Endometrial synthesis and secretion of complement component-3 by patients with and without endometriosis**Supported by grants HD-20025 and HD-06274 (C.R.L.) from the National Institutes of Health, Bethesda, Maryland; by the Lalor Foundation (C.C.), Kennet Square, Pennsylvania; and the Mellon Foundation, New York, New York. ††Presented as a poster presentation at the Second International Meeting on Endometriosis, Houston, Texas, May 1 to May 3, 1989

Insights into the role of complement system in the pathophysiology of endometriosis

Endometriosis (EM) is a gynecologic disorder characterized by the presence of endometrium-like tissue outside of normal location that affects up to 10 % of all women in reproductive age. The pathogenesis of endometriosis is not completely known. The relationship between complement and EM has already been demonstrated in some studies, indicating an important role in the pathophysiology of the disease, however, researches are scarce and sometimes controversial. The objective of this review is to bring state-of-the-art knowledge on the subject and promote better understanding of the complement system role in the pathophysiology of EM. We searched in databases up to December 2020 and found 1213 articles that were screened, from which were selected 54 articles from title and abstract. We found that there is a dysfunction of the immune system on endometriosis, including the complement system. Apparently, the complement system is dysregulated in endometriosis and several proteins of the three complement pathways presented serum levels altered in women with endometriosis compared with those without the disease. The most studied protein is C3. Future investigations on the innate immune response and complement system could offer a further understanding on the inflammatory pathogenesis of EM, which will support a new therapeutic plan.

Endometrial biomarkers for the non-invasive diagnosis of endometriosis

BACKGROUND

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

OBJECTIVES

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

SEARCH METHODS

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

Single-nucleotide polymorphisms in the lysyl oxidase-like protein 4 and complement component 3 genes are associated with increased risk for endometriosis and endometriosis-associated infertility

This study was conducted to assess genetic associations with endometriosis in a Puerto Rican population. Statistically significant differences in the allelic frequencies and genotype distribution of genetic variants in lysyl oxidase-like protein 4 (LOXL4) and complement component 3 (C3) were documented in patients with endometriosis-associated infertility versus controls, and in patients with endometriosis versus controls, respectively. In women who have the risk genotype at both single-nucleotide polymorphisms, the estimated risk for endometriosis nearly doubled.

The endometrial response to chorionic gonadotropin is blunted in a baboon model of endometriosis

Endometriosis-associated infertility has a multifactorial etiology. We tested the hypothesis that the endometrial response to the early embryonic signal, human chorionic gonadotropin (hCG), alters over time in a nonhuman primate model of endometriosis. Animals with experimental or spontaneous endometriosis were treated with hCG (30 IU/d), from d 6 after ovulation for 5 d, via an oviductal cannula. Microarray analysis of endometrial transcripts from baboons treated with hCG at 3 and 6 months of disease (n=6) identified 22 and 165 genes, respectively, whose levels differed more than 2-fold compared with disease-free (DF) animals treated with hCG (P<0.01). Quantitative RT-PCR confirmed abnormal responses of known hCG-regulated genes. APOA1, SFRP4, and PAPPA, which are normally down-regulated by hCG were up-regulated by hCG in animals with endometriosis. In contrast, the ability of hCG to induce SERPINA3 was lost. Immunohistochemistry demonstrated dysregulation of C3 and superoxide dismutase 2 proteins. We demonstrate that this abnormal response to hCG persists for up to 15 months after disease induction and that the nature of the abnormal response changes as the disease progresses. Immunohistochemistry showed that this aberrant gene expression was not a consequence of altered LH/choriogonadotropin receptor distribution in the endometrium of animals with endometriosis. We have shown that endometriosis induces complex changes in the response of eutopic endometrium to hCG, which may prevent the acquisition of the full endometrial molecular repertoire necessary for decidualization and tolerance of the fetal allograft. This may in part explain endometriosis-associated implantation failure.

