Gonadotrophin-releasing hormone treatment for induction of follicular maturation and ovulation in amenorrhoeic women with anorexia nervosa

New Aspects of Corpus Luteum Regulation in Physiological and Pathological Conditions: Involvement of Adipokines and Neuropeptides

The corpus luteum is a small gland of great importance because its proper functioning determines not only the appropriate course of the estrous/menstrual cycle and embryo implantation, but also the subsequent maintenance of pregnancy. Among the well-known regulators of luteal tissue functions, increasing attention is focused on the role of neuropeptides and adipose tissue hormones-adipokines. Growing evidence points to the expression of these factors in the corpus luteum of women and different animal species, and their involvement in corpus luteum formation, endocrine function, angiogenesis, cells proliferation, apoptosis, and finally, regression. In the present review, we summarize the current knowledge about the expression and role of adipokines, such as adiponectin, leptin, apelin, vaspin, visfatin, chemerin, and neuropeptides like ghrelin, orexins, kisspeptin, and phoenixin in the physiological regulation of the corpus luteum function, as well as their potential involvement in pathologies affecting the luteal cells that disrupt the estrous cycle.

Diagnosis and treatment of luteal phase deficiency: a committee opinion

Luteal phase deficiency (LPD) is a clinical diagnosis associated with an abnormal luteal phase length of ≤10 days. Potential etiologies of LPD include inadequate progesterone duration, inadequate progesterone levels, or endometrial progesterone resistance. LPD has not only been described in association with medical conditions but also in fertile, normally menstruating women. Although progesterone is important for the process of implantation and early embryonic development, LPD has not been proven to be an independent entity causing infertility or recurrent pregnancy loss. Controversy exists regarding the multiple proposed measures for diagnosing LPD and, assuming it can be diagnosed accurately, whether treatment improves outcomes. This document replaces the document entitled "Current clinical irrelevance of luteal phase deficiency: a committee opinion," last published in 2015 (Fertil Steril 2015;103:e27-e32).

Xenopus laevis ovarian CYP17 is a highly potent enzyme expressed exclusively in oocytes. Evidence that oocytes play a critical role in Xenopus ovarian androgen production

Progesterone has long been considered the primary mediator of Xenopus oocyte maturation. We have recently shown, however, that androgens, which are equal or more potent promoters of maturation and are present at higher levels in ovulating frogs, may also be playing an important physiologic role in mediating maturation. Here, we examined the role of CYP17, a key enzyme mediating sex steroid synthesis, in Xenopus ovarian androgen production. We found that the 17,20-lyase activities of Xenopus CYP17 exceeded the 17alpha-hydroxylase activities in both the Delta4 and Delta5 pathways; thus, Xenopus CYP17 rapidly converted pregnenolone and progesterone to dehydroepiandrosterone (DHEA) and androstenedione, respectively. This remarkably robust activity exceeds that of CYP17 from most higher vertebrates, and likely explains why virtually no progesterone is detected in ovulating frogs. Additionally, ovarian CYP17 activity was present exclusively in oocytes, although all other enzymes involved in sex steroid production were expressed almost entirely in surrounding follicular cells. This compartmentalization suggests a "two-cell" model whereby Xenopus ovarian androgen production requires both follicular cells and oocytes themselves. The requirement of oocytes for ovarian androgen production further introduces the unusual paradigm whereby germ cells may be responsible for producing important steroids used to mediate their own maturation.

Adjusting the dose to the individual response of the patient during the induction of ovulation with pulsatile gonadotropin-releasing hormone

To identify the effective dose of intravenous pulsatile gonadotropin-releasing hormone necessary to induce ovulation in patients with chronic anovulation of diverse etiology, 40 women were subdivided into four groups: idiopathic hypogonadotropic hypogonadism (IHH), functional hypothalamic amenorrhea, normoandrogenic oligomenorrhea, and polycystic ovarian syndrome (PCOS). During 90 treatment cycles, the dose was the only parameter that was progressively adjusted. The overall ovulation rate per cycle was 100% in IHH, functional hypothalamic amenorrhea, and normoandrogenic oligomenorrhea, using only 5 micrograms/90 minutes in functional hypothalamic amenorrhea and normoandrogenic oligomenorrhea and up to 7.5 micrograms/90 minutes in IHH. In PCOS, the ovulation rate was 67.6%, using up to 20 micrograms/90 minutes. The lesser degree of effectiveness observed in PCOS can probably be explained by the different basal endocrine profile presented by these subjects.

