Integrin adhesion molecules in the endometrial glandular epithelium in patients with endometriosis or adenomyosis

Expression of Talin-1 in endometriosis and its possible role in pathogenesis

BACKGROUND

Endometriosis is a disease that involves active cell invasion and migration. Talin-1 can promote cell invasion, migration and adhension in various cancer cells, but its role in endometriosis has not been investigated. This study was to investigate the expression level of Talin-1 in endometriosis and the role of Talin-1 in the proliferation, adhesion, migration, and invasion of human endometrial stromal cells (ESCs).

METHODS

Ectopic and eutopic endometrial tissues were collected from women with endometriosis, and the control endometrial tissues were obtained from patients without endometriosis. The expression level of Talin-1 was detected in each sample using quantitative real-time polymerase chain reaction and immunohistochemistry. The expression of Talin-1 was inhibited using RNA interference in ESCs, and its proliferation, apoptosis, adhesion, migration, and invasion capacity were analyzed. Western blotting was performed to detect the expression of related molecules after the downregulation of Talin-1.

RESULTS

The results showed that the mRNA and protein expression of Talin-1 were significantly increased in the ectopic endometrium and eutopic endometrial tissues compared with the controls. The knockdown of Talin-1 did not affect the proliferation and apoptosis of ESCs. The results indicated that the downexpression of Talin-1 inhibited the adhesion, invasion, and migration of ESCs. In addition, the expressions of N-cadherin, MMP-2, and integrin β3 were significantly lower after the deregulation of Talin-1, whereas the levels of E-cadherin were significantly increased.

CONCLUSIONS

The expression of Talin-1 was increased in the ectopic and eutopic endometrial tissues compared with the control endometrium. The downregulation of Talin-1 inhibited the adhesion, invasion, and migration of ESCs.

Epithelial-Mesenchymal Transition in Endometriosis-When Does It Happen?

Epithelial-mesenchymal transition (EMT) is an important process of cell remodeling characterized by the gradual loss of the epithelial phenotype and progressive gain of a mesenchymal phenotype. EMT is not an all-or-nothing process, but instead a transition of epithelial to mesenchymal cells with intermediate cell states. Recently, EMT was described in endometriosis, and many EMT-specific pathways like Twist, Snail, Slug, Zinc finger E-box-binding homeobox 1/2 (ZEB1/2), E/N-cadherin, keratins, and claudins are involved. However, as pointed out in this review, a comparison of the eutopic endometrium of women with and without endometriosis yielded only subtle changes of these EMT markers. Furthermore, only very few alterations in cell-cell contacts could be found but without changes in the epithelial phenotype. This suggests only a partial EMT which is not a prerequisite for the detachment of endometrial cells and, thus, not critical for the first step(s) in the pathogenesis of endometriosis. In contrast, the majority of changes in the EMT-related marker expression were found in the ectopic endometrium, especially in the three endometriotic entities, ovarian, peritoneal, and deep infiltrating endometriosis (DIE), compared with the eutopic endometrium. In this review, we examine the most important EMT pathways described in endometriosis and propose that partial EMT might result from the interaction of endometrial implants with their surrounding microenvironment.

Connective tissue growth factor mediates transforming growth factor β-induced collagen expression in human endometrial stromal cells

Background

Adenomyosis is a medical condition defined by the abnormal presence of endometrial tissue within the myometrium, in which fibrosis occurs with new collagen deposition and myofibroblast differentiation. In this study, the effect of several mediators and growth factors on collagen expression was investigated on human endometrial stromal cells (fibroblasts) derived from adenomyotic endometrium.

Experimental approach

RT-PCR, Western blot analysis, pharmacological interventions and siRNA interference were applied to primary cultured human endometrial stromal cells (fibroblasts). Immunohistochemistry was used to analyze protein expression in adenomyotic endometrium tissue specimens.

