Clinical diagnosis
Case 231
【Progress】
She was introduced to the expert hospital where obstetrician would consult her.
【Discussion】
The definition of polycystic ovaries that she has 20 or more follicles in at least one ovary (1, 2). Polycystic ovary syndrome (PCOS) is found in 10-15% of patients suffering from female infertility (2 - 4). The Rotterdam definition of PCOS is as follows; polycystic ovaries, ovary dysfunction, androgen excess (2, 3). At least, two of them meet the criteria of PCOS. Meanwhile, the Japanese definition of PCOS is polycystic ovaries, ovary dysfunction and hyper luteinizing hormone (LH)/normal follicular stimulating hormone (FSH) (4). All three factors must fulfill to meet the criteria of PCOS. This revision of Japanese is attributable to the difference of the incidence of obesity in the patients with PCOS between Western countries and Asian countries. Namely, in Western countries, obesity patients with PCOS are extraordinary more than in Asian countries (2-4). Then, the mechanism between hyper insulin secretion (insulin resistant) and hyper androgen is much discussed in Western countries (2, 3). For example, overproduction of insulin is considered to increase androgen: Insulin-resistant body cells cause obesity and PCOS (1). Meanwhile, of all patients with PCOS in Japan, the rate of obese patients is 20 to 30% (4). The relation of hyper-androgen with overproduction of insulin causing obesity and PCOS is not so meaningful.
Progesterone and estrogen are necessary to preserve normal menstruation cycle. Progesterone is secreted by corpus luteum temporally created after ovulation for pregnancy, while estrogen is secreted by granulosa cells. Granulosa cells create estrogen with use of androgen secreted by theca cells. Until recently androgen from theca cells was thought to be material for granulosa cells to create estrogen but also to play a role of closure of corpus luteum (5, 6). Orisaka et al. clarified that androgen from theca cells under direction of LH functions to breed from primary follicles to premature-follicular cyst (4). Subsequently, along with decreasing of LH, FSH functions to breed premature-follicular cyst to mature-follicular cyst, leading to ovulation. In the circumstances with higher LH level, FSH-induced follicular maturation is repressed. The continuance of high-level LH leads to create a great number of immature follicular cysts without ovulation, resulting in large ovary with many immature follicular cysts (4).
In our case, she had bilateral large ovaries with a great number of follicular cysts more than 20. She suffered from infertility and received egg retrieval for In Vitro Fertilization, inducing intraperitoneal bleeding. Laboratory test revealed no evidence of anemia. She was transported to the expert hospital where obstetricians could serve her.
【Summary】
We presented a twenty five-year-old female suffering from abdominal fulness and pain for three days after egg retrieval for fertility treatment. Enhanced CT showed intraperitoneal fluid suspicious bleeding and polycystic ovaries. Polycystic ovaries that include 20 or more follicles in at least one ovary can cause infertility, approximately 10 to 15% of women infertility. The definition of polycystic ovary syndrome by Japan Obstetrics association meets three criteria together at the same time: ovary dysfunction, polycystic ovaries and high level of luteinizing hormone (LH) & normal level of FSH. LH stimulates theca cells to secrete androgen which functions not only for closure of corpus luteum but also bleeds primary follicle to immature follicle. When LH decreases and FSH elevates, immature follicles can become mature follicle inducing ovulation. When the high level of LH continues, immature follicles cannot grow to mature follicles, inducing enlarged polycystic ovaries with a great number of follicles.
【References】
1.Franks S, et al. Insulin action in the normal and polycystic ovary. Endocrinol Metab Clin North Am. 1999 Jun;28(2):361-78.
2.Rotterdam ESHRE/ASRM-Sponsored PCOS Consensus Workshop Group Revised 2003 consensus on diagnostic criteria and long-term health risks related to polycystic ovary syndrome（PCOS）. Hum Reprod 2004; 19: 414-417.
3.Azziz R. Diagnosis of polycystic ovarian syndrome The Rotterdam criteria are premature. J Clin Endocrinol Metab 2006; 91:781-785.
4.Orisaka M. Aiming to clarify pathophysiology of non-obese typical PCOS in Asian females - High LH level repress growth of FSH-induced follicles. J Nihon Seishokugakkai. 2012; 17:27-31
5.Mohamed MA, et al. Urinary follicle-stimulating hormone（FSH）is more effective than recombinant FSH in older women in a controlled randomized study. Fertil Steril 2006; 85: 1398-1403
6.Blank SK, et al. The origins and sequelae of abnormal neuroendocrine function in polycystic ovary syndrome. Hum Reprod Update 2006; 12: 351-361.
2021.5.19