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The Journal of Clinical Endocrinology & Metabolism Vol. 82, No. 7 2192-2197
Copyright © 1997 by The Endocrine Society


Experimental Studies

Epidermal Growth Factor and Sex Steroids Dynamically Regulate a Marker of Endometrial Receptivity in Ishikawa Cells1

Stephen G. Somkuti2, Lingwen Yuan, Marc A. Fritz and Bruce A. Lessey

Department of Obstetrics and Gynecology, Division of Human Reproduction and Infertility, University of North Carolina, Chapel Hill, North Carolina 27599-7570

Address all correspondence and requests for reprints to: Dr. Bruce A. Lessey, Department of Obstetrics and Gynecology, CB #7570, Old Clinic Building, University of North Carolina, Chapel Hill, North Carolina 27599-7570.


    Abstract
 Top
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
 References
 
The factors regulating human endometrial receptivity remain poorly understood. The {alpha}vß3 integrin cell adhesion molecule appears to be regulated in the human endometrium, appearing on postovulatory days 5–6, corresponding to the time of initial embryo attachment. This integrin has been extensively studied as a potential marker of endometrial receptivity and is aberrantly expressed in the endometrial epithelium of some infertile women. Ishikawa cells are a well differentiated endometrial adenocarcinoma cell line that maintain functional estrogen and progesterone receptors and are a useful model to study steroid-mediated events in human endometrial epithelium. This cell line expresses most of the normal endometrial epithelial integrins, including the {alpha}vß3 vitronectin receptor. The regulation of this integrin was studied with fluorescence immunocytochemistry, flow cytometry, and Northern blot analysis. Estrogen with or without progesterone treatment down-regulates {alpha}vß3 in this cell line. Several growth factors, including epidermal growth factor and the closely related transforming growth factor-{alpha} significantly increase the expression of this integrin. We conclude that endometrial differentiation is influenced by both steroid hormones and growth factors. The {alpha}vß3 integrin appears to be an excellent marker to study the molecular events leading to the establishment of uterine receptivity and successful implantation.


    Introduction
 Top
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
 References
 
THAT THE endometrium is receptive to embryo implantation for only a brief and defined interval in each cycle has long been suspected (for review, see Refs. 1 and 2). The concept of an implantation window was introduced by Finn (3) and has since been validated in numerous animal models (4, 5, 6). In humans, the temporal limits of this window of endometrial receptivity have been effectively defined by clinical experience with transfer of embryos derived from donor oocytes into the uteri of recipients receiving exogenous steroid hormone replacement (7). Results using this model are consistent with earlier observations by Hertig and colleagues which suggested that implantation occurs on or about cycle day 20 of an idealized 28-day menstrual cycle (8). The molecular mechanisms involved in implantation and those that confer receptivity remain poorly understood, but systematic studies using specific markers of endometrial receptivity promise to further our understanding of these processes (9).

Certain integrins, members of a family of cell adhesion molecules, have emerged as effective markers of endometrial receptivity in the human (10, 11). These heterodimeric glycoproteins are present on the surface of virtually all cells and participate in cell-cell and cell-substratum interactions with the extracellular matrix (12, 13). Each integrin consists of an {alpha}-subunit and a ß-subunit (14). We (10, 15) and others (11) recently described the patterns of integrin expression in the normal cycling endometrium. Three cycle-specific integrins have now been described, the {alpha}1ß1 collagen receptor, the {alpha}4ß1 fibronectin receptor, and the {alpha}vß3 vitronectin receptor, all coexpressed only during the suspected window of implantation (15). Interestingly, {alpha}vß3 is not expressed in the endometrium of some women with minimal and mild forms of endometriosis (16), luteal phase deficiency (10, 17), communicating hydrosalpinx (18), recurrent pregnancy loss (19), and unexplained infertility (20).

