Endocrinology: Reduced implantation rate associated with a subtle rise in serum progesterone concentration during the follicular phase of cycles stimulated with a combination of a gonadotrophin-releasing hormone agonist and gonadotrophin

Our objective was to assess the effects of subtle increasesin serum progesterone concentration (1.0–2.0 ng/ml) onthe outcome of in-vitro fertilization (IVF), particularly onthe quality of embryos, during the follicular phase of cyclesstimulated with gonadotrophin-releasing hormone agonist (GnRHa)and human menopausal gonadotrophin (HMG). A total of 97 patientsunderwent 116 cycles of IVF and were stimulated with a combinationof HMG and GnRHa. They were divided into two groups: those witha subtle progesterone rise and those with no progesterone rise.The two groups were compared with respect to serum oestradiol,progesterone, immunoreactive luteinizing hormone (I-LH), bioactiveLH (B-LH), and results of IVF. The groups did not differ significantlyin mean age or in total dose of HMG received. On the day thathuman chorionic gonadotrophin was administered, concentrationsof oestradiol and progesterone were significantly higher inthe subtle progesterone rise cycles than in the no progesteronerise cycles. In the no progesterone rise cycles, the percentagesfor embryos beyond the 4-cell stage, grade 1 embryos, and implantationrates were significantly higher than those in subtle progesteronerise cycles. The combination of GnRHa and HMG eliminated anysignificant rise in serum I-LH or B-LH concentration duringthe follicular phase, but did not suppress the subtle rise inprogesterone. These results confirm our previous finding thata subtle progesterone rise adversely affects the outcome ofIVF. It is also suggested that a reduction in embryo qualitymay influence the lower rate of implantation in subtle progesteronerise cycles.     

The influence of ovarian follicular activity on late proliferative phase serum IGFBP-1 in down-regulated assisted conception cycles

Serum insulin-like growth factor binding protein-1 (IGFBP-1)concentrations were measured at the end of the proliferativephase in infertility patients undergoing normal menstrual cyclefrozen embryo transfer, exogenous hormone-supported frozen embryotransfer and in-vitro fertilization (IVF) treatment cycles.These patients were divided into five groups according to theirovarian follicular activity. The exogenous hormone-supportedfrozen embryo transfer group, who had no ovarian follicles,and the IVF groups (number of follicles ranging from 4–38)showed statistically higher serum IGFBP-1 concentrations whencompared to the normal menstrual cycle group (P0.01). Therewas no significant difference in the serum IGFBP-1 concentrationsbetween the exogenous hormone support frozen embryo transfergroup and the poor or normal response IVF groups (number offollicles ranging from 4 to 16). An IVF group that displayedan excessive response to our standard human menopausal gonadotrophinstimulation (>>20 mature follicles or oestradiol >>10000 pmol/1) showed a significantly higher serum IGFBP-1 concentrationwhen compared with the other groups (P = 0.001). This subgroupwas subsequently given a modified (follicle-stimulating hormone)stimulation regime which resulted in a significant reductionin serum IGFBP-1 concentrations (P << 0.05). There wasno correlation between serum oestradiol and IGFBP-1 overallor within the patient groups. We conclude that serum IGFBP-1concentrations in our down-regulated assisted conception cyclesdid not increase in line with ovarian follicular activity, unlessan excessive response was displayed.     

Pregnancy and birth after high serum progesterone concentrations during the follicular phase in an in-vitro fertilization cycle with gonadotrophin-releasing hormone agonist suppression

This case illustrates the possibility of achieving a pregnancyand birth when elevated progesterone concentrations (>4 ng/ml)are present during the follicular phase (from 6 days beforehuman chorionic gonadotrophin injection) of a gonadotrophin-releasinghormone agonist/menotrophin cycle for in-vitro fertilization(IVF). The present patient underwent three IVF/embryo transfercycles in which progesterone concentrations were repeatedlyincreased from the mid-follicular phase onwards. A pregnancywas achieved after the first IVF attempt but ended in a miscarriagein the 19th week of gestation. During the second IVF attemptan endometrial biopsy taken on the day of oocyte retrieval revealedan endometrial advancement of 2 days. A successful pregnancyand birth was again achieved after the third IVF attempt althoughprogesterone concentrations were considerably increased from6 days before the ovulatory stimulus.     

