Method of endometrial preparation for implantation in women with endocrine form of infertility

One of the main functions of the endometrium is to ensure implantation and nidation of the embryo. An important role in this process is played by the maturity of the endometrium, its synchronization with the hormonal background throughout the menstrual cycle. The main diagnostic criterion for assessing the state of the endometrium for implantation is its thickness, the optimal parameters of which for the onset of pregnancy are 9-12 mm. Disturbances in the maturation of the endometrium are mainly associated with dyshormonal conditions, changes in blood supply in the uterus and its hypoplasia, trauma to the endometrium as a result of excessively active curettage, etc. Apoptosis, which is responsible for maintaining homeostasis in the tissues of the body, plays an important role in the process of growth and differentiation of the endometrium.

Endometrial rehabilitation is understood as therapy aimed at restoring its functions. In order to enhance proliferation in all endometrial structures, cyclic hormone therapy with natural estrogens in combination with gestagens in increased doses is currently used. The literature contains data on the high efficiency of using exogenous nitric oxide (NO) in the complex treatment of endocrine infertility. The therapeutic effect of NO in the treatment of hormonal disorders is based on the fact that the pituitary gland receives widely branched NO-ergic innervation from the hypothalamus and modulates the secretion of the main pituitary hormones that affect the ovaries and ensure the growth and development of follicles and the endometrium.

Considering the important role of NO in the regulation of hormonal synthesis, correction of endothelial relaxation disorders, as well as the positive effect of NO on the state of central hemodynamics, it can be used to improve the maturation and trophism of the endometrium.

The study involved 75 women of reproductive age divided into 2 groups. The control group (Group 1) included 15 healthy, potentially fertile women. The main group (Group 2) included 60 women with endocrine infertility lasting from 2 to 5 years. The cause of infertility in the examined patients was impaired endometrial maturation against the background of anovulatory menstrual cycle (MC) and luteal phase deficiency, confirmed by ultrasound examinations, dynamics of changes in serum hormone concentrations in different phases of the menstrual cycle, and functional diagnostic tests (FDT). The diagnosis was established after excluding immunological and male factors of infertility (detailed spermogram of the husband), the absence of anatomical changes in the uterus and fallopian tubes, and tubal-peritoneal factor of infertility (according to hysterosalpingography). Clinical symptoms of “inadequate” endometrium included various menstrual cycle disorders (amenorrhea, hypomenorrhea, menometrorrhagia), miscarriage, unsuccessful IVF attempts, absence of pregnancy after laparoscopy for polycystic ovary syndrome (PCOS), uterine leiomyoma, etc.

The examination of women was carried out according to plan for 3-5 months in accordance with the unified protocol approved by the order of the Ministry of Health of Ukraine dated 28.12.2002 No. 503 “On improving obstetric and gynecological care in Ukraine”.

The condition of the endometrium in different phases of the menstrual cycle in patients with endocrine infertility was determined by transabdominal echography using a Medison 128 BW apparatus using a standard technique. According to the method of therapy used, the patients of group 2 were divided into three subgroups: subgroup 2-a - 20 women with endocrine infertility, whose endometrial maturation correction (EMC) was performed using duphaston (dydrogesterone); subgroup 2-6 - 20 women with endocrine infertility, whose EMC was performed using NO; subgroup 2-b - 20 women with endocrine infertility, whose EMC was performed using a combination of duphaston and NO.

The drug duphaston is a unique gestagen, the molecular structure of which is almost identical to natural progesterone. Duphaston was prescribed from the 12th to the 25th day of the menstrual cycle in a daily dose of 60 mg.

