1. CONVEGNO : High Tech in Endometriosi ed Infertilità Roma 04 Marzo 2009
L’Alto Patronato del Presidente della Repubblica
E con il
Patrocinio della Presidenza del
Consiglio dei Ministri
Patrocino del Ministero del Lavoro,della Salute e delle Politiche Sociali
Patrocino del Ministero delle Pari
Opportunità
Patrocinio dell’INPS
Patrocinio dell’INAIL
Fondazione Italiana Endometriosi

2. High Tech in Endometriosi ed Infertilità Lettura Magistrale : Genesis of the Endometriosis
Fondazione Italiana Endometriosi

3. Definition of Endometriosis
High Tech in Endometriosi ed Infertilità
Definition of Endometriosis
ECTOPIC ENDOMETRIUM
Fondazione Italiana Endometriosi

4. History of Endometriosis
High Tech in Endometriosi ed Infertilità
1690
Daniel Shroen
early descriptions of what today we call endometriosis and adenomyosis. Disputatio Inauguralis Medica de Ulceribus Ulceri
1776
Roederer, Broughton, Tailford, Duff, Ludgers
in the de ulceribus utero molestis observationibus descrived the desease and the simptoms
1769
Arthur Duff
described the intense pain of endometriosis, and it was first seen microscopically in the late 1800s.
History of Endometriosis
Fondazione Italiana Endometriosi

5. History of Endometriosis
High Tech in Endometriosi ed Infertilità
History of Endometriosis
1860
Carl von Rokitansky
found endometrial glands in the myometrium and designated this finding as ‘cystosarcoma adenoids uterinum’.
Over the following 60 years ‘adenomyoma’ were considered pat hologies separate from the so-called ‘haemorrhagic ovarian cysts’ (endometriosis).
Fondazione Italiana Endometriosi

6. History of Endometriosis
High Tech in Endometriosi ed Infertilità
History of Endometriosis
1917
Thomas Stephen Cullen
researched the ‘mucosal invasion’ already observed by a number of investigators in several parts of the lower abdominal cavity. Cullen clearly identified the epithelial tissue invasion as being made of ‘uterine mucosa’ and defined the mechanism through which the mucosa invades the underlying tissue.
Fondazione Italiana Endometriosi

7. History of Endometriosis
High Tech in Endometriosi ed Infertilità
History of Endometriosis
1923
J.Sampson
created the term ‘endometriosis’.
Dr. John Sampson was the first person to hypothesize that retrograde menstruation contributed to endometriosis 1927
Fondazione Italiana Endometriosi

8. History of Endometriosis
High Tech in Endometriosi ed Infertilità
History of Endometriosis
1972
C.C.Bird
The current definition of adenomyosis : ‘Adenomyosis may be defined as the benign invasion of endometrium into the myometrium, producing a diffusely enlarged uterus which microscopically exhibits ectopic non-neoplastic, endometrial glands and stroma surrounded by the hypertrophic and hyperplastic myometrium’.
Fondazione Italiana Endometriosi

9. Theories of the Endometriosis
High Tech in Endometriosi ed Infertilità
Theories of the Endometriosis
Postulated
Iatrogenic transplantation - Endometriosis is accidentally transported during surgery.
Coelomic Metaplasia - This theory holds that certain cells, when stimulated, can transform themselves into a different kind of cells’.
The hereditary theory - Women with family members who have Endometriosis are more likely, or are susceptible to developing the disease.
Liver disorders - The liver regulates and removes estrogen from the body. If the function of the liver is compromised then serious health problems can emerge, including Endometriosis.
Auto-immune disorder - This disease is an autoimmune disease . Autoimmune diseases are now widely believed to occur based on genetic predisposition that may be triggered by environmental and other external factors.
Fondazione Italiana Endometriosi

10. Theories of the Endometriosis
High Tech in Endometriosi ed Infertilità
Theories of the Endometriosis
Postulated
Retrograde menstruation - this theory was postulated in the early 1927 by Dr Sampson. He speculated that during menstruation, a certain amount of menstrual fluid flowed backward from the uterus to ‘shower the pelvic organs and pelvis lining’ with endometrium cells.
Fondazione Italiana Endometriosi

