Role of folliculo luteal function in human reproduction

Role of Folliculoluteal Function in
Human Reproduction

György Siklósi

123


Role of Folliculo-luteal Function in Human
Reproduction



György Siklósi

Role of Folliculo-luteal
Function in Human
Reproduction


György Siklósi
Semmelweis University
Second Department of Obstetrics and Gynecology
Budapest
Hungary

ISBN 978-3-319-39539-5
ISBN 978-3-319-39540-1
DOI 10.1007/978-3-319-39540-1

(eBook)

Library of Congress Control Number: 2016944621
© Springer International Publishing Switzerland 2016
This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of
the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation,
broadcasting, reproduction on microfilms or in any other physical way, and transmission or information
storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology
now known or hereafter developed.
The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication
does not imply, even in the absence of a specific statement, that such names are exempt from the relevant
protective laws and regulations and therefore free for general use.
The publisher, the authors and the editors are safe to assume that the advice and information in this book
are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the
editors give a warranty, express or implied, with respect to the material contained herein or for any errors
or omissions that may have been made.
Printed on acid-free paper
This Springer imprint is published by Springer Nature
The registered company is Springer International Publishing AG Switzerland


This book is dedicated to the memory of
Ignaz Philipp Semmelweis (1818–1865)
“saviour of mothers”,
the eponym of our university,
on the occasion of the 150th anniversary of his death



Foreword

I accepted with honour and joy when György Siklósi invited me to write the
Foreword to his book titled “Role of Folliculo-luteal Function in Human
Reproduction”. I did so also because we worked together in the management of the
Hungarian Society of Obstetrics and Gynaecology for more than a decade.
“The rays of the sun, when the figure of Semmelweis is uncovered, will be
reflected from the white marble primarily onto us, Hungarian doctors and obstetricians. Let these rays light the ways of truth, the ways that Semmelweis walked; but
also let them fire us up for such labour as Semmelweis did: labour after which life
and happiness can spring forth” (part of the speech given by Dr. Árpád Bókay on 30
September 1906, at the inauguration of the statue of Semmelweis). After reading the
book of Professor Siklósi, we feel struck by the realisation that the author’s life
work possesses great, epoch-making importance: it gave rise to novel knowledge,
and after it “life and happiness can spring forth”. Beyond his energetic and ambitious working style always dwelled the great love he guided with both his young and
experienced colleagues on the often bumpy ways of science.
The immense progress of technical science during the last decades established a
great advance in medical science as well. Within the medical areas, these changes
are probably most evident in the field of obstetrics. The new diagnostic and therapeutic methods developed by Professor Siklósi establish the basis of a qualitatively
new practice in possibly the most important obstetric issues (infertility, spontaneous
and habitual miscarriage, preterm birth, intrauterine retardation, preeclampsia, etc.);
it opens a whole new world before the reader.
Assuring sufficient number of population is of national interest. The procedures
developed and described by the professor are of vital importance in this problem as
well. They are vitally important as our homeland is in a demographic crisis. The
number of births has been decreasing for years. Since 2000, the number of births
fails to reach 100 thousand per year, whereas 120 thousand newborns should be
born to maintain the national population. The situation is worsened by the high
prevalence of infertility, the high preterm birth rates and the large number of miscarriages and intrauterine growth abnormalities. The work of Professor Siklósi has an
incredible significance for this reason: it gives profoundly grounded, effective and
successful ways to solve these problems in the clinical practice.
I am convinced that extensive implementation of the methods presented in the
book would decisively improve the results, and this would help to stop the

vii


viii

Foreword

population decline and contribute to the sustenance of the nation and last, but not
least, to the joy of families. The question arises: what was the motivational force of
this enormous, epoch-making research work that is also of considerable use in the
clinical practice? Knowing the results, only one answer is possible. Professor
Siklósi has taken on board the unquenchable love for the medical profession and
every mother, the strive for true service of the nation and, finally, the thoroughness
of the marvellously fruitful scientific area that he created and developed and which
helped him to steadily achieve these goals.
I am recommending an excellent book. I definitely recommend reading this
book. It contains new, gap-filling information that means very much to the clinical
practice, and the adaptation of this knowledge would help us to promote the growth
of the nation and the happiness of families. I think that the life course of Professor
Siklósi is a fine example of the unselfish servitude of science and healing, as this
book justifies as well.
Pécs, Hungary

