Immune physiology in tissue regeneration and aging, tumor growth, and regenerative medicine

The immune system plays an important role in immunity (immune surveillance), but also in the regulation of tissue homeostasis (immune physiology). Lessons from the female reproductive tract indicate that immune system related cells, such as intraepithelial T cells and monocyte-derived cells (MDC) in stratified epithelium, interact amongst themselves and degenerate whereas epithelial cells proliferate and differentiate. In adult ovaries, MDC and T cells are present during oocyte renewal from ovarian stem cells. Activated MDC are also associated with follicular development and atresia, and corpus luteum differentiation. Corpus luteum demise resembles rejection of a graft since it is attended by a massive influx of MDC and T cells resulting in parenchymal and vascular regression. Vascular pericytes play important roles in immune physiology, and their activities (including secretion of the Thy-1 differentiation protein) can be regulated by vascular autonomic innervation. In tumors, MDC regulate proliferation of neoplastic cells and angiogenesis. Tumor infiltrating T cells die among malignant cells. Alterations of immune physiology can result in pathology, such as autoimmune, metabolic, and degenerative diseases, but also in infertility and intrauterine growth retardation, fetal morbidity and mortality. Animal experiments indicate that modification of tissue differentiation (retardation or acceleration) during immune adaptation can cause malfunction (persistent immaturity or premature aging) of such tissue during adulthood. Thus successful stem cell therapy will depend on immune physiology in targeted tissues. From this point of view, regenerative medicine is more likely to be successful in acute rather than chronic tissue disorders

Modificazioni metaboliche e cardiovascolari in donne con sindrome dell’ovaio policistico

Obiettivo: analizzare la relazione tra intervallo QTc e fattori di rischio vascolari in donne con sindrome dell’ovaio policistico (PCOS, PolyCysic Ovary Syndrome). Metodi: il gruppo in studio era costituito da 119 donne PCOS (età: 32,2 ± 5,2 anni), quello di controllo da 64 donne sane appaiate per età; in tutte veniva misurato l’intervallo QT e determinati i livelli plasmatici di proteina C reattiva ad alta sensibilità (hsCRP, high-sensitivity C Reactive Protein), endotelina-1 (ET1), insulina e testosterone. Risultati: nelle donne con PCOS, i livelli di hsCRP (2,35 ± 2,14 mg/L vs 1,01 ± 1,28 mg/L; P = 0,04), ET1 (23,6 ± 10,3 ng/L vs 7,7 ± 15,9 ng/L; P = 0,01) e insulina (16,5 ± 7,8 mUI/L vs 11,8 ± 10,7 mUI/L; P = 0,03) erano significativamente più alti, e l’intervallo QTc significativamente più breve che nei controlli (401 ± 61 ms vs 467 ± 61 ms; P = 0,007). In 67 (56%) pazienti con PCOS e intervallo QTc breve (<400 ms), i livelli plasmatici di testosterone erano significativamente maggiori che in quelle con PCOS e intervallo QTc normale (2,3 ± 2,1 nmol/L vs 1,4± 1,7 nmol/L; P = 0,02). Conclusioni: nelle pazienti con PCOS, gli aumentati livelli di testosterone possono attenuare gli effetti dei fattori di rischio coronarico

Premature ovarian failure: etiology, diagnostic and therapeutic procedures

Background: Premature ovarian failure (POF) and connected problems are usually underestimated by the therapists. Precise analysis of etiology and adequate treatment enable resumption of reproductive function in some groups of the women with POF.Methods: Etiology of POF is heterogenous. It can be defined as genetic, autoimmune, iatrogenic, the rest presents as idiopathic. Among basic diagnostic procedures there are precise patient’s history and determinations of FSH, LH, TSH, inhibin B, AMH (antimüllerian hormone) concentration, kariotype and ACTH test. Additional procedures encomprise determinations of atherogenic factors (LDL, HDL, VLDL, hSCRP), determination of lenght of Q-T interval on standard EKG and immunologic investigations on cellular and humoral level. Therapeutic possibilities include estrogen replacement treatment in case of idiopathic etiology and corticosteroid administration in case of autoimmune etiology of POF.Conclusions: Precise analysis of POF etiology enables specific treatment and resumption of reproductive function in some forms of POF (idiopathic and autoimmune).</p

