Urinary follicle-stimulating hormone peak as a biomarker for estimating the day of ovulation

Detection of ovulation, a review of currently available methods

The ability to identify the precise time of ovulation is important for women who want to plan conception or practice contraception. Here, we review the current literature on various methods for detecting ovulation including a review of point‐of‐care device technology. We incorporate an examination of methods to detect ovulation that have been developed and practiced for decades and analyze the indications and limitations of each—transvaginal ultrasonography, urinary luteinizing hormone detection, serum progesterone and urinary pregnanediol 3‐glucuronide detection, urinary follicular stimulating hormone detection, basal body temperature monitoring, and cervical mucus and salivary ferning analysis. Some point‐of‐care ovulation detection devices have been developed and commercialized based on these methods, however previous research was limited by small sample size and an inconsistent standard reference to true ovulation.

Reclaiming fertility awareness methods to inform timed intercourse for HIV serodiscordant couples attempting to conceive

INTRODUCTION

Increased life expectancy of HIV-positive individuals during recent years has drawn attention to their quality of life, which includes fulfillment of fertility desires. In particular, heterosexual HIV serodiscordant couples constitute a special group for whom the balance between desired pregnancy and the risk of viral transmission should be carefully considered and optimized. Although advanced assisted reproductive technologies are available, such treatments are expensive and are often unavailable. Moreover, standard viral load testing and antiretroviral therapy may not be accessible due to structural or individual barriers. To reduce the risk of HIV transmission, a lower cost alternative is timed condomless sex combined with other risk-reduction strategies. However, timed condomless sex requires specific knowledge of how to accurately predict the fertile window in a menstrual cycle. The aim of this study was to summarize inexpensive fertility awareness methods (FAMs) that predict the fertile window and may be useful for counselling HIV-positive couples on lower cost options to conceive.

METHODS

Original English-language research articles were identified by a detailed Medline and Embase search in July 2014. Relevant citations in the included articles were also retrieved.

RESULTS AND DISCUSSION

Calendar method, basal body temperature and cervicovaginal mucus secretions are the most accessible and sensitive FAMs, although poor specificity precludes their independent use in ovulation detection. In contrast, urinary luteinizing hormone testing is highly specific but less sensitive, and more expensive. To maximize the chance of conception per cycle, the likelihood of natural conception needs to be assessed with a basic fertility evaluation of both partners and a combination of FAMs should be offered. Adherence to other risk-reduction strategies should also be advised, and timely referral to reproductive medicine specialists is necessary when sub/infertility is suspected.

CONCLUSIONS

FAMs provide effective, economical and accessible options for HIV serodiscordant couples to conceive while minimizing unnecessary viral exposure. It is important for health care providers to initiate conversations about fertility desires in HIV-positive couples and to educate identified couples on safer conception strategies.

Biological variability in serum anti-Müllerian hormone throughout the menstrual cycle in ovulatory and sporadic anovulatory cycles in eumenorrheic women

STUDY QUESTION

Does serum anti-Müllerian hormone (AMH) vary significantly throughout both ovulatory and sporadic anovulatory menstrual cycles in healthy premenopausal women?

SUMMARY ANSWER

Serum AMH levels vary statistically significantly across the menstrual cycle in both ovulatory and sporadic anovulatory cycles of healthy eumenorrheic women.

WHAT IS KNOWN ALREADY

Studies to date evaluating serum AMH levels throughout the menstrual cycle have conflicting results regarding intra-woman cyclicity. No previous studies have evaluated an association between AMH and sporadic anovulation.

STUDY DESIGN, SIZE, DURATION

We conducted a prospective cohort study of 259 regularly menstruating women recruited between 2005 and 2007.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Women aged 18-44 years were followed for one (n = 9) or two (n = 250) menstrual cycles. Anovulatory cycles were defined as any cycle with peak progesterone concentration ≤5 ng/ml and no serum LH peak on the mid or late luteal visits. Serum AMH was measured at up to eight-time points throughout each cycle.

