1 The Infertility Clinic of the Family Federation of Finland in Helsinki and 2 Oulu, 3 Department of Gynaecology and Obstetrics and 4 Department of Clinical Genetics, Helsinki University Central Hospital, Helsinki, Finland and 5 Department of Obstetrics and Gynaecology, Karolinska Institutet, Huddinge University Hospital, Sweden
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Abstract |
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Key words: FSH receptor/mutation/oocyte donation/ovary/pregnancy
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Introduction |
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As some of the women with FSHR mutations were relatively young, and there was an ongoing oocyte donation programme, this treatment was offered to the women in the two units of the Infertility Clinic of the Family Federation of Finland, in Helsinki and Oulu. In addition, our units also have ample experience of using this treatment in individuals with ovarian failure from other causes (Söderström-Anttila et al., 2001).
Oocyte recipients often differ from traditional IVF patients as regards the cause of infertility and endocrine background. Recipients with ovarian failure appear to have a higher incidence of complications, such as first trimester bleeding, intrauterine growth retardation and pre-eclampsia than women with functioning ovaries (Abdalla et al., 1990;Söderström-Anttila, 2001
). Although previous studies have shown that oocyte donation treatment is successful in individuals with primary amenorrhoea, it was not known if the lack of FSH action would interfere with the outcome of pregnancy, and therefore it was important to analyse the obstetrical and perinatal outcome of these pregnancies.
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Materials and methods |
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A total of 12 women, mean age 33 years (SD 4.9, range 2647) at the beginning of the treatment, underwent 15 embryo transfers with fresh embryos and 13 transfers with frozenthawed embryos.
The oocyte donors were healthy unpaid volunteers, <35 years of age, who were recruited through the media. The donors underwent down-regulation using intra-nasal buserelin (Suprecur; Hoechst, Frankfurt, Germany), 1200 µg daily, and menopausal gonadotrophin (Pergonal or Fertinorm HP; Serono Nordic, Finland) or FSH (Gonal F; Serono) was given for ovarian stimulation at 150300 IU/day until the leading follicles were 18 mm in diameter. The oocytes were retrieved using trans-vaginal ultrasound-guided puncture. They were inseminated with the recipient's spouse's sperm or injected with spouse's spermatozoa (ICSI, 1 treatment) depending on sperm quality.
The women with the FSHR mutation were treated with hormone replacement therapy (HRT) using 24 mg estradiol valerate (Progynova; Leiras, Turku, Finland) and 20 mg medroxyprogesterone acetate (Gestapuran; Lövens, Ballerup, Denmark) daily to induce menstrual cycles and to prime receptive endometrium before the actual transfer cycle. If the endometrium was <7 mm thick during a test cycle, the dose of estradiol was increased to 6 mg daily. During the planned transfer cycle, bleeding was induced to occur at the same time as the potential donor started her stimulation. Estradiol at 46 mg daily was used, and the thickness of the endometrium was monitored after 1012 days. On the day of oocyte retrieval from the donor, the recipient started intra-vaginal micronized progesterone (Lugesteron; Leiras, Tampere, Finland), 600 mg daily.
Embryo transfer was carried out 2 days after fertilization. The HRT using estradiol and progesterone was continued until a pregnancy test was carried out 2 weeks after the transfer. If the result was positive, HRT was continued until week 12 of pregnancy.
Usually only two embryos, and more recently only one embryo, were transferred at a time. At the beginning of the programme, some women received three fresh embryos, and one received three frozenthawed embryos. All additional embryos were frozen using propanediol-sucrose as a cryoprotectant for possible treatment during later cycles. If the woman did not have an optimal endometrium, or there were problems in timing, all the embryos were frozen, and frozenthawed embryos were transferred later. In cycles for frozenthawed embryo transfer, similar estradiol valerate substitution was given, and vaginal micronized progesterone was started 2 days prior to embryo transfer. The embryos were thawed on the day of transfer.
