2003, Vol.32, Issues 3, Reproductive Endocrinology

Endocrinol Metab Clin N Am
32 (2003) ix–xi
Preface
Mechanisms of infertility: does diagnosis

dictate therapy?
Sarah L. Berga, MD,

Guest Editor
Infertility care logically involves a firm grounding in reproductive biol-

ogy, endocrinology, genetics, and cellular and molecular physiology. Given
this dependence on traditional scientific foundations, it is surprising that the
treatment of infertility is so often laden with opinion and superstition. Per-
haps the reason for this irony can be found in the behavioral and mathe-
matical sciences. First, it is no surprise to anyone that reproduction is
fundamental to our sense of self. Being unable to conceive when and with
whom one wants may be experienced as a psychologic threat akin to death.
This emotional vulnerability predisposes to magical thinking and the stages
of grief, including depression and bargaining. Second, conception and gesta-
tion are governed by probability, that is, the rules of chance. When outcome
is probabilistic, humans tend toward magical thinking as a means of gaining
control over uncertainty. An outcome that is both psychologically impor-
tant and uncertain inspires mysticism and superstitious behaviors in patients
and physicians alike.
One of the objectives of this collection of articles is to demystify infertility
by focusing on what is known about its causes. In an ideal world, cause dic-
tates, in a straightforward manner, intervention. The more we understand
0889-8529/03/$ - see front matter Ó 2003 Elsevier Inc. All rights reserved.
doi:10.1016/S0889-8529(03)00039-2
x S.L. Berga / Endocrinol Metab Clin N Am 32 (2003) ix–xi
about underlying pathogenetic mechanisms, the greater should be our abil-

ity to intervene in a rational manner. The last article outlines what it takes,
in terms of study design and statistical considerations, to determine the effi-
cacy of an intervention or to compare interventions. We have been urged to
practice ‘‘evidence-based’’ medicine. Although important information is
derived from clinical trials, it is helpful to remember that there are other
types of evidence that contribute to the best clinical practice. I like to think
of the practice of medicine as continuously improving through the ‘‘cycle of
evidence’’: mechanistic insights drive new interventions that need to be
tested in clinical trials, and clinical trials suggest new questions to be
answered by mechanistic studies.
Current infertility interventions fall into categories based on the limits of
our diagnostic armamentarium and therapeutic options. Ideally, we aim for
cures and outright corrections. However, because this is often not com-
pletely possible, the second line of defense may be needed, which is to increase
the odds by increasing gamete number and physical approximation of
gametes. These latter therapies might be best viewed as ‘‘enhancements’’
of probability. When all else fails, we offer substitutions. In the past, this
took the form of adoption of infants. Now our technology allows for gamete
and embryo substitutions. Although it is a general impression that the avail-
ability of these options relieves the psychologic burden and suffering of
infertility, in truth little attention has been paid to the actual psychologic
consequences of treating or not treating infertility.
What would most improve the lives of infertile couples? Clearly, access to
care is limited and should be improved. However, infertility is rarely seen as
a disease. By creating barriers to access, we trivialize both the medical and
psychologic aspects of infertility. To those involved in caring for infertile
couples, this callousness is mind-boggling, but it may be a paradoxical reac-
tion (denial) elicited by the incredible importance that we attach as a society
to reproduction. Again, many hold deep superstitions and may prohibit
what is often seen as tampering with Mother Nature or playing God. In
addition to limiting access to infertility care, another consequence of these
attitudes is a lack of research about the causes of and best therapies for
infertility. We clearly need more research on the mechanisms of embryogen-
esis, but this type of research is often viewed with the same suspicion as stem
cell research. Research on implantation evokes the controversies of abortion
politics. Clinical trials, which are sorely needed even if they do not specifi-
cally illuminate pathogenesis, would be especially useful for comparing the
efficacies of current therapies so as to permit cost-benefit analyses; however,
given the low probability of pregnancy in any given treatment cycle and the
corresponding need for enrolling many subjects, such trials are often deemed
as too expensive or not feasible in the short time frame demanded by federal
and private funding agencies.
In short, infertility remains an area that is filled with taboos, superstition,
mysticism, and awe. Herein we attempt to dispose of some of this baggage
S.L. Berga / Endocrinol Metab Clin N Am 32 (2003) ix–xi xi
by considering the therapeutic implications of what is known about the

causes of common infertility conditions.
Sarah L. Berga, MD
Departments of Gynecology and Obstetrics
Emory University School of Medicine
Atlanta, GA, USA
E-mail address: sberga@emory.edu
32 (2003) 549–572
Genetic causes of human infertility

Lawrence C. Layman, MD
Section of Reproductive Endocrinology, Infertility, and Genetics,
Department of Obstetrics and Gynecology, Developmental Neurobiology Program,
The Institute of Molecular Medicine and Genetics, The Medical College of Georgia,
1120 15th Street, Augusta, GA 30912-3360, USA
Infertility is typically defined as the absence of pregnancy after 1 year of un-

protected intercourse. The basic infertility evaluation usually includes a hys-
terosalpingogram, semen analysis, an assessment of ovulation, and, in select
patients, a laparoscopy to rule out endometriosis. Men with sperm abnor-
malities should be examined for testes position and size and to exclude hy-
pospadius. Men with azoospermia should be evaluated for congenital bilateral
absence of the vas deferens by physical examination and by the presence or
absence of fructose in the semen. Women with ovulation disorders should be
evaluated for a specific cause, if possible. It seems that some sperm abnor-
malities and ovulation disorders most likely have a genetic component. The
genetic causes of infertility are somewhat arbitrarily categorized by their likely
location as follows: hypothalamus (compartment I), pituitary (compartment
II), gonad (compartment III), or gamete outflow track (compartment IV) [1,2].
Men and women who are hypogonadal (low testosterone in men, low
estradiol in women) should undergo a determination of serum gonado-
tropins to aid in determining the cause of the hypogonadism. If both the
follicle-stimulating hormone (FSH) and luteinizing hormone (LH) levels
are low, the patient has hypogonadotropic hypogonadism with the cause
located in either the hypothalamus (compartment I) or the pituitary (com-
partment II). If gonadotropin levels are elevated, gonadal failure
(compartment III) is diagnosed.
Men with normal puberty and normal serum testosterone levels may also
have gonadal (compartment III) disorders (eg, oligospermia or azoosper-
mia) without endocrine failure. In contrast, women with gonadal
abnormalities caused by a genetic factor typically have a deficiency of
Portions of this work were supported by the US Public Health Service–National Institute
of Child Health and Human Development (grants HD33004 and HD040287).
E-mail address: llayman@mail.mcg.edu
doi:10.1016/S0889-8529(03)00040-9
550 L.C. Layman / Endocrinol Metab Clin N Am 32 (2003) 549–572
endocrine and gamete function. Gamete obstruction (compartment IV) of

the outflow tract from the testis in men and the uterus/vagina in women
typically presents with normal pubertal development. By far, most of the
known genetic disorders causing infertility to date affect gonadal function.
Although many of the genes discussed later have been known by other
names, the most current standard nomenclature symbols are used.
Compartment I: the hypothalamus

Deficient gonadotropin-releasing hormone (GnRH) secretion impairs
normal gonadotropin secretion, which then causes a corresponding re-
duction of sex steroids in men and women. This hypogonadism manifests as
varying degrees of pubertal underdevelopment. Gonadal function is normal,
and fertility may be achieved by therapy with exogenous gonadotropins or
pulsatile GnRH (Table 1) [1,2]. Some of these disorders affect only men (eg,
X-linked recessive), whereas some are autosomal and affect men and
women.
X-linked recessive genes: KAL1 and NROB1 genes

Kallmann syndrome is an X-linked recessive form of idiopathic hypo-
gonadotropic hypogonadism (IHH) and anosmia caused by mutations in
the KAL1 gene [3–6]. KAL1 encodes anosmin-1, a protein that has neural cell
adhesion molecular properties critical for timely neuronal migration of
olfactory and GnRH neurons. When anosmin-1 is absent or defective,
GnRH and olfactory neurons fail to synapse normally, resulting in
Kallmann syndrome. The KAL2 (FGFR1) gene has also been discovered
to cause autosomal dominant Kallmann syndrome [97].
The KAL1 gene has been characterized in chickens and humans, and
although the gene has not yet been identified in rodents, immunoreactivity
has been demonstrated, suggesting that a gene with less homology to
humans and chickens is present. In the chicken, KAL1 is expressed in
olfactory epithelium, oculomotor nucleus, Purkinje fibers of the cerebellum,
midfacial mesenchyme, and meso- and metanephros [7,8].
Human fetuses also express KAL1 in similar tissues and in the
corticospinal tract of the spinal cord [9,10].
Table 1
Human gene mutations of compartment I: the hypothalamus
Gene symbol Chromosome Disease Inheritance
KAL1 Xp22.32 Kallmann syndrome XLR
NROB1 Xp21.3 AHC/IHH XLR
LEP 7q31.3 Leptin deficiency/IHH AR
LEPR 1p31 Leptin resistance/IHH AR
Abbreviations: AR, autosomal recessive; XLR, X-linked recessive.
L.C. Layman / Endocrinol Metab Clin N Am 32 (2003) 549–572 551
KAL1 expression patterns correlate well with the following associated

phenotypic anomalies seen in some men with Kallmann syndrome:
synkinesia (mirror movements of extremities), visual abnormalities, midline
facial clefting, and renal agenesis. In one small-scale study, approximately
half of families with multiple affected male family members had KAL1
mutations, and of these, half also had unilateral renal agenesis [6].
The frequency of KAL1 mutations in unselected men with IHH is
approximately 10% to 15%, but mutations are uncommon in men with
IHH who do not have anosmia [11]. No mutations have been described in
women with IHH and anosmia, suggesting that other autosomal genes
produce a similar phenotype.
Another X-linked recessive disorder affecting men is adrenal hypoplasia
congenita (AHC). Boys usually present with adrenal failure in infancy or
childhood because of a lack of development of the permanent zone of the
adrenal gland, resulting in deficiency of glucocorticoids and mineralocorti-
coids. Appropriately treated, children with AHC do not experience puberty
because of IHH. NROB1 gene (formerly AHC or DAX1) mutations cause
AHC and hypogonadotropic hypogonadism [12–15]. The NROB1 gene
encodes the protein DAX1 (dosage-sensitive sex reversal-AHC critical
region of the X chromosome, gene 1), an orphan receptor belonging to the
steroid hormone superfamily. DAX1 functions as a transcription factor
important for the development of the pituitary gonadotropes and adrenal
cortex, and it also seems to regulate gonadotropin secretion at the pituitary
and hypothalamus [16].
Most NROB1 mutations are non-sense and frameshift inactivating
mutations throughout the gene [14,17], although missense mutations occur
less commonly and are located almost exclusively in the C-terminus of the
gene. NROB1 gene mutations do not seem to cause IHH in men without
associated adrenal failure [18] but have been reported in one woman with
IHH who did not have adrenal disease. Initially, NROB1 was postulated to
be an ovarian determinant gene because of its localization within the
dosage-sensitive sex reversal region of the X chromosome, a region of Xp,
which when duplicated is associated with sex reversal (feminization) in men
with a 46,XY cell line. Conditional knockout (KO) studies, however, do not
support its role as an ovarian determinant gene but instead point to an
important role in spermatogenesis [19].
Autosomal genes: LEP and LEPR genes

Leptin plays an important role in metabolism and puberty in humans and
rodents. Leptin-deficient ob/ob mice and leptin-resistant db/db mice manifest
obesity and hypogonadotropic hypogonadism. In human studies, a similar
phenotype has been described in several families with leptin (LEP)
mutations, with extreme obesity, hyperinsulinemia, and IHH, but, unlike
ob/ob mice, these individuals did not have stunted growth, hyperglycemia,
or hypercortisolemia [20,21]. Leptin receptor (LEPR) mutations associated

with leptin resistance and elevated levels of serum leptin produced a similar
phenotype [22]. These human and mouse mutations strongly implicate a role
for leptin in normal pubertal development.
Compartment II: the pituitary

Mutations in genes affecting pituitary gonadotropins also cause IHH
(Table 2). Combined pituitary deficiencies of additional pituitary hormones,
such as thyroid-stimulating hormone (TSH), prolactin, and growth
hormone (GH) may also occur. All known genes of compartment II pro-
duce autosomal recessive or autosomal dominant diseases (except NROB1,
which is an X-linked recessive gene). Similar to hypothalamic causes, the
reproductive potential for men and women with pituitary failure is excellent
when the missing tropic factors are administered.
GNRHR gene
No mutations in the GNRH1 gene encoding GnRH have been described
in patients with IHH, despite the finding that a hypogonadal mouse had
a naturally occurring Gnrh1 gene deletion [23–26]. In contrast, mutations
have been characterized in the gonadotropin-releasing hormone receptor
(GNRHR), the G-protein coupled receptor for GnRH [27,28]. The GNRHR
gene was the first autosomal gene found to possess mutations causing
human IHH. Most GNRHR mutations are compound heterozygous mis-
sense mutations that affect binding or signal transduction [27–30].
The phenotype of patients with GNRHR mutations ranges from complete
IHH (no evidence of puberty) to incomplete IHH (partial pubertal defects)
and infertility. The prevalence of GNRHR mutations among all patients
with IHH is 2% of total patients with IHH. This percentage is slightly
higher (7%) in families with an affected female family member [28]. In
a more recent study, approximately 10% of normosmic patients with
Table 2
Human gene mutations of compartment II: the pituitary
NROB1 Xp21.3 AHC/IHH XLR
GNRHR 4q21.2 GnRH resistance/IHH AR
FSHB 11p13 Isolated FSH deficiency AR
LHB 19q13.3 Isolated LH deficiency AR
PROP1 5q35.2 Combined pituitary deficiency AR
HESX1 3p21.2–p21.1 Septo-optic dysplasia AR, AD
LHX3 9q34.3 Combined pituitary deficiency AR
Abbreviations: AD, autosomal dominant; AR, autosomal recessive; XLR, X-linked
recessive.
IHH had GNRHR mutations [31]. To date, all GNRHR mutations have
been inactivating mutations with a phenotype of IHH. No activating
GNRHR mutations have been described in women with polycystic ovary
syndrome [32], but it seems reasonable that they could occur in patients with
precocious puberty or another state of gonadotropin overproduction.
Gonadotropin genes: FSHB and LHB

The gonadotropins FSH, LH, and human chorionic gonadotropin
(hCG), with TSH, comprise the pituitary glycoprotein hormones. These
peptides are dimers, consisting of a common a subunit encoded by the single
CGA gene, and a specific b subunit. No human common a-subunit gene
(CGA) mutations have been described, but the combination of IHH and
hypothyroidism would be predicted. It is possible that CGA gene mutations
might be lethal in humans, particularly a null mutation, because hCG would
be deficient in the early embryo.
Only a handful of mutations have been described for the FSHB gene
in humans; however, they correlate with those of KO mice. Female
homozygous FSHb KO mice are infertile because of the arrest of follicular
development just before or up to the antral stage [33]. Estradiol levels,
however, were normal in these mice. Humans have a similar phenotype, with
absent breast to partial breast development, castrate estradiol levels,
primary amenorrhea, and infertility [34–37].
Male homozygous FSHb KO mice have normal levels of serum
testosterone, small testes, and oligospermia, but were fertile [33]. Men with
FSHb mutations present with azoospermia, but puberty may be normal
(with normal testosterone) or absent (with low testosterone) [37–39]. FSH
deficiency in humans suggests that FSH is essential for normal spermato-
genesis.
There is only one well-characterized mutation in the LHb gene, which
exists as a single-copy gene in a gene complex, with six human chorionic
gonadotropin-b (CGB) genes. A man presented with pubertal delay;
bilaterally small, descended testes; low testosterone; and elevated levels of
both gonadotropins. Evidence that LH was responsible came from his
normal testosterone response after hCG administration. He was found to be
homozygous for a missense mutation of the LHb gene, with elevated serum
LH by immunoassay but undetectable by radioreceptor assay [40]. Although
many LHb polymorphisms have been described, their precise effect on
phenotype remains speculative but the effect is not as severe as with the
missense mutation [2]. Women with LHb mutations might be predicted to
have normal breast development but with an ovulation disorder.
PROP1 gene
The Ames dwarf mouse has a causative mutation in the Prop1 (Prophet
of Pit1) gene, the mouse ortholog of the human PROP1 gene. Human
PROP1 mutations cause a phenotype of combined pituitary hormone

deficiency of GH, TSH, prolactin, and gonadotropins [41–43]. Affected
individuals typically present with short stature, hypothyroidism, and absent
puberty. Various PROP1 mutations have been identified in these families,
but a particular frameshift deletion is common and appears to be a hotspot
for mutations [41–43].
Homeobox genes: HESX1 and LHX3

HESX1 mutations have been characterized in some families with septo-
optic dysplasia, a disorder consisting of optic nerve atrophy, agenesis of the
corpus callosum and septum pellucidum, and panhypopituitarism [44].
Autosomal recessive [44] and autosomal dominant [45] HESX1 mutations
have been identified in humans. The mouse ortholog—Hesx1—is expressed
in the early forebrain but is later limited to Rathke’s pouch, which ulti-
mately becomes the anterior pituitary gland. Patients with septo-optic
dysplasia may have IHH caused by gonadotropin deficiency.
Mutations in the LHX3 gene cause combined pituitary deficiency with
a phenotype consisting of severe growth retardation (caused by GH and
TSH deficiency) and hypogonadotropic hypogonadism. All pituitary
hormones (TSH, prolactin, GH, FSH, and LH) but adrenocorticotropic
hormone (ACTH) are deficient. There is severe restriction of rotation of the
cervical spine and elevating and anteverting the shoulders. These findings
correlate with those of the mouse ortholog, which include normal
development of all anterior pituitary cell types except corticotropes and
cervical spine development.
Compartment III: the gonad

Gonadal causes of infertility constitute the largest group of disorders
with a molecular basis (Table 3). Genetic disorders affecting gonadal
function include chromosomal deletions and mendelian disorders of various
genes, such as gonadotropin receptors, steroid hormone receptors, steroid
synthesis defects, and miscellaneous causes. Infertility caused by gonadal
failure in general has a poor prognosis for treatment of the underlying
condition; the best therapy usually involves the use of donor gametes.
These disorders are classified according to the presence of an X or Y
chromosome abnormality and by those autosomal loci affecting both men
and women. In most men with oligospermia and/or azoospermia associated
with infertility, pubertal development is normal because the sex-determining
gene (SRY) on the short arm (p) of the Y chromosome is normal, and
putative spermatogenesis genes reside on the long arm (q) of Y. In contrast,
genetic disorders in women usually produce absent pubertal development
and infertility.
Table 3
Human gene mutations of compartment III: the gonad
Y chromosome
SRY Yp11.3 Swyer syndrome YL
USP9Y Yq11.2 Severe oligospermia or azoospermia YL
DBY Yq11.2 Severe oligospermia or azoospermia YL
DAZ Yq11 Severe oligospermia or azoospermia YL
RBMY Yq11 Severe oligospermia or azoospermia YL
X chromosome
45,Xa — Turner syndrome Sporadic
POF1 Xq26–28 Premature ovarian failure Sporadic
or XLD
POF2 Xq22 See DIAPH2 —
DIAPH2 Xq22 Disrupted in 1 case of POF ?
FMR1 Xq27 Fragile X syndrome XLD
Autosomal
LHR 2p21 Undermasculinization AR
FSHR 2p21-p16 FSH resistance AR
HSD17B3 9q22 17-Ketosteroid reductase deficiency AR
SRD5A2 2p23 5-a Reductase type II deficiency AR
CYP21A2 6p21.3 CAH AR
CYP17 10q24.3 CAH: 17-OH deficiency AR
STAR 8p11.2 Congenital lipoid hyperplasia AR
CYP19 15q21.1 Aromatase deficiency AR
CYP11A1 15q23–q24 Congenital lipoid hyperplasia AD
HSD3B2 1p13.1 Type II 3-b hydroxysteroid AR
dehydrogenase deficiency
AIRE 21q22.3 APECED AR, AD
NR5A1 9q33 Undermasculinization AD
WTI 11p13 Frasier and Denys-Drash syndromes AD
SOX9 17q24.3–q25.1 Sex reversal; campomelic dysplasia AD
AMH 19p13.3 Persistent müllerian duct syndrome AR
AMHR2 12q13 Persistent müllerian duct syndrome AR
DNAH5 5p15-p14 Primary ciliary dyskinesia; Kartagener syndrome AR
DHH 12q13.1 Gonadal dysgenesis with AR
minifascicular neuropathy
Abbreviations: AD, autosomal dominant; AR, autosomal recessive; CAH, congenital
adrenal hyperplasia; XLD, X-linked dominant; YL, Y-linked.
a
Karyotype.
Chromosomal abnormalities
The X chromosome
Entire X-chromosome deletions
Women with a 45,X cell line, with or without mosaicism (46,XY, 46,XX,
47,XXX, or 46,X iXq), usually have ovarian failure. Approximately 90% of
patients with a 45,X cell line (or nearly all if the second line is 46,XY)
present with complete failure of pubertal development and absent menarche
[46–48]. Typically, women with a 45,X cell line have irreversible ovarian
failure with elevated gonadotropin levels and low estradiol levels [46–48].
Those patients with a 45,X cell line who do develop normal puberty
essentially all have ovarian failure before age 40. Patients with a 45,X cell
line have an increased risk of cardiac and aortic defects, and ruptured aortas
(from a dilated aortic root) have been reported in pregnancy in donor egg in
vitro fertilization (IVF) cycles. These risks necessitate a careful pre-IVF
evaluation and discussion involving a cardiologist.
The pathogenesis of 45,X gonadal dysgenesis (Turner syndrome) remains
unknown, although it is likely caused by haploinsufficiency of multiple genes
on the X chromosome that affect ovarian function and stature [46–48].
Classic Turner stigmata may or may not be present, but short stature is
virtually invariant. A statural determinant gene (with a pseudogene on the Y
chromosome), known officially as short-stature homeobox (SHOX) but also
termed pseudoautosomal homeobox-containing osteogenic (PHOG) gene,
is a transcription factor expressed in osteogenic cells that could be involved
in the short stature typical of Turner syndrome [49]. SHOX mutations on
one allele cause Leri-Weill dyschondrosteosis, a skeletal dysplasia with
disproportionate short stature, mesomelic limbs, and the Madelung
deformity (sometimes seen in Turner syndrome) [50,51]. SHOX deletions
on both X chromosomes also have been identified in a girl with Langer
mesomelic dysplasia, whose mother was hemizygous for the deletion.
Although deletions of the SHOX gene have been postulated to cause the
short stature typical of Turner syndrome, there are no descriptions of
patients with Turner syndrome who have mutations in this gene.
X-chromosome deletions
Partial deletions of the X chromosome have been reported in many
patients, but most are isolated instances, rather than familial. In general,
deletions affecting Xp11 result in ovarian failure in half of women, with
some degree of menstrual function in the other half. Even in those women
with normal menstruation, fertility is rare. With more distal (Xp21 region)
p-arm deletions, the phenotype is generally milder, although secondary
amenorrhea or infertility is common. Most women with Xp deletions are
short, regardless of their ovarian function, indicating the presence of other
statural determinant genes within these regions [46,48,52].
q-Arm deletions generally result in ovarian failure if they involve the
proposed critical region (the critical region hypothesis; ie, Xq13–q26).
Although nearly all patients with deletions within this region have gonadal
failure, exceptions have been reported [52]. Similar to p-arm deletions,
proximal (Xq13) deletions are usually more severe, with absent thelarche,
primary amenorrhea, and gonadal failure occurring in most women. With
more distal q-arm deletions, menarche may occur, with or without sub-
sequent ovarian failure. There have been reports of familial X-chromosome
deletions that include multiple female family members with gonadal failure.
Puberty is normal so that these women achieve fertility, but ovarian function
ceases before the age of 40 years. These familial ovarian failure syndromes
are transmitted in a gender-specific X-linked dominant fashion, with a 50%
risk for each female offspring. Two regions on the X chromosome were
hypothesized to contain putative ovarian determinant genes, the POF1 region
at Xq26–q28 and another region at Xq13.3–q22 (critical region hypothesis)
[52]. A more recently designated region of Xq22 is now termed POF2 and
contains the diaphanous 2 (DIAPH2) gene (discussed later).
The molecular basis for gonadal failure with X-chromosome deletions
could involve the loss of a putative ovarian determinant gene or genes
necessary to be present in two copies during ovarian development. Deleted
ovarian determinant genes probably increase follicular atresia, but perhaps
not to the extent of that observed in patients with a complete X-
chromosome deletion. It has also been hypothesized that partial X-
chromosome deletions might affect mitosis or meiosis, leading to enhanced
follicular atresia.
X-chromosome: autosome translocations

Although extremely rare, X-autosome translocations may affect re-
productive capability depending on the location of breakpoints of the
X chromosome. With a balanced X-autosome translocation, when one
X is normal (Xn) and the other is an X autosome translocation (Xt)
chromosome, X inactivation is not usually random so that Xn is usually
inactivated. If the translocated chromosome were to be inactivated, the
autosome would also be inactivated. Because monosomy for autosomes is
lethal, the normal X chromosome must be inactivated to secure normalcy.
In an unbalanced translocation involving the X chromosome, Xn is
normally active, whereas the X autosome translocated product Xt con-
taining XIST is inactivated in some cells.
Virtually all men and about half of women with X-autosome trans-
locations are sterile [48]. In women, the phenotype of a balanced X-
autosome translocation depends on the position of the X-chromosome
breakpoint and the functional status of the Xt chromosome. Approximately
three fourths of patients will have an active Xt (and inactive Xn), whereas
the others will have inactivation of Xt in some cells. In women with an active
Xt in all cells and breakpoint that does not interrupt any functional gene,
approximately half have ovarian failure (breakpoints within the Xq13–q26
region) and the other half have a normal phenotype (breakpoints outside
Xq13–q26) [48].
The location of the X-chromosome breakpoints involved in the trans-
location is evenly distributed when different studies are combined. The most
common autosomes involved in X-autosome translocations are the acro-
centric chromosomes 15, 21, and 22 [48], because the pericentromeric re-
gions of these autosomes appear particularly predisposed to pairing with
the X chromosome. Translocations involving the X chromosome may
potentially cause ovarian failure by a position effect, the deletion of ovarian

determinant genes, or by impairing the normal activity of the X chro-
mosome in meiosis or mitosis, leading to accelerated oocyte atresia.
Single-gene disorders of the X chromosome

DIAPH2 gene
The last intron of the DIAPH2 gene in the POF2 region was found to be
disrupted in one woman with ovarian failure who had a balanced X;12
translocation, t(X;12)(q21;p1.3) [53]. DIAPH2 on Xq22 is suspected to be
an ovarian determinant gene because it has high homology to the Dia gene
of Drosophila, which is expressed in the testes and ovary, and causes sterility
when mutant [53]. No point mutations have been described in the DIAPH2
gene, so its importance in human gonadal development and function
remains unknown.
FMR1 gene
Fragile X syndrome is an X-linked dominant disorder with incomplete
penetrance, characterized in men by mental deficiency, macro-orchidism
(but normal testicular histology), and large ears and jaws. The FRM1 gene
at the Xq27 fragile site (within the POF1 region) contains a triplet repeat of
cytosine guanine (CGG) bases, which, when expanded to a premutation
range, results in a female carrier. When female carriers have further meiotic
expansion into the full mutation range, fragile X syndrome results in men.
Some women with premutation alleles may be affected with mild degrees of
mental deficiency or learning disability, and they also appear to be at an
increased risk of premature ovarian failure (POF) before age 40.
Of women with sporadic POF who are screened, approximately 2% to
3% are premutation carriers [54,55]. In families of women with POF,
however, 12% to 15% may harbor FMR1 premutation alleles [54,55]. Full
mutations are rarely seen in women with POF, suggesting that the pre-
mutation allele either causes or segregates with POF. FMR1 is expressed in
the gonad, and although the exact mechanism is unknown, premutations of
FMR1 might affect ovarian development or function, or both [54,55].
The Y chromosome
A normal semen analysis as defined by World Health Organization
(WHO) criteria consists of a sperm concentration of more than 20 million/
cm3, motility of 50% or greater, and normal sperm forms of 30% or more.
Infertility in men may be manifested by oligospermia (\20 million/cm3) or
azoospermia (the absence of sperm), asthenospermia (\50% motility), or
teratospermia (abnormal sperm, normal sperm \30% by WHO criteria
or \4%–6% by strict Kruger morphology). Most gene mutations and
chromosomal abnormalities affect sperm count or motility.
Chromosomal disorders in men, including in those with 47,XXY and

46,XX cell lines, generally result in azoospermia, potentially because the
presence of an extra X chromosome interferes with normal spermatogenesis.
These men typically have elevated gonadotropin levels and small, fibrotic
testes. The prevalence of karyotypic abnormalities in men with hyper-
gonadotropic hypogonadism is approximately 15%, with 47,XXY being the
most common and 46,XX the second most common abnormality [46,47].
Balanced translocations have been identified in 1% to 2% of men with
severe oligospermia and azoospermia, whether or not hypogonadism is
present. It is currently unknown if chromosomal translocations cause the
defects of sperm; however, it is clinically important to counsel these patients
about the increased risk of live-born malformed children, which could be as
high as 10% to 15% [46,47]. X-autosomal translocations cause azoospermia
in most men, possibly because of disruption of spermatogenesis genes.
Single-gene disorders on the Y chromosome

SRY gene
SRY (the sex-determining region on the Y chromosome) is located on
the distal portion of Yp, adjacent to the more proximal pseudoautosomal
region. Approximately 10% to 15% of patients with 46,XY gonadal
dysgenesis (Swyer syndrome) have SRY mutations [56,57]. The most com-
mon phenotype of a patient with Swyer syndrome is a woman who is
completely hypoestrogenic with absent breast development; a normal vulva,
vagina, and uterus; streak gonads; and with an increased predisposition
(20%–25%) for developing gonadoblastomas and germ cell tumors. Because
the gonads are nonfunctional in patients with Swyer syndrome, both anti-
müllerian hormone (AMH) and testosterone are deficient. The absence of
AMH permits normal uterine development and the deficient testosterone
causes undermasculinization of 46,XY men, both of which give a prepubertal
female appearance. Fertility is only possible with donor egg IVF. Swyer
syndrome may be X-linked recessive in some families, suggesting that genes
of the X chromosome may have an important interaction with SRY.
Spermatogenesis genes
Most infertile men have normal puberty and testosterone levels. Putative
spermatogenesis genes on the Y chromosome have been mapped to the so-
called ‘‘azoospermia factor’’ (AZF) region on Yq11. From proximal to
distal are AZFa, AZFb, and AZFc. In AZFa, spermatogenesis genes include
USP9Y (ubiquitin-specific protease 9 on the Y chromosome) and DBY
(dead box Y). The RBMY gene complex (RNA-binding motif on the Y
chromosome) is located in AZFb; the DAZ (deleted in azoospermia) genes
reside in AZFc [58]. DAZ was the first spermatogenesis gene to be
characterized [59].
Several of the spermatogenesis genes are multicopy, and several are

single-copy genes. There seem to be four to six copies of the DAZ gene, and
about 20 to 50 RBMY genes or pseudogenes [58]. Both DBY and USP9Y
are single-copy genes, however. There has been tremendous difficulty in
dissecting out the important regions of the Y chromosome involved in
spermatogenesis because of the large number of repeated sequences and the
variation in study design. For example, deletions of the AZF regions of Yq
have largely been determined by studying sequence-tagged sites (STSs),
which are simply markers for specific chromosomal regions. The more STSs
studied, the higher the likelihood of finding deletions. In general, deletions
of the AZF regions tend to occur more frequently in infertile men, but they
also have been reported in fertile men.
Proof that the AZF region contains genes for spermatogenesis requires
the demonstration of an intragenic mutation, which was recently described
in the USP9Y gene, also known as DFFRY (Drosophila fat facets-related, Y-
linked) because of its homology to the corresponding gene in Drosophila
[60]. A de novo 4-base pair (bp) deletion was identified in an affected man,
and was absent in his fertile brother, suggesting that the USP9Y mutation
caused the spermatogenic failure. This splicing mutation caused exon
skipping and predicted a truncated protein. In a reanalysis of a previously
published study, these investigators also identified a single-gene deletion of
USP9Y associated with spermatogenic failure.
A review of the nearly 5000 infertile men screened for Y-chromosome
mutations in the literature estimated that approximately 8.2% of infertile
men and 0.4% of fertile men had deletions of one or more AZF regions. The
prevalence ranged from 1% to 35% in individual studies, however [58]. In
this review, AZFc deletions were the most common (60%), followed by
AZFb (16%), and then AZFa deletions (5%). In the rest of the men,
deletions of more than one of the regions were present (most commonly
involving AZFc). Most all mutations were found in men with azoospermia
(84%) or severe oligospermia (14%)—defined as less than 5 million sperm/
cm3 [58]. The interpretation of these studies of the AZF deletion data was
extremely challenging for the following reasons: (1) deletions were identified
in both infertile and fertile men, (2) multigene clusters of DAZ and RBM
complicated the analysis, (3) different clinical phenotypes (ie, sperm para-
meters) were studied, (4) there was incomplete assembly of Y-chromosome
contigs because of repeated sequences, and (5) there was a lack of complete
data on fertile control subjects.
Several years ago, a double-blind molecular study was published in which
full endocrine parameters and semen analyses were known for 138
consecutive men seen for intracytoplasmic sperm injection (ICSI) during
IVF, 100 fertile men, and 107 young Danish men enrolled in the military
[61]. Men undergoing ICSI represented the most severe male-factor pa-
tients. Of 21 STSs for AZFa to AZFc studied, no deletions were found in
men with a normal semen analysis or in any man with a count of more than
1 million/cm3. AZFc deletions were identified in 17% of men with idiopathic

azoospermia/cryptoozoospermia (\1 million sperm/cm3) and in 7% with
nonidiopathic azoospermia/cryptoozoospermia [61]. No deletions of AZFa
or AZFb were found in any of the men studied, suggesting that genes in the
AZFc region may play the most important role in spermatogenesis.
Autosomal disorders
FSHR gene
FSH is important for follicular development in females and spermato-
genesis in males, as indicated by human mutations and KO mice.
Homozygous FSHR KO female mice have a similar phenotype to the
FSHb KO mice, except that serum FSH levels are elevated in the FSHR KO
mice [62]. Homozygous male FSHR KO mice had reduced testicular size,
low testosterone, and oligospermia, but were fertile, although fertility was
impaired.
Several human FSHR gene mutations have been identified in women
[63–66] and men [67,68]. Women typically have primary amenorrhea, and
approximately half have evidence of breast development [63–66]. The
Finnish Ala189Val mutation is common in Finland, but rare outside that
country [69,70]. This Finnish mutation has also been observed in men and
results in a variable phenotype. Puberty and testosterone levels are normal,
but testes are small and sperm concentrations vary tremendously, from
severe oligospermia (\1 million/cm3) to normal [67]. Compared with FSHB
mutations, the phenotypic effects of FSHR gene mutations in humans do
not seem to be as severe. Several FSHR polymorphisms also have been
identified in men but were found in both fertile and infertile men, so their
significance remains uncertain [71].
A single activating missense FSHR mutation has been reported in a man
who underwent a transsphenoidal hypophysectomy for a pituitary ade-
noma. He had multiple normal semen analyses despite low levels of serum
gonadotropins postoperatively [68]. Familial segregation of this constitu-
tively active FSHR could not be determined, however, because there were no
available family members for study.
LHR gene
The receptor binding LH and hCG, now known as the LH receptor
(LHR) is a G-protein-coupled receptor. Constitutive activation of the LHR
gene causes autosomal dominant familial male precocious puberty (FMPP),
but there is no known phenotype for women. Inactivating LHR mutations,
however, cause autosomal recessive infertility in both men and women.
Inactivating LHR mutations in 46,XY men generally result in severe
undermasculinization, with a blind-ending vagina and absent uterus and
fallopian tubes (because AMH is produced normally). Less commonly,
a milder phenotype consisting of descended testes and a micropenis may
occur. Serum levels of both basal and hCG-stimulated testosterone are

reduced, basal LH levels are elevated (20 mIU/mL), and FSH levels are
normal [72]. Testicular histology usually demonstrates absent germ cells and
a reduction of Leydig cells.
Women with a 46,XX cell line and with LHR mutations usually have
normal breast development and amenorrhea [73,74]. Serum LH may be
normal or elevated, whereas FSH and follicular phase estradiol levels are
normal and progesterone is low. The uterus is small, and the ovaries may
contain cysts. Even though LH levels are elevated, testosterone levels are
normal and hirsutism is absent.
Steroid enzyme genes (STAR, CYP17, HSD17B3, and SRD5A2)

Undermasculinization of 46,XY men may also occur from testosterone
synthesis defects, most of which are autosomal recessive (Fig. 1). Gene
mutations in encoding 17-hydroxysteroid dehydrogenase type 3 (HSD17B3)
[75] and SRD5A2 encoding 5-a reductase type 2 [76] cause undermasculi-
nization (sexual ambiguity) of 46,XY men, who are also infertile (see Fig. 1).
Mutations in CYP19 encoding aromatase cause sexual ambiguity at birth
and subsequent ovarian failure at the time of adolescence in girls [77].
CYP19 is suspected to affect spermatogenesis in men, but definitive evidence
is lacking in humans [78].
Some forms of congenital adrenal hyperplasia (CAH), in which the
patient survives adrenal failure, manifest as infertility. The most common
form of CAH is 21-hydroxylase deficiency, which results in an over-
production of androgens and deficiency of cortisol. Salt wasting may be
Fig. 1. Steroidogenesis, illustrating the locations of gene defects. Proteins are shown as ovals.
Only the enzymes for which there are gene defects are shown. 17OH-Preg, 17-hydroxypreg-
nenolone; 17OHP, 17-hydroxyprogesterone; A’dione, androstenedione; DHT, dihydrotesto-
sterone; 11-deoxyDOC, 11-deoxycorticosterone. Gene symbols are standard and annotated in
text. Note that DHT binds to the androgen receptor.
present. Men and women with mutations in the CYP21A2 gene are fertile,
but there is some evidence for a reduction of fertility [79,80]. This finding is
presumably because of ovulation disorders in women [79] and the presence
of adrenal rests of the testes in men [80].
The CYP17 gene encoding for 17-hydroxylase protein has both 17-
hydroxylase activity (converting progesterone to 17-hydroxyprogesterone
and pregnenolone to 17-hydroxypregnenolone) and 17–20 desmolase ac-
tivity (converting 17-hydroxypregnenolone to dehydroepiandrosterone, or
DHEA, and 17-hydroxyprogesterone to androstenedione). In men and
women with CYP17 mutations, androgen, progestin, and estrogen de-
ficiency results. Cortisol is also deficient because it is derived from the
precursor 17-hydroxyprogesterone; however, the mineralocorticoids 11-
deoxycorticosterone and corticosterone may be elevated and cause
hypertension and hypokalemic alkalosis. The phenotype of women with
CYP17 mutations consists of absent puberty with a normal vagina and
uterus, whereas men display absent puberty with a blind vaginal pouch
(because AMH produced from their normal testes causes regression of
müllerian structures, including the upper vagina). Some men with partial
deficiency may have sexual ambiguity. Many different CYP17 mutations
have been characterized, many of which are deletions and insertions [81].
Severe CAH caused by mutations in steroidogenic acute regulatory
protein (STAR), CHP11A, and HSD3B2 rarely occur. Mutations in STAR
[55] cause congenital lipoid hyperplasia and deficiency of all steroids, with
a resulting phenotype of a sexually infantile woman. A heterozygous, de
novo mutation in the P450 side chain cleavage (CYP11A) was identified
in a man with atypical congenital lipoid hyperplasia [82]. Mutations in
HSD3B2 also produce CAH and may cause male infertility. In all of these
CAH forms, sex steroids are deficient; men therefore present with absent
puberty and a blind vaginal pouch and women present with absent puberty
and a normal vagina and uterus.
AIRE gene
The autoimmune polyendocrinopathy-candidiasis-ectodermal dystrophy
(APECED), also termed autoimmune polyglandular syndrome type 1, is
a multisystem autoimmune disease most commonly transmitted in an
autosomal recessive fashion [83,84], although autosomal dominant in-
heritance also has been described [58]. The disease usually consists of
hypoparathyroidism, adrenal failure, and mucocutaneous candidiasis and is
common in Finns, Jewish Iranians, and Sardinians. Initial symptoms
typically involve the following: moniliasis (60% of patients), but endocrine
disease is common; hypoparathyroidism (80% of patients); adrenal failure
(70% of patients); ovarian failure (60% of patients); and testicular failure
(14% of patients) [83,84].
Mutations in the autoimmune regulator (AIRE) gene, a nuclear
transcriptional factor, have been shown to cause this disease [83,84]. The
demonstration of AIRE mutations represents the first description of a single-

gene defect causing systemic autoimmune disease in humans. More than
three fourths of the mutations in Finns and Sardinians are homozygous for
a non-sense mutation (Arg257X in Finns, Arg139X in Sardinians). More
than half of mutations in North American patients consist of a homozygous
13-bp deletion. There is only a single reported case of heterozygosity for
a Gly228Trp mutation segregating in an autosomal dominant fashion,
although in vitro analysis was not described [58].
NR5A1 gene
The NR5A1 gene (formerly FTZF1) encodes for steroidogenic factor 1
(SF1) protein, a transcription factor important for steroidogenesis in the
adrenal glands and gonads. Only one NR5A1 mutation has been found
in a 46,XY man (one was found in a 46,XX woman). The man had a pheno-
type consisting of undermasculinization and subsequent infertility [85]. He
presented with phenotypic female characteristics with adrenal failure in
neonatal life, and later demonstrated impaired testosterone response to
exogenous hCG administration, which suggested defective gonadal func-
tion. At laparotomy, a normal uterus and bilateral streak gonads were
present. These findings suggested that SF1 regulates the regression of the
müllerian system in humans, either directly on AMH or indirectly because
of an abnormality of Sertoli cell development or function. [85]. The proband
had a heterozygous point mutation of the NR5A1 gene in the proximal (P)
box of the first zinc finger, eliminating DNA binding [85]. A mutation has
been found in a girl with adrenal failure, but she is too young to know the
effects on puberty [86].
WT1 and SOX9 genes

Gene mutations in WT1 and SOX9 cause sexual ambiguity in 46,XY
men, resulting in infertility. Mutations in the WT1 gene on chromosome
11p13 cause either the Denys-Drash syndrome [87] or Frasier syndrome [88],
depending on the mutation. Dominant-negative WT1 mutations produce
Denys-Drash syndrome, the more severe disorder, which is characterized
by Wilms tumor, nephropathy, sexual ambiguity in 46,XY men, and
gonadoblastoma [87]. In contrast, heterozygous inactivating splicing WT1
mutations cause the less severe Frasier syndrome, which consists of Wilms
tumor, sexual ambiguity, streak gonads, and renal failure [88]. Wilms tumor
is much more common in individuals with Denys-Drash syndrome than in
those with Frasier syndrome. Mutations in the SOX9 gene also cause
autosomal dominant undermasculinization of males and campomelic
dysplasia; however, most children die at or just after birth [89].
AMH and AMHR2 genes

Men with mutations in either the AMH or AMHR2 genes have
cryptorchidism and persistent müllerian structures, which results in
infertility [90]. A deletion (27 bp) of AMHR2 is the most common mutation
in men with this rare disorder [90].
DNAH5 gene
Mutations in the DNAH5 (dynein axonemal heavy chain 5) gene result in
ciliary dyskinesia and randomization of left-right asymmetry [91]. Patients
with this autosomal recessive disorder may have only primary ciliary
dyskinesia, which consists of bronchiectasis, immotile cilia, ciliary dyskine-
sia, sinusitis, and nasal polyps, or they may have Kartagener syndrome,
which also includes situs inversus [91]. Fertility is impaired in both men and
women. In men, sperm is typically nonmotile. Families with DNAH5
mutations may include members with and without situs inversus, indicating
a randomness of left-right symmetry.
DHH gene
A homozygous missense mutation has been described in the desert
hedgehog (DHH) gene in a man with a 46,XY cell line [92]. This patient
presented with partial gonadal dysgenesis and minifascicular neuropathy.
He was 153 cm (60 in) tall, with a unilateral testis and a contralateral streak,
a uterus, and a blind vagina [92]. His serum FSH was elevated, whereas his
LH level was normal. Sural nerve biopsy showed minifascicle formation.
This mutation was predicted to cause a failure of translation because it
affected the first methionine, but no in vitro analysis was performed.
Compartment IV: the outflow tract

The obstruction of gametes from the gonad into the reproductive tract
may also cause infertility. The best example is congenital bilateral absence of
the vas deferens (CBAVD), which is also one of the most common genetic
causes of infertility in men. Mutations in the androgen receptor (AR) gene
are also included here because the testes are often inguinal or intra-
abdominal and the vagina is not patent (Table 4).
AR gene
The AR gene belongs to the steroid superfamily of nuclear hormone
receptors. The AR gene encodes for a protein with a unique amino-terminus,
a DNA-binding domain, and a carboxyterminal androgen-binding domain.
Men with a 46,XY cell line with complete androgen insensitivity syndrome
caused by AR mutations present with phenotypic female characteristics
and primary amenorrhea [93]. They demonstrate normal female breast de-
velopment, absent (or minimal) axillary and pubic hair, and a blind vaginal
pouch. The testes are normal, so AMH is produced, inhibiting müllerian
development. The testes may be intra-abdominal or inguinal and produce
normal adult male testosterone levels (300–1100 ng/dL). Incomplete
Table 4
Human gene mutations of compartment IV: gamete outflow obstruction
CFTR 7q31–q32 Congenital bilateral absence of the AR
vas deferens; cystic fibrosis
AR Xq11.2–q12 Androgen insensitivity XLR
Abbreviations: AR, autosomal recessive; XLR, X-linked recessive.
androgen insensitivity syndrome causes undermasculinization and varying

degrees of sexual ambiguity and infertility [93].
Many AR mutations (commonly missense mutations) have been reported
to cause androgen insensitivity syndrome [94]. Although there is much
speculation that estrogen receptor (ESR1) and aromatase (CYP19) genes
could cause male infertility, there is currently no conclusive evidence to
support this.
CFTR gene
CBAVD occurs in approximately 1% of men with infertility. Approx-
imately 70% to 80% of these men are compound heterozygotes for
mutations in the CFTR (cystic fibrosis transmembrane conductance re-
gulator) gene [95,96]. Men affected with CBAVD have azoospermia with
absent fructose, but they usually have normal testicular sperm. Therefore,
epididymal or testicular aspiration may provide sperm for intracytoplasmic
sperm injection of oocytes at the time of IVF.
The genetics of CBAVD caused by CFTR mutations is extremely
complex, because some men with CBAVD will be compound heterozygotes
for an allele that might only cause CBAVD and another allele that may
cause cystic fibrosis (CF) [70]. In addition, an intronic polymorphism—5T/
7T/9T (referring to the number of consecutive Ts in the intron)—may occur
on the same (cis) allele or other (trans) allele, and this will affect the
phenotype. For example, if a specific missense mutation (Arg117His) is cis
to a 7T allele, with a CF mutation on the other allele, the man will have
CBAVD with the potential to transmit a severe CF allele to an offspring
[70]. Because of the complexity, strong consideration should be given to
referral to a geneticist if mutation data are uncertain. It is also extremely
important that all female partners be screened for CFTR mutations as well.
In couples in which both partners carry known CFTR mutations, then there
is a 25% risk for each child to be affected with CF.
Summary
The currently characterized chromosomal disorders and gene mutations
that cause infertility in humans were reviewed. Of the four arbitrary
compartments, genes expressed in the gonad comprise the most common site
affected by mutations causing infertility. Clinicians should be aware of the
most common causes that have clinical implications: (1) women with a 45,X
cell line commonly have cardiac anomalies that may pose a risk for mater-
nal death in pregnancies achieved by donor egg IVF; (2) men with Y-
chromosome deletions may produce male offspring with the same deletion,
rendering them infertile; (3) CBAVD must be ascertained in men with
azoospermia because of the risk for having a child with CF; and (4) some
women with premature ovarian failure may be fragile X syndrome carriers,
so other family members may be at risk for the full syndrome. In the future,
more genes will be identified to cause infertility in humans, which will
translate into clinical significance. In select cases, in which the genetic defect
is known, it may be possible to use preimplantation genetic diagnosis to
screen embryos prior to uterine transfer.
References
[1] Layman LC. The molecular basis of human hypogonadotropic hypogonadism. Mol Genet
Metab 1999;68:191–9.
[2] Layman LC. The genetics of human hypogonadotropic hypogonadism. Am J Med Genet
1999;89:240–8.
[3] Franco B, Guioli S, Pragliola A, et al. A gene deleted in Kallmann’s syndrome shares
homology with neural cell adhesion and axonal path-finding molecules. Nature 1991;
353:529–36.
[4] Legouis R, Hardelin J, Levilliers J, et al. The candidate gene for the X-linked Kallmann
syndrome encodes a protein related to adhesion molecules. Cell 1991;67:423–35.
[5] Bick D, Franco B, Sherins RS, et al. Intragenic deletion of the KALIG-1 gene in
Kallmann’s syndrome. N Engl J Med 1992;326:1752–5.
[6] Hardelin JP, Levilliers J, Blanchard S, et al. Heterogeneity in the mutations responsible for
X chromosome-linked Kallmann syndrome. Hum Mol Genet 1993;2:373–7.
[7] Rugarli EI, Lutz B, Kuratani SC, et al. Expression pattern of the Kallmann syndrome
gene in the olfactory system suggests a role in neuronal targeting. Nat Genet 1993;4:
19–26.
[8] Rugarli E, Ballabio A. Kallmann syndrome from genetics to neurobiology. JAMA
1993;270:2713–6.
[9] Duke VM, Winyard PJ, Thorogood P, Soothill P, Bouloux PM, Woolf AS. KAL, a gene
mutated in Kallmann’s syndrome, is expressed in the first trimester of human development.
Mol Cell Endocrinol 1995;110:73–9.
[10] Lutz B, Karatani S, Rugarli EI, et al. Expression of the Kallmann syndrome gene in human
fetal brain and in the manipulated chick embryo. Hum Mol Genet 1994;3:1717–23.
[11] Oliveira LM, Seminara SB, Beranova M, et al. The importance of autosomal genes in
Kallmann syndrome: genotype-phenotype correlations and neuroendocrine characteristics.
J Clin Endocrinol Metab 2001;86:1532–8.
[12] Muscatelli F, Strom TM, Walker AP, et al. Mutations in the DAX-1 gene give rise to both
X-linked adrenal hypoplasia congenita and hypogonadotropic hypogonadism. Nature
1994;372:672–6.
[13] Zanaria E, Muscatelli F, Bardoni B, et al. An unusual member of the nuclear hormone
receptor superfamily responsible for X-linked adrenal hypoplasia congenita. Nature
1994;372:635–41.
[14] Zhang Y-H, Guo W, Wagner RL, et al. DAX1 mutations provide insight into structure-
function relationships in steroidogenic tissue development. Am J Hum Genet 1998;62:
855–64.
[15] McCabe E. Disorders of glycerol metabolism. In: Scriver C, Beaudet A, Sly W, Valle D,
editors. The metabolic and molecular basis of inherited disease. 7th edition. New York:
McGraw-Hill; 1995. p. 1631–52.
[16] Habiby RL, Boepple P, Nachtigall L, Sluss PM, Crowley WF Jr, Jameson JL. Adrenal
hypoplasia congenita with hypogonadotropic hypogonadism: evidence that DAX-1
mutations lead to combined hypothalmic and pituitary defects in gonadotropin pro-
duction. J Clin Invest 1996;98:1055–62.
[17] Guo W, Mason JS, Stone CG, et al. Diagnosis of X-linked adrenal hypoplasia congenita by
mutation analysis of the DAX1 gene. JAMA 1995;274:324–30.
[18] Achermann JC, Gu W-X, Kotlar TJ, et al. Mutational analysis of DAX1 in patients with
hypogonadotropic hypogonadism or pubertal delay. J Clin Endocrinol Metab 1999;84:
4497–500.
[19] Yu RN, Ito M, Saunders TL, Camper SA, Jameson JL. Role of Ahch in gonadal
development and gametogenesis. Nat Genet 1998;20:353–7.
[20] Montague CT, Farooqi S, Whitehead FP, et al. Congenital leptin deficiency is associated
with severe early-onset obesity in humans. Nature 1997;387:903–8.
[21] Strobel A, Issad T, Camoin L, Ozata M, Strosberg AD. A leptin missense mutation
associated with hypogonadism and morbid obesity. Nat Genet 1998;18:213–5.
[22] Clement K, Vaisse C, Lahlou N, et al. A mutation in the human leptin receptor gene causes
obesity and pituitary dysfunction. Nature 1998;392:398–401.
[23] Weiss J, Crowley WF Jr, Jameson JL. Normal structure of the gonadotropin-releasing
hormone (GnRH) gene in patients with GnRH deficiency and idiopathic hypogonado-
tropic hypogonadism. J Clin Endocrinol Metab 1989;69:299–303.
[24] Weiss J, Adams E, Whitcomb RW, Crowley WF Jr, Jameson JL. Normal sequence of
the gonadotropin-releasing hormone gene in patients with idiopathic hypgonadotropic
hypogonadism. Biol Reprod 1991;45:743–7.
[25] Layman LC, Wilson JT, Huey LO, Lanclos KD, Plouffe L Jr, McDonough PG.
Gonadotropin-releasing hormone, follicle-stimulating hormone beta, and luteinizing
hormone beta gene structure in idiopathic hypogonadotropic hypogonadism. Fertil Steril
1992;57:42–9.
[26] Layman LC, Lanclos KD, Tho SPT, Sweet CR, McDonough PG. Patients with idiopathic
hypogonadotropic hypogonadism have normal gonadotropin-releasing hormone gene
structure. Adolesc Pediatr Gynecol 1993;6:214–9.
[27] de Roux N, Young J, Misrahi M, et al. A family with hypogonadotropic hypogonadism and
mutations in the gonadotropin-releasing hormone receptor. N Engl J Med 1997;337:
1597–602.
[28] Layman LC, Cohen DP, Jin M, et al. Mutations in the gonadotropin-releasing hormone
receptor gene cause hypogonadotropic hypogonadism. Nat Genet 1998;18:14–5.
[29] de Roux N, Young J, Brailly-Tabard S, Misrahi M, Milgrom E, Chaison G. The same
molecular defects of the gonadotropin-releasing hormone determine a variable degree of
hypogonadism in affected kindred. J Clin Endocrinol Metab 1999;84:567–72.
[30] Caron P, Chauvin S, Christin-Maitre S, et al. Resistance of hypogonadotropic patients
with mutated GnRH receptor genes to pulsatile GnRH administration. J Clin Endocrinol
Metab 1999;84:990–6.
[31] Beranova M, Oliveira LM, Bedecarrats GY, et al. Prevalence, phenotypic spectrum, and
modes of inheritance of gonadotropin-releasing hormone receptor mutations in idiopathic
hypogonadotropic hypogonadism. J Clin Endocrinol Metab 2001;86:1580–8.
[32] Cohen DP, Stein EM, Li Z, Matulis CK, Ehrmann DA, Layman LC. Molecular analysis of
the gonadotropin releasing hormone receptor in polycystic ovarian syndrome. Fertil Steril
1999;72:360–3.
[33] Kumar TR, Wang Y, Lu N, Matzuk MM. Follicle-stimulating hormone is required for
ovarian follicle maturation but not male fertility. Nat Genet 1997;15:201–4.
[34] Matthews CH, Borgato S, Beck-Peccoz P, et al. Primary amenorrhea and infertility due to
a mutation in the b-subunit of follicle-stimulating hormone. Nat Genet 1993;5:83–6.
[35] Layman LC, Lee EJ, Peak DB, et al. Delayed puberty and hypogonadism caused by
a mutation in the follicle stimulating hormone b-subunit gene. N Engl J Med 1997;337:
607–11.
[36] Matthews C, Chatterjee VK. Isolated deficiency of follicle-stimulating hormone re-
revisited. N Engl J Med 1997;337:642.
[37] Layman LC, Porto AL, Xie J, et al. FSH beta gene mutations in a female with partial
breast development and a male sibling with normal puberty and azoospermia. J Clin
Endocrinol Metab 2002;87:3702–7.
[38] Lindstedt G, Nystrom E, Matthews C, Ernest I, Janson PO, Chatterjee K. Follitropin
(FSH) deficiency in an infertile male due to FSHbeta gene mutation. A syndrome of
normal puberty and virilization but underdeveloped testicles with azoospermia, low FSH
but high lutropin and normal serum testosterone concentrations. Clin Chem Lab Med
1998;36:663–5.
[39] Phillip M, Arbelle JE, Segev Y, Parvari R. Male hypogonadism due to a mutation in the
gene for the b-subunit of follicle stimulating hormone. N Engl J Med 1998;338:1729–32.
[40] Weiss J, Axelrod L, Whitcomb RW, Harris PE, Crowley WF Jr, Jameson JL. Hypo-
gonadism caused by a single amino acid substitution in the b subunit of luteinizing
hormone. N Engl J Med 1992;326:179–83.
[41] Wu W, Cogan JD, Pfaffle RW, et al. Mutations in PROP1 cause familial combined
pituitary hormone deficiency. Nat Genet 1998;18:147–9.
[42] Cogan JD, Wu W, Phillips JA III, et al. The PROP1 2-base pair deletion is a common
cause of combined pituitary hormone deficiency. J Clin Endocrinol Metab 1998;83:3346–9.
[43] Fofanova OV, Takamura N, Kinoshita E, et al. A mutational hot spot in the Prop-1 gene
in Russian children with combined pituitary hormone deficiency. Pituitary 1998;1:45–9.
[44] Dattani MT, Martinez-Barbera J-P, Thomas PQ, et al. Mutations in the homeobox gene
HESX1/Hesx1 associated with septo-optic dysplasia in human and mouse. Nat Genet
1998;19:125–33.
[45] Thomas PQ, Dattani MT, Brickman JM, et al. Heterozygous HESX1 mutations associated
with isolated congenital pituitary hypoplasia and septo-optic dysplasia. Hum Mol Genet
2001;10:39–45.
[46] Layman LC, Reindollar RH. The genetics of hypogonadism. Infertil Reprod Med Clin N
Am 1994;5:53–68.
[47] Layman LC, Reindollar RH. The diagnosis and treatment of pubertal disorders. Adolesc
Med 1994;5:37–55.
[48] Layman L. Familial ovarian failure. In: Lobo RL, editor. Perimenopause. New York:
Springer Verlag; 1997. p. 46–77 [chapter 6].
[49] Rao E, Weiss B, Fukami M, et al. Pseudoautosomal deletions encompassing a novel
homeobox gene cause growth failure in idiopathic short stature and Turner syndrome.
Nat Genet 1997;16:54–63.
[50] Belin V, Cusin V, Viot G, et al. SHOX mutations in dyschondrosteosis (Leri-Weill
syndrome). Nat Genet 1998;19:67–9.
[51] Shears DJ, Vassal HJ, Goodman FR, et al. Mutation and deletion of the pseudoautosomal
gene SHOX cause Leri-Weill dyschondrosteosis. Nat Genet 1998;19:70–3.
[52] Simpson JL, Rajkovic A. Ovarian differentiation and gonadal failure. Am J Med Genet
1999;89:186–200.
[53] Bione S, Sala C, Manzini C, et al. A human homologue of the Drosophila melanogaster
diaphenous gene is disrupted in a patient with premature ovarian failure: evidence for
conserved function in oogenesis and implications for human sterility. Am J Hum Genet
1998;62:533–41.
[54] Murray A. Premature ovarian failure and the FMR1 gene. Semin Reprod Med 2000;18:
59–66.
[55] Uzielli ML, Guarducci S, Lapi E, et al. Premature ovarian failure (POF) and fragile X
premutation females: from POF to to fragile X carrier identification, from fragile X carrier
diagnosis to POF association data. Am J Med Genet 1999;84:300–3.
[56] Jager RJ, Anvret M, Hall K, Scherer G. A human XY female with a frame shift mutation
in the candidate testis-determining gene SRY. Nature 1990;348:452–4.
[57] Ostrer H. Sexual differentiation. Semin Reprod Med 2000;18:41–9.
[58] Foresta C, Moro E, Ferlin A. Y chromosome microdeletions and alterations of
spermatogenesis. Endocr Rev 2001;22:226–39.
[59] Reijo R, Lee T-Y, Salo P, et al. Diverse spermatogenic defects in humans caused by Y
chromosome deletions encompassing a novel RNA-binding protein gene. Nat Genet
1995;10:383–93.
[60] Sun C, Skaletsky H, Birren B, et al. An azoospermic man with a de novo point mutation in
the Y-chromosomal gene USP9Y. Nat Genet 1999;23:429–32.
[61] Krausz C, Rajpert-de Meyts EW, Frydelund-Larsen L, Quintana-Muro L, McElreavey K,
Skakkebaek NE. Double-blind Y chromosome microdeletion analysis in men with known
sperm parameters and reproductive hormone profiles: microdeletions are specific for
spermatogenic failure. J Clin Endocrinol Metab 2001;86:2638–42.
[62] Dierich A, Sairam MR, Monaco L, et al. Impairing follicle-stimulating hormone (FSH)
signaling in vivo: targeted disruption of the FSH receptor leads to aberrant gametogenesis
and hormonal imbalance. Proc Natl Acad Sci USA 1998;95:13612–7.
[63] Aittomaki K, Lucena JLD, Pakarinen P, et al. Mutation in the follicle-stimulating
hormone receptor gene causes hereditary hypergonadotropic hypogonadism. Cell 1995;
82:959–68.
[64] Aittomaki K, Herva R, Stenman U-H, et al. Clinical features of primary ovarian failure
caused by a point mutation in the follicle stimulating hormone receptor gene. J Clin
[65] Beau I, Touraine P, Meduri G, et al. A novel phenotype related to partial loss of
function mutations of the follicle stimulating hormone receptor. J Clin Invest 1998;102:
1352–9.
[66] Touraine P, Beau I, Gougeon A, et al. New natural inactivating mutations of the follicle-
stimulating hormone receptor: correlations between receptor function and phenotype. Mol
Endocrinol 1999;13:1844–54.
[67] Tapanainen JS, Aittomaki K, Min J, Vaskivuo T, Huhtaniemi IT. Men homozygous for an
inactivating mutation of the follicle-stimulating hormone (FSH) receptor gene present
variable suppression of spermatogenesis and fertility. Nat Genet 1997;15:205–6.
[68] Gromoll J, Simoni M, Nieschlag E. An activating mutation of the follicle stimulating
hormone receptor autonomously sustains spermatogenesis in a hypophysectomized man.
[69] Whitney EA, Layman LC, Lanclos KD, Wall SW, McDonough PG. The follicle-
stimulating hormone receptor gene is polymorphic in premature ovarian failure and
normal controls. Fertil Steril 1995;64:518–24.
[70] Jiang M, Aittomaki K, Nilsson C, et al. The frequency of an inactivating point mutation
(566C-T) of the human follicle-stimulating hormone receptor gene in four populations using
allele-specific hybridization and time-resolved fluorometry. J Clin Endocrinol Metab
1998;83:4338–43.
[71] Simoni M, Gromoll J, Hoppner W, et al. Mutational analysis of the follicle-stimulating
hormone (FSH) receptor in normal and infertile men: identification and characterization of
two discrete FSH receptor isoforms. J Clin Endocrinol Metab 1999;84:751–5.
[72] Kremer H, Kraaij R, Toledo SPA, et al. Male pseudohermaphroditism due to
a homozygous missense mutation of the luteinizing hormone receptor gene. Nat Genet
1995;9:160–4.
[73] Latronico AC, Anasti J, Arnhold IJP, et al. A novel mutation of the luteinizing hormone
receptor gene causing male gonadotropin-independent precocious puberty. J Clin Endo-
crinol Metab 1995;80:2490–4.
[74] Toledo SPA, Brunner HG, Kraaij R, et al. An inactivating mutation of the luteinizing
hormone receptor causes amenorrhea in a 46,XX female. J Clin Endocrinol Metab 1996;
81:3850–4.
[75] Geissler WM, Davis DL, Wu L, et al. Male pseudohermaphroditism caused by mutations
of testicular 17-beta-hydroxysteroid dehydrogenase 3. Nat Genet 1994;7:34–9.
[76] Andersson S, Berman DM, Jenkins EP, Russell DW. Deletion of steroid 5-alpha-reductase
2 gene in male pseudohermaphroditism. Nature 1991;354:159–61.
[77] Ito Y, Fisher CR, Conte FA, Grumbach MM, Simpson ER. Molecular basis of aromatase
deficiency in an adult female with sexual infantilism and polycystic ovaries. Proc Natl Acad
Sci USA 1993;90:11673–7.
[78] Bulun S. Aromatase deficiency and estrogen resistance: from molecular genetics to clinic.
Semin Reprod Med 2000;18:31–9.
[79] Jaaskelainen J, Tiitinen A, Voutilainen R. Sexual function and fertility in adult females and
males with congenital adrenal hyperplasia. Horm Res 2001;56:73–80.
[80] Cabrera MS, Vogiatzi MG, New MI. Long term outcome in adult males with classic
congenital adrenal hyperplasia. J Clin Endocrinol Metab 2001;86:3070–8.
[81] Yanase T, Simpson ER, Waterman MR. 17-Alpha-hydroxylase/17,20-lyase deficiency:
from clinical investigation to molecular definition. Endocr Rev 1991;12:91–108.
[82] Tajima T, Fujieda K, Kouda N, Nakae J, Miller WL. Heterozygous mutation in the
cholesterol side chain cleavage enzyme (p450scc) gene in a patient with 46, XY sex reversal
and adrenal insufficiency. J Clin Endocrinol Metab 2001;86:3820–5.
[83] Nagamine K, Peterson P, Scott HS, et al. Positional cloning of the APECED gene. Nat
Genet 1997;17:393–8.
[84] Consortium F-GA. An autoimmune disease, APECED, caused by mutations in a novel
gene featuring two PHD-type zinc-finger domains. Nat Genet 1997;17:399–403.
[85] Achermann JC, Ito M, Ito M, Hindmarsh PC, Jameson JL. A mutation in the gene
encoding steroidogenic factor-1 causes XY sex reversal and adrenal failure in humans. Nat
Genet 1999;22:125–6.
[86] Biason-Lauber A, Schoenle EJ. Apparently normal ovarian differentiation in a prepubertal
girl with transcriptionally inactive steroidogenic factor 1 (NR5A1/SF-1) and adrenocortical
insufficiency. Am J Hum Genet 2000;67:1563–8.
[87] Pelletier J, Bruening W, Kashtan CE, et al. Germline mutations in the Wilms’ tumor
suppressor gene are associated with abnormal urogenital development in Denys-Drash
syndrome. Cell 1991;67:437–47.
[88] Barbaux S, Niaudet P, Gubler M-C, et al. Donor splice-site mutations in WT1 are
responsible for Frasier syndrome. Nat Genet 1997;17:467–70.
[89] Foster JW, Dominguez-Steglich MA, Guioli S, et al. Campomelic dysplasia and autosomal
sex reversal caused by mutations in an SRY-related gene. Nature 1994;372:525–30.
[90] Imbeaud S, Belville C, Messika-Zeitoun L, et al. A 27 base-pair deletion of the anti-
mullerian type II receptor gene is the most common cause of the persistent mullerian duct
syndrome. Hum Mol Genet 1996;5:1269–77.
[91] Olbrich H, Haffner K, Kispert A, et al. Mutations in DNAH5 cause primary ciliary
dyskinesia and randomization of left-right asymmetry. Nat Genet 2002;30:143–4.
[92] Umehara F, Tate G, Itoh K, et al. A novel mutation of desert hedgehog in a patient with
46,XY partial gonadal dysgenesis accompanied by minifascicular neuropathy. Am J Hum
Genet 2000;67:1302–5.
[93] Brown TR, Lubahn DB, Wilson EM, Joseph DR, French FS, Migeon CJ. Deletion of the
steroid-binding domain of the human androgen receptor gene in one family with complete
androgen insensitivity syndrome: evidence for further genetic heterogeneity in this
syndrome. Proc Natl Acad Sci USA 1988;85:8151–5.
[94] Patterson MNH, Hughes IA, Gottlieb B, Pinsky L. The androgen receptor gene mutations
database. Nucleic Acids Res 1994;22:3560–2.
[95] Mercier B, Verlingue C, Lissens W, et al. Is congenital bilateral absence of vas deferens
a primary form of cystic fibrosis? Analyses of the CFTR gene in 67 patients. Am J Hum
Genet 1995;56:272–7.
[96] Chillon M, Casals T, Mercier B, et al. Mutations in the cystic fibrosis gene in patients with
congenital absence of the vas deferens. N Engl J Med 1995;332:1475–80.
[97] Dode C, Levilliers J, Dupont JM, et al. Loss-of-function mutations in FGFR1 cause
autosomal dominant Kallmann syndrome. Nat Genet 2003;33:463–5.
32 (2003) 573–592
Impaired fertility caused by endocrine

