Decremental follicle-stimulating hormone and dominant follicle development during the normal menstrual cycle

Differentiation of the bovine dominant follicle from the cohort upregulates mRNA expression for new tissue development genes

This study was designed to identify genes that regulate the transition from FSH- to LH-dependent development in the bovine dominant follicle (DF). Serial analysis of gene expression (SAGE) was used to compare the transcriptome of granulosa cells isolated from the most oestrogenic growing cohort follicle (COH), the newly selected DF and its largest subordinate follicle (SF) which is destined for atresia. Follicle diameter, follicular fluid oestradiol (E) and E:progesterone ratio confirmed follicle identity. Results show that there are 93 transcript species differentially expressed in DF granulosa cells, but only 8 of these encode proteins known to be involved in DF development. Most characterised transcripts upregulated in the DF are from tissue development genes that regulate cell differentiation, proliferation, apoptosis, signalling and tissue remodelling. Semiquantitative real-time PCR analysis confirmed seven genes with upregulated (P≤0.05) mRNA expression in DF compared with both COH and SF granulosa cells. Thus, the new genes identified by SAGE and real-time PCR, which show enhanced mRNA expression in the DF, may regulate proliferation (cyclin D2;CCND2), prevention of apoptosis or DNA damage (growth arrest and DNA damage-inducible, β;GADD45B), RNA synthesis (splicing factor, arginine/serine rich 9;SFRS9) and unknown processes associated with enhanced steroidogenesis (ovary-specific acidic protein; DQ004742) in granulosa cells of DF at the onset of LH-dependent development. Further studies are required to show whether the expression of identified genes is dysregulated when abnormalities occur during DF selection or subsequent development.

Follicular growth pattern in normal-cycling Brazilian adolescents

OBJECTIVE

To examine the follicular growth characteristics in normal Brazilian adolescents.

DESIGN

Descriptive study.

SETTING

Adolescent clinic in a university hospital.

PATIENT(S)

Healthy normal cycling adolescents.

INTERVENTION(S)

Endovaginal ultrasound; blood samples for hormone measurement.

MAIN OUTCOME MEASURE(S)

Follicular-phase length, follicular growth rate.

RESULT(S)

The menstrual-cycle interval was 29.5 +/- 1.6 days. Sixty-five percent of adolescents had follicular-phase length of <or=16 days (group 1), and nearly 35% had follicular-phase length of >16 days (group 2). In the early follicular phase, the levels of FSH, LH, and E(2) were 5.1 mIU/mL, 3.0 mIU/mL, and 28.3 pg/mL, respectively. There was a mild negative correlation between FSH and follicular-phase length across the whole cohort (r = -0.464), but after analysis as a separate group, the correlation was present only in those adolescents with follicular phase lasting </=16 days. There was no correlation between LH or E(2) levels and the follicular-phase length in either group. There was good correlation between the follicular size and follicular-phase length in both groups of adolescents. The follicular growth rate was 1.11 +/- 0.05 mm/d across the whole cohort, 1.33 +/- 0.05 mm/d in the adolescents with follicular-phase length of <or=16 days, and 0.88 +/- 0.06 mm/d in those in whom the follicular phase lasted >16 days.

CONCLUSION(S)

A long follicular phase is common in normal-cycling, healthy adolescents as a consequence of slow follicular growth rate.

Differential actions of FSH and LH during folliculogenesis

In the gonadotrophin-dependent stage of follicular development, FSH- and LH-signalling pathways play an obligatory role in follicle differentiation, selection and survival. Under the effect of LH the theca-interstitial cell layer acts as an androgen producer. Thus, androgen diffusing into the mural granulosa cell layer represents the substrate for FSH-induced aromatase for follicular oestradiol synthesis. This is the landmark 'two cell-two gonadotrophin' concept in the physiology of ovarian function in mammals. The increase in plasma FSH during luteo-follicular transition is the basis for follicle selection. The rise of FSH to the threshold concentration represents a critical condition for the growth of the most sensitive follicle in a given time frame of the last 14 days of the dominant follicle odyssey. The gonadotrophin-induced follicular oestradiol secretion inhibits pituitary secretion of FSH, which in turn causes the concentration of FSH in the developing cohort follicles to drop below threshold concentrations and the arrest of the development of the less FSH-sensitive follicle (FSH threshold and window concept). In the gonadotrophin-dependent phase of follicular development, LH also seems to acts within a critical window of the hormone concentration framed between the minimal threshold and a ceiling for the normal functions of the follicle unit.

Hopes and facts about mild ovarian stimulation

Over the last two decades, easier and less expensive stimulation treatments have been largely replaced by more complex and more demanding protocols. Since the mid-nineties, long-term gonadotrophin-releasing hormone agonist stimulation protocols have been widely used. Such lengthy expensive regimens are not free from short- and long-term risks and complications. Mild stimulation protocols reduce the mean number of days of stimulation, the total amount of gonadotrophins used and the mean number of oocytes retrieved. The proportion of high quality and euploid embryos seems to be higher compared with conventional stimulation protocols and the pregnancy rate per embryo transfer is comparable. Moreover, the reduced costs, the better tolerability for patients and the less time needed to complete an IVF cycle make mild approaches clinically and cost-effective over a given period of time. However, further prospective randomized studies are needed to compare cumulative pregnancy rates between the two protocols. Natural cycle IVF, with minimal stimulation, has been recently proposed as an alternative to conventional stimulation protocols in normo- and poor responder patients. Although acceptable results have been reported, further large prospective randomized studies are needed to better evaluate the efficacy of these minimal regimens compared with conventional stimulation approaches.

Cumulative live birth rates following IVF in 41- to 43-year-old women presenting with favourable ovarian reserve characteristics

For women aged 41-43 years old, success rates in IVF are generally poor. This study aimed to assess cumulative live birth rate related to treatment costs over a maximum of three IVF cycles in selected women who were considered to still have adequate ovarian reserve. Fifty-five patients (38% of the total cohort, n = 144) were excluded from IVF treatment based on low antral follicle count (<5 follicles) and/or elevated basal FSH (>15 IU/l). Of those admitted, 66 (74%) actually started and completed a total of 125 IVF/intracytoplasmic sperm injection cycles. Treatment resulted in 10 live births (8% per cycle). Kaplan-Meier survival analysis revealed a realistic cumulative live birth rate after three cycles of 17%. The direct medical costs per live birth were calculated to be approximately 44,000 euro. These results show that selection towards favourable ovarian reserve status in the female age group 41-43 years yielded disappointing results in terms of cumulative live birth rates after IVF. In view of the costs raised per live birth, improvement of selection parameters for treatment in this age group is warranted.

Anti-Müllerian hormone and anti-Müllerian hormone type II receptor polymorphisms are associated with follicular phase estradiol levels in normo-ovulatory women

BACKGROUND

In mice, anti-Müllerian hormone (AMH) inhibits primordial follicle recruitment and decreases FSH sensitivity. Little is known about the role of AMH in human ovarian physiology. We hypothesize that in women AMH has a similar role in ovarian function as in mice and investigated this using a genetic approach.

METHODS

The association of the AMH Ile(49)Ser and the AMH type II receptor (AMHR2) -482 A > G polymorphisms with menstrual cycle characteristics was studied in a Dutch (n = 32) and a German (n = 21) cohort of normo-ovulatory women.

RESULTS

Carriers of the AMH Ser(49) allele had higher serum estradiol (E(2)) levels on menstrual cycle day 3 when compared with non-carriers in the Dutch cohort (P = 0.012) and in the combined Dutch and German cohort (P = 0.03). Carriers of the AMHR2 -482G allele also had higher follicular phase E(2) levels when compared with non-carriers in the Dutch cohort (P = 0.028), the German cohort (P = 0.048) and hence also the combined cohort (P = 0.012). Women carrying both AMH Ser(49) and AMHR2 -482G alleles had highest E(2) levels (P = 0.001). For both polymorphisms no association with serum AMH or FSH levels was observed.

