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Implications in the management of pregnancy: II. Low levels of gene expression but enhanced uptake and accumulation of umbilical cord glycodelin.

OBJECTIVE: We recently reported the presence of glycodelin in the endothelial cells of human umbilical cord. The objective of the current study is to determine whether human umbilical cord endothelial cells synthesize glycodelin. DESIGN: Controlled clinical study. SETTING: Healthy women undergoing normal delivery at Grady Memorial Hospital, Atlanta, Georgia. PATIENT(S): Healthy women undergoing normal delivery. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): Human umbilical cord was collected after full-term delivery and total RNA from endothelial cells was isolated. Reverse-transcription polymerase chain reaction (RT-PCR) was performed by using primers from glycodelin sequence. Human umbilical cord endothelial cells at passage 3 were incubated with glycodelin-derived peptide or glycodelin-rich amniotic fluid. Immunocytochemical analysis was performed by using purified chicken anti-glycodelin peptide antibody to detect the accumulation of glycodelin in cells. RESULT(S): Little or no glycodelin message was detectable in the endothelial cells from human umbilical cord vein by RT-PCR and Southern blot analysis. However, these cells readily took up glycodelin protein and glycodelin-derived synthetic peptide from the medium. CONCLUSION(S): The presence and accumulation of glycodelin in the umbilical cord might indicate their potential role in the survival of fetal tissue in the maternal environment.

Blotting, Western↗

Purification and characterization of an immunomodulatory endometrial protein, glycodelin.

Human glycodelin is synthesized by endometrial cells in the late secretory phase and early pregnancy under hormonal regulation. Whereas the precise physiological functions of glycodelin are unknown, its expression during embryonic nidation and its inhibition of T cell proliferation suggest an immunomodulatory role. We purified human glycodelin from first trimester human decidual cytosol by using a rapid two-step high-performance liquid chromatography method and investigated its effects on human monocyte migration. Human U937 cells were used as a model of monocyte chemotaxis in Boyden chamber migration assays. N-Formyl-Met-Leu-Phe and the beta-chemokine RANTES (regulated on activation normal T cell expressed and secreted) were used as monocyte chemoattractants. Purified glycodelin inhibited monocyte migration in a dose-dependent fashion (IC50 = 550 nm). Glycodelin activity was totally reversed by heat inactivation (95 degrees C x 15 min) and neutralized by pretreatment with specific anti-glycodelin antibodies. Deglycosylated glycodelin was equipotent to intact glycodelin in the monocyte migration assay. 125I-Glycodelin binding to whole U937 cells revealed a single, saturable site with a Kd = 48 +/- 21 nm by Scatchard analysis. Cross-linking studies indicated that glycodelin binds to a high molecular mass (approximately 250 kDa) protein complex at the monocyte cell surface. Our findings support the hypothesis that glycodelin reduces the local maternal inflammatory response toward the implantation of a semiallogeneic conceptus.

Amino Acid Sequence↗

Development and characterization of monoclonal antibodies for the immunohistochemical detection of glycodelin A in decidual, endometrial and gynaecological tumour tissues.

AIMS: Glycodelin is a glycoprotein with a molecular weight of 28 kDa. Unusual LacdiNAc structures have been identified on glycodelin A, isolated from amniotic fluid. Three major functions of this glycoprotein have been identified. Glycodelin is an immunosuppressive molecule, a marker of morphological differentiation, and a contraceptive. Because no monoclonal antibodies for glycodelin A are commercially available, our aim was to develop and characterize three monoclonal antibodies against this glycoprotein. METHODS AND RESULTS: Glycodelin A was purified from amniotic fluid by three chromatographic steps and its purity was checked by SDS-PAGE. Antibodies were generated from immunized BALB/c mice. Three IgG1 monoclonal antibodies detecting glycodelin A were cloned. All three antibodies recognized carbohydrate structures of glycodelin A and did not cross-react with glycodelin S. They are applicable to immunohistochemistry (frozen and paraffin sections), ELISA and Western blots. CONCLUSION: The new antibodies can be used for the detection of glycodelin A in frozen and paraffin-embedded decidual and endometrial tissue. One antibody (A87-B/D2) can be used for the detection of glycodelin in endometrial and ovarian tumour tissues. Because glycodelin A is a major secretory endometrial product during the luteal phase, in early pregnancy and in gynaecological tumours, the new antibodies are, potentially, valuable tools for the study of endometrial development and tumour progression.

