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Identification of immune cell infiltration and effective biomarkers of polycystic ovary syndrome by bioinformatics analysis
BMC Pregnancy and Childbirth volume 23, Article number: 377 (2023)
Patients with polycystic ovary syndrome (PCOS) exhibit a chronic inflammatory state, which is often accompanied by immune, endocrine, and metabolic disorders. Clarification of the pathogenesis of PCOS and exploration of specific biomarkers from the perspective of immunology by evaluating the local infiltration of immune cells in the follicular microenvironment may provide critical insights into disease pathogenesis.
In this study, we evaluated immune cell subsets and gene expression in patients with PCOS using data from the Gene Expression Omnibus database and single-sample gene set enrichment analysis.
In total, 325 differentially expressed genes were identified, among which TMEM54 and PLCG2 (area under the curve = 0.922) were identified as PCOS biomarkers. Immune cell infiltration analysis showed that central memory CD4+ T cells, central memory CD8+ T cells, effector memory CD4+ T cells, γδ T cells, and type 17 T helper cells may affect the occurrence of PCOS. In addition, PLCG2 was highly correlated with γδ T cells and central memory CD4+ T cells.
Overall, TMEM54 and PLCG2 were identified as potential PCOS biomarkers by bioinformatics analysis. These findings established a basis for further exploration of the immunological mechanisms of PCOS and the identification of therapeutic targets.
Polycystic ovary syndrome (PCOS) is a common reproductive endocrine metabolic disease in women of childbearing age and is often characterised by chronic anovulation and hyperandrogenaemia. Its clinical manifestations include menstrual disorders, hirsutism, acne, and polycystic ovarian changes, and these symptoms can be accompanied by metabolic diseases, such as obesity, insulin resistance (IR), and dyslipidaemia . However, the pathogenic mechanisms of PCOS are still unclear. In addition to the ovarian-pituitary-hypothalamic-gonadal axis, studies of PCOS pathogenesis must also consider ovarian local cytokines, immunology, and genetics.
Recent studies have found that the inflammatory immune mechanism is closely related to the occurrence and development of PCOS. Under physiological conditions, appropriate inflammatory stress is conducive to the growth and development of oocytes [2, 3]. However, under pathological conditions, the inflammatory response is enhanced, the development of oocytes may be limited, and the further development of chronic inflammation leads to decreased ovum quality, thereby affecting ovulation . Systemic and ovarian cytokines (e.g., tumour necrosis factor [TNF]-α, interleukin [IL]-6, and IL-18) can change the local microenvironment in the ovary, regulate ovarian function, induce excessive androgen production, and promote IR through various mechanisms . Inflammation in the follicular microenvironment may be involved in the dysfunction of the hypothalamic-pituitary-gonad axis and the occurrence and development of follicular dysplasia.
In studies of the distribution of white blood cells in the ovary and cytokine mRNA expression in the follicular fluid (FF) of patients with PCOS and non-PCOS women undergoing fertilisation embryo transfer in vitro, Wu et al.  showed that T lymphocytes play important roles in the local pathological mechanisms of PCOS. T lymphocytes secrete various inflammatory and immunomodulatory molecules that participate in the regulation of ovarian function. T-cell subsets have also been shown to be dysregulated in the peripheral blood and ovaries of patients with PCOS owing to disruption of sex hormone levels in these patients .
The pathogenesis of PCOS is multifactorial and complex. In addition to reproductive abnormalities, the pathogenic mechanisms also include interactions between the immune system and reproduction, resulting in a variety of changes to cytokines and immune cells. Therefore, evaluation of immune cell infiltration in patients with PCOS based on changes in the expression levels of genes may be essential for elucidating the immunological mechanisms of PCOS and identification of novel biomarkers.
In this study, we aimed to identify the roles of immune cell subsets and related gene expression changes in the pathogenesis of PCOS. We downloaded four PCOS datasets from the Gene Expression Omnibus (GEO) database and analysed differentially expressed genes. Two different machine learning algorithms were then used to further identify PCOS biomarkers. We also studied PCOS from the perspective of immunology using single-sample gene set enrichment analysis (ssGSEA) to evaluate the differences in the compositions of 28 immune cell subsets between patients with PCOS and healthy women of reproductive age. In addition, the relationships between PCOS biomarkers and immune cell infiltration were studied to improve our understanding of the immunological mechanisms of PCOS occurrence and development.
