La Scoperta - High Tech in Endometriosi ed Infertilità Roma 04

CONVEGNO : High Tech in Endometriosi ed InfertilitàRoma 04 Marzo 2009

Con

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

High Tech in Endometriosi ed Infertilità

Lettura Magistrale :

Genesis of the Endometriosis


Definition of Endometriosis

ECTOPIC ENDOMETRIUM



History of Endometriosis

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.




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).




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.




1923

J.Sampson

created the term ‘endometriosis’.

Dr. John Sampson was the first person to hypothesize that retrograde menstruation contributed to endometriosis 1927




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’.



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.



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.



Retrograde Menstruation Theory

Postulated

Present in 90% of women

does not explain adenomyosisretroperitoneal extra abdominal prepuberal*post hysterectomyprostatic 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.



Diffusion of Endometriosis

PUBMED works

Endometriosis : Diffusion in the body N°

Brain 2

Spinal Cord 3

Pericardium 1

Lung 95

Diaphragm 22

Leg 5

Nois and Eye 4

Lips 1

Kidney 23

Bladder 128

Liver 14

Pancresas 5

Bowel 85

Adrenals 1

Breast 1

Skin 26

Prostate 2

Total410



Theories of the EndometriosisProved

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.



Fetal Weeks Sexual Female Differentiation

0 Inattivation of one chromosome X4 Initial development of Wolff ducts5 Migration of primitive germ cells

6 Development of Muller ducts9 Reduction of sensivity of Muller ducts

9 First meiotic profase in to the oogones10 Regression of the Wolff ducts16 First ovarian follicles24 Complete Canalizzation of the vagina28 End of moltiplication of oogones

PC Sizonenko in pediatric Endocrinology,edidet J.Bertrand,R.Rappaport,and PC Sizonenko.(Baltimore:Williams e Wilkins,1993),pp.88-99.



Muller ducts and Genital Tract



Internal Female Genitalia



Muller , Wolff Ducts and Gonad


Mesonephro cranial Mesonephro caudal Paramesonephro Gonad

7 W


Muller, Wolff Duct and Gonad


Mesonephro Mesonefphro Paramesonephro Gonad

7 W


Internal Genitalia


Tube Gonad Uterus Vagina

11 W


Embriogenetic theory is demonstrated

1690 - 2009



Uterus in mammals

• Bipartite ungulates (deer, moose, elk etc.), carnivores (cats, and dogs).

• Bicornpigs.

• Simplex• humans, other primates and horses.• Duplex • rodents (such as mice, rats and guinea pigs),

marsupials and lagomorpha (rabbits and hares).



Endometriosis is related to the Tipe of Uterus

Uterus Simplex endometriosishumans, other primates

and horses

Uterus Bipartite,

Bicorn, Duplex absence of endometriosis

all others placentals

mammals



Septum Uterus

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.



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,



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



Mullerianosis

• 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. [email protected]

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. [email protected]

Hum Pathol. 2005 Aug;36(8):927-31.

• 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-34125 Trieste, Italy. [email protected]



http://www.ncbi.nlm.nih.gov/entrez/utils/fref.fcgi?PrId=3048&itool=AbstractPlus-def&uid=16213861&db=pubmed&url=http://linkinghub.elsevier.com/retrieve/pii/S0015-0282(05)01433-0

http://www.ncbi.nlm.nih.gov/entrez/utils/fref.fcgi?PrId=3048&itool=AbstractPlus-def&uid=16112012&db=pubmed&url=http://linkinghub.elsevier.com/retrieve/pii/S0046-8177(05)00288-1

Embriologic theory

Proved

Explains adenomyosis

retroperitoneal

extra abdominal

prepuberal

post hysterectomy

prostatic

endometriosis only in mammals with simplex uterus




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 18-20 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 21-22 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 CytologyVol. 70 (2007) , No. 1 p.21-28Ultrastructural dynamics of the human endometrium from 14 to 22 weeks of gestationFabrizio 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


Demonstration of embriogenetic Theoryn 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.



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.



Fetuses Enrolled

• 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

1 18 weeks Voluntary abortion Yes 2 24 weeks Placental pathology Yes 3 25 weeks Placental pathology Yes 4 16 weeks Voluntary abortion Yes

Yes : Ectopic Endometrium



Methods

• 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.



Methods

• 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.



Ectopic Endometrium Prevalence in Fetuses

Fetuses* 11%

Adult 10%-15%

* First observation



Distribution of Ectopic Endometrium in the Fetus

Case 1 25 weeks fetus

Ectopic endometrial structure in the deep recto-vaginal septum, near perineal floor.








Ectopic endometrial structure in the proximity of the Douglas pouch.








Ectopic endometrial structure in the rectal tube at the level of

muscularis propria








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





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Conclusion

Past Origin Endometriosis unknown (chronic desease)

Present Embriogenetic minimal defect at theorigin 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


SI RINGRAZIANO

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 10.000 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



Health & Medicine

La Scoperta - High Tech in Endometriosi ed Infertilità Roma 04