Gynecological Endocrinology

ISSN: 0951-3590 (Print) 1473-0766 (Online) Journal homepage: http://www.tandfonline.com/loi/igye20

The neuro control of the ovarain cycle – a

hypothesis

Bruno Lunenfeld & Klaus Bühler

To cite this article: Bruno Lunenfeld & Klaus Bühler (2017): The neuro control of the ovarain cycle
– a hypothesis, Gynecological Endocrinology, DOI: 10.1080/09513590.2017.1405933

To link to this article: https://doi.org/10.1080/09513590.2017.1405933

Published online: 24 Nov 2017.

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 GYNECOLOGICAL ENDOCRINOLOGY, 2017
https://doi.org/10.1080/09513590.2017.1405933

REVIEW ARTICLE

The neuro control of the ovarain cycle – a hypothesis

€hlerb
Bruno Lunenfelda and Klaus Bu
a
Faculty of Life Sciences, Bar-Ilan University, Ramat Gan, Israel; bCentre for Gynaecology Endocrinology and Reproductive Medicine – Stuttgart
and Ulm, Stuttgart, Germany

ABSTRACT ARTICLE HISTORY

Since more than 100 years, it is known that pituitary function depends upon the function of higher cen- Received 8 November 2017
ters in the brain. It was already assumed at this time that pituitary extracts could influence the gonads Accepted 13 November 2017
and postulated that their use could have practical applications. In 1926, the ‘gonadal principle’ was dis- Published online 23 Novem-
covered revealing the regulation of ovarian function by the pituitary. The two pituitary hormones were ber 2017
Downloaded by [University of Southern Queensland] at 11:11 27 November 2017

called ‘Prolan A’ and ‘Prolan B’ which are responsible for ovarian function especially secretion of the hor- KEYWORDS
mones: ‘lutein’ and ‘foliculin’. If the names of Prolan A and B are changed to follicle-stimulating hormone Cycle function; pituitary;
(FSH) and luteinizing hormone (LH), and the names of foliculin and lutein to estrogen and progesterone, GnRH pulsatility;
it becomes obvious that the pituitary–gonadal relationship, as we know it today, was first described in gonadotropin secretion;
1930. Then, the next step was the isolation, sequence and synthesis of gonadotropin releasing hormone KNDy neurons
(GnRH) responsible for the secretion of gonadotropins (Gn). It could be shown that GnRH pulse frequency
has differential effects on Gn secretion: low-frequency pulses of GnRH stimulate preferentially FSH and
high frequency LH secretion. The pulse frequency control depends from a subpopulation of kisspeptin
neurons within the infundibular region of the hypothalamus with coexpression of neurokinin B and dynor-
phin A – KNDy neurons showing a negative feedback to estrogen. A second group of kisspeptide neurons
in the rostral periventricular area of the third ventricle is devoid of neurokinin-B and dynorphin, mediates
positive feedback from estrogen and so induces the midcycle LH-surge. Therefore, the variability in the
frequency and amplitude of GnRH pulsatility is central to the differential regulation of LH and FSH and
thus ovarian follicle development, the correct selection of a single dominant follicle for ovulation, the LH
surge and the luteal phase.

Introduction ovarian function is regulated by the pituitary. In 1927, Smith

The first experimental evidence suggesting that the pituitary had
a role in regulating the gonads stemmed from the studies of
Crowe and his coworkers. They showed that partial pituitary
ablation resulted in atrophy of the genital organs in adult dogs,
and a persistence of infantilism and sexual inadequacy in puppies
[1]. Two years later, in 1912, Aschner confirmed these findings
and also postulated that pituitary function depends upon the
function of higher centers in the brain. He observed that men
and women with diseases, tumors or injuries of the hypophysis,
pituitary stalk and centers including and above the medulla
oblongata suffered hypopituitarism and, consequently, gonadal
atrophy [2]. He further demonstrated that sectioning of the pitu-
itary stalk affected the genital organs and, therefore, hypothesized
that pituitary extracts may affect the gonads. He postulated that
their use might have practical applications.
Another 15 years were to elapse before two different groups
independently discovered the ‘gonadotrophic principle’. In 1926,
Smith showed that daily implants of fresh anterior pituitary
gland tissue from mice, rats, cats, rabbits and guinea pigs into
immature male and female mice and rats rapidly induced preco-
cious sexual maturity, marked enlargement of the ovaries and
superovulation [3,4]. In the same year, Zondek implanted anter-
ior pituitary glands from adult cows, bulls and humans into
immature animals, and this evoked a rapid development of sex-
ual puberty [5]. These pioneering experiments revealed that
demonstrated that hypophysectomized immature male or
female rats and mice failed to mature sexually and that
removal of the pituitary gland from adult animals without
injury to the brain resulted in profound atrophy of genital
organs, rapid regression of sexual characteristics and total loss
of reproductive function in both sexes [6]. Only 2 years later,
Zondek proposed the idea that the pituitary secretes two hor-
mones that stimulate the gonads. He named these biological
substances ‘Prolan A’ and ‘Prolan B’. He postulated that
Prolan A stimulated follicular growth, that Prolan A together
with Prolan B stimulated the secretion of ‘foliculin’ and that
Prolan B-induced ovulation, the formation of the corpus
luteum and the secretion of the hormones: ‘lutein’ and folicu-
lin. These two hormones induced glandular transformation of
the endometrium, with endometrial proliferation, and also
caused changes in the vaginal epithelium. Zondek realized that
the dynamics of Prolan A secretion by the anterior pituitary
and the correct timing of Prolan B discharge are responsible
for the rhythm of ovarian function: this in turn controlled the
proliferation and function of the endometrium to create opti-
mal conditions for nidation of the fertilized oocyte.
If we merely change the names of Prolan A and B to follicle-
stimulating hormone (FSH) and luteinizing hormone (LH),
and the names of foliculin and lutein to estrogen and progester-
one, we can see that by 1930 Zondek had described the
pituitary–gonadal relationship, as we know it today [6].

