Luteal phase dysfunction infertility: a sequel to aberrant folliculogenesis

Prospective evaluation of luteal phase length and natural fertility

OBJECTIVE

To evaluate the impact of a short luteal phase on fecundity.

DESIGN

Prospective time-to-pregnancy cohort study.

SETTING

Not applicable.

PATIENT(S)

Women trying to conceive, ages 30-44 years, without known infertility.

INTERVENTION(S)

Daily diaries, ovulation prediction testing, standardized pregnancy testing.

MAIN OUTCOME MEASURE(S)

Subsequent cycle fecundity.

RESULT(S)

Included in the analysis were 1,635 cycles from 284 women. A short luteal phase (≤11 days including the day of ovulation) occurred in 18% of observed cycles. Mean luteal phase length was 14 days. Significantly more women with a short luteal phase were smokers. After adjustment for age, women with a short luteal phase had 0.82 times the odds of pregnancy in the subsequent cycle immediately following the short luteal phase compared with women without a short luteal phase. Women with a short luteal length in the first observed cycle had significantly lower fertility after the first 6 months of pregnancy attempt, but at 12 months there was no significant difference in cumulative probability of pregnancy.

CONCLUSION(S)

Although an isolated cycle with a short luteal phase may negatively affect short-term fertility, incidence of infertility at 12 months was not significantly higher among these women.

CLINICAL TRIAL REGISTRATION NUMBER

NCT01028365.

Effects of hyperandrogenemia and increased adiposity on reproductive and metabolic parameters in young adult female monkeys

Many patients with hyperandrogenemia are overweight or obese, which exacerbates morbidities associated with polycystic ovary syndrome (PCOS). To examine the ability of testosterone (T) to generate PCOS-like symptoms, monkeys received T or cholesterol (control) implants (n = 6/group) beginning prepubertally. As previously reported, T-treated animals had increased neuroendocrine drive to the reproductive axis [increased luteinizing hormone (LH) pulse frequency] at 5 yr, without remarkable changes in ovarian or metabolic features. To examine the combined effects of T and obesity, at 5.5 yr (human equivalent age: 17 yr), monkeys were placed on a high-calorie, high-fat diet typical of Western cultures [Western style diet (WSD)], which increased body fat from <2% (pre-WSD) to 15-19% (14 mo WSD). By 6 mo on WSD, LH pulse frequency in the controls increased to that of T-treated animals, whereas LH pulse amplitude decreased in both groups and remained low. The numbers of antral follicles present during the early follicular phase increased in both groups on the WSD, but maximal follicular size decreased by 50%. During the late follicular phase, T-treated females had greater numbers of small antral follicles than controls. T-treated monkeys also had lower progesterone during the luteal phase of the menstrual cycle. Although fasting insulin did not vary between groups, T-treated animals had decreased insulin sensitivity after 1 yr on WSD. Thus, while WSD consumption alone led to some features characteristic of PCOS, T + WSD caused a more severe phenotype with regard to insulin insensitivity, increased numbers of antral follicles at midcycle, and decreased circulating luteal phase progesterone levels.

A factor analysis approach to examining relationships among ovarian steroid concentrations, gonadotrophin concentrations and menstrual cycle length characteristics in healthy, cycling women

STUDY QUESTION

How are ovarian steroid concentrations, gonadotrophins and menstrual cycle characteristics inter-related within normal menstrual cycles?

SUMMARY ANSWER

Within cycles, measures of estradiol production are highly related to one another, as are measures of progesterone production; however, the two hormones also show some independence from one another, and measures of cycle length and gonadotrophin concentrations show even greater independence, indicating minimal integration within cycles.

WHAT IS KNOWN ALREADY

The menstrual cycle is typically conceptualized as a cohesive unit, with hormone levels, follicular development and ovulation all closely inter-related within a single cycle. Empirical support for this idea is limited, however, and to our knowledge, no analysis has examined the relationships among all of these components simultaneously.

STUDY DESIGN, SIZE, DURATION

A total of 206 healthy, cycling Norwegian women participated in a prospective cohort study (EBBA-I) over the duration of a single menstrual cycle. Of these, 192 contributed hormonal and cycle data to the current analysis.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Subjects provided daily saliva samples throughout the menstrual cycle from which estradiol and progesterone concentrations were measured. FSH and LH concentrations were measured in serum samples from three points in the same menstrual cycle and cycle length characteristics were calculated based on hormonal data and menstrual records. A factor analysis was conducted to examine the underlying relationships among 22 variables derived from the hormonal data and menstrual cycle characteristics.

MAIN RESULTS AND THE ROLE OF CHANCE

Six rotated factors emerged, explaining 80% of the variance in the data. Of these, factors representing estradiol and progesterone concentrations accounted for 37 and 13% of the variance, respectively. There was some association between measures of estradiol and progesterone production within cycles; however, cycle length characteristics and gonadotrophin concentrations showed little association with any measure of ovarian hormone concentrations.

LIMITATIONS, REASONS FOR CAUTION

Our summary measures of ovarian hormones may be imprecise in women with extremely long or short cycles, which could affect the patterns emerging in the factor analysis. Given that we only had data from one cycle on each woman, we cannot address how cycle characteristics may covary within individual women across multiple cycles.

WIDER IMPLICATIONS OF THE FINDINGS

Our findings are generalizable to other healthy populations with typical cycles, however, may not be applicable to cycles that are anovulatory, extreme in length or otherwise atypical. The results support previous findings that measures of estradiol production are highly correlated across the cycle, as are measures of progesterone production. Estradiol and progesterone concentrations are associated with one another, furthermore. However factor analysis also revealed more complex underlying patterns in the menstrual cycle, highlighting the fact that gonadotrophin concentrations and cycle length characteristics are virtually independent of ovarian hormones. These results suggest that despite integration of follicular and luteal ovarian steroid production across the cycle, cycle quality is a multi-faceted construct, rather than a single dimension.

STUDY FUNDING/COMPETING INTEREST(S)

The EBBA-I study was supported by a grant from the Norwegian Cancer Society (49 258, 05087); Foundation for the Norwegian Health and Rehabilitation Organizations (59010-2000/2001/2002); Aakre Foundation (5695-2000, 5754-2002) and Health Region East. The current analyses were completed under funding from the National Institutes of Health (K12 ES019852). No competing interests declared.

Evaluation of ultrasonography for monitoring follicular growth in rhesus monkeys

The purpose of this study was to determine if the ovaries and uterus of rhesus monkeys could be visualized by ultrasonography and to detect changes associated with follicular growth and ovulation. Animals were examined during 15 menstrual cycles, for an average of nine consecutive days. Ultrasonic recordings were correlated with hormonal parameters (estradiol 17beta, E(2); luteinizing hormone, LH; and progesterone, P) and laparoscopic findings. The uterus and both ovaries were observed in more than 90% of the examinations. A dominant follicle (DF) was identified during all ovulatory cycles, on average 1 d preceding the E(2) peak. The maximal diameter of the DF ranged from 3 to 7 mm. Laparoscopic examinations to determine the site of the DF confirmed ultrasonic findings in 10 of 14 cycles (P < 0.1). There was no significant difference in the size of the dominant and contralateral ovaries; however, more follicles with a diameter of 2 to 7 mm were found on the dominant ovary (P < 0.05). Two animals stimulated with exogenous gonadotropins showed a linear increase in ovarian size for 6 d prior to oocyte recovery (P < 0.05), reflecting an increase in the number of developing follicles. Ultrasonography can be used to identify the DF during spontaneous cycles in rhesus monkeys and to monitor the response of monkeys to exogenous gonadotropins.

