Progesterone blocks the estradiol-stimulated luteinizing hormone surge by disrupting activation in response to a stimulatory estradiol signal in the ewe

Characterization of MicroRNA expression profiles in the ovarian tissue of goats during the sexual maturity period

BACKGROUND

The ovary is an important reproductive organ in mammals, and its development directly affects the sexual maturity and reproductive capacity of individuals. MicroRNAs (miRNAs) are recognized as regulators of reproductive physiological processes in various animals and have been shown to regulate ovarian development through typical targeting and translational repression. However, little is known about the regulatory role of miRNAs in ovarian tissue development during sexual maturity in goats. To comprehensively profile the different physiological stages of sexual maturation in goats, we performed small-RNA sequencing of ovarian tissue samples collected at four specific time points (1 day after birth (D1), 2 months old (M2), 4 months old (M4), and 6 months old (M6)). In addition, we used ELISAs to measure serum levels of reproductive hormones to study their temporal changes.

RESULTS

The results showed that serum levels of gonadotropin-releasing hormone, follicle-stimulating hormone, luteinizing hormone, oestradiol, progesterone, oxytocin, and prolactin were lower in goats at the D1 stage than at the other three developmental stages (P < 0.05). The secretion patterns of these seven hormones show a similar trend, with hormone levels reaching their peaks at 4 months of age. A total of 667 miRNAs were detected in 20 libraries, and 254 differentially expressed miRNAs and 3 groups of miRNA clusters that had unique expression patterns were identified (|log2-fold change|> 1, FDR < 0.05) in the 6 comparison groups. RT‒qPCR was employed to confirm that the expression pattern of the 15 selected miRNAs was consistent with the Illumina sequencing results. Gene ontology analyses revealed significant enrichment of GO terms such as cell proliferation regulation, epithelial cell development, and amino acid transport, as well as important signaling pathways including the MAPK signaling pathway, the PI3K-Akt signaling pathway, and the oestrogen signaling pathway. Further miRNA‒mRNA regulation network analysis revealed that 8 differentially expressed miRNAs (chi-miR-1343, chi-miR-328-3p, chi-miR-877-3p, chi-miR-296-3p, chi-miR-128-5p, chi-miR-331-3p, chi-miR-342-5p and chi-miR-34a) have important regulatory roles in ovarian cell proliferation, hormone secretion and metabolism-related biological processes.

CONCLUSIONS

Overall, our study investigated the changes in serum hormone and miRNA levels in the ovaries. These data provide a valuable resource for understanding the molecular regulatory mechanisms of miRNAs in ovarian tissue during the sexual maturity period in goats.

Efficacy of progestin-primed ovarian stimulation in women with polycystic ovary syndrome undergoing in vitro fertilization: a systematic review and meta-analysis

Polycystic ovary syndrome (PCOS) is a common endocrinopathy causing infertility in childbearing women. Progestin-primed ovarian stimulation (PPOS) protocol has recently been used for infertile women. However, whether PPOS provides a significant benefit over gonadotropin-releasing hormone (GnRH) analogue protocols in PCOS is still controversial. The objective of this systematic review is to investigate the efficacy of PPOS in patients with PCOS during in vitro fertilization (IVF) or intracytoplasmic sperm injection (ICSI). We searched Medline, Embase, Google Scholar, ClinicalTrials, and Cochrane Central Register of Controlled Trials from inception to April 1, 2023. Randomized controlled trials (RCTs) and observational studies comparing the efficacy between PPOS and conventional GnRH analogue protocols in patients with PCOS in English were included. The primary outcomes included live birth rate, the incidence of moderate or severe ovarian hyperstimulation syndrome (OHSS), and the number of metaphase II oocytes. The pooled estimates were calculated using the random-effects models as odds ratios (OR) or mean differences (MD) with 95% confidence intervals (CIs). Three RCTs and six cohort studies involving 2289 patients were included. Results from RCTs suggest that PPOS leads to no significant difference in the risk of OHSS, the number of metaphase II oocytes, or the rate of live birth when compared to GnRH analogue protocols. The pooling estimates of cohort studies showed consistent results. Additionally, in cohort studies, PPOS required a higher dose of Gn and tended to improve the implantation rate, clinical pregnancy rate, and ongoing pregnancy rate. For subgroup analyses, the higher implantation rate, clinical pregnancy rate, and ongoing pregnancy rate were found in PPOS compared to the GnRH agonist short protocol. However, the certainty of the evidence for the outcomes was generally low. Overall, There is currently no evidence to support that PPOS could reduce the risk of OHSS, increase oocyte maturation, or improve pregnancy outcomes in women with PCOS undergoing IVF/ICSI when compared to GnRH analogue protocols. Considering its efficiency and safety, this protocol could be a patient-friendly and viable alternative for PCOS patients, especially when frozen-thawed embryo transfer is planned. Future high-quality randomized trials with children's long-term safety and cost-effective analyses are still required.

System Review Registration

NPLASY (202340059). https://inplasy.com/inplasy-2023-4-0059/.

