endometriosis and infertlity

Endometriomas & Endometriomas & InfertilityInfertility

Dr. Nagendra S. Sardeshpande

Consultant Gynecologist & EndoscopistBombay Hospital Institute of Medical Sciences

Mumbai

“Even if peritoneal endometriosis arises from the implantation of endometrial and

tubal tissue on the surface of the peritoneum, as I believe it does, this does

not prove that all instances of endometrium-like tissue involving the peritoneum arises from this source”

John A. Sampson, 1927

IntroductionIntroductionEndometriosis is a benign, estrogen

dependent gynecological disease affecting 5-10% of women of reproductive age (20-40% of women undergoing ART) with symptoms including chronic pain, dysmenorrhoea, dyspareunia & infertility

Endometriomas17% of subfertile women 17-44% of endometriosis

EndometriomaEndometriomaEtiologyEtiologySuperficial implant with invagination of ovarian

cortex secondary to bleeding (Hughesdon, 1957)Cortex becomes internal wall Invagination of ovarian cortex secondary to

metaplasia of coelomic epithelium (Donnez, 1996)Recurrence due to metaplastic epithelium within

ovaryEndometriotic transformation of functional cysts

(Nezhat, 1992)

“Any path which narrows future possibilities may become a trap. Humans

are not threading their way through a maze; they scan a vast horizon filled with

unique opportunities”Kevin Anderson

Sampson RevisitedSampson Revisited Sampson noted retrograde flow &

intravasation of dye during menstruation & not with intact endometrium

The term “endometriosis” did not exist Sampson, from radiologic studies,

inferred retrograde endometrial sloughing into Fallopian tubes & veins

Coined the term “implantation adenomas”

Sampson JA. Am J Obstet, 78: 161-75; 1918

Sampson’s Theory of Retrograde Sampson’s Theory of Retrograde DisseminationDissemination

Evidence Supporting Implantation Theory Viable cells obtained from menstrual affluent & peritoneal

fluid Endometrial cells grow in peritoneal cavity Retrograde menstruation almost universal phenomenon Association of endometriosis with obstruction of menstrual

flow Transtubal, lymphatic, hematologic or iatrogenic

deposition D’Hooghe TM, Debrock S.Hum Reprod Update, 8: 84-8; 2002

Sampson’s Theory of Retrograde Sampson’s Theory of Retrograde DisseminationDissemination

Evidence Contradicting Implantation Theory Studies were with “chocolate cysts” with few histologically proven

endometriomas Focused only on severe disease Inferred that pelvic endometriosis was from “leaking” endometriomas Assumed that mode of spread similar to ovarian cancer Multiple extrapolations & hypotheses without supporting evidence No photomicrographic proof of initial attachment of endometrial cells

to peritoneum / ovary Cannot explain distant / male endometriosis Redwine DB in Redwine DB (ed): Surg Mgt Endomet, NY, Martin Dunitz,

Taylor & Francis Gr; 2004

Predisposition to EndometriosisPredisposition to EndometriosisImmunological ChangesImmunological Changes

NK Cell Dysfunction Increased number Killer Cell Inhibitory

Receptors (KIR) in circulating & peritoneal NK cells

Increased ICAM-1 & p40 subunit of IL-2 (potent inhibitors of NK cells) in endometrial cells

Increased PGE2? (inhibitor of NK cells, T cells & macrophages)

Finas D et al. Hum Reprod, 23 (5): 1053-62; 2008


Macrophage Dysfunction Increased production of cytokines (BLyS) associated with

humoral immunity & autoantibodies Increased TNF alpha productionT Cell Dysfunction Altered Th1:Th2 ratios with induction of humoral immunity

in ectopic endometrium Increased T-cell apoptosisB Cell Dysfunction Increased levels of autoantibodies Parham P. The Immune System (2nd ed), NY, Garland Sci; 2005

Predisposition to EndometriosisPredisposition to EndometriosisGenetic FactorsGenetic Factors

EndometriumIncreased expression of cell cycling & anti-

apoptotic genes -Dysregulation of cell cycle genes GOS2 &

SALP controlling mitosis -Increased Ki67 gene expression (indicative of

dividing cells) -Increased expression of Bcl-2 Gaetje R et al. Fertil Steril, 87: 651-6; 2007

Predisposition to EndometriosisPredisposition to EndometriosisGenetic FactorsGenetic Factors

Endometrium Increased expression of embryonic genes -Aberrant methylation of HOXA10 and 11 -Higher expression of WNT7A & PAX8 Aberrant methylation of PR-B receptor gene in response to

