Current Women's Health Reviews

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Current Women’s Health Reviews Volume 6, Number 2, May 2010

Current Concepts in Female Infertility Management (Part I) Guest Editors: Sajal Gupta and Ashok Agarwal Contents

Biography of Contributors 68

Preface 71

Management of Infertility:

Low-Cost Infertility Management 73 Ahmed Abdel-Aziz Ismail and Sharif Hassan Sakr

Female Infertility and Antioxidants 84 Lucky H. Sekhon, Sajal Gupta, Yesul Kim and Ashok Agarwal

Role of Oxidative Stress in Polycystic Ovary Syndrome 96 Joo Yeon Lee, Chin-Kun Baw, Sajal Gupta, Nabil Aziz and Ashok Agarwal

Polycystic Ovary Syndrome in Adolescents 108 Mohamed Yahya Abdelrahman, Mohamed A. Bedaiwy, Elizabeth A. Kiracofe and Marjorie Greenfield

Advanced Management Options for Endometriosis 123 Jashoman Banerjee, Mona H. Mallikarjunaiah and John M. Murphy

Prevention and Management of Ovarian Hyperstimulation Syndrome 130 Botros Rizk and Christopher B. Rizk

Non-Surgical Treatment Options for Symptomatic Uterine Leiomyomas 146 Julierut Tantibhedhyangkul and Millie A. Behera

Contd…..

Surgery:

Surgical Management Options for Patients with Infertility and 161 Endometriosis Michelle Catenacci and Tommaso Falcone

Surgical Strategies for Fertility Preservation in Women with Cancer 167 Mohamed A. Bedaiwy, Kristine Zanotti, Ahmed Y. Shahin, Mohamed Yahya Abdel Rahman and William W. Hurd

Innovative Roles for Surgical Robotics in Reproductive Surgery 177 Ehab Barakat, Mohamed Bedaiwy and Tommaso Falcone

Surgical Management of Müllerian Duct Anomalies 183 Ali M. El Saman, Jennifer A. Velotta and Mohamed A. Bedaiwy

68 Current Women’s Health Reviews, 2010, 6, 68-70

BIOGRAPHY OF CONTRIBUTORS

Jashoman Banerjee, MD

Jashoman Banerjee is a trained Ob-Gyn specialist from India. He is currently graduating as a chief resident in Ob-Gyn from the University of Toledo Medical Center in Toledo, Ohio. Dr. Banerjee will start his fellowship in reproductive endocrinology and infertility at Wayne State University. He has actively participated in extensive research involving endometriosis and infertility at the Cleveland Clinic Foundation. His other research interests are to explore effects of oxidative stress on oocyte quality and ovarian cryopreservation as means of fertility preservation. He has published his research work in peer reviewed journals.

Tommaso Falcone, MD, FRCS(C), FACOG Tommaso Falcone is the Professor and Chairman of the Department of Obstetrics-Gynecology at the Cleveland Clinic. Dr. Falcone is certified by the American Board of Obstetrics and Gynecology in general obstetrics and gynecology, as well as reproductive endocrinology. He is also certified by the Royal College of Physicians and Surgeons of Canada. Dr. Falcone has published more than 200 scientific papers, abstracts, and book chapters. He is co-author of a laparoscopic surgery atlas and is an ad hoc reviewer of many journals. He serves on the editorial board of the Journal of Gynecologic Surgery.

Majorie Greenfield, MD Marjorie Greenfield is a board-certified obstetrician-gynecologist and fellow of the American College of Obstetrics and Gynecology. Dr. Greenfield has practiced and taught obstetrics and gynecology since 1987, currently as Professor and Division Director of General Obstetrics and Gynecology at MacDonald Women’s Hospital, University Hospitals Case Medical Center. In addition to clinical practice and teaching, she writes extensively for the Web and had several publications and authored books.

William W. Hurd, MD

William W. Hurd is a Professor of Reproductive Biology and holds the Lilian Hanna Baldwin en- dowed Chair in Gynecology and Obstetrics at Case Western Reserve University School of Medicine in Cleveland, Ohio. He is Chief of Reproductive Endocrinology Infertility at University Hospitals Case Medical Center. For two decades, he has been an active researcher in the area of laparoscopic safety, and is the past President of the Society of Reproductive Surgeons. Currently, Dr. Hurd is a member of the American College of Surgeons Liaison Committee for Obstetrics and Gynecology and is a member of the Board of Directors of the Society of Gynecologic Surgeons.

Lucky H. Sekhon, MD Lucky H. Sekhon is a graduate of Royal College of Surgeons in Ireland (RCSI). She obtained her Bachelors of Science in Biology from McGill University in Montreal, Canada. Her major research interests lie in the field of reproductive endocrinology and infertility.

Botros Peter Rizk, MD Botros Rizk is Professor and Chief of the Division of Reproductive Endocrinology and Infertility of the Department of Ob-Gyn at the University of South Alabama. His main research interests include the modern management, prediction and the genetics of ovarian hyperstimulation syndrome (OHSS), as well as the role of vascular endothelial growth factor and interleukins in the pathogenesis of severe OHSS. He has authored more than 300 peer-reviewed published papers, book chapters and has edited and authored ten medical textbooks on various topics in reproductive medicine.

Ali M. El Saman, MD Ali M. El Saman received his medical degree from Assiut University School of Medicine in Egypt. He is an Associate Professor of Obstetrics and Gynecology. He has special interests in innovative medical technologies especially those related to endoscopy and has got five patents related to medical innovations and is registering for another 5 patents. His clinical and research activities are concentrated mainly on innovative treatment modalities of mullerian duct anomalies and was successfully generated 16 peer-reviewed publications, being the first author in the majority.

Julierut Tantibhedhyangkul, MD Julierut Tantibhedhyangkul is a reproductive endocrinologist at the Cleveland Clinic in Cleveland, Ohio. Dr. Tantibhedhyangkul earned her medical degree from Siriraj Hospital, Mahidol University in Bangkok, Thailand. She completed her obstetrics and gynecology residency at the University Hospitals of Cleveland, Case Western Reserve University in Cleveland, Ohio, followed by fellowship training in reproductive endocrinology and infertility at Duke University Medical Center in Durham, North Carolina. She has joined the Obstetrics, Gynecology and Women’s Health Institute at the Cleve- land Clinic since 2008. Her special interests include infertility, polycystic ovary syndrome and uterine fibroids.

Michelle Catenacci, MD Michelle Catenacci is a graduate from Wayne State University School of Medicine. After medical school, she completed a four year residency training program in Obstetrics and Gynecology at Case Western Reserve University MetroHealth/Cleveland Clinic Foundation Program. Currently, Dr. Catenacci is a fellow in Reproductive Endocrinology and Infertility at the Cleveland Clinic Founda- tion. Her research interests include fertility preservation for cancer patients and endometriosis related infertility.

Sajal Gupta, MD Sajal Gupta is an Ob-Gyn specialist with a special interest in the field of reproductive endocrinology and infertility. She is a member of Cleveland Clinic Professional Staff and serves as the Assistant Co- ordinator of Research at the Center for Reproductive Medicine. She has published over 40 original articles, invited reviews and chapters. Dr. Gupta serves as a reviewer for Human Reproduction, Fertil- ity & Sterility, and European Journal of Obstetrics and Gynecology. She is a co-investigator or principal investigator on 8 research grants. Her current research interests include the role of oxidative stress in female infertility, endometriosis, assisted reproductive techniques and gamete cryobiology.

70 Current Women’s Health Reviews, 2010, Vol. 6, No. 2 Biography

Ahmed Abdel Aziz Ismail, MD Ahmed Abdel Aziz Ismail graduated with a Baccalaureate of Medicine and Surgery from Alexandria University. He completed his masters in obstetrics and gynecology with a 1st on order from Alxandria University, Egypt. He has been a Professor of Obstetrics and Gynecology at University of Alexandria from 1993 till date. He is a member of British Medical Ultrasound Society, Middle East Fertility Society and Egyptian Fertility Society. He has received several awards such as award in family planning from the Academy of Scientific Research and Technology, Egypt and award for scientific research promotion.

Ashok Agarwal, Ph.D, HCLD Ashok Agarwal is a Professor in the Lerner College of Medicine at Case Western Reserve University and the Director of Center for Reproductive Medicine, and the Clinical Andrology Laboratory at The Cleve- land Clinic, Cleveland Ohio, United States. He has published over 500 scientific articles and reviews and is currently editing 8 text books in different areas of andrology/embryology, male and female infertility and fertility preservation. His research program is known internationally for its focus on disease oriented cutting edge research in the fileld of human reproduction. His team has presented over 700 papers at national and international meetings. More than 200 scientists, clinicians and biologists have received their training in Ashok’s Lab. His long term research interests include unraveling the role of oxidants- antioxidants, genomic integrity, and apoptosis in the pathophysiology of male and female reproduction.

Preface Current Women’s Health Reviews, 2010, Vol. 6, No. 2 71

PREFACE This Special Issue on "Recent Advances in Reproductive Endocrinology and Women’s Health" published by Current Women’s Health Reviews is a two–volume series on both cutting edge and contemporary topics of importance to general gynecologists and specialists alike. The first volume “Current Concepts in Female Infertility Management” is dedicated to important topics such as endometriosis, PCOS and fibroids, which affect millions of women worldwide. Professor Abdel-Aziz Ismail discusses low-cost infertility management options. His comments—that we should not fail to specify the best cost-effective regimen for our patients and that evidence-based choices can be made without compromising success rates--are very pertinent. Dr. Sekhon has written an excellent and comprehensive chapter analyzing the role that antioxidant supplementation plays in improving female fertility and pregnancy outcomes. This article reviews the current literature on the effects of antioxidant therapy and elucidates whether antioxidant supplementation is useful in preventing and/or treating infertility and poor pregnancy outcomes related to various obstetric and gynaecologic conditions. There are two articles on PCOS in this special issue by researchers from CASE Medical Center, Cleveland Clinic and Liverpool Women’s Hospital. The article on adolescent PCOS characterizes polycystic ovary syndrome as a heterogeneous endocrinopathy that affects girls and women during their reproductive years. The exact etiology of PCOS is still a topic of debate. This chapter explains why PCOS is a multifactorial syndrome, involving genetic, endocrinologic, metabolic and environmental factors and illustrates that further research on the basic pathophysiology of PCOS and the roles of the different etiologic components will aid in the understanding of this condition and help clinicians in their management of adolescents with PCOS. The second article on PCOS, written by Lee et al, substantiates the etiological relationship between PCOS and metabolic syndrome. The authors report a lack of clarity on the role oxidative stress plays in the pathogenesis of PCOS and suggest that there is an association amongst the oxidative microenvironment of the ovarian tissue and ovarian steroidogenesis and follicular development. The article on Advanced Management Options for Endometriosis focuses on new treatment options for endometriosis while it also briefly describes the pathogenesis, diagnosis and controversies of existing treatment modalities. According to the authors, assisted reproduction holds promise in patients with advanced endometriosis. They highlight that most of the newer therapies are still experimental, but results in animal models show promise, which have served as an impetus for conducting human trials. Professor Botros Rizk has written an excellent and authoritative chapter on OHSS that explains how this syndrome remains the most serious complication of ovulation induction. According to the authors, OHSS could be successfully prevented in the future if a high index of suspicion is exercised and methodical steps are taken. Newer technologies such as in vitro maturation might completely eliminate its occurrence. Dr. Tan and colleagues discuss the limitations of current treatment options for women with symptomatic uterine fibroids such as mechanical methods of excision, ablation, and devascularization. According to the authors, increased use of conservative, non-surgical procedures will expand patient eligibility and allow safe and effective long-term resolution of fibroid-related symptoms. In addition, four articles by leading experts in the field of reproductive health cover various women’s health issues: • The article on robotics in reproductive surgery, written by Drs. Barakat and Falcone, evaluates the current application of robotics in reproductive surgery. The article highlights the advantages of robotic surgery over conventional laparoscopic surgery. • Drs. Catenacci and Falcone highlight the pathogenesis of endometriosis and review the current clinical evidence for treatment in regards to improving fertility outcomes. The authors comment that as treatment evolves in this direction, the role diagnostic laparoscopy plays in infertile patients is becoming uncertain. Specifically, the value of diagnostic laparoscopy for patients who do not suffer from pain and have normal imaging studies is in question. Due to the controversial effects that Stage I/II endometriosis has on infertility, recommendations are moving away from performing diagnostic laparoscopies in infertile patients. Ultimately, this will lead to fewer surgeries and increased medical management for patients with infertility-related endometriosis. • Drs. Bedaiwy and Hurd discuss that the future of fertility preservation for women of reproductive age with cancer is likely to involve removal of ovarian tissue, followed by in vitro follicle culture of the tissue and removal of oocytes. The article highlights that more effective techniques are being developed for cryopreservation of both oocytes and embryos. The authors explain that the surgical approaches for fertility preservation can also be used for reproductive-age women diagnosed with cancer who require pelvic irradiation or systemic chemotherapy. • Dr. Saman and colleagues highlight the available treatment options for müllerian duct anomalies with a special emphasis on simple and advanced surgical approaches. Surgical options are presented based on a novel treatment plan classification system adapted from the American Fertility Society classification of müllerian duct anomalies. The authors have taken care to include all previously termed unclassified anomalies as well as the important category of longitudinal fusion defects. Important 72 Current Women’s Health Reviews, 2010, Vol. 6, No. 2 Preface diagnostic approaches are discussed with special emphasis on detection of associated anomalies of the urinary system and other relevant systems We hope that the readers will enjoy reading the latest, informative and authoritative articles by some of the most recognized and prolific leaders in reproductive endocrinology from across the globe. We would like to extend our appreciation to all the authors for their hard work and valuable contributions. We are indebted to our colleagues and associates in Cleveland Clinic for their valuable contributions. We gratefully acknowledge the fabulous support of Ms. Amy Slugg Moore (Manager, Medical Editing Services) for her help. We are grateful to Prof. Jose Belizan, Editor in Chief of Current Women’s Health Review, for his constant encouragement and support. We are most thankful to the editorial team of CWHR for their support and hard work. Finally, we extend our sincere thanks for the opportunity to serve as a Guest Editor on the special issue of CWHR. We are confident that readers will benefit from the latest knowledge incorporated in these valuable articles.

Sajal Gupta, MD, TS (ABB) Ashok Agarwal, PhD, HCLD (Co-Guest Editor) (Guest Editor) Assistant Coordinator & Project Staff Professor, Lerner College of Medicine Center for Reproductive Medicine and Case Western Reserve University Glickman Urological and Kidney Institute & Director, Andrology Laboratory and OB/ GYN and Women’s Health Institute Reproductive Tissue Bank Cleveland Clinic Director, Center for Reproductive Cleveland, OH 44195 Medicine Staff, Glickman Urological USA & Kidney Institute and Ob-Gyn Tel: 216-444-9485 and Women's Health Institute Fax: 216-445-6049 Cleveland Clinic E-mail: [email protected] Cleveland, OH 44195 USA Tel: 216-444-9485 Fax: 216-445-6049 E-mail: [email protected]

Current Women’s Health Reviews, 2010, 6, 73-83 73 Low-Cost Infertility Management

Ahmed Abdel-Aziz Ismail* and Sharif Hassan Sakr

Department of Obstetrics and Gynecology, University of Alexandria, Egypt

Abstract: Objectives: To review the evidence regarding the magnitude of infertility as well as the various proposed approaches highlighting the use of the most cost-effective investigatory and treatment regimens. Data Sources and Methods: Medline and Pubmed were searched for all relevant papers published between 1975 and 2009 using a combination of the following keywords: ‘affordable, cost-effective, infertility, IVF, investigations, treatment’. Results: In an era of evidence-based medicine, we often fail to specify the most cost-effective regimen for an infertile couple. Setting a predetermined algorithm can help simplify the management approach. Prevention and education are important as well. Conclusions: A cost-effective approach that does not compromise success rates should be offered to all couples seeking help for infertility. This includes making evidence-based choices when choosing investigatory tools and treatment options. The “patient- friendly” regimen should not necessarily be equated with “minimal stimulation IVF” because to provide the best medical care for patients, it should be evidence-based and without bias. The ESHRE Task Force is working to tackle the challenge of providing a cost-effective simplified assisted reproduction program in developing countries. Keywords: Infertility, low cost, cost-effective, cheap, investigations, treatment, IVF.

LOW-COST INFERTILITY MANAGEMENT national study found that 64% of infertile women in sub- Saharan Africa had some sort of infection (vaginal and/or Magnitude of the Problem cervical), which is about double the rate of other regions. Infertility is defined as the inability to conceive after at Tubal problems and other infection-related diagnoses also least 1 full year of unprotected sexual intercourse [1-3]. It is are associated with postpartum and post-abortion complica- estimated that worldwide, between 70 and 80 million tions. The results of the WHO study suggest that repeated couples suffer from infertility, and most of these are pregnancies play a greater role in the etiology of infertility in residents of developing countries, including the Middle East Africa and Latin America, while repeated abortions are more [4, 5]. important in Asia and developed countries. Health care practices and policies also contribute to infertility, most The prevalence of subfertility and infertility differs notably unhygienic obstetric practices, which can lead to tremendously between developing countries. The figures postpartum infections. Septic abortions and their complica- are as low as 9% in some African countries such as Gambia tions are another important factor [12]. [6] and as high as 35% in Nigeria [7, 8]. The reported international prevalence of infertility ranges from 4% to 14% Inappropriate gynecological practices also may also lead with a consensus estimate of 10% among married and to infertility. In Egypt, for example, physicians routinely cohabiting couples [9-11]. misdiagnose cervical erosion and then treat it inappropriately with cervical electrocautery, potentially causing infertility in What accounts for the variation in infertility levels? It is the process [13]. important to understand that there is a core of about five In the Middle East, the prevalence of infertility varies percent of all couples who suffer from anatomical, genetic, between 10% and 15% in married couples because of a high endocrinological, and immunological problems that cause prevalence of post-partum infection, post-abortive infection, infertility [10]. The remaining couples are infertile largely iatrogenic infertility, schistosomiasis and tuberculosis (TB) because of preventable conditions such as sexually [14, 15]. Bilateral tubal occlusion is the most common transmitted infections (STIs), parasitic diseases, health care underlying cause of infertility following such infections [12, practices and policies, and exposure to potentially toxic 16]. substances in the diet or the environment. Tubal and pelvic infertility are the leading causes of Worldwide, STIs are the leading preventable cause female infertility in many countries in the Middle East. Other of infertility. A World Health Organization (WHO) multi- infectious and parasitic diseases—and the medications used to treat them—contribute to infertility. For example, in India,

where 40% of the population is exposed to TB, genital TB *Address correspondence to this author at the Department of Obstetrics and Gynecology, University of Alexandria, Egypt; Tel: 002 034962020; contributes to female infertility [17]. In Africa, schistoso- Fax: +203-4299986; E-mail: [email protected] miasis, malaria, and sickle-cell disease all contribute to

1573-4048/10 $55.00+.00 © 2010 Bentham Science Publishers Ltd. 74 Current Women’s Health Reviews, 2010, Vol. 6, No. 2 Ismail and Sakr infertility [18]. It has been proposed that the success of occurred during use of the algorithm than in between IVF malaria-control programs may help explain a reduction in cycles [28]. Although not universally acceptable, this infertility rates seen in Tanzania over the past 20 years [19]. algorithm has proven acceptable to many providers in the United States and has been accepted by the insurance In Nigeria, where hernia repairs are routinely performed by inexperienced surgeons, there is a pattern of male industry in states with mandated insurance coverage as the basis for contractual agreements [29]. infertility due to vascular injuries sustained during these procedures [20]. Increasingly, men and women in develop- Preliminary results from a prospective study analyzing a ing countries face exposure to environmental and workplace cohort of patients who used this algorithm support the pollution, which can play a role in infertility. outcome data in Fig. (1), although there are considerable Infertility is a major problem in these countries and drop-out rates at each treatment step. Obviously, this causes extensive social and psychological suffering. Provid- decreases the chances of conception [26]. ing infertility treatment in resource-poor countries should be To design a cost-effective, medically appropriate part of an integrated reproductive care program that includes evaluation and treatment plan, we must consider the patient's family planning and motherhood care [21]. age. While there is little necessity to initiate aggressive It is important to note that the problem of infertility is not therapy for the 20 year old with unexplained infertility, those limited to developing countries. Nearly all European older than 35 years deserve a more aggressive approach. countries are currently experiencing long-term downtrends in fertility and, consequently, a reduction in the proportion of LEVEL 1 OF CARE working-age individuals [22]. As a result, many govern- 1. Prevention ments around the world are currently providing incentives to their citizens to promote parenthood [23]. However, to date, It is often argued that in the Middle East, where there are there has been little recognition of the role of infertility many low income and middle income countries, the solution services in these programs. Therefore, there is mounting to the problem of infertility is in the prevention of post- pressure on governments to enhance their “baby-friendly” partum infection, unsafe abortion, iatrogenic infertility, TB, policies as a measure to reverse future reductions in fertility schistosomiasis and STIs, which are preventable causes of [24]. infertility [14]. Reducing the incidence of postpartum infections can be achieved through safer birth practices, The limited availability of resources mandates their including the training of traditional birth attendants on how judicious use. The definition of “better care” should not be to used hygienic practices during deliveries, and by equated with “aggressive care.” More aggressive care may developing mechanisms to help women with potentially result in a quicker establishment of pregnancy and higher complicated deliveries to deliver in clinics. pregnancy rates per treatment attempt. However, they may also result in a higher incidence of multiple implantations. The most effective ways to reduce postabortion infec- Better care should be defined as a balance between attempts tions are: to achieve pregnancy quickly and efficiently with as low of a (1) Promoting family planning, because effective contracep- multiple implantation rate as possible [25]. tion eliminates the need for abortion; Cost-effective care must also satisfy patient demands. (2) Providing treatment for postabortion complications at a High-quality patient care may not necessarily lead to patient variety of health facilities. satisfaction if the patients’ expectations are not met. Once these expectations are defined, then they can be met by the Where other diseases are a common cause of infertility, provider or if not, addressed with the patient in the hopes aggressive campaigns to control their spread may have an that the expectations can be redirected. Failure to do so will impact. For example, reducing the incidence of TB or result in high drop-out rates from treatment- a wasteful use treating affected women before TB spreads to the genital of resources [26]. tract would prevent many cases of female infertility in India [17]. The ultimate goal is to create an approach that provides the greatest chance for pregnancy and birth while using Likewise, testicular biopsies of Nigerian and Ghanaian limited resources in the most cost-effective fashion. To men, which found a high incidence of inflammatory lesions, fulfill that goal, simplified treatment algorithms that attempt suggest that efforts to control and treat schistosomiasis to minimize costs at every step of the management process would reduce levels of both male and female infertility have been proposed. Norbert Gleicher has proposed an in these countries [18]. While preventing reproductive algorithm that would help 80% of the couples who proceed tract infections may be the most effective way to reduce through all the treatment steps to conceive, provided there infertility problems in developing countries, this long-term are no drop-outs during any of the treatment steps (see Fig. strategy does not address the need for immediate infertility 1) [27]. treatment.

Interestingly, a prospective randomized trial that 2. Judicious/Cost-Effective use of Diagnostic Work Up/ compared this algorithm to the use of in vitro fertiliza- Monitoring tion (IVF) as an initial infertility treatment showed that it was more cost effective and efficient, largely due to a Any one of a long list of tests can be used to determine larger number of “treatment independent” pregnancies that the cause of infertility during the diagnostic evaluation of Low-Cost Infertility Management Current Women’s Health Reviews, 2010, Vol. 6, No. 2 75

Fig. (1). Treatment algorithm for infertility and expected pregnancy rates [27]. infertile couple. Lack of agreement exists, however, among characteristics via CASA is of limited value when opti- trained infertility specialists in regards to which tests have mizing the evaluation of male fertility [31]. good prognostic utility and the criteria of normality of many Previously, the postcoital test (PCT), which assesses of these tests i.e. a universally accepted range of normality, sperm motility in a sample of postcoital cervical mucus, was whether it is for a hormonal level or an imaging technique. considered an integral part of the basic infertility evaluation. Only those tests that are cost effective and correlate directly However, past investigations revealed a poor correlation with the likelihood of conception should be used. These tests between postcoital sperm motility and pregnancy outcome include conventional semen analysis, documentation of [32]. In addition, a 1995 blinded, prospective study found ovulation by measuring midluteal progesterone levels and that there was poor test reproducibility amongst trained assessing uterine factor and tubal patency with hystero- observers, further questioning the validity of the PCT as a salpingography (HSG) or sono-hysterography. diagnostic tool [33]. A comprehensive semen analysis following WHO In 2000, Oehninger, et al., conducted a meta-analysis to guidelines is fundamental at the primary care level if one is determine the diagnostic accuracy and predictive value of to make a rational initial diagnosis and select the appropriate various sperm function assays in couples undergoing IVF. clinical management [30]. Despite its limitations, conven- They assessed the following tests: CASA, acrosome reaction tional semen analysis is the cornerstone for assessment of testing, the zona-free hamster egg penetration test or sperm- male factor infertility; computer assisted semen analysis penetration assay (SPA) and sperm-zona pellucida binding (CASA) is not superior. A study conducted by Krause W. in assays. The results showed that the sperm-zona pellucida 1995 concluded that the determination of elaborate motility binding test and the induced-acrosome reaction assays for 76 Current Women’s Health Reviews, 2010, Vol. 6, No. 2 Ismail and Sakr fertilization outcome had the highest predictive power. On The BBT chart was less accurate at confirming ovulation the other hand, the findings indicated that the SPA had a than urinary LH testing and serum progesterone assessment. poor clinical value when used as a predictor of fertilization. A single serum progesterone assessment in the midluteal Furthermore, the authors stated that there was a real need for phase seemed as effective as repeated serum progesterone standardization and further investigation of the potential measures [43]. clinical utility of CASA systems. The authors concluded In a comparison of low-tech and high-tech methods of that basic semen analysis remains the cornerstone in monitoring CC ovulation induction, it was shown that the evaluation of the male partner and validated sperm urinary detection of the LH surge and vaginal ultrasound functional tests should expand the initial work up as offered no advantage over BBT charts alone in achieving indicated [34]. pregnancy [44]. Female factor infertility is usually assessed by tracking Although endometrial biopsy results were previously ovulation, examining the uterus for malformations/polyps/ used to diagnose luteal phase defects, they do not correlate fibroids, etc. and determining tubal patency and ovarian with fertility status and hence are no longer recommended reserve. When assessing ovarian reserve, patient’s age is one [45]. From the above data, it can be concluded that midluteal of the main determinants; with advancing age, fertility serum progesterone and ultrasound may be the two most declines. This is due to progressive follicular depletion and cost-effective means of documenting ovulation. increased abnormalities in the aging oocytes (oocyte aneuploidy) [35]. Testing includes obtaining a cycle day 3 In a study assessing the feasibility and acceptability of an serum follicle-stimulating hormone (FSH) and estradiol out-patient-based investigation of infertile couples level and performing a clomiphene citrate (CC) challenge (ultrasound, diagnostic hysteroscopy and culdoscopy), the test and/or an ultrasonographic ovarian antral follicle count average time needed to perform these three procedures was [36]. 41.2 minutes. Most patients appreciated the fact that only 1 hospital visit was needed and that the results were A patient with menstrual abnormalities should be immediately available. However, this “One Stop” approach investigated for underlying causes such as polycystic ovarian to the investigation of infertility is not suitable for or desired syndrome, thyroid disease, hyperprolactinemia, and by all infertile couples [46]. hypothalamic causes secondary to weight changes. It is worth mentioning that a group of researchers from Australia 3. Judicious/Cost-Effective use of Medical Treatment/ conducted a cost-savings analysis of a weight loss program Surgery (Endoscopy) for obese infertile women (in Australian dollars). Their results showed that weight loss improved the reproductive Proper utilization of surgical procedures, usually outcome for all forms of fertility treatments and cost endoscopic procedures, represents the single most significant considerably less. Prior to the programme, 67 women had factor in providing cost-effective infertility care [47]. treatment costing a total of A$550 000 for two live births, a Assessment of the uterine contour and tubal patency is an cost of A$275 000 per baby. After the programme, the same integral part of the basic infertility evaluation [36]. Hyster- women had treatment costing a total of A$210 000 for 45 osalpingography is the gold standard for the assessment of babies, a cost of A$4600 per baby [37]. tubal and uterine factors. Along with laparoscopic dye pertubation, it can best assess tubal patency: the concordance Eumenorrhea—normal menstrual cycles by history—is a of HSG with laparoscopic dye pertubation is estimated to be highly accurate marker of ovulation, and anovulatory levels near 90% [48]. of serum progesterone (< 3 ng/mL) are found in only a very small minority of eumenorrheic patients [38]. Obviously, if a Severi F.M. et al. showed that hydrosonography can pregnancy occurs or if an oocyte can be isolated from the accurately evaluate the uterine cavity and any malfor- reproductive tract, it means that a patient is ovulating. But mations, particularly in young women, reaching a diagnostic neither can be used clinically as reference methods for accuracy similar to that of hysteroscopy. They also found predicting or confirming ovulation in infertile women [39]. that the accuracy of hydrosonography is similar to that of HSG, when the two techniques are compared with laparo- Although it is now well accepted that the basal body scopic chromopertubation [49]. temperature (BBT) graph is an unreliable marker for the prediction of ovulation [40], it still could be used as a simple Moreover, Goldberg found that in the evaluation of method for retrospective identification of the presumptive patients with infertility or recurrent pregnancy loss and day of ovulation [41]. Among the numerous parameters used uterine abnormalities, hydrosonography was more accurate to detect the day of ovulation, the identification of the than HSG and provided additional information about uterine luteinizing hormone (LH) surge appears to be the most abnormalities, particularly on the relative proportion of the reliable indicator of impending ovulation [42]. intracavitary and intramyometrial components of submucus myomas [50]. In a 2001 study assessing reliability of ovulation tests in infertile women, Guermandi E., et al. concluded that urinary In a study to determine the feasibility and acceptability of LH was accurate in predicting ovulation with ultrasono- an out-patient based infertility investigation that used a graphy as the standard for detection, but time varied widely screening test for tubal occlusion called hysterosalpingo- (LH surge was detected in urine from 72 hours before contrast sonography (HyCoSy), the results showed that the ovulation to the same day of ultrasonographic disappearance former was a valuable and cost effective alternative to of the follicle). The nadir of BBT predicted ovulation poorly. laparoscopy and the dye test [51]. Low-Cost Infertility Management Current Women’s Health Reviews, 2010, Vol. 6, No. 2 77

The Practice Committee of the American Society for LH was accurate in predicting ovulation. In another study Reproductive Medicine (ASRM 2006) has published conducted by Luciano AA et al. [58], the temporal relation- guidelines for standard infertility evaluation. It includes a ship and reliability of the clinical, hormonal, and ultrasono- semen analysis, assessment of ovulation, a hysterosalpingographic indices of ovulation in infertile women were gram, and, if indicated, tests for ovarian reserve and laparo- assessed. Urine LH testing correlated well with the serum scopy. LH peak, particularly in the evening urine, and predicted ovulation in all patients. In addition, the use of urinary LH The role of laparoscopy in the investigation of infertility surge for the timing of intrauterine insemination (IUI) in has changed over the past decade. Whereas laparoscopy used CC-IUI cycles resulted in a higher pregnancy rate compared to be part of the basic infertility workup, it is now reserved with hCG-induced ovulation [59]. Lastly, it remains to for selected cases. According to the guidelines of the ASRM, laparoscopy should be performed in women with be mentioned that the average cost of the ovulation kits is approximately $0.5-0.8, which highlights its cost effective- unexplained infertility or signs and symptoms of endo- ness. metriosis or when reversible adhesive tubal disease is suspected [36]. A prospective multicenter randomized trial compared in a parallel design the efficacy of CC with rFSH for ovarian The idea of a `one-stop shop' for subfertility investigation is certainly an attractive one for both patients and clinicians hyperstimulation in an IUI program for couples with unexplained or male subfertility of at least 24 months. There alike. It is simply aimed at checking the “Seed, Soil and was no significant difference in live birth rates and multiple Passage” involved in conception and can be performed pregnancy rates between the two groups. It was concluded within an hour. There is evidence to suggest that the use of that unless larger studies demonstrate otherwise, for econo- an ultrasound-based system is not only more acceptable to mic reasons, CC should still be the drug of choice for couples, but it is also more cost-effective and provides diagnostic information of a caliber comparable with that of ovarian stimulation in IUI cycles [60]. more traditional investigative methods. It is diagnostically Patients who fail to conceive after level 1, despite accurate, expeditious and reliable. The HycoSy test can also adequate ovulation (unexplained infertility) or due to failure be performed at the same time if necessary [52]--it is of ovulation with CC, should proceed to level 2 where they minimally invasive and provides both the patient and will be given gonadotrophins for 3 cycles based on the clinician with useful prognostic information. The male assumption that the efficacy of gonadotrophins decreases partner can have a detailed sperm test at the same time. after 2-4 cycles [61]. In agreement with the ‘one stop approach’, Ekerhovd E, A. M. Case, in the Table 1, compared the cost of various et al. also proposed the use of the ultrasound for the treatment regimens for infertility and their success rates. It is assessment of infertility, including the evaluation of tubal clear that the more complicated and expensive treatments are patency [53]. more successful although they may be not be as cost- In the end, it would be fair enough to say that the effective [62]. feasibility of transvaginal ultrasound use, in the infertility In another comparison of the costs of infertility clinic, for the assessment of female factor infertility makes it treatments, IUI, CC-IUI, and hMG-IUI had a similar cost per the most cost-effective tool; i.e. transvaginal ultrasound delivery of between $7,800 and $10,300. All 3 of these replaces the need for assessing ovarian reserve by measuring treatments were more cost-effective than IVF-ET, which had the ovarian volume and the antral follicular count, replaces a cost per delivery of $37,000. The use of IVF in women the need for tubal and uterine factor assessment by with blocked fallopian tubes was more cost-effective than performing hysterosonography, documents ovulation by tubal surgery via laparotomy, which had a cost per delivery follicular scanning and finally, replaces the need for of $76,000 [67]. This study seems to support the proposed hormonal monitoring (estradiol) during ovarian stimulation algorithm, previously described in Fig. (1); i.e.the use of IUI, by measuring the endometrial thickness [54]. Monitoring of CC-IUI, and hMG-IUI before IVF in women with open follicular development in an IVF cycle, as well as the timing fallopian tubes. For women with blocked fallopian tubes, of hCG administration, can be done using sonographic IVF-ET appears to be the best treatment from a cost- criteria with basic inexpensive ultrasound equipment, effectiveness standpoint. thereby avoiding the need for expensive endocrine investigations [55, 56]. In a recent review by J. Collins on the current best evidence for the advanced treatment of unexplained When the results of a standard infertility evaluation are subfertility, he concluded that IVF is superior to FSH/IUI normal, practitioners assign a diagnosis of unexplained treatment, but this benefit is achieved only at considerable infertility. Although estimates vary, the likelihood that all cost, and the evidence is not robust, comprising only a few such test results for an infertile couple are normal (ie, that trials. The small increase in effectiveness with IVF over the couple has unexplained infertility) is approximately 15% FSH/IUI treatment is achieved only at considerable to 30% [57]. incremental cost, whether it is measured per cycle or per In the algorithm proposed by N. Gleicher, in level 1, CC couple. Current best evidence is consistent with a is given for 3 cycles without monitoring ( ovulation kits may progression from low-tech to high-tech treatment, but it is be used ).As previously mentioned, in the study assessing not convincing enough to support a rigid management reliability of ovulation tests in infertile women conducted by protocol; thus a large multi-center factorial trial is needed to Guermandi E., et al. in 2001, it was concluded that urinary 78 Current Women’s Health Reviews, 2010, Vol. 6, No. 2 Ismail and Sakr

Table 1. Indications, Costs, and Success Rates of Commonly Used Infertility Treatments

Treatment Indication Cost Per Cycle($) Success Rate Per Cycle (%)

CC Oligo-ovulation 50-150 10-15 [63]

CC Unexplained 4-6 [64]

CC & IUI Unexplained 150-300 8-10 [64,65]

SO & IUI Unexplained 750-2000 18-20 [65]

IVF Tubal factor 5000-8000

IVF Male factor 40 ( 30 years ) [66]

IVF Endometriosis 35 (30-35) [66]

IVF Unexplained 25(35-39) [66]

IVF and ICSI Male factor 8000-10000 15 ( 40) [66]

CC- clomiphene citrate, ICSI – intracytoplasmic sperm injection, IUI – intrauterine insemination, IVF – in vitro fertilization, SO – superovulation( using gonadotrophins). evaluate the relative value of existing empiric treatments for blister full of multiple follicles, and neither the body nor the unexplained infertility [68]. endometrium are exposed to supra-physiological levels of estradiol. Natural cycle IVF is safe and less stressful, results In agreement with this, another study assessing in fewer multiple births and is cost effective (one–fifth of the conventional treatment in normogonadotrophic anovulatory price of the current standard stimulation regimen) [76,84]. infertility (WHO 2) (CC followed by exogenous gonadotrophins [FSH] and IVF), showed that using CC › In a study conducted by M.J. Janssens, et al., the authors FSH ›IVF compared with FSH› IVF generated more concluded that Natural IVF is an easy, inexpensive and pregnancies against lower costs but when compared with CC realistic method to achieve pregnancy for patients with tubal ›IVF, it also produced more pregnancies, but at higher infertility. Ongoing pregnancy rates approach 5.3% per costs. The average costs per cycle were 53 ($72), 1108 cycle, 6.5% per oocyte retrieval, 11.4% per embryo transfer ($1,515), 1830 ($2,502) for CC, FSH and IVF, respectively, and 11.4% per embryo [77]. and the costs per ongoing pregnancy were 544($743), In 1995, Daya et al. reported that despite the high failure 8584($11,737), 7686($10,510) [69]. rate seen with each step in the process, natural cycle IVF was Recently, the validity of evidence used by the Royal more cost-effective than stimulated-cycle IVF, which College of Obstetricians and Gynecologists in recommend- incurred an incremental cost per live birth of $48,000. The ing ovarian stimulation with IUI as an effective treatment for total cost for one live birth was five times lower with Natural couples with unexplained infertility has been questioned, re- IVF. In Daya’s study, a pregnancy rate of 12% was igniting the debate on what the initial treatment for confirmed [78]. Mild approaches to ovarian stimulation idiopathic infertility should be. The current best available promise to be more science-based and patient-friendly and evidence, using the results of randomized controlled trials, is they may also help improve the health of the offspring, that the initial treatment for idiopathic infertility should be through reduced perinatal morbidity, mortality, multiple IUI as opposed to IVF [70]. This was supported by a pregnancies and the need for fetal reduction. Although a mild prospective, randomized, parallel trial that concluded that in stimulation protocol resulted in a lesser number of embryos idiopathic or male subfertility, IUI offers the same likelihood retrieved when compared to a high dose conventional of successful pregnancy as IVF and is a more cost-effective protocol, it was associated with a significantly higher approach [71]. Cost-effectiveness studies showed that three proportion of chromosomally normal embryos [79]. IUIs were as successful, but much cheaper, than one A multi-center study published in 2005 by Groen et al., IVF/ICSI cycle [67,71-75]. compared the effects and costs of conventional IVF with those of Manipulated Natural Cycle-(MNC) IVF. Full THE CONCEPT OF FRIENDLY IVF / NATURAL treatment costs of MNC-IVF, including costs of pregnancy CYCLE IVF and delivery, ranged from 1,329 ($971) to 1,465Euro Keeping things simple without altering the success rate ($1071) per cycle, depending on the treatment phases com- of IVF is the idea behind “Friendly IVF”. Friendly IVF aims pleted and the number of pregnancies achieved. Medication to reduce the burden of the IVF procedures and its related costs ranged between 265 ($193) and 275 Euro ($201) per complications, thereby giving a couple the chance to cycle versus 885 Euro ($647) for conventional IVF. The cost conceive using procedures that are less costly in terms of per live birth after three cycles of MNC-IVF was 17,197 physical, emotional, social and financial costs. The rationale Euro ($12,571), which is comparable to the costs per live behind natural cycle IVF (probably the "gold standard" of birth after a single cycle of conventional IVF. It was friendly IVF) is that it is more nearly natural. The body itself concluded that three cycles of MNC-IVF achieve pregnancy selects its own "best egg" for that cycle. The ovaries do not rates similar to those of conventional IVF but with much Low-Cost Infertility Management Current Women’s Health Reviews, 2010, Vol. 6, No. 2 79 lower twin pregnancy rates. Thus, MNC-IVF may be a cost- because patients do not like taking medications, viewing effective alternative for conventional IVF [80]. Alter- them as unnatural. Minimal stimulation protocols thrive on natively, low-dose hCG can be administered in the later that appeal. But a recent review of abstracts presented at the stages of controlled ovarian stimulation. This results in a First World Congress on Natural Cycle/Minimal Stimulation significantly reduced dose of recombinant FSH/hMG while reports inconclusive supporting evidence and the availability the outcome is comparable to that of traditional Controlled of procedures that ‘‘might be superior’’[101]. Ovarian Hyperstimulation (COH) regimens [81,82]. MAKING IVF AFFORDABLE A non-randomized clinical trial of minimal ovary stimulation compared CC and gonadotropin outcomes and In 2006, the European Society of Human Reproduction direct costs to those of a conventional GnRHa-gonadotropin and Embryology (ESHRE) created a Special Task Force stimulation protocol for infertile patients undergoing IVF. whose mission was to focus on infertility in developing The pregnancy rate per oocyte retrieval cycle in the GnRHa- countries; the Arusha-project looks for ways to make IVF gonadotropin protocol was similar to the minimal affordable for African couples by vastly simplifying stimulation protocol (13.1% vs 13.0%). However, the cost conventional IVF technologies. This task force is also per pregnancy of the minimal stimulation protocol was less attempting to: document the problem of infertility in than that of the GnRHa-gonadotropin protocol ($6,021.95 vs. developing countries; develop and test the effectiveness of a $10,785.65) [83]. The use of CC stimulation seems to be simplified ‘one-step clinic’ for the diagnosis of infertility; superior to natural or minimal stimulation IVF [84,85]. and develop and test the effectiveness of simplified IVF- related procedures. It plans to begin offering IVF at clinics in On the other hand, CC may be no better than natural Cairo and Alexandria, Egypt, for around $360. In the US and cycle IVF, which has repeatedly been shown to be inefficient the UK, the price of one round of treatment can cost as much (<10% clinical pregnancy per cycle) [86-89]. Repeating one procedure that has a 10% chance of success four times is not as $12,000 and £5000 ($8000), respectively, and is rarely covered by health insurance. mathematically equivalent to performing a single procedure with a 40% chance of success. Cumulative pregnancy rates One of the aspects of IVF the task force is looking at is after three cycles of minimal stimulation have been the stimulation protocol. The recombinant form of FSH can disappointingly low, yielding per-cycle success rates of only cause women to release a large number of oocytes per cycle 8%, similar to the expected rate of CC–IUI rates, limiting its and thus, some embryos can be frozen. However, this has the utility [90]. disadvantage of being enormously expensive. On the other hand, clomiphene costs just $11 for one round of treatment. In a study evaluating the acceptability of stimulated It can induce the maturation of up to four viable eggs per versus natural cycle IVF among couples attending one cycle. That is far fewer than seen with the use of FSH. And infertility clinic, with respect to cost and pregnancy outcome, because low-cost IVF facilities are unlikely to have the 15% (16/107) of the patients who were indicated for IVF cancelled, mostly due to financial reasons (12/16). Most equipment or liquid nitrogen for freezing extra embryos, fewer eggs are needed anyway. Using clomiphene, the patients who completed their IVF treatment (82/91, 90.1%) ESHRE group plans to transfer no more than two embryos to believed that the price of the medical service offered was the woman's uterus whereas the Low Cost IVF Foundation high, and 68.1% (62/91) accepted the idea of using less (LCIF) initiative plans to transfer only one. As clomiphene expensive drugs with fewer side effects but with possibly a has fewer side effects than recombinant FSH, women may be lower chance of pregnancy [91]. more likely try further rounds of IVF if earlier attempts fail. A policy of elective single embryo transfer (eSET) is the The ESHRE group estimates this approach will achieve a most efficacious measure of reducing the incidence of pregnancy rate of 15% to 20%, lower than the European rate multiple pregnancies in ART [92-98]. This highlights the of 25% and US rate of 35%. The ESHRE group plans to importance of natural cycle and minimal stimulation IVF and transfer the embryo on the first or second day after the lesser need for the production of many embryos per cycle fertilization [102]. in decreasing the burden imposed by multiple pregnancies. Another aspect of assisted reproduction that is being On the other hand, a systematic review of studies looking at assessed is cutting down on the incubator expenses. Simple the cost-effectiveness of IVF-SET versus IVF with double portable table-top incubators cost less than $1000. LCIF is embryo transfer (DET) used in a health economic model counting on the use of warm water baths to incubate compared three strategies: (1) IVF-SET, (2) IVF-DET, and embryos. The use of a ‘humidicrib’, a plastic box that is (3) IUI with gonadotropin stimulation (sIUI). IVF-DET was the most cost-effective strategy at $35,144/live birth, commonly used for keeping newborns snug, instead of an expensive laminar flow hood, has also been proposed followed by sIUI at $66, 960/live birth, and IVF-SET at [103, 104]. Others argue that incubators can be avoided $109,358/live birth. The results were sensitive both to the completely since women themselves can act as a natural one. cost of IVF cycles and to the probability of live birth [99]. Intravaginal culture was described approximately 20 years ‘‘Patient-friendly’’ IVF must be associated with a healthy ago [105-108]. A tube filled with 3 ml of culture medium newborn achieved in a safe, cost-effective, and timely containing 1–5 oocytes with 10 000–20 000 washed manner. Patients are best served when physicians provide spermatozoa per millilitre was hermetically closed and honest appraisal of treatment techniques and outcomes using placed in the vagina. It was held in place by a diaphragm for the evidence available from scientific study [100]. The ‘‘less incubation for 44–50 h. Comparable success rates with is better’’ approach has tremendous emotional appeal, conventional IVF were reported [106]. 80 Current Women’s Health Reviews, 2010, Vol. 6, No. 2 Ismail and Sakr

The INVOcell is a small plastic capsule into which first step in tackling the challenge of providing a cost- fertilized eggs are placed together with culture media. The effective simplified assisted reproduction program. capsule, encased in a protective shell, is then inserted into a However, studies on a wide scale must be a part of that woman's vagina for three days, which keeps the embryos at experience. the desired temperature. Fertilization of the oocyte(s) and early embryo development occur in the INVOcell, which is FIVE YEAR REVIEW placed into the maternal vaginal cavity for incubation. The Infertility is a major problem in low-resource countries vaginal cavity replaces the complex IVF laboratory. After and causes extensive social and psychological suffering. removal, the two best embryos are selected and transferred to Providing infertility treatment in resource-poor countries the woman's uterus. It costs between $85 in Africa and $185 should be part of an integrated reproductive care program in Europe and can cut the cost of IVF by half. The INVOcell that includes family planning and motherhood care. Access overcomes the disadvantages of the previously used to preventive treatment in terms of detection and treatments prototype and makes the procedure simpler and reproducible. of STIs is an important preventative aspect, and it should be Over 800 cycles have been published worldwide that showed available to all patients in developing economies. Patients in a clinical pregnancy rate of 19.6%. The INVO technology low-resource and developing countries have a right to can be performed in an office setting with minor capital infertility treatment including ART. equipment. INVO is a simple low-cost procedure that can be available almost everywhere [109]. KEY POINTS Bicarbonate-free media can be used to maintain the pH, 1. The incidence, severity and the gravity of infertility is obviating the need for cylinders of CO which are expensive 2, highest in many low-resource countries. and unnecessary if an embryo is incubated for only one or two days. Also, the need for CO2 cylinders can be overcome 2. The most common cause of infertility is tubal damage, simply by exhaling across the culture medium before sealing which is preventable through early detection and it in a plastic bag. This bag, containing the Petri dish with the treatment of STIs. embryos, can be dropped into a warm bath without the need 3. In practicing medicine, we should not fail to specify the for expensive incubators. This technique has been best cost-effective regimen for our patients. Evidence- successfully used for more than 10 years for cow embryos in based choices can be made without compromising veterinary IVF [110,111]. success rates. Less expensive microscopes for confirming cell division 4. 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Received: January 10, 2010 Revised: February 08, 2010 Accepted: April 15, 2010

84 Current Women’s Health Reviews, 2010, 6, 84-95 Female Infertility and Antioxidants

Lucky H. Sekhon, Sajal Gupta, Yesul Kim and Ashok Agarwal*

Center for Reproductive Medicine, Glickman Urological & Kidney Institute and Ob/Gyn& Women’s Health Institute, Cleveland Clinic 9500 Euclid Avenue, Desk A19.1, Cleveland, OH 44195, USA

Abstract: Aim: Many studies have implicated oxidative stress in the pathogenesis of infertility causing diseases of the female reproductive tract. The aim of this study was to review the current literature on the effects of antioxidant therapy and to elucidate whether antioxidant supplementation is useful to prevent and/or treat infertility and poor pregnancy outcomes related to various obstetric and gynecologic conditions. Methods: Review of recent publications through Pubmed and the Cochrane data base. Results: Antioxidant supplementation has been shown to improve insulin sensitivity and restore redox balance in patients with PCOS. Supplementation with RU486, Curcuma longa, melatonin, caffeic acid phenethyl ester (CAPE) and catechins may induce remission and halt disease progression in endometriosis. Selenium therapy may improve pregnancy rates in unexplained infertility. Currently there is no evidence to substantiate the use of antioxidants to prevent or treat preeclampsia. Up to 50-60% of recurrent pregnancy loss may be attributable to oxidative stress. Observational studies have confirmed a link between antioxidant-poor diet and recurrent pregnancy loss. Conclusion: Although many advances are being made in the field of antioxidants therapy, there is a need for further investigation using randomized controlled trials within a larger population to determine the efficacy and safety of antioxidant supplementation. Keywords: Oxidative stress, antioxidants, polycystic ovarian syndrome (PCOS), endometriosis, unexplained infertility, preeclampsia, spontaneous abortion.

INTRODUCTION fertility and the importance of antioxidant strategies to inter- cept OS to overcome its adverse effects. Reactive oxygen species (ROS) can modulate cellular functions, and oxidative stress (OS) can impair the intracel- WHAT IS OXIDATIVE STRESS? lular milieu, resulting in diseased cells or endangered cell survival. Reproductive cells and tissues remain stable when Oxidative stress arises from an imbalance between pro- free radical production and the scavenging antioxidants re- oxidant molecules generated from aerobic metabolism and main in balance. The role of ROS in various diseases of the protective antioxidants. OS influences the entire reproduc- female reproductive tract has been investigated. ROS can tive lifespan of a woman. Reactive oxygen species may act affect a variety of physiological functions in the reproductive as key signalling molecules in physiological processes but tract, and excessive levels can result in precipitous patholo- at excess, uncontrolled levels they may also mediate patho- gies affecting female reproduction. The oxidant status can logical processes involving the female reproductive tract. influence early embryo development by modifying the key There is a body of literature providing clinical evidence that transcription factors, hence modifying gene expression. substantiates the link between OS and female infertility. The review will focus on ROS homeostasis and genera- Pro-Oxidants tion of OS in the female reproductive processes. Our review elucidates the role of ROS in physiological processes such as Under physiological conditions, biomolecules are com- folliculogenesis, oocyte maturation, endometrial cycle, lute- prised of stable bonds formed by paired electrons. Weak- olysis, implantation, and embryogenesis and the role of anti- ened, disrupted bonds allow for the generation of free radi- oxidants in various reproductive pathologies. This review cals- unstable and highly reactive species with one or more encapsulates the role of OS, which is becoming increasingly unpaired electrons. They gain stability by acquiring electrons important as new evidence of its role in conditions such as from nearby nucleic acids, lipids, proteins, and carbohy- polycystic ovarian disease and abortions is discovered. The drates, initiating a cascade of chain reactions that may result review highlights how OS modulates natural and assisted in cellular damage and disease [1-4].

Reactive oxygen species are formed endogenously during *Address correspondence to this author at the Professor & Director, Center aerobic metabolism and as a result of various metabolic for Reproductive Medicine, Glickman Urological & Kidney Institute and pathways of oocytes and embryos or as part of the body’s Ob/Gyn & Women’s Health Institute, Cleveland Clinic, 9500 Euclid Avenue, Desk A19.1, Cleveland, OH 44195, USA; Tel: (216) 444-9485; defense mechanisms. ROS also can arise from exogenous Fax: (216) 445-6049; E-mail: [email protected] sources, such as alcohol, tobacco, and various environmental

1573-4048/10 $55.00+.00 © 2010 Bentham Science Publishers Ltd. Female Infertility and Antioxidants Current Women’s Health Reviews, 2010, Vol. 6, No. 2 85 pollutants. ROS include hydroxyl radicals, superoxide anion, cells, illustrating the role of OS in ovarian steroidogenesis hydrogen peroxide, and nitric oxide (NO) [5]. Several bio- [11]. markers indicative of redox status, including superoxide ROS is controlled and kept at physiological levels within dismutase (SOD), glutathione peroxidase (GSH-Px), lipid peroxides, and nitric oxide, have been identified within the the ovary by various antioxidant systems, including catalase, ovary, endometrium, fallopian tubes, embryo, placenta, and vitamin E, glutathione and carotenoids [4]. SOD, a metal- the peritoneal fluid of women. At controlled levels, free containing enzymatic antioxidant that catalyzes the radicals are capable of exerting physiological effects and decomposition of superoxide into hydrogen peroxide and mediating processes such as tissue remodelling, hormone oxygen, has been characterized in the theca interna cells in signalling, oocyte maturation, folliculogenesis, tubal func- the antral follicles. Therefore, the theca interna cells may tion, ovarian steroidogenesis, cyclical endometrial changes, protect the oocyte from excess ROS during its maturation and germ cell function [6, 7]. However, when ROS increase [15]. Another antioxidant factor important for healthy to pathological levels they are capable of inflicting signifi- follicle development is transferrin, an iron-chelating glyco- cant damage to cell structures. protein that suppresses ROS generation [16]. Vitamin C also is known to have a protective effect within the follicle as Antioxidants vitamin C deficiency has been reported to result in ovarian atrophy, extensive follicular atresia, and premature resump- Under normal conditions, antioxidants act to oppose ROS tion of meiosis [15]. production, scavenge existing free radicals, and promote the repair of ROS-induced damage to cell structures [8]. Non- The overall ROS scavenging ability of antioxidants enzymatic antioxidants include vitamin C, vitamin E, sele- within the follicular fluid microenvironment may diminish nium, zinc, beta carotene, carotene, taurine, hypotaurine, with reproductive aging. Carbone et al. demonstrated cysteamine, and glutathione. Enzymatic antioxidants include decreased levels of follicular fluid catalase and SOD in older SOD, catalase, GSH-Px, glutaredoxin and glutathione reduc- women, whose oocytes were seen to exhibit lower tase [5]. The degree of antioxidant defense present is often fertilization rates and decreased blastocyst development expressed as total antioxidant capacity (TAC) [6]. compared with oocytes of younger women [17]. Therefore, the redox status of the follicle is closely related to oocyte A disruption in the delicate balance between antioxidants quality and fertilization capacity. and pro-oxidant molecules can result in OS. OS arises when the generation of reactive oxygen species and other radical Endometrium species overrides the scavenging capacity by antioxidants, either due to the excessive production of ROS or an inade- The relationship between OS and cyclical changes in the quate availability of antioxidants. Thus, oral antioxidant endometrium is well-established. OS-promoting alterations supplementation may serve to prevent and alleviate OS and in ROS and SOD levels have been demonstrated just prior to its contribution to the pathogenesis of obstetrical disease menstruation, during the late-secretory phase [18]. Estrogen such as preeclampsia and recurrent pregnancy loss and gyne- and progesterone withdrawal in endometrial cells in vitro has cological disorders such as polycystic ovarian syndrome been associated with a decrease in SOD activity, resulting in (PCOS) and endometriosis. the unopposed activity of ROS [18]. Elevated lipid peroxide and decreased SOD in the endometrium during the late- OS IN THE FEMALE REPRODUCTIVE TRACT – secretory phase may modulate endometrial breakdown, PHYSIOLOGICAL ROLE OF OS leading to menstruation. NO is known to regulate the endometrial microvasculature and is produced by endothelial Follicle NO synthase (NOS), which is distributed in the glandular The expression of various markers of OS has been surface epithelial cells of the endometrium [19]. NO is demonstrated in normally cycling ovaries [9, 10]. The thought to mediate endometrial decidualization and follicular fluid microenvironment contains leukocytes, menstruation as endothelial NOS mRNA expression has macrophages, and cytokines, all of which are known sources been detected in the mid-secretory and late-secretory phase. of ROS. ROS within the follicular fluid plays a role in Endothelial NOS is also implicated in the changes seen in modulating oocyte maturation, folliculogenesis, ovarian the endometrium in preparation for implantation [20]. ROS steroidogenesis, and luteolysis [11]. Follicular development may mediate the physiological processes of shedding and involves the progression of small primordial follicles into implantation by its activation of nuclear factor B within large pre-ovulatory follicles. Studies have implicated the the endometrium, leading to increased cyclooxygenase-2 nitric oxide radical in the follicular growth and programmed mRNA and prostaglandin F2 synthesis [18]. follicular cell death that occur during folliculogenesis [12, 13]. Moderate OS levels are required for ovulation. The final Infertility stages of oocyte maturation are associated with fluctuations Approximately 1.3 million American couples receive in cytokines, prostaglandins, proteolytic enzymes, nitric medical advice or treatment for infertility every year [21]. oxide, and steroids, which increase the level of ROS, Infertility is a disease defined as the inability to conceive influencing ovarian blood flow and eventually facilitating following 12 or more months of unprotected sex [22]. In follicle rupture [14]. A degree of oxidative enzyme activity general, an estimated 84% of couples conceive after 1 year is exhibited by thecal cells, granulosa lutein cells, and hilus of intercourse, and 92% of the couples conceive after 2 years 86 Current Women’s Health Reviews, 2010, Vol. 6, No. 2 Sekhon et al.

