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Tactics of management with a defective luteal phase outside of pregnancy

 
, medical expert
Last reviewed: 15.05.2018
 
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According to the tests of functional diagnostics, an inferior luteal phase is revealed.

Infection, as the cause of chronic endometritis, in which there may be an inferior luteal phase, is excluded. There are no intrauterine synechias, but there may be uterine hypoplasia, genital infantilism and malformations of the uterus without ischemic-cervical insufficiency. Features karyotype can be or not. There is no compatibility for the HLA system. There are no autoimmune disorders (lupus anticoagulant, anti-HG, etc.). Simultaneously with the incomplete luteal phase, the content of progesterone in the middle of the luteal phase of the cycle is reduced.

To prepare for pregnancy, cyclic hormone therapy can be used. The administration of only progestational drugs in phase II of the cycle will not be sufficient, since a decreased level of progesterone is most often due to a low level of estrogens in the I phase of the cycle due to the formation of an inferior follicle. Currently, for cyclic hormone therapy, it is advisable to use the drug Femoston. Femoston is a combined two-phase preparation containing as a estrogen component micronized 17beta-estradiol (2 mg) and as a progestogen component dydrogesterone (Duphaston) 10 mg. Dydrogesterone (Dufaston) does not have an androgenic effect and anabolic effect, provides complete secretory activity of the endometrium, helps maintain the beneficial effect of estrogens on the lipid profile of the blood, does not have a negative effect on carbohydrate metabolism. Femoston is prescribed for 1 tablet continuously for 28 days of the cycle. The drug because of its estrogen component is contraindicated in pregnancy, but if pregnancy has occurred, then there is nothing terrible, since the dose of Duphaston 10 mg does not violate the process of ovulation, and this drug can be used in pregnancy.

Unlike many hormonal drugs, Femoston does not affect hemostasis and does not cause thrombophilic complications.

In the absence of Femoston or because of its high cost, combined hormone therapy with microfollin and progesterone can be used.

The use of Dufaston as a mono drug for NLF (active when given orally, can be used before the 20th week of pregnancy), is administered orally. It is safe and well tolerated, since it is a spatial isomer of natural progesterone.

Mikrofolin (ethinylestradiol) - a synthetic estrogen preparation (tablets contain 50 mcg) is administered from the 5th day of the cycle at a dose of 50 mcg per day. From the 15th to the 18th day of the cycle, progesterone 10 mg intramuscularly (sol. Progesterone oleosoe 0.5% - 2.0) is added to 1 microfollin pill, and only progesterone 10 mg per day from 18 to 26 day of the cycle. Instead of injectable progesterone, you can use dufaston 10 mg 2 times a day on the same days or as 100 mg twice daily.

Utrozhestan is a drug completely identical to natural progesterone. Micronized form provides maximum bioavailability in both oral and intravaginal applications. In pregnancy, the most widely used vaginal form (1 capsule 2-3 times a day) due to sufficiently high absorption, primary passage through the endometrium, high efficiency and ease of use. Utrozhestan, like endogenous progesterone, has the ability to control the level of androgens, which is of fundamental importance in the sexual differentiation of the fetus.

It does not have antigonadotropic activity, does not affect the lipid profile, blood pressure, carbohydrate metabolism; due to the expressed antialdosterone effect does not cause a fluid retention in the body. The major metabolites of uterine are indistinguishable from the metabolites of endogenous progesterone.

Norkolut currently is not useful for preparing for pregnancy, it is less active in terms of secretory transformation, affects hemostasis, causing hypercoagulability and a tendency to thrombosis, adversely affects the embryo if the cycle of treatment has been conception.

Cyclic therapy is prescribed for 2-3 cycles under the control of rectal temperature charts. Simultaneously with hormonal preparations, vitamins for pregnant women and folic acid are prescribed so that the total dose of folic acid is 400 μg.

With minor manifestations of NLF and alternating cycles with NLP with normal cycles, preparation for pregnancy can be carried out with estrogen-progestational medications according to the usual contraceptive regimen. Treatment is 2 cycles. In the period of treatment, ovulation is inhibited and on the abolition of the drug there is a ribaum effect, full ovulation and a full development of the yellow body, which provides secretory transformation of the endometrium and its preparation for implantation of the embryo.

If the II phase of the cycle can not be normalized by the above methods, in recent years, the stimulation of ovulation with clostilbehyde or clomiphene citrate has been successfully used to prepare for pregnancy.

The rational basis for the treatment of phase II deficiency is to ensure full ovulation, as in most women the inferiority of the luteal phase is a consequence of insufficient maturation of the follicle.

The mechanism of stimulation of ovulation with clomiphen citrate can be schematically represented as follows: clomiphene-citrate competes with 17beta-estradiol, blocks of rouestrogen-dependent receptors in the hypothalamus, which loses its ability to react to endogenous estrogens. By the mechanism of negative feedback, synthesis and release into the bloodstream of pituitary gonadotropins (FSH and LH) is enhanced, which provides stimulation of follicular maturation and the synthesis of estrogens. After reaching the critical level of estrogens in the blood, by the mechanism of reverse positive connection, a signal is given to the beginning of the cyclic ovulatory peak of LH. By this time, the blocking effect of clomiphene-citrate estrogen receptors in the hypothalamus ends, and it reacts again to the endogenous steroid signal.

In patients with miscarriage with NLF to stimulate ovulation should be treated cautiously, since most of them have their own ovulation. To resort to this kind of therapy follows when alternating anovulation with NLF. Treatment is prescribed in a dose of 50 mg from the 5 day of the cycle, once a day for 5 days. Side effects with clomiphene-citrate are rare and, in general, when using large doses. The most common complication is an increase in the ovaries and the formation of cysts. Seldom can there be complaints of pain in the lower abdomen, unpleasant sensations in the mammary glands, nausea, headache. After the drug is discontinued, all phenomena usually pass quickly.

For proper evaluation of the effectiveness of therapy, determining the time of ovulation, and later on, pregnancy, it is advisable to control the nature of the basal temperature. To diagnose the most severe complication after stimulation of ovulation - ovarian hyperstimulation - it is advisable to conduct ultrasound and determine the level of estrogen.

Treatment with clomiphene-citrate should not be performed more than 3 consecutive cycles and the dose is not advisable to increase. In the absence of an ovulatory peak (according to the rectal temperature schedule) on the 14-15 day of the cycle, some authors recommend using a good level of estrogen to prescribe the introduction of chorionic gonadotropin in a dose of 5-10 thousand units. In the absence of ovulation, chorionic gonadotropin is repeated in the same dose after 1-2 days. In these cases, chorionic hormone supplements or replaces LH release.

With NLF, but the normal level of hormones (progesterone and estrogens) in the II phase of the NLF cycle is most often due to damage to the receptor apparatus of the endometrium. Treatment of NLF in this situation with hormonal drugs is ineffective. Very good results, according to our observations, were obtained by treatment with Ca electrophoresis, starting from the 5th day of the cycle, 15 procedures. This method can be used for 2 consecutive cycles.

Good results were obtained when using an electromagnetic field with a power of 0.1 mW / cm and a frequency of 57 GHz at 30 min exposure for 10 days of the first phase of the menstrual cycle. An increase in the level of progesterone, normalization of the antioxidant activity of plasma and the appearance of secretory transformation of the endometrium were noted.

Good results were obtained using acupuncture.

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