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Oocyte Donation and Endometriosis: What Are the Lessons? Erik E. Hauzman, MD1
Juan A. Garcia-Velasco, MD1,2
1 Division of Reproductive Endocrinology and Infertility IVI-Madrid 2 Department of Obstetrics and Gynecology, Rey Juan Carlos
University, Madrid, Spain
Antonio Pellicer, MD3,4 Address for correspondence and reprint requests Juan A. GarciaVelasco, MD, IVI Madrid, Avda del Talgo 68-70, 28023 Madrid, Spain (e-mail:
[email protected]).
3 Division of Reproductive Endocrinology and Infertility IVI-Valencia 4 Department of Pediatrics, Obstetrics and Gynecology, Valencia
University, Valencia, Spain Semin Reprod Med 2013;31:173–177
Abstract
Keywords
► endometriosis ► oocyte donation ► endometrial receptivity
Outcomes of in vitro fertilization cycles in women with endometriosis are significantly worse than in patients without this condition. The impact of endometriosis on ovarian reserve and the quality of retrieved oocytes seems evident. Lower implantation rates, however, raise the question whether this finding is purely the consequence of lower number and poorer quality of embryos, or whether it also reflects compromised endometrial receptivity. Oocyte donation provides an interesting model to investigate reproductive outcome because factors affecting the oocytes are excluded, especially if cycles using oocytes derived from the same donor are analyzed. These studies have shown lower implantation rates in nonendometriotic patients who received oocytes from women with endometriosis, whereas healthy donated oocytes have proven to contribute to a pregnancy with similar chances in women without the disease. The question still to be answered is whether this situation applies for natural cycles or whether it is the use of gonadotropin-releasing hormone analogs and hormonal replacement therapy used for endometrial priming in oocyte recipients that reestablishes an adequate uterine environment. Using a genomic tool based on microarray technology (endometrial receptivity array), the study of differential gene expression in the eutopic endometrium of endometriosis patients undergoing oocyte donation treatment is still underway.
Endometriosis affects 6 to 10% of reproductive-age women.1 The prevalence of this condition in women experiencing pain, infertility, or both is as high as 35 to 50%.2 The monthly fecundity rate in couples diagnosed with both endometriosis and infertility is between 2% and 10% per month,3 whereas it is 25 to 30% for normal couples of reproductive age for the first three cycles. It declines to 4% when couples have been trying to conceive for >1 year.4 Even minimal endometriosis may be associated with marked subfertility.5 Outcomes of in vitro fertilization (IVF) cycles performed in women with endometriosis are significantly worse than in patients without this condition,6–9 although some authors report that these differences are only observed in patients Issue Theme Ramifications and Adaptations to Endometriosis-Induced Infertility; Guest Editor, Dan I. Lebovic, MD
with endometriomas.10 Impaired parameters include the number of oocytes retrieved, peak E2 (estradiol) concentration, fertilization rate, pregnancy rate (PR), and implantation rate (IR).11 Some investigators suggest an altered embryo quality,6,12 possibly due to aberrant events in morphological embryogenesis13 or a higher in vitro embryo blockage in patients with endometriosis.14 The impact of endometriosis on ovarian reserve and the quality of retrieved oocytes seems evident. Lower IR, however, raises the obvious question whether this finding is purely the consequence of poorer embryo quality or number, or whether it also reflects compromised endometrial receptivity. Copyright © 2013 by Thieme Medical Publishers, Inc., 333 Seventh Avenue, New York, NY 10001, USA. Tel: +1(212) 584-4662.
DOI http://dx.doi.org/ 10.1055/s-0032-1333483. ISSN 1526-8004.
