Follicle growth and endocrine dynamics in women with spontaneous luteinized unruptured follicles versus ovulation.

STUDY QUESTION: Do growth patterns and endocrine profiles differ between ovulatory follicles (OvFs) and luteinized unruptured follicles (LUFs) in women? SUMMARY ANSWER: Growth rates, diameters and associated endocrine profiles differed between OvFs and LUFs in unstimulated cycles. WHAT IS KNOWN ALREADY: Two-three waves of antral follicles develop during the menstrual cycle in ovulatory women of reproductive age, with the second or third wave terminating in ovulation. In contrast, some women can develop LUFs, where a preovulatory follicle fails to rupture and there is subsequent luteinization of the follicle wall. However, no study has compared OvFs and LUFs in unstimulated cycles. STUDY DESIGN, SIZE, DURATION: This retrospective observational study was conducted in 56 healthy women of reproductive age (range: 19-41 years) and with a history of regular menstrual cycles. PARTICIPANTS/MATERIALS, SETTING, METHODS: Participants who met inclusion criteria were enrolled, as previously reported. Daily transvaginal ultrasonography was performed for one interovulatory interval (IOI) to measure the diameters of all follicles >2 mm. Blood samples were collected every 3 days during the IOI to measure serum concentrations of FSH, LH, estradiol and progesterone. MAIN RESULTS AND THE ROLE OF CHANCE: The interval from emergence to deviation (i.e. follicle selection) was shorter (P < 0.05) for LUFs compared to OvFs. However, the intervals from emergence to maximum diameter and deviation to maximum diameter were longer (P < 0.05) for LUFs compared to OvFs. Follicle deviation in LUFs occurred at a larger diameter (P < 0.05) compared to OvFs, and LUFs grew to larger (P < 0.0001) diameters compared to OvFs. Moreover, LUFs grew faster (P < 0.05) from emergence to deviation and from deviation to maximum diameter, compared to OvFs. LUFs were associated with low (P < 0.05) systemic LH levels at emergence and maximum diameter compared to OvFs. LUFs were also associated with low (P < 0.05) systemic FSH and high (P < 0.05) systemic progesterone at deviation and maximum diameter, respectively. Estradiol was higher (P < 0.05) at deviation and lower (P < 0.05) at maximum diameter for LUFs compared to OvFs. LIMITATIONS, REASONS FOR CAUTION: A 3-day interval of blood sampling for hormonal analyses was conducted, as a more frequent sampling interval was not considered acceptable by the study volunteers. A 3-day sampling interval did not allow characterization of acute changes in hormone production during the IOI. In addition, study visits were less frequent when LUFs persisted long after the expected day of the second ovulation of the IOI. WIDER IMPLICATIONS OF THE FINDINGS: Information about the growth and endocrine dynamics of OvFs and LUFs developing in unstimulated cycles in women may be applied to the early detection of LUF-associated anovulatory infertility and clinical management of women with this condition. STUDY FUNDING/COMPETING INTEREST(S): No external funding sources were used for this study. The authors have no conflicts of interest in publishing this manuscript. TRIAL REGISTRATION NUMBER: ClinicalTrials.gov Identifier: NCT01389141.

The mare as a model for luteinized unruptured follicle syndrome: intrafollicular endocrine milieu.

Luteinized unruptured follicle (LUF) syndrome is a recurrent anovulatory dysfunction that affects up to 23% of women with normal menstrual cycles and up to 73% with endometriosis. Mechanisms underlying the development of LUF syndrome in mares were studied to provide a potential model for human anovulation. The effect of extended increase in circulating LH achieved by administration of recombinant equine LH (reLH) or a short surge of LH and decrease in progesterone induced by prostaglandin F2α (PGF2α) on LUF formation (Experiment 1), identification of an optimal dose of COX-2 inhibitor (flunixin meglumine, FM; to block the effect of prostaglandins) for inducing LUFs (Experiment 2), and evaluation of intrafollicular endocrine milieu in LUFs (Experiment 3) were investigated. In Experiment 1, mares were treated with reLH from Day 7 to Day 15 (Day 0=ovulation), PGF2α on Day 7, or in combination. In Experiment 2, FM at doses of 2.0 or 3.0 mg/kg every 12 h and human chorionic gonadotropin (hCG) (1500 IU) were administered after a follicle ≥32 mm was detected. In Experiment 3, FM at a dose of 2.0 mg/kg every 12 h plus hCG was used to induce LUFs and investigate the intrafollicular endocrine milieu. No LUFs were induced by reLH or PGF2α treatment; however, LUFs were induced in 100% of mares using FM. Intrafollicular PGF2α metabolite, PGF2α, and PGE2 were lower and the ratio of PGE2:PGF2α was higher in the induced LUF group. Higher levels of intrafollicular E2 and total primary sex steroids were observed in the induced LUF group along with a tendency for higher levels of GH, cortisol, and T; however, LH, PRL, VEGF-A, and NO did not differ between groups. In conclusion, this study reveals part of the intrafollicular endocrine milieu and the association of prostaglandins in LUF formation, and indicates that the mare might be an appropriate model for studying the poorly understood LUF syndrome.

