LUTEAL-PHASE INADEQUACY - DIAGNOSIS, MANAGEMENT, AND COST CONCERNS

Since its introduction into the Literature over 40 years ago by Dr. Jo nes,(1) luteal phase inadequacy (LPI) has been controversial for both diagnosis and treatment. The intent of this review is to examine the b asic pathophysiology, diagnosis, and treatment of LPI, and also to def ine those groups of women who are most likely to benefit from its diag nosis and treatment from a cost-benefit perspective. In presenting the information in this fashion, it is hoped that the clinician will be a ssisted in determining which patients may benefit from the diagnosis a nd treatment of LPI. LPI, according to its initial definition, is char acterized by an inadequate endometrial response to hormonal stimulatio n during the luteal phase, as determined from the histological interpr etation of a biopsy specimen. When the specimen does not reflect an ap propriate response, it is termed ''out of phase.'' This endometrial in adequacy has classically been thought to result from insufficient prog esterone secretion or reception during the luteal phase.(2) Recent res earch, however, suggests that other mediators, such as epidermal growt h factor (EGF),(3) insulinlike growth factors (IGF)(4) and their bindi ng protein (IGFBPs),(5) and other endometrial peptides,(6) may play in tegral roles in the growth and differentiation of luteal endometrium. The role of these substances on endometrial development as it pertains to infertility and recurrent pregnancy loss (RPL) will be discussed i n greater detail herein. While correlations between endometrial histol ogy and hormonal treatment are important issues in LPI, perhaps a broa der view of this problem should consider the cost-effectiveness of the diagnosis and treatment of this disorder. Provocative questions must be asked to maximize our health care resources. For example, what is t he likelihood of a particular patient displaying LPI? Are certain grou ps more likely to demonstrate this disorder? What are the costs of the diagnosis and treatment? Does the treatment significantly alter repro ductive outcome? These questions and others must be evaluated in order to deliver high quality, cost-effective health care to reproductive-a ged women.