Amniotic Fluid↗

Immunolocalization of glycodelin in the genital tract of rats.

Glycodelin, also known as placental protein 14 has been predominantly localized to organs of the human genital tract. Unfortunately the physiological role of glycodelin is largely unknown since it depends on limited availability of tissues. Therefore, a suitable animal model to study the role of glycodelin would be desirable. Previously, it was shown that glycodelin mRNA is expressed in the genital tract of male and female rats. In the present study, we demonstrate the expression of glycodelin protein in male and female rats by immunohistochemistry and Western blot analysis. For this purpose a polyclonal antibody was generated against glycodelin peptide. In female rats, glycodelin was found in the epithelial gland cells of the uterus, epithelial cells of the fallopian tube as well as in corpora lutea, interstitial and theca cells of the ovary. Glycodelin was distributed in all epithelial cells of the epididymis and the seminal vesicle. In the seminiferous epithelium, glycodelin was seen in all developmental stages of spermatogonia and spermatocytes and in Sertoli cells. Whereas in the rat male reproductive tract glycodelin expression is slightly different from human or primate tissues, in organs of the rat female genital tract glycodelin expression is similar to humans and primates.

Animals↗

RU486 inhibits expression of lysophosphatidic acid induced glycodelin.

OBJECTIVE: This study was undertaken to provide evidence for the mode of action of RU486 on glycodelin produced in K562 cells. To show that histiocytes may be a source of glycodelin in leiomyoma. STUDY DESIGN: With the use of K562, a leukemia cell line, the effect of lysophosphatidic acid (LPA), RU486, antioxidants, and ZK112,993 on glycodelin protein and gene expression was studied. Immunocytochemistry for glycodelin and HAM-56 (macrophage) was performed on leiomyoma and myometrium. RESULTS: Incubation of K562 cells with LPA, progesterone, ZK112,933 and RU486 significantly induced the expression of glycodelin protein and messenger RNA. The addition of RU486 to LPA activated cells markedly reduced expression of glycodelin. Addition of ZK112,993, an antiprogestin without antioxidant properties, to LPA activated cells did not reduce glycodelin. Histiocytes in leiomyoma and myometrium co-localize with glycodelin. CONCLUSION: RU486, partly acting as an antioxidant, markedly reduces LPA stimulated glycodelin production. Histiocytes in leiomyoma and myometrium immunostain for glycodelin and suggests a source for glycodelin in leiomyoma.

Adult↗

Cord serum glycodelin concentrations in normal pregnancies and pregnancies complicated by diabetes.

OBJECTIVE: Glycodelin is a glycoprotein released by secretory/decidualized endometrial glands. Its synthesis increases during pregnancy. Hormonal factors whose levels have been shown to change in diabetes (vascular endothelial growth factor, relaxin) may mediate the actions or regulate the synthesis of glycodelin. Cord serum glycodelin levels have not been studied in pregnancies complicated by diabetes. METHODS: Cord serum glycodelin concentrations were measured at birth by an immunofluorometric assay in 62 normal pregnancies, in 67 pregnancies complicated by type 1 diabetes, and in 28 pregnancies complicated by insulin-treated gestational diabetes. RESULTS: The mean glycodelin concentration in cord serum was 2.7 ng/ml (standard error of the mean 0.6) in normal pregnancies. The concentration was not altered in pregnancies complicated by diabetes. Cord serum glycodelin concentrations were also unaltered in diabetic pregnancies with hypertensive disorders (chronic hypertension, pregnancy-induced hypertension or pre-eclampsia) or fetal macrosomia. There was a negative borderline correlation between cord serum glycodelin concentrations and the birth weight in pregnancies complicated by diabetes (r=-0.21, p=0.049). CONCLUSIONS: Decidual function, as assessed by cord serum glycodelin levels, is not markedly altered in diabetic pregnancies. The negative correlation between cord serum glycodelin and the birth weight of the newborns in diabetic pregnancies may be due to the decline in glycodelin levels with advancing pregnancy in the third trimester.

Adult↗

Glycodelin is present in pinopodes of receptive-phase human endometrium and is associated with down-regulation of progesterone receptor B.

