Histopathological Study of Endometrium in Cases of Infertility

Infertility is worldwide problem. Approximately one marriage is ten is barren, Sophia [1]. In India there are an estimated 10.2 million couples of infertility, dawn [2]. The purpose of investigating the infertile couple is to assess their chance of achieving a pregnancy and to identify the factors amenable to treatment. Inspite of many investigatory tools available endometrial histology is a sensitive indicator of ovarian function. Premenstrual endometrial biopsy plays an important diagnostic role in cases of infertility.

Endometrial biopsies of 50 cases of primary and secondary infertility were received in department of pathology, NIMS medical college, Jaipur, during the period of june 2013 to june 2014. Detailed clinical history regarding menstrual cycle, last menstrual period, age at marriage and obstetric history was obtained. Clinical examination was carried out in each case. Premenstrual endometrial biopsy specimens were obtained.

The material was processed and paraffin embedded sections of 5 microns were cut. Haematoxylin and eosin stained sections were studied to date the endometrium accurately based on the criteria describe by Dallenbach Hellweg [3].

Periodic acid Schiff staining was done in 50 cases & 25 normal controls to detect the amount of glycogen. PAS positivity was graded as nil, scanty, moderate and abundant arzac and blanchet [4]. The findings were analysed to find out the incidence of various changes in infertile endometrium.

Amongst 50 cases of infertility 37 cases (74%) were of primary infertility, 13 (26%) cases were of secondary infertility.

The maximum numbers of patient were in the age range of 21-30 years. The youngest patient was 18 years old and the oldest was 40 years. In primary infertility group 40% patient came in 2-3 years duration of infertility. In secondary infertility group 38.46% patients came in 6-7 years duration after last conception.

Menstrual problems were seen in 8 (21.62%) cases of primary infertility and 3 (23.08%) cases of secondary infertility. Irregular menses were seen in 14 (37.84%) cases of primary infertility & 5 (38.46%) cases of secondary infertility. 50 endometrial specimens were analysed for the incidence of changes in endometria (Table 1).

Table 1: Incidence of changes in endometria.

Anovulatory endometrium was seen in 11 (29.7%) cases of primary infertility and 3 (23.08%) cases of secondary infertility. 1 case of primary infertility showed endometrial tuberculosis. Zeihl neelsen staining for AFB was negative in all 1 case (Table 2).

Table 2: Histology and glycogen content in the endometrium of patient with infertility.

The glycogen content was graded as follow arzac & blanchet:

O – Negative reaction

+ - Very small granules

++ - Coarse granules

+++ - Small masses

Human endometrium is important site in nidation in young fertilized ovum, myaema [5]. Present studies evaluated the adequacy of endometrial development based on correlating menstrual history with glandular & stromal morphology.

Adequate follicular development & functionally efficient corpus luteum formation are the essential prerequisites for the preparation of good endometrial bed which is essential for successful implantation of blastocyst & continuation of pregnancy [6].

The diagnosis of luteal phase defect was made by using jone’s criteria [7]. According to him luteal phase defect is defined as lag more than two days in histological development of endometrium compared to the day of cycle.

Histopathological abnormalities in the form of anovulatory endometrium and luteal phase defect formed major cause of infertility in present series and observed by other authors (Table 3)

Table 3: Histopathological abnormalities in the form of anovulatory endometrium and luteal phase defect.

Anovulatory cycles are quite common in cases of infertility. In present study anovulatory endometrium was present in 28.2% cases. The secretory phase of endometrium in the premenstrual period is indicative of ovulation and thus it rules out anovulation as a cause of infertility. Luteal phase defect may be the cause of infertility in ovulatory cycles. In present study luteal phase defect was, seen in 20% cases. Wentz ac [15,16], Soules M [17], and Kumar A found luteal phase defect in 19%, 16% and 5% of infertility patients respectively.

Tuberculous endometritis and cystoglandular hyperplasia formed a minor cause of infertility in present studies. Rani PR [18] found that in patients of genital tuberculosis, the most common site of involvement is endometrium in 46.6% cases. Manjiri [19] and Kumar A [20], Nagpal M [21] found endometrial involvement in 86.66%, 50% and 60% respectively in patient of genital tuberculosis. Nandita B [22] and Tripathy [23] found the endometrial tuberculosis present with complaint of infertility in 79.04% and 58% respectively (Table 4).

Table 4: Incidence of tuberculous endometritis in present series observed by other a uthor.

The endometrial hyperplasia due to excess level of estrogen can also prevent pregnancy. In present study cystoglandular hyperplasia was seen in 1.8% of cases (Table 5).

Table 5: Glycogen deficiency as a cause of infertility observed by various authors.

Gupta et al. [9], sabharwal [12], Krishnamohan [13] and shastrabudhe [14] found hyperplasia in 5.9%, 2.66%, and 4.4% respectively.

In present study, PAS stain was done in 50 cases of infertility to assess the amount of glycogen content. For the proper implantation and subsequent growth and development of fertlized ovum in the uterus. It is necessary that adeqaute amount of carbohydrate in general and glycogen in particular should be present in the glandular secretions. In the endometrium the high glycogen content of these glands serve as a major source of energy for maintain an embryo.

Histopathological study of endometrium forms an important safe and cheaper diagnostic tool in cases of primary and secondary infertility.

In present study anovulatory endometrium and luteal phase defect formed etiological basis of many cases in infertility. In the present studies of glycogen deficiency seen mainly in the luteal phase defect indicating histopathological immaturity of endometrium.