No therapy for infertile patients with premature ovarian failure has been proven effective.
Some anecdotal reports have suggested that high dose, long term prednisone (steroid) therapy
may be useful in treating autoimmune ovarian failure. However, prednisone, when used in
high-doses for long periods of time has substantial side effects, including aseptic necrosis
of bone where portions of bone die without the presence of infection and are surrounded by
healthy tissue. Aseptic necrosis of bone often requires major surgical treatment. Even with
this known level of risk, patients with premature ovarian failure are being treated based on
this anecdotal evidence.
This study will test the hypothesis that a lower risk therapy (alternate-day, lower dose,
shorter-term prednisone) will cause a remission of autoimmune ovarian failure. There is no
reliable blood test to identify patients who have premature ovarian failure. Therefore, all
patients must undergo a laparoscopic ovarian biopsy to confirm the presence of an auto
immune reaction in the ovaries (autoimmune oophoritis). Laparoscopy is a surgical procedure
that allows doctors to explore the abdomen using a camera-like device called a laparoscope.
The procedure has been used clinically by some reproductive endocrinologists to identify
patients with premature ovarian failure who have an autoimmune mechanism for the disorder.
The treatment will be deemed successful based on the return of ovulation as determined by
weekly serum progesterone levels.
Autoimmune oophoritis is a distinct clinical entity and a known cause of premature ovarian
failure. It is characterized by the presence of circulating adrenal antibodies. No therapy
for infertile patients with premature ovarian failure due to autoimmune oophoritis has been
proven effective by prospective controlled study. Anecdotal reports have suggested that
high-dose, long-term prednisone therapy may be useful in treating autoimmune ovarian
failure. However, prednisone, when used in high-dose for a long-term has substantial side
effects, including aseptic necrosis of bone requiring major surgical intervention. Despite
this risk, patients with premature ovarian failure are being treated based on this anecdotal
evidence. We are aware of two patients with premature ovarian failure who developed aseptic
necrosis of bone on high-dose, long-term prednisone therapy administered elsewhere.
This protocol will test the hypothesis that a lower risk therapy (alternate-day, lower dose,
shorter-term prednisone) will induce remission of ovarian failure caused by autoimmune
oophoritis. The protocol will use a double-masked, placebo-controlled design. Patients with
premature ovarian failure who have serologic evidence of steroidogenic cell autoimmunity
will be candidates. Successful outcome will be defined as a return of ovulation as
determined by weekly serum progesterone levels. The hypothesis that short-term,
alternate-day prednisone therapy restores ovulation will be tested with an equality of
proportions test comparing the proportion of patients who ovulate during placebo with the
proportion of patients who ovulate during prednisone therapy.
- INCLUSION/EXCLUSION CRITERIA:
Women 18 to 39 years of age with premature ovarian failure who meet the following
requirements will be candidates for the study:
At least a four month history of amenorrhea not due to pregnancy,
Clearly elevated gonadotropins with a serum FSH greater than or equal to 40 IU/L on two
separate occasions at least one month apart,
Positive adrenal or ovarian antibodies demonstrated by indirect immuno-fluorescence using
monkey tissue as substrate or other laboratory evidence of steroidogenic cell autoimmunity
such as the presence of antibodies against 21-hydroxylase,
No evidence for genetic, metabolic, toxic, or iatrogenic cause of the ovarian failure,
No medical contraindication to glycocorticoid therapy,
No glycocorticoid therapy taken in the past year (patients on appropriate replacement
therapy for Addison's disease are not excluded),
No medical contraindication to pregnancy.