CONCLUSIONS

Polymorphisms in the AMH and AMHR2 genes are associated with follicular phase E(2) levels, suggesting a role for AMH in the regulation of FSH sensitivity in the human ovary.

Effects of oral contraceptives administered at defined stages of ovarian follicular development

OBJECTIVE

To elucidate the effects of initiating oral contraceptives (OC) at defined stages of ovarian follicle development.

DESIGN

Prospective longitudinal study.

SETTING

Healthy volunteers in an academic research environment.

PATIENT(S)

Forty-five healthy women between the ages of 18 and 35 years, randomized to initiate OC when a follicle diameter of 10, 14, or 18 mm was first detected.

INTERVENTION(S)

The OC administration at defined stages of dominant follicle development.

MAIN OUTCOME MEASURE(S)

Fates of all dominant follicles and serum concentrations of E(2)-17beta, LH, and P before and after initiating OC.

RESULT(S)

No ovulations (0/16) were observed when OC use was initiated at a follicle diameter of 10 mm, 4/14 (29%) follicles ovulated when OC were initiated at 14 mm, and 14/15 (93%) ovulated when OC were initiated at 18 mm. When ovulation did not occur, follicles regressed or became anovulatory cysts. Peak LH and E(2) levels were lowest in the 10-mm group, moderate in the 14-mm group, and greatest in the 18-mm group. Peak endocrine levels in all treatment groups were lower than the historic reference group.

CONCLUSION(S)

Follicular development, ovulation, and endocrine concentrations were not suppressed effectively when OC were initiated at late stages of dominant follicle development.

Ovarian feedback, mechanism of action and possible clinical implications

The secretion of gonadotrophins from the pituitary in women is under ovarian control via negative and positive feedback mechanisms. Steroidal and non-steroidal substances mediate the ovarian effects on the hypothalamic-pituitary system. During the follicular phase of the cycle, estradiol (E(2)) plays a key role, while circulating progesterone (at low concentrations) and inhibin B contribute to the control of LH and FSH secretion respectively. During the luteal phase, both E(2) and progesterone regulate secretion of the two gonadotrophins, while inhibin A plays a role in FSH secretion. The intercycle rise of FSH is related to changes in the levels of the steroidal and non-steroidal substances during the luteal-follicular transition. In terms of the positive feedback mechanism, E(2) is the main component sensitizing the pituitary to GnRH. Activity of a non-steroidal ovarian substance, named gonadotrophin surge-attenuating factor (GnSAF), has been detected after ovarian stimulation. It is hypothesized that GnSAF, by antagonizing the sensitizing effect of E(2) on the pituitary, regulates the amplitude of the endogenous LH surge at midcycle. Disturbances in the feedback mechanisms can occur in various abnormal conditions or after treatment with pharmaceutical compounds that interfere with the production or the action of endogenous hormones.

The science behind 25 years of ovarian stimulation for in vitro fertilization

To allow selection of embryos for transfer after in vitro fertilization, ovarian stimulation is usually carried out with exogenous gonadotropins. To compensate for changes induced by stimulation, GnRH analog cotreatment, oral contraceptive pretreatment, late follicular phase human chorionic gonadotropin, and luteal phase progesterone supplementation are usually added. These approaches render ovarian stimulation complex and costly. The stimulation of multiple follicular development disrupts the physiology of follicular development, with consequences for the oocyte, embryo, and endometrium. In recent years, recombinant gonadotropin preparations have become available, and novel stimulation protocols with less detrimental effects have been developed. In this article, the scientific background to current approaches to ovarian stimulation for in vitro fertilization is reviewed. After a brief discussion of the relevant aspect of ovarian physiology, the development, application, and consequences of ovarian stimulation strategies are reviewed in detail.

Pretreatment with transdermal testosterone may improve ovarian response to gonadotrophins in poor-responder IVF patients with normal basal concentrations of FSH

BACKGROUND

Treatment of poor-responder patients to controlled ovarian stimulation for assisted reproduction, who have normal basal FSH concentrations, is one of the most difficult challenges in reproductive medicine. This study investigated the usefulness of testosterone pretreatment in such patients.

METHODS

Prospective, therapeutic, self-controlled clinical trial including 25 consecutive infertile patients who had a background of the first and second IVF treatment cycle cancellations due to poor follicular response, in spite of vigorous gonadotrophin ovarian stimulation and having normal basal FSH levels. In the third IVF attempt, all patients received transdermal testosterone treatment (20 microg/kg per day) during the 5 days preceding gonadotrophin treatment.

RESULTS

Twenty patients (80%) showed an increase of over fivefold in the number of recruited follicles, produced 5.8+/-0.4 (mean+/-SEM) oocytes, received two or three embryos and achieved a clinical pregnancy rate of 30% per oocyte retrieval. There were 20% cancelled cycles.

CONCLUSION

Pretreatment with transdermal testosterone may be a useful approach for women known to be low responders on the basis of a poor response to controlled ovarian stimulation but having normal basal FSH concentrations.

Systemic concentrations of hormones during the development of follicular waves in mares and women: a comparative study

Changes in systemic concentrations of FSH, LH, oestradiol and progesterone during the ovulatory follicular wave were compared between 30 mares and 30 women. Based on a previous study, the emergence of the future ovulatory follicle was defined as occurring at 13.0 mm in mares and 6.0 mm in women, and deviation in diameter between the two largest follicles was expected to begin at 22.7 mm in mares and 10.3 mm in women. Mean FSH concentrations were high in mares during the luteal phase, resulting from statistically identified FSH surges occurring in individuals on different days and in different numbers (mean, 1.5 +/- 0.2 surges/mare); the internadir interval was 3.9 +/- 0.3 days. In contrast, mean FSH in women was low during the luteal phase and increased to a prolonged elevation during the follicular phase. The prolonged elevation was apparent in each individual (internadir interval, 15.2 +/- 0.4 days). Changes in LH or oestradiol concentrations encompassing deviation were not detected in mares, but both hormones increased slightly but significantly between emergence and deviation in women. The hypothesis that a greater number of growing follicles causes a greater predeviation decrease in FSH was supported for mares (r, -0.39; P< 0.04), but a similar negative correlation (r, -0.36) was not significant in women. The hypothesis that the increase in oestradiol during the luteal phase in women was at least partly attributable to luteal-phase anovulatory follicular waves was not supported. Normalization of FSH concentrations to the day of emergence showed maximum value on the day of emergence with a significant increase and decrease on each side of emergence in both species. The day of expected deviation occurred 3 days after emergence during the decline in FSH in both species. These results indicated that the previously reported striking similarities in emergence and deviation between mares and women during the ovulatory follicular wave are associated with species similarities in the temporal relationships between follicle events and FSH concentration changes. Thus, mares may be useful research models for studying the role and mechanism of the action of FSH in emergence and deviation during the ovulatory follicular wave in women.

Cigarette smoking and effects on hormone function in premenopausal women

Cigarette smoke contains compounds that are suspected to cause reproductive damage and possibly affect hormone activity; therefore, we examined hormone metabolite patterns in relation to validated smoking status. We previously conducted a prospective study of women of reproductive age (n = 403) recruited from a large health maintenance organization, who collected urine daily during an average of three to four menstrual cycles. Data on covariates and daily smoking habits were obtained from a baseline interview and daily diary, and smoking status was validated by cotinine assay. Urinary metabolite levels of estrogen and progesterone were measured daily throughout the cycles. For the present study, we measured urinary levels of the pituitary hormone follicle-stimulating hormone (FSH) in a subset of about 300 menstrual cycles, selected by smoking status, with the time of transition between two cycles being of primary interest. Compared with nonsmokers, moderate to heavy smokers (>/= 10 cigarettes/day) had baseline levels (e.g., early follicular phase) of both steroid metabolites that were 25-35% higher, and heavy smokers (>/= 20 cigarettes/day) had lower luteal-phase progesterone metabolite levels. The mean daily urinary FSH levels around the cycle transition were increased at least 30-35% with moderate smoking, even after adjustment. These patterns suggest that chemicals in tobacco smoke alter endocrine function, perhaps at the level of the ovary, which in turn effects release of the pituitary hormones. This endocrine disruption likely contributes to the reported associations of smoking with adverse reproductive outcomes, including menstrual dysfunction, infertility, and earlier menopause.