[23]. A primary diagnosis of male factor infertility is made for oral antioxidant supplementation (Fig. 1). Additional in 30% of infertile couples. High levels of ROS biomarkers research is needed to determine whether such supplementa- have been detected in semen samples of 25-40% of infertile tion can ensure successful fertilization and pregnancy by men [5]. Although ROS have a physiological role in normal controlling the OS experienced by patients with endometri- sperm function, mediating the acrosome reaction, hyperacti- osis, PCOS, unexplained infertility, preeclampsia, and recur- vation, motility, and capacitation of spermatozoa, excessive rent pregnancy loss. levels of ROS may arise from immotile or morphologically abnormal spermatozoa and leukocytes. Spermatozoa lack THE USE OF ANTIOXIDANTS IN TREATMENT OF the necessary cytoplasmic antioxidant enzymes and are GYNECOLOGICAL CONDITIONS vulnerable to OS-induced DNA damage and apoptosis Polycystic Ovarian Syndrome [5, 24]. Substantial evidence exists that implicates OS in many causes of male infertility. Oral antioxidant supple- PCOS is an anovulatory cause of infertility affecting 6- mentation has become standard practice for male infertility 10% of premenopausal women [29-32]. PCOS often can be [5]. characterized by hyperandrogenism, hirsutism, and oligomenorrhea or amenorrhea. Metabolic, endocrinologic, and Combined female and male factor infertility is responsi- cardiovascular disorders may also coexist. Oxidative stress ble for 20%–30% of cases. If the results of a standard infertility examination are normal, a diagnosis of unexplained has been implicated in mediating the insulin resistance and increase in androgens seen in these patients [33]. or idiopathic infertility is assigned [25]. OS has a well- established role in pathogenesis of unexplained infertility, A recent study by Kuscu et al. demonstrated increased which is seen to affect 15% of couples [25]. Although the MDA levels and upregulated SOD activity in patients with frequency and origin of different forms of infertility varies, PCOS compared to controls. MDA levels were highest in 40%–50% of the etiology of infertility studied is due to patients who exhibited insulin resistance [34]. Insulin female causes [26]. resistance and hyperglycemia are established as factors that increase oxidative stress. Fulghesu et al. evaluated the effect OS induces infertility in women through a variety of of N-acetyl-cysteine (NAC), known to replenish stores of the mechanisms. Excess ROS in the follicle may overwhelm anti-oxidant glutathione, on insulin secretion and peripheral follicular fluid antioxidant defense and directly damage oo- insulin resistance in subjects with PCOS. Patients were cytes. The DNA of oocytes and spermatozoa may be dam- aged, leading to defective fertilization when the peritoneal treated for 5-6 weeks with a 1.8g oral NAC per day. Massively obese patients were given a higher dose of 3g per cavity microenvironment is plagued with severe OS. Even day. NAC treatment was found to improve parameters of when fertilization is achieved, OS-induced apoptosis may glucose control in hyperinsulinemic patients. Insulin levels result in embryo fragmentation, implantation failure, abor- were reduced, with increased peripheral insulin sensitivity. tion, impaired placentation, and congenital abnormalities Therefore, the anti-oxidant effects of NAC may serve as a [27]. Excess ROS may hinder the endometrium, which normally functions to support the embryo and its development therapeutic strategy to improve the level of circulating insulin and insulin sensitivity in PCOS patients with [28]. OS may induce luteal regression and insufficient luteal hyperinsulinemia [35]. hormonal support for the continuation of a pregnancy [8]. The association of OS with various gynecologic and obstet- Non-obese PCOS patients without insulin resistance also ric conditions related to infertility suggests a potential role have been reported to have elevated total oxidant and anti-

Fig. (1). The role of oxidative stress in obstetric and gynecologic conditions that contribute to infertility. Female Infertility and Antioxidants Current Women’s Health Reviews, 2010, Vol. 6, No. 2 87 oxidant status [36]. Verit et al. demonstrated that total anti- endometriosis-associated infertility. Differential gene ex- oxidant status in these types of PCOS patients was correlated pression of ectopic and normal endometrial tissue has been with raised luteinizing hormone levels and free androgen and identified, including differential gene expression of glu- dehydroepiandrosterone (DHEAS) levels [36]. Yilmaz et al. tathione-S-transferase, an enzyme in the metabolism of the studied the effects of 12 weeks of treatment with oral potent antioxidant glutathione [45]. This suggests that altered hypoglycemic agents on OS in lean patients with PCOS [37]. molecular genetic pathways may determine the development Before treatment, PCOS patients exhibited OS with of OS and its ability to induce cellular proliferation and an- significantly raised serum MDA and homocysteine and giogenesis in women with endometriosis. significantly decreased serum TAS. PCOS patients treated Peritoneal fluid of women with endometriosis has been with rosiglitazone showed an increase in TAS and a decrease reported to exhibit increased ROS generation by activated in MDA levels, compared with a metformin-administered patient group in which these parameters did not change [37]. peritoneal macrophages [46]. Increased macrophage activity Therefore, rosiglitazone may be useful in combating OS in is accompanied by the release of cytokines and other im- hyperinsulinemic PCOS patients. mune mediators such as NO. NO is a pro-inflammatory free radical that exerts deleterious effects on fertility by increas- Zhang et al. used methods of chemicalorimetry to ing the amount of OS in the peritoneal fluid, an environment measure and compare levels of serum lipid peroxides (LPO), that hosts the processes of ovulation, gamete transportation, MDA, SOD, vitamin E, and vitamin C in patients with sperm-oocyte interaction, fertilization, and early embryonic PCOS and normal women [38]. Levels of serum LPO and development [2, 47, 48]. However, the results of further MDA in patients with PCOS were significantly higher than studies with large patient numbers failed to confirm an anti- those found in normal women. Levels of vitamin E, vitamin oxidant or oxidant imbalance as ROS levels in peritoneal C, and SOD were lower in patients with PCOS than in the fluid of patients with endometriosis were not reported to be control group. After 3 months of therapy with oral significantly higher than controls [49, 50]. ethinylestradiol and cyproterone acetate tablets (Diane-35®, Merck, Whitehouse Station, N.J.), an anti-androgenic oral After adjusting for confounding factors such as age, contraceptive often used to treat hirsutism associated with BMI, gravidity, serum vitamin E, and serum lipid levels, PCOS, MDA and LPO levels decreased, while vitamin E, Jackson et al. reported a weak relationship of elevated levels vitamin C, and SOD levels increased in patients with PCOS of thiobarbituric acid reactive substances (TBARS), an over- [38]. Therefore, this therapy may alleviate the symptoms of all measure of OS, in women with endometriosis [51]. In- PCOS through both its anti-androgenic and anti-oxidant creased NO production and lipid peroxidation have been actions. reported in the endometrium of women with endometriosis [2, 52]. However, several studies failed to find significant Endometriosis differences in the peritoneal fluid levels of NO, lipid peroxide, and ROS in women with and without endometriosis- Severe cases of endometriosis are thought to render a associated infertility. woman infertile by mechanical hindrance of the sperm-egg union by adhesions, endometriomata, and pelvic anatomy The failure of some studies to confirm alterations in peri- malformations. However, in women with mild-to-moderate toneal fluid NO, lipid peroxide and antioxidant status in forms of endometriosis and no pelvic anatomical distortion, women with endometriosis may be explained by the fact that the mechanism by which their fertility is reduced is poorly OS may occur locally, without affecting total peritoneal fluid understood. ROS concentration. Also, markers of OS may be transient and not detected at the time endometriosis is diagnosed. ROS production may be amplified in the setting of endometriosis due to menstrual reflux, which subjects the peri- An imbalance between ROS and antioxidant levels may toneal cavity to pro-inflammatory hemoglobin and heme play an important role in the pathogenesis of endometriosis- molecules released from transplanted erythrocyte debris. associated infertility. Increased concentrations of oviductal Peritoneal fluid containing ROS-generating iron, macro- fluid ROS may adversely affect oocyte and spermatozoa phages, and environmental contaminants such as polychlori- viability and the process of fertilization and embryo implan- nated biphenyls may disrupt the prooxidant/antioxidant bal- tation. Also, pro-inflammatory macrophages and activated ance, resulting in increased proliferation of tissue and adhe- neutrophils in the oviductal fluid may significantly amplify sions [39-42]. ROS are thought to promote the growth and ROS production by endometriotic foci [43]. Increased ROS adhesion of endometrial cells in the peritoneal cavity, con- production may inflict oxidative damage to the sperm plasma tributing to the pelvic anatomical distortion known to cause and acrosomal membranes, resulting in a loss of motility and infertility in endometriosis [43]. OS may have a role in pro- decreased spermatozoal ability to bind and penetrate the oo- moting angiogenesis in ectopic endometrial implants by cyte. The various possible consequences of OS-induced increasing vascular endothelial growth factor (VEGF) produc- DNA damage include failed fertilization, reduced embryo tion [44]. This effect is partly mediated by glycodelin, quality, pregnancy failure, and spontaneous abortion. a glycoprotein whose expression is stimulated by OS. Modest levels of OS have been shown to induce the pro- Glycodelin may act as an autocrine factor within ectopic liferation of endometrial stromal cells in vitro, which has endometrial tissue by augmenting VEGF expression [44]. been shown to be inhibited by antioxidants [53]. Several Altered molecular genetic pathways may contribute to studies have shown that the peritoneal fluid of women with the effects of OS in the pathogenesis of endometriosis and endometriosis-associated infertility have insufficient antioxi- 88 Current Women’s Health Reviews, 2010, Vol. 6, No. 2 Sekhon et al. dant defense, with lower total antioxidant capacity (TAC) that treatment with melatonin was also shown to cause re- and significantly reduced SOD levels [2, 47, 54]. gression and atrophy of endometriotic lesions in rats [61]. An early study used a simple rabbit model to demonstrate Endometrial lesions treated with melatonin demonstrated the beneficial effect of antioxidant therapy in halting pro- lower MDA levels and significantly increased SOD and cata- gression of the disease [55]. SOD and catalase were instilled lase activity [61], corroborating the usefulness of this hor- in the rabbit peritoneal cavity and were shown to signifi- mone in neutralizing OS. cantly reduce the formation of intraperitoneal adhesions at Guney et al. conducted another study that evaluated the endometriosis sites by blocking the toxic effects of the su- effects of antioxidant and anti-inflammatory caffeic acid peroxide anion and hydrogen peroxide radicals [55]. More phenethyl ester (CAPE) on experimental endometriosis in a recently, RU486- a potent antiprogestational agent with anti- rat model, and the levels of peritoneal SOD and catalase ac- oxidant activity, has been shown to decrease the proliferation tivity, and MDA [62]. Treatment with CAPE was seen to of epithelial and stromal cells in endometriosis [56]. decrease peritoneal MDA levels and antioxidant enzyme activity in rats. Endometriotic lesions treated with CAPE Another drug being investigated for its potential use in were histologically demonstrated to undergo atrophy and the treatment of endometriosis-associated infertility is pen- regression, compared with untreated controls [62]. toxifylline, a 3’,5’-nucleotide phosphodiesterase inhibitor. Pentoxifylline has potent immunomodulatory properties and As previously mentioned, OS stimulates factors that in- has been shown to significantly reduce the embryotoxic ef- crease VEGF expression and promote angiogenesis of en- fects of hydrogen peroxide [57]. Zhang et al. conducted a dometriotic lesions. The green tea-containing compound, recent randomized control trial in which pentoxifylline epigallocatechin gallate (EGCG) has been evaluated as a treatment failed to demonstrate significant reduction in en- treatment for endometriosis due to its powerful antioxidant dometriosis-associated symptoms such as pain. Furthermore, and anti-angiogenic properties. Xu et al. conducted a study there was no evidence of an increase in the clinical preg- in which eutopic endometrium transplanted subcutaneously nancy rates in the pentoxifylline group compared with pla- into a mouse model was used to compare the effects of cebo [58]. Currently, there is not enough evidence to warrant EGCG treatment on endometriotic implants to the effects the use of pentoxifylline in the management of premeno- seen with vitamin E treatment or untreated controls [63]. pausal women with endometriosis-associated pain and infer- Lesions treated with EGCG exhibited significantly down- tility. regulated VEGF-A mRNA. While the control endometrial implants exhibited newly developed blood vessels with Curcumin is a polyphenol derived from turmeric proliferating glandular epithelium, the EGCG group demon- (Curcuma longa) with antioxidant, anti-inflammatory, and strated significantly smaller endometriotic lesions and antiproliferative properties. This compound has been shown smaller and more eccentrically distributed glandular epithe- to have an anti-endometriotic effect by targeting aberrant lium. Despite its widely studied benefits as a potent antioxi- matrix remodelling in a mouse model. Matrix metalloprote- dant in the treatment of female infertility, vitamin E was inase-9 (MMP-9) has been shown to correlate with severity not shown to control or decrease angiogenesis compared of endometriosis. In randomized controlled trials, curcumin with baseline controls [63]. As EGCG was shown to signifi- treatment was seen to reverse MMP-9 activity in endometri- cantly inhibit the development of experimental endometriotic otic implants near to control values. Furthermore, the anti- lesions in a mouse model, its effectiveness as an oral inflammatory property of curcumin was evidenced by the supplement in female patients to limit progression and fact that the attenuation of MMP-9 was accompanied by a induce remission of their endometriosis should be further reduction in cytokine release. Decreased expression of tumor investigated. necrosis factor alpha (TNF-) was demonstrated during regression and healing of endometriotic lesions within the A recent study by Mier-Cabrera et al. utilized question- mouse model. Pretreatment of endometriotic lesions with naires to compare the dietary intake of antioxidant vitamins curcumin was shown to prevent lipid peroxidation and pro- and minerals by women with and without endometriosis. tein oxidation within the experimental tissue, attesting to its Relative to healthy control subjects, women with endometri- therapeutic potential to provide antioxidant defense against osis were found to have a significantly lower intake of vita- OS-mediated infertility in endometriosis [59]. mins A, C, E, zinc, and copper. However, intake of selenium was not significantly different between the two groups stud- MMP-9 also was identified as a therapeutic target in the ied [64]. A randomized control trial in which the effect of treatment of OS-mediated endometriosis in another study antioxidant supplementation was studied revealed a signifi- evaluating the effectiveness of melatonin in treating experi- cant increase in the concentrations of serum retinol, alpha- mental endometriosis in a mouse model [60]. Melatonin is a tocopherol, leukocytes, and plasma ascorbate after 2 months major secretory product of the pineal gland with anti-oxidant of treatment. Antioxidant supplementation was also observed properties. Melatonin was shown to arrest lipid peroxidation to increase the activity of antioxidant enzymes (SOD and and protein oxidation, while downregulating MMP-9 activity GPx), while decreasing markers of oxidative stress such as and expression in a time- and dose-dependent manner. Tis- malondialdehyde and lipid peroxides [64]. These effects sue inhibitors of metalloproteinase (TIMP)-1 were found to were not observed in the control group, suggesting a role for be elevated. Regression of peritoneal endometriotic lesions antioxidant supplementation in decreasing the levels of oxi- was seen to accompany the alteration in metalloproteinase dative stress afflicting patients with endometriosis-associated expression [60]. Guney et al. confirmed these findings in infertility. Female Infertility and Antioxidants Current Women’s Health Reviews, 2010, Vol. 6, No. 2 89

Unexplained Infertility mechanism by which preeclampsia develops is not known, there is increasing evidence that corroborates the role of Elevated levels of ROS that disturb the redox balance OS in its etiopathogenesis. Reduced antioxidant response within the body may be the root cause of infertility in [71, 72], reduced levels of antioxidant nutrients [73], and women who do not have any other obvious cause. The ovum increased lipid peroxidation [72, 73] have been observed in released from the ovary, the zygote or embryo, and sper- patients with preeclampsia. matozoa are very vulnerable to damage inflicted by OS [8]. Wang et al. compared ROS levels in peritoneal fluid be- Preeclampsia is associated with defective placentation, in tween women undergoing laparoscopy for infertility evalua- which the dislodging of extravillous trophoblast plugs in the tion and fertile women undergoing tubal ligation and demon- maternal spiral arteries leads to the onset of blood flow into strated that higher levels of ROS exist in the peritoneal fluid the intervillous space, causing an oxidative burst that gener- aspirated from patients with unexplained infertility compared ates ROS. Abnormal placentation leads to reduced fetopla- to that measured within the peritoneal fluid of fertile women cental circulation secondary to decreased NO-mediated [65]. Polak et al. analyzed peritoneal fluid samples obtained vascular relaxation. Placental ischemia and hypoxia leads to at laparoscopy and found that women with unexplained ischemic reperfusion injury to the placenta in which there is infertility had increased MDA concentrations and TAS, release of cytokines and prostaglandins, which triggers the implicating the role of redox imbalance in its pathogenesis endothelial cell dysfunction seen in preeclampsia. Hypoxia [66]. and reperfusion injury leads to increased expression of Elevated ROS levels in patients with unexplained infertil- xanthine oxidase and NADPH oxidase and increased genera- ity implies exhausted antioxidant defense, resulting in the tion of SOD. inability to scavenge ROS and neutralize their toxic effects Poorly perfused placental tissue, abnormal lipid metabo- [65]. This was substantiated by the results of a study in lism, and resultant lipid peroxidation and redox imbalance which antioxidant concentrations were seen to be signifi- are established factors that promote the development of cantly lower in the peritoneal fluid of patients with unex- preeclampsia. Numerous studies have demonstrated insuffi- plained infertility compared with antioxidant levels in fertile cient antioxidant defenses and overwhelming degrees of patients [47]. The link between decreased antioxidant status ROS in women with preeclampsia [73]. Oxidative stress has and lowered fecundity suggests a potential use for antioxi- been evaluated by measuring elevated lipid peroxidation in dant supplementation to treat the high levels of ROS seen in patients with preeclampsia, as well as elevated protein car- patients with idiopathic infertility. bonyl concentrations, plasma MDA levels, and SOD activity. Howard et al. described a group of patients with a history Placental oxidative stress has been proposed as a promoter of of unexplained infertility and abnormal red blood cell mag- lipid peroxidation and endothelial cell dysfunction [74-78]. nesium (RBC-Mg) levels. These patients’ RBC-Mg levels Increased lipid peroxidation may result in the consumption were unresponsive to oral magnesium supplementation and of antioxidants and depletion of vitamin A, C, and E, eryth- shown to be associated with deficient red blood cell glu- rocyte thiol, glutathione, and SOD. tathione peroxidase (RBC-GSH-Px) activity [67]. Treatment There currently is no accepted method of preventing the with 200 μg of oral selenium as selenomethionine and oral development of preeclampsia. Some trials have evaluated the magnesium for a period of 2 months was shown to normalize use of supplementation with antioxidants vitamin C and RBC-Mg and RBC-GPx levels. This correlated with 100% vitamin E for prevention. Early intervention at 16–22 weeks of previously infertile women in the treatment group of pregnancy with supplementation of vitamin E and C re- successfully achieving clinical pregnancies within 8 months sulted in significant reduction of preeclampsia in the treat- of normalizing their RBC-Mg [67]. ment group [79]. However, supplementation in women with Badawy et al. conducted a prospective, randomized, established preeclampsia did not yield any benefit [80]. A double-blind, controlled trial comparing the effects of using recent randomized trial failed to demonstrate any beneficial clomiphene citrate combined with glutathione-replenishing effects of vitamin C and E supplementation in preventing N-acetyl cysteine versus clomiphene citrate alone in induc- preeclampsia [81]. Poston et al. investigated the use of vita- ing ovulation in women with unexplained infertility [68]. min C and E supplementation to reduce OS, limit the injury Despite the proposed benefits of strengthening the antioxi- of endothelial cells, and prevent or reduce disease severity of dant defense of women with unexplained infertility, no dif- preeclampsia. In this placebo-controlled trial in a diverse ference was seen in the rates of successful pregnancy be- group of high-risk women, antioxidant supplementation was tween both groups [69]. Therefore, the use of N-acetylcysteine not associated with a reduction in the preeclampsia risk. In- to improve outcome during ovulation induction in women stead, treatment was associated with a significantly higher with unexplained infertility is not justified. incidence of complications, including low birth weight, gestational hypertension, and increased need for intravenous THE USE OF ANTIOXIDANTS TO PROMOTE antihypertensive and magnesium sulphate therapy [82]. HEALTHY PREGNANCY Although a causal relationship between OS and Preeclampsia preeclampsia is well-established, trials have failed to detect any risk reduction for preeclampsia with antioxidant sup- Preeclampsia complicates 5% of all pregnancies and 11% plementation. Trials powered to detect any smaller, more of first pregnancies and is associated with high maternal and subtle benefits of antioxidant therapy in preventing placental fetal morbidity and mortality [70]. Although the exact pathology must be conducted before the routine use of anti- 90 Current Women’s Health Reviews, 2010, Vol. 6, No. 2 Sekhon et al. oxidant vitamins by nulliparous, pregnant women can be tory chain occurs. This increase in oxygen concentration may recommended. also lead to acute stress in the syncytiotrophoblast, with loss of function and extensive degeneration [88]. The syn- Recurrent Pregnancy Loss cytiotrophoblast is susceptible to OS because of its location Abnormal placentation has been implicated in the patho- on the villous surface, which makes this tissue first to experience the increase in intervillous PO2. Also, the syn- genesis of both preeclampsia and miscarriage [71]. Recurrent cytiotrophoblast possesses much lower concentrations of the pregnancy loss is a condition in which three or more con- antioxidant enzymes than other villous tissues during early secutive, spontaneous abortions occur [83]. It affects 0.5% to gestation [87]. 3% of women of reproductive age. Recurrent pregnancy loss has been associated with several factors, including maternal The connection between recurrent pregnancy loss and OS age, genetic factors, endocrinologic factors, anatomic prob- is not only corroborated by the increase in ROS generation lems, and environmental toxins [83]. Moreover, the etiology seen in early pregnancy but also can be related to increased of recurrent pregnancy loss may be linked to chromosomal levels of antioxidants needed to neutralize and scavenge abnormalities, uterine anatomic anomalies, immunologic excessive ROS present in women affected by habitual disorders such as antiphospholipid antibody syndrome, clot- abortion. Wang et al. has reported that levels of plasma ting disorders, and sperm DNA fragmentation [6]. However, vitamin E and lipid peroxides are increased in pregnant 50%-60% of recurrent pregnancy losses are considered idio- women versus non-pregnant controls [89]. Lipid peroxida- pathic [84]. Oxidative stress may be implicated in this sub- tion is an oxidative process that normally occurs at low group as placental oxidative stress can lead to recurrent abor- levels, and antioxidant function has the ability to control the tions by impairing placental development and causing syn- amount of oxidative stress it induces. However, when there cytiotrophoblast degeneration [85]. During pregnancy both is a deterioration of the antioxidants’ capacity to neutralize extracellular and intracellular ROS production increases ROS, peroxidative activity occurs at the expense of polyun- sharply, originating from the developing embryo [84]. Thus, saturated fatty acids. the demand for enzymatic antioxidant defense is increased Simsek et al. evaluated the outcome of deficient antioxi- in embryos and oocytes and their tubal and follicular fluid dant defense in women with habitual abortion and demon- microenvironments to successfully support a pregnancy and strated elevated lipoperoxides and significantly decreased the heightened OS it produces. vitamin A, E, and beta carotene in this population compared The increase in peripheral white blood cell count consist- with the control group. Their findings confirm that OS may ing of polymorphonuclear leukocytes (PMNL) accounts for be involved in the pathogenesis of recurrent pregnancy loss the normal and natural rise in OS seen with normal preg- [90]. Sane et al. found that women undergoing induced or nancy [86]. Fait et al. compared the changes in peripheral spontaneous abortions exhibited a maximum rise in serum PMNL counts during early pregnancy with the non-pregnant lipid peroxidase levels immediately before the onset of abor- state and found that in an uncomplicated early pregnancy, tion and significantly depressed levels of serum lipid peroxi- peripheral PMNL and neutrophilia counts were elevated dase after the abortion was complete [91]. Jenkins et al. stud- [86]. The priming of the PMNL is known to cause an in- ied changes in antioxidant levels by measuring SOD levels, creased release of ROS and OS, which occur in early preg- which measure the amount of oxygen ion scavenger that may nancy [86]. This conclusion is also supported by a study by result in increased ROS production [92]. This study found Safronova et al. that explored the changes in regulation of that SOD levels were significantly lower in women whose oxidase activity of peripheral blood granulocytes in women pregnancies ended in miscarriage than in healthy pregnant with habitual abortion. Researchers found that in the early women [92]. stages of pregnancy, the peripheral polymorphonuclear The glutathione and glutathione transferase family of leukocyte count increases [84]. enzymes has been investigated in patients who experience A successful pregnancy requires a successful embryo recurrent pregnancy loss [70, 71]. The glutathione peroxi- implantation and adequate uteroplacental circulation for ma- dase reductase antioxidant system is an ROS scavenger, pre- terno-fetal exchange [84,87]. The sharp peak in the expres- venting lipid peroxidation in cells and maintaining intracel- sion of OS markers in the trophoblast in normal pregnancy lular homeostasis and redox balance [84]. Studies have may result in damage to protein, lipids, and DNA, which shown glutathione concentration and activity to be signifi- may ultimately lead to cell death if this oxidative burst be- cantly higher in women with recurrent miscarriage compared comes excessive. Joanne et al. confirmed the contribution of with the glutathione concentration seen in women with nor- placental oxidative stress to early pregnancy failure, in dem- mal pregnancies or in healthy, non-pregnant woman [93]. onstrating significant increases in both morphological and Red blood cell GSH-Px activity was not seen to differ be- immunohistochemical evidence of syncytial oxidative stress tween pregnant women and the control group, but were seen and damage in miscarried placental tissues. In a miscarriage, to be significantly deficient in women that had a miscarriage disorganized placental blood flow may lead to hypoxia and [93]. reperfusion injury with a resultant increase in the oxygen The bioavailability of selenium is directly related to the tension within the early placenta [88]. activity of the GSH-Px system. GSH-Px catalyzes the reduc- Moreover, the increase in oxygen concentration seen tion of hydrogen peroxide and hydroxyperoxides, acting as a during normal early pregnancy renders the body more vul- free radical scavenger and preventing the lipid peroxidation nerable to ROS formation, particularly within the mitochon- of cell membranes and [93]. And because GSH-Px is an en- dria where electron leakage from the enzymes of the respira- zyme that is essential in cells to neutralize the effects of free Female Infertility and Antioxidants Current Women’s Health Reviews, 2010, Vol. 6, No. 2 91 radicals, selenium concentrations may decrease in those pa- to protect against OS-related damage and thereby serve as an tients at risk of recurrent miscarriage because selenium is antioxidant. In a normal pregnancy, vitamin E level naturally incorporated into the active site of GSH-Px [94,95]. Al- increases, while in an abnormal pregnancy, vitamin E con- Kunani et al. reported significantly lower concentrations of centrations are lower [102]. Moreover, vitamin C levels in- selenium in the hair samples of women with recurrent preg- crease physiologically during pregnancy [102]. These occur- nancy loss compared with controls [96]. Although this study rences suggest that perhaps vitamins C and E may play a role failed to confirm a difference in the overall blood plasma in compensating for the oxidative burst during early preg- selenium concentrations in women who had a miscarriage nancy, reducing the risk of pregnancy loss [102]. However, it compared with those with viable pregnancies, selenium lev- is necessary to perform an accurate assessment of the appro- els were found to be significantly higher in non-pregnant priate type and dosage of vitamins that can be tolerated women [96], confirming that pregnancy in general is accom- without causing deleterious side-effects to the mother and panied by a state of increased OS. baby [100]. In addition to the various female factors related to recur- Homocysteine is a thiol-containing amino acid that is rent pregnancy loss, several male factors can contribute to involved in the sulfurylation and methylation metabolic OS in these patients. A recent study by Gil-Villa et al. as- pathways and has been proposed to have pro-oxidant effects sessed sperm factors possibly involved in early recurrent [84]. Normally, plasma homocysteine levels fall during a pregnancy loss by evaluating and comparing standard sperm normal pregnancy. However, Del Banco et al. demonstrated parameters, lipid peroxidation of sperm plasma membranes, significantly elevated homocysteine levels in women with a antioxidant capacity of seminal plasma, and sperm chromatin history of at least two consecutive miscarriages [105]. integrity in ejaculates from partners who have a history of Quere et al. conducted a study evaluating the effect recurrent pregnancy loss with those from a control group of vitamin supplementation on pregnancy outcome in 25 [97]. Reactive oxygen species in semen from sources such as women with recurrent early pregnancy loss and hyperhomo- seminal leukocytes and morphologically abnormal sper- cysteinemia in the absence of any folate supplementation matozoa is harmful to the functionality and structure of the during pregnancy [106]. This study involved hyperhomocys- sperm. An increase in sperm DNA damage has been associ- teinemic patients. Folic acid supplements are believed to ated with increased risk of undergoing embryo loss and reduce a woman’s risk for having a baby with a neural-tube augmented time to reach pregnancy [98]. This study success- defect. The potential for folic acid to prevent elevated homo- fully showed that a larger number of individuals of the recur- cysteine levels and OS- induced miscarriage has been the rent pregnancy loss group presented alterations in sperm focus of many investigations. Szymanski et al. found that concentration, motility, morphology, and thiobarbituric acid- women receiving folic acid supplements had better quality reactive substance production and lower antioxidant capacity oocytes and a higher degree of mature oocytes compared of seminal plasma than did the individuals in the control with those who did not receive folic acid supplementation group [97]. These findings may justify the use of antioxidant [107]. However, the results of a study by Gindler et al. failed therapy in the male partner in couples experiencing recurrent to confirm that the consumption of folic acid decrease a pregnancy loss [97]. woman’s risk for miscarriage [108]. Thus, the role of folic Given the array of evidence implicating OS in the patho- acid supplementation to prevent recurrent pregnancy loss is genesis of recurrent abortion, many studies have focused on inconclusive and requires further analysis. the role of antioxidant supplementation in women affected Antiphospholipid (aPL) antibody syndrome is a known by recurrent pregnancy loss [99]. Poor dietary intake of vi- autoimmune cause of recurrent pregnancy loss [84]. The tamins has been associated with an increased risk of miscar- pathophysiology of antibody formation is still not clear; riage [100]. For instance, there are a variety of non- however, OS has been proposed to have a role in the forma- enzymatic antioxidants, including vitamins C, E, and A, ly- tion of these antibodies [84]. Omega-3 supplements have copenes, selenium compounds, lipoic acid, and ubiquinones been used in prevention of recurrent miscarriage with an- [101] that have the ability to scavenge ROS and ultimately tiphospholipid syndrome [109]. Del Bianco et al. studied the prevent OS and cellular damage [102]. An observational effects of omega-3 fatty acid supplementation in women study demonstrated an association between the risk of spon- with three or more miscarriages associated with antiphos- taneous early miscarriage and intake of green vegetables, pholipid syndrome [105]. All of the subjects in this trial fruit, and dairy products [103]. Some evidence suggests that achieved successful pregnancy with no further miscarriages reduced intake of micronutrients during pregnancy exposes [105]. Although the results of this study are promising, the women to nutritional deficiencies and may affect fetal safety and efficacy of omega-3 supplementation must be growth [104]. Thus, adequate maternal nutrition, particularly confirmed by follow-up trials. vitamin intake, may be an important factor in preventing miscarriage [100]. Although the evidence in regards to ex- Melatonin, a hormone that acts as a powerful agent actly what vitamin combinations, type, and amount are opti- against ROS, has been hypothesized to have properties es- mal for a pregnant woman is insufficient, the use of any vi- sential for successful pregnancy and prevention of spontane- tamin supplements in pregnancy needs to be carefully moni- ous abortion [110]. Tamura et al. propose that deficient tored and evaluated [100]. melatonin production in early pregnancy may be related to the development of spontaneous abortion as melatonin is a Vitamin C and E are two popular vitamins that may have free-radical scavenger and antioxidant that is known to a potential role in alleviating the effects of OS in women physiologically increase to compensate for the oxidative affected with miscarriages. Vitamin E’s principal function is burst during normal pregnancy [110]. Therefore, the safety 92 Current Women’s Health Reviews, 2010, Vol. 6, No. 2 Sekhon et al. and efficacy of melatonin supplementation to combat OS and overrides the scavenging capacity of antioxidants, either prevent recurrent pregnancy loss should be further investi- due to excessive ROS production or an inadequate avail- gated. ability of antioxidants.

EXPERT COMMENTARY • At controlled levels, OS facilitates the following physiological female reproductive functions: oocyte The purpose of this article was to discuss the role of maturation, folliculogenesis, ovarian steroidogenesis, antioxidant supplementation in the treatment of various luteolysis, ovulation, cyclical endometrial changes, and gynecological and obstetric conditions known to contribute menstruation. to female infertility and poor pregnancy outcome. The At higher levels, OS is implicated in pathological pro- association between high levels of uncontrolled oxidative • stress and polycystic ovarian syndrome, endometriosis, cesses of the female reproductive tract that contribute to unexplained infertility, preeclampsia, and recurrent infertility and poor pregnancy outcome, such as polycystic pregnancy loss has been well established by numerous ovarian syndrome (PCOS), endometriosis, unexplained studies that have measured various biomarkers of redox infertility, preeclampsia, and recurrent pregnancy loss. status. As high degrees of reactive oxygen species and low • Antioxidant treatment of PCOS: N-acetyl cysteine may antioxidant status has been implicated in these diseases, improve glucose control and peripheral insulin sensitivity treatment based on strategies to boost the exhausted in hyperinsulinemic patients. Oral hypoglycaemic agent antioxidant defense of the female reproductive micro- rosiglitazone and anti-androgenic oral contraceptives environment are intuitive. This approach seems especially have been shown to reduce parameters of OS in hyper- plausible in light of the fact that oral antioxidant supple- insulinemic patients. mentation in males has been proven effective to treat male infertility and is widely employed in current clinical practice. • Endometriosis: The antioxidants catalase, RU486, However, reports regarding the safety and efficacy of oral curcumin, melatonin, and catechins may have anti-pro- antioxidant supplementation in the treatment of female liferative and anti-angiogenic effects capable of halting infertility are conflicting. Additional studies using double- disease progression. blinded, randomized, controlled trials are needed to further • Selenium supplementation of women with unexplained evaluate the potential use of antioxidants to treat female infertility has been shown to normalize patient’s RBC- reproductive disease. Mg levels and result in clinical pregnancy after 8 months of treatment. FIVE YEAR VIEW • Despite the well-established causal relationship between There is a need for continued investigation of the efficacy OS and preeclampsia, studies have failed to detect any and safety profiles of various oral antioxidant supplements risk reduction for preeclampsia with vitamin C and vita- before this modality of treatment can be relied upon to min E supplementation. modulate the levels of oxidative stress that contribute to infertility and abnormal pregnancy in women with • The antioxidants folic acid, melatonin, and omega-3 fatty obstetrical and gynecologic disease. Observational studies acids (particularly in women with antiphospholid anti- and randomized control trials have identified several body syndrome) have been investigated for their use in antioxidant therapies of interest which have demonstrated preventing recurrent pregnancy loss. Further studies to striking promise in the prevention and treatment of female confirm the safety and efficacy of these compounds are reproductive disease. However, it is still unclear as to what needed. types or combinations of therapy as well as the amounts and dosing that are optimal for women, particularly during REFERENCES pregnancy. It is necessary to conduct further studies to [1] Pierce JD, Cackler AB, Arnett MG. Why should you care about identify any possibility of deleterious side effects of free radicals? RN 2004, 67: 38-42. quiz 43 antioxidants on mothers and their unborn baby. Despite the [2] Szczepanska M, Kozlik J, Skrzypczak J, Mikolajczyk M. 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Received: January 10, 2010 Revised: February 09, 2010 Accepted: April 15, 2010

96 Current Women’s Health Reviews, 2010, 6, 96-107 Role of Oxidative Stress in Polycystic Ovary Syndrome

Joo Yeon Lee1, Chin-Kun Baw1, Sajal Gupta1, Nabil Aziz2 and Ashok Agarwal1,*

1Center for Reproductive Medicine, Cleveland Clinic, Cleveland, USA; 2Liverpool Women’s Hospital, Liverpool, UK

Abstract: Polycystic ovary syndrome (PCOS) is a multifactorial disorder affecting many women of reproductive age, typically due to hyperandrogenemia, hyperinsulinemia, and enigmatic genetic factors. The complex nature of PCOS is reflected in the broad spectrum of the disorder’s clinical presentation, including metabolic and reproductive disorders. As a result, while the European Society for Human Reproduction and Embryology and the American Society for Reproduc- tive Medicine (ESHRE/ASRM) have agreed on a consensus definition of PCOS to help clinical investigators, the condition is recognized to have multiple clinical phenotypes. Oxidative stress (OS) occurs when destructive reactive oxygen species (ROS) outbalance antioxidants, causing DNA damage and/or cell apoptosis. Moreover, reactive nitrogen species (RNS), such as nitrogen oxide (NO) with an unpaired electron also are highly reactive and toxic. In a quest to delineate the role of OS in the pathogenesis of PCOS, investigators have examined patients with the disorder for a wide array of OS biomarkers, including malondialdehyde (MDA), protein carbonyl, total antioxidant capacity (TAC), superoxide dismutase (SOD), glutathione peroxidase (GPx), and glutathione (GSH). Keywords: Polycystic ovary syndrome (PCOS), oxidative stress (OS), insulin resistance, hyperandrogenism, reactive oxygen species (ROS), nitric oxide synthase (NOS).

INTRODUCTION overview of current knowledge in PCOS and ROS’ roles in women during their reproductive years, exhibiting a wide PCOS is one of the most common endocrinological spectrum of clinical manifestations in PCOS women, which pathologies in women during their reproductive years exhib- have been investigated more actively in recent years. iting a wide spectrum of clinical manifestations. PCOS women commonly have features of hyperandrogenism and DEFINITION AND DIAGNOSIS OF POLYCYSTIC the primary cause of PCOS is probably multifactorial in OVARY SYNDROME origin [1]. Increased insulin resistance is viewed as a central feature of PCOS irrespective of the body mass index (BMI). The definition of PCOS has been controversial and still The resulting hyperinsulinemia together with central obesity, remains unclear due to the syndrome’s heterotrophic nature. which is frequently encountered in PCOS patients, are com- Following the first report on women with polycystic ovaries ponents of metabolic syndrome. Metabolic syndrome, which in 1935, the term “polycystic ovarian syndrome” was estab- affects one in five people, increases the risk of developing lished as more clinicians noticed the correlations between cardiovascular disease and type II diabetes, and its preva- hyperinsulinemia, androstenedione, testosterone levels, and lence increases with age. PCOS patients have been reported PCOS [5]. However, a wide spectrum of clinical manifesta- to have markers of cardiovascular and endothelial disorders tions, including impaired glucose tolerance [6], prevalence of in addition to the familiar features of hirsutisms, acne, and type II diabetes [7], increased risk of hypertension and dis- anovulatory infertility [2]. lipidemia, and elevated endothelial dysfunction [8] further complicated the debate on defining PCOS. The presence of Oxidative stress is commonly referred as the imbalance clinical or biochemical hyperandrogenism or polycystic ova- between oxidants and antioxidants. When the imbalance fa- ries with regular cycles was broadly interpreted as PCOS [9, vors oxidants, generation of excessive amounts of reactive 10]. As a result, there were no widely accepted diagnostic oxygen species harm our body in various ways [3] through criteria available until the National Institute of Health (NIH) the generation of excessive amounts of reactive oxygen spe- criteria were introduced in 1990. cies. In other words, reproductive cells and tissues will remain stable only when antioxidant and oxidant status is in In 1990, the NIH established diagnostic criteria that char- balance. Oxidative stress, which is generally known to be acterize PCOS as the combination of oligomenorrhea or present in women with PCOS regardless of whether they are amenorrhea and hyperandrogenemia in the absence of non- lean or have metabolic abnormalities, has been documented classical adrenal hyperplasia, hyperprolactinemia, and thy- in infertile women [4]. The present review study provides an roid dysfunction [11]. These criteria, however, did not include ultrasound morphology of polycystic ovaries in the

belief that broader clinical diagnostic criteria were in need *Address correspondence to this author at the, Center for Reproductive for clinicians to accurately diagnose multi-etiologic PCOS. Medicine, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA; Tel: 216-444-9485; Fax: 216-445-6049; In Europe, clinicians maintained that the ultrasound appear- E-mail: [email protected] ance of polycystic ovary was an essential criterion to diag-

1573-4048/10 $55.00+.00 © 2010 Bentham Science Publishers Ltd. Role of Oxidative Stress in Polycystic Ovary Syndrome Current Women’s Health Reviews, 2010, Vol. 6, No. 2 97 nose PCOS. As a result of the continued dialogue between hyperandrogenism, acanthosis nigricans, insulin resistance, the ESHRE and the ASRM, a consensus document was pro- reproductive aberration and obesity (Fig. 1). duced, commonly referred to as the Rotterdam 2003 criteria for defining PCOS. Oligomenorrhea The new definition of PCOS suggested that the diagnosis PCOS is an ovarian dysfunction caused by androgens, of PCOS must be based on the presence of two of the three which inhibit folliculogenesis and lead to polyfollicular following criteria: (i) oligo- and/or anovulation, (ii) clinical morphology, which then disturbs the menstrual cycle and and/or biochemical signs of hyperandrogenism, and (iii) leads to anovulation [15]. Among women experiencing oli- polycystic ovaries on ultrasonography and exclusion of re- goanovulation, 65-87% have PCOS [16]. The wide range lated disorders [12, 13]. The ultrasound criteria for polycys- may be attributed to the heterogeneous and complex nature tic ovaries is defined as the presence of 12 or more follicles of PCOS as well as the variation in criteria used for diagno- measuring 2 to 9 mm in diameter and /or an increased ovar- sis. According to Balen et al. (1995), among women with ian volume > 10 cm3 on transvaginal ultrasound scanning. PCOS, 47% experience oligomenorrhea [17], defined as six PCOS is diagnosed even when only one polycystic ovary is or fewer menses annually. A majority of women with PCOS present [14]. However, these criteria do not apply to women experience irregular menstrual cycles, of which the most taking oral contraceptive pills since their use modifies ovar- common manifestation is infrequent menstruation related to ian morphology that slightly different biochemical findings anovulation [14]. In a study of 173 women, polycystic ova- were included in Rotterdam criteria (Table 1) [14]. While ries were observed on pelvic ultrasound scan in 87% of NIH criteria considered total testosterone, free testosterone, women who also suffered from oligomenorrhea [9]. Moreo- androstenedione, and DHEA as biochemical markers, the ver, some evidence indicates the presence of oligomenorrhea 2003 Rotterdam criteria now consider free androgen index, to be highly suggestive of PCOS in adolescents [18]. total testosterone, and DHEA as diagnostic biochemical markers. Moreover, the Rotterdam criteria recognize the role Hyperandrogenism (Hirsutism, Acne, and Male Pattern of genetics in PCOS and encourage clinicians to take family Alopecia) histories to identify PCOS individuals more effectively [12, Hypersecretion of androgens is the most widespread bio- 13]. Compared with the NIH definition, the new definition chemical feature in PCOS women [19]. PCOS accounts for introduced two new phenotypes: (i) ovulatory women with 70-80% of hyperandrogenism and is associated with elevated polycystic ovaries and hyperandrogenism, and (ii) oligo- serum total or free testosterone concentrations [20]. Hyper- anovulatory women with polycystic ovaries without hyperandrogenism can manifest as hirsutism, acne, and male pat- androgenism. This has stimulated more debate as to where tern alopecia. Whether hyperandrogenemia affects oxidant the boundaries should be set in diagnosing PCOS [1]. and antioxidant status in women with PCOS is unknown. However, in a human study, ROS generation was demon- Table 1. Comparison of Two Established Diagnostic Criteria strated to directly correlate with testosterone and andros- of PCOS tenedione [21], suggesting that ROS induces OS, which may consequently contribute to hyperandrogenism in PCOS women. Plasma testosterone or androstenedione and ROS NIH Criteria (1990) Rotterdam Criteria (2003) generation are associated, suggesting that OS may directly stimulate hyperandrogenism. In vitro studies have demon- (i) Oligomenorrhea or amenrrhea (i) Oligo- and/or anovulation strated that OS stimulates the androgen-producing ovarian (ii) Hyperandrogenemia in the (ii) Clinical and/or biochemical signs steroidogenic enzymes, while antioxidants such as statins absence of related disorders of hyperandrogenism suppress these enzymes [22]. (iii) Polycystic ovaries on PCOS is present in 60-90% of women with hirsutism [16, ultrasonography and exclusion of 17, 23, 24] as increased androgen production leads to hirsu- related disorders tism and acne. Among women with PCOS, 35% have acne, Both (i) and (ii) must be present Two of three criteria must be satisfied and 6% express alopoecia [17]. An inflammatory disorder of the hair follicle, acne is associated mainly with elevated lev- Diagnostic markers: total Diagnostic markers: free androgen els of sebaceous secretion [25, 26]. Among women of mixed testosterone,free testosterone, index, total testosterone, and DHEA ethnicities with androgenic alopecia, 67% had polycystic androstenedione and DHEA ovaries compared with the 27% expressed in the BMI-, waist-hip-ratio- and age-matched control group [27]. Also, 21% of the women with androgenic alopecia demonstrated CLINICAL MANIFESTATIONS AND EPIDEMIOL- hirsutism, while this is true for only 4% of the BMI-, waist- OGY OF POLYCYSTIC OVARY SYNDROME hip-ratio- and age-matched control group. PCOS occurs in 4-8% of women during their repro- Ovarian invasion by macrophages has been observed in ductive years, and it is the most frequent endocrine disease PCOS women [28]. Moreover, mononuclear cells in the in women [8]. Approximately one in 15 women experiences polycystic ovary activated by glucose can generate OS that PCOS [1], and an enlarged ovary is observed on ultrasound could stimulate a local inflammatory response, which could in 22% of women [14] during their reproductive years. Other in turn induce the generation of ovarian androgen in PCOS common clinical manifestations include oligomenorrhea, women [29]. More specifically, theca cells in the ovarian 98 Current Women’s Health Reviews, 2010, Vol. 6, No. 2 Lee et al.

