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Table of Contents
Year : 2021  |  Volume : 10  |  Issue : 6  |  Page : 269-273

Association between eNOS gene promoter polymorphism (-786T>C) and idiopathic recurrent pregnancy loss in Iranian women

1 Department of Biology, Medical Biotechnology Research Center, Ashkezar Branch, Islamic Azad University, Ashkezar, Yazd, Iran
2 Diabetes Research Center, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
3 Abortion Research Centre, Yazd Reproductive Sciences Institute, Shahid Sadoughi University of Medical Sciences, Yazd, Iran

Date of Submission23-May-2021
Date of Decision20-Jul-2021
Date of Acceptance26-Sep-2021
Date of Web Publication30-Nov-2021

Correspondence Address:
Nasrin Ghasemi
Abortion Research Centre, Yazd Reproductive Sciences Institute, Shahid Sadoughi University of Medical Sciences, Yazd
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/2305-0500.331264

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Objective: To investigate the frequency of -786T>C variant in endothelial nitric oxide synthase (eNOS) gene promoter in Iranian women with recurrent pregnancy loss.
Methods: Blood samples were obtained from 100 unrelated women affected by recurrent pregnancy loss and 100 unaffected women as the controls. Genomic DNA was extracted and -786T>C polymorphism in eNOS gene promoter was investigated by PCR-RFLP method. Statistical analyses and Hardy-Weinberg equilibrium in the groups of patients and controls were performed by Chi-square test and SPSS standard software (Version 21).
Results: The frequency of homozygous TT was 40% in cases and 46% in the control group; the frequency of CC was 7% in cases and 5% in the control group; frequency heterozygote TC was 53% in cases and 49% in the control group. Genotype frequencies between the two groups showed no significant differences (P>0.05).
Conclusions: The -786T>C polymorphism is not more frequent in recurrent pregnancy loss in this population.

Keywords: Repeated pregnancy loss; Endothelial nitric oxide synthase; eNOS; -786T>C variant; PCR-RFLP; Iranian women

How to cite this article:
Jalili MS, Asadollahi S, Seifati SM, Ashrafzadeh HR, Ghasemi N. Association between eNOS gene promoter polymorphism (-786T>C) and idiopathic recurrent pregnancy loss in Iranian women. Asian Pac J Reprod 2021;10:269-73

How to cite this URL:
Jalili MS, Asadollahi S, Seifati SM, Ashrafzadeh HR, Ghasemi N. Association between eNOS gene promoter polymorphism (-786T>C) and idiopathic recurrent pregnancy loss in Iranian women. Asian Pac J Reprod [serial online] 2021 [cited 2022 Dec 8];10:269-73. Available from: https://www.apjr.net/text.asp?2021/10/6/269/331264

  1. Introduction Top

Recurrent pregnancy loss, one of the most common complications of pregnancy, occurs in 2% to 5% of clinically recognized pregnancies. It defined as two or more consecutive miscarriages before 20 weeks gestation, which is greater than expected by chance (0.34%)[1],[2]. Consequently, recurrent pregnancy loss is an extremely stressful condition for couples and physicians and is an important area of research. This is a multifactorial obstetric problem with a polygenic background[3].

The important and evident roles of nitric oxide (NO) within the body and in diseases have been highlighted. NO is produced by the NO synthase (NOS) family of enzymes. There are three separate enzymes each coded by a separate gene, with clear contrasts in location, regulation, catalytic properties, and sensitivity to inhibitors[4]. The three NOS isoforms are named accordingly to their position within the human body; NOS found in the endothelium is known as endothelial NOS (also known as Type III, NOS3), NOS found in macrophages is known as inducible NOS (also known as Type II, NOS2) and the final type is neuronal NOS (also known as Type I, NOS1)[5].

The structure of the eNOS gene was first determined by Marsden et al[6]. It was discovered to contain 26 exons incorporating 21 kb of genomic DNA, encoding for 1 203 amino acids in the form of a 135-kD protein. Also, this gene is located in chromosome 7 (7q35-q36)[7]. The eNOS gene has been shown to exhibit different variations. The influence of these variations on eNOS function and consequently disease is still disputed. The hypothesis is that the presence of the variation within this gene may individually or collectively reduce eNOS function and subsequently NO synthesis.

