Uterine receptivity: alterations associated with benign gynecological disease

The role of the endometrium is to establish and maintain pregnancy. Endometrial receptivity is established during the mid-secretory phase, between cycle day (CD) 20 to 24, or 6 to 10 days after ovulation. In some cases of infertility or recurrent pregnancy loss, implantation failure is due to a lack of expression of specific critical participating proteins such as cell adhesion molecules. Numerous cell adhesion molecules (including integrins, selectins, and cadherins) are expressed by the endometrium and appear to be necessary for the successful interaction of the embryo with the endometrium. One of the best-characterized cell adhesion molecules are the integrins. Integrins are transmembrane glycoproteins that belong to a large family comprising alpha and beta subunits, and are present on virtually all cells in the body. Women with various benign gynecologic disorders, including endometriosis, polycystic ovarian syndrome, hydrosalpinges, and luteal phase defect, appear to exhibit decreased uterine receptivity and abnormal expression of endometrial biomarkers. This review addresses proposed mechanisms of implantation and endocrine and paracrine signals responsible for the establishment of endometrial receptivity as well has the possible mechanisms of dysfunction in certain types of infertility in women with benign gynecologic disease.

Endometriosis markers: immunologic alterations as diagnostic indicators for endometriosis

Because endometriosis, a chronic disease affecting 7% to 10% of women, is associated with immunologic aberrations, the authors hypothesize that the presence of specific immune alterations may be diagnostic. Autoantibodies were assayed by Western immunoblotting using antigens derived from the plasma membrane, cytosol, and nucleus from endometrial and ovarian cells. Natural killer (NK) activity was defined by levels of signaling protein zeta and induction of interferon (IFN)-gamma following exposure to patients' sera. Patients with endometriosis exhibited autoantibodies reactive with cellular proteins; endometrial membrane proteins exhibited the greatest reactivity, followed by nuclear antigens. In all subcellular fractions, patients with stage 3 endometriosis exhibited significantly more immunoreactivity than did stage 2 patients, which was greater than that observed in stage 1 patients. The stage-associated increased reactivity resulted from both recognition of additional proteins and enhanced reactivity with shared proteins. Patient sera suppressed NK zeta expression, which resulted in suppression of NK IFN induction. Alterations in autoreactivity and NK activity are observed in endometriosis and may be useful as diagnostic markers, even in early stage disease.

Gene expression analysis of endometrium reveals progesterone resistance and candidate susceptibility genes in women with endometriosis

The identification of molecular differences in the endometrium of women with endometriosis is an important step toward understanding the pathogenesis of this condition and toward developing novel strategies for the treatment of associated infertility and pain. In this study, we conducted global gene expression analysis of endometrium from women with and without moderate/severe stage endometriosis and compared the gene expression signatures across various phases of the menstrual cycle. The transcriptome analysis revealed molecular dysregulation of the proliferative-to-secretory transition in endometrium of women with endometriosis. Paralleled gene expression analysis of endometrial specimens obtained during the early secretory phase demonstrated a signature of enhanced cellular survival and persistent expression of genes involved in DNA synthesis and cellular mitosis in the setting of endometriosis. Comparative gene expression analysis of progesterone-regulated genes in secretory phase endometrium confirmed the observation of attenuated progesterone response. Additionally, interesting candidate susceptibility genes were identified that may be associated with this disorder, including FOXO1A, MIG6, and CYP26A1. Collectively these findings provide a framework for further investigations on causality and mechanisms underlying attenuated progesterone response in endometrium of women with endometriosis.

Endometrial Expression of Cyr61

OBJECTIVE

To compare the expression of Cyr61 in normal cycling endometrium with endometrium from women with polycystic ovarian syndrome (PCOS) and endometrial hyperplasia and adenocarcinoma.

METHODS

This is a retrospective study of 59 samples of normal and abnormal endometrium. Endometrial biopsies were obtained from normal fertile controls throughout the menstrual cycle and compared with endometrium from ovulatory and anovulatory women with PCOS and complex endometrial hyperplasia and endometrioid adenocarcinoma. Cyr61 expression was evaluated by using immunohistochemistry and reverse transcription PCR for Cyr61, estrogen receptor (ER)-alpha, a marker of cell proliferation (Ki67), and another marker of early estrogen action, cFos. Regulation of Cyr61 protein was studied in a steroid-responsive endometrial carcinoma cell line, ECC1.

RESULTS

Cyr61 protein was regulated by estrogen. In normal endometrium, Cyr61 was highest in the proliferative phase and lowest in the normal midsecretory phase. In contrast, elevated levels of Cyr61, ER-alpha, Ki67, and cFos were all found in the midsecretory endometrium of ovulatory PCOS patients, endometrial cancer patients, and hyperplasia patients.

