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American Journal of Research Communication www.usa-journals.com
Al-Katib, et al., 2013: Vol 1(8) ajrc.journal@gmail.com
24
Effects of Vitamin C on the Endometrial Thickness and Ovarian Hormones of
Progesterone and Estrogen in Married and Unmarried Women
Sami R. Al-Katib*, Meissam MH. Al-Kaabi* and Karim A. Al-Jashamy**
*Department of Physiology-Collage of Medicine-University of Kufa, Iraq
** Faculty of Medicine, SEGi University, Malaysia
*Correspondence email: alkatibsami@yahoo.com
ABSTRACT
Vitamin C supplementation has effect on the endometrial thickness and ovarian hormones in
married and unmarried women during luteal phase. The objective of this study was to determine
the effect of vitamin C on the endomerium thickness and ovarian hormones of progesterone and
estrogen in married and unmarried women. This study was carried out on thirty women selected
randomly from private clinics and relatives in a period of eight months started from December
2008 to July 2009. Ten of them were unmarried, another twenty were married: ten of them fertile
and the remaining ten were infertile. They were subjected to ultrasonic examination for
estimations of their endometrial thickness, and measurements of their serum concentrations of
both estrogen and progesterone that are associated with vitamin C supplementations in a period
that continues for about (58 ±2 days). The results of this study show the effect of vitamin C
supplementation on the endometrial thickness which is increased significantly during first and
second periods (A1 and A2) as compared with the period before vitamin C supplementation of
control group (C) in married and unmarried women. It also shows the effect of vitamin C
supplementation on serum progesterone concentration which is increased significantly in A2 as
compared with C in fertile and infertile women only and the effect of vitamin C supplementation
on serum estrogen that is increased significantly in A1 and A2 as compared with C in both fertile
and unmarried women. In conclusion, the results show that there was significant increase on the
endometrial thickness in both A1 and A2 as compared with C for both fertile and infertile women.
Keywords: Vitamin C, Endometrium, Progesterone, Estrogen, Married, Unmarried Women
{Citation: Sami R. Al-Katib, Meissam MH. Al-Kaabi, Karim A. Al-Jashamy. Effects of vitamin
“C” on the endometrial thickness and ovarian hormones of progesterone and estrogen in married
and unmarried women. American Journal of Research Communication, 2013, 1(8): 24-31}
www.usa-journals.com, ISSN: 2325-4076.
INTRODUCTION
Vitamin C (L-ascorbic acid) is an essential nutrient for humans and other mammalian species
(Eteng et al., 2006). Ascorbate is required for a range of essential metabolic reactions it is made
internally by almost all organisms. Ascorbate is an antioxidant, which might protect the body from
some oxidative stresses, and is considered a cofactor in several vital enzymatic reactions
(Padayatty et al., 2003). The main source of vitamin C is found in the fruits and vegetables,
therefore the plasma vitamin C concentration is a marker of fruits and vegetables intake. Previous
studies showed that the occurrence of cardiovascular disease and cancer is inversely related to
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25
vitamin C intake and plasma vitamin C concentrations (Block et al., 2001). Hence, the protective
effects were attributed to the fruits and vegetables intake specifically those containing vitamin C,
which might contribute to this protection (Padayatty et al., 2003).
Female reproductive failure is a significant public health concern. Although, relatively little is
known about factors affecting fertility and early pregnancy loss, most of literatures suggested that
the environmental and lifestyle factors played important roles of fertility. There is sufficient
evidence to hypothesize that diet particularly its constituent antioxidants and oxidative stress
might influence the timing and maintenance of a viable pregnancy (Ruder et al., 2008). Systemic
supplementation with antioxidant may help overcome oxidative stress in the female infertility;
therefore, vitamin C might play a role in fertilization. Systemic supplementation with vitamin C is
used in women who are infertile, in those with luteal phase defects and in those who have
experienced recurrent abortions (Agarwal et al., 2005). Vitamin C has multiple functions
including antioxidant and collagen-stimulating properties. A study performed on anovulatory
women for whom clomiphene failed showed that oral supplementation with vitamin C (400 mg
per day) increased the ovulation in both with and without clomiphene citrate (Chris and Nieske,
2006; Igarashi, 1977).
