The Effect Of Oral Contraceptive Pills On Endometrial Receptivity In Infertile Women With Elevated Basal Follicle-stimulating Hormone

Follicle-stimulating hormone (FSH) is a peptide hormone secreted by pituitary and regulated by gonadotropin-releasing hormone (GnRH), estradiol, progesterone and other endocrine, paracrine and autocrine hormones. Advancing age is the most important factor increasing basal FSH level. When the women are older than40years of age, the diminished ovarian reserve and decreased estradiol secretions result in a reduction of the negative feedback to the hypothalamus-pituitary-gonad axis, which leads to a physiologic increasing secretion of FSH with an elevated serum FSH level. However, in clinic, an elevated basal FSH can be found in some younger women aged <40years, with or without a diminished ovarian reserve. These women usually have an anomalous follicle development and a short menstrual cycle. Down-regulation of FSH receptor can occur when the ovaries exposed to high FSH environment and the ovarian reactivity to FSH is further reduced. In our previous retrospective study of535infertile women with artificial insemination with Husband’s sperm, a significant low pregnancy rate and high miscarriage rate were found in women with elevated FSH and the outcome of low pregnancy rate could not be improved by using follicle-stimulating drug. It is unclear whether these results are due to a poor eggs quality or decreased endometrial receptivity associated with elevated FSH level.A study found that high FSH can significantly increases embryonic aneuploidy rate and concluded that elevated FSH was related to poor quality of oocyte. But the other studies debated that elevated basal FSH reflected only the ovarian reserve, not the quality of oocyte. There are few literatures having reported the influence of elevated FSH on the endometrial receptivity.A common way to treat the infertile women with high FSH is to use oral contraceptive pills (OCP), which includes mainly two compositions of estrogen and progesterone and acts to hypothalamus-pituitary-gonad axis by negative feedback resulting in a decrease secretion of FSH. The ovarian reaction to FSH is expected to be recovered following the relief of high FSH environment. Nevertheless, according to some results reported by literatures the curative effect of OCP in treating high FSH is indeterminate. The effect of OCP therapy on the endometrial receptivity is also not clear. Thus, the objectives of present study are to assess, by means of immunohistochemical assay and scanning electron microscope, the developing synchronization, various biochemical markers expressions and ultra-structure of endometria at mid-luteal phases of infertile women with elevated FSH, and to determine whether the endometrial receptivity is improved by treatment with OCP, so as to provide infertile clinic some beneficial references when using OCP to treat the high FSH women.Part1The effect of oral contraceptive pills on the synchronization of endometrial development in infertile women with elevated basal FSH Objective:To observe the synchronization of endometrial development before and after treatment with oral contraceptive pills in infertile women with elevated basal FSH.Materials and methods:Fifteen infertile women with elevated basal FSH (>10IU/L) were involved in our Department of Reproductive Health between December2011and August2012. The ovulation was monitored with vaginal ultrasonography. The inclusion criteria were as follow:women no more than40years of age, regular menstrual cycles and spontaneous ovulation, no use of intrauterine devices or OCP for at least3months before study. Exclusion criteria were as follows:women with polycystic ovarian syndrome, endometriosis, polypus or adhere of uterine cavity and a history of uterine cavity operation. The ovulations were monitored daily by transvagial ultrasound scan starting from day8of the cycle. When the diameter of follicle was≥14mm, urine luteinizing hormone (LH) surge was assayed. The endometrial biopsy was performed on ovulation day+7(group1), and the endometrial sample was collected using an aspiration biopsy device. OCP,1table daily for21days, was administered next cycle from day5onward and continued for three cycles. The second biopsy was performed on ovulation day+7of the first natural cycle after finished OCP treatment (group2). Collected samples were washed with4℃normal saline. The samples for scanning electron microscopy were fixed in a solution containing2.5%(wt/vol) glutaradialehyde. The samples for histological dating and immunohistochemical assay were fixed in4%formalin. The peripheral blood samples were obtained by vein puncture on6-7days after ovulation (mid-luteal phase) and the serum estrodiol (E2) and progesterone concentrations were assayed. Results:1. The sex hormones