How precise is histologic dating of endometrium using the standard dating criteria?

Endometrial human chorionic gonadotropin (hCG) expression is a marker for adequate secretory transformation of the endometrium

PURPOSE

Successful embryo implantation into the endometrium depends on embryonic characteristics and proper endometrial development. Reproductive medicine often focuses on embryo quality, whereas reliable diagnostic tests for endometrial receptivity are still needed. We previously found that human chorionic gonadotropin (hCG), one of the earliest proteins secreted by the embryo, was also expressed by the luteal phase endometrium around the implantation window. Here, we tested our hypothesis of endometrial hCG as an implantation marker.

METHODS

Endometrial biopsies and serum samples were taken from patients undergoing routine infertility diagnostics. Correlations of immunohistochemically detected endometrial hCG expression with adequate endometrial secretory transformation, the infiltration of CD45-positive leukocytes, clinical diagnostic parameters, and endometrial thickness were analyzed.

RESULTS

A highly significant correlation between the endometrial score, as a measurement for regular secretory transformation, and the intensity of hCG staining was found. The invasion of CD45-positive leukocytes increased with progressing endometrial secretory transformation and rising endometrial hCG expression. In addition, serum progesterone concentrations correlated with hCG expression by the endometrial glands.

CONCLUSIONS

Our results suggest endometrial hCG as a possible diagnostic parameter characterizing the endometrial secretory transformation and, thus, possibly also its implantation capability.

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.

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.

Causes of Fetal Wastage

Fetal wastage has many causes, but genetic factors are by far the most common. The earlier the pregnancy loss occurs, the greater the likelihood of genetic causation. Among first trimester abortions, 50% to 80% show chromosomal abnormalities, usually aneuploidy. This is greater than all other causes combined. Chromosomal numerical abnormalities can be recurrent and sporadic; failure to take this into account is a major pitfall in many reports addressing causation. Moreover, many causes of fetal wastage that are traditionally considered to be "nongenetic" are actually the result of perturbations of gene products-proteins. Among nongenetic causes of first trimester fetal wastage, the best established are thyroid abnormities; antifetal antibodies; and the inherited and acquired thrombophilias. The latter are more established in the second trimester. Uterine anomalies can lead to second trimester losses. Infections seem uncommon, and alloimmune causes are not validated.

Progesterone supplementation to prevent recurrent miscarriage and to reduce implantation failure in assisted reproduction cycles

Implantation failure has been questioned for many cases of recurrent miscarriage and unsuccessful assisted reproduction. The exact cause of implantation failure is not known, but luteal phase defect is encountered in many of these cases. Consequently, women with recurrent miscarriages have been treated with progesterone supplementation with various degrees of success, and a recent meta-analysis has shown trends for improved live birth rates in those women. Progesterone probably acts as an immunological suppressant blocking T-helper (Th)1 activity and inducing release of Th2 cytokines. Numerous studies have confirmed that ovarian stimulation used in assisted reproduction is associated with luteal phase insufficiency, even when gonadotrophin-releasing hormone antagonists are used. In those patients, advanced endometrial histological maturity and a decrease in the concentration of cytoplasmic progesterone receptors are observed. Progesterone supplementation results in a trend towards improved ongoing and clinical pregnancy rates, except in patients treated with human menopausal gonadotrophin-only regimens, in whom ongoing pregnancy rates increase significantly. More randomized controlled trials are needed to increase the power of the currently available meta-analyses to further evaluate progesterone supplementation in both conditions.

Evidence-based care of recurrent miscarriage

Between 0.5 and 1.0% of couples experience recurrent pregnancy loss (RPL), which is defined as three or more consecutive miscarriages. Losses are classified as pre-embryonic (<5 weeks), embryonic (5-10 weeks) or fetal (>10 weeks). Genetic abnormalities are responsible for RPL in 2-4% of these couples. Inadequate progesterone production has been proposed a cause of RPL and progesterone is given to prevent miscarriage, despite a lack of supportive evidence. The factor V Leiden and prothrombin G20210A mutations are common inherited thrombophilias also associated with RPL. Antenatal thromboprophylaxis is sometimes recommended although no data exist regarding efficacy. Antiphospholipid syndrome is known to cause RPL and antenatal thromboprophylaxis reduces the risk of miscarriage. Uterine abnormalities might also result in RPL. About 50% of cases of RPL have no identifiable cause. Alloimmune incompatibility has been proposed as a cause for RPL in these women. The concept of alloimmune-related RPL has not been scientifically validated.

