A premature luteinizing hormone surge without elevated progesterone levels has no adverse effect on cumulative live birth rate in patient undergoing a flexible GnRH antagonist protocol: a retrospective study.

BACKGROUND: A premature luteinizing hormone (LH) surge refers to an endogenous LH peak that occurs before follicle maturation or human chorionic gonadotropin injection in the process of controlled ovarian hyperstimulation. The effect of premature LH surge on pregnancy outcomes in fresh embryo transfer cycles is still controversial. The aim of this study was to explore the effect of a premature LH surge without elevated progesterone levels on the cumulative pregnancy rate (CPR) and cumulative live birth rate (CLBR) of patients during a flexible GnRH antagonist protocol. METHODS: A total of 730 infertile women undergoing IVF/ICSI were recruited for this retrospective study. Only women who either delivered a live infant or had no remaining frozen embryos after a single stimulation cycle were included in the analysis. During the study period, each patient underwent a flexible GnRH antagonist protocol. Women were divided into two groups according to the presence or absence of a premature LH surge. The primary outcome measures were the CPR and CLBR per ovarian stimulation cycle. The secondary outcome measures were the number of oocytes retrieved, fertilization rate, good-quality embryo rate, and clinical pregnancy rate. RESULTS: Ninety-one women (12.47%) experienced a premature LH surge without elevated progesterone levels, and the other 639 (87.53%) women were assigned to the control group. The numbers of oocytes retrieved and fertilization rate were significantly greater in the premature LH surge group than in the control group. There was no significant difference between groups in the good-quality embryo rate, clinical pregnancy rate or live birth rate in the fresh embryo transfer cycle. The primary outcome measures, the CPR and CLBR per ovarian stimulation cycle, were not significantly different between the premature LH surge group and the control group. According to the analysis stratified by ovarian response (normal or high), there were no significant differences in pregnancy outcomes between the groups with and without a premature LH surge. CONCLUSIONS: The retrospective study demonstrated that the patients experiencing a transient premature LH surge without progesterone elevation had equivalent pregnancy outcomes with those without a premature LH surge on a flexible GnRH antagonist protocol. The present conclusions need to be further validated in a prospective well-designed large-scale study.

Female fertility does not require Bmal1 in suprachiasmatic nucleus neurons expressing arginine vasopressin, vasoactive intestinal peptide, or neuromedin-S.

Disruptions to the circadian system alter reproductive capacity, particularly in females. Mice lacking the core circadian clock gene, Bmal1, are infertile and have evidence of neuroendocrine disruption including the absence of the preovulatory luteinizing hormone (LH) surge and enhanced responsiveness to exogenous kisspeptin. Here, we explore the role of Bmal1 in suprachiasmatic nucleus (SCN) neuron populations known to project to the neuroendocrine axis. We generated four mouse lines using Cre/Lox technology to create conditional deletion of Bmal1 in arginine vasopressin (Bmal1fl/fl:Avpcre ), vasoactive intestinal peptide (Bmal1fl/fl:Vipcre ), both (Bmal1fl/fl:Avpcre+Vipcre ), and neuromedin-s (Bmal1fl/fl:Nmscre ) neurons. We demonstrate that the loss of Bmal1 in these populations has substantial effects on home-cage circadian activity and temperature rhythms. Despite this, we found that female mice from these lines demonstrated normal estrus cycles, fecundity, kisspeptin responsiveness, and inducible LH surge. We found no evidence of reproductive disruption in constant darkness. Overall, our results indicate that while conditional Bmal1 knockout in AVP, VIP, or NMS neurons is sufficient to disrupted locomotor activity, this disruption is insufficient to recapitulate the neuroendocrine reproductive effects of the whole-body Bmal1 knockout.

Circadian Rhythms in the Neuronal Network Timing the Luteinizing Hormone Surge.

