Endometriosis and infertility: a review of the pathogenesis and treatment of endometriosis-associated infertility

Virtual reality-based pain control in endometriosis: a questionnaire-based pilot study of applications for relaxation and physical activity

PURPOSE

Virtual reality (VR) based technology may offer new avenues in the management of chronic endometriosis-related pain. Our prospective, 14-week, open, three-phase, cross-over pilot study investigated whether the use of VR technology equipped with a relaxation-inducing application (VR-R) or an activity-stimulating application (VR-A) could change endometriosis-related chronic pelvic pain levels and impairment of daily life.

METHODS

23 women aged 32.7 (SD 8.2) with endometriosis-related pelvic pain were each assigned to a permutated sequence of three 4-week phases: (A) the VR-R, (B) VR-A, and (C) intervention-free control phases. Phases were separated by two interspersed 1-week washout phases. Main outcome measures included: momentary, average, and maximum pain intensities on a 0-10 numerical rating scale (NRS); the Pain Disability Index (PDI) score; the Pain Catastrophizing Scale (PCS) score; sleep quality (Medical Outcomes Study Sleep Scale (MOS-SS) score); the Depression Anxiety Stress Scales (DASS) score; and the general health-related quality-of-life score (Short Form (12) Health Survey (SF-12)).

RESULTS

Compared to baseline, VR-R use showed statistically significant positive effects for several scores (NRS "average pain"; PDI "total score"; PCS "total score" and the "magnification", "rumination", and "helplessness" subscores; MOSS-SS "index I and II"; and the DASS "depression" and "stress" subscores), whereas VR-A yielded significant positive changes only for PDI "total score"; PCS "total score" and the "helplessness" and "magnification" subscores; MOSS-SS "index II"; and DASS "depression" and "stress". As four scale scores also showed significant improvements for control, a comparison of the effects was performed to offset a potential placebo-like effect by comparing difference from baseline against control. This analysis yielded significantly greater positive effects only for VR-R: PCS "total score" and "helplessness"; MOSS-SS "index I" and "index II"; and the three DASS subscores "depression", "anxiety", and "stress". SF-12 showed no significant changes in either analysis.

CONCLUSIONS

VR-R and VR-A showed positive effects on several pain and quality-of-life scores, which were significant for some scores compared to baseline. For VR-R, some of these improvements were indeed significantly greater than under control conditions, while the effects with VR-A were not. Larger studies are needed to corroborate these findings.

TRIAL REGISTRATION

DRKS00030189.

Pharmacokinetic considerations for gonadotropin-releasing hormone agonists and antagonists to treat endometriosis

INTRODUCTION

Endometriosis is a chronic disease characterized by endometriotic cells implanted outside the uterus triggering a chronic inflammatory state. Estradiol stimulates the endometriotic implants, which overexpress estrogen receptor□. Lowering estradiol levels to a range within 40-50 pg/ml allows antagonizing the growth of endometriotic implants and counteracting its-related disabling symptoms.

AREAS COVERED

By blocking the Gonadotropin-Releasing-Hormone (GnRH) receptors, GnRHagonists, peptide GnRHantagonists, non-peptide GnRHantagonists induce hypoestrogenism, due to the suppression of pituitary gonadotropins. This manuscript provides the results of an electronic literature search on pharmacological features of GnRHagonists and GnRHantagonists to treat endometriosis. Hypoestrogenism-dependent side effects can be counteracted by concomitant estrogen and progestin compounds (add-back-therapy). GnRHagonists chronic administration induces hypoestrogenism after 10-12 days, since initial administrations stimulate gonadotropin rise (flare-up effect). Peptide GnRHantagonists quickly block GnRH-receptors inducing an immediate hypoestrogenism. Similarly to GnRHagonists, their peptide structure impedes the oral administration. The non-peptide GnRHantagonists have the advantage both of being taken orally and inducing a rapid dose-dependent hypoestrogenism.

EXPERT OPINION

GnRHagonists and peptide GnRHantagonists are effective to treat endometriosis, but require complex ways of administration. Non-peptide GnRHantagonists offer more important prospects in the tailored medical treatment of endometriosis, given their rapid onset of action and their oral way of administration.

Predictive factors for spontaneous conception in women with moderate and severe endometriosis following operative laparoscopy: A cohort study

STUDY OBJECTIVE

To externally validate the Endometriosis Fertility Index (EFI) and to assess cumulative spontaneous pregnancy rates in women with moderate to severe endometriosis following fertility-enhancing minimally invasive surgery.

DESIGN

Retrospective cohort study.

SETTING

Tertiary-care center for infertility treatment.

PARTICIPANTS

Women diagnosed with r-ASRM Stage III or IV endometriosis following fertility-sparing surgery between June 2013 and July 2023, and who desired for fertility.

INTERVENTION

Minimally invasive laparoscopy.

MEASUREMENTS AND MAIN RESULTS

The follow-up rate was 76.3 %, with a median duration of 15 months [Range (1-130 months)]. The mean age of women was 28.5 ± 3.8 years. Women with low EFI scores (0-3) had lower cumulative spontaneous pregnancy rates (11.4 % at six months, 17 % at three years) compared to those with higher EFI scores (7-8), who had significantly higher rates (35 % at six months, 84.5 % after three years) (P < 0.001). A similar trend was observed for overall pregnancy rates. Factors negatively correlated with spontaneous pregnancy included lower least function scores (P < 0.001), increasing maternal age (P = 0.003), rASRM scores of 16-40 vs. ≥ 71 (P < 0.001), lower antral follicle count (P = 0.02), and increasing paternal age (P < 0.001). Cystectomy (P = 0.001) was positively associated with spontaneous pregnancy post-surgery. Among the 518 women identified with moderate and severe endometriosis, 395 were followed up, out of which 370 attempted spontaneous conception for at least six months, resulting in a pregnancy rate of 37.3 % (138/370).

CONCLUSION

The current study demonstrated that EFI scores correlate with pregnancy rates, validating the scoring system in a South Asian population. Additionally, clinical factors such as low antral follicle count, and advanced paternal age may be considered to make informed clinical decisions post-surgery for women with advanced endometriosis who wish to conceive.

Association between endometriosis and type and age of menopause: a pooled analysis of 279 948 women from five cohort studies

STUDY QUESTION

What is the association between endometriosis and the type and age of menopause?

SUMMARY ANSWER

Women with endometriosis had a 7-fold increased risk of undergoing surgical menopause rather than natural menopause and were more likely to experience premature or early menopause, both surgically and naturally.

WHAT IS KNOWN ALREADY

Endometriosis is associated with reduced ovarian reserve, but evidence on its relationship with the type of menopause (surgical vs natural) and timing (especially premature and early menopause) is limited. Women with endometriosis are more likely to undergo hysterectomy and/or oophorectomy (either unilateral or bilateral), but the average age of these surgeries remains unclear.

STUDY DESIGN, SIZE, DURATION

The study analysed individual-level data from 279 948 women in five cohort studies conducted in the UK, Australia, Sweden, and Japan between 1996 and 2022.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Women whose menopause type and age could not be determined due to premenopausal hysterectomy with ovarian preservation or use of menopausal hormone therapy were excluded. Endometriosis was identified through self-reports and administrative data. Surgical menopause was defined as premenopausal bilateral oophorectomy. Fine-Gray subdistribution hazard models estimated hazard ratios (HRs) for surgical and natural menopause. Age at menopause was determined by the ages at the final menstrual period or bilateral oophorectomy. Linear regression assessed mean differences in menopause age, while multinomial logistic regression estimated odds ratios (ORs) for categorical menopause age: <40 (premature), 40-44 (early), 45-49, 50-51 (reference), 52-54, and ≥55 years. Spontaneous premature ovarian insufficiency (POI) was defined as natural menopause before age 40 years.

MAIN RESULTS AND THE ROLE OF CHANCE

Endometriosis was identified in 3.7% of women. By the end of follow-up, 7.9% had surgical menopause and 58.2% experienced natural menopause. Using a competing risk model, women with endometriosis had a 7-fold increased risk of surgical menopause (HR: 7.54, 95% CI 6.84, 8.32) and were less likely to experience natural menopause (HR: 0.40, 95% CI 0.33, 0.49). On average, surgical menopause occurred 1.6 years (19 months) earlier (β: -1.59, 95% CI -1.77, -1.42) in women with endometriosis. Among women who experienced natural menopause, it was 0.4 years (5 months) earlier (β: -0.37, 95% CI -0.46, -0.28) for those with endometriosis. Women with endometriosis were twice as likely to experience premature surgical menopause (<40 years) (OR: 2.11, 95% CI 2.02, 2.20) or 1.4 times more likely to develop spontaneous POI (OR: 1.36, 95% CI 1.17, 1.59). They were also at increased odds of early surgical and natural menopause (40-44 years).

LIMITATIONS, REASONS FOR CAUTION

This study could not differentiate between subtypes and stages of endometriosis or assess treatments for ovarian endometrioma, which may impact ovarian reserve. Self-reported menopause type and age could introduce recall bias.