Neuroendocrine control of gonadotropin-releasing hormone: Pulsatile and surge modes of secretion

The concept that different systems control episodic and surge secretion of gonadotropin-releasing hormone (GnRH) was well established by the time that GnRH was identified and formed the framework for studies of the physiological roles of GnRH, and later kisspeptin. Here, we focus on recent studies identifying the neural mechanisms underlying these two modes of secretion, with an emphasis on their core components. There is now compelling data that kisspeptin neurons in the arcuate nucleus that also contain neurokinin B (NKB) and dynorphin (i.e., KNDy cells) and their projections to GnRH dendrons constitute the GnRH pulse generator in mice and rats. There is also strong evidence for a similar role for KNDy neurons in sheep and goats, and weaker data in monkeys and humans. However, whether KNDy neurons act on GnRH dendrons and/or GnRH soma and dendrites that are found in the mediobasal hypothalamus (MBH) of these species remains unclear. The core components of the GnRH/luteinising hormone surge consist of an endocrine signal that initiates the process and a neural trigger that drives GnRH secretion during the surge. In all spontaneous ovulators, the core endocrine signal is a rise in estradiol secretion from the maturing follicle(s), with the site of estrogen positive feedback being the rostral periventricular kisspeptin neurons in rodents and neurons in the MBH of sheep and primates. There is considerable species variations in the neural trigger, with three major classes. First, in reflex ovulators, this trigger is initiated by coitus and carried to the hypothalamus by neural or vascular pathways. Second, in rodents, there is a time of day signal that originates in the suprachiasmatic nucleus and activates rostral periventricular kisspeptin neurons and GnRH soma and dendrites. Finally, in sheep nitric oxide-producing neurons in the ventromedial nucleus, KNDy neurons and rostral kisspeptin neurons all appear to participate in driving GnRH release during the surge.

Neonatal outcomes and congenital malformations in children born after progestin-primed ovarian stimulation protocol

PURPOSE

The purpose of this study is to assess the safety of progestin-primed ovarian stimulation (PPOS) protocol regarding the neonatal outcomes and congenital malformations in babies born after in vitro fertilization (IVF) and frozen embryo transfer (FET).

METHODS

In this large retrospective cohort study, a total of 16,493 infants born between 1 September 2013 and 31 July 2021 from IVF and FET cycles after treatment with either PPOS (n = 15,245) or gonadotropin-releasing hormone antagonist (GnRH-ant) (n = 1,248) were finally enrolled. The primary outcome measure was the incidence of congenital malformations. The secondary outcome measures were rates of low birth weight (LBW), very low birth weight (VLBW), preterm birth (PTB), very preterm birth (VPTB), and early neonatal death.

RESULTS

Birth characteristics for both singletons and twins regarding the sex of infants, gestational age, birth weight, and birth length were comparable between the PPOS group and the GnRH-ant group. Rates of LBW, VLBW, PTB, VPTB, and early neonatal death were also similar. The reanalysis using propensity score matching (PSM) and multivariable logistic regression indicated that the PPOS protocol could not increase the risk of adverse neonatal outcomes compared with the GnRH-ant protocol. Furthermore, no significant difference was observed in the overall incidence of congenital malformations in live-born babies. After PSM and controlling for all confounders, the results remained insignificant with an adjusted odds ratio of 0.66 [95% confidence interval (CI) 0.32-1.34] and 2.43 [95% CI 0.97-6.06], respectively, for singletons and twins.

CONCLUSIONS

Our study suggests that compared with GnRH-ant treatment for IVF, the PPOS protocol could not produce a negative effect on the newborn population in terms of neonatal outcomes and congenital malformations.

Infertility treatment for Chinese women with P450 oxidoreductase deficiency: Prospect on clinical management from IVF to FET

Cytochrome P450 oxidoreductase deficiency (PORD) is a rare recessive disease with multiple clinical manifestations, which is usually diagnosed in neonates and children because of ambiguous genitalia or skeletal malformations. Moreover, the paucity of studies does not allow us to establish whether adult-onset PORD is associated with infertility. Here, we report clinical and laboratory findings in two phenotypically normal women diagnosed with PORD who underwent in vitro fertilization (IVF) and frozen embryo transfer (FET). We modified the gonadotropin stimulation protocol during controlled ovarian hyperstimulation (COH) and suggest the use of the vaginal 17β-estradiol route for endometrium preparation in hormone replacement therapy (HRT) cycles. We presume that PORD may be associated with infertility in several aspects, including disordered steroidogenesis, endometrium impairment, attenuation of drug metabolism, and the high risk of miscarriage. Our observations will help the early diagnosis and make a tailored approach to infertility management in adult-onset PORD.

Epithelial-to-mesenchymal transition contributes to the downregulation of progesterone receptor expression in endometriosis lesions

Endometriosis is a common, estrogen-dependent disease, in which endometrial tissue grows in the peritoneal cavity. These lesions often express low levels of progesterone receptors (PR), which potentially play an important role in the insufficient response to progestin treatment. Here, we uncover an interconnection between the downregulated PR expression and the epithelial-to-mesenchymal transition (EMT) in endometriotic lesions. The majority of ectopic epithelial glands (93.1 %, n = 67/72) display heterogeneous states of EMT by immunohistochemistry staining. Interestingly, low PR expression associated with high N-cadherin expression, a hallmark of EMT. In order to gain mechanistic insights, we performed in vitro functional assays with the endometriotic epithelial cell lines EM'osis and 12Z. TGF-β-induced EMT, marked by elevations of CDH2 and SNAI1/2, led to a significant downregulation of PR gene expression in both cell lines. In contrast, silencing of SNAI1 in EM'osis and of SNAI1 plus SNAI2 in 12Z elevated PR gene expression significantly. We found that not only in vitro, but also in the epithelial component of endometriotic lesions strong expression of SNAI1/2 concurred with weak expression of PR. In summary, these results suggested the negative correlation association of the heterogeneous states of EMT and suppressed PR expression in endometriotic lesions. Our functional assays indicate that EMT contributes to the downregulation of PR expression via the upregulation of EMT-TFs, like SNAI1 and SNAI2, which may ultimately lead to progesterone resistance.

Granulosa cells apoptosis and follicular fluid hormones: comparison of progestin-primed ovarian stimulation versus GnRH antagonist protocols

OBJECTIVE

To explore the effect of progestin-primed ovarian stimulation protocol (PPOS) on mural granulosa cells (GCs) apoptosis and hormonal profiles in follicular fluid (FF) and efficacy over GnRH antagonist (GnRH-A) protocols.

