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Enhanced pre-ovulatory progesterone levels in fertile cycles during clomiphene citrate treatment
239
Znt. J. Gynecol. Ohstet., 1989.29: 239-242
International Federation of Gynecology and Obstetrics
Enhanced pre-ovulatory progesterone levels in fertile cycles during clomiphene citrate treatment L. Fedele, D.Brioschi, I +a Clinica
M. Marchini,
M. Dorta and A. Baglioni
Ostetrico-Ginecologica, Universirb di Milcno. Milan0 (Italy)
(Received March 7th. 1988) (Revised and accepted July 12th, 1988)
Abstract
We compared ovulatory changes in fertile and preceding infertile cycles in 21 patients with unexplained infertility conceiving after clomiphene citrate treatment. No significant differences were observed .in follicular growth, cervical score and follicle stimulating hormone (FSH) levels. Progesterone was higher (P < 0.05) in the 2 days preceding ovulation in fertile cycles, luteinizing hormone (LH) higher (P < 0.05) the day before, and 17-@stradiol lower (P < 0.05) 4 days &fore. Stimulatingprogesterone secretion by systematic LH administration before ovulation could improve secretory endometrial transformation and thus reproductive prognosis. Keywords: Clomiphene citrate; Conception; Endometrium; Ovulatory changes; Progesterone; Unexplained infertility. Introduction Numerous methods of investigation are now available to study follicular development [1,11,18]. Body temperature charts [3,9], cervical mucus score8 [2,4,6], measurements of LH, 17-P-estradiol (E,) and progesterone 0020-7292/89/$03.50
0 1989 International Federation of Gynecology and Obstetrics Published and Printed in Ireland
levels [ 13,191 and ultrasound monitoring of follicular growth [7,8,10,12,16,17] allow the day of ovulation to be predicted and confirmed with adequate precision. However, no indexes have yet been identified that predict if an ovulatory cycle will be followed by pregnancy. We compared the pattern of ovulatory changes in cycles followed by pregnancy (fertile cycles) with that in cycles in which conception did not occur (infertile cycles). Materials and methods We studied the cycles of 21 patients with unexplained primary infertility [ 14,151 who conceived after treatment with clomiphene citrate, whose partners were normospermic. The patients, of mean age 30.3 years (range 24-39), with a mean duration of infertility of 3.6 year8 (range 2-Q, took clomiphene citrate at the dose of 100 mg/day from day 3 to day 7 of the cycle. Each patient noted her body temperature daily, and the following determinations were performed daily from day 9 of the cycle until ovulation: mean follicular diameter by transabdominal ultrasonography, Moghissi’s cervical score [4], serum levels of LH, FSH, E, and progesterone with radioimmunoassay (RIA) methods. Blood samples were taken on days 3, 5 and 7 Clinical and Clinical Rerearch
240
Fedele et al.
t
after ovulation to determine serum progesterone. For each cycle we calculated the daily estrogen production of each follicle (E/j’) by dividing the total E, concentration by the number of follicles measurable at sonography. The mean growth curve for E was calculated by adding the E,/f values o z each cycle and dividing by the number of the cycles. The patients were instructed to have intercourse daily, after a period of abstinence of at least 3-S days, from the day on which at least one follicle of 18 mm diameter was demonstrated until ovulation [9]. Cycles were considered ovulatory when rupture of a dominant follicle of at least 18 mm mean diameter was observed at sonography [4,7], the temperature curve was biphasic and serum progesterone levels in the second phase of the cycle were adequate. Tukey’s test and analysis of variance were used to perform statistical analysis on the parameters monitored in the 21 cycles in which conception occurred and in the 37 preceding infertile cycles of the same patients.