TNF alphaImmune System Increased CD-158A gene expression (NK cell inhibitor) in NK

cells Wu Y et al. Am J Obstet Gynecol, 192; 2005

Initiation of EndometriosisInitiation of EndometriosisOxidative StressOxidative Stress

Reduced levels of SOD, glutathione peroxidase, xanthine oxidase & serum paroxanase-1 (prevents oxidation of LDL) in few studies

Reactive oxygen species (released by macrophages & mononuclear cells) increase VEGF production via glycodelin

NO & H2O2 activate cell adhesion molecules via NFkb & AP-1

DeFrere S et al. Gynecol Obstet Inv, 65: 145-54; 2008

Initiation of EndometriosisInitiation of EndometriosisEnvironmental AgentsEnvironmental Agents

Environmental Estrogens Bisphenol A reduce vaginal size, thins endometrial

lamina propria & induces ER alpha & PR in endometrium

Dioxins Activates ER beta Suppresses CMI & humoral immunity Increases endometriotic lesions in primates Edwards TM, Myers JP. Environ Health Persp, 115: 1264-

70; 2007

Initiation of EndometriosisInitiation of EndometriosisEnvironmental Agents & Epigenetic Environmental Agents & Epigenetic

ModulationModulation SF1 methylated (inactive)

in normal endometrium Toxins demethylate SF1

which is activated by SF2 Overexpression of ER

alpha & downregulation of ER beta & PR

Increased steroidogenesis & endometrial proliferation

Dolinoy DC et al. Reprod Toxicol, 23: 297-307; 2007

Maintenance of EndometriosisMaintenance of EndometriosisEndogenous HormonesEndogenous Hormones

Evidence Supporting Role of Hormones Requires estrogen (rare in childhood & after

menopause) Rare in ovarian dysgenesis Hyperprogestogenic, hypoestrogenic states

(pregnancy, breast feeding, aromatase inhibitors, GnRH analogues, progestins) beneficial

Tissues express E & P receptors Gurates B, Bulun SE. Semin Reprod Med, 21: 125-34;

2003


EstrogenAromatase expression in endometriotic tissueEstrogen activates EMMPRIN (glycosylated

transmembrane protein) which activates MMP (involved in endometrial cell adherence & proliferation)

Braundmeier AG et al. J Clin Endocrinol Metab, 91: 2358-65; 2006


Progesterone Downregulates PR-B but not PR-A receptor (failure of

hypermethylation) in endometriosis Unpredictable responseAndrogens 5alpha reductase activity demonstrated in

endometriosis May stimulate aromatase activity in low concentrations Wu Y et al. Epigenetics, 1: 106-11; 2006 Carneiro MM et al. BJOG, 115: 113-7; 2008

Maintenance of EndometriosisMaintenance of EndometriosisRole of IronRole of Iron

Peritoneal macrophage heme-oxygenase 1 (HO1) oxidises hemoglobin to generate iron, CO & bilirubin

Iron (as transferrin) ingested by macrophages & removed as ferretin

Defective HO1 leads to Hb-Hp (haptoglobin) complexes which damage mesothelium & stimulates inflammatory cytokines

Demir AY et al. Proteonomics, 4: 2608-23; 2004 Hemosiderin laden

macrophages

Maintenance of EndometriosisMaintenance of EndometriosisRole of IronRole of Iron

Maintenance of EndometriosisMaintenance of EndometriosisInflammationInflammation

Macrophages secrete fibronectin, MCP-1, VEGF, MDGF, IL-8 & TNFalpha which induce angiogenesis, endometrial proliferation & synthesis of collagen

Macrophages secrete Th2 cytokines IL-4, Il-5, IL-6, IL-10 &IL-13, TGF beta which promote B cell immunity & suppress T cell cytotoxicity

Berbic M et al. Hum Reprod, 24: 325-32; 2009

Inflammatory stromal reaction in endometriosis

EndometriosisEndometriosisMechanism of Adhesion FormationMechanism of Adhesion Formation

PAI-1 -Inhibits fibrinolysis TGF -Growth inhibitor of epithelium PDGF -Migration & proliferation of fibroblasts, smooth muscle cells & monocytes FGF -Angiogenesis & proliferation of fibroblasts & macrophages VEGF -Angiogenesis -Produced by hypoxic endometrium, macrophages & T cells EGF -Promotes granulation tissue formation Vaze MN et al. Vet World. 3 (12): 561-6; 2010