Normal breast lobular architecture in breast biopsy samples from breast cancer cases and benign disease controls

Rodent studies suggest a relationship between lobular maturation and breast cancer risk. Human data are sparse, and were developed using whole mounts of mastectomy or mammoplasty samples, without consideration of menstrual phase in premenopausal women. We studied normal breast lobules in relation to cancer risk in 284 women, using surgical biopsy material (mean two sections and 43.2 lobular structures per subject): 167 were premenopausal; 89 with breast cancer (cases) and 78 undergoing benign breast biopsy (controls). Of 117 postmenopausal women, 67 were cases and 50 were controls. Normal lobular type was classified based on size, and was designated predominant if it constituted 60% or more of the total lobules classified. The control group showed 66% type I, 34% type II and 1% type III lobules while cases showed 69% type I, 31% type II and 7% type III structures. Predominant lobule type showed no association with cancer (p = 0.9). Postmenopausal women had a substantially higher proportion of type I lobules compared to premenopausal women, irrespective of the parity or cancer status (p < 0.001). Lobule type was not associated with menstrual phase classified by dates; however, when menstrual phase was classified using breast morphological characteristics, type I lobules were more abundant in follicular phase and type II in the luteal phase (p < 0.001). In conclusion, we did not observe a relationship between lobular architecture and breast cancer susceptibility when using smaller breast samples usually available in epidemiological studies, but these data highlight the need for menstrual phase stratification in future investigations.

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.

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.

A successful pregnancy following SEM fine tuning of hormonal priming

BACKGROUND: Manipulation of the uterine epithelium utilising standard dose exogenous oestrogen (E2) and progesterone (P4) has been shown to achieve a mature secretory morphological response. However, in an in vitro fertilisation (IVF) setting, frozen embryo transfer (ET) has had a low success rate. We propose that in patients with previously failed ET attempts, the uterine epithelium can be directly visualised by biopsy and Scanning Electron Microscopy (SEM) and that with an individualised fine tuning of the hormone supplementation regime, based on the SEM examination of sequential uterine biopsies, it is possible to provide a uterine environment conducive to successful ET. METHODS: A 47 year old women was chosen for endometrial biopsy, histopathological dating and endometrial observation utilising SEM to determine the integrity of her secretory uterine epithelium because of her age and several previously failed attempts at frozen ET. Exogenous E2 and P4 supplementation was administered in modified doses according to the SEM result, in consecutive cycles until the epithelial response appeared satisfactory for potential implantation. RESULTS: This case study demonstrates the dramatic change in epithelial characteristics that can be achieved as a response to these altered doses of E2 and P4. The uterine morphology changed from a hypotrophic to a mature, receptive epithelium such that ET resulted in the birth of healthy twin boys. CONCLUSION: The comparison between the consecutive biopsies in direct response to the SEM analysis and tailored modification of E2 and P4 dose clearly demonstrates, in this case, the effectiveness of individual morphological monitoring to maximise the successful outcome of ET.

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.

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.

Prevalence of out-of-phase endometrial biopsy specimens

OBJECTIVE

We attempted to determine the prevalence of out-of-phase endometrial biopsy specimens among fertile and infertile women and women with recurrent pregnancy loss, histologic dating of biopsies was compared with four reference points for expected ovulation. These reference points included last menstrual period, next menstrual period, luteinizing hormone testing, and ultrasonographic documentation of ovulation.

STUDY DESIGN

Four hundred eighty-five endometrial biopsies were performed 7 days after documented ovulation-based ultrasonographic evidence for follicle collapse. The histologic dating was referenced to the last menstrual period, next menstrual period, and ultrasonographic documentation of ovulation. One hundred thirty-two of these women also performed urinary luteinizing hormone surge testing before ovulation and serum progesterone determinations. A comparison of the prevalence of out-of-phase biopsy specimens among groups was determined with the chi 2 test and Fisher's exact test.

RESULTS

The prevalence of out-of-phase endometrial biopsy specimens ranged from 42% when last menstrual period was used to 26% with next menstrual period, to 21% with luteinizing hormone testing, and to 4% with ultrasonographic documentation of ovulation. Serum progesterone values among women with a diagnosis of out-of-phase biopsy specimens by any of the reference dates progesterone were similar to those with in-phase biopsy specimens.

CONCLUSION

The accuracy of histologic endometrial dating was best determined by ultrasonographic monitoring rather than by last menstrual period, next menstrual period, or luteinizing hormone testing in infertile populations and in those with recurrent pregnancy loss. Additionally, because no significant difference in out-of-phase biopsy specimens exists between fertile and infertile patients and recurrent pregnancy loss, those with the role of this procedure is called into question.

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.

