Endogenous Progesterone Production Research Articles

Comparison between Agonist Trigger with HCG Luteal Phase Supplementation vs HCG Trigger with Progesterone Luteal Phase Supplementation in Antagonist Controlled Hyperstimulation Cycle Regarding Clinical Pregnancy Rate

For the last two decades, exogenous progesterone administration has been used as luteal phase support (LPS) in connection with controlled ovarian stimulation combined with use of the human chorionic gonadotropin (hCG) trigger for the final maturation of follicles. The introduction of the GnRHa trigger to induce ovulation showed that exogenous progesterone administration without hCG supplementation was insufficient to obtain satisfactory pregnancy rates. This has prompted development of alternative strategies for LPS. Augmenting the local endogenous production of progesterone by the multiple corpora lutea has been one focus with emphasis on one hand to avoid development of ovarian hyper-stimulation syndrome and, on the other hand, to provide adequate levels of progesterone to sustain implantation. The present study evaluates the use of micro-dose hCG for LPS support and examines the comparison between conventional HCG trigger and progesterone luteal phase support vs Agnosit trigger and HCG microsdose luteal phase support as regards to pregnancy rate. Methods 100 patients were recruited for this trial Cases with Polycyctic ovaries were excluded from the study. The study was approved by Ethical committee of Ain Shams university. Patients received Gonal-F (Merck Serono S.p.A., Via delle Magnolie 15, I70026 Modugno (Bari), Italy.) in a dose ranginging between 150-300 IU for stimulation and the dose was adjusted according to response starting day 6. Premature LH surge was prevented with 0.25 mg of a GnRH antagonist (Cetrotide; Merck international) starting on day 6, when two or more follicles reach a size of 18–20 mm, patients were randamized into 2 groups of 50 each. Trigger of ovulation was done by a single dose of 0.2 mg triptorelin (Decapeptyl®ferring pharmaceutical company, Germany) and luteal phase support with daily 125 IU HCG injections in Group 1. Group 2 received A single dose of HCG 10000 IU was given followed by progesterone supplementation with 100mg IM progesterone (Prontogest® IBSA Swisserland). 2 Embryo were transferred and an ultrasound at 4 weeks after embryo transfer for cases with positive pregnancy test. As regards to clinical pregnancy group 1 had 28 of the 50 (56%) Positive clinical pregnancy while control was 26 of the 50 (52%), the difference was not statistically significant (P > 0.68). No cases of moderate or severe ovarian hyperstimulation were observed during the study. To conclude, Agonist trigger combined with microdose HCG had a comparable pregnancy rate resulst to HCG trigger and conventional progesterone support for luteal support without increasing the risk of ovarian hyper stimulation.

Effect of altrenogest on endogenous progesterone during early pregnancy in recipient mares

Altrenogest is commonly utilised for hormonal support of pregnancy, with undefined effects. We investigated effects of altrenogest supplementation on endogenous progesterone (P4) production in embryo recipient mares (RM). RM were managed onsite and selected on the basis of ‘best tone' on transfer day. Thirty RM received a 150mg depot altrenogest intramuscularly from transfer, at 7-day intervals, through to 42 days (ALT), a further 31 RM received no altrenogest (CON). Blood was collected at 7-day intervals, starting 7 days after transfer and P4 assayed by amplified enzyme-linked immunoassay. Data were analysed by total (tP4, ng/ml) and P4 corrected by number of corpora lutea (CL; cP4). Statistical comparisons of non-parametric data were performed by Kruskal-Wallis ANOVA and Friedman repeated measures; values presented as median and 95% confidence interval. Odds ratios (OR) were calculated to evaluate associations between ALT and secondary ovulation, and tP4 values of <3ng/ml. In ALT, tP4 was lower on days 21, 28 and 35 when compared to days 14 and 42 (p<0.01), and no difference was seen between days 14 and 42 (p=0.715). The same pattern was seen with cP4 lower on days 21, 28 and 35 compared to days 14 and 42 (p<0.01), and no difference between days 14 and 42 (p=0.273). A similar profile was seen in CON, with tP4 loweron days 21, 28 and 35 compared to days 14 and 42 (p<0.01) and no difference between days 14 and 42 (p=0.095). However, compared to day 14, cP4 was lower on days 21, 28, 35 (p<0.01), and also on day 42 (p=0.026). When compared to days 21, 28 and 35 there were no differences with day 42 (p>0.10). Secondary CL occurred in 17.24% CON and in 26.67% ALT (OR 1.55; 0.45-5.28, p=0.487). Total P4 was lower in ALT 4.8 (3.9-6.3), compared with CON 6.0 (5.4-7.3, p=0.04), and in ALT 4.7 (3.9-5.3), compared with CON 5.7 (5.1-7.4, p=0.02) at 21 and 28 days respectively. This held true for cP4 at 21 (ALT 3.7; 2.8-4.3 versus CON 4.7; 3.7-6.6, p=0.03) and 28 days (ALT 3.4; 2.5-4.3 versus CON 5.0; 4.0-5.8, p=0.005) where effect of multiple ovulations was nullified. In 40% of ALT, tP4 was <3.0 at ≥1 time-point compared to 3.2% in CON. The odds of a mare having a tP4 concentration <3.0 at any time-point was greater for ALT (OR 11.2; 1.37-91.83, p=0.024). Three ALT (10%) and no CON had tP4 ≤3.0 at 42 days (p=0.212). In conclusion, altrenogest led to suppressed endogenous P4 production with the greatest magnitude at 28 days of gestation; we hypothesize that this is mediated via negative feedback of altrenogest on pituitary LH release and effective reduction of its luteotrophic influence.

