Endocrinology: Daily measurements and in-vitro effects of human chorionic gonadotrophin in the early luteal phase

The purpose of the present study was to analyse daily measurementsof human chorionic gonadotrophin (HCG) in in-vitro fertilization(IVF) cycles and to reproduce the effects of HCG in vitro usinghuman granulosa—luteinized cells from the same patients.The study population consisted of nine women undergoing IVFbecause of tubal infertility in whom blood was drawn every 24h from the day of the ovulatory dose of HCG (10 000 IU) until6 days after ovum pick-up. Granulosa—luteal cells fromthe follicular aspirates were collected and cultured in vitroup to 6 days in the presence of increasing concentrations (0,0.01, 0.1, 1.0 and 100.0 IU/ml) of HCG. Serum progesterone andHCG in vivo as well as progesterone accumulation in vitro ondays 2, 4 and 6, were the main outcome measures. Maximum HCGconcentrations (0.25 IU/ml) were reached the day before ovumpick-up, and continuously decreased until day 6 after ovum retrieval.HCG did not stimulate progesterone production in vitro at anydose tested until day 6 after ovum pick-up. Then, 0.01 IU/mlresulted significantly (P < 0.05) stimulatory compared tocontrols, while 1.0 IU/ml was inhibitory (P < 0.05). It isconcluded that HCG supplementation in an IVF cycle is unnecessaryuntil day 6 after ovum pick-up. On day 6, progesterone productionis stimulated with very low concentrations of HCG.     

Uterus and endometrium: Immunohistochemical localization of extracellular matrix proteins in luteal phase endometrium of fertile and infertile patients

The lack of expression of certain components involved in celladhesion and migration is believed to contribute to endometrialdysfunction and implantation failure. The purpose of this studywas to investigate whether luteal phase endometrium in womenwith unexplained infertility differs, with respect to specificextracellular matrix (ECM) proteins, from endometrium of normalfertile women. A panel of monoclonal antibodies to collagentype IV, fibronectin and laminin was used to characterize thelocalization of ECM components in the different endometrialcompartments. Precisely timed endometrial biopsies obtainedat 4, 7, 10 and 13 days following the luteinizing hormone surgewere obtained from 22 normal fertile women (group 1) and 24women suffering from unexplained infertility (group 2). Paraffin-embeddedsections were labelled using the streptavidin-biotin alkalinephosphatase technique. In group 1, collagen type IV, fibronectinand laminin were absent from the luminal epithelium but presentin stromal cells and the basement membrane of glands and bloodvessels. In group 2, these components were absent from all endometrialregions using equivalent titres of antibody to those used ingroup 1. This suggests that the endometrium of women with unexplainedinfertility demonstrates defects in the distribution of certainECM glycoproteins. A possible consequence of this defect maybe implantation failure.     

The artificial cycle as an effective treatment of persistently retarded endometrium in the luteal phase

The objective of this study was to examine the results of twohormonal treatment modalities on subjects who had persistentlyabnormal endometrial development in the luteal phase. A prospectivestudy design was used to investigate 14 women who had persistentlyretarded endometrium associated with infertility (n = 11) orrecurrent miscarriage (n = 3). Treatment A consisted of progesteronesupplementation in the form of i.m. progesterone at a dailydose of 25–50 mg starting on day luteinizing hormone (LH)+1for 14 days. Treatment B consisted of artificial cycles producedafter down-regulation of the hypothalamic-pituitary-ovarianaxis with Goserelin (3.6 mg s.c.) followed by the administrationof a standard hormone replacement therapy. Endometrial biopsywas taken on day 19 of the artificial cycle or days LH +5 to+7 in the progesterone supplementation cycle. A histologicalstudy was made of the endometrial specimens by standard datingcriteria and morphometry. The artificial cycle resulted in normaldevelopment in all subjects (n = 11), whereas progesterone supplementationrestored normal endometrial development in only seven of 11(64%) subjects. We conclude that persistently retarded endometriumcould be treated more effectively with the artificial cyclethan with progesterone supplementation.     

