A new method of histologic dating of human endometrium in the luteal phase

Endogenous progesterone in unexplained infertility: a systematic review and meta-analysis

PURPOSE

To investigate the possibility that altered actions of endogenous progesterone affect receptivity and contribute to unexplained infertility (UI).

METHODS

Two authors electronically searched MEDLINE, CINAHL and Embase databases from inception to 6 July 2022 and hand-searched according to Cochrane methodology. We included all published primary research reporting outcomes related to endogenous progesterone in natural cycles in women with UI. Studies were assessed for risk of bias using a modified Newcastle-Ottawa Score or NHLBI Score. We pooled results where appropriate using a random-effects model. Findings were reported as odds ratios or mean differences.

RESULTS

We included 41 studies (n = 4023). No difference was found between the mid-luteal serum progesterone levels of women with UI compared to fertile controls (MD 0.74, - 0.31-1.79, I² 36%). Women with UI had significantly higher rates of 'out-of-phase' endometrium than controls. Nine out of 10 progesterone-mediated markers of endometrial receptivity were significantly reduced in women with UI compared to fertile controls (the remaining 1 had conflicting results). Resistance in pelvic vessels was increased and perfusion of the endometrium and sub-endometrium reduced in UI compared to fertile controls in all included studies. Progesterone receptor expression and progesterone uptake were also reduced in women with unexplained infertility.

CONCLUSIONS

End-organ measures of endogenous progesterone activity are reduced in women with UI compared to fertile controls. This apparently receptor-mediated reduction in response affects endometrial receptivity and is implicated as the cause of the infertility. Further research is required to confirm whether intervention could overcome this issue, offering a new option for treating unexplained infertility.

TRIAL REGISTRATION

PROSPERO registration: CRD42020141041 06/08/2020.

Use of 'omics for endometrial timing: the cycle moves on

For some years, the prospect of precise and personalized timing of the endometrial cycle for optimal embryo replacement has been held out as a potential solution to low implantation rates. It is envisaged that a receptive state can be defined and reached at a predictable time, and embryo replacement performed in synchrony. In the last century, morphological changes characteristic of the mid secretory phase were defined in precisely timed cycles in women of proven fertility, but when deviations from this standardized schedule occur, their significance for implantation has remained uncertain. ‘Omics technologies have been widely advocated for staging the endometrial cycle and defining a set of biochemical requirements for implantation, but after two decades of research, improvements to pregnancy rates have not followed, and there is a striking lack of agreement regarding the molecular characterization of the receptive state. Some of the rationale underlying these problems is now emerging with the application of higher-level computational and biological methodology. Here, we consider the challenges of defining an endometrial phenotype that can support implantation and continuing pregnancy. Receptivity may be an emergent trait depending on contributions from multiple proteins that have low pathway connectivity. We recommend that authors choose language which rigorously avoids the implication that protocols for molecular staging of the mid secretory phase inherently identify a state of receptivity to the implanting blastocyst.

Endometrial Dating Method Detects Individual Maturation Sequences During the Secretory Phase

BACKGROUND/AIM

This study assessed whether a new immunohistochemical dating method allows precise endometrial dating allowing optimal timing for embryo transfer.

PATIENTS AND METHODS

A novel method was used for endometrial dating, with parameters including menstrual cycle days, Noyes histological criteria, along with immunohistochemical expression pattern of estrogen and progesterone receptors and proliferation marker Ki-67. Endometrial maturation was analyzed on days +5 to +10 after ovulation or progesterone administration in 217 biopsies from 151 subfertile patients during the secretory phase.

RESULTS

Endometrial maturation varied individually, occurring 1.68±1.67 days late. Comparison of histological maturation with clinical days after ovulation showed a delay of about 2 days.

CONCLUSION

Endometrial maturation requires 8 days, rather than the expected 6 days, to reach the histological mid-secretory phase. This is not a delay and is also seen in fertile patients. The new analysis method used is superior to that using Noyes criteria alone and provides a better basis for determining conditions for optimal timing of embryo transfers.

The use of multiplex staining to measure the density and clustering of four endometrial immune cells around the implantation period in women with recurrent miscarriage: comparison with fertile controls

Serval studies showed an increased uterine natural killer cell density in women with recurrent miscarriage. However, no study has previously investigated the density and clustering of major immune cells simultaneously in precisely timed endometrial specimen section of this group of women. This study aimed to investigate the profile of endometrial immune cells populations and clustering level simultaneously in women with recurrent miscarriage and compare the results to fertile controls. A total of 30 women with unexplained recurrent miscarriage and 30 fertile controls were included in this study. Endometrial biopsy was performed precisely 7 days after LH surge. The cells density was expressed as percentage of positive immune cell/total stromal cells and the clustering of different endometrial cells was measured by R language toolbox 'spatstat'. Multiplex immunohistochemical method was employed to stain a panel of human endometrium samples simultaneously with antibodies against CD3 for T cells, CD20 for B cells, CD68 for macrophages and CD56 for uterine natural killer cells. The median CD3⁺, CD68⁺ and CD56⁺ cell density in the miscarriage group were significantly higher than those of the fertile controls. In addition, the clustering between CD56⁺ uterine natural killer cells and CD68⁺ macrophages in the miscarriage group was significantly increased compared with fertile controls. In conclusion, the significant change in numbers of three out of four endometrial immune cell density and a significant increase in clustering between CD68⁺ and CD56⁺ cells suggest that several immune cells and their interactions may be important in the function of the endometrium; abnormal interactions may predispose to recurrent miscarriage.

Correlation between three-dimensional power Doppler and morphometric measurement of endometrial vascularity at the time of embryo implantation in women with unexplained recurrent miscarriage

Power Doppler in combination with three-dimensional (3D-PD) ultrasonography has been used as a noninvasive tool to evaluate the vascularity. However, it is unclear whether 3D-PD can accurately reflect endometrial vascularization and replace the invasive endometrial biopsy. This study aims to investigate the correlation between 3D-PD and micro vessel morphometric measurement of endometrial vascularity. Twenty-five women with unexplained recurrent miscarriage were recruited for 3D-PD and endometrial biopsy on precisely day LH + 7. Immunohistochemistry using vWF was employed to identify micro vessels in endometrial biopsy specimens followed by the use of morphometric technique to measure the mean vessel diameter and volume fractions. The vascularization index (VI), flow index (FI) and vascularization flow index (VFI) assessed by 3D-PD were calculated for both the endometrial and sub-endometrial regions. There were no significant correlations between any of the ultrasonographic measurements (endometrial thickness, endometrial volume, endometrial VI/FI/VFI, sub-endometrial volume, sub-endometrial VI/FI/VFI) and morphometric features (number of micro vessel, mean diameter of micro vessel and volume fraction measurement of vessel). This study indicates that endometrial vascularity assessed by 3D-PD could not be used to reflect changes in micro vessels of the endometrium at the time of embryo implantation in women with unexplained recurrent miscarriage.

