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European Review for Medical and Pharmacological Sciences
Effects of Myo-Inositol supplementation
on oocyte’s quality in PCOS patients:
a double blind trial

L. CIOTTA, M. STRACQUADANIO, I. PAGANO, A. CARBONARO,M. PALUMBO, F. GULINO Microbiological and Gynecological Science Department, Gynecology Section “Santo Bambino”Hospital (Catania), University of Catania (Italy) Abstract. – Background: Polycystic ovary
Introduction
syndrome is the most common cause of chronic
anovulation infertility in women in fertile period,

Polycystic Ovary Syndrome (PCOS) is a com- and it’s characterized by an increased produc-
tion of androgens and estrogens. The adminis-

plex disease characterized by various endocrine tration of D-chiro-inositol, a B complex vitamin,
disorders that can be the potential cause of was associated with a decreased of serum
anovulation and hyperandrogenism condition. testosterone and simultaneously, due to its abili-
This heterogenous syndrome affects about 5- ty to increase insulin sensitivity, women who re-
10% of female population in the reproductive ceived D-chiro-inositol showed a great improve-
age, and it can be considered as the most com- ment of the ovulary function. Besides, the sup-
plementation of inositol improves the oocytes’

mon endocrine disorder affecting women during quality and increase the number of oocytes col-
lected after ovarian stimulation in patients un-
dergoing IVF (in vitro fertilization).
ovarian dysfunction or a central hypothalamus- Aim: The aim of this study is to determine the
ovary-pituitary defect, but it is the expression of effects of myo-inositol on oocyte’s quality on a
a complex functional alteration of the whole re- sample of women with polycystic ovary syndrome.
Material and Methods: The patients were di-
vided into two groups: patients of Group A in-
Under a hormonal point of view, the micropoly- took 2 g of myo-inositol + 200 µg of folic acid (In-
cystic ovary is characterized by an increased pro- ofolic®, LO.LI. Pharma, Rome, Italy) while Group
duction of androgens and estrogens, and a dissoci- B only 200 µg of folic acid, both groups took the
ation of gonadotropins serum concentrations: ele- treatment twice a day, continuously for 3
vated luteinizing hormone (LH), low or normal follicle stimulating hormone (FSH) and LH/FSH Results: At the end of treatment, the number
of follicles of diameter >15 mm, visible at ultra-
ratio that usually exceeds 2.5 in the typical forms. sound during stimulation, and the number of
In the blood of PCOS patients testosterone oocytes recovered at the time of pick-ups were
(T), androstenedione (AS), dehydroepiandros- found to be significantly greater in the group
terone (DHEA), DHEA-S (sulfate), 17-hydrox- treated with myo-inositol, so as the aver-age
yprogesterone (17-OHP) and estrone resulted el- number of embryos transferred and embryo
evated. The circulating levels of sex hormone- Score S1. Significantly reduced was the average
binding globulin (SHBG) are instead lower.
number of immature oocytes (vesicles germ and
degenerated oocytes) too.

The enhancing peripheral conversion of an- Conclusions: These data suggest that myo-
drostenedione to estrone leads to the modest rela- inositol may be useful in the treatment of PCOS
patients undergoing ovulation induction, both
SHBG levels are reduced of about 50% due to for its insulin-sensitizing activity, and its role in
oocyte maturation.