Successful mule embryo transfer to a recipient mule during late diestrus

Mating between a donkey (Equus asinus) and a mare (Equus caballus) results in a mule foal, which is an infertile hybrid due to the different number of chromosomes in the parent species. However, mules have been successfully used as recipients of donkey embryos, horse embryos and, recently, mule embryos. In non-cyclic recipient mules, progesterone supplementation is needed to sustain pregnancy, but some mules can develop pre-ovulatory follicles which ovulate and form active CLs that produce enough progesterone to sustain pregnancy. In spite of this, it is possible that the induction of additional CL formation to increase progesterone concentrations prior to embryo transfer could increase the chances of successful pregnancy. In this study an 8-day old mule embryo produced by the insemination of a mare with fresh donkey semen was transferred to a cyclic mule that had been induced to form a secondary CL by the injection of 1.8mg of deslorelin acetate on day 8 post-ovulation, when a spontaneously developed follicle reached 38 mm of diameter. Progesterone concentrations at that time confirmed that the primary CL was active. Secondary ovulation occurred 2 days later and a secondary CLformed during the following days, resulting in a significant increase in blood progesterone concentrations. The 8-day old embryo was transferred nine days after the secondary ovulation (19 days after the primary ovulation), when both the primary and secondary CL were fully active as indicated by sustained progesterone concentrations and by their diameters of 37 and 35.5 mm, respectively. Pregnancy diagnosis was made 4 days after transfer of the embryo, that is, 23 days after the primary ovulation and 13 days after the secondary ovulation. At that time, the 12-day old embryo was within a 15mm embryonic vesicle. On days 55 and 58 of pregnancy two new supplementary CL formed spontaneously, reaching diameters of 36 and 29mm. This report of a successful mule-in-mule pregnancy using as a recipient a mule with both a primary and an artificially induced secondary CL suggests the possibility of improving the chances of successful pregnancy in recipient mules by increasing endogenous progesterone production through induction of secondary ovulations prior to embryo transfer. Acknowledgements. This study was supported by grant PAPIIT IN 223920, DGAPA-UNAM.

291 Synchronization and Seasonality Effects on Follicular Development, Estrus Expression, and Pregnancy in Brahman Females

Abstract Control of follicular development is essential for estrous synchronization. This experiment determined differences in follicular development during synchronization in Brahman females. Cows (n=219) and heifers (n=90) in Fall (n=170) and Spring (n=139) were synchronized with a CIDR insert and administration of GnRH or PG treatment on d0 (1/2GnRH: n=106, GnRH: n=103, PG: n=100), and CIDR removal and PG administration on d6 followed by estrus detection and AI for 96h. Blood samples were collected on d0, d6, and d8 and/or AI to determine circulating progesterone (P4) concentrations. Transrectal ovarian ultrasonography occurred daily. Cows were grouped by CL presence (d0CL, d6CL) and P4 concentrations (d0P4, d6P4, d8P4, Low&amp;lt; 1 ng/mL, High≥1 ng/mL) on d0 and d6. The GLIMMIX procedure of SAS was used to analyze follicular wave initiation, wave emergence day, estrus expression, and pregnancy success. There were significant interactions of treatment by d0CL (P=0.0237), and season by d0P4 (P=0.0118) on wave initiation. Cows receiving 1/2GnRH with a CL on d0 (97±2%) and Fall cows having High d0P4 (96±3%) had the greatest probability of wave initiation. Age significantly impacted wave initiation (P=0.0213; heifers: 93±4%, cows: 79±5%). Interactions of treatment by season (P=0.0405) and treatment by d0CL (P=0.0379) significantly impacted wave emergence timing. Season (P&amp;lt; 0.0001; Fall: 23±5%, Spring: 65±6%), and the interactions of treatment by d0P4 (P=0.0291) and new wave by d0P4 (P=0.0357) influenced estrus expression. Cows receiving 1/2GnRH with High d0P4 and cows with High d0P4 that initiated a new wave had the greatest probability of estrus expression. Pregnancy rate differed by estrus expression (P=0.0055; no estrus=25±6%, estrus=54±8%) and semen type (P=0.0105; conventional=52±9%, sexed=26±6%), and tended to differ by d8P4 (P=0.0570; Low=30±7%, High=48±8%). These results suggest that differences in follicular development and behavioral estrus in synchronized Brahman females may be due to seasonality and endogenous progesterone production.