Differential effects of gonadotrophin-releasing hormone agonists administered as desensitizing or flare protocols on hormonal function in the luteal phase of hyperstimulated cycles

The incorporation of gonadotrophin-releasing hormone agonist (GnRHa) in in-vitro fertilization (IVF) stimulation protocols has led to doubt about the quality of the subsequent luteal phase. The effects of two GnRHa stimulation protocols on luteal phase concentrations of oestradiol (E2), progesterone (P), luteinizing hormone (LH) and follicle stimulating hormone (FSH) were compared with the standard clomiphene stimulation regimen. Subjects receiving clomiphene with human menopausal gonadotrophin (HMG, n = 377) showed essentially similar luteal phase P concentrations to those receiving leuprolide acetate/HMG as a desensitization protocol. Subjects receiving concomitant leuprolide and HMG from day 2 to utilize the flare effect of the GnRHa exhibited significantly lower P levels in the luteal phase compared to clomiphene/HMG and leuprolide desensitization protocols despite the addition of HCG support. This occurred despite equivalent E2 concentrations at the time of ovulation and identical numbers of oocytes recovered. LH concentrations in non-conception cycles were suppressed for at least 14 days in the luteal phase in both GnRHa protocols compared to clomiphene stimulation. Differences were less obvious in cycles where conception occurred suggesting that implantation may proceed more favourably when the luteal endocrinology was optimal. It is concluded that flare methods of GnRHa hyperstimulation are associated with significantly different luteal phases compared with clomiphene or desensitization protocols. It is proposed that the use of the flare type of stimulation may significantly influence the response of the granulosa cells to LH or HCG via gonadotrophin receptors or through altered post-receptor function.     

The usefulness of endometrial biopsy for luteal phase evaluation in infertility.

To assess the usefulness of the late luteal phase endometrial biopsy in infertility, we evaluated a total of 1492 biopsies performed in 1055 patients. Of these women, 699 underwent one biopsy during spontaneous ovulatory cycles, 288 had two, 57 had three, nine had four, and five biopsies were done in two patients. As controls we included 45 fertile women who were requesting contraception. We analysed histological dating of the endometrium and its abnormality rates in first and successive biopsy specimens, as well as the association of the pregnancy outcome with the endometrial patterns and treatment for luteal phase deficiency (LPD). Our results show firstly that diagnosis of LPD in both infertile and fertile women represents only a chance event; secondly, histological endometrial adequacy or inadequacy in the cycle of conception or in previous cycles is not related to the outcome of pregnancy in infertile patients. Finally, treatment of LPD does not improve pregnancy outcome in infertile women. Thus, luteal phase evaluation by histological dating of the endometrium is not worthwhile.     

The benefits of mid-luteal addition of human chorionic gonadotrophin in in-vitro fertilization using a down-regulation protocol and luteal support with progesterone

Luteal support is essential in in-vitro fertilization (IVF)when long-acting gonadotrophin-releasing hormone agonist (GnRHa)is used. Because progesterone lacks luteotrophic stimulation,it seems to be the drug of choice in cases with an increasedrisk of ovarian hyperstimulation syndrome (OHSS). The aim ofthis study was to assess the beneficial effect of the mid-lutealaddition of human choriomc gonadotrophin (HCG) in IVF, usinga down-regulation protocol and luteal support with progesterone,in a prospective randomized study. The study included 170 IVFcycles down-regulated with long-acting GnRHa which were supportedwith 50 mg/day progesterone i.m. during the luteal phase. Patientswere evaluated in the mid-luteal period. Those without clinicalsigns of OHSS, oestradiol concentrations <1000 pg/ml andprogesterone concentrations <50 mg/ml were randomly allocatedto either the addition of 2500 IU HCG (HCG+ group) or no HCG(HCG– group). End luteal phase progesterone concentrationsamong non-pregnant patients were used to assess the contributionof exogenous progesterone and to categorize pregnancies accordingto their corpus luteum function. Similar low OHSS (2.7 and 1.8%)and pregnancy (30 and 29%) rates were observed in the HCG+ andHCG– groups respectively. Of the 26 pregnancies in theHCG+ cases, there was only one case with reduced corpus luteumfunction, compared with 12 of the 25 pregnancies among HCG–patients. Cases with reduced corpus luteum function requiredcontinuous progesterone support and presented lower HCG concentrationsand a higher rate of adverse pregnancy outcome. We concludethat mid-luteal HCG addition does not affect pregnancy rate,but in fact helps to preserve corpus luteum function and avoidsthe need for further supplementation during early pregnancy.     

