Comparative study of hormonal dynamics in pregnant and nonpregnant cycles during pulsatile subcutaneous administration of human menopausal gonadotropin in anovulatory infertile women

OBJECTIVE

To assess the clinical relevance of daily hormonal changes for achieving a successful pregnancy in anovulatory infertile women.

DESIGN

A comparative study of hormonal dynamics in pregnant and nonpregnant cycles during the pulsatile subcutaneous administration of hMG. Subjects received subcutaneous injection of either 9.375 IU or 14.0625 IU of hMG diluted in 50-microL physiological saline (total daily dose, 150 or 225 IU) at 90-minute intervals by means of a portable peristaltic pump.

SETTING

Kyorin University Hospital and Ichikawa General Hospital.

PATIENTS

We analyzed 18 pregnant and 42 nonpregnant cycles in 17 patients with secondary hypothalamic/pituitary amenorrhea who conceived after receiving pulsatile hMG treatment. Another 14 women with normal spontaneous ovulation, including 14 pregnant and 15 nonpregnant cycles, served as controls.

MEASUREMENTS

Serum concentrations of LH, FSH, E2, and P were measured, and the P:E2 ratio was determined.

RESULTS

Serum concentrations of LH and FSH did not differ significantly between the pregnant and nonpregnant cycles. Serum levels of P and E2 were significantly higher during the hMG treatments than those of the spontaneous ovulatory cycles throughout the follicular and luteal phases. Up to the midluteal phase, the P and E2 values in the nonpregnant cycles during the hMG treatments did not differ significantly from those in the pregnant cycles. The P:E2 ratios were comparable between the pulsatile stimulatory cycles and the normal spontaneous ovulatory cycles. However, the P:E2 ratio in the early and midluteal phases was significantly greater in the pregnant cycles than in the nonpregnant cycles.

CONCLUSION

The P:E2 ratio in the early and midluteal phases is a more important indicator of hormonal function for implantation than the absolute levels of either P or E2.

Viable term pregnancy despite "subluteal" serum progesterone levels in the first trimester

This is a report of a 34-year-old patient with a 3-year history of unexplained infertility, who conceived after IVF-ET. Her serum P levels were < 2.0 ng/mL (conversion factor to SI unit, 3.180) between 5 and 6 weeks of gestation. She subsequently delivered a viable infant at term.

A clomiphene citrate and tamoxifen citrate combination therapy: a novel therapy for ovulation induction

OBJECTIVE

To assess the efficacy of a clomiphene citrate (CC) and tamoxifen citrate (CC/tamoxifen) combination therapy in ovulation induction by comparing with a CC alone therapy.

DESIGN

A randomized cross-over study with CC alone and CC/tamoxifen combination therapies for 20 normoprolactinemic anovulatory women. Randomly selected 10 of the 20 women (group A) underwent a CC alone therapy (100 mg CC during cycle days 5 to 9) for the initial three consecutive treatment cycles and a CC/tamoxifen combination therapy (50 mg CC and 20 mg tamoxifen during cycle days 5 to 9) for the subsequent three consecutive treatment cycles. The remaining 10 (group B) were treated similarly but with the inverse sequence. Ovulation was documented when a high BBT phase persisted for 11 days or more, when midluteal serum P levels exceeded 7 ng/mL (22.3 nmol/L), or when pregnancy ensued.

RESULTS

The rates of ovulatory/treated, pregnant/treated, and pregnant/ovulatory cycles were 42 of 56 (75.0%), 3 of 47 (6.4%), and 3 of 35 (8.6%) for CC/tamoxifen, respectively. Those were 25 of 57 (43.9%), 1 of 48 (2.1%), and 1 of 21 (4.8%) for CC, respectively. Clomiphene citrate/tamoxifen was more effective in ovulation induction than CC. All the pregnancies were normal and single. None of the treatments was accompanied by any remarkable side effects.

CONCLUSION

Clomiphene citrate/tamoxifen is a novel treatment modality of ovulation induction with high efficacy.