The Polycomb Group Protein EZH2 Impairs DNA Damage Repair Gene Expression in Human Uterine Fibroids

Uterine fibroids are benign, smooth muscle tumors that occur in approximately 70%-80% of women by age 50 yr. The cellular and molecular mechanism(s) by which uterine fibroids (UFs) develop are not fully understood. Accumulating evidence demonstrates that several genetic abnormalities, including deletions, rearrangements, translocations, as well as mutations, have been found in UFs. These genetic anomalies suggest that low DNA damage repair capacity may be involved in UF formation. The objective of this study was to determine whether expression levels of DNA damage repair-related genes were altered, and how they were regulated in the pathogenesis of UFs. Expression levels of DNA repair-related genes RAD51 and BRCA1 were deregulated in fibroid tissues as compared to adjacent myometrial tissues. Expression levels of chromatin protein enhancer of zeste homolog 2 (EZH2) were higher in a subset of fibroids as compared to adjacent myometrial tissues by both immunohistochemistry and Western blot analysis. Treatment with an inhibitor of EZH2 markedly increased expression levels of RAD51 and BRCA1 in fibroid cells and inhibited cell proliferation paired with cell cycle arrest. Restoring the expression of RAD51 and BRCA1 by treatment with EZH2 inhibitor was dependent on reducing the enrichment of trimethylation of histone 3 lysine 27 epigenetic mark in their promoter regions. This study reveals the important role of EZH2-regulated DNA damage-repair genes via histone methylation in fibroid biology, and may provide novel therapeutic targets for the medical treatment of women with symptomatic UFs.

Morphometric study of GnRH analog/HMG/HCG effects on ultrastructure of human endometrial epithelium in early and mid-luteal phase

AIM

The aim of the present study was to investigate the effects of long protocol ovulation induction on the ultrastructure of the human endometrial epithelium on days luteinizing hormone (LH) + 4 and LH+ 6 of the menstrual cycle.

METHODS

Endometrial biopsies were obtained on days LH+ 4 (n = 9) and LH+ 6 (n = 10) from infertile women who were under standard long protocol with luteal phase supplementation with IM (intramuscular) progesterone, but where the embryo had not been formed or transferred, due to the male factor problem. Biopsies were also taken on days LH+ 4 (n = 5) and LH+ 6 (n = 5) from fertile women who had not received ovulation induction drugs as control groups. After preparation and taking light and electron micrographs from samples, qualitative and quantative evaluations (morphological and morphometric) were accomplished and the data was compared using the unpaired student t-test.

RESULTS

Qualitative results showed the presence of the nuclear channel system, vacuoles of glycogen and giant mitochondria in all of the samples. Qualitative analysis showed that the volume fraction (Vv) of the euchromatin to the nucleus, the rough endoplasmic reticulum and the mitochondria to the cell, were not statistically different (P > 0.05) in samples taken on LH+ 4 in both control and test groups. The Vv of these features, however, to the cell in the test group was significantly (P < 0.05) higher than those in the control taken on LH+ 6.

CONCLUSIONS

These results suggest that long protocol ovulation induction with luteal phase support with progesterone alter the normal development of the human endometrium in the mid luteal phase and could decrease the implantation success rate.

The effects of GnRH antagonist on the endometrium of normally menstruating women

PURPOSE

To study the effects of GnRH antagonist (ganirelix-Orgalutran) on the endometrium of regularly menstruating women.

MATERIALS AND METHODS

Prospective, self-controlled study. The thirty-five volunteers were studied for two cycles: one as a control and the other, GnRH antagonist-treated cycles in which ganirelix 0.25 mg/d was given daily for 3 days, starting when the largest follicle reached 15 mm. In both cycles, serum estradiol, LH and endometrial thickness were measured when the largest follicle was > or =18 mm. Endometrial biopsy was performed on day 6 after ovulation for histological dating and morphometric study.

RESULTS

No statistical differences between histological dating and the endometrial thickness in the control and GnRH antagonist-treated cycles. All morphometric parameters were also not different. Serum estradiol and LH levels were significantly lower in GnRH antagonist-treated cycles.

CONCLUSION

GnRH antagonist has no effect on the endometrium of regularly menstruating women as assessed by either histological dating or morphometric analysis.

Endometrial expression of IL-1RtI in patients undergoing miscarriage or unsuccessful IVF cycles

This study sought to compare the endometrial expression of interleukin-1 receptor type I in patients with a history of spontaneous recurrent miscarriage and patients with unsuccessful IVF cycles. Eight patients who had undergone two or more consecutive unsuccessful IVF cycles (group I), in which at least one good quality embryo was transferred, and 18 patients with at least three spontaneous late miscarriages (group II) were included in the study. Endometrial and follicular development were evaluated by ultrasonography. Plasma concentrations were evaluated for FSH and prolactin on cycle day 3 and for progesterone on day 7 after ovulation, when an endometrial biopsy was performed; samples were cryopreserved for interleukin-1 receptor type I immunohistochemistry and embedded in paraffin for endometrial dating. Patients with no ovulation or any anomalies in hormone concentrations, uterine cavity or endometrial histology were excluded. Interleukin-1 receptor type I was expressed in the lumenal epithelium of both groups. There was a significant difference (P = 0.0357, two-tailed Fisher's exact test) in the glandular epithelium expression of interleukin-1 receptor type I between groups I (87.5% of patients) and II (38.9% of patients). Endometrial expression of interleukin-1 receptor type I does not seem to be involved in embryo implantation in IVF patients, but may play a role in spontaneous recurrent miscarriage.

Glycodelin is present in pinopodes of receptive-phase human endometrium and is associated with down-regulation of progesterone receptor B

OBJECTIVE

To test the hypothesis that glycodelin is localized on pinopodes and correlates with temporal immunostaining of leukemia inhibitory factor (LIF), LIF receptor (LIFR), and progesterone receptor B (PRB).

DESIGN

Prospective clinical study.

SETTING

Hospital-based reproductive health unit and research laboratories.

PATIENT(S)

Twenty-five healthy fertile women with normal menstrual cycles.

INTERVENTION(S)

Endometrial biopsy specimens were obtained from healthy fertile women in the luteal phase of the menstrual cycle.

MAIN OUTCOME MEASURE(S)

Immunohistochemical staining of glycodelin, ultrastructural immunostaining of glycodelin, and double staining of glycodelin and PRB.

RESULT(S)

Glycodelin is present in the glands when pinopodes appear. Glycodelin is localized on pinopodes but is also secreted from luminal epithelial cells regardless of pinopode formation. There was a negative correlation between glycodelin secretion from the glands and PRB staining. A weak correlation between the presence of LIFR (but not LIF) and glycodelin was found.

CONCLUSION(S)

Pinopode appearance, intense staining of LIFR in pinopodes and glycodelin staining in the glands are synchronized events. Down-regulation of PRB in the endometrium is concomitant with the presence of glycodelin in the endometrium, suggesting interaction.

