Hoon Jang1. 1. Dept. of Biomedical Science, College of Life Sciences, CHA University, Seongnam 13488, Korea.
Abstract
CREBZF (cAMP-response element binding protein zhangfei) is a member of ATF/CREB family, and which regulates various cellular functions by suppressing major factors with direct interaction. In this study, we have examined the expression of CREBZF on mouse endometrium during uterus estrous cycles and estrogen (E2) treatment. In uterus, CREBZF mRNA expression was higher than other organs and mRNA and protein of CREBZF was increased in proestrus phase and decreased in estrus phase. The expression of CREBZF in 3-weeks old mouse uterus was reduced by E2 injection in endometrium. In addition, the expression of progesterone receptor, a marker of E2 in ovariectomized mice was found to be strongly expressed in stroma, while CREBZF was only expressed in epithelium. Also, we conformed that E2-suppressed CREBZF was restored by co-injection of ICI 182,780, an estrogen receptor antagonist. Overall, these results suggest that CREBZF is regulated by estrogen and involved in ER signaling pathway in mouse uterus.
CREBZF (cAMP-response element binding protein zhangfei) is a member of ATF/CREB family, and which regulates various cellular functions by suppressing major factors with direct interaction. In this study, we have examined the expression of CREBZF on mouse endometrium during uterus estrous cycles and estrogen (E2) treatment. In uterus, CREBZF mRNA expression was higher than other organs and mRNA and protein of CREBZF was increased in proestrus phase and decreased in estrus phase. The expression of CREBZF in 3-weeks old mouse uterus was reduced by E2 injection in endometrium. In addition, the expression of progesterone receptor, a marker of E2 in ovariectomized mice was found to be strongly expressed in stroma, while CREBZF was only expressed in epithelium. Also, we conformed that E2-suppressed CREBZF was restored by co-injection of ICI 182,780, an estrogen receptor antagonist. Overall, these results suggest that CREBZF is regulated by estrogen and involved in ER signaling pathway in mouse uterus.
Entities:
Keywords:
Cyclic AMP-response element binding protein zhangfei (CREBZF); Endometrium; Estrogen; Uterus
The uterus is essential organ for reproduction of most mammals, and regulated by
several specific steroid hormones as estrogen (E2) and progesterone (P4) in
endometrium during uterus cycles (Martıín et al., 2002; Riesewijk et al., 2003). Endometrium, one of the three layers of the
uterus, is the most active layer and composed with luminal epithelium (LE),
glandular epithelium (GE), and stroma (Hu et al.,
2004; Huang et al., 2012).
Repeated implantation failure (RIF) is occurred due to dysfunction of uterine
receptivity with abnormal gene expression in the endometrium. Recent studies attempt
to fine the cause of fertilization failure, but it remains as yet unknown due to
lack of research on the signaling pathway.The E2 plays important roles in physiological regulations in the whole body including
reproductive organ, central nerve system, skeletal tissues and vascular (Gruber et al., 2002; Hewitt et al., 2005). E2 activities are mediated by the estrogen
receptor alpha (ERα) and estrogen receptor beta (ERβ). E2 and ERs are
up regulated by insulin resistance, and insulin resistance-mediated inflammation
might be modulator for estrogen activity (Calle
& Kaaks, 2004). cyclic AMP-response element binding protein
zhangfei (CREBZF) is an insulin-inducible co-repressor during gluconeogenesis in
hepatocyte, and insulin resistance decreases CREBZF expression (Lee et al., 2016).CREBZF belongs to basic region of leucine zipper (bZIP) family, and it has the
ability to dimerize like other bZIP family (Akhova et
al., 2005; Misra et al., 2005;
Xie et al., 2008). CREBZF has been
reported as a co-regulator of ATF4 and CREB3, another HCF-binding transcription
factor (Misra et al., 2005; Hogan et al., 2006). Recently, CREBZF regulates
bone formation and adipocyte differentiation by interacting transcription factors
(Jang et al., 2014; Jang et al., 2015). Also, recent study indicated that CREBZF is
induced by estrogen and closely related to implantation (Lin et al., 2013). However, this study is unclear and lacks the
correlation between estrogen and CREBZF expression in endometrium of uterus. To
discover the function of CREBZF during menstrual cycle, we examined the expression
of CREBZF in endometrium during mouse estrous cycle.
