Genome-wide association studies on endometriosis and endometriosis … · Introduction...
Transcript of Genome-wide association studies on endometriosis and endometriosis … · Introduction...
Genome-wideassociationstudiesonendometriosisandendometriosis-relatedinfertilityAuthors:GenevièveGalarneau1,PierreFontanillas2,theCelmatixResearchTeam1,the23andMeResearchTeam2,CaterinaClementi1,TinaHu-Seliger1,David-EmlynParfitt1,JoyceY.Tung2,PirayeYurttasBeim1*1CelmatixInc.,NewYork,NY,USA223andMe,Inc.,MountainView,CA,USA*CorrespondencetoPirayeYurttasBeimCelmatixInc.,14WallSt,Suite16DNewYork,NY10005Abstract
Endometriosisaffects~10%ofwomenofreproductiveage.Itischaracterizedbythegrowthof
endometrial-liketissueoutsidetheuterusandisfrequentlyassociatedwithseverepainand
infertility.Weperformedthelargestendometriosisgenome-wideassociationstudy(GWAS)to
date,with37,183casesand251,258controls.AllwomenwereofEuropeanancestry.Wealso
performedthefirstGWASofendometriosis-relatedinfertility,including2,969casesand3,770
controls.OurendometriosisGWASstudyreplicated,atgenome-widesignificance,sevenloci
identifiedinpreviousendometriosisGWASs(CELA3A-CDC42,SYNE1,KDR,FSHB-ARL14EP,
GREB1,ID4,andCEP112)andidentifiedsevennewcandidatelociwithgenome-wide
significance(NGF,ATP1B1-F5,CD109,HEY2,OSR2-VPS13B,WT1,andTEX11-SLC7A3).Noloci
demonstratedgenome-widesignificanceforendometriosis-relatedinfertility,however,the
threemoststronglyassociatedloci(MCTP1,EPS8L3-CSF1,andLPIN1)wereinorneargenes
associatedwithfemalefertilityorembryoniclethalityinmodelorganisms.Theseresultsreveal
newcandidategeneswithpotentialinvolvementinthepathophysiologyofendometriosisand
endometriosis-relatedinfertility.
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Introduction
Endometriosisaffects~10%ofwomenofreproductiveageandischaracterizedbythegrowth
ofendometrial-liketissueoutsidetheuterus.Theovaryistheorganthatismostoftenaffected
byendometrioticlesions[1],butotherorgans,includingthebowel,fallopiantubes,orbladder,
canbeaffected.Endometriosisisanestrogen-dependentinflammatorydisease,withthe
endometrioticlesionscontinuingtorespondtoestrogenandtothickenfollowingthemenstrual
cycle,creatinginflammationandscartissuecalledadhesions.Theadhesionsandassociated
inflammationarethoughttounderliethesymptomsofendometriosis,whichincludepelvic
pain,dysmenorrhea,andpainduringintercourse.
Endometriosisisalsofrequentlyassociated(30-50%)withinfertility[2].Womenwith
endometriosishavealowermonthlyfecundityratethanfertilecontrols[3].Ameta-analysisof
22publishedstudiesshowedthatwomenwithendometriosisundergoinginvitrofertilization
(IVF)hadsignificantlyreducedoocyteretrieval,fertilization,andimplantationrates,aswellasa
significantlylowerchanceofachievingpregnancy,comparedtopatientswithtubalfactor[4].
Womenwithendometriosis-relatedinfertilitytendtohavealongertimetonaturalconception
thanwomenwithidiopathicinfertility[5,6]andlongertimetoconceptionthroughartificial
inseminationthanwomenwithnofemaleinfertilityfactors[7].Evenmildendometriosiscan
affectawoman’sfertility,andinfertility-relatedendometriosismaybeassociatedwith
endometriosisgrade—forexample,pregnancyratesfollowingIVFweresignificantlylowerin
womenwithsevereendometriosisthaninwomenwithmildendometriosis[4].Endometriosis
mayalsoreduceoocytequality,assuggestedbyastudyinwhichwomenwhoreceivedoocytes
donatedbywomenwithendometrioticovarieshadalowerimplantationratethanthose
receivingoocytesdonatedbywomenwithoutknownendometriosis[8].
Thecausalmechanismsofendometriosis-relatedinfertilityarenotfullyunderstood.Different
aspectsofendometriosismayleadtoinfertility,andtheexactcauseofendometriosis-related
infertilityineachpatientmaydependonthecourseofherspecificpathology.Proposed
mechanismsforendometriosis-relatedinfertilityincludeovarian-tubaldysfunction,
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immunologicaldisorder,abnormalperitonealenvironment,anddysregulatedendometrial
function[9].Ovarian-tubaldysfunctioncouldbecausedbyadistortionoftheovaryand/or
fallopiantubeaffectedbyendometrioticlesions,ovulationfailure,orabnormalfollicle
development.AnimmunologicaldisordercouldbecausedinpartbytheIgGandIgManti-
endometrialantibodies,whichhavebeendetectedin60%ofendometriosispatientsandcould
impairimplantation[10].Abnormalitiesintheperitonealenvironmentcouldincludeincreased
peritonealfluidsandahigherconcentrationofcytokinesand/oractivatedmacrophages.
Womenwithendometriosis-relatedinfertilityhaveanincreasedvolumeofperitonealfluid,and
thisfluidmayhaveincreasedlevelsofinflammatorycytokinesduetotheactivationof
macrophagesbytheendometrioticlesions.Activatedmacrophagesincreasereactiveoxygen
speciesintheperitonealfluidofwomenwithendometriosis[11],causingoxidativestress,
whichhasbeenassociatedwithnegativeoutcomesinassistedreproductivetechnology
fertilization[12].Forexample,thisincreaseincytokinesmayreduceoocytequality,sperm
motility,andtubalmotility,andimpairembryodevelopment.Finally,endometrialreceptivityis
acrucialprocesstoachievepregnancyandinvolvescomplexregulationofhormones,cytokines,
andadhesionmolecules.Thisprocessmaybedysregulatedinwomenwithendometriosis.