Mitochondrial DNA variations associated with recurrent pregnancy loss among Indian women

Several genetic factors have been found to be associated with recurrent pregnancy loss (RPL). However, not many attempts have been made to associate the mitochondrial DNA (mtDNA) variations with RPL. Therefore, we have analyzed the complete mtDNA of 100 women with RPL and 12 aborted fetal tissues. Our analysis revealed a total of 681 variations, most of which were in NADH Dehydrogenase (ND) genes that encode mitochondrial enzyme Complex I. Presence of T4216C variation (ND1 gene) in 9% of the RPL women and several pathogenic, and novel mutations suggest the role of mtDNA variations in RPL.

Follicular growth pattern in normal-cycling Brazilian adolescents

OBJECTIVE

To examine the follicular growth characteristics in normal Brazilian adolescents.

DESIGN

Descriptive study.

SETTING

Adolescent clinic in a university hospital.

PATIENT(S)

Healthy normal cycling adolescents.

INTERVENTION(S)

Endovaginal ultrasound; blood samples for hormone measurement.

MAIN OUTCOME MEASURE(S)

Follicular-phase length, follicular growth rate.

RESULT(S)

The menstrual-cycle interval was 29.5 +/- 1.6 days. Sixty-five percent of adolescents had follicular-phase length of <or=16 days (group 1), and nearly 35% had follicular-phase length of >16 days (group 2). In the early follicular phase, the levels of FSH, LH, and E(2) were 5.1 mIU/mL, 3.0 mIU/mL, and 28.3 pg/mL, respectively. There was a mild negative correlation between FSH and follicular-phase length across the whole cohort (r = -0.464), but after analysis as a separate group, the correlation was present only in those adolescents with follicular phase lasting </=16 days. There was no correlation between LH or E(2) levels and the follicular-phase length in either group. There was good correlation between the follicular size and follicular-phase length in both groups of adolescents. The follicular growth rate was 1.11 +/- 0.05 mm/d across the whole cohort, 1.33 +/- 0.05 mm/d in the adolescents with follicular-phase length of <or=16 days, and 0.88 +/- 0.06 mm/d in those in whom the follicular phase lasted >16 days.

CONCLUSION(S)

A long follicular phase is common in normal-cycling, healthy adolescents as a consequence of slow follicular growth rate.

Nonhuman primates contribute unique understanding to anovulatory infertility in women

Anovulatory infertility affects a large proportion of reproductive-aged women. Major improvements in successful clinical treatment of this prevalent disorder in women's health have been made possible because of biomedical research employing nonhuman primates. Experiments on female rhesus monkeys were the first to demonstrate that the key hypothalamic neurotransmitter, gonadotropin-releasing hormone, involved in stimulating pituitary gonadotropin synthesis, storage, and release was bioactive only when released in approximately hourly bursts. This breakthrough in understanding gonadotropin regulation enabled identification of hypogonadotropic, apparently normogonadotropic, and hypergonadotropic forms of anovulatory infertility, and development of appropriate stimulatory or inhibitory gonadotropin therapies. Treatments to overcome anovulatory infertility represent one of the major advances in clinical reproductive endocrinology during the last 25 yr. The future promise of nonhuman primate models for human ovulatory dysfunction, however, may be based on an increased understanding of molecular and physiological mechanisms responsible for fetal programming of adult metabolic and reproductive defects and for obesity-related, hyperinsulinemic impairment of oocyte development.

Pregnancy in Dairy Cows After Synchronized Ovulation Regimens With or Without Presynchronization and Progesterone

Two experiments examined pregnancy after synchronized ovulation (Ovsynch) with or without progesterone (P4) administered via controlled internal drug release (CIDR) intravaginal inserts. In experiment 1, 262 lactating cows in one herd were in 3 treatments: Ovsynch (n = 91), Ovsynch + CIDR (n = 91), and control (n = 80). The Ovsynch protocol included injections of GnRH 7 d before and 48 h after an injection of PGF20. Timed artificial insemination (TAI; 57 to 77 d postpartum) was 16 to 20 h after the second GnRH injection. Cows in the Ovsynch + CIDR group also received a CIDR (1.9 g of P4) insert for 7 d starting at first GnRH injection. Control cows received A-I when estrus was detected using an electronic estrus detection system. Based on serum P4, 44.1% of cows were cyclic before Ovsynch. Pregnancy rates at 29 d (59.3 vs. 36.3%) and 57 d (45.1 vs. 19.8%) after TAI and embryo survival (75.9 vs. 54.5%) from 29 to 57 d were greater for Ovsynch + CIDR than for Ovsynch alone. In experiment 2, 630 cows in 2 herds received TAI at 59 to 79 d postpartum after 6 treatments. Estrous cycles were either presynchronized (2 injections of PGF2alpha 14 d apart; n = 318) or not presynchronized (n = 312). Within those groups, Ovsynch was initiated 12 d after second presynchronization PGF2alpha, and used alone (n = 318) or with CIDR inserts for 7 d (1.38 g of P4/insert, n = 124 or 1.9 g of P4/insert, n = 188). Before Ovsynch, 80% of cows were cyclic. Presynchronization increased pregnancy (46.8 vs. 37.5%) at 29 d after TAI, but CIDR inserts had no effect on pregnancy in experiment 2. Overall embryonic survival between 29 and 57 d in experiment 2 was 57.7%. Use of CIDR inserts with Ovsynch improved conception and embryo survival in experiment 1 but not in experiment 2, in part due to differing proportions of cyclic cows at the outset. Presynchronization before Ovsynch enhanced pregnancy rate.

Temporal regulation of gene expression during the expected window of receptivity in the rhesus monkey endometrium

Progesterone has been shown to regulate a number of genes and gene networks in the primate endometrium. This action of progesterone is essential to provide an appropriate milieu for embryo-endometrial communication that can lead to implantation and the successful initiation of pregnancy. A temporal regulation of endometrial genes is most likely required to achieve an appropriate state of receptivity in the primate endometrium. Using simulated menstrual cycles in the rhesus monkey, endometrial tissue was harvested at days that encompass the expected window of receptivity (4-10 days after the estradiol surge) and subsequently converted to cycle day-specific cDNA populations. Using differential display reverse transcriptase-polymerase chain reaction, 12 cDNA fragments were isolated and sequenced whose mRNA levels were elevated during this time frame. The temporal expression patterns of these mRNAs were confirmed by semiquantitative polymerase chain reaction. Two of these fragments exhibited high homology to previously characterized human genes: 1) secretory leukocyte protease inhibitor, also known as antileukoprotease, an endometrial neutrophil elastase inhibitor with antibacterial and anti-inflammatory properties; and 2) syncytin, also known as endogenous retrovirus W envelope protein, a highly fusogenic membrane glycoprotein that induces formation of giant syncytia and is believed to be important in decidual and placental development. The temporal regulation of these genes by progesterone supports their likely role in the orchestration of molecular and cellular events that are required to achieve a state of receptivity in the primate endometrium.

