The role of viral infection in implantation failure: direct and indirect effects

Implantation is the key initial complex stage of pregnancy. Several factors are involved in implantation, but acute and controlled inflammation has been shown to play as a key role. On the other hand, the role of viral infections in directly infecting blastocyst and trophoblast and inducing chronic and uncontrolled inflammation and disrupting microRNAs expression can make this review strongly attractive and practical. We aim to provide an overview of viral infections as the potential etiology of unsuccessful implantation pathophysiology through alteration of the cellular and molecular endometrial microenvironment. Based on our search, this is the first review to discuss the role of inflammation associated with viral infection in implantation failure.

Effect of sildenafil citrate on treatment of infertility in women with a thin endometrium: a systematic review and meta-analysis

OBJECTIVE

Endometrial thickness is a prognostic factor for successful pregnancy. This meta-analysis aimed to examine the role of sildenafil citrate on infertile women with a thin endometrium.

METHODS

Two investigators independently searched the literature on sildenafil citrate and infertile women with a thin endometrium from PubMed, EMBASE, and the Cochrane Controlled Trials Register Database from inception to January 2019.

RESULTS

Nine studies involving 1452 patients were included for analysis in our study. We found that endometrial thickness in patients who received sildenafil citrate was significantly higher than that in the control group (placebo or no treatment) (weighted mean difference: 1.22; 95% confidence interval [CI]: 1.07-1.38). The radial artery resistance index was significantly lower (weighted mean difference: -0.12; 95% CI: -0.17 to -0.06), and the clinical pregnancy rate (risk ratio: 1.31; 95% CI: 1.11-1.53) and biochemical pregnancy rate (risk ratio: 1.45; 95% CI: 1.11-1.89) were significantly higher in the sildenafil citrate group compared with the control group.

CONCLUSION

Sildenafil citrate is effective in improving endometrial thickness, the clinical pregnancy rate, and the biochemical pregnancy rate in women who have a thin endometrium. This treatment is a potential therapeutic intervention for a thin endometrium.

Reactive oxygen and nitrogen species in normal physiological processes

Abstract Reactive oxygen species (ROS) and reactive nitrogen species have generally been considered as being highly reactive and cytotoxic molecules. Besides their noxious effects, ROS participate in physiological processes in a carefully regulated manner. By way of example, microbicidal ROS are produced in professional phagocytes, ROS function as short-lived messengers having a role in signal transduction and, among other processes, participate in the synthesis of the iodothyronine hormones, reproduction, apoptosis and necrosis. Because of their ability to mediate a crosstalk between key molecules, their role might be dual (at least in some cases). The levels of ROS increase from a certain age, being associated with various diseases typical of senescence. The aim of this review is to summarize the recent findings on the physiological role of ROS. Other issues addressed are an increase in ROS levels during ageing, and the possibility of the physiological nature of this process.

Estradiol 17-beta and progesterone modulate inducible nitric oxide synthase and high mobility group box 1 expression in human endometrium

The aim of the present study is to investigate the effects of ovarian sex steroid hormones on the expression and the release of several locally active substances by human endometrium. Specific objectives are (1) to ascertain if estradiol 17-beta (E2) and progesterone modulate inducible nitric oxide synthase (iNOS) expression and nitric oxide release; (2) to determine whether human endometrium can express High Mobility Group Box 1 (HMGB1), a multifunctional cytokine, and whether sexual steroid hormones can modulate this expression; and (3) to evaluate whether nitric oxide can influence HMGB1 expression in this tissue. Endometrial tissue was obtained from 40 healthy premenopausal women who underwent hysteroscopy for suspected benign gynecological conditions. Endometrium was incubated with E2, progesterone, or sodium nitroprusside, a nitric oxide donor. Nitrite assay was used to quantify stable nitric oxide metabolites in culture medium, and Western blot analysis was used to detect iNOS and HMGB1. Incubation of endometrium with E2 results in an increase in iNOS expression and nitric oxide metabolite production. The opposite effect is obtained by incubating tissues with progesterone. HMGB1 is expressed by human endometrium, and its expression is increased by E2 and decreased by progesterone. Incubation with sodium nitroprusside results in a reduction in HMGB1 expression. Both E2 and progesterone modulate iNOS expression and nitric oxide production in human endometrium. HMGB1 is expressed in the human endometrium, and its expression is modulated by E2, progesterone, and nitric oxide.