Plasma C3a-des-Arg levels in women with and without endometriosis

PROBLEM

The lack of a reliable method for early non-invasive detection of endometriosis often results in delayed diagnosis. The aim of this study was to test the hypothesis that the plasma concentration of complement factor C3a (anaphylatoxin) can be used as a non-invasive test in the diagnosis of endometriosis.

METHOD OF STUDY

The C3a concentration was analyzed using ELISA in 160 patients with (n = 109) or without (n = 51) endometriosis during menstruation (n = 49), follicular phase (n = 55), and luteal (n = 56) phase.

RESULTS

Plasma C3a concentration was comparable between patients with [102 (27-2213) ng/mL] and without [105 (32-2340) ng/mL] (P = 0.84) endometriosis, also when assessed separately during menstruation, follicular phase, and luteal phase.

CONCLUSION

We found no difference in C3a levels between women with and without endometriosis and did not confirm our hypothesis that plasma C3a levels can be used as diagnostic test for endometriosis.

Activation of estrogen receptor-beta by a special extract of Rheum rhaponticum (ERr 731), its aglycones and structurally related compounds

The special extract ERr 731 from the roots of Rheum rhaponticum is the major constituent of Phytoestrol N which is used for the treatment of climacteric symptoms in menopausal women. However, the molecular mode of action of ERr 731 was unknown. For the first time, ERr 731 and its aglycones trans-rhapontigenin and desoxyrhapontigenin were investigated with regard to the activation of the estrogen receptor-alpha or estrogen receptor-beta (ERalpha, ERbeta). The related hydroxystilbenes cis-rhapontigenin, resveratrol and piceatannol were studied as comparators. As controls, 17beta-estradiol or the selective ERalpha-(propylpyrazoltriol) or ERbeta-agonists (diarylpropionitril) were used. Neither in ERalpha-expressing yeast cells, in the ERalpha-responsive Ishikawa cells, nor in human endometrial HEC-1B cells transiently transfected with the ERalpha an activation of ERalpha by ERr 731 or the other single compounds was detected. Furthermore, an antiestrogenic effect was not observed. In contrast in human endometrial HEC-1B cells transiently transfected with the ERbeta, 100 ng/ml ERr 731 and the single compounds significantly induced the ERbeta-coupled luciferase activity in a range comparable to 10(-8)M 17beta-estradiol. All effects were abolished with the pure ER antagonist ICI 182780, indicating an ER-specific effect. The ERbeta agonistic activity by ERr 731 could be of importance for its clinical use, as central functions relevant to climacteric complaints are proposed to be mediated via ERbeta activation.

Levels of complement components iC3b, C3c, C4, and SC5b-9 in peritoneal fluid and serum of infertile women with endometriosis

OBJECTIVE

To assess whether complement components iC3b, C3c, C4, and SC5b-9 may be involved in the pathogenesis of endometriosis.

DESIGN

Prospective, experimental trial.

SETTING

Medical university.

PATIENT(S)

112 women infertile women undergoing laparoscopy.

INTERVENTION(S)

Venipuncture and laparoscopic peritoneal fluid collection.

MAIN OUTCOME MEASURE(S)

Peritoneal fluid and serum iC3b, C3c, C4, and SC5b-9 levels were measured by the enzyme-linked immunosorbent assay (ELISA) method.

RESULT(S)

Higher levels of C3c, C4, and SC5b-9 complement components were found in the serum compared with the peritoneal fluid, but the levels of iC3b were higher in the peritoneal fluid. We observed higher concentrations of C3c, C4, and SC5b-9 in the peritoneal fluid and serum of women with endometriosis compared with healthy women. However, the levels of iC3b in both peritoneal fluid and serum were statistically significantly lower than in the control group.

CONCLUSION(S)

The impairment of the mechanisms involved in the regulation of activation of complement system may be an important factor in the pathogenesis of endometriosis and endometriosis-associated infertility.