WIDER IMPLICATIONS OF THE FINDINGS

Given the consistent findings across individual studies, our results are likely to be generalizable to different populations, highlighting the need for tailored management of endometriosis to prevent medically induced or premature menopause. Long-term monitoring of women with endometriosis is recommended, given their elevated risk of surgical menopause and premature or early menopause, which are associated with adverse health outcomes in later life.

STUDY FUNDING/COMPETING INTEREST(S)

The InterLACE Consortium is funded by the Australian National Health and Medical Research Council project grant (APP1027196) and Centres of Research Excellence (APP1153420). G.D.M. is funded by the Australian National Health and Medical Research Council Leadership Fellowship (APP2009577). This research is funded in part by the Japan Society for the Promotion of Science (JSPS KAKENHI: 19KK0235, 23KK0167). The authors have no conflict of interest. Where authors are identified as personnel of the International Agency for Research on Cancer or WHO, the authors alone are responsible for the views expressed in this article, and they do not necessarily represent the decisions, policy, or views of the International Agency for Research on Cancer or WHO.

TRIAL REGISTRATION NUMBER

N/A.

From infection to infertility: a review of the role of human papillomavirus-induced oxidative stress on reproductive health and infertility

Infertility has emerged as a significant global health concern, affecting nearby 8-12% of couples in reproductive age worldwide. Increasing evidence suggests a potential link between human papillomavirus (HPV) and infertility in both men and women. Some research indicate that HPV can infect various components of semen, potentially affecting sperm quality by decreasing motility, viability, and increasing DNA fragmentation, all of which may contribute to male infertility. The virus can attach to the equatorial region of the sperm head, enabling infected sperm to transmit the virus to the oocyte or placenta. Consequently, HPV potentially induces apoptosis in trophoblastic cells and disrupts their adhesion to endometrial cells, which raises the risk of miscarriage. HPV may also affect ovarian reserve by causing chronic inflammation, which can impair granulosa cell function and lower serum anti-Müllerian hormone (AMH) levels. Besides, HPV-related immune responses also contribute to infertility by producing anti-sperm antibodies (ASAs), which cause sperm clumping, reduce motility through cervical mucus, activate the complement system that damages sperm in the female reproductive tract and interfere with sperm-egg interactions. Moreover, HPV infection has been linked to reduced success rates in assisted reproductive technologies (ART), potentially disrupting critical processes such as the acrosome reaction, sperm-oocyte interaction, and fusion. One potential mechanism through which HPV contributes to infertility is oxidative stress (OS). Triggered OS can negatively impact sperm quality and cause damage to the female reproductive system, ultimately contributing to infertility. Despite these associations, the precise mechanisms and the strength of the relationship remain uncertain. Thus, this review seeks to investigate the potential impact of HPV on infertility, particularly its effects on the reproductive system through OS. A clearer understanding of these processes could inform future health strategies for addressing HPV-related infertility.

Identification of fatty acid metabolism hub genes in endometriosis using integrative bioinformatics analysis

Background

Fatty acid metabolism plays a major role in several inflammatory diseases such as endometriosis. However, its specific mechanism in endometriosis remains unclear. Therefore, this study aimed to investigate the hub genes involved in endometriosis and fatty acid metabolism using bioinformatics analyses.

Methods

The R package sva was used to remove batch effects from the GSE120103 and GSE25628 datasets, resulting in the creation of a combined GEO dataset. Differential analysis of the combined GEO dataset was interposed with fatty acid metabolism-related genes. Differentially expressed genes associated with fatty acid metabolism (FAMRDEGs) were subsequently identified. Functional enrichment analyses were performed using the clusterProfiler package, whereas gene set enrichment analysis (GSEA) was used to identify significant pathways. Protein-protein interaction (PPI) networks were constructed using STRING and visualized using Cytoscape to identify hub genes. Moreover, regulatory networks involving transcription factors and microRNAs were constructed using ChIPBase and ENCORI databases, respectively. Hub genes were validated via expression comparison and receiver operating characteristic curve analysis.

Results

We identified 405 DEGs in the combined dataset, including 168 and 237 with upregulated and downregulated expression, respectively. Of these, 17 were FAMRDEGs. These genes were significantly involved in arachidonic acid and fatty acid metabolic processes. GSEA highlighted pathways such as Hamai_apoptosis_via_trail_dn for genes whose expression was downregulated, along with nuclear receptors in lipid metabolism and toxicity for genes with upregulated expression. The PPI network identified six hub genes: PTGS2, CYP2C9, HSDL2, HSD17B3, ACSL4, and CYP2C18. ACSL4 showed the strongest positive correlation with immune cell effector memory CD8 T cells, whereas HSDL2 showed the strongest negative correlation with immune cell-activated CD8 T cells.

Conclusion

The identified hub genes may be potential biomarkers of fatty acid metabolism in endometriosis. This reveals the potential molecular mechanisms underlying this metabolic process and identifies therapeutic targets for future interventions.

Imaging of endometriosis-related infertility

Endometriosis is a common cause of subfertility and infertility through myriad mechanisms. Imaging of endometriosis is critical for its diagnosis, characterization, and treatment. Understanding its imaging appearance, surgical management, and implications for assisted reproductive therapy is essential to providing the most clinically relevant and impactful reports in endometriosis patients. This manuscript will review imaging techniques used to diagnose and characterize endometriosis-related infertility. We will describe relevant imaging findings by anatomic site and review the impact of surgery and ART on its appearance.

PARP-2 acts on ILK signaling and pharmacological targeting of PARP-2 ameliorate endometriosis in a mouse model

Endometriosis, an endocrine disorder in reproductive-aged women with an occurrence of ∼10 %, gives rise to inflammation, pelvic pain, menstrual irregularity, infertility, etc. One study demonstrated the elevated plasma level of PARP during endometriosis. Thus, we studied the role of PARP-2 during endometriosis using human endometriotic tissue and cells along with an endometriosis mouse model. We found an increased expression level of PARP-2 in the endometriotic tissue from human endometriosis patients, likewise in the endometriotic cells, 12Z and mouse model. The expression level of PARP-2 was suppressed by progesterone (P4) in the immortalized human endometriotic cells (IHECs). However, the danazol (100 mg/kg body weight) treatment reduced the lesion size, but not the expression level of PARP-2 in the endometriotic lesion from the mouse model. PARP-2 inhibition by UPF-1069 (5 mg/kg b. wt.) treatment in the mouse model of endometriosis reduced the endometriotic lesion area. During ovulation and letrozole (1 mg/kg b.wt.) treatment in the endometriosis SD rat model, the expression level of PARP-2 was high. The cell aggregation, a spheroid formation assay using IHECs was reduced by PARP-2 inhibition. The inflammatory chemokines, CCL-11 and -22, GSK-3beta and ILK were downregulated in IHECs by PARP-2 inhibitor (10 μM). Transient overexpression of ILK in endometriotic cells showed reduced levels of PARP-2 and GSK-3beta. In conclusion, PARP-2 is upregulated in the endometriotic tissue in response to estradiol (E2) and inhibition of it pharmacologically reduced the IHECs congregation and the endometriotic lesion, possibly affecting the inflammatory response via ILK-GSK-3beta, in the mouse model and human endometriotic cells.

Effect of dietary patterns and nutritional supplementation in the management of endometriosis: a review

Endometriosis is an estrogen-dependent chronic inflammatory disease which causes dysmenorrhea, chronic pelvic pain, and infertility in women of childbearing age, significantly impacting their quality of life and physical and mental health. The etiology of endometriosis remains unclear, with oxidative stress and inflammation currently thought to play pivotal roles in its pathophysiology. Epidemiological studies and clinical trials indicate that varying dietary patterns and specific nutrient supplementation can influence oxidative stress markers and levels of inflammatory factors and related pathways, potentially impacting the progression of endometriosis. In this review, we summarize the roles of oxidative stress and inflammation in endometriosis and thoroughly examine the current understanding of the effect of dietary patterns and nutrient supplementation in treating endometriosis. This study suggests that nutrients may prevent the occurrence of endometriosis by modulating levels of inflammatory factors, regulating angiogenesis, and influencing the metabolism of estrogen pathways. The findings might provide new insights into the treatment of endometriosis patients and the potential benefits of dietary patterns and nutrient supplementation in patients with endometriosis.

