Eutopic endometrium from women with endometriosis shows altered ultrastructure and glycosylation compared to that from healthy controls--a pilot observational study

Protein glycosylation: bridging maternal-fetal crosstalk during embryo implantation†

Infertility is a challenging health problem that affects 8-15% of couples worldwide. Establishing pregnancy requires successful embryo implantation, but about 85% of unsuccessful pregnancies are due to embryo implantation failure or loss soon after. Factors crucial for successful implantation include invasive blastocysts, receptive endometrium, invasion of trophoblast cells, and regulation of immune tolerance at the maternal-fetal interface. Maternal-fetal crosstalk, which relies heavily on protein-protein interactions, is a critical factor in implantation that involves multiple cellular communication and molecular pathways. Glycosylation, a protein modification process, is closely related to cell growth, adhesion, transport, signal transduction, and recognition. Protein glycosylation plays a crucial role in maternal-fetal crosstalk and can be divided into N-glycosylation and O-glycosylation, which are often terminated by sialylation or fucosylation. This review article examines the role of protein glycosylation in maternal-fetal crosstalk based on two transcriptome datasets from the GEO database (GSE139087 and GSE113790) and existing research, particularly in the context of the mechanism of protein glycosylation and embryo implantation. Dysregulation of protein glycosylation can lead to adverse pregnancy outcomes, such as missed abortion and recurrent spontaneous abortion, underscoring the importance of a thorough understanding of protein glycosylation in the diagnosis and treatment of female reproductive disorders. This knowledge could have significant clinical implications, leading to the development of more effective diagnostic and therapeutic approaches for these conditions.

High MutS homolog 2 expression predicts poor prognosis and is related to immune infiltration in endometrial carcinoma

Several studies have shown that MutS homolog 2 (MSH2) is highly expressed in many cancer tissues. Transcriptome expression data were collected from the Cancer Genome Atlas (TCGA) database. We analyzed the expression of MSH2 in normal and tumor tissues, the relationship between MSH2 expression and various prognostic factors, and the relationship between MSH2 expression and overall survival, disease specific survival, and progression free interval. We also examined MSH2 promoter methylation between endometrial cancer and normal endometrial tissues, and identified the prognostic value of MSH2 methylation in endometrial cancer. MSH2 was highly expressed in endometrial cancer tumor tissues compared with normal tissues. High MSH2 expression might be an independent prognostic factor for OS, DSS, and PFI. Further, high MSH2 expression was correlated with age and histological type, but not with BMI, clinical stage, tumor invasion, or other clinical features. MSH2 promoter methylation in endometrial cancer was significantly lower than in normal tissues. Additionally, MSH2 levels, OS, DSS, and PFI were associated with BMI, age, tumor invasion, and histological type. ssGSEA showed that MSH2 expression was positively correlated with the infiltration of Th2 cells, Tcm cells, T helper cells, and Tgd cells, whereas it was negatively correlated with NK CD56 bright cells, pDC cells, iDC cells, cytotoxic cells, and neutrophils. Increased MSH2 expression and reduced MSH2 methylation in endometrial cancer predicts poor prognosis. MSH2 may be used as a biomarker for the diagnosis and prognosis of endometrial cancer and as an immunotherapy target.

Novel diagnostic options for endometriosis - Based on the glycome and microbiome

Background

Endometriosis is a chronic gynaecological disease whose aetiology is still unknown. Despite its prevalence among women of reproductive age, the pathology of the disease has not yet been elucidated and only symptomatic treatment is available. Endometriosis has high latency and diagnostic methods are both limited and invasive.

Aim of review

The aim of this review is to summarise minimally invasive or non-invasive diagnostic methods for endometriosis and their diagnostic efficiencies. Furthermore, we discuss the identification and diagnostic potential of novel disease biomarkers of microbial or glycan origin.

Key scientific concepts of review

Great efforts have been made to develop minimally invasive or non-invasive diagnostic methods in endometriosis. The problem with most potential biomarker candidates is that they have high accuracy only in cases of severe disease. Therefore, it is necessary to examine other potential biomarkers more closely. Associations between gastrointestinal and genital tract microbial health and endometriosis have been identified. For instance, irritable bowel syndrome is more common in women with endometriosis, and hormonal imbalance has a negative impact on the microbiome of both the genital tract and the gastrointestinal system. Further interrogation of these associations may have potential diagnostic significance and may identify novel therapeutic avenues. Glycomics may also be a potent source of biomarkers of endometriosis, with a number of glyco-biomarkers already approved by the FDA. Endometriosis-associated microbial and glycomic profiles may represent viable targets for development of innovative diagnostics in this debilitating disease.

Menstrual flow as a non-invasive source of endometrial organoids

Assessment of the endometrium often necessitates a biopsy, which currently involves an invasive, transcervical procedure. Here, we present an alternative technique based on deriving organoids from menstrual flow. We demonstrate that organoids can be derived from gland fragments recovered from menstrual flow. To confirm they faithfully reflect the in vivo state we compared organoids derived from paired scratch biopsies and ensuing menstrual flow from patients undergoing in vitro fertilisation (IVF). We demonstrate that the two sets of organoids share the same transcriptome signature, derivation efficiency and proliferation rate. Furthermore, they respond similarly to sex steroids and early-pregnancy hormones, with changes in morphology, receptor expression, and production of 'uterine milk' proteins that mimic those during the late-secretory phase and early pregnancy. This technique has wide-ranging impact for non-invasive investigation and personalised approaches to treatment of common gynaecological conditions, such as endometriosis, and reproductive disorders, including failed implantation after IVF and recurrent miscarriage.

