Reproduction of menstrual changes in transplanted human endometrial tissue in immunodeficient mice

Early GnRH-agonist therapy does not negatively impact the endometrial repair process or live birth rate

Study objective

To investigate whether different timings of GnRH-a downregulation affected assisted reproductive outcomes in infertile women with moderate-to-severe intrauterine adhesions (IUAs) accompanied by adenomyosis.

Design

A retrospective case series.

Setting

An assisted reproductive technology center.

Patients

The study reviewed 123 infertile women with moderate-to-severe IUAs accompanied by adenomyosis undergoing their first frozen-thawed embryo transfer (FET) cycles between January 2019 and December 2021.

Measurements and main results

The majority of patients had moderate IUA (n=116, 94.31%). The average Basal uterine volume was 73.58 ± 36.50 cm3. The mean interval from operation to the first downregulation was 21.07 ± 18.02 days (range, 1-79 days). The mean duration of hormone replacement therapy (HRT) was 16.93 ± 6.29 days. The average endometrial thickness on the day before transfer was 10.83 ± 1.75 mm. A total of 70 women achieved clinical pregnancy (56.91%). Perinatal outcomes included live birth (n=47, 67.14%), early miscarriage (n=18, 25.71%), and late miscarriage (n=5, 7.14%). The time interval between uterine operation and the first downregulation was not a significant variable affecting live birth. Maternal age was the only risk factor associated with live birth (OR:0.89; 95% CI: 0.79-0.99, P=0.041).

Conclusions

The earlier initiation of GnRH-a to suppress adenomyosis prior to endometrial preparation for frozen embryo transfer did not negatively impact repair of the endometrium after resection.

Decreased CD56+CD16-CD94+uNK cells in the mid-luteal phase in women with recurrent implantation failure are associated with IL-15 deficiency

PROBLEM

Whether the abnormal development of uterine natural killer (uNK) cells contributes to women with recurrent implantation failure (RIF) remains unclear.

METHOD OF STUDY

We characterized the development of uNK cells and peripheral blood NK cells (pbNK) in the mid-luteal phase in women with RIF (n = 31) and controls (n = 14) by flow cytometry. Endometrial IL-15 mRNA expression was studied by quantitative reverse transcription-PCR. The GSE58144 dataset was used to validate the correlation results.

RESULTS

We found decreased proportions of stage 4 CD56+CD16-CD94+ uNK cells (median: 9.56% vs. 17.78%, P .014) and increased proportions of stage 6 CD56+CD16+CD57+ uNK cells (median: 1.54% vs. 0.74%, P = .020) in the mid-luteal endometrium of women with RIF compared to fertile women. We also found that there was no quantitative correlation between uNK cells and the corresponding pbNK cell subpopulations (P > .05). In addition, IL-15 mRNA levels in the mid-luteal endometrium were positively correlated with the proportion of CD56+ uNK cells (r = .392, P = .008), especially with stage 4 uNK cell populations (r = .408, P = .005).

CONCLUSIONS

We showed that the proportion of stage 4 uNK cells decreased in the RIF group compared to controls, and the decrease in stage 4 uNK cells correlated positively with low IL-15 mRNA expression. We suggest that the reduced stage 4 uNK cells in women with RIF are associated with IL-15 deficiency.

Endometrial Stem/Progenitor Cells–Their Role in Endometrial Repair and Regeneration

The human endometrium is a remarkable tissue, undergoing ~450 cycles of proliferation, differentiation, shedding (menstruation), repair, and regeneration over a woman's reproductive lifespan. Post-menstrual repair is an extremely rapid and scar-free process, with re-epithelialization of the luminal epithelium completed within 48 h of initiation of shedding. Following menstruation, the functionalis grows from the residual basalis layer during the proliferative phase under the influence of rising circulating estrogen levels. The regenerative capacity of the endometrium is attributed to stem/progenitor cells which reside in both the epithelial and stromal cell compartments of the basalis layer. Finding a definitive marker for endometrial epithelial progenitors (eEPCs) has proven difficult. A number of different markers have been suggested as putative progenitor markers including, N-cadherin, SSEA-1, AXIN2, SOX-9 and ALDH1A1, some of which show functional stem cell activity in in vitro assays. Each marker has a unique location(s) in the glandular epithelium, which has led to the suggestion that a differentiation hierarchy exists, from the base of epithelial glands in the basalis to the luminal epithelium lining the functionalis, where epithelial cells express different combinations of markers as they differentiate and move up the gland into the functionalis away from the basalis niche. Perivascular endometrial mesenchymal stem cells (eMSCs) can be identified by co-expression of PDGFRβ and CD146 or by a single marker, SUSD2. This review will detail the known endometrial stem/progenitor markers; their identity, location and known interactions and hierarchy across the menstrual cycle, in particular post-menstrual repair and estrogen-driven regeneration, as well as their possible contributions to menstruation-related disorders such as endometriosis and regeneration-related disorder Asherman's syndrome. We will also highlight new techniques that allow for a greater understanding of stem/progenitor cells' role in repair and regeneration, including 3D organoids, 3D slice cultures and gene sequencing at the single cell level. Since mouse models are commonly used to study menstruation, repair and regeneration we will also detail the mouse stem/progenitor markers that have been investigated in vivo.

The Role of Uterine Natural Killer Cells on Recurrent Miscarriage and Recurrent Implantation Failure: From Pathophysiology to Treatment

Uterine natural killer (uNK) cells constitute a unique uterine leucocyte subpopulation facilitating implantation and maintaining pregnancy. Herein, we critically analyze current evidence regarding the role of uNK cells in the events entailed in recurrent implantation failure (RIF) and recurrent miscarriages (RM). Data suggest an association between RIF and RM with abnormally elevated uNK cells’ numbers, as well as with a defective biological activity leading to cytotoxicity. However, other studies do not concur on these associations. Robust data suggesting a definitive causative relationship between uNK cells and RIF and RM is missing. Considering the possibility of uNK cells involvement on RIF and RM pathophysiology, possible treatments including glucocorticoids, intralipids, and intravenous immunoglobulin administration have been proposed towards addressing uNK related RIF and RM. When considering clinical routine practice, this study indicated that solid evidence is required to report on efficiency and safety of these treatments as there are recommendations that clearly advise against their employment. In conclusion, defining a causative relationship between uNK and RIF–RM pathologies certainly merits investigation. Future studies should serve as a prerequisite prior to proposing the use of uNK as a biomarker or prior to targeting uNK cells for therapeutic purposes addressing RIF and RM.

Uterine natural killer cell biology and role in early pregnancy establishment and outcomes

Objective

While immune cells were originally thought to only play a role in maternal tolerance of the semiallogenic fetus, an active role in pregnancy establishment is becoming increasingly apparent. Uterine natural killer (uNK) cells are of specific interest because of their cyclic increase in number during the window of implantation. As a distinct entity from their peripheral blood counterparts, understanding the biology and function of uNK cells will provide the framework for understanding their role in early pregnancy establishment and adverse pregnancy outcomes.

Evidence Review

This review discusses unique uNK cell characteristics and presents clinical implications resulting from their dysfunction. We also systematically present existing knowledge about uNK cell function in three processes critical for successful human embryo implantation and placentation: stromal cell decidualization, spiral artery remodeling, and extravillous trophoblast invasion. Finally, we review the features of uNK cells that could help guide future investigations.