The theory and practice of ovulation induction with gonadotropin-releasing hormone

Gonadotropin-releasing hormone therapy has undergone sufficient basic and clinical investigation as a tool for ovulation induction that it should now be considered a safe and effective infertility therapy for office practice. Nevertheless, there remains sufficient mystique about patient selection, optimal dosage and route of delivery, and apprehension on the part of both physicians and patients about cost and inconvenience of medication pumps that gonadotropin-releasing hormone therapy has not enjoyed the widespread acceptance it deserves. This article presents straightforward guidelines for therapy that are based on a detailed review of current literature, together with new information about evolving pump technologic characteristics, that should offer reassurance to the practitioner considering use of gonadotropin-releasing hormone therapy in her/his practice.

Pulsatile luteinizing hormone releasing hormone treatment for induction of ovulation. Radioimmunoassay of plasma LHRH and comparative study of subcutaneous versus intravenous routes of administration

To investigate the efficacy of the different routes of luteinizing hormone releasing hormone (LHRH) administration upon pituitary responsiveness, we compared plasma LHRH concentrations and pituitary LH responses in four patients with hypothalamic amenorrhea treated with pulsatile LHRH. A portable computerized infusion pump delivered sc or iv LHRH pulses of 5, 10 or 20 micrograms every 90 min. Comparison of the two modes of LHRH delivery was performed using radioimmunoassay of exogenous LHRH and studying its pharmacokinetics for a 3 pulses period. With 10 micrograms of LHRH given iv, plasma LHRH levels increased between 700 and 1000 pg/ml within 3 min and returned to basal levels in 30 min. When given sc (10 micrograms), plasma LHRH levels peaked between 80 and 100 pg/ml in 15 min and returned to basal levels 60 min later. In one patient treated with 5 micrograms per pulse iv or sc, plasma LHRH increased to 380 and 60 pg/ml respectively. In all patients, computerized analysis of LH pulses was performed during sc and iv LHRH administration. LH pulsatile release displayed a similar rhythm period with both routes. However, for the same dose of LHRH (10 micrograms), the adjusted mean of LH plasma levels was lower with the sc route. In conclusions, the pharmacokinetics of LHRH administered sc or iv displayed a similar pattern but, with equivalent doses, higher plasma LHRH levels are attained with the iv route. Concomitantly, the mean LH levels were also greater after iv administration. Ovulation can be successfully induced by both pulsatile iv and sc LHRH therapy. However, with the sc route, a higher dose of LHRH should be used to prevent a delay of ovulation or a luteal deficiency.

Gonadotrophin control of follicular development

In order to investigate the endocrine requirements for induction of follicle maturation, ovulation and luteal function we have measured plasma LH and FSH concentrations in 109 cycles induced by treatment with LHRH in 25 women with amenorrhoea of diverse aetiology. The major clinical and endocrine subgroupings were polycystic ovarian disease (PCO), Kallmann's syndrome, weight related amenorrhoea and hyperprolactinaemia. By analysis of variance of the LH and FSH concentrations obtained three times per week in the follicular phase in 77 ovulatory cycles (including 24 conception cycles), we found that in women with PCO the mean LH concentration was 19.5 IU/l. In hyperprolactinaemia and secondary amenorrhoea of non-specific aetiology the mean LH concentration was 11.6 IU/l and in patients with hypogonadotrophic hypogonadism and weight-related amenorrhoea it was 7.2IU/l. These mean LH concentrations were significantly different from each other (P less than 0.001). We speculate that the high LH concentrations in the follicular phase may impair the final stages of oocyte maturation and so contribute to the infertility of these patients. FSH concentrations in the follicular phase were lower in patients with hypogonadotrophic hypogonadism and weight-related amenorrhoea than in other groups. Although the differences were statistically significant (P less than 0.001) the difference was small (mean FSH in hypogonadotrophic hypogonadism and weight-related amenorrhoea 4.3 IU/l vs 6.3 IU/l in the others) and of uncertain biological significance. During the luteal phase, no differences between any of the groups in LH and FSH concentrations were found.

Long-term stability of aqueous solutions of luteinizing hormone-releasing hormone assessed by an in vitro bioassay and liquid chromatography

The stability of aqueous solutions of luteinizing hormone-releasing hormone (LHRH) after extended storage at various temperatures was investigated using a newly developed HPLC assay and an in vitro dispersed pituitary cell culture bioassay. Good correlations were obtained between the potency obtained by HPLC and bioassay in samples stored at 37 degrees C or subjected to different stress conditions. No significant decrease in activity of LHRH was observed in aqueous solutions stored at 37 degrees C for up to 10 weeks, at 4 degrees C for 2 years, or subjected to repeated freezing and thawing for 5 d. Heating to 60 degrees C in sterile pH 9.0 buffer up to 11 d and storage at ambient temperature in nonsterile solution for 4 months produced well-distinguished degradation products and a decrease in potency. It is concluded that sterile aqueous solutions of LHRH are stable for at least 10 weeks at 37 degrees C and, thus, could be reliably used for chronic administration when long-term stability at body temperature is important.