CONCLUSION

Cyr61 is overexpressed in PCOS endometrium, reflecting a heightened responsiveness to estrogen. As a unique marker of estrogen action, Cyr61 may be an early biomarker for the development of hyperplasia or adenocarcinoma in this group of women.

ECC-1 Cells: A Well-Differentiated Steroid-Responsive Endometrial Cell Line with Characteristics of Luminal Epithelium1

Endometrial cancer cell lines have provided a valuable model to study endometrial epithelial cells in vitro. Since the first development of HEC1B over 35 yr ago, many different cell lines have been isolated and described. One valuable cell line that maintains hormone responsiveness and unique stability over time is the ECC-1 cell line, developed originally by the late P.G. Satyaswaroop. In this study, we investigated some of the properties of these cells and present their salient characteristics. Like Ishikawa cells, ECC-1 cells maintain both estrogen receptors (ESR1 [ER alpha] and ESR2 [ER beta]), progesterone receptors (PR A and B; PGRs), and androgen receptors (ARs), along with the p160 steroid receptor coactivators NCOA1 (formerly SRC1), NCOA2 (formerly TIF2), and NCOA3 (formerly AIB1). The karyotype of these cells is abnormal, with multiple structural rearrangements in all cells analyzed. Unlike Ishikawa cells that express glandular epithelial antigens, ECC-1 cells maintain a luminal phenotype, with expression of KRT13 (cytokeratin 13) and KRT18 (cytokeratin 18). Apparent differences in the regulation of ESR2 also were evident in ECC-1 cells compared to Ishikawa cells. Like other endometrial cell lines, ECC-1 cells express the steroid receptor coactivators and exhibit epidermal growth factor-stimulated expression of known luminal proteins thought to be involved in implantation, including the hyaluronate receptor CD44 and SPP1 (formerly osteopontin) and CD55 (decay-accelerating factor). These characteristics appear to be stable and persistent over multiple cell passages, making this well-differentiated cell line an excellent choice to study endocrine and paracrine regulation of endometrial epithelium in vitro.

MUC1 is a scaffold for selectin ligands in the human uterus

MUC1 is a large, transmembrane mucin glycoprotein abundantly expressed at the apical surface of uterine epithelia in all species examined to date. Loss of MUC1 at the time of embryo implantation occurs in many species; however, this does not appear to be the case in humans. Recent studies indicate that human blastocysts express L-selectin at their external surfaces raising the possibility that selectin ligands expressed at the apical surface of the uterine epithelium support early stages of blastocyst attachment. In the current study, we have used a panel of antibodies specific for selectin ligands to determine if MUC1 functions as a scaffold for these carbohydrate motifs in fertile women. The results demonstrate that MUC1 carries selectin ligands throughout the secretory phase of the menstrual cycle, including the mid-secretory (receptive) phase. Consequently, MUC1 represents a potential ligand for selectins expressed by human blastocysts.

Extracellular matrix metalloproteinase inducer regulates metalloproteinases in human uterine endometrium

CONTEXT

Endometrial remodeling occurs during each menstrual cycle in women and also during the establishment of endometriosis. Both processes involve the production of metalloproteinases (MMPs) by uterine endometrial cells.

OBJECTIVE

The objective of this study was to determine whether tissue remodeling and endometrial invasion involve activation of MMPs by extracellular matrix metalloproteinase inducer (EMMPRIN).

MAIN OUTCOME MEASURES

EMMPRIN expression was examined by immunohistochemistry and real-time PCR in ectopic and eutopic endometria. For functional assays, human uterine fibroblasts were treated in the absence or presence of IL-1beta (10 ng/ml) or purified native EMMPRIN (0.5 or 1 microg/ml) for 24 h. Cellular RNA and conditioned medium were assayed by real-time PCR or immunoblotting.

RESULTS

EMMPRIN protein localized to epithelial and fibroblast cells of eutopic and ectopic endometria. The pattern of localization was regulated by ovarian hormones. EMMPRIN mRNA levels varied throughout the menstrual cycle in parallel with the cyclic changes in estradiol. EMMPRIN treatment (0.5 microg/ml) of human uterine fibroblast cells stimulated MMP-1 (5.23-fold) and MMP-2 (8.55-fold), but not MMP-3, mRNA levels over levels in control cells (P < 0.05). EMMPRIN treatment (1 microg/ml) stimulated endogenous EMMPRIN (1.6-fold) mRNA levels (P > 0.05). IL-1beta stimulated MMP-1 (5.6-fold), MMP-2 (2.8-fold), and MMP-3 (75-fold) gene expression, but not EMMPRIN, over levels in control cells (P < 0.05). Both EMMPRIN and IL-1beta treatments stimulated MMP-1, -2, and -3, but not EMMPRIN protein secretion, with 0.5 microg/ml producing the greatest response.