The concentration of ascorbic acid showed higher in mature ovarian follicles than in the serum
(Paszkowski and Clarke, 1999), this suggests an active uptake of vitamin C by the follicle
resulting in the sequestration of vitamin C (Agarwal et al., 2005). In patients undergoing in vitro
fertilization (IVF)-embryo transfer, the vitamin C supplementation is given during the period of
hormonal stimulation, which resulted in higher follicular fluid concentrations of vitamin C (Crha
et al., 2003). Another study showed that three months of supplementation results in a trend
towards an increase in mean mid-luteal progesterone concentrations and a significant increase in
the number of days with basal body temperatures >37OC. After five months of supplementation,
the pregnancy rates were significantly higher in the supplemented group (33 versus 0%, P<0.01)
(Westphal et al., 2004).
Another randomized controlled trial examined the effects of vitamin C supplementation (750 mg
daily) in patient with luteal phase defects. The serum progesterone concentrations (13.27±0.63
versus 7.51±0.22 ng/ml) and pregnancy rates were increased significantly with ascorbic acid
supplementation. Most of literatures collected showed lack the study about the effects of vitamin
C on the endometrial thickness. Hence, the objective of this study was to determine the effect of
vitamin C on the endomerium thickness and ovarian hormones of progesterone and estrogen in
married and unmarried women.
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MATERIALS AND METHODS
Study Population
The study was achieved throughout a period extended from December 2008 to July 2009. The
total number of participations in study was 30 women that involved 10 unmarried and fertile,
which randomly selected from relatives and friends to ensure successful results, while 20 married
women were divided into two groups with 10 individuals each named fertile and infertile selected
from private clinics of gynecology and obstetrics. All participants were in reproductive age, the
age range was 15-45 years in unmarried women, while the age range of fertile and infertile was
18-38 years and 17-40 years respectively. The body mass index (BMI) ranges was 16-35 kg/m2.
The proposal of this study was approved by the ethics committee of medicine college Al-kufa
University. The synthetic vitamin C was used as oral tablets (250mg) manufactured by Iraqi
Pharmaceutical Industry (IPI) Company.
Demographical Information
The history was obtained from each woman involved in the study that including the name,
address, contact number, age, marital status (married or unmarried), fertility state (fertile or
infertile) and type of fertility (explained or unexplained infertility). Menstrual history included the
duration, regularity, the date of last cycle to determine the 23rd day (mid luteal phase) were
recorded. Past medical and surgical, medicines, degree of fruit consumption (DFC) rich in vitamin
C as lemon and orange that considered good degree (GD) of daily or every other and poor degree
(PD) every three day or more of fruit consumption were recorded.
Vitamin C Supplementation, Ultrasound Examinations and Hormone Measurement
Determination on the 23rd day of the cycle as a mid secretary phase, and before vitamin C
supplementation, each woman was sent for abdominal ultrasonic examination to estimate the
endometrial thickness. Before half an hour of ultrasound examination, the examined women
drank a water to get full bladder to give an acoustic window for proper uterine examination. The
ultrasound was achieved using Ultra mark ATL 9 (USA, 1992). The convex probe 3.5 MHz was
used for transabdominal approach examination (Daftary and Patki, 2009).
Blood specimens were collected for serum estrogen and progesterone concentrations
measurement. However, five ml blood specimens were collected from all participants before
vitamin C supplements, which consider as a control group (CG). Also, five ml blood specimens
were collected from all participants after vitamin C supplements, where each woman started to
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27
take 2 tablet of 250 mg 3 times/ day of vitamin C that ingested orally after meal. The first dose of
vitamin C supplementation was taken on the first day of next period (29±1 day) as a first period
after the vitamin C supplements group (A1). On 23rd day of the first cycle, the last same dose and
duration of treatment was repeated. On the 23rd day of the second period group (A2), the serums’
progesterone and estrogen concentrations as quantitative determined using progesterone and
Estradiol (E2) Enzyme Immunoassay Test Kit using ELIZA apparatus.
Height and Weight Measurements
The height of women was measured using tap measurement and the weight was measured using
movable balance. Measurement of the height and weight for each woman was archived to
calculate their body mass index (BMI) according to the following equation: BMI = Weight (kg) /
Height (m2) (Eknoyan and Garabed, 2008).