Concentrations of leptin and C-reactive protein in serum and follicular fluid during assisted reproductive cycles

BACKGROUND: There are only a few studies that have investigated inflammatory processes during ovarian hyperstimulation, with contradictory results especially concerning outcome. The aim of the study was to investigate the inflammatory markers C-reactive protein and leptin in serum and follicular fluid and to correlate these with the outcome. METHODS: One hundred and sixty-two gonadotrophin stimulated cycles were evaluated. Serum concentrations of leptin and C-reactive protein were measured at the initiation of stimulation, on the day of hCG administration or the day before, and on the day of oocyte retrieval. They were also determined in the follicular fluid. RESULTS: Serum leptin and C-reactive protein levels increased significantly during stimulation until the day of oocyte pick up, but following different patterns. After stimulation, they correlated with each other in serum and follicular fluid, but not with estradiol or progesterone concentration, embryo quality, or the pregnancy rate. CONCLUSIONS: Leptin and C-reactive protein levels change significantly during assisted reproductive treatment. In contrast to estradiol they are, however, not a marker of success.     

Leptin concentrations in the follicular phase of spontaneous cycles and cycles superovulated with follicle stimulating hormone

It has been reported that oestradiol may play a role in the production of leptin from adipocytes. To investigate this relationship further, nine normally ovulating women were studied during two menstrual cycles, i.e. an untreated spontaneous cycle and a cycle treated with follicle stimulating hormone (FSH) from cycle day 2 until the day of human chorionic gonadotrophin (HCG) injection. Serum leptin values on cycle day 2 did not differ significantly between the spontaneous and the FSH cycles. In the spontaneous cycles, leptin values declined gradually and significantly up to day 7 and then increased progressively up to the day of luteinizing hormone (LH) surge onset, at which point they achieved the highest values. In the FSH cycles, serum leptin values increased gradually and significantly up to day 6, remaining stable thereafter, and were in the midfollicular phase significantly higher than in the spontaneous cycles. Significant positive correlations were found between mean values of leptin and mean values of oestradiol during the second half of the follicular phase in the spontaneous cycles and during the first half in the FSH cycles. A significant negative correlation was found between these two parameters in the spontaneous cycles during the first half of the follicular phase. Serum leptin levels were significantly higher in the midluteal than in the follicular phase in both cycles. These results demonstrate for the first time significant changes in leptin values during the follicular phase of the human menstrual cycle and a significant increase during superovulation induction with FSH. It is suggested that oestradiol may be involved in the regulation of leptin production in women.      

The duration of pre-ovulatory serum progesterone elevation before hCG administration affects the outcome of IVF/ICSI cycles

STUDY QUESTION: During controlled ovarian stimulation (COS), does the duration of premature serum progesterone (P) elevation before administration of hCG affect the outcomes of IVF/ICSI embryo transfer (-ET) cycles? SUMMARY ANSWER: The duration of the premature serum P elevation is inversely related to the clinical pregnancy rate of IVF/ICSI-ET cycles. WHAT IS KNOWN AND WHAT THIS PAPER ADDS: The majority of the previous studies only considered a single serum P measurement made on the day of hCG administration and the results of attempts to relate this to IVF/ICSI-ET outcomes were controversial. However, the effect of the duration of premature serum P elevation before the hCG administration on the outcomes of IVF/ICSI-ET cycles has not been studied well. Here we demonstrate that the duration of premature serum P elevation has a more significant inverse correlation than the absolute serum P concentration on the day of hCG administration with IVF/ICSI-ET outcomes. DESIGN: It is a retrospective, single-centre cohort study. A total of 1784 IVF and/or ICSI-ET cycles were included from October 2005 to June 2011. PARTICIPANTS AND SETTING: A total of 1784 patients underwent their IVF and/or ICSI-ET cycles in a university hospital IVF unit. The inclusion criteria include (i) age between 20 and 42 years and (ii) eligible indications for COS before IVF/ICSI. MAIN RESULTS AND THE ROLE OF CHANCE: The duration of premature serum P elevation to >1 ng/ml is significantly inversely associated with the probability of clinical pregnancy (odds ratio = 0.773, 95% confidence interval: 0.660-0.891, P < 0.001), after adjustment for possible confounders with multivariate logistic regression analysis. However, the significance of inverse correlation between the absolute serum P concentration on the day of hCG administration with clinical pregnancy rate decreased after adjustment. BIAS, CONFOUNDING AND OTHER REASONS FOR CAUTION: The cutoff value we chose to define premature serum P elevation (P > 1.0 ng/ml) might not be able to be applied to different immunoassay kits and study population. The retrospective nature of this study inevitably might be influenced by some selection bias. GENERALIZABILITY TO OTHER POPULATIONS: Older patients (>42 years) are excluded from our study.     

