Stefan Kissler

Physiology of upward transport in the human female genital tract.

Abstract:  The uterus and fallopian tubes represent a functionally united peristaltic pump under the endocrine control of ipsilateral ovary. We have examined this function by using hysterosalpingoscintigraphy (HSS), recording of intrauterine pressure, electrohysterography, and Doppler sonography of the fallopian tubes. An uptake of labeled particles into the uterus was observed during the follicular and luteal phases of the cycle after application into the vagina. Transport into the oviducts, however, could only be demonstrated during the follicular phase. Furthermore, the predominant transport was into the tube ipsilateral to the ovary containing the dominant follicle. The pregnancy rate following spontaneous intercourse or insemination was higher in those women in whom ipsilateral transport could be demonstrated. The amount of material transported to the ipsilateral tube was increased after oxytocin administration, as demonstrated by radionuclide imaging and by Doppler sonography following instillation of ultrasound contrast medium. An increase in the basal tone and amplitude of contractions was observed after oxytocin administration. These results support the idea that the uterus and fallopian tubes act as a peristaltic pump, which increases transport of sperm into the oviduct ipsilateral to the ovary bearing the dominant follicle. Oxytocin appears to play a critical role in this peristaltic pump. A failure of the peristaltic mechanism is possibly responsible for infertility. We propose the term tubal transport disorder (TTD) as a nosological entity. Results from HSS could be a useful adjunct for choosing treatment modalities in patients with patent fallopian tubes suffering from infertility. These patients may be better served with in vitro fertilization (IVF).

Ovarian hyperstimulation syndrome prevention by gonadotropin-releasing hormone agonist triggering of final oocyte maturation in a gonadotropin-releasing hormone antagonist protocol in combination with a "freeze-all" strategy: a prospective multicentric study.

OBJECTIVE To prospectively study ovarian hyperstimulation syndrome (OHSS) incidence and cumulative live birth rate in a cohort of patients at risk of OHSS undergoing ovarian stimulation in a GnRH antagonist protocol and receiving a GnRH agonist triggering followed by cryopreservation of all two pronuclei (2PN)-stage zygotes by two methods, vitrification or slow-cooling, for later ET. DESIGN Prospective, clinical cohort study. SETTING Five IVF centers in Germany; time frame: June 2008 to June 2010. PATIENT(S) Fifty-one female patients undergoing IVF considered at risk of developing severe OHSS (≥20 follicles≥11 mm and/or E2 level≥4,000 pg/mL) after ovarian stimulation in a GnRH antagonist protocol. INTERVENTION(S) Triptorelin (0.2 mg SC) for triggering final oocyte maturation. All 2PN-stage zygotes were cryopreserved by vitrification or slow-cooling for later repetitive frozen-thawed ET. MAIN OUTCOME MEASURE(S) Severe OHSS incidence and cumulative live birth rate per patient. RESULT(S) Of 51 patients, 1 patient (2%, 95% confidence [CI] 0.3%-10.3%) had zero oocyte retrieved, 1 patient did not undergo frozen-thawed ET, and 1 patient had no surviving oocyte after thawing. Thus, 48 patients underwent at least one frozen-thawed ET. The cumulative live birth rate was 37.3% (19/51, 95% CI 25.3%-51.0%). The live birth rate per first frozen-thawed ET was 5.9% (1/17, 95% CI 10.0%-27.0%) and 19.4% (6/31, 95% CI 9.2%-36.3%) in the slow-cooling and vitrification group, respectively (difference: 13.5%, 95% CI of the difference: -9.9%-31.1%). Three cases of OHSS II (3/51, 5.9%, 95% CI 2.0%-15.9%) and one early-onset case of OHSS III (1/51, 2%, 95% CI 0.3%-10.3%) occurred. CONCLUSION(S) Agonist triggering with cryopreservation is efficacious and safe, although a single case of a severe early-onset OHSS occurred.

