Hormonal, functional and genetic biomarkers in controlled ovarian stimulation: tools for matching patients and protocols

Background

The G protein-coupled estrogen receptor (GPER) is thought to be involved in non-genomic estrogen responses as well as processes such as cell proliferation and migration. In this study, we analyzed GPER expression patterns from endometriosis samples and normal endometrial tissue samples and compared these expression profiles to those of the classical sex hormone receptors.

Methods

A tissue microarray, which included 74 samples from different types of endometriosis (27 ovarian, 19 peritoneal and 28 deep-infiltrating) and 30 samples from normal endometrial tissue, was used to compare the expression levels of the GPER, estrogen receptor (ER)-alpha, ER-beta and progesterone receptor (PR). The immunoreactive score (IRS) was calculated separately for epithelium and stroma as the product of the staining intensity and the percentage of positive cells. The expression levels of the hormonal receptors were dichotomized into low (IRS?<?6) and high (IRS?>?=6) expression groups.

Results

The mean epithelial IRS (+/?standard deviation, range) of cytoplasmic GPER expression was 1.2 (+/?1.7, 0?C4) in normal endometrium and 5.1 (+/?3.5, 0?C12) in endometriosis (p?<?0.001), of nuclear GPER 6.4 (+/?2.6, 0?C12) and 6.8 (+/?2.9, 2?C12; p?=?0.71), of ER-alpha 10.6 (+/?2.4, 3?C12) and 9.8 (+/?3.0, 2?C12; p?=?0.26), of ER-beta 2.4 (+/?2.2; 0?C8) and 5.6 (+/?2.6; 0?C10; p?<?0.001), and of PR 11.5 (+/?1.7; 3?C12) and 8.1 (+/?4.5; 0?C12; p?<?0.001), respectively. The mean stromal IRS of nuclear GPER expression was 7.7 (+/?3.0; 2?C12) in endometrium and 10.8 (+/?1.7; 6?C12) in endometriosis (p?<?0.001), of ER-alpha 8.7 (+/?3.1; 2?C12) and 10.6 (+/?2.4; 2?C12; p?=?0.001), of ER-beta 1.8 (+/?2.0; 0?C8) and 5.4 (+/?2.5; 0?C10; p?<?0.001), and of PR 11.7 (+/?0.9; 8?C12) and 10.9 (+/?2.0; 3?C12; p?=?0.044), respectively. Cytoplasmic GPER expression was not detectable in the stroma of endometrium and endometriosis. The observed frequency of high epithelial cytoplasmic GPER expression levels was 50% (n?=?30/60) in the endometriosis and none (0/30) in the normal endometrium samples (p?<?0.001). High epithelial cytoplasmic GPER expression levels were more frequent in endometriomas (14/20, 70%; p?=?0.01), as compared to peritoneal (9/18, 50%) or deep-infiltrating endometriotic lesions (7/22, 31.8%). The frequency of high stromal nuclear GPER expression levels was 100% (n?=?74/74) in endometriosis and 76.7% (n?=?23/30) in normal endometrium (p?<?0.001). The frequency of high epithelial nuclear GPER expression levels did not differ between endometriosis and normal endometrium.

Conclusions

The present data indicate a unique GPER expression pattern in endometriosis, especially in endometriomas as compared to the normal endometrium. The overexpression of GPER in endometriotic lesions suggests a potential role for GPER in the hormonal regulation of endometriosis, which should be taken into consideration for future hormonal treatment strategies.     

The Parkes lecture: controlled ovarian stimulation in women

Recent advances in knowledge of the endocrine and paracrine mechanisms that regulate human ovarian folliculogenesis have been parallelled by the introduction into clinical practice of new drugs that can be used safely and effectively to stimulate ovarian function in infertile women. Most notably, recombinant DNA technology has been applied to the production of molecularly pure forms of the gonadotrophins, FSH and LH, opening the way to the development of improved strategies for manipulating the ovarian paracrine system. The clinical objectives of controlled ovarian stimulation fall into two categories, depending on patient needs: (1) induction of multiple follicles from which mature oocytes can be harvested for use in assisted reproduction protocols such as in vitro fertilization and embryo transfer; or (2) induction of spontaneous ovulation of a single mature follicle so that conception might occur in vivo. This review summarizes the physiological principles upon which the use of gonadotrophins for clinical purposes is based, highlighting new opportunities for improved treatment as a result of the availability of recombinant FSH and LH.     