The origin of the follicular capillaries in the human spleen

The major arteries which supply the follicular capillaries in the human spleen do not arise as they do in most mammals as lateral or radial branches from the central artery but come from penicillar arteries which penetrate the marginal zone and enter the follicle at various points around its circumference. Such arteries may have a very short course through the red pulp or they may pursue very long courses. Upon entering the follicle, these arteries branch a number of times, the branches remaining together in a tight array of parallel arterioles along with capillaries formed from them, the whole bundle being enveloped by a reticular fiber sheath. There is thus formed an arteriolar-capillary bundle. The whole bundle may branch. From the sides, especially from its central end, arterioles and capillaries radiate out to all parts of the follicle to terminate in the marginal zone or in the follicle itself.     

Oocyte and embryo quality as well as pregnancy rate in intracytoplasmic sperm injection are not affected by high follicular phase serum progesterone

The effect of elevated serum progesterone concentrations (>1ng/1) on or before the day of human chorionic gonadotrophin(HCG) injection on the outcome of women receiving gonadotrophin-releasinghormone analogue (GnRHa)/ human menopausal gonadotrophin (HMG)for ovarian stimulation prior to intracytoplasmic sperm injection(ICSI) was evaluated. A total of 1275 ICSI cycles were analysedretrospectively. In 53 cycles (4.5%), serum progesterone concentrationswere > 1 ng/ml. Patients in the high progesterone group hadsignificantly higher oestradiol and luteinizing hormone concentrationson the day of HCG injection. The characteristics of the cumulus-coronacell complexes and the nuclear maturity of the oocytes weresimilar in the groups of patients with high and low serum progesteronelevels. Fertilization and cleavage rates as well as embryo qualitywere not different in the two groups. No difference in implantationor clinical pregnancy rates was observed between the high progesteroneand low progesterone groups. Moreover, the cumulative exposureto progesterone during the follicular phase, as expressed bythe area under the curve (AUC), and the duration of exposureto high serum progesterone levels (>1 ng/ml) were not significantlydifferent between pregnant and non-pregnant women in the highprogesterone group. We conclude that in ICSI cycles pretreatedwith GnRHa, increased serum progesterone concentrations on orbefore the day of HCG injection do not affect ICSI outcome.     

EndocrinologyHormonal profile during the follicular phase in cycles stimulated with a combination of human menopausal gonadotrophin and gonadotrophin-releasing hormone antagonist (Cetrorelix)

A third-generation gonadotrophin-releasing hormone antagonist(Cetrorelix) was used during ovarian stimulation in 32 patientsundergoing assisted reproduction, in order to prevent the prematureluteinizing hormone (LH) surge. In all patients, ovarian stimulationwas carried out with two or three ampoules of human menopausalgonadotrophin (HMG), starting on day 2 of the menstrual cycle.In addition, 0.5 mg of Cetrorelix was administered daily fromday 6 of HMG treatment until the day of ovulation inductionby human chorionic gonadotrophin (HCG). A significant drop inplasma LH concentration was observed within a few hours of thefirst administration of Cetrorelix (P<0.005). Moreover, noLH surge was detected at any point in the treatment period inany of the 32 patients. A mean oestradiol concentration of 2122±935ng/1 was observed on the day of the HCG administration, indicatingnormal folliculogenesis. Like LH, progesterone concentrationalso dropped within a few hours of the first administrationof Cetrorelix (P< 0.005). A 0.5 mg daily dose of Cetrorelixprevented a premature LH surge in all the 32 patients treated.     