Results

It is clear the uNK cells are intimately involved in multiple facets of early pregnancy. This is accomplished directly, through the secretion of factors that regulate stromal cells and trophoblast function; and indirectly, via interaction with other maternal cell types present at the maternal-fetal interface. Current work also suggests that uNK cells are a heterogenous population, with subsets that potentially accomplish different functions.

Conclusion

Establishment of pregnancy through successful embryo implantation and placentation requires crosstalk between multiple maternal cell types and invading fetal trophoblast cells. Defects in this process have been associated with multiple adverse perinatal outcomes including hypertensive disorders of pregnancy, placenta accreta, and recurrent miscarriage though the mechanism underlying development of these defects remain unclear. Abnormalities in NK cell number and function which would disrupt physiological maternal-fetal crosstalk, could play a critical role in abnormal implantation and placentation. It is therefore imperative to dissect the unique physiological role of uNK cells in pregnancy and use this knowledge to inform clinical practice by determining how uNK cell dysfunction could lead to reproductive failure.

Biology and pathology of the uterine microenvironment and its natural killer cells

Tissues are the new frontier of discoveries in immunology. Cells of the immune system are an integral part of tissue physiology and immunity. Determining how immune cells inhabit, housekeep, and defend gut, lung, brain, liver, uterus, and other organs helps revealing the intimate details of tissue physiology and may offer new therapeutic targets to treat pathologies. The uterine microenvironment modulates the development and function of innate lymphoid cells [ILC, largely represented by natural killer (NK) cells], macrophages, T cells, and dendritic cells. These immune cells, in turn, contribute to tissue homeostasis. Regulated by ovarian hormones, the human uterine mucosa (endometrium) undergoes ~400 monthly cycles of breakdown and regeneration from menarche to menopause, with its fibroblasts, glands, blood vessels, and immune cells remodeling the tissue into the transient decidua. Even more transformative changes occur upon blastocyst implantation. Before the placenta is formed, the endometrial glands feed the embryo by histiotrophic nutrition while the uterine spiral arteries are stripped of their endothelial layer and smooth muscle actin. This arterial remodeling is carried out by invading fetal trophoblast and maternal immune cells, chiefly uterine NK (uNK) cells, which also assist fetal growth. The transformed arteries no longer respond to maternal stimuli and meet the increasing demands of the growing fetus. This review focuses on how the everchanging uterine microenvironment affects uNK cells and how uNK cells regulate homeostasis of the decidua, placenta development, and fetal growth. Determining these pathways will help understand the causes of major pregnancy complications.

Uterine natural killer cells: from foe to friend in reproduction

BACKGROUND

Recurrent miscarriage and pre-eclampsia are common reproductive disorders, but their causes are often unknown. Recent evidence has provided new insight into immune system influences in reproductive disorders. A subset of lymphocytes of the innate immune system known as uterine natural killer (uNK) cells are now recognized as fundamental to achieving embryo implantation and successful pregnancy, but were initially attributed a bad reputation. Indeed, immune therapies have been developed to treat the 'exaggerated' immune response from uNK cells. These treatments have been based on studies of peripheral blood natural killer (pbNK) cells. However, uNK cells and pbNK cells have different phenotypic and functional characteristics. The functions of uNK cells are closely related to their interactions with the extravillous trophoblast cells (EVTs) and spiral arteries, which underlie an essential role in regulating vascular function, controlling trophoblast invasion and promoting placental development. EVTs express MHC molecules of class I HLA-C/E/G/F, while uNK cells express, among other receptors, killer cell immunoglobulin-like receptors (KIRs) that bind to HLA-C or CD94/NKG2A inhibitory receptors, and then bind HLA-E. Associations of certain KIR/HLA-C combinations with recurrent miscarriage, pre-eclampsia, and foetal growth restriction and the interactions between uNK cells, trophoblasts and vascular cells have led to the hypothesis that uNK cells may play a role in embryo implantation.

OBJECTIVE AND RATIONALE

Our objective was to review the evolution of our understanding of uNK cells, their functions, and their increasingly relevant role in reproduction.

SEARCH METHODS

Relevant literature through June 2020 was retrieved using Google Scholar and PubMed. Search terms comprised uNK cells, human pregnancy, reproductive failure, maternal KIR and HLA-C, HLA-E/G/F in EVT cells, angiogenic cytokines, CD56+ NK cells, spiral artery, oestrogen and progesterone receptors, KIR haplotype and paternal HLA-C2.

OUTCOMES

This review provides key insights into the evolving conceptualization of uNK cells, from their not-so-promising beginnings to now, when they are considered allies in reproduction. We synthesized current knowledge about uNK cells, their involvement in reproduction and their main functions in placental vascular remodeling and trophoblast invasion. One of the issues that this review presents is the enormous complexity involved in studying the immune system in reproduction. The complexity in the immunology of the maternal-foetal interface lies in the great variety of participating molecules, the processes and interactions that occur at different levels (molecular, cellular, tissue, etc.) and the great diversity of genetic combinations that are translated into different types of responses.

WIDER IMPLICATIONS

Insights into uNK cells could offer an important breakthrough for ART outcomes, since each patient could be assessed based on the combination of HLA and its receptors in their uNK cells, evaluating the critical interactions at the materno-foetal interface. However, owing to the technical challenges in studying uNK cells in vivo, there is still much knowledge to gain, particularly regarding their exact origin and functions. New studies using novel molecular and genetic approaches can facilitate the identification of mechanisms by which uNK cells interact with other cells at the materno-foetal interface, perhaps translating this knowledge into clinical applicability.

How Do Uterine Natural Killer and Innate Lymphoid Cells Contribute to Successful Pregnancy?

Innate lymphoid cells (ILCs) are the most abundant immune cells in the uterine mucosa both before and during pregnancy. Circumstantial evidence suggests they play important roles in regulating placental development but exactly how they contribute to the successful outcome of pregnancy is still unclear. Uterine ILCs (uILCs) include subsets of tissue-resident natural killer (NK) cells and ILCs, and until recently the phenotype and functions of uILCs were poorly defined. Determining the specific roles of each subset is intrinsically challenging because of the rapidly changing nature of the tissue both during the menstrual cycle and pregnancy. Single-cell RNA sequencing (scRNAseq) and high dimensional flow and mass cytometry approaches have recently been used to analyse uILC populations in the uterus in both humans and mice. This detailed characterisation has significantly changed our understanding of the heterogeneity within the uILC compartment. It will also enable key clinical questions to be addressed including whether specific uILC subsets are altered in infertility, miscarriage and pregnancy disorders such as foetal growth restriction and pre-eclampsia. Here, we summarise recent advances in our understanding of the phenotypic and functional diversity of uILCs in non-pregnant endometrium and first trimester decidua, and review how these cells may contribute to successful placental development.

