Clinical use of aromatase inhibitors (AI) in premenopausal women

Aromatase inhibitors (AI) block the last enzymatic step of estrogen production, the aromatization of the A-cycle of aromatizable androgens and particularly, androstenedione (Δ4) and testosterone (T). Molecules designed for interfering with aromatase activity have existed for many years. Yet the activity of products of the aminogluthetimide era was unspecific and these substances carried too many side effects for being used clinically. Newer third generation AIs, however, are highly specific and essentially devoid of side effects. These molecules have recently been approved for treating breast cancer in postmenopausal women either, in advanced forms or, as part of adjuvant therapy.

In women whose ovaries are active, a temporary inhibition of E2 production will raise gonadotropins and in turn, stimulate follicular growth. In cancer patients, this property precludes the use of AIs in women whose ovaries are still active, unless gonadotropins are blocked. But in infertility patients, this property of AIs has been put to play for inducing ovulation. AIs have been used both in women who do not ovulate but whose hypothalamo-pituitary-gonadal (HPG) axis is active (oligo-anovulators of PCOD type) and those who ovulate regularly but in whom multiple ovulation is sought for treating unexplained infertility or as part of IVF. Like clomiphene citrate (CC), AIs are not usable in women whose gonadotropins are suppressed, as in the case of hypothalamic amenorrhea.

The sum of data available on the use of AI for inducing ovulation remains however meager to this date and is mainly constituted of pilot and non-randomized trials. Yet mounting evidence tends to support AIs’ advantages over CC for induction of ovulation. Hence, we think that the likelihood that these drugs will play a key role in induction of ovulation in the future is high. AIs appear particularly interesting for treating unexplained infertility because AI-FSH/hMG regimens are lighter than FSH-only regimens while retaining the high pregnancy rates of these latter treatments.     

Anti-Mullerian hormone levels decline under hormonal suppression: a prospective analysis in fertile women after delivery

Aromatase inhibitors have been introduced as a new treatment modality that could challenge clomiphene citrate as an ovulation induction regiment in patients with PCOS. Although several randomized trials have been conducted regarding their use as ovulation induction agents, only few trials are available regarding their efficacy in IVF stimulated cycles. Current available evidence support that letrozole may have a promising role in stimulated IVF cycles, either when administered during the follicular phase for ovarian stimulation. Especially for women with poor ovarian response, letrozole appears to have the potential to increase clinical pregnancy rates when combined with gonadotropins, whereas at the same time reduces the total gonadotropin dose required for ovarian stimulation. However, given that in all of the trials letrozole has been administered in GnRH antagonist cycles, it is intriguing to test in the future how it may perform when used in GnRH agonist cycles. Finally administration of letrozole during luteal phase in IVF cycles offers another treatment modality for patients at high risk for OHSS taking into account that it drastically reduces estradiol levels     

Iodine requirements and the risks and benefits of correcting iodine deficiency in populations.

Iodine deficiency has multiple adverse effects on growth and development due to inadequate thyroid hormone production that are termed the iodine deficiency disorders (IDD). IDD remains the most common cause of preventable mental impairment worldwide. IDD assessment methods include urinary iodine concentration, goiter, thyroglobulin and newborn thyrotropin. In nearly all iodine-deficient countries, the best strategy to control IDD is salt iodization, one of the most cost-effective ways to contribute to economic and social development. When salt iodization is not possible, iodine supplements can be targeted to vulnerable groups. Introduction of iodized salt to regions of chronic IDD may transiently increase the incidence of thyroid disorders, and programs should include monitoring for both iodine deficiency and excess. Although more data on the epidemiology of thyroid disorders caused by differences in iodine intake are needed, overall, the relatively small risks of iodine excess are far outweighed by the substantial risks of iodine deficiency.     

