Peritoneal fluid volume, 17beta-estradiol and progesterone concentrations in women with endometriosis and/or luteinized unruptured follicle syndrome

Data on the presence of an ovulation ostium and the volume and the concentrations of estradiol (17 beta-estradiol) and progesterone In women with endometriosis (n = 80) and women with luteinized unruptured follicle (LUF) syndrome (n = 32) are reported and compared with data obtained from normal ovulatory women, previously reported. in women with endometriosis, less ovulation ostia were observed, the difference being significant in moderate and severe endometriosis. During the luteal phase, no statistical difference was found in the amount of peritoneal fluid of women with endometriosis. Estradiol and progesterone levels in the peritoneal fluid of normal women and women with mild endometriosis were not significantly different. Lower steroid concentrations found in peritoneal fluid of women with moderate (phase days 20-22) and severe endometriosis (phase days 14-19 and 20-22) may explain the high incidence of infertility reported in these women (peritoneal steroids deficiency). During the phases days 14-19 and 20-22, very low peritoneal steroid concentrations were found in women with LUF syndrome. It is suggested that progesterone assay in peritoneal fluid is an aid to diagnose the luteinized unruptured syndrome.     

Ovarian adhesions impair ovulation

The concentration of progesterone in peritoneal fluid, aspirated from the pouch of Douglas by laparoscopy, 72 hours after the peak of the luteinizing hormone in serum is believed to indicate whether the ovarian follicle has ruptured or not. Twenty six patients were studied. The volume of peritoneal fluid 72 hours after the peak of the luteinizing hormone was markedly decreased when bilateral ovarian adhesions were present. Progesterone concentrations, assayed during the early luteal phase in peritoneal fluid of women with bilateral ovarian adhesions, were significantly lower than in women with a corpus luteum presenting an ovulation stigma and even significantly lower than in those without ovulation stigma (luteinized unruptured follicle syndrome). The assay of progesterone in peritoneal fluid during the early luteal phase may be of value in women with ovarian adhesions.     

Peritoneal fluid in female fertility and sterility (author's transl)

The authors have analyzed samples of peritoneal liquid to determine how and in which measure the level of steroid hormones allows to distinguish between follicular rupture and ovulation, and follicular luteinization without rupture and lack of ovulation. Volume of peritoneal fluid is not influenced by endometriosis or by pelvic varicosities, but it increases during the luteal phase; peritoneal protein concentration is also at its highest during the luteal phase. Progestin and estradiol-17 beta are higher in peritoneal fluid than in serum; such high concentration is maintained for at least a week after ovulation. The concentration of such hormones is higher in women with ovulatory scars than in those with luteinized unruptured follicle syndrome. Such findings show that peritoneal liquid is a transudate of the hyperemic active ovary, and that the level of concentration of progestin and estradiol-17 beta can be used in the diagnosis of luteinized unruptured follicle syndrome.     

Peritoneal fluid volume and steroid hormone concentrations in baboons with and without either spontaneous minimal/mild endometriosis or the luteinized unruptured follicle syndrome

This study was performed to document for the first time peritoneal fluid volumes and steroid hormone levels in baboons with and without endometriosis. A laparoscopy was carried out in 19 female baboons (11 with a normal pelvis and 8 with histologically proven spontaneous minimal/mild endometriosis) during 64 cycles in the early luteal phase. Peritoneal fluid was measured and aspirated. The pelvis was examined for evidence of recent ovulation and endometriosis. Peritoneal fluid and serum were assayed for 17beta-estradiol and progesterone. The mean volume of peritoneal fluid and its concentration of 17beta-estradiol and progesterone were 2.6 ml, 679 pmol/l and 64 nmol/1, respectively. No differences were observed between animals with or without either endometriosis or luteinized unruptured follicle syndrome. The peritoneal fluid and serum steroid levels were comparable to those found in women. The results presented are similar to those obtained in women with endometriosis and this suggests that the baboon can be used for the study of this disease.Supported by the Commission of the European Communities (DG VIII Development and DG XII Science, Research and Development) and by the Vlaamse Interuniversitaire Raad (Flemish Interuniversity Council), Brussels, Belgium     

Incidence of the luteinized unruptured follicle syndrome in fertile women and in women with endometriosis

One-hundred normal fertile women with normal luteal phase and 118 women with endometriosis underwent luteal phase laparoscopy before day 22. The luteal phase was ascertained by the presence of secretory endometrium and serum progesterone levels higher than 3 ng/ml. The ovaries were carefully inspected for the presence or absence of an ovulation ostium. The percentage of ostii that was observed in fertile women (91%) was similar to that observed in women with mild endometriosis (85%). However, in women with moderate and severe endometriosis, significantly less ostii were noted, respectively 72 and 51%. It is therefore argued that the absence of an ovulation ostium (so-called luteinized unrupted follicle syndrome, LUF) is more frequent in women with moderate and severe endometriosis and may contribute to infertility in this group of women.     

