The relation between daily salivary progesterone profile and endometrial development in the luteal phase of fertile and infertile women

Endogenous progesterone in unexplained infertility: a systematic review and meta-analysis

PURPOSE

To investigate the possibility that altered actions of endogenous progesterone affect receptivity and contribute to unexplained infertility (UI).

METHODS

Two authors electronically searched MEDLINE, CINAHL and Embase databases from inception to 6 July 2022 and hand-searched according to Cochrane methodology. We included all published primary research reporting outcomes related to endogenous progesterone in natural cycles in women with UI. Studies were assessed for risk of bias using a modified Newcastle-Ottawa Score or NHLBI Score. We pooled results where appropriate using a random-effects model. Findings were reported as odds ratios or mean differences.

RESULTS

We included 41 studies (n = 4023). No difference was found between the mid-luteal serum progesterone levels of women with UI compared to fertile controls (MD 0.74, - 0.31-1.79, I² 36%). Women with UI had significantly higher rates of 'out-of-phase' endometrium than controls. Nine out of 10 progesterone-mediated markers of endometrial receptivity were significantly reduced in women with UI compared to fertile controls (the remaining 1 had conflicting results). Resistance in pelvic vessels was increased and perfusion of the endometrium and sub-endometrium reduced in UI compared to fertile controls in all included studies. Progesterone receptor expression and progesterone uptake were also reduced in women with unexplained infertility.

CONCLUSIONS

End-organ measures of endogenous progesterone activity are reduced in women with UI compared to fertile controls. This apparently receptor-mediated reduction in response affects endometrial receptivity and is implicated as the cause of the infertility. Further research is required to confirm whether intervention could overcome this issue, offering a new option for treating unexplained infertility.

TRIAL REGISTRATION

PROSPERO registration: CRD42020141041 06/08/2020.

A multi-centre international study of salivary hormone oestradiol and progesterone measurements in ART monitoring

RESEARCH QUESTION

Ovarian stimulation during IVF cycles involves close monitoring of oestradiol, progesterone and ultrasound measurements of follicle growth. In contrast to blood draws, sampling saliva is less invasive. Here, a blind validation is presented of a novel saliva-based oestradiol and progesterone assay carried out in samples collected in independent IVF clinics.

DESIGN

Concurrent serum and saliva samples were collected from 324 patients at six large independent IVF laboratories. Saliva samples were frozen and run blinded. A further 18 patients had samples collected more frequently around the time of HCG trigger. Saliva samples were analysed using an immunoassay developed with Salimetrics LLC.

RESULTS

In total, 652 pairs of saliva and serum oestradiol were evaluated, with correlation coefficients ranging from 0.68 to 0.91. In the European clinics, a further 237 of saliva and serum progesterone samples were evaluated; however, the correlations were generally poorer, ranging from -0.02 to 0.22. In the patients collected more frequently, five out of 18 patients (27.8%) showed an immediate decrease in oestradiol after trigger. When progesterone samples were assessed after trigger, eight out of 18 (44.4%) showed a continued rise.

CONCLUSIONS

Salivary oestradiol hormone testing correlates well to serum-based assessment, whereas progesterone values, around the time of trigger, are not consistent from patient to patient.

The luteal phase after ovarian stimulation

Evaluation of the luteal phase after ovarian stimulation presents several difficulties. Until today, it has not been proved that in cycles stimulated with clomiphene citrate/human menopausal gonadotrophins, luteal supplementation with progesterone significantly increases implantation rate. On the contrary, it is accepted that in cycles stimulated with GnRH agonists/gonadotrophins, support of the luteal phase is essential for the achievement of pregnancy. In GnRH antagonist cycles luteal supplementation, although widely practised, is not at present supported by randomized controlled trials. Finally, it appears that the combination of gonadotrophin stimulation with human chorionic gonadotrophin results in an inadequate luteal phase with or without the use of either agonists or antagonists.

A prospective study of early pregnancy loss in humans

OBJECTIVE

To test two hypotheses: In spontaneous conceptions, early pregnancy loss (EPL) is associated with [1] inadequate luteal (ovarian) P, and/or [2] elevated follicular (adrenal) P.

