Evaluation of tumor necrosis factor alpha serum level in obese and lean women with clomiphene citrate resistant polycystic ovary disease Middle East Fertility Society Journal xxx (2017) xxx–xxx Conten[.]
Middle East Fertility Society Journal xxx (2017) xxx–xxx Contents lists available at ScienceDirect Middle East Fertility Society Journal journal homepage: www.sciencedirect.com Original Article Evaluation of tumor necrosis factor alpha serum level in obese and lean women with clomiphene citrate resistant polycystic ovary disease Emaduldin Seyam a,⇑, Momen Hasan a, Eissa M Khalifa a, Ahmad Ramadan b, Enas Hefzy c a Obstetrics and Gynecology Department, Minia University College of Medicine, Egypt Minia General Hospital, Egypt c Microbiology and Immunology, Fayoum University College of Medicine, Egypt b a r t i c l e i n f o Article history: Received 12 January 2017 Accepted 29 January 2017 Available online xxxx Keywords: Polycystic ovary syndrome Clomiphene citrate Tumor necrosis factor alfa (TNF-a) BMI Inflammatory markers Insulin resistance and hyperinsulinism a b s t r a c t Objective: The aim of this work was to investigate the level of the serum level of tumor necrosis factor alpha (TNF-a) as an inflammatory biomarker in lean and obese women with polycystic ovary disease (PCOD), who are resistant to clomiphene citrate (CCR-PCOD) Patients and design: It is a case controlled study, where one hundred and fifty (n = 150) PCOD women (study group), who are resistant to clomiphene citrate (CCR-PCOD) had been recruited, in addition to one hundred (n = 100) women with PCOD, who are not resistant to clomiphene citrate (NCCR-PCOD) as the first control group, and another one hundred women (n = 100) fertile women with normal reproductive health, as the second control group All the recruited subjects had been divided into subgroups according to the BMI: One obese group with BMI P 27, and the second lean group with BMI < 27 TNFa had been measured in all women groups recruited, in addition to the other essential, basic and PCOD relevant biochemical and hormonal tests Results: TNF-a level was found to be higher in all PCOD women, either the study or control PCOD groups, than the fertile control group (49.93 ± 3.39 vs 35.83 ± 2.47 pg/ml, P < 0.001) The level of TNF-a has come highest in the obese clomiphene citrate resistant PCOD women (obese CCR-PCOD), while the lowest has come in the lean PCOD women, who are not resistant to clomiphene citrate (NCCR-PCOD) Free Androgen Index (FAI) and androgenic obesity with higher W/H ratio were clearly going with TNF-a pattern, and have come higher in all PCOD compared to the fertile control group Insulin Resistance (IR) shows a positive correlation with BMI regardless off PCOD status and androgen level as well The level of other basic and PCOD relevant hormones like FSH, TSH, and prolactin have never shown statistically significant differences between all the study and control groups, except LH serum level which has shown a non significant higher level in all PCOD women included either resistant to CC or not Conclusion: TNF-a serum level has come significantly higher in all women with PCOD, especially in those resistant to CC Androgenic obesity with higher W/H ratio has shown a positive correlation with TNF-a level, which could consider it a good severity index of PCOD status, and an informative predictor of CCR before its use Ó 2017 Middle East Fertility Society Production and hosting by Elsevier B.V This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/) Introduction Polycystic Ovary Disease (PCOD) is one of the most common endocrine disorders in women of reproductive age with a prevalence of 5–7% PCOD is associated with a broad range of adverse sequelae, including hypertension, dyslipidemia, insulin resistance, Peer review under responsibility of Middle East Fertility Society ⇑ Corresponding author E-mail addresses: eemsseyam@yahoo.com (E Seyam), memoharty@yahoo.com (M Hasan), eissa_mmk@yahoo.com (E.M Khalifa), ahmadramadan@yahoo.com (A Ramadan), emhefzy@yahoo.com (E Hefzy) hyperandrogenaemia, gestational and type diabetes, which ultimately increase the risk of cardiovascular morbidity Obesity is present in varying degrees in women with PCOD [1–3] Polycystic ovary disease have been proved to be a proinflammatory disorder and several publications on PCOD have show increased levels of circulatory inflammatory markers such as plasminogen activator inhibitor-1, TNF-a, Il-6, Il-18, and C Reactive Protein (CRP) The reason of increased inflammation in PCOD has not been clarified yet, and it remains uncertain whether it is associated with PCOD itself or the accompanying obesity [4–7] A consensus between several studies have shown that, the most effective dosage of clomiphene citrate (CC) to induce ovulation, is http://dx.doi.org/10.1016/j.mefs.2017.01.008 1110-5690/Ó 2017 Middle East Fertility Society Production and hosting by Elsevier B.V This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/) Please cite this article in press as: E Seyam et al., Evaluation of tumor necrosis factor alpha serum level in obese and lean women with clomiphene citrate resistant polycystic ovary disease, Middle East Fertil Soc J (2017), http://dx.doi.org/10.1016/j.mefs.2017.01.008 E Seyam et al / Middle East Fertility Society Journal xxx (2017) xxx–xxx 100–150 mg/day and over 75% of ovulations occur within these dosages For these