Fig. (1). Schematic description of various pathogenic factors that manifest PCOS in women of reproductive age. Such patients are at risk of developing a spectrum of disease phenotypes. tissue overproduce androgens and insulin receptors and lead Insulin resistance encourages oxidative stress because to hyperandrogenism [31]. Moreover, some researchers have hyperglycemia and higher levels of free fatty acids lead to investigated genetically programmed androgen secretion by ROS production. An increase in ROS generation resulting the ovary during early childhood or puberty, which may con- from hyperglycemia has been observed in women with tribute to pathophysiology in PCOS women [30]. PCOS [36], and insulin infusion in obese individuals has been shown to inhibit ROS production [37]. Thus, insulin Acanthosis Nigricans may defend against pro-inflammatory responses to hypergly- Acanthosis nigricans, a disorder seen as dark and velvety cemia by acting as an anti-inflammatory agent. skin with hyperpigmentation and papillomatosis, manifests Approximately 75% of obese PCOS women have IR and itself normally in the axillae, skin flexures, and nape of the hyperinsulinemia [38]. However, insulin resistance inde- neck. Among women with PCOS, only 3% express acantho- pendent of obesity can play a role in PCOS. Young, non- sis nigricans [17], which is associated with insulin resistance obese PCOS patients with high triglyceride levels as the only and, consequently, hyperinsulinemia [32]. dyslipidemic feature have demonstrated high oxidative levels Insulin Resistance [2]. Furthermore, 20-40% of women with PCOS have impaired glucose tolerance [6], and women with PCOS exhibit Increased oxidant status has been shown to correlate with higher levels of type II diabetes (T2DM) than non-PCOS insulin resistance. Insulin resistance can be found in 25-60% controls (15% vs 2-3% in normal women) [7]. Insulin resis- of women with PCOS [33]. The wide range may be due to tance and hyperinsulinemia also are features of metabolic varying diagnostic criteria, the heterogeneous nature of syndrome, and women with PCOS exhibit an increased risk PCOS, and ethnic variations. Insulin resistance (IR) and hy- of hypertension, dyslipidemia, elevated plasminogen inhibi- perglycemia both can increase OS levels, although higher tor type 1, elevated endothelin, endothelial dysfunction, and levels of total oxidant and antioxidant status have been dem- cardiovascular disease similar to the risks associated with onstrated in non-obese PCOS patients without IR [34]. Hy- metabolic syndrome [8]. perglycemia has been demonstrated to increase lipid peroxidation and lower antioxidant levels [35]. A significantly Reproductive Aberration (Irregular Menses, Infertility, negative correlation between MDA levels, a marker of OS, Miscarriage) and insulin sensitivity, as well as MDA levels and GSH (antioxidant) levels has been demonstrated [4]. This may imply PCOS is a known cause of menstrual irregularity as well that insulin resistance decreases antioxidant levels and as infertility. Most commonly, irregular menstruation is as- increases lipid hydroperoxide (LPO). Role of Oxidative Stress in Polycystic Ovary Syndrome Current Women’s Health Reviews, 2010, Vol. 6, No. 2 99 sociated with anovulation. Between 30-40% of women with ETIOLOGY OF POLYCYSTIC OVARY SYNDROME amenorrhea are found to have PCOS [39]. Pathogenesis of PCOS Among PCOS women, more than 60% manifest infertil- Women with PCOS manifest a wide spectrum of symp- ity (primary/secondary), and 19% experience amenorrhea toms and clinical features, including hyperandrogenism, ovu- [17]. Moreover, pregnancy in PCOS women is more likely to latory disturbances and polycystic ovaries and metabolic be complicated by gestational diabetes, preeclampsia, preg- syndromes (Fig. 1). The latter is linked to insulin resistance nancy hypertension, and preterm labor leading to miscarriage and obesity that are often associated with PCOS [6, 49, 50]. [40]. Obesity in PCOS further increases resistance to ovula- In other words, the heterogeneity of PCOS is reflected in the tion induction treatment since obesity is associated with a multiplicity of factors such as insulin resistance, hyperan- disturbed pattern of gonadotrophin-releasing hormone pro- drogenism, and dysfunctional gonadotrophin dynamics that duction resulting in chronic elevation of tonic LH level with must come into play to manifest the disorder, and no single negative consequences on follicular development in the mechanism accounts for all clinical and biochemical forms ovary [40]. of this syndrome. Moreover, environmental factors such as diet or stress also can trigger underlying risk factors and Obesity cause the development of PCOS. The most commonly dis- Obesity is more common in women with PCOS, and it cussed causes of PCOS can be categorized into three mecha- can lead to severe hyperandrogenism. According to Franks nisms: (i) insulin resistance and hyperinsulinemia, (ii) hyper- (1989), 35% of women with PCOS are obese [10]. Increas- androgenemia and (iii) genetic factors. ing visceral adipose tissue and/or its activity may contribute (i) Insulin Resistance and Hyperinsulinemia to androgenic modulation [41]. Androgen excess is a known contributor to visceral adiposity in women, which provides Insulin resistance, in which an abnormally high amount high metabolically active tissue that stimulates the ovaries of insulin (hyperinsulinemia) is required to initiate a cellular and adrenal to proceed with androgenization [15]. Both response, is the most commonly encountered clinical disorder in both obese and non-obese PCOS women [51]. An oral androgens and IR seem to have a combined effect on upper glucose tolerance test is recommended for PCOS patients body adipose distribution. Obesity contributes to PCOS, as it with BMI greater than 27 kg/m3 [14] because of the high risk affects hyperandrogenism and IR. In fact, the most influen- for developing impaired glucose tolerance and diabetes in tial factor in endocrinologic and metabolic disturbances in obese PCOS women (31% of obese PCOS patients vs. women with PCOS has been shown to be an elevated BMI > 10.3% of lean PCOS patients and 7.5% of obese PCOS 25 [42]. patients vs. 1.5% of lean PCOS patients, respectively) [6]. Central obesity is also related to increased oxidant status Women with IR display increased fasting insulin level com- [4]. Obesity has been shown to play an important role in ele- pare with controls of similar age and body weight. As a re- vated oxidative stress, which contributes to IR [43]. PCOS sult, clinical and molecular research has focused on insulin patients who are obese express higher levels of insulin resis- receptor and post-receptor defects [19]. Some studies have tance than lean PCOS patients [8]. The study by González et correlated severity of hyperinsulinemia to the degree of al. (2006) shows that compared with lean controls, PCOS clinical manifestation. women express higher p47phox levels independent of obesity. Insulin signaling, mediated through a protein tyrosine In oxidative stress, p47phox plays a role as part of enzymes kinase receptor, has been investigated in PCOS patients. that produce the superoxide radical. Increase in p47phox ex- Dunaif et al. (1997) reported excessive serine phosphoryla- pression decreases insulin sensitivity. It also has been shown tion, which inhibits insulin receptortyrosine kinase activity, to be greater in PCOS women versus controls and in obese of insulin receptors in insulin- resistant PCOS patients. PCOS and non-PCOS women versus lean PCOS women and Moreover, adverse roles of serine phosphorylation in insulin non-PCOS women [29]. Thus, increased obesity may deter- signaling were further supported by the mechanism of tumor mine ROS-induced OS in obese PCOS women. PCOS also necrosis factor (TNF)--mediated insulin resistance in obese affects insulin performance, as increase in abdominal fat is women [53] and P450c17 enzyme activity leading to hyper- associated with insulin resistance [1]. Slightly reducing the androgenism in PCOS women [54]. Hyperinsulinemia also body weight of anovulatory, obese women was demonstrated potentiates the effects of LH on theca interstitial cells, result- to restore ovulation and increase insulin sensitivity by 71% ing in increased androgen production [19] while arresting the follicular maturation process [55, 56]. [44]. Weight loss also reduces testosterone concentration, improves menstrual function and conception rates, decreases (ii) Hyperandrogenemia the likelihood of miscarriage, and increases sex hormone- The ovary is the primary source of hyperandrogenism in binding globulin (SHBG) concentration [45-48]. PCOS, driven by increased levels of LH hormone as ovarian Aside from obese PCOS women, lean PCOS women can dysfunction causes LH insensitivity [57]. The increase in express increased levels of abdominal adiposity [21]. In basal LH level is the result of a disrupted hypothalamic- a study of 16 women with PCOS and 15 women without pituitary-gonadal axis [58]. Moreover, hyperandrogenemia PCOS, mononuclear cells produced elevated levels of ROS impairs progesterone’s ability to slow down the gonadotro- in response to hyperglycemia in PCOS women, independent pin-releasing hormone (GnRH) pulse [58]. As a result, of obesity [29]. elevated GnRH pulses further increase LH level and reduce

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FSH, which converts excess androgen into estrogens via Hyperandrogenemia in PCOS women is due partially to aromatase activity in normal women [15]. The elevated LH intrinsic defects in metabolic pathways. Because hyperan- level arrests follicular cells and stimulates theca-cell- drogenism is prevalent among PCOS patients, genes in- mediated androgen synthesis. Consequently, the increased volved in steroidogenesis such as cytochrome P450 17- androgenic environment in the ovary impairs follicular matu- hydroxylase/17,20-desmolase (CYP17) and the aromatase rations [8]. gene (CYP19) have been investigated. Upregulations of 3- hydroxysteroid dehydrogenase and17-hydroxylase/17,20- Some studies have shown hyperandrogenemia and lyase activities in PCOS women [68] are reflected in in- hypoestrogenemia in PCOS-like conditions as the result of creased mRNA expression and an enhanced promoter region ovarian steroidogenic enzyme deficiencies such as 3- of CYP17 genes of the theca cells in young girls compared hydroxysteroid dehydrogenase type II and aromatase [59] In with controls [69]. On the other hand, a functional mutation other words, follicles that are unable to change their sur- of the CYP19 aromatase gene leads to excess circulating roundings from androgen-dominant to estrogen-dominant androgens in PCOS women [70-72]. However, family stud- environments will not acquire normal follicular growth and ies have not yet shown a correlation between CYP19 and manifest as a polycystic ovary, a characteristic feature of PCOS [73], and more evidence is needed to confirm this PCOS. Adrenal steroidogenesis dysfunction also has been hypothesis. implicated in establishing a state of hyperandrogenemia in PCOS. When adrenal steroidogenesis dysfunction results in Genes involved in insulin signal transduction have been reduced cortisol production, adrenocorticotrophic hormone investigated. Variable number tandem repeat (VNTR) poly- (ACTH) production is increased to maintain normal serum morphism in the promoter region of the insulin gene at 11p15.5 cortisol level [8]. Increased ACTH production consequently has shown quite confusing results. While Waterworth et al. stimulates adrenal androgen excess [8]. Thus, hyperandro- (1997) [74] found strong correlations between class III genism in PCOS women is caused by synergic aberration in variable number tandem repeats of the insulin gene allele and steroidogenesis of both ovary and adrenal glands. PCOS, Urbanek et al. (1999) [75] did not find evidence to link the class III allele and PCOS. The insulin receptor gene As stated above, hyperinsulinemia drives increased an- is another probable candidate gene since it seems to be si- drogen production by theca cells [60]. Studies have shown lenced in molecular studies [19]. However, defective insulin that bilateral oophorectomy, the surgical removal of both receptor function is observed in the presence of serine phos- ovaries [61, 62], the administration of GnRH-agonists to phorylation instead of tyrosine phosphorylation in insulin mimic an increased GnRH pulse [63], or antiandrogenic receptors [52], suggesting more studies are required on compounds [64] did not alter hyperinsulinemia and IR in downstream targets of the insulin receptor gene [19]. PCOS women. Evidence supports disordered insulin action as a predecessor to development of hyperandrogenemia in Hormonal Markers in PCOS Patients PCOS patients. Hormonal markers in PCOS women are viewed as a way (iii) Genetic Factors to evaluate steroidogenesis. The most commonly encountered markers include, but are not limited to LH, FSH, estro- Given that the incidence of PCOS is 6-8% in the general gen, sex hormone-binding globulins (SHBG), insulin-like population [65], 35% of premenopausal mothers and 40% of growth factor -1 (IGF-1), total/free testosterone, andros- sisters of PCOS women [65] suggests a probable role for tenedione, dehydroepiandrosterone (DHEA) and DHEA me- genetics in PCOS. However, no conclusive role for any gene tabolite DHEAS, anti-Mullerian hormone (AMH), and 17- has been defined. This may be due to the limited selection of hydroxyprogesterone [8, 19, 60, 76]. candidate genes, PCOS’s heterogeneous nature, or lack of knowledge of disease pathophysiology and the role of envi- Testosterone production and high insulin level in PCOS ronmental and lifestyle factors such as diet and obesity in women directly down-regulate SHBG synthesis by the liver, modifying gene expressions [66]. Moreover, lack of univer- which makes a low SHBG level a good indicator of insulin sal male patterns and reliable markers for PCOS in women resistance [77]. SHBG has strong binding affinity to testos- further challenge investigations of the syndrome’s genetic terone and dihydrotestosterone thus controlling androgen origin. The proposed male phenotypes, such as increased bioavailability in serum [78]. Reduced SHBG results in serum dehydroepiandrosterone sulfate concentrations in increased levels of bioavailable testosterone. Since serum- brothers of PCOS women and insulin resistance in fathers bound testosterone (T) is the most frequent androgen and brothers of PCOS women still require further investiga- measured to diagnose hyperandrogenemia, the reduction in tion for their practical uses [67]. However, more than 100 the proportion bound to SHBG makes the assessment some- candidate gene approaches have selected genes based on what unreliable [76]. As a result, the free androgen index their hypothetical roles in PCOS and target four general (FAI=T/SHBG * 100%) or the association constant for areas: (i) steroid biosynthesis and action; (ii) gonadotrophin testosterone binding to SHBG and albumin are utilized to synthesis and action; (iii) weight and energy regulation; and account for these metabolic changes [79]. Free T also may be (iv) insulin secretion and action, as well as several areas measured directly via equilibrium dialysis [76]. Although added recently such as cardiovascular disease via inflamma- other androgens such as androstenedione (A4) or total testos- tion, hypercoagulation, and blood pressure [66]. Of those, terone may also be utilized to diagnose hyperandrogenemia, genes involved in steroidogenic abnormalities and insulin no studies have indicated their superiority as surrogate mark- metabolism aberrations have been investigated the most due ers. For example, Knochenhauer et al. (1998) showed that to their importance in PCOS’ clinical manifestations. only 2 out of 11 (18%) PCOS women had abnormally higher Role of Oxidative Stress in Polycystic Ovary Syndrome Current Women’s Health Reviews, 2010, Vol. 6, No. 2 101 thyroxine (T4) level, which is blunted by high testosterone carbohydrates, and other nearby molecules [97], thus induc- level. ing cellular damage. The two major forms of free radicals are ROS and RNS. Free electrons typically form reactive oxygen Insulin binds to IGF-1 receptors on theca cells with sig- species during oxygen reduction as a by-product of natural nificantly higher affinities than IGF-1 [81]. Hepatic IGF-1 metabolic pathways [98]. Most of the mitochondrial genera- binding protein secretion also is inhibited in PCOS women, tion of ROS occurs at complexes I (where NADH dehydro- leading to excessive free IGF-1, which is suspected to play a genase acts), and III (where the ubiquinol to ubisemquinone role in the abnormal androgenesis of theca cells along with to ubiquinone conversion occurs) of the electron transport high LH [82]. IGF-1 and insulin further increase mRNA of chain (ETC) [99]. P450c17, leading to increased androgen biosynthesis in ovary and adrenal glands [8]. The use of insulin-sensitizing Of inspired oxygen, 98% is reduced during lipolysis and agents such as metformin has been demonstrated not only to chemical energy generation, and 2% is incompletely re- reduce circulating insulin concentration but also to reduce duced, leading to three major forms of ROS [97]. The three main forms of reactive oxygen species are the superoxide ovarian androgen biosynthesis [83]. 2- · radical [O ], hydrogen peroxide [H2O2], and hydroxyl [HO ]. DHEA secreted from the adrenal zona reticularis is an- Superoxide is formed through electron leakage at the elec- other actively investigated hormonal marker in PCOS tron transport train. At complex IV, molecular oxygen nor- women. However, DHEA has several shortcomings as a sur- mally is converted to water, but it may gain an extra electron rogate marker due to its diurnal variation, intra-subject varia- as they are being passed down the ETC during ATP generation and low serum concentration [84]. On the other hand, tion [100]. Hydrogen peroxide is formed from either super- DHEAS, DHEA’s sulfate ester, is not subject to these varia- oxide dismutation or oxidase enzymes. The most reactive tions, making it a more preferred marker to assess increased form is the hydroxyl ion, as it has three extra electrons. adrenal androgen production [85]. In clinical studies, ap- Through alteration of purines and pyramidines it can cause proximately 20-70% of PCOS women manifest excess strand breaks and damage DNA. When the balance between DHEAS serum levels [86-88]. However, DHEAS levels de- antioxidants and oxidants does not exist, modification of key crease with age [88], and levels are controlled by the activity transcription factors can occur, which can alter gene expres- of DHEA sulfotransferase [89]. Moreover, ethnicity also sion (Fig. 2). The superoxide radical can be converted to may affect circulating DHEAS levels with lower circulating hydrogen peroxide by mitochondrial superoxide dismutase 2, levels of DHEAS is reported in Mexican American group preceding further modification by GSH peroxidase to form compared with Caucasian American controls [90]. Conse- water. Thus, the presence of antioxidants is vital to maintain- quently, in PCOS patients with high DHEAS measurements, ing redox homeostasis. Decreased amounts of antioxidants to only 10% will actually have hyperandrogenaemia [76]. Thus, counteract the production of ROS can lead to cell damage DHEAS measurements should be interpreted with caution [99]. [76]. ROLE OF ROS IN PCOS AMH is secreted from the Sertoli cells of the fetal testis to inhibit female Mullerian ducts development in a male em- ROS are free radicals with oxygen centers. An unpaired bryo. It also is produced by the granulosa cells of small an- electron in the outermost shell is an extremely unstable con- tral and pre-antral follicles to disrupt FSH’s aromatase in- figuration, and free radicals quickly react with other mole- duction in the ovary [91], compromising normal ovulation in cules or radicals to achieve the stable configuration of pairs PCOS women. Studies have shown that AMH levels are sig- of electrons in their outermost shells [101]. Several basic nificantly higher in PCOS women [92] and confirmed that cellular processes lead to the production of ROS within a granulosa cells release more AMH when cultured in vitro cell. Cellular respiration involves the reduction of molecular [93]. Moreover, AMH level was positively correlated with oxygen (O2) to water in the electron transport chain. This reduction occurs through a series of reactions: (i) O2 + e- antral follicle counts [94], suggesting that serum AMH -· -· -· · O2 , (ii) O2 + 2H2O 2H2O2, (iii) O2 + H2O2 OH + measurements may serve as an alternative diagnostic tool - OH + O2. As mentioned earlier, the superoxide anion radical when ultrasonography is not an option inpatients younger -· (O2 ), hydrogen peroxide (H2O2), and the hydroxyl radical than 35 (1). While AMH’s role in folliculogenesis is gener- · ally established, its association with circulating androgens is (HO ) are three major species of ROS [97]. more controversial. Pigny et al. (2003) [95] found a correlation between AMH and testosterone and androstenedione Role of MDA in PCOS only in PCOS women, while Piltonen et al. (2005) [96] Unsaturated fatty acid peroxidation is a radical chain reported AMH levels in both PCOS women and controls reaction initiated by the abstraction of a hydrogen atom from were correlated with both testosterone and androstenedione. a methylene group of the fatty acid chain. The carbon radical In conclusion, no hormonal marker can be used as the formed by this reaction tends to be stabilized by molecular sole criterion to diagnose PCOS. Hormonal assays may serve rearrangement, leading to conjugated double bonds. By reac- as supplementary diagnostic tools for clinicians and scien- tion with oxygen, a reactive peroxy radical is generated that tists. can abstract a hydrogen atom from lipids [102]. Products of lipid peroxidation reactions have been widely INTRODUCTION TO OXIDATIVE STRESS employed as biomarkers for OS. MDA, produced during the Unstable and highly reactive, free radicals achieve stabil- decomposition of polyunsaturated fatty acids, is one of the ity by stealing electrons from nucleic acids, proteins, lipids, stable end products of lipid peroxidation that can serve as a 102 Current Women’s Health Reviews, 2010, Vol. 6, No. 2 Lee et al. good biomarker [102]. Several methods are available for with controls also were also found by Palacio et al. (2006) quantification of lipid hydroperoxides and secondary lipid [103]. peroxidation products. MDA is most commonly measured Zhang et al. (2008) demonstrated that serum MDA levels by a thiobarbituric acid-reactive substances (TBARS) assay in PCOS patients (n=30) were significantly higher than those with a simple spectrophotometric method. The amount of controls (12.313±2.512 vs 6.932±1.663 mol/L, P<0.05) of MDA corresponds to the chromogen found from MDA (104). A negative point of this study was that some of the and thiobarbituric acid (TBA) with a maximum absorption at important patient characteristics, such as BMI and age, were 532-535 nm. While the assay for MDA is non-specific, not recorded. HPLC is a more accurate tool for MDA estimation. However, Karadeniz et al. (2008) [105] found MDA levels in PCOS patients (n=58) were similar to those of controls (5.38±2.47 vs 4.475±2.06, p>0.05) (105). Furthermore, MDA levels were found to be similar in a PCOS patient group where the homeostatic model assessment (HOMA)-IR was below and above the cutoff value of 1.75. This observation suggests that the presence of insulin resistance in PCOS patients has no effect on MDA levels. In addition, Dursun et al. studied PCOS patients (n=23, mean BMI 23.0 and mean age 24.4 years) and found serum MDA levels in PCOS patients were similar to those of BMI- and smoking status- matched controls (3.60±1.22 vs 3.53±1.0 mol/l) [106]. Role of Protein Carbonyl Protein oxidation status often is assessed with a col- orimetric assay that measures protein carbonyl (PC) content, after reacting the serum with dinitrophenylhydrazine. Fenkci et al. (2007) demonstrated that the PC level was significantly higher in PCOS patients with normal BMI compared with controls (18.01±0.80 vs 14.19±0.40 nmol/L, p=0.001). This observation of higher protein oxidation suggested that free radicals damage proteins in PCOS patients [107]. Further- more, protein carbonyls were shown to have a positive corre-

lation with fasting insulin, suggesting a strong association between insulin resistance and protein oxidation in PCOS [107]. Role of NOS in PCOS

Fig. (2). Oxidative stress occurs when the balance between highly RNS are free radicals with nitrogen centers. The two reactive radicals (oxidants) and antioxidants tips towards the major examples of RNS are nitric oxide (NO) and nitrogen oxidants; it negatively contributes to reproductive processes. dioxide (NO2). NO is specifically synthesized by NOS during the conversion of L-arginine to L-citrulline [97]. Under Kuçu et al. (2009) compared PCOS patients (n=31, normal physiological process, NO acts in a variety of tissues mean age 23.8 years and mean BMI 21.8) with healthy con- to regulate normal cell functions, but excess of NO can be trols. Blood MDA level, not specified as measured from se- toxic [101]. NO, with an unpaired electron, is highly reactive rum or erythrocyte, was found to be significantly higher in and can damage proteins, carbohydrates, nucleotides and the PCOS group (0.12±0.03 vs 0.10±0.03, p=0.01). This lipids. RNS have been associated with asthma, ischemic/ study demonstrated that PCOS subjects had significantly reperfusion injury, septic shock, and atherosclerosis [108]. elevated concentration of plasma MDA independent of obesity. PCOS patients in this study were further divided into Role of NO two subgroups in terms of insulin resistance, IR- and IR+. - - Measuring plasma concentration of NO3 and NO2 The results showed that MDA level is significantly higher in - - assesses NO concentration. The sum of NO and NO is young, non-obese PCOS patients even in the absence of IR 3 2 assumed as the best index of total NO. NO contents are when compared with controls (0.125±0.03 vs 0.101±0.03, assessed by a two-step process consisting of the conversion p=0.03) (2). of nitrate to nitrite first, followed by spectrophotometric Sabuncu et al. (2001) compared PCOS patients (n=27, detection of total nitrite at 540 nm [109]. mean BMI 31.4 and mean age 26.7 years) with BMI- and Nácul et al. (2007) reported that NO levels in PCOS pa- age-matched controls. They demonstrated that higher levels tients (n=31, mean age 22.4±7.1 years and mean BMI of erythrocyte MDA were seen in PCOS patients (mean=70.9 26.7±10.1) were similar to that of age- and BMI-matched mol/mol Hb) compared with controls (p=0.009). Signifi- controls (NO mean value 11.5 vs 10.2 mol/L, p>0.05). cantly higher levels of MDA in PCOS patients compared Moreover, a significantly negative correlation was observed Role of Oxidative Stress in Polycystic Ovary Syndrome Current Women’s Health Reviews, 2010, Vol. 6, No. 2 103 between NO and fasting insulin levels (r=-0.39, p=0.03) and assay measures the combined antioxidant capacity of all its HOMA (r=-0.41, p=0.02) (84). These data suggested that components including vitamins, proteins, lipids, glutathione, NO was related to the presence of insulin resistance in PCOS uric acid, etc. [113]. patients, although further studies are needed to clarify the Another method to measure TAC is through the produc- role of NO in PCOS. tion of hydroxyl radical via Fenton reaction. It is initiated by the hydroxyl radical, and the brown-colored dianisidinyl ROLE OF ANTIOXIDANTS IN PCOS radical cations are produced in the reaction medium of the Antioxidants scavenge excess ROS to counteract poten- assay [114]. Antioxidant capacity of the added sample tial for significant cell damage by excess ROS. Antioxidants against these colored potent free-radical reactions is meas- help create a balance between beneficial oxidant generation ured as a whole to represent TAC. The results also were (frequently act as cell signaling molecules) and damaging expressed as millimoles of Trolox equivalent per liter [34]. oxidative stress. There are two categories of antioxidants: Fenkci et al. (2003) demonstrated that TAC was signifi- enzymatic and non-enzymatic. Enzymatic antioxidants in- cantly lower in PCOS patients (n=30 mean age 25.80±0.63 clude SOD, catalase, and GPx. Non-enzymatic antioxidants years and mean BMI 24.3±1.1) compared with the age-, include GSH, -tocopherol (vitamin E), -carotene, ascor- BMI-, and smoking status-matched controls (1.15±0.01 vs bate (vitamine C), taurine, L-carnitine, coenzyme Q10, etc 1.30±0.02 mmol/L, p=0.001) [115]. This observation sug- (97). There are three SOD isoforms in eukaryotes: manga- gested that the oxidative status imbalance in PCOS women nese SOD (Mn-SOD), copper/zinc SOD (Cu/Zn-SOD), and might contribute to their increased risk of cardiovascular extracellular SOD (EC-SOD)1. diseases. Moreover, there was a negative correlation between Antioxidants that prevent or limit the damaging effects of fasting insulin level and TAC, suggesting that that IR may oxygen radicals have been reported to have important roles have a detrimental effect on antioxidant defense system in in the female reproductive system and in the pathogenesis of PCOS. female infertility.2 Changes in antioxidant concentrations in However, Verit et al. (2008) reported that TAC levels serum and peritoneal fluid have been studied in idiopathic were significantly higher in PCOS patients (n=63 mean age infertility, tubal infertility, and endometriosis patients [111, 24.4±4.1 years and mean BMI 21.2±1.8) compared with age- 112]. Results indicate that investigation of antioxidant con- and BMI-matched controls (1.8±0.5 vs 1.1±0.2 mmol Trolox centrations in PCOS patients is promising. Various studies Eq/L, p<0.0001). This study demonstrated that TAC was have measured antioxidant markers to correlate OS and increased in non-obese, normoinsulinemic PCOS patients PCOS and the diverse clinical manifestations of metabolic (fasting insulin 10.7±5.0 IU/mL, no significant difference syndrome including diabetes, obesity, and cardiovascular compared with controls). High levels of antioxidants in diseases. PCOS are thus suggested to have detrimental effects. This result was inconsistent with other studies in the literature. Role of TAC in PCOS Although the complete mechanism of this elevation is un- Total antioxidant capacity is the ability of serum to known, it is proposed that TAC was increased as to compen- quench free radical production, protecting the cell structure sate for the increase in total oxidative stress (19.1±7.6 vs from molecular damage. Various detection assays for TAC 12.3±4.8 mol H2O2 Eq/L, p<0.0001) [34]. have been described, one of which is the spectrophotometric Although results of studies about antioxidant levels are assay in which long-lived 2,2’-azino-di-[3-ethylbenzthia- conflicting, it is possible to conclude that an imbalance be- zoline sulfonate] (ABTS) radical cation is measured. ABTS tween oxidants and antioxidants occurs in PCOS. Further radical is formed by the incubation of ABTS with a peroxi- studies of oxidative stress defenses in PCOS are needed to dase (metmyoglobin) and hydrogen peroxide. The principle clarify the association between antioxidants and PCOS. of the assay is to measure the ability of aqueous and lipid + antioxidants to inhibit the oxidation of ABTS to ABTS Role of SOD in PCOS [113]. The capacity of the antioxidants to prevent ABTS oxidation was compared with that of standard Trolox, a SOD induces the conversion of superoxide to H2O2, a brand name for 6-hydroxy-2,5,7,8-tetramethylchroman-2- toxic substance that is converted to water by GPx. High SOD carboxylic acid, a water-soluble derivative of vitamin E. This levels may explain the absence of endothelial dysfunction markers. Generation of an adequate antioxidant response against such an intrinsic oxidative load may provide proper functioning of vascular system. 1 Mn-SOD, which contains a manganese prosthetic group, resides in the mitochondria. -· It is thought to protect mitochondrial membranes, proteins, and DNA from O2 gener- Kuçu et al. (2009) demonstrated that SOD levels were ated as a result of the electron transport chain. The Cu/Zn-SOD, which contains copper significantly higher in a PCOS group compared with a con- and zinc prosthetic groups, often resides in cytosol. EC-SOD, is secreted and binds to trol group (8.0±0.7 vs 7.28±0.8, p=0.001). In this study the -· the elements of the extracellular matrix. All forms of SODs are thought to reduce O2 PCOS patients were further divided into two subgroups: IR- to form O2 via the oxidation of the prosthetic group [110]. and IR+. SOD levels were significantly higher in both sub-

2 · groups compared with the control (7.99±0.7 vs 8.22±0.8 vs The production of H2O2 within cells may lead to the production of HO and subse- 7.28±0.8, p=0.009 and 0.03, respectively). This elevation quent cellular damage. Thus, it is important to remove H2O2. Catalase functions to may have been due to the body’s defense mechanisms. Sub- rapidly transform H2O2 to water and oxygen via the redox reactions achieved by its jects used in this study were relatively young (mean age manganese or heme group. Catalase resides mainly in peroxisomes, mitochondria and the cytosol [110]. 104 Current Women’s Health Reviews, 2010, Vol. 6, No. 2 Lee et al.

23.8±4.37 years) with greater ability to cope with higher KEY POINTS levels of ROS production. • PCOS is the most common female endocrinological ab- Sabuncu et al. (2001) demonstrated elevated SOD levels normality, affecting 4-8% of women in their reproductive (mean value 94.62 MU/mol Hb) in a group of PCOS patients years. with mean BMI 31.4 (p<0.05). They proposed that the increase in SOD levels might be due to a compensatory • Clinical PCOS is diagnosed in women based on presence response to OS. of at least two of the following criteria a) oligo- or anovulation, b) biochemical and/or clinical features of Zhang et al. (2008) demonstrated that the serum SOD hyperandrogenism, c) polycystic ovary appearance on ul- level in PCOS patients (n=30) was significantly lower trasound scanning. than that in the control group (67.316±12.463 vs 113.815± 13.003 U/mL, P<0.05) [104]. However, the study did not • The condition is multifactorial, but insulin resistance capture other patients’ characteristics, making it difficult to appears to be a central feature that explains many of the comment as to why SOD level was lower in this selected manifestations of the syndrome and the increased risk of PCOS group. developing type II diabetes. Role of GPx • Components of metabolic syndrome, particularly hyperinsulinemia and central obesity (visceral adiposity), are Sabuncu et al. (2001) demonstrated that GPx did not dif- frequently encountered in PCOS. fer between a PCOS group and a healthy control group (2.88±0.52 vs 2.98±0.54 MU/mol Hb). In an environment • Risk markers for cardiovascular disease, endothelial with increased H2O2, an increase in GPx is to be expected. dysfunction, and dyslipedemia are increased in PCOS However, the fact that GPx activity did not increase in PCOS women might result from the low amount of GSH, which is • Oxidative stress seems to be involved in altered steroi- the substrate of GPx [4]. dogenesis in the ovaries, thus contributing to increased androgen production, disturbed follicular development, Role of GSH and, ultimately, infertility. GSH was often determined by adding 5,5’-dithiobis(2- EXPERT COMMENTARY nitro-benzoic acid), which is a disulfide chromogen that is readily reduced by sulfhydryl compounds, to an intensely There is mounting evidence to substantiate the etiological yellow compound. Reduced chromogen absorbance is meas- relationship between PCOS and metabolic syndrome. How- ured at 412 nm and is directly proportional to GSH concen- ever, epidemiological research thus far has failed to demon- tration [116, 117]. strate that the markers of cardiovascular disease, endothelial dysfunction, and dyslipedemia in PCOS are associated with Sabuncu et al. (2001) demonstrated that GSH was sig- increased mortality. The role of oxidative stress in the patho- nificantly lower in the PCOS patient group than in the con- genesis of PCOS is not fully understood, and the evidence is trol group (0.39±0.07 vs 0.44±0.07 mol/mol Hb, p=0.03). conflicting. The current evidence merely points towards an Low levels of GSH may have been partly related to IR. In- creased ROS and peroxides may also have led to GSH deple- association between the oxidative microenvironment of the tion. ovarian tissue and ovarian steriodogenesis and follicular development. Whether oxidative stress is the cause or the result In accordance with the findings of Sabuncu et al. (2001), of the metabolic disturbances encountered in PCOS remains Dincer et al. (2005) also found GSH levels to be signifi- to be elucidated. However, a strong relationship among hy- cantly lower in women with PCOS than in the control group perinsulinemia, hyperlipaedemia, and oxidative stress is rec- (5.03±0.96 vs 5.59±0.82 mol/gHb, p<0.05) [118]. They ognized. proposed that GSH depletion might have resulted from increased production of ROS in PCOS patients. FIVE-YEAR VIEW CONCLUSION Research is underway to determine whether reducing visceral adiposity in PCOS patient is associated with reduced In this review we documented the burgeoning interest in markers of cardiovascular risk, improved insulin resistance, the relationship between OS and PCOS, evidenced by a rap- and the amelioration of the clinical symptoms of PCOS. idly increasing body of literature. The discussion has in- Health economic constraints mean that issues associated cluded multiple biomarkers of both ROS and antioxidants in with PCOS should be addressed in a radical way to modify various PCOS patient groups. Cumulative studies to date do the associated health risks. A prominent example of this is not yield a definitive conclusion regarding the association the increased adoption of systems in which the availability of between OS and PCOS. Measurement of biomarkers of OS also is known to be a controversial issue. Units of measure- fertility treatment is restricted for overweight PCOS patients ment in published studies are not consistent. Standardized because of poor treatment outcome. In the next few years measurement units of each biomarker should be used in the clinical trials will determine the role of exercise, diet, and future to facilitate comparison across studies. Additional other life style modifications, as well as pharmacological studies are recommended to examine the association and intervention, on improving fertility outcomes and reducing mechanism of OS on PCOS. health risks in these patients.

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Received: January 10, 2010 Revised: February 09, 2010 Accepted: April 15, 2010

108 Current Women’s Health Reviews, 2010, 6, 108-122 Polycystic Ovary Syndrome in Adolescents

Mohamed Yahya Abdelrahmana,c, Mohamed A. Bedaiwya,b, Elizabeth A. Kiracofed and Marjorie Greenfielda,* aDepartment of Obstetrics and Gynecology, University Hospitals Case Medical Center, Case Western Reserve University, Cleveland, OH 44106, USA bDepartment of Obstetrics and Gynecology, Assiut University Hospitals, Egypt cDepartment of Obestetrics and Gynecology, Sohag University Hospitals, Egypt dCase Western Reserve University School of Medicine, Cleveland, OH 44106, USA

Abstract: Polycystic ovary syndrome (PCOS) is the most common endocrinopathy in women, typically presenting with menstrual irregularities and signs of androgen excess. Approximately 4-10% of reproductive aged women have PCOS. The fact that PCOS often presents in adolescence and the chance of long-term adverse health consequences indicate the need for early diagnosis and intervention. Menstrual dysfunction and hyperandrogenism are key features of the diagnosis of PCOS in reproductive aged women. Diagnosis can be challenging, however, in adolescent girls. The etiology of PCOS is complex and incompletely understood. Therapy should focus on alleviating symptoms and preventing adverse health consequences. Keywords: Polycystic ovary syndrome, polycystic ovaries, adolescence, diagnosis, management.

INTRODUCTION of PCOS through the effects of obesity. Strong data suggest that PCOS can be inherited [3]. Studies on monozygotic and Polycystic ovary syndrome (PCOS) is the most common dizygotic twin sisters from the Netherlands twin registry endocrinopathy in women, and typically presents with signs showed a high correlation of heritability between monozy- of androgen excess and menstrual irregularities Approxi- gotic and dizygotic twins [4]. mately 4-10% of reproductive aged women have PCOS [1]. The prevalence in adolescent girls may be higher when com- The fact that PCOS often presents in adolescence sug- pared to other cohorts; as high as 9% in girls with regular gests that the underlying predisposition to the typical ovarian cycles, 28% with irregular cycles, and 45% with oligomenor- abnormalities originates before puberty. Franks et al. pro- rhea [2]. The incidence varies with the definition of PCOS posed that the ovary is genetically predisposed to hyper- being used. secretion of androgens, perhaps as early as intrauterine life, PCOS is a major risk factor for a number of chronic but certainly during the activation of the hypothalamic- health problems including type 2 diabetes mellitus (DM pituitary-ovarian axis that occurs transiently in infancy and type 2), cardiovascular disease, infertility, and endometrial in a sustained manner at puberty. This predisposition to hy- carcinoma. Early diagnosis and treatment are mandatory perandrogenism was shown to be associated with luteinizing to improve quality of life and prevent progression towards hormone (LH) abnormalities and amplification of the so- serious health problems. This review will address the patho- called physiologic insulin resistance of puberty. Higher than physiologic mechanisms and current guidelines in the diag- normal concentrations of LH and insulin further enhance nosis and management of PCOS in adolescence. ovarian androgen production and may contribute to the mechanism of anovulation [3]. ETIOLOGY Many genes have been investigated as possible suscepti- The etiology of PCOS is complex and incompletely un- bility loci but the effect of any one gene is likely small. One derstood. It is clear from twin studies that a significant ge- candidate gene is a locus on chromosome 19 (p13.2), which netic component contributes to the pathogenesis of PCOS. is close to the insulin receptor gene. Its function remains Environmental factors, principally dietary, are also likely to uncertain [5, 6]. Large family-based case-control studies are be involved in the modulation of the phenotypic expression needed.

The clinical and biochemical abnormalities seen in PCOS *Address correspondence to this author at the Department of Obstetrics and are amplified by obesity. In a series of 350 women with Gynecology, University Hospitals Case Medical Center, Case Western PCOS, an increase in body mass index (BMI) seemed to Reserve University School of Medicine, 11100 Euclid Ave, Cleveland, OH 44106, OH 44106, USA; Tel: 216-844-8551; Fax: 216-201-4239; negatively affect metabolic indices [7]. Many studies report E-mail: [email protected] that calorie restriction and lifestyle modification with as little

1573-4048/10 $55.00+.00 © 2010 Bentham Science Publishers Ltd. Polycystic Ovary Syndrome in Adolescents Current Women’s Health Reviews, 2010, Vol. 6, No. 2 109 as a 5% reduction in body weight in obese women with normality in this disorder [20]. These increased circulating PCOS improve metabolic indices and infertility [8, 9]. androgens are believed to be associated with LH abnormalities. In Rhesus monkeys, positive feedback driven by in- In utero androgen exposure has also been proposed to creased levels of LH increase androgen secretion by theca influence the phenotypic expression of PCOS. In fact, in cells. [The result is often PCOS with anovulation, signs of nonhuman primates, fetal exposure to high levels of andro- androgen excess and polycystic ovaries.] The central role of gen during early intrauterine development is associated with elevated insulin in many cases of PCOS is evidenced by defects in insulin secretion and action in adult life. Prenatally studies that show that lowering insulin levels in women with androgenized female rhesus monkeys exhibit glucoregula- IR using oral insulin sensitizers often results in spontaneous tory deficits similar to those seen in adult women with PCOS ovulation [21]. [10]. However, a recent prospective human study failed to find a relationship between prenatal androgen exposure and Compensatory hyperinsulinemia may contribute to PCOS in adolescence [11]. anovulation directly by interfering with follicular development, causing premature follicular atresia and follicular ar- PATHOGENESIS rest, and indirectly, by diminishing gonadotropins’ effects on the follicles [22]. On the other hand, increased insulin binds Altered Gonadotropins Secretion to insulin growth factor-I receptors (IGF-I), enhancing the One of the well-described features of PCOS is an in- theca cell production of androgen in response to LH stimula- crease in LH levels and a relative decrease in follicle stimu- tion [22]. lating hormone (FSH) levels [12]. The relative decrease in Insulin may increase the cytochrome P450 17 activity, a FSH could be the chief cause of PCOS-associated anovula- key enzyme in the biosynthesis of ovarian and adrenal an- tion. The pulsatile secretion of LH from the pituitary gland is drogens. In ovarian theca cells, the 17 -hydroxylase activity increased in amplitude and frequency in PCOS [13]. In addi- converts progesterone to 17 -hydroxyprogesterone, whereas tion, the pituitary in women with PCOS exhibits a greater its 17, 20 lyase activity converts 17 -hydroxyprogesterone response to gonadotropin releasing hormone (GnRH) than to androstenedione. Androstenedione is then converted to the pituitary in typical women [13,14]. This eventually leads testosterone by the enzyme 17-reductase. Thus, the increase to an abnormal circulating LH- to- FSH ratio in some women in P450c17 activity is accompanied by an increase in the with PCOS. Overall, these data suggest the presence of a serum testosterone concentration. In this regard, this abnor- defect in the hypothalamic-pituitary axis in PCOS. mality may be responsible for exaggerating the 17- hydroxyprogesterone response to stimulation by GnRH ana- Obesity, Insulin Resistance and Androgen Excess logs [23]. Obesity is commonly associated with PCOS. More than Excess insulin has a major impact at the hepatic level. 50% of women with PCOS are obese, which is defined as a 2 Hyperinsulinemia inhibits the synthesis of sex hormone BMI >30 kg/m [15]. In many cases, obesity is believed to binding globulin (SHBG), increasing free androgens and cause the hormonal abnormalities that lead to PCOS, as dis- consequently peripheral androgen action. At the same time, cussed below. However, the fact that PCOS can be diag- hyperinsulinemia inhibits the hepatic secretion of the insulin nosed in women of normal weight indicates that obesity is growth factor binding protein (IGFBP 1), leading to in- not the only cause of PCOS. creased bioactivity of IGF-I and IGF-II. Eventually, this will The link between PCOS and obesity is often insulin resis- augment ovarian androgen production from theca cells by tance (IR) [16]. IR can be defined as a state in which a stimulating IGF-I receptors [22]. greater than normal amount of insulin is required to facilitate glucose transport into cells. Early in the IR disease process, DIAGNOSIS pancreatic beta cells increase insulin secretion; compensa- PCOS is a syndrome, not a disease, and it may have sev- tory hyperinsulinemia maintains plasma glucose levels in the eral different etiologies with a final common pathway. Even normal range. If the ability of the pancreas to secrete insulin the definition and diagnosis are still controversial. declines or the degree of IR becomes greater than can be compensated for by hyperinsulinemia, impaired glucose tol- PCOS was first described by Stein and Leventhal in 1935 erance (IGT) or frank Type 2 diabetes develops, both of [24]. They made their diagnosis of PCOS when patients with which are manifested by abnormally elevated plasma glucose amenorrhea and infertility were seen to have enlarged ova- levels [17]. Impaired fasting glucose is a relatively late ab- ries at surgery. normality that develops in patients with IR. Therefore, so In 1990, a National Institutes of Health (NIH) conference fasting glucose is not recommended as a screening test for led to diagnostic criteria based on a majority opinion of con- diabetes in the PCOS population. ference participants [25]. The criteria included: hyperandro- Androgen excess in women with IR is believed to be the genism and/or hyperandrogenemia, chronic anovulation, and result of insulin’s stimulatory effect on androgen production exclusion of other similar disorders. The NIH criteria did not by ovarian theca cells [18]. Approximately 70% of women comment on ovarian morphology. At a PCOS consensus with PCOS have elevated serum androgen levels and 25% workshop in Rotterdam, both the European Society of Re- have high concentrations of dehydroepiandrosterone sul- production and Embryology (ESHRE) and American Society phate (DHEAS) [19]. This has led investigators to suggest of Reproductive Medicine (ASRM) revised the diagnostic that uncontrolled steroidogenesis may be the primary ab- criteria for PCOS. Their revised criteria state that PCOS re- 110 Current Women’s Health Reviews, 2010, Vol. 6, No. 2 Abdelrahmanet al. mains a diagnosis of exclusion, and diagnosis is complete in presence of excessive thick, pigmented (terminal) hair in women found to have at least two of the following condi- androgen-dependent body areas such as the lip, chin, side- tions: 1) ovulation dysfunction as evidenced by oligo or ame- burn area, neck, abdomen, and inner thighs [31]. As stated norrhea, 2) hyperandrogenism, determined either clinically by DeUgrate et al., degrees of hirsutism vary greatly in dif- or biochemically, and 3) polycystic ovaries demonstrated ferent ethnic populations (e.g. it is rare in Asian women ultrasonographically [26]. [32]), so the threshold of defining hirsutism should be set based on the population [33]. However, the Androgen Excess and PCOS Society (AE - PCOS Society) disputes this definition. They claim that PCOS is a hyperandrogenic disorder, meaning that hyperan- Table 2. Proposed Criteria for Diagnosis of PCOS in Adoles- drogenism, either clinical or biochemical, is the cornerstone cents: Four of Five Criteria [30] of the diagnosis. Diagnosing a woman with PCOS implies that there is an increased risk for many health conditions [27] Oligomenorrhea or amenorrhea, two years after menarche associated with the hyperandrogenism. The AE - PCOS So- Clinical hyperandrogenism: persistent acne, severe hirsutism ciety suggests the following criteria for diagnosis; 1) hyper- Biologic hyperandrogenism: plasma testosterone >50 ng/ androgenism: either hirsutism or hyperandrogenemia, 2) ovarian dysfunction: oligo-ovulation and/or polycystic ova- dl, or increased LH/FSH ratio >2 ries and 3) exclusion of other causes of androgen excess or Insulin resistance/hyperinsulinemia: acanthosis nigricans, related conditions [28] (Table 1). abdominal obesity, glucose intolerance Polycystic ovaries on ultrasound scan: enlarged ovaries, Table 1. Definition of PCOS by Different Organizations peripheral microcysts, increased stroma

NIH Criteria (Both 1 and 2)* 1- Chronic anovulation. Another sign of androgen excess is acne, which will be found in 15-25% of women with PCOS. However, it is un- 2- Hyperandrogenism (Clinical or biochemical) clear whether the prevalence of acne is significantly in- Rotterdam Criteria (2 out of the following 3)* creased in PCOS over that observed in the general popula- 1- Chronic anovulation. tion [34]. The present recommendation regarding acne and alopecia is to consider them as unreliable clinical signs of 2- Hyperandrogenism (Clinical or biochemical) hyperandrogenism, particularly if they are the only diagnos- 3- Polycystic appearance of the ovaries. tic features [27]. Androgen Excess and PCOS Society (Both 1 and 2)* Approximately 70% of women with PCOS will be found 1- Hyperandrogenism (Clinical or biochemical) to have mildly elevated serum androgen levels, and 20-30% 2- Ovarian dysfunction (Oligo-anovulation and/or polycystic will have mildly elevated dehydroepiandrosterone sulfate ovaries) (DHEAS) levels [19]. Marked elevations of total testosterone, DHEAS, or 17 hydroxyprogesterone may indicate un- *After exclusion of other related disorders. derlying pathology that is mimicking PCOS such as an ovar- Adoption of any of the above criteria in diagnosing ian or adrenal tumor (especially if these elevations are asso- PCOS is challenging in adolescent girls. For two to three ciated with symptoms and signs of rapid onset virilization), years after menarche, adolescents exhibit a transient phase of or non-classical congenital adrenal hyperplasia [35]. anovulation [29], during which the menstrual cycle can be Serum analysis may fail to identify biochemical hyperan- irregular. The difficulty of diagnosing PCOS in adolescence drogenism in 20-40% of patients [36]. Even semi- is not only due to the physiologic anovulation, but also to quantitative measurements, such as the Ferriman-Gallwey transient hyperactivity of the hypothalamic-pituitary-gonadal score for hirsutism [37], may underestimate clinical hyper- axis leading to increased androgen production [29] and androgenism [33]. relative insulin resistance related to growth hormone levels. Most commercial assays for total testosterone are not More stringent criteria have been proposed to diagnose designed or validated for use in women [38], raising con- PCOS in adolescents. These include four out of the five cri- cerns about their diagnostic value. Moreover, the range that teria shown in (Table 2) [30]. is regarded as healthy for women by commercial laboratories is very broad and may fail to diagnose hyperandrogenemia CLINICAL FEATURES even in some women with severe hirsutism [39]. An alternative explanation for the disparity between normal serum PCOS presents as a spectrum of clinical disorders with androgens and the presence of clinically significant hirsutism at the extreme hyperandrogenism, ovulatory dysfunction, is the fact that some individuals may have different hair fol- obesity, and insulin resistance. licle sensitivity to androgens (idiopathic hirsutism). This patient category will still benefit from suppression of their Hyperandrogenism normal levels of androgens, however. Another issue to be Clinical signs of androgen excess are the most constant considered is that women with asymptomatic polycystic ova- and prominent components of PCOS. Approximately 72% of ries who have normal baseline serum androgens on repeated women with PCOS will exhibit hirsutism, defined as the testing may have occult androgen excess [40]. Polycystic Ovary Syndrome in Adolescents Current Women’s Health Reviews, 2010, Vol. 6, No. 2 111

Although controversial, many investigators believe that Imaging for polycystic ovaries in virginal adolescent failure to detect biochemical or clinical hyperandrogenism girls, if desired, can be done by transabdominal ultrasound. should not exclude diagnosis of PCOS in the presence of The ovarian volume may be the only parameter that should other clinical signs [41]. This is supported by the Rotterdam be measured, because the follicle criteria are much less reli- criteria, which allow the diagnosis of PCOS in patients with- able by the abdominal route, especially in obese individuals out androgen excess. [47]. The transperineal or transrectal route may be an alternative when abdominal ultrasonography is not conclusive. A Laboratory Criteria for Androgen Excess combination of abdominal and three-dimensional transrectal ultrasound revealed accurate and reliable results in adoles- Biochemically, hyperandrogenemia is most commonly cent girls in one study [48]. assessed by measuring serum total testosterone (T) and sex hormone binding globulin (SHBG), followed by calculation Measurement of serum anti-Mullerian hormone (AMH) of the free fraction by the free androgen index (Testoster- is emerging as a potential surrogate for ultrasonography; one/Sex Hormone Binding Globulin 100) or the mass values correlated closely to the antral follicle count in pilot action equation [38, 42]. [The mass action equation, which investigations [49]. This assay may facilitate the diagnosis of utilizes Testosterone, Sex Hormone Binding Globulin, Al- PCOS when transvaginal ultrasonography is not appropriate. bumin, and the association constants for the interactions of T with SHBG and albumin, is regarded as the method of Other Phenotypes choice to calculate free serum testosterone, if reliable assays Although obesity and IR are common in women with are used and normative data specific to each assay are avail- PCOS, their presence is not necessary to make the diagnosis. able.] Radioimmunoassays that claim to directly measure Their presence, however, increases the risk of metabolic free testosterone are widely available, but the results are syndrome and other health consequences [3]. highly unreliable and should be interpreted carefully [38, 43]. The concentrations of other serum androgens, such as LONG TERM RISKS OF PCOS androstenedione or adrenal androgen dehydroepiandrosterone sulfate (DHEAS) are often high in women with PCOS, Pregnancy, Infertility, and Miscarriage but their measurement is of little value in the average clinical Girls with PCOS and their parents may worry about their setting. future fertility. PCOS is the most common cause of anovulatory infertility so it is important to reassure adolescent girls Ovulation Dysfunction that if they do have difficulty conceiving in the future, they Ovulation dysfunction is the most common cause of fe- can be treated with medications and/or assisted reproductive male infertility and is diagnosed in 70-80% of infertile technologies. However, obese patients should be warned of women with PCOS [27]. The most frequent sign of ovulation the pregnancy complications associated with obesity. Preg- dysfunction is irregular menses. The irregularity may be in nancy complications (gestational diabetes, preeclampsia, and amount, duration, or frequency. It occurs in 75% of PCOS macrosomia) are significantly increased in morbidly obese patients, and is often one of the earliest symptoms [7]. How- individuals [50-52]. In addition, the risk of first trimester ever, using menstrual irregularity to diagnose PCOS in ado- miscarriage is reported to be significantly higher for patients lescence is difficult because irregular cycles may be normal with PCOS--possibly as high as 30% [53]. in the first few years after menarche [44]. Diabetes Mellitus Anovulation in adult women with PCOS is attributed to the disturbance of folliculogenesis that characterizes the Women with PCOS are at increased risk for glucose in- syndrome. The follicular defect in PCOS consists of acceler- tolerance, manifesting as either impaired glucose tolerance ated early follicular growth and interference with the selec- (IGT) or Type 2 diabetes mellitus (DM) [54]. This increased tion of the dominant follicle [45]. Accelerated early follicular risk is related to the association of PCOS with obesity and IR; both are risk factors for glucose intolerance. The inci- growth is mainly due to androgen excess and increased dence of IGT and type 2 DM was reported as 10% and 5%, insulin that induces LH receptor expression and premature respectively, in a cohort of adolescents with PCOS [55]. luteinization of granulosa cells. Excess amounts of insulin and LH further enhance ovarian androgen production [3]. Women with PCOS and baseline normal glucose tolerance have a 16% conversion rate per year to DM type 2 [56], Ultrasonographic Criteria for Polycystic Ovaries whereas by the age of 30 years, 30-50% of obese women with PCOS develop IGT or overt DM type 2. This is a 3-7 Significant advances in ultrasonography made in the last fold greater risk than that for an age-comparable population decade, especially coupled with use of the transvaginal ap- [17]. proach, have made evaluation of the ovaries more accurate and detailed. Polycystic ovaries are defined by the Rotter- The mechanisms underlying the association between dam Criteria as “the presence of at least 1 ovary, using a PCOS and glucose metabolism impairment are still un- transvaginal probe, featuring 12 or more follicles having a known. During fetal life, growth restriction, low birth mean diameter 2 to 9 mm, irrespective of location, and/or a weight, and/or small size for gestational age followed by total ovarian volume > 10 ml.” This definition is applied to catch-up weight gain during infancy may lead to hyperinsu- the follicular phase ovary (one that lacks follicles larger than linemia, IR, obesity, PCOS, and DM type 2 in later life [57, 10mm in diameter) [46]. 58]. 112 Current Women’s Health Reviews, 2010, Vol. 6, No. 2 Abdelrahmanet al.

