Endometrial Flushing Tumor Necrosis Factor Alpha and Interleukin 2 Levels in Women with Polycystic Ovary Syndrome, Leiomyoma and Endometrioma: Comparison with Healthy Controls

Abstract

Introduction An important open question in the literature is whether endometrial receptivity marker levels are different in infertility related diseases than healthy women. The aim of the study is to compare the levels of interleukin two (IL-2) and tumor necrosis factor alpha (TNF-α) during the implantation window in the endometrial flushing fluid of polycystic ovary syndrome (PCOS), endometrioma, leiomyoma patients with healthy controls.

Material and Methods In this case control study, after obtaining endometrial flushing fluids at mid-luteal phase of ovulatory women with PCOS (n = 20), endometrioma (n = 19), leiomyoma (n = 20) and healthy controls (n = 20), IL-2 and TNF-α levels were measured using ELISA kits in BioTek ELISA devices.

Results Mean TNF-α levels (ng/mL) were similar for the PCOS (305.6, p = 0.220) and the leiomyoma group (246.3, p = 0.502) compared to healthy patients (261.1). However, the levels were higher in the endometrioma group (338.2, p = 0,004) than the control group (261.1) in a statistically significant way. Mean IL-2 levels (ng/mL) were significantly lower in the PCOS (290.9, p = 0.0005), the leiomyoma (282.9, p = 0.0002) and the endometrioma patients (229.5, p = 0.0009) than the control group (416.0).

Conclusion Relative to the control group, endometrial flushing fluid TNF-α levels were significantly higher in endometrioma patients and IL-2 levels were significantly lower in PCOS, leiomyoma and endometrioma patients. In benign gynecological diseases, endometrial markers related to infertility seem to show differences in endometrial flushing fluid. Future studies might identify the reference values for these markers, and endometrial markers can be used to diagnose gynecologic disorders causing infertility.

Zusammenfassung

Einleitung Eine wichtige, in der Literatur oft diskutierte Frage ist, ob Markerwerte, welche die Empfänglichkeit von endometrialem Gewebe anzeigen, anders sind bei Frauen mit Infertilität, verglichen mit gesunden Frauen. Ziel dieser Studie war es, die Interleukin-2-(IL-2) und Tumornekrosefakor-α-(TNF-α-)Spiegel in der endometrialen Spülflüssigkeit während des Implantationsfensters bei Frauen mit polyzystischem Ovarsyndrom (PCOS), Endometriomen oder Leiomyomen mit den Werten einer gesunden Kontrollgruppe zu vergleichen.

Material und Methoden In dieser Fallkontrollstudie wurden die IL-2- and TNF-α-Werte von Frauen mit PCOS (n = 20), Endometriomen (n = 19) und Leiomyomen (n = 20) gemessen und mit den Werten einer gesunden Kontrollgruppe (n = 20) verglichen. Die Werte wurden während der Lutealphase in der endometrialen Spülflüssigkeit der Frauen gemessen. ELISA Kits und BioTek ELISA-Geräte wurden zur Messung der IL-2- und TNF-α-Spiegel verwendet.

Ergebnisse Die durchschnittlichen TNF-α-Werte (ng/mL) der PCOS-Gruppe (305,6, p = 0,220) und der Leiomyomgruppe (246,3, p = 0,502) waren ähnlich; beide waren höher als die in der gesunden Kontrollgruppe gemessenen Werte (261,1). Die Werte der Endometriomgruppe (338,2, p = 0,004) waren noch höher verglichen mit der Kontrollgruppe (261,1), und dieser Unterschied war statistisch signifikant. Durchschnittliche IL-2-Werte (ng/mL) waren wesentlich niedriger in der PCOS-Gruppe (290,9, p = 0,0005), der Leiomyomgruppe (282,9, p = 0,0002) und der Endometriomgruppe (229,5, p = 0,0009) verglichen mit der Kontrollgruppe (416,0).

Schlussfolgerung Relativ zur Kontrollgruppe waren die TNF-α-Werte in der endometrialen Spülflüssigkeit signifikant höher in der Patientinnengruppe mit Endometriomen, und die IL-2-Werte waren signifikant niedriger in den Patientinnen mit Leiomyomen und Endometriomen. Bei gutartigen gynäkologischen Erkrankungen scheinen sich die Werte fertilitätsassoziierter, in der endometrialen Spülflüssigkeit gemessener Marker von den Werten gesunder Frauen zu unterschieden. Die Referenzwerte dieser Marker könnten Gegenstand zukünftiger Studien sein, und die endometrialen Marker könnten zur Diagnose von gynäkologischen Störungen, die ursächlich für Infertilität sind, herangezogen werden.

