Steroids and gonadotropins during the last pre-ovulatory phase of the menstrual cycle. Time relationships between plasma hormones levels and luteinizing hormone surge onset

Effective method for emergency fertility preservation: random-start controlled ovarian stimulation

OBJECTIVE

To determine whether random-start controlled ovarian stimulation (COS), in which a patient is stimulated on presentation regardless of her menstrual-cycle phase, has outcomes similar to conventional early follicular phase-start COS for fertility preservation in cancer patients.

DESIGN

Retrospective cohort study.

SETTING

Academic medical center.

PATIENT(S)

Women recently diagnosed with cancer and in preparation for gonadotoxic therapy.

INTERVENTION(S)

Random- versus conventional-start COS.

MAIN OUTCOME MEASURE(S)

PRIMARY OUTCOME

number of mature oocytes retrieved; secondary outcomes: pattern of follicular development, oocyte yield, and fertilization rate.

RESULT(S)

The number of total and mature oocytes retrieved, oocyte maturity rate, mature oocyte yield, and fertilization rates were similar in random- (n = 35) and conventional-start (n = 93) COS cycles. No superiority was noted when comparing COS started in the late follicular (n = 13) or luteal phase (n = 22). The addition of letrozole, in the case of estrogen-sensitive cancers, did not adversely affect COS outcomes or oocyte maturity and competence in either random- or conventional-start protocols.

CONCLUSION(S)

Random-start COS is as effective as conventional-start COS in fertility preservation. This protocol would minimize delays and allow more patients to undergo fertility preservation and still proceed with cancer treatment within 2-3 weeks.

Ovarian stimulation in cancer patients

The patients referred for fertility preservation owing to a malignant disease do not represent the typical population of subfertile patients treated in IVF units. Cancer may affect multiple tissues throughout the body and can result in a variety of complications during controlled ovarian stimulation. Determination of the controlled ovarian stimulation protocol and gonadotropin dose for oocyte/embryo cryopreservation requires an individualized assessment. This review highlights the new protocols that are emerging to reduce time constraints and emphasizes management considerations to decrease complications.

Positive and negative feed-back effect of progesterone on luteinizing hormone secretion in post-menopausal women

Progesterone is known to exert a biphasic feedback effect on luteinizing hormone (LH) secretion in animals and it has been demonstrated that this effect is dependent upon both duration of exposure to progesterone and the dose administered. In this paper we sought to determine whether a similar biphasic effect exists in humans. The pattern of LH secretion was assessed in six healthy oestrogen treated post-menopausal women before and after they were given progesterone (50 mg/day) for 1 and 7 days. Progesterone treatment for 1 day resulted in a significant elevation in the basal serum LH concentration and in individual LH pulse amplitude with no change in LH pulse frequency. In contrast, progesterone treatment for 7 days increased LH pulse amplitude with no change in basal serum LH concentrations and a significant reduction in LH pulse frequency. We concluded that firstly, progesterone does exert a biphasic feedback effect on LH secretion and that the nature of this effect is determined by the duration of exposure to the progesterone stimulus. Secondly, as LH pulsatility has been shown to be an accurate indicator of GnRH pulsatility, that the reduction in LH pulse frequency after a long exposure to progesterone is due to a hypothalamic effect of progesterone whereas the positive feedback effect may be the result of a pituitary or hypothalamic action.

Changes in plasma levels of prolactin, in relation to those of FSH, oestradiol, androstenedione and progesterone around the preovulatory surge of LH in women

Plasma samples were obtained at 8 hourly intervals around the preovulatory surge of LH in three groups of women with spontaneously ovulatory menstrual cycles, in order to clarify the hormonal events around the time of ovulation. In 21 of 25 women in whom samples were collected every 8 hours the start of the LH surge occurred between midnight and 0800. In 16 of these women the concentration of LH, FSH and progesterone was measured every 8 hours around the pre-ovulatory surge of LH. A progressive increase in progesterone started with the onset of the LH surge, with a transient fall after 32-40 h at a time coincident with that of ovulation. In 10 women oestradiol, androstenedione and prolactin were measured 8 hourly around the pre-ovulatory surge of LH beginning at 0800 h. Prolactin showed a sustained increase in levels beginning at the start of and lasting for the duration of the pre-ovulatory LH surge; oestradiol levels did not rise around this time, and declined by 24 h after the onset of the LH surge. These results suggest that (1) the pre-ovulatory LH surge begins between midnight and 0800 h in the majority of women, (2) luteinization of the granulosa cells within the pre-ovulatory follicle occurs in response to the LH surge, (3) the increase in prolactin at the time of the LH surge is not directly related to increasing levels of oestradiol but may be due to a decrease in hypothalamic inhibition of prolactin secretion which occurs coincident with the release of LHRH associated with the preovulatory LH surge.

Time relationships between basal body temperature and ovulation or plasma progestins

The basal body temperature (BBT) curve and the estimated time of ovulation, defined by the onset of gonadotropin preovulatory discharge, were analyzed in 38 spontaneous cycles. The BBT nadir was usually located at the beginning of the luteinizing hormone surge, and the first high point was 8 hours after ovulation, which was itself usually at the time when the temperature passed 37 degrees C. This temperature rise was related to the increases in plasma progesterone and 17-hydroxyprogesterone with 24 to 36 hours' delay. The BBT was found to be an unreliable technique for precise ovulation timing but would be of use if the clinical precision required for the diagnosis of ovulation were less.