Results

Of the tested mediators, transforming growth factor β1 (TGFβ1) and its isoforms were effective to induce collagen and connective tissue growth factor (CTGF) expression. Collagen and CTGF induction by TGFβ1 could be reduced by the inhibitors targeting DNA transcription, protein translation, and Smad2/3 signaling. Interestingly, TGFβ1 induced Smad2/3 phosphorylation and CTGF mRNA expression, but not collagen mRNA expression, suggesting that TGFβ1 mediates collagen expression through CTGF induction and Smad2/3 activation. In parallel, TGFβ1 and CTGF also induced expression of heat shock protein (HSP) 47, a protein required for the synthesis of several types of collagens. However, only CTGF siRNA knockdown, could compromise TGFβ1-induced collagen expression. Finally, the immunohistochemistry revealed vimentin- and α-SMA-positive staining for (myo)fibroblasts, TGFβ1, collagen, and CTGF in the subepithelial stroma region of human adenomyotic endometria.

Conclusion and implications

We reveal here that TGFβ1, collagen, and CTGF are expressed in the stroma of adenomyotic endometria and demonstrate that TGFβ1 can induce collagen production in endometrium-derived fibroblasts through cellular Smad2/3-dependent signaling pathway and CTGF expression, suggesting that endometrial TGFβ may take part in the pathogenesis of adenomyosis and ectopic endometrium may participate in uterine adenomyosis.

Increased expression of Talin1 in the eutopic and ectopic endometria of women with adenomyosis

Adenomyosis is a prevalent gynecologic benign disease in women. Despite its significance, there is only a limited understanding of its pathological mechanisms. Talin1, a cytoskeletal protein, plays an important role in cell survival, proliferation, invasion and migration. The objective of this study was to investigate the mRNA and protein expression of talin1 in both the eutopic and ectopic endometria of women with adenomyosis. Higher talin1 mRNA levels were observed in both ectopic and eutopic endometria from the adenomyosis subjects compared with the eutopic endometria from women without adenomyosis. Immunohistochemistry revealed increased epithelial expression of talin1 in the ectopic and eutopic endometria from patients with adenomyosis compared with those without adenomyosis. When tests were performed on matched samples of eutopic and ectopic endometria of adenomyosis subjects, the mRNA and protein expression of talin1 was much higher in the ectopic endometria than in the eutopic endometria. The results reveal that the expression pattern of talin1 in the eutopic and ectopic endometria is enhanced in women with adenomyosis. Increased talin1 expression may play a role in the pathogenesis and development of adenomyosis.

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.

ART and uterine pathology: how relevant is the maternal side for implantation?

BACKGROUND

Assisted reproduction technology (ART) has become a standard treatment for infertile couples. Increased success rates obtained over the years have resulted primarily from improved embryo quality, but implantation rates still remain lower than expected. The uterus, an important player in implantation, has been frequently neglected. While a number of uterine pathologies have been associated with decreased natural fertility, less information exists regarding the impact of these pathologies in ART. This report reviews the evidence to help clinicians advise ART patients.

METHODS

An electronic search of PubMed and EMBASE was performed to identify articles in the English, French or Spanish language published until May 2014 which addressed uterine pathology and ART. Data from natural conception were used only in the absence of data from ART. Studies were classified in decreasing categories: RCTs, prospective controlled trials, prospective non-controlled trials, retrospective studies and experimental studies. Studies included in lower categories were only used if insufficient evidence was available. Pooled data were obtained from systematic reviews with meta-analyses when available. The summary of the evidence for the different outcomes and the degree of the recommendation for interventions were based on the GRADE (Grading of Recommendations Assessment, Development and Evaluation) statement recommendations.

RESULTS

There is strong evidence that surrogacy is effective for uterine agenesia. For the remaining pathologies, however, there is very little evidence that the established treatments improve outcomes, or that these pathologies have a negative effect on ART. In the presence of an apparently normal uterus, assessing endometrial receptivity (ER) is the goal; however diagnostic tests are still under development.

CONCLUSIONS

The real effect of different uterine/endometrial integrity pathologies on ART is not known. Moreover, currently proposed treatments are not based on solid evidence, and little can be done to assess ER in normal or abnormal conditions. No strong recommendations can be given based on the published experience, bringing an urgent need for well-designed studies. In this context, we propose algorithms to study the uterus in ART.

Detection of Endometrial Nerve Fibres – a Novel Technique to Diagnose Endometriosis

Purpose

To detect the presence of nerve fibres by immunohistochemical staining method using anti-PGP9.5 antibody in the eutopic and ectopic endometrium of patients with endometriosis.