METHODS

We performed a prospective cohort study from June through August 2017 at a tertiary teaching hospital. 63 Patients meeting our criteria were recruited in this prospective study voluntarily and stratified to PPOS or GnRH-A group randomly. Mural GCs and FF were collected during oocyte retrieval. Apoptosis of GCs was assessed using the Annexin V-affinity assay by flow cytometry and hormonal profiles in FF were measured using electrochemiluminescence.

RESULTS

A total of 63 women were assessed for eligibility, with 25 cases in PPOS group and 38 in GnRH-A group. Difference of early stage apoptosis rate, late stage apoptosis rate, and total apoptosis rate did not reach statistical significance between groups. Meanwhile, concentrations of hormones in FF were comparable in two groups. No statistically significant differences were observed in number of oocytes retrieved, mature oocyte rate, fertilization rate, and top-quality embryos rate. No patients experienced premature LH surge in both groups during the study.

CONCLUSION

Compared to GnRH antagonist protocol, PPOS had comparable laboratory outcomes, GCs apoptosis rate and hormonal profiles in FF. PPOS is an effective and safe alternative option to provide controlled ovarian hyperstimulation (COH).

Medroxyprogesterone acetate is a useful alternative to a gonadotropin-releasing hormone antagonist in oocyte donation: a randomized, controlled trial

OBJECTIVE

To compare ovarian response and reproductive outcomes in oocyte donors undergoing pituitary suppression with medroxyprogesterone acetate (MPA) versus those undergoing conventional treatment with a gonadotropin-releasing hormone (GnRH) antagonist.

DESIGN

A prospective, randomized, controlled trial of cycles was conducted from October 2017 to June 2019 to evaluate ovarian response in terms of the number of oocytes. The reproductive outcomes of the recipients were retrospectively analyzed later.

SETTING

A university-affiliated private in vitro fertilization center.

PATIENT(S)

We randomly divided 318 donors into 2 groups in a 1:1 ratio. The oocytes obtained were assigned to 364 recipients. One hundred sixty-one donors were treated with a daily dose of 10 mg of MPA administered orally from the beginning of ovarian stimulation (OS), and 156 were treated with a GnRH antagonist (initiated once the leading follicle reached a diameter of 13 mm). Transvaginal ultrasound was performed, and serum estradiol, luteinizing hormone, and progesterone levels were recorded during monitoring. The following additional parameters were analyzed: endocrine profile (in follicular fluid), number of metaphase II oocytes, and pregnancy outcome.

INTERVENTION(S)

The donors included in the study group were stimulated using recombinant follicle-stimulating hormone and MPA at 10 mg/day, simultaneously begun on cycle day 2 or 3. Ovulation was induced using a GnRH agonist when dominant follicles matured. A short protocol with ganirelix at 0.25 mg/day was used for the control group. Oocytes were assigned to the recipients, followed by routine in vitro fertilization procedures in which 1 embryo was usually transferred.

MAIN OUTCOME MEASURE(S)

The primary outcome measure was the numbers of oocytes and metaphase II oocytes retrieved. The secondary outcomes were the incidence of premature luteinizing hormone surge, serum and follicular fluid hormone profiles, and clinical pregnancy outcomes in the recipient group.

RESULT(S)

The number of oocytes retrieved was 21.4 ± 11.7 in the MPA group and 21.2 ± 9.2 in the antagonist group (mean difference 0.14; 95% confidence interval -2.233, 2.517). The total dose of recombinant follicle-stimulating hormone, duration of OS, and endocrine profiles of the serum and follicular fluids were comparable in the 2 groups. No early ovulation was observed in either group. No statistically significant differences with respect to implantation rate (68.1% in the MPA group vs. 62% in the antagonist group), clinical pregnancy rate (64.5% in the MPA group vs. 57.8 in the antagonist group), ongoing pregnancy rate (55.4% in the MPA group vs. 48.5% in the antagonist group), live birth rate (55.1% in the MPA group vs. 48.5% in the antagonist group), or cumulative live birth rate (73.8% in the MPA group vs. 70.7% in the antagonist group) were observed between the groups.

CONCLUSION(S)

The administration of MPA resulted in oocyte retrieval rates, endocrine profiles, viable embryo numbers, and pregnancy outcomes similar to those achieved with the GnRH antagonist. Therefore, MPA can be recommended for OS in oocyte donation because it permits a more patient-friendly approach.

CLINICAL TRIAL REGISTRATION NUMBER

NCT03300960.

Endocrinological effects of social exclusion and inclusion: Experimental evidence for adaptive regulation of female fecundity

When current conditions are probabilistically less suitable for successful reproduction than future conditions, females may prevent or delay reproduction until conditions improve. Throughout human evolution, social support was likely crucial to female reproductive success. Women may thus have evolved fertility regulation systems sensitive to cues from the social environment. However, current understanding of how psychological phenomena might affect female ovarian function is limited. In this study, we examined whether cues of reduced social support-social ostracism-impact women's hormone production. Following an in-lab group bonding task, women were randomly assigned to a social exclusion (n = 88) or social inclusion (n = 81) condition. After social exclusion, women with low background levels of social support experienced a decrease in estradiol relative to progesterone. In contrast, socially-included women with low background social support experienced an increase in estradiol relative to progesterone. Hormonal changes in both conditions occurred specifically when women were in their mid-to-late follicular phase, when baseline estradiol is high and progesterone is low. Follow-up analyses revealed that these changes were primarily driven by changes in progesterone, consistent with existing evidence for disruption of ovarian function following adrenal release of follicular-phase progesterone. Results offer support for a potential mechanism by which fecundity could respond adaptively to the loss or lack of social support.

