Understanding the apical surface markers of uterine receptivity: pinopods-or uterodomes?

Uterine cellular changes during mammalian pregnancy and the evolution of placentation

There are many different forms of nutrient provision in viviparous (live bearing) species. The formation of a placenta is one method where the placenta functions to transfer nutrients from mother to fetus (placentotrophy), transfer waste from the fetus to the mother and respiratory gas exchange. Despite having the same overarching function, there are different types of placentation within placentotrophic vertebrates, and many morphological changes occur in the uterus during pregnancy to facilitate formation of the placenta. These changes are regulated in complex ways but are controlled by similar hormonal mechanisms across species. This review describes current knowledge of the morphological and molecular changes to the uterine epithelium preceding implantation among mammals. Our aim is to identify the commonalities and constraints of these cellular changes to understand the evolution of placentation in mammals and propose directions for future research. We compare and discuss the complex modifications to the ultrastructure of uterine epithelial cells and show that there are similarities in the changes to the cytoskeleton and gross morphology of the uterine epithelial cells, especially of the apical and lateral plasma membrane of the cells during the formation of a placenta in all eutherians and marsupials studied to date. We conclude that further research is needed to understand the evolution of placentation among viviparous mammals, particularly concerning the level of placental invasiveness, hormonal control and genetic underpinnings of pregnancy in marsupial taxa.

Morphological features of the secretory phase endometrium in women with unexplained infertility

In this study, we evaluated the structural features of the endometrial tissues, the immunohistochemical expression of MUC-1, which plays an important role in implantation, and the biochemical markers during the implantation window. Randomly chosen 18 fertile and 18 unexplained infertile women that have 27-32 days long menstrual cycle, normal hormonal values, normal USG findings of ovary and endometrium were included. Five, six, and seven days after ovulation, endometrial biopsies were taken and prepared in accordance with light and electron microscopy tissue preparation methods. Immunohistochemical methods were used to determine MUC-1 expression in the tissues. Serum hormone levels were determined. The MUC-1 immunoreactivity, as well as the serum levels of FSH, LH, TSH, estrogen, progesterone, and total testosterone did not differ significantly between the two groups; however, prolactin levels were higher in the infertile group. In the unexplained infertile samples, intraepithelial lymphocytes were frequently observed, the microvilli of the surface columnar epithelium were widespread, cells with pinopodes as well as vesiculated cells were minimal, pinopode development was insufficient, and the development of the endometrial glands was deficient. It was concluded that these structural differences observed in the surface and glandular epithelium of the endometrium in unexplained infertile patients may be due to the insufficiency of these cells in responding to steroid hormones; therefore, these changes may affect the implantation of the blastocyst in the endometrium.

Rictor/mTORC2 is involved in endometrial receptivity by regulating epithelial remodeling

Successful embryo implantation requires well-functioning endometrial luminal epithelial cells to establish uterine receptivity. Inadequate uterine receptivity is responsible for approximately two thirds of implantation failures in humans. However, the regulatory mechanism governing this functional process remains largely unexplored. A previous study revealed that the expression of Rictor, the main member of mTORC2, in mouse epithelial cells is increased on the fourth day of gestation (D4). Here, we provide the first report of the involvement of Rictor in the regulation of endometrial receptivity. Rictor was conditionally ablated in the mouse endometrium using a progesterone receptor cre (PRcre ) mouse model. Loss of Rictor altered polarity remodeling and the Na+ channel protein of endometrial cells by mediating Rac-1/PAK1(pPAK1)/ERM(pERM) and Sgk1/pSgk1 signaling, respectively, ultimately resulting in impaired fertility. In the endometrium of women with infertility, the expression of Rictor was changed, along with the morphological transformation and Na+ channel protein of epithelial cells. Our findings demonstrate that Rictor is crucial for the establishment of uterine receptivity in both mice and humans. The present study may help improve the molecular regulatory network of endometrial receptivity and provide new diagnostic and treatment strategies for infertility.

GLUT4 in Mouse Endometrial Epithelium: Roles in Embryonic Development and Implantation

GLUT4 is involved in rapid glucose uptake among various kinds of cells to contribute to glucose homeostasis. Prior data have reported that aberrant glucose metabolism by GLUT4 dysfunction in the uterus could be responsible for infertility and increased miscarriage. However, the expression and precise functions of GLUT4 in the endometrium under physiological conditions remain unknown or controversial. In this study, we observed that GLUT4 exhibits a spatiotemporal expression in mouse uterus on pregnant days 1–4; its expression especially increased on pregnant day 4 during the window of implantation. We also determined that estrogen, in conjunction with progesterone, promotes the expression of GLUT4 in the endometrial epithelium in vivo or in vitro. GLUT4 is an important transporter that mediates glucose transport in endometrial epithelial cells (EECs) in vitro or in vivo. In vitro, glucose uptake decreased in mouse EECs when the cells were treated with GLUT4 small interfering RNA (siRNA). In vivo, the injection of GLUT4-siRNA into one side of the mouse uterine horns resulted in an increased glucose concentration in the uterine fluid on pregnant day 4, although it was still lower than in blood, and impaired endometrial receptivity by inhibiting pinopode formation and the expressions of leukemia inhibitory factor (LIF) and integrin ανβ3, finally affecting embryonic development and implantation. Overall, the obtained results indicate that GLUT4 in the endometrial epithelium affects embryo development by altering glucose concentration in the uterine fluid. It can also affect implantation by impairing endometrial receptivity due to dysfunction of GLUT4.

Promoting Roles of Embryonic Signals in Embryo Implantation and Placentation in Cooperation with Endocrine and Immune Systems

Embryo implantation in the uterus is an essential process for successful pregnancy in mammals. In general, the endocrine system induces sufficient embryo receptivity in the endometrium, where adhesion-promoting molecules increase and adhesion-inhibitory molecules decrease. Although the precise mechanisms remain unknown, it is widely accepted that maternal–embryo communications, including embryonic signals, improve the receptive ability of the sex steroid hormone-primed endometrium. The embryo may utilize repulsive forces produced by an Eph–ephrin system for its timely attachment to and subsequent invasion through the endometrial epithelial layer. Importantly, the embryonic signals are considered to act on maternal immune cells to induce immune tolerance. They also elicit local inflammation that promotes endometrial differentiation and maternal tissue remodeling during embryo implantation and placentation. Additional clarification of the immune control mechanisms by embryonic signals, such as human chorionic gonadotropin, pre-implantation factor, zona pellucida degradation products, and laeverin, will aid in the further development of immunotherapy to minimize implantation failure in the future.