11. Retrograde Menstruation Theory
High Tech in Endometriosi ed Infertilità
Retrograde Menstruation Theory
Postulated
Present in 90% of women
does not explain adenomyosis
retroperitoneal
extra abdominal
prepuberal*
post hysterectomy
prostatic
lack of endometriosis in all placentals mammals
*An Esp Pediatr. 1996 Apr;44(4):397-8
[Neonatal ovarian endometriosis. Its conservative treatment]
Díez García R, Prieto Díez M, Aguilar Tremoya F.
Departamento de Pediatría y Cirugía Pediátrica, Hospital General Universitario Gregorio Marañón, Madrid.
Fondazione Italiana Endometriosi

12. Diffusion of Endometriosis
High Tech in Endometriosi ed Infertilità
Diffusion of Endometriosis
PUBMED works
Endometriosis : Diffusion in the body N°
Brain
Spinal Cord
Pericardium
Lung
Diaphragm
Leg
Nois and Eye
Lips
Kidney
Bladder
Liver
Pancresas
Bowel
Adrenals
Breast
Skin
Prostate
Total
Fondazione Italiana Endometriosi

13. Theories of the Endometriosis
High Tech in Endometriosi ed Infertilità
Theories of the Endometriosis
Proved
Embriologic theory - This theory suggests that endometriosis is caused by microscopic remnants of a women's embryonic endometrial tissue (from when she was an embryo), that later develops into endometriosis.
Fondazione Italiana Endometriosi

14. Fetal Weeks Sexual Female Differentiation
High Tech in Endometriosi ed Infertilità
Fetal Weeks Sexual Female Differentiation
0 Inattivation of one chromosome X
4 Initial development of Wolff ducts
5 Migration of primitive germ cells
6 Development of Muller ducts
9 Reduction of sensivity of Muller ducts
9 First meiotic profase in to the oogones
10 Regression of the Wolff ducts
16 First ovarian follicles
24 Complete Canalizzation of the vagina
28 End of moltiplication of oogones
PC Sizonenko in pediatric Endocrinology,edidet J.Bertrand,R.Rappaport,and PC Sizonenko.(Baltimore:Williams e Wilkins,1993),pp
Fondazione Italiana Endometriosi

15. Muller ducts and Genital Tract
High Tech in Endometriosi ed Infertilità
Muller ducts and Genital Tract
Fondazione Italiana Endometriosi

16. Internal Female Genitalia
High Tech in Endometriosi ed Infertilità
Internal Female Genitalia
Fondazione Italiana Endometriosi

17. Muller , Wolff Ducts and Gonad
High Tech in Endometriosi ed Infertilità
Muller , Wolff Ducts and Gonad
7 W
Mesonephro cranial Mesonephro caudal Paramesonephro Gonad
Fondazione Italiana Endometriosi

18. Muller, Wolff Duct and Gonad
High Tech in Endometriosi ed Infertilità
Muller, Wolff Duct and Gonad
7 W
Mesonephro Mesonefphro Paramesonephro Gonad
Fondazione Italiana Endometriosi

19. Tube Gonad Uterus Vagina
High Tech in Endometriosi ed Infertilità
Internal Genitalia
11 W
Tube Gonad Uterus Vagina
Fondazione Italiana Endometriosi

20. High Tech in Endometriosi ed Infertilità
Embriogenetic theory is demonstrated
Fondazione Italiana Endometriosi

21. ungulates (deer, moose, elk etc.), carnivores (cats, and dogs). Bicorn
High Tech in Endometriosi ed Infertilità
Uterus in mammals
Bipartite 
ungulates (deer, moose, elk etc.), carnivores (cats, and dogs).
Bicorn
pigs.
Simplex
humans, other primates and horses.
Duplex 
rodents (such as mice, rats and guinea pigs), marsupials and lagomorpha (rabbits and hares).
Fondazione Italiana Endometriosi

22. Endometriosis is related to the Tipe of Uterus
High Tech in Endometriosi ed Infertilità
Endometriosis is related to the Tipe of Uterus
Uterus Simplex   endometriosis
humans, other primates
and horses
Uterus Bipartite,
Bicorn, Duplex absence of endometriosis
all others placentals
mammals
Fondazione Italiana Endometriosi

23. Septum Uterus High Tech in Endometriosi ed Infertilità
The uterus is formed by the fusion of the two mullerian ducts.
During this fusion a resorption process eliminates the partition between the two ducts to create a single cavity.
This process begins caudally and advances cranially, thus a complete septum formation represents an earlier disturbance of this absorption than the incomplete form.
Causes for incomplete absorption are not known.
Heinonen PK (March 2006). "Complete septate uterus with longitudinal vaginal septum". Fertil. Steril. 85 (3): 700–5. 
Fondazione Italiana Endometriosi