Evidence suggests that insulin resistance may play a ma- meta-analysis suggests that women with PCOS have a more jor pathophysiological role in the development of glucose than 2-fold risk of developing cancer of the endometrium intolerance [59]. There is also a subset of women with PCOS compared to the general population [69]. who are not obese, but have IR because of some molecular abnormality, such as an insulin receptor defect [60]. Because DIFFERENTIAL DIAGNOSIS of the strong association of PCOS and DM type 2, effective Some disorders may mimic PCOS (Table 4). These DM screening of PCOS patients is imperative. disorders must be ruled out before making the diagnosis of PCOS [27, 46, 70]. Metabolic Syndrome and Cardiovascular Risks Metabolic syndrome (MtS) is a cluster of cardiovascular Table 4. Differential Diagnosis of PCOS risk factors, including diabetes or prediabetes, central (abdominal) obesity, atherogenic dyslipidemia, and hyperten- • Congenital Adrenal Hyperplasia sion [61]. Adult women with PCOS were found to have an 11-fold increased risk of MtS when compared to that of • Androgen-secreting neoplasm healthy controls [61]. Thirty seven percent of adolescent • Cushing Syndrome girls with PCOS have been shown to have MtS, compared • Thyroid Disease with 5% of the general population [62]. • Prolactin-secreting tumor The World Health Organization (WHO) defines the MtS as the presence of IGT or IR, with at least two of the follow- Congenital Adrenal Hyperplasia ing: hypertension, dyslipidemia, obesity and microalbuminu- ria [63]. Many revisions have been made to that definition Congenital adrenal hyperplasia (CAH) is a group of auto- [64,65], although most are difficult to use in everyday prac- somal recessive disorders resulting from mutations in the tice or clinical studies. The most commonly used definition genes coding for steroidogenic enzymes. In these disorders, a for diagnosing MtS is the updated Adult treatment Panel III block in cortisol biosynthesis leads to loss of negative feed- criteria [66,67] (Table 3). back inhibition, increased adrenocroticotropic hormone (ACTH) secretion, and subsequent excessive adrenal andro- Table 3. Updated Adult Treatment Panel III for diagnosis of gen secretion [71]. The most common form of CAH is 21- Metabolic Syndrome* hydroxylase deficiency, which accounts for 90 to 95% of patients with CAH [71]. 11 -hydroxylase deficiency and 3 -hydroxysteroid deficiency represent 5 to 10% of CAH Fasting glucose 6.1 mmol/L [110 mg/dL] • [72,73]. “Late onset” non-classical congenital adrenal hyper- • HDL-C <1.3 mmol/L [50 mg/dL] plasia can present in adulthood. • Triglycerides 1.7 mmol/L [150 mg/dL] 2 Androgen-Secreting Tumors • Obesity BMI > 30 kg/m • Waist circumference 88 cm Androgen-secreting tumors, although rare, may initially mimic the hyperandrogenism and menstrual dysfunction • Hypertension 130/85 mm Hg seen in PCOS. However, they tend to present with rapidly *Three or more criteria required for the diagnosis progressive hyperandrogenism and early development of (HDL-C: High Density Lipoprotein Cholesterol). frank virilization. Sertoli Lydig cell tumors are the most common virilizing ovarian tumor and account for 0.5% of all PCOS and metabolic syndrome are related conditions. ovarian neoplasms [74]. Androgen-secreting adrenal neo- Adult women with MtS are at a greater risk of developing plasms are less common than ovarian neoplasms [35]. They cardiovascular disease; women with PCOS also appear to usually present with a mixed picture of Cushing syndrome carry an increased risk in their postmenopausal life. Women and virilization [75]. with MtS may also experience reproductive disturbances more commonly than their counterparts from the general Cushing Syndrome population [68]. Cushing Syndrome, caused by excess cortisol, is charac- Gynecologic symptoms may be the earliest manifestation terized by moon face, buffalo hump, obesity, hypertension, of MtS in young women. Early presentation affords a clini- and dyslipidemia. The most common cause of Cushing phe- cian the opportunity for diagnosis, counseling, and treatment notypes is exogenous glucocorticoids. Endogenous Cushing to alter the risk profile for the development of MtS and car- syndrome may be dependent on ACTH secretion or may be diovascular disease later in life. due to autonomous cortisol secretion by the adrenal gland [76]. Excess ACTH secretion results in androgen secretion Endometrial Cancer and then hirsutism in a slowly progressive fashion. If a pa- Endometrial hyperplasia is a consequence of unopposed tient with Cushing syndrome presents with rapid hair estrogen stimulation of the endometrium. Adolescents and growth, an adrenal tumor is more likely [77]. Although women with PCOS are at increased risk because chronic Cushing syndrome is a rare etiology of hirsutism, excess anovulation results in this dysfunction. Untreated endo- facial and body hair are present in approximately 81% of metrial hyperplasia can lead to adenocarcinoma. Recent patients with Cushing’s [78]. Polycystic Ovary Syndrome in Adolescents Current Women’s Health Reviews, 2010, Vol. 6, No. 2 113

SUGGESTED EVALUATION OF ADOLESCENTS DHEAS measurements are not necessary in the workup of WITH FEATURES OF PCOS hirsutism or PCOS. History 17 Hydroxy Progesterone A detailed menstrual history should be obtained. Ap- 17 hydroxyprogesterone (17-OH-P) is a byproduct of proximately one half of menstrual cycles during the first 2 cortisol synthesis in congenital adrenal hyperplasia. A morn- years after menarche are anovulatory [79], and bleeding pat- ing serum level of 17-OH-P during the follicular phase of the terns may be slightly irregular. By five years after menarche, cycle that is less than 3 ng/dl can be used to exclude non- 80% of cycles are ovulatory. During the history, the patient classical CAH. In a patient with irregular cycles, is often should be questioned about chronic illness, weight changes, helpful to draw a serum progesterone level simultaneously, unwanted hair growth, drug use, and a family history of to establish that the patient is not in the luteal phase. If the endocrine malfunction, including dysfunctional bleeding, 17-OH-P level is elevated (greater than 2 ng/ml), a cortico- infertility, diabetes, and MtS. Depression is common in tropin stimulation test can help establish the diagnosis. Intra- adolescents with hirsutism and obesity. venous injection of 250 ug of synthetic corticotropin, followed by measuring 17-OH-P after 60 minutes, is used. A Physical level above 10 ng/dL is diagnostic for non-classic adrenal A focused physical examination is essential in the hyperplasia [84] evaluation of adolescents suspected of having PCOS. The clinician should document the blood pressure, BMI, and 24 Hour Urine Free Cortisol waist circumference to determine body fat distribution. A Adolescents with clinical evidence of Cushing syndrome BMI > 30 defines obesity and waist circumference greater (moon face, buffalo hump, obesity, hypertension, and dyslip- than 35 inches is considered abnormal and suggests MtS idemia) should undergo a 24 hour urine free cortisol test, [70]. Stigmata of hyperandrogenism include acne, hirsutism, which has a sensitivity of 95 -100% and a specificity of 98% and (rarely) androgenic alopecia. Acanthosis nigricans, a [85] in the diagnosis of Cushing Syndrome. The 24 hour velvety hyperpigmentation usually seen around the neck, urine free cortisol test has virtually no false negative results. correlates with insulin resistance. False-positive results may be attributable to conditions such The gynecologic examination should include inspection as depression, chronic active alcoholism, and glucocorticoid of the external genitalia for clitorimegaly. If bimanual ex- resistance [86]. The dexamethasone stimulation test and amination to exclude adnexal masses can not be tolerated, midnight salivary test may be helpful if the 24 urinary free ultrasound can be performed if necessary. In the context of cortisol result is suspected of being falsely positive. fairly normal testosterone levels, examination of the ovaries Prolactin for tumor is not imperative. It is not uncommon to detect mild elevations of prolactin LABORATORY (30-100 g/L) in women with PCOS. If serum prolactin is Testosterone found to be elevated, then thyroid function should be assessed. Magnetic resonance imaging (MRI) of the pituitary The current criteria for the diagnosis of PCOS permit should be obtained to exclude pituitary tumor if prolactin hirsutism to serve as a surrogate marker for biochemical evi- levels exceed 100 g/L. dence of androgen excess. However, total testosterone must be measured to exclude the presence of androgen-secreting Thyroid Stimulating Hormone tumors. A total testosterone level greater than 90 ng/dl usu- Hypothyroidism and hyperthyroidism should be excluded ally indicates the presence of androgen excess [80] while before making the diagnosis of PCOS. Subclinical thyroid levels of serum testosterone greater than 200 ng/dl are dysfunction may be the cause of anovulation and menstrual strongly suggestive of virilizing tumors [81]. irregularities. Thyroid stimulating hormone (TSH) is the Although free testosterone is the best single indicator of screening test of choice, particularly in patients with irregu- androgen excess, there is no standardization of the test, and lar cycles [83]. measured free testosterone levels are unreliable [42]. For Oral Glucose Tolerance Test (OGTT) research purposes, utilization of the free androgen index (Testosterone/Sex Hormone Binding Globulin 100) is rec- The 75 gram glucose, two hour OGTT has been recom- ommended. Values greater than 5 are diagnostic of androgen mended by many organizations for both initial and periodic excess [41]. screening for IGT and DM in women with PCOS [26, 70, 87, 88] (Table 5). Dehydroepiandrosterone Sulfate (DHEAS) Recently, both the American Diabetes Association DHEAS is exclusively secreted by the adrenal glands, (ADA) and the endocrine society encouraged clinicians to making it a good marker for adrenal androgen production. It use glycosylated hemoglobin testing when screening for and may be elevated in anovulation [82] with approximately 20- diagnosing Type 2 diabetes mellitus in the general popula- 30% of women with PCOS having elevated DHEAS levels tion [50,89]. No recent published data addressing the use of [19]. DHEAS values above 700 ng/dl suggest adrenal neo- glycosylated hemoglobin in adults or adolescents with PCOS plasm [83]. If serum testosterone is not exceedingly elevated, 114 Current Women’s Health Reviews, 2010, Vol. 6, No. 2 Abdelrahmanet al. are available. Currently, the OGTT is the gold standard for They are all easy, safe, and inexpensive. However mild skin screening for IGT and diabetes in patients with PCOS. irritation, either due to local trauma or chemical reaction, may occur [94]. Women using these methods can be reas- Table 5. American Diabetic Association Criteria for Hyper- sured that they do not increase future hair growth, but they glycemia will not prevent progression of hirsutism related to hyperandrogenemia. Combining one of these local measures with 2 Hour GTT Fasting Glucose systemic treatment may help achieve rapid response and adequate patient satisfaction. Normal < 140 mg/dl < 100 mg/dl* Laser Hair Removal Impaired 140-199 mg/dl 100-125 mg/dl** Laser hair removal reduced the number of hairs by 50% Diabetes 200 mg/dl 126 mg/dl over six months in a systematic review of 11 trials, but * WHO defines normal fasting glucose < 110 mg% the long-term efficacy of these treatments is not well estab- ** WHO defines impaired fasting glucose from 110 mg% to 125 mg% lished [95]. Laser targets the pigmented hair at the base of the hair follicle, and is most effective in light-skinned Fasting Lipid and Lipoprotein Levels individuals. Most patients experience 2 to 6 months of Patients with PCOS should be screened for cardiovascu- growth delay after a single treatment, while some have lar risk using fasting lipids and lipoprotein levels. A high permanent resolution of excess hair growth after multiple density lipoprotein cholesterol (HDL) level less than or equal sessions. Despite the lack of evidence of efficacy, laser to 50 mg/dl and a triglyceride level greater than or equal to hair removal is frequently asked for by patients who choose 150 mg/dl are considered abnormal [90]. permanent hair removal therapy once their androgens are under control [96]. IMAGING STUDIES Electrolysis Ultrasonography Electrolysis is a procedure by which a fine needle is in- Ultrasonography is a useful tool in evaluating both the troduced into the hair shaft and an electric current is applied ovaries and the adrenal glands [91], and ovarian characteris- to destroy the hair follicle. In comparison to laser treatment, tics are included in some diagnostic criteria for PCOS. Ultra- electrolysis is less expensive, but laser therapy has been sonography is imperative if serum androgen levels are in shown to be more effective, less painful, and time-saving tumor range. If a mass is found, computed tomography (CT) and MRI should be used as they are more accurate in distin- [97]. guishing between benign and malignant neoplasms [92]. Topical Creams CT Scan and MRI Eflornithine is a topical cream used in many countries for CT and MRI are indicated if there is a strong suspicion of the treatment of hirsutism. It does not remove the hair, but adrenal neoplasm. CT can diagnose an adrenal nodule of less decreases the rate of growth by inhibiting ornithine decar- than 5 mm [75]. MRI provides a clear discrimination of tu- boxylase, an important enzyme for hair growth [98]. Eflor- mor invasion into the blood vessels. Recent CT and MRI nithine will limit the rate of hair growth after 6-8 weeks of techniques allow accurate differentiation between adenomas therapy [99]. and malignant nodules of the adrenal gland [93]. SYSTEMIC TREATMENTS TREATMENT First Line Therapy Treatment of the adolescent with PCOS should be started as soon as the diagnosis has been made. Early intervention Combined Oral Contraceptives will help not only to alleviate the distressing symptoms and Combined oral contraceptive pills (COCs) are the first progression of hirsutism but also to prevent long-term health line treatment for the majority of patients with hirsutism who consequences retard mental health consultation may be do not wish to become pregnant. COCs decrease androgen needed in adolescents with marked emotional distress. levels by several mechanisms. First, they inhibit gonadotropin secretion from the pituitary, leading to decreased andro- Treatment of Hirsutism gen secretion by the ovary. Second, they increase SHBG The majority of adolescent girls with PCOS seek medical levels, which decrease free circulating androgens. Theoreti- advice due to cosmetic issues related to hirsutism. Many of cally, pills with the least androgenic progestins may be of these patients may have considerable emotional distress and most therapeutic benefit; however, all COCs suppress ovar- psychological morbidity with symptoms of anxiety and de- ian androgens and raise SHBG levels and therefore can be pression mental health referral should be considered in girls used for treatment [100]. The contraceptive ring provides a who exhibit significant distress. similar combination of estrogen and progestin and can be used interchangeably with COCs for girls who are willing to NON-SYSTEMIC TREATMENTS use a vaginal route of administration. Many women are familiar with different hair removal Oral contraceptive pills that contain antiandrogenic pro- methods like shaving, waxing, and using depilatory creams. gestins (cyproterone acetate and drospirenone) have theoreti- Polycystic Ovary Syndrome in Adolescents Current Women’s Health Reviews, 2010, Vol. 6, No. 2 115 cal benefits over other oral contraceptives in the treatment review and one meta-analysis of 8 trials collectively found of hirsutism. In women treated with drospirenone over 12 no significant difference in hirsutism scores between COCs cycles, hirsutism scores improved from the sixth cycle of and metformin [116, 117]. On the other hand, antiandrogen treatment more significantly than those after treatment with drugs (spironolactone, cyproterone acetate, and flutamide) placebo [101]. The effects of other oral contraceptives on have been found to significantly reduce hirsutism scores hirsutism have not been studied. when compared to metformin in a recent meta-analysis [116]. Women being treated for hirsutism may have relative contraindications to COC use, including hypertension. The Troglitazone was withdrawn from the market due to usual exclusion criteria for oral contraceptives apply in this hepatotoxicity, and rosiglitazone (thiazolidinediones) may population [102]. increase the risk of cardiovascular events in patients at risk of or having diabetes mellitus [118]. Metformin is a Antiandrogens category B drug that can be used for patients with PCOS desiring pregnancy, but its effects on hirsutism may not be Antiandrogens are another group of agents used as a first significant. line therapy for hirsutism. However, the teratogenic potential of these drugs means that they should be used in conjunction Second Line Therapies with adequate contraception in women of reproductive age. Spironolactone, an aldosterone antagonist, competes with Glucocorticoids and gonadotropin releasing hormone testosterone and dihydrotestosterone at the androgen recep- agonists (GnRHa) can be used as a second line therapy for tor. Although it is primarily used as a diuretic, a dose of 50- treatment of hirsutism in patients with PCOS. They may be 200 mg/day will reduce facial hair growth in the majority of useful in patients with severe hirsutism who do not respond patients after 6 cycles of treatment [103]. Concurrent use of to first line therapy [119]. spironolactone with oral contraceptive pills has been shown to significantly improve hirsutism and reduce serum andro- Glucocorticoids gen levels [104]. For patients with hirsutism that is refractory Glucocorticoids are known to decrease adrenal androgen to oral contraceptives after 6 months, adding spironolactone secretion. They produce long-term suppression of the adrenal may be effective. glands [120]. Unfortunately, even in women with non- Flutamide is an anti androgen used for the treatment of classical congenital adrenal hyperplasia, the results of treat- prostate cancer. It is more effective in treating hirsutism than ment of hirsutism with glucorticoids are disappointing. spironolactone [105]. However, a recent study concluded Cyproterone acetate has been shown to be more effective that although flutamide is very effective in treating hirsu- than hydrocortisone after one year of use in hirsute women tism, it is associated with frequent side effects and low long- with late onset adrenal hyperplasia [121]. Moreover, in a term compliance [117]. Hepatic cell damage, the major com- study comparing cyproterone acetate COCs to dexametha- plication of flutamide, may be fatal [106]. Consequently, sone, which has a longer half-life than hydrocortisone, the flutamide is not approved by the FDA for treatment of hirsu- hirsutism scores were significantly lower in the former group tism. (66% versus 31%) [122]. Of note, glucocorticoids are effective in maintaining ovulation and improving fertility out- Cyproterone acetate is an anti androgen as well as a pro- comes for patients with non-classic adrenal hyperplasia gestin. In one systematic review, cyproterone acetate (2mg) was more effective than placebo, but not better than any [123]. other anti androgen [107] in the treatment of hirsutism. It is Gonadotropin Releasing Hormone Agonist (GnRHa) also available in an oral contraceptive pill, as cyproterone acetate (2mg) with 35 ug ethinyl estradiol, which has been GnRH is a hypothalamic hormone released in a pulsatile shown to be well tolerated. This drug is not currently avail- manner that regulates the production of FSH and LH from able in the United States. the anterior pituitary in a permissive fashion. Exogenous use of a GnRHa in a non-pulsatile manner results in suppression Fenasteride, also an anti androgen, inhibits only the type of gonadotropin secretion (FSH and LH) [124]. GnRHa ther- 2 isoenzyme of 5 -reductase. It is anticipated that the effect apy has been tried in uncontrolled and controlled trials [120, of fenasteride may be partial. Whether it is equally effective 125, 126]. Although weak evidence suggests that GnRHa or less effective than spironolactone is controversial [108, therapy is more effective than placebo or no therapy for 109]. The FDA has not approved fenasteride for treatment of hirsutism. hirsutism, it appears to have no therapeutic advantage when compared with other available agents such as COCs and anti Insulin Sensitizing Agents androgens. Furthermore, GnRH agonists are expensive and may have undesirable side effects. The current recommenda- Hyperinsulinemia has been shown to increase ovarian tion suggests that use of a GnRHa for most women with androgen production [110] and decrease SHBG production hirsutism should be avoided [96]. [111]. Consequently, reducing insulin levels with insulin sensitizing agents such as metformin should lower total and TREATMENT OF MENSTRUAL IRREGULARITY free androgen levels. However, the effects on hirsutism are Oligomenorrhea and Amenorrhea not clearly better than if oral contraceptives are used; some studies have shown insulin sensitizing agents to improve Menstrual irregularity should be treated in adolescents hirsutism and others have not [112-115]. One systematic with PCOS to prevent prolonged unopposed estrogen stimu- 116 Current Women’s Health Reviews, 2010, Vol. 6, No. 2 Abdelrahmanet al. lation of the endometrium. Although the risk of endometrial one pill daily. Then the patient should begin a new package hyperplasia has not been studied in adolescent girls with containing the same amount of estrogen for 21 days taking PCOS, the risk of endometrial hyperplasia is significantly one pill daily. At the end of that time, withdrawal bleeding correlated with an inter-menstrual interval longer than 3 can be allowed, or continuous suppression with pills can be months and/or endometrial thickness greater than 7 mm in chosen. women with PCOS [127]. In addition, anovulatory bleeding can be heavy and prolonged, leading to iron deficiency ane- TREATMENT OF OBESITY mia as well as difficulties managing the menstrual flow. Weight loss counseling is an important component of any In adolescents with amenorrhea or oligomenorrhea, pro- treatment provided to obese women with PCOS [131]. A loss gestins have been widely used to induce withdrawal bleed- of 5-10% of body weight is enough to greatly improve hirsu- ing. Micronized progesterone (100-200 mg daily), me- tism, reduce testosterone, increase sex hormone binding droxyprogesterone acetate (5mg/day) or norethindrone ace- globulin, resume ovulation and effectively modulate insulin tate (2.5 or 5 mg/day) for 5-10 days is sufficient to induce resistance in a majority of patients [8,132-137]. In light of withdrawal bleeding. However, 12 days of progestin therapy the health risks associated with PCOS, including diabetes, every one to three months is necessary to fully oppose the hypertension, heart disease (hypercholesterolemia), and en- effects of continuous endogenous estrogen. Progestin- dometrial cancer (unopposed estrogen), patients should be induced withdrawal bleeds should be considered if sponta- advised and helped to achieve sustained weight loss. neous menses occur with a frequency of less than 8 weeks Regular exercise and behavioral modification programs [128]. Continuous progestin treatment with depot me- are essential for acute and long-term weight management. droxyprogesterone acetate or the levonorgestrel-containing Different exercise regimens have been advocated from thirty intrauterine device (IUD) can be considered for some ado- minutes three times a week, to ten minutes multiple times a lescents, particularly those who also need a birth control day, to one hour of exercise most days of the week. The best method. program is one that the patient will actually follow [138]. Restricting calories should accompany increased energy ex- Treatment of Mild to Moderate Anovulatory Bleeding penditure. With an average weight loss of 1b Clark et al. Progestins have an important role in the treatment of [133] found a 92% ovulation rate and 33% to 45% spontane- the anovulatory dysfunctional uterine bleeding (DUB) often ous pregnancy rate after applying calorie restriction and seen in adolescents with PCOS. For moderate DUB, cyclic exercise to a group of women with PCOS. Unfortunately, progestins can be administered for 12 days every month to lifestyle modification and weight loss programs require stabilize the endometrium and prevent the action of unop- prolonged patient motivation and are therefore difficult posed estrogen. Low dose oral contraceptives are another to achieve beyond the research setting. Advice alone is alternative, especially when progestins fail to control the typically ineffective at promoting sustained weight loss. bleeding. Treatment should be continued for 3-6 months Insulin sensitizing agents have been reported to suppress [129] or until regular ovulation is established. Concurrent the appetite and enhance weight loss. Metformin appears to oral iron intake is encouraged if the hemoglobin level is low have the most utility among insulin sensitizers. A position or bleeding is excessive. statement of the American Association of Clinical Endocri- nologists recommends the use of metformin in most women Severe Anovulatory Bleeding with PCOS, particularly if they are overweight or obese [87]. Hospitalization must be offered in cases of severe DUB. In a recent meta-analysis of 5 trials [139] in obese children Immediate resuscitation with intravenous fluids or even and adolescents, metformin reduced BMI by 1.42 kg/m2 blood transfusion may be necessary to restore hemodynamic (95% CI: 0.83-2.02) and insulin resistance scores by 2.01 stability. Intravenous conjugated equine estrogens in a dose (95% CI 0.75-3.26) compared with placebo. Another study of 25 mg every 4 hours until bleeding resolves (the maxi- found metformin significantly reduced waist circumference mum is four doses) provides excellent control of heavy and testosterone levels when used in a dose of 1500 mg/day bleeding in most cases [130]. To prevent recurrence of over 6 months when compared to lifestyle modification, oral anovulatory hemorrhage, a combination of 2.5 mg conju- contraceptives, and placebo [140]. However, no significant gated equine estrogen and 10 mg medroxyprogesterone ace- change in BMI was found between the groups. Lifestyle tate for 20-25 days, or oral contraceptive pills, should follow modification combined with metformin in obese patients intravenous therapy [129]. Consideration should be given with PCOS may improve long-term outcomes regarding obe- to menstrual suppression with continuous oral contraceptive sity and metabolic consequences [131] than either treatment pills (without placebo) until severe anemia is resolved. alone. This usually requires prolonged treatment, since In teens with severe uterine bleeding leading to anemia weight is often regained after drug therapy is discontinued requiring transfusion or with bleeding that occurs at the time [141]. of the first menstrual period, workup for coagulopathy is Although controversial, anti-obesity drugs (Orlistat and indicated. Sibutramine) have been proven to be relatively safe and ef- COCs induce regular menstrual periods with a high defective in treating obesity in the general population. gree of reliability. In the setting of severe DUB, after estab- Sibutramine is not approved for use in adolescents. Studies lishing hemodynamic balance, COCs containing 35-50 g on adolescents and Orlistat are inconclusive. Gastrointestinal ethinyl estradiol may be taken every 6 hours. After 8 doses side effects often limit compliance in teenagers [142]. in the first 48 hours, the dose can be tapered over 3 days to Polycystic Ovary Syndrome in Adolescents Current Women’s Health Reviews, 2010, Vol. 6, No. 2 117

Bariatric surgery may be the last resort for patients un- acne, and insulin resistance are important phenotypes of able to lose weight with other strategies. The current recom- PCOS, they are not required for the diagnosis. mendation is to offer bariatric surgery for any adult patient Diagnosis of the syndrome in adolescence provides the with a BMI of 40 or greater, or for those with BMI of 35 or opportunity to alleviate distressing symptoms and prevent or greater who have a serious coexisting medical problem delay long-term health consequences. Metabolic syndrome, worsened by obesity [143]. The advantages of bariatric sur- Type 2 DM, cardiovascular disease, infertility, and endo- gery include weight loss, improved diabetes, hypertension, metrial cancer are all potential risks in untreated women. and dyslipidemia, and resumption of normal cycle rhythm and fertility [144-146]. A recent randomized control trial The diagnosis of PCOS is clinical and can be made only reported that 84% of adolescents with BMI >35 kg/m2 who after ruling out other causes of hyperandrogenism.While the underwent bariatric surgery lost more than 50% of their Rotterdam criteria can be used to make the diagnosis, PCOS weight versus 12% in the control group. Furthermore, MtS presents along a continuum, and making a strict diagnosis was eliminated in 100% of participants in the bariatric sur- may not be critical except in a research environment. Time gery group compared to 22% in the lifestyle group after 24 will often help differentiate an adolescent who is destined to months follow up [147]. However, current data are not suffi- struggle with PCOS from one who is temporarily suffering cient to support bariatric surgery for adolescents with PCOS. with irregular menses and acne. Effective strategies, including the use of medications and Treatment should focus on prevention of medical com- surgery, for sustained weight loss in obese adolescents with plications and alleviation of symptoms. Lifestyle modifica- PCOS should be evaluated by large long-term randomized tion and weight loss are the mainstay of treatment in obese control trials [131]. individuals with PCOS. Oral contraceptives will regulate menstruation and decrease the chance of endometrial cancer, Insulin Resistance and Metabolic Sequelae and may slow the progression of hirsutism. Metformin is IR is a significant component of the etiology of PCOS indicated in the context of IGT or diabetes. Its use in insulin and plays an important role in the risk of type 2 diabetes resistance is controversial, although studies have shown mellitus and MtS. Many studies on the treatment of PCOS promise in metformin’s ability to prevent overt diabetes. address therapies that target IR [148, 149] Insulin sensitizers More research in adolescent PCOS is needed to guide rec- have been used in women with PCOS, aiming to reduce in- ommendations on diagnostic criteria and appropriate phar- sulin resistance and improve lipid profiles. Some studies maceutical and surgical management. report positive effects of metformin on insulin sensitivity and lipid parameters in women with PCOS [150-152]. Although FIVE YEAR VIEW the Food and Drug Administration does not approve the use Causes of PCOS of metformin for PCOS, many clinical practitioners support the use of metformin as a protective measure against the PCOS is a multifactorial syndrome, involving genetic, metabolic and cardiovascular effects of insulin resistance endocrinologic, metabolic and environmental factors. Fur- [153] and for the prevention of diabetes. ther research on the basic pathophysiology of PCOS and the roles of the different etiologic components will aid in the The Endocrine Society guidelines recommend diet con- understanding of this condition, and help clinicians in their trol and moderate physical activity for 30 minutes 5 days a management of adolescents with PCOS. week to prevent diabetes before drug therapy is initiated, even in patients with risk factors for MtS [154]. The PREVENTION OF PCOS ASRM/ESHRE consensus also reserves drug therapy for patients who have PCOS with impaired glucose tolerance Rates of obesity in the US increased in the 1980s and [155]. 1990s and have stabilized in the past decade [156]. On a public health level, efforts at improving the rates of overweight EXPERT COMMENTARY and obesity in the population, if effective, could have the greatest effect on the incidence of PCOS in adolescents. Na- Polycystic ovary syndrome is a heterogeneous endocri- tional programs like first lady Michele Obama’s Let’s Move nopathy that affects girls and women during their reproduc- campaign (http://www.letsmove.gov/) are good first steps tive years. The exact etiology of PCOS is still unknown. toward systematically addressing the obesity epidemic with However, hyperinsulinemia and hyperandrogenism are the prevention. Research on effective treatments for childhood main pathologic features responsible for most of the conse- and adolescent obesity and programs to support successful quences of the syndrome. In adolescents, the irregular cycles weight loss for individuals are sorely needed. of PCOS may be hard to distinguish from physiologic anovulation. However, persistence for more than 2 years DIAGNOSTIC CRITERIA after menarche is a strong predictor of long-term ovulatory dysfunction. Menstrual irregularity in the context of obesity, Controversies exist in the diagnosis of PCOS in adoles- hirsutism, and acanthosis nigricans is likely to represent cents. The Rotterdam criteria (Table 1) or Sultan’s criteria PCOS that will be longstanding. Polycystic ovaries may or specifically for adolescents (Table 2) are useful but may not may not be present in women and girls with PCOS. Ovarian identify all the adolescents who could benefit from sympto- size may be used as a surrogate for polycystic ovaries when matic treatment and anticipatory guidance. Population-based abdominal ultrasonography is being used. Although obesity, studies to identify diagnostic criteria that would predict 118 Current Women’s Health Reviews, 2010, Vol. 6, No. 2 Abdelrahmanet al. which adolescents will continue to struggle with PCOS as and diagnosis of diabetes in general population. We are cur- adults would be most useful. rently evaluating the accuracy of glycosylated hemoglobin compared to the oral glucose tolerance test for diabetes de- Management of PCOS tection in women with PCOS

Most recommendations for management of PCOS are KEY POINTS based on expert opinion. Evidence-based recommendations that encompass the optimal management for symptom con- 1. PCOS is a complex metabolic derangement involving trol and the prevention of sequelae would allow a more sci- insulin resistance, hyperandrogenism, and anovulation. entific approach to patient care. For example, although Genetic, metabolic, endocrinologic and environmental fourth generation COCs containing drospirenone have the factors all play a role. Obesity contributes to the devel- theoretical advantage of direct anti-androgen effects, they opment of PCOS in most but not all patients. have not been compared with COCs containing other progestins in the treatment of PCOS symptoms. Optimum man- 2. PCOS is a clinical diagnosis made after eliminating other agement of hirsutism is another area for research. causes of androgen excess and anovulation (Fig. 1). Sev- eral organizations have attempted to create strict defini- COCs do not treat metabolic features of PCOS including tions of PCOS (see Table 1), which are most useful in the obesity, insulin resistance, metabolic syndrome and diabetes research setting. The varied definitions of PCOS influ- mellitus. Metformin is recommended for impaired glucose ence reports of the incidence of this condition. tolerance and frank diabetes, although its use in insulin resistance requires further evaluation. 3. Patients diagnosed with PCOS should be screened for glucose intolerance and dyslipidemia. Diabetes screening Prevention of Long-Term Sequelae of PCOS should be repeated periodically. Fasting glucose is usu- The Oral Glucose Tolerance Test is currently the gold ally normal in the IGT and diabetes associated with standard test for diabetes screening in women with PCOS, PCOS. Serum glucose testing two hours after a 75 gram and needs to be repeated at undetermined intervals. Glycosy- glucose challenge is the standard for testing. lated hemoglobin was recently recommended for screening

Fig. (1). Flow Chart showing the evaluation of adolescents with PCOS to exclude other conditions. (TSH=thyroid stimulating hormone; T=testosterone; DHEAS=dehydroepiandrosterone sulphate; 17 OH-P= 17 hydroxypeogesterone; ACTH=adrenocorticotropic hormone). *24 hour urinary cortisol is required when Cushing syndrome is suspected. DHEAS screening is optional if total T is normal. Polycystic Ovary Syndrome in Adolescents Current Women’s Health Reviews, 2010, Vol. 6, No. 2 119

4. Long-term consequences of untreated PCOS include an polycystic ovary syndrome: an analysis of 263 consecutive cases. increased risk for diabetes, hypertension, heart disease, Clin Endocrinol (Oxf) 1990; 32(2): 213-20. [8] Kiddy DS, Hamilton-Fairley D, Bush A, et al. Improvement in infertility and endometrial cancer. endocrine and ovarian function during dietary treatment of obese 5. Weight loss is the mainstay of treatment for obese women with polycystic ovary syndrome. Clin Endocrinol (Oxf) 1992; 36(1): 105-11. women with PCOS. As little as a 5% weight reduction [9] Palomba S, Giallauria F, Falbo A et al. Structured exercise training can reverse many of the metabolic disturbances of PCOS programme versus hypocaloric hyperproteic diet in obese and diminish lifetime risks. polycystic ovary syndrome patients with anovulatory infertility: a 24-week pilot study. Hum Reprod 2008; 23(3): 642-50. 6. 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Inappropriate secretion of follicle- such as plucking or shaving, or permanent methods stimulating hormone and luteinizing hormone in polycystic ovarian like laser or electrolysis. Progression of hirsutism can disease. J Clin Endocrinol Metab 1970; 30(4): 435-42. be slowed by decreasing free androgen exposure of [13] Berga SL, Guzick DS, Winters SJ. Increased luteinizing hormone the hair follicle via COCs, systemic anti androgens and alpha-subunit secretion in women with hyperandrogenic anovulation. J Clin Endocrinol Metab 1993; 77(4): 895-901. like spironolactone, or topical eflornithine. [14] Morales AJ, Laughlin GA, Butzow T, Maheshwari H, Baumann G, c. Insulin resistance is best treated with weight loss. Yen SS. Insulin, somatotropic, and luteinizing hormone axes in lean and obese women with polycystic ovary syndrome: common While insulin sensitizing agents like metformin may and distinct features. 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Received: January 10, 2010 Revised: March 01, 2010 Accepted: April 15, 2010 Current Women’s Health Reviews, 2010, 6, 123-129 123 Advanced Management Options for Endometriosis

Jashoman Banerjee*, Mona H. Mallikarjunaiah and John M. Murphy

University of Toledo Medical Center, Toledo, OH 43614, USA

Abstract: Endometriosis is a benign disease affecting 10 % of reproductive age females. Approximately 35% of women with this condition are infertile. The exact cause of the disease is still unknown, but advances in human and animal research have further elaborated its pathogenesis. Conventional, non-fertility related treatment for endometriosis focuses on chronic pelvic pain, which is the most common manifestation of this disease. While traditional methods of treatment have not proven to be completely effective, both medical and surgical therapies still hold some promise in controlling pain. Empiric medical therapy is still the most common mode for initiating treatment. Controversies exist regarding fertility outcomes after surgical treatment. Assisted reproduction holds promise in patients with advanced endometriosis. New treatment options have arisen in response to advances in research targeting the pathogenesis of the disease. Most of the newer therapies are still experimental, but results in animal models show promise, which has served as an impetus for conducting human trials. This article will focus on these new treatment options for endometriosis while also briefly describing the pathogenesis, diagnosis and controversies of existing treatment modalities. Keywords: Endometriosis, infertility, angiogenesis, matrix metalloproteinase, SPRM, cytokine, IVF.

INTRODUCTION PATHOGENESIS OF ENDOMETRIOSIS Infertility is a growing problem worldwide, which not The pathogenesis for endometriosis is somewhat unclear, only affects individual health issues but also has a significant though many hypotheses have been proposed. Sampson’s social and economical impact [1]. About 10% of reproduc- theory of retrograde menstruation suggests that during tive age females (15 to 45 years) are infertile based on 2002 menses, endometrial tissue simultaneously flows in both data from NCHS (National Center for Health Statistics) [2]. anterograde as well as retrograde directions, thereby seeding The prevalence of female infertility has increased in recent the pelvis through the fallopian tubes [11, 12]. While intui- years due to multiple factors including age, delayed child- tive, this theory fails to explain the documented presence bearing due to career interests, an increased incidence of of endometriosis in distant sites not contiguous with the sexually transmitted infections, and endometriosis This re- pelvis. It also does not explain why some women develop view will highlight endometriosis, focusing on its patho- pelvic implants in response to retrograde menstruation while genesis, diagnosis and treatment options. others do not. Theories such as celomic metaplasia [13, 14] and lymphatic and vascular dissemination have been ENDOMETRIOSIS AND INFERTILITY proposed to explain the shortcomings in Sampson’s theory. Endometriosis is associated with both infertility and Recent research has focused on a potential genetic basis subfertility. Some studies suggest that monthly fecundity for the disease with an emphasis on tissue factors and the rates (MFR) range from 2-10% in patients with endo- possible role of stem cells in the pathogenesis of endometri- metriosis compared with 30% in healthy controls [3]. osis [15, 16]. Various factors may cause infertility in patients with endo- The basic pathogenesis of endometriosis at the cellular metriosis. Severe endometriosis may induce adhesion forma- level is quite complicated. It is thought to be an immuno- tion in the fallopian tubes, thereby mechanically impairing inflammatory state [17, 18]. The peritoneal fluid milieu has tubal function. More recently, evidence suggests that there been demonstrated to be altered due to multiple factor aris- is an association between endometriosis and ovulatory ing from this immuno inflammatory state. Cytokines (TNF- dysfunction [4, 5]. Poor oocyte quality, abnormal folliculo- , IL-6,IL-18,TGF-) [5, 17] and oxidative stress have been genesis [6] , poor implantation [7] and luteal phase defects implicated in the causation and progression of this benign have been associated with the presence of endometriosis [8]. disease [19]. Cytokines, which are mediators of inflamma- Furthermore, in-vitro fertilization studies (IVF) have sug- tion, are released by macrophages, which assemble in the gested that endometriosis is a contributing factor to abnormal peritoneal environment to defend against foreign endometrial sperm parameters [9, 10]. tissue and thus create the state of inflammation in the peritoneal cells and fluid [17]. Micro array analyses of peritoneal fluid have demonstrated that the expression of cytokines in *Address correspondence to this author at the Department of Obstetrics patients with endometriosis is altered overall and that the and Gynecology, University of Toledo Medical Center, Toledo, OH 43614, USA; Tel: 419-383-4590; Fax: 419-383-3090; level of expression varies according to the different stages of E-mail: [email protected] the disease [20].

Pain is the most common symptom, and it has been Angiogenesis is a key factor in the survival of ectopic correlated in some studies with disease stage (i.e, pain endometrial issue in the pelvis. Neovascularisation from the increases as the disease becomes more widespread) and with effects of vascular growth factors, tissue factors [16], and cytokine expression. Although the etiology of endometriotic other cytokines allow the implants to remain viable and help pain is still not clear, recent evidence has focused on the maintain the ectopic endometrium .Studies have shown that role of prostaglandins and proinflammatory cytokines angiogenesis in cancer and endometriosis behave similarly released by the endometriotic implants into the peritoneal and that surgery for endometriosis reduces expression of cavity [21]. vascular growth factors in the peritoneal fluid [38-40].

The ultimate fate of the pelvic peritoneum is healing DIAGNOSIS by scarring. This process can distort the tubal anatomy indirectly, affecting the tubes’ ability to receive an ovum Diagnosing endometriosis based solely on the clinical and transport it to the uterus [22]. These adhesions at spe- presentation can be difficult, given the non-specific nature of cific places have also been related to pelvic pain during men- many of its symptoms and the common occurrence of pelvic ses (progressive dysmenorrhoea) and also during intercourse pain in women without endometriosis. Therefore, laboratory (deep dysperunia), which is the classical presenting symptom studies, imaging studies and diagnostic laparoscopy are often [23-25]. necessary [41]. Previous studies have suggested that there is a significant delay in the diagnosis for many women, with Peritoneal adhesions are not the only etiology of infertil- some studies showing a mean delay of 11.7 years in the ity. It has been established by in vitro studies that the cytoki- United States [42]. Failure to identify a noninvasive tool or a nes and oxidative stress may affect the oocyte, early embryo serum marker makes clinical examination, imaging and development and sperm qualities by either altering the laparoscopy the most reliable diagnostic tools. A study per- morphology or assaulting the nuclear DNA [10, 26]. formed to verify the use of the concomitant serum levels of Apart from cytokines, endometriotic implants in the peri- CA 125, CA 19-9 and interleukin – 6 with CA 125 alone toneal fluid have been shown to possess abnormal prote- concluded that the former did not add significant information olytic and fibrinolytic properties, which may assist their im- in diagnosing either early or advanced stages of endometri- plantation. Plasminogen activator and plasminogen activator osis [43]. inhibitor have also been studied in the pathogenesis of en- Imaging has emerged as an additional tool in the diagno- dometriosis. A state of hypofibrinolysis has been hypothesis of endometriosis. Transvaginal ultrasonography (TVUS) sized which may aid the persistence of endometrial implants. is usually the first imaging modality to be used for further This may be an indirect result of altered polymorphism in the evaluation of a patient with chronic pelvic pain with sus- genes expressing plasminogen activator inhibitor-1 (PAI-1) pected endometriosis. TVUS is sensitive in detecting ovarian [27, 28]. Newer theories focus on their roles not only in endometriomas and other endometriotic plaques located near endometriosis but also in subfertile populations [29]. the vagina [44]. However, it can not detect pelvic adhesions The role of matrix metalloproteinase (MMPs) has also or superficial peritoneal foci. A combination of clinical and been extensively studied as a contributor to the pathogenesis vaginal probe ultrasound findings may improve the accuracy of endometriosis. These proteolytic enzymes erode the ex- of diagnosis [45]. Abaro et al. and Goncalves et al. state that tracellular matrix and help the endometriotic implants to TVUS may be more sensitive in detecting rectovaginal deep grow into peritoneal cells. Under normal circumstances, their endometriosis [46, 47]. action is kept in check by tissue inhibitors of metalloprotein- MRI is now being used more commonly to diagnose en- ases (TIMP). The TIMP-MMP balance may be disturbed in dometriotic lesions. Small nodules may be recognized as endometriosis, leading to uninhibited MMP expression [30]. hyperintense lesions on T1-weighted sequences, and plaque The expression of both TIMP and MMP in endometriosis lesions have a similar appearance, with a variable signal on implants is higher than in normal endometrial tissue [31]. It T2-weighted sequences [48] . Even though MRI is superior has also been found that matrix degrading MMP-1 is ex- to TVS in detecting small peritoneal lesions, it is recom- pressed along with its regulator cytokine IL-1 alfa in stroma mended in patients with chronic pelvic pain with suspected of endometrial implants [32, 33]. adhesions with endometriosis. TVUS seems superior in de- Oxidative stress has a key role in the pathogenesis of the tecting rectovaginal disease [49, 50]. disease. This is a state where the balance between pro- oxidants and anti-oxidants in any cell or tissue is perturbed MANAGEMENT in favor of the pro–oxidants which are mainly free oxygen Endometriosis is a chronic disease marked by acute flare radicals. This abundance of free radicals can damage cells, ups. The condition is generally managed with medical ther- mainly by affecting membrane stability and accelerating apy. Surgical treatment is reserved for more problematic apoptosis [5, 18, 31, 34-36]. Oxidative stress not only affects cases. Medical management encompasses the use of tradi- the disease directly but also plays synergistic roles in modi- tional treatments: combined oral contraceptives, GnRH ana- fying cytokine actions and assisting MMP activity in logues, and progesterone, although the most common medi- the peritoneal cells. Reactive oxygen species have been cation used for pain relief is NSAIDs (non steroidal anti in- demonstrated to activate latent MMPs to their active forms flammatory drugs). We will discuss options of surgical and also to increase adhesion formation in the peritoneal treatment, traditional medical treatment and newer treatment cavity [37]. in this section. Advanced Management Options for Endometriosis Current Women’s Health Reviews, 2010, Vol. 6, No. 2 125

SURGICAL MANAGEMENT phin receptors, abolishing the pulsatility in natural secretion [56]. These drugs include leupreolide, goserelin, nafarelin, Laparoscopy is still considered the gold standard in diagnosing endometriosis [41, 51, 52]. Recent reviews have buserelin, and histrelin. The main side effect is the hypoes- demonstrated that in selected groups of patients, laparo- trogenic state that ensues after an initial flare effect. This scopic surgery improves pelvic pain, irrespective of the hypoestrogenic state can manifest as post menopausal vascu- nature of surgery [53, 54]. lar symptoms and also by bone mineral density loss [68]. These effects can be counteracted by using “add back ther- Various surgical treatments have been utilized to treat apy” either with norethindrone or combined oral contracep- chronic pelvic pain in patients with endometriosis including tives [63, 69]. Disease recurrence is also common after lysis of adhesions, laser ablation of implants, and aspiration GnRH therapy is stopped [70]. and excision of endometriomas [55, 56]. Whether these ablative surgeries compromise ovarian reserve is not currently Danazol known. Multiple authors have concluded that surgery for endometriosis does not negatively alter IVF outcomes This 17-ethinyl-testosterone derivative has shown to have [57, 58]. similar efficacy when compared with GnRH agonists in re- Minimally invasive surgery for endometriosis might im- lieving pain. It has fallen out of favor secondary to its andro- prove pain in most patients, but the overall debate on genic side effects, which include weight gain, hirsutism, al- whether surgery is essential to improve fertility outcomes in tered lipid profile and abnormal liver enzymes [71]. patients with endometriosis still prevails. Littman et al. demonstrated that of 29 patients with IVF failure, 22 conceived Progestins after laparoscopic surgery. Fifteen of these pregnancies were Progesterone treatment creates a pseudo pregnant state. spontaneous and the other 7 were initiated by IVF [59]. Ad- The exact mechanism of action is unknown but it is believed amson et al. while studying the factors affecting reproduc- that it not only counteracts estrogenic effects on the endo- tive outcomes after surgery in patients with endometriosis metrial cells but also affects MMP activity and prevents an- stressed the importance of the combination of surgical skills giogenesis as seen in animal studies [72]. Murine studies and proper patient selection for IVF is required to achieve have also demonstrated the repressive effect of progesterone success [60]. on estrogen-induced stroma cell derived factor in endo- MEDICAL MANAGEMENT metrial implants, which were unaffected by selective progesterone receptor modulators (Asoprisnil) or anti progestogens Medical management is largely empirical and based (RU486) [73]. mostly on clinical findings. Management can be broadly divided into traditional and newer treatment groups. Various types of progestins are used for treatment including medroxyprogesterone acetate (20-30 mg/day), Depo Me- TRADITIONAL droxyprogesterone acetate (DMPA/ Depo-Provera, Pfizer) and Depo SubQ -104–Provera (Pfizer). These agents have NSAIDs comparable efficacy with GnRH analogues but have lesser The most commonly used medication for pain in hypoestrogenic effects on the bone. A recent study con- endometriosis is the NSAID. But its role and efficacy are ducted in Japan found that a highly selective progesterone doubtful, and the side effect profile is extensive [61]. receptor analogue called Dienogest (DNP) had antiproliferative and inhibitory effects on cytokines. It has been Oral Contraceptives shown to be as effective as intranasal buserelin in relieving With hormone therapy, the goal is to create a pseudo- pain [74]. pregnancy or a pseudo-menopause state in order to ablate the The Levonorgestrel (LNG) IUD system may have thera- active endometriotic deposits. Oral contraceptives may be peutic implications in patients with endometriosis. One used cyclically or continuously. Combined oral contracep- animal study found that LNG microspheres created a pseudo tive (those containing a combination of an estrogen and pregnancy state in the uterus of a rabbit model [75]. a progestin) decidualizes endometriotic implants, thus reducing their activity [56], possibly by inducing apoptosis [62]. Comparative Studies Contraceptives containing androgenic progestogens are normally preferred, but those containing desogestrel may GnRH agonists have been compared with Danazol in be used with acceptable results [63, 64]. With cyclical OC randomized studies, and the results showed little if any sig- therapy, dysmenorrhea can recur during the pill-free period. nificant difference in pain control [76]. When compared with In that case, continuous usage might be more beneficial COCs in a small randomized trial, goserelin was better able [65]. The use of combined oral contraceptives did not alter to alleviate dysmenorrhoea [77] but the combination of trip- recurrence rates in post surgical patients with endometriosis torelin and COC had a better efficacy at 1 year follow up [66]. [78]. Human studies have compared the effects of LNG IUD with GnRH agonist therapy on endometrial thickness as Gonadotrophin Releasing Hormone Agonists (GnRH) evaluated by ultrasonography. This study demonstrated This is the most commonly used medication to treat en- smaller uterine changes in the LNG arm but similar effects dometriosis [67]. It acts by down-regulating the gonadotro- on endometrial thickness [79]. 126 Current Women’s Health Reviews, 2010, Vol. 6, No. 2 Banerjee et al.

NEWER TREATMENT METHODS treatment for endometriosis is still experimental and needs further research. Advancements in animal and human research exploring the pathogenesis of endometriosis have opened up newer Anti-Angiogenic Agents avenues of treatment. Medications targeting the disease pathology are being developed. Some of these agents under The process of angiogenesis helps keep ectopic endo- investigation include aromatase inhibitors, matrix metallo- metrial implants biologically active. These implants express proteinase (MMP) inhibitors, anti-angiogenic agents, anti- vascular endothelial growth factor-A (VEGF –A) in perito- TNF-, selective estrogen receptor modulators (SERMs), neal fluid, which initiates endothelial migration, proliferation and selective progesterone receptor modulators (SPRM) and neovascularisation. This in turn stimulates production of estrogen and PGE2. VEGF in turn stimulates COX-2 pro- (Asoprisnil, Schering and TAP Pharmaceuticals). duction, thus maintaining PGE levels and leading to a vis- Aromatase Inhibitors cous cycle of persistent vascular growth [87]. Most anti-angiogenic therapies are currently being used Normal endometrial tissue does not express high levels in patients with advanced cancer. Bevacizumab, a humanized of aromatase activity whereas endometrial implants do, anti-VEGF antibody (Avastin, Genentec), has been approved secondary to the inflammatory effects of prostaglandins by FDA [88], but no human studies have been performed (PGE) and estradiol. Letrozole and Anastrozole are the two rd using such agents for endometriosis. Many animal studies most commonly used 3 generation aromatase inhibitors. have documented that use of a competitive inhibitor, or anti- They act by inhibiting aromatase, the enzyme that converts bodies to VEGF, may retard implant survival and growth by androstenedione to estrone and testosterone to estradiol by preventing new vessel growth [89, 90]. The only drawback binding competitively with the heme moiety of the cyto- of these studies was that they could not demonstrate whether chrome P450 subunit. This mainly reduces excess estrogen the therapy had effect on existing mature vessels. Human and prostaglandin (PGE) production in peripheral tissues, studies have yet to be conducted. Other angiogenesis inhibit- thus inhibiting the endometrial implants’ ability to prolifer- ing factors, namely TNP-470 [90], endostatin [91], and angi- ate [80]. A mouse model study demonstrated that aromatase nex [90], are still experimental agents. inhibitors did not prevent implants from becoming estab- Recently, vascular-disruptive agents (VDAs) have been lished in the mouse peritoneum but significantly reduced studied in cancer therapy. They have some advantages over their growth when administered on day 1 of the menstrual existing angiogenic inhibitors regarding their effect on pre- cycle. Letrozole also increased apoptosis when started on existing vasculature and mature vessels. They can be used in day 28. They also reduced vascular endothelial growth factor acute treatment and also in advanced disease [92]. VDAs can (VEGF) and prostaglandin (PGE) production in the perito- be used in advanced endometriosis as they are able to neal fluid [81]. specifically target the new and existing vessels supplying the implants better than other anti-angiogenic agents, but no Several studies have shown that aromatase inhibitors may human studies have been reported to date. act singly or in combination with combined oral contraceptives or with GnRH agonists in alleviating pain [82, 83]. The Recent animal research also has targeted tissue factor in advantage of combining aromatase inhibitors with a GnRH the endothelium of endometriotic implants. A novel agent agonist is that they can prevent the sudden growth of ovarian called ICON (Immuno Conjugate), designed from Factor cysts due to excess FSH secreted secondary to low estrogen VII-a, has been used to target the tissue factor in the endo- levels [84]. This combination therapy, however, can pro- thelium. ICON binds with the tissue factor and recruits NK foundly reduce bone mineral density (BMD) immediately cells to destroy the entire endometriotic lesion [16, 93, 94]. following treatment, which can take 2 years to rebuild after discontinuing treatment. Anti-TNF- TNF- plays an important role in the pathogenesis of Matrix Metalloproteinase Inhibitors endometriosis. Targeting this cytokine may help by disrupt As discussed in the pathogenesis section, a balance be- the signaling pathways leading to decreased angiogenesis tween MMP and TIMP is essential to maintain homeostasis and reduced MMP activity. This type of therapy may also in peritoneal fluid. In patients with endometriosis, the strict help prevent oocyte and sperm damage. regulation of MMPs is lost, and TIMP expression declines, Animal models mainly the baboon and rat have been as shown in animal studies [85]. As a result, ectopic endo- used to demonstrate the effects of monoclonal antibodies on metrial tissue can implant more readily within the pelvic endometriotic implants. In one study, the size of endometri- peritoneum [31]. otic lesions decreased, and the efficacy was comparable to The role of melatonin as an antioxidant has been docu- that of GnRH agonists [95]. Randomized trials in humans mented in animal studies in relation to MMPs. It has been with anti- TNF- have not been conducted. Results from a shown to reduce the activity of pro- MMP-9 in the peritoneal single case report were not encouraging after long-term use cavity [85]. This may be attributed to its anti-oxidant proper- of Etanarcept and Leflumide. There was no reduction of le- ties by which it reduces protein oxidation and lipid peroxida- sion size although the patient was able to conceived with the tion. It can also augment antioxidants such as superoxide help of IVF after 8 years of treatment [96]. Hence, the thera- dismutase and catalase and decrease malondialdehyde levels, peutic role of anti- TNF- agents in established endometri- as seen in murine studies [86]. The role of melatonin in the osis has yet to be proven. Advanced Management Options for Endometriosis Current Women’s Health Reviews, 2010, Vol. 6, No. 2 127

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Received: January 10, 2010 Revised: February 17, 2010 Accepted: April 15, 2010

130 Current Women’s Health Reviews, 2010, 6, 130-145 Prevention and Management of Ovarian Hyperstimulation Syndrome

Botros Rizk1,* and Christopher B. Rizk2

1Department of Obstetrics and Gynecology, University of South Alabama, Mobile, Alabama, USA; 2Rice University, Houston Texas, USA

Abstract: Ovarian hyperstimulation is an iatrogenic syndrome that presents as the most serious complication of ovarian induction. This syndrome is characterized by bilateral multiple cysts and third space fluid distribution. While mild forms have no consequences to the patient, severe forms may result in mortality and severe morbidity. A new classification of the syndrome is proposed based on the severity. The classification should guide the fertility specialist in determining the plan of management. OHSS is most prevalent in patients with polycyctic ovarian syndrome. Prediction depends on the clinical acumen and careful monitoring using ultrasounagraphy and serum estradiol measurements. The most popular method for prevention is coasting. The role of dopamine agonists has become part of the standard management. The management of OHSS could be achieved on an outpatient basis in many circumstances. Correction of the circulatory volume and the prevention of thromboembolism are the two basics that should be achieved by all clinicians involved in the management of the patient. Keywords: OHSS, ascites, pleural effusion, thromboembolism, genetics, dopamine agonist.

INTRODUCTION tion by chorionic gonadotropin, which is abundant in early pregnancy. Ovarian hyperstimulation syndrome (OHSS) is the most serious iatrogenic complication of ovulation induction [1- 20]. OHSS is characterized by bilateral, multiple follicular and theca-lutein ovarian cysts (Fig. 1) and an acute shift in body fluid distribution resulting in ascites (Fig. 2) and pleural effusion (3) (Fig. 3). Induction of ovulation by gonadotropins is one of the major advances in the treatment of infertility in the second half of the 20th century. Some degree of ovarian hyperstimulation occurs in all women who respond to ovulation induction but this should be distin- guished from the clinical entity of ovarian hyperstimulation syndrome. Whilst mild OHSS is of no clinical relevance, severe OHSS, characterized by massive ovarian enlargement, ascites, pleural effusion, oliguria, hemoconcentration and thromoembolic phenomena, is a life-threatening complication. This manuscript is based on our previous publications and reviews [1-3].

OHSS CLASSIFICATIONS OHSS may be moderate or severe, early or late in onset Fig. (1). Bilateral enlarged cystic ovaries Reproduced with (Fig. 4), and spontaneous or iatrogenic in etiology. Early permission from: Rizk B , Rizk CB , Nawar MG, Garcia-Velasco OHSS presents 3 to 7 days after the ovulatory dose of HCG, JA, Sallam HN. Ultrasonography in the prediction and management whereas late OHSS presents 12 to 17 days after HCG. Early of ovarian hyperstimulation syndrome IN: Rizk B, Ed. Ulrasono- OHSS relates to “excessive” preovulatory response to stimu- graphy in reproductive medicine and infertility Cambridge, UK: lation. Late OHSS develops only in connection with preg- Cambridge University Press 2010; Chaper 36: 299-312. nancy, is more likely to be severe and has a low correlation There has been no unanimity in classifying OHSS, and with pre-ovulatory events. Most cases of OHSS are iatro- divergent classifications have made comparisons between genic following gonadotropin stimulation. Rarely, OHSS studies difficult [2]. Aboulghar and Mansour [6] (2003) re- occurs spontaneously as a result of mutations in the follicle viewed the classifications used for OHSS over the last four stimulating hormone (FSH) receptor leading to its stimula- decades (Table 1). The most recent classification was introduced in 1999 by Rizk and Aboulghar (1999) [7]. They clas- *Address correspondence to this author at the Department of Obstetrics and sified the syndrome into only two categories, moderate and Gynecology, University of South Alabama, Mobile, Alabama 36604-1512, severe, with the intent of categorizing patients into more USA; Tel: (251) 415-8602; E-mail: [email protected] defined clinical groups that correlate with the syndrome’s

a b

c d

e f

Fig. (2a). Ascites in severe ovarian hyperstimulation syndrome Reproduced with permission from: Rizk B , Rizk CB , Nawar MG, Garcia- Velasco JA, Sallam HN. Ultrasonography in the prediction and management of ovarian hyperstimulation syndrome In: Rizk B, Ed. Ulrasono- graphy in reproductive medicine and infertility Cambridge, UK: Cambridge University Press 2010; Chapter 36: 299-312. (2b). Ascites in severe ovarian hyperstimulation syndrome Reproduced with permission from: Rizk B, Rizk CB, Nawar MG, Garcia-Velasco JA, Sallam HN. Ultrasonography in the prediction and management of ovarian hyperstimulation syndrome In: Rizk B, Ed. Ulrasonography in reproductive medicine and infertility, Cambridge, UK: Cambridge University Press 2010; Chapter 36: 299-312. (2c). Ascites in severe ovarian hyperstimulation syndrome Reproduced with permission from: Rizk B, Rizk CB, Nawar MG, Garcia-Velasco JA, Sallam HN. Ultrasonography in the prediction and management of ovarian hyperstimulation syndrome In: Rizk B, Ed. Ulrasonography in reproductive medicine and infertility Cambridge, UK: Cambridge University Press 2010; Chapter 36: 299-312. (2d). Ascites in severe ovarian hyperstimulation syndrome. Reproduced with permission from: Rizk B, Rizk CB, Nawar MG, Garcia-Velasco JA, Sallam HN. Ultrasonography in the prediction and 132 Current Women’s Health Reviews, 2010, Vol. 6, No. 2 Rizk and Rizk

Fig. (1). contd….. management of ovarian hyperstimulation syndrome In: Rizk B, Ed. Ulrasonography in reproductive medicine and infertility Cambridge, UK: Cambridge University Press 2010; Chapter 36: 299-312. (2e). Ascites in severe ovarian hyperstimulation syndrome. Reproduced with permission from: Rizk B, Rizk CB, Nawar MG, Garcia-Velasco JA, Sallam HN. Ultrasonography in the prediction and management of ovarian hyperstimilation syndrome In: Rizk B, Ed. Ulrasonography in reproductive medicine and infertility Cambridge, UK: Cambridge University Press 2010; Chaper 36: 299-312. (2f). Ascites in severe ovarian hyperstimulation syndrome. Reproduced with permission from: Rizk B, Rizk CB, Nawar MG, Garcia-Velasco JA, Sallam HN. Ultrasonography in the prediction and management of ovarian hyperstimulation syndrome In: Rizk B, Ed. Ulrasonography in reproductive medicine and infertility Cambridge, UK: Cambridge University Press 2010; Chapter 36: 299-312. prognosis. Their classifications can be correlated with the OHSS. In addition to the presence of ascites on ultrasound, treatment protocol and prognosis. the patient’s complaints usually are limited to mild abdominal pain and distension and hematological and biochemical

profiles are normal.

