Presentation on theme: "Dr. Shiuli Mukherjee MD, Fellow in Reproductive Medicine Institute of Reproductive Medicine, Kolkata, India."— Presentation transcript:
Dr. Shiuli Mukherjee MD, Fellow in Reproductive Medicine Institute of Reproductive Medicine, Kolkata, India
Introduction Recurrent spontaneous miscarriage (RSM) represents most common complication of reproductive failure 60–70% remains unexplained Impaired immunoregulatory atmosphere of endometrium may be a contributing factor Raghupathy R et al, Immunology Today,1997
SUMMARY OF EVENTS IN ENDOMETRIAL RECEPTIVITY Physiological BiochemicalImmuno modulatory Genetic expression PINOPODES Adhesion Molecules Cytokines NK cells HOXA 10 Trophinin ‘E2’ stimulates‘P’ activates Receptive endometrium Window of implantation ( 7 th – 9 th post ovulation day)
“Implantation is biomarkers’ interplay” Apposition Pinopode Adhesion Integrin ( αvβ3) L-selectin Invasion LIF cytokine Co-expression with integrin & LIF Nardo & Nikas et al and Aghajanova L, Stavreus-Evers et al Fert.Stert 2003
Future and Facts Fact Future Failure of implantation due to deficient expression of different biomarkers Pinopode α v β 3 Integrin LIF L-selectin Acosta et al, 2000 To establish their role in pathogenesis of unexplained RSM in 1 st trimester via alteration of endometrial receptivity
Objectives To asses the expression level of different implantation markers in endometrium of women with Idiopathic Recurrent Miscarriage α v β 3 Integrin Leukemia Inhibitory Factor (LIF) L-Selectin Pinopode and compare them with that of fertile women
Materials and methods Prospective Case-control study August 2009 to July 2010 Institute of Reproductive Medicine, Kolkata and IIMST, Kharagpur, India Approval obtained from the institutional ethical committee and written consent taken.
Patient selection Case ( n = 47) Women with past history of idiopathic spontaneous recurrent miscarriage Control ( n = 39) Fertile women without previous pregnancy loss
Inclusion criteria Age between 24-35 years Previous ≥ 2 miscarriages (<12wk) Not on any kind of medication
Exclusion criteria Autoimmune defects (APLA-Anti cardiolipin and anti lupus antibody) Endocrine causes ( thyroid function test) Chromosomal defect (karyotyping) Coagulopathy ( P/H or F/H of thrombophilia) Infectious disease Uterine malformation ( HSG/hysteroscopy) Sperm defects (DNA fragmentation)
Method TVS - folliculometry from 10 th day of natural menstrual cycle Endometrial biopsy done between 7 th and 9 th day of post ovulation Serum Progesterone level estimation on day of biopsy
Tissue preparation & assessment Immunohistochemistry to asses cell surface expression of α v β 3 Integrin, LIF and L-selectin Pinopodes observed under scanning electron microscope. Endometrial dating by histopathology. Statistical analysis by Statistica version 6
Pinopode Expression QualitativeQuantitative Developing - Small, smooth, naked, with short microvilli. Fully developed – large, smooth, with/without small wrinkles. Regressing - wrinkled surface, deflated ball Percentage of endometrial surface occupied Abundant - > 50% Moderate – 20-50% Scanty - < 20% Mean values of 30 randomly selected fields taken Nikas et al, 1995,1999.
Qualitative estimation of Pinopode Developing Fully developed
Quantitative estimation of Pinopode Scanty (< 20%) Abundant (>50%)
Result analysis Clinical characteristicsPatient with RSM ( n= 47 ) Control ( n= 39 ) Age ( years )29.97±3.028.61±3.5 BMI (kg/m 2 )26.83±4.1725.27±4.1 Day of EB22.08±1.0921.84±1.03 Histopathology datingMid-secretory Progesterone (ng/ml)11.28±1.2711.81±1.39 Unpaired student t test, mean ± SD
Comparison of biomarkers in endometrium P < 0.001
Comparison of pinopode morphology Fisher’s exact test with Freeman-Halton extension P =.051
Comparison of pinopode numbers Fisher’s exact test with Freeman-Halton extension P < 0.01
Discussion Few studies have demonstrated correlation between unexplained recurrent miscarriage and expression of cytokines. Cork et al 1999, Laird & Tuckerman et al,2003 Relation with pinopode not been discussed thoroughly Aghajanova L et al,2003, Nardo LG et al, 2003 Nothing conclusive had yet been achieved
Discussion continued.. Present study shows statistically significant difference in expression levels of α v β 3 Integrin ( P <0.001 vs NS in Tuckerman et al, 2006 ) LIF ( P <0.001 similar to Cork et al, 1999 ) L-selectin ( P <0.001 ≈ Kruse C.et al 2003, Foulk R.A. et al, 2007)
Discussion continued.. Pinopode expression in RSM Morphological comparison – no significant difference ( P = 0.051) Comparison of numbers – had significant difference ( P < 0.001) Other studies have shown correlation in unexplained infertility, endometriosis, PCOs Aghajanova L et al,2003
Conclusion Expression of cytokines, pinopodes and adhesion molecules seem to be deficient in recurrent miscarriage group. A combined protocol of biomarkers like integrin, pinopode and LIF could have a good predictive value of endometrial receptivity in idiopathic recurrent miscarriage.
Acknowledgement Prof. (Dr.) B.N.Chakravarty Prof. K. Chowdhury Prof. ( Dr.) A.Hazra Dr. S. Ghosh Ms. P. Banerjee Dr. R. chatterjee Dr. S. Sharma Dr. S. Rajani
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