dysfunction in women
Brinda N. Kalro, MD, MRCOG
Division of Reproductive Endocrinology and Infertility, Departments of Obstetrics,
Gynecology, and Reproductive Sciences, University of Pittsburgh School of Medicine,
Magee-Women’s Hospital, 300 Halket Street, Pittsburgh, PA 15213, USA
The inability to conceive is often a distressing experience for couples.

Fertility in women is tightly regulated by the hypothalamo-pituitary-ovarian
(HPO) axis. Any derangement of the HPO axis results in menstrual
irregularities and ovulation disorders, with consequent sub- or infertility. In
addition, endocrine dysfunction of the thyroid, pancreas, adrenal, and
pituitary gland frequently disrupts the HPO axis and adversely influences
overall fecundity. An abnormal endocrine milieu is not conducive to
a healthy pregnancy. Between 10% and 23% of repetitive pregnancy losses
are attributed to endocrine dysfunction [1,2]. Menstrual irregularity and
ovulatory dysfunction, with resultant impairment in fertility, may therefore
serve as a protective mechanism against maternal and fetal complications.
This article addresses the impact of thyroid, adrenal, growth hormone (GH)
disorders, and diabetes on female reproduction.
Thyroid disorders
Thyroid dysfunction is more common in women than in men. Thyroid
antibodies are present in approximately 5% of women. Clinical manifes-
tations of thyroid disease can be subtle and insidious. Various reproductive
disorders ranging from abnormal sexual development to menstrual ir-
regularities and infertility have been associated with thyroid disorders.
Subclinical hypothyroidism often manifests as menstrual irregularities,
particularly menorrhagia and luteal phase defects, and can cause female
subfertility or infertility. Overt hypothyroidism is associated with amenor-
rhea and anovulatory infertility. Routine screening for occult thyroid
E-mail address: bkalro@mail.magee.edu
doi:10.1016/S0889-8529(03)00041-0
574 B.N. Kalro / Endocrinol Metab Clin N Am 32 (2003) 573–592
dysfunction in an infertile population revealed that 5.1% had abnormal

thyroid function tests [3]. In another series, 2.3% of women who failed to
conceive over a year had elevated thyroid-stimulating hormone (TSH) levels
and ovulatory dysfunction [4].
Hyper- and hypothyroidism can result in menstrual irregularities,
compromise fertility, and, if unrecognized in pregnancy, can be associated
with increased fetal morbidity and mortality. Goiter is more common in
women because increased renal loss of iodine results in a mild iodine-
deficient state, which sensitizes the thyroid gland to the growth-promoting
properties of TSH [5]. The degree of iodine deficiency is usually insufficient
to induce frank hypothyroidism, but it may induce goiter formation during
puberty and pregnancy when there is increased iodine demand. Renal loss of
iodide in pregnancy increases threefold [6]. Goiters caused by iodine
deficiency are prevalent in women who reside in certain geographic areas,
particularly high-altitude regions, and in those who consume a diet rich in
goitrogens. The consumption of iodized salt is an easy, convenient
preventive measure, but iodized salt may not be easily available. The use
of iodized oil, either orally or by intramuscular injection, is another option.
With improved diagnostic tests, early diagnosis, and treatment, fertility
can be restored with normalization of the thyroid axis [7]. The frequency
and type of menstrual irregularities associated with thyroid disorders largely
depends on the extent of the disease and timing of diagnosis during the
course of the disease.
With the availability of ovulation-inducing agents, there is a possibility
that thyroid disorders may be overlooked in women presenting with
menstrual irregularities and anovulation. Pregnancy in women with overt
thyroid disease is uncommon, but when it does occur, it can be fraught with
complications and have grave consequences. Therefore, evaluation of the
thyroid axis in women presenting with fertility problems is imperative.
Hyperthyroidism
Oligomenorrhea seems to be the most common menstrual disorder in
hyperthyroidism [8] and may progress to amenorrhea. Polymenorrhea occurs
less frequently. In one series of women with hyperthyroidism, 58% had
oligomenorrhea or amenorrhea and 5% had polymenorrhea [9]. In another
study, 64.7% of women with hyperthyroidism had menstrual irregularities,
compared with 17.2% of healthy control subjects [10]. Menstrual irregular-
ities sometimes precede overt thyroid dysfunction.
Amenorrhea is a feature of severe hyperthyroidism, with elevated
luteinizing hormone (LH) and follicle-stimulating hormone (FSH) levels,
loss of midcycle LH peak, and consequent anovulation and low pro-
gesterone levels [11,12]. Excess thyroid hormones typically increase sex
hormone–binding globulin (SHBG) production and serum levels, reflecting
increased tissue response to these hormones. Circulating total estrogen and
B.N. Kalro / Endocrinol Metab Clin N Am 32 (2003) 573–592 575
testosterone levels are therefore increased [11], but active or free fractions
are often reduced. Caution must therefore be exercised when interpreting
serum testosterone and estradiol levels, because the total fraction is
increased out of proportion to free-fraction levels. In addition, there is
excess conversion of androgens to estrogens in hyperthyroidism [13].
Thyrotoxicosis in 95% of patients is caused by Graves’ disease. Increased
levels of thyroid hormones in the maternal circulation do not increase the
risk to the fetus per se, but transplacental passage of thyroid-stimulating
immunoglobulin, thyroid receptor antibodies, or antithyroid medications
may result in a hypothyroid or thyrotoxic fetus [14].
Subclinical or mild hyperthryoidism is often not associated with
subfertility and anovulation. Endometrial biopsy specimens obtained from
women with hyperthyroidism confirmed the presence of ovulation [15].
Hence, pregnancy should be considered in an amenorrheic woman presenting
with symptoms of hyperthyroidism. Maternal and fetal morbidity is
increased when a thyrotoxic woman conceives. In addition, the risk of pre-
eclampsia, fetal loss, and intrauterine growth restriction (IUGR) is increased
[16,17].
Treatment of hyperthyroid states and restoration of a euthyroid state
results in resumption of regular ovulatory menstrual cycles and fertility.
Mid-luteal-phase progesterone levels in thyrotoxic women improve follow-
ing treatment [18]. Radioactive iodine treatment is contraindicated in women
contemplating pregnancy immediately after treatment. Hyperthyroidism can
also be treated with drugs such as carbimazole, methimazole, or propylth-
iouracil. However, these drugs cross the placenta, and pose a potential risk of
inducing fetal hypothyroidism. b-Blockers, such as propranolol, are reserved
for peripheral manifestations, such as tremor and palpitations. When
pharmacotherapy has not been effective or significantly large doses of
medication are required, surgery should be considered.
Hypothyroidism
Hypothyroidism can be secondary to primary thyroid failure, auto-
immune (Hashimoto’s) thyroiditis, ablation of the thyroid gland in the
treatment of Graves’ disease or other conditions, or iodine deficiency.
Hypothyroidism often causes polymenorrhea and oligomenorrhea
[12,15,16,19,20], occasionally causes anovulation, and rarely amenorrhea.
Joshi et al [10] reported menstrual abnormalities in 68.2% of women with
hypothyroidism versus 12.2% of healthy control subjects.
Patients with subclinical and frank hypothyroidism can present with
metrorrhagia or menorrhagia [21–23], which usually resolves with thyroid
replacement therapy in 3 to 6 months [24]. Occasionally, hypothyroidism
may be associated with prolonged periods of amenorrhea and anovulation.
Patients with hypothyroidisms have reduced levels of SHBG [25] and,
consequently, reduced levels of circulating estrogens and testosterone [26].
With anovulatory cycles, LH and FSH may also be reduced. Hypothyroid-

ism can cause a von Willebrand–like bleeding disorder [27]. Other defects in
hemostasis noted in hypothyroid states are decreased levels of factors VII,
VIII, IX, and XI [28]. In addition, hypothyroidism alters steroid metabolism
and clearance, making endometrial dysfunction more likely [29]. Menor-
rhagia is believed to be an early manifestation of hypothyroidism and
generally responds to thyroxine replacement.
Hypothyroid states are often associated with increased thyrotropin-
releasing hormone levels, which increase both TSH and prolactin levels
[19,30,31]. Galactorrhea may be present in 1% to 3% of women with long-
standing untreated hypothyroidism and resolves with adequate replacement
of thyroid hormones [30,32,33]. The pituitary gland may be enlarged and
detectable radiologically [34]. Hyperprolactinemia from long-standing
primary hypothyroidism may be responsible for varying degrees of ovulatory
dysfunction from luteal-phase insufficiency to oligomenorrhea or amenor-
rhea [35].
Subclinical hypothyroid states have been associated with luteal-phase
insufficiency [36]. Patients with subclinical hypothyroidism are generally
asymptomatic with suboptimal levels of serum thyroid hormones and
compensatory increase in TSH output. The reported incidence varies.
Strickland and Whitted [37] noted a 3.8% incidence of subclinical
hypothyroidism in infertile women with ovulatory cycles versus 11.3% in
women with ovulatory dysfunction.
Pregnancy, although rare in frank hypothyroidism, can occur [38] and is
associated with adverse outcomes such as spontaneous abortions, stillbirths,
prematurity [8,16,39], congenital malformations [39–42], and neurologic
dysfunction [43]. Thyroid hormone replacement in women with hypothy-
roidism with previous bad obstetric outcomes significantly improves the
outcome in subsequent pregnancies [44,45].
Hypothyroidism in the first trimester can impair fetal neuropsychologic
development, causing low IQ, deafness, and spasticity. In early pregnancy,
maternal thyroid hormones predominate in fetal circulation. Although the
fetal thyroid gland is capable of synthesizing hormones after the first
trimester, the fetal hypothalamic-pituitary-thyroid axis is immature. The
developing fetus relies on maternal contribution of thyroid hormones, which
decreases after midgestation, but continues until term (20%–50% of
normal values). Hence, the severity and impact of hypothyroxinemia are
greater in premature neonates born at 24 to 27 weeks of gestation when
compared with term infants, with grave fetal consequences, such as impaired
mental development and cerebral palsy [46].
Antithyroid antibodies
Autoimmune disorders are more common in women and tend to occur
during the reproductive years, thereby affecting fecundity and pregnancy
outcome. Antibodies against thyroglobulin (whose primary function is

synthesis and storage of thyroid hormones) and thyroid peroxidase (the
enzyme responsible for iodination of thyroid residues and coupling of
iodinated residues) are responsible for autoimmune thyroid disorders. The
prevalence of antithyroid antibodies (ATAs) in healthy pregnant women is
estimated at 15% to 20%, in women with recurrent miscarriages at 20% to
25%, and in women undergoing in vitro fertilization (IVF) at 20% [47].
Recurrent pregnancy loss is traditionally defined as three pregnancy losses,
and occurs in approximately 1% of women. Causes for recurrent miscarriage
are varied and multifactorial; in approximately 40% to 50% of women, the
cause remains unknown. The association between ATA and pregnancy loss is
unclear because of poorly understood mechanisms and conflicting data.
Women with recurrent pregnancy loss had a higher prevalence of ATA
(22.5%) when compared with those undergoing assisted reproduction
(19.2%) and control subjects (14.5%) [48]. There seemed to be no difference
in pregnancy outcomes, however, in women with ATAs undergoing assisted
reproduction treatment when compared with control subjects [49]. Bussen
et al [50] studied a cohort of euthyroid women who failed to conceive despite
multiple attempts at IVF and embryo transfer and found a higher
prevalence of ATAs in these women when compared with control subjects
who were also euthyroid. It is theoretically possible that women with higher
levels of ATAs have a poorer reproductive outcome, but this is debatable.
Routine assessment of ATA status is therefore not currently recommended
in women with normal thyroid function undergoing IVF.
Some studies have demonstrated an association between the presence of
ATAs and spontaneous abortion [51–56], usually in the first trimester [57,58].
Stagnaro-Green et al [52] demonstrated that the presence of ATAs were
markers for an ‘‘at risk’’ pregnancy, and several studies have supported these
data. It is believed that high titers of ATAs cause subtle thyroid dysfunction,
but studies have failed to explain the increase in miscarriage rates in women
with ATAs based on thyroid hormone levels [53–55,59]. Thyroid antibodies
may coexist with other non-organ-specific autoantibodies, suggesting an
underlying immunoregulatory defect, which may result in pregnancy loss. In
one series, 45% of women with systemic lupus erythematosus had ATAs [60].
Women with ATAs are also at risk for premature ovarian failure. A
diminished cohort of follicles with reduced oocyte quantity may present as
subfertility or poor response to exogenously administered gonadotropins,
and may herald the onset of incipient premature ovarian failure.
Increased endometrial T-cell population and interferon-c have been
observed in women with autoimmune thyroid disease (ATD), with a decrease
in interleukins 4 and 10, suggesting that activated T cells in the endometria
of women with ATD secrete cytokines that adversely affect pregnancy
outcome [61,62] and possibly impair implantation. Glinoer et al [63]
proposed that women with ATD are subfertile rather than infertile, with
delayed occurrence of pregnancy.
Acromegaly
Acromegaly is caused by hypersecretion of growth hormone (GH) and
secondary excess production of insulin-like growth factor 1 (IGF-1),
previously known as somatomedin C. As a result, overgrowth of bone and
soft tissues occurs with metabolic abnormalities and mass effects of
a pituitary tumor. Acromegaly is a rare disorder with an incidence of 3 to
4 cases per million and a prevalence of 58 cases per million [64] and occurs
with equal frequency in both genders. Progression of the disease is insidious
and diagnosis may be delayed, with a 5- to 10-year lag between onset of
symptoms and diagnosis. Approximately 99% of cases are secondary to
pituitary GH-secreting adenomas. In addition, 70% to 80% of pituitary
tumors are macroadenomas at the time of diagnosis and may enlarge
significantly [65]. They are often diagnosed in the third and fourth decades of
life. Approximately 25% to 30% of pituitary adenomas are GH-secreting
tumors; 20% to 25% of these adenomas also secrete prolactin, corticotropin
(ACTH), or TSH in addition to GH. Approximately 25% to 40% of patients
with untreated acromegaly have hyperprolactinemia [66,67], resulting in
galactorrhea, amenorrhea, and decreased libido. Amenorrhea can also occur
in the presence of normal prolactin levels.
Nearly 75% of women with acromegaly have menstrual irregularities
[68]. Women presenting with amenorrhea or menstrual cycle irregularities
should be carefully evaluated, particularly for pituitary tumors, before being
given ovulation-inducing agents. Ovarian dysfunction and loss of fertility in
acromegaly is consequent to pituitary mass effect, which results in impaired
gonadotropin secretion with or without hyperprolactinemia, and possibly
also secondary to coexisting ovarian hyperthecosis caused by concomittant
insulin resistance [69]. Placental secretion of GH variant increases normally
in the second trimester and exerts a negative feedback effect on pituitary GH
secretion; this restraint does not occur in acromegaly.
Somatic fetal growth appears to be GH independent [70]. Normal fetal
birth weights in woman with acromegaly and fetal macrosomia have been
described [71,72]. It has been postulated that fetal macrosomia may be
secondary to maternal carbohydrate intolerance rather than from direct
effects of maternal GH, because maternal-fetal transfer of GH is negligible.
There seems to be no increase in fetal mortality and morbidity in nondiabetic
acromegalic mothers [73]. Women who conceive following treatment with
radiation or surgery should be monitored closely during pregnancy for
pituitary enlargement.
Pituitary GH levels are normally suppressed during pregnancy and return
to normal levels a few weeks after delivery. On the contrary, the IGF-1 level,
although a better indicator of disease activity, is often increased in pregnancy,
and therefore unreliable in the diagnosis of acromegaly in pregnant women.
GH-secreting tumors tend to be influenced by other hormonal activities.
Estrogen in rats, for example, induces enlargement and arteriogenesis in the
anterior pituitary gland and this effect can be inhibited by bromocriptine

[74].
Spontaneous pregnancy is rare in women with untreated acromegaly.
However, a few pregnancies in women with untreated acromegaly have been
reported [75]. Several successful pregnancies in acromegalic women
following treatment with pharmacologic agents or surgery and radiation
have been reported [76–83].
Colao et al [84] observed 10 pregnancies in six women with acromegaly.
One patient spontaneously aborted at 12 weeks’ gestation. Acromegaly was
diagnosed in four women during pregnancy, all of whom delivered healthy
infants vaginally. All of these infants were at or above the 97th percentile for
height and weight at birth. Three women conceived following surgery, two of
these women had persistent, mildly elevated GH and IGF-1 levels. Two other
women conceived during octreotide treatment. Octreotide was discontinued
in one patient, whereas the other patient opted to continue taking medication.
The patient who remained on octreotide delivered an infant with a normal
birth weight, whereas the woman who discontinued medication delivered an
overweight infant. None of these patients exhibited tumor enlargement
during pregnancy as shown by CT scans and MRIs after delivery. Visual field
studies did not reveal any defects through the course of pregnancy.
Another pregnancy in a patient with acromegaly who was treated with
bromocriptine before becoming pregnant was reported by Bigazzi et al [85].
The patient was maintained on bromocriptine through the duration of her
pregnancy, and the authors detected no enlargement of the tumor or appear-
ance of visual symptoms postpartum. Fetal development monitored by ultra-
sound scan was normal. Serum GH levels remained elevated during pregnancy
despite treatment but declined after delivery. GH levels in the infant were
normal, suggesting that maternal GH does not cross the placenta into fetal
circulation. Prolactin levels in the fetus, however, were suppressed, with re-
bound increase after delivery, suggesting that bromocriptine does cross the
placenta. Amniotic fluid prolactin levels were normal at 28 and 36 weeks’ ges-
tation. Bromocriptine appeared to be effective in preventing enlargement of a
GH-secreting adenoma despite high circulating levels of estrogen in this patient.
Transplacental transfer of octreotide, a long-acting somatostatin analog,
has been demonstrated and likely occurs by passive diffusion. Its half-life is
prolonged fourfold in the fetus [86], but, to date, no adverse effects have
been noted at birth in infants exposed to octreotide during pregnancy.
Long-term use of octreotide in adults is associated with gallstones and,
rarely, cholangitis [87].
Diabetes
Women who have diabetes have several gynecologic issues, including
fertility and contraception. Before the advent of insulin in 1921, pregnancies
in women who had diabetes mellitus were rare. Insulin therapy in diabetic
women successfully restored menstruation [88] and fertility, and significantly

decreased maternal mortality rates, although perinatal mortality rates
remained high.
Diabetic women have a higher incidence of secondary hypogonadotropic
amenorrhea, more so if BMI is low and glycosylated hemoglobin Alc
(HbA1c) is higher than normal [89]. Improved nutritional and metabolic
status in women with insulin-dependent diabetes mellitus (IDDM) did not
result in spontaneous resumption of menses, however [90]. Onset of IDDM
before age of menarche is more likely to be associated with delayed
menarche and menstrual irregularities thereafter [89,91,92].
Amenorrhea and oligomenorrhea are 3 times more common in diabetic
individuals when compared with nondiabetic control subjects [93]. Approx-
imately 30% of women who have IDDM also have menstrual irregularities
[91,92]. The possible causes for this could be reduced gonadotropin-releasing
hormonal (GnRH) drive because of the stress of diabetes, altered pituitary
secretion of LH in diabetic women with amenorrhea, or an abnormal
response of LH to GnRH [94–96]. Serum LH and FSH levels increased in
response to exogenous luteinizing hormone–releasing hormone (LHRH),
and, although mean basal LH levels were comparable between diabetic and
nondiabetic age- and weight-matched control subjects, mean LH response
was considerably blunted in women who had diabetes. A significant inverse
correlation was observed between serum glucose levels and magnitude of LH
response. On the contrary, basal FSH levels tended to be lower in diabetic
women, and response to exogenous LHRH was also blunted when compared
with control subjects [94]. Pituitary dysfunction in women with IDDM could
also be secondary to glycogen infiltration [97] and deficient use of glucose [98]
by the pituitary gland as demonstrated in diabetic rats.
Women with IDDM and secondary amenorrhea had lower basal
concentrations of pituitary gonadotropins and estradiol when compared
with eumenorrheic diabetic women with IDDM [99]. Amenorrheic women in
this study also had elevated basal cortisol levels with blunted ACTH response
to corticotropin-releasing hormone (CRH) when compared with eumenor-
rheic diabetic control subjects, suggesting chronic stress from IDDM.
Insulin deficiency and uncontrolled diabetes can also have detrimental
consequences on folliculogenesis and preimplantation embryo development.
Untreated hyperglycemic diabetic mice had significantly delayed oocyte
maturation when compared with nondiabetic controls. This retardation was
reversed with improved metabolic milieu when diabetic mice were treated
with insulin and rendered euglycemic [100]. Early development and cleavage
of embryos was also adversely affected in diabetic hyperglycemic mice but
was reversed successfully by prior treatment with insulin and improved
glycemic control [100]. Progression of two-cell-stage embryos to the
blastocyst stage lagged behind in untreated diabetic mice when compared
with controls [101]; this phenomenon was partially reversed with insulin
treatment [100]. Retardation of progression to the blastocyst stage and
teratogenic effects in embryo cultures has been ascribed to high concen-

trations of glucose and ketones [102–104].
Pre-pregnancy counseling is essential for diabetic women contemplating
a pregnancy. Adequate glycemic control before conception is critical to
reduce the risk of spontaneous abortion, fetal abnormalities, and other
pregnancy complications, such as macrosomia. Major malformations were
two- to threefold higher in infants of insulin-dependent diabetic mothers,
despite good glycemic control [105]. Effective management of diabetes
before and during pregnancy can significantly reduce associated perinatal
mortality and morbidity [106–111]. Although a large meta-analysis of
American and European literature did not reveal an increased risk of
spontaneous pregnancy loss in diabetic women [112], Miodovnik et al
[113,114] noted a higher spontaneous abortion rate in women with IDDM.
Women who had IDDM and adequate glycemic control had significantly
lower miscarriage rates than those who did not receive pre-pregnancy
counseling. Suboptimal glycemic control, indicating poor metabolic control
at the time of conception, increases the likelihood of adverse pregnancy
outcome [115].
In addition, women who have IDDM are at increased risk for magnesium
deficiency because of increased renal loss [116,117], and reduced magnesium
levels may be a causative factor in early pregnancy loss in women with
IDDM. Animal studies have confirmed that magnesium deficiency in
diabetic rats was associated with increased fetal loss rate [118]. Existing
data, although limited, do not appear to indicate an increased risk of
repeated pregnancy losses in diabetic women per se unless glycemic control
is suboptimal [119–121]. Maternal diabetes during early pregnancy also has
been associated with mild early fetal growth restriction and may serve as
a marker for congenital malformations [121,122].
Adrenal disorders
The adrenal cortex synthesizes and secretes mineralocorticoids, gluco-
corticoids, and sex steroids. Cortisol plays a vital role in metabolism, and its
secretion is controlled by the hypothalamus and pituitary gland. Adrenal
cortical dysfunction disrupts normal reproductive function and complicates
pregnancy.
Congenital adrenal hyperplasia

Congenital adrenal hyperplasia (CAH) represents a group of recessive
disorders resulting from an inherited dysfunction of enzymes involved in
cortisol synthesis from cholesterol in the adrenal cortex. 21-Hydroxylase
deficiency is the most common type of CAH (90% of cases), followed by
11b-hydroxylase deficiency and 3b-hydroxysteroid dehydrogenase (3b-HSD)
deficiency accounting for most of the remaining cases. The latter can
affect both adrenal and gonadal steroidogenesis. Severe forms of 3b-HSD
deficiency in infants can be fatal if not diagnosed early. Affected girls have
either normal sexual development or mild virilization, often detected at
puberty. Hyperandrogenism in these girls may be responsible for disruption
of the HPO axis and consequent menstrual irregularities or anovulation.
Women with congenital adrenal lipoid hyperplasia treated with cortico-
steriod and mineralocorticoid supplementation have normal pubertal
development and menarche but are at increased risk for premature ovarian
failure caused by damage to ovarian cells from accumulation of cholesterol.
Women with 17a-hydroxylase deficiency exhibit hypertension and hypoka-
lemia, sexual infantalism, and hypergonadotropic hypogonadism, although
their ovaries contain normal numbers of antral follicles. Follicular atresia,
however, is marked and preovulatory follicles are absent.
Amenorrhea and infertility in women with CAH have been attributed to
hyperandrogenic states secondary to adrenal hyperandrogenism [123,124],
and more recently, to ‘‘mini pill–like’’ endometrial effects of elevated levels
of progestagenic steroids of adrenal origin [125–129]. Reduced fertility rates
in women with CAH also have been attributed to inadequate introitus and
sexual dysfunction [130], noncompliance with therapy [131], and non-
suppressible progesterone levels resulting in amenorrhea and failure to
respond to normal ovulation stimulation [128]. Fertility rates further
decrease with increased severity of anatomic defects.
Psychosexual factors may also play a role in decreased fertility rates
associated with CAH. These factors may stem from genital ambiguity or
deformities, hirsutism, and disturbed body image. In addition, it has been
proposed that chronic exposure of the hypothalamus and central nervous
system to a hyperandrogenic state predisposes to boyish behavior in
childhood, and decreased heterosexual and increased homosexual activity
in adult life [132].
Women with milder forms of 21-hydroxylase deficiency resume having
normal ovulatory cycles with adequate cortisol replacement and are able to
conceive spontaneously. In more severe forms of this condition, however,
fertility and childbirth rates are compromised despite treatment
[126,128,130,133]. Another explanation offered for the decreased fertility
rates and childbirth in these women is possible decreased sexual drive and
libido caused by elevated progesterone levels [134] and elevated glucocorti-
coid levels in treated women [126]. Persistent androgen excess may also
predispose to first-trimester miscarriages in women not being replaced with
corticosteroids [135].
Adrenal insufficiency
Adrenal insufficiency can be caused by deficient hypothalamic secretion
of CRH, deficient pituitary secretion of ACTH, or destruction of the
adrenal cortex (Addison’s disease, primary adrenal insufficiency). Primary

adrenal insufficiency is rare, with a reported incidence of 6 cases per million
adults per year. Approximately 75% of cases of primary adrenal failure are
secondary to an autoimmune etiology. Adrenal androgen deficiency results
in loss of axillary and pubic hair in women, and decreased libido.
Approximately 25% of women who have Addison’s disease are amenorrheic
secondary to chronic illness, weight loss, or autoimmune-mediated pre-
mature ovarian failure [136]. Decreased libido and potency and amenorrhea
can be present in both primary and secondary adrenal insufficiency. Modest
hyperprolactinemia may also be present. Women with autoimmune adrenal
insufficiency are at increased risk of premature ovarian failure [137,138],
with a reported incidence of approximately 7% [139].
Pregnancy in women with untreated adrenal insufficiency is rare, and
before the advent of glucocorticoid replacement therapy, maternal mortality
rates were as high as 45% [140]. Diagnosis in pregnancy is not easy because
symptoms include nausea with or without vomiting, weakness and fatigue,
weight loss, anorexia, and abdominal pain. Therefore, the index of suspicion
should be high if symptoms are unremitting in the presence of postural
hypotension and personality changes. Treatment includes replacing both
mineralocorticoids and corticosteroids with additional doses during labor
and delivery, surgery, or illness. Addisonian crisis is rare but can be life
threatening.
Fetal growth may be suboptimal or lower than normal, if the diagnosis is
confirmed late in pregnancy [141]. Infants usually do not display any
abnormalities at birth. Maternal adrenal antibodies do cross the placenta
but do not seem to adversely affect fetal adrenal function [142].
Cushing’s syndrome
Menstrual abnormalities, hirsutism, acne, lower back pain, and di-
minished libido secondary to cortisol and androgen excess are some of the
prominent features in women who have Cushing’s syndrome. Approxi-
mately 70% to 85% of premenopausal women who have Cushing’s
syndrome have amenorrhea and oligomenorrhea [143,144]. Pregnancy
rarely occurs in Cushing’s syndrome because these women have ovulatory
dysfunction and difficulty conceiving [145]. When Cushing’s syndrome does
occur in pregnant women, it is difficult to diagnose and is fraught with
complications, such as hypertension, gestational diabetes, congestive heart
failure, hypokalemia, myopathy, emotional lability (eg, depression, suicidal
states, psychosis), spontaneous abortion, IUGR, and preterm delivery
with associated increased fetal morbidity and mortality, and rarely, fetal
adrenal insufficiency [145,146]. Maternal death occurs in approximately
4% of cases and the incidence of perinatal death is approximately 15.4%
[145].
Hypercortisolism and adrenal hyperandrogenemia suppress gonadotropin

secretion with impaired LH response to GnRH [147,148]. LH levels improve
in pre- and postmenopausal women following treatment and normalization
of cortisol levels [149]. Cushing’s disease may also be associated with
hyperprolactinemia, which suppresses gonadal function [150–152]. An
aggregate of 67 pregnancies in women with Cushing’s syndrome has been
reported in the literature [146]. Because symptoms of hypercortisolism, such
as edema, striae, hypertension, and diabetes, can occur in pregnancy,
diagnosis of Cushing’s syndrome in milder cases may be delayed. Women
with untreated excess cortisol states are prone to recurrent pregnancy losses
[153–155] and display delayed wound healing [156–159]. A heightened level
of suspicion is necessary to diagnose Cushing’s syndrome in pregnancy
complicated by hypertension [146,154], gestational diabetes [160], or
androgen excess. Diagnostic difficulties exist in pregnant women because of
physiologic alterations in adrenocorticosteroid metabolism. As pregnancy
advances, dexamethasone suppressibility of cortisol decreases [161]. Radio-
logic localization of tumors should be limited in pregnant women to avoid
radiation risks to the fetus. Adrenal ultrasonography can be performed to
detect adrenal tumors. MRI of the pituitary and adrenal glands also can be
performed.
Treatment significantly improves maternal and perinatal outcome. The
mode of treatment is dictated by the cause of cortisol excess and includes
surgery, pituitary irradiation, or oral medication. Surgery is the recom-
mended choice of treatment of Cushing’s disease or adrenal tumors.
Transsphenoidal surgery for Cushing’s disease is the preferred treatment
and restores normal functioning of the hypothalamo-pituitary-adrenal axis.
Approximately 80% to 90% of the pituitary gland can be resected in women
for whom fertility is not an issue. Surgical cure rates are better with micro-
rather than macroadenomas. Taft et al [162] observed a series of women
who had undergone either surgical (unilateral or bilateral adrenalectomy)
treatment or pituitary irradiation for Cushing’s syndrome. Postoperative
fertility included 10 pregnancies in seven women. One woman had a first-
trimester miscarriage, and there were eight live births. All women were on
adequate steroid replacement and had uneventful pregnancies. Three
women with Cushing’s syndrome were pregnant with active disease before
treatment. Two lost their infants; one of these two women had a subsequent
pregnancy with a successful outcome following treatment. The third woman
had three successful pregnancies.
Pharmacologic agents, such as metyrapone and aminoglutethamide, must
be used with caution in pregnant women because they inhibit steroidogen-
esis, with possible teratogenic effects on the fetus. Transplacental passage of
these drugs could alter normal fetal adrenal steroidogenesis [156,163].
Ketokonazole is teratogenic and embryotoxic in animals [164,165].
Antiprogestins, which can be used to treat Cushing’s syndrome, are
contraindicated in pregnancy.
Summary
Infertility can be frustrating for patients and physicians. Endocrine
dysfunction can impair fertility and alter pregnancy outcome. Once the
diagnosis is secured, most endocrine disorders are reversible or can be
adequately managed to restore fertility and decrease associated pregnancy
complications. Improved understanding of the subtleties and intricacies of
mechanisms by which endocrinopathies can hinder fertility and influence the
course of a pregnancy is vital, more so in the era of assisted reproductive
technology, because pregnancy in an abnormal endocrine environment can
be disastrous. The role of autoimmunity in infertility and pregnancy loss is
less clear; in this context, there are limited management options to improve
fertility and overall pregnancy outcomes.
References
[1] Tho PT, Byrd JR, McDonough PG. Etiologies and subsequent reproductive performance
of 100 couples with recurrent abortion. Fertil Steril 1979;32:389–95.
[2] Fedele L, Simoni G, Zamberletti D, et al. Etiologia ed evolzione reproducttiva di 143
coppie con aborto abituale. Contracept Fertil Sess 1980;5:501 [in Italian].
[3] Stratford GA, Barth JH, Rutherford AJ, Balen AH. Value of thyroid function tests in
routine screening of women investigated for infertility. Hum Fertil [Camb] 2000;3:203–6.
[4] Lincoln SR, Ke RW, Kutteh WH. Screening for hypothyroidism in infertile women.
J Reprod Med 1999;44:455–7.
[5] Bray GA. Increased sensitivity of the thyroid in iodine depleted rats to the goitrogenic
effect of thyrotropin. Clin Invest 1968;47:1640–7.
[6] Aboul-Khair SA, Crooks J, Turnbull AC, et al. The physiological changes in thyroid
function during pregnancy. Clin Sci [Colch] 1964;27:195–207.
[7] Louvet JP, Gouarre M, Salandini AM, Boulard CL. Hypothyroidism and anovulation.
Lancet 1979;1:1032.
[8] Longcope C. The male and female reproductive systems in thyrotoxicosis. In: Baverman
LE, Utiger RD, editors. Werner and Ingbar’s the thyroid: a fundamental and clinical text.
6th edition. New York: Lippincott; 1991. p. 828–35.
[9] Goldsmith RE, Sturgis SH, Lerman J, Stanbury JB. The menstrual pattern of thyroid
disease. J Clin Endocrinol Metab 1952;18:846–55.
[10] Joshi JV, Bhandarkar SD, Chandha M, Balaiah D, Shah R. Menstrual irregularities and
lactation failure may precede thyroid dysfunction or goiter. J Postgrad Med 1993;39:
137–41.
[11] Akande EO, Hockaday TR. Plasma concentration of gonadotropins, estrogen and
progesterone in thyrotoxic women. Br J Obstet Gynecol 1975;82:541–51.
[12] Thomas R, Reid RL. Thyroid disease and reproductive dysfunction: a review. Obstet
Gynecol 1987;70:789–98.
[13] Southren AL, Olivio J, Gorelon GG, et al. The conversion of androgens to estrogens in
hyperthyroidism. J Clin Endocrinol Metab 1974;38:207.
[14] Zakarija M, MacKenzie JM. Pregnancy associated changes in the thyroid stimulating
antibody in Grave’s disease and the relationship to neonatal hyperthyroidism. J Clin
[15] Goldsmith R, Sturgis S, Lerman J, et al. Menstrual pattern in thyroid disease. J Clin
Endocrinol Metab 1952;12:846.
[16] Daniels GH. Thyroid disease and pregnancy: a clinical overview. Endocr Pract
1995;1:287–301.
[17] Davis LE, Lucas MJ, Hankins GDV, Roark ML, Cunningham FG. Thyrotoxicosis
complicating pregnancy. Am J Obstet Gynecol 1989;160:63–70.
[18] Pontikides N, Kaltsas TH, Krassas GE. The LH, FSH, PRL and progesterone levels in
thyrotoxic female patients before and after treatment [abstract]. J Endocrinol Invest
1990;13(suppl 2):164.
[19] Longcope C. The male and female reproductive systems in hypothyroidism. In: Baverman
LE, Utiger RD, editors. Werner and Ingbar’s the thyroid: a fundamental and clinical text.
6th edition. New York: Lippincott; 1991. p. 1052–5.
[20] Camargo CA. Hypothyroidism and goiter during pregnancy. In: Brody SA, Ueland K,
editors. Endocrine disorders of pregnancy. Norwalk, CT: Appleton and Lange; 1989.
p. 165–76.
[21] Greer MA. Disorders of the thyroid. In: Stein JH, editor. Internal medicine. 2nd edition.
Boston: Little Brown; 1987. p. 1918–40.
[22] Hoffenberg R. Thyroid disorders. In: Wetherall DJ, Ledingham JGG, Warrell DA,
editors. Oxford textbook of medicine. 2nd edition. Oxford, UK: Oxford Medical
Publications; 1987. p. 1030–48.
[23] Wilansky DL, Greisman B. Early hypothyroidism in patients with menorrhagia. Am J
Obstet Gynecol 1989;160:673–7.
[24] Brenner PF. Differential diagnosis of abnormal uterine bleeding. Am J Obstet Gynecol
1996;175:766–9.
[25] Anderson DC. Sex hormone binding globulin. Clin Endocrinol 1974;3:69–96.
[26] Akande EO. Plasma concentrations of gonadotropins, estrogen and progesterone in
hypothyroid women. Br J Obstet Gynaecol 1975;82:552–6.
[27] Tachman ML, Guthrie GP. Hypothyroidism: diversity of presentation. Endocr Rev
1984;5:456–65.
[28] Ansell JE. The blood in hypothyroidism. In: Baverman LE, Utiger RD, editors. Werner
and Ingbar’s the thyroid: a fundamental and clinical text. 6th edition. New York:
Lippincott; 1991. p. 1022–6.
[29] Winters SJ, Berga SL. Gonadal dysfunction in patients with throid disorders.
Endocrinologist 1997;7:167–73.
[30] Edwards CRW, Forsyth IA, Besser GM. Amenorrhea, glactorrhea, and primary
hypothyroidism with high circulating levels of prolactin. BMJ 1971;3:462–4.
[31] Tolino A, Nicotra M, Romano L, Petrone A, Langella L. Subclinical hypothyroidism and
hyperprolactinemia. Acta Eur Fertil 1991;22:275–7.
[32] Honbo KS, VanHerle AJ, Kellet KA. Serum prolactin in untreated primary
hypothyroidism. Am J Med 1978;64:782.
[33] Kleinberg DL, Noel G, Frantz AG. Galactorrhea: a study of 235 cases. N Engl J Med
1977;296:589.
[34] Yamada T, Tsuki T, Ikejiri K, et al. Volume of sella turcica in normal subjects and in
patients with primary hypothyroidism and hyperthyroidism. J Clin Endocrinol Metab
1976;42:87.
[35] DelPozo E, Wyss H, Tolis G, et al. Prolactin and deficient luteal function. Obstet Gynecol
1979;53:282.
[36] Bohnet HG, Fiedler K, Leidenberger FA. Subclinical hypothyroidism and infertility.
Lancet 1981;2:1278.
[37] Strickland DM, Whitted WA. Screening infertile women for subclinical hypothyroidism.
Am J Obstet Gynecol 1990;163:262–3.
[38] Montoro M, Collea JV, Frasier SD, Mestman JH. Successful outcome of pregnancy in
women with hypothyroidism. Ann Intern Med 1981;94:31–4.
[39] Davis LE, Leveko KJ, Cunningham FG. Hypothyrodism complicating pregnancy. Obstet
Gynecol 1988;72:108–12.
[40] Man EB, Jones WS, Holden RH, Mellitis ED. Thyroid dysfunction in human pregnancy.
VIII. Retardation of progeny aged 7 years: relationships to maternal age and maternal
thyroid function. Am J Obstet Gynecol 1971;111:905–16.
[41] Man EB. Maternal hypothyroxinaemia: development of 4 and 7 year old offspring. In:
Fisher DA, Burrow GN, editors. Perinatal thyroid physiology and disease. New York:
Raven Press; 1975. p. 117–29.
[42] Balen AH, Kurtz AB. Successful outcome of pregnancy with severe hypothyroidism. Case
report and literature review. Br J Obstet Gynaecol 1990;97:536–9.
[43] Haddow JE, Palomaki GE, Allan WC, et al. Maternal thyroid deficiency during
pregnancy and subsequent neuropsychological development of the child. N Engl J Med
1999;341:549–55.
[44] Winikoff D, Malinek M. The predictive value of thyroid ‘‘test profile’’ in habitual
abortion. Br J Obstet Gynaecol 1975;82:760.
[45] Greenman GW, Gabrielson MD, Howard-Flanders J, et al. Thyroid dysfunction in
pregnancy. N Engl J Med 1962;267:426.
[46] Ares S, Escobar-Morreale HF, Duran JQS, et al. Neonatal hypothyroxinemia: effects of
iodine intake and premature birth. J Clin Endocrinol Metab 1997;82:1704–12.
[47] Ghazeeri GS, Kutteh WH. Autoimmune factors in reproductive function. Curr Opin
[48] Kutteh WH, Yetman DL, Carr AC, et al. Increased prevalence of antithyroid antibodies
identified in women with recurrent pregnancy loss but not in women undergoing assisted
reproduction. Fertil Steril 1999;71:843–8.
[49] Kutteh WH, Schoolcraft WB, Scott RT Jr. Antithyroid antibodies do not affect
pregnancy outcome in women undergoing assisted reproduction. Hum Reprod
1999;14:2886–90.
[50] Bussen S, Steck T, Dietl J. Increased prevalence of thyroid antibodies in euthyroid women
with a history of recurrent in-vitro fertilization failure. Hum Reprod 2000;15:545–8.
[51] Matalon ST, Blank M, Oroy A, Shoenfeld Y. The association between anti-thyroid
antibodies and pregnancy loss. Am J Reprod Immunol 2001;45:72–7.
[52] Stagnaro-Green A, Roman SH, Cobin RH, Harazy E, Davies TF. Detection of at risk
pregnancy by means of highly sensitive assays for thyroid autoantibodies. JAMA
1990;264:1422–5.
[53] Lejeune B, Grun JP, De Nayer P, Servais G, Glinoer D. Antithyroid antibodies
underlying thyroid abnormalities and miscarriage or pregnancy-induced hypertension. Br
J Obstet Gynaecol 1993;100:669–72.
[54] Pratt D, Novoyny M, Kaberlein G, Dudkieicz A, Gleicher N. Antithyroid antibodies and
the association with non-organ specific antibodies in recurrent pregnancy loss. Am J
[55] Pratt DE, Kabarelein G, Dudkiewicz A, Karande V, Gleicher N. The association of
antithyroid antibodies in euthyroid nonpregnant women with recurent first trimester
abortions in the next pregnancy. Fertil Steril 1993;60:1001–5.
[56] Dendrinos S, Papasteriades C, Tarassi K, Christodoulakos G, Prasinos G, Creatsas G.
Thyroid autoimmunity in patients with recurrent spontaneous miscarriages. Gynecol
Endocrinol 2000;14:270–4.
[57] Glinoer D. Thyroid autoimmunity and spontaneous abortion. Fertil Steril 1999;72:
373–74.
[58] Toyoshima K, Makino T, Sugi T, et al. Correlation between trimester of fetal wastage and
anti-cardiolipin antibody titer. Int J Fertil 1991;63:89–93.
[59] Harger JH. Etiology of recurrent pregnancy losses and outcome of subsequent
pregnancies. Obstet Gynecol 1983;62:574–81.
[60] Magero M, Zoli A, Atomonte L, Mirone L, Barini LSA, Scuder F. The association of
silent hyroiditis and active systemic lupus erythematosus. Clin Exp Rheumatol
1992;10:67–70.
[61] Kaider AS, Kaider BD, Janowicz PB, Roussev RG. Immunodiagnostic evaluation in
women with reproductive failure. Am J Rep Immunol 1999;42:335–46.
[62] Stewart A, Kers AM, Krasnow JS, Brekosky J, Deloia JA. Endometrial leukocytes are
altered numerically and functionally in women with implantation defects. Am J Rep
Immunol 1998;39:1–11.
[63] Glinoer D, Riahi M, Grun JP, Kinthaet J. Risk of subclinical hypothyroidism in pregnant
women with asymptomatic thyroid disorders. J Clin Endocrinol Metab 1994;79:197–204.
[64] Holdaway IM, Rajasoorya C. Epidemiology of acromegaly. Pituitary 1999;2:29–41.
[65] Molitch ME. Clinical manifestations of acromegaly. Endocrinol Metab Clin North Am
1992;21:597–614.
[66] Bloch B. Pituitary tumours in pregnancy: a case report. S Afr Med J 1979;55:57.
[67] Melmed S. Acromegaly. In: Melmed S, editor. The pituitary. Cambridge, MA: Blackwell;
1995. p. 413–42.
[68] Jadresic A, Banks LM, Child DF, et al. The acromegaly syndrome: relation between
clinical features, growth hormone values and radiological characteristics of the pituitary
tumors. Q J Med 1982;51:189.
[69] Nagamani M, Lingold JC, Gomez LG. Hyperthecosis of the ovaries in acromegaly.
Obstet Gynecol 1980;56:258.
[70] Frohman LA. Therapeutic options in acromegaly. J Clin Endocrinol Metab 1991;72:1175.
[71] Abelove WA, Rupp JJ, Paschkis KE. Acromegaly and pregnancy. J Clin Endocrinol
Metab 1954;14:32.
[72] Fisch RO, Prem KA, Feinberg SB, et al. Acromegaly in a gravida and her infant. Obstet
Gynecol 1974;43:861.
[73] Ezzat S. Living with acromegaly. Endocrinol Metab Clin North Am 1992;21:753–60.
[74] Elias KA, Weiner RI. Inhibition of estrogen-induced anterior pituitary enlargement and
arteriogenesis by bromocriptine in Fischer 344 rats. Endocrinology 1987;120:480.
[75] Yap AS, Clouston WM, Mortimer RH, Drake RF. Acromegaly first diagnosed in
pregnancy: the role of bromocriptine therapy. Am J Obstet Gynecol 1990;163:477–8.
[76] Landolt AM, Schimd J, Karlsson ERC, Boerlin V. Successful pregnancy in a previously
infertile woman treated with SMS-201-995 for acromegaly. N Engl J Med 1989;320:671–2.
[77] Montini M, Pagani G, Gianola D, Pagani MD. Acromegaly and primary amenorrhea:
ovulation and pregnancy induced by SMS 201-995 and bromocriptine. J Endocrinol
Invest 1990;13:193.
[78] Herman-Bonert V, Seliverstov M, Melmed S. Pregnancy in acromegaly: successful
therapeutic outcome. J Clin Endocrinol Metab 1998;83:727–31.
[79] Mozas J, Ocon E, Lopez de la Torre M, Surez AM, Miranda JA, Herruzo AJ. Successful
pregnancy in a woman with acromegaly treated with somatostatin analog (octreotide)
prior to surgical resection. Int J Obstet Gynecol 1999;65:71–3.
[80] Takeuchi K, Funakoshi T, Oomori S, Maruo T. Successful pregnancy in an acromegalic
woman treated with octreotide. Obstet Gynecol 1999;93:848.
[81] De Menis E, Gussoni G. Uneventful pregnancy in an acromegalic patient treated with
slow-release lanreotide: a case report. J Clin Endocrinol Metab 1999;84:1489.
[82] Hierl T, Ziegler R, Kasperk C. Pregnancy in persistent acromegaly. Clin Endocrinol
2000;53:262–3.
[83] Nasser M. Octreotide treatment of acromegaly during pregnancy. Mayo Clin Proc
2002;77:297–8.
[84] Colao A, Merola B, Ferone D, Lombardi G. Acromegaly. J Clin Endocrinol Metab
1997;82:2777–81.
[85] Bigazzi M, Ronga R, Lalcranjan I, et al. A pregnancy in an acromegalic woman during
bromocriptine treatment: effects on growth hormone and prolactin in the maternal, fetal,
and amniotic compartments. J Clin Endocrinol Metab 1979;48:9–12.
[86] Caron P, Gerbeau C, Pradayrol L. Maternal-fetal transfer of octreotide. N Engl J Med
1995;333:601–2.
[87] Plockinger U, Dienemann D, Quabbe HJ. Gastrointestinal side effects of octreotide