The NO exposure was carried out using the Plazon device (registration certificate in Ukraine No. 5392/2006 dated 04.08.2006), which generates exogenous gaseous NO from atmospheric air. Vaginal irrigation with gaseous NO was performed on the 5th, 7th, 9th, 11th days of the menstrual cycle using a special vaginal tip connected to the device, which was inserted into the vagina perpendicular to the surface of the posterior fornix for 10 min.
Hormonal levels were determined by the radioimmunoassay method using test kits of reagents (Hungary). The level of follicle-stimulating hormone (FSH), luteinizing hormone (LH), estradiol was determined on the 8th-10th day of the cycle, progesterone - on the 20th-21st day.

In healthy women of the control group, on the 14th-15th day of the cycle, the thickness of the proliferative endometrium in diameter increases by 2-3 mm while maintaining its three-layer structure, reaching 9-10 mm before ovulation. At the same time, the density of the functional layer of the epithelium increases, especially at the border with the basal layer, the general structure of the mucosa remains three-layered. On the 15th-17th day of the cycle, the thickness of the endometrium reached 10.5±0.85 mm, maintaining a three-layer structure. After ovulation, in healthy women, the thickness of the endometrium reaches 11-13 mm. The echo density of the endometrium increases uniformly, and by the beginning of the middle stage of secretion, the uterine mucosa is a homogeneous tissue of average echo density. In the middle stage of secretion (20th-26th day of the cycle), the diameter of the uterine mucosa reaches 12-15 mm. In the late stage of secretion (27-30th day of the cycle), the overall echo density of the endometrium decreases slightly. Single small areas of decreased echo density become noticeable in the structure. An echo-negative rim of rejection appears around the mucosa.

In women of the 2nd group, retardation of follicle growth, short-term polymicrofollicular reaction, delayed appearance of the dominant follicle (DF), shortening of the luteal phase of the menstrual cycle were observed in 49 (54.4%), which is typical for luteal phase deficiency (LPD). In 34 (37.8%), there was no ovulation, which indirectly confirms the presence or predisposition of this category of patients to PCOS.

The echo density of the mucosa increased uniformly with the disappearance of the three-layer structure, and by the beginning of the stage of average secretion, the endometrium in 39 (43.3%) patients was a homogeneous tissue of average echo density - secretory endometrium. After treatment with duphaston (subgroup 2-a), the thickness of the endometrium significantly (p < 0.05) increased: before treatment in the periovulatory period it was 5.5 ± 0.42 mm, after treatment - 6.4 ± 0.54 mm. In the stage of average secretion - 7.0 ± 0.5 mm and 7.2 ± 0.62 mm (respectively) with the preservation of 3-linear M-echo in 93.3% of observations. In subgroup 2-a, the increase in the thickness of the endometrium by the middle of the secretion stage may indicate a positive effect of duphaston on the condition of the endometrium.

In subgroups 2-6 and 2-b, against the background of NO use, the endometrial thickness in the periovulatory period was 9.0±0.4 mm and 9.25±0.72 mm (respectively) and was significantly greater (p < 0.05) compared to group 2 (patients before treatment) - 5.5±0.42 mm and subgroup 2-a - 6.4±0.54 mm, and also had no significant differences compared to the control group (10.5±0.85 mm).

By the middle of the secretion stage, the endometrial thickness in subgroups 2-6 and 2-c was 10.0+0.16 mm and 10.5±0.32 mm, respectively (Table 1). The endometrial thickness values in these subgroups did not differ significantly, but were significantly lower (p < 0.05) compared to the control group of women (12.0±0.23 mm). The use of NO contributed to the transformation of the 3-linear endometrium of the M-echo at the stage of middle secretion into a homogeneous, echo-positive M-echo in 13.4±3.2% of cases in subgroup 2-6 and in 26.7±1.7% of cases in subgroup 2-c.

Thus, the proposed complex method of treatment with duphaston and NO in a greater percentage of cases (p < 0.05) promotes secretory transformations of the endometrium (26.7±1.7%) according to ultrasound data than the isolated use of NO (13.4±3.2%) and duphaston (6.6±2.2%).

