Error in histologic dating of secretory endometrium: variance component analysis

Evaluation of endometrial receptivity and implantation failure

PURPOSE OF REVIEW

To succinctly review the basic mechanisms of implantation and luteal phase endometrial differentiation, the etiologies of impaired endometrial function and receptivity, and the current methods that exist to evaluate and treat impaired endometrial receptivity.

RECENT FINDINGS

Human embryo implantation requires bidirectional communication between blastocyst and a receptive endometrium. Etiologies of impaired endometrial receptivity are varied. Some of these include delayed endometrial maturation, structural abnormalities, inflammation, and progesterone resistance. Current methods to evaluate endometrial receptivity include ultrasonography, hysteroscopy, and endometrial biopsy. Treatments are limited, but include operative hysteroscopy, treatment of endometriosis, and personalized timing of embryo transfer.

SUMMARY

Although some mechanisms of impaired endometrial receptivity are well understood, treatment options remain limited. Future efforts should be directed towards developing interventions targeted towards the known mediators of impaired endometrial receptivity.

Spectroscopy analysis of endometrial metabolites is a powerful predictor of success of embryo transfer in women with implantation failure: a preliminary study

OBJECTIVE

To investigate whether prior endometrium spectroscopy predicts the success of embryo transfer in patients with recurrent implantation failure (RIF).

MATERIALS AND METHODS

Twenty women with RIF who were scheduled for IVF-ET and six fertile women were included the study. All women with RIF and fertile controls underwent endometrium spectroscopy before embryo transfer. A multi-voxel spectroscopy sequence was used for the detection of choline (Cho), creatine (Cr), lactate, and lipids. Women with RIF were divided into two subgroups as successful (n = 8) and unsuccessful RIF (n = 12) according to both Cho and Cr metabolite characteristics and whether pregnancy was achieved. Associations between the metabolite intensities of the RIF subjects and the implantation rate (IR) and clinical pregnancy rate (CPR) were assessed.

RESULTS

While 8 of 20 RIF cases became pregnant, pregnancy could not be achieved in 12 cases. The common spectroscopy finding in all 8 cases who conceived was high Cho and low lactate. The main metabolite change detected in 12 patients who could not conceive was the increase in lactate and lipid signals. The cutoff value of Cho, Cr, lactate and lipid were 1.01 ppm, 1.44 ppm, 0.86 ppm and 1.22 ppm respectively in patients who achieved pregnancy following ET. A positive and significant correlation was found between Cho and Cr intensities and IR or CPR.

CONCLUSIONS

Receptive endometrium represents some specific metabolites in spectroscopy that can be used for prediction of the success or failure of embryo transfer in women suffering implantation failure.

What is the contribution of embryo-endometrial asynchrony to implantation failure?

PURPOSE

The synchronized development of a viable embryo and a receptive endometrium is critical for successful implantation to take place. The aim of this paper is to review current thinking about the importance of embryo-endometrial synchrony in in vitro fertilization (IVF).

METHODS

Detailed review of the literature on embryo-endometrial synchrony.

RESULTS

By convention, the time when the blastocyst first attaches and starts to invade into the endometrium has been defined as the 'window of implantation'. The term window of implantation can be misleading when it is used to imply that there is a single critical window in time that determines whether implantation will be successful or not. Embryo maturation and endometrial development are two independent continuous processes. Implantation occurs when the two tissues fuse and pregnancy is established. A key concept in understanding this event is developmental 'synchrony', defined as when the early embryo and the uterus are both developing at the same rate such that they will be ready to commence and successfully continue implantation at the same time. Many different events, including controlled ovarian hyperstimulation as routinely used in IVF, can potentially disrupt embryo-endometrial synchrony. There is some evidence in humans that implantation rates are significantly reduced when embryo-endometrial development asynchrony is greater than 3 days (±1.5 days).

CONCLUSIONS

Embryo-endometrial synchrony is critical for successful implantation. There is an unmet need for improved precision in the evaluation of endometrial development to permit better synchronization of the embryo and the endometrium prior to implantation.

