Premature Ovarian Premature Ovarian FailureFailure

Premature Ovarian Premature Ovarian FailureFailure

Santiago, October 5th, 2007 Santiago, October 5th, 2007

Pr Philippe Touraine Pr Philippe Touraine

philippe.touraine@psl.aphp.frphilippe.touraine@psl.aphp.fr

Inserm Unit 845Inserm Unit 845, , Research Center Growth & Research Center Growth &

Signaling, Signaling, Faculty of Medicine Necker, ParisFaculty of Medicine Necker, Paris

Dept Endocrinology & Dept Endocrinology & ReprodReproductive Medicine,uctive Medicine,

Hospital Pitié Salpetrière, ParisHospital Pitié Salpetrière, Paris

8th week : 600 000 oogonia8th week : 600 000 oogonia

5 th Week of embryogenesis 5 th Week of embryogenesis

Endodermal stem cells Genital crestEndodermal stem cells Genital crest

OvogoniaOvogonia

Oogonia MitosisOogonia Mitosis

28th Week28th Week

MeiosisMeiosis

Primary OocytesPrimary Oocytes

AtresiaAtresia

Maximal at 20thWeekMaximal at 20thWeek

6-7 Million germ cells at 20th Week6-7 Million germ cells at 20th Week

2/3 are oocytes in meiosis2/3 are oocytes in meiosis

1/3 are oogonia 1/3 are oogonia

AtresiaAtresia

< 20 % germ cells at birth la naissance< 20 % germ cells at birth la naissance

300 000 at puberty300 000 at puberty

400-500 follicles during genital life400-500 follicles during genital life

Premature Ovarian Failure Premature Ovarian Failure (POF)(POF)

Premature Ovarian Failure Premature Ovarian Failure (POF)(POF)

WHO WHO : Permanent Cessation of menstruations : Permanent Cessation of menstruations secondary to loss of follicular activitysecondary to loss of follicular activity

Characterized by Characterized by : : Women < 40 yrsWomen < 40 yrsAmenorrhea > 4 monthsAmenorrhea > 4 monthsHypergonadotrophic Hypogonadism (FSH > 30 Hypergonadotrophic Hypogonadism (FSH > 30 UI/L)UI/L)

Anasti JN, Fertil. Steril., 1998, Anasti JN, Fertil. Steril., 1998, 70 : 1-5.70 : 1-5.

IncidenceIncidence : # 1% : # 1% Coulam CB et al., Obstet. Gynecol., 1986, 67 : 604-6Coulam CB et al., Obstet. Gynecol., 1986, 67 : 604-6

Premature Ovarian FailurePremature Ovarian FailurePremature Ovarian FailurePremature Ovarian Failure

1%1% of of 40 40--yearyear--oldold-women-women

Etiology most often remains unknownEtiology most often remains unknown

AutoimmunityAutoimmunityFSHR anomaliesFSHR anomalies

Cx37, GDF9, BMP-15Cx37, GDF9, BMP-15Enzyme deficienciesEnzyme deficiencies

Follicular DysfunctionFollicular Dysfunction

Accelerated atresiaAccelerated atresia

Follicular DepletionFollicular DepletionChemotherapyChemotherapy

X chromosome anomaliesX chromosome anomaliesAutoimmunityAutoimmunity

Premature Ovarian Premature Ovarian FailureFailure

Premature Ovarian Premature Ovarian FailureFailure

Accelerated atresiaAccelerated atresia

Follicular DepletionFollicular DepletionChemotherapyChemotherapy

X chromosome anomaliesX chromosome anomaliesAutoimmunityAutoimmunity

Schlessinger et al., Am J Med Genet, 2002Schlessinger et al., Am J Med Genet, 2002

Total of cases with POFTotal of cases with POF % cases with POF% cases with POF

Primary amenoorheaPrimary amenoorheaSecondary amenorrheaSecondary amenorrhea

POF - POF - FMR1FMR1POF - POF - FMR1FMR1

20% premutated and 14% grey zone develop POF (20% premutated and 14% grey zone develop POF (Bretherick, 2005Bretherick, 2005)) 13-21% familial forms POF are premutated13-21% familial forms POF are premutated 3-7% sporadic POF are premutated (3-7% sporadic POF are premutated (Shermann, 2000Shermann, 2000)) Prevalence: 0.4% women with normal fertilityPrevalence: 0.4% women with normal fertility