Immunology and Endometriosis

PROBLEM

Accumulating data suggests that aberrant immune responses during retrograde menstruation may be involved in the development of endometriosis.

METHOD OF STUDY

The role of immunology in the etiology of endometriosis is reviewed and summarized from the available literature.

RESULTS

Immunologic factors may affect a woman's susceptibility to implantation of exfoliated endometrial cells. Immune alterations include increased number and activation of peritoneal macrophages, decreased T cell reactivity and natural killer cell cytotoxicity, increased circulating antibodies, and changes in the cytokine network.

CONCLUSION

There is substantial evidence that immunologic factors play a role in the pathogenesis of endometriosis and endometriosis-associated infertility. Decreased natural killer cell cytotoxicity leads to an increased likelihood of implantation of endometriotic tissue. In addition, macrophages and a complex network of locally produced cytokines modulate the growth and inflammatory behavior of ectopic endometrial implants.

Implantation defects in infertile women with endometriosis

The endometrium undergoes characteristic histologic changes during the menstrual cycle as it prepares for embryo implantation. Historic and current data suggest the presence of a defined period of maximal uterine receptivity during the mid-secretory phase occurring between days 7 and 10 postovulation. In recent years, we and others have sought to define biochemical markers of receptivity that might be used to better understand this time of endometrial differentiation. Based on the work with cell adhesion molecules, we have discovered three different integrins that are only coexpressed during this time in the cycle when embryos will successfully implant. By studying the regulation of one of these, the alpha(v)beta3 integrin, and its extracellular matrix ligand, osteopontin (OPN), we have defined two separate regulatory pathways that may regulate endometrial receptivity. While alpha(v)beta3 expression appears to be stimulated by EGF or heparin-binding EGF, osteopontin is stimulated by progesterone. We now believe the former pathway is a paracrine-mediated signal, while the latter is a direct effect of progesterone on the estrogen-primed endometrial epithelium. In women with endometriosis, it appears that alpha(v)beta3 expression is reduced, while OPN expression is unaffected. Interestingly, binding of OPN to the surface epithelium appears quite limited when alpha(v)beta3 expression is lacking. Such evidence continues to reinforce the notion that endometrium from some women with endometriosis is dysfunctional and may account for the reduction in cycle fecundity noted in this group of patients.

Endometrial anomalies in women with endometriosis

Endometriotic lesions are defined by extrauterine growth of endometrial glands and stroma. Retrograde menstruation with subsequent attachment, invasion, and neovascularization are believed to give rise to the endometriotic lesions. As most women exhibit some degree of retrograde menstruation, some other unidentified factor(s) must render certain women susceptible to attachment and growth of ectopic endometrial tissue. A variety of theories have been proposed to account for this susceptibility, including genetic predisposition, aberrant immunological response, and an altered peritoneal environment. Ectopic endometriotic lesions are histologically similar to their putative eutopic precursors, yet significant biochemical differences exist between these two tissues. Less information is available regarding differences between eutopic endometrium from women with or without endometriosis. This report describes anomalies in structure, proliferation, immune components, adhesion molecules, proteolytic enzymes and inhibitors, steroid and cytokine production and responsiveness, and gene expression and protein production that have been identified in eutopic endometrium from women with endometriosis.

Theories of endometriosis

Endometriosis is characterised by the presence of abnormally located tissue resembling the endometrium with glands and stroma. Several hypotheses have attempted to explain the development of such tissue. The oldest theory, that of metaplasia, suggests that under diverse influences coelomic tissue could be transformed into endometrium. The most often cited theory, that of implantation, proposes that the physiological phenomenon of endometrial reflux in the fallopian tubes during menstruation may, in certain conditions, overcome local defense mechanisms, implant, and proliferate. The peritoneal fluid in unaffected women possesses the capacity to prevent endometriotic tissue from becoming established. The reasons for the occurrence of endometriosis and its consequences (pain, sterility, adhesions) are probably numerous and involve the endometrium, the immune system (macrophages, natural killer cells), the peritoneum, and fallopian tubes. The failure to clear the peritoneal cavity of fragments of endometrium could cause a state of local inflammation with hyperactivation of macrophages secreting a variety of different compounds. Some of these compounds may bring about metaplasia of the peritoneum or the development of Mullerian residues.