Expression of monocyte chemotactic protein 2 and tumor necrosis factor alpha in human normal endometrium and endometriotic tissues

Endometriosis is a gynocological disease characterized by the presence of the endometrial glands and stroma outside the uterine cavity. This disease affects % 6-10 of women with reproductive age and it causes serious problems such as pelvic pain, dysmenorrhea and infertility. Although endometriosis is one of the most investigated disease of gynecology, its pathogenesis is not clear completely. In recent years, many studies revealed the inflammatory nature of endometriosis. Many of the immune cells and their secretory products cytokines and chemokines has been detected in body fluids of women with endometriosis. Cytokines are protein or glycoprotein in structures and hormon-like molecules that act generally in a paracrine fashion to regulate immun responses. They involved in chemotaxis, cell proliferation, cell activation, motility, adhesion and morphogenesis. Tumor necrosis factor alpha (TNF-α) is a proinflammatory cytokine secreted by the macrophages, monocytes, neutrophiles, T cells and natural killer cells. It stimulates increase in the level of the chemokines in body fluids. Monocyte chemotactic protein 2 (MCP-2) is a chemokine act to recruit and activate monocytes into sites of inflammation area. The aim of this study to investigate the ultrastructural properties and whether the expression and localization of TNF-α and MCP-2 in the eutopic endometrium (normal endometrium of women with endometriosis) and endometritic tissues of women with endometriosis. Eutopic endometrial and endometriotic tissue samples were obtained from women with endometriosis between 20-41 y and normal endometrial tissues were collected from 5 women without endometriosis as a control group. Tissues were processed for light and electron microscopy and examined. The epithelial cells of endometriotic tissues were revealed strongly cytoplasmic TNF-α and MCP-2 immunreactivities. Eutopic endometrial tissues were also stained prominently for both TNF-α and MCP-2. Furthermore, a significant increase in stromal macrophages were observed in endometriotic tissues. Moreover, the ultrastructural observations on the normal and endometriotic tissues were exhibited microvilli-rich cells and ciliated cells. These findings suggest that TNF-α and MCP-2 may be involved in normal endometrial biology and in the pathogenesis of endometriosis.

FACTORS OF ENDOMETRIAL RECEPTIVITY DOWN-REGULATION IN GENITAL ENDOMETRIOSIS

Endometriosis, or endometrioid disease, is a chronic estrogen-dependent gynecological disease caused by ectopic localization of endometrial tissue, mainly in the pelvis and ovaries. However, at the present stage of development of reproductive medicine, the classical topographic definition of endometriosis should be expanded with new significant characteristics established using the achievements of cell and molecular biology, which allowed a more detailed study of the pathogenesis of this disease. In addition, the introduction of personalized approaches to the treatment of patients with endometriosis and infertility, more attention should be paid to the search for disease predictors and the formation of risk groups with the observation of patients from puberty to menopause. In this review, we have analyzed the literature data and our own studies with an emphasis on factors and markers of decreased receptivity of eutopic endometrium in women with endometriosis, as well as pain, the manifestations of which can contribute to the exact diagnosis of external genital endometriosis.

Reviewing the role of progesterone therapy in endometriosis

Endometriosis is a benign, chronic inflammatory condition characterized by the presence and growth of endometrial implants outside the uterine cavity. The cause of endometriosis is multifactorial. It is due to the diversity of hypothesis and plausibility of hormonal alterations which could play a major role. Evidence has shown that progesterone resistance is a key factor for endometriosis sufferers. Medical therapy can avoid surgical intervention, which may lead to a reduced in ovarian reserve, and its effects of earlier menopause and reduced fecundity. Progesterone receptor isoform has provided new insight as the potential treatment. Progestin, anti-progestin and selective progesterone receptor modulators usage, which target these receptors, could avoid hypo-estrogenic side effects, which can be debilitating. Numerous types of these medications have been used on and off labeled to treat endometriosis with varying success. This review aims to consolidate series of clinical trials using progestins in endometriosis.

Increased α2-6 sialylation of endometrial cells contributes to the development of endometriosis

Endometriosis is a disease characterized by implants of endometrial tissue outside the uterine cavity and is strongly associated with infertility. Focal adhesion of endometrial tissue to the peritoneum is an indication of incipient endometriosis. In this study, we examined the effect of various cytokines that are known to be involved in the pathology of endometriosis on endometrial cell adhesion. Among the investigated cytokines, transforming growth factor-β1 (TGF-β1) increased adhesion of endometrial cells to the mesothelium through induction of α2-6 sialylation. The expression levels of β-galactoside α2-6 sialyltransferase (ST6Gal) 1 and ST6Gal2 were increased through activation of TGF-βRI/SMAD2/3 signaling in endometrial cells. In addition, we discovered that terminal sialic acid glycan epitopes of endometrial cells engage with sialic acid-binding immunoglobulin-like lectin-9 expressed on mesothelial cell surfaces. Interestingly, in an in vivo mouse endometriosis model, inhibition of endogenous sialic acid binding by a NeuAcα2-6Galβ1-4GlcNAc injection diminished TGF-β1-induced formation of endometriosis lesions. Based on these results, we suggest that increased sialylation of endometrial cells by TGF-β1 promotes the attachment of endometrium to the peritoneum, encouraging endometriosis outbreaks.