Role of LH in controlled ovarian stimulation

Controlled ovarian stimulation has become an integral part of infertility treatment. Specific gonadotropin based protocols become the main strategies for controlled stimulation. To avoid the potentially detrimental effect of premature LH surge on oocytes and/or endometrium development, the GnRH analogs have been incorporated into controlled ovarian stimulation strategies. With the availability of recombinant gonadotropins (i.e. recombinant FSH devoided of LH activity) it is necessary to establish precise role of LH in the folliculogenesis and endometrium development. The benefit of exogenous LH may vary with the GnRH-agonists and antagonists regiment used. The optimal amount of LH or ratio FSH to LH used during therapeutically stimulated growth of follicles is still a problem that needs to be solved in the near future.     

Time of ovarian follicle selection during the porcine estrous cycle

Two experiments were conducted to: 1) determine the time during the procine estrous cycle when compensation in ovulation rate after unilateral ovariectomy (ULO) ceases to be complete, 2) compare the follicle selection process in gilts selected for high ovulation rate with unselected control gilts and 3) determine the number of follicles on the right ovary at various stages of the estrous cycle. Experiment I included 25 crossbred gilts, while Experiment II included 17 gilts selected for high ovulation rate and 16 unselected control gilts. The right ovary was removed via a mid-ventral laparotomy on either day 13, 15, 17 or 19 of the cycle. In Experiment I, compensation in ovulation rate ceased between days 13 and 15; whereas, in Experiment II, cessation occurred between days 15 and 17. Selected and control gilts responded alike to ULO, indicating similarity in the follicle selection process. Follicle numbers in the right ovary showed a general decline, especially between days 17 and 19, indicating that atresia was occurring during the follicular phase. The results indicate that the selection of ovarian follicles for ovulation at the ensuing estrus occurs before day 17 of the porcine estrous cyle.     

Improving ovarian stimulation protocols for IVF in baboons: lessons from humans and rhesus monkeys

The aim of this review paper is to provide a scientific basis for the development of ovarian stimulation (OS) protocols for in vitro fertilization (IVF) in baboons. Firstly, the evidence available regarding OS for assisted reproduction in baboons is reviewed based on available published data, assessed by a Pub Med search of papers published between 1970 and 2008 using the following key words: baboon, assisted reproduction, IVF, embryo, oocyte. Secondly, we discuss how state-of-the-art or potentially new OS protocols used in humans and in rhesus monkeys may offer guidance for the development of standardized and reliable OS protocols for IVF in baboons. Based on this review and discussion, we conclude that more randomized trials are needed to improve standardization of OS protocols for IVF in baboons with respect to gonadotrophin type, dose, duration of stimulation, ultrasound monitoring, and time interval between ovulation trigger and oocyte retrieval.     

Cerebral blood flow is increased during controlled ovarian stimulation

Estrogen appears to enhance cerebral blood flow (CBF). An association between CBF and physiologically altered hormonal levels due to menstrual cycle, menopause, or exogenous manipulations such as ovariectomy or hormone replacement therapy has been demonstrated. The purpose of this study was to determine the association between ovarian stimulation and CBF in vivo by measuring blood flow in the internal carotid artery (ICA) after pituitary suppression and during controlled ovarian stimulation in women undergoing in vitro fertilization treatment cycles. ICA volume flows were measured by angle-independent dual-beam ultrasound Doppler in 12 women undergoing controlled ovarian stimulation. Measurements were performed after pituitary/ovarian suppression, in the late follicular phase, and at midluteal phase. Blood flow in the ICA increased by 22.2% and 32% in the late follicular and midluteal phases compared with the respective values obtained during ovarian suppression (P < 0.0005 and P < 0.0001, respectively). There was a significant correlation between increments in estrogen levels and increments in CBF when the late follicular phase was compared with the ovarian suppression period (r = 0.8, P < 0.001). Mean blood flow velocity significantly increased (by 15.7% and 16.9%, respectively) and cerebral vascular resistance significantly decreased (by 17.6% and 26.5%) during the late follicular and midluteal phases compared with respective measures during ovarian suppression. There was a significant correlation between an increase in estrogen levels and a decrease in cerebral vascular resistance when the late follicular phase was compared with the ovarian suppression period (r = -0.6, P < 0.05). These changes imply sex hormone-associated intracranial vasodilation leading to increased CBF during controlled ovarian stimulation.     

Peptide regulators in the ovarian follicle

Data generated within the last several years have shown that follicular fluid contains substances, presumably peptide in nature, which exert potentially important effects on granulosa cells and the oocyte. This review briefly summarizes the current evidence concerning the nature and importance of these putative regulators including the luteinization inhibitor, oocyte maturation inhibitor, inhibitors of the binding of luteinizing hormone and follicle stimulating hormone, stimulators of ornithine decarboxylase and intrafollicular peptides with gonadotrophin-releasing activity. Although the existence of such activities has been clearly demonstrated, the evidence for a regulatory role of these agents in the control of ovarian physiology is not compelling. However, their occurrence must now be taken into account in our attempts to understand the mechanism of follicular growth, differentiation and atresia.     