Inducción de la lactancia en ganado Holstein con dosis reducidas de benzoato de estradiol y sin suplementar progesterona exógena

Lactation induction in cattle is an alternative way to increase the life span of cows with reproductive and productive issues that would otherwise be culled. An alternative lactation induction protocol is proposed. This 21-d protocol takes advantage of endogenous progesterone production and uses low doses of estradiol to stimulate udder growth and function. Holstein cows (n= 5) and heifers (n= 4) were injected with 500 mg of somatotropin on days one, eight, fourteen, and twenty-one. Estradiol benzoate (3-10 mg d-1) was applied from day one to fourteen. Cloprostenol (500 µg) was administered to the animals am and pm on d 1, and from d 18 to 21, they were injected dexamethasone (5 mg d-1). The cows and heifers were milked for the first time on d 22. Exogenous progesterone was not supplemented, but lactation protocol began in the diestrus phase of the estrous cycle and GnRH was injected to induce formation of an accessory corpus luteum. Lactation induction was successful in all animals, milk production ranged from 18.3 to 25.5 kg d-1. In conclusion, endogenous progesterone production in combination with reduced doses of estradiol benzoate is sufficient to induce lactation in Holstein cattle.

Does the HCG trigger dose used for IVF impact luteal progesterone concentrations? a randomized controlled trial

Research questionIs there an association between the ovulation trigger dose of human chorionic gonadotrophin (HCG) and endogenous progesterone production during the luteal phase? DesignThis randomized controlled four-arm study, at the Fertility Clinic, Odense University Hospital, Denmark, included women undergoing gonadotrophin-releasing hormone (GnRH) antagonist IVF treatment with ≤11 follicles ≥12 mm. Group 1–3 were triggered with 5000 IU, 6500 IU or 10,000 IU HCG, respectively, receiving 17α-hydroxyprogesterone caproate intramuscularly for luteal-phase support (LPS) to measure endogenous progesterone production. Group 4 received 6500 IU HCG trigger and vaginal progesterone. During the study, the 5000 IU and 10,000 IU HCG groups were switched from urinary to recombinant HCG, as urinary HCG was removed from market. Eight blood samples were drawn during the luteal phase. ResultsNinety-four participants completed the study. There was a significant positive association between the HCG trigger dose and the progesterone at 8 days (P < 0.001), 10 days (P < 0.001) and 14 days (P < 0.001) post-oocyte retrieval. Comparing the groups individually revealed a significant difference in progesterone concentration between low and high trigger doses at 4 days (P = 0.037) and 8 days (P = 0.007) post-oocyte retrieval and between all intervention groups at oocyte retrieval + 6 days: group 1 and 2 (P = 0.011), group 2 and 3 (P = 0.042) and group 1 and 3 (P < 0.001). Higher HCG trigger dose increased the progesterone from the individual follicle. ConclusionsIncreasing HCG trigger doses significantly increased endogenous progesterone concentration during the mid–late luteal phase.

P–681 Will the hCG trigger dose used for final oocyte maturation in IVF impact endogenous progesterone during the luteal phase? - A randomized controlled trial