MODERATE OHSS o Abdominal discomfort, pain, nausea, abdominal distension, ultrasonic evidence of ascites and enlarged ovaries, normal hematological and biological profiles. Treatable on an outpatient basis with extreme vigilance. SEVERE OHSS o Grade A: Dyspnea, oliguria, nausea, vomiting, diarrhea, abdominal pain, clinical evidence of ascites plus marked distension of abdomen or hydrothorax, large ovaries and marked ascites on ultrasound, normal biochemical profiles. Can be treated as inpatient or outpatient depending on physician’s experience, patient compliance, and medi-

cal facility.

o Grade B: All symptoms of grade A, plus massive tension Fig. (3). Right pleural effusion in OHSS. Reproduced with per- ascites, markedly enlarged ovaries, severe dyspnea, and mission from: Rizk B, Rizk CB, Nawar MG, Garcia-Velasco JA, marked oliguria; biochemical changes, including in- Sallam HN. Ultrasonography in the prediction and management of creased hematocrit, elevated serum creatinine, and liver ovarian hyperstimulation syndrome In: Rizk B, Ed. Ultrasonography dysfunction. Treated as a hospital inpatient hospital in reproductive medicine and infertility Cambridge, UK: Cam- under expert supervision. bridge University Press 2010; Chapter 36: 299-312. o Grade C: OHSS complicated by respiratory distress The new classification omits mild OHSS, used by most syndrome, renal shut-down or venous thrombosis. previous authors, as this level of OHSS occurs in the major- Considered critical and should be treated in an intensive ity of cases of ovarian stimulation and does not require care setting. special treatment. Most cases of OHSS present as moderate

Fig. (4). Classification of ovarian hyperstimulation syndrome early and late. Reproduced with permission from: Rizk B, Rizk CB, Nawar MG, Garcia-Velasco JA, Sallam HN. Ultrasonography in the prediction and management of ovarian hyperstimulation syndrome In: Rizk B, Ed. Ulrasonography in reproductive medicine and infertility Cambridge, UK: Cambridge University Press 2010; Chapter 36: 299-312. Prevention and Management of Ovarian Hyperstimulation Syndrome Current Women’s Health Reviews, 2010, Vol. 6, No. 2 133

Table 1. Classifications of Ovarian Hyperstimulation Syndrome (1967-1999) Reproduced with Permission from Aboulghar MA, Mansour RT, Ovarian Hyperstimulation Syndrome: Classifications and Critical Analysis of Preventive Measures. Hum Reprod Update 2003; 9: 275-89

Study Mild Moderate Severe

Rabau etal. Grade 1: estrogen >150 ug and Grade 3: grade 2 + Grade 5: grade 4 + ascites and Grade 6: grade 5 + changes in (1967) pregnanediol >10 mg 24 h confirmed palpable possibly hydrothorax blood volume, viscosity and Grade 2: + enlarged ovaries and cysts and distended coagulation, time

possibly palpable cysts Grade 1 abdomen and 2 were not Grade 4: grade 3 + included under the title of vomiting and possibly mild OHSS diarrhoea

Schenker and Grade 1: estrogen >150 (ig/24 h Grade 3: grade 2 + Grade 5: grade 4 + large ovarian cysts, Grade 6: marked Weinstein and pregnanediol >10 mg 24 h abdominal distension ascites and/or hydrothorax haemoconcentration + (1978) Grade 2: grade 1+ enlarged Grade 4: grade 3 + increased blood viscosity ovaries, sometimes small cysts nausea, vomiting and possibly coagulation

and/or diarrhoea abnormalities

Golan et al. Grade 1: abdominal distension Grade 3: grade 2 + Grade 4: grade 3 + clinical evidence of Grade 5: grade 4 + (1989) and discomfort ultrasound evidence ascites and/or hydrothorax and breath- haemoconcentration, Grade 2: grade 1 + nausea, of ascites ing difficulties increased blood viscosity, vomiting and/or diarrhoea, coagulation abnormality and enlarged ovaries 5-12 cm diminished renal perfusion

Navot et al. Severe OHSS: variable enlarged ovary; Critical OHSS: variable (1992) massive ascites ± enlarged ovary; tense ascites ± hydrothorax; Hct >45%; hydrothorax; Hct >55%; WBC

WBC >15 000; oliguria; 22=25 000; oliguria; creatinine creatinine 1.0-1.5; creatinine 5=1.6; creatinine clearance <50 clearance >50 ml/min; liver ml/min; renal failure; throm- dysfunction; anasarca boembolic phenomena; ARDS

Rizk and Discomfort, pain, Grade A: Dyspnoea, Grade B: Grade A Grade C: Aboulghar nausea, distension, oliguria, nausea, vomiting, plus massive tension Complications as (1999) ultrasonic evidence of diarrhoea, abdominal pain, ascites, markedly respiratory distress ascites and enlarged clinical evidence of enlarged ovaries, syndrome, renal ovaries, normal ascites, marked severe dyspnoea and shut-down or haematological and distension of abdomen marked oliguria, venous thrombosis biological profiles or hydro¬thorax, US increased haematocrit, showing large ovaries and elevated serum marked ascites, normal creatinine and liver biochemical profile dysfunction

COMPLICATIONS OF OHSS Venous compression due to enlarged ovaries and ascites, together with immobility and a transient change in coagula- Vascular Complications tion were thought to be the main etiological factors in Cerebrovascular complications are by far the most seri- thromboembolism. Internal jugular vein thrombosis occurred ous complications of OHSS. The first cases of severe throm- >6 weeks after ovulation, and a subclavian vein thrombosis boembolic phenomena following human menopausal go- occurred 7 weeks after egg collection for in vitro fertilization nadotropin and human chorionic gonadotropin (hMG/hCG) (IVF). Both of these cases suggest a generalized effect on the treatment caused the death of one patient (carotid embolism) coagulation system that may persist for several weeks. and a limb amputation in the other [2, 3]. Hemoconcentration and increased hematocrit value in the Liver Dysfunction presence of normal coagulation parameters were found in 9 Hepatic function abnormalities have been recognized of 25 patients [2, 3]. Increased levels of factor V, platelets, increasingly as a complication in severe OHSS that may per- fibrinogen, profibrinolysin, fibrinolytic inhibitors, and sist for >2 months. Liver biopsies typically demonstrate sig- thromboplastin generation were observed [2, 3]. Thrombo- nificant morphological abnormalities only at the ultrastruc- phlebitis occurred in 2 of 25 patients and deep venous tural level [2, 3]. Electron microscopy revealed paracrystal- thrombosis has been reported in at least one case of severe line inclusions in the majority of the liver cell mitochondria. OHSS [2, 3]. There were prominent membrane-bound bodies containing

134 Current Women’s Health Reviews, 2010, Vol. 6, No. 2 Rizk and Rizk granular matrix material and interpreted as microbodies or patients. Laparoscopic unwinding of twisted ischemic hem- peroxisomes. The cisternae of the smooth endoplasmic orrhagic adnexum after IVF was successfully accomplished reticulum were dilated. and focal microvillus proliferation [2, 3]. was present in the region of the canaliculi. No significant changes in the Golgi apparatus or glycogen granules were PATHOPHYSIOLOGY OF OHSS noted. These changes may be related to the increased estro- Over the years many substances involved in the regula- gen production induced by hMG. Similar hepatic changes tion of vascular permeability have been implicated as a cause have been found after the administration of oral contracep- of OHSS [11], and several of them are still under investiga- tives or anabolic steroids. The ultrastructural changes may be tion. The list of potential mediators includes estradiol; his- a compensatory morphological change in response to the tamines; prostaglandins; the ovarian rennin-angiotensin sys- increase in demand on the liver enzymes rather than true tem; interleukin (IL)0-6, IL-2 and IL-8; angiogenin; endo- pathological alterations. thelin-1; insulin; and the ovarian kinin-kallikrein system. Rizk et al. (1997) and Pellicer et al. (1999) investigated Respiratory Complications the role of vascular endothelial growth factor (VEGF) as Respiratory distress, secondary to ascitic fluid accumula- a mediator for capillary permeability and fluid leakage [8] (Figs. 5-7). VEGF production is dependent on human tion, is common in severe OHSS and is usually relieved by chorionic gonadotropin stimulation that is administered to aspiration of ascitic fluid. Adult respiratory distress syn- trigger ovulation or during the early phase of pregnancy. drome was reported in a patient with severe OHSS. A rare case of pleural effusion as the sole presentation of OHSS and PREDICTION OF OHSS a similar case after IVF have been described [2, 3]. Predicting the risk of OHSS is the cornerstone of preven- Gastrointestinal Complications tion. Prediction is based on identifying the characteristics of With the widespread use of ovulation induction for as- patients who are high responders as well as the use of ultra- sisted conception, it is mandatory that general practitioners sonography and estradiol assessment (Table 2). Rizk et al. become aware that gastrointestinal symptoms could be the (2010) studied the role of ultrasonography before, during, initial presentation of ovarian hyperstimulation. One such and after ovarian stimulation as the key to early prediction case presented with a cerebrovascular accident due to such and successful prevention (Figs. 8-11) [3]. Rizk and Aboul- symptoms being overlooked [2, 3]. ghar emphasized the role of estradiol measurement in the detection of high responders who are at risk for severe OHSS Adnexal Torsion [7]. Adnexal torsion after superovulation is caused primarily Rizk (2009) investigated the role of FSH receptor by ovarian enlargement due to the development of multiple (FSHR) mutations and polymorphisms in the development of follicular or luteal cysts that make this complication more OHSS [16]. Mutations in FSH receptors could be either acti- common in cases of OHSS [2, 3]. OHSS may worsen during vated, thus resulting in OHSS, or inactivating, thus resulting the pregnancy with the continuing increase in ovarian in sterility. To date, 744 single nucleotide polymorphisms size eventually leading to torsion. In a series of 154 patients have been identified in the FSH receptor gene. Genetic stud- hospitalized for severe OHSS, torsion was noted in 16% of ies of FSH receptor mutations have increased the expecta- the pregnant patients compared with 2.3% of non-pregnant tions that OHSS could be predicted based on the FSH recep-

Fig. (5). Pathophysiology of ovarian hyperstimulation syndrome. Reproduced with permission from: Rizk B, Rizk CB, Nawar MG, Garcia-Velasco JA, Sallam HN. Ultrasonography in the prediction and management of ovarian hyperstimulation syndrome In: Rizk B Ed. Ulrasonography in reproductive medicine and infertility Cambridge, UK: Cambridge University Press 2010; Chapter 36: 299-312. Prevention and Management of Ovarian Hyperstimulation Syndrome Current Women’s Health Reviews, 2010, Vol. 6, No. 2 135 tor genotype. The potential association of the S680 allele with also associated with high quality ooctyes and subsequent poor responders to ovarian stimulation for IVF led to the embryonic development. A genetic association study of hypothesis that the N680 allele could be associated with the ovarian stimulation outcome in 307 unrelated women with hyper-responders, i.e., patients at risk of iatrogenic OHSS. In normal ovarian function who underwent ovarian stimulation an elegant study, no statistically significant differences be- using recombinant FSH was performed. Four single nucleo- tween the IVF control population and the OHSS patients in tide polymorphisms located at the BMP-15 gene were ana- allelic or genotypic frequencies were found. However, a sig- lyzed in order to investigate the role of this gene in relation nificant enrichment in allele 680 was observed as the sever- to ovarian stimulation outcome. The results support the ity of OHSS increased (P = 0.034). The results of this study hypothesis that BMP-15 alleles predict over-response to also suggested that the genotype in position 680 of the FSH recombinant FSH and ovarian hyperstimulation syndrome in receptor cannot predict which patient will develop OHSS but humans [16]. could be a predictor of severity of OHSS symptoms in women who develop the syndrome.

Fig. (7). Vascular endothelial growth factor receptors and vascular permeability. Reproduced with permission from: Rizk B, Rizk CB, Nawar MG, Garcia-Velasco JA, Sallam HN. Ultrasonography in the prediction and management of ovarian hyperstimulation

syndrome In: Rizk B, Ed. Ulrasonography in reproductive medicine and infertility Cambridge, UK: Cambridge University Press 2010; Chapter 36: 299-312. Table 2. Prediction of OHSS

History and Physical 1. OHSS in a previous cycle 2. Polycystic ovarian syndrome (PCOS)

3. Young age

Fig. (6). Vascular endothelial growth factor receptors. Reproduced 4. Low body mass index with permission from: Rizk B, Rizk CB, Nawar MG, Garcia- 5. Hyperinsulinism Velasco JA, Sallam HN. Ultrasonography in the prediction and 6. Allergies management of ovarian hyperstimulation syndrome In: Rizk B, During Ovarian Stimulation Ed. Ulrasonography in reproductive medicine and infertility Cambridge, UK: Cambridge University Press 2010; Chapter 36: 1. High serum estradiol, rapid slope of E2 and absolute value 299-312. 2. Ultrasonography Bone morphogenetic protein-15 (BMP-15) is an impor- a. Baseline PCO pattern tant oocyte-derived growth factor which is essential for b. PCO pattern of response to GnRH before gonadotropins normal folliculogenesis and female fertility of mammals. c. Large number of follicles > 20, on each ovary BMP-15 is a member of the transforming growth factor (TGF) superfamily. Within the ovary, BMP-15 mRNA is 3. Doppler low intraovarian vascular resistance found exclusively in the oocyte. In the human, BMP-15 is Outcome of ART Cycles detected in the oocytes of primordial follicles and progres- 1. Conception cycles sively expressed by oocytes in growing follicles through 2. Multiple pregnancy folliculogenesis [16]. High BMP-15 in follicular fluid is 136 Current Women’s Health Reviews, 2010, Vol. 6, No. 2 Rizk and Rizk

Fig. (8). Polycystic ovaries at the beginning of an IVF cycle. Reproduced with permission from: Rizk B, Rizk CB, Nawar MG, Garcia- Velasco JA, Sallam HN. Ultrasonography in the prediction and management of ovarian hyperstimulation syndrome In: Rizk B, Ed. Ulrasono- graphy in reproductive medicine and infertility Cambridge, UK: Cambridge University Press 2010; Chapter 36: 299-312.

PREVENTION OF OVARIAN HYPERSTIMULATION tients at risk, use of treatment of other than gonadotropins SYNDROME for PCOS patients (such as metformin and ovarian diathermy), and use of low doses and GnRH antagonists when Rizk in 1993 [17] suggested a ‘Ten Commandments’ for gonadotropins were necessary (Table 3). A second ‘Ten the prevention of OHSS. These consisted of identifying pa- Commandments’ addressed the secondary prevention of Prevention and Management of Ovarian Hyperstimulation Syndrome Current Women’s Health Reviews, 2010, Vol. 6, No. 2 137

OHSS and included withholding or delaying hCG, follicular aspiration, switching to IVF with cryopreservation of all embryos, and progesterone for luteal phase support (Table 4) [10]. Other measures unique to prevention of OHSS are: use of GnRH antagonists instead of agonists to prevent premature LH surge, decrease in the dose of hCG, use of LH or GnRH agonist in place of hCG for triggering ovulation, administration of albumin, use of glucocorticoids, and administration of dopaminergic drugs.

Fig. (11). Coasting for prevention of ovarian hyperstimulation syndrome. Reproduced with permission from: Rizk B, Rizk CB, Nawar MG, Garcia-Velasco JA, Sallam HN. Ultrasonography in the prediction and management of ovarian hyperstimulation syndrome In: Rizk B, Ed. Ulrasonography in reproductive medicine and infertility Cambridge, UK: Cambridge University Press 2010; Chapter 36: 299-312.

Table 3. Primary Prevention of OHSS

The Ten Commandments 1. Prediction of OHSS from history, exam and ultrasound Fig. (9). Ascites in moderate ovarian hyperstimulation syndrome in early pregnancy. Reproduced with permission from: Rizk B, 2. Laparoscopic ovarian drilling in PCOS patients Rizk CB, Nawar MG, Garcia-Velasco JA, Sallam HN. Ultrasono- 3. Metformin in PCOS patients graphy in the prediction and management of ovarian hyperstimula- 4. Octreotide in PCOS patients tion syndrome In: Rizk B, Ed. Ulrasonography in reproductive medicine and infertility Cambridge, UK: Cambridge University 5. Low-dose gonadotropins in PCOS patients Press 2010; Chapter 36: 299-312. 6. GnRH antagonist protocol 7. Recombinant LH to trigger ovulation 8. GnRH agonist to trigger ovulation

9. In vitro maturation of oocytes

10. Replacement of only one embryo

Reproduced with permission from: Rizk B. Ovarian Hyperstimulation Syndrome: Epidemiology, Prevention and Management. Cambridge, UK, New York, New York. (2006) Cambridge University Press.

GnRH Antagonist as an Alternative to the Long Agonist Protocol

In a Cochrane review, the efficacy of GnRH antagonist was compared to the long agonist protocol in assisted conception [18]. In comparison with the long GnRH agonist protocol, there was no statistically significant reduction in the occurrence of severe OHSS (RR=0.50; OR=0.79; 95% CI, 0.22-1.18); however, there were significantly fewer pregnancies with GnRH antagonist (OR=0.79; 95%CI, 0.63- 0.99). In a review that compared the two GnRH antagonists Fig. (10). Twins associated with OHSS. Reproduced with permis- Cetrorelix and Ganirelix to the long protocol, a difference sion from: Rizk B, Rizk CB, Nawar MG, Garcia-Velasco JA, Sal- was observed [19]. A significant reduction of OHSS was lam HN. Ultrasonography in the prediction and management of observed in Cetrorelix studies (OR=0.2; 95%CI, 0.10-0.54), ovarian hyperstimulation syndrome In: Rizk B, Ed. Ulrasonography but no reduction was observed for Ganirelix, (OR=1.13; 95% in reproductive medicine and infertility Cambridge, UK: CI, 0.24-5.31). The pregnancy rate in the Cetrorelix studies Cambridge University Press 2010; Chapter 36: 299-312. was not significantly different from that found in the long 138 Current Women’s Health Reviews, 2010, Vol. 6, No. 2 Rizk and Rizk

GnRH agonist protocol, (OR=0.91; 95%CI, 0.68-1.22). The employed in ovulation induction since the late 1980s and pregnancy rate in the Ganirelix protocols was significantly early 1990s. Shortly afterwards, coasting was used to prevent lower compared with that in the long GnRH agonist protocol severe OHSS in IVF cycles. Many studies and critical (OR=0.76; 95%CI, 0.59-0.98). The final word has not been reviews have evaluated the effect of coasting on OHSS. said in relation to the development of OHSS in GnRH antagonist cycles. Further studies will clarify this situation. Advantages of Coasting Coasting offers three potential advantages. The first is Table 4. Secondary Prevention of OHSS that the cycle is rescued and not canceled. Secondly, the embryos that are generated during the treatment cycle will The Ten Commandments be transferred, eliminating the need for cryopreservation. Thirdly, coasting avoids the need for gonadotropins or other 1. Withholding HCG +/- continuation of GnRH-a/GnRH medications or any supplementary procedures. antagonist 2. Coasting or delaying hCG: currently most popular method How Coasting Works 3. Use of GnRH-a to trigger ovulation The association between OHSS and high estradiol levels 4. Follicular aspiration is very well established. This certainly does not mean that 5. Progestesterone for luteal phase high estradiol levels per se result in the manifestations of 6. Cryopreservation and replacement of frozen-thawed embryos increased permeability associated with OHSS. at a subsequent cycle Coasting may diminish the functional granulosa cell co- 7. Dopamine agonist hort, resulting in a gradual decline in circulating estradiol levels and, more importantly, reduction of the chemical 8. Albumin, administration at time of retrieval mediators that augment capillary permeability and fluid re- 9. Glucocorticoid administration tention. VEGF concentration in follicular fluid may depend 10. Aromatase inhibitors on the quality and number of granulosa cells. Coasting acts through down-regulation of VEGF gene expression and Reproduced with permission from: Rizk B. Ovarian Hyperstimulation Syndrome: Epidemiology, Prevention and Management. Cambridge, UK, New York, New York. protein secretion. The fact that medium and small follicles (2006) Cambridge University Press. are more sensitive to undergoing atretic changes is of crucial relevance in both steroid and vasoactive mediator secretion Cancelling Cycles to Avoid OHSS When to Initiate Coasting Withholding hCG used to be the most common method used to prevent OHSS in patients at high risk for developing Three factors should be considered in deciding to initiate the syndrome [11]. The estradiol criteria for withholding coasting. The first is plasma estradiol concentration, which hCG to prevent OHSS ranged from 800 pg/ml to 4000 pg/ml reflects the total functional granulose cell population; second [11]. Mostly all authorities recommend withholding hCG is the number of ovarian follicles, which predicts the poten- when the estradiol level exceeds 4500 pg/mL. Equal or more tial for further granulose cell population and estradiol rise; important than estradiol levels as criteria for canceling cycles and third is the diameter of the leading follicles. are the number of 8-10 mm follicles that may have acquired Most publications addressing coasting reflect that an es- LH receptors. tradiol concentration of 3000 pg/ml was the value most commonly chosen by clinicians. This relatively low thresh- Decrease in HCG Dosage old for coasting has been shown to reduce the incidence of Several clinical trials have been published in the litera- OHSS effectively without compromising the cycle outcome. ture regarding the impact of the dose of hCG on the occur- High cut-off levels of around 6000 pg/ml are associated with rence of OHSS [22, 23]. Tsoumpou et al. elegantly reviewed a higher incidence of OHSS and the need for longer periods the studies in the IVF agonist and antagonist cycles. No de- of coasting. finitive conclusions could be made because of the differ- After withholding gonadotropins, serum estradiol exhib- ences in study design. Only one of the four trials regarding its a subsequent increase for one or more days. When coast- HCG dose using GnRH agonist was a randomized controlled ing was initiated at a plasma estradiol value of over 3000 and one of the two trials using GnRH antagonist was a ran- pg/ml, the plasma estradiol increased to over 6000 pg/ml domized controlled trial. during the coasting period [20]

Coasting -- Delaying hCG Administration Timing of hCG and Ending Coasting Coasting,” also known as a “controlled drift period” is Administration of hCG when the estradiol level drops the postponement of hCG administration to allow serum es- below 3000 pg/ml has been termed to be effective in lower- tradiol levels to drop below a certain threshold. ing the risk of OHSS. Coasting is the most popular method among physicians in the United States or Europe to prevent OHSS in patients Duration of Coasting undergoing IVF. Withholding gonadotropins and delaying The number of recorded days of coasting has varied be- the administration of HCG are techniques that have been tween 1 and 11. The effect of coasting duration has remained Prevention and Management of Ovarian Hyperstimulation Syndrome Current Women’s Health Reviews, 2010, Vol. 6, No. 2 139 controversial. While some studies suggested that gonadotro- others found no protective effect of intravenous glucocorti- pins could be withheld for 10 or more days without com- coids. promising the outcome, others have experienced a decrease in pregnancy rate when duration exceeds 4 days [20]. Ovarian Electrocautery Laparoscopic ovarian electrocautery may be effective in How Successful is Coasting in Eliminating OHSS? preventing OHSS in selected patients. Although the mecha- From an evidence-based medicine point of view, only nisms of action are not clear, electrocautery appears to ma- limited data in terms of prospective randomized trials are nipulate the intraovarian endocrine environment through available. Ethical considerations make it difficult to subject rupture of androgen-rich cysts, destruction of androgen- a test population to randomization in which one of the producing stroma, or disruption of the thickened ovarian arms would not be coasted and thereby at risk for severe capsule. The recommendation is that electrocautery should OHSS. Therefore these studies used a control group of be reserved for women who previously have experienced another modality of OHSS prevention or a group of normo- cancellation of at least cycle due to risk of OHSS. responders.

GnRH Agonist as an Alternative to hCG to Trigger Ovulation

Alternatives to hCG to trigger ovulation include GnRH agonists, native GnRH, and recombinant LH. Although the incidence of OHSS is lowered, the ongoing pregnancies in IVF cycles are also reduced when ovulation has been trig- gered by a GnRH agonist or recombinant LH rather than urinary or recombinant hCG [7].

Intravenous Albumin

Experience in subjects with different forms of third space fluid accumulation has shown that albumin is efficacious in preventing and correcting hemodynamic instability. How- ever, a series of publications for and against the efficacy of albumin in preventing OHSS have been published with con- tradictory results. A multifactorial role of albumin in prevention of OHSS has been proposed. First, it acts to sequester Fig. (12). Cabergoline and prevention of ovarian hyperstimulation vasoactive substances released from the corpora lutea. Al- syndrome. Reproduced with permission from: Rizk B, Rizk CB, bumin also serves to sequester any additional substances that Nawar MG, Garcia-Velasco JA, Sallam HN. Ultrasonography in the may have been synthesized as a result of OHSS. Finally, the prediction and management of ovarian hyperstimulation syndrome oncotic properties of albumin serve to maintain intravascular In: Rizk B, Ed. Ulrasonography in reproductive medicine and infer- volume and prevent the ensuing effects of hypovolemia, as- tility Cambridge, UK: Cambridge University Press 2010; Chapter cites, and hemoconcentration. Aboulghar et al. published, a 36: 299-312. Cochrane database review and found albumin to be effective in preventing OHSS [24]. However, a new Cochrane review Dopamine Agonists in OHSS Prevention soon to be published, includes new studies and found that there was no advantage in the use of albumin (Aboulghar, VEGF secreted by the hyperstimulated ovary acting via personal communication). the VEGF receptor 2 (VEGFR-2) is a major cause of OHSS [26-28]. Dopamine receptor 2 (Dp-r2) agonists, used in the Hydroxyethyl Starch Solution treatment of human hyperprolactinemia, inhibit VEGFR-2- dependent vascular permeability (VP) and angiogenesis Hydroxyethyl starch (HES) is a synthetic colloid, glyco- when administered at high doses in animals. The dopamine gen-like polysacharride derived from amylopectin. It has agonist bromocriptine and, more recently, the Dp-r2 agonist been used as an effective volume expander and is available cabergoline (Dostinex, Pharmacia & Upjohn, Bridgewater, in several molecular weights with different chemical proper- N.J.) 0.5 mg daily for 8 days beginning the day of hCG ad- ties. Several small studies suggested a beneficial effect of ministration (Fig. 13) have successfully prevented OHSS HES in decreasing OHSS and indicate that HES should be symptoms [26]. further investigated [25]. To test whether VEGFR-2-dependent vascular perme- Glucocorticoid Administration ability and angiogenesis could be segregated in a dose- dependent fashion with cabergoline (Cb2), a well-established The pathophysiology of OHSS suggests the involvement OHSS rat model supplemented with prolactin was used. A of an inflammatory mechanism during the development of low dose (100 ug/kg) of Cb2 reversed VEGFR-2-dependent the fluid leakage that is associated with the syndrome. There- vascular permeability without affecting luteal angiogenesis fore, investigators hypothesized that glucocorticoids possibly through partial inhibition of ovarian VEGFR-2 phosphoryla- could prevent OHSS in patients at high risk. Rizk [2] and tion levels. No luteolytic effects (no increase in serum pro- 140 Current Women’s Health Reviews, 2010, Vol. 6, No. 2 Rizk and Rizk gesterone concentrations or luteal apoptosis) were observed. and pleural puncture should be performed carefully when Cb2 administration also did not affect VEGF/VEGFR-2 indicated. ovarian mRNA concentration.

Fig. (13). Molecular mechanism of dopamine agonist on vascular permeability. Reproduced with permission from: Rizk B, Rizk Fig. (14). Management of OHSS. Reproduced with permission CB, Nawar MG, Garcia-Velasco JA, Sallam HN. Ultrasonography from: Rizk B, Rizk CB, Nawar MG, Garcia-Velasco JA, Sallam in the prediction and management of ovarian hyperstimulation syn- HN. Ultrasonography in the prediction and management of ovarian drome In: Rizk B, Ed. Ulrasonography in reproductive medicine hyperstimulation syndrome In: Rizk B, Ed. Ulrasonography in re- and infertility Cambridge, UK: Cambridge University Press 2010; productive medicine and infertility Cambridge, UK: Cambridge Chapter 36: 299-312. University Press 2010; Chaper 36: 299-312. In a recent prospective, double-blind study, more than 20 oocytes were retrieved from 54 donors in whom 20-30 folli- Successful medical management of OHSS requires cles > 12 mm developed. Immediately after hCG administra- familiarity with the disease. Many problems occur due to tion, patients were divided into two groups by computer ran- a lack of understanding by clinicians of the differences domization. The study group (n=29) received 0.5 mg oral between OHSS and other medical syndromes that present Cb2 daily for eight days; the control group (n=25) received with similar symptoms. A better understanding of the under- one placebo tablet daily for eight days. Subjects were moni- lying pathophysiological mechanisms will help in refining tored every 48 hours from the day of hCG (day 0) up to day the management of the disease. 8. Hemoconcentration and the presence and volume of as- Outpatient Management for Moderate OHSS citic fluid were significantly reduced in the study group. OHSS developed in 25 % of women in the study group com- Based on the classification of Rizk and Aboulghar [7], pared with 65% in the control group. moderate OHSS should be followed with regular telephone The frequency of OHSS was reduced by half in the do- calls at least daily and twice weekly office visits. Office as- pamine agonist, quinagolide group compared with placebo sessment includes pelvic ultrasound, a complete blood count, [28]. Implantation rates and ongoing pregnancy rates did not liver function tests, and a coagulation profile. The patient differ. Interestingly, patients who did not become pregnant in should be instructed to report to the hospital if she develops the study cycle experienced more clinical benefits from dyspnea, diminished urine volume, or any unusual symptoms treatment than did those women who achieved pregnancy. such as leg swelling, dizziness, numbness, or neurological This leads to speculation that other vascular permeability problems. parameters may reduce the effect of dopamine agonists in Outpatient Management for Severe OHSS women who do become pregnant. Whether severe OHSS should be managed on an outpa- TREATMENT OF OVARIAN HYPERSTIMULATION tient basis depends on the classification and definition of SYNDROME severity, the physician’s level of knowledge and experience The clinical course of OHSS depends on its severity, with the disease, and the patient’s willingness to comply the presence of complications, and whether the woman is with treatment. OHSS grade A is treatable on an outpatient pregnant [27, 28]. Clinical management involves dealing basis by aspiration of ascitic fluid, administration of intrave- with electrolytic imbalance, neurohormonal and hemody- nous fluids, and evaluation of all biochemical parameters. namic changes, pulmonary manifestation, liver dysfunction, hypoglobulinaemia, febrile morbidity, thromboembolic phe- Inpatient Management of Severe OHSS nomena, neurological manifestations, and adnexal torsion Patients with severe OHSS grade B and C are admitted to (Fig. 14) [7-10]. The general approach should be adapted to the hospital for treatment. Indications for hospitalization are the severity level. Specific approaches such as paracentesis shown in Table 5. Hospitalization should be considered if Prevention and Management of Ovarian Hyperstimulation Syndrome Current Women’s Health Reviews, 2010, Vol. 6, No. 2 141 one or more of these symptoms or signs are present [29] the extravascular space, further exacerbating ascites forma- Great caution is required in all grades of severe OHSS tion. Albumin has been utilized at 200 ml. of 25% albumin because complications can develop suddenly. solution. Dextran, mannitol, fresh frozen plasma, and hy- dryoxyethylstarch (HES) have also been used. HES have the Table 5. Indications for Hospitalization of Patients with advantage of being non-biologic in origin and a high mo- Severe OHSS lecular weight (200-1000 kDA vs. 69 kDA for albumin). HES 6% and 10% have been used successfully, but larger prospective randomized controlled studies are needed [10]. 1. Severe abdominal pain or peritoneal signs 2. Intractable nausea and vomiting that prevents ingestion of food Electrolyte Replacement and adequate fluids ppropriate solutions will correct electrolyte imbalances. 3. Severe oliguria or anuria If hypokalemia is significant, a cation exchange resin may be 4. Tense ascites needed. Sodium and water restriction have been reported to 5. Dyspnea or tachyspnea be successful by some, but others found no change in the patient’s weight, abdominal circumference, or peripheral 6. Hypotension (relative to baseline), dizziness, or syncope edema when sodium and water were restricted. With these 7. Severe electrolyte imbalance (hypernatremia, hyperkalemia) inconclusive reports, salt and water restriction are not widely advocated [10]. reproduced with permission from: Rizk B. Ovarian Hyperstimulation Syndrome: Epidemiology, Prevention and Management. Cambridge, UK, New York, New York. (2006) Cambridge University Press. Anticoagulant Therapy

Inpatient Clinical and Biochemical Monitoring Anticoagulant therapy is indicated if there is clinical evidence of thromboembolic complications or laboratory evi- The patient’s general condition must be assessed regu- dence of hypercoagulability [30,31]. Venous thrombosis is larly, including documentation of vital signs, daily weight the most common serious complication of OHSS, and pre- and girth measurement. Strict fluid balance recording is ventative heparin treatment should be used whenever there is needed, particularly of urine output. a thromboembolic risk. In cases of severe OHSS, the following situations are recognized as indicating an increased risk Biochemical monitoring should include serum and elec- of thromboembolism: immobilization, compression of pelvic trolytes, renal and liver function tests, a coagulation profile, vessels by large ovaries or ascites, pregnancy coagulation and blood count. Serum and urinary osmolarity and urinary abnormalities, and hyperestrogenemia. Prevention using mo- electrolyte estimation may be required as the disease pro- bilization and antithrombosis stockings is insufficient as gresses in severity. Respiratory compromise and/or signifi- thrombosis may occur at all localizations and may be sys- cant deterioration of renal function require evaluation of temic in nature. blood gases and acid-base balance. The frequency of these evaluations depends on the severity of the condition. Anticoagulant Prophylaxis Ultrasonographic examination provides accurate assess- Prophylaxis with heparin remains debatable on the basis ment of ovarian size and the presence or absence of ascites, that no randomized studies proving its efficacy in preventing as well as pleural or pericardial effusions. Ultrasound also is thromboembolic complications during severe OHSS have helpful in the diagnosis of intra- or extrauterine pregnancy as been published. In fact, in some clinical scenarios, throm- well as multiple or heterotrophic pregnancy. -hCG assay boembolism still occurs despite giving heparin [12]. Despite will help to diagnose pregnancy as early as possible, and a these reservations, Rizk [10] recommends giving heparin or chest X-ray will provide information on the presence of hy- enoxaparin (Lovenox, Sonofi-Aventis, Bridgewater, N.J.) for drothorax. patients with severe OHSS. The incidence of deep vein Invasive hemodynamic monitoring (central venous pres- thrombosis (DVT) is markedly increased in patients with sure and pulmonary artery pressures) may be needed under Factor V Leiden mutation, one of the thrombophilias [32]. certain circumstances in which volume expanders are being The mutation occurs in 4% of Northern European women. employed. Patients should be questioned about a history of personal or familial thrombosis, and those with a positive history should MEDICAL TREATMENT be tested for Factor V Leiden mutation.Patients with Factor V Leiden mutation who develop OHSS should be placed on Circulatory Volume Correction prophylactic heparin. Others risk factors for DVT in OHSS The main line of treatment is correction of the circulatory include protein C and S deficiency and antithrombin III defi- volume and the electrolyte imbalance. Every effort should be ciency. directed towards restoring a normal intravascular volume and preserving adequate renal function. Volume replacement Duration of Anticoagulation should begin with intravenous crystalloid fluids at 125-150 The optimal duration of anticoagulant administration is ml/h. Normal saline and lactated Ringer have been success- undetrmined. Some investigators have reported late throm- fully used. Plasma colloid expanders may be used if neces- bosis up to 20 weeks post-transfer, and many investigators sary. One concern with using plasma expanders is that the favor maintaining heparin therapy for many weeks [4]. The beneficial effect is transitory before their redistribution into severity of OHSS must be separated from the risk of throm- 142 Current Women’s Health Reviews, 2010, Vol. 6, No. 2 Rizk and Rizk boembolism because intrinsic coagulopathy may trigger Aspiration of Ascitic Fluid and Pleural Effusion in Severe the problem even in moderate cases. However, those who OHSS have followed a more liberal policy for prophylaxis have had Ascites is the hallmark of OHSS, and symptoms resulting to deal with operating on ruptured ectopic pregnancies in from ascites are the most common reason for hospitalization. anticoagulated patients. Therefore, thromboembolism will remain a more difficult complication to prevent and may Aspiration is not indicated in every patient. Paracentesis by the transabdominal or transvaginal route is indicated for se- complicate the outcome of OHSS. vere abdominal pain, pulmonary compromise as demon- Antibiotic Treatment strated by pulse oximetry, or tachypnea and renal compromise as demonstrated by oliguria and increased creatinine Infections are not uncommon in the setting of treatment concentration [36, 37]. of OHSS because of frequent catheterizations, venipuncture, transvaginal aspiration of ascitic fluid, and pleural drainage. Abdominal Paracentesis Furthermore, hypoglobulinemia is present in severe cases. Paracentesis is followed by increased urinary output Preoperative antibiotic prophylaxis is highly recommended. shortly after the procedure, with a concomitant decrease in Some authors suggest the administration of immunoglobu- the patient’s weight, leg edema, and abdominal circumfer- lins. However, this intervention still awaits further evalua- ence. Creatinine clearance rate is increased following the tion. procedure. Paracentesis offers temporary relief of respiratory and abdominal distress, but, since the fluid tends to recur, Diuretics some patients need repeated paracentesis and drainage of Diuretic therapy without prior volume expansion may effusions before spontaneous improvement occurs. The prove detrimental, by further contracting the intravascular amount of fluid aspirated can range between 200 and 4000 volume, thereby worsening hypotension and its sequelae. ml. The risk of injury to ovaries is minimized by ultrasono- Diuretics will increase blood viscosity and increase the risk graphic guidance. Monitoring of plasma proteins is essential, of venous thrombosis. Diuretic use should be restricted to the and human albumin should be infused whenever necessary. management of pulmonary edema. Percutaneous placement of a pigtail catheter is a safe and effective treatment modality for severe OHSS that may rep- Dopamine resent an alternative to multiple vaginal or abdominal paracentesis [10]. Dopamine used in oliguric patients with severe OHSS results in significant improvement in renal function [34,35]. Transvaginal Ultrasound-Guided Aspiration Dopamine produces its renal effect by increasing renal blood flow and glomerular filtration. Dopamine therapy should be Transvaginal ultrasound-guided aspiration is an effective given cautiously and under strict observation. and safe procedure. Injury to the ovary is easily avoided by puncture under ultrasonic visualization. No anesthesia is In one report, intravenous dopamine 4.32 mg/kg per 24 required for the procedure, and better drainage of the ascitic hours, was administered to 7 patients hospitalized with fluid is accomplished because the pouch of Douglas is the severe OHSS following gonadotropin stimulation for IVF or most dependent part. gamete intra-fallopian transfer (GIFT), beginning within 10 hours of admission [34]. Additional treatment consisted Autotransfusion of Ascitic Fluid of bed rest, restriction of fluid intake to 500 ml/day, and Transvaginal aspiration of ascitic fluid and autotransfu- daily monitoring of urine output, abdominal girth, and sion of the aspirated fluid has been used in treatment of se- weight. Biochemical and hematological clotting factors were vere OHSS. The procedure is simple, safe, and straightfor- measured daily in the pregnant women. Serum hCG was ward and shows a striking physiological success in correct- measured every 2 days, and patients were given a protein- ing the maldistribution of fluid and proteins without the use and salt-rich diet to increase the oncotic and osmotic blood of heterogenous biological material. However, autotransfu- pressure. Dopamine treatment was continued until complete sion is not recommended because of the possible reinjection resolution of ascites. In the 5 patients who were pregnant, of cytokines into the circulation. dopamine treatment was required for 9 to 22 days. The duration of treatment was related to the magnitude of the increase Pleurocentesis and Treatment of Pulmonary Complica- of hCG. The longest duration (18-22 days) was needed in tions patients with triplets and the shortest (9-10 days) in patients with a singleton pregnancy; for patients with twins, treat- Evaluation and treatment of patients with severe OHSS ment duration was intermediate (14 days). In the 2 non- complaining of dyspnea includes physical examination, chest pregnant women, dopamine was required for only 7 days. ultrasound and X-ray, and arterial blood gases. An accurate evaluation of any pulmonary complications that may result In another report, a 750-mg tablet of docarpamine in hypoxia. When a pulmonary embolus is suspected, a CT (Dostinex) was taken orally every 8 hours by 27 patients scan or ventilation perfusion scan should be performed. who were hospitalized because of OHSS and refractory to Pulmonary compromise should be treated with oxygen sup- therapy with intravenous albumin [35]. Clinical symptoms plementation. Thoracocentesis may be necessary for patients associated with ascites were gradually improved; no major with significant hydrothorax. However, a dramatic improve- adverse effects occurred. ment in the clinical status may occur after paracentesis. Prevention and Management of Ovarian Hyperstimulation Syndrome Current Women’s Health Reviews, 2010, Vol. 6, No. 2 143

Adult Respiratory Distress Syndrome (ARDS) sistant to medical intervention. Posterolateral thoracotomy and subclavian arteriotomy and thromboarterectomy by the ARDS is encountered after fluid overload. The impor- Fogarthy technique have been reported. Inferior vena cava tance of a strict fluid input/output balance in patients with interruption to prevent massive thromboembolism also has moderate complications of OHSS is stressed. Optimum man- been used [10]. agement may require admission to an intensive care unit. ARDS subsides after 3 to 6 days with fluid restriction, forced Pregnancy Termination diuresis, and dopamine therapy. Pregnancy termination may be performed in extreme Pericardiocentesis cases and has been reported to improve the clinical picture of neurological, hematological, and vascular complications Pericardial effusion rarely occurs; if it does, drainage by [10]. specialists may be necessary [31]. CONCLUSION SURGICAL TREATMENT OHSS is preventable in the majority of cases. However, Anesthesia Considerations in OHSS Patients there is a narrow margin in which severe cases may still Although surgery is needed only infrequently, when it is occur, and this remains a challenge for the future [40]. required there are several important considerations for the EXPERT COMMENTARY anesthesiologist [10]. Careful positioning of patients during surgery is important as the Trendelenberg position may fur- Ovarian hyperstimulation syndrome remains the most ther compromise the residual pulmonary functional capacity. serious complication of ovulation induction. Without under- Establishment of access lines may be necessary in patients standing the pathophysiology, the treatment will remain em- with contracted vascular volume. Drainage of pleural effu- pirical in nature. Human chorionic gonadotropin is a central sions may assist in improving pulmonary status. piece that triggers a cascade of events that result in an over- production of VEGF. Decreasing the dose of gonadotropins Surgery for Ruptured Cysts and HCG and utilization of other agents such as dopamine Laparotomy, in general, should be avoided in OHSS. If agonists and metformin will help in the prevention. Success- deemed necessary, in cases of hemorrhage hemorrhagic ful prediction and active prevention is more helpful than ovarian cysts, it should be performed by an experienced gy- active treatment. necologist and only hemostatic measures undertaken so as to preserve the ovaries. FIVE YEAR VIEW OHSS could be successfully prevented over the next five Ovarian Torsion years if a high index of suspicion is exercised and methodi- Ovarian torsion is an infrequent complication of ovula- cal steps are taken for the prevention of the syndrome. Iden- tion induction, which, if unrecognized and untreated, results tification of these patients and judicious use of gonadotro- in the loss of one or both ovaries [38]. Presenting symptoms pins is the beginning of the right path. The use of insulin are severe unilateral adenexal pain, in a patient with enlarged sensitizers and dopamine agonists will be more refined. ovaries due to ovulation stimulation or with multiple preg- Newer technologies as in vitro maturation might completely nancy. Sonography with Doppler flow analysis can be diag- abolish the syndrome. nostic, but a finding of apparently normal blood flow does KEY POINTS not rule out ovarian torsion [38]. Although the adnexa usually appear dark, hemorrhagic, and ischemic, they can be • Ovarian hyperstimulation syndrome (OHSS) is character- saved by simply unwinding them if a timely diagnosis is ized by bilateral cystic ovarian xpe made. This often can be performed as a laparoscopic proce- Severe OHSS may result in thromboembolism, adult res- dure. • piratory distress syndrome, or kidney failure. Surgery for Ectopic Pregnancy Associated with OHSS • Human chorionic gonadotropin increases VEGF production by granulose cells and endothelial cells, resulting in The combination of OHSS and ectopic pregnancy is not increased vascular permeability. encountered frequently. Diagnosis of tubal pregnancy by vaginal ultrasound examination at this stage is not always • The cornerstone of successful prevention of OHSS is possible. The presence of large ovaries filling the pelvis accurate risk prediction. makes ultrasound scanning of other structures difficult. Fluid • Previous history of OHSS or polycystic ovary syndrome in the cul de sac is of limited diagnostic importance in the is highly predictive of the development of OHSS during presence of ascites. ovarian stimulation. Other Surgery • Ultrasound is essential for the prediction of OHSS before, during, and after the treatment cycle. Mesenteric resection after massive arterial infarction has been reported. Rarely, vascular surgery is required to treat • Necklace sign, baseline antral follicle count, and ovarian thromboses that are complicated by recurrent emboli or re- volume are strongly associated with OHSS. 144 Current Women’s Health Reviews, 2010, Vol. 6, No. 2 Rizk and Rizk

• The presence of a large number of follicles (>20 per hyperstimulation for in vitro fertilization. Fertil Steril 1999; 71: ovary) and an increase in the number of small and inter- 808-14. [15] Fedorcsak P, Dakle PO, Stroeng R, et al. The impact of obesity and mediate follicles are associated with an increases risk for insulin resistance on the outcome of IVF or ICSI in women with the development of severe OHSS. polycystic ovarian syndrome. Hum Reprod 2001; 16: 1086-9. [16] Rizk B. Genetics of ovarian hyperstimulation syndrome. Reprod • Increased intraovarian blood flow and low intravascular Biomed Online 2009; 19(1): 14-27 ovarian resistance are correlated with the severity of [17] Rizk B. Prevention of ovarian hyperstimulation syndrome: the Ten OHSS in patients who develop the syndrome. Commandments. Presented at the 1993 European Society of Hu- man Reproduction and Embryology Symposium, Tel Aviv, Israel • The presence of multiple pregnancy increases the risk of 1993; 1-2 the severity and duration of OHSS. [18] Al-Inany H, Aboulghar MA, et al. GnRH agonists in assisted reproduction: a Cochrane review. Hum Reprod 2002; 17: 874-85. • Primary prevention of OHSS can be achieved by the use [19] Ludwig M, Katalinic A, Diedrich K. Use of GnRH antagonists in of low-dose gonadotropins and, in some cases, ovarian ovarian stimulation for assisted reproductive technecologies com- drilling prior to IVF. pared to the long protocol, Meta-analysis. Arch Gynecol Obstet 2001; 265:175-82. • Secondary prevention of OHSS involves delaying hCG [20] Rizk B Coasting for the prevention of critical OHSS: an American (coasting) , or, in some cases, cancellation of hCG. perspective In: Gerris J, Olivennes F, Delvigne A, Eds. Ovarian hypestimulation syndrome Taylor and Francis 2006, chapter. • Medical treatment of OHSS consists of correction of cir- [21] Porchet HC, Le Cotonnec J-Y, Loumaye E. Clinical pharmacology culatory volume and electrolyte imbalance. of recombinant human follicle-stimulating hormone. III Pharma- cokinetic-pharmacodynamic modeling after repeated subcutaneous • Ultrasonographic guidance of transvaginal or transab- administration. Fertil Steril 1994; 61: 687-95. dominal aspiration of ascites improves the symptoms of [22] Abdalla HI, Ahmoye NM, Brinsden P, et al. The effect of the dose OHSS. of human chorionic gonadotropin and the type of gonadotropin stimulation on oocyte recovery rates in an in-vitro fertilization program. Fertil Steril 1987; 48: 958-63 REFERENCES [23] Tsoumpou I, Muglu J, Gelbaya TA, Nardo LG. Optimal dose of HCG for final oocyte maturation in IVF cycles: absence of evi- [1] Rizk B, Smitz J. Ovarian hyperstimulation syndrome after dence? RBM Online 2009; 19(1): 52-58 superovulation for IVF and related procedures. Hum Reprod 1992; [24] Aboulghar M, Evers JH, Al-Inany H. Intravenous albumin for 7:320-7. preventing severe ovarian hyperstimulation syndrome. Cochrane [2] Rizk B. Ovarian hyperstimulation syndrome. In: Studd J, Ed. Database Syst Rev 2000; 2: CD001302. Progress in Obstetrics and Gynecology. Edinburgh: Churchill [25] Rizk B, Aboulghar MA, Mansour RT, et al. Severe ovarian hyper- Livingstone, 1993; 11: 311-49. stimulation syndrome: analytical study of twenty-one cases. Pro- [3] Rizk B , Rizk CB , Nawar MG, Garcia-Velasco JA, Sallam HN. ceedings of the VII World Congress on In-vitro Fertilization and Ultrasonography in the prediction and management of ovarian Assisted Precreations, Paris. Hum Reprod 1991: 368-9 hyperstimulation syndrome. In : Rizk B. Ed. 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[36] Ferraretti AP, Gianaroli L, Diotallevi L, et al. Dopamine treatment Cambridge, UK: Cambridge University Press 2010; Ch. 15: for severe hyperstimulation syndrome. Hum Reprod 1992; 7: 180- pp.152-60 3. [39] Busso C. Prevention of OHSS In: Nardo L, RonEl R, Rizk B [37] Tsunoda T, Shibahara H, Hirano Y et al. Treatment of ovarian Eds. Symposium on OHSS. Reprod Biomed Online 2009; 19(1): hyperstimulation syndrome using an oral dopamine prodrug, 43-51. docarpamine. Gynecol Endocrinol 2003; 17: 281-6. [40] Rizk B, Aboulghar M. Ovarian hyperstimulation syndrome. In: [38] Rizk B. Complications of ovulation induction II Ovarian hyper- Aboulghar M and Rizk B, Eds. Ovarian stimulation. Cambridge, stimulation syndrome In: Dickey RP , Brinsden PR, Pyrzak R, Eds. Cambridge University Press 2010; Ch. 11: pp. 122-32. Manual of intrauteine insemination and oulation induction

Received: January 10, 2010 Revised: February 10, 2010 Accepted: April 15, 2010

146 Current Women’s Health Reviews, 2010, 6, 146-160 Non-Surgical Treatment Options for Symptomatic Uterine Leiomyomas

Julierut Tantibhedhyangkul1,* and Millie A. Behera2

1Obstetrics, Gynecology and Women's Health Institute, Cleveland Clinic, Cleveland, OH 44195, USA; 2Division of Repro- ductive Endocrinology and Fertility, Department of Obstetrics and Gynecology, Duke University Medical Center, Dur- ham, NC, USA

Abstract: Uterine leiomyomas (or uterine fibroids), benign tumors of the uterine smooth muscle cells, can cause significant morbidity and impair quality of life in many women. For those who are asymptomatic, watchful waiting constitutes appropriate management. For women with symptomatic fibroids, hysterectomy and myomectomy are traditionally the standard treatments. In the last two decades, many alternatives to surgery for the management of fibroids have been developed. Most of the current medical treatments involve hormone manipulation. Newer treatments such as mifepristone, asoprisnil and aromatase inhibitors show promising results in fibroid symptom and size reduction; however, larger studies are needed. A safe and effective therapy as an alternative to hysterectomy is uterine artery embolization (UAE), which offers shorter recovery times and fewer major complications, though fertility and pregnancy outcomes after a UAE may be affected. Limited data are available for the efficacy and safety of temporary uterine artery occlusion. Magnetic resonance-guided focused ultrasound surgery (MRgFUS) is the newest treatment option for uterine fibroids. It also shows promising results for symptom relief. The degree of symptom relief depends significantly on the amount of fibroid volume that is non-perfused after treatment and the experience of the physician performing the procedure. Keywords: Fibroids, hormones, NSAIDs, progestins, oral contraceptives, mifepristone, asoprisnil, gonadotropin-releasing hormone agonists, uterine artery embolization, selective estrogen receptor modulators, transvaginal temporary uterine artery occlusion, magnetic resonance-guided focused ultrasound surgery.

