Doi:10.1016/j.fertnstert.2004.07.960

POLYCYSTIC OVARY SYNDROME
N-acetyl-cysteine is a novel adjuvant to clomiphene
citrate in clomiphene citrate-resistant patients
with polycystic ovary syndrome
Ahmed Y. Rizk, M.D.,a Mohamed A. Bedaiwy, M.D.,b and Hesham G. Al-Inany, M.D.c a Department of Obstetrics and Gynecology, Benha University, Benha; b Department of Obstetrics and Gynecology AssiutSchool of Medicine, Assiut; and c Department of Obstetrics and Gynecology, Cairo University, Cairo, Egypt Objective: To evaluate the effect of N-acetyl-cysteine (NAC), a mucolytic drug with insulin sensitizing properties,
as an adjuvant therapy in subjects with polycystic ovary syndrome (PCOS) resistant to clomiphene citrate (CC).
Design: Placebo-controlled, double-blind randomized trial.
Setting: University-based hospital and private infertility practice.
Patient(s): One hundred fifty women diagnosed with CC-resistant PCOS, aged 18 -39 years undergoing therapy
for infertility were included.
Intervention(s): The patients were assigned randomly to receive either NAC 1.2 g/d (group I) or placebo (group
II) with CC 100 mg/d for 5 days starting at day 3 of the cycle.
Main Outcome Measure(s): Ovulation rate and pregnancy rate (PR).
Result(s): Combination of CC and NAC significantly increased both ovulation rate and PR in women with
CC-resistant PCOS (49.3% vs. 1.3% and 21.3% vs. 0%, respectively). No cases of ovarian hyperstimulation
syndrome (OHSS) were reported in the NAC group; two cases of miscarriage (12.5%) were reported.
Conclusion(s): The NAC as an adjuvant to CC was more effective than placebo for CC-resistant patients with
PCOS. It is safe and well tolerated. (Fertil Steril௡ 2005;83:367-70. 2005 by American Society for Reproductive
Medicine.)
Key Words: N-acetyl-cysteine, polycystic ovary syndrome, clomiphene citrate resistance, pregnancy
Polycystic ovary syndrome (PCOS) affects up to 10% of A promising agent is N-acetyl-cysteine (NAC). It is a safe women of reproductive age, in which hyperandrogenism, and well-tolerated mucolytic drug that softens tenacious enlarged cystic ovaries, and chronic anovulation often coex- mucous secretions. It is the acetylated precursor of both ist with obesity, hyperinsulinemia, and insulin resistance amino acid L-cysteine and reduced glutathione It has Obesity in women with PCOS is rather high, ranging been shown to have proven activity on insulin secretion in from 30%- 60% whereas hyperinsulinemia is present in pancreatic cells, as well as on the regulation of the insulin more than 50% of patients with PCOS.
receptor in human erythrocytes In addition, it is a pow-erful antioxidant and a potential therapeutic agent in the Clomiphene citrate (CC) therapy has variable success treatment of cancer, and other diseases characterized by the rates in anovulatory women; however, it is the lowest in generation of free oxygen radicals The peak plasma level women with PCOS, particularly those with insulin resis- of NAC is attained 1 hour after an oral dose and it disappears tance. Currently there is increasing evidence that insulin from the plasma after 12 hours. The biological activity of sensitizers are particularly effective in inducing ovulation NAC is attributed to its sulfhydryl group, which enhances in patients with PCOS However, not all cases respond glutathione-S-transferase activity aiding in the protection of to insulin sensitizers Exploring other mechanisms to induce or augment ovulation in CC-resistant patients is adesirable goal in reproductive medicine.