Sensory cues and the suppression of reproduction in subordinate female marmoset monkeys, Callithrix jacchus

Subordinate female marmoset monkeys remain anovulatory and have low plasma concentrations of luteinizing hormone (LH) when maintained with their dominant females. Olfactory cues from the dominant female have been implicated in maintaining this reproductive suppression. Subordinate females that received either ablation of the vomeronasal organ (an accessory olfactory organ; n = 3), ablation of the main olfactory epithelium (n = 4), or both lesions (n = 5) did not ovulate in the following 7 weeks while housed with their dominant female. Plasma LH concentrations following either or both lesions were similar to pre-lesion concentrations. Olfactory lesions (verified by histological and behavioural trials) did not impair reproductive activity, as olfactory-lesioned dominant females underwent ovarian cycles of similar duration to intact dominant females. Lesioned subordinate females (n = 6), maintained in visual-only contact with their dominant female and group ovulated 29.1 +/- 9.3 days (mean +/- SEM) after physical separation from their dominant females; this first onset of ovulation was significantly delayed (P < 0.05) compared with intact subordinate females completely isolated from their dominant females and group (10.8 +/- 1.3 days, n = 8). Behavioural and visual cues together with olfaction all appear to play important roles in maintaining the suppression of ovulation in subordinate female marmoset monkeys.

The role of insulin-like growth factor-1 (IGF-1) and IGF binding protein-1 (IGFBP-1) in the pathogenesis of polycystic ovary syndrome

The objective of this study was to elucidate the relationship and role of insulin-like growth factor-1 (IGF-1), IGF binding protein-1 (IGFBP-1), insulin and luteinizing hormone (LH) in the pathogenesis of polycystic ovary syndrome (PCOS). In a pilot study, serum concentrations of IGF-1 were determined in women with PCOS (n = 10), hypopituitarism (n = 12) and normal controls (n = 10). In the main study, serum concentrations of IGF-1, IGFBP-1, insulin and LH in women with anovulation associated (n = 23) and not associated (n = 47) with PCOS were determined. Serum concentrations of IGF-1 were not different in women with PCOS, anovulatory non-PCOS and healthy women but were low in those with hypopituitarism. Mean serum IGFBP-1 in PCOS (33.8 +/- 21.2 micrograms/l) was decreased compared with anovulatory non-PCOS (60.0 +/- 22 micrograms/l) (P = 0.0001), and correlated negatively with insulin concentrations (r = -0.67, P = 0.0006). Patients with PCOS could be separated into those with high LH and those with high insulin levels. It was concluded that women with PCOS have normal serum IGF-1 concentrations but IGFBP-1 levels, regulated by insulin, are low. Hyperinsulinaemia and raised LH are independently capable of stimulating ovarian androgen production. Growth factors may have an important role in the pathogenesis of PCOS.

[Changes in melatonin blood levels during gonadotropin releasing hormone loading tests in women with anovulatory disorders]

The results of seven gonadotropin releasing hormone (GnRH) loading tests are presented with special respect to the changes of melatonin level. The tests were carried out after a withdrawal bleeding triggered by progesterone (100 mg for 5 days) and plasma FSH, LH, prolactin and melatonin level were determined. The initial melatonin values were between 3.9 and 35.7 pg/ml and were in inverse ratio with the basal gonadotropin levels. In the case of reactive hypophyseal response the melatonin level decreased in every case in inverse ratio with the increase of gonadotropins. In one case, after the GnRH administration there was no increase in gonadotropin production and at the same time the melatonin secretion remained unchanged. According to our examinations the melatonin secretion during the GnRH loading test showed a good correlation with the changes of gonadotropins.