INTRODUCTION lated to fibroids include menorrhagia, which leads to iron- deficiency anemia; pressure-related symptoms such as uri- Uterine leiomyomas (uterine fibroids) are one of the most nary frequency, pelvic pressure, dyspareunia and difficulty common benign tumors in the female reproductive tract. with urination or defecation; pain; and infertility. African-American women generally have a higher incidence of fibroids than white women [1]: current estimates indicate The treatment for patients with fibroids depends on sev- that more than 80% of African-American women and nearly eral factors such as the size, number and location of the fi- 70% of white women will develop fibroids by the age of 50 broids, the severity of the symptoms, and the patient’s child- [2]. Other risk factors commonly associated with fibroids bearing concerns (Fig. 1). Medical treatment is often used as include nulliparity, advanced age and obesity [3]. The a first line therapy, although many women might later need growth of fibroids is hormone driven, as demonstrated by surgical intervention. Hysterectomy and myomectomy per- evidence that fibroids develop after puberty, fibroid growth formed by laparotomy have been the traditional therapies for increases with age, and fibroid size increases during the re- women with symptomatic fibroids [5]. Hysterectomy is the productive years and regresses after menopause [3]. Leio- most common procedure because it is the only definitive myoma tissues are monoclonal in origin [3, 4]. Many have option and it eliminates the risk of recurrence. In fact, uterine non-random chromosomal abnormalities such as deletions, fibroid is the most common indication for hysterectomy in translocations and duplication. The most common mutations the United States, and each year, more than 250,000 hyster- involve regions in chromosomes 7, 12 and 14, which contain ectomies are performed due to symptoms related to fibroids genes essential in cell proliferation, regulation of transcrip- [6]. Myomectomy is a traditional option for women who tion, or cell cycle control [3, 4]. anticipate future child bearing; hysteroscopic myomectomy is an appropriate treatment for women with submucosal Fibroids are often discovered incidentally during a physi- fibroids; and endometrial ablation is often the treatment cal or radiological examination. For women who are asymp- of choice for women with menorrhagia who do not wish to tomatic, watchful waiting is an appropriate treatment option undergo major surgery and do not desire to bear children. as fibroids are rarely malignant and pathology results are not required for the diagnosis. For many other women, however, In the last two decades, many new therapeutic ap- uterine fibroids can cause significant morbidity and have a proaches for symptomatic fibroids have become available detrimental effect on their quality of life. The symptoms re (Table 1). Uterine artery embolization is a non-surgical approach that has been extensively studied and for which short- and long-term outcome data are available. New techniques *Address correspondence to this author at the Obstetrics, Gynecology and Women’s Health Institute, Cleveland Clinic, Mail Code A81, 9500 Euclid such as magnetic resonance imaging (MRI)-guided focused Avenue, Cleveland, OH 44195, USA; Tel: (216) 445-9706; Fax: (216) 445- ultrasound and temporary uterine artery occlusion are being 5526; E-mail: [email protected] extensively studied and show promising results. Further-

1573-4048/10 $55.00+.00 © 2010 Bentham Science Publishers Ltd. Non-Surgical Treatment Options for Symptomatic Uterine Leiomyomas Current Women’s Health Reviews, 2010, Vol. 6, No. 2 147 more, several new medications are being studied as a poten- COMBINED ORAL CONTRACEPTIVES AND tial long-term treatment for fibroids. The clinical outcomes PROGESTINS of the non-surgical approaches to fibroid treatment will be Combined oral contraceptives have been used effectively reviewed here. to reduce blood loss in women with idiopathic menorrhagia. Since it is a non-invasive approach, many physicians pre- scribe oral contraceptives for women with fibroids and menorrhagia before turning to other more invasive options. There are conflicting reports regarding the effect of combined oral contraceptives on fibroids. A large prospective study including over 3,000 patients with fibroids found a positive correlation between fibroid diagnosis and the use of oral contraceptives at a very young age (prior to 17 years old) [7]. Other controlled studies, however, did not find any such relationship [8, 9]. One study found that using combined oral contraceptives containing a newer generation of progestins did not increase the size of the fibroids [10]. Progestins are an effective

treatment for idiopathic menorrhagia, but data on the effectiveness of progestins for fibroid treatment is limited. In a study using GnRH agonists for fibroid treatment, an increase

in uterine size was found in patients who used progestin for

add-back therapy [11]. Another study, however, observed Fig. (1). Fibroid Uterus. that progestin decreased fibroid size [12]. Due to the conflicting information regarding the effects of estrogen and Table 1. Currently Available Treatment Options for Leio- progestins on fibroid growth, the uterine and fibroid size myomas should be closely monitored during the course of treatment with combined oral contraceptives or progestins [13]. Medical Treatments • NSAIDs LEVONORGESTREL-RELEASING INTRAUTERINE SYSTEM • Combined oral contraceptives and progestins • Danazol The levonorgestrel-releasing intrauterine system (LNG- IUS) releases a daily dose of levonorgestrel locally and con- GnRH agonists • tinuously into the uterine cavity for at least 7 years. It has Surgical Management been used effectively to reduce blood loss in women with • Hysterectomy (abdominal, vaginal, laparoscopic) menorrhagia, and it is one of the most effective medical • Myomectomy (abdominal, laparoscopic, vaginal, hystero- treatments [14]. The studies looking at LNG-IUS for fibroid scopic) treatment are limited to case reports and small case series. All of the studies have recruited women with fibroids who • Endometrial ablation had a small uterus (<12 weeks size) and normal uterine cav- • Laparoscopic myolysis ity [15-20]. LNG-IUS was shown to significantly decrease Uterine Artery Occlusion the amount of bleeding and improve hematocrit in women with menorrhagia due to fibroids. The largest study, which • Uterine artery embolization included 46 women with fibroid-related menorrhagia, • Laparoscopic uterine artery occlusion showed a significant decrease in menstrual bleeding at 3 Magnetic resonance-guided focused ultrasound surgery (MRgFUS) months after the IUS insertion in all of the subjects. At 6 months, fifty-six percent of the women in the study had become amenorrhic and 22% were experiencing only spotting MEDICAL MANAGEMENT or oligomenorrhea [15] . The rest of the subjects in the study maintained a normal cycle [15]. No changes, however, in the A number of medical therapies are available for fibroid fibroids or uterine volume were noted during the treatment treatment. Oral contraceptives or non-steroidal anti- [15, 16]. inflammatory drugs are often the first line of therapy to decrease pain and bleeding caused by fibroids, but these medi- NON-STEROID ANTI-INFLAMMATORY DRUGS cations do not decrease the size of the fibroids. The available (NSAIDS) medical options that could decrease the size of the fibroids, such as GnRH agonists, have multiple side effects, so these Non-steroidal anti-inflammatory drugs (NSAIDs) have options cannot be used long term. Thus, many patients still been shown to be an effective treatment for idiopathic me- require surgical therapy. However, many new and promising norrhagia [21]. However, NSAIDs are ineffective in reduc- options for medical treatment are currently being studied for ing blood loss in women with fibroid-related menorrhagia potential long-term use. [22]. NSAIDs are often given to patients with fibroids to 148 Current Women’s Health Reviews, 2010, Vol. 6, No. 2 Tantibhedhyangkul and Behera reduce pain symptoms, although their effectiveness for pain weeks and 45% at 24 weeks [30]. Most patients become relief in this population has not been documented [7]. amenorrhic during the therapy; thus GnRH agonist treatment improves the hematocrit level in patients with anemia. DANAZOL AND GESTRINONE The effects of GnRH agonists are not sustained after the The androgenic steroids danazol and gestrinone may be therapy is discontinued. Although symptomatic improvement effective treatment options for symptomatic fibroids. Dana- still persists in many women [30, 31], the fibroids return to zol is a derivative of 17-ethinyltestosterone. It acts primar- the pretreatment size within 4-6 months after therapy [31]. ily by inhibiting the luteinizing hormone (LH) surge, thereby Long-term use of GnRH agonists, however, is limited by inhibiting ovulation and inducing amenorrhea. It also inhibits significant side effects, in particular osteoporosis, which may many of the steroidogenic enzymes and increases free testos- begin to develop after six months of the therapy. Other side terone levels. It has been used in the treatment of endometri- effects of GnRH agonists include hot flashes, vaginal dry- osis and menorrhagia. Because danazol induces amenorrhea, ness, headache, arthralgia, myalgia, depression, insomnia, it might have a role in reducing menorrhagia and anemia due emotional instability and decreased libido. Nevertheless, to fibroids, although data on the effects of danazol on fi- most women who develop side effects during treatment tol- broids is very limited. A Cochrane review did not find any erate them relatively well and continue with the duration of reliable evidence from randomized controlled trials showing treatment. either that using danazol is beneficial or harmful in the treatment of fibroids [23]. The side effects of danazol are Add-back therapy with estrogen and progestins has been related to its androgenic properties and include weight gain, used to reduce the side effects of GnRH agonists during muscle cramps, acne, hirsutism, hot flashes, fluid retention, long-term treatment – in particular, to inhibit bone loss. In fatigue, and decreased breast size. one study, patients with symptomatic fibroids were randomized to receive add-back therapy with an estrogen-progestin Gestrinone is a 19-nortestosternoe derivative. It has been combination or high-dose progestin after 3 months of injec- used in Europe for the treatment of endometriosis but is not tion treatment with leuprolide acetate, a GnRH agonist. Pa- available in the United States. Gestrinone, starting at a dose tients were continued on leuprolide acetate for a total of 2 of 2.5 mg three times weekly for 6-24 months, has been years [11]. In both groups, uterine size decreased by 40% shown to decrease the size of fibroids and uterine volume and bone mineral density decreased by 2.6% during the first [24, 25]. Most of the patients who used gestrinone for 6 3 months of the treatment, but there was no significant months maintained their decreased uterine size (compared with the pretreatment size) 18 months after discontinuing the change in bone mineral density at the end of the study. Inter- medication [24]. estingly, the uterine size in the progestin-only group increased up to 95% of pretreatment size, while there was no GONADOTROPIN-RELEASING HORMONE AGO- change in the uterine size in the estrogen-progestin group NISTS (GnRH AGONISTS) [11]. These results are likely due to the role of progesterone as a fibroid growth promoter. GnRH agonists have proven to be effective in the treatment of fibroids, although mainly as short-term therapy for Other medications have also been studied for use as up to 3-6 months prior to surgery. Long-term use of GnRH add-back therapy during GnRH agonist treatment. Tibolone, agonists for fibroid treatment is limited because of the hypo- a synthetic compound structurally related to 19-nortest- estrogenic side effects. The continuous administration of a osterone progestins, has been used to relieve postmenopausal GnRH agonist causes initial hypersecretion of follicle stimu- symptoms and osteoporosis. A small randomized trial lating hormone (FSH) and LH (flare effect), which lasts ap- showed that daily tibolone add-back treatment combined proximately 7-10 days, followed by a significant decrease in with 6 months of leuprolide acetate treatment reduced vaso- FSH and LH secretion due to pituitary GnRH receptor down motor symptoms and prevented bone loss without compro- regulation. This in turn causes a reduction in ovarian steroi- mising leuprolide’s ability to reduce fibroid size [32]. An- dogenesis and results in a hypoestrogenic state, which is other randomized controlled trial using tibolone as an add- likely the main mechanism causing the reduction in fibroid back therapy during 6 months of goserelin treatment found size. GnRH-agonist treatment also causes a reduction in the that patients in the tibolone group had significantly less bone expression of several growth factor proteins such as trans- loss than those in the control group, but there was no signifi- formal growth factor , epidermal growth factor, insulin-like cant difference in the reduction of fibroid volume in either growth factor (IGF-I), and IGF II [26]. Microarray analysis group [33]. Long-term use of tibolone and leuprolide acetate has shown alteration in the expression of several genes for 2 years has also been found to reduce hot flashes and within the myometrium and fibroid tissues after GnRH- prevent bone loss without changing the lipid profile [34]. In agonist treatment [27, 28]. another study, raloxifene, a selective estrogen receptor GnRH agonists have been shown to reduce both fibroid modulator, was administered daily during 18 months of le- size and uterine size during the course of treatment, with a uprolide acetate treatment for fibroids [35]. After 18 months reduction in the fibroid volume of 35% to 65% noted within of treatment, a significant reduction in fibroid size was noted the first 3 months of treatment [26, 29]. Fibroid and uterine while the bone mineral density and bone metabolic markers volume reductions usually occur during the first 3 months of remained unchanged from pretreatment levels. treatment [30, 31]. In one randomized controlled trial, Pretreatment with a GnRH agonist for 3-4 months prior monthly injection of the GnRH agonist depot leuprolide ace- to surgery has many benefits. A Cochrane Database Sys- tate every 4 weeks decreased uterine volume by 36% at 12 temic Review evaluated the role of GnRH pretreatment prior Non-Surgical Treatment Options for Symptomatic Uterine Leiomyomas Current Women’s Health Reviews, 2010, Vol. 6, No. 2 149 to hysterectomy and myomectomy [36]. Twenty-one trials volume ranging from 26% to 74%. A significant decrease in were included in the analysis. The review showed signifi- blood loss and a high incidence of amenorrhea were reported cantly higher hemoglobin and hematocrit levels prior to in all the studies. A recently study by Eisenger et al. used a and after the surgery in women who were pretreated with much lower dose of mifepristone – 2.5 mg/day for 6 months a GnRH agonist. Patients who used a GnRH agonist prior – than in other studies [50]. An 11% reduction in uterine to hysterectomy also experienced significantly less blood volume with significant reduction in pain and improvement loss and a shorter hospital stay than the patients who in quality of life were noted at the end of the study. received no pretreatment, although there was no difference The main side effect of mifepristone is vasomotor symp- in the transfusion rate. Using a GnRH agonist prior to toms. Hot flashes are dose related; no hot flashes have been hysterectomy also allowed many women to undergo vaginal reported in patients using a 5 mg dose [46]. Mifepristone has rather than abdominal hysterectomy due to the decrease no effect on bone density, which makes this medication more in their uterine size and lead to shorter operating times. In attractive than the GnRH agonists. The major concern for addition, the decrease in uterine size due to GnRH agonist long-term use of mifepristone is the potential risk of endo- treatment allows surgeons to use a transverse incision instead metrial hyperplasia from unopposed estrogen. The rates of of a vertical incision in many patients undergoing hysterec- endometrial hyperplasia range from 2% to 28% [43, 44, 46, tomy or myomectomy. The disadvantage of using GnRH- and 50]. Two reports on studies using low doses (2.5 and 5 agonist pretreatment prior to myomectomy is the resulting mg) of mifepristone show no evidence of endometrial hyper- increase in the rate of fibroids recurring after surgery, which plasia [50]. In contrast, a report from Bavaria et al. using 10 is likely because smaller fibroids were not seen or were mg revealed a much higher rate of endometrial hyperplasia ignored during the myomectomy. Results from the Cochrane (63%) compared with other studies [42]. One patient in the review, however, did not have enough data to support this Bavaria et al. study also had complex hyperplasia. The concept. available data available suggests that the incidence of endometrial hyperplasia is likely dose dependent. None of the GnRH ANTAGONISTS endometrial biopsies conducted in any of the studies showed GnRH antagonists competitively bind to the GnRH evidence of atypical hyperplasia or cancer. receptor, causing an immediate reduction of gonadotropin Few randomized controlled trials using mifepristone for secretion and a reduction of ovarian steroidogenesis without fibroid treatment are available. A study by Engman et al. causing the initial flare effects seen with the use of GnRH randomized 30 women with symptomatic fibroids to receive agonists. GnRH antagonists have also been shown to directly 50 mg of mifepristone or a placebo every other day for 3 induce apoptosis in uterine leiomyoma cells [37, 38]. A months [43]. Significant fibroid volume reduction averaging clinical study using daily subcutaneous injections of geni- 28% was noted in the mifepristone group but not in the con- relix, a GnRH antagonist, in 20 women with fibroids showed trol group. Most of the patients who took mifepristone were a rapid decrease in fibroid and uterine size (median duration amenorrhic after 4 weeks of treatment. There was no evi- of 19 days, range 1-65 days) [39]. During the first 3 weeks of dence of endometrial hyperplasia reported in this study. A treatment, the fibroid size was decreased by 42.7% (14% to double blind, randomized controlled trial comparing the use 77%) and uterine size was decreased by 46.6% (6% to 78%). of 10 mg of mifepristone or a placebo daily for 3 months in Another study using the GnRH antagonist cetrorelix also 40 women also showed a 26%-32% reduction of uterine vol- showed a rapid reduction in fibroid size by 16 days of treat- ume with mifepristone [42]. In the mifepristone group, 83% ment, with a mean fibroid size reduction of 16% [40]. Side of the patients showed improvement in dysmenorrhea but effects of the GnRH antagonists are mainly related to hypo- still had other fibroid-related symptoms. As mentioned ear- estrogenism. GnRH antagonists are usually administered in lier, this study reported a much higher incidence of endo- daily subcutaneous doses and currently, there are no longer- metrial hyperplasia than other studies. A randomized study acting GnRH antagonists available, which make long-term conducted by Carbonell Esteve et al. compared the efficacy usage impractical. of using daily doses of 5 mg and 10 mg mifepristone for 3 months for the reduction of fibroid volume in 100 women MIFEPRISTONE [44]. Both dosages showed comparable reductions in fibroid Mifepristone (RU486), a selective progesterone receptor volume (57% and 45% in the 5 and 10 mg groups, respec- modulator, has been studied for many clinical implications tively) and uterine volume (36% and 40% in the 5 and 10 mg including fibroids. In the presence of progesterone, mifepris- groups, respectively). Only one patient (2%) in this study, tone act as a competitive inhibitor of the progesterone recep- from the 10 mg group, developed endometrial hyperplasia. tor. It also has an antiglucocorticoid property. The first re- Further trials have studied the efficacy of long-term us- port describing the use of mifepristone for the treatment of age of mifepristone. A controlled study using 5 mg mifepris- fibroids was authored by Murphy et al. [41]. In the study, 10 tone daily for 6 months and a placebo in the control group patients received 50 mg of mifepristone for 3 months. At the showed significant reduction in fibroid volume without evi- end of the study, a 49% reduction in fibroid volume was dence of endometrial hyperplasia in the treatment group [45]. noted and all of the patients had become amenorrrhic. Sub- Another study comparing the use of 5 mg and 10 mg of sequent to this study, several smaller studies, with a duration mifepristone for 1 year showed a comparable volume reduc- of 3 months to 1 year, used different dosages of mifepris- tion and amenorrhea rate in both groups [51]. The efficacy of tone, ranging from 5- 50 mg, for fibroid treatment [42-49]. mifepristone was sustained after treatment for 9 patients in All of the studies revealed a decrease in uterine and fibroid this study, who maintained reduction of fibroids at 6 months 150 Current Women’s Health Reviews, 2010, Vol. 6, No. 2 Tantibhedhyangkul and Behera after treatment [51]. The dosage of mifepristone currently raloxifene for 12 months showed a significant decrease in available in the market is much higher (600 mg) than the mean uterine and fibroid size starting from 6 months of dosage used in the aforementioned studies, thus limiting the treatment [60]. Studies in premenopausal women, however, use of this medication for fibroid treatment. show conflicting results. A study by Palomba et al. randomized 90 premenopausal women with asymptomatic fibroids ASOPRISNIL into three treatment groups: raloxifine at 60 mg/day, raloxifine at 180 mg/day, or a placebo. During the 6 months of Asoprisnil is another selective progesterone receptor therapy, no significant changes in uterine or fibroid size or modulator that has shown some promising results as a medi- the amount of uterine bleeding were noted among the three cal treatment for fibroids. Unlike mifepristone, asoprisnil is groups [61]. Another study by Jirecek et al. randomized 25 not effective in inducing labor in animals [52]. Asoprisnil has an antiproliferative effect in the endometrium of both premenopausal women with fibroids to receive 180 mg/day of raloxifene (the same dose used in Palomba’s study) or no animals and humans [52]. In vitro, asoprisnil inhibits leio- treatment for 3 months [62]. Interestingly, after 3 months of myoma cell growth and induces apoptosis but has no effect treatment, women in the raloxifene group showed a signifi- on normal myometrial cell growth [53]. It up-regulates the cant decrease in fibroid size when compared with those in extracellular matrix metalloproteinase inducer in cultured the control group. Jirecek et al. speculated that the difference leiomyoma cells resulting in down-regulation of collagen synthesis [54]. It also down-regulates the expression of sev- in the results of the two studies might be due to the difference in the average age of the subjects (36 years old and 40 eral growth factors, such as EGF, IGF-I and TGF-ß cultured years old in the Palomba and Jirecek studies, respectively) leiomyoma cells [55]. [61, 62]. A Cochrane Database Systemic Review of this A very limited number of published studies have reported topic found no evidence that SERMs reduce the size of on the use of asoprisnil for fibroid therapy in humans. A fibroids or improve outcomes [63]. phase one randomized trial comparing the use of different In conclusion, there is currently not enough information dosages of asoprisnil (5 – 100 mg per day) and a placebo for to conclude that SERMs have any benefit in fibroid treat- 28 days showed that asoprisnil delays the onset of the men- ment or improve outcomes in premenopausal women. strual cycle and increases the cycle length [56]. This effect was observed in women using a dose of 10 mg or higher, and AROMATASE INHIBITORS was dose dependent. The largest published study is a phase two, multi-centered, double-blind, randomized controlled Aromatase, an enzyme that converts androgens to estro- trial including 129 patients who were randomized to use 3 gen, is very important in the production of estrogen. Aro- different dosages of asoprisnil (5, 10, or 25 mg per day) or a matase activity and its transcripts have been found in leio- placebo for fibroid treatment for 12 weeks [57]. A 36 % re- myoma tissues, showing that these tissues can synthesize duction in fibroid volume was noted by week 12 in the 25 estrogen locally and promote their own growth [64]. The mg group. A significant decrease in uterine bleeding was aromatase mRNA level is much higher in leiomyoma tissues observed in all three asoprisnil treatment groups, with the than in normal myometrial tissue, especially in African- greatest effect seen in the 25 mg group. Amenorrhea was American women [65]. This might account for the higher noted in 16%, 36%, and 70% of patients in the 5, 10, and 25 prevalence of fibroids seen in African-American women. mg groups, respectively. At the same time, significant symp- Since estrogen plays an important role in the pathophysiol- toms were noted in the 10 and 25 mg groups. While no evi- ogy of fibroids, and aromatase, which is essential to the pro- dence of endometrial hyperplasia was noted in any of the duction of estrogen, is found in fibroid tissues, aromatase studies, two unique endometrial pathologies called ‘non- inhibitors are a potential candidate for fibroid treatment. physiologic secretory effects’ and ‘secretory patterns, mixed Published data on aromatase inhibitors and fibroids is type’ were seen in many patients who took asoprisnil [56- limited to case reports and small trials [66-68]. Two studies 58]. These are characterized by the presence of weak secre- using anastrazole at 1 mg/day for 3 months in women with tory glands with minimal or absent proliferation and variable fibroids showed an average fibroid volume reduction of be- effects in the stroma [56]. tween 9.3% and 55.7% [67, 68], and most patients reported The side effects of asoprisnil are mild, including bloat- improvement in their fibroid-related symptoms. One of the ing, flatulence, breast pain and vasomotor symptoms. All of studies noted a significant change in fibroid volume in the symptoms were reported as mild and none of the patients women older than 40 years but found no change in women stopped the treatment due to side effects [57]. A decrease in younger than 40 years. A study comparing fibroid treatment uterine artery blood flow was seen in another study when with letrozole (2.5mg/day) with a GnRH agonist for 3 subjects took 25 mg of asoprisnil for 12 weeks [59]. This months revealed comparable effects in the reduction of fi- might serve as one of the mechanisms by which asoprisnil broid volume in both groups [66]. No serious side effects reduces uterine and fibroid volume. were reported in any of these studies. In conclusion, aromatase inhibitors are a promising SELECTIVE ESTROGEN RECEPTOR MODULA- TORS (SERMS) medication for the treatment of fibroids. However, randomized controlled trials are needed to confirm the efficacy of Data on the effects of SERMs in the treatment of fibroids this medication for this indication. The long-term effects of is limited. Raloxifene has been used for fibroid treatment in this medication in premenopausal women also need to be several small studies with conflicting results. A study of 70 studied. postmenopausal women with fibroids taking 60 mg/day of Non-Surgical Treatment Options for Symptomatic Uterine Leiomyomas Current Women’s Health Reviews, 2010, Vol. 6, No. 2 151

UTERINE ARTERY EMBOLIZATION gery [70]. The most serious complication is intrauterine/pelvic infection requiring surgery, which occurs in 2.6% Uterine Artery Embolization (UAE) is a minimally inva- of patients [79]. There was no death reported in any of the sive procedure performed by interventional radiologists. The large clinical trials. There were, however, 2 case reports of procedure has been used since the 1970’s for the treatment of death after UAE due to septicemia [80, 81]. One letter to the obstetric hemorrhage, but it was first utilized as a treatment editor reported a death after UAE due to systemic non-target for fibroids by Ravina et al. in 1995 [69]. Since then, it is embolization from an arteriovenous malformation within the estimated that more than 200,000 UAEs for fibroid treatment fibroids and patent foramen ovale [82]. have been performed worldwide [70]. Short-term and mid-term outcomes of UAE have been Of all the minimally invasive treatments for fibroids, reported by several large case series. Significant decreases in UAE is the most thoroughly studied to date. The procedure fibroid and uterine volume after treatment range from 40% involves passing an angiographic catheter into each uterine to 70%. Most patients show improvement in menorrhagia artery through the femoral artery and then injecting the em- and pain reduction associated with fibroids after the treat- bolization particulate agents to occlude the branches of the ment [75, 78, 83-86], as well as a decrease in emotional and uterine arteries that supply the fibroids [71]. The emboliza- somatic concerns [87]. Patients who undergo UAE experi- tion particulate agents normally used include polyvinyl alco- ence a very high rate of satisfaction (ranging from 85% to hol, tris-acryl gelatin microspheres and gelatin sponge parti- 95%) at different time points after the procedure. cles [72]. The purpose of the procedure is to significantly decrease the blood supply to the uterus and fibroids, causing Long-term outcomes of UAE are very encouraging. At 3 permanent ischemia and necrosis of the fibroid tissues while years after treatment, most patients in the FIBROID registry having no permanent effects on normal myometrial tissues continued to have significant improvement in their quality of [73, 74]. The treatment causes the global reduction of fibroid life and 85.68% of patients stated that they would recom- volume and results in the improvement of the symptoms mend UAE to family members or friends [88]. Fourteen per- associated with fibroids. During the procedure, patients nor- cent of the patients in the studies required additional treat- mally receive conscious sedation, although some centers use ments or repeat embolization to further alleviate their symp- epidural or spinal anesthesia instead [72]. After the proce- toms. Another study including 200 patients showed that 73% dure, most patients experience moderate to severe pelvic of the patients continued to have symptom improvement pain for several hours due to ischemia and postembolization after 5 years of treatment [89]. If patients do not improve by syndrome. Thus, most centers admit the patients overnight 1 year or if they have large fibroids, symptoms may still re- for pain management. Postembolization syndrome is a side main at 5 years [89]. effect generally occurring after the embolization of solid The Uterine Artery Embolization (UAE) versus Hyster- organs, likely from the immune response related to ischemia ectomy for Uterine Fibroids trial (EMMY) was a multicenter, or degeneration [73, 75]. It occurs in up to 40% of patients randomized trial in which uterine fibroid embolization was who undergo UAE [74]. The symptoms of postembolization compared with hysterectomy in 177 patients. At 24 months syndrome include diffuse abdominal pain, low grade fever, after treatment, 24% of the patients in the UAE group un- malaise, loss of appetite, nausea, vomiting and leukocytosis derwent hysterectomy [90]. The remaining patients in the [74]. The syndrome is self limiting and lasts from a few UAE group continued to show improvement in health- hours to a few days [74, 75]. The treatment for the syndrome related quality-of-life outcomes. Uterine and fibroid volume includes supportive management with anti-inflammatory and reduction in the UAE patients was 48.2% and 60.5%, respec- antipyretic drugs. Patients usually return to normal activity tively [90]. Walker et al. reported long-term clinical out- within 7 to 14 days [71, 76]. comes at 5-7 years after UAE in 172 women [91]. More than Complications after the procedure are few and mostly 80% of the patients continued to experience improvement in minor and transient. Data from the Fibroid Registry for Out- fibroid-related symptoms. Five percent of the patients moni- come data (FIBROID) registry, the largest prospective regis- tored in this report became amenorrhic after UAE and 75% try, which has collected data from more than 3,000 patients continued to have reduced menstrual flow after surgery. who underwent UAE at 72 sites, reports perioperative com- Overall, most of the patients (86%) remained “very satis- plications of 2.7% with a rate of major events of 0.66%. fied” or “satisfied’ with the procedure. Sixteen percent of the Those complications include pain, contrast/drug reaction, patients required additional procedures for fibroid treatment. urinary retention, groin hematoma, nausea, vessel injury, Eighty-five percent of the patients reported improved quality device related and non-target embolization [76]. Spies et al. of life and 88% of the patients would recommend the proce- reported perioperative complications of 5% in 400 consecu- dure to others. tive patients following UAE [77]. The FIBROID registry reported adverse events within 30 days after treatment at COMPARATIVE STUDIES 26%, with reporting of major events at 4.8 % [76]. The most A number of studies have compared the outcomes of common major adverse events were inadequate pain control UAE with those of surgical procedures. All showed compa- requiring an emergency room visit or readmission (2.1%) rable outcomes between UAE and the surgeries, although for and vaginal expulsion of the fibroids (0.7%). Minor adverse some patients in the UAE group, the therapy failed and they events include hot flashes, vaginal discharge, infection, later required additional treatment for their symptoms. bleeding, headache and passing of fibroid tissues [76-78]. Transvaginal expulsion of the fibroid tissues is a common Most of the large studies have compared the outcomes complication following UAE and sometimes requires sur- between UAE and hysterectomy. A randomized trial by 152 Current Women’s Health Reviews, 2010, Vol. 6, No. 2 Tantibhedhyangkul and Behera

Pinto et al. assigned 57 women to a UAE or hysterectomy The Randomized Embolization versus Surgical Treat- group for symptomatic fibroid treatment in a ratio of two to ment for Fibroids (REST) trial randomized 157 patients in one [92]. The controversial randomized method used by Ze- the UK in a 2:1 ratio to undergo either UAE or surgery (hys- len, in which women in the hysterectomy group were not terectomy and myomectomy) for symptomatic fibroids [98]. informed about the study or alternative treatments, was used The primary purpose was to compare the quality of life at 12 in this study. There was also some overlapping in the ran- months after treatment. The study found no significant dif- domization in that 3 of the patients who underwent hysterec- ference in health-related quality of life between the two tomy had undergone UAE first. The primary outcome of the groups at 12 months, although women in the surgery group study concerned the length of hospital stay. The results had significantly greater symptom improvement scores than showed that the length of hospital stay for the UAE group the UAE group. A high percentage of patients in both groups was shorter than for the hysterectomy group by 4.14 days said they would recommend their treatment to a friend (93% (1.59 and 5.85 days for the UAE and hysterectomy groups, and 88% in the surgery and UAE groups, respectively). The respectively). Recovery time was also shorter for patients median hospital stay and the recovery time after procedure who underwent UAE compared with the hysterectomy pa- were shorter for the UAE group than for the surgery group. tients (9.5 vs. 36.2 days, P<0.001). On the other hand, more Twenty of the patients in the UAE group required additional patients in the UAE group developed complications after the therapy due to continued or recurrent symptoms, whereas procedure compared with those in the hysterectomy group. only one patient in the surgery group required additional The complications in the UAE group, however, were minor treatment. (PES, pelvic pain, urinary tract infection), whereas the hys- A few studies have compared the outcomes of UAE and terectomy group experienced mostly major complications myomectomy. A study by Goodwin et al. compared the (surgical incision abscess, intra-abdominal abscess plus treatment outcomes of 149 patients who underwent UAE and anemia, and urinary retention). 60 patients who underwent myomectomy [99]. The primary The EMMY trial (The Uterine Artery Embolization endpoint in the study was an improvement of at least 5 [UAE] versus Hysterectomy for Uterine Fibroids trial) was a points in the uterine fibroid quality-of-life questionnaire multicenter, randomized trial that compared UAE and hys- score (UFQoLs) from baseline to 6 months after the proce- terectomy for treatment of symptomatic fibroids among 177 dure. Significant and comparable improvement in UFQoLs, patients in the Netherlands [78, 93-97]. The primary end menstrual bleeding, uterine volume, and overall quality of point of this study was avoidance of a subsequent hysterec- life were noted in both groups. Patients in the UAE group, tomy in at least 75% of patients undergoing UAE. The sec- however, had a shorter hospital stay (23.8 hr vs. 61.6 hr; ondary end points were symptom improvement in symptoms P<0.0001) and a shorter recovery time (14.6 days vs. 44.4) and reduction of uterine and fibroid volume. The study met than patients in the myomectomy group (P<0.05). At one the primary end point. At two years after UAE, 23.5% of the year, only 1.7% of the patients in the UAE group required patients in the UAE group were required to undergo a hys- additional treatment. terectomy; thus, 76.5% of these patients avoided hysterec- A study by Mara et al. randomized 121 women with fi- tomy [78]. Patients in the UAE group had a shorter hospital broids who wished to remain fertile into 2 treatment groups, stay than the patients in the hysterectomy group (2.7 vs. 5.1 one to undergo UAE and the other myomectomy [100]. The days in the hospital), and the overall recovery time was aim of the study was to compare the safety, efficacy and re- much shorter in the UAE patients [96]. Similar improve- productive outcomes between the two treatments. The pa- ments in health-related quality of life were noted in both tients were followed for 2 years. There were no differences groups. At 2 years after treatment, most patients in both in the rate of treatment failure (10% in both groups) and groups reported they were at least “moderately satisfied” early complications between the two groups. Patients in the (92% and 90% in UAE and hysterectomy groups, respec- myomectomy group required longer hospital stays than pa- tively) with their treatments [90]. tients in the UAE group. Safety and efficacy in reducing HOPEFUL (Hysterectomy Or Percutaneous Embolisa- symptoms were found to be comparable in the two groups. tion For Uterine Leiomyomata), a multicenter retrospective However, significantly more patients in the UAE group re- study, compared the outcomes for over 1100 women who quired additional intervention (32% vs. 3%), the most com- underwent UAE or hysterectomy in the UK [75, 79]. All of mon reason being the persistence of large fibroids > 5 cm. the patients were followed up 2 to 5 years postoperatively in The reproductive outcomes between the 2 groups also dif- the UAE group and up to 9 years in the hysterectomy group. fered. This result is discussed in detail in the section below At baseline, women in the UAE group were younger and describing reproductive outcomes after UAE . were more likely to have had prior pelvic surgery than the hysterectomy cohort (P < 0.001). Obesity, co-morbidity, and REPRODUCTIVE OUTCOMES AFTER UTERINE history of pelvic surgery increased the risk of complications ARTERY EMBOLIZATION of the UAE. Patients in the UAE group developed fewer Significant concerns after uterine artery embolization complications than patients who underwent hysterectomy: include amenorrhea and premature ovarian failure. The inci- the odd ratio was 0.60 (95% CI 0.32–1.15) [75]. Interesting, dence of amenorrhea after UAE has been reported to range although more women in the hysterectomy cohort reported from 3% to 7% [86, 89, 101]. Most of the patients who de- symptom relief (95% vs. 85%, P < 0.0001), fewer women in veloped permanent amenorrhea were women who were older that cohort (85%) said they would recommend the treatment than 45 years at the time of the procedure [86, 101-103]. The to a friend, compared with 91% in the UAE group (P= largest available data set comes from the FIBROID registry, 0.007) [75]. Non-Surgical Treatment Options for Symptomatic Uterine Leiomyomas Current Women’s Health Reviews, 2010, Vol. 6, No. 2 153 which shows evidence of amenorrhea in 7.3% of UAE pa- pregnancies in the control group. The study showed no dif- tients [89]. Eighty-six percent of these were women were 45 ferences in preterm labor, malpresentation, or intrauterine years of age or older [102]. The potential mechanism by growth restriction between the two groups. However, the which UAE causes premature ovarian failure is non-target rates of cesarean section (66% vs. 48.5%) and postpartum embolization of utero-ovarian collateral circulation [71], hemorrhage (13.9% vs., 2.5%) were significantly higher in which can cause a reduction in the ovarian blood supply, the UAE group. The miscarriage rate in the UAE group was which in turn results in a decrease in the ovarian reserve or also double that of the control group. (35.2% vs. 16.5%, OR ovarian failure. To evaluate the effects of UAE on the ovar- 2.8, 95% CR 2.0-3.8) Since this was a retrospective review, ian reserve, a small number of studies have compared basal it was difficult to account for confounding factors such as levels of FSH (an ovarian reserve marker) before and after weight or parity. The patients in the UAE group were more the procedure [104,105]. All of the studies showed no evi- likely to be symptomatic than patients who had not received dence of a decrease in the ovarian reserve after the proce- any treatment and might have larger fibroids. Regardless of dure, except in patients who were older than 45 years. One these limitations, the authors concluded that early pregnan- study comparing the FSH level and the antral follicle count cies are significantly vulnerable after UAE, and their data before and after UAE in 20 women aged 33-39 years showed supports the recommendation of ACOG that UAE is rela- no difference in the before and after measurements [104]. tively contraindicated in women who desire future childbear- Another study that compared the difference in FSH levels ing [117]. before and after UAE in 63 patients found, on the whole, no Mara et al. compared the reproductive outcomes of difference before and after surgery [105]. However, when women who underwent myomectomy and UAE [100]. The the data were stratified by age, 15% of the patients who were patients were followed for up to 2 years after treatment. Of older than 44 years (4 patients) had FSH in the menopausal 121 patients in the study, 26 from the UAE group and 40 range after surgery. A study by Healey et al. looked at the from the myomectomy group attempted to conceive after ovarian reserve prior to and after UAE and myomectomy and treatment. Thirteen women (50%) from the UAE group and found no difference in the ovarian reserve prior to or after 31 women (78%) from the myomectomy group became either procedure [106]. pregnant within 2 years after the procedures. Women who Data on pregnancy outcomes after UAE are limited to underwent UAE had a significantly lower pregnancy rate, case reports and case series. Although uncomplicated preg- lower delivery rate (19% vs. 48%, 6 and 19 patients), and nancies have been reported, several studies show an in- higher miscarriage rate (64% vs. 23%, 9 and 6 patients) than creased risk of pregnancy complications after UAE, such as women who underwent myomectomy in this study. Although miscarriage, malpresentation, postpartum hemorrhage, ab- the number of patients who became pregnant was very small, normal placentation and cesarean section [75,100,107-115]. the authors concluded that myomectomy is a better choice of In the HOPEFUL study, 27 women achieved 37 pregnancies treatment for women who desire future fertility. A retrospec- after UAE [75]. Among these, 15 miscarriages, 2 ectopic tive study by Goldberg et al. using all the data available from pregnancies, 1 termination and 19 live births were reported. the literature compared pregnancy outcomes between women In the Ontario multicenter trial, 24 pregnancies occurred, of who underwent UAE and laparoscopic myomectomy [118]. which 4 resulted in miscarriages, 14 in full-term deliveries, They found 53 pregnancies after UAE and 139 pregnancies and 4 in preterm deliveries [110]. Of the 18 deliveries, 9 after laparoscopic myomectomy. The study found a higher were vaginal deliveries and 9 were cesarean sections. Three incidence of preterm labor (OR 6.2%; 95% CR 1.4, 27.7) patients with abnormal placentation were also noted, and one and malpresentation (OR 4.3%; 95% CR 1.0, 20.5) in the of them needed a cesarean hysterectomy because of severe UAE group. While there was no significant difference in the postpartum hemorrhage. rates of postpartum hemorrhage and spontaneous abortion In a report by Walker et al., 108 out of approximately between the two groups, the rates in both groups were higher 1200 women who underwent UAE tried to conceive [109]. than those found in the general population. Thirty three women became pregnant which resulting in 56 pregnancies. Of these, there were 17 (30.4%) miscarriages, 3 TRANSVAGINAL TEMPORARY UTERINE ARTERY stillbirths and 33 deliveries. The cesarean section rate in this OCCLUSION study was 72.7% and there were 6 cases of postpartum hem- Transvaginal temporary uterine artery occlusion, using a orrhage. It is difficult to conclude that the complications suf- Doppler-Guided Uterine Artery Occlusion Device, is a new fered by these women after UAE were related to the proce- procedure originally developed to decrease blood loss during dure alone, since fibroids themselves constitute a risk factor gynecologic surgeries. Its use for fibroid treatment has been for pregnancy complications. Furthermore, many of these described in a very small number of case reports and case women were in the advance-reproductive age group and their series [119-121]. The procedure is based on the theory that age could have contributed to an increased risk of miscar- fibroid tissues undergo necrosis after uterine ischemia--the riage. same theory that underlies UAE. The device, known as the A recent systemic review by Homer et al., using the data FlostatTM system (Vascular Control Systems, San Juan Cap- available in the existing literature, compared pregnancy out- istrano, CA, USA – now owned by Johnson & Johnson), comes in women who underwent UAE with pregnancy out- consists of a guiding cervical tenaculum, a transvaginal vas- comes in an age-matched control group of women with un- cular clamp with integrated Doppler ultrasound crystals, and treated fibroids [116]. Two hundred and twenty-seven preg- a small battery-powered transceiver that generates the Dop- nancies in the UAE group were compared with over 4000 pler sound. The clamp slides along the guiding tenaculum to 154 Current Women’s Health Reviews, 2010, Vol. 6, No. 2 Tantibhedhyangkul and Behera the lateral vaginal fornices at the 3 and 9 o’clock cervical vided with intravenous medications given to the patient positions. Using the Doppler ultrasound signal, the right and throughout the duration of the procedure. The treatment it- left uterine arteries are identified. The clamp then advances self consists of a series of high-energy ultrasound pulses further into the vaginal fornices and displaces the uterine (sonications), each lasting approximately 20 to 40 seconds. arteries superior to the point of insertion into the uterus. The interval between each sonication is approximately 90 When the clamp is closed, it occludes both of the uterine seconds to allow the tissue temperature to normalize. Multi- arteries against the cervix. For the treatment of uterine fi- ple sonications are required over one to four hours to treat broids, the instrument is left in place for 6 hours and then each fibroid, depending on its size. The patient normally removed. During the procedure, patients receive a paracervi- returns home within 1 to 2 hours after the procedure. Post- cal block or epidural anesthesia [121]. Minimal pain procedure pain is usually manageable with over the counter has been noted during the procedure, with no pain medica- oral analgesics. Patients typically return to normal activity tion required after the patient’s discharge from the hospital within three days. The ExAblate 2000 (InSightec, Inc. Haifa, [122]. Israel) was the first MRgFUS system approved by the U.S. Food and Drug Administration in 2004 for the treatment of The published data on the use of this system for fibroid symptomatic fibroids in women who had completed child- treatment is still preliminary. A case report by Vilos et al. bearing. showed a significant decrease in uterine fibroids and uterine volume of more than 44% in a patient treated with the in- Because MRgFUS has only recently come into use for strument [122]. At three months after treatment, the patient fibroid treatment, only short-term outcome data are available reported significant improvements in her symptoms. A feasi- in the literature. The treatment has been shown to improve bility study by Hald et al. recruited eight patients for this fibroid symptoms, with the degree of improvement varying procedure [121], of which only 4 patients had successful significantly according to the treatment volume. In an early occlusion. The authors reported two cases of hydronephrosis, study, Hindley et al. report a case series including 109 pa- and 2 of the 4 patients required additional therapy for fibroid tients who underwent MRgFUS for fibroid treatment [124]. treatment. The protocol used in the study resulted in a treatment volume of approximately 25% and a mean fibroid volume reduction This procedure has some advantages over UAE in that of approximately 13.5% at 6 months. Interestingly, despite there is no radiation exposure, less pain after the procedure the small degree of volume reduction, 79.3% of the patients and no risk of non-target embolization. However, there is experienced significant improvement of their symptoms as very limited data on both short-term and long-term outcomes measured by the Uterine Fibroid Symptoms and Quality of on which to base a recommendation. Because the uterine Life Questionnaire score. The follow-up report from the arteries are occluded only temporarily using this instrument, same study showed that 51.2% of the patients who still re- the degree of fibroid ischemia is potentially less than in mained in the study at 12 months (42 of 82 patients) still had UAE. Thus, this treatment might not be favorable to UAE in significant improvement in their symptoms [125]. Nine seri- the long term for this reason. Furthermore, the potential for ous adverse events were reported in the study, although only urethral injury noted in the feasibility study needs to be ad- one patient had nausea after the procedure that was thought dressed in larger studies. to be related to the surgery [124]. The rest of the adverse events were related to patients’ underlying conditions MAGNETIC RESONANCE-GUIDED FOCUSED (fibroids) or treatment failure. Five percent of the patients ULTRASOUND SURGERY reported minor skin burns after treatment, which were due to Magnetic resonance-guided focused ultrasound surgery incomplete removal of the abdominal wall hair. Previous (MRgFUS) has been used in the treatment of uterine fibroids studies have shown an increased risk of minor skin burn since 2000. This technique combines the use of high-energy from abdominal wall hair, likely from air becoming en- focused ultrasound technology with real-time MRI guidance. trapped in the particular areas [126]. One patient reported leg High-energy focused ultrasound is a thermal ablation proce- and buttock pain from sciatic nerve palsy (which was shown dure in which high-intensity ultrasound waves are transmit- in the MRI images to be in the far field of the sonication ted from transducers outside the body to a small area within path). The patient was noted to have recovered completely the targeted treatment region deep inside the body. Within from the symptoms, using only symptomatic management, at seconds, the temperature of the targeted tissues rapidly in- a 12-month follow-up visit. Since the incident, the treatment creases, causing tissue necrosis, while the surrounding areas protocol has changed to ensure at least a 4 cm distance be- remain unaffected. MRI guidance provides accurate imaging tween the treatment area and any major nerve bundles that of the tissues and surrounding organs, allowing extreme pre- are situated in close proximity to the bone surface of the sa- cision with planning, monitoring, and treatment. During crum. treatment, MRI thermal imaging provides real-time tempera- Later studies modified the treatment protocol to include a ture monitoring and thus assures the proper energy exposure larger treatment volume. A case series by Fennessy et al. in the target tissues and prevents injury to the surrounding compared the outcomes of 96 patients who were treated with organs. This technology is currently being used not only for the original protocol with that of 64 patients who were uterine fibroids, but also for different types of tumors [123]. treated with the modified protocol [127]. The modified pro- MRgFUS for the treatment of fibroids is normally done tocol leads to a larger treatment area and longer treatment on an outpatient basis. During the procedure, the patient lies time. Repeat treatment, if needed, was also allowed within 2 prone on the MRI table with her abdomen positioned over weeks in the modified protocol. In both protocol groups, the the ultrasound transducer. Conscious sedation is usually pro- greatest symptom improvement was noted at 3 months and Non-Surgical Treatment Options for Symptomatic Uterine Leiomyomas Current Women’s Health Reviews, 2010, Vol. 6, No. 2 155 the effects were sustained up to the 12 month time point of nancies in 51 women who were treated with MRgFUS [135]. the study. At 3 months, patients in the modified protocol Forty-one percent (22 patients) of the pregnancies resulted in group reported greater improvement in symptoms than the delivery and 20% were ongoing. Twenty-six percent of the original protocol group, and 91% and 72% of patients in the pregnancies resulted in miscarriage (13% of those were elec- modified and original protocol groups continued to report tive terminations). Two patients had placenta previa whereas symptom improvement at 12 months. Thus, the degree of 12 of 22 patients delivered without complications, with all symptom improvement seems to be associated with treat- but one delivery at full term. One patient developed uterine ment volume. At the end of the procedure, 28% and 37% of atony and severe postpartum hemorrhage after a cesarean the patients in the original and modified protocol groups section due to breech presentation and intramural fibroids. required alternative therapy. Although the sample size was small, the pregnancy out- The longest outcome report was authored by Stewart comes and complications are favorable in comparison to the pregnancy outcomes after UAE. Currently, the trial using et al. [128]. In that study, 359 patients who were treated by MRgFUS for patients with fibroids who have infertility is MRgFUS were followed for 24 months. Because 4 different ongoing and likely will provide us with more information in protocols were used to treat patients, the relationship be- the future. tween the outcomes and treatment protocols was standardized by the degree of treatment volume. As expected, pa- In conclusion, MRgFUS is a promising new technology tients who had higher treatment volume (>20%) had signifi- for the treatment of fibroids that appears to be safe and effec- cantly more improvement in their fibroid symptoms than the tive. However, the procedure also has limitations, and long- patients with lower treatment volume (<20%) both at 3 term outcomes are not yet available. months and beyond 3 months. This study also found that treatment volume has a significant effect on the number of EXPERT COMMENTARY patients who need additional therapy and the increase in he- Currently, there are several treatment options available matocrit in women with anemia. for fibroid treatment. Hysterectomy is the only definitive The advantages of MRgFUS are that it is a non-invasive, treatment for relief of fibroid symptoms and the only proce- outpatient procedure, requiring no surgical incision, and re- dure that prevents the recurrence of fibroids. For sympto- sults in a short recovery time after surgery compared with matic women who wish to preserve their fertility or simply hysterectomy or myomectomy. Unlike UAE, after which do not want to undergo invasive surgical procedures, many most patients develop severe pain from post-embolization minimally invasive or radiological procedures are available. syndrome immediately after the procedure, post-MRgFUS Hormone and NSAID therapy are appropriate for first-line pain can be managed with oral analgesics. MRgFUS has symptoms, particularly those related to menorrhagia and many limitations as well, including limits on the size, type, anemia, but they have no effect on the size of fibroids. and location of fibroids that can be treated with this method GnRH agonists are effective in improving hemoglobin and [129]. The cost of treatment and the very limited availability, hematocrit as well as in reducing uterine size. Due to the side due to few treatment centers in the U.S., are also major limi- effect of bone loss with long term use, GnRH-agonist usage tations. The procedure cannot be performed if the patient has is limited to short term use (between 3 to 6 months) for de- abdominal wall scar tissue or if the fibroids are too close to creasing uterine and fibroid size prior to surgery. The the neurovascular bundle or other vital organs (such as the levonorgestrel-releasing intrauterine system has been shown bowel or bladder) or if there are structures (for example, to increase hematocrit in women with menorrhagia due to bowel loop) that could interfere with the ultrasound beam. fibroids who have a normal uterine cavity, although the pres- The procedure is also not suitable for patients with multiple ence of fibroids theoretically could increase the chances of fibroids due to the duration of the treatment, which takes 2 to expulsion of the device. Uterine artery embolization is a safe 4 hours per fibroid. Thus, only 1 or 2 fibroids can be treated and effective alternative to hysterectomy. It provides a at a time. The procedure is currently limited to the treatment shorter recovery time and fewer major complications than of six or fewer fibroids that are less than 10 cm in diameter. hysterectomy. Patients, however, should be aware that ap- Smart et al. reported a protocol that involved pretreating proximately 20% to 25% of patients will later require further patients who have fibroids larger than 10 cm with a GnRH treatment due to treatment failure. MRgFUS has promising agonist for 3 months prior to MRgFUS, with promising re- short-term outcomes, but data on long-term outcomes are sults (130). In this study, patients who were pretreated with a currently not available. It is important that patients talk with GnRH agonist had a larger treatment area than the patients their physicians about their treatment options and the relative who did not receive a GnRH agonist. The authors hypothe- risks and benefits of each procedure prior to undergoing any sized that GnRH agonists decrease the vascularity in the fi- procedures or treatments. broids, which in turn contributes to the rate of temperature increase in the fibroids during MRgFUS treatment and in- FIVE-YEAR VIEW creases the extent of the tissue necrosis [130]. Current therapy options for women with symptomatic The effect of MRgFUS in patients who desire future fer- uterine fibroids are primarily limited to mechanical methods tility is still not well studied. Thus far, there are only 4 case of excision, ablation, or devascularization. With increased reports and one case series that have reported pregnancy experience using conservative, non-surgical procedures to outcomes after MRgFUS [131-135]. All of the case reports treat uterine fibroids, non-invasive technologies will con- reveal patients who had vaginal delivery at term after tinue to improve to expand eligibility, and allow safe and MRgFUS [131-134]. In the case series, there were 54 preg- effective long-term resolution of fibroid-related symptoms. 156 Current Women’s Health Reviews, 2010, Vol. 6, No. 2 Tantibhedhyangkul and Behera

The approach to fibroids will also benefit from a comprehen- have been possible prior to treatment due to uterine size. sive approach, including the incorporation of evolving medi- The pretreatment might also allow surgeons to use trans- cal management options in the fibroid treatment armamen- verse incision instead of vertical incision. tarium. Ultimately, the future of fibroid management may • Mifepristone and asoprisnil have been shown in small involve multimodal therapy that will allow early intervention studies to be effective in reducing fibroid size and to prevent growth of fibroids that are asymptomatic or re- improving fibroid-related symptoms. Large randomized duce rate of fibroid recurrence after treatment. controlled trials are needed to confirm their efficacy. As we continue to increase our understanding of the • The levonorgestrel-releasing intrauterine system is pathophysiology of fibroids, we are learning about several effective in decreasing the amount of bleeding in women compounds involved in fibroid growth, which may provide with fibroids who have a normal uterine cavity. therapeutic targets in the future. The influences on growth of leiomyoma cells are multifactorial. Although modulation of • Uterine artery embolization has been shown to be an ex- hormonal effects, for both estrogen and progesterone, on cellent alternative to hysterectomy for the treatment of leiomyoma cells are an area of particular research interest, fibroids; resulting in shorter hospital stay, shorter many studies show that there are other important cytokines recovery time, and fewer major complications. and growth factors that play a critical role in the develop- • Approximately 20%-25% of patients who undergo UAE ment of fibroids. Many of these growth factors are still being will require further treatment. studied in cell culture systems or they are in early phases of clinical trials. However, these limited studies show therapeu- • The short-term and long-term outcomes of UAE are tic potential for inhibition of leiomyoma cell growth path- promising, with more than 80% of the patients still ways or interference with collagen production as promising satisfied with their treatment 3 to 5 years after treatment. adjuncts to the non-hormonal management for fibroids [136]. • Pregnancy outcomes after UAE are limited. Although Interferon-alpha (IFN-) has been shown to inhibit leio- successful pregnancies have been reported, several re- myoma cell growth in vitro [137]. One case report found ports showed increased risks of pregnancy complications persistent shrinkage of a single fibroid in a patient who in UAE patients when compared with the general popula- received IFN- for hepatitis treatment [138]. Pirfenidone, an tion. antifibrotic agent being studied for treatment of pulmonary • MRgFUS is the newest minimally invasive treatment for fibrosis, has been shown to inhibit DNA synthesis and fibroids. The short-term outcomes of this procedure are inhibit mRNA production for collagen type I in leiomyoma promising. cells and normal myometrial cell cultures in a dose-dependent manner [139]. A heparin-like compound, RG13577, has been REFERENCES shown to inhibit DNA synthesis of normal myometrial and leiomyoma cells, with the effect more pronounced in Articles of special notes have been marked as: leiomyoma cells [139]. Halofuginone significantly inhibits of interest cell proliferation, collagen production, and TGF mRNA of considerable interest. levels in both normal and leiomyoma cells [140]. 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Received: January 10, 2010 Revised: February 10, 2010 Accepted: April 15, 2010

Current Women’s Health Reviews, 2010, 6, 161-166 161 Surgical Management Options for Patients with Infertility and Endometriosis

Michelle Catenacci1,* and Tommaso Falcone2

1Department of Obstetrics and Gynecology, Reproductive Endocrinology and Infertility, Cleveland Clinic, Department of Obstetrics and Gynecology-A81, 9500 Euclid Avenue, Cleveland, Ohio 44159, USA; 2Cleveland Clinic Department of Obstetrics and Gynecology-A81, 9500 Euclid Avenue, Cleveland, Ohio 44159, USA

Abstract: Aim: Endometriosis is an important cause of infertility. The disease is both diagnosed and treated surgically. Its pathogenesis is not entirely known; however, retrograde menstrual flow and a pro-inflammatory state in the peritoneum are thought to support its development. Many studies have been done to help better assess the effects of the disease on fertility rates and how surgical removal of disease can improve these fertility rates. The aim of this study was to review the current literature on the effects of endometriosis on infertility and the benefit of surgical treatment for these patients. Methods: Review of recent publications through Pubmed and the Cochrane data base. Results: The effects of minimal and mild disease on infertility are debatable, and studies have shown inconsistent results. Surgery through laparoscopic removal has been shown to be beneficial for women with moderate and severe endometriosis; however, those with severe disease may not benefit as much. Removal of ovarian endometriomas by an excisional process appears to be superior to fenestration and coagulation for spontaneous pregnancy outcomes. Conclusion: Laparoscopic removal of endometriosis is an important treatment option for patients with endometriosis- related infertility. Questions remain, however, and further research should be done on the effects of Stage I/II disease and bowel endometriosis on infertility. Keywords: Infertility, endometriosis, laparoscopy, ovarian endometrioma.

INTRODUCTION time of menstruation significantly increase the likelihood of finding blood in the peritoneal cavity [2, 3]. This increase in Endometriosis is the presence of ectopic endometrial peritoneal blood is thought to be from refluxed menstrual glands and stroma outside the uterine cavity and it is blood; however, actual endometrial cells in the peritoneal frequently associated with infertility. The disease and its cavity have yet to be identified [3]. pathogenesis are not entirely understood, but continued research is helping to better understand this disease. Women The anatomic distribution of endometriosis seen in the can present with a spectrum of disease severity with the most abdomen and pelvis give additional support to the theory by severe disease leading to deep adhesions and alteration of Sampson [4]. Gravity appears to have an influence on normal anatomy. The main treatment options for infertile location of endometriosis lesions with a greater proportion of patients with endometriosis include surgical removal of endometriosis adhesions/deep implants being located in the disease and in vitro fertilization (IVF). The focus of this pelvis, particularity the posterior (most dependent) pelvic article is to briefly review the pathogenesis of endometriosis compartment [5, 6]. Additional support is that locations of and review current literature on disease treatment for peritoneal fluid stasis show increased endometriosis implants infertility with a focus on laparoscopy. when compared with other compartments in the peritoneal cavity. Specifically, the Pouch of Douglas, the region of the PATHOGENESIS appendix, the region of the sigmoid colon, and the right The most widely accepted theory to explain the develop- paracolic gutter are areas in which peritoneal fluid can ment of endometriosis was described by Sampson in 1927. get trapped, and these regions correspond to areas where His theory of retrograde menstruation describes menstrual endometriosis lesions are commonly seen [4, 6, 7]. If debris escaping through the fallopian tubes into the pelvis retrograde menstruation is indeed an important step in the [1]. It has been found that patent fallopian tubes during the disease process, then it would seem understandable that regions exposed to increased menstrual blood would be more likely to develop the disease. Gravity would cause the

*Address correspondence to this author at the Department of Obstetrics and majority of the blood to be deep in the pelvis, leading to Gynecology, Reproductive Endocrinology and Infertility, Cleveland Clinic, more disease in the more dependent regions of the pelvis, Department of Obstetrics and Gynecology-A81, 9500 Euclid Avenue, Cleveland, Ohio 44159, USA; Tel: +1 216 444 1758; Fax: +1 216 445 6325; and upper abdominal lesions could be formed with menstrual E-mail: [email protected] blood trapped in regions of peritoneal fluid stasis.