Expression of Delta-like protein 4 in the human endometrium

Activation of Delta-Notch signaling pathway promotes the development of the vascular system in embryo, normal adult tissues, and cancerous lesions. Delta and Notch genes are known to be expressed in endothelial cells, and little is known of their expression beyond the vascular system. The purpose of this study was to investigate whether Delta gene would be expressed in cells of the uterine endometrium. In this study, we found that the human endometrial cells expressed one of the Delta ligands, Delta-like 4 protein (Dll4). Dll4 was expressed in human endometrium in a spatiotemporal fashion. Immunohistochemistry studies showed the cytoplasm as well as membrane staining with apical localization both in the luminal and glandular epithelium and moderate diffuse staining in the cytoplasm of the stromal cells. Western blot analysis showed that the size of the endometrial Dll4 was identical to that in the human umbilical endothelial cells. The expression of Dll4 mRNA in human endometrial cells was quantitatively determined by real-time PCR. Dll4 mRNA expressed in the glandular epithelium showed large variations, and it was significantly elevated in the mid and late proliferative and early secretory endometrium. Endometrial stromal cells contained less Dll4 mRNA and had no clear correlation with the menstrual cycle. The effect of hormones was studied in the primary culture of isolated glandular epithelial and stromal cells. In glandular cells, estradiol had little effect, and medroxyprogesterone acetate significantly reduced the mRNAs compared with that of control. Relaxin induced the Dll4 mRNA. In stromal cells, both estradiol and medroxyprogesterone acetate reduced the Dll4 mRNA. To our knowledge, this is the first report of the expression of Dll4 in the endometrium. We propose that endometrial Dll4 may enhance the development of the endometrial microvascular system and facilitate the implantation of blastocyst in a fertile cycle.

Regulation of nitric oxide synthase isoforms by estrogen in the human endometrium

OBJECTIVE

To examine the influence of estrogen on the expression of nitric oxide synthase (NOS) isoforms in human endometrial surface epithelial cell line (HES) and primary endometrial cells.

DESIGN

Laboratory-based investigation.

SETTING

Academic center.

INTERVENTION(S)

The expression of NOS isoform protein levels and mRNA was determined following estrogen/progesterone stimulation.

MAIN OUTCOME MEASURE(S)

NOS protein and mRNA levels in HES and primary endometrial cells.

RESULT(S)

Estradiol 17-beta (E2) induced a dose- and time-dependent increase in the expression of eNOS mRNA and protein and iNOS protein in HES cells which could be blocked by the estrogen receptor antagonist ICI 182,780. Estradiol increased the expression of eNOS mRNA and protein in primary endometrial cells. Estrogen also induced phosphorylation of eNOS which could not be blocked by ICI 182,780. Progesterone in physiologic concentrations augmented the effect of estrogen on the expression of both eNOS and peNOS but not of iNOS. ICI 182,780 in high concentrations stimulated the expression of iNOS protein while inhibiting eNOS.

CONCLUSION(S)

Estradiol through a genomic mechanism stimulates the expression of NOS isoforms in endometrial derived primary and HES cells. This effect is potentiated by progesterone.