EndometriosisEndometriosisMechanism of Adhesion FormationMechanism of Adhesion Formation

EndometriosisEndometriosisEffect on FertilityEffect on Fertility

Endometrial Changes Out of phase endometrium Glycodelin gene downregulation (affecting embryo implantation) Lack of integrin beta3 in proliferative phase with lack of MMP

activation and defective embryo adhesion, migration & implantation

Immunological Changes TNFalpha cytotoxic Cytokines, PG cytotoxic & increase uterine & tubal motility Ovulatory dysfunction? Minici F et al. Hum Reprod, 23: 530-7; 2008

Etiopathogenesis of EndometriosisEtiopathogenesis of EndometriosisClinical ImplicationsClinical Implications

Role of Multiple Therapies Combined GnRH analogue & aromatase inhibitorsNovel Therapies COX2 inhibitors Immunomodulators VEGF / TNF alpha inhibitors PR modulators StatinsRebirth of Older Therapies Danazol Gestrinone

AdenomyosisAdenomyosisPredispositionPredisposition

Endometrial Changes Aromatase activity in endometrium Increased PRL, PRL receptor, HCG, LH receptor expression Higher levels of MMP-2 in endometrial epithelium & stroma

predispose to basement membrane breakdown & invasion Increased IL-8 & ENF-78 by endometrium induces

chemokine secretion by macrophages Increased ECAM (E-cadherin) expression Tanwar PS et al. Biol Reprod, 81: 545-52; 2009 Ueki K et al. Int J Gynec Pathol, 23: 248-58; 2004

AdenomyosisAdenomyosisPredispositionPredisposition

Immunological Changes Increased GM-CSF secretion by macrophages induces

endometrial epithelial & stromal proliferation Increased humoral responseGenetic Changes Increased Survivin gene (chromosome 17q25)

expression which inhibits capsase induced endometrial cell apoptosis

Zaitseva M et al. Mol Hum Reprod, 13: 577-85; 2007 White C et al. Reprod Biol Endocrinol, 2: 76; 2004

AdenomyosisAdenomyosisInitiation & MaintenanceInitiation & Maintenance

Neovascularization VEGF, PDGF, MIF &

TNF induce vascularization, increase vascular permeability & increase endometrial proliferation

Peng L et al. Fertil Steril, 91: 2664-75; 2009

Metaplasia Theory of EndometriosisMetaplasia Theory of Endometriosis Peritoneal Disease -Metaplastic potential of pelvic

mesothelium Ovarian Endometriomas -Invagination of the cortex -Metaplasia of coelomic

epithelium Rectovaginal Nodules -Metaplasia of mullerian rests

into endometriotic glands -Secondary infiltration of

peritoneal endometriosis of POD

Glandular element with surrounding stromal & smooth

muscle hyperplasia in endometriosis

Metaplasia Theory of EndometriosisMetaplasia Theory of EndometriosisEvidence Supporting Metaplasia Theory Epithelial invagination in continuation with

ectopic endometrial tissue Endometriomas in MRKH syndrome Primordial follicles found surrounding

endometrioma Presence of smooth muscle, stoma admixed

with endometrium Absence of evolution after removal of

nodule Vigano P in Garcia-Velasco JA, Rizk BRMB

(ed): Endometriosis, St. Louis (USA), Jaypee Publishers; 2010

Smooth muscle & stroma in rectovaginal nodule

Predisposition to Predisposition to EndometriosisEndometriosis

Endometrial ChangesEndometrial Changes Prolonged proliferative phase

of ectopic endometrium Electron microscopic findings

include persistent mitosis, increased glycogen deposition, incomplete ciliogenesis, giant mitochondria & nucleolar channel systems in secretory phase of cycle

Increased aromatase activity Szymanowski K. Eur J Obstet

Gynecol, 132: 107-10; 2007

Increased glycogen

Increased mitosis & nucleolar channel systems

Predisposition to EndometriosisPredisposition to EndometriosisEndometrial ChangesEndometrial Changes

Alteration in TNFalpha induced cell apoptosis via altered sphingomyelinase mediated pathway with increased cell survival

Increased TNF alpha receptors Increased FAS ligand expression by endometrial

epithelial & stromal cells which induces T-cell apoptosis IL-6 (secreted by monocytes, macrophages, endothelial

cells & endometrium) increases Endo-1 (a haptoglobin) which blocks macrophage phagocytosis

Hudelist G et al. Reprod Sci, 14: 798-805; 2007

endometriosis and infertlity

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