A reappraisal of the endometrium in infertility

It will be obvious to the reader that the author has gone to considerable lengths to exculpate the endometrium from playing a significant role in the aetiology and pathogenesis of infertility. No apology is necessary for this approach as it is known to obstetricians and gynaecologists engaged in the management and treatment of the infertile couple that most causes of infertility have little to do directly with endometrial abnormalities. This does not mean, however, that an endometrial biopsy or curettage specimen has no place in the investigation of the infertile woman. It can be used as an adjunct to the monitoring of the efficacy of treatment for ovulatory failure and in the confirmation and typing of endometrial hyperplasia in the woman with persistent anovulatory cycles. It is virtually indispensable for the diagnosis of genital tuberculosis and as a means of culturing the mycobacterium for antibiotic sensitivity testing so that appropriate therapy can be given. While there are better methods now available, such as laparoscopy, for the diagnosis of pelvic inflammatory disease, the finding of unsuspected endometritis in the infertile woman can be used as an indicator of low-grade chronic genital tract infection that may not be otherwise apparent. There would seem to be no need for routine investigation of the endometrium in women afflicted with endometriosis or tubal disorders. The most controversial use of endometrial biopsy as an investigational technique is in the diagnosis of luteal deficiency and related disorders. If it is to be used in this circumstance, then it is essential that there should be the closest possible consultation between the clinician and the pathologist. It is too early yet to declare the endometrium always blameless in reproductive failure but there is little hope that purely morphological studies, even at the ultrastructural level, will supply answers to the unresolved questions. The investigation of the complex biochemistry and biology of the endometrium is still very much in the developmental stage. Pathologists interested in reproductive biology must be prepared to adapt and to devise new techniques based on biochemical discoveries to supplement their traditional morphological assessment of this important and fascinating tissue.