For billions of years before electric light was invented, life on Earth evolved under the pattern of light during the day and darkness during the night. Through evolution, nearly all organisms internalized the temporal rhythm of Earth's 24-hour rotation and evolved self-sustaining biological clocks with a ~24-hour rhythm. These internal rhythms are called circadian rhythms, and the molecular constituents that generate them are called molecular circadian clocks. Alignment of molecular clocks with the environmental light-dark rhythms optimizes physiology and behavior. This phenomenon is particularly true for reproductive function, in which seasonal breeders use day length information to time yearly changes in fertility. However, it is becoming increasingly clear that light-induced disruption of circadian rhythms can negatively impact fertility in nonseasonal breeders as well. In particular, the luteinizing hormone surge promoting ovulation is sensitive to circadian disruption. In this review, we will summarize our current understanding of the neuronal networks that underlie circadian rhythms and the luteinizing hormone surge.

Plasticity of Anterior Pituitary Gonadotrope Cells Facilitates the Pre-Ovulatory LH Surge.

Gonadotropes cells located in the anterior pituitary gland are critical for reproductive fitness. A rapid surge in the serum concentration of luteinizing hormone (LH) secreted by anterior pituitary gonadotropes is essential for stimulating ovulation and is thus required for a successful pregnancy. To meet the requirements to mount the LH surge, gonadotrope cells display plasticity at the cellular, molecular and morphological level. First, gonadotrope cells heighten their sensitivity to an increasing frequency of hypothalamic GnRH pulses by dynamically elevating the expression of the GnRH receptor (GnRHR). Following ligand binding, GnRH initiates highly organized intracellular signaling cascades that ultimately promote the synthesis of LH and the trafficking of LH vesicles to the cell periphery. Lastly, gonadotrope cells display morphological plasticity, where there is directed mobilization of cytoskeletal processes towards vascular elements to facilitate rapid LH secretion into peripheral circulation. This mini review discusses the functional and organizational plasticity in gonadotrope cells including changes in sensitivity to GnRH, composition of the GnRHR signaling platform within the plasma membrane, and changes in cellular morphology. Ultimately, multimodal plasticity changes elicited by gonadotropes are critical for the generation of the LH surge, which is required for ovulation.

The effect of a transient premature luteinizing hormone surge without elevated serum progesterone on in vitro fertilization outcomes in a gonadotropin-releasing hormone antagonist flexible protocol.

During controlled ovarian stimulation, the LH rising before triggering can lead to follicular luteinizations. However, LH can be suppressed immediately and no progesterone elevation with GnRH antagonist. This study retrospectively compared fresh IVF/ICSI cycle outcomes in antagonist protocols between the group with and the group without a premature LH surge. Logistic regression models were fitted to reduce the relevant confounders. Compared between premature LH surge group and control group, the implantation rates were 12.9% (30/233) vs 25.0% (141/536), p = .000; clinical pregnancy rates were 21.0% (25/119) vs 41.6% (119/286), p = .000; live birth rates were17.6% (21/119) vs 29.7% (85/286), p = .012. After adjusting for age, BMI, bFSH, and infertility factors, the adverse effects were still as pronounced for the clinical pregnancy rate (OR = 0.39, 95% CI = 0.24-0.66) and live birth rates (OR = 0.54, 95% CI = 0.32-0.93. In a GnRH antagonist flexible protocol, a transient premature LH surge which can be suppressed immediately after the initiation of antagonist without elevated serum progesterone, will cause a detrimental effect on the development of the embryo and IVF/ICSI pregnancy outcomes in fresh embryo transfer cycles.

Role of kisspeptin neurons as a GnRH surge generator: Comparative aspects in rodents and non-rodent mammals.