István Szabó


Preface

Preterm birth, intrauterine growth retardation (IUGR) and preeclampsia (PE) are perhaps the greatest challenges in obstetrics today. Their underlying cause is virtually
unknown and thus, treatment and prevention is unresolved. These three complications are responsible for three-quarters of foetal perinatal mortality, they are the leading cause of death, morbidity and disability among newborns and children, and their

adverse health consequences affect the entire life. Their significance is further
emphasised by the fact that their incidence shows a rising tendency even in developed countries such as the USA: the incidence of preterm births increased from 9.4
to 12.5 % between 1981 and 2004. From approximately 140 million births in the
world, 15 million ends with preterm birth; birth of a retarded newborn occurs in 15
million cases and birth complicated with preeclampsia in 7 million cases per year,
and more than 20 million planned clinical pregnancies end up with abortion. About
eight million newborns die before the age of one each year, 3.1 million out of which
is attributable solely to preterm birth. Mortality in retarded babies is four to eightfold
higher compared to eutrophic newborns. Preeclampsia still causes 50,000 deaths
among mothers worldwide. With the rapid development of neonatology, survival rate
of preterm infants swiftly increased; however, this could not result in the reduction of
lifelong adverse health effects of preterm birth and IUGR, and the number of disabled people also increased significantly. Preterm birth and retardation increases the
incidence of insulin resistance, glucose tolerance and hypertension as early as prepubertal age or young adulthood. Preterm birth and retardation significantly increase
the incidence of coronary diseases, stroke, type 2 diabetes mellitus, obesity, metabolic syndrome and osteoporosis later in life. Recurrent miscarriage or habitual abortion (5 % of couples), unexplained infertility (5–6 % of couples) and polycystic ovary
syndrome (approximately 10 % of women) are also unresolved problems. Infertility
affects about 72 million couples in the world at any given time. Obviously, we can
provide a substantial solution for the problems described above only by appropriate
treatment and prevention methods based on the understanding of their underlying
causes. The purpose of our work is to give an overview of the causes of these problems as well as the effective methods for their prevention and treatment.
According to international scientific societies on human reproduction and the
general view of experts, the confirmed presence of ovulation is sufficient for diagnosing physiological menstrual cycle. The presence and role of luteal insufficiency
in human reproduction cannot be demonstrated. Our methods for the prevention and
ix


x

Preface

treatment of the human reproductive disorders described above were based on the

recognition of the fact that – contrary to the general concept – a significant proportion of ovulatory cycles are not sufficient for conception and physiological reproduction. This opened the door for a new, unknown field – the very important field of
hormonal insufficiency of ovulatory cycles (folliculo-luteal insufficiency) – where
new relationships could be found that are very important to study, treat and prevent
human reproductive disorders.
The application of our method for the quantitative diagnosis of ovulatory menstrual cycles clearly showed that the most common disorders of human reproduction
can be attributed to varying degrees of hormonal insufficiency (FLI) of ovulatory
cycles. Our studies have demonstrated that FLF does not only fundamentally determine female fertility but also has a role in the overall outcome of pregnancy via
determining the characteristics of the developing placenta. Mild impairment of FLF
(folliculo-luteal insufficiency grade I) is the underlying cause of preterm birth,
intrauterine growth retardation and preeclampsia. Moderate impairment of FLF
(folliculo-luteal insufficiency grade II) results in miscarriage in the first and second
trimester (frequently in an oocyte unable to reproduce), and the most pronounced
form (folliculo-luteal insufficiency grade III) leads to inability to conceive and to
infertility. Great individual variability of ovulatory cycles is the underlying cause of
high complication rates in planned pregnancies of the whole population (38–40 %)
(miscarriage, preterm birth, IUGR, preeclampsia, etc.). Age-related reduction of
childbearing potential (especially over 35 years of age) and the increasingly more
common obstetrical complications listed above are also caused by folliculo-luteal
insufficiency. Hormonal normalisation of ovulatory cycle disorders also minimises
the occurrence of random chromosome disorders mostly of numerical nature. All
our statements and conclusions are based on studies performed on a representative
patient population and on treatment results.
In our book, we invite the reader to explore this area. We introduce our simple and
efficient method for the diagnosis and treatment of habitual abortion and unexplained
infertility in a representative patient population. We present our therapeutic procedure called “hormonal wedge resection” implemented for the successful treatment of
anovulatory infertility associated with polycystic ovary syndrome. We describe our
results that demonstrate the close relationship between FLF and pregnancy outcome.
We give an overview on a simple method for the prevention of preterm birth, IUGR,
preeclampsia and miscarriages that allows for the reduction of incidence of all human
reproductive disorders to less than 10 % of the current rate. Regular testing and treatment of preconception FLF can contribute to the birth of healthy generations in the

