Concentrations of placental protein 14 in uterine flushings from infertile women: validation of the collection technique and method of expression of results

The role of CFTR channel in female infertility

The cystic fibrosis transmembrane conductance regulator (CFTR) is a cAMP-activated trans-membrane ATP gated anion channel present in most epithelia, which transports chloride and bicarbonate ions across the apical membrane. Mutations in the CFTR protein are known to result in defective expression or function, notably the inhibition of chloride and bicarbonate transport. This can result in cystic fibrosis (CF), a disorder characterised by thickness of the mucus lining of the epithelial cells of the alimentary and respiratory tracts, sweat ducts and reproductive organs. As a consequence, there is a reduction in fluid transport at the apical surface. While the most devastating effect of CF is mortality, about 98% of men with CF are infertile, consequent of early blockage of or failure to develop the mesonephrotic ducts as well as the vas deferens. The effect of CF of female fertility is less well-understood. This review highlights the genetics and pathophysiology as well as the mechanism of action of CF on female infertility.

Combinatorial effects of quercetin and sex-steroids on fluid and electrolytes' (Na+, Cl-, HCO3-) secretory mechanisms in the uterus of ovariectomised female Sprague-Dawley rats

Dysregulation of uterine fluid environment could impair successful reproduction and this could be due to the effect of environmental estrogens. Therefore, in this study, effect of quercetin, an environmental estrogen on uterine fluid and electrolytes concentrations were investigated under sex-steroid influence. Ovariectomised adult female Sprague-Dawley rats were given 10, 50 or 100mg/kg/day quercetin subcutaneously with 17-β estradiol (E) for seven days or three days E, then three days E plus progesterone (P) (E+P) treatment. Uterine fluid secretion rate, Na⁺, Cl^- and HCO₃^- concentrations were determined by in-vivo perfusion. Following sacrifice, uteri were harvested and levels of the proteins of interest were identified by Western blotting and Realtime PCR. Distribution of these proteins in the uterus was observed by immunofluorescence. Levels of uterine cAMP were measured by enzyme-linked immunoassay (EIA). Administration of quercetin at increasing doses increased uterine fluid secretion rate, Na⁺, Cl^- and HCO₃^- concentrations, but to the levels lesser than that of E. In concordant, levels of CFTR, SLC4A4, ENaC (α, β and γ), Na⁺/K⁺-ATPase, GPα/β, AC and cAMP in the uterus increased following increased in the doses of quercetin. Co-administration of quercetin with E caused uterine fluid secretion rate, Na⁺, Cl^- and HCO₃^- concentrations to decrease. In concordant, uterine CFTR, SLC26A6, SLC4A4, ENaC (α, β and γ), Na⁺/K⁺-ATPase, GPα/β, AC and cAMP decreased. Greatest effects were observed following co-administration of 10mg/kg/day quercetin with E. Co-administration of quercetin with E+P caused uterine fluid Na⁺ and HCO₃^- concentrations to increase but no changes in fluid secretion rate and Cl^- concentration were observed. Co-administration of high dose quercetin (100 mg/kg/day) with E+P caused uterine CFTR, SLC26A6, AC, GPα/β and ENaC (α, β and γ) to increase. Quercetin-induced changes in the uterine fluid secretion rate and electrolytes concentrations could potentially affect the uterine reproductive functions under female sex-steroid influence.

Testosterone decreases fluid and chloride secretions in the uterus of adult female rats via down-regulating cystic fibrosis transmembrane regulator (CFTR) expression and functional activity

OBJECTIVES

Estrogen is known to stimulate uterine fluid and Cl(-) secretion via CFTR. This study investigated testosterone effect on these changes in a rat model.

METHODS

Ovariectomized adult female rats received estrogen for five days or estrogen for three days followed by two days peanut oil or testosterone either alone or in the presence of flutamide or finasteride. At the end of treatment, uteri were perfused with perfusate containing CFTRinh-172. The rate of fluid and Cl(-) secretion were determined. Dose-dependent effect of testosterone and effect of forskolin on fluid secretion rate were measured. Animals were sacrificed and uteri were removed for CFTR protein and mRNA expression analyses, histology and cAMP measurement. Morphology of uterus, levels of expression of CFTR protein and mRNA and distribution of CFTR protein were observed.

RESULTS

Estrogen causes increase while testosterone causes decrease in uterine fluid and Cl(-) secretions. The effects of estrogen but not testosterone were antagonized by CFTRinh-172. Luminal fluid volume and apical expression of CFTR in the luminal epithelia were highest under estrogen and lowest under testosterone influences. Similar changes were observed in CFTR protein and mRNA expressions. Uterine cAMP level was highest under estrogen and lowest under testosterone influence. Forskolin increases fluid secretion rate in estrogen but not in testosterone-treated animals. Testosterone effects were dose-dependent and were antagonized by flutamide however, not finasteride.