MATERIALS AND METHODS
1. Animals
All animal experiments were approved by Institutional Agricultural Animal Care
and Use Committee of CHA University (IACUC No. 160018). The animal studies were
conducted with 3-week old and 6 week old female ICR mice from KOATECH (Korea).
Mice were housed in animal care facility at the CHA University of CHA biocomplex
with a temperature-controlled environment under 12 hour dark-light cycle and
free access to standard rodent diet and water. Six-weeks old female ICR mice
were ovariectomized (OVX) and then following a recovery period for 2 weeks.
2. Hormone injection
Three-week old and OVX female ICR mice were injected subcutaneously with
17β-estradiol (E2, 10 ug/kg, Sigma-Aldrich, USA) and Sesame oil (100 uL,
Acros, USA) as control group. The Uteri were collected at 0, 1, 3, 6, 12, and 24
hours after injection of hormones from sacrificed mice. To identify whether the
expression of CREBZF is regulated by E2 administration, an estrogen receptor
antagonist (ICI 182,780, 25 mg/kg) was co-injected to OVX mice.
3. Vaginal cytology
To obtain a sample of epithelial cells from the mouse vagina some of the saline
solution was flushed into mouse vagina using pipette tip to a depth of about 5
mm. The isolated cells were placed on glass slide and dried. The cells were
fixed using methanol and stained by Hematoxylin and eosin solution. The stage of
the estrous cycles were determined by vaginal smear cytology (Evans & Long, 1922).
4. RT-PCR and real-time PCR
To extract total RNA from four cycles of uterus and each of tissues, 6-week old
female ICR mice were sacrificed and isolated after analysis of vaginal cytology.
The tissues were placed into a vessel and homogenized in Trizol reagent
(Invitrogen, USA) using homogenizer. The total RNA extraction was according to
manufacturer’s protocol. cDNA synthesis was performed using SensiFAST
cDNA Synthesis Kit (Bioline, UK) according to manufacturer’s protocol,
and the thermal cycling conditions were as follows: reverse transcription at
45℃ for 60 minutes, and 4℃ for 10 minutes. Real-time PCR and
RT-PCR analyses were performed in triplicate using Solg Taq DNA polymerase
(Solgent, Korea) and iQ SYBR Green Supermix (Bio-Rad, USA). The thermal cycling
conditions were as follows: initial denaturation at 95℃ for 3 minutes,
followed by 40 cycles of 95℃ for 10 seconds, 60℃ for 15 seconds,
and 72℃ for 20 seconds. Expression levels were normalized to those of
endogenous glyceraldehyde 3-phosphate dehydrogenase
(GAPDH).
5. Western blot analyses
Transfected 293T cells were prepared using PRO-PREP solution (iNtRON
Biotechnology, Korea) according to manufacturer’s protocol. Western blot
was performed using anti-CREBZF antibody (Santacruz, USA) and β-Actin
(Santacruz, USA).
6. Immunostaining
Uteri isolated from mice were fixed for 1 week in 4% formaldehyde at 4℃
for immunostaining. After fixation, uteri were embedded in paraffin and
sectioned at 5 μm of thickness using a microtome and put on microscope
slides (HistoBond, Germany). Sections were deparaffinized as follows; slides
were dipped three times for 5 min in xylene (Biosesang, Korea), two times for 5
min in 95% ethanol, one time for 5 min in 90 %, 80 %, 70 %, 50% ethanol, and 10
min in distilled water. For immunofluorescence, deparaffinized slides were
placed into a Retrieval Steamer (IHCworld, USA) and antigen retrieval was
performed using an Epitope Retrieval Solution (IHCworld, USA) according to the
manufacturer’s protocol. After washing in PBS, excess PBS was removed,
and blocking buffer (4% BSA and 5% rabbit serum in PBS) was added to the slides.