OBJECTIVE: To test the hypothesis that glycodelin is localized on pinopodes and correlates with temporal immunostaining of leukemia inhibitory factor (LIF), LIF receptor (LIFR), and progesterone receptor B (PRB). DESIGN: Prospective clinical study. SETTING: Hospital-based reproductive health unit and research laboratories. PATIENT(S): Twenty-five healthy fertile women with normal menstrual cycles. INTERVENTION(S): Endometrial biopsy specimens were obtained from healthy fertile women in the luteal phase of the menstrual cycle. MAIN OUTCOME MEASURE(S): Immunohistochemical staining of glycodelin, ultrastructural immunostaining of glycodelin, and double staining of glycodelin and PRB. RESULT(S): Glycodelin is present in the glands when pinopodes appear. Glycodelin is localized on pinopodes but is also secreted from luminal epithelial cells regardless of pinopode formation. There was a negative correlation between glycodelin secretion from the glands and PRB staining. A weak correlation between the presence of LIFR (but not LIF) and glycodelin was found. CONCLUSION(S): Pinopode appearance, intense staining of LIFR in pinopodes and glycodelin staining in the glands are synchronized events. Down-regulation of PRB in the endometrium is concomitant with the presence of glycodelin in the endometrium, suggesting interaction.

Adult↗

Increased glycodelin levels in gynecological malignancies.

Glycodelin, an immunosuppressive protein with contraceptive properties, is synthesized by a variety of tissues and cell types. The ability of reproductive tissues to synthesize glycodelin is of major interest in pregnancy and disease conditions. We studied glycodelin levels in subjects with malignant gynecological tumors and in control subjects. Using a polyclonal glycodelin antibody against the synthetic glycodelin peptide sequence, an enzyme-linked immunosorbent assay (ELISA) was devised to measure plasma glycodelin levels. The assay detected as much as 5 ng/ml of glycodelin. There was a significant increase in plasma glycodelin levels in endometrial > ovarian > cervical cancer subjects when compared to those of controls. Strong expression of mRNA and protein were found in the ovarian and endometrial tumor tissues. Given glycodelin's immunosuppressive abilities, increased level of glycodelin may facilitate tumor growth in gynecological malignancies.

Adolescent↗

Glycodelin levels in uterine flushings and in plasma of patients with leiomyomas and polyps: implications for implantation.

BACKGROUND: Glycodelin, a glycoprotein, is present in both blood plasma and uterine flushings. It has been implicated in the process of implantation and angiogenesis. During the secretory phase, progesterone secretion is related to glycodelin production. METHODS AND RESULTS: We obtained uterine flushings, prospectively, from 47 infertile patients during the proliferative phase. Patients were recruited from our university practice. Transvaginal ultrasound and sonohysterography permitted the stratification of patients into control, leiomyoma or polyp groups. Total plasma and uterine flushing glycodelin was measured with enzyme-linked immunosorbent assay. Blood was also analysed for progesterone. Uterine flushing glycodelin levels were significantly increased in patients with polyps when compared with controls. An increase in uterine flushing glycodelin levels was noted in patients with leiomyomas compared with controls, though not statistically significant. Plasma glycodelin levels were significantly increased in patients with leiomyomas and polyps when separately compared with controls. There was a significant relationship between plasma glycodelin production and progesterone levels in patients with polyps. CONCLUSIONS: Leiomyomas and polyps are growing tumours and thus produce significant plasma glycodelin levels. Uterine glycodelin flushings are elevated in patients with both polyps and leiomyomas. Elevated glycodelin levels in the follicular and peri-ovulatory period may impair fertilization and implantation.

Embryo Implantation↗

Regulation of the glycosylated beta-lactoglobulin homolog, glycodelin [placental protein 14:(PP14)] in the baboon (Papio anubis) uterus.