A growth factor involved in cell differentiation and proliferation contributes to the development of endometriosis by stimulating a protein modification mechanism that increases the adhesiveness of cells lining the uterus. Endometriosis results when these cells, known as endometrial cells, start growing outside the uterus causing pelvic pain, heavy periods and, in some cases, infertility. Ki-Tae Ha at Pusan National University, Yangsan, South Korea, and colleagues found that transforming growth factor-β1 signaling promoted the addition of sialic acid sugar units onto endometrial cell surface proteins. This modification enhanced the adhesion of endometrial cells to mesothelial cells, which line other internal organs, and the formation of endometriosis lesions in mice. Preventing sialic acid binding to its mesothelial cell receptor reduced lesion formation. The findings reveal a new molecular mechanism underlying endometriosis and a potential treatment strategy.

Correlation between replicative senescence of endometrial gland epithelial cells in shedding and non-shedding endometria and endometriosis cyst during menstruation

To investigate correlation between abnormal replicative senescence of endometrial gland epithelial cells (EGECs) in shedding and non-shedding endometria and endometriosis cyst during menstruation. Musashi-1 expression, β-catenin expression, and EGECs ultrastructure in shedding and non-shedding endometrium when menstruation were observed through real-time PCR and transmission electron microscopy technologies. (1) Musashi-1 and β-catenin exhibited a high expression in shedding and non-shedding endometria in experimental group, showing a positive correlation between each other; and were significantly higher than that in control group. However; there was no correlation between these two in control group. (2) Transmission electron microscopy results: In experimental group, organelles in EGECs in shedding endometrium obtained were abundant on the first day of menstruation, nuclei were irregular, double nucleoli could be observed, and chromatin was rich. Furthermore, morphology of EGECs in non-shedding endometrium was irregular, organelles were abundant, basement membrane was irregular with abnormal curvature, and a large amount of collagenic fibers were found in intercellular spaces. On the fifth day of menstruation, the cilia and microvilli on secretory cells in endometrium increased and prolongated, and organelles became extremely rich. EGECs have potentials of division, proliferation, invasion and migration; and is associated with formation of endometriosis cysts.

Endometriosis, especially mild disease: a risk factor for miscarriages

OBJECTIVE

To investigate the prevalence of miscarriage in women with endometriosis (WwE) compared with disease-free control women (CW).

DESIGN

Cross-sectional analysis nested in a retrospective observational study (n = 940).

SETTING

Hospitals and associated private practices.

PATIENT(S)

Previously pregnant women (n = 268) within reproductive age in matched pairs.

INTERVENTION(S)

Retrospective analysis of surgical reports and self-administered questionnaires.

MAIN OUTCOME MEASURE(S)

Rate of miscarriage, subanalysis for fertility status (≤12 vs. >12 months' time to conception), endometriosis stages (revised American Society of Reproductive Medicine classification [rASRM] I/II vs. III/IV) and phenotypic localizations (superficial peritoneal, ovarian, and deep infiltrating endometriosis).

RESULT(S)

The miscarriage rate was higher in WwE (35.8% [95% confidence interval 29.6%-42.0%]) compared with CW (22.0% [16.7%-27.0%]); adjusted incidence risk ratio of 1.97 (95% CI 1.41-2.75). This remained significant in subfertile WwE (50.0% [40.7%-59.4%]) vs. CW (25.8% [8.5%-41.2%]) but not in fertile WwE (24.5% [16.3%-31.6%]) vs. CW (21.5% [15.9%-26.8%]). The miscarriage rate was higher in women with milder forms (rASRM I/II 42.1% [32.6%-51.4%] vs. rASRM III/IV 30.8% [22.6%-38.7%], compared with 22.0% [16.7%-27.0%] in CW), and in women with superficial peritoneal endometriosis (42.0% [32.0%-53.9%]) compared with ovarian endometriosis (28.6% [17.7%-38.7%]) and deep infiltrating endometriosis (33.9% [21.2%-46.0%]) compared with CW (22.0% [16.7%-27.0%]).

CONCLUSION(S)

Mild endometriosis, as in superficial lesions, is related to a great extent of inflammatory disorder, possibly leading to defective folliculogenesis, fertilization, and/or implantation, presenting as increased risk of miscarriage.

CLINICAL TRIAL REGISTRATION NUMBER

NCT02511626.

CCL19/CCR7 contributes to the pathogenesis of endometriosis via PI3K/Akt pathway by regulating the proliferation and invasion of ESCs

PROBLEM

The level of CCL19 increased in the peritoneal fluid of women with endometriosis, but the precise mechanism of CCL19/CCR7 in the pathogenesis of endometriosis remains unknown.

METHODS

ELISA and immunohistochemistry were performed to analyze CCL19/CCR7 expressions in peritoneal fluid and endometrium from women with endometriosis (n = 38) and controls (n = 32). Cell proliferation and transwell invasion assays were applied to detect proliferation and invasion of human endometrial stromal cells (ESCs). Expressions of Bcl2, MMP2, MMP9, and p-AKT/AKT were analyzed by Western blot.

RESULTS

Peritoneal fluid concentration of CCL19 in patients with endometriosis was higher than that in controls. Those patients with moderate/severe endometriosis had significantly higher peritoneal fluid concentrations of CCL19 compared to those with minimal/mild endometriosis. Higher CCL19 and CCR7 were found in the endometrium with endometriosis compared to control. CCL19 significantly enhanced ESC proliferation and invasion through CCR7 via activating PI3K/Akt signal pathways. CCL19/CCR7 interaction significantly enhanced phosphorylation of Akt, Bcl2, MMP2, and MMP9 in ESCs.

CONCLUSION

These data indicate CCL19/CCR7 contributes to proliferation and invasion of ESCs, which are conducive to the pathogenesis of endometriosis through activating PI3K/Akt pathway.

Frozen embryo transfer cycles in women with deep endometriosis

OBJECTIVE

To compare the transfer pregnancy rates with frozen embryos from patients with deep endometriosis and non-endometriosis patients.