Plasminogen activator in the rat ovary. Production and gonadotropin regulation of the enzyme in granulosa and thecal cells

The production of plasminogen activator by ovarian granulosa cells has been previously reported to be temporally correlated with ovulation in the rat and to be under hormonal control of gonadotropins. We have examined the type of plasminogen activator produced by granulosa cells and also investigated other ovarian cell types for synthesis of this enzyme. Using antibodies specific for tissue-type or urokinase-type plasminogen activator, we have found that granulosa cells produce exclusively the tissue-type enzyme. However, in cultures of whole follicles isolated from the ovary, there is primarily synthesis of urokinase-type plasminogen activator. Examination of other isolated ovarian cell types has demonstrated that thecal cells secrete the urokinase-type plasminogen activator and that the production of this enzyme is also regulated by gonadotropins and temporally correlated with ovulation. These results suggest that ovulation requires both types of plasminogen activator and that the neighboring granulosa and thecal cells cooperate to ensure rupture of the follicle wall and unimpeded passage of the ovum into the oviduct.     

Anti-TNF therapies in the management of acute and chronic uveitis

Patients with anterior uveitis may be treated with topical therapy alone but patients with posterior uveitis and those with sight threatening complications of anterior uveitis usually require systemic treatment especially if the disease is bilateral. The mainstay of treatment is corticosteroids and additional immunosuppressive agents such as cyclosporin and mycophenolate are used when necessary. There remains a significant cohort of patients in whom this therapy is either not tolerated or is ineffective. The use of the anti-tumour necrosis factor (TNF) antibodies has been very successful in controlling other immune-mediated disorders such as rheumatoid arthritis and has subsequently been extended to use in other arthritidies and other disorders such as psoriasis and Crohn's disease. TNF is known to play a key role in ocular inflammation as shown by animal studies and its detection in the ocular fluids of inflamed eyes in man. In some disorders all types of anti-TNF antibodies have similar efficacy but that does not appear to be the case with uveitis where infliximab is at present looking to be more effective than etanercept. The data on the use of anti-TNF drugs in uveitis is presented together with new data on its role as a steroid sparing agent.     

SUBCLINICAL HYPOTHYROIDISM—Recognition and Treatment

Often patients in whom there is little to suggest myxedema or cretinism have subclinical hypothyroidism. Once the condition is suspected, it can be diagnosed by determination of protein-bound iodine and, if the PBI is low, by response to therapy with thyroid hormone.Patients in the following categories should have protein-bound iodine determination: Those having (1) a history of previous treatment for hypothyroidism; (2) suboptimal development in children; (3) ovarian dysfunction, infertility, habitual abortion or unusual menopausal disorders; (4) symptoms of malaise and debility, such as undue fatigue, somnolence, mental asthenia and anxiety; (5) unexplained anemia; (6) colloid goiter, adenomatous goiter and cancer of the thyroid gland.If hypothyroidism is diagnosed, administration of thyroid hormone in increasing amounts, as determined by serial serum PBI tests, should be carried out indefinitely. Instruction of the patient is essential.     

Ovulatory patterns in the squirrel monkey (Saimiri sciureus)

The results of induced ovulation regimens on 95 squirrel monkeys (Saimiri sciureus) over a 7-year period are described. A distinct seasonal pattern of response was observed in the temperate climate.The pretreatment of squirrel monkeys with progesterone slightly suppresses the total number of follicles showing growth in response to the FSH but results in a significantly higher number of animals showing at least one ovulation.No significant differences were noted for ovarian response based on the length of time the animal had been in captivity.The effectiveness of the ovulation induction regimen over 20 or more consecutive courses of treatment was not significantly reduced, suggesting that antibodies were not formed against the gonadotropins.     

Peripheral administration of metastin induces marked gonadotropin release and ovulation in the rat

Metastin is a novel peptide that has been isolated from the human placenta as the cognate ligand of the G-protein-coupled receptor OT7T175 (or GPR54). However, its physiological functions have not yet been fully investigated. In the present study, we show that subcutaneous administration of metastin increased the plasma levels of gonadotropins (follicle-stimulating hormone and luteinizing hormone) and induced ovulation in prepubertal female rats that had been pretreated with pregnant mare serum gonadotropin to induce follicle maturation. Furthermore, metastin administration drastically increased the plasma levels of gonadotropins in male rats. This action was abolished by pretreatment with a GnRH antagonist, and was accompanied by induction of c-Fos immunoreactivity in GnRH neurons. These results suggest that s.c. administered metastin induces the release of gonadotropin via activation of the hypothalamic GnRH neurons.     

