Frozen embryo transfer and preeclampsia: where is the link?

PURPOSE OF REVIEW: Preeclampsia is the leading cause of maternal death and has a higher incidence in patients undergoing assisted reproduction treatments. New studies about the mechanisms by which it is more frequent in this population have emerged. The purpose of this review is to gather current information about the available results on this correlation and its possible physiopathology. RECENT FINDINGS: Recent publications on the physiopathology of preeclampsia indicate that the corpus luteum is the main source of hormonal production until placental formation and that apart from the secretion of estrogen and progesterone, corpus luteum also produces important substances involved in maternal circulatory adaptation, such as relaxin.With the recent increasing number of frozen embryos transfer in natural cycles or under hormonal replacement, this adaptive circulatory process may be unbalanced and predispose this population to preeclampsia. SUMMARY: This article provides a review of frozen embryo transfer and available protocols, the highest incidence of gestational hypertensive disorders presented by the infertile population and an overview of the possible impact of the absence of corpus luteum on the genesis of this disease.

What is the optimal means of preparing the endometrium in frozen-thawed embryo transfer cycles? A systematic review and meta-analysis.

BACKGROUND Frozen-thawed embryo transfer (FET) enables surplus embryos derived from IVF or IVF-ICSI treatment to be stored and transferred at a later date. In recent years the number of FET cycles performed has increased due to transferring fewer embryos per transfer and improved laboratory techniques. Currently, there is little consensus on the most effective method of endometrium preparation prior to FET. METHODS Using both MEDLINE and EMBASE database a systematic review and meta-analysis of literature was performed. Case-series, case-control studies and articles in languages other than English, Dutch or Spanish were excluded. Those studies comparing clinical and ongoing pregnancy rates as well as live birth rates in (i) true natural cycle FET (NC-FET) versus modified NC-FET, (ii) NC-FET versus artificial cycle FET (AC-FET), (iii) AC-FET versus artificial with GnRH agonist cycle FET and (iv) NC-FET versus artificial with GnRH agonist cycle FET were included. Forest plots were constructed and relative risks or odds ratios were calculated. RESULTS A total of 43 publications were selected for critical appraisal and 20 articles were included in the final review. For all comparisons, no differences in the clinical pregnancy rate, ongoing pregnancy rate or live birth rate could be found. Based on information provided in the articles no conclusions could be drawn with regard to cancellation rates. CONCLUSIONS Based on the current literature it is not possible to identify one method of endometrium preparation in FET as being more effective than another. Therefore, all of the current methods of endometrial preparation appear to be equally successful in terms of ongoing pregnancy rate. However, in some comparisons predominantly retrospective studies were included leaving these comparisons subject to selection and publication bias. Also patients' preferences as well as cost-efficiency were not addressed in any of the included studies. Therefore, prospective randomized studies addressing these issues are needed.

Potencial envolvimento da adiponectina e seus receptores na modulação da esteroidogênese em corpo lúteo de cadelas ao longo do diestro / Potential involvement of adinopectin and its receptors in the modulation of steroidogenesis in corpus luteum of bitches during diestrus

No ciclo estral de cadelas a fase luteínica, denominada diestro, compreende um período que varia de 60 a 100 dias em animais não-prenhes, caracterizado pela elevação plasmática de progesterona nos primeiros 20 dias pós ovulação (p.o). A adiponectina é a mais abundante proteína secretada pelo tecido adiposo, porém sua concentração plasmática diminui significativamente em alterações metabólicas como resistência insulínica e Diabetes mellitus tipo2, alterações descritas como relacionadas em algumas cadelas com o período de diestro. O objetivo do estudo foi determinar a expressão e imunolocalização do sistema adiponectina (adiponectina e seus receptores, adipoR1 e adipoR2) no corpo lúteo de cadelas ao longo do diestro, correlacionando-o ao perfil hormonal de 17β-estradiol e progesterona, assim como à expressão de um dos genes alvo do sistema, o PPAR-γ. Para realização do estudo foram coletados corpos lúteos de 28 cadelas durante ovariosalpingohisterectomia de eleição nos dias 10, 20, 30, 40, 50, 60 e 70 pós ovulação (o dia zero da ovulação foi considerado aquele no qual a concentração plasmática de progesterona atingiu 5ng/mL). Os corpos lúteos foram avaliados por imunohistoquímica para adiponectina e seus receptores e a expressão do RNAm do PPAR-γ por PCR em tempo real. A análise estatística da avaliação gênica foi realizada com o teste ANOVA, seguido por comparação múltipla Newman-Keuls. O sinal da adiponectina apresentou-se mais intenso até os primeiros 20 dias p.o, momento de regência da progesterona; houve queda gradativa após este período, coincidindo com a ascensão do 17β-estradiol, cujo pico foi notado próximo do dia 40 p.o. A queda marcante da adiponectina ocorreu após 50 dias p.o. O sinal do adipoR1 mostrou-se bem evidente até os 40 dias p.o e o do adipoR2 até os 50 dias p. o, decaindo posteriormente. Foi observada maior expressão do gene PPAR-γ aos 10, 30 e 70 dias p.o. Estes resultados mostram que a expressão protéica da adiponectina e de seus receptores se altera ao longo do diestro e que estas alterações podem estar relacionados às alterações hormonais e expressão do PPAR- γ, participando do mecanismo fisiológico de desenvolvimento, manutenção, atividade e regressão luteínica em cadelas.