METHODS

We conducted a retrospective cohort study of review of medical records of 181 women aged 18-40 years, undergoing transfer of frozen embryos into a fertility center. The data collected was from January 2007 to December 2013.

RESULTS

Regarding the patients with endometriosis, there was no statistical difference in proportion to compare polycystic ovarian syndrome, male factor, tubal factor and unexplained infertility.

CONCLUSION

There was no difference between pregnancy rates obtained from frozen embryo transfer in deep endometriosis compared to other causes of infertility.

Local upregulation of transient receptor potential ankyrin 1 and transient receptor potential vanilloid 1 ion channels in rectosigmoid deep infiltrating endometriosis

Transient Receptor Potential Vanilloid 1 (TRPV1) and Transient Receptor Potential Ankyrin 1 (TRPA1) expressed mainly by primary sensory neurons function as major nociceptive integrators. They are also present on the rat endometrium in an oestrogen-regulated manner. TRPV1 is upregulated in peritoneal and ovarian endometriosis patients, but there is no information about TRPA1 and their pathophysiological significances. In this study, patients undergoing laparoscopic surgery were investigated: severe dysmenorrhoea due to rectosigmoid deep infiltrating endometriosis ( n = 15), uterine fibroid-induced moderate dysmenorrhoea ( n = 7) and tubal infertility with no pain ( n = 6). TRPA1 and TRPV1 mRNA and protein expressions were determined by quantitative polymerase chain reaction and semi-quantitative immunohistochemistry from the endometrium samples taken by curettage. Results were correlated with the clinical characteristics including pain intensity. TRPA1 and TRPV1 receptors were expressed in the healthy human endometrium at mRNA and protein levels. Sparse, scattered cytoplasmic TRPA1 and TRPV1 immunopositivities were found in the stroma and epithelial layers. We detected upregulated mRNA levels in deep infiltrating endometriosis lesions, and TRPV1 gene expression was also elevated in autocontrol endometrium of deep infiltrating endometriosis patients. Histological scoring revealed significant TRPA1 and TRPV1 difference between deep infiltrating endometriosis stroma and epithelium, and in deep infiltrating endometriosis epithelium compared to control samples. Besides, we measured elevated stromal TRPV1 immunopositivity in deep infiltrating endometriosis. Stromal TRPA1 and TRPV1 immunoreactivities strongly correlated with dysmenorrhoea severity, as well TRPV1 expression on ectopic epithelial cells and macrophages with dyspareunia. Epithelial TRPA1 and stromal TRPV1 immunopositivity also positively correlated with dyschezia severity. We provide the first evidence for the presence of non-neuronal TRPA1 receptor in the healthy human endometrium and confirm the expression of TRPV1 channels. Their upregulations in rectosigmoid deep infiltrating endometriosis lesions and correlations with pain intensity suggest potential roles in pathophysiological mechanisms of the disease.

Endometrial biomarkers for the non-invasive diagnosis of endometriosis

BACKGROUND

About 10% of reproductive-aged women suffer from endometriosis, which is a costly, chronic disease that causes pelvic pain and subfertility. Laparoscopy is the gold standard diagnostic test for endometriosis, but it is expensive and carries surgical risks. Currently, there are no non-invasive tests available in clinical practice that accurately diagnose endometriosis. This is the first diagnostic test accuracy review of endometrial biomarkers for endometriosis that utilises Cochrane methodologies, providing an update on the rapidly expanding literature in this field.

OBJECTIVES

To determine the diagnostic accuracy of the endometrial biomarkers for pelvic endometriosis, using a surgical diagnosis as the reference standard. We evaluated the tests as replacement tests for diagnostic surgery and as triage tests to inform decisions to undertake surgery for endometriosis.

SEARCH METHODS

We did not restrict the searches to particular study designs, language or publication dates. To identify trials, we searched the following databases: CENTRAL (2015, July), MEDLINE (inception to May 2015), EMBASE (inception to May 2015), CINAHL (inception to April 2015), PsycINFO (inception to April 2015), Web of Science (inception to April 2015), LILACS (inception to April 2015), OAIster (inception to April 2015), TRIP (inception to April 2015) and ClinicalTrials.gov (inception to April 2015). We searched DARE and PubMed databases up to April 2015 to identify reviews and guidelines as sources of references to potentially relevant studies. We also performed searches for papers recently published and not yet indexed in the major databases. The search strategies incorporated words in the title, abstract, text words across the record and the medical subject headings (MeSH).

SELECTION CRITERIA

We considered published peer-reviewed, randomised controlled or cross-sectional studies of any size that included prospectively collected samples from any population of reproductive-aged women suspected of having one or more of the following target conditions: ovarian, peritoneal or deep infiltrating endometriosis (DIE).

DATA COLLECTION AND ANALYSIS

Two authors independently extracted data from each study and performed a quality assessment. For each endometrial diagnostic test, we classified the data as positive or negative for the surgical detection of endometriosis and calculated the estimates of sensitivity and specificity. We considered two or more tests evaluated in the same cohort as separate data sets. We used the bivariate model to obtain pooled estimates of sensitivity and specificity whenever sufficient data were available. The predetermined criteria for a clinically useful test to replace diagnostic surgery was one with a sensitivity of 94% and a specificity of 79%. The criteria for triage tests were set at sensitivity at or above 95% and specificity at or above 50%, which in case of negative results rules out the diagnosis (SnOUT test) or sensitivity at or above 50% with specificity at or above 95%, which in case of positive result rules in the diagnosis (SpIN test).