The Elusive Endometrial Epithelial Stem/Progenitor Cells

The human endometrium undergoes approximately 450 cycles of proliferation, differentiation, shedding and regeneration over a woman's reproductive lifetime. The regenerative capacity of the endometrium is attributed to stem/progenitor cells residing in the basalis layer of the tissue. Mesenchymal stem cells have been extensively studied in the endometrium, whereas endometrial epithelial stem/progenitor cells have remained more elusive. This review details the discovery of human and mouse endometrial epithelial stem/progenitor cells. It highlights recent significant developments identifying putative markers of these epithelial stem/progenitor cells that reveal their in vivo identity, location in both human and mouse endometrium, raising common but also different viewpoints. The review also outlines the techniques used to identify epithelial stem/progenitor cells, specifically in vitro functional assays and in vivo lineage tracing. We will also discuss their known interactions and hierarchy and known roles in endometrial dynamics across the menstrual or estrous cycle including re-epithelialization at menses and regeneration of the tissue during the proliferative phase. We also detail their potential role in endometrial proliferative disorders such as endometriosis.

Vascular Adhesion Protein-1 Determines the Cellular Properties of Endometrial Pericytes

Vascular adhesion protein-1 (VAP-1) is an inflammation-inducible adhesion molecule and a primary amine oxidase involved in immune cell trafficking. Leukocyte extravasation into tissues is mediated by adhesion molecules expressed on endothelial cells and pericytes. Pericytes play a major role in the angiogenesis and vascularization of cycling endometrium. However, the functional properties of pericytes in the human endometrium are not known. Here we show that pericytes surrounding the spiral arterioles in midluteal human endometrium constitutively express VAP-1. We first characterize these pericytes and demonstrate that knockdown of VAP-1 perturbed their biophysical properties and compromised their contractile, migratory, adhesive and clonogenic capacities. Furthermore, we show that loss of VAP-1 disrupts pericyte-uterine natural killer cell interactions in vitro. Taken together, the data not only reveal that endometrial pericytes represent a cell population with distinct biophysical and functional properties but also suggest a pivotal role for VAP-1 in regulating the recruitment of innate immune cells in human endometrium. We posit that VAP-1 could serve as a potential biomarker for pregnancy pathologies caused by a compromised perivascular environment prior to conception.

Placental bed research: I. The placental bed: from spiral arteries remodeling to the great obstetrical syndromes

The term placental bed was coined to describe the maternal-fetal interface (ie, the area in which the placenta attaches itself to the uterus). Appropriate vascularization of this area is of vital importance for the development of the fetus; this is why systematic investigations of this area have now been carried out. Initially, the challenge was the identification and classification of the various successive branching of uterine arteries in this area. These vessels have a unique importance because failure of their physiological transformation is considered to be the anatomical basis for reduced perfusion to the intervillous space in women with preeclampsia, fetal growth restriction, preterm labor, preterm premature rupture of membranes, abruptio placentae, and fetal death. To investigate in depth the pathophysiology of the placental bed, some 60 years ago, a large number of placental bed biopsies, as well as of cesarean hysterectomy specimens with placenta in situ, from both early and late normotensive and hypertensive pregnancies, were carefully dissected and analyzed. Thanks to the presence of a series of specific physiological changes, characterized by the invasion and substitution of the arterial intima by trophoblast, this material allowed the identification in the placental bed of normal pregnancies of the main vessels, the uteroplacental arteries. It was then discovered that preeclampsia is associated with defective or absent transformation of the myometrial segment of the uteroplacental arteries. In addition, in severe hypertensive disease, atherosclerotic lesions were also found in the defective myometrial segment. Finally, in the basal decidua, a unique vascular lesion, coined acute atherosis, was also identified This disorder of deep placentation, coined defective deep placentation, has been associated with the great obstetrical syndromes, grouping together preeclampsia, intrauterine growth restriction, preterm labor, preterm premature rupture of membranes, late spontaneous abortion, and abruptio placentae. More recently, simplified techniques of tissue sampling have been also introduced: decidual suction allows to obtain a large number of decidual arteries, although their origin in the placental bed cannot be determined. Biopsies parallel to the surface of the basal plate have been more interesting, making possible to identify the vessels' region (central, paracentral, or peripheral) of origin in the placental bed and providing decidual material for immunohistochemical studies. Finally, histochemical and electron microscopy investigations have now clarified the pathology and pathogenetic mechanisms underlying the impairment of the physiological vascular changes.

Uterine natural killer cells: Time for a re-appraisal?

The presence of unusual natural killer cells in human endometrium has been recognized for 30 years, but despite considerable research effort, the in vivo role of uterine natural killer (uNK) cells in both normal and pathological pregnancy remains uncertain. uNK cells may differentiate from precursors present in endometrium, but migration from peripheral blood in response to chemokine stimuli with in situ modification to a uNK cell phenotype is also possible. uNK cells produce a wide range of secretory products with diverse effects on trophoblast and spiral arteries which may play an important role in implantation and early placentation. Interactions with other decidual cell populations are also becoming clear. Recent evidence has demonstrated subpopulations of uNK cells and the presence of other innate lymphoid cell populations in decidua which may refine future approaches to investigation of the role of uNK cells in human pregnancy.

Ovarian and endometrial immunity during the ovarian cycle

Immune tolerance is crucial for the successful pregnancy, while immune effectors and their products are required to safeguard a fetus from the infectious pathogens. The key immune effectors, such as T, B, and natural killer (NK) cells, monocytes, macrophages, and dendritic cells take part in regulating the immune responses at the maternal-fetal interface. The immune effectors become involved in intraovarian reproductive processes as well, such as ovulation, production of corpus luteum (CL) and its degeneration and determine the quality and evolution of the oocyte during the folliculogenesis. In the cycling endometrium, NK cells are rapidly infiltrated into the endometrium after ovulation and participate in angiogenesis and spiral artery remodeling process. In this study, we reviewed the characteristics and action mechanisms of immune effectors and their products in the peripheral blood, ovary, and endometrium during the ovarian cycle, since a comprehensive understanding of immune responses during the ovarian cycle and the time of implantation can help us to predict the pregnancy outcome and take effective measures for the prevention of potential obstetrical complications.

Xenografted tissue models for the study of human endometrial biology

The human endometrium undergoes extensive morphological, biochemical and molecular changes under the influence of female sex steroid hormones. Besides the fact that estrogen stimulates endometrial cell proliferation and progesterone inhibits this proliferation and induces differentiation, there is limited knowledge about precise molecular mechanisms underlying human endometrial biology. The importance of paracrine signaling in endometrial physiology explains why in vitro culture of endometrial cells has been challenging. Researchers, therefore, have developed alternative experimental in vivo models for the study of endometrial biology. The objective of this review is to summarize the recent developments and work on these in vivo endometrial research models. The in vivo recombinant tissue models in which wild-type endometrial cells are combined with endometrial cells from a gene-targeted mouse strain followed by xenografting to host mice have been critical in confirming the significance of paracrine signaling between the epithelium and stroma in the growth regulation of the endometrium. Additionally, these studies have uncovered differences between the mouse and human, emphasizing the need for the development of experimental models specifically of the human endometrium. Recently, xenotransplants of human endometrial fragments into the subcutaneous space of host mice and endometrial xenografts of dissociated and recombined epithelial and stromal cells beneath the kidney capsule of immunodeficient host mice have proven to be highly promising tools for in vivo research of endometrial functions. For the first time, the latter approach provides an immense opportunity for the application of genome engineering, such as targeted ablation of endometrial genes for example by using CRISPR/CAS9 system. This research will begin to elucidate the functional role of specific genes in this complex tissue. Another advantage of xenotransplantation and xenograft models of the human endometrium is their use to investigate endometrial effects of new compounds and drugs without needing to give them to women. Underpinning the molecular mechanisms underlying endometrial functions is critical to ultimately advance our understanding of endometrial pathophysiology and develop targeted therapies to prevent and cure endometrial pathologies as well as enhance endometrial function when it is desired for fertility.

