Pii: s0015-0282(01)02841-2

FERTILITY AND STERILITY௡
Copyright 2001 American Society for Reproductive Medicine Printed on acid-free paper in U.S.A.
Vaginal versus oral E administration: effects
on endometrial thickness, uterine perfusion,
and contractility
Renato Fanchin, M.D., Claudia Righini, M.D., Luca Maria Scho¨nauer, M.D.,Franc¸ois Olivennes, M.D., Joa˜o Sabino Cunha Filho, M.D., and Rene´ Frydman, M.D. Department of Obstetrics and Gynecology and Reproductive Endocrinology, Hoˆpital Antoine Be´cle`re,Clamart, France Objective: To compare the effects of vaginal or oral E administration on endometrial thickness, uterine
Design: Prospective, randomized, crossover study.
Setting: Assisted Reproduction Unit, Clamart, France.
Patient(s): Thirty-nine infertile women undergoing 78 E /P cycles.
Intervention(s): Women received micronized 17␤-E , 2 mg/day orally (cycle days 1 to 28) and P, 300
mg/day vaginally (cycle days 15 to 28). After a menstrual cycle washout interval, women received a similartreatment except that 17␤-E was administered vaginally.
Main Outcome Measure(s): Endometrial thickness, mean uterine artery pulsatility index, endometrial blood
flow, and uterine contraction frequency assessed in ultrasound scans on cycle days 14 and 18.
Result(s): On day 14, the endometrium was thicker (8.7 Ϯ 0.6 vs. 7.1 Ϯ 0.3 mm, PϽ.0001), pulsatility index
values were lower (2.4 Ϯ 0.1 vs. 3.0 Ϯ 0.2, PϽ.0002), and endometrial blood flow tended to be increased in
the vaginal E cycles as compared to the oral E cycles. On day 18, similar differences remained. However,
P-induced decrease in contraction frequency was slighter in vaginal E cycles (33% vs. 18%, PϽ.0003).
Conclusion(s): Vaginal E administration improves endometrial proliferation and uterine perfusion, presum-
ably because of combined local and systemic effects, but may interfere with P-induced uterine relaxation.
(Fertil Steril௡ 2001;76:994 – 8. 2001 by American Society for Reproductive Medicine.)
Key Words: Hormonal replacement cycle, E , P, ultrasound, endometrial receptivity, embryo implantation
Received February 21,2001; revised andaccepted May 24, 2001.
Adequate uterine estrogenization is a neces- either the oral (1–3, 16) or transdermal (15) sary condition for uterine receptivity (1–3).
routes have been used, with comparable effi- Estrogens partake in key mechanisms that reg- cacy (17). However, in a fraction of cases, both ulate uterine preparation to embryo implanta- approaches fail to achieve proper uterine estro- tion, such as stimulation of endometrial prolif- genization and lead to defective endometrial Annual Meeting of theAmerican Society for eration (4, 5) and improvement of uterine (6, 7) thickness (4, 5, 18), uterine perfusion (7–9), and endometrial (8, 9) perfusion. In addition, and pregnancy rates (4, 5, 7–9, 18).
estrogens are likely to stimulate myometrial contractile activity during the follicular phase may be an interesting alternative. A recent of the menstrual cycle (12, 14). Subsequently, study by Tourgeman et al. (19) showed that uterine contractility undergoes a significant de- vaginal E administration induces serum and crease during the luteal phase as a result of P endometrial tissue E concentrations, respec- (12–14), presumably to assist in embryo im- tively, 10-fold and 70-fold higher than the oral route at similar doses (19). These data provide further support to the hypothesis of a preferen- modalities of frozen-thawed ET cycles (15, tial uterine absorption of vaginally adminis- 16), satisfactory priming of the uterus with tered drugs (20, 21). However, clinical docu- 0015-0282/01/$20.00PII S0015-0282(01)02841-2 exogenous E before ET is required. For this, mentation on possible beneficial effects of vaginal E administration on endometrial proliferation and To prevent the possibility that the effect of one cycle carried over to the other cycle, women were randomly allo-cated to start the protocol by cycle I or cycle II (19 women In addition, possible overstimulation of uterine contrac- followed the cycle I– cycle II sequence, and 20 women tility by the high peripheral and local E levels (12, 14) followed the cycle II– cycle I sequence). In addition, be- induced by vaginal E administration, as well as the effec- tween the two subsequent cycles, all women respected a tiveness of subsequent uterine relaxation mediated by P, washout interval of one menstrual cycle without hormonal remain to be investigated. This issue is of particular impor- tance because high-frequency contractions at the time of ETare associated with poor implantation rates (11). The hyper- Ultrasonographic Monitoring
contractility at the time of ET may be attributable to an On days 14 and 18 of cycles I and II, ultrasound scans of incomplete uterine quiescent action of P in the presence of a sagittal plane of the uterus were performed using a 4.5- to the supraphysiologic E levels triggered by controlled ovar- Elegra, Siemens S.A.S., Saint-Denis, France) by one single Therefore, we elected to investigate the possible uterine operator (L.M.S.) at approximately 9:00 AM. The operator impact of E administered vaginally on endometrial thick- was not aware of the treatment schedule or the clinical ness, uterine perfusion, and uterine contractions before and outcome. Environmental conditions were standardized throughout the ultrasound examination.