CONCLUSIONS

Testosterone inhibition of estrogen-induced uterine fluid and Cl(-) secretion occurs via inhibition of CFTR expression and functional activities. These changes could explain the adverse effects of testosterone on fertility.

Glycodelin in endometrial flushing fluid and endometrial biopsies from infertile and fertile women

OBJECTIVE

To investigate in the natural cycle just before IVF, whether glycodelin levels in endometrial flushing fluid obtained days LH+1 and LH+7 can be used in predicting pregnancy in the following IVF cycle, and whether there are differences in women with tubal factor infertility compared to women with unexplained infertility and fertile controls.

STUDY DESIGN

A prospective observational multicentre study of 21 fertile and 75 infertile women (25 showed abnormal tubes with no signs of hydrosalpinges, 18 had uni- or bi-lateral hydrosalpinges, 17 were salpingectomised because of hydrosalpinges, and 15 women had unexplained infertility). Endometrial flushing at days LH+1 and LH+7, endometrial biopsy, and blood sampling at day LH+7 were performed before down-regulation for IVF. Glycodelin levels in endometrial flushing fluids (EFF), biopsies, and plasma samples were related to tubal pathology, endometrial dating and IVF outcome. Furthermore, total protein concentration was measured in EFF to investigate the influence of normal endometrial maturation on protein concentrations from days LH+1 and LH+7.

RESULTS

At day LH+1, EFF glycodelin levels were higher in infertile women with abnormal tubes compared to fertile women, particularly in women conceiving after the following IVF. For women with unexplained infertility, a higher level at day LH+1 was present only in women not conceiving after the following IVF. ROC curve analysis showed that at day LH+1 EFF glycodelin levels had no predictive value for IVF outcome. At day LH+7, glycodelin levels in endometrial flushing fluids and biopsies depended on endometrial dating.

CONCLUSIONS

At day LH+1, glycodelin concentration is increased in endometrial flushing fluid from infertile women with abnormal tubes compared to fertile controls without being a valuable predictor of subsequent pregnancy. At day LH+7 the glycodelin level depends on endometrial dating.

A comparative study of glycodelin concentrations in uterine flushings in women with subseptate uteri, history of unexplained recurrent miscarriage and healthy controls

OBJECTIVE

To compare the concentration of glycodelin in uterine flushing at the implantation window obtained from women with subseptate uteri, women with a history of recurrent first trimester miscarriage and fertile controls.

STUDY DESIGN

Glycodelin concentration was assessed using Enzyme Linked Immunohistochemistry (ELISA) at The Early Pregnancy & Gynaecology Assessment Unit, King's College Hospital, London, England. Eight women with a subseptate uterus, 20 women with a history of unexplained recurrent first trimester miscarriage and 16 fertile controls had uterine cavity flushing, for glycodelin concentration, done 7 days after the luteinising hormone surge.

RESULTS

Glycodelin concentrations in uterine flushing obtained from women with subseptate uteri (n=8) (median 32.9 ng/ml, range 17.1-52.4 ng/ml) and recurrent miscarriage (n=20) (median 26.8 ng/ml, range 9.7-78.5 ng/ml) were significantly lower than in the control group (n=16) (median 67.7 ng/ml, range 59.0-77.6 ng/ml) (chi(2)=19.565, p<0.001).

CONCLUSION

Peri-implantation levels of glycodelin are lower in women at high risk of early pregnancy failure.

Specific isoforms of leucine-rich alpha2-glycoprotein detected in the proliferative endometrium of women undergoing assisted reproduction are associated with spontaneous pregnancy

OBJECTIVE

To examine differences in specific protein expression from the surface of the human endometrium with respect to eventual pregnancy in infertile women.

DESIGN

Laboratory study.

SETTING

University hospital.

PATIENT(S)

Thirty-one women presenting for investigation into infertility at an assisted reproductive unit.

INTERVENTION(S)

Endometrial flushings were collected during the proliferative phase of the menstrual cycle and subjected to electrophoretic separation on the basis of isoelectric point and molecular weight. Computerized analysis of the resulting spots was performed, and the proteins were identified using tandem mass spectrometry.

MAIN OUTCOME MEASURE(S)

The expression of individual isoforms of leucine-rich alpha2-glycoprotein (LRG) was compared in nonpregnant patients (n = 25), those who became pregnant as a result of treatment (n = 3), and those who had treatment-independent pregnancies (n = 3).

RESULT(S)

A statistically significant difference was found in expression of two LRG isoforms, which were higher in the women who subsequently became pregnant independent of treatment.