future and would significantly and constantly increase the national annual birth rates
(by at least 20–25 %). In Hungary, the number of couples failing to have a child is
estimated about 150,000. The appropriate care of these couples (by using the efficient, simple and inexpensive methods described herein) can further improve the
demographical situation of our country significantly within a few years.
Budapest, Hungary

György Siklósi


Acknowledgements

Above all, I am deeply thankful to my mentor, Dr. Imre Zoltán (1909–2002),
professor, doctor of medicine, the former head of department at the 2nd Department
of Obstetrics and Gynaecology at Semmelweis University, the former rector of the
Semmelweis University and up to now the only Hungarian vice-president of the
International Federation of Gynecology and Obstetrics (FIGO). Seeing my interest
in reproductive endocrinology, he extensively supported me.
I owe special thanks to my close colleagues working in the Endocrine Laboratory,
Mr. Ferenc Olajos who is the chemical engineer and Mrs. Géza Merényi, Mrs. Dr.
Tibor Tóth, Mrs. László Kovács and Mrs. Sarolta Sárközi Nagy who are the laboratory assistants who helped my work to their fullest, and their exceptional diligence
and precision were a quintessential necessity for my work.
I am grateful to my friend, Dr. Zoltán Marcsek, PhD in biological sciences, former leader of the United Research Organization of the Semmelweis Medical
University and the Hungarian Academy of Science, who provided me devoted,
unselfish and versatile help; his irreplaceable help and friendship gave me unique
support.
I owe my thanks to every employee of the department, who inspired and helped
my work in any way.

xi

List of Abbreviations

ACTH
ACOG
APS
ASRM
CBG
CC
95 % CI
CPR
CRH
CRF
CV
DEX
DHEA-S (DS)
E1
E2
ESHRE
FLF
FLI
FSH
GnRh
HA
HAN
HPA
HPO
HCG
HMG

IR
IUI
IUGR
IVF
CA
LH
MPR
NS

Adrenocorticotropic hormone
American College of Obstetricians and Gynecologists
Antiphospholipid syndrome
American Society of Reproductive Medicine
Corticoid-binding globulin
Clomiphene citrate
95 %-os confidence interval
Cumulative pregnancy rate
Corticotropin-releasing hormone (or CRF)
Corticotropin-releasing factor (or CRH)
Coefficient of variation
Dexamethasone
Dehydroepiandrosterone sulphate
Oestron
Oestradiol-17ß
European Society of Human Reproduction and Embryology
Folliculo-luteal function
Folliculo-luteal insufficiency
Follicle-stimulating hormone
Gonadotropin-releasing hormone
Habitual abortion

Hyperandrogenism
Hypothalamus-pituitary-adrenal axis
Hypothalamus-pituitary-ovary axis
Human chorionic gonadotropin
Human menopausal gonadotropin
Insulin resistance
Intrauterine insemination
Intrauterine growth retardation
In vitro fertilisation
Chromosome abnormality
Luteinising hormone
Monthly pregnancy rate
Non-significant
xiii


xiv

P
PCOS
RCOG
RM
SD
SHBG
TEBG
TTP
UI

List of Abbreviations

Progesterone
Polycystic ovary syndrome
Royal College of Obstetricians and Gynaecologists
Recurrent miscarriage
Standard deviation
Sexual steroid-binding globulin (or TEBG)
Testosterone-oestradiol-binding globulin (or SHBG)
Time to pregnancy
Unexplained (idiopathic) infertility