Connective tissue growth factor expression in the human corpus luteum: paracrine regulation by human chorionic gonadotropin

CONTEXT

The molecular mechanisms of luteolysis and its inhibition during maternal recognition of pregnancy remain unclear.

OBJECTIVE

The objective of this study was to investigate the differential regulation of connective tissue growth factor (CTGF) expression in human corpora lutea using in vivo and in vitro models.

DESIGN

Corpora lutea from different stages of the luteal phase and after luteal rescue with human chorionic gonadotropin (hCG) were studied. Primary cultures and cocultures of luteinized granulosa cells and luteal fibroblast-like cells were performed.

SETTING

This study was performed at the research center of a university teaching hospital.

PATIENTS

Women with regular cycles having hysterectomy for nonmalignant conditions and women undergoing oocyte collection for assisted conception were studied.

INTERVENTIONS

CTGF localization was determined by in situ hybridization, and expression by quantitative RT-PCR.

OUTCOMES

The outcome measures were the effect of hCG on the expression and localization of CTGF mRNA in human corpora lutea and the effect of hCG on CTGF expression in primary cultures of luteinized granulosa cells and luteal fibroblast-like cells.

RESULTS

Luteal rescue reduced CTGF expression compared with that in the late luteal phase (P < 0.05). CTGF expression was localized to fibroblast-like cells and endothelial cells of larger blood vessels, not to steroidogenic cells. The expression of CTGF by fibroblast-like cells in vitro was not regulated by hCG. When cocultured with luteinized granulosa cells, fibroblast-like cell CTGF expression was inhibited by hCG (P < 0.001). This effect was independent of stimulated progesterone concentrations and was not blocked by follistatin or indomethacin. Both IL-1alpha (P < 0.05) and cAMP (P < 0.001) inhibited CTGF expression in fibroblast-like cells.

CONCLUSIONS

These results provide evidence for negative regulation of CTGF by hCG during luteal rescue mediated by paracrine signals.

The effect of human chorionic gonadotrophin on the expression of progesterone receptors in human luteal cells in vivo and in vitro

The human corpus luteum expresses genomic progesterone receptors (PRs) suggesting that progesterone may have an autocrine or paracrine role in luteal function. We hypothesised that the reduction in luteal PR reported in the late-luteal phase augmented progesterone withdrawal and had a role in luteolysis. We therefore tested the hypothesis that luteal rescue with human chorionic gonadotrophin (hCG) would maintain PR expression. PR was immunolocalised to different cell types in human corpora lutea (n = 35) from different stages of the luteal phase and after luteal rescue with exogenous hCG. There was no change in the staining intensity of theca-lutein cell or stromal cell PR throughout the luteal phase or after luteal rescue. In the late-luteal phase, granulosa-lutein cell PR immunostaining was reduced (P < 0.05) but the trend to reduction was also seen after luteal rescue with hCG (P = 0.055). To further investigate the effect of hCG on granulosa-lutein cell PR expression, an in vitro model system of cultured human luteinised granulosa cells was studied. Cells were cultured for 12–13 days exposed to different patterns of hCG and aminoglutethamide to manipulate progesterone secretion (P < 0.0001). Expression of PR A/B and PR B isoforms was examined by quantitative real-time RT-PCR. PR A/B mRNA was lower (P < 0.05) after 11–13 days of culture than after 7 days of culture. This reduction could not be prevented by hCG in the presence (P < 0.05) or absence (P < 0.05) of stimulated progesterone secretion. The expression of PR B mRNA showed a similar pattern (P = 0.054). Simulated early pregnancy in vivo and hCG treatment of luteinised granulosa cells in vitro did not appear to prevent the down-regulation of PR seen during luteolysis.

Endometrial evaluation in superovulation programs: relationship with successful outcome

It is well known that an adequate endometrial receptivity is required for successful implantation in both natural and assisted reproductive cycles. In particular, a brief "implantation window", during which endometrium undergoes anatomical and molecular changes necessary for embryo implantation, has been observed. The hormonal treatment applied to induce ovulation seems to be able to modify the normal development of the prenidatory endometrium, with possible negative effect on the implantation rate. For this reason, several attempts have been made to identify specific markers of endometrial receptivity, useful for predicting implantation outcome in clinical practice. Even if different histological, immunohistochemical, and ultrasonographic parameters are studied, none unfortunately has been univocally shown to be predictive of pregnancy outcome. Therefore, the evaluation of endometrial receptivity remains a challenge in clinical practice.

Localization and quantification of cyclic changes in the expression of endocrine gland vascular endothelial growth factor in the human corpus luteum

Angiogenesis is essential for normal growth and function of the corpus luteum. The roles of various angiogenic factors in these events are being elucidated. Endocrine gland vascular endothelial growth factor (EG-VEGF) has recently been described in the human ovary. To define the localization of EG-VEGF mRNA in the corpus luteum and determine changes in its expression, dated human corpora lutea were studied at the early, mid-, and late luteal phases. Quantitative RT-PCR was employed to determine changes in EG-VEGF mRNA and compare expression to its related factor prokineticin-2 and the established angiogenic factor, VEGF. In situ hybridization was used to localize sites of production of EG-VEGF. To investigate whether expression of EG-VEGF was under the influence of LH or progesterone, luteinized granulosa cells were stimulated with human chorionic gonadotropin in the presence or absence of a progesterone synthesis inhibitor. EG-VEGF mRNA increased throughout the luteal phase, whereas there was no change in VEGF mRNA. The relative abundance of RNAs based upon PCR signal intensity showed that VEGF and EG-VEGF were highly expressed, whereas expression of prokineticin-2 was low. EG-VEGF mRNA was localized predominantly to granulosa-derived cells of the corpus luteum. Human chorionic gonadotropin stimulated both VEGF and EG-VEGF mRNA in vitro, but the level of expression was not influenced by progesterone. These results establish that in the human corpus luteum EG-VEGF is principally derived from granulosa lutein cells and that its synthesis is highest during the mid- to late luteal phase.

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.

Angiogenesis in the human corpus luteum: simulated early pregnancy by HCG treatment is associated with both angiogenesis and vessel stabilization

BACKGROUND

This study examined changes in the luteal vasculature throughout the menstrual cycle and during simulated pregnancy with human chorionic gonadotrophin (HCG) in the human.

METHODS

Endothelial cell and pericyte area were assessed by quantitative immunocytochemistry for CD34 and alpha-smooth muscle actin respectively, taking into consideration the dynamics of lutein cell hypertrophy and atrophy throughout the cycle and after HCG treatment. Endothelial cell proliferation was detected by Ki-67/CD34 dual staining and a proliferation index was obtained. The molecular regulation of angiogenesis was studied by examining changes in vascular endothelial growth factor (VEGF) immunostaining.