MAIN RESULTS

We included 54 studies involving 2729 participants, most of which were of poor methodological quality. The studies evaluated endometrial biomarkers either in specific phases of the menstrual cycle or outside of it, and the studies tested the biomarkers either in menstrual fluid, in whole endometrial tissue or in separate endometrial components. Twenty-seven studies evaluated the diagnostic performance of 22 endometrial biomarkers for endometriosis. These were angiogenesis and growth factors (PROK-1), cell-adhesion molecules (integrins α3β1, α4β1, β1 and α6), DNA-repair molecules (hTERT), endometrial and mitochondrial proteome, hormonal markers (CYP19, 17βHSD2, ER-α, ER-β), inflammatory markers (IL-1R2), myogenic markers (caldesmon, CALD-1), neural markers (PGP 9.5, VIP, CGRP, SP, NPY, NF) and tumour markers (CA-125). Most of these biomarkers were assessed in single studies, whilst only data for PGP 9.5 and CYP19 were available for meta-analysis. These two biomarkers demonstrated significant diversity for the diagnostic estimates between the studies; however, the data were too limited to reliably determine the sources of heterogeneity. The mean sensitivities and specificities of PGP 9.5 (7 studies, 361 women) were 0.96 (95% confidence interval (CI) 0.91 to 1.00) and 0.86 (95% CI 0.70 to 1.00), after excluding one outlier study, and for CYP19 (8 studies, 444 women), they were were 0.77 (95% CI 0.70 to 0.85) and 0.74 (95% CI 0.65 to 84), respectively. We could not statistically evaluate other biomarkers in a meaningful way. An additional 31 studies evaluated 77 biomarkers that showed no evidence of differences in expression levels between the groups of women with and without endometriosis.

AUTHORS' CONCLUSIONS

We could not statistically evaluate most of the biomarkers assessed in this review in a meaningful way. In view of the low quality of most of the included studies, the findings of this review should be interpreted with caution. Although PGP 9.5 met the criteria for a replacement test, it demonstrated considerable inter study heterogeneity in diagnostic estimates, the source of which could not be determined. Several endometrial biomarkers, such as endometrial proteome, 17βHSD2, IL-1R2, caldesmon and other neural markers (VIP, CGRP, SP, NPY and combination of VIP, PGP 9.5 and SP) showed promising evidence of diagnostic accuracy, but there was insufficient or poor quality evidence for any clinical recommendations. Laparoscopy remains the gold standard for the diagnosis of endometriosis, and using any non-invasive tests should only be undertaken in a research setting. We have also identified a number of biomarkers that demonstrated no diagnostic value for endometriosis. We recommend that researchers direct future studies towards biomarkers with high diagnostic potential in good quality diagnostic studies.

Uterine Leukocyte Function and Dysfunction: A Hypothesis on the Impact of Endometriosis

Endometriosis is a chronic inflammatory disease characterized by the growth of endometrial glands and stroma outside of the uterus. The disease affects approximately 10-15% of women of reproductive age and presents with clinical symptoms of pelvic pain and infertility. Changes in the leukocyte populations within the ectopic tissue and eutopic endometrium have been reported, and data suggest these alterations contribute to the pathology and symptoms of the disease. In this review, we discussed differences when comparing uterine NK cells and regulatory T cells within the eutopic endometrium between patients with endometriosis and healthy patients, and how these differences relate to implantation failure and/or decreased clearance of menstrual tissue in patients with the disease. The data demonstrate a critical need to examine endometrium and menstrual tissue in patients with endometriosis excluded from studies examining unknown causes of infertility and heavy menstrual bleeding. The information gathered from excluded patients will further enhance our understanding of how the immune system contributes to the pathophysiology of endometriosis and help to identify biomarkers for patients at higher risk for developing endometriosis-associated infertility.

Optimal uterine anatomy and physiology necessary for normal implantation and placentation

The authors review aberrations of uterine anatomy and physiology affecting pregnancy outcomes with IVF. In the case of endometriosis and hydrosalpinx, pathologies outside of the uterus alter the uterine endometrium. In the case of endometriosis, Dominique de Ziegler outlines the numerous changes in gene expression and the central role of inflammation in causing progesterone resistance. With endometriosis, the absence of ovarian function inherent in deferred transfer, with or without a more lengthy suppression of ovarian function, appears to be sufficient to restore normal function of eutopic endometrium. Because laparoscopy is no longer routine in the evaluation of infertility, unrecognized endometriosis then becomes irrelevant in the context of assisted reproductive technology. With hydrosalpinx and submucus myomas, the implantation factor HOXA-10 is suppressed in the endometrium and, with myomas, even in areas of the uterus not directly affected. Daniela Galliano reviews various uterine pathologies, the most enigmatic being adenomyosis, where the endometrium also manifests many of the changes seen in endometriosis and deferred transfer with extended suppression appears to provide the best outcomes. Ettore Cicinelli's group has extensively studied the diagnosis and treatment of endometritis, and although more definitive diagnosis and care of this covert disorder may await techniques such as sequencing of the endometrial microbiome, it undoubtedly is an important factor in implantation failure, deserving our attention and treatment.

Dienogest. A possible conservative approach in bladder endometriosis. Results of a pilot study

Deep endometriosis involvement of the bladder is uncommon but it is symptomatic in most of the cases. Although laparoscopic excision is very effective, some patients with no pregnancy desire require a medical approach. We performed a pilot study on the effect of a new progestin dienogest on bladder endometriosis. Six patients were treated for 12 months with dienogest 2 mg/daily. Pain, urinary symptoms, quality of life, nodule volume and side effects were recorded. During treatment, symptoms improved very quickly and the nodules exhibit a remarkable reduction in size. Dienogest may be an alternative approach to bladder endometriosis.

