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Table of Contents
Year : 2019  |  Volume : 39  |  Issue : 2  |  Page : 244-248

Endometrial biopsy in recurrent implantation failure: a histopathological and immunohistochemical study

1 Department of Pathology, Mansoura University, Mansoura, Egypt
2 Department of Obstetrics and Gynecology, Faculty of Medicine, Mansoura, Mansoura, Egypt

Date of Submission15-May-2019
Date of Acceptance15-Jun-2019
Date of Web Publication30-Sep-2020

Correspondence Address:
PhD Reham M Nagib
Department of Pathology, Mansoura University Hospitals, Elgomhouria Street, Mansoura City, Dakahlia 35111
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/EGJP.EGJP_30_19

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Background Recurrent implantation failure (RIF) may be related to a defect in endometrial receptivity. There is still lack of data regarding the effect of progesterone on endometrial receptivity, namely, expression of adhesion molecules. This study aimed at investigating the endometrium for histopathological changes and expression of E-cadherin and progesterone receptors (PR).
Patients and methods This study was conducted on 40 endometrial biopsies from patients with RIF compared with 10 biopsies from age-matched control. Biopsies were examined for pathological changes and immunostained with PR and E-cadherin.
Results There was a statistically significant reduction in stromal PR in cases compared with control, but no statistically significant difference was found in glandular PR expression. A significant reduction in glandular E-cadherin expression was evident in cases.
Conclusion Endometrial biopsy may have a role in investigating women with RIF. Maintained stromal PR acts to allow expression of adhesion molecules like E-cadherin and opening of implantation window.

Keywords: E-cadherin, endometrial biopsy, progesterone receptors, recurrent implantation failure

How to cite this article:
Nagib RM, Youssef SM, Wageh A. Endometrial biopsy in recurrent implantation failure: a histopathological and immunohistochemical study. Egypt J Pathol 2019;39:244-8

How to cite this URL:
Nagib RM, Youssef SM, Wageh A. Endometrial biopsy in recurrent implantation failure: a histopathological and immunohistochemical study. Egypt J Pathol [serial online] 2019 [cited 2021 Apr 15];39:244-8. Available from: http://www.xep.eg.net/text.asp?2019/39/2/244/296052

  Introduction Top

Cross-talk between a competent blastocyst and a receptive uterus is essential for successful embryo implantation. The absence of no clinical pregnancy after transfer of at least four good-quality embryos in a minimum of three fresh or frozen in-vitro fertilization cycles in a female below the age of 40 years is referred to as recurrent implantation failure (RIF) (Coughlan et al., 2014).

As logical consequence causes have been related to either a genetic defect in the embryo or defective endometrium, there is a limited period in which the endometrial tissue acquires a status allowing blastocyst implantation and therefore pregnancy initiation, which is known as endometrial receptivity (Miravet-Valenciano et al., 2015; Choi et al., 2016).

This period was classically considered to occur 8–10 days after ovulation (mid-luteal) and lasting 2 or 3 days (Huang et al., 2017). However, the focus has been shifted toward personalized receptivity status that differs among women, which is known as the window of implantation (WOI).

This WOI is suggested to occur under sequential actions of estrogen and progesterone. Progesterone is well known for its critical action on endometrial stroma through induction of decidualization (Young, 2013). Emerging data suggested that progesterone-driven decidualization can be essential for early implantation (Lucas, 2013).

Additionally, WOI is characterized by the unique transcriptomic signature of receptive endometrium, among which are adhesion molecules. Studies have addressed the role of integrins; however, E-cadherin was not widely investigated (Katzorke et al., 2016; Makker et al., 2017).

Despite being known as the hormone of pregnancy, there is a lack of data regarding the effect of progesterone on endometrial receptivity, namely, expression of adhesion molecules. Therefore, our study aimed at investigating the endometrium of women with RIF for immunohistochemical expression of E-cadherin, as one of the adhesion molecules, and progesterone receptors (PR) and whether there is a correlation between the expressions of both markers as well as detection of any associated pathological changes.