To assess the endometrial thickness, endometrial borders MATERIALS AND METHODS
were set arbitrarily as the outer limits of the hyperechogenicmyometrium– endometrium interfaces. Endometrial thick- Patient Characteristics
ness (truly double endometrial thickness) was calculated as We prospectively studied 39 infertile candidates under- the greatest distance between the outer limits of the proximal going 78 E /P replacement cycles with frozen-thawed ETs.
and distal endometrial–myometrial interfaces. Sensitivity of To limit the possibility of confounding factors in the analysis endometrial thickness calculation was 0.1 mm. Intra-analysis of our results, we included only young (Ͻ38 years of age), coefficient of variation of our measurements were Ͻ5%.
nonsmoking, regularly ovulating, lean (body mass indexes Uterine perfusion was assessed by uterine artery imped- ranging between 18 and 25) women, whose uteri were mor- ance (6, 7) and endometrial blood flow (8, 9) measurements.
phologically normal as confirmed by hysteroscopy and ul- To evaluate uterine artery impedance, blood flow of the trasound (absence of fibroids, adenomyosis, or polyps).
ascending branches of the right and left uterine arteries was Women whose uterine position did not allow adequate visu- detected by color Doppler and assessed with the mean pul- alization of the uterus by transvaginal ultrasonography were satility index calculation. Furthermore, the presence or ab- not included. In addition, women with a history of dilation sence of endometrial blood flow was evaluated by power and curettage or uterine surgery were also excluded, because Doppler. Power Doppler settings were standardized for ad- of possible confounding effects of these conditions on uter- equate sensitivity using a high pass filter at 60 Hz, pulsed ine perfusion and endometrial morphology. Informed con- repetition frequency at 400 Hz, and moderate long persis- sent was obtained from all patients, and this investigation was approved by our Institutional Review Board.
To assess uterine contraction frequency, 2-minute ultra- Study Protocol
sound scans of a sagittal plane of the uterus were digitized Each subject underwent two hormone replacement cycles.
on-line using a two image/second rate with a computer- In cycle I, all 39 women received micronized 17␤-E tablets assisted image analysis system (IoˆTEC 3.1.2, IoˆDP, Paris, by the oral route (2 mg/day; Provame`s, Cassenne Laborato- France), which assists in the quantification of frequency of ries, Puteaux, France), in the evening, from cycle day 1 to myometrial contractile activity. The present study respected 28. From day 15 to 28, vaginal micronized P was adminis- similar methodologic characteristics as previously described tered at doses of 100 mg in the morning and 200 mg in the (11, 22). Briefly, uterine contraction frequency assessment evening (Utrogestan; Besins-Iscovesco Pharmaceuticals, was based on the analysis of time-dependent variation in the Paris, France). Two or 3 days after P discontinuation, with- myometrial– endometrium interfaces and uterine cavity by using a three-dimension-derived methodology (11, 22).
In cycle II, the same women received the same dose of Hormonal Monitoring
micronized 17␤-E (2 mg/day) from cycle day 1 to 28, but E On days 14 and 18, women underwent blood samplings tablets were placed in the vaginal fornix. Tablets of E used for serum E and P measurements. Serum E was determined in both the oral and the vaginal cycles were similar. From by an immunometric technique using an Estradiol-60 Amer- days 15 to 28, women received vaginal micronized P treat- lite kit (Ortho Clinical Diagnostics, Strasbourg, France). The lower limit of detection was 14 pg/mL, and intra-assay and FERTILITY & STERILITY௡
Serum E and progesterone levels in oral and vaginal E cycles.
