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Endometrial morphology and hormonal profiles in in vitro fertilization patients
EuroDean Journal of Obstetrics & Gvnecolonv and Reproductive Biolonv. 44 (1992) 117-121
117
0 1992 Elsevier S&nce Publishers B.V. All rights reserved 0028-2243/92/$05.00 EUROBS 01257
Endometrial morphology and hormonal profiles in in vitro fertilization patients Amihai Barash a, Bernard Czernobilsky b, Vaclav Insler ‘, Richard Borenstein Moshe Rosenberg ’ and Aharon Fink ’ a Department
a,
of Obstetrics and Gynecology, ’ Department of Pathology and ’ Clinical Laboratories, Kaplan Hospital, Rehovot, Affilliated to Hebrew University Hadassah Medical School, Israel
Accepted for publication 8 July 1991
Summary Endometrial biopsy was performed in 27 infertile women participating in the IVF program. Their mean age was 31.8 years, 33% of the women being over 35 years old. The average duration of infertility was 6.9 years. The superovulation protocol consisted of hMG/hCG in 5 cases, of combined GnRH analog/gonadotropin therapy in 20 women, and 2 patients received combined contraceptive pill/gonadotropin treatment. Judging by hormonal profiles, follicular growth rate and number of oocytes retrieved, the response to stimulation was normal. The mean estradiol (E,) levels increased from 132.7 pg/ml on day -5 (SEM = 9.67) to 1272 pg/ml (SEM = 103.7) on the day of hCG administration and to 1813 pg/ml (SEM = 209.6) 1 day later. One day before the hCG application, the mean progesterone and LH levels were 1.34 ng/ml and 8.38 IU/ml, respectively. Only one patient had clinical hyperstimulation syndrome. Ova were harvested in all women, the mean number of oocytes being 7.7 (SEM = 0.83) per patient. In all 27 cases lack of fertilization or faulty ovum cleavage were observed. Thus, an endometrial biopsy (EB) was performed 72 h after oocytes retrieval. The mean estrogen and progesterone levels on the EB day were 610.9 pg/ml (SEM = 78.44) and 45.4 ng/ml (SEM = 7.531, respectively. Histologic examination of the endometrium showed normal secretory endometrium consistent with day 16-17 of spontaneous ovulatory cycle. Two women who received combined contraceptive pills/ gonadotropin therapy showed inactive endometrium with subnuclear vacuoles and decidual reaction in the stroma similar to that observed in women on estrogen-progestin birth control medication. The above findings do not support the supposition that defective endometrial structure is the main reason for nidation failure in the IVF-ET programs. In vitro fertilization-embryo
transfer; Endometrium;
Estrogen level, Progesterone
level
Introduction Correspondence:
Amihai Barash, M.D., Department of Obstetrics and Gynecology, Kaplan Hospital (Affiliated to Hebrew University Hadassah Medical School), Rehovot, Israel.