Ovulation induction with subcutaneous pulsatile gonadotropin-releasing hormone: singleton pregnancies in patients with previous multiple pregnancies after gonadotropin therapy

Three patients with hypothalamic amenorrhea who had previously had multiple pregnancies following gonadotropin therapy were treated with subcutaneous pulsatile gonadotropin-releasing hormone (GnRH), administered by a portable pump. After treatment with lower doses in some cases, pulses of 5 to 10 micrograms were given at 90-minute intervals, resulting in ovulation on six occasions. Ovarian steroid profiles closely resembled those of normal ovulatory cycles, and spontaneous ovulation of a single ovarian follicle was consistently demonstrated by ultrasound. Singleton pregnancy was confirmed in each patient. The results imply normal operation of the ovarian-pituitary feedback loop and suggest that subcutaneous pulsatile GnRH therapy is a safe and effective means of ovulation induction in clomiphene-resistant cases of hypothalamic amenorrhea and may possibly become the preferred method of treatment.

Gonadotrophin regulation and clinical applications of GnRH

Gonadotrophin secretion is determined by the interplay of neural and gonadal influences. The neural influence is mediated for both LH and FSH by the decapeptide GnRH which is secreted into the hypophyseal portal vessels. LH is secreted in a pulsatile fashion apparently driven by episodic release of GnRH. Unremitting exposure of the pituitary to GnRH eventually abolishes gonadotrophin secretion. In primates, as opposed to the rat, GnRH appears to have a permissive role in the regulation of gonadotrophin secretion, priming the pituitary to secrete and show both negative and positive feedback responses to oestrogen in adult females. Striking physiological changes occur from fetal life to puberty in gonadotrophin regulation. GnRH acts on surface receptors. Chemical dissection of the GnRH molecule has disclosed a structure-activity relationship, allowing the development of both antagonist and 'superagonist' analogues. The initial stage in activation of gonadotrophs by GnRH appears to be binding to and clustering--probably dimerization--of GnRH receptors. Subsequent intracellular events are not fully clarified but grounds exist to suggest the involvement of both cyclic AMP and calcium fluxes within the cell. There is strong evidence that GnRH secretion influences the number of its own receptors in various situations in the rat. The phenomenon of pulsatile GnRH release in experimental animals survives hypothalamic deafferentation. Catecholamines are probably intimately involved in the generation of GnRH pulses--which for noradrenaline poses a paradox as all noradrenergic cell bodies lie outside the MBH. LH pulse frequency can be absent or altered in various states (e.g., Kallman's syndrome, hyperprolactinaemia and exposure to opiates--exogenous or apparently endogenous). The existence of GnRH receptors in gonadal tissue has been described but it is debatable whether this is true in man. Therapeutic uses of GnRH initially was aimed at correcting hypogonadotrophic hypogonadism. Development of GnRH superagonists demonstrated desensitization and thus their paradoxical application to the areas of contraception, precocious puberty and endocrine-dependent cancers. The development of miniaturized programmable infusion pumps has made pulsatile GnRH therapy a practical prospect. It holds considerable therapeutic promise in selected cases of hypogonadotrophic hypogonadism, especially in women.

A rational approach to ovulation induction

Appropriate investigation has led to the recognition of five major endocrinologic categories of anovulatory patients. The clinician is able to follow a definitive therapeutic program for each of these; and except where the FSH levels are elevated, pregnancy rates should approach values observed for normally ovulating women. Although clomiphene citrate is likely to remain the most common drug prescribed to anovulatory women, treatment programs with clomiphene have recently been modified with much improved success rates resulting. Bromocriptine, the drug of choice for women with hyperprolactinemia, restores ovulatory cycles in most women treated. It not only restores fertility, however, but also reduces tumor growth in patients with pituitary adenomas, making surgical removal often unnecessary. Exogenous gonadotropin therapy should be reserved for patients who do not respond to treatment with clomiphene and/or bromocriptine. With adequate monitoring, the multiple pregnancy rate should be able to kept below 20% and high-multiple pregnancies avoided. Pulsatile GnRH therapy is likely to replace gonadotropin therapy for most patients, because this therapy has distinct advantages in terms of cost, patient convenience, and a lowering of multiple pregnancy rates.