  Patients and methods Top

This is an observational case–control study done by comparing findings of endometrial biopsies from the RIF group and the control group. All participants were recruited from the Fertility Care Unit of Mansoura University and private practice. The study was approved by our Institution ethical committee (R/17.01.42), and informed consent was taken from participants.

RIF group consisted of patients who had at least three failed in-vitro fertilization cycles with good-quality embryos (n=40).

Biopsies from RIF cases were collected during hysteroscopy workup or collected using pipelle provided to be in the mid-secretory phase of the cycle guided by the date of the last menstrual period.

Biopsies from control (n=10) are considered only for women whose D&C revealed mid-secretory endometrium without associated pathology. These patients were included provided that each had at least one normal pregnancy and delivery, and not currently on oral contraceptive therapy or with intrauterine contraceptive devices.

Cases and control were matched regarding age, BMI, and cycle length.

Biopsies were formalin fixed, from which paraffin blocks were prepared. Hematoxylin and eosin-stained slides were prepared for studying the endometrial date as well as any associated pathological changes.

Tissue microarray blocks were constructed and immunostained with antibodies for E-cadherin and PR (rabbit, monoclonal; Genemed, South San Francisco, California, USA). Both markers were assessed regarding the intensity of reaction (weak=1, moderate=2, and strong=3) as well as the percentage of cells, and H score was calculated. E-cadherin was assessed in the epithelium, whereas PR was assessed in both the epithelium and stroma of endometrium (Chen et al., 2017).

Statistical analysis

Data were analyzed using IBM SPSS software package, version 20.0 (IBM). Qualitative data were expressed using the number and percent. Quantitative data were described using the median (minimum and maximum) for nonparametric data. Mean±SD was used for parametric data after testing normality using Kolmogorov–Smirnov test.

Fischer exact test and Monte Carlo test were used for categorical variables. Student t test was used for parametric quantitative variables.

Mann–Whitney test was used for nonparametric quantitative variables. Spearman correlation was used to correlate nonparametric continuous variables. Binary stepwise logistic regression analysis was used for prediction of independent variables of cases. Significant predictors in the univariate analysis were entered into a regression model using a forward Wald method. Adjusted odds ratios and their 95% confidence interval were calculated.

  Results Top

Clinical data

The mean age for cases was 29.1±1.9 and that for control was 30.53±2.5. BMI for cases was 21.9±1.8, whereas that for control was22.6±1.6. Cycle length for cases and control is illustrated in [Table 1]. No statistically significant difference was found between cases and control regarding age, BMI, or cycle length.
Table 1 Cycle frequency between cases and control group

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Histopathological data

Considering endometrial dating, there was a lag in 10 cases, where the endometrium was in the early secretory phase. The early secretory phase is detected by the presence of subnuclear vacuoles in more than 50% of the endometrial glands that are more or less retaining the tubular appearance in absence of stromal edema.

In still other seven cases, the endometrium showed the appearance of disordered proliferative endometrium in absence of any evidence of ovulation.

The mid-secretory phase, evident by the presence of supranuclear vacuoles and luminal secretions with simple tortuosity of the glandular outline together with stromal edema in absence of predecidua, was seen in 23 cases.

Considering pathological findings, chronic nonspecific endometritis was present in 11 (27.5) cases, and one case showed endometrial polyp.

Immunohistochemical data

Regarding E-cadherin, membranous staining was seen in the luminal and glandular epithelium, with nearly similar H score for both glandular and luminal epithelium. There was a statistically significant reduction in E-cadherin expression among patients with RIF (P<0.001) ([Figure 1]). Considering PR stromal expression, there was a statistically significant reduction in RIF than control (P<0.001) ([Figure 2]). On the contrary, there was no statistically significant difference in glandular PR between cases and control ([Table 2]).
Figure 1 Strong membranous reaction for E-cadherin in control (a) compared with weak to the absent reaction in cases (b) (immunohistochemistry, ×200).

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Figure 2 Strong nuclear reaction for PR in stromal cells of control (a) compared with the weak nuclear reaction in stromal cells of cases (b). In both groups, glandular PR is absent in mid-secretory endometrium (immunohistochemistry, ×400). PR, progesterone receptor.