The slides were incubated in a humidified chamber for 4 h at room temperature
(RT). Then, the slides were incubated with the following primary antibodies for
16 h at 4℃: Goat polyclonal antibody against CREBZF (1:1000, Santacruz,
USA), rabbit polyclonal antibody against PR (1:500, Santacruz, USA). After three
washes in PBS, the slides were incubated with Alexa 488mouse anti-Goat and
Alexa 546mouse anti-rabbit (1:1,500, Invitrogen, UK) for 2 h at RT. A
4’,6-diamidino-2-phenylindole (DAPI, 1:20000, Life Technologies, USA) was
used to stain the nuclei. Mounting medium (DAKO, USA) was applied to the tissue
sections prior to covering them with glass coverslips. All images were obtained
using a confocal microscope (Leica) and analyzed by the imaging software LAS
lite (Leica). For immunohistochemistry, antigen-retrieved sections were washed
with PBS with 0.5% Tween 20 (PBS/T) and incubated in 0.5% hydrogen peroxide in
distilled water for 10 minutes (min) to quench endogenous peroxidase activity.
Then, the slides were washed two times in cold PBS/T for 10 min. Blocking was
conducted using blocking solution (4% BSA and 5% rabbit serum in PBS/T) for 2 h
at RT. The sections were incubated in the previously described primary antibody
against CREBZF (1:1,500) for 16h at 4℃, followed by incubation in diluted
rabbit HRP-conjugated anti-goat antibody (1:500, Invitrogen, UK) for 1 h at RT.
The slides were washed in PBS/T three times for 5 min and put into distilled
water. A 3,3’-diaminobenzidine (DAB) solution (Vector Laboratories, USA)
was dropped on the sections until the desired staining was obtained, according
to the manufacturer’s manual. The sections were counterstained with
hematoxylin and dehydrated using ethanol and xylene. The mounting was performed
using Permount mounting medium (Fisher Scientific, USA), and then coverslips
were added.
7. Statistical analysis
All values are reported as standard error of mean. The results were analyzed
using student’s t-test and one-way ANOVA for statistical
evaluation. For all analyses, p<0.05 was considered to
be statistically significant.
RESULTS AND DISCUSSION
1. CREBZF expression is significantly increased in the
uterus
To examine expression levels of CREBZF transcript in various
tissues, we performed RT-PCR and qRT-PCR using respective cDNA from 6-weeks old
mice organs and designed mouseCREBZF primers (Table 1). The CREBZF
transcript was detected in various tissues and was highly expressed in uterus
than other tissues in adult mice (Fig.
1A-B). Recent studies showed that CREBZF expression is regulated by
insulin and regulates hepatic gluconeogenesis (Kim & Ahn, 2016; Lee et al.,
2016). These results suggest that CREBZF plays major roles in liver
tissue and that expression is also high in liver tissue. Therefore, we examined
the expression of CREBZF in several tissues of mice based on liver tissue, and
found that CREBZF expression is highest in the uterus. Taken together, our
results indicated that CREBZF has an important role in uterus.
Table 1
Primer sequences
Genes
Primer sequences
Human GAPDH
F 3ʼ-
AAGGTGAAGGTCGGAGTCAAC - 5ʼ
R 3ʼ-
GGGGTCATTGATGGCAACAAT - 5ʼ
Human CREBZF
F 3ʼ-
ATGAGGCATAGCCTGACCAAG - 5ʼ
R 3ʼ- GCAGCGAACAAGTTGCAGC
- 5ʼ
Mouse GAPDH
F 3ʼ-
AGGTCGGTGTGAACGGATTTG - 5ʼ
R 3ʼ-
TGTAGACCATGTAGTTGAGGT - 5ʼ
Mouse CREBZF
F 3ʼ- CTGCCCGTCTTAATCGGCTC
- 5ʼ
R 3ʼ-
CCGTAGGTAGCGACTCTCCTC - 5ʼ
GAPDH, Glyceraldehyde 3-phosphate dehydrogenase; CREBZF, cyclic
AMP-response element binding protein zhangfei.
Fig. 1
CREBZF expression in mouse tissues.
(A) RT-PCR and (B) qRT-PCR analyses of CREBZF transcript
expression were performed using total RNA from 6-weeks-old mouse
tissues. Mouse GAPDH was used as an internal control. Expression levels
were calculated from ΔΔCT values and normalized against
GAPDH mRNA. The fold changes were evaluated by comparing the level of
CREBZF mRNA at Liver. **, p-value
(p<0.01). CREBZF, cyclic AMP-response
element binding protein zhangfei; Li, Liver; Ki, Kidney; Ht, Heart; St,
Stomach; Ut, Uterus; Si, Small intestine; PCR, p/oableymerase chain
reaction.
GAPDH, Glyceraldehyde 3-phosphate dehydrogenase; CREBZF, cyclic
AMP-response element binding protein zhangfei.