Laparoscopyiscurrentlytheonlywaytodiagnoseendometriosiswithcertainty.Itinvolvesa
surgicalprocedureinwhichasurgeonvisualizestheendometrioticlesionsorcollectstissue
samplesforhistologicassessment.Laparoscopyisoftenusedtoexcisetheendometriotic
lesionstorelievepain,butsymptomsoftenreturninfollowingyears.Becauseendometriosis
painlevelsanddiseaseseverityarenotdirectlycorrelated,thediagnosisandgradingof
endometriosiswithoutsurgeryisdifficult.However,becauseoftheinvasivenatureofthe
diagnosticprocedure,womenwithsuspectedendometriosisareoftentreatedwithhormone
therapywithoutadefinitivediagnosis.Despiteitshighprevalenceanditsassociationwith
severepainandinfertility,treatmentforendometriosisremainslimited.Surgicalandmedical
managementofendometriosiscanhelptreatsymptoms.Surgicalmanagementincreasesthe
monthlyfecundityrateofwomenwithendometriosisbutevenwithsurgicalmanagement,it
remainsmuchlowerthaninthegeneralpopulation[13].Hormonetreatmentsincludeoral
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contraceptives,androgenicagents,progestins,andgonadotropin-releasinghormoneanalogs,
buttheyarenotalwayseffective.
Endometriosisisacomplextrait,withbothgeneticandenvironmentalfactorscontributingto
thepathophysiologyofthedisease.Theheritabilityofendometriosisisestimatedtobe47-51%
[14,15],butthe13lociidentifiedbypreviousgenome-wideassociationstudies(GWASs)only
explain1.75%ofthephenotypicvariance[16-23].Further,fewstudieshaveinvestigated
whethergeneticfactorsmightbeinvolvedinthepathophysiologyofendometriosis-related
infertility.Theidentificationofnovelgeneticfactorsimplicatedinendometriosisor
endometriosis-relatedinfertilitycouldhelptoelucidatethepathophysiologyofendometriosis
andtoidentifypotentialnewdrugtargets.Here,weconductedaGWASonendometriosis
including37,183casesand251,258controlsandthefirstGWASonendometriosis-related
infertility,including2,969womenwithendometriosis-relatedinfertilityand3,770womenwith
endometriosiswhoreportedafirsttime-to-conception≤6months.
MaterialsandMethods
Participants
Participantsinthisstudywerecustomersoftheconsumergeneticscompany23andMe,Inc.,
whoprovidedinformedconsenttoparticipateinresearchbycompletingsurveysonlineundera
protocolapprovedbyEthical&IndependentReviewServices,anindependentinstitutional
reviewboard(http://www.eandireview.com)accreditedbytheAssociationforthe
AccreditationofHumanResearchProtectionPrograms,Inc.Thisstudywasrestrictedto
unrelatedfemaleparticipantswith>97%Europeanancestry.Percentageancestrywasassessed
throughalocalancestryanalysis.
Genotyping
DNAextractionandgenotypingwereperformedonsalivasamplesbytheNationalGenetics
Institute.Samplesweregenotypedononeoffourcustomgenome-widegenotypingarrays
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targeting560-950kSNPs.Onlysamplesthatachievedanaveragegenotypingrate≥98.5%were
includedintheanalysis.
Qualitycontrol
GenotypedSNPswereexcludediftheyhadagenotypingrateof<90%,didnotpassaparent-
offspringconcordancetest,weremonomorphic,werenotinHardy-Weinbergequilibrium
(p<1×10−20),orshowedbatcheffects.
Imputation
ImputationwasperformedusingtheSeptember2013releaseofthe1000GenomesProject
PhaseIasreferencehaplotypes.ThephasingwasperformedwithShapeIt2andtheimputation
withMinimac2.ImputedSNPswereflaggedandexcludediftheyhadanaverager2<0.5across
genotypingplatformoraminimumr2<0.3oriftheyshowedstrongevidenceofimputation
batcheffect(p<10−50).
Principalcomponentscalculations
Theprincipalcomponentanalysiswasperformedusing~65,000highqualitygenotypedvariants
presentinallfivegenotypingplatformswith1millionofparticipantsfromEuropeanancestry
randomlysampledacrossallthegenotypingplatforms.PCscoresforparticipantsnotincluded
intheanalysiswereobtainedbyprojection,combiningtheeigenvectorsoftheanalysisandthe
SNPweights.
Phenotypedefinition
Case-controlascertainmentwasbasedonparticipants’surveyresponses.Fortheendometriosis
case-controlGWAS,caseswerewomenwhoreportedbeingtreatedforand/ordiagnosedwith
endometriosis.Controlswerewomenwhoreportednotbeingtreatedforordiagnosedwith
endometriosis.
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Fortheendometriosis-relatedinfertilityGWAS,bothcasesandcontrolswerewomenwho
reportedbeingtreatedforand/ordiagnosedwithendometriosisandwhohadansweredat
leastonequestionontimetofirstconception.Thetimetofirstconceptionwasascertained
basedontheiranswerstothequestion(s):"Forhowlongdidyoutrytoconceive?Ifyouare
currentlytryingtoconceive,pleasestatehowlongyouhavebeentryinguptothispoint","The
firsttimeyoutriedtoconceiveachild,forhowlongwereyoutryingtoconceive?Ifyouare
currentlytryingtoconceiveforthefirsttime,pleaseanswerforhowlongyouhavebeentrying
uptothispoint."Thequestionsregardingtimetofirstconceptionhadmultiplechoiceanswers
withthefollowingoptions:0-6months,7-12months,13-24months,24months,24+months,
notsuccessful,andnotsure.‘Infertile’casesweredefinedaswomenwhorespondedwith13-
24months,24months,24+months,ornotsuccessful(35.7%ofwomenwithendometriosisin
23andMedatabase).Womenwhorespondedwith7-12months(13.1%)orI’mnotsurewere
excludedfromtheanalysis(<0.1%).Controlswerewomenwhoindicated0-6months(51.2%)
andreportedhavingatleastonebiologicalchild.
Statisticalanalysis
Assuminganadditivemodel,weperformedlogisticregressionsonendometriosiscase-control
statusandonendometriosis-relatedinfertilitycase-controlstatuswithcurrentage,thetopfive
principalcomponents,andthegenotypingplatformascovariates.Theassociationresultswere
adjustedfortheobservedgenomiccontrolinflationfactorinthedistributionofthep-values
(λ=1.141andλ=1.011,respectively,SupplementaryFigures1-2).
Prioritizationofputativefunctionalvariants
The99%crediblesetsweregeneratedbyfirstcalculatinganapproximateBayesfactor(ABF)for
eachSNP,usingthemethodproposedbyWakefield[24]andassumingapriorvariance(W)of
0.1.ThecrediblesetswerethenestimatedfromtheABFs,usingthemethodofMalleretal[25].