The cycle-specific patterns of integrin expression in the endometrium suggest that these molecules are hormonally regulated (10, 11, 15). During the midsecretory phase of the endometrial cycle, when implantation presumably occurs, circulating levels of estrogen (E) and progesterone (P) are high, resulting in an abrupt decline in E and P receptors (ER and PR) in the endometrial epithelium (21, 22). Recently, we have shown that this down-regulation of PR closely correlates with the rise in endometrial {alpha}vß3 expression and that in women with documented luteal phase deficiency, delayed endometrial maturation is associated with persistence of epithelial PR and absent {alpha}vß3 expression (17). This reciprocal relationship between PR and the {alpha}vß3 integrin suggests that the expression of this integrin and, by inference, the onset of uterine receptivity, may normally be inhibited by E and P, appearing only after the supply of epithelial receptor for these steroids is exhausted. Evidence suggests that certain growth factors, in particular epidermal growth factor (EGF) and related species, may also play a role in rendering the endometrium receptive to embryo implantation (23, 24).

Few models exist for studies of human endometrium in vitro. Ishikawa cells represent a well differentiated endometrial adenocarcinoma cell line (25) that is well suited for studies of hormonally regulated events in human endometrial epithelium (26, 27, 28, 29). These cells are unique, in that they exhibit functional ER (26, 27) and estrogen-induced functional PR (28). Patterns of integrin expression in Ishikawa cells are remarkably similar to those observed in normal endometrial epithelium. As in native endometrium, {alpha}2ß1, {alpha}3ß1, and {alpha}6ß4 expression is constitutive, whereas {alpha}1ß1 and {alpha}vß3 are sensitive to hormonal regulation (29). Consequently, we employed this model system in studies designed to further investigate the mechanisms that regulate expression of the {alpha}vß3 integrin, which is now gaining acceptance as a valid molecular marker of endometrial receptivity in vivo.


    Materials and Methods
 Top
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
 References
 
Cell culture, steroid hormones, growth factors, and cytokines

Ishikawa cells were cultured to confluence in 150-cm2 flasks (Costar, Cambridge, MA) containing DMEM-Ham’s F-12 supplemented with charcoal-stripped FCS (pH 7.2), 200 mmol/L L-glutamine, and penicillin/streptomycin at 37 C in 95% air-5% CO2. Reagents were obtained from Sigma Chemical Co. (St. Louis, MO) except where otherwise specified. Cells were cultured in the presence or the absence of 10-8 mol/L 17ß-estradiol (E) and/or 10-6 mol/L P. Hormones were drawn from a 1000-fold concentrated stock in 100% ethanol (ethanol), maintaining equal concentrations of ethanol in control flasks. Steroid-treated and untreated cells were also cultured in the presence of recombinant human EGF (0.1–10 ng/mL), recombinant basic fibroblast growth factor (bFGF; 10 ng/mL), recombinant insulin-like growth factor II (IGF-II; 0.5 ng/mL), recombinant human interleukin-1{alpha} (IL-1{alpha}) and IL-1ß (0.5 and 0.2 ng/mL, respectively), macrophage colony-stimulating factor (m-CSF; 20 U/mL), recombinant platelet-derived growth factor (PDGF-AA, -AB, and -BB; 10 ng/mL), recombinant human transforming growth factor-{alpha} (TGF{alpha}; 5 ng/mL), TGFß (0.5 ng/mL), and recombinant human tumor necrosis factor-{alpha} (TNF{alpha}; 5 ng/mL) for a period of 6 days. In separate experiments, the influence of dosage and time in culture were investigated.

Immunocytochemistry and flow cytometry

Fluorescence immunocytochemistry was performed using formalin-fixed Ishikawa cells that had been cultured on coverslips, using a Vectastain kit (Vector Laboratories, Burlingame, CA). After initial incubation with blocking antibody for 15 min at room temperature (1:100 dilution of nonimmune mouse serum), primary antibody was applied for 1 h. Monoclonal antibodies (mAbs) directed against the ß3-subunit (AP3 and SSA6) were provided by Drs. Peter Newman (Milwaukee, WI) and James Hoxie (University of Pennsylvania, Philadelphia, PA). Both have been characterized previously (10, 15) and can detect intact {alpha}vß3 in situ. After a 5-min wash in phosphate-buffered saline (PBS; pH 7.2–7.4), biotinylated goat antimouse IgG conjugated to fluorescein isothiocyanate (1:100 dilution) was applied to the coverslips. After a 30-min incubation at room temperature, coverslips were rinsed three times with PBS and mounted. Photomicrographs were prepared using Kodak (Rochester, NY) TMZ 3200 ASA film in a Nikon Optiphot fluorescence microscope (Melville, NY).

