Management of endometriosis-associated infertility

Lovastatin Reduces Stemness via Epigenetic Reprograming of BMP2 and GATA2 in Human Endometrium and Endometriosis

OBJECTIVE

The stem cell theory in the endometriosis provides an advanced avenue of targeting these cells as a novel therapy to eliminate endometriosis. In this regard, studies showed that lovastatin alters the cells from a stem-like state to more differentiated condition and reduces stemness. The aim of this study was to investigate whether lovastatin treatment could influence expression and methylation patterns of genes regulating differentiation of endometrial mesenchymal stem cells (eMSCs) such as BMP2, GATA2 and RUNX2 as well as eMSCs markers.

MATERIALS AND METHODS

In this experimental investigation, MSCs were isolated from endometrial and endometriotic tissues and treated with lovastatin and decitabin. To investigate the osteogenic and adipogenic differentiation of eMSCs treated with the different concentration of lovastatin and decitabin, BMP2, RUNX2 and GATA2 expressions were measured by real-time polymerase chain reaction (PCR). To determine involvement of DNA methylation in BMP2 and GATA2 gene regulations of eMSCs, we used quantitative Methylation Specific PCR (qMSP) for evaluation of the BMP2 promoter status and differentially methylated region of GATA2 exon 4.

RESULTS

In the present study, treatment with lovastatin increased expression of BMP2 and RUNX2 and induced BMP2 promoter demethylation. We also demonstrated that lovastatin treatment down-regulated GATA2 expression via inducing methylation. In addition, the results indicated that CD146 cell marker was decreased to 53% in response to lovastatin treatment compared to untreated group.

CONCLUSION

These findings indicated that lovastatin treatment could increase the differentiation of eMSCs toward osteogenic and adiogenic lineages, while it decreased expression of eMSCs markers and subsequently reduced the stemness.

Isolation and identification of epithelial and stromal stem cells from eutopic endometrium of women with endometriosis

OBJECTIVE

The recent characterization of possible stem/progenitor cells in the endometrium has shed new light on the origins of ectopic endometrial tissue and the mechanism for the pathogenesis of endometriosis, but has raised new questions. Is it possible that abnormal endometrial stem/progenitor cells increase their capacity to implant and establish themselves as ectopic tissue, or that normal stem cells implant in abnormal peritoneum? This study investigated key stem cell properties in cologenic epithelial and stromal cells obtained from eutopic endometrium of women with endometriosis.

STUDY DESIGN

Single cell suspensions of endometrial epithelial and stromal cells were cultured at densities of 20, 50, 100 and 200cells/cm(2). Cloning efficiency (CE) was determined, and stem cell phenotypic surface markers were detected using Western blotting and quantitative real-time polymerase chain reaction.

RESULTS

CE was significantly higher in cells cultured at a density of 50cells/cm(2) compared with the other groups. After 15 days of culture, small and large colonies were observed. Large-colony-derived epithelial and stromal cells had high proliferative potentials, producing millions of cells in vitro, with strong expression of epithelial and stromal stem cell phenotypic surface markers EMA, CK, CD49f, THY-1(CD90), collagen type I, 5B5 and vimentin.

CONCLUSION

Adult stem cells were found in eutopic endometrium of women with endometriosis, and this may play an important role in disease development.

Endometriosis impairs bone marrow-derived stem cell recruitment to the uterus whereas bazedoxifene treatment leads to endometriosis regression and improved uterine stem cell engraftment

Endometriosis is a disease defined by the ectopic growth of uterine endometrium. Stem cells contribute to the generation of endometriosis as well as to repair and regeneration of normal endometrium. Here we demonstrate that the selective estrogen receptor modulator bazedoxifene (BZA), administered with conjugated estrogens (CEs), leads to regression of endometriosis lesions as well as reduction in stem cell recruitment to the lesions. Female mice underwent transplantation of male bone marrow. Endometrium was transplanted in the peritoneal cavity of half to create experimental endometriosis. Mice with or without experimental endometriosis were randomized to BZA/CE or vehicle treatment. Endometriosis lesions, bone marrow-derived mesenchymal stem cell engraftment of the lesions, and eutopic endometrium as well as ovarian stimulation were assessed. BZA treatment significantly reduced lesion size, gland number, and expression of proliferation marker proliferating cell nuclear antigen. Ovarian weight was not affected. Stem cells were recruited to the endometriosis lesions, and this recruitment was dramatically reduced by BZA/CE treatment. Stem cell engraftment was reduced in the uterus of animals with endometriosis; however the number of stem cells engrafting the uterus was completely restored by treatment with BZA/CE. Competition between endometriosis and the eutopic endometrium for a limited supply of stem cells and depletion of normal stem cells flux to the uterus is a novel mechanism by which endometriosis interferes with endometrial function and fertility. BZA/CE not only treats lesions of endometriosis, it also dramatically reduces stem cell recruitment to the lesions and restores stem cell engraftment of the uterine endometrium.