Note: Hormonal levels are expressed as means Ϯ SE.
a Progesterone.
b Not significant.
Fanchin. Uterine effects of vaginal E . Fertil Steril 2001. interassay coefficients of variation were 8% and 9% for E , E administration induced a remarkable increase in endome- respectively. Serum P was measured by RIA using an I125 trial thickness as compared to oral E administration on days Progesterone Coatria kit (Bio-Me´rieux, Paris, France). The 14 and 18 (PϽ.0001). After endometrial exposure to P, an lower limit of detection was 0.05 ng/mL and intra-assay and additional increase in endometrial thickness occurred in both interassay coefficients of variation were, respectively, 8% Vaginal E administration improved uterine perfusion as Statistics
compared to oral E administration, with significantly lower Measures of central tendency used were means and mea- mean uterine artery pulsatility index values on days 14 and sures of variability were standard errors. With the inclusion 18. Consistently, the presence of endometrial blood vessels of 39 patients into this two-treatment, crossover study the in the endometrium detected by power Doppler tended to be probability is Ն90% that the study will detect a treatment more often observed in the vaginal E cycles than in the oral difference at a two-sided .05 significance level, if the antic- E cycles on days 14 and 18. However, these differences did ipated true difference between the treatments is 1 mm for endometrial thickness, 1 unit of pulsatility index, and 0.5 The consequences of vaginal or oral E on uterine con- uterine contraction/minute. Because data distribution was traction frequency are shown in Table 1. In contrast with the parametric, statistical assessment of pairwise differences be- markedly different circulating E levels, uterine contraction tween cycles I and II was performed by using the paired frequency remained similar in both cycles on day 14. As Student’s t-test. A P value of Ͻ.05 was considered statisti- expected, after P administration, a significant reduction in the contraction frequency occurred from days 14 to 18 inboth the vaginal and oral E cycles (PϽ.0001, respectively).
Yet, the pace of decrease in uterine contraction frequency Hormonal Results
as a result of P administration differed in both cycles. Inter- Consequences of oral or vaginal E administration on estingly, when women received vaginal E , the decrease in serum E and P levels are summarized in Table 1. On day 14, uterine contraction frequency from days 14 to 18 was less circulating E levels in the vaginal E cycles were approxi- than when they received E orally (18% vs. 33%, PϽ.0003), mately 10-fold as high as in the oral E cycles, whereas thereby leading to higher contraction frequency levels in the serum P remained at very low levels in all women in both vaginal E cycles on day 18 (PϽ.007).
DISCUSSION
slightly yet significantly in the vaginal E cycles. As ex- The present study compared the relative uterine effects of pected, vaginal P administration increased serum P to levels vaginal and oral routes for E administration. To address this commonly observed in the midluteal phase of the menstrual issue our investigation set stringent methodologic parame- cycle in both cycles. Furthermore, both modalities for E2 ters. It selected only young, regularly ovulating, lean, non- administration were observed to be well tolerated by patients smoking women. Cases of morphologic uterine abnormali- with no concurrent bleeding and no detectable side effects.
ties or inadequate uterine visualization at ultrasound scans Ultrasound Results
were excluded. In addition, the crossover design used for E2 Uterine effects of oral or vaginal E administration ob- administration reduced confounding effects of individual served in ultrasound scans are detailed in Table 2. Vaginal attributes in the interpretation of results. Finally, ultrasound Fanchin et al.
Uterine effects of oral and vaginal E administration.
Note: Continuous variables are expressed as means Ϯ SE.
a Pulsatility index.
b Expressed as % of cases in which presence of blood flow in the endometrium was detected by power Doppler.
c Not significant.
Fanchin. Uterine effects of vaginal E . Fertil Steril 2001. scans were analyzed by an independent operator who was The slight but significant decrease in serum E levels not aware of treatment modalities, and the assessment of observed from days 14 to 18 in the vaginal E cycles may uterine contraction frequency was assisted by a computer- result from an interference of P administration in the absorp- tion of vaginal E tablets. Yet, it is noteworthy that this Our results showed improved endometrial proliferation, phenomenon did not exert measurable consequences on en- as reflected by thicker endometria, and increased uterine dometrial thickness or induced uterine bleeding. This issue perfusion, as reflected by lower uterine artery pulsatility needs, however, to be further clarified in women receiving index values and enhanced endometrial vascularization, in oral P rather than vaginally. Incidentally, the uniformly low the vaginal E as compared to the oral E cycles, at the same P levels observed on day 14 in all 78 cycles studied confirm doses (2 mg/day). Moreover, uterine contraction fre- that either oral and vaginal administration of micronized 17␤-E starting in the early follicular phase of the menstrual cycles, underwent a less notable reduction after P adminis- cycle (cycle day 1) are effective to prevent ovulation in tration in the vaginal E than in the oral E cycles.