CONCLUSIONS

The ability of EMMPRIN to stimulate MMP secretion by endometrial fibroblasts indicates its potential role in uterine remodeling and the pathogenesis of endometriosis.

Molecular phenotyping of human endometrium distinguishes menstrual cycle phases and underlying biological processes in normo-ovulatory women

Histological evaluation of endometrium has been the gold standard for clinical diagnosis and management of women with endometrial disorders. However, several recent studies have questioned the accuracy and utility of such evaluation, mainly because of significant intra- and interobserver variations in histological interpretation. To examine the possibility that biochemical or molecular signatures of endometrium may prove to be more useful, we have investigated whole-genome molecular phenotyping (54,600 genes and expressed sequence tags) of this tissue sampled across the cycle in 28 normo-ovulatory women, using high-density oligonucleotide microarrays. Unsupervised principal component analysis of all samples revealed that samples self-cluster into four groups consistent with histological phenotypes of proliferative (PE), early-secretory (ESE), mid-secretory (MSE), and late-secretory (LSE) endometrium. Independent hierarchical clustering analysis revealed equivalent results, with two major dendrogram branches corresponding to PE/ESE and MSE/LSE and sub-branching into the four respective phases with heterogeneity among samples within each sub-branch. K-means clustering of genes revealed four major patterns of gene expression (high in PE, high in ESE, high in MSE, and high in LSE), and gene ontology analysis of these clusters demonstrated cycle-phase-specific biological processes and molecular functions. Six samples with ambiguous histology were identically assignable to a cycle phase by both principal component analysis and hierarchical clustering. Additionally, pairwise comparisons of relative gene expression across the cycle revealed genes/families that clearly distinguish the transitions of PE-->ESE, ESE-->MSE, and MSE-->LSE, including receptomes and signaling pathways. Select genes were validated by quantitative RT-PCR. Overall, the results demonstrate that endometrial samples obtained by two different sampling techniques (biopsy and curetting hysterectomy specimens) from subjects who are as normal as possible in a human study and including those with unknown histology, can be classified by their molecular signatures and correspond to known phases of the menstrual cycle with identical results using two independent analytical methods. Also, the results enable global identification of biological processes and molecular mechanisms that occur dynamically in the endometrium in the changing steroid hormone milieu across the menstrual cycle in normo-ovulatory women. The results underscore the potential of gene expression profiling for developing molecular diagnostics of endometrial normalcy and abnormalities and identifying molecular targets for therapeutic purposes in endometrial disorders.

Estrogen receptor-alpha (ER-alpha) and defects in uterine receptivity in women

Endometriosis is a disorder that affects 5% of the normal population but is present in up to 40% of women with pelvic pain and/or infertility. Recent evidence suggests that the endometrium of women with endometriosis exhibits progesterone insensitivity. One endometrial protein that fluctuates in response to progesterone is the estrogen receptor-alpha (ER alpha), being down-regulated at the time of peak progesterone secretion during the window of implantation. Here we demonstrate that the biomarker of uterine receptivity, beta 3 integrin subunit, is reduced or absent in some women with endometriosis and that such defects are accompanied by inappropriate over-expression of ER alpha during the mid-secretory phase. Using a well-differentiated endometrial cell line we showed that the beta 3 integrin protein is negatively regulated by estrogen and positively regulated by epidermal growth factor (EGF). By competing against estrogen with various selective estrogen receptor modulators (SERMs) and estrogen receptor agonists and antagonists, inhibition of expression of the beta 3 integrin by estrogen can be mitigated. In conclusion, we hypothesize that certain types of uterine receptivity defects may be caused by the loss of appropriate ER alpha down-regulation in the mid-secretory phase, leading to defects in uterine receptivity. Such changes might be effectively treated by timely administration of the appropriate anti-estrogens to artificially block ER alpha and restore normal patterns of gene expression. Such treatments will require further clinical studies.

Reduced expression of progesterone receptor-B in the endometrium of women with endometriosis and in cocultures of endometrial cells exposed to 2,3,7,8-tetrachlorodibenzo-p-dioxin

OBJECTIVE

To analyze endometrial progesterone receptor (PR) expression in women with endometriosis compared with disease-free women and to assess the impact of in vitro 2,3,7,8-tetrachlorodibenzo-p-dioxin (TCDD) exposure on PR isotype expression.

