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Luteal Phase Deficiency
Author: Dr. Anna Kaplan
If a woman’s uterus cannot support an embryo, this will prevent a successful pregnancy. In a condition referred to as a luteal phase deficiency (LPD), an egg is released and may be fertilized by sperm, but the tiny embryo does not implant into the lining of the uterus. This is because the ovarian follicle that released the egg does not turn into what is called a corpus luteum. The corpus luteum makes the progesterone which the lining of the uterus needs in order for an embryo to attach.
This condition is believed to cause less than 5% of infertility. It has been diagnosed more commonly in the past than it is today.
Technically speaking, this is not infertility in the same way as some other conditions because a woman with LPD may be able to get pregnant but may lose the pregnancy so early that it seems like she was never pregnant. LPD actually causes early pregnancy loss and not infertility.
LPD can be associated with other conditions such as polycystic ovary syndrome (PCOS). Female athletes also often have cycles with deficient luteal phases. This may be more common than complete lack of ovulation. It can occur in recreational athletes as well as those in competitive training. Since there is ovulation, a woman with LPD may have what appear to be normal menstrual cycles and will not know there is a problem until she tries to get pregnant.
It is not clear what causes LPD. The corpus luteum is normally stimulated by small frequent pulses of LH (luteinizing hormone), as well as other hormones and molecules. Research on athletes with LPD seems to indicate that they are in a state of lowered metabolism, like athletes who do not ovulate. This may be a way for the body to conserve energy. The hormonal changes seen in women with LPD are not as severe as those seen in athletes who do not ovulate. LPD also occurs in women who cut calories.
LPD is also common in women who are undergoing fertility treatment, including in vitro fertilization (IVF). This may be because of the treatment. Changes can be made in the medications given to women undergoing IVF to help support the development of the corpus luteum. This will make it more likely that an embryo will be able to implant.
In women with PCOS, low progesterone levels from LPD are associated with high levels of insulin and insulin resistance. Treatment with metformin can help correct the abnormalities and result in a normal luteal phase.
The gold standard in diagnosing LPD has been taking a sample, or biopsy, of endometrial tissue. This must be done at the right time, on approximately the 12 day of the second half of the menstrual cycle, 2 days before the next expected period.If this biopsy shows that the lining is not matured as much as needed, LPD is diagnosed.
A biopsy is uncomfortable, and there is evidence that the results are not as accurate as doctors used to think. An ultrasound examination may be helpful. So may a blood test that shows a high enough progesterone level. With LPD, even after ovulation there are low levels of progesterone during the second half of the menstrual cycle.
At this time, research is being done to try and find blood tests that can diagnose LPD, as well as indicate if the uterus is ready to support an embryo.
If LPD is suspected, a reduction in exercise and an increase in calories may be suggested. Patients with PCOS can be given metformin. Assuming there are no other medical problems, a patient with LPD can be treated with progesterone in various forms during the second half of the menstrual cycle. Progesterone can be given by injection or suppository. Clomiphene citrate can also be used to increase follicular development.
This is an area of active research. In the future, both the diagnosis and treatment of LPD may change.
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