Key words

endometrial receptivity - interleukin 2 - tumor necrosis factor alpha - polycystic ovary syndrome - leiomyoma - endometrioma

Schlüsselwörter

Empfänglichkeit des endometrischen Gewebes - Interleukin 2 - Tumornekrosefaktor-α - polyzystisches Ovarsyndrom - Leiomyom - Endometriom

• References

• 1 Aghajanova L, Simón C, Horcajadas JA. Are favorite molecules of endometrial receptivity still in favor?. Expert Rev Obstet Gynecol 2008; 3: 487-501
• 2 Giudice LC. Potential biochemical markers of uterine receptivity. Hum Reprod 1999; 14 (Suppl. 02) 3-16
• 3 Wang H, Dey SK. Roadmap to embryo implantation: clues from mouse models. Nat Rev Genet 2006; 7: 185-199
• 4 Erten G. Sitokinler. In: Camcıoğlu Y. ed. Sempozyum Dizisi No: 80, Bağışıklık Sistemi ve Yetersizlikleri. İstanbul: İ.Ü. Cerrahpaşa Tıp Fakültesi Sürekli Tıp Eğitimi Etkinlikleri; 2013: 55-62
• 5 Ghosh D, Sengupta J. Recent developments in endocrinology and paracrinology of blastocyst implantation in the primate. Hum Reprod Update 1998; 4: 153-168
• 6 Lalitkumar PG, Sengupta J, Ghosh D. Endometrial tumor necrosis factor alpha (TNFalpha) is a likely mediator of early luteal phase mifepristone-mediated negative effector action on the preimplantation embryo. Reproduction 2005; 129: 323-335
• 7 Abbas AK, Lichtman AH. Cytokines. In: Abbas AK, Lichtman AH. Cellular and molecular Immunology. 5th ed.. Saunders; 2005: 264-267
• 8 Soni C, Karande AA. Glycodelin-A interferes with IL-2/IL-2R signalling to induce cell growth arrest, loss of effector functions and apoptosis in T-lymphocytes. Hum Reprod 2012; 27: 1005-1015
• 9 Hamai Y, Fujii T, Yamashita T. et al. Evidence for an elevation in serum interleukin-2 and tumor necrosis factor-alpha levels before the clinical manifestations of preeclampsia. Am J Reprod Immunol 1997; 38: 89-93
• 10 Donaghay M, Lessey BA. Uterine receptivity: alterations associated with benign gynecological disease. Semin Reprod Med 2007; 25: 461-475
• 11 Maheux-Lacroix S, Dodin S, Moore L. et al. Preovulatory uterine flushing with saline as a treatment for unexplained infertility: a randomised controlled trial protocol. BMJ Open 2016; 6: e009897
• 12 Demir M, Ince O, Ozkan B. et al. Endometrial flushing alphaVbeta3 integrin, glycodelin and PGF2alpha levels for evaluating endometrial receptivity in women with polycystic ovary syndrome, myoma uteri and endometrioma. Gynecol Endocrinol 2017; 33: 716-720
• 13 Rotterdam ESHRE/ASRM-Sponsored PCOS Consensus Workshop Group. Revised 2003 consensus on diagnostic criteria and long-term health risks related to polycystic ovary syndrome. Fertil Steril 2004; 81: 19-25
• 14 Ben-Nagi J, Miell J, Mavrelos D. et al. Endometrial implantation factors in women with submucous uterine fibroids. Reprod Biomed Online 2010; 21: 610-615
• 15 Tabibzadeh S. Molecular control of the implantation window. Hum Reprod Update 1998; 4: 465-471
• 16 Toder V, Fein A, Carp H. et al. TNF-alpha in pregnancy loss and embryo maldevelopment: a mediator of detrimental stimuli or a protector of the fetoplacental unit?. J Assist Reprod Genet 2003; 20: 73-81
• 17 Staun-Ram E, Goldman S, Gabarin D. et al. Expression and importance of matrix metalloproteinase 2 and 9 (MMP-2 and -9) in human trophoblast invasion. Reprod Biol Endocrinol 2004; 2: 59
• 18 Arck PC, Troutt AB, Clark DA. Soluble receptors neutralizing TNF-alpha and IL-1 block stress-triggered murine abortion. Am J Reprod Immunol 1997; 37: 262-266
• 19 Stefanski AL, Specker C, Fischer-Betz R. et al. Maternal Thrombophilia and Recurrent Miscarriage – Is There Evidence That Heparin is Indicated as Prophylaxis against Recurrence?. Geburtsh Frauenheilk 2018; 78: 274-282
• 20 Minici F, Tiberi F, Tropea A. et al. Endometriosis and human infertility: a new investigation into the role of eutopic endometrium. Hum Reprod 2008; 23: 530-537
• 21 Iwabe T, Harada T, Terakawa N. Role of cytokines in endometriosis-associated infertility. Gynecol Obstet Invest 2002; 53 (Suppl. 01) 19-25
• 22 Zhang RJ, Wild RA, Ojago JM. Effect of tumor necrosis factor-alpha on adhesion of human endometrial stromal cells to peritoneal mesothelial cells: an in vitro system. Fertil Steril 1993; 59: 1196-1201