育龄女性在月经周期三个时相中的情绪Stroop效应

目的:探索正常育龄女性在月经周期不同时相的情绪注意偏向。方法:方便选取某高校育龄女性80名,运用情绪Stroop任务,采用被试内2因素重复测量设计,比较卵泡初期、排卵期和黄体中期对不同情绪效价双字词颜色辨别的正确率和反应时。结果:对情绪词颜色辨别正确率的时相主效应显著,女性在排卵期低于黄体中期(P<0.05)。词语类型和月经时相在情绪词颜色辨别的正确率和反应时上均存在交互作用。对负性词颜色判断的正确率,女性在排卵期低于卵泡初期和黄体中期(均P<0.05);负性词颜色判断的反应时,女性在黄体中期高于卵泡初期和排卵期,差异虽无统计学意义但达边缘显著水平(均P<0.08)。中性词和正性词在3个时相中的成绩差异无统计学意义。结论:女性在黄体中期较其他时相表现出更为明显的情绪Stroop效应,在月经周期的3个时相中对负性情绪注意偏向变化较为明显。     

The effect of luteal support with human chorionic gonadotrophin or progesterone on the daily progesterone profile after different types of ovarian stimulation.

Attempts have been made to increase the low pregnancy rate in in-vitro fertilization (IVF) cycles by luteal phase support with progesterone or human chorionic gonadotrophin (HCG). Previously, this practice has been inconsistent and the results unclear. The detailed effect of support on the progesterone profile in the luteal phase was assessed by daily salivary progesterone measurements in non-conception IVF cycles. The comparison of HCG and progesterone support in two different stimulation protocols showed that the profile of luteal progesterone concentrations was similar in control cycles and those supported with a vaginal progesterone suppository, showing an early decrease by the fourth luteal day. In cycles supported with multiple doses of HCG, the progesterone profile was normal but slightly increased up to the 9th luteal day subsequently falling to basal levels by the fourteenth luteal day.     

Comparison of luteal phase profile in gonadotrophin stimulated cycles with or without a gonadotrophin-releasing hormone antagonist.

BACKGROUND: The aim of our study was to explore luteal phase hormone profiles in gonadotrophin-stimulated cycles with or without gonadotrophin-releasing hormone (GnRH) antagonist therapy during intrauterine insemination (IUI). Forty-one infertile couples were recruited in this randomized clinical study. METHODS: The 19 patients included in group A were treated for 21 cycles with recombinant FSH 150 IU/day starting from day 3 of the cycle and with the GnRH antagonist cetrorelix at the dose of 0.25 mg/day starting from the day in which a follicle with a mean diameter of > or =14 mm was seen at ultrasound scan. Cetrorelix was administered until human chorionic gonadotrophin (HCG) administration. The 22 patients included in group B were administered recombinant FSH alone at the same dosage for 27 cycles. RESULTS: The two treatment groups showed a similar increase in progesterone concentration during the luteal phase. In the mid-luteal phase (day 6 after HCG), oestradiol concentrations in group B were significantly higher compared with group A (P < 0.05) but the oestradiol:progesterone ratio was similar in the two groups. Serum LH was completely suppressed during the follicular phase only in group A, concomitantly with GnRH antagonist administration. A total of six pregnancies, all ongoing, were achieved (14.3% per patient and 12.2% per cycle), equally distributed in group A and in group B. CONCLUSION: GnRH antagonists can be safely administered in gonadotrophin-stimulated IUI cycles without luteal phase supplementation because no deleterious effects of GnRH antagonist administration were noted on luteal progesterone concentration or on the duration of the luteal phase.     

Hormonal and histological evaluation of the luteal phase after combined GnRH-agonist/gonadotrophin treatment for superovulation and luteal phase support in in-vitro fertilization.

A hormonal and histological study of the luteal phase was performed in 21 stimulated in-vitro fertilization (IVF) patients not undergoing embryo transfer. Ovarian stimulation was carried out with gonadotrophins [follicle stimulating hormone (FSH) + human menopausal gonadotrophin (HMG)] under pituitary suppression with buserelin. Ovulation was induced with 5000 IU human chorionic gonadotrophin (HCG) and additional doses of 5000, 2500 and 2500 IU were given on the day of follicular aspiration, and 2 and 5 days later respectively, to support the luteal phase. Supraphysiological levels of oestradiol (E2) and progesterone in plasma were found in the midluteal phase of all women, while prolactin was in the normal range. An endometrial biopsy taken in the late luteal phase was normal in 90.5% (19/21) of patients, most of them (15/19, 79%) having E2 greater than 1500 pg/ml on the day of HCG. Conversely, both patients with defective endometrial biopsies had E2 levels less than 1500 pg/ml.     