Individualized cost-effective conventional ovulation induction treatment in normogonadotrophic anovulatory infertility (WHO group 2)

BACKGROUND

Conventional treatment in normogonadotrophic anovulatory infertility (WHO 2) consists of clomiphene citrate (CC), followed by exogenous gonadotrophins (FSH) and IVF. Response to these treatments may be predicted on the basis of individual patient characteristics. We aimed to devise a patient-tailored, cost-effective treatment algorithm involving the above-mentioned treatment modalities, based on individual patient characteristics.

METHODS

Sixteen prognostic groups are defined, according to the presence or absence of: age >30 years, amenorrhea, elevated androgen levels and obesity. The chances of response with each of the three treatments were calculated using prediction models. Treatment costs were based on the data of 240 patients visiting a specialist academic fertility unit. Outcome was an ongoing pregnancy within 12 months after initiation of treatment. The costs per pregnancy of three different strategies were compared, with a threshold for cost-effectiveness of 10 000.

RESULTS

The strategy CC + FSH + IVF compared with FSH + IVF generated more pregnancies against lower costs. Compared with CC + IVF, it also produced more pregnancies, but at higher costs. For <30 years of age with normal androgen levels, costs per pregnancy were less than 10 000. For women >30 years old, costs per pregnancy were 25 000 and over 200 000, when presenting with normal or elevated androgen levels, respectively.

CONCLUSIONS

The conventional treatment protocol is efficient for women aged <30 years with normal androgen levels. For women >30 years old with elevated androgen levels, FSH may be skipped.

Gonadotrophins in ovulation induction

For anovulatory women who fail to ovulate or conceive with clomiphene citrate, gonadotrophin ovulation induction has been the conventional second-line therapy. The aim of treatment is to achieve monofollicular development and ovulation. This differs fundamentally from the aim of ovarian stimulation for IVF, in which multiple follicular development is the goal. The small therapeutic window of ovulation induction requires a rigorous approach to monitoring, and willingness to cancel the cycle when multiple follicle development occurs. The two most widely used approaches are the low-dose step-up and the step-down protocols. While the latter more closely mimics the normo-ovulatory cycle, outcomes are similar. For safety reasons, the step-down protocol has not been widely adopted. The principle risks of ovulation induction are ovarian hyperstimulation syndrome and multiple pregnancy. There is a need to individualize treatment if outcomes are to be optimized. The role of adjuvant therapies remains unclear. However, prediction models based on initial screening parameters enable the optimal dose of FSH to be determined, and the identification of patients with a poor prognosis for successful treatment.

Multiple birth resulting from ovarian stimulation for subfertility treatment

Assisted reproductive technologies (ARTs) aim to increase a woman's chances of becoming pregnant by bringing many female and male gametes into close proximity. Techniques to achieve this objective include ovarian hyperstimulation by maturation of several oocytes, intrauterine insemination (IUI) of concentrated sperm, or in-vitro fertilisation (IVF) by bringing gametes together outside the female body. The very nature of ovarian hyperstimulation--with or without IUI--enhances the risk of multiple pregnancy (eg, two or more babies). In most IVF cycles, more than one embryo is transferred, again resulting in an increased chance of multiple pregnancy. Developed societies have witnessed a large rise in prevalence of twin, triplet, and higher order multiple births, mainly resulting from ARTs. The primary aim of this Review is to increase awareness of the many implications of the present iatrogenic epidemic of multiple births. The background of ovarian hyperstimulation, trends supporting current practice, and strategies to reduce the chance of multiple pregnancy are highlighted.

Relationship between inhibin A and B, estradiol and follicle growth dynamics during ovarian stimulation in normo-ovulatory women

OBJECTIVE

To investigate the relationship between serum concentrations of inhibin A, inhibin B and estradiol (E(2)) and the number of developing follicles during the administration of exogenous follicle-stimulating hormone (FSH) in various regimens in normo-ovulatory volunteers and to evaluate if inhibins act as suitable markers for the number of developing follicles during ovarian stimulation.

DESIGN AND METHODS

Serial hormone determinations and assessment of follicle numbers were carried out during unstimulated cycles and during various interventions with exogenous FSH. Subjects were randomized for FSH administration into the following groups: a single high dose (375 IU) during the early follicular phase (group A), 5 consecutive low doses (75 IU/day) starting in the mid follicular phase (group B) or daily low doses (75 IU/day) during the early to late follicular phase (starting on cycle days 3, 5 or 7; groups C, D and E respectively).

RESULTS

Extending the FSH window increases the number of small antral follicles and hence inhibin B serum concentrations. If such an intervention results in multi-follicular growth, mid follicular phase inhibin B (P = 0.001) as well as late follicular phase inhibin B and inhibin A levels are significantly (P < 0.05 and P < 0.01 respectively) increased compared with mono-follicular cycles or the natural cycle. Although mid follicular inhibin B levels correlated well with the number of small antral (P < 0.05) and pre-ovulatory (P < 0.001) follicles in the late follicular phase, mid follicular inhibin A and estradiol serum concentrations only correlated with the number of pre-ovulatory follicles (P < 0.001 and P < 0.01 respectively).

CONCLUSIONS

The present data extend our understanding of the relationship between follicle dynamics, serum inhibins and FSH during ovarian hyperstimulation. However, although mid follicular inhibin B does correlate with the number of developing follicles, it does not facilitate the identification of women at risk for multiple follicle development.

Previous cycle cancellation due to poor follicular development as a predictor of ovarian response in cycles stimulated with gonadotrophin-releasing hormone agonist-gonadotrophin treatment

BACKGROUND

There is scanty information analysing the predictive value of a poor response, in terms of cancellation of the IVF cycle because of poor follicular development, as a predictor of ovarian response in a subsequent treatment cycle. This study, where logistic regression analysis was used, was undertaken to investigate the relative power of the woman's age, basal FSH, and previous cycle cancellation both as single and combined predictors of ovarian response in an IVF program where pituitary desensitization is routinely used.

METHODS

One hundred and twenty-nine consecutive patients having their first cycle of IVF/ICSI treatment cancelled because of poor follicular response and undergoing a second attempt within 6 months after the failed treatment cycle were initially selected (group 1). Group 2 comprised 129 patients undergoing the first cycle of IVF/ICSI treatment and who were randomly selected from our assisted reproductive treatment program matching by BMI and indication for IVF/ICSI to those in group 1.

RESULTS

Cancellation rate was significantly higher but ovarian response significantly lower in group 1 as compared with group 2. As indicated by the AUC(ROC) determined with ROC analysis, such a poor outcome in patients having a previous IVF/ICSI cycle cancelled due to poor response was observed whatever the level of basal FSH. In a logistic regression analysis and according to the odds ratio values, the predictive capacity of a previous poor response was 9 and 7.6 times higher than the predictive capacity of age and basal FSH, respectively. Any two or all three variables studied did not improve the predictive value of previous cycle cancellation alone.

CONCLUSIONS

The history of an IVF/ICSI cancelled cycle due to poor follicular response in a standard stimulation protocol is a better predictor of cancellation in subsequent treatment cycles than age or FSH. The poor ovarian response associated with previous cycle cancellation occurs whatever the level of basal FSH.

