Circulating and Endometrial Regulatory T Cell and Related Populations in Endometriosis and Infertility: Endometriosis Is Associated with Blunting of Endometrial Cyclical Effects and Reduced Proportions in Moderate-Severe Disease

Evidence to date supports regulatory T cell (Treg) alterations in endometriosis; however, the relationship remains unclear, and Tregs have not previously been investigated with respect to infertility in endometriosis. This prospective cross-sectional cohort study details circulating and endometrial tissue-specific disturbances in Tregs and broader gated populations in women of reproductive age with and without endometriosis (n = 57 and 29, respectively) using flow cytometry and immunohistochemistry. Participants were characterised by menstrual cycle phase, r-ASRM endometriosis disease stage and fertility status. In the endometrium of women with endometriosis, endometrial Tregs and CD4+ lymphocyte proportions did not change between the proliferative and secretory phases, while in women without the disease, they significantly decreased (p = 0.045 and p = 0.039, respectively). In women with endometriosis, endometrial Tregs were lower than in women without endometriosis overall (p = 0.050 as a proportion of all CD45+ immune cells). We have shown for the first time that proportions of CD4+ lymphocytes (p = 0.021), overall lymphocytes (p = 0.034) and non-granulocytes (p = 0.027) were significantly decreased in the endometrium of women with moderate-severe (r-ASRM stages III and IV) compared to minimal-mild (r-ASRM stages I and II) endometriosis. During the secretory phase, circulating Treg proportions were significantly increased in infertile compared to fertile women (p = 0.049). This study confirms differences in endometrial Tregs in women with endometriosis, with blunting of normal menstrual cyclical variations, reduced proportions during the proliferative phase and disease stage-specific relationships. Similar content being viewed by others

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The authors thank Professor Ian S. Fraser (Department of Obstetrics and Gynaecology, The University of New South Wales), Dr Marina Berbic (Department of Obstetrics and Gynaecology, The University of New South Wales), the late Professor Derek N.J. Hart (Dendritic Cell Research Group, ANZAC Research Institute), Associate Professor Georgina Clark (Dendritic Cell Research Group, ANZAC Research Institute), the late Professor Robert P.S. Jansen (Department of Obstetrics, Gynaecology and Neonatology, The University of Sydney and Genea Limited, Sydney) and Uli Schmidt (Genea Limited, Sydney) for useful comments in the project’s early stages. The authors also thank Associate Professor Georgina Luscombe (School of Rural Health, The University of Sydney) for statistical advice, Associate Professor Lyndal Anderson for histopathological input, Dr Louise Cole (Advanced Microscopy Facility at the Bosch Institute, The University of Sydney) for technical advice and Dr Emily Miller, Ms Cecilia Wong and Dr Cecilia Ng for assistance with sample collection. Special thank you to all the gynaecology surgical staff at Royal Prince Alfred Hospital (Sydney) and women who generously gave their time and provided biological samples. Availability of Data and Material The data underlying this article will be shared on reasonable request to the corresponding author. Code Availability Not applicable. Funding This research was financially supported by a Sydney Medical School and Balnaves Foundation Kick Start Grant and the Department of Obstetrics, Gynaecology and Neonatology at The University of Sydney. Author information Authors and Affiliations Contributions A.J. Hey-Cunningham: substantial contributions to study conception and design, analysis and interpretation of data; drafting of the bulk of the article and revising it critically for important intellectual content; and final approval of the version to be published A. Riaz: involvement in study conception and design and substantial contributions to data acquisition and final approval of the version to be published P.D. Fromm: involvement in study conception and design and substantial contributions to data acquisition, critical revisions of manuscript and final approval of the version to be published F. Kupresanin: involvement in study conception and design and substantial contributions to data acquisition, critical revisions of manuscript and final approval of the version to be published R. Markham: role in study conception and design, critical revisions of manuscript and final approval of the version to be published H.M. McGuire: substantial contributions to analysis and interpretation of data, role in drafting the article and driver of revising it critically for important intellectual content and final approval of the version to be published Corresponding author Ethics declarations Ethics Approval This study was approved by the human research ethics committees of Sydney Local Health District (Royal Prince Alfred Hospital Zone; Protocol No X12-0344, HREC/12/RPAH/525 and SSA/13/RPAH/36) and The University of Sydney (Protocol No 2013/112). Consent to Participate Not applicable. Consent for Publication Not applicable. Conflict of Interest The authors declare no competing interests. Additional information Publisher’s Note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. Supplementary Information Supplementary Figure S1 Schematic indicating study participant sample pairing across flow cytometry (blood and endometrial tissue) and immunohistochemistry (IHC) platforms. *Denotes total number of samples within each sample type (column) for endo and non-endo groups. ^Denotes total number of participants within each samples type combination (row) for endo and non-endo groups. (PNG 282 kb) ESM 1 (download DOCX ) (DOCX 52 kb) Rights and permissions About this article Cite this article Hey-Cunningham, A.J., Riaz, A., Fromm, P.D. et al. Circulating and Endometrial Regulatory T Cell and Related Populations in Endometriosis and Infertility: Endometriosis Is Associated with Blunting of Endometrial Cyclical Effects and Reduced Proportions in Moderate-Severe Disease. Reprod. Sci. 29, 229–242 (2022). https://doi.org/10.1007/s43032-021-00658-4 Received: Accepted: Published: Version of record: Issue date: DOI: https://doi.org/10.1007/s43032-021-00658-4