DESIGN

Controlled laboratory study.

SETTING

University medical center.

PATIENT(S)

Healthy volunteers and women with surgically diagnosed endometriosis.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Analysis of in vivo PR-A and PR-B expression in endometrium from women with and without endometriosis. The impact of in vitro TCDD exposure on PR-B/PR-A ratio and cell-specific matrix metalloproteinase (MMP) expression was also determined.

RESULT(S)

The PR-B/PR-A ratio was lower in endometrial tissues from women with endometriosis compared with normal tissues. A similar ratio was induced in normal stromal cells cocultured with epithelial cells and exposed to TCDD. Disruption of stromal PR expression following TCDD exposure was associated with a failure of P-mediated down-regulation of both stromal-specific pro-MMP-3 and epithelial-specific pro-MMP-7.

CONCLUSION(S)

Our data suggest that reduced progesterone (P) sensitivity in the endometrium of women with endometriosis may be related to an altered pattern of PR expression. The ability of TCDD to selectively down-regulate stromal PR-B expression and increase MMP expression in both stromal and epithelial cells suggests that exposure to this toxin may negatively impact P-mediated cell-cell communication in the human endometrium.

Assisted reproductive technology (ART) in the upstate: reducing the risks of multiple births

Multiple pregnancies from ART procedures are all too common. Efforts to reduce high-order multiple pregnancies will require both social and medical reforms. In lieu of a legislative agenda to reduce multiple pregnancies in the United States, efforts must come from the personnel within the individual ART clinics. The approach to the problem includes accepting a lower pregnancy rate than otherwise might be obtainable, if the observed rate of high-order multiple pregnancies is above a certain threshold. Expanding the opportunities for ART reimbursement will ultimately address this problem in the United States, but until then, it is a problem that will not go away without commitment and resolve.

Prevention of endometrial apoptosis: randomized prospective comparison of human chorionic gonadotropin versus progesterone treatment in the luteal phase

To study control of apoptosis in human endometrium, we examined late luteal-phase endometrial biopsies obtained in the late luteal phase for evidence of apoptosis and compared the effects of exogenous human chorionic gonadotropin (hCG) and progesterone on this process. Using a controlled, prospective, and randomized study design, 12 healthy, fertile, reproductive-age women (ages 20-34 yr) with regular menstrual cycles (range, 26-32 d) were recruited. Each underwent an endometrial biopsy 12 d after a urinary LH surge in a control and treatment cycle. After biopsy in a natural cycle, subjects were randomized to receive luteal doses of either 200 mg intravaginal progesterone (d 18-27) or a single im injection of 10,000 IU of hCG (d 19) followed by repeat endometrial biopsy and collection of serum on d 26. Apoptosis was assessed by DNA laddering, localizing apoptotic bodies using immunofluorescent labeling of DNA fragments (the terminal deoxynucleotidyl transferase-mediated dUTP nick-end labeling method), and immunohistochemical assessment of apoptosis markers bcl-2, bcl-x, and bax. Serum progesterone levels were compared between treatment groups. Evidence of apoptosis in control cycles was significantly reduced in endometrium after both luteal-phase treatments. The terminal deoxynucleotidyl transferase-mediated dUTP nick-end-labeling results demonstrated significantly less apoptosis in the hCG treatment group compared with controls. Immunostaining for bcl-2 was higher in hCG- and progesterone-treated cycles, whereas bax expression was decreased and bcl-x immunostaining was not different between treatments. Serum progesterone levels were highest in the hCG-treated group, although statistical significance was not reached (P = 0.08). These results demonstrate that signs of apoptosis, already apparent by d 26 of the menstrual cycle can be reduced with either hCG or progesterone treatment. The clinical utility of these findings includes a rational use of luteal-phase support for treatment of women with infertility and/or recurrent pregnancy loss.

A critical analysis of the accuracy, reproducibility, and clinical utility of histologic endometrial dating in fertile women

OBJECTIVE

To refine or redefine the traditional histologic criteria used to date the secretory phase endometrium.

DESIGN

Randomized, observational study.

SETTING

Academic clinical research center.

PATIENT(S)

One hundred and thirty healthy, regularly cycling, fertile volunteers, aged 18 to 35 years.

INTERVENTION(S)

Patients were randomized to undergo endometrial sampling and measurement of serum estradiol and progesterone 1 to 14 days after the midcycle urinary luteinizing hormone surge. Three gynecologic histopathologists objectively scored each tissue specimen for 32 distinct histologic features and dated the endometrium using traditional histologic criteria.