Weprioritizedgeneticvariantsinthecrediblesetsforfurtherfollow-upinGTExPortaland
RegulomeDBandusedLDlink[26]toidentifypotentialgeneticvariantsthatwouldnothave
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passedgenotyping/imputationQCbutwouldbeinhighlinkagedisequilibrium(LD)(r2>0.8in
individualsofEuropeanancestryinthe1000GenomesProject).
Results
Fourteenlocireachedgenome-widesignificance(p<5×10−8),includingsevenlocinotreportedin
previousGWASs(NGF,ATP1B1-F5,CD109,HEY2,OSR2-VPS13B,WT1,andTEX11-SLC7A3)
(Figure1,Table3).Amongthelocithatwerepreviouslyreportedintheliteratureanddidnot
reachgenome-widesignificance,fourwerenominallyassociated(p<0.05)withaconsistent
directionofeffect(FGD6-VEZT,RMND1-ESR1,NPVF-NFE2L3,andCDKN2B-DMRTA1)andtwo
hadp-values>0.05(IGFBP3-TNS3andTTC39B)(Table4).
Nolocireachedgenome-wideassociationwithendometriosis-relatedinfertility(Figure2,Table
5).Amongthe14locithatreachedgenome-widesignificanceintheendometriosiscase-control
GWAS,four(NGF,CELA3A-CDC42,SYNE1,andKDR)reachednominalassociation(p<0.05)with
sharedriskallelesforbothendometriosisandendometriosis-relatedinfertility(Table3).Five
locireachedsuggestivelevelsofassociation(p<1×10−6)withendometriosis-relatedinfertility
(MCTP1,EPS8L3-CSF1,LPIN1,GRM8,andFSTL5-NAF1)(Table5).
Discussion
Self-reportedendometriosisphenotype
Althoughtheendometriosisphenotypeinourstudywasself-reported,sevenendometriosisloci
previouslyidentifiedinGWASwerereplicatedatgenome-widesignificanceandfourwere
replicatedatanominallevelwithaconsistentdirectionofeffect.Onlytwolocididnotreplicate
(Tables3-4).Theseresultsareconcordantwiththereportedaccuracyofself-reported
endometriosisphenotypesincomparisonwiththeSwedishNationalInpatientRegistrywitha
specificityof97.0%,asensitivityof61.8%andreceiveroperatingcharacteristicsareaof0.79
[27].However,replicatingournovellociindatasetswithsurgicallyconfirmedcasesisimportant
toavoididentificationoflociassociatedwithdysmenorrheaintheabsenceofendometriosis.
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Interestingly,22.2%ofwomenwithendometriosis-relatedinfertilityreportedhavingbeen
diagnosedwithand/ortreatedforpolycysticovarysyndrome(PCOS),comparedto14.8%of
fertilewomenwithendometriosis(Table2).BecauseofthecomplexityofthePCOSdiagnosis
andtheself-reportednatureofthePCOSphenotypeinourdataset,itispossiblethatsomeof
thewomenwhoreportedhavingPCOS,hadanovulationduetotheirendometriosis[28],which
couldcontributetotheirinfertility.ItisalsopossiblethatPCOScontributestotheinfertilityof
someofourendometriosis-relatedinfertilitycases.
Novelendometriosisloci
Sevennovellociwereassociatedwithendometriosisatgenome-widesignificanceinour
analysis.ThenovellocusNGFwasalsoassociatedatgenome-widesignificancewithseverityof
dysmenorrheainanotherstudyof23andMefemaleparticipantsofEuropeanancestry[29].
Interestingly,theexpressionlevelofNGFintheperitonealfluidhasbeenobservedtobehigher
inwomenwithendometriosis,andblockingNGFsignificantlydecreasesneuriteoutgrowthin
endometrioticlesions[30].Multipletranscriptionfactorshavebeenfoundtobindtheregion
coveredbythecredibleSNPssetwithintheNGFlocus(Table6).Thisregionalsooverlapswith
predictedenhancersinmultipletissues,includingthefetaladrenalgland,fetalstomach,fetal
kidney,colonsmoothmuscle,adiposenuclei,fetallung,primarymonocytesfromperipheral
blood,fetalmuscletrunk,andfetalmuscleleg.
ThecredibleSNPssetofthesecondnovelendometriosislocus,ATP1B1-F5,includestheFactor
VLeiden(F5)p.Gln534Argmissensevariantrs6025,whichhasbeenassociatedwithvenous
thromboembolism[31-33],thrombosis[34],inflammatoryboweldisease[35],andrecurrent
pregnancyloss[36],althoughtheriskalleleforendometriosisisinverted.
ThethirdnovelendometriosislocusisnearthegeneCD109,whichencodesaglycosyl
phosphatidylinositol(GPI)-linkedglycoproteinthatnegativelyregulatessignalingby
transforminggrowthfactorbeta(TGFB1).TGFB1isthoughttobeinvolvedindifferentaspects
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ofthepathophysiologyofendometriosisincludingendometrialcellproliferationandtissue
remodeling[37,38].
ThefourthnovelendometriosislocusisnearthegeneHesRelatedFamilybHLHTranscription
FactorwithYRPWMotif2(HEY2),theexpressionofwhichisdownregulatedby17β-estradiolin
ovariectomizedmice[39].ThenearbygeneNCOA7modulatestheactivityoftheestrogen
receptor(ER)[40].Thelocushasbeenassociatedatgenome-widesignificancewithendometrial
[41]andbreast[42]cancer.ItisaneQTLforbothHEY2andNCOA7,isboundbymultiple
transcriptionfactors(Table6),andcontainspredictedenhancersinmultipletissuesincluding
theovary,psoasmuscle,aorta,leftventricle,skeletalmuscleinfemales,fetallung,fetaladrenal
gland,andfetalheart.
ThefifthnovelendometriosislocusisOSR2-VPS13B.Thegeneodd-skippedrelatedtranscription
factor2(OSR2)isatranscriptionfactorthatishighlyexpressedintheendometriumandthe
ovary,anditsexpressionisdown-regulateduponprogesteronereceptorknockdowninhuman
endometrialstromalcells,suggestingthatitmaybeinvolvedindecidualization[43].Ina
genome-wideepigeneticsstudybasedonCpGmethylation,OSR2showedincreased
methylationanddecreasedexpressioninendometrioticstromalcellscomparedtostromalcells
fromnormalendometrium[44].Over40transcriptionfactorshavebeenidentifiedasbinding
theregioncoveredbythecredibleSNPset(Table6),andtheregionalsooverlapswith
predictedenhancersinnumeroustissues.Thevariantrs3019295,partofthecredibleSNPset,is
inanactivatedtranscriptionsiteofOSR2intheovary,psoasmuscle,andaorta.