The syndrome’s etiology is still unknown, but it is probably multifactorial, due to an excessive E1production, or to an alteration of the primitive hy- Inositol, Oocyte’s quality, Polycystic ovary syn- pothalamic regulation and of the ovarian and/or drome, Infertility, In vitro fertilization. Corresponding Author: Mariagrazia Stracquadanio, MD; e-mail: mariagrazia.stracquadanio@gmail.com L. Ciotta, M. Stracquadanio, I. Pagano, A. Carbonaro, M. Palumbo, F. Gulino The diagnosis of PCOS is based on the clini- Clomiphene is a drug normally used for this cal, hormonal and ultrasound patterns. In accor- purpose: it is a weak estrogen that acts also as dance with the Rotterdam Criteria, drawn in anti-estrogen. Probably, it interacts with the hy- 2003, PCOS diagnosis can be made only after pothalamic estrogen receptors, displacing the en- the exclusion of other causes of hyperandro- dogenous estradiol and creating a condition of genism and amenorrhea, and in the presence of at artificial hypoestrogenism, due to its biological activity almost absent in this district. Hypothala-mic centers, responsible for gonadotropin-releas- • Oligo- and/or anovulation with menstrual ir- ing hormone (GnRH) release are thus stimulated to greater activity. Following the administration • Elevated levels of circulating androgens or of clomiphene, in fact, the frequency of pulsatile clinical manifestation of hyperandrogenism; secretion of LH and FSH increases, while the • Transvaginal pelvic ultrasound evidence of amplitude remains unchanged. Ovulation in PCOS is induced in 80% of cases, while preg-nancy occurs in 20% of cases.
Due to the pulsatility of LH, only one blood parameter is not enough for the PCOS diagnosis, clomiphene and metformin was obtained, or and there is no unanimous consensus on which where an in vitro fertilization/intracytoplasmic androgen blood’s level should be considered for sperm injection (IVF/ICSI) was necessary, ovula- a precise diagnosis (total or free testosterone, tion induction was performed by the administra- testosterone/SHBG ratio or androstenedione).
tion of gonadotropins. Gonadotropins used for Usually, elevated levels of only DHEA or 17- this purpose are obtained from the urine of post- menopausal women (Menotrophin). Recently, Since menarche, or after a short period, men- gonadotropins obtained with biosynthetic tech- strual cycles show an irregular rhythm. In many nique from recombinant DNA have been intro- cases they gradually distance themselves from duced (Follicotropin α and Follicotropin β). The each other, up to result in short periods of amen- goal of the therapy with gonadotropins, or rather orrhea or in permanent amenorrhea. Menstrual with FSH, is acting on the follicles in the last dysfunction in women affected by PCOS may stage of their maturation process that, under manifest in different ways, but the probably most physiological conditions is restricted to the first common way is anovulation with erratic bleed- two weeks of the menstrual cycle in which ovula- Androgens excess is responsible for hirsutism, The aim of this study is to determine the ef- oily skin, acne and, in the ovary, for the thicken- fects of Myo-Inositol, a compound belonging to ing of the tunica albuginea. The degree of hir- vitamin B complex, on oocyte’s quality in a sutism can be measured with the Ferriman-Gall- group of patients with PCOS, suffering from chronic anovulation and infertility, undergoing In rare cases virilization patterns can be ob- medically assisted reproduction techniques served, with increased size of clitoris, muscle mass hypertrophy, deep voice, temporal balding Scientific studies have shown that D-chiro-in- and masculine aspect. In these cases, however, a ositol, thanks to its ability to increase insulin sen- lower ovarian or an adrenal androgen-secreting sitivity, has beneficial effects on ovulation and on the androgens production in women with PCOS.
At the same time an overweight pattern, up to The administration of D-chiro-inositol was asso- obesity can be associated to the syndrome.
ciated with a decreased of serum testosterone8 and increased of SHBG concentration. Simulta- causes of female infertility: if you want to get neously to the reduction of insulin secretion, pregnant, ovulation should be induced5.
women who received D-chiro-inositol showed a Ovulatory cycles are obtained, usually, after great improvement of the ovulary function9,10.