One of the main problems of in vitro fertilization and embryo transfer (IVF-ET) programs is
118
the significant difference between the number of oocytes harvested and fertilized and the rate of pregnancy achieved. This difference has been generally attributed to three factors: (a) the number and quality of ova fertilized; (b) the number and quality of zygotes implanted in the uterus [l]; (c) the structural and functional capacity of the endometrium to harbor the embryos. The last factor has usually been connected with the abnormal steroid levels observed at the periovulatory and luteal phases of the superovulation treatment regimes used in IVF-ET programs [2-31. Studies dealing with endometrial structure and function in patients undergoing IVF-ET are rather scarce. Materials and Methods Twenty-seven women from the IVF-ET program, in whom oocytes were harvested but were not fertilized or did not develop and cleave within the next 72 h, agreed to participate in this study. The average patients’ age was 31.8 years (SEM = 1.13; range: 22-44). The mean duration of infertility was 6.9 years (SEM = 0.56; range: 3-13). All patients had spontaneous menstruation. Three stimulation protocols were employed: hMG/hCG (5 patients); pituitary suppression by GnRH agonist (GnRHa) combined with ovarian stimulation by hMG/hCG (20 women); and pituitary suppression by contraceptive pills followed by ovarian stimulation with hMG/hCG (2 cases). The GnRH agonist (Buserelin, nasal spray, Hoechst, F.R.G.) was started on the first menstrual day and continued until one day before the hCG administration; ovarian stimulation by gonadotropins was begun when plasma estradiol (E,) levels decreased below 30 pg/ml. The contraceptive pills (Levonorgestrel 0.15 mg and ethinylestradiol 0.03 mg, Schering, AG, F.R.G.) were started on the 5th day of the preceding cycle and continued until the beginning of active phase of hMG stimulation. The patients were followed up by E, assays and vaginal ultrasound examination every 2-3 days. During the active phase, i.e., following the steady rise of E,, the examinations were performed daily until one day after hCG administra-
tion. The day of hCG application was designated as DAY 0,the preceding days were nominated as DAY - 1 etc., and the days following hCG were named as DAY + 1 etc. In the majority of patients progesterone (P) assays were performed on DAY - 1 or on DAY 0 and in some also LH was examined on the same days. All hormone examinations were carried out using standard radioimmunoassays. The oocytes harvest was performed by the vaginal route under sonographic control 30-34 h after administration of hCG. Seventy-two h after ovum pick up, if no fertilization or cleavage were observed, endometrial biopsy (EB) using a Novak curette was performed. In 14 women E, and P were also assayed on this day. The tissue obtained by endometrial biopsy was fixed in 10% formalin and embedded in paraffin. Sections of 5 ,um were stained by hematoxyline and and eosin and examined by light microscopy. Histologic criteria applied for evaluation were those proposed by Noyes et al. [41. The hormonal and sonographic parameters of response to stimulation were similar in the three treatment protocols employed. No supplement treatment was administered after induction of ovulation by hCG. Statistical evaluation of hormonal data (descriptive statistics, t-test for matched pairs and correlation analysis) was performed using a computerized statistical package. Results The mean number of ova harvested was 7.7 (SEM = 0.83; range: l-18). The rise in E, during the active stimulation phase was typical for the IVF-ET patients (Fig. 1). The mean E, levels on each succeeding day were significantly higher than on the previous day (P < 0.03). The mean E, level on the day of hCG administration (DAY 0) was 1272.2 pg/ml (SEM = 103.7; range: 4702800). On the day of endometrial biopsy the estrogen levels were 610.9 pg/ml (SEM = 78.44; range: 360-1280). The average P values on the EB day were 45.40 ng/ml (SEM = 7.53; range: 21.0-105.0). As judged by the LH and P values on DAY - 1 none of the patients had premature
119 E-2 (pg/ml)
fertilizable ova before or after the study cycle indicate that this group of patients does not represent a special population of poor responders or inadequate ova producers.
1600 1600
1400 1200 1000
Discussion
800 600
Fig. 1. Mean estradiol levels during stimulation and on the day of endometrial biopsy (E.B.). The E.B. day corresponds to the day of embryo transfer in IVF program and to the 16th or 17th day of a spontaneous cycle.
Within the framework of IVF-ET programs, the problem of endometrial receptivity enabling the initial harboring and subsequent nidation of embryos is still controversial. Luteal phase support by hCG or progesterone administration has been advocated but its efficacy is equivocal [6-71. It has been speculated that ovarian hyperstimulation followed by a consequent hormonal imbalance results in reduced endometrial receptiv-
luteinization, the levels being 8.38 mIU/ml @EM = 0.61) and 1.31 ng/ml (SEM = 0.621, respectively. The histological examination of the endometrial samples showed secretory endometrium compatible with day 16 or 17 of a normal cycle (Fig. 2) in all cases except of two. In the two women who were pre-treated with contraceptive pills the endometrium showed small inactive glands with no proliferative or secretory activity except for occasional subnuclear vacuoles. The stroma showed a diffuse decidual type reaction in one case and a focal reaction of this type in the other (Fig. 3). This picture was similar to that described in women on estrogen-progestin oral contraceptives [5]. Only one patient had clinical hyperstimulation and had to be admitted and treated with plasma expanders and fluid for several days. It has to be noted that of the 27 patients participating in this research 11 women underwent only one IVF treatment (i.e., the study cycle) and 15 other cases had fertilization of ova in IVF cycles performed before or after the study. Six clinical pregnancies were achieved; two of them ended in abortion, one delivered a healthy baby and three pregnancies are ongoing. The hormonal values observed during stimulation, the number of eggs retrieved and the fact that the majority of these patients were able to produce
Fig. 2. Secretory endometrium showing large glands with well developed subnuclear vacuoles and edematous stroma, consistent with day 16-17 of menstrual cycle. Hematoxylin-eosin, x 150. Ovarian stimulation by combined GnRH analogue and hMG/hCG therapy.