Methods

Patients presenting with pelvic pain and/or infertility were subjected to premenstrual endometrial biopsy during laparoscopy. Thirty patients diagnosed with endometriosis formed the study group and 30 patients with no histological/laparoscopic evidence of endometriosis formed the control group. Endometrial biopsy tissue of all the 60 patients along with biopsy from endometriomas and peritoneal implants of confirmed cases of endometriosis (n = 30) were subjected to immunohistochemical staining to detect nerve fibres.

Results

Neural elements were observed in the eutopic endometrium of 24/30 cases (80%) in the study group and in none of the controls (p<0.01), while the sections from endometriomas and peritoneal implants demonstrated nerve fibres in all the 30 cases of confirmed endometriosis. The nerve fibres in the endometrial tissue were heterogeneously distributed and were sparse in number with an observed density of <1 nerve fibre/mm2 while they were present in large numbers in the ectopic endometrium (10 ± 3 nerve fibre/mm2). Also, the presence of nerve fibres in the eutopic and ectopic endometrium positively correlated with the intensity of pain (p<0.001).

Conclusion

Eutopic endometrium exhibited positivity for nerve fibres in 24 out of 30 cases of proven endometriosis, though the density of nerve fibres was low as compared to that reported in a few studies.

Growth mechanisms of endometriotic cells in implanted places: a review

Endometriosis is a common gynecological disease defined by extrauterine growth of endometrial glands and stroma. A variety of theories have been proposed to account for the pathogenesis of this disease, including retrograde transplantation theory, metaplasia of coelomic epithelium, hematogenic and lymphogenic spread, and remnants of the Mŭllerian duct. However, the etiopathology of endometriosis is still obscure. In this article, we aim to summarize recent researches concerning the growth mechanisms of endometriotic cells in implanted sites systematically, including the adhesion, invasion, angiogenesis, proliferation, apoptosis of endometriotic cells, variations of the immune molecules and endometriotic cells themselves, which may provide clues for future researches in the pathogenesis of endometriosis.

The Endometrium in Adenomyosis

Eutopic and ectopic endometria of women with adenomyosis show a series of metabolic and molecular abnormalities that increase angiogenesis and proliferation, decrease apoptosis, allow local production of estrogens, create progesterone resistance, and impair cytokine expression. These changes enhance the ability of the endometrium to infiltrate the junctional zone myometrium and the growth of ectopic tissue. In addition, in these subjects several immunological abnormalities have been observed, together with an increased production of ‘free radicals’ leading to excessive growth of endometrial stromal cells that may facilitate the establishment of adenomyosis. A limiting factor is that these studies have been performed on hysterectomy specimens representing final stages of the disease. This increased knowledge has created new therapeutic options, including the block of local aromatase production through the use of selective estrogen receptor modulators, estrogen-progestin combinations and gonadotropin-releasing hormone super agonists. Also promising are investigations into the mechanism of dysmenorrhea and abnormal uterine bleeding.

Is adenomyosis the neglected phenotype of an endomyometrial dysfunction syndrome?

Since the dissociation between adenomyoma and endometriosis in the 1920s and the laparoscopic progress in the diagnosis and surgery of endometriosis, the literature has been greatly focused on the disease endometriosis. The study of adenomyosis, on the other hand, has been neglected as the diagnosis remained based on hysterectomy specimens. However, since the introduction of magnetic resonance and sonographic imaging techniques in the 1980s, the myometrial junctional zone has been identified as a third uterine zone and interest in adenomyosis was renewed. This has also been the start for the interest in the role of the myometrial junctional zone dysfunction and adenomyosis in reproductive and obstetrical disorders.