Nitric oxide in blastocyst implantation in the rhesus monkey

Successful blastocyst implantation depends on the interaction between cells of maternal endometrium and conceptus, as well as adequate blood supply to the site of blastocyst implantation. Nitric oxide (NO) generally plays a significant role in the local regulation of vascular physiology in a variety of mammalian tissue systems, however, its role in blastocyst implantation and placentation in the primate is not known. The aim of the present study was to examine: (i) NADH-diaphorase activity and expression of three isoforms of nitric oxide synthase (NOS), namely endothelial NOS (eNOS), inducible NOS (iNOS) and neuronal NOS (nNOS) in pre-implantation stage monkey embryos, morula (n= 4) and blastocyst (n= 10), as well as, in different compartments of conceptus and maternal endometrium at primary implantation sites during lacunar (n= 6) and villous (n= 9) stages of placentation in the rhesus monkey, and (ii) the potential anti-nidatory effect of vaginal administration of NOS inhibitor during the peri-implantation period of conception cycles in rhesus monkeys. Pre-implantation stage blastocysts exhibited marked NADPH-diaphorase activity along with immunopositive iNOS mainly in the inner cell mass. During the lacunar stage, marked eNOS expression was observed in cytotrophoblast cells lining the embryonic cavity. However, cytotrophoblast cells lining villi, forming columns, and constituting anchoring villi expressed all the three isoforms of NOS in villous placenta stage tissue. During the lacunar stage, eNOS and iNOS protein expressions were observed in epithelial and decidual cells of endometrium. As gestation advanced, mRNAs for all three isoforms of NOS were observed to increase in epithelial and decidual cells, however, with no marked change in protein expression. Vaginal administration of a NOS inhibitor (NG-nitro-l-arginine methyl ester, L-NAME, 4, 6, and 8 mg/kg body weight or aminoguanidine, AG, 4 mg/kg body weight) during days 6 to 12 after ovulation resulted in pregnancy failure in a higher number of animals (L-NAME: 8 confirmed pregnancies in 25 animals; AG: 2 confirmed pregnancies in 8 animals) compared with control animals (5 pregnancies in 7 animals). It appears that NO may play an important role in the establishment of pregnancy in the rhesus monkey.

Adenomyosis: what is the impact on fertility?

PURPOSE OF REVIEW

This review is timely and relevant for several reasons. The incidence of adenomyosis begins to rise from the mid-thirties. Moreover, more women are delaying their first pregnancy until later in their thirties or forties, and consequently adenomyosis is encountered more frequently in the fertility clinic during diagnostic work-up. Furthermore, it is difficult to diagnose adenomyosis before surgery, because there are no pathognomonic signs, symptoms or physical findings. Finally, reference data are very limited.

RECENT FINDINGS

This review refers to adenomyosis of the uterus as a factor in female infertility. The clinical presentation of adenomyosis uteri is also reviewed, as well as animal and human studies concerning the effect of adenomyosis in female infertility. Different treatment options are discussed, especially those referring to patients who wish to maintain their fecundity.

SUMMARY

Uterine adenomyosis remains a fairly frequent and debilitating disease that will be encountered with increasing incidence in the infertile female population. While spectacular advances have been made in recent years in the non-invasive diagnosis of the condition, non-surgical treatment options for infertile patients with adenomyosis arise but need to be confirmed in larger series.

Does nitric oxide play a role in maternal tolerance towards the foetus?

In pregnancy there occurs maternal tolerance to the foetus. Several mechanisms have been proposed to explain this phenomenon. The main immune population in the decidua are macrophages and natural killer cells, but with some "special" suppressor characteristics. There is also a predominant TH2 response. The non classical MCH type I HLA-G is expressed by trophoblasts and can suppress lymphomononuclear cytotoxicity. Other system to avoid the immune system is the expression of indoleamine-2,3-dioxygenase, that suppresses T cell activation by degrading tryptophan. Even though in the placenta there is a high production of nitric oxide, a well-known immune modulator, low attention has been paid to its role in maternal tolerance. There are many data showing that NO affects the IDO, CD95/CD95-L and the balance between TH1/TH2. Maybe NO could interact with several mechanisms at the same time, which could modify the tolerogenic activity depending on the concentration and the presence of other factors in the medium.

Effects of mifepristone on expression of endothelial nitric oxide synthase in human endometrium during the implantation phase

OBJECTIVE

To investigate the effects of the antiprogestin mifepristone on expression of endothelial (eNOS) nitric oxide synthase in human endometrium during the implantation phase.