RESULTS

The early luteal phase is associated with intense angiogenesis, as indicated by high endothelial cell proliferation, and by the mid-luteal phase a mature vasculature was apparent, as shown by maximal endothelial cell and pericyte areas. During the late luteal phase, decreased endothelial proliferation, endothelial cell and pericyte area indicated vascular regression. HCG treatment induced a second burst of total and endothelial cell proliferation and a concomitant increase in endothelial cell and pericyte areas. VEGF protein was expressed throughout the luteal phase and a significant increase was found after HCG treatment.

CONCLUSION

Luteal rescue with HCG is associated with a second wave of angiogenesis and vascular stabilization.

Effect of vaginally administered (Ala(8,13,18))-magainin II amide on the morphology of implantation stage endometrium in the rhesus monkey (Macaca mulatta)

Intravaginal administration of an anti-microbial agent, (Ala(8,13,18))-magainin II amide, during blastocyst implantation inhibits pregnancy establishment in a dose-related manner in the rhesus monkey (Macaca mulatta). In the present study, mated female rhesus monkeys were vaginally inserted with tampons containing vehicle (Group 1; n = 5) and test agent (magainin, 0.5 mg/animal; Group 2; n = 6) on cycle day 20. Endometrial tissue samples were collected on Cycle Day 24 from all monkeys and processed for morphometric and ultrastructural analysis. Concentrations of estradiol-17beta, progesterone, and chorionic gonadotrophin in peripheral circulation were determined, which revealed that two monkeys in Group 1 were pregnant while no animals were pregnant in Group 2. Endometrial morphology, however, revealed histologic evidence of pregnancy in three out of the six magainin-treated animals. It appears that intra-vaginal administration of magainin II amide had a marginal effect on the implantation stage endometrium and the initiation of the implantation process in the rhesus monkey.

Morphometric analysis of peri-implantation endometrium in patients having excessively high oestradiol concentrations after ovarian stimulation

The present study investigated whether high oestradiol concentrations after ovarian stimulation in infertile women affect endometrial development around the time of implantation. The glandular and stromal components of the endometrium were assessed by morphometric criteria. Endometrial biopsies were taken on day 7 (+/-1) after the ovulating dose of human chorionic gonadotrophin in stimulation cycles and on day 7 after the LH surge in natural cycles. Women (n = 38) undergoing assisted reproduction treatment were evaluated: 12 women in natural cycles, 11 women in stimulation cycles with oestradiol <20,000 pmol/l and failed fertilization after oocyte collection (moderate responders) and 15 women with an oestradiol concentration of > or =20,000 pmol/l in stimulation cycles (high responders). High responders showed delayed glandular maturation and advanced stromal morphology, whereas moderate responders demonstrated synchronous development of glandular and stromal features. In natural cycles, the glands were in phase. The effect of excessively high oestradiol concentrations could be explained by quantitative evaluation of the endometrial biopsies as gland--stromal dyssynchrony, which indicates a deficient secretory transformation of the endometrium that represents a suboptimal endometrial environment for implantation. This substantiates our previous clinical observation of significantly lower pregnancy rates in IVF cycles of women with high oestradiol concentrations (> or =20,000 pmol/l).

Effect of vaginally administered fumagillin on the morphology of implantation stage endometrium in the rhesus monkey

Intravaginal administration of an anti-angiogenic agent, fumagillin, during blastocyst implantation, inhibits pregnancy establishment in a dose-related manner in the rhesus monkey. In the present study, mated female rhesus monkeys were vaginally inserted with tampons containing vehicle (group 1; n = 5) and test agent (fumagillin, 4 mg/animal; group 2; n = 6) on cycle day 20, and endometrial tissue samples were collected on cycle day 24 from all monkeys and processed for morphometric and ultrastructural analysis. Concentrations of estradiol-17beta, progesterone and chorionic gonadotrophin in peripheral circulation were determined. From serum profiles of hormones, two monkeys in group 1, and one animal in group 2 appeared pregnant. Endometrial morphology revealed histologic evidence of pregnancy in three of six fumagillin-treated animals, while other three fumagillin-treated animals showed degenerative changes in glands and venules along with marked extravasation. It is possible that the function of corpus luteum was affected by fumagillin treatment resulting in inadequate progesterone production (p <0.05), and consequent inadequate endometrial secretory preparation and receptivity, as revealed from decline in apical movement of vacuoles (p <0.05) and increase (p <0.05) in extravasation of red cells and leukocytes.

Angiogenesis in the human corpus luteum: localization and changes in angiopoietins, tie-2, and vascular endothelial growth factor messenger ribonucleic acid

In the menstrual cycle, extensive angiogenesis accompanies luteinization. During luteolysis, endothelial cells die, whereas in a conceptual cycle, the corpus luteum (CL) persists, and endothelial cell survival is extended. A main stimulator for angiogenesis is vascular endothelial growth factor (VEGF), while the angiopoietins (Ang-1 and Ang-2) may be important modulators. The aim of this study was to investigate the localization of Ang-1, Ang-2, their common receptor Tie-2, and VEGF messenger ribonucleic acid (mRNA) at the different stages of the functional luteal phase and after rescue by hCG. Ang-1 mRNA was uniformly expressed at a low level throughout the CL. The signal was highest during the early luteal phase. In contrast, Ang-2 mRNA expression was localized strongly to individual granulosa and thecal luteal and endothelial cells. Administration of hCG was associated with an increase in the Ang-2 mRNA area of expression and grain density in individual luteal and endothelial cells. The Tie-2 receptor mRNA was localized in endothelial cells, and the area of expression was highest during the early luteal phase and during luteal rescue. VEGF mRNA was found exclusively in granulosa luteal cells, and the area of expression was highest in corpora lutea during simulated pregnancy. These results begin to characterize the molecular regulation of the divergent processes involved in luteal angiogenesis during luteinization, luteolysis, and rescue in the human and imply that the angiopoietins are involved during the initial angiogenic phase and in luteal rescue.

A rapid decline in serum oestradiol concentrations around the mid-luteal phase had no adverse effect on outcome in 763 assisted reproduction cycles

Progesterone is essential in the luteal phase whereas luteal oestradiol may play only a permissive role on the endometrium. However, a rapid decline in oestradiol concentrations around the mid-luteal period may compromise the endometrial integrity leading to poor IVF outcomes. A retrospective analysis of 763 women aged <40 years undergoing their first IVF cycle and having < or =3 embryos replaced was undertaken. In cycles receiving human chorionic gonadotrophin (HCG) for luteal support, 25th, 50th and 75th centiles of the ratio of day-of-HCG oestradiol to mid-luteal oestradiol (oestradiol ratio) were 1.8, 2.8 and 5.0 respectively. Hormonal parameters were not different between pregnant and non-pregnant cycles. The outcomes were similar irrespective of the oestradiol ratio. Progesterone supplementation was used instead when the HCG oestradiol was >18 000 pmol/l or there were features of ovarian hyperstimulation syndrome. Pregnancy rates of these hyperstimulated cycles were 16.7 and 11.4% per cycle respectively when oestradiol ratio was < or =5.0 and >5.0. This difference did not reach statistical significance. Our results could not find an adverse outcome in cycles showing a rapid decline in oestradiol during the mid-luteal phase.