Uterine epithelial remodelling during pregnancy in the marsupial Monodelphis domestica (Didelphidae): Implications for mammalian placental evolution

Mammalian pregnancy involves remodelling of the uterine epithelium to enable placentation. In marsupials, such remodelling has probably played a key role in the transition from ancestral invasive placentation to non-invasive placentation. Identifying uterine alterations that are unique to marsupials with non-invasive placentation can thus elucidate mechanisms of marsupial placental evolution. We identified apical alterations to uterine epithelial cells prior to implantation in Monodelphis domestica, a member of the least derived living marsupial clade (Didelphidae) with invasive (endotheliochorial) placentation. We then compared these traits with those of Macropus eugenii (Macropodidae) and Trichosurus vulpecula (Phalangeridae), both with non-invasive placentation, to identify which alterations to the uterine epithelium are ancestral and which facilitate secondarily evolved non-invasive placentation. In M. domestica, remodelling of the uterine epithelium involves reduced cellular heterogeneity and development of uterodome-like cells, suggesting that similar alterations may also have occurred in the marsupial common ancestor. These alterations also overlap with those of both T. vulpecula and Ma. eugenii, suggesting that the placental shift from invasive to non-invasive placentation in marsupials involves essential, conserved characteristics, irrespective of placental mode. However, unique apical alterations of both T. vulpecula and Ma. eugenii, relative to M. domestica, imply that lineage-specific alterations underpin the evolutionary shift to non-invasive placentation in marsupials.

Pinopodes: Recent advancements, current perspectives, and future directions

Successful embryo implantation is a complex and highly regulated process involving precise synchronization between the fetal-derived trophoblast cells and maternal uterine luminal epithelium. Multiple endocrine-driven factors are important for controlling the timely receptivity of the uterus, and this complexity underscores implantation failure as a major cause of recurrent infertility associated with assisted reproductive technologies. One particular cellular structure often hypothesized to promote receptivity is the pinopode or uterodome - a hormonally regulated, large cellular protrusion on the uterine epithelial surface. Recent clinical studies associate pinopodes with favorable fertility outcomes in women, and because they are directly linked to an increase in progesterone levels, the potential utility of these hormone-regulated cell biological structures in predicting or improving implantation in a clinical setting holds promise. In this review, we aim to generate interest in pinopodes from the broader cell biology and endocrinology communities, re-examine methodologies in pinopode research, and identify priorities for future investigation of pinopode structure and function in women's reproductive health.

Uterine Luminal Epithelium as the Transient Gateway for Embryo Implantation

The uterine luminal epithelium (LE) is the first maternal contact for an implanting embryo. Intrauterine fluid resorption, cessation of LE proliferation and apoptosis, and LE structural changes are prerequisites for establishing transient uterine receptivity for embryo implantation. Vesicle trafficking in the LE and receptor-mediated paracrine and autocrine mechanisms are crucial both for LE preparation and LE communications with the embryo and stroma during the initiation of embryo implantation. This review mainly covers recent in vivo studies in LE of mouse models from 0.5 days post-coitus (D0.5) to ∼D4 20 h when the trophoblasts pass through the LE layer for embryo implantation. The review is organized into three interconnected sections: preimplantation LE preparation for embryo attachment, embryo-LE communications, and LE-stroma communications.

Sex steroids influence the plasma membrane transformation in the uterus of the fat-tailed dunnart (Sminthopsis crassicaudata, Marsupialia)

The uterine epithelium undergoes remodelling to become receptive to blastocyst implantation during pregnancy in a process known as the plasma membrane transformation. There are commonalities in ultrastructural changes to the epithelium, which, in eutherian, pregnancies are controlled by maternal hormones, progesterone and oestrogens. The aim of this study was to determine the effects that sex steroids have on the uterine epithelium in the fat-tailed dunnart Sminthopsis crassicaudata, the first such study in a marsupial. Females were exposed to exogenous hormones while they were reproductively quiescent, thus not producing physiological concentrations of ovarian hormones. We found that changes to the protein E-cadherin, which forms part of the adherens junction, are controlled by progesterone and that changes to the desmoglein-2 protein, which forms part of desmosomes, are controlled by 17β-oestradiol. Exposure to a combination of progesterone and 17β-oestradiol causes changes to the microvilli on the apical surface and to the ultrastructure of the uterine epithelium. There is a decrease in lateral adhesion when the uterus is exposed to progesterone and 17β-oestradiol that mimics the hormone environment of uterine receptivity. We conclude that uterine receptivity and the plasma membrane transformation in marsupial and eutherian pregnancies are under the same endocrine control and may be an ancestral feature of therian mammals.

High-Protein Diet Ameliorates Arsenic-Induced Oxidative Stress and Antagonizes Uterine Apoptosis in Rats

Arsenic toxicity purportedly threats a broad spectrum of female reproductive functions. We investigated the remedial role of a casein- and pea protein-enriched high-protein diet (HPD) in combating the arsenic insult. Cyclic female rats maintained on standard diet (n = 6) or an isocaloric HPD (n = 6) were gavaged with As₂O₃ at 3 mg/kg BW/rat/day (n = 12) for 28 days. Vehicle-fed rats (n = 6) maintained on the standard diet served as the control. We monitored the estrus cycles and performed the histomorphometric analyses of the uterus and ovary. Uterine luminal epithelial (ULE) ultrastructure was appraised by scanning electron microscopy. Uterine oxidative stress was evaluated in the forms of ROS generation and activities of the ROS scavengers. The uterine apoptotic manifestation was blueprinted by Western blot analysis of caspase-3 and Bax expression. Arsenic treatment arrested the follicular maturation and disrupted the estrus cycles with a typical increase in the diestrus index. Shrunken endometrial glands and thinned microvilli density of the ULE reflected loss of cell polarity and mislaid uterine homeostasis. Increased ROS generation and attenuated activities of the ROS scavengers marked a state of uterine oxidative imbalance and loss of redox regulation. Superfluous expression of procaspase-3, cleaved caspase-3, and Bax mirrored an inflated state of uterine apoptosis. HPD supplementation, by and large, counteracted these arsenic impacts and maintained the frameworks close to the control levels. In conclusion, arsenic mediates its reproductive toxicity, at least in part, by upsetting the uterine ROS homeostasis and redox regulation. Pea proteins and casein-supplemented HPD can counteract the arsenic effects and maintain the reproductive functions.