Ovulation defects despite regular menses: Part III

OBJECTIVE: To describe subtle ovulatory defects that can contribute to infertility and/or miscarriage despite regular menses with apparent ovulation. METHODS: By using follicular maturation studies and measurement of serum estradiol, progesterone, and LH certain imperfections in the ovulatory process can be ascertained. RESULTS: Careful evaluation of follicular maturation was able to determine infertility factors, e.g., premature luteinization, luteinized unruptured follicle syndrome, and luteal phase defects. Effective treatment agents include follicular maturing drugs and gonadotropin releasing hormone antagonists in the follicular phase, human chorionic gonadotropins and leuprolide acetate at time of peak follicular maturation and progesterone in the luteal phase. CONCLUSIONS: Progesterone supplementation alone is more effective than follicle maturing drugs in women with luteal phase defects with mature follicles. Small doses of follicle stimulating hormone in the late follicular phase is most effective for luteal phase deficiency associated with immature follicles. Sometimes leuprolide acetate can allow egg release when hCG has failed.     

Histologic and hormonal documentation of the luteinized unruptured follicle syndrome

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

Luteal cysts and unexplained infertility: biochemical and ultrasonic evaluation

A prospective, controlled study of ovarian function using ovarian ultrasound and daily plasma hormone estimations (estradiol, progesterone [P], follicle-stimulating hormone [FSH], luteinizing hormone [LH]) was carried out on 175 spontaneously cycling patients with unexplained infertility. Forty-one (23.4%) demonstrated luteal phase cyst formation. In 21 cycles the dominant follicle reduced in size after the LH peak (cystic corpus luteum cycles), and in 20 no shrinkage was seen (luteinized unruptured follicles). Progesterone concentrations in the early luteal phase were significantly reduced in the luteinized unruptured follicle cycles. Elevation in plasma FSH was seen in the early follicular and luteal phases of both cyst forming groups and may be due to disturbances in ovarian metabolism. Follicular rupture is important for efficient P release by the corpus luteum.     

Oocyte retention after follicle luteinization

Indirect evidence supports the existence of the luteinized unruptured follicle syndrome in infertile women. To seek direct evidence of oocyte retention, infertile and normal women were studied in the early and midluteal phase by visual documentation of ovulation stigma, needle aspiration of ovarian follicles, and peritoneal fluid collection for estradiol and progesterone assay. Luteal phase was confirmed by endometrial biopsy (postovulation day 2 to 8). In normal control subjects (n = 16), 25% of test cycles were stigma-negative and no oocytes were recovered. In infertile group (n = 23), 43% of test cycles were stigma-negative. Five oocytes were recovered including one from a stigma-bearing follicle. Peritoneal fluid steroid levels failed to discriminate stigma-positive from stigma-negative cycles in either group. Oocyte retention after luteinization occurs in infertile women.     

Incidence, recurrence and treatment of the luteinized unruptured follicle syndrome

The frequency of the luteinized unruptured follicle (LUF) was determined in a population of 220 regularly cycling women, infertile for at least two years. Laparoscopy was performed during the very first days of the luteal phase. In 26 women without other demonstrable cause of infertility, a diagnosis of LUF was made based on the absence of an ovulation stigma and the low concentrations of progesterone (P) and 17 beta-oestradiol (E2) in peritoneal fluid (PF). Twenty of these 26 women underwent a culdocentesis 72-96 hours after the serum LH-rise in a following cycle. In 19 out of 20, low P and E2 concentrations in PF were again found, suggesting the recurrence of LUF. Subsequently, ovulation was induced with human menopausal gonadotrophins (hMG) alone (n = 4), or in combination with human chorionic gonadotrophin (hCG, n = 9). At carefully timed culdocentesis (at LH/hCG + 72-96 hours), P concentration in PF was high in the hMG-hCG treated women but remained low in those given hMG alone. The combination of hMG and hCG may be a valuable treatment of LUF.     

Effect of indomethacin on the vascular architecture of preovulatory ovine follicles: possible implication in the luteinized unruptured follicle syndrome

Ovarian follicles sometimes fail to rupture and accumulate large quantities of fluid, yet undergo luteinization and form a steroidogenically competent luteal structure, the luteinized unruptured follicle syndrome. This condition can be mimicked in mammals by administration of indomethacin, an inhibitor of biosynthesis of prostaglandins. Blockade of ovulation by this drug is exerted at the follicular level. Ovulatory failure in sheep given a single intramuscular injection of indomethacin after induction of a surge of of luteinizing hormone was associated with follicular hyperemia as assessed by scanning electron microscopic examination of microcorrosion vascular casts and light microscopic quantification of follicular vascular space. The apical stigma of control (ovulatory) follicles was ischemic. The luteinized unruptured follicle syndrome appears to be the consequence of a chronic follicular inflammatory-like reaction involving inhibition of synthesis of prostaglandins.     

