Ultrasonic evidence for luteinization of unruptured preovulatory follicles

Non-invasive translational Cynomolgus model for studying folliculogenesis and ovulation using color Doppler ultrasonography

BACKGROUND

In women, different events of folliculogenesis can be measured and evaluated using ultrasound (US) technology. The availability of a non-invasive translational non-human primate model to study these processes would represent a major contribution to further advance R&D efforts toward novel therapies in assisted reproduction.

METHODS

In our study, follicular growth and ovulation was measured in six cyclic Cynomolgus monkeys using abdominal Doppler US.

RESULTS

The mean follicular diameter on cycle day -6 (cycle day 0=day of ovulation) was 3.7mm that increased to 6.8mm on cycle day -1. After ovulation, the mean diameter decreased to 4.6mm, confirming ovulation. The mean percentage of follicular size reduction after ovulation was 31%.

CONCLUSION

Ultrasonography in combination with color-flow Doppler imaging was shown to be a useful, non-invasive translational method to measure ovarian follicular growth and occurrence and timing of follicular rupture in Cynomolgus monkeys.

Ultrasound characteristics of experimentally induced luteinized unruptured follicles (LUF) and naturally occurring hemorrhagic anovulatory follicles (HAF) in the mare

The development of hemorrhagic anovulatory follicles (HAF) involves luteinization and hemorrhage of the follicle. This is observed on ultrasound as an increase in the echogenicity of the granulosa layer and formation of echoic particles in the antrum. The inhibition of prostaglandin synthesis with flunixin meglumine (FM) during the periovulatory period induces ovulatory failure with development of luteinized unruptured follicles (LUF). These two types of anovulatory follicles appear to share similar ultrasound features but they have not been compared critically. The following endpoints: follicle diameter, follicular contents score, interval from hCG administration to beginning of follicular hemorrhage, interval from hemorrhage to organization of follicular contents, and cycle length were studied and compared in mares with HAF (n = 11) and LUF (n = 13). The objective of this study was to elucidate whether these two unruptured follicles have a consistent clinical pattern of development and therefore can be considered as part of the same anovulatory syndrome. None of the endpoints analyzed differed significantly between HAF and LUF. However, there was a greater individual variation in HAF as compared with LUF in regards to interval from hCG to hemorrhage, follicular diameter at the administration of hCG, and beginning of hemorrhage. In conclusion, HAF share a similar cascade of ultrasound characteristics with the experimentally induced LUF. This finding may provide new insights in elucidating the pathogenesis of HAF.

The effect of hormone treatments (hCG and cloprostenol) and season on the incidence of hemorrhagic anovulatory follicles in the mare: a field study

The association between use of hormone treatments to induce estrus and ovulation and the incidence of hemorrhagic anovulatory follicles (HAFs) was studied in a mixed population of mares (Equus caballus) during two breeding seasons in a commercial breeding clinic. Mares treated with cloprostenol (CLO) were more likely to develop HAFs than were mares with spontaneous cycles (P<0.001) or those treated with human chorionic gonadotropin alone (P=0.08). There was no significant effect of season on the incidence of HAFs. The mean (+/-SEM) interval from CLO treatment to beginning of HAF development was 6.1+/-0.5 d. Age of mares with HAF cycles was not different (12+/-1.3 yr; P>0.05) from that of mares with ovulatory cycles (10.5+/-1.5 yr).

Effect of luteinized unruptured follicle cycles on clinical outcomes of frozen thawed embryo transfer in Chinese women

OBJECTIVE

To determine the effect of luteinized unruptured follicle (LUF) cycles on frozen thawed embryo transfer (FET).

DESIGN

A retrospective analysis comparing the clinical outcomes after FET among 144 cases of luteinized unruptured follicle (LUF) cycles and 866 cases of ovulation cycles.

SETTING

Reproductive medical center, Beijing China.

PATIENTS

Chinese infertile women who underwent FET.

INTERVENTIONS

None.

MAIN OUTCOME MEASURES

Clinical pregnancy rate (PR), implantation rate.