Age and ovarian reserve are distinct predictive factors of cycle outcome in low responders

The respective roles of age and ovarian reserve in predicting IVF outcome do not seem to be equivalent, as a high pregnancy rate seems to be preserved in the youngest women, despite low ovarian recruitment. The purpose of this study was to analyse the outcome of IVF/intracytoplasmic sperm injection (ICSI) procedures according to both age and ovarian reserve of patients with a low ovarian response to stimulation. A total of 163 IVF/ICSI cycles selected by a low response were analysed. The IVF outcome differed according to the women's age, with a cut-off value at 36 years. While the number of transferred embryos was similar, the pregnancy rate (PR) was 14.6% in younger patients but 4.9% (P < 0.04) in older ones. An elevated FSH was constantly associated with a poor cycle outcome. In contrast, when the FSH was normal, PR was significantly higher (P < 0.05) in women aged <36 (23.8%) than in women aged > or =36 (6.5%). This study shows that assisted reproduction outcome in women with a low ovarian response is primarily dependent on the ovarian status. The negative influence of age is relevant in patients with normal FSH. Therefore, even if the ovarian response to stimulation is low, patients aged <36 years with a normal FSH should proceed to oocyte retrieval.

FSH: what is the highest dose for ovarian stimulation that makes sense on an evidence-based level?

The widely applied practice of a gonadotrophin dose increase in case of low response is not on an evidence-based level and not efficacious. All known comparative studies failed to show a difference in favour of the high-dose group regarding their pregnancy rate per embryo transfer. However if more oocytes and more embryos are available for cryopreservation, the real benefit in terms of cumulative pregnancy outcome might be with the high-dose regimen. This publication will show - as a review of the literature - that the frequent clinical practice of increasing the FSH dose does not lead to a higher pregnancy rate, which is in line with recommendation for milder stimulation regimes in IVF. Thus, the collective evidence to date would suggest that 150 IU/day to 250 IU/day of FSH or human menopausal gonadotrophin (HMG) is an appropriate starting dose for most women undergoing ovarian hyperstimulation for IVF as part of a gonadotrophin-releasing hormone (GnRH) antagonist or a long GnRH agonist protocol.

One, two or three: how many directions are useful in transvaginal ultrasound measurement of ovarian follicles?

OBJECTIVE

To investigate whether it is necessary to measure an ovarian follicle in three directions using transvaginal ultrasonography.

METHODS

In 36 healthy female volunteers transvaginal ultrasonography was performed every other day during a spontaneous menstrual cycle. The diameter of the largest follicle in each ovary was measured in two directions in the sagittal plane, and in two directions in the coronal plane. In total, 304 follicular measurements were performed. The largest follicular diameter was compared to the mean diameter of two and three directions, respectively. The mean diameter of two directions was compared to that of three directions.

RESULTS

The mean difference between measurement in one and two directions was 1.2 mm (standard deviation (S.D.) = 1.1 mm), between measurement in one and three directions 1.2 mm (S.D. = 1.0 mm), and between measurement in two and three directions -0.03 mm (S.D. = 0.3 mm). The mean difference and the standard deviation of the difference increased with the follicular diameter.

CONCLUSIONS

In non-stimulated menstrual cycles, follicle measurement in only one direction is less accurate than measurement in two and three directions, and may result in clinically relevant differences. However, measurement in three directions gives no additional information compared to measurement in two directions.

Relationship between follicle-stimulating hormone levels at the beginning of the human menstrual cycle, length of the follicular phase and excreted estrogens: the FREEDOM study

Although reproductive aging has been separately related to elevated FSH and shorter follicular phase (FP), the direct association between both parameters has not been investigated. Also, the exact effects of increased FSH on estrogen production are yet to be established.A large database of daily urinary concentrations of FSH, LH, and estrone 3-glucuronide (E1G) from 37 regularly menstruating women (median 11 cycles per patient) was used. Initial FSH levels (iFSH) were estimated as the mean value of d 1-5. The day of E1G take-off (ETO) was determined by an algorithm, and accordingly, the FP was divided into early (d 1 to ETO) and late (ETO+1 to LH peak). FP maximum and integrated E1G were calculated. Subjects were distributed according to their mean iFSH into three categories (</=5, >5 to 10, and >10 IU/liter). There was a gradual decrease in FP length with increasing category (15.2 +/- 3.8, 14.1 +/- 3.6, and 13 +/- 2.6 d, respectively; P < 0.0001). A similar effect occurred in early FP (7.5 +/- 4, 6.4 +/- 3.7, and 5.4 +/- 2.7; P < 0.0001); in contrast, late FP was unaffected (7.7 +/- 2.1, 7.7 +/- 2.1, and 7.6 +/- 2.4; P = 0.86). No consistent increase in E1G was found with advancing iFSH category; however, women with mean initial LH higher than 6 IU/liter had significantly elevated maximum (P < 0.0001) and integrated (P = 0.002) E1G.FP length decreases in parallel with increasing iFSH, with a selective effect on the early FP. Increased FSH does not affect E1G; however, elevated initial LH level was related to higher E1G.

Manipulation of the pill-free interval in oral contraceptive pill users: the effect on follicular suppression

OBJECTIVE

The purpose of this study was to compare follicular suppression that was produced by 3 different oral contraceptive regimens that differ by treatment in the pill-free interval.

STUDY DESIGN

In a university setting, 54 women were assigned randomly to receive either 20 microg ethinyl estradiol+100 microg levonorgestrel followed by 7 pill-free days, 20 microg ethinyl estradiol+150 microg desogestrel followed by 2 days of placebo then 10 microg ethinyl estradiol for 5 days, or 28 days of 20 microg ethinyl estradiol plus 150 microg desogestrel. Follicular suppression was evaluated by serial ultrasound scans and by serum and urinary hormone levels during a 2-month study period. Data were analyzed by nonparametric statistical tests.

RESULTS

There was a significant difference in follicle count among the 3 groups (P=.005). Women who were treated with a 7-day pill-free interval experienced the least suppression. Estrogen levels were more variable and led to an observation that overweight (body mass index, >25 kg/m(2)) was associated with reduced follicle suppression (relative risk, 1.6; 95% CI, 1.0, 2.7) and higher estrogen levels (relative risk, 5.3; 95% CI, 1.3, 21).

CONCLUSION

Contraceptive pill users who were treated with a 7-day pill-free interval demonstrated less follicular suppression than women who were supplemented with either estrogen alone or estrogen plus progestin. Overweight women were less suppressed than women of normal weight.

Mild stimulation in in vitro fertilization

Current approaches to ovarian stimulation for in vitro fertilization (IVF) are aimed at optimizing the number of oocytes retrieved in a treatment cycle. This approach is not without risks. Moreover, as the true costs of multiple pregnancy become clearer, the need to produce multiple embryos for transfer is increasingly questioned. Increasing knowledge of the physiological mechanisms involved in follicular development and dominance has led to new strategies in ovarian stimulation for IVF. The clinical availability of GnRH antagonists allows the normal cycle to be harnessed and manipulated by mild interventions to produce sufficient oocytes for successful IVF treatment. Recent evidence suggests that oocyte quality after mild stimulation may be superior to that after conventional stimulation regimens.

Characterization of ovarian follicular wave dynamics in women

A wave phenomenon of ovarian follicular development in women has recently been documented in our laboratory. The objective of the present study was to characterize follicular waves to determine whether women exhibit major and minor wave patterns of follicle development during the interovulatory interval (IOI). The ovaries of 50 women with clinically normal menstrual cycles were examined daily using transvaginal ultrasonography for one IOI. Profiles of the diameters of all follicles >or=4 mm and the numbers of follicles >or=5 mm were graphed during the IOI. Major waves were defined as those in which one follicle grew to >or=10 mm and exceeded all other follicles by >or=2 mm. Minor waves were defined as those in which follicles developed to a diameter of <10 mm and follicle dominance was not manifest. Blood samples were drawn to measure serum concentrations of estradiol-17beta, LH, and FSH. Women exhibited major and minor patterns of follicular wave dynamics during the IOI. Of the 50 women evaluated, 29/34 women with two follicle waves (85.3%) exhibited a minor-major wave pattern of follicle development and 5 women (14.7%) exhibited a major-major wave pattern. Ten of the 16 women with three follicle waves (62.5%) exhibited a minor-minor-major wave pattern, 3 women (18.8%) exhibited a minor-major-major wave pattern, and 3 women (18.8%) exhibited a major-major-major wave pattern. Documentation of major and minor follicular waves during the menstrual cycle challenges the traditional theory that a single cohort of antral follicles grows only during the follicular phase of the menstrual cycle.