Comparison of the effects of Duphaston and Cetrotide on oocyte and embryo quality in women undergoing ICSI: A cross-sectional study

Background

Premature luteinizing hormone (LH) surge is one of the causes for assisted reproductive technology cycle cancellation, and it is needed to find novel approaches with improved efficacy and safety profile.

Objective

To compare the effects of Duphaston and Cetrotide on the prevention of premature LH surge and characteristics of retrieved follicles and embryos in women undergoing intracytoplasmic sperm injection.

Materials and Methods

In this retrospective cross-sectional study, 200 patients who were administrated recombinant follicle-stimulating hormone from the third day of menstruation cycle were included. When the follicular diameter reached above 13-14 mm, Cetrotide was prescribed in the control group, while in the case group, Duphaston was taken orally from the third day of cycle. The retrieved oocytes were fertilized in vitro by intracytoplasmic sperm. The level of hormones on the third day of menstruation and the characteristic of follicles, oocytes, and embryos were compared between the two groups.

Results

Duphaston successfully inhibits premature LH surge. There was no significant difference in the level of follicle-stimulating hormone, estradiol, and LH between the case and control groups (p > 0.05). However, results also showed that Duphaston causes more oocyte retrieval in comparison with Cetrotide (p = 0.04). Although, the number of follicles above 14 mm, mature oocyte, and the total number of viable embryos in the case group was slightly higher, it did not reach a significant difference compared with the control group (p > 0.05).

Conclusion

Duphaston could be used as an appropriate medication instead of gonadotropin-releasing hormone antagonists in women undergoing controlled ovarian hyperstimulation. Duphaston prescription not only prevents premature LH surge but also improves the number of retrieved oocytes.

Medroxyprogesterone acetate versus ganirelix in oocyte donation: a randomized controlled trial

STUDY QUESTION

Is oral medroxiprogesterone acetate (MPA) non-inferior compared to ganirelix with respect to the number of mature oocytes (MII) retrieved at ovum pick-up (OPU) in oocyte donation cycles?

SUMMARY ANSWER

MPA is comparable to ganirelix in terms of number of MII retrieved at OPU in oocyte donation cycles.

WHAT IS KNOWN ALREADY

Oral treatment with MPA inhibits the pituitary LH surge during ovarian stimulation in infertile patients. Because of its negative effect on the endometrium, MPA suppression is combined with freeze-all. Published reports indicate that both the number of MII retrieved and pregnancy rates from these oocytes are comparable to short protocol of GnRH agonists during IVF cycles with freeze-all. MPA might allow for more comfortable and cost-effective ovarian stimulation.

STUDY DESIGN, SIZE, DURATION

Randomized clinical trial, open-label, single center, to assess the non-inferiority of MPA (10 mg/day) versus ganirelix (0.25 mg/day) from Day 7, in ovarian stimulation cycles triggered with triptoreline acetate. Trigger criterion was ≥3 follicles of diameter >18 mm.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Overall, 252 oocyte donors were selected (eligible), 216 were randomized and 173 reached OPU: 86 under MPA and 87 under ganirelix. The main outcome was the number of MII retrieved at OPU. Secondary outcomes were embryological laboratory outcomes and reproductive outcomes in recipients. The study was powered to test that the lower limit of the 95% confidence interval of the difference in retrieved MII between groups will be above the non-inferiority limit of -3. Differences were tested using a two-sided Student's t-test or a Pearson's Chi2 test, as appropriate.

MAIN RESULTS AND THE ROLE OF CHANCE

All participants were in their first cycle of oocyte donation. On average, donors were 24 (SD 4.5) years old and with a BMI of 23 (SD 2.9) kg/m2. Duration of stimulation was similar in both groups (11.2 days), as well as the total gonadotropin dose up to trigger (2162 IU in MPA and 2163 IU in ganirelix). The number of MII retrieved was no different: 15.1 (SD 8.3) with MPA and 14.6 (SD 7.0), 95% CI of the difference -2.78, -1.83 excluding the pre-defined non-inferiority limit (-3). Recipients and embryo transfer (ET) characteristics were also similar between groups. The average age of recipients was 42 (SD 4.8) years and the BMI was 24 (SD 4.4) kg/m2. The mean number of MII assigned to each recipients was 6.7 (SD 1.2) in MPA and 6.6 (SD 1.2) in ganirelix (P = 0.58). MII were fertilized with partner sperm in 84% cycles overall and fertilization rate was 76% in MPA versus 74% in ganirelix (P = 0.34). Overall, there was 54% of double ET and 46% of single ET, with 40% of ETs were performed in D5. In spite of similar recipients and cycle characteristics, reproductive outcomes were unexpectedly lower with MPA. Biochemical pregnancy rate was 44 versus 57% (P = 0.023); clinical pregnancy rate 31 versus 46% (P = 0.006); ongoing pregnancy rate 27 versus 40%, (P = 0.015) and live birth rate 22 versus 31%, (P = 0.10).

LIMITATIONS, REASONS FOR CAUTION

Although oocyte recipient and ET characteristics are similar among groups, this RCT has been designed under a hypothesis of non-inferiority in the number of MII obtained and recipients were not randomized; therefore, the reproductive outcomes in recipients should be evaluated with extreme caution.

WIDER IMPLICATION OF THE FINDINGS

Ovarian stimulation using MPA for prevention of LH surge yields comparable number of MII oocytes compared to ganirelix in oocyte donation cycles. The unexpected finding in reproductive outcomes should be further investigated.

STUDY FUNDING/COMPETING INTEREST(S)

None to report.

TRIAL REGISTRATION NUMBER

EudraCT number: 2015-004328-73; ClinicalTrials.gov Identifier: NCT02796105.