The Estrogen Early Response Gene FOS Is Altered in a Baboon Model of Endometriosis1

Endometriosis, the presence of a functional endometrium outside of the uterine cavity, is associated with infertility. In our simulated model of pregnancy in baboons with experimental endometriosis, hCG infusion fails to induce expression of the immunoregulatory protein glycodelin. To test the hypothesis that the development of endometriosis is associated with an aberrant endometrial immunological environment, we examined the expression of a series of immunoregulatory genes in endometrium from baboons with and without endometriosis. Six months following intraperitoneal inoculation with menstrual endometrium, eutopic endometrium was surgically collected between Days 9 and 11 postovulation. Control endometrium was similarly collected from disease-free animals. Total RNA was extracted, and biotinylated cDNA probes were hybridized to the SuperArray GEArray Q series Th1/Th2/Th3 cDNA array, representing 96 genes. Gene expression levels were determined using ScanAlyze and GEArray Analyzer software. Seven genes were upregulated, including JUND, FOS, CCL11, NFKB1 and others, in the endometrium from baboons with endometriosis compared with the endometrium from disease-free animals; one gene, IL1R1, was downregulated. Quantitative RT-PCR confirmed upregulation of FOS and CCL11 in endometriotic eutopic endometrium. Immunohistochemical analysis revealed altered levels and distribution of FOS protein in the eutopic endometrium of baboons with induced endometriosis. These data suggest that in an induced model of endometriosis an aberrant eutopic immunological environment results in a decreased apoptotic potential and in rapid alterations in endometrial gene expression. We propose that the reduced fecundity associated with endometriosis has a multifold etiology in spontaneous and induced disease.

[Adenomyosis: update on a frequent but difficult diagnosis]

Adenomyosis is a frequent entity, with difficult diagnosis, often obtained by pathological analysis performed after hysterectomy. This condition can cause abnormal uterine bleeding and dysmenorrhea, frequent reasons for consultation and hysterectomy. The development of ultrasonographic and magnetic resonance imaging techniques allow preoperative diagnosis. They also permit the use of hysteroscopic techniques for conservative uterine surgery, and have brought diagnosis and management of this disease to the front of the scene. This article reviews the pathological description of the disease, its epidemiology, clinical presentations, useful and necessary explorations, etiopathogeny and available therapies.

In Vivo Correlation between IL-1beta Concentration in Uterine Fluid and Integrin Expression Pattern in Infertile Women

PROBLEM

To evaluate the possible correlation between interleukin-1beta (IL-1beta) and integrin expression.

METHOD OF STUDY

Endometrium and uterine fluid from 77 infertile women and 24 fertile, healthy control were studied with immunohistochemistry and enzyme-linked immunosorbent assay for the presence of IL-1beta and integrin alphaVbeta3 and alpha4beta1 expression.

RESULTS

Highest expression of alphaVbeta3 was found in epithelium and glands in endometria from fertile women. There was no positive correlation between IL-1beta and integrin expression pattern.

CONCLUSION

This study confirms the importance of alphaVbeta3 as molecular marker of receptive phase. Also supports the views that synchrony in development of endometrium is necessary for successful nidation. There was however, contrary to results of previous in vitro studies, no positive correlation between IL-1beta and endometrial integrin patter expression.

A baboon model for endometriosis: implications for fertility

Endometriosis is one of the most common causes of chronic pelvic pain and infertility in women in the reproductive age group. Although the existence of this disease has been known for over 100 years our current knowledge of its pathogenesis and the pathophysiology of its related infertility remains unclear. Several reasons contribute to our lack of knowledge, the most critical being the difficulty in carrying out objective long-term studies in women. Thus, we and others have developed a model of this disease in the non-human primate, the baboon (Papio anubis). Intraperitoneal inoculation of autologous menstrual endometrium results in the development of endometriotic lesions with gross morphological characteristics similar to those seen in the human. Multiple factors have been implicated in endometriosis-associated infertility. We have described aberrant levels of factors involved in multiple pathways important in the establishment of pregnancy, in the endometrium of baboons induced with endometriosis. Specifically, we have observed dysregulation of proteins involved in invasion, angiogenesis, methylation, cell growth, immunomodulation, and steroid hormone action. These data suggest that, in an induced model of endometriosis in the baboon, an increased angiogenic capacity, decreased apoptotic potential, progesterone resistance, estrogen hyper-responsiveness, and an inability to respond appropriately to embryonic signals contribute to the reduced fecundity associated with this disease.

High density of small nerve fibres in the functional layer of the endometrium in women with endometriosis

BACKGROUND

Endometriosis is a common gynaecological disease and is frequently associated with recurrent and serious pelvic pain such as dysmenorrhoea and dyspareunia, but the mechanisms by which these symptoms are generated are not well understood.