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Uterine Receptivity in Endometriosis Patients Uterine receptivity is defined as a restricted time-related period when the uterus is receptive to blastocyst attachment and implantation.15 The changes of this endometrial transition are primarily coordinated by E2 and progesterone (P4), which modulate events in a spatiotemporal manner.16 Although numerous molecules involved in implantation have been identified, analysis of the human receptive phase endometrium has provided limited information on the significance of differences in endometrial gene expression between fertile and infertile women.17–19 The molecular mechanisms that regulate endometrial–blastocyst interaction remain poorly defined. A lack of understanding about the physiologic mechanisms of embryo implantation makes it difficult to explain why women with endometriosis have a decreased implantation capacity.20 Reduced endometrial receptivity may be secondary to delayed histologic maturation or biochemical disturbances,21 mediated through paracrine or endocrine actions or as a result of a change in the immune response. Several studies have demonstrated that the peritoneal fluid and serum of women with endometriosis contain abnormal levels of factors such as tissue inhibitor of metalloproteinase-1 (a regulator of extracellular matrix remodeling),22 interleukin-1,23 and many other cytokines and growth factors.24 In an attempt to find an answer to the reduced fertility rate in women with endometriosis, some recent reports claimed that the endometrium of women with endometriosis may not be exactly the same as in women without the disease. It was found that dysregulation of selected genes in the endometrium of patients with endometriosis may lead to impaired embryonic attachment, embryotoxicity, immune dysfunction, and apoptosis during the window of implantation.25 Several molecules involved in implantation have been investigated and seem to be differently expressed.26–28 Decreased expression of implantation markers during the window of implantation might contribute to impaired implantation in endometriosis.29–31 Lower IRs may be related to reduced or absent expression of the cellular adhesion molecule αvβ3 integrin in patients with endometriosis, which is normally increased in the endometrium during the window of implantation.30 This aberration can be explained by altered methylation of HOXA10, a potent stimulator of αvβ3 expression.32 However, it is well known that single-molecule analysis is not informative enough because there is a redundancy in protein function, so if any of these molecules is incorrectly expressed, others will overtake their function. To this end, a genomic tool based on microarray technology has been designed. This method, called endometrial receptivity array (ERA), allows the simultaneous study of the molecules that make up the transcriptomic signature of genes involved in implantation.19 Most of these genes are related to the immune response or code for cytoskeleton proteins needed for remodeling the endometrium during the window of implantation. The study of differential gene expression in the eutopic endometrium of endometriosis patients with ERA is still underway. Seminars in Reproductive Medicine
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A functional impairment of the zona pellucida was also proposed to affect implantation in women with endometriosis. However, assisted hatching performed for overcoming this problem did not lead to improved IRs or PRs.33 Inadequate corpus luteum function has also been described in patients with endometriosis, with abnormal P4 values in serum detected in the luteal34 and follicular phases.35 Estrogen receptors are usually downregulated at the time of implantation. Women with endometriosis, however, were found to have an upregulation of estrogen receptors.36 Successful endometrial receptivity requires an increase in progesterone relative to estrogens. Progesterone resistance through the absence of the β isoform of its receptor is most likely due to aberrant methylation.37
Studies in Oocyte Donation Cycles In an attempt to determine the primary cause of low fecundity in endometriosis patients, several oocyte donation studies were devised (►Table 1). This therapeutic strategy provides an interesting model to investigate reproductive outcome as factors affecting the oocytes are excluded, especially if cycles using oocytes derived from the same donor are analyzed. Within this setting, two different approaches have been applied for the study of the role of endometriosis in the outcome of oocyte donation cycles: (1) by splitting the oocytes from the same donor between recipients with and without endometriosis in a prospective study and comparing outcomes,38 and (2) by a retrospective study of oocyte donation cycles with discordant outcomes, comparing indications for oocyte donation.39,40 Moreover, the role of the origin of donated oocytes was also analyzed in early studies undertaken by our group, comparing women who received fresh oocytes from nonendometriotic women with those receiving oocytes from women with endometriosis.6,41 In a matched case-control study of 58 recipients performed by our group,38 oocytes were donated to 25 recipients diagnosed with stage III/IV endometriosis; the remaining 33 patients (receiving oocytes from the same donors as their matched pairs) were free of the disease (some of the donors supplied oocytes for more than two patients). Recipients underwent steroid replacement therapy as well as a previous depot gonadotropin-stimulating hormone (GnRH) agonist for endometrial preparation. The number of oocytes donated and fertilized, as well as the number of available and transferred embryos, was not statistically different between the two groups. Pregnancy, implantation, miscarriage, and live-birth rates (LBRs) were not affected by stage III/IV endometriosis when compared with the control group, suggesting that implantation is not affected by stage III/IV endometriosis when the oocytes come from healthy donors. In a later larger-scale study,39 we analyzed retrospectively 365 oocyte donation cycles in which oocytes were shared from donors between recipients with discordant outcome (i.e., at least one of the oocyte recipients from the same donor achieved pregnancy, whereas the others did not). Oocytes were evenly distributed among recipients
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Table 1 Studies on the Outcome of Oocyte Donation Cycles in Endometriosis Patients Study
Study setting
Main findings
Retrospective study of oocyte donation cycles
Lower IR with oocytes donated by endometriosis patients
Pellicer et al41
Prospective study in donors or recipients with endometriosis
Lower PR and IR with oocytes donated by endometriosis patients to recipients without endometriosis; PR and IR not affected in recipients with endometriosis with oocytes derived from donors without known endometriosis
Díaz et al38
Splitting oocytes from the same donor between recipients with and without stage III/IV endometriosis (prospective matched case-control study)
PRs, IRs, MRs, and LBRs not affected by recipients’ endometriosis status
Garcia-Velasco et al39
Retrospective study of cycles with discordant outcomes, comparing indications
No differences in indications (i. e., proportion of endometriosis patients)
Bodri et al40
Retrospective matched case-control study of cycles with discordant outcomes
No differences in indications (i.e., proportion of endometriosis patients)
Simón et al
6
PR, pregnancy rate; IR, implantation rate; MR, miscarriage rate; LBR, live-birth rate.