RESULTS

The implantation rate, clinical pregnancy rate, on-going pregnancy rate and live birth rate in LUF group were 12.76% (49/384), 27.78% (40/144), 24.31% (35/144) and 19.44% (28/144), respectively, and in ovulation group, 14.74% (332/2251), 31.29% (271/866), 28.29% (245/866) and 22.23% (193/866), respectively (p > 0.05).

CONCLUSIONS

LUF does not affect the clinical outcomes of FET. Patients of LUF should be included in FET treatment.

[Pregnancy results in in vitro fertilization in one case of luteinized-unruptured-follicle syndrome]

Luteinized unruptured follicle syndrome can explain female infertility. The precise mechanism by which the ovulatory follicle fails to rupture is unclear. The following case reports a pregnancy result in in vitro fertilization (IVF). The first stimulation, a long IVF protocol with low FSH dose, was successful. Different methods used for detection and treatment are discussed.

Power Doppler ultrasound studies of ovarian, uterine, and endometrial blood flow in regularly menstruating women with respect to luteal phase defects

The menstrual cycle outcome of 71 regularly menstruating women was ovulatory in 60.5% of the cases, luteal phase defect in 25.3%, luteinized unruptured follicle in 11.2%, and anovulatory in 2.8%. Significantly lower resistance indices were seen in the uterine, arcuate, radial, and spiral arteries of the ovulatory group in the midluteal phase, which was inversely related to the P level.

Women with poor response to IVF have lowered circulating gonadotrophin surge-attenuating factor (GnSAF) bioactivity during spontaneous and stimulated cycles

BACKGROUND

Up to 13% of IVF cancellations are due to poor responses during down-regulated cycles. Because premature luteinization occurs more frequently in older or "poor responder" patients, defective production of gonadotrophin surge-attenuating factor (GnSAF) may be involved.

METHODS

Nine women with normal previous IVF response (NORM) and 9 with previous poor IVF response (POOR) were monitored in a spontaneous cycle (blood samples: days 2, 7, 11, 15 and 20) and then stimulated with recombinant human FSH (rFSH) under GnRH agonist (blood samples: treatment days GnRH agonist + 2, GnRH agonist + 7, day of HCG administration and days HCG + 1 and HCG + 8). LH, FSH, estradiol, progesterone and inhibin-A and -B were assayed in individual samples while GnSAF bioactivity was determined in samples pooled according to day, cycle and IVF response.

RESULTS

During spontaneous cycles LH, steroids and inhibins were similar between NORM and POOR women, FSH was elevated in POOR women (4.9 +/- 0.3 versus 6.7 +/- 0.6 mIU/l, P < 0.01) and GnSAF bioactivity was detectable on days 2, 7 and 11 in NORM women only. During IVF cycles inhibin-A and -B rose more markedly in NORM than POOR women. Similarly GnSAF production peaked on day GnRH agonist + 7 in NORM women, but on the day of HCG administration in POOR women.

CONCLUSIONS

Defects in ovarian responsiveness to FSH include reduced GnSAF production. This suggests that GnSAF should be investigated as a marker of ovarian reserve once an immunoassay becomes available.

Doppler study of arterial and venous intraovarian blood flow in stimulated cycles

OBJECTIVE

To evaluate arterial and venous intraovarian blood flow in follicle stimulating hormone-stimulated cycles.

SUBJECTS AND METHODS

This was a prospective study of 76 follicle stimulating hormone-stimulated cycles carried out in 39 infertile patients who were included in a timed intercourse or intrauterine insemination program in a referral center for assisted reproduction. Transvaginal color and pulsed Doppler measurements of the follicular and luteal phase resistance index, pulsatility index, peak systolic velocity and maximum venous velocity were made and serum progesterone levels during the mid-luteal phase were recorded. Velocimetric parameters were established and then used to classify ovarian function as having a normal ovulatory cycle, or a cycle in which there was either luteal phase deficiency or a luteinized unruptured follicle.