ThesixthnovelendometriosislocusisnearthegeneWilmstumor1(WT1).WT1encodesa
transcriptionfactorthatishighlyexpressedintheendometrium,thetestis,andtheovary,and
thathasanessentialroleinthenormaldevelopmentoftheurogenitalsystem.Itisselectively
expressedinneuronsofdeependometriosis[45]andisdown-regulatedinendometriotic
stromalcellscomparedtoendometrialstromalcells[46,47].Theregioncoveredbythe
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credibleSNPsetoverlapswiththebindingsitesofseveraltranscriptionfactorsandwith
predictedenhancersinmultipletissues.
TheseventhnovelendometriosislocusisTEX11-SLC7A3.Thegenesolutecarrierfamily7
member3(SLC7A3)encodesasodium-independentcationicaminoacidtransporter,anditis
highlyexpressedintheendometrium.Testisexpressed11(TEX11)isexpressedinthepancreas,
testis,andhumanfetalovary,andisassociatedwithazoospermiaandmaleinfertility[48-52].
TEX11competeswithestrogenreceptorbeta(ERβ)forbindingtohematopoieticpre-Bcell
leukemiatranscriptionfactor-interactingprotein(HPIP),whichmodulatesthefunctionofERs
[53].TEX11suppressesestrogen-stimulatedgermcellproliferationandaffectstheexpression
ofestrogentargetgenesthroughitsbindingtoHPIP[53].
Endometriosis-relatedinfertilityassociationresults
Nolocireachedgenome-widesignificanceintheendometriosis-relatedinfertilityGWAS.Ofthe
14genome-wideendometriosisloci,onlyfourshowednominalassociationwithendometriosis-
relatedinfertility,suggestingthatthegeneticfactorsinvolvedinendometriosisand
endometriosis-relatedinfertilitymaydiffer.
Themoststronglyassociatedlocuswithendometriosis-relatedinfertilityisarare(minorallele
frequencyof8.8×10−3)insertionintheintronofthegeneMultipleC2andTransmembrane
DomainContaining1(MCTP1).ThehomologofMCTP1inCaenorhabditiselegans(D2092.1)is
anessentialgene,anditsablationleadstoearlyembryoniclethality[54].Theregioncoveredby
thecrediblesetispredictedtocontainanenhancerinhumanumbilicalveinendothelial
primarycells,fetallung,fetalmuscleleg,andfetalstomach.TheproteinencodedbyMCTP1is
notwellcharacterized,butitisanevolutionarilyconservedproteinthatcontainsC2domainsof
highCa2+-bindingaffinity.ItmayhaveaCa2+-controlledregulatoryfunctionorserveasa
Ca2+buffer[55].FunctionalstudiesincentralnervoussystemneuronsshowedthatMCTP1
over-expressionsignificantlyinhibitedneuronaltransferrinendocytosis,secretoryvesicle
retrieval,cellmigration,andoxidativestressfromglutamatetoxicity[56].Ifconfirmed,the
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associationofthislocuswithendometriosis-relatedinfertilitymightinvolveMCTP1protecting
oocytehomeostasis,maturation,andfertilizationfromtheoxidativestressgeneratedby
endometriosis.
Thesecondmoststronglyassociatedlocusintheendometriosis-relatedinfertilityGWASwas
EPS8L3-CSF1.ThegeneCSF1encodesanestrogen-regulatedcytokinethatcontrolsthe
production,differentiation,andfunctionofmacrophages.Inhumans,CSF1levelisincreasedin
thepregnantendometriumcomparedtothenonpregnantandishighintheplacenta
throughoutpregnancy[57,58].Inmice,femaleslackingCSF1haveextendedestruscyclesand
poorovulationrates[59,60].CSF1levelsareincreasedintheperitonealfluidofpatientswith
endometriosis[61]andCsf1expressionwassignificantlyhigherinlesionsofanendometriosis
mousemodel[62].TheER-dependentregulationofCSF1inperipheralnervefibershasbeen
suggestedtoplayacriticalroleinearlydevelopmentofendometrioticlesions[63]andin
modulatingmacrophagesurvival[62].Giventhepotentialroleofoxidativestressin
endometriosis-relatedinfertility,itisalsoworthnotingthattheoxidativestressresponsegenes
GSTM1,GSTM2,GSTM3,GSTM4,andGSTM5are<200kbfromtheassociatedvariantinthis
locus,althoughahighrecombinationrateseparatesthegenesfromthetopvariant.
The third most strongly associated locus in the endometriosis-related infertility GWAS was
LPIN1, which acts as a proinflammatory mediator during TLR signaling and during the
developmentof in vivo inflammatoryprocesses [64]. Inmice,Lpin1 is down-regulated in the
uterusbyestradiolviatheER[65]andLpin1deficiencyisassociatedwithimpairedfertility[66,
67].Lipin1mightalsoplayaroleintheregulationoftheuterinecellcyclebecauseithasbeen
foundtohaveanti-proliferativeeffectsinmurineproBcells[68].
Conclusion
OurstudyreplicatedsevenlociidentifiedinpreviousendometriosisGWASsandidentified
sevennewcandidatelociwithgenome-widesignificance.Thesenewlocineedtobereplicated,
andfurtherstudiesareneededtodeterminethecausalvariants.Althoughnolocihadgenome-
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widesignificanceforendometriosis-relatedinfertilityinthisstudy,thethreemoststrongly
associatedlociwereinorneargeneswithrolesinfemalefertilityorembryoniclethalityin
modelorganisms.Thesegenesarethoughttobeinvolvedinoxidativestress,macrophage
survival,andinflammation.Theseresultsprovidenewcandidategenesinvolvedinthe
pathophysiologyofendometriosisandendometriosis-relatedinfertility.
Acknowledgements
WethanktheresearchparticipantsandemployeesofCelmatixand23andMewhocontributed
tothisstudy.WeacknowledgethecontributionsfromadditionalmembersoftheCelmatix
ResearchTeam,includingR.MarkAdams,DanielaS.Colaci,ChrisGlazner,SamuelT.Globus,
SeanO'Keeffe,UrsulaM.Schick,LeiTan,CameronD.Wellock,DanielleWhite,andRajeshwari
R.Valiathan.Membersofthe23andMeResearchTeamare:MichelleAgee,BabakAlipanahi,
AdamAuton,RobertK.Bell,KatarzynaBryc,SarahL.Elson,NicholasA.Furlotte,DavidA.Hinds,
KarenE.Huber,AaronKleinman,NadiaK.Litterman,MatthewH.McIntyre,JoannaL.