OVARIAN STIMULATION IN ASSISTED REPRODUCTION

Background. It has passed more than 50 years from the developmental phase of ovulation induction. During this period new medications have been introduced, new protocols and dosage established, but the regimen, that would suit all women, has not been designed yet. Methods. The success of ovulation induction in assisted reproduction technologies (ART) does not depend only on medications used, but is influenced by contributing key factors, such as woman’s age, characteristics of the menstrual cycle, body mass index, ovarian reserve and concomitant diseases. The first successful pregnancy followed ART in natural cycle without medications. Because of a relatively low success rate natural cycle was replaced in 70’s by protocols that included clomiphene-citrate or gonadotropins. The introduction of gonadoliberin agonists represented the greatest advantage in this field. The use of human menopausal gonadotropins and recombinants: recombinant FSH, recombinant LH and recombinant HCG in combination with GnRH agonists resulted in significantly higher pregnancy rate (cumulative up to 65 %), but also higher multiple pregnancy rate and ovarian hyperstimulation rate. That is why cheaper, less complicated and patient friendly principles have been renewed, including natural cycle, minimal and mild ovarian stimulation (the use of clomiphene-citrate, letrozole and small doses of HMG or rFSH) that enable ovulation induction and pregnancy in about 30 % of treated women. For a half of the century sophisticated protocols of ovarian stimulation have been developed, but recent European recommendations favour the use of less aggressive, cheaper, effective and patient friendly methods of ovulation induction in ART. There are also protocols for low responding ovaries, which we classify as development of three or less follicles 16 mm in size, only one dominant follicle, or if in past there had been previous cancellations of the cycle because of less than three follicles developed in spite of correct stimulation with gonadotropins. In the literature there are some suggestions how to treat such patients: – long protocol with higher daily doses of gonadotropins, – lowering doses of GnRH agonists or stopping the application soon or immediately after stimulation with gonadotropins has started, – short term use of GnRH agonists in follicular phase, – sequential use of CC and exogene gonadotropins. Ovarian response is monitored by serum estradiol determinations and vaginal ultrasound measurement of follicular size together with echographic estimation of endometrial development. The procedure must comply with each individual and consider her obligations. There should be regular controls, if the dose of gonadotropins is suiting. The application of HCG should be optimized, the hyperstimulation of ovaries should be avoided and the possibility of multiple pregnancies should be lowered. We should also consider the economical side of the use of drugs and the development of the laboratory techniques in reproductive biology. Conclusions. For a half of the century sophisticated protocols of ovarian stimulation have been developed, but recent European recommendations favour the use of less aggressive, effective and patient friendly methods of ovulation induction in AR