24. Human Uterine Malformations
High Tech in Endometriosi ed Infertilità
Human Uterine Malformations
Prevalence
general population 6,7%,
infertility population 7,3%,
recurrent miscarriages 16% 
Sotirios H. Saravelos, Karen A. Cocksedge and Tin-Chiu Li. "Prevalence and diagnosis of congenital uterine anomalies in women with reproductive failure: a critical appraisal.". Human Reproduction Update,
Fondazione Italiana Endometriosi

25. Is there an association between septate uterus and endometriosis?
High Tech in Endometriosi ed Infertilità
Is there an association between septate uterus and endometriosis?
Septate uterus (n = 120)
Endometriosis (%) 31 (25.8)
Controls (n = 486)
Endometriosis (%) 74 (15.2)
Human Reproduction Vol.21, No.2 pp. 542–544, 2006
Is there an association between septate uterus and endometriosis?
Frank Nawroth1,3, Gohar Rahimi2, Claudia Nawroth2, Dolores Foth2, Michael Ludwig1
and Torsten Schmidt2
1Endokrinologikum Hamburg, Centre for Hormone and Metabolic Diseases, Reproductive Medicine and Gynaecological Endocrinology,
and 2Department of Obstetrics and Gynaecology, University of Cologne, Germany
Fondazione Italiana Endometriosi

26. Mullerianosis High Tech in Endometriosi ed Infertilità
Uterus-like mass of müllerian origin in the lumbosacral region causing cord tethering. Report of two cases.
Sharma MC, Sarkar C, Jain D, Suri V, Garg A, Vaishya S.
Department of Pathology, All India Institute of Medical Sciences, New Delhi, India.
Fertil Steril. 2005 Oct;84(4):1017.  
Accessory uterine appendage may be a new Müllerian malformation.
Umobi MA, Meltz RC, Barmat LI.
Department of Obstetrics and Gynecology, Crozer-Chester Medical Center, Upland, Pennsylvania 19013, USA.
Hum Pathol. 2005 Aug;36(8):
Intra-abdominal ovarian-type mucinous cystadenoma associated with fallopian tube-like structure and aberrant epididymal tissue in a male patient.
Rizzardi C, Brollo A, Thomann B, Santirocco C, Melato M.
Unit of Pathology of the University of Trieste, Ospedale Maggiore, I Trieste, Italy.
Fondazione Italiana Endometriosi

27. Explains adenomyosis retroperitoneal extra abdominal prepuberal
High Tech in Endometriosi ed Infertilità
Embriologic theory
Proved
Explains adenomyosis
retroperitoneal
extra abdominal
prepuberal
post hysterectomy
prostatic
endometriosis only in mammals with simplex uterus
Fondazione Italiana Endometriosi

28. High Tech in Endometriosi ed Infertilità Development of the uterus
Initial stratification of the uterine wall occurred at 14 WG. At this age, the endometrial epithelium was simple columnar to pseudostratified and consisted of microvillous cells.
At WG the endometrial epithelium became clearly pseudostratified, with active ciliogenesis and a predominance of microvillous cells.
Primordia of tubular glands were present at 20 WG.
Microvillous cells still predominated in the endometrial epithelium at WG and showed morphological features of apoptosis.
The endometrial stroma at this stage was organizing into a thick lamina propria provided with subepithelial capillary plexuses.
Our data showed that the epithelial differentiation and distribution in the uterus occur in the human fetus in a similar way as in the adult.
Archives of Histology and Cytology
Vol. 70 (2007) , No. 1 p.21-28
Ultrastructural dynamics of the human endometrium from 14 to 22 weeks of gestation
Fabrizio Barberini1), Sayoko Makabe2), Gianfranco Franchitto1), Silvia Correr1), Michela Relucenti1), Rosemarie Heyn1) and Giuseppe Familiari1)
1) Department of Anatomy, University of Rome “La Sapienza” 2) Department of Obstetrics and Gynaecology, Toho University
Fondazione Italiana Endometriosi