Contents

1

Patients and Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

2

Diagnosis of Folliculo-Luteal Function . . . . . . . . . . . . . . . . . . . . . . . . . . .
2.1 A Short Summary of the Regulation and Main Events
of the Menstrual Cycle . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2.1.1 History . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2.1.2 Histologic Examination of the Endometrium . . . . . . . . . . . .
2.1.3 Testing Serum Progesterone . . . . . . . . . . . . . . . . . . . . . . . . .
2.1.4 Other Diagnostic Methods . . . . . . . . . . . . . . . . . . . . . . . . . . .
2.1.5 Ultrasound Test of Endometrial Thickness . . . . . . . . . . . . . .
2.1.6 Measuring the Dominant Follicle Diameter . . . . . . . . . . . . .
2.2 A Quantitative Method for Diagnosing

Folliculo-Luteal Function . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2.3 Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

3

4

Aetiology and Pathomechanism of Folliculo-Luteal
Insufficiency. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3.1 History . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3.2 Stress Is the Main Cause of Folliculo-Luteal Insufficiency . . . . . . . .
3.3 Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Treatment of Folliculo-Luteal Insufficiency . . . . . . . . . . . . . . . . . . . . . .
4.1 Literature Review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
4.1.1 Progesterone Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
4.1.2 Human Chorionic Gonadotropin (HCG) Treatment . . . . . . .
4.1.3 Bromocriptine Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . .
4.1.4 Clomiphene Citrate Treatment . . . . . . . . . . . . . . . . . . . . . . . .
4.1.5 Aromatase-Inhibitor Treatment . . . . . . . . . . . . . . . . . . . . . . .
4.1.6 FSH and HCG Treatment. . . . . . . . . . . . . . . . . . . . . . . . . . . .
4.2 Controlled Clomiphene Citrate Treatment
of Folliculo-Luteal Insufficiency . . . . . . . . . . . . . . . . . . . . . . . . . . . .

5
7
10
10
12

13
13
13
14
22
25
31
31
33
36
40
45
45
46
47
47
47
49
50
50

xv


xvi

Contents

4.3 Treatment of Folliculo-Luteal Insufficiency with Low-Dosage
Corticoid or Combined Corticoid and Clomiphene

Citrate Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54
4.4 Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56
5

6

Recurrent Miscarriage and Folliculo-Luteal Function . . . . . . . . . . . . .
5.1 Most Investigated Causes and Risk Factors
of Recurrent Miscarriage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
5.1.1 Genetic Factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
5.1.2 Anatomical Factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
5.1.3 Thrombophilia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
5.1.4 Immunological Factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
5.1.5 Hormonal Causes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
5.1.6 Psychological Factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
5.1.7 Infectious Origin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
5.1.8 Unknown Origin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
5.2 Why the Above Enlisted Causes Cannot Be the Real
Cause of Recurrent Miscarriage. . . . . . . . . . . . . . . . . . . . . . . . . . . . .
5.3 The Crucial Role of Folliculo-Luteal Function
in Recurrent Miscarriage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
5.3.1 Patients and Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
5.3.2 Power Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
5.3.3 Treatment Protocol. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
5.3.4 Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
5.3.5 Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
5.3.6 Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
5.4 Successful Treatment of Recurrent Miscarriage
by the Normalisation of Folliculo-Luteal Function . . . . . . . . . . . . . .