MAIN RESULTS AND THE ROLE OF CHANCE

Geometric mean AMH levels were observed to vary across the menstrual cycle (P < 0.01) with the highest levels observed during the mid-follicular phase at 2.06 ng/ml, decreasing around the time of ovulation to 1.79 ng/ml and increasing thereafter to 1.93 (mid-follicular versus ovulation, P < 0.01; ovulation versus late luteal, P = 0.01; mid-follicular versus late luteal, P = 0.05). Patterns were similar across all age groups and during ovulatory and anovulatory cycles, with higher levels of AMH observed among women with one or more anovulatory cycles (P = 0.03).

LIMITATIONS, REASONS FOR CAUTION

Ovulatory status was not verified by direct visualization. AMH was analyzed using the original Generation II enzymatically amplified two-site immunoassay, which has been shown to be susceptible to assay interference. Thus, absolute levels should be interpreted with caution, however, patterns and associations remain consistent and any potential bias would be non-differential.

WIDER IMPLICATIONS OF THE FINDINGS

This study demonstrates a significant variation in serum AMH levels across the menstrual cycle regardless of ovulatory status. This variability, although statistically significant, is not large enough to warrant a change in current clinical practice to time AMH measurements to cycle day/phase.

STUDY FUNDING/COMPETING INTERESTS

This research was supported by the Intramural Research Program of the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), National Institutes of Health, Bethesda, MD (Contracts # HHSN275200403394C, HHSN275201100002I Task 1 HHSN27500001). The authors have no conflicts of interest to declare.

Characterization of follicle stimulating hormone profiles in normal ovulating women

OBJECTIVE

To describe FSH profile variants.

DESIGN

Observational study.

SETTING

Multicenter collaborative study.

PATIENT(S)

A total of 107 women.

INTERVENTION(S)

Women collected daily first morning urine and underwent serial ovarian ultrasound.

MAIN OUTCOME MEASURE(S) FSH RESULT(S)

The individual FSH cyclic profiles demonstrated a significant departure from the currently accepted model. A decline in FSH levels at the end of the follicular phase was observed in only 42% of cycles. The absence of this decline was significantly associated with a shorter luteal phase and higher pregnanediol-3α-glucuronide, FSH, and LH levels at the time of ovulation. In 34% of the cycles, significant FSH variability was observed throughout the follicular phase; this variability was associated with higher body mass index and lower overall FSH and LH levels throughout the cycle. The FSH peak occurs on average 2 hours before ovulation. The FSH peak duration was shorter than the LH peak.

CONCLUSION(S)

These results suggest that average FSH profiles may not reflect the more complex dynamics of daily hormonal variations in the menstrual cycle. It is possible that discrepancies between the average normal FSH profile and the individual day-to-day variants can be used to detect abnormalities.

Exposure to multiple low-level chemicals in relation to reproductive hormones in premenopausal women involved in liquid crystal display manufacture

Background: Liquid crystal display (LCD) manufacturing involves three fabrication processes: array, panel and module processes, which result in different levels of volatile organic compound (VOC) exposure. The aim of this study was to assess the potential reproductive endocrine effects of occupational exposures during LCD manufacturing predictive of menstrual cycles as subclinical markers of female reproductive dysfunction effects of low-dose exposures. Methods: A total of 94 fabrication workers were followed for one complete menstrual cycle using daily urine samples: 23 were from the array, 53 from the panel, and 18 from the module work areas. The menstrual cycle characteristics of the study population were measured using a self-administered questionnaire. Urine samples were collected during the first urination in the morning for at least one complete menstrual cycle. The urine was then analyzed to determine the urinary concentrations of follicular stimulating hormone (FSH), estrone conjugates (E1C), and pregnanediol-3-glucuronide (PdG). The results of this analysis were used to assess the potential effects of chemical exposure as determined by handheld volatile organic compound (VOC) monitors and 24 h canisters. Results: The concentration of total VOCs was much higher in the module making area (ND–21,000 ppb) than in panel (ND–766 ppb) and array (58–1,472 ppb) making areas. The concentrations of ethanol and acetone were much higher in the module (1,974.9 and 2,283.2 ppb, respectively) and panel (2256.9 and 592.2 ppb, respectively) making areas. Compared to those in the array making area, we found that E1C (12.55, 95% confidence interval (CI): 8.49, 16.61 μg/mg Cr) and PdG (0.53, 95% CI: 0.29, 0.77 μg/mg Cr) levels in the module group were significantly higher in the early follicular phase; E1C (11.93, 95% CI: 6.21, 17.65 μg/mg Cr) and PdG (0.53, 95% CI: 0.29, 0.77 μg/mg Cr) levels were significantly higher in the periovulatory phase; and all the hormone levels, FSH (1.48, 95% CI: 0.81, 2.15 μg/mg Cr), E1C (9.29, 95% CI: 4.92, 13.66 μg/mg Cr), and PdG (1.01, 95% CI: 0.42, 1.60 μg/mg Cr) were also significantly higher in the luteal phase. In addition, the FSH (0.89, 95% CI: 0.07, 1.71 μg/mg Cr) level in the panel group was significantly higher but E1C (−4.49, 95% CI: −7.90, −1.08 μg/mg Cr) was lower in the early follicular phase; and E1C (−5.16, 95% CI: −9.61, −0.71 μg/mg Cr) level was significantly lower in the periovulatory phase. Conclusions: Our findings add to the evidence that exposure to multiple low-level chemicals is associated with modest changes in reproductive hormone urinary concentrations in healthy premenopausal women. In addition, the FSH (0.89, 95% CI: 0.07, 1.71 μg/mg Cr) level in the panel group was significantly higher but E1C (−4.49, 95% CI: −7.90, −1.08 μg/mg Cr) lower in the early follicular phase; and E1C (−5.16, 95% CI: −9.61, −0.71 μg/mg Cr) level was significantly lower in the periovulatory phase.