Concentração plasmática de progesterona em novilhas receptoras submetidas à administração de rbST, GnRH ou hCG no quinto dia do ciclo estral

Avaliaram-se a habilidade de diferentes hormônios administrados no quinto dia do ciclo estral em induzir a ovulação do folículo dominante da primeira onda folicular (FDPO) e formar um corpo lúteo acessório (CLa) e seus efeitos sobre a concentração plasmática de progesterona (P4) em novilhas receptoras. Cinqüenta e duas novilhas mestiças Holandês-Zebu foram aleatoriamente distribuídas em quatro tratamentos: T1-controle, T2-administração subcutânea de 500mg de rbST, T3-administração intramuscular (IM) de 100mig de GnRH e T4-administração IM de 2000UI e endovenosa de 1000UI de hCG. Realizou-se palpação transretal nos dias 5, 13 e 60 para detecção de corpo lúteo original (CLo), de CLa e de gestação, respectivamente. A formação de CLa foi de: T1-0/12 (0,0%), T2-0/13 (0,0%), T3-5/12 (41,7%) e T4-10/15 (66,7%)(P<0,05) sendo T1 e T2 diferentes de T3 e T4. A concentração plasmática de P4 foi determinada por radioimunoensaio a partir de amostras de sangue coletadas na veia jugular nos dias 5, 13, 17 e 21 do ciclo estral. Trinta e dois embriões foram transferidos para as receptoras no sétimo dia do ciclo estral (T1-8, T2-8, T3-7 e T4-9). Apenas novilhas não transferidas tiveram sangue coletado nos dias 17 e 21. Observaram-se diferenças na concentração plasmática de P4 (ng/ml) entre os tratamentos (P<0,05) somente no 13ºdia do ciclo, com valores de T1=5,01± 1,04, T2=4,80± 1,26, T3=6,42± 1,47 (diferente de T1, T2 e T4) e T4=11,16± 2.79 (diferente de T1, T2 e T3), mas não houve efeito da presença do embrião (P>0,05). As taxas de gestação, T1=37,5% (3/8), T2=62,5% (5/8), T3=28,6% (2/7) e T4=33,3% (3/9), não diferiram entre tratamentos (P>0,05). Estes resultados mostraram que o FDPO no quinto dia do ciclo estral foi capaz de responder ao GnRH e à hCG, ovular e formar um CLa, o que elevou a concentração plasmática de P4 de novilhas no 13º dia do ciclo estral, período crítico para o estabelecimento da gestação em bovinos.

Taxas de gestação de novilhas receptoras submetidas à administração de rbST, GnRH ou hCG no quinto dia do ciclo estral

Estudou-se a habilidade de diferentes hormônios administrados no quinto dia do ciclo estral em elevar a taxa de gestação em 196 novilhas receptoras, mestiças Holandês-Zebu, aleatoriamente distribuídas em quatro tratamentos: T1-controle (n=50), T2-administração subcutânea de 500mg de rbST (n=44), T3-administração intramuscular de 100m g de GnRH (gonadorelina; n=46) e T4-administração de 3000UI de hCG (1000UI endovenosa e 2000UI intramuscular; n=56). Embriões coletados aos sete dias foram eqüitativamente distribuídos (estádio e qualidade) e transferidos para as receptoras no sétimo dia do ciclo estral. As taxas de gestação detectadas por palpação transretal 53 dias após a transferência dos embriões não diferiram entre os tratamentos, sendo: 15/24 em T1 (62,5%), 15/25 em T2 (60,0%), 13/29 em T3 (44,8%) e 22/31 em T4 (71,0%). Estes resultados demonstraram que a administração de rbST, GnRH ou hCG no quinto dia do ciclo estral não foi capaz de elevar as taxas de gestação.

LH pulses and the corpus luteum: the luteal phase deficiency LPD)

The proper function of the GnRH pulse generator in the hypothalamus is essential for normal ovarian function, hence also for proper function of the corpus luteum. During the luteal phase LH pulses stimulate progesterone release, which is essential for normal endometrial transformation. Approximately one-half of all luteal phase deficiencies (LPD) are due to improper function of the GnRH pulse generator. Obviously, following ovulation the increased serum progesterone levels oversuppress the GnRH pulse generator, resulting in too few LH pulses and therefore improper luteal function. Also, latent hyperprolactinemia may lead to an LPD which can be effectively treated with plant extracts containing dopaminergic (prolactin-suppressing) compounds. Our increasing knowledge of auto- and paracrine mechanisms between nonsteroidogenic and steroidogenic cells now allow subclassification of LPDs of ovarian origin. The so-called small luteal cells are LH-responsive. If they develop improperly the regularly occurring LH pulses are unable to stimulate progesterone secretion from the small luteal cells, which results in what we call the small luteal cell defect. In addition, there is also evidence that the large luteal cells may function improperly. Hence, basal progesterone release is too low while LH-stimulated progesterone release from the small luteal cells appears to be intact. This subclassification of luteal phase deficiency results in the suggestion of different treatments. In cases where the corpus luteum is LH-responsive, such as the hypothalamic corpus luteum insufficiency and the large luteal cell defect, HCG treatment or pulsatile treatment with GnRH is advisable. In the case of LH/hCG-unresponsive small luteal cell defect a progesterone substitution is suggested.

Duration and amplitude of the luteal phase progesterone increment times the estradiol-induced luteinizing hormone surge in ewes

Progesterone (P) powerfully inhibits the neuroendocrine reproductive axis, but the mechanisms and site or sites of action of this steroid remain poorly understood. Progesterone exposure during the luteal phase also alters the responsiveness of the hypothalamus to increased concentrations of estrogen (E) during the follicular phase. Using an ovariectomized ovine follicular phase model, we investigated whether the amplitude and duration of the luteal phase increase in circulating P affects the E-induced surge in LH. Treatment of ewes for 10 days with two, one, or half an intravaginal P-releasing implant or with an empty implant demonstrated that P concentrations significantly (P: < 0.0001) delayed the time to surge onset upon exposure to an equal concentration of E. This delay was not due to a time-related difference in responsiveness to E after P clearance because the time of surge onset was not different when E treatment began 6, 12, or 24 h after the withdrawal of two P implants that had been present for 10 days. The final study demonstrated that the duration of P before treatment (5, 10, or 30 days) significantly (P: < 0.0001) delayed the responsiveness of the estradiol-dependent surge-generating system. There was no effect on surge amplitude or duration in any experiment. Thus, the amplitude and duration of exposure to luteal phase P significantly affect the neural elements targeted by E to induce the preovulatory LH surge.

Induction of ovulation in postpartum suckled beef cows: a review

Prolonged postpartum acyclicity in suckled beef cows reduces the calf crop, and causes economic loss to beef cattle producers. Once anterior pituitary LH stores have been replenished between Days 15 and 30 post partum in suckled beef cows, methods to initiate cyclicity include non-hormonal methods such as weaning of calves (either complete, temporary or partial), or exposure to bulls, and hormonal methods such as administration of GnRH (either single injection, intermittent injections, or continuous infusion), gonadotropins (eCG, FSH, hCG), and steroids (estrogens, anti-estrogens, and progestogens). Weaning is costly, reduces growth rate of weaned calves, and short cycles are common after weaning-induced ovulation. Exposure of cows to bulls is not practical and its effect is not predictable. Repeated injections of GnRH, or a single injection of hCG are not always effective; ovulation is always followed by a short cycle, and usually a return to acyclicity. Estrogens and anti-estrogens do not consistently shorten postpartum anestrus. Exogenous progestogens include intravaginal devices, such as controlled-internal drug release (CIDR) or progesterone-releasing intravaginal device (PRID), norgestomet implants, and the feed-additive melengestrol acetate (MGA). Administration of exogenous progestogens is more practical than, and offers more advantages over, other treatments to shorten postpartum acyclicity in suckled beef cows. Mimicking the short cycle after Week 3 post partum, by maintaining circulating progesterone at subluteal concentrations or circulating progestin at intermediate concentrations, extends the life-span and allows terminal maturation of the postpartum dominant follicle as in cyclic cows, by initiating endogenous GnRH and LH pulses. This is followed by an LH surge, ovulation and normal cycles. The benefit from using exogenous progestogens after Week 3 post partum in suckled beef cows is that ovulation is induced, cyclicity is initiated, the resulting CL has a normal life-span and function, and there is no need to change management, such as weaning of calves. We present a model for the induction of ovulation and initiation of cyclicity using exogenous progestogens after Week 3 post partum in suckled beef cows.

Relationship between midcycle luteinizing hormone surge quality and oocyte fertilization

OBJECTIVE

To determine whether alterations in preovulatory follicular fluid (FF) levels of LH, FSH, and steroids are associated with the probability of fertilization.