5.4.1 Patients and Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
5.4.2 Treatment Protocol. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
5.4.3 Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
5.4.4 Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
5.5 The Relationship of Random Chromosomal Abnormalities
and Folliculo-Luteal Insufficiency in Recurrent Miscarriage . . . . . .
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Unexplained Infertility and Folliculo-Luteal Function . . . . . . . . . . . .
6.1 Folliculo-Luteal Insufficiency Is the Main Cause
of Unexplained Infertility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
6.1.1 Patients and Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
6.1.2 Treatment Protocol. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
6.1.3 Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
6.2 Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

61
62
62
63
64
64
66
67
67
67
68
71
71
72

72
73
76
80
81
81
82
82
90
97
98
103
105
105
106
107
110
116


Contents

7

The Role of Folliculo-Luteal Function in the Outcome
of Pregnancy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
7.1 History . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
7.2 The Crucial Role of Folliculo-Luteal Function
in Placentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
7.2.1 Patients . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

7.2.2 Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
7.2.3 Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

xvii

119
119
121
123
123
131
138

8

Preventing Preterm Birth, Intrauterine Growth
Retardation (IUGR) and Preeclampsia by the Normalisation
of Placentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 141
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 152

9

The Role of Folliculo-Luteal Insufficiency in the Emergence
of Random Chromosomal Abnormalities . . . . . . . . . . . . . . . . . . . . . . . 155
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 158

10

The Role of Folliculo-Luteal Function in the Emergence

of Age-Related Reproductive Disorders . . . . . . . . . . . . . . . . . . . . . . . . 161
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 164

11

“Hormonal Wedge Resection”: An Effective Treatment
Method of Anovulatory Infertility Associated with Polycystic
Ovary Syndrome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
11.1 The Role of Folliculo-Luteal Insufficiency in the Failed
Treatment of Anovulatory Conditions . . . . . . . . . . . . . . . . . . . . . .
11.2 Studies to Better Understand the Pathogenesis of PCOS
and Associated Anovulation . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
11.3 “Hormonal Wedge Resection”: An Effective Treatment
Method for Polycystic Ovary Syndrome . . . . . . . . . . . . . . . . . . . .
11.3.1 Patients and Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
11.3.2 Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
11.3.3 Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

12

165
165
168
173
173
176
178
182

The Beneficial Effects of Preconceptional Normalisation
of Folliculo-Luteal Function on Reproduction . . . . . . . . . . . . . . . . . . . 185
12.1 A Scheme for Preconceptional Care to Prevent Fertility
Disorders and Obstetric Complications . . . . . . . . . . . . . . . . . . . . . 189
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 194

Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 195
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 199



About the Author

György Siklósi graduated from Semmelweis
University with the award “Sub Auspiciis Rei
Publicae Popularis” and a gold ring from the president of the Republic of Hungary. Since graduating,
he has worked in the 2nd Department of Obstetrics
and Gynaecology of the Semmelweis University.
He has worked in all departments of the clinic
either as a junior physician or the head of department or unit. He was the first deputy director of the
clinic for 13 years. He was the head of the first
Department of Gynaecological Endocrinology in
the country for 15 years. He has been interested in
reproductive endocrinology since the beginning of
his scientific work. To date, he has published 130
scientific articles in Hungarian and foreign languages and made 150 scientific presentations in Hungarian and at international forums. He achieved a PhD degree in
1986 with his thesis entitled “A nő hyperandrogen állapotai és az azokkal összefüggő
reproduktív funkciózavarok” (Hyperandrogenic conditions in women and associated reproductive dysfunctions) and gained a scientific degree of the Hungarian
Academy of Sciences in medicine in 1996 by successfully defending his thesis
entitled “A luteális funkció meghatározó szerepe az emberi reprodukcióban”

(Fundamental role of luteal function in human reproduction). He was among the
first individuals to gain habilitation in 1994 in Hungary. He became a university
professor in 1997. He was an elected member of the College of Obstetrics and
Gynaecology in four cycles and the secretary general of the Hungarian Society of
Obstetrics and Gynaecology in two cycles.