To our knowledge, the potential reproductive effects of NAC were never evaluated. The NAC may be a noveltreatment option for augmenting or inducing ovulation in Received March 31, 2004; revised and accepted July 16, 2004.
patients with chronic anovulation including PCOS. Conse- Presented at the 20th annual meeting of the European Society of Human quently, the current study was performed to evaluate the Reproduction and Embryology, Berlin, Germany, June 27-30, 2004.
effect of NAC administration as an adjuvant to CC on Reprint requests: Ahmed Rizk, M.D., Benha University, P.O. 113, Benha, ovulation and pregnancy rates (PR) as compared to placebo Kaloubia, Egypt (FAX: 002-013-26-70-80; E-mail: ahmadrezk@yahoo.
com).
Fertility and Sterilityா Vol. 83, No. 2, February 2005 Copyright 2005 American Society for Reproductive Medicine, Published by Elsevier Inc.
MATERIALS AND METHODS
ipant had only one treatment cycle. Allocation was done by The present study was conducted in a university-based hos- a third party (nurse). The NAC and placebo were supplied in pital and private infertility practice between March 2002 and identical sachets. The patients and the physician monitoring November 2003. We studied 150 women affected by PCOS, the cycles were blinded to the identity of each medication.
aged 18 -39 years. As described elsewhere PCOS wasdiagnosed by a finding of bilaterally normal or enlarged Outcome Measures
ovaries (ovarian volume Ͼ12 cm3) with the presence of at The primary outcome was the ovulation rate in the treatment least 7-10 peripheral cysts per ovary. No patient showed cycle. Secondary outcomes included PR, number of follicles of hyperprolactinemia, clinical evidence of hypercorticism, or Ն18 mm, the serum E concentration, serum P, and endome- thyroid dysfunction. All patients had to have at least one trial thickness. The major safety end points were the incidence patent fallopian tube observed at hysterosalpingography or of ovarian hyperstimulation syndrome (OHSS) and multiple laparoscopy. The patients' male partners underwent a semen gestations. An ongoing pregnancy was defined as a viable analysis and the results were determined to be adequate pregnancy at least 12 weeks after hCG administration.
according to the latest WHO guidelines.
Eligible patients could not have been receiving any hor- monal medications except P for withdrawal bleeding for 2 Hormonal Assay
months before the study. No patient had taken any medica- Estradiol was measured with an RIA using direct double- tion known to affect carbohydrate metabolism for at least 3 antibody kits (Pantex, Santa Monica, CA). The assay sensi- months before the study. The body mass index (BMI) was tivity was 10 pg/mL. The interassay and intra-assay preci- calculated according to the following formula: body weight sion of low, middle, and high controls were 14.2% and 16%, in kilograms/height in meters squared and obesity was de- 10.6% and 7.9%, and 11.4% and 4.2%, respectively. Folli- fined as BMI Ͼ30 kg/m2. Informed consent was obtained cle-stimulating hormone and LH were measured with the from each patient before the entry into the study. The study fluorimetric enzyme immunoassay kits (Baxter Diagnostics was approved by Benha School of Medicine Institutional Inc., Miami, FL). The assay sensitivity of both assays was 0.3 mIU/mL. The interassay and intra-assay precision oflow, middle, and high controls were 1.5% and 4.3%, 2.95% Patients who met the inclusion criteria were found to have and 2.1%, and 3.15% and 3%, respectively, for FSH. For CC resistance, which was defined as lack of ovulation after LH, the values were 6.35% and 8.1%, 2.9% and 1.9%, and treatment with CC, 100 mg, for 5 days in three consecutive 2.8% and 2.5%, respectively. Progesterone was measured with an RIA using the antibody coated-tube method (Coat-A-Count; Diagnostic Products Corporation, Los Angeles, Experimental Protocol
CA). The sensitivity of this assay was 0.02 ng/mL. The Amenorrheic patients began treatment with induction of interassay precision of low, middle, and high controls for the menses using P-in-oil (100 mg). On day 3, each patient assay was 8.8%, 3.6%, and 3.9%, respectively. Insulin was underwent a baseline ultrasonographic examination. Clomi- measured with Axsym insulin diagnostic division 100 (Ax- phene citrate, 100 mg, was given from day 3 until day 7. In sym; Abbot, IL). The sensitivity of the assay was 6 -24 addition to the CC, each patient was selected randomly to mIU/mL. The interassay and intra-assay precision of low, receive either NAC (Sedico, Cairo, ARE), in a dose of 1.2 middle, and high controls were 6 -10 u/mL, 32- 48 u/mL, g/d orally, or a placebo (sugar) of the same volume twice daily from day 3 until day 7. Monitoring of the cycle in-cluded transvaginal determination of the mean follicular Statistical Analysis
diameter and measurement of serum E levels. Monitoring The proportion of pregnancies that occurred in each group intervals were determined by patient response. Human cho- was compared with Fisher's exact test. Comparisons of rionic gonadotropin was administered when at least one serum levels between the NAC and placebo groups were follicle measured 18 mm and the E level had increased.