Women in Steady Exercise Research (WISER): study design and methods

PURPOSE

Observational studies have shown that physical activity is inversely associated with breast cancer etiology. WISER is a randomized controlled trial examining the effects of exercise training on oxidative stress, and hormonal and metabolic factors associated with breast cancer risk.

METHOD

Subjects were recruited via emails, flyers, and mass media advertising. Inclusion criteria included: sedentary, age 18-30 years, non-smokers, BMI 18-40 kg/m2, not using any hormonal contraceptives. After completion of all baseline measures subjects were randomized into a control group or an exercise intervention for 4 menstrual cycles. The exercise group was asked to complete five 45 min exercise sessions per week. Exercise intensity was set at 65-70% of maximum age- predicted heart rate (max HR) and increased every four weeks. All women provided blood samples four times during the study for measurement of blood F2-isoprostanes, hormones and IGF-axis proteins. In addition, 24-hour urine samples were collected at baseline and follow-up for measurement of estrogen metabolites, as well as 24-hour food records to monitor participants' diets.

DISCUSSION

WISER consented 683 women among which 391 enrolled and 319 successfully completed the study. The overall dropout rate was 18.4% (n=72) with a higher number of participants dropping from the exercise group (n=46). No differences were found between dropouts and completers with respect to age, body weight, BMI, and demographic characteristics with the exception of degree of education. Findings from this trial will be useful in understanding the physiologic mechanisms by which exercise possibly contributes to decreased breast cancer risk.

FSH biosensor to detect postpartum ovarian recrudescence

Preliminary evidence of FSH suppression as a marker of postpartum ovarian recrudescence is presented. Falling FSH concentration in response to ovarian follicular estrogenic secretory activity apparently signals the reestablishment of menstrual cycles. We propose to investigate further this phenomenon with the development of a portable FSH biosensor. The FSH biosensor design is based on SPR and biological thin-film technologies and is incorporated as a key element of the fertility information appliance. It is possible that the device could be a useful natural family planning tool, especially during the return to fertility after childbirth.

Hourly human chorionic gonadotropin secretion profiles during the peri-implantation period of successful pregnancies

OBJECTIVE

To characterize the hourly profiles of hCG secretion in blood during conceptive cycles that ended in successful pregnancy.

DESIGN

Prospective study.

SETTING

University fertility clinic and research laboratories.

PATIENT(S)

Healthy spontaneously ovulating women with regular menses, no history of infertility, and either no male partner or an azospermic partner.

INTERVENTION(S)

Frequent blood samples were collected daily from 11 spontaneously ovulating women during 11 cycles of artifical insemination with donor semen. The concentrations of hCG, LH, and FSH were measured in the blood by immunoassay.

MAIN OUTCOME MEASURE(S)

The concentration of hCG in the frequent blood samples and the rate that the concentration of hCG changed during the period of frequent sampling.