patients with functioning ovaries (15, 16), even at doses as The increased endometrial thickness and improved uter- ine vascularization observed after vaginal E administration Yet, in contrast with the differences observed in serum E may be explained by at least two mechanisms. First, as levels as well as in endometrial proliferation and perfusion, supported by our own previous data (20) and those of other uterine contraction frequency remained similar in both investigators (19, 21), it is possible that the vaginal route groups on day 14. This observation agrees with our previous allows a direct, preferential transport of hormones to the data that indicated that circulating E levels and uterine uterus. The privileged uterine effects of drugs administered contraction frequency in COH cycles are not correlated (11, vaginally presumably are due to a direct in-between or 22). Furthermore, despite the supraphysiologic E through cell vagina-to-uterus diffusion or a more elaborate observed in vaginal E cycles, uterine contraction frequency local transport mechanism involving either a countercurrent did not increase beyond the values commonly observed at circulation system with venous to artery diffusion (20, 21).
the late follicular phase of the menstrual cycle (3– 4 contrac-tions/minute) (10, 14). Taken together, these results lead us Second, it is conceivable that the markedly high periph- to hypothesize that maximum uterine contractile activity is eral E levels achieved with the vaginal route concurred with reached at physiologic E levels and additional increases in the direct uterine effects to foster endometrial proliferation circulating E levels are ineffective to further stimulate uter- and perfusion. Indeed, the 10-fold gradient between serum E levels achieved by the vaginal as compared to the oral route observed in the present study is remarkably similar to Furthermore, the expected decrease in uterine contraction that reported by Tourgeman et al. (19) and consistent with frequency as a result of P administration was milder in the earlier observations (23–25). These discrepancies in serum vaginal E cycles as compared to the oral E cycles. This E levels probably are a consequence of the hepatic inacti- observation is in keeping with the fact that uterine contrac- vation of orally administered E (26).
tion frequency remains high during the early luteal phase of FERTILITY & STERILITY௡
COH cycles, at the time of ET (11, 22), a phenomenon The value of ultrasonographic endometrial measurement in the predic-tion of pregnancy following in vitro fertilization. Fertil Steril 1986;45: associated with poor pregnancy rates (11). The observed “uterine resistance” to P may result from persistent uterine 5. Gonen Y, Casper RF, Jacobson W, Blankier J. Endometrial thickness and growth during ovarian stimulation: a possible predictor of implan- stimulating effects of supraphysiologic E levels that thwart tation in in vitro fertilization. Fertil Steril 1989;52:446 –50.
the uterine quiescent action of P. Contrasting with the lack of 6. Sterzik K, Grab D, Sasse V, Hutter W, Rosenbusch B, Terinde R.
Doppler sonographic findings and their correlation with implantation in measurable effects on uterine contraction frequency, it is an in vitro fertilization program. Fertil Steril 1989;52:825– 8.
possible that chronic uterine exposure to supraphysiologic E 7. de Ziegler D, Bessis R, Frydman R. Vascular resistance of uterine arteries: physiological effects of estradiol and progesterone. Fertil Steril levels in the vaginal E cycles increases uterine excitability to levels that are scarcely counterbalanced by P. Our obser- 8. Steer CV, Campbell S, Tan SL, Crayford T, Mills C, Mason BA, et al.
vation of a more profound uterine relaxation mediated by P The use of transvaginal color flow imaging after in vitro fertilization toidentify optimum uterine conditions before embryo transfer. Fertil in the presence of lower circulating E levels (oral E cycle) supports this hypothesis. Hence, increasing the exposure of 9. Yang JH, Wu MY, Chen CD, Jiang MC, Ho HN, Yang YS. Association of endometrial blood flow as determined by a modified colour Doppler the uterus to P to restore satisfactory uterine relaxation at the technique with subsequent outcome of in-vitro fertilization. Hum Re- time of transfer of frozen/thawed or egg donation embryos 10. IJland MM, Evers JL, Dunselman GA, Volovics L, Hoogland HJ.
should be considered. Yet, it is noteworthy that mean uterine Relation between endometrial wavelike activity and fecundability in contraction frequency after P administration remained below spontaneous cycles. Fertil Steril 1997;67:492– 6.