CREBZF expression in mouse tissues.
(A) RT-PCR and (B) qRT-PCR analyses of CREBZF transcript
expression were performed using total RNA from 6-weeks-old mouse
tissues. MouseGAPDH was used as an internal control. Expression levels
were calculated from ΔΔCT values and normalized against
GAPDH mRNA. The fold changes were evaluated by comparing the level of
CREBZF mRNA at Liver. **, p-value
(p<0.01). CREBZF, cyclic AMP-response
element binding protein zhangfei; Li, Liver; Ki, Kidney; Ht, Heart; St,
Stomach; Ut, Uterus; Si, Small intestine; PCR, p/oableymerase chain
reaction.
2. CREBZF is highly expressed at estrus cycle and localized in epithelial
cells of endometrium
To evaluate expression patterns of CREBZF in the uterus, we
identified changes in expression over the development of the estrous cycle such
as diestrus, proestus, estrus, and metestrus. Semi-quantitative PCR showed that
CREBZF was significantly increased at estrus stage (Fig. 2A). Because the estrogen is
dramatically decreased at estrus stage (Miller
& Takahashi, 2014), it suggested that CREBZF is sensitively
regulated by estrogen. To obtain definite results, we performed an antibody test
by western blot using 293T cells transfected with the mouseCREBZF over-expression vector and found that the antibody
was well working (Fig. 2B). To evaluate the
localization of CREBZF protein during estrous cycle, we conducted
immunohistochemistry analysis in uterine sections collected from all stages of
the estrous cycle using CREBZF antibody. CREBZF expression was more highly
expressed in the LE and GE than stroma cells in the endometrium of uterus at the
estrus stage (Fig. 2C
left panel). Each stage of the estrous cycle was identified by
the ratio of leukocytes and epithelial cells in the vagina using hematoxylin and
eosin staining method (Fig. 2C
right panel). In the uterus, the endometrium is dynamically
regulated throughout the estrous cycle and it consists of the LE, GE, and the
stroma. The proliferation and differentiation of endometrium were closely
controlled by two major ovarian hormones, E2 and P4. The sexual steroid hormones
from ovary controlled estrous cycle which is critical for a pregnancy due to
modulate uterus. Circulating E2 levels are increased at the proestrus stage and
then decline during estrus stage (Walmer et al.,
1992; McLean et al., 2012),
whereas P4 begin to elevate after estrus and peak at diestrus (McLean et al., 2012; Miller & Takahashi, 2014). Also, E2 stimulates
uterine cell proliferation and P4 stimulates uterine cell differentiation (Finn & Martin, 1974). In addition,
numerous studies demonstrated that E2 and P4 regulates various signaling factors
(Altmäe et al., 2010; Cha et al., 2012; Choi et al., 2016; Rosario
et al., 2016). Taken together, our results suggest that CREBZF
expression is closely regulated by blood E2 levels in epithelial cells of
endometrium.
Fig. 2
CREBZF expression in mouse uterus during the estrous
cycle.
A: qRT-PCR analysis of CREBZF transcript expression in
mouse uteri at different stages in the estrous cycle. Expression levels
were calculated from ΔΔCT values and normalized against
GAPDH mRNA. The fold changes were evaluated by comparing the level of
CREBZF mRNA at diestrus B: Antibody test of CREBZF
for the experiment. Mouse CREBZF gene was cloned into
pcDNA3.1 expression vector, and then transfected to hek293T cells with
blank vector for 48 h. Western blot analysis showed that anti-CREBZF
antibody detected the protein product of cloned CREBZF. (C, left
panel) Immunohistochemistry of CREBZF at different stages
of the estrous cycle in mouse uterus. Sections of uteri were stained
with goat polyclonal antibody against CREBZF. Black arrow indicates LE.
(C, right panel) Representative images of vaginal smear
analysis conforming stages of the estrous cycle. Pink stained cells are
cornified epithelial cells and purple dots are leukocyte. The scale bars
represented into figures. CREBZF, cyclic AMP-response element binding
protein zhangfei; LE, Luminal epithelium; GE, glandular epithelium; ST,
Stroma; PCR, polymerase chain reaction.
CREBZF expression in mouse uterus during the estrous
cycle.