In vitro studies indicate that glycodelin (PP14) synthesis by the human endometrium increases dramatically at the time of implantation and early pregnancy. It has been postulated that this protein may have an immunosuppressive function. Due to the limitations associated with in vivo studies in the human, this study was undertaken to study the regulation of the baboon glycodelin homolog in vivo during the menstrual cycle and early pregnancy. In nonpregnant baboons, between days 10-12 postovulation (n = 3) the mid and apical regions of the glandular epithelium showed a distinct punctate staining pattern, which increased between days 12-18 of pregnancy (n = 3). Between days 25-60 of pregnancy, staining intensity in the glandular epithelium decreased. The decrease was more apparent at the implantation site compared with the nonimplantation site. The immunostaining correlated with the synthesis of radiolabeled baboon glycodelin in explant culture. Northern blot analysis demonstrated two messenger RNA (mRNA) transcripts [1.0 and 1.7 kilobases (kb)] in the baboon uterus compared with a single 1.0-kb transcript in the human, and mRNA expression was consistent with protein localization and synthesis. The protein and mRNA expression was consistently higher in the deeper glands of the functionalis and basalis during early pregnancy. Because the increased expression of glycodelin in the baboon endometrium coincided with peak levels of CG, a simulated pregnant baboon model was used to confirm hormonal regulation. Exogenous human CG (hCG) followed by estrogen and progesterone treatment in intact and ovariectomized baboons up-regulated glycodelin expression between days 18-25 postovulation (n = 10). By day 32 postovulation (n = 3), glycodelin synthesis decreased. Estrogen and progesterone treatment in the absence of exogenous hCG did not result in an increase of glycodelin synthesis. Analysis of uterine flushings from hCG-treated animals revealed that a minimum of 7 days of hCG treatment was required for glycodelin to be detectable in the uterine lumen. These studies indicate that a posttranslationally modified glycodelin homolog is synthesized by the baboon uterus during early pregnancy and appears to be regulated directly by CG. This pattern of synthesis is comparable with that observed with in vitro studies in the human. Because glycodelin expression is associated with CG secretion, we suggest that this protein may have a functional role during implantation in the primate. Thus, the baboon may serve as a nonhuman primate model to elucidate the function of this protein in vivo.

Amino Acid Sequence↗

Normal human ovary and ovarian tumors express glycodelin, a glycoprotein with immunosuppressive and contraceptive properties.

Glycodelin is a glycoprotein with potent immunosuppressive and contraceptive activities. It reacts with antibodies against placental protein 14, or progesterone-associated endometrial protein, and has a unique carbohydrate structure. Previous nomenclature is misleading, because glycodelin is neither synthesized in the placenta nor is it endometrium specific. No ovarian synthesis of glycodelin has been demonstrated. We present evidence for glycodelin synthesis in the human ovary and ovarian tumors. In follicular phase, immunoperoxidase staining of microwave-treated tissue sections employing affinity-purified polyclonal antibodies localized glycodelin to areas of stromal cell condensation in ovarian cortex, theca interna, and the granulosa. In luteal phase, cortical stroma was negative or only weakly positive, whereas glycodelin was present in theca interna of the corpus luteum and luteinized granulosa cells and also in corpus albicans and Leydig cells of the ovarian hilus. In situ hybridization gave negative results for glycodelin mRNA in normal ovary, whereas in ovarian tumors strong expression of both the glycodelin mRNA and the protein were found in benign and malignant serous cystadenomas, mucinous ovarian tumors being negative. We conclude that glycodelin is synthesized in human ovarian tumors, and its occurrence in normal human ovary may represent either synthesis or a site of glycodelin action.

Adult↗

Epithelial expression of glycodelin in biphasic synovial sarcomas.

Glycodelin is a 28 kDa glycoprotein of the lipocalin family that was previously considered to be specific for the reproductive tract. Glycodelin is found in the secretory glandular epithelium of endometrium and in seminal vesicles. Given the cyclic differentiation of normal endometrial epithelium, we studied by immunohistochemistry a possible expression of glycodelin in other tissues displaying stroma-to-epithelium maturation. We report here that 11/11 biphasic synovial sarcomas expressed glycodelin in the cells exhibiting epithelial or glandular differentiation while the sarcomatous spindle cells remained negative. Glycodelin was also found in secreted material in the lumina of the gland-like structures. In only 1 of the 7 monophasic synovial sarcomas studied, focal glycodelin reactivity was seen in some flattened spindle cells. The expression of glycodelin in biphasic synovial sarcoma tissue was further verified by the demonstration of glycodelin mRNA by reverse transcriptase-polymerase chain reaction. Considering the monoclonal origin of synovial sarcomas, our findings raise the intriguing possibility that activation of expression of the glycodelin gene is involved in the molecular regulation of mesenchyme-to-epithelium differentiation.