Use of urinary luteinizing hormone immunoassays in the assessment of luteal function in infertile women

It has been suggested that the chronologic date of an endometrial biopsy performed to evaluate luteal adequacy should be based on the date of the luteinizing hormone surge rather than the date of the next menstrual period. Sixty-four infertile women used a urinary luteinizing hormone immunoassay to identify the luteinizing hormone surge; timed serum progesterone level tests and an endometrial biopsy were then performed. An out-of-phase endometrium was identified in 26.6% of cycles dated traditionally and 28.1% of cycles dated from the luteinizing hormone surge. No relationship was identified between progesterone levels and endometrial biopsy results when the next menstrual period was used. When the luteinizing hormone surge was used no progesterone cutoff value could be identified that would reliably distinguish between in-phase and out-of-phase cycles. Use of a urinary luteinizing hormone immunoassay offers no advantage over the next menstrual period and does not lead to better agreement between histologic and chronologic dating.

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.

Error in histologic dating of secretory endometrium: variance component analysis

OBJECTIVE

To characterize the extent and sources of imprecision in histologic dating of the endometrial biopsy.

DESIGN

Duplicate endometrial biopsies from 25 women were dated by five evaluators on two separate occasions to evaluate the overall precision of the measure. Using variance component analysis, estimates of intrauterine, intraevaluator, and interevaluator variability were determined.

SETTING

Samples were obtained during outpatient fertility testing. Evaluators were colleagues at the same institution.

PATIENTS, PARTICIPANTS

Women presenting with infertility undergoing routine evaluation.

INTERVENTIONS

None.

MAIN OUTCOME MEASURE

Variability in histologic dating of the endometrium.

RESULTS

Inconsistencies between evaluators accounted for 65% of the observed variability, whereas 27% was because of inconsistencies in duplicate readings by the same evaluator. Regional differences in the uterus accounted for only 8% of the total variability.

CONCLUSIONS

The overall error from these sources have the potential to result in a substantial false-positive rate for diagnosis of luteal phase defect.

Comparison of endometrial biopsy and urinary pregnanediol glucuronide concentration in the diagnosis of luteal phase defect

To determine if pregnanediol glucuronide (PG) excretion is useful in luteal phase assessment, we compared daily first morning urinary PG concentrations during the luteal phase in nine normal and nine deficient cycles. Total luteal pregnanediol excretion (44.1 +/- 11.3 versus 64.0 +/- 11.6 area units +/- SEM) was not different. However, significantly less pregnanediol was excreted by the abnormal group during the 1st 5 days of the luteal phase (12.7 +/- 1.2 versus 18.0 +/- 1.7 area units +/- SEM, respectively). Thus, delayed PG excretion may be characteristic of luteal phase defect and measurement of urinary PG may be useful only if daily samples during the early luteal phase are obtained.

Luteal insufficiency: correlation between endometrial dating and integrated progesterone output in clomiphene citrate-induced cycles

Midluteal phase endometrium was histologically dated with midcycle luteinizing hormone surge time in 29 cycles from 10 parous women during untreated cycles (control) and treatment with clomiphene citrate 50 mg and 150 mg daily on days 5 through 9. Integrated progesterone output for 7 days after luteinizing hormone surge calculated from the daily plasma progesterone levels was 66.6 +/- 9.8 ng/ml in the control group compared with 117.5 +/- 18.6 ng/ml for clomiphene citrate 50 mg treatment and 152.1 +/- 11 ng/ml for clomiphene citrate 150 mg treatment (p less than or equal to 0.05). Only one cycle (clomiphene citrate 150 mg) had an out-of-phase endometrium and a significantly reduced integrated progesterone output of 28 ng/ml. All other cycles showed synchronous endometrial maturation. We conclude that luteal insufficiency as a result of clomiphene citrate treatment in ovulatory women is infrequent and is more likely to be a result of functional outcome of a relative lack of luteal phase progesterone output.

A quantitative study of endometrial development in the luteal phase: comparison between women with unexplained infertility and normal fertility

This study compared endometrial development in the luteal phase of women with unexplained infertility (n = 30) with that in women with normal fertility (n = 70) by the use of quantitative histological techniques (morphometric analysis) on endometrial specimens which were precisely timed from the luteinizing hormone surge. When overall endometrial development (histological dating) was considered, the proportion of women with unexplained infertility who had retarded endometrial development (20%) was found to be significantly higher than for women with normal fertility (3%) (P less than 0.01). When individual histological features were considered, women with unexplained infertility were found to have significant deviation from the normal range established from fertile women in only five of the 14 histological features measured. All of these five features related to the glandular but not to the stromal component of the endometrium; four of these five features are related to glandular secretory activity.