The mere presence of blood, however, is not the only is thought to contribute to decreased fertility. The elevated causal factor leading to the development of endometriosis. cytokines seen are thought to disrupt the normal cell cycle, Considering that women with and without the disease have leading to increased infertility [18]. Other observations that been found to have increased blood in the peritoneal cavity have been noted include reduced sperm motility on exposure during menstruation, other factors need to be present for to interleukin-6 [19]. Increases in inflammation seen in the endometriosis lesions to develop. Endometrial cells would peritoneum of these patients can lead to an increase in need to attach to the peritoneal cavity. This attachment is oxidative stress and reactive oxygen species thought to thought to be due to abnormalities of both the endometrium further hinder fertility. as well as the patient’s immune system. Endometrial lesions need a vascular supply for support after attachment to Table 1. Factors Hypothesized to Contribute to The Patho- the peritoneal layer. Increased vascularization has been genesis of Endometriosis documented in the red endometriotic lesions [8]. Angiogenic factors are thought to play a critical role in the increased vascularization and endometriosis disease process. In parti- - Retrograde menstruation cular, vascular endothelial growth factor (VEGF) has been - Gravity and peritoneal stasis found in increased amounts in the peritoneal fluid of patients - Increased vasularization with endometriosis when compared with controls [9, 10]. - Disorders of apoptosis Other endometrial abnormalities thought to lead to - Matrix Metalloproteinases development of endometriosis include disorders of apoptosis. Apoptosis is thought to remove endometrial cells - Abnormalities of the immune response during the late secretory and menstrual phases of the - Pro-inflammatory state menstrual cycle. In patients with endometriosis, apoptosis is decreased, leading to increased survival of endometriotic An increase in oxidative stress is seen in patients with cells [11]. Matrix metalloproteinase (MMP) also has been endometriosis and is thought to contribute to decreased implicated in the pathogenesis of endometriosis. This family fertility [20]. Endometriosis patients may have damage to of enzymes participates in normal tissue remodeling, and their oocytes from the increase in oxidative stress. One altered expression of MMPs has been noted in women with mechanism studied showed that hydrogen peroxide and endometriosis [12]. Further research is needed to help clarify tumor necrosis factor- alter oocyte microtubule and spindle the roles of these endometrial abnormalities as they pertain cell structure. The amount of damage was increased with to the development of endometriosis. higher concentration of hydrogen peroxide and tumor Immune response abnormalities also seem to play a role necrosis factor- and longer exposure to these substances in the development of endometriosis. The immune system [21]. This is just one example of how oxidative stress can be should provide a defense to the formation of endometriosis, detrimental to fertility in endometriosis patients. and its alteration has been found in patients with the disease. Cytokines are associated with a pro-inflammatory state that Treatment of Stage I/II Endometriosis is hypothesized to promote endometriosis implantation. As stated previously, some controversy exists regarding Several studies have demonstrated increased levels of the association between minimal or mild endometriosis and various cytokines in the peritoneal fluid of women with infertility. Several studies give conflicting results when endometriosis [13-15]. However, other studies have failed to looking at fecundability of patients with minimal and mild confirm these findings and further investigations are disease. Some studies have shown no significant difference warranted [16]. in fertility rates when comparing these patients to those with Other areas of the immune system that have been studied unexplained infertility [22, 23]. A more recent retrospective in regards to their association with endometriosis include study looked at natural conception rates between women natural killer cells and macrophages. Macrophages speci- with Stage I/II disease and women with unexplained fically are thought to exacerbate inflammation, and studies infertility. Patients were diagnosed by visualization of have found increased number of macrophages in endometrial disease and no treatment was given. The study reports that tissue in patients with endometriosis [17]. Studies continue these patients were followed for three years and found that to support the idea that women with an altered immune patients without endometriosis had a significantly greater response leading to a pro-inflammatory state are more chance of pregnancy [24]. To add to the discrepancies, the susceptible to developing endometriosis (Table 1). removal of minimal and mild endometriosis has been shown to have mixed results in regards to fertility outcomes. Endometriosis and Infertility Several studies have suggested a benefit for treating minimal and mild disease for both natural cycles and cycles using Endometriosis is a known cause if subfertility and controlled ovarian hyperstimulation and intrauterine infertility. Stage III/IV disease leads to infertility with insemination [25, 26]. Others, however, have failed to adhesions and distortion of normal anatomy. There is more replicate these results [27, 28]. Several of these studies are debate, however, on the extent of infertility caused by Stage flawed, however, due to their retrospective nature and small I/II disease. Several studies have looked at the peritoneal study numbers. fluid in these patients in the hopes of discovering a potential cause of decreased fertility. The increase in cytokines and Two groups have studied the effect and treatment of inflammatory cells found in the peritoneum of these patients minimal and mild endometriosis in larger prospective studies Surgical Management Options for Patients with Infertility and Endometriosis Current Women’s Health Reviews, 2010, Vol. 6, No. 2 163 in an attempt to settle this debate. A Canadian group first disease [34]. However, pregnancy rates still may remain low published its result on infertility associated with minimal and after laparoscopic removal, especially for patients with the mild disease. The group’s first objective was to look at the most severe disease. One prospective study found the pre- effects of mild and minimal endometriosis on fertility. gnancy rate for infertile women after laparoscopic removal Women enrolled in the study underwent diagnostic laparo- of Stage III disease to be 44%. Women in the same laparoscopy for infertility. The first part of the study looked at scopic study with Stage IV had a pregnancy rate of only women with Stage I/II endometriosis that had only diag- 16.7% after disease removal [35]. nostic laparoscopy without any treatment or disease removal. These women were compared with women with unexplained Some women with severe endometriosis will have bowel infertility (no endometriosis found on laparoscopy). The involvement. Bowel resections have been done for these women were followed for 36 weeks after laparoscopy to patients to relieve pain symptoms associated with the deeply compare pregnancy rates between the two groups. In total infiltrating disease, but the utility of bowel resection in 168 women with minimal and mild endometriosis were regards to improving fertility outcomes in these patients is compared with 263 women with unexplained infertility. The unclear. Few studies have started to look at fertility probability of becoming pregnant and carrying the outcomes in this subgroup of patients with severe disease. pregnancy to 20 weeks gestation did not differ statistically One retrospective study looked at pregnancy rate and live between the two groups [29]. birth rates after bowel resection. In this study, 22 women desired pregnancy after bowel resection, and 10 of these The same researchers then looked at the effects of women achieved pregnancy after surgery with a median time treating minimal and mild endometriosis on fertility to conceive after surgery of 8 months. Although this small outcomes. This portion of the study compared women study showed promising results for fertility outcomes in randomized to laparoscopic treatment of disease with patients after bowel resection, it also discussed potential laparoscopic diagnosis only. This study compared 172 complications. Two patients in this study had complications. women with excision or ablation of disease to 169 women in One developed a rectovaginal fistula and the other developed the diagnosis only group and again followed them for 36 a pelvic abscess. Both of these women required further weeks. Removal of disease was associated with a clear surgery, reminding us that bowel resection is not a benign advantage to patients. Treatment increased the cumulative surgery [36]. probability of pregnancy by 73% with 30.7% of the treatment group achieving pregnancy and 17.7% of the Another prospective non-randomized study compared diagnosis group achieving pregnancy in the 36 week follow pregnancy rates in infertile patients after bowel resection by up period [30]. either laparotomy or laparoscopy. This study found improved outcomes in the group that underwent laparoscopic The second prospective randomized trial to examine the surgery with 57.6% of the women in the laparoscopic group effects of treatment on Stage I/II endometriosis came from a becoming pregnant compared with only 23.1% of the women group in Italy. Women were randomized at time of in the laparotomy group [37]. Another interesting study laparoscopy to treatment or diagnosis alone and followed for looking at the influence of bowel endometriosis on fertility one year postoperatively. Unlike the Canadian study, the compared three groups of patients: Group A had surgery for study in Italy failed to show that surgery was beneficial to endometriosis with colorectal resection, Group B had women with minimal and mild disease. In the treatment surgery for endometriosis and evidence of endometriosis in group, 12/51 (24%) women achieved pregnancy compared bowel but did not have a colorectal resection, and Group C with 13/45 (29%) of the no-treatment group. This was not had surgery for moderate or severe endometriosis with no statistically significant. After spontaneous abortions, only evidence of disease in the bowel. These women were then 10/51 (20%) of the treatment group and 10/45 (22%) followed for four years with pregnancy rate being a primary delivered. This again was not significant [31]. Due to the outcome. Pregnancy rate was found to be significantly lower discrepancies found in these two studies, additional, larger in the group that had bowel endometriosis present (Group studies are needed to help clarify the impact minimal and B). The monthly fecundity rate in Group A was 2.3%, Group mild endometriosis have on fertility. B 0.84% and Group C 3.95% [38]. These studies appear to indicate that removal of bowel endometriosis may not only Treatment of Stage III/IV Endometriosis benefit a patient’s pain symptoms, but may also improve their chances for successful pregnancy. There is less debate surrounding the effect of moderate to severe endometriosis on infertility. Dense adhesions/fibrosis Although surgery for infertility related to moderate- can lead to a loss of normal anatomy and obvious hurdles in severe endometriosis has been shown to improve fertility achieving pregnancy. The best treatment for these patients to outcomes, many patients will not achieve success after give them the highest chance for success, however, is still surgical resection. Pregnancy rates are the highest in the being investigated. months immediately following surgery [39]. Many physicians will use one year as the time point for additional Laparoscopic removal of disease can be utilized to treat intervention if pregnancy has not occurred. Six months also infertile patients. Early studies reported a benefit to laparo- can be used, especially in older patients. Options for the scopic removal of severe disease in regards to fertility patient at that point include re-operation or IVF. Two studies outcomes [32, 33]. Although technically challenging, laparo- have compared these choices. One looked at women who scopic removal is minimally invasive and cost-effective and had laparotomies for endometriosis and compared those who is the preferred treatment method for moderate and severe underwent repeat laparotomy verses those who underwent 164 Current Women’s Health Reviews, 2010, Vol. 6, No. 2 Catenacci and Falcone

IVF. Pregnancy rates in this study were low and only one endometriomas that looked at both spontaneous pregnancy cycle of IVF was compared, but this study found a 22% outcomes and controlled ovarian hyperstimulation [48]. The chance of achieving pregnancy within one year of re- review included three randomized, controlled trials that operation and a 12% chance of pregnancy after one cycle of evaluated the two laparoscopic surgical techniques on IVF [40]. Another study looking at laparoscopic reoperation patients with ovarian endometriomas of at least 3 cm [49- versus IVF found cumulative pregnancy rates to be 5.9%, 51]. 18.1%, and 24.4% at 3, 7, and 9 months out from reopera- Two prospective studies in the Cochrane review tion. This was significantly lower then the pregnancy rate considered the effect of these two surgical techniques on after two cycles of IVF (69.9%) [41]. In the absence of other spontaneous pregnancy outcomes [49, 50]. In one study of symptoms, moving to IVF may be more beneficial for 62 infertile patients with endometriomas, 32 were treated patients than repeat surgery. with cystectomy, and 30 were treated with fenestration and coagulation. Patients were followed for one year during Treatment of Ovarian Endometriomas which no infertility medications or procedures were One area that has been studied extensively is the effect of administered or performed. The group that had cystectomies ovarian endometriomas on fertility and infertility treatments. had a significantly higher pregnancy rate (59.4%) compared Ovarian endometriomas can usually be easily detected with with the group that underwent fenestration and coagulation transvaginal ultrasound. Several studies have looked at the (23.3%) [49]. The other study included in the Cochrane risks and benefits of removing these masses for both review also compared spontaneous pregnancy outcomes after spontaneous pregnancies and prior to IVF. A potential risk of laparoscopic cystectomy versus drainage and coagulation of removing endometriomas would be incidental removal of endometriomas. This was a smaller study that compared 9 normal ovarian tissue. Ovarian endometriomas can be more infertile patients in the cystectomy group to 17 patients in the challenging to remove than other ovarian cysts. That being coagulation group. Pregnancy rates were monitored for 24 said, the removal of normal ovarian tissue along with the months, and the cystectomy group exhibited a statistically cyst has been shown to be more likely when removing higher pregnancy rate (66.7%) than the coagulation group endometriomas compared with other ovarian cysts [42]. In (23.5%) [50]. The Cochrane review used these two studies to addition to loss of normal ovarian tissue, removal of ovarian conclude that overall spontaneous pregnancy rates favor endometriomas also potentially can lead to decreased blood excision with an odds ratio of 5.21 [48]. flow to the ovary if damage to its vascular supply occurs The same Cochrane review also compared follicular during the removal. Loss of normal ovarian tissue or response to ovaries during controlled hyperstimulation after decreased vascular supply to tissue can lead to a decreased cystectomy versus fenestration and coagulation. A single ovarian response during controlled ovarian hyperstimulation. prospective study compared fenestration and coagulation Alternatively, one could leave the endometrioma and versus cystectomies prior to controlled ovarian proceed to IVF. Somigliana et al. looked at women with one hyperstimulation. In one arm of the study, patients had ovary affected by at least one endometrioma during IVF bilateral endometriomas with one removed by cystectomy stimulation and found that larger endometriomas or multiple and one by fenestration and coagulation. Patients in the other endometriomas resulted in a decreased response in the ovary two arms had one enodmetrioma and were randomized to be with disease [43]. treatment by cystectomy or by fenestration and coagulation. Several other retrospective studies have looked at the This study failed to find a significant difference in the effects of ovarian endometriomas on IVF cycles with mixed number of follicles obtained regardless of treatment method. results. Some studies suggested that removal of Neither was there a difference in the number of follicles endometriomas did not affect the number of follicles obtained between treated ovaries and normal ovaries that did obtained during IVF cycle [44, 45]. This is in contrast to not require surgery [51]. The Cochrane review stated that other studies that have found a significant reduction in the evidence is insufficient at this time to state which surgical number of follicles generated after laparoscopic cystectomy technique should be employed prior to controlled ovarian for endometriomas [46]. A prospective randomized trial hyperstimulation [48]. compared women with endometriomas of 3 - 6 cm during IVF cycles. They were randomized into two groups: Group I CONCLUSION underwent cystectomy prior to IVF; Group II had no surgical Endometriosis is believed to arise from a combination of intervention prior to IVF. They found that Group I needed menstrual blood refluxed through the fallopian tubes and a more stimulation and had less oocytes retrieved then the peritoneal environment that is supportive of its implantation. group that did not have surgery. However, there was no An alteration of immune response leading to a pro- difference in fertilization, implantation, or clinical pregnancy inflammatory state is thought to promote its development. rates between these two groups [47]. Larger prospective Endometriosis is classified based on the extent of disease studies should be done to help clarify the mixed results seen found during surgery. Stage I and II are also termed minimal regarding the effects of endometriomas and their removal and mild disease, and their effects on infertility remain prior to IVF. controversial. Further prospective studies should be done to After deciding to operate on an ovarian endometrioma help clarify the role of minimal and mild disease in sub- and for fertility treatment, a choice should be made on the infertility and what effects removal of disease has on fertility treatment method to be used. A Cochrane review was outcomes. published comparing excisional versus ablative treatment of Surgical Management Options for Patients with Infertility and Endometriosis Current Women’s Health Reviews, 2010, Vol. 6, No. 2 165

Unlike Stage I/II disease, clear evidence supports the Current trends are moving towards less invasive procedures, negative impact that Stage III/IV disease has on fertility. and serum markers have the potential to play an important Moderate and severe endometriosis can lead to extensive role in the diagnosis and management in endometriosis adhesions and deep infiltrating disease. Surgical removal of patients. Stage III/IV disease will improve fertility rates; however, As treatment evolves in this direction, the role of those with the most severe disease may not benefit as much diagnostic laparoscopy for infertile patients is becoming with surgery alone. Recent studies have suggested the uncertain. Specifically, the value of diagnostic laparoscopy removal of bowel endometriosis may also improve fertility for patients that do not suffer from pain and have normal outcomes in this subset of patients, although studies remain imaging studies is in question. Limited data currently limited on this subject. Finally, large or multiple endome- support the removal of minimal and mild endometriosis for triomas can lead to a decreased ovarian response in con- infertility. Due to the controversial role that Stage I/II trolled ovarian hyperstimulation. Further studies need to be endometriosis have on infertility, recommendations are done to determine what surgical technique for endometrioma moving away from performing diagnostic laparoscopies on removal will give the best results during controlled ovarian infertile patients. Ultimately, this will lead to less surgery for hyperstimulation. On the other hand, it has been shown that these patients and increased medical management for removal of endometriomas by excisional procedures appears patients with infertility-related endometriosis. to be superior to ablation of endometriomas in improving spontaneous pregnancy outcomes. It is clear from the studies reviewed here that laparoscopy has a significant role for KEY ISSUES the treatment of endometriosis-related infertility. Many ques- • Mixed data on the effects of treating Stage I/II endo- tions remain, however, and continued research is needed to metriosis. help specify these roles so that the best recommendations Pregnancy rates are highest in the months immediately can be offered to this patient population. • following surgery. EXPERT COMMENTARY • Removal of bowel endometriosis may improve fertility rates. This article’s intention was to briefly highlight the pathogenesis of endometriosis and then review current • If surgery fails to restore fertility, IVF may yield a higher clinical evidence for treatment of this disease in regards to success rate. improving fertility outcomes. We still have much to be • Cystectomy for endometriomas gives superior natural learned about the disease mechanism, and continued research pregnancy results. will not only help understand this disease but also will help formulate improved treatment options. Additional investi- • Mixed data on the effects of ednometriomas or their gations are needed on the molecular level to help clarify the removal prior to IVF. roles of various cytokines and inflammatory cells. This will give us a better understanding of why endometriosis occurs REFERENCES in some women and may lead to prevention and treatment [1] Sampson JA. Peritoneal endometriosis due to the menstrual options for these patients. dissemination of endometrial tissue into the peritoneal cavity. Am J Obstet Gynecol 1927;14: 422-69. In addition to improving our understanding of disease on [2] Halme J, Hammond MG, Hulka JF, et al. 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Received: January 10, 2010 Revised: February 11, 2010 Accepted: April 15, 2010

Current Women’s Health Reviews, 2010, 6, 167-176 167 Surgical Strategies for Fertility Preservation in Women with Cancer

Mohamed A. Bedaiwya,b, Kristine Zanottia, Ahmed Y. Shahinb, Mohamed Yahya Abdel Rahmana,c, and William W. Hurda,* aDepartment of Obstetrics and Gynecology, University Hospitals Case Medical Center, Case Western Reserve University, Cleveland, OH 44106, USA; bDepartment of Obstetrics and Gynecology, University of Assiut, Asyut, Egypt; cDepartment of Obstetrics and Gynecology, University of Sohag, Sohag, Egypt

Abstract: Survival has significantly improved for women diagnosed with cancer during the reproductive years. The majority of these women will desire children after completion of their cancer therapy. Future fertility often is eliminated or impaired by surgical removal of reproductive organs for the treatment of gynecologic cancers or by radiation or chemotherapy for the treatment of other cancers. As a result, several strategies have been developed in an attempt to preserve fertility in these women, including alternate surgical approaches, protecting reproductive organs during treatment, and removing and storing oocytes prior to cancer treatment for future use. Surgical approaches used in women with early gynecologic cancers include unilateral oophorectomy for ovarian cancer, radical trachelectomy for cervical cancer, and progestin therapy to avoid surgery for endometrial cancer. Ovarian function and fertility can be preserved in women requiring pelvic irradiation by ovarian transposition away from the treatment field. In women requiring systemic chemotherapy, surgical removal of ovarian tissue followed by cryopreservation and subsequent transplantation after the patient is determined to be in remission has been shown to restore ovarian function and result in pregnancy. To provide the best chance of future fertility, these surgical approaches to fertility preservation must be implemented as part of the initial cancer therapy, prior to definitive radiation or chemotherapy. Keywords: Fertility preservation, gynecological cancers, ovarian transplatation.

INTRODUCTION recommendation addressing the need for more research on fertility preservation [5]. Survival has significantly improved for women diagnosed with cancer during the reproductive years primarily as Several strategies for fertility preservation have been a result of significant advances in the field of cancer treat- developed for reproductive-age women diagnosed with can- ment [1]. The overall cancer death rates for women de- cer. These strategies include 1) altering surgical treatment of creased by 11.4% from 1991 to 2005, particularly because of gynecologic cancer to preserve fertility, 2) protecting repro- advances made in the diagnosis and treatment of breast and ductive organs during radiation or chemotherapy, and 3) colorectal cancers. Between 1991 and 2005, more than removal and cryopreservation of ovarian tissue prior to can- 160,000 cancer deaths were averted in women in the United cer treatment for later transplantation back into the patient States [1]. when she is in remission. This review will address the surgical approaches for these strategies that are currently being Approximately 70% of reproductive-aged women diag- used in reproductive-age women with cancer. nosed with cancer will desire children after completion of their cancer therapy [2,3]. Although modern cancer therapy GYNECOLOGIC CANCERS: SURGICAL TREAT- dramatically improves survival, it often adversely impacts MENTS THAT PRESERVE FERTILITY fertility as a result of the effects of chemotherapy and radiotherapy on reproductive organs. In the case of gynecologic Treatment for most gynecologic cancers includes re- cancers, surgical removal of reproductive organs can also moval of the uterus, ovaries, and tubes, often rendering the impair or completely eliminate future fertility. patient sterile. However, for reproductive-age women with early disease, fertility-sparing surgery sometimes is possible. The increasing need to consider fertility preservation This section will address fertility-preserving surgical ap- in these women is well appreciated. The American Society proaches to cancer of the cervix, ovary and endometrium of Clinical Oncology recommends that cancer patients in (Table 1). the reproductive years be counseled about fertility preservation [4]. The President’s Cancer Panel released a strong Cervical Cancer

Cervical cancer is the most common gynecologic cancer

*Address correspondence to this author at the Department of Obstetrics and diagnosed in the reproductive years. Although cervical can- Gynecology, University Hospitals Case Medical Center, Case Western cer accounts for only 16% of all cancers in women, 40% are Reserve University School of Medicine, 11100 Euclid Ave, MCA 7007, diagnosed before the age of 45 [6]. In the United States, the Cleveland, OH 44106, USA; Tel: 216-844-5345; Fax: 216-844-3796; age-adjusted incidence rate is approximately 8 per 100,000 E-mails: [email protected], [email protected]

Table 1. Fertility-Sparing Surgery for Reproductive-Age Women with Gynecologic Cancers

Cancer Type Standard Therapy Fertility-Sparing Approach Requirements

Cervical Total abdominal hysterectomy, bilateral 1. Cone biopsy 1. Stage IA1 salpingoophorectomy 2. Radical trachelectomy 2. Stage IA2- IB1

Ovarian Total abdominal hysterectomy, bilateral Unilateral oophorectomy 1. Borderline tumors salpingoophorectomy 2. Stage IA-C Grade I or II

Endometrial Total abdominal hysterectomy, bilateral Surgical staging without hysterectomy Stage I, Grade I salpingoophorectomy or oophorectomy; endometriod cancer Progestin therapy women per year, and almost 1/3 of these women will die where the cervix is removed along with the surrounding from their disease [6]. The five-year survival rate is currently vaginal and parametrial tissue while preserving the uterine 70%. fundus [14-17]. This approach might be used for smaller, Standard Therapy cervix-confined lesions, such as lesions otherwise meeting criteria for microinvasion but are accompanied by lympho- Therapy for cervical cancer depends on the extent of the vascular invasion, Stage IA2 lesions; and Stage IB1, visible disease (i.e. stage) at diagnosis. Approximately 50% of lesions < 4 cm confined to the cervix with superficial inva- women with cervical cancer will be Stage II-IV, where the sion and no vascular space invasion [9]. cancer is found to have spread beyond the cervix, either Radical trachelectomy can be performed using an ab- to adjacent structures, to regional lymph nodes, or to more dominal approach combined with pelvic lymphadenectomy distance sites [6]. Standard therapy for most of these women to exclude lymphatic spread [18]. Alternatively, this proce- is a combination of chemotherapy and radiotherapy. dure can be performed vaginally with the addition of laparo- The remaining women will be found to have Stage I cer- scopic lymphadenectomy [19]. After excision of the cervix vical cancer, where the disease is confined to the cervix [6]. and parametria, a permanent cerclage is typically placed Surgical therapy for women with this condition who no and the vaginal mucosa is re-approximated to the uterine longer desire fertility is radical hysterectomy with pelvic stump. lymphadenectomy [3]. Cases have been reported in which The recurrence and survival rates for this approach ap- women who have undergone this procedure have had chil- pear to be similar to traditional radical hysterectomy in ap- dren utilizing in vitro fertilization (IVF) and the assistance of propriate early-stage patients. Three studies with a total of a surrogate mother to carry the pregnancy [7, 8]. Depending 151 patients followed for 23-60 months reported acceptable on recurrence risk factors, adjuvant pelvic radiotherapy may recurrence rates of 2.8% to 5% [15, 20, 21]. Data focusing be administered after radical hysterectomy. However, the on oncologic outcomes in women with larger cervical lesions ovary has poor tolerance to radiation, and standard pelvic is more limited. radiotherapy doses of 45 to 50 Gy will reliably induce premature ovarian failure. Successful surrogate pregnancies Radical trachelectomy is often effective in preserving have been reported when either oocytes were removed from fertility, although obstetric complications are increased. the ovaries or the ovaries were surgically transposed out of While first trimester miscarriage rates are similar to that seen the pelvic radiation field at the time of radical hysterectomy in the general population, rates of both second trimester [7,8]. losses and pre-term delivery are significantly increased in patients who have undergone trachelectomy. In a review of Fertility-Sparing Surgery 520 patients treated with radical vaginal trachelectomy, 43% Cone Biopsy attempted to conceive after surgery and 70% of these women achieved pregnancy [22]. Of these 227 pregnancies, 21% Observational data suggest that lesions meeting criteria ended in first trimester miscarriage and 8% in second trimes- for microinvaasive cervical carcinoma, designated as “Stage ter miscarriage, 21% were born prematurely, and 50% were Ia1,” have a negligible risk for lymphatic metastasis and can born at < 36 weeks. As many will have a permanent cerclage be excised using less radical procedures, such as cold knife placed at the time of their trachelectomy, delivery by elective conization [9]. Controversy exists regarding the impact of cesarean section is typically warranted. cone biopsy on obstetric outcomes. While some studies report no increase in adverse outcome [10, 11], other studies, Ovarian Cancer including a recent large meta-analysis, have suggested that this approach increases the risk of both pre-term delivery and Ovarian cancer was ranked as the fifth leading cause of low birth weight infants [12, 13]. cancer deaths in the United States in 2009 [1]. Although the peak age of occurrence of ovarian cancers is after meno- Radical Trachelectomy pause, up to 17% of all ovarian cancers occur in women <40 years of age [23]. Many women in this age group wish to Another fertility-sparing approach for patients with very preserve their reproductive potential and ovarian endocrine early invasive cervical cancer is radical trachelectomy, function. Surgical Strategies for Fertility Preservation in Women with Cancer Current Women’s Health Reviews, 2010, Vol. 6, No. 2 169

Survival rates can be predicted by the stage and his- jacent fallopian tube. Often staging lymphadenectomy and tological grade of ovarian cancer at the time of diagnosis. In relevant biopsies are performed as well. However, the con- general, women with ovarian cancer confined to the ovary tralateral ovary and uterus are not removed. There are many (Stage I) have >90% five-year survival rate, whereas those situations in which removal of the contralateral ovary and with Stage III-IV tumors have < 40% five-year survival rate. uterus does not impact overall oncologic outcomes or prog- Because >75% of ovarian cancers are Stage III-IV at diagno- nosis. In these cases, fertility-sparing surgery is quite reason- sis, the overall five-year survival rate for women diagnosed able practice. with ovarian cancer is <45% [6, 24]. Most unilateral germ cell and sex cord stromal malignan- Ovarian Cancer Subtypes cies will be amenable to fertility-sparing surgery. Fortu- nately, aggressive histologic subtypes and/or advanced sur- Ovarian cancer can be divided into three major catego- gical stage are uncommon in the reproductive age groups. In ries: epithelial ovarian tumors, germ cell tumors, and stromal these cases, adjuvant multi-agent chemotherapy often is rec- tumors. Each histologic subtype is associated with clinical ommended to reduce the risk of recurrence [30]. One series features that are relevant to determining the advisability of a reported a 90% 10-year overall survival following fertility- fertility-sparing procedure, such as age at presentation, typi- sparing surgery for germ cell malignancies; moreover, suc- cal stage at presentation, and incidence of bilateral ovarian cessful subsequent pregnancies are reported, even among involvement. Fortunately, many of the histologic subtypes women who received chemotherapy [31]. seen more commonly during the reproductive years are amenable to less radical surgical approaches. Unilateral borderline tumors usually are amenable to fertility-sparing surgery, and there is little evidence that on- Epithelial ovarian malignancies usually arise from the cologic outcomes are compromised, even in the setting of ovarian surface epithelium or within epithelial inclusion metastatic disease [32]. In one series, the recurrence rate was cysts. They account for at least 80% of ovarian malignancies approximately 5%, regardless of whether patients were [25]. Approximately 75% of invasive epithelial cancers pretreated with radical or fertility-sparing surgery. That being sent in stages III or IV; however, most are diagnosed in post- said, bilateral ovarian involvement is common in borderline reproductive age women [24]. An important group to distin- malignancies, and the remaining ovarian tissue was the most guish are tumors of low malignant potential, or borderline common site of tumor recurrence in those opting for fertility- epithelial tumor. These relatively indolent lesions are found sparing procedures, thus indicating a need for close surveil- most frequently in the reproductive age group. Moreover, lance of the remaining ovary [32]. In this series, 18% of 184 they tend to remain ovary-confined for long periods of time women subsequently had successful pregnancies after fertil- and can often reach an impressive size prior to diagnosis. ity-sparing surgery. Approximately 90% present with Stage I disease (confined to one or both ovaries) but will be bilateral in 25% of cases Invasive epithelial ovarian cancers can be treated with [26, 27]. conservative fertility-sparing surgery in selected unilateral Stage I cases [33]. When fertility-sparing surgery is planned Germ cell tumors account for approximately 10-15% of for these women, complete staging is silll recommended. ovarian tumors, but malignant germ cell tumors are rare. Pelvis washings, lymph node sampling, and omentectomy While germ cell malignancies account for fewer than 5% of will reveal occult metastases in 15% of women presenting all ovarian cancers, they account for 2/3 of the ovarian ma- with apparent ovary-confined disease [25, 34]. Some experts lignancies seen in the first two decades of life [28]. Ovarian suggest performing a wedge biopsy on the contralateral nor- dysgerminoma is the most common malignant germ cell tu- mal-appearing ovary with intraoperative frozen section to mor, accounting for 40% of germ cell cancers. Approxi- exclude occult malignancy [35]. Except in cases of low- mately 75% are Stage I at diagnosis;, however, 15% present grade histology, most women diagnosed with invasive with bilateral ovarian involvement. Other germ cell malig- epithelial ovarian carcinoma of any stage will be treated with nancies, such as immature teratoma, endodermal sinus tu- adjuvant chemotherapy after surgery. mor, and choriocarcinoma are rarely bilateral. Even after unilateral oophorectomy and chemotherapy, Ovarian stromal tumors, such as granulosa-theca and many women with malignant epithelial ovarian tumors will Sertoli-Leydig cell tumors are quite rare and usually low- be able to conceive. The majority will experience resumption grade; approximately 70% are Stage I at presentation. They of menstrual function, and in one series more than 70% sub- are rarely bilateral [24, 29]. sequently had a successful pregnancy [25, 36]. Standard Therapy Endometrial Cancer Surgical therapy for women with ovarian cancer who no longer desire fertility is hysterectomy and bilateral salpingo- Endometrial cancer is the most common gynecologic oophorectomy. For staging purposes, many patients also cancer, accounting for approximately 6% of all cancers in undergo lymphadenectomy and partial omentectomy. For women [37, 38]. However, the majority of women diagnosed those with sufficient risk for recurrence, adjuvant combina- with endometrial cancer are post menopausal. Less than 5% tion chemotherapy may be advised postoperatively [25]. of endometrial cancers are diagnosed in women <40 years of age, and in this cohort these neoplasms tend to be well dif- Fertility-Sparing Surgery ferentiated with an indolent biology and confined to the Fertility-sparing surgery for ovarian malignancies refers uterus at diagnosis [6]. Excess estrogen, such as that seen in to unilateral oophorectomy, usually with removal of the ad- obesity and anovulation, is the main risk factor for the de- 170 Current Women’s Health Reviews, 2010, Vol. 6, No. 2 Bedaiwy et al. velopment of low-grade endometrial neoplasms. Indeed, day for women with advanced disease, and thromboembolic approximately 25% of young women who develop endo- complications were markedly increased [43]. metrial cancer will have polycystic ovary syndrome (PCOS) [38]. The overall five-year survival rate for this so-called Follow-up “low risk” endometrial cancer is in excess of 90%. Definitive assessment of treatment response requires en- Standard Therapy dometrial sampling, either biopsy or D&C, which has been recommended every 1 to 3 months [41]. Once D&C verifies The standard therapy for endometrial cancer is hysterec- that the endometrium has reverted to normal histology, preg- tomy and bilateral salpingo-oophorectomy [39]. Adjuvant nancy can be attempted [40]. Monthly transvaginal ultra- postoperative radiation therapy or chemotherapy may be sonography and serum CA-125 might be useful as early in- recommended for high-risk histology or advanced disease. dicators of disease progression [41, 49]. Since the majority of women with endometrial cancer are beyond the reproductive years, fertility-sparing surgery is Outcomes rarely considered. Approximately 50% of well-differentiated tumors show a Fertility-Sparing Therapy complete response to hormonal treatment. As a result of on- In select younger women with low-grade endometrial going risk factors, approximately 25% of responders will carcinoma who are motivated to preserve their fertility, fer- suffer a relapse after initial successful therapy [50]. Thus, tility-sparing approaches may be considered. These ap- patients should be counseled regarding the potential for fail- proaches typically involve medical treatment with progestin ure with this approach. therapy. This approach is appropriate only in young women with non-invasive (Stage Ia), hormone-sensitive lesions Subsequent Fertility (typically Grade I histology) who desire fertility preservation Several authors have reported successful pregnancies and have an otherwise reasonable chance for conception af- after progestin therapy for endometrial carcinoma [40]. Al- ter therapy [40-42]. though the reports are somewhat limited, it appears that as many as 1/3 of women will conceive after such therapy. Un- Pre-Treatment Studies fortunately, as stated before, recurrence is common, and so Thorough endometrial sampling though D&C and accu- continued close follow-up is required as long as the patient rate pathology review are essential prior to embarking on a retains her uterus [40]. Unfortunately reported conception strategy of medical management for endometrial carcinoma rates are low, reflecting both inadequate regression of endo- [40]. Immunohistochemistry studies evaluating progesterone metrial pathology as well as inherent fertility issues in this receptor content are to be helpful in predicting response to typically subfertile patient population. As PCOS and anovu- progestin therapy. However, in a study of metastatic endo- lation are common in this population, ovulation induction is metrial carcinoma, 37% of women with tumors demonstrat- often necessary. ing progesterone content responded to progestin therapy, whereas only 8% of those responded whose tumors did not PROTECTING OVARIES AND OOCYTES DURING [43]. Most FIGO Grade I endometrial neoplasms will ex- CANCER TREATMENT press progesterone receptors to varying degrees. The value of further quantifying progesterone content in women consider- Cancer therapy often has devastating effects on ovarian ing for medical management has not yet been evaluated. function and future fertility. Pelvic irradiation can be cura- tive for a number of cancers common in young women, in- As non-invasive or minimally invasive lesions are con- cluding gynecologic cancers and lymphomas. However, if sidered the only candidates potentially amenable to medical the ovaries are within the treatment field, premature ovarian management for endometrial carcinoma, an important part of failure is common. Likewise, systemic chemotherapy is an pre-treatment evaluation is determining depth of myometrial effective treatment for these types of cancers in addition to invasion. The most accurate imaging technique available for cancers outside the pelvis such as breast cancer and leuke- this purpose is the contrast-enhanced MRI [44,45]. Pelvic mia. Multi-agent chemotherapy results in ovarian failure in MRI is also highly sensitive for detection of neoplastic approximately 40% of women < 40 years and more than75% lymph node involvement, albeit lymphatic metastasis is oth- in women > 40 years and is likely to impair fertility in an erwise a very uncommon occurrence for non-invasive and even greater number [51]. early-invasive FIGO Grade I endometrial lesions [46]. The key to fertility preservation in women requiring pel- Progestin Therapy vic irradiation or systemic chemotherapy is protection of oocytes from damage. Both non-surgical and surgical meth- To avoid the need for hysterectomy, progestin therapy is ods for fertility preservation have been developed for women used in an attempt to eradicate early-stage, well-differentiated undergoing these cancer therapies. endometrial cancer [6, 47, 48]. Although there is no standard treatment regimen, two commonly use progestin regimens Non-Surgical Approaches are megestrol acetate, 80 mg/day or medroxyprogesterone, 200 mg/day. Medroxyprogesterone doses as high as 1000 Although the focus of this manuscript is surgical ap- mg/day have been advocated by some; however, this higher proaches to fertility preservation, existing non-surgical ap- dose has not been found to be more effective than 200 mg/ proaches should be mentioned. These approaches fall into Surgical Strategies for Fertility Preservation in Women with Cancer Current Women’s Health Reviews, 2010, Vol. 6, No. 2 171 two categories: oocyte retrieval for in vitro manipulation a [60]. In vitro studies of human ovarian tissue have and cryopreservation, and pituitary down-regulation during suggested that preantral follicles exhibit FSH independent chemotherapy. growth, and this might explain why pituitary down- regulation does not completely inhibit antral follicle devel- Oocyte Retrieval for In Vitro Manipulation opment [52]. Other researchers have observed that primor- Oocyte removal for in vitro manipulation is the most ef- dial follicles continue to initiate growth during GnRH-a fective non-surgical approach to fertility preservation [52]. therapy and during the hypogonadal state before puberty The highest pregnancy rates have been achieved with a com- [61]. bination of hormonal stimulation followed by timed A recent review of clinical studies of GnRH-a use during transvaginal retrieval of mature oocytes, in vitro fertilization chemotherapy concluded that, although there is some evi- and embryo cryopreservation (IVF-ET). The cumulative dence that GnRH-a therapy reduces chemotherapy-related pregnancy rate with this approach after thawing and intrau- gonadotoxicity, it has yet to be proven statistically [62]. In terine transfer is currently > 60% per embryo [53]. Oocyte the nine studies they analyzed the incidence of ovarian fail- cryopreservation can be used if the woman does not desire ure after chemotherapy was 11% in patients who received fertilization of her oocytes; the current pregnancy rate after GnRH-a compared with 56% in those who had not. How- thawing, fertilization, and intrauterine transfer is 57% per ever, because most of these studies were small, retrospective, embryo [54]. The disadvantages of these techniques is that and non-randomized, the benefit of GnRH-a remains uncer- they delay planned cancer therapy for two or more weeks tain. from the beginning of the next menstrual period and expose the women to higher than normal estrogen levels during SURGICAL APPROACHES FOR PRESERVING ovarian stimulation. OVARIAN FUNCTION To decrease the time until retrieval and avoid high estro- Radiation therapy and chemotherapy are commonly used gen levels in women with estrogen dependent cancers (e.g. treatments for gynecologic cancers and other cancers in the breast, endometrial), methods have been developed to re- reproductive years, most notably breast cancer and lympho- trieve immature oocytes [55, 56]. The oocytes can be hor- mas. Since both pelvic irradiation and systemic chemother- monally treated using a process called in vitro maturation apy can damage the ovaries, surgical methods have been (IVM). The resulting mature oocytes can be fertilized and developed that attempt to preserver ovarian function. Two the embryos frozen, or the oocytes can be frozen without surgical approaches have been reported for this purpose: 1) being fertilized. Although there have been reports of preg- ovarian transposition and 2) ovarian tissue cryopreservation nancy rates comparable to those attained with standard IVF- and reimplantation (Table 2). ET, these approaches have yet to become widely applied [57]. Ovarian Transposition Pituitary Down-Regulation During Chemotherapy Ovarian transposition (or oophoropexy) is the surgical A pharmacologic approach to decreasing ovarian damage mobilization of the ovary with its vascular pedicle, followed from chemotherapy is down-regulation of the pituitary with by relocation of the ovary out of the planned field of radia- gonadotropin-releasing hormone agonist (GnRHa) [58]. Sev- tion therapy. The goal is to minimize ovarian radiation expo- eral hypotheses exist to explain why this approach might sure to preserve ovarian function and possibly fertility [63]. limit the gonadotoxic effects of chemotherapy. First, inhibi- Techniques and results for ovarian transposition have been tion of FSH secretion might hinder recruitment of preantral reported for women undergoing local pelvic or abdominal follicles. Second, decreased FSH and LH stimulation might radiotherapy for a number of cancers, including cervical, diminish ovarian perfusion. Finally, decreased FSH stimula- vaginal, dysgerminona and Hodgkin disease [64-67]. tion of the ovary up-regulates sphingosine-1-phosphate Standard external beam radiation and brachytherapy are which might serve as an ovarian cytoprotectant [52, 58, 59]. designed to deliver a radiation dose to the pelvis of >4000 The ability of pituitary down-regulation to inhibit re- cGy [68]. Doses to the ovary of > 1200 cGy will result in cruitment of preantral follicles has been called into question. premature ovarian failure in >50% of women. After transpo- It has been observed that primordial follicles continued to sition from the pelvis, ovaries receive approximately 5–10% grown in a patient with Hodgkin disease treated with GnRH- of the total pelvic dose as a result of scatter [69]. As a result

Table 2. Surgical Methods for Preserving Ovarian Function for Reproductive-Age Women with Cancer Undergoing Pelvic Irradiation or Systemic Chemotherapy

Method Indication Approaches Effectiveness

Ovarian Cancer requiring pelvic radiation • Lateral transposition • Often preserves ovarian function transposition therapy • Medial transposition • Might require IVF to restore fertility

Ovarian Cancer requiring pelvic 1. Laparoscopic removal of ovarian tissue • Remains experimental transplantation irradiation or systemic 2. Cryopreservation • Preservation of ovarian function and chemotherapy 3. Transplantation of ovarian tissue fertility is possible 172 Current Women’s Health Reviews, 2010, Vol. 6, No. 2 Bedaiwy et al. of both radiation scatter and changes in circulation resulting ovaries from the fallopian tubes and lateral displacement is from surgery, ovarian function is not uniformly spared by likely to significantly decrease fertility. In one series of 37 surgical transposition. patients, 16 pregnancies occurred spontaneously, although in12 of these women the ovaries were not separated from the Technique fallopian tubes [66]. Ovarian transposition was originally performed via lapa- In some cases where the ovaries have been separated rotomy [70, 71]. More recent reports utilize a laparoscopic from the fallopian tubes and spontaneous pregnancy does not approach [67]. A standard technique begins with occlusion occur, oocyte retrieval followed by IVF-ET has been suc- and division of the utero-ovarian ligament followed by sepa- cessful. However, transvaginal oocyte retrieval is likely to be ration of the fallopian tube from the ovary [71]. The ovaries difficult following lateral transposition and might require a are mobilized by incising the peritoneum along the in- transabdominal or laparoscopic approach for retrieval. fundibulo-pelvic ligament. Finally, the ovaries are laterally displaced and fixed to the peritoneum high in paracolic OVARIAN TISSUE TRANSPLANTATION gutters. For many patients with cancer, especially adolescent girls Alternatively, the ovaries can be repositioned behind the and children, ovarian tissue transplantation is an experimen- uterus when lateral pelvic radiation therapy is required, as is tal approach with significant potential. Ovarian tissue is s often the case with lymphomas [67]. The theoretical disad- removed surgically prior to radiation or chemotherapy and vantage of the midline oophoropexy is higher radiation ex- cryopreserved. After the patient has completed cancer ther- posure of the ovaries as a result of internal scatter. apy and is in remission, the ovarian tissue is transplanted back into the patient (e.g. autologous transplantation). This Ovarian Function Preservation experimental approach has been used to preserve both ovar- Ovarian transposition prior to pelvic irradiation has been ian function and fertility. reported to preserve ovarian function in 50 to 79% of women Two approaches have been used for surgical removal of [66, 70]. These relatively short-term studies have not deter- ovarian tissue for later transplantation: 1) removal of the mined how many patients will subsequently experience pre- entire ovary or large sections of the ovary with a vascular mature ovarian failure. pedicle, and 2) removal of ovarian cortex tissue. Ovarian cortex tissue can be transplanted back on to the ovary Fertility Preservation (termed “orthotopic”) or to subcutaneous sites distant from Ovarian transposition is less effective for preserving the pelvis (termed “heterotopic”) Fig. (1) shows different fertility than ovarian hormonal function. Separation of the sites and approaches for ovarian transplantation.

Fig. (1). Various sites of ovarian transplantation with and without vascular anastomoses. A- Those with vascular anastomosis could be at orthotopic or heterotopic locations. Microvascular anastomosis could be performed using end-to-end, end-to side or fish mouth modification approaches. The heterotopic sites are the upper limb to the humeral vessels and the abdominal wall to the inferior epigastric vessels. B-Those without vascular anatomosis entail transplantation of part or most of the cortical tissue orthotopically or heterotopically. From: Bedaiwy MA, Shahin AY, Falcone T. Reproductive organ transplantation:advances and controversies. Fertil Steril 2008; 90(6): 2031-55. Surgical Strategies for Fertility Preservation in Women with Cancer Current Women’s Health Reviews, 2010, Vol. 6, No. 2 173

Ovarian Tissue Transplant with Vascular Pedicles will require oocyte retrieval and IVF. To date, no pregnancies have been reported with this technique. Surgical removal of ovarian tissue with a vascular pedicle with subsequent orthotopic transplantation back into the Expert Commentary adnexal region has been used to re-establish ovarian function in women with premature ovarian failure by transplanting The purpose of this article is to review the surgical ap- the ovary of her identical twin into her adnexa [72]. Cur- proaches to preserving fertility in reproductive-age women rently, microvascular anastomoses are performed via lapa- with cancer. A subset of reproductive-age women and gyne- rotomy, although laparoscopic methods are being investi- cologic cancers can be treated with fertility-sparing surgery. gated [73]. Appropriate patient selection can result in survival rates comparable to traditional radical surgery, while sparing fer- This approach remains experimental. It has been shown tility. Select women with ovarian cancer that is borderline or to be feasible in the animal model where the ovaries were Grade I, Stage I can be treated with unilateral oophorectomy. harvested with their vascular pedicles and then autotrans- Women with Stage I cervical cancer can be treated with planted. The ovarian vessels were anastomosed to the deep radical trachelectomy. Young women with Stage I endo- inferior epigastric vessels using either end-to-end, end-to- metrial cancer can be treated with progestins so that hyster- side, or fish mouth modification. The end-to- end anastomo- ectomy can be avoided. sis yielded the highest patency rate of the vascularized grafts [73]. Surgical approaches for fertility preservation can also be used for reproductive-age women diagnosed with cancer Ovarian Cortex Transplant who require pelvic irradiation or systemic chemotherapy. Ovarian translocation prior to pelvic irradiation has been Surgical removal of ovarian cortex followed by cryopre- demonstrated to preserve subsequent ovarian function. When served subsequent orthotopic transplantation back to the systemic chemotherapy is planned, experimental methods donor’s adnexal region has had some success in humans are being developed to surgically remove and cryopreserve [74]. Heterotropic transplantation to a subcutaneous site ovarian tissue. After the patient is determined to be in remis- distant from the adnexal has also been reported in humans sion, transplantation of ovarian tissue back into the patient [75-77]. has been demonstrated to restore both ovarian function and Orthotopic Transplantation pregnancies. Reimplantation of human ovarian cortex back to the Methods continue to be developed to preserve ovarian ovarian surface has been reported by several investigators function and fertility in reproductive-age women undergoing [78-81]. Reestablishment of ovarian functions after trans- cancer treatment. These methods must be implemented as plantation usually takes more than 4 months [82]. The length part of the initial approach to cancer therapy and prior to of time that grafts remain viable after transplantation is vari- definitive radiation or chemotherapy if the patient is to have able and has been reported to range from a few months to the best chance of continued ovarian function and fertility. more than 5 years [82]. Although this approach can restore menstrual function in women with previous ovarian failure, Five-Year View basal FSH levels remain elevated; indicating decreased ovar- The future of fertility preservation for reproductive-aged ian reserve [83]. women with cancer is likely to involve removal of ovarian Fertility Preservation tissue, followed by in vitro follicle culture of the tissue and removal of oocytes [86]. Immature eggs thus obtained will Live births have been reported after autologus transplan- be subjected to in vitro maturation. More effective tech- tation of frozen-thawed cortical tissue to orthotopic sites [78, niques are being developed for cryopreservation of both oo- 79, 81]. The majority of these pregnancies occur spontane- cytes and embryos. ously after establishment of menstrual function and normali- zation of the FSH and most often occurred during the first KEY ISSUES year after transplantation. WhenIVF is attempted in the Survival has significantly improved for women diag- transplanted ovaries, oocytes harvested from transplanted • nosed with cancer during the reproductive years. ovarian cortex might tend to be immature and of poor quality [84]. • The majority of these women desire children after com- Heterotropic Transplantation pletion of their cancer therapy. Reimplantation of human ovarian cortex to subcutaneous • For women with early gynecologic cancers, fertility- sites distant to the pelvis has also been reported [53, 85]. It sparing surgery is often possible. avoids the risk of a second surgery required to transplant For women requiring pelvic irradiation or systemic che- tissue back onto the ovary. However, the ischemia experi- motherapy for a variety of cancers, surgical methods for pre- enced by the tissue prior spontaneous neovascularization is serving ovarian function include ovarian transposition, and likely to be detrimental to subsequent functionality of an removal of ovarian tissue prior to therapy for cryopreserva- ovarian tissue transplant. In addition, subsequent fertility tion and later transplantation. 174 Current Women’s Health Reviews, 2010, Vol. 6, No. 2 Bedaiwy et al.

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Received: January 10, 2010 Revised: February 12, 2010 Accepted: April 15, 2010

Current Women’s Health Reviews, 2010, 6, 177-182 177 Innovative Roles for Surgical Robotics in Reproductive Surgery

Ehab Barakat1,*, Mohamed Bedaiwy2 and Tommaso Falcone1

1Department of Obstetrics and Gynecology, Cleveland Clinic Foundation, Cleveland, OH 44195, USA; 2University Hospitals Case Medical Center, Case Western Reserve University, Cleveland, OH 44106, USA

Abstract: In the area of reproductive surgery and infertility, minimally invasive techniques appear to have outcomes similar to those of laparotomy for tubal reanastomosis and myomectomy. Studies have shown that robotic use in these surgeries is feasible and that it may be used as an alternative for conventional laparoscopic surgery. The robot can overcome many of the limitations seen with conventional laparoscopy through improved dexterity and ergonomics. In this review, we will evaluate the current applications of robotics in reproductive surgery. Keywords: Robotic surgery, reproductive medicine, tubal reanastomosis, myomectomy, Da Vinci.

HISTORY OF ROBOTIC SURGERY Computer Motion Inc., Goleta, CA) device, which was the first commercially available surgical robotic technology. It The first appearance of the robot in surgery was in 1985 was used to hold a laparoscopic camera guided by a voice when the PUMA 560 robot was used to perform CT-guided command system [7]. brain tumor biopsies [1]. The next step in the surgical use of the robots occurred at the Imperial college, London in 1988 The second system was the ZEUS robot (Computer where a device named PROBOT was involved in performing Motion Inc., Goleta, CA, USA). It was developed in the transurethral resection of the prostate guided by a preopera- early 1990’s. This system was composed of three robotic tive construction of a three-dimensional image [2]. In 1992, arms attached to an operating table and a robotic console the ROBODOC machine was used in orthopedic surgery to where the surgeon was sitting. One of the robotic arms perform total hip replacement in humans [3]. These early was used to hold a laparoscope camera, and it was voice robots were designed to function autonomously after preop- activated. The surgeon controlled the other two arms using erative mapping [4]. handles on the console. The tip of ZEUS instrument had an articulation that allowed some wrist movement but was The biggest step in the development of the surgical robot never intuitive [8]. was the evolution of robotic telepresence technology, which gives the surgeon the ability to operate remotely. This was The third robotic system used in gynecologic surgeries is created in a collaboration between the Stanford Research the da Vinci. In 2000, the FDA approved the da Vinci robot Institute, United States Department of Defense and the system for use in abdominal surgeries. This system (Intuitive United States National Aeronautics and Space Administra- surgical, Mountain View, California) consists of a surgical tion (NASA) [5].The main goal for developing this system console where the surgeon sits and a surgical tower at the was to provide immediate surgical care to soldiers in a bat- bedside. The insight vision system provides binocular vision with a three-dimensional view. The console has two handles tlefield area. Robotic arms were designed to be mounted on that control the robot arms [9]. an armored vehicle that would travel to the wounded soldiers guided by a surgeon from a remote location [6]. This tech- The patient tower has three to four robotic arms one nology was subsequently commercialized, and the surgical holds the camera and the others hold surgical instruments robot was no longer autonomous but functioned only with such as graspers or scissors. The use of the da Vinci robot help from surgeon’s movements [4]. provides a three-dimensional view of the operative field as well as increased dexterity and precision in both dissection In this review, we will evaluate the current applications and suturing procedures. The use of the endowrist instru- of robotics in reproductive surgery. ments that imitate the human wrist gives seven degrees of freedom in movement, facilitating a wide range of motion. SURGICAL ROBOTS USED IN GYNECOLOGY There are some limitations with the use of the surgical robot, Three surgical robot systems have been described in the however, that include the initial system cost, maintenance area of gynecologic surgery. The first was the AEOSP costs and the expense of disposable instruments. The system (Automated Endoscopic System for Optimal Positioning is very bulky, limiting patient access. Lack of tactile feedback during the procedure requires use of visual cues to

properly perform surgical tasks. There are no randomized *Address correspondence to this author at the Cleveland Clinical Founda- tion, Department of Obstetrics and Gynecology, Cleveland Clinic Founda- clinical trials comparing robotic to conventional laparoscopy tion, Cleveland, OH, 44195, USA; Tel: 216-444-4402; Fax: 216-636-3100; or laparotomy [10]. Also, it is unclear how many surgeries E-mails: [email protected], [email protected] are needed before a surgeon obtains technical proficiency.

