Lactational control of reproduction

In most mammalian species lactation suppresses fertility. There is no doubt that it is the suckling stimulus that provides the controlling signal, and, in human reproduction, this is the only truly physiological signal that suppresses fertility in normally nourished, healthy women. In breastfeeding women, the return of normal fertility follows a relatively well-defined path progressing through: an almost complete inhibition of gonadotrophin-releasing hormone/luteinizing hormone (GnRH/LH) pulsatile secretion in the early stages of lactation; return of erratic pulsatile secretion with some ovarian follicle development associated with increases in inhibin B and oestradiol; a resumption of apparently normal follicle growth associated with a normal increase in oestradiol, but often an absence of ovulation, or formation of an inadequate corpus luteum; and a return to normal ovulatory menstrual cycles. A key element in controlling the rate of this progression is the impact of the suckling stimulus on the GnRH pulse generator, a common feature of lactation in those species for which there is information. The variability in the duration of lactational amenorrhoea between women is related to the variation in the strength of the suckling stimulus, a unique situation between each mother and baby. Full breastfeeding can provide a reliable contraceptive effect in the first 6 to 9 months, but the precise mechanisms whereby the suckling stimulus affects GnRH pulsatile secretion remain unknown. Many studies on the hypothalamic pathways that might be involved in the translation of the neural suckling stimulus to suppression of hypothalamic GnRH secretion have been undertaken, principally in rats. In women, suckling increases the sensitivity of the hypothalamus to the negative feedback effect of oestradiol on suppressing the GnRH/LH pulse generator, a mechanism that appears to be common across species. In contrast, the role of prolactin in the control of GnRH appears to be species-dependent, with the importance varying from none to an important role in late or throughout lactation. In women, there is little evidence for a role of leptin, opioids or dopamine, although this may merely reflect the ethical dilemma of being able to give sufficient drug to test the system in the mother since these drugs will pass through the breast milk to the baby. Regardless of mechanism, practical guidelines for using breastfeeding as a natural contraceptive have been developed, which allows mothers to utilize the only natural suppressor of fertility in women as an effective means of spacing births.