{"paper_id":"f15b978b-3b99-4d7a-aeaa-2fbcf484490c","body_text":"Abstract\nThe goal of this study was to identify genes that were differentially methylated and differentially expressed and their related signaling pathways in ovarian endometriosis tissue. First, the DNA methylation and gene expression profiles in the endometrial tissue of patients with ovarian endometriosis were studied using Illumina 450K methylation microarray analysis and the GSE141549 gene expression dataset. Second, differentially methylated and differentially expressed genes, herein referred to as differentially methylated/expressed genes, were identified and protein-protein interaction networks and functional analysis of these genes were determined. Third, qPCR and immunohistochemistry of patient samples was used to confirm the differential expression of a subset of differentially methylated/expressed genes. Finally, the GSE7305 dataset was used confirm the expression profile of differentially methylated/expressed genes and to determine the potential usefulness of these genes for diagnosis of endometriosis. A total of 37 hypermethylated low-expression genes and 66 hypomethylated high-expression genes were identified in ovarian endometriosis patients. Protein-protein interaction and functional analysis highlighted 8 hypermethylated low-expression genes (KRT19, KRT8, ESR1, PRL, SFN, IL20RA, IL2RB, and PAX8) and 4 hypomethylated high-expression genes (CYP11A1, NR5A1, ME1, and GSTM1). Significantly, both of these gene sets had a diagnostic value for patients with ovarian endometriosis. Signaling pathways that were identified included JAK-STAT (involving IL20RA and IL2RB), prolactin (involving PRL and ESR1), Staphylococcus aureus infection (involving KRT19), viral protein interaction with cytokine and cytokine receptor (involving IL20RA and IL2RB), cytokine-cytokine receptor interaction (involving IL20RA and IL2RB), and drug metabolism-cytochrome P450 (involving GSTM1). The differentially methylated/expressed genes and enriched signaling pathways identified in this study are likely to be associated with the process of ovarian endometriosis.\nSimilar content being viewed by others\nData Availability\nAll data are available in the article.\nReferences\nHickey M, Ballard K, Farquhar C. Endometriosis. BMJ (Clin Res ed). 2014;348:g1752. https://doi.org/10.1136/bmj.g1752.\nKoukoura O, Sifakis S, Spandidos DA. DNA methylation in endometriosis (Review). Mol Med Rep. 2016;13(4):2939–48. https://doi.org/10.3892/mmr.2016.4925.\nEhrlich M. Cancer-linked DNA hypomethylation and its relationship to hypermethylation. Curr Top Microbiol Immunol. 2006;310:251–74. https://doi.org/10.1007/3-540-31181-5_12.\nLi XX, Gao SY, Wang PY, Zhou X, Li YJ, Yu Y, Yan YF, Zhang HH, Lv CJ, Zhou HH, Xie SY. Reduced expression levels of let-7c in human breast cancer patients. Oncol Lett. 2015;9(3):1207–12. https://doi.org/10.3892/ol.2015.2877.\nFraga MF, Ballestar E, Villar-Garea A, Boix-Chornet M, Espada J, Schotta G, Bonaldi T, Haydon C, Ropero S, Petrie K, Iyer NG, Pérez-Rosado A, Calvo E, Lopez JA, Cano A, Calasanz MJ, Colomer D, Piris MA, Ahn N, et al. Loss of acetylation at Lys16 and trimethylation at Lys20 of histone H4 is a common hallmark of human cancer. Nat Genet. 2005;37(4):391–400. https://doi.org/10.1038/ng1531.\nHapangama DK, Raju RS, Valentijn AJ, Barraclough D, Hart A, Turner MA, Platt-Higgins A, Barraclough R, Rudland PS. Aberrant expression of metastasis-inducing proteins in ectopic and matched eutopic endometrium of women with endometriosis: implications for the pathogenesis of endometriosis. Hum Reprod (Oxford, England). 