xix


1

Patients and Methods

The studies contained in this book were performed on patients of the Reproductive
Endocrine Unit of the 2nd Department of Obstetrics and Gynaecology, Semmelweis
University. All studies conformed to the directives of the Helsinki Declaration and
informed consent of patients was obtained. The studies were part of the high-priority
ministerial scientific issue of the Department. The clinical and hormonal features of
patients and control groups in the studies within each chapter will be described in
detail in the corresponding chapters.
The core of the studies was hormone determination, performed at the endocrine laboratory of the department (laboratory head: Dr. György Siklósi) up until
several years ago, when the laboratory was merged into the Department of
Laboratory Medicine of the university. Hormone studies described in the book
were conducted over a period of approximately 37 years. Due to technical developments, the determination of 13 hormone types has changed several times during
this interval, and to review every means of determination would be an almost
impossible undertaking; furthermore, these methods have been described in detail
in our publications from the Department over the years. Initially hormones were
determined by radioimmunoassay (RIA) later by luminescent-immunometric
assay (LIA) and electro-chemiluminescent immunoassay (ECLIA, Roche) for steroids and chemiluminescent-microparticle immunoassay (CMIA, Abbot) for
hypophyseal hormones. The reliability of the methods was continuously supervised in the framework of the WHO External Quality Assessment Programme

until the programme was closed; after this, reliability was tested using external
standards. Reliability parameters (intra-assay and inter-assay variation coefficient, accuracy) of the methods were in accordance with the expectations raised
by international literature. The continuous reliable quality of the methods is guaranteed by the personal presence of Ferenc Olajos, a chemical engineer who has
been in charge of hormone determination procedures and their control for 36 years.
He still works at the Department of Laboratory of Medicine.
Statistical analysis: The different statistical parameters were calculated using
internationally accepted formulae and methods (Dinya 2001). We describe research
© Springer International Publishing Switzerland 2016
G. Siklósi, Role of Folliculo-luteal Function in Human Reproduction,
DOI 10.1007/978-3-319-39540-1_1

1


2

1

Patients and Methods

data by determining the ± SD and ±2SD values. To calculate the differences between
groups, we used one- and two-sampled t-test as well as X2 statistics. When testing
hypotheses, we put great emphasis on determining the 95 % confidence interval
values besides calculating significance (p < 0.05). We performed Pearson’s correlation analysis to investigate the relationship between different parameters. The 95 %
confidence intervals (95 % CI) of prevalence rates, their relationship with the odds
ratio and its 95 % confidence interval were described, and we considered the difference significant if CI was ≥1.
For hormones with only slight or no changes at all during the cycle, the serum
levels were determined from a mixture containing equal amounts of three serum
samples obtained during the luteal phase in each case in order to reduce the representative error arising from episodic secretion and the so-called day-to-day variation (Siklósi et al. 1984a, b). Levels of hormones that exhibit significant changes
during the cycle were determined from each sample. After we retrospectively

checked the time of blood sampling related to the time when menstruation occurred,
we described the average luteal levels of progesterone (P) and oestradiol (E2) with
the mean of three P or E2 values obtained from serum samples collected every other
day between the 4th and 9th day before menstruation.
Serum levels of different hormones were given in SI units of measure widely
accepted and used in Hungary, with the exception of progesterone (P) and oestradiol
(E2). In the case of P and E2, we favoured the conventional units ng/ml and pg/ml,
in accordance with international use. Nevertheless, in the texts, figures and tables,
we sought to give the nmol/l and pmol/l values as well (multiplication factor 3.18
and 3.64, respectively) to facilitate comparison with the data in literature.
We considered a 23–35-day cycle length as eumenorrheal, menstrual bleeding
occurring in 36–90-day intervals as oligomenorrheal and bleeding at intervals of
more than 90 days or the complete lack of bleeding as amenorrheal (Zoltán 1975;
Papp 1999).
We verified that ovulation took place by repeated measurements of serum progesterone timed to the baseline temperature and/or by the histologic examination
of the endometrium. We regarded it as a certain sign of ovulation if the average of 3
P values determined between the 4th and 9th day before menstruation exceeded the
3 ng/ml (10 nmol/l) threshold (ESHRE 2000).
Morphological features of the internal reproductive organs were assessed by
ultrasound. Patency testing of fallopian tubes was done by hysterosalpingography
(HSG) with Foley catheter (Siklósi et al. 1984, 1985).
We determined the level of hirsutism by the Ferriman and Galloway method
(1961): the extent of hirsutism was marked with 0–4° on nine body regions (upper
lips, chin, breast, upper part of the abdomen, lower abdomen, sacral region, back,
thighs and upper arms) based on the strength and extension of terminal hair, and the
level of hirsutism was described with the sum of the values found on individual
regions. As different body regions are not equally involved in particular patients,
this determination method, which covers all regions, seemed the most appropriate.
Weight percentile values for newborns were determined based on the table constructed by Joubert (2000) and Berkő and Joubert (2009) that he compiled by