Endometriosis and Infertility: Gynecological Examination Practical Guide

Endometriosis, a prevalent gynecological condition affecting 10-15% of reproductive-age women, involves the growth of endometrial-like tissue outside the uterine cavity. This chronic inflammatory disease can significantly impact fertility by disrupting ovulation, tubal transport, and implantation. Clinical manifestations vary widely, ranging from asymptomatic cases to severe pelvic pain, dysmenorrhea, and dyspareunia. Accurate diagnosis remains challenging, often requiring a combination of patient history, clinical examination, and imaging studies. This paper will discuss the clinical approach to endometriosis during a first-line gynecological appointment, focusing on patient history, including detailed assessment of menstrual, pelvic, and bowel symptoms, and clinical examination; thorough gynecological examination, including abdominal and pelvic palpation, speculum examination, and bimanual examination; imaging evaluation (particularly of the role of ultrasound in identifying and characterizing endometriotic lesions, including the use of the #ENZIAN classification for deep infiltrating endometriosis and evaluation of fertility impact); and discussion of the Endometriosis Fertility Index (EFI) as a tool for assessing fertility potential. This comprehensive approach aims to guide clinicians in identifying and managing endometriosis effectively, improving patient outcomes and optimizing fertility management strategies. Methods: A literature search for suitable articles published from January 1974 to 2024 in the English language was performed using PubMed. Results: Endometriosis is associated with infertility rates ranging from 20% to 68%, with mechanisms including pelvic adhesions, chronic inflammation, and immune dysregulation. The revised American Society for Reproductive Medicine (rASRM) classification and #ENZIAN classification were identified as essential tools for staging and characterizing the disease. Transvaginal ultrasound (TVS) demonstrated high diagnostic accuracy for deep infiltrating endometriosis, with a sensitivity of up to 96% and specificity of 99%. EFI emerged as a valuable predictor of natural conception post-surgery. Additionally, the review underscores the frequent co-occurrence of adenomyosis in women with endometriosis, which may further compromise fertility. Despite advancements in imaging techniques and classification systems, the variability in symptom presentation and disease progression continues to challenge early diagnosis and effective management. Conclusions: Endometriosis is a prevalent gynecological condition affecting women of reproductive age and is associated with infertility. This paper describes the diagnostic approach to endometriosis during a first-line gynecological appointment, focusing on clinical history, physical examination, and the role of imaging, particularly ultrasound, in identifying and characterizing endometriosis lesions. The adoption of standardized classification systems such as #ENZIAN and EFI enhances disease staging and fertility prognosis, allowing for tailored treatment strategies. Despite improvements in non-invasive diagnostic methods, challenges persist in correlating symptom severity with disease extent, necessitating continued research into biomarkers and novel imaging techniques. Additionally, the frequent coexistence of adenomyosis further complicates fertility outcomes, underscoring the need for comprehensive management strategies. Further research is needed to enhance early detection strategies and optimize fertility preservation techniques for affected women.

Investigating The Rate of Pregnancy Success after Endometriosis Surgery in Infertile Patients with Advanced Endometriosis: A Retrospective Study

BACKGROUND

This study aims to determine the effect of laparoscopic surgery for advanced endometriosis on spontaneous pregnancy rates and assisted reproductive techniques (ARTs) in patients with endometriosis.

MATERIALS AND METHODS

This retrospective study included 74 reproductive-aged patients who were diagnosed with deep infiltrating endometriosis (DIE), desired to conceive, and underwent resection surgery at the Arash Women's Hospital, Tehran, Iran between March 2017 and March 2021. Patients with any plausible infertility factors or abnormalities in their partner's semen analysis were excluded. At least 6 months after surgery, the patients were contacted by phone to evaluate the success rate of pregnancy in patients and by which approach they were convinced, i.e., naturally, ovulation induction, or using ARTs. Besides, the impact of patients's factors on pregnancy success was evaluated.

RESULTS

During 3 years after surgery, 37 patients (50%) became pregnant. Out of the 37 pregnancies, 16 patients (43.2%) conceived spontaneously, while 21 patients (56.8%) used ARTs. The mean age of women who became pregnant was significantly lower than those who did not conceive. These two groups do not show any significant differences in terms of endometriosis stage, the maximum size of the cyst, DIE nodule type, and the number and anatomical places of nodules. Additionally, patients who benefit from ART are more likely to have adenomyosis.

CONCLUSION

DIE surgery is associated with a considerable fertility rate. It is also important to note that patient age plays a significant role in the pregnancy rate of this population. Further randomized clinical trials are required to validate the obtained results.

The Molecular and Cellular Mechanisms of Endometriosis: From Basic Pathophysiology to Clinical Implications

Endometriosis is a complex gynecological disorder characterized by endometrial-like tissue growing outside the uterus, leading to chronic pain, infertility, and reduced quality of life. Its pathophysiology involves genetic, epigenetic, immune, and molecular factors. Theories such as retrograde menstruation, coelomic metaplasia, and stem cell involvement explain lesion formation. Endometrial mesenchymal stem cells (eMSCs) and epithelial progenitors (eEPs) contribute to lesion establishment by adhering to peritoneal surfaces, proliferating, and differentiating into ectopic tissue. Aberrant adhesion molecules, inflammatory cytokines, and molecular pathways like PI3K/Akt and Wnt/β-catenin drive proliferation, angiogenesis, and resistance to apoptosis. Elevated estrogen levels and progesterone resistance further promote lesion growth and immune evasion. Immune dysfunction, including altered macrophage activity and reduced natural killer (NK) cell function, contributes to inflammation and lesion persistence. Pain is linked to prostaglandin E2 (PGE2) and nerve infiltration, emphasizing the need for targeted pain management. Current therapies, such as GnRH agonists, suppress ovarian hormone production but face limitations in long-term efficacy and side effects. Integrating molecular insights into clinical practice may advance diagnostics and treatment, with emerging approaches focusing on molecular pathways, immune modulation, and hormonal regulation for more effective, personalized therapies. Future research should unravel the complex mechanisms driving endometriosis to improve patient outcomes.

Love Thy Neighbor? Exploring Gastroenterology Attitudes Toward Endometriosis Screening

Endometriosis is a chronic painful condition affecting 10% of reproductive-aged women with a high prevalence of overlapping gastrointestinal symptoms. There is a significant diagnostic delay for endometriosis and current screening practices for endometriosis in gastroenterology clinic populations have not been evaluated. 112 gastroenterology providers (57.5% females, 64.3% physicians) completed an anonymized exploratory survey (40.1% response rate). Most respondents (59.4%) currently do not screen for endometriosis, but the majority (72.1%) reported they would be "extremely likely" or "somewhat likely" to screen for endometriosis after being presented with data on the high prevalence of chronic GI symptoms in patients with endometriosis.

Effect of endometriosis-linked microRNAs on hepatic gene expression

OBJECTIVE

To determine if microRNAs that are altered in the circulation of women with endometriosis affect metabolic gene expression in hepatic cells.

DESIGN

In vitro study.

SUBJECTS

Deidentified tissue from women with endometriosis.

INTERVENTION

MicroRNAs were used to induce or suppress target genes in hepatic cells.

MAIN OUTCOME MEASURES

Effect of the microRNAs that are aberrantly expressed in endometriosis on hepatic cell gene expression using quantitative polymerase chain reaction.

RESULTS

Prior microarray studies on the serum of women with endometriosis showed differential expression of microRNAs miR-Let-7b, miR-125b-5p, miR-150-5p, and miR-3613-5p. Bioinformatic analyses revealed that these microRNAs have predicted binding sites in multiple genes involved in liver metabolism. Transfection of these miRs in HepG2 cells followed by real-time quantitative polymerase chain reaction showed that miR-Let-7b mimic increased the expression of Igfbp1 by 8-fold and reduced the expression of Mrc1 by 3.2-fold, whereas its inhibitor reduced Igfbp1 by 2.8-fold and increased Mrc1 by 5.2-fold. MiR-3613-5p mimic reduced the expression of Cyp2r1 by 2.2-fold and Mrc1 by 4-fold. MiR-125b-5p mimic increased the expression of Fabp4 by 4.1-fold, whereas miR-150-5p mimic increased the expression of Mrc1 by 1.8-fold and Cyp2r1 by 2.5-fold. Inhibitors of both miR-125b-5p and miR-150-5p did not show any effect on any of the genes.

CONCLUSION

Circulating microRNAs, known to be aberrant in endometriosis-regulated hepatic gene expression, likely contribute to the metabolic defects seen in this disease. Treatment with miR-Let-7b and miR-3613-5p, which are downregulated in endometriosis, reversed the effect of endometriosis on the expression of IGFBP1, MRC1, and CYP2r1 genes. Therefore, miR-Let-7b and miR-3613-5p may be novel candidate therapies for endometriosis, potentially correcting the metabolic changes seen in patients with endometriosis.

Two patients with endometriosis require peripregnancy surgical treatment for pelvic abscesses after egg collection and embryo transfer

Assisted reproductive technology procedures infrequently cause pelvic abscesses, but the risk is higher in patients with endometriosis. If antibiotic treatment of a pelvic abscess is unsuccessful, surgery is required-even during pregnancy. We report two patients with endometriosis who suffered from pelvic abscesses formed after egg collection and embryo transfer. Patient 1 underwent laparoscopic resection of the left adnexa and right ovarian cystectomy after diagnosis of the implantation failure. Surgical findings showed severe adhesions in the pelvis due to endometriosis. Patient 2 underwent open drainage surgery at 11 weeks of pregnancy due to pan-peritonitis caused by a pelvic abscess. The patient delivered at 36 weeks of gestation. We conclude that egg collection and embryo transfer in patients with endometriosis confers a high risk for pelvic infection. An accurate diagnosis and appropriate treatment, including surgery, are mandatory in case of severe pelvic abscesses during pregnancy to save both mother and fetus.

Chronic Endometritis and Endometriosis: Two Sides of the Same Coin?

