Luteal phase deficiency after completely normal follicular and periovulatory phases

Daytime Variation in Serum Progesterone During the Mid-Luteal Phase in Women Undergoing In Vitro Fertilization Treatment

OBJECTIVE

To investigate whether mid-luteal serum progesterone (P₄) exhibits significant fluctuations during a 12-h daytime period in women undergoing in vitro fertilization (IVF) and to explore whether the extent of these fluctuations could impact the interpretation of luteal progesterone levels in a clinical setting.

DESIGN

Explorative pilot study.

SETTING

Public hospital-based fertility unit.

PATIENTS

Ten women undergoing IVF treatment.

INTERVENTION

Seven days after oocyte pick-up, patients underwent frequent repeated blood sampling (every 60 min for 12 h and during two of these hours, every 15 min). Serum samples were analyzed for progesterone, estradiol, and luteinizing hormone (LH).

MAIN OUTCOME MEASURES

Daytime fluctuations in s-progesterone and s-estradiol.

RESULTS

There was a significant positive correlation between median P₄ levels and the magnitude of P₄ variations-women with median P₄ < 60 nmol/l had clinically stable P₄ levels throughout the day, while patients with median P₄ > 250 nmol/l exhibited periodic P₄ peaks of several hundred nanomoles per liter. These endogenous P₄ fluctuations were observed irrespective of the type of stimulation protocol or mode of triggering of final oocyte maturation and despite the fact that LH was under the detection limit at the time of measurement. Simultaneously, large fluctuations were seen in s-estradiol.

CONCLUSION

Monitoring of early to mid-luteal P₄ levels in IVF cycles may be valuable in the planning of individualized luteal phase support in the attempt to increase reproductive outcomes. The prerequisite for luteal phase monitoring is, however, that the validity of a single measured P₄ value is reliable. We show for the first time, that a single P₄ measurement in the low progesterone patient quite accurately reflects the corpus luteum function and that the measurement can be used to detect IVF patients with a need of additional exogenous luteal P₄ administration.

Three-step method for menstrual and oral contraceptive cycle verification

OBJECTIVES

Fluctuating endogenous and exogenous ovarian hormones may influence exercise parameters; yet control and verification of ovarian hormone status is rarely reported and limits current exercise science and sports medicine research. The purpose of this study was to determine the effectiveness of an individualised three-step method in identifying the mid-luteal or high hormone phase in endogenous and exogenous hormone cycles in recreationally-active women and determine hormone and demographic characteristics associated with unsuccessful classification.

DESIGN

Cross-sectional study design.

METHODS

Fifty-four recreationally-active women who were either long-term oral contraceptive users (n=28) or experiencing regular natural menstrual cycles (n=26) completed step-wise menstrual mapping, urinary ovulation prediction testing and venous blood sampling for serum/plasma hormone analysis on two days, 6-12days after positive ovulation prediction to verify ovarian hormone concentrations.

RESULTS

Mid-luteal phase was successfully verified in 100% of oral contraceptive users, and 70% of naturally-menstruating women. Thirty percent of participants were classified as luteal phase deficient; when excluded, the success of the method was 89%. Lower age, body fat and longer menstrual cycles were significantly associated with luteal phase deficiency.

CONCLUSIONS

A step-wise method including menstrual cycle mapping, urinary ovulation prediction and serum/plasma hormone measurement was effective at verifying ovarian hormone status. Additional consideration of age, body fat and cycle length enhanced identification of luteal phase deficiency in physically-active women. These findings enable the development of stricter exclusion criteria for female participants in research studies and minimise the influence of ovarian hormone variations within sports and exercise science and medicine research.

Progesterone and the luteal phase: a requisite to reproduction

Progesterone production from the corpus luteum is critical for natural reproduction. Progesterone supplementation seems to be an important aspect of any assisted reproductive technology treatment. Luteal phase deficiency in natural cycles is a plausible cause of infertility and pregnancy loss, though there is no adequate diagnostic test. This article describes the normal luteal phase of the menstrual cycle, investigates the controversy surrounding luteal phase deficiency, and presents the current literature for progesterone supplementation during assisted reproductive technologies.

Histological dating of timed endometrial biopsy tissue is not related to fertility status

OBJECTIVE

To assess the ability of histological dating to discriminate between women of fertile and infertile couples. The utility of histological dating of endometrium in the evaluation of infertile couples is uncertain.