Progesterone serum levels during the follicular phase of the menstrual cycle originate from the crosstalk between the ovaries and the adrenal cortex

BACKGROUND: The preovulatory rise of progesterone is important for ovulation, but both its regulation and its origin are controversial. Three experiments were performed to determine whether follicular phase progesterone arises from the ovary, the adrenal cortex or both. METHODS: The first study was performed in patients scheduled for assisted reproduction, who received a long-acting GnRH agonist either during intake of an oral contraceptive or during the luteal phase of an otherwise untreated menstrual cycle. The second study was also performed during down-regulation with a GnRH agonist: some patients with elevated progesterone levels received dexamethasone (DXM). Others with similarly elevated basal progesterone levels and those with low progesterone levels were not treated with DXM and served as controls. Finally, adrenocorticotrophic hormone (ACTH) tests were performed in normocyclic volunteers both during early and late follicular phase and during intake of a contraceptive pill. RESULTS: During the suppression of endogenous gonadotrophin secretion progesterone levels rose after the administration of ACTH, but not of GnRH. DXM did not prevent the preovulatory rise of the serum progesterone concentration. The ACTH-stimulated concentration of progesterone and of 17alpha-hydroxyprogesterone were significantly reduced during intake of ethinyl estradiol. CONCLUSIONS: Progesterone arises in the adrenal cortex during most of the follicular phase, whereby its function is modulated by an unknown ovarian factor, which is suppressed by ethinyl estradiol. The source of progesterone shifts towards the ovaries prior to ovulation.     

Analysis of the bleeding pattern in assisted reproduction cycles with luteal phase supplementation using vaginal micronized progesterone

This study was designed to determine the effects of a vaginal micronized progesterone preparation on bleeding patterns and pregnancy outcomes after in-vitro fertilization and intracytoplasmic sperm injection (IVF-ICSI). The study population consisted of 149 consecutive women who had undergone IVF-ICSI using 'long-protocol' stimulation with buserelin-human menopausal gonadotrophin (HMG). A retrospective chart analysis of computerized medical records was undertaken. Vaginal progesterone (200 mg three times daily) was begun the day before oocyte retrieval and continued for a minimum of 16-19 days following human chorionic gonadotrophin (HCG) administration. Occurrence of bleeding following HCG injection, pregnancy rate and outcomes, and serum concentrations of oestradiol were measured. Women undergoing IVF and embryo transfer with ICSI and using vaginal progesterone for luteal support had normal luteal phase lengths (day of HCG minus day of onset of bleeding). In the absence of pregnancy, bleeding occurred after 19.2 +/- 3.9 days (mean +/- SD). Out of the pregnant group only three women bled within 19 days of HCG administration: two had biochemical pregnancies which spontaneously vanished and one evolved to term. The results reflect the normal bleeding pattern to be expected when vaginal progesterone is used for luteal support in IVF and embryo transfer, an approach whose efficacy has been amply proven. No shortened luteal phases were observed using vaginally administered progesterone.     

Predictive value of serum and follicular fluid leptin concentrations during assisted reproductive cycles in normal women and in women with the polycystic ovarian syndrome