during long-term treatment of acromegaly. J Clin Endocrinol Metab 1990;71:1658.
[88] White P. Diabetes in childhood and adolescence. Lea and Fibiger. 1932. p. 110–1.
[89] Kjaer K, Hagen C, Sando SH, Eshoj O. Epidemiology of menarche and menstrual
disturbances in an unselected group of women with insulin-dependent diabetus compared
to controls. J Clin Endocrinol Metab 1992;75:524–9.
[90] O’Hare JA, Eichold BH, Vignati L. Hypogonadotropic secondary amenorrhea in
diabetes: effects of central opiate blockade and improved metabolic control. Am J Med
1987;83:1080–4.
[91] Bergqvist N. The gonadal function in female diabetics. Acta Endocrinol 1954;19:3–20.
[92] Yashaya A, Orvieto R, Dicker D, Karp M, Ben-Rafael Z. Menstrual characteristics of
women suffering from insulin-dependent diabetes mellitus. Int J Fertil 1995;40:269–73.
[93] Rzepka I, Prochorow M, Tolwinska Z. Menstruation in diabetic girls. Ginekol Pol
1977;46:157–61.
[94] Distiller LA, Sagel J, Morley JE, et al. Pituitary responsiveness to luteinizing hormone
releasing hormone on insulin dependent diabetes mellitus. Diabetes 1975;24:37–80.
[95] Djursing H, Hagen C, Nyholm HC, et al. Gonadotropin responses to gonadotopin-
releasing hormone and prolactin responses to thyrotropin-releasing hormone and
metoclopramide in women with amenorhea and insulin-dependent diabetes. J Clin
[96] South SA, Asplin CM, Carlsen EC, et al. Alterations in luteinizing hormone secretory
activity in women with insulin dependent diabetes mellitus and secondary amenorrhea.
[97] Dixit PK, Lazarow A. Effect of hyperglycemia and hypoglycemia on the glycogen content
of the pituitary and adrenal glands of normal, subdiabetic and diabetic rats.
Endocrinology 1962;71:745–51.
[98] Goodner CJ, Freinkel N. Studies of anterior pituitary tissue in vitro: effects of insulin and
experimental diabetes mellitus upon carbohydrate metabolism. J Clin Invest 1961;40:
261–72.
[99] La Marca A, Morgante G. De Leo V. Evaluation of hypothalamic-pituitary-adrenal axis
in amenorrheic women with insulin-dependent diabetes. Hum Reprod 1999;14:298–302.
[100] Diamond MP, Moley KH, Pellicer A, et al. Effects of streptozotocin- and alloxan-induced
diabetes mellitus on mouse follicular and early embryo development. J Reprod Fertil
1989;86:1.
[101] Moley KH, Vaughn WK, DeCherney AH, Diamond MP. Effect of diabetes mellitus on
mouse pre-implantation embryo development. J Reprod Fertil 1991;93:325–32.
[102] Shum L, Sadler TW. Recovery by mouse embryos following teartogenic exposure to
ketosis. Diabetologia 1991;34:289.
[103] Zusman I, Yaffe P, Ornoy A. Effects of metabolic factors in the diabetic state on the in
vitro development of pre-implantation mouse embryos. Teratology 1987;35:77.
[104] Moley KH, Vaughn WK, Diamond MP. Manifestations of diabetes mellitus on mouse
pre-implantation embryo development: effect of elevated concentration of metabolic
intermediates. Hum Reprod 1994;9:113–21.
[105] Reis RA, DeCosta EJ, Gerbie AB. Pregnancy in the diabetic woman. Am J Obstet
Gynecol 1950;76:1148.
[106] Mills JL, Baker L, Goldman AS. Malformations in infants of diabetic mothers occur
before the seventh gestational week. Implications for treatment. Diabetes 1979;28:292.
[107] Mills JL, Knopp RH, Simpson JL, et al. National Institute of Child Health and Human
Development-Diabetes in Early Pregnancy Project: lack of relation of increased
malformation rates in infants of diabetic mothers to glycemic control during
organogenesis. N Engl J Med 1988;318:671.
[108] Kitzmiller JL, Cloherty JP, Younger MD, et al. Diabetic pregnancy and perinatal
morbidity. Am J Obstet Gynecol 1978;13:560.
[109] Jovanovic L, Drozin M, Peterson CM. Effect of euglycemia on the outcome of pregnancy
in insulin dependent diabetic women as compared with normal control subjects. Am J
Med 1981;71:921.
[110] Fuhrmann K, Reiher H, Semmler K, et al. Prevention of congenital malformations in
infants of insulin dependent diabetic mothers. Diabetes Care 1983;6:219.
[111] Fuhrmann K, Reiher H, Semmler K, et al. The effect of intensified conventional insulin
therapy before and during pregnancy on the malformation rate in offspring of diabetic
mothers. Exp Clin Endocrinol 1984;83:173.
[112] Kalter H. Diabetes and spontaneous abortion: a historical review. Am J Obstet Gynecol
1987;156:1243.
[113] Miodovnik M, Lavin JP, Knowles HC, et al. Spontaneous abortion among insulin
dependent diabetic women. Am J Obstet Gynecol 1984;150:372.
[114] Miodovnik M, Skillman C, Holroyde JC, et al. Elevated maternal glycohemoglobin in
early pregnancy and spontaneous abortion among insulin dependent diabetic women. Am
J Obstet Gynecol 1985;153:439–42.
[115] Dicker D, Feldberg D, Samuel N, et al. Spontaneous abortion in patients with insulin
dependent diabetes mellitus: the effect of preconceptional diabetic control. Am J Obstet
Gynecol 1988;158:1161.
[116] Atchley DW. On diabetic acidosis: detailed study of electrolyte balance following
withdrawal and re-establishment of insulin therapy. J Clin Invest 1933;12:297.
[117] Mimouni F, Midoovnik M, Tsand R, et al. Decreased maternal serum magnesium
concentration and adverse fetal outcome in insulin dependent diabetic women. Obstet
Gynecol 1987;70:85.
[118] Hurley LS, Cosens C, Theriavlt LL. Teratogenic effects of magnesium deficiency in rats.
J Nutr 1976;106:254.
[119] Glass RH, Golbus MS. Habitual abortion. Fertil Steril 1978;29:257.
[120] Crane JP, Wahl N. The role of maternal diabetes in repetitive spontaneous abortion.
Fertil Steril 1981;36:477.
[121] Brown ZA, Mills JL, Metzger BE, et al. Early sonographic evaluation for fetal growth
delay and congenital malformations in pregnancies complicated by insulin-requiring
diabetes. National Institute of Child Health and Human Development Diabetes in early
pregnancy study. Diabetes Care 1992;15:613–9.
[122] Pederson JF, Molsted Pederson L. Early fetal growth delay detected by ultrasound
marks increased risk of congenital malformation in diabetic pregnancy. BMJ
1981;283:269–71.
[123] Hughes IA, Read GF. Menarche and subsequent ovarian function in girls with congenital
adrenal hyperplasia. Horm Res 1982;16:100–6.
[124] Klingensmith GJ, Garcia SC, Jones HW, Migeon CJ, Blizzard RM. Glucocorticoid
treatment of girls with congenital adrenal hyperplasia: effects of height, sexual maturation
and fertility. J Pediatr 1977;90:996–1004.
[125] Rosenfield RL, Bickel S, Razdan AK. Amenorrhea related to progestin excess in
congenital adrenal hyperplasia. Obstet Gynecol 1980;56:208–15.
[126] Helleday J, Siwers B, Ritzen EM, Carlstrom K. Subnormal androgen and elevated
progesterone levels in women treated for congenital virilizing 21-hydroxylase deficieny.
[127] Eden JA. Two cases of partial 21-hydroxylase deficiency associated with progesterone
excess. Aust N Z J Obstet Gynecol 1989;29:268–70.
[128] Holmes-Walker DJ, Conway GS, Hoour JW, Rumsby G, Jacobs HS. Menstrual
disturbance and hypersecretion of progesterone in women with congenital adrenal
hyperplasia due to 21-hydroxylase deficiency. Clin Endocrinol 1995;43:291–6.
[129] Landgren BM. Mechanism of action of gestagens. Int J Gynecol Obstet 1990;32:95–110.
[130] Mulaikal RM, Migeon J, Rock JA. Fertility rates in female patients with congenital
adrenal hyperplasia due to 21-hydroxylase deficiency. N Engl J Med 1987;316:178–82.
[131] Blumberg DL, Reggiardo D, Sklar C, David R. Congenital adrenal hyperplasia and
fertility. N Engl J Med 1988;319:951.
[132] Meyer-Bahlburg HFL. What causes low rates of child-bearing in congenital adrenal
hyperplasia? J Clin Endocrinol Metab 1999;84:1844–7.
[133] Kuhnle U, Bullinger M, Schwartz HP. The quality of life in adult female patients with
congenital adrenal hyperplasia: a comprehensive study of impact of genital malformations
and chronic disease on female patients life. Eur J Pediatr 1995;154:708–16.
[134] Bradford JW. Pharmacological treatment of the paraphilias. Am Psychiatr Press Rev
Psychiatry 1995;14:755–77.
[135] Feldman S, Billaud L, Thalabard JC, et al. Fertility in women with late-onset adrenal
hyperplasia due to 21-hydroxylase deficiency. J Clin Endocrinol Metab 1992;74:635–9.
[136] Irvine WJ, Barnes EW. Adrenocortical insufficiency. Clin Endocrinol Metab 1972;1:549–94.
[137] Betterle C, Rossi A, Dalla Pria S, et al. Premature ovarian failure: autoimmunity and
natural history. Clin Endocrinol [Oxf] 1993;39:35–43.
[138] Ahonen P, Miettinen A, Perheentupa J. Adrenal and steroidal cell antibodies in patients
with autoimmune polyglandular disease type I and risk of adrenocortical and ovarian
failure. J Clin Endocrinol Metab 1987;64:494–500.
[139] Zellison PM, Bast EJ, Croughs RJ. Associated autoimmunity in Addison’s disease.
J Autoimmun 1995;8:121–30.
[140] Brent F. Addison’s disease in pregnancy. Am J Surg 1950;79:645–52.
[141] Drucker D, Shumak S, Angel A. Schmidt syndrome presenting with intrauterine growth
retardation and Addisonian crises. Am J Obstet Gynecol 1984;149:229.
[142] Nader S. Other endocrine disorders of pregnancy. In: Creasy RK, Resnik R, editors.
Maternal fetal medicine. 4th edition. Philadelphia: WB Saunders; 1999. p. 1015–37.
[143] Aron DC, Findling JW, Tyrrell JB. Cushing’s disease. Endocrinol Metab Clin North Am
1987;16:705–30.
[144] Plotz CM, Knowlton AI, Raan C. The natural history of Cushing’s syndrome. Am J Med
1952;13:597–614.
[145] Buescher MA, McClamrock HD, Adashi EY. Cushing’s syndrome in pregnancy. Obstet
Gynecol 1992;79:130–7.
[146] Aron DC, Schnall AM, Sheeler LR. Cushing’s syndrome and pregnancy. Am J Obstet
Gynecol 1990;162:244–52.
[147] Boccuzzi G, Angeli A, Bisbocci D, Fonzo D, Gaidano GP, Ceresa F. Effect of synthetic
luteinizing hormone releasing-hormone (LHRH) on the release of gonadotropins in
Cushing’s disease. J Clin Endocrinol Metab 1975;40:892–5.
[148] Sakakura M, Takebe K, Nakagawa S. Inhibition of luteinizing hormone secertion
induced by synthetic LRH by long-term treatment with glucocorticoids in human
subjects. J Clin Endocrinol Metab 1975;40:774–9.
[149] Fitzgerald PA, Aron DC, Findling JW, et al. Cushing’s disease: transient secondary
adrenal insufficiency after selective removal of pituitary microadenomas. Evidence for
a pituitary origin. J Clin Endocrinol Metab 1982;54:413–22.
[150] Jurney TH, deRuyter H, Vigersky RA. Cushing’s disease presenting as amenorrhea with
hyperprolactinemia—report of two cases. Clin Endocrinol 1981;14:539–46.
[151] Lamberts SWJ, DeLange SA, Stefanko S. Adrenocorticotropin-secreting pituitary
adenomas originate from the anterior or the intermediate lobe in Cushing’s disease:
differences in regulation of hormone secretion. J Clin Endocrinol Metab 1982;54:286–91.
[152] Rodriguez S, Alger M, Forsbach G, Contreras SN, Canales ES, Zarate A. Amenorrhea-
galactorrhea associated with Cushing’s disease due to pituitary tumor. J Endocrinol
Invest 1981;4:37–40.
[153] Grimes EM, Fayez JA, Miller GL. Cushing’s syndrome and pregnancy. Obstet Gynecol
1973;42:550–9.
[154] Koerten JM, Morales WJ, Washington SR III, Castaldo TW. Cushing’s syndrome in
pregnancy: a case report and literature review. Am J Obstet Gynecol 1986;154:626–8.
[155] Parra A, Cruz-Krohn J. Intercurrent Cushing’s syndrome and pregnancy. Am J Med

1966;40:961–6.
[156] Gormley MJJ, Hadden DR, Kennedy TL, Montgomery DAD, Murnahan GA, Sgeridan
B. Cushing’s syndrome in pregnancy—treatment with metyrapone. Clin Endocrinol
1982;16:283–93.
[157] Tuimala R, Heinonen PK, Markkula H, Salmi J. Low serum oestriol and Cushing’s
syndorme during pregnancy. Ann Chir Gynaecol 1985;74(Suppl 197):61–3.
[158] Semple CG, McEwan H, Teasdle GM, McNicol AM, Thompson JA. Recurrence of
Cushing’s disease in pregnancy. Case report. Br J Obstet Gynaecol 1985;92:295–8.
[159] Bevan JS, Gough MH, Gillmer MDG, Burke CW. Cushing’s syndrome in pregnancy: the
timing of definitive treatment. Clin Endocrinol 1987;27:225–33.
[160] MacGibbon AL, Brieger GM. Cushing syndrome in pregnancy secondary to an adrenal
cortical adenoma. Aust N Z J Obstet Gynaecol 1995;35:217–9.
[161] Cousins L, Rigg L, Hollingsworth D, et al. Qualitative and quantitative assessment of the
circadian rhythm of cortisol in pregnancy. Am J Obstet Gynecol 1983;145:411–6.
[162] Taft P, Martin FIR, Melick R. Cushing’s syndrome—a review of the response to
treatment in 42 patients. Aust Ann Med 1970;4:295–303.
[163] Hanson TJ, Ballonoff LB, Northcutt RC. Aminoglutethamide and pregnancy. JAMA
1974;280:963–4.
[164] Sonino N. The use of ketokonazole as an inhibitor of steroid production. N Engl J Med
1987;317:812–8.
[165] McEvoy GK, editor. Drug information 87. Bethesda, MD: American Society of Hospital
Pharmacists; 1987. p. 1874.
32 (2003) 593–612
Central causes of
hypogonadism—functional and organic
Michelle P. Warren, MDa,b,*, Caroline Vua
a
Department of Obstetrics and Gynecology, Columbia College of Physicians and Surgeons,
PH 16-127, 622 West 168th Street, New York, NY 10032, USA
b
Department of Medicine, Columbia College of Physicians and Surgeons, PH 16-127,
622 West 168th Street, New York, NY 10032, USA
Hypogonadism is a condition defined by an abnormal decrease in the

functional capability of the gonads, resulting in the delay of growth and
sexual development. The two main classifications of hypogonadism are
primary hypogonadism and secondary hypogonadism. Primary or hyper-
gonadotropic hypogonadism is characterized by sex organ failure, result-
ing from testicular or ovarian disease. Secondary or hypogonadotropic
hypogonadism refers to a communication failure between the neuroendo-
crine system and the gonads, even though the sex organs themselves may
be intact. Primary hypogonadism is chiefly distinguishable from second-
ary hypogonadism in that subnormal serum sex hormones and gamete
production levels occur in conjunction with high or normal serum follicle-
stimulating hormone (FSH) and luteinizing hormone (LH) levels. In
secondary hypogonadism, the serum FSH and LH levels are low or normal
[1–3].
Primary hypogonadism is more common in men than in women because
of the higher frequency of Klinefelter’s syndrome, the most common cause of
male hypergonadotropic hypogonadism. The incidence of hypogonado-
tropic hypogonadism is comparable in men and women. There is no common
age of onset, although the occurrence of hypogonadism can usually be
categorized as prepubertal or postpubertal. If the disorder manifests itself
before puberty, primary amenorrhea will ensue. If the onset is postpu-
bertal, then secondary amenorrhea is the most prevalent manifestation.
Hypogonadism arises from no one single cause. Often, the disorder results
from the interaction of several external and internal factors, and in some
* Corresponding author.
E-mail address: mpw1@columbia.edu (M.P. Warren).
doi:10.1016/S0889-8529(03)00042-2
594 M.P. Warren, C. Vu / Endocrinol Metab Clin N Am 32 (2003) 593–612
circumstances, the cause can be idiopathic or functional. Functional causes

imply the absence of an organic origin and the potential for reversal.
The hypothalamic–pituitary–gonadal axis

Gonadal function depends on the intricately interdependent relationship
between the sex organs and the hypothalamic–pituitary axis. The gonado-
tropin-releasing hormone (GnRH) neurons of the arcuate nucleus of the
hypothalamus are endogenously pulsatile and when their firings are
synchronized, GnRH (also called LH-releasing hormone, or LHRH) is
released into the portal vasculature. In turn, GnRH stimulates the anterior
pituitary gland to synthesize and secrete the gonadotropins LH and FSH.
In male physiology, LH stimulates testosterone production in the Leydig
cells, whereas FSH binds to Sertoli cells, enabling, in conjunction with
testosterone, spermatogenesis. In women, LH modulates oogenesis and the
secretion of sex hormones, including androgens by way of the theca cells,
whereas FSH induces the maturation of ovarian follicles and enables
steroidogenesis, primarily estrogen, by way of granulosa cells. A negative
feedback loop—involving the sex hormones and inhibin (an FSH-stimulated
peptide)—regulates the secretion of LH and FSH by inhibiting the anterior
pituitary gland and the hypothalamus.
Of the numerous components maintaining the integration of the
hypothalamic–pituitary–gonadal (HPG) axis, GnRH is perhaps the most
crucial element in terms of defining the causes of secondary hypogonadism.
To generate a single pulse, many GnRH neurons must be synchronized for
secretion almost simultaneously. The pulsatile release of GnRH is the
first step in the cascade of neuroendocrinal events that enable reproduc-
tion, sexual differentiation, and physical development. GnRH is especially
important for the attainment of puberty. The GnRH pulse generator remains
dormant until preadolescence, when increasing activity of the GnRH pulse
generator permits the pubertal process.. The basal GnRH pulse frequency is
roughly one pulse every 90 minutes, although this pattern shifts in response
to ovarian secretion during the menstrual cycle. Faster GnRH pulse
frequencies favor LH secretion, whereas slower rates facilitate FSH release.
Generally, the LH pulse pattern provides a good indication of the GnRH
pulsatile rate. GnRH pulsatile rate is once every 90 to 120 minutes during the
luteal-follicular transition. As a result, FSH secretion is favored. As the cycle
shifts to the mid- to late follicular stage, the pulsatile rate increases to one
pulse per hour, thus enhancing LH secretion. Across the follicular phase, the
ovarian secretion of estradiol and inhibin suppresses FSH relase. Following
ovulation, progesterone slows the GnRH pulse pattern to one pulse every 3
to 5 hours. FSH production is increased but is simultaneously inhibited from
release by estradiol and inhibin from the corpus luteum. Once the corpus
luteum regresses, FSH is freed from inhibition and its rise permits the next
follicular phase.
M.P. Warren, C. Vu / Endocrinol Metab Clin N Am 32 (2003) 593–612 595
The GnRH pulse generator is modulated by many factors, including

those that are concomitant factors to stress. The presence of stressors can
stimulate corticopin-releasing hormone (CRH), which in turn suppresses
GnRH secretion [4,5]. Prolactin, which is downregulated by dopamine and
secreted from the anterior pituitary, also exerts an inhibitory influence
on the reproductive axis. Prolactin suppresses hypothalamic secretion of
GnRH and ovarian response to LH. There also has been mounting evidence
about the role of metabolic factors, including leptin, in GnRH pulsatile
dysfunction. Leptin is a hormone produced by the obesity (ob) gene and
its receptors are primarily located in the hypothalamus. The hormone is
synthesized by adipocytes [6] and placenta [7], secreted into the circulation,
and translocated to the hypothalamic nuclei. Leptin plays a role in food
intake, energy expenditure, growth, and sexual maturation [8]. Leptin
receptors may modulate the GnRH pulse generator [9]. Studies have found
a correlation between leptin and GnRH and gonadotropin secretion [10–12].
It is believed that if leptin drops below a critical level, menstruation will not
occur [13]. Low leptin levels may indicate nutritional deficiency. Conse-
quently, deficient nutrition can suppress the reproductive axis—including
GnRH secretion—by other metabolic signals in addition to leptin [14].
Causes of hypogonadotropic hypogonadism

Low serum sex hormone levels in conjunction with low or normal
gonadotropin concentrations characterize secondary hypogonadism. The
central causes of hypogonadism can be traced to an acquired or congenital
origin. Some congenital central causes of hypogonadism include Kallmann’s
and Prader-Willi syndromes. Acquired causes of hypogonadism include
environmental toxins, radiation, chronic systemic illness, tumors, brain
trauma, and infections. For a comprehensive list of central causes of hypo-
gonadism, see Box 1. Although some causes overlap for men and women,
the source of hypogonadism is usually gender specific. This article focuses
on secondary female hypogonadism.
Functional causes
Functional causes of hypogonadotropic hypogonadism are common.
Factors causing physical or emotional stress may induce hypogonadism.
These factors include drug use, nutritional insult, and emotional distress.
Hypothalamic amenorrhea
Hypothalamic amenorrhea is one of the most frequently encountered
forms of anovulation. The clinical manifestation of hypothalamic amenor-
rhea is a lack of regular menstrual periods, which may be classified either as
Box 1. Central causes of hypogonadism

Hypothalamic localization
Hypothalamic amenorrhea
Exercise-induced
Anorexia nervosa
Psychogenic
Postcontraceptive
Tumors
Hypothalamic glioma
Other hypothalamic tumors
Infiltrative diseases
Laurence-Moon syndrome
Bardet-Biedl syndrome
Prader-Willi syndrome
Head trauma
Chronic or acute systemic illness
Cranial irradiation
Continuous GnRH analog use
Drug use
Isolated GnRH deficiency
Idiopathic hypogonadotropic hypogonadism
Kallmann’s syndrome
Adrenal hypoplasia congenita
Pituitary localization
Pituitary lesions
Prolactin-secreting adenoma
Craniopharyngioma
Other pituitary adenomas
Other benign tumors and cysts
Pituitary apoplexy
Infiltrative diseases
Cranial irradiation
primary or secondary. Primary amenorrhea refers to absence of menarche

by the age of 14 in the absence of secondary sexual characteristic devel-
opment or by the age of 16 with the presence of secondary sexual charac-
teristics. Secondary amenorrhea applies to women who have not been
menstruating for 3 to 6 months but who have previously menstruated. The
pathology of hypothalamic amenorrhea lies within the hypothalamic-
pituitary axis. Hypothalamic amenorrhea is characterized by slowed or
suppressed GnRH pulsatile secretion—which in turn prevents appropriate
LH pulsatility. Therefore, patients with hypothalamic amenorrhea usually
demonstrate relative hypoestrogenism and normal or low serum gonado-

tropin levels.
Excessive exercise
Physical exercise for aesthetic and competitive purposes has become an
increasingly common feature of women’s lives in the past 30 years. In 1970,
only one woman ran the New York City Marathon and she did not finish
the race. Twenty years later, 5249 women entered the marathon and 4500
finished [15]. Although physical exercise can contribute to better health,
excessive physical strain can be deleterious to the body, especially the
reproductive system. Statistics show that the prevalence of reproductive
dysfunction is 6% to 79% in athletic women [16], depending on the degree
of competition and sport-specific expectations. Women in athletic fields that
require low body weight, such as ballet, figure skating, gymnastics, or long-
distance running, are most likely to develop exercise-induced menstrual
irregularities (Table 1). In such sports, women are often pressured to
maintain body fat levels at less than 10%. The stress placed on the body is
not only from intense exercise but also from psychologic and dietary
pressures to stay thin [5,15].
There are two hypotheses to explain the correlation between athletics and
functional hypothalamic amenorrhea. The body composition hypothesis
purports that normal menstrual function requires a minimum of 22% body
fat [17]. The hypothesis is primarily based on correlation rather than
experimental evidence [18], however, and further investigation has recorded
normal menstruation in female athletes with less than 17% body fat [19]. The
Table 1
Prevalence of menstrual irregularities in different athletic fields
Activity Study No. of subjects Irregularities, %
General population Petterson et al (1973) 1862 2
Singh (1981) 900 5
Weight-bearing sports
Ballet Abraham et al (1982) 29 79
Brooks-Gunn et al (1987) 53 59
Feicht et al (1978) 128 6–43
Glass et al (1987) 67 34
Running Shangold and Levine (1982) 394 24
Sanborn et al (1982) 237 26
Non–weight-bearing sports
Cycling Sanborn et al (1982) 33 12
Swimming Sanborn et al (1982) 197 12
Data from Constantini NW, Warren MP. Physical activity, fitness, and reproductive health
in women: clinical observations. In: Bouchard C, Shephard RJ, Stephens T, editors. Physical
activity, fitness, and health: international proceedings and consensus statement. Champaign, IL:
Human Kinetics; 1994. p. 955–66.
exercise stress hypothesis, however, theorizes that the stress generated by

intensive athletic regimens disrupts GnRH pulsatility by way of the
hypothalamic–pituitary–adrenal (HPA) axis. The HPA axis secretes three
primary stress-coping hormones, including cortisol. It is common that in
situations of intense stress, the central nervous system, by way of negative
feedback from cortisol, shuts down certain behavioral functions, such as
reproduction. Exercise in conjunction with caloric restriction led to LH
suppression, however, whereas exercise alone did not influence LH pulsatility
[16,20]. A more likely causal factor of exercise-induced reproductive
abnormalities may be energy drain. An energy drain occurs when caloric
intake is insufficient for the level of physical activity [5]. Because leptin is
believed to be regulated by total energy intake, a negative energy balance will
lower leptin levels. Lowered leptin levels are associated with suppression of
the GnRH pulse generator. As such, low leptin levels have been reported in
amenorrheic subjects who exercise regularly at a high level [14]. A negative
energy balance has also been observed in women with exercise-induced
hypothalamic amenorrhea [21–23]. The hypothalamic dysfunction seen in
exercise-induced amenorrhea therefore may be multifactorial.
Anorexia nervosa
In the last few decades, eating disorders have become common in
adolescent girls who live in affluent nations such as the United States and
Japan. Among the different types of eating disorders, anorexia nervosa has
the highest profile. Anorexia nervosa is the third most prevalent chronic
illness in the United States [24]. In today’s social environment, young girls’
self-perceptions have been deeply warped by unrealistic expectations to
adopt a reed-thin, waiflike body image. The contemporary obsession with
thinness permeates all aspects of society, including television, film, fashion,
and advertisements that promise instantaneous weight loss. Cultural
influences are not the only influence in the development of anorexia ner-
vosa, however. Familial and hereditary predispositions are among some of
the other environmental factors contributing to anorexia nervosa. The
Diagnositc and Statistical Manual of Mental Disorders, Fourth Edition,
criteria for a diagnosis of anorexia nervosa must encompass four require-
ments: refusal to maintain body weight over a minimal normal weight for age
and height, intense fear of becoming fat despite low weight, distortion of
body image, and the occurrence of primary or secondary amenorrhea.
Anorexia nervosa almost always results in hypogonadotropic hypogonad-
ism. Individuals who have anorexia nervosa are characterized by low
gonadotropin levels in conjunction with a subnormal concentration of sex
steroids [25]. The mechanisms of hypogonadism in anorexia nervosa involve
previously mentioned GnRH regulators, including CRH and possibly leptin.
Elevated levels of CRH in the spinal fluid of individuals with anorexia have
been recorded [26–28]. Lowered leptin levels, probably resulting from
nutritional deprivation, also have been reported in women with anorexia

nervosa [29–31]. Because anorexia nervosa is often associated with de-
pression, there may also be the added component of psychotropic agents,
which also affect menstrual function. These agents are discussed separately.
Psychogenic amenorrhea
In today’s society, women juggle the demands of career, family, and
cultural standards. Women are simultaneously expected to perform on par
with their male counterparts in the workplace, remain the primary caregivers
in the home, and maintain thin bodies. Psychogenic amenorrhea is defined as
the lack of menses with a psychologic origin and usually excludes intense
exercise and eating disorders as possible causes of anovulation. Patients
diagnosed with psychogenic amenorrhea often recall a significant stressful
life event at the time of the loss of menses [32,33]. Current research indicates
that patients with psychogenic or idiopathic hypothalamic amenorrhea
exercise more regularly, exhibit nutritional deficiency, and adhere to eating-
disordered–like diets, despite the lack of an eating disorder diagnosis [34–36].
Therefore, psychogenic amenorrhea may not be purely mental in nature but
the result of the interaction between psychologic and physical factors.
Oral contraceptives and postpill amenorrhea

The incidence of amenorrhea following discontinuation of oral contra-
ceptives (OCs) was first documented in 1966 [37,38]. In 1979, a study
determined that 55% of postpill amenorrhea (PPA) cases was primarily
caused by the use of OCs, whereas the other 45% of cases resulted from
underlying causes that were aggravated or masked by the use of OCs [39].
The prevalence of PPA has been estimated at less than 1 in 1000 [40]. PPA
is defined as the failure of resumption of menses within 3, 6, or 12 months
of discontinuing OCs. A woman’s susceptibility to PPA is accentuated if
she has a history of oligomenorrhea, secondary amenorrhea, or irregular
menstrual cycles. In some cases, galactorrhea also occurred in patients with
PPA. Pituitary adenomas are among the more common causes of PPA and
are present in 24% of patients who have PPA with galactorrhea and in 1%
to 3% of patients with PPA alone [41]. Nevertheless, the more likely cause of
PPA remains hypothalamic deficiency, engendered by low weight or weight
loss during the use of OCs [42,43].
Alcohol
The persistent abuse of alcohol, especially in people with cirrhosis, may
have some deleterious effects on the reproductive axis. Ethanol and its
metabolite, acetyl aldehyde, are toxic to the gonads. It has been theorized
that prolonged use of alcohol may lead to decreased circulating LH levels
and desensitization of LH to GnRH [44,45]. Reports on the effect of ethanol
on gonadal hormones, however, are inconsistent—reports have shown it to

have both a stimulatory and an inhibitory influence. It is, however, safe
to predict that women who are chronic alcohol abusers may become
amenorrheic and experience the loss of secondary sexual characteristics. The
mechanism of alcohol-related hypogonadotropic hypogonadism remains
unclear, although elevated prolactin levels may be involved [46–50]. As
previously mentioned, prolactin inhibits the GnRH pulse generator. Some
current studies have reported that acute, but not chronic, ethanol exposure
led to hypersecretion of prolactin in rodents [47,48]. Some have proposed
that the elevated prolactin levels are a consequence of ethanol-induced
changes in opioid and dopamine levels [47,50]. Nevertheless, ethanol-related
hypogonadotropic hypogonadism remains a controversial issue.
Smoking
Statistics demonstrate that smokers reach menopause about 1 to 2 years
earlier than do nonsmokers [51,52]. Although cigarette smoking has known
antiestrogenic components, studies have yet to find a solid correlation
between nicotine and endocrine alterations. A small-scale Italian study
reported elevated adrenocorticotropic hormone, cortisol, and prolactin levels
in smokers versus nonsmokers [53]. Several studies performed on rodents
found that nicotine administration inhibited LH secretion by way of
suppression of GnRH [54,55]. No such findings have been recorded in
humans, however.
Opioids
Prolonged use of opioids is common among patients who have cancer and
those who suffer nonmalignant pain. Their exploitation among drug abusers
must likewise be noted. Like nicotine and ethanol, opioids may have a toxic
effect on the reproductive axis. Despite the notion that opioids exert some
control and influence over several endocrine pathways [56], there has been
little research documenting the endocrine effects in humans. A Belgian study
concerning the long-term use of opioids in treating intractable, nonmalignant
pain observed that most subjects developed hypogonadotropic hypogonad-
ism following intrathecal administration of opioids [57]. Similar results were
reported by an Australian study [58]. Both male and female patients receiving
intrathecal morphine demonstrated low to normal serum gonadotropin
concentrations and low to normal serum sex hormone levels. The researchers
deduced that the mechanism of amenorrhea in the female opioid users was
attributable to opioid-induced hypothalamic GnRH suppression. A pituitary
cause can be deemed unlikely because most opioid receptors are located in the
hypothalamus. GnRH suppression by exogenous opioids could be explained
through the mechanisms involved in the reception of endogenous opioids.
Neurons containing endogenous opioid peptides can be found in close
proximity to hypothalamic areas rich in GnRH. The release of b-endorphins

from endogenous opioid peptides interferes with GnRH secretion, resulting
in decreased LH production, an action observed during the luteal phase
of the menstrual cycle [59]. Nevertheless, the subject of opioid-related
reproductive dysfunction requires much more extensive investigation to
convincingly explicate its potential influence on the HPG axis.
Other drugs
Certain psychotropic drugs, such as phenothiazines and risperidone, block
prolactin-inhibiting dopamine release [60,61]. This effect thereby increases
prolactin and possibly causes, or makes patients more susceptible to,
menstrual irregularity. Anabolic androgenic steroids, often used by athletes,
can also lead to hypogonadotropic hypogonadism in women. A 1991 study of
female athletes using androgens noted physical symptoms of hyperandrogen-
ism, including menstrual irregularity. The female athletes also had subnormal
FSH and estradiol levels, although their LH levels remained normal [62].
Critical and chronic systemic illness

The onset of any form of critical illness or the existence of chronic
systemic disease will acutely suppress the HPG axis. The endocrine
response, including that of the GnRH pulse generator, to the physiological
stress of severe illness mirrors that of its reaction to emotional or metabolic
stress. The suppression of gonadotropin release should be expected when
there is acute [63,64] or chronic [65,66] systemic disease. Chronic systemic
illnesses most associated with hypothalamic–pituitary dysfunction include
chronic renal failure and AIDS. The categorization for critical illness as
a central cause of hypogonadism includes intracranial disease, although
severe disease in general indiscriminantly affects reproductive endocrine
response [64,67]. Acute illness—excluding cranial injury, surgery, medical
treatment, and hyperprolactinemia—may lead to transient forms of either
hypergonadotropic or hypogonadotropic hypogonadism [67,68].
Organic causes
Most central causes of hypogonadism that are organic in nature can be
attributed to pituitary and hypothalamic lesions. Other causes of structural
etiology include infiltrative diseases, including sarcoidosis and hemochro-
matosis, head trauma, genetic mutations, and cranial irradiation.
Anticancer treatments
With the advent of life-sparing technologies, women and young girls
diagnosed with cancer can expect a greater chance of survival. A somewhat
inevitable side effect of the therapies, however, is reproductive dysfunction.
Anticancer treatments are some of the most common causes of toxin-induced

hypogonadism [69–71]. Hypogonadism from cancer therapy is more likely to
be caused by an ovarian rather than a central defect. Chemotherapeutic
drugs and ovarian ablation typically lead to hypergonadotropic hypogonad-
ism [72]. Cranial irradiation—common in the treatment of brain tumors and
non-Hodgkin’s lymphomas [73,74]—and GnRH analogs likely result in
hypogonadotropic hypogonadism. The added component of psychologic
stress and weight loss, associated with the emotional and physical trauma
of diagnosis and treatment, may also play a part in the neuroendocrine
suppression of the hypothalamic-pituitary-ovarian axis. Although the effect
of cranial irradiation on the neuroendocrine system is dose and exposure
dependent, possible hypogonadotropic side effects include hyperprolactine-
mia and gonadotropin deficiency caused by hypopituitarism [74,75]. It has
been estimated that 70% of women undergoing cranial irradiation experience
menstrual irregularities [76].
Breast cancer is the most common cancer in women. In 2001, 192,200
women developed breast cancer and 40,200 women died of the disease [77].
Given the long-held, but highly disputed, correlation between estrogen and
breast cancer [78], estrogen-suppressing GnRH administration is rarely used
but remains a viable alternative to chemotherapy in the treatment of
metastatic forms of the disease [79,80]. This particular course of treatment is
not exclusive to breast cancer and may also be used in the treatment of
ovarian cancer and prostate cancer. GnRH analogs lead directly or
indirectly to marked decreases in gonadotropin secretion. Ovarian folliculo-
genesis and sex steriod secretion is halted. Estrogen secretion falls to castrate
levels [81,82]. Although the impact of GnRH analogs on breast cancer cells
remains disputed, it is believed that GnRH may exert a direct inhibitory
influence on the proliferation of breast cancer cells [83]. This antiprolifer-
ative element is not well understood, however.
Pituitary stalk damage or transection is another consequence of
anticancer therapy that may lead to hypogonadotropic hypogonadism.
It is an option in the treatment of metastatic breast carcinoma [84].
Reproductive dysfunction is most likely to occur if the transection is near
the hypothalamus [42]. Interruption of the communication pathways
between the hypothalamus and pituitary prevents GnRH signals from stim-
ulating the release of gonadotropins and hypogonadism ensues.
Bardet-Biedl and Laurence-Moon syndromes

Historically fused as the Laurence-Moon-Biedl syndrome, Bardet-Biedl
and Laurence-Moon are now considered two separate, but related, entities.
The Laurence-Moon syndrome lacks the obesity and polydactyly found in
the Bardet-Biedl syndrome [85,86]. Nevertheless, hypogonadism remains
one of the clinical consequences of the two disorders. In general, gonadal
dysfunction is hypogonadotropic in nature, although concomitant primary
gonadal failure may also occur [87]. The syndromes are hereditary and
autosomally recessive. A high rate of consanguinity has been observed
among people afflicted by both syndromes [88]. The hypogonadism may
arise from a congenital defect in the hypothalamus.
Prader-Willi syndrome
Prader-Willi syndrome is a rare congenital condition, affecting anywhere
from 1 in 16,000 [89] to 1 in 22,000 [90] persons. Characteristics of the
syndrome include obesity, voracious appetite, short stature, mental re-
tardation, hypotonia, cryptorchidism, and hypogonadotropic hypogonad-
ism. The inheritance of a paternal deletion of chromosome region 15q11-13
forms the genetic origin of the disorder. This chromosomal deletion may lead
to abnormal development of the hypothalamus, thereby inhibiting or
interfering with normal GnRH pulsatile secretion. Despite the long-held
belief that Prader-Willi syndrome invariably causes infertility, recent
evidence disputes the claim. Two pregnancies have been reported in women
with Prader-Willi syndrome [91,92].
Tumors
In general, tumors impede normal reproductive function by destroying the
pituitary gland by means of spatial encroachment. Tumors are also apt to
compress the portal vessels and thus impede the flow of GnRH from the
hypothalamus to the pituitary gland [42]. Craniopharyngioma is the most
common pituitary tumor in children [93–95]. The incidence of craniophar-
yngiomas is 1.3 per 1 million persons per year. It is more prevalent in children
and older adults [96]. Although it is congenital in nature, this benign type of
tumor is slow growing and may not be diagnosed until late puberty or early
adulthood. It arises from the remnants of the craniopharyngeal duct, or
Rathke’s pouch. Calcification of the suprasellar region with a likely cystic
component is commonly observed in patients with craniopharyngiomas.
Neurologic symptoms of craniopharyngioma include amenorrhea, hypopi-
tuitarism resulting in gonadotropin deficiency, hyperprolactinemia, obesity,
ocular defects, recurrent frontal headaches, and vomiting. Other principal
lesions affecting GnRH and gonadotropin secretion include prolactinomas,
germinomas, meningiomas, astrocytomas, and gliomas [42,66,87]. Of those,
prolactinomas are the most common pituitary tumors [97]. In rare instances,
pituitary apoplexy occurs. Pituitary apoplexy caused by blood loss or
a sudden, large decrement in blood pressure during delivery is referred to as
Sheehan’s syndrome. On the whole, pituitary tumors, which are more
common than hypothalamic tumors, account for only 10% of intracranial
neoplasms (25 cases per 1 million persons) [98]. The overall incidence of
hypothalamic tumor–induced hypogonadotropic hypogonadism remains
low.
Infiltrative disease
Infiltrative disease can cause hypogonadism by directly affecting either
the hypothalamus or pituitary. Sarcoidosis and Langerhans cell histiocytosis
(LCH) are associated with hypothalamic dysfunction. Sarcoidosis is an
idiopathic granulomatous disease, affecting mostly young adults between
the ages of 29 and 40. In most cases, the lungs and thoracic lymph glands are
the primary affected organs. Its neurologic prevalence is estimated to be 5%
to 15% [99]. The cause of LCH remains unknown. The likelihood of
hypogonadism in LCH may be expected if the patient also suffers from
central diabetes insipidus [100,101]. Little is known about LCH, which is
a multisystem disease, other than that it may be the result of immunologic
dysfunction [102]. Hemachromatosis also can result in pituitary hypogo-
nadism. The hypogonadism is caused by storage of excess iron in pituitary
cells. The iron overload interferes with normal gonadotropin secretion [103].
Head trauma
Any kind of cranial trauma can alter hypothalamic and pituitary
function. Trauma isolated to the hypothalamus can disrupt the transmission
of GnRH pulses, resulting in low gonadotropin levels. Physical damage to
just the anterior pituitary will suppress gonadotropin release and negate
FSH and LH responses to GnRH. Injury to the base of the skull, such as
that seen in whiplash, may sever the connection between hypothalamus and
pituitary, thereby interrupting the portal vasculature and the communica-
tion between the hypothalamus and pituitary. In most head traumas, injury
will be incurred by both the hypothalamus and pituitary gland [104].
Idiopathic hypogonadotropic hypogonadism

Advances in elucidating the pathogenesis of secondary male hypogonad-
ism have primarily centered on the genetic aspects of idiopathic hypogona-
dotropic hypogonadism (IHH). IHH is based on a diagnosis of exclusion. It
is characterized by isolated GnRH deficiency. Overall hypothalamic and
pituitary function usually remain intact. Four genes have been identified with
IHH: KAL, DAX1, GNRHR (genetic mutations of the GnRH receptor), and
PC1 (PC1 is associated with malfunctioning prohormone processing)
[3,105,106].
Kallmann’s syndrome
Kallman’s syndrome affects both genders, but it is far more prevalent in
men [43]. The disorder was first described in 1856, but was not clinically
identified until 1944 by the American geneticist Kallmann [107,108].
Kallmann’s syndrome, which is closely associated with IHH, is classically
defined as hypogonadotropic hypogonadism accompanied by anosmia. In
general, the disorder affects 1 of 10,000 men [109,110]. The incidence is 5 to

7 times lower for women [110]. Hypogonadism is caused by inadequate
hypothalamic secretion of GnRH. The deficiency involves anomalies in the
migration of GnRH-releasing neurons from the olfactory placode to the
hypothalamus during fetal development. Recently, scientists have isolated
the KAL gene as a cause of at least some forms of Kallmann’s syndrome
[43,106,107,111]. There are three derivatives of the KAL gene: the more
prevalent X-linked KAL-1, the autosomal dominant KAL-2, and the
autosomal recessive KAL-3 [106]. The KAL gene product gates cell adhesion
and its loss precludes timely neuronal migration. Incomplete forms appear to
exist.
Diagnosis of hypogonadotropic hypogonadism

Although the diagnosis of hypogonadism is fairly simple, the localization
of the underlying cause often proves problematic. Hypergonadotropic
causes can be excluded by measuring circulating FSH and LH (Table 2). In
children, such a diagnosis may be more difficult to establish because of
naturally low FSH and LH levels. A recent large-scale case study on delayed
puberty [112] produced data that suggest gonadotropin levels in hypogo-
nadal children may not differ greatly from the criteria set for adult
hypogonadism (Table 3). Family history may provide a clue about the
likelihood of constitutional delay and inherited disorders. If an organic
cause is suspected, an MRI is recommended. In general, patients with
hypogonadism of organic origin present with inappropriate vegetative
and neurologic symptoms. Hypothalamic lesions may be associated with
behavioral disorders, disturbances in temperature control, or alterations in
visual acuity, appetite, and sleep-wake patterns [42]. Although it is a
functional cause of hypogonadism, inability to stabilize core temperature
also has been observed in anorexia nervosa [113,114]. Ventromedial
neoplasms, in particular, are associated with hyperphagia, rage, and
dementia [115]. Identification of hypothalamic lesions is missed in 51.7%
of cases [42] Thus, a high index of suspicion is warranted. Pituitary disease
may present with some of the symptoms of hypothalamic lesions, which
makes it difficult to differentiate between the two. Other symptoms
Table 2
Female hypogonadism
Clinical state Serum FSH Serum LH
Hypogonadotropic \ 5 mlU/mL \ 5 mlU/mL
Hypergonadotropic [ 40 mlU/mL [ 25 mlU/mL
Adapted from Speroff L, Glass RH, Kase NG. Amenorrhea. In: Speroff L, Glass RH, Kase
NG, editors. Clinical gynecologic endocrinology and infertility. 4th edition. Baltimore, MD
Williams and Wilkins: 1989. p. 173.
Table 3
Evaluation of gonadotropin levels in hypogonadal children
Characteristic Serum FSH Serum LH
Boys
Hypogonadotropic 0.7 1.0 mlU/mL 0.3 0.4 mlU/mL
Hypergonadotropic 49.9 27.0 mlU/mL 21.4 11.3 mlU/mL
Girls
Hypogonadotropic 1.3 1.4 mlU/mL 0.6 0.6 mlU/mL
Hypergonadotropic 104.2 61.3 mlU/mL 32.3 20.9 mlU/mL
Data from Sedlmeyer IL, Palmert MR. Delayed puberty. analysis of a large case series from
an academic center. J Clin Endocrinol Metab 2002;87(4):1613–20.
characteristic of pituitary lesions include loss of axillary hair, low libido, and
short stature. Because functional causes share some of the same symptoms
as organic lesions, the diagnosis can only be made through exclusion.
Overall, the use of GnRH stimulation tests is not helpful, because such tests
only indicate the severity of reproductive dysfunction.
Treatment of hypogonadotropic hypogonadism

The course of treatment should be tailored to the cause. In most cases,
successful treatment of the underlying cause will restore partial, if not
complete, reproductive function. A summary of treatments for amenorrhea,
which is one of the most common features of female hypogonadotropic
hypogonadism, is shown in Table 4. When fertility is desired, gonadotropins
can be administered. Because of decreased or suppressed GnRH secretion in
hypogonadotropic hypogonadism, pulsatile GnRH administration can be
used if pituitary function remains intact. In children and adolescents, such
a practice, sometimes adjusted with gradually increasing pulsatile dosage to
mimic the normal pubertal pattern, has proven to be successful for the
Table 4
Treatment of amenorrhea
Model Study Therapy
Hypothalamic amenorrhea Hergenroeder (1995) Oral contraceptive randomized,
(including eating disorders) 12 mo 0.035 mg ethinyl estradiol
0.5–1.0 mg norethindrone
Exercise-induced amenorrhea Cumming et al (1987) HRT observed 24–39 mo
Warren et al (1986) HRT randomized, 24 mo
Anorexia nervosa Klibanski et al (1995) HRT randomized
Abbreviation: HRT, hormone replacement therapy.
Data from Warren MP, Perlroth NE. The effects of intense exercise on the female
reproductive axis. J Endocrinol 2001;170(1):3–11; reproduced with permission of the Society of
Endocrinology.
induction of puberty [116,117]. In several instances, however, resistance to

GnRH analogs has been encountered [118,119]. In these cases, attempts
with exogenous gonadotropin administration may solve the problem.
Resistance to GnRH pulsatile therapy has been mainly associated with
GnRH receptor gene mutations [119].
Summary
Whether caused by environmental factors, lesions, genetic mutations,
drug interactions, or unknown origins, the path of the central causes of
hypogonadism frequently leads back to the GnRH pulse generator. In some
cases, the cause can be unequivocally traced to a single factor, such as some
of the congenital syndromes previously described. In most instances, how-
ever, hypogonadism is occult or functional. Because of the wide spectrum
and complexity of underlying causes, a definitive diagnosis, especially in
functional causes of the disorder, is not always attainable.
References
[1] Plymate SR. Male hypogonadism. In: Becker KL, editor. Principles and practice of
endocrinology and metabolism. 3rd edition. Philadelphia: Lippincott, Williams &
Wilkins; 2001. p. 1125–47.
[2] Speroff L, Glass RH, Kase NG. Amenorrhea. In: Speroff L, Glass RH, Klase NG,
editors. Clinical gynecologic endocrinology and infertility. 4th edition. Baltimore, MD:
Williams & Wilkins; 1989. p. 165–205.
[3] Achermann JC, Weiss J, Lee E-J, Jameson JL. Inherited disorders of the gonadotropin
hormones. Mol Cell Endocrinol 2001;179:89–96.
[4] Hayes FJ, Seminara SB, Crowley WF Jr. Hypogonadotropic hypogonadism. Endocrinol
Metab Clin North Am 1998;27(4):739–63.
[5] Warren MP, Fried JL. Hypothalamic amenorrhea. The effects of environmental stresses
on the reproductive system: a central effect of the central nervous system. Endocrinol
Metab Clin North Am 2001;30(3):611–23.
[6] Elmquist JK, Maratos-Flier E, Saper CB, Flier JS. Unraveling the central nervous system
pathways underlying responses to leptin. Nat Neurosci 1998;1(6):445–50.
[7] Yura S, Sagawa N, Mise H, Mori T, Masuzaki H, Ogawa Y, et al. A positive umbilical
venous-arterial difference of leptin level and its rapid decline after birth. Am J Obstet
Gynecol 1998;178(5):926–30.
[8] Casanueva FF, Dieguez C. Neuroendocrine regulation and actions of leptin. Front
Neuroendocrinol 1999;20(4):317–63.
[9] Cheung CC, Thornton JE, Kuijper JL, Weigle DS, Clifton DK, Steiner RA. Leptin is
a metabolic gate for the onset of puberty in the female rat. Endocrinology
1997;138(2):855–8.
[10] Tezuka M, Irahara M, Ogura K, Kiyokawa M, Tamura T, Matsuzaki T, et al. Effects of
leptin on gonadotropin secretion in juvenile female rat pituitary cells. Eur J Endocrinol
2002;146(2):261–6.
[11] Chan JL, Mantzoros CS. Leptin and the hypothalamic-pituitary regulation of the
gonadotropin-gonadal axis. Pituitary 2001;4(1–2):87–92.
[12] Baldelli R, Dieguez C, Casanueva FF. The role of leptin in reproduction: experimental
and clinical aspects. Ann Med 2002;34(1):5–18.
[13] Kopp W, Blum WF, von Prittwitz S, Ziegler A, Lubbert H, Emons G, et al. Low leptin
levels predict amenorrhea in underweight and eating disordered females. Mol Psychiatry
1997;2(4):335–40.
[14] Warren MP, Ramos R, Davis LB. Updates in exercise-associated amenorrhea and leptin.
In: Nattiv A, Ireland ML, editors. The female athlete. Philadelphia: Harcourt Health
Sciences. In press [chapter 14].
[15] Warren MP, Ramos R, Davis LB. Updates in exercise-associated amenorrhea and leptin.
In: Nattiv A, Ireland ML, editors. The female athlete. Philadelphia: Harcourt Health
Sciences; 2003.
[16] Warren MP, Perlroth N. The effects of intense exercise on the female reproductive system.
J Endocrinol 2001;170(1):3–11.
[17] Frisch RE, McArthur JW. Menstrual cycles: fatness as a determinant of minimum weight
for height necessary for their maintenance or onset. Science 1974;185(4155):949–51.
[18] Schneider JE, Wade GN. Letter to the Editor. Am J Phys 1997;273:E231–2.
[19] Sanborn CF, Albretch BH, Wagner WW Jr. Athletic amenorrhea: lack of association with
body fat. Med Sci Sports Exerc 1987;19(3):207–12.
[20] Loucks AB. Exercise training in the normal female. In: Warren MP, Constantini NW,
editors. Sports Endocrinology. Totowa, NJ: Humana Press; 2000. p. 165–80.
[21] Laughlin GA, Yen SS. Hypoleptinemia in women athletes: absence of a diurnal rhythm
with amenorrhea. J Clin Endocrinol Metab 1997;82(1):318–21.
[22] Warren MP, Brooks-Gunn J. Delayed menarche in athletes: the role of low energy intake
and eating disorders and their relation to bone density. In: Laron Z, Rogol AD, editors.
Hormones and sport. New York: Raven Press; 1989. p. 41–54.
[23] Myerson M, Gutin B, Warren MP, May M, Contento I, Lee M, et al. Resting metabolic
rate and energy balance in amenorrheic and eumenorrheic runners. Med Sci Sports Exerc
1991;23(1):15–22.
[24] Emans SJ. Eating disorders in adolescent girls. Pediatr Int 2000;42(1):1–7.
[25] Warren MP. Anorexia nervosa and the reproductive axis. In: Adashi EY, editor. Repro-
ductive endocrinology, surgery, and technology. New York: Raven Press; 1995. p. 1039–60.
[26] Boyar RM, Hellman LD, Roffwarg H, Katz J, Zumoff B, O’Connor J, et al. Cortisol
secretion and metabolism in anorexia nervosa. N Engl J Med 1977;296(4):190–3.
[27] Gold PW, Gwirtsman H, Avgerinos PC, Nieman LK, Gallucci WT, Kaye W, et al.
Abnormal hypothalamic-pituitary-adrenal function in anorexia nervosa. Pathophysio-
logic mechanisms in underweight and weight-corrected patients. N Engl J Med 1986;
314(21):1335–42.
[28] Hotta M, Shibasaki T, Masuda A, Imaki T, Demura H, Ling N, et al. The responses of
plasma adrenocorticotropin and cortisol to corticotropin-releasing hormone (CRH) and
cerebrospinal fluid immunoreactive CRH in anorexia nervosa patients. J Clin Endocrinol
Metab 1986;62(2):319–24.
[29] Grinspoon S, Gulick T, Askari H, Landt M, Lee K, Anderson E, et al. Serum leptin levels
in women with anorexia nervosa. J Clin Endocrinol Metab 1996;81(11):3861–3.
[30] Lear SA, Pauly RP, Birmingham CL. Body fat, caloric intake, and plasma leptin levels in
women with anorexia nervosa. Int J Eat Disord 1999;26(3):283–8.
[31] Matejek N, Weimann E, Witzel C, Molenkamp G, Schwidergall S, Bohles H.
Hypoleptinaemia in patients with anorexia nervosa and in elite gymnasts with anorexia
athletica. Int J Sports Med 1999;20(7):451–6.
[32] Sirakov M, Slavova A. Chronic stress and the degree of anxiety in girls with menstrual
cycle disorders. Akush Ginekol [Sofiia] 1989;28(2):51–4.
[33] Facchinetti F, Fava M, Fioroni L, Genazzani AD, Genazzani AR. Stressful life events
and affective disorders inhibit pulsatile LH secretion in hypothalamic amenorrhea.
Psychoneuroendocrinology 1993;18(5–6):397–404.
[34] Laughlin GA, Dominguez CE, Yen SS. Nutritional and endocrine-metabolic aberrations
in women with functional hypothalamic amenorrhea. J Clin Endocrinol Metab 1998;
83(1):25–32.
[35] Warren MP, Holderness CC, Lesobre V, Tzen R, Vossoughian F, Brooks-Gunn J.
Hypothalamic amenorrhea and hidden nutritional insults. J Soc Gynecol Investig
1994;1(1):84–8.
[36] Marcus MD, Loucks TL, Berga SL. Psychological correlates of functional hypothalamic
amenorrhea. Fertil Steril 2001;76(2):310–6.
[37] Shearman RP. Amenorrhea after treatment with oral contraceptives. Lancet 1966;
2(7473):1110–1.
[38] Whitelaw MJ, Nola VF, Kalman CF. Irregular menses, amenorrhea, and infertility
following synthetic progestational agents. JAMA 1966;195(9):780–2.
[39] Moghissi KS, Sajed F. Postpill amenorrhea. In: Hafez ESE, editor. Human ovulation.
New York: Elsevier; 1979. p. 243.
[40] Hull MG, Bromham DR, Savage PE, Barlow TM, Hughes AO, Jacobs HS. Post-pill
amenorrhea: a causal study. Fertil Steril 1981;36(4):472–6.
[41] Dickey RP, editor. Galactorrhea/post-pill amenorrhea. In: Managing contraceptive pill
patients. New Orleans, LA: CIP; 1991. p. 234–6.
[42] Christy NP, Warren MP. Disease syndromes of the hypothalamus and anterior pituitary.
In: DeGroot LJ, editor. Endocrinology. New York: Grune and Stratton; 1979. p. 215–52.
[43] Marshall JC, Eagleson CA, McCartney CR. Hypothalamic dysfunction. Mol Cell
Endocrinol 2001;183:29–32.
[44] Smanik EJ, Barkoukis H, Mullen KD, McCullogh AJ. The liver and its effect on
endocrine function in health and disease. In: Shiff L, Shiff E, editors. Diseases of the liver.
Philadelphia: JB Lippincott; 1993. p. 1373.
[45] Van Thiel DH, Gavaler JS. Endocrine consequences of alcohol abuse. Alcohol@Alcohol
1990;25:341–4.
[46] De Maria N, Colantoni A, Van Thiel DH. The liver and endocrine function. In: Becker
KL, editor. Principles and practice of endocrinology and metabolism. 3rd edition.
Philadelphia: Lippincott, Williams & Wilkins; 2001. p. 1870–85.
[47] Sato F, Nakamura K, Taguchi M, Aoki H, Aoki T, Yasuda N. Studies on the site
of ethanol action in inducing prolactin release in male rats. Metabolism 1996;45(11):
1330–4.
[48] Emanuele NV, Lapaglia N, Emanuele MA. Impact of acute and chronic ethanol exposure
on prolactin in both male and female rats. Endocrine 2001;16(1):29–37.
[49] Frias J, Rodriguez R, Torres JM, Ruiz E, Ortega E. Effects of acute alcohol intoxication
on pituitary-gonadal axis hormones, pituitary-adrenal axis hormones, beta-endorphin
and prolactin in human adolescents of both sexes. Life Sci 2000;67(9):1081–6.
[50] Sarkola T, Makisalo H, Fukunaga T, Eriksson CJ. Acute effect of alcohol on estradiol,
estrone, progesterone, prolactin, cortisol, and luteinizing hormone in premenopausal
women. Alcohol Clin Exp Res 1999;23(6):976–82.
[51] McKinlay SM, Bifano NL, McKinlay JB. Smoking and age at menopause in women. Ann
Intern Med 1985;103(3):350–6.
[52] Harlow BL, Signorello LB. Factors associated with early menopause. Maturitas
2000;35(1):3–9.
[53] Sartori MP, Sellini M, Baccarini S, Fabiani F. Cigarette smoking and hormonal changes
in the course of the menstrual cycle. Clin Ter 1993;143(1):15–8.
[54] Sano A, Funabashi T, Kawaguchi M, Shinohara K, Kimura F. Intravenous injections of
nicotine decrease the pulsatile secretion of LH by inhibiting the gonadotropin-releasing
hormone (GnRH) pulse generator activity in female rats. Psychoneuroendocrinology
1999;24(4):397–407.
[55] Hodson CA, Davis MC, Burden HW. Effect of prior nicotine treatment on drug induced
changes in serum LH concentrations in rats. Life Sci 1997;60(25):2303–8.
[56] Morley JE. The endocrinology of the opiates and opioid peptides. Metabolism
1981;30(2):195–209.
[57] Abs R, Verhelst J, Maeyaert J, Van Buyten JP, Opsomer F, Adriaensen H, et al.
Endocrine consequences of long-term intrathecal administration of opioids. J Clin
Endocrinol Metab 2000;85(6):2215–22.
[58] Finch PM, Roberts LJ, Price L, Hadlow NC, Pullan PT. Hypogonadism in patients
treated with intrathecal morphine. Clin J Pain 2000;16(3):251–4.
[59] Ferin M, Vande Wiele R. Endogenous opioid peptides and the control of the menstrual
cycle. Eur J Obstet Gynecol Reprod Biol 1984;18(5–6):365–73.
[60] Petty RG. Prolactin and antipsychotic medications: mechanism of action. Schizophr Res
1999;35(Suppl):S67–73.
[61] Kleinberg DL, Davis JM, de Coster R, Van Baelen B, Brecher M. Prolactin levels and ad-
verse events in patients treated with risperidone. J Clin Psychopharmacol 1999;19(1):57–61.
[62] Malarkey WB, Strauss RH, Leizman DJ, Liggett M, Demers LM. Endocrine effects in
female weight lifters who self-administer testosterone and anabolic steroids. Am J Obstet
Gynecol 1991;165(5 Pt 1):1385–90.
[63] Van Steenbergen W, Naert J, Lambrecht S, Scheys I, Lesaffre E, Pelemans W.
Suppression of gonadotropin secretion in the hospitalized postmenopausal female as an
effect of acute critical illness. Neuroendocrinology 1994;60(2):165–72.
[64] Woolf PD, Hamill RW, McDonald JV, Lee LA, Kelly M. Transient hypogonadotropic
hypogonadism caused by critical illness. J Clin Endocrinol Metab 1985;60(3):444–50.
[65] Baker HW. Reproductive effects of nontesticular illness. Endocrinol Metab Clin North
Am 1998;27(4):831–50.
[66] Traggiai C, Stanhope R. Delayed puberty. Best Pract Res Clin Endocrinol Metab
2002;16(1):139–51.
[67] Spratt DI, Bigos ST, Beitins I, Cox P, Longcope C, Orav J. Both hyper- and
hypogonadotropic hypogonadism occur transiently in acute illness: bio- and immunoac-
tive gonadotropins. J Clin Endocrinol Metab 1992;75(6):1562–70.
[68] Warren MP. The effects of altered nutritional states, stress, and systemic illness on
reproduction in women. In: Vaitukaitis JL, editor. Clinical reproductive neuroendocri-
nology. New York: Elsevier; 1982. p. 177–206.
[69] Chapman RM, Sutcliffe SB, Malpas JS. Cytotoxic-induced ovarian failure in Hodgkin’s
disease. II. Effects on sexual function. JAMA 1979;242(17):1882–4.
[70] Clark ST, Radford JA, Crowther D, Swindell R, Shalet SM. Gonadal function following
chemotherapy for Hodgkin’s disease: a comparative study of MVPP and a seven-drug
hybrid regimen. J Clin Oncol 1995;13(1):134–9.
[71] Horning SJ, Hoppe RT, Kaplan HS, Rosenberg SA. Female reproductive potential after
treatment for Hodgkin’s disease. N Engl J Med 1981;304(23):1377–82.
[72] Meirow D, Lewis H, Nugent D, Epstein M. Subclinical depletion of primordial follicular
reserve in mice treated with cyclophosphamide: clinical importance and proposed
accurate investigative tool. Hum Reprod 1999;14(7):1903–7.
[73] Müller J. Disturbance of pubertal development after cancer treatment. Best Pract Res
Clin Endocrinol Metab 2002;16(1):91–103.
[74] Ogilvy-Stuart AL, Shalet SM. Effect of radiation on the human reproductive system.
Environ Health Perspect 1993;101(Suppl):109–16.
[75] Samaan NA, Bakdash MM, Caderao JB, Cangir A, Jesse RH Jr, Ballantyne AJ.
Hypopituitarism after external irradiation. Evidence for both hypothalamic and pituitary
origin. Ann Intern Med 1975;83(6):771–7.
[76] Constine LS, Woolf PD, Cann D, Mick G, McCormick K, Raubertas RF, et al.
Hypothalamic-pituitary dysfunction after radiation for brain tumors. N Engl J Med
1993;328(2):87–94.
[77] American Cancer Society. Breast cancer facts and figures. New York: American Cancer
Society; 2001.
[78] Beatson W. On the treatment of inoperable cases of carcinoma of the mamma:

suggestions for a new method of treatment with illustrative cases. Lancet 1896;2:104.
[79] Mainwaring PN, Dowsett M. LHRH superagonists and antagonists in the treatment of
breast cancer. In: Manni A, editor. Contemporary endocrinology. Endocrinology of
breast cancer. Totowa, NJ: Humana Press; 1999. p. 313–28.
[80] Dowsett M. Use of risk determinants for different breast cancer prevention strategies. Eur
J Cancer 2000;36(10):1283–7.
[81] Dowsett M, Jacobs S, Aherne J, Smith IE. Clinical and endocrine effects of leuprorelin
acetate in pre- and postmenopausal patients with advanced breast cancer. Clin Ther
1992;14(Suppl):97–103.
[82] Nicholson RI, Walker KJ, Turkes A, Dyas J, Plowman PN, Williams M, et al.
Endocrinological and clinical aspects of LHRH action (ICI 118630) in hormone
dependent breast cancer. J Steroid Biochem 1985;23(5B):843–7.
[83] Chen A, Kaganovsky E, Rahimipour S, Ben-Aroya N, Okon E, Koch Y. Two forms of
gonadotropin-releasing hormone (GnRH) are expressed in human breast tissue and
overexpressed in breast cancer: a putative mechanism for the antiproliferative effect of
GnRH by down-regulation of acidic ribosomal phosphoproteins P1 and P2. Cancer Res
2002;62(4):1036–44.
[84] Newsome JF, Timmons RL, Van Wyk J, Dugger GS. Pituitary stalk section for metastatic
carcinoma of the breast. Ann Surg 1971;174(5):769–73.
[85] Hryncak PK. Bardet-Biedl syndrome. Optom Vis Sci 2000;77(5):236–43.
[86] Bray GA. Laurence, Moon, Bardet, and Biedl: reflections on a syndrome. Obes Res
1995;3(4):383–6.
[87] Walvoord EC, Waguespack SG, Pescovitz OH. Precocious and delayed puberty. In:
Becker KL, editor. Principles and practice of endocrinology and metabolism. 3rd edition.
Philadelphia: Lippincott, Williams & Wilkins; 2001. p. 893–908.
[88] Ammann F. Clinical and genetic studies on the Bardet Biedl syndrome in Switzerland.
J Genet Human 1970;18(Suppl):1.
[89] Burd L, Vesely B, Martsolf J, Kerbeshian J. Prevalence study of Prader-Willi syndrome in
North Dakota. Am J Med Genet 1990;37(1):97–9.
[90] Butler JV, Whittington JE, Holland AJ, Boer H, Clarke D, Webb T. Prevalence of, and
risk factors for, physical ill-health in people with Prader-Willi syndrome: a population-
based study. Dev Med Child Neurol 2002;44(4):248–55.
[91] Akefeldt A, Tornhage CJ, Gillberg C. A woman with Prader-Willi syndrome gives birth
to a healthy baby girl. Dev Med Child Neurol 1999;41(11):789–90.
[92] Schulze A, Mogensen H, Hamborg-Petersen B, Graem N, Ostergaard JR, Brondum-
Nielsen K. Fertility in Prader-Willi syndrome: a case report with Angelman syndrome in
the offspring. Acta Paediatr 2001;90(4):455–9.
[93] Banna M, Hoare RD, Stanley P, Till K. Craniopharyngioma in children. J Pediatr
1973;83(5):781–5.
[94] Banna M. Craniopharyngioma: based on 160 cases. Br J Radiol 1976;49(579):206–23.
[95] Lin KL, Wang HS, Lui TN. Diagnosis and follow-up of craniopharyngiomas with
transcranial Doppler sonography. J Ultrasound Med 2002;21(7):801–6.
[96] Bunin GR, Surawicz TS, Witman PA, Preston-Martin S, Davis F, Bruner JM. The
descriptive epidemiology of craniopharyngioma. J Neurosurg 1998;89(4):547–51.
[97] Biller BM. Hyperprolactinemia. Int J Fertil Womens Med 1999;44(2):74–7.
[98] Clayton RN. Sporadic pituitary tumours: from epidemiology to use of databases.
Baillieres Best Pract Res Clin Endocrinol Metab 1999;13(3):451–60.
[99] Vannemreddy PS, Nanda A, Reddy PK, Gonzalez E. Primary cerebral sarcoid
granuloma: the importance of definitive diagnosis in the high-risk patient population.
Clin Neurol Neurosurg 2002;104(4):289–92.
[100] Maghnie M, Cosi G, Genovese E, Manca-Bitti ML, Cohen A, Zecca S, et al. Central
diabetes insipidus in children and young adults. N Engl J Med 2000;343(14):998–1007.
[101] Sampathkumar S, Younger C, Cramer H, Chalasani N, Skierczynski PA. Langerhans’

cell histiocytosis involving the pituitary, thyroid, lung, and liver. Endocr Pract 2002;
8(3):217–21.
[102] Egeler RM, Favara BE, van Meurs M, Laman JD, Claassen E. Differential In situ
cytokine profiles of Langerhans-like cells and T cells in Langerhans cell histiocytosis:
abundant expression of cytokines relevant to disease and treatment. Blood 1999;94(12):
4195–201.
[103] Kontogeorgos G, Handy S, Kovacs K, Horvath E, Scheithauer BW. The anterior
pituitary in hemochromatosis. Endocr Pathol 1996;7(2):159–64.
[104] Yuan XQ, Wade CE. Neuroendocrine abnormalities in patients with traumatic brain
injury. Front Neuroendocrinol 1991;12(3):209–30.
[105] Seminara SB, Oliveira LM, Beranova M, Hayes FJ, Crowley WF Jr. Genetics of
hypogonadotropic hypogonadism. J Endocrinol Invest 2000;23(9):560–5.
[106] Seminara SB, Crowley WF Jr. Perspective: the importance of genetic defects in humans in
elucidating the complexities of the hypothalamic-pituitary-gonadal axis. Endocrinology
2001;142(6):2173–7.
[107] Hardelin JP. Kallmann syndrome: towards molecular pathogenesis. Mol Cell Endocrinol
2001;179(1–2):75–81.
[108] Kallmann FJ, Schoenfeld WA, Barrera SE. The genetic aspects of primary eunuchoidism.
Am J Ment Defic 1944;48:203–36.
[109] Jones JR, Kemmann E. Olfacto-genital dysplasia in the female. Obstet Gynecol Annu
1976;5:443–66.
[110] Seminara SB, Hayes FJ, Crowley WF Jr. Gonadotropin-releasing hormone deficiency in
the human (idiopathic hypogonadotropic hypogonadism and Kallmann’s syndrome):
pathophysiological and genetic considerations. Endocr Rev 1998;19(5):521–39.
[111] MacColl G, Quinton R, Bouloux PM. GnRH neuronal development: insights into
hypogonadotrophic hypogonadism. Trends Endocrinol Metab 2002;13(3):112–8.
[112] Sedlmeyer IL, Palmert MR. Delayed puberty: analysis of a large case series from an
academic center. J Clin Endocrinol Metab 2002;87(4):1613–20.
[113] Mecklenburg RS, Loriaux DL, Thompson RH, Andersen AE, Lipsett MB. Hypothalamic
dysfunction in patients with anorexia nervosa. Medicine [Baltimore] 1974;53(2):147–59.
[114] Vigersky RA, Loriaux DL, Andersen AE, Lipsett MB. Anorexia nervosa: behavioural
and hypothalamic aspects. Clin Endocrinol Metab 1976;5(2):517–35.
[115] Reeves AG, Plum F. Hyperphagia, rage, and dementia accompanying a ventromedial
hypothalamic neoplasm. Arch Neurol 1969;20(6):616–24.
[116] Stanhope R, Brook CG, Pringle PJ, Adams J, Jacobs HS. Induction of puberty by
pulsatile gonadotropin releasing hormone. Lancet 1987;2(8558):552–5.
[117] Delemarre-Van de Waal HA, Odink RJ. Pulsatile GnRH treatment in boys and girls with
idiopathic hypogonadotrophic hypogonadism. Hum Reprod 1993;8(Suppl):180–3.
[118] Quinton R, Barnett P, Coskeran P, Bouloux PM. Gordon Holmes spinocerebellar ataxia:
a gonadotrophin deficiency syndrome resistant to treatment with pulsatile gonadotro-
phin-releasing hormone. Clin Endocrinol [Oxf] 1999;51(4):525–9.
[119] Caron P, Chauvin S, Christin-Maitre S, Bennet A, Lahlou N, Counis R, et al. Resistance
of hypogonadic patients with mutated GnRH receptor genes to pulsatile GnRH
administration. J Clin Endocrinol Metab 1999;84(3):990–6.
32 (2003) 613–637
Mechanisms of follicular dysfunction

in 46,XX spontaneous premature
ovarian failure
Lawrence M. Nelson, MD, MBA*,
Vladimir K. Bakalov, MD
Developmental Endocrinology Branch, National Institute of Child Health and Human
Development, National Institutes of Health, Building 10, Room 10N262, Bethesda,
MD 20892-1862, USA
Spontaneous 46,XX premature ovarian failure is not rare. The age-

specific incidence is approximately 1 in 250 women by age 35 and 1 in 100 by
age 40 [1]. Young women with the condition develop amenorrhea and sex
hormone deficiency, but the infertility associated with the diagnosis is the
most troublesome aspect of the disorder for these young women [2]. This
article focuses on managing the infertility experienced by women who have
46,XX spontaneous premature ovarian failure. Iatrogenic premature
ovarian failure and ovarian failure related to X-chromosomal abnormalities
are beyond the scope of this article.
Previously, the infertility associated with premature ovarian failure was
considered to be absolute and irreversible. Early studies referred to the
condition as premature menopause, because, as with menopause, the cause
was considered to be from the complete depletion of functional primordial
follicles [3,4].
Accumulating evidence now has demonstrated conclusively that the
infertility associated with premature ovarian failure is not absolute and
irreversible. After a clearly established diagnosis, some patients who have
46,XX spontaneous premature ovarian failure can spontaneously ovulate,
conceive, carry a normal pregnancy to term, and deliver a healthy baby,
even years after the diagnosis [5–7]. In such cases, potentially functional
follicles had been present in the ovary at the time of the diagnosis of
premature ovarian failure, but some pathologic process prevented them
E-mail address: lawrence_nelson@nih.gov (L.M. Nelson).
0889-8529/03/$ - see front matter. Published by Elsevier Inc.

doi:10.1016/S0889-8529(03)00043-4
614 L.M. Nelson, V.K. Bakalov / Endocrinol Metab Clin N Am 32 (2003) 613–637
from functioning normally. Thus, although some patients develop 46,XX

spontaneous premature ovarian failure from ovarian follicular depletion,
there is another group of patients who develop this condition from ovarian
follicular dysfunction [8]. Insight into the mechanisms of follicular dys-
function in these cases would advance physicians’ understanding of pre-
mature ovarian failure.
A review of the literature suggests that approximately 5% to 10% of young
women with premature ovarian failure will conceive spontaneously following
diagnosis, but there is no evidence that any treatment can enhance this
pregnancy rate [9]. To best restore ovarian function and fertility for these
young women, clinicians need to do the following: (1) be able to identify those
women who have follicles remaining in the ovary, (2) make a diagnosis as to
the mechanism of the ovarian follicular dysfunction, and (3) attempt to reverse
this dysfunction and restore fertility by providing a specific treatment that
is proven safe and effective by prospective randomized controlled trials.
Presently, this approach is only a theoretic possibility, but ongoing research
and development may someday make it a reality.
Anatomy and physiology of the ovarian follicle

Endowment and expenditure
Normal ovarian function and fertility depend on the presence of
functional primordial follicles. An initial finite endowment of primordial
follicles is established during fetal development. This endowment reaches
a peak of about 7 million during the 5th month of gestation, and thereafter
no additional primordial follicles are created [10,11].
Oocytes within primordial follicles are arrested in the prophase of the first
meiosis. They are stored in this arrested meiotic state for future use, some
for more than 50 years [12]. If the expenditure of primordial follicles is
regulated properly, this initial endowment of oocytes will last a woman
throughout her normal reproductive life span.
Few oocytes are expended by ovulation; most are expended by atresia.
Organisms that use external fertilization produce vast numbers of oocytes. It
seems that, after internal fertilization evolved, organisms adapted this system
of vast oocyte overproduction by developing a mechanism of atresia to limit
the number of eggs available for fertilization [12]. Follicle atresia occurs by
apoptosis, and a small increase in the atretic rate can have dramatic effects on
the number of follicles [13–16]. Doubling the rate of follicular atresia will cause
follicular depletion much sooner than if the number of follicles in the original
endowment is reduced by the same factor [17].
Activation and function

The ovary is unique in the endocrine system in that it develops an entirely
new secretory structure each month. This secretory structure, the graafian
L.M. Nelson, V.K. Bakalov / Endocrinol Metab Clin N Am 32 (2003) 613–637 615
follicle, arises from a primordial follicle. The mechanism by which resting

primordial follicles are activated to enter the pool of growing and
functioning follicles remains obscure, however [18,19]. The initial stage of
follicular activation seems to be gonadotropin independent [20]. Sub-
sequently, normal follicular function requires stimulation of theca and
granulosa cells by gondadotropins and other growth factors interacting with
their respective receptors [21]. Critical interactions between the developing
oocyte and neighboring somatic cells are also being recognized [19]. Recent
evidence suggests that the oocyte plays a critical role in directing the
developmental program of the growing follicle [22].
Multiple branched pathways are activated in turn within the oocyte,
granulosa, and theca to promote follicular growth and function [19,21].
Growth occurs through orderly cell proliferation and antral formation.
Steroidogenesis occurs through acquisition or synthesis of cholesterol and
activation of enzyme systems needed for sex steroid synthesis. In women,
normal cyclic sex steroid production is linked to gamete production. When
ovarian follicles are depleted or fail to function, normal cyclic production of
estrogen and progesterone ceases, and menstruation stops.
Clinical presentation
Most women who develop 46,XX spontaneous premature ovarian failure
experienced normal puberty and established regular menses before the
diagnosis [23]. Few are first seen with a chief complaint of infertility. Most
women present initially with a disturbance in menstrual pattern, but there
is no characteristic menstrual history that heralds the onset of 46,XX
spontaneous premature ovarian failure [2]. Patients may develop acute
amenorrhea or experience a prolonged prodrome of oligomenorrhea or
dysfunctional uterine bleeding. The disorder may first become apparent
when menstruation fails to return after a pregnancy or after stopping
hormonal contraception. In approximately 10% of patients, the disorder is
familial [24].
In a few patients, vasomotor symptoms, presumably related to relative
estrogen deficiency, can precede the development of a disturbed menstrual
pattern [2]. With progression to the development of amenorrhea and
profound estrogen deficiency, vasomotor symptoms and symptoms of
atrophic vaginitis eventually become prominent.
Pathophysiology of the associated infertility

The clinical situation may be much more complex if menopausal serum
gonadotropin levels are discovered in a young woman with amenorrhea.
Based on established dogma, there can be a tendency to assume that this is
a static situation similar to the commonly encountered normal menopause
in older women. A clinician might conclude that the associated infertility is

caused by ovarian follicular depletion. Although accumulating evidence
has demonstrated conclusively that the infertility associated with 46,XX
spontaneous premature ovarian failure is not absolute and irreversible, it is
understandable why many clinicians may find this concept difficult to
accept.
In a research setting, the situation is different [7,25,26]. Clinicians may see
intermittent and unpredictable ovarian follicular function that can persist
for decades. Rather than follicular depletion, a picture of follicular dys-
function emerges. In a research setting, to define ovarian function more
precisely, it is possible to measure serum estradiol and progesterone levels
on a weekly basis over a 4-month period. With this approach, clinicians
can demonstrate that 50% of young women with 46,XX spontaneous
premature ovarian failure have follicles remaining in the ovary. These
patients clearly have follicular dysfunction rather than follicular depletion.
When the current authors examined patients in this manner, they found
serum estradiol levels greater than 50 pg/mL in 28 of 57 patients (49%) and
serum progesterone levels considered presumptive evidence of ovulation in
9 patients (16%) [26]. Furthermore, by serial sonography, the authors
intermittently detected the presence of graafian follicles in 41.5% of women
with 46,XX spontaneous premature ovarian failure [26]. They found that
the probability of detecting a follicle did not decline as the time from the
diagnosis increased. In one patient, the authors found a follicle 11 years
after her diagnosis of 46,XX spontaneous premature ovarian failure. It is
important to stress that there is no means by which to establish a diagnosis
of complete ovarian follicular depletion. The authors recently observed a
31-year-old woman with spontaneous premature ovarian failure diagnosed
3 years prior. On evaluation, her follicle-stimulating hormone (FSH) level
was 148 IU/L, her luteinizing hormone (LH) level was 98 IU/L, her estradiol
level was less than 10 pg/mL, and she had very small ovaries with no follicles
visible on transvaginal ultrasound. Nine months later she conceived without
treatment and delivered a healthy baby. Even ovarian biopsy, because of
sampling error, can fail to detect follicles. Pregnancy has been reported after
an ovarian biopsy failed to detect follicles [27].
When examined in a research setting, a clear picture of infertility caused
by ovarian follicular dysfunction emerges for about one half of women who
have 46,XX spontaneous premature ovarian failure. In women without this
condition, serum estradiol levels have a strong positive correlation with
maximum follicle diameter (r = 0.91, P\0.005; Fig. 1A), but the authors
could detect only a weak trend toward this correlation in young women with
46,XX spontaneous premature ovarian failure (r = 0.24, P\0.10; Fig. 1B)
[26]. In addition, during the follicular phase in women without 46,XX
spontaneous premature ovarian failure, serum progesterone levels are
strongly correlated with follicular diameter (r = 0.83, P\0.005; Fig. 2A),
but the authors could not detect a correlation between serum progesterone
Fig. 1. Serum estradiol correlated with maximum follicular diameter in women with and without
premature ovarian failure. (A) Each point represents the findings in 1 of 10 women with regular
menses examined during the follicular phase. Two congruent points are noted by the numeral 2.
(B) Each point represents the findings in a patient with premature ovarian failure who had an
ovarian follicle detected by sonogram (37 sonograms in 27 patients). There are eight congruent
points. (From Nelson LM, Anasti JN, Kimzey LM, Defensor RA, Lipetz KJ, White BJ, et al.
Development of luteinized graafian follicles in patients with karyotypically normal spontaneous
premature ovarian failure. J Clin Endocrinol Metab 1994;79:1470–5; with permission.)
levels and follicular diameter in women with 46,XX spontaneous premature

ovarian failure (Fig. 2B) [26]. Graafian follicles clearly are present is some of
these women, even years after the diagnosis, but they fail to function
normally.
Mechanisms of ovarian follicular dysfunction

Autoimmune oophoritis
Autoimmune lymphocytic oophoritis as a mechanism of ovarian follicular
dysfunction was first described in association with Addison disease [28]. The
disorder may present as isolated premature ovarian failure, with the
subsequent development of adrenal insufficiency years later [29]. Autoim-
mune oophoritis also occurs as part of the autoimmune polyendocrinopathy
syndrome, type 1 (Mendelian Inheritance in Man [MIM] 240300) [30].
Autoimmune lymphocytic oophoritis is a clearly established mechanism
of 46,XX spontaneous premature ovarian failure. Although it is generally
considered a rare condition, it is unclear how many cases of premature
ovarian failure are caused by this mechanism. Ascertainment bias plays
a role in this uncertainty. The evidence regarding autoimmune oophoritis
comes largely from anecdotal case reports, review articles, case series
reported from groups primarily interested in polyglandular autoimmunity,
or case series that focus primarily on the pathologic findings [31–44]. The
current authors’ unpublished work in progress suggests that approximately
Fig. 2. Serum progesterone correlated with maximum follicular diameter in women with and
without premature ovarian failure. (A) Serum progesterone levels were positively correlated with
maximum follicular diameter in women without ovarian failure. (2) Indicates there are two
congruent points at this location. (B) A correlation was not detected between serum progesterone
levels and maximum follicular diameter in patients with premature ovarian failure. There are six
congruent points. (From Nelson LM, Anasti JN, Kimzey LM, Defensor RA, Lipetz KJ, White BJ,
et al. Development of luteinized graafian follicles in patients with karyotypically normal sponta-
neous premature ovarian failure. J Clin Endocrinol Metab 1994;79:1470–5; with permission.)
5% of women who present initially with premature ovarian failure have

autoimmune oophoritis as the mechanism.
Folliclular development to the graafian stage is present in most cases of
autoimmune oophoritis, and markedly enlarged ovaries containing lutei-
nized cysts may be encountered [31,45]. Lymphokines, produced locally as
part of the inflammatory reaction, may impair follicular steroidogenesis, as
has been reported in animal models [46]. In some cases, the impaired
steroidogenesis likely causes the development of enlarged cystic ovaries from
reduced negative feedback on gonadotropin release [32], as can be seen with
enzyme deficiencies [47].
One characteristic of autoimmune oophoritis is the well-established
sparing of primordial follicles, despite the presence of an intense
lymphocytic infiltration in the theca of developing graafian follicles
(Fig. 3) [31,45]. This finding makes autoimmune oophoritis a potentially
reversible cause of premature ovarian failure. The inflammatory infiltrate is
more intense in mature follicles, suggesting that the inciting antigen is
gonadotropin dependent. In large antral follicles, the inflammation may
involve granulosa cells, and rarely, sarcoid-like granulomata of the theca
have been described. The associated luteinization of the theca and granulosa
cells can be so intense as to mimic corpus luteum formation [31]. The
cellular infiltrate present in established autoimmune oophoritis includes
Fig. 3. (A) Mature follicle consisting of a blood-filled antrum (left) surrounded by a heavy
lymphocytic infiltrate invading the theca (center). Unremarkable ovarian stroma is shown on
the right (hematoxylin-eosin stain, original magnification 100). (B) The heavy infiltration of
lymphocytes into the theca is highlighted by immunoperoxidase staining for the leukocyte
common antigen (center; immunoperoxidase stain, same area and magnification as shown in A).
(C) High-power magnification of an early secondary follicle showing three layers of granulosa
cells surrounding an unremarkable oocyte (hematoxylin-eosin stain). (D) There is no
lymphocytic involvement of this follicle as demonstrated by the absence of leukocyte common
antigen-positive cells with immunoperoxidase stains (immunoperoxidase stain, same area as
shown in C). Bar (A, B) = 100 lm; bar (C, D) = 12 lm. (From Kalantaridou SN, Braddock
DT, Patronas NJ, Nelson LM. Treatment of autoimmune premature ovarian failure. Hum
Reprod 1999;14:1777–82; with permission.)
macrophages, natural killer cells, T lymphocytes, B cells, and plasma cells

[39].
Evidence suggests that autoimmune oophoritis and adrenal autoim-
munity may represent a continuum of one pathophysiologic process.
Autoimmunity against steroid-producing cells and their steroidogenic
enzymes is the common denominator. To determine the true prevalence of
steroid cell autoimmunity as a mechanism of premature ovarian failure, it
is necessary to prospectively evaluate a group of young women who are
representative of the population at large. To this end, the current authors
have been recruiting young women with 46,XX spontaneous premature
ovarian failure who meet two primary criteria: (1) infertility and
amenorrhea are their primary concerns and (2) they generally consider
themselves to be in good health otherwise. In a prospective series, the
authors evaluated 123 women with 46,XX spontaneous premature ovarian
failure [48]. They found evidence for steroid cell autoimmunity in 6 of 123
women (4.9%; 95% CI, 1.7, 9.4) [48]. Furthermore, a thorough study of the
hypothalamic-pituitary-adrenal axis in these women revealed four cases
of early asymptomatic adrenal insufficiency. These findings fit well with
the fact that the first evidence to suggest an autoimmune mechanism of
premature ovarian failure was the observation that ovarian failure was
associated with the subsequent development of idiopathic Addison disease,
another manifestation of steroid cell autoimmunity. One early report,
combined with a literature review, found that ovarian failure preceded the
adrenal insufficiency in 9 of 10 cases when the two conditions occurred
together [29]. Other literature reviews have indicated that 2% to 10% of
patients with premature ovarian failure have associated Addison disease or
adrenal autoimmunity [43,49]. Together, these findings raise the possibility
that steroid cell autoimmunity is a single disease entity with variable
penetration. In women, the most common early manifestation of steroid cell
autoimmunity is ovarian failure from autoimmune oophoritis; the later
manifestation is adrenal insufficiency.
Reduced follicle number

Having a low number of follicles can be an indirect mechanism of follicular
dysfunction mediated by inappropriate luteinization [26]. Serum LH rises into
the menopausal range late in the normal menopausal transition and is believed
to result from inadequate negative feedback caused by the reduced number of
follicles [50]. A low follicle cohort size, if it develops prematurely in young
women, is incapable of providing adequate negative feedback to maintain
serum FSH and LH levels in the normal range. In a normal menstrual cycle,
a properly timed luteinization reduces granulosa cell mitogenic activity [51]
and induces changes in the steady state level of messenger ribonucleic acids for
enzymes involved in progesterone production [52]. Thus, in young women,
inappropriate luteinization of a growing follicle would be expected to impair
follicular growth and reduce estradiol production.
Some young women develop 46,XX spontaneous premature ovarian
failure from germ cell deficiency [8]. The few remaining follicles that are
present in these patients can grow in response to the high FSH levels, but
once these growing follicles express LH receptors, they are prematurely
luteinized by the chronically high LH levels [26]. Thus, it seems that, in
normal physiology, the surplus of atresia-destined follicles plays a much
more important role than has been previously recognized. The surplus
follicles provide negative feedback to maintain a proper gonadotropin
environment and thus prevent premature luteinization of the dominant
follicle [26,53,54]. In a sense, the atresia-destined follicles are a support
group for the dominant follicle. In addition, there is other precedence for
luteinized follicles developing in a setting of low follicle number and elevated
gonadotropins [55,56].
The current authors previously reported that inappropriate luteinization

of graafian follicles is a major mechanism of follicular dysfunction in young
women with 46,XX spontaneous premature ovarian failure [26]. The
authors performed ovarian biopsies on six women—after a graafian follicle
10 mm or more in diameter could be imaged—as part of a human
investigative protocol approved by the authors’ institutional review board.
Follicles were very few and far between in the authors’ biopsy specimens
[26], and this finding is in agreement with a larger series of ovarian biopsies
reported by Coulam [57]. In five of six patients, gross examination of the
antral tissue revealed a yellow appearance, characteristic of lutein. On
histologic examination, the authors found luteinized graafian follicles in all
six patients (Fig. 4). Therefore, statistically, luteinized graafian follicles
account for at least 60% of the antral structures imaged in young women
with 46,XX spontaneous premature ovarian failure (95% confidence limit).
The mechanisms that give rise to germ cell deficiency as a cause of 46,XX
spontaneous premature ovarian failure are largely unknown. Many reports
suggest a genetic mechanism for premature ovarian failure, but the small
family size associated with the infertility makes genetic linkage analysis
studies extremely difficult. Another approach that has proven successful has
been to examine candidate genes based on known genetic phenotypes in
other species [58,59]. For example, the diaphanous (DIA) gene (MIM
300108), known to cause sterility in Drosophila, has been associated with
premature ovarian failure in women [60]. More study is needed to determine
the prevalence of mutations in this gene. Studies in mice have demonstrated
that c-kit, a transmembrane tyrosine kinase receptor, plays a critical role in
gametogenesis [61]. Mutations in the human KIT gene appear to be an
uncommon cause of premature ovarian failure, however [62].
Idiopathic ovarian follicular dysfunction

In 1961, Hertz [63,64] first reported on young women in whom follicle
units were present in the ovary but were unresponsive to exogenous or
endogenous gonadotropin stimulation. The author reported, ‘‘There are
numerous primordial follicles and a few follicles with a double or triple
layer of granulosa cells. However, no antrum-containing follicles are to be
found.’’ In 1969, Jones and De Moraes-Ruehsen [65] described three
patients who had normal pubertal development, primary or early secondary
amenorrhea, elevated gonadotropins, and follicles found on ovarian biopsy.
It is not known whether these patients, originally reported as having the
resistant ovary syndrome, might actually have had mutations in the FSHR
gene. The failure of normal-appearing follicles to respond to elevated
gonadotropin levels could also be caused theoretically by the production of
a mutant FSH that, although devoid of sufficient bioactivity, might retain
immunoreactivity. It is unclear whether other reported causes of hereditary
46,XX spontaneous premature ovarian failure are associated with ovarian
follicular depletion or dysfunction [60,66–76].
Diverse pathophysiologic mechanisms can be invoked to explain the

failure of follicles to function despite high serum gonadotropin levels. When
diagnostic methods become more precise, many patients with resistant ovary
syndrome may be found to have gonadotropin receptor binding immuno-
globulins [77]. A study using human recombinant receptors to test this
hypothesis in a pure group of women with biopsy-demonstrated resistant
ovary syndrome might establish this as a mechanism. Immunoglobulins
directed against animal LH and FSH receptors have been demonstrated in
a few selected patients with ovarian failure [78,79]. A study that used human
recombinant LH and FSH receptors did not detect inhibitory immunoglo-
bulins in any of 38 women with 46,XX spontaneous premature ovarian
failure. Therefore, if blocking antibodies that interfere with the gonadotro-
pin-receptor interaction are mechanisms for premature ovarian failure, they
account for a small minority of patients (95% CI, \8%) [80].
FSHR mutations
In rare cases, mutations in the FSH receptor gene (FSHR) can cause
ovarian follicular dysfunction (MIM 136435). A nationwide population-
based study from Finland identified cases of autosomal recessive 46,XX
spontaneous premature ovarian failure [81]. Even within Finland, the geo-
graphic distribution of cases suggested a strong founder effect located in
a sparsely populated part of the country. By linkage analysis, the locus
mapped to chromosome 2p, and subsequently a mutation in the ligand-
binding domain of the FSHR gene was found to segregate perfectly with the
disease phenotype. Expression studies demonstrated a dramatic reduction of
FSHR binding capacity and signal transduction [82].
All 22 women with FSHR mutations presented with primary amenorrhea
[83]. In 10 patients, the pubertal development was otherwise categorized as
normal, and in 6 patients it was delayed. Ovarian histology was evaluated in
9 patients with confirmed FSHR mutations. Primordial follicles were
demonstrated in ovarian biopsies for all 9 patients. Primary follicles were
found in 4 patients, preantral follicles in 2 patients, and a mature follicle in
1 patient. The authors commented that the number of follicles was very low
and there appeared to be more fibrosis than normal. They concluded that
the clinical and laboratory findings suggested a low level of residual function
b
Fig. 4. (A) Luteinized follicle containing a structure that suggests an oocyte undergoing
degeneration (hemotoxylin-eosin stain, original magnification 150). (B) Higher magnification
of the putative oocyte (hematoxylin-eosin stain, original magnification 250). (C) Higher
magnification of the same follicle showing luteinized cells characterized by their larger size,
abundant eosinophilic cytoplasm, and prominent nucleus (hematoxylin-eosin stain, original
magnification 250). (From Nelson LM, Anasti JN, Kimzey LM, Defensor RA, Lipetz KJ,
White BJ, et al. Development of luteinized graafian follicles in patients with karyotypically
normal spontaneous premature ovarian failure. J Clin Endocrinol Metab 1994;79:1470–5; with
permission.)
of the FSH receptor [83]. In subsequent reports, partial loss-of-function

mutations were associated with normal-sized ovaries and follicle de-
velopment to the 5-mm antral stage, despite markedly elevated FSH levels
[84–86].
The Finnish FSHR mutations are a rare cause of 46,XX spontaneous
premature ovarian failure in other populations [85,87,88]. This is not
entirely unexpected because a founder effect was noted even in Finland, and
few women with 46,XX spontaneous premature ovarian failure present with
primary amenorrhea [23].
LHCGR mutations
LH acts on its receptor on theca cells to produce androgen precursors
that are subsequently aromatized to estradiol by the granulosa cells.
Inactivating mutations in the LH/chorionic gonadotropin receptor gene
(LHCGR; MIM 152790) would be expected to impair estradiol synthesis
and thus be a cause of follicular dysfunction. In one reported case, a young
woman presented with amenorrhea, normal breast development, multicystic
ovaries on ultrasound, low serum estradiol levels, and an elevated serum
LH. Her serum FSH level was in the normal range, however, presumably
from normal ovarian follicular inhibin-B production [89]. In a similar case
report, the FSH level was minimally elevated [90]. This disorder is rare,
however.
GALT mutations
Galactose-1-phosphate uridylytransferase (GALT) catalyzes the conver-
sion of galactose-1-phosphate and glucose-1-phosphate by means of transfer
of uridine monophosphate. GALT deficiency causes galactosemia (MIM
606999). The classic features of this condition are hepatomegally, cataracts,
and mental retardation. Failure to thrive is the initial presentation.
Premature ovarian failure is common in women with galactosemia [91,92].
Although follicular depletion is believed to be the mechanism of the
premature ovarian failure in most of these patients, follicular dysfunc-
tion has been reported in one patient with galactosemia who had normal-
appearing follicles on ovarian biopsy, yet no follicular growth or
development [93]. The exact mechanisms of follicular depletion and dys-
function in this disorder have yet to be elucidated.
FOXL2 mutations
The putative forkhead transcription factor FOXL2 (MIM 605597) is
expressed prominently in the ovary, and mutations in this gene are
associated with ovarian follicular dysfunction [94,95]. The gene mutation
gives rise to the blepharophimosis/ptosis/epicanthus inversus syndrome
(BPES) [96]. In type 1 BPES, in which familial 46,XX spontaneous

premature ovarian failure develops in addition to the eyelid deformities, the
mutant FOXL2 gene produces truncated proteins. Ovarian biopsies taken
from these women can show the presence of large numbers of primordial
follicles [94,95]. The mechanism of the follicular dysfunction in this syn-
drome remains to be elucidated. The syndrome is a rare cause of 46,XX
spontaneous premature ovarian failure [97].
GNAS mutations
The GNAS gene (MIM 139320) encodes the guanine nucleotide–binding
protein, a-stimulating activity polypeptide 1. Activated FSH receptors
promote the exchange of guanosine 59-triphosphate (GTP) for guanosine
59-diphosphate (GDP) on the Gs-a subunit, resulting in Gs activation.
Multihormone resistance results when a Gs-a loss-of-function mutation is
inherited maternally [98]. Ovarian resistance to gonadotropins has been
associated with a defect in this system. A woman with pseudohypopar-
athyroidism has been reported who experienced menarche but then develop-
ed amenorrhea, a mildly elevated gonadotropin level, and hypoestrogenemia
that responded to gonadotropin therapy [99]. Theoretically, a G-protein
second-messenger defect with clinical penetrance confined to the ovary
could cause ovarian failure without concomitant hypoparathyroidism.
CYP17 mutations
The CYP17 gene (MIM 202110) encodes the P450c17 enzyme, which
is responsible for both 17-a-hydroxylase and 17-20-desmolase activities.
Both activities are required for the production of C-19 steroids, including
estradiol synthesis. Thus, defects in this gene cause follicular dysfunction.
Women with these mutations generally experience primary amenorrhea,
failure of pubertal development, elevated gonadotropin levels, and low
serum estradiol levels. The clinical presentation could be confused with
46,XX spontaneous premature ovarian failure. This is especially true in the
rare case of 170-20-desmolase deficiency because there is no associated
hypertension or hypokalemia, as is seen with 17-a-hydroxlase deficiency.
Patients with CYP17 mutations do not have an adrenal crisis in the
postnatal period [100].
Growth and development of ovarian follicles can occur in women with
these mutations despite the impaired estradiol synthesis. In one patient,
despite undetectable peripheral serum estradiol levels, a fertilizable egg
could be retrieved [101]. This rare demonstration of dissociated follicular
growth and estradiol synthesis probably explains the excessive follicular
growth these patients can develop related to reduced negative feedback.
These patients may develop ovarian enlargement that can lead to torsion
and infarction requiring laparotomy.
CYP19 mutations
The CYP19 gene (MIM 107910) encodes cytochrome P450 aromatase,
which catalyzes the formation of C18 estrogens from C-19 androgens.
Inactivating mutations in this gene would be expected to impair follicular
function by impairing estradiol synthesis. A syndrome of hypergonado-
tropic hypogonadism in a 46,XX adolescent girl with multicystic ovaries
has been associated with missense mutations in this gene [102]. Because
of the block in aromatization from C-19 androgens to estrogens, however,
this syndrome is also associated with elevated serum testosterone and
androstenedione levels sufficient to induce clinically evident virilism.
Therefore, the clinical presentation differs from that of 46,XX spontaneous
premature ovarian failure.
Patient evaluation
Making the diagnosis
Regular and predictable menstrual cycles occur if ovarian follicles are
functioning normally in a young woman. Disturbance in menstrual pattern
is the earliest sign of premature ovarian failure in most cases [2]. The
condition can be easily detected by measuring serum FSH levels. Premature
ovarian failure in its fully developed form is associated with amenorrhea
and markedly elevated gonadotropin levels. In reality, however, 46,XX
spontaneous premature ovarian failure is part of a clinical continuum.
The current authors have suggested that this clinical continuum might better
be divided into clinical stages and termed ‘‘primary ovarian insuffi-
ciency’’ [103].
Young women who have premature ovarian failure perceive a need for
clinicians to be more aggressive in evaluating secondary amenorrhea and
oligomenorrhea [2]. Loss of menstrual regularity may be a sign of ovarian
insufficiency, and the associated estrogen deficiency is a well-established risk
factor for osteoporosis [104,105]. Young women who experience loss of
menstrual regularity for 3 or more consecutive months should be evaluated
appropriately at their first visit [106]. In a survey, the authors found that the
median time from the onset of disordered menses until the diagnosis of
premature ovarian failure was 2 years; more than one half of these women
had seen three or more clinicians before laboratory testing was performed to
uncover the diagnosis [2].
A careful history and physical examination can narrow the differential
diagnosis of oligomenorrhea and amenorrhea and lead to an appropriately
targeted evaluation [106]. For the remaining women, after pregnancy
excluded, the authors recommend obtaining levels of serum prolactin, FSH,
and estradiol. They advise against the use of the progestin-withdrawal test
as a substitute for laboratory evaluation; the test can be falsely reassuring
and lead to a delay in diagnosis [23]. Women who have had 4 months of
amenorrhea and two FSH levels in the menopausal range (>40 IU/L by
RIA), at least 1 month apart, meet diagnostic criteria for premature ovarian
failure. For these women, the authors recommend a karyotype, thyroid
function studies, and screening for adrenal insufficiency by measuring
adrenal antibodies [8,48,107]. Investigative procedures, such as ovarian
ultrasound, ovarian biopsy, and measurement of antiovarian antibodies, do
not change management and have no proven clinical benefit. Testing for the
fragile X permutation should be considered if there is a history of mental
retardation in the family and appropriate pretest genetic counseling is
available.
Management
Informing the patient
Young women with premature ovarian failure are unprepared for the
diagnosis. Most are dissatisfied with the manner in which they were
informed about it [2]. It is best to schedule a return office visit to review the
laboratory results when the diagnosis is suspected. It is also important to
inform patients who have 46,XX spontaneous premature ovarian failure
that, in some cases, spontaneous remission can occur. Approximately 5% to
10% of women unexpectedly become pregnant sometime after the diagnosis
[9].
Counseling
It is important to stress that there are no prospectively proven treatments
that will restore ovulation [9]. Gonadotropin therapy is unproven and
theoretically could exacerbate unrecognized autoimmune ovarian failure
[108]. Prednisone for treatment of suspected autoimmune ovarian failure
also is unproven. Furthermore, it carries the risk of iatrogenic Cushing
syndrome and osteonecrosis of the hip requiring joint replacement (Fig. 5)
[45]. In addition, although rarely considered, unproven therapies carry a real
risk of interfering with a spontaneous conception that would have occurred
had the system not been perturbed by the intervention [109].
Patients who desire fertility often feel an urgent need to act immediately
to achieve a pregnancy when diagnosed with premature ovarian failure. It is
important for clinicians to help them consider their options carefully. Many
couples choose adoption or a change in their life goals to resolve their
problem with infertility rather than invite the intrusion of high technology
into their lives. Some couples are satisfied to accept the small but real chance
that their infertility will resolve spontaneously over the ensuing years.
Couples should be advised to avoid unproven therapies that might set them
up for failure. Oocyte donation is a successful solution for some couples, but
Fig. 5. Coronal MRI scan of the right knee using inversion recovery technique. An abnormal
area of decreased signal intensity is present in the medial femoral condyle. A small focal defect is
also seen in the articular cortex (arrow). These findings are most consistent with the diagnosis of
osteonecrosis. (From Kalantaridou SN, Braddock DT, Patronas NJ, Nelson LM. Treatment of
autoimmune premature ovarian failure. Hum Reprod 1999;14:1777–82; with permission.)
there is no rush to proceed to this. The success rate of oocyte donation

depends primarily on the age of the oocyte donor [110].
Intense feelings of grief and loss for the biologic children they expected to
have are normal and expected feelings for those couples whose life plans
included building a family. Asking about these feelings and validating them
for the couple is therapeutic, and at the same time, it sends the message that
the clinician takes the situation seriously. A brief explanation of the normal
grieving process and stressing the need for clear communication between
spouses about the strains that the diagnosis might bring to their relationship
are also helpful.
Some young women mistakenly interpret the diagnosis of premature
ovarian failure as an indication that they have become menopausal and are
‘‘growing old overnight’’ [109]. Symptoms of estrogen deficiency, such as
hot flashes and vaginal dryness, can be interpreted as signs of aging. It is
important to clarify that this is not the case.
Young women with premature ovarian failure have appropriate concerns
about their general health. Most of these women are aware of the
association between estrogen deficiency and osteoporosis, but they are also
concerned about the risks of estrogen replacement therapy [111]. It is
important to stress the need for a healthy lifestyle: avoid smoking, get
adequate exercise, eat a healthy diet, and ensure adequate calcium intake. It
is also important to stress to these young women that they differ from
normally menopausal women in important ways with regard to the risk-to-
benefit ratio of estrogen replacement.
It is important to clarify for young women that the risk-benefit analysis

for extending ovarian hormone therapy beyond the normal menopause
(after age 50) differs from that for replacing ovarian hormones in young
women with premature ovarian failure. In the authors’ clinical judgment,
remaining sex-hormone deficient as a young woman carries a greater health
risk than does replacing the hormones normally supplied by the ovaries.
Based on recent evidence, the authors advise that women with premature
ovarian failure should not routinely extend their hormone replacement
beyond age 50 [111]. The authors do advise young women with premature
ovarian failure, however, that they should replace the hormones the ovary
would normally provide them until age 50.
As with any life-altering diagnosis, women with premature ovarian
failure benefit from encouragement and support that help them to regain
a sense of control and confidence. The first step along this path is to
encourage the couple, when they are ready, to express their emotions about
the diagnosis, and validate those feelings. A simple and effective entrée into
this discussion is ‘‘many patients with premature ovarian failure tell us that
this is a very difficult diagnosis to accept emotionally’’ [109]. Coming to
grips with emotions about this diagnosis is a gradual process, and the
patient needs to give herself time and permission to work through these
issues. Referral to the Premature Ovarian Failure Support Group
(www.pofsupport.org) can be helpful. The current authors’ group has been
impressed with the amount of underlying anxiety and depression that they
see in patients with spontaneous premature ovarian failure. They now recom-
mend that all patients with this diagnosis consider undertaking a three-
session visit with a professional counselor for a baseline evaluation. In some
cases, ongoing individual or group counseling is in order [109].
Providing hormone replacement