Abstract Study question Is there an association between the hCG dose used for ovulation trigger and the endogenous progesterone production during the luteal phase? Summary answer Increased hCG dosing significantly increased the endogenous progesterone level during the luteal phase. What is known already During the luteal phase of an IVF treatment, the endogenous progesterone (P4) production is negatively impacted due to reduced circulating endogenous LH, caused by negative feed-back of elevated steroids; thus, luteal phase support (LPS) with exogenous P4 remains mandatory in IVF. Apart from inducing final oocyte maturation, the gold standard HCG trigger also functions as an early LPS, boosting P4 production by the corpora lutea (CL). P4 plays a pivotal role for embryo implantation and pregnancy, and an optimal P4 level around peri-implantation seems to be essential for the reproductive outcomes of fresh and frozen/thaw embryo transfer cycles. Study design, size, duration A randomized controlled 4-arm study, including a total of 127 IVF patients, enrolled from January 2015 until September 2019 at the Fertility Clinic, Odense University Hospital, Denmark. Participants/materials, setting, methods IVF patients with ≤ 11 follicles ≥ 12 mm were randomized to four groups. Groups 1–3 were triggered with: 5.000 IU, 6.500 IU or 10.000 IU, hCG, respectively, receiving a LPS consisting of 17-α-hydroxy-progesterone (17α OH P4) to distinguish the endogenous P4 from the exogenous supplementation. Group 4 (control) was randomized to a 6.500 IU hCG trigger and standard LPS. A total of eight blood samples were drawn during the early luteal phase. Main results and the role of chance A total of 94 patients completed the study: 21, 22, 25 and 26 patients in each group, respectively. Baseline characteristics were similar, except for the endogenous LH level and cycle lengths. There were no significant differences between groups regarding ovarian stimulation, number of oocytes and embryos. The median number of follicles ≥ 12mm on the day of trigger was 8.5, resulting in 6.6 oocytes being retrieved. Significant differences in P4 levels were seen at OPU+8 (p &amp;lt; 0.001), OPU+10 (p &amp;lt; 0.001) and OPU+14 (p &amp;lt; 0.001), with positive correlations between P4 level and hCG dose. Groups compared individually showed significant difference in P4 between low and high trigger dose at OPU+4 group 1 and 3 (p = 0.037) and OPU+8 group 1 and 3 (p = 0.007) and between all the three groups around implantation at OPU+6 group 1 and 2 (p = 0.011), group 2 and 3 (p = 0.042) and group 1 and 3 (p &amp;lt; 0.001). Higher P4 levels around implantation were related to follicle count and to pregnancy. After logistic regression analyses there were still significant individual differences between the groups. Limitations, reasons for caution Although patients were randomized and strict inclusion and exclusion criteria were used, the RCT was un-blinded, including a relatively small number of patients. Moreover, for dosing purposes urinary hCG as well as recombinant hCG was used and pharmacokinetics differ. Finally, the P4 level could be influenced by circadian fluctuations. Wider implications of the findings: This is the first study to explore dose-responses in circulating P4 after hCG trigger in IVF patients. Increasing the hCG trigger dose increased the endogenous P4 around peri-implantation. Personalizing the hCG trigger dose could be a key point to secure the most optimal P4 mid-luteal phase P4 level. Trial registration number Eudract 2013–003304–39

P-681 Will the hCG trigger dose used for final oocyte maturation in IVF impact endogenous progesterone during the luteal phase? - A randomized controlled trial

Abstract Study question Is there an association between the hCG dose used for ovulation trigger and the endogenous progesterone production during the luteal phase? Summary answer Increased hCG dosing significantly increased the endogenous progesterone level during the luteal phase. What is known already During the luteal phase of an IVF treatment, the endogenous progesterone (P4) production is negatively impacted due to reduced circulating endogenous LH, caused by negative feed-back of elevated steroids; thus, luteal phase support (LPS) with exogenous P4 remains mandatory in IVF. Apart from inducing final oocyte maturation, the gold standard HCG trigger also functions as an early LPS, boosting P4 production by the corpora lutea (CL). P4 plays a pivotal role for embryo implantation and pregnancy, and an optimal P4 level around peri-implantation seems to be essential for the reproductive outcomes of fresh and frozen/thaw embryo transfer cycles. Study design, size, duration A randomized controlled 4-arm study, including a total of 127 IVF patients, enrolled from January 2015 until September 2019 at the Fertility Clinic, Odense University Hospital, Denmark. Participants/materials, setting, methods IVF patients with ≤ 11 follicles ≥ 12 mm were randomized to four groups. Groups 1-3 were triggered with: 5.000 IU, 6.500 IU or 10.000 IU, hCG, respectively, receiving a LPS consisting of 17-α-hydroxy-progesterone (17α OH P4) to distinguish the endogenous P4 from the exogenous supplementation. Group 4 (control) was randomized to a 6.500 IU hCG trigger and standard LPS. A total of eight blood samples were drawn during the early luteal phase. Main results and the role of chance A total of 94 patients completed the study: 21, 22, 25 and 26 patients in each group, respectively. Baseline characteristics were similar, except for the endogenous LH level and cycle lengths. There were no significant differences between groups regarding ovarian stimulation, number of oocytes and embryos. The median number of follicles ≥ 12mm on the day of trigger was 8.5, resulting in 6.6 oocytes being retrieved. Significant differences in P4 levels were seen at OPU+8 (p &amp;lt; 0.001), OPU+10 (p &amp;lt; 0.001) and OPU+14 (p &amp;lt; 0.001), with positive correlations between P4 level and hCG dose. Groups compared individually showed significant difference in P4 between low and high trigger dose at OPU+4 group 1 and 3 (p = 0.037) and OPU+8 group 1 and 3 (p = 0.007) and between all the three groups around implantation at OPU+6 group 1 and 2 (p = 0.011), group 2 and 3 (p = 0.042) and group 1 and 3 (p &amp;lt; 0.001). Higher P4 levels around implantation were related to follicle count and to pregnancy. After logistic regression analyses there were still significant individual differences between the groups. Limitations, reasons for caution Although patients were randomized and strict inclusion and exclusion criteria were used, the RCT was un-blinded, including a relatively small number of patients. Moreover, for dosing purposes urinary hCG as well as recombinant hCG was used and pharmacokinetics differ. Finally, the P4 level could be influenced by circadian fluctuations. Wider implications of the findings This is the first study to explore dose-responses in circulating P4 after hCG trigger in IVF patients. Increasing the hCG trigger dose increased the endogenous P4 around peri-implantation. Personalizing the hCG trigger dose could be a key point to secure the most optimal P4 mid-luteal phase P4 level. Trial registration number Eudract 2013-003304-39

Detection of early placental hormone production in embryo transfer cycles lacking a corpus luteum.