Diagnostics and treatment of patients with polycystic ovary syndrome

Background. Polycystic ovary syndrome (PCOS) is the most common female endocrinopathy of reproductive age affecting 15–22 % of women according to European standards. It is a multisystem reproductive-metabolic disorder and its diagnostics and treatment remain controversial. Women with PCOS are at increased risk of developing type II diabetes, metabolic syndrome, cardiovascular disease, depression, non-alcoholic fatty liver disease, endometrial hyperplasia and cancer and few other types of carcinoma. Due to all above, early correct diagnosis, treatment and permanent surveillance of PCOS are of great importance. The main difficulty with diagnosis of PCOS was until recently lack of clear diagnostic criteria. In 2003 the European Society for Human Reproduction and Embryology and the American Society for Reproductive Medicine published a definition of PCOS. For a diagnosis of PCOS two of three criteria have to be met: oligo- or chronic anovulation (less than 8 menses per year or menses that occur at intervals greater than 35 days), clinical or biochemical signs of hyperandrogenism (alopecia, hirsutism, seborrhoea, acne, virilism), polycystyc ovaries seen on vaginal ultrasound (VUS) (presence of 12 or more follicles in both ovaries measuring 2–9 mm in diameter and/or ovarian volume larger than 10 cm3 of either or both ovaries). Exclusion of other diseases with similar clinical presentation is necessary. Treatment depends on the age of the patient, predominating clinical signs and aim we try to achieve. First-line treatment for all patients includes life-style changes and weight reduction in obese patients. Management of adolescent patients is aimed at abolishment of menses irregularity and endometrial protection, treatment of hyperandrogenism, obesity, and insulin resistance (IR). In the first-line treatment we also recommend oral hormonal contraceptives (OHC) with non-androgenic gestagens (NG) with or without antiandrogens (AA) and topical dermatological treatment (TDT) if necessary. In the second-line treatment we recommend gestagens combined with AA an insulin sensitizing agents (ISA). Management of patients in reproductive age, who do not want to conceive, is aimed at endometrial protection and treatment of hyperandrogenism, obesity, IR and metabolic risks. In the first-line treatment we also recommend OHC with NG preferably combined with AA. Antiandrogenic effect could be strengthened by adding ISA, which also reduce risks of developing diabetes and cardiovascular disease. In cases of very distinctive hyperandrogenism TDT is possible. To protect endometrium and prevent conception insertion of intrauterine device with levonorgestrel is appropriate. In perimenopause we prescribe low-dosage hormonal replacement therapy. First-line treatment of patients of reproductive age, who want to conceive, is medicamental or surgical induction of ovulation. Clomiphene citrate (CC) is most suitable for medicamental induction of ovulation. Recommended duration of treatment with CC is up to six months. At least in the first cycle of treatment response of ovaries and endometrium with VUS is advisable. If response is satisfactory and a patient did not conceive after six months of treatment an intrauterine insemination is recommendable. In obese women, if treatment with CC is unsuccessful, addition of ISA is recommended. In case of failure of induction of ovulation we proceed as in other patients with whom the next step is treatment with gonadotrophines given by a step-up protocol or ovary electrocoagulation (OEC), if it has not been performed during management of infertility. The latter is advisable first of all for CC resistant women with high LH serum levels. After six unsuccessful months of treatment with gonadotrophines and OEC assisted reproduction techniques are recommended. Conclusions. Because of its complicated nature management of PCOS remains a challenge. According to most recent guidelines diagnosis of PCOS requires two of three criteria to be met: oligo- or chronic anovulation, clinical or biochemical signs of hyperandrogenism and polycystyc ovaries seen on VUS. Women with PCOS are at increased risk of developing diabetes, cardiovascular disease and certain types of carcinoma. Thus long-term treatment of systemic effects of PCOS is of great importance. The latter also has an important role in treating gynaecological problems because combined treatment together with traditional methods offers even more successful management of patients with PCOS. In the first-line treatment we still recommend life-style changes and weight reduction in obese patients. Further treatment depends on the age, predominating clinical signs and reproductive desires of the patient