Diagnosis of Endometrial-Factor Infertility: Current Approaches and New Avenues for Research

Over the last decade, research to improve success rates in reproductive medicine has focused predominantly on the understanding and optimization of embryo quality. However, the emergence of personalized medicine in ovulation induction and embryology has shifted the focus to assessing the individual status of the endometrium. The endometrium is considered receptive during an individually defined period, the window of implantation (WOI), when the mother permits a blastocyst to attach and implant. This individual receptivity status can now be objectively diagnosed using the endometrial receptivity array (ERA) developed in 2011. The ERA, together with a computational algorithm, detects the unique transcriptomic signature of endometrial receptivity by analyzing 238 differentially expressed genes and reliably predicting the WOI. We and others have illustrated the utility of this personalized diagnostic approach to discriminate between individual physiological variation in endometrial receptivity and unknown endometrial pathology, deemed as causal in recurrent implantation failure (RIF). An international randomized controlled trial ("The ERA as a diagnostic guide for personalized embryo transfer." ClinicalTrials.gov Identifier: NCT01954758) is underway to determine the clinical value of this endometrial diagnostic intervention in the work-up for reproductive care. In this review, we analyse the current clinical practice in the diagnosis of the endometrial factor together with new avenues of research.

MicroRNA and implantation

We provide a review of microRNA (miRNA) related to human implantation which shows the potential diagnostic role of miRNAs in impaired endometrial receptivity, altered embryo development, implantation failure after assisted reproduction technology, and in ectopic pregnancy and pregnancies of unknown location. MicroRNAs may be emerging diagnostic markers and potential therapeutic tools for understanding implantation disorders. However, further research is needed before miRNAs can be used in clinical practice for identifying and treating implantation failure.

The luteal phase after ovarian stimulation

Evaluation of the luteal phase after ovarian stimulation presents several difficulties. Until today, it has not been proved that in cycles stimulated with clomiphene citrate/human menopausal gonadotrophins, luteal supplementation with progesterone significantly increases implantation rate. On the contrary, it is accepted that in cycles stimulated with GnRH agonists/gonadotrophins, support of the luteal phase is essential for the achievement of pregnancy. In GnRH antagonist cycles luteal supplementation, although widely practised, is not at present supported by randomized controlled trials. Finally, it appears that the combination of gonadotrophin stimulation with human chorionic gonadotrophin results in an inadequate luteal phase with or without the use of either agonists or antagonists.

Gene expression confirms a potentially receptive endometrium identified by histology in fertile women

BACKGROUND

To use contemporary biochemical markers to characterize mRNA/gene expression in the potentially fertile secretory endometrium to confirm its identification based on histological characteristics in order to develop a clinically applicable test.

METHODS

Nine, fertile, cycling Caucasian women were sampled from one IVF clinic. Endometrial samples were collected from them in two to four menstrual cycles at 2 and 7 days post first significant rise in blood LH. Separate endometrial glands and stroma populations were obtained by laser microdissection. Linear polymerase chain reaction amplified mRNAs which were hybridized to both Affymetrix U133 Plus2 and Agilent 4 × 44K microarrays followed by gene set analysis. Four histopathologists reviewed the sample set using the same histological criteria to date and characterize the non-receptive and potentially receptive samples.

RESULTS

mRNA expression of microdissected glands and stroma provided molecular signatures that characterized the two specific phases of the cycle with distinct clustering patterns. Cell proliferation and five other associated biological pathways were significantly down-regulated when the endometrium is considered potentially receptive accompanied by an increase in secreted glycoproteins mRNAs in the potentially receptive glands. Reported histological findings identified the presence of one histological feature characteristic of each phase: glandular mitoses indicated a non-receptive endometrium, whereas a potentially receptive endometrium was distinguished by supranuclear vacuolation.

CONCLUSIONS

This study defined a transcriptome characteristic of active cell proliferation in the non-receptive samples with a marked overall down-regulation of this pathway in potentially receptive samples-suggesting a transitional state associated with receptivity but not implantation. However, microarrays involve expensive, specialized testing and require significant post-data analysis. Sampling according to endocrinological and molecular prediction improved the consistency of histological assessment and allowed reliable histological markers of glandular mitosis in the non-receptive phase and supranuclear vacuolation of the potentially receptive endometrium to be identified. Thus, histology can provide an affordable, clinically applicable test in the context of reproduction.