Interleukin-1β induces cyclooxygenase-2 expression and promotes the invasive ability of human mesenchymal stem cells derived from ovarian endometrioma

OBJECTIVE

To elucidate the role of interleukin-1β (IL-1β) on cyclooxygenase-2 (COX-2) expression and invasion of endometrioma-derived ectopic endometrial mesenchymal stem cells (EN-MSCs) and to develop an organoid method to study the invasive ability of endometrial cells.

DESIGN

Gene expression and cell functions.

SETTING

Kaohsiung Medical University, Kaohsiung, Taiwan.

PATIENT(S)

Human eutopic and endometrioma-derived ectopic EN-MSCs were isolated from different endometrium biopsy samples after surgery for treatment of endometriosis.

INTERVENTION(S)

Chemical treatment of cell culture.

MAIN OUTCOME MEASURE(S)

Comparative analysis of genomewide messenger RNA (mRNA) expression, cell migration, and invasion abilities in cell culture and organoid culture.

RESULT(S)

Gene expression profiles revealed that the expression of IL-1β and COX-2 were statistically significantly higher in ectopic EN-MSCs compared with eutopic EN-MSCs. These enhanced expressions coincided with a greater ability for cell migration and invasion in ectopic EN-MSCs and were found to be distinctly regulated by IL-1β which up-regulates COX-2 expression. Furthermore, IL-1β treatment of ectopic EN-MSCs in organoids was found to induce tentacle-like structures that mimicked cell invasion.

CONCLUSION(S)

These results indicate that COX-2 and IL-1β regulate the invasion ability of ectopic EN-MSCs. The information may be useful for developing a new therapeutic strategy for endometriosis. The ex vivo invasion model will be useful for characterization of EN-MSCs.

Implantation Rate Remains Unaffected in Women with Endometriosis Compared to Tubal Factor Infertility

Purpose

To reconsider the implantation and delivery rates which occurred six years later in women with endometriosis from the Yale IVF Programme.

Methods

Five hundred and ninety-seven consecutive IVF and ICSI treatment cycles were analyzed retrospectively. Patients with endometriosis (n=130; 258 cycles) were compared with an age-matched control group with tubal infertility (n=104; 206 cycles) and also with a group with male infertility (n=59; 133 cycles). Data from the endometriosis group were analyzed further in minimal-mild (144 cycles) and moderate-severe (114 cycles) subgroups. All the patients underwent laparoscopy prior to IVF treatment.

Results

Fewer oocytes were retrieved and similar fertilization (59% vs. 61%), implantation (12.3% vs. 16%), and delivery (23.7% vs. 26.3%) rates were found in patients with endometriosis compared to tubal infertility. A trend towards reduced pregnancy rate per transfer (17.5%) in the male infertility vs. endometriosis or tubal infertility groups (34% and 37.8% respectively) was observed. The number of embryos transferred in each group was comparable. Analysis of first cycles only across all groups revealed that the implantation rate did not have any statistically significant differences in the endometriosis versus the tubal or male infertility groups. Within the endometriosis group, the implantation, pregnancy, and delivery rates were similar in subgroups.

Conclusions

We conclude that in patients with endometriosis, implantation, pregnancy, and delivery rates are similar with tubal factor infertility, and higher compared to male infertility. Our results suggest that embryo quality and uterine receptivity remain unaffected in women with endometriosis.

The immunoconjugate "icon" targets aberrantly expressed endothelial tissue factor causing regression of endometriosis

Endometriosis is a major cause of chronic pain, infertility, medical and surgical interventions, and health care expenditures. Tissue factor (TF), the primary initiator of coagulation and a modulator of angiogenesis, is not normally expressed by the endothelium; however, prior studies have demonstrated that both blood vessels in solid tumors and choroidal tissue in macular degeneration express endothelial TF. The present study describes the anomalous expression of TF by endothelial cells in endometriotic lesions. The immunoconjugate molecule (Icon), which binds with high affinity and specificity to this aberrant endothelial TF, has been shown to induce a cytolytic immune response that eradicates tumor and choroidal blood vessels. Using an athymic mouse model of endometriosis, we now report that Icon largely destroys endometriotic implants by vascular disruption without apparent toxicity, reduced fertility, or subsequent teratogenic effects. Unlike antiangiogenic treatments that can only target developing angiogenesis, Icon eliminates pre-existing pathological vessels. Thus, Icon could serve as a novel, nontoxic, fertility-preserving, and effective treatment for endometriosis.

