1 Centrum Clinic, 2 Gülhane School of Medicine, Department of Obstetrics and Gynecology, Division of Reproductive Endocrinology and Infertility and 3 Zekai Tahir Burak Womens Health and Education Hospital, Department of Prenatal Diagnosis and Genetics, Ankara, Turkey 06700
4 To whom correspondence should be addressed at: Centrum Clinic, Nenehatun, No: 59 GOP, Ankara, Turkey 06700. e-mail: gogsenonalan{at}yahoo.com
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Abstract |
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Key words: cyclic AMP/empty follicle syndrome/ICSI/IVF
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Introduction |
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Congenital deafness (70% non-syndromic, 30% syndromic), occurs in approximately one in 1000 live births and 50% of these cases are hereditary (85% of these cases have autosomal recessive transmission while 1215% have an autosomal dominant form, X-linked forms represent 13%). There has been a tremendous progress in research on the genetic basis of deafness and mutations in 10 different genes for non-syndromic deafness have been identified since 1997. The GBJ2 gene encoding for gap junction protein connexin-26 (CX 26) has a high prevalence (one deaf person among 1765 people) and has been established as a common cause of autosomal recessive non-syndromic hearing loss. The identification of mutation in the GBJ2 gene should be a practical proposition for screening deafness (Lefebvre and Van De Water, 2000
).
The aim of the present report is to highlight the possibility of genetic factors that could be responsible for some cases of EFS or even unexplained infertility. To the best of our knowledge, this is the first reported case of two sisters with sensorineural deafness having EFS in three IVF/ICSI cycles despite the rescue trial of follicles with second hCG injection.
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Case report |
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The patients sister was 32 years old, with 14 years of primary infertility history. Two cycles of ICSI were tried with an interval of 3 months with a diagnosis of unexplained infertility; however both of the cycles resulted in EFS. During the first trial of ICSI, on day 2 of spontaneous cycle, FSH and E2 levels were 7 mIU/ml and 60 pg/ml respectively. Leuprolide acetate (0.1 mg/day, s.c.) was initiated from day 21 of the cycle preceding COH and recombinant FSH (rFSH) (300 IU/day, i.m.) was started on day 3 of the subsequent cycle. E2 levels were 149, 458 and 1152 pg/ml on days 4, 6 and 8 of stimulation respectively. On the day of hCG injection, the levels for E2, progesterone and LH were 1722 pg/ml, 2 ng/ml and 1.2 IU/ml respectively. hCG (10 000 IU) was administered for ovulation triggering on day 10 of stimulation. Serum hCG and E2 levels were 294 mIU/ml and 1626 pg/ml, 12 h post hCG. Total number of follicles was 10 in both ovaries (3, 18 mm in the left ovary). When we aspirated three mature follicles from the right ovary, neither oocytes, nor cumuluscorona complexes were recovered and hCG level was 351 mIU/ml at that time. After careful interrogation of the patient we could not find any drug-related problem. Thirty-five hours after the second administration of hCG (10 000 IU) for possible rescue, we could not recover either oocytes or granulosa cells from the left ovary. A second cycle was performed after the first attempt. On day 2 of spontaneous cycle, FSH and E2 levels were 6.3 mIU/ml and 20 pg/ml respectively. Pituitary desensitization was achieved by triptorelein (0.1 mg, Decapeptyl®, Ferring) given 0.05 mg s.c. from day 21 of the previous cycle and rFSH (450 IU day, s.c.) was started on day 3 of the subsequent cycle. E2 levels were 388 and 1537 pg/ml on days 5 and 9 of stimulation respectively. hCG (10 000 IU) was administered on day 10 of stimulation with E2, progesterone and LH levels of 1598 pg/ml, 0.9 ng/ml and 1.1 IU/ml respectively. E2 level was 1357 pg/ml, 12 h post hCG and serum hCG level was 300 mIU/ml. Total number of follicles was 9 in both ovaries (4,
18 mm leading follicles in the right ovary; 5,
18 mm leading follicles in the left ovary). When follicular aspiration was performed from the left ovary, neither oocytes, nor granulosa cells were recovered again. hCG plasma level was 262 IU/ml, at that time. Despite detecting bioavailable hCG in plasma, hCG (10 000 IU) was administered for a second time. We did not recover any oocyte by aspiration of the right ovary, 24 h later. Follicular fluid levels of steroids, hCG, LH and inhibin B in three cycles are presented in Table I.
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Both couples had normal peripheral blood karyotypes and there was no evidence of hypogonadotrophic hypogonadism, history of anosmia, primary amenorrhoea and systemic disorders or neurological defect. During all three cycles, in the two sisters, there was normal follicular development, E2 levels and bio-available hCG plasma levels. No oocytes and cumuluscorona complexes were retrieved, despite the second hCG injections, and subsequently no obtain cumuluscorona complexes were available for tissue culture.
