Endometrial responses to corpus luteum products in cycles with induced ovulation: theoretical and practical considerations

Should we still offer elective freezing of all embryos in all IVF cycles?

Elective 'freeze all', also called 'freeze only', refers to an IVF cycle where all embryos are frozen for later embryo transfer in a non-stimulated cycle, with the promise of increased success rates and prevention of ovarian hyperstimulation syndrome (OHSS) in most patients. However, 'freeze all' is associated with significantly higher perinatal complications including eclampsia, preeclampsia, chronic hypertension and large-for-gestational-age infants, without the demonstrated advantages of providing better results, except for a decrease in the incidence of OHSS, which should matter to women with polycystic ovary syndrome (PCOS) and high responders to ovarian stimulation but not to all patients. 'Freeze all' is also suggested for all simulated IVF cycles, due to the alleged 'faulty endometrium' caused by ovarian stimulation. However, there is no direct evidence that asynchronous endometrium exists, and only if preovulatory progesterone level increase, can 'freeze all' confer an advantage. We conclude that an alleged diagnosis of 'faulty endometrium' should not be used as an indication for 'freeze all'. To offset the risk of OHSS more simply, less costly and less risky solutions such as mild ovarian stimulation, to dampen the number of oocytes and to aim for transfer of a single blastocyst, should be the preferred solution to treat women with PCOS and high responders for oocyte retrieval.

The endometrium during and after ovarian hyperstimulation and the role of segmentation of infertility treatment

Controlled ovarian hyperstimulation (COH) is a crucial part of assisted reproductive technologies (ART) that resulted in a substantial increase in pregnancy rates from in vitro fertilization (IVF). However, in spite of the apparent benefit of COH on an increase in the number of follicles and the number of oocytes retrieved, allowing for extended embryo culture and enabling the selection of the best quality embryo for transfer, several reports has shown that the supraphysiologic hormonal levels may indeed have a detrimental effect at the endometrial level. The current article revises the pathophysiological mechanisms through which ovarian stimulation may negatively affect endometrial receptivity. Also, the evidence is analyzed explaining how segmentation of IVF treatment may allow us to overcome the deleterious effects of hyperstimulation on endometrial receptivity. Deferred embryo transfer may be performed in a more physiologic uterine environment in a subsequent cycle, improve endometrial receptivity, decrease uterine contractility, diminishes the impact of premature luteinization and allow individualized stimulation according to the level of response.

In vitro effects of relaxin on gene expression in porcine cumulus-oocyte complexes and developing embryos

BACKGROUND

Relaxin hormone peptide is found in porcine follicular and utero-tubal fluids, but its possible actions during early embryo development are still undetermined. Here, we investigated the effects of porcine relaxin during oocyte maturation and embryo development, and gene expression in the pig.

METHODS

Immature cumulus-oocyte complexes (COCs) were obtained from ovarian follicles of sows. In experiment 1, COCs were matured in the presence of 0, 20, or 40 ng relaxin/ml, or 10% (v/v) porcine follicular fluid. In experiment 2, COCs were in vitro matured, fertilized and resulting embryos were cultured in the presence of 0, 20, or 40 ng relaxin/ml. In experiment 3, COCs were matured in the presence of 40 ng relaxin/ml, fertilized and zygotes were cultured as indicated in experiment 2. We evaluated the proportions of matured oocytes in experiment 1, cleaved and blastocysts on Day 2 and Day 7 post insemination in all experiments. The total cell number of blastocysts was also evaluated. In parallel, transcription levels of both relaxin and its receptors (RXFP1 and RXFP2), as well as a pro- (Bax) and anti- (Bcl2-like 1) apoptotic-related genes were determined. All data were analyzed by ANOVA and significant differences were fixed for P < 0.05.

RESULTS

In experiment 1, relaxin significantly increased the proportions of matured oocytes and cleaved embryos, as well as the expression level of RXFP2 mRNA compared to RXFP1 (P < 0.05). There was no effect on endogenous expression of relaxin and Bcl2-like1/Bax ratios. In all experiments, relaxin did not affect the proportions of blastocysts, but did significantly increase their total cell numbers (P < 0.05). Furthermore, no effect of relaxin was observed on Bcl2-like1/Bax expression ratios, which were similar between groups.

CONCLUSIONS

Exogenous relaxin influences its own receptors expression, improves oocyte nuclear maturation. Its beneficial effect on total cell number of blastocysts appears to be through a Bcl2-like1/Bax-independent mechanism.