MAIN OUTCOME MEASURE(S)

The 32 features were evaluated for [1] temporally dependent variation, [2] the amplitude of variations in score observed across the secretory phase, and [3] interobserver variability. Additionally, traditional dating criteria were analyzed.

RESULT(S)

The traditional endometrial histologic dating criteria are much less temporally distinct and discriminating than originally described, due to considerable intersubject, intrasubject, and interobserver variability. Neither traditional dating criteria nor any combination of the best performing histologic features identified by our objective and systematic analyses could reliably distinguish any specific cycle day or narrow interval of days.

CONCLUSION(S)

Histologic endometrial dating does not have the accuracy or the precision necessary to provide a valid method for the diagnosis of luteal phase deficiency or to otherwise guide the clinical management of women with reproductive failure.

Cycle-dependent endometrial expression and hormonal regulation of thefibulin-1gene

Fibulin-1 is a secreted protein associated with elastic matrix fibres and basement membranes. It plays a role in stabilizing blood vessels and can also regulate cell motility and invasiveness. We studied the regulation of the fibulin-1 gene in the rat and human endometrium, an organ where cyclic tissue remodeling and angiogenesis take place. The rat fibulin-1C and -1D-specific DNA sequences were first identified and a comparison of the deduced amino acid sequence with the mouse and human counterparts showed a very strong conservation. The exon-intron structure was also maintained. Primers were derived for RT-PCR analysis of fibulin-1 expression in rat endometrium. The highest levels of fibulin-1C and -1D transcripts were measured at metestrous and diestrous, and in early pregnancy at day 3 post-coitum. In vivo studies showed stimulation of endometrial fibulin-1D expression after estrogen application, an effect prevented by parallel treatment with progesterone. Analysis of human endometrial tissues indicated that the fibulin-1D transcript levels were higher during the mid-secretory phase than during the proliferative and early secretory phases. Cultured human endometrial stromal cells treated with progesterone responded with a dramatic increase of fibulin-1 protein expression. This was enhanced by parallel treatment with epidermal growth factor and prevented by application of the antiprogestin RU486. Altogether the results show a cycle-dependent regulation of endometrial fibulin-1 expression controlled by both progesterone and estrogen. Based on its implication in tissue remodeling and angiogenesis, fibulin-1 may play an important role in endometrial receptivity for embryo implantation.

Soy protein isolate with isoflavones does not prevent estradiol-induced endometrial hyperplasia in postmenopausal women: a pilot trial

OBJECTIVE

To test the hypothesis that soy protein isolate (SPI) with isoflavones opposes the proliferative effects of exogenous estradiol (E2) on the endometrium after menopause.

DESIGN

Thirty-nine postmenopausal women were randomized to receive daily for 6 months either 0.5 mg E2 + placebo, 1.0 mg E2 + placebo, 0.5 mg E2 + 25 g SPI with 120 mg isoflavones, or 1.0 mg E2 + 25 g SPI with 120 mg isoflavones. Primary outcome measures were endometrial histology, ultrasound endometrial thickness, and Ki67 staining quantification, a marker of cellular proliferation. Secondary outcome measures were serum lipids and markers of bone resorption.

RESULTS

Endometrial hyperplasia, endometrial stromal and epithelial cellular proliferation, and sonographically measured endometrial thickness were similarly affected in all groups. SPI did not lessen the beneficial effects of E2 on lipids and markers of bone resorption.

CONCLUSION

In this pilot study, SPI with isoflavones did not protect the endometrium from E2-induced hyperplasia in postmenopausal women. If higher, long-term doses of isoflavone supplementation are found to be safe for postmenopausal women, then future studies combining E2 with isoflavones may be feasible as an alternative to traditional hormone replacement therapy.

Salpingectomy or proximal tubal occlusion of unilateral hydrosalpinx increases the potential for spontaneous pregnancy

BACKGROUND

Studies carried out over the past 10 years have suggested that hydrosalpinges reduce the pregnancy rate in IVF. Here we report our observations of spontaneous pregnancies in patients who underwent salpingectomy (n = 18) or proximal tubal occlusion (n = 7) following diagnoses of unilateral hydrosalpinges and patent contralateral tubes.

METHODS

This multi-centre, retrospective study included 25 infertility patients with known unilateral hydrosalpinges with a patent contralateral Fallopian tube. Laparoscopic treatment of unilateral hydrosalpinges by either salpingectomy or tubal occlusion was performed in each patient. Rates of subsequently observed spontaneous pregnancy, and time to pregnancy, are reported.