RESULTS

In 52 normal ovulatory cycles, the luteal phase peak systolic and maximum venous velocities were significantly higher and resistance and pulsatility indices were significantly lower than those found in the follicular phase. In 15 women with luteal phase deficiency we did not find any differences in arterial velocimetric parameters when compared with normal ovulatory cycles. However, luteal phase maximum venous velocities were lower in the luteal phase deficiency cycles and there was a significant correlation between luteal phase maximum venous velocity and serum progesterone levels (r = 0.36). Luteinized unruptured follicle cycles (n = 9) did not show significant changes during the ovarian cycle and no 'luteal conversion' of the Doppler signal was identified.

CONCLUSIONS

Follicle stimulating hormone-stimulated cycles in infertile patients can have a high percentage of abnormal functional responses that can be diagnosed only by sonographic assessment, Doppler and the appropriate hormonal follow-up. Arterial and venous intraovarian blood flow remain unaltered during luteinized unruptured follicle cycles and serum progesterone levels correlated with luteal phase maximum venous velocity, which makes Doppler a potentially useful non-invasive test to assess ovulation and luteal function.

The Role of Sonography in Diagnosing and Treating Female Infertility

The most common forms of female infertility and the role of sonography in both the diagnosis and management of female infertility are discussed. A descriptive cause of each disorder is offered, followed by current and experimental sonographic methods of treatment.

Cycle abnormalities in infertile women with regular menstrual cycles: effects of clomiphene citrate treatment

OBJECTIVE

To investigate the incidence and nature of cycle abnormalities and the effect of clomiphene citrate (CC) treatment in women with apparently ovulatory cycles and unexplained infertility.

DESIGN

Nonrandomized, open study of patients before and during treatment.

SETTING

The Reproductive Medicine Clinic of a District General Hospital.

PATIENTS

Thirty-five women with regular, apparently ovulatory menstrual cycles and unexplained infertility.

INTERVENTIONS

Detailed ultrasound and hormonal cycle tracking was performed before and during treatment with CC.

MAIN OUTCOME MEASURES

Serial ultrasound scans and measurements of serum LH, FSH, E2, and P.

RESULTS

Before treatment, 54% of cycles were uniovulatory, 40% were characterized by cyst formation, and 6% were characterized by poor follicular growth. Fifty-one percent of pretreatment cycles had normal hormone profiles, 31% had defective luteal phases, 14% had increased early follicular phase serum FSH levels, and 9% had increased early follicular phase serum LH levels. Treatment with CC reduced the incidence of cyst formation to 9% and the incidence of luteal phase defects to 3%. However, 28% of CC-treated cycles showed ultrasound features of overstimulation and 51% had high follicular phase E2 peaks so that only 34% of CC-treated cycles had normal hormone profiles.

CONCLUSIONS

Cycle abnormalities are common in unexplained infertility. The incidence of cyst formation and luteal phase defects, the most common abnormalities in this group, is reduced by CC treatment.

Comparison of leuprolide acetate and human chorionic gonadotropin for the induction of ovulation in clomiphene citrate-stimulated cycles

OBJECTIVE

To examine the relative efficacies of leuprolide acetate (LA) and hCG in inducing ovulation and a normal luteal phase during clomiphene citrate (CC)-stimulated superovulation cycles.

DESIGN

Prospective, randomized, blinded, and cross-controlled in consecutive cycles.

SETTING

Large military tertiary care center.

PATIENTS

Twenty-one ovulatory patients undergoing superovulation with CC and IUIs for the treatment of unexplained or male factor infertility.

INTERVENTIONS

Clomiphene citrate (100 mg/d) on cycle days 5 through 9 in both of the study cycles. Administration of 2 mg SC LA in one cycle and 10,000 IU IM hCG in another cycle for induction of the midcycle surge.

MAIN OUTCOME MEASURES

Serum LH, FSH, E2, and P levels every 12 hours for 36 hours after administration of either LA or hCG to characterize the midcycle hormonal dynamics. Luteal phase duration and serum P levels during the midluteal phase were used to estimate the adequacy of the luteal phase. Serial ultrasounds also were done to determine the incidence of luteinized unruptured follicle syndrome.