[Bladder endometriosis and barrenness: diagnostic and treatment strategy]

Deep infiltrating endometriosis is a well-known female disease responsible for chronic pelvic pain, urinary dysfunction, infertility, and altered quality of life. Endometriosis and infertility are complex entities and the optimal choice of management of both of them remains obscure. Mechanism of development of the disease has to be understood to optimize patients care. The link between barrenness and endometriosis is well known, but there is no direct link between bladder lesion and infertility. Bladder endometriosis is a deeply infiltrating endometriosis lesion. Its management is first diagnostic and then remedial. In case of ineffectiveness of medical strategy, surgical treatment is indicated. However, for patient suffering from symptomatic isolated bladder endometriosis, surgical management can be offered in first intention. Isolated bladder injuries due to endometriosis are mostly treated by conservative laparoscopic surgery, after a complete evaluation of endometriosis disease and barrenness by clinical exam and imaging techniques.

Endometriosis and infertility: epidemiology and evidence-based treatments

Endometriosis is an estrogen-dependent disorder defined as the presence of endometrial tissue outside of the uterine cavity. A leading cause of infertility, endometriosis has a prevalence of 0.5-5% in fertile and 25-40% in infertile women. The optimal choice of management for endometriosis-associated infertility remains obscure. Removal or suppression of endometrial deposits by medical or surgical means constitutes the basis of endometriosis management. Current evidence indicates that suppressive medical treatment of endometriosis does not benefit fertility and should not be used for this indication alone. Surgery is probably efficacious for all stages of the disease. Controlled ovarian hyperstimulation with intrauterine insemination is recommended in early-stage and surgically corrected endometriosis when pelvic anatomy is normal. In advanced cases, in vitro fertilization is a treatment of choice, and its success may be augmented with prolonged gonadotropin-releasing hormone analog treatment. Further randomized clinical trials focusing on diverse etiopathogenic mechanisms and therapeutic innovation are necessary to find more conclusive, evidence-based answers regarding this enigmatic disease.

Stem cells and the pathogenesis of endometriosis

Endometriosis is a common gynecological disorder that is defined by the presence of endometrial tissue outside the uterine cavity. This disease often results in extensive morbidity, including chronic pelvic pain and infertility. The pathogenesis of endometriosis is likely multifactorial, and extensive investigation has explored the role of genetics, environmental factors, and the immune system in predisposing patients to developing endometriosis. A series of recent publications have described the identification of endometrial stem/progenitor cells. Such cells have long been speculated to function in the cyclic regeneration of the endometrium during the menstrual cycle and in the pathogenesis of several gynecological disorders. This narrative review will (i) examine the evidence for endometrial stem cells, (ii) examine their potential role in the pathogenesis of endometriosis, and (iii) identify important unanswered questions with suggestions for future investigation.

Cetrorelix in the treatment of female infertility and endometriosis

The use of cetrorelix within ovarian-stimulation protocols demonstrates several advantages compared with gonadotropin-releasing hormone (GnRH) agonist-containing protocols, which include, for example, significantly less time for analogue treatment and a reduction in the amount of gonadotropins needed. Furthermore, fewer side effects can be expected. There is no difference regarding endometrium quality and hormone profiles, and the results of assisted reproduction cycles are comparable. Cetrorelix also seems to be useful in the treatment of endometriosis which, in most cases, is an estrogen-dependent disease. Furthermore, fewer side effects occur with this agent (e.g., postmenopausal symptoms) and no estradiol add-back is needed. In the future, new nonpeptic GnRH antagonists are expected to be available for oral administration. Although they are still under investigation, these agents have the potential to improve patients' comfort and compliance.