CONTACT Klaus B€
uhler buehler@ivf-zentrum.de Centre for Gynecological Endocrinology and Reproductive Medicine – Stuttgart and Ulm, Stuttgart, Germany
ß 2017 Informa UK Limited, trading as Taylor & Francis Group
 2 €
B. LUNENFELD AND K. BUHLER
In 1962, using a sequential step-up/step-down
regimen with human menopausal gonadotropins and inducing
ovulation with hCG, we were able to prove Zondek’s
concept [7].
It was only in 1955 that Harris showed through a series of
elegant experiments that ‘the hypothalamo–hypophysial portal
vasculature is necessary for the maintenance and control of nor-
mal activity of the anterior pituitary’. He proposed that
‘that nerve fibers from the hypothalamus liberate some humoral
substance(s) into the capillaries of the primary plexus in the
median eminence [8]. Harris stated three requirements that must
be met for a compound to be accepted as a releasing factor of
adenohypophysial hormones:
(a) show this substance is present in the blood in the hypophysial
portal vessels in greater amount than in systemic blood,
(b) show that the concentrations of this substance in the blood
Downloaded by [University of Southern Queensland] at 11:11 27 November 2017
of the hypophysial portal vessels varies according to electrical
or reflex activation of the hypothalamic nerve tracts,
(c) demonstrate that activity of the adenohypophysis is correlated
with this varying concentration.
It took another 16 years until Andrew Schally announced the iso-
lation, sequence and synthesis of gonadotropin releasing hormone
(GnRH) in 1971 [9]. It was hypothesized that GnRH was responsible
of inducing ovulation by stimulating the LH surge [10,11].
Newton J and Collins WP in 1972 demonstrated that with
50 lg GnRH there was a variable rise in LH (3–16 times the
mean basal level): a small rise in FSH (two to three times the
mean basal level) and a twofold to threefold rise in estradiol
three to eight hours after the rise in gonadotrophins [12].
Three years later in 1975, we were able to prove the concept
that GnRH could induce an LH surge followed by ovulation in
hypopituitary hypo gonadotropic women following follicle stimu-
lation with gonadotropins using intranasal self-administered
gonadotrophin-releasing hormone (our project was called: ‘sniff
your way to pregnancy’) [13].
How does GnRH pulse frequency influence
gonadotropin secretion?
In 1980, Knobil demonstrated that only pulsatile administration
of GnRH stimulates gonadotropic secretion, whereas continuous
administration inhibits gonadotropin secretion. Thus, the control
of the ovarian cycle shifted to the hypothalamus [14].
In the same year, this concept was proven by Leyendecker
et al. [15]. They demonstrated that in patients with severe hypo-
thalamic amenorrhea, associated with absent or deficient hypo-
thalamic secretion of GnRH, ovarian function could be restored
by chronic intermittent (pulsatile) GnRH administration. They
delivered using a peristaltic pump and a computerized timing
device 50 microliters of a GnRH containing solution once every
90 min via an i.v. catheter into the circulation. The patient ovu-
lated and became pregnant.
Soon afterwards, Wildt et al. clearly showed that GnRH pulse
frequency has differential effects on LH and FSH secretion. In
adult ovariectomized rhesus monkeys bearing hypothalamic
lesions which reduced circulating LH and FSH to undetectable
levels, low-frequency pulses of GnRH stimulated preferentially
FSH secretion and high-frequency GnRH secretion stimulated
