Extracts from BBC web page - Friday,

11 October, 2002,
Frozen egg birth brings IVF hope

“The first British woman to become

pregnant using her own frozen eggs
has given birth to a healthy baby girl.
Helen Perry, 36, from Ludlow,
Shropshire, became pregnant using an
egg which had been taken from her
ovary six months earlier, frozen, stored
then thawed and replanted.

“Dr Gillian Lockwood, whose team made the breakthrough, says: "The
technology ... will work just as well for the Bridget Jones generation who want
to freeze their eggs to keep their reproductive options open.“. On ITV1's
Tonight with Trevor McDonald on Friday, she explains: "I think that egg
freezing may come to be seen as the ultimate kind of family planning."
 The reproductive
lifespan
Ovarian
cycles
Pregnancy Lactation
Reproductive
potential

Male

Female
Puberty Menopause Age
 Menstrual cycle lengths

16 Note: Variations in cycle

length are normal!
14
12
Particularly:
10
%of cycles

• just after menarche

8
(1st menstrual period)
6
4
• approaching the
2 menopause
0
20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36
Cycle length (days)
Menstruation is an
external indicator Hypothalamus
of ovarian events
controlled by the GnRH (gonadotrophin
hypothalamic- Pituitary releasing
pituitary axis hormone)
LH
FSH
Feedback + (“gonadotrophins”)
Ovaries

Roles of the ovary

Steroids
1. Gametes (ova)
(oestradiol,
progesterone).
2. Hormones

Reproductive tract
MENSTRUATION
Other targets
What are oestrogens? Ovaries
OH
Testes
CH3 Placenta
Oestradiol-17

HO
Bone
Brain
Answer: Steroids with characteristic effects, esp. on female
reproductive tract. Some are more potent than others.
` Cardovascular
Breast
system

Reproductive tract
“GnRH pulse
Hypothalamus Pulsatile activity of
generator” GnRH neurones
GnRH Pulses of GnRH
Pituitary

LH Pulses of LH
FSH Plasma LH
+
Ovaries

24 hours
Natural suppression Modulation during
Before puberty menstrual cycle
Lactation Diet
Diet induced Stress?
Anorexia
Malnutrition
Exercise
Hypothalamic neurones
“GnRH pulse generator”

Frequency and amplitude

of GnRH pulses

Pituitary

Changing patterns of
LH and FSH
 Timing events in the menstrual cycle.
1. Onset of menstruation

Day 1 Day 1

0 4 8 12 16 20 24 28

Menstruation
 Timing events in the menstrual cycle.
2. LH surge
LH
Days before Days after

Day 1 Day 1
Follicular phase Luteal phase

0 4 8 12 16 20 24 28

Menstruation
OVULATION
Animated ovarian events

Key events in the ovarian cycle

LH
1. Follicular
Day 1 growth

0 4 8 12 16 20 24 28

Menstruation Oestradiol
OVULATION
Animated ovarian events

Key events in the ovarian cycle

2. Ovulation LH
1. Follicular
Day 1 growth

0 4 8 12 16 20 24 28

Menstruation Oestradiol
OVULATION
Animated ovarian events

Key events in the ovarian cycle

2. Ovulation LH
1. Follicular 3. Luteal function
Day 1 growth

0 4 8 12 16 20 24 28

Menstruation Oestradiol Progesterone

(and oestradiol)
OVULATION
Animated ovarian events

Key events in the ovarian cycle

2. Ovulation LH
1. Follicular 3. Luteal function
Day 1 growth
4. Luteal
regression

0 4 8 12 16 20 24 28

Menstruation Oestradiol Progesterone

(and oestradiol)
OVULATION
The follicle is the fundamental element of the ovary:
Blood vessels
Granulosa
cells
Theca
Antrum

Cumulus
cells

Oocyte

Zona pellucida
(non-cellular glycoprotein coat)
 Cumulus
Oocyte cells

Cytoplasmic
bridges from
cumulus cells
to oocyte for
transport

Zona pellucida
(non-cellular glycoprotein coat)
Where do follicles come from?
 Male Female
Spermatogonia Primordial germ cells
(oogonia)