RESULT(S)

For the conceptive cycles resulting in successful pregnancies analyzed, hourly hCG concentrations were observed to increase in a consistent nonpulsatile manner.

CONCLUSION(S)

These data provide the first characterization of the hourly secretion profile of hCG in early pregnancy as well as provide further evidence that individual daily blood samples are sufficient for the accurate assessment of pregnancy.

Assessment of Urinary Gonadotropin and Steroid Hormone Profiles of Female Cynomolgus Monkeys after Treatment with Pueraria mirifica

This study investigated the changes in the urinary hormone levels of female monkeys (Macaca fascicularis) after single-dose and long-term treatments with Pueraria mirifica (PM). The monkeys were separated into 3 groups (n=3) and orally treated with 10, 100, or 1,000 mg of PM in each group. Two series of experiments were performed. In the first series of experiments, the monkeys were orally treated with a single dose of PM. The experimental schedule was divided into a one menstrual cycle pretreatment period and a two menstrual cycle post-treatment period. In the second series of experiments, the monkeys were orally treated daily with PM for 90 days. The experiment schedule was divided into a one menstrual cycle pretreatment period, a three menstrual cycle treatment period, and a two menstrual cycle post-treatment period. Urinary samples were collected daily and assayed for the FSH, LH, estradiol, and progesterone levels. The results showed that there were no changes in the FSH, LH, estradiol, and progesterone levels after treatment with a single dose of 10, 100, or 1,000 mg of PM or after daily treatment with 10 mg of PM for 90 days compared with the levels observed during the pretreatment period. Daily treatment with 100 mg and 1,000 mg of PM for 90 days only produced a clear reduction in the urinary FSH levels. This suggests that changes of urinary FSH levels can be considered an indicator for study of estrogenic effects on hormonal levels in female monkeys.

[Identification of the intercycle FSH signal in urine samples (uFSH)]

OBJECTIVE

The intercycle FSH signal that initiates follicular recruitment and marks the functional onset of the menstrual cycle is of small amplitude and while it commonly occurs on cycle day 3, this often varies. Hence, its identification and measurement in serum (sFSH) requires serial daily samplings. We attempted to determine whether urine measurements of FSH (uFSH) could offer a non-invasive alternative, using a model where the intercycle FSH signal is controlled by timely use of exogenous E2.

PATIENTS AND METHODS

Pilot prospective trial in 21 infertile women having received E2, from day 25 of the previous cycle until the 1st Friday after menses. Blood and first void urine samples were collected, starting on the last day of E2 (baseline) for assessing FSH and creatinin. A sonogram was performed for identification of maturing follicles (>12 mm).

RESULTS

uFSH and uFSH/Cr showed good correlation with sFSH (R = 0.52 and 0.63, P < 0.0001 and P < 0.0001, respectively). In 15/21 patients who had an intercycle sFSH elevation, this was confirmed by uFSH elevation, both occurring within 2-4 days after stopping E2. In all these women, the sonogram showed evidence of impending ovulation. The amplitude of the uFSH signal was on average 3 times higher than its sFSH counterpart. In 6/21 women, no intercycle FSH elevation was detected and no ovulation occurred.

DISCUSSION AND CONCLUSION

Our results show that the intercycle FSH signal can easily be identified and measured in urine. This novel approach permits more precise assessments of ovarian physiology than with blood measurements.

Daily immunoactive and bioactive human chorionic gonadotropin profiles in periimplantation urine samples

A need exists for broadly applicable biomarkers of pregnancy outcome in population-based studies that assess environmental hazards to human reproduction. Previous studies have demonstrated that during the periimplantation period, measures of the circulating levels of immunoreactive hCG (IhCG) are not predictive of pregnancy outcome, whereas measurements of the circulating levels of bioactive hCG (BhCG) provide information relating to pregnancy outcome and might provide the basis for an early biomarker of pregnancy outcome. However, for this biomarker to have broad application in population-based studies, it must be adapted to urinary hCG metabolites. The principle objective of the present study was to characterize the periimplantation excretion patterns of urinary hCG metabolites of pregnancies that resulted in live birth (LB), early pregnancy loss (EPL), and recognized clinical abortion (CAB) with an immunoenzymometric assay specific to intact hCG and an LH/chorionic gonadotropin cellular bioassay as the basis for a preliminary comparison between successful (LB) and failing (EPL and CAB) outcome groups. Automated immunoassays for FSH and hCG were used to define each conceptive cycle's implantation window. The timing of first hCG detection was significantly later for the EPL group. Pregnancies that resulted in LB had consistently rising average daily IhCG and BhCG levels, with no significant differences when average daily IhCG and BhCG measurements were compared (Student t-test, P>0.05), whereas pregnancies that resulted in CAB and EFL had lower average daily IhCG and BhCG levels that increased inconsistently. These findings demonstrate that critical information related to pregnancy outcome may be present when multiple urinary hCG isoforms are measured. Further data suggest that the rate of change for the ratio of daily BhCG over IhCG levels might be useful as the basis of a broadly applicable early biomarker for pregnancy outcome.