In the estrous cycle of bitches, the luteal phase or diestrus includes a period ranging from 60 to 100 days in non-pregnant animals, characterized by elevated serum progesterone during the first 20 days post-ovulation (p.o). Adiponectin is the most abundant protein secreted by adipose tissue, but plasma concentration decreases significantly in metabolic disorders like insulin resistance and diabetes mellitus type 2, described as related changes in some bitches in diestrus. The aim of this study was to determine the expression and immunolocalization of the adiponectin system (adiponectin, and adipoR1 adipoR2) in the corpus luteum during diestrus, and correlate it to hormonal profile of 17β-estradiol and progesterone, as well as the expression of a gene target of the system, the PPAR-γ. For the study, corpora lutea were collected from 28 dogs during ovariosalpingohysterectomy on days 10, 20, 30, 40, 50, 60 and 70 post ovulation (day zero of ovulation was considered the day when the plasma progesterone concentration reached 5ng/mL). The corpora lutea were evaluated by immunohistochemistry for adiponectin, adipoR1 and adipoR2 and mRNA expression of PPAR-γ by real-time PCR. Statistical analysis of gene expression was performed with ANOVA followed by Newman-Keuls multiple comparisons. Adiponectin positive signal was stronger during the first 20 days p.o, time of the regency of progesterone; there was a gradual adiponectin and progesterone decline after this period, coinciding with the rise of 17β-estradiol, whose peak was near the 40 days p.o. The markedly adiponectin decrease occurred after 50 days p.o. The signal of adipoR1 was markedly evident at 40 days p.o and that of adipoR2 up to 50 days p.o, declining afterwards. We observed higher expression of PPAR-γ gene at 10, 30 and 70 days p.o. These results show that adiponectin and its receptors protein expression is altered during the diestrus and that these changes may be related to hormonal changes and expression of PPAR-γ, participating in the physiological mechanism of development, maintenance, activity and luteal regression in bitches.

Judge, jury and executioner: the auto-regulation of luteal function.