DESIGN

A population-based prospective study.

SETTING

Thirty rural Bolivian communities.

PATIENT(S)

Women volunteers (n = 191), 19-40 years old, in stable sexual unions and not using contraception.

INTERVENTION(S)

Collection of serial saliva samples throughout sequential ovarian cycles and urine samples during late luteal phases. Collections continued throughout pregnancy for each detected conception.

MAIN OUTCOME MEASURE(S)

Occurrence of spontaneous conceptions and subsequent outcomes. Salivary concentrations of P. Test for elevated urinary human chorionic gonadotropin (hCG).

RESULT(S)

Luteal (through implantation) P levels were similar in pregnancies lost within 5 weeks after conception (EPL; n = 8) and those pregnancies that were maintained longer (sustained conceptions, SC; n = 32). Follicular P was significantly higher in EPL than in SC.

CONCLUSION(S)

[1] Elevated follicular P was associated with EPL in natural conceptions in healthy women. [2] Early pregnancy loss exhibits absolute luteal P levels comparable to SC, but lower luteal/follicular P ratios.

Importance of endometrial quality in women with tubal infertility during a natural menstrual cycle for the outcome of IVF treatment

PURPOSE

The importance of endometrial maturation at estimated time of implantation for the outcome of IVF treatment in regularly menstruating women with tubal infertility was evaluated.

METHODS

FSH was measured on cycle day 3, on days 10-15 urine and blood were collected to estimate the day of the LH peak, and E2 and P4 were measured during the luteal phase, on cycle days 19-26. An endometrial biopsy was obtained on days LH + 3 to LH + 6.

RESULTS

The number of subjects with delayed endometrial maturation was larger in the group of infertile women who did not become pregnant compared to pregnant women and controls. Those infertile women who did not become pregnant after IVF treatment also presented with a higher basal FSH on cycle day 3 and lower E2 and P4 AUC in the luteal phase. Six infertile women and two controls presented with mid- and late-proliferative endometrium in the luteal phase on cycle days LH + 3 to LH + 6, in the presence of adequate E2 and P4 secretion. Six morphological characteristics were compared in the three groups: (1) 17 infertile women who became pregnant, (2) 18 who did not become pregnant, and (3) 28 controls. The pregnant infertile women did not differ from the controls. The numbers of glandular and stromal mitoses were significantly higher in those women who did not become pregnant (P < 0.01) compared with those who became pregnant. Endometrial biopsies obtained on cycle days LH + 5 and LH + 6 showed significant differences in glandular epithelial height (P < 0.05) and number of vacuolated cells among the nonpregnant women (P < 0.01), the pregnant women (P < 0.05), and controls.

CONCLUSIONS

A higher frequency of retarded endometrial development in women who did not become pregnant following IVF treatment was found. In some cases, endometrial insensitivity could most likely cause retarded endometrial development and failure of implantation after IVF treatment, which could not be overcome by routine luteal-phase support. However, our results do not allow conclusions concerning its relative importance compared to preembryo quality; this has to be investigated further.

Endometrial differentiation in the peri-implantation phase of women with recurrent miscarriage: a morphological and immunohistochemical study

OBJECTIVES

To study endometrial differentiation in the peri-implantation phase of women with recurrent miscarriage and to compare the results with endometrium of normal fertile women.

DESIGN

A prospective study of endometrial specimens precisely timed from the LH surge, using traditional histologic dating (Noyes' criteria), quantitative histologic measurement (morphometric analysis), and immunohistochemical techniques.

RESULTS

Fifteen of 25 (60%) subjects in the recurrent miscarriage group had retarded endometrial development in the peri-implantation period as monitored by morphometry. The recurrent miscarriage group showed reduced levels of four mucin-related secretory epitopes, and greater reductions were associated with morphological retardation. Normal differentiation was observed in all of the 14 subjects in the control group.

CONCLUSIONS

Women with idiopathic recurrent pregnancy loss may be divided into two distinct subgroups on the basis of their endometrial response in the peri-implantation period. Precisely timed endometrial biopsy should be incorporated in the investigation of recurrent miscarriage.