Uterotubal transport disorder in adenomyosis and endometriosis—a cause for infertility

Objective  Uterine hyperperistalsis and dysperistalsis are common phenomena in endometriosis and may be responsible for reduced fertility in cases of minimal or mild extent of disease. Since a high prevalence of adenomyosis uteri has been well documented in association with endometriosis, we designed a study to examine whether hyperperistalsis and dysperistalsis are caused by the endometriosis itself or by the adenomyotic component of the disease.

Utero-Tubal Sperm Transport and Its Impairment in Endometriosis and Adenomyosis

Abstract:  The uterus is composed of different smooth muscle layers that serve various functions. First, menstrual debris is expulsed at the time of the menses. Second, sperm is transported in the preovulatory phase to maximize fertility, and third, the human embryo is placed in an adequate setting during implantation. Endometriosis is a gynecologic disorder leading to severe pain symptoms such as severe pain during menstruation (dysmenorrhea), chronic pelvic pain, pain during sexual intercourse (dyspareunia), and abnormal uterine bleeding. Besides, endometriosis is often associated with female infertility and exhibits a massive impairment in the physiology of uterine contractility that can be documented by the in vivo examination method of hysterosalpingoscintigraphy (HSSG). In addition, endometriosis is associated in 80–90% of subjects with adenomyosis and our data clearly indicate that sperm transport is disturbed by hyperperistalsis when at least one focus of adenomyosis can be detected via magnetic resonance imaging (MRI) and turns into dysperistalsis (a complete failure in sperm transport capacity) when diffuse adenomyosis affecting all myometrial uterine muscle layers is detected. Hence, dysperistalsis is significantly associated with reduced spontaneous pregnancy rates. We therefore recommend MRI and HSSG in every sterility workup.

Diminished pregnancy rates in endometriosis due to impaired uterotubal transport assessed by hysterosalpingoscintigraphy

Objective  To investigate uterotubal transport by means of hysterosalpingoscintigraphy (HSSG) in women with and without endometriosis.

Uterine contractility and directed sperm transport assessed by hysterosalpingoscintigraphy (HSSG) and intrauterine pressure (IUP) measurement

Background.  Uterine peristalsis sustains sperm transport and can be detected by hysterosalpingoscintigraphy (HSSG). This study is the first to be designed to investigate utero‐tubal transport function by HSSG and uterine contractility by intrauterine pressure measurement (IUP) consecutively on the same day in the periovulatory phase.

Estradiol regulates human QT-interval: acceleration of cardiac repolarization by enhanced KCNH2 membrane trafficking

BACKGROUND Modulation of cardiac repolarization by sexual hormones is controversial and hormonal effects on ion channels remain largely unknown. In the present translational study, we therefore assessed the relationship between QTc duration and gonadal hormones and studied underlying mechanisms. METHODS AND RESULTS We measured hormone levels and QTc intervals in women during clomiphene stimulation for infertility and women before, during, and after pregnancy. Three heterozygous LQT-2 patients (KCNH2-p.Arg752Pro missense mutation) and two unaffected family members additionally were studied during their menstrual cycles. A comprehensive cellular and molecular analysis was done to identify the mechanisms of hormonal QT-interval regulation. High estradiol levels, but neither progesterone nor estradiol/progesterone ratio, inversely correlated with QTc. Consistent with clinical data, in vitro estradiol stimulation (60 pmol/L, 48 h) enhanced IKCNH2. This increase was mediated by estradiol receptor-α-dependent promotion of KCNH2-channel trafficking to the cell membrane. To study the underlying mechanism, we focused on heat-shock proteins. The heat-shock protein-90 (Hsp90) inhibitor geldanamycin abolished estradiol-induced increase in IKCNH2. Geldanamycin had no effect on KCNH2 transcription or translation; nor did it affect expression of estradiol receptors and chaperones. Estradiol enhanced the physical interaction of KCNH2-channel subunits with heat-shock proteins and augmented ion-channel trafficking to the membrane. CONCLUSION Elevated estradiol levels were associated with shorter QTc intervals in healthy women and female LQT-2 patients. Estradiol acts on KCNH2 channels via enhanced estradiol-receptor-α-mediated Hsp90 interaction, augments membrane trafficking and thereby increases repolarizing current. These results provide mechanistic insights into hormonal control of human ventricular repolarization and open novel therapeutic avenues.

