Letters to Editor

Hyperprolactinemia with High-dose hook effect in

normal serum prolactin: prolactin macroadenomas:
“Hook effect” a concern in A diagnostic concern
laboratory medicine aspect Sir,
Sir,
I read the interesting case report by Agarwal et al., with a
great interest.[1] There are some additional discussions on this
case. It is no doubt that “all gynecologists should consider
galactorrhea even in women with normal serum prolactin.”[2]
The interpretation of the serum prolactin level needs careful
consideration. In laboratory medicine, the false negative in
prolactin level determination can be expected. A high-dose
hook effect in the PRL assay that leads to falsely low serum
prolactin level is mentioned in some literatures.[3-6] The hook
effect should be considered in any case with a large pituitary
mass.[4] A pre-dilution preparation can help in solving this
specific false negative problem.[3-6]
Viroj Wiwanitkit
Wiwanitkit House, Bangkhae, Bangkok - 10160, Thailand
Address for correspondence:
Prof. Viroj Wiwanitkit,
Wiwanitkit House, Bangkhae, Bangkok - 10160, Thailand.
E-mail: wviroj@yahoo.com
REFERENCES
1. Agarwal M, Das A, Singh SA. Hyperprolactinemia with normal serum
prolactin: Its clinical significance. J Hum Reprod Sci 2010;3:111-2.
2. Nahid E. Fertility Rate with bromocriptine in infertile women with
galactorrhoea and normal prolactin level. Int Congr Ser 2004;1271:22-5.
3. Schöfl C, Schöfl-Siegert B, Karstens JH, Bremer M, Lenarz T, Cuarezma
JS, et al. Falsely low serum prolactin in two cases of invasive
macroprolactinoma. Pituitary 2002;5:261-5.
4. Al Sifri SN, Raef H. The hook effect in prolactin immunoassays. Saudi
Med J 2004;25:656-9.
5. Frieze TW, Mong DP, Koops MK. "Hook effect" in prolactinomas: Case
report and review of literature. Endocr Pract 2002;8:296-303.
6. St-Jean E, Blain F, Comtois R. High prolactin levels may be missed by
immunoradiometric assay in patients with macroprolactinomas. Clin
Endocrinol (Oxf) 1996;44:305-9.
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DOI:
10.4103/0974-1208.74163
160 Journal of Human Reproductive Sciences / Volume 3 / Issue 3 / Sep - Dec 2010
I have gone through the letter to the editor regarding
laboratory concern for the high-dose hook effect in prolactin
assays.The intensity of an antigen–antibody interaction
depends primarily on the relative proportion of the antigen
and the antibody. A relative excess of either will impair
adequate immune complex formation. This is called the
“high-dose hook effect” or the “prozone phenomenon.”
Extremely high levels of prolactin (PRL) can interfere with
the assay and produce low readings. This high-dose hook
effect may occur because there is not enough antibody
to bind to both ends of all antigenic (prolactin) peptides.
Most of the PRL is now complexed to a single antibody.
Only the few remaining PRL peptides are “sandwiched”
and therefore detectable. This results in a falsely low PRL
value. Hence, as the antigen concentrations increase, there
is a proportional increase in assay titers up to a certain
level. Antigen concentrations above this threshold level
would “hook” down the assay values resulting in very
low measurements.[1,2] In addition, high-antigen titers can
directly dissolve the antigen–antibody complex.[1] In order
to avoid the high-dose hook effect, the serum PRL should
be estimated in appropriate dilution in all patients with
large pituitary tumors. The high-dose PRL hook effect is
observed particularly in patients with very large tumors.
The immunoradiometric PRL assay must be performed with
serum dilution in order to overcome the high-dose PRL hook
effect in all new patients with pituitary macroadenomas
who may have a prolactinoma.[3] Other suggested remedies
for the hook effect include the use of an excess antibody,
a cumbersome two-step procedure, and the use of a
computer to predict the head to dilute serum samples.[1]
Though repeatedly demonstrated in other immunoassays,
the high-dose hook effect has only occasionally been observed
in chemiluminescence assay systems for PRL estimation.[1]
Whatever the author has cited with references is no
doubt of laboratory concern in prolactin assays, but
has little relevance to our case report. Our case is not a
patient of pituitary prolactinoma with moderate to severe
hyperprolactinemia, where the high-dose hook effect of
prolactin is of more significance. Moreover, our laboratory
uses chemiluminescence assays for prolactin estimation
which rarely shows fallacies due to the high-dose effect.
 Letters to Editor