The nucleolar channel system reliably marks the midluteal endometrium regardless of fertility status: a fresh look at an old organelle

OBJECTIVE

To determine whether nucleolar channel systems (NCSs) in the midluteal endometrium are associated with overall fertility status and/or with unexplained infertility.

DESIGN

Retrospective and prospective clinical studies.

SETTING

Repository of stored specimens from prior multicenter study and private infertility center.

PATIENT(S)

Retrospective study that included 97 women (49 fertile couples, 48 infertile couples) who had been randomized for endometrial biopsy during the midluteal or late luteal phase. The prospective study included 78 women with a variety of infertility diagnoses.

INTERVENTION(S)

Endometrial biopsies were obtained and assessed for the presence of NCSs by indirect immunofluorescence.

MAIN OUTCOME MEASURE(S)

The presence of NCS was graded semiquantitatively and dichotomized as normal versus low or absent.

RESULT(S)

Normal presence of NCS was significantly associated with the midluteal phase compared with the late luteal phase (80% vs. 29%). However, there was no association between presence of NCS and fertility status or between presence of NCS and unexplained infertility.

CONCLUSION(S)

Midluteal phase endometrium consistently forms NCSs regardless of fertility status, including unexplained infertility. This indicates a possible role for the NCS in initiating the window of endometrial receptivity. However, the consistent presence of NCSs across several different types of infertility challenges the likelihood that inadequate secretory transformation is a cause of infertility.

Integrins in the endometrium

The endometrium expresses many of the same integrins displayed by other tissues. Endometrial epithelial cells maintain the ‘classic’ epithelial integrins, including α2, α3, α6, and β4, while the stroma expresses the fibronectin receptor, α5β1. During the menstrual cycle, the endometrium undergoes dynamic changes in morphology in preparation for implantation. With these histological changes are concomitant alterations in integrin expression that appear to ‘frame’ the window of implantation, by the co-expression of glandular αvβ3 and α4β1 during days 20 to 24 of the menstrual cycle. The changes in integrin expression shift from epithelial to stroma predominance late in the menstrual cycle, extending into early pregnancy. Decidual integrins that appear upregulated in pregnancy include α1β1, α3β1, α6β1 and αvβ3. Markers of uterine receptivity hold promise for a better understanding of the implantation process and may help to explain many different types of infertility. These markers will be essential for monitoring and improving infertility therapies. The importance of integrins in the human endometrium now seems well established and promises to be an area of great clinical and basic science activity in the future.

Impact of high body mass index on endometrial morphology and function in the peri-implantation period in women with recurrent miscarriage

There is evidence that women with a high body mass index may have a higher risk of miscarriage. It is not known if this is due to an endometrial or embryo defect. The aim of this retrospective study was to examine markers of endometrial function in overweight and obese women with recurrent unexplained miscarriage. A total of 136 women were included in the study and classified according to their body mass index (BMI) into two groups, normal BMI (< 25 kg/m(2), n = 70) and high BMI (> or = 25 kg/m(2), n = 66). Endometrial morphology was examined in all patients. A subgroup of 28 patients was examined for endometrial oestrogen and progesterone receptors in different components of the endometrium, and in a further subgroup of 28 patients, endometrial glandular leukaemia inhibitory factor and leukocyte populations were examined. A modest increase in the BMI (30.4 +/- 0.71 kg/m(2)) does not have a significant impact on endometrial steroid receptors, leukocyte populations or endometrial morphology. However, there was a significant negative correlation between endometrial glandular leukaemia inhibitory factor concentrations and the BMI (r = -0.4, P = 0.02), warranting further investigation in prospective studies that include patients with higher BMI levels.

Optimization of endometrial preparation results in a normal endometrial function test® (EFT®) and good reproductive outcome in donor ovum recipients

PURPOSE

Numerous studies have investigated potential markers of endometrial receptivity as predictors of successful implantation. Cyclin E and p27 have recently been studied using the endometrial function test (EFT). Our objective is to determine the correlation between the expression of cyclin E and p27 and the adequacy of uterine preparation of recipients using donor oocytes.