TRIAL REGISTRATION DATE

29 September 2015 (EudraCT); 9 June 2016 (ClinicalTrials.gov).

DATE OF FIRST PATIENT’S ENROLLMENT

The date of enrollment of the first participant was 07 July 2016, and the last participant last visit in the study was on 10 July 2017.

Dydrogesterone-primed ovarian stimulation is an effective alternative to gonadotropin-releasing hormone antagonist protocol for freeze-all cycles in polycystic ovary syndrome

OBJECTIVE

To compare the effects of progestin-primed ovarian stimulation using dydrogesterone (DYD) and a gonadotropin-releasing hormone (GnRH) antagonist protocol on cycle characteristics and pregnancy rates in freeze-all cycles in patients with polycystic ovary syndrome (PCOS).

METHODS

Medical records of PCOS patients who underwent freeze-all in vitro fertilization cycles between April 2017 and April 2019 at the Novafertil in vitro fertilization Center were retrospectively evaluated. The primary outcome measure was the incidence of premature luteinizing hormone surge. Secondary outcome measures were the total number of mature oocytes retrieved, fertilization rate, clinical pregnancy rates and ongoing pregnancy rates.

RESULTS

A total of 525 patients were included in the study. DYD-primed ovarian stimulation and a GnRH antagonist protocol were applied in 258 and 267 patients, respectively. The baseline parameters were similar between the two groups. The numbers of mature and fertilized oocytes were similar in the cetrorelix (CET) group and DYD group (11.43 ± 3.48 vs. 11.29 ± 4.34, respectively, P = 0.692; and 8.98 ± 2.93 vs. 8.62 ± 3.67, respectively, P = 0.208). Premature luteinization was rare in both groups, and the difference between the groups was not statistically significant (2.9% vs. 1.5%, respectively, P = 0.268). There was no significant difference in clinical pregnancy rate of the first frozen embryo transfer cycle between the DYG group and the CET group (56% [120/214] vs. 55.6% [113/203], respectively, P = 0.283). There were no significant differences in biochemical pregnancy rates, implantation rates, miscarriage rates or ongoing pregnancy rates between the two groups (P > 0.05).

CONCLUSION

Dydrogesterone-primed ovarian stimulation seems to be an effective alternative to the GnRH antagonist protocol for freeze-all cycles in PCOS patients.

Luteal phase stimulation versus follicular phase stimulation in poor ovarian responders: results of a randomized controlled trial

BACKGROUND

In young women with poor ovarian response, luteal-phase ovarian stimulation (LPOS) is a potential method for collecting competent oocytes. The aim of this study was to assess the efficacy of LPOS compared with follicular phase ovarian stimulation (FPOS) in young women with poor ovarian response (POR).

METHODS

This single-center, prospective, randomized pilot study compared LPOS and FPOS in women with POR fulfilling Bologna criteria who underwent in vitro fertilization at the Instituto Bernabeu. The primary outcome was the number of metaphase II (MII) oocytes obtained by follicular puncture.

RESULTS

Sixty women were included in the study, with 27 women completing LPOS and 30 undergoing FPOS. There was no statistically significant difference in the number of MII oocytes obtained between the LPOS group and the FPOS group (2.1 ± 2.0 vs. 2.6 ± 2.2, p = 0.31). Length of stimulation was also similar in both groups (8.35 ± 2.8 vs. 8.15 ± 4.1 days, p = 0.69). Similarly, there was no significant difference in the follicle-stimulating hormone total dose, number of cumulus-oocyte complexes, survival rate, fertilization rate, or cancellation rate between groups. A significantly higher Ovarian Sensitivity Index was observed in the LPOS group versus the FPOS group (0.96 vs. 0.57, p = 0.037).

CONCLUSION

LPOS was comparable with FPOS in terms of efficacy and may improve ovarian responsiveness in young women with POR.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT02625532; EudraCT identifier: 2015-003856-31.

Luteal phase stimulation, the future of fertility preservation? Retrospective cohort study of luteal phase versus follicular phase stimulation

RESEARCH QUESTION

Is luteal phase stimulation capable of improving fertility preservation?

MATERIALS AND METHODS

We performed a retrospective cohort study of consecutive ovarian stimulations, during July 2012 and September 2018 at Strasbourg University Teaching Hospital in France. Enrollment criteria were patients aged below 40 who had been referred to our center following a diagnosis of cancer or requiring gonadotoxic treatment. All patients enrolled had regular menstrual cycles and normal ovulation. Non-enrollment criteria were an expected low ovarian response (defined by an anti-Müllerian hormone (AMH) level <0.75μg/L and/or an antral follicle count inferior (AFC) inferior than 5), polycystic ovarian syndrome, amenorrhea, prior history of infertility or gonadotoxic treatment. The primary endpoint is the number of mature oocytes (metaphase II) obtained. Secondary outcomes were oocyte yields obtained, stimulation duration, initial gonadotropin dose and total gonadotropin dose.

RESULTS

A total of 100 patients were included: 20 in luteal phase and 80 in follicular phase. A larger number of mature oocytes was obtained in luteal phase versus follicular phase (13.1+/8.0 versus 9.2+/-5.8 with p=0.01). A greater amount of total (mature and immature) oocytes was obtained in luteal phase versus follicular phase with a significant difference (16.8+/-9.3 versus 11.8+/-7.3 with p=0.01). No difference was found for the initial and total doses of gonadotropin.

CONCLUSIONS

Luteal phase stimulation has the advantage of a better flexibility with positives results as to the number of oocytes obtained in fertility preservation.

Neonatal outcomes and congenital malformations in children born after human menopausal gonadotropin and medroxyprogesterone acetate treatment cycles

PURPOSE

To investigate neonatal outcomes and congenital malformations in children born after in vitro fertilization (IVF) and vitrified embryo transfer cycles using human menopausal gonadotrophin and medroxyprogesterone acetate (hMG + MPA) treatment.