Neurotransmitter, opiodergic system, steroid-hormone interaction and involvement in the replacement therapy of sexual disorders

Dopamine (DA) and serotonin (5-HT) are the neurotransmitters most directly involved in sexual activity. DA plays a stimulatory role while 5-HT has an inhibitory effect. The two monoaminergic systems modulate the secretion of many hormones (GnRH, LH, testosterone, prolactin and endorphins) involved in sexual functional capacity. Furthermore, hormones influence synthesis and storage of brain neurotransmitters. Impotence can often be associated to clinical depression and altered neurotransmitter function. Moreover, stress represents an unbalance between various neurotransmitter systems and can induce impotence especially when disorders of the endorphinic system are present. Replacement therapy is based upon the understanding of these basic concepts. Impotence due to an underlying depressive illness must be treated with dopaminergic antidepressant drugs; while in stressful conditions a good response to the naloxone test is the preliminary criterion to subsequent naltrexone treatment. When a hormonal deficiency has been proved, the hormone replacement therapy is of course highly effective (gonadotropins in hypogonadotropic syndromes, testosterone in aging, etc.). Finally, idiopathic impotence could be treated by DA agonist and/or 5-HT antagonist drugs either alone or better yet in association with psychotherapy.     

Plasma atrial natriuretic peptide in states of altered thyroid function

To examine a possible role of atrial natriuretic peptide (ANP) in water and electrolyte disturbances associated with thyroid disorders, plasma ANP levels were studied in patients with hyper- and hypothyroidism. In 5 of the 21 hyperthyroid patients, including two patients with atrial fibrillation and two patients with mild cardiomegaly, the plasma ANP concentration was increased when compared to normal subjects. After treatment with methimazole or propylthiouracil, the plasma ANP concentration fell to normal in 4 patients, while it remained high in one patient who had persistent atrial fibrillation. No significant correlation was found between plasma ANP and the heart rate in untreated hyperthyroid patients. Plasma ANP was within the normal range in all 8 patients with hypothyroidism. During treatment with T4, the plasma ANP concentration increased in 6 of the 7 patients. Chest X-ray films and ultrasonic echocardiography demonstrated pericardial effusion in 4 of these patients before therapy. A weak but significant correlation was found between the plasma ANP and T4 concentration, and between plasma ANP and free T4 in hyper- and hypothyroid patients before and after treatment. These results indicate that abnormalities in ANP dynamics in thyroid disorders may probably be caused by hemodynamic changes resulting from a thyroid hormone excess or deficiency.     

Interferon-induced thyroiditis during treatment of chronic hepatitis C

Thyroid function disorders affect between 5% and 15% of patients treated with IFNα and RBV for chronic hepatitis C. Women and patients with thyroid peroxidase antibodies (TPOAb) found before the treatment are at risk of developing the disorders (46.1% vs. 5.4%). The spectrum of IFNα-induced thyroiditis (IIT) includes two groups. Disorders with an autoimmune background are: presence of thyroid autoantibodies without clinical disease, Hashimoto's disease and Graves' disease. The second group comprises diseases caused by the direct toxic effect of IFNα on the thyroid gland, i.e. destructive thyroiditis and non-autoimmune hypothyroidism. Thyroid diseases are not an absolute contraindication for IFNα and RBV therapy. In patients diagnosed with thyroid dysfunction, before the antiviral therapy it is necessary to achieve euthyreosis. Thyroid function disorders may occur at any moment of the therapy. The earliest have been observed in the 4th week of treatment, and the latest 12 months after its termination. During the therapy, in order to diagnose IIT early, it is recommended to determine TSH level every 2-3 months depending on the presence of TPOAb before the treatment. The diagnosis and treatment of thyroid function disorders should be conducted in co-operation with an endocrinologist.     