Mountain,ElizabethS.Noblin,CarrieA.M.Northover,StevenJ.Pitts,J.FahSathirapongsasuti,
OlgaV.Sazonova,JanieF.Shelton,SuyashShringarpure,ChaoTian,VladimirVacic,CatherineH.
Wilson.
ConflictsofInterest
PF,JYT,andmembersofthe23andMeResearchTeamareemployeesof23andMe,Inc.,and
holdstockorstockoptionsin23andMe.GG,THS,DEP,PYBandmembersoftheCelmatix
ResearchTeamareemployeesofCelmatixInc.,andholdstockorstockoptionsinCelmatixInc.
Dataavailability
ThefullGWASsummarystatisticsforthe23andMedatasetswillbemadeavailablethrough
23andMetoqualifiedresearchersunderanagreementwith23andMethatprotectstheprivacy
ofthe23andMeparticipants.Pleasevisitresearch.23andMe.com/collaborateformore
informationandtoapplytoaccessthedata.
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Table1.Cohortdescriptionforendometriosiscase-controlGWAS
Cases Controls
N 37,183 251,258
Agemean(SD) 56.0(13.3) 51.0(16.5)
Body-massindexmean(SD) 27.4(6.5) 26.4(6.2)
Agefirst-time-to-conception(SD) 24.3(5.8) 25.4(5.8)
Numberofpregnanciesmean(SD) 2.0(1.5) 1.9(1.5)
Numberoflivebirthsmean(SD) 1.6(1.3) 1.6(1.4)
Numberofmiscarriagesmean(SD) 1.5(0.7) 1.4(0.6)
Self-reportedPCOSn(%) 6,028(16.2%) 13,005(5.2)
Self-reportedPOIn(%) 443(1.2) 849(0.3)
Self-reportedDORn(%) 975(2.6) 3,190(1.3)
SD:Standarddeviation,PCOS:Polycysticovarysyndrome,POI:Primaryovarianinsufficiency,DOR:Diminishedovarianreserve
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Table2.Cohortdescriptionforendometriosis-relatedinfertilityGWAS
Cases Controls
N 2,969 3,770
Agemean(SD) 56.0(13.3) 51.0(16.5)
Body-massindexmean(SD) 27.4(6.5) 26.4(6.2)
Agefirst-time-to-conception(SD) 24.3(5.8) 25.4(5.8)
Numberofpregnanciesmean(SD) 2.0(1.5) 1.9(1.5)
Numberoflivebirthsmean(SD) 1.6(1.3) 1.6(1.4)
Numberofmiscarriagesmean(SD) 1.5(0.7) 1.4(0.6)
Self-reportedPCOSn(%) 6,028(16.2%) 13,005(5.2)
Self-reportedPOIn(%) 443(1.2) 849(0.3)
Self-reportedDORn(%) 975(2.6) 3,190(1.3)
SD:Standarddeviation,PCOS:Polycysticovarysyndrome,POI:Primaryovarianinsufficiency,DOR:Diminishedovarianreserve
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Figure1.ManhattanplotofendometriosisGWAS
EndometriosisGWASassociationresults.Fourteenlocireachedgenome-widesignificance(p<5×10−8).
Figure2.Manhattanplotofendometriosis-relatedinfertilityGWAS
Endometriosis-relatedinfertilityGWASassociationresults.Nolocireachedgenome-widesignificance(p<5×10−8).
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Table3.Endometriosiscase-controlGWASgenome-wideloci
Endometriosiscase-controlGWAS
Endometriosis-relatedinfertility
Variantid Chr Pos(hg19) Nearestgene(s) RA OA RAF OR[95%CI] P OR[95%CI] P
Novellocirs12030576 1 115817221 NGF G T 0.65 1.07[1.05-1.09] 5.2×10−13 1.09[1.00,1.18] 0.03rs1209731 1 169324793 ATP1B1-F5 C T 0.98 1.19[1.12-1.26] 2.0×10−8 1.11[0.86,1.43] 0.44rs1595344 6 74611632 CD109 G A 0.66 1.05[1.03-1.07] 1.2×10−8 1.04[0.96,1.13] 0.32rs2226158 6 125995467 HEY2 G A 0.47 1.05[1.03-1.07] 2.6×10−8 0.95[0.90,1.01] 0.16
rs6468654 8 100062724 OSR2-VPS13B C T 0.24 1.06[1.04-1.08] 2.5×10−8 1.00[0.93,1.08] 0.96
rs7924571 11 32350027 WT1 C A 0.77 1.06[1.04-1.08] 3.5×10−8 0.99[0.92,1.08] 0.90
rs13441059 X 70108889 TEX11-SLC7A3 A G 0.36 1.05[1.03-1.07] 4.1×10−8 1.01[0.93,1.09] 0.82
Previouslyreportedloci
rs80173514 1 22354538 CELA3A-CDC42 A C 0.15 1.13[1.10-1.15] 7.5×10−25 1.15[1.05,1.27] 2.7×10−3
rs17215781 6 152570274 SYNE1 A G 0.92 1.13[1.10-1.17] 1.5×10−14 1.16[1.01,1.33] 0.04rs9312658 4 56005526 KDR C A 0.67 1.07[1.05-1.09] 2.9×10−14 1.09[1.00,1.17] 0.03
rs10616649 11 30349488 FSHB-ARL14EP ACTCTA - 0.84 1.09[1.07-1.12] 4.0×10−14 0.94[0.85,1.04] 0.23
rs11674184 2 11721535 GREB1 T G 0.61 1.07[1.05-1.08] 1.4×10−12 0.99[0.92,1.07] 0.83rs6456259 6 19761718 ID4 G A 0.16 1.07[1.05-1.10] 2.1×10−9 0.95[0.86,1.04] 0.25
rs746628 17 63850547 CEP112 T C 0.69 1.06[1.04-1.08] 3.7×10−9 0.99[0.91,1.07] 0.70Genome-widesignificantlociinendometriosiscase-controlGWASChr:chromosome,Pos:position,RA:riskallele,OA:Otherallele,RAF:Riskallelefrequency,OR:Oddsratio,P:P-value
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Table4.Endometriosiscase-controlGWASassociationresultsforotherpreviouslyreportedloci
Endometriosiscase-controlGWAS Endometriosis-relatedinfertility
