1
|
Dolmans MM, Donnez J. Solving the mysteries surrounding uterine fibroids: are we almost there? Fertil Steril 2024:S0015-0282(24)00454-0. [PMID: 38740322 DOI: 10.1016/j.fertnstert.2024.05.144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2024] [Accepted: 05/09/2024] [Indexed: 05/16/2024]
Abstract
A better understanding of uterine fibroid-related pathogenesis and symptoms like uterine bleeding and infertility is mandatory.
Collapse
Affiliation(s)
- Marie-Madeleine Dolmans
- Gynecology Research Unit, Institut de Recherche Expérimentale et Clinique, Universite Catholique de Louvain, Brussels, Belgium;; Gynecology Department, Cliniques Universitaires SaintLuc, Brussels, Belgium;.
| | - Jacques Donnez
- Université Catholique de Louvain, Brussels, Belgium;; Society for Research into Infertility (SRI),Brussels, Belgium
| |
Collapse
|
2
|
Donnez J, Becker C, Taylor H, Carmona Herrera F, Donnez O, Horne A, Paszkowski M, Petraglia F, Renner SP, Patel A, Boolell M, Bestel E, Dolmans MM. Linzagolix therapy versus a placebo in patients with endometriosis-associated pain: a prospective, randomized, double-blind, Phase 3 study (EDELWEISS 3). Hum Reprod 2024:deae076. [PMID: 38648863 DOI: 10.1093/humrep/deae076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Revised: 03/07/2024] [Indexed: 04/25/2024] Open
Abstract
STUDY QUESTION Does linzagolix administered orally once daily for up to 3 months at a dose of 75 mg alone or 200 mg in combination with add-back therapy (ABT) (1.0 mg estradiol; 0.5 mg norethindrone acetate, also known as norethisterone acetate [NETA]) demonstrate better efficacy than placebo in the management of endometriosis-related dysmenorrhea and non-menstrual pelvic pain? SUMMARY ANSWER Combining 200 mg linzagolix with ABT was found to significantly reduce dysmenorrhea and non-menstrual pelvic pain at 3 months of therapy, while a daily dose of 75 mg linzagolix yielded a significant decrease only in dysmenorrhea at 3 months. WHAT IS KNOWN ALREADY? A previously published Phase 2, dose-finding study reported that at a dose of 200 mg daily, linzagolix promotes full suppression of estradiol secretion to serum levels below 20 pg/ml and noted that the addition of ABT may be needed to manage hypoestrogenic side effects. At lower doses (75 mg and 100 mg/day), linzagolix maintains estradiol values within the target range of 20-60 pg/ml, which could be ideal to alleviate symptoms linked to endometriosis. STUDY DESIGN, SIZE, DURATION EDELWEISS 3 was a multicenter, prospective, randomized, placebo-controlled, double-blind, double-dummy Phase 3 study to evaluate the safety and efficacy of linzagolix for the treatment of moderate-to-severe endometriosis-associated pain. Treatment was administered orally once daily for up to 6 months. PARTICIPANTS/MATERIALS, SETTING, METHODS In the EDELWEISS 3 trial, 486 subjects with moderate-to-severe endometriosis-associated pain were randomized at a 1:1:1 ratio to one of the three study groups: placebo, 75 mg linzagolix alone or 200 mg linzagolix in association with ABT. Pain was measured daily on a verbal rating scale and recorded in an electronic diary. MAIN RESULTS AND THE ROLE OF CHANCE At 3 months, the daily 200 mg linzagolix dose with ABT met the primary efficacy objective, showing clinically meaningful and statistically significant reductions in dysmenorrhea and non-menstrual pelvic pain, with stable or decreased use of analgesics. The proportion of responders for dysmenorrhea in the 200 mg linzagolix with ABT group was 72.9% compared with 23.5% in the placebo group (P < 0.001), while the rates of responders for non-menstrual pelvic pain were 47.3% and 30.9% (P = 0.007), respectively. The 75 mg linzagolix daily dose demonstrated a clinically meaningful and statistically significant reduction in dysmenorrhea versus placebo at 3 months. The proportion of responders for dysmenorrhea in the 75 mg linzagolix group was 44.0% compared with 23.5% in the placebo group (P < 0.001). Although the 75 mg dose showed a trend toward reduction in non-menstrual pelvic pain at 3 months relative to the placebo, it was not statistically significant (P = 0.279). Significant improvements in dyschezia and overall pelvic pain were observed in both linzagolix groups when compared to placebo. Small improvements in dyspareunia scores were observed in both linzagolix groups but they were not significant. In both groups, hypoestrogenic effects were mild, with low rates of hot flushes and bone density loss of <1%. A daily dose of 200 mg linzagolix with ABT or 75 mg linzagolix alone was found to significantly reduce dysmenorrhea and non-menstrual pelvic pain also at 6 months of therapy. LIMITATIONS, REASONS FOR CAUTION Efficacy was compared between linzagolix groups and placebo; however, it would be useful to have results from comparative studies with estro-progestogens or progestogens. It will be important to ascertain whether gonadotropin-releasing hormone antagonists have significant benefits over traditional first-line medications. WIDER IMPLICATIONS OF THE FINDINGS Linzagolix administered orally once daily at a dose of 200 mg in combination with add-back therapy (ABT) demonstrated better efficacy and safety than placebo in the management of moderate-to-severe endometriosis-associated pain. The quality of life was improved and the risks of bone loss and vasomotor symptoms were minimized due to the ABT. The 75 mg dose alone could be suitable for chronic treatment of endometriosis-associated pain without the need for concomitant hormonal ABT, but further research is needed to confirm this. If confirmed, it would offer a viable option for women who do not want to wish to have ABT or for whom it is contraindicated. STUDY FUNDING/COMPETING INTEREST(S) Funding for the EDELWEISS 3 study was provided by ObsEva (Geneva, Switzerland). Analysis of data and manuscript writing were partially supported by ObsEva (Geneva, Switzerland), Theramex (London, UK) and Kissei (Japan) and grant 5/4/150/5 was awarded to M.-M.D. by FNRS. J.D. was a member of the scientific advisory board of ObsEva until August 2022, a member of the scientific advisory board of PregLem, and received personal fees from Gedeon Richter, ObsEva and Theramex. J.D. received consulting fees, speakers' fees, and travel support from Gedeon Richter, Obseva and Theramex, which was paid to their institution. C.B. has received fees from Theramex, Gedeon Richter, and Myovant, and travel support from Gedeon Richter-all funds went to the University of Oxford. He was a member of the data monitoring board supervising the current study, and served at an advisory board for endometriosis studies of Myovant. H.T. has received grants from Abbvie and was past president of ASRM. F.C.H. has received fees from Gedeon Richter and Theramex. O.D. received fees for lectures from Gedeon Richter and ObsEva and research grants for clinical studies from Preglem and ObsEva independent from the current study. A.H. has received grants from NIHR, UKRI, CSO, Wellbeing of Women, and Roche Diagnostics; he has received fees from Theramex. A.H.'s institution has received honoraria for consultancy from Roche Diagnostics, Gesynta, and Joii. M.P. has nothing to declare. F.P. has received fees from Theramex. S.P.R. has been a member of the scientific advisory board of Gedeon Richter and received fees from Gedeon Richter. A.P. and M.B. are employees of Theramex. E.B. was an employee of ObsEva, sponsor chair of the data monitoring board supervising the current study, and has been working as a consultant for Theramex since December 2022; she owns stock options in ObsEva. M.-M.D. has received fees and travel support from Gedeon Richter and Theramex. TRIAL REGISTRATION NUMBER NCT03992846. TRIAL REGISTRATION DATE 20 June 2019. DATE OF FIRST PATIENT’S ENROLLMENT 13 June 2019.
Collapse
Affiliation(s)
- Jacques Donnez
- Department of Gynecology, Université Catholique de Louvain, Brussels, Belgium
- Department of Gynecology, Société de Recherche pour l'Infertilité (SRI), Brussels, Belgium
| | - Christian Becker
- Nuffield Department of Women's & Reproductive Health, Endometriosis CaRe Centre, University of Oxford, Oxford, UK
| | - Hugh Taylor
- Department of Obstetrics, Gynecology and Reproductive sciences, Yale School of Medicine, New Haven, CT, USA
| | - Francisco Carmona Herrera
- Gynaecology Department, Clinic Institute of Gynaecology, Obstetrics and Neonatology (ICGON), Hospital Clinic of Barcelona, Universitat de Barcelona, Barcelona, Spain
| | - Olivier Donnez
- Département de Gynécologie, Centre de l'Endométriose Complexe, Chirurgie endoscopique pelvienne, Polyclinique Urbain V (ELSAN Group), Avignon, France
| | - Andrew Horne
- Department of Gynecology, EXPPECT and MRC Centre for Reproductive Health, University of Edinburgh, Edinburgh, UK
| | - Maciej Paszkowski
- Third Chair and Department of Gynecology, Medical University of Lublin, Lublin, Poland
| | - Felice Petraglia
- Obstetrics and Gynecology Unit, Department of Clinical Experimental and Biomedical Sciences, University of Florence, Florence, Italy
| | - Stefan P Renner
- Department of Gynecology and Obstetrics, Hospital Böblingen, Klinikverbund-Suedwest, Sindelfingen 71065, Germany
| | - Amisha Patel
- Department of Medical Affairs, Theramex UK Ltd, London, UK
| | - Mitra Boolell
- Department of Medical Affairs, Theramex UK Ltd, London, UK
| | - Elke Bestel
- Department of Medical Affairs, Theramex UK Ltd, London, UK
| | - Marie-Madeleine Dolmans
- Gynecology Research Laboratory, Institut de Recherche Expérimentale et Clinique, Department of Gynecology, Université Catholique de Louvain, Brussels, Belgium
- Gynecology Department, Cliniques Universitaires St-Luc, Brussels, Belgium
| |
Collapse
|
3
|
Vitale F, Cacciottola L, Camboni A, Houeis L, Donnez J, Dolmans MM. Assessing the effect of adipose-tissue-derived stem cell conditioned medium on follicles and stromal cells in bovine ovarian tissue culture. Reprod Biomed Online 2024; 49:103938. [PMID: 38759499 DOI: 10.1016/j.rbmo.2024.103938] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Revised: 01/31/2024] [Accepted: 03/05/2024] [Indexed: 05/19/2024]
Abstract
RESEARCH QUESTION Does adipose-tissue-derived stem cell conditioned medium (ASC-CM) supplementation enhance follicle and stromal cell outcomes in vitro? DESIGN Bovine ovaries (n = 8) were sectioned and cultured in vitro for 8 days in two different groups: (i) standard culture (OT Ctrl D8); and (ii) culture with ASC-CM supplementation (OT + CM D8). Half of the culture medium was replaced every other day, and stored to measure the production of oestradiol. Follicle classification was established using haematoxylin and eosin staining. Follicle and stromal cell DNA fragmentation was assessed by TUNEL assays, while growth differentiation factor-9 (GDF-9) staining served as a marker of follicle quality. Additionally, three factors, namely vascular endothelial growth factor (VEGF), interleukin 6 (IL-6) and transforming growth factor beta 1 (TGF-β1), were evaluated in ASC-CM in order to appraise the potential underlying mechanisms of action of ASC. RESULTS The OT + CM D8 group showed a significantly higher proportion of secondary follicles (P = 0.02) compared with the OT Ctrl D8 group. The OT + CM D8 group also demonstrated significantly lower percentages of TUNEL-positive follicles (P = 0.014) and stromal cells (P = 0.001) compared with the OT Ctrl D8 group. Furthermore, follicles in the OT + CM D8 group exhibited a significant increase (P = 0.002) in expression of GDF-9 compared with those in the OT Ctrl D8 group, and oestradiol production was significantly higher (P = 0.04) in the OT + CM D8 group. All studied factors were found to be present in ASC-CM. VEGF and IL-6 were the most widely expressed factors, while TGF-β1 showed the lowest expression. CONCLUSIONS Addition of ASC-CM to culture medium enhances follicle survival, development and oestradiol production, and promotes the viability of stromal cells. VEGF, IL-6 and TGF-β1 could be paracrine mediators underlying the beneficial effects.
Collapse
Affiliation(s)
- Francisco Vitale
- Gynaecology Research Unit, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Brussels, Belgium
| | - Luciana Cacciottola
- Gynaecology Research Unit, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Brussels, Belgium
| | - Alessandra Camboni
- Gynaecology Research Unit, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Brussels, Belgium; Pathology Department, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Lara Houeis
- Gynaecology Research Unit, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Brussels, Belgium
| | - Jacques Donnez
- Société de Recherche pour l'Infertilité, Brussels, Belgium; Professor Em, Université Catholique de Louvain, Brussels, Belgium
| | - Marie-Madeleine Dolmans
- Gynaecology Research Unit, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Brussels, Belgium; Gynaecology Department, Cliniques Universitaires Saint-Luc, Brussels, Belgium.
| |
Collapse
|
4
|
Cacciottola L, Camboni A, Gatti E, Marbaix E, Vignali M, Donnez J, Dolmans MM. Fertility potential and safety assessment of residual ovarian cortex in young women diagnosed with epithelial borderline and early-stage malignant ovarian tumors. Gynecol Oncol 2024; 183:15-24. [PMID: 38492474 DOI: 10.1016/j.ygyno.2024.03.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2023] [Revised: 03/04/2024] [Accepted: 03/09/2024] [Indexed: 03/18/2024]
Abstract
OBJECTIVE To establish the safety and quality of ovarian cortex surrounding epithelial ovarian tumors in women eligible for fertility-sparing surgery by identifying occult malignant lesions and characterizing the ovarian follicle pool. METHODS Multicentric retrospective study of 48 subjects (15-45 years), diagnosed with borderline ovarian tumors (BOTs) or early-stage epithelial ovarian cancers (EOCs) and eligible for fertility-sparing surgery. Histological samples of ovarian cortex surrounding tumors were analyzed to characterize the follicle pool, find any occult malignant lesion using tumor-specific markers (cytokeratin 7 and mucin 1), and quantify tumor-infiltrating lymphocytes (TILs) by CD3 and tumor associated macrophages (TAMs) by CD68. RESULTS Occult ovarian lesions were observed in 6 out of 45 cases investigated (14.6%), including one mucinous stage-I BOT (1/14), one serous stage-I BOT (1/13), 3 advanced-stage serous BOTs (3/11) and one early-stage serous EOC (1/7). Notably, follicle density was significantly lower in subjects diagnosed with ovarian tumors compared to controls (p < 0.001) and at a younger age. Significantly higher follicle atresia was encountered in the ovarian tumor group then in controls (20.1 ± 8.8% vs 9.2 ± 9.4%, p < 0.001) at all ages. Both TILs and TAMs were found in ovarian tumors irrespective of histotype, but no link was established with the status of the ovarian reserve. CONCLUSIONS Personalized counseling for fertility preservation is required in the event of BOTs and early-stage EOCs. Fertility-sparing surgery and adjuvant gamete preservation should be considered, balancing the oncological risks according to tumor stage and histotype and fertility potential, especially at a younger age.
Collapse
Affiliation(s)
- L Cacciottola
- Gynecology Research Unit, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Brussels, Belgium
| | - A Camboni
- Gynecology Research Unit, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Brussels, Belgium; Department of Anatomopathology, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - E Gatti
- Department of Biomedical Science for Health, University of Milan, Milan, Italy
| | - E Marbaix
- Department of Anatomopathology, Cliniques Universitaires Saint-Luc, Brussels, Belgium; Prof Emeritus, Université Catholique de Louvain, Belgium
| | - M Vignali
- Department of Biomedical Science for Health, University of Milan, Milan, Italy
| | - J Donnez
- Prof Emeritus, Université Catholique de Louvain, Belgium; Société de Recherche Pour l'Infertilité, Brussels, Belgium
| | - M M Dolmans
- Gynecology Research Unit, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Brussels, Belgium; Gynecology Department, Cliniques Universitaires Saint-Luc, Brussels, Belgium.
| |
Collapse
|
5
|
Dolmans MM, Petraglia F, Catherino WH, Donnez J. Pathogenesis of uterine fibroids: current understanding and future directions. Fertil Steril 2024:S0015-0282(24)00169-9. [PMID: 38453042 DOI: 10.1016/j.fertnstert.2024.02.048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2024] [Accepted: 02/29/2024] [Indexed: 03/09/2024]
Abstract
Fibroids are benign uterine tumors characterized by the proliferation of uterine smooth muscle cells, embedded in an abundant extracellular matrix. Their prevalence is estimated to be >50% in women aged >45 years. Fibroids represent a considerable health burden. It is time to acquire a deeper mechanistic understanding of uterine fibroid-related etiology and pathogenesis, which may help pinpoint new strategies and an individualized approach. There is a need to gather prospective data and conduct studies to compare alternative approaches and assess long-term outcomes with respect to quality of life, recurrence of symptoms (bleeding and bulk symptoms), fertility, and even complications The goal of this review was to evaluate the widely accepted pathogenesis and identify risks factors and future directions for clinical and basic research into fibroids.
Collapse
Affiliation(s)
- Marie-Madeleine Dolmans
- Pôle de Recherche en Gynécologie, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain (UCL), Brussels, Belgium; Gynecology Department, Cliniques Universitaires Saint-Luc, Brussels, Belgium.
| | - Felice Petraglia
- Obstetrics and Gynecology, Department of Maternal-Infancy, Careggi University Hospital Florence, Florence, Italy; Department of Experimental, Clinical and Biomedical Sciences, University of Florence, Largo Brambilla, Italy
| | - William H Catherino
- Department of Gynecologic Surgery and Obstetrics, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Jacques Donnez
- Université Catholique de Louvain, Brussels, Belgium; Society for Research into Infertility (SRI), Brussels, Belgium
| |
Collapse
|
6
|
Donnez J, Taylor HS, Marcellin L, Dolmans MM. Uterine fibroid-related infertility: mechanisms and management. Fertil Steril 2024:S0015-0282(24)00170-5. [PMID: 38453041 DOI: 10.1016/j.fertnstert.2024.02.049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2024] [Accepted: 02/29/2024] [Indexed: 03/09/2024]
Abstract
Fibroids are a common pathology and increasingly observed in women seeking medical treatment for infertility. The longer reproductive horizon because of improvements in medical care and current trend for women to postpone childbearing are making fibroid-related infertility increasingly common. This review aimed to critically analyze the association between uterine fibroids and infertility, mechanisms by which uterine fibroids may impair fertility, and management of myoma-related infertility. The association of fibroids with infertility is a source of controversy. As the focus of this review is infertility, it is crucial to analyze the mechanisms by which fertility may be impaired by the presence of fibroids. Current management strategies involve mainly surgical interventions, including myomectomy by hysteroscopy, laparotomy, or laparoscopy, and nonsurgical approaches, such as uterine artery embolization and focused ultrasound performed under radiologic or echographic guidance. The risks and benefits of each option should be discussed with patients, and several factors need to be considered, including the skills of surgeons and availability of different resources in various centers. Concerning the efficacy of oral gonadotropin-releasing hormone antagonists (i.e., elagolix, relugolix, and linzagolix), they were shown to have a rapid impact on heavy menstrual bleeding (HMB) in >70% of women. When used without add-back therapy, these drugs cause a significant reduction in fibroid volume, namely, approximately 50% from baseline to week 24. Further studies are required to determine the best protocol and optimal dosage if a reduction in myoma volume is the main goal, as in case of myoma-related infertility.