METHODS

Twenty recipients undergoing preparatory cycles with leuprolide acetate, estrogen, and progesterone. Endometrial biopsies were obtained 10-12 days after progesterone supplementation following the course of estrogen. The tissue was prepared for histological analysis and immunohistochemical staining for cyclin E assessment. The outcome of their subsequent ovum donation cycle was blinded to the reviewer of the EFT.

RESULTS

All recipients showed normal luteal transformation. Nineteen (95%) of the recipients had a normal EFT. This is significantly higher than what we demonstrated, previously, in unexplained infertility patients, where only 40% of such patients had a normal EFT. Thirteen recipients with a normal EFT had a clinical pregnancy, while 6 did not become pregnant in their subsequent transfer cycles. The sole patient with an abnormal EFT did not conceive on 2 subsequent cycles.

CONCLUSIONS

While a normal EFT does not guarantee a successful pregnancy, an abnormal EFT appears to be associated with pregnancy failure. This may be useful in identifying women who need adjustments to their stimulation protocols prior to progressing to a physically, emotionally, and financially costly cycle.

The human endometrium as a fertility-determining factor

Intensive research work has been performed to better understand the regulation of the endometrium and its clinical implications to improve implantation. Although many proteins and molecules may influence endometrial development, their co-ordinated contribution to the implantation process is still poorly understood and a translation into clinical use has not sufficiently been performed. Clinical evaluation of the endometrium by ultrasound and other techniques, like endometrial biopsy and analysis of uterine secretions, has been intensively studied and therapeutic options to improve endometrial function have been suggested and tested. Systemic treatment with heparin, aspirin or corticosteroids did not result in improved implantation rates. Gene therapy and cervical treatment, e.g. with seminal plasma, are still in the phase of clinical research. Therefore, this review focuses on different aspects of endometrial research, which all contribute to the diagnosis, evaluation and therapy of endometrial function and dysfunction. First, the endometrial development towards a receptive milieu is described. Second, the actual clinical evaluation of endometrial receptivity, possible therapeutic strategies and in particular, the evaluation of endometrial function in the non-natural situation of hormonal stimulation is critically evaluated. In conclusion, the endometrium shall be considered as an important fertility-determining factor and therapeutic options should be developed in near future.

Luteal phase defect: myth or reality

Although the diagnosis of luteal phase defect (LPD) has been described convincingly in the research setting, it remains a controversial clinical entity. Apart from many uncertainties that surround the diagnosis of LPD, there is no convincing evidence that LPD is associated with infertility and recurrent abortion. Once diagnosed, the treatment options are empiric and include those that are recommended for unexplained infertility. The efforts to diagnose LPD in patients who have infertility or recurrent abortion are not justified.

Interobserver and intraobserver variability in the histological dating of the endometrium in fertile and infertile women

OBJECTIVE

To assess effects of biopsy timing and fertility status on inter- and intraobserver variability in dating of the endometrium.

DESIGN

Endometrial biopsy slides randomly selected from a multicenter study testing the utility of biopsy in the diagnosis of infertility were distributed to three gynecologic pathologists, who estimated cycle day using standard criteria. Readers were blinded to the purpose of the study, patient age, fertility status, or timing of biopsy relative to LH surge or next menses.

SETTING

Multicenter academic research programs in reproductive medicine.

PATIENT(S)

Eighty-two women with proven fertility, 83 infertile patients.

INTERVENTION(S)

Endometrial biopsy during midluteal (days 21-22) or late (days 26-27) luteal phase.

MAIN OUTCOME MEASURE(S)

Intraclass correlation coefficient (ICC), kappa.

RESULT(S)

Overall agreement was excellent (ICC 0.88); addition of readings by local pathologists decreased ICC only slightly. In subgroup analyses, ICCs were lowest for infertile women during the midluteal phase (0.65 vs. 0.71 for fertile women in the midluteal phase, and 0.88-0.90 for both groups in the late luteal phase). Intraobserver reliability was excellent (0.9-0.99). Agreement for diagnoses of "out-of-phase" was only moderate, with kappa values between 0.4 and 0.6.

CONCLUSION(S)

Observer variability in dating the endometrium was greatest in infertile women during the window of implantation.