Manika Agarwal, Ananya Das, A Santa Singh
Department of Obstetrics & Gynaecology,
North Eastern Indira Gandhi Regional Institute of
Health & Medical Sciences (NEIGRIHMS),
Mawdiangdiang, Shillong, Meghalaya, India
Address for correspondence:
Dr. Manika Agarwal,
Department of Obstetrics & Gynaecology,
North Eastern Indira Gandhi Regional Institute of
Health & Medical Sciences (NEIGRIHMS),
Mawdiangdiang, Shillong – 793 018, Meghalaya, India.
E-mail: drmanika89@yahoo.com
REFERENCES
1. Unnikrishnan AG, Rajaratnam S, Seshadri MS, Kanagasapabathy AS,
Stephen DC. The ‘hook effect’ on serum prolactin estimation in a
patient with macroprolactinoma. Neurol India 2001;49:78-80.
2. Yener S, Comlekci A, Arda N, Men S, Yesil S. Misdiagnosis due to the
hook effect in prolactin assay. Med Princ Pract 2008;17:429-31.
3. St-Jean E, Blain F, Comtois R. High prolactin levels may be missed by
immunoradiometric assay in patients with macroprolactinomas. Clin
Endocrinol (Oxf) 1996;44:305-9.
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There are some previous reports on using this specific test
for this prediction purpose. Here, the author performed a
summative analysis to assess the value of human chorionic
gonadotrophin (hCG). The author performed a retrospective
literature search on this specific topic to find published
papers in PubMed and Scopus. The derived 3 publications
on 810 cases are extracted for data on diagnostic properties
and summative assessment was done.[1-3] Indeed, there are
two other publications on this area that are excluded. One is
due to the different period of hCG measurement from other
published papers (on the second week)[4] and the other is due to
lack of English text.[5] Based on this assessment, the summative
sensitivity and specificity for prediction of viable pregnancy
are equal to 85.7 and 72.4%, respectively. For differentiation
between single and multiple pregnancies in viable group, the
summative sensitivity and specificity for prediction of viable
pregnancy are equal to 84.3 and 79.2%. Based on this appraisal,
it can be seen that hCG measurement gives only fair diagnostic
property for determining the outcome of early pregnancy
achieved by assisted reproductive technology.
Viroj Wiwanitkit
Wiwanitkit House, Bangkhae,
Bangkok - 10160, Thailand,

Address for correspondence:

DOI: Prof. Viroj Wiwanitkit,
Wiwanitkit House, Bangkhae,
10.4103/0974-1208.74164
Bangkok 10160, Thailand
E-mail: wviroj@yahoo.com

REFERENCES

Predictive value of 1. Sereepapong W, Suwajanakorn S, Pruksananonda K, Boonkasemsanti

W, Virutamasen P. Predictive value of human chorionic gonadotrophin
human chorionic in the outcome of early pregnancy achieved by assisted reproductive
technology. J Med Assoc Thai 2002;85:S447-54.

gonadotrophin in 2. Schmidt LL, Asch RH, Frederick JL, Rojas FJ, Stone SC, Balmaceda JP.
The predictive value of a single beta human chorionic gonadotrophin
in pregnancies achieved by assisted reproductive technology. Fertil
the outcome of early 3.
Steril 1994;62:333-8.
Heiner JS, Kerin JF, Schmidt LL, Wu TC. Can a single, early quantitative

pregnancy achieved by human chorionic gonadotrophin measurement in an in vitro

fertilization-gamete intrafallopian transfer program predict pregnancy
outcome? Fertil Steril 1992;58:373-7.

assisted reproductive 4. Legro RS, Paulson RJ, Lobo RA, Sauer MV. Association of early beta-human
chorionic gonadotrophin values with pregnancy wastage and multiple

technology: A summative
implantation in a donor oocyte programme. Hum Reprod 1995;10:3293-6.
5. Hauzman E, Murber A, Fancsovits P, Papp Z, Urbancsek J. Use of
biochemical markers to predict the outcome of pregnancies conceived

assessment by in vitro fertilization. Orv Hetil 2006;147:1409-20.

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Sir, Website:

Prediction of the early pregnancy achieved by assisted www.jhrsonline.org

reproductive technology is an important practice in the

field. There are several ways to predict. Using of blood DOI:
tests is an important approach. The use of human chorionic 10.4103/0974-1208.74165
gonadotrophin (hCG) level determination is a test of interest.

Journal of Human Reproductive Sciences / Volume 3 / Issue 3 / Sep - Dec 2010 161