METHODS

Histological sections of endometrial tissue were prepared from endometrial curettings and hysterectomies performed on women with endometriosis (n=25 and n=10, respectively) and without endometriosis (n=47 and n=35, respectively). These were stained immunohistochemically for the highly specific polyclonal rabbit anti-protein gene product 9.5 (PGP9.5) and monoclonal mouse anti-neurofilament protein (NF) to demonstrate both myelinated and unmyelinated nerve fibres.

RESULTS

Small nerve fibres were identified throughout the basal and functional layers of the endometrium in all endometriosis patients, but were not seen in the functional layer of the endometrium in any of the women without endometriosis (P<0.001). NF-immunoreactive nerve fibres were present in the basal layer in all endometriosis patients but not in non-endometriosis patients, with one exception (P<0.001).

CONCLUSIONS

Small nerve fibres detected in the functional layer in all women with endometriosis may have important implications for understanding the generation of pain in these patients. The presence of nerve fibres in an endometrial biopsy may be a novel surrogate marker of clinical endometriosis.

Endometriosis affects sperm–endosalpingeal interactions

BACKGROUND

The interaction between spermatozoa and the epithelium of the isthmic region of the uterine tube is thought to be an important part of the mechanisms of sperm transport to the site of fertilization and in preparing them for fertilization. However, it is unclear whether a dysfunction of this mechanism may contribute to subfertility in some individuals.

METHODS

The sperm-binding characteristics of the epithelium from the uterine tubes of three groups of women were examined: (i) eight with pelvic endometriosis (not involving the uterine tubes); (ii) five women who had been receiving zoladex injections to control their symptoms; and (iii) as controls 10 women undergoing an elective procedure for benign gynaecological problems but with no other pathology of the reproductive tract.

RESULTS

Significantly more spermatozoa bound per unit area to the ampullary epithelium of the uterine tubes taken from women with a previous diagnosis of endometriosis.

CONCLUSIONS

These findings suggest that the characteristics of sperm binding to tubal epithelium may be disrupted in women with a gynaecological pathology such as endometriosis. It is suggested that this may have the potential to interfere with the availability of freely motile spermatozoa, of the appropriate physiological status, to take part in fertilization. This may be a newly described mechanism by which endometriosis can cause infertility.

Genomic alterations in the endometrium may be a proximate cause for endometriosis

OBJECTIVE

To test the hypothesis that endometriosis may originate from genomic alterations in the endometrium by genomic analysis of endometrial tissues in patients with endometriosis and compare them with those from normal controls.

METHODS

Endometrial tissue samples were taken from five women with endometriosis. For controls, we used endometrial tissue samples from four women who underwent elective abortions and one sample from placenta. Using array-based comparative genomic hybridization (CGH), we determined the normal range of variation in CGH signals using normal controls. CGH results were further confirmed by real-time quantitative PCR and loss of heterozygosity analysis.

RESULTS

We identified several regions of genomic alterations in all five patients. Some of these regions were the same regions identified previously in endometriotic lesions. For select markers, the genomic alterations were confirmed by real-time PCR and LOH analyses.

CONCLUSIONS

There is evidence that the endometrium in women with endometriosis has genomic alterations. This is consistent with numerous reports that the endometrium of women with endometriosis differ from those of women without. Our finding suggests that genomic alterations in the endometrium may be a proximate cause for endometriosis.

Évolutions physiopathologiques, diagnostiques et thérapeutiques dans la prise en charge de l’adénomyose : revue de la littérature

OBJECTIVE

Adenomyosis is a relatively frequent disease of unknown origin, which is difficult to diagnose. Appropriate treatment for women who want to preserve or improve their fertility remains to be defined.

METHODS

This review summarized the reports found on Medline database about pathophysiology, diagnosis and management of adenomyosis.