A: qRT-PCR analysis of CREBZF transcript expression in
mouse uteri at different stages in the estrous cycle. Expression levels
were calculated from ΔΔCT values and normalized against
GAPDH mRNA. The fold changes were evaluated by comparing the level of
CREBZF mRNA at diestrus B: Antibody test of CREBZF
for the experiment. MouseCREBZF gene was cloned into
pcDNA3.1 expression vector, and then transfected to hek293T cells with
blank vector for 48 h. Western blot analysis showed that anti-CREBZF
antibody detected the protein product of cloned CREBZF. (C, left
panel) Immunohistochemistry of CREBZF at different stages
of the estrous cycle in mouse uterus. Sections of uteri were stained
with goat polyclonal antibody against CREBZF. Black arrow indicates LE.
(C, right panel) Representative images of vaginal smear
analysis conforming stages of the estrous cycle. Pink stained cells are
cornified epithelial cells and purple dots are leukocyte. The scale bars
represented into figures. CREBZF, cyclic AMP-response element binding
protein zhangfei; LE, Luminal epithelium; GE, glandular epithelium; ST,
Stroma; PCR, polymerase chain reaction.
3. CREBZF expression is suppressed by estradiol in epithelium of pre-pubertal
mice
To investigate whether CREBZF is regulated by E2 treatment in the uterus of
prepubertal mice, we performed E2 injection to 3-week-old female ICR mice.
Semi-quantitative PCR and immunohistochemistry were performed using collected
uterus at various time points. The results showed that E2 treatment dramatically
reduced CREBZF mRNA expression from 3 hours after
administration (Fig. 3A). CREBZF protein
expression was specifically declined by E2 in only epithelium of endometrium
(Fig. 3B). To further confirm that
CREBZF is down-regulated by E2 in other cells, E2 was treated to Ishikawa cells,
a human endometrial cell line. Similar to the previous results, E2 reduced humanCREBZF mRNA expression level (Fig. 3C). Next, to further determine whether CREBZF was reduced by
E2 in OVX mice, we treated the E2 to OVX mice and collected the uteri at various
times. A progesterone receptor (PR), an intra-uterine E2 marker, was also
identified to conform whether E2 was administrated correctly. Immunofluorescence
showed that expression of CREBZF was decreased in the OVX mouse endometrium
while it was expressed only in epithelium, but the expression of PR markedly
decreased in epithelium and dramatically increased in stroma after 12 hours of
E2 injection (Fig. 4). Previous studies
have shown that the E2 response has progressed from about 2 hours after E2
injection (Seong et al., 2014). In light
of that study, it is possible to interpret the result of qRT-PCR that did not
affect the expression of CREBZF in uterine samples after 1 hour of E2 injection
(Fig. 3A). In addition, since the
reaction by E2 is rapid in cell based experiments, the expression level of
CREBZF is decreased even at 1 hour (Fig.
3C). Interestingly, our results indicate that CREBZF is expressed
specifically in endometrial epithelium, whereas PR is expressed in the
epithelium when the E2 concentration is low, but is specifically expressed in
the stroma when the E2 concentration is high Respectively (Fig. 4). These results indicate that the expression of PR is
rapidly decreased when blood E2 level is elevated, thereby controlling the
environment of endometrial epithelium. The CREBZF has been reported as a
co-regulator without a DNA binding domain and plays a role through interactions
with major regulators to perform most roles (Misra et al., 2005; Hogan et al.,
2006; Jang et al., 2015).
Recently, Seo et al have suggested the possibility of role of
the transcription factor egr1, an important regulator of cell growth,
differentiation, and apoptosis, in the uterus (Seo et al., 2014). These results suggest that CREBZF may interact
with critical factors as egr1 or PR.
Fig. 3
Regulation of CREBZF expression by E2 in the uterus of pre-pubertal
mouse.
A: qRT-PCR analysis for examining relative fold of
CREBZF mRNA in the uteri of 3-week-old mice after
E2 (10 ug/kg) or sesame oil injection. GAPDH was used for normalization.
B: Immunohistochemistry to localize and identify CREBZF protein
expression in the endometrium. Sections of uteri were stained with goat
polyclonal antibody against CREBZF. C: IgG is without anti-CREBZF
antibody for negative control. qRT-PCR analysis of human
CREBZF mRNA expression level in the human
endometrial stroma (Ishikawa) cells after E2 treatment for different
time point. Expression levels were calculated from ΔΔCT
values and normalized against GAPDH mRNA. The fold changes were
evaluated by comparing the level of CREBZF mRNA at
Liver. **, p-value (p<0.01).