and follicular phases profilesThere were no significant differences in the basal LH, FSH, E2, T and PRL between group1and group2. The mean E2and P concentrations in mid-luteal phase in group1were also similar to group2(p>0.05). The mean follicular phases were found significantly longer in group2than in group1(15.53±4.05days versus13.26±1.23days,p<0.05).2. Evaluation of light microscopyIn group1, only9out of15(60.0%) of biopsies showed in-phase endometrium and remaining6biopsies were out-of-phase (40%), of whom4showed proliferative phase and2were found proliferative-secretive phase endometrium. In group2, however, all of15mid-luteal biopsies (100.0%) were in-phase and the synchronization of endometrial development was significantly higher than groupl (P <0.05).Conclusions:The women with elevated FSH had a shorten follicular phases and low synchronous rate of endometrial development in mid-luteal phase, which suggested a low endometrial receptivity and might be a important factor for low pregnancy rate and high miscarriage rate. Oral contraceptive pills therapy could increase synchronous rate of endometrial development and improve endometrial receptivity in these high FSH women. Part2The effect of oral contraceptive pills on the endometrial ultra-structure of infertile women with elevated FSHObjective:To explore the effect of oral contraceptive pills treatment on endometrial ultra-structrue in infertile women with elevated FSH.Materials and methods:The participants, ovulation monitoring and sample collection were the same as those in part1. Samples were fixed in a solution containing2.5%(wt/vol) glutaradialehyde and observed with scanning electron microscopy. The quantity and morphology of pinopodes developments were evaluated and compared between group1and group2. For each biospy, three visual fields were observed. The pinopodes quantity on endometrial face were calculated according to the pinopode proportion of coverage, which were classified into three grades:rich (>50%), moderate (20%-50%) and small amount (<20%).The morphology of pinopode were classified into growth period, mature period (fully developed), withdrawal period. The negation showed no pinopode of development..Results:1. The comparison of pinopode morphology between two groupsThe numbers of visual fields for developing pinopodes plus regressing pinopodes were29(64.4%), and fully developed pinopodes were16(35.6%) in groupl. Various morphologies, including developing, fully developed and regressing pinopodes could be found in single section. In group2, the fields of developing pinopodes plus regressing pinopodes were19(42.2%) and fully developed pinopodes were26(57.8%). The fully developed pinopodes rate was significantly higher when compared with group1(P<0.05).2. The comparison of pinopode quantity between two groupsThe numbers of pinopodes were7(15.6%) of moderate and38(84.4%) of rich fields in group1. No significant difference was found when compared with3(6.7%) of moderate and42(93.3%) of rich fields in group2(P>0.05).ConclusionThere were a significant low rate of fully developed pinopodes and asynchronous development of pinopodes in mid-luteal phase of infertile women with high FSH, which could be improved by oral contraceptive therapy, suggesting that oral contraceptive treatment improved the endometrial receptivity in infertile women with high FSH.Part3The effect of oral contraceptive pills on the expressions of biochemical markers of endometrial receptivity in infertile women with elevated FSHObjective:To explore the effect of oral contraceptive pills on the expressions of biochemical markers of endometrial receptivity in infertile women with elevated FSH.Materials and methods:The participants, ovulation monitoring, sample collection were the same as those in part1. The endometrial samples were fixed with4%formalin. Vascular endothelial growth factor (VEGF), leukemia inhibitory factor (LIF), matrix metalloproteinase-9(MMP-9) and integrin β3were evaluated with historoimmunochemistry assay.Results:1. Expressions of LIF in the endometrial glandIn group1, the mean expressions of LIF were1.91±0.46and significantly lower than2.41±0.50in group2(P<0.05).2. Expressions of integrinβ3in the endometrial glandThe mean expressions of integrinβ3of2.10±0.26were also significantly lower in group1than that of2.39±0.41in group2(p<0.05).3. Expressions of VEGF and MMP-9in the endometrial glandThe mean expressions of VEGF and MMP-9were2.20±0.37and2.88±0.97in group1,2.47±0.52and3.04±0.96in group2, No significant differences were detected between two groups (P>0.05,p>0.05).Conclusion:Oral contraceptive pills administration improved the endometrial expressions of biochemical markers LIF, intergrin β3, suggesting that oral contraceptive pills treatment improved endometrial receptivity in infertile women with elevated basal FSH.