METHODS

We performed a retrospective cohort study including 4596 live born babies. During January 2014-June 2016, children born after either hMG + MPA treatment, gonadotropin releasing hormone agonist short protocol, or mild ovarian stimulation were included. The main outcome measures were neonatal outcomes and congenital malformations.

RESULTS

Neonatal outcomes both for singletons and twins such as mean birth weight and length, gestational age, the frequency of preterm birth were comparable between groups. Rate of stillbirth and perinatal death were also similar. No significant differences were found in the overall incidence of congenital malformations between the three groups. Multivariable logistic regression indicated that hMG + MPA regimen did not significantly increase the risk of congenital malformations compared with short protocol and mild ovarian stimulation, with adjusted odds ratio of 1.22 [95% confidence interval (CI) 0.61-2.44] and 1.38 (CI 0.65-2.93), respectively, after adjusting for confounding factors.

CONCLUSIONS

Our data suggested that compared with conventional ovarian stimulations, hMG + MPA treatment neither compromised neonatal outcomes of IVF newborns, nor did increase the prevalence of congenital malformations.

Hypothalamic effects of progesterone on regulation of the pulsatile and surge release of luteinising hormone in female rats

Progesterone can block the oestradiol-induced GnRH/LH surge and inhibit LH pulse frequency. Recent studies reported that progesterone prevented premature LH surges during ovarian hyperstimulation in women. As the most potent stimulator of GnRH/LH release, kisspeptin is believed to mediate the positive and negative feedback effects of oestradiol in the hypothalamic anteroventral periventricular (AVPV) and arcuate (ARC) nuclei, while the region-specific role of progesterone receptors in these nuclei remains unknown. This study examined the hypothesis that progesterone inhibits LH surge and pulsatile secretion via its receptor in the ARC and/or AVPV nuclei. Adult female rats received a single injection of pregnant mare serum gonadotropin followed by progesterone or vehicle. Progesterone administration resulted in a significant prolongation of the oestrous cycle and blockade of LH surge. However, microinjection of the progesterone receptor antagonist, RU486, into the AVPV reversed the prolonged cycle length and rescued the progesterone blockade LH surge, while RU486 into the ARC shortened LH pulse interval in the progesterone treated rats. These results demonstrated that progesterone's inhibitory effect on the GnRH/LH surge and pulsatile secretion is mediated by its receptor in the kisspeptin enriched hypothalamic AVPV and ARC respectively, which are essential for progesterone regulation of oestrous cyclicity in rats.

Controlled Ovarian Stimulation Using Medroxyprogesterone Acetate and hMG in Patients With Polycystic Ovary Syndrome Treated for IVF: A Double-Blind Randomized Crossover Clinical Trial

Ovarian hyperstimulation syndrome (OHSS) during ovarian stimulation is a current challenge for patients with polycystic ovarian syndrome (PCOS). Our previous studies indicated that progestin can prevent premature luteinizing hormone (LH) surge or moderate/severe OHSS in the general subfertile population, both in the follicular-phase and luteal-phase ovarian stimulation but it is unclear if this is true for patients with PCOS. The aim of the article was to analyze cycle characteristics and endocrinological profiles using human menopausal gonadotropin (hMG) in combination with medroxyprogesterone acetate (MPA) for PCOS patients who are undergoing IVF/intracytoplasmic sperm injection (ICSI) treatments and investigate the subsequently pregnancy outcomes of frozen embryo transfer (FET). In the randomized prospective controlled study, 120 PCOS patients undergoing IVF/ICSI were recruited and randomly classified into 2 groups according to the ovarian stimulation protocols: hMG and MPA (group A, n = 60) or short protocol (group B, n = 60). In the study group, hMG (150-225IU) and MPA (10 mg/d) were administered simultaneously beginning on cycle day 3. Ovulation was cotriggered by a gonadotropinreleasing hormone (GnRH) agonist (0.1 mg) and hCG (1000IU) when dominant follicles matured. A short protocol was used as a control. The primary end-point was the ongoing pregnancy rate per transfer and incidence of OHSS. Doses of hMG administrated in group A are significantly higher than those in the controls. LH suppression persisted during ovarian stimulation and no incidence of premature LH surge was seen in both groups. The fertilization rate and the ongoing pregnant rate in the study group were higher than that in the control. The number of oocytes retrieved, mature oocytes, clinical pregnancy rates per transfer, implantation rates, and cumulative pregnancy rates per patient were comparable between the 2 groups. The incidence of OHSS was low between the 2 groups, with no significant difference. The study showed that MPA has the advantages of an oral administration route, easy access, more control over LH levels. A possible reduction in the incidence of moderate or severe OHSS with the MPA protocol should be viewed with caution as the data is small. Large randomized trials with adequate sample size remain necessary.

Medroxyprogesterone acetate is an effective oral alternative for preventing premature luteinizing hormone surges in women undergoing controlled ovarian hyperstimulation for in vitro fertilization

OBJECTIVE

To investigate the use of medroxyprogesterone acetate (MPA) to prevent LH surge during controlled ovarian hyperstimulation (COH) and to compare cycle characteristics and pregnancy outcomes in subsequently frozen-thawed ET (FET) cycles.

DESIGN

A prospective controlled study.

SETTING

Tertiary-care academic medical center.

PATIENT(S)

Three hundred patients undergoing IVF/intracytoplasmic sperm injection treatment.

INTERVENTION(S)

In the study group, hMG and MPA were administered simultaneously beginning on cycle day 3. Ovulation was induced with a GnRH agonist or cotriggered by a GnRH agonist and hCG when dominant follicles matured. A short protocol was used in the control group. Viable embryos were cryopreserved for later transfer in both protocols.