RESULTS

Serum FSH levels in the periovulatory interval were significantly higher after the administration of LA. There were no differences in the periovulatory E2 or P levels or the incidence of sonographic evidence of ovulation after administration of either LA or hCG. Although midluteal serum P levels were higher in the cycles in which hCG was administered, all 42 treatment cycles had adequate luteal phases as assessed by luteal phase duration and three midluteal P levels. Ongoing pregnancies occurred after both LA- and hCG-stimulated cycles.

CONCLUSION

Leuprolide acetate and hCG were equivalent in their abilities to induce ovulation. Further evaluation of the adequacy of the luteal phase and the ensuing pregnancy rates after LA induction of an endogenous gonadotropin surge are indicated.

Comparison of hCG versus GnRH analog for releasing oocytes following ultra low-dose gonadotropin stimulation

Previous data have suggested there is a higher incidence of luteinized unruptured follicle (LUF) syndrome (defined as failure to release any oocyte as determined by sonography) in gonadotropin-treated patients following human chorionic gonadotropin (hCG) versus the gonadotropin releasing hormone agonist (GnRH-a) leuprolide acetate. The present study was designed to determine if an ultra low-dose gonadotropin regimen, designed not to raise the serum estradiol level much above normal for non-stimulated cycles, might result in a decrease in LUF following hCG treatment, and even reduce the rate to that seen following leuprolide acetate. The hypothesis tested was that the higher estradiol levels might suppress the pre-ovulatory follicle stimulating hormone (FSH) surge which, in turn, would inhibit plasmin production, thus preventing detachment of the oocyte from the follicle. The data did show a reduced rate of LUF incidence with either hCG or leuprolide acetate in ultra low-dose human menopausal gonadotropin-(hMG-) treated patients compared to data from previous studies with conventional hMG/hCG therapy. Pregnancy rates were also similar following hCG or leuprolide acetate for release in low-dose hMG-treated patients. Preliminary data show that leuprolide acetate is superior to hCG for causing oocyte release when stimulation is with low-dose purified FSH, and possibly also that low-dose hMG is superior to low-dose purified FSH for producing superior pregnancy rates.

Pregnancy rates after timed intercourse or intrauterine insemination after human menopausal gonadotropin stimulation of normal ovulatory cycles: a controlled study

Forty-eight patients with male (n = 16) or idiopathic (n = 32) infertility were stimulated with human menopausal gonadotropin. Intrauterine insemination (IUI) or natural intercourse were performed after either human chorionic gonadotropin (hCG)-induced or spontaneous, urinary luteinizing hormone (LH) surge-monitored ovulation. A total of 148 cycles were analyzed. In 40 cycles treated with hCG-induced ovulation and IUI, 3 (7.5%) patients conceived, whereas 37 women accomplished natural intercourse after hCG-induced ovulation and 2 (5.5%) became pregnant. When inseminated after a spontaneous LH surge, 3 (8.8%) of 34 patients achieved a pregnancy; no conception occurred in 37 spontaneously ovulatory cycles combined with timed intercourse. Pregnancy rates did not substantially differ between the treatment modalities or between mono-ovulatory and polyovulatory cycles. The cycle characteristics between spontaneous ovulatory and hCG-induced cycles significantly did differ.

The accuracy of urinary luteinizing hormone testing in predicting ovulation

Transvaginal ultrasonography and daily urinary luteinizing hormone testing were used to evaluate the accuracy of urinary luteinizing hormone testing in predicting ovulation in 33 spontaneously ovulating women beginning on cycle day 10. Ovulation was confirmed in all patients with luteal phase progesterone levels and endometrial biopsy specimens. The results demonstrated that transvaginal ultrasonography and urinary luteinizing hormone testing detected ovulation in all cycles. However, the onset of urinary luteinizing hormone occurred after follicle rupture was documented by ultrasonography in 9% of the women studied. Thus the question of accuracy of urinary luteinizing hormone testing in prediction contrasted to detection of ovulation is raised. This observation is of importance in patients in whom prediction of ovulation is critical to treatment management. Therefore, an ultrasonographic examination to confirm the presence of an unruptured follicle on the day of onset of urinary luteinizing hormone surge is recommended, particularly in patients failing to conceive after three to six cycles of artificial insemination when the inseminations are timed with the onset of urinary luteinizing hormone surge.

