do not differ.

Publisher Summary Insulin-like growth factor (IGF)-I and IGF-II, IGF receptors, and IGF-binding proteins (IGFBPs) are all present within the human follicle, and IGF-II is produced by granulosa cells (GC). IGFs augment gonadotropin stimulated steroidogenesis by both theca and granulosa cells in culture. All known IGFBP species except IGFBP-6 antagonize the actions of IGF-I on GC, presumably by competing with IGF receptors for binding to IGF ligands. This chapter provides an overview of the examination of hypothesis that in human granulosa cells, activin-A stimulates expression of messenger RNA (mRNA) coding for one or more IGFBP species. The findings of the experiment discussed in this chapter lend support to the hypothesis that the inhibition of steroidogenesis by activin-A is mediated by an increase in medium IGFBP-5, resulting in antagonism of the steroidogenic effects of IGF peptides. The experiments described in this chapter show that IGFBP-5, which is localized to granulosa cells in atretic antral follicles in the human and rat, may be a mediator of follicular atresia. Activin-A may promote atresia by increasing expression of IGFBP-5, with resultant neutralization of IGF-I and/or IGF-II.