Materials and methods
First, the “GEOquery” package in R software (version 3.6.1, http://r-project.org/) was used to download the PCOS expression profile datasets GSE84958, GSE106724, GSE137684, GSE114419 and GSE193812 from the GEO database (https://www.ncbi.nlm.nih.gov/geo/). A description of all databases is presented in Supplementary Table S1.
We combined the GSE84958, GSE106724, GSE137684, and GSE114419 gene expression matrices, and interbatch differences were removed using the “sva” package . Boxplots  and two-dimensional principal component analysis (PCA) cluster plots were used to visualise the effects of removing interbatch differences. The flow chart for this study is shown in Supplementary Figure S1.
Evaluation of the distribution of immune cell subtypes
ssGSEA was used to quantify the infiltration of immune cells in patients with PCOS. The abundances of the following 28 types of immune cells were obtained from the R package “GSVA” : activated B cells, activated CD4+ T cells, activated CD8+ T cells, activated dendritic cells (DCs), CD56+ natural killer (NK) cells, CD56− NK cells, central memory CD4+ T cells, central memory CD8+ T cells, effector memory CD4+ T cells, effector memory CD8+ T cells, eosinophils, γδT cells, immature B cells, immature DCs, mast cells, myeloid inhibitory cells, memory B cells, monocytes, NK cells, NK T cells, neutrophils, plasmacytoid DCs, macrophages, regulatory T cells (Tregs), follicular helper T cells, type 1 T helper (Th1) cells, type 17 T helper (Th17) cells, and type 2 T helper (Th2) cells.
Screening of differentially expressed genes (DEGs)
DEGs were filtered through the “limma” package . The DEG threshold point was an adjusted P value less than 0.05 and a |log2 fold change| greater than 0.5.
Functional enrichment analysis
The gene names of DEGs were converted to gene IDs using the R package “org.hs.eg.db”. Gene ontology (GO), Kyoto Encyclopaedia of Genes and Genomes [12, 13] (KEGG), and disease ontology (DO) analyses were performed using the R package “clusterProfiler” , and p value correction from multiple trials was performed using the BH method. GO, DO, and KEGG pathways with significant enrichment of DEGs were screened. GO annotations of DEGs included cellular components, biological processes, and molecular functions, which were used to analyse the functional enrichment of DEGs.
Screening of biomarkers
Protein-protein interaction (PPI) network results for DEGs were obtained using STRING, and LASSO regression and BORUTA algorithm analyses were used for feature selection to screen biomarkers of PCOS. The LASSO algorithm was implemented through the R package “glmnet” . The BORUTA algorithm was implemented through the R package “Boruta” . Similar to a random forest classifier, this approach reduced the error caused by random fluctuation and correlation by adding randomness to the system and collecting results from a random sample set. The candidate biomarkers obtained using the two methods were intersected using a Venn diagram to extract the final candidate biomarkers.
Correlation analysis between biomarkers and immune cells
Spearman rank correlation analysis was used to investigate the correlations between the selected biomarkers and the level of immune cell infiltration.
Analysis of the predictive value of biomarkers
In order to determine the predictive value of biomarkers for PCOS, receiver operating characteristic (ROC) curve analysis was carried out to explore the sensitivity and specificity of candidate biomarkers for PCOS prediction. Screening of the ROC area under the curve (AUC) values identified the dataset that could distinguish PCOS from normal control samples. An external data set and some peripheral blood samples were then used for testing. In this study, 6 PCOS patients who visited Guangdong Provincial Fertility Hospital from March 2022 to September 2022 were included and 6 women of reproductive age who visited the hospital and passed physical examination during the same period were included as the control group. Using peripheral blood RNA as template, cDNA was synthesized using Evo M-MLV reverse transcription reagent premix configuration system. Three groups of replicates were set for each sample, 2-ΔΔCT formula was used to calculate the relative change of each gene expression in each sample.
Statistical analysis and graphical visualisation
All analyses in this paper were carried out by R version 4.0.5. The analysis results were visualised using the R packages “corrplot” , “ggplot2” , and “pheatmap”  and spliced with “patchwork”.