Experiments were conducted to further our understanding of the cellular and molecular mechanisms that regulate luteal function in ewes. Inhibition of protein kinase A (PKA) reduced (P < 0.05) secretion of progesterone from both small and large steroidogenic luteal cells. In addition, the relative phosphorylation state of steriodogenic acute regulatory protein (StAR) was more than twice as high (P < 0.05) in large vs small luteal cells. Large steroidogenic luteal cells appear to contain constitutively active PKA and increased concentrations of phosphorylated StAR which play a role in the increased basal rate of secretion of progesterone. To determine if intraluteal secretion of prostaglandin (PG) F2alpha was required for luteolysis, ewes on day 10 of the estrous cycle received intraluteal implants of a biodegradable polymer containing 0, 1 or 10 mg of indomethacin, to prevent intraluteal synthesis of PGF2alpha. On day 18, luteal weights in ewes receiving 1 mg of indomethacin were greater (P < 0.05) than controls and those receiving 10 mg were greater (P < 0.05) than either of the other two groups. Concentrations of progesterone in serum were also increased (P < 0.05) from days 13 to 16 of the estrous cycle in ewes receiving 10 mg of indomethacin. Although not required for decreased production of progesterone at the end of the cycle, intraluteal secretion of PGF2alpha appears to be required for normal luteolysis. To ascertain if oxytocin mediates the indirect effects of PGF2alpha on small luteal cells, the effects of 0, 0.1, 1 or 10 mM oxytocin on intracellular concentrations of calcium were quantified. There was a dose-dependent increase (P < 0.05) in the number of small luteal cells responding to oxytocin. Thus, oxytocin induces increased calcium levels and perhaps apoptotic cell death in small luteal cells. Concentrations of progesterone, similar to those present in corpora lutea (approximately 30 microg/g), prevented the increased intracellular concentrations of calcium (P < 0.05) stimulated by oxytocin in small cells. In large luteal cells the response to progesterone was variable. There was no consistent effect of high quantities of estradiol, testosterone or cortisol in either cell type. It was concluded that normal luteal concentrations of progesterone prevent the oxytocin and perhaps the PGF2alpha-induced increase in the number of small and large luteal cells which respond to these hormones with increased intracellular concentrations of calcium. In summary, large ovine luteal cells produce high basal levels of progesterone, at least in part, due to a constituitively active form of PKA and an enhanced phosphorylation state of StAR. During luteolysis PGF2alpha of uterine origin reduces the secretion of progesterone from the corpus luteum, but intraluteal production of PGF2alpha is required for normal luteolysis. Binding of PGF2alpha to receptors on large luteal cells stimulates the secretion of oxytocin which appears to activate PKC and may also inhibit steroidogenesis in small luteal cells. PGF2alpha also activates COX-2 in large luteal cells which leads to secretion of PGF2alpha. Once intraluteal concentrations of progesterone have decreased, oxytocin binding to its receptors on small luteal cells also results in increased levels of intracellular calcium and presumably apoptosis. Increased secretion of PGF2alpha from large luteal cells activates calcium channels which likely results in apoptotic death of this cell type.

The role of luteal steroid hormones in the regulation of the estrous cycle of high fecundity Olkuska sheep.

The study was undertaken to investigate the steroid hormone production by sheep luteal cells. Corpora lutea were collected from 30 Olkuska sheep on Days 3, 6, 9, 12 and 15 of the estrous cycle during the reproductive season. In Experiment 1, steroid hormone concentration was estimated in extracts of CL. In Experiment 2, luteal cells were cultured in vitro for 24 h. Luteal cells isolated on Days 9 and 12 secreted high amounts of progesterone and androgens but smaller amounts of estradiol. Concentration of these steroids in CL extracts collected on the same days showed the same trend. In CL harvested on Day 15, a decrease in androgens and progesterone as well as a significant increase in estradiol were observed in culture media and in extracts. Judging from the high amounts of estradiol and low amounts of androgen observed at the end of the luteal phase, we speculate that the steroid hormones secreted by the regressing CL may play an active role in the regulation of the estrous cycle in the Olkuska sheep with autocrine influence on the luteal activity or a possible paracrine action on follicular growth. In the third Experiment, the possibility of heterogeneity in the multiple corpora lutea population of prolific Olkuska sheep was investigated. Differences were found in the level of progesterone and estradiol secretion by individual corpora lutea recovered from the same animal, which also varied in terms of weight. This is the first study which shows the existence of intra-ovarian and individual heterogeneity between corpora lutea recovered from ewes during the normal estrous cycle.

Primiparous rhesus monkey mothers are more sensitive to the nursing-induced inhibition of LH and ovarian steroid secretion.

