1Center
David H Barad, MD1,2
Norbert Gleicher, MD1,3
for Human Reproduction and Foundation for Reproductive Medicine; 2
Department of Obstetrics, Gynecology and Women’s Health, Albert Einstein
College of Medicine; 3 Department of Obstetrics, Gynecology and Reproductive
Sciences, Yale University School of Medicine
The speaker declares the potential conflicts of interest.
Dr. Gleicher and Dr. Barad are listed as co-inventors on an already
awarded and other pending patent applications which claim therapeutic
benefits of DHEA in women with diminished ovarian reserve. Dr.s
Gleicher and Barad are also listed as co-inventor son a pending patent
application, which claims diagnostic benefits from evaluating the FMR1
gene in regards to ovarian reserve. Both doctors have received research
support, speakers fees and travel funds from various pharmaceutical
companies, none in any way related to the topic of this presentation.
The speakers declare that no brand-name
medications and/or off-label, non-FDA-approved
uses are discussed in the lecture.
 How
to measure aging?
 How
to treat aging?
 FSH
 AMH
 AFC
 CCT
FMR1
Appears to regulate ovarian reserve
Fu et al. Cell,Vol. 67, 1047-1056, DECEMBER, 1991
This box and whisker
plot for the whole
study population of
339 women
reconfirmed the
previously defined
normal range of 26-32
CGG repeats (median
30). The graph in the
right lower corner
represents the
frequency distribution
of individual alleles,
confirming the median
CGG count at 30.
Gleicher et al., RBN
Online ; in press.
Gleicher et al RBM Online 2010;20:485-91.
 Normal: both
alleles in 26 – 34 range
 Heterozygous: one
allele in 26 – 34 range
one allele <26 or >34
• Het-norm/low
• Het-norm/high
 Homozygous: both
alleles outside of 26 – 34
range
The figure represents egg donors and
infertility patients at all ages. Normal
females at young ages have the highest,
and women with homozygous CGG count
abnormalities the lowest AMH levels. AMH
levels, however, decline in normal women
more rapidly than in heterozygous and
homozygous patients. At approximately 35
years of age AMH levels in heterozygous
women start to exceed those of normal
women. AMH levels in homozygous women
track those of normal women almost till age
50, when they start exceeding the latter.
Gleicher et al. Reprod Biomed Online; In Press.
The figure represents egg donors and
infertility patients of all ages. Under
age 30years AMH levels significantly
differ amongst all three patient groups
(p=0.009). Specifically, AMH in normal
women is significantly higher between
normal women and homozygous
females (p<0.001) and between
heterozygous and homozygous patients
(p=0.002). By age 34.99, these
statistical differences no longer are
present.
Gleicher et al. Reprod Biomed Online; In Press.
 Abnormal
CGG counts on FMR1 denote
risk for POA
 Women
identified at risk can be
monitored with AMH
 Continued
POA→ Fertility preservation
→ Change in reproductive
planning
Ovary, like thyroid and
adrenals: Differentiation
between function and
autoimmunity
 Function
 Autoimmunity
Suppressing
Stimulating
We previously postulated the
presence of autoimmuneinduced ovarian hyperactivity
(PCO, stimulating antibodies)
and hypoactivity (POA,
suppressive autoantibodies)
Gleicher et al, Autoimmune Rev, 2007;7:42-45.
Evidence of autoimmune
activation in women with
different FMR1-genotypes
Gleicher et al, ASRM, 2010.
 339 consecutive patients
• 183 (50.0%) norm
• 62 (18.3%) het – norm/high
• 94 (27.7%) het – norm/low
 206
(60.8%) no autoimmunity
 133
(39.2%) autoimmune +
 75
PCO (≥12 oocytes / AMH
>4.0ng/mL)
90%
83.50%
80%
All Patients
Autoimmunity (%)
70%
P=0.003
PCO Patients
60%
P<0.0001
50%
40%
51.10%
38.30%
34%
30%
24.20%
20%
10%
10%
0%
norm
het - norm/high het - norm/low
 Het
– norm/low defines an autoimmuneassociated, quickly OR-depleting PCO
phenotype, while het – norm/high defines
low autoimmune risk
 Confirms
involvement of FMR1 in
recruitment and functional OR
 Establishes
an association between het –
norm/low genotype and female
autoimmunity
Pregnancy chances based on
FMR1 genotype
Gleicher et al, ASRM, 2010.