2012;27(2):394–407. https://doi.org/10.1093/humrep/der412.\nGuo SW. Epigenetics of endometriosis. Mol Hum Reprod. 2009;15(10):587–607. https://doi.org/10.1093/molehr/gap064.\nDeiana D, Gessa S, Anardu M, Daniilidis A, Nappi L, D'Alterio MN, Pontis A, Angioni S. Genetics of endometriosis: a comprehensive review. Gynecol Endocrinol Official J Int Soc Gynecol Endocrinol. 2019;35(7):553–8. https://doi.org/10.1080/09513590.2019.1588244.\nWang L, Zhao J, Li Y. Genome-wide analysis of DNA methylation in endometriosis using Illumina Human Methylation 450 K BeadChips. Mol Reprod Dev. 2019;86(5):491–501. https://doi.org/10.1002/mrd.23127.\nGabriel M, Fey V, Heinosalo T, Adhikari P, Rytkönen K, Komulainen T, Huhtinen K. A relational database to identify differentially expressed genes in the endometrium and endometriosis lesions. Scientific Data. 2020;7(1):284. https://doi.org/10.1038/s41597-020-00623-x.\nLeek JT, Johnson WE, Parker HS, Jaffe AE, Storey JD. The sva package for removing batch effects and other unwanted variation in high-throughput experiments. Bioinformatics (Oxford, England). 2012;28(6):882–3. https://doi.org/10.1093/bioinformatics/bts034.\nRitchie ME, Phipson B, Wu D, Hu Y, Law CW, Shi W, Smyth GK. limma powers differential expression analyses for RNA-sequencing and microarray studies. Nucleic Acids Research 43 (7):e47. 2015. https://doi.org/10.1093/nar/gkv007.\nAshburner M, Ball CA, Blake JA, Botstein D, Butler H, Cherry JM, Davis AP, Dolinski K, Dwight SS, Eppig JT, Harris MA, Hill DP, Issel-Tarver L, Kasarskis A, Lewis S, Matese JC, Richardson JE, Ringwald M, Rubin GM, Sherlock G. Gene Ontology: tool for the unification of biology. The Gene Ontology Consortium. Nat Genet. 2000;25(1):25–9. https://doi.org/10.1038/75556.\nKanehisa M, Goto S. KEGG: Kyoto Encyclopedia of Genes and Genomes. Nucleic Acids Res. 2000;28(1):27–30. https://doi.org/10.1093/nar/28.1.27.\nHever A, Roth RB, Hevezi P, Marin ME, Acosta JA, Acosta H, Rojas J, Herrera R, Grigoriadis D, White E, Conlon PJ, Maki RA, Zlotnik A. Human endometriosis is associated with plasma cells and overexpression of B lymphocyte stimulator. Proc Natl Acad Sci U S A. 2007;104(30):12451–6. https://doi.org/10.1073/pnas.0703451104.\nPospisilova E, Kiss I, Souckova H, Tomes P, Spicka J, Matkowski R, Jedryka M, Ferrero S. Circulating endometrial cells: a new source of information on endometriosis dynamics. J Clin Med. 2019;8(11). https://doi.org/10.3390/jcm8111938.\nNavarro A, Yin P, Monsivais D, Lin SM, Du P, Wei JJ, Bulun SE. Genome-wide DNA methylation indicates silencing of tumor suppressor genes in uterine leiomyoma. PLoS One. 2012;7(3):e33284. https://doi.org/10.1371/journal.pone.0033284.\nCong Q, Li B, Wang Y, Zhang W, Cheng M, Wu Z, Zhang X, Jiang W, Xu C. In vitro differentiation of bone marrow mesenchymal stem cells into endometrial epithelial cells in mouse: a proteomic analysis. Int J Clin Exp Pathol. 2014;7(7):3662–72.\nChen M, Zhou Y, Xu H, Hill C, Ewing RM, He D, Zhang X, Wang Y. Bioinformatic analysis reveals the importance of epithelial-mesenchymal transition in the development of endometriosis. Sci Rep. 2020;10(1):8442. https://doi.org/10.1038/s41598-020-65606-9.\nEl-Halawany N, Ponsuksili S, Wimmers K, Gilles M, Tesfaye D, Schellander K. Quantitative expression analysis of blastocyst-derived gene transcripts in preimplantation developmental stages of in vitro-produced bovine embryos using real-time polymerase chain reaction technology. Reprod Fertil Dev. 2004;16(8):753–62. https://doi.org/10.1071/rd04041.