The role of aromatase inhibitors in ameliorating deleterious effects of ovarian stimulation on outcome of infertility treatment

Clinical utilization of ovulation stimulation to facilitate the ability of a couple to conceive has not only provided a valuable therapeutic approach, but has also yielded extensive information on the physiology of ovarian follicular recruitment, endometrial receptivity and early embryo competency. One of the consequences of the use of fertility enhancing agents for ovarian stimulation has been the creation of a hyperestrogenic state, which may influence each of these parameters. Use of aromatase inhibitors reduces hyperestrogenism inevitably attained during ovarian stimulation. In addition, the adjunct use of aromatase inhibitors during ovarian stimulation reduces amount of gonadotropins required for optimum stimulation. The unique approach of reducing hyperestrogenism, as well as lowering amount of gonadotropins without affecting the number of mature ovarian follicles is an exciting strategy that could result in improvement in the treatment outcome by ameliorating the deleterious effects of the ovarian stimulation on follicular development, endometrial receptivity, as well as oocyte and embryo quality.

Glycodelin A and differentiation of first trimester trophoblast cells in vitro

AIM

The glycoprotein, glycodelin A (GdA) is a main product of the maternal decidua in the first trimester of pregnancy and is secreted into the amniotic fluid. The purpose of this study was to investigate the effect of GdA on secretion and surface markers of isolated first trimester trophoblasts in vitro.

METHODS

Cytotrophoblasts were prepared from human first trimester placentae and incubated with varying concentrations of GdA or transfected separately with the expression plasmid of GdA. Supernatants were assayed for human chorionic gonadotropin (hCG) protein concentrations. Expression of human placental lactogen (hPL), mucin 1 (MUC1) and the Thomsen-Friedenreich (TF) epitope was analysed in stimulated trophoblast cells and in unstimulated controls by immunocytochemistry.

RESULTS

Glycodelin A induced a reduced expression of hPL compared with unstimulated controls. Expression of MUC1 was not affected by GdA. Freshly isolated trophoblast cells showed no TF expression but became positive for this antigen after 96 h of cultivation. GdA-stimulated trophoblast cells inhibited TF expression after 96 h of cultivation. GdA plasmids induced a significantly higher hCG production in transfected cells than in cells transfected with the empty plasmid.

CONCLUSIONS

The results obtained in this study suggest that GdA is involved in the differentiation of trophoblast cells. The treatment of GdA plasmid transfected trophoblast cells stimulated hCG production in isolated trophoblast cells and inhibited hPL and TF expression, suggesting a functional link between hCG and GdA.

Endometrial hormone receptors and proliferation index in the periovulatory phase of stimulated embryo transfer cycles in comparison with natural cycles and relation to clinical pregnancy outcome

OBJECTIVE

To investigate the endometrial steroid receptors and proliferation index in GnRH analogue/hMG-stimulated cycles in comparison with natural cycles and their relation to clinical pregnancy outcome.

DESIGN

Prospective observational study.

SETTING

Tertiary referral center.

PATIENT(S)

Twenty-seven stimulated patients with GnRH agonist and hMG. Twenty normo-ovulatory patients were the natural cycle controls.

INTERVENTION(S)

Endometrial aspiration biopsies: in stimulated cycles on the day of oocyte retrieval within the ET cycle (Day OPU) (n = 20) or 2 days later (Day OPU + 2) (n = 7); in natural cycles on the natural day of ovulation (Day NO) (n = 10) or on the day of ovulation + 2 (Day NO + 2) (n = 10).

MAIN OUTCOME MEASURE(S)

Comparison of endometrial maturation, estrogen (ER) and P receptor (PR), and proliferation index by immunohistochemistry in natural and stimulated cycles, correlation with pregnancy outcome in stimulated cycles.

RESULT(S)

Stimulated cycles Day OPU showed significantly advanced endometrial maturation compared to natural cycles Day NO; stromal ER and glandular and stromal PR staining was lower in stimulated than in natural cycles, but higher on Day OPU than on Day NO + 2; proliferation index was lower in all stimulated cycles. Steroid receptors and proliferation index in stimulated cycles were unrelated to clinical pregnancy occurrence.

CONCLUSION(S)

Compared to natural cycles, ovarian stimulation induced an imbalance in endometrial ER and PR and led to a profound antimitotic effect in the peri-ovulatory phase. These parameters were, however, not predictive of clinical pregnancy in cycles with ET.