MAIN OUTCOME MEASURE(S)

The primary outcome measure was the number of oocytes retrieved. Secondary outcomes included the number of mature oocytes, the incidence of premature LH surge, and clinical pregnancy outcomes from FETs.

RESULT(S)

The number of oocytes retrieved in the study group was similar to those in the controls (9.9 ± 6.7 vs. 9.0 ± 6.0), and higher doses of hMG were administered. In the study group, LH suppression persisted during ovarian stimulation, and the incidence of premature LH surge was 0.7% (1/150). No statistically significant differences were found in the clinical pregnancy rates (47.8% vs. 43.3%), implantation rates (31.9% vs. 27.7%), and live-birth rates (42.6% vs. 35.5%) in the study group and controls.

CONCLUSION(S)

The results show that MPA is an effective oral alternative for the prevention of premature LH surge in woman undergoing COH. This finding will help establish a new regimen for ovarian stimulation in combination with embryo cryopreservation.

CLINICAL TRIAL REGISTRATION NUMBER

ChiCTR-ONRC-14004419.

Utrogestan as an effective oral alternative for preventing premature luteinizing hormone surges in women undergoing controlled ovarian hyperstimulation for in vitro fertilization

A major cause of cycle cancellation during controlled ovarian hyperstimulation (COH) in women undergoing in vitro fertilization (IVF) is the occurrence of premature luteinizing hormone (LH) surges. Steroidal preparations can modulate the secretion of gonadotropins (Gn); however, few studies using progesterone to inhibit the premature LH surges in COH have been published. The purpose of the study was to evaluate the oral delivery of progesterone soft capsules (Utrogestan) to prevent LH surges from the follicular phase and to compare cycle characteristics as well as to evaluate pregnancy outcomes in subsequent frozen-thawed embryo transfer (FET) cycles. A total of 374 patients were enrolled in this retrospective study, among which 187 patients were simultaneously administered Utrogestan and human menopausal gonadotrophin (hMG) from cycle day 3 until the trigger day. A short protocol including 187 controls with comparable age, body mass index (BMI), infertility duration, and antral follicle count was also used. GnRH agonist (0.1 mg) or hCG (3000 IU) was used for a trigger when the dominant follicles matured. Viable embryos were cryopreserved for later transfer in both groups. The primary outcome was the number of oocytes retrieved. The secondary outcomes included the number of mature oocytes, incidence of premature LH surge, and clinical pregnancy outcomes from FET cycles. Consistent LH suppression was achieved during COH, with a range of 0.07 to 8.9 IU/L, and no premature LH surge was detected. The number of oocytes retrieved in the Utrogestan and hMG protocol was comparable with that in the short protocol (10.92 ± 5.74 vs 10.6 ± 6.22, P > 0.05), and the dose of hMG was higher than that used in the short protocol (1884.22 ± 439.47 IU vs 1446.26 ± 550.48 IU, P < 0.05). No significant between-group difference was observed in the mature oocyte rate (88.88% vs 90.12%), cleavage rate (96.58% vs 96.58%), clinical pregnancy rate (54.27% vs 51.65%), or implantation rate (33.59% vs 34.02%). The study shows that Utrogestan is an effective oral alternative for preventing premature LH surges in women undergoing COH, which will help to establish a convenient user regimen in combination with FET.

Tissue-specific bioconcentration of the synthetic steroid hormone medroxyprogesterone acetate in the common carp (Cyprinus carpio)

The steroid hormone medroxyprogesterone acetate (MPA), commonly used in oral and injectable contraceptives, has been detected in surface and wastewaters near urban and agricultural areas in several rivers of the world. The objectives of this study were to examine the accumulative potential and tissue distribution of MPA in fish. A freshwater species, the common carp (Cyprinus carpio), was exposed to 100 μg/L of MPA for a 7-day period followed by a depuration phase in which fish were maintained in dechlorinated tap water for an additional 7 days. Tissues (muscle, brain, plasma, and liver) were sampled during the uptake (days 1, 3, and 7) and depuration (day 14) phases of the experiment. Tissue-specific bioconcentration factors (BCF) ranged from 4.3 to 37.8 and uptake was greatest in the liver>brain>plasma and lowest in the muscle. From a regulatory standpoint, MPA shows little tendency to bioaccumulate in fish.

GnRH signaling, the gonadotrope and endocrine control of fertility

Mammalian reproductive cycles are controlled by an intricate interplay between the hypothalamus, pituitary and gonads. Central to the function of this axis is the ability of the pituitary gonadotrope to appropriately respond to stimulation by gonadotropin-releasing hormone (GnRH). This review focuses on the role of cell signaling and in particular, mitogen-activated protein kinase (MAPK) activities regulated by GnRH that are necessary for normal fertility. Recently, new mouse models making use of conditional gene deletion have shed new light on the relationships between GnRH signaling and fertility in both male and female mice. Within the reproductive axis, GnRH signaling is initiated through discrete membrane compartments in which the receptor resides leading to the activation of the extracellular signal-regulated kinases (ERKs 1/2). As defined by gonadotrope-derived cellular models, the ERKs appear to play a central role in the regulation of a cohort of immediate early genes that regulate the expression of late genes that, in part, define the differentiated character of the gonadotrope. Recent data would suggest that in vivo, conditional, pituitary-specific disruption of ERK signaling by GnRH leads to a gender-specific perturbation of fertility. Double ERK knockout in the anterior pituitary leads to female infertility due to LH biosynthesis deficiency and a failure in ovulation. In contrast, male mice are modestly LH deficient; however, this does not have an appreciable impact on fertility.