In preparation for flow cytometry, Ishikawa cells were first detached from culture flasks by light trypsin-ethylenediamine tetraacetate digestion for 5 min (Life Technologies, Grand Island, NY), then neutralized with an equal volume of medium containing 5% FCS and centrifuged at 300 x g for 10 min. The supernatant was discarded, and cells were resuspended in a volume of PBS to yield a concentration of 100,000 cells/mL. A 500-µL aliquot of cell suspension was transferred to individual polypropylene tubes, pelleted, resuspended in 300 µL PBS-4% BSA containing primary mouse antihuman mAb (ß3; 1:100), and incubated for 60 min at 4 C on a shaker. Tubes were then centrifuged for 10 min at 300 x g, rinsed in PBS, and again centrifuged at 300 x g for 10 min. Pellets were resuspended in 300 µL PBS-4% BSA and then incubated with a 1:100 dilution of fluorescein isothiocyanate-conjugated horse antimouse IgG for 30 min at 4 C on a shaker in the dark. After two additional wash/centrifuge cycles, the pellet was finally resuspended in 500 µL PBS containing 0.02% propidium iodide (Sigma Chemical Co., St. Louis, MO) for viability gating. Instrumentation used for flow cytometry consisted of a FACScan (Becton Dickinson, San Jose, CA) linked to a Consort 32 computer (Becton Dickinson).

Lysis II software (Becton Dickinson) was used for both data acquisition and analysis. Cells analyzed by flow cytometry were excited by an argon laser emitting 15 mW at 488 nm. Propidium iodide-stained cells were gated out during data collection. Green fluorescence of the remaining live cells was collected by a photomultiplier through a 530/30-nm bandpass filter. A logarithmic amplifier was used to compress the resulting fluorescence signal for storage and display on a four-decade log scale by Lysis II. Subsequent analysis of green fluorescence was used to determine the relative median fluorescence of each sample, calculated as follows. Cells incubated with fluorescent second antibody in the absence of primary antibody were used to determine median background fluorescence for each set of samples. This background fluorescence was then subtracted from the median fluorescence of each of the other samples in the set. The resulting adjusted median for each treatment condition was divided by the adjusted median of its control to obtain the relative median fluorescence of the stimulated sample as a multiple of the control. Statistical analysis included ANOVA with Scheffe’s correction of the mean of triplicate determinations.

Northern blot studies

Ishikawa cells exposed to E, E plus P, or increasing concentrations of EGF for 4–6 days were harvested and pelleted for Northern blot studies. Total ribonucleic acid (RNA) was extracted with TriReagent (Molecular Research Center, Cincinnati, OH). Equal amounts of RNA (20 µg lane) were separated by electrophoresis in 1.0% Maxi-Blot Agarose (Molecular Research Center, Cincinnati, OH) and transferred to a Nytran membrane (Schleicher and Schuell, Keene, NH). The RNA was then cross-linked to the membrane by Stratalinker UV cross-linker 1800 (Stratagene, La Jolla, CA). Filters were incubated with prehybridization buffer \[50% formamide, 0.5% SDS, 1.0% glycine, 50 mmol/L NaPO4 (pH 6.5), 5 x Denhart’s solution, and 250 g/mL salmon sperm DNA\] for 2 h at 42 C and hybridized overnight at 42 C with 32P-labeled probe in hybridization buffer (50% formamide, 0.5% SDS, 10% dextran sulfate, 20 mmol/L NaPO4 (pH 6.5), 5 x SSC (standard saline citrate), 1 x Denhart’s solution, and 100 g/mL salmon sperm DNA). Filters were washed twice with 2 x SSC-0.1% SDS at room temperature for 5 min, then twice with 0.1 x SSC-0.1% SDS at 65 C for 30 min, and exposed to Kodak X-Omat film for 3 days at -70 C. A ß3-specific complementary DNA (cDNA) probe (provided by Dr. Clayton S. Buck, Wistar Institute, Philadelphia, PA) was prepared as follows: a 1.4-kb EcoRI/BamHI fragment of ß3 cDNA was [32P]deoxy-CTP labeled by the random priming method (Boehringer Mannheim, Indianapolis, IN). A specific cDNA probe for EGF receptor was provided by Dr. Shelton Earp (Chapel Hill, NC). Autoradiograms were performed to verify the removal of all prior radioactive probes before rehybridization with the glyceraldehyde-3-phosphate dehydrogenase cDNA probe to assess equal loading of RNA.