Decreased expression of the decoy interleukin-1 receptor type II in human endometriosis

Many of the biological changes occurring in the endometrium during the menstrual cycle bear a striking resemblance to those associated with inflammatory and reparative processes. Hence, it would not be surprising to find that cytokines known for their pro-inflammatory properties, such as interleukin-1 (IL-1), could play a key role in the physiology of this tissue and that their action would be tightly controlled by local mechanisms. In the present study, immunohistochemical and Western blot analyses show that in normal women (n = 39), the endometrial tissue expresses, in a cycle-dependent manner, the IL-1 receptor type II (IL-1RII), a molecule of which the only biological property known to date is that of capturing IL-1, inhibiting thereby its binding to the functional type I IL-1 receptor. IL-RII immunostaining was particularly intense within the lumen of the glands and at the apical side of surface epithelium. Interestingly, the intensity of staining was markedly less pronounced in the endometrium of women with endometriosis (n = 54), a disease believed to arise from the abnormal development of endometrial tissue outside the uterus, especially in the early stages of the disease (stages I and II). This study is the first to show the local expression in endometrial tissue of IL-1RII, a potent and specific down-regulator of IL-1 action and its decreased expression in women suffering from endometriosis.

Precursor lesions of ovarian epithelial malignancy

Most ovarian carcinomas arise from the mesothelial surface lining of the ovaries, or from invaginations of this lining into the superficial ovarian cortex to form cortical inclusion cysts. The native ovarian surface mesothelium is of an 'uncommitted' phenotype, and has potential to modulate to epithelial or mesenchymal phenotypes in response to signals such as those associated with ovulation. The exposure of the mesothelial lining of an inclusion cyst to the ovarian stromal microenvironment may be responsible for the phenotypic change to Müllerian epithelium so commonly seen in these cysts. Müllerian metaplasia is usually to a serous phenotype, and it is possible that undefined molecular events occurring in an inclusion cyst that has undergone Müllerian metaplasia may initiate neoplastic change in these cysts. This may be the developmental pathway of most invasive serous carcinomas. Occasional rare cases of ovarian intraepithelial neoplasia, manifested by epithelial atypia in an inclusion cyst or on the surface epithelium without invasive carcinoma, are identified histologically. Serous borderline tumours represent a separate category and in most cases probably do not progress to frank carcinoma. Mucinous carcinomas may in some cases have arisen from pre-existing benign and borderline mucinous tumours. Endometriosis of the ovary is associated with genetic abnormalities and is frequently found in association with clear cell and endometrioid carcinomas, suggesting that in many cases these latter two types of carcinoma may have arisen directly from endometriotic deposits. Ovaries removed prophylactically from women with a family history of ovarian carcinoma or with a mutation in one of the genes predisposing to ovarian carcinoma should be processed in their entirety, and examined closely not just for obviously neoplastic lesions, but also for more subtle morphological abnormalities of the surface epithelium or the epithelium lining cortical inclusion cysts.

Is endometriosis an endometrial disease?