400 200 0 (DAYS)
-5
-4
-3
-2
-1
0
*I
+2
*3
+4
.5
t hCG
120
ity and may interfere with the nidation process [3,8-91. Indeed, our study confirmed that application of either hMG/hCG or combined GnRHa/ hMG/hCG therapy results in ovarian hyperstimulation and hormonal imbalance. The E, values on DAY + 1 ranged from 630 to 4000 pg/ml (a difference of over 630%). Neither was there any significant correlation between the E, and P levels on the day of endometrial biopsy (r = 0.5) (Fig. 4). It ha s t o b e pointed out, however, that this hormonal imbalance did not affect the structure of the endometrium. All the endometrial samples (except of the two obtained in women pre-treated with contraceptive pills) corresponded to the day on which embryo transfer
Fig. 3. Small glands lined by inactive epithelium in stroma with decidual type reaction and thin-walled capillaries. Hematoxylin-eosin, X 150. The patient received combined contraceptive pill/hMG/hCG treatment.
E-Z (pglml)
P hg/ml)
1200
100
1100 1000
30
900 500 700
60
BOO 500
40
400 300 200
20
100 0
0
INDIVIDUAL PATIENTS =
E-2
PROGESTERONE
Fig. 4. Estrogen and progesterone levels on the day of endometrial biopsy (E.B.). The E.B. day corresponds to the day of embryo transfer in IVF program and to the 16th or 17th day of a spontaneous cycle.
would be performed (see Fig. 2), i.e., to day 16th or 17 of a normal cycle. Our results do not conform to those obtained by Sterzik and his co-workers [lo]. They examined 58 endometrial samples of women in IVF-ET program who did not have embryo transfer. Twenty-three patients were stimulated with hMG/hCG. Among them the endometrial samples showed a normal secretory phase in 11 cases only. Of the 12 remaining women 9 had various types of structural abnormalities and in 3 the specimen was insufficient for diagnosis. In women treated with clomiphene citrate in combination with gonadotropins the frequency of endometrial abnormalities was significantly higher then in those stimulated with hMG/hCG. One more difference between Sterzik’s report and the present study should be pointed out: Seventeen (29%) of women in their series were over 35 years old. In none of them the endometrial sample showed a normal luteal phase. In contrast, 9 out of 27 patients (33%) studied by us were over 35 years and all had a secretory endometrium corresponding to the 16th or 17th day of a normal cycle. According to the present study the structure of the endometrium, as judged by microscopical evaluation should not be considered as the main cause for failure of IVF-ET, particularly in patients stimulated with hMG/hCG or a combination of GnRHa and gonadotropins. This does not
121
preclude the possibility of functional disturbances which do not result in structural abnormalities observable on light microscopy. Manners [ll] reported that in some cases (but not in all) the standard histological examination showed a normal secretory endometrium but the pattern of protein secretion examined by a immunohistochemical method was abnormal. Seliger et al. [12] found that a good correlation existed between the histological examination and steroid receptors quantity and binding capacity of the endometrium. The authors also pointed out that no correlation was found between the serum steroid levels and the endometrial histology or receptor parameters. Other studies [13] showed that a discrepancy existed between light microscopy and electronmicroscopy of endometrial specimens obtained in stimulated cycles. In presumably normal endometria, electronmicroscopy showed impaired development of nucleolar channel system and stronger intercellular junctions. When discussing the uterine receptivity, the role of the embryo itself should not be overlooked. It is logical to assume that the embryo releases an array of signals which affect the uterus and the endometrium. The role of human chorionic gonadotropin is well established. Cocchiara et al. [14] reported that an embryo derived histamine releasing factor (EHRF) could prevent maternal immuno-rejection at the implantation stage. Other groups [15] found that embryos that resulted in pregnancy produced significantly higher levels of embryo-derived platelet activating factor (PAF) than embryos that failed to result in pregnancy. In summary: it seems that the embryo implantation rate is determined mainly by the number and quality of the embryos replaced and to a much lesser degree by the disturbances of endometrial structure or function caused by hormonal imbalance.