Collapse
Affiliation(s)
- Jacques Donnez
- Université Catholique de Louvain, Ottignies-Louvain-la-Neuve, Belgium; Society for Research into Infertility (SRI), Brussels, Belgium.
| | - Hugh S Taylor
- Department of Obstetrics, Gynecology and Reproductive Sciences, Yale School of Medicine, New Haven, Connecticut
| | - Louis Marcellin
- Département de Gynécologie Obstétrique II et Médecine de la Reproduction, Université Paris Cité, Assistance Publique-Hôpitaux de Paris (AP-HP), Centre Hospitalier Universitaire (CHU) Cochin, Hôpital Universitaire Paris Centre (HUPC), Paris, France
| | - Marie-Madeleine Dolmans
- Pôle de Recherche en Gynécologie, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain (UCL), Brussels, Belgium; Gynecology Department, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| |
Collapse
|
7
|
Donnez J, Dolmans MM. Uterine adenomyosis: Is there an impact on in vitro fertilization outcomes? Fertil Steril 2024; 121:442-443. [PMID: 38143013 DOI: 10.1016/j.fertnstert.2023.12.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Accepted: 12/20/2023] [Indexed: 12/26/2023]
Affiliation(s)
- Jacques Donnez
- Gyne Unit, Society for Research into Infertility (SRI), Brussels, Belgium; Gyne Unit, Université Catholique de Louvain, Brussels, Belgium
| | - Marie-Madeleine Dolmans
- Pôle de Recherche en Gynécologie, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain (UCL), Brussels, Belgium; Gynecology Department, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| |
Collapse
|
8
|
Donnez J, Stratopoulou CA, Dolmans MM. Endometriosis and adenomyosis: Similarities and differences. Best Pract Res Clin Obstet Gynaecol 2024; 92:102432. [PMID: 38103509 DOI: 10.1016/j.bpobgyn.2023.102432] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Accepted: 10/25/2023] [Indexed: 12/19/2023]
Abstract
Deep endometriosis and uterine adenomyosis are two frequently encountered conditions affecting approximately 200 million women worldwide. They are closely related, showing similar histological patterns and multiple common pathogenic features, and share the same symptoms. It is therefore not surprising that they are often thought to have a common developmental origin. Indeed, both deep endometriosis and adenomyosis appear to derive from estrogen-dependent overproliferation of endometrial tissue and its subsequent implantation in ectopic sites. Although the scientific community has shown increasing interest in these diseases over recent years, neither pathogenesis has yet been elucidated, so there are currently no efficient treatment options. Understanding the mechanisms underlying disease development, as well as discerning their relationship, are key to improving clinical management for millions of patients. The aims of this review are to summarize current knowledge on deep endometriosis and adenomyosis pathogeneses and discuss the possibility that these two entities are actually differential phenotypes of the same disease.
Collapse
Affiliation(s)
- Jacques Donnez
- Prof Emeritus, Université Catholique de Louvain, Belgium; Society for Research into Infertility (SRI), 143 Avenue Grandchamp, 1150, Brussels, Belgium.
| | - Christina Anna Stratopoulou
- Pôle de Recherche en Gynécologie, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain (UCL), Brussels, Belgium
| | - Marie-Madeleine Dolmans
- Pôle de Recherche en Gynécologie, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain (UCL), Brussels, Belgium; Gynecology Department, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| |
Collapse
|
9
|
Barretta M, Cacciottola L, Hossay C, Donnez J, Dolmans MM. Impact of human ovarian tissue manipulation on follicles: evidence of a potential first wave of follicle activation during fertility preservation procedures. J Assist Reprod Genet 2023; 40:2769-2776. [PMID: 37713145 PMCID: PMC10656389 DOI: 10.1007/s10815-023-02930-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Accepted: 09/04/2023] [Indexed: 09/16/2023] Open
Abstract
PURPOSE The aim of this study was to investigate the impact of processing human ovarian tissue on follicle activation dynamics. METHODS Fresh ovarian tissue was retrieved from 9 women undergoing laparoscopic surgery for benign conditions. Biopsies from each patient were divided into 3 fragments, the first of which was immediately fixed in the operating room (T0) and the second and third just after processing at 25 (T25) and (T90) 90 min. To evaluate follicle activation, markers of the PI3K and Hippo signaling pathways were immunolabeled at each time point, targeting phospho-Akt (p-Akt) by immunohistochemistry and yes-associated protein (YAP) cellular localization in the granulosa cell layer by immunofluorescence. RESULTS Four hundred forty primordial follicles were evaluated for p-Akt and 420 for YAP. Significantly stronger p-Akt expression was observed at T25 (23.01 ± 13.45%; p=0.04) and T90 (38.99 ± 25.21%; p<0.001) than at T0 (2.72 ± 3.35%). A significant nucleus-to-cytoplasm shift in YAP was detected at T25 (1.21 ± 0.25; p=0.015 compared to T0 (0.95 ± 0.09), while T90 (1.10 ± 0.16) values were similar to T25. CONCLUSION Our data prove that ovarian tissue manipulation significantly impacts follicle dynamics by stimulating the PI3K and Hippo signaling pathways involved in primordial follicle activation. Further experimental evidence must nevertheless be gathered to understand and gain control of follicle activation mechanisms in non-physiological conditions (like ovarian tissue manipulation), in order to optimize fertility preservation and restoration strategies.
Collapse
Affiliation(s)
- Marta Barretta
- Gynecology Research Unit, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Avenue Mounier 52, bte B1.52.02, 1200, Brussels, Belgium
- Department of Biomedical Science for Health, University of Milan, Milan, Italy
| | - Luciana Cacciottola
- Gynecology Research Unit, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Avenue Mounier 52, bte B1.52.02, 1200, Brussels, Belgium
| | - Camille Hossay
- Gynecology Research Unit, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Avenue Mounier 52, bte B1.52.02, 1200, Brussels, Belgium
| | - Jacques Donnez
- Université Catholique de Louvain, Brussels, Belgium
- Société de Recherche pour l'Infertilité, Brussels, Belgium
| | - Marie-Madeleine Dolmans
- Gynecology Research Unit, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Avenue Mounier 52, bte B1.52.02, 1200, Brussels, Belgium.
- Gynecology Department, Cliniques Universitaires Saint-Luc, Avenue Mounier 52, bte B1.52.02, 1200, Brussels, Belgium.
| |
Collapse
|
10
|
Donnez J, Dolmans MM. Fertility preservation in girls with Turner syndrome: to do or not to do? Fertil Steril 2023; 120:993-994. [PMID: 37660879 DOI: 10.1016/j.fertnstert.2023.08.971] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Accepted: 08/29/2023] [Indexed: 09/05/2023]
Affiliation(s)
- Jacques Donnez
- Society for Research into Infertility, Brussels, Belgium; Université Catholique de Louvain, Brussels, Belgium
| | - Marie-Madeleine Dolmans
- Pôle de Recherche en Gynécologie, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Brussels, Belgium; Gynecology Department, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| |
Collapse
|
11
|
Donnez J, Donnez O, Dolmans MM. Evolution of uterine adenomyosis volume during and after GnRH antagonist (linzagolix) treatment: lessons for further clinical trials. Fertil Steril 2023; 120:1071-1073. [PMID: 37495010 DOI: 10.1016/j.fertnstert.2023.07.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Revised: 07/20/2023] [Accepted: 07/20/2023] [Indexed: 07/28/2023]
Affiliation(s)
- Jacques Donnez
- Society for Research into Infertility, Brussels, Belgium; Gynecology department, Catholic university of Louvain, Brussels, Belgium.
| | - Olivier Donnez
- Polyclinique Urbain V, Institut du Sein et de Chirurgie Gynécologique d'Avignon, Avignon, France
| | - Marie-Madeleine Dolmans
- Pôle de Recherche en Gynécologie, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Brussels, Belgium; Gynecology Department, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| |
Collapse
|
12
|
Cacciottola L, Vitale F, Donnez J, Dolmans MM. Use of mesenchymal stem cells to enhance or restore fertility potential: a systematic review of available experimental strategies. Hum Reprod Open 2023; 2023:hoad040. [PMID: 37954935 PMCID: PMC10637864 DOI: 10.1093/hropen/hoad040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Revised: 09/15/2023] [Indexed: 11/14/2023] Open
Abstract
STUDY QUESTION To what extent does regenerative medicine with stem cell therapy help to address infertility issues for future clinical application? SUMMARY ANSWER Regenerative medicine using different stem cell sources is yielding promising results in terms of protecting the ovarian reserve from damage and senescence, and improving fertility potential in various preclinical settings. WHAT IS KNOWN ALREADY Regenerative medicine using stem cell therapy is emerging as a potential strategy to address a number of issues in the field of human reproduction. Indeed, different types of adult and fetal mesenchymal stem cells (MSCs) have been tested with promising results, owing to their ability to differentiate into different tissue lineages, move toward specific injured sites (homing), and generate a secretome with wound-healing, proangiogenic, and antioxidant capacities. STUDY DESIGN SIZE DURATION Guided by the checklist for preferred reporting items for systematic reviews and meta-analyses, we retrieved relevant studies from PubMed, Medline, and Embase databases until June 2023 using the following keywords: 'mesenchymal stem cells' AND 'ovarian follicles' OR 'ovarian tissue culture' OR 'ovarian follicle culture' OR 'cumulus oocyte complex'. Only peer-reviewed published articles written in English were included. PARTICIPANTS/MATERIALS SETTING METHODS The primary outcome for the experimental strategies was evaluation of the ovarian reserve, with a focus on follicle survival, number, and growth. Secondary outcomes involved analyses of other parameters associated with the follicle pool, such as hormones and growth factors, ovarian tissue viability markers including oxidative stress levels, oocyte growth and maturation rates, and of course pregnancy outcomes. MAIN RESULTS AND THE ROLE OF CHANCE Preclinical studies exploring MSCs from different animal origins and tissue sources in specific conditions were selected (n = 112), including: in vitro culture of granulosa cells, ovarian tissue and isolated ovarian follicles; ovarian tissue transplantation; and systemic or intraovarian injection after gonadotoxic or age-related follicle pool decline. Protecting the ovarian reserve from aging and gonadotoxic damage has been widely tested in vitro and in vivo using murine models and is now yielding initial data in the first ever case series of patients with premature ovarian insufficiency. Use of MSCs as feeder cells in ovarian tissue culture was found to improve follicle outcomes and oocyte competence, bringing us one step closer to future clinical application. MSCs also have proved effective at boosting revascularization in the transplantation site when grafting ovarian tissue in experimental animal models. LIMITATIONS REASONS FOR CAUTION While preclinical results look promising in terms of protecting the ovarian reserve in different experimental models (especially those in vitro using various mammal experimental models and in vivo using murine models), there is still a lot of work to do before this approach can be considered safe and successfully implemented in a clinical setting. WIDER IMPLICATIONS OF THE FINDINGS All gathered data on the one hand show that regenerative medicine techniques are quickly gaining ground among innovative techniques being developed for future clinical application in the field of reproductive medicine. After proving MSC effectiveness in preclinical settings, there is still a lot of work to do before MSCs can be safely and effectively used in different clinical applications. STUDY FUNDING/COMPETING INTERESTS This study was supported by grants from the Fonds National de la Recherche Scientifique de Belgique (FNRS-PDR T.0077.14, FNRS-CDR J.0063.20, and grant 5/4/150/5 awarded to Marie-Madeleine Dolmans), Fonds Spéciaux de Recherche, and the Fondation St Luc. None of the authors have any competing interest to disclose. REGISTRATION NUMBER N/A.
Collapse
Affiliation(s)
- L Cacciottola
- Gynecology Research Unit, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Brussels, Belgium
| | - F Vitale
- Gynecology Research Unit, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Brussels, Belgium
| | - J Donnez
- Society for Research into Infertility, Brussels, Belgium
- Université Catholique de Louvain, Brussels, Belgium
| | - M M Dolmans
- Gynecology Research Unit, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Brussels, Belgium
- Department of Gynecology, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| |
Collapse
|
13
|
d'Argent M, Stratopoulou CA, Cussac S, Camboni A, Jadoul P, Donnez J, Dolmans MM. Are lower levels of apoptosis and autophagy behind adenomyotic lesion survival? Reprod Biomed Online 2023; 47:103248. [PMID: 37451972 DOI: 10.1016/j.rbmo.2023.06.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2022] [Revised: 04/04/2023] [Accepted: 06/12/2023] [Indexed: 07/18/2023]
Abstract
RESEARCH QUESTION How are markers of cell death, invasiveness and progesterone signalling expressed in endometrium and ectopic lesions from adenomyosis patients? DESIGN Formalin-fixed paraffin-embedded tissue was collected from 15 control and 15 adenomyosis participants . To assess cell survival capacity, caspase 3 and microtubule-associated proteins 1A/1B light chain 3B (LC3B) were immunolabelled as markers of apoptosis and autophagy respectively. Matrix metalloproteinase 9 (MMP9) expression served as a marker of extracellular matrix degradation and invasion activity. Progesterone receptors were immunostained to detect evidence of progesterone resistance. RESULTS Caspase 3 expression was significantly lower in the stromal (P = 0.0013) and epithelial (P = 0.0157) compartments of adenomyotic lesions than in healthy endometrial tissue. In the stroma, caspase 3 expression was significantly weaker in lesions than in corresponding eutopic endometrium (P = 0.0006). LC3B immunostaining was significantly decreased in adenomyotic stroma compared with corresponding eutopic endometrium (P = 0.0349). A significantly higher expression of MMP9 was detected in eutopic stroma from adenomyosis patients than in healthy tissue (P = 0.0295). Progesterone receptor immunostaining was found to be significantly weaker in the stroma of endometrium and ectopic lesions from adenomyosis patients than disease-free women (P = 0.0001; P = 0.0021). CONCLUSIONS Adenomyotic lesions show lower levels of apoptosis and autophagy, suggesting that aberrant cell survival may be involved in disease pathogenesis. MMP9 appears to contribute to endometrial invasiveness in adenomyosis, as its expression is more pronounced in endometrium from these women than women without the disease. Evidence of progesterone resistance can be found in endometrium and ectopic lesions from adenomyosis patients, and may drive disease development and account for the failure of certain patients to respond to progestogens.
Collapse
Affiliation(s)
- Marie d'Argent
- Pôle de Recherche en Gynécologie, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Brussels, Belgium
| | - Christina Anna Stratopoulou
- Pôle de Recherche en Gynécologie, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Brussels, Belgium
| | - Sophie Cussac
- Pôle de Recherche en Gynécologie, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Brussels, Belgium
| | - Alessandra Camboni
- Pôle de Recherche en Gynécologie, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Brussels, Belgium; Anatomopathology Department, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Pascale Jadoul
- Gynecology Department, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Jacques Donnez
- Société de Recherche pour l'Infertilité, Brussels, Belgium; Université Catholique de Louvain, Brussels, Belgium
| | - Marie-Madeleine Dolmans
- Pôle de Recherche en Gynécologie, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Brussels, Belgium; Gynecology Department, Cliniques Universitaires Saint-Luc, Brussels, Belgium.
| |
Collapse
|
14
|
Vitale F, Cacciottola L, Yu FS, Barretta M, Hossay C, Donnez J, Dolmans MM. Importance of oxygen tension in human ovarian tissue in vitro culture. Hum Reprod 2023:7194693. [PMID: 37308325 DOI: 10.1093/humrep/dead122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Revised: 05/23/2023] [Indexed: 06/14/2023] Open
Abstract
STUDY QUESTION Is there any difference between 20% and 5% oxygen (O2) tension in vitro culture (IVC) on the viability and quality of human follicles contained in cultured ovarian cortex? SUMMARY ANSWER An O2 tension of 5% yields higher follicle viability and quality than does 20% O2 tension after 6 days of IVC. WHAT IS KNOWN ALREADY The primordial follicle (PMF) pool resides within the ovarian cortex, where the in vivo O2 tension ranges between 2% and 8%. Some studies suggest that lowering O2 tension to physiological levels may improve in vitro follicle quality rates. STUDY DESIGN, SIZE, DURATION This prospective experimental study included frozen-thawed ovarian cortex from six adult patients (mean age: 28.5 years; age range: 26-31 years) who were undergoing laparoscopic surgery for non-ovarian diseases. Ovarian cortical fragments were cultured for 6 days at (i) 20% O2 with 5% CO2 and (ii) 5% O2 with 5% CO2. Non-cultured fragments served as controls. PARTICIPANTS/MATERIALS, SETTING, METHODS Cortical fragments were used for the following analyses: hematoxylin and eosin staining for follicle count and classification; Ki67 staining to evaluate PMF proliferation; cleaved caspase-3 immunostaining to identify follicle apoptosis; 8-hydroxy-2-deoxyguanosine and gamma-H2AX (γH2AX) immunolabeling to detect oxidative stress damage and DNA double-strand breaks (DSBs) in oocytes and granulosa cells (GCs); and β-galactosidase staining to assess follicle senescence. Droplet digital PCR was also performed to further explore the gene expression of superoxide dismutase 2 (SOD2) and glutathione peroxidase 4 (GPX4) from the antioxidant defense system and cyclin-dependent kinase inhibitors (p21 and p16) as tissue senescence-related genes. MAIN RESULTS AND THE ROLE OF CHANCE Apoptosis (P = 0.002) and follicle senescence (P < 0.001) rates were significantly lower in the 5% O2 group than in the 20% O2 group. Moreover, GCs in follicles in the 20% O2 group exhibited significantly (P < 0.001) higher oxidative stress damage rates than those in the 5% O2 group. DNA DSB damage rates in GCs of follicles were also significantly higher (P = 0.001) in the 20% O2 group than in the 5% O2 group. SOD2 expression was significantly greater in the 5% O2 group compared to the 20% O2 group (P = 0.04) and the non-cultured group (P = 0.002). Expression of p21 was significantly increased in both the 20% O2 (P = 0.03) and 5% O2 (P = 0.008) groups compared to the non-cultured group. Moreover, the 20% O2 group showed significantly greater p16 expression (P = 0.04) than the non-cultured group, while no significant variation was observed between the 5% O2 and no culture groups. LARGE SCALE DATA N/A. LIMITATIONS, REASONS FOR CAUTION This study focuses on improving follicle outcomes during the first step of ovarian tissue IVC, where follicles remain in situ within the tissue. The impact of O2 tension in further steps, such as secondary follicle isolation and maturation, was not investigated here. WIDER IMPLICATIONS OF THE FINDINGS Our findings suggest that 5% O2 tension culture is a promising step toward potentially solving the problem of poor follicle viability after IVC. STUDY FUNDING/COMPETING INTEREST(S) This study was supported by grants from the Fonds National de la Recherche Scientifique de Belgique (FNRS-PDR T.0064.22, CDR J.0063.20 and grant 5/4/150/5 awarded to M.M.D.). The authors have nothing to disclose.