\nFang X, Ni N, Lydon JP, Ivanov I, Bayless KJ, Rijnkels M, Li Q. Enhancer of zeste 2 polycomb repressive complex 2 subunit is required for uterine epithelial integrity. Am J Pathol. 2019;189(6):1212–25. https://doi.org/10.1016/j.ajpath.2019.02.016.\nBondesson M, Hao R, Lin CY, Williams C, Gustafsson J. Estrogen receptor signaling during vertebrate development. Biochim Biophys Acta. 2015;1849(2):142–51. https://doi.org/10.1016/j.bbagrm.2014.06.005.\nSun HS, Hsiao KY, Hsu CC, Wu MH, Tsai SJ. Transactivation of steroidogenic acute regulatory protein in human endometriotic stromalcells is mediated by the prostaglandin EP2 receptor. Endocrinology. 2003;144(9):3934–42. https://doi.org/10.1210/en.2003-0289.\nCao D, Bromberg PA, Samet JM. COX-2 expression induced by diesel particles involves chromatin modification and degradation of HDAC1. Am J Respir Cell Mol Biol. 2007;37(2):232–9. https://doi.org/10.1165/rcmb.2006-0449OC.\nCoward WR, Watts K, Feghali-Bostwick CA, Knox A, Pang L. Defective histone acetylation is responsible for the diminished expression of cyclooxygenase 2 in idiopathic pulmonary fibrosis. Mol Cell Biol. 2009;29(15):4325–39. https://doi.org/10.1128/mcb.01776-08.\nMitani Y, Oue N, Hamai Y, Aung PP, Matsumura S, Nakayama H, Kamata N, Yasui W. Histone H3 acetylation is associated with reduced p21(WAF1/CIP1) expression by gastric carcinoma. J Pathol. 2005;205(1):65–73. https://doi.org/10.1002/path.1684.\nYang H, Kang K, Cheng C, Mamillapalli R, Taylor HS. Integrative analysis reveals regulatory programs in endometriosis. Reprod Sci (Thousand Oaks, Calif). 2015;22(9):1060–72. https://doi.org/10.1177/1933719115592709.\nSmolarz B, Szyłło K, Romanowicz H. The genetic background of endometriosis: can ESR2 and CYP19A1 genes be a potential risk factor for its development? Int J Mol Sci. 2020;21(21). https://doi.org/10.3390/ijms21218235.\nPaskulin DD, Cunha-Filho JS, Paskulin LD, Souza CA, Ashton-Prolla P. ESR1 rs9340799 is associated with endometriosis-related infertility and in vitro fertilization failure. Dis Markers. 2013;35(6):907–13. https://doi.org/10.1155/2013/796290.\nGordon K, Aso T, Williams RF. Lactational anovulation in non-human primates: restriction of nursing inhibits Prl secretion without precipitating the return of ovulatory menstrual cyclicity in cynomolgus monkeys. Contraception. 1995;51(4):265–72. https://doi.org/10.1016/0010-7824(95)00044-b.\nKoch Y, Wimberger P, Grümmer R. Human chorionic gonadotropin induces decidualization of ectopic human endometrium more effectively than forskolin in an in-vivo endometriosis model. Exp Biol Med. 2018;243(11):953–62. https://doi.org/10.1177/1535370218782658.\nKobayashi H, Higashiura Y, Koike N, Akasaka J, Uekuri C, Iwai K, Niiro E, Morioka S, Yamada Y (2014) Genes downregulated in endometriosis are located near the known imprinting genes. Reprod Sci (Thousand Oaks, Calif) 21 (8):966-972. https://doi.org/10.1177/1933719114526473\nKlemmt PA, Carver JG, Kennedy SH, Koninckx PR, Mardon HJ. Stromal cells from endometriotic lesions and endometrium from women with endometriosis have reduced decidualization capacity. Fertil Steril. 2006;85(3):564–72. https://doi.org/10.1016/j.fertnstert.2005.08.046.\nDassen H, Punyadeera C, Kamps R, Klomp J, Dunselman G, Dijcks F, de Goeij A, Ederveen A, Groothuis P. Progesterone regulation of implantation-related genes: new insights into the role of oestrogen. Cell Mol Life Sci: CMLS. 2007;64(7-8):1009–32. https://doi.org/10.1007/s00018-007-6553-9.\nLogan PC, Yango P, Tran ND. Endometrial stromal and epithelial cells exhibit unique aberrant molecular defects in patients with endometriosis. Reprod Sci (Thousand Oaks, Calif). 