IVF outcome in anovulatory infertility (WHO group 2)--including polycystic ovary syndrome--following previous unsuccessful ovulation induction

This follow-up study represents IVF treatment characteristics and outcomes in women with World Health Organization (WHO) group 2 anovulatory infertility after previous unsuccessful ovulation induction compared with controls. Furthermore, the possibility of initial screening parameters of these anovulatory women to predict IVF outcome was examined. Twenty-six patients with WHO 2 anovulatory infertility who failed to achieve a live birth following previous induction of ovulation (using clomiphene citrate as first line and exogenous FSH as second line) were compared with 26 IVF patients with tubal infertility matched for age, treatment period and treatment regimen. The WHO 2 patients underwent 49 IVF cycles, whereas the normo-ovulatory controls underwent 46 cycles. In WHO 2 patients 15 cycles were cancelled compared with six cycles in controls (P = 0.04). Cycles were predominantly cancelled due to insufficient response (P = 0.04). In cases in whom the cycle was cancelled, body mass index (BMI) was significantly higher (P < 0.001) in WHO 2 women compared with controls. Overall live birth rates were comparable (P = 0.9). Obese women suffering from WHO 2 anovulatory infertility are at an increased risk of having their IVF cycle cancelled due to insufficient response. Once oocyte retrieval is achieved, live birth rates are comparable with controls.

Prediction of chances for success or complications in gonadotrophin ovulation induction in normogonadotrophic anovulatory infertility

This follow-up study evaluated whether initial screening characteristics predict treatment outcome of gonadotrophin induction of ovulation. One hundred and fifty-four women with normogonadotrophic anovulatory infertility for whom clomiphene citrate induction of ovulation was unsuccessful were included in the present study. Daily FSH injections were initiated on day 3-5 after spontaneous or progestagen-induced withdrawal bleeding. In most patients, a dose finding low-dose step-up regimen was applied during the first treatment cycle in order to identify the individual FSH response dose. In all subsequent cycles, a step-down protocol was applied. Initial serum concentrations of LH, testosterone and androstenedione were significant predictors for the probability of multi-follicular development. FSH treatment resulted in a total of 67 (44%) ongoing pregnancies. Comparing those women who did, versus those who did not, achieve an ongoing pregnancy in a multivariate Cox regression analysis, initial serum insulin-like growth factor-I (IGF-I), testosterone and women's age entered into the final model (AUC = 0.67). The individual treatment outcome following gonadotrophin induction of ovulation may be predicted by initial screening characteristics.

New approach to polycystic ovary syndrome and other forms of anovulatory infertility

Anovulation can be classified in the clinic on the basis of serum hormone assays. Low gonadotropins along with low estrogen concentrations are suggestive of a central origin of the disease, whereas low estrogen levels along with elevated gonadotropins indicate a primary defect at the ovarian level. Most anovulatory patients (approximately 80%) present with serum FSH and estradiol levels within the normal range (World Health Organization class II). Polycystic ovary syndrome (PCOS) is a common but poorly defined heterogeneous clinical entity. Historically, characteristic ovarian abnormalities represented a hallmark of the syndrome. Because several etiological factors may lead to a similar end point (i.e., polycystic ovaries), the development of a clinically applicable classification of the syndrome has proven difficult. Clinical, morphological, biochemical, endocrine, and, more recently, molecular studies have identified an array of underlying abnormalities and added to the confusion concerning the pathophysiology of the disease. Despite the vast literature regarding the etiology and classification of PCOS, no consensus has been reached regarding the validity of criteria used to diagnose the syndrome. For instance, the significance of elevated serum luteinizing hormone (LH) concentrations, insulin resistance or polycystic-appearing ovaries assessed by ultrasound for PCOS diagnosis remains uncertain. In contrast, hyperandrogenism and chronic anovulation generally are believed to be mandatory diagnostic features. Patients with PCOS might visit a dermatologist for hirsutism, a generalist, or internist for complaints related to obesity or a gynecologist for irregular or absent bleeding. However, most patients seek the care of a gynecologist because of cycle abnormalities (oligomenorrhea) and infertility. In PCOS, serum FSH and estradiol (E2) levels are usually found to be within the (broad) normal ranges, whereas LH may either be normal or elevated. Because PCOS with normal or high LH does not seem to represent different clinical entities, it seems justifiable to consider this syndrome as a subgroup of WHO-II patients, although estrogen levels may be tonically elevated in these patients. This review will focus on characteristics of the heterogeneous group of WHO-II patients in an attempt to identify factors involved in the etiology and possible ovulation induction outcome of PCOS.

TARGET AUDIENCE

Obstetricians & Gynecologists, Family Physicians.

LEARNING OBJECTIVES

After completion of this article, the reader will be able to outline the current classification of anovulatory infertility and to explain the characteristics and features used for classification.

FSH and ovarian response: spontaneous recovery of pituitary-ovarian activity during the pill-free period vs. exogenous recombinant FSH during high-dose combined oral contraceptives

OBJECTIVE

Compare spontaneous recovery of pituitary-ovarian activity during the pill-free period following the correct use of low-dose oral contraceptives and subsequent ovarian function during the administration of exogenous recombinant FSH (recFSH) after switching to continued Lyndiol (2.5 mg lynestrenol + 0.05 mg ethinyl-oestradiol) medication.

DESIGN

Prospective, randomized, group-comparative, single-centre study. Following the monitoring of the pill-free period (week 1) and subsequent treatment with Lyndiol (for a total of 5 weeks), all subjects were randomly allocated to one of four groups receiving daily FSH injections for 1 week [75, 150, 225 IU recFSH or 150 IU purified urinary FSH (uFSH)] during the fourth week of Lyndiol use.

PATIENTS

Thirty-six healthy volunteers aged 18-39 years, prestudy oral contraceptive use for at least 3 months, cycle length between 24 and 35 days.

MEASUREMENTS

Serum FSH, LH and oestradiol (E2) concentrations as well as transvaginal ultrasound assessment of the number and diameter of follicles > 2 mm were used to monitor pituitary ovarian function.

RESULTS

At the start of the pill-free period following the prestudy contraceptive medication, 67% of the women presented with LH and FSH levels < 1 IU/l and only one follicle > 10 mm was observed. Initial levels of LH and FSH correlated (P < 0.05) with the extent of pituitary-ovarian activity during the pill-free period. At the end of the pill-free period a follicle > 10 mm had emerged in one subject only. During the first 3 days of Lyndiol use, seven women (19%) eventually showed at least one follicle > 10 mm. During combined exogenous FSH and Lyndiol administration, LH levels remained completely suppressed (< or = 0.5 IU/l) in all women studied. FSH levels and number and size of follicles increased with increasing doses of exogenous FSH in a dose-dependent manner. E2 levels remained low in all groups (< 150 pmol/l). During the week following FSH administration, FSH levels and E2 levels decreased gradually while the number of follicles > 10 mm still increased.

CONCLUSIONS

We have confirmed that dominant follicles > 10 mm are present at the end of the pill-free period and during the first days after resumption of pill intake. Once follicles > 10 mm arose at the end of the pill-free period, continued use of Lyndiol did not reduce follicle diameters. One week of Lyndiol reduces pituitary-ovarian activity to levels observed after 3 weeks of low-dose pills. FSH administration during Lyndiol resulted in dose-dependent follicle growth despite extremely low LH levels. E2 secretion (56 +/- 51 pmol/l) occurred to a limited and variable extent along with extremely low serum LH concentrations. Recovery of pituitary-ovarian activity at the end of the pill-free period is comparable to FSH levels and follicle dynamics following 7 days of 75-150 IU/l recFSH.