29. Demonstration of embriogenetic Theory
High Tech in Endometriosi ed Infertilità
Demonstration of embriogenetic Theory
n press
ECTOPIC ENDOMETRIUM IN HUMAN FETUSES IS A COMMON EVENT AND SUSTAINS THE THEORY OF MULLERIANOSIS IN THE PATHOGENESIS OF ENDOMETRIOSIS
Pietro G. Signorile1*, Feliciano Baldi2, Rossana Bussani3, Mariarosaria D’Armiento4, Maria De Falco5, Alfonso Baldi1,2*
1 Fondazione Italiana Endometriosi, Rome, Italy; 2 Dept Biochemistry, Sect Pathology, Second University of Naples, Naples, Italy; 3 Dept. of Pathology, University of Trieste, Trieste, Italy; 4 Dept. Scienze Biomorfologiche, University of Naples "Federico II", Naples, Italy. 5 Dept Evolutive and Comparative Biology, University of Naples "Federico II", Naples, Italy.
Fondazione Italiana Endometriosi

30. Demonstration of embriogenetic Theory
High Tech in Endometriosi ed Infertilità
Demonstration of embriogenetic Theory
We speculated that, if the basis of endometriosis is an alteration during organogenesis, it would be possible to see ectopic endometrial tissue dislocated outside the uterine cavity of human female fetuses.
Fondazione Italiana Endometriosi

31. Fetuses Enrolled High Tech in Endometriosi ed Infertilità
N° Gestational age Cause of death Presence of ectopic endometrium
5 23 weeks Placental pathology No
6 15 weeks Voluntary abortion No
7 20 weeks Voluntary abortion No
8 newborn Primary atypical pneumonia No
9 newborn Acute interstitial pneumonitis No
10 16 weeks Voluntary abortion No
11 23 weeks Placental pathology No
12 14 weeks Placental pathology No
13 21 weeks Voluntary abortion No
14 20 weeks Voluntary abortion No
15 20 weeks Voluntary abortion No
16 18 weeks Voluntary abortion No
17 19 weeks Voluntary abortion No
18 16 weeks Voluntary abortion No
19 23 weeks Placental pathology No
20 25 weeks Placental pathology No
21 newborn Acute interstitial pneumonitis No
22 newborn Primary atypical pneumonia No
23 20 weeks Voluntary abortion No
24 19 weeks Voluntary abortion No
25 newborn Cardiac malformation No
26 newborn Cardiac malformation No
27 20 weeks Voluntary abortion No
28 23 weeks Placental pathology No
29 19 weeks Voluntary abortion No
30 newborn Cardiac malformation No
31 newborn Cardiac malformation No
32 19 weeks Voluntary abortion No
33 newborn Acute interstitial pneumonitis No
34 20 weeks Voluntary abortion No
35 newborn Cardiac malformation No
36 21 weeks Placental pathology No
weeks Voluntary abortion Yes
weeks Placental pathology Yes
weeks Placental pathology Yes
weeks Voluntary abortion Yes
Yes : Ectopic Endometrium
Fondazione Italiana Endometriosi

32. Methods High Tech in Endometriosi ed Infertilità
Pelvic organs were collected en-block, fixed in paraphormaldeyde and included in paraffin. We performed histological analysis of the pelvic organs for each fetus, using Hematoxylin/Eosin and Hematoxylin/Van Gieson staining. For immunohistochemistry 5-7 μm specimen sections embedded in paraffin, were cut, mounted on glass and dried overnight at 37°C. All sections were then deparaffinized in xylene, rehydrated through a graded alcohol series and washed in phosphate-buffered saline (PBS). PBS was used for all subsequent washes and for antiserum dilution. Tissue sections were quenched sequentially in 3% hydrogen peroxide in aqueous solution and blocked with PBS-6% non-fat dry milk (Biorad, Hercules, CA, U.S.A.) for 1 h at room temperature.
Fondazione Italiana Endometriosi