Amenorrhea and chronic anovulation. Finding and addressing the underlying cause

Amenorrhea is a common problem with a complex etiology. However, the same diagnostic approach can be used in evaluation of all amenorrheic patients. Complete history taking and physical examination are important for determining the presence of congenital abnormalities and chronic conditions. Pregnancy is the most common cause of amenorrhea and should be ruled out in initial laboratory evaluation. Progesterone can then be given to assess endogenous estrogen production and the functioning of the uterus and vagina. Response to this hormone suggests the presence of ovarian, hypothalamic, or pituitary dysfunction, which can be confirmed with further testing. Lack of response to progesterone indicates hypoestrogenism or obstruction of the outflow tract. An estrogen-progesterone challenge helps differentiate these conditions. Chronic anovulation is the second most common cause of amenorrhea. Treatment of chronic anovulation is important to prevent the effects of unopposed estrogen stimulation of the endometrium and to reduce the risk of endometrial adenocarcinoma.

Peripheral plasma met-enkephalin levels in ovulatory and anovulatory human menstrual cycles

OBJECTIVE

To test the hypothesis that met-enkephalin has a role in human ovulation and that plasma levels may differ between ovulatory and anovulatory ovarian cycles.

DESIGN

This is a descriptive study comparing levels of plasma met-enkephalin, gonadotropins, and ovarian steroids in 12 ultrasonically confirmed ovulatory cycles and 12 anovulatory cycles.

SETTING

The study took place in the infertility clinic of a large teaching hospital receiving primary and tertiary referrals of both private and public sector patients.

PATIENTS

All patients (n = 16) had infertility greater than or equal to 3 years and normal findings on previous investigation including evidence of ovulation.

INTERVENTIONS

Ovarian cycles were defined using transabdominal ultrasound scanning. Biochemical analyses were by radioimmunoassay.

MAIN OUTCOME MEASURES

The differences between plasma met-enkephalin levels in the two groups of cycles were compared.

RESULTS

Met-enkephalin levels are significantly higher in ovulatory cycles with a significant peak in the 2 postovulatory days (Duncan's multiple range test; P less than 0.05).

CONCLUSION

Human ovulation is associated with cyclic elevation of plasma met-enkephalin. Further studies are required to elucidate causality.

[Gonadotropin releasing hormone loading test with bromocryptin therapy: a new possibility in the differential diagnosis of normo-prolactinaemic anovulation]

An anovulation group with normal basal prolactin level (less than 600 mU/l) was found during GnRH loading tests. After GnRH administration there was a definite increase in prolactin value together with an insufficient hypophyseal response. Bromocriptine treatment was commenced on the 10th day (daily 2.5 mg) before carrying out the GnRH loading tests again. During the repeated tests prolactin levels remained normal, basal FSH and LH values increased and reactive hypophyseal responses occurred. On the basis of the examination a group ("latens hyperprolactinemia") responding with increased prolactin production during GnRH administration was found. This higher prolactin level inhibits gonadotropin release from hypophysis. In these cases ovulation induction with bromocriptine is adviseable in spite of basal prolactin level is normal.

Ovulation induction increases serum levels of insulin-like growth factor binding protein 1

The effect of ovulation induction on serum insulin-like growth factor binding protein 1 (IGFBP-1) level in relation to sex hormone binding globulin (SHBG) levels was evaluated. Serum samples were collected 8 to 12 days after ovulation from 26 women undergoing ovulation induction with clomiphene citrate (CC), and from 58 women treated with CC in combination with human menopausal gonadotropin (hMG) and human chorionic gonadotropin (hCG). In addition, serum samples were obtained from 63 spontaneously ovulating women and from 12 women during an anovulatory cycle. Luteal phase serum IGFBP-1 levels were 4.22 +/- 2.95 micrograms/L (P less than .05) in the CC group and 7.31 +/- 6.13 micrograms/L (P less than .001) in the CC/hMG/hCG group as compared to unstimulated ovulatory cycles (2.64 +/- 2.52 micrograms/L). No significant difference in IGFBP-1 levels was seen between spontaneously ovulatory and anovulatory cycles. The serum IGFBP-1 levels correlated positively to SHBG levels (r = .52, P less than .001). The data show that ovulation induction increases serum IGFBP-1 levels in parallel to SHBG levels, indicating that ovarian stimulation, which results in increased steroid hormone production, also induces changes in other factors known to modulate steroid hormone actions.