Hormonal effects of zinc on growth in children

Zinc deficiency impairs the metabolism of thyroid hormones, androgens, and above all growth hormones. In view of their important role in growth, it is not surprising to find growth disorders associated with zinc deficiency. Stunted growth linked to zinc deficiency is found during gestation, and also in the newborn and children up to adolescence. Depending on the country, 5–30% of children suffer from moderate zinc deficiency, responsible for small-for-age height. Zinc supplementation has proven effective in many studies, mainly in children where zinc deficiency has first been found. Finally, zinc supplementation makes it possible in certain cases to overcome resistance to growth hormone treatment.     

碘与甲状腺疾病

碘是人体必需的微量元素,是合成甲状腺激素（thyroid hormone,TH）的主要原料。人体内的碘主要从饮水及食物中获取。碘的摄入缺乏或过量,不仅对TH的合成及分泌有至关重要的影响,而且与甲状腺形态及多种甲状腺疾病的发生、发展及转归密切相关。加碘盐的推广有效预防了碘缺乏可能引起的相关疾病;而碘过量导致的甲状腺疾病谱和发病率的急剧变化,也引起各界高度重视。流行病学调查表明,碘的摄入量与甲状腺功能亢进、自身免疫性甲状腺炎、甲状腺功能减退、甲状腺肿大和甲状腺癌等疾病的发病率密切相关。针对碘的相关生物学问题,对近年来的基础研究和人群研究进行综述,希望借此抛砖引玉,引起相关部门的重视,提高人民群众对碘营养的科学认识水平。     

Induction and synchronization of estrus in dogs

Indications for estrus induction in the bitch include missed breeding opportunities or conception failure, the treatment of primary or secondary anestrus and synchronization of ovulation for embryo transfer programs. Reported methods for canine estrus induction include the use of synthetic estrogens (diethylstilbesterol), dopamine agonists (bromocryptine and cabergoline), GnRH agonists (lutrelin, buserelin, fertirelin, deslorelin, and leuprolide) and exogenous gonadotropins (luteinizing hormone, follicle stimulating hormone, human chorionic gonadotropin, pregnant mare serum gonadotropin, and human menopausal gonadotropin). These methods vary widely in efficacy of inducing estrus, as well as in the fertility of the induced estrus. The applicability of some of these methods for clinical practice is questionable. This review will summarize published reports on estrus induction and synchronization in bitches and summarize preliminary results using a long-acting injectable preparation of deslorelin.     

Comparison of the effects of gonadotropic preparations of the carp and stellate sturgeon pituitaries on in vivo and in vitro oocyte maturation in the Siberian sturgeon Acipenser baeri brandt

Injections of 2.5 mg/kg of stellate sturgeon (Acipenser stellatus Pall.) pituitary extract and 5 mg/kg of carp (Cyprinus carpio L.) pituitary extract in Siberian sturgeon (Acipenser baeri Brandt) females did not reveal significant differences in the effects of these preparations. There were no differences in the percentage of females that responded by ovulation, duration of the period from injection to ovulation, rate of ovulation, or quality of mature eggs as estimated by the percentage of fertilization or percentage of normal embryos at the small yolk plug stage. Thus, an insufficient efficiency in the artificial reproduction of the Siberian sturgeon grown in captivity is not related to the use of the carp pituitary preparation as a stimulus. Estimation of the ratio of specific activities of the pituitary extracts and purified gonadotropins of the stellate sturgeon and carp by in vitro oocyte maturation has shown that it varies within wide limits as a function of the medium composition and physiological state of follicles. Hence, the ratio of activities of the gonadotropins of different species as determined by in vitro maturation of sturgeon oocytes may markedly differ from that upon injection of these preparations in breeders.     

Prevention of multiple pregnancy during ovulation induction.