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Table 2 Comparison of disease markers between case and control groups

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Correlation between E-cadherin and progesterone receptor

There was a significant positive correlation between stromal PR and epithelial E-cadherin among cases (rs=0.421, P=0.046).

  Discussion Top

RIF is the other coin face for unexplained infertility. As the endometrium is the site for implantation, this has raised consideration about differences in endometrium histology as well as immunohistochemical marker expression in such group of patients. When investigated in endometrial biopsies of a female cohort with RIF, our study found luteal phase defect in 25% of cases and absence of ovulation in 17.5%, highlighting the importance of progesterone for receptive endometrium. These results were nearly similar to Evans et al. (2012), who reported that late implantation as well as advanced implantation into out-of-phase endometrium is associated with decreased pregnancy rate.

Moreover, we found chronic endometritis in 27.5% of cases. Similar figures were reported by Yang et al. (2014) and Bouet et al. (2016). Chronic endometritis can contribute to defective implantation by altering endometrial cytokine production as well as the presence of abnormal lymphocyte population, together with the production of paracrine factors that alter endometrial receptivity (Park et al., 2016).

Endometrial receptivity is a key factor for successful implantation. Expression of adhesion molecules is essential for receptive endometrium to help blastocyst attachment. Being one of the adhesion molecules, our study found reduced E-cadherin expression in patients with RIF than fertile control ones, with a statistically significant difference, confirming its role in endometrial receptivity. Expression of E-cadherin in patients with RIF was not widely studied in the literature. Our results were supported by Makker et al. (2017) and Yang et al. (2017).

Progesterone is well known as the hormone of pregnancy. We hypothesized that defective progesterone effect may be related to RIF. Our results supported our hypothesis, as we found a significant reduction in PR stromal expression in patients with RIF when compared with age-matched control. On the contrary, there was no significant difference between cases and control regarding glandular PR expression. This indicates the critical role of progesterone on endometrial stroma, not epithelium, that affects the implantation. Our results were contradictory to Choi et al. (2016), who did not record the difference in PR between cases and control. This may be owing to a small number of the studied population, as Choi et al. (2016) conducted their study on 15 patients only.

The relation between PR and E-cadherin was not investigated on a wide scale. In their earlier study in 1996, Lessey et al. (1996) highlighted the importance of decreased epithelial PR in the establishment of the implantation window. In their study, Lessey et al. (1996) established a relation between glandular PR expression and aberrant integrin expression, suggesting it to be a cause of infertility in patients with luteal phase defect (). This was supported by Li et al. (2006), who reported from his in-vitro study that progesterone can induce calcitonin in the endometrial epithelium, which reduces E-cadherin expression, concluding that reduced glandular PR is essential for upregulation of E-cadherin.

Interestingly, our study was novel in correlating PR and E-cadherin in patients with RIF. There was a statistically significant correlation between stromal PR and E-cadherin expression. As the normal profile of glandular PR is still associated with reduced E-cadherin, this may indicate that E-cadherin is more tightly linked to stromal PR than glandular one and that action of progesterone on stromal cells can affect the epithelial adhesion and consequently affecting endometrial receptivity.

In support of our results, Young (2013), reported that both estrogen and PRs are reduced in endometrial epithelium during the mid to late secretory phases. Therefore, epithelial effects of estrogen and progesterone during these cycle phases are mediated by paracrine factors produced in the stroma termed oestromedins and progestogens (Young, 2013).

To clarify, Halasz and Szekeres-Bartho (2013), suggested that decidualized stromal cells under the effect of progesterone express transcription factors that block the mitogenic effect of estrogen, so decreasing endometrial epithelial proliferation to give chance for blastocyst adhesion and increase expression of adhesion molecules on the endometrial epithelium (Halasz and Szekeres-Bartho, 2013).