Uterine glands impact uterine receptivity, luminal fluid homeostasis and blastocyst implantation

Uterine glands are essential for pregnancy in mice and likely humans, because they secrete or transport bioactive substances that regulate uterine receptivity for blastocyst implantation. In mice, the uterus becomes receptive to blastocyst implantation on day 4, but is refractory by day 5. Here, blastocysts could be recovered from progesterone-induced uterine gland (PUGKO) but not wildtype (WT) mice on day 5 post-mating. Anti-adhesive Muc1 protein and microvilli were present on the luminal epithelium of PUGKO but not WT uteri. A number of known uterine receptivity genes and gland-specific genes were altered in the PUGKO uterus. Next, the uterus and uterine luminal fluid (ULF) were obtained from WT and PUGKO mice on day 3, 4 and 5. Transcriptome analysis revealed that 580 genes were decreased in the PUGKO uterus, however ULF secrotome analysis revealed that many proteins and several amino acids were increased in the PUGKO ULF. Of note, many proteins encoded by many gland-specific genes were not identified in the ULF of WT mice. These results support the ideas that uterine glands secrete factors that regulate ULF homeostasis and interact with other cell types in the uterus to influence uterine receptivity and blastocyst implantation for the establishment of pregnancy.

Actin crosslinking protein filamin A during early pregnancy in the rat uterus

During early pregnancy the endometrium undergoes a major transformation in order for it to become receptive to blastocyst implantation. The actin cytoskeleton and plasma membrane of luminal uterine epithelial cells (UECs) and the underlying stromal cells undergo dramatic remodelling to facilitate these changes. Filamin A (FLNA), a protein that crosslinks actin filaments and also mediates the anchorage of membrane proteins to the actin cytoskeleton, was investigated in the rat uterus at fertilisation (Day 1) and implantation (Day 6) to determine the role of FLNA in actin cytoskeletal remodelling of UECs and decidua during early pregnancy. Localisation of FLNA in UECs at the time of fertilisation was cytoplasmic, whilst at implantation it was distributed apically; its localisation is under the influence of progesterone. FLNA was also concentrated to the first two to three stromal cell layers at the time of fertilisation and shifted to the primary decidualisation zone at the time of implantation. This shift in localisation was found to be dependent on the decidualisation reaction. Protein abundance of the FLNA 280-kDa monomer and calpain-cleaved fragment (240 kDa) did not change during early pregnancy in UECs. Since major actin cytoskeletal remodelling occurs during early pregnancy in UECs and in decidual cells, the changing localisation of FLNA suggests that it may be an important regulator of cytoskeletal remodelling of these cells to allow uterine receptivity and decidualisation necessary for implantation in the rat.

A variety of opportunities for immune interactions during trophoblast development and invasion

During human implantation and placentation, the direct cell to cell contact of fetal and maternal tissues gives room for a variety of immune interactions. Especially, the invasion of a subset of fetal trophoblast cells, called extravillous trophoblast, generate a very close interplay between the two individuals, enabling the attachment of the placenta to the uterine wall and the transformation of maternal spiral arteries to facilitate adequate nutrition of the fetus. During pregnancy, maternal and fetal factors closely interact to maintain pregnancy and smooth the process of delivery. At each and every stage and site, immunological interactions take place, including attachment of the blastocyst, development and invasion of trophoblast, and flow of maternal plasma and blood through the intervillous space of the placenta. Control mechanisms tightly regulate these interactions helping to evade fetal rejection by the mother. In this review, we highlight the morphological sites of development and feto-maternal interaction to help immunological interested scientists and clinicians to develop hypotheses on the feto-maternal immunological network during pregnancy.

Unique uterine localization and regulation may differentiate LPA3 from other lysophospholipid receptors for its role in embryo implantation

OBJECTIVE

To determine factors differentiating LPA3 from other lysophospholipid (LP) receptors for its role in embryo implantation.

DESIGN

Experimental mouse models.

SETTING

Institute/university research laboratories.

ANIMAL(S)

Wild-type, Lpar3(-/-), Lpar1(-/-)Lpar2(-/-), and S1pr2(-/-)S1pr3(-/-) mice.

INTERVENTION(S)

Ovariectomy.

MAIN OUTCOME MEASURE(S)

Blue dye injection for determining implantation sites on gestation day 4.5. Real-time polymerase chain reaction for measuring gene expression in whole uterus and separated uterine layers. In situ hybridization for detecting progesterone (P)-induced Lpar3 expression in the uterine luminal epithelium (LE).

RESULT(S)

Normal implantation was observed in Lpar1(-/-)Lpar2(-/-) and S1pr2(-/-)S1pr3(-/-) females. Temporal expression showed peak expression of Lpar3 in the preimplantation uterus and constitutive expression of the other nine LP receptors in the periimplantation uterus. Spatial localization revealed main expression of Lpar3 in the LE and broad expression of the remaining LP receptors in all three main uterine layers: LE, stromal, and myometrial layers. Hormonal regulation in ovariectomized uterus indicated up-regulation of Lpar3 but down-regulation or no effect of the remaining nine LP receptors by P, and down-regulation of most LP receptors, including Lpar3, by 17β-estradiol.

CONCLUSION(S)

LE localization and up-regulation by P differentiate LPA3 from the other nine LP receptors and may underlie its essential role in embryo implantation.

Research on Blastocyst Implantation Essential Factors (BIEFs)

Blastocyst implantation is a process of interaction between embryo and the uterus. To understand this process, this review tries to summarize what blastocyst implantation essential factors (BIEFs) play what roles, as well as where in the uterus and at what stage of implantation process. Addition of more new data to this kind of compilation of information will help the development of diagnosis and treatment of infertility caused by implantation failure. The major, important cells of the endometrial cells that interact with invading blastocyst (trophoblast) are luminal epithelial cells, stromal cells (decidual cells) and resident immune cells. BIEFs regulate these cells to successfully maintain pregnancy.