Collapse
Affiliation(s)
- F Vitale
- Gynecology Research Unit, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Brussels, Belgium
| | - L Cacciottola
- Gynecology Research Unit, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Brussels, Belgium
| | - F S Yu
- Gynecology Research Unit, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Brussels, Belgium
| | - M Barretta
- Gynecology Research Unit, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Brussels, Belgium
| | - C Hossay
- Gynecology Research Unit, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Brussels, Belgium
| | - J Donnez
- Société de Recherche pour l'Infertilité, Brussels, Belgium
- Université Catholique de Louvain, Brussels, Belgium
| | - M M Dolmans
- Gynecology Research Unit, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Brussels, Belgium
- Gynecology Department, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| |
Collapse
|
15
|
Peek R, Nadesapillai S, Thi Nguyen TY, Vassart S, Smeets D, van de Zande G, Camboni A, Braat D, van der Velden J, Donnez J, Fleischer K, Dolmans MM. Assessment of folliculogenesis in ovarian tissue from young patients with Turner syndrome using a murine xenograft model. Fertil Steril 2023:S0015-0282(23)00293-5. [PMID: 37061159 DOI: 10.1016/j.fertnstert.2023.04.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Revised: 03/13/2023] [Accepted: 04/03/2023] [Indexed: 04/17/2023]
Abstract
OBJECTIVE To study the impact of aneuploid granulosa and stromal cells on folliculogenesis of small ovarian follicles from mosaic Turner syndrome patients using a murine xenograft model. DESIGN Laboratory study SUBJECTS: Ovarian cortical tissue was obtained by laparoscopic surgery from 18 mosaic TS patients (aged 5-19 years) and 13 controls (aged 5-18 years). INTERVENTION Part of each tissue fragment was used to karyotype ovarian cells in non-grafted tissue by fluorescence in situ hybridization. The remaining tissue was xenografted to severe combined immunodeficient mice for 5 months. Grafted tissue was analyzed for aneuploidy, and follicle density and morphology were determined. Expression of proliferating cell nuclear antigen and anti-Müllerian hormone were investigated by immunohistochemistry. MAIN OUTCOME MEASURES The impact of aneuploid granulosa and stromal cells on folliculogenesis. Fluorescence in situ hybridization of ovarian tissue before grafting was performed to determine the level of aneuploidy in stromal cells, and oocytes and granulosa of small follicles. After xenografting the level of aneuploidy of the newly formed layers of granulosa cells was again determined in secondary and antral follicles. RESULTS Follicle density in ovarian tissue from Turner syndrome patients was significantly lower than in controls before grafting. Fluorescence in situ hybridization analysis confirmed that 101/104 oocytes from non-grafted tissue of Turner syndrome patients showed normal X chromosome content, while granulosa and stromal cells were mainly 45,X. Fragments from 12 Turner syndrome patients contained follicles at all stages after xenografting, including secondary and antral follicles. Follicle density in Turner syndrome patients and controls decreased significantly after grafting. Moreover, a shift from high to low proportions of 45,X granulosa cells was observed during folliculogenesis. Expression of PCNA in follicles from TS patients increased significantly during grafting. Secretion of AMH was impaired before grafting in peri-/postpubertal TS girls, but recovered after grafting. CONCLUSION Our study showed that small follicles from mosaic Turner syndrome patients undergo folliculogenesis, despite the presence of aneuploid granulosa and stromal cells. Ovarian tissue cryopreservation could therefore be a valid option to preserve fertility in young mosaic Turner syndrome patients if sufficient numbers of follicles are present, thus preferably before the age of 12.
Collapse
|
16
|
Donnez J, Cacciottola L, Squifflet JL, Dolmans MM. Profile of Linzagolix in the Management of Endometriosis, Including Design, Development and Potential Place in Therapy: A Narrative Review. Drug Des Devel Ther 2023; 17:369-380. [PMID: 36789095 PMCID: PMC9922511 DOI: 10.2147/dddt.s269976] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Accepted: 01/17/2023] [Indexed: 02/10/2023] Open
Abstract
Estrogens play a critical role in the pathogenesis of endometriosis and it is logical to assume that lowering estradiol levels with oral gonadotropin-releasing hormone (GnRH) antagonists may prove effective, especially in women who fail to respond to progestogens. Indeed, due to progesterone resistance, oral contraceptives and progestogens work well in two-thirds of women suffering from endometriosis, but are ineffective in 33% of women. Oral GnRH antagonists have therefore been evaluated for management of premenopausal women with endometriosis-associated pelvic pain. The first publication on these drugs reported the efficacy of elagolix. The present paper is a narrative review of linzagolix, which is an orally administered GnRH receptor antagonist with low pharmacokinetic/pharmacodynamic variability. It binds to and blocks the GnRH receptor in the pituitary gland, resulting in a dose-dependent drop in luteinizing hormone (LH) and follicle-stimulating hormone (FSH) production. This reduction in LH and FSH levels in turn leads to a dose-dependent decline in estrogen. Phase 2 and 3 trials are reviewed and discussed here. There is a place for GnRH antagonists in the management of symptomatic endometriosis, and linzagolix with or without add-back therapy (ABT) is one option that can be used at low doses, avoiding the need for ABT, which is contraindicated in some patients.
Collapse
Affiliation(s)
- Jacques Donnez
- Department of Gynaecology, Université Catholique de Louvain, Brussels, Belgium,Société de Recherche pour l’Infertilité (SRI), Brussels, Belgium
| | - Luciana Cacciottola
- Gynecology Research Laboratory, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Brussels, Belgium
| | - Jean-Luc Squifflet
- Gynecology Department, Cliniques Universitaires St-Luc, Brussels, Belgium
| | - Marie-Madeleine Dolmans
- Gynecology Research Laboratory, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Brussels, Belgium,Gynecology Department, Cliniques Universitaires St-Luc, Brussels, Belgium,Correspondence: Marie-Madeleine Dolmans, Gynecology Research Unit, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Avenue Mounier 52, bte B1.52.02, Brussels, 1200, Belgium, Tel +32 02 764 5237, Fax +32 02 764 9507, Email
| |
Collapse
|
17
|
Stratopoulou CA, Cussac S, d'Argent M, Donnez J, Dolmans MM. M2 macrophages enhance endometrial cell invasiveness by promoting collective cell migration in uterine adenomyosis. Reprod Biomed Online 2023; 46:729-738. [PMID: 36792417 DOI: 10.1016/j.rbmo.2023.01.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Revised: 12/12/2022] [Accepted: 01/03/2023] [Indexed: 01/10/2023]
Abstract
RESEARCH QUESTION Are M2 macrophages implicated in endometrial invasiveness in adenomyosis? DESIGN Seventeen formalin-fixed paraffin-embedded uterine samples and 16 fresh endometrial biopsies were collected from women with or without adenomyosis. Double immunofluorescence was performed to determine the predominant macrophage population in adenomyosis between M1 and M2 phenotypes. The invasion capacity of endometrial cells was assessed by invasion assays and quantitative polymerase chain reaction for genes involved in cell motility and epithelial-mesenchymal transition (EMT). Specific mechanisms of invasion were investigated by immunohistochemistry for E-cadherin, N-cadherin and matrix metalloproteinase 9 (MMP9). RESULTS Only M2 macrophages were found to accumulate in adenomyosis, in higher numbers in both eutopic endometrium (P = 0.0109) and lesions (P = 0.0267) than healthy tissue. Co-culture with M2 macrophages significantly boosted invasion capacity in endometrial epithelial (P = 0.0002; P = 0.002) and stromal cells (P = 0.0469; P = 0.0047) from both adenomyosis patients and healthy controls. No gene expression differences indicating EMT were noted, either between co-cultured and control cells, or between healthy and adenomyotic cells. E- and N-cadherin protein expression did not differ significantly between endometrium from adenomyosis subjects and healthy tissue but MMP9 expression was increased in eutopic stroma from adenomyosis patients (P = 0.0492). In adenomyosis, both E-cadherin (P = 0.0379) and N-cadherin (P = 0.0196) were more extensively expressed in basal glands than functional glands. CONCLUSIONS M2 macrophages accumulate in adenomyosis and enhance invasion capacity of adenomyotic and even healthy endometrial cells, implying that macrophage infiltration alone may be sufficient to promote the disease. This study failed to detect any changes pointing to EMT, suggesting an alternative mode of invasion. Strong E- and N-cadherin-positive intercellular junctions in basal (invasive) glands suggest the involvement of collective cell migration in the invasion process of endometrium.
Collapse
Affiliation(s)
- Christina Anna Stratopoulou
- Pôle de Recherche en Gynécologie, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Brussels, Belgium
| | - Sophie Cussac
- Pôle de Recherche en Gynécologie, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Brussels, Belgium
| | - Marie d'Argent
- Pôle de Recherche en Gynécologie, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Brussels, Belgium
| | - Jacques Donnez
- Société de Recherche pour l'Infertilité, Brussels, Belgium; Université Catholique de Louvain, Brussels, Belgium
| | - Marie-Madeleine Dolmans
- Pôle de Recherche en Gynécologie, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Brussels, Belgium; Gynecology Department, Cliniques Universitaires Saint-Luc, Brussels, Belgium.
| |
Collapse
|
18
|
Cacciottola L, Camboni A, Cernogoraz A, Donnez J, Dolmans MM. Role of apoptosis and autophagy in ovarian follicle pool decline in children and women diagnosed with benign or malignant extra-ovarian conditions. Hum Reprod 2023; 38:75-88. [PMID: 36346333 DOI: 10.1093/humrep/deac237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Revised: 09/26/2022] [Indexed: 11/09/2022] Open
Abstract
STUDY QUESTION Which biological mechanisms are responsible for physiological ovarian reserve decline owing to aging, or pathological follicle depletion triggered by inflammation or a pro-oxidant environment throughout a woman's lifetime? SUMMARY ANSWER Ovarian follicle pool size is modulated by both apoptosis and autophagy, the first responsible for its physiological decline over time and increasing in the event of prior chemotherapy in children, and the latter playing a major role in physiological ovarian follicle pool diminution before puberty. WHAT IS KNOWN ALREADY Among the different pathways of controlled cell death, apoptosis and autophagy are implicated in follicle loss. Apoptosis participates in eliminating damaged follicles, such as those impaired by chemotherapy (CHT), but its involvement in physiological age-related follicle decline is less well understood. Autophagy has proved crucial in follicle quiescence maintenance in murine models, but its contribution to human follicle pool modulation is still unclear. STUDY DESIGN, SIZE, DURATION This retrospective study included 84 patients with benign or malignant extra-ovarian conditions aged between 1 and 35 years, with ovarian tissue stored for histological analyses at the time of cryopreservation (between 2012 and 2021) at a tertiary care center. PARTICIPANTS/MATERIALS, SETTING, METHODS Ovarian fragments were used for the following analyses: hematoxylin and eosin staining for follicle count and classification; cleaved caspase-3 immunostaining to identify follicle apoptosis; and microtubule-associated proteins 1A/1B light chain 3B immunolabeling to detect follicle autophagy. Transmission electron microscopy was also carried out to investigate ultrastructural features of oocytes and granulosa cells. All analyses stratified patients by age, menarchal status (premenarchal = 32; postmenarchal = 52), potentially gonadotoxic CHT before cryopreservation (n = 14), presence of endometriosis and use of hormonal treatment. MAIN RESULTS AND THE ROLE OF CHANCE Premenarchal patients had a larger follicle pool in terms of total follicle density [mean, range 4979.98 (342.2-21789) versus 918.8 (26.18-3983), P < 0.001], but higher rates of morphologically abnormal [8.52 (0-25.37)% versus 3.54 (0-17.5)%, P < 0.001] and atretic [15.8 (0‒31.85)% versus 10.6 (0-33.33)%, P < 0.01] follicles than postmenarchal subjects. Apoptosis rates did not change with increasing age [27.94 (0-93.2)% in prepubertal subjects and 29.5 (0-100)% in postpubertal subjects], but autophagic follicles were around 10 times more common in premenarchal than postmenarchal subjects [10.21 (0-62.3)% versus 1.34 (0-25)%, P < 0.001], playing a crucial role in age-related follicle decline and elimination of 'abnormal' follicles, that are rarely seen after menarche. The impact of diagnosis and previous CHT varied according to age. In premenarchal patients with previous CHT, significantly more apoptotic [40.22 (0-100)% versus 26.79 (0-87)%, P < 0.05] and fewer abnormal [3.84 (0-10-76)% versus 9.83 (0-25.37)%, P < 0.01] follicles were detected than in subjects with no CHT prior to ovarian tissue cryopreservation, suggesting a direct effect on follicle elimination, especially of those with abnormalities. In postmenarchal subjects with previous CHT, quiescent follicle rates were lower than in patients with no CHT before tissue freezing [71.57 (0-100)% versus 85.89 (50-100)%, P < 0.05], suggesting accelerated follicle activation and growth. Moreover, increased autophagic activity was observed in the event of a cancer diagnosis compared to benign conditions after puberty [26.27 (0-100)% versus 9.48 (0-29.41)%, respectively, P < 0.05]. LIMITATIONS, REASONS FOR CAUTION The impact of specific CHT protocols could not be investigated since the group of patients with previous CHT was highly heterogeneous. WIDER IMPLICATIONS OF THE FINDINGS This study yields a deeper understanding of regulation of the follicle pool decline, showing for the first time that both apoptosis and autophagy pathways are involved in physiological follicle depletion, the latter being crucial before puberty. Moreover, our data showed a different response to non-physiological damage according to age, with higher apoptosis rates only in premenarchal subjects with previous CHT, confirming that this pathway is activated by drugs known to induce DNA damage in oocytes, such as alkylating agents, but not by cancer itself. STUDY FUNDING/COMPETING INTEREST(S) This study was supported by grants from the Fonds National de la Recherche Scientifique de Belgique (F.R.S.-FNRS/FRIA FC29657 awarded to L.C., CDR J.0063.20 and grant 5/4/150/5 awarded to M.M.D.), grants from the Fondation contre le Cancer (grant 2018-042 awarded to A.Ca.), the Fondazione Comunitaria del Varesotto and Provincia di Varese ('Amalia Griffini' Fellowship in Gynecology and Obstetrics awarded to A.Ce.), Fonds Spéciaux de Recherche, Fondation St Luc and donations from the Ferrero family. The authors have no competing interests to declare. TRIAL REGISTRAION NUMBER N/A.
Collapse
Affiliation(s)
- L Cacciottola
- Gynecology Research Unit, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Brussels, Belgium
| | - A Camboni
- Gynecology Research Unit, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Brussels, Belgium.,Department of Anatomopathology, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - A Cernogoraz
- Gynecology Research Unit, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Brussels, Belgium.,Department of Gynecology and Obstetrics, F. Del Ponte Hospital, University of Insubria, Varese, Italy
| | - J Donnez
- Society for Research into Infertility, Brussels, Belgium.,Professor EM, Université Catholique de Louvain, Brussels, Belgium
| | - M M Dolmans
- Gynecology Research Unit, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Brussels, Belgium.,Department of Gynecology, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| |
Collapse
|
19
|
Hossay C, Tramacere F, Cacciottola L, Camboni A, Squifflet JL, Donnez J, Dolmans MM. Follicle outcomes in human ovarian tissue: effect of freezing, culture, and grafting. Fertil Steril 2023; 119:135-145. [PMID: 36481098 DOI: 10.1016/j.fertnstert.2022.09.360] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Revised: 09/23/2022] [Accepted: 09/28/2022] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To study the effect of freezing, in vitro culture (IVC) and grafting to chorioallantoic membrane (CAM) on follicle outcomes in human ovarian tissue. DESIGN An experimental study. SETTING University-based research laboratory. PATIENTS Fresh and cryopreserved ovarian tissue from 10 patients was donated to research with their consent and institutional review board approval. INTERVENTIONS Fresh and frozen-thawed ovarian cortical pieces were in vitro-cultured and compared (fresh-IVC vs FT-IVC). The FT-IVC fragments were then examined against fragments grafted to CAM (FT-CAM). After both IVC and CAM grafting, ovarian cortical pieces (4×2×1 mm3) were analyzed on days 0, 1, and 6. MAIN OUTCOME MEASURES Follicle analyses included histology (count and classification) and immunohistochemistry (Ki67 [proliferation], caspase-3 [apoptosis], 1A and 1B light chain 3B [autophagy], p-Akt, FOXO1, and p-rpS6 [PI3K activation]). Droplet digital polymerase chain reaction further explored expression of PI3K pathway- and oocyte-related genes in tissue sections. RESULTS No major differences were detected between fresh-IVC and FT-IVC tissues in any conducted analyses. Although a significant drop was observed in primordial follicle (PF) proportions in the fresh-IVC and FT-IVC groups (d0 vs. d6, P<.002), they held steady in the FT-CAM group (d0 vs. d6, P>.05). The PF rates were also significantly higher in the FT-CAM group than the FT-IVC group on d6 (P=.02). Importantly, avian erythrocytes were already present in 30% of implants from d1. Apoptotic and autophagic follicle rates increased during IVC (P<.008), but remained significantly lower in the FT-CAM group (P<.01), confirming superior follicle preservation in CAM-grafted tissue. Upregulation of the PI3K/FOXO pathway was established in the IVC groups, demonstrating PF activation, whereas significant pathway downregulation was detected in the FT-CAM group (P<.03). The droplet digital polymerase chain reaction tests confirmed oocyte growth during IVC and follicle autophagy in all groups; however, the PI3K pathway appeared to be differentially modulated in tissues and follicles. CONCLUSIONS In vitro culture induces PF depletion with no additional impact of freezing. Grafting to CAM preserves the PF pool by curbing follicle activation, apoptosis, and autophagy, probably thanks to rapid graft revascularization and/or the circulating embryonic antimüllerian hormone. These findings highlight the importance of enhancing neoangiogenesis in ovarian grafts and investigating the potential benefits of administering antimüllerian hormone to prevent PF burnout.
