Lalitkumar et al 1. The uterus as a biosensor. Endometrial Contraception. Overview of the presentation. Disclosures of Financial Relationships

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1 Disclosures of Financial Relationships Endometrial Contraception Gemzell-Danielsson has received honorarium as an advisory board member and/or invited speaker at Merck (MSD), Bayer, Exelgyne, Actavis, Gedeon Richter, Exeltis, and HRA-Pharma Kristina Gemzell Danielsson, MD, PhD, Department of Women s and Children s Health Karolinska Institutet/ Karolinska University Hospital Stockholm, Sweden Overview of the presentation Endometrial receptivity Studies in vivo Control of endometrial receptivity - Endometrial contraception Studies in vitro Implantation model Foto: Lennart Nilsson S Robertson Control of endometrial receptivity. K Gemzell The uterus as a biosensor Search for morphological and molecular markers of endometrial receptivity Pinopodes Integrin, adhesion molecules Glycodelin PG Cytokines (LIF) PR LIF-R ErB4 PGE 2 PGF 2a IL-1α IL-1ß IL-1ra Glycodelin LIF HB-EGF α v ß3 IL-RtI LIF-R Teklenburg G, et al PLoS ONE 5 (4 ): e /journal.pone Lalitkumar et al 1

2 Mifepristone Effects during the cycle and in pregnancy Contragestion Control of endometrial receptivity Endometrial contraception Follicular phase Contraception Pregnancy Interruption Labour Induction Adjuvant to late Pregnancy termination Ovulation 1 28 Postovulatory treatment: effects on the endometrium 200 mg Mifepristone Normal bleeding pattern + plasma levels of E2, P4 Endometrial effects of mifepristone Morphometric analysis Increased glandular apoptosis Decreased secretory activity à General (DBA lectin binding) à S-Glycodelin,Specific endometrial proteins Reduced glandular enos Reduced 17HSD Increased expression of PR, ER, AR Vascular compartment Johannesson et al Chritchley et al., 1999, 2002 Gemzell Danielssonet al., 1994, 1996, 2004 Endometrial Contraception ONCE-A-MONTH TREATMENT WITH 200MG MIFEPRISTONE ON DAY LH+2 AS A CONTRACEPTIVE METHOD Number of cycles with an intercourse from 3 days before to 1 day after ovulation Treatment No. of cycles No. of pregnancies Probability of pregnancy Mifepristone None* Effects on fertilization and embryo development Mifepristone, 100 mg, 1h prior to induction of ovulation (n=20) and controls (n=20) Oocytes collected 34 h after hcg, IVF No differences in retrieved oocytes (80%), fertilization rate (60%) or cleavage rate No direct effect on monkey embryos Messinis & Templeton 1988 Wolf et al., 1990 *Unprotected intercourse during the time period 3 days before to 1 day after mucus peak day (from WHO multicentre study, Fertil Steril 40:773,1993) Lalitkumar et al 2

3 In vitro model: 3D endometrial-embryo construct In vitro3d-endometrial construct Mechanical + enzymatic Separation. Biopsy (LH + 4 / 5), n=22 Stromal cell Alpha meium E + P Epithelial cell Stromal cell Collagen bed Top view view Cross sectional E C Epithelial cell P Human Embryo S Lalitkumar et al., 2007 Lalitkumar et al., Lalit kum ar et al 14 Human embryo attached to the endometrial construct Blastocyst attachment rate in vitro Control Embryo Endometrial construct Mifepristone Lalitkumar et al., ***P<0.01 compared with the control Lalitkumar et al., Hum Reprod Nov;22(11): MIFEPRISTONE Emergency contraception Post-ovulatory contraception Low dose treatment Pills IUS Vaginal ring Is the endometrium the target? Endometrial inhibition Lalitkumar et al 3

4 Blastocyst attachment rate in vitro Results: LNG Control UPA 200 ng/m L Mifepristone ***P<0.01 compared with the control Lalitkumar et al., Hum Reprod Nov;22(11): Nam n Ef t er nam n June 3, Blastocyst attachment rate with LIFR inhibitor LIF and human endometrial receptivity ** Fisher s exact test P<0.02 LIF concentration in uterine flushings - 36 pg/ml (median) Lalitkumar et al Mikolajczyk et al., Same sample, many studies, different results! Omics era in endometrial receptivity research Number of genes referred as biomarkers of endometrial receptivity that were common to the six microarray studies. Two genes were common to the six studies, Five genes to five studies, 28 genes to four studies, 67 genes to three studies Omics technologies, such as transcriptomic and proteomic approaches, have recently been used to identify biomarkers of human endometrial recepetivity Studies have identified new biomarkers of endometrial receptivity by analysing the gene- or protein-expression-pr ofile shift between the pre-receptive and receptive stages of natural cycles (Carson et al., 2002; Domı nguez et al., 2009; Dı az-gimeno et al., 2011; Haouzi et al., 2009a; Li et al., 2006; Mirkin et al.,2005; Riesewijk et al., 2003; Talbi et al., 2006). Haouzi et al., Repr oductive Lalitkumar et al 23 BioMedicine Online Volum e 24, Issue

5 Laser dissection capture - microarray Molecular Network Gland Stroma Studied mrna expression genes Lalitkumar et al., (unpublished) 25 Major genes altered ENPP3 - mrna expression values - microarray Novel marker ENPP3 1000" 900" 800" Intensity 700" 600" 500" 400" 300" Control (with Progesterone) SPRM 200" 100" 0" Control"(P)" Lalitkumar et al., An6"P" Endometrial ENPP3 Effect of SPRM on the expression of ENPP3 With mifepristone treatment (0.5 μm) Fold Change With UPA (200 ng/ml) Fold Change Co n tro l UPA Mi fe p ri s to n e , ,0 4-7 Lalitkumar et al 29 5

6 ENPP3 in uterine fluid ENPP- 3 3D structure Summary Today many women are reluctant to use any of the existing contraceptive methods due to side effects or fear of experiencing such effects. The concept of endometrial contraception refers to methods that exert their effect after fertilization. Mifepristone has been shown to be effective when used onceweekly or once-a-month. New options should be explored to allow women all possible options for controlling and preserving their reproductive health and lives. Foto: Lennart Nils s on Endometrial Danielsson receptivity. K Gemzell WHO Collaborating Centre for Research in Human Reproduction Kristina Gemzell Danielsson Lena Marions Marc Bygdeman Annette Aronsson Lalit Kumar Xiaoxi Sun Angelos Sioutas Marja-Liisa Swahn Karin Andersson Chunxia Meng Christian Fiala Sten Cekan Lena Elffors Söderlund Eva Broberg, Karin Emtell I Inga-Maj Andersson Ingrid Sääv Kjell Wånggren Mikael Engman Sujata Lalitkumar Ursula Bentin-Lay, Denmark. Research Group on Post-Ovulatory Methods for Fertility Regulation,UNDP/UNFPA/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction, WHO, Geneva Swedish research council Cont r ol of endom et r ial r ecept ivit y. Lalitkumar et al K G em zell Danielsson 6