Epigenetic regulation of E-cadherin controls endometrial receptivity

Key to the success of human reproduction is the capacity of an embryo to attach and implant into the endometrial wall after which a nutrient supply is established through placentation. Herein, we have examined the potential epigenetic regulation of uterine receptivity by use of the receptive RL95-2 and nonreceptive AN3-CA endometrial epithelial carcinoma cell lines. Using an in vitro model of embryo implantation, we demonstrate that inhibition of DNA methylation by 5'-aza-2'-deoxycytidine (AZA), resulted in the nonreceptive AN3-CA cell line becoming receptive to BeWo cell spheroid attachment. Examination of components of the adherens junction complex revealed that AZA specifically increased the expression of E-cadherin and plakoglobin at the mRNA and protein levels in AN3-CA cells, and E-cadherin protein expression was found to localize to sites of intercellular contact. Forced expression of E-cadherin in AN3-CA cells significantly enhanced receptivity. Small interfering RNA (siRNA)-mediated depletion of the individual DNA methyltransferase (DNMT) molecules did not induce E-cadherin expression in AN3-CA cells; however, concomitant siRNA-mediated depletion of both DNMT3A and DNMT3B induced the expression of E-cadherin. Furthermore, E-cadherin expression was significantly increased after the concomitant siRNA-mediated depletion of DNMT-1, -3A, and -3B in AN3-CA cells. Therefore, we have provided evidence that E-cadherin plays an important role in uterine receptivity and that E-cadherin expression is epigenetically regulated in AN3-CA cells, suppressed by the combined actions of DNMT-1, -3A, and -3B.

Haploinsufficiency for adrenomedullin reduces pinopodes and diminishes uterine receptivity in mice

Adrenomedullin (AM) is a multifunctional peptide vasodilator that signals through a G-protein-coupled receptor when the receptor, called calcitonin receptor-like receptor (CL), is associated with a receptor activity-modifying protein 2 (RAMP2). We demonstrated previously that haploinsufficieny for each of these genes led to reduced maternal fertility, and that even a modest genetic reduction of AM peptide caused maternal defects in implantation, placentation, and fetal growth. Here, we further demonstrate that Adm(+/-) female mice displayed reduced pregnancy success rates that were not caused by defects in folliculogenesis, ovulation, or fertilization. The poor fertility of Adm(+/-) female mice could not be rescued by transfer of wild-type blastocysts, which suggested an underlying defect in uterine receptivity. In fact, we found that Adm, Calcrl, and Ramp2 gene expressions are tightly and spatiotemporally regulated in the luminal epithelial cells of the uterus during the estrus cycle and the peri-implantation period. RAMP3, which also generates an AM receptor when associated with CL, had a diametrically opposite expression pattern than that of Adm, Calcrl, and Ramp2 and was most robustly induced in the stroma of the uterus. Finally, we discovered that Adm(+/-) female mice have a substantially reduced number of pinopodes on the uterine luminal epithelial surface, which is indicative and possibly causative of the poor uterine receptivity. Taken together, our studies identify a new class of pharmacologically tractable proteins that are involved in establishing uterine receptivity through the regulation of pinopode formation.

MUC16 is lost from the uterodome (pinopode) surface of the receptive human endometrium: in vitro evidence that MUC16 is a barrier to trophoblast adherence

In order for the preimplantation embryo to implant into the uterus, the trophoblast cells must initially adhere to the uterine epithelial surface. In preparation, the luminal secretory cells of the epithelium lose their nonadhesive character and their surface microvilli and bulge into the lumen, forming uterodomes (pinopodes; uterodome is used instead of pinopode, since in humans the surface membrane exocytoses rather than endocytoses (Murphy, Hum Reprod 2000; 15:2451-2454). Previous research has led to the hypothesis that loss of the nonadhesive membrane-spanning mucin MUC1 from the uterodome surface allows trophoblast adherence. Immunofluorescence microscopic assay of luminal epithelia on human uterine biopsies taken from LH+0 to LH+13 show that another membrane-spanning mucin, MUC16, was lost from uterodome surfaces in all samples taken during the receptive phase, LH+6 to LH+8 (n = 12), and that MUC1 was present on uterodomes in 4 of 12 samples and on all ciliated cells of the epithelium in the receptive phase. Short interfering RNA (siRNA) knockdown of MUC16 in a uterine epithelial cell line ECC-1 that, like uterine epithelium, expresses MUC16 and MUC1 allowed increased adherence of cells of a trophoblast cell line. In parallel experiments, siRNA knockdown of MUC1 did not affect trophoblast cell adherence. These data indicate that MUC16 is a membrane component of the nonreceptive luminal uterine surface, which prevents cell adhesion, and that its removal during uterodome formation facilitates adhesion of the trophoblast.

Pinopodes are present in Lif null and Hoxa10 null mice

OBJECTIVE

To assess pinopode formation in Lif null and Hoxa10 null mice with infertility secondary to failed implantation.

DESIGN

Controlled animal experiment.

SETTING

Animal research and laboratory facility.

ANIMAL(S)

Lif null, Hoxa10 null, and ICR mice and Sprague-Dawley rats.

INTERVENTION(S)

Endometrial tissue was collected during the peri-implantation period and after ovariectomy.

MAIN OUTCOME MEASURE(S)

Endometrial epithelial tissue was examined under scanning-electron microscopy and assigned a score depending on the number of pinopodes present.

RESULT(S)

Pinopode scores in ICR, Lif null, and Hoxa10 null mice were comparable throughout the peri-implantation period, rising on day 3.5 of pregnancy and remaining elevated through to day 7.5, suggesting that pinopodes are not a good indicator of receptivity in mice. In contrast, pinopode scores in rats clearly demarcated the window of receptivity, appearing on day 4 of pregnancy and declining sharply on day 6. Pinopode scores were low in E(2)-treated ovariectomized mice, but unexpectedly, pinopode scores in vehicle-injected ovariectomized ICR mice were markedly elevated.

CONCLUSION(S)

Lif null and Hoxa10 null mice, in which implantation is impaired, have a similar number of pinopodes to fertile ICR mice. Pinopodes do not define a window of implantation in mice.

The feto-maternal interface: setting the stage for potential immune interactions

Human implantation and placentation comprise the direct contact of fetal with maternal tissues culminating in the erosion of maternal tissues by fetal cells. A complex interplay of maternal and fetal factors is key to maintain pregnancy until delivery. Immunological interactions can be found at different stages, such as blastocyst attachment, trophoblast invasion into maternal tissues, and flow of maternal blood through the placenta. These interactions need tightly controlled mechanisms to avoid rejection of the conceptus. In this study, these sites of interaction are introduced on a morphological level to help immunologists create their hypotheses on how the immunological interactions may work.

