Luteal Phase Inadequacy

 

What is luteal phase??  :- It is during this phase when the follicle transforms into a degenerating tissue within the ovary, releases progesterone. The pre-existing estrogen and newly formed progesterone from lutein cells results in an endometrial environment ready for embryo implantation

When to Suspect LPD?? Etiology of LPD?? -1) Hyperprolactinaemia, 2) Polymenorrhoea with less duration of Foll phase, 3) cases with tonic rise of LH (in PCOS & Cases where one suspects there is possibility of Premature Luteinization and resultant poor functioning of such immature leutin cells.4) Adenomyosis,5)  Endometriosis, 6) Aged women, 7) Thin women with less adipose tissue—à therefore low leptin in serum. Why lean women have low LH? The answer is it is known that leptin in low level suppress GnRH pulse ->low LH in luteal phase.

Luteal Phase Defect: How It Impacts Fertility Though this entity is largely treatable , but there is considerable controversy surrounding the definition of luteal phase defect. Not only is there debate about its existence, there are also questions surrounding its impact on fertility and recurring miscarriage and how luteal phase defect can be diagnosed. 

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 What was the earlier modalities of diagnosis  LPD?? Theoretically, a luteal phase defect may occur if there is not sufficient progesterone produced to develop the endometrium. This has led to many proposed methods for diagnosis including: 1) measuring a progesterone level during the luteal phase, 2) monitoring the number of days between ovulation and menses, or 3) very rarely  performing an endometrial biopsy. Unfortunately, none of these methods have been proven to accurately predict infertility and have limited value in evaluating an infertile patient.

What does a short luteal phase implies?? If progesterone production is low, the luteal phase is shortened and menses occur too soon following ovulation. In a normal luteal phase, menses occurs on average 14 days following ovulation. Now with the development of home ovulation prediction kits, women can accurately predict ovulation when used correctly during the follicular phase. Temperature charts are not very effective and highly inaccurate when used to diagnose luteal phase defect.

How reliable is progesterone value in the diag of LPD?? Ans:-There is a wide range of normal values for progesterone during the luteal phase because it is released in a pulsating fashion from the corpus luteum. Levels measured have been as low as 2.3 and as high as 40.1 ng/ml1 but still cannot accurately gauge the quality of luteal function.

However, endometrial samples are assessed with considerable variation and its poor ability to predict fertility has led some to prove against using this method.

How best to treat  a supposed/ LPD albeit  empirically as LPD is not written on her face and till date sensitivity & specificity of all available tests  including Colour Doppler floe studies of CL arenotstandardized.?? Ans:- Progesterone supplementation for luteal support is commonly provided during infertility treatment. There are three methods of therapy that have been utilized to treat luteal phase defect:

1.   Controlled ovarian stimulation with clomiphene citrate or human menopausal gonadotropin (hMG) to produce more than one follicle and therefore more than one corpus luteum.

2.   Supplemental hCG to increase corpus luteum secretion of progesterone.

3.   Supplementation of progesterone after ovulation.

4.   If luteal phase defect is suspected, treatments designed to increase luteal phase progesterone have been proposed and may help support implantation and pregnancy. If a natural cycle (unstimaulted) one is having a short luteal phase, it may be presumed that there is a possibility of luteal phase defect and treatment may be planned   accordingly..

 

Special notes on endometriosis and LPD:--Endometriosis has been associated with corpus luteum inadequacy and abnormalities of luteal phase progesterone secretion. There have been abnormal luteolysis, as a chief cause of luteal dysfunction.

Researchers have assessed in 13 women with endometriosis and 25 control patients by measurement of ovarian vein estradiol (E2) and P during the follicular phase.

The results reveal that women with endometriosis have (1) significantly lower ovarian vein E2, (2) significantly higher both peripheral and ovarian vein P, and (3) threefold higher P/E2 ratios than controls during the follicular phase.

 

 These data support the concept of continued P production from an active corpus luteum well into the follicular phase of the following cycle in women with endometriosis. Failure of adequate luteolysis is a second aspect of luteal dysfunction in endometriosis and strongly supports the growing body of data confirming ovulatory asynchrony in the minimal; endometriosis infertility syndrome