Gonadotrophin ovulation induction is currently used for a heterogeneous group of ovulation disorders and unexplained infertility. In the United States it is reported that multiple pregnancy rates of greater than 30% occur as a result of ovulation induction, most commonly after controlled ovarian hyperstimulation and intrauterine insemination. Treatment strategies to reduce the incidence of multiple pregnancies on ovulation induction programs can be targeted to reducing multiple follicular development and subsequent ovulation by a more aggressive cancellation policy, follicle reduction by fine needle aspiration or conversion to IVF; or dealing with the problem of multiple gestation after it has occurred (i.e., multifetal pregnancy reduction). The procedures and abilities exist to resolve this problem. What is needed are appropriate treatment guidelines and well constructed trials to demonstrate that higher order multiple pregnancies can be substantially reduced and/or eliminated without compromising a couple's chances to conceive.     

Ovulation induction with gonadotropins causes increased sister chromatid exchanges

Gonadotropins are widely accepted agents for ovulation induction in infertile women. On the other hand, several authors discuss the possible effect of gonadotropins on the developmental mechanism of ovarian cancer. SCE is a method of genotoxicity investigation and it is an excellent parameter to monitor the DNA damage and repair. There are numbers of studies showing the relationship between endogenous or exogenous hormones and SCEs. The aim of this study was to investigate with SCE techniques the effects of long-term (6 months) use of gonadotropins on DNA as we couldn't find any other study on the effect of long term use. We found increased sister chromatid exchange rates in a study group as compared to a control group. This may be one of the causes of increased ovarian cancer risk in infertile population.     

The role of aromatase inhibitors in ameliorating deleterious effects of ovarian stimulation on outcome of infertility treatment

Clinical utilization of ovulation stimulation to facilitate the ability of a couple to conceive has not only provided a valuable therapeutic approach, but has also yielded extensive information on the physiology of ovarian follicular recruitment, endometrial receptivity and early embryo competency. One of the consequences of the use of fertility enhancing agents for ovarian stimulation has been the creation of a hyperestrogenic state, which may influence each of these parameters. Use of aromatase inhibitors reduces hyperestrogenism inevitably attained during ovarian stimulation. In addition, the adjunct use of aromatase inhibitors during ovarian stimulation reduces amount of gonadotropins required for optimum stimulation. The unique approach of reducing hyperestrogenism, as well as lowering amount of gonadotropins without affecting the number of mature ovarian follicles is an exciting strategy that could result in improvement in the treatment outcome by ameliorating the deleterious effects of the ovarian stimulation on follicular development, endometrial receptivity, as well as oocyte and embryo quality.     

The role of vitamins in the prevention and treatment of thyroid disorders

Although vitamin deficiencies are uncommon in Poland or other developed countries, many patients take vitamin supplements. Despite the widespread availability of vitamins and the universal belief that vitamins offer health benefits, few publications have addressed their role in the prevention and treatment of thyroid diseases. There is some evidence to suggest that the administration of vitamins with anti-oxidant properties in patients with hyperthyroidism can decrease the severity of clinical symptoms, and that vitamin D supplementation can have a beneficial effect on the bone system for these patients. It has also been suggested that patients with autoimmune thyroid diseases should be periodically screened for vitamin B12 deficiency. There has been no data to support vitamin supplementation in the primary or secondary prevention of thyroid malignancies.     

Estrus induction and synchronization in canids and felids

Indications for estrus induction in the dog and cat include potential missed breeding opportunities or conception failure, the treatment of primary or secondary anestrus, out-of-season breeding (feline) and synchronization of ovulation for embryo transfer programs. Reported methods for estrus induction in bitches and queens include the use of synthetic estrogens (diethylstilbesterol), dopamine agonists (bromocriptine and cabergoline), GnRH agonists (lutrelin, buserelin, fertirelin, deslorelin, and leuprolide), exogenous gonadotropins (LH, FSH, hCG, PMSG, and human menopausal gonadotropin) and opiate antagonists (naloxone). These methods vary widely in efficacy of inducing estrus as well as in the fertility of the induced estrus. The applicability of some of these methods for clinical practice is questionable. This review will summarize published reports on estrus induction in canids and felids, both wild and domestic, and provide an update on research using a long-acting injectable deslorelin preparation in bitches.