Welcome. IV INTERNATIONAL WORKSHOP ON OPTIMIZING INFERTILITY TREATMENTS Sao Paulo, Brazil September 3-6, Visit

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1 Welcome IV INTERNATIONAL WORKSHO ON OTIMIZING INFERTILITY TREATMENTS Sao aulo, Brazil September 3-6, 2003 Visit

2 The role of the endometrium in implantation in human beings rof. Antonio ellicer

3 OBJECTIVES To review the molecular basis of implantation To analyze the clinical relevance of the endometrium in implantation To discuss the screening methods of endometrial receptivity To improve IVF outcome through enhanced endometrial receptivity

4 OBJECTIVES To review the molecular basis of implantation To analyze the clinical relevance of the endometrium in implantation To discuss the screening methods of endometrial receptivity To improve IVF outcome through enhanced endometrial receptivity

5 THE IMLANTATION ROCESS AOSITION ADHESION glandular epithelium capillary endothelium macrophages endometrial stroma

6 THE IMLANTATION ROCESS EITHELIAL ENETRATION INVASION glandular epithelium capillary endothelium macrophages endometrial stroma

7 MOLECULAR BASIS OF IMLANTATION Chemokines IL-1 CSF-1 LIF Leptin Adhesion and anti-adhesion molecules Integrins Glycodelin MUC-1 EEC apoptosis

8 Lindhard et al, Fertil Steril 2002; 78: 221

9 LH+2 LH+7 Total RNA (Dnase I Treatment, RT reaction) Methodology Gene Expression rofile Wash, film exposure 33 cdnas probes (Gene-specific primers) Hybridization cdna filters of known genes Dominguez et al. J Clin Endocrinol Metab 2003; 88: : 375 genes Riesewijk et al. Mol Hum Reprod 2003; 9: 1-13: 14,000 genes

10 Genes regulated during human endometrial receptivity Strong (>10) Medium (5-10) Weak (3-5) Up at LH Down at LH

11 EXERIMENTAL AROACHES TO ANALYZE HUMAN ENDOMETRIAL RECETIVITY Kao et al. 11 SAMLES RNA NOT OOLED roliferative phase VS Receptive phase AFFIMETRIX HG-U95A 156 Up Fold > Down (Endocrinology) Carson et al. 6 SAMLES RNA OOLED LH+(2-4) VS LH+(7-9) AFFIMETRIX HG-U95A 323 Up Fold > Down (Molec Hum Reprod) Riesewijk et al. 10 SAMLES RNA NOT OOLED LH+2 VS LH+7 AFFIMETRIX HG-U95A 153 Up Fold > Down (Molec Hum Reprod) Borthwick et al. 10 SAMLES RNA OOLED roliferative 9-11 VS LH+(6-8) AFFIMETRIX HG-U95A-E 90 Up Fold > Down (Molec Hum Reprod)

12 CONSENSUS GENES: FOLD CHANGE >3 Accesion number (Function) Gene name Riesewijk Kao Carson Borthwick U-REGULATED GENES RESENT IN THE FOUR WORKS AF (Structural protein) Osteopontin J02611 (Trasporter) Apolipoprotein D AB (Signalling) Dickkopf/DKK1 (hdkk-1) U-REGULATED GENES RESENT IN THREE OUT OF FOUR WORKS J04129 (Secretory protein) lacental protein-14/glycodelin M31516 (Immnunomodulator) Decay accelerating factor for complement (CD55, Cromer blood group system) M84526 (Complement protein) Adipsin/complement factor D M55543 (GT-Binding protein) Guanylate binding protein 2, interferon-inducible AB (Receptor) Claudin 4/CE-R AA (Signalling) Monoamine oxidase A (MAOA) M60974 (Regulatory protein) Growth arrest and DNA-damageinducible protein (gadd45) AB (Cell death factor) Nip2 TOTAL GENES ANALYZED DOWN-REGULATED GENES RESENT IN THE FOUR WORKS U79299 (Secretory protein) Olfactomedin-related ER localized protein TOTAL GENES ANALYZED

13 Diagnosis Clinical applications Gene targeting rotein analysis Diagnostic method must be non-invasive and at the time of embryo transfer Endometrial fluid

14 EMBRYONIC REGULATION OF ENDOMETRIAL MOLECULES Chemokines De los Santos et al, BOR 1996 Simón et al, JCEM 1997, Adhesion and anti-adhesion molecules Martin et al, BOR 2001 Leptin González et al, JCEM 2000 Meseguer et al, BOR 2001 EEC apoptosis Galán et al, BOR 2001

15 Antibodies (protein study) SIALIDASE MUC1/SEC HMFG-1 (ICRF, UK) MUC1/Y 7H8/2 (Wreschner,, Israel) BC-2 (Serotec( Serotec,, UK) BC-3 ( 232A (Hilkens, Netherland) CT-1 (ICRF, UK)

16 Densitometric AU EMBRYONIC REGULATION OF MUC1 mrna Adenoids B C A EC MUC1 mrna Hybridization signal 28s rrna Hybridization signal 4.7 Kb Kb Densitometric AU MUC1 mrna levels N=8 * Control S1 ArrestedBlastocyst Blastocyst

17 1 2 3 BC-2 Results Flow cytometry on cocultured EEC * Fluorescence arbitrary units * <0,05 N=10 HMFG-1+ Sialidase HMFG-1 CT-1 N=8 Control N=9 N=16 N=16 N=8 N=14 Arrested N=5 * N=15 N=8 N=18 N=11 Blastocyst