analyzed with Student's t test. A P level of Ͻ.05 was Timed intercourse was advised 24 -36 hours after hCG injection. A serum P level was checked on cycle days 21-22.
A serum hCG level was determined 14 days after hCG injection if menses had not yet occurred. Pregnancy wasdefined as an increase in the serum hCG level on serial A total of 150 patients were randomized to (NAC: n ϭ 75; determinations at least 2 days apart.
placebo: n ϭ 75) in a total of 150 CC cycles. As shown inthere was no difference in age, infertility duration,BMI, weight/height, and in FSH/LH during the cycles in Randomization and Blinding
which NAC or placebo was given. All participants had BMI In both groups, patients were randomized to receive CC and Ͼ25 kg/m2 and the mean BMI in both groups was Ͼ30 either NAC or placebo using sealed envelopes. Each partic- kg/m2 (obese). The mean E level and the number of follicles Use of N-acetyl-cysteine in patients with PCOS
Comparison of the baseline features and clinical outcomes of the two treatment groups.
Variable
P value
aOnly one follicle was shown to be more than 18 mm in one patient.
Rizk. Use of N-acetyl cysteine in patients with PCOS. Fertil Steril 2005. Ͼ18 mm at the time of hCG administration in the NAC values The NAC is commonly used as a safe mucolytic group were significantly higher than the placebo group.
drug, and at higher doses it increases the cellular levels of Similarly, significantly higher ovulation rates as well as PRs reduced glutathione, an antioxidant, which has been shown to influence insulin receptor activity It has been shown thatNAC is able to improve insulin secretion in response to glucose.
There were five cases of multiple pregnancies in the NAC Moreover, its administration was proposed for the prevention of group. No cases of OHSS were reported. There were two endothelial damage due to oxidant agents in non-insulin-depen- cases of miscarriage (12.5%) (one singleton and one multiple pregnancy). On performing subgroup analysis in the NACgroup, it was found that at insulin level Ͼ20 ␮/mL there More recently, it has also been shown to have other were 8 pregnancies (one twin) of 35 (22.8%), whereas at diverse biological effects, notably: antiapoptotic anti- insulin Ͻ20 ␮/mL, 8 pregnancies (three multiple pregnan- oxidant protection against focal ischemia inhibi- cies) of 40 (20%) were observed (odds ratio ϭ 1.14, 95% tion of phospholipid metabolism, proinflammatory cytokine confidence interval [CI] ϭ 0.38 -3.36).
release, and protease activity The NAC may exert thesame effects at the ovarian level and these activities may beas important as its insulin-enhancing effects in inducing DISCUSSION
Clomiphene citrate failure is a frequent encounter in patientswith PCOS. Insulin resistance is a cause of CC failure in In the current study, NAC was well tolerated by all the patients with PCOS, not only in obese, but in lean patients as patients and no adverse effects were observed. The results of well In addition, hyperinsulinemia might influence our study are encouraging. We obtained a significant in- ovarian as well as adrenal steroidogenesis. Consequently, crease of both ovulation and PRs in the NAC group. All insulin-lowering drugs were proved effective in the treat- participants in our study had only one cycle and this facili- ment of patients with PCOS. The potential insulin-sensitiz- tated completion of our study. In addition, the study partic- ing properties of NAC in patients with PCOS were recently ipants were on oral medications of well-known tolerability explored To our knowledge, no previous study and compliance. These two factors made this study achieve focused on the reproductive functions as an end point as a a high level of compliance and completion. Furthermore, no result of NAC treatment in patients with PCOS.
manifestations of OHSS were reported.