The effects of chronic treatment with LHRH on gonadotrophin secretion and pituitary responsiveness to LHRH in women with secondary hypogonadism

Twenty women with secondary hypogonadism and four normal women in the early follicular phase of the cycle were treated for 7 days with 10, 50 or 100 micrograms synthetic LHRH administered intramuscularly at 4 h intervals. Concentrations of pituitary and ovarian hormones in plasma were measured at intervals during the treatment period. The episodic pattern of LH secretion and the gonadotrophin responses to acute stimulation with LHRH were evaluated before and after treatment. In normal women the concentrations of gonadotrophins and the LH response to LHRH remained unchanged, whilst the FSH response to LHRH was reduced after treatment. Concentrations of oestradiol rose progressively in response to treatment, indicating follicular development. In hypogonadal subjects with unimpaired pituitary function, treatment with LHRH induced a marked but transient increase in the concentrations of LH and FSH in plasma and a progressive rise in that of oestradiol. The concentration of progesterone was increased in four of the 11 subjects. However, the amplitude of LH pulses and the responses of FSH and LH to LHRH after treatment were suppressed below pretreatment values. Women with hypogonadotrophic hypogonadism and diminished pituitary responses to LHRH exhibited a sustained increase in the concentrations of LH, FSH and oestradiol in plasma to normal follicular phase levels. The amplitude of LH pulses and the LH response to LHRH were increased after treatment but did not reach normal values. The FSH response to LHRH was further reduced after treatment. Treatment of similar subjects with 10 micrograms LHRH induced a small increase in the concentration of gonadotrophins but not of ovarian steroids. These data demonstrate that the effect of chronic treatment with LHRH on women with secondary hypogonadism depends on the level of endogenous gonadotrophins. The dose of LHRH used in hypogonadal women receiving treatment by intermittent injection may require adjusting according to the level of gonadotrophin secretion if an optimal response is to be obtained.

Ovulation induction with luteinizing hormone--releasing hormone in amenorrheic, infertile women

Thirteen women with infertility thought due to anovulation were treated with LRH. Etiologic diagnoses of amenorrhea included hypothalamic or "idiopathic" and PCOD. All patients had normal gonadotropins and otherwise normal endocrinologic and infertility evaluations; none had ovulated with clomiphene. Patients were studied for six 35 day cycles, single blind, and received LRH or placebo by subcutaneous injections for 28 days/cycle (LRH dosage 1.0 mg 2 or 3 times each day). Frequent assessments of physical status, cervical mucus, vaginal cytology, and serum LH, FSH, estrogen, and progesterone were performed. Ovulation was documented by basal temperature, serum progesterone and, on occasion, endometrial biopsy. Follow-up was continued for 6 months after therapy. Of the 13 patients treated, eight have ovulated and five have conceived. There were no complications of therapy.

Effects of prolonged luteinizing hormone-releasing hormone therapy on follicular maturation, ovulation and corpus luteum function in amenorrhoeic women with anorexia nervosa

Nine amenorrhoeic women with anorexia nervosa (AN) were given long-term treatment with 500 microgram of synthetic luteinizing hormone-releasing hormone (LRH) every 8 h. All the women had impaired luteinizing hormone (LH) secretion and no evidence of endogenous oestrogen production. Three of them also had deficient follicle-stimulating hormone (FSH) secretion. The pituitary reserve capacity for gonadotrophin secretion was normal but the response pattern to LRH was similar to that described in prepubertal girls. The constant administration of LRH normalized basal LH and FSH secretion and induced a cyclical gonadotrophin secretory pattern with differential changes of the LH and FSH responses to LRH during the treatment. LRH-induced gonadotrophin secretion produced follicular growth and maturation in all the women. Presumptive ovulation also occurred during the 8 treatment courses in which only LRH was administered. However, inadequate luteal phases were observed during 6 of these 8 cycles. Combined therapy with LRH and human chorionic gonadotrophin (HCG) during 5 treatment courses resulted in normal ovulatory cycles with adequate corpus luteum function.