Embryo implantation: the molecular mechanism remains elusive

Low rates of implantation are an impediment to more efficient assisted reproduction techniques. Improved endometrial receptivity and embryo preparation should lead to higher pregnancy rates, lower rates of early pregnancy failure and fewer multiple pregnancies. As the first site of contact between embryo and endometrium, the luminal epithelium (LE) is responsible for the non-receptive status of proliferative and early secretory tissue, and transformation to receptivity in the mid-secretory phase presumably requires alterations in expression, organization or activation of adhesion systems. Luminal cells are less abundant than their glandular counterparts, and are under-represented in global tissue datasets. Furthermore, alterations in cell surface composition can be readily accomplished by mechanisms that do not rely on altered transcription or translation. Current data from in-vitro models are consistent with initial attachment to mucin in the apical glycocalyx, perhaps via a carbohydrate-mediated interaction, after which the epithelial phenotype is modified by a medium- or short-range embryonic signal. A cascade of interactions follows, mediating embryo migration across the epithelium. Strikingly, numerous potential mediators of adhesion at implantation are located in the lateral rather than the apical surface of LE cells. Attached embryos appear to gain rapid access to this highly adhesive lateral membrane domain.

Tyrosine phosphorylated proteins in the reproductive tract of the viviparous lizard Eulamprus tympanum and the oviparous lizard Lampropholis guichenoti

Plastic changes occur in the morphology of the uterus at various stages of the reproductive cycle in both oviparous and viviparous lizards and these may be influenced by estrogen. Estrogen driven phosphorylation of effector proteins on tyrosine residues plays a major role in the plastic modulation of uterine anatomy and physiology in vertebrates. We used electrophoresis and Western blotting to characterize the phosphotyrosine protein profiles at various stages of the reproductive pathway in an oviparous lizard Lampropholis guichenoti and a viviparous lizard Eulamprus tympanum. L. guichenoti displayed major bands in the 200-35 kDa range and a triplet of bands of molecular masses 61 kDa, 52 kDa and 48 kDa in 50% of specimens and a 38 kDa band in all specimens. In contrast, E. tympanum samples all displayed a single major band at 40 kDa, which was significantly elevated at the early pregnancy stage. Somewhat paradoxically, the viviparous species, which has the more complex uterine epithelial changes during pregnancy, has the fewest phosphotyrosine bands, so how tyrosine phosphorylation is affected during the evolution of viviparity is not clear.

Metoclopramide-induced hyperprolactinaemia caused marked decline in pinopodes and pregnancy rates in mice

BACKGROUND

The impact of hyperprolactinaemia on endometrial function, along with embryo implantation, has been the subject of discussion. This article examines whether experimental hyperprolactinaemia can affect mouse ovarian function, endometrial pinopodes and embryo implantation.

METHODS

For pinopode analysis, 60 female mice were randomly divided into two groups: control (vehicle) and experimental [metoclopramide (MCP) 200 microg per day]. Injections were given subcutaneously for 50 days, and then, normally cycling females were housed with male mice for copulation during proestrus. The animals were killed on the fifth day following coitus when the antimesometrium portions of the uterine horns were removed for endometrial analysis. Blood was collected for prolactin (PRL) determination. In the second experiment, 60 female mice were used to evaluate the ovarian function by measuring estrogen and progesterone levels and counting luteal bodies and oocytes in the oviduct and uterus during estrus.

RESULTS

The highest pregnancy rates and the largest population of pinopodes were both found in the vehicle group (P<0.01). Estrogen and progesterone levels in MCP-treated mice were lower than those in control mice (P<0.05). Also, the number of implantations was significantly lower in the MCP-treated group compared with the vehicle group after embryo transfer (P<0.001).

CONCLUSION

PRL seems to have suppressive effects on ovarian function and the number of pinopodes; conceivably, hyperprolactinaemia has a negative effect on mouse embryo implantation.

The hormonal control of uterine luminal fluid secretion and absorption

The secretion of uterine luminal fluid initially provides a transport and support medium for spermatozoa and unimplanted embryos, while the absorption of uterine luminal fluid in early pregnancy results in the closure of the lumen and allows blastocysts to establish intimate contact with the uterine epithelium. We have established an in vivo perfusion technique of the lumen to study the hormonal control of the events in the peri-implantation period. Fluorescein-labelled dextran was included in the perfusion medium to monitor fluid movements and the concentrations of Na(+) and CI(-) ions in the effluent were monitored. Using an established regimen of steroid treatment of ovariectomized rats mimicking early pregnancy, oestradiol caused fluid secretion, while progesterone resulted in an amiloride-sensitive fluid absorption. Fluid absorption peaked at about the expected time of implantation. The effect of progesterone could be inhibited by treatment with a high dose of oestradiol, by the anti-progestin RU486, and by the presence of an intra-uterine contraceptive device. Studies of expression of Na(+) and CI(-) channels (ENaC, CFTR) indicated that these channels were subject to tissue-specific regulation within the uterus, but more work is required to determine their role and the factors controlling their abundance and localization in early pregnancy.

Endometrial receptivity: Clinical assessment in relation to fertility, infertility, and antifertility

Fertility in humans and other mammalian species depends absolutely on synchronous events that render the developing blastocyst and the receiving uterus competent for implantation. Endometrial receptivity is defined as the period during which the endometrial epithelium acquires functional, but transient, ovarian steroid-dependent status supportive to blastocyst acceptance and implantation. Once inside the uterus, the blastocyst is surrounded by an intact luminal epithelium, which is considered to act as barrier to its attachment, except for this short period of high endometrial receptivity to blastocyst signal(s). Its transport and permeability properties, in conjunction with cellular action of the endometrium and the embryo, have been suggested to influence creation and maintenance of informational and nutritional status of uterine luminal milieu. This period, also termed as the 'window of implantation,' is limited to days 20-24 of menstrual cycle in humans. However, establishment of endometrial receptivity is still a biological mystery that remains unsolved despite marked advances in our understanding of endometrial physiology following extensive research associated with its development and function. This review deals with various structural, biochemical, and molecular events in the endometrium coordinated within the implantation window that constitute essential elements in the repertoire that signifies endometrial receptivity and is aimed to achieve a better understanding of its relationship to fertility, infertility, and for the development of targeted antifertility agents for human use and welfare.