Ovulation is an essential phenomenon for reproduction in mammalian females along with follicular growth. It is well established that gonadal function is controlled by the neuroendocrine system called the hypothalamus-pituitary-gonadal (HPG) axis. Gonadotropin-releasing hormone (GnRH) neurons, localized in the hypothalamus, had been considered to be the head in governing the HPG axis for a long time until the discovery of kisspeptin. In females, induction of ovulation and folliculogenesis has been linked to a surge mode and pulse mode of GnRH releases, respectively. The mechanisms of how the two modes of GnRH are differently regulated had long remained elusive. The discovery of kisspeptin neurons, distributed in two hypothalamic nuclei, such as the arcuate nucleus in the caudal hypothalamus and preoptic area or the anteroventral periventricular nucleus in the rostral hypothalamic regions, and analyses of the detailed functions of kisspeptin neurons have led marked progress on the understanding of different mechanisms regulating GnRH surges (ovulation) and GnRH pulses (folliculogenesis). The present review will focus on the role of kisspeptin neurons as the GnRH surge generator, including the sexual differentiation of the surge generation system and factors that regulate the surge generator. Comparative aspects between mammalian species are especially focused on.

Different progestin-primed ovarian stimulation protocols in infertile women undergoing in vitro fertilization/intracytoplasmic sperm injection: an analysis of 1188 cycles.

PURPOSE: To evaluate the efficacy in suppressing the premature LH surge, embryo quality and pregnancy outcomes of progestin-primed ovarian stimulation (PPOS) protocols using medroxyprogesterone acetate versus utrogestan in women of all ages undergoing in vitro fertilization or intracytoplasmic sperm injection. METHODS: 1188 patients were enrolled in the retrospective study, of which 1002 patients were treated with medroxyprogesterone acetate (M group) and recombinant follicle-stimulating hormone (r-FSH)simultaneously from day 3 of the cycle until trigger day, while 186 patients were treated with utrogestan (U group) and r-FSH instead. Viable embryos were cryopreserved for later transfer in both groups. Differences in baseline characteristics, ovarian stimulation characteristics, endocrinological characteristics, embryo development and clinical outcome between two groups were assessed. Statistical analyses were performed stratified by age and number of oocytes retrieved. RESULTS: No significant differences were observed in the baseline characteristics, ovarian stimulation characteristics and clinical outcome of patients between groups. However, blastulation rate in the U group was significantly higher than that in the M group (49.4% vs. 32.9%, P < 0.001). During ovarian stimulation, LH levels remained steady in both groups. Higher percentage of premature LH surge was found in the U group (2.4% vs. 10.2%, P < 0.001), especially for patients aged more than 35 years or who had three oocytes or less retrieved. CONCLUSIONS: Both the administration of medroxyprogesterone acetate and utrogestan in PPOS were sufficient to prevent an untimely LH rise, while for patients with poor ovarian response or aged above 35 years, MPA may result in a more satisfactory LH level. PPOS protocol using medroxyprogesterone acetate or utrogestan was comparable in terms of oocytes and pregnancy outcome, whereas the administration of utrogestan may result in an improved blastulation than medroxyprogesterone acetate, which needs further exploration.

Progestin-primed ovarian stimulation is a feasible method for poor ovarian responders undergoing in IVF/ICSI compared to a GnRH antagonist protocol: A retrospective study.

BACKGROUND: Poor ovarian response (POR) to ovarian hyperstimulation is one of the biggest challenges in assisted reproduction technology. The objective of this study was to compare the efficacy of progestin-primed ovarian stimulation (PPOS) with a GnRH antagonist (GnRH-ant) in poor ovarian response (POR) patients. MATERIALS AND METHODS: This retrospective analysis included a total of 186 cycles of POR patients between 2014 and 2016. The patients were divided into two groups according to the method of stimulation protocol, as follows: 63 cycles were PPOS, and 123 cycles were GnRH-ant. Reproduction-related clinical outcomes in the two groups were compared. RESULTS: There were no significant differences in patients' age, dose and duration of gonadotropin (Gn) treatment, serum luteinizing hormone (LH) and E2 levels on the day of hCG injection, or the number of oocytes retrieved between the two groups. The MII oocyte rates, fertilization rates, good-quality embryo rates were significantly higher in the PPOS group than they were in the antagonist group (p<0.05). In the subsequent frozen-thawed embryo transfer (FET), clinical pregnancy and live birth rates were significantly higher in the PPOS group than they were in the antagonist group (p<0.05). CONCLUSIONS: Compared with the GnRH-ant protocol, the PPOS protocol may be a better regime for POR that can effectively improve clinical pregnancy and live birth rates.