Large animal models for the study of ovarian follicular dynamics in women.

Initial studies of the ovaries were based on postmortem anatomic descriptions, followed by histologic and endocrine approaches. The introduction of high-resolution ultrasonography provided a long-awaited tool to image the reproductive tissues in situ in both animals and humans. Critical studies of the characteristics and control of ovarian follicular and luteal dynamics in nonhuman primates, rodents, and domestic farm animals have involved frequent (i.e., daily or multiple times a day) blood sampling and ultrasonography. Studies of this nature in women are difficult, and often unethical to conduct. Differences in antral folliculogenesis between humans and animals appear to be more in detail rather than in essence, and may reflect differences in intrinsic physiology or merely differences in our ability to detect changes in a given species. In women, the presence of endometrial shedding and symmetric luteal and follicular phases are different from that observed during the estrous cycles of domestic farm animals but despite these differences, general similarities in antral follicular dynamics exist. A continuous pattern of antral follicle development was originally proposed in domestic livestock species; however, the use of frequent serial ultrasonography and simultaneous endocrine profiling in these animal species has resulted in a broad understanding of follicular wave dynamics. Follicular waves have now been described in every species in which this approach has been used, including humans. The relatively large diameters of antral follicles in cows and mares, compared with monkeys, sheep, and rodents provide greater feasibility for characterizing antral follicular dynamics ultrasonographically. While the use of large animal models has increased our understanding of ovarian function and provides the hypothetical basis for studies in women, differences in vocabulary, culture, and research methodologies has hampered knowledge translation. These differences represent a systemic impediment to a broad understanding of ovarian function and limits progress and innovation in the development of safer and more efficacious treatments for infertility and contraception.

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.

Form and function of the corpus luteum during the human menstrual cycle.

OBJECTIVE: To characterize the growth and regression of the corpus luteum (CL) during an interovulatory interval (IOI) using serial transvaginal ultrasonography. METHODS: Fifty healthy women of reproductive age with a history of regular menstrual cycles underwent daily transvaginal ultrasonography for one IOI. Measurements of luteal area and luteal numerical pixel value (NPV) were recorded each day after ovulation until the CL could no longer be detected. Blood was drawn every third day during the IOI to measure serum concentrations of progesterone and estradiol-17beta. RESULTS: Corpora lutea were of two morphological types: those with a central fluid-filled cavity (CFFC) (78%) and those without (22%). Eighty-eight percent of women exhibited a CL containing a CFFC 2 days after ovulation, followed by 34% 13 days after ovulation and 2% 27 days after ovulation. Luteal area, progesterone concentration and estradiol concentration increased for approximately the first 6 days following ovulation followed by a subsequent decline. Luteal NPV decreased from days 1 to 11 and increased during days 11-16. Changes in luteal area, NPV, progesterone and estradiol concentrations did not differ in women with two versus three waves of follicular development. CONCLUSIONS: Peak luteal function, as determined by maximum luteal area, progesterone concentration and estradiol concentration, is observed 6 days following ovulation. Luteal NPV is reflective of morphological and endocrinological changes in the CL. The development of a CFFC during luteinization is a normal physiological phenomenon. The CL can be detected, but is not functional, during the follicular phase of the menstrual cycle.

Ovarian follicular development is initiated during the hormone-free interval of oral contraceptive use.