Continuous
replacement Mitoses stop
in adult in fetal life

Mitoses All enter

Meiosis
MEIOSIS

Spermatozoa Arrested in 1st meiotic

This means there is division
Continuous
a fixed, limitedsperm
pool “Primary oocytes” in
ofproduction
oocytes. primordial follicles
 (Fig adapted from Johnson
& Everitt, 2000)
~7 m

Continuous loss

No. of 99.9% by
germ cells “Atresia”
(millions)
Ovulation
(post-puberty)

Puberty
BIRTH ~ 300,000

3 6 9 1 10 20 40
months years
Conception Age from conception
 Growth of follicles:

Antral Graafian
follicle follicle

Primordial
follicle

Oocyte Ovulation
Antrum
Granulosa (fluid filled
cells space)
Thecal
cells
Lets look at follicular growth first… How many follicles
There are a number of questions to ask… reach this point?

Normally 1

Ovulation

Menstruation
Many! 30-50

How many follicles

are growing at the
start of the cycle?

Ovulation

Menstruation
 Many! 30-50 Why is only 1
selected and
becomes
How many follicles
“dominant”?
are growing at the
start of the cycle?

When do
follicles
start
growing? Ovulation

2-3 months Menstruation

earlier!
What controls Hypothalamus
follicular
growth?
GnRH (gonadotrophin
Pituitary releasing hormone)

LH
(“gonadotrophins”)
FSH
Steroid
feedback
+
Ovaries

Oestradiol (E2)

+
Reproductive tract
Other targets
 What controls
follicular growth? OVULATORY
FOLLICLE

??????
Gonadotrophin
FSH
independent
+ LH

Ovulation

Menstruation
 OVULATORY
FOLLICLE

FSH
+ LH

Ovulation

OESTRADIOL
As each follicle grows, it produces
Menstruation increasing amounts of oestradiol.
 How is oestradiol Granulosa cells
production controlled ? Theca

LH
Androgens are
converted
Androgens (aromatized) to
oestradiol by the
granulosa cells
(Note: the production of
androgens is a normal
part of ovarian FSH
physiology)
Inhibin OESTRADIOL
(protein) (steroid)
 Hypothalamus

_ GnRH
(gonadotrophin
releasing
Pituitary hormone)

FSH
LH
Increasing
amounts of +
oestradiol. Ovaries

Oestradiol (E2)

+
Reproductive tract
Other targets
 Hypothalamus
Increasing
negative
feedback
_ GnRH
(gonadotrophin
releasing
Pituitary hormone)
INHIBIN
(suppresses FSH) Decreased
FSH
Increasing
amounts of +
oestradiol. Ovaries

Oestradiol (E2)

+
Reproductive tract
Other targets
 As the follicles grow, FSH
levels fall due to the
negative feedback,

FSH
Oestradiol

0 4 8 12 16 20 24 28
 Why is only 1
selected and
becomes
Many follicles at
“dominant”?
the start of the
cycle

Ovulation

Menstruation
 Hypothalamus

GnRH
Pituitary

FSH
+
Ovaries

Small follicles: Large follicles: less

Population of growing
very dependent dependent on FSH
Oestradiol (E2)
follicles
on FSH
 Hypothalamus

GnRH
Pituitary

FSH
+
Ovaries

Small follicles: Large follicles: less

very dependent dependent on FSH
on FSHOestradiol (E2)
 Hypothalamus

_
Increasing
negative
feedback GnRH
Pituitary

INHIBIN Decreased
Oestradiol FSH
FSH
+
Ovaries
Large follicles: less


Small follicles:
very dependent dependent on FSH
on FSHOestradiol (E2)
Growth factors
Insufficient Oestradiol Dominant
FSH follicle
+ +
 FSH
secretion
suppressed

FSH Dominant follicle(s)

Oestradiol can survive

Insufficient FSH to
keep smaller follicles
going – they become
atretic.