Numerous studies imply that several gene polymorphisms could be proposed as a risk factor for recurrent pregnancy loss. One of these genes is eNOS which produces NOS in the vascular endothelium and causes vasodilation and smooth muscle relaxation[8]. This enzyme catalyzes the biosynthesis of L-citrulline and NO from L-arginine[9]. The level of NO as a signaling molecule will increase during pregnancy. These result in fetal blood supply without hypertension. Therefore, decreasing serum NO levels at the beginning of pregnancy can interfere with oxygen supply and nutrition for the fetus and lead to abortion[10]. In this study, we aimed to analyze the relationship of -786T>C polymorphism (rs2070744) in eNOS gene regulatory region and recurrent pregnancy loss among central and southern Iranian women.

  2. Material and methods Top

2.1. Study participants

One hundred Iranian women with two or more idiopathic spontaneous repeated pregnancy losses which had clinically occurred from the beginning of pregnancy to the end of the 20th week of gestation were recruited in this study. They had attended to the Abortion Research and Clinical Center, Yazd Reproduction Sciences Institute, Shahid Sadoughi University of Medical Sciences. Also, 100 healthy women with no history of abortion with at least two successful pregnancies who were referred to this clinic for routine checkups were selected as the control group. Inclusion criteria included: patients with repeated pregnancy loss based on tests and physician diagnosis and examinations that there was no specific cause for their miscarriage. Moreover, normal people had no history of miscarriage and no disease or factors related to repeated pregnancy loss. Exclusion criteria included: people with one of the types of autoimmune diseases, hormonal disorders, chromosomal defects, hematological diseases, infections, anatomic uterine defects, and other known factors associated with repeated pregnancy loss. All participants were from 20 to 40 years old. In this study, the participants were selected according to the mentioned criteria by the purposive sampling method, and the sample size was calculated using the odds ratio calculation formula.

2.2. Blood collection and DNA extractions

Five mL peripheral blood samples were collected in blood collection tubes containing ethylene diamine tetraacetic acid for anticoagulation. The samples were stored at -20 °C until further use for DNA extraction. Genomic DNA extraction was carried out by using a commercially available kit (Qiagen, Germany; Cat. No.51104) according to the manufacturer’s protocol.

The quality of DNA was assessed by using 1% agarose gel electrophoresis. Concentration and purity of DNA were estimated in absorbance at 260 nm by spectrophotometer (thermo scientific).

2.3. Polymerase chain reaction (PCR) analyses

The length of the target gene in our study was 180 bp and the genomic DNA was amplified by the following primer sequences. Besides, the melting temperature was considered at 68 °C. Forward primer: 5’-TGGAGAGTGCTGGTGTACCCCA- 3’ Reverse primer: 5’-GCCTCCACCCCCACCCTGTC- 3’

Optimized PCR reaction was performed in a total reaction volume of 25 μL containing: 12/5 μL PCR master mix (2×), 1 μL forward primer (10 pmol), 1 μL reverse primer (10 pmol), 3 μL genomic DNA (50 ng), and 7/5 μL distilled water. Finally, the tubes were placed onto a thermocycler (Astec-Japan). Cycling conditions were as follows: initial denaturation at 95 °C for 10 min; followed by 35 cycles of amplification; 95 °C for 15 s; 68 °C for 15 s; 72 °C for 30 s. The final extension was done at 72 °C for 5 min. Amplification of PCR products was also confirmed by gel electrophoresis (1/5% agarose gel).

2.4. PCR-restriction fragment length polymorphism (RFLP) technique

The final assessment was performed by PCR-RFLP method. In other words, the alleles of -786T>C were detected by digestion of the PCR product with the restriction enzyme NgoMIV. This enzyme cleavage site on the gene is shown in [Supplementary Figure 1]. [Additional file 1] The digestion reaction was carried out in a total volume of 25 μL, containing 10 μL PCR product, 0/25 μL R buffer (10×), 0/25 μL NgoMIV enzyme, and 14/5 μL distilled water. The tubes were incubated at 37 °C for 3 h. After digestion, the samples were separated by gel electrophoresis (2% agarose gel) so as to visualize the different products.

2.5. Statistical analysis

All data were analyzed by using the SPSS standard software (Version 21.0, IBM, Armonk, NY, USA) and Chi-square test. Hardy-Weinberg equilibrium analysis was also done. Additionally, the results were reported as a graphical representation by GraphPad Prism 6 software. P<0.05 was considered statistically significant for all data.

2.6. Ethics statement

The study was approved by the Institutional Ethics Committee of the Shahid Sadoughi University of Medical Sciences of Yazd (No. IR.SSU.MEDICINE.REC.1396.221), and all of the controls and subjects who agreed to participate in this study had signed informed consent before the collection of peripheral blood samples.