A prospective randomized trial of human chorionic gonadotrophin or dydrogesterone support following in-vitro fertilization and embryo transfer

A randomized, prospective blind study was carried out to investigate the need for luteal phase support in patients undergoing in-vitro fertilization (IVF). One-hundred-and-fifty-six patients undergoing IVF in cycles stimulated with human menopausal gonadotropin (HMG) and human chorionic gonadotrophin (HCG) stimulated IVF, were divided into three different groups for luteal phase treatment. Fifty-four patients received dydrogesterone three times daily (TID) beginning on the day of embryo transfer (ET). Fifty-one patients received HCG on days 3, 6 and 10 following ET. Fifty-one patients received placebo p.o. TID beginning on the day of ET. There was no difference between the groups in pregnancy rate, rate of spontaneous abortion, proportion of normally developing fetuses or rate of chemical pregnancy. The data indicate that supplementation of the luteal phase may not improve the success rates of IVF-ET cycles.     

Endocrinology: Vasopressin and atrial natriuretic hormone response to hypertonic saline during the follicular and luteal phases of the menstrual cycle

We studied the hormonal responses to hypertonic saline duringthe follicular (days 2–9) and luteal (days 21–28)phases of the menstrual cycle in nine healthy young women, aged19–25 years. On both study days, each woman was infusedwith 5% hypertonic saline for 1 h at the rate of 0.1 ml/kg/min.Serum progesterone and oestradiol concentrations confirmed thereported stage of the menstrual cycle. No difference in weightor haematocrit was observed between the two stages of the studyfor each woman. Baseline blood pressure, serum sodium, plasmaosmolality, plasma vasopressin and thirst levels were almostidentical for both stages, and changed to the same degree duringinfusion of hypertonic saline. Baseline atrial natriuretic hormoneconcentrations were higher during the follicular phase and becamesignificantly higher than during the luteal phase followinginfusion of hypertonic saline. We concluded that the intravascularvolume during the luteal phase may be effectively decreasedin comparison to the follicular phase.     

Luteal phase progesterone excretion in ovulatory women with polycystic ovaries

BACKGROUND: Various studies have reported a prevalence of polycystic ovaries (PCO) of approximately 20% in the 'normal' population. Our aim was to investigate the frequency of ovulation and pattern of luteal phase progesterone secretion in a group of women with PCO who reported regular cycles and in whom ovulation had been established on the basis of previous investigations. METHODS: Subjects collected early morning urine samples for pregnanediol-3-glucuronide measurement from day 10 of the cycle to day 1 of their next menses. Results in three consecutive cycles from women with PCO (group 1, n = 10 and 29 for patients and cycles respectively) were compared with results from two groups with normal ovaries; with either infertility (group 2, n = 10 and 30) or proven fertility (group 3, n = 6 and 19). RESULTS: There were considerable variations in cycle length. The median (range) was group 1: 28 (23-47); group 2: 26 (21-36) and group 3: 27 (25-38) days with more short cycles in both infertile groups. There was more variation in pregnanediol:creatinine in the normal-ovary infertile and PCO groups than in the fertile controls. Levels were higher in the early luteal phase in the fertile normal group than in either infertile group, and the mid-luteal phase peak was lower in the infertile women with normal ovaries. In summary, there was greater variability in luteal phase pregnanediol:creatinine ratios in the PCO and infertile normal-ovary groups than in women with normal ovaries and proven fertility. CONCLUSION: Women with PCO did not have more variation in cycle length than fertile women with normal ovaries, but there were significantly lower levels of progesterone in the early luteal phase. This may contribute to the delay in conception in these patients.     