RESULTS

The average duration of infertility in these patients was 3 years with a range of 1-10 years. Following laparoscopic surgical treatment, a total of 22 patients (88%) achieved intrauterine pregnancies, all without IVF treatment. Pregnancies occurred in an average of 5.6 months with a range of 1-21 months. There were no ectopic pregnancies in the study population.

CONCLUSIONS

Selected patients with unilateral hydrosalpinges and a patent contralateral Fallopian tube may exhibit increased cycle fecundity after salpingectomy or proximal tubal occlusion of the affected tube and conceive without the need for IVF.

Two pathways of progesterone action in the human endometrium: implications for implantation and contraception

The endometrium is the site of implantation and pregnancy. Preparation for this important biological event relies primarily on progesterone, which takes the estrogen-primed endometrium toward a state of receptivity. As a steroid target tissue, the endometrium is also prone to abnormal growth sometimes leading to the development of hyperplasia or cancer. It is the balance between estrogen and progesterone that maintains the endometrium in a state of health and provides the synchronous timing necessary for a successful implantation to occur. In our efforts to understand the role of progesterone in the endometrium we have focused on the use of specific protein biomarkers. Based on examination of a cell adhesion molecule, the alphavbeta3 integrin, and its ligand, osteopontin, we have come to conclude that progesterone action can be direct or indirect. Progesterone acting on the stromal compartment provides paracrine mediators that influence epithelial gene expression. Conversely, acting directly, progesterone may primarily stimulate gene expression of the endometrial epithelium. The complexity of the system is extended since progesterone itself works through two different receptor isoforms. Regulated differential expression of PR-A versus PR-B also appears to fine tune the effect of progesterone on specific genes. Progesterone may also inhibit specific genes that undergo cyclic variation during the menstrual cycle. Together, using in vitro models we have shown that progesterone dynamically regulates gene expression in the endometrium and that imbalances between estrogen and progesterone may have far reaching consequences on normal cycle fecundity and on the balance between health and disease in this hormone-target tissue.

Identification, characterization, and regulation of the canonical Wnt signaling pathway in human endometrium

Members of the Wnt family of signaling molecules are important in cell specification and epithelial-mesenchymal interactions, and targeted gene deletion of Wnt-7a in mice results in complete absence of uterine glands and infertility. To assess potential roles of the Wnt family in human endometrium, an endocrine-responsive tissue, we investigated in the proliferative and secretory phases of the menstrual cycle, endometrial expression of several Wnt ligands (Wnt-2, Wnt-3, Wnt-4, Wnt-5a, Wnt-7a, and Wnt-8b), receptors [Frizzled (Fz)-6 and low-density lipoprotein receptor-related protein (LRP)-6], inhibitors [FrpHE and Dickkopf (Dkk)-1], and downstream effectors (Dishevelled-1, glycogen synthase kinase-3beta, and beta-catenin) by RT-PCR, real-time PCR and in situ hybridization. No significant menstrual cycle dependence of the Wnt ligands (except Wnt-3), receptors, or downstream effectors, was observed. Wnt-3 increased 4.7-fold in proliferative compared with secretory endometrium (P < 0.05). However, both inhibitors showed dramatic changes during the cycle, with 22.2-fold down-regulation (P < 0.05) of FrpHE and 234.3-fold up-regulation (P < 0.001) of Dkk-1 in the secretory, compared with the proliferative phase. In situ hybridization revealed cell-specific expression of different Wnt family genes in human endometrium. Wnt-7a was exclusively expressed in the luminal epithelium, and Fz-6 and beta-catenin were expressed in both epithelium and stroma, without any apparent change during the cycle. Both FrpHE and Dkk-1 expression were restricted to the stroma, during the proliferative and secretory phase, respectively. These unique expression patterns of Wnt family genes in different cell types of endometrium and the differential regulation of the inhibitors during the proliferative and secretory phase of the menstrual cycle strongly suggest functions for a Wnt signaling dialog between epithelial and stromal components in human endometrium. Also, they underscore the likely importance of this family during endometrial development, differentiation and implantation.