RESULTS

Many pathophysiological factors may be involved in the occurrence of adenomyosis: immunological factors, estrogen sulfatase activity, tenascin which is a fibronectin inhibitor and angiogenesis and growth factors such as EGF, VEGF and GM-CSF. Endovaginal ultrasonography seems to be as effective as MRI for the diagnosis of adenomyosis. GnRH agonist decreases symptoms and uterine volume; however, the symptoms reappear after discontinuation of agonist therapy, and side effects limit their prolonged use. Progesterone receptor modulators, anti-progestative and danazol or levonorgestrel-releasing intra-uterine system have been used as therapeutic modalities for adenomyosis, but the lack of controlled studies make their efficacy difficult to quantify. Some women with superficial adenomyosis may theoretically benefit from hysteroscopic myometrial or endometrial resection, but these procedures would be limited to women not wishing to conceive. Laparoscopic myometrial electrocoagulation or excision has proven to be effective but pregnancy following these techniques poses special problems, particularly the increased risk of uterine rupture.

CONCLUSION

Transvaginal ultrasonography can successfully diagnose adenomyosis. Medical and conservative surgical treatments are already available.

Immunolocalization of integrins and fibronectin in tubal pregnancy

Integrins are a large family of cell adhesion molecules that serve as receptors involved in cell-to-cell and cell-to-matrix interactions during implantation. We studied immunohistochemical staining of integrins (alpha 3, alpha V, beta 1, and alpha 2 beta 1) and fibronectin in ectopic tubal pregnancy. Thirty fallopian tube samples with ectopic pregnancies and five normal tubal segments were obtained during ligation operations; the latter specimens served as controls in the study. Formalin-fixed paraffin-embedded tissue sections were stained with hematoxylin-eosin or primary antibodies against alpha 3, beta 1, alpha V, and alpha 2 beta 1 integrins and fibronectin, using the avidin-biotin-peroxidase method. A semi-quantitative grading system was used to compare staining intensities. In the control samples, immunostaining of all integrins was found in a single layer of tall columnar epithelial cells, the lamina propria (Lp) and the muscular layer. Fibronectin staining was detected in the Lp and the muscular layer. Staining intensities of alpha 3 and beta 1 integrins and fibronectin were increased in the normal part of fallopian tubes with ectopic pregnancies. Staining of beta 1 integrin was more intense than staining of alpha 3 and fibronectin, whereas there was no difference in alpha V and alpha 2 beta 1 integrin expression between normal tubal tissue in the ectopic pregnancy group and control tubal tissue. In the tubal pregnancy group at the site of implantation, staining intensity of alpha 3 and beta 1 integrins and fibronectin was strong in decidual cells, supporting tissue and placental villi, whereas alpha V and alpha 2 beta 1 staining was mild. We concluded that integrins, especially beta 1 and alpha 3, and fibronectin may play a role in progression of tubal implantation. Although the role of integrins has not yet been clearly defined, these molecules may function as markers of normal and abnormal states of receptivity. We like to suggest that integrins and fibronectin, which are needed in utero implantation, are expressed in tubal tissues during ectopic pregnancy and are involved in ectopic implantation.

The endometrium as a cause of implantation failure

One of the biggest obstacles to reproductive success is our inability to diagnose or treat effectively the non-receptive endometrium. The endometrium becomes receptive for a limited period of time under the influence of steroid hormones and paracrine signals from the developing embryo. It is likely that the receptive state is characterized by the expression of particular genes that allow the normally refractory endometrium to respond to the embryo and permit attachment. Recently, several molecules have been reported whose function is essential for uterine receptivity in rodents and primates. This article will review current models of the control of receptivity and early implantation and assess progress in defining markers for the receptive endometrium in women. Although some genes have been identified whose expression is altered in women with subfertility, none of these molecular markers have yet proven clinically useful in the assessment of functional receptivity. The use of high throughput techniques such as microarrays and proteomic methods to investigate gene expression in the endometrium provides a novel approach to defining receptivity at the molecular level. The potential impact of these tools on clinical practice will be discussed.

Noninvasive diagnosis of endometriosis: the role of imaging and markers

Endometriosis is defined by the presence of endometrial tissue outside the uterus. Clinical and basic research in endometriosis has been hampered severely by the lack of accurate noninvasive diagnostic techniques. Transvaginal ultrasonography, MRI, and endometrial and serum markers have the potential to facilitate the diagnosis and can be useful in the follow-up of patients. Endometriosis research has entered the postgenomic era, and powerful genomic and proteomic technology is being applied in the search for novel diagnostic and therapeutic approaches. This article explores the recent advances in imaging techniques and the development of diagnostic molecular markers of endometriosis.