CONCLUSION(S)

Several indirect lines of evidence suggest a role for LRG in implantation/decidualization. [1] LRG is implicated in transforming growth factor beta signal transduction. [2] Similar sequences have been identified in murine uterine tissues. [3] LRG may be involved in the infiltration of decidua by uterine natural killer cells, given that the murine homolog of LRG supports lymphocyte infiltration into secondary lymphoid tissues. [4] Human uterine natural killer cells differentiate into granular forms during early pregnancy, and LRG is known to support neutrophil granulocytic differentiation in humans.

The hormonal control of uterine luminal fluid secretion and absorption

The secretion of uterine luminal fluid initially provides a transport and support medium for spermatozoa and unimplanted embryos, while the absorption of uterine luminal fluid in early pregnancy results in the closure of the lumen and allows blastocysts to establish intimate contact with the uterine epithelium. We have established an in vivo perfusion technique of the lumen to study the hormonal control of the events in the peri-implantation period. Fluorescein-labelled dextran was included in the perfusion medium to monitor fluid movements and the concentrations of Na(+) and CI(-) ions in the effluent were monitored. Using an established regimen of steroid treatment of ovariectomized rats mimicking early pregnancy, oestradiol caused fluid secretion, while progesterone resulted in an amiloride-sensitive fluid absorption. Fluid absorption peaked at about the expected time of implantation. The effect of progesterone could be inhibited by treatment with a high dose of oestradiol, by the anti-progestin RU486, and by the presence of an intra-uterine contraceptive device. Studies of expression of Na(+) and CI(-) channels (ENaC, CFTR) indicated that these channels were subject to tissue-specific regulation within the uterus, but more work is required to determine their role and the factors controlling their abundance and localization in early pregnancy.

Human embryo implantation: current knowledge and clinical implications in assisted reproductive technology

A pregnancy rate of approximately 15% per cycle renders the process of human reproduction inefficient. The cycle-dependent expression of molecules involved in the embryo-endometrial dialogue has lead to the identification of a 'window of implantation'. This is the unique temporal and spatial expression of factors that allows the embryo to implant (via signalling, appositioning, attachment and invasion) in a specific time frame of 48 h, 7-10 days after ovulation. Integrin molecules, L-selectin ligands, mucin-1, heparin-binding epidermal growth factor and pinopodes are involved in appositioning and attachment. The embryo produces cytokines and growth factors [interleukins, prostaglandins, vascular endothelial growth factor (VEGF)] and receptors for endometrial signals (leukaemia inhibitory factor receptor, colony stimulating factor receptor, insulin-like growth factors and heparin binding epidermal growth factor receptor). The immune system plays an important role. Immunomodulatory factors such as glycodelin, inhibin and interleukin prevent a graft-versus-host reaction. Angiogenesis controlled by VEGF and prostaglandins is needed for formation of a receptive endometrium and a placenta. Identification of these factors has led to their use as markers of implantation that may identify defects causing subfertility. An ideal marker of implantation is sensitive and specific, and easy to obtain without disturbing implantation. Glycodelin and leukaemia inhibitory factor (serum) and integrins and pinopodes (biopsies) are promising candidates.

Placental protein 14 concentrations in circulation related to hormonal parameters and reproductive outcome in women undergoing IVF/ICSI

Serum concentrations of placental protein 14 (PP14), steroids and gonadotrophins were related to the outcome of IVF/intracytoplasmic sperm injection in 195 normogonadotrophic women subjected to the long protocol gonadotrophin-releasing hormone agonist (GnRHa; buserelin) pituitary down-regulation protocol and gonadotrophin stimulation (HMG or rFSH). Pituitary down-regulation was initiated on cycle day 21 and the patients were randomized to either intranasal or s.c. administration of buserelin. After 14 days of down-regulation, the patients were randomized on stimulation day 1 (S1) to ovarian stimulation with 225 IU per day of either human menopausal gonadotrophin (HMG) or recombinant FSH (rFSH) for a fixed period of 7 days. The daily gonadotrophin dose was adjusted on the following day according to ovarian response. Patient's blood was sampled for PP14 and hormone analysis on cycle days 21, S1, S8 and on the day of oocyte retrieval. Mean concentrations of PP14 on day 21 of the cycle were significantly lower in conception than in non-conception cycles, whereas progesterone and oestradiol were similar in conception and non-conception cycles. PP14 concentrations on the first day of stimulation and at oocyte retrieval were significantly higher in conception than in non-conception cycles, whereas concentrations after 8 days of stimulation were similar. Neither mode of GnRHa administration nor type of gonadotrophin significantly influenced PP14 concentrations throughout ovarian stimulation. Circulating PP14 is thus an important physiological signal of the fertility status of the individual in the cycle antecedent to and during ovarian stimulation. Measuring mid-luteal serum PP14 may offer a clinical test helping to decide if infertility treatment should be initiated in the subsequent cycle.