DESIGN

Retrospective analysis of prospective study results.

SETTING

Reproductive medicine clinic of a university teaching hospital.

PATIENT(S)

Infertile women, with unstimulated, apparently regular cycles in an IVF research program.

INTERVENTION(S)

Measurement of preovulatory FF levels of LH, FSH, E2, and P and serum LH levels by fluoroimmunometry.

MAIN OUTCOME MEASURE

Oocyte fertilization.

RESULT(S)

There were 84 transferable embryos (rate of normal fertilization and cleavage, 67%), and 41 oocytes (33%) failed to fertilize. Analysis of the matched FF showed that the median concentration of FF LH was significantly higher for cleaving embryos than for unfertilized oocytes (14.6 vs. 10.4 IU/L). Serum LH concentrations were similarly higher in cycles with cleaving embryos. There were no statistically significant differences in FF concentrations of FSH, E2, or P in the two groups.

CONCLUSION

Reduced preovulatory FF LH levels are associated with impaired fertilization of oocytes in vitro, despite normal FF FSH and steroid levels.

Identification of progesterone-dependent messenger ribonucleic acid regulatory patterns in the rhesus monkey endometrium by differential-display reverse transcription-polymerase chain reaction

We used differential-display reverse transcription-polymerase chain reaction (DDRT-PCR) to identify different patterns of progesterone (P4)-dependent gene regulation in rhesus monkey endometria. Complementary DNA populations representing the proliferative phase (estrogen dominant, EcDNA) and an inadequate secretory phase (low level of P4, IcDNA) were compared with a cDNA population representing an adequate secretory phase (normal level of P4, PcDNA). We were able to distinguish four different levels of mRNA regulation: 1) up-regulation by P4 during an adequate secretory phase, 2) autologous down-regulation (IcDNA versus PcDNA), 3) lower abundance in IcDNA compared to PcDNA, and 4) P4-dependent inhibition of EcDNA gene expression. We isolated and sequenced 16 fragments representing these different levels of P4 regulation. The sequence of three fragments that were autologously down-regulated (I1, I2, I4) matched previously entered GenBank mRNAs: I1 encodes serine/threonine protein phosphatase A; I2 encodes oxobutanoate dehydrogenase E1b-beta; and I4 encodes line-1 reverse transcriptase homologue. Six other fragments exhibited homology to uncharacterized expressed sequence tags, sequence site tags, and cosmid clones. The remaining seven fragments exhibited no significant homology to GenBank entries at this time. The various patterns of P4-dependent gene regulation identified in the present study are likely to play roles in the temporal orchestration of events that lead to proper maturation of the endometrium.

Ovulation and luteal characteristics following removal of the ovine corpus luteum (lutectomy) at four times during the oestrous cycle

The life span of the corpus luteum (CL) may depend on follicular development. To provide evidence relating to this hypothesis, each of 32 ewes was randomly assigned to have its CL removed on day 2, 3, 4 or 10 after oestrus. Twenty ewes were treated with 1000 IU of human chorionic gonadotrophin (hCG) 36 h after CL removal to induce ovulation; the other 12 ewes were not treated with hCG. Blood samples were collected daily to monitor the ovulatory response and the characteristics of the next cycle at the first sign of oestrus and up to day 21 after surgery or hCG administration. Every animal ovulated within 7 days of hCG administration, regardless of when its CL had been removed. It was concluded that the follicles found in the ovary as early as the second day after oestrus respond to endogenous or exogenous ovulatory stimuli affecting the life span of resulting CL.

Effects of buserelin injection and deslorelin (GnRH-agonist) implants on plasma progesterone, LH, accessory CL formation, follicle and corpus luteum dynamics in Holstein cows

The influence of Buserelin injection and Deslorelin (a GnRH analogue) implants administered on Day 5 of the estrous cycle on plasma concentrations of LH and progesterone (P4), accessory CL formation, and follicle and CL dynamics was examined in nonlactating Holstein cows. On Day 5 (Day 1 = ovulation) following a synchronized estrus, 24 cows were assigned randomly (n = 4 per group) to receive 2 mL saline, i.m. (control), 8 micrograms, i.m. Buserelin or a subcutaneous Deslorelin (DES) implant in concentrations of 75 micrograms, 150 micrograms, 700 micrograms or 2100 micrograms. Blood samples were collected (for LH assay) at 30-min intervals for 2 h before and 12 h after GnRH-treatment from cows assigned to Buserelin, DES-700 micrograms and DES-2100 micrograms treatments and thereafter at 4-h intervals for 48 h. Beginning 24 h after treatment, ovaries were examined by ultrasound at 2-h intervals until ovulation was confirmed. Thereafter, ultrasonography and blood sampling (for P4 assay) was performed daily until a spontaneous ovulation before Day 45. A greater release of LH occurred in response to Deslorelin implants than to Buserelin injection (P < 0.01). Basal levels of LH between 12 and 48 h were higher in DES-700 micrograms group than in DES-2100 micrograms and Buserelin (P < 0.05). The first wave dominant follicle ovulated in all cows following GnRH treatment. Days to CL regression did not differ between treatments, but return to estrus was delayed (44.2 vs 27.2 d; P < 0.01) in cows of DES-2100 micrograms group. All GnRH treatments elevated plasma P4 concentrations, and the highest P4 responses were observed in the DES-700 micrograms and DES-2100 micrograms groups. The second follicular wave emerged earlier in GnRH-treated than in control cows (9.9 vs 12.8 d; P < 0.01). However, emergence of the third dominant follicle was delayed in cows of DES-2100 micrograms treatment (37.0 d) compared with DES-700 micrograms (22.2 d), Buserelin (17.8 d) or control (19.0 d). In conclusion, Deslorelin implants of 700 micrograms increased plasma P4 and LH concentrations and slightly delayed the emergence of the third dominant follicle. On the contrary, Deslorelin implants of 2100 micrograms drastically altered the P4 profiles and follicle dynamics.

A regimen of oral contraceptives restricted to the periovulatory period may permit folliculogenesis but inhibit ovulation

Increased safety of oral contraceptives (OC) has resulted from a reduction in the estrogen and progestin content per tablet. A reduction in the number of hormonally active pills and their placement at critical points within the cycle may provide a novel regimen for further reducing the hormonal content of OC per cycle and their attendant side effects without compromising efficacy. The objective of this study was to determine the effectiveness of two OC regimens that incorporate a delayed start and limited midcycle use of the combination of ethinyl estradiol and norethindrone, and limited use of norethindrone only during the second half of the cycle. Main outcome measures were defined as ovulation, serum concentrations of estradiol (E2), luteinizing hormone (LH), follicle stimulating hormone (FSH), progesterone (P), follicular diameters, and endometrial thickness. Volunteers were issued blister packs containing 28 pills and randomized to one of two groups. Group 1 used a combination of 50 micrograms ethinyl estradiol and 1 mg norethindrone per tablet day 6-10, and 0.70 mg norethindrone only day 11-19. Placebo tablets were used on days 1-5 and day 20-28. Group 2 used a combination of 50 micrograms ethinyl estradiol and 1 mg norethindrone per tablet on day 8-12, and 0.70 mg norethindrone only on day 13-21. Placebo tablets were used on day 1-7 and day 22-28. A total of 20 cycles were studied using 10 volunteers. To assess any possible carryover effect, two successive cycles were studied for each subject. Serum sampling for E2, FSH, LH, and P, and transvaginal ultrasound imaging to assess endometrial thickness and follicle diameter were carried out at 4 day intervals throughout the cycle. One ovulation occurred in 10 cycles in group 1. Five ovulations occurred in 10 cycles in group 2. All ovulations, regardless of group, occurred in the second cycle. Peak E2 concentrations were not significantly different between groups (152.04 +/- 107.1 pg/mL vs 162.1 +/- 56.1 pg/mL [mean +/- SD] for groups 1 and 2, respectively] but occurred earlier in the cycle in group 1. No differences were noted between the groups in serum concentrations of FSH or LH for any given cycle day. Maximum follicle diameters were not different between groups 1 and 2, regardless of ovulatory status (20.5 +/- 8.1 mm2 vs 20.6 +/- 14.2 mm2, respectively). Ultrasound imaging assessment of midcycle follicle growth revealed diameters ranging from 18.5 mm2 to 34.0 mm2 with gradual resolution through the second half of the cycle in anovulatory cycles, and 16.0 mm2 to 23.5 mm2 with abrupt disappearance in ovulatory cycles. Endometrial thickness did not exceed 10 mm for any anovulatory cycle regardless of group, but ranged from 6 to 9 and 6 to 11 during the luteal phase of ovulatory cycles of groups 1 and 2, respectively. Peak serum P concentrations at midluteal phase in ovulatory cycles ranged from 9.2 ng/ml to 18.2 ng/ml. Data from this preliminary study suggest that ovulation may be prevented with a combination of ethinyl estradiol and norethindrone started as late as cycle day 6 and limited to 5 days' duration using norethindrone only for 9 days during the second half of the cycle. Such a restricted regimen may offer both an effective method of contraception and a means of further reducing both estrogen and progestin content per cycle and the possible short and long term adverse side effects of these hormones.