Leptin is an adipocyte-derived hormone which plays a central role in the regulation of body weight and energy homeostasis and in signalling to the brain that adequate energy stores are available for reproduction. Although leptin may affect reproduction by regulating the hypothalamic-pituitary-gonadal axis, recent in-vitro observations indicate that leptin may also have direct intra-ovarian actions. Leptin concentrations were measured in women who succeeded in becoming pregnant within three cycles of in-vitro fertilization (IVF) or gamete intra-fallopian transfer (n = 53), in women who failed to become pregnant within three cycles (n = 50), and in women with polycystic ovarian syndrome (PCOS) (n = 22). It was found that lower follicular fluid leptin concentrations were a marker of assisted reproduction treatment success in normal women. Women with PCOS had higher leptin concentrations than women without such a diagnosis, but this was due to their higher body mass index (BMI). After adjustment for age and BMI, women with PCOS who became pregnant tended to have lower mean follicular fluid leptin concentrations than women with PCOS who did not succeed at becoming pregnant. Further studies exploiting the strengths of the IVF model are needed to assess whether the prognostic role for follicular fluid leptin in human reproduction is independent of other factors, and to elucidate the underlying mechanisms.     

Early follicular rise of serum progesterone concentration in response to a flare-up effect of gonadotrophin-releasing hormone agonist impairs follicular recruitment for in-vitro fertilization

A retrospective study of 150 cycles of in-vitro fertilization(IVF) was undertaken to determine the impact of elevated serumprogesterone in the early follicular phase of IVF cycles utilizinggonadotrophin-releasing hormone agonist (GnRHa) initiated inthe follicular phase. A total of 127 patients identified asbeing at risk for poor response to stimulation were treatedwith a flare-up protocol of GnRHa combined with high dose folliclestimulating hormone (FSH). Patients were excluded for severemale factor requiring micromanipulation. Patients were stimulatedwith GnRHa beginning on cycle day 2, and high dose FSH beginningon cycle day 3. Some 85% of the cycles exhibited a rise of serumprogesterone to a peak concentration of > 1.0 ng/ml (range,1.2–4.2 ng/ml) during cycle days 2–6. When comparedto cycles with no demonstrable progesterone rise, cycles witha rise were associated with a significantly decreased ovarianresponse: more ampoules of gonadotrophin were required (mean26.8 versus 22.6, P < 0.05), lower peak oestradiol concentrationwas reached (mean 774 pg/ml versus 1030; P < 0.05), and fewermature oocytes were harvested (mean 4.6 versus 7.5; P < 0.01).Among the different pregnancy outcomes (clinical pregnancy,no pregnancy, ongoing pregnancy, and miscarrige), there wereno significant differences detected in the early follicularprogesterone concentrations as measured by peak progesterone,progesterone area undre the curve (days 2–6), and dayof peak progesterone. The follicular phase initiation of GnRHascan result in significant elevations of serum progesterone inthe early follicular phase, which may impair follicular recruitmentand overall ovarian response.     

Serum and follicular resistin levels in women with polycystic ovarian syndrome during IVF-stimulated cycles

BACKGROUND: Resistin is a hormone linking obesity and insulin resistance. The aim of this study was to compare resistin levels in serum or follicular fluid from women with polycystic ovarian syndrome (PCOS) and controls, both of whom were undergoing IVF. METHODS: We compared serum and follicular resistin levels in 21 PCOS women and in 18 healthy, normal ovulation, age- and body mass index (BMI)-matched non-PCOS women undergoing IVF. Correlations between serum or follicular fluid resistin levels and reproductive outcome were evaluated. RESULTS: There was no significant difference in either serum or follicular resistin levels between the control group and the PCOS group as a whole or those with insulin resistance [homeostasis model assessment of insulin resistance index applied to oral glucose tolerance test (HOMA(OGTT)) <4.7]. However, resistin levels in follicular fluid were unexpectedly significantly lower than serum levels (P<0.0001) in both the PCOS and control groups. No significant correlation was found between resistin levels and BMI, estradiol, LH, or fasting or 2 h glucose or insulin levels or between follicular resistin levels and fertilization rate, implantation rate, clinical pregnancy rate, or early miscarriage rate in PCOS. CONCLUSION: Resistin is unlikely to be a major determining factor in the growth and maturation of oocytes during IVF-stimulated cycles in PCOS.     

Endocrine abnormalities during the follicular phase in women with recurrent spontaneous abortion.

