Effects of hyperprolactinemia treatment with the dopamine agonist quinagolide on endometriotic lesions in patients with endometriosis-associated hyperprolactinemia  Raul Gómez, Ph.D., Antonio Abad, M.D., Francisco Delgado, Ph.D., Silvia Tamarit, M.D., Carlos Simón, M.D., Antonio Pellicer, M.D.  Fertility and Sterility  Volume 95, Issue 3, Pages 882-888.e1 (March 2011) DOI: 10.1016/j.fertnstert.2010.10.024 Copyright © 2011 American Society for Reproductive Medicine Terms and Conditions

Figure 1 The effect of quinagolide treatment on lesion size in three different patients (A-B, C-D, and E-F). Images in the first column show index lesions left untouched during first laparoscopy (L1). Images in the right column show the appearance of the same index lesions during second-look laparoscopy (L2) after quinagolide administration. The corresponding index lesions or the place where lesions were expected to be found during L2 have also been circled. White arrows point to original L1 lesions which had vanished at L2. Black arrow points to a lesion originally labelled during L1 and whose size has been reduced. Paired images A-B and C-D show two cases in which all index endometriotic samples disappeared after quinagolide treatment. Paired images E-F show a case in which lesions had either vanished or been reduced in size after quinagolide treatment. Blue arrowhead in F points to a silk suture marking an index lesion left untouched during L1. Fertility and Sterility 2011 95, 882-888.e1DOI: (10.1016/j.fertnstert.2010.10.024) Copyright © 2011 American Society for Reproductive Medicine Terms and Conditions

Figure 2 Image-Pro Plus software size measurements of the same endometriotic lesion during the first (L1) and second (L2; after 4 months of quinagolide therapy) laparoscopies. Lesion size area is expressed in mm2. (A) Each of the lesions analyzed during the study period is represented by a case (“serie”) number. Note that all but two endometriotic lesions undergo a reduction in size or disappear (value 0) after quinagolide treatment. A Wilcoxon paired test was used for statistical comparison: ∗P<.05. (B) Hatched bar represents mean ± SD surface area of index lesions left untouched and video recorded during L1. Bricked bar represents mean ± SD surface area of the same (paired) index lesions after 4 months of quinagolide treatment (L2). Note an overall 69.5% decrease in lesion size after quinagolide treatment. A Mann Whitney test was used for statistical comparison, ∗P<.05. Fertility and Sterility 2011 95, 882-888.e1DOI: (10.1016/j.fertnstert.2010.10.024) Copyright © 2011 American Society for Reproductive Medicine Terms and Conditions

Figure 3 (A–D) Histologic analysis of index lesions obtained during first (L1) and second (L2) laparoscopies. Intermediate-power (×20) representative images of index red lesions obtained during L1 (A) and L2 (B). Morphological analysis confirms glandular (purple) presence of endometrium surrounded by dried blood (redish color) typical of red lesions. High-power magnification of L1 untreated (C) and L2 quinagolide-treated (D) index red lesions. Endometriotic lesions in L1 show a typical high cellular stroma and glands well defined and surrounded by peritoneal tissue. In L2 lesions, a lax stroma is observed with a nonprominent glandular epithelium suggesting an atropic or degenerative status of tissue (B). (E–L) Representative paired images of immunohistochemical analysis in index endometritic lesions removed before (L1; left column) and left behind and recovered after (L2; middle column) quinagolide treatment.. Vascularizaton (vessel density) was assayed by immunostaining against CD31 antigen (brown color) in blood vessels (E, F). Repesentative images (G, H) of dopamine receptor 2 (Drd2; brown staining). Note the significant increase in brown staining after quinagolide treatment in H vs. G. Broad expression of vascular endothelial growth factor receptor 2 (VEGFR2) (I, J) staining (brown staining) was detected in both untreated and treated lesions. A slight decrease in VEGFR2 levels is observed in treated vs. untreated lesion. An antibody recognizing VEGFR2 specifically phosphorylated at tyrosine site 951 reveals faint antigen expression (brown color) before (K) and after (L) quinagolide treatment. The right column shows corresponding quantitative analyses of the stained areas in the row pair. Positive-stained area for each immunohistochemical parameter was outlined by setting a background noise level automatically with Image-Pro Plus. Area of interest was subsequently highlighted, quantified, compared with the total tissue, and expressed as percentage stained area. Results represent the ratio of stained/total area multiplied by 100. A Mann-Whitney test was used for comparisions, ∗P<.05. Fertility and Sterility 2011 95, 882-888.e1DOI: (10.1016/j.fertnstert.2010.10.024) Copyright © 2011 American Society for Reproductive Medicine Terms and Conditions

Prolactin levels as measured by enzyme-linked immunoassay in blood serum obtained from our nine parients at different time points during the quinagolide treatment. Patients started daily quinagolide administration 1 week after surgery (QX) and continued for 4 months. Pre-QX = blood samples taken with first laparoscopy just before starting the quinagolide treatment. Post-Qx 1 month = blood samples taken during the first monthly visit after 1 month of quinagolide administration. Post-QX 3 months = blood samples taken during the third monthly visit after 3 months of quinagolide administration. Prolactin levels were found to be <20 ng/mL in all cases after 1 month of quinagolide treatment and continued below that baseline during treatment. Wilcoxon paired test was for statiscal comparision: ∗∗ P<.01 compared with Pre-QX. Fertility and Sterility 2011 95, 882-888.e1DOI: (10.1016/j.fertnstert.2010.10.024) Copyright © 2011 American Society for Reproductive Medicine Terms and Conditions