FERTILITY AND STERILITY

VOL. 80, NO. 2, AUGUST 2003

Copyright 2003 American Society for Reproductive Medicine
Published by Elsevier Inc.
Printed on acid-free paper in U.S.A.

Effects of ascorbic acid supplementation on serum

progesterone levels in patients with a luteal phase
defect
Luteal phase defect is a common endocrine disorder associated with infertility and spontaneous miscarriage. Abnormalities of the luteal phase are found in 3% to 10% of the female population with primary or
secondary infertility and in 35% of those with repeated or habitual abortion (1).
Infertility and pregnancy loss associated with this disorder are thought to be caused by inadequate
maturation and development of the endometrium. Failure of the endometrium is believed to be attributable to
insufficient P production by the corpus luteum.
Many causes of luteal phase defect have been postulated and proven. Recently, oxygen radicals have been
reported to play a part in the etiologies of many diseases.
Serum lipoperoxidation was reported to be significantly elevated in patients with luteal phase defect
compared to normal women. Levels of antioxidant substances, such as ascorbic acid, -tocopherol, and
erythrocyte glutathione were found to be significantly lower in recurrent aborters with luteal phase defects than
in healthy women (2).
The ovary has long been recognized as a site of ascorbic acid accumulation and turnover. The highest
concentrations are found in the theca interna, granulosa, and luteal compartments (3, 4).
The concentration of ascorbic acid is reported to be much higher in human follicular fluid than in blood
serum. This suggests active transport of ascorbic acid against the concentration gradient (5, 6) and that
ascorbic acid may play a role as an antioxidant vitamin during folliculogenesis (7).
We assessed the effectiveness of ascorbic acid supplementation in patients with luteal phase defects.
Between January 1997 and December 2000, 313 patients with luteal phase defect who visited two centers
(Sapporo Medical University Hospital and Sapporo Toho Hospital) for treatment of infertility were considered
for enrollment. Patients receiving IVF-ET treatment were excluded.
The study was approved by the institutional review board of Sapporo Medical University and Sapporo
Toho Hospital. Informed consent was obtained from each patient after the purpose and nature of the study had
been fully explained.

Received July 8, 2002;

revised and accepted
January 21, 2003.
Supported by Grant-Aid for
Scientific Research
(11671637) of the
Japanese Ministry of
Education, Science and
Culture (T. Endo).
Reprint requests: Toshiaki
Endo, M.D., Department of
Obstetrics and
Gynecology, Sapporo
Medical University School
of Medicine, South 1 West
16 Chuou-ku, Sapporo
060-8543, Japan (FAX: 8111-614-0860; E-mail:
endot@sapmed.ac.jp).
0015-0282/03/$30.00
doi:10.1016/S0015-0282(03)
00657-5

Patients were eligible if the peak serum P level was less than 10 ng/mL in the mid-luteal phase, as
measured at three time points (5, 7, and 9 days after ovulation). We based this criterion on a report stating that
normal luteal function depended on the serum P level in normal women (10 ng/mL in the mid-luteal phase)
(8).
Because the diagnosis of luteal phase defect is still controversial, we ascertained luteal phase defect in two
consecutive menstrual cycles. The third cycle was the study cycle. We considered the serum P level to have
improved if the highest level of serum P after the supplementation was greater than 10 ng/mL and that the
increase from the previous cycles to the third cycle was greater than 5 ng/mL, because the amplitudes of P
pulses are reported to range from 3 to 5 ng/mL (9).
One hundred fifty patients who fulfilled the entry criteria were randomly assigned to the control group (46
of 74 patients with no treatment in the third cycle; 28 patients were withdrawn) or the study group (76 patients
given oral vitamin C, 750 mg/d [HICEE Granules; Takeda Chemical Industries, Tokyo, Japan]), started on the
first day of the third cycle until a urinary pregnancy test was positive). Serum P and E2 levels were measured
at the mid-luteal phase as described above. Pregnancy rate was checked for at most 6 months after the study
cycle was started.
All results are expressed as means (SE). The Student t-test was used for statistical evaluation where
appropriate, and 2 analysis and the Fisher exact probability test were used to evaluate the rate of improvement
in luteal phase defect, pregnancy rate, and miscarriage rate.
The two groups did not differ significantly in the hormonal profile at diagnosis of luteal phase defect. Table
1 shows the highest serum P level in two consecutive menstrual cycles as the level of serum P before
treatment.

459

TABLE 1
Effects of ascorbic acid supplementation on patients with luteal phase defects.
Control group (n 46)
Characteristic

Pretreatment

Age (y)
Serum P level (ng/ml)
Improvement rate
Serum E2 level (pg/mL)
Pregnancy rate
Miscarriage rate

34.1 0.6
7.95 0.25b
102.1 0.78b

Ascorbic acid group (n 76)

Post-treatment
8.73 0.50b
10/46 (21.7)a
104.3 6.41b
5/46 (10.9)a
1/5 (20.0)d

Pretreatment
35.3 0.4
7.51 0.22c
105.7 6.7c

Post-treatment

P
valuea
.098

13.27 0.63c
40/76 (52.6)a
138.7 7.8c
19/76 (25.0)a
3/19 (15.8)d

.01
.0447
.635

Note: Values are means ( SE) in number (percentage) of patients. Serum steroid levels before treatment are the highest values of two consecutive cycles
before supplementation.
a 2
test, Control group vs. ascorbic acid supplementation group in the post-treatment group indicated.
b
No significant difference between pretreatment control value and post-treatment control value in either value in the treatment group.
c
Significant difference between pretreatment and post-treatment values in the ascorbic acid group. (P.01).
d
Fishers exact probability test. Control group vs. ascorbic acid supplementation group in the post-treatment group.
Endo. Ascorbic acid for luteal phase defect. Fertil Steril 2003.