reasons, almost all infertility studies published during the last years have defined CC resistance (CCR) as the absence of ovulation after CC administration at doses of 150 mg/day for three successive cycles This CCR state could be used as a severity marker for the PCOD problem, regarding; reproductive prognosis [8–11] Approximately 60–70% of PCOD patients are obese, with a central body fat distribution pattern described as visceral obesity that is well known to be highly associated with insulin resistance However, PCOD patients have evidence of insulin by 35–40% in women with PCOD, independent of obesity Obesity is associated with a state of chronic systemic inflammation manifested by increased serum levels of inflammatory cytokines as well as alterations in peripheral blood lymphocyte frequencies and function [2,5,8] Still lean PCOD women with a MBI < 27 are complaining of severe state of PCOD, evidenced with a relatively comparable CCR, which is almost similar to those obese PCOD women, which could confirm the fact, that general obesity with (BMI P 27) should not be considered the main causative agent of PCOD Andorgenic obesity, with increased visceral fact in specific body parts might be the acceptable explanation in lean PCOD women [3,7,9,12] The aim of the current study is to investigate the correlation between TNF-a serum levels as an inflammatory biomarker in obese and lean PCOD women, who are CCR, so trying to use the studied TNF-a serum levels in PCOD women, not only as a PCOD severity indicator, but also as a preliminary predictor for CC treatment success to induce ovulation in PCOD women (see Figs and 2) Fig The relationship between the TNF-a value in different group subjects included The value was highest in group I (Obese CCR-PCOD), and lowest in group VI (lean healthy women) Fig The differences in Free Androgen Index values (FAI) in between the groups included The highest was in group I (Obese CCR-PCOD), and there was almost no difference in between Groups IV, V, and VI, which reflected the positive correlation between FAI and BMI Patients and methods One hundred and fifty (n = 150) PCOD women, who are CCR had been recruited as a study group Another one hundred (n = 100) PCOD women, who are not CCR, as a control group A third group included one hundred (n = 100) fertile women as another control group Both the study and control groups had been subdivided into two subgroups according to the BMI: Obese one whose BMI P 27, and a lean one whose BMI < 27; so finally we had six subdivided groups: GI (n = 80) termed obese CCR-PCOD, GII (n = 70) termed lean CCR-PCOD, GIII (n = 50) termed obese NCCR-PCOD, GIV (n = 50), GV (n = 50) who are obese fertile, and GVI (n = 50), who are lean fertile The exclusion criteria adopted during cases selection were: other causes of irregular menstrual cycles and/or androgen excess (i.e., Cushing’s syndrome, hyperprolactinemia, congenital adrenal hyperplasia, or other diseases of the adrenal gland, thyroid disorders, galactorrhea, breastfeeding and pregnancy), impaired glucose tolerance or type 1/type diabetes, hypertension, hyperlipidemia, active or chronic liver or renal failure, or congestive heart failure, a history of coronary artery disease, and gestational diabetes mellitus (GDM) Absence of acute infection (within the preceding 14 days), presence of any chronic inflammatory and autoimmune disease, known malignancy, and hormonal contraception and/or anti-androgen therapy (within the preceding months) had been also excluded The use of medications for dyslipidemia, hypertension, hyperglycemia, insulin resistance or obesity was an exclusion criterion for these studies The local university medical ethical committee has approved the study and a written informed consent was obtained from patients All women were examined clinically (general, gynecologic examination, weight, height), then examined by transvaginal ultrasonography to fulfill the PCOD diagnosis criteria Of the women included in the study, a detailed history was taken Following general physical examination of the cases, anthropometric measurements were performed (age, weight, height and waist circumference) Height (centimeter) and weight (kilogram) were measured with the subject barefoot in light daily clothes Body mass index (BMI) was calculated using the formula weight (kg)/square meter of height (m2) Waist circumference (cm) was measured midway between the lower rib margin and the iliac crest at the end of a gentle expiration The diagnosis of PCOD was made on the basis of the revised 2003 Rotterdam ESHRE/ASRM diagnostic criteria, women with PCOD meet two of the following three criteria after exclusion of other etiologies (pituitary insufficiency, persistent hyperprolactinemia, congenital adrenal hyperplasia): (1) oligomenorrhea or anovulation; (2) clinical and/or biochemical signs of hyperandrogenism; (3) polycystic ovaries Samples were obtained between days and of normal spontaneous or withdrawn menstrual cycle Determination of tumor necrosis factor alpha (TNF-a), by (Boster Biological Technology Co Ltd, Wuhan, China) levels were measured using commercially available ELISA kits according to manufacturer recommendations The intra-assay coefficient of variation (CV) was 0.0001 >0.0001 0.05 not significant for overall F test P < 0.05; P < 0.01; P < 0.001; P < 0.0001 significant for overall F test * Significant p < 0.05 compared to control (BMI