  3. Results Top

3.1. Study characteristics

PCR was performed and after loading the PCR product on 1/5% agarose gel, the bands were seen at 180 bp [Supplementary Figure 2] [Additional file 2]. Enzymatic digestion by NgoMIV was done to produce two smaller fragments (89 bp, 91 bp) and the sequences containing the T base in that position were not cut [Supplementary Figure 3] [Additional file 3].

3.2. Allele and genotype frequency distribution

The frequency of TT, TC, CC in cases were 40%, 53%, and 7%, respectively; whereas in the controls, they were matched with 46%, 49%, and 5%, in that order. [Table 1] shows that the differences of these genotypes in cases and controls were not significant (P=0.687). Also, [Table 2] displays that there were no differences between the frequency of C and T alleles among cases and controls (P=0.091).
Table 1: Frequency of different eNOS genotypes in the control and the case groups of recurrent pregnancy loss.

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Table 2: Distribution of different alleles of eNOS gene in the control and the case group of recurrent pregnancy loss.

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Furthermore, calculation of Chi-square showed that the case (P=0.058, χ2 =3.592) and control (P=0.075, χ2 =3.169) groups for the distribution of rs2070744 in eNOS gene, were in the Hardy- Weinberg equilibrium.

  4. Discussion Top

Recurrent pregnancy loss presents a critical and stressful clinical problem, which affects about 5% of couples around the world[11]. The extensive research had been carrying out about its causes and treatment. Although several reasons had been recognized for it, about 50% of recurrent pregnancy loss cases are still unexplained[12],[13].

A normal pregnancy is a complex and dependent process on several essential factors such as cytokines, hormones, growth factors, angiogenesis agents and some signaling pathways. Any dysfunction of these, depending on the stage of pregnancy, can lead to disturbing in adjustments of the pathways involved in fetal development and consequently may cause miscarriage or the other fetus disorders[14].

Some researches disclosed the role of eNOS gene in recurrent pregnancy loss. Changes in physiological levels of NO could be related to eNOS variants[15]. It had been shown that -786T>C, 27-bp repeat 4b/4a, 894G>T in the eNOS gene supported an association with increasing the risk of recurrent pregnancy loss[16], but the role of some of these variants like -786T>C in recurrent pregnancy loss is less studied and there is still a controversy about them.

The present study investigated the prevalence of alleles of the eNOS gene promoter -786T>C polymorphism in women mostly from south and center of Iran with recurrent pregnancy loss, compared to normal control of that population. The Chi-square test results demonstrated that there were no significant differences between genotype distribution in the controls and women with recurrent pregnancy loss as a whole group. According to -786T>C position in the gene promoter, studies have focused more on this gene expression level. The in vitro investigations asserted the substitution T allele by C in -786 position caused a 50% decline in transcription level and maybe this is the result of replication protein A1 binding as a gene suppressor to this region in peoples with mutant allele[17],[18]. Also, some researches exposed the lower levels of serum nitrite in patients with endothelial and vascular disease[19],[20]. Previous studies had investigated the distribution of -786T>C polymorphism in various groups. No association of this variant and recurrent pregnancy loss in a cohort of Tunisian had been reported[21]. Some other studies among different ethnicities after that had also reported similar findings[22],[23],[24],[25]. In contrast, a study on the South Korean population had discovered that -786T-4b-894T haplotype significantly increased in the recurrent pregnancy loss group[23]. Another study on Lebanon women suggested that eNOS gene promoter variation (-786T>C) sustained a substantial impact on recurrent pregnancy loss in their women population[26]. An investigation on a group of Egyptian women exposed a significant association between recurrent pregnancy loss and this variant[27]. A meta-analysis study reported that this variant has a significant correlation with the recurrent pregnancy loss risk[28]. Azani et al had analyzed the prevalence of this variant among Iranian women in Tabriz, Iran. They had revealed that there was a significant relationship between this variant and recurrent pregnancy loss[29].

Unlike the studies mentioned so far, one research evaluated the effect of eNOS gene polymorphisms on the aborted embryos and it displayed that CC and TC genotypes for -786T>C variant in the eNOS gene in fetus had a significant relationship with spontaneous abortion. Indeed, it claimed this gene polymorphisms special -786T>C promoter variant in the fetus is more likely to be related to recurrent pregnancy loss than in women[30].

The limitations of this study were: small sample size and lack of the broadly available data of the participants.

In conclusion, the results of this study suggested that the mentioned polymorphism is not related to recurrent pregnancy loss in the south and center of Iran population. As point out before, the outcomes of various studies are contradictory. These results infer the association of this polymorphism with recurrent pregnancy loss among distinct ethnic groups from different countries can be inconsistent, and it is because of their genetic variations.