References

3

processing data of the largest national population (680 thousand births). Furthermore,
we found the use of Joubert’s table reasonable because it relates to the whole country, and about half of our patients were rural inhabitants. It did not seem practical to
compile an internal table of our institute, because the patients at the department are
under negative selection (premature birth frequency is almost 30 % because of in
utero transportation and progressive patient care). We determined intrauterine retardation on the exclusive basis of weight percentile values without correction, as this
is the only way to compare data of patients giving birth in other institutes and with
our own data.

References
Berkő P, Joubert K. The effect of intrauterine development and nutritional status on perinatal mortality. J Matern Fetal Neonatal Med. 2009;22(7):552–9.
Dinya E. Biometry in medical practice. Medicina. 2001. (In Hungarian).
ESHRE 2000 - Crosignani PG, Rubin BL. Optimal use of infertility diagnostic tests and treatments. The ESHRE Capri Workshop Group. Hum Reprod. 2000;15:723–32.
Ferriman D, Gallwey JD. Clinical assessment of body hair growth in women. J Clin Endocrinol
Metab. 1961;21:1449–52.
Joubert K. Standards of birth weight and length based on liveborn data in Hungary, 1990–1996.
J Hungarian Gynecol. 2000;63:155–63. (In Hungarian with English summary).
Papp Z. Textbook of obstetrics and gynaecology. Semmelwes Kiadó. 1999. Budapest. (In
Hungarian).
Siklósi G, Siklós P, Hintalan A, Olajos F, Marcsek Z. Episodic secretion of hormones and the
diagnostic value of single blood estimates. II. progesterone, oestradiol and oestrone. Acta Med
Hung. 1984a;41:203–11.
Siklósi G, Vígváry Z, Makó E. Hysterosalpyngographia Foley katéterrel. Orv Hetilap.
1984b;125:2311–4. (In Hungarian with English summary).
Siklósi G, Vígváry Z, Makó E. Hysterosalpingographie mit Foley Katheter. Zblatt Gynäkol.
1985;107:1432–37. (In German).

Zoltán I. Textbook of obstetrics. Medicina. 1975. Budapest. (In Hungarian).


2

Diagnosis of Folliculo-Luteal Function

Nearly three and a half centuries have passed since the first description of the human
corpus luteum (Reigner de Graaf 1672), but it was only in 1949 that Jones concluded that the insufficient function of the corpus luteum can lead to infertility or
recurrent miscarriage. Since then almost every detail of the events and regulation of
the menstrual cycle has been clarified to the molecular level (Mihm et al. 2011,
Halász and Szekeres-Bartho 2013). However, clinical practice is still lagging well
behind this. Even today there is no accepted diagnostic method that can distinguish
between physiological and insufficient ovulatory cycles. Thus, luteal insufficiency
cannot be viewed as an independent entity (ASRM 2008, 2012a, b). An increasing
number of observations in clinical practice suggest that hormonal insufficiency of
the ovulatory cycle may play an essential role in the development of reproductive
function disorders (Sonntag and Ludwig 2012).
To deem a cycle physiologic, most authors consider it satisfactory if the ovulation is verified (Reindollar et al. 2010) or if there is a single P measurement with a
value of at least 10 ng/ml (=31.8 nmol/l) in the middle of the luteal phase. However,
the propriety of these methods is in many aspects questioned by clinical practice,
and this suggests that, even despite verified ovulation, the menstrual cycle can be
insufficient to lead to reproduction. For example, in what is known as unexplained
infertility (UI) with normospermia, ovulation and intact female anatomical features,
though ovulation is verified, pregnancy does not occur within 1 year, and the
monthly pregnancy rates are extremely low even later on (1–3 %). UI is most commonly treated by a number of stimulation methods (CC, aromatase inhibitors, FSHHCG). These multiply the rate of spontaneous pregnancy (from 1–3 % to 10–20 %)
during the first few months of application (Merviel et al. 2010). If stimulation of
folliculogenesis and the consequent improvement of luteal function increase fertility, this implies that despite the ovulation obstacle to conceiving prior to treatment,
the cycle was hormonally insufficient (low follicular E2 and then luteal P). Knowing
the quantitative characteristics of physiological cycles seems indispensable in the

