多囊卵巢综合征

多囊卵巢综合征与胰岛素抵抗2013-4-1流行病学和定义 5-10% 慢性不排卵， 高雄激素水平， 不孕, 早期流产， 脂代谢异常和胰岛素抵抗 主要见于肥胖人群同时也见于正常体重者PCOS的诊断 NIHdiagnosticcriteria(1990) TheRotterdamcriteria(2003)NIHdiagnosticcriteria(1990) 高雄激素表现(临床and/or生化) 慢性不排卵（除外卵巢特异性疾患，肾上腺疾患,甲状腺和垂体疾患。Thepresenceofpolycysticovaries(PCO),withmorphologyassessedbyultrasound,wasnotincludedasadiagnosticcriterionbecauseofthelackofspecificityofthisfinding.[15]PCOcanbepresentinwomenwithnormalovulationandsex-hormonelevels,whereaswomenwithalltheendocrinefeaturesofPCOScanoccasionallyhavenormalovarianmorphologyasassessedbyultrasoundexaminationTheRotterdamcriteria(2003) 高雄激素表现 慢性不排卵;卵巢多囊样改变AllwomenconsideredtohavePCOSaccordingtotheNIHcriteriawouldalsobeidentifiedbyuseoftheRotterdamcriteria;however,theRotterdamcriteriaalsoincludewomenwithPCOwhowouldbeexcludedbytheNIHcriteria:thosewithPCO,hyperandrogenismandovulatorycycles,andthosewithPCO,chronicanovulationandnormalandrogenlevels..Thepresence,however,oftheclassicsonographicimageofPCOS,withenlargedovarieswithincreasedbrightechogenicstromaandanincreasednumberofsmallantralfolliclesalignedunderathickenedcapsulelocatedattheperiphery,likeastringofpearls,cannotestablishthediagnosisofPCOSasasolecriterion,sinceitisanonspecificfindinginover20%ofthenormalfemalepopulation,giventhefactthatdysfunctionofthehypothalamic–pituitaryaxis,hyperprolactinemia,eatingdisorders,orthenormaladolescenttransitionmayalsohavethesameresults[13].anexpertpaneloftheAndrogenExcessSociety(AES)recommendedthatPCOSshouldbeconsideredadisorderofandrogenexcess theNIHdiagnosticcriteriashouldbeused hyperandrogenismandinfrequentorirregularovulation,aswellashyperandrogenism,regularovulationandPCO,alsofulfillAEScriteriaforPCOSOvulatorywomenwithPCOseemtobelessinsulin-resistantthananovulatorywomenwithPCO;[18-20]further,astudypublishedin2007[21]suggeststhatwomenwithPCO,chronicanovulationandnormalandrogenlevelsarenotinsulin-resistant.Patients 临床and/or生化高雄and慢性排卵减少,伴or不伴多囊卵巢 临床and/or生化高雄and多囊卵巢,但是正常月经周期 慢性不排卵and卵巢多囊样表现,但没有高雄体征Metabolicdysregulationwithinsulinresistance,hyperinsulinism,highbodymassindex,andelevatedcardiovascularriskismoresevereamongpatientsofthefirstcategory.BothclassicPCOSandovulatoryPCOSpatients,however,presentinsulinresistanceandincreasedcardiovascularriskfactors[3,11].Usingnoninvasivemethodologies,endothelialdysfunctioninthemacrocirculationandearlyimpairmentinthemicrocirculationweredemonstratedinyoungwomenwithPCOS,whohadanormalprofileofglycaemia,lipidemia,andbloodpressure,andhadnoevidenceofstructuralarterialimpairment[12•].[3]病因学 遗传原因 类固醇生成原因 胰岛素分泌异常supportthatalocusneartotheinsulinreceptorgeneonchromosome19p13.2takespartintothepathogenesisofthesyndrome,bydysregulatingtheovarianandadrenalandrogenbiosynthesisGeneticpolymorphismsrelatedtothesecretionand/oractivityofinsulinandandrogens,suchastheinsulingeneVNTR,theandrogenreceptorgeneCAGrepeatpolymorphism,andthearomatasegenehaplotype,arealsoinvestigated病理 卵巢产生过量雄激素 