Investigating unexplained infertility

In an attempt to reduce the number of couples whose basic infertility evaluation fails to reveal any abnormality, 57 couples with the diagnosis of unexplained infertility were further investigated by ultrasound monitoring for folliculogenesis, sperm antibody testing, hamster egg penetration assay, and major histocompatibility (human leukocyte antigen) typing. The use of these techniques allowed the diagnosis of luteinized unruptured follicle in 5% (three patients), sperm antibodies in 5% (three patients), low sperm penetration in 11% (six patients), and human leukocyte antigen-B locus homozygosity in 37% (21 couples). When the incidence of B locus homozygosity among the 57 couples with unexplained infertility was compared with that in 51 fertile couples, the difference was significant at p = 0.025. Thus by adding the diagnostic tools of ultrasound monitoring of folliculogenesis, sperm antibody testing, hamster egg penetration assay, and major histocompatibility antigen typing, the diagnosis of unexplained infertility can be reduced by 60%.

Characteristics and incidence of dysfunctional ovulation patterns detected by ultrasound

The nature and incidence of normal and abnormal spontaneous ovarian cycles, identified with ultrasound and endocrine tracking, were examined in 45 regularly cycling infertile women with no definitive cause and 15 women who were apparently normal and were receiving donor insemination because of clearly infertile partners. In 136 cycles, four apparently distinct abnormal patterns were detected. The total incidence in the infertile group was 58% compared with 23% in the donor insemination group (P less than 0.005). Twelve of 26 subjects who had at least three cycles tracked showed two different abnormalities, and 1 subject had three different abnormalities in five abnormal cycles. These results suggest that abnormal cycles are a significant factor in unexplained infertility and that diagnosis and treatment cannot be based on the study of a single cycle.

The luteinized unruptured follicle syndrome: anovulation in disguise

The luteinized unruptured follicle syndrome is a form of anovulation and a subtle cause of female infertility. The syndrome cannot be diagnosed by traditional progesterone-dependent ovulation detection methods. Without the use of invasive procedures or sophisticated equipment, the luteinized unruptured follicle syndrome may go unnoticed. The patient diagnosed as ovulatory, on the basis of traditional ovulation detection methods, who does not conceive may be experiencing the luteinized unruptured follicle syndrome, and thus infertility. The syndrome's incidence, detection, etiology, and treatment are described.

Ovarian sonographic findings during intermittent intranasal luteinizing hormone-releasing hormone agonist sequentially combined with an oral progestogen as antiovulatory contraceptive approach

Ovarian ultrasounds were performed in four groups of six or seven women taking intranasal luteinizing hormone-releasing hormone agonist Buserelin (200 micrograms twice daily or 400 micrograms once daily) for periods of 14 or 21 days. Medroxyprogesterone acetate (5 mg by mouth twice daily) was added on days 15 to 21. A pause of 7 days followed each of the four treatment periods. Between days 12 to 15 of the first Buserelin cycle, sonograms showed in 17 cases (68%) various degrees of follicular stimulation ranging from numerous 4- to 10-mm follicles (24%), to 10- to 27-mm developing follicle(s) (24%), to greater than 27-mm ovarian cysts (20%). At the fourth Buserelin cycle, the predominant observation was large follicle(s) in the 14-day schedules, whereas ovarian scans did not reveal follicular stimulation in 66% of the 21-day schedules. The area under estradiol (E2) curves was above control in cycles with induced large follicles mainly in the 14-day schedules at the 200 micrograms/12 hour dose. Occasional brief and low elevation of progesterone was compatible with luteinized follicles. In the 21-day schedules at 400 micrograms/24 hours, absence of follicular development was frequently associated with serum E2 in the early follicular phase range. The most appropriate dosage regimen for potential contraception was 200 micrograms/12 hours for 21 days because it was associated with small follicles and serum E2 was in the range of control cycles.