Endometriosis

Endometriosis is an oestrogen-dependent disorder that can result in substantial morbidity, including pelvic pain, multiple operations, and infertility. New findings on the genetics, the possible roles of the environment and the immune system, and intrinsic abnormalities in the endometrium of affected women and secreted products of endometriotic lesions have given insight into the pathogenesis of this disorder and serve as the background for new treatments for disease-associated pain and infertility. Affected women are at higher risk than the general female population of developing ovarian cancer, and they also may be at increased risk of breast and other cancers as well as autoimmune and atopic disorders. Clinicians should assess and follow up affected women for these and other associated disorders. There will probably be a new repertoire of approaches for treatment and perhaps cure of this enigmatic disorder in the near future.

Aspiration of ovarian endometriomas before intracytoplasmic sperm injection

OBJECTIVE

To investigate whether aspiration of ovarian endometriomas before controlled ovarian stimulation (COH) improves intracytoplasmic sperm injection (ICSI) outcomes.

DESIGN

Prospective study.

SETTING

University hospital.

PATIENT(S)

A prospective analysis of 171 patients with ovarian endometriosis and tubal factor infertility were divided into four groups: aspiration of endometriomas at the beginning of COH in patients with ovarian endometriomas and no history of previous surgery (n = 41) (group 1); nonaspirated endometriomas (n = 40) (group 2); history of ovarian surgery for endometriomas in patients without ovarian endometriomas at the beginning of COH (n = 44) (group 3); and tubal factor infertility (n = 46) (control group 4).

INTERVENTION(S)

Aspiration of endometriomas.

MAIN OUTCOME MEASURE(S)

Clinical parameters, characteristics of COH, and ICSI results were analyzed.

RESULT(S)

We observed higher levels of E(2) on the day of hCG injection after aspiration of endometriomas compared with nonaspirated endometriomas. When we compared all endometriomas and tubal factor (control) groups, we observed a lower number of total follicles (>17 mm) and metaphase II (MII) oocytes in nonaspirated and resected endometrioma groups and a longer duration of COH in the nonaspirated endometrioma group compared with the tubal factor group. Implantation and clinical pregnancy rates were similar among all groups.

CONCLUSION(S)

In the current study, all patients with endometriomas had significantly lower numbers of MII oocytes compared with those in patients with tubal factor infertility. We propose that aspiration of endometriomas before COH neither reduces the amount of gonadotropins nor increases the number of follicles >17 mm, the number of MII oocytes retrieved, the implantation rates, or the clinical pregnancy rates. Resection of small endometriomas (1-6 cm) may not present any additional benefits to the IVF-ICSI cycle outcomes.

Results of in vitro fertilization in patients with endometriomas: is surgical removal beneficial?

OBJECTIVE

The purpose of this study was to investigate the effect of endometriomas on clinical pregnancy rates of in vitro fertilization-embryo transfer.

STUDY DESIGN

Infertile patients with endometriosis who underwent in vitro fertilization-embryo transfer were divided into group 1 patients who had a history of ovarian endometriomas and group 2 patients who did not. The patients in group 1 were further divided into group 1A who had their endometriomas removed by laparoscopic ovarian cystectomy before the start of in vitro fertilization-embryo transfer and group 1B who underwent in vitro fertilization-embryo transfer with the presence of endometriomas. The clinical pregnancy rates of these groups were compared.

RESULTS

Clinical pregnancy rates per transfer were similar in group 1 and group 2 (40% vs 47%; P =.38) and similar in patients in group 1A and group 1B (47% vs 34%; P =.28), although the direction was toward improved pregnancy rates in the groups of patients without endometriomas present at the time of in vitro fertilization stimulation. When patients >39 years of age were excluded, the overall pregnancy rate was higher in those patients who had no current endometriomas than in those patients who had endometriomas present at the time of stimulation (65% vs 39%; P =.05). For patients with unilateral endometriomas, similar numbers of mature oocytes were aspirated between the affected and unaffected ovaries.

CONCLUSION

Although the history of endometriomas does not appear to affect in vitro fertilization-embryo transfer outcomes adversely, there may be a benefit in the removal of endometriomas before in vitro fertilization.

Ovarian stimulation for in vitro fertilization in patients with endometriosis

The use of gonadotropin-releasing hormone (GnRH) agonists in a long protocol appears to enhance the probability of conception in the presence of endometriosis. In addition, there is evidence to suggest that the use of prolonged downregulation with GnRH agonists prior to ovarian stimulation for in vitro fertilization (IVF) is beneficial for achieving pregnancy. Until now, GnRH antagonists have not been used in patients with endometriosis. The management of endometriomas prior to stimulation for IVF and its impact on reproductive outcome are still subject to debate.