In this study, we selected 83 samples from four different datasets, including 34 PCOS samples and 49 normal control samples. A two-dimensional PCA diagram and boxplot showed the effects before and after treatment (Fig. 1A–D). The results demonstrated that clustering of the two groups of samples was more obvious after normalisation, indicating that differences between batches had been eliminated and that the samples were from reliable sources.
Evaluation of the distributions of immune cell subtypes
ssGSEA revealed differences in the compositions of 28 immune cell subsets in the follicular microenvironment between healthy controls and patients with PCOS (Fig. 2A and Supplementary Table S2). Spearman co-expression analysis of 28 types of immune cells (Fig. 2B and Supplementary Table S3) showed that macrophages were significantly positively correlated with activated CD8+ T cells. Myeloid inhibitory cells were positively correlated with Tregs, Th1 cells, and activated DCs. Central memory CD4+ T cells were negatively correlated with Th2 cells. Additionally, compared with normal controls, patients with PCOS showed increased infiltration of central memory CD4+ T cells, central memory CD8+ T cells, and γδT cells, but decreased infiltration of effector memory CD4+ T cells and Th17 cells (Fig. 2C).
Screening of DEGs
The above 83 samples were used to identify DEGs. In total, 325 DEGs were obtained, including 148 upregulated genes and 177 downregulated genes (Supplementary Table S4, Fig. 3A and B).
Functional enrichment analysis
DEG functional enrichment analysis was performed using GO, KEGG, and DO analysis. GO analysis showed that DEGs were mainly related to signal transduction and biological functions of cell activities, such as hormone receptor binding and ATP-dependent microtubule motility (Fig. 4A and Supplementary Table S5). KEGG analysis confirmed that DEGs were mainly related to growth metabolic signalling pathways, such as the Hippo signalling pathway, vesicle transportation, and vitamin digestion and absorption (Fig. 4B and Supplementary Table S6). DO analysis showed that DEGs were mainly related to autosomal recessive diseases and were also related to neurological and systemic haematological diseases (Fig. 4C and Supplementary Table S7).
Screening of biomarkers
PPI network results for DEGs were obtained using STRING (Supplementary Figure S2). LASSO regression analysis was used to screen out 29 candidate biomarkers (Fig. 5A and B and Supplementary Table S8), the BORUTA algorithm was used to extract genes with high importance, and 55 candidate biomarkers were obtained (Fig. 5C and Supplementary Table S6). After analysis of the overlap of biomarkers obtained using the two algorithms, 20 candidate biomarkers were finally obtained (Fig. 5D and Supplementary Table S8), as follows: AAK1, AIFM1, CCDC114, PTPRN2, TMEM54, CDH15, CXCR1, ABI3BP, FAM149A, SLC9A3R1, ISPD, VIT, TEAD3, BAK1, PSMD3, FUT11, PLCG2, CFP, TRAPPC6B, and JDP2. Most genes were upregulated in PCOS, except AAK1, CCDC114, PTPRN2, CDH15, ISPD, FUT11, and CFP (Fig. 6A and B). Correlation analysis between genes showed that the CXCR1 gene was significantly positively correlated with SLC9A3R1 and PSMD3, whereas CCDC114 was significantly negatively correlated with JDP2 (Fig. 6C and Supplementary Table S9). Moreover, correlation analysis between the candidate biomarkers and 28 types of immune cells showed that AIFM1 was negatively correlated with activated CD4+ T cells (R = − 0.42), and CXCR1 was positively correlated with neutrophils (R = 0.72; Fig. 7 and Supplementary Table S9).
Analysis of the predictive value of biomarkers
ROC analysis of candidate biomarkers showed that the combination of TMEM54 and PLCG2 had a high value for distinguishing PCOS from healthy women of reproductive age (AUC = 0.922). This indicated that the expression of TMEM54 and PLCG2 was related to PCOS and that combination of these two genes could be used as a biomarker for distinguishing PCOS from healthy women of reproductive age and for evaluating the efficacy of PCOS treatment (Fig. 8).
The predictive value of the selected biomarkers was tested using the external dataset GSE193812 and collected peripheral blood, and it was found that the biomarkers selected in this study still have good predictive ability both in the external dataset (AUC = 0.812) and in the peripheral blood samples (AUC = 0.889), as shown in Fig. 9.