New trends of progestins treatment of endometriosis

The management of endometriosis with OC or progestins is generally safe, effective and well-tolerated and should constitute the first line of medical treatment in symptomatic patients who do not want to have children. Progestins, synthetic progestational agents, have been used in the management of symptomatic endometriosis both as primary therapy and as an adjunct to surgical time. A variety of oral agents have been employed in this regard and investigators have demonstrated differing degrees of benefit. The lack of a standardized instrument to evaluate painful symptoms makes comparative analysis more difficult. Concern about efficacy and side effect has pushed the research on the development of new well-tolerated drugs and to develop new administration routes to minimize general side effects. Aim of the present review is to present the results of clinical studies on new trends of progestins in the treatment of endometriosis.

Total Laparoscopic Hysterectomy: Overtreatment for Misdiagnosed Organic cause or Undertreatment for Idiopathic Chronic Pelvic Pain?

Background

Chronic pelvic pain (CPP) is considered a symptom but also a syndrome with misunderstood pathophysiology and treatment options ranging from conservative management to opioid analgesia and surgical intervention. The aim of this study was to evaluate the role of gynecological surgery in modifying presurgical pain status and reducing the postoperative analgesic use of patients suffering CPP. The second aim of the study was to analyze intraoperative and histological differences in patients who benefited from surgery versus those without benefit.

Methods

An observational study was conducted in 16 fertile women affected by CPP, treated by total laparoscopic hysterectomy (TLH) to solve their pelvic pain. In 7 cases, undetected pelvic endometriosis was found.

Results

A complete resolution of pre-operative pain symptoms (score 0) occurred in 9 patients (56.2%), an occasional pelvic discomfort (score 1) in 2 cases (12.5%), 2 patients reported minimal benefit of pelvic pain (score 2), while in 3 cases, severe pain persisted (score 3). The correlation between intraoperative/histological features and reported symptoms after surgery showed that 7 of 9 patients (77.7%) who benefited from surgery were affected by an organic cause; while 5 women with minimal or no benefits from the surgery did not have any organic disease (idiopathic CPP).

Conclusions

If conservative treatment fails to treat CPP, investigative laparoscopy represents a necessary step to discriminate patients with misdiagnosed organic from idiopathic CPP, selecting those who will potentially benefit from hysterectomy. The role of concomitant appendectomy needs to be defined in surgical treatment of idiopathic CPP.

Diaphragmatic Endometriosis: Review of the Literature and First Case of Robot-Assisted Laparoscopic Treatment

Background

Thoracic endometriosis is a rare disorder affecting women in reproductive age. The etiopathogenesis of this disease is not well understood. The symptoms appear, but not necessarily, during periods in person affected by the condition.

Methods

A 35-year-old woman came to our clinic, the Infertility and Assisted Reproduction Center of the University of Pisa, for infertility treatment. She described a clinical history of abdominal pain with irradiation up to the right shoulder, depending on her breathing or position, during menstruation. She also reported that she did not experience these symptoms while taking an oral contraceptive. Pelvic ultrasound examination and thorax X-ray were normal. The patient also underwent thoracic and abdominal pelvis magnetic resonance imaging (MRI). Thoracic MRI revealed a nodule on the right hemidiaphragm. It was decided to perform surgical removal of the nodule. Robotic-assisted surgery was used because of its multiple advantages in comparison with laparoscopic surgery, such as a 3-dimensional view, a decrease in surgeon fatigue and tremors, and an increase of wrist motion with improved dexterity and greater surgical precision. The surgery was performed in May 2012. The patient was put on the left lateral bedside. Pneumoperitoneum with CO2 was established with an intra-abdominal pressure of 12 mm Hg using a Veress needle. Robotic trocars of 8-mm diameter were introduced at the diaphragmatic level and connected to the robot arms. Her pelvic and abdominal organs appeared healthy. The right hemidiaphragm presented adherence with the liver due to endometriosis disease. We removed the adhesion, and we performed the excision of the diaphragmatic endometriotic nodule. The nodule was extracted through an endobag. Operative time lasted 2 hours.

Conclusions

The postoperative evolution was satisfactory, and the patient left the hospital on the third postoperative day. No complications occurred. We showed that this approach is feasible and safe, without conversion to laparotomy.

Pain control and quality of life after laparoscopic en-block resection of deep infiltrating endometriosis (DIE) vs. incomplete surgical treatment with or without GnRHa administration after surgery

PURPOSE

To evaluate the role of post-surgical medical treatment with GnRHa in patients with DIE (Deep Infiltrating Endometriosis) that received complete or incomplete surgery laparoscopic excision.

METHODS

Hundred fifty-nine patients with deep infiltrating endometriosis of the cul-de-sac and of the rectovaginal septum with pelvic pain undergoing laparoscopic surgery in academic tertiary-care medical center. Eighty patients underwent complete laparoscopic excision of DIE (Arm A) while 79 patients underwent incomplete surgery (Arm B). After surgery each surgical arm was randomized in two groups: no treatment groups 1A [40 pts] and 1B [40 pts] and GnRHa treatment for 6 months groups 2A [40 pts] and 2B [39 pts]. Pain recurrence and quality of life were evaluated in follow-up of 12 months and compared between groups.

RESULTS

No differences were observed between patient groups 1A and 2A. Groups 1A, 2A and 2B obtained significantly lower pain scores than those achieved by the group 1B undergoing incomplete surgical treatment and no post-surgical therapy. At 1-year follow-up patients treated with en-block resection (Groups 1A and 2A) showed the lowest pain scores and the highest quality of life in comparison with the other two groups (Group 1B and 2B).