Peritoneal fluid and serum steroids in infertility patients

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

Luteinized unruptured follicle in the early stages of endometriosis as a cause of unexplained infertility.

OBJECTIVE: We attempted to clarify the relationship between luteinized unruptured follicle, which occurs in the early stages of endometriosis, and unexplained infertility. STUDY DESIGN: Seventy patients who had unexplained infertility were reviewed. RESULTS: Laparoscopic examination showed that 47 patients (67%) had endometriosis; of these, 40 (85%) had minimal or mild disease. The incidence of luteinized unruptured follicle was higher (p < 0.05) in patients who had endometriosis (35%/patient and 25%/cycle) compared with patients who did not have endometriosis (11%/patient and 7%/cycle). Degenerated oocyte cumuli were collected in 6 (43%) of 14 luteinized unruptured follicles diagnosed by transvaginal ultrasound. CONCLUSIONS: These results show that luteinized unruptured follicle is common in patients who have mild or minimal endometriosis and that it may be one of the causes of endometriosis-associated infertility. Transvaginal ultrasound-guided follicular puncture of luteinized unruptured follicle during the mid luteal phase may be useful in establishing a definitive diagnosis of luteinized unruptured follicle.     

Luteinized unruptured follicle syndrome: hormone assay on peritoneal fluid in a laparoscopic study of infertile women

33 infertile women with normal ovulatory cycles were investigated for the presence of a Luteinized Unruptured Follicle Syndrome (L.U.F.) using steroid hormone assays in peritoneal fluid and laparoscopic visualization of ovulation stigmata. We failed to identify a stigma in 36% (12) of the patients in the early luteal phase, 1 subject had a cystic corpus luteum and in 4 cases no diagnosis was made due to the presence of adhesions. The mean hormone concentrations in PF were significantly higher when the stigma was present (17-beta-estradiol, P less than 0,05; progesterone, P less than 0,01; 17-oh-progesterone, P less than 0,05). The two groups (with and without ovulation stigmata) showed no differences in plasma levels of Estradiol (E2) and Progesterone (P). Stigmata were detected only in 17% of subjects with concomitant endometriosis. 3 patients with a luteal phase defect showed low levels of steroids in PF in spite of the presence of an ovulation stigma.     

The efficacy of progesterone in achieving successful pregnancy: II. In women with pure luteal phase defects

Controversy still exists as to the proper therapy of luteal phase defects. Some advocate using drugs to improve follicular dynamics, e.g., clomiphene citrate, while others treat luteal phase defects with progesterone. The possibility exists that in some cases the luteal phase defect is secondary to failure to produce a mature follicle, the better drug then being an ovulation-inducing drug, e.g., clomiphene. However, if the follicle is mature, then progesterone may be the best treatment. We defined mature follicle as one between 18 and 24 mm while the serum estradiol (E2) level is over 200 pg/mL. The efficacy of exclusive P therapy was evaluated in 50 women, all with a minimum of 1 1/2 years infertility and with no obvious fertility problems other than luteal phase defect. Seventy percent of the women conceived within 6 months. The abortion rate was 14.7%. The average period of infertility was 2.8 years in the 35 patients who conceived within 6 months. These data suggest that determining the degree of follicular maturation by serum E2 and pelvic sonography plus excluding the luteinized unruptured follicle syndrome by pelvic sonography helps determine the proper therapy for luteal phase defect.     

Subtle abnormalities in follicular development and hormonal profile in women with unexplained infertility

A prospective study of six unselected couples diagnosed as having unexplained infertility was done. In three of six patients, subtle abnormalities in follicular development were detected. In the first case poor follicular growth was observed. There was a premature small rise of luteinizing hormone (LH) with subsequent low levels of estradiol (E2) in the late follicular phase and unusual wide LH peak. This was followed by low progesterone levels in the luteal phase. In the second case follicular growth was abrupted by premature LH surge. This surge was triggered by early rise of E2 level while the follicle was still small in size. In the third case luteinized unruptured follicle syndrome was diagnosed, on ultrasound examination. All of the abnormalities were repetitive.     