Both chronic endometritis and endometriosis are common entities in infertile patients. The association and the co-existence of these two entities are poorly evaluated. The aim of this systematic review and meta-analysis was to examine the association between chronic endometritis and endometriosis and to find the prevalence of chronic endometritis in women with endometriosis. A systematic electronic search was conducted using the MEDLINE, Scopus and Cochrane databases up to May 2022. Observational studies which examined the prevalence of chronic endometritis in women with endometriosis were included. Newcastle-Ottawa Scale was used for the quality assessment. Odds ratios (OR) with 95% confidence intervals (CIs) for dichotomous outcomes and pooled prevalences with 95% CIs were calculated. 855 studies were identified, of which six studies were included in the systematic review and five in the meta-analysis. The prevalence of chronic endometritis in women with endometriosis was 28%, with higher frequency observed in women with endometriosis rASRM stage III-IV (43%) in comparison to women with endometriosis rASRM stage I-II (25%). The meta-analysis showed a significantly higher chronic endometritis in women with endometriosis in comparison to the control group (five studies, 264 endometriosis vs. 435 control, OR = 2.07; 95% CI 1.11-3.84, I2 43%, p = 0.02). The present meta-analysis showed a significantly higher risk of chronic endometritis in women with endometriosis in comparison to the control group. These findings contribute to a better understanding of the causes and consequences of endometriosis and chronic endometritis and may help in the development of more efficient treatment strategies for women with associated infertility.

Endometriosis Presenting as a Rare Cause of Intestinal Perforation: A Case Report With Literature Review

This case report details a 39-year-old woman with a history of endometriosis who presented with severe abdominal pain, vomiting, and nausea, leading to a diagnosis of intestinal perforation caused by endometriosis. The patient underwent emergency surgery to resect the perforated bowel and an adjacent mass. Pathology confirmed the presence of endometrial tissue within the intestinal wall. This case underscores the importance of considering endometriosis in the differential diagnosis of acute abdominal pain, particularly in women with a history of the disease. Early diagnosis and prompt surgical intervention are crucial for managing this potentially life-threatening complication.

Comparison of chromatin accessibility remodeling of granulosa cells in patients with endometrioma or pelvic/tubal infertility

PURPOSE

To elucidatethe epigenetic alteration associated with impaired oogenesis in endometrioma using multi-omic approaches.

METHODS

ATAC-seq was performed on the granulosa cells (GCs) of 6 patients (3 with endometrioma and 3 without). Follicular samples from another 20 patients (10 with endometrioma and 10 without) were collected for mRNA-seq analysis of GCs and extracellular vesicles (EVs) of follicular fluid. qRT-PCR validated candidate genes in GCs from 44 newly enrolled patients (19 with endometrioma and 25 without). mRNA abundance was compared with the Mann-Whitney test. Pearson's correlation analyzed relationships between candidate genes and oocyte parameters.

RESULTS

Chromatin accessibility and gene expression profiles of GCs from endometrioma patients differed significantly from the pelvic/tubal infertility group. RNA-seq revealed most differentially expressed genes were downregulated (6216/7325) and enriched in the cellular localization pathway. Multi-omics analyses identified 22 significantly downregulated genes in the GCs of endometrioma patients, including PPIF (P < 0.0001) and VEGFA (P = 0.0148). Both genes were further confirmed by qRT-PCR. PPIF (r = 0.46, p = 0.043) and VEGFA (r = 0.45, p = 0.048) correlated with the total number of retrieved oocytes.

CONCLUSIONS

GC chromatin remodeling may disrupt GC and EV transcriptomes, interfering with somatic cell-oocyte communication and leading to compromised oogenesis in endometrioma patients.

The impact of endometriosis on patients' quality of sexual life

The objective of this study was to evaluate the prevalence and impact of female sexual dysfunction and sexual distress in women with endometriosis. This retrospective, analytical, observational study included patients diagnosed with ovarian endometriomas who underwent surgery to remove endometriosis lesions. The impact of endometriosis on the quality of sexual lives of patients before and after surgery was analyzed using a self-administered questionnaire consisting of 20 closed-ended questions. The study included 70 patients with endometriosis with a mean age of 32.70 ± 7.39 years. The majority of patients reported that the diagnosis of endometriosis negatively influenced their quality of sexual life (65.7%). Most patients (88.6%) experienced dyspareunia before surgery. A total of 36 patients (51.4%) stated that they had difficulty in obtaining pleasure during sexual intercourse. The intensity of dyspareunia had an important negative effect on the quality of sexual life of the patients. Following surgery, most patients (81.4%) reported improvements in their sexual quality of life, with a statistically significant reduction in pain intensity during intercourse (P < 0.001). These findings suggest that endometriosis may contribute to sexual avoidance and diminished pleasure. Surgical removal of endometriosis lesions significantly improved sexual quality of life, particularly by reducing dyspareunia intensity.

Progesterone receptor status predicts aggressiveness of human endometriotic lesions in murine avatars

OBJECTIVE

To use murine avatars for studying human endometriotic lesion response to 2 different hormonal regimens to determine whether progesterone receptor (PR) can prospectively predict response to progestin-based therapy. Endometriosis is a chronic gynecologic disease afflicting 1-in-10 reproductive-age women; however response to medical therapy is highly variable because endometriotic lesions do not consistently respond to first-line progestin-based therapy. We have previously demonstrated in a retrospective study that PR status in lesions is correlated with response to progestins. Here, we hypothesize that a prospective approach using PR status to predict response to medical will allow clinicians to individualize effective, timely treatment for this debilitating disease.

DESIGN

Patient-derived xenograft murine model.

SUBJECTS

Eight-week old NOD/SCID mice undergoing transplantation of endometrioma lesions collected from women undergoing surgery for endometriosis.

EXPOSURE

Daily subcutaneous injections with vehicle (dimethyl sulfoxide), medroxyprogesterone acetate (MPA), or gonadotropin-releasing hormone (GnRH) antagonist, cetrorelix, for 1 month.

MAIN OUTCOME MEASURES

Lesion size 1 month after treatment.

RESULTS

Lesions with high PR demonstrated a robust response to MPA compared with lesions with low PR. The mean post-MPA treatment size in high-PR lesions was sixfold smaller than that in low-PR lesions. Low-PR lesions respond far more completely to GnRH antagonist than to MPA. Surprisingly, there were differences in response to GnRH antagonist between low- and high-PR lesions. High-PR lesions responded almost completely to GnRH antagonist with a 21-fold smaller posttreatment size on average than low-PR lesions.

CONCLUSIONS

The use of murine avatars to test clinical response is a novel approach in endometriosis. Hormonal suppression of disease is a cornerstone of therapy; however, response is not fully predictable. We have previously shown that women with low-PR lesions respond poorly to progestin-based therapy. Here, we prospectively validate our previous work using a mouse xenograft model, demonstrating that lesions with low-PR expression do not respond to progestin-based therapy; PR status predicted response to progestin-based therapy. Moreover, PR status identifies a more aggressive form of endometriosis that is not only progesterone resistant but is also less dependent on estradiol for growth. Our findings highlight the need to develop novel nonhormonal therapies aimed at targeting the more aggressive forms of endometriosis that do not rely on the usual hormonal signals.

The ignored structure in female fertility: cilia in the fallopian tubes

Cilia in the fallopian tubes (CFT) play an important role in female infertility, but have not been explored comprehensively. This review reveals the detection techniques for CFT function and morphology, and the related analysis of female infertility and other gynaecological disorders. CFT differentiate from progenitor cells, and develop into primary cilia and motile cilia. Primary cilia coordinate multiple signalling pathways, and motile cilia produce laminar flow through bidirectional intraflagellar transport, which drives the movement of oocytes and gametes. Several methods for quantitative detection and protein analysis have been used to explore the factors contributing to the decrease in ciliary beat frequency (CBF), and the cellular mechanism of ciliary cell death and shedding. In both primary and secondary ciliary disorders associated with reproductive diseases, abnormal alterations in ciliary quantity, ciliary structure, CBF and ciliary signalling pathways result in abnormal tubal laminar flow, and diminished oocyte retrieval and transport capabilities.

A Narrative Review Regarding Implication of Ovarian Endometriomas in Infertility

Endometriosis is a multifaceted gynecological disorder defined by endometrium-like tissue outside the uterine cavity. It is mainly localized in the pelvis and creates a local inflammatory environment responsible for its manifestations and complications. In 30-50% of cases, endometriosis is associated with infertility. In 17-44% of cases, the ovaries are affected in the form of ovarian endometriomas (OEs). The symptoms of OEs are not very pronounced. The development is slow. Diagnosis is difficult because OEs resemble cystic ovarian pathology, which is so diverse. The actual diagnosis is possible through direct visualization or laparoscopy. Surgical treatment by cystectomy is common for OEs. Recently, other therapeutic modalities have emerged that have less impact on ovarian reserves and pregnancy rates. In this context, the review attempts to shed light on the best diagnostic and treatment methods for an insidious pathology with a major impact on fertility.