The duration of lactational infertility is prolonged significantly in adolescent, primiparous rhesus monkey (Macaca mulatta) mothers compared with adult, multiparous mothers. The present study examined the hypothesis that this parity/age difference in lactational infertility is due to a difference in the physiological responsiveness to nursing behaviour between adolescent and fully adult mothers and is not a consequence of differences in nursing behaviour, per se. At 22 weeks postpartum, mother-infant pairs were randomly assigned to one of four conditions: primiparous, nursing restricted (PR; n = 9); primiparous, nursing unrestricted (PU; n = 11); multiparous, nursing restricted (MR; n = 12); and multiparous, nursing unrestricted (MU; n = 8). Nursing was restricted for a 2-week period by mothers wearing a primate vest which prevented suckling behaviour but allowed infants to interact with their mothers. Nursing restriction resulted in a significant increase in serum oestradiol concentrations in both PR and MR mothers. Although nursing bout frequencies and durations were similar between PU and MU mothers, serum oestradiol also rose in MU mothers but remained suppressed in PU mothers. Once the nursing manipulation period ended and all mothers were allowed to nurse ad libitum, serum oestradiol concentrations continued to rise in all but the PU mothers. This brief interruption of nursing at 22 weeks postpartum advanced the subsequent timing of the first postpartum ovulation in MR and PR mothers relative to that of PU mothers. Again, despite similarities in nursing behaviour, the occurrence of first ovulation was also advanced in MU mothers compared with PU mothers. Just prior to the first postpartum ovulation, females were randomly assigned to one of four treatment groups to determine the effects of nursing behaviour on the hormonal parameters of the luteal phase: primiparous, nursing restricted (PRL; n = 9); primiparous, nursing unrestricted (PUL; n = 11); multiparous, nursing restricted (MRL; n = 10); and multiparous, nursing unrestricted (MUL; n = 10). Nursing restriction significantly elevated serum progesterone concentrations in PRL females compared with other mothers. Serum concentrations of oestradiol were higher in PRL, MRL and MUL mothers relative to PUL females. Again, this difference in oestradiol between PUL and MUL mothers occurred despite similarities in nursing behaviour. These data suggest that parity/age differences in the period of lactational infertility are not due to differences in nursing behaviour but rather to an increased sensitivity to the inhibitory aspects of the suckling stimulus in adolescent primiparous mothers.(ABSTRACT TRUNCATED AT 400 WORDS)

[New aspects concerning the corpus luteum]. / Nuovi aspetti riguardanti il corpo luteo.

We have summed up current knowledge about the formation and lysis of corpus luteum with the co-ordinate intervention of luteotrophic and luteolytic factors. Then we re-examined the function of the corpus luteum in the physiologic menstrual cycle and in the first period of pregnancy, with special attention to luteal insufficiency as a cause of endocrine miscarriage.

The interaction of testosterone and gonadotropins in stimulating estradiol and progesterone secretion by cultures of corpus luteum cells isolated from pigs in early and midluteal phase.

The first objective of this research was to define the capacity of corpora lutea of pig to secrete estradiol in the presence of an androgen substrate which was testosterone. The second objective was to define the synergism between gonadotropic hormones such as LH, FSH, and PRL and testosterone as measured by estradiol and progesterone secretion by two types of porcine luteal cells. Luteal cells were collected from newly forming corpora lutea (0-3 days after ovulation) and from mature corpora lutea (8-10 days after ovulation). After dispersion, luteal cells were suspended in medium M199 supplemented with 10% of calf serum and grown as monolayers at 37 degrees C. Control cultures were grown in medium alone while other cultures were supplemented with either testosterone alone at a concentration of 1 x 10(-7) M or with 10, 100, 500 ng LH plus testosterone, 10, 100, 500 ng FSH plus testosterone or 10, 100, 500 ng PRL plus testosterone. After 2 days of cultivation all cultures were terminated and media were frozen at 20 degrees C for further steroid analysis. Testosterone added to the culture medium in the absence of gonadotropins was without effect on estradiol and progesterone secretion by luteal cells collected in the corpora lutea of the early luteal phase. On the other hand testosterone added to the medium significantly increased progesterone and estradiol secretion by cultured luteal cells collected in the midluteal phase of the cycle. No additive stimulatory action of gonadotropins and testosterone on progesterone secretion was observed in cultures of luteal cells from the early luteal phase but this was not the case in cultures of luteal cells from the midluteal phase.(ABSTRACT TRUNCATED AT 250 WORDS)

Luteal peptides and intercellular communication.

The variety of peptides synthesized by the corpus luteum (relaxin, vasopressin, oxytocin and oxytocin-related neurophysin) and their possible intracellular effects are reviewed. After luteinization of the granulosa cells and in response to LH and FSH, the output of oxytocin is increased. In addition, insulin-like growth factor is a very potent stimulus of oxytocin secretion. Although luteal cells respond to gonadotrophins by increased production of progesterone, there is no further secretion of oxytocin. Oxytocin is localized in large luteal cells which seem not to be under the direct control of gonadotrophins. Synthesis of luteal oxytocin seems to occur during the early luteal phase according to measurements of oxytocin mRNA. Highest tissue concentrations and secretion under in-vitro conditions were observed during the mid-luteal phase, and so synthesis, storage and secretion are unlikely to occur concomitantly. Under in-vitro conditions, oxytocin is secreted concomitantly with neurophysin and progesterone, and there appears to be some form of communication between small and large luteal cells for the secretion of progesterone and oxytocin under in-vivo conditions. Evidence has been obtained that oxytocin may have local effects in the ovary by inhibition of secretion (synthesis ?) of progesterone, especially during the early luteal phase. A mechanism can be suggested whereby, under physiological conditions, oxytocin may delay the increase of progesterone by inhibition of progesterone secretion and therefore delay down regulation of its own receptor. This would prolong the life-span of the CL and the oestrous cycle. Exogenous progesterone given on Days 1-4 shortens the cycle to about 12 days. The best evidence that oxytocin may be involved in controlling luteolysis comes from immunization experiments in ewes and goats, but there is no clear evidence of this type for cattle. Basal concentrations of oxytocin at the end of the luteal phase may interact with oxytocin receptors after the inhibitory effect of progesterone in the uterus is reduced, thus initiating synthesis of PGF-2 alpha.