Characteristics of corpus luteum formed from the first wave dominant follicle following hCG in cattle

Two experiments were conducted to characterize the development and function of corpus luteum (CL) induced by hCG. In Experiment 1, cows (n = 18) were randomly assigned either to serve as controls (CONT, n = 6) or to receive hCG on Day 7 with (hCG-LUT, n = 6), or without (hCG-CONT, n = 6) surgical removal of the spontaneous CL on Day 12. The diameters of the hCG-induced and spontaneous CL of similar age did not differ (P > 0.05) between Days 1 and 4. At Day 5, the CONT (spontaneous) CL diameter (29.3 +/- 1.4 mm) was larger (P < 0.05) than that of the hCG-LUT (24.5 +/- 1.5 mm) or the hCG-CONT (24.6 +/- 1.7 mm) induced CL. Similarly, induced CL diameter for hCG-LUT and hCG-CONT groups was smaller (P < 0.01) than the CONT (spontaneous) CL between Days 10 to 14. Plasma progesterone (P(4)) levels were not different (P > 0.05) among treatment groups until Day 12. On Day 14, the P(4) concentration of hCG-LUT cows decreased (P < 0.01) to 1.1 +/- 0.9 ng/ml, then increased to 3.1 +/- 0.9 ng/ml by Day 18. Comparative values for hCG-CONT and CONT cows were 5.8 +/- 0.8 and 4.2 +/- 0.8; 4.5 +/- 0.8 and 5.5 +/- 0.8 ng/ml, respectively. The onset of regression of CL as well as estrous cycle length were similar (P > 0.05) for all treatment groups. In Experiment 2, the effects of intrauterine infusion of indomethacin on the diameter, function and life span of hCG-induced CL were examined. A slight, albeit not significant, suppression of PGFM levels was observed in indomethacin-infused cows (n = 4) compared with the controls (n = 4) in blood samples obtained once a day during the infusion period. However, in 2 cows from which blood samples were collected every 6 h, the control cow showed several pulses of PGFM while the indomethacin-treated cow exhibited none. Induced CL diameter and lifespan were not affected by indomethacin infusion. However, mean P(4) levels were higher (P < 0.05) between Days 16 and 20 in the indomethacin-infused group. In conclusion, the results suggest that 1) hCG-induced CL are functional but appear to be smaller and secrete less P(4) than spontaneous CL of similar age, and 2) the small size and reduced secretary function observed is not necessarily due to PGF(2alpha) secreted by the uterine endometrium but, probably, to inherent characteristics.

Decreased expression of endometrial decay accelerating factor (DAF), a complement regulatory protein, in patients with luteal phase defect

PROBLEM

We investigated the level of decay accelerating factor (DAF) in the endometrium of luteal phase defect (LPD) patients, before and after treatment with progesterone.

METHODS

Endometrial samples from fourteen normal-cycling controls and six samples from infertility patients with LPD before and four samples after progesterone treatment were stained by anti-DAF IgG using immunohistochemistry.

RESULTS

Mean DAF OD in LPD patients was 15% compared to 60% in the control group. The mean DAF OD was 88% after treatment with progesterone.

CONCLUSION

Results support interpretation that progesterone upregulates DAF while decreased progesterone may be associated with reduced expression of the DAF in LPD patients.

Adverse effects of fertility drugs

Ovulation-induction agents are commonly used in the treatment of infertility in patients with or without ovulatory disturbances. These agents include clomifene, bromocriptine, gonadotrophin preparations and gonadotrophin-releasing hormone (GnRH) and its analogues. Each agent is associated with its own specific adverse effects. Although many of these adverse effects are benign and self-limited, some, in particular those effects associated with gonadotrophins, may be life-threatening. Commonly noted adverse effects encountered with the use of pharmacological agents to treat infertility include the following. Clomifene has been associated with hot flushes, multiple gestation, visual disturbances, cervical mucus abnormalities and luteal phase deficiency. Similarly, most of the adverse symptoms associated with bromocriptine are short-lived, such as nausea and postural hypotension. On the other hand, gonadotrophin therapy, even when used appropriately, may lead to the ovarian hyperstimulation syndrome (which is occasionally life-threatening) and a high incidence of multiple gestation. Pulsatile GnRH therapy maybe accompanied by similar adverse effects to those of gonadotrophins, but with a far lower incidence. With regards to the long term safety of these medications, the relationship between fertility drugs and epithelial ovarian cancer is controversial, and causality has yet to be proven. Indeed, a working knowledge of the many adverse effects associated with these medications is essential to any physician prescribing ovulation induction agents, in order to ensure maximum patient safety, compliance and understanding.

Altered luteinizing hormone pulse frequency in early follicular phase of the menstrual cycle with luteal phase defect patients in women

OBJECTIVE

To delineate the relationship between the pulsatile gonadotropin inputs in early follicular phase of the menstrual cycle and the P secretions by the corpus luteum in women.

DESIGN

For measuring pulsatile release of gonadotropin, blood samples were drawn every 15 minutes for 24 hours in the early follicular phase. Daily blood samples were drawn for LH, FSH, E2, and P.

SETTING

The reproductive endocrine unit of a university hospital.

PATIENTS

Fourteen patients with luteal phase defect (LPD) and 12 normally cycling women.

RESULTS

The length of follicular phase in LPD was significantly shorter than that of women with normal cycles. There were significant differences in LH pulsatile secretions and amplitudes in LPD patients when compared with those of women with normal cycles. Basal E2, PRL, and preovulatory E2 concentrations were not different between the two groups whereas the peak of P secretions in luteal phase was significantly decreased in LPD.

CONCLUSIONS

These data suggest that LPD may result from the altered LH pulse frequency in early follicular phase of the menstrual cycle. Whether this increased LH pulse frequency results from an intrinsic disease of the pulse oscillator or to some event in the preceding cycle remains unknown. It is tempting to speculate that an increased LH pulsatile secretion in the early follicular phase of menstrual cycles in patients with LPD may down-regulate the LH secretion at midcycle, thereby lowering the LH surge, which in turn reduces the P secretion in luteal phase.