Histological dating of timed endometrial biopsy tissue is not related to fertility status

OBJECTIVE

To assess the ability of histological dating to discriminate between women of fertile and infertile couples. The utility of histological dating of endometrium in the evaluation of infertile couples is uncertain.

DESIGN

Prospective multicenter study, with subjects randomly assigned to biopsy timing. Criterion standard for infertility was 12 months of unprotected, regular intercourse without conception and for fertility at least one live birth within 2 years.

SETTING

University-based infertility practices.

PATIENT(S)

Volunteer subjects (847) recruited at 12 clinical sites participating in the National Institutes of Health-funded Reproductive Medicine Network. Inclusion criteria included ages 20-39 years, regular menstrual cycles, and no hormonal treatment or contraceptive use for 1 month before the study. Fertile controls were excluded if they had a history of infertility, recurrent pregnancy loss, or recent breastfeeding.

INTERVENTION(S)

Subjects underwent daily urinary LH testing. After detection of the LH surge, subjects were randomized to biopsy in the mid (days 21-22) or the late (days 26-27) luteal phase. Pathologists at each site estimated the cycle day based on standard criteria. For the primary analysis, an out-of-phase biopsy was defined as a greater than 2-day delay in the histological maturation of the endometrium.

MAIN OUTCOME MEASURE(S)

The proportion of out-of-phase biopsies in fertile and infertile women was compared using logistic regression models with age at randomization as a covariate. Comparisons were also made between fertile vs. infertile at the midluteal or late luteal phase time points.

RESULT(S)

Biopsies were evaluated (301 mid and 318 late; N = 619). Out-of-phase biopsy results poorly discriminated between women from fertile and infertile couples in either the midluteal (fertile: 49.4%, infertile: 43.2%) or late luteal phase (fertile: 35.3%, infertile 23.0%). Results did not substantially differ using alternative definitions of "out-of-phase" or standardized cycle day.

CONCLUSION(S)

Histological dating of the endometrium does not discriminate between women of fertile and infertile couples and should not be used in the routine evaluation of infertility.

A critical analysis of the accuracy, reproducibility, and clinical utility of histologic endometrial dating in fertile women

OBJECTIVE

To refine or redefine the traditional histologic criteria used to date the secretory phase endometrium.

DESIGN

Randomized, observational study.

SETTING

Academic clinical research center.

PATIENT(S)

One hundred and thirty healthy, regularly cycling, fertile volunteers, aged 18 to 35 years.

INTERVENTION(S)

Patients were randomized to undergo endometrial sampling and measurement of serum estradiol and progesterone 1 to 14 days after the midcycle urinary luteinizing hormone surge. Three gynecologic histopathologists objectively scored each tissue specimen for 32 distinct histologic features and dated the endometrium using traditional histologic criteria.

MAIN OUTCOME MEASURE(S)

The 32 features were evaluated for [1] temporally dependent variation, [2] the amplitude of variations in score observed across the secretory phase, and [3] interobserver variability. Additionally, traditional dating criteria were analyzed.

RESULT(S)

The traditional endometrial histologic dating criteria are much less temporally distinct and discriminating than originally described, due to considerable intersubject, intrasubject, and interobserver variability. Neither traditional dating criteria nor any combination of the best performing histologic features identified by our objective and systematic analyses could reliably distinguish any specific cycle day or narrow interval of days.

CONCLUSION(S)

Histologic endometrial dating does not have the accuracy or the precision necessary to provide a valid method for the diagnosis of luteal phase deficiency or to otherwise guide the clinical management of women with reproductive failure.

Hertig and beyond: a systematic and practical approach to the endometrial biopsy

Evaluation of the endometrial biopsy is a challenge to practicing pathologists, largely due to the wide range of morphologic patterns resulting from both normal and abnormal cyclic changes, exogenous hormones, infections, and intrauterine tumors. Successfully addressing these challenges requires that the practitioner (i) understand the clinical questions being asked, (ii) have a realistic expectation for answering these questions, and (iii) have a systematic approach to resolving these questions in the context of these expectations. The approach outlined begins with the subdividing of women with endometrial alterations into three general categories: (i) women in their fourth decade undergoing evaluation for infertility, (ii) women in their fifth decade who experience abnormal uterine bleeding, and (iii) women in their sixth decade and beyond who experience postmenopausal bleeding. The clinical expectations for each group are unique, as are the morphologic patterns most commonly encountered. Algorithms for the laboratory management of cyclic changes, dysfunctional bleeding, and mixed-pattern endometria are provided, as are pitfalls in interpretation and exclusion of neoplasia.