DESIGN

Prospective multicenter study, with subjects randomly assigned to biopsy timing. Criterion standard for infertility was 12 months of unprotected, regular intercourse without conception and for fertility at least one live birth within 2 years.

SETTING

University-based infertility practices.

PATIENT(S)

Volunteer subjects (847) recruited at 12 clinical sites participating in the National Institutes of Health-funded Reproductive Medicine Network. Inclusion criteria included ages 20-39 years, regular menstrual cycles, and no hormonal treatment or contraceptive use for 1 month before the study. Fertile controls were excluded if they had a history of infertility, recurrent pregnancy loss, or recent breastfeeding.

INTERVENTION(S)

Subjects underwent daily urinary LH testing. After detection of the LH surge, subjects were randomized to biopsy in the mid (days 21-22) or the late (days 26-27) luteal phase. Pathologists at each site estimated the cycle day based on standard criteria. For the primary analysis, an out-of-phase biopsy was defined as a greater than 2-day delay in the histological maturation of the endometrium.

MAIN OUTCOME MEASURE(S)

The proportion of out-of-phase biopsies in fertile and infertile women was compared using logistic regression models with age at randomization as a covariate. Comparisons were also made between fertile vs. infertile at the midluteal or late luteal phase time points.

RESULT(S)

Biopsies were evaluated (301 mid and 318 late; N = 619). Out-of-phase biopsy results poorly discriminated between women from fertile and infertile couples in either the midluteal (fertile: 49.4%, infertile: 43.2%) or late luteal phase (fertile: 35.3%, infertile 23.0%). Results did not substantially differ using alternative definitions of "out-of-phase" or standardized cycle day.

CONCLUSION(S)

Histological dating of the endometrium does not discriminate between women of fertile and infertile couples and should not be used in the routine evaluation of infertility.

Hertig and beyond: a systematic and practical approach to the endometrial biopsy

Evaluation of the endometrial biopsy is a challenge to practicing pathologists, largely due to the wide range of morphologic patterns resulting from both normal and abnormal cyclic changes, exogenous hormones, infections, and intrauterine tumors. Successfully addressing these challenges requires that the practitioner (i) understand the clinical questions being asked, (ii) have a realistic expectation for answering these questions, and (iii) have a systematic approach to resolving these questions in the context of these expectations. The approach outlined begins with the subdividing of women with endometrial alterations into three general categories: (i) women in their fourth decade undergoing evaluation for infertility, (ii) women in their fifth decade who experience abnormal uterine bleeding, and (iii) women in their sixth decade and beyond who experience postmenopausal bleeding. The clinical expectations for each group are unique, as are the morphologic patterns most commonly encountered. Algorithms for the laboratory management of cyclic changes, dysfunctional bleeding, and mixed-pattern endometria are provided, as are pitfalls in interpretation and exclusion of neoplasia.

Manipulation of the follicular phase: Uterodomes and pregnancy - is there a correlation?

BACKGROUND: Manipulation of the follicular phase uterine epithelium in women undergoing infertility treatment, has not generally shown differing morphological effects on uterine epithelial characteristics using Scanning Electron Microscopy (SEM) and resultant pregnancy rates have remained suboptimal utilising these manipulations. The present study observed manipulation of the proliferative epithelium, with either 7 or 14 days of sequential oestrogen (E) therapy followed by progesterone (P) and assessed the appearance of pinopods (now called uterodomes) for their usefulness as potential implantation markers in seven women who subsequently became pregnant. Three endometrial biopsies per patient were taken during consecutive cycles: day 19 of a natural cycle - (group 1), days 11/12 of a second cycle after 7 days E then P - (group 2), and days 19/22 of a third cycle after 14 days E then P - (group 3). Embryo transfer (ET) was performed in a subsequent long treatment cycle (as per Group 3). RESULTS: Seven pregnancies resulted in seven viable births including one twins and one miscarriage. Analysis of the individual regimes showed 5 days of P treatment to have a higher correlation for uterodomes in all 3 cycles observed individually. It was also observed that all 7 women demonstrated the appearance of uterodomes in at least one of their cycles. CONCLUSIONS: We conclude that manipulation of the follicular phase by shortening the period of E exposure to 7 days, does not compromise uterine epithelial morphology and we add weight to the conclusion that uterodomes indicate a receptive endometrium for implantation.

