The significance of lymphocytic-leukocytic infiltrates in interpreting late luteal phase endometrial biopsies

Transcription

1 FERTILITY AND STERILITY Copyright 1982 The American Fertility Society Vol. 37, No. 6, June 1982 Printed in U.S A. The significance of lymphocytic-leukocytic infiltrates in interpreting late luteal phase endometrial biopsies Douglas C. Daly, M.D.* Narendra Tohan, M.D. Thomas J. Doney, M.D. Ila A. Maslar, Ph.D. Daniel H. Riddick, M.D., Ph.D. Division of Reproductive Endocrinology, Department of Obstetrics and Gynecology, University of Connecticut School of Medicine, Farmington, Connecticut The effectiveness of the endometrial biopsy in diagnosing luteal phase defects as a cause of infertility depends upon the accurate determination of a histologic date based on the morphologic features of tissue. The criteria--- dema, predecidual reaction, stromal mitosis, and lymphocytic-leukocytic infiltrate-used to interpret such biopsies were based on changes occurring in the normal ideal menstrual cycle. The present study examines the criteria used for dating endometrium as applied to endometrial biopsies for luteal phase deficiency. It was determined that one of these criteria, lymphocytic and leukocytic infiltration, correlated with subsequent onset of menses and not with the other indications of histologic maturity during the late secretory phase. Fertil Steril37:786, 1982 The histologic appearance of late luteal phase endometrial biopsy specimens is often used in the diagnosis of luteal phase defects. 1 2 The standards by which endometrial biopsies are usually interpreted were described in the classic paper by Noyes et al. 3 They emphasized that "during the second week [of the secretory phase] stromal changes, namely, edema, predecidual reaction, mitosis, and leukocytic infiltration are the key criteria" for assessing histologic dates. Further, "the differentiation of predecidua is accompanied by a sharp increase in lymphocytic infiltration." This description has led to the use of these four factors, including lymphocytic and leukocytic in- Received October 23, 1981; revised and accepted February 16, *Reprint requests: Douglas C. Daly, M.D., Division of Reproductive Endocrinology, Department of Obstetrics and Gynecology, University of Connecticut School of Medicine, Farmington, Connecticut Daly et al. Lymphocytic-leukocytic infiltrates filtration, in the evaluation of biopsies and the identification of luteal phase defects. In this study, we evaluated one of these criteria, lymphocytic-leukocytic infiltration, in order to determine its significance in the dating of endometria with the luteal phase defect. Specimens with the luteal phase defect were compared with normal specimens of similar histologic or menstrual age in order to determine whether lymphocytic-leukocytic infiltration was a reflection of tissue maturity or impending menses. Throughout the paper the term lymphocyteleukocyte is used to conform with the descriptive terms used by Noyes et al. 3 In fact, all these cells are leukocytes, and a more accurate terminology would be nonpolymorphonuclear leukocytes and polymorphonuclear leukocytes. MATERIALS AND METHODS The histologic slides examined were prepared from endometrial biopsies performed by the institution endocrine-infertility service during the Fertility and Sterility