DESIGN

Prospective clinical study.

SETTING

Teaching university hospital.

PATIENT(S)

Endometrial samples were obtained from nine healthy women with proven fertility.

INTERVENTION(S)

One control and one treatment cycle were performed. Treatment with 200 mg of mifepristone was administered on LH day 2. Endometrial biopsy specimens were obtained on LH day 6 to 8.

MAIN OUTCOME MEASURE(S)

Expression of eNOS was identified by using immunohistochemistry and Western blot assay, and messenger RNA levels were determined with semiquantitative reverse transcription polymerase chain reaction.

RESULT(S)

Endothelial nitric oxide synthase was detected in vascular endothelium and glandular epithelium in the endometrium. Treatment with mifepristone significantly decreased eNOS expression in the endometrial glandular epithelium but did not affect endothelial eNOS.

CONCLUSION(S)

Mifepristone has differential effects on eNOS expression in the epithelium and endothelium in the human endometrium at the time of implantation. The results support a role of epithelial eNOS in human endometrial receptivity.

Expression of endothelial and inducible nitric oxide synthases is modulated in the endometrium of cyclic and early pregnant mares

The expression of the endothelial and inducible nitric oxide synthases (eNOS and iNOS, respectively) was examined in the endometrium of cyclic and pregnant mares by real-time polymerase chain reaction and immunohistology. The concentration of eNOS mRNA varied throughout the oestrous cycle, with significantly higher transcripts on Day 5 of the oestrous cycle (P < 0.05), whereas iNOS transcription did not change significantly over time (P > 0.05). In early pregnant mares both eNOS and iNOS mRNA increased between Days 12 and 15 (P < 0.05). In cyclic mares, eNOS protein was detected immunocytochemically in endometrial epithelia, the basement membrane, the endothelial layer and smooth muscle cells of the vasculature. Using immunocytochemical methods, iNOS protein was undetectable in the endometrium of cyclic mares but could be demonstrated in pregnant mares. Endometrial epithelia of pregnant mares were immunopositive for both proteins with a more intense labelling for iNOS. Thus, the present study describes for the first time the modulation and spatial distribution of eNOS and iNOS expression during the oestrous cycle and early pregnancy, suggesting that ovarian steroids are differently involved in the regulation of each NOS. Localisation of eNOS protein in endometrial epithelia and various vascular components indicates that this isoform may be involved in the regulation of endometrial cyclicity. The presence and increase of both forms of NOS during early gestation suggest a role for them in the control of endometrial vascular bed and glandular activity to provide a suitable microenvironment for successful pregnancy.

Stromal vascularization in the endometrium during adenomyosis

In adenomyosis, the two major frequent symptoms are hypermenorrhea and dysmenorrhea. The incidence of the former is said to be high, ranging from 36 to 70%. It has been found that vascular distribution of the endometrium in adenomyosis is diversely different from fertile patients without adenomyosis. For example, hysteroscopy revealed that approximately half of the patients have abnormal vascularization. In these patients, vascular distribution was generally irregular, and vessels were thick, dilated, and/or reticular in some patients. Moreover, morphometric analysis of the endometrium revealed that in the fertile women, the mean surface area, total surface area, and total number of capillaries, all increased significantly in the secretory phase compared to the proliferative phase. In contrast, the above parameters increased in the adenomyosis group in both the proliferative phase and secretory phase compared to the fertile women. In particular, the total surface area of capillaries per mm(2) markedly rose, by 11.6 times, compared to that of the proliferative phase in the fertile women. These findings suggest that regulatory factors involved in the vascular proliferation are diversely exaggerated, and that the abnormal vascularization of the endometrium is closely related with hypermenorrhea.

Role of nitric oxide and bcl-2 family genes in the regulation of human endometrial apoptosis

OBJECTIVE

To investigate the role of nitric oxide (NO) and death regulatory genes, bcl-2 and bax, in human endometria apoptosis.