Oxidative Stress and the NLRP3 Inflammasome: Focus on Female Fertility and Reproductive Health

Chronic inflammation is increasingly recognized as a critical factor in female reproductive health; influencing natural conception and the outcomes of assisted reproductive technologies such as in vitro fertilization (IVF). An essential component of innate immunity, the NLR family pyrin domain-containing 3 (NLRP3) inflammasome is one of the major mediators of inflammatory responses, and its activation is closely linked to oxidative stress. This interaction contributes to a decline in oocyte quality, reduced fertilization potential, and impaired embryo development. In the ovarian milieu, oxidative stress and NLRP3 inflammasome activation interact intricately, and their combined effects on oocyte competence and reproductive outcomes are significant. The aims of this review are to examine these molecular mechanisms and to explore therapeutic strategies targeting oxidative stress and NLRP3 inflammasome activity, with the goal of enhancing female fertility and improving clinical outcomes in reproductive health.

Serum copper to zinc ratio and risk of endometriosis: Insights from a case-control study in infertile patients

Purpose

Endometriosis is a prevalent gynecological disorder, yet data on the role of trace metal elements in its risk remain limited. We aimed to investigate the relationship between serum copper (Cu), zinc (Zn), iron (Fe), magnesium (Mg) levels, and the Cu/Zn ratio with the risk of endometriosis.

Methods

This study involved 568 infertile patients diagnosed with endometriosis, compared to 819 infertile patients without endometriosis (Control group). Basic characteristics, hormonal parameters, and essential trace elements of the patients were measured and analyzed.

Results

The findings indicated a notable decrease in serum Zn levels in the endometriosis group compared to controls, alongside a significant increase in the Cu/Zn ratio (p < 0.001). Restricted cubic spline (RCS) analysis revealed a linear relationship between Zn levels and the Cu/Zn ratio and endometriosis risk. Moreover, Zn levels exhibited a negative correlation with endometriosis risk (p trend = 0.005), while the Cu/Zn ratio displayed a positive correlation with endometriosis risk, even after adjusting for age, body mass index (BMI), and baseline hormones (p trend < 0.001). Compared to the first quartile of Cu/Zn ratio after adjustment, the odds ratios (ORs) with 95% confidence intervals (CIs) for the second and fourth quartiles were 1.97 (1.37, 2.83) and 2.63 (1.80, 3.84), respectively.

Conclusions

This study provided evidence of decreased serum Zn levels and an increased Cu/Zn ratio being associated with an elevated risk of endometriosis among infertile patients. These findings offer valuable real-world data, enriching our understanding of endometriosis.

Endoplasmic reticulum stress of endometrial mesenchymal stem cells in endometriosis

OBJECTIVE

The human endometrium has significant regenerative abilities due to stem cells, which are vital in immunomodulation, immune tolerance, steroid hormone response, and inflammation. Endometriosis, an inflammatory gynecological disorder where endometrium-like tissue grows outside uterus, affects millions of women and often causes infertility. Recent research indicates that stem cells contribute to pathology of endometriosis. ER stress is implicated in various diseases, including endometriosis. This study aims to examine ER stress in eMSCs within endometriosis pathogenesis and uncover underlying disease mechanisms.

METHODS

Samples were collected from healthy subjects and women with endometriosis in both proliferative and secretory phases. eMSCs were isolated and characterized via flow cytometry. ER stress protein levels were assessed using proteomic analysis, with validation through Western Blot and immunofluorescence staining. Gene expression was analyzed by RT-qPCR, and ultrastructural examination of eMSCs was conducted using TEM. ER stress markers in tissue samples were detected in SUSD2+ eMSCs through immunofluorescence staining and visualized using a confocal microscope. Statistical analysis was performed using SPSS program.

RESULTS

The proteomics analysis uncovered ER stress-related proteins (DDRGK1, RTN3, ERp44, TMED2, TMEM33, TMX3) whose levels were significantly distinct from control group. Western Blot analysis and immunofluorescence staining results at protein level; RT-qPCR results at gene level supported these findings. TEM analysis also showed ultrastructural presence of ER stress in endometriosis groups.

CONCLUSION

Presence of ER stress in eMSCs in pathogenesis of endometriosis has been demonstrated using various methods. Our research has potential to shed light on pathology of endometriosis and offer promising avenues for non-invasive diagnosis and potential treatment.

Effects of various controlled ovarian hyperstimulation protocols and surgery on pregnancy outcomes in women with endometriosis

Endometriosis is a common gynecological condition in women of childbearing age that causes symptoms such as menstrual changes and dysmenorrhea, and is also a major cause of infertility. Therefore, women with endometriosis usually need to use assisted reproductive technology (ART), such as in vitro fertilization or intracytoplasmic sperm injection, to increase their chances of conceiving. Numerous clinical observations and studies have indicated that endometriosis can affect the success of ART, such that women with endometriosis who use ART have a lower live-birth rate than those without endometriosis who use ART. Therefore, this article reviews the impact of various controlled ovarian hyperstimulation protocols and surgery on the pregnancy outcomes of women with endometriosis using ART to explore the selection of individualized treatment.

Oocyte cryopreservation for women with endometriosis: Justification, indications, and reproductive outcomes

Women with endometriosis often experience diminished ovarian reserve and a decreased number of oocytes retrieved. This reduction is exacerbated after surgery. Nevertheless, oocyte quality does not seem to be compromised in these patients. When embryos of good quality are obtained, in vitro fertilization outcomes are generally satisfactory. Oocyte cryopreservation may represent a fertility preservation option for women with planned and/or prior surgery, as it enables the collection of oocytes in advance. Given the diverse manifestations of endometriosis, which vary by type, age, and ovarian reserve, the decision to pursue oocyte cryopreservation should be weighed individually. Moreover, the potential benefits of this approach on future fertility must be carefully considered. Considering current guidelines, the most appropriate candidates for oocyte cryopreservation among women with endometriosis are: patients with bilateral endometriomas, typically larger than 3 cm; those with prior surgery for unilateral endometrioma who exhibit ipsilateral or contralateral recurrence; and those with unilateral endometrioma on a single ovary. However, the size criteria for endometrioma warrant further discussion. Conversely, oocyte cryopreservation is inadvisable for patients: with unilateral endometrioma smaller than 3 cm and good ovarian reserve; who have undergone surgery for bilateral endometriomas, regardless of recurrence; and who have diminished ovarian reserve. While consensus indicates that decisions regarding diminished ovarian reserve should be individualized, fertility preservation should often be considered for patients with serum anti-Müllerian hormone levels below 0.5 ng/mL. In such cases, a prolonged duration may be necessary to retrieve the desired 10 to 15 oocytes.

MiR-19b-3p inhibits cell viability and proliferation and promotes apoptosis by targeting IGF1 in KGN cells

BACKGROUND

Endometriosis (EM) is a major cause of infertility, but the pathogenesis and mechanisms are not yet fully elucidated. MiR-19b-3p is involved in many diseases, but its functional role in EM-associated infertility remains unexplored. This study aimed to examine miR-19b-3p abundance and IGF1 concentration in cumulus cells (CCs) and follicular fluid of EM-associated infertility patients, and to investigate the potential role of miR-19b-3p in KGN cells by identifying its target and elucidating the underlying mechanisms.

RESULTS

The results from the case-control study indicated that, compared to the control group consisting of patients with tubal infertility, patients with EM-associated infertility exhibited a lower percentage of mature oocytes. MiR-19b-3p level was elevated in CCs from EM-associated infertility patients. IGF1 was identified as a direct target of miR-19b-3p and was negatively regulated by miR-19b-3p in KGN cells. Overexpression of miR-19b-3p significantly inhibited cell viability and proliferation, promoted apoptosis, and arrested the cell cycle at G0/G1 phase in KGN cells. The effects of miR-19b-3p were reversed by co-transfection of IGF1, and the biological effects of miR-19b-3p in KGN cells were mediated by IGF1. Additionally, miR-19b-3p targeted IGF1 to down-regulate AKT phosphorylation and participate in the apoptotic pathway in KGN cells.

CONCLUSIONS

This study demonstrates that miR-19b-3p level is elevated in CCs and IGF1 concentration is decreased in follicular fluid in patients with EM-associated infertility. MiR-19b-3p regulates the biological effects of KGN cells by targeting IGF1.

Evidence based management of patients with endometriosis undergoing assisted conception: British fertility society policy and practice recommendations

Endometriosis is a chronic inflammatory condition in women of reproductive age, which can lead to infertility and pelvic pain. Endometriosis associated infertility is multifactorial in nature adversely affecting each step of the natural reproductive physiology and thereby processes and outcomes of Assisted Reproductive Technology (ART) cycles. These outcomes are further complicated by the subtype of endometriosis, being peritoneal, deep infiltrating and ovarian, which bear negative effects on ovarian reserve, response to stimulation, accessibility for oocyte retrieval, intraoperative safety and endometrial receptivity. There is still a lack of clear guidance about the role of surgery for ovarian endometriosis/endometriomas. This guideline evaluates the evidence of the impact of pelvic endometriosis and endometriomas on the outcome of ART and provides recommendations for management options before and during ART including intra-uterine insemination. Recommendations are made based on the current evidence for the management of patients with endometriosis across each step of ART with the primary aim of improving ART outcomes.