Fig. 2.
cycles, respectively, are shown in Fig. 1. In the fertile cycles there was a mean daily increase of 1.8 mm (range l.l-2.6), with a mean maximum diameter of 21.6 mm (range 18-32 mm) the day before ovulation, compared with a mean daily increase of 1.5 mm (range 0.1-2.8 mm) in the infertile cycles, with a mean maximum diameter of 20.3 mm (range 18-25.6 mm) the day before ovulation. The mean number of dominant follicles developing per cycle was 2.07 (range l-4) in the fertile cycles versus 1.36 (range l-2) in the infertile cycles. Cervical mucus showed fertility characteristics (cervical score 310) in 18 of the 21 fertile cycles compared with 33 of the 37 infertile ones. In the other three fertile cycles the maximum scores attributed were 7, 8 and 9, respectively, and in the other four infertile
Results All the cycles studied patients conceived after (range l-4) from the citrate treatment. The growth curves for the
Mean cervical scores.
were ovulatory. The a mean of 2.7 cycles start of clomiphene follicular diameter fertile and infertile
;
8 -6
-5
-4
II
-3
I,
-2
I,
5 I
300
_
i
250
_
F g
200
_
L.8”150
_
100
_
50
_
I,
-,
0
dW
fertile Fig. 1. Mean follicular diameters (mm). X-X, cycles, mean values f S.E.; e-0, infertile cycles, mean values f SE.; Day 0 = day of sonographicovulation. Int J Gynecol Obstet 29
400 _
350 _
: i
I’
6
5
E
Fig. 3.
Mean growth curves for E, (pg/rd for each follicle).
Pm-ovulatory progesterone in fertile cycle3
The mean growth curves for E, are shown in Fig. 3, and the values of LH and preovulatory progesterone concentrations in Figs. 4 and 5. Analysis of the data did not show any significant difference between the fertile and infertile cycles in the pattern of follicular growth, cervical mucus score and FSH levels. Significant differences were instead observed in the mean concentrations of progesterone 1 and 2 days before ovulation (P < 0.05), LH 1 day before (P < 0.05) and E, 4 days before (P< 0.05).
85 -
aa75 70 65 60 55 -
2
EQ-
5
45 -
E
ul
3
35 -
g
30 -
_
26 20 -
1
15 10 5 -6
Fig. 4.
-5
-4
-3
-2
-1
, 0 day
Discussion
Mean growth curves for LH (mILJ/ml).
cycles the maximum score was 8. In the fertile cycles the maximum cervical score was observed 5 days before ultrasonographic ovulation in one cycle, 3 days before in eight, 2 days before in eight, the day before in three, and the day of ovulation in one. In the infertile cycles the maximum cervical score was attained 3 days before ovulation in 11 cycles, 2 days before in 14, the day before in 11, and the same day in one. The mean cervical score in the fertile and infertile cycles are shown in Fig. 2.
4.4
-
-6
Fig.
5.
@g/mu.
Mean
-6
growth
241
-4
curves
-3
-*
-1
0 day
for pre-ovulatory progesterone
This study reports the hormonal changes following clomiphene citrate treatment in cycles of women who became pregnant versus cycles of the same women which were ovulatory but pregnancy did not ensue. Furthermore, the cycles considered were consecutive in the same patient; thus presumably the psychophysical picture and the other factors influencing fertility did not vary. The series studied was moreover homogeneous since all the patients had unexplained infertility and were given the same drug treatment. The day of ovulation was identified accurately by ultrasound monitoring of follicular growth. One finding of our study was an irregular rise of E levels in the infertile cycles; an initial rapidincrease occurred followed by a fall that preceded the pre-ovulatory peak. A progressive and regular increase of E, was instead recorded in the fertile cycles. It may be hypothesized that in the infertile cycles there was an initial greater recruitment of follicles. that became atretic in the early follicular phase, or a greater initial production of E, by each follicle. The first hypothesis seems more probable, but the number of follicles recruited cannot be shown by ultrasonography since at this phase they have a diameter of under 10 mm, which is below the usual standards of sonographic resolution. Clinical and Clinical Research
242
Fedele et al.