Longitudinal evaluation of the different gonadotropin pulsatile patterns in anovulatory cycles of young girls

We studied 13 adolescents (mean gynecological age 29.2 +/- 14.1 months) with anovulatory cycles and 7 women with ovulatory cycles (mean gynecological age 33.1 +/- 15.3 months) as a control group. Adolescents with anovulatory cycles were grouped on the basis of mean plasma LH values: group 1 (n = 7) with high LH values, and group 2 (n = 6) with normal LH values. In all women plasma gonadotropin concentrations were measured at 10-min intervals for 8 h on day 4 of the cycle. Pulsatile gonadotropin secretion was also studied in each subject a second time 40 months later, to establish the outcome of the different pulsatile patterns. Group 1 had more frequent and greater LH pulses than the other two groups (which were similar) and had the highest plasma 17 beta estradiol, testosterone, androstenedione, and 17 hydroxyprogesterone concentrations. Longitudinal control showed that: in group 1, three subjects out of seven acquired ovulatory cycles and there was a fall in mean LH plasma levels (30 +/- 5 vs. 9 +/- 4 IU/L; P less than 0.01), number of pulses (8.3 +/- 1.5 vs. 5 +/- 0; P less than 0.025), mean amplitude (13 +/- 3 vs. 5 +/- 2 IU/L; P less than 0.02) and an increase in interpulse interval (56 +/- 10 vs. 91 +/- 6 min; P less than 0.01). In four subjects anovulatory cycles persisted and the LH pulsatile profile remained unchanged. In group 2, five subjects out of six acquired ovulatory cycles, but there were no significant changes in the number of pulses (6 +/- 1 vs. 6 +/- 2; P = NS), interpulse interval (97 +/- 30 vs. 85 +/- 30 min; P = NS), or amplitude (5 +/- 2 vs. 4 +/- 2 IU/L; P = NS). The results indicate that: 1) anovulatory young women with early normal plasma LH values have an adequate GnRh pulsatile pattern which will easily lead to ovulation; 2) anovulatory young women with high LH plasma values may have a reproductive system blocked in a pathological condition, similar to that observed in polycystic ovary syndrome; 3) only few subjects with high plasma LH values are able to achieve ovulation and normalize LH pulsatile pattern as a consequence of a new mode of GnRh release.

The source of pulsatile secretion of progesterone during the human follicular phase

This study was designed to establish the normal pattern of serum progesterone and the origin of its secretion during the follicular phase of the normal menstrual cycle. In the first study, 12 normal women were studied on 3 occasions each at different times during a single follicular phase. Serum samples were collected every 10 min over 8 h, for 6 h before and 2 h after an injection of naloxone (5 mg iv). The mean serum progesterone remained constant (0.9 nmol/L) across the follicular phase until just before ovulation; individual subjects showed pulsatility of progesterone (1-6 pulses/6 h) but there was no relationship of this to LH pulsatility and no variation of progesterone pulsatility across the follicular phase. Naloxone caused an increase in the mean serum progesterone in the early follicular phase to 1.9 +/- 0.7 nmol/L and in the mid and late follicular phase to 2.1 +/- 0.7 nmol/L and 3.4 +/- 2.5 nmol/L, respectively. The second study was performed to assess the contribution of the residual corpus luteum and the developing follicle to the pulsatile secretion of progesterone. Seven anovulatory women with low levels of serum LH and absent LH pulsatility were studied before and after clomiphene (100 mg/day for 5 days) by collecting blood samples every 15 min for 6 h before GnRH (10 mg iv) and for 2 h afterwards. The anovulatory women had comparable mean serum concentration of progesterone (0.9 +/- 0.5 nmol/L) to normal women and similar frequency of progesterone pulsatility (2.1 +/- 1.1 pulses/6 h). After administration of clomiphene, there was no significant change in progesterone pulsatility (1.7 +/- 1.0 pulses/6 h) despite a substantial increase in LH pulsatility (from none to 3.0 +/- 1.0 pulses/6 h). There was no significant increase in serum progesterone after clomiphene or GnRH which both caused a substantial increase in serum LH. The third study involved eight normal women studied before and after treatment with dexamethasone (2 mg/day for 2 days) to assess the adrenal component of progesterone secretion. Blood samples were collected every 10 min for 6 h before and 2 h after naloxone (5 mg iv). Dexamethasone reduced serum progesterone to below assay sensitivity (less than 0.2 nmol/L) and obliterated progesterone pulsatility. The increase in serum progesterone and cortisol induced by naloxone was blocked by dexamethasone; the naloxone-induced rise of serum LH was not affected by dexamethasone. We conclude that neither the preceding corpus luteum nor the developing follicle are important contributors to the serum concentration of progesterone during the normal follicular phase.(ABSTRACT TRUNCATED AT 400 WORDS)