the overweight correction, or immediately after Scientific evidence has also shown that the sup- the estrogen-progestins suspension. If it does not plementation with inositol contributes to reduc- happen, ovulation should be induced pharmaco- ing the amount of FSH necessary to ovulation, to logically (usually associated with metformin ad- improving oocyte’s quality (reduction of the total amount of the germinal vesicles and the degener- Effects of Myo-Inositol supplementation on oocyte’s quality in PCOS patients: a double blind trial ated oocytes) and to increasing the number of Oocyte’s quality assessment was performed oocytes collected after ovarian stimulation in pa- after the oocyte pick-up conducted during the as- tients undergoing ART techniques, as IVF or IC- sisted reproductive technology procedure in SI11-13. Inositol cannot be defined exactly as a vit- which patients have been submitted. The ICSI or amin, but it is considered a vitamin factor be- IVF includes several phases (ovarian stimulation, longing to B complex. In the human organism it oocyte collection, oocyte quality assessment, is present in the phospholipids, and it can stimu- oocytes in-vitro fertilization, embryo culture and late endogenous production of lecithin. Its role scoring, embryo transfer), all crucial for the suc- also includes a specific biological activity of con- cess of the technique. They were all followed by trol on fat and sugar metabolism, and on the cel- the medical team of the Reproduction Pathophys- lular function of the nervous system. It is also es- iology Centre of “Santo Bambino” Hospital, in sential to hair growth and it can prevent baldness.
Catania at the IVF clinic with the attached Scientific studies revealed that diabetic subjects eliminate amounts of inositol significantly higherthat no-diabetic ones14.
In case of insulin resistance or type II diabetes, inositol helps to improve the whole clinical pat- tern. In these cases, inositol may be useful to pre-vent and to correct pathophysiological mecha- • Χ2 test for qualitative data (β-hCG positivity); nisms underlying the metabolic and reproductive • Student t test for quantitative data normally distributed (age, BMI, total FSH units admin-istered, number of follicles of diameter >15mm); • U test for quantitative data not normally dis- Materials and Methods
All the patients were enrolled and treated in the Department of Gynecological Sciences(“Santo Bambino” Hospital, Catania), at the Gy-necological Endocrinology Clinics and Human Results
Reproduction Pathophysiology Centre. In the 12-month enrollment phase a total of 34 women, During the study period, patients were ran- aged <40 years with polycystic ovary syndrome domly divided into two groups, as described be- fore, and the investigation was performed in a PCOS diagnosis was indicated by oligo-amen- orrhea (six or fewer menstrual cycles during a No significant differences were found between period of one year), hyperandrogenism (hir- the two groups in mean age and body mass index sutism, acne or alopecia) or hyperandrogenemia (elevated levels of total or free testosterone), and Total r-FSH units administered for the ovari- typical feature of ovaries at ultrasound scan.
an stimulation were significantly reduced in Concomitant endocrine and metabolic patholo- gies, as hypothyroidism, hyperthyroidism, diabetes As reported in literature, peak E levels at hu- mellitus, androgen-secreting cancers, adrenal hy- man chorionic gonadotropin (hCG) administra- perplasia, Cushing syndrome were excluded.
tion were lower in group A, but our data were not The ICSI or IVF procedures were recommend- ed after the evaluation of the sperm semen of the Two cycles were cancelled in group A, where- as in group B five cycles were suspended, be- According to a randomization table, patients cause of peak E >4,000 pg/mL (risk of hyper- were divided into two groups: patients of Group A intook 2 g of myo-inositol + 200 µg of folic acid The number of follicles with a diameter >15 (Inofolic®, LO.LI. Pharma, Rome, Italy) while mm, visible at ultrasound scan during stimula- Group B only 200 µg of folic acid, both groups tion, and the number of oocytes retrieved at the took the treatment twice a day, continuously for 3 pick-up resulted significantly higher in the myo- L. Ciotta, M. Stracquadanio, I. Pagano, A. Carbonaro, M. Palumbo, F. Gulino Table I. Retrieved oocytes at the pick-up.
therapies in spontaneous ovulation restoration,with a potential positive action even on meiotic Percentiles
oocyte maturation. These therapies seem to di-rectly influence steroidogenesis, by reducing an- Group
Median
25°
75°
drogen production in theca cells. In fact, the ad-ministration of D-chiro-inositol has been demon- strated to increase the insulin action in PCOS pa- tients, improving ovulatory function10, and reduc- ing serum testosterone concentration8, 9,19.