Endometrial expression of ERRβ and ERRγ: prognostic significance and clinical correlations in severe endometriosis

Background

Endometriosis (EMs) results in approximately 50% of reproductive-age women facing infertility. Currently, no precise model is available to predict successful postoperative pregnancy.

Methods

This study involved 81 patients with severe EMs (stages III and IV) and 38 controls with benign gynecological conditions, matched by age and BMI, diagnosis at Fujian Maternity and Child Health Hospital from January 2018 to December 2019. Relative expression levels of ERRβ and ERRγ mRNA in ectopic and ectopic endometrial tissues were measured using fluorescence quantitative PCR. Serum levels of ERRβ, ERRγ, and fertility-related hormones (AMH, FSH, LH, CA125) were assessed. Correlations were analyzed, and the predictive value of ERRγ for postoperative pregnancy was evaluated using a nomogram based on LASSO and multivariate logistic regression. Internal validation using bootstrapping techniques assessed the nomograms performance, including calibration and DCA.

Results

ERRβ and ERRγ mRNA levels from ectopic tissues were significantly reduced in patients with severe EMs compared to controls. High serum CA125 correlated with increased ERRγ mRNA expression in ectopic tissues. ERRγ mRNA expression in ectopic endometrial tissues was negatively correlated with age, BMI, and FSH levels, and positively with AMH and LH/FSH ratio. ERRγ mRNA and FSH were significant predictors of postoperative pregnancy, with the nomogram model showing a Brier score of 0.175 and a consistency statistic of 0.811.

Conclusions

ERRβ and ERRγ are downregulated in ectopic tissues from severe EMs. Elevated ERRγ mRNA expression and lower FSH levels are predictive factors for successful postoperative pregnancy.

Prevalence of thyroid autoantibody positivity in women with infertility: a systematic review and meta-analysis

BACKGROUND

Thyroid autoimmunity (TAI) is associated with infertility and complications during pregnancy. However, the prevalence of thyroid autoantibodies in women with infertility remains unclear due to variability in study designs, sample sizes, and populations. In this meta-analysis, we aimed to assess the prevalence of thyroid autoantibodies in women with infertility compared with that in healthy controls.

METHODS

Systematic searches were conducted across PubMed, Embase, Web of Science, and the Cochrane Library from inception to February 5, 2024. The inclusion criteria were women with infertility and those with autoimmune thyroid antibodies. Studies in which relevant data could not be extracted, randomized control trial reports, studies with non-original or duplicate data, and non-English articles were excluded. The main outcome was prevalence rate.

RESULTS

The worldwide pooled prevalence of thyroid autoantibody positivity was 20%. In contrast, a significantly higher TAI prevalence was noted in the population with infertility than in healthy controls (risk ratio [RR] = 1.51). Subgroup analyses indicated that TAI prevalence was higher in patients receiving both assisted reproductive technology (ART) and non-ART treatments than in healthy controls (RR = 1.37 and 3.06, respectively). TAI prevalence was also higher in the recurrent abortion and non-recurrent abortion groups of infertility than in healthy controls (RR = 1.80 and 1.39, respectively). Additionally, a higher TAI prevalence was found in the euthyroid and non-simple euthyroid groups than in the control group (RR = 2.77 and 1.43, respectively). The prevalence was significantly higher in cases of unexplained infertility, endometriosis, ovulation disorders, and fallopian tube factors among women with infertility than among the control group (RR = 1.53, 1.83, 1.42, and 2.00, respectively).

CONCLUSIONS

Thyroid autoantibodies are more prevalent in patients with infertility than in healthy controls. Given the presence of thyroid autoantibodies, screening patients with infertility is clinically important.

Mesenchymal stem cells and mesenchymal stem cell-derived exosomes: attractive therapeutic approaches for female reproductive dysfunction

Infertility is a reproductive health problem in the male or female reproductive system. Traditional assisted reproductive technology (ART) has been unable to solve various cases of infertility for years. Clinical researchers have sought to treat infertility using new methods that are more effective and noninvasive than the old methods. Recently, Mesenchymal stem cells (MSCs) and MSCs-derived Exosomes (MSC-Exos) via paracrine activity play an important role in treating various causes of infertility and improving pregnancy outcomes. In this review, we focus on the roles of MSCs and MSC-Exos cell therapy in female infertility in the different types of female reproductive disorders.

Novel Minimally Invasive Surgical Approaches to Endometriosis and Adenomyosis: A Comprehensive Review

Endometriosis and adenomyosis are chronic gynecological conditions that significantly impact women's quality of life, leading to symptoms such as pelvic pain, dysmenorrhea, and infertility. Despite ongoing research, a definitive cure for these conditions remains elusive, and treatment often focuses on managing symptoms. Minimally invasive surgery is considered the gold standard for surgical management, but novel surgical techniques are continuously being developed to enhance outcomes. These innovations aim to reduce disease recurrence, improve fertility rates, and provide better long-term symptom relief. In addition, techniques like robot-assisted laparoscopy (RAS) have revolutionized the treatment of complex cases, such as deep infiltrating endometriosis (DIE), offering improved precision and effectiveness. This review explores the latest advancements in surgical approaches, their clinical efficacy, and future directions, emphasizing the need for individualized multidisciplinary care to optimize patient outcomes.

Clinical Factors Affecting the Quality of Life of Women With Endometriosis

AIM

The study aimed to analyse selected clinical data affecting the quality of life of women with endometriosis.

DESIGN

A cross-sectional study.

METHOD

The study was conducted in 2020-2022 among 425 women with endometriosis receiving health care. A diagnostic survey method with a questionnaire technique was used. The research tools are the Endometriosis Health Profile and a standardised interview questionnaire.

RESULTS

Infertility, medical treatment and sexual intercourse were the dimensions of quality of life most poorly rated by respondents with endometriosis. Lower quality of life was linked to the presence of painful periods, the presence of pain during intercourse and having surgery for endometriosis.

CONCLUSION

The main clinical variables influencing the quality of life of women with endometriosis include problems with getting pregnant, the necessity for long-term therapy and sexual problems caused by the condition. The occurrence of painful menstruation, dyspareunia and having undergone surgery for endometriosis is associated with lower ratings of women's general quality of life.

IMPLICATIONS FOR THE PROFESSION

The study will help to develop a more holistic approach to caring for endometriosis patients. This will result in a better diagnosis, individualised therapy and psychological support, all of which will enhance the overall quality of life. The study's results may impact the development of health policies, endometriosis support services for women and public awareness initiatives.

IMPACT

The study highlighted key determinants affecting health-related quality of life for women with endometriosis. The analysis of clinical data revealed that infertility, treatment and dyspareunia are the dimensions of quality of life most poorly rated by women with endometriosis. These findings are significant for those providing care to women with endometriosis, as well as for policymakers responsible for the organisation of health care systems.

REPORTING METHOD

The STROBE guidelines.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution.

R-954, a bradykinin B1 receptor antagonist, as a potential therapy in a preclinical endometriosis model

Endometriosis is a gynecological condition characterized by the growth of endometrium-like tissues outside of the uterine cavity. Currently available drugs are efficacious in treating endometriosis-related pain, however it's not a targeted treatment. The aim of this work is to evaluate the effects of R-954, a bradykinin B1 receptor antagonist, in a murine model of endometriosis. The model was induced in animals through autologous transplantation of part of the uterine horn. After 51 days, it was observed that implants developed into endometriotic lesions. The administration of R-954 or progesterone, for 15 consecutive days, prevented the progression of cyst development, reduced the size and weight of the cysts. Both treatments also reduced cellular infiltrate and production of inflammatory mediators (interleukin-1β, interleukin-6, tumor necrosis factor). However, only R-954 decreased angiogenic factors (VEGF and VEGF receptor). In addition, treatment with the antagonist did not interfere in the females' estrous cycle, as well as prevented gestational losses (reduction in the number of intermediate resorptions in pregnant females with endometriosis). Data suggested that R-954 has anti-inflammatory and anti-angiogenic effects; does not influence the estrous cycle; and prevents the number of gestational losses suggesting it as a good candidate for endometriosis treatment.

A seed or soil problem in early endometriosis: stromal cell origin drives cellular invasion and coupling over mesothelial cell origin

OBJECTIVE

To study the role of the mesothelial cells in early endometriosis lesion formation by assessing in vitro cell-to-cell communication and invasion of endometrial cells across a mesothelial cell monolayer, with both cell types derived from both patients with endometriosis and control patients.

DESIGN

Laboratory-based experimental study.

SETTING

University hospital and laboratory.

PATIENT(S)

Consenting reproductive-age women who underwent laparoscopy for gynecologic reasons and were confirmed to have either endometriosis with pathology tissue diagnosis (n = 8) or no endometriosis n = 8) at the time of surgery.

INTERVENTION(S)

Primary stromal cells cultured from endometrial pipelle biopsies and primary mesothelial cells cultured from peritoneal explants were used in transmesothelial invasion assays and gap junction coupling assays.

MAIN OUTCOME MEASURE(S)

Comparison of potential for lesion formation, using in vitro models, of both primary endometrial and mesothelial cells from patients with endometriosis and control patients, establishing the former as the primary disease driver.