Intravaginal instillation of gonadotropin-releasing hormone analogues with an absorption enhancer induced a surge of luteinizing hormone in lactating dairy cows.

Our objectives were to evaluate circulating LH concentrations after intravaginal (IVG) instillation of GnRH analogs in lactating dairy cows. In 2 experiments, lactating Holstein cows (experiment 1: n = 32; experiment 2: n = 47) received the experimental treatments 48 h after the first of 2 PGF2α treatments given 12 h apart and 7 d after a modified Ovsynch protocol (GnRH at -7 d, PGF2α at -24 h, PGF2α at -56 h, GnRH at 0 h). In experiment 1, cows were stratified by parity and randomly allocated to receive the following treatments: 2 mL of saline IVG (SAL, n = 6), 100 µg of gonadorelin (Gon) i.m. (G100-IM, n = 5), and 100 (G100, n = 7), 500 (G500, n = 8), or 1,000 µg of Gon IVG (G1000, n = 7). In experiment 2, treatments were SAL (n = 8), G100-IM (n = 8), G1000 (n = 7), 1,000 µg of Gon plus 10% citric acid (CA) IVG (G1000CA, n = 8), 80 µg of buserelin IVG (B80, n = 8), and 80 µg of buserelin plus 10% CA IVG (B80CA, n = 8). In both experiments, blood was collected every 15 min from -15 min to 4 h, and every 30 min from 4 to 6 h after treatment. Data for area under the curve (AUC), mean LH concentrations, and time to maximum LH concentration were analyzed by ANOVA with (mean LH only) or without repeated measures using PROC MIXED of SAS (version 9.4, SAS Institute Inc., Cary, NC). The proportion of cows with a surge of LH was evaluated with Fisher's exact test using PROC FREQ of SAS. In both experiments, LH concentrations were affected by treatment, time, and the treatment by time interaction. In experiment 1, the AUC for LH and maximum LH concentration were greatest for the G100-IM treatment and were greater for the G1000 than for the SAL and G500 treatments. The proportion of cows with an observed surge of LH was 100 and 0% for cows that received Gon i.m. and IVG, respectively. In experiment 2, the AUC and maximum LH concentrations were greater for the G100-IM, G1000CA, and B80CA treatments than for the other IVG treatments. The proportion of cows with a surge of LH differed by treatment (SAL = 0%, G100-IM = 100%, G1000 = 14%, G1000CA = 88%, B80 = 13%, and B80CA = 100%). For the treatments with a surge of LH, time to maximum concentration of LH was the shortest for the G100-IM treatment, intermediate for the G1000CA treatment, and the longest for cows in the B80CA treatment. In conclusion, Gon (up to 1,000 µg) absorption through intact vaginal epithelium after a single IVG instillation was insufficient to elicit a surge of LH of normal magnitude. Conversely, IVG instillation of 1,000 µg of Gon and 80 µg of buserelin with the addition of citric acid as absorption enhancer resulted in a surge of LH of similar characteristics than that induced after i.m. injection of 100 µg of Gon.

Estradiol Upregulates Kisspeptin Expression in the Preoptic Area of both the Male and Female Rhesus Monkey (Macaca mulatta): Implications for the Hypothalamic Control of Ovulation in Highly Evolved Primates.