Lead concentrates in ovarian follicle compromises pregnancy

Following absorption, lead can concentrate in bodily compartments where it disrupts cellular processes and can result in detrimental health consequences. The concentration and impact of lead within follicular fluid has not been characterized and we used inductively coupled plasma mass spectroscopy (ICP-MS) to determine lead levels in blood and follicular fluid from nine patients undergoing in vitro fertilization (IVF) treatment. Lead levels within follicular fluid were found to be significantly higher in non-pregnant patients compared to pregnant patients suggesting that elevated concentrations of the environmental toxicant lead adversely affect female reproduction.     

Differential gene expression in human granulosa cells from recombinant FSH versus human menopausal gonadotropin ovarian stimulation protocols

Background  

The study was designed to test the hypothesis that granulosa cell (GC) gene expression response differs between recombinant FSH and human menopausal gonadotropin (hMG) stimulation regimens.     

Effect of luteal-phase support on endometrial microRNA expression following controlled ovarian stimulation

ABSTRACT: BACKGROUND: Studies suggested that microRNAs influence cellular activities in the uterus including cell differentiation and embryo implantation. In assisted reproduction cycles, luteal phase support, given to improve endometrial characteristics and to facilitate the implantation process, has been a standard practice. The effect of different types of luteal phase support using steroid hormones in relation to endometrial miRNA profiles during the peri-implantation period has not seen described. This study was designed to evaluate the expression of miRNAs during the luteal phase following controlled ovarian stimulation for IVF and the influence of different luteal phase support protocols on miRNA profiles. METHODS: The study was approved by the Johns Hopkins Hospital Institutional Review Board. Endometrial biopsies were obtained on the day of oocyte retrieval from 9 oocyte donors (group I). An additional endometrial biopsy was obtained 3-5 days later (Group II) after the donors were randomized into three groups. Group IIa had no luteal-phase support, group IIb had luteal support with micronized progesterone (P), and Group IIc had luteal support with progesterone plus 17-beta-estradiol (P+E). Total RNA was isolated and microarray analysis was performed using an Illumina miRNA expression panel. RESULTS: A total of 526 miRNAs were identified. Out of those, 216 miRNAs were differentially regulated (p<0.05) between the comparison groups. As compared to the day of retrieval, 19, 11 and 6 miRNAs were differentially regulated more than 2 fold in the groups of no support, in the P support only, and in the P+E support respectively, 3-5 days after retrieval. During the peri-implantation period (3-5 days after retrieval) the expression of 33 and 6 miRNAs increased, while the expression of 3 and 0 miRNAs decreased, in the P alone and in the P+E group respectively as compared to the no steroid supplementation group. CONCLUSION: Luteal support following COS has a profound influence on miRNA profiles. Up or down regulation of miRNAs after P or P+E support suggest a role(s) of luteal support in the peri-implantation uterus in IVF cycles through the regulation of associated target genes.     

Antiangiogenesis in swine ovarian follicle: a potential role for 2-methoxyestradiol

Inhibition of angiogenesis is an important new approach for cancer treatment and the research on this topic deserve special attention. 2-Methoxyestradiol (2-ME), a molecule shown to possess antiangiogenic activity, is a naturally occurring derivative of estradiol which can be potentially produced in the ovarian follicle. This study was therefore aimed firstly to asses 2-ME content in swine follicular fluid. Moreover, we evaluated the effect of this substance on VEGF production, superoxide anion generation (O(2)(-)) and superoxide dismuatase activity in granulosa cells. Our data evidence that 2-ME is present in follicular fluid where it potentially acts as a physiological inhibitor of angiogenesis by reducing VEGF production by granulosa cells: this effect could be mediated by a decrease of O(2)(-) generation.     

Follicle selection in cattle: follicle deviation and codominance within sequential waves

Follicle deviation during bovine follicular waves is characterized by continued growth of a developing dominant follicle and reduction or cessation of growth of subordinate follicles. Characteristics of follicle deviation for waves with a single dominant follicle were compared between wave 1 (begins near ovulation; n = 15) and wave 2 (n = 15). Follicles were defined as F1 (largest), F2, and F3, according to maximum diameter. No mean differences were found between waves for follicle diameters at expected deviation (F1, > or =8.5 mm; Hour 0) or observed deviation or in the interval from follicle emergence at 4.0 mm to deviation. For both waves, circulating FSH continued to decrease (P < 0.05) after Hour 0, estradiol began to increase (P < 0.05) at Hour 0, and immunoreactive inhibin began to decrease (P < 0.05) before Hour 0. A transient elevation in circulating LH reached maximum concentration at Hour 0 (P < 0.01) in both waves and was more prominent (P < 0.0001) for wave 1. Waves with codominant follicles (both follicles >10 mm) were more common (P < 0.02) for wave 1 (35%) than for wave 2 (4%). Codominants (n = 6) were associated with more (P < 0.05) follicles > or=4 mm and a greater concentration (P < 0.04) of circulating estradiol at Hours -48 to -8 than were single dominant follicles (n = 15). A mean transient increase in FSH and LH occurred in the codominant group at Hour -24 and may have interfered with deviation of F2. In codominant waves, deviation of F3 occurred near Hour 0 (F1, approximately 8.5 mm). A second deviation involving F2 occurred in four of six waves a mean of 50 h after the F3 deviation and may have resulted from a greater suppression (P < 0.05) of FSH in the codominant group after Hour 0. In conclusion, follicle or hormone differences were similar for waves 1 and 2, indicating that the deviation mechanisms were the same for both waves. Waves that developed codominant follicles differed in hormone as well as follicle dynamics.     