Collapse
Affiliation(s)
- Camille Hossay
- Gynecology Research Unit, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Brussels, Belgium
| | - Francesca Tramacere
- Gynecology Research Unit, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Brussels, Belgium
| | - Luciana Cacciottola
- Gynecology Research Unit, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Brussels, Belgium
| | - Alessandra Camboni
- Gynecology Research Unit, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Brussels, Belgium; Anatomopathology Department, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Jean-Luc Squifflet
- Gynecology Department, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Jacques Donnez
- Society for Research into Infertility, Brussels, Belgium; Professor Emeritus, Université Catholique de Louvain, Brussels, Belgium
| | - Marie-Madeleine Dolmans
- Gynecology Research Unit, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Brussels, Belgium; Gynecology Department, Cliniques Universitaires Saint-Luc, Brussels, Belgium.
| |
Collapse
|
20
|
Dolmans MM, Donnez J. Emerging Drug Targets for Endometriosis. Biomolecules 2022; 12:biom12111654. [PMID: 36359004 PMCID: PMC9687824 DOI: 10.3390/biom12111654] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Revised: 10/27/2022] [Accepted: 10/27/2022] [Indexed: 11/09/2022] Open
Abstract
Endometriosis is a chronic inflammatory disease causing distressing symptoms and requiring a life-long management strategy. The objective of this review is to evaluate endometriosis-related pathways and identify novel therapies to treat it. We focused on the crucial role of inflammation and inflammatory molecules in order to define new perspectives for non-hormonal treatment of the disease by targeting inflammation, nuclear factor kappa B and cytokines, or reactive oxygen species, apoptotic and autophagic pathways, regulators of epithelial-mesenchymal transition, and angiogenesis and neuroangiogenesis. Novel non-steroidal therapies targeting these pathways for endometriosis were explored, but multiple challenges remain. While numerous agents have been investigated in preclinical trials, few have reached the clinical testing stage because of use of inappropriate animal models, with no proper study design or reporting of preclinical strategies. Targeting estrogens is still the best way to control endometriosis progression and inflammation.
Collapse
Affiliation(s)
- Marie-Madeleine Dolmans
- Gynecology Department, Cliniques Universitaires St-Luc, Avenue Hippocrate 10, 1200 Brussels, Belgium
- Gynecology Research Laboratory, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Avenue Mounier 52, bte B1.52.02, 1200 Brussels, Belgium
| | - Jacques Donnez
- Department of Gynaecology, Université Catholique de Louvain, 1200 Brussels, Belgium
- Société de Recherche pour l’Infertilité (SRI), 143 Avenue Grandchamp, 1150 Brussels, Belgium
- Correspondence:
| |
Collapse
|
21
|
Donnez J, Taylor HS, Stewart EA, Bradley L, Marsh E, Archer D, Al-Hendy A, Petraglia F, Watts N, Gotteland JP, Bestel E, Terrill P, Loumaye E, Humberstone A, Garner E. Linzagolix with and without hormonal add-back therapy for the treatment of symptomatic uterine fibroids: two randomised, placebo-controlled, phase 3 trials. Lancet 2022; 400:896-907. [PMID: 36116480 DOI: 10.1016/s0140-6736(22)01475-1] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Revised: 07/11/2022] [Accepted: 07/29/2022] [Indexed: 12/21/2022]
Abstract
BACKGROUND Uterine fibroids are common non-cancerous neoplasm that cause heavy menstrual bleeding and other signs. Linzagolix is an oral gonadotropin-releasing hormone receptor antagonist taken once per day that dose-dependently suppresses gonadal steroids and might reduce uterine-fibroid-associated signs. Two phase 3 trials were conducted to confirm the efficacy and safety of linzagolix at full-suppression (200 mg) and partial-suppression (100 mg) doses with or without hormonal add-back therapy (1 mg oestradiol and 0·5 mg norethisterone acetate) compared with placebo for the treatment of symptomatic uterine fibroids. METHODS PRIMROSE 1 and PRIMROSE 2 were identical 52-week, randomised, parallel, double-blind, placebo-controlled, phase 3 trials conducted at clinics in the USA (PRIMROSE 1) and Europe and the USA (PRIMROSE 2). Eligible women with uterine fibroid-associated heavy menstrual bleeding (menstrual blood loss >80 mL per cycle) were randomly assigned in a 1:1:1:1:1 ratio to one of five masked treatments: (1) placebo, (2) 100 mg linzagolix per day alone, (3) 100 mg linzagolix per day with once-per-day hormonal add-back therapy (1 mg oestradiol and 0·5 mg norethisterone acetate), (4) 200 mg linzagolix per day alone, or (5) 200 mg linzagolix per day with once-per-day hormonal add-back therapy (1 mg oestradiol and 0·5 mg norethisterone acetate). The primary endpoint was a response (menstrual blood loss ≤80 mL and ≥50% reduction from baseline) at 24 weeks in women who received at least one dose of treatment and did not meet any exclusion criteria based on predosing assessments. These trials are registered with ClinicalTrials.gov (NCT03070899 and NCT03070951). The trials have been completed. FINDINGS Between May, 2017, and October, 2020, in PRIMROSE 1, 574 women were enrolled, of which 48 discontinued and 15 were excluded; therefore, 511 women were included in the full analysis set; and in PRIMROSE 2, 535 women were enrolled, of which 24 did not receive the study drug and ten women were excluded from the study, resulting in 501 women being included in the full analysis set. In both trials, a significantly higher proportion of women had a reduction in heavy menstrual bleeding in all linzagolix (with or without add-back therapy) treatment groups compared with the placebo group (p≤0·003). In PRIMROSE 1, the response rates were 56·4% (95% CI 45·8-66·6%) in the 100 mg group, 66·4% (56·6-75·2%) in the 100 mg plus add-back therapy group, 71·4% (61·8-79·8%) in the 200 mg group, and 75·5% (66·0-83·5%) in the 200 mg plus add-back therapy group, compared with 35·0% (25·8-45·0%) in the placebo group. In PRIMROSE 2, the response rates were 56·7% (46·3-66·7%) in the 100 mg group, 77·2% (67·8-85·0%) in the 100 mg plus add-back therapy group, 77·7% (68·4-85·3%) in the 200 mg group, and 93·9% (87·1-97·7%) in the 200 mg plus add-back therapy group, compared with 29·4% (20·8-39·3%) with placebo. The most common adverse events up to 24 weeks were hot flushes (35% of participants in PRIMROSE 1 and 32% in PRIMROSE 2 with linzagolix [200 mg] alone and 3-14% in all other groups). INTERPRETATION Linzagolix (100 mg or 200 mg) with or without add-back therapy significantly reduced heavy menstrual bleeding. Partial suppression with once-per-day linzagolix (100 mg) without add-back therapy potentially provides a unique option for the chronic treatment of symptomatic uterine fibroids in women who cannot or do not want to take concomitant hormonal add-back therapy. FUNDING ObsEva.
Collapse
Affiliation(s)
- Jacques Donnez
- Société de Recherche pour l'infertilité, Catholic University of Louvain, Brussels, Belgium
| | - Hugh S Taylor
- Yale University School of Medicine, New Haven, CT, USA
| | - Elizabeth A Stewart
- Division of Reproductive Endocrinology, Mayo Clinic and Mayo Clinic Alix School of Medicine, Rochester, MN, USA
| | - Linda Bradley
- Department of Obstetrics and Gynecology, Cleveland Clinic, Cleveland, OH, USA
| | - Erica Marsh
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, University of Michigan Medical School, Ann Arbor, MI, USA
| | - David Archer
- Department of Obstetrics and Gynecology, Eastern Virginia Medical School, Norfolk, VA, USA
| | - Ayman Al-Hendy
- Department of Obstetrics and Gynecology, University of Chicago, Chicago, IL, USA
| | - Felice Petraglia
- Obstetrics and Gynecology, Department of Experimental and Clinical Biomedical Sciences, University of Florence, Florence, Italy
| | - Nelson Watts
- Mercy Health Osteoporosis and Bone Health Services, Cincinnati, OH, USA
| | | | | | | | | | | | | |
Collapse
|
22
|
Koninckx P, Ussia A, Alsuwaidi S, Amro B, Keckstein J, Adamyan L, Donnez J, Dan M, Wattiez A. Reconsidering evidence-based management of endometriosis. Facts Views Vis Obgyn 2022; 14:225-233. [DOI: 10.52054/fvvo.14.3.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Background: Without an adequate animal model permitting experiments the pathophysiology of endometriosis remains unclear and without a non-invasive diagnosis, information is limited to symptomatic women. Lesions are macroscopically and biochemically variable. Hormonal medical therapy cannot be blinded since recognised by the patient and the evidence of extensive surgery is limited because of the combination of low numbers of interventions of variable difficulty with variable surgical skills. Experience is spread among specialists in imaging, medical therapy, infertility, pain and surgery. In addition, the limitations of traditional statistics and p-values to interpret results and the complementarity of Bayesian inference should be realised.
Objectives: To review and discuss evidence in endometriosis management
Materials and Methods: A PubMed search for blinded randomised controlled trials in endometriosis.
Results: Good-quality evidence is limited in endometriosis.
Conclusions: Clinical experience remains undervalued especially for surgery.
What is new? Evidence-based medicine should integrate traditional statistical analysis and the limitations of P-values, with the complementary Bayesian inference which is predictive and sequential and more like clinical medicine. Since clinical experience is important for grading evidence, specific experience in the different disciplines of endometriosis should be used to judge trial designs and results. Finally, clinical medicine can be considered as a series of experiments controlled by the outcome. Therefore, the clinical opinion of many has more value than an opinion.
Collapse
|
23
|
Donnez J, Taylor H, Gemzell-Danielsson K, Catherino W, Bestel E, Gotteland J, Humberstone A, Moore L, Garner E. O-306 LINZAGOLIX FOR ENDOMETRIOSIS-ASSOCIATED PAIN: SAFETY RESULTS FROM EDELWEISS 3, A PHASE 3, RANDOMIZED, DOUBLE-BLIND, PLACEBO-CONTROLLED TRIAL. Hum Reprod 2022. [DOI: 10.1093/humrep/deac105.103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Study question
Is once-daily linzagolix treatment for women with moderate to severe endometriosis-associated pain (EAP) safe for use for up to 6 months of treatment?
Summary answer
Both doses of linzagolix were well-tolerated with minimal BMD decrease and few TEAEs >5% in either linzagolix arm.
What is known already
Linzagolix (LGX) is an investigational once-daily oral GnRH receptor antagonist that reduces serum estradiol in a dose-dependent manner and is being developed in two dosages for the treatment of endometriosis-associated pain (EAP): 75 mg, and 200 mg dose with hormonal add-back therapy (ABT).
Study design, size, duration
EDELWEISS 3 is a randomized, double-blind, placebo-controlled, multicenter Phase 3 trial of linzagolix in women with moderate to severe EAP. The trial includes 3 treatment arms: 75 mg LGX, 200 mg LGX with ABT (E2 1 mg/ NETA 0.5 mg), or placebo. Here we present safety results up to 6 months (24 weeks) of treatment.
Participants/materials, setting, methods
Eligible reproductive-aged women with moderate-to-severe EAP were randomized and treated (n = 484) for 6 months with 75 mg LGX, 200 mg LGX with ABT (E2 1 mg/ NETA 0.5 mg), or placebo. Safety and tolerability objectives reported here include 6-month results for treatment emergent adverse events (TEAEs), assessment of mean percent change from baseline (CfB) in lumbar spine (LS) bone mineral density (BMD) and Z-scores.
The safety analysis set included 484 subjects across the 3 treatment groups.
Main results and the role of chance
The overall incidence of TEAEs was similar between the placebo and LGX 75 mg group (46.9%) and slightly higher (56.8%) in the LGX 200 mg + ABT group. There were few (3) serious TEAEs, and none were related to LGX. TEAEs that occurred in over 5% of patients in either active treatment arm included headache (10.5%, 8.1%, and 8.0%), hot flush (6.8%, 7.5%, and 2.5%), and fatigue (6.8%, 3.8%, and 2.5%) for the 200 mg LGX with ABT, 75 mg LGX, and placebo groups, respectively. Mean percent CfB (95% CI) in LS BMD was -0.79% (-1.15, -0.43%), -0.89% (-1.31, -0.47%), and +0.78% (0.41, 1.15%) for the 200 mg LGX with ABT, 75 mg LGX, and placebo groups, respectively. Z-scores at 6 months remained within the same range as baseline in all groups.
Limitations, reasons for caution
Additional efficacy and safety results from the trial's 24 weeks (6 mo) extension phase are pending. (Edelweiss 6 protocol: NCT04335591)
Wider implications of the findings
These results support further development of ABT and non-ABT doses of linzagolix that have potential to provide flexibility and choice for women seeking treatment for EAP. A non-ABT option is important for women who have a contraindication to, are at increased risk for complications, or prefer not to use ABT.
Trial registration number
ClinicalTrials.gov: NCT02778399
Collapse
Affiliation(s)
- J Donnez
- Catholic University of Louvain , Ob/Gyn, Brussels, Belgium
| | - H Taylor
- Yale University , Ob/Gyn, New Haven, U.S.A
| | | | - W Catherino
- Uniformed Services University of the Health Sciences , Ob/Gyn, Bethesda, U.S.A
| | - E Bestel
- ObsEva SA, Research & Development , Geneva, Switzerland
| | - J.P Gotteland
- ObsEva SA, Research & Development , Geneva, Switzerland
| | | | - L Moore
- ObsEva Inc., Medical Affairs , Boston, U.S.A
| | - E Garner
- ObsEva Inc., Medical Affairs , Boston, U.S.A
| |
Collapse
|
24
|
Cacciottola L, Camboni A, Cernogoraz A, Donnez J, Dolmans MM. O-038 Role of apoptosis and autophagy in ovarian follicle pool decline from birth to late reproductive age and after gonadotoxic chemotherapeutic treatments. Hum Reprod 2022. [DOI: 10.1093/humrep/deac104.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Study question
Which biological mechanisms are responsible for physiological age-dependent and non-physiological ovarian reserve decline throughout a woman’s life?
Summary answer
Ovarian follicle pool size is modulated by both apoptosis and autophagy, the latter playing a major role in its decline before puberty.
What is known already
Among different pathways of controlled cell death, apoptosis and autophagy are both involved in follicle death. Apoptosis participtes in eliminating damaged follicles, like those affected by chemotherapy (CHT)-induced DNA damage, but its role in physiological age-related follicle decline is less understood. Autophagy has proved crucial in follicle quiescence maintenance in murine models, but its contribution to human follicle pool modulation is still unclear.
Study design, size, duration
Eighty-four patients aged between 1 and 35 years, with ovarian tissue stored for histological analyses at the time of cryopreservation (between 2012 and 2021) at the Université Catholique de Louvain (Belgium) were included in retrospective evaluations.
Participants/materials, setting, methods
Ovarian fragments were used for the following analyses: hematoxylin and eosin staining for follicle count and classification; caspase-3 immunostaining to identify follicle apoptosis; and microtubule-associated proteins 1A/1B light chain 3B (LC3B) immunolabeling to detect follicle autophagy. Ovarian fragments from 9 patients were assigned for transmission electron microscopy to investigate ultrastructural features of oocytes and granulosa cells. All analyses were conducted stratifying patients by age, menarchal status (premenarchal=32; postmenarchal=52), and potentially gonadotoxic CHT before cryopreservation (n = 14).
Main results and the role of chance
Premenarchal patients had a larger follicle pool in terms of total follicle density (4979.98±4952.16 vs 918.8±903.86, p < 0.0001), but higher rates of morphologically abnormal (8.52±6.48% vs 3.54±4.54%, p < 0.0001) and atretic follicles (15.8±9.14% vs 10.6±9.43%, p = 0.01) than postmenarchal subjects. Apoptosis rates did not change with increasing age (27.94±28.78% in prepubertal subjects and 29.5±33.58% in postpubertal subjects). Autophagic follicles were around 10 times more common in premenarchal compared to postmenarchal subjects (10.21±16.% vs 1.34±4.02%, p < 0.0001), playing a crucial role in age-related follicle decline and elimination of ‘abnormal follicles’, that are rarely seen after menarche. The impact of previous CHT varied according to age. In premenarchal patients with previous CHT, significantly more apoptotic (40.22±40.44% vs 26.79±25.35%, p = 0.04) and fewer abnormal (3.84±3.91% vs 9.83±6.5%, p = 0.02) follicles were detected than in those with no CHT prior to ovarian tissue cryopreservation, suggesting a direct effect on follicle elimination, especially of those with abnormalities. In postmenarchal subjects with previous CHT, lower quiescent follicle rates were observed compared to patients with no CHT before tissue freezing (70.1±36.36% vs 85.89±12.61%, p = 0.04), suggesting accelerated follicle activation and growth.
Limitations, reasons for caution
The present study could not investigate the impact of specific CHT protocols, since the group of patients with previous CHT was highly heterogeneous. However, these patients could not be excluded a priori, since the effect of follicle pool depletion has not been fully elucidated.
Wider implications of the findings
This study yields a deeper understanding of follicle pool decline regulation, evidencing for the first time that (i) different cell death pathways are involved in physiological and non-physiological follicle depletion, and (ii) the follicle pool responds differently to gonadotoxic damage according to age and ovarian reserve size.
Trial registration number
N/A
Collapse
Affiliation(s)
- L Cacciottola
- Université Catholique de Louvain, Gynecology Researche Unit, Brussels , Belgium
| | - A Camboni
- Université Catholique de Louvain- Clinique Universitaires Saint Luc, Gynecology Researche Unit- Department of Anatomopathology, Brussels , Belgium
| | - A Cernogoraz
- F. Del Ponte Hospital- University of Insubria, Department of Gynecology and Obstetrics, Varese , Italy
| | - J Donnez
- Professor EM- Université Catholique de Louvain, Sociey for Research into Infertility, Brussels , Belgium
| | - M M Dolmans
- Université Catholique de Louvain- Clinique Universitaires Saint Luc, Gynecology Researche Unit- Department of Gynacology, Brussels , Belgium
| |
Collapse
|
25
|
Hossay C, Tramacere F, Camboni A, Cacciottola L, Van Kerk O, Donnez J, Dolmans M. P-437 Follicle activation in human ovarian tissue: impact of freezing, culture and grafting. Hum Reprod 2022. [DOI: 10.1093/humrep/deac107.412] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Study question
How does freezing, in vitro culture (IVC) and grafting to chorioallantoic membrane (CAM) affect follicle activation through the PI3K pathway in human ovarian tissue?
Summary answer
Freezing does not trigger further follicle activation. Although IVC and CAM do induce follicle activation, the process is significantly curbed in the CAM group.
What is known already
While massive follicle activation has been shown to occur through the PI3K pathway in frozen-thawed human ovarian tissue after both short-term xenotransplantation and IVC, it remains poorly understood in fresh ovarian tissue, raising many questions about the effect of freezing on follicle activation. Furthermore, grafting ovarian tissue to CAM has been found to limit follicle activation in animal ovarian tissue, though its impact on human follicles is yet to be elucidated.
Study design, size, duration
Thirty fresh cortical fragments from 5 patients and 50 frozen-thawed tissue pieces from another 5 patients were investigated. We first compared fresh fragments (fresh-IVC) with frozen-thawed tissue (FT-IVC) by IVC. These cultured frozen-thawed fragments were then examined against frozen-thawed fragments grafted to CAM (FT-CAM). After both IVC and CAM grafting, ovarian cortical pieces (4x2x1 mm) were analyzed on day (D) 0, 1 and 6.
