Management of Asherman's syndrome

4DryField vs. hyalobarrier gel for preventing the recurrence of intrauterine adhesions - a pilot study

INTRODUCTION

This was a single-center pilot study that sought to describe an innovative use of 4DryField® PH (premix) for preventing the recurrence of intrauterine adhesions (IUAs) after hysteroscopic adhesiolysis in patients with Asherman's syndrome (AS).

MATERIAL AND METHODS

Twenty-three patients with AS were enrolled and 20 were randomized (1:1 ratio) to intrauterine application of 4DryField® PH (n = 10) or Hyalobarrier® gel (n = 10) in a single-blind manner. We evaluated IUAs (American Fertility Society [AFS] score) during initial hysteroscopy and second-look hysteroscopy one month later. Patients completed a follow-up symptoms questionnaire three and reproductive outcomes questionnaire six months later.

RESULTS

The demographic and clinical characteristics, as well as severity of IUAs, were comparable in both groups. The mean initial AFS score was 9 and 8.5 in the 4DryField® PH and Hyalobarrier® gel groups, respectively (p = .476). There were no between-group differences in AFS progress (5.9 vs. 5.6, p = .675), need for secondary adhesiolysis (7 vs. 7 patients, p = 1), and the follow-up outcomes.

CONCLUSION

4DryField® PH could be a promising antiadhesive agent for preventing the recurrence of IUAs, showing similar effectiveness and safety to Hyalobarrier® gel. Our findings warrant prospective validation in a larger clinical trial.

CLINICAL TRIAL REGISTRY NUMBER

ISRCTN15630617.

An endometrial biomimetic extracellular matrix (ECM) for enhanced endometrial regeneration using hyaluronic acid hydrogel containing recombinant human type III collagen

Endometrial injury poses a significant challenge in tissue regeneration, with type III collagen (COL III) playing a pivotal role in maintaining endometrial integrity and facilitating repair. Our study explored the utility of recombinant human type III collagen (RHC) as an intervention for endometrial damage. To address the challenges associated with the inherent instability and rapid degradation of COL III in vivo, we developed an RHC-HA hydrogel by conjugating RHC with hyaluronic acid (HA), thus ensuring a more stable and sustained delivery. Our findings suggested that the RHC-HA hydrogel significantly promoted endometrial regeneration and restored fertility. The hydrogel facilitated prolonged retention of RHC in the uterus, leading to a substantial improvement in the repair process. The synergistic interaction between RHC and HA greatly enhances cell proliferation and adhesion, surpassing the efficacy of HA or RHC alone. Additionally, the RHC-HA hydrogel demonstrated notable anti-fibrotic effects, which are crucial for preventing abnormalities during endometrial healing. These findings suggested that the RHC-HA hydrogel presented a therapeutic strategy in the treatment of uterine endometrial injuries, which may improve female reproductive health.

[First-line management of infertile couple. Guidelines for clinical practice of the French College of Obstetricians and Gynecologists 2022]

OBJECTIVE

To update the 2010 CNGOF clinical practice guidelines for the first-line management of infertile couples.

MATERIALS AND METHODS

Five major themes (first-line assessment of the infertile woman, first-line assessment of the infertile man, prevention of exposure to environmental factors, initial management using ovulation induction regimens, first-line reproductive surgery) were identified, enabling 28 questions to be formulated using the Patients, Intervention, Comparison, Outcome (PICO) format. Each question was addressed by a working group that had carried out a systematic review of the literature since 2010, and followed the Grading of Recommendations Assessment, Development and Evaluation (GRADE®) methodology to assess the quality of the scientific data on which the recommendations were based. These recommendations were then validated during a national review by 40 national experts.

RESULTS

The fertility work-up is recommended to be prescribed according to the woman's age: after one year of infertility before the age of 35 and after 6months after the age of 35. A couple's initial infertility work-up includes a single 3D ultrasound scan with antral follicle count, assessment of tubal permeability by hysterography or HyFOSy, anti-Mullerian hormone assay prior to assisted reproduction, and vaginal swabbing for vaginosis. If the 3D ultrasound is normal, hysterosonography and diagnostic hysteroscopy are not recommended as first-line procedures. Chlamydia trachomatis serology does not have the necessary performance to predict tubal patency. Post-coital testing is no longer recommended. In men, spermogram, spermocytogram and spermoculture are recommended as first-line tests. If the spermogram is normal, it is not recommended to check the spermogram. If the spermogram is abnormal, an examination by an andrologist, an ultrasound scan of the testicles and hormonal test are recommended. Based on the data in the literature, we are unable to recommend a BMI threshold for women that would contraindicate medical management of infertility. A well-balanced Mediterranean-style diet, physical activity and the cessation of smoking and cannabis are recommended for infertile couples. For fertility concern, it is recommended to limit alcohol consumption to less than 5 glasses a week. If the infertility work-up reveals no abnormalities, ovulation induction is not recommended for normo-ovulatory women. If intrauterine insemination is indicated based on an abnormal infertility work-up, gonadotropin stimulation and ovulation monitoring are recommended to avoid multiple pregnancies. If the infertility work-up reveals no abnormality, laparoscopy is probably recommended before the age of 30 to increase natural pregnancy rates. In the case of hydrosalpinx, surgical management is recommended prior to ART, with either salpingotomy or salpingectomy depending on the tubal score. It is recommended to operate on polyps>10mm, myomas 0, 1, 2 and synechiae prior to ART. The data in the literature do not allow us to systematically recommend asymptomatic uterine septa and isthmoceles as first-line surgery.

