Hormone excretion patterns in anovulatory infertility.

BEFORE embarking upon a discussion of anovulatory infertility, it is necessary to define a physiologically normal menstrual cycle and to review our present knowledge of the hormonal changes that occur. In humans a 'normal' cycle has a mean length of 28 32 days+0 6 days (SD = 5 41 days), ovulation occurs and there must be normal corpus luteum function. Recent reviews of the normal changes in the menstrual cycle-Van de Wiele et al. (1970); Ross et al. (1970) and Henzl & Segre (1970)-all indicate a premenstrual rise in luteinizing hormone (LH) and follicle-stimulating hormone (FSH). For this reason it is perhaps best to consider these hormonal changes in relation to the regression of the corpus luteum at about day 23. Figure 1 shows these changes starting 5 days before menstruation-here the plasma progesterone level is falling together with 1 7oc-hydroxyprogesterone. Plasma FSH and LH rise and this rise continues for the first 3-4 days of the cycle. This appears to initiate ripening of the Graafian follicle chosen for ovulation and this ripening follicle produces increasing amounts of oestradiol-17r. Once a critical level of oestradiol is reached then the pituitary releases a surge of LH and FSH; ovulation follows about 30 hr after this surge. Following ovulation the plasma progesterone increases rapidly as the corpus luteum is formed; 17x-hydroxyprogesterone being a precursor on the biosynthetic pathway shows a peak prior to progesterone and coincident with LH and FSH. Figure 2 shows a composite diagram of urinary hormone levels, also taken from regression of the corpus luteum and here the LH and FSH patterns mimic those of the plasma, as do urinary pregnanediol and pregnanetriol mimic those of plasma progesterone and 1 7x-hydroxyprogesterone. The urinary classical oestrogens, oestradiol, oestrone and oestriol show the characteristic biphasic curve described by Brown (1955a), and here the luteal maximum is more marked for oestriol than for the other two oestrogens. Methodology In the clinical conditions to be described the urinary classical oestrogens have been measured by the method of Brown (1955b), urinary total oestrogens by the method of Brown et al. (1968) and