RESULT(S)

When comparing mesothelial cells from control patients with those from patients with endometriosis, there was no significant difference in the amount of stromal cell invasion across either barrier. In contrast, when comparing stromal cell origin, the amount of invasion by endometriosis stromal cells was greater than control stromal cells regardless of whether the mesothelial cell monolayer was derived from patients with the disease or control patients. Additionally, primary mesothelial cells induced more gap junction coupling, a requirement for invasion, in stromal cells from patients with endometriosis than control patients, again independent of mesothelial origin. The notable exception was mesothelial cells derived from endometriotic lesion-affected areas that showed depressed ability to support invasion.

CONCLUSION(S)

Although both endometrial and mesothelial cells need to function for establishment of endometriosis lesions, the endometrium seems to be the key player, serving as an ideal target for diagnostic strategies and therapeutic intervention. While this notion is consistent with previous studies, to our knowledge, we are the first to directly test both primary mesothelial and endometrial cells from patients with endometriosis and control patients to compare propensities for mesothelial invasion.

Infertility Prevention and Health Promotion: The Role of Nurses in Public Health Initiatives

Infertility is a growing public health concern, affecting millions of individuals and couples worldwide. Despite advancements in medical treatments, prevention remains a critical strategy for reducing the burden of infertility. Nurses, as frontline healthcare providers, play a pivotal role in infertility prevention and health promotion, particularly through public health initiatives. This review aims to explore the diverse roles of nurses in infertility prevention and their contributions to public health strategies. A review of existing literature was conducted to examine the epidemiology of infertility, key risk factors, and the preventive measures that can be employed by nursing professionals. Emphasis is placed on the role of nurses in health education, screening, early detection, and community-based interventions, which are essential in reducing infertility rates. In addition, this review identifies barriers that impede effective nurse-led infertility prevention, such as disparities in access to care, cultural sensitivity challenges, and policy constraints. Evidence suggests that nurses are well-positioned to lead public health campaigns, conduct reproductive health counseling, and advocate for policy reforms to improve infertility prevention. The review concludes with recommendations for future research, suggesting enhanced nursing education and training, as well as the need for stronger integration of nurses into public health policy-making. This study underscores the critical role of nurses in promoting reproductive health and preventing infertility, advocating for their inclusion in comprehensive public health strategies aimed at addressing infertility on a global scale.

Per- and Polyfluoroalkyl Substances (PFAS) Affect Female Reproductive Health: Epidemiological Evidence and Underlying Mechanisms

PFAS (per- and polyfluoroalkyl substances) have been extensively used across numerous industries and consumer goods. Due to their high persistence and mobility, they are ubiquitous in the environment. Exposure to PFAS occurs in people via multiple pathways such as dermal contact, water supply, air inhalation, and dietary intake. Even if some PFAS are being phased out because of their persistent presence in the environment and harmful impacts on human health, mixes of replacement and legacy PFAS will continue to pollute the ecosystem. Numerous toxicological investigations have revealed harmful effects of PFAS exposure on female reproductive health, e.g., polycystic ovaries syndrome, premature ovarian failure, endometriosis, reproductive system tumors, pregnancy complications, and adverse pregnancy outcomes. Despite extensive epidemiological studies on the reproductive toxicity of PFAS, research findings remain inconsistent, and the underlying mechanisms are not well understood. In this review, we give an in-depth description of the sources and pathways of PFAS, and then review the reproductive toxicity of PFAS and its possible mechanisms.

The SPRi determination of cathepsin L and S in plasma and peritoneal fluid of women with endometriosis

PURPOSE

Endometriosis is a common disease with a complex pathomechanism and atypical symptoms, often leading to delayed diagnosis. Currently, the sole method for confirming the presence of the disease is through laparoscopy and histopathological examination of collected tissue. However, this invasive procedure carries potential risk and complications, necessitating the exploration of non-surgical diagnostic methods for endometriosis. This study aims to analyze peritoneal fluid and plasma samples for the expression of cathepsin L and cathepsin S to identify potential biomarkers for non-invasive diagnostic approaches to endometriosis.

MATERIAL AND METHODS

In this cross-sectional study, plasma and peritoneal fluid samples were obtained during laparoscopy from 63 patients diagnosed with chronic pelvic pain or infertility. The study group consisted of women with confirmed endometriosis. The concentrations of cathepsins L and S were determined using an SPRi biosensor.

RESULTS

The study did not reveal significant differences in the concentrations of cathepsin L and cathepsin S between the control group and the study group, both in peritoneal fluid and plasma.

CONCLUSIONS

Based on the results of this study, it appears that cathepsins L and S are not suitable candidates as biomarkers for endometriosis.

Indirect markers of oocyte quality in patients with ovarian endometriosis undergoing IVF/ICSI: a systematic review and meta-analysis

This systematic review and meta-analysis aimed to evaluate the impact of ovarian endometriomas (OMA) on indirect markers of oocyte quality in patients undergoing IVF, compared with women without anatomical or functional ovarian abnormalities. The search spanned original randomized controlled trials, case-control studies and cohort studies published in MEDLINE, the Cochrane Controlled Trials Register and the ClinicalTrials.gov database up to October 2023. Thirty-one studies were included in the meta-analysis, showing no significant differences in fertilization (OR 1.10, 95% CI 0.94-1.30), blastulation (OR 0.86, 95% CI 0.64-1.14) and cancellation (OR 1.06, 95% CI 0.78-1.44) rates. However, patients with OMA exhibited significantly lower numbers of total and mature (metaphase II) oocytes retrieved (mean difference -1.59, 95% CI -2.25 to -0.94; mean difference -1.86, 95% CI -2.46 to -1.26, respectively), and lower numbers of top-quality embryos (mean difference -0.49, 95% CI -0.92 to -0.06). The Ovarian Sensitivity Index was similar between the groups (mean difference -1.55, 95% CI -3.27 to 0.18). The lack of data published to date prevented meta-analysis on euploidy rate. In conclusion, although the presence of OMA could decrease the oocyte yield in patients undergoing IVF/intracytoplasmic sperm injection, it does not appear to have an adverse impact on oocyte quality.

The Impact of Laparoscopic Surgery on Fertility Outcomes in Patients with Minimal/Mild Endometriosis

Minimal/mild endometriosis (MME) is independently associated with reduced fecundity rates. In this review article, we discuss the role of laparoscopic surgery in enhancing the fertility outcomes of patients with MME. Laparoscopic management of MME enhances fecundity and increases the chances of spontaneous conception in appropriately selected cases. However, laparoscopy cannot be routinely recommended in asymptomatic patients with the sole purpose of diagnosing and treating potentially present MME. Equally, and based on existing information, the laparoscopic management of MME cannot be routinely recommended prior to in vitro fertilisation (IVF) attempts due to the lack of robust and beneficial evidence. Because an overlap between unexplained infertility and MME cases likely exists, the development of reliable, widely available, non-invasive tests for the diagnosis of MME may revolutionise the management of cases currently classified as unexplained infertility. In a disease as diverse as endometriosis, management decisions should be based on a multitude of factors. Future studies should focus on reporting the outcomes of interventions for MME on fertility and obstetric outcomes, clearly differentiating between disease stages and phenotypes.

Uterine Endometrium Microbiome in Women with Repeated Implantation Failure Complicated by Endometriosis

Objectives: This prospective study evaluated whether endometriosis is associated with chronic endometritis (CE) and affects the uterine endometrium microbiome (UEM) in women with repeated implantation failure (RIF). Methods: Forty-three women with RIF were divided into 12 with endometriosis (EM) and 31 without endometriosis (non-EM). The UEM was examined by 16S ribosomal RNA (rRNA) sequencing, and CE was determined by CD 138 staining (plasma cells > 5.15/10 mm2) simultaneously. Results: The EM group had a higher bacterial number (EM vs. non-EM; median [range], 6.5 vs. 3 [3-11, 1-16], p = 0.009), while the frequency of Lactobacillus species did not change. The rates of presence of Dialister (41.7% [5/12] vs. 3.3% [1/31], p = 0.004) and Streptococcus species (58.3% [7/12] vs. 16.1% [5/31], p = 0.017) were higher in the EM group. The prevalence of CE did not differ between the two groups. Multivariable logistic regression analysis revealed that the presence of Dialister species (odds ratio, 10.97, 95% confidence interval, 1.17-249.37, p = 0.036) was associated with endometriosis. In the EM group, five women with Dialister species had a higher number of bacterial species (10 vs. 5 [6-11, 3-7], p = 0.021) and higher Shannon diversity index (0.50 vs. 0.20 [0.19-1.39, 0.03-0.46], p = 0.026) than seven without Dialister species. Conclusions: Dialister and Streptococcus species, and the increased number of bacterial species in UEM may be related to the pathogenesis of RIF complicated by endometriosis.

Identification of programmed cell death-related genes and diagnostic biomarkers in endometriosis using a machine learning and Mendelian randomization approach

Background

Endometriosis (EM) is a prevalent gynecological disorder frequently associated with irregular menstruation and infertility. Programmed cell death (PCD) is pivotal in the pathophysiological mechanisms underlying EM. Despite this, the precise pathogenesis of EM remains poorly understood, leading to diagnostic delays. Consequently, identifying biomarkers associated with PCD is critical for advancing the diagnosis and treatment of EM.