The hormonal profile data of the examined patients are presented in Table 2, according to which the FSH level did not differ significantly. In patients with endocrine infertility (group 2) in the natural cycle, the LH content (5.8±0.3 IU/ml) was significantly (p < 0.05) lower compared to patients of the 1st (control) group (11.6+0.5 IU/ml). Stimulation of endometrial growth with duphaston contributed to a significant (p < 0.05) increase in LH in patients of subgroup 2-a (6.9±0.3 IU/ml) compared to group 2 (5.8±0.3 IU/ml), however, compared to patients of group 1 (11.6+0.5 IU/ml), this indicator was significantly (p < 0.05) lower.

The level of LH due to the use of NO in patients of subgroup 2-6 (10.9±0.6 IU/ml) approached the indicators of group 1, as a result of which it became reliably (p < 0.05) higher in comparison with group 2 before treatment (5.8±0.3 IU/ml) and subgroup 2-a patients (6.9±0.3 IU/ml). The content of LH in patients of subgroup 2-b (14.4±0.4 IU/ml) was reliably (p < 0.05) higher in comparison with patients of groups 1, 2 and subgroups 2-a, 2-6.

The content of estradiol significantly (p < 0.05) differed in all examined groups and subgroups and had a multidirectional character: in the 2nd group (76±5.4 nmol/l) and in subgroup 2-6 (98.0±2.3 nmol/l) the concentration of estradiol was lower, in subgroups 2-a (149±14 nmol/l) and 2-b (172.0±2.3 nmol/l) it was higher in comparison with the 1st group (116+7.2 nmol/l).

Analyzing the changes in estradiol content depending on the applied ovulation stimulation, it can be concluded that against the background of NO (subgroup 2-6), the estradiol level (98.0±2.3 nmol/l) was significantly (p < 0.05) lower in comparison with subgroups 2-a and 2-b, and against the background of stimulation with duphaston in combination with NO (subgroup 2-b) - 172.0±2.3 nmol/l, which is significantly (p < 0.05) higher in comparison with isolated stimulation with duphaston in patients of subgroup 2-a - 149±14 nmol/l.

In women of the 2nd group with endocrine infertility before treatment (6.7+1.1 ng/ml), as well as in women of subgroup 2-a (8.3±0.6 ng/ml) with stimulation of endometrial growth with duphaston, the progesterone content was significantly (p < 0.05) lower compared to the 1st group (17.3+1.2 ng/ml).

The use of NO in women of subgroups 2-6 (16.2±0.7 ng/ml) and 2-b (26.3±4.8 ng/ml) contributed to a reliable (p < 0.05) increase in progesterone concentration compared to the 2nd group before treatment (6.7+1.1 ng/ml) and subgroup 2-a (8.3±0.6 ng/ml). In patients of subgroup 2-6 (16.2±0.7 ng/ml) and group 1 (7.3±1.2 ng/ml), these indicators did not differ significantly. The proposed complex method of endometrial growth stimulation contributed to a greater extent to the production of progesterone, which was manifested by a reliable increase in the progesterone level in subgroup 2-b compared to subgroup 2-6, where NO was used alone.

Thus, the use of NO against the background of stimulation of endometrial growth with duphaston (subgroup 2-c) contributed to the correction of the hormonal status in patients with endocrine infertility and was manifested by the normalization of the FSH level, a reliable (p < 0.05) increase in the content of LH, progesterone, estradiol in comparison with the indicators of the control group. The proposed complex method of stimulation of endometrial growth with duphaston together with NO contributed to a more significant correction of the hormonal background in comparison with isolated stimulation with duphaston and NO, which was manifested by a significantly greater (p < 0.05) increase in the level of LH, estradiol and progesterone.

Prof. I. Yu. Kuzmina, PhD O. V. Tkacheva, Prof. N. A. Shcherbina, DSc I. N. Shcherbina, Prof. O. P. Lipko, PhD O. A. Kuzmina. Method of preparing the endometrium for implantation in women with endocrine infertility // International Medical Journal No. 4 2012

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