Radiotherapy : 6 Gy on ovaries : non reversible POFRadiotherapy : 6 Gy on ovaries : non reversible POF

POF and POF and chemotherapychemotherapy

POF and POF and chemotherapychemotherapy

OligomenorrheaOligomenorrheaNormal CyclesNormal Cycles

DrugsDrugs Normal cyclesNormal cycles

AmenorrheaAmenorrhea

Premature Ovarian Premature Ovarian FailureFailure

Premature Ovarian Premature Ovarian FailureFailure

AutoimmunityAutoimmunityFSHR anomaliesFSHR anomalies

Cx37, GDF9, BMP-15Cx37, GDF9, BMP-15Enzyme deficienciesEnzyme deficiencies

Follicular DysfunctionFollicular Dysfunction

Genetics of Genetics of POFPOF

Genetics of Genetics of POFPOF

Is there any argument for a genetic compoundIs there any argument for a genetic compound

Genes and physiological menopauseGenes and physiological menopause

– Correlation between age of menopause in mother and Correlation between age of menopause in mother and

girlsgirls

De Bruin, Hum Reprod 2001De Bruin, Hum Reprod 2001

– Cohort of twins: POF described in up to 63%Cohort of twins: POF described in up to 63%

Snieder, J Clin Endocrinol Metab 1998Snieder, J Clin Endocrinol Metab 1998

Gosden R, Hum Reprod, 2007Gosden R, Hum Reprod, 2007

– Familial cases in 15 to 20%Familial cases in 15 to 20%

Primordial

Primary

Ovulation

Hsueh, Endocrine Review, 2000Hsueh, Endocrine Review, 2000

Antral

Secondary

AtresiaAtresia

Blocade of follicular maturationBlocade of follicular maturation

22 patients with primary amenorrhea22 patients with primary amenorrhea Pubertal development variablePubertal development variable Hypoplasic ovaries at histological examinationHypoplasic ovaries at histological examination Presence of primordial and primary folliclesPresence of primordial and primary follicles

FSH receptor gene mutation in theFSH receptor gene mutation in theFinnish populationFinnish population

FSH receptor gene mutation in theFSH receptor gene mutation in theFinnish populationFinnish population

NH2NH2

COOHCOOH

AlaAla189 189 Val Val

Setting up a POF Setting up a POF NetworkNetwork

Setting up a POF Setting up a POF NetworkNetwork

Phenotyping of the patients (specificities of Phenotyping of the patients (specificities of

subgroups)subgroups)

Constitution of a DNA BankConstitution of a DNA Bank Identification of new mutations of genes involvedIdentification of new mutations of genes involved

in folliculogenesisin folliculogenesis

Constitution of an ovarian tissue bankConstitution of an ovarian tissue bank Immunohistochemistry / steroidogenesisImmunohistochemistry / steroidogenesis

Ovarian transcriptomeOvarian transcriptome

Prospective follow-up of populationProspective follow-up of population

Current EvaluationCurrent EvaluationCurrent EvaluationCurrent Evaluation

Clinical PhenotypeClinical Phenotype

QuestionnaireQuestionnaireKaryotypeKaryotype

BiologicalBiologicalPhenotypePhenotype

HormonalHormonalevaluationevaluation

MorphologicalMorphologicalPhenotypePhenotype

UltrasonographyUltrasonographyLaparoscopy - HistologyLaparoscopy - Histology

351 patients351 patients

50 excluded50 excluded40 yrs 40 yrs

FSH<30 mUI/lFSH<30 mUI/lSecondary POFSecondary POF

Karyotype “Turner-like”Karyotype “Turner-like”

301 patients301 patients8 karyotypic anomalies8 karyotypic anomalies

293293 46,XX  idiopathic 46,XX  idiopathic

74 patients74 patients< 18 yrs< 18 yrs(25%)(25%)

Bachelot et al., 2007, submittedBachelot et al., 2007, submitted

Age at diagnosis (yrs)

Mean age: 26.5 ± 7.8

Nu

mb

er

of

Pati

en

ts

0

2

4

6

8

10

12

14

16

18

20

1112131415161718192021222324252627282930313233343536373839

Bachelot et al., 2007, submittedBachelot et al., 2007, submitted

Primary amenorrheaSecondary amenorrhea

Nu

mb

er

of

Pati

en

ts

0

50

100

150

200

250

absencepartialnormal

Puberty

Bachelot et al., 2007, submittedBachelot et al., 2007, submitted

Clinical PhenotypeClinical PhenotypeClinical PhenotypeClinical Phenotype

41 patients with a history of familial POF41 patients with a history of familial POF13.6% des POF13.6% des POF