2018;25(1):140–59. https://doi.org/10.1177/1933719117704905.\nHsieh YY, Chang CC, Tsai FJ, Hsu CM, Lin CC, Tsai CH. Interleukin-2 receptor beta (IL-2R beta)-627*C homozygote but not IL-12R beta 1 codon 378 or IL-18 105 polymorphism is associated with higher susceptibility to endometriosis. Fertil Steril. 2005;84(2):510–2. https://doi.org/10.1016/j.fertnstert.2005.02.025.\nArakawa T, Fukuda S, Hirata T (2019) PAX8: a highly sensitive marker for the glands in extragenital endometriosis. 1933719119828095. https://doi.org/10.1177/1933719119828095\nMittag J, Winterhager E, Bauer K, Grümmer R. Congenital hypothyroid female pax8-deficient mice are infertile despite thyroid hormone replacement therapy. Endocrinology. 2007;148(2):719–25. https://doi.org/10.1210/en.2006-1054.\nBulun SE, Zeitoun KM, Takayama K, Sasano H. Estrogen biosynthesis in endometriosis: molecular basis and clinical relevance. J Mol Endocrinol. 2000;25(1):35–42. https://doi.org/10.1677/jme.0.0250035.\nAttar E, Tokunaga H, Imir G, Yilmaz MB, Redwine D, Putman M, Gurates B, Attar R, Yaegashi N, Hales DB, Bulun SE. Prostaglandin E2 via steroidogenic factor-1 coordinately regulates transcription of steroidogenic genes necessary for estrogen synthesis in endometriosis. J Clin Endocrinol Metab. 2009;94(2):623–31. https://doi.org/10.1210/jc.2008-1180.\nBernardi LA, Dyson MT, Tokunaga H, Sison C, Oral M, Robins JC, Bulun SE. The Essential role of GATA6 in the activation of estrogen synthesis in endometriosis. Reprod Sci (Thousand Oaks, Calif). 2019;26(1):60–9. https://doi.org/10.1177/1933719118756751.\nXue Q, Zhou YF, Zhu SN, Bulun SE. Hypermethylation of the CpG island spanning from exon II to intron III is associated with steroidogenic factor 1 expression in stromal cells of endometriosis. Reprod Sci (Thousand Oaks, Calif). 2011;18(11):1080–4. https://doi.org/10.1177/1933719111404614.\nZhao L, Gu C, Ye M, Zhang Z, Li L, Fan W, Meng Y. Integration analysis of microRNA and mRNA paired expression profiling identifies deregulated microRNA-transcription factor-gene regulatory networks in ovarian endometriosis. Reprod Biol Endocrinol: RB&E. 2018;16(1):4. https://doi.org/10.1186/s12958-017-0319-5.\nPoli-Neto OB, Meola J, Rosa ESJC, Tiezzi D. Transcriptome meta-analysis reveals differences of immune profile between eutopic endometrium from stage I-II and III-IV endometriosis independently of hormonal milieu. Sci Rep. 2020;10(1):313. https://doi.org/10.1038/s41598-019-57207-y.\nKalinina EV, Chernov NN, Novichkova MD. Role of glutathione, glutathione transferase, and glutaredoxin in regulation of redox-dependent processes. Biochem Biokhimiia. 2014;79(13):1562–83. https://doi.org/10.1134/s0006297914130082.\nArvanitis DA, Koumantakis GE, Goumenou AG, Matalliotakis IM, Koumantakis EE, Spandidos DA. CYP1A1, CYP19, and GSTM1 polymorphisms increase the risk of endometriosis. Fertil Steril. 2003;79(Suppl 1):702–9. https://doi.org/10.1016/s0015-0282(02)04817-3.\nBaranova H, Canis M, Ivaschenko T, Albuisson E, Bothorishvilli R, Baranov V, Malet P, Bruhat MA. Possible involvement of arylamine N-acetyltransferase 2, glutathione S-transferases M1 and T1 genes in the development of endometriosis. Mol Hum Reprod. 1999;5(7):636–41. https://doi.org/10.1093/molehr/5.7.636.\nTempfer CB, Simoni M, Destenaves B, Fauser BC. Functional genetic polymorphisms and female reproductive disorders: part II--endometriosis. Hum Reprod Update. 2009;15(1):97–118. https://doi.org/10.1093/humupd/dmn040.