DESIGN

Expression of bcl-2, bax, NO synthases (NOS), and the apoptotic effect of L-arginine on endometrial explants in vitro.

SETTING

Prospective study.

PATIENT(S)

Thirty-seven eumenorrheic women.

INTERVENTION(S)

Endometrial samples were obtained with Pipelle suction curette after women signed institutional informed consent forms.

MAIN OUTCOME MEASURE(S)

DNA fragmentation (TUNEL), immunohistochemistry, and reverse transcription polymerase chain reaction.

RESULT(S)

Apoptosis was detected in mid and late secretory endometria. L-arginine induced an increase in apoptosis in stroma (threefold), glands (eightfold), and surface epithelia (fourfold) in proliferative but not secretory endometria explants. Immunostaining of Bcl-2 was almost absent in the secretory endometria, whereas Bax increased in the stroma at the end of the menstrual cycle, coincident to the decrease in the bcl-2/bax mRNA relative ratio (P<.05) observed in secretory endometria.

CONCLUSION(S)

The induction of DNA fragmentation by L-arginine on proliferative endometria suggests that NO may be involved in the endometrial apoptotic process, whose control may be related predominantly to the changes of Bcl-2 expression.

Expression and localization of inducible nitric oxide synthase in human non-pregnant and early pregnant endometrium

The aim of the present study was to investigate the expression and distribution patterns of inducible nitric oxide synthase (iNOS) in human non-pregnant and early pregnant endometrium using Northern blot analysis, reverse transcription-polymerase chain reaction (RT-PCR) and immunohistochemistry. Northern blot analysis revealed the expression of iNOS mRNA in human decidua and chorionic villi in the first trimester but not in the endometrium at any stage of the menstrual cycle. Nested RT-PCR, however, detected iNOS mRNA in human endometrium at all stages of the menstrual cycle. Immunohistochemical staining of the secretory endometrium using an anti-human iNOS polyclonal antibody revealed labelling specifically concentrated in glandular epithelial cells. Staining was absent in stromal cells. However, iNOS staining was positive in decidualized stromal cells in tissues obtained in the first trimester of pregnancy. Furthermore, extensive staining was observed in both syncytiotrophoblastic and cytotrophoblastic cells. The finding of a large amount of iNOS mRNA at the feto-maternal interface throughout the first trimester of pregnancy suggests that iNOS may play an important role in the maintenance of pregnancy.

Endothelial nitric oxide synthase in the endometrium during the menstrual cycle in patients with endometriosis and adenomyosis

OBJECTIVE

To determine the expression of endothelial nitric oxide synthase in the endometrium during the menstrual cycle in endometriosis and adenomyosis.

DESIGN

Immunohistochemical identification of endothelial nitric oxide in endometrial tissues using the monoclonal antibody.

SETTING

Department of obstetrics and gynecology in a university hospital.

PATIENT(S)

The subjects were divided into three groups: 35 patients with endometriosis, 33 patients with adenomyosis proven histologically, and 46 fertile controls.

MAIN OUTCOME MEASURE(S)

Semiquantitative immunostaining (evaluation nomogram) score in endometrial cells.

RESULT(S)

The analyses revealed phase-dependent changes in the expression of endothelial nitric oxide synthase in the surface and glandular epithelia during the menstrual cycle in the fertile controls. The expression was weakest in the early proliferative phase, gradually increased, was most marked in the midsecretory phase, and decreased thereafter. In contrast, stromal cells did not change throughout the cycle. Contrary to expectations, the expression of endothelial nitric oxide synthase in endometriosis and adenomyosis was persistently greater than the control levels throughout the menstrual cycle.

CONCLUSION(S)

This study has shown that endothelial nitric oxide synthase is changed in a phase-dependent manner during the menstrual cycle. The exaggerated expression of endothelial nitric oxide synthase in the endometrium throughout the cycle suggests some pathologic role in endometriosis and adenomyosis.