Evaluation of the luteal phase

The values of various methods used to evaluate the luteal phase, including basal body temperature, measurement of progesterone (P), endometrial biopsy, ultrasonographic measurement of endometrial thickness, and measurement of endometrial proteins, are reviewed. Luteal phase defect (LPD) is a controversial entity. The diagnosis of this condition is best based on a histological study of the endometrium. Methods to improve the accuracy of the diagnosis are discussed. LPD is more likely to be a result of an abnormal response of the endometrium to P, than to a subnormal production of P by the corpus luteum. Many methods of treatment for LPD have been proposed but none is based on a properly controlled clinical trial. Treatment designed to improve the response of the endometrium to P may be more rewarding than P supplementation.     

The onset of the initial rise in follicle-stimulating hormone during the human menstrual cycle

BACKGROUND: The rise in FSH (FSHr) that leads to the recruitment of a cohort of follicles during the menstrual cycle occurs during the luteal-follicular transition, however, it is unclear whether it consistently occurs on one particular day, or is subjected to reproductive ageing. METHODS: We determined the FSHr in 836 complete menstrual cycles from 102 women with regular menses using an algorithm, and additionally compared the relative variation in FSH during the last 14 days of the cycle. Possible effects of reproductive ageing on the onset of FSHr were also investigated. RESULTS: The day of FSHr follows a normal distribution with a median value of -4 (relative to first day of menses), mean -4.1 and SD 2.1. Analysis of the relative changes in FSH during the last 14 days of the cycle revealed the first significant rise on day -4 (P=0.0033), coinciding with the first significant drop in estrogens (P=0.0002). No effect of chronological age, or initial FSH levels, on FSHr was found, however, there was an inverse relationship between total follicular phase length (from day of FSHr to LH peak) and initial FSH levels (P<0.0001). CONCLUSIONS: The initial FSH rise in the cycle occurs consistently 4 days before menses, is related to a drop in estrogen levels, and is not affected by reproductive ageing.     

The luteal phase after in-vitro fertilization and related procedures

To evaluate any beneficial effect of progesterone supplemen–tationduring the luteal phase of GIFT or IVF cycles stimulated byclomiphene citrate and HMG, two random prospective studies wereperformed. In the first study, a group of patients receiveda luteal phase supplement of 50 mg natural progesterone i.m.daily from the day of oocyte retrieval onwards. Initial resultson 168 patients indicated that the pregnancy rate was similarin patients with or without progesterone supplements. No differenceswere found between the two groups in an analysis of pregnantand failed cycles. In a second study two different protocolsof luteal phase sup–plementation after Buserelin–HMGstimulation were com–pared: natural progesterone in combinationwith oestradiol valerate (50 patients) or HCG supplements (41patients). A 32% pregnancy rate per cycle was encountered inboth groups. Endometrial biopsies, taken during the luteal phasefrom patients who did not undergo embryo replacement, revealedretarded endometrial development in most of the biopsies.     

CA-125 secretion by luteal phase endometrium in vitro

The source of CA-125 in normal women and the mechanisms which control CA-125 production remain to be defined. This study was initiated to examine the pattern of secretion of CA-125 from luteal phase endometrium. Endometrial samples were obtained during the early luteal phase (histological days 16-18) and late luteal phase (histological days 25-27) from ovulatory women with a laparoscopically normal pelvis. The tissue was maintained in explant culture using Trowell's T-8 medium with either no additions (NA), progesterone (P), oestradiol (E2), or E2 + P. The concentration of CA-125 in spent media from the second day in culture was determined by immunoradiometric assay. In early luteal endometrium, the concentration of CA-125 in spent media from the NA treated wells was significantly higher than when the endometrium was exposed to either P or E2 + P. Similar differences were noted between treatments for the late luteal endometrium. Within each treatment, there was a higher concentration of CA-125 in the spent media from the late versus the early luteal endometrium. We conclude that the endometrium is a potential source of serum CA-125 and that endometrial CA-125 is suppressed by P in both the early and the late luteal phase. Further, there appears to be an increase in endometrial CA-125 secretion from the early to the late luteal phase.     