0 4 8 12 16 20 24 28
 Polycystic ovaries
The classical picture of PCO: a string of
follicles, 2-8 mm in diameter

Section of ovary showing Ultrasound of ovary showing

multiple follicles in PCO multiple follicles
 Granulosa cells
Theca

LH
Androgens are
converted
Androgens (aromatized) to
oestradiol by the
granulosa cells
(Note: the production of
androgens is a normal
part of ovarian FSH
physiology)
OESTRADIOL
(steroid)
4. The disturbed steroid
feedback may re-inforce the 1. Raised LH, lowered FSH
abnormal LH/FSH secretion

3. The high LH
induces high
androgen secretion 2. ….. leads to
from the theca disturbed follicle
growth

HIRSUTISM ANOVULATION
Disturbed cycles
4. The disturbed steroid
feedback may re-inforce the 1. Raised LH, lowered FSH
abnormal LH/FSH secretion

3. The high LH
induces high
androgen secretion 2. ….. leads to
from the theca disturbed follicle
growth

HIRSUTISM ANOVULATION
Disturbed cycles
4. The disturbed steroid
feedback re-inforces the
abnormal LH/FSH
secretion 1. Raised LH, lowered FSH

3. The high LH
induces high
androgen secretion
from the theca 2. ….. leads to disturbe
follicle growth

HIRSUTISM ANOVULATION
Disturbed cycles
 What causes
ovulation?

0 4 8 12 16 20 24 28
 What causes
ovulation?

LH

0 4 8 12 16 20 24 28
 What effects
does it have?

What causes
the LH surge?

0 4 8 12 16 20 24 28
 NOT
HUMANS!

What causes
the LH surge?

Reflex
ovulation

0 4 8 12 16 20 24 28

Mating Neuroendocrine reflex LH

 Oestradiol

0 4 8 12 16 20 24 28
 Hypothalamus
For most of the cycle,
negative feedback
operates…
_
_ GnRH

Pituitary

LH Inhibited by
FSH oestradiol

Oestradiol
Ovary
BUT, with high
levels of E2
maintained for
Hypothalamus
long enough……
+
+ Pituitary
GnRH

LHLH
FSH
surge
Oestradiol
Ovary
BUT, with high
levels of E2
maintained for
Hypothalamus
long enough……
+ Increased GnRH

+ Pituitary
GnRH
Increased
sensitivity
to GnRH

LHLH
FSH
surge
Oestradiol
Ovary
How does the LH surge
affect the follicle?

About 36 h between LH
surge and oocyte release…..
Oocyte:
• Completion of the 1st meiotic
division (unequal division;
extrusion of 1st polar body)

• 2nd meiotic division starts

but becomes arrested before
completion.

Microvilli across the

zona pellucida are
withdrawn.

Loosening of cumulus cells

Enzyme induction in the
follicle wall
Transformation of ruptured follicle into corpus luteum (CL)

• Ruptured follicle
becomes solid corpus
luteum
• Thecal cells and blood
vessels invade
• Granulosa cells
hypertrophy and
terminally differentiate
(“luteinisation”).

Steroid secretion changes – Progesterone

+
Oestradiol
 Follicular phase: Luteal phase:
Oestradiol domination Progesterone domination
What maintains
the CL?

Oestradiol
Progesterone
Why does the
CL degenerate
at the end of the
cycle?

0 4 8 12 16 20 24 28

OVULATION
What maintains
Hypothalamus
the CL?

 8 hr
between GnRH
LH pulses
Pituitary

LH
+
CL
(low levels)

CL very
Progesterone sensitive to LH
+ E2
What maintains
Hypothalamus
the CL?

Steroid negative
- GnRH
feedback keeps
LH and FSH - Pituitary

levels relatively
LH
low
Progesterone
+ E2
+
CL
(low levels in
luteal phase)

CL very
Reproductive tract etc sensitive
 Hypothalamus
Towards the end of
the cycle, the
sensitivity to LH
GnRH
reduces.
Pituitary
The low levels of LH
are insufficient to keep LH

the CL going

Progesterone
+ E2 CL degenerates
 Hypothalamus

GnRH
As CL degenerates… Pituitary

steroid negative feedback FSH

reduces .. + LH

Progesterone
+ E2
 Hypothalamus

GnRH
As CL degenerates… Pituitary

steroid negative feedback FSH

reduces .. + LH

New wave of follicles

stimulated by rising
Progesterone
FSH
+ E and LH
2
 Oestradiol
Progesterone

0 4 8 12 16 20 24 28

OVULATION
 Oestradiol
Progesterone

0 4 8 12 16 20 24 28

OVULATION
 Oestradiol
Progesterone

0 4 8 12 16 20 24 28

OVULATION
 Oestradiol
Progesterone

0 4 8 12 16 20 24 28

OVULATION
Other changes in the cycle

a) Outer muscle layer – the

myometrium

b) Inner glandular mucosa – the

endometrium
 Uterine changes in the menstrual cycle.
Endometrial
depth More secretion from
the glands – hence the
Oestradiol causes
term “secretory
an increase in
phase”
thickness (the
“proliferative
phase”)

0 4 8 12 16 20 24 28

Menstruation
OVULATION
 Terminal differentiation of
stromal cells – “decidualisation”

Characteristic “spiral arteries”

0 4 8 12 16 20 24 28
Optimal time for
Menstruation implantation
What causes the onset of menstruation?