Surveillance of the pregnancies was initiated with a first ultrasound scan at 5 weeks after embryo transfer. Follow-up was then continued in collaboration with the maternity unit of the teaching hospital to which each woman belonged. Data regarding the pregnancies and deliveries were collected by the units. To follow up the health of the children, all families have voluntarily been in contact with the infertility units of the Family Federation of Finland.
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Results |
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Discussion |
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FSH is the central hormone of human reproduction. It acts by binding to specific receptors localized exclusively in the gonads. In the female, FSH binding has been localized to the granulosa cells (Simoni et al., 1997). Recent reports have indicated the possible presence of FSHR protein and mRNA in cultures of human myometrial smooth muscle cells (Kornyei et al., 1996
). Thus, it might be possible that FSH exerts its action also in other female reproductive tissues, including decidua and placenta. This localization is in contrast with the expression pattern observed for the LH receptor, which can be demonstrated in a variety of tissues. The subjects with the FSHR mutation appear to have normal LH action, but they have high circulating LH concentrations.
The pregnancies of these women were not without complications. However, the problems seen in our subjects were typical of pregnancies resulting from donated oocytes (Abdalla et al., 1990; Sauer and Paulson, 1990
; Pados et al., 1992
; Söderström-Anttila et al., 1998
;Söderström-Anttila, 2001
). Women with an FSHR defect are generally healthier than those having Turner's syndrome, but we have obtained similarly good pregnancy results (22 pregnancies in 18 individuals) with some pregnancy complications (pre-eclampsia and hypertension) among women with Turner's syndrome (Foudila et al., 1999
; Hovatta, 1999
). The mild pre-eclampsia, gestational diabetes, and premature rupture of the membranes with pulmonary embolism were all different types of complication. They were probably more associated with oocyte donation treatment than with the FSHR mutation.
Although the Finnish-type FSHR mutation seems to be rare in other populations, new inactivating mutations have been identified in subjects from other countries (Beau et al., 1998; Touraine et al., 1999
). It is important to note that women who have these mutations, and probably also other genetic causes of ovarian failure, can be successfully helped using donated oocytes. Women with the FSHR mutation, however, differ from many other women with primary ovarian failure in having primary and occasionally early secondary follicles in their ovaries (Aittomäki et al., 1996
).
In the future, in-vitro maturation of oocytes from ovarian cortical tissue might enable the treatment of these women, using their own oocytes. Cryopreservation of human ovarian tissue is already feasible (Hovatta et al., 1996; Newton et al., 1996
). Ovarian cortical tissue might hence be cryopreserved at a young age, and oocytes matured at the time when the woman desires children. Fresh ovarian tissue could also be used if the woman is young enough to have good numbers of follicles at that time.
To obtain mature oocytes from ovarian tissue without FSH activity is a challenging task. In the mouse, mature oocytes and one live, though not healthy, pup have already been obtained starting from primordial follicles (Eppig and O'Brien, 1996). In humans, primordial follicles can be regularly cultured to secondary, and occasionally to early antral, stage when ovarian cortical tissue slices are cultured within extracellular matrix (Hovatta et al., 1999
), but improvements in culturing oocytes are needed before meiotically competent oocytes are obtained, which could then be matured for fertilization. However, even if this could be achieved with donated normal tissue, it may not be feasible with FSHR-deficient follicles, as FSH probably regulates the expression of a number of genes in the granulosa cells, the target cells of FSH action in developing follicles. This is of relevance for oocyte maturation, as important interactions are likely to occur between the oocyte and granulosa cells (Picton and Gosden, 2000
).
We have not routinely tested any healthy male partners or oocyte recipients for the mutation, because the carrier frequency (1 in 85) means that the risk for a child to be homozygous for this mutation, and hence infertile, is lower than 1%. This makes it also acceptable to use the affected woman's own oocytes in this recessive disorder. All the couples are receiving genetic counselling, and testing can be offered for those who desire it.
For the time being, the present results show that these women can be helped by using donated oocytes.
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Acknowledgements |
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Notes |
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References |
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Submitted on June 26, 2001; accepted on September 18, 2001.