PCOS is one of the most common ovo-derived endocrine diseases in women of reproductive age. Its basic pathophysiological features include hyperandrogenaemia and IR caused by disruption of the local internal environment, cytokine expression, and ovary function.
In this study, we identified DEGs between PCOS and normal controls and showed that the combination of TMEM54 and PLCG2 was a biomarker of PCOS. We also found that central memory CD4+ T cells, central memory CD8+ T cells, effector memory CD4+ T cells, γδT cells, and Th17 cells may influence the occurrence of PCOS. PLCG2 was highly correlated with γδT cells and central memory CD4+ T cells.
The follicular microenvironment is composed of FF and granulosa cells (GCs). GCs regulate the local microenvironment of FF through various mechanisms, participate in the metabolism of oocytes, and protect oocytes from the invasion of components in the external environment . The composition of the oocyte GC regulatory loop and follicular microenvironment is critical for the coordination of reproductive activities, and any changes in the composition of FF/GC molecules may affect the quality of oocytes . Therefore, analysis of the immune infiltrating microenvironment of GCs can provide insights into the microenvironment of FF.
As the most important adaptive immune response cells in the immune system, T lymphocytes secrete various inflammatory and immunomodulatory molecules and are involved in regulating multiple ovarian functions, such as follicle formation, ovulation, and luteal degeneration. Activated lymphocytes secrete inflammatory cytokines, including IL-1, IL-6, IL-12, TNF-α, and insulin-like growth factor-1 . In recent years, many domestic and foreign studies have reported that the levels of inflammatory factors, such as IL-6, TNF-α, and C-reactive protein, are higher in patients with PCOS than in normal women . Moreover, inflammatory factors can mediate IR directly or indirectly through adipose tissue, suggesting that the occurrence and development of PCOS are closely related to inflammatory factors [24, 25]. Mature T cells can be categorised as CD4+ T cells or CD8+ T cells according to their CD molecular phenotype. Studies have shown that the ratio of CD4+/CD8 + is related to IL-2 [26, 27], IL-7  and IL-16 . CD4+ T cells and CD8+ T cells have different functions, which play synergistic or restrictive roles, and the ratio of CD4+/CD8+ T cells reflects changes in immune regulation.
Central memory T cells have the ability to expand, differentiate, and self-renew like stem cells and can differentiate unidirectionally into effector memory T cells and short-term effector T cells to prevent chronic infection and cancer . In our study, central memory CD8+ T cells and central memory CD4+ T cells were increased in patients with PCOS, whereas effector memory CD4+ T cells were decreased, albeit without statistical significance. In the local ovarian microenvironment of patients with PCOS, abnormal CD4+/CD8+ T cell ratios may disrupt immune regulation. However, the differentiation of central memory T cells into effector memory T cells may also be blocked, resulting in increased central memory T cells and decreased effector memory T cells.
The functions of γδT cells were first discovered and studied in the field of autoimmune rheumatism. Although γδT cells are a highly conserved T-cell subpopulation, they have important implications in various aspects of immunobiology . Animal models have shown that γδT cells regulate classical autoantigen reactive αβT cells and B cells [32, 33] and play independent pro-inflammatory roles via direct secretion of IL-17 , TNF-α, and interferon (IFN)-γ  in a non-antigen-driven pattern. Many studies have confirmed that the levels of TNF-α, IFN-γ, and IL-18 are significantly increased in patients with PCOS and are positively correlated with IR [24, 36, 37]. In this study, the numbers of γδT cells were higher in patients with PCOS than in normal controls, this observation may be related to the observed increases in TNF-α and IFN-γ secretion by high numbers of γδT cells. Notably, CD3+CD4−CD8− γδT cells are increased in women with recurrent abortion, contributing to foetal loss by regulating transforming growth factor-β and IL-17 secretion and promoting inflammation . The risk of abortion after pregnancy in patients with PCOS is more than three times higher than that in normal women, which may be related to the presence of a chronic inflammatory state and autoimmune disorders, such as active autoimmunity.