In the current authors’ judgment, young women with spontaneous
premature ovarian failure should be given cyclic hormone replacement
therapy that will induce regular menses. The potential for a spontaneous
and unexpected pregnancy makes this important. Patients with ovarian
failure who are taking estrogen should be informed of the need to obtain
a prompt pregnancy test if they fail to menstruate when expected. The
authors’ clinical experience has shown that these spontaneous pregnancies
progress normally in most cases. There seems to be no need for exogenous
hormone supplementation during pregnancy. There are theoretic reasons
why estrogen therapy might have a salutary effect on fertility for these
women (eg, possibly contributing to negative feedback and reducing LH
levels) [26]. The question as to whether hormone replacement improves
pregnancy rates in these women has not been addressed by prospective
study. In any event, it is clear that estrogen replacement therapy will not
prevent conception in these patients [112].
The principal estrogen produced by the functioning premenopausal ovary

is estradiol-17b. Daily serum measurements of estradiol in regularly
menstruating women indicate that the mean serum estradiol level averaged
across the menstrual cycle is approximately 104 pg/mL (382 pmol/L) [113].
The authors’ goal in hormone replacement for young women who have
premature ovarian failure is to try to mimic normal ovarian function as
much as possible. In the authors’ experience, to control vasomotor
symptoms and to fully estrogenize the vaginal epithelium, most young
women with 46,XX spontaneous premature ovarian failure need a full
replacement dose of estrogen (the equivalent of a 100-lg estradiol patch).
The 100-lg patches generally achieve serum estradiol levels in a range
corresponding to the mean estradiol level averaged across the normal
menstrual cycle (100 pg/mL). Although there is certainly room for
individualized recommendations, the authors prefer to provide estradiol by
transdermal patch for several reasons: (1) it provides estradiol-17b, (2) it
avoids the first-pass effect on the liver, (3) it provides the replacement by
steady infusion rather than by bolus, and (4) it permits measurement of
serum estradiol levels by clinically available assays should the need arise to
adjust the replacement dose.
Some young women who have premature ovarian failure will take
hormone replacement for decades. Therefore, providing an effective
progestin regimen to fully reduce the risk of adenocarcinoma to normal
is critical. The authors’ first-line progestin replacement is 10 mg of oral
medroxyprogesterone acetate for the last 12 days of a 28-day cycle. There is
good evidence that this regimen adequately protects the endometrium [114].
Other progestin regimens are available, such as oral micronized pro-
gesterone, but there is less long-term experience with these regimens. The
authors do not recommend oral contraceptives as a method of hormone
replacement for these women. A contraceptive dose of steroid hormones
is more than is what is required for hormone replacement and is likely
associated with a higher incidence of thromboembolic phenomenon related
to changes in clotting factors. More research is needed to define the role of
androgen replacement for young women with premature ovarian failure.
Prognosis
With appropriate management (evaluation, treatment, education, and
support), most young women who have 46,XX spontaneous premature
ovarian failure will lead healthy and fulfilling lives. At the time of their
initial diagnosis, most patients have difficulty envisioning this perspective.
The infertility associated with the disorder is the most troubling part of
the diagnosis. Many will decide to allow some time for a spontaneous
conception to occur while they work toward the emotional equanimity that
comes with accepting the reality of the diagnosis. Approximately 5% to
10% will conceive without treatment and deliver a healthy baby. Adoption
or a change in life plans may resolve the infertility for some couples. For
other couples, at the appropriate time, oocyte donation will be an option.
Generally, the symptoms of estrogen deficiency can be effectively managed
with currently available hormone replacement regimens. Patients who have
46,XX spontaneous premature ovarian failure should be seen at least
annually to monitor their hormone replacement therapy and to watch for
the development of associated disorders, such as hypothyroidism or
Addison disease. Patients should be forewarned regarding the symptoms
of adrenal insufficiency, even though the incidence is only approximately
3% [48].
The future
It is encouraging that approximately one half of young women who have
premature ovarian failure have follicles remaining in the ovary. The lack of
prospectively proven treatments that will get these follicles functioning again
is frustrating, however. What might the future hold for infertile young
women who have ovarian follicle dysfunction as the mechanism for their
46,XX spontaneous premature ovarian failure?
Inappropriate luteinization of follicles caused by follicular deficiency
seems to be the most prevalent mechanism for the follicular dysfunction in
these women. Developing strategies that specifically suppress LH into the
normal range without suppressing FSH might be one research approach to
restoring follicular function for these women. Another research approach
might be the development of specific LH antagonists.
Clearly, the established presence of primordial follicles in most women
with autoimmune oophoritis raises the possibility that the right immuno-
suppressive regimen might restore fertility for these women. For this to
become a reality, clinicians will need an accurate serum marker to detect the
condition and a prospectively proven immunosuppressive regimen that is
safe and effective.
Molecular genetics and recombinant technologies are powerful advances
that are beginning to provide insights into the pathogenesis of 46,XX
spontaneous premature ovarian failure. Presently, the molecular mechanism
of this condition has been defined only in rare cases, with seemingly rare
causes. Patients and their clinicians look forward to the day when the
molecular pathogenic mechanism can be defined in most women who
develop 46,XX spontaneous premature ovarian failure.
Summary
Approximately one half of young women who have 46,XX spontaneous
premature ovarian failure have ovarian follicles remaining in the ovary.
These follicles function intermittently and unpredictably, and pregnancies

can occur in these women without intervention, even many years after the
diagnosis. Clearly, the term ‘‘premature menopause’’ is an inaccurate term
for this condition. At present, there are no proven therapies that will
improve follicular function for these women. Inappropriate luteinization
related to low follicle number seems to be a major mechanism of follicular
dysfunction. Autoimmune oophoritis, although apparently an uncommon
cause of follicular dysfunction in these women, nonetheless presents the
opportunity to develop an effective therapy to restore fertility. Young
women with 46,XX spontaneous premature ovarian failure benefit from the
care of a sensitive clinician, one who is willing to spend a little more time
informing them about the diagnosis and referring them to other sources of
information. With appropriate medical management and emotional support
provided by a sensitive clinician, most young women with 46,XX spon-
taneous premature ovarian failure will lead happy, healthy, and fulfilling
lives.
References
[1] Coulam CB, Adamson SC, Annegers JF. Incidence of premature ovarian failure. Obstet
Gynecol 1986;67:604–6.
[2] Alzubaidi NH, Chapin HL, Vanderhoof VH, Calis KA, Nelson LM. Meeting the needs of
young women with secondary amenorrhea and spontaneous premature ovarian failure.
Obstet Gynecol 2002;99(5):720–5.
[3] De Moraes-Ruehsen M, Jones GS. Premature ovarian failure. Fertil Steril 1967;18:
440–61.
[4] Goldenberg RL, Grodin RL, Rodbard D, Ross GT. Gonadotropins in women with
amenorrhea. Am J Obstet Gynecol 1973;116:1003–9.
[5] Schreiber JR, Davajan V, Kletzky OA. A case of intermittant ovarian failure. Am J
[6] Szlachter BN, Nachtigall LE, Epstein J, Young BK, Weiss G. Premature menopause:
a reversible entity? Obstet Gynecol 1979;54:396–8.
[7] Rebar RW, Erickson GF, Yen SSC. Idiopathic premature ovarian failure: clinical and
endocrine characteristics. Fertil Steril 1982;37:35–41.
[8] Nelson LM, Anasti JN, Flack MR. Premature ovarian failure. In: Adashi EY, Rock JA,
Rosenwaks Z, editors. Reproductive endocrinology, surgery, and technology. New York:
Raven Press; 1995. p. 1393–410.
[9] van Kasteren YM, Schoemaker J. Premature ovarian failure: a systematic review on
therapeutic interventions to restore ovarian function and achieve pregnancy. Hum
Reprod Update 1999;5(5):483–92.
[10] Baker TG. A quantitative and cytological study of germ cells in the human ovaries. Proc
R Soc Lond 1963;158:417–33.
[11] Baker TG, Sum OW. Development of the ovary and oogenesis. Clin Obstet Gynecol
1976;3:3–26.
[12] Ohno S, Klinger HP, Atkin NB. Human oogenesis. Cytogenetics 1962;1:42–51.
[13] Hughes FM Jr, Gorospe WC. Biochemical identification of apoptosis (programmed cell
death) in granulosa cells: evidence for a potential mechanism underlying follicular atresia.
Endocrinol 1991;129:2415–22.
[14] Thomford PJ, Jelovsek FR, Mattison DR. Effect of oocyte number and rate of atresia on
the age of menopause. Reprod Toxicol 1987;1:41–51.
[15] Tilly JL. Commuting the death sentence: how oocytes strive to survive. Nat Rev Mol Cell
Biol 2001;2(11):838–48.
[16] Markstrom E, Svensson EC, Shao R, Svanberg B, Billig H. Survival factors regulating
ovarian apoptosis—dependence on follicle differentiation. Reproduction 2002;123(1):
23–30.
[17] Mattison DR, Thomford PJ, Jelovsek FR. Disposition of oocytes and age at menopause.
N Engl J Med 1988;318:644.
[18] Picton HM. Activation of follicle development: the primordial follicle. Theriogenology
2001;55(6):1193–210.
[19] Matzuk MM, Burns KH, Viveiros MM, Eppig JJ. Intercellular communication in the
mammalian ovary: oocytes carry the conversation. Science 2002;296(5576):2178–80.
[20] Hirshfield AN. Comparison of granulosa cell proliferation in small follicles of
hypophysectomized, prepubertal, and mature rats. Biol Reprod 1985;32:979–87.
[21] Richards JS, Russell DL, Ochsner S, Hsieh M, Doyle KH, Falender AE, et al. Novel
signaling pathways that control ovarian follicular development, ovulation, and
luteinization. Recent Prog Horm Res 2002;57:195–220.
[22] Eppig JJ, Wigglesworth K, Pendola FL. The mammalian oocyte orchestrates the rate of
ovarian follicular development. Proc Natl Acad Sci USA 2002;99(5):2890–4.
[23] Rebar RW, Connolly HV. Clinical features of young women with hypergonadotropic
amenorrhea. Fertil Steril 1990;53:804–10.
[24] van Kasteren YM, Hundscheid RD, Smits AP, Cremers FP, van Zonneveld P, Braat DD.
Familial idiopathic premature ovarian failure: an overrated and underestimated genetic
disease? Hum Reprod 1999;14(10):2455–9.
[25] Mehta AE, Matwijiw I, Lyons EA, Faiman C. Noninvasive diagnosis of resistant ovary
syndrome by ultrasonography. Fertil Steril 1992;57:56–61.
[26] Nelson LM, Anasti JN, Kimzey LM, Defensor RA, Lipetz KJ, White BJ, et al.
Development of luteinized graafian follicles in patients with karyotypically normal
spontaneous premature ovarian failure. J Clin Endocrinol Metab 1994;79:
1470–5.
[27] Menon V, Edwards RL, Butt WR, Bluck M, Lynch SS. Review of 59 patients with
hypergonadotrophic amenorrhoea. Br J Obstet Gynaecol 1984;91:63–6.
[28] Irvine WJ, Chan MMW, Scarth L, Kolb FO, Hartog M, Bayliss RIS, et al.
Immunological aspects of premature ovarian failure associated with idiopathic Addison’s
disease. Lancet 1968;2:883–90.
[29] Turkington RW, Lebovitz HE. Extra-adrenal endocrine deficiencies in Addison’s disease.
Am J Med 1967;43:499–507.
[30] Ahonen P, Myllarniemi S, Sipila I, Perheentupa J. Clinical variation of autoimmune
polyendocrinopathy-candidiasis-ectodermal dystrophy (APECED) in a series of 68
patients. N Engl J Med 1990;322:1829–36.
[31] Bannatyne P, Russell P, Shearman RP. Autoimmune oophoritis: a clinicopathologic
assessment of 12 cases. Int J Gynecol Pathol 1990;9:191–207.
[32] Biscotti CV, Hart WR, Lucas JG. Cystic ovarian enlargement resulting from autoimmune
oophoritis. Obstet Gynecol 1989;74:492–5.
[33] Case records of the Massachusetts General Hospital CC Case 46–1986. N Engl J Med
1986;315:1336–43.
[34] Betterle C, Rossi A, Dalla Pria S, Artifoni A, Pedini B, Gavasso S, et al. Premature
ovarian failure: autoimmunity and natural history. Clin Endocrinol 1993;39:35–43.
[35] Betterle C, Volpato M. Adrenal and ovarian autoimmunity. Eur J Endocrinol
1998;138:16–25.
[36] Friedman CI, Gurgen-Varol F, Lucas J, Neff J. Persistent progesterone production
associated with autoimmune oophoritis. J Reprod Med 1987;32:293–6.
[37] Rabinowe SL, Berger MJ, Welch WR, Dluhy RG. Lymphocyte dysfunction in
autoimmune oophoritis. Am J Med 1986;81:347–50.
[38] Russell P, Bannatyne P, Shearman RP, Fraser IS, Corbett P. Premature hyper-
gonadotropic ovarian failure: clinicopathological study of 19 cases. Int J Gynecol Pathol
1982;1:185–201.
[39] Sedmak DD, Hart WR, Tubbs RR. Autoimmune oophoritis: a histopathologic study of
involved ovaries with immunologic characterization of the mononuclear cell infiltrate. Int
J Gynecol Pathol 1987;6:73–81.
[40] Somerville JE, Iftikhar M, O’Sullivan JF, Hayes D. Autoimmune oophoritis. An
incidental finding. Pathol Res Pract 1993;189:475–80.
[41] Burrell LM, Murdoch A, Angus B, White MC. Autoimmune ovarian failure with elevated
serum levels of luteinizing hormone and enlarged ovaries. Case report. Br J Obstet
Gynaecol 1990;97(4):362–4.
[42] Fox R. Autoimmune ovarian failure with elevated serum levels of luteinizing hormone
and enlarged ovaries. Br J Obstet Gynaecol 1991;98(1):115–6.
[43] Hoek A, Schoemaker J, Drexhage HA. Premature ovarian failure and ovarian
autoimmunity. Endocr Rev 1997;18:107–34.
[44] Falorni A, Laureti S, Candeloro P, Perrino S, Coronella C, Bizzarro A, et al. Steroid-cell
autoantibodies are preferentially expressed in women with premature ovarian failure who
have adrenal autoimmunity. Fertil Steril 2002;78(2):270–9.
[45] Kalantaridou SN, Braddock DT, Patronas NJ, Nelson LM. Treatment of autoimmune
premature ovarian failure. Hum Reprod 1999;14(7):1777–82.
[46] Rivier C, Vale W. In the rat, interleukin-1a acts at the level of the brain and the gonads
to interfere with gonadotropin and sex steroid secretion. Endocrinology 1992;124:
2105–9.
[47] Larrea F, Lisker R, Banuelos R, Bermudez JA, Herrera J, Rasilla VN, et al.
Hypergonadotrophic hypogonadism in an XX female subject due to 17,20 steroid
desmolase deficiency. Acta Endocrinol 1983;103:400–5.
[48] Bakalov VK, Vanderhoof VH, Bondy CA, Nelson LM. Adrenal antibodies detect
asymptomatic auto-immune adrenal insufficiency in young women with spontaneous
premature ovarian failure. Hum Reprod 2002;17(8):2096–100.
[49] LaBarbera AR, Miller MM, Ober C, Rebar RW. Autoimmune etiology in premature
ovarian failure. Am J Reprod Immunol 1988;16:115–22.
[50] Sherman BM, Korenman SG. Hormonal characteristics of the human menstrual cycle
throughout reproductive life. J Clin Invest 1975;55:699–706.
[51] Yong EL, Baird DT, Yates R, Reichert LE Jr., Hillier SG. Hormonal regulation of the
growth and steroidogenic function of human granulosa cells. J Clin Endocrinol Metab
1992;74:842–9.
[52] Doody KJ, Lorence MC, Mason JI, Simpson ER. Expression of messenger ribonucleic
acid species encoding steroidogenic enzymes in human follicles and corpora lutea
throughout the menstrual cycle. J Clin Endocrinol Metab 1990;70:1041–5.
[53] Lacker HM, Ethan A. How do the ovaries count? Math Biosci 1988;90:305–32.
[54] Duncan M, Cummings L, Chada K. Germ cell deficient (gcd) mouse as a model of
premature ovarian failure. Biol Reprod 1993;49:221–7.
[55] Stevens ML, Plotka ED. Functional lutein cyst in a postmenopausal woman. Obstet
Gynecol 1977;50:27S–9S.
[56] Strickler RC, Kelly RW, Askin FB. Postmenopausal ovarian follicle cyst: an unusual
cause of estrogen excess. Int J Gynecol Pathol 1984;3:318–22.
[57] Coulam CB. Premature gonadal failure. Fertil Steril 1982;38:645–55.
[58] Elvin JA, Matzuk MM. Mouse models of ovarian failure. Rev Reprod 1998;3(3):
183–195.
[59] Yan C, Matzuk MM. Transgenic models of ovarian failure. J Soc Gynecol Investig
2001;8(Suppl):S30–3.
[60] Bione S, Sala C, Manzini C, Arrigo G, Zuffardi O, Banfi S, et al. A human homologue of
the Drosophila melanogaster diaphanous gene is disrupted in a patient with premature
ovarian failure: evidence for conserved function in oogenesis and implications for human
sterility. Am J Hum Genet 1998;62(3):533–41.
[61] Besmer P, Manova K, Duttlinger R, Huang EJ, Packer A, Gyssler C, et al. The kit-ligand
(steel factor) and its receptor c-kit/W: pleiotropic roles in gametogenesis and
melanogenesis. Development 1993;(Suppl):125–37.
[62] Shibanuma K, Tong ZB, Vanderhoof V, Vanevski K, Nelson L. Investigation of KIT
gene mutations in women with 46,XX spontaneous premature ovarian failure. BMC
Womens Health 2002;2(1):8.
[63] Hertz R. Comments. In: Villee CA, editor. Control of ovulation. New York: Pergamon
Press; 1961. p. 221.
[64] Hertz R. Pituitary independence of the prepubertal development of the ovary of the rat
and the rabbit and its pertinence to hypo-ovarianism in women. In: Grady HG, Smith
DE, editors. The ovary. Baltimore, MD: Williams & Wilkins; 1963. p. 120–7.
[65] Jones GS, De Moraes-Ruehsen M. A new syndrome of amenorrhea in association with
hypergonadotropism and apparently normal ovarian follicular apparatus. Am J Obstet
Gynecol 1969;104:597–600.
[66] Nishi Y, Hamamoto K, Kajiyama M, Kawamura I. The Perrault syndrome: clinical
report and review. Am J Med Genet 1988;31:623–9.
[67] Conway GS, Hettiarachchi S, Murray A, Jacobs PA. Fragile X premutation in familial
premature ovarian failure. Lancet 1995;346:309–10.
[68] Schwartz CE, Dean J, Howard-Peebles PN, Bugge M, Mikkelsen M, Tommerup N, et al.
Obstetrical and gynecological complications in fragile X carriers: a multicenter study. Am
J Med Genet 1994;51:400–2.
[69] Simpson JL, Christakos AC, Horwith M, Silverman FS. Gonadal dysgenesis in
individuals with apparently normal chromosomal complements: tabulation of cases and
compilation of genetic data. Birth Defects 1971;7:215–28.
[70] Smith A, Fraser IS, Noel M. Three siblings with premature gonadal failure. Fertil Steril
1979;32(5):528–30.
[71] Granat M, Amar A, Mor-Yosef S, Brautbar C, Schenker JG. Familial gonadal germinative
failure: endocrine and human leukocyte antigen studies. Fertil Steril 1983;40(2):215–9.
[72] Youlton R, Michelsen H, Be C, Cruz-Coke R. Pure XX gonadal dysgenesis in identical
twins. Clin Genet 1982;21(4):262–5.
[73] Purandare VN, Sathe AV. Gonadal dysgenesis variants in sisters: a hitherto undescribed
combination. Int J Gynaecol Obstet 1979;16(5):416–8.
[74] Aleem FA. Familial 46,XX gonadal dysgenesis. Fertil Steril 1981;35(3):317–20.
[75] Mattison DR, Evans MI, Schwimmer WB, White BJ, Jensen B, Schulman JD. Familial
premature ovarian failure. Am J Hum Genet 1984;36:1341–8.
[76] Turner G, Robinson H, Wake S, Martin N. Dizygous twinning and premature ovarian
failure in fragile X syndrome. Lancet 1994;344:1500.
[77] Maxson WS, Wentz AC. The gonadotropin resistant ovary syndrome. Semin Reprod
Endocrinol 1983;1:147–60.
[78] Chiauzzi V, Cigorraga S, Escobar ME, Rivarola MA, Charreau EH. Inhibition of follicle-
stimulating hormone receptor binding by circulating immunoglobulins. J Clin Endocrinol
Metab 1982;54:1221–8.
[79] Kuki S, Morgan RL, Tucci JR. Myasthenia gravis and premature ovarian failure. Arch
Intern Med 1981;141:1230–2.
[80] Anasti JN, Flack MR, Froehlich J, Nelson LM. The use of human recombinant
gonadotropin receptors to search for immunoglobulin G-mediated premature ovarian
failure. J Clin Endocrinol Metab 1995;80:824–8.
[81] Aittomaki K. The genetics of XX gonadal dysgenesis. Am J Hum Genet 1994;
54(5):844–51.
[82] Aittomaki K, Lucena JLD, Pakarinen P, Sistonen P, Tapanainen J, Gromoll J, et al.

Mutation in the follicle-stimulating hormone receptor gene causes hereditary hyper-
gonadotropic ovarian failure. Cell 1995;82:959–68.
[83] Aittomaki K, Herva R, Stenman UH, Juntunen K, Ylostalo P, Hovatta O, et al. Clinical
features of primary ovarian failure caused by a point mutation in the follicle-stimulating
hormone receptor gene. J Clin Endocrinol Metab 1996;81(10):3722–6.
[84] Beau I, Touraine P, Meduri G, Gougeon A, Desroches A, Matuchansky C, et al. A novel
phenotype related to partial loss of function mutations of the follicle stimulating hormone
receptor. J Clin Invest 1998;102(7):1352–9.
[85] Jiang M, Aittomaki K, Nilsson C, Pakarinen P, Iitia A, Torresani T, et al. The frequency
of an inactivating point mutation (566C!T) of the human follicle-stimulating hormone
receptor gene in four populations using allele-specific hybridization and time-resolved
fluorometry. J Clin Endocrinol Metab 1998;83(12):4338–43.
[86] Touraine P, Beau I, Gougeon A, Meduri G, Desroches A, Pichard C, et al. New natural
inactivating mutations of the follicle-stimulating hormone receptor: correlations between
receptor function and phenotype. Mol Endocrinol 1999;13(11):1844–54.
[87] Takakura K, Takebayashi K, Wang HQ, Kimura F, Kasahara K, Noda Y. Follicle-
stimulating hormone receptor gene mutations are rare in Japanese women with premature
ovarian failure and polycystic ovary syndrome. Fertil Steril 2001;75(1):207–9.
[88] Fonte Kohek MB, Batista MC, Russell AJ, Vass K, Giacaglia LR, Mendonca BB, et al.
No evidence of the inactivating mutation (C566T) in the follicle-stimulating hormone
receptor gene in Brazilian women with premature ovarian failure. Fertil Steril 1998;
70(3):565–7.
[89] Latronico AC, Anasti J, Arnhold IJ, Rapaport R, Mendonca BB, Bloise W, et al. Brief
report: testicular and ovarian resistance to luteinizing hormone caused by inactivating
mutations of the luteinizing hormone-receptor gene. N Engl J Med 1996;334(8):
507–12.
[90] Toledo SPA, Brunner HG, Kraaij R, Post M, Dahia PLM, Hayashida CY, et al. An
inactivating mutation of the luteinizing hormone receptor causes amenorrhea in a 46,XX
female. J Clin Endocrinol Metab 1996;81(11):3850–4.
[91] Kaufman FR, Kogut MD, Donnell GN, Goebelsmann U, March C, Koch R.
Hypergonadotropic hypogonadism in female patients with galactosemia. N Engl J Med
1981;304:994–8.
[92] Waggoner DD, Buist NRM, Donnell GN. Long-term prognosis in galactosaemia: results
of a survey of 350 cases. J Inher Metab Dis 1990;13:802–18.
[93] Fraser IS, Russell P, Greco S, Robertson DM. Resistant ovary syndrome and premature
ovarian failure in young women with galactosaemia. Clin Reprod Fertil 1986;4:133–8.
[94] Fraser IS, Shearman RP, Smith A, Russell P. An association among blepharophimosis,
resistant ovary syndrome, and true premature menopause. Fertil Steril 1988;50:747–51.
[95] Panidis D, Rousso D, Vavilis D, Skiadopoulos S, Kalogeropoulos A. Familial
blepharophimosis with ovarian dysfunction. Hum Reprod 1994;9:2034–7.
[96] Crisponi L, Deiana M, Loi A, Chiappe F, Uda M, Amati P, et al. The putative forkhead
transcription factor FOXL2 is mutated in blepharophimosis/ptosis/epicanthus inversus
syndrome. Nat Genet 2001;27(2):159–66.
[97] Harris SE, Chand AL, Winship IM, Gersak K, Aittomaki K, Shelling AN. Identification
of novel mutations in FOXL2 associated with premature ovarian failure. Mol Hum
Reprod 2002;8(8):729–33.
[98] Weinstein LS, Chen M, Liu J. Gs(alpha) mutations and imprinting defects in human
disease. Ann N Y Acad Sci 2002;968:173–97.
[99] Wolfsdorf JI, Rosenfield RL, Fang VS, Kobayashi R, Razdan AK, Kim MH. Partial
gonadotrophin-resistance in pseudohypoparathyroidism. Acta Endocrinol 1978;88:321–8.
[100] Auchus RJ. The genetics, pathophysiology, and management of human deficiencies of
P450c17. Endocrinol Metab Clin North Am 2001;30(1):101–19.
[101] Rabinovici J, Blankstein J, Goldman B, Rudak E, Dor Y, Pariente D, et al. In vitro

fertilization and primary embryonic cleavage are possible in 17a-hydroxylase defi-
ciency despite extremely low intrafollicular 17b-estradiol. J Clin Endocrinol Metab 1989;68:
693–7.
[102] Conte FA, Grumbach MM, Ito Y, Fisher CR, Simpson ER. A syndrome of female
pseudohermaphrodism, hypergonadotropic hypogonadism, and multicystic ovaries
associated with missense mutations in the gene encoding aromatase (P450arom). J Clin
Endocrinol Metab 1994;78(6):1287–92.
[103] Nelson LM, Bakalov V, Pastor C. Ovarian insufficiency. Available at: http://www.
emedicine.com/MED/topic3374.htm. eMed J [serial online] 2002; 1–14.
[104] Osteoporosis prevention, diagnosis, and therapy. JAMA 2001;285(6):785–95.
[105] Davies MC, Hall ML, Jacobs HS. Bone mineral loss in young women with amenorrhoea.
BMJ 1990;301(6755):790–3.
[106] Mishell DRJ, Stenchever MA, Droegemueller W, Herbst AL. Primary and secondary
amenorrhea. Comprehensive gynecology. St. Louis, MO: Mosby; 1997. p. 1043–67.
[107] Kim TJ, Anasti JN, Flack MR, Kimzey LM, Defensor RA, Nelson LM. Routine
endocrine screening for patients with karyotypically normal spontaneous premature
ovarian failure. Obstet Gynecol 1997;89(5):777–9.
[108] Tidey GF, Nelson LM, Phillips TM, Stillman RJ. Gonadotropins enhance HLA-DR
antigen expression in human granulosa cells. Am J Obstet Gynecol 1992;167:1768–73.
[109] Nelson LM. Spontaneous premature ovarian failure: young women, special needs.
Menopause Manage 2001;10:1–6.
[110] Sauer MV, Paulson RJ, Lobo RA. A preliminary report on oocyte donation extending
reproductive potential to women over 40. N Engl J Med 1990;323:1157–60.
[111] Risks and benefits of estrogen plus progestin in healthy postmenopausal women: principal
results from the Women’s Health Initiative randomized controlled trial. JAMA 2002;
288(3):321–33.
[112] Alper MM, Jolly EE, Garner PR. Pregnancies after premature ovarian failure. Obstet
Gynecol 1986;67:59S–62S.
[113] Mishell DR Jr., Nakamura RM, Crosignani PG, Stone S, Kharma K, Nagata Y, et al.
Serum gonadotropin and steroid patterns during the normal menstrual cycle. Am J Obstet
Gynecol 1971;111(1):60–5.
[114] Effects of hormone replacement therapy on endometrial histology in postmenopausal
women. The Postmenopausal Estrogen/Progestin Interventions (PEPI) trial. The Writing
Group for the PEPI trial. JAMA 1996;275(5):370–5.
32 (2003) 639–651
Assessment and management of

anovulatory infertility in polycystic
ovary syndrome
Stephen Franks, MD, Hon MD(Uppsala), FRCOG,
FRCP, FMedSci
Division of Pediatrics, Obstetrics, and Gynecology, Faculty of Medicine,
Institute of Reproductive and Developmental Biology, Imperial College London,
Hammersmith Hospital, DuCane Road, London W12 0NN, UK
Polycystic ovary syndrome (PCOS) is a common endocrine disorder of

uncertain origin and it is the major cause of anovulatory infertility. In its
classic form [1], it is characterized by the combination of menstrual
disturbance and symptoms of excessive androgen secretion (hirsutism, acne,
or androgenic alopecia), but it is typically heterogeneous in presentation [2].
Polycystic ovaries may be present in women with regular, ovulatory menses
who have symptoms of hyperandrogenism alone (or none of the classic
endocrine symptoms of PCOS) [2]. The primary cause of infertility in PCOS
is ovulatory failure, and there is no clear evidence that women with
polycystic ovaries and regular ovulatory cycles are less likely to be fertile. It
is therefore helpful to make a distinction between the diagnosis of polycystic
ovaries (which simply refer to the typical morphologic appearance of the
ovaries on pelvic ultrasound scanning, irrespective of symptoms) and PCOS
(which is defined as polycystic ovaries plus at least one typical symptom,
such as menstrual disturbance or hirsutism) [2,3].
Prevalence of polycystic ovaries in women with infertility

PCOS is a major cause of anovulatory infertility, but estimations of the
prevalence of PCOS have been hampered by the lack of agreement about its
definition and diagnosis. The traditional view of the clinical presentation of
PCOS is one of an obese, hirsute patient with oligo- or amenorrhea. This is
a caricature of PCOS, describing the patient who represents the extreme end
E-mail address: s.franks@imperial.ac.uk
doi:10.1016/S0889-8529(03)00044-6
640 S. Franks / Endocrinol Metab Clin N Am 32 (2003) 639–651
of a wide spectrum of presentation. The application of ultrasonographic

studies has highlighted the known heterogeneity of the syndrome and changed
clinicians’ view of the definition, diagnosis, and prevalence of PCOS [2,4,5].
Clinicians now know that PCOS is the most common cause of oligomenor-
rhea or irregular menses and is one of the most common causes of amenorrhea
[6,7]. In a recently reported series of more than 500 consecutive couples who
attended an infertility clinic, Kousta et al [8] found that 83% of women with
anovulatory infertility (who complained of irregular periods, oligomenr-
rhoea, or amenorrhea) had polycystic ovaries on ultrasound examination.
This finding is consistent with previous reports that are based on ultrasound
or clinical and biochemical criteria, indicating that PCOS accounts for
approximately three fourths of cases of infertility caused by ovulatory failure
[6,9]. Because anovulation is estimated to be the primary cause of infertility in
approximately 25% of couples, PCOS is one of the most common causes of
infertility overall—affecting about one in five infertile couples.
Diagnosis of polycystic ovary syndrome

The diagnosis of PCOS is primarily clinical (Box 1). A patient presenting
with irregular menses, oligomenorrhea, or amenorrhea (without estrogen
deficiency) has a high chance of having PCOS, particularly if there are signs
of hyperandrogenism. No single test is diagnostic of the syndrome and the
choice of investigations should be dictated by the clinical presentation. Serum
luteinizing hormone (LH) levels are typically elevated in women who have
PCOS (follicle-stimulating hormone [FSH] levels are within the normal
range), but up to 50% of women with all other clinical and biochemical
features of the syndrome may have normal serum LH levels [5]. Measurement
of LH is therefore of limited diagnostic value; it is specific—the combination
of raised LH and normal FSH levels essentially occurs only in PCOS—but it
is not sensitive. Pelvic ultrasonography will define the polycystic ovarian
morphology, but accurate assessment of the ovaries by ultrasound is
a particular skill and false-negative results are not uncommon. Conversely,
the presence of polycystic ovaries does not necessarily mean that the patient
Box 1. Clinical and endocrine features that suggest diagnosis of

PCOS in women with anovulatory infertility
Oligomenorrhea or estrogen-replete amenorrhea
Clinical and/or biochemical evidence of hyperandrogenism
Normal serum FSH levels with raised LH levelsa
Polycystic ovaries on ultrasound
a
Many patients with anovulatory PCOS have normal LH levels.
S. Franks / Endocrinol Metab Clin N Am 32 (2003) 639–651 641
has PCOS. For example, polycystic ovaries may be found coincidentally in

women who have hypothalamic, estrogen-deficient amenorrhea.
The cause of anovulation in PCOS

Although PCOS is by far the most common cause of anovulation, the
precise reason or reasons for the failure of ovulation remain unclear [10,11].
The characteristic feature of anovulation in PCOS is that the later stages of
growth and maturation of the Graafian follicle, which take place just before
ovulation, seem to be impaired or ‘‘arrested.’’ Thus, the polycystic ovary in
an anovulatory subject typically contains multiple follicles ranging in size
from 2 to 8 mm in diameter, but with none exceeding 8 mm.
The final stage of follicular development leading to ovulation—when a
single leading or ‘‘dominant’’ follicle grows from about 5 mm to around 20 mm
in diameter—is dependent, principally, on the effects of FSH. Circulating
concentrations of FSH are within the normal range in women with PCOS
[4–6], but the normal intercycle rise in serum FSH levels is lacking. There has
been much debate about the cause of arrested follicle development in PCOS.
If serum concentrations of FSH are raised therapeutically, ovulation can
usually be induced (see later), suggesting that a relative deficiency of FSH is
an important factor in the mechanism of anovulation. It is unlikely, however,
that this alone can account for abnormal follicular growth and maturation.
There is evidence for premature advancement in the maturation of a
subpopulation of follicles in the polycystic ovary [12]. Not only are these
follicles incapable of further growth but, by virtue of their inappropriate
production of estrogen and progesterone, they suppress endogenous FSH
levels, thereby preventing maturation of the ‘‘healthy’’ follicles that must be
present within the same cohort [11]. It is unknown whether these phenomena
represent an intrinsic abnormality in the ‘‘programming’’ of development of
follicles of the polycystic ovary or whether they reflect a response of the ovary
to an abnormal endocrine environment—or to a combination of these factors.
One of the most important of these endocrine factors is insulin (Fig. 1).
Insulin and polycystic ovary syndrome

In recent years, it has become clear that women with the classic form
of PCOS—that is, the combination of anovulation and hyperandro-
genism—also have typical metabolic abnormalities. Hyperinsulinemia and
insulin resistance are central to this so-called ‘‘metabolic syndrome’’. Women
with PCOS have higher circulating insulin levels and reduced sensitivity to
the effects of insulin (insulin resistance) than weight-matched control
subjects [2,13]. These findings are relevant to reproductive performance
and long-term health.
Hypersecretion of insulin may have an adverse affect on ovarian function
by contributing to premature arrest of follicular development [10,11,14].
Fig. 1. Arrest of follicular growth in PCOS. In normal ovulatory cycles, the dominant follicle,
only responds to LH after it has reached about 10 mm in diameter. In follicles from anovulatory
women with PCOS (anovPCO), the response to LH occurs, inappropriately, in smaller follicles.
This effect may be precipitated by (or amplified by) the actions of insulin and mediated by
changes in cyclic adenosine monophosphate (cAMP). High intracellular concentrations of
cAMP lead to terminal differentiation of granulosa cells (see refs [10,11]).
The effects of obesity and, conversely, calorie restriction on ovulatory

function provide good clinical evidence of the effects of hyperinsulinemia on
the ovary. Obese women with PCOS (who are invariably hyperinsulinemic)
are more likely to have menstrual disturbances compared with lean women
with PCOS. In addition, obese anovulatory women respond poorly to
induction of ovulation compared with women with PCOS whose weight falls
within the normal range. Calorie restriction in obese women with PCOS
results in a fall in circulating insulin levels and improvement of menstrual
pattern and fertility [15,16]. Dietary advice is an important facet of man-
agement of overweight PCOS patients with anovulatory infertility.
Regarding the long-term implications of the metabolic abnormalities of
PCOS, perhaps the most important is the increased risk of developing type 2
diabetes mellitus. It has been estimated that women with PCOS are 3 to
6 times more likely to develop type 2 diabetes in middle age than an
appropriate reference population, matched for age, weight, and other
relevant factors [17,18]. In addition, obese young women with PCOS are
much more likely to have impaired glucose tolerance (or frank diabetes)
than obese control subjects [13]. Clearly, PCOS is a risk factor for diabetes
and appropriate counseling regarding diet and lifestyle is an important part
of the management of young women with PCOS.
Management of anovulatory infertility in polycystic ovary syndrome

It is usually possible to restore normal fertility to anovulatory women
who have PCOS. For the reasons stated previously, in obese subjects, the
most important initial step in ensuring an optimal response to induction of

ovulation is dietary modification [16]. In addition, the recent medical
literature (both scientific and popular publications) has emphasized the
potential use of insulin-modifying drugs in management of PCOS. These
insulin-modifying treatments are discussed later.
Clomiphene
The treatment of first choice for induction of ovulation is antiestrogen
therapy; the most commonly used agent is clomiphene citrate. Clomiphene is
given orally, usually at a starting dose of 50 mg/day for 5 days, generally
starting on day 2 or 3 after the onset of spontaneous or progestin-induced
menses. The drug stimulates endogenous FSH secretion, leading to
development of a dominant follicle and ovulation in approximately 75% of
patients. The fecundity rate after clomiphene-induced ovulation (70% of
women conceive within 6 cycles) is close to normal [19]. Although clomiphene
treatment is relatively straightforward, it is important that ultrasound
and endocrine monitoring are performed—at least in the first cycle of
treatment—so that the dose can be adjusted, if necessary, in subsequent
cycles. Possible problems range from failure to develop a preovulatory
follicle to hyperstimulation syndrome—a potentially dangerous complica-
tion that, although more commonly associated with gonadotropin therapy,
can occur following antiestrogen treatment. Predictors of ovulation in
response to clomiphene include body weight and free androgen index [19–22].
Gonadotropin treatment in polycystic ovary syndrome

The management of subjects who do not ovulate in response to
clomiphene presents more of a problem. Induction of ovulation by con-
ventional doses of exogenous gonadotropins is associated with lower rates
of ovulation and pregnancy than in hypogonadotropic women but with an
increased chance of multiple follicle development (and an associated increase
in the risk of hyperstimulation syndrome and of multiple pregnancy) and
a higher rate of miscarriage compared with gonadotropin-deficient patients
[23–25]. There is an increasing awareness of the adverse medical and
sociologic implications of multiple gestation, and it should be the aim of an
induction of the ovulation program to achieve unifollicular ovulation [25].
Many centers therefore have adopted a low-dose regimen for induction of
ovulation with gonadotropins in women with PCOS. This regimen is based
on the work by Brown et al [26,27]. The authors observed that, by making
small, stepwise increments in the dose of FSH of approximately 30% at
5-day intervals in women who were given human pituitary gonadotropin
(HPG), it was possible to define a ‘‘threshold’’ dose at which a significant
rise in estrogen excretion was detectable and beyond which multiple
folliculogenesis was more likely. Subsequently, Kamrava et al [28] reported
successful induction of ovulation in two patients with PCOS following the

administration of urinary-derived FSH at a fixed daily dose of only 75 IU.
The low-dose gonadotropin regimen

In the current author’s unit, gonadotropin treatment (human menopaus-
al gonadotropin [hMG] or FSH) is started at a dose of 52.5 IU by daily
intramuscular injection following the onset of spontaneous or progestin-
induced menses [29–31]. Ultrasound and endocrine assessment are
performed initially at 3- to 4-day intervals and, in the preovulatory phase,
on alternate days (or daily, if indicated). Decisions about changes in
treatment are usually made from ultrasound scanning with retrospective
analysis of LH and estradiol measurements when necessary. The initial dose
of hMG is maintained for up to 14 days in the first cycle and the dose is
increased to 75 IU only if no follicle larger than 10 mm is observed by that
stage. Further increments of 37.5 IU are made, if necessary, at weekly
intervals, to a maximum of 225 IU/day. If a dominant follicle emerges, that
dose of hMG (the threshold dose) is continued until the follicle has reached
a diameter of at least 18 mm.
Ovulation is triggered by a single intramuscular dose (5000 IU) of human
chorionic gonadotropin (hCG), and hMG is stopped. The hCG is given
routinely because although some patients will have a spontaneous LH surge,
it is not possible to predict this with any reliability. Treatment is dis-
continued if there are more than three follicles 15 mm or greater in diameter
to minimize the risk of hyperstimulation or multiple pregnancy. Serum
progesterone is measured 5 to 8 days after hCG (5000 IU).
If further cycles of treatment are necessary, hMG is reintroduced at a dose
below the previous threshold (and no more than 75 IU/day). In the second
and subsequent cycles, the first increment in dose is usually made after 7,
rather than 14, days. In women who develop multiple follicles, either a smaller
starting dose (eg, 37.5IU) is given or the dose is increased by only 25 IU.
A variation of this ‘‘step-up’’ low-dose gonadotropin regimen is the so-
called ‘‘step-down’’ protocol [32]. Both produce similar results, but the latter
is generally considered more difficult to institute because careful monitoring
is required in the first few days of treatment and there is an increased risk of
multiple follicle development [33].
Results. Of the 269 patients treated (Table 1), fewer than 5% failed to
ovulate. Seventy-three percent of cycles were ovulatory and, of these, 72%
were single-follicle ovulations. There were 129 pregnancies, of which only 7
(5%) were multiple—and these were all twins. The overall conception
rate was 48%, which compares favorably with the results of treatment
using conventional doses of gonadotropins. Although the starting dose of
FSH was scheduled to continue for up to 14 days before being increased, the
average length of the ‘‘follicular phase’’ (ie, from starting treatment to
Table 1
Out come of treatment of 269 clomiphene-resistant women with PCOS given low-does FSH
Results Number (%)
Cycles 1117
Ovulatory cycles 810 (73)
Uniovulatory cycles 585 (72)
Pregnancies 129 (48)
Multiples (all twin) 7 (5)
Data from Franks S, White DM. Low-dose gonadotrophin treatment in polycystic ovary
syndrome: the step-up protocal. In: Tarlatzis B, editor. Ovulation induction. Paris: Elsevier;
2000. p. 101–7.
administration of hCG) was only 15 days. In most subjects, ovulation was

induced by FSH with doses of 52.5 or 75 IU per day. Cumulative conception
data are shown in Fig. 2. As observed with other regimens for induction of
ovulation, most pregnancies occurred within the first three cycles of
treatment. Only one pregnancy occurred after six cycles; the current author’s
policy, therefore, is to offer patients a maximum of six ovulatory cycles.
Outcome of pregnancy. The miscarriage rate in patients who were started on

a dose of 52.5 IU of FSH was 19%, which is not much greater than the
prevalence of spontaneous abortion (12%–15%) that has been reported in
the general population [34]. Ovarian hyperstimulation, classified as mild
or moderate [35], occurred in 8% of completed cycles and in 26% of
abandoned cycles. Hyperstimulation in all but one patient settled with
Fig. 2. Cumulative conception rate, calculated by life-table analysis, in 100 women treated with
low-dose gonadotropins (excluding women who never ovulated and those with male factor
infertility). (Adapted from Hamilton-Fairley D, Kiddy D, Watson H, Sagle M, Franks S. Low-
dose gonadotrophin therapy for induction of ovulation in 100 women with polycystic ovary
syndrome. Hum Reprod 1991;6:1095–9; with permission.)
expectant management. Only two patients required admission to hospital

for observation.
Predictors of outcome. When the endocrine data were analyzed according to

outcome of treatment, there were no differences in serum concentrations of
LH or testosterone between patients whose treatment resulted in successful
pregnancy compared with those who did not conceive or who suffered
pregnancy loss. Hypersecretion of LH has been associated with reduced
conception rates and increased rates of miscarriage [36–38], but during
uniovulatory cycles, endogenous concentrations of LH tend to decrease in
the midfollicular phase and premature elevation of LH is not observed
[29,39]. Therefore, if the low-dose protocol is used, there seems little rational
basis for the concurrent use of gonadotropin-releasing hormone (GnRH)
analogs to suppress LH, as has been suggested in the context of conventional
gonadotropin treatment [40–42]. In the event, subjects who were started on
52.5 IU of FSH, serum concentrations of LH (or testosterone) did not have
a significant negative impact on the outcome of treatment.
Systematic analysis of endocrine factors, including serum insulin-like
growth factor-1 and testosterone, may help predict the response to
gonadotropins [43]; however, in the current author’s series, the only factor
that influenced outcome significantly was body mass index (BMI) [37]. Of 20
women with a BMI greater than 27 kg/m2, only 5 conceived and 3 of these
miscarried. Age can clearly have an adverse effect on fertility; however, in this
series, there were too few women aged older than 37 years to evaluate this
factor.
Comparison of follicle-stimulating hormone and human menopausal gonado-

tropin. There have been claims that FSH is more effective than hMG in
the management of patients with PCOS [44], but careful examination of
the literature does not support this contention. In the few prospective,
randomized, controlled trials that have been conducted, there have been no
significant differences between FSH and hMG treatment with regard to
rates of ovulation and pregnancy [39,45]. The results of a recent Cochrane
review support this conclusion [46].
Recombinant human follicle-stimulating hormone. Although it has been

suggested that human recombinant FSH is safer and more effective than
urinary FSH for induction of ovulation in women who have PCOS [47],
a recent Cochrane review concluded that there were insufficient data to
demonstrate that recombinant FSH has a significant advantage in efficacy
or safety over urinary-derived gonadotropins in management of PCOS [48].
Nevertheless, it makes sense, in the long term, to replace urinary
gonadotropins with these very pure recombinant preparations, although
currently the price of the latter is high.
Use of gonadotropin-releasing hormone analogs in combination with low-dose

gonadotropins. The rationale for cotreatment with long-acting analogs of
GnRH during induction of ovulation with gonadotropins in women with
PCOS is to prevent hypersecretion of LH, which may have an adverse effect
on outcome. Although tonically elevated LH levels and premature LH surges
occur commonly during conventional dose regimens (principally because of
multiple follicles and hypersecretion of estradiol), these phenomena are less
likely to occur when low-dose regimens are used [49]. There have, to the
current author’s knowledge, been no prospective controlled trials of
sufficient power to demonstrate either higher pregnancy rates or significantly
lower miscarriage rates from GnRH analog treatment. Given that the rate of
miscarriage in the author’s recent series is approximately 20% [31], he
estimates that clinicians would need upwards of 200 patients per treatment
arm to demonstrate a difference in outcome. Because a 20% miscarriage rate
is little more than one would expect in the normal population, it seems
difficult to justify the effort and expense of such an exercise.
Laparoscopic ovarian diathermy

Laparoscopic ovarian diathermy (LOD) is now a well-established
alternative method of treating infertility in clomiphene-resistant women
with PCOS. Although it is an ‘‘invasive’’ procedure and carries the risk of
pelvic adhesion formation, it is usually effective and well tolerated. In a recent
prospective, controlled study comparing LOD with low-dose gonadotropin
therapy, the rates of ovulation, pregnancy, and miscarriage were similar in
the two groups studied. Subsequent questionnaires revealed that most
women preferred a single surgical procedure to repeated gonadotropin inj-
ections and monitoring [50].
In vitro fertilization
The outcome of treatment following superovulation and in vitro
fertilization (IVF) in women with PCOS is similar to that in women with
normal ovaries with respect to successful pregnancy rates [51]. Women with
PCOS, however, are at increased risk of OHSS after superovulation and IVF
is not advocated as first-line therapy in those who present with anovulation
but no other infertility factors. IVF should usually be reserved for man-
agement of couples with additional causes of infertility or for those who fail
other therapies.
Role of diet and insulin-sensitizing drugs in management of anovulation in

polycystic ovary syndrome
Because hyperinsulinemia has been implicated in the mechanism of
anovulation in PCOS, it seems logical that treatment that reduces plasma
insulin levels and insulin resistance will be beneficial for metabolic and
reproductive reasons. Calorie restriction in obese women with PCOS

improves insulin sensitivity and glucose tolerance. It also leads to resumption
of spontaneous ovulatory cycles and normal fertility in many women [16,52].
Significantly, such improvements in glucose-insulin homeostasis and re-
productive function can be achieved with weight reduction of as little as 5%
of the initial body weight [16]. Insulin-sensitizing drugs also may have a role
in reducing the risk of diabetes and improving ovarian function. The
thiazolidinediones (TZDs) are a relatively new class of insulin-sensitizing
drugs that have been introduced primarily for the control of type 2 diabetes.
In a large, randomized, multicenter study, troglitazone improved insulin
sensitivity and menstrual cyclicity in obese women with PCOS [53]. This drug
has been withdrawn because of serious side effects, however, and although
there are newer, apparently safer preparations available, there remain
concerns about prescribing TZDs in women of reproductive age.
Metformin is a well-established medication in management of type 2
diabetes. Its mechanism of action is complex but its effects include reduction
of insulin resistance and insulin levels. Recent studies in women with PCOS
have suggested that this may be a safe and effective means of improving the
metabolic profile and reproductive function in lean and obese women with
PCOS. Results so far have been encouraging but not conclusive. There have
been few randomized controlled trials and these have produced conflicting
results; however, the consensus from controlled trials is that chronic
treatment with metformin is associated with an approximately 30% im-
pr ovement in the frequency of ovulation compared with placebo [54,55].
Summary
PCOS is the most common cause of anovulatory infertility. Anovulation
in PCOS is exacerbated by weight gain and improved by calorie restriction
in overweight subjects. Fertility can usually be restored by appropriate
choice of induction of ovulation, but careful monitoring is required, even
when using clomiphene alone.
References
[1] Zawadzki JK, Dunaif A. Diagnostic criteria for polycystic ovary syndrome: towards
a rational approach. In: Dunaif A, Givens JR, Haseltine FP, Merriam GR, editors.
Polycystic ovary syndrome. Oxford, UK: Blackwell Scientific; 1992. p. 377–84.
[2] Franks S. Polycystic ovary syndrome: a changing perspective. Clin Endocrinol 1989;31:
87–120.
[3] Jacobs HS. Polycystic ovaries and polycystic ovary syndrome. Gynecol Endocrinol
1987;1:113–31.
[4] Conway GS, Honour JW, Jacobs HS. Heterogeneity of the polycystic ovary syndrome:
clinical, endocrine and ultrasound features in 556 patients. Clin Endocrinol 1989;30:
459–70.
[5] Franks S. Polycystic ovary syndrome. N Eng J Med 1995;333:853–61.

[6] Adams J, Polson DW, Franks S. Prevalence of polycystic ovaries in women with
anovulation and idiopathic hirsutism. BMJ 1986;293:355–9.
[7] Knochenhauer ES, Key TJ, Kahsar-Miller M, Waggoner W, Boots LR, Azziz R. Prevalence
of the polycystic ovary syndrome in unselected black and white women of the southeastern
United States: a prospective study. J Clin Endocrinol Metab 1998;83:3078–82.
[8] Kousta E, White DM, Cela E, McCarthy MI, Franks S. The prevalence of polycystic
ovaries in women with infertility. Hum Reprod 1999;14:2720–3.
[9] Hull MGR. Epidemiology of infertility and polycystic ovarian disease: endocrinological
and demographic studies. Gynecol Endocrinol 1987;1:235–45.
[10] Franks S, Robinson S, Willis D. Nutrition, insulin and polycystic ovary syndrome. Rev
Reprod 1996;1:47–53.
[11] Franks S, Mason D, Willis D. Follicular dynamics in the polycystic ovary syndrome. Mol
Cell Endocrinol 2000;163:49–52.
[12] Willis D, Watson H, Mason D, Galea R, Bricat M, Franks S. Premature response to LH of
granulosa cells from anovulatory women with polycystic ovaries: relevance to mechanism
of anovulation. J Clin Endocrinol Metab 1998;83:3984–91.
[13] Dunaif A. Insulin resistance and the polycystic ovary syndrome: mechanism of action and
implications for pathogenesis. Endocr Rev 1997;18:774–800.
[14] Willis D, Mason H, Gilling-Smith C, Franks S. Modulation by insulin of follicle
stimulating and luteinizing hormone action in human granulosa cells of normal and
polycystic ovaries. J Clin Endocrinol Metab 1996;81:302–9.
[15] Pasquali R, Antenucci D, Casimirri F, et al. Clinical and hormonal characteristics of obese
amenorrheic hyperandrogenic women before and after weight loss. J Clin Endocrinol
Metab 1989;68:173–9.
[16] Kiddy DS, Hamilton-Fairley D, Bush A, et al. Improvement in endocrine and ovarian
function during dietary treatment of obese women with polycystic ovary syndrome. Clin
Endocrinol 1992;36:105–11.
[17] Dahlgren E, Johansson S, Lindstedt G, et al. Women with polycystic ovary syndrome
wedge resected in 1956 to 1965: a long-term follow-up focusing on natural history and
circulating hormones. Fertil Steril 1992;57:505–13.
[18] Wild S, Pierpoint T, McKeigue P, Jacobs H. Cardiovascular disease in women with
polycystic ovary syndrome at long-term follow-up: a retrospective cohort study. Clin
Endocrinol 2000;52:595–600.
[19] Kousta E, White DM, Franks S. Modern use of clomiphene citrate in induction of
ovulation. Hum Reprod Update 1997;3:359–65.
[20] Polson DW, Kiddy DS, Mason HD, Franks S. Induction of ovulation in patients with
clomiphene citrate in women with polycystic ovary syndrome: the difference between
responders and non-responders. Fertil Steril 1989;51:30–4.
[21] Imani B, Eijkemans MJ, te Velde ER, Habbema JD, Fauser BC. Predictors of patients
remaining anovulatory during clomiphene citrate induction of ovulation in normogonado-
tropic oligoamenorrheic infertility. J Clin Endocrinol Metab 1998;83:2361–5.
[22] Imani B, Eijkemans MJ, te Velde ER, Habbema JD, Fauser BC. A normogram to predict
live birth probability after clomiphene citrate induction of ovulation in normogonado-
tropic oligoamenorrheic infertility. Fertil Steril 2002;77:91–7.
[23] Hamilton-Fairley D, Franks S. Common problems in induction of ovulation. Baillieres
Clin Obstet Gynaecol 1990;4:609–26.
[24] Franks S, Hamilton-Fairley D. Ovulation induction: gonadotropins. In: Adashi EY, Rock
JA, Rosenwaks Z, editors. Reproductive endocrinology, surgery, technology. New York:
Raven Press; 1996. p. 1207–24.
[25] Jacobs HS. Regular-dose gonadotropins in polycystic ovary syndrome: outcome and
complications. In: Filicori M, Flamigni C, editors. Ovulation induction, update ’98.
London: Parthenon; 1998. p. 41–5.
[26] Brown JB, Evans JH, Adey FD, Taft HP, Townsend L. Factors involved in the induction
of fertile ovulation with human gonadotrophins. J Obstet Gynaecol Br Commonw
1969;76:289–306.
[27] Brown JB. Pituitary control of ovarian function—concepts derived from gonadotrophin
therapy. Aust N Z J Obstet Gynaecol 1978;18:47–54.
[28] Kamrava MM, Seibel MM, Berger MJ, Thompson I, Taymor ML. Reversal of persistent
anovulation in polycystic ovarian disease by administration of chronic low-dose follicle-
stimulating hormone. Fertil Steril 1982;37:520–3.
[29] Polson DW, Mason HD, Saldahna MB, Franks S. Ovulation of a single dominant follicle
during treatment with low-dose pulsatile follicle stimulating hormone in women with
polycystic ovary syndrome. Clin Endocrinol 1987;26:205–12.
[30] Hamilton-Fairley D, Kiddy D, Watson H, Sagle M, Franks S. Low-dose gonadotrophin
therapy for induction of ovulation in 100 women with polycystic ovary syndrome. Hum
Reprod 1991;6:1095–9.
[31] White DM, Polson DW, Kiddy D, et al. Induction of ovulation with low-dose
gonadotropins in polycystic ovary syndrome—an analysis of 109 pregnancies in 225
women. J Clin Endocrinol Metab 1996;81:3821–4.
[32] van Santbrink EJP, Donderwinkel PFJ, van Dessel TJHM, Fauser BCJM. Gonadotrophin
induction of ovulation using a step-down dose regimen: a single centre experience in 82
patients. Hum Reprod 1995;10:1048–53.
[33] Balasch J, Fabregues F, Creus M, Puerto B, Penarrubia J, Vanrell JA. Follicular development
and hormone concentrations following recombinant FSH administration for anovulation
associated with polycystic ovarian syndrome: prospective randomised comparison between
low-dose step-up and modified step-down regimens. Hum Reprod 2001;16:652–6.
[34] Regan L, Braude PR, Trembath PL. Influence of past reproductive performance on risk of
spontaneous abortion. BMJ 1989;299:541–5.
[35] Salat-Baroux J, Antoine JM. Accidental hyperstimulation during ovulation induction.
Baillieres Clin Obstet Gynaecol 1990;4:627–37.
[36] Fleming R, Haxton MJ, Hamilton MPR, et al. Successful treatment of infertile women
with oligomenorrhoea using a combination of an LHRH agonist and exogenous
gonadotrophins. Br J Obstet Gynaecol 1985;92:369–79.
[37] Hamilton-Fairley D, Kiddy D, Watson H, Paterson C, Franks S. Association of moderate
obesity with a poor pregnancy outcome in women with polycystic ovary syndrome treated
with low dose gonadotrophin. Br J Obstet Gynaecol 1992;99:128–31.
[38] Balen AR, Tan SL, Jacobs HS. Hypersecretion of luteinising hormone: a significant cause
of infertility and miscarriage. Br J Obstet Gynaecol 1993;100:1082–9.
[39] Sagle MA, Hamilton-Fairley D, Kiddy DS, Franks S. A comparative, randomized study of
low-dose human menopausal gonadotropin and follicle-stimulating hormone in women
with polycystic ovarian syndrome. Fertil Steril 1991;55:56–60.
[40] Hoffman DI, Lobo RA, Campeau JD, et al. Ovulation induction in clomiphene-resistant
anovulatory women: differential follicular response to purified urinary follicle-stimulating
hormone (FSH) vs. purified urinary FSH and luteinizing hormone. J Clin Endocrinol
Metab 1985;60(5):922–7.
[41] Dodson WC, Hughes CJ, Yancy SE, Haney AF. Clinical characteristics of ovulation
induction with human menopausal gonadotropins with and without leuprolide acetate in
polycystic ovary syndrome. Fertil Steril 1989;5:915–8.
[42] Homburg R, Eshel A, Kilborn J, Adams J, Jacobs HS. Combined luteinizing hormone
releasing hormone analogue and exogenous gonadotrophins for the treatment of infertility
associated with polycystic ovaries. Hum Reprod 1990;5:32–5.
[43] Imani B, Eijkemans MJ, Faessen G, Bouchard P, Giudice LC, Fauser BC. Prediction of the
individual follicle-stimulating hormone threshold for gonadotropin induction of ovulation
in anovulatory infertility: an approach to minimize multiple gestation, ovarian
hyperstimulation and treatment expense. Fertil Steril 2002;77:83–90.
[44] Daya S. HMG versus FSH: is there any difference? In: Filicori M, Flamigni C, editors.
Ovulation induction, update ’98. London: Parthenon; 1998. p. 183–92.
[45] Tanbo T, Dale PO, Kjekshus E, et al. Stimulation with human menopausal gonadotropin
versus follicle stimulating hormone after pituitary suppression in polycystic ovarian
syndrome. Fertil Steril 1990;53:798–803.
[46] Hughes E, Collins J, Vandekerckhove P. Ovulation induction with urinary follicle
stimulating hormone versus human menopausal gondadotropin for clomephene-resistant
polycystic ovary syndrome. Cochrane Database Syst Rev 2000;2:CD00087.
[47] Fulghesu AM, Apa R, Belosi C, et al. Recombinant versus urinary follicle stimulating
hormone in the low-dose regimen in anovulatory patients with polycystic ovary syndrome:
a safer and more effective treatment. Horm Res 2001;55:224–8.
[48] Bayram N, van Wely M, van Der Veen F. Recombinant FSH versus urinary
gonadotrophins or recombinant FSH for ovulation induction in subfertility associated
with polycystic ovary syndrome. Cochrane Database Syst Rev 2001;2:CD002121.
[49] Franks S, White DM. Low-dose gonadotrophin treatment in polycystic ovary syndrome:
the step-up protocol. In: Tarlatzis B, editor. Ovulation induction. Paris: Elsevier; 2002.
p. 101–7.
[50] Farquhar CM, Williamson K, Gudex G, Johnson NP, Garland J, Sadler L. A randomised
controlled trial of laparoscopic ovarian diathermy versus gonadotropin therapy for women
with clomiphene-resistant polycystic ovary syndrome. Fertil Steril 2002;78:404–11.
[51] Franks S, Roberts LR, Hardy K. Gonadotropin regimens and oocyte quality in women
with polycystic ovary syndrome. Reprod Biomed Online 2003;6:181–4.
[52] Clark A, Ledger W, Galletly C, et al. Weight loss results in significant improvement
in pregnancy and ovulation rates in anovulatory obese women. Hum Reprod 1995;10:
2705–12.
[53] Azziz R, Ehrmann D, Legro RS, et al. Troglitazone improves ovulation and hirsutism in
the polycystic ovary syndrome: a multicenter, double blind, placebo-controlled trial. J Clin
[54] Taylor AE. Insulin-lowering medications in polycystic ovary syndrome. Obstet Gynecol
Clin North Am 2000;27:583–95.
[55] Fleming R, Hopkinson ZE, Wallace M, Greer IA, Sattar N. Ovarian function and
metabolic factors in women with oligomenorrhoea treated with metformin in a randomised
double blind placebo-controlled trial. J Clin Endocrinol Metab 2002;87:1–6.
32 (2003) 653–667
An evidence-based evaluation of
endometriosis-associated infertility
Elizabeth A. Pritts, MDa,*,
Robert N. Taylor, PhD, MDb
a
Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and
Gynecology, University of Wisconsin, H4/630 CSC, 600 Highland Avenue, Madison,
WI 53792-6188, USA
b
Division of Reproductive Endocrinology and Infertility, Department of Obstetrics,
Gynecology, and Reproductive Sciences, Center for Reproductive Sciences,
University of California, 513 Parnassus Avenue HSW 1656, San Francisco,
CA 94143-0556, USA
Definition
Endometriosis is a disease characterized by the growth of endometrial
glands and stroma in areas outside the uterus. The most common place
to find endometriotic implants is in the peritoneal cavity, but lesions
occasionally have been found in the pleural cavity, liver, kidney, gluteal
muscles, and bladder, and even in men. The anatomic location and in-
flammatory response to these lesions are believed to account for the
symptoms and signs associated with endometriosis.
Epidemiology
Endometriosis has been observed in women aged 12 to 80 years, with an
average age at diagnosis of approximately 28 years. Exposure to ovarian
hormones appears to be essential for the development of this condition.
There is no known racial or socioeconomic predilection [1]. With severe
disease, there seems to be a familial correlation, but no clear mendelian
inheritance has been identified, and most researchers believe it to be
a multifactorial, polygenic trait [2].
E-mail address: eapritts@wisc.edu (E.A. Pritts).
doi:10.1016/S0889-8529(03)00045-8
654 E.A. Pritts, R.N. Taylor / Endocrinol Metab Clin N Am 32 (2003) 653–667
The prevalence of endometriosis ranges from 2% to 50% of re-

productive-aged women. The variance in estimated rates of prevalence
reflects the study population and method of ascertainment. In women with
infertility, the prevalence ranges from 20% to 50%, which may be because
endometriosis plays a causal role in infertility. This finding also may reflect
a diagnostic selection bias, because women with infertility are more likely to
undergo laparoscopy as part of their clinical evaluation.
Between 1965 and 1984, endometriosis increased as the primary indication
for hysterectomy in the United States from 10% to 19%. This increase
happened during an era in which more conservative laparoscopic therapies
for endometriosis were introduced [3]. This finding suggests that a true
increase in the incidence of this disease may be evolving. Varying theories
have been proposed to explain the increase, including delay of childbearing,
declining use of oral contraceptives, and exposure to potentially causative
environmental toxins, such as dioxin [4]. These theories, although intriguing,
require further investigation to be substantiated.
Symptoms and signs

