Method of preparation of endometrium for implantation in women with endocrine infertility

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

Under the rehabilitation of the endometrium is understood the therapy aimed at restoring its functions. For the purpose of enhanced proliferation in all structures of the endometrium, cyclic hormone therapy with natural estrogens is currently used in combination with gestagens in elevated doses. In the literature, there are data on the high efficiency of the use of 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 receives from the hypothalamus a widely ramified NO -ergic innervation and modulates the secretion of the main pituitary hormones that affect the ovaries and provide the growth and development of follicles and endometrium.

Given the important role of NO in the regulation of hormonal synthesis, correction of endothelial relaxation, and the positive effect of NO on the state of central hemodynamics, it is possible to use it to improve maturation and trophism of the endometrium.

A survey of 75 women of reproductive age, which were divided into 2 groups. The control group (group 1) consisted of 15 healthy, potentially fertile women. The main (2nd group) included 60 women with infertility of endocrine genesis lasting from 2 to 5 years. The cause of infertility in the examined patients was a violation of the maturation of the endometrium against the background of the anovulatory menstrual cycle (MC) and the luteal phase deficiency, confirmed by ultrasound, the dynamics of changes in the serum hormone concentration in different phases of the menstrual cycle and the data of functional diagnostic tests (TFD). The diagnosis was established after exclusion of immunological and male factors of infertility (unfolded spermogram of the husband), absence of anatomical changes in the uterus and fallopian tubes, tubal peritoneal factor of infertility (according to hysterosalpingography). Clinical symptoms of "inadequate" endometrium were various disorders of the menstrual cycle (amenorrhea, hypomenorrhea, menometroragia), miscarriage, unsuccessful IVF attempts, no pregnancy after laparoscopy for polycystic ovary syndrome (PCOS), uterine leiomyoma, etc.

The women were examined according to the plan for 3-5 months according to the unified protocol approved by the order of the Ministry of Health of Ukraine from 28.12.2002 № 503 "About the procurement of obstetric and gynecological assistance in Ukraine".

The state of the endometrium in various phases of the menstrual cycle in patients with endocrine infertility was determined by transabdominal echography using Medison 128 BW apparatus by a standard procedure. By the method of therapy applied, the patients of the 2nd group were divided into three subgroups: a subgroup of 2-a-20 women with endocrine infertility, endometrial maturation correction (CSE) which was performed with the drug dyufastone (dydrogesterone); subgroup 2-6 - 20 women with endocrine infertility, CSE which was carried out with NO; subgroup 2-in-20 women with endocrine infertility, CSE which was carried out by a combination of dufaston and NO.

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

The effect of NO was carried out with the help of the Plazon apparatus (registration certificate in Ukraine No. 5392/2006 of 04.08.2006), which generates exogenous gas-like NO from the air. Irrigating the vagina with gaseous NO was performed on the 5th, 7th, 9th, 11th days of the menstrual cycle with a special vaginal tip docked with the device, which was inserted into the vagina perpendicular to the surface of the posterior for 10 minutes.
The content of hormones was determined by radioimmunoassay using test kits of reagents (Hungary). The level of follicle-stimulating hormone (FSH), luteinizing hormone (LH), estradiol was determined on the 8-10th day of the cycle, progesterone on the 20-21 day.

In healthy women of the control group on the 14-15th day of the cycle, the thickness of the proliferative endometrium grows 2-3 mm in diameter, maintaining its three-layer structure, reaching 9-10 mm before ovulation. Simultaneously, the density of the functional layer of the epithelium increases, especially at the border with the basal layer, the overall structure of the mucosa remains three-layered. On the 15-17th 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 endometrial density of the endometrium is uniformly increased, and by the beginning of the middle stage of secretion the mucous membrane of the uterus is a homogeneous tissue of medium echinostensity. In the middle stage of secretion (20-26th day of the cycle), the diameter of the mucous uterus reaches 12-15 mm. In the late stage of secretion (the 27th-30th day of the cycle), the overall echomodality of the endometrium diminishes slightly. In the structure, single small areas of low echolocation become noticeable. An echo-negative rim of rejection appears around the mucosa.