Differentiation of human umbilical cord Wharton's jelly-derived mesenchymal stem cells into endometrial cells

BACKGROUND

Wharton's jelly-derived mesenchymal stem cells (WJ-MSCs) are a novel and promising strategy for tissue engineering because of their ability to differentiate into many cell types. We characterized the differentiation of WJ-MSCs into endometrial epithelial cell (EEC)-like and endometrial stromal cell (ESC)-like cells and assessed the effect of 17β-estradiol and 8-Br-cAMP on the differentiation system.

METHODS

WJ-MSCs were treated in two ways to differentiate into EEC-like and ESC-like cells respectively: cocultured with ESCs in control/differentiation medium (17β-estradiol, growth factors); and cultured in control/differentiation medium (8-Br-cAMP alone or 8-Br-cAMP plus 17β-estrogen and growth factors). Three signaling pathway inhibitors (SB203580, PD98059, H89) were used to investigate the mechanism of WJ-MSC differentiation into ESC-like cells. Immunofluorescence, western blot and flow cytometry analyses were used to analyze expression of epithelial markers and stromal cell markers. Enzyme-linked immunosorbent assays were used to test the production of secretory proteins associated with the differentiation of ESC-like cells.

RESULTS

17β-estradiol at 1 μM downregulated vimentin and CD13 and upregulated cytokeratin and CD9 proteins, promoting the differentiation of WJ-MSCs into EEC-like cells in the coculture system. 8-Br-cAMP at 0.5 mM upregulated vimentin and CD13 and downregulated CK and CD9, promoting the differentiation of WJ-MSCs into ESC-like cells. Prolactin (PRL) and insulin-like growth factor-binding protein 1 (IGFBP1) were upregulated and the protein kinase A (PKA) signaling pathway was activated, whereas extracellular signal-regulated (ERK)1/2 and p38 mitogen-activated protein kinase (MAPK) were not affected.

CONCLUSIONS

17β-estradiol at 1 μM is a good inducer for facilitating the differentiation of WJ-MSCs into EEC-like cells. 8-Br-cAMP plus estrogen and growth factors can induce the differentiation of WJ-MSCs into ESC-like cells. During the differentiation of WJ-MSCs into ESC-like cells, PRL and IGFBP1 were upregulated by the treatment and the PKA signaling pathway was activated, whereas ERK1/2 and p38 MAPK were not affected. These findings suggest a promising approach to the treatment of endometrial damage and other endometrial diseases and suggest new applications for WJ-MSCs in clinical practice.

Uterine Natural Killer Cells: Functional Distinctions and Influence on Pregnancy in Humans and Mice

Our understanding of development and function of natural killer (NK) cells has progressed significantly in recent years. However, exactly how uterine NK (uNK) cells develop and function is still unclear. To help investigators that are beginning to study tissue NK cells, we summarize in this review our current knowledge of the development and function of uNK cells, and what is yet to be elucidated. We compare and contrast the biology of human and mouse uNK cells in the broader context of the biology of innate lymphoid cells and with reference to peripheral NK cells. We also review how uNK cells may regulate trophoblast invasion and uterine spiral arterial remodeling in human and murine pregnancy.

Evaluation of endometrial natural killer cell expression of CD4, CD103, and CD16 cells in women with unexplained infertility

OBJECTIVE

To determine whether natural killer cell (NK) concentrations in the mid-secretory endometrial tissue of women with unexplained infertility differ from those in the mid-secretory endometrial tissue of fertile women.

METHODS

This study was conducted with 22 patients with unexplained infertility caused by unsuccessful ovulation induced with gonadotrophins and 12 healthy fertile women, who formed a control group. Mid-secretory endometrial tissue samples were obtained with a Pipelle catheter, and the endometrial NK cell phenotypes were determined by flow cytometry.

RESULTS

The median number of CD4+ cells in the endometrium was significantly lower in women with unexplained infertility compared with in the fertile controls (3.31 vs. 5.81; p=0.02). The CD4(+)/CD8(+) cell ratio in the unexplained-infertility group was significantly lower than that in the control group (0.42 vs. 0.76, p=0.01). The median number of CD103(+) cells in the endometrium of the infertile group was significantly lower than that in the endometrium of the control group (4.40 vs. 6.73, p=0.02). The median number of CD16(+) cells was significantly higher in infertile women than in control women (0.12 vs. 0.001, p=0.01).

CONCLUSIONS

Significant reductions in the numbers of CD4(+) and CD103(+) cells as well as in the CD4(+)/CD8(+) ratio but an increased number of CD16(+) cells in the endometrium of infertile women suggest that disordered NK cell activity may be a contributor to the etiology of unexplained infertility.

Animal Models in Endometriosis Research

The initiation of endometriosis in women is difficult to investigate, because there is usually a delay of several years from the onset of lesion development to the clinical diagnosis. Animal models of endometriosis, on the other hand, provide an important contribution to the investigation of the disease pathogenesis and the efficacy of therapeutic intervention strategies.

Induction of post-menstrual regeneration by ovarian steroid withdrawal in the functionalis of xenografted human endometrium

STUDY QUESTION

Does the endometrial functionalis have the potential to undergo self-renewal after menstruation and how is this process controlled by ovarian steroids?

SUMMARY ANSWER

Endometrial xenografts subjected to withdrawal of estradiol and progesterone shrink but also show signs of proliferation and tissue repair; new estradiol supply prevents atrophy but is not sufficient to increase graft volume.

WHAT IS KNOWN ALREADY

Menstruation, i.e. cyclic proteolysis of the extracellular matrix of endometrial functionalis, is induced by a fall in estrogen and progesterone concentration and is followed by tissue regeneration. However, there is debate about whether regenerating cells must originate from the basalis or from stem cells and whether new estrogen supply is required for the early repair concomitant with menstruation.

STUDY DESIGN, SIZE, DURATION

Fragments from human endometrial functionalis (from 24 hysterectomy specimens) were xenografted in ovariectomized SCID mice and submitted to a 4-day estradiol and progesterone withdrawal (to mimic menstruation) followed by re-exposure to estradiol (to mimic the proliferative phase). We measured signs of proliferation and changes in graft volume.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Endometrium was collected from spontaneously cycling women. Cell proliferation was examined by immunolabeling Ki-67, cyclin D1 and phosphorylated-histone H3. Xenograft volume was measured by magnetic resonance imaging. Xenograft histomorphometry was performed to determine how the different tissue compartments contributed to volume change.

MAIN RESULTS AND THE ROLE OF CHANCE

Hormone withdrawal induced a rapid decrease in graft volume mainly attributable to stroma condensation and breakdown, concomitant with an increase of proliferation markers. Reinsertion of estradiol pellets after induced menstruation blocked volume decrease and stimulated epithelial and stromal growth, but, surprisingly, did not induce graft enlargement. Reinsertion of both estradiol and progesterone pellets blocked apoptosis.