\nKim SH, Choi YM, Lee GH, Hong MA, Lee KS, Lee BS, Kim JG, Moon SY. Association between susceptibility to advanced stage endometriosis and the genetic polymorphisms of aryl hydrocarbon receptor repressor and glutathione-S-transferase T1 genes. Hum Reprod (Oxford, England). 2007;22(7):1866–70. https://doi.org/10.1093/humrep/dem112.\nPemble S, Schroeder KR, Spencer SR, Meyer DJ, Hallier E, Bolt HM, Ketterer B, Taylor JB. Human glutathione S-transferase theta (GSTT1): cDNA cloning and the characterization of a genetic polymorphism. Biochem J. 1994;300(Pt 1):271–6. https://doi.org/10.1042/bj3000271.\nBaxter SW, Thomas EJ, Campbell IG. GSTM1 null polymorphism and susceptibility to endometriosis and ovarian cancer. Carcinogenesis. 2001;22(1):63–5. https://doi.org/10.1093/carcin/22.1.63.\nZhao J, Wang L, Li Y, Zhao W, Kang S. Hypomethylation of the GSTM1 promoter is associated with ovarian endometriosis. Hum Reprod (Oxford, England). 2019;34(5):804–12. https://doi.org/10.1093/humrep/dez039.\nFahey JV, Rossoll RM, Wira CR. Sex hormone regulation of anti-bacterial activity in rat uterine secretions and apical release of anti-bacterial factor(s) by uterine epithelial cells in culture. J Steroid Biochem Mol Biol. 2005;93(1):59–66. https://doi.org/10.1016/j.jsbmb.2004.11.002.\nJiang L, Zhang M, Wang S, Han Y, Fang X. Common and specific gene signatures among three different endometriosis subtypes. PeerJ. 2020;8:e8730. https://doi.org/10.7717/peerj.8730.\nMirabi P, Alamolhoda SH, Golsorkhtabaramiri M, Namdari M, Esmaeilzadeh S. Prolactin concentration in various stages of endometriosis in infertile women. JBRA Assisted Reproduction. 2019;23(3):225–9. https://doi.org/10.5935/1518-0557.20190020.\nKim BG, Yoo JY, Kim TH, Shin JH, Langenheim JF, Ferguson SD, Fazleabas AT, Young SL, Lessey BA, Jeong JW. Aberrant activation of signal transducer and activator of transcription-3 (STAT3) signaling in endometriosis. Hum Reprod (Oxford, England). 2015;30(5):1069–78. https://doi.org/10.1093/humrep/dev050.\nZhang H, Zhao X, Liu S, Li J, Wen Z, Li M. 17betaE2 promotes cell proliferation in endometriosis by decreasing PTEN via NFkappaB-dependent pathway. Mol Cell Endocrinol. 2010;317(1-2):31–43. https://doi.org/10.1016/j.mce.2009.11.009.\nCapobianco A, Monno A, Cottone L, Venneri MA, Biziato D, Di Puppo F, Ferrari S, De Palma M, Manfredi AA, Rovere-Querini P. Proangiogenic Tie2(+) macrophages infiltrate human and murine endometriotic lesions and dictate their growth in a mouse model of the disease. Am J Pathol. 2011;179(5):2651–9. https://doi.org/10.1016/j.ajpath.2011.07.029.\nWilcox AJ, Baird DD, Weinberg CR. Time of implantation of the conceptus and loss of pregnancy. N Engl J Med. 1999;340(23):1796–9. https://doi.org/10.1056/nejm199906103402304.\nSalamonsen LA, Nie G, Hannan NJ, Dimitriadis E. Society for Reproductive Biology Founders’ Lecture 2009. Preparing fertile soil: the importance of endometrial receptivity. Reprod Fertil Dev. 2009;21(7):923–34. https://doi.org/10.1071/rd09145.\nSon KN, Hwang J, Kwon BS, Kim J. Human CC chemokine CCL23 enhances expression of matrix metalloproteinase-2 and invasion of vascular endothelial cells. Biochem Biophys Res Commun. 2006;340(2):498–504. https://doi.org/10.1016/j.bbrc.2005.12.037.\nHwang J, Son KN, Kim CW, Ko J, Na DS, Kwon BS, Gho YS, Kim J. Human CC chemokine CCL23, a ligand for CCR1, induces endothelial cell migration and promotes angiogenesis. Cytokine. 2005;30(5):254–63. https://doi.org/10.1016/j.cyto.2005.01.018.\nZhang J, Echeverry S, Lim TK, Lee SH, Shi XQ, Huang H. Can modulating inflammatory response be a good strategy to treat neuropathic pain? Curr Pharm Des. 2015;21(7):831–9. https://doi.org/10.2174/1381612820666141027115508.