CONCLUSION

Based on strong agreement between experts, we have been able to formulate updated recommendations in 28 areas concerning the initial management of infertile couples.

Comparing the efficacy and pregnancy outcome of intrauterine balloon and intrauterine contraceptive device in the prevention of adhesion reformation after hysteroscopic adhesiolysis in infertile women: a prospective, randomized, controlled trial study

STUDY OBJECTIVE

To evaluate the efficacy and pregnancy outcomes of intrauterine balloon and intrauterine contraceptive devices in the prevention of adhesion reformation following hysteroscopic adhesiolysis in infertile women with moderate to severe intrauterine adhesion.

DESIGN

A prospective, randomized, controlled trial study.

SETTING

A tertiary university hospital.

PATIENTS

A total of 130 patients with moderate (American Fertility Society [AFS] score of 5-8) and severe (AFS score of 9-12) intrauterine adhesions were recruited.

INTERVENTIONS

86 patients were evenly allocated to group treated with an IUD for 1 month and group treated with an IUD for 2 months. 44 patients were allocated to group treated with a Foley catheter balloon.(IUD: Yuangong IUD).

MEASUREMENTS AND MAIN RESULTS

The primary outcome measures were the AFS score, endometrial thickness, and pregnancy outcome. After hysteroscopy, the AFS score was significantly decreased(P<0.05), whereas endometrial thickness was significantly increased across the three groups(P<0.001). Notably, the decline in the AFS score in the balloon group was greater than that in the IUD-1-month group and IUD-2-month group(P<0.01), with no significant difference between the IUD groups(P = 0.298). Lastly, In addition, the extent of the increase in endometrial thickness(P = 0.502) and the pregnancy outcomes(P = 0.803) in the three groups were not significantly different.

CONCLUSION

Inserting a balloon or placing an IUD for one or two months can effectively lower the risk of adhesion recurrence and restore the shape of the uterine cavity. While the therapeutic effect of the balloon was superior to that of the IUD, no significant differences were observed in the one-month and two-month IUD groups.

TRIAL REGISTRATION

This research was registered in the Chinese Clinical Trial Registry ( http://www.chictr.org.cn/enIndex.aspx ); Clinical trial registry identification number: ChiCTR-IOR-17,011,943 ( http://www.chictr.org.cn/showprojen.aspx?proj=17979 ). Date of trial registration: July 11, 2017.

Surgical evacuation with intraoperative ultrasound (SEE U): A randomised controlled trial

OBJECTIVES

To test whether intraoperative ultrasound can reduce the incidence of early and late complications following surgical removal of products of conception.

DESIGN

This was a prospective, multicentre, randomised, open clinical trial to assess feasibility. It was performed in two University Teaching hospitals in the West Midlands, England. The population consisted of women aged 16 years or over who were referred for surgical management of miscarriage. Patients were randomised to surgical management of miscarriage with either continuous intraoperative ultrasound or without intraoperative ultrasound. Process outcomes included the proportion of eligible women screened and proportion of eligible women randomised, attrition rates, evaluation of outcome measurement tools and acceptability. The primary clinical outcome was a composite outcome of unsuccessful procedure or a complication.

RESULTS

Fifty-nine women requiring surgical management of miscarriage were randomised. The conversion rate for entry into the trial was 59/79(75 %; 95 %CI = 64-84 %). The composite clinical outcome was attained in 5/27(19 %) patients who had surgery without ultrasound and 7/28(25 %) patients who had surgery with ultrasound (RR = 0.74;95 %CI = 0.26, 2.10). When we excluded the patients that could not attend their hysteroscopy appointment, due to COVID-19 pandemic, 5/27(19 %) of patients who had surgery without ultrasound and 5/25(20 %) of patients who had surgery with ultrasound attained the composite clinical outcome (RR = 0.93;95 %CI = 0.30, 2.90).

CONCLUSIONS

This multicentre pilot study showed that a large RCT comparing surgical management of miscarriage with and without intraoperative ultrasound is feasible.