Besides its insulin-sensitizing effect NAC treatment induced Based on the previous hypothesis that NAC treatment is a significant decrease in T levels and in free androgen index effective only in those patients who were compromised from a metabolic point of view the lack of any positive 11. Coelingh Bennink HJ, Fauser BC, Out HJ. Recombinant follicle- reproductive outcome in placebo-treated patients further stimulating hormone (FSH; Puregon) is more efficient than urinaryFSH (Metrodin) in women with clomiphene citrate-resistant, nor- confirmed the effectiveness of NAC administration.
mogonadotropic, chronic anovulation: a prospective, multicenter, The magnitude of the observed clinical changes is sig- assessor-blind, randomized, clinical trial. European Puregon Collab- nificant from a clinical point of view, especially when orative Anovulation Study Group. Fertil Steril 1998;69:19 -25.
12. Holte J, Bergh T, Berne C, Berglund L, Lithell H. Enhanced early compared with previously reported data about the use of insulin response to glucose in relation to insulin resistance in women metformin or troglitazone In addition, the anti- with polycystic ovary syndrome and normal glucose tolerance. J Clin apoptotic effects of NAC may be responsible for the significantly higher number of follicles in the NAC group 13. Moghetti P, Castello R, Negri C, Tosi F, Perrone F, Caputo M, et al.
compared to placebo, as it is well known that apoptosis is Metformin effects on clinical features, endocrine and metabolicprofiles, and insulin sensitivity in polycystic ovary syndrome: a the main mechanism involved in follicular cohort atresia.
randomized, double-blind, placebo-controlled 6-month trial, fol- Its protective effects against ischemic insults as well lowed by open, long-term clinical evaluation. J Clin Endocrinol as its inflammatory-modulating capacity may be the contributory mechanisms that added to the NAC positive 14. Weidmann P, de Courten M, Bohlen L. Insulin resistance, hyperinsu- reproductive effects. However, our study was limited to linemia and hypertension. J Hypertens Suppl 1993;11(Suppl 5):S27-38.
one treatment cycle, whereas the reported data about other 15. Fulghesu AM, Ciampelli M, Muzj G, Belosi C, Selvaggi L, Ayala GF, et al. N-acetyl-cysteine treatment improves insulin sensitivity in women insulin-sensitizing agents are the result of 12-24 weeks of with polycystic ovary syndrome. Fertil Steril 2002;77:1128 -35.
treatment. Moreover, the effects of NAC on the hormonal 16. Ammon HP, Muller PH, Eggstein M, Wintermantel C, Aigner B, and metabolic profiles of patients with PCOS should be Safayhi H, et al. Increase in glucose consumption by acetylcysteine further investigated as other insulin-sensitizing agents do during hyperglycemic clamp. A study with healthy volunteers. Arzne- affect both hormonal and metabolic features 17. Pieper GM, Siebeneich W. Oral administration of the antioxidant, In conclusion, NAC may be a novel adjuvant treatment for N-acetylcysteine, abrogates diabetes-induced endothelial dysfunction.
patients with PCOS. It is a simple, well-tolerated, and inex- J Cardiovasc Pharmacol 1998;32:101-5.
pensive agent. It could be used as an alternative to other 18. Odetti P, Pesce C, Traverso N, Menini S, Maineri EP, Cosso L, et al.
