HOW TO TREAT THE SUB-FERTILE MARE Endometrial biopsies can be performed when the


mare is in estrus or diestrus. If the mare is in diestrus, the author prefers to perform the proce- dure 6 days post ovulation so that prostaglandin can be administered to bring the mare back into estrus and open the cervix allowing any hemorrhage or contamination that occurred during the process to be evacuated. For the biopsy, the rectum is evacu- ated and the perineal area cleaned. The biopsy instrumentb is hand guided through the vagina and cervix into the uterus. The instrument is then identified per rectum and advanced to allow sam- pling at the base of a horn. If pathology has been noted on ultrasound, sampling of that area or horn on the ventral aspect of the uterus may be more representative. The sample is then removed from the biopsy basket with a 25-gauge needle so as not to destroy the sample architecture, and the biopsy is placed in 10% formalin or Bouin’s solution for fixa- tion. The sample is then sectioned for histopatho- logical examination. If the biopsy is to be used for culture and cytology then placing a sterile speculum in the vagina through which to pass the biopsy in- strument allows less contamination on insertion and removal.4 The author has also placed a sterile sleeve over the biopsy instrument for passage through the vagina and into the cervix, at which point the biopsy instrument is pushed through the finger of the sleeve and inserted into the uterus. There may be some contamination on removal of the biopsy instrument; however, this has been found to be minimal. The sample is then smeared on Mac- Conkey and blood agar for bacteriology and a slide is prepared for cytology.


3. Results


Cytological evaluation of any uterine sample should not only include the presence, type, and quantity of inflammatory cells, but also identify endometrial cells, red blood cells, bacteria, amount of mucus, debris, fungal elements or yeast, and anything else that is seen that would provide pertinent informa- tion i.e., urine crystals, squamous epithelial cells, sperm, and powder crystals.16 The presence of en- dometrial cells suggests that the sample is represen- tative of the uterine environment, whereas the presence of stratified squamous epithelial cells sug- gests vaginal contamination or possible pneumome- tra. Identification of the other parameters allows the clinician to devise an appropriate treatment plan. Slides should be reviewed first on 10 to scan for cellular material, then at 40 to quantitate cells, and oil immersion (100) to quantitate and identify bacteria.16 Ten fields should be examined and the average of the ten fields used to determine quantity. At Hagyard Laboratory, the inflamma- tory cells and bacteria are quantitated as follows:


● Rare: 0–1 per 5 fields ● 1, Occasional, scant: 1–3 per field ● 2, Moderate: 6–10 per field


166 2016  Vol. 62  AAEP PROCEEDINGS


● 3, Heavy: 10–15 per field ● 4, Gross: too numerous to count


Culture results should contain the name of the organism, the growth quantity, and an antibiotic susceptibility report. It should also be noted on the report if normal skin flora was present. At Hagyard Laboratory the growth is quantitated as follows:


● Scant: 10 colonies or less ● Light: growth on primary streak only ● Moderate: growth on secondary streak ● Heavy: growth on last streak


Endometrial biopsy provides histological identifica- tion of what type of inflammatory cells are present (i.e., neutrophils, lymphocytes, eosinophils), the se- verity, distribution (focal, diffuse) and the area within the endometrium in which they reside (i.e., luminal epithelium, interstitium, perivascular, periglandular). There is a seasonal and a hor- monal influence on the endometrium with obvious differences between anestrus, estrus, and diestrus. Glandular density, epithelial height, and mitotic ac- tivity should be recognized along with glandular distension and nesting. The severity of fibrosis around individual glands and around nesting should be quantified. The quantity of blood vessels, and more importantly, the amount of elastosis or degen- erative changes should be noted. To do this, a large and deep enough piece of endometrium is necessary to include the deeper vascular structures. Finally, the extent of lymphatic dilation or lacunae should be identified and reported. A biopsy report from a pa- thologist will take into account the presence and severity of the first three factors identified above to provide the Kenny-Doig grade, giving a predictive value or percentage for that mare to carry a foal to term. In addition, a histopathological description of other changes within the endometrium will be provided, commenting on all the anatomy described above. Further examination of the biopsy slide by a theriogenologist can provide a clinical interpretation of the changes and conditions present, with subse- quent potential therapeutic recommendations.


4. Discussion


By identifying the underlying pathologies within the uterus, specific management and treatment of the individual sub-fertile mare is possible. On cytolog- ical examination, the inflammatory components most commonly identified are white blood cells (neu- trophils). The presence of more than two white blood cells per high powered field (HPF) suggests that there is an inflammatory response.16 Degen- erative versus nondegenerative neutrophils suggest chronic versus acute inflammation. Care must be taken in differentiating the dark staining nucleus nuclei of degenerative cells from yeast.16 Identifi- cation of eosinophils is suggestive of pneumovagina/


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