Extended balloon stent placement for reducing intrauterine adhesion recurrence: a retrospective cohort study

RESEARCH QUESTION

What are the efficacy, safety and reproductive outcomes of intrauterine balloon stent placement for 4 or 6 weeks after hysteroscopic adhesiolysis?

DESIGN

This retrospective cohort study was conducted at a university-affiliated hospital, and included 155 women with moderate to severe intrauterine adhesions who underwent hysteroscopic adhesiolysis between March 2016 and December 2019. Participants were divided according to whether the heart-shaped balloon stent was left in place for 4 (group 1) or 6 (group 2) weeks after surgery. Stents removed at the second-look hysteroscopy 4 or 6 weeks after surgery were sent for culturing of common bacteria. The incidence of adhesion reformation, adhesion score reduction, bacterial colonization of the intrauterine balloon stent, live birth rate and time to live birth were analysed.

RESULTS

Group 2 had a significantly lower adhesion reformation rate (45.7% versus 28.2%, P = 0.024) and a more significant reduction in adhesion score (5.2 ± 2.1 versus 6.3 ± 2.2, P = 0.003) compared with group 1. However, no statistical difference was observed in the percentage of bacterial colonization of the intrauterine balloon stent (55.9% versus 66.7%, P = 0.174), live birth rate (52.4% versus 42.3%, P = 0.331) or time to live birth (hazard ratio 1.09, 95% confidence interval 0.60-1.96, P = 0.778) between the two groups.

CONCLUSIONS

Extending intrauterine balloon stent use from 4 to 6 weeks further reduces the adhesion reformation rate after hysteroscopic adhesiolysis in patients with moderate to severe intrauterine adhesion. No increase in bacterial colonization of the balloon stent was observed. Extending the duration of intrauterine balloon stent placement did not significantly affect live birth rates.

Intrauterine adhesions treated with hysteroscopic adhesiolysis and subsequent obstetric outcome: A retrospective matched cohort study

OBJECTIVE

To examine whether a history of hysteroscopic adhesiolysis (HA)-treated intrauterine adhesions (IUAs) was associated with an increased risk of adverse obstetrical outcomes in subsequent pregnancies.

DESIGN

Retrospective cohort study.

SETTING

A tertiary-care hospital in Shanghai, China.

POPULATION

A cohort of 114 142 pregnant women who were issued an antenatal card and received routine antenatal care in Shanghai First Maternity and Infant Hospital, between January 2016 and October 2021.

METHODS

From the cohort of 114 142 pregnant women, each woman with a history of HA-treated IUA prior to the current pregnancy (n = 780) was matched with four women without a history of IUAs (n = 3010) using propensity score matching. The matching variables were maternal age and parity, mode of conception, pre-pregnancy body mass index and prior history of abortion.

MAIN OUTCOME MEASURES

Pregnancy complications, placental abnormalities, postpartum haemorrhage and adverse birth outcomes.

RESULTS

Compared with women with no history of IUAs, women with a history of HA-treated IUAs were at higher risk of pre-eclampsia (RR 1.69, 95% CI 1.23-2.33), placenta accreta spectrum (RR 4.72, 95% CI 3.9-5.73), placenta praevia (RR 4.23, 95% CI 2.85-6.30), postpartum haemorrhage (RR 2.86, 95% CI 1.94-4.23), preterm premature rupture of membranes (RR 3.02, 95% CI 1.97-4.64) and iatrogenic preterm birth (RR 2.86, 95% CI 2.14-3.81). Those women were also more likely to receive cervical cerclage (RR 5.63, 95% CI 3.95-8.02) during pregnancy and haemostatic therapies after delivery (RR 2.17, 95% CI 1.75-2.69). Moreover, we observed that the RRs of those adverse obstetrical outcomes increased with the increasing number of hysteroscopic surgeries.

CONCLUSIONS

This study found that a history of HA-treated IUAs, especially a history of repeated HAs, was associated with an increased risk of adverse obstetrical outcomes.

Establishment and comparison of different procedures for modeling intrauterine adhesion in rats: A preliminary study

The establishment of a stable animal model for intrauterine adhesion (IUA) can significantly enhance research on the pathogenesis and pathological changes of this disease, as well as on the development of innovative therapeutic approaches. In this study, three different modeling methods, including phenol mucilage combined mechanical scraping, ethanol combined mechanical scraping and ethanol modeling alone were designed. The morphological characteristics of the models were evaluated. The underlying mechanisms and fertility capacity of the ethanol modeling group were analyzed and compared to those of the sham surgery group. All three methods resulted in severe intrauterine adhesions, with ethanol being identified as a reliable modeling agent and was subsequently subjected to further evaluation. Immunohistochemistry and RT-PCR results indicated that the ethanol modeling group exhibited an increase in the degree of fibrosis and inflammation, as well as a significant reduction in endometrial thickness, gland number, vascularization, and endometrial receptivity, ultimately resulting in the loss of fertility capacity. The aforementioned findings indicate that the intrauterine perfusion of 95 % ethanol is efficacious in inducing the development of intrauterine adhesions in rats. Given its cost-effectiveness, efficacy, and stability in IUA formation, the use of 95 % ethanol intrauterine perfusion may serve as a novel platform for evaluating innovative anti-adhesion materials and bioengineered therapies.