Variantid Chr Pos(hg19) Nearestgene(s) RA OA RAF OR[95%CI] P OR[95%CI] P
rs10859853rs4762326
1212
9561495395668951 FGD6-VEZT C
TTC
0.370.48
1.05[1.03,1.06]1.04[1.02,1.06]
1.1×10−7
1.6x10-61.04[0.96,1.12]1.02[0.96,1.08]
0.280.49
rs4870024rs1971256
66
151830769151816011
RMND1-ESR1
CC
TT
0.190.21
1.06[1.04,1.08]1.05[1.03,1.07]
1.8×10−7
9.2x10-70.95[0.88,1.03]0.96[0.90,1.04]
0.240.35
rs12700667 1 25901639 NPVF-NFE2L3 A G 0.75 1.04[1.02,1.06] 6.3×10−5 1.05[0.97,1.13] 0.24
rs1537377 9 22169700 CDKN2B-DMRTA1 C T 0.38 1.04[1.03,1.06] 1.6×10−6 0.97[0.90,1.05] 0.48
rs74491657 7 46947633 IGFBP3-TNS3 G A 0.90 1.02[1.00,1.04] 0.12 1.00[0.89,1.13] 0.95
rs519664 9 15246652 TTC39B T C 0.21 1.01[0.99,1.03] 0.34 0.96[0.89,1.04] 0.35AssociationresultsforotherpreviouslyreportedendometriosislociChr:chromosome,Pos:position,RA:riskallele,OA:Otherallele,RAF:Riskallelefrequency,OR:Oddsratio,P:P-value
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Table5.Toplociassociatedwithendometriosis-relatedinfertility
Variantid Chr Pos(hg19)Nearest
gene(s)RA OA RAF OR[95%CI] P
rs201312237 5 94607502 MCTP1 ATAG - 8.8×10−3 2.96[1.93-4.55] 2.3×10
−7
rs182207890 1 110356869EPS8L3-
CSF1C T 0.998 Inf[10-Inf] 3.3×10
−7
rs113318830 2 11897940 LPIN1 - AT 0.78 1.25[1.14-1.36] 3.7×10−7
rs796733043 7 125639265 GRM8 TATT - 0.82 1.32[1.18-1.47] 7.7×10−7
rs142956186 4 163162586 FSTL5 T C 1.7×10−3 Inf[11.17-Inf] 9.9×10
−7
Lociwithp<1×10−6withendometriosis-relatedinfertility
Chr:chromosome,Pos:position,RA:riskallele,OA:Otherallele,RAF:Riskallelefrequency,OR:Oddsratio,P:P-
value
Table6.TranscriptionfactorsbindingtheDNAregioncoveredbythecrediblesetaccordingtoChiP-seqintheEncodedata
Locus Transcriptionfactors
NGF AR,FOXP2,RFX3,SPI1
ATP1B1-F5 RFX3
CD109 CTCF,SETDB1,E2F4,FOS,RAD21,SMC3,CEBPB,EP300,JUND,MAFK,RFX5,TEAD4,
EGR1,NFYB
HEY2 BATF,GATA3,FOXA1,POLR2A,RFX3,CEBPB,TRIM28,CTCF,RAD21,EBF1,ATF2,
TAF7,GATA2,FOS,MAFF,MAFK,CHD1,GTF2F1,SETDB1
OSR2-VPS13B ARID3A,ATF1,ATF2,ATF3,BATF,BCL11A,CBX3,CCNT2,CHD1,CTPBP2,EGR1,ESR1,
EZH2,FOS,FOSL1,FOXA1,FOXA2,CEPBP,EP300,FOS,FOXM1,GABPB1,GATA1,
GATA2,GATA3,HDAC2,IRF1,IRF4,JUN,JUNB,JUND,MAFF,MAFK,MAX,MTA3,
MYC,NFKB1,NFIC,NR2F2,POLR2A,POU5F1,RCOR1,REST,RUNX3,SETDB1,SPDEF,
SPI1,STAT5A,SUZ12,TAF1,TAL1,TBL1XR1,TCF3,TCF7L2,TCF12,TEAD4,TRIM28,
ZNF143,ZNF217,ZNF263
WT1 AR,ARID3A,ATF3,CBX3,CEBPB,CTCF,E2F6,EP300,ESR1,FOS,FOXA1,GTF2F1,
IKZF1,JUND,MAFF,MAFK,MAX,MXI1,MYC,NR3C1,POLR2A,RAD21,RFX5,SIN3A,
SMARCC1,SMARCC2,SMC3,TAF1,USF1,USF2,ZNF143,ZNF263
TEX11-SLC7A3CEBPB,CTCF,ELF1,EP300,GABPB1,MXI1,NR2F2,PML,RCOR1,STAT5A,TAL1,
TEAD4,USF1,YY1
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References
1. Jenkins,S.,D.L.Olive,andA.F.Haney,Endometriosis:pathogeneticimplicationsofthe
anatomicdistribution.ObstetGynecol,1986.67(3):p.335-8.2. Gao,X.,etal.,Economicburdenofendometriosis.FertilSteril,2006.86(6):p.1561-72.3. Bulletti,C.,etal.,Endometriosisandinfertility.JAssistReprodGenet,2010.27(8):p.
441-7.
4. Barnhart,K.,R.Dunsmoor-Su,andC.Coutifaris,Effectofendometriosisoninvitro
fertilization.FertilSteril,2002.77(6):p.1148-55.5. Akande,V.A.,etal.,Differencesintimetonaturalconceptionbetweenwomenwith
unexplainedinfertilityandinfertilewomenwithminorendometriosis.HumReprod,
2004.19(1):p.96-103.6. Johnson,N.P.,etal.,TheFLUSHtrial--flushingwithlipiodolforunexplained(and
endometriosis-related)subfertilitybyhysterosalpingography:arandomizedtrial.Hum
Reprod,2004.19(9):p.2043-51.7. Jansen,R.P.,Minimalendometriosisandreducedfecundability:prospectiveevidence
fromanartificialinseminationbydonorprogram.FertilSteril,1986.46(1):p.141-3.8. Simon,C.,etal.,Outcomeofpatientswithendometriosisinassistedreproduction:
resultsfromin-vitrofertilizationandoocytedonation.HumReprod,1994.9(4):p.725-9.9. Khine,Y.M.,F.Taniguchi,andT.Harada,Clinicalmanagementofendometriosis-
associatedinfertility.ReprodMedBiol,2016.15(4):p.217-225.10. Gajbhiye,R.,etal.,Multipleendometrialantigensaretargetedinautoimmune
endometriosis.ReprodBiomedOnline,2008.16(6):p.817-24.11. Osborn,B.H.,etal.,Induciblenitricoxidesynthaseexpressionbyperitoneal
macrophagesinendometriosis-associatedinfertility.FertilSteril,2002.77(1):p.46-51.12. Agarwal,A.,etal.,Theeffectsofoxidativestressonfemalereproduction:areview.
