Kohei Odagiri, M. D. , Ryo Konno, M. D. , Ph. D, Hiroyuki Fujiwara, M

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Smooth muscle metaplasia and innervation in interstitium of endometriotic lesions related to pain Kohei Odagiri, M.D., Ryo Konno, M.D., Ph.D, Hiroyuki Fujiwara, M.D., Ph.D., Sachiho Netsu, M.D., Chenghui Yang, M.D., Ph.D., Mitsuaki Suzuki, M.D., Ph.D. Fertility and Sterility Volume 92, Issue 5, Pages 1525-1531 (November 2009) DOI: 10.1016/j.fertnstert.2008.08.101 Copyright © 2009 American Society for Reproductive Medicine Terms and Conditions

Figure 1 Immunohistochemistry of α-smooth muscle actin (ASMA) in human endometriotic lesions.(A) Ovarian endometrioma; magnification, ×100.(B) Peritoneal lesion; magnification, ×100.(C) Deep infiltrating lesion; magnification, ×100. Control sections.(D) Human ovarian serous cystadenoma; magnification, ×100.(E) Human eutopic endometrium in proliferative phase; magnification, ×100.(F) Rat endometriotic lesion; magnification, ×100. Intense immunostaining for ASMA is detected in the interstitial space outside of the stromal area around the endometriotic cyst in all three of the human endometriotic lesions and the rat endometriotic lesion (arrows), whereas normal human endometrium showed immunostaining only for myometrium and vascular smooth muscle in stroma. Ovarian serous cystadenoma show slight immunostaining for ASMA compared to ovarian endometrioma. EC = endometriotic cyst. Fertility and Sterility 2009 92, 1525-1531DOI: (10.1016/j.fertnstert.2008.08.101) Copyright © 2009 American Society for Reproductive Medicine Terms and Conditions

Figure 2 Immunohistochemistry of neural cell adhesion molecule (NCAM) in human endometriotic lesions.(A) Ovarian endometrioma; magnification, ×100.(B) Peritoneal lesion; magnification, ×100.(C) Deep infiltrating lesion; magnification, ×100. Control sections.(D) Human ovarian serous cystadenoma; magnification, ×100.(E) Human eutopic endometrium in secretory phase; magnification, ×100.(F) Rat endometriotic lesion; magnification, ×100. Intense immunostaining for NCAM is detected in the interstitial area of human endometriosis in the shape of a bundle of fibers (arrows), whereas there are no fibrotic cells stained by this antibody in eutopic endometrium and ovarian serous cystadenoma. EC = endometriotic cyst. Fertility and Sterility 2009 92, 1525-1531DOI: (10.1016/j.fertnstert.2008.08.101) Copyright © 2009 American Society for Reproductive Medicine Terms and Conditions

Figure 3 Immunohistochemistry of nerve growth factor (NGF) in human endometriotic lesions.(A) Ovarian endometrioma; magnification, ×100.(B) Peritoneal lesion; magnification, ×100.(C) Deep infiltrating lesion; magnification, ×100. Control sections.(D) Human ovarian serous cystadenoma; magnification, ×100.(E) Human eutopic endometrium in secretary phase; magnification, ×100.(F) Rat endometriotic lesion; magnification, ×100. Some of fibroblastic cells in interstitial spaces around an endometriotic cyst are moderately stained by anti-NGF antibody in human endometriosis (arrows), whereas no immunostaining in eutopic endometrium and weak in ovarian serous cystadenoma are detected in control sections. Weak immunostaining is detected in interstitial area in rat endometriotic lesions. EC = endometriotic cyst. Fertility and Sterility 2009 92, 1525-1531DOI: (10.1016/j.fertnstert.2008.08.101) Copyright © 2009 American Society for Reproductive Medicine Terms and Conditions

Figure 4 Postulated mechanism for endometriotic pain. First, some cytokines including nerve growth factor (NGF), produced by macrophages, induce smooth muscle metaplasia and innervation in the interstitium. Subsequently, the contraction of smooth muscle cells and hyperalgia of sensory nerve cells derived from innervation in interstitial lesions induce endometriotic pain. Mϕ: macrophage. Fertility and Sterility 2009 92, 1525-1531DOI: (10.1016/j.fertnstert.2008.08.101) Copyright © 2009 American Society for Reproductive Medicine Terms and Conditions