Participants/materials, setting, methods
Follicle analyses included histology (count and classification), transmission electron microscopy (ultrastructure), immunohistochemistry (Ki67 for follicle proliferation, c-caspase-3 for follicle apoptosis, LC3B for follicle autophagy, p-AKT for PI3K activation and p-rpS6 for PI3K/mTOR activation), and immunofluorescence (FOXO1 for PI3K/FOXO activation). Subcellular localization of FOXO1 was determined in primordial follicles on high-resolution images using structured illumination microscopy. Droplet digital PCR further investigated expression of PI3K pathway-related genes (TSC1 and CDKN1B) and oocyte growth-related genes (GDF9 and LHX8).
Main results and the role of chance
No differences were detected between the fresh-IVC and the FT-IVC groups in any conducted analyses. After both IVC and CAM grafting, a significant decrease was observed in primordial follicle proportions in all groups on D6 vs D0 (p < 0.01), associated with a substantial increase in intermediate follicle proportions (p < 0.05). In the FT-CAM group, however, the percentage of primordial follicles stabilized between D1 and D6, showing significantly higher rates than the FT-IVC group on D6 (p = 0.04) and reflecting better preservation of the primordial follicle pool in the FT-CAM group. While apoptotic follicle rates increased in all conditions (D0 vs D6, p < 0.03), they remained significantly lower in the FT-CAM group than in the FT-IVC group on D6 (p = 0.01), confirming superior follicle preservation in CAM-grafted tissue. In primordial follicles, significantly lower levels of p-rpS6 were noted over time in all conditions (D0 vs D6, p < 0.009), but there was a significant shift in FOXO1 to a nuclear localization in the FT-CAM group compared to the FT-IVC group on D1 (p = 0.03), indicating inhibition of follicle activation.
Limitations, reasons for caution
As demonstrated by our results, the CAM model appears to be effective at preserving the follicle pool. However, our study did not investigate the underlying mechanisms behind this improved follicle preservation after thawing.
Wider implications of the findings
Our data confirm that the freezing procedure itself does not cause follicle burnout. Moreover, the CAM model looks to be capable of preserving the follicle pool, hypothetically thanks to rapid revascularization and circulating embryonic anti-Müllerian hormone.
Trial registration number
Not applicable
Collapse
Affiliation(s)
- C Hossay
- Université Catholique de Louvain, Institut de Recherche Expérimentale et Clinique- Pôle de Recherche en Gynécologie , Brussels, Belgium
| | - F Tramacere
- Université Catholique de Louvain, Institut de Recherche Expérimentale et Clinique- Pôle de Recherche en Gynécologie , Brussels, Belgium
| | - A Camboni
- Université Catholique de Louvain, Institut de Recherche Expérimentale et Clinique- Pôle de Recherche en Gynécologie , Brussels, Belgium
- Cliniques Universitaires Saint-Luc, Anatomopathology department , Brussels, Belgium
| | - L Cacciottola
- Université Catholique de Louvain, Institut de Recherche Expérimentale et Clinique- Pôle de Recherche en Gynécologie , Brussels, Belgium
| | - O Van Kerk
- Université Catholique de Louvain, Institut de Recherche Expérimentale et Clinique- Pôle de Recherche en Gynécologie , Brussels, Belgium
| | - J Donnez
- Society for Research into Infertility, Avenue Grandchamp 143- 1150, Brussels, Belgium
| | - M.M Dolmans
- Université Catholique de Louvain, Institut de Recherche Expérimentale et Clinique- Pôle de Recherche en Gynécologie , Brussels, Belgium
- Cliniques Universitaires Saint-Luc, Gynecology department , Brussels, Belgium
| |
Collapse
|
26
|
Donnez J. O-225 Endometrioma and fertility preservation: how can we save the oocytes? Hum Reprod 2022. [DOI: 10.1093/humrep/deac106.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Endometriosis is a benign estrogen-dependent disease
In the ovary, endometrioma formation may cause local inflammation, giving rise to structural alterations to the ovarian cortexwhich manifest as massive fibrosis and loss of cortex-specific stroma that maintains follicular nests.
Subsequent dysregulation of folliculogenesis results in “burn out” of the stockpile of dormant follicles. Moreover, endometriomas contain much higher concentrations of free iron, reactive oxygen species (ROS) and proteolytic enzymzes which could reach adjacent ovarian tissue and lead to follicular loss and intraovarian vascular injury.
Fertility preservation is a major challenge when therapeutic approaches of ovarian endometrioma are contemplated.
Surgery is often proposed in cases of endometrioma more than 3 cm in size but there are two main risks associated with the surgical treatmant of endometrioma :
1. the risk of excessive surgery (removal or destruction of normal ovarian cortex together with the endometrioma pseudocapsula).Close the ovarian hilus, ovarian tissue removed with the endometrioma wall contained follicles in more than 60% of cases in a study of Muzii and some meta-analyses have revealed significant decreases in AMH after excision.
2. The risk of incomplete surgery with subsequent early recurrence.
A correct surgical approach is therefore the first step to preserve oocytes and several techniques are discussed.
How to preserve fertility in women at risk of premature ovatian insufficiency (POI) due to severe and/or recurrent ovarian endometriosis?
Two main options are currently available :
1. COS,ovum pick-up and vitrification of oocytes is an important fertility preservation approach. Cobo et all published several series and reported high cumulative live birth rates in women less than 35 years, suggesting that patients with endometrioma should be encouraged to freeze oocytes at a younger age.
2. In some circonstances, orthotopic autotransplantation of cryopreserved ovarian cortex (which has led to more than 200 live births ) could be proposed to maintain the follicular pool.
Collapse
Affiliation(s)
- J Donnez
- SRI Society for Research into Infertility, gynecology , Brussels, Belgium
| |
Collapse
|
27
|
Donnez J, Cacciottola L. Endometriosis: An Inflammatory Disease That Requires New Therapeutic Options. Int J Mol Sci 2022; 23:ijms23031518. [PMID: 35163463 PMCID: PMC8836207 DOI: 10.3390/ijms23031518] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 01/26/2022] [Indexed: 11/16/2022] Open
Affiliation(s)
- Jacques Donnez
- Société de Recherche pour l’Infertilité (SRI), 143 Avenue Grandchamp, 1150 Brussels, Belgium;
- Université Catholique de Louvain, 1200 Brussels, Belgium
| | - Luciana Cacciottola
- Gynecology Research Unit, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Avenue Mounier 52, 1200 Brussels, Belgium
- Correspondence:
| |
Collapse
|
28
|
Stratopoulou CA, Donnez J, Dolmans MM. Conservative Management of Uterine Adenomyosis: Medical vs. Surgical Approach. J Clin Med 2021; 10:4878. [PMID: 34768397 PMCID: PMC8584979 DOI: 10.3390/jcm10214878] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Revised: 10/15/2021] [Accepted: 10/21/2021] [Indexed: 12/13/2022] Open
Abstract
Uterine adenomyosis is a commonly encountered estrogen-dependent disease in reproductive-age women, causing heavy menstrual bleeding, intense pelvic pain, and infertility. Although adenomyosis was previously considered a disease of multiparous women, it is becoming increasingly evident that it also affects younger nulliparous women and may compromise their fertility potential. It is clear that hysterectomy, the standard approach to definitively manage the disease, is not an option for patients wishing to preserve their fertility, so there is an urgent need to develop novel conservative strategies. We searched the current literature for available methods for conservative management of adenomyosis, including both pharmacological and surgical approaches. There is no existing drug that can cure adenomyosis at present, but some off-label treatment options may be used to tackle disease symptoms and improve fertility outcomes. Adenomyosis in patients wishing to conceive can be 'treated' by conservative surgery, though these procedures require highly experienced surgeons and pose a considerable risk of uterine rupture during subsequent pregnancies. While currently available options for conservative management of adenomyosis do have some capacity for alleviating symptoms and enhancing patient fertility perspectives, more effective new options are needed, with gonadotropin-releasing hormone antagonists showing encouraging results in preliminary studies.
Collapse
Affiliation(s)
- Christina Anna Stratopoulou
- Pôle de Recherche en Gynécologie, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, 1200 Brussels, Belgium;
| | - Jacques Donnez
- Société de Recherche pour l’Infertilité, 1150 Brussels, Belgium;
- Université Catholique de Louvain, 1200 Brussels, Belgium
| | - Marie-Madeleine Dolmans
- Pôle de Recherche en Gynécologie, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, 1200 Brussels, Belgium;
- Gynecology Department, Cliniques Universitaires Saint-Luc, 1200 Brussels, Belgium
| |
Collapse
|
29
|
Stratopoulou CA, Camboni A, Donnez J, Dolmans MM. Identifying Common Pathogenic Features in Deep Endometriotic Nodules and Uterine Adenomyosis. J Clin Med 2021; 10:4585. [PMID: 34640603 PMCID: PMC8509556 DOI: 10.3390/jcm10194585] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Revised: 09/28/2021] [Accepted: 09/30/2021] [Indexed: 02/06/2023] Open
Abstract
Increasing imaging data point to a link between deep endometriotic nodules (DENs) and uterine adenomyosis (AD). The study aimed to investigate this link at the histological level and detect potential features shared by the two diseases. We collected formalin-fixed paraffin-embedded tissue (endometrium and lesions) from women with DENs of the rectovaginal septum (n = 13), AD (n = 14), and control subjects (n = 14). Immunohistochemical analyses of CD41 and CD68 were conducted to explore the roles of platelets and macrophages, respectively. Picrosirius red staining was carried out to gather evidence of fibrosis. Vascular endothelial growth factor (VEGF) was assessed, and total numbers of CD31-positive vessels were calculated to investigate the mechanism governing angiogenesis. Double immunohistochemistry for CD31 and alpha smooth muscle actin (αSMA) was performed to discern stable vessels. Platelet aggregation was significantly decreased in both types of lesions compared to their corresponding eutopic endometrium and healthy controls. Macrophage numbers were higher in both lesions than in their corresponding endometrium and healthy subjects. Significantly higher rates of collagen accumulation were detected in DENs and AD lesions compared to their corresponding eutopic and healthy endometrium. VEGF expression was downregulated in the stromal compartment of AD lesions compared to the healthy endometrium. The total number of vessels per area was significantly higher in DENs and AD lesions than in the healthy endometrium. Rates of αSMA-surrounded vessels were decreased in DENs and AD lesions compared to their corresponding eutopic and healthy endometrium. We report common pathogenic mechanisms between DENs and AD, namely excessive macrophage accumulation, fibrosis, and irregular angiogenesis. Our results further support the notion of DENs and AD being linked at the histological level.
Collapse
Affiliation(s)
- Christina Anna Stratopoulou
- Pôle de Recherche en Gynécologie, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, 1200 Brussels, Belgium; (C.A.S.); (A.C.)
| | - Alessandra Camboni
- Pôle de Recherche en Gynécologie, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, 1200 Brussels, Belgium; (C.A.S.); (A.C.)
- Anatomopathology Department, Cliniques Universitaires Saint-Luc, 1200 Brussels, Belgium
| | - Jacques Donnez
- Société de Recherche pour l’Infertilité, 1150 Brussels, Belgium;
- Université Catholique de Louvain, 1200 Brussels, Belgium
| | - Marie-Madeleine Dolmans
- Pôle de Recherche en Gynécologie, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, 1200 Brussels, Belgium; (C.A.S.); (A.C.)
- Gynecology Department, Cliniques Universitaires Saint-Luc, 1200 Brussels, Belgium
| |
Collapse
|
30
|
Donnez J, Donnez O, Brethous M, Bestel E, Garner E, Charpentier S, Humberstone A, Loumaye E. Treatment of symptomatic uterine adenomyosis with linzagolix, an oral gonadotrophin-releasing hormone antagonist: a pilot study. Reprod Biomed Online 2021; 44:200-203. [PMID: 34799277 DOI: 10.1016/j.rbmo.2021.09.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Revised: 08/30/2021] [Accepted: 09/24/2021] [Indexed: 10/20/2022]
Abstract
RESEARCH QUESTION Does a once-daily regimen of linzagolix, a new oral gonadotrophin-releasing hormone (GnRH) antagonist, given at a fully suppressive dose (200 mg) for 12 weeks, followed by a partially suppressive dose (100 mg) for a further 12 weeks, reduce adenomyotic uterine size and associated symptoms? DESIGN Eight women (aged 37-45 years) with adenomyosis confirmed by magnetic resonance imaging (MRI) were enrolled in a single-centre, open-label pilot study. The primary efficacy end-point was the change in uterine volume on MRI at 24 weeks. Secondary efficacy end-points included serum oestradiol, overall pelvic pain, dysmenorrhoea, non-menstrual pelvic pain, dyspareunia, dyschezia and quality of life (QoL). Bone mineral density (BMD) was assessed at baseline and 24 weeks. RESULTS At baseline, uterine volume (mean ± SD) was 333 ± 250 cm3. After 24 weeks, it was 204 ± 126 cm3, a reduction of 32% from baseline (P = 0.0057). After 12 weeks, it was 159 ± 95 cm3, a reduction of 55% (P < 0.0001). Median serum oestradiol was suppressed below 20 pg/ml during the 12 weeks on 200 mg linzagolix, and maintained below 60 pg/ml on 100 mg linzagolix. Improvements in overall pelvic pain, dysmenorrhoea, non-menstrual pelvic pain, dyspareunia, dyschezia and QoL were observed. Mean percentage change in BMD loss at 24 weeks was -2.4%, -1.3% and -4.1% for the spine, femoral neck and total hip, respectively. The most common adverse events were hot flushes. CONCLUSIONS A once-daily regimen of 200 mg linzagolix for 12 weeks and then 100 mg for another 12 weeks decreased adenomyotic uterine volume and improved associated symptoms.
Collapse
Affiliation(s)
- Jacques Donnez
- Université Catholique de Louvain, Louvain, Belgium; Société de Recherche pour l'infertilité (SRI), Brussels, Belgium.
| | - Olivier Donnez
- Polyclinique Urbain V (ELSAN Group), Institut du Sein et de Chirurgie Gynécologique d'Avignon, Avignon, France
| | | | | | | | | | | | | |
Collapse
|
31
|
Dolmans MM, Cacciottola L, Donnez J. Conservative Management of Uterine Fibroid-Related Heavy Menstrual Bleeding and Infertility: Time for a Deeper Mechanistic Understanding and an Individualized Approach. J Clin Med 2021; 10:jcm10194389. [PMID: 34640407 PMCID: PMC8509802 DOI: 10.3390/jcm10194389] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Revised: 09/22/2021] [Accepted: 09/23/2021] [Indexed: 12/17/2022] Open
Abstract
(1) Background: Uterine fibroids are the most common form of benign uterine tumors, causing heavy menstrual bleeding (HMB), pelvic pain, infertility and pressure symptoms. Almost a third of women with uterine fibroids seek treatment. The objective of this review is to understand the mechanisms linking fibroids to these symptoms and evaluate different options for their management, particularly the place of gonadotropin-releasing hormone (GnRH) antagonist. (2) Methods: We gathered the most recent and relevant papers on the main fibroid-related symptoms and medical and surgical therapy for their treatment. Those reporting use of oral GnRH antagonists were investigated in detail. (3) Results: The mechanisms explaining myoma-related HMB and infertility were reviewed, as they are essential to a deeper mechanistic understanding and oriented approach. The choice of treatment depends on the number, size, and location of fibroids, and is guided by the patient’s age and desire to preserve her fertility. Economic impacts of myomas in terms of direct costs, lost workdays, and complications were found to be significant. Medical, surgical, and non-surgical strategies were analyzed in this context. Novel medical approaches with GnRH antagonist were explored and found to represent an effective new option. (4) Conclusion: The need for alternatives to surgical intervention is very real, especially for women seeking to preserve their fertility. New options now exist, with GnRH antagonists proven to treat fibroid symptoms effectively, opening the door to novel strategies for the management of myomas.
Collapse
Affiliation(s)
- Marie-Madeleine Dolmans
- Gynecology Department, Cliniques Universitaires St-Luc, Avenue Hippocrate 10, 1200 Brussels, Belgium;
- Gynecology Research Unit, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Avenue Mounier 52, 1200 Brussels, Belgium;
| | - Luciana Cacciottola
- Gynecology Research Unit, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Avenue Mounier 52, 1200 Brussels, Belgium;
| | - Jacques Donnez
- Université Catholique de Louvain, 1200 Brussels, Belgium
- Société de Recherche pour l’Infertilité (SRI), 143 Avenue Grandchamp, 1150 Brussels, Belgium
- Correspondence:
| |
Collapse
|
32
|
Donnez J, Stratopoulou CA, Dolmans MM. Uterine Adenomyosis: From Disease Pathogenesis to a New Medical Approach Using GnRH Antagonists. Int J Environ Res Public Health 2021; 18:ijerph18199941. [PMID: 34639243 PMCID: PMC8508387 DOI: 10.3390/ijerph18199941] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Revised: 09/13/2021] [Accepted: 09/14/2021] [Indexed: 12/24/2022]
Abstract
Uterine adenomyosis is a common chronic disorder frequently encountered in reproductive-age women, causing heavy menstrual bleeding, intense pelvic pain, and infertility. Despite its high prevalence, its etiopathogenesis is not yet fully understood, so there are currently no specific drugs to treat the disease. A number of dysregulated mechanisms are believed to contribute to adenomyosis development and symptoms, including sex steroid signaling, endometrial proliferation and invasiveness, and aberrant immune response. Abnormal sex steroid signaling, particularly hyperestrogenism and subsequent progesterone resistance, are known to play a pivotal role in its pathogenesis, which is why various antiestrogenic agents have been used to manage adenomyosis-related symptoms. Among them, gonadotropin-releasing hormone (GnRH) antagonists are swiftly gaining ground, with recent studies reporting efficient lesion regression and symptom alleviation. The aim of the present review is to compile available information on the pathogenesis of adenomyosis, explore the etiology and mechanisms of hyperestrogenism, and discuss the potential of antiestrogenic therapies for treating the disease and improving patient quality of life.
Collapse
Affiliation(s)
- Jacques Donnez
- Société de Recherche Pour l’Infertilité, 1150 Brussels, Belgium
- Université Catholique de Louvain, 1200 Brussels, Belgium
- Correspondence:
| | - Christina Anna Stratopoulou
- Pôle de Recherche en Gynécologie, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, 1200 Brussels, Belgium; (C.A.S.); (M.-M.D.)
| | - Marie-Madeleine Dolmans
- Pôle de Recherche en Gynécologie, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, 1200 Brussels, Belgium; (C.A.S.); (M.-M.D.)