LIMITATIONS, REASONS FOR CAUTION

Mechanisms of endometrial remodeling are different in women and mice and the contribution of circulating inflammatory cells in both species remains to be clarified. Moreover, during human menstruation, endometrial fragments resulting from tissue proteolysis can be expelled by the menstrual flow, unlike in this model.

WIDER IMPLICATIONS OF THE FINDINGS

Menstruation is a multifocal event within the functionalis. This is the first evidence that endometrial fragments that are not shed after menstrual tissue breakdown can support endometrial regeneration. Endometriosis is commonly thought to result from the retrograde migration of menstrual fragments of the degraded functionalis into the peritoneal cavity. Our study supports their potential to regenerate as ectopic endometrium.

STUDY FUNDING/COMPETING INTERESTS

This work was supported by the Fonds de la Recherche Scientifique Médicale, Concerted Research Actions, Communauté Française de Belgique, Région wallonne, Région bruxelloise and Loterie nationale. P.H. and B.F.J. are research associates of the Belgian Fonds de la Recherche Scientifique (F.R.S.-F.N.R.S.). E.M. is Associate Editor at Human Reproduction. There is no conflict of interest to declare.

The Role of Uterine NK Cells in Normal Reproduction and Reproductive Disorders

The human endometrium contains a substantial population of leucocytes which vary in distribution during the menstrual cycle and pregnancy. An unusual population of natural killer (NK) cells, termed uterine NK (uNK) cells, are the most abundant of these cells in early pregnancy. The increase in number of uNK cells in the mid-secretory phase of the cycle with further increases in early pregnancy has focused attention on the role of uNK cells in early pregnancy. Despite many studies, the in vivo role of these cells is uncertain. This chapter reviews current information regarding the role of uNK cells in healthy human pregnancy and evidence indicating their importance in various reproductive and pregnancy problems. Studies in humans are limited by the availability of suitable tissues and the limitations of extrapolation from animal models.

The importance of the macrophage within the human endometrium

The human endometrium is exposed to cyclical fluctuations of ovarian-derived sex steroids resulting in proliferation, differentiation (decidualization), and menstruation. An influx of leukocytes (up to 15% macrophages) occurs during the latter stages of the menstrual cycle, including menses. We believe the endometrial macrophage is likely to play an important role during the menstrual cycle, especially in the context of tissue degradation (menstruation), which requires regulated repair, regeneration, and phagocytic clearance of endometrial tissue debris to re-establish tissue integrity in preparation for fertility. The phenotype and regulation of the macrophage within the endometrium during the menstrual cycle and interactions with other cell types that constitute the endometrium are currently unknown and are important areas of study. Understanding the many roles of the endometrial macrophage is crucial to our body of knowledge concerning functionality of the endometrium as well as to our understanding of disorders of the menstrual cycle, which have major impacts on the health and well-being of women.

Commitment of decidual haematopoietic progenitor cells in first trimester pregnancy

PROBLEM  The aim of this study was to investigate the phenotype and commitment of decidual haematopoietic progenitor cells (HPCs) in healthy pregnant women and in women with early miscarriage. METHOD OF STUDY  Peripheral blood and decidual tissue from healthy and pathological pregnant women were examined for HPCs and lymphoid progenitors using flow cytometric analysis. RESULTS  Compared with peripheral blood, we found a significant increase in decidual HPCs in both healthy pregnant women and women with spontaneous abortion. T/NK, natural killer (NK), gamma-delta and NKT cell progenitors were identified in all peripheral blood and decidual samples. In pathologic pregnant women, the ratios of decidual T/NK and NK cell progenitors were significantly increased compared with healthy pregnant controls. CONCLUSION  We demonstrated decidual cells with haematopoietic progenitor cell phenotype in human decidua. Increased levels of NK progenitors in the decidua of women with early spontaneous abortion suggest a dysregulation of this pathway that may contribute to pregnancy failure.

Establishment of a novel xenograft model for human uterine leiomyoma in immunodeficient mice

Uterine leiomyomas are the most common gynecological benign tumor and greatly affect reproductive health and wellbeing, but the pathophysiology and epidemiology of uterine leiomyoma are poorly understood. One of the major reasons for the slow progress in leiomyoma research is the lack of a good in vivo model system. We therefore aimed to develop a novel model by transplanting human uterine leiomyoma xenografts in an immunodeficient mouse strain (NOD/SCID/gammac-null: NOG). Human uterine leiomyoma tissues were cut into small pieces and inserted subcutaneously into the right and left flanks of NOG mice. Estrogen supplementation was needed to maintain the features of uterine leiomyoma in xenografted tissues. After 4 weeks or 8 weeks of transplantation, xenografted tissues were harvested and analyzed regarding tissue morphology, collagen content, and proliferation and apoptosis of uterine leiomyoma smooth muscle cells. The xenografts that were harvested after 4 weeks and 8 weeks retained the histological architecture of original uterine leiomyoma tissue both in cellular and collagen components. The expression profiles of key markers of uterine leiomyoma were also maintained, including estrogen receptor, progesterone receptor, and alpha-smooth muscle actin, as judged by immunohistochemical staining. The proportion of proliferating cells was significantly increased (1.5-fold) in the xenografts after 8 weeks of transplantation, whereas that of the apoptotic cells remained unchanged. Importantly, the reproducible results were obtained with the tumor tissues derived from six patients. The present in vivo model may provide a useful tool for development of novel therapeutic strategies for uterine leiomyoma.

Establishment of long-term model throughout regular menstrual cycles in immunodeficient mice

PROBLEM

The number of uterus natural killer (NK) cells change through the menstrual cycle, but the origin of uterus NK cell was not unclear. Our aims are to study whether we can reproduce repetition of menstrual cycle and to reveal the origin of uterus NK cells.

METHOD OF STUDY

Endometrial samples were obtained from fertile women, and the tissues were transplanted into ovariectomized non-obese diabetic (NOD)/severe combined immunodeficiency (SCID)/γCnull (NOG) mice. Mice were treated with sex hormones which were in accord with human menstrual cycle.

RESULTS

The replants showed similar histological changes as in eutopic endometrium repeatedly. CD56-positive, CD16-negative NK cells increased significantly during the treatment with estradiol and progesterone combination.

CONCLUSION

Histological assessment demonstrated that this model of NOG mice repeatedly exhibited regular menstrual cycles, and this model mimicked not 'ectopic endometrium', but 'eutopic endometrium' in humans. Change in number of NK cells suggested that NK cell might be derived from the endometrium.