This study sought to identify the initiation of placental hormonal production as defined by the production of endogenous estradiol (E2) and progesterone (P4) in a cohort of patients undergoing programmed endometrial preparation cycles with single embryo transfers resulting in live-born singletons. In this retrospective cohort study, patients undergoing either programmed frozen-thawed embryo transfer (FET) with autologous oocytes or donor egg recipient (DER) cycles with fresh embryos were screened for inclusion. Only patients who underwent a single embryo transfer, had a single gestational sac, and a resultant live-born singleton were included. All patients were treated with E2 patches and intramuscular progesterone injections. Main outcome measures were serial E2 and P4, with median values calculated for cycle days 28 (baseline), or 4w0d gestational age (GA), through 60, or 8w4d GA. The baseline cycle day (CD) 28 median value was compared to each daily median cycle day value using the Wilcoxon signed rank test. A total of 696 patients, 569 using autologous oocytes in programmed FET cycles and 127 using fresh donor oocytes, from 4/2013 to 4/2019 met inclusion criteria. Serum E2 and P4 levels stayed consistent initially and then began to increase daily. Compared to baseline CD 28 E2 (415pg/mL), the serum E2 was significantly elevated at 542pg/mL (P< 0.001) beginning on CD 36 (5w1d GA). With respect to baseline CD 28 P4 (28.1ng/mL), beginning on CD 48 (6w6d GA), the serum P4 was significantly elevated at 31.6ng/mL (P< 0.001). These results demonstrate that endogenous placental estradiol and progesterone production may occur by CD 36 and CD 48, respectively, earlier than traditionally thought.

Autoimmune progesterone dermatitis in the adolescent population.

Autoimmune progesterone dermatitis (APD) is a rare autoimmune hypersensitivity reaction that occurs cyclically at the peak of endogenous progesterone production during the menstrual cycle in women. No study characterizing APD in the adolescent population is found; it appears likely to be underdiagnosed and undertreated. A retrospective, single-center, review of all adolescent and pediatric patients (<20years old at onset) with documented diagnosis of APD. Seventeen adolescent APD patients were included (mean age at diagnosis: 14.4±2years, mean interval of 13.6±11.1months between symptom onset and diagnosis). Twelve patients presented with urticaria, two with fixed drug eruption. Erythema multiforme, eczema, and recurrent aphthous stomatitis were present in one patient each. Exposure to exogenous progestin was present in two patients prior to disease onset. Progesterone skin test was performed in six patients with positive results in two. Fourteen patients received antihistamines and/or a topical corticosteroid. Combined oral contraceptives (COCs) were given to eleven patients, in seven via continuous daily dosing. Gonadotropin-releasing hormone agonist (GnRHa) was used in five, progesterone desensitization in four, omalizumab in two, and danazol in one patient. Adolescent APD is associated with a significant delay in diagnosis. The most common manifestation is urticaria. Exogenous exposure to progestins is uncommon in adolescent APD. Continuous COC, GnRHa, and progesterone desensitization have been used to control symptoms. Large, multicenter studies are required to better define, diagnose, and treat this under recognized condition among adolescent patients.

Luteal Phase in Assisted Reproductive Technology.

Luteal phase (LP) is the period of time beginning shortly after ovulation and ending either with luteolysis, shortly before menstrual bleeding, or with the establishment of pregnancy. During the LP, the corpus luteum (CL) secretes progesterone and some other hormones that are essential to prepare the uterus for implantation and further development of the embryo, the function known as uterine receptivity. LP deficiency (LPD) can occur when the secretory activity of the CL is deficient, but also in cases of normal CL function, where it is caused by a defective endometrial response to normal levels of progesterone. LPD is particularly frequent in treatments using assisted reproductive technology (ART). Controlled ovarian stimulation usually aims to obtain the highest number possible of good-quality oocytes and requires the use of gonadotropin-releasing hormone (GnRH) analogs, to prevent premature ovulation, as well as an ovulation trigger to achieve timed final oocyte maturation. Altogether, these treatments suppress pituitary secretion of luteinizing hormone (LH), required for the formation and early activity of the CL. In addition to problems of endometrial receptivity for embryos, LPD also leads to dysfunction of the local uterine immune system, with an increased risk of embryo rejection, abnormally high uterine contractility, and restriction of uterine blood flow. There are two alternatives of LPD prevention: a direct administration of exogenous progesterone to restore the physiological progesterone serum concentration independently of the CL function, on the one hand, and treatments aimed to stimulate the CL activity so as to increase endogenous progesterone production, on the other hand. In case of pregnancy, some kind of LP support is often needed until the luteal–placental shift occurs. If LPD is caused by defective response of the endometrium and uterine immune cells to normal concentrations of progesterone, a still poorly defined condition, symptomatic treatments are the only available solution currently available.