Ovulation detection methods for urinary hormones: precision, daily and intermittent sampling and a combined hierarchical method

BACKGROUND

We evaluate the performance of ovulation detection methods and present new approaches, including evaluation of methods for precision, combining multiple markers into a hierarchical system and using ovulation markers in intermittent sampling designs.

METHODS

With serum LH peak day as the 'gold standard' of ovulation, we estimated accuracy and precision of ovulation day algorithms using 30 ovulatory menstrual cycles with daily urinary and serum hormones and transvaginal ultrasound. Sensitivity and specificity for estimating the presence of ovulation were tested using visually assessed ovulatory (30) and anovulatory (22) cycles.

RESULTS

Sensitivity and specificity ranged from 70 to 100% for estimating presence of ovulation with twice-per-cycle, weekly, twice weekly, every-other-day and daily specimens. A combined hierarchical method estimated ovulation day using daily specimens within +/-2 days of the gold standard in 93% of cases. Accuracy of estimating ovulation day within +/-2 days using intermittent sampling ranged from 40% (weekly sampling) to 97% (every-other-day).

CONCLUSIONS

A combined hierarchical algorithm using precise and accurate markers allows maximal use of available data for efficient and objective identification of ovulation using daily specimens. In intermittent sampling designs, the presence and the timing of ovulation can be estimated with good sensitivity, specificity and accuracy.

Cigarette smoking and effects on hormone function in premenopausal women

Cigarette smoke contains compounds that are suspected to cause reproductive damage and possibly affect hormone activity; therefore, we examined hormone metabolite patterns in relation to validated smoking status. We previously conducted a prospective study of women of reproductive age (n = 403) recruited from a large health maintenance organization, who collected urine daily during an average of three to four menstrual cycles. Data on covariates and daily smoking habits were obtained from a baseline interview and daily diary, and smoking status was validated by cotinine assay. Urinary metabolite levels of estrogen and progesterone were measured daily throughout the cycles. For the present study, we measured urinary levels of the pituitary hormone follicle-stimulating hormone (FSH) in a subset of about 300 menstrual cycles, selected by smoking status, with the time of transition between two cycles being of primary interest. Compared with nonsmokers, moderate to heavy smokers (>/= 10 cigarettes/day) had baseline levels (e.g., early follicular phase) of both steroid metabolites that were 25-35% higher, and heavy smokers (>/= 20 cigarettes/day) had lower luteal-phase progesterone metabolite levels. The mean daily urinary FSH levels around the cycle transition were increased at least 30-35% with moderate smoking, even after adjustment. These patterns suggest that chemicals in tobacco smoke alter endocrine function, perhaps at the level of the ovary, which in turn effects release of the pituitary hormones. This endocrine disruption likely contributes to the reported associations of smoking with adverse reproductive outcomes, including menstrual dysfunction, infertility, and earlier menopause.

Secretion and excretion of human chorionic gonadotropin during early pregnancy

OBJECTIVE

To characterize the profiles of human chorionic gonadotropin (hCG) secretion in blood and its subsequent excretion in urine during conceptive cycles that ended in successful pregnancy and in spontaneous abortion.

DESIGN

A prospective study.

SETTING

University fertility clinic and research laboratories.

PATIENT(S)

Healthy, spontaneously ovulating women with regular menses, no history of infertility, and either no male partner or an azoospermic partner.