Methods

This study used datasets from the Gene Expression Omnibus (GEO) to identify differentially expressed genes (DEGs) following preprocessing. By cross-referencing these DEGs with genes associated with PCD, differentially expressed PCD-related genes (DPGs) were identified. Enrichment analyses for KEGG and GO pathways were conducted on these DPGs. Additionally, Mendelian randomization and machine learning techniques were applied to identify biomarkers strongly associated with EM.

Results

The study identified three pivotal biomarkers: TNFSF12, AP3M1, and PDK2, and established a diagnostic model for EM based on these genes. The results revealed a marked upregulation of TNFSF12 and PDK2 in EM samples, coupled with a significant downregulation of AP3M1. Single-cell analysis further underscored the potential of TNFSF12, AP3M1, and PDK2 as biomarkers for EM. Additionally, molecular docking studies demonstrated that these genes exhibit significant binding affinities with drugs currently utilized in clinical practice.

Conclusion

This study systematically elucidated the molecular characteristics of PCD in EM and identified TNFSF12, AP3M1, and PDK2 as key biomarkers. These findings provide new directions for the early diagnosis and personalized treatment of EM.

Endometriosis: A Comprehensive Exploration of Inflammatory Mechanisms and Fertility Implications

Endometriosis is a prevalent gynecological disorder characterized by the ectopic growth of endometrial-like tissue outside the uterus. This condition poses significant challenges due to its chronic nature, debilitating symptoms such as pelvic pain and infertility, and substantial impact on quality of life. Central to the pathogenesis of endometriosis are inflammatory mechanisms that perpetuate tissue proliferation, adhesion formation, and immune dysregulation within the pelvic cavity. Inflammation plays a pivotal role in the development and progression of endometriosis, influencing the severity of symptoms and complications associated with the disease. Dysregulated immune responses contribute to the persistence of ectopic endometrial implants, exacerbating pelvic pain and other symptoms experienced by affected individuals. Moreover, the inflammatory milieu created by endometriotic lesions disrupts normal ovarian function, impairs follicular development, and compromises reproductive outcomes, thereby posing challenges to fertility. This review comprehensively explores the inflammatory mechanisms underlying endometriosis and their implications for fertility. Synthesizing current research and clinical insights elucidates the intricate interplay between inflammation, disease progression, and reproductive health outcomes. Understanding these complex interactions is essential for developing targeted diagnostic strategies and optimizing therapeutic approaches tailored to alleviate symptoms and improve fertility outcomes in individuals with endometriosis. Ultimately, this review aims to enhance the understanding of endometriosis pathophysiology, inform clinical practice, and stimulate further research to advance personalized care and management strategies for this challenging condition.

Iatrogenic Endometriosis of the Breast Mimicking Fat Necrosis: A Case Report

A female patient with a history of ductal carcinoma in situ in the left breast, status-post bilateral mastectomy with deep inferior epigastric perforator artery flap reconstructive surgery, presented with a right breast asymmetry concerning for fat necrosis. Histological analysis revealed the presence of benign glands and associated stroma within fibroadipose tissue, confirmed as endometriosis by immunohistochemical analysis. Further investigation revealed that the patient had a previous diagnosis of endometriosis associated with a cesarean section scar that likely seeded the ectopic endometrial glands into a tertiary site by utilizing abdominal tissue that may have harbored endometriosis.

Effect of norethisterone dose and duration in the management of abnormal uterine bleeding: a narrative review and case report

Abnormal uterine bleeding (AUB) is an acute/chronic variation in the normal menstrual cycle that affects adolescents, women of reproductive age and perimenopausal women. AUB affects approximately 3-30% of reproductive-aged women worldwide, and reduces their quality of life and productivity whilst increasing the overall healthcare burden. Its management requires thorough medical evaluation and individualized treatment. Depending on the severity and cause of AUB, its treatment ranges from lifestyle modifications and hormonal therapies to more invasive procedures or surgery. Although hormonal therapy is the preferred first-line measure in AUB, the available pharmacological options have various adverse effects. There exists a need for safer and more efficient treatment regimens with high patient compliance to effectively treat AUB. Norethisterone, also known as norethindrone, is a widely used synthetic analogue of progestogen. Controlled release formulations of norethisterone/ norethisterone acetate help maintain constant drug levels in the blood and exert minimal side-effects; therefore, they are promising therapeutic agents for effective AUB management. The present review summarizes the epidemiology and diagnosis of AUB, with a focus on the safety, efficacy and tolerability of norethisterone/ norethisterone acetate in AUB management. We also report a case of AUB in a 40-year-old woman, who was treated with NETA tablets. The treatment resulted in favourable outcomes, and patient satisfaction.

Hormonal Therapies before in vitro fertilization in women with endometriosis: The Minotaur's Labyrinth and the Ariadne's Thread

Endometriosis-related infertility is one of the most debated topics in reproductive medicine. In recent years, prolonged pre-cycle hormonal regimens gained attention as a mean of improving the assisted reproduction technologies (ART) success rates in endometriosis patients. GnRH agonists, dienogest, medroxyprogesterone acetate, and aromatase inhibitors are the most studied medications. Conflicting results and a high risk of bias exist in almost all of the conducted studies in the field. However, current evidence suggests that pre-cycle treatment with GnRH agonists may be beneficial for patients with stage III/IV endometriosis. Dienogest and medroxyprogesterone acetate-based progestin-primed ovarian stimulation protocol was shown to be comparable to the prolonged GnRH agonists protocol. Finally, aromatase inhibitors seem to be of limited benefit to the assisted reproductive outcomes of endometriosis patients. Although it is challenging to draw any clinical conclusions, pre-cycle hormonal treatments seem to be best indicated in endometriosis patients who had previously failed ART treatment.

Analysis of determinants of infertility among women at <i>in vitro</i> fertilization clinic in Surabaya

In social life and global health, infertility is common. History of abdominal surgery, body mass index (BMI), endometriosis, menstrual history, and polycystic ovarian syndrome (PCOS) have not been fully explained as female infertility factors. This study examined infertility causes at ASHA in vitro fertilization Primasatya Husada Citra (PHC) Hospital Surabaya. This quantitative study was cross-sectional. In May-July 2023, 82 childbearing-age women with infertility issues visited the hospital and completed questionnaires. Description and analysis were performed using the Wilcoxon rank test to evaluate menstrual history, BMI, PCOS, endometriosis, and abdominal surgery history in relation to infertility. Infertility was statistically associated with abdominal surgery history (P=0.008), BMI (P=0.000), endometriosis diagnosis (P=0.000), and PCOS (P=0.000). Women with abdominal surgery, endometriosis, and PCOS had significant infertility. Women’s infertility can be caused by ovulation disorders, tubal and pelvic disorders, or uterine disorders, but one-third of cases are unexplained. Infertility treatment may benefit from addressing abdominal surgery history, BMI, endometriosis, and PCOS. Early intervention and targeted care based on these determinants may improve fertility outcomes and reduce unexplained infertility.

Surgical Treatment of Patients with Endometriosis in the Certified Endometriosis Centers of the DACH Region - A Subanalysis of the Quality Assurance Study QS ENDO pilot

Introduction After puberty, at least 10% of all women and girls suffer from endometriosis. Surgery is useful for both the diagnosis and therapy. To date, quality indicators for the surgical treatment of endometriosis are lacking. QS ENDO aims to record the quality of care provided in the DACH region and to introduce quality indicators for the diagnosis and treatment of endometriosis. In the first phase of the study, QS ENDO real, the reality of care was recorded using a questionnaire. The second phase, QS ENDO pilot, investigated the treatment of patients who underwent surgery in certified endometriosis centers in a defined time-period. Material and Methods The surgical data of 10 patients from each of the 44 endometriosis centers in the DACH region was recorded using an online tool. Collected data included the approach used, the endometriosis phenotype, a description of the surgical site, resection status, histological confirmation, the use of a classification, and any complications. All operations were carried out in October 2016 as the defined time-period. The surgical approaches used were compared with the recommendations in the current guidelines. Results The data of 435 patients with a median age of 34 years were evaluated. 315 (72.4%) were nulliparous. 120 patients had given birth to at least one child and 42.5% (51) of them had delivered their child by caesarean section. About 50% of all patients also had deep infiltrating endometriosis in addition to ovarian endometriosis, and the median NAS score was 7.5. With regards to the surgical treatment, endometriomas were completely resected in 81% (94) of patients. 87.3% of patients underwent resection of peritoneal endometriosis. Forty-one patients had a hysterectomy, with a total hysterectomy carried out in 26 (63.4%) and a supracervical hysterectomy in 15 (36.6%) patients. Of the 59 patients with bowel endometriosis, half had segmental resection and half had shaving of the anterior rectal wall. Complications requiring revision occurred in 0.9% of cases. Conclusion The surgical procedures carried out in the certified endometriosis centers of the DACH region are largely in line with the recommendations for appropriate surgical approaches in the current standard guidelines.