Effect of altrenogest supplementation on endogenous progesterone production in embryo recipient mares in a commercial embryo transfer program

To determine the physiologic and behavioral effects and pharmacokinetic profile of hydromorphone administered intravenously (IV) to horses.Prospective, randomized, crossover study.A group of six adult healthy horses weighing 585.2 ± 58.7 kg.Each horse was administered IV hydromorphone (0.025 mg kg–1; treatment H0.025), hydromorphone (0.05 mg kg–1; treatment H0.05) or 0.9% saline in random order with a 7 day washout period. For each treatment, physiologic, hematologic, abdominal borborygmi scores and behavioral data were recorded over 5 hours and fecal output was totaled over 24 hours. Data were analyzed using repeated measures anova with significance at p < 0.05. Blood samples were collected in treatment H0.05 for quantification of plasma hydromorphone and hydromorphone-3-glucuronide and subsequent pharmacokinetic parameter calculation.Hydromorphone administration resulted in a dose-dependent increase in heart rate (HR) and systolic arterial pressure (SAP). HR and SAP were 59 ± 17 beats minute–1 and 230 ± 27 mmHg, respectively, in treatment H0.05 at 5 minutes after administration. No clinically relevant changes in respiratory rate, arterial gases or temperature were observed. The borborygmi scores in both hydromorphone treatments were lower than baseline values for 2 hours. Fecal output did not differ among treatments and no evidence of abdominal discomfort was observed. Recorded behaviors did not differ among treatments. For hydromorphone, mean ± standard deviation for volume of distribution at steady state, total systemic clearance and area under the curve until the last measured concentration were 1.00 ± 0.29 L kg–1, 106 ± 21 mL minute–1 kg–1 and 8.0 ± 1.5 ng hour mL–1, respectively.Hydromorphone administered IV to healthy horses increased HR and SAP, decreased abdominal borborygmi and did not affect fecal output.

The Steroid Metabolome in the Isolated Ovarian Follicle and Its Response to Androgen Exposure and Antagonism.

The ovarian follicle is a major site of steroidogenesis, crucially required for normal ovarian function and female reproduction. Our understanding of androgen synthesis and metabolism in the developing follicle has been limited by the sensitivity and specificity issues of previously used assays. Here we used liquid chromatography–tandem mass spectrometry to map the stage-dependent endogenous steroid metabolome in an encapsulated in vitro follicle growth system, from murine secondary through antral follicles. Furthermore, follicles were cultured in the presence of androgen precursors, nonaromatizable active androgen, and androgen receptor (AR) antagonists to assess effects on steroidogenesis and follicle development. Cultured follicles showed a stage-dependent increase in endogenous androgen, estrogen, and progesterone production, and incubations with the sex steroid precursor dehydroepiandrosterone revealed the follicle as capable of active androgen synthesis at early developmental stages. Androgen exposure and antagonism demonstrated AR–mediated effects on follicle growth and antrum formation that followed a biphasic pattern, with low levels of androgens inducing more rapid follicle maturation and high doses inhibiting oocyte maturation and follicle growth. Crucially, our study provides evidence for an intrafollicular feedback circuit regulating steroidogenesis, with decreased follicle androgen synthesis after exogenous androgen exposure and increased androgen output after additional AR antagonist treatment. We propose that this feedback circuit helps maintain an equilibrium of androgen exposure in the developing follicle. The observed biphasic response of follicle growth and function in increasing androgen supplementations has implications for our understanding of polycystic ovary syndrome pathophysiology and the dose-dependent utility of androgens in in vitro fertilization settings.

Micro-dose hCG as luteal phase support without exogenous progesterone administration: mathematical modelling of the hCG concentration in circulation and initial clinical experience.