- Gynecology Department, Cliniques Universitaires Saint-Luc, 1200 Brussels, Belgium
| |
Collapse
|
33
|
Donnez J, Donnez O, Brethous M, Bestel E, Humberstone A, Garner E. EFFICACY AND SAFETY OF LINZAGOLIX FOR THE TREATMENT OF SEVERE ADENOMYOSIS: FINAL Results FROM A PILOT STUDY. Fertil Steril 2021. [DOI: 10.1016/j.fertnstert.2021.07.881] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
|
34
|
Donnez J. The heterogeneity of endometriotic lesions could be explained by their progesterone resistance. Hum Reprod 2021; 36:2624-2625. [PMID: 34160579 DOI: 10.1093/humrep/deab151] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Indexed: 12/12/2022] Open
Affiliation(s)
- Jacques Donnez
- SRI (sociéte de la recherche pour l'infertilité), Brussels, Belgium
| |
Collapse
|
35
|
Cacciottola L, Nguyen TYT, Amorim CA, Donnez J, Dolmans MM. O-192 Modulating hypoxia and oxidative stress in human ovarian tissue xenografts using adipose tissue-derived stem cells. Hum Reprod 2021. [DOI: 10.1093/humrep/deab127.093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Study question
To investigate whether adipose tissue-derived stem cells (ASCs) modulate hypoxia and oxidative stress in human ovarian tissue transplants to reduce early follicle loss.
Summary answer
ASCs protect the follicle pool by mitigating the hypoxia-related response through HIF1↑ signaling in human xenografts and enhancing revascularization by ensuring faster tissue reperfusion.
What is known already
ASCs are known for their angiogenic potential and capacity to boost angiogenesis by secreting growth factors and differentiating into vessels in numerous models of wound healing in regenerative medicine. In a 2-step ovarian tissue xenotransplantation involving grafting inside a fibrin scaffold two weeks prior to transplantation, ASCs reduced follicle loss after short- and long-term grafting, as well as abnormal follicle activation, by increasing reoxygenation and revascularization in human xenografts.
Study design, size, duration
Prospective experimental study. Cryopreserved ovarian cortex from five adult women was transplanted to 30 nude mice, with or without ASCs (ASC group; OT group). Ovarian grafts were retrieved on days 3 (n = 5), 10 (n = 5) and 21 (n = 5). One piece of ovarian tissue per patient was fixed for analysis after thawing to serve as non-grafted controls.
Participants/materials, setting, methods
The 10 animals grafted for 21 days underwent in vivo microdialysis evaluation to investigate direct reactive oxygen species (ROS) kinetics. Analyses of ovarian grafts at all time points and non-grafted controls included immunolabeling for double CD34 (revascularization by host and graft components), immunofluorescence for HIF1α (hypoxia-related response), Nrf2 (oxidative stress-related response) and 8OHdG (oxidative stress-related DNA damage), and gene expression (RT-qPCR) for VEGF-A (neoangiogenesis), SOD2 (antioxidant activity) and Nrf1 (mitochondrial biogenesis).
Main results and the role of chance
ROS peaked sooner in the ASC group (day 2, p < 0.0001) than the OT group (day 10, p = 0.01) after grafting, indicating earlier tissue reperfusion. Total vascularization was stable in the ASC group at all time points, but lower in the OT group 3 days after grafting (p = 0.01) due to a drop in both host and graft vascular components. HIF1α expression, detected mainly in follicles, was significantly lower in primordial follicles in the ASC group than the OT group on days 3 (p = 0.008) and 10 (p = 0.01). VEGF gene expression rose significantly (around 40x) in both groups on day 3 and persisted significantly longer in the ASC group (10 days) than the OT group (3 days) (p = 0.04), emphasizing the role of ASCs as enhancers of proangiogenic factors. There was no upturn in the oxidative stress-related response (Nrf2 pathway) nor DNA damage (8OHdG) to follicles in any of the grafted groups over time, while a modest increase in both markers was observed only in the stroma after 21 days. Neither was there any major increase in SOD2 and Nrf1 gene expression, suggesting no significant activation of the Nrf2 pathway for cytoprotection from oxidative stress.
Limitations, reasons for caution
Although Nrf2 signaling activation was detected in human granulosa cell cultures in increasing ROS concentrations, our findings did not confirm its role in tissue damage modulation after ovarian tissue transplantation. Further studies may evidence the involvement of other pathways that modulate oxidative stress after transplantation.
Wider implications of the findings
The role of ASCs in protecting the follicle pool appears to be related to a decrease in hypoxia and faster ovarian graft revascularization and reperfusion, sustained by an increase in VEGF for a longer period after grafting. There was no evidence of oxidative stress-related damage, irrespective of the transplantation strategy.
Trial registration number
Collapse
Affiliation(s)
- L Cacciottola
- Institut de Recherche Expérimentale et Clinique- Université Catholique de Louvain, Gynecology Research Unit, Brussels, Belgium
| | - T Y T Nguyen
- Institut de Recherche Expérimentale et Clinique- Université Catholique de Louvain, Gynecology Research Unit, Brussels, Belgium
| | - C A Amorim
- Institut de Recherche Expérimentale et Clinique- Université Catholique de Louvain, Gynecology Research Unit, Brussels, Belgium
| | - J Donnez
- Society for Research into Infertility, society for Research into Infertility, Brussels, Belgium
| | - M M Dolmans
- Institut de Recherche Expérimentale et Clinique- Université Catholique de Louvain, Gynecology Research Unit- Department of Gynecology- Cliniques Universitaires Saint-Luc, Brussels, Belgium
| |
Collapse
|
36
|
Taylor H, Donnez J, Petraglia F, Gemzell Danielsson K, Renner S, Bestel E, Gotteland JP, Humberstone A, Garner E. O-135 Long term secondary efficacy of linzagolix for heavy menstrual bleeding (HMB) due to uterine fibroids (UF): 52-week results from two placebo-controlled, randomized, phase 3 trials. Hum Reprod 2021. [DOI: 10.1093/humrep/deab126.060] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Abstract
Study question
Are symptomatic improvements in women with UF observed after 24 weeks of linzagolix treatment with or without add-back therapy (ABT) maintained over 52 weeks?
Summary answer
Improvements in anemia, pain and quality of life previously reported at 24 weeks were maintained at 52 weeks.
What is known already
We previously reported that partial or full suppression of estradiol (E2) with once daily doses of either 100 or 200 mg linzagolix for 24 weeks, with or without ABT, were effective in reducing heavy menstrual bleeding associated with uterine fibroids, improving other symptoms such as pain and anemia and improving quality of life. Here we report the maintenance of effect on secondary endpoints after 52 weeks of treatment.
Study design, size, duration
Linzagolix is an investigational, oral GnRH antagonist being developed to treat HMB due to UF. PRIMROSE 1 (P1, USA, NCT03070899) and PRIMROSE 2 (P2, Europe and USA, NCT03070951) are randomized, double-blind, placebo-controlled Phase 3 trials, with essentially identical design, investigating the efficacy and safety of linzagolix with and without hormonal add-back therapy (ABT: 1 mg estradiol/0.5 mg norethindrone acetate) once daily for 52 weeks.
Participants/materials, setting, methods
Participants had HMB due to UF (>80mL menstrual blood loss (MBL)/cycle) and were equally randomized to: placebo, linzagolix 100mg, linzagolix 100mg+ABT, linzagolix 200mg, or linzagolix 200mg+ABT. After 24 weeks, subjects originally randomized to placebo or linzagolix 200mg were switched to linzagolix 200mg+ABT except in P1 where 50% placebo subjects continued placebo until 52 weeks. Secondary efficacy assessments included hemoglobin, pain (0–10 numeric rating scale) and health related quality of life (HRQL) on the UF-QoL questionnaire.
Main results and the role of chance
P1 trial subjects (n = 526) had a mean age of 42 years, pain score of 6.6 and HRQL total score (0–100) of 36.4 and 63% were Black. P2 trial subjects (n = 511) had a mean age of 43 years, pain score 4.8 and HRQL total score of 46.1 and 5% were Black. Mean baseline MBL was about 200 mL per cycle in both studies. In both trials, significant improvements compared to placebo observed at week 24 for secondary endpoints, including pain, anemia and QoL in all linzagolix treatment groups were maintained at 52 weeks.
Mean±SD hemoglobin levels in anemic patients (<12 g/dL) increased from baseline by 1.7±1.9, 1.9±1.7, 2.2±2.4, 2.7±1.9 in P1 and 1.2±1.9, 2.9±1.8, 2.4±2.1, 3.0±1.4 in P2 in the 100mg, 100mg+ABT, 200mg/200mg+ABT, 200mg+ABT groups, respectively, compared to 0.6±1.8 with placebo (P1).
Mean±SD change from baseline in pain scores were -3.3±3.1, -2.7±3.2, -2.6±3.0, -3.9±3.2 in P1 and -2.6±3.1, -2.6±2.8, -3.0±2.6, -2.8±3.0 in P2 in the 100mg, 100mg+ABT, 200mg/200mg+ABT, 200mg+ABT groups, respectively, compared to -0.4±2.5 with placebo (P1).
Mean±SD change in HRQL total scores were 25.0±26.2, 34.2±30.1, 29.7±29.2, 38.3±29.2 in P1 and 16.8±24.0, 29.6±23.2, 31.9±26.8, 30.7±26.0 in P2 in the 100mg, 100mg+ABT, 200mg/200mg+ABT, 200mg+ABT groups, respectively, compared to 14.6±23.9 with placebo (P1).
Limitations, reasons for caution
Here we report data in both trials up to 52 weeks of treatment. No statistical comparisons were done at 52 weeks (the primary analysis was done after 24 weeks treatment). Post-treatment follow-up will provide more information in symptom recurrence after stopping treatment.
Wider implications of the findings
All linzagolix treatments provided sustained benefit. Two regimens previously identified for potential long-term treatment, 200mg with ABT and 100mg without ABT, provided sustained improvements of anemia, pain and associated quality of life. These different treatment regimens could be important to address the diverse needs of women suffering from uterine fibroids.
Trial registration number
ClinicalTrials.gov: NCT03070899, NCT03070951
Collapse
Affiliation(s)
- H Taylor
- Yale University- School of Medicine, Dept. of Reproductive Endocrinology and Infertility, New Haven- CT, U.S.A
| | - J Donnez
- Catholic University of Louvain, Société de Recherche pour l’Infertilité SRI, Brussels, Belgium
| | - F Petraglia
- University of Florence, Maternal-Infancy Unit- Careggi Hospital, Florence, Italy
| | - K Gemzell Danielsson
- Karolinska Institute, Department of Womeńs and Childreńs Health, Stockholm, Sweden
| | - S Renner
- Böblingen Clinics, Clinic for Gynecology and Obstetrics, Böblingen, Germany
| | - E Bestel
- ObsEva SA, Research and Development, Geneva, Switzerland
| | - J P Gotteland
- ObsEva SA, Research and Development, Geneva, Switzerland
| | - A Humberstone
- ObsEva SA, Research and Development, Geneva, Switzerland
| | - E Garner
- ObsEva Inc., Medical, Boston, U.S.A
| |
Collapse
|
37
|
Abstract
Abstract
Study question
Is a once daily regimen of the GnRH antagonist, linzagolix, high-dose (200mg) for 12 weeks then low-dose (100mg) for 12 weeks, effective in severe adenomyosis?
Summary answer
After 12 weeks, there was marked shrinkage of uterine volume, regression of adenomyotic lesions and symptom improvement (pain, anemia), 24 weeks data is pending.
What is known already
Suppression of estradiol using GnRH antagonists has been shown to be an effective treatment for endometriosis and uterine fibroids. Linzagolix is an investigational, oral GnRH receptor antagonist, which dose-dependently reduces E2 levels, providing full suppression (serum E2 < 20 pg/mL) and partial suppression with once daily oral dosing of 200 mg and 100 mg, respectively. We hypothesized that a regimen of full suppression for 12 weeks followed by partial suppression maintenance therapy for 12 weeks could be effective for the treatment of severe adenomyosis.
Study design, size, duration
This was a single-center, open-label exploratory study in women with symptomatic adenomyosis confirmed by Magnetic Resonance Imaging (MRI) (EudraCT number: 2017–004–042–14). Patients were recruited from a single private clinic and infertility research unit between March 2019 to June 2020.
Participants/materials, setting, methods
Eligible patients were premenopausal women 18 to 48 years old with symptomatic uterine adenomyosis confirmed by MRI, moderate-to-severe pain and abnormal uterine bleeding. The primary measure of efficacy was the reduction in uterine volume assessed by MRI. Other endpoints included adenomyosis lesion volume, pelvic pain, haemoglobin, uterine bleeding and quality of life (EHP–30 domains: pain, control and powerlessness, emotional well-being, social support and self-image).
Main results and the role of chance
Eight (3 black and 5 white) enrolled subjects had mean±SD age 42±3 years and weight 75±19 kg. At baseline (day 2 of the cycle) all patients presented with pelvic pain, severe dysmenorrhea and heavy menstrual bleeding. In all cases, MRI showed an enlarged uterus (mean±SD volume 343±253 cm3) with severe adenomyosis characterized by heterogenous myometrium with multiple myometrial cysts. The mean±SD junctional zone was 29.0±14.2 mm. Median serum estradiol was suppressed to 12 pg/mL by 4 weeks and this was maintained up to 12 weeks. After 12 weeks, mean±SD uterine volume was 162±117 cm3, a 57±16% reduction from baseline, with marked regression of adenomyotic lesions and the junctional zone was 21.0±13.4 mm. Mean±SD overall pelvic pain score (0–10 NRS) was reduced from 8.4±1.1 at baseline to 2.4±3.4 (p = 0.0035) and there were also improvements in dysmenorrhea, dyspareunia, non-menstrual pelvic pain and dyschezia scores. No subjects reported uterine bleeding between Weeks 4 to 12. Mean±SD haemoglobin was 12.1±2.0 at baseline and 12.8±1.1 at 12 weeks. Anemia at baseline (≤10g/dL) was resolved by 12 weeks. Substantial improvements were observed on each of the EHP–30 domains.
The most common side effect was the expected hypoestrogenic side effects of hot flushes, which were reported by 6/8 subjects.
Limitations, reasons for caution
This was a single-centre, open-label pilot study in 8 patients with symptomatic adenomyosis. We report the results after the first 12 weeks treatment of a high full suppression dose of linzagolix. Results after 24 weeks will further inform on the potential for a low partial suppression dose to maintain efficacy.
Wider implications of the findings: The initial results of this open-label pilot study in women with severe adenomyosis indicate that a high full suppression dose of linzagolix 200 mg is effective in reducing uterine and adenomyosis lesion size, reducing abnormal uterine bleeding and pelvic pain and improving quality of life.
Trial registration number
EudraCT number: 2017–004–042–14
Collapse
Affiliation(s)
- O Donnez
- Polyclinique Urbain V ELSAN Group, Institut du sein et de Chirurgie gynécologique d’Avignon ICA, Avignon, France
| | - J Donnez
- Catholic University of Louvain, Société de Recherche pour l’Infertilité SRI, Brussels, Belgium
| |
Collapse
|
38
|
Nguyen TYT, Cacciottola L, Camboni A, De Vos M, Demeestere I, Donnez J, Dolmans MM. O-179 Safety of ovarian tissue cryopreservation and transplantation in patients with central nervous system cancers. Hum Reprod 2021. [DOI: 10.1093/humrep/deab127.080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Study question
Is cryopreserved ovarian tissue transplantation safe in patients with central nervous system (CNS) tumors?
Summary answer
Cancer cell contamination was not detected in any ovarian samples from patients with CNS tumors by histological analysis, immunohistochemistry, molecular biology or long-term xenotransplantation.
What is known already
Frequently encountered CNS cancers in childhood include astrocytoma, medulloblastoma, ependymoma, glioblastoma and germinoma. CNS tumors have the capacity for extraneural metastases in 0.5-18% of cases. There are two publications reporting metastases to patients’ ovaries from medulloblastoma.
Study design, size, duration
Prospective experimental study conducted in an academic gynecology research laboratory using frozen-thawed ovarian tissue from 20 patients suffering from 6 types of CNS tumors, including the most common forms mentioned above and primitive neuroectodermal tumors (PNET). Five-month xenotransplantation was performed to severe combined immunodeficient (SCID) mice.
Participants/materials, setting, methods
Cryopreserved ovarian tissue from 20 patients with CNS cancers was thawed and analyzed for minimal disseminated disease and long-term xenografting to immunodeficient mice. The presence of malignant cells was assessed in both cryopreserved and xenografted ovarian tissue using histological analysis, immunohistochemistry for disease-specific markers (neuron-specific enolase [NSE] and glial fibrillary acidic protein [GFAP]) and reverse transcription droplet digital polymerase chain reaction (RT-ddPCR) for quantification of GFAP gene amplification.
Main results and the role of chance
No malignant cells were detected in frozen-thawed ovarian tissue from any of the patients by histology, immunolabeling for NSE and GFAP, RT-ddPCR for detection of GFAP gene amplification or xenotransplantation to SCID mice. One patient successfully underwent frozen-thawed ovarian tissue transplantation, resulting in the birth of 3 healthy children, but suffered a recurrence of her PNET 6 years after reimplantation and sadly died. Scrupulous analysis of her remaining frozen tissue showed no infiltration by malignant cells, neither after thawing nor long-term xenotransplantation. No relationship was ever established between the patient’s relapsed cancer and reintroduction of her cryopreserved ovarian tissue. The risk of reseeding cancer cells when transplanting ovarian tissue in patients with CNS cancers can therefore be considered low.
Limitations, reasons for caution
The risk of ovarian metastases cannot be completely ruled out for any type of tumor because we cannot analyze the actual fragments that will be reimplanted.
Wider implications of the findings
Our results indicate that the risk of disseminated disease in ovarian tissue from CNS patients is minimal. This is useful information for doctors when counseling women looking to undergo ovarian tissue transplantation.