2
3
4 5
6
7
8
9
10
11
12
13
14
References 15 1 Hill GA, Freeman M, Bastias MC, Rogers BJ, Herbert CM, Osteen KG, Wentz AC. The influence of oocyte maturity and embryo quality on pregnancy rate in program
for in vitro fertilization-embryo transfer. Fertil Steril 1989;52:801-806. Nylund L, Beskow C, Carlstrom K, Fredricsson B, Gustafson 0, Lunell NO, Pousette A, Rosenborg L, Slotte H, Akerlof E. The luteal phase in successful and unsuccessful implantation after IVF-ET. Hum Reprod 1990; 5:40-42. Huang KE, Muechler EK, Schwarz KR, Goggin M, Graham MC. Serum progesterone levels in women treated with human menopausal gonadotropin and human chorionic gonadotropin for in vitro fertilization. Fertil Steril 1986;46:903-906. Noyes RN, Hertig AT, Rock J. Dating the endometrial biopsy. Fertil Steril 1950;1:3-9. Ober WB. Effect of oral and intrauterine administration of contraceptives on the uterus. Hum Pathol 1977;8:513518. Buvat J, Marcolin J, Herbaut JC, Dehaene I-J. Verbecq P, Fourlinie JC. A randomized trial of human chorionic gonadotropin support following in vitro fertilization and embryo transfer. Fertil Steril 1988;49:458-461. Buvat J, Marcolin G, Guittard C, Herbaut JC, Louvet AL, Dehaene JL. Luteal support for in vitro fertilization: superiority of human chorionic gonadotropin over oral progesterone. Fertil Steril 1990;53:490-494. Sharma V, Riddle A, Mason BA, Pampiglione J, Campbell S. An analysis of factors influencing the establishment of a clinical pregnancy in an ultrasound-based ambulatory in vitro fertilization program. Fertil Steril 1988;49:468-478. Paulson RJ, Sauer MV, Lobo RA. Embryo implantation after human in vitro fertilization: importance of endometrial receptivity. Fertil Steril 1990;53:870-874. Sterzik K, Dallenbach Ch, Schneider V, Sasse V, Dallenbath-Hellweg G. In vitro fertilization: the degree of endometrial insufficiency varies with the type of ovarian stimulation. Fertil Steril 1988;50:457-462. Manners CV. Endometrial assessement in a group of infertile women on stimulated cycles for IVF: immunohistological findings. Human Reprod 1990;5:128-132. Seliger E, Schoneich C, Kaltwasser P, Bergleiter R, Buchmann J, Rothe K. Ovarian stimulation in IVF procedure: influence on endometrial estrogen and progesterone receptors Zentralbl Gynaekol 1988;110:1499-1506. Dehou MF, Lejeune B, Arijs C, Leroy F. Endometrial morphology in stimulated in vitro fertilization cycles and after steroid replacement therapy in cases of primary ovarian failure. Fertil Steril 1987;48:995-1000. Cocchiara R, Di-Trapani G, Azzolina A, Albeggiani G, Geraci D. Early embryonic histamine releasing factor: a new model for human implantation. Hum Reprod 1986; 11445-447. ONeill C, Gidley-Baird AA, Pike IL, Saunders DM. Use of a bioassay for embryo-derived-platelet-activating factoras a means of assessing quality and pregnancy potential of human embryos. Fertil Steril 1987;47:969-975.