The first application of the surgical robot in reproductive reported case of robotic tubal reanastomosis was with the surgery was tubal renastomosis. After an initial success, it Zeus robot in 1999 [15]. The most commonly used system was implemented in myomectomies, complex hysterecto- for robotic surgery is the da Vinci system, which provides a mies and more intensively in gynecologic oncology–parti- three-dimensional view of the tubal architecture. The endow- cularly for endometrial cancer staging. rist instruments provide seven degrees of freedom in dissection and knot tying. In addition, it eliminates the tremors ROBOTICALLY ASSISTED TUBAL REANASTO- resulting from user fatigue and the use of fine sutures [16- MOSIS 18]. Tubal reanastomosis surgery was traditionally performed We reviewed the literature for previous evaluations through a small Pfannenstiel incision; microsurgical tech- on the use of the robot in tubal reanastomosis surgery. nique was used for the reconstruction. The disadvantages of Eight publications were identified and are summarized in this procedure were postoperative pain and prolonged conva- Table 1. lescence. A minilaparotomy approach can be performed as The first attempt at implementing robotics in reproduc- an outpatient procedure with good results [11]. However this tive surgery was in 1998 at Cleveland Clinic when an animal approach has not been generally adapted. With the develop- study using a pig model was performed. Three approaches to ment of minimally invasive surgery, tubal reanastomosis was tubal reversal-type surgery were compared: open and laparo- performed laparoscopically with shorter hospital stays and scopic with or without robotic assistance. This animal recovery times, smaller incisions and decreased postopera- experiment concluded that the use of Zeus robot is helpful in tive pain levels [12]. performing tubal microsurgical reanastmsois and results in The use of laparoscopy in such a procedure requires pre- shorter operative times compared with those of conventional cise dissection, delicate handling, and suturing of the fallo- laparoscopy [19]. pian tubes. In addition, the learning curve of conventional A case report of full robotic assistance in tubal steriliza- laparoscopy is high and requires a multitude of laparoscopic tion reversal was published in 1999 by the same group. Sur- surgical skills [13]. The skill set needed to perform such pro- gery with the Zeus Robot was accomplished successfully cedures has made this approach less popular. Consequently, without conversion to laparotomy. Tubal patency was docu- use of the minimally invasive approach, which could obviate mented at the end of the operation [15]. In further work by all these limitations, is desirable. Robotically assisted tubal Falcone et al., a human pilot study with the Zeus robot was reanastomosis appears to be a good alternative to conven- conducted with 10 patients undergoing tubal reanastomosis. tional approaches [14]. The procedure was completed successfully except in one Use of the surgical robot managed to overcome many of patient with dense intraperitoneal adhesions, which allowed the limitations seen with conventional laparoscopy. The first only unilateral access of the tube. There was 100% patency

Table 1. Summary of Literature on Robotic Tubal Reanastmosis Surgery

Author Year Robot Used Number of Robotic Cases Tubal Patency Rate Pregnancy Rate

1 Margossian, 1998 [19] 1998 Zeus System 1 Pig animal 100% -

2 Falcone, 1999 [15] 1999 Zeus System A case Report 100 % Not followed up

3 Degueldre, 2000 [14] 2000 Da Vinci 8 patients 100% 2 of 8 (25%)

4 Falcone, 2000 [18] 2000 Zeus System 10 patients 97.5% 5 of 10 (50%)

5 Goldberg, 2003 [20] 2003 Zeus System 10 patients 89.5% 5 of 10 (50%)

6 Rodgers, 2007 [21] 2007 Da Vinci 26 patients NA 19 pregnancies of 14 patients (61%) (11%) ectopic 16% spontaneous abortion

7 Vlahos, 2007 [22] 2007 Da Vinci 5 patients 100% 4 of 5 (80%)

8 Dharia Patel, 2008 [16] 2008 Da Vinci 18 patients NA (62.5%) (28%) intrauterine (22%) ectopic (11%) sp pregnancy loss Innovative Roles for Surgical Robotics in Reproductive Surgery Current Women’s Health Reviews, 2010, Vol. 6, No. 2 179 in all reanastomosed tubes with a 70 ml mean blood loss. versus x (30%), x (10%) and x (10%), respectively, in the By 12 months, 5 patients (50 %) had achieved pregnancy laparotomy group [16]. [18]. ROBOTICALLY ASSISTED MYOMECTOMY In 2003, Goldberg and Falcone compared 10 patients who underwent robotically assisted tubal reanastomosis The evolution of robotics in gynecologic surgery offered surgery with a control group of 15 patients who underwent the chance for a minimally invasive approach to be used for the same procedure by conventional laparoscopy. Five preg- complicated surgical procedures that were challenging by nancies (50 %) were reported in the robotic group and all conventional laparoscopy. Hysterectomy and colposacro- carried their pregnancies to term. The recorded operative pexy are widely performed with robotic assistance [17, 23] time was significantly longer in the robotic group. A statisti- as are procedures in gynecologic oncology [24]. cally but not clinically significant higher blood loss was Myomectomy remains the best choice of treatment for detected in the robotic group [20]. The Zeus robot is no symptomatic fibroids in patients desiring to preserve their longer available. fertility, even with newer modalities such as uterine artery In 2000, a feasibility study described 8 women who embolization [25, 26]. Open myomectomy was the preferred desired fertility restoration after tubal ligation surgery. Using approach until the emergence of the minimally invasive the da Vinci surgical system, bilateral tubal reanastomosis surgical technique. Laparoscopy was used to perform was performed in all the patients. There was no recorded myomectomy with better cosmesis and shorter postoperative perioperative or postoperative complications. Short and pain and hospital stay but the procedure was highly challeng- long-term follow up data showed patent tubes on HSG ing for the surgeon. With conventional laparoscopy, precise (hysterosalpingogram) in four patients and pregnancy in 2 dissection of the fibroid without unnecessary breaching patients within 4 months after surgery [14]. of the endometrial cavity is key. Moreover, it is necessary to suture the fibroid bed in layers with precise approxima- Rodgers et al., in 2007, compared minilaparotomy as an tion of edges to prevent rupture of the uterus during outpatient procedure with the use of robotics in performing labor [27]. Laparoscopic suturing is a difficult skill to tubal reanastomosis surgery. In 26 patients, the da Vinci master. These challenges limited the acceptance of this robot was used whereas the minilaparotomy was the pre- technique, and open myomectomy remained the approach ferred approach in 40 other patients. The operative time was of choice. longer and costs were higher with the use of robotics. In addition, there was no significant difference between the 2 We reviewed the literature for previous experiences in groups in hospitalization times, but there was a significantly robotic myomectomy 7 studies were identified (Table 2). decreased convalescence time seen in the robotic patients. The first work was reported by Advincula P, et al. in There was no significant difference in pregnancy rates: 61% 2004. This was a preliminary study that included 35 patients of the patients in the robotic group and 79% of patients in the who underwent robotically assisted myomectomy between minilaparotomy group became pregnant. The ectopic preg- 2001 and 2004. The number; weight and diameter of the nancy rate was 11% in the robotic group versus 13% in the removed myomas were recorded. All cases were performed minilaparotomy group. The rate of spontaneous abortion was with the da Vinci Robot the conversion rate to laparotomy 16% in the robotic group and 38 % in the minilaparotomy was 8.6%. The average estimated blood loss was 169 ±198.7 group [21]. ml and the median length of stay was 1 day [27]. In 2007, Vlahos et al. published a study that reviewed 5 A case report was published by Mao SP, et al. in 2007 patients who underwent robotic tubal reanastomosis surgery. that featured a 38-year-old gravida 2 para 2 female patient All procedures were completed successfully without major with an anterior wall subserosal myoma measuring 7x 8 x 9 complications. They also noticed a trend in the time needed cm. The myoma was successfully removed with the use of to prepare for surgery by robot positioning and set up and the da Vinci Robot in 3 hours with an estimated blood loss of perform the robotic surgery both declined as the surgeons 150 ml. There were no recorded adverse events [28]. became more familiar with using the technology. Four of the five patients conceived resulting in two viable pregnancies Bocca S, et al. in 2007 documented for the first time (there was one ectopic pregnancy and a chemical pregnancy an uncomplicated full-term pregnancy in a patient who had that resolved spontaneously) [22]. undergone robotically assisted myomectomy. The surgery was successfully completed with the use of da Vinci robot, Finally, Daharia et al., in 2008, reported on a prospective which removed a 3-cm single fundal intramural uterine study comparing tubal renanastmosis surgery performed via myoma. Approximately four months later, the patient an open technique versus robotic assistance. There were 18 became pregnant after clomiphen citrate and HCG (human patients in the robotic group and 10 patients in the lapa- chorionic gonadotropin) treatment. Delivery of a full-term rotomy group. Although the operative time was significantly healthy baby was done by Caesarian section at 38 weeks longer in the Robotic assistance, these patients needed [29]. less postoperative analgesia and less time to recover. Both approaches had similar overall costs. In the robotic group, In 2007, Advincula et al. compared robotically assisted there were x (28%) intrauterine pregnancies, x (22%) ectopic myomectomy with open myomectomy. This study included pregnancies and x (11%) spontaneous pregnancy losses 58 patients; 29 in the robotic group and 29 in the open group. 180 Current Women’s Health Reviews, 2010, Vol. 6, No. 2 Barakat et al.

Table 2. Summary of Literature on Robotic Myomectomy Surgery

Author Year Number of Type of Study Removed Myomas Results Robotic Cases Weight

1 Advincula 2004 35 Preliminary experience Mean=223.2±244.1 Robotic Myomectomy is AP, et al. [27] g new promising approach

2 Mao SP, 2007 1 Case report Not Available Successful Robotically assisted et al. [28] excision of large uterine myoma measuring 9x8x7 cm

3 Bocca S, 2007 1 Case Report Not Available Achievement of uncomplicated et al. [29] full term pregnancy after robotic myomectomy

4 Advincula 2007 29 Retrospective case matched Mean Robotic myomectomy approach AP, et al. [30] study between robotic and = 227.86±247.54 g is comparable to open approach open myomectomy regarding short term surgical outcome and costs

5 Nezhat C, 2009 15 Retrospective case matched Mean= 116 g Robotic Myomectomy had significant et al. [31] between robotic and Laparo- (min25-max350) g longer surgical time without offering scopic myomectomy any major advantages.

6 George A, 2009 77 Effect of the BMI on the Median =235g Obesity is not a risk factor for et al. [32] surgical outcome (range 21.2-980) g poor surgical outcome in Robotic Myomectomy

7 Bedient CE, 2009 40 Comparing Robotic to Mean 210 g No difference in relation to et al. [33] laparoscopic Myomectomy (range 7-1076) g short term surgical outcome measures.

No statistically significant differences were seen between the 40 patients were in the robotic group and 41 patients were in two groups in regards to age, BMI and weight of the re- the laparoscopic group. No differences were recorded be- moved myomas. The patients in the robotic group had sig- tween the 2 groups regarding the operative time, mean blood nificantly less blood loss and a shorter length of stay but the loss or length of stay. There was a significant difference, Hospital costs were higher in this group. The operative time however, noted in the laparoscopic group they had a larger was longer in the robotic group, but the rate of complications preoperative uterine size, a larger mean size and a larger was higher in the laparotomy group [30]. number of removed fibroids [33].When adjusted for uterine size, there was no difference in regards to intra-operative or More recently, in 2009, Nezhat C, et al. compared 15 postoperative complications. cases of robotically assisted myomectomy with 35 cases of standard laparoscopic myomectomy. No differences were CONCLUSION seen between the 2 groups in regards to patient age, BMI, Robotic surgery has been successfully implemented in parity, and previous abdominopelvic surgery. No significant reproductive surgery. The surgical robot offers 3-D vision, difference was seen between both groups in the size, number improved dexterity, and easier precise suturing, which ap- and location of the removed myomas. However, the mean pears to be critical in fertility preserving surgeries. The sur- surgical time was longer in the robotic group. There were no gical robot can provide the surgeon with the dexterity of an differences between the 2 groups in regards to estimated open approach while keeping the minimally invasive advan- blood loss, length of hospital stay or rate of postoperative tages. The disadvantages of using this technology remain the complications [31]. cost and the bulky size of the robot. Further studies are war- A retrospective data analysis was conducted by George ranted to evaluate the potential role of the robot in random- A, et al. that included 77 cases of robotically assisted myo- ized clinical trials. The cost effectiveness and long-term post mectomy. The aim of this work was to analyze the effect of surgical reproductive outcomes of these surgeries need to be the patients’ BMI on the surgical outcomes of the procedure. critically evaluated. This study recorded no association between patient BMI and short-term surgical outcomes such as length of stay, esti- EXPERT COMMENTARY mated blood loss and length of procedure [32]. The main objective of this article is to review the current Bedient CE, et al., compared robotic and laparoscopic experience of robotic surgery in the field of reproductive myomectomy in a retrospective chart review of 81 patients-- medicine. The robotic approach has been used successfully Innovative Roles for Surgical Robotics in Reproductive Surgery Current Women’s Health Reviews, 2010, Vol. 6, No. 2 181 to perform tubal reanastomosis and myomectomy. The use [5] Satava RM. Robotic surgery: from past to future--a personal of the robot has overcome many of the challenges seen pre- journey. Surg Clin North Am 2003; 83: 1491-500, xii. [6] Advincula AP, Wang K. Evolving role and current state of robotics viously with conventional laparoscopy such as precise in minimally invasive gynecologic surgery. 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Received: January 10, 2010 Revised: February 11, 2010 Accepted: April 15, 2010

Current Women’s Health Reviews, 2010, 6, 183-196 183 Surgical Management of Müllerian Duct Anomalies

Ali M. El Samana,*, Jennifer A. Velottab and Mohamed A. Bedaiwya,b aDepartment of Obstetrics & Gynecology, Assiut University, Assiut, Asyut, Egypt; bDepartment of Obstetrics and Gynecology, University Hospitals Case Medical Center, Case Western Reserve University, Cleveland, OH 44106, USA

Abstract: Developmental anomalies of the müllerian duct system represent an interesting field of disorders in obstetrics and gynecology as they can affect any of the reproductive organs from the Fallopian tubes to the hymen. The purpose of this article is to review the available treatment options for müllerian duct anomalies with special emphasis on simple and advanced surgical approaches. Surgical options are presented based on a novel treatment plan classification system adapted from the American Fertility Society classification of müllerian duct anomalies. Care was taken to include all previously termed unclassified anomalies as well as the important category of longitudinal fusion defects. Important diagnostic approaches are discussed with special emphasis on detection of associated anomalies of the urinary system and other relevant systems. Early establishment of an accurate diagnosis is important for planning management options and preventing complications in the genital organs and surrounding systems. Classifying müllerian anomalies based on the available treatment options seems logical and the inclusion of previously unclassified entities is important for a comprehensive understanding and management of this group of disorders. The surgical approach for the correction of müllerian duct anomalies is individualized to the type of malformation. The value of a given surgical procedure should be assessed on terms of its capability to improve a patient's postoperative ability to have healthy sexual relations and achieve successful reproductive outcomes. Keywords: Müllerian duct anomalies, vaginoplasty, vaginal agenesis, bicornuate uterus, septate uterus, transverse vaginal septum.

INTRODUCTION two sets of paired genital ducts: the müllerian ducts and the wolffian ducts. In females, the wolffian ducts regress, and Developmental anomalies of the müllerian duct system the vestiges provide a template for the developing müllerian represent an interesting spectrum of disorders in obstetrics ducts. This explains the frequent associations observed later and gynecology [1]. The exact prevalence is unknown, and between müllerian defects and renal-urinary system malfor- the present classifications have inherent limitations. The mations [2-4]. The traditional hypothesis maintains that the main objective of current treatment modalities is to conserve müllerian ducts are fused in a caudal-cranial direction. How- or restore all or some of a patient’s reproductive goals. These ever, the müllerian anomalies characterized by a septate goals include restoring menstrual functions through treat- uterus, cervical duplication, and longitudinal vaginal septum ment of crypto menorrhea, which eliminates pain, prevents supports the alternative hypothesis in which fusion of the endometriosis and other consequences, and gives the patient müllerian ducts is segmental and bidirectional [4]. a true chance for natural conception. In other cases where functioning uterine or vaginal tissue are not present, treat- Recent data, both experimental and observational, [2, 5, ment goals are directed towards achieving a normal sexual 6] support early 20th century studies that identified the sino- life via the creation of a neovagina and appropriate psycho- vaginal bulbs as being derived from the caudal aspects of the sexual support. The later field has undergone continuous wolffian ducts and the müllerian ducts. These bulbs were improvement, especially in the past five years—for example, designated as wolffian bulbs. The hymen is a vestige of the patients who have undergone partial or total construction or endodermal membrane that separates the vaginal lumen from reconstruction of the vulvovaginal complex can initiate sex- the UGS cavity; it usually ruptures perinatally and remains ual activity as early as one week after surgery. In the future as a thin mucous membrane [7, 8]. restoration, of full reproductive potentials for those women without functioning endometrial tissues through stem cell Etiological Backgrounds therapy and/or uterine transplant may become possible. The diversity of structural anomalies seen in müllerian duct defects results from interruption or inappropriate regu- Embryological Backgrounds lation in müllerian-duct development at various stages of The genital systems of male and female embryos are morphogenesis. Well-known factors, such as intrauterine and morphologically identical at 6 weeks. Both embryos have extrauterine elements, genetics, and teratogens (eg, diethyl- stilbestrol [DES], thalidomide), have been associated with müllerian duct anomalies [7]. The genetics of müllerian duct *Address correspondence to this author at the Department of Obstetrics & anomalies are complex. In general, they occur sporadically, Gynecology, Assiut University, PO Box 30, Assiut, Asyut, Egypt; Tel: 01120-88-2354488; Fax: 01120-88-2337333; and most familial cases are multifactorial. Other modes of E-mail: [email protected] inheritance, including autosomal dominant, autosomal reces-

1573-4048/10 $55.00+.00 © 2010 Bentham Science Publishers Ltd. 184 Current Women’s Health Reviews, 2010, Vol. 6, No. 2 El Samanet al. sive, and X-linked disorders, also exist. Müllerian anomalies morphogenesis. However, this method is awkward and con- may also represent a component of a multiple malformation fusing. syndrome [9, 10]. The most widely accepted method of categorizing mülle- rian duct anomalies is the American Fertility Society (AFS) Classifications classification [11]. There are some limitations of the AFS The form of classification that includes agenesis or hy- classification, however. We suggest the treatment plan clas- poplasia, lateral fusion defects, vertical fusion defects, and sification, which will be discussed in this article (Table 1). DES-related abnormalities, is not mutually exclusive because many müllerian duct anomalies often coexist. Classify- SURGICAL MANAGEMENT OF MÜLLERIAN DUCT ing müllerian duct anomalies using the method described by ANOMALIES Buttram and Gibbons and others [8, 12-18] bears merit be- According to the treatment plan classification, the surgi- cause it correlates anatomic anomalies with arrests in cal management of müllerian duct anomalies is organized

Table 1. AFS and Treatment Plan Classification of Müllerian Duct Anomalies

Classification AFS Classification Treatment Plan Classification

Class I Agenesis and hypoplasia may involve the vagina, cervix, Class Ia – Affecting Fallopian tubes. Segmental or fundus, tubes, or any combination of these structures. Class Ib - Affecting the uterine fundus. complete agenesis Mayer-Rokitansky-Kuster-Hauser (MRKH) syndrome is the Class Ic- müllerian aplasia (MRKH) syndrome. most common example in this category. or hypoplasia. Class Id- cervical aplasia (isolated or associated with vaginal aplasia). Class Ie- isolated vaginal aplasia.

Class II When an associated horn is present, this class is subdivided Class IIa-Unicornuate uterus without a rudimentary horn. Unicornuate uterus into communicating (continuity with the main uterine cavity Class IIb- Communicating horn with or without with or without a is evident) and noncommunicating (no continuity with the functioning endometrium. rudimentary horn. main uterine cavity). The noncommunicating type is further Class IIc-Non-communicating without functioning endometrium. subdivided on the basis of whether an endometrial cavity is Class IId-Non-communicating with functioning endometrium present in the rudimentary horn. These malformations have previously been classified under asymmetric lateral fusion defects. The clinical significance of this classification is that they are invariably accompanied by ipsilateral renal and ureter agenesis.

Class III Complete or partial duplication of the vagina, cervix, Class IIIa – Partial bicornuate uterus Didelphys uterus. and uterus characterizes this anomaly. Class IIIb - Complete bicornuate 2 separate horns and single cervix. Class IV Class IIIc- Partial duplication with two cervices. Complete or partial Complete bicornuate uterus is characterized by a uterine Class IIId- Complete duplication of the uterus, cervix, and vagina. bicornuate uterus. septum that extends from the fundus to the cervical os. The Class IIIe- any of the above with unilateral or bilateral partial bicornuate uterus. obstruction of menstrual outflow

Class IV A complete or partial midline septum is present Class IVa - A complete or partial midline septum is Complete or within a single uterus. present within a single uterus without fundal depression, partial septate In both variants, the vagina and cervix Class IVb- A complete or partial midline septum is present uterus. each have a single chamber. within a single uterus with fundal depression, Class IVc – Any combination of the above in addition to septate cervix and vagina. Class IVd – Any combination of the above with unilateral or bilateral obstruction.

Class V Not mentioned in the AFS classification. Class Va- partial transverse vaginal septum Longitudinal Class Vb-complete transverse vaginal septum. fusion defects Class Vc- lower segmental vaginal atresia with upper heamtocolpos. Class Vd- imperforate hymen.

Class VI Arcuate A small septate indentation is present at the fundus. Class VI (insignificant & historical anomalies). uterus A T -shaped uterine cavity with or without Class VIa – Arcuate uterus. Class VII DES- dilated horns is evident. Class VIb - DES-related abnormalities related abnormalities Surgical Management of Müllerian Duct Anomalies Current Women’s Health Reviews, 2010, Vol. 6, No. 2 185 based on the anatomical hierarchy of each class. Also in- Treatment of Class I (Segmental or complete agenesis or cluded in the organization is the clinical significance of the hypoplasia) (Table 2- Fig. 1) available interventions as well as the presence or absence of current surgical options. Class Ia – Segmental or Complete Agenesis or Hypoplasia Affecting the Fallopian Tubes For example, the first category includes segmental or complete agenesis or hypoplasia of the tubes, uterus, or va- Congenital fallopian tube disorders are either asympto- gina. According to the anatomical hierarchy presentation, matic or presenting with infertility, ectopic pregnancy or tubal anomalies will be addressed first followed by uterine acute abdominal pain due to torsion of an accessory tube anomalies then cervical and vaginal anomalies. [12-14]. Types of tubal anomalies range from aplasia, hy-

Table 2. Description of AFS and Treatment Plan Classification of Class I Müllerian Duct Anomalies

Classification AFS Classification Treatment Plan Classification

Class I Agenesis and hypoplasia may Class Ia – Segmental or complete agenesis or hypoplasia affecting the Fallopian tubes. involve the vagina, cervix, Class Ib - Segmental or complete agenesis or hypoplasia affecting the uterine fundus. Segmental or complete fundus, tubes, or any combination of Class Ic - müllerian aplasia (Mayer-Rokitansky-Kuster-Hauser (MRKH) syndrome these structures. Mayer-Rokitansky- agenesis or hypoplasia Class Id - cervical aplasia (isolated or associated with vaginal aplasia) Kuster-Hauser (MRKH) syndrome is the most common example Class Ie - isolated vaginal aplasia in this category. Segmental or complete agenesis or hypoplasia affecting the vagina

Subclass Available Treatment Options

Class Ia Microsurgery, open, laparoscopic, robotic reconstruction/excision or ART Class Ib No surgical treatment if the vagina is adequate+ psychosocial support Class Ic Neovagina + appropriate psychosocial Class Id Cervical canalization + utero vaginal anastomosis Class Ie Neovagina + uteroneovaginal anastomosis

Fig. (1). Shows segmental or complete agenesis or hypoplasia affecting the fallopian tubes, uterine fundus, (Class Ib) müllerian aplasia (Mayer-Rokitansky-Kuster-Hauser (MRKH) syndrome, (Class Ic) cervical aplasia (isolated or associated with vaginal aplasia Class Id) and isolated vaginal aplasia (Class Ie). 186 Current Women’s Health Reviews, 2010, Vol. 6, No. 2 El Samanet al. poplasia, non-canalization, segmental atresia, accessory Whereas a number of vaginoplasty methods have been ostia, congenital diverticula, and elongation to accessory developed, refined, and modified, no state-of-the-art surgical tubes and duplication. Few anomalies are amenable to surgi- approach has been established. This is due to a number of cal correction through open microsurgery, laparoscopic mi- factors including regional differences, surgeon experience crosurgery or robotic surgery. Others may require corrective and preference for a method, and patient choice [26, 28, 29]. surgery and or excisions in the event of torsion or ectopic pregnancy. Assisted reproductive technology (ART) repre- The goal of vaginoplasty is to develop a space between sents an important effective backup for uncorrectable iso- the bladder and the rectum. This is followed by grafting– lated tubal anomalies such as aplasia, hypoplasia and non either by a full or split-thickness skin graft. The later has had canalization. high rates of success and patient satisfaction. Scar formation at the graft site has been a concern [30]. Human amnion has Class Ib - Segmental or Complete Agenesis or Hypoplasia also been used as a graft for vaginoplasties. Affecting the Uterine Fundus Transposition flaps have been used successfully in some In cases of isolated uterine aplasia and/or hypoplasia cases. One method is to use a de-epithelialized vulvar trans- with a functioning vagina, there are no treatment options if position flap as the graft. Another method is a pudendal the present vaginal pouch permits adequate marital relations thigh fasciocutaneous flap, which has been described as [1]. having good cosmetic and functional outcomes [31]. Most Class Ic - Müllerian Aplasia (Mayer-Rokitansky-Kuster- recently, a triple flap relying on the use of labia minora Hauser Syndrome) and suburetheral tissue has been reported with high success rates. Vaginal agenesis occurs in 1 out of 4,000-10,000 females. The most common cause of vaginal agenesis is mülle- Autologous buccal mucosa has also been used as a graft rian aplasia or agenesis (Mayer-Rokitansky-Kuster-Hauser source. These approaches used harvested bilateral full- [MRKH] syndrome). The hormonal profile helps distinguish thickness buccal mucosa grafts that are expanded with the MRKH syndrome from androgen insensitivity syndromes several stabs incisions and sutured over a condom-covered [15-17]. soft stent. They are then placed in the newly created space. Trans-abdominal and trans-rectal ultrasonographic and Artificial dermis and absorbable adhesion barriers have MRI findings can add support to the clinical findings and been used as exogenous graft sources in vaginal reconstruc- detect the presence of normal ovaries [18-20]. Fusion of the tion with promising results. An acrylic resin form was cov- cervical vertebrae, a component of Klippel-Feil syndrome, ered with artificial dermis, inserted, and fixed to the newly can result in cervical rigidity that may substantially interfere created vaginal space. The form was usually removed after 7 with the intubation procedure [21]. Discovery of a pelvic days; good results were reported with continued use of the kidney is important in planning corrective surgery because form at nighttime [32]. its presence may limit the potential space available for graft placement [22, 23]. Laparoscopy is confirmatory for diagno- Absorbable adhesion barrier (Interceed; Ethicon, sis and is one of the indispensable methods for treatment [24, Somerville, NJ) was used in a similar technique where 25]. There are three main well known treatment strategies for neovaginal epithelialization was reported in 1-4 months [33-

MRKH syndrome—a fourth one was recently introduced 34]. [26]. The first strategy, and the least invasive one, is the non- A laparotomy procedure for peritoneal mobilization was surgical use of successive dilators, which requires high com- reported in 1969 by Davydov. The peritoneum from the pliance and patience, and good results are achievable over uterorectal space (pouch of Douglas) is advanced in such a months of dilatation only if the patient is sufficiently moti- manner that a vaginal canal is created. Recently, a laparo- vated. The second strategy is the surgical correction via the scopic modification was developed where the peritoneum is creation of a surgical space at the site of the absent vagina. It pulled through the newly created vesicorectal space using is covered with a graft, and then a form is used to maintain high tension and by approximating it at the introitus. A stent the graft. The third strategy is creation of neovagina from is then used for vaginal dilation. There are several benefits of native tissue through traction that is applied from above us- this procedure, including minimal scarring and functional ing an acrylic olive placed on the vaginal dimple vaginas associated with comfortable intercourse [35]. The fourth and newest treatment option is balloon vaginoplasty where traction is applied from above on a silicon Bowel vaginoplasty involving the distal sigmoid colon to coated balloon catheter, creating a natural neovagina over a line the neovaginal space has gained popularity with some shorter period of time [24]. Interestingly, with balloon pediatric surgeons. Classically, this approach requires concomitant laparotomy and bowel anastomosis. However, re- vaginoplasty, there is a possibility of manipulating both the depth as well as the width of the neovagina using different cent reports describe a laparoscopic approach [34, 36, 37]. schedules of catheter traction and balloon distention [25]. Bowel vaginoplasty does not require persistent dilation, and the neovagina is self-lubricating [38]. Any surgical treatment should be well thought-out only when the patient can participate in the decision making The goal of split-thickness grafting is to generate a suffi- wishes to become sexually active [27]. In certain countries, cient space between the urethra and/or bladder. The graft is the operation is only performed after planning for marriage placed over a sterilized stent with the epidermis facing the or after actual marriage [24-26]. surface of the stent and the dermis facing out. The labia mi- Surgical Management of Müllerian Duct Anomalies Current Women’s Health Reviews, 2010, Vol. 6, No. 2 187 nora are sutured around the stent, and, to avoid applying un- and maintained by applying a plastic clamp over a special desirable pressure to the stented graft, the transurethral supporting plate [47, 48]. catheter is replaced with a suprapubic bladder catheter [22, Balloon vaginoplasty was recently introduced by El 39, 40]. Saman et al. using a laparoscopic approach. A silicon coated Continuous, prolonged dilatation and stent care during balloon catheter is manipulated by a specially designed in- the healing phase is important [23]. The patient is educated serter, which is passed transperitoneally and through the pel- to use the form continuously for 6 weeks, removing it only vic floor where the balloon is positioned at the vaginal dim- for urination and defecation. Six weeks later, a silicone form ple. An upward, gradual (1-2cm/day) traction is applied on is used nightly for one year. In most cases, the vagina is the catheter stem from the abdominal side for one week. A functional 6-10 weeks after surgery [22, 39, 40]. concomitant increase in balloon capacity (5ml every other day) to increase the width of the neovagina is also done [26]. Serious complications include postoperative fistula (4% Sexual relations were reported as early as one week after risk) and enterocele [22, 41]. Other complications including surgery [24]. hemorrhage, infection, graft failure, graft contracture and excess granulation tissue have been reported [22]. Rarely, The concept of manipulating the neovaginal depth and primary malignancy of the neovagina has been reported and width is a novel characteristic of balloon vaginoplasty. for this reason, yearly Pap smears are recommended as part The manipulation is done using different distensions and of long-term follow-up care [42, 43]. tractions schedules. This only served to worsen existing dyspareunia. This resulted in more initial dyspareunia com- The Williams vulvovaginoplasty procedure is useful for pared to cases predominant distension. On the other hand, patients with a previously failed vaginoplasty or for patients patients who underwent a predominant increase in the bal- who have undergone radical pelvic surgery in areas where loon distention developed a neovagina that was wide but a other better alternatives are not affordable. The vagina cre- bite shallower, and this resulted in minimal or no initial ated by this approach is not anatomically similar to a normal dyspareunia. With time, both groups showed improvement in vagina as its axis is directly posterior and horizontal to the dyspareunia perineum. However, the vagina is functional and well received by patients, and dilation is required for only 3-4 The idea of retropubic balloon vaginoplasty was born weeks [44]. when a patient with vaginal aplasia was referred to the As- siut University Women Health Center for laparoscopic bal- Native epithelium covered neovaginas are developed loon vaginoplasty. However, because of her past medical and from by expanding the natural epithelium at the dimple. Tis- surgical history, laparoscopy was considered risky due to sue expansion is classically achieved either by pushing from extensive pelvic adhesion. Thus, the retropubic space was below with graduated dilators or by traction from above as in thought to be a safe pass for catheter insertion. Through a the Vecchietti operation and its laparoscopic version. Re- small supra pubic puncture, the catheter inserter was passed cently, a bidirectional (axial and circumferential) tissue ex- into the retropubic space just behind the pubic bone and pansion technique was developed through introduction of guided to the center of the vaginal dimple. Then, a balloon vaginoplasty where axial expansion which increases cystoscopic examination was performed to ensure bladder vaginal length is effected through traction on the catheter and uretheral integrity. This was followed by gradual con- stem and circumferential expansion that increases the trolled distention of the balloon and traction on the catheter neovaginal width is achieved through increasing balloon stem as described in laparoscopic balloon vaginoplasty [49]. distension. A native epithelium covered neovagia is more One inherent limitation of balloon vaginoplasty is the need favorable to one made from foreign tissue. for a customized set of instruments such as the catheter inserter, supporting plate, and vaginometer for assessment of The original Vecchietti operation was developed in 1965. outcomes. The authors of original balloon vaginoplasty Through laparotomy, sutures are attached to the traction de- modified ed their the technique to allow its performance with vice, which are connected to an oval plastic olive placed at conventional laparoscopic instruments and other commer- the vaginal dimple. By gradually increasing suture tension, cially available accessories. The procedure was successfully upward traction and continuous pressure lengthens the preformed with comparable outcomes [24]. neovaginal space over a period of one week. Class Id - Cervical Aplasia (Isolated or Associated with The laparoscopic Vecchietti vaginoplasty (LVV) was Vaginal Aplasia) developed in 1992 with outcomes similar to those of the original technique. The long-term clinical and sexual func- Cervical aplasia and / or hypoplasia are rare but challeng- tion outcomes were evaluated after LVV in 106 patients with ing Müllerian anomalies. Hysterectomy was recommended müllerian aplasia. Sexual function was successfully achieved by some authors when canalization procedures fail or are not in 97% of cases and was comparable with that reported in viable for successful relief of the related symptoms [50]. the control group [45, 46]. Others adopted a conservative policy [50, 51]. Recently, two endoscopic procedures were described. The principal advan- Another procedure is termed transretropubic traction tage is that dissection in atretic areas is not necessary as the (TRT) vaginoplasty. In this procedure, a plastic olive is uterovaginal anastomosis can be established endoscopically. placed on the vaginal dimple and is lifted by a mesh tape The first technique is endoscopically monitored canalization inserted through the space of Retzius and anchored to the of isolated cervical atresia. In this procedure, a special in- anterior abdominal wall. Traction is placed on the mesh tape serter with a silicon drain attached to its caudal end is passed 188 Current Women’s Health Reviews, 2010, Vol. 6, No. 2 El Samanet al. across the uterine fundus to the vaginal pouch. The silicon tioning rudimentary horn. MRI reliably helps make this tubal drain is passed across the aplastic/hypoplastic cervix diagnosis and represents the gold standard diagnostic tool for and fixed securely for one month. The results were promis- all subclasses of unicornuate uterus [18-20, 54-56]. High- ing but more studies are required [52]. The second procedure resolution ultrasonography, intravenous urography and/or is a novel blend of retropubic balloon vaginoplasty and renal ultrasonography assist in the evaluation of ipsilateral laparoscopically monitored canalization, which is applied in renal agenesis, horseshoe kidney, and ipsilateral pelvic patients with combined cervical and vaginal aplasia. The kidney [57]. retropubic balloon vaginoplasty is the fastest way to create a Women with unicornuate uterus subclasses IIa, IIb and neovagina. This was done using upward traction on a silicon IIc (Fig. 2) are not normally considered for reconstruction coated catheter that was placed across the retropubic space to metroplasty [7, 58]. The main indication for surgery is the the vaginal dimple. Another balloon catheter was manipu- presence of functioning endometrium in the accessory horn. lated from below to the distended uterine cavity to drain. Laparoscopic hemihysterectomy of the rudimentary horn is Hematometra; down traction is exerted on the lower uterine the treatment of choice [59-61]. The pedicle of the rudimen- segment. Both up and down tractions are applied for few tary horn is coagulated using bipolar coagulation, and it is days to one week, and the balloons are monitored by trans- excised (scissor excision) along with the ipsilateral Fallopian rectal US when they are suspected of being too close (kissing tube; the functional ovary is not removed. Morcellation may balloons). The final step is utero-neovaginal anastomosis be required when the rudimentary horn is bulky. Successful [53]. pregnancy in the major horn has been reported after laparo- Class Ie - Isolated Vaginal Aplasia: Segmental or Complete scopic removal of the accessory horn. . Agenesis or Hypoplasia Affecting the Vagina Hysteroscopic endometrial ablation of the accessory horn Patients with this class of anomalies present with hema- endometrium as well as hysteroscopic drainage of a hematometra with or without upper hematocolops. This condition tometra in a noncommunicating accessory horn using elec- is treated by uterovestibular anastomosis or vaginoplasty and trocautery to create a communication between the horns has uteroneovaginal anastomosis. Uterovestibular anastomosis is been reported [62, 63]. No specific major complications apart performed via combined abdominal and perineal approaches of those associated with laparoscopy and postsurgical obstet- that mobilize the uterus from above and create the anastomo- ric outcomes have been reported [59, 60]. sis from below. However, the logical management plan should involve creation of a neovagina by any of the afore- Class III - Uterus Didelphys and Bicornuate Uterus mentioned techniques followed by utero-neovagina anasto- Table 4 mosis. Because balloon vaginoplasty is the fastest way to Both a bicornuate and a didelphys uterus arise when mid- create a functional neovagina, it is the first choice of treat- line fusion of the müllerian ducts is arrested [64]. An ex- ment in cases of isolated vaginal aplasia [53]. traordinary capacity of the didelphys uterus is that, in many cases, intercourse is often possible in both vaginas. Moreo- Management of Class II (Unicornuate Uterus) Table 3 ver, simultaneous pregnancies in each uterus can occur, al- Fig. (2) though this is rare. Each pregnancy may be considered a A unicornuate uterus may be not be diagnosed until the separate entity. In fact, a twin may be delivered after a long end of the reproductive years, especially if there is no func-

Table 3. Description of AFS and Treatment Plan Classification of Class II Müllerian Duct Anomalies

Classification AFS Classification Treatment Plan Classification

Class II When an associated horn is present, this class is Class IIa-Unicornuate uterus without a rudimentary horn. subdivided into communicating and noncommuni- When a rudimentary horn is present, (asymmetric lateral cating. The noncommunicating type is further Unicornuate uterus fusion defects) it is classified as follow: subdivided on the basis of whether an endometrial with or without a Class IIb – Communicating horn with or without functioning cavity is present in the rudimentary horn. The rudimentary horn endometrium. clinical significance of this classification is that they are invariably accompanied by ipsilateral Class IIc –Non-communicating without functioning endometrium. renal and ureter agenesis. Class IId –Non-communicating with functioning endometrium.

Subclass Available Treatment Options

Class IIa No surgical treatment Class IIb No surgical treatment vs. excision Class IIc Usually no surgical treatment is required Class IId Laparoscopic hemihysterectomy is required as early as possible. Surgical Management of Müllerian Duct Anomalies Current Women’s Health Reviews, 2010, Vol. 6, No. 2 189

Fig. (2). Shows Unicornuate uterus without a rudimentary horn, (Class IIa) unicornuate uterus with communicating horn,( Class IIb) unicornuate uterus with non-communicating without functioning endometrium.( Class IIc) and unicornuate uterus with non-communicating horn with functioning endometrium (Class IId).

Table 4. Description of AFS (Class III&IV) and Treatment Plan Classification of Müllerian Duct Anomalies

Classification AFS Classification Treatment Plan Classification

Class III Complete or partial duplication of the vagina, Class IIIa – Partial bicornuate uterus (characterized by 2 externally incompletely Didelphys cervix, and uterus characterizes this anomaly separate horns with unified lower uterus and cervix). uterus Complete bicornuate uterus is characterized Class IIIb - Complete bicornuate uterus is characterized by 2 externally & by a uterine septum that extends from the completely separate horns and single cervix. Class IV fundus to the cervical os. The partial bicornuate Class IIIc- Partial duplication with two cervices. uterus demonstrates a septum, which is located Complete or Class IIId- Complete duplication of the uterus, cervix, and vagina. at the fundus. In both variants, the vagina and partial cervix each have a single chamber. Class IIIe- any of the above with unilateral or bilateral obstruction bicornuate of menstrual outflow. uterus

Subclass Available Treatment Options

Class IIIa No surgical treatment, strassman`s metroplasty is rarely if ever required Class IIIb No surgical treatment vs. strassman`s metroplasty in selected cases Class IIIc No surgical treatment vs. strassman`s metroplasty in selected cases Class IIId Excision of vaginal septum +/- strassman`s metroplasty in selected cases Class IIIe Excision of vaginal septum, unification of obstructed hemi uterus is required as early as possible. interval, ranging from 3 hours to 5 days to 8 weeks, after the results of unification surgery, especially for the uterine delivery of its sibling [65-67]. didelphys, may be disappointing. Furthermore, cervical unification is technically difficult and can result in cervical Without obstruction, all subclasses are usually asympto- stenosis or incompetence [70]. matic until menarche. These patients are not candidates for surgical unification. The condition is associated with favor- Management of Class IIIa – Partial Bicornuate Uterus able obstetrical outcomes and usually remains undiagnosed The partial bicornuate uterus is characterized by two until cesarean delivery or other procedures reveal its exis- separate horns with unified lower uterus and cervix originat- tence [39, 68, 69]. Undeniably, some authorities contend that 190 Current Women’s Health Reviews, 2010, Vol. 6, No. 2 El Samanet al. ing from failure of fusion. Its reproductive performance is Class IIIe- any of the above with Unilateral or Bilateral good, and Strassmann metroplasty of the partial bicornuate Obstruction of Menstrual Outflow uterus is very rarely, if ever, required [71]. In hemivaginal obstruction, the clinical presentations are Management of Class IIIb – Complete Bicornuate Uterus variable and depend on the degree of obstruction and

Complete bicornuate uterus rarely requires surgical re- whether the obstruction is complete or incomplete [73]. The obstructed unilateral vagina is a clear indication for resection construction. The condition is associated with favorable ob- of the vaginal septum. Uterine didelphys with obstructed stetrical outcomes and usually remains undiagnosed until unilateral vagina requires full excision and marsupialization cesarean delivery or other procedures reveal its existence of the vaginal septum. After the septum has been excised, [39, 68, 69]. Metroplasty should be reserved for women who laparoscopic evaluation and treatment of associated endome- have a history of recurrent spontaneous abortions, midtri- mester loss, and premature birth and in whom no other etio- triosis, adhesions, or both is recommended [74]. Excision of an obstructing vaginal septum during pregnancy requires logic factor has been identified [58]. The Strassmann proce- leaving an adequate pedicle to help minimize possible bleed- dure removes the septum by wedge resection with subse- ing should the vaginal mucosa retract. In addition, leaving a quent unification of the two cavities. Transabdominal metro- generous pedicle behind allows the surgeon to place hemo- plasty can considerably improve the reproductive perform- static sutures in basal parts of the septum rather than in the ance of women with a bicornuate uterus who have had recurrent spontaneous abortions or premature deliveries before walls of the vagina [39]. surgery [72]. Hemihysterectomy with or without salpingo-oophorectomy is rarely indicated and should be avoided to provide the Management of Class IIIc- Partial Duplication with Two best opportunity for a successful reproductive outcome. Cervices = Didelphys Uterus Favorable obstetrical outcomes were reported in ten intrau- The decision to perform metroplasty should be individu- terine pregnancies. Five resulted in term delivery, four re- alized, and only selected patients with a long history of sulted in preterm delivery, and one resulted in early sponta- recurrent spontaneous abortions or preterm deliveries may neous abortion [74]. benefit from Strassmann metroplasty [70]. Class IV: Complete or Partial Septate Uterus with or Management of Class IIId- Complete Duplication of the without Fundal Depression or Obstruction Table 5 Uterus, Cervix, and Vagina Management of Class IVa - A Complete or Partial Midline The management of a nonobstructing longitudinal sep- Septum is Present within A Single Uterus without Fundal tum is simple and appears to be associated with improve- Depression ment of fecundablity. Excision of the septum allows simultaneous insemination of both hemiuteri during a single act of A uterine septum can be diagnosed by HSG, hystero- coitus. Cold knife/ scissor excision and diathermy excision scopy, and laparoscopy. HSG reveals a 2-chambered uterus. are reported to have similar outcomes. The management of a Laparoscopy can help the surgeon determine whether the nonobstructing longitudinal septum in pregnancy is not clear. fundal contour is normal, which is the best approach for dis- Some authors advocate excision whereas others recommend tinguishing between these entities. The partial septum does leaving it undisturbed unless it becomes obstructing during not extend to the os. In the case of partial septa that is less labor [39]. than 1 cm in length, there are usually no adverse effects on

Table 5. Description of AFS (Class IV) and Treatment Plan Classification of Class IV Müllerian Duct Anomalies

Classification AFS Classification Treatment Plan Classification

Class V A complete or partial Class IVa - A complete or partial midline septum is present within a single uterus without fundal depression, Complete midline septum is Class IVb- A complete or partial midline septum is present within a single uterus with fundal depression, or partial present within a Class IVc – Any combination of the above in addition to septate cervix and vagina. septate uterus single uterus.. Class IVd – Any combination of the above with unilateral or bilateral obstruction.

Subclass of TP Available Treatment Options Classification

Class IVa Hysteroscopic metroplasty is usually required with or without laparoscopy Class IVb Hysteroscopic metroplasty is usually required with concomitant laparoscopy Class IVc Excision of vaginal septum & hysteroscopic metroplasty with concomitant laparoscopy Class IVd Excision of vaginal septum, unification of obstructed hemi uterus is required as early as possible followed by hysteroscopic metroplasty. Surgical Management of Müllerian Duct Anomalies Current Women’s Health Reviews, 2010, Vol. 6, No. 2 191 reproductive outcomes, and operative intervention is not and it can be performed in an outpatient setting. In addition, indicated based on data obtained from residual septa after it allows for subsequent vaginal delivery [89]. hysteroscopic metroplasty [75]. Not all women with a partial Management of Class IVd – Any Combination of the septate uterus require surgery. However, those with recurrent Septate Uterus, Cervix and Vagina with Unilateral or spontaneous abortions, a single second-trimester loss, or Bilateral Obstruction of Menstrual Outflow histories of preterm delivery are considered candidates for correction [76-78]. An obstructed unilateral vagina is a clear indication for resection of the vaginal septum. A septate uterus with an Hysteroscopic metroplasty with concurrent laparoscopy obstructed unilateral vagina requires full excision and mar- is the state-of-the-art treatment plan [75, 79]. Laparoscopy supialization of the vaginal septum. After the septum has helps reduce the risk of uterine perforation and diagnose associated pelvic pathology [80]. As an alternative, ultra- been excised, laparoscopic evaluation and treatment of associated endometriosis, adhesions, or both is recommended sonographic guidance has been used as a monitoring tool for [74]. javascript:showcontent('active','references'); Excision hysteroscopic metroplasty [81]. Hysteroscopic metroplasty of an obstructing vaginal septum during pregnancy requires can be performed by using microscissors, electrosurgery, or the same precautions as mentioned for obstruction of a laser. Thick septa with broad base are best excised with a hemivagina uterine didelphys [39]. However, definitive re- resectoscope using monopolar or bipolar diathermy. In the septate uterus with cervical extension, the cervical portion is section of a cervicouterine extension of the septum. incised at the proximal aspect using Metzenbaum scissors, Class V Longitudinal Fusion Defects Table 6 laser, or needle electrode followed by hysteroscopic metroplasty [82]. Division of the septum is considered complete This important class represents a group of defects that when the hysteroscope can be moved freely from one cor- are not classified by the AFS system. Appropriate timely nual end to the other without obstruction [80, 82]. diagnosis and management will alleviate many unfavorable consequences on the reproductive organs. Fortunately, this Class IVb - A Complete or Partial Midline Septum is group of defects is amenable to complete surgical correction. Present within A Single Uterus with Fundal Depression Class Va- Partial Transverse Vaginal Septum The fundal depression in this subclass results from incomplete fusion of the paramesonephric ducts at the fundus. Incomplete transverse vaginal septum (TVS) allows Failure of resorption in the remaining part makes the down menstrual flow to escape periodically, but hematocolpos and prolongation of the dividing septum. Its presentation and hematometra often develop over time. Complaints include diagnosis is the same as that of the septate uterus. On laparo- foul-smelling vaginal discharge, dyspareunia secondary to scopy, there is a shallow fundal depression. However, confu- a short vagina, and infertility. The existence and severity sion may result by relying on the anatomic appearance of the of the above mentioned symptoms varies according to external uterine fundus without correlating the depth of fun- the caliber of the opening. In addition, TVS can cause soft dal depression with the depth of the internal division. Thus, tissue dystocia in patients who eventually become pregnant it is important to incorporate the results of other investiga- [90]. tions (MRI, US & HSG) with the laparoscopic appearance. Definitive resection of an incomplete transverse vaginal The depth of the groove and length of the uterine septum septum is not required often. However, this anatomic con- depend in the adult uterus on the length of the incompletely genital defect may contribute to primary infertility [91]. Di- fused müllerian ducts in the fetus. Symptomatic cases with lation under anesthesia followed by regular dilation is suffi- this disorder are candidates of hysteroscopic metroplasty but cient for patients who experience difficult or painful coitus. are at a greater risk of perforation. The use of laparoscopy In other cases where symptoms are inadequately addressed for monitoring is important for avoiding uterine perforation. with dilation alone, definitive resection is required. Asymp- Reproductive performance appears to be considerably tomatic cases may manifest themselves for the first time dur- improved after surgery [82-87]. javascript:showcontent ing delivery where a generous episiotomy may be needed for ('active','references');. Cervical laceration during instrumen- a low-seated vaginal septa. High seated and thick septa, tation, blood loss, postoperative hemorrhage and uterine rup- especially those involving a long segment of the upper third ture during a subsequent pregnancy are infrequently reported of the vagina, are best managed by cesarean section with complications [85, 88]. definitive management accomplished at a later time [92, 93]. Class IVc – Any Combination of the above in Addition to Class Vb-Complete Transverse Vaginal Septum Septate Cervix and Vagina TVS can occur at nearly all levels in the vagina, but most Excision of the vaginal septum is done either by cold of these septa are located in the superior vagina [94]. Be- knife/scissor division or diathermy resection. The decision to cause management of a transverse vaginal septum is more perform metroplasty should be individualized; only selected technically difficult, treatment should occur at a tertiary-care patients with a long history of recurrent spontaneous abor- center with a qualified surgical team. Cases presenting with tions or preterm deliveries may benefit from hysteroscopic acute pain can be treated with laparoscopic drainage, which metroplasty [70]. Hysteroscopic metroplasty is less morbid provides a novel approach to the acute management of a than abdominal metroplasty which is cost-effective and as- transverse vaginal septum, providing pain relief without sociated with limited risk of pelvic adhesions. Recovery is compromising the success of definitive surgery that can be rapid with no prolonged postoperative delay in conception, performed at a later date [95]. Cases with concurrent imper- 192 Current Women’s Health Reviews, 2010, Vol. 6, No. 2 El Samanet al.

Table 6. Description Treatment Plan Classification of Class V Müllerian Duct Anomalies (longitudinal fusion defects) which is not Classified by the AFS

Classification AFS Classification Treatment Plan Classification

Class V Not mentioned Class Va- partial transverse vaginal septum Longitudinal fusion defects Class Vb-complete transverse vaginal septum. Class Vc- lower segmental vaginal atresia with upper heamtocolpos. Class Vd- imperforate hymen

Subclass Available Treatment Options

Class Va No surgical treatment, vs. dilatation v. excision. Class Vb Adequate surgical excision. Class Vc Adequate surgical excision & end to end anastomosis +/- vaginoplasty. Class Vd Hymenectomy, hymenotomy, or circular excision to preserve hymeneal structural integrity in certain societies forate hymen and transverse complete vaginal septum have quired. Other techniques used for the creation of neovaginas been reported [95, 97]. could be used for treatment of this rare condition. Some surgeons have difficulty connecting the neovagina to the Excision of the septum should be performed under tran- superior functioning vagina. After surgical correction, most sabdominal or transrectal ultrasound guidance. The widest patients can expect normal reproductive outcomes. possible excision should be made by making two crossing X- shaped incisions followed by excision of the four margins. Class Vd- Imperforate Hymen Careful approximation of the upper (proximal) and lower Imperforate hymen is a simple but often overlooked di- (distal) edges at the base of the cut septum with fine delayed agnosis. It was found in 9.8% of 81 cases with vaginal absorbable sutures is important in preventing recurrence anomalies [107-109]. Early diagnosis of the imperforate hy- [98]. men and timely optimized interventions are of fundamental Cyclical hematuria is a rare presentation of transverse importance in prevention of the largest part of its related vaginal septum and occurs by menstrual blood flow out of complications [110-115]. the lower urinary tract because of a vesical-vaginal commu- Premenarchal girls with asymptomatic cases diagnosed nication. One treatment that has been reported for this condi- on routine inspection of the external genitalia [116] are best tion is reconstruction using a transvaginal and transabdomi- treated conservatively and followed up till puberty where nal approach to create a direct anastomosis between the definitive treatment can be implemented. However, cases proximal vaginal segment and the distal vaginal pouch [99]. presenting with mucolops or hydrocolops are treated at the Class Vc- Lower Segmental Vaginal Atresia with Hemato- time of presentation to avoid two important complications; colpos infection and conversion into pyocoplos and urinary tract obstruction [117, 118]. Traditionally, imperforate hymen is Vaginal atresia occurs when the urogenital sinus (UGS) treated with two perpendicular or X-shaped hymenotomy fails to contribute to the inferior portion of the vagina. The incisions followed by complete excision. However, the im- müllerian structures are usually normal, but fibrous tissue completely replaces the inferior segment of the vagina. Non- portance of the integrity of hymen varies in different cultures and hymen sparing procedures are willingly preferred by surgical methods may be recommended as the first approach many patients and families in many countries [108, 119, 120, in managing vaginal atresia. When nonsurgical methods fail, 121]. surgical approaches are recommended. Children with this anomaly may develop pyometrocolpos and present with ob- Class VI - Insignificant and Historical Anomalies Table 7 structive uropathy, septicemia, or renal failure [100-102]. Transperineal ultrasonography reveals the presence of ova- This class is further subdivided into 2 subclasses: VIa- ries, a uterus, a cervix, and an obstructed blind-ending supe- Arcuate uterus, a small septate indentation is present at the rior vagina. All of these features distinguish vaginal atresia fundus, and VIb- DES-related abnormalities. from vaginal agenesis [102, 103]. MRI can aid in detecting The arcuate uterus represents an insignificant anomaly the presence of a cervix, which should distinguish this that results from near-complete resorption of the uterovagi- anomaly from cervical agenesis, which is quite rare [104]. nal septum. It is characterized by a small intrauterine inden- Segmental atresias usually require some form of push tation shorter than 1 cm and located in the fundal region. It is through or pull through vaginoplasty or reconstructive sur- the most commonly observed uterine anomaly detected by gery to cover the raw area created from excision of long HSG [122, 123]. It is a clinically benign anomaly--adverse atretic segments [105, 106]. In extreme cases of segmental obstetric outcomes are rare-- and it may not affect reproduc- vaginal atresia, retropubic balloon vaginoplasty may be re- tive outcomes [69, 122]. HSG reveals a single uterine cavity Surgical Management of Müllerian Duct Anomalies Current Women’s Health Reviews, 2010, Vol. 6, No. 2 193

Table 7. Description of AFS and Treatment Plan Classification of Class VI Müllerian Duct Anomalies

Classification AFS Classification Treatment Plan Classification

Class VI A small septate indentation is present at the fundus. Both are put in one class (insignificant and historical anomalies) Arcuate uterus & A T -shaped uterine cavity with or without dilated Class VIa – Arcuate uterus Class VII horns is evident. Class VIb - DES-related abnormalities DES-related abnormalities

Subclass Available Treatment Options

Class VIa No surgical treatment, hysteroscopic metroplasty is not usually , required Class VIb No surgical treatment, hysteroscopic correction is usually not required with a saddle-shaped fundal indentation. MRI findings show tion) should be adopted as they are technically simple to per- convex or flat external uterine contour. The indentation is form and safety and have a high efficacy. broad and smooth. Aberrant vascularity within the fundal Fertility preserving procedures should be adopted, re- myometrium has been suggested [122, 124]. Arcuate uterus fined and offered to cases with MDAs as a first choice rarely, if ever, requires surgical correction. It may be man- treatment options. aged similarly to septate uterus, but only in selected patients who fulfill poor reproductive performance criteria after Expert Commentary: The past five years have seen the exclusion of all other factors. introduction of balloon vaginoplasty where postoperative dilatation was not needed and sexual activity could be initiated as early as on the day of discharge from hospital (one CONCLUSION week after surgery). Compared to other procedures, this is Early establishment of an accurate diagnosis is indispen- considered a great advance in management of vaginal aplasia sable for planning treatment and preventing complications in where vaginal functions were initially achieved only after the genital organs and surrounding systems. Classifying months of postoperative care. Also, the vagina created by müllerian anomalies based on the available treatment options balloon vaginoplasty mimics the natural vagina and repre- seems logical, and the inclusion of previously unclassified sents an excellent choice for cases with cervical aplasia asso- entities is important for comprehensive understanding and ciated with vaginal apalsia where in these cases a utero- management of this group of disorders. The surgical ap- neovaginal anastomosis represents an attractive, effective proach for correction of müllerian duct anomalies is indi- and logical management option. . We hope the future carries vidualized to the type of malformation. The value of a given more benefits for cases with MDAs through blends of trac- surgical procedure should be assessed on terms of its ability tion/ distension vaginoplasty, refined corrective surgeries, to improve a patient's postoperative ability to have healthy uterine transplants and stem cell therapy. sexual relations and achieve successful reproductive outcomes. REFERENCES [1] Breech LL, Laufer MR. Mullerian anomalies. Obstet Gynecol Clin Key Points North Am 2009; 36: 47-68. [2] Lindenman E, Shepard MK, Pescovitz OH. Mullerian agenesis: an Mullerian duct anomalies (MDA) represent an open update. Obstet Gynecol 1997; 90: 307-12. ended spectrum of disorders that present either in isolation [3] Chang AS, Siegel CL, Moley KH, Ratts VS, Odem RR. Septate (affecting one organ e.g. tubes, uterus, cervix or vagina), in uterus with cervical duplication and longitudinal vaginal septum: a combination (affecting more than one organ) or in associa- report of five new cases. Fertil Steril 2004; 81: 1133-6. tions with other body systems anomalies (renal, skeletal, [4] Duffy DA, Nulsen J, Maier D, Schmidt D, Benadiva C. Septate uterus with cervical duplication: a full-term delivery after resection etc). of a vaginal septum. Fertil Steril 2004; 81: 1125-6. Appropriate and early diagnosis of MDA is of special [5] Hashimoto R. Development of the human Mullerian duct in the sexually undifferentiated stage. Anat Rec A Discov Mol Cell Evol importance in the prevention of complications. The diagnos- Biol 2003; 272: 514-9. tic workup should include a search for associated anomalies [6] Lee DM, Osathanondh R, Yeh J. Localization of Bcl-2 in the and complications. human fetal mullerian tract. Fertil Steril 1998; 70: 135-40. [7] Golan A, Langer R, Bukovsky I, Caspi E. Congenital anomalies of Treatment should be individualized, and only sympto- the mullerian system. Fertil Steril 1989; 51: 747-55. matic cases with poor reproductive outcomes should be con- [8] Acien P. Embryological observations on the female genital tract. sidered for surgical correction. Obstructive cases are given a Hum Reprod 1992; 7: 437-45. [9] Carson SA, Simpson JL, Malinak LR, et al. Heritable aspects of unique priority for earliest corrective interventions. Simpli- uterine anomalies. II. Genetic analysis of Mullerian aplasia. Fertil fied approaches for treatment of vaginal aplasia (e.g.balloon Steril 1983; 40: 86-90. vaginoplasty) and cervical atresia (e.g endoscopic canaliza- 194 Current Women’s Health Reviews, 2010, Vol. 6, No. 2 El Samanet al.

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Received: January 10, 2010 Revised: March 08, 2010 Accepted: April 15, 2010