according to their quality and maturity. All oocyte recipients were prepared with hormone replacement therapy. In patients with ovarian function, depot GnRH agonist was administered in the midluteal phase of the previous cycle. Hormonal replacement was started on the first day of the cycle with increasing doses of E2 valerate: 2 mg/day for the first 8 days of the cycle, followed by 4 mg/day for the next 3 days, and then 6 mg/day was continued. Micronized P4 (800 mg/day) intravaginally was administered starting the day of oocyte donation, and embryo transfer was performed according to each patient’s program on day 2, 3, or 6 of embryo cleavage. Pregnant and nonpregnant recipients were similar in terms of age, serum E2 levels, endometrial thickness, indications for oocyte donation, and abnormal sperm parameters. No differences were found in the number of oocytes received per patient, fertilization rate, embryo quality, or on embryo transfer difficulty. Similar results were found in another matched case-control study by Bodri et al,40 analyzing 444 cycles of 222 pairs of oocyte recipients. Among other findings, the authors found no significant difference in the distribution of indications for treatment, including the prevalence of endometriosis. Two earlier studies performed by our group in oocyte recipients also underlined the role of ovarian and embryonic factors, as opposed to the role of endometrial receptivity, in decreased chances of pregnancy in endometriosis patients. In a retrospective study of 178 embryo transfers in 141 women, significantly lower implantation rates were observed in patients who received oocytes from women with endometriosis.6 To eliminate the inherent bias of the retrospective model, a prospective study was then designed in which three groups were established41: group 1, 44 donors and recipients without signs of endometriosis; group 2, 14 donors with endometriosis who donated oocytes to recipients without the disease; and group 3, 16 donors without endometriosis
who donated oocytes to recipients with the disease. Lower pregnancy rates per transfer were observed in group 2 (28.6%) compared with the other two groups (61.4% for group 1 and 60.0% for group 3), despite the similar number of embryos that were replaced. A significant decrease in implantation rates was also noted in group 2 (6.8%) compared with groups 1 (20.1%) and 3 (20.8%), confirming that embryos derived from oocytes of women with endometriosis display a reduced ability to implant. Thus patients with endometriosis who were prepared with depot GnRH agonist and steroid replacement therapy had the same chances of implantation and pregnancy as other recipients when the oocytes came from donors without known endometriosis. These findings are in line with a large retrospective analysis of >10,000 oocyte donation cycles performed at our group over a 10-year period, showing that cumulative pregnancy rates did not differ significantly among different indications for oocyte donation.42 Results derived from studies in recipients of donor oocytes show that women with severe endometriosis undergoing steroid replacement therapy are as likely to conceive as women without this condition, suggesting that uterine receptivity is not impaired in endometriosis. The question still to be answered is whether this situation applies for natural cycles or whether the use of GnRH analogs and hormonal replacement therapy makes a difference in the endometrial milieu of these cycles, and whether this is why endometriosis does not affect outcome. We might hypothesize that endometrial priming protocols used in oocyte donation cycles reestablish an adequate uterine cavity environment. In fact, one report has demonstrated that GnRH analogs in media used for in vitro culture of eutopic endometrial cells from patients with endometriosis can restore the normal apoptotic rate (usually low in eutopic and ectopic endometrial cells from women with this condition).43 A 3-month course of GnRH analogs before an ovarian Seminars in Reproductive Medicine
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stimulation cycle for IVF in patients with endometriosis is reported to produce significantly higher ongoing PRs and LBRs, with a trend to a higher IR.44,45 Interestingly, this improvement in cycle outcome is not associated with any increase in the number of oocytes retrieved, fertilization rate, or number of embryos replaced. In light of the abnormalities observed in natural menstrual cycles of women with endometriosis, artificial endometrial priming for oocyte donation could be beneficial in that downregulation and the exogenous supply of E2 and P4 would correct problems related with the inadequate P4 levels described in these women.34,35 Furthermore, pinopode formation with artificial priming has been found to be normal in these patients.46 In summary, after years of experience with both IVF and egg donation, in which different implicated factors have been analyzed, we can conclude that the main limiting factor of fertility in women with endometriosis is oocyte dependent. In patients with endometriosis, healthy donated oocytes will contribute to a pregnancy with similar chances as in women without the disease. However, endometriotic oocytes will show poorer reproductive outcome even if a receptive endometrium is evident from the morphological and molecular point of view. Between these two key players, oocyte quality is the driving force, and although a receptive endometrium is also required, it seems to follow the oocyte in terms of relevance.
11 Arici A, Oral E, Bukulmez O, Duleba A, Olive DL, Jones EE. The effect
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