The most common symptom in women with endometriosis is cyclic pelvic
pain, although this complaint is not universal. The pain typically begins just
before menses and continues throughout the duration of menstrual flow
and may include dysmenorrhea, dyspareunia, dysuria, or dyschezia. The
pain also may be referred to musculoskeletal regions, such as the flank, low
back, or thighs.
Another common symptom is infertility. Women with moderate and
severe disease can have fertility problems caused by the mechanical blockage
of sperm-egg union, either from adhesions or disruption of normal pelvic
anatomy. Women with minimal or mild disease, however, also have de-
creased fecundity when compared with women without clinical evidence
of endometriosis. The exact causes remain elusive to date, but several
postulated mechanisms are discussed later.
Because of the diffuse and often pusillanimous nature of endometriotic
lesions, the physical examination is commonly unrevealing. Clinical signs
are variable and of limited precision with respect to localization or diagnosis
of endometriosis. Astute clinicians may find pain or induration in the
vicinity of otherwise nonpalpable lesions, most commonly in the cul-de-sac
or rectovaginal septum. Clinicians also may find uterine or adnexal fixation,
or an adnexal mass. Tender nodules may be palpable along the uterosacral
ligaments or within the cul-de-sac, especially if the examination is performed
just before menses. Because endometriosis is commonly found in dependent
areas of the pelvis, it is critical to perform a systematic rectovaginal
examination, taking care to evaluate the cul-de-sac and uterosacral
ligaments and the adnexa [5].
E.A. Pritts, R.N. Taylor / Endocrinol Metab Clin N Am 32 (2003) 653–667 655
Clinical appearance
Grossly, peritoneal endometriosis can take on a spectrum of visual
appearances. Classically, it was taught that endometriosis implants were
blue-black ‘‘powder burns’’ or ‘‘mulberry lesions’’ of the peritoneum. In
recent years, more subtle stages of implant development have been seen,
each with a corresponding appearance. Early, active lesions can appear
as papular excrescences or vesicles and can range in color from clear to
bright red [6]. Approximately a third of these lesions are histologically
synchronous with the eutopic (intrauterine) endometrium. Like eutopic
tissue, these implants spontaneously grow and regress, manifesting a
fluctuation of proliferation in association with hormone production during
the menstrual cycle [7]. Advanced, active lesions are associated with
inflammation, fibrosis, and hemorrhage and take on a more classic ap-
pearance identifiable at surgery. These implants can express a myriad of
colors (eg, black, brown, purple, red, or green), reflecting the presence of
heme degradation products as the foci undergo hemorrhage and fibrosis.
Dormant and healed lesions can appear either white or calcified, repre-
senting remnants of glands embedded in fibrous tissue [6].
A specific manifestation is the ovarian endometrioma or chocolate cyst.
These cysts gained their moniker by the characteristic chocolate-syrup
appearance of their contents. They arise after implantation of ectopic
endometrial tissue and subsequent invagination and invasion into the
ovarian cortex. The cell types present in these cysts include endometrial
epithelium, both as glands and flattened cells, endometrial stroma, and
hemosiderin-laden macrophages. In some cases, ciliated cells, similar to
those of oviduct epithelium, have been observed [8].
Scanning electron microscopy has revealed the presence of microscopic
lesions within normal-appearing peritoneum of women with and without
endometriosis [9]. The clinical significance of these findings is con-
troversial at present but raises the possibility that the propensity for endo-
metriosis may affect an even larger proportion of women than is currently
recognized.
Diagnostic modalities
Histopathologic dogma states that a biopsy of the lesion showing
endometrial glands and stroma is the only way to truly confirm the presence
of disease. Over the past two decades, however, laparoscopic visualization
has become the gold standard in diagnosis of endometriosis. For those
surgeons trained in advanced laparoscopy and experienced in the re-
cognition of subtle manifestations of implants, direct visual identification
of endometriosis also allows treatment to be instituted immediately.
Laparoscopy is preferred over laparotomy because it provides visualization
of the entire abdomen and pelvis at magnified views, with less morbidity
than laparotomy, and carries a decreased risk of adhesion formation
[10,11].
Attempts to develop radiologic imaging techniques as diagnostic tools for
endometriosis have been limited by lack of specificity. CT was initially
proposed to identify endometriomas in the setting of adnexal masses. It was
difficult to distinguish between benign versus malignant masses, however,
and often impossible to distinguish between adnexal structures and loops of
bowel [12,13]. More-recent technological advances, including transvaginal
ultrasonography and MRI have been used to evaluate possible endome-
triomas preoperatively. Sonographic features characteristic of endometrio-
mas have been described [14], but the specificity of these findings to
distinguish endometriomas from other benign or malignant ovarian lesions
is inadequate. When used as a screening tool for focal implants, the
sensitivity of ultrasound drops as low as 11% [15]. Hence, significant
advances in technology are required before ultrasonography can be used
more effectively in screening for endometriosis.
At present, MRI is the best imaging modality in the diagnostic
armamentarium for identifying endometriomas. MRI is reported to detect
implants as small as 3 mm [16–18]. In addition, it has been shown to dif-
ferentiate benign from malignant lesions with excellent sensitivity and spe-
cificity [19,20].
Attempts to establish biochemical markers of endometriosis have been
an active focus of investigation. Monoclonal antibodies raised against
a high-molecular-weight ovarian epithelial cancer antigen, CA-125, have
been used as a biochemical marker of endometriosis. Moderate and severe
endometriosis is associated with elevated levels of CA-125 in the peripheral
blood [21]. This marker is nonspecific, however, as it also is increased in
the blood of women with ovarian cancer, liver disease, colon cancer,
and pelvic inflammatory disease, and even during menstruation of women
without disease. Although this marker may help in the monitoring
of progression of disease in individual patients, its diagnostic utility is
limited.
Several other serum protein analytes have been proposed as candidates
for diagnosing endometriosis. Tissue inhibitor of metalloproteinase-1 is
decreased in both peritoneal fluid and serum of patients with endometriosis
compared with control subjects [22]. Other candidates include soluble
intercellular adhesion molecule-1 [23,24], tumor-associated trypsin inhibitor
[25], soluble human leukocyte antigen-1 [24], and C-reactive protein [26].
Circulating antibodies against haptoglobin-like proteins [27], transferrin
[28], Z-HS glycoprotein [28], and cardiolipin [26] also have been reported.
Although these proteins have yet to be validated as diagnostic tools,
ongoing studies continue. Perhaps in the future there may be a simple serum
test that can aid in diagnosing endometriosis or monitoring response to
intervention.
Infertility and endometriosis

Infertility and endometriosis are associated, but it is unclear whether
endometriosis is a cause of infertility. In the 1970s, investigators realized
that an objective, quantifiable analysis of this question would require
consistent comparisons among different clinicians and centers. The concept
of a classification scheme to identify manifestations of endometriosis that
might respond predictably to specific therapy was introduced. Early at-
tempts at classification were centered on descriptions from surgeries or
histopathologic findings, but later, the classification focused on prognostic
factors, namely, fertility outcomes in relation to extent of disease [29]. In
1985, the revised classification scheme for endometriosis was introduced
widely through the American Fertility Society. It was based on a scalar
scoring system with arbitrary values assigned to disease localization, with an
emphasis on adnexal adhesions and deep endometriotic invasion [30].
Despite refinements, however, this scheme still does not fulfill criteria for an
adequate classification scheme. In large part, the staging is based more on
clinical opinion and subjectivity than scientific data. Moreover, recent
attempts at validation of the scheme have shown intra- and interobserver
scores to differ by as much as 38% to 52% [31].
A new classification scheme, which takes into account surgical findings
based on the American Fertility Society classification scheme and historical
factors that have been shown to be pregnancy predictors, is currently being
devised and validated. This scheme is termed the Endometriosis Fertility
Index (EFI) [32]. The EFI ranges from 0 to 10, with 0 representing the
poorest prognosis and 10 representing the best prognosis. It was derived
from the results of more than 550 consecutive patients and has been
validated prospectively on an independent cohort of more than 400 subjects.
The results appear promising.
When endometriosis creates distortion of normal pelvic anatomy, or
obstruction of fallopian tubes, the risk of infertility is high. In women with
moderate to severe endometriosis (those with gross distortion of normal
pelvic anatomy), many studies cite a near zero pregnancy rate. Studies exist in
animal models to support this theory [33,34]. Many uncontrolled studies
show a benefit of surgical restoration of normal pelvic anatomy in these
women [35–37]. When considering the effects of minimal or mild endome-
triosis, however, there is much more controversy. Although an association
between early-stage endometriosis and impaired reproductive function exists,
the exact relationship remains unclear [38]. Experimental animal models
exist, using rabbits [39] and monkeys [33]. Although endometrium trans-
planted into the peritoneal cavity seems to decrease fertility rates in these
animals, this effect is primarily associated with the presence of pelvic
adhesions. Because endometriosis seems to be associated with an increased
risk of infertility independent of pelvic adhesions, these animal models have
limited value for understanding this uniquely human condition.
Aberrant activation of immunologic or inflammatory responses has been

postulated to decrease fecundity in women with endometriosis. Increased
monocyte activity and natural killer cell activity have been implicated, and
studies are currently ongoing to further delineate the role of the immune
system in the pathogenesis of the infertility associated with endometriosis. A
broad review of this topic has been published recently [40].
Further clinical studies attempting to identify mechanisms of endometri-
osis-associated infertility have presented a series of conflicting results. In
the evaluation of ovulatory function in women with mild or minimal
endometriosis, rates of luteinized unruptured follicles have been reported as
both increased [41] and decreased [42,43]. In addition, endometrial re-
ceptivity has been reported as being perturbed [44,45] and no different [46]
in women with endometriosis compared with unaffected control subjects. In
one study performed in a population of 21 donor sperm recipients with
endometriosis, pregnancy rates reached upwards of 20%, no different than
would be expected in women undergoing donor insemination without
endometriosis [47]. In contrast, a prospective study was performed with
women using donor sperm for their fertility treatment. The women in the
group with known endometriosis had significantly lower pregnancy rates
than those without endometriosis [48]. In another study, oocytes were
donated from women without endometriosis to women both with and
without endometriosis. Similar pregnancy and implantation rates were
found between both groups [49]. In addition, oocytes from a disease-free
donor, when donated to women with either no endometriosis or stage III–
IV disease, yielded nearly identical implantation pregnancy and live birth
rates [50].
Impaired sperm function has been implicated in the pathogenesis of
endometriosis-associated infertility, as has embryo toxicity and oocyte
toxicity. Again, the data are conflicting. Increased phagocytosis of sperm
was found during incubation with peritoneal cells from women with
endometriosis [51,52]. Others have not been able to substantiate this
finding [53]. Results from in vitro motility studies also are mixed [46],
although sperm transport through the fallopian tube does not seem to be
different in women with mild endometriosis [54] from that in normal
women.
Data in support of endometriosis-associated embryo toxicity are based
on the effect of human peritoneal fluid from women with and without
endometriosis on mouse oocyte and embryo models. In some studies, an
adverse effect of endometriotic peritoneal fluid on cleavage has been shown
[55–58], whereas in others, embryo toxicity is found only if women are
afflicted with both endometriosis and infertility, not endometriosis alone
[59]. In other studies, toxicity has not been confirmed [53,60].
Poor oocyte quality has been implicated as a causative factor in
endometriosis-associated infertility. Granulosa cells aspirated during in
vitro fertilization (IVF) cycles had higher rates of apoptosis, more
alterations of the cell cycle, and more evidence of oxidative stress when they
were harvested from women with endometriosis, compared with all other
forms of infertility [61]. Some investigators found that embryos derived
from oocytes of women with endometriosis had a lower likelihood of
implantation when transferred to women with or without endometriosis
[62]. This hypothesis was further addressed indirectly by a multitude of
studies that looked at outcomes of IVF cycles in women with endometriosis
compared with either unexplained or tubal factor infertility. In some studies,
fertility outcomes were poorer for women with endometriosis compared
with control subjects [63–66]. Several other investigators, however, found
similar fertility outcomes in women with endometriosis compared with
control subjects [67–73]. In an attempt to clarify the issue, a meta-analysis
was performed using all the published trials that address the effect of
endometriosis on IVF outcomes [74]. Of the 22 studies included, six did not
have control groups. Of these, three included results from patients treated
between 1981 and 1988. Pregnancy rates since the 1990s have been much
higher because of the introduction of different medication regimens
(including gonadotropin-releasing hormone agonists) and improved labo-
ratory media and techniques. Twelve of the studies included patients
undergoing IVF before 1990. In these studies, women routinely underwent
follicle aspiration by means of a transabdominal or laparoscopic approach.
The technical difficulty involved in visualizing and accessing the ovaries of
women with moderate and severe endometriosis could lead to decreased
numbers of oocytes retrieved and subsequently to poorer outcomes in these
women but should not lead to decreased implantation rates as noted the
meta-analysis. In results gathered from the North American Society for
Assisted Reproductive Technology, or SART, database, the live birth rates
for women undergoing IVF in 1999 were no different among women with
endometriosis (28.5%), unexplained infertility (27.6%), or tubal factor
infertility (26.8%) [75].
The outcomes of assisted reproduction in patients with endometriomas
also are controversial. In both natural and clomiphene-stimulated cycles,
prior endometrioma resection was associated with decreased follicular
response in that ovary [76]. Theoretically, surgery may be associated with the
inadvertent removal of normal ovarian tissue and damage caused by
electrocoagulation used for hemostasis. Moreover, the inadvertent exposure
of oocytes to endometrioma fluid during transvaginal aspiration does not
decrease fertility outcomes in women undergoing IVF [77]. These data are
further strengthened by some trials that show no differences in IVF outcomes
in patients with endometriomas compared with control subjects [78,79]. In
contrast, however, other investigators found that women with endometrio-
mas had decreased numbers of preovulatory follicles, fertilization rates, and
number of embryos transferred compared with patients who had hydro-
salpinges and adhesions [80]. In addition women with endometriomas had
increased miscarriage rates [81].
Questions still remain as to the effect of endometriosis and endome-

triomas, irrespective of adhesion formation, on assisted reproductive
technologies. Further studies are needed before firm conclusions can be
drawn.
Does treatment of endometriosis increase fertility rates?

Surgical treatment
The role of laparoscopic surgery in the amelioration of infertility in
women with minimal to mild endometriosis was addressed in a meta-
analysis of the two randomized, controlled trials that have been conducted
in this setting [82]. Included were the multicenter Canadian trial and
a smaller study performed in Italy. Destruction of lesions, even in early-
stage disease, led to increased pregnancy rates in women attempting
spontaneous conception.
Although at first glance, surgery seems to be beneficial, it is important to
translate this statistical finding into a clinically relevant context. Based on
the larger of the two studies (with the more optimistic outcomes) [83], 7.7
operative laparoscopies would need to be performed on women with
endometriosis for each additional pregnancy. Based on an estimated 30%
prevalence of endometriosis in infertile populations, however, the total
number of infertile women requiring laparoscopy jumps to 25.4 to attain
a single additional pregnancy. Hence, although surgical treatment is in-
dicated for infertile women with endometriosis, the need for surgery in every
infertile woman may not be justified.
There are no published trials that compare surgical treatment versus no
treatment in women with moderate to severe endometriosis; however, many
publications cite a near zero pregnancy rate for women with extensive
disease [84]. Uncontrolled trials show increased pregnancy rates for these
women if normal pelvic anatomy is restored [85]. The current authors
therefore believe that surgery in these patients is useful for enhancing
fertility outcomes.
When considering surgical extirpation of endometriomas, the data are
again limited and conflicting. Some studies showed cystectomy to be
deleterious to the residual normal ovarian cortex [76,86], whereas another
showed no differences in fertility outcomes between those women with
resected endometriomas, those with endometriosis, and those with tubal
infertility [87]. In another study, women undergoing recurrent surgery for
endometriomas had fewer oocytes retrieved and fewer embryos replaced but
no differences in pregnancy and delivery rates compared with women whose
endometriomas were left in situ [88]. Again, further studies are needed to
elucidate the risk-to-benefit ratio of endometrioma excision in women with
endometriosis-associated infertility.
Medical treatment
Most established medical therapies have been aimed at inhibition of
ovulation as a means of interrupting hormonal stimulation of endometriotic
implants. Medical therapies typically have been used for short periods
of time to decrease the size, or activation state, of focal lesions before
attempted conception. Five randomized trials compared six different
treatments with placebo or no treatment [88–92]. Another eight randomized
trials were performed in which danazol was compared with a second
medication. A meta-analysis of these trials showed no differences between
the treatment and control arms of the studies with respect to fertility
outcomes [93].
These data can be considered in a different manner, however. Those
women undergoing treatment are anovulatory during the period that the
control group is actively attempting conception. If the same data are
analyzed to compare cumulative pregnancy rates starting from the time of
diagnosis of endometriosis, then patients undergoing medical treatment
have a significantly lower monthly fecundity rate than does the control
group [82]. Conventional hormonal regimens, therefore, have no place in the
treatment of endometriosis-associated infertility. These therapies may play
a role, however, in suppressing or controlling endometriosis in those women
not seeking immediate conception.
A novel treatment for endometriosis-associated infertility is pentoxifyl-
line, a phosphodiesterase inhibitor with anti-inflammatory properties. In
a single small-scale, randomized, controlled trial, pregnancy rates were 31%
with treatment and 18.5% with placebo. Although not statistically sig-
nificant, the findings suggest that anti-inflammatory strategies might be of
benefit in fertility treatment in the future [94].
Assisted reproductive technology

Three randomized trials have been published in which ovulation
induction [95] and ovulation induction combined with intrauterine in-
semination were performed for women with endometriosis [96,97]. It was
clear that these treatments enhanced fertility relative to timed coitus alone.
In addressing the issue of IVF treatment for women with endometriosis,
a single randomized, controlled trial was completed that compared 15
subjects using IVF with 6 control subjects. These numbers are too small to
derive meaningful conclusions, however. In a retrospective study, no dif-
ferences were found in women undergoing IVF versus none over a 3-year
cumulative period [98]. Although it seems that IVF may reduce the time to
pregnancy, it is unknown whether it actually increases the absolute
pregnancy rate. Further trials are needed before recommendations can be
made.
Summary
Although endometriosis is associated with infertility, a clear causal
relationship has yet to be established, unless adhesive disease is found.
Despite this indirect association, multiple theories have been promulgated
and studies are currently underway to investigate theoretic pathogenetic
mechanisms.
The data regarding the treatment of endometriosis-associated infertility
are limited and conflicting; however, some general preliminary conclusions
can be drawn. It seems that, with early-stage disease, surgical treatment
increases pregnancy rates. Using the US Preventive Services Task Force
classification scheme [99], the evidence in support of this finding is of the
highest quality, or level I. Surgical treatment for moderate and severe
disease also confers benefit, although the evidence in support of this
treatment is of lesser quality, level II-3 by the scheme.
Medical treatment, particularly if it induces an anovulatory state, has no
benefit and may delay fertility. This evidence is again of the highest quality,
with a classification of level I. Although assisted reproductive technologies
are of benefit regarding fertility for women with endometriosis, the IVF
evidence is inconclusive, with both treatments being evaluated by at least one
randomized, controlled trial conferring a level I classification to the evidence.
It is unclear at this time whether endometriomas have an impact on IVF
outcome. The evidence consists of only a few lower-quality studies, with
a classification level of II-2.
Despite the haziness of current insight into the treatment of endometri-
osis-associated infertility, well-designed clinical trials and basic mechanistic
investigations are underway in many reproductive medicine centers. As the
data from these scientific inquiries emerge, clinicians will have a clearer view
of effective treatment regimens for endometriosis.
References
[1] Chatman DL. Endometriosis and the black woman. J Reprod Med 1976;16:303–6.
[2] Malinak LR, Buttram VC Jr, Elias S, Simpson JL. Heritage aspects of endometriosis. II.
Clinical characteristics of familial endometriosis. Am J Obstet Gynecol 1980;137:332–7.
[3] National Center for Health Statistics. Hysterectomies in the United States, 1965–84.
Hyattsville, MD: National Center for Health Statistics; 1987 [Vital and Health Statistics,
Series 13, Data from the National Health Survey, No. 92]. DHHS Publication #PHS.
88–1753.
[4] Rier SSE, Martin DC, Bowman RE, Dmowski WP, Becker JL. Endometriosis in Rhesus
monkeys Macaca mulatta following chronic exposure to 2,3,7,8-tetrachlorodibenzo-p-
dioxin. Fundam Appl Toxicol 1993;2:433–41.
[5] Schenken BS, editor. Endometriosis. In: Contemporary concepts in clinical management.
Philadelphia: JB Lippincott; 1989. p. 1–32.
[6] Nisolle M, Casanas-Roux F, Donnez J. Histogenesis of peritoneal endometriosis. In:
Nezhat CR, Berger GS, Nezhat FR, Buttram VC Jr, Nezhat CH, editors. Endometriosis:
advanced management and surgical techniques. New York: Springer; 1995. p. 19–25.
[7] Evers J. The second look laparoscopy for the evaluation of the results of medical
treatment of endometriosis should not be performed during ovarian suppression. Fertil
Steril 1987;47:502–4.
[8] Nisolle-Pochet M, Casanas-Roux F, Donnez J. Histologic study of ovarian endometriosis
after hormonal therapy. Fertil Steril 1988;49:423–6.
[9] Brosens IA, Vasquez G, Gordts S. Scanning electron microscopic study of the pelvic
peritoneum in unexplained infertility and endometriosis. Fertil Steril 1984;41(Suppl):S21.
[10] Lundberg W, Wall J, Mathers J. Laparoscopy in evaluation of pelvic pain. Obstet
Gynecol 1973;43:872–6.
[11] Operative Laparoscopy Study Group. Postoperative adhesion development after
operative laparoscopy: evaluation at early second look procedures. Fertil Steril 1991;
55:700–4.
[12] Shiels RA, Peel KR, MacDonald HN, Thorogood J, Robinson PJ. A prospective trial of
computed tomography in the staging of ovarian malignancy. Br J Obstet Gynaecol
1985;92:407–12.
[13] Buy JN, Ghossain MA, Mark AS, Deligne L, Hugol L, Hugol D, et al. Focal hyperdense
areas in endometriomas: a characteristic finding on CT. Am J Roentgenol 1992;159:769–71.
[14] Wood C, Maher P, Hill D. Diagnosis and surgical management of endometriomas. Aust
N Z J Obstet Gynaecol 1992;32:161–3.
[15] Friedman H, Vogelzangh RL, Mendelson EB, Neiman HL, Cohen M. Endometriosis
detection by US with laparoscopic correlation. Radiology 1985;157:217–20.
[16] Arrive L, Hricak H, Martin MC. Pelvic endometriosis: MR imaging. Radiology
1989;171:687–92.
[17] Togashi K, Nishimura K, Kimura I, Tsuda Y, Yamashita K, Shibata T, et al.
Endometrial cysts: diagnosis with MR imaging. Radiology 1991;180:73–8.
[18] Manfredi R, Valentina AL. Magnetic resonance imaging of pelvic endometriosis. Rays
1998;23:702–8.
[19] Mawhinney RR, Powell MC, Worthington BS, Symonds EM. Magnetic resonance
imaging of benign ovarian masses. Br J Radiol 1988;61:179–86.
[20] Woodward PJ, Gilfeather M. Magnetic resonance imaging of the female pelvis. Semin
Ultrasound CT MR 1998;19:90–103.
[21] Pittaway DE, Fayez JA. The use of CA-125 in the diagnosis and management of
endometriosis. Fertil Steril 1986;46:790–5.
[22] Sharpe-Timms KL, Keisler LW, McIntusch EW, Keisler DH. Tissue inhibitor of
metalloproteinase-1 concentrations are attenuated in peritoneal fluid and sera of women
with endometriosis and restored in sera by gonadotropin-releasing hormone agonist
therapy. Fertil Steril 1998;69:1128–34.
[23] Perfumo F, Semino C, Melioli G, Venturini PL. A defective expression of ICAM-1
(CD54) on secretory endometrial cells is associated with endometriosis. Immunol Lett
2002;80(1):49–53.
[24] DePlacido G, Alviggi C, Di Palma G, Carravetta C, Mataroso G, Landino G, et al. Serum
concentrations of soluble human leukocyte class 1 antigens and of the soluble intercellular
adhesion molecule-1 in endometriosis: relationship with stage and non-pigmented
peritoneal lesions. Hum Reprod 1998;13:3206–10.
[25] Medl M, Ogris E, Peters-Engl C, Mierau M, Buxbaum P, Leodolter S. Serum levels of
tumor-associated trypsin inhibitor in patients with endometriosis. Br J Obstet Gynaecol
1997;104(1):78–81.
[26] Abrao M, Podgaec S, Martorelli F, Ramos LO, Pinotti JA, De Oliveira RM. The use
of biochemical markers in the diagnosis of pelvic endometriosis. Hum Reprod 1997;12:
2523–7.
[27] Berkova N, Lemay A, DeGrandpre P, Goupil S, Maheaux R. Immunoblot detection of
decreased antibodies to haptoglobin-like protein in the serum of infertile women with or
without endometriosis. Biol Reprod 1997;57:178–85.
[28] Mathur SP, Holt VL, Lee JH, Jiang H, Rust PF. Levels of antibodies to transferrin and
alpha Z-HS glycoprotein in women with and without endometriosis. Am J Reprod
Immunol 1998;40:69–73.
[29] Acosta AA, Buttram VC Jr, Besch PK, Malinak LR, Franklin RR, Vanderheyden JD. A
proposed classification of pelvic endometriosis. Obstet Gynecol 1973;42(1):19–25.
[30] American Fertility Society. Revised American Fertility Society classification of
endometriosis: 1985. Fertil Steril 1985;43(3):351–2.
[31] Hornstein MD, Gleason RE, Orav J, Haas ST, Friedman AJ, Rein MS, et al. The
reproducibility of the revised American Fertility Society classification of endometriosis.
Fertil Steril 1993;59:1015–21.
[32] Adamson GD, Pasta DJ. Pregnancy rates can be predicted by validated endometriosis
fertility index. Fertil Steril 2002;77(Suppl):S48.
[33] Schenken RS, Asch RH, Williams RF, Hodgen GD. Etiology of infertility in monkeys
with endometriosis: lutenized unruptured follicles, luteal phase defects, pelvic adhesions
and spontaneous abortions. Fertil Steril 1984;41(1):122–30.
[34] Werlin LB, DiZerega GS, Hodgen GD. Endometriosis: effect of ovulation, ovum pickup,
and transport in monkeys: an interim report [abstract]. Fertil Steril 1981;35:263.
[35] Falcone T, Goldberg JM, Miller KF. Endometriosis: medical and surgical interventions.
Curr Opin Obstet Gynecol 1996;8:178–83.
[36] Garcia CR, David SS. Pelvic endometriosis: infertility and pelvic pain. Am J Obstet
Gynecol 1997;129:740–7.
[37] Olive DL, Stohs GF, Metzger DA, Franklin RR. Expectant management and
hydrotubation in the treatment of endometriosis-associated infertility. Fertil Steril 1985;
44:35–41.
[38] Buyalos RP, Agarwal SK. Endometriosis-associated infertility. Curr Opin Obstet Gynecol
2000;12:377–81.
[39] Kaplan CR, Eddy CA, Olive DL, Schenken RS. Effect of ovarian endometriosis on
ovulation in rabbits. Am J Obstet Gynecol 1989;160(1):40–4.
[40] Lebovic DI, Mueller MD, Taylor RN. Immunobiology of endometriosis. Fertil Steril
2001;75:1–10.
[41] Mio Y, Toda T, Harada T, Terakawa N. Luteinized unruptured follicle in the early stages of
endometriosis as a cause of unexplained infertility. Am J Obstet Gynecol 1992;167:271–3.
[42] Mahmood TA, Templeton A. Folliculogenesis and ovulation in infertile women with mild
endometriosis. Hum Reprod 1991;6:227–31.
[43] Bancroft K, Vaughan-Williams CA, Elstein M. Pituitary ovarian function in women with
minimal or mild endometriosis and otherwise unexplained infertility. Clin Endocrinol
1992;36:177–81.
[44] Grant A. Additional sterility factors in endometriosis. Fertil Steril 1966;17:514–9.
[45] Lessey BA. Implantation defects in infertile women with endometriosis. Ann N Y Acad
Sci 2002;955:265–80.
[46] Burns WN, Schenken RS. Pathophysiology of endometriosis-associated infertility. Clin
[47] Chauhan M, Barratt CLR, Cooke SMS, Cook ID. Differences in the infertility of donor
insemination recipients—a study to provide prognostic guidelines as to its success and
outcome. Fertil Steril 1989;51(5):815–9.
[48] Jansen RP. Minimal endometriosis and reduced fecundability: prospective evidence from
an artificial insemination by donor program. Fertil Steril 1986;46(1):141–3.
[49] Sung L, Mukherjee T, Takeshige T, Bustillo M, Copperman AB. Endometriosis is not
detrimental to embryo implantation in oocyte recipients. J Assist Reprod Genet 1997;
14:152–6.
[50] Diaz I, Navarro J, Blasco L, Simon C, Pellicer A, Remohi J. Impact of stage III–IV
endometriosis on recipients of sibling oocytes: matched case-control study. Fertil Steril
2000;74:31–4.
[51] Muscato JJ, Haney AF, Weinberg JB. Sperm phagocytosis by human peritoneal
macrophages: a possible cause of infertility in endometriosis. Am J Obstet Gynecol
1982;144:503–10.
[52] Jha P, Farooq A, Agarwal N, Buckshee K. In vitro sperm phagocytosis by human
peritoneal macrophages in endometriosis-associated infertility. Am J Reprod Immunol
1996;36:235–7.
[53] Awadalla SG, Friedman CI, Haq AU, Roh SI, Chin NW, Kim NH. Local peritoneal
factors: their role in infertility associated with endometriosis. Am J Obstet Gynecol 1987;
157:1207–14.
[54] Stone SC, Himsl K. Peritoneal recovery of motile and nonmotile sperm in the presence of
[55] Taketani Y, Kuo TM, Mizuno M. Comparison of cytokine levels and embryo toxicity in
peritoneal fluid in infertile women with untreated or treated endometriosis. Am J Obstet
Gynecol 1992;167:265–70.
[56] Morcos RN, Gibbons WE, Findley WE. Effect of peritoneal fluid on in vitro cleavage of
2-cell mouse embryos: possible role in infertility associated with endometriosis. Fertil
Steril 1985;44:678–83.
[57] Prough SG, Aksel S, Gilmore SM, Yeoman RR. Peritoneal fluid fractions from patients
with endometriosis do not promote two-cell mouse embryo growth. Fertil Steril 1990;
54:927–30.
[58] Tzeng CR, Chien LW, Changge SR, Chen AC. Effect of peritoneal fluid and serum from
patients with endometriosis on mouse embryo in vitro development. Chin Med J
1994;54:145–8.
[59] Martinez-Roman S, Balasch J, Creus M, Fabregues F, Carmona F, Vilella R, et al.
Immunological factors in endometriosis-associated reproductive failure: studies in
fertile and infertile women with and without endometriosis. Hum Reprod 1997;12:
1794–9.
[60] Dodds WG, Miller FA, Friedman CI, Lisko B, Goldberg JM, Kim MH. The effect of
preovulatory peritoneal fluid from cases of endometriosis on murine in vitro fertilization,
embryo development, oviduct transport, and implantation. Am J Obstet Gynecol 1992;
166:219–24.
[61] Saito H, Seino T, Kaneko T, Nakahara K, Toxa M, Kurachi H. Endometriosis and
oocyte quality. Gynecol Obstet Invest 2002;53(Suppl):46–51.
[62] Simon C, Gutierrez A, Vidal A, de los Santos MJ, Tarin JJ, Remohi J, et al. Outcome of
patients with endometriosis in assisted reproduction: results from in-vitro fertilization and
oocyte donation. Hum Reprod 1994;9(4):725–9.
[63] Arici A, Oral E, Bukulmez O, Dulela A, Olive D, Jones EE. The effect of endometriosis on
implantation: results from the Yale University in vitro fertilization and embryo transfer
program. Fertil Steril 1996;65:603–7.
[64] Yovich JL, Matson PL, Richardson PA, Hilliard C. Hormonal profiles and embryo
quality in women with severe endometriosis treated by in vitro fertilization and embryo
transfer. Fertil Steril 1988;50:308–13.
[65] Pellicer A, Oliveira N, Ruiz A, Remohi J, Simon C. Exploring the mechanism(s) of
endometriosis-related infertility: an analysis of embryo development and implantation in
assisted reproduction. Hum Reprod 1995;10(Suppl):91–7.
[66] Azem F, Lessing JB, Geva E, Shara A, Lerner-Geva L, Yovel I, et al. Patients with stages
II and IV endometriosis have a poorer outcome of in vitro fertilization-embryo transfer
than patients with tubal infertility. Fertil Steril 1999;72(6):1107–9.
[67] Geber S, Paraschos T, Atkinson G, Margara R, Winston RM. Results of IVF in patients
with endometriosis: the severity of the disease does not affect outcome or the incidence of
miscarriage. Hum Reprod 1995;10:1507–11.
[68] Inoue M, Kobayashi Y, Honda I, Awahi H, Fujii A. The impact of endometriosis on the
reproductive outcome of infertile patients. Am J Obstet Gynecol 1992;167:278–82.
[69] Olivennes F, Feldberg D, Liu HC, Cohen J, Moy F, Rosenwaks Z. Endometriosis: a stage-
by-stage analysis—the role of in vitro fertilization. Fertil Steril 1995;64:392–8.
[70] Dmowski WP, Rana N, Michalowska J, Friberg J, Papierniak C, el-Roeiy A. The effect of
endometriosis, its stage and activity, and of autoantibodies on in vitro fertilization and
embryo transfer success rates. Fertil Steril 1995;63:555–62.
[71] Tanbo T, Omland A, Dale PO, Abyholm T. In vitro fertilization/embryo transfer in
unexplained infertility and minimal peritoneal endometriosis. Acta Obstet Gynecol Scand
1995;74:539–43.
[72] Bergemda A, Naffah S, Nagy C, Bergqvisst A, Sjoblom P, Hillensjo T. Outcome of IVF in
patients with endometriosis in comparison with tubal-factor infertility. J Assist Reprod
Genet 1998;15(9):530–4.
[73] Burke LM, Davenport AT, Russell GB, Deaton JL. Predictors of success after embryo
transfer: experience from a single provider. Am J Obstet Gynecol 2000;182:1001–4.
[74] Barnhart K, Dunsmoor-Su R, Coutifaris C. Effect of endometriosis on in vitro
fertilization. Fertil Steril 2002;77(6):1148–55.
[75] National Center for Chronic Disease Prevention Health Promotion. Division of
Reproductive Health. Assisted reproductive technology success rates: national
summary and fertility clinic reports. Atlanta GA: Centers for Disease Control and
Prevention; 1999. Available at: http://www.cdc.gov/nccdphp/drh/ART99/PDF’s/1999
ART.pdf. Accessed November 2002.
[76] Loh FH, Tan AT, Kumar J, Mg SC. Ovarian response after laparoscopic ovarian
cystectomy for endometriotic cysts in 132 monitored cycles. Fertil Steril 1999;72(5):
316–21.
[77] Khamsi F, Yavas Y, Lacanna IC, Roberge S, Endman M, Wong JC. Exposure of human
oocytes to endometrioma fluid does not alter fertilization or early embryo development.
J Assist Reprod Genet 2001;18:106–9.
[78] Al-Azemi M, Bernal AL, Steele J, Gramsbergen I, Barlow D, Kennedy S. Ovarian
response to repeated controlled stimulation for in vitro fertilization cycles in patients with
ovarian endometriosis. Hum Reprod 2000;15(1):72–5.
[79] Isaacs JD Jr, Hines RD, Sopelak VM, Cown BD. Ovarian endometriomas do not
adversely affect pregnancy success following treatment with in vitro fertilization. J Assist
Reprod Genet 1997;14:551–3.
[80] Dugli AM, Loy RA, Dieterie S, Byer SR, Seibel MM. The effect of endometriomas on in
vitro fertilization outcome. J In Vitro Fert Embro Transf 1989;6:338–41.
[81] Yanushpolsky EH, Best CL, Jackson KV, Clarke RN, Barbieri RL, Hornstein MD.
Effects of endometriomas on oocyte quality, embryo quality, and pregnancy rates in in
vitro fertilization cycles: a prospective, case-controlled study. J Assist Reprod Genet
1998;15(4):193–7.
[82] Olive DL, Pritts EA. The treatment of endometriosis. A review of the evidence. Ann N Y
Acad Sci 2001;955:360–72.
[83] Marcoux S, Maheux R, Berube S. Laparoscopic surgery in infertile women with minimal
or mild endometriosis. Canadian Collaborative Group in Endometriosis. N Engl J Med
1997;337:217–22.
[84] Olive DL, Keek L. Analysis of sequential treatment protocols for endometriosis-
associated infertility. Am J Obstet Gynecol 1986;154:613–9.
[85] Falcone T, Goldberg JM, Miller KF. Endometriosis: medical and surgical interventions.
Curr Opin Obstet Gynecol 1996;8:178–83.
[86] Hemmings R, Bissonnette F, Bouzayen R. Results of laparoscopic treatments of ovarian
endometriomas: laparoscopic ovarian fenestration and coagulation. Fertil Steril 1998;
70:527–9.
[87] Canis M, Pouly JL, Tamburro S, Mage G, Wattiez A, Bruhat MA. Ovarian response
during IVF-embryo transfer cycles after laparoscopic ovarian cystectomy for endometri-
otic cysts of >3cm in diameter. Hum Reprod 2001;16(12):2583–6.
[88] Bayer SR, Seibel MM, Saffan DS, Berger MJ, Taymor ML. Efficacy of danazol treatment
for minimal endometriosis in infertile women: a prospective, randomized study. J Reprod
Med 1988;33:179–83.
[89] Telimaa S. Danazol and medroxyprogesterone acetate inefficacious in the treatment of
infertility in endometriosis. Fertil Steril 1988;50:872–5.
[90] Harrison RF, Barry-Kinsella C. Efficacy of medroxyprogesterone treatment in infertile
women with endometriosis: a prospective, randomized, placebo-controlled study. Fertil
Steril 2000;74:24–30.
[91] Fedele L, Parazzini F, Radici E, Bocciolone L, Bianchi S, Bianchi C, et al. Buserelin
acetate versus expectant management in the treatment of infertility associated with
minimal or mild endometriosis: a randomized clinical trial. Am J Obstet Gynecol 1992;
166:1345–50.
[92] Thomas E, Cooke I. Successful treatment of asymptomatic endometriosis: does it benefit
infertile women? BMJ 1987;294:1117–9.
[93] Hughes E, Ferorkow D, Collins J, Vandekerckhone P. Ovulation suppression for
endometriosis [Cochrane review]. In: The Cochrane library. Issue 1. Oxford, UK: Update
Software; 2000.
[94] Balasch J, Creus M, Fabregues F, Carmona F, Martinez-Roman S, Manau D, et al.
Pentoxifylline versus placebo in the treatment of infertility associated with minimal or
mild endometriosis: a pilot randomized clinical trial. Hum Reprod 1997;12:2046–50.
[95] Fedele L, Bianchi S, Marchini M, Villa L, Brioschi D, Parazzini F. Superovulation with
human menopausal gonadotropins in the treatment of infertility associated with minimal,
or mild endometriosis: a controlled randomized study. Fertil Steril 1992;58:28–31.
[96] Deaton JL, Gibson M, Blackmer KM, Nakajima ST, Badger GJ, Brumsted JR. A
randomized, controlled trial of clomiphene citrate and intrauterine insemination in
couples with unexplained infertility or surgically corrected endometriosis. Fertil Steril
1990;54(6):1083–8.
[97] Tummon IS, Asher LJ, Martin JS, Tulandi T. Randomized controlled trial of
superovulation and insemination for infertility associated with minimal or mild
[98] Kodama H, Fukuda J, Karube H, Marsui T, Shimity Y, Tanaka T. Benefit of in vitro
fertilization treatment for endometriosis-associated infertility. Fertil Steril 1996;66(6):
974–9.
[99] US Preventive Services Task Force. Guide to clinical preventive services. 2nd edition.
Baltimore, MD: Williams & Wilkins; 1995.
Further reading
Soliman S, Daya S, Collins J, Jarrell J. A randomized trial of in vitro fertilization versus
conventional treatment for infertility. Fertil Steril 1993;59:1239–44.
32 (2003) 669–688
Age-related decline in fertility

Lubna Pal, MD*, Nanette Santoro, MD
Reproductive Endocrinology and Infertility, Albert Einstein College of Medicine,
Department of Obstetrics, Gynecology, and Women’s Health, 1300 Morris Park Avenue,
Mazer 325, Bronx, NY 10461, USA
Global improvements in health, the prolongation of the average life span

[1], increasing involvement of women in the workforce, and a trend toward
‘‘planned reproductive endeavors’’ have contributed to a postponement of
attempts at reproduction into the fourth and fifth decades of life [2,3],
thereby unmasking the phenomenon of reproductive senescence accompa-
nying chronologic aging. Longitudinal studies examining populations that
do not use contraception clearly demonstrate a decline in fertility rates with
advancing age [4–6]. Furthermore, a declining ability to procreate with
aging is noted across species.
The ability to procreate is influenced by many variables, especially when
considered in the context of aging. Contraceptive practices, sexuality, and
hence the frequency of exposure relative to the timing of ovulation, and the
time lag between initiation of attempts at conception impact on the eventual
outcome. Fecundibility, defined as the possibility of pregnancy per at-
tempted cycle, may be a better term to be used in examining the impact
of age on fertility, because the cumulative pregnancy rates may not always
be statistically significantly different across varying ages. Older couples take
longer to attain pregnancy compared with their younger counterparts
(Fig. 1) [7,8].
A classic study by Tietze [6] demonstrated a bimodal decline in fertility
with aging. A gradual decline was noted from the age of 25 years, with an
acceleration of the slope beyond age 35 [6]. Others [4,5] have confirmed the
age-related diminution in fecundity when adjusting for a decreasing coital
frequency in the aging couple [7] and a male factor contribution. A marked
decline in fecundity was demonstrated beyond age 35 for the female partner
following donor insemination cycles in women with azoospermic hus-
bands [4]. These results have since been consistently reproduced [9]. The
E-mail address: lubnapal@hotmail.com
doi:10.1016/S0889-8529(03)00046-X
670 L. Pal, N. Santoro / Endocrinol Metab Clin N Am 32 (2003) 669–688
Fig. 1. Cumulative pregnancy rates according to the number of insemination cycles in women
of different ages. Note the rising pregnancy rate for women aged older than 34 years with
increasing number of inseminations. (Reprinted from Berkowitz G, Skowron ML, Lapinski R.
Delayed childbearing and outcome of pregnancy. N Engl J Med 1990;322:659–64; with
permission.)
detrimental influences of chronologic age primarily target the females of the

species; the mid-30s is regarded as the threshold for the definition of
advanced reproductive age, beyond which a steep decline in fertility and
fecundity occurs [2].
Determinants of fecundity
Gametes, fertilization, uterine receptivity, embryo-uterine cross-talk
Procreation in humans involves a timely and proximate release of mature
haploid gametes within a hormonally primed female genital tract; normal
fertilization follows the impregnation of the oocyte by a single sperm.
Progressive cleavage and migration of the diploid embryo toward the
uterine cavity is finely attuned, with synchronous development of the
endometrium under the influence of a hormonal milieu dictated by
the corpus luteum. The endometrial implantation window is stringently
controlled temporally, spanning days 19 to 22 in a 28-day menstrual cycle
[10], allowing for an optimal environment for implantation. Hormonal
output, specifically progesterone, maintains an optimal endometrial envi-
ronment and sustains the growing conceptus until the establishment of
full placental function. The luteoplacental switch has been demonstrated
as early as 5 weeks’ gestation [11]. The placental trophoblast is subsequently
responsible for nurturing the growing fetus until completion of gestation.
L. Pal, N. Santoro / Endocrinol Metab Clin N Am 32 (2003) 669–688 671
The ovaries are endowed with a finite number of germ cells [12], the
quantum of the oocyte repertoire being genetically determined [13]. From
inception, the cohort of 6 to 8 million germ cells is destined for progressive
attrition with advancing age [12]. Germ cell atresia is initiated in utero and
involves the process of apoptosis [12]. It continues into the postnatal life
until almost complete exhaustion of the gamete pool, the latter marking the
end of reproductive life and synonymous with menopause [13–16]. At
menarche, women enter the reproductive span of life with approximately
300,000 remaining oocytes [17]. With each menstrual cycle, a cohort of
primordial follicles is recruited from the resting pool and a process of
growth is initiated, which culminates in only one of the follicles achieving
dominance. The remainding are lost by apoptosis, initiating an exponential
depletion of the finite gamete pool [18]. This background rate of follicular
loss seems to be genetically determined [16], with wide individual variations
[19], and is independent of gonadotrophic stimulation [18]. A spectrum of
extraneous influences can augment the rate of age-related follicular attrition,
including smoking [20–22] and various pelvic diseases and iatrogenic
interventions [23,24].
The reproductive life span is less clearly defined in men. In contrast to
the finite repertoire of germ cells as seen in women, male gametes are
characterized by a state of continuous mitotic activity and augmentation of
the pool through the life span. Despite the evidence for declining fecundity
in aging men [25,26], the eventual outcome may not be significantly affected
by the age of the male partner [27].
Reproductive aging has been shown to impact each stage of the
previously described events, as shown in Box 1.
Reproductive senescence and aging

Aging gametes: declining quantity, quality, or both?
During a woman’s reproductive years, as many as 10 to 30 primordial
follicles may be initiating growth on a daily basis, with hundreds being lost
every month [14,15], defining the magnitude of gamete attrition over a life
span. Histologic evidence of the age-related decline in the number of
primordial follicles is well documented [19,28]. The number of residual
follicles declines to approximately 1000 per ovary during menopause
transition [29]. This process of gamete attrition seems to accelerate in the
decade preceding menopause [18,29]. Gougeon [18], using mathematical
models, suggested that, unlike in women younger than 38 years, when the
depletion of the gamete pool is a combined effect of loss by growth initiation
and background loss, in older women gamete attrition is solely secondary to
growth initiation occurring at a faster rate [18].
Box 1. Determinants of declining fecundity with aging

Women
Declining oocyte number and ovulatory disturbances
Declining oocyte quality and increasing chromosomal and
genetic mutations
Luteal phase dysfunction (?)
Impaired fertilization rates (?)
Implantation failures
Poor-quality embryos and genetic abnormalities
Impaired endometrial receptivity (?)
Higher incidence of age-related gynecologic problems,
including uterine fibroids and polyps
Declining sexuality
Increased pregnancy wastage
Early implantation failures and preclinical losses
Clinical losses
Increased incidence of general medical problems
accompanying aging (eg, type 2 diabetes mellitus,
hypertension)
High incidence of obstetric complications and poor pregnancy
outcomes
Men
Declining semen parameters: number, motility, and
morphology
Increasing incidence of medical problems, including
hypertension, cardiovascular disease, and type 2 diabetes
mellitus, contributing to erectile dysfunction and ejaculatory
problems
Declining sexuality and frequency of intercourse
Higher incidence of chromosomal aberrations in sperm
Declining fertilization potential of sperm (?)
The candidate molecules involved in expediting the rate of gamete

attrition in the period of perimenopause may well be the inhibins. Inhibin B
is a glycoprotein produced by the granulosa cells of the developing follicles
and hence reflects the residual repertoire of preantral and antral follicles
within the ovaries. An inverse correlation exists between inhibin B and
follicle-stimulating hormone (FSH) during a menstrual cycle [30]. Inhibin B
suppresses the secretion of FSH at the hypothalamic-pituitary level [31].
Elevation of FSH in the early follicular phase of the cycle is a hallmark of
diminishing ovarian reserve, reflecting a declining production of inhibin B

by the depleting ovarian complement of granulosa cells [31–33]. Acceler-
ation in the rate of follicular depletion has been documented around the age
of 37 years [14,34]. Elevated FSH is believed to cause this hastened
consumption of primordial follicles, as it may recruit a larger follicular
cohort with advancing age, eventually leading to the almost complete ex-
haustion of follicles at menopause [29]. A threshold effect of number of
follicles on fertility has been demonstrated in rats [35]; a minimal number of
follicles being required for normal reproductive function. A similar pheno-
menon has been postulated in humans [2]. A higher incidence of anovulatory
cycles is seen in the decade preceding menopause [36], providing yet another
biologically plausible explanation for the declining frequency of conceptive
cycles with advancing age. Irregularities of the menstrual cycle are in
part dependent on the number of residual follicles [29]. Cycle irregularities
predate menopause by 6 to 7 years, regardless of the chronologic age [37].
The age-related decline in the reproductive performance in women
cannot be solely accounted for by a diminishing number of gametes; a
concomitant deterioration in the quality of oocytes accompanies aging [18].
Data from assisted reproductive technology (ART) have provided detailed
insights into detrimental influences of aging on oocytes. Before the
availability of donor oocytes [38,39], the outcome of various therapeutic
modalities in the management of age-related infertility remained dismal
[40,41]. Attempts at ovulation induction seen with advancing age reflect the
small and relatively resistant residual cohort of selectable follicles [18].
Morphologic markers of poor oocyte quality, including thickness and ir-
regularity of the zona pellucida, are frequently noted in oocytes obtained
from older patients [42]. Impaired fertilization rates and enhanced rates
of abnormal fertilizations have been demonstrated with advancing age in
women [43]. In addition, higher rates of chromosomal nondysjunction [44–
47], chromosomal fragility [48], meiotic spindle aberrations, and microtu-
bular disarray [49] have been described in oocytes from older women.
Spindle abnormalities could account for the increasing risk for aneuploi-
dies noted with advancing maternal age [50]. An independent association
of elevated FSH levels, irrespective of the chronologic age, with enhanced
risk for aneuploidy has been demonstrated in mice [51], suggesting a
correlation between risk for aneuploidy and biologic markers of repro-
ductive senescence rather than the actual chronologic age [51]. An un-
expectedly higher prevalence of elevated FSH levels has been reported in
mothers of babies with trisomy 21 [52], and stigmata of diminished ovarian
reserve have been proposed as risk factors for aneuploidies, including
trisomy 21 [53].
Aging in men is confounded by the female partner’s concomitant
chronologic aging [25]. After adjusting for the woman’s age, Ford et al [25]
demonstrated a progressive increase in the time to conception relative to
advancing paternal age. Various age-related detriments in semen parameters
have been documented, including a decline in semen volume [26,27], total

count [26,54], motility, and morphology [55]. Declining success following
donor insemination has been noted with advancing age of the semen donor
[56]. Use of zona-free hamster egg sperm penetration assays, however, has
demonstrated no significant decline in the fertilization potential of sperm
with increasing age of the male [57]. Despite the reported alterations in
semen parameters noted with advancing age, the ability of aging men to
procreate is not significantly affected, and it is not uncommon for men to
father children well into their 70s and 80s [54].
Similar to women, a tendency toward increasing aneuploidy within the
sperm has been documented with paternal aging [27]. An association of
advanced paternal age with sex chromosome fetal aneuploidies (Klinefelter’s
syndrome and Turner’s syndrome) is well described [27,58]; furthermore, an
association of X-linked recessive mutations with advancing paternal age has
been demonstrated [59], suggesting a chromosome-specific insult with
advancing age in men.
Possible mechanisms for detrimental influences of aging on gametes

The mechanisms driving the exponential attrition of oocytes with aging
are unclear [60]. The process seems to be genetically determined [16].
The mature oocyte appears to be affected biologically and genetically by
aging [60]. An age-related decrease in the number of chiasmata between
homologous chromosomes is described in mouse oocytes [61] and the
‘‘production-line hypothesis’’ has been proposed, which suggests that
oocytes formed early in oogenesis are ovulated earlier in reproductive life.
Oocytes formed later in the period of oogenesis may remain in the rest-
ing phase for as long as 40 years [60], during which time they remain
metabolically active and prone to damage by a multitude of environmental
detriments, including reactive oxygen species (ROS) [60,62]. Mitrochondria
lack a DNA repair mechanism and ROS are known to be responsible for
increasing the risk of mitochondrial DNA (mtDNA) mutations [60]. A
higher incidence of mtDNA mutations has been documented in ovarian
tissue after 45 years of age [63], and similar mutations have been observed in
unfertilized oocytes obtained from women older than 38 [64]. The cumulus
cells from aging ovaries are a source of ROS and can induce oocyte
apoptosis in mice [65]. Impaired vascularity of the follicular microenviron-
ment with aging can result in hypoxia, which may further contribute to age-
related oocyte insult [66]. A hypoxic environment is associated with poor
oocyte quality and elevations in vascular endothelial growth factor (VEGF)
in follicular fluid [67]. Friedman et al [66] have demonstrated increased
VEGF in follicular fluid with advancing age, implying a role for hypoxia at
the level of the follicle in the declining ovarian function with aging. The few
reported successes with the experimental technique of nuclear transfer [68]
and cytoplasmic transfer [69] implicate a role for damaged mitochondria
and other cytoplasmic organelles in poor reproductive outcomes associated

with aging.
Is the aging uterus a contributor to declining fertility?