Effect of a nonsteroidal aromatase inhibitor on in vitro and in vivo secretion of estradiol and on the estrous cycle in ewes

Three experiments were performed to study effects of decreased concentrations of estradiol-17 beta (E2) on lifespan and function of ensuing ovine corpora lutea (CL). In experiment 1, 52 follicles were collected from 10 ewes and placed into individual culture with 0 or .01 microCi 3H-androstenedione (10 ng; 3H-A) and 0, 10(-11), 10(-9), 10(-7), or 10(-5) M of a nonsteroidal aromatase inhibitor, CGS16949A (CGS). Concentrations of E2 secreted into the medium, and synthesis of estrogens as estimated by formation of 3H-water from 3H-A were decreased by 10(-5) and 10(-7) (P < .01), but not 10(-9) or 10(-11) M CGS. In experiment 2, luteolysis was induced in 24 ewes by injection of PGF2 alpha on days 5 to 10 of the estrous cycle (0 hr). Ewes received 0, 0.5, 1.0, 2.0 or 4.0 mg CGS per kg BW i.v. at -12, 0, 12 and 24 hr, and an ovulatory dose of hCG at 36 hr. Jugular (P < .001) and vena caval (P < .001) concentrations of E2 were decreased by CGS at all doses tested for 8 to 10 hr, but had returned to levels similar to control ewes by the time of the next injection. Concentrations of E2 around the time of the LH surge were similar in control and treated ewes. During the subsequent luteal phase, concentrations of progesterone (P4) were similar in control and treated ewes. Thus, transient decreases in E2 during the follicular phase were not deleterious to the subsequent luteal phase. In experiment 3, luteolysis was induced in 18 ewes by injection of PGF2 alpha on days 6 or 7 (0 hr) of the estrous cycle. Ewes received 0 or 1 mg CGS per kg BW i.v. every 8 hr from 0 to 40 hr. Ovulation was induced with hCG at 36 hr. CGS reduced jugular (P < .001) and vena caval (P < .001) concentrations of E2, prevented an endogenous surge of LH (P < .05) and increased (P < .001) concentrations of FSH. All ewes had ovulated a marked follicle by 72 hr, but onset of the luteal phase, as assessed by concentrations of P4, was delayed (P < .01) in ewes receiving CGS. Delayed luteal phases were not solely attributable to the presence of new CL or to luteinization of follicular cysts. When data were aligned according to the day ewes were observed in estrus, profiles of P4 did not differ with treatment.(ABSTRACT TRUNCATED AT 400 WORDS)

Prevalence of out-of-phase endometrial biopsy specimens

OBJECTIVE

We attempted to determine the prevalence of out-of-phase endometrial biopsy specimens among fertile and infertile women and women with recurrent pregnancy loss, histologic dating of biopsies was compared with four reference points for expected ovulation. These reference points included last menstrual period, next menstrual period, luteinizing hormone testing, and ultrasonographic documentation of ovulation.

STUDY DESIGN

Four hundred eighty-five endometrial biopsies were performed 7 days after documented ovulation-based ultrasonographic evidence for follicle collapse. The histologic dating was referenced to the last menstrual period, next menstrual period, and ultrasonographic documentation of ovulation. One hundred thirty-two of these women also performed urinary luteinizing hormone surge testing before ovulation and serum progesterone determinations. A comparison of the prevalence of out-of-phase biopsy specimens among groups was determined with the chi 2 test and Fisher's exact test.

RESULTS

The prevalence of out-of-phase endometrial biopsy specimens ranged from 42% when last menstrual period was used to 26% with next menstrual period, to 21% with luteinizing hormone testing, and to 4% with ultrasonographic documentation of ovulation. Serum progesterone values among women with a diagnosis of out-of-phase biopsy specimens by any of the reference dates progesterone were similar to those with in-phase biopsy specimens.

CONCLUSION

The accuracy of histologic endometrial dating was best determined by ultrasonographic monitoring rather than by last menstrual period, next menstrual period, or luteinizing hormone testing in infertile populations and in those with recurrent pregnancy loss. Additionally, because no significant difference in out-of-phase biopsy specimens exists between fertile and infertile patients and recurrent pregnancy loss, those with the role of this procedure is called into question.

Interference with ovulation and luteal function by human ovarian follicular fluid peptide in bonnet monkeys, Macaca radiata

Partially purified human ovarian follicular fluid peptide (hGF2) was administered during follicular phase in 5 bonnet monkeys. In control as well as hGF2-injected animals, ovulation was synchronized by treatment with FSH, Pergonal and hCG. All the 5 control bonnet monkeys showed plasma estradiol peak followed by increased progesterone levels. In 4 out of 5 hGF2-injected animals, plasma progesterone levels were drastically reduced. Plasma estradiol levels were decreased only in 3 animals in which amenorrhea was observed. These data reveal that hGF2 injection disrupted ovarian function in bonnet monkeys.

Reproductive hormone levels after pituitary allograft in cyclosporin-treated monkeys

OBJECTIVE

To determine the course of events during the onset of hyperprolactinemic amenorrhea, a nonhuman primate model was sought that did not require suckling or interference with the in situ hypothalamic-pituitary axis.

DESIGN

Because removal of the adenohypophysis from hypothalamic influence results in secretion of large quantities of prolactin (PRL) but little of the other adenohypophyseal hormones, we explored the possibility of establishing pituitary allografts in monkeys. Normally cycling female rhesus monkeys were immunosuppressed with a daily regimen of cyclosporin A (CyA; 10 to 15 mg/kg per day) and then subcutaneously grafted with a pituitary from another animal (allograft). Blood samples were obtained daily via saphenous vein puncture during control, only CyA-treatment, and allografted-plus CyA- menstrual cycles.

SETTING

Oregon Regional Primate Research Center, Beaverton, Oregon.

PARTICIPANTS

Female Macaca mulatta exhibiting regular menstruation.

INTERVENTIONS

None.

MAIN OUTCOME MEASURES

Prolactin, luteinizing hormone (LH), estradiol (E2), and progesterone (P) levels were determined in harvested serum.

RESULTS

Temporary survival of 5 of 11 (45%) allografts was assumed based on elevations in serum PRL. Of the viable grafts, 4 of 5 (80%) resulted in reproductive dysfunction, as first evidenced by delay or loss of the preovulatory rise in E2. When the peak of follicular E2 was delayed, then the LH surge occurred, but it was also delayed. If follicular E2 levels did not peak, then the LH surge was absent as was luteal P production.

CONCLUSION

These data suggest that in the etiology of PRL-induced infertility in women, the first event is a suppression of follicular E2 production. In addition, the hypothalamus probably remains responsive to the positive feedback of E2 during early or moderate hyperprolactinemia.

The luteal phase during gonadotropin therapy: effects of two human chorionic gonadotropin regimens

OBJECTIVE

Luteal phase abnormalities are known to complicate ovulation induction with gonadotropins. This study was performed to test the effect of a modified human chorionic gonadotropin (hCG) regimen on the luteal phase during gonadotropin treatment.

DESIGN

Fifteen women from a private practice setting volunteered to be studied during each of two nonconception, gonadotropin-stimulated cycles. After ovarian stimulation with human menopausal gonadotropins (hMG), hCG was administered either as a single dose of 10,000 IU (single dose) or in two divided doses of 5,000 IU given 1 week apart (split dose).

MAIN OUTCOME MEASURES

Early, midluteal, and late luteal estradiol (E2) and progesterone (P) levels and luteal phase lengths were measured, and their median values and intraquartile ranges (IQR) compared using nonparametric analysis.

RESULTS

Early and midluteal E2 and P levels were similar regardless of which hCG regimen was administered. The median late luteal E2 level was 1,146.0 pg/mL (the IQR ranged from 633 to 1,650, IQR = 1,017) with the split-dose regimen and 240.0 pg/mL (the IQR ranged from 150 to 460, IQR = 310) with the single-dose regimen. The median late luteal P level was 108.0 ng/mL (the IQR ranged from 58.5 to 129, IQR = 70.5) with the split-dose regimen and 4.2 ng/mL (the IQR ranged from 1.9 to 11.7, IQR = 9.8) with the single-dose regimen. Median luteal phase lengths were 16 days (the IQR ranged from 15 to 17, IQR = 2) for the split-dose regimen and 11 days (the IQR ranged from 10 to 12, IQR = 2) for the single-dose regimen.