Comprehensive analysis of leukocytes, vascularization and matrix metalloproteinases in human menstrual xenograft model

In our previous study, menstrual-like changes in mouse were provoked through the pharmacologic withdrawal of progesterone with mifepristone following induction of decidualization. However, mouse is not a natural menstruation animal, and the menstruation model using external stimuli may not truly reflect the occurrence and development of the human menstrual process. Therefore, we established a model of menstruation based on human endometrial xenotransplantation. In this model, human endometrial tissues were transplanted subcutaneously into SCID mice that were ovarectomized and supplemented with estrogen and progestogen by silastic implants with a scheme imitating the endocrinological milieu of human menstrual cycle. Morphology, hormone levels, and expression of vimentin and cytokeratin markers were evaluated to confirm the menstrual-like changes in this model. With 28 days of hormone treatment, transplanted human endometrium survived and underwent proliferation, differentiation and disintegration, similar to human endometrium in vivo. Human CD45+ cells showed a peak of increase 28 days post-transplantation. Three days after progesterone withdrawal, mouse CD45+ cells increased rapidly in number and were significantly greater than human CD45+ cell counts. Mouse CD31+ blood vascular-like structures were detected in both transplanted and host tissues. After progesterone withdrawal, the expression levels of matrix metalloproteinases (MMP) 1, 2, and 9 were increased. In summary, we successfully established a human endometrial xenotransplantation model in SCID mice, based on the results of menstrual-like changes in which MMP-1, 2 and 9 are involved. We showed that leukocytes are originated from in situ proliferation in human xenografts and involved in the occurrence of menstruation. This model will help to further understand the occurrence, growth, and differentiation of the endometrium and the underlying mechanisms of menstruation.

Uterine natural killer (uNK) cells and their missions during pregnancy: a review

Natural killer (NK) cells are lymphocytes of the innate immune system. The aim of this review is to describe the properties and roles of NK cells in the human uterus during pregnancy. Uterine natural killer cells (uNK) constitute a major lymphocyte population during early gestation in the uterus. The uterine natural killer cells are recognized owing to their CD56(bright), CD16(-), CD3(-) phenotype. Their number increases in the first trimester with a subsequent decline as pregnancy progresses. They have been shown to be closely associated with cells of the extravillous trophoblast (EVT) and spiral arteries. They play important roles in remodeling of the spiral arteries, control of trophoblast invasion and in the development of the placenta. Some studies have shown the number and repertoire of receptors of uNK differ between women with healthy pregnancies and those with pathologic pregnancies, such as pre-eclampsia or intrauterine growth retardation. During pregnancy, the cytotoxic characteristics of the uterine killer cells are not directed towards the fetus, and scientists continue to question and explore this phenomenon with increasing evidence that these cells may perform differing beneficial roles during pregnancy. Contrary to their previously suspected "hostile" characteristics, the uterine killer cells are considered to be "friendly" and appear to be essential and very important regulators of successful implantation and pregnancy.

Immature NK cells, capable of producing IL-22, are present in human uterine mucosa

NK cells are the dominant population of immune cells in the endometrium in the secretory phase of the menstrual cycle and in the decidua in early pregnancy. The possibility that this is a site of NK cell development is of particular interest because of the cyclical death and regeneration of the NK population during the menstrual cycle. To investigate this, we searched for NK developmental stages 1-4, based on expression of CD34, CD117, and CD94. In this study, we report that a heterogeneous population of stage 3 NK precursor (CD34(-)CD117(+)CD94(-)) and mature stage 4 NK (CD34(-)CD117(-/+)CD94(+)) cells, but not multipotent stages 1 and 2 (CD34(+)), are present in the uterine mucosa. Cells within the uterine stage 3 population are able to give rise to mature stage 4-like cells in vitro but also produce IL-22 and express RORC and LTA. We also found stage 3 cells with NK progenitor potential in peripheral blood. We propose that stage 3 cells are recruited from the blood to the uterus and mature in the uterine microenvironment to become distinctive uterine NK cells. IL-22 producers in this population might have a physiological role in this specialist mucosa dedicated to reproduction.

Stem/progenitor cells and the regeneration potentials in the human uterus

The human uterus is unique in that it possesses the tremendous regenerative capacity required for cyclical regeneration and remodeling throughout a woman's reproductive life. Not only must the uterus rapidly enlarge to accommodate the developing fetus, the endometrium must also regenerate with each menstrual cycle. This plasticity of the reproductive system has recently been highlighted. My research group and collaborators showed that functional endometrial tissue could be regenerated from only a small number of singly dispersed human endometrial cells, transplanted beneath the kidney capsule of severely immunodeficient mice. This artificially generated endometrium resembles the natural endometrium, and contains human blood vessels that invade the mouse kidney parenchyma. Additionally, it mimics normal hormone-dependent changes including proliferation, differentiation, and tissue breakdown (menstruation). The regenerative capacity of endometrial cells makes them ideal candidates for tissue reconstitution, angiogenesis, and human-mouse chimeric vessel formation. The smooth muscle cells of the uterus (myometrium) share the plasticity of the endometrium. This is evidenced by their capacity for dramatic, repeatable, pregnancy-induced enlargement. Regeneration and remodeling in the female reproductive tract allude to the existence of endometrial and myometrial stem cell systems. We have recently isolated candidate populations of adult stem cells from both the human endometrium and myometrium. Characterization of these endometrial and myometrial cells, along with the study of the mechanisms controlling their regeneration, will improve the understanding of the physiology and pathophysiology of the female reproductive tract. Furthermore, myometrial and endometrial stem-like cells might also represent a novel source of biological material that could be used for the reconstruction of not only the human uterus but other organs as well.

The unique properties of uterine NK cells

Natural killer (NK) cells are lymphocytes of the innate immunity system that are able to kill various hazardous pathogens and tumors. However, it is now widely accepted that NK cells also possess non-destructive functions, as has been demonstrated for uterine NK cells. Here, we review the unique properties of the NK cells in the uterine mucosa, prior to and during pregnancy. We discuss the phenotype and function of mouse and human endometrial and decidual NK cells and suggest that the major function of decidual NK cells is to assist in fetal development. We further discuss the origin of decidual NK cells and suggest several possibilities that might explain their accumulation in the decidua during pregnancy.

The developmental role of natural killer cells at the fetal-maternal interface

Natural killer (NK) cells have been extensively studied in their traditional roles in host defense against tumor or virally infected cells. Uterine NK cells are of 2 distinct subsets: endometrial NK (eNK) cells, found in the uterus during the menstrual cycle, and decidual NK (dNK) cells, found in the decidua during pregnancy. This review will explore the immunosurveillance and cytotoxicity profiles of NK cells, the inert nature of eNK cells, and the role of dNK cells as builders at the maternal-fetal interface that create a pregnancy-favorable environment by inducing angiogenesis, trophoblast invasion, and vascular remodeling.

Mixed origin of neovascularization of human endometrial grafts in immunodeficient mouse models

BACKGROUND

In vivo mouse models have been developed to study the physiology of normal and pathologic endometrium. Although angiogenesis is known to play an important role in endometrial physiology and pathology, the origin of neovasculature in xenografts remains controversial. The aim of this study was to assess the origin of the neovasculature of endometrial grafts in different mouse models.

METHODS

Human proliferative endometrium (n = 19 women) was grafted s.c. in two immunodeficient mouse strains: nude (n = 8) and severely compromised immunodeficient (SCID; n = 20). Mice were also treated with estradiol, progesterone or levonorgestrel. Fluorescence in-situ hybridization using a centromeric human chromosome X probe, immunohistochemistry (von Willebrand factor and collagen IV) and lectin perfusion were performed to identify the origin of the vessels.