AUTOIMMUNE ASPECTS OF PREMATURE OVARIAN FAILURE

Background. The prevalence of premature ovarian failure (POF) of 1 % has important psychosocial consequences and impact on general health. Besides known etiology (genetic, chromosomal, infections, iatrogenic) autoimmunity can be the pathologic mechanism for POF. Material and methods. Eleven women with POF, with excluded other reasons for the disease except autoimmunity were included in this study. The control group consisted of 13 healthy normo-ovulatory women. In both groups targeted family and personal history was taken and determinations of: FSH, LH, TSH, prolactin, antimüllerian hormone (AMH), inhibin B, thyroid antibodies TG and TPO. At the cellular level periferal blood T-lymphocytes were analyzed by flow cytometry, on humoral level ovarian antibodies were detected with indirect immunofluorescence on human ovary sections. Quick ACTH test was performed in study group only. Results. In 9 patients POF was associated with another autoimmune disease. Six patients of the study group (55 %) presented very elevated thyroid autoantibodies TG and TPO, in the control group the levels of both autoantibodies were within normal range. Hormonal analyses in the study group exhibited the values of hypergonadotropic hypogonadism and consequently low levels of inhibin B and AMH. Lymphocyte subset in study group namely CD4+, CD19+ and CD8+ was significantly higher, while natural killer cells and regulatory T cells were significantly lower then in the control. group. In 4 patients (36 %) antiovarian autoantibodies were detected. Results of the quick ACTH test in the study group were normal. Conslusions. POF is frequently associated with autoimmune disorders. The presence of antithyroid and antiovarian antibodies together with abnormalities of the cellular immunity can potentionally represent an autoimmune mechanism of POF. The question of immunomodulatory therapy in selected patients with POF is open

USE OF HYALURONAN-RICH TRANSFER MEDIUM FOR A SINGLE BLASTOCYST TRANSFER IN VITRO FERTILIZATION PROCEDURE

Background. The best way to avoid undesirable multiple pregnancies following in vitro fertilization procedure (IVF) is to perform elective single embryo transfer, but the procedure might result in a reduction of the pregnancy rates. Aim of our study was to establish whether a single blastocyst transfer using a hyaluronan rich transfer medium results in higher pregnancy rates in comparison to the transfer using a conventional transfer medium. Material and methods. Our prospective randomized study included 107 patients enrolled in the 1st, 2nd and 3rd classical IVF or intracytoplasmic sperm injection (ICSI) treatment attempt. Patients included were under 37 years of age with at least one blastocyst developed in the procedure. In the study group (47 patients) blastocyst transfers using the hyaluronan rich transfer medium were performed and in the control group (60 patients) the conventional medium was used. The pregnancy rates in the study and in the control group were compared. Results. The average pregnancy rate per single blastocyst transfer was 30 %; there were no twin pregnancies. The single blastocyst transfer using hyaluronan resulted in a non-significantly higher pregnancy rate (11 %). A significantly higher pregnancy rate with the use of hyaluronan was found in the subgroup of patients with two or more blastocysts developed in their 2nd and 3rd IVF attempt (p = 0.045). Conslusions. The single blastocyst transfer results in high implantation rates. Hyaluronan significantly contributes to higher implantation rates in a selected subgroup of patients following previous implantation failure and with multiple blastocysts developed

Decreased Androgen Levels and Improved Menstrual Pattern after Angiotensin II Receptor Antagonist Telmisartan Treatment in Four Hypertensive Patients with Polycystic Ovary Syndrome: Case Series

We describe 4 consecutive hypertensive women with polycystic ovary syndrome, classified according to the National Institute of Child Health and Human Development (NICHD) criteria, treated with telmisartan 40 mg/d for six months. Blood pressure, menstrual pattern, body mass index (BMI), homeostasis model assessment of insulin resistance, testosterone, dehydroepiandrosterone sulfate (DHEAS), and androstenedione were recorded and measured before and after telmisartan treatment. Obese hypertensive polycystic ovary syndrome patients had a decrease in systolic blood pressure. Marked drop-off in serum androgen concentrations was observed in all four patients. Three patients improved their menstrual cyclicity. The improvements were independent of changes in weight. The reduction of androgen concentrations and improvement in menstrual pattern was achieved despite a non-significant change of fasting insulin levels in patients, who were not considered severely insulin resistant at baseline. These findings may provide a new basis for a proper choice of the antihypertensive drug in hypertensive women with polycystic ovary syndrome