preferentially LH secretion [16].
But it took more than a decade until Kaiser et al. [17–19]
proposed mathematical and molecular models of pulse-coded
hormone signal responses in pituitary gonadotrophic cells.
They demonstrated that slow pulses generated by the GnRH
pulse generator activated the G Protein cascade resulting in
CREB activation that dictates the FSHb transcriptional
response. Rapid pulses go through Path B of the G Protein
cascade (PKC- MEK I/II to ERK-) leading to ICER produc-
tion; an antagonist of CREB and resulting in predominantly
LHb production.
How is pulse frequency controlled?
A subpopulation of kisspeptin neurons with coexpression of neu-
rokinin B and dynorphin A has been discovered within the
infundibular region of the hypothalamus (commonly called the
‘KNDy neurons’).
They form an autosynaptic estrogen-responsive negative feed-
back loop within the hypothalamus, and modulate GnRH pulsa-
tility and subsequent FSH and LH release in the pituitary [20].
Sex steroids mediate their negative feedback on KNDy neu-
rons in the infundibular nucleus by inhibiting both dynorphin
secretion (a suppressor of pulse frequency) and kisspeptide neu-
rons (stimulators of pulse amplitude) as well as and neurokinin-
B (its specific role in woman has not been fully elucidated).
A second group of kisspeptide neurons in the rostral periven-
tricular area of the third ventricle (RP3V) corresponds to antero-
ventral periventricular nucleus (AVPV) in rodents, is devoid of
neurokinin-B and dynorphin and mediates positive feedback
from estrogen [21].
The neural control of the menstrual cycle
The predominant rise of FSH during the luteal–follicular transi-
tion is critical for follicular recruitment and growth. The luteal–
follicular transition is characterized by decreasing plasma levels
of E, progesterone, and inhibin A, with concomitant increases in
FSH.
One of the mechanisms by which predominantly FSH is dif-
ferentially synthesized involves the up regulation (by decreasing
ovarian steroids) of kisspeptides, neurokinin b and dynorphin
neurons in the infundibular area – kisspeptides increasing ampli-
tude of GnRH pulses and dynorphin simultaneously decreasing
GnRH pulse frequency. Pulse frequency decreases from 3–4 h
pulses per hour to 1 pulse per hour resulting in a predominant
FSH increase (Figure 1(A)).
Increasing E2 levels during the follicular phase by growing
follicles, downregulate the KNDy neurons in the infundibular
area. The decrease in kisspeptides and neurokinin decrease the
amplitude of GnRH pulses and the decrease in dynorphin
increases the frequency of GnRH pulses. This results in a
decrease of gonadotrophins and a predominance of LH. FSH is
further decreased by inhibin secreted by the growing follicles
(Figure 1(B)).
Only the follicle with the largest number of FSH receptors
will continue its development in the presence of reduced FSH
levels. The increasing LH levels due to upregulation of kisspep-
tide neurons in the rostral periventricular area of the third ven-
tricle by increasing estrogens are responsible for luteinization
and or atresia of all other follicles [22] (Figure 1(C)).
High levels of estrogens restore and upregulate kisspeptin
expression in the neurons of the rostral periventricular area of
the third ventricle to induce high amplitude GnRH pulses. The
high frequency of the pulses due to the decreased dynorphin lead
to the preovulatory predominantly LH surge (Figure 1(D)).
 GYNECOLOGICAL ENDOCRINOLOGY 3