CREBZF, cyclic AMP-response element binding protein zhangfei; PCR,
polymerase chain reaction.
Fig. 4
Localization of CREBZF and PR after E2 injection in the endometrium
of OVX mice.
Confocal microscopic images showed the localization of CREBZF and PR in
uteri of ovariectomized mice after treated with E2. Sections of uteri
were stained with antibody against progesterone receptor (PR, red) and
CREBZF (green). The enlarged images corresponding to the box lined in
white on merged images. The scale bars represented into figures. OVX,
ovariectomized.
Regulation of CREBZF expression by E2 in the uterus of pre-pubertal
mouse.
A: qRT-PCR analysis for examining relative fold of
CREBZF mRNA in the uteri of 3-week-old mice after
E2 (10 ug/kg) or sesame oil injection. GAPDH was used for normalization.
B: Immunohistochemistry to localize and identify CREBZF protein
expression in the endometrium. Sections of uteri were stained with goat
polyclonal antibody against CREBZF. C: IgG is without anti-CREBZF
antibody for negative control. qRT-PCR analysis of humanCREBZF mRNA expression level in the humanendometrial stroma (Ishikawa) cells after E2 treatment for different
time point. Expression levels were calculated from ΔΔCT
values and normalized against GAPDH mRNA. The fold changes were
evaluated by comparing the level of CREBZF mRNA at
Liver. **, p-value (p<0.01).
CREBZF, cyclic AMP-response element binding protein zhangfei; PCR,
polymerase chain reaction.
Localization of CREBZF and PR after E2 injection in the endometrium
of OVX mice.
Confocal microscopic images showed the localization of CREBZF and PR in
uteri of ovariectomized mice after treated with E2. Sections of uteri
were stained with antibody against progesterone receptor (PR, red) and
CREBZF (green). The enlarged images corresponding to the box lined in
white on merged images. The scale bars represented into figures. OVX,
ovariectomized.
4. Estrogen-dependent expression of CREBZF is mediated through estrogen
receptors
In order to examine whether CREBZF expression is affected by E2 in estrogen
receptor dependent (ER) manner, OVX ICR mice were co-treated with an ER
antagonist, ICI 182,780 (ICI), and E2. As shown in Fig. 5, immunohistochemistry presented that ICI treatment
significantly restored E2-induced CREBZF suppression. Most induction of target
factors by hormones occurs via hormone receptor, stimulated by extra nuclear
actions. We demonstrated that the CREBZF expression is regulated by the ER
signaling pathway through experiment of co-administration of ICI.
Fig. 5
Regulation of CREBZF expression through estrogen receptor (ER)
signaling pathway.
The OVX mice were treated with ICI 182,780 (ICI), an ER antagonist, and
E2 (10 ug/kg). The expression pattern of CREBZF in epithelium of
endometrium was examined by immunohistochemistry analysis using
anti-CREBZF antibody. The enlarged images corresponding to the box lined
in black and black arrows indicate luminal epithelium. The scale bars
represented into figures. OVX, ovariectomized.
Regulation of CREBZF expression through estrogen receptor (ER)
signaling pathway.
The OVX mice were treated with ICI 182,780 (ICI), an ER antagonist, and
E2 (10 ug/kg). The expression pattern of CREBZF in epithelium of
endometrium was examined by immunohistochemistry analysis using
anti-CREBZF antibody. The enlarged images corresponding to the box lined
in black and black arrows indicate luminal epithelium. The scale bars
represented into figures. OVX, ovariectomized.Further study will be conducted to determine what mechanism is involved in CREBZF
among various ER signaling pathways in endometrium.In conclusion, we showed that CREBZF was specifically expressed in the uterine
epithelium and its expression was regulated by E2 levels, and also, the CREBZF
expression is moderated by ER signaling pathway. It will give us better
understanding the function and mechanism of CREBZF in dynamic cycles of
uterus.
Authors: S Altmäe; J A Martínez-Conejero; A Salumets; C Simón; J A Horcajadas; A Stavreus-Evers Journal: Mol Hum Reprod Date: 2009-11-22 Impact factor: 4.025