For the last two decades, exogenous progesterone administration has been used as luteal phase support (LPS) in connection with controlled ovarian stimulation combined with use of the human chorionic gonadotropin (hCG) trigger for the final maturation of follicles. The introduction of the GnRHa trigger to induce ovulation showed that exogenous progesterone administration without hCG supplementation was insufficient to obtain satisfactory pregnancy rates. This has prompted development of alternative strategies for LPS. Augmenting the local endogenous production of progesterone by the multiple corpora lutea has been one focus with emphasis on one hand to avoid development of ovarian hyper-stimulation syndrome and, on the other hand, to provide adequate levels of progesterone to sustain implantation. The present study evaluates the use of micro-dose hCG for LPS support and examines the potential advances and disadvantages. Based on the pharmacokinetic characteristics of hCG, the mathematical modelling of the concentration profiles of hCG during the luteal phase has been evaluated in connection with several different approaches for hCG administration as LPS. It is suggested that the currently employed LPS provided in connection with the GnRHa trigger (i.e. 1.500 IU) is too strong, and that daily micro-dose hCG administration is likely to provide an optimised LPS with the current available drugs. Initial clinical results with the micro-dose hCG approach are presented.

Daily low-dose hCG stimulation during the luteal phase combined with GnRHa triggered IVF cycles without exogenous progesterone: a proof of concept trial.

Can the luteal phase support be improved in terms of efficacy, hormonal profiles and convenience as compared with today's standard care? Daily low-dose rhCG supplementation in GnRHa triggered IVF cycles can replace the traditional used luteal phase support with exogenous progesterone. A bolus of hCG for final maturation of follicles in connection with COS may induce the risk of OHSS and the luteal phase progesterone levels rise very abruptly in the early luteal phase. This is a proof-of-concept study conducted as a three arm RCT with a total of 93 patients. First patient enrolled in January 2012 and the study finished in January 2014. Normal responder women undergoing IVF/ICSI treatment in a university hospital. One arm served as control, where women followed a standard antagonist protocol. Two study arms were included both having 125 IU hCG daily for luteal phase support without exogenous progesterone after using a GnRHa trigger for ovulation induction. In both study arms exogenous FSH was stopped on stimulation day 6 and replaced by exogenous hCG that was initiated on either stimulation day 2 or day 6. Blood samples were obtained on the day of ovulation induction, on the day of oocyte pickup (OPU) and day OPU + 7. The mean serum levels of hCG did not exceeded the normal physiological range of LH activity in any samples. Mid-luteal progesterone levels were significantly higher in the two study groups receiving daily low-dose hCG for luteal phase support as compared with the control group (control group: 177 ± 27 nmol/l; study group 1: 334 ± 42 nmol/l; study group 2: 277 ± 27 nmol/l; (mean ± SEM). No differences in reproductive outcome were seen between groups. The number of patients included is limited and conclusions need to be verified in a larger RCT. Endogenous production of progesterone may become more attractive as the luteal phase support with levels of LH-like activity only in the physiological range and may, from the patients' point of view, replace inconvenient exogenous progesterone preparation. Further hCG may reduce the cost of stimulation and may collectively be used for stimulation of the follicular phase, ovulation induction and for luteal phase support. An unrestricted grant from ARTS Biologics made this study possible. None of the authors has any competing interests to declare. ClinicalTrial.gov number: NCT01504139. 28 December 2011.

Cystic Endometrial Hyperplasia and Pyometra in Three Captive African Hunting Dogs (Lycaon pictus)

Pyometra and cystic endometrial hyperplasia are common in domestic canids and are suspected to develop as a consequence of elevated progesterone levels. Reports of uterine pathology in exotic canids are limited, with some speculating of association with contraception. This report describes pyometra, cystic endometrial hyperplasia, and ovariohysterectomy in three African hunting dogs (Lycaon pictus). Ovarian corpora lutea were detected in two of the dogs, suggesting endogenous progesterone production. One dog had a uterine adenocarcinoma and two had ovarian granulosa cell tumors. Clinical signs included anorexia, lethargy, vulvar discharge, polyuria, polydipsia, and abdominal distention. Diagnosis was based on clinical signs, physical examination, bloodwork, radiography, and ultrasonography, with confirmation through histopathologic evaluation of tissues. Cystic endometrial hyperplasia, pyometra, and uterine neoplasia have rarely been diagnosed in exotic canids; however, they should be considered as differential diagnoses in intact bitches that present with suspected reproductive disease.

Superovulation in goats during the second follicular wave, with or without exogenous progesterone