(A) GnRH neurons

rostral periventricular area of the third ventricle

KiSS-1 mRNA
-
Lepn + KISS1R,
GPR54
Ghrelin - infundibular nucleus
Low frequency
NEUROKININ B GnRH
KP

DYNORPHIN A
+ KiSS-1 mRNA

-E2
Up-regulaon

FSH
E2
LH
Downloaded by [University of Southern Queensland] at 11:11 27 November 2017

GnRH neurons
(B)
rostral periventricular area of the third ventricle

Up-regulaon
KiSS-1 mRNA

+ KISS1R,
KiSS-1 mRNA GPR54
infundibular nucleus
GnRH

-E2 Down regulaon

E2
inhibin

FSH
- LH

(C) GnRH neurons

rostral periventricular area of the third ventricle

Up-regulaon
KiSS-1 mRNA

+ KISS1R, GnRH
KiSS-1 mRNA GPR54
infundibular nucleus

-E2
Down regulaon

E2
inhibin
FSH
- LH

Figure 1. LH and FSH secretion depending from the KNDy neuron in infundibular nucleus and the KISS1R in the rostral periventricular area of the third ventricle.
(A). During early follicular phase. (B). During mid follicular phase. (C). During late follicular phase. (D). During the period of LH surge.
 4 €
B. LUNENFELD AND K. BUHLER
(D)
rostral periventricular area of the third ventricle
(Pre opc area)
Kisspepn
Up regulaon infundibular nucleus
NEUROKININ B
DYNORPHIN A
E2
Down regulaon
Downloaded by [University of Southern Queensland] at 11:11 27 November 2017
Figure 1. Continued.
Besides the increasing E2 levels, the anteroventral periven-
tricular nucleus receives afferent fibers from the suprachiasmatic
nucleus, the location of circadian clock, which coordinates and
provides precise timing for the LH surge (demonstrated in ani-
mals). With the beginning of the LH surge, the dominant follicle
undergoes Meiosis 1, 36 h later it ruptures and releases the sec-
ondary oocyte.
The LH surge causes the remaining parts of the dominant fol-
licle to transform into the corpus luteum with a significant
increase in Progesterone [23].
The LH surge is terminated by desensitization due to clathrin-
mediated internalization of arrestin and KISS1R in internalized
vesicles after kisspeptin activation [24].
Apart from securing the function of the corpus luteum, LH
plays a crucial role during the luteal phase by upregulating
growth factors like vascular endothelial growth factor A
(VEGFA) and fibroblast growth factor 2 (FGF2).
These factors are thought to enhance and support implant-
ation and early neo-vascularization.
E2 and progesterone secreted by the corpus luteum inhibit
KNDy decreasing GnRH amplitude leading to a decrease in LH.
This leads to the decline of the corpus luteum followed it by
menstruation and the luteal–follicular transition.
In the case that the egg was fertilized the trophoblast layer of
the developing blastocyst begins to produce and secrete hCG and
rescue the corpus luteum. hCG's primary role is to keep the cor-
pus luteum functioning, so that the corpus luteum continues to
produce estrogen and progesterone and other substances to pre-
pare and facilitate implantation.
Conclusions
The variability in the frequency and amplitude of GnRH pulsatil-
ity is central to the differential regulation of LH and FSH and
thus for ovarian follicle development, for the correct selection of
a single dominant follicle for ovulation, for the LH surge and the
luteal phase. There is strong evidence for proposing that in the
infundibular nucleus NKB/kisspeptin/dynorphin neurons are part
of the neural network influencing the pulsatile secretion of
GnRH neurons
High frequency
GnRH
KISS1R,
GPR54
Kisspepn
inhibin
FSH
LH
GnRH and contribute to the multiunit activity known as the
GnRH pulse generator. This represents a complexity of a system
regulated by multiple inputs (sex steroids, seasons, stress, circa-
dian rhythms and energy balance) with cell bodies that are
widely scattered in the basal forebrain.
In humans, KNDy neurones mediate negative sex steroid
feedback in the infundibular nucleus by suppressing the secretion
of kisspeptin and neurokinin B (stimulators of GnRH) and stim-
ulating the secretion of dynorphin (an inhibitor of GnRH). Thus,
kisspeptin in the infundibular nucleus mediates negative feedback
of estrogen in humans. AVPV nucleus receives afferent fibers
from the suprachiasmatic nucleus, the location of circadian clock,
which coordinates and provides precise timing for the LH surge
and the kisspeptin system, devoid of neurokinin-B and dynor-
phin, mediates positive feedback from estrogen and so induces
the midcycle LH-surge.
Accepting that frequency of GnRH pulses is controlled by
dynorphin and amplitude by kisspeptide, it can be speculated
that the elevated dynorphin and elevated kisspeptide at the initi-
ation of the ovarian cycle are responsible for the elevated pre-
dominant FSH and so for recruitment and development of
follicles. With the increase of estrogens by the growing follicles
dynorphin decreases and GnRH frequency increases causing an
increase in LH and decrease of FSH responsible for selection of a
single follicle. A further increase of estrogen by the maturing fol-
licle upregulates kisspeptide neurons in the rostral periventricular
area of the third ventricle and increases the amplitude of the
high frequency GnRH pulses to provoke the LH surge respon-
sible for ovulation and formation of the corpus luteum. Beside
the neuro-regulation, intraovarian mechanism like activin,
inhibin and kisspeptides play an important part for ‘fine-tuning’
and must not be neglected. It has been shown that receptors of
kisspeptin and neurokinin B are expressed in human granulosa
cells [25]. Referring to Ruohonen et al. [26], having demon-
strated kisspeptin receptors in oocytes, the hypothesis can be
established that kisspeptides protect follicles from atresia. The
high amount of kisspeptides in the beginning of the cycle and
before ovulation protect the follicle(s) from atresia. In the late
follicular phase, when kisspeptides are low, together with higher

levels of LH they promote atresia of smaller and not well devel-
oped follicle and help so in the selection of the best follicle.
Disclosure statement
BL and KB have nothing to declare.
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