الفهرس 
Subject and methodsOnly 14 pages are availabe for public view
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Abstract
Endometrial adequacy is important in implantation. Accurate
assessment of luteal adequacy is of critical importance in an
investigation of the infertile couples. LPD is identified as a repetitive
entity in about 10% of infertile women (Wentz, 1990). The test of
luteal adequacy currently available however, are less than ideal. At
present, the PEB is the diagnostic method of choice of LPD. A lag of 2
days or more in at least 2 cycles is necessary to support the diagnosis
The present study was performed to evaluate the merit of
ultrasonagraphic assessment of (A) follicular development & (B)
endometrial changes throughout the menstrual cycle as a diagnostic
tool for LPD. This methodology is comfortable and harmless and could
be repeated in clinical practice.
This study was conducted on two groups of women :
Group (I) (Study group):
_ Consists of 50 women with only LPD selected from the patients
complaining of Iry infertility for at least IY.
Group (II) : (Control group) :
_ Consists of 50 normal healtly fertile women.
The followingwere done for each women in both groups for two
consecutive cycles:
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.summar!! &: Conclusion
1- Serial ultrasonographic examination by abdominal sector probe
3.5MHz, starting from menstrual day 8 every other day or every day
according to the size of the follicles till ovulation, then every two or
three days till next menstruation, to assess the follicular
development & endometrial characteristics (thickness, echogenicity
& posterior acoustic enhancement).
2- PEB on PsOD 12 or 13 (12 or 13 days after expected ovulation in
LUFs), for histologic dating ofthe endometrium
3- Mid-luteal serum progesterone level on PsOD 7 (7 days after
expected ovulation in LUFs), using RIA technique.
Analysis of the results revealed atbe following items:
o Ultrasound assessment showed that:
a- Follicular growth in cases ofLPD patients (study group) showed 3
different growth patterns. (I) cycles with normal size follicles
(44%). (II) cycles with small size (immature) fellicles (51%).(III)
cycles with LUFs (5%). THe patients could be seen with only one
pattern, normal size follicles (44%), small size follicles (50%) &
LUFs (4%), or with mixed pattern (2%) (one cycle with small size
follicle & the other with LUFs).
In normal women (control group), all the women showed normal
size follicles.
b- Endometrial echogenicity m LPD patients (study group) was
different from that in the normal women (control grpup) .
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Summary & Conclusion
• In LPD cycles with normal follicles & LUFs, endometrial
echogenicity was adequate in late follicular phase (Pattern I) &
adequate in the mid-secretory phase (Pattern III), but it could not
maintain this adequacy & regressed to the inadequate pattern
(Pattern II) in the last four days preceding menstruation.
• In LPD cycles with immature follicles, endometrial echogenicity
was inadequate in late follicular phase (Hypoechoic pattern) & was
inadequate in the mid secretory phase (Patten II). This inadequate
pattern was persistent up to menstruation .
• In normal women (control grpup), endometrial echogenicity in most
women (92%) was adequate in late follicular phase (Pattern I), (5%)
was inadequate (Hypoechoic pattern) & (3%) was advanced
(Pattern III). The women with adequate late follicalar growth were
also adequate in the mid secretary phase (Pattern III), (90%) of
them maintined this adequacy up to the late secretory phase & only
(2%) regressed to inadequate pattern (Pattern II). The women with
inadequate late follicular growth, were also inadepuate in the mid
secretory phase (Pattern II) & persisted with this inadequate pattern
up to the late secretory phase. The women with advanced pattern in
the late follicular phase (Pattern III), maintained this pattern up to
the late secretory phase.
* At day of ovulation (expected ovulation in LUFs), endometrial
echogenicity could help in detection of only 51% ofLPD cycles
(cycles with immature follicles) with the inadequate (Hypoechoic
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c’3ummary ’” Conclusion
pattern). The other 49% ofLPD cycles (cycles with normal follicles
& LUFs) showed adequate (Pattern I).
In normal women (control groups), 92% were with adequate
(Pattern I) & 8% were non adequate (5% hypoechic & 3%
advanced patterns).
The sensitivity was 51%, the specificity was 92%, the positive
predicitive value was 86.4%. & the negative predicitive value was
65.2%.
The importance of study of the echogenicity at that time is to detect
the maturity of the follicle whatever its size (through the adequacy
of the pattern) and to foretell the adequacy in the mid-secretory
phase (the time of nidation). Since all the patients with adequate late
follicular growth will be seen with adequate mid-secretory growth
& all the patients with inadequate growth will be seen with
inadequate mid-secretory growth.
• At the mid-secretory phase (psOD 7), endometrial echogenicity
could not detect more than what was detected before at day of
ovulation. Evaluation at that time is needed either to confirm the
results at ovulation or when the patient is missed to follow at
ovulation.