Endometriosis is characterised by the presence of abnormally located tissue resembling the endometrium with glands and stroma. Several hypotheses have attempted to explain the development of such tissue. The most often cited theory, that of implantation, proposes that the physiological phenomenon of endometrial reflux in the fallopian tubes during menstruation may, in certain conditions, overcome local defense mechanisms, implant, and proliferate. The implantation theory does not explain why endometriosis will develop only in approximately 10-15% of women, while the reflux of endometrial tissue via the fallopian tubes during menstruation is a quasi-universal phenomenon. The endometrium of women affected by endometriosis could be abnormal compared with endometrium of healthy women. The abnormal endometrium could be able to protect itself from harmful effects of immune cells by expressing specific antigens, by harbouring a different immune cell population and by synthetizing and secreting immunosuppressive factors. Several others characteristic features of endometrium have been described in women with endometriosis: (1) production of its own estrogens in too heavy amount; (2) aptitude for setting up on peritoneum; (3) tendencies to proliferate and to invade tissue; (4) aggressiveness for the peritoneum; (5) auto-protection from physiological apoptosis; (6) abnormal expression of heat shock proteins; and (7) excessive angiogenesis.

Induction of an angiogenic phenotype in endometriotic stromal cell cultures by interleukin-1beta

Activated peritoneal macrophages are associated with endometriosis and may play a central role in its aetiology by releasing interleukin-1beta (IL-1beta) in response to refluxed endometrium. Pari passu with the establishment of endometriotic implants is the development of a vascular supply. In this study we investigated the angiogenic properties of two endometrial proteins, vascular endothelial growth factor (VEGF) and interleukin-6 (IL-6), and assessed their production in response to IL-1beta stimulation in human stromal cells isolated from normal endometrium (NE) and endometriotic lesions (EI). Proliferation of bovine brain capillary endothelial cells (BBCE) with a [(3)H]-thymidine incorporation assay was observed when VEGF (2.1 +/- 0.2-fold; P < 0.05) or VEGF and IL-6 (1.8 +/- 0.1-fold; P < 0.05) were added in vitro, relative to saline-treated control cultures. Northern blot analysis showed induction of VEGF mRNA (2.6-fold; P < 0.05) and IL-6 mRNA (6.3-fold; P < 0.05) transcripts in EI cells, but not NE cells, exposed to IL-1beta. A similar induction was seen with VEGF and IL-6 protein secretion in the responsive EI cells. Reverse transcription-polymerase chain reaction (RT-PCR) for the IL-1 receptor type I (IL-1 RI) indicated that the differential effects of IL-1beta on NE and EI cells was associated with 2.4 +/- 0.1-fold more receptor mRNA in EI versus NE cells. We propose that the ability of IL-1beta to activate an angiogenic phenotype in EI stromal cells but not in NE cells, is mediated by the IL-1 RI.

The SCID mouse: an experimental model for endometriosis

The purpose of this study was to validate the suitability of the severe combined immunodeficient (SCID) mouse as an experimental model for endometriosis, by defining the morphological and histological features of induced endometrial implants, and characterizing specific biochemical properties of these implants. Human secretory endometrial tissues were injected into the peritoneal cavity of SCID/SCID CB17 mature female mice. Successful peritoneal implantation was observed in 55 of 57 (96.5%) SCID mice and consisted of circumscribed elevated nodules. Haematoxylin-eosin staining of implanting lesions demonstrated the presence of endometrial glandular tissue in a mixed background of stromal and inflammatory cells. When progesterone was administered to mice, epithelial glands underwent well-defined secretory changes. Immunohistochemical analysis using polyclonal human pan-cytokeratin antibodies demonstrated selective positive staining in the glandular epithelium of the human implants with none in the surrounding stroma. In-situ hybridization analysis using complement component 3 cDNA radiolabelled riboprobes yielded significantly more intense signals in glands compared to stroma. As human endometrial implants in SCID mice were shown to retain specific histological, functional and biochemical properties, we conclude that the SCID mouse is an attractive animal model for the study of endometriosis.

Increased expression of complement component 3 in human ectopic endometrium compared with the matched eutopic endometrium

OBJECTIVE

To compare the gene expression of complement component 3 (C3) in human eutopic and ectopic endometrium.

DESIGN

A prospective, controlled study.

SETTING

Academic hospital.

PATIENT(S)

Women with documented endometriosis.

INTERVENTION(S)

Eutopic and ectopic endometrial tissues were collected simultaneously at laparoscopy.