    Results
 Top
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
 References
 
Ishikawa cells clearly express the {alpha}vß3 integrin as shown by immunocytochemistry in Fig. 1Go. Fluorescence was not present in the absence of primary antibody (Fig. 1AGo). The {alpha}vß3 integrin localized to the pericellular borders and areas of cell-cell contact (Fig. 1BGo and inset). A dramatic decrease in fluorescence intensity was noted in cells treated with E and E plus P (Fig. 1CGo). E treatment alone for up to 6 days was less inhibitory, and P alone had no effect (not shown). To quantify relative expression of {alpha}vß3 under these conditions, flow cytometry studies were undertaken. As shown in Fig. 2Go, combined E plus P treatment decreased relative fluorescence intensity by 75% compared to a 45% decrease after treatment with E alone.



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Figure 1. A–D, Photomicrographs of Ishikawa cells displaying immunofluorescent {alpha}vß3 integrin. A, The control with no primary antibody added shows little if any immunofluorescence. B, Localization of immunofluorescence staining of the {alpha}vß3 integrin to pericellular borders and areas of cell-cell contact (inset) in untreated Ishikawa cells. C, Decreased expression of the {alpha}vß3 integrin after 6 days of E (10-8 mol/L) and P (10-6 mol/L) treatment. D, EGF (1 ng/mL) treatment induced a dramatic increase in {alpha}vß3 expression. Magnification, x200.

 


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Figure 2. Flow cytometry of the {alpha}vß3 integrin in Ishikawa cells treated with either E (10-8 mol/L) or E plus P (10-6 mol/L). Ishikawa cells were specifically labeled with the SSA6 monoclonal antibody, which recognizes the ß3-subunit of the {alpha}vß3 vitronectin receptor (see Materials and Methods). As shown by flow cytometry (upper panel), both E (upper left) and E plus P (upper right) resulted in a downward shift in immunofluorescence relative to that in control (untreated) cells. These data are summarized in bar graph form (lower panel).

 
To study the influence of potential paracrine factors on the expression of {alpha}vß3 in Ishikawa cells, the effects of a variety of growth factors and cytokines were examined using flow cytometry (Fig. 3Go). Whereas TGFß, IGF-II, IL-1{alpha}, IL-1ß, m-CSF, PDGF-AA, PDGF-BB, PDGF-AB, and TNF{alpha} had little or no effect on {alpha}vß3 expression, EGF, TGF{alpha}, and bFGF dramatically increased the {alpha}vß3 relative median fluorescence (P < 0.01). These findings were confirmed by immunofluorescence staining (Fig. 1DGo, EGF); similar results were obtained with TGF{alpha} and bFGF. Subsequent experiments focused on the effects of EGF on {alpha}vß3 expression.



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Figure 3. Effects of growth factors and cytokines on {alpha}vß3 expression as measured by flow cytometry. Ishikawa cells were treated for 6 days with recombinant human EGF (1 ng/mL); recombinant human TGF{alpha} (5 ng/mL); TGFß (0.5 ng/mL); recombinant bFGF (10 ng/mL); recombinant IGF-II (0.5 ng/mL); recombinant human IL-1{alpha} and -ß (0.5 and 0.2 ng/mL, respectively); m-CSF (MCSF; 20 U/mL); recombinant PDGF-AA, -AB, and -BB (10 ng/mL each); and recombinant human TNF{alpha} (5 ng/mL). Note the dramatic increase in {alpha}vß3 expression in cells treated with TGF{alpha}, EGF, or bFGF (P < 0.01). Little or no effect was noted with the other growth factors. The bars represent the mean ± SE of triplicate determinations of relative median fluorescence.