We evaluated ovarian follicular development in women during compliant use of oral contraceptives (OC). Thirty-six healthy women received: [35 microg ethinyl estradiol (21)/180 microg norgestimate (7), 215 microg norgestimate (7), 250 microg norgestimate (7)]; [30 microg ethinyl estradiol (21)/150 microg desogestrel (21)]; or [20 microg ethinyl estradiol (21)/100 microg levonorgestrel (21)] for 3 consecutive 28-day cycles. Transvaginal ultrasonography was performed every third day to monitor follicular development. If a follicle reached > or = 14 mm, ultrasonography was performed daily and blood drawn every other day to determine estradiol-17beta concentrations. Seventeen of 36 women (47%) grew follicles > or = 10 mm. Nine of the 17 women (53%) grew follicles > or = 14 mm, in association with increased serum concentrations of estradiol-17beta. Thirty-seven of 43 follicles > or = 10 mm (86%) emerged during the hormone-free interval (HFI). No ovulations were observed. Our results supported the hypothesis that follicular development to an ostensibly ovulatory diameter occurs during compliant OC use, in association with loss of endocrine suppression during the HFI.

Endometrial development in association with ovarian follicular waves during the menstrual cycle.

OBJECTIVES: Waves of ovarian follicular development during the menstrual cycle have recently been documented in our laboratory. The objective of this study was to test the hypothesis that ultrasonographically detectable changes in the endometrium during the menstrual cycle would differ between women with two vs. three waves of ovarian follicular development and among women with different major and minor wave patterns of follicle growth. METHODS: Fifty women of reproductive age (mean age +/- SD, 28.0 +/- 6.9 years) underwent daily transvaginal ultrasonography for one interovulatory interval (IOI). Ultrasonographic images of the endometrium were obtained each day, and measurements of endometrial area and perimeter (based on the shape of an ellipse, in the transverse plane) and thickness and pattern (in the sagittal plane) were recorded. Endometrial area, perimeter, thickness and pattern were compared between women with two and three waves of follicle development and among women with different minor and major wave patterns of follicular growth during the IOI. RESULTS: Endometrial area, perimeter, thickness and pattern increased earlier during the follicular phase in women with two vs. three waves of follicular development. In women with two follicle waves, endometrial area and perimeter increased earlier in those with major major vs. minor major follicle wave patterns. CONCLUSIONS: Ultrasonographically detectable changes in the endometrium occurred in association with follicle wave dynamics in women. Earlier development of the endometrium during the follicular phase in women with two vs. three follicle waves was attributed to an earlier increase in dominant follicle estradiol production.

Comparative study of the dynamics of follicular waves in mares and women.

Deviation in growth rates of the follicles of the ovulatory wave begins at the end of a common growth phase and is characterized by continued growth of the developing dominant follicle (F1) and regression of the largest subordinate follicle (F2). Follicle diameters during an interovulatory interval were compared between 30 mares and 30 women, using similar methods for collecting and analyzing data. Follicles were tracked and measured daily by ultrasonography. Diameter at follicle emergence (mares, 13 mm; women, 6 mm) and the required minimal attained diameter for assessment of follicles (mares, 17 mm; women, 8 mm) were chosen to simulate the reported ratio between the two species in mean diameter of F1 at the beginning of deviation (mares, 22.5 mm; women, 10.5 mm). F1 emerged before F2 (P < 0.02) in each species, and the interval between emergence of the two follicles was similar (not significantly different) between species. Growth rate for F1 and F2 during the common growth phase was similar within species, and the percentage of diameter increase was similar between species. Proportionality between species in diameter of F1 at deviation (2.2 times larger for mares than for women) and at maximum preovulatory diameter (2.1 times larger) indicated that relative growth of F1 after deviation was similar between species. A predeviation follicle was identified in 33% of mares and 40% of women and was characterized by growth to a diameter similar to F1 at deviation but with regression beginning an average of 1 day before the beginning of deviation. The incidence of a major anovulatory wave preceding the ovulatory wave was not different between species (combined, 25%). Results indicated that mares and women have comparable follicle interrelationships during the ovulatory wave, including 1) emergence of F1 before F2, 2) similar length of intervals between sequential emergence of follicles within a wave, 3) similar percentage growth of follicles during the common growth phase, and 4) similar relative diameter of F1 from the beginning of deviation to ovulation. Similar follicle dynamics between mares and women indicate the mare may be a useful experimental model for study of folliculogenesis in women, with the advantage of larger follicle size.