11. Fanchin R, Righini C, Olivennes F, Taylor S, de Ziegler D, Frydman R.
potentially harmful levels (Ն5 contractions/minute) (11) in Uterine contractions at the time of embryo transfer alter pregnancy rates both treatment cycles, which is reassuring with regard to ET after in-vitro fertilization. Hum Reprod 1998;13:1968 –74.
12. Csapo AI, Pinto-Dantas CR. The cyclic activity of the nonpregnant human uterus. A new method for recording intrauterine pressure. FertilSteril 1966;17:34 – 8.
In conclusion, the favorable proliferative and vascular 13. Martinez-Gaudio M, Yoshida T, Bengtsson LP. Propagated and non- propagated myometrial contractions in normal menstrual cycles. Am J with the adequate tolerance by patients observed by the 14. Lyons EA, Taylor PJ, Zheng XH, Ballard G, Levi CS, Kredentser JV.
present investigation, encourage us to consider the use of the Characterization of subendometrial myometrial contractions throughoutthe menstrual cycle in normal fertile women. Fertil Steril 1991;55: vaginal route for E priming of the uterine receptivity in frozen-thawed ETs and in egg donation cycles. The observed 15. Schmidt CL, de Ziegler D, Gagliardi CL, Mellon RW, Taney FH, Kuhar MJ, et al. Transfer of cryopreserved-thawed embryos: the natural improvement of endometrial thickness and uterine vascular- cycle versus controlled preparation of the endometrium with gonado- ization may be attributed to both the putative direct uterine tropin-releasing hormone agonist and exogenous estradiol and proges-terone (GEEP). Fertil Steril 1989;52:609 –16.
effects of vaginally administered hormones (20, 21) or the 16. Lelaidier C, de Ziegler D, Gaetano J, Hazout A, Fernandez H, Frydman high circulating E levels achieved by vaginal E adminis- R. Controlled preparation of the endometrium with exogenous oestra- diol and progesterone: a novel regimen not using a gonadotrophin- releasing hormone agonist. Hum Reprod 1992;7:1353– 6.
17. Steingold KA, Matt DW, de Ziegler D, Sealey JE, Fratkin M, Reznikov Hence, this novel approach may be particularly useful in S. Comparison of transdermal to oral estradiol administration on hor- the cases of suboptimal endometrial thickness or unsatisfac- monal and hepatic parameters in women with premature ovarian failure.
J Clin Endocrinol Metab 1991;73:275– 80.
tory uterine perfusion not only in hormone replacement 18. Hassan HA, Saleh HA. Endometrial unresponsiveness: a novel ap- cycles, but potentially also in COH cycles. Possible benefi- proach to assessment and prognosis in in vitro fertilization cycles. FertilSteril 1996;66:604 –7.
cial effects of increasing uterine exposure to P to counter- 19. Tourgeman DE, Gentzchein E, Stanczyk FZ, Paulson RJ. Serum and balance the uterine exciting effects of supraphysiologic E tissue hormone levels of vaginally and orally administered estradiol.
Am J Obstet Gynecol 1999;180:1480 –3.
levels and further improve uterine quiescence at the time of 20. Fanchin R, De Ziegler D, Bergeron C, Righini C, Torrisi C, Frydman ET deserve further investigation (27). Finally, prospective R. Transvaginal administration of progesterone. Obstet Gynecol 1997;90:396 – 401.
randomized studies are needed to ascertain that the beneficial 21. Cicinelli E, de Ziegler D, Bulletti C, Matteo MG, Schonauer LM, proliferative and vascular uterine effects of vaginal E ad- Galantino P. Direct transport of progesterone from vagina to uterus.
ministration will lead to a significant improvement of em- 22. Fanchin R, Ayoubi JM, Olivennes F, Righini C, de Ziegler D, Frydman bryo implantation outcome in hormone replacement or COH R. Hormonal influence on the uterine contractility during controlledovarian hyperstimulation. Hum Reprod 2000;15:90 –100.
23. Schiff I, Tulchinsky D, Ryan KJ. Vaginal absorption of estrone and 17beta-estradiol. Fertil Steril 1977;28:1063– 6.
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Fanchin et al.

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