Characterization of copper in uterine fluids of patients who use the copper T-380A intrauterine device

BACKGROUND

The copper intrauterine device (IUD) is a highly effective method of contraception that requires the dissolution of the copper into uterine cavity. However, there is little information about the amount and form of copper in the fluid and whether the presence of this element produces any change in the protein concentration.

METHODS

Twenty-seven women were divided into three groups that had used IUD for about 6 months, 1 year and > or =3 years. The samples were collected during the proliferative phase (Pp), secretory phase (Sp) and menstruation (M). Square-wave anodic stripping voltammetry (SWASV), cyclic voltammetry (CV), high performance liquid chromatography (HPLC) and atomic absorption spectrometry (AAS) were used in this study.

RESULTS

Total copper concentrations were between 3.9 and 19.1 micro g/ml. The mean and standard deviations were as follows: 6 months, 11.4+/-4.7 micro g/ml of copper; 1 year, 11.5+/-7.0 micro g/ml of copper; and 3 years, 6.2+/-1.5 micro g/ml of copper. Total proteins were quantified by measuring the area under the chromatographic peaks. The mean areas obtained with uterine fluid samples from women who used IUDs for 6 months, 1 year and 3 years were 290,013, 538,934 and 201,863 arbitrary units (AU), respectively. The control sample was only 22323.

CONCLUSIONS

The amount of copper released from IUD, although high, is in the form of complexes with proteins. IUDs have a constant copper release for at least 6-12 months. Copper(I) was not detected in the fluid. Copper induces a change in the total protein concentration. The amount of copper released and the amount of proteins is slightly larger during the menstrual stage.

Assessment of leukemia inhibitory factor levels by uterine flushing at the time of egg retrieval does not adversely affect pregnancy rates with in vitro fertilization

OBJECTIVE

To assess intrauterine levels of leukemia inhibitory factor (LIF) by uterine flushing at the time of egg retrieval and to confirm that the procedure has no detrimental effect on pregnancy rates.

DESIGN

Prospective study.

SETTING

Assisted reproductive unit of a university hospital.

PATIENT(S)

Uterine flushing was performed in 148 IVF patients. The first 100 patients were compared with a matched control group.

INTERVENTION(S)

Uterine flushing at the time of egg retrieval.

MAIN OUTCOME MEASURE(S)

IVP-ET results, pregnancy rates, and intrauterine LIF levels.

RESULT(S)

Pregnancy rates were not different in the group of patients with (27%) or without uterine flushing (28%). Leukemia inhibitory factor was detected in 60 patients (46%). Pregnancy rates did not differ between patients' detectable LIF and those in whom LIF was undetectable. Mean levels of LIF were 30.1 +/- 49.3 pg/mL and 28.6 +/- 51.2 pg/mL in pregnant and nonpregnant patients respectively.

CONCLUSION(S)

The flushing procedure at the time of egg retrieval did not adversely affect pregnancy rates. Leukemia inhibitory factor was detected in 46% of patients at the time of egg retrieval, but no correlation were observed with better pregnancy rates in patients with detectable LIF. Mean LIF levels did not differ in pregnant and nonpregnant women. Access to endoluminal secretions of the endometrium during IVF-ET may represent a new research in human implantation.

Biochemical evaluation of endometrial function at the time of implantation

OBJECTIVE

To review the literature on various endometrial factors assumed to be of importance to implantation and to evaluate their potential clinical value in the assessment of endometrial function at the time of implantation in infertile women in natural and stimulated cycles.

DESIGN

Literature review.

RESULT(S)

Cytokines such as leukemia inhibitory factor, colony-stimulating factor-1, and interleukin-1 have all been shown to play important roles in the cascade of events that leads to implantation. They participate in a synchronized cooperation between the endometrium and the preimplanting embryo under the influence of steroid hormones. The same applies to the integrin alpha(v)beta(3), glycodelin, and the polymorphic mucin 1. The usefulness of these factors to assess endometrial receptivity and to estimate the prognosis for pregnancy in natural and artificial cycles remains to be proven.

CONCLUSION(S)

The studies performed to date have mostly included only small groups of patients with a lack of fertile controls, and only a few prospective, controlled trials have been carried out. Therefore, definite conclusions about the clinical value of these factors in the assessment of endometrial function and prognosis for pregnancy after artificial reproductive therapy cannot be drawn at present. Further evaluation of their importance for and function during implantation is needed.