Statistical analysis was performed using the least significant differences (LSD) and analysis of
variance (ANOVA), utilizing (SPSS: ver. 17 for windows) and (Excel) programs. Student t-test
and X -2-chi-square also were used in this study. All values were expressed as Mean± SD, P-
value of less than 0.05 was considered statistically significant.
Results
The results of this study showed there was no significant difference in the age and body mass
index (BMI) (kg/m2) between unmarried, fertile and infertile women (Table 1).
Table (1): Anthropometric data for unmarried, fertile and infertile women (n=30)
Married Anthropometric data
(Mean ±SD)
Unmarried
N=10 Fertile N=10 Infertile N=10
P-value
Age (years) 28.3±10.57 30.6±6.2 25.4±6.83 NS
BMI(kg/m2) 25.72±6.21 26.93±3.29 25.07±2.99 NS
NS: No significant differences at P<0.05
The effect of vitamin C on the endometrial thickness in fertile, infertile and unmarried
women
The ultrasound examination of endometrial thickness showed increase significantly at P<0.05 in
group A1, and A2, where the highest thickness was seen in the married infertile (10.1±1.76) and
unmarried women (10.44±0.85) compared control group (CG). Meanwhile there was no
significant increase at P<0.05 between A1and A2 groups. The highest endometrial thickness
showed increase in the unmarried women (8-11.5 mm in A2), fertile (7-13mm A1) and infertile
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(6-12.5 mm in A1) in a period extends for two successful regular cycles with vitamin C
supplements (Table 2).
Table (2): The Effect of vitamin C on the endometrial thickness of all groups
Endometrial thickness range (mm) in association with vitamin C supplementations
(Mean ± SD)
Marital status
CG A1 A2
Married Fertile 6.87±1.56 5-9 9.7±2.0* 7-13 9.57±1.59* 7.5-12
Married Infertile 5.95±2.07 3-9 9.9±2.44* 6-12.5 10.1±1.76* 7.5-12
Unmarried 6.84±2.15 4-10 9.05±1.89* 5.5-11 10.44±0.85* 8-11.5
* Significant increase differences at (P<0.05)
The effect of vitamin C on serum progesterone (P) (ng/ml) concentration showed significant
increase (P<0.05) in group A2 in fertile, infertile and unmarried women compared with CG. The
effect of vitamin C on serum estrogen (E) (pg/ml) concentration in fertile, infertile and unmarried
women showed significant increase (P<0.05) in A2 compared with CG in both fertile and
unmarried women only, while there is no significant difference (P<0.05) in serum estrogen
concentration in all group when compared between fertile, infertile and unmarried women (Table
3).
Table (3): The Effect of vitamin C on serum progesterone (P) and estrogen (E)
concentrations in fertile, infertile and unmarried women
Serum progesterone and estrogen concentrations (Mean ±SD)
CG A1 A2
Marital Status
P E P E P E
Married Fertile 1.2±0.98 44.9±14.3 1.75±1.37 51.0±15.87 2.42±1.42* 62.6±15.16*
Married Infertile 1.07±0.35 44.1±17.54 1.98±0.65 51.3±14.86 2.55±0.83* 56.4±17.04
Unmarried 1.18±0.89 33.7±11.75 1.52±0.97 42.2±15.01 2.21±1.31* 48.7±15.17*
*Significant increase (P<0.05)
The results of relation between the degree of fruit consumption those rich in vitamin C
and vitamin C supplements showed increases significantly (P<0.05) of endometrial thickness of
fertile and infertile women in A1and A2 compared with CG in both GD and PD of fruit
consumption. While there was no significant increase (P<0.05) showed in A1 compared with A2
(Table 4) (Figure 1).
The results of this study showed there was significantly increase (p<0.05) of the serum
progesterone concentrations in the A1and A2 compared with of fertile and infertile, the highest
increasing showed the in A2 group fertile women with PD (Table 5).