The present study also demonstrated higher LH concentrations in the fertile cycles during all the pre-ovulatory phase, reaching significance on the day before ovulation. Presumably the more regular rise in E, levels determines an increased response to the positive LH feedback at the hypothalamicpituitary level. On the other hand, at the ovarian level a constant estrogenic impregnation could favor regular differentiation of follicular LH receptors. Also pre-ovulatory progesterone was significantly higher in the cycles in which conception occurred, whereas significant differences were not observed in the levels of postovulatory progesterone. This increase, possibly a result of the higher levels of circulating LH, could induce early secretory manifestations in the pre-ovulatory endometrium [5]. Interestingly, in the infertile cycles the pre-ovulatory progesterone concentrations were similar to those found by other authors, whereas such values were significantly higher in our fertile cycles. Furthermore, three of our patients conceived despite having an unfavorable cervical mucus score (between 5 and 9). In conclusion, it is possible that, in cycles induced with clomiphene citrate, ovulation does not always result in adequate secretory transformation of the endometrium and that only appropriate pre-ovulatory levels of LH, and thus of progesterone, ensure an optimal endometrial preparation. Our data suggest that stimulating progesterone secretion by systematic LH administration in the pre-ovulatory phase may be proposed for patients with unexplained infertility treated with clomiphene citrate.
5
6
7
8
9 10 11
12
13
14
15 16
References 1 Affandi ZM. Doctor V, Jhaveri K: The endocervical smear as a simple and quick method for the determination of ovulation. Acta Cytol29: 638,1984. 2 Bailey E, March MC, Mishell D: The cervical factor in clomiphene treated patients. Fertil Steri132: 489, 1979. 3 Bauman JE: Basal body temperature: unreliable method of ovulation detection. Fertil Steril36: 729,198l. 4 Belsey MA. Eliasson R. Gallegos AJ, et al: Sperm cervical mucus interaction. In Laboratory Manual for the
Int J Gynecol Obstet 29
Examination of Human Semen and Semen-Cervical Mucus Interaction (eds MA Belsey, R Eliasson, AJ Gallegos), p 33. Press Concern, Singapore. 1980. Birkenfeld A, Navot D, Levij IS, et al: Advanced sccretory changes in the proliferative human endometrial epithelimn following clomiphene citrate treatment. Fertil Steril45: 462,1986. Cohen MR, Perez Pelaez M: The effect of norethindrone acetate, ethinyl oestradiol. clomiphene citrate and dydrogesterone on spinnbarkeit. Fertil Steril 16: 141, 1%5. Coulam CE, Hi LM, Breckle R: Ultrasonic assessment of subsequent unexplained infertility after ovulation induction. Br J Obstet Gynaecol90: 460.1983. De Crespigny LJ, O’Herlihy C, Robinson HP: Ultrasonic observation of the mechanism of human ovulation. Am J Obstet Gynccol139: 636,198l. Downs KA, Gibson M: Basal body temperature graph and the luteal phase defect. Fertil Steril40: 466,1983. Hackeloer BJ, Sallam J: Ultrasound scanning of ovarian follicles. Clin Obstet Gynaecol IO: 603, 1983. Leader A, Wiseman D. Taylor PJ: The prediction of ovulation: a comparison of the basal body temperature graph, cervical mucus score, and real-time pelvic ultrasonography. Fertil Steri143: 3851985. Lenz S: Ultrasonic study of follicular maturation, ovulation and development of corpus luteum during normal menstrual cycles. Acta Obstet Gynecol Stand 64: 15. 1985. Levrier M, Broussin B. Denechaud M, et al: Marquers de la phase p&i-ovulatoire en vue d’insbmination: correlations E,/LH. Rev Fr Gynecol Obstet 80: 813,1985. MC Bain JC, Pepperell RJ: Unexplained infertility. In The infertile couple (eds RJ Pepperell, B Hudson, C Wood), p 164. Churchill Livingstone, Edinburgh, 1980. Moghissi KS, Wallach EE: Unexplained infertility. Fertil Steril39: 5.1983. Paulson JD. Speck G, Albarelli JN: The use of ultrasonography in patients with infertility. Fertil Steril 42: 489, 1984. Ritchie WGM: Ultrasound in the evaluation of normal and induced ovulation. Fertil Steril43: 167,1985. Vermesh M. Kletzky OA, Davajan R. et al: Monitoring techniques to predict and detect ovulation. Fertil Steril 47: 259.1987. World Health Organization: Temporal relationships between ovulation and defined changes in the concentrations of plasma estradiol-178, luteinizing hormone, follicle-stimulating hormone and progesterone. Am J Obstet Gynecol138: 383,198O.