18 CONFOCAL MICROSCOY OF HUMAN BLASTOCYST ATTACHMENT Cytokeratin FITC A 450x B 450x MUC1 FITC C 450x D 450x

19 CONCLUSIONS The human blastocyst induces a coordinated regulation of EEC MUC-1 during aposition and adhesion Aposition Adhesion MUC-1 MUC-1

20 OBJECTIVES To review the molecular basis of implantation To analyze the clinical relevance of the endometrium in implantation To discuss the screening methods of endometrial receptivity To improve IVF outcome through enhanced endometrial receptivity

21 layers involved in implantation Embryo (morfologic & genetic) Endometrium (morfologic & genetic)

22 Bergh, Navot D. Fertil Steril 1992; 58:

23 Methodology COCULTURE/ TRANSFER (day 5) ICSI (day 0) EMBRYO BIOSY (day 3) FISH

24 Biochemical pregnancies in chromosomally normal embryos GD Day 3 Blastocyst p value Cycles Age a 34.4 ± 3.7 b 33.4± ±3.5 b Days of treatment 10.7 ± ± ± Gonadotropins a 3967 ± 1932 c 3613± ± 985 c 0.02 E2 day hcg a 3586 ±1621 d 2592±1363 d 3458 ± Oocytes a 21.3 ± ±8.6 e 25.4 ±10.7 <0.001 Embryos transfer a 2.1 ± 0.9 f 2.9± ± 0.7 <0.001 Implantation rate a 51.5 ± ± ± Biochemical (%) 16 (25,8) 15 (24,2) 16 (25,8) >0.05 Troncoso et al, Fertil Steril 2003; 79: 449

25 When implantation fails?

26 Simón et al. Fertil Steril 1999; 72: 1061

27 Simón et al. Fertil Steril 1999; 72: 1061

28 OBJECTIVES To review the molecular and genetic basis of implantation To analyze the clinical relevance of the endometrium in implantation To discuss the screening methods of endometrial receptivity To improve IVF outcome through enhanced endometrial receptivity

29 Lindhard et al, Fertil Steril 2002; 78: 221

30 High within-subject between cycle variability in markers of endometrial receptive status Table 2. Cycle to cycle agreement for each endometrial variable investigated in three consecutive cycles in 15 patients. 1 st biopsy Agreement between 1 st and 2 nd biopsies Agreement between 1 st and 3 rd biopsies Variable Yes No % k-value () Level of agreement % k-value () Level of agreeme nt Histological dating within the implantation window 8 (53%) 7 (47%) (0.10) Fair (0.19) Fair Biopsy in phase 12(80%) 3 (20%) (0.78) oor (0.50) Slight avb3 expression 6 (40%) 9 (60%) (0.93) oor (0.19) Fair inopod formation 12(80%) 3 (20%) (0.83) oor (0.70) oor Ordi et al. J Clin Endocrinol Metab 2003; 88:2119

31 OBJECTIVES To review the molecular basis of implantation To analyze the clinical relevance of the endometrium in implantation To discuss the screening methods of endometrial receptivity To improve IVF outcome through enhanced endometrial receptivity

32 Clinical implications High responders have lower implantation rates compared to normal responders due to alteration of endometrial receptivity (Simón et al, Hum Reprod Valbuena et al, Hum Reprod 1999) Determination of peri-implantation estradiol levels (E 2 ) in high versus normal responders (ellicer et al, Fertil Steril Valbuena et al, Hum Reprod 1999) Increasing implantation rates by decreasing estradiol levels during the preimplantation period in high responders with the use of a step-down regimen (Simón et al, Fertil Steril Valbuena et al, Hum Reprod 1999)

33 Uterine sensitivity to E 2 3 ng ng 1.5 ng Refractory Receptive re-receptive hours Genes associated with uterine preparation to the receptive state in mice (COX-1, Lif, Hoxa 10, amphiregulin) are aberrantly expressed after high dose of estrogen Ma et al. NAS 2003; 100:

34 LEUKEMIA INHIBITING FACTOR (LIF) Concentration of LIF in uterine flushing is predictive of embryo implantation (Lédée-Bataille et al, Hum Reprod 2002;17: 213) Administration of LIF improves implantation (ESHRE, 2003, 0-058) rospective Multicenter study

35 CONCLUSIONS There are endometrial-embryonic interactions at the molecular level, but the embryo seems to drive all these orchestrated events The endometrium is an independent and important factor in implantation The screening methods of endometrial receptivity are difficult to apply due to individual variability and effect of the embryo IVF outcome can be improved through enhanced endometrial receptivity

36 AKNOWLEDGEMENTS Marcos Meseguer Josep LL. RomeroJosé Remohí Arancha Galán M.C. Rubio Julio Martín Ernesto Bosch Ana Cobo A. Requena M.J. de los SantosAmparo Ruiz Amparo Mercader Carmina Vidal José Bellver J.A. G. Velasco J. Martínez Juana Crespo Jaime Ferro Carlos Simón Manuel Rodriguez Diana Valbuena

37 Wen-ge, M. et al. roc.natl. Acad. Sci. U. S. A. (2003) A Uterine sensitivity to E ng 1.5 ng Implantation No implantation B Uterine sensitivity to E 2 3 ng ng 1.5 ng hours Refractory Receptive re-receptive C Days of seudopreganancy Ovariectamized Mice Estradiol Injection Blastocyst Transfer