Epithelium↗

Expression of glycodelin in human breast and breast cancer.

Glycodelin is a 28 kDa glycoprotein with structural homology to beta-lactoglobulins, particularly expressed in steroid-responsive tissues of the female reproductive tract. We previously found that transfection of glycodelin cDNA into MCF-7 breast cancer cells induces differentiation into organized acinar epithelium and up-regulation of epithelial markers. In this study, we used immunohistochemistry, Northern blotting and reverse transcription-polymerase chain reaction (RT-PCR) analyses to study glycodelin expression in normal and in malignant breast tissues. The results were compared with the expression of estrogen (ER) and progesterone receptors (PR) and p53 tumor suppressor protein. Glycodelin was found in ductal and lobular epithelium of 6/6 normal breast tissues, 27/29 morphologically normal breast tissues from breast cancer patients, 6/6 benign lactating adenomas, 21/35 ductal carcinomas, 9/9 tubular carcinomas, 9/9 mucinous carcinomas, 3/3 mixed ductal/tubular carcinomas and 7/11 lobular carcinomas. In the latter, of particular interest was the presence of glycodelin in paranucleolar vacuoles of carcinoma cells. Northern blot analysis of fresh frozen tissues revealed the normal full length 0.9 kb mRNA of glycodelin in ductal breast carcinoma. Using RT-PCR analysis, glycodelin messenger ribonucleic acid was found in 13/13 ductal and in 3/3 tubular tumor tissues. We also detected a splicing variant lacking exon 4, which includes the nucleotide sequence encoding the potential N-glycosylation site at Asn-85. Our results demonstrate the synthesis of glycodelin in normal breast and breast cancer. In addition, we show that the paranuclear vacuole, characteristically present in lobular breast cancer cells, contains abundant amounts of glycodelin.

Adenoma↗

Stimulation of hCG and inhibition of hPL in isolated human trophoblast cells in vitro by glycodelin A.

The immunosuppressive protein glycodelin A (formerly named PP14) is produced by human decidua and secreted in the maternal circulation. Glycodelin A concentrations in serum have been used as indicators of endometrial function. The purpose of this study was to investigate the effect of glycodelin A on human chorionic gonadotropin (hCG) and human placental lactogen (hPL) release by freshly isolated cytotrophoblasts (in vitro). Cytotrophoblasts have been prepared from human term placenta by the three-step trypsin-DNase dispersion method of villous tissue followed by a percoll gradient centrifugation step. When placed in culture, the isolated mononuclear trophoblasts differentiated into syncytial counterparts within 12-72 h after plating. Trophoblasts were incubated with varying concentrations (60-300 microg/ml) of glycodelin A. Glycodelin A was isolated and purified by chromatographic methods from amnion fluid. Supernatants of the trophoblast cell cultures were assayed for hCG and hPL by immunological methods. The release of hCG is increased in glycodelin A-treated trophoblast cell cultures compared to untreated trophoblast cells. Glycodelin A inhibits the production of hPL in vitro. Differences in Glycodelin A stimulated cells and untreated controls are statistical significant. hCG and hPL are markers for the differentiation process of trophoblast cells to syncytial trophoblasts. The results imply that glycodelin A secreted by decidualised endometrium modulates endocrine function, as well as the differentiation of trophoblasts in culture.

Cells, Cultured↗

Glycodelin-A interacts with fucosyltransferase on human sperm plasma membrane to inhibit spermatozoa-zona pellucida binding.

Fertilization depends on successful binding of the spermatozoa to the zona pellucida of the oocyte. Glycodelin-A inhibits spermatozoa-zona pellucida binding. Previous data showed that glycodelin-A receptor(s) and zona pellucida protein receptor(s) on human spermatozoa are closely related. Using a chemical cross-linking approach, the glycodelin-A-sperm receptor complex was isolated. The receptor was identified to be fucosyltransferase-5 (FUT5) by mass spectrometry and confirmed with the use of anti-FUT5 antibodies. Sperm FUT5 was an externally oriented integral membrane protein in the acrosomal region of human spermatozoa. Biologically active FUT5 was purified from spermatozoa. Co-immunoprecipitation confirmed the interaction between glycodelin-A and sperm FUT5. Solubilized zona pellucida reduced the binding of glycodelin-A to sperm FUT5. An anti-FUT5 antibody and FUT5 acceptor blocked the binding of glycodelin-A to spermatozoa and the zona binding inhibitory activity of glycodelin-A. Sperm FUT5 bound strongly to intact and solubilized human zona pellucida. The equilibrium dissociation constant of sperm FUT5 binding to solubilized zona pellucida was 42.82 pmol/ml. These observations suggest that human sperm FUT5 is a receptor of glycodelin-A and zona pellucida proteins, and that glycodelin-A inhibits spermatozoa-zona binding by blocking the binding of sperm FUT5 to the zona pellucida.