Improved endometrial assessment using cyclin E and p27

OBJECTIVE

To evaluate endometrial expression of cyclin E and p27 in fertile and infertile women.

DESIGN

Retrospective clinical study.

SETTING

University medical center and private practice.

PATIENT(S)

Thirty-three fertile volunteers, 83 women seeking infertility treatment, and 23 women undergoing mock cycles.

INTERVENTION(S)

Endometrial biopsy.

MAIN OUTCOME MEASURE(S)

Cyclin E and p27 immunohistochemistry.

RESULT(S)

Glandular cyclin E and p27 expression dramatically changed in intensity and subcellular localization throughout the menstrual cycle. In normal control biopsies, glandular cyclin E progressed from the basal to the lateral cytoplasm (midproliferative phase) to the nucleus (days 18 to 19) and was absent in biopsies after day 20. First appearing on days 17 to 19, p27 was found only in the nuclei. Cyclin E was more frequently seen after day 20 in infertility patients. In the hyperstimulated cycles, staining for cycle E in proliferative samples was more intense than in the natural cycles, but p27 staining was unchanged.

CONCLUSION(S)

Cyclin E and p27 may be clinically useful markers of development in the endometrium. As cell cycle regulators, cyclins reveal underlying biochemical processes driving endometrial progression and may partly represent the means by which estrogen and progesterone regulate this dynamic tissue.

Endometrial effects of lower doses of conjugated equine estrogens and medroxyprogesterone acetate

OBJECTIVE

To determine the endometrial safety of lower doses of continuous combined conjugated equine estrogens (CEE) and medroxyprogesterone acetate (MPA).

DESIGN

Randomized, double-blind, placebo-controlled study (the Women's Health, Osteoporosis, Progestin, Estrogen study).

SETTING

Study centers across the United States.

PATIENT(S)

Healthy, postmenopausal women (n = 2,673) with an intact uterus.

INTERVENTION(S)

Patients received CEE 0.625 mg/day, CEE 0.625/MPA 2.5 mg/day, CEE 0.45 mg/day, CEE 0.45/MPA 2.5 mg/day, CEE 0.45/MPA 1.5 mg/day, CEE 0.3 mg/day, CEE 0.3/MPA 1.5 mg/day, or placebo for 1 year. Endometrial biopsies were evaluated at baseline, cycle 6, and year 1 using a centralized protocol.

MAIN OUTCOME MEASURE(S)

Efficacy of lower doses of CEE/MPA in reducing the incidence of endometrial hyperplasia rates associated with unopposed CEE.

RESULT(S)

Endometrial hyperplasia rates ranged from 0 to 0.37% for all CEE/MPA doses. Twenty-nine of the 32 cases of endometrial hyperplasia developed in women who were administered CEE 0.625 mg or CEE 0.45 mg. The incidence of endometrial hyperplasia increased with age for patients administered CEE alone. As expected, there were some inconsistencies among pathologists' ratings in the numbers of hyperplasias and incidence rates for the CEE-alone regimens. There were too few cases of hyperplasia in the combination groups to evaluate consistency among pathologists.

CONCLUSION(S)

One year of treatment with lower doses of CEE/MPA provides endometrial protection comparable to commonly prescribed doses. These regimens may be used by clinicians to individualize hormone replacement therapy in postmenopausal women.