CONCLUSION

GnRHa administration is followed by a temporary improvement of pain in patients with incomplete surgical treatment. It seems that it has no role on post-surgical pain when the surgeon is able to completely excise DIE implants.

Obstetric Outcomes in Patients Treated for Deep Pelvic Endometriosis

Purpose

The aim of this study was to assess obstetric outcomes and symptoms during and after pregnancy in women submitted to surgical treatment for deep pelvic endometriosis.

Methods

We evaluated 123 women who underwent surgery for severe deep pelvic endometriosis-related symptoms. Interventions were excision of rectovaginal septum nodule with or without rectal or vaginal resection, or excision of nodule of uterosacral ligaments. On the basis of pregnancy desire, patients were submitted to a telephone interview and asked if there had been a pregnancy and its outcome. They were also asked to describe their pain symptoms before, after and during the pregnancy.

Results

From the 123 patients, we selected 43 women desiring pregnancy after surgery, who answered the telephone interview. Twenty-four patients (55.8%) got pregnant. We recorded 34 pregnancies a mean 21.8 ± 17.9 months after surgery. In the group of 25 full-term pregnancies, 14 women (56%) had a vaginal delivery without complications, and 11 (44%) underwent a cesarean section. In only 3 cases, was the indication of cesarean section related to previous surgery. Seventy-one percent of women treated without rectal or vaginal resection delivered vaginally. We also registered 1 case of uncomplicated vaginal delivery in a patient with vaginal resection and another 1 in a patient with rectal resection. In the patients who complained of pain before pregnancy, we observed a resolution of pain symptoms during pregnancy, but after delivery these symptoms reappeared.

Conclusions

In patients submitted to surgery for deep pelvic endometriosis, even in cases of vaginal or rectal resection, a cesarean section is not always mandatory.

Alexithymia in Women with Deep Endometriosis? A Pilot Study

Objectives

The aim of the study was to evaluate the presence of alexithymia in a group of patients with endometriosis and chronic pelvic pain, and compare the results obtained, with those for a group of healthy controls.

Methods

Forty-one patients with pain and surgical diagnosis of deep endometriosis and 40 healthy controls were recruited for the study. All subjects were assessed using the Toronto Alexithymia Scale (TAS-20). Moreover, the intensity of chronic pelvic pain and dysmenorrhea in patients was evaluated using a modified version of the Biberoglu-Behrman pain scale. In addition, the patients' state of general health was investigated with the SF-36.

Results

A positive score for alexithymia was achieved in 14.6% (n = 6) of patients with endometriosis, while the condition was absent in the control group. Alexithymia was indeterminate in 29.3% (n = 12) and 12.5% (n = 5) of patients and controls, respectively, and absent in 56.1% (n = 22) and 87.5% (n = 35). Intergroup differences were significant for 3 factors evaluated by the TAS-20.

Discussion

The present study underlined how women with endometriosis are significantly more alexithymic compared with controls.

Correlation of changes of (non)exfoliated endometrial organelles and expressions of Musashi-1 and β-catenin with endometriosis in menstrual period

This study aims to investigate the correlation of structural changes of endometrial organelles and expressions of Musashi-1 (Msi-1) and β-catenin with the endometriosis (EMs) in the menstrual period. The structural changes of exfoliated and nonexfoliated endometrial organelles in the experimental group and the control group were observed by the transmission electron microscopy (TEM) on the first and fifth day of menstruation. (1) TEM: compared with the control group, the exfoliated endometrial organelles in the experimental group on the first day were rich, with irregular nucleus, the bi-nucleolus could be seen, with rich chromatin; while the shapes of epithelial secretory cells in the nonexfoliated endometrial gland were irregular, with abundant organelles, the basal film varied in width, with abnormal curvature, and a lot of intercellular collagen fibers could be seen. (2) The expressions of Msi-1 and β-catenin in the exfoliated and nonexfoliated endometrium of the experimental group were higher than those of the control group and exhibited positively correlation, while no correlation could be found within the control group. (1) The organelles' structural changes might cause the changes of endometrial cellular functions. (2) Msi-1 might participate in the formation of EMs through activating the Wnt/β-catenin signaling pathway.

The effect of endometriosis on in vitro fertilisation outcome: a systematic review and meta-analysis

BACKGROUND

Endometriosis is found in 0.5-5% of fertile women and 25-40% of infertile women. It is known that endometriosis is associated with infertility, but there is uncertainty whether women with endometriosis have adverse pregnancy outcomes in in vitro fertilisation (IVF) treatment.

OBJECTIVES

To explore the association between endometriosis and IVF outcome.

SEARCH STRATEGY

Searches were conducted on MEDLINE, EMBASE, Cochrane Library and Web of Science (inception, December 2012) in all languages, together with reference lists of retrieved papers.

SELECTION CRITERIA

Studies comparing IVF outcome in women with endometriosis with women without endometriosis. Patients were classified by stage of endometriosis. The outcomes were fertilisation, implantation, clinical pregnancy and live birth rates. Study selection was conducted independently by two reviewers. The Newcastle-Ottawa Quality Assessment Scale was used for quality assessment.

DATA COLLECTION AND ANALYSIS

Data extraction was conducted independently by two reviewers. Relative risks from individual studies were meta-analysed.

MAIN RESULTS

Twenty-seven observational studies were included, comprising 8984 women. Meta-analysis of these studies showed that fertilisation rates were reduced in stage I/II of endometriosis (relative risk [RR] = 0.93, 95% confidence interval [95% CI] 0.87-0.99, P = 0.03). There was a decrease in the implantation rate (RR = 0.79, 95% CI 0.67-0.93, P = 0.006) and clinical pregnancy rate (RR = 0.79, 95% CI 0.69-0.91, P = 0.0008) in women with stage III/IV endometriosis undergoing IVF treatment.