Trial registration number
Not applicable
Collapse
Affiliation(s)
- T Y T Nguyen
- Université Catholique de Louvain- Brussels, Pole de Recherche en Gynecologie- IREC, Brussels, Belgium
| | - L Cacciottola
- Université Catholique de Louvain- Brussels, Pole de Recherche en Gynecologie- IREC, Brussels, Belgium
| | - A Camboni
- Université Catholique de Louvain- Brussels, Pole de Recherche en Gynecologie- IREC, Brussels, Belgium
- Cliniques Universitaires Saint-Luc, Service d’Anatomie Pathologique, Brussels, Belgium
| | - M De Vos
- Universitair Ziekenhuis Brussel UZ Brussel, Centre for Reproductive Medicine, Brussels, Belgium
- Vrije Universiteit Brussel VUB, Follicle Biology Laboratory FOBI- UZ Brussel, Brussels, Belgium
| | - I Demeestere
- Université Libre de Bruxelles, Research Laboratory in Human Reproduction- Faculty of Medicine, Brussels, Belgium
| | - J Donnez
- Société de Recherche pour l’Infertilité SRI, Société de Recherche pour l’Infertilité SRI, Brussels, Belgium
| | - M M Dolmans
- Université Catholique de Louvain- Brussels, Pole de Recherche en Gynecologie- IREC, Brussels, Belgium
- Cliniques Universitaires Saint-Luc, Gynecology Department, Brussels, Belgium
| |
Collapse
|
39
|
Masciangelo R, Chiti MC, Camboni A, Amorim CA, Donnez J, Dolmans MM. Mitochondrial content, activity, and morphology in prepubertal and adult human ovaries. J Assist Reprod Genet 2021; 38:2581-2590. [PMID: 34331619 DOI: 10.1007/s10815-021-02282-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Accepted: 07/15/2021] [Indexed: 11/25/2022] Open
Abstract
PURPOSE To investigate whether mitochondrial content, activity, and morphology differ in prepubertal versus adult ovarian follicles. METHODS Ovarian tissue was collected from 7 prepubertal girls (age 1-10 years) and 6 adult women (age 20-35 years). Primordial and primary follicles were isolated from frozen-thawed prepubertal and adult ovarian tissue and their viability was assessed. Mitochondrial content was investigated by TOMM20 immunostaining of prepubertal and adult ovarian tissue, while mitochondrial activity in isolated follicles was analyzed by MitoTracker CM-H2XRos and JC-1. Frozen-thawed ovarian tissue from the same patients was also evaluated by transmission electron microscopy to examine mitochondrial morphology. RESULTS Higher TOMM20 staining was detected in prepubertal follicles compared to their adult counterparts, indicating the presence of more mitochondria in prepubertal follicles. Analysis of mitochondrial activity by MitoTracker showed higher fluorescence intensity in prepubertal follicles, suggesting that follicles in this group are more active than adult follicles. JC-1 analysis did not reveal any statistically significant difference in the inactive/active ratio between the two groups. Moreover, ultrastructural analysis by TEM detected morphological differences in the shape and cristae of prepubertal mitochondria, probably suggesting a mechanism of response to autophagy. CONCLUSION Differences in the number, activity, and morphology of mitochondria were reported, suggesting that consequential modifications might occur during puberty, which could be the window of opportunity required by mitochondria to undergo changes needed to reach maturity, and hence the capacity for ovulation and fertilization.
Collapse
Affiliation(s)
- Rossella Masciangelo
- Pôle de Recherche en Gynécologie, Institut de Recherche Expérimentale Et Clinique, Université Catholique de Louvain, Avenue Mounier 52, bte. B1.52.02, 1200, Brussels, Belgium
| | - Maria Costanza Chiti
- Pôle de Recherche en Gynécologie, Institut de Recherche Expérimentale Et Clinique, Université Catholique de Louvain, Avenue Mounier 52, bte. B1.52.02, 1200, Brussels, Belgium
| | - Alessandra Camboni
- Pôle de Recherche en Gynécologie, Institut de Recherche Expérimentale Et Clinique, Université Catholique de Louvain, Avenue Mounier 52, bte. B1.52.02, 1200, Brussels, Belgium
| | - Christiani Andrade Amorim
- Pôle de Recherche en Gynécologie, Institut de Recherche Expérimentale Et Clinique, Université Catholique de Louvain, Avenue Mounier 52, bte. B1.52.02, 1200, Brussels, Belgium
| | - Jacques Donnez
- Société de Recherche Pour L'Infertilité, Avenue Grandchamp 143, 1150, Brussels, Belgium
| | - Marie-Madeleine Dolmans
- Pôle de Recherche en Gynécologie, Institut de Recherche Expérimentale Et Clinique, Université Catholique de Louvain, Avenue Mounier 52, bte. B1.52.02, 1200, Brussels, Belgium.
- Département de Gynécologie, Cliniques Universitaires St. Luc, Avenue Hippocrate 10, 1200, Brussels, Belgium.
| |
Collapse
|
40
|
Cacciottola L, Donnez J, Dolmans MM. Can Endometriosis-Related Oxidative Stress Pave the Way for New Treatment Targets? Int J Mol Sci 2021; 22:ijms22137138. [PMID: 34281188 PMCID: PMC8267660 DOI: 10.3390/ijms22137138] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Revised: 06/28/2021] [Accepted: 06/28/2021] [Indexed: 12/18/2022] Open
Abstract
Endometriosis is a disease of reproductive age characterized by chronic pelvic pain and infertility. Its pathogenesis is complex and still partially unexplained. However, there is increasing evidence of the role of chronic inflammation, immune system dysregulation, and oxidative stress in its development and progression. The latter appears to be involved in multiple aspects of the disease. Indeed, disease progression sustained by a hyperproliferative phenotype can be related to reactive oxygen species (ROS) imbalance, as numerous experiments using drugs to counteract hyperproliferation have shown in recent years. Chronic pelvic pain is also associated with cell function dysregulation favoring chronic inflammation and oxidative stress, specifically involving macrophages and mast cell activation. Moreover, there is increasing evidence of a role for ROS and impaired mitochondrial function not only as deleterious effectors of the ovarian reserve in patients with endometriomas but also in terms of oocyte quality and, hence, embryo development impairment. Targeting oxidative stress looks to be a promising strategy to both curb endometriotic lesion progression and alleviate endometriosis-associated symptoms of chronic pain and infertility. More investigations are nevertheless needed to develop effective therapeutic strategies for clinical application.
Collapse
Affiliation(s)
- Luciana Cacciottola
- Gynecology Research Unit, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, 1200 Brussels, Belgium;
| | - Jacques Donnez
- Society for Research into Infertility, 1150 Brussels, Belgium;
- Université Catholique de Louvain, 1200 Brussels, Belgium
| | - Marie-Madeleine Dolmans
- Gynecology Research Unit, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, 1200 Brussels, Belgium;
- Department of Gynecology, Cliniques Universitaires Saint-Luc, 1200 Brussels, Belgium
- Correspondence: ; Tel.: +32-(0)2-764-5287
| |
Collapse
|
41
|
Cacciottola L, Donnez J, Dolmans MM. Ovarian tissue damage after grafting: systematic review of strategies to improve follicle outcomes. Reprod Biomed Online 2021; 43:351-369. [PMID: 34384692 DOI: 10.1016/j.rbmo.2021.06.019] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Revised: 05/14/2021] [Accepted: 06/21/2021] [Indexed: 12/17/2022]
Abstract
Frozen-thawed human ovarian tissue endures large-scale follicle loss in the early post-grafting period, characterized by hypoxia lasting around 7 days. Tissue revascularization occurs progressively through new vessel invasion from the host and neoangiogenesis from the graft. Such reoxygenation kinetics lead to further potential damage caused by oxidative stress. The aim of the present manuscript is to provide a systematic review of proangiogenic growth factors, hormones and various antioxidants administered in the event of ovarian tissue transplantation to protect the follicle pool from depletion by boosting revascularization or decreasing oxidative stress. Although almost all investigated studies revealed an advantage in terms of revascularization and reduction in oxidative stress, far fewer demonstrated a positive impact on follicle survival. As the cascade of events driven by ischaemia after transplantation is a complex process involving numerous players, it appears that acting on specific molecular mechanisms, such as concentrations of proangiogenic growth factors, is not enough to significantly mitigate tissue damage. Strategies exploiting the activated tissue response to ischaemia for tissue healing and remodelling purposes, such as the use of antiapoptotic drugs and adult stem cells, are also discussed in the present review, since they yielded promising results in terms of follicle pool protection.
Collapse
Affiliation(s)
- Luciana Cacciottola
- Gynecology Research Unit, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Brussels, Belgium
| | - Jacques Donnez
- Prof. Emeritus, Université Catholique de Louvain, Brussels, Belgium
| | - Marie-Madeleine Dolmans
- Gynecology Research Unit, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Brussels, Belgium; Department of Gynecology, Cliniques Universitaires Saint-Luc, Brussels, Belgium.
| |
Collapse
|
42
|
Manavella DD, Herraiz S, Soares M, Buigues A, Pellicer A, Donnez J, Díaz-García C, Dolmans MM. Disease-inducing potential of two leukemic cell lines in a xenografting model. J Assist Reprod Genet 2021; 38:1589-1600. [PMID: 33786735 PMCID: PMC8266930 DOI: 10.1007/s10815-021-02169-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Accepted: 03/22/2021] [Indexed: 10/21/2022] Open
Abstract
PURPOSE Cryopreserved ovarian tissue transplant restores ovarian function in young cancer patients after gonadotoxic treatment. However, leukemia is associated with increased risk of malignant cell transmission. We aimed to assess the tumor-inducing potential of two different leukemic cell lines when xenografted to immunodeficient mice. METHODS Fifty-four female immunodeficient mice were grafted with either 100, 200, 500, 1000, and 10,000 chronic myeloid leukemia in blast crisis (BV-173) cells or relapsed acute lymphoblastic leukemia (RCH-ACV) cells, embedded inside a fibrin scaffold along with 50,000 human ovarian stromal cells. Two mice per cell line received the fibrin matrix without leukemic cells as negative controls. Clinical signs of disease were monitored for 20 weeks. Grafts, liver tissue, and masses were collected for macroscopic analysis and gene expression of BCR-ABL1 and E2A-PBX fusion transcripts present in BV-173 and RCH-ACV respectively. RESULTS BV-173 cells: Mice grafted with 100, 200, or 500 cells showed no sign of disease after and were negative for BCR-ABL1 expression. Three of the 5 animals grafted with 1000 cells and all mice with 10,000 cells developed disease and showed BCR-ABL1-positive expression. RCH-ACV cells: Two out of 4 mice grafted with 100 cells developed disease and were E2A-PBX1-positive. All the animals grafted with higher cell doses showed signs of disease and all but one were E2A-PBX1-positive. CONCLUSION The present work proves that the disease-inducing potential of BV-173 and RCH-ACV leukemic cells xenografted to SCID mouse peritoneum differs between cell lines, depending on cell number, type, status, and cytogenetic disease profile when ovarian tissue is harvested.
Collapse
MESH Headings
- Animals
- Cell Line, Tumor
- Cryopreservation
- Disease Models, Animal
- Female
- Fertility Preservation/methods
- Fusion Proteins, bcr-abl/genetics
- Gene Expression Regulation, Neoplastic/genetics
- Heterografts
- Homeodomain Proteins/genetics
- Humans
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/genetics
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/pathology
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/therapy
- Mice
- Oncogene Proteins, Fusion/genetics
- Ovarian Follicle/transplantation
- Precursor Cell Lymphoblastic Leukemia-Lymphoma/genetics
- Precursor Cell Lymphoblastic Leukemia-Lymphoma/pathology
- Precursor Cell Lymphoblastic Leukemia-Lymphoma/therapy
- Translocation, Genetic/genetics
- Transplantation, Heterologous
- Transplants/growth & development
- Transplants/metabolism
Collapse
Affiliation(s)
- D D Manavella
- Pôle de Recherche en Gynécologie, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Avenue Mounier 52, bte. B1.52.02, 1200, Brussels, Belgium
- Neolife-Medicina y Cirugía Reproductiva, Brasilia 760, 1434, Asunción, Paraguay
| | - Sonia Herraiz
- IVI Foundation-Instituto de Investigación Sanitaria Hospital La Fe (IIS La Fe), Valencia, Spain.
| | - M Soares
- Pôle de Recherche en Gynécologie, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Avenue Mounier 52, bte. B1.52.02, 1200, Brussels, Belgium
| | - A Buigues
- IVI Foundation-Instituto de Investigación Sanitaria Hospital La Fe (IIS La Fe), Valencia, Spain
| | - A Pellicer
- IVI Foundation-Instituto de Investigación Sanitaria Hospital La Fe (IIS La Fe), Valencia, Spain
| | - J Donnez
- Society for Research into Infertility, Brussels, Belgium
| | - C Díaz-García
- IVI Foundation-Instituto de Investigación Sanitaria Hospital La Fe (IIS La Fe), Valencia, Spain
- IVI London, IVIRMA Global, London, W1G 9RQ, UK
- Department of Reproductive Health, UCL, London, WC1E 6AU, UK
| | - M M Dolmans
- Pôle de Recherche en Gynécologie, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Avenue Mounier 52, bte. B1.52.02, 1200, Brussels, Belgium
- Gynecology Department, Cliniques Universitaires Saint-Luc, 1200, Brussels, Belgium
| |
Collapse
|
43
|
Griesinger G, Blockeel C, Pierzynski P, Tournaye H, Višňová H, Humberstone A, Terrill P, Pohl O, Garner E, Donnez J, Loumaye E. Effect of the oxytocin receptor antagonist nolasiban on pregnancy rates in women undergoing embryo transfer following IVF: analysis of three randomised clinical trials. Hum Reprod 2021; 36:1007-1020. [PMID: 33534895 DOI: 10.1093/humrep/deaa369] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Revised: 12/07/2020] [Indexed: 02/07/2023] Open
Abstract
STUDY QUESTION Does a single oral dose of nolasiban 900 mg administered 4 h before embryo transfer (ET) increase pregnancy rates in women undergoing IVF? SUMMARY ANSWER In an individual patient data (IPD) meta-analysis of three clinical trials, a single oral dose of nolasiban 900 mg was associated with an increased ongoing pregnancy rate of an absolute 5% (relative 15%). WHAT IS KNOWN ALREADY Several clinical studies have shown that blocking activation of oxytocin receptors by an oxytocin receptor (OTR) antagonist has the potential to decrease uterine contractions, increase endometrial perfusion and enhance endometrial decidualisation and other parameters of endometrial receptivity. It has been hypothesised that antagonism of oxytocin receptors could improve the likelihood of successful embryo implantation and thus increase pregnancy and live birth rates following ET. STUDY DESIGN, SIZE, DURATION This is an analysis of three randomised, double-blind, placebo-controlled trials, which randomised 1836 subjects between 2015 and 2019. We describe the results of a meta-analysis of individual participant data (IPD) from all three trials and the pre-specified analyses of each individual trial. PARTICIPANT/MATERIAL, SETTING, METHODS Participants were patients undergoing ET following IVF/ICSI in 60 fertility centres in 11 European countries. Study subjects were below 38 years old and had no more than one previously failed cycle. They were randomised to a single oral dose of nolasiban 900 mg (n = 846) or placebo (n = 864). In IMPLANT 1, additional participants were also randomised to nolasiban 100 mg (n = 62) or 300 mg (n = 60). Fresh ET of one good quality embryo (except in IMPLANT 1 where transfer of two embryos was allowed) was performed on Day 3 or Day 5 after oocyte retrieval, approximately 4 h after receiving the study treatment. Serum hCG levels were collected at 14 days post oocyte retrieval (Week 2) and for women with a positive hCG result, ultrasound was performed at Week 6 post-ET (clinical pregnancy) and at Week 10 post-ET (ongoing pregnancy). Pregnant patients were followed for maternal (adverse events), obstetric (live birth, gestational age at delivery, type of delivery, incidence of twins) and neonatal (sex, weight, height, head circumference, Apgar scores, congenital anomalies, breast feeding, admission to intensive care and specific morbidities e.g. jaundice, respiratory distress syndrome) outcomes. MAIN RESULTS AND THE ROLE OF CHANCE In an IPD meta-analysis of the clinical trials, a single oral dose of nolasiban 900 mg was associated with an absolute increase of 5.0% (95% CI 0.5, 9.6) in ongoing pregnancy rate and a corresponding increase of 4.4% (95% CI -0.10, 8.93) in live birth rate compared to placebo. Similar magnitude increases were observed for D3 or D5 transfers but were not significantly different from the placebo. Population pharmacokinetics (PK) demonstrated a correlation between higher exposures and pregnancy. LIMITATIONS, REASON FOR CAUTION The meta-analysis was not a pre-specified analysis. While the individual trials did not show a consistent significant effect, they were not powered based on an absolute increase of 5% in ongoing pregnancy rate. Only a single dose of up to 900 mg nolasiban was administered in the clinical trials; higher doses or extended regimens have not been tested. Only fresh ET has been assessed in the clinical trials to date. WIDER IMPLICATIONS OF THE FINDINGS The finding support the hypothesis that oxytocin receptor antagonism at the time of ET can increase pregnancy rates following IVF. The overall clinical and population PK data support future evaluation of higher doses and/or alternate regimens of nolasiban in women undergoing ET following IVF. STUDY FUNDING/COMPETING INTERESTS The trials were designed, conducted and funded by ObsEva SA. A.H., O.P., E.G., E.L. are employees and stockholders of ObsEva SA. E.L. is a board member of ObsEva SA. G.G. reports honoraria and/or non-financial support from ObsEva, Merck, MSD, Ferring, Abbott, Gedeon-Richter, Theramex, Guerbet, Finox, Biosilu, Preglem and ReprodWissen GmbH. C.B. reports grants and honoraria from ObsEva, Ferring, Abbott, Gedeon Richter and MSD. P.P. reports consulting fees from ObsEva. H.T. reports grants and or fees from ObsEva, Research Fund of Flanders, Cook, MSD, Roche, Gedeon Richter, Abbott, Theramex and Ferring. H.V. reports grants from ObsEva and non-financial support from Ferring. P.T. is an employee of Cytel Inc., who provides statistical services to ObsEva. J.D. reports consulting fees and other payments from ObsEva and, Scientific Advisory Board membership of ObsEva. TRIAL REGISTRATION NUMBERS ClinicalTrials.gov: NCT02310802, NCT03081208, NCT03758885. TRIAL REGISTRATION DATES December 2014 (NCT02310802), March 2017 (NCT03081208), November 2018 (NCT03758885). FIRST PATIENT’S ENROLMENT January 2015 (NCT02310802), March 2017 (NCT03081208), November 2018 (NCT03758885).