Effect of Humidified and Heated CO2 During Gynecologic Laparoscopic Surgery on Analgesic Requirements and Postoperative Pain

STUDY OBJECTIVE To determine the effect of humidified and heated CO(2) for pneumoperitoneum during laparoscopic surgery on analgesic requirements, postoperative pain, and patient satisfaction. DESIGN Prospective, randomized, double-blind, controlled study (Canadian Task Force classification I). SETTING University hospital. PATIENTS Ninety consecutive women scheduled for gynecologic laparoscopic surgery. INTERVENTION Operative laparoscopic management of adnexa surgery or adhesiolysis. MEASUREMENTS AND MAIN RESULTS Thirty consecutive patients were randomized into each study group. Group I received humidified, heated gas; group II dry, heated gas; and group III (control group) standard dry, cold gas. No significant difference in intraoperative and postoperative analgesic requirements or postoperative pain score between group I and group II was found. There was even a tendency (not significant) toward less pain and higher postoperative satisfaction in patients in the control group. Therefore, the evaluation was stopped after 53 patients. CONCLUSION The use of humidified, heated gas did not reduce postoperative pain or intraoperative analgesic requirements and is thus not preferable to standard dry, cold gas in gynecologic laparoscopic surgery.

Expression of membrane-type 5 matrix metalloproteinase in human endometrium and endometriosis

Background. The metalloproteinases (MMPs) are a family of proteolytic enzymes involved in tissue remodeling and cell migration. Endometrial tissue remodeling proceeds during the menstrual cycle and requires a temporary and spatially balanced expression of several different MMPs. Various members of the MMPs also seem to play an important role in the invasion process of endometriosis; however, so far only a limited number of studies have focused on membrane-associated MMPs. Methods. The present study investigated the expression of membrane-type 5 metalloproteinase (MT5-MMP) in the human endometrium and endometriotic lesions by microarray hybridization, real-time polymerase chain reaction (PCR) and immunofluorescence. Results. Both the gene chip expression analyses as well as PCR indicated expression of MT5-MMP in normal human endometrium and strongly elevated transcript levels in most peritoneal endometriosis lesions analyzed. Moreover we detected enhanced MT5-MMP expression in the eutopic endometrium from patients suffering from endometriosis, further supporting a role of MT5-MMP in the formation of endometriosis. Immunohistochemical analysis was used to determine the intracellular localization and tissue distribution of MT5-MMP. While the MT5-MMP antigen expression could be clearly attributed to the membrane of epithelial cells, a highly complex differential immunohistochemical staining of MT5-MMP in the various compartments of endometrial tissue was observed. The strongest staining was seen in luminal epithelial cells, whereas endometrial glands frequently showed partial expression of MT5-MMP. Conclusion. Our microarray analysis and real-time PCR of MT5-MMP transcripts may point to an elevated tissue remodeling and cell migration in endometrium from endometriosis patients as implied by the function of related MMPs.

Differential expression of claudins in human endometrium and endometriosis.

Membrane proteins of the claudin superfamily are important components of cellular tight and adherens junctions. Although their exact function remains unclear, these proteins may play a role in tissue remodeling, a process which is associated with several diseases including endometriosis. In the present work we analyzed the expression of 13 members of the claudin family in the endometrium and peritoneum by microarray analysis. Real-time polymerase chain reaction and immunohistochemistry in human endometrium and peritoneal endometriotic lesions were performed for validation of the expression of claudin-1, -3, -4, -5 and -7. Diminished expression of claudin-3, -4 and -7 in ectopic endometrium was frequently observed as indicated by all three methods. In contrast to a higher expression of claudin-5 mRNA detected in bulk biopsies of ectopic endometrium, immunohistochemistry revealed no alteration of claudin-5 protein expression in glandular cells of endometriosis samples. The downregulation of various members of the claudin family may contribute to endometrial cell detachment and increase the number of cells invading pelvic organs.