Purification and characterization of an immunomodulatory endometrial protein, glycodelin

Human glycodelin is synthesized by endometrial cells in the late secretory phase and early pregnancy under hormonal regulation. Whereas the precise physiological functions of glycodelin are unknown, its expression during embryonic nidation and its inhibition of T cell proliferation suggest an immunomodulatory role. We purified human glycodelin from first trimester human decidual cytosol by using a rapid two-step high-performance liquid chromatography method and investigated its effects on human monocyte migration. Human U937 cells were used as a model of monocyte chemotaxis in Boyden chamber migration assays. N-Formyl-Met-Leu-Phe and the beta-chemokine RANTES (regulated on activation normal T cell expressed and secreted) were used as monocyte chemoattractants. Purified glycodelin inhibited monocyte migration in a dose-dependent fashion (IC50 = 550 nm). Glycodelin activity was totally reversed by heat inactivation (95 degrees C x 15 min) and neutralized by pretreatment with specific anti-glycodelin antibodies. Deglycosylated glycodelin was equipotent to intact glycodelin in the monocyte migration assay. 125I-Glycodelin binding to whole U937 cells revealed a single, saturable site with a Kd = 48 +/- 21 nm by Scatchard analysis. Cross-linking studies indicated that glycodelin binds to a high molecular mass (approximately 250 kDa) protein complex at the monocyte cell surface. Our findings support the hypothesis that glycodelin reduces the local maternal inflammatory response toward the implantation of a semiallogeneic conceptus.

Endocrinology of the peri-implantation period

Current research suggests that the appearance of endometrial integrins and pinopode appearance signal the opening of the receptive phase of the endometrium. These integrins may be activated by the interleukin-1 system (IL-1). IL-1beta, expressed by the blastocyst, induces vascular endothelial growth factor (VEGF) which, in turn, promotes angiogenesis and integrin expression in endometrial cells. The IL-1 system also triggers the expression of gamma interferon (IFN-gamma) from T lymphocytes. Decidual natural killer (NK) lymphocytes interact with invading trophoblast to generate leukaemia inhibitory factor (LIF). LIF induces uPA and gelatinase, enzymes which play a crucial role in trophoblastic invasion. Progesterone is a potent inhibitor of LIF, while oestrogen is a potent inducer. Oestrogen in serum reflects follicular IL-1beta level and correlates with the outcome of embryo transfer after in vitro fertilization (IVF). Progesterone induces nitric oxide (NO) synthesis in the decidua, and NO promotes local vasodilatation and uterine quiescenceMeasurement of placental protein 14 (PP14, glycodelin-A) in serum may be of value as a screening test for implantation potential. However, human chorionic gonadotrophin (hCG) remains the most reliable predictor of successful implantation and pregnancy viability. An ovulation + 14 hCG level < 50 IU/l is often predictive of a non-viable outcome, while an ovulation + 21 hCG of < 200 IU/l always indicates a non-viable pregnancy. hCG secretion by invading trophoblast appears to be negatively modulated by endothelin-1 (ET-1) and prostaglandin F(2alpha)(PGF2alpha), while tissue growth factors and collagenases are positive modulators of hCG expression.ProalphaC, an inhibin pro-monomer, may have some value in monitoring corpus luteum function. Inhibin A, activin A and follistatin all rises throughout pregnancy and peak at 36 weeks of gestation. Relaxin is another ovarian hormone that may have a role in predicting implantation. Relaxin induces placental protein 14 (PP14, glycodelin-A) expression in a receptive endometrium, and measurement of serum PP14 may be of value as a screening test for implantation potential.

Clinical applications of serum placental protein 14 (PP14) measurement in the IVF-ET cycle

OBJECTIVE

Placental protein 14 (PP14) is known to be one of the endometrial proteins that reflect endometrial functioning throughout the menstrual cycle. In this study, we examined PP14 as a marker for human endometrial receptivity in order to predict the outcome of in vitro fertilization and the embryo-transfer (IVF-ET) cycle.

PATIENTS AND METHODS

The subjects were 72 women who had 96 IVF-ET cycles and who were examined at Tokyo Medical University Hospital during the period of January 1998 to June 1998 because of mechanical or unexplained infertility for a duration of at least 2 years. Serum samples were collected from all patients during treatment cycles, and serum PP14 concentrations were measured by a newly established enzyme-linked immunosorbent assay (ELISA).