Correlations between mean LH levels and LH pulse characteristics: differences between normal and anovulatory women

OBJECTIVE

Since LH secretion occurs as a series of pulses, relationships between mean LH levels and LH pulse characteristics are to be expected. The aim of this study was to determine whether such relationships are similar in normal women and anovulatory patients.

DESIGN

We studied the correlations between mean LH levels and the products amplitude x frequency and area x frequency of LH pulses in normal women and in patients with disorders of ovulation. Blood samples were taken from each subject every 10 minutes during 6 hours on the 8th day after the last menses.

PATIENTS

The patients were divided into three groups: patients with polycystic ovary syndrome (n = 11), patients with idiopathic anovulation (n = 14) and patients with short luteal phase (n = 13). Their results were compared to those of 12 normal women.

MEASUREMENTS

LH was evaluated with an immunoradiometric assay. LH data were analysed with a 3 standard deviation threshold criterion for significant peaks, and with cluster analysis algorithm using 1, 2.5 and 5% false positive error rates and 'optimal parameters' (which give less than 5% false positive and false negative error rates in LH male data).

RESULTS

Highly significant correlations between amplitude x frequency, area x frequency and mean LH were found in normals and patients with short luteal phase; no significant correlation was found in patients with polycystic ovary syndrome, while significant correlations were found in patients with idiopathic anovulation only with some of our criteria for peak detection.

CONCLUSION

The differences that we found between the groups suggest that when commonly used methods are employed to determine LH pulse characteristics, most of the significant LH pulses are taken into account in normals and patients with short luteal phase, but not in anovulatory patients, especially in patients with polycystic ovary syndrome. This method using two correlations appears to be a simple and useful way to show the differences in the mechanisms by which mean LH levels are achieved in normal subjects and patients.

Ovarian sensitization to gonadotrophins by human growth hormone. Persistence of the effect beyond the treated cycle

OBJECTIVE

To document the persistence of a sensitizing effect of human growth hormone on the ovarian responsiveness to human menopausal gonadotrophin in anovulatory patients resistant to standard gonadotrophin doses.

DESIGN

We performed an open study of three patients given 4, 12 or 24 IU recombinant growth hormone on alternate days for 5-7 doses, concomitantly with gonadotrophin, and assessed gonadotrophin dose requirements before, during and after the cycle of growth hormone therapy.

PATIENTS

We studied two with isolated gonadotrophin deficiency and primary amenorrhoea and one with a pituitary tumour and hyperprolactinaemia which normalized with bromocriptine but in whom there was persisting secondary amenorrhoea.

MEASUREMENTS

We measured body mass index, FSH, LH, prolactin, growth hormone, insulin-like growth factor I (IGF-I), oestradiol and inhibin at baseline and growth hormone, IGF-I, oestradiol and inhibin during treatment. In addition we noted the numbers of ampoules (75 IU) and the last pre-hCG dose of gonadotrophin used before, during and after growth hormone therapy.