Antibodies↗

Maternal serum glycodelin in premature rupture of membranes.

AIM: Few studies address decidual function in abnormal pregnancies, due obviously to shortage of appropriate markers. Glycodelin is produced by epithelial cells of pregnancy decidua. We investigated whether serum glycodelin concentrations are altered in premature rupture of membranes (PROM). METHODS: Serum glycodelin concentrations were measured in 32 women with PROM and in 27 gestational age-matched healthy women. Serum C-reactive protein (CRP) concentrations were measured to indicate infection. RESULTS: Glycodelin concentrations were similar in PROM patients and control subjects. No difference was found in glycodelin concentrations between the 17 PROM patients with CRP > 12 mg/l and controls, or between the 15 PROM patients with CRP < or = 12 mg/l and controls. There was no correlation between the highest antepartum glycodelin level and the interval from PROM to delivery. A negative correlation between the last glycodelin concentration and the birth weight of the newborns was found in the PROM patients (rs = -0.369, p = 0.038). CONCLUSIONS: Decidual epithelial cell function does not seem to be compromised in PROM. The inverse correlation between serum glycodelin and the birth weight of the newborns in PROM may be explained by the normally occurring decline of serum glycodelin with advancing pregnancy in the third trimester.

Adult↗

Seminal plasma glycodelin and fertilization in vitro.

Endometrium-derived glycodelin-A inhibits sperm-egg binding, whereas differentially glycosylated seminal plasma glycodelin-S does not. The difference has been ascribed to the specific type of glycosylation of glycodelin-A. We studied whether the total glycodelin concentration or the relative glycodelin-A concentration in seminal plasma are related to the in vitro fertilization rate of oocytes. We found that total glycodelin levels were significantly higher in a quartile of men with the lowest in vitro fertilization rate compared with the remaining 3 quartiles combined (P = .01). However, for predicting low fertilization capacity of sperm, combining the glycodelin and sperm concentrations by logistic regression analysis did not significantly increase the information obtained from sperm concentration alone. We used specific lectin-immunoassays to determine whether increased glycodelin-A-type glycosylation in seminal plasma would be related to failure to fertilize. No difference was found between the groups with high fertilization and no fertilization in vitro. It is concluded that, although high seminal plasma total glycodelin level has a tendency of being associated with a lower fertilization rate, the difference has limited value to predict fertilization in vitro.

Blood Proteins↗

Stimulation of hCG protein and mRNA levels in trophoblast tumour cells Jeg3 and BeWo by glycodelin A.

The placental hormone human chorionic gonadotropin (hCG) represents a marker for the differentiation process of cytotrophoblast cells into syncytial trophoblasts and is also found in the serum and urine of patients with malignant trophoblastic diseases. During pregnancy, serum concentration curves of hCG and glycodelin A show a similar course. The main source of hCG is the trophoblast and trophoblast cells in vitro show an increased hCG release if treated with glycodelin A. In addition, hCG is a tumour marker for chorion carcinoma cells. We investigated the effect of native and recombinant glycodelin on the trophoblast tumour cells Jeg3 and BeWo and the role of expression plasmids of glycodelin A in the same cells. Our study shows that glycodelin A stimulates the secretion of hCG protein in Jeg3 trophoblast tumour cells in a time- and dose-dependent manner. Our results were confirmed on the mRNA level by real-time RT-PCR. The effect of glycodelin A on hCG mRNA regulation is time- and dose-dependent. We observed an increase of hCG mRNA copy numbers after glycodelin A treatment leading to a higher hCG protein production. Glycodelin A had no effect on BeWo trophoblast tumour cells, suggesting that production of hCG is not regulated by glycodelin A in these cells.

Chorionic Gonadotropin↗