 
To demonstrate that EGF regulation of {alpha}vß3 occurred at the level of transcription, Northern blots were performed using E and/or P and EGF (10 ng/mL). As shown in Fig. 4AGo, basal expression of the ß3-subunit in Ishikawa cells was diminished by both E and P, consistent with earlier results. In response to EGF, transcription of the ß3-subunit increased in a dose-dependent manner. The predominant species was a 5.2-kilobase (kb) band, although two smaller and lesser bands (3.0 and 1.7 kb) were also present and appeared to be regulated. These latter species probably represent alternatively spliced forms of the ß3-subunit. As shown in Fig. 4BGo, Ishikawa cells also expressed the EGF receptor (EGF-R) which was present at the expected 7.7-kb size, but the EGF-R did not appear to be regulated by either sex steroids or EGF in this cell line.



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Figure 4. Northern blot analysis of ß3-subunit expression and EGF receptor in Ishikawa cells. Multiple transcripts of the ß3-subunit were identified (top panel) by Northern blot analysis. Total RNA was prepared from Ishikawa cells, untreated or treated for 6 days with E (10-8 mol/L), E plus P (10-6 mol/L), or EGF (10 ng/mL) for 2 h to 8 days (see Materials and Methods). Note the apparent decrease in messenger RNA abundance after sex steroid treatment and the significant and time-dependent increase after EGF treatment. When the blot was washed and reprobed with a cDNA specific to the EGF receptor (middle panel), there did not appear to be significant regulation of this transcript in the different treatment groups. Equal loading of RNA was confirmed by examination of glyceraldehyde-3-phosphate dehydrogenase (lower panel).

 
To determine the minimum concentration of EGF necessary to induce the expression of {alpha}vß3, a dose-response curve was produced by flow cytometry (Fig. 5Go). Stimulation of {alpha}vß3 expression was dose dependent, with maximum stimulation occurring at concentrations of 1 ng/mL EGF or more (P < 0.01). To investigate the net effects of steroid inhibition and EGF-induced up-regulation of {alpha}vß3, Ishikawa cells were cultured in the presence of E and P with or without increasing concentrations of EGF. Treatment with E and P decreased {alpha}vß3 expression relative to levels observed in control cells (untreated), but EGF treatment negated this effect in a dose-dependent manner that was maximal at 1 ng/mL (Fig. 6Go).



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Figure 5. EGF dose-response curve for stimulation of the {alpha}vß3 integrin. Flow cytometry was performed with SSA6 monoclonal antibody specific to the ß3 integrin subunit (see Materials and Methods). By increasing the concentrations of recombinant EGF (0.01–100 ng/mL), there was a noted increase in {alpha}vß3 expression, reaching a maximum level at 1 ng/mL (P < 0.01). Bars represent the mean ± SD of triplicate determinations.

 


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Figure 6. Interaction between sex steroid suppression and EGF stimulation of the {alpha}vß3 integrin. Flow cytometric analysis was performed on Ishikawa cells treated with E (10-8 mol/L) and P (10-6 mol/L) for 6 days or after cotreatment of the cells with E plus P and increasing concentrations of EGF. There was the expected decrease in {alpha}vß3 expression in cells treated with the sex steroids alone, which was overcome by EGF at a concentration of 0.5 ng/mL or higher. Bars represent the mean percent change relative to the value in control cells ± SD.

 

    Discussion
 Top
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
 References
 
The mechanisms that establish, maintain, and regulate endometrial receptivity probably involve a host of growth factors, cytokines, and steroid hormones. Many of the key events in this process may be linked to the down-regulation of endometrial epithelial ER and PR that occurs at the time of embryo attachment (21). Evidence suggests that the expression of critical proteins, such as the {alpha}vß3 integrin, is regulated directly or indirectly by steroid hormones and these shifts in ER and PR (17). In addition, there is growing appreciation for the roles of various growth factors in the implantation process (23, 24, 30, 31). Although the factors that regulate endometrial receptivity remain somewhat obscure, studies employing recently identified markers of receptivity, like certain members of the integrin family of cell adhesion molecules, offer the means to investigate events surrounding the periimplantation period (32).

The lack of a suitable in vitro model of human endometrium has limited this area of study. Our previous work with the Ishikawa cell line has validated its use as a model system for studies of hormonally regulated events in endometrial epithelium (28, 29). These well differentiated adenocarcinoma cells have both functional ER (26, 27) and PR (28). Northern blot studies have demonstrated that E exerts transcriptional control over PR expression in a manner similar to that seen in native endometrium. Ishikawa cells also express the same complement of integrins as that in normal endometrium in vivo. Both constitutive ({alpha}2ß1, {alpha}3ß1, and {alpha}6ß4) and cycle-dependent ({alpha}1ß1 and {alpha}vß3) integrins (29) are present on these cells. Moreover, the ability to inhibit and stimulate the expression of these marker proteins in Ishikawa cells makes them a useful tool for studies of the implantation process.