RESULTS

Baseline growth hormone levels were low but IGF-I levels were normal. IGF-I increased by 20% in the subject given 4 IU growth hormone, and by 50-100% in the other two. Pretreatment daily gonadotrophin dosage of 8-11 ampoules pre-hCG was reduced to 3-6 ampoules during growth hormone and 3-4 post growth hormone. This effect persisted for 4 cycles over 7 months in one subject.

CONCLUSION

Growth hormone causes persisting ovarian sensitization to gonadotrophin and may produce a substantial lowering of gonadotrophin requirement for ovulation induction in patients with large dosage needs.

Exaggerated prolactin response to thyrotropin-releasing hormone in infertile women with the luteinized unruptured follicle syndrome

Ten cases of luteinized unruptured follicle (LUF) syndrome out of 250 women with unexplained infertility were detected on ultrasonography, giving a frequency of 4%. Hormonal analysis revealed lower serum progesterone levels at mid-luteal phase in LUF cases, suggesting a link between LUF syndrome and inadequate luteal phase. Prolactin response to thyrotropin-releasing hormone was exaggerated in LUF cases as compared with ovulatory cases. Aberrant prolactin release may be a contributory factor in the pathophysiology of the LUF syndrome.

Treatment of anovulation due to polycystic ovarian syndrome by laparoscopic ovarian electrocautery

Our experience of ovarian electrocautery for the treatment of polycystic ovarian syndrome (PCOS) in ten women is described. We found that nine responded favourably, either ovulating spontaneously or becoming more responsive to ovulation induction. There was a significant and persistent fall in serum testosterone levels, and a transient fall with subsequent rise in inhibin. We recommend that laparoscopic ovarian electrocautery is considered as an alternative to ovulation induction with gonadotrophins, in women with PCOS who fail to respond to clomiphene citrate.

Gonadotropin, steroid, and inhibin levels in women with incipient ovarian failure during anovulatory and ovulatory rebound cycles

We have identified a group of women with infertility and regular menses who have persistently raised FSH levels and probable incipient ovarian failure (IOF). Thirteen such women (19 cycles) had serum samples taken for RIA of LH, FSH, estradiol, and progesterone (P) 3 times a week over 1 menstrual cycle. Sixty infertile women with normal ovulatory cycles (as determined by hormones and ultrasound scan) served as controls. Overall, the FSH was higher (P less than 0.01) on all days of the cycle in the IOF group, serum LH was raised on days-14 to-5 before and days 5-11 after the LH surge. There was no difference between estradiol and P levels in the two groups. Ultrasound scanning showed failure of normal ovulation in the IOF group. Inhibin, measured by RIA in 9 cycles in the IOF group was lower (P less than 0.01) during the follicular phase than in 43 normal cycles. The highest inhibin level was seen in the luteal phase, as in normal cycles, but levels were still lower (P less than 0.01) in the IOF group. Inhibin was inversely correlated with FSH (P less than 0.05) during the follicular and luteal phases and was correlated with P during the luteal phase (P less than 0.05) in the IOF group. After 3 weeks of suppression (39 cycles) with an estrogen-progestogen preparation in the IOF group, LH and FSH fell to normal values. Ovulation occurred in 22 cycles on withdrawal of suppression in the presence of high FSH levels and low inhibin levels. No pregnancies occurred. These findings are consistent with the suggestion that diminished ovarian inhibin secretion may contribute to the elevated FSH levels of IOF and indicate that ovulation in the rebound cycle after suppression occurs in the presence of high FSH and low inhibin levels. Such cycles, however, still appear to be subfertile.