Nano-biomaterial Fibrinogen/P(LLA-CL) for prevention of intrauterine adhesion and restoration of fertility

Endometrial damage resulting from surgical procedures is a significant cause of intrauterine adhesion, thin endometrium, and subsequent miscarriage and infertility. Unfortunately, there is currently no effective clinical solution to promote endometrial regeneration after severe injury. In this study, we combined fibrinogen (Fg) and P(LLA-CL) by electrostatic spinning to form a stable nano-biomaterial Fg/P(LLA-CL), which can promote endometrial regeneration. After inducing physical injury to rat endometrium, we found that Fg/P(LLA-CL) membranes placed in the uterine cavities increased endometrial thickness and the number of glands after injury, while reducing the area of endometrial fibrosis. In addition, Fg/P(LLA-CL) increased neovascularization and decreased COL1A1 deposition. The expression of TGF-β1, a cytokine that promotes fibrosis, was down-regulated in the early stage of injury. Finally, fertility assays confirmed that Fg/P(LLA-CL) improved the pregnancy rate in rats with endometrial injury, and its safety was verified by blood tests and pathological examination of heart, liver, spleen, lung, and kidney. Therefore, Fg/P(LLA-CL) shows great potential as a safe and nontoxic biomaterial for endometrial regeneration, ultimately improving pregnancy outcomes in patients with intrauterine adhesion.

E2-Loaded Microcapsules and Bone Marrow-Derived Mesenchymal Stem Cells with Injectable Scaffolds for Endometrial Regeneration Application

Bone marrow-derived mesenchymal stem cells (BMSCs) have been recognized as new candidates for the treatment of serious endometrial injuries. However, owing to the local microenvironment of damaged endometrium, transplantation of BMSCs yielded disappointing results. In this study, Pectin-Pluronic® F-127 hydrogel as scaffolds were fabricated to provide three-dimensional architecture for the attachment, growth, and migration of BMSCs. E2 was encapsulated into the W/O/W microspheres to construct pectin-based E2-loaded microcapsules (E2 MPs), which has the potential to serve as a long-term reliable source of E2 for endometrial regeneration. Then, the BMSCs/E2 MPs/scaffolds system was injected into the uterine cavity of mouse endometrial injury model for treatment. At 4 weeks after transplantation, the system increased proliferative abilities of uterine endometrial cells, facilitated microvasculature regeneration, and restored the ability of endometrium to receive an embryo, suggesting that the BMSCs/E2 MPs/scaffolds system is a promising treatment option for endometrial regeneration. Furthermore, the mechanism of E2 in promoting the repair of endometrial injury was also investigated. Exosomes are critical paracrine mediators that act as biochemical cues to direct stem cell differentiation. In this study, it was found that the expression of endometrial epithelial cell (EEC) markers was upregulated in BMSCs treated by exosomes secreted from endometrial stromal cells (ESCs-Exos). Exosomes derived from E2-stimulated ESCs further promoted the expression level of EECs markers in BMSCs, suggesting exosomes released from ESCs by E2 stimulation could enhance the differentiation efficiency of BMSCs. Therefore, exosomes derived from ESCs play paracrine roles in endometrial regeneration stimulated by E2 and provide optimal estrogenic response.

S100A8/A9 promotes endometrial fibrosis via regulating RAGE/JAK2/STAT3 signaling pathway

Intrauterine adhesion (IUA) is characterized by endometrial fibrosis. S100A8/A9 plays an important role in inflammation and fibroblast activation. However, the role of S100A8/A9 in IUA remains unclear. In this study, we collect normal and IUA endometrium to verify the expression of S100A8/A9. Human endometrial stromal cells (hEnSCs) are isolated to evaluate fibrosis progression after S100A8/A9 treatment. A porcine IUA model is established by electrocautery injury to confirm the therapeutic effect of menstrual blood-derived stromal cells (MenSCs) on IUA. Our study reveals increased S100A8/A9 expression in IUA endometrium. S100A8/A9 significantly enhances hEnSCs proliferation and upregulates fibrosis-related and inflammation-associated markers. Furthermore, S100A8/A9 induces hEnSCs fibrosis through the RAGE-JAK2-STAT3 pathway. Transplantation of MenSCs in a porcine IUA model notably enhances angiogenesis, mitigates endometrial fibrosis and downregulates S100A8/A9 expression. In summary, S100A8/A9 induces hEnSCs fibrosis via the RAGE-JAK2-STAT3 pathway, and MenSCs exhibit marked effects on endometrial restoration in the porcine IUA model.