ReprodBiolEndocrinol,2012.10:p.49.13. Marcoux,S.,R.Maheux,andS.Berube,Laparoscopicsurgeryininfertilewomenwith
minimalormildendometriosis.CanadianCollaborativeGrouponEndometriosis.NEnglJ
Med,1997.337(4):p.217-22.14. Treloar,S.A.,etal.,GeneticinfluencesonendometriosisinanAustraliantwinsample.
FertilSteril,1999.71(4):p.701-10.15. Saha,R.,etal.,Heritabilityofendometriosis.FertilSteril,2015.104(4):p.947-952.16. Adachi,S.,etal.,Meta-analysisofgenome-wideassociationscansforgenetic
susceptibilitytoendometriosisinJapanesepopulation.JHumGenet,2010.55(12):p.816-21.
17. Painter,J.N.,etal.,Genome-wideassociationstudyidentifiesalocusat7p15.2
associatedwithendometriosis.NatGenet,2011.43(1):p.51-4.18. Nyholt,D.R.,etal.,Genome-wideassociationmeta-analysisidentifiesnewendometriosis
riskloci.NatGenet,2012.44(12):p.1355-9.19. Albertsen,H.M.,etal.,Genome-wideassociationstudylinknovellocitoendometriosis.
PLoSOne,2013.8(3):p.e58257.
not certified by peer review) is the author/funder. All rights reserved. No reuse allowed without permission. The copyright holder for this preprint (which wasthis version posted September 7, 2018. . https://doi.org/10.1101/401448doi: bioRxiv preprint
20. Rahmioglu,N.,etal.,Geneticvariantsunderlyingriskofendometriosis:insightsfrom
meta-analysisofeightgenome-wideassociationandreplicationdatasets.HumReprod
Update,2014.20(5):p.702-16.21. Steinthorsdottir,V.,etal.,CommonvariantsupstreamofKDRencodingVEGFR2andin
TTC39Bassociatewithendometriosis.NatCommun,2016.7:p.12350.22. Sapkota,Y.,etal.,Meta-analysisidentifiesfivenovellociassociatedwithendometriosis
highlightingkeygenesinvolvedinhormonemetabolism.NatCommun,2017.8:p.15539.
23. Uno,S.,etal.,Agenome-wideassociationstudyidentifiesgeneticvariantsinthe
CDKN2BASlocusassociatedwithendometriosisinJapanese.NatGenet,2010.42(8):p.707-10.
24. Wakefield,J.,ABayesianmeasureoftheprobabilityoffalsediscoveryingenetic
epidemiologystudies.AmJHumGenet,2007.81(2):p.208-27.25. WellcomeTrustCaseControl,C.,etal.,Bayesianrefinementofassociationsignalsfor14
lociin3commondiseases.NatGenet,2012.44(12):p.1294-301.26. Machiela,M.J.andS.J.Chanock,LDlink:aweb-basedapplicationforexploring
population-specifichaplotypestructureandlinkingcorrelatedallelesofpossible
functionalvariants.Bioinformatics,2015.31(21):p.3555-7.27. Saha,R.,L.Marions,andP.Tornvall,Validityofself-reportedendometriosisand
endometriosis-relatedquestionsinaSwedishfemaletwincohort.FertilSteril,2017.
107(1):p.174-178e2.28. Soules,M.R.,etal.,Endometriosisandanovulation:acoexistingproblemintheinfertile
female.AmJObstetGynecol,1976.125(3):p.412-7.29. Jones,A.V.,etal.,Genome-wideassociationanalysisofpainseverityindysmenorrhea
identifiesassociationatchromosome1p13.2,nearthenervegrowthfactorlocus.Pain,
2016.157(11):p.2571-2581.30. BarcenadeArellano,M.L.,etal.,Overexpressionofnervegrowthfactorinperitoneal
fluidfromwomenwithendometriosismaypromoteneuriteoutgrowthinendometriotic
lesions.FertilSteril,2011.95(3):p.1123-6.31. Heit,J.A.,etal.,Agenome-wideassociationstudyofvenousthromboembolismidentifies
riskvariantsinchromosomes1q24.2and9q.JThrombHaemost,2012.10(8):p.1521-31.
32. Germain,M.,etal.,Meta-analysisof65,734individualsidentifiesTSPAN15andSLC44A2
astwosusceptibilitylociforvenousthromboembolism.AmJHumGenet,2015.96(4):p.532-42.
33. Klarin,D.,etal.,GeneticAnalysisofVenousThromboembolisminUKBiobankIdentifies
theZFPM2LocusandImplicatesObesityasaCausalRiskFactor.CircCardiovascGenet,
2017.10(2).34. Hinds,D.A.,etal.,Genome-wideassociationanalysisofself-reportedeventsin6135
individualsand252827controlsidentifies8lociassociatedwiththrombosis.HumMol
Genet,2016.25(9):p.1867-74.35. Liu,J.Z.,etal.,Associationanalysesidentify38susceptibilitylociforinflammatorybowel
diseaseandhighlightsharedgeneticriskacrosspopulations.NatGenet,2015.47(9):p.979-986.
not certified by peer review) is the author/funder. All rights reserved. No reuse allowed without permission. The copyright holder for this preprint (which wasthis version posted September 7, 2018. . https://doi.org/10.1101/401448doi: bioRxiv preprint
36. Sergi,C.,T.AlJishi,andM.Walker,FactorVLeidenmutationinwomenwithearly
recurrentpregnancyloss:ameta-analysisandsystematicreviewofthecausal
association.ArchGynecolObstet,2015.291(3):p.671-9.37. DelaCruz,C.andF.M.Reis,TheroleofTGFbetasuperfamilymembersinthe
pathophysiologyofendometriosis.GynecolEndocrinol,2015.31(7):p.511-5.38. Young,V.J.,etal.,TheroleofTGF-betainthepathophysiologyofperitoneal
endometriosis.HumReprodUpdate,2017.23(5):p.548-559.39. Nakamura,T.,etal.,SequentialchangesintheexpressionofWnt-andNotch-related
genesinthevaginaanduterusofovariectomizedmiceafterestrogenexposure.InVivo,
2012.26(6):p.899-906.40. Shao,W.,S.Halachmi,andM.Brown,ERAP140,aconservedtissue-specificnuclear
receptorcoactivator.MolCellBiol,2002.22(10):p.3358-72.41. Cheng,T.H.,etal.,Fiveendometrialcancerrisklociidentifiedthroughgenome-wide
associationanalysis.NatGenet,2016.48(6):p.667-74.42. Higginbotham,K.S.,etal.,Amultistageassociationstudyidentifiesabreastcancer
geneticlocusatNCOA7.CancerRes,2011.71(11):p.3881-8.43. Cloke,B.,etal.,Theandrogenandprogesteronereceptorsregulatedistinctgene
networksandcellularfunctionsindecidualizingendometrium.Endocrinology,2008.
