Management tactics for incomplete luteal phase outside pregnancy

Functional diagnostic tests revealed an incomplete luteal phase.

Infection as a cause of chronic endometritis, which may be accompanied by an incomplete luteal phase, is excluded. There are no intrauterine adhesions, but there may be uterine hypoplasia, genital infantilism and uterine malformations without isthmic-cervical insufficiency. Karyotype features may or may not be present. There is no compatibility according to the HLA system. There are no autoimmune disorders (lupus anticoagulant, anti-CG, etc.). Simultaneously with the incomplete luteal phase, the progesterone content in the middle of the luteal phase of the cycle is reduced.

Cyclic hormone therapy can be used to prepare for pregnancy. Prescribing only gestagen drugs in the second phase of the cycle will not be enough, since the reduced level of progesterone is most often due to the low level of estrogens in the first phase of the cycle due to the formation of a defective follicle. Currently, it is advisable to use Femoston for cyclic hormone therapy. Femoston is a combined two-phase drug containing micronized 17beta-estradiol (2 mg) as an estrogenic component and dydrogesterone (Duphaston) 10 mg as a gestagen component. Dydrogesterone (Duphaston) does not have an androgenic effect or anabolic effect, ensures full secretory activity of the endometrium, helps to maintain the beneficial effect of estrogens on the lipid profile of the blood, and does not have a negative effect on carbohydrate metabolism. Femoston is prescribed 1 tablet continuously for 28 days of the cycle. The drug is contraindicated during pregnancy due to its estrogen component, but if pregnancy occurs, then there is nothing to worry about, since a dose of Duphaston 10 mg does not disrupt the ovulation process, and this drug can be used during pregnancy.

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

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

The use of Duphaston as a monodrug for NLF (active when administered orally, can be used up to the 20th week of pregnancy), is used orally. Safe and well tolerated, as it is a spatial isomer of natural progesterone.

Microfollin (ethinylestradiol) is a synthetic estrogen drug (tablets contain 50 mcg) prescribed 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 is added to 1 tablet of microfollin at 10 mg intramuscularly (sol. progesterone oleosoe 0.5% - 2.0), and from the 18th to the 26th day of the cycle, only progesterone at 10 mg per day. Instead of injectable progesterone, you can use duphaston at 10 mg 2 times a day on the same days or utrogestan 100 mg 2 times a day.

Utrozhestan is a drug that is completely identical to natural progesterone. The micronized form provides maximum bioavailability both when taken orally and intravaginally. During pregnancy, the vaginal form is most widely used (1 capsule 2-3 times a day) due to its fairly high absorption, primary passage through the endometrium, high efficiency and ease of use. Utrozhestan, like endogenous progesterone, has the ability to control androgen levels, which is of fundamental importance in the sexual differentiation of the fetus.

Utrozhestan does not have antigonadotropic activity, does not affect the lipid profile, blood pressure, carbohydrate metabolism; due to the pronounced antialdosterone effect, it does not cause fluid retention in the body. The main metabolites of Utrozhestan are indistinguishable from the metabolites of endogenous progesterone.

Norcolut is currently not advisable to use for the purpose of preparing for pregnancy, it is less active in terms of secretory transformation, affects hemostasis, causing hypercoagulation and a tendency to thrombosis, and has an adverse effect on the embryo if conception occurs during the treatment cycle.

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

In case of minor manifestations of NLF and alternation of cycles with NLF with normal cycles, preparation for pregnancy can be carried out with estrogen-gestagen drugs according to the usual scheme for contraceptives. Treatment is carried out for 2 cycles. During the treatment period, ovulation is inhibited and upon discontinuation of the drug, a ribaum effect is observed, full ovulation and full development of the corpus luteum occurs, which ensures secretory transformation of the endometrium and its preparation for implantation of the embryo.

If it is not possible to normalize the second phase of the cycle using the above methods, in recent years, ovulation stimulation with clostilbegid or clomiphene citrate has been successfully used to prepare for pregnancy.

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

The mechanism of ovulation stimulation by clomiphene citrate can be schematically represented as follows: clomiphene citrate competes with 17beta-estradiol, blocking ruetestrogen-dependent receptors in the hypothalamus, which loses the ability to respond to endogenous estrogens. According to the mechanism of negative feedback, the synthesis and release of pituitary gonadotropins (FSH and LH) into the bloodstream is enhanced, which stimulates follicle maturation and estrogens. After reaching a critical level of estrogens in the blood, according to the mechanism of positive feedback, a signal is given to begin the cyclic ovulatory peak of LH. By this time, the blocking effect of clomiphene citrate on estrogen receptors in the hypothalamus ends, and it again responds to the endogenous steroid signal.

In patients with miscarriage with NLF, ovulation stimulation should be approached with caution, since most of them have their own ovulation. This type of therapy should be used when anovulation alternates with NLF. Treatment is prescribed at a dose of 50 mg from the 5th day of the cycle, 1 time per day for 5 days. Side effects when using clomiphene citrate are rare and mainly when using high doses. The most common complication is enlargement of the ovaries and the formation of cysts. Rarely, there may be complaints of pain in the lower abdomen, discomfort in the mammary glands, nausea, headache. After discontinuing the drug, all phenomena usually pass quickly.

To correctly assess the effectiveness of therapy, determine the time of ovulation, and subsequently pregnancy, it is advisable to monitor the nature of the basal temperature. To diagnose the most severe complication after ovulation stimulation - ovarian hyperstimulation - it is advisable to conduct an ultrasound and determine the level of estrogens.

Treatment with clomiphene citrate should not be carried out for more than 3 cycles in a row and increasing the dose is inappropriate. In the absence of an ovulatory peak (according to the rectal temperature chart) on day 14-15 of the cycle, some authors recommend, with a good estrogen level, prescribing the introduction of human chorionic gonadotropin at a dose of 5-10 thousand units. In the absence of ovulation, human chorionic gonadotropin is repeated in the same dose after 1-2 days. In these cases, human chorionic gonadotropin supplements or replaces the LH surge.

In case of NLF, but normal hormone levels (progesterone and estrogens) in the II phase of the cycle, NLF is most often caused by 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 with treatment with Ca electrophoresis, starting from the 5th day of the cycle - 15 procedures. This method can be used 2 cycles in a row.

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

Good results have been obtained using acupuncture.