The humanin analogue (HNG) alleviates intrauterine adhesions by inhibiting endometrial epithelial cells ferroptosis: a rat model-based study

STUDY QUESTION

Does a humanin analogue (HNG) have a therapeutic effect on intrauterine adhesions (IUAs) caused by uterine cavity surgery in a rat model?

SUMMARY ANSWER

HNG supplementation attenuated the development of endometrial fibrosis and IUAs, improved fertility, and contributed to the regulation of endometrial fibrosis by inhibiting endometrial ferroptosis in rats with IUAs.

WHAT IS KNOWN ALREADY

IUAs, which are characterized by endometrial fibrosis, are a common cause of female infertility. Humanin (rattin in rats) is a mitochondrial-derived peptide that is widely expressed in multiple tissues. S14G-humanin (HNG) is an HNG that has been reported to have a protective effect against myocardial fibrosis.

STUDY DESIGN, SIZE, DURATION

Endometrial tissues from three patients with IUAs and three controls were tested for humanin expression. Two animal models were used to evaluate the modelling effect of IUAs and the preventive effect of HNG against IUAs. In the first model, 40 rats were equally randomized to control and Day 7, 14, and 21 groups to establish the IUA model. In the second model, 66 rats were equally randomized to the control, IUA, and IUA + humanin analogue (HNG) groups. Erastin was used to induce ferroptosis in the Ishikawa cell line.

PARTICIPANTS/MATERIALS, SETTING, METHODS

The endometrium was scraped with a surgical spatula, combined with lipopolysaccharide treatment, to establish the rat model of IUAs. Rats were intraperitoneally injected with 5 mg/kg/day HNG for 21 consecutive days beginning from the day of operation to evaluate the therapeutic effect on IUAs. Haematoxylin-eosin and Masson's trichrome staining were used to assess endometrial morphology and evaluate fibrosis. Ferroptosis-related markers, namely nuclear factor E2-related factor 2 (Nrf2), acyl-CoA synthetase long-chain family member 4 (ACSL4), haeme oxygenase-1 (HO-1), solute carrier family 7 member 11 (SLC7A11), glutathione peroxidase 4 (GPX4), and ferritin, were measured by immunohistochemistry and western blotting to determine whether ferroptosis was involved in the development of IUAs and to assess the attenuative effect of HNG on ferroptosis. Additionally, the female rats were mated with male rats with normal fertility to assess fertility.

MAIN RESULTS AND THE ROLE OF CHANCE

Humanin was widely expressed in endometrial cells, including epithelial and stromal cells, in both humans and rats. Humanin expression levels were downregulated in the endometria of patients and rats with IUAs relative to the endometria of controls. Endometrial thickness and the number of glands were significantly decreased on Day 7, 14, and 21 after endometrial scraping when compared with the controls (all P < 0.05), whereas the fibrotic area was significantly increased (P < 0.05). Among the tested ferroptosis markers, the expression levels of Nrf2, SLC7A11, and GPX4 were significantly downregulated and those of ACSL4, HO-1, and ferritin were significantly upregulated after endometrial scraping relative to their expression levels in controls (all P < 0.05). The mating rates in the control, IUA, and IUA + HNG groups were 100% (10/10), 40% (4/10), and 80% (8/10), respectively. The number of embryos in rats with IUAs (mean ± SD: 1.6 ± 2.1) was significantly less than the number in the controls (11.8 ± 1.5). HNG supplementation significantly attenuated this decrease in the number of implanted embryos (6.3 ± 4.5) (P < 0.01). Further results showed that HNG significantly attenuated the altered expression levels of proteins involved in ferroptosis in the endometria of rats with IUAs. Moreover, in vitro experiments showed that HNG significantly attenuated the erastin-induced decrease in the viability of the Ishikawa cell line and also attenuated the increase in reactive oxygen species production and the downregulation of GPX4.

LARGE SCALE DATA

None.

LIMITATIONS, REASONS FOR CAUTION

The findings of this study showed that HNG inhibited ferroptosis and reduced fibrosis in a rat model of IUAs. However, we could not establish a causal relationship between ferroptosis and the development of IUAs.

WIDER IMPLICATIONS OF THE FINDINGS

HNG may be effective at alleviating fibrosis during the development of IUAs, and the inhibition of ferroptosis is a promising new strategy for IUA therapy.