RESULTS

In the pregnant group, serum PP14 concentrations were markedly increased after ET, and a significant difference between the pregnant group and the nonpregnant group was observed 8 days following ET (p < 0.01). PP14 concentrations were higher in patients with endometria that exhibited homogenous patterns and that were more than 7 mm thicker than in other patients, as determined by ultrasound on the day of oocyte collection (p < 0.005). The pregnancy rates of patients with homogeneous patterns were lower than those of patients showing a trilaminar pattern. No pregnancies were observed when serum PP14 concentrations were greater than 6.85 U/l on the day of oocyte collection.

CONCLUSION

PP14 might be a useful marker for human endometrial receptivity to predict the outcome of IVF-ET cycles.

Effects of progestins and relaxin on glycodelin gene expression in human endometrial cells

OBJECTIVE

Glycodelin is an endometrial protein proposed to play an important role in embryonic implantation. We examined the effects of progestins and relaxin on glycodelin transcription, synthesis, and secretion.

STUDY DESIGN

Northern blotting, metabolic labeling, and fluorography were used to assess glycodelin messenger ribonucleic acid and protein synthesis in endometrial tissue and cells. Luciferase reporter constructs transfected into endometrial adenocarcinoma cells (Ishikawa cells) were used to determine whether progestins or relaxin could activate the glycodelin gene promoter.

RESULTS

Progestins but not relaxin stimulated glycodelin secretion in primary epithelial cell cultures. A 452-base pair fragment of the glycodelin gene promoter was activated 4.3 +/- 0.7 times normal by 10-nmol/L promegestone; however, addition of relaxin to the same construct repressed progestin-stimulate promoter activation by >30%.

CONCLUSION

Glycodelin transcription, synthesis, and secretion by endometrial epithelial cells were stimulated by progestins. However, relaxin failed to stimulate production of this immunomodulatory protein and, in fact, repressed progestin-stimulated activation of the glycodelin gene promoter.

Regulation of HOXA-10 and its expression in normal and abnormal endometrium

HOXA-10 is a member of a family of genes that serve as transcription factors during development and have been shown to be important for uterine function. Using immunohistochemistry and RNAse protection assays (RPA), HOXA-10 was shown to be expressed in both epithelial and stromal cells with increased expression during the window of implantation. By in-vitro culture of isolated endometrial epithelium or stroma, HOXA-10, expression was increased after treatment with oestradiol (10(-8) mol/l) with or without progesterone (10(-6) mol/l). In stromal cells, oestradiol and progesterone both appeared to increase HOXA-10 expression and were additive. Relaxin (30 ng/ml) appeared to further increase stromal HOXA-10 expression. HOXA-10 expression during the window of implantation was compared in normal menstrual cycles to endometrium from women with endometriosis and suspected defects in uterine receptivity. Little or no difference was seen in luminal, glandular or endothelial HOXA-10 expression but a significant reduction in stroma HOXA-10 expression was noted in women with endometriosis. In conclusion, HOXA-10 is a hormone-regulated endometrial transcription factor that appears to be responsive to both ovarian steroids and relaxin. The appearance of this nuclear protein during the window of implantation in epithelium and stroma may offer new insight into the regulation of uterine receptivity and assist in the identification of other genes that are critical to the establishment of a successful pregnancy.

Expression of alpha6 and beta4 integrin subunits throughout the menstrual cycle: no correlation with uterine receptivity

OBJECTIVE

To compare the expression of alpha6 and beta4 integrin subunit levels throughout the menstrual cycle in the endometrium of healthy women and infertile women.

DESIGN

Prospective study.

SETTING

An academic teaching hospital.

PATIENT(S)

Endometrium was collected from 58 women, including healthy subjects (n = 28) and patients undergoing diagnostic testing for infertility (n = 30).

INTERVENTION(S)

Endometrial biopsies were performed throughout the menstrual cycle in healthy women and infertile women.

MAIN OUTCOME MEASURE(S)

Immunohistochemical staining intensity of alpha6 and beta4 using the semiquantitative immunohistochemical score, compared using regression analysis and analysis of variance with Scheffé's correction.

RESULT(S)

There was no correlation between menstrual cycle phase and endometrial integrin subunit alpha6 or beta4 on glandular or luminal epithelium. Even women with identified luteal phase defects had indistinguishable patterns of expression for these integrin subunits during the window of implantation.

CONCLUSION(S)

The integrin subunits alpha6 and beta4 are expressed uniformly throughout the menstrual cycle on glandular and luminal epithelium. These integrins may have a housekeeping role in anchoring endometrial epithelium and do not appear to be useful markers of uterine receptivity.