INTERVENTION(S)

Blood and urine samples were collected daily from 63 spontaneously ovulating women during 167 cycles of artificial insemination (AI) with donor semen; hCG concentrations were measured in blood and urine, and luteinizing hormone (LH) and follicle-stimulating hormone (FSH) concentrations were measured in blood by immunoassay.

MAIN OUTCOME MEASURE(S)

Fecundity, the day of ovulation, the day of hCG detection, and the concentration of hCG on the day of detection in blood and urine.

RESULT(S)

In 62 conceptions detected, 14 resulted in clinical spontaneous abortion (CAB) and 8 resulted in early pregnancy loss (EPL). When successful pregnancies and pregnancy losses were compared, no significant differences existed between the days of hCG appearance in serum or in urine, the concentrations of hCG on the day of detection, or the incremental change in hCG concentration on the day of detection.

CONCLUSION(S)

These data validate the use of urinary hCG as a biomarker for assessing peri-implantation pregnancy events.

The effect of 2,3,7,8-tetrachlorodibenzo-p-dioxin (TCDD) on chorionic gonadotrophin activity in pregnant macaques

As many as 62% of all human conceptions are lost prior to 12 weeks of pregnancy and it is unknown how many of these losses result from environmental hazards. Previous studies have shown that single doses of 1, 2, and 4 microg/kg 2,3,7,8-tetrachlorodibenzo-p-dioxin (TCDD) administrated orally to cynomolgus macaques during the peri-implantation period leads to early fetal loss (EFL) within 10-20 days. TCDD induced EFL is associated with a reduction in the biological activity of monkey chorionic gonadotrophin (mCG) but no change in the immunoreactive mCG profile. These studies are consistent with either a direct effect of TCDD on differentiation of the trophoblast and an indirect effect on mCG synthesis, or a direct effect on mCG synthesis and secretion independent of trophoblast development. The present study was designed to test the hypothesis that the action of TCDD is directly on mCG synthesis rather than on the differentiation of the trophoblast. Female macaques (Macaca fascicularis) were treated with a single dose of TCDD (4 microg/kg b.wt.) on Gestational Day 20, a stage of pregnancy following initial trophoblast differentiation and invasion. Circulating mCG concentrations were monitored for the next 6 days. Compared to the controls, the peak level of serum bioactive mCG was lower in the treated group (P<0.05), with a decrease observed on the day following exposure. The bioactive/immunoreactive mCG ratio was also lower in the treated group compared to the controls (P<0.05). There was no difference in serum immunoreactive mCG levels between the groups. Histological evaluation of the embryo-placental unit showed increased apoptosis and vascular congestion after treatment but was otherwise grossly normal. Because exposure of the conceptus to TCDD following differentiation of the trophoblast decreased the bioactivity of circulating mCG, we conclude that the action of TCDD in the placenta is directly on mCG synthesis.

Assessing menstrual cycles with urinary hormone assays

The Study of Women's Health Across the Nation (SWAN) is a multiethnic cohort study of middle-aged women enrolled at seven US sites. A subset of 848 women completed a substudy in which their urinary gonadotropins and sex steroid metabolites were assessed during one complete menstrual cycle or up to 50 consecutive days. Urine was analyzed for LH, FSH, estrone conjugates (E1c), and pregnanediol glucuronide (Pdg). To prepare for serial analysis of this large, longitudinal database in a population of reproductively aging women, we examined the performance of algorithms designed to identify features of the normal menstrual cycle in midreproductive life. Algorithms were based on existing methods and were compared with a "gold standard" of ratings of trained observers on a subset of 396 cycles from the first collection of Daily Hormone Substudy samples. In evaluating luteal status, overall agreement between and within raters was high. Only 17 of the 396 cycles evaluated were considered indeterminate. Of the 328 cycles rated as containing evidence of luteal activity (ELA), 320 were considered ELA by use of a Pdg threshold detection algorithm. Of 51 cycles that were rated as no evidence of luteal activity, only 2 were identified by this algorithm as ELA. Evaluation of the day of the luteal transition with methods that detected a change in the ratio of E1c to Pdg provided 85-92% agreement for day of the luteal transition within 3 days of the raters. Adding further conditions to the algorithm increased agreement only slightly, by 1-8%. We conclude that reliable, robust, and relatively simple objective methods of evaluation of the probability and timing of ovulation can be used with urinary hormonal assays in early perimenopausal women.