STUDY FUNDING/COMPETING INTEREST(S)

This study was supported by the National Natural Science Foundation of China (No. 82171647); the '1000 Talent Plan' of Yunnan Province (No. RLQN20200001); and the Basic Research Project of the Yunnan Province-Outstanding Youth Foundation (No. 202101AW070018). The authors declare no competing financial interests.

Mechanisms of Regeneration and Fibrosis in the Endometrium

The uterine lining (endometrium) regenerates repeatedly over the life span as part of its normal physiology. Substantial portions of the endometrium are shed during childbirth (parturition) and, in some species, menstruation, but the tissue is rapidly rebuilt without scarring, rendering it a powerful model of regeneration in mammals. Nonetheless, following some assaults, including medical procedures and infections, the endometrium fails to regenerate and instead forms scars that may interfere with normal endometrial function and contribute to infertility. Thus, the endometrium provides an exceptional platform to answer a central question of regenerative medicine: Why do some systems regenerate while others scar? Here, we review our current understanding of diverse endometrial disruption events in humans, nonhuman primates, and rodents, and the associated mechanisms of regenerative success and failure. Elucidating the determinants of these disparate repair processes promises insights into fundamental mechanisms of mammalian regeneration with substantial implications for reproductive health.

Comparison of the efficacy of autologous platelet gel and medical chitosan in the prevention of recurrence of intrauterine adhesions after transcervical resection of adhesion: a prospective, randomized, controlled trial

PURPOSE

Intrauterine adhesion (IUAs) in women is a debatable topic and there is no clear consensus in its management and treatment strategies. Previous treatment measures have limitations which necessitates to consider effective measures for prevention of recurrence of IUAs. Hence, the aim of this study to explore the efficacy and safety of intrauterine infusion of autologous platelet gel (APG) and medical chitosan in preventing recurrence of IUAs in females after transcervical resection of adhesion (TCRA).

METHODS

A prospective, randomized controlled trial was conducted among 80 patients presented with moderate to severe IUAs. Patients were randomized into two groups, APG group (n = 40) and medical chitosan group (n = 40). All patients were injected with either APG or medical chitosan after TCRA.

RESULTS

The postoperative recurrence rate of adhesions in APG group was significantly lower than those in medical chitosan group (21% vs 49%). The median AFS score during the second-look hysteroscopy was significantly lower in APG group than in medical chitosan group (P = 0.008). The median AFS score reduction after TCRA surgery was significantly higher in APG group than in medical chitosan group (median, 95% CI 7.000, 6.0 to 8.3 vs. 6.000, 5.0 to 7.0, P = 0.004). Subgroup analysis of platelet concentration (1000 as cut-off value) into high- and low-dose subgroups reported no significant correlation existed between APG and baseline characteristics, recurrence rate and postoperative AFS reduction score except for previous intrauterine operation (P < 0.05).

CONCLUSION

Thus, after TCRA, intrauterine injections of APG provides better efficacy and safety compared with intrauterine injections of medical chitosan in preventing recurrence of intrauterine adhesions.

Effect of Blood Gel Derivatives on Wound Healing in Mouse Injured Tissue Models

Several previous studies in the field of assisted reproduction have focused on the use of blood gel derivatives, such as platelet-rich fibrin (PRF), as a treatment for endometrial rehabilitation. However, the ability to release growth factors and the gel form of this product led to the evolution of platelet lysates. In this study, blood gel derivatives, including PRF lysate, which was in liquid form, and PRF gel, were collected and evaluated for growth factors. It was shown to be effective in endometrial wound healing and regeneration in mouse injured uterine tissue models through structure and function (pinopode expression, embryo implantation) evaluation. The results demonstrated that the concentrations of growth factors, including PDGF-AB and VEGF-A, were higher in the PRF lysate compared to the PRF gel (p < 0.05). PRF lysate could release these growth factors for 8 days. Furthermore, both PRF gel and PRF lysate restored the morphology of injured endometrial tissues in terms of luminal and glandular epithelia, as well as uterine gland secretory activity. However, the presence of pinopodes and embryonic implantation were only observed in the PRF lysate group. It can be concluded that PRF lysate promotes wound healing in mouse injured tissue models in vitro, which can act as healing products in tissue repair.

Platelet-rich fibrin improves repair and regeneration of damaged endometrium in rats

Purpose

Intrauterine adhesion (IUA) is the most common cause of uterine infertility. This study aims to evaluate whether platelet-rich fibrin (PRF) treatment can stimulate damaged endometrium regeneration in rats.

Methods

First, hematoxylin and eosin (HE) staining, scanning and transmission electron microscopy, and ELISAs were used to evaluate the microstructure of PRF. Then, mechanical damage was used to establish an IUA rat model. A total of 40 SD female rats were randomized to three groups: PRF transplantation group, IUA group, and sham group. Rats were sacrificed at 3, 7, and 14 days and uteruses were obtained for further analysis. Finally, functional and histological recovery of the damaged endometrium was analyzed by pregnancy test, HE staining, Masson's staining, and immunohistochemistry.