Antimüllerian hormone serum levels: a putative marker for ovarian aging

OBJECTIVE

To investigate whether serum concentrations of antimüllerian hormone may be used as a marker for ovarian aging.

DESIGN

Longitudinal observational study.

SETTING

Academic research center.

PATIENTS

Forty-one normo-ovulatory premenopausal women and 13 healthy postmenopausal women.

MAIN OUTCOME MEASURE(S)

Concentrations of serum antimüllerian hormone (assessed on two occasions 2.6 +/- 1.7 years apart), FSH, inhibin B, and estradiol and number of ovarian follicles on ultrasonography.

RESULT(S)

Concentrations of antimüllerian hormone decreased significantly over time (median value, 2.1 microg/L [range, 0.1-7.4 microg/L] at visit 1 vs. 1.3 microg/L [range, 0.0-5.0 microg/L] at visit 2), whereas the number of antral follicles and levels of FSH and inhibin B did not change. During visits 1 and 2, concentrations of antimüllerian hormone correlated with age (r = -.40, P=.01 and r = -.57, P<.001, respectively); number of antral follicles (r =.66, P<.001 and r =.71, P<.001); and, to a lesser extent, with FSH level (r = -.29, P=.07 and r = -.37, P<.05) but not with inhibin B levels.

CONCLUSION(S)

Serum concentrations of antimüllerian hormone decreased over time in young normo-ovulatory women, whereas other markers associated with ovarian aging did not change. Concentrations of antimüllerian hormone correlate with the number of antral follicles and age and less strongly with FSH level. Concentrations of antimüllerian hormone may be a novel marker for ovarian aging.

A nomogram to predict the probability of live birth after clomiphene citrate induction of ovulation in normogonadotropic oligoamenorrheic infertility

OBJECTIVE

To establish whether initial screening characteristics of normogonadotropic anovulatory infertile women can aid in predicting live birth after induction of ovulation with clomiphene citrate (CC).

DESIGN

Prospective longitudinal single-center study.

SETTING

Specialist academic fertility unit.

PATIENT(S)

Two hundred fifty-nine couples with a history of infertility, oligoamenorrhea, and normal follicle-stimulating hormone (FSH) concentrations who have not been previously treated with any ovulation-induction medication.

INTERVENTION(S)

50, 100, or 150 mg of oral CC per day, for 5 subsequent days per cycle.

MAIN OUTCOME MEASURE(S)

Conception leading to live birth after CC administration.

RESULT(S)

After receiving CC, 98 (38%) women conceived, leading to live birth. The cumulative live birth rate within 12 months was 42% for the total study population and 56% for the ovulatory women who had received CC. Factors predicting the chances for live birth included free androgen index (testosterone/sex hormone-binding globulin ratio), body mass index, cycle history (oligomenorrhea versus amenorrhea), and the woman's age.

CONCLUSION(S)

It is possible to predict the individual chances of live birth after CC administration using two distinct prediction models combined in a nomogram. Applying this nomogram in the clinic may be a step forward in optimizing the decision-making process in the treatment of normogonadotropic anovulatory infertility. Alternative first line of treatment options could be considered for some women who have limited chances for success.

Prediction of the individual follicle-stimulating hormone threshold for gonadotropin induction of ovulation in normogonadotropic anovulatory infertility: an approach to increase safety and efficiency

OBJECTIVE

To predict the FSH response (threshold) dose in normogonadotropic, anovulatory infertile women undergoing gonadotropin induction of ovulation.

DESIGN

Prospective longitudinal clinical study.

SETTING

Specialist academic fertility unit.

PATIENT(S)

Normogonadotropic, oligoamenorrheic, infertile women who were resistant to clomiphene citrate or in whom clomiphene citrate therapy had failed.

INTERVENTION(S)

Daily exogenous FSH administration in a low-dose, step-up regimen.

MAIN OUTCOME MEASURE(S)

The FSH dose on the day of ovarian response (follicle growth > 10 mm in diameter).

RESULT(S)

Multivariate analysis was used to devise the following equation to predict the individual FSH response dose (75 to >187 IU/d) before initiation of therapy: [4 body mass index (in kg/m(2))] + [32 clomiphene citrate resistance (yes = 1 or no = 0)] + [7 initial free insulin-like growth factor-I (in ng/mL)] + [6 initial serum FSH level (in IU/L)] - 51. The SE of the predicted dose is 35 IU.

CONCLUSION(S)

The individual FSH response dose for gonadotropin induction of ovulation in anovulatory infertile women can be predicted on the basis of initial screening characteristics. The prediction model developed in this study may increase the safety and efficiency of low-dose gonadotropin protocols (step-up and step-down) by correctly determining the appropriate starting dose for a given patient.

Follicle-stimulating hormone and advanced follicle development in the human

The great majority of human oocytes is destined to undergo atresia. Only follicles able to respond to stimulation by follicle-stimulating hormone (FSH) will enter the final stage of development and ovulate. While the role of FSH in early follicle development is unclear, late follicular development is FSH-dependent. FSH levels increase during the luteo-follicular transition and give rise to continued growth of a cohort of follicles. In the normo-ovulatory cycle, one follicle achieves a diameter of >8 mm and produces high concentrations of estradiol. In response to negative feedback from rising estradiol and inhibin levels, FSH levels fall in the late follicle phase. The dominant follicle has increased sensitivity to the falling FSH levels and continues growing. Follicles that initiate the latter stages of development after FSH levels begin to fall undergo atresia. The duration of this FSH window during which FSH levels are above the threshold required to stimulate ongoing development determines the number of follicles that can develop to the pre-ovulatory stage. Recognition of this concept has resulted in new approaches in ovulation induction treatment and ovarian hyperstimulation therapy for in vitro fertilization (IVF).

Follicle selection in monovular species

Follicle deviation is proposed to be the eminent event in follicle selection in monovular species. At deviation, the largest follicle establishes dominance apparently before the second-largest follicle can reach a similar diameter. In cattle, based on diameters of the two follicles at the beginning of deviation, the mechanism becomes established in <8 h. An FSH:follicle-coupling hypothesis has been supported as the essence of follicle selection. According to the hypothesis, the growing follicles cause the FSH decline from the peak of the wave-stimulating FSH surge until deviation, even though the follicles continue to require FSH (two-way functional coupling involving multiple follicles). During multiple-follicle coupling, inhibin is the primary FSH suppressant. Near the beginning of deviation, the largest follicle secretes increased estradiol, and apparently both estradiol and inhibin contribute to the continuing FSH decline; only the more-developed largest follicle is able to utilize the low FSH concentrations (single-follicle coupling). Deviation is encompassed by a transient elevation in LH in heifers and by a component, often distinct, of the long ovulatory LH surge in mares. In heifers, receptors for LH appear in the granulosa cells of the future dominant follicle about 8 h before the beginning of deviation. The LH stimulates the production of estradiol and insulin-like growth factor-1. These intrafollicular factors and perhaps others account for the responsiveness of the largest follicle to the low concentrations of FSH. The smaller follicles have not reached a similar developmental stage and because of their continued and close dependency on FSH become susceptible to the low concentrations. Thereby, follicle selection is established.

Dynamics of the development of multiple follicles during ovarian stimulation for in vitro fertilization using recombinant follicle-stimulating hormone (Puregon) and various doses of the gonadotropin-releasing hormone antagonist ganirelix (Orgalutran/Antagon)

OBJECTIVE

To investigate relations between dose of GnRH antagonist and follicular phase characteristics.

DESIGN

Randomized controlled multicenter trial.

SETTING

Tertiary referral fertility centers.

PATIENT(S)

Three hundred and twenty-nine IVF patients.

INTERVENTION(S)

Ovarian stimulation for IVF with recombinant FSH starting on cycle day 2. From cycle day 7 onwards, cotreatment was provided with 0.0625, 0.125, 0.25, 0.5, 1.0, or 2.0 mg/d GnRH antagonist.

MAIN OUTCOME MEASURE(S)

Number of follicles, total follicular surface area, gonadotropin, and serum steroid concentrations.