Relationship between blood radioimmunoreactive beta-endorphin and hand skin temperature during the electro-acupuncture induction of ovulation

Thirteen cycles of anovulation menstruation in 11 cases were treated with Electro-Acupuncture (EA) ovulation induction. In 6 of these cycles which showed ovulation, the hand skin temperature (HST) of these patients was increased after EA treatment. In the other 7 cycles ovulation was not induced. There were no regular changes in HST of 5 normal subjects. The level of radioimmunoreactive beta-endorphin (r beta-E) fluctuated, and returned to the preacupunctural level in 30 min. after withdrawal of needles in normal subjects. After EA, the level of blood r beta-E in cycles with ovulation declined or maintained the range of normal subjects. But the level of blood r beta-E in cycles in which the induction failed to cause ovulation was kept higher that that of normal. (P less than 0.05). There was a negative correlation in the decrease of blood r beta-E and increase of HST after EA (r = 0.677, P less than 0.01). EA is able to regulate the function of the hypothalamic-pituitary-ovarian axis. Since a good response is usually accompanied with the increase of HST, monitoring HST may provide a rough but simple method for predicting the curative effect of EA. The role of r beta-E in the mechanism of EA ovulation induction was discussed.

[The effect of a peripheral androgenic blockade on plasma lipoproteins in hirsutism patients]

We studied the effect of flutamide, a peripheral androgenic blocking agent, 500 mg daily for 28 days in 7 non ovulating patients with hirsutism. Total and HDL cholesterol, triglycerides, testosterone and dehydroepiandrosterone sulphate (S-DHEA) plasma levels were measured in patients and in 6 non ovulating control women of similar age and weight. Only basal HDL levels were lower in patients than in controls (40.2 +/- 1.6 vs 51.4 +/- 3.3 mg/dl, p < 0.01). A decrease in S-DHEA levels was observed after flutamide in patients with hirsutism (3.2 +/- 0.4 to 2.1 +/- 0.4, p < 0.01) which may be attributed to the lowering of cortisol clearance induced by the drug. Total testosterone and plasma lipoproteins remained stable. Thus, peripheral androgenic blockade does not modify the decreased levels of HDL cholesterol in non ovulating patients with hirsutism.

[Hypothalamo-hypophyseal amenorrhea. I. The clinical and laboratory manifestations]

This study included 15 women 18-36 years old with primary or secondary amenorrhea, low FSH and LH, a negative response to clormadinone and serum prolactin (Prl) levels less than 20.0 ng/ml. The following tests were performed on alternate days: LH and FSH determinations every 20 minutes (pulses) during 2-4 hours (n = 15); LH and FSH response to a single dose of GnRH 100 micrograms IV (n = 15) and after administration of 100 micrograms IM of GnRH daily during four consecutive days (n = 7); TRH test 200 micrograms IV (n = 9); oral metoclopramide-Prl induced response (10 mg) (n = 2); one to three basal determinations of cortisol, estradiol (E2), T3, T4, and TSH (n = 15). All patients had serum E2 levels less than 10.0 pg/ml and none showed a regular LH or FSH pulsatility. In seven patients (group A) serum LH had a 10-30 fold increase above basal levels in response to GnRH, while the other eight patients (group B) showed no response at all; serum FSH changes were most irregular in both group. In group A no other hormonal deficiencies were detected, while in group B only three patients had an isolated LH-FSH deficiency, and in the other five this deficiency was accompanied by Prl, TSH, and/or ACTH lack. The present results suggest that: 1) group A represents isolated GnRH deficiency and the amenorrhea has hypothalamic etiology; 2) group B had LH-FSH deficiency of pituitary origin, in most cases associated to other pituitary hormone deficiencies; 3) the lack of LH response to an initial single dose of GnRH is not an absolute indicator of hypophyseal amenorrhea.