Expression profiling of endometrium from women with endometriosis reveals candidate genes for disease-based implantation failure and infertility

Endometriosis is clinically associated with pelvic pain and infertility, with implantation failure strongly suggested as an underlying cause for the observed infertility. Eutopic endometrium of women with endometriosis provides a unique experimental paradigm for investigation into molecular mechanisms of reproductive dysfunction and an opportunity to identify specific markers for this disease. We applied paralleled gene expression profiling using high-density oligonucleotide microarrays to investigate differentially regulated genes in endometrium from women with vs. without endometriosis. Fifteen endometrial biopsy samples (obtained during the window of implantation from eight subjects with and seven subjects without endometriosis) were processed for expression profiling on Affymetrix Hu95A microarrays. Data analysis was conducted with GeneChip Analysis Suite, version 4.01, and GeneSpring version 4.0.4. Nonparametric testing was applied, using a P value of 0.05, to assess statistical significance. Of the 12,686 genes analyzed, 91 genes were significantly increased more than 2-fold in their expression, and 115 genes were decreased more than 2-fold. Unsupervised clustering demonstrated down-regulation of several known cell adhesion molecules, endometrial epithelial secreted proteins, and proteins not previously known to be involved in the pathogenesis of endometriosis, as well as up-regulated genes. Selected dysregulated genes were randomly chosen and validated with RT-PCR and/or Northern/dot-blot analyses, and confirmed up-regulation of collagen alpha2 type I, 2.6-fold; bile salt export pump, 2.0-fold; and down-regulation of N-acetylglucosamine-6-O-sulfotransferase (important in synthesis of L-selectin ligands), 1.7-fold; glycodelin, 51.5-fold; integrin alpha2, 1.8-fold; and B61 (Ephrin A1), 4.5-fold. Two-way overlapping layer analysis used to compare endometrial genes in the window of implantation from women with and without endometriosis further identified three unique groups of target genes, which differ with respect to the implantation window and the presence of disease. Group 1 target genes are up-regulated during the normal window of implantation but significantly decreased in women with endometriosis: IL-15, proline-rich protein, B61, Dickkopf-1, glycodelin, N-acetylglucosamine-6-O-sulfotransferase, G0S2 protein, and purine nucleoside phosphorylase. Group 2 genes are normally down-regulated during the window of implantation but are significantly increased with endometriosis: semaphorin E, neuronal olfactomedin-related endoplasmic reticulum localized protein mRNA and Sam68-like phosphotyrosine protein alpha. Group 3 consists of a single gene, neuronal pentraxin II, normally down-regulated during the window of implantation and further decreased in endometrium from women with endometriosis. The data support dysregulation of select genes leading to an inhospitable environment for implantation, including genes involved in embryonic attachment, embryo toxicity, immune dysfunction, and apoptotic responses, as well as genes likely contributing to the pathogenesis of endometriosis, including aromatase, progesterone receptor, angiogenic factors, and others. Identification and validation of selected genes and their functions will contribute to uncovering previously unknown mechanism(s) underlying implantation failure in women with endometriosis and infertility, mechanisms underlying the pathogenesis of endometriosis and providing potential new targets for diagnostic screening and intervention.

Regulated expression of osteopontin in the peri-implantation rabbit uterus

Blastocyst attachment to the lining of the mammalian uterus during early implantation involves the initial apposition of the trophoblast to the uterine epithelial surface. Osteopontin (OPN) is a glycoprotein component of the extracellular matrix that is secreted by the glandular epithelium of mammalian uteri at the time of implantation. This protein is recognized by several members of the integrin family and promotes cell-cell attachment and adhesion. In the present study, rabbit uteri were examined using Northern and in situ hybridization to evaluate the temporal and spatial distribution of OPN mRNA during early pregnancy. Northern blot analysis demonstrated a dramatic increase in OPN expression on Days 4-7 of pregnancy, corresponding to the rise in circulating progesterone and the time of initial embryo attachment in this species. In situ hybridization analysis revealed OPN mRNA expression on Day 6.75 of pregnancy, which was most prominent on endometrial epithelium. Using immunofluorescence, OPN protein was present on the glandular epithelium on Day 6.75 of pregnancy, but was absent on blastocysts. Further, no expression of OPN mRNA or protein was found in the nonpregnant endometrium. Induction of endometrial OPN expression was observed in unmated rabbits treated with progesterone alone and was prevented by cotreatment with the antiprogestin ZK137.316. Estradiol-17beta had no effect on OPN expression by itself, and estrogen priming was not necessary to demonstrate the stimulatory effect of progesterone. In The rabbit uterus, as in other mammalian species studied, OPN is expressed in a stage-specific manner by the endometrial glands during the peri-implantation period and is regulated by progesterone.

Temporal and morphologic characteristics of pinopod expression across the secretory phase of the endometrial cycle in normally cycling women with proven fertility

OBJECTIVE

To assess the temporal and morphologic characteristics of pinopod expression on the surface of endometrium across the secretory phase, in LH-timed endometrial samples in normal, healthy women.

DESIGN

Prospective, randomized study.

SETTING

Academic teaching hospital.