Addrem for
reprinta:
L. Fedele lo clinica ostetrico-GiIlecohgica Universith di Milan0 Via Commenda, 12 20122 - MILAN0 IMY
Znt. J. Gynecol. Ohstet., 1989.29: 239-242
International Federation of Gynecology and Obstetrics
Enhanced pre-ovulatory progesterone levels in fertile cycles during clomiphene citrate treatment L. Fedele, D.Brioschi, I +a Clinica
M. Marchini,
M. Dorta and A. Baglioni
Ostetrico-Ginecologica, Universirb di Milcno. Milan0 (Italy)
(Received March 7th. 1988) (Revised and accepted July 12th, 1988)
Abstract
We compared ovulatory changes in fertile and preceding infertile cycles in 21 patients with unexplained infertility conceiving after clomiphene citrate treatment. No significant differences were observed .in follicular growth, cervical score and follicle stimulating hormone (FSH) levels. Progesterone was higher (P < 0.05) in the 2 days preceding ovulation in fertile cycles, luteinizing hormone (LH) higher (P < 0.05) the day before, and 17-@stradiol lower (P < 0.05) 4 days &fore. Stimulatingprogesterone secretion by systematic LH administration before ovulation could improve secretory endometrial transformation and thus reproductive prognosis. Keywords: Clomiphene citrate; Conception; Endometrium; Ovulatory changes; Progesterone; Unexplained infertility. Introduction Numerous methods of investigation are now available to study follicular development [1,11,18]. Body temperature charts [3,9], cervical mucus score8 [2,4,6], measurements of LH, 17-P-estradiol (E,) and progesterone 0020-7292/89/$03.50
0 1989 International Federation of Gynecology and Obstetrics Published and Printed in Ireland
levels [ 13,191 and ultrasound monitoring of follicular growth [7,8,10,12,16,17] allow the day of ovulation to be predicted and confirmed with adequate precision. However, no indexes have yet been identified that predict if an ovulatory cycle will be followed by pregnancy. We compared the pattern of ovulatory changes in cycles followed by pregnancy (fertile cycles) with that in cycles in which conception did not occur (infertile cycles). Materials and methods We studied the cycles of 21 patients with unexplained primary infertility [ 14,151 who conceived after treatment with clomiphene citrate, whose partners were normospermic. The patients, of mean age 30.3 years (range 24-39), with a mean duration of infertility of 3.6 year8 (range 2-Q, took clomiphene citrate at the dose of 100 mg/day from day 3 to day 7 of the cycle. Each patient noted her body temperature daily, and the following determinations were performed daily from day 9 of the cycle until ovulation: mean follicular diameter by transabdominal ultrasonography, Moghissi’s cervical score [4], serum levels of LH, FSH, E, and progesterone with radioimmunoassay (RIA) methods. Blood samples were taken on days 3, 5 and 7 Clinical and Clinical Rerearch
240
Fedele et al.
t
after ovulation to determine serum progesterone. For each cycle we calculated the daily estrogen production of each follicle (E/j’) by dividing the total E, concentration by the number of follicles measurable at sonography. The mean growth curve for E was calculated by adding the E,/f values o z each cycle and dividing by the number of the cycles. The patients were instructed to have intercourse daily, after a period of abstinence of at least 3-S days, from the day on which at least one follicle of 18 mm diameter was demonstrated until ovulation [9]. Cycles were considered ovulatory when rupture of a dominant follicle of at least 18 mm mean diameter was observed at sonography [4,7], the temperature curve was biphasic and serum progesterone levels in the second phase of the cycle were adequate. Tukey’s test and analysis of variance were used to perform statistical analysis on the parameters monitored in the 21 cycles in which conception occurred and in the 37 preceding infertile cycles of the same patients.