American Journal of Research Communication www.usa-journals.com
Table (4): The relation between the degree of fruit consumption rich in vitamin C and
endometrial thickness in association with vitamin C supplementation in fertile
(n=10) and infertile (10) women
Al-Katib, et al., 2013: Vol 1(8) ajrc.journal@gmail.com
29
Endometrial thickness (mm) Mean ±SD
DFC+ C Fertility Status
CGA1 A2
Fertile 7.92±0.66 9.83±1.94* 10.3±1.68* GD
Infertile 8.67±0.58 11.17±1.44* 10.67±0.58*
Fertile 3.53±1.01 9.5±2.38* 8.89±1.38* PD
Infertile 4.97±1.04 9.36±2.66* 9.86±2.08*
*Significant increase (P<0.05) compared A1or A2 with CG
Table (5): The relation between the degree of fruit ingestion riches in vitamin C and serum
progesterone and estrogen concentrations in association with vitamin C
supplementations in fertile and infertile women
Serum progesterone and estrogen concentrations (Mean ±SD)
CG A1 A2
DFC+C Fertility
state
P E P E P E
Fertile 1.4±1.03 46.3±14.29 1.72±1.23 55.±15.53 2.57±1.46 65.17±15.82 GD
Infertile 1.13±0.29 61.33±26.8 2.33±0.76* 61.33±23.3 2.8±0.97* 67.66±22.50
Fertile 0.35±0.05 42.5±16.2 1.8±1.78* 47±17.4 2.2±1.54* 58.75±15.48 PD
Infertile 1.04±0.4 36.71±3.25 1.83±0.6* 47±9.09* 2.31±0.77* 51.57±13.26*
*Significant increase (P<0.05)
Figure (1): The ultrasound examination of endometrial thickness showed increase
significantly the highest thickness was seen in the married infertile 1A1 (10.1±1.76)
and unmarried women 1A2 (10.44±0.85) compared control group (1C).
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DISCUSSION
The effect of vitamin C supplementation on the endometrial thickness and ovarian hormones in
married and unmarried women during luteal phase was shown a significant increasing in thickness
of the endometrium after first period 29±1days and second period 58±2 days as compared with
thickness before vitamin C supplementation for married (fertile and infertile) and unmarried
women and this significant increasing may be attributed to vitamin C. Firstly, vitamin C may
have indirect effect on the thickness of the endometrium by its effect on ovarian hormones of
progesterone and estrogen. There was significant increased in serum progesterone after A2 as
compared with CG in both fertile and infertile women, also serum estrogen was significantly
increased after A2 compared with B in married (fertile) and unmarried women and this may help
to increase the endometrial thickness during luteal phase. The results of this study agreed with the
pervious study by McKinley and Olouchlin (2006) on responsibility of both progesterone and
estrogen in increasing the endometrial thickness during luteal phase of menstrual cycle, another
report by Karanth et al., (2001) suggested that the antioxidants properties of vitamin C stimulate
the release of gonadotrophins from adenohypophysis. Luteal phase defects decreased about 53%
in the supplemented group while the defects spontaneously improved about 22% in non-
supplemented group (Henmi et al., 2003). The maximal thickening of the endometrial thickness
that reached during this secretary phase between 23rd-25th day of cycle (Kenneth et al., 2001).
Secondly, the role of vitamin C as antioxidant that may help to protect the tissue of the
endometrium from oxidative stress (Ruder et al., 2008). Also the effect of vitamin C
supplementation on the endometrial thickness might be related to antioxidant properties of
estrogen which investigated in woman's reproductive organs (Liu et al., 2006). Murdoch (1998)
was investigated the antioxidant properties of estrogen in pig luteal and follicular tissue exposed
to hydrogen peroxide in vitro, in which high doses of estrogen (≥40 pg/ml) protected against
apoptosis, suggesting that ovarian estrogen (E2) function as reactive oxygen species scavenger
during pregnancy mediated luteal rescue and fulliculogenesis.
Thirdly, the endometrial thickness increasing might related to the role of vitamin C as cofactor in
the synthesis of collagen in the luteal extra cellular matrix (Eteng et al., 2006). The formation of
collagen fibers can lead to increase in thickness of the endometrium and this agree with previous
study on bovine endometrium in which bovine endometrial stromal (BES) cells were cultured to
confluence in medium with L-ascorbic acid phosphate magnesium salt n-hydrate which stimulate
collagen synthesis of BES (Yamauchi et al., 2003). In conclusion, the results show that there was
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significant increase on the endometrial thickness in both A1 and A2 as compared with C for both
fertile and infertile women.
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