Diagnosis of luteinized unruptured follicle by ultrasound and steroid hormone assays in peritoneal fluid: a comparative study

Luteinized unruptured follicle detection was carried out in 27 women by means of ultrasound scans three times per day and estimation of 17 beta-estradiol and progesterone levels in peritoneal fluid. The incidence of luteinized unruptured follicle diagnosed by ultrasound was 2 of 27 and by estimation of steroid levels was 8 of 27. In three women, a follicle-like structure appeared within 24 hours after ovulation was established by ultrasound; this was accompanied by extremely low progesterone levels in the peritoneal fluid. The disparity between these methods requires further evaluation.

Follicle growth patterns and endocrinological abnormalities in infertile women with minor degrees of endometriosis

Eighteen patients whose only demonstrable cause of infertility was a minor degree of endometriosis and whose partners were normal, were investigated prospectively for one menstrual cycle using ultrasonography and endocrine profiles. Twelve cycles appeared to be normal. A luteinized unruptured follicle (LUF) occurred in two cycles and one patient had a follicular cyst. In a further two patients there was inadequate or abnormal folliculogenesis whilst in the last patient the follicle ruptured prematurely. This study describes the variety of endocrinological abnormalities found in women with mild endometriosis, and concludes that, in this series at least, there is a low frequency of LUF.

Histologic and hormonal documentation of the luteinized unruptured follicle syndrome

Histologic and hormonal documentation of a luteinized unruptured follicle that occurred during a spontaneous menstrual cycle in a rhesus monkey is presented. Frequent (every 2 hours) blood sampling to assess midcycle hormonal dynamics in the monkey with the luteinized unruptured follicle and in five monkeys with an ovulatory stigma revealed significant aberrations in the gonadotropin and steroid hormone profiles associated with a luteinized unruptured follicle. Although the midcycle 17 beta-estradiol surge was normal, the monkey with the luteinized unruptured follicle demonstrated (1) blunted midcycle bioassayable luteinizing hormone, immunoassayable luteinizing hormone, and follicle-stimulating hormone surges; (2) absence of disparity in the bioassayable luteinizing hormone: immunoassayable luteinizing hormone ratio during the gonadotropin surge; (3) absence of progesterone and 17 alpha-hydroxyprogesterone secretion during the gonadotropin surge; and (4) delayed and blunted rise in progesterone and 17 alpha-hydroxyprogesterone after the gonadotropin surge. These findings suggest that an impaired luteinizing hormone surge, perhaps mediated by insufficient midcycle progestin secretion, is one possible cause of the luteinized unruptured follicle syndrome.

Follicle growth curves and hormonal patterns in patients with the luteinized unruptured follicle syndrome

A prospective longitudinal and standardized study is presented, dealing with ultrasonographic and hormonal characteristics of the luteinized unruptured follicle (LUF) syndrome. Among 600 cycles monitored in 270 infertility patients, 40 cycles in 27 patients showed no evidence of follicle rupture, in spite of signs of luteinization, as reflected by basal body temperature recordings and progesterone determinations. In this study, 20 LUF cycles in 20 infertile patients were compared with 45 ovulatory cycles in 45 control women. During the follicular phase, no substantial difference in follicle growth was found, but after the luteinizing hormone peak, LUF follicles, instead of rupturing, showed a typical accelerated growth pattern. Both mean luteinizing hormone peak levels and midluteal progesterone levels were significantly lower in LUF cycles than in the control cycles. However, the duration of the luteal phase was not affected. Both central and local factors can be held responsible for the lack of follicle rupture. Ultrasound offers new possibilities as a noninvasive method in diagnosing the LUF syndrome.