stall-mediated extrinsic control of ovarian follicle formation in Drosophila

Complex patterns of morphogenesis require intricate coordination of multiple, regulatory processes that control cellular identities, shapes, and behaviors, both locally and over vast distances in the developing organism or tissue. Studying Drosophila oogenesis as a model for tissue morphogenesis, we have discovered extraovarian regulation of follicle formation. Clonal analysis and ovary transplantation have demonstrated that long-range control of follicle individualization requires stall gene function in cells outside of the ovary. Although tissue nonautonomous regulation has been shown to govern follicle maturation and survival, this is the first report of an extraovarian pathway involved in normal follicle formation.     

Endocrine regulation of ovarian antral follicle development in cattle

Antral follicle growth in cattle occurs in two distinct phases; the first 'slow' growth phase spans the time from antrum acquisition to a size of approximately 3 mm detectable by transrectal ultrasound, and the second 'fast' phase is gondadotrophin-dependent and includes cohort growth, dominant follicle (DF) selection, and DF growth. This review summarises current concepts of the relative roles FSH and LH, ovarian and metabolic hormones play mainly in the second phase of antral follicle growth in animals of different reproductive and nutritional states. It is proposed that differential FSH response may enable one cohort follicle to become selected, and that follicular secretions, particularly inhibin, suppress FSH and thus are responsible for DF selection and dominance. Acute dependence of the DF on LH pulses will determine DF lifespan, and the LH pulse profile can be influenced by metabolic hormones such as leptin, providing one possible link for nutritional state and reproduction. Direct ovarian effects of acute and chronic changes in growth hormone, insulin and insulin-like growth factor (IGF)-I have been described on cohort follicles, DF oestrogen activity and on DF growth. Influences of metabolic hormones on early antral follicles undergoing their first 'slow' growth phase are less well described, yet metabolic hormones appear to enhance growth into the cohort available for FSH-induced emergence, and may influence subsequent developmental competence of oocytes.     

缝隙连接在小鼠卵泡发育过程中的作用

缝隙连接广泛分布于各组织细胞中,由其构成的胞间通道允许小分子在胞间直接传递,在胞间通讯方面起着重要的作用。缝隙连接由连接蛋白(Cx)组成,已发现Cx家族有20多个成员。在哺乳动物卵泡发育过程中,卵母细胞与周围的颗粒细胞之间形成的缝隙连接,介导胞间通讯,对原始生殖细胞迁移、卵母细胞减数分裂能力恢复、颗粒细胞分层、卵泡成腔、黄体形成、促性腺激素信号传递均有非常重要的调节作用。本文根据近年来相关的研究报道,总结了不同的缝隙连接在小鼠卵泡发育过程中的调节作用。     

Aromatase inhibitors in ovarian stimulation

The selective estrogen receptor modulator, clomiphene citrate (CC), has been the principal drug used for induction of ovulation in women with polycystic ovarian syndrome (PCOS). CC is associated with adverse side effects and low pregnancy rates attributed to long-lasting estrogen receptor depletion. Anastrozole and letrozole are potent, non-steroidal, reversible aromatase inhibitors, developed for postmenopausal breast cancer therapy. We hypothesized that aromatase inhibitors could mimic the action of CC in reducing estrogen negative feedback on follicle stimulating hormone (FSH) secretion, without depleting estrogen receptors. In a series of preliminary studies, we reported the success of aromatase inhibition in inducing ovulation in anovulatory women with PCOS. Moreover, we showed that concomitant use of aromatase inhibitors resulted in a significant reduction of the FSH dose needed for controlled ovarian hyperstimulation. We suggest that aromatase inhibitors act through an increase in endogenous gonadotropin secretion as well as through increased intraovarian androgen levels that may increase ovarian FSH receptors. Recently, we demonstrated the safety of aromatase inhibitors in pregnancy outcome studies examining spontaneous pregnancy loss, multiple pregnancy rates and congenital anomalies compared to a control group of infertility patients treated with CC.