Morphological evidence for the 'implantation window' in human luminal endometrium

Endometrial tissue was taken from 21 normal fertile women (aged 18-40 years) between 4 and 13 days after the luteinizing hormone (LH) surge. Systematic random samples of luminal epithelium were taken for both light and electron microscopy and examined morphometrically. Throughout the luteal phase there were remarkably few changes in the volume fraction of nucleus, mitochondria, rough endoplasmic reticulum and 'vesicular system' to cell. Nuclear profile dimensions and cell height also did not change over time. Cell and organelle volume (estimated as volume weighted mean volume) did not change significantly, but showed numerically smallest values on day LH + 13. However the ratio of desmosomes to whole cell and both arithmetic mean thickness and harmonic mean thickness of basement membrane were minimal at the time when implantation would be most likely to occur, i.e. approximately 6 days after the LH peak. Therefore it appears that while some morphometric parameters in human luminal epithelial cells change little during the luteal phase, specific cellular changes occur to the basement membrane and desmosomes which may facilitate embryo implantation. These changes occurred around day LH+ 6 and may be a morphological representation of the 'implantation window'.

Correlation between endometrial dating of luteal phase days 6 and 10 of the same menstrual cycle

CONTEXT

Endometrial maturation, important in the diagnosis of infertile couples, has been evaluated since 1950 using the Noyes criteria. Nevertheless, there is no consensus regarding the most suitable period of the luteal phase for performing the biopsy.

OBJECTIVE

This study evaluated the correlation between the histological dating of two endometrial biopsies performed in the same menstrual cycle, on luteal phase days six and ten.

DESIGN

Prospective study.

SETTING

Human Reproduction Division of the Federal University of São Paulo, referral center.

PATIENTS

Twenty-five women complaining of infertility had their menstrual cycles monitored by ultrasound and LH plasma levels, to obtain evidence of ovulation.

PROCEDURES

Endometrial biopsies were performed on luteal phase days LH + 6 and LH + 10 (luteal phase day 1 = LH + 1 = the day that follows LH peak). Dating was done according to morphometric criteria, in which an endometrium sample is considered out of phase if the minimum maturation delay is one day. On day LH + 6, blood was drawn for plasma progesterone level determination.

RESULTS

All patients had an ovulatory cycle (mean LH peak: 47.4 U/L; mean follicular diameter on LH peak day: 18.9 mm; mean endometrial thickness on LH peak day: 10.3 mm; mean plasma progesterone level on day LH + 6: 14.4 ng/ml). 14 patients had both biopsies in phase; 5 patients had out of phase biopsies only on day LH + 6; 3 had out of phase biopsies only on day LH + 10 and 3 patients had out of phase biopsies on both days. McNemar's test showed no statistical difference between these data (p > 33.36%).

CONCLUSIONS

The correlation found between the endometrial datings suggests that biopsies performed on either of these two days are suitable for evaluation of endometrial maturation.

Endometrial leucocytes: expression of steroid hormone receptors

BACKGROUND

Stromal leucocyte populations in human endometrium comprise T cells, macrophages, and phenotypically unusual endometrial granulated lymphocytes. Their proportions vary during the menstrual cycle and, in particular, endometrial granulated lymphocytes increase in number in the late secretory phase. The stimulus responsible for these cyclical changes is unknown but it is likely that the steroid hormones oestrogen and progesterone play a role.

AIMS

To define further the expression of steroid hormone receptors by leucocytes in non-pregnant and pregnant human endometrium.

METHODS

Frozen and paraffin wax embedded sections of endometrium from non-pregnant women and early pregnancy decidua were labelled using single and double immunohistochemical techniques with monoclonal antibodies directed against oestrogen and progesterone receptors and various leucocyte subpopulations.

RESULTS

Despite the prominence of CD56 positive endometrial granulated lymphocytes in late secretory phase endometrium and early pregnancy decidua, double immunohistochemical labelling showed no evidence of expression of either progesterone or oestrogen receptors by these cells or other endometrial leucocyte populations.

CONCLUSIONS

Rather than acting directly, steroid hormones are likely to influence endometrial leucocyte populations indirectly via products of endometrial stromal or epithelial cells that express steroid hormone receptors.

Importance of endometrial quality in women with tubal infertility during a natural menstrual cycle for the outcome of IVF treatment

PURPOSE

The importance of endometrial maturation at estimated time of implantation for the outcome of IVF treatment in regularly menstruating women with tubal infertility was evaluated.

METHODS

FSH was measured on cycle day 3, on days 10-15 urine and blood were collected to estimate the day of the LH peak, and E2 and P4 were measured during the luteal phase, on cycle days 19-26. An endometrial biopsy was obtained on days LH + 3 to LH + 6.

RESULTS

The number of subjects with delayed endometrial maturation was larger in the group of infertile women who did not become pregnant compared to pregnant women and controls. Those infertile women who did not become pregnant after IVF treatment also presented with a higher basal FSH on cycle day 3 and lower E2 and P4 AUC in the luteal phase. Six infertile women and two controls presented with mid- and late-proliferative endometrium in the luteal phase on cycle days LH + 3 to LH + 6, in the presence of adequate E2 and P4 secretion. Six morphological characteristics were compared in the three groups: (1) 17 infertile women who became pregnant, (2) 18 who did not become pregnant, and (3) 28 controls. The pregnant infertile women did not differ from the controls. The numbers of glandular and stromal mitoses were significantly higher in those women who did not become pregnant (P < 0.01) compared with those who became pregnant. Endometrial biopsies obtained on cycle days LH + 5 and LH + 6 showed significant differences in glandular epithelial height (P < 0.05) and number of vacuolated cells among the nonpregnant women (P < 0.01), the pregnant women (P < 0.05), and controls.

CONCLUSIONS

A higher frequency of retarded endometrial development in women who did not become pregnant following IVF treatment was found. In some cases, endometrial insensitivity could most likely cause retarded endometrial development and failure of implantation after IVF treatment, which could not be overcome by routine luteal-phase support. However, our results do not allow conclusions concerning its relative importance compared to preembryo quality; this has to be investigated further.

Endometrial evaluation by aspiration biopsy on the day of oocyte retrieval in the embryo transfer cycles in patients with serum progesterone rise during the follicular phase

OBJECTIVE

To investigate the effect of subtle serum P rise before hCG administration on endometrial maturation in stimulated cycles.

DESIGN

Case-control study.

SETTING

Tertiary referral center.

PATIENT(S)

Twenty patients with serum P < or = 0.9 ng/mL (group I) (conversion to SI unit, 3.180), 20 patients with premature P rise (> or = 1.1 ng/mL, group II), and 20 patients with normal serum P (group III).

INTERVENTION(S)

Patients in groups I and II underwent endometrial aspiration biopsies on the day of oocyte retrieval in the ET cycles themselves. Patients in group III, without endometrial biopsies, were chosen as controls.