RESULTS

More than 90% of vessels within xenografts were of human origin 4 weeks after implantation. Some vessels (9.67 +/- 2.01%) were successively stained by human or mouse specific markers, suggesting the presence of chimeric vessels exhibiting a succession of human and murine portions. No difference in staining was observed between the two strains of mouse or different hormone treatments. Furthermore, erythrocytes were found inside human vessels, confirming their functionality.

CONCLUSION

This article shows that human endometrial grafts retain their own vessels, which connect to the murine vasculature coming from the host tissue and become functional.

Higher susceptibility of NOG mice to xenotransplanted tumors

The purpose of tumorigenicity testing, as applied not only to cell substrates used for viral vaccine manufacture but also stem cells used for cell-based therapy, is to discriminate between cells that have the capacity to form tumors and cells that do not. Therefore, tumorigenicity testing is essential in assessing the safety of these biological materials. Recently developed NOD/Shi-scid IL2Rg(null) (NOG) mice have been shown to be superior to NOD/Shi-scid (SCID) mice for xenotransplantation of both normal and cancerous cells. To select a suitable mouse strain as a xenogenic host for tumorigenicity testing, we compared the susceptibility of NOG (T, B, and NK cell-defective), SCID (T and B cell-defective), and the traditionally used nude (T cell-defective) mice to tumor formation from xenotransplanted HeLa S3 cells. When 10(4) HeLa S3 cells were subcutaneously inoculated into the flanks of these mice, the tumor incidence on day 22 was 10/10 (100%) in NOG, 2/10 (20%) in SCID, and 0/10 (0%) in nude mice. The subcutaneous tumors formed reproducibly and semiquantitatively in a dose-dependent manner. Unexpectedly, half of the NOG mice (5/10) that had been inoculated with a mere 10(1) HeLa S3 cells formed progressively growing subcutaneous tumors on day 78. We confirmed that the engrafted tumors originated from inoculated HeLa S3 cells by immunohistochemical staining with anti-HLA antibodies. These data suggest that NOG mice may be the best choice as a suitable strain for testing tumorigenicity.

Development of an animal experimental model to study the effects of levonorgestrel on the human endometrium

BACKGROUND

This study was designed to develop an animal model to test the response of endometrium to local progestin delivery.

METHODS

Proliferative human endometrium was subcutaneously grafted in two groups of SCID mice that received, 2 days before, a subcutaneous estradiol (E(2)) pellet and, for half of them, an additional implant of levonorgestrel (LNG). Mice were sacrificed 1, 2, 3 or 4 weeks after endometrial implantation and grafts were histologically analysed. Proliferation, steroid hormone receptors, blood vessels and stromal decidualization in both groups (E(2) and LNG) were immunohistologically evaluated and compared with proliferative endometrium and endometrium from women with an LNG intrauterine device.

RESULTS

Grafts presented normal morphological endometrial characteristics. The expression of progesterone receptors was significantly decreased in glands and stroma of the LNG group as compared with the E(2) group at all times. A significant decrease was also observed in the stromal expression of estrogen receptor-alpha in the LNG group. At 4 weeks, the mean cross-sectional area of vessels was significantly higher after LNG treatment.

CONCLUSIONS

These morphological and immunohistochemical characteristics are similar to those observed in women treated with local LNG. This mouse model might facilitate further investigations needed to understand the mechanisms responsible for the breakthrough bleeding frequently observed in progestin users.

Establishment of a humanized model of liver using NOD/Shi-scid IL2Rgnull mice

Severely immunodeficient NOD/Shi-scid IL2Rg(null) (NOG) mice are used as recipients for human tissue transplantation, which produces chimeric mice with various types of human tissue. NOG mice expressing transgenic urokinase-type plasminogen activator in the liver (uPA-NOG) were produced. Human hepatocytes injected into uPA-NOG mice repopulated the recipient livers with human cells. The uPA-NOG model has several advantages over previously produced chimeric mouse models of human liver: (1) the severely immunodeficient NOG background enables higher xenogeneic cell engraftment; (2) the absence of neonatal lethality enables mating of homozygotes, which increased the efficacy of homozygote production; and (3) donor xenogeneic human hepatocytes could be readily transplanted into young uPA-NOG mice, which provide easier surgical manipulation and improved recipient survival.

Endometrial NK cells are special immature cells that await pregnancy

NK cells populate the human endometrium before pregnancy. Unlike decidual NK cells that populate the decidua during pregnancy, the NK cells present in the human endometrium, before pregnancy, have not been fully characterized. In this study, we provide a detailed analysis of the origin, phenotype, and function of endometrial NK cells (eNK). We show that eNK cells have a unique receptor repertoire. In particular, they are negative for NKp30 and chemokine receptor expression, which distinguishes them from any other NK subset described so far. We further show that eNK cells lack NK-specific functional phenotype and activity such as cytokine secretion and cytotoxicity, before IL-15 stimulation. Following such stimulation, endometrial NK cells acquire phenotype and function that are similar to those of decidual NK cells. We therefore suggest that eNK cells are inactive cells (before IL-15 activation and in relation to the known NK activity) that are present in the endometrium before conception, waiting for pregnancy.

Mouse models with human immunity and their application in biomedical research

Biomedical research in human beings is largely restricted to in vitro studies that lack complexity of a living organism. To overcome this limitation, humanized mouse models are developed based on immunodeficient characteristics of severe combined immunodeficiency (SCID) or recombination activating gene (Rag)(null) mice, which can accept xenografts. Peripheral constitution of human immunity in SCID or Rag(null) mice has been achieved by transplantation of mature human immune cells, foetal human thymus, bone marrow, liver tissues, lymph nodes or a combination of these, although efficiency needs to be improved. These mouse models with constituted human immunity (defined as humanized mice in the present text) have been widely used to investigate the basic principles of human immunobiology as well as complex pathomechanisms and potential therapies of human diseases. Here, elements of an ideal humanized mouse model are highlighted including genetic and non-genetic modification of recipient mice, transplantation strategies and proposals to improve engraftments. The applications of the humanized mice to study the development and response of human immune cells, human autoimmune diseases, virus infections, transplantation biology and tumour biology are reviewed as well.

NOD/Shi-scid IL2rgamma(null) (NOG) mice more appropriate for humanized mouse models

"Humanized mice," in which various kinds of human cells and tissues can be engrafted and retain the same functions as in humans, are extremely useful because human diseases can be studied directly. Using the newly combined immunodeficient NOD-scid IL2rgamma(null) mice and Rag2(null) IL2rgamma(null) humanized mice, it has became possible to expand applications because various hematopoietic cells can be differentiated by human hematopoietic stem cell transplantation, and the human immune system can be reconstituted to some degree. This work has attracted attention worldwide, but the development and use of immunodeficient mice in Japan are not very well known or understood. This review describes the history and characteristics of the NOD/Shi-scid IL2rgamma(null) (NOG) and BALB/cA-Rag2(null) IL2rgamma(null) mice that were established in Japan, including our unpublished data from researchers who are currently using these mice. In addition, we also describe the potential development of new immunodeficient mice that can be used as humanized mice in the future.