59 patients with autoimmunity biomarkers59 patients with autoimmunity biomarkers19.6 % of POF19.6 % of POF3737 with thyroid disorders with thyroid disordersDiabetes, juvenile arthritis, vitiligo,….Diabetes, juvenile arthritis, vitiligo,….6 patients with antiovarian antibodies (IFI)6 patients with antiovarian antibodies (IFI)

41 patients with fluctuating POF41 patients with fluctuating POF

5 pregnancies; 3 births5 pregnancies; 3 births

Median (Range)Median (Range) Normal Normal rangerange

FSH (IU/l)FSH (IU/l) 82.6 (30.3–284)82.6 (30.3–284) 3–93–9

LH (IU/l)LH (IU/l) 32.5 (5.9–109)32.5 (5.9–109) 1–51–5

Estradiol Estradiol (pg/ml)(pg/ml)

25.8 (5–246)25.8 (5–246) 20-35020-350

Inhibin B Inhibin B (pg/ml)(pg/ml)

10 (5–105)10 (5–105) 60–20060–200

• 134 woman have detectable E2 levels and 58 inhibin 134 woman have detectable E2 levels and 58 inhibin

BB

• AMH detectable in 105 patientsAMH detectable in 105 patientsBachelot et al., 2007, submittedBachelot et al., 2007, submitted

Available for 151 patients Available for 151 patients

Mean age 28.7 yrs (15-42)Mean age 28.7 yrs (15-42)

Definition WHO Definition WHO

• 66 patients (42%) BMD normal 66 patients (42%) BMD normal

• 63 patients osteopenia (42%), 14 at neck and 63 patients osteopenia (42%), 14 at neck and

25 at lumbar25 at lumbar

• 22 patients osteoporosis (15%), 7 at neck and 22 patients osteoporosis (15%), 7 at neck and

20 at lumbar 20 at lumbar

Bone Mineral DensityBone Mineral DensityBone Mineral DensityBone Mineral Density

100µm100µm 100µm100µm

N= 29N= 29 N = 75N = 75

Two Different PatternsTwo Different PatternsTwo Different PatternsTwo Different Patterns

Bachelot et al., 2007, submittedBachelot et al., 2007, submitted

Ovarian HistologyOvarian HistologyOvarian HistologyOvarian Histology

0

10

20

30

40

50

60

70

Secondary70%

secondary

primordialprimary

Early antral

Absence of foll

antrum

Follicular Histology

Primary25%

AmenorrheaBachelot et al., 2007, submittedBachelot et al., 2007, submitted

Histo -Histo - Histo +Histo +

5

10

15

20

25

30

35

40

Foll +Foll +

Foll +Foll +

Foll -Foll -

Foll -Foll -

Ult

raso

nog

ap

hy

Ult

raso

nog

ap

hy

Massin et al., 2004Massin et al., 2004

FSH Receptor gene FSH Receptor gene mutationsmutations

FSH Receptor gene FSH Receptor gene mutationsmutations

Patient 1Patient 1 Patient 2Patient 2 Patient 3

NH2NH2

COOHCOOH

IleIle160 160 Thr Thr

ArgArg573 573 Cys Cys

AspAsp224 224 Val Val

AlaAla189 189 Val Val

LeuLeu601 601 Val Val

Pro519 Thr

IleIle191191 Leu Leu

Ala419 Thr

ProPro272272Leu ThrLeu Thr

Beau et al. JCI, 1998Beau et al. JCI, 1998 Touraine et al., Mol Endocrinol, 1999Touraine et al., Mol Endocrinol, 1999 Meduri et al., JCEM, 2003Meduri et al., JCEM, 2003