The aim of this immunohistochemical study was to evaluate the distribution of kisspeptin neurons in the preoptic area (POA) of gonadally intact adult male and female rhesus monkeys, and to determine whether imposition of an estradiol (E2)-positive feedback signal in the castrate male increased kisspeptin in the POA. Additionally, kisspeptin in the POA of the intact female was examined during an LH surge induced prematurely by E2 administered in the early follicular phase. The number of kisspeptin neurons in the POA of males and females was similar. Immunoactive kisspeptin perikarya were not observed in the POA of castrate adult males, but such neurons in these animals were present within 12 h of imposing an increment in circulating E2 concentrations that in a screening study conducted 4-6 weeks earlier had elicited an LH surge. As expected, premature induction of an LH surge by E2 early in the follicular phase was associated with upregulation of kisspeptin in the POA. These results represent the first description of immunoreactive kisspeptin cell bodies in the POA of the macaque brain and provide further support for the view that (1) kisspeptin neurons in the POA of the female monkey are a target for the positive feedback action of E2 and (2) the hypothalamic mechanism which mediates this action of E2 in primates is not subjected to perinatal programming by testicular testosterone. Moreover, our findings indicate that maintenance of the kisspeptin content in the POA of intact male monkeys requires the action of E2, presumably generated by aromatization of testicular testosterone at the hypothalamic level.

Progesterone has rapid positive feedback actions on LH release but fails to reduce LH pulse frequency within 12 h in estradiol-pretreated women.

In women, progesterone suppresses luteinizing hormone (LH) (gonadotropin-releasing hormone) pulse frequency, but how rapidly this occurs is unknown. In estradiol-pretreated women in the late follicular phase, progesterone administration at 1800 did not slow sleep-associated LH pulse frequency. However, mechanisms controlling LH pulse frequency may differ according to sleep status; and we thus hypothesized that progesterone acutely suppresses waking LH pulse frequency. This was a randomized, double-blind, crossover study of LH secretory responses to progesterone versus placebo administered at 0600. We studied 12 normal women in the late follicular phase (cycle days 7-11), pretreated with 3 days of transdermal estradiol (0.2 mg/day). Subjects underwent a 24-h blood sampling protocol (starting at 2000) and received either 100 mg oral micronized progesterone or placebo at 0600. In a subsequent menstrual cycle, subjects underwent an identical protocol except that oral progesterone was exchanged for placebo or vice versa. Changes in 10-h LH pulse frequency were similar between progesterone and placebo. However, mean LH, LH pulse amplitude, and mean follicle-stimulating hormone exhibited significantly greater increases with progesterone. Compared to our previous study (progesterone administered at 1800), progesterone administration at 0600 was associated with a similar increase in mean LH, but a less pronounced increase in LH pulse amplitude. We conclude that, in estradiol-pretreated women in the late follicular phase, a single dose of progesterone does not suppress waking LH pulse frequency within 12 h, but it acutely amplifies mean LH and LH pulse amplitude - an effect that may be influenced by sleep status and/or time of day.

Hindbrain lactate regulates preoptic gonadotropin-releasing hormone (GnRH) neuron GnRH-I protein but not AMPK responses to hypoglycemia in the steroid-primed ovariectomized female rat.

Steroid positive-feedback activation of the gonadotropin-releasing hormone (GnRH)-pituitary luteinizing hormone (LH) neuroendocrine axis propagates the pre ovulatory LH surge, a crucial component of female reproduction. Our work shows that this key event is restrained by inhibitory metabolic input from hindbrain A2 noradrenergic neurons. GnRH neurons express the ultra-sensitive energy sensor adenosine 5'-monophosphate-activated protein kinase (AMPK); here, we investigated the hypothesis that GnRH nerve cell AMPK and peptide neurotransmitter responses to insulin-induced hypoglycemia are controlled by hindbrain lack of the oxidizable glycolytic end-product L-lactate. Data show that hypoglycemic inhibition of LH release in steroid-primed ovariectomized female rats was reversed by coincident caudal hindbrain lactate infusion. Western blot analyses of laser-microdissected A2 neurons demonstrate hypoglycemic augmentation [Fos, estrogen receptor-beta (ER-ß), phosphoAMPK (pAMPK)] and inhibition (dopamine-beta-hydroxylase, GLUT3, MCT2) of protein expression in these cells, responses that were normalized by insulin plus lactate treatment. Hypoglycemia diminished rostral preoptic GnRH nerve cell GnRH-I protein and pAMPK content; the former, but not the latter response was reversed by lactate. Results implicate caudal hindbrain lactoprivic signaling in hypoglycemia-induced suppression of the LH surge, demonstrating that lactate repletion of that site reverses decrements in A2 catecholamine biosynthetic enzyme and GnRH neuropeptide precursor protein expression. Lack of effect of lactate on hypoglycemic patterns of GnRH AMPK activity suggests that this sensor is uninvolved in metabolic-inhibition of positive-feedback-stimulated hypophysiotropic signaling to pituitary gonadotropes.