Although the available data strongly point toward oocytes as the
principal target affected by aging [70], uterine senescence cannot be
completely refuted [71,72]. The enhanced pregnancy rates seen in donor
egg recipients strongly favor oocytes as the prime target for the adverse
influences associated with aging [70–74]. Declining uterine receptivity seems
to play a major role in age-related reproductive compromise in animal
models, however [75–77]; a similar mechanism has been proposed as
a contributor in humans [71,72]. Stratification of donor oocyte data ac-
cording to age of the recipient has demonstrated a significant decrease in
pregnancy rates in some studies [78–80]. An increased incidence of biopsy-
proven luteal phase endometrial defects also has been shown with advancing
age [81].
Aging and pregnancy

Preclinical losses and spontaneous miscarriages
The spectrum of poor reproductive performance with aging extends
beyond the declining chances of conception. The association of reproductive
aging and escalating pregnancy loss is well known [56,82,83]. An enhanced
pregnancy wastage seen in older women is a prime contributor to a decline
in fecundity [84]; total and apparent fecundity are affected by aging, the
latter being the probability of conception resulting in a clinically recogniz-
able pregnancy [8]. Miscarriage rates of 34% and 53% have been de-
monstrated in women aged 40 and 45 years, respectively, against a
background rate of 15% for women aged younger than 35 years [85].
Widespread use of ART has provided insight into the mechanisms involved
in declining implantation rates and the higher incidence of preclinical
pregnancy losses seen with advancing age [86]. Blastomere biopsy-proven
chromosomal abnormalities have been shown in as many as 60% to 70% of
embryos resulting from in vitro fertilization (IVF) in women of advanced
reproductive age [87,88]. Improved pregnancy rates following IVF have
been demonstrated in women of advanced reproductive age, using selection
of chromosomally normal embryos by preimplantation genetic diagnosis
(PGD) testing [89,90], confirming a genomic insult as a major mechanism
underlying the poor reproductive performance seen with aging. Documen-
tation of fetal cardiac activity on transvaginal ultrasound is regarded as
a reassuring landmark, with the risk of subsequent loss quoted as 2% [82]. A
significant increase in spontaneous miscarriages is seen in women older than
35 years, even after establishment of fetal viability as evidenced by detection
of fetal cardiac activity on ultrasound [82,83]. In women older than 40, this
risk is increased fivefold compared with women aged 30 to 35 years.
Common karyotypic abnormalities associated with advancing maternal
age, which may result in ongoing pregnancies, include trisomy 21, 18, and
13 [50].
Aging and obstetric performance

Beyond the first trimester, a higher incidence of obstetric and medical
morbidities accompanies advancing maternal age [56]. The probability of
having a healthy baby decreases by 3.5% per year after age 30 [8] (Fig. 2). In
the elderly gravidae, elevated risks exist for pregnancy-induced hypertensive
disorders, gestational diabetes, fetal growth restriction, placental abruption,
preterm delivery, and risk for cesarean section [39,92,93]; furthermore,
perinatal and maternal mortalities are significantly higher in women older
than 40 years [91,93].
Aging, fertility, and extraneous Influences

Smoking
The ovariotoxic effects of cigarette smoking are well described [20,21].
Acceleration of menopause by an average of 2 years is recognized in women
who smoke [94]. The detrimental effects of smoking appear to be at the
oocyte level. A qualitative and quantitative decline in the ovarian response
has been seen in smokers undergoing IVF [20,21]. Moreover, passive
smokers may not be immune to the detrimental influences [95]. A role for
Fig. 2. Outcome of pregnancy with advancing age. (Reprinted from Berkowitz G, Skowron ML,
Lapinski R. Delayed childbearing and outcome of pregnancy. N Engl J Med 1990;322:659–64;
with permission.)
oxidative insults in the follicular microenvironment in women who smoke

has been proposed [95]. In addition, an association of smoking with
increased risk for aneuploidy has been demonstrated [96], outlining yet
another mechanism for an adverse impact of smoking on fecundity.
Pelvic vascular insults

Pelvic surgery has been shown to provoke a rise in basal FSH levels
suggestive of an adverse effect on ovarian reserve [24,97]. A similar
phenomenon has been demonstrated following uterine embolization for the
management of symptomatic uterine fibroids [98]. In this latter instance, the
decline in ovarian function may be transient because spontaneous
pregnancies have been documented [99].
Chemo- and radiotherapy

Chemo- and radiotherapy are detrimental to gonadal function. The
extent of damage invoked by these exposures is determined not only by the
type of agent, duration of exposure, and the dose involved but also the age
of the patient at the time of exposure [100]. The chance of residual ovarian
function following exposure to chemotherapeutic agents or radiotherapy is
much higher in younger patients, with a steep decline noted with advancing
age [100].
Pelvic pathologies
Uterine fibroids, endometrial polyps, endometriosis, and pelvic infections
increase in prevalence with advancing age and may contribute to declining
fertility in individual patients [2,101]. A significant association has been
demonstrated between extent of pelvic adhesive disease, irrespective of the
underlying cause, and residual ovarian reserve [23].
Aging and sexuality

Dual dimensions are involved in materialization of fecundity, ie,
a susceptible population capable of getting pregnant and exposure to
pregnancy [102]. A decline in coital frequency with prolonged cohabitation
is well established [102]. The frequency of sexual exposure in a relationship
is affected by the ages of the husband and wife and length of cohabitation
[102]. The length of time between ovulation and insemination has been
shown to impact on the outcome of the cycle [102]. Barret and Marshall
[103] reported a curvilinear relationship between the frequency of coitus
within a 6-day period around timing of ovulation and fecundibility,
demonstrating an increasing fecundity with higher number of exposures
[103]. Guerrero and Rojas [104] demonstrated an association between
increased pregnancy losses with increasing length of interval between

insemination and ovulation. The impact of declining coital frequency with
aging on overall fecundity, however, is far surpassed by the physiologic
events discussed previously.
Aging and the neuroendocrine axis

The neuroendocrine hypothesis of aging attributes central alterations in
the hypothalamic pulse generator as initiators of the cascade of events
leading to ultimate exhaustion of ovarian follicles [105]. Such disturbances
have been demonstrated in aging rodents [106]. Despite evidence of centrally
mediated hormonal changes with aging, including a progressive decline
in the secretion of growth hormone [107,108] and a rise in cortisol [109],
the role of an aging neuroendocrine axis in humans as a mediator of
reproductive decline remains secondary to the chronology of events
targeting the gonads (ovarian hypothesis of aging).
Prognosticators of declining fertility

The term diminished ovarian reserve (DOR) refers to the age-related
decline in the quantity and quality of the oocyte repertoire. Numerous tests
have been validated as predictors of success following various interventions
for the management of infertility, but these have a limited role in predicting
the age-related decline in fertility [73]. The decline in age-related fecundity
predates most clinically or biochemically observable change [110], as
demonstrated by the significant reductions in pregnancy rates in women in
their mid-30s undergoing ART [74]. Irregularities of the menstrual cycle are
a hallmark of late stages of the perimenopausal period and predate
menopause by 6 to 7 years [37]. An outline for assessment of the aging,
subfertile patient is presented in Box 2.
Biochemical markers of ovarian reserve

Subtle elevations in the early follicular phase levels of FSH and estradiol
are independently recognized markers of DOR [111,112] and are associated
with a poor prognosis for pregnancy; these markers remain the most widely
used biochemical parameters for the assessment of ovarian reserve. Early
follicular phase estimation of serum inhibin B, which reflects the residual
complement of antral follicles, has been demonstrated as a sensitive marker
of ovarian reserve and may predate the rise in FSH levels [113,114]. Routine
testing of inhibin B is not universally recommended because of lack of
a widely available and reliable assay and an absence of uniformity in the
reported data [2,73].
Box 2. Suggested workup of subfertile women in their 40s

History: particular reference to menstrual history and
symptoms of perimenopause; history suspicious for pelvic
adhesive disease; coital history; social history, including
assessment of risk for domestic violence; history of smoking
and use of recreational drugs and alcohol; and pertinent family
history
Examination: particular reference to stigmata of medical
disorders; breast examination
Laboratory assessment
Evaluation of ovarian reserve: baseline FSH/estradiol (E2)
Hormone profile: thryoid-stimulating hormone, prolactin
Screening tests: fasting blood sugar, pap smear, cervical
cultures, mammogram; screening for cystic fibrosis and
specific genetic abnormalities in racially predisposed
individuals; complete blood count; renal function; liver
function; lipid panel; screening for infectious diseases
Uterotubal assessment: hysterosalpingogram (HSG) versus
sonohysterogram (HSN)
Psychologic assessment (?); counseling, if indicated
Perinatology consultation (?), especially if medical disorders
coexist
Genetic consultation (?): regarding higher risk for aneuploidies
Discussion regarding donor oocytes (?), if indicated
Provocative tests for assessment of ovarian reserve

The clomiphene citrate challenge test (CCCT) and the gonadotropin-
releasing hormone agonist stimulation test (GAST) are amongt the available
provocative methods for assessment of the ovarian reserve and provide
additional insight into the potential for response to attempts at ovulation
induction [115,116]. The CCCT predicts diminished ovarian response during
natural cycles and following ovulation induction and IVF [115] and may
unmask patients who have normal circulating basal FSH values. Unlike the
CCCT, the GAST has limited available data on which to base its use [74].
Morphologic markers of ovarian reserve

The number of antral follicles 2 to 10 mm in diameter visible on
transvaginal ultrasound performed in the early follicular phase of the cycle
[117,118] and the mean ovarian volume [119,120] have been shown to
correlate with response to attempts at ovulation induction. Assessment of
the mean stromal ovarian blood flow using color Doppler has been
proposed as a prognosticator of ovarian response and outcome of IVF [121].
Evaluation of the perifollicular blood flow using color pulsed Doppler has
recently been proposed for an indirect assessment of the biologic com-
petence of corresponding oocytes [122].
Histologic evidence of a decline in the number of primordial follicles with
aging is clearly documented [19,28]. Gulekli et al [123] compared bio-
chemical (FSH) and provocative testing (CCCT, GAST) values with the
follicular count on histology of removed ovaries and unmasked the poor
predictive values of the available tests in accurately reflecting true anatomic
ovarian reserve. A role for ovarian biopsy in the evaluation of ovarian
reserve has been proposed but remains experimental [124].
Advances in assisted reproductive technology: can the age-related decline in

fertility be surmounted?
Conventional techniques
Oocyte donation remains the only widely available option at present that
guarantees a high degree of success following ART for the older
reproductive-aged woman [74]. Results of ovulation induction and in-
trauterine insemination (COH/IUI) are universally dismal in women older
than 40 years with unexplained infertility [40,41,125], with a typical preg-
nancy rate per cycle of 5% or less. The results of IVF using autologous
oocytes are only slightly better than for COH/IUI [43,126–128]; a pro-
gressive age-related decline in the ovarian response is clearly seen in terms of
the number of oocytes retrieved. Significantly declining implantation rates
and pregnancy rates with IVF are noted with advancing age [43,74,126]; live
birth rates of 18.5% are reported for women aged 38 to 40 years compared
with 26.2% and 32.2% for those aged 35 to 37 and those younger than 35
years, respectively. The prognosis is dismal for women older than 44 years as
demonstrated by a recent review of 431 initiated IVF cycles in women older
than 41 years. No clinical pregnancies were attained in the group of women
aged older than 45 years and no live births were achieved in the women aged
44 years [40]. Embryonic aneuploidy seems to be a major contributor to the
declining implantation and pregnancy rates with aging [89,90]; replacement
of chromosomally normal embryos following PGD has been associated with
significantly improved implantation rates and pregnancy rates in women of
advanced age [87,89,90] as demonstrated by a significant improvement in
outcome of IVF cycles following PGD.
The success of donor oocytes in achieving a live birth is primarily
predicted by the age of the donor [38,39,70,129]; this technique has yielded
the highest live birth rates of any ART treatment [74]. Precycle screening of
donor oocyte recipients should include a thorough evaluation for disease
processes associated with aging, including hypertension and diabetes
mellitus. A higher rate of perinatal mortality (3% versus 0%) has been dem-
onstrated in pregnancies resulting from donor oocytes when compared with
an age-matched cohort undergoing conventional IVF [130]; elevated

incidences of obstetric morbidities, including first-trimester bleeding [130]
and pregnancy-induced hypertension [39,130], also have been demonstrated
in pregnancies resulting from donor oocytes. An alteration in the immune
system within the recipients has been proposed as the instigating mechanism
for these morbidities [129].
Various modifications of protocols for ovarian stimulation in ART have
been proposed to improve the response in women with diminished ovarian
reserve. Gonadotropin-releasing hormone (GnRH) agonists used with
gonadotropins in the low-dose [131] or microflare [132] protocol, or GnRH
antagonists [133], have been associated with improved cycle parameters.
Despite claims of improved success, however, the response of aging ovaries
to the existing stimulation regimens remains uniformly poor. Assisted
hatching of cleaving embryos also has been claimed to improve implanta-
tion rates in older patients [134–136]; however, data on the benefits of this
technique are not consistent [41].
Experimental methods
Cytoplasmic transfer and germinal vesicle transfer are amongst the
evolving techniques that attempt to mitigate age-related oocyte dysfunction
[68,69]. Although numerous births of healthy offspring have been reported
following cytoplasmic transfer, neither the safety nor the efficacy of this
method has been adequately investigated [137]. Barritt et al [69] have reported
evidence of donor mtDNA in the blood cells of 2 of the 15 children born with
the assistance of the cytoplasmic transfer technique. Epigenetic modifications
following the combination of genetically diverse components, as follows
nuclear and cytoplasmic transfer [137], have been demonstrated in mice; in
humans, cytoplasmic inheritance of familial Down syndrome has been
suggested [138], raising concerns regarding the safety of these techniques.
From premise that ROS plays an integral role in the age-related detriment to
reproductive performance, Tarin et al [139] have demonstrated a mitigation
of age-related compromise on the number and quality of oocytes in mice with
the use of oral antioxidants; however, this approach remains unaddressed in
humans. Prolonged use of birth control pills and pituitary suppression with
GnRH agonists has been evaluated as therapeutic modalities to stem the tide
of age-related follicular depletion, without success [140,141]. The technique
of ovarian cryopreservation, although still nascent, may provide an option
for promoting reproductive longevity in the future [142].
Summary
A progressive decline in fecundity with advancing age is a reality,
attributed primarily to the detrimental impact of various aging processes on
female gametes. Despite medical advances that have dramatically prolonged

the female life span, declining numbers and deteriorating quality of oocytes,
and an increasing incidence of meiotic errors and aneuploidy of gametes and
embryos, reduce clinical pregnancy rates and escalate pregnancy wastage.
Increased fetal aneuploidies in ongoing pregnancies and an increased
predisposition to obstetric morbidities further contribute to the diminishing
reproductive successes associated with advancing age.
The age of male partners, despite the decline in semen parameters
and sexual performance with aging, does not appear to have a major
impact on the eventual fertility of the aging couple. The contributions of age-
related impaired sexuality and ejaculatory problems, although slight albeit
significant, to declining fertility in the aging should be appreciated in
appropriate cases.
With the realization of the age-related detriment on fertility potential and
the limitations of available therapeutic interventions, management of
subfecundity in women beyond their mid-30s should be approached ag-
gressively. Success of ovulation induction with clomiphine citrate or
gonadotropins is marginal in women aged older than 40 years; a case can
be made to proceed directly with ART in women in this age group,
especially when there is coexisting male factor or pelvic disease [73]. Except
for the use of donor oocytes, the outcome of various therapeutic
interventions to optimize reproductive performance in women aged older
than 44 years remains dismal. A broader application of PGD techniques
may contribute to improved live birth rates in reproductively aging women.
The greater likelihood of obstetric complications in pregnancies resulting
from donor oocytes and an increased prevalence of age-related medical
problems complicating pregnancy should prompt a thorough medical eval-
uation before proceeding with ART [73].
References
[1] Harman D. Aging: overview. Ann N Y Acad Sci 2001;928:1–21.
[2] Klein J, Sauer MV. Assessing fertility in women of advanced reproductive age. Am J
[3] Mosher WD, Pratt WF. Fecundity and infertility in the United States: incidence and
trends. Fertil Steril 1991;56:192–3.
[4] Schwartz D, Mayaux MJ and the Federation des Centres d’Etude et de Conservation du
Sperme-Humain. Female fecundity as a function of age. Results of artificial insemination
in 2193 nulliparous women with azoospermic husbands. N Engl J Med 1982;306:404–6.
[5] Stovall DW, Toma SK, Hammond MG, Talbert LM. The effect of age on female
fecundity. Obstet Gynecol 1991;77:33–6.
[6] Tietze C. Reproductive span and rate of reproduction among Hutterite women. Fertil
Steril 1957;8:89–97.
[7] Bongaarts J. The proximate determinants of natural marital fertility. New York:
Population Council; 1982. Center for Policy Studies Working Paper 89.
[8] Van Noord-Zaadstra BM, Looman CWN, Alsbach H, Habbema JDF, te Velde ER,
Karbaat J. Delaying childbearing: effect of age on fecundity and outcome of pregnancy.
BMJ 1991;302:1361–5.
[9] Menken J, Trussell J, Karsen U. Age and infertility. Science 1986;233:1389–95.

[10] Navot D, Bergh PA, Williams MA, et al. Poor oocyte quality rather than implantation
failure as a cause of age related decline in female fertility. Lancet 1991;337:1375–7.
[11] Scott R, Navot D, Liu HC, Rosenwaks Z. A human in vivo model for the luteoplacental
shift. Fertil Steril 1991;56:481–4.
[12] Reynaud K, Draincourt MA. Oocyte attrition. Mol Cell Endocrinol 2000;163:101–8.
[13] Treolar AE. Menstrual cyclicity and the perimenopause. Maturitas 1981;3:49–64.
[14] Faddy MJ, Gosden R, Gougen A, Richardson SJ, Nelson JF. Accelerated disappearance
of ovarian follicles in mid life: implications for forecasting menopause. Hum Reprod
1992;7:1342–6.
[15] Faddy MJ, Gosden RG. A mathematical model of follicle dynamics in the human. Hum
Reprod 1995;10:770–5.
[16] Hsueh AJW, Billig H, Tsafriri A. Ovarian follicular atresia: a hormonally controlled
apoptotic process. Endocr Rev 1994;15:707–24.
[17] Van Zonneveld P, Scheffer GJ, Broekmans FJM, te Velde ER. Hormones and
reproductive aging. Maturitas 2001;38:83–94.
[18] Gougeon A. Regulation of ovarian follicular development in primates: facts and
hypotheses. Endocr Rev 1996;17:121–55.
[19] Lass A, Silye R, Abrams DC, et al. Follicular density in ovarian biopsy in infertile women.
A novel method to assess ovarian reserve. Hum Reprod 1997;12:1028–31.
[20] Van Voornis BJ, Syrop CH, Hammit DG, Dunn MS, Snyder GD. Effects of smoking on
ovulation induction for assisted reproductive techniques. Fertil Steril 1992;58:981–5.
[21] Zenses MT, Wang P, Casper RF. Cigarette smoking may affect meiotic maturation of
human oocytes. Hum Reprod 1991;10:3213–7.
[22] Midgette AS, Baron JA. Cigarette smoking and the risk of natural menopause.
Epidemiology 1990;1:474–80.
[23] Bowman MC, Cooke ID, Lentin EA. Investigation of impaired ovarian function as
a contributing factor to infertility in women with pelvic adhesions. Hum Reprod 1993;
8:1654–6.
[24] Cooper GS, Thorp JM Jr. FSH levels in relation to hysterectomy and to unilateral
oophorectomy. Obstet Gynecol 1999;94:969–72.
[25] Ford WCL, North K, Taylor H, Farrow A, Hull MGR, Golding J, and the ALSPAC study
team. Increasing paternal age is associated with delayed conception in a large population
of fertile couples: evidence for declining fecundity in older men. Hum Reprod 2000;
15(8):1703–8.
[26] Kidd SA, Eskenazi B, Wyrobek AJ. Effects of male age on semen quality and fertility:
a review of literature. Fertil Steril 2001;75:237–48.
[27] Lowe X, Eskenazi B, Nelson DO, Kidd S, Aime A, Wyrobek AJ. Frequency of XY sperm
increases with age in fathers of boys with Kleinfelters syndrome. Am J Hum Genet
2001;69:1046–54.
[28] Qu J, Godin PA, Nisolle M, Donnez J. Distribution and epidermal growth factor receptor
expression of primordial follicles in human ovarian tissue before and after cryopreser-
vation. Hum Reprod 2000;15:302–10.
[29] Richardson SJ, Senikas V, Nelson JF. Follicular depletion during the menopausal
transition: evidence for accelerated loss and ultimate exhaustion. J Clin Endocrinol Metab
1987;65:1231–7.
[30] Groome NP, Illingworth PJ, O’Brien M, Pai R, Rodger FE. Inhibin B throughout the
human menstrual cycle. J Clin Endocrinol Metab 1996;81:1401–5.
[31] Welt CK, McNichill DJ, Taylor AE. Female reproductive aging is marked by a decreased
secretion of dimeric inhibin. J Clin Endocrinol Metab 1999;84:105–11.
[32] Te Velde ER, Scheffer GJ, Dorland M, Broekmans FJ, van Kooij RJ. Age-dependant
changes in serum FSH level. In: Fauser BCJM, Coelingh Bennik HJT, Evers JLH, editors.
FSH action and intraovarian regulation. UK: Parthenon; 1997. p. 145–55.
[33] Soules MR, Battaglia DE, Klein NA. Inhibin and reproductive aging in women.
Maturitas 1998;30:193–204.
[34] Block E. Quantitative morphological investigation of follicular system in women. Acta
Anat [Basel] 1952;14:108.
[35] Sopelak VM, Butcher RL. Decreased amount of ovarian tissue and maternal age affect
embryonic development in old rats. Biol Reprod 1982;27:449–55.
[36] Prior JC. The ageing female reproductive axis. II: ovulatory changes with perimenopause.
Novartis Found Symp 2002;242:172–86; discussion, 186–92.
[37] den-Tonkelaar I, te Velde ER, Looman CWN. Menstrual cycle length preceding
menopause in relation to age at menopause. Maturitas 1998;29:115–23.
[38] Sauer MV, Paulson RJ, Lobo RA. A preliminary report on oocyte donation extending
reproduction potential to women over 40. N Engl J Med 1990;323:1157–60.
[39] Sauer MV, Paulson RJ, Macaso TM, Francis MM, Lobo RA. Oocyte and pre-embryo
donation to women with ovarian failure: an extended clinical trial. Fertil Steril 1991;
55:39–43.
[40] Ron-El R, Raxiel A, Strassburger D, Schachter M, Bern O, Friedler S. Outcome of
assisted reproductive technology in women over the age of 41. Fertil Steril 2000;74:471–5.
[41] Frederick DL, Denker MS, Rojas A, et al. Is there a role for ovarian stimulation and
intrauterine insemination after age 40? Hum Reprod 1994;9:2284–6.
[42] De Vos A, Van Steirteghem A. Zona hardening, zona drilling and assisted hatching: new
achievements in assisted reproduction. Cells Tissues Organs 2000;166:220–7.
[43] Piette C, Mouzon J, Blachelot A, Spira A. In-vitro fertilization: influence of women’s age
on pregnancy rates. FIVNAT. Hum Reprod 1990;5:56–9.
[44] Angell R. First meiotic division nondisjunction in human oocytes. Am J Hum Genet
1997;61:23–32.
[45] Angell RR, Xian J, Keith J. Chromosomal anomalies in human oocytes in relation to age.
Hum Reprod 1993;8:1047–54.
[46] Angell RR. Aneuploidy in older women. Higher rates of aneuploidy in oocytes from older
women. Hum Reprod 1994;9:1199–201.
[47] Dailey T, Dale B, Cohen J, Munne S. Association between non-disjunction and maternal
age in meiosis II in human oocytes detected by FISH analysis. Am J Hum Genet
1996;59:176–84.
[48] Lim A, Tsakok M. Age related decline in fertility: a link to degenerative oocyte? Fertil
Steril 1997;68:265–71.
[49] Battaglia DE, Goodwin P, Klein NA, Soules MR. Influence of maternal age on meiotic
spindle assembly in oocytes from naturally cycling women. Hum Reprod 1996;11:
2217–22.
[50] Hassold T, Chiu D. Maternal age-specific rates of chromosomal abnormalities with
special reference to trisomy. Hum Genet 1985;70:11–7.
[51] Brook JD, Gosden RG, Chandley AC. Maternal aging and aneuploid embryos—evidence
from the mouse that biological and not chronological age is the important influence. Hum
Genet 1984;66:41–5.
[52] Van Montfrans JM, Dorland M, Oosterhuis GJ, et al. Increased concentrations of FSH in
mothers of children with Down’s syndrome. Lancet 1999;353:1853–4.
[53] Van Montfrans JM, Lambalk CB, Van Hooff MH, Van Vugt JM. Are elevated FSH
concentrations in the pre-conceptional period a risk factor for Down’s syndrome
pregnancies? Hum Reprod 2001;16:1270–3.
[54] Paulson RJ, Milligan RC, Sokol RZ. The lack of influence of age on male fertility. Am J
[55] Schwartz D, Mayaux MJ, Spira A, et al. Semen characteristics as a function of age in 833
fertile men. Fertil Steril 1983;39:530–5.
[56] Lansac J. Is delayed childbearing a good thing? Hum Reprod 1995;10:1033–5.
[57] Nieschlag E, Lammers U, Freischem CW, Langer K, Wickings EJ. Reproductive

functions in young fathers and grandfathers. J Clin Endocrinol Metab 1982;55:676–81.
[58] Liebaers I, Bonduelle M, Van Assche F, Devroey P, Steirteghem A. Sex chromosome
abnormalities after intracytoplasmic sperm injection. Lancet 1995;346:1095–7.
[59] Borsdon B, Leonardo V. The appropriate upper age limit for semen donors: a review of
the genetic effect of paternal age. Fertil Steril 1991;56:397–401.
[60] Dorland M, van Kooij RJ, te Velde ER. General aging and ovarian aging. Maturitas
1998;30:113–8.
[61] Hendersen SA, Edwards RG. Chiasma frequency and maternal age in mammals. Nature
1968;218:22–8.
[62] Tarin JJ. Potential effects of age associated oxidative stress on mammalian oocytes/
embryos. Mol Hum Reprod 1996;2:717–24.
[63] Kittagawa T, Suganuma N, Nawa A, et al. Rapid accumulation of deleted mitochondrial
deoxyribonucleic acid in postmenopausal women. Biol Reprod 1993;49:730–6.
[64] Keefe DL, Niven-Fairchild T, Powell S, Buradagunta S. Mitochondrial deoxyribonucleic
acid deletions in oocytes and reproductive aging in women. Fertil Steril 1995;64:577–83.
[65] Perez GI, Tilly JL. Cumulus cells are required for the increased apoptotic potential in
oocytes of aged mice. Hum Reprod 1997;12:2781–3.
[66] Friedman CI, Danforth DR, Herbosa-Encarnacion C, Arbogast L, Alak BM, Seifer DB.
Follicular fluid vascular endothelial growth factor concentrations are elevated in women of
advanced reproductive age undergoing ovulation induction. Fertil Steril 1997;68:607–12.
[67] Van Blerkom J, Antezak M, Schrader R. The developmental potential of the human
oocyte is related to the dissolved oxygen content of follicular fluid: association with
vascular endothelial growth factor levels and perifollicular blood flow characteristics.
Hum Reprod 1997;12:1047–55.
[68] Zhang J, Wang CW, Krey L, et al. In vitro maturation of human preovulatory oocytes
reconstructed by germinal vesicle transfer. Fertil Steril 1999;71:726–31.
[69] Barritt J, Willadsen S, Brenner C, Cohen J. Cytoplasmic transfer in assisted reproduction.
Hum Reprod Update 2001;7:428–35.
[70] Navot D, Drew MR, Vergh PA, et al. Age-related decline in female fertility is not due
to diminished capacity of the uterus to sustain embryo implantation. Fertil Steril 1994;61:
97–101.
[71] Cano F, Simon C, Remohi J, Pellicer A. Effect of aging on the female reproductive system:
evidence for a role of uterine senescence in the decline in female fecundity. Fertil Steril
1995;64:584–9.
[72] Meldrum DR. Female reproductive aging-ovarian and uterine factors. Fertil Steril
1993;59:1–5.
[73] American Society of Reproductive Medicine. Practice committee report. Fertil Steril
2002;78:215–9.
[74] Centers for Disease Control and Prevention. American Society for Reproductive
Medicine, Society for Assisted Reproductive Technology. RESOLVE 1999. Assisted
reproductive technology success rates. Atlanta, GA: Centers for Disease Control and
Prevention; 2001.
[75] Talbert GB, Krohn PL. Effect of maternal age on viability of ova and uterine support of
pregnancy in mice. J Reprod Fertil 1966;11:399–406.
[76] Blaha GC. Effect of the age of donor and recipient on the development of transferred
golden hamster ova. Anat Rec 1964;150:413–6.
[77] Adams CE. Aging and reproduction in the female mammals with particular reference to
the rabbit. J Reprod Fertil Suppl 1979;12:1–16.
[78] Levran D, Ben-Shlomo L, Dor J, Ben-Rafael Z, Nebel L, Mashiach S. Aging of
endometrium and oocytes: observations on conception and abortion rates in an egg
donation model. Fertil Steril 1991;56:1091–4.
[79] Abdalla HI, Babar R, Kirkland A, Leonard T, Power M, Studd JWW. A report of 100
cycles of oocyte donation: factors affecting the outcome. Hum Reprod 1990;5:1018–22.
[80] Rotsztejn DA, Asch RH. Effect of aging on assisted reproductive technologies (ART):
experience from egg donation. Semin Reprod Endocrinol 1991;9:272–9.
[81] Lenton EA, Landgren BM, Sexton L. Normal variation in the length of the luteal phase of
the menstrual cycle: identification of the short luteal phase. Br J Obstet Gynaecol
1984;91:685–9.
[82] Smith KE, Buyalos RP. The profound impact of patient age on pregnancy outcome after
early detection of fetal cardiac activity. Fertil Steril 1996;65:35–40.
[83] Edmonds DK, Lindsay KS, Miller JF, Williamson E, Wood PJ. Early embryonic
mortality in women. Fertil Steril 1982;38:447–53.
[84] O’Connor KA, Holman DJ, Wood JW. Declining fecundity and ovarian ageing in natural
fertility populations. Maturitas 1998;30:127–36.
[85] Warburton D, Kline J, Stein Z. In: Porter H, Wiley A, editors. Perinatal Genetics:
Diagnosis and Treatment. New York: Academic Press; 1986. p. 133.
[86] Levi AJ, Raynault MF, Bergh PA, Drews MR, Miller TB, Scott RT Jr. Reproductive
outcome in patients with diminished ovarian reserve. Fertil Steril 2001;76:666–9.
[87] Gianaroli L, Magli MC, Ferraretti AP, Fiorentino A, Garrisi J, Munne S. Pre-
implantation genetic diagnosis increases the implantation rate in human in vitro
fertilization by avoiding the transfer of chromosomally abnormal embryos. Fertil Steril
1997;68:1128–31.
[88] Munne S, Alikani M, Tomkin G, Grifo J, Cohen J. Embryo morphology, developmental
rates and maternal age are correlated with chromosomal abnormalities. Fertil Steril
1995;64:382–91.
[89] Munne S, Magli C, Cohen J, et al. Positive outcome after preimplantation diagnosis of
aneuploidy in human embryos. Hum Reprod 1999;14:2191–9.
[90] Kahraman S, Bahce M, Amli H, et al. Healthy births and ongoing pregnancies obtained
by preimplantation genetic diagnosis in patients with advanced maternal age and
recurrent implantation failure. Hum Reprod 2000;15:2003–7.
[91] Berkowitz G, Skowron ML, Lapinski R. Delayed childbearing and outcome of
pregnancy. N Engl J Med 1990;322:659–64.
[92] Aldous M, Edmonson M. Maternal age at first childbirth and risk of low birth weight and
preterm delivery in Washington state. JAMA 1993;270:2574–7.
[93] Bouvier-Colle MH, Varnoux N, Costes P. Mortalite maternelle en France [in French].
J Gynecol Obstet Biol Reprod 1991;20:885–91.
[94] Brambilla DJ, McKiley SM. A prospective study of factors affecting age at menopause.
J Clin Epidemiol 1989;42:1031–9.
[95] Paszkowski T, Clarke RN, Hornstein MD. Smoking induces oxidative stress inside the
graffian follicle. Hum Reprod 2002;17:921–5.
[96] Yang Q, Sherman SL, Hassold TJ, et al. Risk factors for trisomy 21: maternal smoking
and oral contraceptive use in a population based case control study. Genet Med
1999;1:80–8.
[97] Khalifa E, Toner JP, Muasher SJ, Acousta AA. Significance of basal follicle stimulating
hormone levels in women with one ovary in a program of in vitro fertilization. Fertil Steril
1992;57:835–9.
[98] McLucas B, Adler L, Perrella R. Uterine fibroid embolization: nonsurgical treatment for
symptomatic fibroids. J Am Coll Surg 2001;192:95–105.
[99] Kovac P, Stangel JJ, Santoro N, Lieman H. Successful pregnancy after transient ovarian
failure following treatment of symptomatic leiomyomata. Fertil Steril 2002;77:292–5.
[100] Anasti JN. Premature ovarian failure: an update. Fertil Steril 1998;70:1–15.
[101] Nagele F, O’Connor H, Davies A, Badawy A, Hossam M, Magos A. 2500 outpatient
diagnostic hysteroscopies. Obstet Gynecol 1996;88:87–92.
[102] Weinstein M, Dtark M. Behavioral and biological determinants of fecundibility. Ann N Y

Acad Sci 1994;709:128–44.
[103] Barrett J, Marshall J. The risk of conception on different days of the menstrual cycle.
Popul Stud 1969;23:455–61.
[104] Guerrero R, Rojas O. Spontaneous abortion and aging of human ova and spermatozoa.
N Engl J Med 1979;293:573–5.
[105] Wise PM, Smith MJ, Dubal DB, Wilson ME, Krajnak KM, Rosewell KL.
Neuroendocrine influences and repercussions of the menopause. Endocr Rev 1999;
20:243–8.
[106] Aschheim P. Relation of neuroendocrine system to reproductive decline in female rats.
In: Meites J, editor. Neuroendocrinology of aging. New York: Plenum Press; 1983.
p. 73–101.
[107] Lieman HJ, Adel TE, Frost C, Von Hagen S, Santoro N. Effects of aging and estradiol
supplementation on GH axis dynamics in women. J Clin Endocrinol Metab 2001;86:
3918–23.
[108] Santoro N, Banwell T, Tortoriello D, Lieman H, Adel T, Skurnick J. Effects of aging and
gonad failure on the hypothalamic-pituitary axis in women. Am J Obstet Gynecol
1998;178:732–41.
[109] Van Cauter E, Leproult R, Kupfer DJ. Effects of gender and age on the levels
and circadian rhythmicity of plasma cortisol. J Clin Endocrinol Metab 1996;81:
2468–73.
[110] Soules MR, Sherman S, Parrott E, et al. Executive summary: Stages of Reproductive
Aging Workshop (STRAW). Fertil Steril 2001;76:874–8.
[111] Frattarelli JL, Bergh PA, Drews MR, Sharara FI, Scott RT. Evaluation of basal estradiol
levels in assisted reproductive technology cycles. Fertil Steril 2000;74:518–24.
[112] Licciardi FL, Liu HC, Rosenwaks Z. Day 3 estradiol serum concentrations as
prognosticators of ovarian stimulation response and pregnancy outcome in patients
undergoing IVF. Fertil Steril 1995;64:991–4.
[113] Seifer DB, Scott RT, Bergh PA, et al. Women with declining ovarian reserve may
demonstrate a decrease in day 3 inhibin-B before a rise in day 3 follicle-stimulating
hormone. Fertil Steril 1999;72:63–5.
[114] Santoro N, Adel T, Skurnic JH. Decreased inhibin tone and increased activin A secretion
characterize reproductive aging in women. Fertil Steril 1999;71:658–62.
[115] Scott RT, Leonardi MR, Hoffman GE, Illions FS, Neal GS, Navot D. A prospective
evaluation of clomiphene citrate challenge test screening in the general infertility
population. Obstet Gynecol 1993;82:539–45.
[116] Navot D, Rosenwaks Z, Margalioth E. Prognostic assessment of female fecundity. Lancet
1989;2:645–7.
[117] Chang MY, Chiang CH, Hsieh TT, et al. Use of the antral follicle count to predict the
outcome of assisted reproductive technologies. Fertil Steril 1998;69:505–10.
[118] Ng EHY, Ttang OS, Ho PC. The significance of the number of antral follicles prior to
stimulation in predicting ovarian responses in an IVF program. Hum Reprod 2000;
15:1937–2000.
[119] Syrop CH, Dawson JD, Husman KJ, Sparks AET, Van Voorhis BJ. Ovarian volume may
predict assisted reproductive outcomes better than follicle stimulating hormone
concentration on day 3. Hum Reprod 1999;120(4):1752–6.
[120] Sharara FI, MClamrock HD. The effect of aging on ovarian volume measurements in
infertile women. Obstet Gynecol 1999;94:57–60.
[121] Engmann L, Sladkevicius P, Argwal R, Bekir JS, Campbell S, Tan SL. Value of ovarian
stromal blood flow velocity measurement after pituitary suppression in the prediction of
ovarian responsiveness and outcome of in vitro fertilization treatment. Fertil Steril
1999;71:770–5.
[122] Huey S, Abuhamad A, Barroso G, et al. Perifollicular blood flow doppler indices, but not
follicular pO2, pCO2, or pH predict oocyte developmental competence in in-vitro
fertilization. Fertil Steril 1999;72:707–12.
[123] Gulekli B, Bulbul Y, Onvural A, et al. Accuracy of ovarian reserve tests. Hum Reprod
1999;14:2822–6.
[124] Lass A. Assessment of ovarian reserve—is there a role for ovarian biopsy? Hum Reprod
2001;14:1055–7.
[125] Corsan G, Trias A, Trout S, Kemman E. Ovulation induction combined with intrauterine
insemination in women 40 years of age and older: is it worthwhile? Hum Reprod
1996;11:1109–12.
[126] Van Kooij RJ, Looman CWN, Habbema JDF, Dorland M, te Velde ER. Age-dependent
decrease in embryo implantation rate after in vitro fertilization. Fertil Steril 1996;66:
769–75.
[127] Watt AH, Legedza ATR, Ginsburg ES, Barbeiri RL, Clarke RN, Hornstein MD. The
prognostic value of age and follicle stimulating hormone levels in women over forty years
of age undergoing in vitro fertilization. J Assist Reprod Genet 2000;17:264–8.
[128] Lass A, Croucher C, Duffy S, Dawson K, Margara R, Winston RML. One thousand
initiated cycles of in vitro fertilization in women 40 years of age. Fertil Steril
1998;70:1030–4.
[129] Serhal PF, Craft IL. Oocyte donation in 61 patients. Lancet 1989;1:1185–7.
[130] Anttila VS, Tiitinen A, Foudila T, Hovatta O. Obstetric and perinatal outcome after
oocyte donation: comparison with the in vitro fertilization pregnancies. Hum Reprod
1998;13:483–90.
[131] Olivennes F, Righini C, Fanchin R, et al. A protocol using a low dose of GnRH agonist
might be the best protocol for patients with high FSH concentrations on day 3. Hum
Reprod 1996;11:1169–72.
[132] Schoolcraft W, Schlenker T, Gee M, Stevens J, Wagley L. Improved COH in poor
responder IVF patients with microdose flare protocol. Fertil Steril 1996;67:93–7.
[133] Chang P, Zeitoun KM, Chan LK, Thornton MH, Sauer MV. GnRH antagonist in older
IVF patients: retrieval rates and clinical outcome. J Reprod Med 2002;47:253–8.
[134] Schoolcraft WB, Schlenker T, Jones GS, Jones HW Jr. In vitro fertilization in women age
40 and older: the impact of assisted hatching. J Assist Reprod Genet 1995;12:581–4.
[135] Lanzendorf SE, Nehchiri F, Mayer JF, Oehninger S, Muasher SJ. A prospective
randomized double blind study for the evaluation of assisted hatching in patients with
advanced maternal age. Hum Reprod 1998;13:409–13.
[136] Meldrum DR, Wisot A, Yee B, Garzo G, Yeo L, Hamilton F. Assisted hatching reduces
the age-related decline in IVF outcome in women younger than 43 without increasing
miscarriage or monozygotic twinning. J Assist Reprod Genet 1998;15:418–21.
[137] Hawes SM, Sapienza C, Latham KE. Ooplasmic donation in humans: the potential for
epigenic modifications. Hum Reprod 2002;17:850–2.
[138] Arbuzova S, Cuckle H, Mueller R, Sehmi I. Familial Down’s syndrome: evidence
supporting cytoplasmic inheritance. Clin Genet 2001;60:456–62.
[139] Tarin JJ, Albala SP, Cano A. Oral antioxidants counteract the negative effects of female
aging on oocyte quantity and quality in the mouse. Mol Reprod Dev 2002;61:385–97.
[140] De Vries E, den Tonkelaar I, van Noord PAH, van der Schouw YT, te Velde ER, Peeters
PHM. Oral contraceptive use in relation to age at menopause in the DOM cohort. Hum
Reprod 2001;16:1657–62.
[141] Ataya K, Tadros M, Ramahi A. Gonadotropin releasing hormone agonist inhibits
physiologic ovarian follicular loss in rats. Acta Endocrinol [Copenh] 1989;121:55–60.
[142] Otkay K, Kan MT, Rosenwaks Z. Recent progress in oocyte and ovarian tissue
cryopreservation and transplantation [review]. Curr Opin Obstet Gynecol 2001;13:263–8.
32 (2003) 689–707
Male factor infertility

Victor M. Brugh, III, MD, H. Merrill Matschke, MD,
Larry I. Lipshultz, MD*
Division of Male Reproductive Medicine and Surgery, Scott Department of Urology, Baylor
College of Medicine, 6560 Fannin, Suite 2100, Houston, TX 77030, USA
Today, more couples than ever are presenting to physicians for care of
their infertility. Typically, female partners contact their gynecologist or
primary care physician about fertility concerns, and that leads to the
appropriate acquisition of a semen analysis from the male partner. Half of
these couples will have a component of male factor infertility and almost
30% of infertility will be caused solely by male factors [1]. After identifying
abnormal semen parameters, the care of a subfertile male partner varies
greatly depending on the desires of the affected couple, available resources,
local referral patterns, and treatment style of the involved physician. The
authors believe that the most productive and cost-effective therapy can be
delivered only after a complete evaluation is performed for these men.
Equally important is the identification of potentially significant medical
pathology presenting only as infertility in 1.3% of infertile men [2]. This
article reviews the evaluation of infertile men and common causes of male
factor infertility.
History and physical examination

The evaluation of subfertile men begins with a detailed history and
physical examination. The history should identify the duration of attempted
conception and prior pregnancies initiated by the presenting couple
(secondary infertility) or either partner during previous relationships. Other
information important to the sexual history includes intercourse timing and
frequency, prior history of reproductive tract infections, and the use of
lubricants during intercourse, which may impair sperm motility (eg, K-Y
E-mail address: larryl@bcm.tmc.edu (L.I. Lipshultz).
doi:10.1016/S0889-8529(03)00047-1
690 V.M. Brugh, III, et al / Endocrinol Metab Clin N Am 32 (2003) 689–707
jelly, Lubifax, Surgilube, hand lotions, petroleum jelly, and saliva) [3]. Other
pertinent details of the medical history include childhood illnesses, such as
pubertal mumps orchititis (leading to infertility in 13% of affected men) [4];
cancers treated by chemotherapy, radiation or surgery; undescended testes;
testicular torsion; hernia repair; or bladder neck surgery.
Any systemic disease processes should be identified. Endocrinopathies,
neurologic injuries or diseases, infectious diseases, and pulmonary, renal,
or hepatic disorders can potentially lead to impaired sperm production or
delivery of sperm to the female genital tract. Prior scrotal, pelvic, or
retroperitoneal surgery may also affect sperm emission or ejaculation and
thus result in inadequate sperm deposition. Exposures to environmental
toxins, radiation, medications, chemotherapy, and use of anabolic steroids,
tobacco, alcohol, and illicit drugs should be thoroughly investigated because
of their potential adverse effects on sperm production.
The physical examination should focus on the male body habitus to
identify whether the individual is appropriately virilized, without evidence of
gynecomastia. A thorough genitourinary examination should be perfor-
med to identify any penile and scrotal pathology. The phallus should be
examined for hypospadias and skin lesions. Testicular size and shape,
including masses, should be carefully examined. Normal adult testicular size
varies between 18 to 20 mL, and small testes most likely indicate impaired
spermatogenesis [5]. The presence of vasa and epididymides, including
epididymal induration or cysts, should be noted. Finally, the most common
correctable cause for male infertility is a varicocele [6], which can be
identified by palpation of the spermatic cords with and without the patient
performing a Valsalva maneuver.
Laboratory evaluation
Endocrine disorders have been identified in up to 20% of infertile men
[7]. Serum testosterone and follicle-stimulating hormone (FSH) levels will
identify 99% of all endocrine abnormalities in men with soft testes and less
than 1 million sperm/mL. Other potentially useful hormone parameters
include levels of luteinizing hormone (LH), prolactin, and estradiol, which
should be assayed contingent on findings during history, physical exami-
nation, and initial hormone evaluation.
The cornerstone of laboratory evaluation of infertile men is the semen
analysis. The semen analysis is not a test of male fertility, however. First,
fertility is a couple-related phenomenon. In addition, routine semen analysis
tells the physician very little about actual sperm function. Semen analyses
should be collected by masturbation after a 2- to 3-day period of abstinence.
Long periods of abstinence will lead to decreased motility, and shorter
periods result in low volume and density. With the recommended intercourse
frequency of every other day, an abstinence period of 2 days will reflect the
semen parameters available during attempted natural conception. (Table 1).
V.M. Brugh, III, et al / Endocrinol Metab Clin N Am 32 (2003) 689–707 691
Table 1
Semen analysis guidelines and pathologic conditions related to abnormal semen parameters
Parameter WHO Possible pathologic conditionsa
Volume, mL 1.5–5.0 Low volume: ejaculatory dyfunction, hypogonadism, poor
collection technique
pH 7.2 Acidic semen: ejaculatory duct obstruction, congenital
absence of the vas deferens
Density, 20 Azoospermia or oligospermia: varicocele, genetic,
106 sperm/mL cyptorchidism, endocrinopathy, drugs, infections, toxins or
radiation, obstruction, idiopathic
Motility, % 50 Asthenospermia: prolonged abstinence, antisperm antibodies,
partial obstruction, infection, sperm structural defects,
idiopathic
Morphology, % 30 Teratospermia: varicocele, genetic, cyptorchidism, drugs,
infections, toxins or radiation, idiopathic
Abbreviation: WHO, World Health Organization.
a
These conditions represent only some of the many possible causes for each defect.
Azoospermia is the complete absence of sperm in the ejaculate and occurs

in 8% of infertile men. Azoospermia may be caused by obstruction of the
extratesticular ductal system or defects in spermatogenesis (nonobstructive
azoospermia [NOA]). Men with obstructive azoospermia typically have
normal-sized testes, possible epididymal fullness, and a normal serum FSH
level. Men with NOA present frequently with small or soft testes and
elevated levels of FSH. Approximately 21.4% of men who are not ob-
structed and have no sperm on routine semen analysis will have motile
sperm present in a centrifuged pellet of their semen; therefore, these men are
not azoospermic [8].
Patients who have NOA should undergo genetic testing (see later) before
proceeding to assisted reproductive technologies (ARTs). Approximately
40% to 60% of these men have sperm present in the testes, which can be
used in in vitro fertilization with intracytoplasmic sperm injection (IVF-
ICSI). A testis biopsy should not be performed only as a diagnostic modality
in these men but should also be a therapeutic maneuver for sperm retrieval
(testicular sperm extraction [TESE]). A testis biopsy for diagnostic purposes
is recommended only when a diagnosis of obstruction or partial obstruc-
tion is suspected. In these cases, normal spermatogenesis will confirm
obstruction.
Varicocele
Varicoceles are found in 15% of the general male population [9]. Among
men with infertility, 19% to 41% of men with primary infertility [10] and
45% to 81% of men with secondary infertility have varicoceles [11], making
varicoceles the most common correctable cause of male infertility.
Varicoceles are dilated internal spermatic veins, also known as the
pampiniform venous plexus, which drain the testis. These dilated veins are
found more commonly around the left testis or bilaterally than on the right
alone [12]. The dilation of these veins is believed to be secondary to
incompetent venous valves. The increased incidence of left-sided varicoceles
compared with the right is caused by the perpendicular insertion of the left
internal spermatic vein into the left renal vein and the extra length of the left
internal spermatic vein (when compared with the right; 8–10 cm).
There are several theories about the pathophysiology of varicoceles leading
to male subfertility. One theory is that poor venous drainage disrupts the
countercurrent exchange of heat in the spermatic cord or increases testi-
cular perfusion, allowing a rise in scrotal temperature [13]. Elevated scrotal
temperatures subsequently lead to impaired spermatogenesis [14]. Another
theory is that gonadotoxins are poorly drained from the testis or that reflux of
adrenal and renal metabolites to the testis leads to impaired spermatogenesis
[15]. Men with varicoceles also have been found to have abnormal testosterone
and FSH concentrations, which improve after varicocele repair [16,17].
Varicocele repair is indicated for men with pain associated with the
varicocele, testicular atrophy, or infertility that is not attributable to any
other causes. Varicoceles can be corrected by surgical ligation of the dilated
internal spermatic veins or radiographic embolization of these veins.
Currently, most male reproductive surgeons use a microsurgical technique
sparing the internal spermatic arteries and lymphatics. Pryor and Howards
[10] found that varicocele repair improved semen quality in 51% to 78% of
patients and 24% to 53% of patients initiated spontaneous pregnancies after
varicocele repair [10]. Prospective, randomized trials of varicocelectomy
have been few, but Madgar et al [18] described 71% of men undergoing
varicocele repair who attained spontaneous pregnancy versus a 10%
spontaneous pregnancy rate in men randomized to ‘‘no therapy’’ in a
prospective, randomized crossover trial. Most notably, improvement in
sperm density and motility and pregnancy rates has been reported. In ad-
dition, improvements in sperm strict morphology [19–21], the sperm
penetration assay [22], and seminal reactive oxygen species recently have
been described following varicocele repair [23]. Finally, a return of sperm to
the ejaculate has been reported for some azoospermic men after varicocele
repair [24–26].
Varicocele repair offers subfertile couples not only improved rates of
spontaneous pregnancy but also improvement of semen quality that can
shift the level of ART (eg, IVF to intrauterine insemination) necessary to
attain pregnancy. Thus, correcting a varicocele often proves to be a cost-
effective treatment [27,28]. In a study of 540 infertile men with varicoceles,
Cayan et al [27] found that 31% of men who required ICSI or IVF (total
motile sperm count, \5 million/mL) to treat their infertility had improve-
ment in semen quality after varicocele repair to allow intrauterine insemina-
tion or spontaneous pregnancy (total motile sperm count,>5 million/mL).
These findings were in addition to a 36.6% spontaneous pregnancy rate.
In another study, Schlegel [28] evaluated the cost-effectiveness of varicocele

repair versus IVF-ICSI. Using a delivery rate of 42.2% and an estimated
cost of successful delivery of $62,263 for IVF- ICSI, varicocele repair was
markedly more cost-effective, with a delivery rate of 30% and cost of
$26,268. Varicocele repair also avoids IVF-related complications, such as
multiple gestation and ovarian hyperstimulation, and allows the possibility
of more than one natural pregnancy with a single therapy.
Endocrinopathies
The hypothalamic–pituitary–gonadal (HPG) axis is a complex, integrated
system that is necessary for normal reproduction. The hypothalamus is the
integrative center of the reproductive hormonal axis; it receives input from
many regions within the brain and feedback in the form of steroid and
protein hormones from the gonads and adrenal glands. The hypothalamus
releases gonadotropin-releasing hormone (GnRH) from the preoptic and
arcuate nuclei as the end result of its integrative function. GnRH, in turn, is
secreted into the portal hypophyseal venous system in a pulsatile fashion to
stimulate the anterior pituitary gland.
GnRH stimulates the release of LH and FSH from the anterior pituitary
gland. LH release is modulated by feedback of androgens at the pituitary
and hypothalamic levels. The release of FSH seems to be further regulated
by negative feedback of inhibin and activin from the Sertoli’s cell of the
testis. LH stimulates testosterone production by the Leydig’s cells, whereas
FSH is crucial to the initiation and maintenance of spermatogenesis. LH
and FSH are necessary for quantitatively normal spermatogenesis.
Feedback within this axis is essential for normal function and it occurs
at multiple levels, allowing for precise regulation of hormonal activity.
Abnormalities anywhere in the HPG axis have the potential for a negative
impact on fertility in men. In general, endocrine defects leading to male
infertility can be initially evaluated by assaying testosterone, LH, FSH,
prolactin, and estradiol (Table 2).
Genetic endocrinopathies
Beginning at the molecular level, genetic anomalies can cause hormonal,
growth factor, and receptor dysfunction affecting the HPG axis [29]. The
following disorders are rare but may severely impair male fertility. These
disorders are usually caused by mutations, small deletions, or polymorphic
expansions within specific genes involved in the endocrine or humoral
regulation of sexual development and function.
Disorders of production or secretion of gonadotropin-releasing hormone

Disorders resulting in abnormal synthesis and release of GnRH and
subsequent low levels of FSH and LH without an anatomic cause are termed
Table 2
Hormone findings in male infertility
Condition FSH LH Testosterone Prolactin
Normal spermatogenesis Normal Normal Normal Normal
Hypogonadotropic Decreased Decreased Decreased Normal
hypogonadism
Impaired spermatogenesis Increased/ Normal Normal Normal
normal
Hypergonadotropic Increased Increased Normal/ Normal
hypogonadism decreased
(testicular failure)
Prolactinoma Normal/ Normal/ Decreased Increased
decreased decreased
Anabolic steroid use/abuse Normal/ Decreased Increased Normal
increased
Clomiphene citrate/tamoxifen Increased Increased Increased Normal
idiopathic hypogonadotropic hypogonadism (IHH; reviewed in [29]). Without

adequate levels of gonadotropins, androgen production and spermatogen-
esis fail.
The most common X-linked disorder in male infertility and a recognized
cause of IHH is Kallmann’s syndrome, which occurs in approximately 1 in
10,000 to 1 in 60,000 live births [30]. A mutation in the Ka1 gene (Xp22.3)
results in a deficiency in GnRH secretion from the hypothalamus [31]. This
deficiency is believed to be from a developmental defect caused by a defec-
tive neural adhesion molecule altering hypothalamic development. Many
patients who have Kallmann’s syndrome are tall and anosmic and present
secondary to failure of pubertal initiation. Because of the lack of FSH and
LH stimulation of the testis, spermatogenesis is absent, as is testosterone
production, and these men have firm pre-pubertal-size testes and a small
penis. Patients may also have congenital deafness, asymmetry of the
cranium and face, cleft palate, cerebellar dysfunction, cryptorchidism, or
renal abnormalities. Fertility can be achieved in many patients with this
syndrome with a combination of hormone replacement therapies (human
chorionic gonadotropin [hCG] and FSH) [3].
Several other gene mutations result in IHH through a variety of
mechanisms. Another X-chromosome gene, Dax1, is associated with con-
genital adrenal hyperplasia (CAH) and IHH. Dax1 encodes for a nuclear
hormone receptor superfamily and seems to function in the maintenance of
testis epithelial integrity and spermatogenesis [32]. Mutations of the GnRH
receptor (GnRHR), which encodes a G-protein-coupled receptor for GnRH,
result in partial to complete hypogonadism with subsequent reproductive
dysfunction [33]. GnRH secretion is influenced by PC1, a convertase-1 gene,
which, when mutated, is associated with IHH, obesity, and diabetes [34].
Finally, Prader-Willi syndrome is characterized by obesity, cryptorchidism,
mild or moderate mental retardation, infantile hypotonia, and IHH. A
mutation or deletion in the short arm of chromosome 15 (15q11q13) is
inherited from the patient’s father or, less commonly, when two chro-
mosomal copies of this locus are inherited from the patient’s mother [35].
Treatment is by replacement of FSH and hCG.
Disorders of luteinizing hormone and follicle-stimulating hormone function

LH and FSH are released from the pituitary gland under the influence of
pulsatile stimulation of GnRH. Mutations that lead to biologically inactive
LH result in a spectrum of disease from complete virilization failure to less
severe hypogonadism [36]. LH receptor defects can lead to constitutive
activation characterized by precocious pseudopuberty or inactivation and
pseudohermaphroditism or Leydig’s cell agenesis [37]. Much less frequently
reported are mutations in FSH or the FSH receptor; men with these genetic
mutations are either healthy or have a mild IHH [38].
Disorders of androgen synthesis and function

Androgen synthesis is a complex stepwise process, and mutations in
the enzymes involved in this biosynthesis influence male reproductive func-
tion. Mutation of the steroidogenic acute regulatory protein (StAR) that
transports cholesterol to mitochondria, the first rate-limiting step in steroid
biosynthesis, results in congenital lipoid adrenal hyperplasia characterized
by salt wasting and feminization caused by the complete absence of steroid
production (and lethality if glucocorticoid replacement is not initiated). Five
enzymes are required for the synthesis of testosterone from cholesterol. The
mutations responsible for the dysfunction of the first three steroidogenic
enzymes (20,22 desmolase, 3b-hydroxysteriod dehydrogenase, 17a-hydrox-
ylase) lead to CAH [39]. In these diseases, corticosteroid and mineralocor-
ticoid synthesis are defective, and defective androgen synthesis leads to
incomplete virilization. Defects in the final two enzymes, 17,20 desmolase
and 17b-hydroxysteroid dehydrogenase, result in men who are pseudoher-
maphrodites with ambiguous genitalia or completely feminized genitalia
with cryptorchid testis [39].
The testosterone metabolite, dihydrotestosterone (DHT), is critical to
normal external genitalia and prostate growth. The enzyme 5aÿreductase
converts testosterone to DHT in these tissues. Mutations in the
5aÿreductase gene lead to incomplete development of the external genitalia,
[39] and infertility follows because of the inability to deliver sperm effectively.
Although testosterone and DHT freely diffuse into all cells, steroid
hormones generally can be delivered to the nucleus only by specific receptors
to affect cellular activity. Defects in the androgen receptor gene (AR) disrupt
this receptor function, leading to aberrant transcriptional activation of
androgen-regulated genes, and may cause a wide range of internal and
external virilization abnormalities. These abnormalities include androgen
insensitivity syndromes such as Reifenstein’s syndrome, testicular feminiza-
tion, LubÕs syndrome, and Rosewater’s syndrome [40]. Androgen in-
sensitivity syndromes are inherited in an X-linked fashion from AR point
mutations or small deletions [41]. Clinically, androgen insensitivity causes

a range of phenotypes. Ambiguous genitalia, micropenis, and hypospadias
result from partial androgen responsiveness, whereas complete androgen
insensitivity leads to a female phenotype with intra-abdominal testis [41].
Another form of androgen insensitivity is associated with an adult-onset
motor neuron disease. Spinal and bulbar muscular atrophy, or Kennedy’s
disease, is an X-linked genetic disease associated with an expansion of
a polyglutamine tract within the AR transactivation domain. Patients with
Kennedy’s disease have a progressive weakness in the proximal spinal and
bulbar muscles with associated gynecomastia, testicular atrophy, and
spermatogenic impairment. Symptoms typically begin during midlife and,
with each subsequent generation, the onset and severity of disease worsens
because of lengthening of the cytosine-adenine-guanine (CAG) tract,
a process referred to as ‘‘anticipation’’ [42].
Testing for subtle genetic endocrinopathies, however, is not widely
available. Men suspected to have Kallmann’s syndrome may be evaluated
for Kal mutations; otherwise, specialized genetic testing for the disorders
described previously is not normally performed.
Nongenetic endocrinopathies
Adenomatous growth of the pituitary gland is another rare but
recognized cause of male infertility. Pituitary masses can interfere with the
release of gonadotropins either by way of direct compression of the portal
system or by decreased FSH/LH secretion resulting in hypogonadotropic
hypogonadism. In patients with decreased testosterone levels in the setting
of low LH, physicians must consider a pituitary adenoma. An MRI of the
head is essential in these patients. Mass lesions of the pituitary can manifest
initially as infertility; if the lesion is large, it can be approached by means of
transphenoidal access for definitive surgical treatment.
Hyperprolactinemia can also be seen in association with adenomas of the
pituitary. Elevated prolactin interferes with the normal pulsatile release of
GnRH and thus can itself be a cause of hypogonadism, with subsequent
sexual dysfunction and infertility. Surgery, radiation, and medical treatment
have been used as effective treatments, with the dopamine agents bromocrip-
tine and cabergoline as the mainstays of medical therapy. Iatrogenic causes of
hyperprolactinemia include the selective serotonin reuptake inhibitors
(SSRIs), which have become widely prescribed for numerous mental health
conditions. In general, evaluation of the pituitary with MRI is only warranted
when routine hormone studies or symptoms suggest pituitary disease.
Administration of exogenous androgen causes a drastic reduction in
endogenous testosterone production by the Leydig’s cells of the testis.
Anabolic steroid use results in negative feedback at the level of the
hypothalamus and pituitary, and LH release is reduced as part of the HPG
axis feedback mechanism. Normal spermatogenesis requires adequate
intratesticular testosterone; therefore, in patients using steroids, sperm

production is significantly reduced and azoospermia is often seen. The
extent and reversibility of the detrimental effect on spermatogenesis is
dependent on dose and duration of exogenous steroid use.
Recent investigations have revealed a new, treatable endocrinopathy in
infertile men. In patients with decreased testosterone-to-estradiol ratios,
treatment with oral aromatase inhibitors has resulted in statistically
significant increases in sperm concentration and motility in oligospermic
men [43]. Aromatase inhibitors prevent the peripheral conversion of
testosterone to estradiol and androstenedione to estrone. In these men with
severe male factor infertility and low testosterone-to-estradiol ratios,
aromatase inhibitor treatment normalized their ratios and significantly
improved semen parameters.
Genetics
A genetic disorder may alter spermatogenesis, impair normal develop-
ment of the genital tract, or decrease sperm motility and fertilization
capacity, any of which may lead to varying degrees of male subfertility or
infertility. Genetic disorders may be characterized as karyotype abnormal-
ities, deletions of specific areas of chromosomes involved in the regulation of
spermatogenesis, or specific mutations within genes.
Karyotype abnormalities are more common in infertile men (5.8%) when
compared with a normal population of male newborns (0.5%) [44]. Sex
chromosome abnormalities are more common (4.2%) than autosomal
chromosome abnormalities (1.5%). Chromosome defects are subcategorized
as either numeric or structural. Numeric chromosome abnormalities include
deletion or duplication of whole chromosomes. Structural chromosome
abnormalities include deletion, inversion, or duplication of a portion of a
chromosome, or translocation of part of a chromosome to another chromo-
some. Structural and numeric chromosome abnormalities are observed in
some patients with azoospermia and severe oligozoospermia and involve
the autosomes, sex chromosomes, or both.
Klinefelter’s syndrome (XXY–XXXXY) is the most common sex
chromosome disorder. One study reported that this syndrome occurred 30
times more frequently in infertile men attending an infertility clinic [45].
Patients who have Klinefelter’s syndrome are azoospermic or severely
oligospermic [46] and account for approximately 14% of all cases of
azoospermia [47]. The phenotype of men with Klinefelter’s syndrome varies,
but can include small, firm testes; increased height; female hair distribu-
tion; lower-extremity varicosities; decreased level of intelligence; diabetes
mellitus; obesity; increased incidence of leukemia; nonseminomatous extra-
gonadal germ cell tumors; and infertility [48]. In addition, patients with
gynecomastia have an increased risk of developing breast cancer.
Approximately 10% of patients who have Klinefelter’s syndrome are 46,XY/