Results

PRF has two distinct zones, platelets and fibrin zone. Long and narrow fibrin fibers interconnected with each other and formed a three-dimensional, flexible, and elastic structure; platelet aggregates were trapped in fibrin fibers, and each platelet is associated with several fibrin fibers. PRF exudates promoted endometrial stromal cell proliferation and migration in vitro. PRF transplantation was beneficial for maintaining uterine structure, promoting endometrial luminal epithelium and endometrial gland regeneration, and decreasing fibrotic areas in vivo.

Conclusion

Intrauterine administration of PRF was demonstrated to be effective in preventing IUA and stimulating damaged endometrium regeneration in rats. This study not only provided a promising method for its potential in endometrial regeneration in women who suffer from uterine infertility but also may prevent IUA after intrauterine surgery in clinical cases.

Hysteroscopic Findings and Operative Treatment: All at Once?

Hysteroscopy is considered not only a diagnostic instrument but also a therapeutic tool for many uterine pathologies. In the early 1990s, advances in technology and techniques made hysteroscopy less painful and invasive, allowing to increase in the number of gynecological procedures performed in an ambulatory setting without significant patient discomfort and with potentially significant cost savings. This is the so-called "office hysteroscopy" or "see-and-treat hysteroscopy", whose spread has permitted the decrease of the number of procedures performed in the operating room with the benefit of obviating the need for anesthesia and dilatation of the cervical canal.

A Case Report of Asherman's Syndrome With Abnormal Placenta Implantation (Intrauterine Adhesion)

We report the case of a 28-year-old patient with a partial placental insertion on an intrauterine adhesion diagnosed at 20 weeks' gestation. The increasing incidence of intrauterine adhesions during the last decade has been attributed to the rising number of uterine surgeries in the fertile population and better imaging studies facilitating diagnosis. Although uterine adhesions during pregnancy are generally considered benign, the existing evidence is conflicting. The obstetric risks in these patients are unclear, but higher numbers of placental abruption, preterm premature rupture of membranes (PPROM), and cord prolapse have been reported. Thus, a prenatal diagnosis should prompt close feto-maternal observation. Surgical resection should be offered to patients with adhesions found prior to pregnancy.

The perinatal outcomes of women treated for Asherman syndrome: a propensity score-matched cohort study

STUDY QUESTION

Do the perinatal outcomes of patients following hysteroscopic treatment for Asherman syndrome (AS) differ from that of a control population?

SUMMARY ANSWER

Perinatal complications including placental issues, high blood loss, and prematurity in women after treatment for AS should be considered as moderate to high risk, especially in patients who have undergone more than one hysteroscopy (HS) or repeated postpartum instrumental revisions of the uterine cavity (Dilation and Curettage; D&C).

WHAT IS KNOWN ALREADY

The detrimental impact of AS on obstetrics outcomes is commonly recognized. However, prospective studies evaluating perinatal/neonatal outcomes in women with AS history are sparse, and the characteristics accounting for the respective morbidity of AS patients remain to be elucidated.

STUDY DESIGN, SIZE, DURATION

We conducted a prospective cohort study utilizing data from patients who underwent HS treatment for moderate to severe AS in a single tertiary University-affiliated hospital (enrolled between 01 January 2009 and March 2021), and who consequently conceived and progressed to at least 22nd gestational week of pregnancy. Perinatal outcomes were compared to a control population without an AS history, retrospectively enrolled concomitantly at the time of delivery for each patient with AS. Maternal and neonatal morbidity was assessed as well as the characteristics-related risk factors of AS patients.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Our analytic cohort included a total of 198 patients, 66 prospectively enrolled patients with moderate to severe AS and 132 controls. We used multivariable logistic regression to calculate a propensity score to match 1-1 women with and without AS history based on demographic and clinical factors. After matching, 60 pairs of patients were analysed. Chi-square test was used to compare perinatal outcomes between the pairs. Spearman's correlation analysis was utilized to investigate the correlation between perinatal/neonatal morbidity and the characteristics-related factors of AS patients. The odds ratio (OR) for the associations was calculated by logistic regression.