Ultrasound in the evaluation of normal and induced ovulation

In the past several years sonography has become an invaluable research tool for the investigation of spontaneous and induced ovulation and has added to the understanding of folliculogenesis and reproductive endocrinology. In practical terms, in ovulation induction sonography assists in the evaluation of the number and distribution of follicles, necessary for adequate interpretation of estrogen levels. Although there is no ideal size when it can be assumed that a follicle is mature, estimation of follicle size is of value and is a good guide to the timing of hCG administration. If the follicles are extremely small or there is evidence of hyperstimulation, these observations, together with the E2 levels, may be used to decide whether a further ultrasonic examination is warranted for the assessment of follicular growth or whether the treatment cycle should be abandoned. Provided follicular size is within normal limits, the diameter of the largest follicle may also be used in IVF programs to determine when the patient should be admitted to the hospital for more intensive monitoring of follicular development and the administration of hCG. Ultrasound is also valuable in patients with only one ovary accessible to laparoscopy. Even if the largest follicle is in the inaccessible ovary, the treatment cycle does not have to be abandoned, provided that several follicles are developing in the contralateral ovary. If neither ovary is accessible laparoscopically, percutaneous oocyte aspiration offers the patient the opportunity of IVF and embryo transfer.

Monitoring techniques for improved pregnancy rates during clomiphene ovulation induction

Despite the introduction of new ovulation-inducing agents, CC remains the drug of choice for most anovulatory patients. Before initiating therapy, patients should be evaluated to determine the cause of anovulation. Patients with ovarian failure, hyperprolactinemia, hypothyroidism, or forms of CAH should be treated with the appropriate replacement therapy. Evaluation of male factor and tubal patency should be obtained. Once CC therapy is initiated, careful monitoring should be continued. Confirmation of ovulation by endometrial biopsy or serum P levels is essential. CC doses should be increased monthly until normal luteal function is demonstrated. If the patient does not conceive in three ovulatory cycles, her treatment should be further evaluated by postcoital testing, repeat serum P measurement, and review of her endocrine findings. Patients with poor cervical mucus may benefit from midcycle estrogen. Patients with elevated T may benefit from prednisone suppressive therapy. Patients with abnormal HSGs should have laparoscopy and surgical correction if feasible. After six ovulatory cycles without conception, all patients should undergo laparoscopy. If laparoscopy is normal, therapy can be continued for a total of 10 to 12 cycles. Patients with reduced fecundability (male factor, minimal endometriosis, or minimal tubal adhesions) may require a longer time to conceive.

Peritoneal fluid and serum steroids in infertility patients

Peritoneal fluid and serum were collected from 78 patients at the time of laparoscopy. Twenty-two were fertile controls (CTL), and 56 were infertility patients, who were subdivided into three main groups: endometriosis (EMS), pelvic adhesions (ADH), and ovarian dysfunction (OvDF). Based on control group data, biochemical criteria indicative of the presence of a stigma, S(+), were established: (1) serum progesterone (P) greater than or equal to 2 ng/ml, (2) peritoneal fluid P greater than or equal to 50 ng/ml, and (3) peritoneal fluid/serum ratio of P greater than or equal to 3. Direct visualization by laparoscopy showed that 21% CTL, 75% EMS, 69% ADH, and 56% OvDF subjects had luteinized unruptured follicle (LUF) syndrome. Biochemical criteria, however, demonstrated only 7% CTL, 37% EMS, 23% ADH, and 56% OvDF subjects had LUF. Peritoneal fluid estradiol (E2) and P concentrations and total content were significantly lower in LUF than in non-LUF patients, whereas serum E2 and P concentrations were not different between the two groups. Values for testosterone and androstenedione in peritoneal fluid and serum were similar between these two groups. Endometrial dating in LUF versus non-LUF patients were also similar. The usual indicators of ovulation, i.e., serum P, endometrial dating, and basal body temperature, failed to identify LUF. The diagnosis of LUF can be best made by P assay of peritoneal fluid and serum.