In the present study we have demonstrated that the {alpha}vß3 integrin is dynamically regulated both by the sex steroids E and P and by growth factors. Whereas the morphological development of the secretory endometrium is clearly dependent on E and P, its functional maturation [as reflected by {alpha}vß3 expression (17) and embryo receptivity] temporally coincides with a sharp decline in epithelial ER and PR (21, 22). These observations suggest that the expression of {alpha}vß3 and perhaps other critical proteins is inhibited by E and P and beginning only after receptors for these steroids in the endometrium are effectively down-regulated.

Growth factors and cytokines are important known regulators of integrins. Endothelial cells, for example, exhibit increased expression of {alpha}2ß1, {alpha}3ß1, {alpha}5ß1, {alpha}6ß1, {alpha}6ß4, and {alpha}vß5 in response to bFGF and simultaneous down-regulation of {alpha}1ß1 and {alpha}vß3 (33). The {alpha}vß3 integrin, recently demonstrated to play an important role in angiogenesis (34), is stimulated by bFGF (35). In the present study, both bFGF and EGF significantly increased expression of {alpha}vß3 in Ishikawa cells. Although bFGF does not exhibit cycle-dependent changes (36), evidence that EGF plays a role in mammalian implantation is accumulating. Data derived from studies in mice localize EGF or EGF-like molecules to the luminal epithelium before implantation and show that EGF mediates estrogen-induced uterine cell proliferation (37, 38). The EGF-R is present on the trophoblast during implantation in the rabbit (39), and EGF or EGF-like molecules are expressed and enhance blastocyst development in the mouse at the time of implantation (37, 40). Local injection of EGF promotes nidation in the delayed implantation rat model (41), and both EGF and EGF-R are present in human endometrium, decidua, and placenta (42, 43).

In the present study, the role of EGF in stimulating the {alpha}vß3 integrin was studied in detail. Using both flow cytometry and Northern blot analyses, we noted a dose-dependent increase in expression of the ß3-subunit. Of interest, the inhibitory influence of E plus P treatment could be overcome by concomitant treatment with EGF. Ongoing studies using the promoter for ß3 in a chloramphenicol acyltransferase reporter gene construct have confirmed that EGF is stimulatory and the sex steroids are inhibitory to ß3-subunit promoter activity (44).

In summary, we investigated the effects of sex steroids and growth factors on expression of the {alpha}vß3 vitronectin receptor in the Ishikawa endometrial cell line. Regulation of this integrin, which normally appears at the time of implantation in human endometrium, may involve both suppression by the sex steroids E and P and stimulation by growth factors, including EGF. Our data suggest that regulation occurs at the transcriptional level. Evidence suggests that development of a receptive endometrium involves a cascade of events orchestrated by hormones and growth factors, including up-regulation of {alpha}vß3 expression during the periimplantation period. The Ishikawa cell line would appear to be a useful model for studies of the mechanisms involved in human embryo implantation.


    Acknowledgments
 
We thank Mr. Jack Vincent and Mr. Charles Yowell for their assistance in the flow cytometry laboratory, and Dr. Johnny Carson and Mr. Todd Gambling for their help with fluorescent microscopy. We thank Drs. Peter Newman, Joel Bennett, and James Hoxie for their generous contribution of antibodies.


    Footnotes
 
1 This work was supported in part by NIH Grants HD-29448, HD-34824, and HD-30476–1 (to B.A.L.), and by the American College of Obstetrics and Gynecology/Ciba Fellowship and the American Society of Reproductive Medicine/TAP Bridge Grant for Reproductive Endocrinology (to S.G.S.). Back

2 Current address: Division of Reproductive Endocrinology, Department of Obstetrics and Gynecology, Suite 404 1245 Highland Avenue, Abington Memorial Hospital, Abington, Pennsylvania 19001. Back

Received January 6, 1997.

Revised March 24, 1997.

Accepted March 28, 1997.


    References
 Top
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
 References
 

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