The frequency of endocrine abnormalities during the follicular phase in non-pregnant women with a history of recurrent abortion was investigated in a case-control study. A total of 42 consecutive women with recurrent spontaneous abortion (three or more consecutive abortions, mean +/- SD: 3.9 +/- 1.1 range 3-8) with no parental chromosome rearrangement or uterine abnormality were studied during the early follicular phase under standardized conditions. Serum concentrations of follicle stimulating hormone (FSH), luteinizing hormone (LH), prolactin, androstenedione, testosterone, dehydroepiandro-stenedione, 17-OH-progesterone, oestradiol, progesterone and thyroid stimulating hormone (TSH) were measured by commercially available radioimmunoassays. Controls were 42 nulligravid females with tubal or male factor infertility without miscarriage. Mean (SD) concentrations of prolactin and androstenedione were 14.2 +/- 6.7 ng/ml versus 10.5 +/- 3.5 ng/ml (95% CI 0.8-6.1) and 2.3 +/- 0.9 ng/ml versus 1.7 +/- 0.6 ng/ml (95% CI 0.2-0.9) in the study and control groups respectively. The other endocrine parameters were comparable in both groups. Obesity [BMI weight (kg)/height (m2) > or = 25] was more prevalent (23 versus 5 women, P = 0.0001) in the study than the control group. Recurrent spontaneous abortion is associated with abnormalities in prolactin and androgen secretion during the follicular phase, suggesting an endocrine aetiology in this disorder. Reduction of body weight and correction of hyperprolactinaemia and of hyperandrogenism may reduce the rate of miscarriage in a subsequent pregnancy in these women.     

The effect of endogenous progesterone on basal body temperature in stimulated ovarian cycles

Whilst it is well recognized that progesterone is involved inthe elevation of body temperature following ovulation, the mechanismfor this process has not been determined. In this study 87 patientsundergoing in-vitro fertilization recorded their basal bodytemperature during one treatment cycle. Exogenous gonadotrophintherapy administered to induce multiple folliculogenesis considerablyelevated periovulatory oestrogen levels and early luteal phaseprogesterone. Body temperature rapidly rase to plateau 48 hafter follicular aspiration in all patients. The amplitude ofthe temperature rise was independent of the progesterone concentrationand the type of hormonal stimulation. There was no correlationbetween the degree of elevation of progesterone and the amplitudeof the rise in body temperature over the first 4 days of theluteal phase. It is postdated that serum progesterone levelsdo not directly control body temperature, but that an oestrogen—progesteronesynergism may be involved.     

The window for embryo transfer in oocyte donation cycles depends on the duration of progesterone therapy

In 192 oocyte donation cycles performed between January 1993 and July 1996, we examined the width of 'the window for embryo transfer' using standard hormonal replacement methods. All transfers were performed within 48 h of insemination. We varied the day of embryo transfer with regard to the initiation of progesterone therapy and, thus, the duration of endometrial exposure to progesterone and analysed the resulting pregnancy rates. Patients were divided into five groups (I-V) and embryo transfers were performed 2, 3, 4, 5 or 6 days following initiation of progesterone therapy. The number of pregnancies per transfer cycle achieved in groups I-V were 0 (0%), 3 (12%), 16 (40%), 29 (48.3%), and 10 (20.4%) respectively. The increased pregnancy rate in group III in comparison to group II is statistically significant (P < 0.03). Furthermore, the pregnancy rate in group IV (5 days of progesterone administration before embryo transfer) was significantly higher than in group V (6 days of progesterone administration before embryo transfer; P < 0.005). We also noted that, when embryos were transferred 4 or 5 days after initiation of progesterone therapy, the pregnancy rates were not significantly different between menopausal and cycling recipients (50% vs 43.7%). Our results indicate that the window for embryo transfer is dependent on duration of treatment with progesterone; it begins approximately 48 h after starting progesterone administration and lasts for approximately 4 days. The optimum period for transferring embryos at the 4- to 8-cell stage corresponds to cycle days 18 and 19. Transfers performed on the 17th and 20th days of the cycle can result in successful implantation, although the rates of implantation are highest when transfers are done on days 18 and 19.