The high correlation between the CXC motif chemokine receptor 1 (CXCR1) gene and various immune cells was notable, and the correlation between CXCR1 and neutrophils reached R = 0.72. The protein encoded by the CXCR1 gene is a member of the G-protein-coupled receptor family and acts as a receptor for IL-8. IL-8 is a powerful neutrophil chemokine that binds to receptors and promotes neutrophil activation. CXCR1 binds to IL-8 with high affinity and transduces signals through a second messenger system activated by G proteins [39, 40]. This explains the results of our analysis from a mechanistic level and supports the accuracy of our results.
One of the selected biomarkers, transmembrane protein 54 (TMEM54), is a member of the transmembrane protein family, which contains many proteins with unknown functions. Studies have shown that TMEM expression is different in tumour tissues than in adjacent healthy tissues, and some TMEM family members have been identified as potential prognostic biomarkers in different types of tumours . In addition, TMEM proteins are tumour suppressors or oncogenes and have been shown to be associated with tumour progression and invasion [42, 43] or chemotherapy resistance [44, 45]. Although there are few studies on TMEM54, our current findings suggest that the TMEM54 gene may have important roles in the development of PCOS; further studies are warranted.
Phospholipase C gamma 2 (PLCG2) is a transmembrane signalling enzyme that is an important driver of many immunological aetiological diseases, such as inflammation, autoimmune diseases, immunodeficiencies, and allergies, as well as haematological malignancies. Some studies have demonstrated that point mutations in the PLCG2 gene may be an important cause of severe spontaneous inflammation and autoimmunity . In a meta-analysis of gene expression in patients with rheumatoid arthritis (RA), PLCG2 was found to be upregulated in several datasets, including many pathways associated with RA inflammatory responses, e.g., inflammasome activation, platelet aggregation, and activation, indicating that PLCG2 is a potential target for the control of RA inflammation . Moreover, PLCG2 is important in bone marrow cells, including monocytes, macrophages, NK cells, DCs, and mast cells, possibly because it promotes downstream signalling involving Fc receptors . In a bioinformatics analysis of the tumour microenvironment in soft tissue sarcoma, PLCG2 was found to be an indicator of the tumour microenvironment and patient prognosis . Additionally, CD8+ T cells, γδT cells, monocytes, and M1 macrophages were shown to be positively correlated with PLCG2 expression, consistent with our current results.
There were some limitations to this study. First, this study was only carried out from the perspective of gene transcriptome, and multi-omics and mechanistic studies were not performed. Further validation of our bioinformatics results through in vitro and in vivo experiments and clinical practice is needed.
In summary, in this study, ssGSEA was used for the first time to analyse immune infiltration into the follicle microenvironment in patients with PCOS. Central memory CD4+ T cells, central memory CD8+ T cells, effector memory CD4+ T cells, γδT cells, and Th17 cells may be involved in the occurrence of PCOS. In addition, differences in gene expression in ovarian tissues between patients with PCOS and healthy women of reproductive age were determined, and our findings showed that the combination of TMEM54 and PLCG2 was a biomarker of PCOS. PLCG2 was shown to be highly correlated with γδT cells and central memory CD4+ T cells. These findings provide a basis for further research on the immunological pathogenesis of PCOS.
Availability of data and materials
The datasets used and/or analysed during the current study are available from NCBI Gene Expression Omnibus (GEO). GSE84958 https://www.ncbi.nlm.nih.gov/geo/query/acc.cgi?acc=GSE84958.
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We would like to thank all the patients for participation in this study. We would also like to thank Editage (www.editage.cn) for English language editing and the GEO Database for providing us with a shareable dataset.
This work was supported by Guangzhou Science and Technology Plan Project (grant number: 202102080062) and Guangdong Province Medical Research Funding (grant number: B2023135).
Ethics approval and consent to participate
The studies involving human participants were reviewed and approved by the Ethics Committee of Guangdong Provincial Fertility Hospital. All methods were performed according to the Declaration of Helsinki. Anonymized and deidentified information for participants was used for analysis, so the requirement for informed consent permission was waived by the Ethics Committee of Guangdong Provincial Fertility Hospital.
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Gao, M., Liu, X., Du, M. et al. Identification of immune cell infiltration and effective biomarkers of polycystic ovary syndrome by bioinformatics analysis. BMC Pregnancy Childbirth 23, 377 (2023). https://doi.org/10.1186/s12884-023-05693-4
- Polycystic ovary syndrome
- Immune cell infiltration
- Single-sample gene set enrichment analysis