Leukaemia inhibitory factor in implantation and uterine biology

Leukaemia inhibitory factor (LIF) is one of the most important cytokines in the reproductive tract. Without expression of LIF in the uterus, implantation of a blastocyst cannot begin. Yet, 13 years after publication of the phenotype of the LIF knockout mouse we are only just beginning to understand how LIF functions in the uterus. This review addresses our knowledge of the role of LIF in regulating implantation through its influence on the luminal epithelium and stromal decidualization, but also its influence on reproductive tract cells such as leukocytes and glandular epithelium, during the pre-implantation phase of pregnancy.

HoxA10-like proteins in the reproductive tract of the viviparous lizard Eulamprus tympanum and the oviparous lizard Lampropholis guichenoti

The gene HoxA10 and its protein product are essential for the formation of the extensions of the plasma membrane called uterodomes or pinopods in mammalian uterine epithelia. In mice, the presence of the HoxA10 protein and uterodomes is needed for uterine receptivity to blastocyst implantation. The viviparous lizard Eulamprus tympanum displays uterodomes whereas the oviparous lizard Lampropholis guichenoti does not. To explore the theory that HoxA10 is involved in the formation of uterodomes we investigated whether HoxA10 immunoreactive proteins were present in both species during their reproductive cycles. Oviduct proteins from vitellogenic, gravid or non-reproductive L. guichenoti (n=19) and E. tympanum (n=28) were separated by electrophoresis and analysed by Western blot and specific antibodies to HoxA10. E. tympanum displayed HoxA10 immunoreactive bands at 59 and 63 kDa in 20 out of the 28 samples. All of the L. guichenoti samples displayed HoxA10 immunoreactive bands, 18 had bands at 59 and 64 kDa and 1 animal had a single band at 59 kDa. There were no significant differences in the level of HoxA10 immunoreactivity between the different stages of reproductive cycle in either species. The different molecular mass of the larger band in L. guichenoti (64 kDa) compared to E. tympanum (63 kDa) indicates that the two lizards express different isoforms of the HoxA10-like proteins and it will be interesting in future studies to determine whether there are differences in the biological activity of the proteins that regulate different physiological functions in the uterus of viviparous and oviparous lizards.

Secretory role for human uterodomes (pinopods): secretion of LIF

The differentiation of human endometrial epithelium is a dynamic event, which occurs throughout the menstrual cycle in preparation for pregnancy. The appearance of uterodomes (pinopods) in this regard was first introduced in rodents with an established pinocytotic function, whereas little evidence was available in humans in this context. This study was undertaken to identify the potential physiological roles of uterodomes in the implantation process. To address this, endometrial biopsies from early, mid- and late luteal phases of the menstrual cycle of 23 fertile female patients with regular menses were used. Scanning and transmission electron microscopies (SEM and TEM) as well as immunofluorescence and immunogold TEM were performed to study the morphological changes and the expression pattern of leukaemia inhibitory factor (LIF) at uterodomes. Our results illustrated a high level of LIF expression in the human uterodomes, which was colocalized with the well-known biochemical markers of exocytosis, including syntaxin-1, 25-kDa synaptosomal protein (SNAP-25) and vesicle-associated membrane protein-2 (VAMP-2). Our morphological and immunocytochemical findings illustrated a secretory function for human uterodomes for the first time. In conclusion, this novel function for uterodomes provides an important clue in detection of their physiological function(s) during the process of the plasma membrane transformation.

The antiprogesterone Org 31710 inhibits human blastocyst-endometrial interactions in vitro

OBJECTIVE

To investigate the effect of the anti-P Org 31710 on human blastocyst attachment to cultured endometrial epithelial cells.

DESIGN

Experimental in vitro study.

SETTING

University hospital.

PATIENT(S)

Eleven fertile endometrial donors.

INTERVENTION(S)

Timed endometrial biopsy for cell cultures.

MAIN OUTCOME MEASURE(S)

Blastocyst attachment rate on endometrial cell cultures; secretion of glycodelin and leukemia inhibitory factor into the culture medium measured by RIA and ELISA techniques; and expression of progesterone receptors, interleukin-1 receptor type-1, and integrin subunit beta(3) on endometrial epithelial cells examined by immunohistochemistry. Endometrial pinopodes visualized by scanning electron microscopy.

RESULT(S)

Eleven of 16 human blastocysts attached to control cultures, whereas none of 10 blastocysts attached when Org 31710 was added to the culture medium (P=.0007). Immunohistochemical studies demonstrated no significant differences between groups. Biochemical analyses displayed a trend toward higher glycodelin secretions and, by scanning electron microscopy, a tendency toward less pinopode formation in the Org 31710 group, but the results did not reach statistical significance. The presence of swollen microvilli, precursors of endometrial pinopodes, was significantly reduced on cultures with Org 31710 (P=.03).

CONCLUSION(S)

The study presents a model for human blastocyst-endometrial interactions responding to an anti-P drug. The exact mechanism for the anti-attachment properties of Org 31710 on the cultured endometrial cells and the blastocysts needs further evaluations.

Characterization of the uterine phenotype during the peri-implantation period for LIF-null, MF1 strain mice

Leukemia inhibitory factor plays a major role in the uterus and in its absence embryos fail to implant. Our knowledge of the targets for LIF and the consequences of its absence is still very incomplete. In this study, we have examined the ultrastructure of the potential implantation site in LIF-null MF1 female mice compared to that of wild type animals. We also compared expression of proteins associated with implantation in luminal epithelium and stroma. Luminal epithelial cells (LE) of null animals failed to develop apical pinopods, had increased glycocalyx, and retained a columnar shape during the peri-implantation period. Stromal cells of LIF-null animals showed no evidence of decidual giant cell formation even by day 6 of pregnancy. A number of proteins normally expressed in decidualizing stroma did not increase in abundance in the LIF-null animals including desmin, tenascin, Cox-2, bone morphogenetic protein (BMP)-2 and -7, and Hoxa-10. In wild type animals, the IL-6 family member Oncostatin M (OSM) was found to be transiently expressed in the luminal epithelium on late day 4 and then in the stroma at the attachment site on days 5-6 of pregnancy, with a similar but not identical pattern to that of Cox-2. In the LIF-null animals, no OSM protein was detected in either LE or stroma adjacent to the embryo, indicating that expression requires uterine LIF in addition to a blastocyst signal. Fucosylated epitopes: the H-type-1 antigen and those recognized by lectins from Ulex europaeus-1 and Tetragonolobus purpureus were enhanced on apical LE on day 4 of pregnancy. H-type-1 antigen remained higher on day 5, and was not reduced even by day 6 in contrast to wild type uterus. These data point to a profound disturbance of normal luminal epithelial and stromal differentiation during early pregnancy in LIF-nulls. On this background, we also obtained less than a Mendelian ratio of null offspring suggesting developmental failure.