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Discussion |
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The surrogate LH surge of administered hCG has overall similar effects on follicular development. Poor quality of the drug, improper dosage or timing of hCG administration may result in an iatrogenic EFS. Ndukwe et al. (1997) reported their cure for EFS and suggested a second attempt of collection after an extra bolus of hCG if the circulating levels of hCG were <10 IU/ml and oocytes were not retrieved from the first ovary. However, Awonuga et al. (1998
) demonstrated that normal bioavailability of
hCG on the day of oocyte recovery does not exclude the diagnosis of EFS. Recent reports (Meniru and Craft, 1997
; Hassan et al., 1998
) suggested that some patients may need a longer exposure to hCG for the detachment of oocytecumulus complexes from the follicle wall. In our cases, the longer exposure to hCG was the rationale of waiting for 35 h before the second oocyte aspiration (rescue protocol).
In all three IVF cycles we aspirated the follicles from one ovary only and made a second attempt on the other ovary later, following a second hCG injection. The rationale for this approach was to increase the possibility of positive outcome with a second hCG injection. Considering IVF cycles as expensive and long-term therapies for the patients, we tried to increase the chances on the behalf of the patients in each cycle. Lack of oocytes and granulosa cells from the other ovary following second hCG injection confirmed our initial diagnosis of EFS.
EFS has been suggested to be a manifestation of ovarian dysfunction (Awonuga et al., 1998) and to represent an advanced stage of ovarian ageing (Ben-Shlomo et al., 1991
; Zreik et al., 2000
). Zreik et al. reported that there were no differences between the number of leading follicles of EFS and normal cycles in the same patient; however lower estradiol concentrations were observed on the day of hCG injection in EFS cases. Interestingly, this finding was also significant 2 days after the oocyte retrieval. They also found that no patient <34 years old had a recurrent EFS cycle. They suggested that the hampered granulosa cell function and/or metabolism led to altered oocyte growth and maturation and consequently to EFS.
In our cases with EFS, serum E2, progesterone and LH levels on the day of hCG administration eliminate the possibility of early luteinization, premature ovulation and improper timing of hCG injection. Follicular fluid levels of steroids, hCG, LH and inhibin B in three cycles indicate that the follicles were neither atretic nor prematurely luteinized.
Overall infertility is not accepted as an inherited condition, however recent genetic studies have revealed that hereditary factors might be involved in the pathogenesis of subfertility and infertility. EFS in two sisters may result from either genetic origin or environmental factors; however hearing loss accompanied by EFS in two sisters with no history of hearing loss in other family members directed us to a genetic origin. To rule out the most frequent cause of non-syndromic hearing loss, we examined two sisters for the GBJ2 gene encoding connexin 26 and we found no mutations. To our knowledge, there are no data about inherited conditions of EFS and hereditary type of syndromic hearing loss associated with other system abnormalities. Perraults syndrome, an autosomal recessive disorder, is associated with ovarian dysgenesis and sensorineural hearing loss. In some cases of Perraults syndrome additional neurological findings (ataxia, nystagmus, sensory polyneuropathy) were reported (Cristiakos et al., 1969; Bozse et al., 1983
); however the major finding was ovarian dysgenesis, hence our cases are not consistent with Perraults syndrome. Another interesting case was reported by Lorda-Sanchez et al. consisting of sensorineural deafness, premature ovarian failure and chorioderma. Aetiology of this case was reported as balanced X-4 translocation where the breakpoint was within the critical region (Xq1326) (Lorda-Sanchez et al., 2000
). X-autosomal translocation causes disruption of the structural coding or regulatory sequences of the gene(s) or submicroscopic deletion of the region leading to a contiguous gene deletion syndrome. As described in this report, our cases could be a contiguous gene syndrome due to a deletion in a critical region or another region related to these symptoms. It can also be related to defect of a gene producing a protein that affect both granulosa cells and hearing function. As the parents are not relatives, autosomal dominant inheritance with reduced penetrance and/or expressivity, X-linked inheritance, or multifactorial inheritance are possible. Autosomal recessive inheritance can also be considered. A gene defect in EFS may cause rapid dysfunction of granulosa cells leading to disordered periovulatory events. cAMP level is a potential modulator of granulosa cell function. Gonadotrophins regulate granulosa cell function primarily by altering the expression of cAMP-responsive genes involved in the regulation of cell proliferation, differentiation and apoptosis (Hillier et al., 1996
). The underlying pathology of EFS may be related to post-receptor signalling system-cAMP that induces the expression of apoptosis genes too early, leading to rapid apoptosis before ovulation or deposition of an appropriate hyaluranic acid matrix for the free-floating of oocytecumulus cell mass. In our cases, molecular studies and clinical follow-up are necessary to establish premature ovarian failure. EFS is thought by some to be a drug-related phenomenonpharmaceutical industry syndrome which is curable with a second hCG injection. In this paper, we concluded that EFS may result from a genetic disorder. Both EFS and moderate deafness may be part of a syndrome resulting from a single gene defect or a contiguous gene syndrome representing a new syndrome. These are the first EFS cases reported with moderate deafness. A number of similar cases, molecular studies and clinical follow-up are necessary in order to confirm or refute the hypothesis of a genetic aetiology of EFS.
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Acknowledgement |
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Submitted on August 12, 2002; resubmitted on March 5, 2003; accepted on May 21, 2003.