Gestational changes in steroid hormone biosynthesis, secretion, metabolism, and action.

This article examines the regulatory mechanisms and anatomic interrelationships governing pregnancy-related steroid hormones from conception through parturition.

The pattern of luteal phase plasma progesterone and estradiol in fertile cycles.

Serum levels of progesterone and estradiol at early, middle, and late luteal phases were compared in nonfertile cycles in which only ovulation occurred to those in cycles in which ovulation was verified by conception. Two groups of patients were studied: 33 normal ovulatory women (12 of whom conceived) and 28 women who underwent induction of ovulation (8 of whom conceived). In each group, mean midluteal levels of progesterone and estradiol were essentially similar in nonfertile and fertile cycles. In fertile cycles, the late luteal levels of both steroids were higher than their respective midluteal values, whereas the late luteal values dropped in the nonfertile cycles. The late luteal rise in estradiol was found to be a more sensitive indicator of pregnancy than that of progesterone. The progesterone/estradiol ratio was stable during the luteal phase of fertile and nonfertile cycles. The ratio in spontaneous cycles was 34.4 +/- 4.7 and only 17.9 +/- 4.3 in induced cycles. This marked decrease suggests an impairment of steroid metabolism in women who require induction of ovulation.

[Radio-immunological testing of progesterone for diagnosis of corpus luteum insufficiency (author's transl)]. / Zur Diagnostik der Corpus-luteum-Insuffizienz durch radioimmunologische Untersuchung des Progesterons.

Radio-immunological assay was used to determine progesterone concentrations in serum during the luteal phase in 34 patients with treated and untreated corpus luteum insufficiency. Twenty patients with normal menstruation cycles were used as controls. Progesterone levels were found to be in agreement with the histological pattern of the endometrium. Progesterone values obtained from serial radio-immunological assay thus are high-accuracy criteria for diagnosis and therapeutic monitoring of corpus luteum insufficiency.

[Detection of corpus luteum insufficiency by histological study of the endometrium]. / Adatok a corpus luteum inszufficiencia felismeréséhez az endometrium hisztológiai vizsgálata kapcsán.

Characteristic morphologic alterations of endometrium following corpus luteum insufficiency are described. It is emphasized that in the majority of cases insufficiency of corpus luteum--which in 22 per cent of cases lies on the basis of functional sterility--brings about decreased output of progesterone in the luteal phase of the cycle and induces "disturbed secretion" i. e. hypoluteal transformation of endometrium. Another variant may also take place: normal function of the corpus luteum may last over a too short period inducing the shortening of the secretory phase and the early breakdown of the endometrium. Both, above mentioned mechanisms may inhibit the implantation of the fertilized ovum and lead to functional sterility.

[Ultramicroscopic studies on the drainage system of the human corpus luteum]. / Ultramikroskopische Untersuchungen über das Drainagesystem des menschlichen Corpus luteum

The granulosa lutein cells of the human corpus luteum have a specialized system of drainage with a particularly formed extracellular space, by which the steroids pass into the capillary vessels. The extracellular space consists of two partial systems: First one finds, similar to the bile capillaries of the liver, lacune-like widnings of the intercellular space, where numerous microvilli of the lining cells are to be found and which are lined by desmosomes and invaginations of the cell membrane. Second there exist relatively wide canals limited by a granular membrane forming a network of their own among the lutein cells. Both systems contact without direct communication. We believe that first the steroids pass into the intracellular lacunes by diffusion or active transport from where they reach the membrane-lined canals by help of the network they pass on to the pericapillar space from where they diffuse into the blood vessels.