Nowadays, there are few data on the action and effects of myo-inositol, a precursor of D-chi- The mean number of immature oocytes (ger- ro-inositol, on the anovulatory women in repro- minal vesicles and degenerated oocytes) was sig- ductive age or on the spontaneous ovulation in nificantly reduced, and there was an increasing trend of the rate of oocytes in metaphase II Anyway, myo-inositol is an important con- (MII), that are oocytes characterized by not visi- stituent of the follicular microenvironment, play- ble germinal vesicles and visible first polar body ing a key role in the nuclear and cytoplasmic No statistical significance in the number of In the assisted reproduction techniques, in fertilized embryos was emerged, but in group A fact, the supplementation with myo-inositol is the mean number of transferred embryos resulted positively related to meiotic progression of significantly higher, with higher amounts of mouse germinal vesicle oocytes, enhancing in- score 1 embryos in comparison with lower-quali- tracellular Ca2+ oscillation20. Furthermore, high- er concentrations of myo-inositol in human fol- In compliance with the italian ART law, no licular fluid provide a marker of good-quality more than three embryos were transferred. No differences in the total number of biochemical Our study is one of the fews focusing on this molecule, that belongs to vitamin B complex,and on its effects in PCOS patients undergoingovulation induction. Preliminary data in ourhands show that, in PCOS patients the treatment Discussion
with myo-inositol and folic acid, compared withfolic acid alone, reduces the number of germinal Polycystic ovary syndrome (PCOS) is one of vesicles and degenerated oocytes, without com- the most common female endocrine disorders.
promising the total number of retrieved oocytes.
Insulin-resistance and hyperinsulinemia are These results, as other trials’, suggest that myo- strictly correlated with the phenotype of a large inositol has a positive effect on mature oocytes A defect in the insulin’s action has been sus- Furthermore, it is well known that ovulation pected, probably because of a deficiency of D- induction in PCOS patients is a pivotal matter, chiro-inositol, that is a component of inositol even because of the risk of the ovarian hyper- phosphoglycans. Insulin-lowering drugs, particu- stimulation syndrome23-24. Elevated basal serum larly different forms of inositol, represent novel levels of androgens are involved in the produc- Table II. Metaphase II (MII) oocytes, degenerated oocytes and germinal vesicles.
Group A
Group B
Frequency
%
Frequency
%
Effects of Myo-Inositol supplementation on oocyte’s quality in PCOS patients: a double blind trial Table III. Number of score 1 embryos.
Group A
Group B
Frequency
%
Frequency
%
tion of high serum E levels, as typically detected 6) ACOG COMMITTEE ON PRACTICE BULLETINS. Polycystic in PCOS patients undergoing ovulation induction ovary syndrome. Int J Gynecol Obstet 2003; 80:335-348.
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particularly on basal serum testosterone reduc- Metabolic and hormonal effects of myo-inositol in tion8,9,25. In fact, in patients treated with myo-in- women with polycystic ovary syndrome: a double- ositol plus exogenous gonadotropins a significant blind trial. Eur Rev Med Pharmacol Sci 2009; 13: reduction in E levels at hCG administration was found. As consequence, it can be supposed that 9) NESTLER JE, JAKUBOWICZ DJ, REAMER P, GUNN RD, AL- this protocol could be adopted to reduce the risk LAN G. Ovulatory and metabolic effects of D chiro-inositol in the polycystic ovary syndrome. N Engl In conclusion, these observations suggest that 10) GERLI S, PAPALEO E, FERRARI A, DI RENZO GC. Ran- myo-inositol may be useful in the treatment of domized, double blind placebo-controlled trial: PCOS patients undergoing ovulation induction, effects of Myo-inositol on ovarian function and both for its insulin-sensitizing activity, and its metabolic factors in women with PCOS. Eur Rev Med Pharmacol Sci 2007; 11: 347-354.
11) PAPALEO E, UNFER V, BAILLARGEON JP , FUSI F, OCCHI F, DE SANTIS L. Myo-inositol may improve oocytequality in intracytoplasmic sperm injection cycles.
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