Progesterone receptor A (PRA) and PRB-independent effects of progesterone on gonadotropin-releasing hormone release

Progesterone's (P4) negative feedback actions in the female reproductive axis are exerted in part by suppression of hypothalamic GnRH release. Here we show that P4 can inhibit GnRH release by a mechanism independent of a nuclear P4 receptor (PR(A/B)). Injections of P4, but not vehicle, allopregnanolone, or dexamethasone, acutely suppressed LH levels in both wild-type and P4 receptor knockout ovariectomized mice; pituitary responsiveness to GnRH was retained during P4 treatment, indicating a hypothalamic action. Superfusion of GnRH-producing GT1-7 cells with medium containing 10(-7) m P4 produced a rapid reduction in GnRH release. Incubation with P4 (10(-9) to 10(-7) M) inhibited forskolin-stimulated cAMP accumulation; cotreatment with pertussis toxin prevented this effect. Treatment of GT1-7 cell membranes with P4 caused activation of an inhibitory G protein (G(i)), as shown by immunoprecipitation with a G(i) antibody of most of the increase in membrane-bound [(35)S]GTPgamma-S. Saturation binding analyses demonstrated the presence of a high affinity (K(d) 5.85 nM), limited capacity (Bmax 62.2 nM) binding site for P4. RT-PCR analysis revealed the presence of mRNAs encoding both isoforms of the membrane P4 receptors, mPRalpha and mPRbeta. Western blotting, immunocytochemistry, and flow cytometry experiments similarly revealed expression of mPR proteins in the plasma membranes of GT1-7 cells. Treatment with mPRalpha siRNA attenuated specific P4 binding to GT1-7 cell membranes and reversed the P4 inhibition of cAMP accumulation. Taken together, our results suggest that negative feedback actions of P4 include rapid PR(A/B)-independent effects on GnRH release that may in part be mediated by mPRs.

Regulation of BCRP/ABCG2 expression by progesterone and 17beta-estradiol in human placental BeWo cells

The breast cancer resistance protein (BCRP) is abundant in the placenta and protects the fetus by limiting placental drug penetration. We hypothesize that pregnancy-specific hormones regulate BCRP expression. Hence, we examined the effects of progesterone (P4) and 17beta-estradiol (E2) on BCRP expression in the human placental BeWo cells. P4 and E2 significantly increased and decreased BCRP protein and mRNA, respectively. Likewise, treatment with P4 and E2 increased and decreased, respectively, fumitremorgin C-inhibitable mitoxantrone efflux activity of BeWo cells. Reduction in BCRP expression by E2 was abrogated by the estrogen receptor (ER) antagonist ICI-182,780. However, the progesterone receptor (PR) antagonist RU-486 had no effect on P4-mediated induction of BCRP. P4 together with E2 further increased BCRP protein and mRNA compared with P4 treatment alone. This combined effect on BCRP expression was abolished by RU-486, ICI-182,780, or both. Further analysis revealed that E2 significantly decreased ER beta mRNA and strongly induced PR(B) mRNA in a dose-dependent manner but had no effect on PR(A) and ER alpha. P4 alone had no significant effect on mRNA of ER alpha, ER beta, PR(A), and PR(B). E2 in combination with P4 increased PR(B) mRNA, but the level of induction was significantly reduced compared with E2 treatment alone. Taken together, these results indicate that E2 by itself likely downregulates BCRP expression through an ER, possibly ER beta. P4 alone upregulates BCRP expression via a mechanism other than PR. P4 in combination with E2 further increases BCRP expression, presumably via a nonclassical PR- and/or E2-mediated synthesis of PR(B).

Progesterone can block the preovulatory gonadotropin-releasing hormone/luteinising hormone surge in the ewe by a direct inhibitory action on oestradiol-responsive cells within the hypothalamus

Elevated oestradiol concentrations during the follicular phase stimulate a surge in gonadotropin-releasing hormone (GnRH) and luteinising hormone (LH) concentrations, which leads to ovulation. Progesterone can block the oestradiol-induced GnRH/LH surge, but the mechanism that is involved is unclear. We examined the effect of progesterone on oestradiol-induced activation of cells within the ovine hypothalamus/preoptic area (POA) to determine: (i) in which regions progesterone acts to block the GnRH/LH surge and (ii) whether progesterone directly or indirectly prevents activation of oestradiol-responsive cells. Cellular activation was assessed by measuring the number of cells that expressed Fos (an immediate early gene). Exposure to increased oestradiol concentrations in the absence of progesterone (which normally stimulates a LH surge) did not cause any region-specific changes in hypothalamic Fos expression during the activation stage of the LH surge-induction process (Experiment 1). The same treatment significantly increased cellular activation within the POA, lateral septum (LS), and arcuate nucleus at the time of surge onset (Experiment 2). Concurrent exposure to increased oestradiol and progesterone concentrations during the activation stage of the surge-induction process (which normally blocks the LH surge) was associated with significantly reduced cellular activation within the ventromedial hypothalamus and anterior hypothalamic area, relative to the positive controls (oestradiol increment alone) and arcuate nucleus relative to the negative controls (no increment in oestradiol) during the activation stage (Experiment 1). At the time of surge onset (Experiment 2), exposure to progesterone during the activation period prevented the oestradiol-induced increase in cellular activation that occurred in the POA, LS and arcuate nucleus of the positive controls. These results demonstrated that oestradiol and progesterone induced differential region- and time-specific effects on cellular activation within the regions of the ovine brain that generate the preovulatory GnRH/LH surge. Moreover, the lack of cellular activation within the POA, LS and arcuate nucleus at the time of surge onset in animals exposed to progesterone during the activation stage is consistent with the hypothesis that progesterone can block the preovulatory surge by direct inhibition of oestradiol-induced cellular activation in these areas.