MAIN OUTCOME MEASURE(S)

Detection of C3 messenger RNA (mRNA) by in situ hybridization and C3 protein by immunohistochemistry and Western blot.

RESULT(S)

Expression of C3 mRNA increased in ectopic endometrium compared with that in the matched eutopic endometrium. The quantitative analysis of C3 mRNA by grain count (mean +/- SE) showed 175.60 +/- 40.02 and 39.97 +/- 8.17 grains per micron2 in ectopic and eutopic glands, respectively, and 67.65 +/- 29.82 and 15.02 +/- 5.80 grains per micron2 in ectopic and eutopic stroma, respectively. Expression of C3 mRNA in ectopic glands was significantly higher than that in eutopic glands. The pattern of immunoreactive staining of C3 protein was consistent with that of C3 mRNA. A higher level of C3 protein in ectopic endometrium than eutopic endometrium was detected by immunohistochemistry and Western blot.

CONCLUSION(S)

Expression of C3 mRNA and protein significantly increased in human ectopic endometrium compared with that in the matched eutopic endometrium.

Increased secretion of hepatocyte growth factor by eutopic endometrial stromal cells in women with endometriosis

OBJECTIVE

We evaluated the secretion of hepatocyte growth factor by eutopic endometrial stromal cells in vitro.

DESIGN

Eutopic endometrial stromal cells were isolated and the culture supernatants were collected after 48 hours of incubation. The secretion of hepatocyte growth factor was analyzed by ELISA.

SETTING

Department of Obstetrics and Gynecology of Tohoku University Hospital.

PATIENT(S)

Specimens of endometrium in the proliferative phase were excised from 11 patients who were undergoing laparoscopy for infertility. Six of the patients had endometriosis and five did not. None of the patients had received hormonal treatment before surgery.

RESULT(S)

Hepatocyte growth factor secretion was found to be increased significantly in cultured endometrial stromal cells from the infertile patients with endometriosis compared with those without endometriosis.

CONCLUSION(S)

The secretion of hepatocyte growth factor was up-regulated in eutopic endometrial stromal cells from patients with endometriosis. An increase in hepatocyte growth factor production may be characteristic of endometriosis and may be involved in the pathophysiology of this disease.

Immunology and endometriosis. Fact, artifact, or epiphenomenon?

Endometriosis is a complex and intriguing disease. If retrograde menstruation normally occurs, then why do all women not develop endometriosis? The exact prevalence of endometriosis is unknown; however, a 20% to 90% prevalency rate has been reported in women with pelvic pain and infertility. This article reviews the factors involved.

Human autoantibodies recognizing human and mouse preimplantation stages

PROBLEM

To find out whether autoantibodies against human preimplantation stages are present in some human sera and, if so, whether the antibodies could be capable to affect the egg development and/or to trigger an activation of the complement system at the procedures of assisted conception.

METHODS

1. Immunohistochemistry on blots of human preimplantation stages. 2. Immunohistochemistry on paraffin sections of human and mouse preimplantation stages. 3. Culture of mouse morulae to analyze complement activation.

RESULTS

1. Some human sera contained autoantibodies against human preimplantation stages. 2. Human-mouse cross-reacting antibodies against preimplantation stages occurred. 3. Immune complexes, formed on mouse preimplantation stages, activated the complement systems in egg cultures, resulting in a damaging of the eggs.

CONCLUSION

The presence of natural autoantibodies to preimplantation stages may be associated with reproduction failure, caused by a direct effect by the autoantibodies and/or an activation of the uterine complement system by the immune complexes formed.

Cell proliferation is increased in the endometrium of women with endometriosis

OBJECTIVE

To compare the proliferation of endothelial, epithelial, and stromal cells in the endometrium of women with endometriosis and normal controls.

DESIGN

Proliferating cells were identified using the monoclonal antibody antiproliferating cell nuclear antigen. A second antibody (CD34) was used to identify endothelial cells (ECs).