117
0 1992 Elsevier S&nce Publishers B.V. All rights reserved 0028-2243/92/$05.00 EUROBS 01257
Endometrial morphology and hormonal profiles in in vitro fertilization patients Amihai Barash a, Bernard Czernobilsky b, Vaclav Insler ‘, Richard Borenstein Moshe Rosenberg ’ and Aharon Fink ’ a Department
a,
of Obstetrics and Gynecology, ’ Department of Pathology and ’ Clinical Laboratories, Kaplan Hospital, Rehovot, Affilliated to Hebrew University Hadassah Medical School, Israel
Accepted for publication 8 July 1991
Summary Endometrial biopsy was performed in 27 infertile women participating in the IVF program. Their mean age was 31.8 years, 33% of the women being over 35 years old. The average duration of infertility was 6.9 years. The superovulation protocol consisted of hMG/hCG in 5 cases, of combined GnRH analog/gonadotropin therapy in 20 women, and 2 patients received combined contraceptive pill/gonadotropin treatment. Judging by hormonal profiles, follicular growth rate and number of oocytes retrieved, the response to stimulation was normal. The mean estradiol (E,) levels increased from 132.7 pg/ml on day -5 (SEM = 9.67) to 1272 pg/ml (SEM = 103.7) on the day of hCG administration and to 1813 pg/ml (SEM = 209.6) 1 day later. One day before the hCG application, the mean progesterone and LH levels were 1.34 ng/ml and 8.38 IU/ml, respectively. Only one patient had clinical hyperstimulation syndrome. Ova were harvested in all women, the mean number of oocytes being 7.7 (SEM = 0.83) per patient. In all 27 cases lack of fertilization or faulty ovum cleavage were observed. Thus, an endometrial biopsy (EB) was performed 72 h after oocytes retrieval. The mean estrogen and progesterone levels on the EB day were 610.9 pg/ml (SEM = 78.44) and 45.4 ng/ml (SEM = 7.531, respectively. Histologic examination of the endometrium showed normal secretory endometrium consistent with day 16-17 of spontaneous ovulatory cycle. Two women who received combined contraceptive pills/ gonadotropin therapy showed inactive endometrium with subnuclear vacuoles and decidual reaction in the stroma similar to that observed in women on estrogen-progestin birth control medication. The above findings do not support the supposition that defective endometrial structure is the main reason for nidation failure in the IVF-ET programs. In vitro fertilization-embryo
transfer; Endometrium;
Estrogen level, Progesterone
level
Introduction Correspondence:
Amihai Barash, M.D., Department of Obstetrics and Gynecology, Kaplan Hospital (Affiliated to Hebrew University Hadassah Medical School), Rehovot, Israel.
One of the main problems of in vitro fertilization and embryo transfer (IVF-ET) programs is
118
the significant difference between the number of oocytes harvested and fertilized and the rate of pregnancy achieved. This difference has been generally attributed to three factors: (a) the number and quality of ova fertilized; (b) the number and quality of zygotes implanted in the uterus [l]; (c) the structural and functional capacity of the endometrium to harbor the embryos. The last factor has usually been connected with the abnormal steroid levels observed at the periovulatory and luteal phases of the superovulation treatment regimes used in IVF-ET programs [2-31. Studies dealing with endometrial structure and function in patients undergoing IVF-ET are rather scarce. Materials and Methods Twenty-seven women from the IVF-ET program, in whom oocytes were harvested but were not fertilized or did not develop and cleave within the next 72 h, agreed to participate in this study. The average patients’ age was 31.8 years (SEM = 1.13; range: 22-44). The mean duration of infertility was 6.9 years (SEM = 0.56; range: 3-13). All patients had spontaneous menstruation. Three stimulation protocols were employed: hMG/hCG (5 patients); pituitary suppression by GnRH agonist (GnRHa) combined with ovarian stimulation by hMG/hCG (20 women); and pituitary suppression by contraceptive pills followed by ovarian stimulation with hMG/hCG (2 cases). The GnRH agonist (Buserelin, nasal spray, Hoechst, F.R.G.) was started on the first menstrual day and continued until one day before the hCG administration; ovarian stimulation by gonadotropins was begun when plasma estradiol (E,) levels decreased below 30 pg/ml. The contraceptive pills (Levonorgestrel 0.15 mg and ethinylestradiol 0.03 mg, Schering, AG, F.R.G.) were started on the 5th day of the preceding cycle and continued until the beginning of active phase of hMG stimulation. The patients were followed up by E, assays and vaginal ultrasound examination every 2-3 days. During the active phase, i.e., following the steady rise of E,, the examinations were performed daily until one day after hCG administra-