Use of urinary luteinizing hormone immunoassays in the assessment of luteal function in infertile women

It has been suggested that the chronologic date of an endometrial biopsy performed to evaluate luteal adequacy should be based on the date of the luteinizing hormone surge rather than the date of the next menstrual period. Sixty-four infertile women used a urinary luteinizing hormone immunoassay to identify the luteinizing hormone surge; timed serum progesterone level tests and an endometrial biopsy were then performed. An out-of-phase endometrium was identified in 26.6% of cycles dated traditionally and 28.1% of cycles dated from the luteinizing hormone surge. No relationship was identified between progesterone levels and endometrial biopsy results when the next menstrual period was used. When the luteinizing hormone surge was used no progesterone cutoff value could be identified that would reliably distinguish between in-phase and out-of-phase cycles. Use of a urinary luteinizing hormone immunoassay offers no advantage over the next menstrual period and does not lead to better agreement between histologic and chronologic dating.

The variation of endometrial response to a standard hormone replacement therapy in women with premature ovarian failure. An ultrasonographic and histological study

The endometrial response to a standard hormone replacement therapy in 18 women with premature ovarian failure was examined by serial ultrasonographic measurement of endometrial thickness and histological study of endometrial biopsy taken on day 19 of the cycle. Women with idiopathic ovarian failure (n = 10) had significantly better response than women with Turner's syndrome (n = 4), whereas women with premature ovarian failure associated with previous chemotherapy (n = 4) had an intermediate response. These observations suggest that the endometria of women with Turner's syndrome responded suboptimally to steroid hormones. However, all endometrial biopsies studied revealed secretory changes. Overall, the results of histological dating of endometrial biopsy were found to be positively correlated with endometrial thickness on day 19 of the cycle (r = 0.72, P less than 0.01). The plasma concentration of oestradiol on days 15, 19 and 29 of the artificial cycle were found to be significantly higher than those on the corresponding days of the natural cycle.

Luteal phase defect in habitual abortion: progesterone in saliva

OBJECTIVE

To re-evaluate the occurrence of luteal phase defect (LPD) in habitual abortion and to determine the value of salivary progesterone (P) assay in its diagnosis.

DESIGN

Prospective study on patients with a history of at least three consecutive miscarriages.

SETTING

Departments I and II of Obstetrics and Gynecology, University Central Hospital of Helsinki, Helsinki, Finland.

PATIENTS

Forty-six patients (27 primary and 19 secondary aborters) and 12 healthy control women without a history of abortion.

RESULTS

Eight patients (17.4%, 5 primary and 3 secondary aborters) exhibited a delay of greater than 2 days in endometrial maturation during two consecutive cycles, whereas in 38 patients (82.6%) endometrial maturation corresponded to the actual cycle day. Salivary P showed a distinct ovulatory rise, but no statistically significant differences were evident between patients (with or without LPD) and healthy control women.

CONCLUSIONS

An endometrial maturation defect may be a factor in 17.4% of patients with habitual abortion, but this cannot be detected by salivary P assay.

Measurements of salivary progesterone throughout the menstrual cycle in women suffering from unexplained infertility reveal high frequency of luteal phase defects

Forty-five women suffering from unexplained infertility collected saliva for progesterone (P) measurements every morning during 1 to 3 complete cycles. A total of 27 cycles analyzed were unstimulated, 19 were stimulated by clomiphene citrate (CC), and 7 with CC, human menopausal gonadotropin (hMG), and human chorionic gonadotropin (hCG). Compared with reference profiles of salivary P from 27 normal cycles, the length and magnitude of P secretion were significantly lower in the infertility group. Luteal P concentrations were normalized during CC stimulation and significantly elevated during the CC-hMG-hCG stimulation. The other abnormalities found in the salivary P profiles of these patients included preovulatory P peaks, interruption of P secretion during luteal phase, and high P level at the beginning of menstruation. The results suggest that patients with prolonged unexplained infertility represent a heterogenous population with common luteal phase defects. The disturbance is effectively corrected with treatments stimulating gonadotropin secretion.