Uterine receptivity and the plasma membrane transformation

This review begins with a brief commentary on the diversity of placentation mechanisms, and then goes on to examine the extensive alterations which occur in the plasma membrane of uterine epithelial cells during early pregnancy across species. Ultrastructural, biochemical and more general morphological data reveal that strikingly common phenomena occur in this plasma membrane during early pregnancy despite the diversity of placental types--from epitheliochorial to hemochorial, which ultimately form in different species. To encapsulate the concept that common morphological and molecular alterations occur across species, that they are found basolaterally as well as apically, and that moreover they are an ongoing process during much of early pregnancy, not just an event at the time attachment, the term 'plasma membrane transformation' is suggested which also emphasises that alterations in this plasma membrane during early pregnancy are key to uterine receptivity.

Characterizing the endometrium in unexplained and tubal factor infertility: A multiparametric investigation

OBJECTIVE

To characterize endometrial development in unexplained and tubal factor infertility.

DESIGN

Prospective study of 20 women with unexplained infertility, 22 with tubal factor infertility, and 21 fertile controls in the midproliferative, periovulatory, and midluteal phases of the menstrual cycle.

SETTING

Reproductive Medicine Department of St. Mary's Hospital, Manchester, United Kingdom.

PATIENT(S)

Women awaiting assisted conception.

INVESTIGATION(S)

Serum hormone assays, transvaginal ultrasound, Doppler, and midluteal endometrial biopsies.

MAIN OUTCOME MEASURE(S)

Serum levels of E2, P, and LH, endometrial ultrasound morphometry, uterine and subendometrial artery Doppler, and endometrial histology and biochemistry.

RESULT(S)

Women with unexplained infertility demonstrated significantly reduced uterine artery flow velocity in all phases, significantly elevated uterine and subendometrial artery impedance in the periovulatory and midluteal phases, and significantly reduced endometrial texture in the midproliferative phase. Women with tubal factor infertility demonstrated significantly reduced uterine artery flow velocity, without a concomitant increase in impedance, and significantly greater expression of endometrial glandular and luminal keratan sulphate.

CONCLUSION(S)

Unexplained infertility is associated with a profound impairment of endometrial perfusion that might be amenable to treatment by perfusion enhancers. Tubal factor infertility is associated with endometrial developmental defects that might be corrected by salpingectomy. Endometrial ultrasound and Doppler studies are likely to become a vital tool in the investigation of infertility.

Human embryo implantation: current knowledge and clinical implications in assisted reproductive technology

A pregnancy rate of approximately 15% per cycle renders the process of human reproduction inefficient. The cycle-dependent expression of molecules involved in the embryo-endometrial dialogue has lead to the identification of a 'window of implantation'. This is the unique temporal and spatial expression of factors that allows the embryo to implant (via signalling, appositioning, attachment and invasion) in a specific time frame of 48 h, 7-10 days after ovulation. Integrin molecules, L-selectin ligands, mucin-1, heparin-binding epidermal growth factor and pinopodes are involved in appositioning and attachment. The embryo produces cytokines and growth factors [interleukins, prostaglandins, vascular endothelial growth factor (VEGF)] and receptors for endometrial signals (leukaemia inhibitory factor receptor, colony stimulating factor receptor, insulin-like growth factors and heparin binding epidermal growth factor receptor). The immune system plays an important role. Immunomodulatory factors such as glycodelin, inhibin and interleukin prevent a graft-versus-host reaction. Angiogenesis controlled by VEGF and prostaglandins is needed for formation of a receptive endometrium and a placenta. Identification of these factors has led to their use as markers of implantation that may identify defects causing subfertility. An ideal marker of implantation is sensitive and specific, and easy to obtain without disturbing implantation. Glycodelin and leukaemia inhibitory factor (serum) and integrins and pinopodes (biopsies) are promising candidates.

Viviparous lizard,Eulamprus tympanum, shows changes in the uterine surface epithelium during early pregnancy that are similar to the plasma membrane transformation of mammals

The "plasma membrane transformation" describes a series of ultrastructural, biochemical, and morphological changes that occur in the uterus of many mammals at the time of blastocyst attachment. These changes, regardless of placental type or length of gestation, include alterations to microvillar length and density and the presence or absence of pinopods or uterodomes. Scanning electron microscopy (SEM) was used to 1) document the topographical ultrastructure of the uterus of Eulamprus tympanum, an eastern Australian viviparous skink with a simple chorioallantoic placenta, for the first time; and 2) determine whether changes identified as "plasma membrane transformation" in mammals occur in E. tympanum. Tissues collected over three seasons from nonreproductive subadult females, preovulatory, postovulatory, and early to mid-gestational females were examined. At low magnification the uterine epithelium of subadults displays a distinctive pattern of tissue folding that includes rectangular areas of tissue delineated by deep lateral and transverse folds. At higher magnification, the uterine epithelium surface is composed of two dominant cell types, i.e., those covered by microvilli and ciliated cells. The folding pattern observed in subadults is less evident in vitellogenic females and the cell surfaces appear highly secretory, with bulging cell apices. Tissue from postovulatory lizards has no distinctive folding pattern and cell surfaces are frequently smooth and lack microvilli. Uterine egg chambers lack ciliated cells at the embryonic pole, but display abundant secretory droplets. Thus, the uterus of E. tympanum undergoes a plasma membrane transformation. The scope of this transformation is not fully understood but may be related to the complexity of placental structure and the development of the embryo/fetus at parturition.

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.

Transmembrane and truncated (SEC) isoforms of MUC1 in the human endometrium and Fallopian tube

The cell surface mucin MUC1 is expressed by endometrial epithelial cells with increased abundance in the secretory phase of the menstrual cycle, when it is found both at the apical cell surface and in secretions. This suggests the presence of a maternal cell surface glycoprotein barrier to embryo implantation, arising from the anti-adhesive property of MUC1. In previous work, we demonstrated alternatively spliced MUC1 variant forms in tumour cells. The variant MUC1/SEC lacks the transmembrane and cytoplasmic sequences found in the full-length variant. We now show that MUC1/SEC mRNA is present in endometrial carcinoma cell lines, endometrial tissue and primary cultured endometrial epithelial cells. The protein can be detected using isoform-specific antibodies in uterine flushings, suggesting release from endometrium in vivo. However, on the basis of immunolocalisation studies, MUC1/SEC also remains associated with the apical epithelial surface both in tissue and in cultured cells. Transmembrane MUC1 and MUC1/SEC are both strikingly localised to the apical surface of tubal epithelium. Thus MUC1 may contribute to the anti-adhesive character of the tubal surface, inhibiting ectopic implantation. The mechanism by which this barrier is overcome in endometrium at implantation is the subject of ongoing investigation.