MAIN OUTCOME MEASURE(S)

Comparison of endometrial maturation, correlation between endometrial dating and cumulative P exposure, and/or number of days of P > or = 1.1 ng/mL and comparison of clinical outcome.

RESULT(S)

Groups I and II showed a secretory activity of the endometrium. In group II, the endometrial dating correlated neither with P exposure nor with the number of days of subtle P rise. Clinical pregnancies were observed in both groups but none in cases with endometrium advanced > 3 days. Similar pregnancy and implantation rates were observed between groups I and III.

CONCLUSION(S)

These data suggest that an endometrial aspiration biopsy performed on the day of oocyte retrieval may be used to assess endometrial receptivity in patients with serum P rise.

MUC1 as a cell surface and secretory component of endometrial epithelium: reduced levels in recurrent miscarriage

The mucin MUC1 is a large, highly glycosylated, hormonally regulated product of endometrial glandular and luminal epithelium with both cell surface-associated and secreted isoforms. The abundance of mRNA coding for MUC1 increases about sixfold from the proliferative to the early secretory phase (Hey et al., J. Clin. Endocrinol. Metab. 78:337-342, 1994). Immunohistochemical studies show intracellular deposits accumulating in the early secretory phase followed by the release of MUC1 into gland lumens. The apical surface of luminal epithelium is strongly immunopositive in the early secretory phase. We have used a two site ELISA to measure MUC1 in uterine flushings as a function of time after the luteinising hormone (LH) peak. Low levels of secretory MUC1 are observed before day LH+7, while values on days LH+7-LH+13 are much higher. Using semi-quantitative immunohistochemical methods we have shown that in women suffering recurrent spontaneous miscarriage, mid secretory phase levels of MUC1 core protein and mucin-associated glycans are reduced (Serle et al., Fertil. Steril. 62:989-996, 1994). Similarly, lower core protein levels are observed in uterine flushings after day LH+7 in these women. Reduced epithelial secretory function and a resultant change in uterine fluid composition are features of endometrium from recurrent miscarriage patients.

Endometrial differentiation in the peri-implantation phase of women with recurrent miscarriage: a morphological and immunohistochemical study

OBJECTIVES

To study endometrial differentiation in the peri-implantation phase of women with recurrent miscarriage and to compare the results with endometrium of normal fertile women.

DESIGN

A prospective study of endometrial specimens precisely timed from the LH surge, using traditional histologic dating (Noyes' criteria), quantitative histologic measurement (morphometric analysis), and immunohistochemical techniques.

RESULTS

Fifteen of 25 (60%) subjects in the recurrent miscarriage group had retarded endometrial development in the peri-implantation period as monitored by morphometry. The recurrent miscarriage group showed reduced levels of four mucin-related secretory epitopes, and greater reductions were associated with morphological retardation. Normal differentiation was observed in all of the 14 subjects in the control group.

CONCLUSIONS

Women with idiopathic recurrent pregnancy loss may be divided into two distinct subgroups on the basis of their endometrial response in the peri-implantation period. Precisely timed endometrial biopsy should be incorporated in the investigation of recurrent miscarriage.

Hormone regulation and hormone antagonist effects on protein patterns of human endometrial secretion during receptivity

Endometrial receptivity is a particular stage of maturation during the luteal phase to permit implantation. We have studied endometrial protein secretion and its patterns evaluated by SDS-PAGE, laser densitometry and Western blots. Uterine secretion electrophoresis (USE) permits highly sophisticated analyses of the intrauterine milieu and allows clinical determination of the receptive stage of the endometrium. This technique reveals direct parameters by patterns of numerous individual protein bands, mainly resolved between 68.0 and 6.5 kD. Characteristic bands appear during the typical functional states of the menstrual cycle presenting evidence on the diagnostic capacity of this method to identify stages of adequate (= normal) or inadequate (= defective) luteal phase maturation. Several individual protein bands appear as characteristic markers for the receptive stage of the luteal phase. We have isolated and molecularly identified several of these proteins: histones H2A, H2B, H3 and H4. In order to identify the endocrine dependency of the protein bands, which significantly contribute to the "receptive stage pattern," patients were treated with the progesterone antagonist RU 486 at day LH +2. The assessment 4 days later revealed deficient USE patterns, particularly diminished and missing bands of the H2A-, H2B-, and H3-histones. These results demonstrate progesterone-dependent components of the endometrium at the receptive stage, which can be used as useful markers for an improved precision in luteal phase diagnostics. On the other hand, essential parts of the protein pattern may serve as new targets for successful contraceptive interventions ("endometrial contraception").

Endometrial structure after superovulation: a prospective controlled study

OBJECTIVE

To demonstrate the effect of superovulation using a GnRH agonist (GnRH-a) and hMG and hCG on endometrial structure.

DESIGN

Prospective, case-controlled study.

SETTING

Tertiary referral assisted reproduction unit in an academic department.

PATIENTS

Eleven women undergoing GIFT or IVF, without ET.

INTERVENTIONS

All women were treated with a long stimulation regimen using the depot GnRH-a Goserelin (ICI, Macclesfield, United Kingdom) and hMG and hCG.

MAIN OUTCOME MEASURES

Comparison of endometrial biopsy specimens taken 4 days after ovulation in an unstimulated cycle with specimens taken 4 days after oocyte recovery, using standard dating criteria and morphometric analysis.

RESULTS

There was no difference in endometrial glandular development as assessed by either standard criteria or morphometric analysis.

CONCLUSIONS

Superovulation preceded by pituitary down regulation is not associated with abnormal endometrial glandular development, even though supraphysiological levels of E2 and P are induced.

A study of endometrial morphology in women who failed to conceive in a donor insemination programme

OBJECTIVE

To examine the morphology of endometrium in women who failed to conceive after nine or more cycles of donor insemination treatment.

DESIGN

Prospective study.

SETTING

Jessop Hospital for Women, Sheffield.

SUBJECTS

Two groups: twenty-six infertile women and a control group of eight fertile women.

INTERVENTION

Endometrial biopsy specimens were obtained in the mid-luteal phase, timed precisely by the luteinising hormone surge.

MAIN OUTCOME MEASURE

Morphological study of endometrial biopsy specimens by the use of traditional dating criteria and established morphometric techniques.

RESULTS

Twelve biopsy specimens (42%) were found to be retarded. In addition, morphometric analysis revealed significant differences in the glandular component of the endometrium between the infertile and fertile groups.

CONCLUSION

Endometrial defect leading to implantation failure may be an important underlying cause of failure to conceive after repeated attempts at donor insemination. The endometrium should be investigated in this group of women, and further attempts at donor insemination treatment should be offered only in conjunction with attempts to restore the normality of the endometrium.

A prospective, randomised, cross-over study comparing the effects of clomiphene citrate and cyclofenil on endometrial morphology in the luteal phase of normal, fertile women

OBJECTIVE

To examine the effect of two anti-oestrogens, clomiphene citrate and cyclofenil, on endometrial morphology in the luteal phase.