Differential expression of T-helper cytokines in the peritoneal fluid of women with normal ovarian cycle compared with women with chronic anovulation

BACKGROUND: Estrogen and progesterone immunoregulate the genital environment by expression of cytokines and growth factors. OBJECTIVE: To investigate the pattern of expression of T-helper cytokines during the ovarian cycle compared with women with chronic anovulation resistant to clomiphene citrate. HYPOTHESIS: Expression of T-helper cytokines in women with chronic anovulation may be different from the pattern in women with a normal ovarian cycle. METHODS: We evaluated 31 infertile women having laparoscopy for evaluation of tubal patency and evidence of ovulation in two groups during (a) the luteal phase (17 women) and (b) the follicular phase (14 women). A third group was composed of 14 women with polycystic ovarian syndrome, but they were resistant to clomiphene citrate for induction of ovulation and had laparoscopic ovarian cautery. Peritoneal fluid was collected during laparoscopy. Estimation of T-helper cytokine interleukin (IL)-2, tumor necrosis factor (TNF)-alpha, IL-4 and IL-6 in serum, peritoneal fluid and culture of the peritoneal mononuclear cells was performed by ELISA. Serum luteinizing hormone (LH), follicle stimulating hormone (FSH), prolactin, estradiol and progesterone were evaluated by the Vidas Parametric System. RESULTS: The LH : FSH ratio was significantly higher in the women with polycystic ovaries than in the ovulatory groups. IL-2 and IFN-gamma were more highly expressed in the follicular phase but the T-helper 2 cytokines IL-4 and IL-6 predominated in the luteal phase, serum, peritoneal fluid and culture of the peritoneal mononuclear cells. From the follicular to the mid-luteal phase, IL-6 increased three to fivefold in the serum and peritoneal fluid, but there was low expression with anovulation. CONCLUSIONS: The peritoneal fluid levels of IL-4 and IL-6 are higher in the luteal phase. Low IL-6 levels in chronic anovulation may be a marker of resistance to clomiphene citrate.     

Cryptic infertility and therapeutic options

Too often infertile patients are given a "herd type" fertility investigation which ultimately leads to expensive, time consuming, and risky in vitro fertilization. However, attention to certain simple details available by non-invasive methods, e.g., checking for premature luteinization, luteinized unruptured follicle syndrome, or performing the post-coital test at the appropriate interval, can lead to a quick solution of the infertility problem. Caution about persistent infertility related to iatrogenic factors, e.g., development of poor post-coital tests or excessively thin endometrium from clomiphene citrate, or development of luteinized unruptured follicle syndrome or premature luteinization by taking follicle maturing drugs, or creating a hostile environment from taking follicle maturing drugs when the woman already made a mature follicle (and would have had a higher success rate with luteal phase support with progesterone) will help achieve pregnancies without necessarily proceeding to the most expensive and invasive procedure of in vitro fertilization. Finally, many wasted cycles of treatment could be avoided by including the simple but very important hypo-osmotic swelling test and measurement of sperm autoantibodies with the first initial semen analysis.     

Clinical significance of the luteinized unruptured follicle syndrome as a cause of infertility

The luteinized unruptured follicle syndrome (LUF) exists and is a cause of infertility. Although the data of the laparoscopic inspection of the ovaries and the corpora lutea and of steroid hormone concentrations in peritoneal fluid constitute strong evidence that the syndrome exists, its role as a cause of infertility is less clear. The only evidence available that the LUF syndrome is a cause of infertility, is the finding that the syndrome occurs statistically more frequently in women with unexplained infertility than in a control group of women. It still has to be proven whether the LUF syndrome occurs repetitively in each cycle and causes infertility, or whether the syndrome occurs intermittently and only reduces the probability of conception.Diagnosis of the syndrome can be made by laparoscopic inspection of the ovaries and by the assay of 17β-estradiol and progesterone, in peritoneal fluid between day 14 and 20 of the cycle.The relationship between the LUF syndrome and pelvic endometriosis and luteal phase insufficiency is discussed. We suggest that the LUF syndrome might be the cause of endometriosis thus explaining the statistical association between both syndromes, and the infertility of women with only mild endometriosis.We favor the hypothesis that the LUF syndrome might be caused by stress thus constituting a ‘psychological infertility’ and we suggest that the syndrome could explain the spontaneous cure rate. Therefore, before any therapy can be accepted as the treatment of the LUF syndrome, it should be strictly assessed with adequate controls.     

Exaggerated prolactin response to thyrotropin-releasing hormone in infertile women with the luteinized unruptured follicle syndrome

Summary Ten cases of luteinized unruptured follicle (LUF) syndrome out of 250 women with unexplained infertility were detected on ultrasonography, giving a frequency of 4%. Hormonal analysis revealed lower serum progesterone levels at mid-luteal phase in LUF cases, suggesting a link between LUF syndrome and inadequate luteal phase. Prolactin response to thyrotropin-releasing hormone was exaggerated in LUF cases as compared with ovulatory cases. Aberrant prolactin release may be a contributory factor in the pathophysiology of the LUF syndrome.