PATIENT(S)

Sixty-eight healthy volunteers with proven fertility.

INTERVENTION(S)

Urinary LH-timed endometrial and blood sampling was performed on each subject on a randomly selected day of the secretory phase.

MAIN OUTCOME MEASURE(S)

Histologic dating, assessment of pinopods using scanning electron microscopy, and comparison with serum P levels.

RESULT(S)

Eighty-six endometrial tissue samples obtained from 68 subjects were evaluated under scanning electron microscopy. Pinopods were first observed on luteal day 5, corresponding with the onset of the midluteal phase increase in serum P levels. Pinopods persisted for the entire duration of the secretory phase, but their morphology changed as the cycle advanced.

CONCLUSION(S)

The present findings demonstrate that pinopods are a characteristic feature of the mid to late secretory phase endometrial epithelium, exhibit cycle-dependent changes in morphology, and are most prominent during the putative implantation interval.

A role for alphavbeta3 integrin during implantation in the rabbit model

The study of implantation has been facilitated by the identification of specific biomarkers that are associated with uterine receptivity. The alpha(v)beta(3) integrin is a cell surface adhesion receptor, whose expression has been shown to be elevated in the endometrium at the time of implantation in both humans and other mammalian species; however, the distribution of alpha(v)beta(3) in the rabbit model is unknown. The rabbit has been shown to be an excellent model for the study of implantation. As an obligate ovulator, the timing of pregnancy can be precisely established, and embryonic attachment occurs through specialized trophoblast-endometrial structures known as trophoblastic knobs. In the present study, the expression of alpha(v)beta(3) integrin subunit in the rabbit uterus was examined by reverse transcription-polymerase chain reaction (RT-PCR), immunohistochemistry, and in situ hybridization. Expression of the alpha(v)beta(3) integrin was examined in Day 6.5 embryos, flushed from pregnant does. Immunofluorescence demonstrated strong immunostaining on the rabbit blastocyst (Day 6.5). RT-PCR analyses showed higher levels of mRNA for beta(3) subunit at the implantation site, with reduced expression in nonimplantation sites and in nonpregnant adult and immature endometrium. Immunohistochemistry demonstrated little, if any, beta(3) immunoreactivity on the endometrial epithelium. In contrast, in situ hybridization showed expression of the beta(3) integrin subunit mRNA in the uterine myometrium and on the trophoblast. To further determine the functional significance of alpha(v)beta(3) integrin expression during implantation, pregnant female rabbits that underwent ventral laparotomy on the morning of Day 6 received intrauterine injection of the following into the right uterine horn: 1) the monoclonal alpha(v)beta(3) neutralizing antibody (LM609), 2) arg-gly-asp (RGD) hexapeptides (GRGDSP), 3) non-RGD hexapeptides (GRGESP), and 4) IgG isotype matched control antibody. The left horn served as a control and received only saline injections. A significant reduction in the number of implantation sites was observed in the horns receiving anti-alpha(v)beta(3) antibody (P < 0.001) and the RGD peptides (P = 0.03). In the rabbit, the alpha(v)beta(3) integrin is present on the embryo and trophoblast and appears to be involved in early embryo-maternal interaction.

Alterations in expression of endometrial endothelial nitric oxide synthase and alpha(v)beta(3) integrin in women with endometriosis

OBJECTIVE

To determine the expression of endometrial endothelial nitric oxide synthase (eNOS) protein and alpha(v)beta(3) integrin in patients with and without endometriosis.

DESIGN

Case-control cohort study.

SETTING

University-based tertiary care center.

PATIENT(S)

Endometrial biopsy samples were obtained from 9 fertile women with regular cycles and 30 infertile women with varying severity of endometriosis. Peritoneal fluid levels of nitric oxide were determined in 13 infertile women with a normal pelvis and 12 infertile women with endometriosis.

MAIN OUTCOME MEASURE(S)

Expression of eNOS and alpha(v)beta(3) integrin protein in the endometrium and peritoneal fluid levels of nitric oxide.

RESULTS

In patients with endometriosis, expression of eNOS was significantly increased in the glandular and luminal epithelium, with no significant changes in the stroma. Peritoneal fluid levels of nitric oxide were unchanged, and expression of alpha(v)beta(3) integrin expression in glandular and luminal epithelium was significantly decreased compared with controls. A significant negative correlation was observed between luminal expression of eNOS and alpha(v)beta(3) integrin and between glandular expression of eNOS and luminal expression of alpha(v)beta(3) integrin.

CONCLUSION(S)

The nitric oxide pathway may play a role in the pathogenesis of endometriosis.