Conflict of interest statement

The authors declare no competing interests.


The authors appreciate the valuable assistance of the experts in the Yazd Research and Clinical Center for Infertility, especially in molecular and cytogenetic laboratories.

Authors’ contributions

Maryam Sadat Jalili and Samira Asadollahi performed all the main steps of study, collected the samples, carried out the main steps of essay and wrote the manuscript. Hamid Reza Ashrafzadeh helped to perform DNA extraction and PCR. Seyed Morteza Seifati made the analysis of results and conducted statistical tests. Nasrin Ghasemi was the head of team, designed the study and was responsible for monitoring and fixing technical errors during all steps of the study.

  References Top

Carp H. Recurrent pregnancy loss: Causes, controversies and treatment. London: CRC Press; 2020.  Back to cited text no. 1
Sazegari A, Kalantar SM, Pashaiefar H, Mohtaram S, Honarvar N, Feizollahi Z, et al. The T657C polymorphism on the SYCP3 gene is associated with recurrent pregnancy loss. J Assist Reprod Genet 2014; 31(10): 1377-1381.  Back to cited text no. 2
El Hachem H, Crepaux V, May-Panloup P, Descamps P, Legendre G, Bouet PE. Recurrent pregnancy loss: Current perspectives. Int J Womens Health 2017; 9: 331.  Back to cited text no. 3
Santolini J. What does “NO-Synthase” stand for? Front Biosci (Landmark Ed) 2019; 24: 133-171.  Back to cited text no. 4
Lind M, Hayes A, Caprnda M, Petrovic D, Rodrigo L, Kruzliak P, et al. Inducible nitric oxide synthase: Good or bad? Biomed Pharmacother 2017; 93: 370-375.  Back to cited text no. 5
Rafikov R, Fonseca FV, Kumar S, Pardo D, Darragh C, Elms S, et al. eNOS activation and NO function: Structural motifs responsible for the posttranslational control of endothelial nitric oxide synthase activity. J Endocrinol 2011; 210(3): 271-284.  Back to cited text no. 6
Salimi S, Naghavi A, Mokhtari M, Noora M, Yaghmaei M. Lack of relationship between endothelial nitric oxide synthase gene 4b/a and T-786C polymorphisms with preeclampsia in southeast of Iran. Arch Gynecol Obstet 2012; 285(2): 405-409.  Back to cited text no. 7
Cattaneo MG, Vanetti C, Decimo I, Di Chio M, Martano G, Garrone G, et al. Sex-specific eNOS activity and function in human endothelial cells. Sci Rep 2017; 7(1): 9612. doi: 10.1038/s41598-017-10139-x.  Back to cited text no. 8
Luo S, Lei H, Qin H, Xia Y. Molecular mechanisms of endothelial NO synthase uncoupling. Curr Pharm Des 2014; 20(22): 3548-3553.  Back to cited text no. 9
Zullino S, Buzzella F, Simoncini T. Nitric oxide and the biology of pregnancy. Vascul Pharmacol 2018; 110: 71-74.  Back to cited text no. 10
Rahmani F, Hadinedoushan H, Ghasemi N. Relative expression of OX40, OX40L mRNA, and OX40L serum levels in women with recurrent spontaneous abortion. Immunol Invest 2019; 48(5): 480-489.  Back to cited text no. 11
Dimitriadis E, Menkhorst E, Saito S, Kutteh W, Brosens J. Recurrent pregnancy loss. Nat Rev Dis Primers 2020; 6(1): 1-19.  Back to cited text no. 12
Ardestani MT, Nodushan HH, Aflatoonian A, Ghasemi N, Sheikhha MH. Case control study of the factor V Leiden and factor II G20210A mutation frequency in women with recurrent pregnancy loss. Int J Reprod Biomed 2013; 11(1): 61.  Back to cited text no. 13
Chiarello DI, Abad C, Rojas D, Toledo F, Vázquez CM, Mate A, et al. Oxidative stress: Normal pregnancy versus preeclampsia. BBA-Mol Basis Dis 2020; 1866(2): 165354.  Back to cited text no. 14
Gantner BN, LaFond KM, Bonini MG. Nitric oxide in cellular adaptation and disease. Redox Biol 2020; 34: 101550.  Back to cited text no. 15
Karvela M, Papadopoulou S, Tsaliki E, Konstantakou E, Hatzaki A, Florentin-Arar L, et al. Endothelial nitric oxide synthase gene polymorphisms in recurrent spontaneous abortions. Arch Gynecol Obstet 2008; 278(4): 349-352.  Back to cited text no. 16