Serum prolactin and gonadotrophin levels before and after luteinizing hormone-releasing hormone in the investigation of amenorrhoea

An intravenous luteinizing hormone-releasing hormone (LRH) test was performed in 287 women with amenorrhoea. Prolactin, progesterone and oestrogens in serum were also measured. Twenty-four women with premature ovarian failure and 9 with gonadal dysgenesis had raised basal follicle-stimulating hormone (FSH) levels. Neither the basal luteinizing hormone (LH) level nor the gonadotrophin responses after LRH gave a better separation of this group of women with irreversible ovarian failure. Measurement of prolactin levels were valuable in that 15 of 42 patients with hyperprolactinaemia had a radiologically abnormal pituitary fossa, whereas pituitary fossa abnormalities were found in only 11 of 245 normoprolactinaemic women. It was thought that 181 women had functional amenorrhoea; 54 per cent of these women had developed amenorrhoea in relation to weight loss and 32 per cent in relation to discontinuation of oral contraceptives. A strong correlation was found between the body weight and the basal gonadotrophin levels. The basal LH levels were correlated with serum oestrogen levels, the basal FSH level and the LH response to LRH. Most of the patients with low basal LH values had developed amenorrhoea in relation to self-imposed weight-loss. The responses to LRH were often impaired in the underweight patients but became normal after weight gain. The polycystic ovary syndrome (PCO) could not be diagnosed by measuring either basal or LRH-stimulated gonatrophin levels. Single FSH and prolactin determinations in serum seemed to be the only indispensible hormone assays in the routine clinical evaluation of amenorrhoea.

Estrogens delay the postpartum recovery of the LH-RH-induced gonadotropin release

In 27 healthy postpartum women, who were neither lactating nor receiving any therapy, LH-RH stimulation tests (50 micrograms i.v.) were performed on days 7, 14, 21 and 28 of the puerperium. In a second group of 9 postpartum women an i.m. injection of 10 mg estradiol valerianate was administered within the 3rd postpartum day, and an LH-RH stimulation test was performed on days 14 and 21 of the puerperium. Blood was withdrawn at standard intervals and LH and FSH measured by radioimmunoassay. No significant FSH and LH response was found on day 7. On day 14 there was a significant release of FSH but no LH was released. On days 21 and 28 there was a significant release of FSH and LH but the magnitude of the FSH response was greater than that of the LH release. The administration of estrogens did inhibit the recovery of the pituitary from its refractoriness: on day 14 no release of LH and FSH was observed; on day 21, only a significant release of FSH could be detected in the second group of postpartum women. This emphasizes the major role played by steroids in the regulation of the hypothalamo-pituitary-gonadal function.

Acute effects of a new stimulatory luteinizing hormone-releasing hormone analogue D-Ser(TBU)(6)-EA(10)-LRH on the gonadotrophin and gonadal steroid secretion in women with amenorrhoea

A new stimulatory luteinizing hormone-releasing hormone (LRH) analogue D-Ser(TBU)(6)-EA(10)-LRH was administered subcutaneously in a dose of 10 microg into 10 women with amenorrhoea. The injection resulted in a 20-fold increase of the LH level in blood and a 5-fold increase of the FSH level with maxima at 4 and 6 h after the administration, respectively. There was an evident biphasic pattern of LH release similar to that described after extended pituitary stimulation by constant infusions of LRH with early and late peaks of LH combined with a gradual, progressive FSH release. The duration of the effect on LH and FSH was at least 12 and 24 h, respectively. All the women responded with evident oestradiol increases in blood during the last 18 h of the 24 h study period. A comparison between the effects of a single subcutaneous injection of 10 microg of the LRH analogue and 500 microg of LRH showed that the initial FSH and LH release was similar. However, the FSH and LH release during the remainder of the study period was significantly greater after administration of the analogue and so was the oestradiol increase. Thus, this study in women confirms previous studies in men that D-Ser(TBU)(6)-EA(10)-LRH is a potent stimulatory LRH analogue with prolonged biological activity.

Luteinizing hormone-releasing hormone for induction of follicular maturation and ovulation in women with infertility and amenorrhea

Five patients with primary infertility and secondary amenorrhea who did not respond to clomiphene with a gonadotropin or estrogen surge were treated with 500 mug of luteinizing hormone, follicle-stimulating hormone-releasing hormone (LH-RH), self-administered subcutaneously every 8 hours for 14 days. Of four patients who responded to this treatment, three showed follicular maturation, ovulation, and menses, although the luteal phase was deficient; in the fourth patient, follicular maturation and menses occurred without evidence of ovulation. For their second course of treatment these four patients were given LH-RH with the addition of human chorionic gonadotropin when the urinary estrogen levels indicated follicular maturation. All four patients responded with ovulation, an adequate luteal phase, and menses, without clinical indication of ovarian hyperstimulation. These results suggest that LH-RH may be a better alternative to human menopausal gonadotropin in the treatment of anovulatory infertility.