\nZhao H, Wang Q, Bai C, He K, Pan Y. A cross-study gene set enrichment analysis identifies critical pathways in endometriosis. Reprod Biol Endocrinol RB&E. 2009;7:94. https://doi.org/10.1186/1477-7827-7-94.\nSacco K, Portelli M, Pollacco J, Schembri-Wismayer P, Calleja-Agius J. The role of prostaglandin E2 in endometriosis. Gynecol Endocrinol Official J Int Soc Gynecol Endocrinol. 2012;28(2):134–8. https://doi.org/10.3109/09513590.2011.588753.\nTsai SJ, Wu MH, Lin CC, Sun HS, Chen HM. Regulation of steroidogenic acute regulatory protein expression and progesterone production in endometriotic stromal cells. J Clin Endocrinol Metab. 2001;86(12):5765–73. https://doi.org/10.1210/jcem.86.12.8082.\nCode Availability\nNot applicable.\nFunding\nThis work was supported by a grant from the Natural Science Foundation of Hebei Province (no. H2018206200), the Scientific Research Fund of Hebei Provincial Health and Family Planning Commission (no. 20201091), the Department of Education of Hebei Province (no. CXZZBS2020120) and Bureau of Science and Technology of Hebei Province (Grant number: 21377775D) Bureau of Science and Technology of Hebei Province (Grant number: 21377775D).\nAuthor information\nAuthors and Affiliations\nContributions\nJW, YL, and GJ analyzed the data. YT and SK interpreted the data. HZ was a major contributor in writing the manuscript. SK designed the project. All authors read and approved the final manuscript.\nCorresponding author\nEthics declarations\nEthics Approval and Consent to Participate\nThis study was approved by the Ethics Committee of Hebei Fourth Medical Hospital (2019MEC035). Specimens and case data were collected with informed consent of patients.\nConsent for Publication\nNot applicable.\nConflict of Interest\nThe authors declare no competing interests.\nAdditional information\nPublisher’s Note\nSpringer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.\nSupplementary Information\nSupplementary Fig. 1A (download PNG )\nThe volcano plot of all differentially methylated sites in ovarian endometriosis. UP and DOWN represent hypermethylation and hypomethylation, respectively, B The volcano plot of all differentially expressed genes in ovarian endometriosis. UP and DOWN represent up-regulation and down-regulation, respectively. (PNG 575 kb)\nSupplementary Fig. 2A (download PNG )\nThe Venn diagram of identified hypermethylated-low expression genes in ovarian endometriosis. DMGs: differentially methylated genes; DEGs: differentially expressed genes. Up and down represent hypermethylation and down-regulation, respectively. (PNG 62 kb)\nSupplementary Fig. 2B (download PNG )\nThe Venn diagram of identified hypomethylated-high expression genes in ovarian endometriosis. DMGs: differentially methylated genes; DEGs: differentially expressed genes. Down and up represent hypomethylation and up-regulation, respectively. (PNG 61 kb)\nESM 1 (download CSV )\n(CSV 49 kb)\nESM 2 (download XLSX )\n(XLSX 11 kb)\nESM 3 (download XLS )\n(XLS 27 kb)\nESM 4 (download XLSX )\n(XLSX 10 kb)\nESM 5 (download XLSX )\n(XLSX 10 kb)\nESM 6 (download DOC )\n(DOC 34 kb)\nRights and permissions\nAbout this article\nCite this article\nZhang, H., Wu, J., Li, Y. et al. Identification of Key Differentially Methylated/Expressed Genes and Pathways for Ovarian Endometriosis by Bioinformatics Analysis. Reprod. Sci. 29, 1630–1643 (2022). https://doi.org/10.1007/s43032-021-00751-8\nReceived:\nAccepted:\nPublished:\nVersion of record:\nIssue date:\nDOI: https://doi.org/10.1007/s43032-021-00751-8","source_license":"CC0","license_restricted":false}