Endometrial thickness is predictive of histologic endometrial maturation in women undergoing hormone replacement for ovum donation

OBJECTIVE

To determine if ultrasonographic endometrial pattern or thickness is predictive of histologic endometrial maturation in women undergoing hormone replacement for ovum donation.

DESIGN

Ultrasonographic endometrial thickness and pattern were determined and compared with histologic assessment of endometrial maturation.

PATIENTS

Forty-six women underwent 52 preparatory cycles for ovum donation. Transvaginal ultrasound (US) was performed after 14 days of E2 replacement and, after 12 days of P, an endometrial biopsy was performed. In 12 cycles, a continuous dose of 2 mg/d E2 was administered. In cycles with out-of-phase biopsies (dated earlier than day 24) and in the last 34 cycles, all women received an escalating dose of E2 before initiation of P. Additionally, the 46 women underwent 55 ETs with USs performed on cycle day 15.

RESULTS

Six women had abnormal biopsies in their first preparatory cycle on the continuous E2 protocol, which normalized with the escalating protocol. All other women had normal biopsies. Women with abnormal biopsies had significantly thinner endometrium (< or = 6 mm) but similar endometrial patterns compared with women with normal biopsies. In women having US in preparatory and transfer cycles, there were no differences in endometrial thickness or pattern between examinations.

CONCLUSIONS

Endometrial thickness > or = 7 mm in hormone replacement cycles predicts in phase endometrial histology and can replace the endometrial biopsy.

The impact of embryonic development and endometrial maturity on the timing of implantation

OBJECTIVE

To gain insight into the peri-implantation period in the human and to answer the question whether timing of nidation is dependent on the stage of embryonic development, endometrial maturation, or a possible dialogue between the two.

DESIGN

Seventy-five women underwent embryo transfer (ET) throughout 93 cycles. Thirty-three ETs resulted in viable pregnancies and deliveries. These pregnancy cycles were used for embryonic signal detection. Embryos of identical age were transferred onto hormonally and histologically defined endometria of different maturational stages (days 15 to 19). Human chorionic gonadotropin (hCG) was measured by a hypersensitive chemiluminescence assay in maternal serum every 1 to 5 days to detect the first embryonic signal.

RESULTS

Individual linear regressions of hCG versus embryonic age and endometrial maturation were performed on 33 viable pregnancy cycles (r2 = 90.5% to 99.9%, P less than 0.02 to 0.002). First signal detection was restricted to an embryonic age of 7.1 +/- 0.28 (mean +/- SD) days (range 6.6 to 7.4) irrespective of endometrial maturation. The pattern of hCG detection was triphasic, described by a sigmoidal curve with the maximal slope corresponding to an hCG doubling time of 15.9 hours. Embryo transfers on cycle day 19 had a steeper slope of hCG detection than days 15 and 16 (P less than 0.05).

CONCLUSIONS

First embryonic signal detection (presumed window of implantation) extends between cycle days 20 and 24. Implantation is dependent on embryonic age and is independent of endometrial maturation within this window. The timing and sigmoidal pattern of hCG detection coincides with structural changes of the implantation bed. The steeper slope of late ETs may represent a compensatory mechanism for late maternal recognition of pregnancy for corpus luteum rescue.

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.

Gonadotropin and ovarian hormone dynamics in luteal phase defects

Blood samples were obtained during early follicular, periovulatory, and luteal phases in four women with out-of-phase endometrial biopsy specimens and four normal controls. In the study cycle, follicular development was evaluated and a late luteal phase endometrial biopsy was performed in each subject. Area under the luteal phase progesterone curve positively correlated with degree of maturity of the endometrial biopsy. Peak serum estradiol, maximum follicular diameter, and both immunoactivity and bioactivity of the preovulatory luteinizing hormone and follicle-stimulating hormone surges were similar in the luteal phase defect cycles as compared with normal cycles. Likewise luteinizing hormone bioactivity in the luteal phase of the luteal phase defect cycles was similar to that of normals. These data show that the immunoactivity and bioactivity of periovulatory and luteal phase gonadotropins may be normal in luteal phase defect cycles.

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.