Luteinizing hormone bioactivity and variable responses to clomiphene citrate in chronic anovulation

In 18 women with infertility and chronic anovulation with normal gonadotropins, three different responses were observed to increasing doses (250 to 750 mg) of clomiphene citrate (CC). Follicle development and ovulation in 8, follicle development but no ovulation without human chorionic gonadotropin (hCG) in 6, and no response to CC in 4. Serum concentrations of bioactive luteinizing hormone (bioactive-LH), immunoactive (immunoactive-LH), follicle-stimulating hormone, and estradiol (E2) were measured and follicle growth was assessed by daily ultrasound. Findings were compared with 8 normal ovulatory controls. Folliculogenesis on CC therapy, based on our data, was 78%; however, only 44% ovulated spontaneously, 34% required hCG for follicle rupture. There were no apparent hormonal indicators to predict responders from nonresponders. The absence of an LH surge in the presence of follicles and sustained high E2 concentrations in 34% of patients may be associated with a decreased E2 sensitivity at the hypothalamic-pituitary level. Ultrasound easily identified patients who responded to CC with folliculogenesis but did not initiate an LH surge. Follicle rupture was achieved promptly by hCG administration.

Efficacy and safety of intravenous pulsatile gonadotropin-releasing hormone: Lutrepulse for injection

A multicenter trial was undertaken to assess the ability of pulsatile gonadotropin-releasing hormone to restore physiologic ovulatory function in women with diminished or absent pulsatile gonadotropin-releasing hormone secretion. In 109 women with primary and secondary hypothalamic amenorrhea, pulsatile gonadotropin-releasing hormone (Lutrepulse [gonadorelin acetate] for Injection) was extremely effective, resulting in ovulation in 91% and 96% of patients, respectively. Overall complications of intravenous line placement ranged from 0% to 11% (mean = 7%). A 12% incidence of multiple pregnancy was noted, and a single case of ovarian hyperstimulation was reported in a woman who also received clomiphene citrate. Pulsatile gonadotropin-releasing hormone treatment appears to be of at least comparable efficacy to human menopausal gonadotropins, with the added benefit of reduced overall risks for the patient with hypothalamic amenorrhea.

Serum CA 125 levels during the menstrual cycle

Serum concentrations of CA 125 were measured in different phases of the menstrual cycle in 16 women with ovulatory and 12 women with anovulatory cycles. CA 125 levels were significantly elevated during menstruation in both groups. In women with anovulatory cycles, but not in those with ovulatory cycles, CA 125 levels were already increased in the premenstrual phase. A negative correlation was found between serum CA 125 and progesterone concentrations in the premenstrual phase of the cycle. We suggest that premenstrual elevation of serum CA 125 in women with anovulatory cycles is related to premature endometrial vascular changes which are the result of the low serum progesterone concentration leading to insufficient endometrial control. Thus the effect of progesterone seems to be indirect rather than a direct effect on CA 125 synthesis. When the CA 125 assay is used for diagnosis of cancer, sampling should not be done immediately before or during menstruation because the physiological elevation of the CA 125 levels may give false positive results.

Inhibin secretion during the ovulatory cycle and pregnancy in the common marmoset monkey

Changes in plasma concentrations of immunoreactive inhibin in the reproductively cyclic, pregnant and ovariectomized female marmoset monkey (Callithrix jacchus) were measured with a heterologous radioimmunoassay. The pattern of inhibin secretion in five marmosets studied individually during four consecutive cycles was shown to resemble that of progesterone. In these animals, data were pooled according to stage of cycle on the basis of plasma progesterone concentrations. Mean values for inhibin were 5465 and 4972 U/l during the early and late follicular phase. Concentrations rose during the luteal phase to 8431, 12,246 and 12,557 U/l for the early, mid- and late luteal phase respectively. The hormonal profile of inhibin during the normal cycle is similar in both marmoset and stumptailed macaque; however, the marmoset has a 28-fold greater level of inhibin during the luteal phase. In six marmosets in which pregnancy occurred, inhibin concentrations showed no decline at the end of the conceptual cycle and remained increased with respect to the follicular phase throughout the subsequent gestation. Inhibin levels were non-detectable (less than 1000 U/l) in ovariectomized and acyclic marmosets. These results suggest that the corpus luteum is the major source of inhibin in this New World monkey, in common with man and the Old World primates.