From the current study, we conclude that not only reduced epithelial PR (which is a normal finding in mid-secretory phase) but also maintained stromal PR levels act synchronous to allow expression of adhesion molecules like E-cadherin and opening of implantation window. Additionally, an endometrial biopsy may have a role in investigating women with RIF that can be applied to women with recurrent miscarriage for the possibility of detecting treatable causes.[16]

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Bouet PE, El Hachem H, Monceau E, Gariepy G, Kadoch IJ, Sylvestre C (2016). Chronic endometritis in women with recurrent pregnancy loss and recurrent implantation failure: prevalence and role of office hysteroscopy and immunohistochemistry in diagnosis. Fertil Steril 105 106–110.  Back to cited text no. 1
Choi Y, Kim HR, Lim EJ, Park M, Yoon JA, Kim YS et al. (2016). Integrative analyses of uterine transcriptome and MicroRNAome reveal compromised LIF-STAT3 signaling and progesterone response in the endometrium of patients with recurrent/repeated implantation failure (RIF). PloS one 11:e0157696.  Back to cited text no. 2
Coughlan C, Ledger W, Wang Q, Liu F, Demirol A, Gurgan T et al. (2014). Recurrent implantation failure: definition and management. Reprod Biomed Online 28;14–38.  Back to cited text no. 3
Evans GE, Phillipson GT, Sin IL, Frampton CM, Kirker JA, Bigby SM, Evans JJ (2012). Gene expression confirms a potentially receptive endometrium identified by histology in fertile women. Hum Reprod 27:2747–2755.  Back to cited text no. 4
Halasz M, Szekeres-Bartho J (2013). The role of progesterone in implantation and trophoblast invasion. J Reprod Immunol 97:43–50.  Back to cited text no. 5
Huang J, Qin H, Yang Y, Chen X, Zhang J, Laird S et al. (2017). A comparison of transcriptomic profiles in endometrium during window of implantation between women with unexplained recurrent implantation failure and recurrent miscarriage. Reproduction 153:749–758.  Back to cited text no. 6
Katzorke N, Vilella F, Ruiz M, Krüssel JS, Simon C (2016). Diagnosis of endometrial-factor infertility: current approaches and new avenues for research. Geburtshilfe Frauenheilkund 76:699.  Back to cited text no. 7
Lessey BA, Yeh IT, Castelbaum AJ, Fritz MA, Ilesanmi AO, Korzeniowski P et al. (1996). Endometrial progesterone receptors and markers of uterine receptivity in the window of implantation. Fert Steril 65:477–483.  Back to cited text no. 8
Li Q, Bagchi MK, Bagchi IC (2006). Identification of a signaling pathway involving progesterone receptor, calcitonin, and tissue tranglutaminase in Ishikawa endometrial cells. Endocrinology 147:2147–2154.  Back to cited text no. 9
Lucas E (2013). Epigenetic effects on the embryo as a result of periconceptional environment and assisted reproduction technology. Reprod Biomed Online 27:477–485.  Back to cited text no. 10
Makker A, Goel MM, Nigam D, Bhatia V, Mahdi AA, Das V, Pandey A (2017). Endometrial expression of homeo box genes and cell adhesion molecules in infertile women with intramural fibroids during window of implantation. Reprod Sci 24:435–444.  Back to cited text no. 11
Miravet-Valenciano JA, Rincon-Bertolin A, Vilella F, Simon C (2015). Understanding and improving endometrial receptivity. Curr Opin Obstetr Gynecol 27:187–192.  Back to cited text no. 12
Park HJ, Kim YS, Yoon TK, Lee WS (2016). Chronic endometritis and infertility. Clin Exp Reprod Med 43:185–192.  Back to cited text no. 13
Yang R, Du X, Wang Y, Song X, Yang Y, Qiao J (2014). The hysteroscopy and histological diagnosis and treatment value of chronic endometritis in recurrent implantation failure patients. Arch Gynecol Obstet 289:1363–1369.  Back to cited text no. 14
Yang Y, Chen X, Saravelos SH, Liu Y, Huang J, Zhang J, Li TC (2017). HOXA-10 and E-cadherin expression in the endometrium of women with recurrent implantation failure and recurrent miscarriage. Fertil Steril 107:136–143.e132.  Back to cited text no. 15
Young SL (2013). Oestrogen and progesterone action on endometrium: a translational approach to understanding endometrial receptivity. Reprod Biomed Online 27:497–505.  Back to cited text no. 16


  [Figure 1], [Figure 2]

  [Table 1], [Table 2]


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