DESIGN

A prospective, randomised, cross-over study.

SETTING

Jessop Hospital for Women, Sheffield, UK.

SUBJECTS

10 women who were previously fertile and regularly cycling.

INTERVENTION

The administration of clomiphene citrate or cyclofenil in the treatment cycles. A LH timed endometrial biopsy was taken on day LH + 6.

MAIN OUTCOME MEASURES

Histological dating and morphometric analysis of the endometrial sample.

RESULTS

Only one out of 10 subjects had abnormal endometrium. There was no difference in the results between cycles treated with clomiphene citrate and cyclofenil.

CONCLUSIONS

Clomiphene citrate or cyclofenil does not have a major adverse effect on endometrial morphology in the luteal phase of normal fertile subjects. The possible adverse effects of anti-oestrogens on endometrium may have been previously overestimated.

Endometrial responses in artificial cycles: a prospective study comparing four different oestrogen dosages

OBJECTIVE

To examine the endometrial response to four different regimens of oestrogen.

DESIGN

A prospective, randomized cross-over study.

SETTING

Jessop Hospital for Women, Sheffield.

SUBJECTS

Twenty one women with premature ovarian failure divided into three equal groups.

INTERVENTIONS

Four different regimens of hormone replacement therapy: variable, fixed 1 mg, fixed 2 mg and fixed 4 mg oestrogen dosages. Each woman received the variable dosage regimen in one cycle and crossed over to receive one of the three fixed dose regimens (1 mg, Group 1; 2 mg, Group 2; 4 mg Group 3) in another cycle.

MAIN OUTCOME MEASURE

Ultrasonographic measurement of endometrial thickness and outpatient endometrial biopsy on day 19 of the artificial cycle; analysis of endometrial specimens by three separate methods: traditional histological criteria, morphometry and immunohistochemistry.

RESULTS

The endometrial response was similar in those treated with the variable and the fixed 2 mg or 4 mg dosage regimens. The response was suboptimal in those treated with the fixed 1 mg dosage regimen.

CONCLUSIONS

Normal endometrial development requires adequate priming of the endometrium by oestrogen, which may be administered in a sequential, variable dosage fashion, or simply by a fixed daily dosage regimen. However, the minimum daily dose required is likely to be 2 mg of oestradiol valerate. No adverse effect on the endometrium was observed at a daily dose of 4 mg oestradiol valerate, which produced plasma levels of oestradiol above the reference ranges of the natural cycle.

The endometrial biopsy as a predictive factor of pregnancy rate in women with unexplained infertility

To investigate whether or not there is any relation between endometrial morphology and subsequent pregnancy rate, 47 couples with unexplained infertility were followed up for 3 years after they had had an endometrial biopsy. Each woman had an LH-timed endometrial biopsy performed in the luteal phase of the cycle. The biopsy was dated chronologically according to the luteinizing hormone (LH) surge and histologically using morphometric criteria. None of the women received any form of treatment in the endometrial biopsy cycle. Of 47 women with unexplained infertility, 36 (76.6%) (Group I) had 'in phase' endometrial development and 11 (23.4%) (Group II) had retarded endometrium. Women with normal endometrial development had a higher pregnancy rate than women with retarded endometrial development (50% vs. 9%; P less than 0.02). The fecundability during treatment cycles was higher in Group I than in Group II (0.051 vs. 0.008; P less than 0.05). In women with 'in phase' endometrium, treatment increased the monthly probability of conception (0.051 vs. 0.006; P less than 0.001). A precisely timed endometrial biopsy should be considered as part of the investigations for women with unexplained reproductive failure, to help determine prognosis.

Delayed endometrial maturation induced by daily administration of the antiprogestin RU 486: a potential new contraceptive strategy

OBJECTIVE

Our objective was to determine if a progesterone antagonist might interdict the development of a secretory endometrium.

STUDY DESIGN

Eleven normally cycling women not at risk for pregnancy received RU 486 (1 mg/day orally) or placebo throughout one menstrual cycle in a randomized, double-blind, crossover fashion. Estradiol, progesterone, and placental protein 14 were measured every 3 days; luteinizing hormone was measured until the midcycle surge was detected. An endometrial biopsy was performed on luteal phase day 7 to 9 and interpreted with Noyes' criteria. Differences between treatment groups were analyzed by the Student t test.

RESULTS

RU 486 delayed ovulation, retarded endometrial maturation, and reduced peak levels of placental protein 14 without affecting gonadal steroid production. The abnormalities in endometrial morphology and function are similar to those seen in infertile women with luteal phase defects.

CONCLUSION

We hypothesize that this regimen of antiprogestin administration may prevent implantation and offer a novel strategy for fertility control.

Endometrial responses in artificial cycles: a prospective, randomized study comparing three different progesterone dosages

OBJECTIVE

To examine the endometrial response to three different regimens of progesterone.

DESIGN

A prospective, randomized study.

SETTING

The Jessop Hospital for Women, Sheffield.

SUBJECTS

14 women with premature ovarian failure divided into two equal groups.

INTERVENTIONS

Three different regimens of hormone replacement therapy containing standard, high and low progesterone dosages. One group received the standard regimen in one cycle and high dosage regimen in another cycle. The second group received the standard regimen in one cycle and low dosage regimen in another cycle. The order of the two dosage regimens was randomized by lottery.

MAIN OUTCOME MEASURES

Ultrasonographic measurement of endometrial thickness and morphological study of endometrial biopsy specimens taken on day 19 of the cycle using the traditional dating criteria and morphometric techniques.

RESULTS

Compared with standard regimen cycles, the endometrial response in cycles treated with the low dosage regimen showed significant retardation of overall endometrial development and changes in a number of morphometric measurements. The response of endometrial glands to the high dosage regimen was similar to that of the standard regimen, although the stromal cell diameter was increased.

CONCLUSIONS

In women receiving hormone replacement therapy normal endometrial development depends on an adequate dosage of progesterone, but increased dosage above our standard regimen does not produce any further change in the glandular component of the endometrium.

Structure of premenstrual endometrium in HMG + HCG induced anovulatory women

In this study structural alterations were tested on anovulatory infertile women who had undergone treatment of HMG + HCG to induce ovulation and subsequently to achieve pregnancy. For this purpose, a single premenstrual endometrial fundal biopsy was performed and evaluated using light and electron microscopy. The aim of the study was to evaluate the biopsies with respect to 'in-phase' or 'out-of-phase' at light microscopic level, in which a series of strict criteria were chosen, and then to detect the additional structural abnormalities at electron microscopic level, if present. Only one of the women in our study who had an in-phase endometrium became pregnant after proper treatment protocol individually adjusted and consequently terminated by an early abortion. Histologic features of the biopsies revealed that about half were normal while the rest had various types of structural abnormalities in the transformation of the secretory endometrium detected by light and/or electron microscopy. At the electron microscopic level, multiple alterations were seen in cellular and intercellular components even in those diagnosed as normal by light microscopy. As a result of the above data it was concluded that the cause of inconceivability might arise from some fine structural alterations which may affect the endometrial receptivity of an implanting embryo.