33. Methods High Tech in Endometriosi ed Infertilità
Slides were then incubated at 4°C overnight at 1:100 dilution with the following antibodies:
the affinity-purified rabbit antibody ERα for the estrogen receptor (Santa Cruz, Santa Cruz, CA, USA; cat. # sc-542) and the mouse monoclonal antibody M11 for CA125( Dako Laboratories, Carpinteria, CA, USA). After three washes in PBS to remove the excess of antiserum, the slides were incubated with diluted goat anti-rabbit or anti-mouse biotinylated antibodies (Vector Laboratories, Burlingame, CA, U.S.A.) at 1:200 dilution in PBS-3% non-fat dry milk (Biorad) for 1 h. All the slides were then processed by the ABC method (Vector Laboratories) for 30 min at room temperature. Diaminobenzidine (Vector Laboratories) was used as the final chromogen and hematoxylin was used as the nuclear counterstain. Negative controls for each tissue section were prepared by leaving out the primary antiserum. Positive controls constituted of tumor tissues expressing either the estrogen receptor or CA125, were run at the same time. All samples were processed under the same conditions.
Fondazione Italiana Endometriosi

34. Ectopic Endometrium Prevalence in Fetuses
High Tech in Endometriosi ed Infertilità
Ectopic Endometrium Prevalence in Fetuses
Fetuses* 11%
Adult 10%-15%
* First observation
Fondazione Italiana Endometriosi

35. Distribution of Ectopic Endometrium in the Fetus
High Tech in Endometriosi ed Infertilità
Distribution of Ectopic Endometrium in the Fetus
Case weeks fetus
Ectopic endometrial structure in the deep recto-vaginal septum, near perineal floor.
Fondazione Italiana Endometriosi

36. Distribution of Ectopic Endometrium in the
Fetus
High Tech in Endometriosi ed Infertilità
Fondazione Italiana Endometriosi

37. Distribution of Ectopic Endometrium in the Fetus
High Tech in Endometriosi ed Infertilità
Distribution of Ectopic Endometrium in the Fetus
Case weeks fetus
Ectopic endometrial structure in the proximity of the Douglas pouch.
Fondazione Italiana Endometriosi

38. Distribution of Ectopic Endometrium in the Fetus
High Tech in Endometriosi ed Infertilità
Distribution of Ectopic Endometrium in the Fetus
Fondazione Italiana Endometriosi

39. Distribution of Ectopic Endometrium in the Fetus
High Tech in Endometriosi ed Infertilità
Distribution of Ectopic Endometrium in the Fetus
Case weeks fetus
Ectopic endometrial structure in the rectal tube at the level of
muscularis propria
Fondazione Italiana Endometriosi

40. Distribution of Ectopic Endometrium in the Fetus
High Tech in Endometriosi ed Infertilità
Distribution of Ectopic Endometrium in the Fetus
Fondazione Italiana Endometriosi

41. Distribution of Ectopic Endometrium in the Fetus
High Tech in Endometriosi ed Infertilità
Distribution of Ectopic Endometrium in the Fetus
Case weeks fetus
Ectopic endometrial structure in the mesenchimal tissue close to the posterior wall of the uterus.
Ectopic endometrial structure in the miometrium, primitive nest of adenomyosis
Fondazione Italiana Endometriosi

42. Distribution of Ectopic Endometrium in the Fetus
High Tech in Endometriosi ed Infertilità
Distribution of Ectopic Endometrium in the Fetus D re D’ * u bl
Fondazione Italiana Endometriosi

43. High Tech in Endometriosi ed Infertilità
Conclusion
Past Origin Endometriosis unknown (chronic desease)
Present Embriogenetic minimal defect at the origin of the Endometriosis (congenital disease)
Future To define the molecular and organogenetic misprogramming events causing the minimal defects in uterus
To develop new strategies for prevention, diagnosis and therapy
Fondazione Italiana Endometriosi

44. SI RINGRAZIANO High Tech in Endometriosi ed Infertilità
Il Presidente della Repubblica Italiana Giorgio Napolitano per l’Alto Patronato
La Presidenza del Consiglio dei Ministri per il Patrocinio
Il Ministero del Lavoro, della Salute e delle Politiche Sociali per Il Patrocinio
Il Ministero delle Pari Opportunità per il Patrocinio
Gli Enti INPS ed INAIL per il Patrocinio
Le Donne iscritte all’Associazione Italiana Endometriosi
Lo staff dell’Associazione Italiana Endometriosi e della Fondazione Italiana Endometriosi
Lo staff medico e di ricerca
Le Università : Federico II e II Università di Napoli, Università di Trieste ed il CNR di Napoli
La EVENTI MADE IN ITALY
Il Rome American Hospital
UN RINGRAZIAMENTO PARTICOLARE A :
Roberta Riposati, Angela Ricci, Sara Alessandrini che con dedizione aiutano le donne
Fondazione Italiana Endometriosi