149(9):p.4462-74.44. Yotova,I.,etal.,EpigeneticAlterationsAffectingTranscriptionFactorsandSignaling
PathwaysinStromalCellsofEndometriosis.PLoSOne,2017.12(1):p.e0170859.45. Coosemans,A.,etal.,Wilms'tumorgene1(WT1)overexpressioninneuronsindeep
endometriosis:apilotstudy.FertilSteril,2009.91(4Suppl):p.1441-4.46. Gurates,B.,etal.,WT1andDAX-1inhibitaromataseP450expressioninhuman
endometrialandendometrioticstromalcells.JClinEndocrinolMetab,2002.87(9):p.4369-77.
47. Matsuzaki,S.,etal.,ExpressionofWT1isdown-regulatedineutopicendometrium
obtainedduringthemidsecretoryphasefrompatientswithendometriosis.FertilSteril,
2006.86(3):p.554-8.48. Sha,Y.,etal.,AnovelTEX11mutationinducesazoospermia:acasereportofinfertile
brothersandliteraturereview.BMCMedGenet,2018.19(1):p.63.49. Yang,F.,etal.,TEX11ismutatedininfertilemenwithazoospermiaandregulates
genome-widerecombinationratesinmouse.EMBOMolMed,2015.7(9):p.1198-210.50. Yatsenko,A.N.,etal.,X-linkedTEX11mutations,meioticarrest,andazoospermiain
infertilemen.NEnglJMed,2015.372(22):p.2097-107.51. Nakamura,S.,etal.,Next-generationsequencingforpatientswithnon-obstructive
azoospermia:implicationsforsignificantrolesofmonogenic/oligogenicmutations.
Andrology,2017.5(4):p.824-831.52. Zhang,X.,etal.,SixpolymorphismsingenesinvolvedinDNAdouble-strandbreakrepair
andchromosomesynapsis:associationwithmaleinfertility.SystBiolReprodMed,2015.
61(4):p.187-93.53. Yu,Y.H.,etal.,TEX11modulatesgermcellproliferationbycompetingwithestrogen
receptorbetaforthebindingtoHPIP.MolEndocrinol,2012.26(4):p.630-42.
not certified by peer review) is the author/funder. All rights reserved. No reuse allowed without permission. The copyright holder for this preprint (which wasthis version posted September 7, 2018. . https://doi.org/10.1101/401448doi: bioRxiv preprint
54. Maeda,I.,etal.,Large-scaleanalysisofgenefunctioninCaenorhabditiselegansbyhigh-
throughputRNAi.CurrBiol,2001.11(3):p.171-6.55. Shin,O.H.,etal.,EvolutionarilyconservedmultipleC2domainproteinswithtwo
transmembraneregions(MCTPs)andunusualCa2+bindingproperties.JBiolChem,
2005.280(2):p.1641-51.56. Qiu,L.,H.Yu,andF.Liang,MultipleC2domainstransmembraneprotein1isexpressedin
CNSneuronsandpossiblyregulatescellularvesicleretrievalandoxidativestress.J
Neurochem,2015.135(3):p.492-507.57. Daiter,E.,etal.,Expressionofcolony-stimulatingfactor-1inthehumanuterusand
placenta.JClinEndocrinolMetab,1992.74(4):p.850-8.58. Kauma,S.W.,etal.,Colony-stimulatingfactor-1andc-fmsexpressioninhuman
endometrialtissuesandplacentaduringthemenstrualcycleandearlypregnancy.JClin
EndocrinolMetab,1991.73(4):p.746-51.59. Cohen,P.E.,etal.,Colony-stimulatingfactor1regulationofneuroendocrinepathways
thatcontrolgonadalfunctioninmice.Endocrinology,2002.143(4):p.1413-22.60. Ovadia,S.,K.Insogna,andG.Q.Yao,Thecell-surfaceisoformofcolonystimulatingfactor
1(CSF1)restoresbutdoesnotcompletelynormalizefecundityinCSF1-deficientmice.
BiolReprod,2006.74(2):p.331-6.61. Fukaya,T.,etal.,Theroleofmacrophagecolonystimulatingfactorintheperitonealfluid
ininfertilepatientswithendometriosis.TohokuJExpMed,1994.172(3):p.221-6.62. Greaves,E.,etal.,Estradiolisacriticalmediatorofmacrophage-nervecrosstalkin
peritonealendometriosis.AmJPathol,2015.185(8):p.2286-97.63. Jensen,J.R.,etal.,Apotentialroleforcolony-stimulatingfactor1inthegenesisofthe
earlyendometrioticlesion.FertilSteril,2010.93(1):p.251-6.64. Meana,C.,etal.,Lipin-1integrateslipidsynthesiswithproinflammatoryresponses
duringTLRactivationinmacrophages.JImmunol,2014.193(9):p.4614-22.65. Gowri,P.M.,etal.,Lipin1regulationbyestrogeninuterusandliver:implicationsfor
diabetesandfertility.Endocrinology,2007.148(8):p.3685-93.66. Reue,K.andM.H.Doolittle,Naturallyoccurringmutationsinmiceaffectinglipid
transportandmetabolism.JLipidRes,1996.37(7):p.1387-405.67. Peterfy,M.,etal.,Lipodystrophyinthefldmouseresultsfrommutationofanewgene
encodinganuclearprotein,lipin.NatGenet,2001.27(1):p.121-4.68. Brachat,A.,etal.,Amicroarray-based,integratedapproachtoidentifynovelregulators
ofcancerdrugresponseandapoptosis.Oncogene,2002.21(54):p.8361-71.
not certified by peer review) is the author/funder. All rights reserved. No reuse allowed without permission. The copyright holder for this preprint (which wasthis version posted September 7, 2018. . https://doi.org/10.1101/401448doi: bioRxiv preprint