Reproductive disorders affecting fertility in endometriosis

The classical concept of endometriosis as a cause of infertility is challenged. Traditionally, both surgical and medical therapy of endometriosis-associated infertility has focused on eliminating or reducing the visible implants. The classic 6-month medical approach has been a failure, and surgery may moderately enhance fertility, but its benefit in the absence of adhesions is still doubtful. Recent studies have shown that endometriosis is characterized by an aberrant response to sex steroid hormones, resulting in pleiotropic dysfunctions of the reproductive system involving the uterine, peritoneal and ovarian micro-environment. Studies on endometriosis and IVF have been highly relevant in revealing the pleiotropic dysfunctions in patients with endometriosis, although the results should be interpreted with caution. The conclusion seems to support the view that infertility in patients with endometriosis is primarily dysfunctional, rather than lesional, in origin. It is concluded that the place of medical therapy in endometriosis should be reviewed and that the surgical approach needs to be complemented by appropriate medical therapy to restore fertility.

Aromatase P450 messenger RNA expression in eutopic endometrium is not a specific marker for pelvic endometriosis

OBJECTIVE

To determine whether expression of aromatase P450 mRNA in eutopic endometrium is predictive of the presence of pelvic endometriosis.

DESIGN

A prospective, multicenter, observational study.

SETTING

Four tertiary centers for reproductive medicine.

PATIENT(S)

Sixty subjects of reproductive age undergoing laparoscopy for subfertility exploration, pain assessment, or sterilization.

INTERVENTION(S)

Endometrial biopsy at time of laparoscopy.

MAIN OUTCOME MEASURE(S)

The expression of aromatase P450 mRNA in endometrial specimens was determined by single-tube reverse transcription-polymerase chain reaction (RT-PCR). Glyceraldehyde-3-phosphate dehydrogenase (GAPDH) mRNA was amplified in parallel to exclude amplification failure.

RESULT(S)

The RT-PCR amplification was successful in 56 of the 60 biopsies (93%). Pelvic endometriosis was diagnosed in 34 patients (61%) and was strongly associated with aromatase P450 mRNA expression in eutopic endometrium. As a diagnostic marker for endometriosis, aromatase P450 mRNA expression yielded a sensitivity of 82%, a specificity of 59%, a positive predictive value of 76%, and a negative predictive value of 67%. If additional uterine pathology was taken in account, the sensitivity increased to 84%, the specificity to 72%, the positive predictive value to 87%, but the negative predictive value remained unchanged (67%).

CONCLUSION(S)

Although endometrial aromatase P450 gene expression is highly predictive of the presence of pelvic disease, the relative high incidence of false-negative results and lack of specificity is likely to impair clinical application.

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.

An immunohistochemical study of the rete ovarii and epoophoron

A study to compare the immuno-histochemical profile of the human rete ovarii, and epoophoron, with the Fallopian tube and ovarian surface epithelium was performed with 31 antibodies and antisera. A reaction was present in the epithelial cytoplasm of the rete ovarii and epoophoron of mesonephric origin, for vimentin, GFAP, cytokeratin markers, (AE1/AE3, MNF116; Cam 5.2, 34 beta E12 and for the monospecific antibodies to cytokeratins 7 and 19), heat shock protein 27, in the cell membrane for HBME-1, EMA and in the subepithelial collagen for collagen IV. Reactions were present only in the epithelium in the rete ovarii for EGFR (one case) and CA-125 (four cases). A reaction was present in the epithelium of the epoophoron only for Ber-EP-4 and S100. There was no reaction with antibodies for desmin, neurofilament protein, cytokeratins 20 or 14, actin, calretinin, E-cadherin, C-erb-B2, or CEA (monoclonal and polyclonal reagents). The immuno-histochemical profile of the Fallopian tube was consistent with its para-mesonephric origin and that in the ovarian surface epithelium was consistent with a proposed modified mesothelial origin. This study provides an immunohistochemical profile of these structures with a large panel of commonly available antibodies and antisera, confirming and extending the findings described in previous studies.