Cattaruzza M, Guzik TJ, Slodowski W, Pelvan Ael, Becker Jr, Halle M, et al. Shear stress insensitivity of endothelial nitric oxide synthase expression as a genetic risk factor for coronary heart disease. Circ Res 2004; 95(8): 841-847.  Back to cited text no. 17
Miyamoto Y, Saito Y, Nakayama M, Shimasaki Y, Yoshimura T, Yoshimura M, et al. Replication protein A1 reduces transcription of the endothelial nitric oxide synthase gene containing a –786TC mutation associated with coronary spastic angina. Hum Mol Genet 2000; 9(18): 2629-2637.  Back to cited text no. 18
Elfi EF, Decroli E, Nasrul E, Yanwirasti Y, Darwin E. The risk factors of coronary heart disease and its relationship with endothelial nitric oxide synthase. Open Access Maced J Med Sci 2021; 9(B): 451-456.  Back to cited text no. 19
Avtandilyan N, Javrushyan H, Petrosyan G, Trchounian A. The involvement of arginase and nitric oxide synthase in breast cancer development: Arginase and NO synthase as therapeutic targets in cancer. Biomed Res Int 2018; 2018: 8696923. doi: 10.1155/2018/8696923.  Back to cited text no. 20
Zammiti W, Mtiraoui N, Mahjoub T. Lack of consistent association between endothelial nitric oxide synthase gene polymorphisms, homocysteine levels and recurrent pregnancy loss in Tunisian women. Am J Reprod Immunol 2008; 59(2): 139-145.  Back to cited text no. 21
Dutra CG, Fraga LR, Nácul AP, Passos EP, Gonçalves RO, Nunes OL, et al. Lack of association between thrombophilic gene variants and recurrent pregnancy loss. Hum Fertil 2014; 17(2): 99-105.  Back to cited text no. 22
Shin SJ, Lee HH, Cha SH, Kim JH, Shim SH, Choi DH, et al. Endothelial nitric oxide synthase gene polymorphisms (-786T>C, 4a4b, 894G>T) and haplotypes in Korean patients with recurrent spontaneous abortion. Eur J Obstet Gynecol Reprod Biol 2010; 152(1): 64-67.  Back to cited text no. 23
Luo L, Li D, Wei S, Zhang H, Li S, Zhao J. Polymorphisms in the endothelial nitric oxide synthase gene associated with recurrent miscarriage. Genet Mol Res 2013; 12(3): 3879-3886.  Back to cited text no. 24
El-Gharably EM, Sharif FA. Endothelial nitric oxide synthase (eNOS) gene polymorphism, nitric oxide and progesterone levels in unexplained recurrent pregnancy loss. Int J Chem Life Sci 2017; 2(3). [Online]: http://hdl.handle.net/20.500.12358/25324.   Back to cited text no. 25
Almawi W, Guarino B, Al-Sulaiti M, Al-Busaidi A, Racoubian E, Finan R. Endothelial nitric oxide synthase gene variants and haplotypes associated with an increased risk of idiopathic recurrent miscarriage. Hum Fertil 2013; 16(3): 200-206.  Back to cited text no. 26
Abulata NN, AbdalWahab DF, Osman OM. Endothelial nitric oxide synthase gene polymorphism in a cohort of Egyptian women with recurrent spontaneous miscarriage. Comp Clin Path 2015; 24(3): 629-634.  Back to cited text no. 27
Zhao X, Li Q, Yu F, Lin L, Yin W, Li J, et al. Gene polymorphism associated with endothelial nitric oxide synthase (4VNTR, G894T, C786T) and unexplained recurrent spontaneous abortion risk: A meta-analysis. Medicine (Baltimore) 2019; 98(4): e14175.  Back to cited text no. 28
Azani A, Hosseinzadeh A, Azadkhah R, Zonouzi AAP, Zonouzi AP, Aftabi Y, et al. Association of endothelial nitric oxide synthase gene variants (-786T>C, intron 4 b/a VNTR and 894G>T) with idiopathic recurrent pregnancy loss: A case-control study with haplotype and in silico analysis. Eur J Obstet Gynecol Reprod Biol 2017; 215: 93-100.  Back to cited text no. 29
Shim SH, Yoon TK, Cha DH, Han WB, Choi DH, Kim NK. Endothelial nitric oxide synthase (eNOS) gene polymorphisms in spontaneously aborted embryos. Genes Genom 2010; 32(3): 283-288.  Back to cited text no. 30


  [Table 1], [Table 2]


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