Comparative trial of N-acetyl-cysteine, taurine, and oxerutin on skin insulin-sensitizing agents like metformin or troglitazone.
and kidney damage in long-term experimental diabetes. Diabetes 2003; The effects of NAC therapy on the hormonal and metabolic profiles, symptoms of hyperandrogenism, and cardiovascular 19. De Mattia G, Bravi MC, Laurenti O, Cassone-Faldetta M, Proietti A, risk factors need further assessment.
De Luca O, et al. Reduction of oxidative stress by oral N-acetyl-L-cysteine treatment decreases plasma soluble vascular cell adhesionmolecule-1 concentrations in non-obese, non-dyslipidaemic, normoten- REFERENCES
sive, patients with non-insulin-dependent diabetes. Diabetologia 1998; 1. Ciampelli M, Lanzone A. Insulin and polycystic ovary syndrome: a new look at an old subject. Gynecol Endocrinol 1998;12:277-92.
20. Sekhon B, Sekhon C, Khan M, Patel SJ, Singh I, Singh AK. N-Acetyl 2. Franks S. Polycystic ovary syndrome. N Engl J Med 1995;333:853- 61.
cysteine protects against injury in a rat model of focal cerebral isch- 3. Franks S. Polycystic ovary syndrome: a changing perspective. Clin 21. Lappas M, Permezel M, Rice GE. N-Acetyl-cysteine inhibits phospho- 4. Nestler JE. Obesity, insulin, sex steroids and ovulation. Int J Obes Relat lipid metabolism, proinflammatory cytokine release, protease activity, Metab Disord 2000;24(Suppl 2):S71-3.
and nuclear factor-kappaB deoxyribonucleic acid-binding activity in 5. Malkawi HY, Qublan HS, Hamaideh AH. Medical vs. surgical treat- human fetal membranes in vitro. J Clin Endocrinol Metab 2003;88: ment for clomiphene citrate-resistant women with polycystic ovary syndrome. J Obstet Gynaecol 2003;23:289 -93.
22. Azziz R, Ehrmann D, Legro RS, Whitcomb RW, Hanley R, Fereshetian 6. Wentzel P, Thunberg L, Eriksson UJ. Teratogenic effect of diabetic AG, et al. Troglitazone improves ovulation and hirsutism in the poly- serum is prevented by supplementation of superoxide dismutase and cystic ovary syndrome: a multicenter, double blind, placebo-controlled N-acetylcysteine in rat embryo culture. Diabetologia 1997;40:7-14.
trial. J Clin Endocrinol Metab 2001;86:1626 -32.
7. Lanzone A, Fulghesu AM, Andreani CL, Apa R, Fortini A, Caruso A, 23. Pasquali R, Gambineri A, Biscotti D, Vicennati V, Gagliardi L, Colitta et al. Insulin secretion in polycystic ovarian disease: effect of ovarian D, et al. Effect of long-term treatment with metformin added to hy- suppression by GnRH agonist. Hum Reprod 1990;5:143-9.
pocaloric diet on body composition, fat distribution, and androgen and 8. Borgstrom L, Kagedal B, Paulsen O. Pharmacokinetics of N-acetylcys- insulin levels in abdominally obese women with and without the teine in man. Eur J Clin Pharmacol 1986;31:217-22.
polycystic ovary syndrome. J Clin Endocrinol Metab 2000;85:2767-74.
9. De Vries N, De Flora S. N-acetyl-l-cysteine. J Cell Biochem 1993; 24. Dunaif A, Scott D, Finegood D, Quintana B, Whitcomb R. The insulin- sensitizing agent troglitazone improves metabolic and reproductive 10. Acbay O, Gundogdu S. Can metformin reduce insulin resistance in abnormalities in the polycystic ovary syndrome. J Clin Endocrinol polycystic ovary syndrome? Fertil Steril 1996;65:946 -9.
Use of N-acetyl-cysteine in patients with PCOS

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