The objective of this study was to evaluate a protocol for superovulation in goats designed to use the animals’ endogenous progesterone production, compared to a common protocol that utilized exogenous progesterone. The numbers of non-ovulated follicles, ova ovulated, and ova collected for each protocol were compared. In addition, the effect on these parameters of the day of first FSH administration, relative to the second follicular wave was investigated in the endogenous progesterone group. Forty alpine goats were divided into two groups. The +CIDR group (n=20) received PGF2α 7 days prior to CIDR® insertion (CIDR insertion=day 0). The CIDR® was inserted for 14 days, and during this period PGF2α was injected on day 7 and FSH given in 8 equal doses over 4 days, starting on day 12. For the −CIDR group (n=20), estrus was checked daily after an initial dose of PGF2α to allotted females that were approximately 7 days (range: 6–9 days) from estrus, when the first dose of FSH was administered. FSH (8 equal doses over 4 days) was administered, and PGF2α given on the second day of FSH administration. In both groups GnRH was given approximately 15–17h after the last dose of FSH and surgery to collect early ova was performed 27–30h later, to evaluate the superovulatory response. No significant differences in the mean numbers of non-ovulated follicles (+CIDR: 5.4±0.8, −CIDR: 5.6±1.0) and ovulation points (+CIDR: 13.8±1.0, −CIDR: 13.7±1.4) per doe were observed, nor in the total number of ova collected per female (+CIDR: 9.6±1.2, −CIDR: 9.3±1.4). In addition, no relationship of these parameters with the day of initial FSH administration in the −CIDR group was found. In conclusion, it was shown that if the time of estrus can be identified, superovulation can be reliably produced in goats, without the need for an exogenous source of progesterone.

Sex Differences in Outcome after Mild Traumatic Brain Injury

The objective of this study was to estimate the independent association of sex with outcome after mild traumatic brain injury (mTBI). We performed an analysis of a subset of an established cohort involving 1425 mTBI patients presenting to an academic emergency department (ED). The associations between sex and three outcomes determined 3 months after the initial ED visit were examined: post-concussive symptom (PCS) score (0, 1-5, 6-16, and >16), the number of days to return of normal activities (0, 1-7, and >7), and the number of days of work missed (0, 1-7,and >7). Logistic regression analyses were used to determine the relationship between sex and each outcome after controlling for 12 relevant subject-level variables. Of the 1425 subjects, 643 (45.1%) were female and 782 (54.9%) were male. Three months after mTBI, males had significantly lower odds of being in a higher PCS score category (odds ratio [OR] 0.62, 95% confidence interval [CI]: 0.50, 0.78); this association appeared to be more prominent during child-bearing years for females. Males and females did not significantly differ with respect to the odds of poorer outcome as defined by the number of days to return of normal activities or the number of days of work missed. Female sex is associated with significantly higher odds of poor outcome after mTBI, as measured by PCS score, after control for appropriate confounders. The observed pattern of peak disability for females during the child-bearing years suggests disruption of endogenous estrogen or progesterone production. Attempts to better understand how mTBI affects production of these hormones acutely after injury and during the recovery period may shed light on the mechanism behind poorer outcome among females and putative therapeutic interventions.

Induction of progesterone receptor A form attenuates the induction of cytosolic phospholipase A2α expression by cortisol in human amnion fibroblasts

Cytosolic phospholipase A2alpha (cPLA(2alpha), now known as PLA2G4A) is the enzyme catalyzing the formation of the rate-limiting substrate, arachidonic acid, for prostaglandin (PG) synthesis. The increasing expression of PLA2G4A toward term gestation in human amnion fibroblasts is believed to be the crucial event in parturition. Human amnion fibroblasts produce cortisol, progesterone and express glucocorticoid receptor (GR), progesterone receptor A (PGRA) form at term. The roles of progesterone and PGRA in the induction of PLA2G4A by cortisol via GR in the amnion fibroblasts remain largely unknown. Using cultured human term amnion fibroblasts, we found that cortisol induced the expression of PGRA, which was attenuated by inhibiting PG synthesis with indomethacin. Knockdown of PGRA expression or inhibition of endogenous progesterone production with trilostane significantly enhanced the induction of PLA2G4A by cortisol, whereas overexpression of PGRA attenuated the induction of PLA2G4A by cortisol. Although exogenous progesterone did not alter PLA2G4A expression under basal conditions, it attenuated cortisol-induced PLA2G4A expression at concentrations about tenfold higher, which might be achieved by competition with cortisol for GR. In conclusion, PGRA in the presence of endogenous progesterone is a transdominant repressor of the induction of PLA2G4A by cortisol. High level of progesterone may compete with cortisol for GR, thus further inhibiting the induction of PLA2G4A by cortisol. Moreover, increased PG synthesis by cortisol may feed back on the expression of PGRA leading to attenuation of cortisol-induced PLA2G4A expression. The above findings may be pertinent to the inconsistent effects of glucocorticoids on parturition in humans.

Case of autoimmune progesterone dermatitis presenting as fixed drug eruption

Autoimmune progesterone dermatitis is a rare disorder that presents as a cyclical cutaneous eruption during the luteal phase of the menstrual cycle. It typically occurs in women due to an autoimmune phenomenon to endogenous progesterone production. We describe a 34-year-old woman with an erythematous round plaque with blistering, which recurred a few days before her menstrual cycle, at the identical site on the left arm. The diagnosis of autoimmune progesterone dermatitis is made with i.d. skin testing on the affected lesion with progesterone. After the beginning of oral prednisolone (40 mg daily) therapy during menstruation, although slight recurrence appeared, the severity was significantly improved.