CONCLUSION

The presence of severe endometriosis (stage III/IV) is associated with poor implantation and clinical pregnancy rates in women undergoing IVF treatment.

Induction of endometriosis alters the peripheral and endometrial regulatory T cell population in the non-human primate

BACKGROUND

Endometriosis is a gynecological condition that is characterized by extreme abdominal pain and also decreased fertility. Regulatory T cells (Tregs) have immunosuppressive activity critical for embryonic implantation and likewise the acceptance of tissue engraftment. Utilizing the induced non-human primate (Papio anubis) model of endometriosis, we hypothesize that endometriosis decreases the peripheral and endomet rial Treg profile, whereas ectopic lesions have increased Treg localization.

METHODS

Peripheral blood and endometrium were obtained throughout the menstrual cycle prior to and after induction of disease. Animals were randomly assigned to control (n = 7) or diseased (n = 16) treatment groups. Endometriosis was induced by i.p. injection of autologous menstrual tissue for 2 consecutive months during menses. Peripheral blood and endometrial tissue were collected at d9-11PO at 1, 3, 6, 9, 12 and 15 months post-induction of disease for fluorescence-activated cell sorting, quantitative RT-PCR and immunohistochemistry. Ectopic lesions were excised at 1 and 6 months post-inoculation and also harvested at necropsy (15 months) and processed for RNA of IHC. Identification of Tregs through analysis of FOXP3 expression was conducted utlilizing several methodologies. Differences were determined by non-parametric statistical analysis between all treatment groups and time points.

RESULTS

In control animals, the proportion of peripheral natural Tregs (nTregs) was reduced (P < 0.05) during the mid- and late secretory stages of the menstrual cycle compared with menses. The induction of disease decreased peripheral Treg expression at early time points (P < 0.05) and this remained low throughout the time course, compared with the pre-inoculatory level of an individual. FOXP3 gene expression and Treg populations were also decreased in the eutopic endometrium (P < 0.05) compared with control animals, whereas these parameters were increased in ectopic lesions (P < 0.05), compared with the eutopic endometrium.

CONCLUSIONS

Our data suggest that a reduction in peripheral Tregs may be a causative factor for endometriosis-associated infertility, while the increase in ectopic Treg expression may aid lesion development. Furthermore, endometriosis appears to disrupt Treg recruitment in both eutopic and ectopic endometrium.

Endometrial aromatase mRNA as a possible screening tool for advanced endometriosis and adenomyosis

Endometriosis (ENDs) and adenomyosis (ADNs) are estrogen-dependent diseases. The aim of this study was to determine the clinical usefulness of examining endometrial biopsy specimens for aromatase cytochrome P450 (CYP19) as a diagnostic importance for endometriosis and adenomyosis. In general, the RT-PCR analyses of 101 samples revealed increased aromatase mRNA expression in eutopic endometrium in women with endometriosis and adenomyosis compared to healthy controls (p = 0.0002). The highest number of positive cases (93.3%) of CYP19 mRNA expression was detected in women with advanced disease stages. Concrete expression of CYP19 mRNA level in controls was 0.68 compared to patients with ADNs (1.21), ENDsL stage I-II (1.15) and ENDsA stage III-IV (1.65) (p < 0.0001), respectively. The possible influence of increased body mass index on aromatase expression in each group showed in controls an insignificant slight increase of aromatase expression, contrary to cases where this trend was the opposite. The results point to the higher (2.45-fold) difference in aromatase expression in patients with endometriosis stage III-IV compared to controls and provide direct evidence that screening for eutopic endometrial aromatase expression in combination with clinical data could be of discriminative value in the prediction of estrogen-dependent diseases, independent from body mass index.

Differences in mitochondrial proteins in the eutopic endometrium of patients with adenomyosis and endometriosis identified using surface-enhanced laser desorption/ionization time-of-flight mass spectrometry

Adenomyosis and endometriosis have a similar pathogenesis; indeed, adenomyosis has been considered by some as a variant of endometriosis ('internal endometriosis'). This study aimed to detect differences in mitochondrial proteins in eutopic endometrial samples from women with adenomyosis (n = 13) and endometriosis (n = 24), and from control patients (n = 29) using surface-enhanced laser desorption/ionization time-of-flight mass spectrometry (SELDI-TOF-MS) protein chip technology. A total of 82 and 78 mitochondrial protein peaks were found in adenomyosis and endometriosis individuals, respectively. Of these, 14 were common to women with adenomyosis and women with endometriosis, although only one of these (mass-to-charge [m/z] ratio 3499) was significantly different between the adenomyosis and endometriosis groups. It is concluded that, compared with control patients, there are differences in the mitochondrial proteins isolated from the eutopic endometrium of patients with adenomyosis and those with endometriosis. Although the changes in mitochondrial proteins in eutopic endometrium from patients with adenomyosis and endometriosis were largely similar, significant differences were also detected. Further identification of these proteins and elucidation of the differences will help towards the differential diagnosis of adenomyosis and endometriosis and new therapeutic approaches.

The non-human primate model of endometriosis: research and implications for fecundity

The development of an animal model of endometriosis is crucial for the investigation of disease pathogenesis and therapeutic intervention. These models will enhance our ability to evaluate the causes for the subfertility associated with disease and provide a first-line validation of treatment modulators. Currently rodents and non-human primate models have been developed, but each model has their limitations. The aim of this manuscript is to summarize the current findings and theories on the development of endometriosis and disease progression and the effectiveness of therapeutic targets using the experimental induced model of endometriosis in the baboon (Papio anubis).