Estrogen is not essential for full endometrial restoration after breakdown: lessons from a mouse model

The current dogma surrounding endometrial regeneration after menses includes a critical need for estrogen-primed proliferation. Although some evidence suggests that estrogen may not be required for the initial reepithelialization of the uterine surface, it is widely believed that it is essential for successful stromal renewal. This study aimed to identify proliferating cell types during endometrial repair and to examine whether estrogen is required for successful repair using a previously developed mouse model. In the model, decidualization is artificially induced, and progesterone support withdrawn; the endometrial tissue progressively breaks down by 24 h after progesterone withdrawal and by 48 h has usually undergone complete repair. Although the mice are ovariectomized, restoration of both the stromal and epithelial components proceeds rapidly after breakdown and results in what appears to be a normal endometrium. However, potential estrogenic influences from extraovarian sources (particularly the diet and fat) remain. In this study, complete removal of extraovarian estrogen was achieved by maintenance of animals on a soy-free diet and administration of aromatase inhibitor letrozole. No significant differences in uterine weight or estrogen-responsive genes lactoferrin and progesterone receptor were observed compared with control ovariectomized but otherwise untreated mice, whereas significantly higher measurements were obtained from an estrogen-added group. Importantly, no significant difference in the rate of endometrial repair was observed in the complete absence of estrogen, demonstrating that estrogen is not essential for complete endometrial restoration in this model.

Targeting mast cells in endometriosis with janus kinase 3 inhibitor, JANEX-1

Endometriosis (EMS) is a chronic inflammatory disease of multifactorial etiology characterized by implantation and growth of endometrial glands and stroma outside the uterine cavity. EMS is a significant public health issue as it affects 15-20% of women in their reproductive age. Clinical symptoms may include pelvic pain, dysmenorrhea, dyspareunia, pelvic/abdominal masses, and infertility. Symptomatic treatments such as surgical resection and/or hormonal suppression of ovarian function and analgesics are not as effective as desired. Consequently, there is an enormous unmet need to develop effective medical therapy capable of preventing the occurrence and recurrence of EMS without undesirable side-effects. EMS-associated intra-abdominal bleeding episodes, local inflammation, adhesions, and i.p. immunologic dysfunction leads to pelvic nociception and pelvic pain. Increasing evidence supports the involvement of allergic-type inflammation in EMS. Invasion of mast cells, degranulation, and proliferation of interstitial component are observed in endometriotic lesions. Presence of activated and degranulating mast cells within the nerve structures can contribute to the development of pain and hyperalgesia by direct effects on primary nociceptive neurons. Therefore, treatments targeting endometrial mast cells may prove effective in preventing or alleviating EMS-associated symptoms. The Janus kinase 3 (JAK3) is abundantly expressed in mast cells and is required for the full expression of high-affinity IgE receptor-mediated mast cell inflammatory sequelae. JANEX-1/WHI-P131 is a rationally designed novel JAK3 inhibitor with potent anti-inflammatory activity in several cellular and in vivo animal models of inflammation, including mouse models of peritonitis, colitis, cellulitis, sunburn, and airway inflammation with favorable toxicity and pharmacokinetic profile. We hypothesize that JAK3 inhibitors, especially JANEX-1, may prove useful to prevent or alleviate the symptoms of EMS.

Cells with haematopoietic stem cell phenotype in adult human endometrium: relevance to infertility?

BACKGROUND

Uterine lymphoid cell repertoires are specialized in order to meet the twin demands of successful pregnancy and local immunosurveillance. The possibility that some of these populations might differentiate locally from progenitor cells has been proposed.

METHODS

Endometrial tissue from women with a history of infertility as well as fertile controls was examined for haematopoietic stem cells (HSCs) and lymphoid progenitors using three-colour flow cytometry.

RESULTS

Significant populations of phenotypic HSCs (CD34+ CD45+ ) were detected in all samples, a high proportion of which co-expressed the differentiation marker CD45RA (45.7%), indicating ongoing differentiation. Almost 30% of uterine HSCs co-expressed CD56 and 44% co-expressed CD7, suggesting the presence of lymphoid progenitors. Small proportions expressed CD127 and CD122, receptors for interleukin (IL)-7 and IL-15, respectively. HSC numbers were similar in the endometrial samples from fertile and infertile women. However, the proportion co-expressing the natural killer (NK) antigen CD56 was significantly increased compared with HSCs found in the endometrium of fertile controls (P = 0.002).

CONCLUSIONS

This is the first demonstration of cells with an HSC phenotype in the human endometrium, and increased proportions of NK progenitors in endometrium of women with infertility suggests a dysregulation of this pathway that may contribute to infertility.

A selective cyclooxygenase-2 inhibitor suppresses the growth of endometriosis xenografts via antiangiogenic activity in severe combined immunodeficiency mice

OBJECTIVE

To investigate the effects of a selective cyclooxygenase (COX)-2 inhibitor on endometriosis xenografts in immunodeficient mice.

DESIGN

Prospective placebo-controlled study.

SETTING

An academic facility at a Japanese university graduate school of medicine.

PATIENT(S)

Eight human ovarian endometriomas from seven patients.

ANIMAL(S)

Twenty-three female severe combined immunodeficiency (SCID) mice.

INTERVENTION(S)

Human ovarian endometriomas were implanted into the peritonea of SCID mice. Vehicle alone or NS398 (a selective COX-2 inhibitor, 10 mg/kg of weight per day) were administered orally daily for 56 days after implantation. Mice were killed on the 56th day.

MAIN OUTCOME MEASURE(S)

Change in explants size and immunohistochemical analyses to evaluating the proliferation index, apoptosis index, microvessel density, and labeling index assessing vascular endothelial growth factor and COX-2 expression by the endometriotic lesion.

RESULT(S)

NS398 significantly decreased implant size in comparison to vehicle alone (NS398 [medians, with range in brackets]: 22.0% [19.0%-36.7%] vs. vehicle: 41.2% [31.0%-55.3%], P<.01). Microvessel density (85.3 per mm2 [53.9-157.0 per mm2] vs. 121.8 per mm2 [97.2-259.6 per mm2], P=.02) and the vascular endothelial growth factor (0.4 [0-1.1] vs. 0.6 [0.5-2.1], P=.03) and COX-2 (0.4 [0.4-0.5] vs. 0.6 [0.4-0.8], P=.03) labeling indices in stromal cells were significantly lower in the NS398 group than in the vehicle group. There were no differences in the proliferation or apoptosis indices between the two groups.

CONCLUSION(S)

Selective COX-2 inhibitors decreased the size of implants and effectively treated endometriosis.

Animal models in endometriosis research

Endometriosis is a common gynaecological disease, defined as the presence of endometrial tissue outside the uterus, causing pelvic pain and subfertility in approximately 10% of women of reproductive age. Current therapies lead to pain relief, however, do not address the causes and entail severe side effects. Still little is known about the pathogenic processes leading to the development and maintenance of endometriosis. Because endometriosis occurs spontaneously only in humans and some non-human primates, animal models of induced endometriosis have been developed and are of high value for the evaluation of pathophysiological mechanisms underlying the development of this disease. These experimental models include the autotransplantation of uterine fragments into the peritoneal cavity of rodents and non-human primates or the heterotransplantation of human endometrial or endometriotic tissue to immunodeficient mice or onto the chicken chorioallantoic membrane (CAM). This review describes the animal models for endometriosis and assesses their different potentials and limitations in regard to endometriosis research, with the aim of developing novel non-invasive diagnostic tools and improved strategies for the treatment of endometriosis in women.