胰岛素抵抗SteroidogenesisinthepathwayfromcholesteroltoandrostenedioneisamplifiedinthecacellswithPCOS.Therearedisordersofproliferationanddifferentiationinboththethecaandgranulosacomponentsofthepathologicovary[19].Theexpressionofluteinizinghormonereceptorsandproteinsassociatedwithsteroidogenesissuchassteroidogenesisacuteregulatoryprotein,cholesterolside-chaincleavagecytochromeP450,3[beta]-hydroxysteroiddehydrogenase,and17[alpha]-hydroxylase/C17–20lyasecytochromeP450isincreasedinthethecacells[20].Theaboveisinfavourofthetheorythatovarianhyperandrogenismiscloselyrelatedwithbothanincreasednumberofandrogen-producingcellsandanincreasedcapacityforandrogenproductionbyeachthecacell[19].InsulinresistanceinPCOSisduetoanabnormalpatternofphosphorylationoftheinsulinreceptorandinsulinreceptorsubstrate-1thatinhibitsmetabolicsignalling治疗 生活方式 药物治疗COCs（口服避孕药）二甲双胍胰岛素增敏剂COCs 炔雌醇35µg/抗雄激素醋酸环丙孕酮2mg 含有三代孕酮的口服避孕药去氧孕烯屈螺酮1effectiveinreducingtestosterone,[DELTA]4-androstenedioneandtheluteinizinghormone/follicle-stimulatinghormoneratioafterthethirdcycle,andimprovinghirsutismandacneafterthesixthcycle23aprogestinwithantimineralcorticoidandantiandrogenreceptoractivities,improvestheandrogenprofilewithouttheuntowardeffectofweightgain4Regardingthelipidprofile,werecentlyfoundthattotalcholesterolaswellaslow-densitylipoprotein-cholesterolincreasedsignificantlyinbothusersofthecyproteroneacetate-containingCOCsandthedesogestrel-containingCOCs,althoughtheformercombinationcausedasignificantincreaseintriglyceridelevels–whicharealreadyincreasedinPCOSpatients[53,54•].sensitivity[15].Themechanismunderlyingtheposi-tiveimpactoforalcontraceptivesinPCOStreatmentiscomplexandcomprises:areductionofLHsecre-tion,inhibitionofovarianandadrenalandrogenpro-ductionandreductionofthefreetestosteronefractionsecondarytotheincreasedSHGBproductionintheliver[30,48].Theprogestins,presentinoralcontra-ceptives,haveprotectiveeffectsontheendometrium[26,39].Ithasbeenproventhatcontraceptivepillsre-ducetheriskofendometrialcancer[48].胰岛素增敏剂 作用包括直接影响类固醇的产生和胰岛素增敏作用胰岛素增敏剂对生殖的影响Hyperandrogenism Metformin:totaltestosterone,androstenedioneandtheadrenalandrogen,dehydroepiandrosteronesulfate 噻唑烷二酮药物不影响总睾酮水平但却显著降低雄烯二酮和脱氢表雄酮水平 显著改善多毛症hyperinsulinemiadownregulatescirculatinglevelsofsex-hormone-bindingglobulin.Totaltestosteronelevelshavebeenunchangedbythiazolidinedionesinthemajorityofstudies,includingalargeRCToftroglitazone,[36]whereassignificantdecreasesincirculatinglevelsofandrostenedioneanddehydroepiandrosteronesulfatehavebeenobserved2.Endocrinology2012Sep;153(9):4354-66.doi:10.1210/en.2012-1145.Epub2012Jul9.MetformininhibitshumanandrogenproductionbyregulatingsteroidogenicenzymesHSD3B2andCYP17A1andcomplexIactivityoftherespiratorychain.HirschA,HahnD,KempnáP,HoferG,NuofferJM,MullisPE,FlückCE.SourceDepartmentofPediatrics,DivisionofPediatricEndocrinology,DiabetologyandMetabolism,UniversityHospitalInselspital,UniversityofBern,3010Bern,Switzerland.AbstractMetforministreatmentofchoiceforthemetabolicconsequencesseeninpolycysticovarysyndromeforitsinsulin-sensitizingandandrogen-loweringproperties.Yet,themechanismofactionremainsunclear.TwopotentialtargetsformetforminregulatingsteroidandglucosemetabolismareAMP-activatedproteinkinase(AMPK)signalingandthecomplexIofthemitochondrialrespiratorychain.Androgenbiosynthesisrequiressteroidenzymes17α-Hydroxylase/17,20lyase(CYP17A1)and3β-hydroxysteroiddehydrogenasetype2(HSD3B2),whichareoverexpressedinovariancellsofpolycysticovarysyndromewomen.Therefore,weaimedtounderstandhowmetforminmodulatesandrogenproductionusingNCI-H295Rcellsasanestablishedmodelofsteroidogenesis.Similartoinvivosituation,metformininhibitedandrogenproductioninNCIcellsbydecreasingHSD3B2expressionandCYP17A1andHSD3B2activities.Theeffectofmetforminonandrogenproductionwasdosedependentandsubjecttothepresenceoforganiccationtransporters,establishinganimportantroleoforganiccationtransportersformetformin'saction.MetformindidnotaffectAMPK,ERK1/2,oratypicalproteinkinaseCsignaling.Bycontrast,metformininhibitedcomplexIoftherespiratorychaininmitochondria.Similartometformin,directinhibitionofcomplexIbyrotenonealsoinhibitedHSD3B2activity.Inconclusion,metformininhibitsandrogenproductionbymechanismstargetingHSD3B2andCYP17-lyase.ThisregulationinvolvesinhibitionofmitochondrialcomplexIbutappearstobeindependentofAMPKsignaling.HumReprod.2012Nov;27(11):3304-14.doi:10.1093/humrep/des264.Epub2012Jul18.Metforminexposureaffectshumanandmousefetaltesticularcells.TartarinP,MoisonD,GuibertE,DupontJ,HabertR,Rouiller-FabreV,FrydmanN,PozziS,FrydmanR,LecureuilC,FromentP.SourceINRAUMR85,UnitédePhysiologiedelaReproductionetdesComportements,NouzillyF-37380,France.AbstractBACKGROUND:Metforminisadrugusedinthetreatmentofdiabetesandofsomedisordersrelatedtoinsulinresistance,suchaspolycysticovarysyndrome.Gestationaldiabetescancausecomplicationsforbothmotherandchild,andsomestudieshaveshownabeneficialeffectofmetforminduringpregnancywithoutanincreaseinperinatalcomplications.However,theeffectsonthegonadshavenotbeenproperlystudied.Hereweinvestigatedtheeffectofmetforminadministeredduringpregnancyonthedevelopmentandfunctionofthefetaltestis.METHODS:Adualapproachinvitroandinvivousinghumanandmousemodelswaschosen.Culturesofhumanandmurineorganotypictestesweremadeandinvivoembryonictesteswereanalysedafteroraladministrationofmetformintopregnantmice.RESULTS:Inhumanandmouseorganotypicculturesinvitro,metformindecreasedtestosteronesecretionandmRNAexpressionofthemainfactorsinvolvedinsteroidproduction.Invitro,thelowestobservedeffectconcentration(LOEC)ontestosteronesecretionwas50µMinhuman,whereasitwas500µMinmousetestis.LactatesecretionwasincreasedinbothhumanandmouseorganotypiccultureswiththesameLOECat500µMasobservedinothercellculturemodelsaftermetforminstimulation.Invivoadministrationofmetformintopregnantmicereducedthetesticularsizeofthefetalandneonataltestesexposedtometforminduringintrauterinelife.Althoughthenumberofgermcellswasnotaffectedbythemetformintreatment,thenumberofSertolicells,thenursecellsofgermcells,wasslightlyyetsignificantlyreducedinbothperiods(fetalperiod:P=0.007;neonatalperiod:P=0.03).TheLeydigcellpopulation,whichproducesandrogens,andthetestosteronecontentwerediminishedonlyinthefetalperiodat16dayspost-coitum.CONCLUSIONS:Thisstudyshowedapotentiallyharmfuleffectofmetformintreatmentonthedevelopmentofthefetaltestisandshouldencouragefuturehumanepidemiologicalstudies.不排卵和不孕 对于PCOS妇女噻唑烷二酮药物以剂量依赖方式显著促进排卵 单独应用二甲双胍,or二甲双胍加克罗米芬要显著优于促排卵药物（二甲双胍剂型和剂量会影响效果）Thereisevidenceforadose-responseeffectofimmediate-releasemetformininobesewomenwithPCOS;[47]fastingmarkersofinsulinresistancedidnotchangewhen500mgofthisformulationwasgiventhreetimesdaily,butimprovedwhen850mgofimmediate-releasemetforminwasgiventhreetimesdaily.Differentmetforminpreparationsmight,therefore,havedifferencesinefficacyinPCOS.Itisimportanttonote,however,thatmostRCTsofovulationinductioninPCOShaveused1.5-1.7gdailyratherthanmaximaldosesofimmediate-releasemetformin怀孕 MetforminpregnancycategoryBdrugstoreducespontaneousabortionsreducetheriskofGDM thiazolidinedionespregnancycategoryCdrugs1ObservationalstudiessuggestthatwomenwithPCOSareatincreasedriskforspontaneousabortion.