2 p<.ooi P> !1.. >. 150 u...j 1, c....j JO (.1 tl Ideal Cyle Day ;::, " " 0 ISO " 7 "' c. E...J "' p< IO_fl 23 2 p< 0001 r. 7 l Histologic Date " ' "' "...J I p>.lo A p<.ol B i9 27 c Ideal Cycle Day p<.05 J_ D Figure 1 Increasing lymphocytic-leukocytic infiltrate (per 3 hpf) in normal biopsy specimens. Figure 2 Significant increase in lymphocytic-leukocytic infiltrate (per 3 hpf) in luteal phase defect specimens (shaded bars), compared with normal biopsies of the same histologic dates. Figure 3 Lack of significant difference in lymphocytic-leukocytic infiltrate in luteal phase defect and normal biopsies on menstrual days 25 and 27 (A and C), significantly less lymphocytic-leukocytic infiltrate in day-26 luteal phase defect endometrium, compared with day-26 normals (B), but significantly more than day-25 normals (D). (Normals, open bars, LPD's, shaded bars). last 6 days of nonconceptional menstrual cycles. All patients were cultured for mycoplasma on the initial visit and adequately treated prior to biopsy. These biopsies were dated on the basis of histologic characteristics by this service and the pathology service, and the subsequent date of the onset of menses determined from the patient's report. The date of menses was used to calculate the ideal menstrual date, as defined by Noyes et al., 3 with the first day of menses defined as day 28 of the cycle. Specimens chosen were from the previous 2 years' files and fell into two categories: (1) normal, those in which the pathologist and the infertility service agreed upon the histologic date, and this date agreed with the menstrual date; and (2) defective, those in which the pathologist and the infertility service agreed upon the histologic date, and this date represented at least a 2-day lag when compared with the menstrual date. We then evaluated each slide of each control and luteal phase defect biopsy for lymphocyticleukocytic infiltration by examining three fields chosen randomly at x 40 power for the following criteria: one field contained epithelium, one contained arterioles, and the third field contained Vol. 37, No.6, June 1982 neither. Lymphocytes and leukocytes were counted separately at x 430 power, and the total number of lymphocytes and leukocytes present in these three fields was determined for each biopsy. For the purpose of statistics, lymphocytes and leukocytes were totaled and considered as a group. The tissues were then grouped according to ideal cycle days as determined by histologic characteristics and by menstrual dates, so that a mean number of cells and standard deviation for each category could be calculated. Differences between these means were evaluated by the Student's t-test. RESULTS The distribution of lymphocytes-leukocytes in the normal biopsies agreed with that observed by Noyes et al. 3 Lymphocytic infiltration began on the 23rd day and increased during the last 4 days of the cycle, and leukocytes became increasingly common on days 26 and 27. In the normal specimens there was a significant increase in the number of lymphocytes-leukocytes present (P < 0.001) on any single day from day 23 to day 26. Daly et al. Lymphocytic-leukocytic infiltrates 787

3 Figure 4 (A), Day 23, demonstrating early predecidual changes and few lymphocytes or leukocytes ( x 400). There was no significant difference between day 26 and day 27 (Fig. 1). Endometria with the luteal phase defect were compared with normal endometria with respect to mean number oflymphocytesleukocytes by two methods. Comparison with normal endometria of the same histologic dates revealed a marked increase in lymphocytic-leukocytic infiltration in the endometrium with the luteal phase defect dated histologically as days 23, 24, and 25 (P < 0.001) (Fig. 2). When defective endometria were compared with the normal endometria of the same menstrual dates for the degree of lymphocytic-leukocytic infiltration, no differences (P > 0.10) were found on ideal menstrual days 25 and 27 (Fig. 3A and C). On ideal menstrual day 26 there was a decrease (P < 0.01) in lymphocytic-leukocytic infiltration in endometrium with the luteal phase defect as compared with normal day-26 endometria (Fig. 3B) However, the day-26 defect endometria contained 788 Daly et al. Lymphocytic-leukocytic infiltrates Figure 4 (B), Day 24. Several layers of decidualization along a longitudinally sectioned vessel. Few lymphocytes or leukocytes ( x250). more (P < 0.05) lymphocytic-leukocytic cells than normal day-25 endometria (Fig. 3D). DISCUSSION The luteal phase defect as a cause of infertility has had variable acceptance in the medical community, in part because of the difficulty in making a diagnosis. After Noyes' description of the histologic changes in the normal endometrium, several papers 4 5 appeared similar in substance to Gillam's 6 describing the "inadequate secretion phase" treated successfully with various progestational agents. Gillam also noted a "peculiar lymphocytic infiltration" in many of his "inadequate" biopsies. 6 However, Noyes, 7 in a review article published in 1959 on underdeveloped secretory endometrium, warned against not using all of the criteria for dating late luteal phase tissues, including lymphocytic-leukocytic infiltration. He went on to state that "underdeveloped Fertility and Sterility