RESULT(S)

In 311 patients, similar follicular growth was observed in all treatment groups. FSH levels increased during the follicular phase. Late follicular phase LH, androstenedione (AD), and E(2) levels showed a GnRH antagonist dose-related decrease (P<0.05). Late follicular phase E(2) levels correlated with total follicular surface area, AD, LH, and FSH (all P<0.001). Increasing GnRH antagonist doses exhibited additional suppressive action on E(2) levels.

CONCLUSION(S)

Follicular growth was unaffected by the dose of GnRH antagonist. A rise in follicular phase FSH serum concentrations during the follicular phase, largely related to exogenous FSH, enabled ongoing follicular growth in all treatment groups. The effect of GnRH antagonist on late follicular phase E(2) levels could not be exclusively attributed to suppression of LH.

A pilot study involving minimal ovarian stimulation for in vitro fertilization: extending the "follicle-stimulating hormone window" combined with the gonadotropin-releasing hormone antagonist cetrorelix

OBJECTIVE

To study whether minimal interference in the process of selection of the single dominant follicle may serve as the basis for a simplified ovarian stimulation regimen for IVF.

DESIGN

Single-center randomized pilot study.

SETTING

Tertiary referral fertility center.

PATIENT(S)

Fifteen normo-ovulatory patients with a regular indication for IVF.

INTERVENTION(S)

Ovarian stimulation for IVF was begun with 100 or 150 IU/d recombinant FSH starting on cycle day 5. From cycle day 8 or later, cotreatment was begun with 0.25 mg/d GnRH antagonist. No luteal support was provided.

MAIN OUTCOME MEASURE(S)

Total number of dominant follicles and characteristics of the endocrine cycle.

RESULT(S)

Multiple follicle development occurred in five of eight patients in the 100-IU group and in all seven women in the 150-IU group. Follicular phase and luteal phase lengths were normal, but the endocrine profile was abnormal.

CONCLUSION(S)

A fixed daily dose of 150 IU recombinant FSH starting in the midfollicular phase resulted in ongoing growth of a restricted number of dominant follicles and sufficient oocytes retrieved to lead to ET. A marked reduction in the total amount of gonadotropins administered compared with standard treatment was achieved. Withholding luteal support did not exclude pregnancies.

Predictors of chances to conceive in ovulatory patients during clomiphene citrate induction of ovulation in normogonadotropic oligoamenorrheic infertility

The present prospective follow-up study was designed to identify whether clinical, endocrine, or ultrasound characteristics assessed by standardized initial screening of normogonadotropic oligo/amenorrheic infertile patients could predict conception in 160 women who reached ovulation after clomiphene citrate (CC) medication. Additional inclusion criteria were total motile sperm count of the partner above 1 million and a negative history for any tubal disease. Daily CC doses of 50 mg (increasing up to 150 mg in case of absent ovarian response) from cycle days 3-7 were used. First conception (defined as a positive urinary pregnancy test) was the end point for this study. A cumulative conception rate of 73% was reached within 9 CC-induced ovulatory cycles. Patients who did conceive presented more frequently with lower age (P < 0.0001) and amenorrhea (P < 0.05) upon initial screening. In a univariate analysis, patients with elevated initial serum LH concentrations (>7.0 IU/L) had a higher probability of conceiving (P < 0.01). In a multivariate analysis, age and cycle history (oligomenorrhea vs. amenorrhea) were identified as the only significant parameters for prediction of conception. These observations suggest that there is more to be gained from CC ovulation induction in younger women presenting with profound oligomenorrhea or amenorrhea. Screening characteristics involved in the prediction of ovulation after CC medication in normogonadotropic oligo/amenorrheic patients (body weight and hyperandrogenemia, as shown previously) are distinctly different from predictors of conception in ovulatory CC patients (age and the severity of cycle abnormality). This disparity suggests that the FSH threshold (magnitude of FSH required for stimulation of ongoing follicle growth and ovulation) and oocyte quality (chances for conception in ovulatory cycles) may be differentially regulated.

Activity of the pituitary-ovarian axis in the pill-free interval during use of low-dose combined oral contraceptives

This study was performed to evaluate pituitary-ovarian recovery in the pill-free interval during use of three low-dose combined oral contraceptives (COC). Either the estrogen component or the progestin component was comparable in the study groups, to evaluate their relative influence. Serum luteinizing hormone (LH), follicle-stimulating hormone (FSH), and estradiol (E2) levels were measured and follicle number and size estimated by transvaginal sonography daily during the 7-day pill-free interval in 44 healthy volunteers using three different low-dose oral contraceptives. Healthy volunteers were enrolled using 20 micrograms ethinyl estradiol (EE) + 75 micrograms gestodene (GSD) (Harmonet, Wyeth-Lederle; n = 15), 20 micrograms EE + 150 micrograms desogestrel (DSG) (Mercilon, Organon n = 17), or 30 micrograms EE + 150 micrograms DSG (Marvelon, Organon, n = 12) given according to the usual regimen of one tablet daily during 3 weeks and 1 week pill-free interval. No ovulations were observed. Pituitary hormones were not statistically significantly different at the beginning of the pill-free interval between the study groups. FSH concentrations were significantly higher at the end of the pill-free interval in the 30 micrograms EE group compared with both 20 micrograms EE groups (7.0 [0.6-12.4] IU/L vs 4.9 [1.4-6.1] IU/L and 4.5 [2.4-7.4] IU/L; p = 0.001). In both 20 micrograms EE groups, a single persistent follicle (24 and 28 mm) was present in one subject. Follicle diameters were statistically significantly smaller at the beginning and at the end of the pill-free period in the 30 micrograms EE group compared with both 20 micrograms EE study groups. Dominant follicles (defined as follicle diameter > or = 10 mm) were observed at the end of the pill-free interval in both 20 micrograms EE groups (in 27% and 18% of women, respectively) but not in the 30 micrograms EE group. Finally, the area-under-the-curve for E2 was statistically significantly lower in the 30 micrograms EE group compared with both 20 micrograms EE groups. In conclusion, the EE content rather than the progestin component in the studied COC determined the extent of residual ovarian activity at the beginning of the pill-free interval. Dominant follicles were encountered only in the 20 micrograms EE study groups.

Endocrine methods of ovulation induction

The rationale of ovulation induction is to achieve the development of a single follicle and ultimately a singleton healthy baby. Problems faced by women with anovulatory polycystic ovary syndrome are the sensitivity of the ovary to stimulation and health issues such as obesity. This chapter will discuss medical management including strategies to lose weight, address hyperinsulinaemia with insulin-sensitizing agents, such as metformin, and outline methods of ovulation induction from the usual first-line therapy of clomiphene citrate and the subsequent use of gonadotrophin therapy in clomiphene-resistant patients. Appropriately directed surgical ovulation induction with laparoscopic ovarian diathermy appears to be as efficacious as gonadotrophin therapy but will not be discussed in the context of this chapter.

Follicle development during the normal menstrual cycle

An understanding of the factors which determine initiation of follicle growth, recruitment and dominant follicle selection may increase our understanding of the underlying process of ovarian aging. In this article, these aspects of the normal menstrual cycle are reviewed. The morphological and endocrinological development in the early follicle is described from the primordial follicle stage. The degree of follicle-stimulating hormone (FSH) dependency is discussed, as is the relationship of estradiol (E2) production to follicle diameter. The principles governing mono-follicular selection are outlined, and the FSH 'threshold' and 'window' concepts are highlighted. Maximum FSH levels in the early follicular phase are shown to be variable between individuals. The relevance of this and the means by which individual sensitivity to FSH may be altered at the ovary in the context of ovarian aging are discussed.