Comparative morphometric study of the endometrium, the fallopian tube, and the corpus luteum during the postovulatory phase in normally menstruating women

OBJECTIVE

To compare function and histologic structure of the corpus luteum (CL) to the morphology of the endometrium and the fallopian tube in normally menstruating women.

DESIGN

Circulating steroid and luteinizing hormone (LH) levels were compared with CL steroid production in vitro and the histology of CL, endometrium, and the fallopian tube at four stages of the postovulatory phase (days LH +/- 0/LH+3, LH+4/LH+7, LH+8/LH+11, LH+12/onset of menstruation). SETTING OF PATIENTS: The study included 28 volunteers with proven fertility undergoing surgical sterilization timed in relation to the LH surge.

INTERVENTIONS

Blood and urine samples for LH, progesterone (P), and estradiol assessment were obtained before (simultaneously with ultrasound examinations), during, and after operation. Biopsy specimens from CL, endometrium, and fallopian tube were taken at the surgical sterilization and subjected to morphometric analyses.

MAIN OUTCOME MEASURES AND RESULTS

Significant correlation was found between the endometrial dating and the LH surge (r = 0.923) and between the dating of the endometrial and CL biopsies (r = 0.918). A significant correlation (P less than 0.01) existed between circulating P levels and two endometrial indices; the number of vacuolated cells (LH+4/LH+7) and the glandular diameter (LH+8/LH+11).

CONCLUSION

In normally menstruating women, the endometrial biopsy is likely to closely gauge the CL activity provided the biopsy is timed in relation to the LH surge.

The variation of endometrial response to a standard hormone replacement therapy in women with premature ovarian failure. An ultrasonographic and histological study

The endometrial response to a standard hormone replacement therapy in 18 women with premature ovarian failure was examined by serial ultrasonographic measurement of endometrial thickness and histological study of endometrial biopsy taken on day 19 of the cycle. Women with idiopathic ovarian failure (n = 10) had significantly better response than women with Turner's syndrome (n = 4), whereas women with premature ovarian failure associated with previous chemotherapy (n = 4) had an intermediate response. These observations suggest that the endometria of women with Turner's syndrome responded suboptimally to steroid hormones. However, all endometrial biopsies studied revealed secretory changes. Overall, the results of histological dating of endometrial biopsy were found to be positively correlated with endometrial thickness on day 19 of the cycle (r = 0.72, P less than 0.01). The plasma concentration of oestradiol on days 15, 19 and 29 of the artificial cycle were found to be significantly higher than those on the corresponding days of the natural cycle.

The effects of the antiprogesterone RU486 (Mifepristone) on an endometrial secretory glycan: an immunocytochemical study

OBJECTIVE

To examine the effects of progesterone (P) receptor blockade by RU486 (Mifepristone; Roussel-Uclaf, Paris, France) on a secretory endometrial glycan recognized by monoclonal antibody D9B1.

DESIGN

Retrospective comparison of endometrial biopsies from treated and untreated women from 2 to 8 days after the luteinizing peak (LH) peak.

SETTING

Infertility clinic, Jessop Hospital for Women, Sheffield.

PATIENTS

Twenty-two normal fertile women received the RU486. A control group of 44 normal fertile women were also assessed.

INTERVENTIONS

RU486 was administered to 22 normal women during the first half of the luteal phase and an endometrial biopsy examined 3 days later.

MAIN OUTCOME MEASURES

Immunohistochemistry was used to assess the production and secretion of the D9B1 epitope.

RESULTS

When the drug was given 2 days after the LH peak, it prevented appearance of the epitope. When RU486 was administered 5 days after the LH peak, epitope already present in gland cells was subsequently secreted.

CONCLUSIONS

These data suggest that production of the sialo-oligosaccharide is P-dependent, but secretion through established intracellular pathways is P-independent.

Correlation of endometrial histology, morphometry, and ultrasound appearance after different stimulation protocols for in vitro fertilization

The role of endometrial factors in controlling embryo implantation is poorly understood. In the present study, histopathology and morphometry were used to investigate differences in endometrial appearance seen by ultrasound (US) in 107 in vitro fertilization patients receiving different superovulation regimens. Seventy-seven patients received clomiphene citrate (CC)/human menopausal gonadotropin (hMG) and 30 buserelin acetate down regulation/hMG. All patients received an endometrial US at the time of embryo transfer (ET). Endometrial biopsies were taken from 17 women (12 CC/hMG, 5 buserelin acetate/hMG) with fertilization failure at the time when ET would normally have occurred. The morphometry results showed that endometrial glandular volume 2 days after oocyte retrieval was significantly reduced after CC/hMG compared with buserelin acetate/hMG, despite the fact that histopathological dating was similar for both groups. In addition, significant differences in endometrial thickness and echogenicity between CC/hMG and buserelin acetate/hMG were evident by US.

Immunocytochemical localization of oestradiol and progesterone receptors in human endometrium: a tool to assess endometrial maturation

Uterine oestrogen (ER) and progesterone (PR) receptors are subject to fine hormonal control by oestradiol and progesterone. In order to assess the role of ER and PR measurement in the evaluation of endometrial maturation, both receptors were studied by immunocytochemical techniques using monoclonal antibodies during the menstrual cycle, and in women with inactive ovaries treated by different regimens of hormonal substitution with oestradiol and progesterone. During the normal menstrual cycle, the concentrations and distribution of ER and PR changed markedly. During the mid follicular period (days 7-8), a small proportion of stromal and glandular cells stained positively for PR while staining for ER was more intense and more frequent. During the late follicular phase and early luteal period (days 9-19), the staining for PR increased markedly in glandular cells. During the mid and late luteal phase (days 21-27), ER and PR staining disappeared in glandular cells. Thus, while oestradiol increases the staining for ER and PR in both glands and stroma, progesterone decreases ER and PR staining in the glands in a dramatic fashion. These variations, especially the disappearance of PR under the effect of progesterone, are potentially useful for studying the cumulative effect of progesterone on endometrial maturation. This was confirmed in anovulatory women, where a late luteal phase aspect was observed, i.e. the absence of a reduction in ER and PR in glandular cells. In women with ovarian failure, the disappearance of ER and PR in glandular cells is correlated with the duration of progesterone therapy.(ABSTRACT TRUNCATED AT 250 WORDS)

The variation of endometrial protein PP14 in different parts of the human endometrium

The levels of the endometrial protein PP14 were shown to vary greatly in different sites in the endometrium (coefficient of variation ranged from 55% to 92%, mean = 73%). The variation was found to have no consistent pattern in the seven subjects studied and was unlikely to be the result of problems related to tissue sampling, processing or assay (intra-assay coefficient of variation of the PP14 assay used was less than 10%). Such a large variation in results suggests that the measurement of PP14 concentration in endometrial tissue may be of limited diagnostic value.