Effects of unilaterally microinjecting ethanol in the preoptic-anterior hypothalamic areas of rats on ovulation.

BACKGROUND: Intragastric or intraperitoneal ethanol (EtOH) treatment inhibits reproductive functions in females and male rats. The area of the hypothalamus where these effects take place is unknown. As the participations of the preoptic-anterior hypothalamic area (POA-AHA) in regulating ovulation is asymmetric, this study aims to analyze the effects on 17ß-estradiol(E2 ), progesterone, luteinizing hormone (LH), follicle-stimulating hormone (FSH) serum levels, the messenger ribonucleic acid (mRNA) expression of estrogen receptor alpha (ERα) and beta (ERß), and ovulation resulting from unilaterally microinjecting water or an EtOH solution into either side of the POA-AHA. METHODS: The treatment consisted of microinjecting a 8.6 µM EtOH solution into either side of the POA-AHA. The study was performed on groups of adult cyclic rats at 09.00 hours on diestrus-1, and sacrificed on diestrus-2 at 13.00, on proestrus at 09.00 or 17.00 or on estrus at 09.00 hours. Ovulation rates were assessed in rats sacrificed on estrus. Hormonal serum levels were measured using radioimmunoassay, and as a function of ERα and ERß mRNA expression in each side of the POA-AHA by reverse transcriptase polymerase chain reaction. RESULTS: EtOH treatment blocked ovulation and the preovulatory release of LH, and lowered E2 levels. Irrespective of the treated POA-AHA side, ERα mRNA expression was consistently lower in the left POA-AHA and higher on the right. EtOH treatment in the left POA-AHA decreased FSH serum levels and lowered ERß mRNA expression. In turn, EtOH treatment on the right POA-AHA resulted in higher FSH levels and ERß mRNA expression. CONCLUSIONS: The present results show that EtOH blocks the preovulatory surge of LH on the POA-AHA. The effects of EtOH treatment of preovulatory FSH surge on the POA-AHA are asymmetric (stimulative on the right and inhibiting in the left). The effects of EtOH treatment on preovulatory LH and FSH surge could be explained by the inhibition of ERα and ERß mRNA expression, respectively.

The naturally occurring luteinizing hormone surge is diminished in mice lacking estrogen receptor Beta in the ovary.

Female ESR2-null mice (betaERKO) display defects in ovarian function and are subfertile. Follicular maturation is impaired and explains smaller litters, but betaERKO also produce fewer litters, which may be partially due to inadequate ovulatory signals. To test this, the amplitude and timing of the naturally occurring luteinizing hormone (LH) surge was measured in individual intact betaERKO and wild-type (WT) mice. Vaginal cytology was evaluated daily, and blood samples were taken from mice in proestrus. The amplitude of the LH surge was severely blunted in betaERKO mice compared to WT, but pituitary LH levels revealed no differences. The betaERKO mice did not produce a preovulatory estradiol surge. To determine if the smaller LH surges and the reduced number of litters in betaERKO were due to the lack of ESR2 in the hypothalamic-pituitary axis or due to the absence of ESR2 in the ovary, ovaries were transplanted from WT into betaERKO mice and vice versa. The size of the LH surge was reduced only in mice lacking ESR2 within the ovary, and these mice had fewer litters. Fertility and size of the LH surge were rescued in betaERKO mice receiving a WT ovary. These data provide the first experimental evidence that the LH surge is impaired in betaERKO females and may contribute to their reduced fertility. ESR2 is not necessary within the pituitary and hypothalamus for the generation of a normal LH surge and for normal fertility, but ESR2 is essential within the ovary to provide proper signals.