Precise day of ovulation determined by real-time ultrasound evidence of graafian follicular development

Physiological aspects and clinical sequelae of energy deficiency and hypoestrogenism in exercising women

Amenorrhoea associated with reduced caloric intake and strenuous exercise leads to hypoestrogenism and is associated with clinical manifestations that include disordered eating, stress fractures, osteoporosis, and, as recently reported, a potential increase in the risk of premature cardiovascular disease. Disordered eating, menstrual irregularities and bone loss comprise the clinical condition known as the 'female athlete triad'. The aetiology of the triad is linked to a high prevalence of disordered eating and cognitive restraint. This results in inadequate caloric intake for high exercise energy expenditures that leads to energy deficiency. This in turn stimulates compensatory mechanisms, such as weight loss or energy conservation, subsequently causing a central suppression of reproductive function and concomitant hypoestrogenism. Because the aetiology of menstrual disturbances and the female athlete triad is causally linked to energy deficiency, there is no justification for fears that exercise itself is unhealthy for women. However, improved detection, monitoring, and treatment of all components of the triad in exercising women should be emphasized. This paper critically reviews the physiological aspects and clinical sequelae of energy deficiency and hypoestrogenism associated with the female athlete triad in exercising women.

Validity of methods for analyzing urinary steroid data to detect ovulation in athletes

PURPOSE

The purpose of this study was to determine whether the accuracy of ovulation detection algorithms is compromised when applied to menstrual cycles exhibiting subclinical hormonal abnormalities, which are particularly prevalent in female athletes.

METHODS

The validity of five ovulation detection algorithms was compared between 25 regularly exercising women and 15 sedentary controls. Subjects collected daily urine samples for an entire menstrual cycle for analysis of estrone-3-glucuronide (E1G), pregnanediol-3-glucuronide (PDG), and luteinizing hormone (LH). The algorithms were applied to determine their sensitivity (% of true ovulatory cycles), specificity (% of true anovulatory cycles), and the deviation from the reference day of ovulation (difference scores).

RESULTS

The sensitivity was > 80% in all algorithms except Baird's E1G/PDG ratio algorithm (74%) and Kassam's PDG ratio algorithm (78%). All algorithms, except Kassam's PDG ratio algorithm (80%), were found to exhibit specificities < 70%. Baird's E1G/PDG ratio algorithm was the most accurate in estimating the day of ovulation by deviating only -0.2 +/- 0.3 d from the reference day in the exercising female cycles and -0.5 +/- 0.3 d in the controls. No statistical differences in the sensitivities of the algorithms were found between the exercising and control cycles. When comparing the deviation from the reference day of ovulation between subject groups, no statistical difference was found.

CONCLUSION

The algorithms display similar validity in determining the presence and day of ovulation between subject groups, and thus may be applied to cycles exhibiting subclinical hormonal abnormalities as commonly observed in exercising women.

Using the ratio of urinary oestrogen and progesterone metabolites to estimate day of ovulation

We have developed a method of estimating day of ovulation using urinary ovarian hormone data. The method identifies a day of luteal transition that occurs at the shift from production of follicular oestrogen to luteal progesterone. The algorithm for identifying this shift was evaluated and judged better than specified alternatives in that it resulted in (1) a high concordance between the day of luteal transition and peaks in urinary luteinizing hormone (LH) for cycles with well-defined peaks, (2) a low variance in the length of the luteal phase of the menstrual cycle, which presumably reflects a low measurement error in estimating day of ovulation, and (3) a high proportion of cycles for which an approximate day of ovulation could be determined. To validate the new algorithm, it was applied to an independent data set. The algorithm identified a day of luteal transition in 88 per cent of these cycles, and the identified day occurred within two days of the urinary LH peak for all the cycles with clear LH peaks. Determination of the day of luteal transition to estimate ovulation requires only first-morning urine specimens, requires no correction for day-to-day variations in urine concentration, and can be applied to a mid-cycle window of data.

Ultrasonic assessment of ovulation in cyclofenil induced ovulatory cycles

Graafian follicle growth was studied by ultrasound scanning during the peri-ovulatory period in 64 ovulatory cycles in 32 infertile patients on cyclofenil treatment, and compared with a control group of 32 patients with confirmed ovulatory cycles assessed on the basis of serum progesterone levels in the middle of the second half of the cycle. The mean maximum diameters of the leading follicles before ovulation were 21.9 +/- 0.6 (S.E.) mm and 24.4 +/- 0.5 (S.E.) mm, respectively for the cyclofenil group and the normal control group (P greater than 0.05). In 79% of the cyclofenil stimulated group and 83% of the spontaneous ovulation group, ultrasonic evidence of ovulation was present between 12 and 36 h after the initial increase in urine LH levels. Ultrasound scanning was found to be simple, and a quick method of monitoring graafian follicle development and ovulation on cyclofenil therapy and the cycles were comparable to the spontaneous ovulatory cycles as assessed on the basis of graafian follicle diameter, and the time of ovulation. Cervical score was not found to be useful to assess ovulation time in the cyclofenil treated group since 31.3% achieved a score of 10 or more on day -4, 93.8% within 24 h of ovulation and 24% on day 3 following the ovulation.

Linear regression analysis of ultrasound follicular growth series: statistical relationship of growth rate and calculated date of growth onset to total growth period

Linear regression analysis was used to assess the serial growth of carefully measured individual mean follicular diameters as a function of menstrual age in a group of normal volunteers in natural, unstimulated cycles (n = 18). Follicle diameter (FD) growth, as measured with serial pelvic ultrasonography, can be shown to be essentially linear (mean R2, 0.92) with respect to time up to the point of ovulation. Growth rate (k) and the calculated date of growth onset (Do) are obtainable from the individual regression equations. Because an approximation of the date of ovulation (Dov, measured by menstrual age at the date of peak mean follicular size) is an available parameter, total growth period (TGP) is calculated with the equation (TGP = Dov - Do). Do, k, and TGP are highly correlated with one another. The mean parameters (+/- standard deviation) are Do = 4.29 +/- 2.77 day, k = 0.24 +/- 0.07 cm/day, TGP = 10.32 +/- 2.35 day, peak FD = 2.34 +/- 0.28 cm, and Dov = 14.61 +/- 2.00 day. The internal correlation of these parameters predicts that information from the first several scans in an individual series may be used to forecast date of ovulation. This may represent an improvement over the use of follicle size or menstrual age alone in planning for human chorionic gonadotropin administration, insemination timing, follicular aspiration and other interventions.

Follicular growth and endocrine profiles in spontaneous and induced conception cycles

Twenty conception cycles were tracked with ultrasound ovarian scanning from the midfollicular to midluteal phase, and simultaneous hormone profiles were obtained in 18 of the cycles. Twelve cycles were spontaneous and 8 were induced with a variety of regimens. Two of the spontaneous cycles did not have endocrine data, and in one other no follicular growth was observed, despite repeated scanning. The induced cycles did not differ significantly from the spontaneous ones in any respect except the number of follicles and the consequent estradiol (E2) levels. E2 levels per unit total follicular surface area, however, were similar in both groups and remained relatively constant throughout the late follicular phase.