Inhibin A and inhibin B in women with polycystic ovarian syndrome during treatment with FSH to induce mono-ovulation

OBJECTIVE

Polycystic ovary syndrome (PCOS) is characterized by the presence of numerous small antral follicles arrested at a diameter of less than 10 mm. As development of large antral follicle(s) can be stimulated by the administration of FSH, it has been suggested that the arrest of follicle development is due to a relative lack of or resistance to FSH. We have measured the concentration of FSH and LH and the ovarian hormones oestradiol, inhibin A and B, in relation to the dynamics of follicular development in women with PCOS under basal conditions and during treatment with FSH.

DESIGN

The concentrations of FSH, LH, oestradiol, inhibin A and B were measured in women with PCOS who were untreated (n = 9) or following progesterone-induced menses (10 cycles in six women) and control women on day 3 of a normal cycle (n = 10). Serial measurements of the same hormones were made during induction of ovulation with low dose of exogenous FSH in the women with PCOS who had been treated with progesterone. The dynamics of follicle development were measured by serial pelvic ultrasound examinations during treatment with FSH in PCOS and in the follicular phase of control cycles.

PATIENTS

Nine anovulatory untreated women with PCOS were compared with 10 normal women and six women with PCOS undergoing FSH treatment.

RESULTS

The concentrations of inhibin B and LH were higher in both groups of women with PCOS than in normal control women on day 3. In untreated women with PCOS the concentration of inhibin A was also significantly elevated compared to control women (P < 0.01) but not in women pretreated with progesterone. Basal concentrations of oestradiol were also significantly higher in women with PCOS than in the early follicular phase of the normal cycle. There were no significant differences in the concentration of FSH between the groups. Treatment of women with PCOS with low doses of FSH stimulated the development of a single dominant follicle which had an identical rate of growth and secretion of oestradiol and inhibin A to that observed in spontaneous cycles in normal women. In contrast to normal women, the concentration of inhibin B rose 7-fold following FSH treatment and remained elevated until the luteal phase.

CONCLUSIONS

The raised concentrations of inhibin A and B in women with PCOS probably reflects the increased number of small antral follicles characteristically present in that condition. The striking similarity in the dynamics of growth of the dominant follicle and the pattern in concentration of oestradiol and inhibin A in normal women and in women with PCOS treated with modest amounts of FSH, suggests that the arrest of follicle development in PCOS may be due to a relative deficiency of FSH which may in turn be secondary to increased secretion of either or both inhibin forms.

Urinary follicle-stimulating hormone for normogonadotropic clomiphene-resistant anovulatory infertility: prospective, randomized comparison between low dose step-up and step-down dose regimens

A low dose step-up and step-down regimen for induction of ovulation using urinary FSH was compared in a prospective randomized fashion in 37 normogonadotropic clomiphene-resistant oligo- or amenorrheic infertile women. The objectives was to assess potential differences in duration of treatment, ovarian stimulation (serum FSH levels), and response [serum estradiol (E2) levels and number and size of follicles]. Monitoring (blood sampling and transvaginal sonography) took place on the day of initiation of treatment, the first day of ovarian response as assessed by ultrasound (i.e. the first day a follicle > or = 10 mm could be recognized), the day of hCG administration to induce ovulation, and 3 days thereafter. The median duration of treatment in the low dose step-up group was 18 (range, 7-41) days compared to 9 (range, 4-16) days in the step-down group (P = 0.003), and the total numbers of ampules administered were 20 (range, 7-69) and 14 (range, 7-33), respectively (P = NS). Serum FSH levels from the first day of sonographic ovarian response until the administration of hCG were constant (median increase, 2%/day) in patients receiving the low dose step-up protocol, but showed a decrease (median, 5%/day) in step-down cycles (P < 0.001). Monofollicular growth, defined as not more than one follicle 16 mm or larger on the day of hCG administration, was observed in 56% of low dose step-up and 88% of step-down cycles (P = 0.04). The percentage of patients with normal range periovulatory E2 serum levels (500-1500 pmol/L) was 33% in the low dose step-up group vs. 71% in the step-down group (P = 0.03). We conclude that a step-down protocol for gonadotropin induction of ovulation exhibits a more physiological, late follicular phase FSH serum profile than a low dose step-up protocol. This results in a shorter duration of treatment, a greater number of monofollicular cycles, and more cycles with periovulatory E2 levels within the normal range in the step-down protocol.

Classification of normogonadotropic infertility: polycystic ovaries diagnosed by ultrasound versus endocrine characteristics of polycystic ovary syndrome

OBJECTIVE

To investigate the predictive value of polycystic ovaries for endocrine signs of polycystic ovary syndrome (PCOS).

DESIGN

Controlled descriptive study.

SETTING

Academic tertiary care fertility clinic.

PATIENT(S)

Normogonadotropic (FSH levels between 1 and 10 mIU/mL conversion factor to SI unit, 1.0) oligomenorrheic or amenorrheic women visiting our fertility clinic and a control group of regularly cycling, healthy, normal weight volunteers recruited by advertisement.

INTERVENTION(S)

Single blood samples and transvaginal sonography were performed.

MAIN OUTCOME MEASURE(S)

Serum levels of FSH, LH, androstenedione (A), and T and ovarian volume, ovarian stroma density, and follicle number.

RESULT(S)

In control women, the 95th percentile was calculated for ovarian volume, follicle number, and stroma count as well as endocrine parameters. The use of these upper limits of normal in the study group resulted in 217 (66%) patients with polycystic ovaries on ultrasound (defined as increased mean ovarian volume and/or mean follicle number per ovary), whereas only 120 (36%) patients exhibited elevated serum androgens (increased A and/or T concentrations) and 155 (47%) showed elevated LH levels. Sensitivity and specificity of single or combined sonographic parameters for prediction of elevated serum LH or androgen concentrations were limited.

CONCLUSION(S)

In the study group of normogonadotropic oligomenorrhea or amenorrheic infertile women, we set strict cutoff levels for various criteria used in the literature for defining PCOS. Groups defined by sonographic or endocrine PCOS criteria did overlap, but sonographic parameters had limited predictive value for abnormal hormone serum levels.

Initial estradiol response predicts outcome of exogenous gonadotropins using a step-down dose regimen for induction of ovulation in polycystic ovary syndrome

OBJECTIVE

To study ovarian stimulation and response patterns during a gonadotropin step-down dose regimen for induction of ovulation by applying a decremental dose regimen in polycystic ovary syndrome (PCOS) patients.

DESIGN

The present prospective study involves 28 infertile clomiphene citrate-resistant PCOS patients during gonadotropin-induced cycles using a modified step-down dose regimen (and adjuvant GnRH agonist medication). Applied gonadotropin doses included initial daily doses of 150 IU IM followed by two reducing steps (37.5 IU each) based on sonographic criteria to a final daily dose of 75 IU IM.

SETTING

Anovulatory infertile women in an academic referral center.

INTERVENTION

Daily blood withdrawal and transvaginal pelvic ultrasound.

MAIN OUTCOME MEASURES

Serum FSH and E2 concentration and follicle growth were investigated daily during gonadotropin administration.

RESULTS

An initial 2.1-fold increase in serum FSH levels was observed followed by a subsequent decrease of 10% (median) per day for 4 days. Growth of ovarian follicles was sustained and ovulation achieved (midluteal P, 11.7 +/- 1.3 ng/mL; conversion factor to SI unit, 3.180; mean +/- SD) in 22 patients. Major variability in day 3 E2 increase (range, 67 to 866 pg/mL; conversion factor to SI unit, 3.671)--not related to differences in FSH serum concentrations and without changes in follicle number and size--suggests differences in ovarian sensitivity for FSH stimulation. A strong correlation (r = 0.82) was found between day 3 E2 increase and the chance of ovulation. Moreover, E2 levels on the day of gonadotropin dose reduction predict (r = 0.68) chances of late follicular phase E2 levels exceeding 871 pg/mL (conversion factor to SI value, 3.671).

CONCLUSIONS

These findings provide the endocrine basis for the concept of gonadotropin induction of ovulation using a step-down dose regimen. Initial E2 increase (before initiation of follicle growth) represent differences in ovarian sensitivity to gonadotropins and predict treatment outcome.