Progesterone secretion by luteinized unruptured follicles in mature female rats

The ability of luteinized unruptured follicles (LUF) to display luteal activity was investigated in mature female rats. Previous findings in our laboratory showed that increasing doses of LH, when injected on late diestrus in 4-day cyclic rats, were capable of inducing the formation of either LUF or postovulatory corpora lutea (POCL) in a dose dependent manner. Four-day cyclers were injected on diestrus 2 at 4.30 p.m. (day 0) with 2.7 micrograms or 5.4 micrograms/100 g of an ovine LH preparation (x 2.94 NIH LH S3) and were killed at different times during the three successive days following injection. Natural 4-day cyclers were killed at corresponding times following spontaneous LH release on proestrus afternoon (day 0). Both LUF and POCL were observed in LH-treated females. LUF appeared more numerous in females given 2.7 micrograms LH than in both natural cyclers and in females injected with 5.4 micrograms LH. On day 1 during the rising phase of luteal activity serum progesterone (P) level did not differ in the three groups despite the high number of LUF in females given 2.7 micrograms LH. On day 2 at 11 a.m. lower P values were observed in both groups of LH-treated females than in natural cyclers, this corresponding to a greater proportion of LUF in the former than in the latter. On day 2, at 5 p.m. by the time of full activity of POCL in natural cyclers, P did not differ in the three groups irrespective of the relative number of ruptured or unruptured follicles. On day 3, P sharply declined in LH-treated and natural cyclers. These results suggest that LUF are capable of secreting P during a period corresponding to the duration of corpus luteum's life span in cyclic female rats.

Diagnosis of luteinized unruptured follicle (LUF) syndrome by ultrasound

To evaluate the role of ultrasound in diagnosing luteinized unruptured follicle (LUF), 37 women with unexplained infertility were examined for two to three menstrual cycles. Laparoscopy or laparotomy was performed on days 16 to 18 of the third study cycle in 25 patients. The LUF syndrome was suspected at ultrasound examination in 57 of 100 cycles observed. In the remaining 43 cycles, follicular collapse was observed in 33, and 10 were diagnosed as anovulatory. At laparoscopy or laparotomy on 25 patients, 18 of the 21 patients diagnosed as having LUF by ultrasound had a corpus luteum without a stigma. The other three cases diagnosed as LUF by ultrasound had ovulation stigmata. Additional findings in the 25 patients who underwent laparotomy or laparoscopy were endometriosis in 7 (5 of whom had LUF as well), ovulation in 5, bilateral hydrosalpinx in 1, and inability to visualize the ovaries because of adhesions in 1. The LUF syndrome was not a consistent change in the ovulatory pattern of most of the patients. It occurred by ultrasound diagnosis in three consecutive cycles in only 34% of patients.

Incidence of the luteinized unruptured follicle phenomenon in cycling women

A prospective study is presented in order to determine the frequency of the luteinized unruptured follicle (LUF) in a population of 66 regularly cycling women. They were monitored by daily ultrasound for a total of 183 cycles, and the LUF was detected in 9 cycles, giving an incidence of 4.9%. The results of daily changes of luteinizing hormone, estradiol, and progesterone provide support for the thesis that the LUF behaves steroidogenically as a corpus luteum and that the luteal phase duration is normal. Continued monitoring in 35 cycles revealed a recurrence in only one case during a fourth subsequent cycle. Thus, the findings indicate that the LUF is a sporadic and infrequent phenomenon. It is therefore an uncommon cause of infertile cycles in potentially fertile women and represents a biologic variable rather than a syndrome. Based on ultrasonic and endocrine observations, a mechanism is proposed for the resolution of the LUF.

Ultrasonic measurement of ovarian follicles during chronic LRH agonist treatment for contraception

Ultrasonic examinations of ovarian follicles were performed in seven healthy women on continuous luteinizing hormone-releasing hormone (LRH) agonist treatment for contraception. Four of the women had 1-4 uterine bleedings during the four-month study period and the remaining three women developed amenorrhea. The follicle diameter varied during LRH agonist treatment up to or above the preovulatory size of the normal menstrual cycle in the menstruating group of women. No ovulation occurred as judged by the low progesterone levels in serum. Slightly raised progesterone concentrations (mean 7.6 nmol/l) were observed during four treatment cycles with persistent follicles indicating luteinization of unruptured follicles. No or only small ovarian follicles (8-10 mm) were visualized by ultrasound in the amenorrheic group of women. This study further establish previous reports that chronic LRH agonist treatment effectively inhibits normal ovulation in regularly menstruating women.