• 23 Toth B, Würfel W, Bohlmann M. et al. Recurrent Miscarriage: Diagnostic and Therapeutic Procedures. Guideline of the DGGG, OEGGG and SGGG (S2 k-Level, AWMF Registry Number 015/050). Geburtsh Frauenheilk 2018; 78: 364-381
• 24 Younis A, Hawkins K, Mahini H. et al. Serum tumor necrosis factor-alpha, interleukin-6, monocyte chemotactic protein-1 and paraoxonase-1 profiles in women with endometriosis, PCOS, or unexplained infertility. J Assist Reprod Genet 2014; 31: 1445-1451
• 25 Gonzalez F, Thusu K, Abdel-Rahman E. et al. Elevated serum levels of tumor necrosis factor alpha in normal-weight women with polycystic ovary syndrome. Metabolism 1999; 48: 437-441
• 26 Pawelczak M, Rosenthal J, Milla S. et al. Evaluation of the pro-inflammatory cytokine tumor necrosis factor-alpha in adolescents with polycystic ovary syndrome. J Pediatr Adolesc Gynecol 2014; 27: 356-359
• 27 Thathapudi S, Kodati V, Erukkambattu J. et al. Tumor necrosis factor-alpha and polycystic ovarian syndrome: a clinical, biochemical, and molecular genetic study. Genet Test Mol Biomarkers 2014; 18: 605-609
• 28 Guo R, Zheng Y, Yang J. et al. Association of TNF-alpha, IL-6 and IL-1beta gene polymorphisms with polycystic ovary syndrome: a meta-analysis. BMC Genet 2015; 16: 5
• 29 Horcajadas JA, Goyri E, Higon MA. et al. Endometrial receptivity and implantation are not affected by the presence of uterine intramural leiomyomas: a clinical and functional genomics analysis. J Clin Endocrinol Metab 2008; 93: 3490-3498
• 30 Kurachi O, Matsuo H, Samoto T. et al. Tumor necrosis factor-alpha expression in human uterine leiomyoma and its down-regulation by progesterone. J Clin Endocrinol Metab 2001; 86: 2275-2280
• 31 Inagaki N, Ung L, Otani T. et al. Uterine cavity matrix metalloproteinases and cytokines in patients with leiomyoma, adenomyosis or endometrial polyp. Eur J Obstet Gynecol Reprod Biol 2003; 111: 197-203
• 32 Günther V, Alkatout I, Junkers W. et al. Active Immunisation with Partner Lymphocytes in Female Patients Who Want to Become Pregnant – Current Status. Geburtsh Frauenheilk 2018; 78: 260-273
• 33 van Mourik MS, Macklon NS, Heijnen CJ. Embryonic implantation: cytokines, adhesion molecules, and immune cells in establishing an implantation environment. J Leukoc Biol 2009; 85: 4-19
• 34 Chen T, Darrasse-Jeze G, Bergot AS. et al. Self-specific memory regulatory T cells protect embryos at implantation in mice. J Immunol 2013; 191: 2273-2281
• 35 Makkar G, Ng EH, Yeung WS. et al. Excessive ovarian response is associated with increased expression of interleukin-2 in the periimplantation endometrium. Fertil Steril 2009; 91: 1145-1151
• 36 Hill JA, Anderson DJ. Lymphocyte activity in the presence of peritoneal fluid from fertile women and infertile women with and without endometriosis. Am J Obstet Gynecol 1989; 161: 861-864
• 37 Zhang S, Wang H, Meng C. [Alteration of peritoneal lymphocyte transformation and its interleukin-2 release in patients with infertility and endometriosis]. Zhonghua Fu Chan Ke Za Zhi 1998; 33: 17-19
• 38 Keenan JA, Chen TT, Chadwell NL. et al. IL-1 beta, TNF-alpha, and IL-2 in peritoneal fluid and macrophage-conditioned media of women with endometriosis. Am J Reprod Immunol 1995; 34: 381-385
• 39 Benson S, Janssen OE, Hahn S. et al. Obesity, depression, and chronic low-grade inflammation in women with polycystic ovary syndrome. Brain Behav Immun 2008; 22: 177-184
• 40 Krishna MB, Joseph A, Subramaniam AG. et al. Reduced Tregs in peripheral blood of PCOS patients – a consequence of aberrant Il2 signaling. J Clin Endocrinol Metab 2015; 100: 282-292
• 41 Garzia E, Clauser R, Persani L. et al. Prolactin and proinflammatory cytokine expression at the fetomaternal interface in first trimester miscarriage. Fertil Steril 2013; 100: 108-115.e2
• 42 Alfer J, Happel L, Dittrich R. et al. Insufficient Angiogenesis: Cause of Abnormally Thin Endometrium in Subfertile Patients?. Geburtsh Frauenheilk 2017; 77: 756-764
• 43 Sherwin JR, Smith SK, Wilson A. et al. Soluble gp130 is up-regulated in the implantation window and shows altered secretion in patients with primary unexplained infertility. J Clin Endocrinol Metab 2002; 87: 3953-3960