CHARACTERISTICS OF HISTORY IN PATIENTS WITH ENDOMETRIOSIS

Background. Endometriosis is an estrogen dependent disease that affects 5 − 20 % of women of reproductive age. Course of the disease is progressive and leads to a variety of symptoms that range from pain complaints to infertility. Some symptoms depend on the location of the break out. The most frequent symptoms are dysmenorrhea, dyspareunia, chronic pelvic pain and infertility. Endometriosis is also found in asymptomatic women. Clinical signs and symptoms with extrapelvic endometriosis are based on the involved organ system. Dysmenorhea may progress and begin prior to the onset of menses or become chronic and be noted throughout most of the menstrual cycle. Pain during menstrual cycle is estimated on 60–80 % of women with endometriosis. Dyspareunia is estimated on 25–50 % of women with endometriosis. It is frequently associated with rectovaginal and uterosacral ligament disease. It was established that advanced endometriosis is more frequently related to dysmenorrhea and deep dyspareunia in comparison with early disease. Chronic pelvic pain is defined as the pain that lasts 6 months and is not cyclic. In women being evaluated for pelvic pain, the diagnosis of endometriosis is made in 40–60 %, especially when it comes to deep infiltrative endometriosis. Infertility can be the only presenting symptom. The incidence of infertility in women with endometriosis is hard to establish. Some women with mild endometriosis are able to conceive, however this mild endometriosis can cause infertility. There is estimation that 20–30 % of women with endometriosis are infertile. Conclusions. Medical history is very important in recognizing the disease. Endometriosis does not threaten life but is associated with significant morbidity of women. It has a major impact on women’s health and life quality and represents a significant public health issue. Because the clinical signs and symptoms are complex and there is sometimes lack of the association between the stage of the disease and intensivity of symptoms, the disease can be diagnosed too late

APPEARANCE OF AUTOIMMUNE DISEASES IN PATIENTS WITH ENDOMETRIOSIS

Background. Endometriosis is a comon, complex gynecological syndrom defined as the growth of endometrial glands and stroma in an extra-uterine location. It affects 5 – 20 % of women of reproductive age.1 Nowadays, prevailing opinion about endometriosis is based on presumption, that endometriosis is a result of changed immune system, according to autoimmune theory.2, 3 Characteristics of autoimmune disease that are also found in endometriosis are female preponderance, multiorgan involvement, family occurence, possible genetic basis, response to hormonal manipulation, tissue damage, polyclonal B lymphocite activation, immunological abnormalities in T lymphocite and B lymphocite function and associated autoimmune disease. Women with endometriosis are more frequently affected by asthma, rheumatoid arthritis, systemic lupus erythematosus, Sjögren syndrom and Hashimoto’s thyroiditis. Autoimmune disease is characterized by the production of autoantibodies against components of apoptotic cells. Anti-endometrial antibodies of IgG and IgM classes could be detected in 60 % of endometriosis patients. They show reactivity in glandular epithelium and stroma. Anti-endothelial antibodies specifically react with vascular endothelium and might be with anti-endometrial antibodies partially responsible for failure of implantation leading to infertility, wich is common in endometriosis patients. Anti-nuclear antibodies are frequent serological findings in patients with autoimmune disease, and could be detected in 29–47 % of women with endometriosis.4 Generation of anti-nuclear antibodies is a risk factor for development of other autoimmune disease in women of reproductive age. Studies have shown conflicting results on the presence of anti-ovarian antibodies in the serum of endometriosis patients and in the peritoneal fluid. Their presence is one of the possible causes of infertility. Conclusions. Ethiopathogenesis of endometriosis still remains uncelar but currently available data suggest that there are many similarites between endometriosis and such autoimmune diseases as rheumathoid arthritis, systemic lupus erythematosus, Sjögren syndrom etc. Important similarity is the presence of auto-antibodies. Autoimmune theory represents a challenge and at the same time opens the possibility of a new mode of treatement of endometriosis with immunomodulators