tion. The day of hCG application was designated as DAY 0,the preceding days were nominated as DAY - 1 etc., and the days following hCG were named as DAY + 1 etc. In the majority of patients progesterone (P) assays were performed on DAY - 1 or on DAY 0 and in some also LH was examined on the same days. All hormone examinations were carried out using standard radioimmunoassays. The oocytes harvest was performed by the vaginal route under sonographic control 30-34 h after administration of hCG. Seventy-two h after ovum pick up, if no fertilization or cleavage were observed, endometrial biopsy (EB) using a Novak curette was performed. In 14 women E, and P were also assayed on this day. The tissue obtained by endometrial biopsy was fixed in 10% formalin and embedded in paraffin. Sections of 5 ,um were stained by hematoxyline and and eosin and examined by light microscopy. Histologic criteria applied for evaluation were those proposed by Noyes et al. [41. The hormonal and sonographic parameters of response to stimulation were similar in the three treatment protocols employed. No supplement treatment was administered after induction of ovulation by hCG. Statistical evaluation of hormonal data (descriptive statistics, t-test for matched pairs and correlation analysis) was performed using a computerized statistical package. Results The mean number of ova harvested was 7.7 (SEM = 0.83; range: l-18). The rise in E, during the active stimulation phase was typical for the IVF-ET patients (Fig. 1). The mean E, levels on each succeeding day were significantly higher than on the previous day (P < 0.03). The mean E, level on the day of hCG administration (DAY 0) was 1272.2 pg/ml (SEM = 103.7; range: 4702800). On the day of endometrial biopsy the estrogen levels were 610.9 pg/ml (SEM = 78.44; range: 360-1280). The average P values on the EB day were 45.40 ng/ml (SEM = 7.53; range: 21.0-105.0). As judged by the LH and P values on DAY - 1 none of the patients had premature
119 E-2 (pg/ml)
fertilizable ova before or after the study cycle indicate that this group of patients does not represent a special population of poor responders or inadequate ova producers.
1600 1600
1400 1200 1000
Discussion
800 600
Fig. 1. Mean estradiol levels during stimulation and on the day of endometrial biopsy (E.B.). The E.B. day corresponds to the day of embryo transfer in IVF program and to the 16th or 17th day of a spontaneous cycle.
Within the framework of IVF-ET programs, the problem of endometrial receptivity enabling the initial harboring and subsequent nidation of embryos is still controversial. Luteal phase support by hCG or progesterone administration has been advocated but its efficacy is equivocal [6-71. It has been speculated that ovarian hyperstimulation followed by a consequent hormonal imbalance results in reduced endometrial receptiv-
luteinization, the levels being 8.38 mIU/ml @EM = 0.61) and 1.31 ng/ml (SEM = 0.621, respectively. The histological examination of the endometrial samples showed secretory endometrium compatible with day 16 or 17 of a normal cycle (Fig. 2) in all cases except of two. In the two women who were pre-treated with contraceptive pills the endometrium showed small inactive glands with no proliferative or secretory activity except for occasional subnuclear vacuoles. The stroma showed a diffuse decidual type reaction in one case and a focal reaction of this type in the other (Fig. 3). This picture was similar to that described in women on estrogen-progestin oral contraceptives [5]. Only one patient had clinical hyperstimulation and had to be admitted and treated with plasma expanders and fluid for several days. It has to be noted that of the 27 patients participating in this research 11 women underwent only one IVF treatment (i.e., the study cycle) and 15 other cases had fertilization of ova in IVF cycles performed before or after the study. Six clinical pregnancies were achieved; two of them ended in abortion, one delivered a healthy baby and three pregnancies are ongoing. The hormonal values observed during stimulation, the number of eggs retrieved and the fact that the majority of these patients were able to produce
Fig. 2. Secretory endometrium showing large glands with well developed subnuclear vacuoles and edematous stroma, consistent with day 16-17 of menstrual cycle. Hematoxylin-eosin, x 150. Ovarian stimulation by combined GnRH analogue and hMG/hCG therapy.
