Clinical trial NCT05885633: Endometrial Vitamin D Receptor in PCOS
Official title: Phenotypic Components of Polycystic Ovary Syndrome Determine Endometrial Vitamin D Receptor mRNA Expression Pattern
Study type: INTERVENTIONAL
Overall status: COMPLETED
Phase: NA
Conditions: Vitamin D Receptor Defect
Keywords: PCOS
Vitamin D
Endometrium
VD receptor
Hyperandrogenemia
Insulin resistance
Lead sponsor: Uşak University
Sponsor class: OTHER
Collaborators: name: Bahçeşehir University
name: Firat University
First posted: 2023-06-02
Enrollment: 64
Sex: FEMALE
Minimum age (years): 26
Maximum age (years): 32
Standard ages: ADULT
Accepts healthy volunteers: no
Allocation: NON_RANDOMIZED
Intervention model: PARALLEL
Intervention model description: While the study group consisted of PCOS patients, the control group was selected from non-PCOS patients with male factor infertility.
Primary purpose: TREATMENT

Brief summary: Vitamin D receptor (VDR) is widely expressed not only in tissues responsible for calcium hemostasis, but also in reproductive organs, including the endometrium. The VDR, which is low in the proliferative phase, starts to increase in the early secretory phase and decreases again in the mid-secretory phase. Enzymes responsible for vitamin d (VD) production and metabolism are expressed locally in the endometrium. Binding of active VD to VDR in nuclear or plasma membrane increases receptivity gene expression and immunomodulators by activating genomic and nongenomic pathways. VDR expression defect has been reported in the decidual cells of recurrent miscarriages. There are no studies investigating the endometrial VDR expression pattern in polycystic ovary syndrome (PCOS) and its phenotypes. The VDR expression pattern in the endometrium of PCOS patients who underwent invitro fertilization /intracytoplasmic sperm injection (IVF/ICSI) and total embryo freezing was analyzed at both mRNA and immunohistochemical. The study group consisted of 44 PCOS patients who were referred to IVF/ICSI because they did not respond to first-line treatment with letrozole or clomiphene citrate (CC). Twenty patients who were scheduled for IVF/ICSI due to male factor infertility and who were matched with the study group in terms of age and body mass index (BMI) were included as the control group. Following egg collection, endometrial tissue was collected by pipelle cannula while the patient was under anesthesia. All good quality blastocysts of both groups were vitrified. The mRNA expression of vitamin D receptor transcript 2 (VDR-X2) and vitamin D receptor transcript 4 (VDR-X4) were determined by quantitative polymerase chain reaction (qPCR). The quantitative cycle equation method was used to calculate the differences between VDR-mRNA expressions. Endometrial VDR and progesterone receptor (PR) immunoreactivity were determined by immunohistochemistry.

Detailed description: Study question: How does the expression of endometrial vitamin D receptor vary according to phenotypes in women with polycystic ovary syndrome (PCOS)?

What is known already: VDR is widely expressed not only in tissues responsible for calcium hemostasis, but also in reproductive organs, including the endometrium. The VDR, which is low in the proliferative phase, starts to increase in the early secretory phase and decreases again in the mid-secretory phase. Enzymes responsible for VD production and metabolism are expressed locally in the endometrium. Binding of active VD to VDR in nuclear or plasma membrane increases receptivity gene expression and immunmodulators by activating genomic and nongenomic pathways. VDR expression defect has been reported in the decidual cells of recurrent miscarriage cases. There are no studies investigating the endometrial VDR expression pattern in PCOS and its phenotypes.

Study design, size, duration: The study group consisted of 44 PCOS patients who were referred to IVF/ICSI because they did not respond to first-line treatment with letrozole or clomiphene citrate (CC). Twenty patients who were scheduled for IVF/ICSI due to male factor infertility and who were matched with the study group in terms of age and BMI were included as the control group. Those who met at least two of the criteria for hyperandrogenemia (HA), ovulatory dysfunction (OD) and polycystic ovarian morphology (PCOM) determined by European Society of Human Reproduction and Embryology/ American Society for Reproductive Medicine were considered PCOS. Following egg collection, endometrial tissue was collected by pipelle cannula while the patient was under anesthesia. All good quality blastocysts of both groups were vitrified.