Evolution of viviparity: what can Australian lizards tell us?

Historically, Australia has been important in the study of, and the development of hypotheses aimed at understanding, the evolution of viviparity in amniote vertebrates. Part of the importance of Australia in the field results from a rich fauna of skinks, including one of the broadest ranges of diversity of placental structures within one geographic region. During the last decade, we have focussed our studies on one lineage, the Eugongylus group of skinks of the subfamily Lygosominae because it contains oviparous species and some that exhibit complex placentae. Our specific objective has been to attempt to understand the fundamental steps required when viviparity, and ultimately complex placentae, evolve from oviparous ancestors. We have taken a three-prong approach: (1) detailed study of the morphology and ontogeny of the placentae of key species at the light microscope level; (2) study of changes in the uterus associated with pregnancy, or the plasma membrane transformation; and (3) measures of the net exchange of nutrients across the placenta or eggshell of key species. In turn, we have found that: (1) details of the morphology and ontogeny of placentae are more complex that originally envisaged, and that the early conclusions about a sequence in the evolution of complex placentae was naïve; (2) a plasma membrane transformation occurs in viviparous, but not oviparous lizards, and thus may be a fundamental feature of the evolution of viviparity in amniotes; and (3) species with more complex chorioallantoic placentae tend to transport more nutrients across the placenta during pregnancy than those with simpler chorioallantoic placentae but, because the correlation is not tight, the importance of the omphaloplacenta in transporting nutrients may have been overlooked. Also, the composition of yolk of highly matrotrophic species is broadly similar, but not identical, to the yolk of oviparous species. Some of the interpretation of our data within the context of our specific objective is not yet possible, pending the publication of a robust phylogeny of Eugongylus group skinks. Once such a phylogeny is available, we are in a position to propose specific hypotheses about the evolution of viviparity that can be tested using another lineage of amniotes, possibly Mabuya group skinks.

Characteristics of the uterine luminal surface epithelium at preovulatory and preimplantation stages in the marmoset monkey

Light and electron microscopy was used to examine the apical luminal epithelial surface of the uterus at preovulatory and preimplantation stages in the marmoset monkey. Luminal surface charge, detected by cationic ferritin staining, progressively decreased from preovulation to day 11 of pregnancy. The smooth, regular apical plasma membrane at preovulatory stages was in contrast to the convoluted, irregular surface observed during early pregnancy, especially at 1 day before blastocyst implantation. Profiles of microvilli were also altered, becoming thicker and more irregular during early pregnancy. Within the epithelial cell body, cyclic morphologic changes were seen, largely in association with secretory organelles. Giant phagocytic bodies were prominent at all stages examined, although their composition and intensity of staining varied throughout the cycle. Weak to moderate estrogen alpha and progesterone receptor immunostaining of the luminal epithelium was found during preovulatory and early pregnancy stages. This study describes complex cyclic changes in the morphology and biochemical make-up of the uterine luminal epithelial surface in a New World monkey in preparation for blastocyst attachment.

Manipulation of the follicular phase: Uterodomes and pregnancy - is there a correlation?

BACKGROUND: Manipulation of the follicular phase uterine epithelium in women undergoing infertility treatment, has not generally shown differing morphological effects on uterine epithelial characteristics using Scanning Electron Microscopy (SEM) and resultant pregnancy rates have remained suboptimal utilising these manipulations. The present study observed manipulation of the proliferative epithelium, with either 7 or 14 days of sequential oestrogen (E) therapy followed by progesterone (P) and assessed the appearance of pinopods (now called uterodomes) for their usefulness as potential implantation markers in seven women who subsequently became pregnant. Three endometrial biopsies per patient were taken during consecutive cycles: day 19 of a natural cycle - (group 1), days 11/12 of a second cycle after 7 days E then P - (group 2), and days 19/22 of a third cycle after 14 days E then P - (group 3). Embryo transfer (ET) was performed in a subsequent long treatment cycle (as per Group 3). RESULTS: Seven pregnancies resulted in seven viable births including one twins and one miscarriage. Analysis of the individual regimes showed 5 days of P treatment to have a higher correlation for uterodomes in all 3 cycles observed individually. It was also observed that all 7 women demonstrated the appearance of uterodomes in at least one of their cycles. CONCLUSIONS: We conclude that manipulation of the follicular phase by shortening the period of E exposure to 7 days, does not compromise uterine epithelial morphology and we add weight to the conclusion that uterodomes indicate a receptive endometrium for implantation.

A successful pregnancy following SEM fine tuning of hormonal priming

BACKGROUND: Manipulation of the uterine epithelium utilising standard dose exogenous oestrogen (E2) and progesterone (P4) has been shown to achieve a mature secretory morphological response. However, in an in vitro fertilisation (IVF) setting, frozen embryo transfer (ET) has had a low success rate. We propose that in patients with previously failed ET attempts, the uterine epithelium can be directly visualised by biopsy and Scanning Electron Microscopy (SEM) and that with an individualised fine tuning of the hormone supplementation regime, based on the SEM examination of sequential uterine biopsies, it is possible to provide a uterine environment conducive to successful ET. METHODS: A 47 year old women was chosen for endometrial biopsy, histopathological dating and endometrial observation utilising SEM to determine the integrity of her secretory uterine epithelium because of her age and several previously failed attempts at frozen ET. Exogenous E2 and P4 supplementation was administered in modified doses according to the SEM result, in consecutive cycles until the epithelial response appeared satisfactory for potential implantation. RESULTS: This case study demonstrates the dramatic change in epithelial characteristics that can be achieved as a response to these altered doses of E2 and P4. The uterine morphology changed from a hypotrophic to a mature, receptive epithelium such that ET resulted in the birth of healthy twin boys. CONCLUSION: The comparison between the consecutive biopsies in direct response to the SEM analysis and tailored modification of E2 and P4 dose clearly demonstrates, in this case, the effectiveness of individual morphological monitoring to maximise the successful outcome of ET.