Phenotype-Genotype Phenotype-Genotype Correlation Correlation

Phenotype-Genotype Phenotype-Genotype Correlation Correlation

Patient 1Patient 1 Patient 2Patient 2 Patient 3Patient 3 FinnishFinnish

populationpopulation

PubertyPuberty NormalNormal NormalNormal Lack ofLack of DelayedDelayed

AmenorrheAmenorrheaa

SecondarySecondary PrimaryPrimary PrimaryPrimary PrimaryPrimary

HistologyHistology Antral Antral FolliclesFollicles

Early Early antral antral

folliclesfollicles

PrimordiaPrimordial Folliclesl Follicles

Primary Primary FolliclesFollicles

In vitroIn vitro

R-FSH R-FSH activityactivity

30% 30% Arg573CysArg573Cys

15% 15% Leu601ValLeu601Val

0%0% UndetectablUndetectablee

Rec FSH StimulationRec FSH StimulationRec FSH StimulationRec FSH Stimulation

Patient 1 Patient 2 Patient 3

E2 (pg/ml)

12 65

<20 <20

< 10

Inhibin B (pg/ml)

60 125 15 30 < 10

Number of follicules

10-15/ovaire 6 - 8/ovary 3-4/ovary

Size " (mm) 2-56-8,8 2 – 42 - 4 2-3 mm

FSH/day (U/d) 150750 100 600 100 à 900

Total dose rec FSH

10 275 U 10 300 U 10 400

Etiology actually possible in Etiology actually possible in 30 patients 30 patients (10%)(10%)

8 with karyotype anomalies 8 with karyotype anomalies

5 with FMR1 premutation5 with FMR1 premutation

16 anomalies of genes involved in POF16 anomalies of genes involved in POF

2 APS type 2, 1 with multiple AI 2 APS type 2, 1 with multiple AI diseasesdiseases

Clinical evaluationClinical evaluation: : HeightHeightFamilial POF syndrome, Syndromic defects, AutoimmunityFamilial POF syndrome, Syndromic defects, Autoimmunity

KaryotypeKaryotypeHormonal evaluationHormonal evaluation: : FSH-E2FSH-E2; ; AndrogensAndrogens

AMH, Inhibine BAMH, Inhibine BUltrasonographyUltrasonography: : SurfaceSurface, , Presence of FolliclesPresence of Follicles

Evaluation of BMDEvaluation of BMDDNA analysisDNA analysis: : XFraXFra

FSHR analysis in patients with presence of follicles at ultrasonographyFSHR analysis in patients with presence of follicles at ultrasonography

Hormonal substitutionHormonal substitutionTreatment of infertilityTreatment of infertility

What to do in our current practice?

What to do in our current practice?

Bachelot et al., 2007, submittedBachelot et al., 2007, submitted

What to say?What to say?What to say?What to say?

Information +++Information +++ Psychological helpPsychological help HRTHRT Explanation about pregnancy plans Explanation about pregnancy plans

(oocyte donation…)(oocyte donation…) Discussion about “ovaries to be frozen”Discussion about “ovaries to be frozen”

Gross et al., Fertil Steril, 2005Gross et al., Fertil Steril, 2005

Around POF Around POF DiagnosisDiagnosisAround POF Around POF DiagnosisDiagnosis

Department of EndocrinologyDepartment of Endocrinology and Reproductive Medicineand Reproductive Medicine

Necker HospitalNecker HospitalPr F. KuttennPr F. Kuttenn

Pathology Pathology CochinCochinCHICCHICHEGPHEGP

G MeduriG MeduriGeneticsGenetics

M Misrahi, BicêtreM Misrahi, BicêtreM Fellous, CochinM Fellous, CochinC Cotinot, INRAC Cotinot, INRA

D Castrillon, Dallas, TXD Castrillon, Dallas, TXL.Messiaen, Gant, BelgiumL.Messiaen, Gant, Belgium

SurgerySurgery F LecuruF LecuruB PanielB Paniel

RadiologyRadiologyC MatuchanskyC MatuchanskyC BalleyguierC Balleyguier

Hormonal BiochemistryHormonal BiochemistryK LabordeK Laborde

CytogeneticsCytogenetics

Nathalie MassinNathalie MassinAnne BachelotAnne Bachelot

Yvette Le RouzicYvette Le Rouzic

Philippe TourainePhilippe Touraine

National and InternationalNational and InternationalCollaborationCollaboration

Team « Centre Maladies rares de la croissance »philippe.touraine@psl.aphp.fr

Beau et al. J. Clin Invest, 1998;Touraine et al., Mol Endocrinol, 1999;Meduri et al., JCE&M, 2003; Massin et al., Hum Reprod, 2004; Bachelot et al., JCE&M, 2005; Massin et al., Horm Res, 2006

Meduri et al., Hum Reprod, 2006; Laissue et al., Eur J Endocrinol, 2006