CONCLUSION

In hMG-stimulated cycles, a second dose of hCG given during the midluteal phase significantly increases late luteal E2 and P levels and consistently lengthens the luteal phase.

The role of superovulation with menotropins in ovulatory infertility: a review

The risks of menotropin therapy (ovarian hyperstimulation syndrome, multiple gestation, adnexal torsion) are well known and have been previously described. Superovulation should not be considered for the indications described herein until more traditional therapies for infertility have been tried and found unsuccessful and sufficient time has elapsed for conception to occur. The cost of superovulation is high: the medications are expensive, frequent E2 monitoring and US studies are costly, and pregnancy complications relating to the higher rate of pregnancy loss and multiple gestation may add substantially to the overall cost. Yet, compared with IVF and GIFT, superovulation cycles combined with IUI cost between one third to one sixth that of an IVF cycle. Protocols involving combined CC/hMG/hCG, which reduce the total number of ampules of Pergonal needed per cycle and still provide multiple follicular development, may further reduce costs. There is a growing consensus that superovulation-IUI protocols should be attempted before GIFT and IVF in couples with normal pelvic viscera. There is little doubt that IVF and GIFT cycles are more costly, stressful, and complex. No comparative data have clearly shown IVF and GIFT to be superior to superovulation protocols in ovulatory women with normal pelvic anatomy. In the only study examining this issue published to date, Kaplan et al. retrospectively analyzed all GIFT and superovulation/IUI cycles at a single university center and found GIFT to be three times more efficient. However, the inherent limitations of a nonrandomized, nonprospective study of this kind are obvious as these authors have suggested. Therefore, it may be wise to consider the use of superovulation before assisted reproductive technologies until this issue is settled. It would be interesting to determine if the high PRs reported for couples with unexplained infertility or mild endometriosis in IVF and GIFT cycles in some centers not incorporating superovulation/IUI protocols would hold up if such an approach was routinely followed. Despite the increasing acceptance of superovulation protocols, we must be aware that many of the studies suggesting a role of hMG in treating ovulatory infertile women with normal pelvic anatomy suffer from deficiencies in experimental design. In a payor-driven system, such as in the United States, the difficulties in designing and carrying out scientifically sound clinical studies examining infertility therapies are obvious. The lack of federal or outside funding for the study of infertility issues contributes to the problem. It is our hope that better designed studies examining the role of superovulation in the treatment of ovulatory infertile women with normal pelvic anatomy will be forthcoming.

Early follicular phase follicle-stimulating hormone treatment of endometrial luteal phase deficiency

Fifteen infertile women with inadequate luteal phase, histologically documented in at least two separate cycles, and normal midluteal plasma levels of progesterone (greater than or equal to 10 ng/mL), estradiol (70 to 300 pg/mL), and prolactin (less than 20 ng/mL) received "pure" follicle-stimulating hormone (pFSH), 150 IU intramuscularly, for 4 days (days 1 to 4 of the cycle). The endometrial defect was corrected in 7 of the 15 (46.7%) patients during the first treated cycle. Hormonal levels were similar in control and treatment cycles. Two of 5 patients with no additional infertility factors except luteal phase deficiency (LPD) became pregnant and carried to term singleton pregnancies. In 5 additional infertile patients with normal luteal function as assessed by endometrial histological study (2 cycles) and hormone measurements (first study cycle), a third biopsy was performed in a consecutive cycle under pFSH administration. In no case was the normal secretory pattern impaired. It is concluded that (1) some forms of LPD may be successfully treated by early follicular pFSH therapy and (2) pFSH does not alter the normal endometrial secretory pattern.

Efficacy of clomiphene citrate in the treatment of luteal phase deficiency: quantity versus quality of preovulatory follicles

We tested the hypothesis that the efficacy of clomiphene citrate (CC) in the treatment of luteal phase defect (LPD) is related more to the number of ovulatory follicles than to the quality of a single follicle. Eighteen ovulatory women with LPD as defined by endometrial biopsies that lagged behind chronological dates by at least 3 days on two separate menstrual cycles were studied. During the menstrual cycle before treatment and also during a treatment cycle (100 mg of CC, on days 5 to 9), we obtained an endometrial biopsy 9 to 12 days after ovulation. All biopsies were read in a blinded fashion by the same gynecological pathologist. During the treatment cycle, 10 women had more than one preovulatory follicle (greater than 15 mm, mean of three dimensions), while 8 had one preovulatory follicle. Luteal phase defect was corrected according to biopsy in 8 of the 10 women with more than one preovulatory follicle, but in only 2 of the 8 women with a single preovulatory follicle.

Luteal phase deficiency after completely normal follicular and periovulatory phases

Luteal phase defect (LPD) accounts for a significant proportion of reproductive disorders, however its etiology is still debated. A prospective study was performed on 37 ovulatory women to determine whether LPD can occur in cycles characterized by completely normal folliculogenesis. Criteria for normal folliculogenesis included: a gradual rise of serum estradiol, a luteinizing hormone (LH) surge, the presence of a dominant follicle that disappeared, an increase of serum progesterone, and normal serum levels of prolactin, testosterone, dehydroepiandrosterone sulfate, follicle-stimulating hormone, and LH. Thirty of 37 women fulfilled the above mentioned strict criteria and underwent endometrial biopsy in the late luteal phase. Seven of 30 (23%) demonstrated a delay in endometrial development and all had normal hormonal and ultrasonographic parameters of folliculogenesis and ovulation. Women with delayed endometrial development demonstrated slightly longer follicular phases (17.0 +/- 1.1 versus 14.5 +/- 0.3 days). Perfectly normal follicular and periovulatory events may be followed by deficient luteal phases.

Follicular growth and corpus luteum function in women with unexplained infertility, monitored by ultrasonography and measurement of daily salivary progesterone

Ovarian function was evaluated over a minimum of 3 consecutive menstrual cycles from each of 41 women with unexplained infertility. Follicular development and ovulation were monitored using real time ultrasonography and luteal function was evaluated by daily salivary progesterone measurement. In 129 spontaneous cycles, normal single ovulations were detected in 121 (93.8%). Luteal phase insufficiency was identified in 21 (17.4%) of these 121 cycles and this was a recurrent phenomenon in the cycles of 5 of the 41 women (12.2%). A successful pregnancy was seen only in association with consistently normal salivary progesterone profiles or where the empirical use of clomiphene citrate therapy had corrected previously diagnosed luteal phase insufficiency. Basal body temperature records or mid-luteal serum progesterone measurements were less satisfactory indices of luteal function than a salivary progesterone profile.

Extension of short cycles in postpartum beef cows by intrauterine treatment with catecholestradiol

Eight multiparous beef cows were used to examine the effects of intrauterine infusion of catecholestradiol (4-hydroxylated estradiol) on development and function of the first corpus luteum after parturition. Calves were weaned on day 1 (day 0 = parturition) to initiate formation of a corpus luteum (CL) by approximately day 10 or 11. Before CL formation, on days 5 to 9, cows received twice daily infusions of catecholestradiol (4 micrograms; n = 4) or vehicle (n = 4) into the uterine horn opposite the previous pregnancy. Plasma progesterone during the first estrous cycle was elevated longer (P less than .001) and reached a higher (P less than .001) concentration in cows treated with catecholestradiol. The decline in progesterone was associated with an increase in plasma 13,14-dihydro, 15-keto-prostaglandin F2 alpha (PGFM) in all cows infused with catecholestradiol. In contrast, a rise in PGFM at the end of the first short cycle was detected in only one of four cows treated with vehicle. Furthermore, PGFM concentrations were linearly related (R2 = .870; P less than .001) to concentrations of progesterone. Estradiol-17 beta concentrations were not different during the infusion period, but after formation of the first CL, estradiol remained elevated (P less than .01) in cows that received vehicle. Results of this experiment suggest that exposure of postpartum beef cows to catecholestradiol extended luteal function in association with enhanced PGFM release.