Collapse
Affiliation(s)
- G Griesinger
- Department of Gynecological Endocrinology and Reproductive Medicine, University Hospital of Schleswig-Holstein, 23538 Kiel, Germany
| | - C Blockeel
- Centre for Reproductive Medicine, Universitair Ziekenhuis, 1090 Brussel, Belgium
| | - P Pierzynski
- OVIklinika Warszawa Fertility Centre, 01-377 Warszawa, Poland
| | - H Tournaye
- Centre for Reproductive Medicine, Universitair Ziekenhuis, 1090 Brussel, Belgium.,Department of Obstetrics, Gynecology, Perinatology and Reproduction, Institute of Professional Education, Sechenov First Moscow State Medical University of the Ministry of Health of the Russian Federation, Trubetskaya str., 8, b. 2, 119992, Moscow, Russia
| | - H Višňová
- IVF Cube, Prague 160 00, Czech Republic
| | | | - P Terrill
- Cytel Inc., Cambridge, MA 02139, USA
| | - O Pohl
- ObsEva Inc., Boston, MA, USA
| | | | - J Donnez
- Université Catholique de Louvain, 1150, Brussels, Belgium.,SRI (Société de recherches pour l'infertilité), 1150, Brussels, Belgium
| | | |
Collapse
|
44
|
Nguyen TYT, Cacciottola L, Camboni A, Ravau J, De Vos M, Demeestere I, Donnez J, Dolmans MM. Ovarian tissue cryopreservation and transplantation in patients with central nervous system tumours. Hum Reprod 2021; 36:1296-1309. [PMID: 33394011 DOI: 10.1093/humrep/deaa353] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 11/24/2020] [Indexed: 11/12/2022] Open
Abstract
STUDY QUESTION Is there a possibility of reseeding cancer cells potentially present in frozen ovarian tissue from patients with central nervous system (CNS) tumours? SUMMARY ANSWER Malignancy reseeding in cryopreserved ovarian tissue from 20 patients with CNS tumours was not detected by histology, immunohistochemistry (IHC), molecular biology or xenotransplantation. WHAT IS KNOWN ALREADY Ovarian metastasis potential has been documented in patients with leukaemia, borderline ovarian tumours, advanced breast cancer and Ewing sarcoma. However, data on the safety of transplanting frozen-thawed ovarian tissue from cancer patients with CNS tumours are still lacking. STUDY DESIGN, SIZE, DURATION This prospective experimental study was conducted in an academic gynaecology research laboratory using cryopreserved ovarian cortex from 20 patients suffering from CNS tumours. Long-term (5 months) xenografting was performed in immunodeficient mice. PARTICIPANTS/MATERIALS, SETTING, METHODS Subjects enrolled in the study were suffering from one of six types of CNS tumours including medulloblastoma, ependymoma, primitive neuroectodermal tumours, astrocytoma, glioblastoma and germinoma. The presence of malignant cells was investigated with disease-specific markers for each patient in cryopreserved and xenografted ovarian tissue by histology, IHC via expression of neuron-specific enolase (NSE) and glial fibrillary acidic protein (GFAP), and reverse transcription droplet digital polymerase chain reaction (RT-ddPCR) for quantification of GFAP and ENO2 gene amplification. MAIN RESULTS AND THE ROLE OF CHANCE Serial sections of cryopreserved and xenografted ovarian tissue from 20 patients showed no malignant cells by histology. All samples were negative for NSE and GFAP, although these neural markers were expressed extensively in the patients' primary tumours. Analysis by RT-ddPCR revealed no cancer cells detected in cryopreserved and xenografted ovarian fragments from subjects with astrocytoma, ependymoma, glioblastoma or medulloblastoma. Taken together, the study found no evidence of malignancy seeding in frozen-thawed and xenotransplanted ovarian tissue from patients affected by CNS cancers. LIMITATIONS, REASONS FOR CAUTION This analysis cannot guarantee complete elimination of disseminated disease from all cryopreserved ovarian cortex, since we are unable to examine the fragments used for transplantation. WIDER IMPLICATIONS OF THE FINDINGS This is the first study to be conducted in patients with CNS cancers undergoing ovarian tissue cryopreservation and transplantation, and clearly demonstrates no tumour seeding in their frozen-thawed and xenografted tissue. This information is vital for doctors to provide patients with meaningful and accurate advice on the possibilities and risks of ovarian tissue reimplantation. STUDY FUNDING/COMPETING INTEREST(S) This study was supported by grants from the Fonds National de la Recherche Scientifique de Belgique-the Excellence of Science (FNRS-EOS), number 30443682 awarded to M.-M.D. and T.Y.T.N., FNRS grant number 5/4/150/5 and FNRS-PDR Convention grant number T.0077.14 awarded to M.-M.D., grant 2018-042 from the Foundation Against Cancer awarded to A.C., and private donations (Ferrero, de Spoelberch). The authors declare no competing financial interests. TRIAL REGISTRATION NUMBER N/A.
Collapse
Affiliation(s)
- Thu Yen Thi Nguyen
- Pôle de Gynécologie, Institut de Recherche Expérimentale et Clinique (IREC), Université Catholique de Louvain, Brussels, Belgium
| | - Luciana Cacciottola
- Pôle de Gynécologie, Institut de Recherche Expérimentale et Clinique (IREC), Université Catholique de Louvain, Brussels, Belgium
| | - Alessandra Camboni
- Pôle de Gynécologie, Institut de Recherche Expérimentale et Clinique (IREC), Université Catholique de Louvain, Brussels, Belgium.,Service d'Anatomie Pathologique, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Joachim Ravau
- Laboratory of Pediatric Hepatology and Cell Therapy, Institut de Recherche Expérimentale et Clinique (IREC), Université Catholique de Louvain, Brussels, Belgium
| | - Michel De Vos
- Centre for Reproductive Medicine, Universitair Ziekenhuis Brussel (UZ Brussel), Brussels, Belgium.,Follicle Biology Laboratory (FOBI), UZ Brussel, Vrije Universiteit Brussel (VUB), Brussels, Belgium
| | - Isabelle Demeestere
- Research Laboratory in Human Reproduction, Faculty of Medicine, Université Libre de Bruxelles, Brussels, Belgium
| | - Jacques Donnez
- Société de Recherche pour l'Infertilité (SRI), Brussels, Belgium
| | - Marie-Madeleine Dolmans
- Pôle de Gynécologie, Institut de Recherche Expérimentale et Clinique (IREC), Université Catholique de Louvain, Brussels, Belgium.,Gynecology Department, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| |
Collapse
|
45
|
Dolmans MM, Taylor HS, Rodriguez-Wallberg KA, Blumenfeld Z, Lambertini M, von Wolff M, Donnez J. Utility of gonadotropin-releasing hormone agonists for fertility preservation in women receiving chemotherapy: pros and cons. Fertil Steril 2021; 114:725-738. [PMID: 33040981 DOI: 10.1016/j.fertnstert.2020.08.011] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Accepted: 08/06/2020] [Indexed: 12/11/2022]
Affiliation(s)
- Marie-Madeleine Dolmans
- Pôle de Gynécologie, Institut de Recherche Expérimentale et Clinique (IREC), Université Catholique de Louvain, Brussels, Belgium; Gynecology Department, Cliniques Universitaires Saint Luc, Brussels, Belgium
| | - Hugh S Taylor
- Department of Obstetrics, Gynecology and Reproductive Sciences, Yale School of Medicine, New Haven, Connecticut
| | - Kenny A Rodriguez-Wallberg
- Department of Oncology-Pathology, Karolinska Institutet, Stockholm, Sweden; Department of Reproductive Medicine, Division of Gynecology and Reproduction, Karolinska University Hospital, Stockholm, Sweden
| | - Zeev Blumenfeld
- Department of Reproductive Endocrinology, Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Matteo Lambertini
- Department of Medical Oncology, U.O.C. Clinica di Oncologia Medica, IRCCS Ospedale Policlinico San Martino, Genova, Italy; Department of Internal Medicine and Medical Specialties (DiMI), School of Medicine, University of Genova, Genova, Italy
| | | | - Jacques Donnez
- Société de Recherche pour l'Infertilité, Brussels, Belgium; Catholic University of Louvain, Brussels, Belgium.
| |
Collapse
|
46
|
Cacciottola L, Nguyen TYT, Amorim CA, Donnez J, Dolmans MM. Modulating hypoxia and oxidative stress in human xenografts using adipose tissue-derived stem cells. F S Sci 2021; 2:141-152. [PMID: 35559749 DOI: 10.1016/j.xfss.2021.01.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Revised: 01/22/2021] [Accepted: 01/28/2021] [Indexed: 01/28/2023]
Abstract
OBJECTIVE To investigate whether adipose tissue-derived stem cells (ASCs) modulate hypoxia and oxidative stress in human ovarian tissue transplants. DESIGN Prospective experimental study SETTING: Gynecological research unit in a university hospital PATIENT(S): Cryopreserved ovarian cortex from 5 adult women. INTERVENTION(S) Thirty mice were grafted with frozen-thawed human ovarian tissue, with or without ASCs (2-step/ASCs+ovarian tissue [OT] group and OT group). The ovarian grafts were retrieved on days 3 (n = 5), 10 (n = 5), and 21 (n = 5). The 10 animals grafted for 21 days underwent in vivo evaluations using microdialysis. One piece of ovarian tissue per patient was fixed for analysis after thawing (non-grafted controls). MAIN OUTCOME MEASURE(S) Direct reactive oxygen species were collected every second day after grafting by means of microdialysis. Analyses of ovarian fragments included immunolabeling for double CD34 (revascularization by host and graft components); immunofluorescence for hypoxia-inducible factor 1α (hypoxia-related response), nuclear factor erythroid 2-related factor 2 (oxidative stress-related response), and 8-hydroxy-deoxyguanosine (oxidative stress-related DNA damage); and gene expression (quantitative reverse transcription polymerase chain reaction) for vascular endothelial growth factor-A (neoangiogenesis), superoxide dismutase 2 (antioxidant activity), and nuclear respiratory factor 1 (mitochondrial biogenesis). RESULT(S) Reactive oxygen species peaked earlier in the ASC group (day 2) compared with that in the OT group (day 10) after grafting. Total vascularization was stable in the ASC group at all time points, while it was lower in the OT group 3 days after grafting. Hypoxia-inducible factor 1α expression, also detected in non-grafted controls, was significantly lower in the ASC group than in the OT group on days 3 and 10. The increase in VEGF gene expression lasted significantly longer in the ASC group than in the OT group. There was no significant upturn in the oxidative stress-related response (nuclear factor erythroid 2-related factor 2 pathway) or oocyte DNA damage (8-hydroxy-deoxyguanosine) in any of the grafted groups. CONCLUSION(S) Use of ASCs allows faster ovarian graft reperfusion and mitigates the hypoxia-related response through rapid revascularization, sustained by prolonged increase in vascular endothelial growth factor after grafting. No evidence of oxidative stress-related damage was detected irrespective of the transplantation strategy.
Collapse
Affiliation(s)
- Luciana Cacciottola
- Gynecology Research Unit, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Brussels, Belgium
| | - Thu Y T Nguyen
- Gynecology Research Unit, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Brussels, Belgium
| | - Christiani A Amorim
- Gynecology Research Unit, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Brussels, Belgium
| | - Jacques Donnez
- Society for Research into Infertility, Brussels, Belgium
| | - Marie-Madeleine Dolmans
- Gynecology Research Unit, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Brussels, Belgium; Department of Gynecology, Cliniques Universitaires Saint-Luc, Brussels, Belgium.
| |
Collapse
|
47
|
Philippart C, Masciangelo R, Camboni A, Donnez J, Dolmans MM. Basal lamina characterization in frozen-thawed and long-term grafted human prepubertal ovarian tissue. Reprod Biomed Online 2021; 42:859-869. [PMID: 33832866 DOI: 10.1016/j.rbmo.2021.02.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Revised: 02/05/2021] [Accepted: 02/19/2021] [Indexed: 11/28/2022]
Abstract
RESEARCH QUESTION Are there differences in the composition and structure of the basal lamina surrounding follicles in prepubertal versus adult human ovarian tissue? DESIGN Frozen-thawed human ovarian tissue from six prepubertal and seven adult patients was divided into three fragments in each case: two for non-grafted tissue evaluation and one for long-term xenografting to mice. Collagen IV and laminin expression were investigated by immunohistochemistry before and after grafting. The basal lamina was analysed by transmission electron microscopy on frozen-thawed tissue. RESULTS In frozen-thawed tissue, collagen IV was significantly less expressed around prepubertal follicles than around adult follicles (primordial, P = 0.02; intermediate/growing follicles, P = 0.03), while laminin was significantly more expressed (primordial, P = 0.03; intermediate, P = 0.01). Collagen IV expression was significantly higher around prepubertal primordial follicles in grafted tissue than in non-grafted tissue, reaching similar levels to those in adult tissue. Ultrastructure analysis showed the basal lamina around follicles in prepubertal frozen-thawed tissue to be rather patchy and thinner than around adult follicles (primordial/intermediate, P = 0.001; primary, P = 0.02). CONCLUSIONS In frozen-thawed tissue, the basal lamina around prepubertal follicles is less mature than around adult follicles, but it becomes similar in both prepubertal and adult subjects after grafting. Grafting could therefore induce maturation of the basal lamina around prepubertal follicles.
Collapse
Affiliation(s)
- Charlotte Philippart
- Pôle de Recherche en Gynécologie, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Brussels, Belgium
| | - Rossella Masciangelo
- Pôle de Recherche en Gynécologie, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Brussels, Belgium
| | - Alessandra Camboni
- Pôle de Recherche en Gynécologie, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Brussels, Belgium
| | - Jacques Donnez
- Société de Recherche pour l'Infertilité, Brussels, Belgium
| | - Marie-Madeleine Dolmans
- Pôle de Recherche en Gynécologie, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Brussels, Belgium; Département de Gynécologie, Cliniques Universitaires St. Luc, Brussels, Belgium.
| |
Collapse
|
48
|
Alonso Pacheco L, Ata B, Bettocchi S, Campo R, Carugno J, Checa MA, de Angelis C, Di Spiezio Sardo A, Donnez J, Farrugia M, Ferro J, Franchini M, Garzon S, Gianaroli L, Gergolet M, Gubbini G, Gordts S, Grimbizis G, Haimovich S, Laganà AS, Li TC, Mencaglia L, Rienzi L, Saravelos S, Soares SR, Tanos V, Ubeda A, Ubaldi FM, Van Herendael B, Vereczkey A, Vitagliano A, Vitale SG, Zullo F. Septate uterus and reproductive outcomes: let's get serious about this. Hum Reprod 2021; 35:2627-2629. [PMID: 32968815 DOI: 10.1093/humrep/deaa230] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
| | - Bariş Ata
- Endoscopy Unit, Centro Gutenberg, Málaga, Spain
| | | | - Rudi Campo
- Department of Obstetrics and Gynecology, Koç University School of Medicine, Istanbul, Turkey
| | - Jose Carugno
- Inter-Departmental Project Unit of "Minimal-Invasive Gynecological Surgery", Integrated Department of Medicine (D.I.M.), University "Aldo Moro", Policlinico of Bari, Italy
| | - Miguel Angel Checa
- Inter-Departmental Project Unit of "Minimal-Invasive Gynecological Surgery", Integrated Department of Medicine (D.I.M.), University "Aldo Moro", Policlinico of Bari, Italy
| | | | | | - Jacques Donnez
- Université Catholique de Louvain, Brussels, Belgium.,Société de Recherche pour l'Infertilité (SRI), Brussels, Belgium
| | | | - Jaime Ferro
- Instituto Valenciano Infertilidad (IVI) Valencia, Valencia, Spain
| | - Mario Franchini
- Demetra Infertility Center and Villa Cherubini Clinic, Firenze, Italy
| | - Simone Garzon
- Department of Obstetrics and Gynecology, "Filippo Del Ponte" Hospital, University of Insubria, Varese, Italy
| | | | | | | | - Stephan Gordts
- Inter-Departmental Project Unit of "Minimal-Invasive Gynecological Surgery", Integrated Department of Medicine (D.I.M.), University "Aldo Moro", Policlinico of Bari, Italy
| | - Grigoris Grimbizis
- Head 1st Department of Obstetrics and Gynecology, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Sergio Haimovich
- Department of Obstetrics and Gynecology, Hillel Yaffe Medical Center, The Rappaport Faculty of Medicine, Technion, Israel
| | - Antonio Simone Laganà
- Department of Obstetrics and Gynecology, "Filippo Del Ponte" Hospital, University of Insubria, Varese, Italy
| | - T C Li
- Department of Obstetrics & Gynaecology, Chinese University of Hong Kong
| | - Luca Mencaglia
- Unit of Phisiopatology of Reproduction USL South Est, Tuscany, Italy
| | - Laura Rienzi
- GENERA, Centre for Reproductive Medicine, Clinica Valle Giulia, Rome, Italy
| | | | | | - Vasilis Tanos
- Aretaeio Hospital and St Georges Medical School, Nicosia University, Nicosia, Cyprus
| | - Alicia Ubeda
- Department of Obstetrics and Gynecology, Institut Universitari Dexeus, Barcelona, Spain
| | - Filippo M Ubaldi
- GENERA, Centre for Reproductive Medicine, Clinica Valle Giulia, Rome, Italy
| | - Bruno Van Herendael
- Department of Obstetrics and Gynecology, "Filippo Del Ponte" Hospital, University of Insubria, Varese, Italy.,Stuivenberg General Hospital, Ziekenhuis Netwerk Antwerpen (ZNA), Antwerp, Belgium
| | | | - Amerigo Vitagliano
- Unit of Gynaecology and Obstetrics, Department of Women and Children's Health, University of Padua, Padua, Italy
| | - Salvatore Giovanni Vitale
- Obstetrics and Gynecology Unit, Department of General Surgery and Medical Surgical Specialties, University of Catania, Catania, Italy
| | - Fulvio Zullo
- Department of Neuroscience, Reproductive Science and Dentistry, School of Medicine, University of Naples Federico II, Naples, Italy
| |
Collapse
|
49
|
Donnez J, Dolmans MM. Fertility preservation in men and women: Where are we in 2021? Are we rising to the challenge? Fertil Steril 2021; 115:1089-1090. [PMID: 33823991 DOI: 10.1016/j.fertnstert.2021.03.028] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Accepted: 03/17/2021] [Indexed: 01/16/2023]
Abstract
Demand for fertility preservation in women for oncologic, nononcologic, and personal reasons has increased dramatically. Meeting that demand is a major challenge, and we are rising to the challenge. Mature oocyte cryopreservation after ovarian stimulation and ovarian tissue cryopreservation are both methods endorsed by the American Society for Reproductive Medicine (formerly The American Fertility Society), and numerous papers confirmed their efficacy. In girls and women with leukemia or cancers who are at a high risk of ovarian metastasis and who may not be eligible for ovarian tissue transplantation, restoration of fertility can only be achieved by in vitro methods. Male fertility preservation has also become a pressing issue and is extensively reviewed in the present journal issue.
Collapse
Affiliation(s)
- Jacques Donnez
- Society for Research into Infertility, Brussels, Belgium; Université Catholique de Louvain, Brussels, Belgium.
| | - Marie-Madeleine Dolmans
- Gynecology Research Unit, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Brussels, Belgium; Department of Gynecology, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| |
Collapse
|
50
|
Dolmans MM, Donnez J. Chemotherapy with alkylating agents: Is follicle activation the only mechanism responsible for the loss of primordial follicles? Fertil Steril 2021; 115:1166-1167. [PMID: 33795138 DOI: 10.1016/j.fertnstert.2021.03.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Revised: 03/10/2021] [Accepted: 03/10/2021] [Indexed: 11/19/2022]
Affiliation(s)
- Marie-Madeleine Dolmans
- Gynecology Research Unit, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Brussels, Belgium; Department of Gynecology, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Jacques Donnez
- Society for Research into Infertility, Brussels, Belgium; Université Catholique de Louvain, Belgium
| |
Collapse
|