Low-dose exogenous FSH initiated during the early, mid or late follicular phase can induce multiple dominant follicle development

This prospective, randomized trial in normo-ovulatory women was designed to test whether administration of low-dose exogenous FSH initiated during the early, mid to late follicular phase can induce multiple dominant follicle development. Forty normal weight women (age 19-35 years, cycle length 25-32 days) participated. A fixed dose (75 IU/day) of recombinant FSH was started on either cycle day 3 (n = 13), 5 (n = 13) or 7 (n = 14) until the induction of ovulation with human chorionic gonadotrophin. Frequent transvaginal ultrasound scans and blood sampling were performed. Multifollicular growth occurred in all groups (overall in 60%), although day 7 starters showed less multifollicular growth. Age, cycle length and initial FSH and inhibin B concentrations were similar between subjects with single or multiple follicle development. However, for all women the lower the body mass index (BMI), the more follicles emerged (r = -0.44, P = 0.007). If multifollicular growth occurred, the length of the luteal phase was reduced (P = 0.002) and midluteal serum concentrations of LH (P = 0.03) and FSH (P = 0.004) were decreased and oestradiol (P = 0.002) and inhibin A (P = 0.01) were increased. In conclusion, interference with decremental serum FSH concentrations by administration of low dose FSH starting on cycle day 3, 5 or as late as day 7, is capable of disrupting single dominant follicle selection. The role of BMI in determining ovarian response suggests that differences in pharmacokinetics of exogenous FSH are involved. Multifollicular growth per se has a distinct effect on luteal phase characteristics. These observations may be relevant for the design of mild ovarian stimulation protocols.     

Adipocyte insulin action during the normal menstrual cycle

The relationship between the menstrual cycle and insulin sensitivityis unclear. The aim of this study was to investigate insulinsensitivity during the normal menstrual cycle using the physiologicalinsulin target organ adipose tissue. A total of 23 normal healthyvolunteers were studied, nine of whom were in the follicularphase, and 14 of whom were age and body mass index-matched andin the luteal phase of the menstrual cycle. Adipocyte insulinreceptor binding was measured and adipocyte insulin action wasassessed by measuring initial rates of 3–0-methylglucoseuptake and by inhibition of lipolysis. The maximum specificinsulin receptor binding was significantly higher in subjectsstudied during the follicular phase of the menstrual cycle comparedto subjects studied during the luteal phase (1.81 ± 0.13versus 136 ± 0.15% per 10 cm2 cell surface, P < 0.05).Maximum rates of 3–0-methylglucose transport were 1.70± 0.22 versus 1.75 ± 0.22 pmol/10 cm2/5 s in thefollicular and luteal phase respectively and were not significantlydifferent between the two groups. The maximum percentage lipolysisinhibition observed was 42.5 ± 7.5% in the follicularphase and 39.9 ± 7.4% in the luteal phase (not significant).This study demonstrated that there is a reduction in insulinreceptor binding in the luteal phase of the normal ovulatorymenstrual cycle. The post-receptor action of insulin is notaffected between the two phases of the menstrual cycle.     

Changes in the biological:immunological ratio of basal and GnRH-releasable FSH during the follicular, pre-ovulatory and luteal phases of the human menstrual cycle

BACKGROUND: Significant changes in charge isoform distribution of serum FSH occur throughout the human menstrual cycle. In the present study, we analysed the impact of the changing endocrine milieu characteristic of the menstrual cycle on the capability of basal and gonadotrophin-releasing hormone (GnRH)-releasable FSH to trigger intracellular signal transduction via the human FSH receptor. METHODS: Seven normal women underwent blood sampling every 10 min for 10 h during the early follicular phase (FP), pre-ovulatory phase (PO) and mid- to late luteal phase (LP) of the menstrual cycle. Serum from successive samples collected across 2 h intervals containing FSH released under baseline and exogenous GnRH-stimulated conditions was tested for bioactivity employing a homologous in-vitro assay. RESULTS: The biological to immunological (B:I) ratio of basal and GnRH-releasable FSH was significantly (P < 0.05 ) higher at LP (range, 0.83 +/- 0.07 to 1.35 +/- 0.30) than during the FP (0.43 +/- 0.02 to 0.65 +/- 0.04) and PO (0.49 +/- 0.05 to 0.62 +/- 0.06). In all phases, the B:I FSH ratio in baseline samples was similar to those exhibited by samples collected after 10 and 90 microg GnRH administration. CONCLUSIONS: The selective increase in the capability of the admixture of FSH isoforms circulating during the LP to activate the FSH receptor, apparently represents an additional mechanism through which the anterior pituitary may regulate the maturation of those follicles destined to ovulate during the coming cycle.