SETTING

University Department of Obstetrics and Gynaecology.

PATIENTS

Women with laparoscopically proven endometriosis, n = 30. Controls were women with a normal pelvis at laparoscopy performed for tubal sterilization or for infertility due to a male factor, n = 27.

MAIN OUTCOME MEASURES

Endothelial cells: proliferative index. Epithelial and stromal cells: semi-quantitative immunostaining score.

RESULTS

The mean EC proliferative index was significantly greater in those with endometriosis compared with controls. This difference was most marked during the proliferative phase of the menstrual cycle. Proliferative phase epithelial and stromal cells demonstrated significantly higher immunostaining scores in endometriosis patients than in controls.

CONCLUSIONS

We have demonstrated increased numbers of proliferating ECs as well as epithelial and stromal cells in proliferative phase endometrium of women with endometriosis. This suggests that the endometrium of these women might have an enhanced ability to implant and survive in ectopic locations.

Hormonal regulation of complement components and receptors throughout the menstrual cycle

OBJECTIVES

Complement components have been recently demonstrated to be present in the reproductive tract. Among these components, C3 synthesis by glandular epithelium of the rat uterus has been shown to be regulated by estrogen; progesterone inhibits this synthesis. However, the hormonal regulation of C3 and the presence of other complement factors in the human has not been investigated to date. In this study we examined the presence and the hormonal regulation of different complement components and receptors in the human endometrium at various phases of the menstrual cycle of normally cycling women with no pelvic pathologic abnormalities.

STUDY DESIGN

Endometrial tissue was obtained from normally cycling women, and immunohistochemistry was performed by means of monoclonal antibodies against C3, factors B, decay-accelerating factor, membrane cofactor protein, and complement receptor types 1, 2, and 3. The tissue was incubated with minimal essential media without methionine containing methionine labeled with sulfur 35. Immunoprecipitations were performed on the media with goat antihuman C3 antibody, and the proteins were analyzed by sodium dodecyl sulfate polyacrylamide gel electrophoresis.

RESULTS

C3 was found to be present in the glandular epithelial cells of luteal endometrium. Biosynthesis as analyzed by immunoprecipitation with anti-C3 antibody was found to increase during the luteal phase of the cycle and to be minimal in the proliferative phase. Like C3, factor B and decay-accelerating factor were localized to the luteal glandular epithelial cells. In contrast, membrane cofactor protein was found to be present in the glandular epithelium throughout the menstrual cycle, and complement receptor type 1 was present only in the stromal compartment of luteal endometrium. Complement receptor type 3 was present only in the infiltrating leukocytes in the luteal endometrium, whereas complement receptor type 2 was undetectable.

CONCLUSIONS

These findings suggest that several components of the complement system exist in the human endometrium in a hormone-dependent manner and may play a role in normal reproductive function.

Hereditary deficiency of C3 in animals and humans

Inherited deficiency of complement C3 has been described in guinea pigs, dogs and 20 humans. Homozygous deficiency of C3 is associated with recurrent pyogenic infections by encapsulated bacteria, especially H. influenzae, S. pneumoniae and N. meningitidis. In dogs and humans there is also an association with development of glomerulonephritis of the mesangiocapillary type. Some patients also develop transient erythematous rashes in association with pyogenic infections, with histology showing predominantly neutrophil infiltration and small vessel vasculitis. Studies of antibody responses, mainly in experimental animals have shown impaired primary and secondary responses to both thymus-dependent and -independent antigens at low immunizing doses, with a reduced switch from IgM to IgG production. The molecular basis of C3 deficiency has been established in two humans with C3 deficiency. In one it was due to a splice junction mutation and in another, to a partial gene deletion. These mutations are not compatible with the production of functional C3 in any tissue. Such patients with absolute C3 deficiency are a valid model for understanding the physiological role of C3 in vivo.