In women of the second group, retardation of follicle growth, a short-term polymicrofollicular reaction, a delayed appearance of the dominant follicle (DF), a contraction of the luteal phase of the menstrual cycle were observed in 49 (54.4%), which is characteristic of insufficiency of the luteal phase (NLF). In 34 (37,8%) there was no ovulation, which indirectly confirms the presence or predisposition of this category of patients to PCOS.

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

In subgroups 2-6 and 2-in the background of the use of NO, the thickness of the endometrium in the period of the period was 9.0 ± 0.4 mm and 9.25 ± 0.72 mm (respectively) and was significantly greater (p <0.05) in comparison with group 2 (patients before treatment) - 5.5 ± 0.42 mm and subgroup 2-a - 6.4 ± 0.54 mm, and also had no significant difference in comparison with the control group (10, 5 ± 0.85 mm).

To the middle of the secretion stage, the thickness of the endometrium in the subgroups 2-6 and 2-in was 10.0 ± 0.16 mm and 10.5 ± 0.32 mm, respectively (Table 1). The endometrial thickness in these subgroups did not differ significantly, but was significantly less (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 medium secretion into the M-echo, homogeneous, echopositive in 13.4 ± 3.2% of cases in the subgroup 2-6 and in 26.7 ± 1.7% in the subgroup 2-in.

Thus, the proposed complex method of treatment with dufaston and NO in the majority 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 dufaston (6.6 ± 2.2%).

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

The level of LH due to the use of NO in patients of subgroup 2-6 (10,9 ± 0,6 MU / ml) was close to the 1 st group, as a result of which it became reliably (p <0,05) higher in comparison with 2 nd group before treatment (5.8 ± 0.3 IU / ml) and a subgroup of 2 patients (6.9 ± 0.3 IU / ml). The content of LH in patients of subgroup 2-in (14,4 ± 0,4 IU / ml) was significantly (p <0,05) higher in comparison with patients of the 1 st, 2 nd groups and subgroups 2-a, 2- 6.

Estradiol content significantly (p <0.05) differed in all the examined groups and subgroups and was multidirectional: in the 2nd group (76 ± 5.4 nmol / l) and in the subgroup 2-6 (98.0 ± 2, 3 nmol / L), the concentration of estradiol was lower in the subgroups 2-a (149 ± 14 nmol / l) and 2-in (172.0 ± 2.3 nmol / L) higher in comparison with the 1st group (116+ 7.2 nmol / l).

Analyzing the changes in the content of estradiol depending on the applied ovulation stimulation, it can be stated that against the background of NO (subgroup 2-6), the level of estradiol (98.0 ± 2.3 nmol / l) was significantly (p <0.05) lower in comparison with subgroups 2-a and 2-in, and against the backdrop of stimulation with duphaston in a complex with NO (subgroup 2-in) - 172.0 ± 2.3 nmol / l, which is significantly (p <0.05) higher in comparison with isolated duftaston stimulation 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 by djufastone, the content progesterone was significantly (p <0.05) lower in comparison with the 1 st group (17.3 + 1.2 ng / ml).

The use of NO in women in subgroups 2-6 (16.2 ± 0.7 ng / ml) and 2-in (26.3 ± 4.8 ng / ml) contributed to a significant (p <0.05) increase in progesterone concentration in comparison with 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 indices did not differ significantly. The proposed complex method of stimulating endometrial growth promoted the development of progesterone to a greater extent, which was manifested by a significant increase in the level of progesterone in the subgroup 2-in compared with subgroup 2-6, where NO was used in isolation.

Thus, the use of NO on the background of stimulation of endometrial growth by dufaston (subgroup 2-in) contributed to the correction of hormonal status in patients with endocrine infertility and showed normalization of FSH level, significant (p <0.05) increase in LH, progesterone, estradiol in comparison with the parameters 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 by dufaston and NO, which was manifested by a significant increase (p <0.05) in the level of LH, estradiol and progesterone.

Prof. I. Yu. Kuzmina, Cand. Honey. Sciences OV Tkachev, prof. NA Shcherbina, Doctor of Science. Honey. Scherbina, prof. O. P. Lipko, Cand. Honey. Sciences OA Kuzmina. Method of preparation of endometrium for implantation in women with endocrine infertility form // International Medical Journal №4 2012

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