Fig. 2.
cycles, respectively, are shown in Fig. 1. In the fertile cycles there was a mean daily increase of 1.8 mm (range l.l-2.6), with a mean maximum diameter of 21.6 mm (range 18-32 mm) the day before ovulation, compared with a mean daily increase of 1.5 mm (range 0.1-2.8 mm) in the infertile cycles, with a mean maximum diameter of 20.3 mm (range 18-25.6 mm) the day before ovulation. The mean number of dominant follicles developing per cycle was 2.07 (range l-4) in the fertile cycles versus 1.36 (range l-2) in the infertile cycles. Cervical mucus showed fertility characteristics (cervical score 310) in 18 of the 21 fertile cycles compared with 33 of the 37 infertile ones. In the other three fertile cycles the maximum scores attributed were 7, 8 and 9, respectively, and in the other four infertile
Results All the cycles studied patients conceived after (range l-4) from the citrate treatment. The growth curves for the
Mean cervical scores.
were ovulatory. The a mean of 2.7 cycles start of clomiphene follicular diameter fertile and infertile
;
8 -6
-5
-4
II
-3
I,
-2
I,
5 I
300
_
i
250
_
F g
200
_
L.8”150
_
100
_
50
_
I,
-,
0
dW
fertile Fig. 1. Mean follicular diameters (mm). X-X, cycles, mean values f S.E.; e-0, infertile cycles, mean values f SE.; Day 0 = day of sonographicovulation. Int J Gynecol Obstet 29
400 _
350 _
: i
I’
6
5
E
Fig. 3.
Mean growth curves for E, (pg/rd for each follicle).
Pm-ovulatory progesterone in fertile cycle3
The mean growth curves for E, are shown in Fig. 3, and the values of LH and preovulatory progesterone concentrations in Figs. 4 and 5. Analysis of the data did not show any significant difference between the fertile and infertile cycles in the pattern of follicular growth, cervical mucus score and FSH levels. Significant differences were instead observed in the mean concentrations of progesterone 1 and 2 days before ovulation (P < 0.05), LH 1 day before (P < 0.05) and E, 4 days before (P< 0.05).
85 -
aa75 70 65 60 55 -
2
EQ-
5
45 -
E
ul
3
35 -
g
30 -
_
26 20 -
1
15 10 5 -6
Fig. 4.
-5
-4
-3
-2
-1
, 0 day
Discussion
Mean growth curves for LH (mILJ/ml).
cycles the maximum score was 8. In the fertile cycles the maximum cervical score was observed 5 days before ultrasonographic ovulation in one cycle, 3 days before in eight, 2 days before in eight, the day before in three, and the day of ovulation in one. In the infertile cycles the maximum cervical score was attained 3 days before ovulation in 11 cycles, 2 days before in 14, the day before in 11, and the same day in one. The mean cervical score in the fertile and infertile cycles are shown in Fig. 2.
4.4
-
-6
Fig.
5.
@g/mu.
Mean
-6
growth
241
-4
curves
-3
-*
-1
0 day
for pre-ovulatory progesterone
This study reports the hormonal changes following clomiphene citrate treatment in cycles of women who became pregnant versus cycles of the same women which were ovulatory but pregnancy did not ensue. Furthermore, the cycles considered were consecutive in the same patient; thus presumably the psychophysical picture and the other factors influencing fertility did not vary. The series studied was moreover homogeneous since all the patients had unexplained infertility and were given the same drug treatment. The day of ovulation was identified accurately by ultrasound monitoring of follicular growth. One finding of our study was an irregular rise of E levels in the infertile cycles; an initial rapidincrease occurred followed by a fall that preceded the pre-ovulatory peak. A progressive and regular increase of E, was instead recorded in the fertile cycles. It may be hypothesized that in the infertile cycles there was an initial greater recruitment of follicles. that became atretic in the early follicular phase, or a greater initial production of E, by each follicle. The first hypothesis seems more probable, but the number of follicles recruited cannot be shown by ultrasonography since at this phase they have a diameter of under 10 mm, which is below the usual standards of sonographic resolution. Clinical and Clinical Research
242
Fedele et al.