 455
consecutive IVF cycles
 Autoimmune
 FMR1
profile: Y/N
genotype
 Multiple
regression analyses adjusted for
age, race, medication dosage, number of
oocytes
Genotype
Pregnancies
(%)
Normal
38.6
Het-norm/high
31.7
Het-norm/low
22.2
P
p=0.001
 Adjusted
for age, het-norm/low
maintained lowest rates (p=0.001), but
significance was lost with adjustment for
race, medication and oocyte numbers.
 Controlling
for all covariates,
autoimmunity almost reached
significance (p=0.06).
 FMR1
genotype is predictive of pregnancy
chances
 Loss
of significance with adjustment for
ovarian factors suggests/confirms a direct
effect of FMR1 on the ovary
 In
contrast, actual significance of
autoimmunity independently may suggest
an autoimmune effect not mediated by
ovaries.
What connects between FMR1
and autoimmunity?
Gleicher et al, ASRM, 2010.
 PubMed, Medline
 Keywords/phrases
Autoimmunity
X
chromosome
FMR1 gene
Xq27 region
 Autoimmunity
& POI/POF closely
associated with X chromosome defects
Turner
syndrome (XO)
 Xq
terminal deletions common
 Often
large & characterized by 1o/2o
amenorrhea
 Xq21
→ 2o amenorrhea (FMR1 at Xq27)
 Fertile
Turners → proximal Xq deletions
 POI: 4Mb
locus exactly at Xq27-q28
 Small
Xq27-q28 deletions → variable
phenotypes, some early menopause but
able to reproduce
 Increased
autoimmunity
Diseases
Autoantibodies
 Only
Xq23-q27 deletions associated with
POI/POF
 Down
Syndrome
 Klinefelter
 Turner
Syndrome
Syndrome
 Autoimmunity
high in practically all
X-linked disorders
 May, therefore, be
caused by
genes/mutations on the X
chromosome
 MHC-paralogue
on long arm of X
chromosome, if defective, reduces
immunologic effectiveness
 The
long arm of the X chromosome is
of paramount importance for
autoimmunity as well as POI/POF
 FMR1
maps to Xq27
FMR1, the crossroad for
autoimmunity and
ovarian function?
Non-disjunctional events and
their consequences
Non-disjunctional events
↓
Chromosomal abnormalities
↓
Miscarriages
FMR1 Gene
Autoimmunity
?
Miscarriages
Non-Disjunctional
Events
 Reduces
(?) aneuploidy
Gleicher et al, ASRM 2007
 Significantly
reduces miscarriages
Gleicher et al, Reprod Biol & Endocrinol 2009;7:108
0.6
0.5
0.4
National
DHEA
0.3
0.2
0.1
0
<35
35-37
38-40
41-42
>42
Gleicher et al. Reprod Biol Endocrinol 2009:108.
When miscarriage rates were
compared, equalized for number of
patients, dhea supplementation
reduced miscarriage rates even more
significantly (p<0.0001), suggestive of
a reduction of ~80%
Indirect
But
proof
direct evidence still lacking
 22
DOR patients on DHEA
 Each
matched with 2 controls (no DHEA)
based on age, years of cycle (mostly
normal OR)
 Univariate
general linear model to assess
DHEA effects on % aneuploidy after
adjustments for age, indications for PGS,
stimulation, gonadotropin dosage
DHEA
No DHEA
P-value
Oocytes
9.6±6.2
11.7±6.3
N.S.
Ets
1.5±0.7
1.4±0.9
N.S.
Cryo
0.6±1.2
0.7±1.6
N.S.
Grade
3.5±0.3
3.4±0.4
N.S.
Biopsies
6.6±3.6
7.3±3.9
N.S.
n
2.8±2.5
4.5±3.1
0.03
%
38.2±24.4
61.0±22.4
<0.001
Aneuploid
 DHEA
effects remained significant after
adjustments (Exception: PGS for gender
had lower aneuploidy; p<0.007)
 Greatest
reduction in aneuploidy with
short-term treatment (4-12 weeks)
(21.6% 95%CI – 2.871 – 46.031)
 First
direct evidence that DHEA
positively affects non-disjunctional
events (aneuploidy)
 Positively
affects autoimmunity
 Autoimmunity
increases nondisjunctional events
 Does
DHEA affect ovaries by reducing
autoimmune effects?
FMR1 Gene
?
Autoimmunity
DHEA
?
Non-disjunctional
Events
Miscarriages