400 200 0 (DAYS)
-5
-4
-3
-2
-1
0
*I
+2
*3
+4
.5
t hCG
120
ity and may interfere with the nidation process [3,8-91. Indeed, our study confirmed that application of either hMG/hCG or combined GnRHa/ hMG/hCG therapy results in ovarian hyperstimulation and hormonal imbalance. The E, values on DAY + 1 ranged from 630 to 4000 pg/ml (a difference of over 630%). Neither was there any significant correlation between the E, and P levels on the day of endometrial biopsy (r = 0.5) (Fig. 4). It ha s t o b e pointed out, however, that this hormonal imbalance did not affect the structure of the endometrium. All the endometrial samples (except of the two obtained in women pre-treated with contraceptive pills) corresponded to the day on which embryo transfer
Fig. 3. Small glands lined by inactive epithelium in stroma with decidual type reaction and thin-walled capillaries. Hematoxylin-eosin, X 150. The patient received combined contraceptive pill/hMG/hCG treatment.
E-Z (pglml)
P hg/ml)
1200
100
1100 1000
30
900 500 700
60
BOO 500
40
400 300 200
20
100 0
0
INDIVIDUAL PATIENTS =
E-2
PROGESTERONE
Fig. 4. Estrogen and progesterone levels on the day of endometrial biopsy (E.B.). The E.B. day corresponds to the day of embryo transfer in IVF program and to the 16th or 17th day of a spontaneous cycle.
would be performed (see Fig. 2), i.e., to day 16th or 17 of a normal cycle. Our results do not conform to those obtained by Sterzik and his co-workers [lo]. They examined 58 endometrial samples of women in IVF-ET program who did not have embryo transfer. Twenty-three patients were stimulated with hMG/hCG. Among them the endometrial samples showed a normal secretory phase in 11 cases only. Of the 12 remaining women 9 had various types of structural abnormalities and in 3 the specimen was insufficient for diagnosis. In women treated with clomiphene citrate in combination with gonadotropins the frequency of endometrial abnormalities was significantly higher then in those stimulated with hMG/hCG. One more difference between Sterzik’s report and the present study should be pointed out: Seventeen (29%) of women in their series were over 35 years old. In none of them the endometrial sample showed a normal luteal phase. In contrast, 9 out of 27 patients (33%) studied by us were over 35 years and all had a secretory endometrium corresponding to the 16th or 17th day of a normal cycle. According to the present study the structure of the endometrium, as judged by microscopical evaluation should not be considered as the main cause for failure of IVF-ET, particularly in patients stimulated with hMG/hCG or a combination of GnRHa and gonadotropins. This does not
121
preclude the possibility of functional disturbances which do not result in structural abnormalities observable on light microscopy. Manners [ll] reported that in some cases (but not in all) the standard histological examination showed a normal secretory endometrium but the pattern of protein secretion examined by a immunohistochemical method was abnormal. Seliger et al. [12] found that a good correlation existed between the histological examination and steroid receptors quantity and binding capacity of the endometrium. The authors also pointed out that no correlation was found between the serum steroid levels and the endometrial histology or receptor parameters. Other studies [13] showed that a discrepancy existed between light microscopy and electronmicroscopy of endometrial specimens obtained in stimulated cycles. In presumably normal endometria, electronmicroscopy showed impaired development of nucleolar channel system and stronger intercellular junctions. When discussing the uterine receptivity, the role of the embryo itself should not be overlooked. It is logical to assume that the embryo releases an array of signals which affect the uterus and the endometrium. The role of human chorionic gonadotropin is well established. Cocchiara et al. [14] reported that an embryo derived histamine releasing factor (EHRF) could prevent maternal immuno-rejection at the implantation stage. Other groups [15] found that embryos that resulted in pregnancy produced significantly higher levels of embryo-derived platelet activating factor (PAF) than embryos that failed to result in pregnancy. In summary: it seems that the embryo implantation rate is determined mainly by the number and quality of the embryos replaced and to a much lesser degree by the disturbances of endometrial structure or function caused by hormonal imbalance.