A quantitative study of endometrial development in the luteal phase: comparison between women with unexplained infertility and normal fertility

This study compared endometrial development in the luteal phase of women with unexplained infertility (n = 30) with that in women with normal fertility (n = 70) by the use of quantitative histological techniques (morphometric analysis) on endometrial specimens which were precisely timed from the luteinizing hormone surge. When overall endometrial development (histological dating) was considered, the proportion of women with unexplained infertility who had retarded endometrial development (20%) was found to be significantly higher than for women with normal fertility (3%) (P less than 0.01). When individual histological features were considered, women with unexplained infertility were found to have significant deviation from the normal range established from fertile women in only five of the 14 histological features measured. All of these five features related to the glandular but not to the stromal component of the endometrium; four of these five features are related to glandular secretory activity.

An endometrial factor in unexplained infertility

OBJECTIVE

To study a group of women with unexplained infertility to see whether they have a defect that is intrinsic to the endometrium.

DESIGN

Evaluation of the functional response of the endometrium by examining endometrial biopsy specimens using immunohistochemical methods in a group of women with unexplained infertility and in a control group of women with normal fertility.

PATIENTS

27 Women with unexplained infertility (average age 33.2); median duration of infertility five years. A control group of 44 women with normal fertility (average age 33.8) who were requesting sterilisation or reversal of sterilisation.

SETTING

Infertility clinic, Jessop Hospital for Women, Sheffield.

INTERVENTION

Secretory phase endometrial biopsy specimens were taken, with informed consent, as an outpatient procedure.

MAIN OUTCOME MEASURES

Immunohistochemistry with monoclonal antibody D9B1, was used to assess the production and secretion of an oligosaccharide epitope produced by endometrial gland cells between two and seven days after the luteinising hormone surge. A reflected light measuring system was used to assess the amount of epitope within the gland cells, and in the gland lumen.

RESULTS

In the control group of women, mean reflected light measurements at the cell base and cell apex peaked at three and five days after the luteinising hormone surge respectively, and in the gland lumen the epitope accumulated rapidly from three days, reaching a peak at seven days. In the women with infertility the peaks of epitope at the cell base and cell apex were lower, broader, and delayed in onset, and the build up of epitope in the gland lumen was retarded. The synthesis and secretion of the epitope in the women with infertility was therefore significantly reduced and delayed, even in the presence of normal concentrations of circulating progesterone.

CONCLUSIONS

The results suggest that a primary dysfunction of the endometrium might be associated with hitherto unexplained infertility.

The effects of steroids on the fine structure of the endometrium

This brief review illustrates the lack of ultrastructural studies on human endometrium, particularly on well-dated material from normal, fertile women. The glandular epithelium, with its triad of unusual organelles in the early luteal phase, poses fascinating problems in cell biology and, probably for this reason, has attracted the most work. Many problems in reproductive biology, in uterine pathology and in the study of unexplained infertility are crying out for detailed study of the luminal epithelium, the stroma and the blood vessels. If this review, by highlighting the gaps in our knowledge, stimulates research into these areas, it will have been successful.

How precise is histologic dating of endometrium using the standard dating criteria?

Sixty-three endometrial biopsies were dated histologically by using the standard criteria on two separate occasions by the same observer. Overall, it was found that exact agreement occurred in 15 (24%), but disagreement of more than 2 days occurred in 6 (10%). The proportion of exact agreement in the first half of the luteal phase (32%) was found to be significantly higher (P less than 0.05) than that in the second half of the luteal phase (9%). In a separate part of the study, 27 women had two endometrial biopsies, each performed in a separate cycle. The within-subject between-cycle variation of the results of endometrial dating (exact agreement: 4%, disagreement of more than 2 days: 41%) was found to be significantly different from intraobserver variation (P less than 0.01 for both). The amount of intraobserver variation suggests that the traditional dating criteria are not precise enough to quantify corpus luteum function in the second half of the luteal phase, whereas the amount of within-subject between-cycle variation implies that the result of endometrial dating in one cycle cannot be used reliably to predict that of another cycle.