[60,61]MuchofthisincreasedriskisapparentlyaccountedforbyobesityratherthanPCOSperse2MetforminisapregnancycategoryBdrug,whichmeansthatthereisnoevidencethatithasriskstothefetusinanimalstudiesbuttherearenoadequatehumansafetystudies.Severalsmallstudies[69-71]aswellasameta-analysisreportedinabstractformin2006[72]havenotfoundevidenceforadversepregnancyoutcomesinwomenreceivingmetformin3ThereisanRCTofmetforminuseduringpregnancy,theMetformininGestationalDiabetes(MiG)trial,[74]whichcompletedenrollmentin2006.ThistrialwillevaluatethesafetyandefficacyofmetformincomparedwithinsulintherapyforGDM.Therewillalsobelong-termfollow-upoftheoffspringtoexaminewhethermaternalmetformintreatmentinfluencestheirsubsequenthealth.4Insummary,thelimiteddatafromRCTsdonotsupporttheuseofmetforminduringpregnancytoreducespontaneousabortionsorGDMinPCOS.Thesafetyofmetforminuseinpregnancyremainsunknownandiscurrentlyunderstudy.代谢异常体重和脂肪组成 二甲双胍治疗能使体重中等程度降低并减少内脏脂肪，特别是与低热量饮食同时进行时这种作用最显著。但一些作用是剂量依赖的。CardiovascularRiskFactors MetformintherapyresultedinsignificantdecreasesinsystolicbloodpressureandLDL-cholesterollevels, bothmetforminandthiazolidinedionesimproveendothelialdysfunctioninPCOS.ThiazolidinedionesalsoimprovefibrinolysisinPCOS比较研究二甲双胍和噻唑烷二酮药物 thiazolidinedionesaremoreeffectivethanmetforminatloweringfreeorbioavailabletestosteronelevelsandAUCsforinsulinlevels.Thereis,however,minimalevidenceforadifferenceinclinicaloutcomessuchashirsutismwiththetwotherapies,andthiazolidinedionesmayresultinweightgaininwomenwithPCOS二甲双胍和口服避孕药 metforminimprovesinsulinsensitivityand,unlikeoralcontraceptives,canalsolowertriglyceridelevels. Oralcontraceptivesmightworseninsulinsensitivity乙炔雌二醇联合孕激素或环丙孕酮会降低胰岛素敏感性副作用* metformin：gastrointestinaldistressthiazolidinedione： weightgain,inpartrelatedtotheirmechanismofactionasPPARγligands,andfluidretentionthatcouldresultinedemaanddilutionalanemia anincreaseinperipheraledema,sleepdisorders,headacheandstomachpain cardiovascularsafetyconcernsThankyouThepresenceofpolycysticovaries(PCO),withmorphologyassessedbyultrasound,wasnotincludedasadiagnosticcriterionbecauseofthelackofspecificityofthisfinding.[15]PCOcanbepresentinwomenwithnormalovulationandsex-hormonelevels,whereaswomenwithalltheendocrinefeaturesofPCOScanoccasionallyhavenormalovarianmorphologyasassessedbyultrasoundexaminationAllwomenconsideredtohavePCOSaccordingtotheNIHcriteriawouldalsobeidentifiedbyuseoftheRotterdamcriteria;however,theRotterdamcriteriaalsoincludewomenwithPCOwhowouldbeexcludedbytheNIHcriteria:thosewithPCO,hyperandrogenismandovulatorycycles,andthosewithPCO,chronicanovulationandnormalandrogenlevels..Thepresence,however,oftheclassicsonographicimageofPCOS,withenlargedovarieswithincreasedbrightechogenicstromaandanincreasednumberofsmallantralfolliclesalignedunderathickenedcapsulelocatedattheperiphery,likeastringofpearls,cannotestablishthediagnosisofPCOSasasolecriterion,sinceitisanonspecificfindinginover20%ofthenormalfemalepopulation,giventhefactthatdysfunctionofthehypothalamic–pituitaryaxis,hyperprolactinemia,eatingdisorders,orthenormaladolescenttransitionmayalsohavethesameresults[13].OvulatorywomenwithPCOseemtobelessinsulin-resistantthananovulatorywomenwithPCO;[18-20]further,astudypublishedin2007[21]suggeststhatwomenwithPCO,chronicanovulationandnormalandrogenlevelsarenotinsulin-resistant.Metabolicdysregulationwithinsulinresistance,hyperinsulinism,highbodymassindex,andelevatedcardiovascularriskismoresevereamongpatientsofthefirstcategory.BothclassicPCOSandovulatoryPCOSpatients,however,presentinsulinresistanceandincreasedcardiovascularriskfactors[3,11].Usingnoninvasivemethodologies,endothelialdysfunctioninthemacrocirculationandearlyimpairmentinthemicrocirculationweredemonstratedinyoungwomenwithPCOS,whohadanormalprofileofglycaemia,lipidemia,andbloodpressure,andhadnoevidenceofstructuralarterialimpairment[12•].[3]supportthatalocusneartotheinsulinreceptorgeneonchromosome19p13.2takespartintothepathogenesisofthesyndrome,bydysregulatingtheovarianandadrenalandrogenbiosynthesisGeneticpolymorphismsrelatedtothesecretionand/oractivityofinsulinandandrogens,suchastheinsulingeneVNTR,theandrogenreceptorgeneCAGrepeatpolymorphism,andthearomatasegenehaplotype,arealsoinvestigatedSteroidogenesisinthepathwayfromcholesteroltoandrostenedioneisamplifiedinthecacellswithPCOS.Therearedisordersofproliferationanddifferentiationinboththethecaandgranulosacomponentsofthepathologicovary[19].Theexpressionofluteinizinghormonereceptorsandproteinsassociatedwithsteroidogenesissuchassteroidogenesisacuteregulatoryprotein,cholesterolside-chaincleavagecytochromeP450,3[beta]-hydroxysteroiddehydrogenase,and17[alpha]-hydroxylase/C17–20lyasecytochromeP450isincreasedinthethecacells[20].Theaboveisinfavourofthetheorythatovarianhyperandrogenismiscloselyrelatedwithbothanincreasednumberofandrogen-producingcellsandanincreasedcapacityforandrogenproductionbyeachthecacell[19].InsulinresistanceinPCOSisduetoanabnormalpatternofphosphorylationoftheinsulinreceptorandinsulinreceptorsubstrate-1thatinhibitsmetabolicsignalling1effectiveinreducingtestosterone,[DELTA]4-androstenedioneandtheluteinizinghormone/follicle-stimulatinghormoneratioafterthethirdcycle,andimprovinghirsutismandacneafterthesixthcycle23aprogestinwithantimineralcorticoidandantiandrogenreceptoractivities,improvestheandrogenprofilewithouttheuntowardeffectofweightgain4Regardingthelipidprofile,werecentlyfoundthattotalcholesterolaswellaslow-densitylipoprotein-cholesterolincreasedsignificantlyinbothusersofthecyproteroneacetate-containingCOCsandthedesogestrel-containingCOCs,althoughtheformercombinationcausedasignificantincreaseintriglyceridelevels–whicharealreadyincreasedinPCOSpatients[53,54•].sensitivity[15].Themechanismunderlyingtheposi-tiveimpactoforalcontraceptivesinPCOStreatmentiscomplexandcomprises:areductionofLHsecre-tion,inhibitionofovarianandadrenalandrogenpro-ductionandreductionofthefreetestosteronefractionsecondarytotheincreasedSHGBproductionintheliver[30,48].Theprogestins,presentinoralcontra-ceptives,haveprotectiveeffectsontheendometrium[26,39].Ithasbeenproventhatcontraceptivepillsre-ducetheriskofendometrialcancer[48].hyperinsulinemiadownregulatescirculatinglevelsofsex-hormone-bindingglobulin.Totaltestosteronelevelshavebeenunchangedbythiazolidinedionesinthemajorityofstudies,includingalargeRCToftroglitazone,[36]whereassignificantdecreasesincirculatinglevelsofandrostenedioneanddehydroepiandrosteronesulfatehavebeenobserved2.Endocrinology2012Sep;153(9):4354-66.doi:10.1210/en.2012-1145.Epub2012Jul9.MetformininhibitshumanandrogenproductionbyregulatingsteroidogenicenzymesHSD3B2andCYP17A1andcomplexIactivityoftherespiratorychain.HirschA,HahnD,KempnáP,HoferG,NuofferJM,MullisPE,FlückCE.SourceDepartmentofPediatrics,DivisionofPediatricEndocrinology,DiabetologyandMetabolism,UniversityHospitalInselspital,UniversityofBern,3010Bern,Switzerland.AbstractMetforministreatmentofchoiceforthemetabolicconsequencesseeninpolycysticovarysyndromeforitsinsulin-sensitizingandandrogen-loweringproperties.Yet,themechanismofactionremainsunclear.TwopotentialtargetsformetforminregulatingsteroidandglucosemetabolismareAMP-activatedproteinkinase(AMPK)signalingandthecomplexIofthemitochondrialrespiratorychain.Androgenbiosynthesisrequiressteroidenzymes17α-Hydroxylase/17,20lyase(CYP17A1)and3β-hydroxysteroiddehydrogenasetype2(HSD3B2),whichareoverexpressedinovariancellsofpolycysticovarysyndromewomen.Therefore,weaimedtounderstandhowmetforminmodulatesandrogenproductionusingNCI-H295Rcellsasanestablishedmodelofsteroidogenesis.Similartoinvivosituation,metformininhibitedandrogenproductioninNCIcellsbydecreasingHSD3B2expressionandCYP17A1andHSD3B2activities.Theeffectofmetforminonandrogenproductionwasdosedependentandsubjecttothepresenceoforganiccationtransporters,establishinganimportantroleoforganiccationtransportersformetformin'saction.MetformindidnotaffectAMPK,ERK1/2,oratypicalproteinkinaseCsignaling.Bycontrast,metformininhibitedcomplexIoftherespiratorychaininmitochondria.Similartometformin,directinhibitionofcomplexIbyrotenonealsoinhibitedHSD3B2activity.Inconclusion,metformininhibitsandrogenproductionbymechanismstargetingHSD3B2andCYP17-lyase.ThisregulationinvolvesinhibitionofmitochondrialcomplexIbutappearstobeindependentofAMPKsignaling.HumReprod.2012Nov;27(11):3304-14.doi:10.1093/humrep/des264.Epub2012Jul18.Metforminexposureaffectshumanandmousefetaltesticularcells.TartarinP,MoisonD,GuibertE,DupontJ,HabertR,Rouiller-FabreV,FrydmanN,PozziS,FrydmanR,LecureuilC,FromentP.SourceINRAUMR85,UnitédePhysiologiedelaReproductionetdesComportements,NouzillyF-37380,France.AbstractBACKGROUND:Metforminisadrugusedinthetreatmentofdiabetesandofsomedisordersrelatedtoinsulinresistance,suchaspolycysticovarysyndrome.Gestationaldiabetescancausecomplicationsforbothmotherandchild,andsomestudieshaveshownabeneficialeffectofmetforminduringpregnancywithoutanincreaseinperinatalcomplications.However,theeffectsonthegonadshavenotbeenproperlystudied.Hereweinvestigatedtheeffectofmetforminadministeredduringpregnancyonthedevelopmentandfunctionofthefetaltestis.METHODS:Adualapproachinvitroandinvivousinghumanandmousemodelswaschosen.Culturesofhumanandmurineorganotypictestesweremadeandinvivoembryonictesteswereanalysedafteroraladministrationofmetformintopregnantmice.RESULTS:Inhumanandmouseorganotypicculturesinvitro,metformindecreasedtestosteronesecretionandmRNAexpressionofthemainfactorsinvolvedinsteroidproduction.Invitro,thelowestobservedeffectconcentration(LOEC)ontestosteronesecretionwas50µMinhuman,whereasitwas500µMinmousetestis.LactatesecretionwasincreasedinbothhumanandmouseorganotypiccultureswiththesameLOECat500µMasobservedinothercellculturemodelsaftermetforminstimulation.Invivoadministrationofmetformintopregnantmicereducedthetesticularsizeofthefetalandneonataltestesexposedtometforminduringintrauterinelife.Althoughthenumberofgermcellswasnotaffectedbythemetformintreatment,thenumberofSertolicells,thenurs