The incidence of luteal phase defect in normal, fertile women, determined by serial endometrial biopsies

Five regularly menstruating women of proven fertility, with normal prolactin and thyroid function studies, underwent a total of 39 endometrial biopsies (EMBs). The slides were dated in blinded fashion, and the cycle date determined by considering the date of the next menstrual period as day 28 and counting backward. Using a 2-day or greater lag in endometrial maturity to define a luteal phase defect (LPD), the incidence of single and sequential out-of-phase EMBs was 51.4% and 26.7%, respectively. Using a 3-day or greater lag to define a LPD, the incidence of single and sequential out-of-phase EMBs was 31.4% and 6.6%, respectively. These incidences in normal, fertile women are as high as the rates quoted for infertile populations, and call into question the standard criteria for defining this condition and evaluating therapies to correct it.

Gonadotrophins, oestradiol and progesterone during the menstrual cycle in bulimia nervosa

Gonadotrophins and gonadal hormones were studied during the menstrual cycle or during 5 weeks when no cycles occurred in 15 patients who were diagnosed as having bulimia by DSM III criteria. Nine healthy age-matched women served as controls. Based on plasma oestradiol (E2) values patients were divided into two groups. Group I (n = 8) did not show E2 increases greater than 444 pmol/l indicating that no follicular development took place. Group II showed normal follicular hormone production during the follicular phase but impaired progesterone (P4) levels during the luteal phase. Studies of episodic gonadotrophin secretion during the follicular phase revealed low average LH and FSH values and reduced amplitude but no significant changes of frequency in group I. Our data indicate that impaired follicular maturation as seen in about half of the bulimic patients is caused by impaired gonadotrophin secretion.

Predictive value of the FSH:LH ratio on follicular and luteal phase characteristics of the human menstrual cycle

A prospective study was designed to assess the predictive value of gonadotropin measurements obtained during the early follicular phase upon the hormonal characteristics of the subsequent cycle. The data obtained in 12 normal cycles were used to compute the mean and confidence interval (mean +/- 2 SEM) of the FSH:LH ratio, FSH and LH plasma levels. The limits of the confidence intervals for these different parameters were used to classify the patients. Data of 204 patients were analysed. Low FSH:LH ratios (less than 1.34) are associated with an increase in follicular phase length (+2.4 days), a lower ovulatory rate, but neither luteal phase length nor progesterone levels differ between these two groups. When patients are classified according to FSH levels, our results show that low FSH levels (less than 2.94 mIU/ml) are associated with longer follicular (+2.6 days) and shorter (-1.1 days) luteal phase lengths, but ovulatory rate and progesterone levels in the luteal phase of the ovulatory cycles are similar to those obtained in patients of the normal or high FSH group. High LH levels (greater than 3.15 mIU/ml) are associated with a decreased ovulation rate but follicular and luteal phase characteristics are similar to those obtained in patients in the normal or low LH group. In conclusion, low FSH: LH ratios and low FSH plasma levels measured in the early follicular phase of the cycle are associated with longer follicular phase lengths; but basal gonadotropin measurements have limited predictive value on luteal phase characteristics.

Prolactin inhibits the steroidogenesis in midfollicular phase human granulosa cells cultured in a chemically defined medium

In vitro studies were conducted on prolactin (PRL) effects on human granulosa cell steroidogenesis. Cells derived from healthy midfollicular phase follicles were cultured in a chemically defined medium supplemented with androstenedione (delta 4 A) 10(-7) M. Cultures treated with follicle-stimulating hormone (FSH) showed a dose-dependent increase of estradiol (E2) and progesterone (P) secretion. The authors demonstrated that PRL (greater than or equal to 10 ng/ml) inhibits basal as well as FSH (10 ng/ml)-stimulated E2 and P secretion. This PRL effect was overcome only by FSH maximal stimulating doses (100 ng/ml). These results suggest a direct inhibitory effect of PRL on granulosa cell steroidogenesis acting as a negative modulator of FSH action. These effects might be related to the ovarian dysfunction observed in hyperprolactinemia.

Ovulatory disturbances in patients with luteal insufficiency

In order to study ovulatory disturbances in patients with luteal insufficiency we evaluated 210 cycles of 170 women from infertile couples by ultrasonographic follicle measurements and hormonal determinations. Only cycles with evidence of luteinization were included into the study. Mid-luteal progesterone (P) levels were determined in relation to the ultrasonographic ovulation time or, where the follicle failed to rupture, in relation to the LH peak. In spontaneous cycles with a mid-luteal P level below 32 nmol/l (10 ng/ml) a luteinized unruptured follicle (LUF) was found in 71.1% of cycles, whereas in spontaneous cycles with a mid-luteal P level above 32 nmol/l only 7.9% cycles exhibited a failure of the follicle to rupture. The same phenomenon was encountered in cycles in which agents had been given to induce ovulation. The incidence of LUF cycles in an average infertility population could be calculated to be as high as 50% if the mid-luteal P level is below 32 nmol/l and as low as 4% if the mid-luteal P level is above 32 nmol/l. The geometric mean mid-luteal P level in spontaneous LUF cycles was 32.5 nmol/l, compared to 55.2 nmol/l in spontaneous ovulatory cycles (P less than 0.001). We conclude that in patients with luteal insufficiency a high incidence is found of a failure of the follicle to rupture. The entrapment of the oocyte in the unruptured follicle constitutes an important cause of infertility in these patients.

Studies of reproductive cyclicity: evaluation of computer modeling as a tool

Assessment of toxic effects on human reproductive function using fetal health or teratogenic criteria presumes the conditions of parental fertility. Toxins that compromise fecundity through derangement of the menstrual cycle may require quite different models and criteria. Nonlinear dynamic interactions of the hormonal and morphological components of the menstrual cycle add to the difficulty of such studies. With appropriate mathematical models, computer simulation can provide a useful guide to the design and conduct of in vivo experiment.

Luteal phase insufficiency: clinical aspects

The author analyzes different controversial clinical aspects of luteal phase insufficiency (LPI) on the basis of his own data. Conceptual and diagnostic concerns include: (1) the lack of predictive value of midluteal plasma progesterone determination regarding the progestational transformation of the endometrium, and (2) the need for a minimum of two, and even three, endometrial biopsies for diagnosis of LPI. From an etiologic point of view, follicular phase determinants of LPI are emphasized. Primary therapeutic approaches of LPI and the effectiveness and significance of such therapy on fertility are discussed.

The endometrial biopsy as a guide to the treatment of the luteal phase defect associated with hyperprolactinemia

Twenty-five hyperprolactinemic patients were given the diagnosis of associated luteal phase defect (LPD) on the basis of endometrial biopsy. Fifteen patients were found to have glandular stromal synchrony, and 10 had glandular stromal asynchrony (GSA). After 3 months of initial bromocriptine therapy, the patients were divided into two groups and treated separately on the basis of the endometrial histologic pattern found. Persistent GSA was complemented with clomiphene citrate. The raw pregnancy rates were identical for both groups. Progesterone values between the two groups were not significantly different. Life-table analysis projected the cumulative pregnancy rate on the basis of the protocol of therapy administered. The efficacy of utilizing a combined drug approach based on the endometrial biopsy seems prudent in managing the fertility rate of the hyperprolactenemic patient with LPD.