Immunohistochemical markers of uterine receptivity in the human endometrium

The factors responsible for the initial interaction between maternal and fetal epithelium leading to the establishment of pregnancy remain poorly understood. Temporal and spatial expression of specific endometrial peptides in response to ovarian steroids is thought to contribute to the development of a period of uterine receptivity, whereby the endometrium becomes hospitable to the implanting blastocyst. The failure to establish receptivity may account for a significant percentage of the cases of infertility in the female, especially affecting women with luteal phase deficiency, leiomyomata uteri, endometriosis, habitual abortion, and unexplained infertility. In addition, despite increasing global experience with advanced reproductive technologies, the majority of In Vitro Fertilization (IVF) attempts remain unsuccessful, most likely on the basis of implantation failure. In this article, we review the concepts involved in the study of uterine receptivity in the human, highlight potential immunohistochemical (IHC) markers that have recently been discovered, and discuss how IHC assessment of the endometrium is a potentially valuable method for the evaluation of the receptive endometrial state. Using this approach we have examined several new potential markers of uterine receptivity. Endometrial progesterone receptors and one of the integrin cell adhesion molecules appear to undergo changes in expression around the time of implantation, and may be sensitive indicators of the receptive state. Further, these markers are delayed in women with infertility and luteal phase deficiency. These studies illustrate the utility of IHC diagnosis for the evaluation of endometrial function.

Endometrial effects during hormone replacement therapy with a sequential oestradiol valerate/cyproterone acetate preparation

Three sequential oestradiol valerate (E2V) and cyproterone acetate (CPA) combinations based on 11 days of oestrogen and 10 days of oestrogen-progestogen administration were investigated during hormone replacement therapy in two prospective, double-blind randomized trials. Treatment A comprised 2 mg E2V and 1 mg CPA, treatment B, 1 mg and 0.5 mg and treatment C, 2 mg and 2 mg, respectively. During treatment A hot flushes (P < 0.0001), night sweating (P < 0.0001), depression (P = 0.0001), dizziness (P = 0.0001) and insomnia (P = 0.003) decreased significantly. The only side effect was breast tenderness, which was experienced by 18% of the women. Weight and blood pressure, thyroid, adrenal, liver and kidney functions, parathyroid hormone and vitamin D, platelets and blood cell counts did not change during the 12 months of therapy. In the women who received treatment A the menstrual flow became less abundant during the early months of treatment (P < 0.0001), the menses being scanty in around 30% of the women, while some 10% had amenorrhoea. Spotting occurred in 10-20% of the subjects. Endometrial biopsies were atrophic in 10% of the women, whereas a normal secretory phase was observed in 45% and irregular secretion in 45%. After careful analysis using visual analog scales, these findings were interpreted as indicating a high-normal progestational effect. In comparison with the pattern observed in normal menstrual cycles the women who received treatment A had a more heterogenic glandular epithelium, with more papillae, larger stromal cells, a more pronounced decidual reaction and more fibrinoid material. No cases of hyperplasia were seen. Treatment B was less effective than treatment A in relieving climacteric complaints. Irregular bleeding was troublesome in over 20% of cases and amenorrhoea occurred in 50%. Endometrial biopsies were atrophic in 57% of the women. The effectiveness of treatment C in alleviating flushes, sweating, dizziness and depression was the same as that of treatment A. The decrease in menstrual flow during the early months and the incidence of amenorrhoea (approx. 10%) and atrophic endometria (approx. 10%) were comparable. Detailed analysis revealed that C had an even stronger progestational effect than A. It was concluded that A was the treatment of choice in comparison with B and C. It proved highly effective in treating climacteric complaints, had no side effects apart from breast tenderness, provided good cycle control and induced a physiological secretory transformation of the endometrium.(ABSTRACT TRUNCATED AT 400 WORDS)

Observer reliability in assessing villitis of unknown aetiology

AIMS

To evaluate observer variation in diagnosis of villitis of unknown aetiology.

METHODS

Fifty haematoxylin and eosin stained sections were circulated to three pathologists who were asked to assess if villitis was present. These slides, with an additional 20, were recirculated and reassessed by the same pathologists.

RESULTS

Intra-observer agreement was 84.7% (range 74--92%) and interobserver agreement was 81%. A conjoint review by the three pathologists revealed that sources of differences included the overlooking of isolated single or small numbers of affected villi, the difficulty in assessing stromal cellularity close to infarcted parenchyma, and apparent stromal hypercellularity in immature villi.

CONCLUSIONS

Experienced pathologists can show a significant interobserver variation in assessing villitis of unknown aetiology. Future studies on villitis of unknown aetiology should address the problem of observer reproducibility of diagnosis.