The same group of LPD (cycles with immature follicles) 51%,
showed the inadequate mid-secretory (pattern II), which is
secondary to the inadequate follicular growth. The other 49% of
LPD (cycles with normal follicles & LUFs) showed adequate midsecretory
(Pattern III).
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e5ummary If Gonclusion
In normal women (control group), 95% were adequate (Pattern III)
& 5% were non-adequate (Pattern II).
The sensitivity was 51%, the specificity was 95%, the positive
predicitive value was 91.1% & the negative predicitive value was
65.9% .
* At the late secretory phase (PsOD 12), endometrial echogenicity
could detect all the LPD patients. All the cycles (100%) were seen
with inadequate late secretory pattern (Pattern II).
In normal women (control group), 93% were adequate (Pattern III)
& 7% were non-adequate (Pattern II).
The sensitivity was 100%, the specificity was 93%, the positive
predicitive value was 93.5% & the negative predicitive value was
100% .
c- Neither endometrial thickness nor posterior acoustic enhancement
was helpful in diagnosis of LPD.
Endometrial thickness at day of ovulation (expected ovulation in
LUFs), at mid secretory phase (PsOD 7) & at late secretory phase
(PsOD 12 or 13), showed non-significant difference in both the
study & control groups.
Posterior acoustic enbancement was seen in 91% of the cycles of
the study group & in 93% of the control group. This difference is
insignificant statistically.
8Serum progesterone assay was misleading in diagnosis LPD
patients. A single mid-luteal serum progesterone level of 10 ng/ml
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<Summary’” Gonclusion
or more is accepted by most of the authors as adequate for corpus
luteum function.
All our control group cycles, was seen with lOng/rnl or more (range
from 10 to 20.5mg/rnl) .
This level was also seen in 68.2% of LPD cycles with normal
follicles, (range from 8 to 17 ng/rnl), 49% of LPD cycles with
immature follicles (range from 7 to 16 ng/ml) & 20% ofLPD cycles
with LUFs (range 7.5 to 15 ng/ml) (totally 56% ofLPD cycles) .
• Histologic dating of PEB was very valuable when dating is done in
relation to the accurate timing of ovulation determined by ultrasound
to-
& done by experinced gynaecologic pathologist. Accuracy of dating
. I
in ~ normal women (control group), was 98%. The error was only
in 2% of the cycles & was only one day. The mean out of phase
days in LPD cycles with normal follicles was (3.1 ± 0.8), with
immature follicles was (6.8 ± 1.5) & in LPD cycles with LUFs was
(4.6 ± 0.5).The difference between the cycles were highly
significant (P<O.Ol).
CONCLUSION:
The ideal diagnostic test for LPD patients would involve the PEB
& ultrasound evaluation of both follicular growth & endometrial
adequacy.
PEB is needed for accurate dating of the endometrium to establish
the diagnosis & it is necessary to date it in relation to the accurate day
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<Summary if GoncNsion
of ovulation determined by ultrasound & by experinced gynaecologic
pathologist .
Ultrasound evaluation of the follicular growth is important to detect
the main underlying defect in these patients. Either it is a pure luteal
phase defect (patients with normal follicles), or secondary to follicular
defect which may be due to immature follicles (patients with small size
follicles), or due to failure of ovulation (patients with LUFs).
Evaluation of endometrial adequacy will be through the study of
endometrial echogenicity which is the most promising feature
indicating the response of the endometrium to the different circulating
hormones. Evaluation of endometrial echogenicity at day of ovulation
c
is important to evaluate the maturity of the follile whatever its size & . )
foretell us about the adequacy in the mid-secretory phase (PsOD 7).
Echogenicity at the mid-secretory phase (PsOD 7) is needed to confirm
the result obtained before at day of ovulation or when the patients
missed to follow at ovulation. Echogenicity at late secretory phase
(PsOD 12 or 13) in considered the most sensitive time for detection of
all cases of LPD patients.
Ultrasound will not only help in making the diagnosis complete &
accurate but also will guide us to the proper treatment of the case
which correct the follicular defect & endometrial pattern to achieve
adequate endometrial pattern for each corresponding phase of the cycle
up to menstruation. The problem of repetition ofPEB could be avoided
whenever this adequate pattern is seen. LPD cases with normal follicles
will be treated by progesterone support during the luteal phase. LPD
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.summary & Conclusion
cases with immature follicles, the treatment will be through
improvement offolliculogensis by clomiphene citrate or HMG. In cases
of LUFs, ovulation will be helped either by HCG or by improvement of
folliculogensis by clomiphene citrate or HMG with or without HCG.
Short luteal phase will be treated by clomiphene citrate. This study is
going on now in our Infertility Unit & the results will be published in
the near future.
We think ultrasound will be more popular in the near future as a
diagnostic modality for LPD & with contin~us development of the
ultrasonics, the time will come when the sensitivity & specificity
become 100%.