2
3
4 5
6
7
8
9
10
11
12
13
14
References 15 1 Hill GA, Freeman M, Bastias MC, Rogers BJ, Herbert CM, Osteen KG, Wentz AC. The influence of oocyte maturity and embryo quality on pregnancy rate in program
for in vitro fertilization-embryo transfer. Fertil Steril 1989;52:801-806. Nylund L, Beskow C, Carlstrom K, Fredricsson B, Gustafson 0, Lunell NO, Pousette A, Rosenborg L, Slotte H, Akerlof E. The luteal phase in successful and unsuccessful implantation after IVF-ET. Hum Reprod 1990; 5:40-42. Huang KE, Muechler EK, Schwarz KR, Goggin M, Graham MC. Serum progesterone levels in women treated with human menopausal gonadotropin and human chorionic gonadotropin for in vitro fertilization. Fertil Steril 1986;46:903-906. Noyes RN, Hertig AT, Rock J. Dating the endometrial biopsy. Fertil Steril 1950;1:3-9. Ober WB. Effect of oral and intrauterine administration of contraceptives on the uterus. Hum Pathol 1977;8:513518. Buvat J, Marcolin J, Herbaut JC, Dehaene I-J. Verbecq P, Fourlinie JC. A randomized trial of human chorionic gonadotropin support following in vitro fertilization and embryo transfer. Fertil Steril 1988;49:458-461. Buvat J, Marcolin G, Guittard C, Herbaut JC, Louvet AL, Dehaene JL. Luteal support for in vitro fertilization: superiority of human chorionic gonadotropin over oral progesterone. Fertil Steril 1990;53:490-494. Sharma V, Riddle A, Mason BA, Pampiglione J, Campbell S. An analysis of factors influencing the establishment of a clinical pregnancy in an ultrasound-based ambulatory in vitro fertilization program. Fertil Steril 1988;49:468-478. Paulson RJ, Sauer MV, Lobo RA. Embryo implantation after human in vitro fertilization: importance of endometrial receptivity. Fertil Steril 1990;53:870-874. Sterzik K, Dallenbach Ch, Schneider V, Sasse V, Dallenbath-Hellweg G. In vitro fertilization: the degree of endometrial insufficiency varies with the type of ovarian stimulation. Fertil Steril 1988;50:457-462. Manners CV. Endometrial assessement in a group of infertile women on stimulated cycles for IVF: immunohistological findings. Human Reprod 1990;5:128-132. Seliger E, Schoneich C, Kaltwasser P, Bergleiter R, Buchmann J, Rothe K. Ovarian stimulation in IVF procedure: influence on endometrial estrogen and progesterone receptors Zentralbl Gynaekol 1988;110:1499-1506. Dehou MF, Lejeune B, Arijs C, Leroy F. Endometrial morphology in stimulated in vitro fertilization cycles and after steroid replacement therapy in cases of primary ovarian failure. Fertil Steril 1987;48:995-1000. Cocchiara R, Di-Trapani G, Azzolina A, Albeggiani G, Geraci D. Early embryonic histamine releasing factor: a new model for human implantation. Hum Reprod 1986; 11445-447. ONeill C, Gidley-Baird AA, Pike IL, Saunders DM. Use of a bioassay for embryo-derived-platelet-activating factoras a means of assessing quality and pregnancy potential of human embryos. Fertil Steril 1987;47:969-975.