Influence of superovulation on endometrial and embryonic development

The authors have studied the temporal relationship between follicular rupture and endometrial development in 13 women during a natural ovarian cycle (length 25 to 35 days), and subsequently after standard treatment with clomiphene citrate, human menopausal gonadotropin and human chorionic gonadotropin (hCG) to induce multiple folliculogenesis for oocyte recovery, in vitro fertilization, and embryo freezing (cycle length 23 to 27 days). An endometrial biopsy was taken during both cycles 1.5 to 2.0 days after the oocytes had been released or removed. The samples were examined by light and transmission electron microscopy. Samples of peripheral blood were taken at defined times for hormone analysis. After treatment 11 subjects (85%) had advanced morphological development of the endometrium (8 women by 3 to 4 days, 3 women by 1 to 2 days). The concentrations of plasma estradiol (E2) and progesterone (P) on the days of follicular rupture and endometrial biopsy were significantly raised in the treatment cycles. The concentration of total urinary estrogens on the day of hCG administration and the mean change in the concentration of plasma E2 (treatment/control) on the days of endometrial biopsy were positively correlated with the extent of endometrial advancement. In addition, the mean change in the concentration of plasma P (treatment/control) was markedly increased on the days of follicular rupture and endometrial biopsy in those subjects with an advanced endometrium. Embryonic development was not so obviously related to the extent of superovulation. Asynchronous endometrial and embryonic development may therefore contribute to the low pregnancy rate in these patients.

The impact of luteal phase inadequacy in an infertile population

A retrospective analysis of patients evaluated and treated for infertility was performed. Luteal phase inadequacy was diagnosed when the late luteal endometrial biopsy pattern was greater than 2 days out of phase in two cycles; in patients treated with clomiphene citrate therapy was changed if one biopsy was out of phase. One hundred ninety-seven patients underwent 242 biopsies. Among 137 women no treated with clomiphene citrate, 24 (17.5%) had out-of-phase biopsy specimens; 7 of 24 (29.2%) repeat biopsies were out of phase, with luteal phase inadequacy in 7 of 137 (5.1%) women. The probability of an out-of-phase biopsy occurring by chance alone was 4.2 of 137 or 3.1%. No woman was diagnosed to have luteal phase inadequacy as the single infertility factor. Fifty-three pregnancies (41%) occurred in 130 women without luteal phase inadequacy and in 2 of 7 (28.6%) diagnosed to have luteal phase inadequacy with other infertility factors. In clomiphene citrate-treated patients, pregnancy occurred in 15 of 26 (57.7%) with corrected luteal phase inadequacy and in 21 of 34 (61.8%) without luteal phase inadequacy. In this population the diagnosis of luteal phase inadequacy was not made more frequently than by chance alone. Moreover, fecundity in patients with treated luteal phase inadequacy is comparable to that in patients without this diagnosis.

Outpatient endometrial biopsy: clinical, endocrinologic and histologic consequences

In this prospective study involving 152 outpatient endometrial biopsies (EBs), it was found that 89% had post-EB spotting which ranged from 1 to 5 days with a median of 2 days. Premenstrual spotting which could not be accounted for by post-EB spotting was present in 14% of the subjects, but less than half of them considered such spotting unusual. Outpatient EB resulted in earlier onset of menstruation in 43% of the subjects, but no overall change in the amount of menstrual flow or discomfort. When compared to control cycles in which an EB was not performed, cycles in which an EB was performed, had significant shortening of the luteal phase by an average of 1.0 day (P less than 0.01). However, there was no change in the corpus luteum function as assessed by the measurement of progesterone concentration in saliva samples collected daily throughout the luteal phase. EB did not appear to have any significant effect on histologic development (dating) of the endometrium, although leucocytic infiltration could be increased.

Follicular growth and corpus luteum function in women with unexplained infertility, monitored by ultrasonography and measurement of daily salivary progesterone

Ovarian function was evaluated over a minimum of 3 consecutive menstrual cycles from each of 41 women with unexplained infertility. Follicular development and ovulation were monitored using real time ultrasonography and luteal function was evaluated by daily salivary progesterone measurement. In 129 spontaneous cycles, normal single ovulations were detected in 121 (93.8%). Luteal phase insufficiency was identified in 21 (17.4%) of these 121 cycles and this was a recurrent phenomenon in the cycles of 5 of the 41 women (12.2%). A successful pregnancy was seen only in association with consistently normal salivary progesterone profiles or where the empirical use of clomiphene citrate therapy had corrected previously diagnosed luteal phase insufficiency. Basal body temperature records or mid-luteal serum progesterone measurements were less satisfactory indices of luteal function than a salivary progesterone profile.