Steroid
levels
fall This is followed
by the onset of
menstruation
1. At end of the luteal phase, steroid production declines.
2. Loss of oedema and gradual shrinking of endometrial tissue. The
spiral arteries become more highly coiled
3. Gradual reduction in blood flow to superficial layers – leading to
ischaemic hypoxia and damage to the epithelial and stroma cells.
4. 4‑24 hours prior to menstrual bleeding, an intense constriction of
spiral arteries occurs.
5. Individual arteries re-open at different times, tearing and
rupturing the ischaemic tissues.
6. Bleeding into the cavity occurs via:
1. red cells diapedese between surface epithelial cells;
2. tears develop in the surface epithelium
3. pieces of weakened superficial endometrium crumble away
7. About 50% of degenerating tissues is resorbed and 50% is lost as
'menstrual bleeding'.
Onset of menstruation is rapid.

Probably 95% of women have

a total blood loss of less than
60 mls.

This blood loss can represent a

significant loss of iron (leading
to anaemia) – especially in
women on marginal diets
 Menstruation - WHY?

In preparation for pregnancy, the human uterine stromal

cells go through complex changes and the stromal cells
terminal differentiate - “Decidualization”.

If implantation and pregnancy do not occur, this tissue is

lost - and the uterus prepares itself again for another
possible pregnancy.
Animated ovarian events

Key events in the ovarian cycle

2. Ovulation LH
1. Follicular 3. Luteal function
Day 1 growth
4. Luteal
regression

0 4 8 12 16 20 24 28

Menstruation Oestradiol Progesterone

(and oestradiol)
OVULATION
 Nearly all
pregnancies
in a 6-day
fertile window

Day of intercourse Ovulation?

Probability of clinical pregnancy following intercourse on a given day
relative to ovulation (estimated from basal body temperature).
Cervical mucus

Abundant mucus
- like “raw egg
Production
white”
of low Cervical
viscosity mucus
mucus
increases Thick, rubbery, high
Variable viscosity -
number of impenetrable to
“dry” days sperm.

0 4 8 12 16 20 24 28

Menstruation
OVULATION
With increasing oestradiol:

1. The mucus becomes more

abundant - up to 30x more and
its water content increases.

2. Its pH becomes alkaline.

3. Increased elasticity –
("spinnbarkeit test")

5. “Ferning pattern” caused by the

interaction of high concentrations
of salt and water with the Characteristic fernlike pattern as
glycoproteins in the mucus. the mucus dries on a glass slide.
 A small (0.5 oC) rise
in BBT typically
38 follows ovulation.
37.8 LH
37.6
37.4
37.2
37
36.8
36.6
Basal body temperature
36.4
36.2
36

0 4 8 12 16 20 24 28

Menstruation
OVULATION
Anovulatory cycle?
 Fertility

LH
Ovulation
Oestradiol
Progesterone

0 4 8 12 16 20 24 28

OVULATION
Basal body temperature

Plasma oestradiol

Plasma progesterone

Volume of cervical mucus

– and sperm penetration

Uterine endometrium
There are a number of potential ways of trying
to identify the “fertile” period..:

a) Calendar Method - which is essentially

based on the previous menstrual history.
b) Temperature method - using a midcycle
rise in body temperature as a sign when
ovulation has occurred.
c) Cervical changes - which can be detected
by feeling the cervix and cervical mucus.
d) Hormonal methods - using over-the-
counter "kits" to assess urinary hormone
levels.
Problem-based powerpoint presentation (using
many of the same screens as this lecture) on the menstrual
cycle can be found at:
www.kcl.ac.uk/ip/stuartmilligan/ppt/pptpage.
html