47,XXY mosaic, and have a less severe phenotype [47]. These patients have
a variable level of sperm production but rarely achieve paternity through
natural conception [49].
Less common sex chromosomal abnormalities include mixed gonadal
dysgenesis, XX males and XYY males. Patients with mixed gonadal
dysgenesis can be phenotypically male or female, or present with ambiguous
genitalia. These patients frequently have a 45,X/46,XY mosaic karyotype,
but approximately one third of these individuals have a normal karyotype
[39]. Most patients have a testis and a streak gonad. The testis may be
cryptorchid or located in the scrotum. If the testis is scrotally located,
normal Leydig’s cell and Sertoli’s cell populations are generally present;
however, the seminiferous tubules lack germ cells. The intra-abdominal
streak gonad is at risk for malignant degeneration to gonadoblastoma.
Despite a normal phenotype, a man with a 46,XX karotype (XX male
syndrome) is infertile. The most common explanation of this syndrome is
a translocation from the testis/sex-determining region (SRY), located on the
short arm of the Y chromosome, to the X chromosome. Although rare, some
patients with XX male syndrome lack this translocation [50]. Patients with the
XX male syndrome are azoospermic, with a Sertoli’s cell-only pathology
found on testis biopsy. The XYY man’s semen analysis varies from normal to
azoospermic [51]. Most XYY men are phenotyically normal, except for
increased height. Those XYY patients with failure of spermatogenesis demon-
strate maturation arrest or Sertoli’s cell-only syndrome on testis biopsy [39].
The Y chromosome plays a major role in male reproductive function.
First, the testis determining factor (SRY), a critical region for normal male
development, is found on the short arm of the Y chromosome (Yp) [52]. The
azoospermia factor region (AZF) of the Y chromosome is also required
for normal spermatogenesis and is located on the long arm of the Y
chromosome (Yq11) [53]. Three nonoverlapping intervals within the AZF
region (AZFa, AZFb, and AZFc) have been identified, and microdeletions
involving these regions are found in some infertile men. Genes in these
regions seem to code for proteins involved in the regulation of spermato-
genesis. The reported incidence of Y-chromosome microdeletions varies
from study to study, depending on patient selection criteria. Overall, 4% of
oligospermic men are found to have Y-chromosome microdeletions, and the
incidence rises to 14% in idiopathic, severely oligospermic men (\5 million
sperm/mL). In all azoospermic men, the incidence of microdeletions is 11%,
and 18% of all idiopathic azoospermic men have Y-chromosome micro-
deletions (reviewed in [54]). To identify Y-chromosome microdeletions, most
laboratories use a polymerase chain reaction assay and gel electrophoresis.
The incidence of karyotype abnormalities and Y-chromosome micro-
deletions increases as the sperm density decreases. Therefore, the authors
recommend high-resolution-banding cytogenetic analysis and Y-chromo-
some microdeletions for all men with sperm densities less than 5 million/mL,
especially those contemplating the use of ART. Infertile patients with

abnormal karyotypes or Y-chromosome microdeletions may have a few
sperm in their ejaculate or within the testis. These sperm may be used with
ICSI-IVF techniques. Successful pregnancies have been achieved with sperm
harboring abnormal karyotypes and Y-chromosome microdeletions using
these techniques. Children of fathers with karyotype abnormalities may be
normal. Because of the risk of unbalanced translocations occurring during
meiosis, however, some of these children may be malformed and may not
survive [49,55]. Male offspring, born to fathers with Y-chromosome
microdeletions, are expected to inherit these microdeletions [56]. Therefore,
a couple with a male partner found to have an abnormal karyotype or Y-
chromosome microdeletion should undergo genetic counseling before
attempting to achieve a pregnancy.
Cryptorchidism
The incidence of cryptorchidism at the age of 1 year is 0.8% [57]. Many
of these male children later will be subfertile, although the exact
pathophysiology of the resultant infertility has not been defined. Two
possible causes for infertility in these patients exist. First, the anatomic
location of the testis outside of the scrotum results in impaired sper-
matogenesis. Cryptorchid testes reveal smaller seminiferous tubules, de-
creased numbers of spermatogonia, and thickened basement membranes by
age 1.5 years [58]. If left in a cryptorchid location, 69.2% of testes will have
a Sertoli’s cell-only histology when removed postpubertally [59]. Cryptor-
chid men also have a poor response to GnRH stimulation and have lower
basal levels of LH and testosterone [60]. If left untreated, 50% to 70% of
unilaterally cryptorchid men will be oligospermic or azoospermic, and
almost all bilaterally cryptorchid men are azoospermic [61]. Of men who
underwent orchidopexy before puberty, 62% and 30% had sperm densities
greater than 20 million sperm/mL for unilateral and bilateral cryptorchi-
dism, respectively [62]. Azoospermic men can undergo testicular sperm
extraction for sperm retrieval to be used in IVF-ICSI cycles. At the time of
TESE, the authors recommend obtaining a testicular biopsy sample to
exclude carcinoma in situ.
Exposure to gonadotoxins
Numerous substances and occupations have been suspected to decrease
semen quality. These potential gonadotoxins have been difficult to study
because of the sample size and confounding factors that are difficult to
control. The authors therefore address the substances that have shown
a repeated association with poor semen quality. Medicines can impair sperm
production and function, and decrease libido and erectile function (Table 3).
Table 3
Gonadotoxic agents and their effects on male reproductive function
Effect on reproductive
Gonadotoxic agent function Mechanism
Drug Decreased spermatogenesis Decreased testosterone and
Spironolactone and decreased libido decreased HPG axis
Calcium channel blockers Decreased fertilization Decreased acrosome reaction
capacity
a-Blockers Restrograde ejaculation Relaxation of bladder neck
Nitrofuratoin (high doses) Decreased spermatogenesis Inhibits carbohydrate and
oxygen consumption in
testicular cells
Erythromycin Decreased sperm density Unknown
and motility
Tetracycline Decreased motility Binds sperm
Cimetidine Decreased spermatogenesis Decreased release of LH
and testosterone
Cyclosporine Decreased spermatogenesis Decreased testosterone
synthesis
Colchicine and allopurinol Decreased fertilization Unknown
capacity
Sulfasalazine Decreased sperm density, Decreased testosterone
motility, and morphology
Thiazides Decreased erectile function Decreased vascular resistance
b-Blockers Decreased erectile function Decreased vascular resistance
and libido
Antipsychotics Decreased libido Decreased HPG axis
Tricyclic antidepressants Decreased libido Increased dopamine and
decreased HPG axis
Chemotherapeutics Decreased spermatogenesis Varies (dependent on agent)
Other drugs
Alcohol (heavy, chronic use) Decreased spermatogenesis T/E imbalance?
Tobacco Decreased spermatogenesis Unknown
Cocaine Decreased spermatogenesis Unknown
Marijuana Decreased spermatogenesis Unknown
Other gonadotoxins
Organic solvents Decreased spermatogenesis Direct toxicity
Pesticides Decreased spermatogenesis Direct toxicity
Heavy metals Decreased spermatogenesis Direct toxicity
Radiation Decreased spermatogenesis Increased DNA double-strand
breakage
Heat Decreased spermatogenesis Unknown
Abbreviation: T-E, testosterone-to-estradiol.
Lifestyle choices that can have a negative impact on semen quality include
cigarette smoking, excessive alcohol consumption, marijuana use, and
the prolonged and repetitive use of hot tubs. Other factors can include
occupational exposure to gonadotoxins, including excess heat or toxins.
Associations between heat, ionizing radiation, heavy metals, pesticides, and
some exposure to organic solvents and a decline in semen quality have been
made. These effects are reversible if the offending agent is removed before
the decline of the semen quality to azoospermia.
Radiation and chemotherapy can permanently damage the germinal
epithelium, leading to variable recovery of spermatogenesis. Therefore, it
is strongly recommended that patients bank their semen before initiating
therapy in an effort to preserve their fertility. After chemotherapy, men are
asked not to try to conceive for 2 years, at which time a semen analysis
should be obtained if the patient is unable to conceive in a timely manner.
Azoospermic men after chemotherapy have a 41% chance of having sperm
present in the testis for TESE to be used in IVF-ICSI cycles [63].
Obstruction
Obstruction of the excretory ductal system can occur along the
ejaculatory ducts, vas deferens, or epididymis. History, physical examina-
tion, semen parameters, and radiologic studies can be used to identify the
location of obstruction. Vasal obstruction may be caused by inguinal or
pelvic surgery. Prior orchidopexy, hydrocelectomy, other scrotal surgery, or
recurrent epididymitis may result in epididymal obstruction. On physical
examination, the absence of the vas deferens is found in patients with
congential bilateral absence of the vas deferens (CBAVD), and dilated
epididymides indicate possible obstruction.
Semen analysis varies with the site of obstruction. Complete ejaculatory
duct obstruction (EJDO) results in a low-volume, acidic, fructose-negative
ejaculate. Obstruction of the vasa or epididymides results in a normal-
volume, basic, fructose-positive ejaculate. Men with obstruction as the only
cause for their infertility have normal testosterone and FSH levels.
Radiographic studies are necessary when obstruction of the excretory ducts
is suspected. Transrectal ultrasound (TRUS) supports the diagnosis of
EJDO by identifying dilated ejaculatory ducts and seminal vesicles and
cystic masses and stones causing obstruction. An aspirate of dilated seminal
vesicles during TRUS that reveals numerous sperm is also evidence that
EJDO is present. Absence of hypoplastic seminal vesicles on TRUS
confirms CBAVD. A vasogram during scrotal exploration confirms vasal
occlusion. The treatment of choice for EJDO is transurethral resection of
the ejaculatory ducts. Approximately half of the men undergoing this
procedure for EJDO have improvement of their semen parameters, and half
of the men who improve subsequently achieve a pregnancy [64]. Men with
vasal obstruction or obstruction at the epididymis are candidates for
microsurgical reconstruction to allow natural conception or microsurgical
epididymal sperm aspiration (MESA) for sperm retrieval to be used in IVF-
ICSI cycles.
CBAVD is the most frequently found abnormality of the extratesticular
ductal system in patients with obstruction affecting 1% to 2% of infertile
men [65]. CBAVD is part of the phenotypic spectrum of cystic fibrosis (CF),
an autosomal recessive disease, of which 1 of 25 white men and women are
carriers [65]. CF is caused by a genetic mutation of the CF transmembrane
conductance regulator gene (CFTR). The CFTR gene is large (250,000 base
pairs) and, to date, more than 1000 CFTR mutations have been identified.
Characteristics of men with CBAVD include absence of the vas deferens;
hypoplastic, nonfunctional, seminal vesicles and ejaculatory ducts; and an
epididymal remnant, frequently composed of only the caput region that is
firm and distended [66]. Spermatogenesis is not impaired in these patients;
therefore, sperm may be harvested from the epididymis (by means of
MESA) for use in ICSI-IVF, allowing affected couples to achieve a
pregnancy. Men with CBAVD and their wives should be screened for CFTR
mutations and referred to genetic counseling.
Routine analysis of the CFTR gene is available from most genetic
laboratories. Only about 30 mutations, of the possible 1000, are regularly
screened in the clinical diagnostic laboratory, so a specific mutation may be
present that will not be identified. Therefore, absence of a mutation in these
limited assays does not guarantee that an offspring will not be born with CF
if the female partner is also a carrier. In addition to the 1000 known
mutations in this gene, there is a polymorphism in intron 8 (noncoding
region) that quantitatively influences the production of the CFTR gene
product. The alleles of this polymorphic region of thymidines in intron 8 of
the CFTR gene contain five (5T), seven (7T), or nine (9T) thymidines. The 5T
allele results in the least efficient processing of the CFTR mRNA. 5T
mutations lead to a lower amount of protein produced and increased severity
of the phenotype observed [66]. To assess this most common polymorphism
(5T), a separate analysis must be ordered, and this test is not routinely run
in all clinical laboratories performing routine CF gene analysis, reinforcing
the limits associated with a negative result. Because of the many variable
mutations and difficulty in identifying all possible mutations in a single
patient, all patients with CBAVD are now believed to have a genetic form of
CF [66]. Patients presenting with unilateral absence of the vas deferens are
also considered at risk and should undergo analysis of the CFTR gene,
although unilateral absence of the vas deferens in a patient with a
contralateral solitary kidney may represent a different congenital anomaly.
Disorders of ejaculation
Ejaculation consists of the coordinated deposition of semen into the
prostatic urethra (emission), closure of the bladder neck, and contraction of
the periurethral and pelvic floor muscles, causing expulsion of the semen
through the urethra (ejaculation). The process of ejaculation depends on
central and peripheral nervous system control. Emission is controlled by
sympathetic neurons originating from T10-L3 that course through the
paravertebral sympathetic ganglia. Ejaculation requires somatic motor

innervation from S2-4 whose fibers course through the pudendal nerves to
the bladder neck and pelvic floor musculature.
Abnormalities of ejaculation can lead to lack of emission and ejaculation
or retrograde ejaculation and may be caused by neurologic, anatomic, and
psychologic conditions. Retrograde ejaculation is caused by incomplete
closure of the bladder neck. Diabetes mellitus causes peripheral nervous
system injury resulting in possible retrograde ejaculation or anejaculation.
Failure of emission or ejaculation can also be caused by excision of a portion
of the sympathetic chain or pelvic nerves during retroperitoneal lymph node
dissection for testicular cancer or other retroperitoneal abdominal or pelvic
surgery. Central nervous system lesions, such as spinal cord injury and
myelodysplasia, can also cause ejaculatory dysfunction. Finally, some
medications will affect ejaculation, such as a-blockers (causing retrograde
ejaculation), antidepressants, antipsychotics, and some antihypertensives.
Anatomic causes for ejaculatory dysfunction include obstruction of the
ejaculatory ducts and prior surgery on the bladder neck (Y-V plasty of the
bladder neck, transurethral incision, or resection of the prostate) leading to
retrograde ejaculation.
Treatment of ejaculatory disorders may be medical or surgical. Neurologic
causes of failure of emission and ejaculation and retrograde ejaculation can
be treated with sympathomimetic agents that enhance emission and close the
bladder neck. These medications include imipramine hydrochloride and
pseudoephedrine hydrochloride. If conversion from retrograde to antegrade
ejaculation fails, functional sperm may be retrieved from the bladder and
used for intrauterine insemination or IVF cycles. Other techniques to attain
semen from men with ejaculatory dysfunction include vibratory stimulation
and electroejaculation. Vibratory stimulation requires the use of a vibrator to
induce ejaculation and requires an intact reflex arc within the thoracolumbar
spinal cord [67]. The best predictors of success using this technique include
reflex hip flexion when the soles of the feet are scratched [68] and an intact
bulbocavernosus reflex [69]. Men who fail both medical therapy and
vibratory stimulation may proceed to electroejaculation.
Summary
There is a male factor involved in up to half of all infertile couples.
Potential causes of male factor infertility are many and require thorough
evaluation for their accurate elucidation. A complete medical history in
conjunction with a focused examination can allow for an appropriate choice
of laboratory and imaging studies. The semen analysis is a crucial first step,
but it is by no means sufficient to determine cause or dictate therapy. A
systematic approach is necessary to help guide the evaluation and exclude
less likely causes. The causes discussed within this article are broad, and the
prognosis for any given couple depends, in large part, on the cause of
the infertility. Without a firm understanding of the genetics, anatomy,
physiology, and their interactions necessary to permit full functioning of the
male reproductive system, the evaluation becomes an inefficient exercise that
often fails to elucidate the precise cause of infertility. Treatment success
relies not just on a clinical diagnosis but on a determination of the cause of
the male factor infertility. Therefore, couples with a component of male
factor infertility need a systematic evaluation directed at the male partner to
maximize their reproductive potential.
References
[1] Poland ML, Moghissi KS, Giblin PT, Ager JW, Olson JM. Variation of semen measures
within normal men. Fertil Steril 1985;44:396–400.
[2] Kolettis PN, Sabanegh ES. Significant medical pathology discovered during a male
infertility evaluation. J Urol 2001;166:178–80.
[3] Sigman M, Lipshultz LI, Howard SS. Evaluation of the subfertile male. In: Lipshultz LI,
Howard SS, editors. Infertility in the male. 3rd edition. St. Louis, MO: Mosby; 1997.
p. 173–93.
[4] Freeman B. Mumps virus. In: Burrows W, Freeman BA, editors. Textbook of micro-
biology. 21st edition. Philadelphia: WB Saunders; 1979. p. 1001–3.
[5] Chipkevitch E, Nishimura RT, Tu DG, Galea-Rojas M. Clinical measurement of
testicular volume in adolescents: comparison of the reliability of 5 methods. J Urol
1996;156:2050–3.
[6] Naughton CK, Nangia AK, Agarwal A. Pathophysiology of varicoceles in male
infertility. Hum Reprod Update 2001;7:473–81.
[7] Sigman M, Jarow JP. Endocrine evaluation of infertile men. Urology 1997;50:659–64.
[8] Jaffe TM, Kim ED, Hoekstra TH, Lipshultz LI. Sperm pellet analysis: a technique to
detect the presence of sperm in men considered to have azoospermia by routine semen
analysis. J Urol 1998;159:1548–50.
[9] Belloli G, D’Agostino S, Pesce C, Fantuz E. Varicocele in childhood and adolescence and
other testicular anomalies: an epidemiological study. Pediatr Med Chir 1993;15:159–62
[English abstract].
[10] Pryor JL, Howards SS. Varicocele. Urol Clin North Am 1987;14:499–513.
[11] Jarow JP, Coburn M, Sigman M. Incidence of varicoceles in men with primary and
secondary infertility. Urology 1996;47:73–6.
[12] Dubin L, Amelar RD. Varicocelectomy: 986 cases in a twelve-year study. Urology
1977;10:446–9.
[13] Saypol DC, Howards SS, Turner TT, Miller ED Jr. Influence of surgically induced
varicocele on testicular blood flow, temperature, and histology in adult rats and dogs.
J Clin Invest 1981;68:39–45.
[14] MacLeod JHR. The effect of hyperperexia on spermatozoa counts in men. Endocrinology
1941;28:780.
[15] Peng BC, Tomashefsky P, Nagler HM. The cofactor effect: varicocele and infertility.
Fertil Steril 1990;54:143–8.
[16] Cayan S, Kadioglu A, Orhan I, Kandirali E, Tefekli A, Tellaloglu S. The effect of
microsurgical varicocelectomy on serum follicle stimulating hormone, testosterone and
free testosterone levels in infertile men with varicocele. British Journal of Urology
International 1999;84:1046–9.
[17] Su LM, Goldstein M, Schlegel PN. The effect of varicocelectomy on serum testosterone
levels in infertile men with varicoceles. J Urol 1995;154:1752–5.
[18] Madgar I, Weissenberg R, Lunenfeld B, Karasik A, Goldwasser B. Controlled trial of
high spermatic vein ligation for varicocele in infertile men. Fertil Steril 1995;63:120–4.
[19] Kibar Y, Seckin B, Erduran D. The effects of subinguinal varicocelectomy on Kruger
morphology and semen parameters. J Urol 2002;168:1071–4.
[20] Schatte EC, Hirshberg SJ, Fallick ML, Lipschultz LI, Kim ED. Varicocelectomy
improves sperm strict morphology and motility. J Urol 1998;160:1338–40.
[21] Vazquez-Levin MH, Friedmann P, Goldberg SI, Medley NE, Nagler HM. Response of
routine semen analysis and critical assessment of sperm morphology by Kruger
classification to therapeutic varicocelectomy. J Urol 1997;158:1804–7.
[22] Ohl DA, MJ, et al. The effect of varicocele repair on optimized sperm penetration assay.
Orlando, FL: ASRM; 2001.
[23] Mostafa T, Anis TH, El-Nashar A, Imam H, Othman IA. Varicocelectomy reduces
reactive oxygen species levels and increases antioxidant activity of seminal plasma from
infertile men with varicocele. Int J Androl 2001;24:261–5.
[24] Kadioglu A, Tefekli A, Cayan S, Kandirali E, Erdemir F, Tellaloglu S. Microsurgical
inguinal varicocele repair in azoospermic men. Urology 2001;57:328–33.
[25] Kim ED, Leibman BB, Grinblat DM, Lipshultz LI. Varicocele repair improves semen
parameters in azoospermic men with spermatogenic failure. J Urol 1999;162:737–40.
[26] Matthews GJ, Matthews ED, Goldstein M. Induction of spermatogenesis and
achievement of pregnancy after microsurgical varicocelectomy in men with azoospermia
and severe oligoasthenospermia. Fertil Steril 1998;70:71–5.
[27] Cayan S, Erdemir F, Ozbey I, Turek PJ, Kadioglu A, Tellaloglu S. Can varicocelectomy
significantly change the way couples use assisted reproductive technologies? J Urol
2002;167:1749–52.
[28] Schlegel PN. Is assisted reproduction the optimal treatment for varicocele-associated male
infertility? A cost-effectiveness analysis. Urology 1997;49:83–90.
[29] Seminara SB, Oliveira LM, Beranova M, Hayes FJ, Crowley WF Jr. Genetics of
hypogonadotropic hypogonadism. J Endocrinol Invest 2000;23:560–5.
[30] Bick D, Franco B, Sherins RJ, Heye B, Pike L, Crawford J, et al. Brief report: intragenic
deletion of the KALIG-1 gene in Kallmann’s syndrome. N Engl J Med 1992;326:1752–5.
[31] Franco B, Guioli S, Pragliola A, Incerti B, Bardoni B, Tonlorenzi R, et al. A gene deleted
in Kallmann’s syndrome shares homology with neural cell adhesion and axonal path-
finding molecules. Nature 1991;353:529–36.
[32] Yu RN, Ito M, Saunders TL, Camper SA, Jameson JL. Role of Ahch in gonadal
development and gametogenesis. Nat Genet 1998;20:353–7.
[33] de Roux N, Young J, Misrahi M, Schaison G, Milgrom E. Loss of function mutations of
the GnRH receptor: a new cause of hypogonadotropic hypogonadism. J Pediatr
Endocrinol Metab 1999;12(Suppl):267–75.
[34] Jackson RS, Creemers JW, Ohagi S, Raffin-Sanson ML, Sanders L, Montague CT, et al.
Obesity and impaired prohormone processing associated with mutations in the human
prohormone convertase 1 gene. Nat Genet 1997;16:303–6.
[35] Smeets DF, Hamel BC, Nelen MR, Smeets HJ, Bollen JH, Smits AP, et al. Prader-Willi
syndrome and Angelman syndrome in cousins from a family with a translocation between
chromosomes 6 and 15. N Engl J Med 1992;326:807–11.
[36] Weiss J, Axelrod L, Whitcomb RW, Harris PE, Crowley WF, Jameson JL. Hypogonad-
ism caused by a single amino acid substitution in the beta subunit of luteinizing hormone.
N Engl J Med 1992;326:179–83.
[37] Wu SM, Leschek EW, Rennert OM, Chan WY. Luteinizing hormone receptor mutations
in disorders of sexual development and cancer. Front Biosci 2000;5:D343–52.
[38] Simoni M, Gromoll J, Hoppner W, Kamischke A, Krafft T, Stahle D, et al. Mutational
analysis of the follicle-stimulating hormone (FSH) receptor in normal and infertile men:
identification and characterization of two discrete FSH receptor isoforms. J Clin

[39] Griffin JE. Androgen resistance—the clinical and molecular spectrum. N Engl J Med
1992;326:611–8.
[40] Quigley CA, De Bellis A, Marschke KB, el Awady MK, Wilson EM, French FS.
Androgen receptor defects: historical, clinical, and molecular perspectives. Endocr Rev
1995;16:
271–321.
[41] Brinkmann AO. Molecular basis of androgen insensitivity. Mol Cell Endocrinol
2001;179:105–9.
[42] Casella R, Maduro MR, Lipshultz LI, Lamb DJ. Significance of the polyglutamine tract
polymorphism in the androgen receptor. Urology 2001;58:651–6.
[43] Pavlovich CP, King P, Goldstein M, Schlegel PN. Evidence of a treatable endocrinopathy
in infertile men. J Urol 2001;165:837–41.
[44] Johnson MD. Genetic risks of intracytoplasmic sperm injection in the treatment of male
infertility: recommendations for genetic counseling and screening. Fertil Steril 1998;70:
397–411.
[45] De Braekeleer M, Dao TN. Cytogenetic studies in male infertility: a review. Hum Reprod
1991;6:245–50.
[46] Palermo GD, Schlegel PN, Sills ES, Veeck LL, Zaninovic N, Menendez S, et al. Births
after intracytoplasmic injection of sperm obtained by testicular extraction from men with
nonmosaic Klinefelter’s syndrome. N Engl J Med 1998;338:588–90.
[47] Therman ESM. Human chromosomes. Structure behavior and effects. 3rd edition. New
York: Springer; 1993.
[48] Gordon DL, Krmpotic E, Thomas W, Gandy HM, Paulsen CA. Pathologic testicular
findings in Klinefelter’s syndrome. 47, XXY vs 46, XY-47, XXY. Arch Intern Med
1972;130:726–9.
[49] Poulakis V, Witzsch U, Diehl W, de Vries R, Becht E, Trotnow S. Birth of two infants with
normal karyotype after intracytoplasmic injection of sperm obtained by testicular extraction
from two men with nonmosaic Klinefelter’s syndrome. Fertil Steril 2001;76:1060–2.
[50] Abusheikha N, Lass A, Brinsden P. XX males without SRY gene and with infertility.
Hum Reprod 2001;16:717–8.
[51] Speed R. Heterologous pairing and fertility in humans. In: CB G, editor. Fertility and
chromosome pairing: recent studies in plants and animals. Boca Raton, FL: CRC Press;
1989. p. 1–36.
[52] Koopman P, Gubbay J, Vivian N, Goodfellow P, Lovell-Badge R. Male development of
chromosomally female mice transgenic for Sry. Nature 1991;351:117–21.
[53] Tiepolo L, Zuffardi O. Localization of factors controlling spermatogenesis in the
nonfluorescent portion of the human Y chromosome long arm. Hum Genet 1976;
34:119–24.
[54] Foresta C, Moro E, Ferlin A. Y chromosome microdeletions and alterations of
spermatogenesis. Endocr Rev 2001;22:226–39.
[55] Belin V, Farhat M, Monset-Couchard M. Intracytoplasmic sperm injection pregnancy
with trisomy 20p and monosomy 22q in a newborn resulting from a balanced paternal
translocation. Biol Neonate 1999;75:398–401.
[56] Page DC, Silber S, Brown LG. Men with infertility caused by AZFc deletion can produce
sons by intracytoplasmic sperm injection, but are likely to transmit the deletion and
infertility. Hum Reprod 1999;14:1722–6.
[57] Villumsen AL, Zachau-Christiansen B. Spontaneous alterations in position of the testes.
Arch Dis Child 1966;41:198–200.
[58] Cooper E. The histology of the retained testis in the human subject at different ages and its
comparison with the testis. J Anat 1929;64:5–10.
[59] Rogers E, Teahan S, Gallagher H, Butler MR, Grainger R, McDermott TE, et al. The
role of orchiectomy in the management of postpubertal cryptorchidism. J Urol
1998;159:851–4.
[60] Job JC, Toublanc JE, Chaussain JL, Gendrel D, Roger M, Canlorbe P. The pituitary-
gonadal axis in cryptorchid infants and children. Eur J Pediatr 1987;146(Suppl):S2–5.
[61] Leissner J, Filipas D, Wolf HK, Fisch M. The undescended testis: considerations and
impact on fertility. British Journal of Urology International 1999;83:885–91.
[62] Lipshultz LI. Cryptorchidism in the subfertile male. Fertil Steril 1976;27:609–20.
[63] Chan PT, Palermo GD, Veeck LL, Rosenwaks Z, Schlegel PN. Testicular sperm
extraction combined with intracytoplasmic sperm injection in the treatment of men with
persistent azoospermia postchemotherapy. Cancer 2001;92:1632–7.
[64] Schlegel P. Management of ejaculatory duct obstruction. In: Lipschultz LI, Howard SS,
editors. Infertility in the male. 3rd edition. St Louis: Mosby; 1997. p. 385–94.
[65] Quinzii C, Castellani C. The cystic fibrosis transmembrane regulator gene and male
infertility. J Endocrinol Invest 2000;23:684–9.
[66] Daudin M, Bieth E, Bujan L, Massat G, Pontonnier F, Mieusset R. Congenital bilateral
absence of the vas deferens: clinical characteristics, biological parameters, cystic fibrosis
transmembrane conductance regulator gene mutations, and implications for genetic
counseling. Fertil Steril 2000;74:1164–74.
[67] Shaban SF, Seaman EK, Lipshultz LI. Treatment of abnormalities of ejaculation. In:
Lipschultz LI, Howard SS, editors. Infertility in the male. 3rd edition. St Louis, MO:
Mosby; 1997. p. 423–38.
[68] Brindley GS. Reflex ejaculation under vibratory stimulation in paraplegic men. Paraplegia
1981;19:299–302.
[69] Bird VG, Brackett NL, Lynne CM, Aballa TC, Ferrell SM. Reflexes and somatic
responses as predictors of ejaculation by penile vibratory stimulation in men with spinal
cord injury. Spinal Cord 2001;39:514–9.
Further reading
World Health Organization. WHO laboratory manual for the examination of human semen
and sperm-cervical mucus interaction. 4th edition. Cambridge, UK: Cambridge University
Press; 1999.
32 (2003) 709–723
Evaluating the efficacy of intervention

David S. Guzick, PhD, MD*, John T. Queenan Jr, MD
School of Medicine and Dentistry, University of Rochester, 601 Elmwood Avenue,
Box 706, Rochester, NY 14642, USA
Elsewhere in this issue are articles that address various conditions

associated with infertility. These include age as well as endocrine, genetic,
and anatomic factors. For these conditions, various treatments have been
proposed. But how should clinicians assess whether these interventions are
successful?
Pregnancy after treatment: coincidence versus consequence

The fundamental problem in assessing the efficacy of interventions for
infertility is that, with few exceptions, there is some baseline probability of
pregnancy independent of the intervention. Thus, the goal of infertility
study design and data analysis is to determine the incremental success rates
that can be attributed to treatment above this baseline level. There are some
conditions that represent absolute barriers to pregnancy, such as ovarian
failure, bilateral tubal obstruction, or azoospermia. In most patients,
however, the factors associated with infertility are not absolute: rather than
ovarian failure, there may be varying degrees of ovulatory dysfunction;
rather than bilateral tubal obstruction, there may be varying degrees of
tubal damage; and rather than azoospermia, there may be varying degrees
of impairment of sperm quantity and function.
Thus, for most couples with infertility, the probability of pregnancy per
month is less than that of a normally fertile population but more than zero.
For any given couple, it is not always straightforward to distinguish between
coincidence and consequence when evaluating the relation between
treatment and pregnancy. Is the pregnancy that occurs in a woman with
endometriosis 4 months after laparoscopic surgery a coincidence or
consequence? Is the pregnancy that occurs in a couple with unexplained
E-mail address: david_guzick@urmc.rochester.edu (D.S. Guzick).
doi:10.1016/S0889-8529(03)00048-3
710 D.S. Guzick, J.T. Queenan, Jr / Endocrinol Metab Clin N Am 32 (2003) 709–723
infertility on the fifth cycle of clomiphene citrate administration a co-

incidence or consequence? In any individual case, these questions cannot be
answered definitively. If a large group of patients are investigated within the
context of a rigorous clinical research design, however, the efficacy of a given
treatment can be inferred if the overall pregnancy rate across time is higher
for patients who receive treatment than for those who do not.
Example of a noninformative research design

The fundamental problem regarding baseline outcomes in control groups
can be shown by a hypothetical example. Consider the question of whether
myomectomy for uterine fibroids is an effective treatment for infertility. A
retrospective review of the last 100 cases of myomectomy among infertile
women is performed. The average duration of infertility before surgery was
30 months. The key result of this hypothetical study is that 53% of the
patients were able to conceive. Although this result might suggest that
myomectomy is efficacious in fostering pregnancy among infertile women
with fibroids, it would clearly be misleading to counsel patients that ‘‘half of
infertile women with fibroids become pregnant after myomectomy.’’ This
statement implies that the pregnancy is a consequence of the treatment,
which isn’t known to be the case because of the absence of a control group
of patients with fibroids who did not undergo a myomectomy. Perhaps 50%
of these patients would have become pregnant as well.
The foregoing study can be summarized by the research design shown in
Fig. 1. The proportion of those pregnant after myomectomy appears
impressive. Because there was no control group of women with comparable
age, duration of infertility, and size of fibroids who were followed up
Fig. 1. Design of myomectomy study without control group.

D.S. Guzick, J.T. Queenan, Jr / Endocrinol Metab Clin N Am 32 (2003) 709–723 711
without myomectomy, however, it is not known what the pregnancy rate

would be in the control group or whether it is different from that found in
the myomectomy group. A more appropriate research design is shown in
Fig. 2.
With respect to this particular research question, it might be tempting for
a clinician to say, ‘‘A randomized study will never be done because infertile
women who know that they have a 50% chance of pregnancy following
myomectomy would never consent to being randomized to a nontreatment
group. Besides, with an average duration of more than 2 years of infertility,
it is unlikely that half of these women would have become pregnant without
treatment.’’ In the absence of a randomized control group, clinicians do not
know in a definitive way whether the pregnancy rate among women with
fibroids is higher with myomectomy than without this procedure. An
important variable that can give clinicians some clue about what the
control-group rate might be, however, is buried in another aspect of the data
related to the duration of observation since treatment. Fig. 3 shows
durations of follow-up after surgery for 10 representative patients in the
study. Fig. 3A shows the date of surgery and the outcome at the time of
chart review. Data in Fig. 3B are repositioned such that the date of surgery
equals day 1. The patients who underwent myomectomy at dates more
remote from the chart review have had a longer period of time to conceive;
thus, women treated more recently should not be given the same weight in
the analysis, because they have had less opportunity to conceive. In total,
among these 10 patients, there were 134 months of observation for
pregnancy after myomectomy, and there were five pregnancies. This implies
a pregnancy rate of approximately 3.7% per month, which is not very
Fig. 2. Randomized, controlled trial of myomectomy.

Fig. 3. Duration of follow-up after myomectomy, with pregnancy outcome dates of

observation (A) and months of observation (B).
different from the pregnancy rates that occur in infertile couples

independent of treatment [1].
This hypothetical study shows various issues that arise with respect to
research design and data analysis in the assessment of efficacy of infertility
interventions. These issues are now considered in greater detail.
Research design
Types of epidemiologic designs
Having shown some of the pitfalls that might occur in trying to conduct
research that links infertility treatment with outcome, the types of epi-
demiologic designs that are available for this purpose, and their strengths
and weaknesses, are now considered.
Fig. 4 shows that the number of papers in the infertility literature that
are observational or descriptive is quite large, with fewer in the analytic
category. The quality of the information, however, is better for analytic
studies than for observational research. The most valid evidence about the
relation between infertility treatment and outcome is derived from ran-
domized clinical trials, and yet this is the most infrequent type of study
reported in the literature.
How can the reader recognize the different types of epidemiologic
designs? Fig. 5 is taken from an overview of clinical research designs by
David Grimes [2]. The key distinction between experimental and obser-
vational studies is whether the investigator assigned a treatment (or
exposures). Assignment of an intrauterine contraceptive device (IUD)
versus oral contraceptives, with subsequent long-term follow-up for rates of
infertility, would be an experimental study, whereas chart review of fertile
and infertile women to determine rates of exposure to IUDs and oral
contraceptives would be an example of an observational study. If an
Fig. 4. Quality and quantity of research papers by study design.
experimental study is performed, bias would be minimized if the treatment

or exposure were assigned randomly. Sometimes, however, this is not
feasible, and assignment may be influenced by factors such as location, time,
financial considerations, or patient choice. Assignment of IUD versus oral
contraceptives based on clinic day, for example, would be an example of
a nonrandomized subject assignment.
If the exposure is not assigned by the investigator (see Fig. 5), the
observational study results may be descriptive (when there is no comparison
group) or analytic (when comparison groups of different exposures or no
exposure are used). Within analytic studies, the distinction between cohort,
case-control, and cross-sectional studies depends on the reference point and
time of observation between exposure and outcome, as shown in Fig. 6. The
previous example comparing fertile and infertile women with respect to their
prior exposure to IUDs and oral contraceptives is a case-control design. If
records were obtained on all women who were exposed to IUDs or oral
contraceptives, however, and records were searched to determine their rates
of subsequent infertility, this would be an example of a cohort study. A
cross-sectional study of this issue would involve surveying a sample of the
population at a point in time and determining, concurrently, their history of
infertility and of oral contraceptive or IUD use.
Clinical research designs in context

Although descriptive studies are at the bottom of the research hierarchy
(see Fig. 4), they have played an important role in development of
innovative infertility treatments. The first human birth from in vitro
fertilization (IVF) was essentially a case report [3]. Important case-report
series in the history of infertility have included reports on the use of
clomiphene citrate [4] and gonadotropins [5] to induce ovulation, the
Fig. 5. Overview of clinical research designs. (From Grimes DA, Schultz KF. An overview of
clinical research: the lay of the land. Lancet 2002;359:57–61; with permission.)
surgical reversal of tubal sterilization [6], the use of superovulation and

intrauterine insemination in the treatment of unexplained and male factor
infertility [7], and the use of intracytoplasmic sperm injection (ICSI) in the
treatment of male factor infertility [8]. Many of these developments created
such a paradigm shift (eg, ICSI) that randomized, controlled trials were not
necessary. Other techniques, such as laparoscopic resection and ablation of
endometriosis, were heralded as important advances in infertility treatment,
and became extremely widespread without the benefit of randomized clinical
trials. This technique is now mired in controversy because of conflicting
results of two randomized trials, one from Canada [9] (showing a benefit)
and one from Italy [10] (showing no benefit). Thus, physicians must balance
the quality of evidence as determined from studies using a variety of
research designs against the sensible approach to making decisions about
the application of such evidence to clinical practice. A parody of George
Fig. 6. Schematic diagram showing temporal direction of three study designs. (From Grimes
DA, Schultz KF. An overview of clinical research: the lay of the land. Lancet 2002;359:57–61;
with permission.)
Orwell’s Animal Farm, by Drife [11], reminds physicians that they should
not be too rigid in evaluating evidence from clinical research.
In the design of treatment studies in infertility, descriptive data are
accumulated on various treatments, which give rise to hypotheses that can
be tested using analytic study designs or randomized trials as described
previously. When there is found to be a statistical dependence between
factors in analytic studies, there is said to be an ‘‘association’’ between these
factors. For example, if a comparison of infertile patients and fertile control
subjects indicates a higher rate of past IUD use among the infertile patients,
one can say that IUDs are ‘‘associated’’ with infertility.
In interpreting such an association, the reader must consider if the
association is the result of chance, systematic error (selection bias), random
error, or confounding. Confounding and selection bias can be neutralized by
a randomized, controlled design but must be adjusted for statistically when
using an analytic design such as a case-control or cohort study. For
example, if an association is found between tubal infertility and IUD use, it
would be important to ascertain the number of sexual partners, as this may
influence a woman’s choice of contraceptive and her risk for tubal infertility.
Randomization of women to IUD and oral contraceptives groups would
neutralize this confounding factor, because one would expect the mean
number of sexual partners to be the same in both groups as result of the

randomization process.
For an association to be considered causal, there needs to be prospective
ascertainment of outcome after treatments are assigned. Also helpful in the
interpretation of causality would be factors such as the biologic credibility
of the association, its magnitude, the presence of a dose-response relation-
ship, and consistency of findings from various studies conducted by different
investigators in different locations.
Research design dictates statistical analysis

The research design dictates the type of statistical analysis needed to test
hypotheses about infertility treatment. In general, the most powerful research
design (ie, randomized clinical trial) leads to the simplest type of statistical
analysis (ie, v2 test of differences in proportions). More elaborate multivariate
methods are needed to adjust for confounding variables in analytic designs.
Statistical analysis
Statistics have been described as fiction in its most uninteresting form.
Although this depiction may reflect the attitude of many physicians, an
understanding of the basic principles of statistics is a necessary prerequisite
to an intelligent interpretation of the medical literature. The first important
principle is that of hypothesis testing.
Hypothesis testing
Clinical trials versus jury trials. To explain hypothesis testing in the context
of an infertility study, it may be helpful to illustrate by means of analogy. In
a courtroom trial, the defendant is either innocent or guilty. The jury must
reach a verdict based on the admissible evidence. The four possible
outcomes, shown in Table 1, are as follows: (1) the defendant may be
innocent and the jury may convict, (2) the defendant may be guilty and the
jury may convict, (3) the defendant may be innocent and the jury may
release him (finding him innocent or a hung jury), and (4) the defendant may
be guilty and the jury may release him.
Table 1
Jury trial outcomes
Defendant is
Jury decision Innocent Guilty
Convict Type I error Correct
Release Correct Type II error
If the jury releases an innocent man or convicts a guilty one, it has made
the right decision. But what if it convicts an innocent man or releases a guilty
one? One of the difficulties of developing a system of justice is dealing with
these two potential mistakes. If the rules are designed to avoid convicting
the innocent, the probability of releasing the guilty is increased. If the rules
are tightened to ensure that all those who are guilty are convicted, then the
number of innocent people convicted for crimes they did not commit will
increase. A decision must be made as to which type of error is more serious.
In the United States, the judicial system is designed to avoid the error
labeled ‘‘type I’’ in Table 1: finding an innocent person guilty. The basic
principle is that a defendant is presumed innocent until proven guilty
‘‘beyond a reasonable doubt.’’ To assign a verdict of ‘‘guilty,’’ all members
of the jury must agree that the state has provided evidence that strongly
contradicts the assumption of innocence.
Null hypotheses and P values. Statistical hypothesis testing operates on

a similar model. The null hypothesis (H0) corresponds to the assumption of
innocence until guilt is proven. If two treatments are compared, the null
hypothesis is that the two treatments have essentially the same effect. Unless
the data provide strong evidence that contradicts this assumption, it cannot
be dismissed. One crucial point about hypothesis testing is that the null
hypothesis is never ‘‘proven’’; researchers state that the available data do
not allow them to reject it. The probability value or P value that is associated
with statistical testing is a more precise way of expressing ‘‘reasonable
doubt.’’ If it is true that the two treatments are essentially equal, sample
data associated with a P value of 0.05 would occur only 5 of 100 times.
Researchers have an advantage over juries in that they can place a treatment
in double jeopardy; only in extreme circumstances should a treatment be
accepted or rejected from one trial.
One major difference between jury trials and infertility treatment trials is
that, in a jury trial, all of the evidence is directed toward making a decision
about one defendant, whereas in an infertility trial, decisions are made
about an entire population based on evidence gathered from a sample of
individuals. For example, before investing in equipment needed for laser-
assisted ICSI, physicians may wish to know whether pregnancy rates after
ICSI performed with the aid of a laser are higher than those with ICSI
performed manually. What physicians really want to know is whether this is
true for the entire population of women undergoing ICSI. Because there are
only limited numbers of patients to study in a given location, however,
researchers collect information on a sample of patients undergoing one
procedure or the other. The method of sampling is critical; ideally, patients
sampled from two infertility treatment groups should not differ in any
important respect other than the type of procedure performed. Underlying
the sampling method is the assumption that the pregnancy rate observed in
the laser-ICSI sample approximates the pregnancy rate in the entire
population of women treated in this manner. Researchers make the same

assumption about the pregnancy rate in the manual-ICSI group.
Reformulating these concepts in statistical language, researchers note
that the population is fixed, so the pregnancy rate, although unknown, is
a constant: it is called a population parameter. The pregnancy rate observed
in the sample is a random variable because it varies from sample to sample.
The sample pregnancy rate observed in this particular group of patients is
an estimate of the population pregnancy rate. As a random variable, it has
a certain probability distribution associated with it. Given estimates of
pregnancy rates in the two treated patient samples (laser and manual ICSI),
and given estimates of the associated probability distributions, it is then
possible to test the null hypothesis that there is no difference in pregnancy
rates between the two groups. This statistical test, which is representative of
virtually all statistical tests, is based on estimates of the probability that the
difference in the sample pregnancy rates observed between the two groups
reflects a true difference in the population rather than the particular
variability of the samples chosen.
Table 2 presents the possible outcomes of the test of the hypothesis that
the probability of pregnancy associated with laser ICSI and manual ICSI is
equal. When the null hypothesis is rejected, researchers claim that one
treatment is better than the other. The error labeled ‘‘type I’’ is considered
the more serious error—claiming that a treatment is a significant im-
provement, when, in reality, it is not. This is also known as an a error. The
error labeled type II occurs when researchers fail to reject the null
hypothesis (ie, researchers cannot claim that one treatment is significantly
better), when, in fact, one treatment is superior. This is a b error, and 1-b is
defined as the ‘‘power’’ of the test. In the current medical literature, b errors
probably occur frequently.
Sample size determination

When a study is conducted with a small sample size, it is difficult to
obtain a statistically significant result, even if the treatments differ. For this
reason, a sample size determination should precede the initiation of a study.
Sample size calculations can help decide whether it is worth attempting
a study with the number of patients available. Collaboration with other
researchers may be necessary to obtain an adequate number of patients.
Table 2
Infertility treatment trial outcomes
Treatments are
Null hypothesis Equal Not equal
Rejected Type I error Correct
Not rejected Correct Type II error
In statistical terminology, a small study lacks ‘‘power.’’ If one of the two

treatments actually is superior, this superiority may not be detected with
a small sample.
To estimate the sample size required for a study of pregnancy rates
comparing patients undergoing a new treatment with a control group, the
researcher must provide estimates of the following:
1. The level of type I error (a) allowable. The traditional value of a is 0.05.
2. The allowable level of type II error (b), or, alternatively, the required
‘‘power,’’ which equals 1-b. Note that power does not imply that the
observed difference between the proportions pregnant will equal the
population difference but only that a statistically significant result in
the right direction will be obtained. Suggested levels for power are 0.80
and 0.90.
3. An estimate of the proportion pregnant in the control group (p1).
4. A realistic guess at what the proportion pregnant might be in the
treatment group (p2). If the value of p2 is set unrealistically high, then
a nonsignificant result will not contribute new knowledge.
Once these preliminary decisions are made, the researcher can consult
tables, such as those shown in Fleiss [12], which give sample sizes for a range
of values of p1, p2, a, and b. (Note that these tables incorporate a continuity
correction.) The required sample sizes are often larger than might be
expected. For example, a might be set at 0.05, power at 0.90, and p1 (the
proportion pregnant with the standard treatment) at 0.25. If researchers
think that the new treatment may have a pregnancy rate of 0.35, then the
required sample size in each group (from the tables in Fleiss [12]) would be
478 patients. If the new treatment is expected to have a success rate of only
0.30, then 1753 patients would be required for each treatment group. This
example emphasizes that it is difficult to detect small, but perhaps clinically
important, differences between treatments.
Sample size calculations are estimates; they should not be used to decide
the exact number of patients to be included. Rather, the tables should be
entered with several possible values to determine what sort of a difference
can be detected with the number of patients available. Consulting sample
size tables before beginning a study may have the positive effect of
encouraging more collaborative trials. Not only are the size of the study and
the chance of reaching a statistically significant conclusion increased but the
results of a collaborative trial can more justifiably be generalized to other
geographic areas and other types of hospitals.
The randomized clinical trial

The gold standard for experimental evaluation of medical or surgical
infertility therapy is the randomized clinical trial. Using randomized trials
with sufficient statistical power, unambiguous evidence may be obtained

concerning the efficacy of therapeutic regimens. Most randomized clinical
trials of infertility treatment require several collaborating centers. This
is because although differences in pregnancy rates between infertility
treatments in the range of 10% to 15% may be clinically significant,
sample size requirements to detect such differences with adequate power at
the 5% level of significance requires recruitment of large numbers of
couples that typically exceed the number available at any one site.
Moreover, patients and their physicians are reluctant to enter into clinical
trials because of preconceived notions about the ‘‘best’’ treatment. In
addition, as clinical practice evolves across time, a novel treatment under
study may become accepted before the clinical trial is completed, thus
leaving fewer patients eligible for enrollment who have not been exposed
to the treatment under study. Necessary, but sometimes complex,
oversight functions performed by independent data safety and monitor-
ing boards and by independent data coordinating centers add to the
complexity of clinical trials. These functions are extremely important to
ensure the safety and statistical validity of the trial, but add cost,
complexity, and time.
The Cochran Collaboration (www.cochrane.org) contains a listing of
randomized clinical trials in the infertility literature. Notable among these
are the following trials: IVF for unexplained subfertility, intrauterine versus
cervical insemination of donor sperm for subfertility, and oral versus
injectable ovulation-induction agents for unexplained subfertility.
Randomized clinical trials are not necessarily definitive, especially when
small in scale or duration. An example of this is the contrary findings of the
previously described two randomized trials on laparoscopic treatment of
endometriosis in infertile women [9,10].
Special features of infertility data

Measurements of outcome
The obvious measurement of outcome in infertility investigation is
pregnancy—yes or no. There are, however, variations on this theme. First,
physicians must decide whether the outcome of interest is conception,
clinical pregnancy, or term delivery. They also must pay close attention to
the distribution of outcomes among pregnancies that are achieved, especi-
ally the proportion that are ectopic and the proportion resulting in multiple
pregnancy.
Another important issue is the duration of follow-up against which the
outcome measure is defined. This problem, illustrated by the myomectomy
example discussed previously, can be handled by performing a life-table
analysis, or by requiring that all patients have a specified duration of follow-
up (eg, 2 years) to be included in the analysis.
Dependent versus independent variables

In statistical terms, outcome is the dependent variable. It is variation in
this dependent variable that researchers try to explain with one or more
independent or explanatory variables. In a study of pregnancy success after
tubal reanastomosis, for example, researchers might wish to explain the
probability of pregnancy (dependent or outcome variable) on the basis
of length of tube, type of tubal ligation, luminal discrepancy, and age
(independent or explanatory variables). Although it may seem obvious, the
distinction between dependent and independent variables is critical, and
establishing explicit definitions in advance of the planned comparison
provides a logical framework for the analysis.
Dichotomous versus continuous variables

In general, the dependent variables in infertility investigations tend to be
dichotomous, or binary (eg, conception versus no conception, fertilization
versus no fertilization, or ovulation versus no ovulation). Many of the
statistical methods available were developed for continuous dependent
variables, however. Blood pressure, serum cholesterol concentration,
temperature, tensile strength of suture material, birth weight, and blood
loss at surgery are continuous variables that commonly serve as measure-
ments of outcome in medical investigations. Standard statistical techniques,
such as analysis of variance and multiple linear regression, can be used
appropriately when the dependent variable is continuous. When the depen-
dent variable is dichotomous, however, as in most infertility investigations,
other techniques should be used, such as logistic regression.
Impact of nonuniform follow-up after treatment

A fundamental problem in evaluating the outcome of infertility therapy is
incomplete or variable follow-up. It is often difficult, for reasons unrelated
to the study, to maintain contact with patients over a prolonged period.
Furthermore, because patients receive therapy at different times, the
duration of follow-up varies among those who are successfully observed
until completion of the study.
For these reasons, the pregnancy rate commonly reported in infertility
research—defined as the number of patients who conceive divided by the
number of patients treated—is a poor measurement of treatment success.
The reported rate may underestimate the true success of therapy because an
unknown fraction of nonpregnant patients who are lost to follow-up early in
the study, or who enter the study at a point close to its completion, become
pregnant at a later date. Moreover, because some infertility centers have
more successful patient follow-up than others, pregnancy rates after
a particular treatment modality reported by different centers cannot be
compared reliably. Similarly, if there is variability in the follow-up of patients
who differ in severity of disease or other characteristics, a comparison of
pregnancy rates according to these patient characteristics is also unreliable.
Summary
The standard for reaching a verdict in civil trials is ‘‘the preponderance of
the evidence.’’ This is a valid standard to apply to evaluating the medical
literature as well. Every published report should be given weight based on
physicians’ judgment of its reliability. Larger-scale studies should be
weighted more heavily than smaller-scale studies, randomized trials more
heavily than observation studies, rigorously designed trials more heavily
than studies that may be biased. If there seems to be a relationship between
a factor and an outcome, this does not necessarily imply that the factor
caused the outcome. The association could be a result of chance variation
between individuals. Statistical testing allows researchers to exclude chance
as a likely cause of the relationship, but this is the only explanation ruled out
by a significance test. The relationship could be a result of bias: bias in the
selection of individuals for the study, bias in measurement of the factor
or the outcome, or bias in differential loss to follow-up. A thorough analysis
of the data is necessary to identify and exclude other possible explana-
tions of the association.
A government agency dealing with environmental regulations experi-
mented with replacing administrative law judges with scientists. It was
believed that scientists were better qualified to make the necessary technical
evaluations. The experiment was not considered successful because, as one
observer remarked, ‘‘Judges are used to having to reach a verdict within
a short period of time based on whatever evidence is presented—scientists
just can’t seem to make decisions.’’ This illustrates a similar difference
between the role of the researcher and the role of the physician. The
physician must decide the best treatment for each patient based only on
whatever evidence is available. There is little question, however, what the
patient would decide if allowed to choose between receiving the standard
therapy today or waiting 5 years until conclusive scientific evidence has been
obtained about whether an alternative treatment is better. Few patients
would choose to wait. Yet the decisions a physician makes today will be
criticized in 5 years, especially by those who never have had to make similar
decisions themselves. Some decisions will turn out to be wrong when
additional data are available, but physicians must make choices based on
the best data currently available. The choice of medicine as a profession
implies the acceptance of a life sentence to jury duty: the evidence will never
stop accumulating, and the verdict must be continually reevaluated.
References
[1] Guzick DS, Sullivan MW, Adamson GD, et al. Efficacy of treatment for unexplained
infertility. Fertil Steril 1998;70:207.
[2] Grimes DA, Schultz KF. An overview of clinical research: the lay of the land. Lancet
2002;359:57–61.
[3] Steptoe PC, Edwards RG. Birth after re-implantation of a human embryo. Lancet
1978;2:366.
[4] Jones GS, Moraes-Ruehsen MD. Clomiphene citrate for improvement for ovarian
function. Am J Obstet Gynecol 1967;99:814.
[5] Spadoni LR, Cox DW, Smith DC. Use of human menopausal gonadotropin for the
induction of ovulation. Am J Obstet Gynecol 1974;120:988.
[6] Henderson SR. The reversibility of female sterilization with use of microsurgery: a report
on 102 patients with more than one year follow up. Am J Obstet Gynecol 1984;149:57.
[7] Hurst BS, Tjaden BL, Kimball A, Schlaff WD, Damewood MD, Rock JA. Superovulation
with or without intrauterine insemination for the treatment of infertility. J Reprod Med
1992;37:237–41.
[8] Van Steirteghem AC, Nagy Z, Joris H, et al. High fertilization and implantation rates after
intracytoplasmic sperm injection. Hum Reprod 1993;8:1061.
[9] Marcoux S, Maheux R, Berube S. and the Canadian Collaborative Group on
Endometriosis. Laparoscopic surgery in infertile women with minimal or mild endome-
triosis. N Engl J Med 1997;337:217–22.
[10] Gruppo Italiano per lo Studio dell’Endometriosi. Ablation of lesions or no treatment in
minimal-mild endometriosis in infertile women: a randomized trial. Hum Reprod
1999;14:1332–4.
[11] Drife JO. Evidence farm. BMJ 1995;311:1375.
[12] Fleiss JL. Statistical methods for rates and proportions. New York: John Wiley & Sons;
1981.

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Endocrinol Metab Clin N Am

Mechanisms of infertility: does diagnosis

Sarah L. Berga, MD,

Infertility care logically involves a ﬁrm grounding in reproductive biol-

about underlying pathogenetic mechanisms, the greater should be our abil-

by considering the therapeutic implications of what is known about the

Genetic causes of human infertility

Infertility is typically deﬁned as the absence of pregnancy after 1 year of un-

endocrine and gamete function. Gamete obstruction (compartment IV) of

Compartment I: the hypothalamus

X-linked recessive genes: KAL1 and NROB1 genes

KAL1 expression patterns correlate well with the following associated

Autosomal genes: LEP and LEPR genes

or hypercortisolemia [20,21]. Leptin receptor (LEPR) mutations associated

Compartment II: the pituitary

Gonadotropin genes: FSHB and LHB

PROP1 mutations cause a phenotype of combined pituitary hormone

Homeobox genes: HESX1 and LHX3

Compartment III: the gonad

X-chromosome: autosome translocations

potentially cause ovarian failure by a position eﬀect, the deletion of ovarian

Single-gene disorders of the X chromosome

Chromosomal disorders in men, including in those with 47,XXY and

Single-gene disorders on the Y chromosome

Several of the spermatogenesis genes are multicopy, and several are

1 million/cm3. AZFc deletions were identiﬁed in 17% of men with idiopathic

occur. Serum levels of both basal and hCG-stimulated testosterone are

Steroid enzyme genes (STAR, CYP17, HSD17B3, and SRD5A2)

demonstration of AIRE mutations represents the ﬁrst description of a single-

WT1 and SOX9 genes

AMH and AMHR2 genes

Compartment IV: the outﬂow tract

androgen insensitivity syndrome causes undermasculinization and varying

Impaired fertility caused by endocrine

The inability to conceive is often a distressing experience for couples.

E-mail address: bkalro@mail.magee.edu

dysfunction in an infertile population revealed that 5.1% had abnormal

With anovulatory cycles, LH and FSH may also be reduced. Hypothyroid-

outcome. Antibodies against thyroglobulin (whose primary function is

anterior pituitary gland and this eﬀect can be inhibited by bromocriptine

women successfully restored menstruation [88] and fertility, and signiﬁcantly

teratogenic eﬀects in embryo cultures has been ascribed to high concen-

Congenital adrenal hyperplasia

adrenal cortex (Addison’s disease, primary adrenal insuﬃciency). Primary

Hypercortisolism and adrenal hyperandrogenemia suppress gonadotropin

[87] Plockinger U, Dienemann D, Quabbe HJ. Gastrointestinal side eﬀects of octreotide

[155] Parra A, Cruz-Krohn J. Intercurrent Cushing’s syndrome and pregnancy. Am J Med

Hypogonadism is a condition deﬁned by an abnormal decrease in the

circumstances, the cause can be idiopathic or functional. Functional causes

The hypothalamic–pituitary–gonadal axis

The GnRH pulse generator is modulated by many factors, including

Causes of hypogonadotropic hypogonadism

Box 1. Central causes of hypogonadism

primary or secondary. Primary amenorrhea refers to absence of menarche

demonstrate relative hypoestrogenism and normal or low serum gonado-

exercise stress hypothesis, however, theorizes that the stress generated by

nutritional deprivation, also have been reported in women with anorexia

Oral contraceptives and postpill amenorrhea