4 Figure 4 (C), Day 25. Early subcapsular predecidua increasing lymphocytes and leukocytes ( x 250). Figure 4 (D), Day 26. Sheet decidualization lymphocytes and leukocytes markedly increased ( x 250). endometrium" as a cause of infertility was probably overemphasized. Jones 8 reemphasized the use of biopsy for diagnosis of luteal phase defects based on the original criteria of Noyes et al. 3 During the 1970's, reports 1 2 became increasingly frequent on the successful use of vaginal progesterone or clomiphene citrate in the treatment of luteal phase defects. The criteria for dating endometrial biopsies has not changed since the description by Noyes et al. 3 in 1950 of morphologic changes in normal tissues; and therefore it has not been clear whether all four criteria Noyes et al. enumerated for dating late secretory endometrium, namely, edema, predecidua reaction, stroma mitosis, and lymphocytic-leukocytic infiltration, are appropriate for dating potential luteal phase defect specimens. The results of this study indicate that the lymphocytic-leukocytic infiltration correlates with subsequent menses and not with the other criteria of dating. It is probable that the relative sparsity of lymphocytes-leukocytes observed in day-26 defect endometria as compared with ideal menstrual day-26 normal endometrium is a function of the edema present in most of the defect endometrial tissues. This is partially substantiated by the observation that day-26 defect biopsy specimens contain more lymphocytes and leukocytes than do ideal day-25 normals. The significant increase in the lymphocytic-leukocytic infiltration in luteal phase defect endometrium otherwise appearing consistent with histologic days 23, 24, and 25 indicates that the lymphocytic-leukocytic infiltrate is a function of the approaching menses and appears regardless of the status of the other histologic criteria in the endometrial specimen. Probably this infiltration by lymphocytes and leukocytes (especially the polymorphonuclear leukocytes) is a reflection of early necrobiosis prior to the onset of actual menstrual flow and therefore Vol. 37, No.6, June 1982 Daly et al. Lymphocytic-leukocytic infiltrates 789

5 Figure 4 (E), Day 23. Early predecidua around vessels. Markedly increased lymphocytes and leukocytes. Menstrual day 26 (X 250). would be expected to be present prior to the menstrual flow regardless of other histologic characteristics. The recent demonstration by Daly et al. 9 that prolactin production from luteal phase defect or normal secretory endometrium correlates with the degree of decidualization and not with the menstrual dates implies a physiologic correlation with endometrial decidual maturity. This correlation suggests that the endometrium itself may have a physiologic deficiency in patients with luteal phase defects. These data, taken together, support the concept that the most important criteria for dating endometrial biopsies is the degree of histologic decidualization. It is concluded from these observations that the degree of lymphocytic and leukocytic infiltration in both normal and luteal phase defect endometria is a reflection of impending menses and not otherwise correlated with endometrial maturity. Therefore, in assigning dates to endometrial biop- 790 Daly et al. Lymphocytic-leukocytic infiltrates Figure 4 (F), Day 24. Early predecidua around vessels. Marked lymphocytic-leukocytic infiltration. Menstrual day 26 ( x 250). sies performed to diagnose a potential luteal phase defect, the presence or absence of lymphocytes and leukocytes should not be considered in histologic dating. In the final interpretation of a specimen, a biopsy specimen that reads as day 24 or earlier histologically and contains significant lymphocytes and leukocytes in the absence of plasma cells may be presumed to reflect a luteal phase defect on histologic grounds pending confirmation by the patient's subsequent menses. REFERENCES 1. Andrews WC: Luteal phase defects. Fertil Steril 32:501, Rosenberg SM, Luciano AA, Riddick DH: The luteal phase defect: the relative frequency of, and encouraging response to, treatment with vaginal progesterone. Fertil Steril34:17, Noyes RW, Hertig AT, Rock J: Dating the endometrial biopsy. Fertil Steril 1:3, 1950 Fertility and Sterility

6 4. Lyon RA: Improved probability of conception following administration of estrin or progestin in women with ovarian deficiency. Fertil Steril 7:312, Glass SJ, Miller W, Rosenblum G: Secretory hypoplasia of the endometrium. Fertil Steril 6:344, Gillam JS: Study of the inadequate secretion phase endometrium. Fertil Steril 6:18, Noyes RW: The underdeveloped secretory endometrium. Am J Obstet Gynecol 77:929, Jones GS: The luteal phase defect. Fertil Steril 27:351, Daly DC, Maslar la, Rosenberg SM, Tohan N, Riddick DH: Prolactin production by luteal phase defect endometrium. Am J Obstet Gynecol140:587, 1981 Vol. 37, No. 6, June 1982 Daly et al. Lymphocytic-leukocytic infiltrates 791