The present study also demonstrated higher LH concentrations in the fertile cycles during all the pre-ovulatory phase, reaching significance on the day before ovulation. Presumably the more regular rise in E, levels determines an increased response to the positive LH feedback at the hypothalamicpituitary level. On the other hand, at the ovarian level a constant estrogenic impregnation could favor regular differentiation of follicular LH receptors. Also pre-ovulatory progesterone was significantly higher in the cycles in which conception occurred, whereas significant differences were not observed in the levels of postovulatory progesterone. This increase, possibly a result of the higher levels of circulating LH, could induce early secretory manifestations in the pre-ovulatory endometrium [5]. Interestingly, in the infertile cycles the pre-ovulatory progesterone concentrations were similar to those found by other authors, whereas such values were significantly higher in our fertile cycles. Furthermore, three of our patients conceived despite having an unfavorable cervical mucus score (between 5 and 9). In conclusion, it is possible that, in cycles induced with clomiphene citrate, ovulation does not always result in adequate secretory transformation of the endometrium and that only appropriate pre-ovulatory levels of LH, and thus of progesterone, ensure an optimal endometrial preparation. Our data suggest that stimulating progesterone secretion by systematic LH administration in the pre-ovulatory phase may be proposed for patients with unexplained infertility treated with clomiphene citrate.
5
6
7
8
9 10 11
12
13
14
15 16
References 1 Affandi ZM. Doctor V, Jhaveri K: The endocervical smear as a simple and quick method for the determination of ovulation. Acta Cytol29: 638,1984. 2 Bailey E, March MC, Mishell D: The cervical factor in clomiphene treated patients. Fertil Steri132: 489, 1979. 3 Bauman JE: Basal body temperature: unreliable method of ovulation detection. Fertil Steril36: 729,198l. 4 Belsey MA. Eliasson R. Gallegos AJ, et al: Sperm cervical mucus interaction. In Laboratory Manual for the
Int J Gynecol Obstet 29
Examination of Human Semen and Semen-Cervical Mucus Interaction (eds MA Belsey, R Eliasson, AJ Gallegos), p 33. Press Concern, Singapore. 1980. Birkenfeld A, Navot D, Levij IS, et al: Advanced sccretory changes in the proliferative human endometrial epithelimn following clomiphene citrate treatment. Fertil Steril45: 462,1986. Cohen MR, Perez Pelaez M: The effect of norethindrone acetate, ethinyl oestradiol. clomiphene citrate and dydrogesterone on spinnbarkeit. Fertil Steril 16: 141, 1%5. Coulam CE, Hi LM, Breckle R: Ultrasonic assessment of subsequent unexplained infertility after ovulation induction. Br J Obstet Gynaecol90: 460.1983. De Crespigny LJ, O’Herlihy C, Robinson HP: Ultrasonic observation of the mechanism of human ovulation. Am J Obstet Gynccol139: 636,198l. Downs KA, Gibson M: Basal body temperature graph and the luteal phase defect. Fertil Steril40: 466,1983. Hackeloer BJ, Sallam J: Ultrasound scanning of ovarian follicles. Clin Obstet Gynaecol IO: 603, 1983. Leader A, Wiseman D. Taylor PJ: The prediction of ovulation: a comparison of the basal body temperature graph, cervical mucus score, and real-time pelvic ultrasonography. Fertil Steri143: 3851985. Lenz S: Ultrasonic study of follicular maturation, ovulation and development of corpus luteum during normal menstrual cycles. Acta Obstet Gynecol Stand 64: 15. 1985. Levrier M, Broussin B. Denechaud M, et al: Marquers de la phase p&i-ovulatoire en vue d’insbmination: correlations E,/LH. Rev Fr Gynecol Obstet 80: 813,1985. MC Bain JC, Pepperell RJ: Unexplained infertility. In The infertile couple (eds RJ Pepperell, B Hudson, C Wood), p 164. Churchill Livingstone, Edinburgh, 1980. Moghissi KS, Wallach EE: Unexplained infertility. Fertil Steril39: 5.1983. Paulson JD. Speck G, Albarelli JN: The use of ultrasonography in patients with infertility. Fertil Steril 42: 489, 1984. Ritchie WGM: Ultrasound in the evaluation of normal and induced ovulation. Fertil Steril43: 167,1985. Vermesh M. Kletzky OA, Davajan R. et al: Monitoring techniques to predict and detect ovulation. Fertil Steril 47: 259.1987. World Health Organization: Temporal relationships between ovulation and defined changes in the concentrations of plasma estradiol-178, luteinizing hormone, follicle-stimulating hormone and progesterone. Am J Obstet Gynecol138: 383,198O.
Addrem for
reprinta:
L. Fedele lo clinica ostetrico-GiIlecohgica Universith di Milan0 Via Commenda, 12 20122 - MILAN0 IMY