diagnostics of fertility and the adequate control of applied treatment. To resolve

© Springer International Publishing Switzerland 2016
G. Siklósi, Role of Folliculo-luteal Function in Human Reproduction,
DOI 10.1007/978-3-319-39540-1_2

5


6

2

Diagnosis of Folliculo-Luteal Function

these controversies, we considered it necessary to review the characteristics of a
cycle that is normal in the aspect of reproduction.
The biological purpose of the normal menstrual cycle is to assure reproduction,
to create an egg cell capable of reproduction and to develop an endometrium that is
fit to generate a normal placenta and a corpus luteum that is suitable to maintain
early pregnancy. During human reproduction, the circumstances of placentation and
the characteristics of the developed placenta (size, blood flow, functionality, etc.)
are essentially determined by the characteristics of the endometrium, which are in
turn determined by hormones produced by the ovaries: the preovulatory oestradiol
(E2) and later the luteal progesterone (P) and E2 levels. Preovulatory E2 levels
essentially determine the histological features, thickness and blood supply of the
proliferative endometrium, the time and value of LH peak (and thus ovulation),
luteinisation and the final karyotic and cytoplasmic oocyte maturation. Following
these processes, depending on the preovulatory E2 influence and the P levels following ovulation, the secretory transformation of endometrium takes place, which
eventually determines the conditions of placentation in a direct way (collectively:

folliculo-luteal function/FLF/). Morphologic and functional characteristics of the
corpus luteum are primarily determined by follicular development and the events of
ovulation (the time of LH peak in relation to the maturity of granulosa cells, LH
peak value, luteal LH levels), and at the same time, these factors determine the karyotic and cytoplasmic maturity state of the egg cell (DiZerega and Hodgen 1981;
Jones 1991; Shoham et al. 1993). As the activity of the corpus luteum is a result of
every preceding event of the cycle, investigating luteal function seems an appropriate way to describe the complete cycle.
The formation of a physiologic corpus luteum implicates that the menstrual cycle
and its complicated central regulatory processes are complete and intact, the slightest disturbance of which would lead to luteal insufficiency (LI). Abnormalities of
the menstrual cycle that cause FLI can occur during folliculogenesis, LH peak or the
luteal phase, although abnormalities of folliculogenesis are inevitably associated
with abnormalities in every subsequent process. The corpus luteum is generated
from a ruptured follicle during ovulation; thus, its morphological and functional
characteristics are essentially determined by the events of folliculogenesis (Jones
1976; McNeely and Soules 1988). However, LI can develop even when folliculogenesis is physiological, as a result of an insufficient LH peak or decreased LH
secretion during the luteal phase. A luteal phase that is normal in length but has
insufficient P secretion, called inadequate luteal phase, can be accounted for by an
insufficient number of granulosa cells or the inadequate LH peak together with
normal luteal LH secretion (pulse frequency and amplitude) and theca cell activity;
meanwhile, short luteal phases arise as a result of insufficient LH peak and a subsequent insufficient LH secretion (Jones 1991; Cohlen et al. 1993). Insufficient corpus
luteum function can cause the failure of implantation (infertility) or, if implantation
occurs, the abortion of pregnancy (miscarriage), depending on the extent of function
decay. LI means that the P secretion of the corpus luteum is insufficient in terms of
its total amount and/or length in time, which is associated with the concurrent
decrease of other secretions of the corpus luteum (Jones 1949, 1976, 1990).