Participants/materials, setting, methods: The 44 participants in the PCOS group were divided into four phenotypic groups as follows according to the National Institutes of Health (NIH) consensus panel. Phenotype A: HA+OD+PCOM (classical/complete, n=17); phenotype B: HA+OD (classical/non-PCOM, n=10); phenotype C: HA+PCOM (ovulatory, n=9); and phenotype D: OD+PCOM (non-hyperandrogenic, n=8). The mRNA expression of vitamin D receptor transcript 2 (VDR-X2) and vitamin D receptor transcript 4 (VDR-X4) were determined by qPCR. The quantitative cycle equation method was used to calculate the differences between VDR-mRNA expressions. Endometrial VDR and progesterone receptor (PR) immunoreactivity were determined by immunohistochemistry. The histological score formula was used for the quantitative evaluation of VDR and PR immunoreactivity.

Limitations, reasons for caution: The lack of an equal number of participants for each phenotype is our first limitation. Due to the collection of endometrial samples in the IVF/ICSI cycle, the possible effect of ovarian stimulation drugs and the associated increased estrogen levels on the endometrium has not been excluded. Changes in endometrial VDR-mRNA expression could not be confirmed by protein measurement.

Eligibility criteria: Inclusion Criteria:

* Clinical diagnosis of PCOS
* Approval for IVF/ICSI and total embryo freezing
* Consent to endometrial sampling

Exclusion Criteria:

* Women with hyperandrogenism or ovulatory dysfunction due to non-PCOS etiologies.
* Patients taking vitamin D, insulin sensitizers, lipid-lowering or other hormonal drugs in the last three months were not included.
* Those with a history of mechanical endometrial injury, polypectomy, hysteroscopic myomectomy, endometrioma resection, dilatation/curettage, ovarian drilling and salpingectomy were also excluded.
* Participants with premalignant or malignant endometrial pathology, those with a history of tubal factor infertility, congenital uterine anomaly or any chronic systemic diseases were not included.
* Azoospermia patients were excluded from the study because we preferred ejaculate sperm for ICSI in patients in the control group.

Primary outcomes:
measure: The primary aim of the study was to investigate whether there is a difference in VDR expression in the endometrium of PCOS patients compared to controls by qPCR and immunohistochemical methods
timeFrame: first 3 months
Secondary outcomes:
measure: To reveal the effects of insulin resistance, HA, OD, and PCOM on endometrial VDR mRNA expression using correlation analyses.
timeFrame: First three months
measure: Clinical pregnancy and miscarriage rates
timeFrame: three months following the first three months
Other outcomes:
Locations:
city: Usak
country: Turkey
facility: Usak University Training and Research Hospital
Study officials:
affiliation: BAU IVF-Center
name: nur DE gungor, assoc. prof.
role: PRINCIPAL_INVESTIGATOR
affiliation: BAU IVF-Center
name: aynur A ersahin, assoc. prof
role: PRINCIPAL_INVESTIGATOR
affiliation: Memorial IVF-Center
name: arzu yurci, assoc. prof.
role: PRINCIPAL_INVESTIGATOR
affiliation: Halic University
name: Ulun ulug, prof
role: PRINCIPAL_INVESTIGATOR
affiliation: Yerkoy State Hospital
name: meltem yardım, specialist
role: PRINCIPAL_INVESTIGATOR
affiliation: Dr. Behcet Uz Children's Hospital
name: nilufer celik, assoc. prof.
role: PRINCIPAL_INVESTIGATOR
affiliation: Firat University
name: ahmet tektemur, assoc. prof
role: PRINCIPAL_INVESTIGATOR
affiliation: Firat University
name: Tuncay Kuloglu, Assoc. prof
role: PRINCIPAL_INVESTIGATOR
affiliation: Medeniyet University
name: Kagan Gungor, Assoc. prof
role: PRINCIPAL_INVESTIGATOR
References:
citation: Carmina E, Longo RA. Increased Prevalence of Elevated DHEAS in PCOS Women with Non-Classic (B or C) Phenotypes: A Retrospective Analysis in Patients Aged 20 to 29 Years. Cells. 2022 Oct 17;11(20):3255. doi: 10.3390/cells11203255.