No differences in serum P levels between the third cycle and the

previous two cycles were seen in the control group. In contrast, the
serum P level was significantly elevated after ascorbic acid supplementation, as was the serum E2 level.
In the control group, the P level spontaneously improved in 10
of 46 (22%) patients. In contrast, ascorbic acid supplementation
improved the P level in 40 of 76 (53%) treated patients. The
difference in improvement rate between the control group and the
ascorbic acid supplementation group was statistically significant.
Nineteen patients (25%) in the ascorbic acid supplementation
group and 5 patients (11%) in the control group became clinically
pregnant. This difference was statistically significant.
Miscarriage rates were 16% and 20% in the ascorbic acid group
and the control group, respectively; these rates did not significantly
differ. All pregnancies occurred in patients in whom the luteal
phase defect resolved, whether spontaneously or as a result of
ascorbic acid supplementation.
In our study, ascorbic acid supplementation significantly increased serum P levels in patients with luteal phase defect. The
clinical pregnancy rate was significantly higher in the ascorbic acid
supplementation group than the control group. Thus, ascorbic acid
supplementation is an effective treatment for some patients with
luteal phase defect.
It is sometimes difficult to diagnose luteal phase defect because
a low level of serum P does not occur during every cycle, even in
patients with the disorder. Because the diagnosis of luteal phase
defect is controversial, we defined luteal phase defect on the basis
of the peak P level during two consecutive menstrual cycles. The
third cycle was the study cycle. Nonetheless, it was not certain that
luteal phase defect would occur in the third cycle.
Therefore, we assessed the effectiveness of ascorbic acid supplementation by comparing it with the rate of spontaneous improvement of luteal phase defect. We found that ascorbic acid supplementation caused improvement in 53% of luteal phase defect cases,
whereas 22% of patients with luteal phase defect had spontaneous
improvement. Thus, ascorbic acid supplementation is effective.

460

Henmi et al.

Correspondence

Several pathophysiologic mechanisms for luteal phase defect

have been proposed, although its etiology is still unclear (10). Free
radicals are thought to be a cause of luteal phase defect. Lipoperoxide levels in patients with luteal phase defect are reported to be
significantly higher than those of normal women (11).
In the same report, the serum E2 level in patients with luteal
phase defect appeared to be nonsignificantly lower than that in
controls. In our study, the mean E2 level in the control group and
the ascorbic acid supplementation group were near the limits of the
normal range in the mid-luteal phase. Ascorbic acid supplementation significantly increased serum E2 levels as well as serum P
levels.
We previously reported that hydrogen peroxide reduced production of both P and E2 by human cultured granulosa lutein cells (12).
Taken together, these findings suggest that some luteolytic substances may suppress both P and E2 production in luteal phase
defect, although it is unclear whether these substances are free
radicals.
Oxidative stress can arise through increased production of reactive oxygen species or through deficiencies that develop owing to
decreased intake of antioxidant substances, such as vitamins C and
E and -tocopherol (13). Plasma levels of ascorbic acid, -tocopherol, and erythrocyte glutathione were found to be significantly
lower in recurrent aborters with luteal phase defects than in healthy
women (2).
Ascorbic acid has three biological functions, each dependent on
its role as a reducing agent. It is required for biosynthesis of
collagen, for biosynthesis of steroids and peptide hormones, and for
prevention or reduction of the oxidation of biomolecules (14).
Infertility is a benchmark of ascorbate deficiency in the guinea
pig, a species that, like humans, requires a dietary source of
ascorbate (15). Ascorbic acid deficiency characteristically produces
ovarian atrophy and extensive follicular atresia and causes premature resumption of meiosis (16, 17). More recently, ascorbic acid
and other antioxidants were shown to inhibit follicular apoptosis in
cultured rat follicles (18). Follicular phase events are known to

Vol. 80, No. 2, August 2003

affect subsequent P production in the luteal phase. Ascorbic acid

supplementation enhances the ovulation-inducing effects of clomiphene by an apparently local ovarian effect (19).
In that study, (19), 400 mg of ascorbic acid was administered
daily. Dietary supplementation during pregnancy may reduce the
frequency of birth defects (20), and a daily supplement of at least
500 mg of vitamin C, starting as early in pregnancy as possible, has
been suggested (21). We chose 750 mg of ascorbic acid for our
study because 750 mg or more of ascorbic acid was suggested to
produce a definite antioxidant effect (22). However, it is not known
what amount of ascorbic acid supplementation is best to treat luteal
phase defect.
We believe that ascorbic acid supplementation improved steroidogenesis in our study, although it is not known whether this
occurred via antioxidant effects. Ascorbic acid supplementation
may not cause improvement in some patients with luteal phase
defect because this condition may have many causes. However,
ascorbic acid supplementation should be tried in these patients, as
it is clearly effective for some cases of luteal phase defect, is
cost-beneficial, and does not have side effects.
Hirofumi Henmi, M.D.a
Toshiaki Endo, M.D.a
Yoshimitsu Kitajima, M.D.a
Kengo Manase, M.D.a
Hiroshi Hata, M.D.b
Ryuich Kudo, M.D.a
Department of Obstetrics and Gynecology,a Sapporo Medical
University Hospital, Sapporo, Japan and Department of
Obstetrics and Gynecology,b Sapporo Toho Hospital,
Sapporo, Japan

Acknowledgments: The authors thank Dr. M. Fujii and Dr. T. Kiya for
helpful discussion and suggestions.

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