MAIN RESULTS AND THE ROLE OF CHANCE

Among the 60 propensity matched pairs, the AS group more frequently experienced overall perinatal morbidity, including abnormally invasive placenta (41.7% vs 0%; P < 0.001), retained placenta requiring manual or surgical removal (46.7% vs 6.7%; P < 0.001), and peripartum haemorrhage occurrence (31.7% vs 3.3%; P < 0.001). Premature delivery (<37 gestational weeks) was reported more frequently also for patients with AS (28.3% vs 5.0%; P < 0.001). However, no increased frequency of intra-uterine growth restriction or worsened neonatal outcomes were observed in AS group. Univariable analysis of risk factors for AS group morbidity outcomes revealed that the main factor related to abnormally invasive placenta was two or more HS procedures (OR 11.0; 95% CI: 1.33-91.23), followed by two or more D&Cs preceding AS treatment (OR 5.11; 95% CI: 1.69-15.45), and D&C performed postpartum as compared to post abortion (OR 3.0; 95% CI: 1.03-8.71). Similarly, two or more HS procedures were observed as the most important factor for retained placenta (OR 13.75; 95% CI: 1.66-114.14), followed by two or more preceding D&Cs (OR 5.16; 95% CI: 1.67-15.9). Premature birth was significantly associated with the number of preceding D&Cs (OR for two or more, 4.29; 95% CI: 1.12-14.91).

LIMITATIONS, REASONS FOR CAUTION

Although the cohort of patients with AS was enrolled prospectively, a baseline imbalance was intrinsically involved in the retrospective enrolment of the control group. However, to reduce the risk of bias, confounding factors were adjusted for using propensity score matching. The limitation to the generalization of our reported results is the single institution design in which all patients were treated for AS in one tertiary medical centre.

WIDER IMPLICATIONS OF THE FINDINGS

Within our search scope, our study represents one of the first and largest prospective studies of perinatal and neonatal outcomes in moderate to severe AS patients with a prospectively analysis of the risks factors of characteristics significantly influencing reported morbidities among patients with AS.

STUDY FUNDING/COMPETING INTEREST(S)

The study was supported by the Charles University in Prague [UNCE 204065] and by the institutional grant of The General Faculty Hospital in Prague [00064165]. No competing interests were declared.

TRIAL REGISTRATION NUMBER

N/A.

Construction and evaluation of intrauterine adhesion model in rats by different methods of mechanical injury

PURPOSE

The study aimed to establish a stable and effective animal model for the experimental study of intrauterine adhesion (IUA) by evaluating various mechanical injury methods.

METHODS

A total of 140 female rats were divided into four groups according to the extent and area of endometrial injury: group A (excision area: 2.0 × 0.5 cm²), group B (excision area: 2.0 × 0.25 cm²), group C (endometrial curettage) and group D (sham operation). On the 3rd, 7th, 15th and 30th day after the operation, the tissue samples of each group were collected, and the uterine cavity stenosis and histological changes were recorded by HE and Masson staining. Immunohistochemistry of CD31 was applied to visualize microvessel density (MVD). The pregnancy rate and the number of gestational sacs were used to evaluate the reproductive outcome.

RESULTS

The results showed that endometrium injured by small-area endometrial excision or simple curettage could be repaired. The ratio of fibrosis in groups A and B was higher than that in groups C and group D 30 days after modeling (P < 0.001). The number of endometrial glands and MVD in group A was significantly lower than those in groups B, C and D (P < 0.05). The pregnancy rate in group A was 20%, which was lower than that in groups B (33.3%), C (89%) and D (100%) (P < 0.05).

CONCLUSION

Full-thickness endometrial excision has a high rate of success in constructing stable and effective IUA models in rats.

Ellagic acid increases implantation rates with its antifibrotic effect in the rat model of intrauterine adhesion

Intrauterine adhesions (IUA) are defined as the adhesion of opposing endometrial tissue with dense fibrous adhesive bands within the uterine cavity. With the increase in cesarean sections and endometrial surgical procedures, intrauterine adhesions have become a problem with increasing incidence and decreasing implantation. The purpose of the study was to investigate the effect of ellagic acid (EA), a phenolic compound, on fibrosis in IUA model rats. Another goal of the study was to increase endometrial receptivity with EA. The groups in the study were planned as control, DMSO, EA, IUA, IUA+DMSO, and IUA+EA, with 8 Sprague Dawley rats in each group. EA was administered at a dose of 100 mg/kg/day for 35 days. At the end of the experiment, the uterine tissues of the rats were removed. Histochemical staining was used to validate the IUA model and determine the degree of fibrosis. The levels of some fibrosis-related genes and proteins in the obtained uterine tissues were evaluated. In addition, implantation rates were determined. In our findings, it was observed that the fibrotic structure was decreased in the treated IUA+EA group compared to the IUA group, while fibrotic improvement was supported by down-regulation of TGFβ1 activity and up-regulation of BMP7 activity. The increase in the expression of the endometrial marker LIF with EA treatment was consistent with the increase in implantation rates with treatment. As a result of the study, it can be said that EA applied as a treatment against IUA causes healing in uterine tissue by reducing fibrosis and increases implantation rates by increasing endometrial receptivity.

Reproductive outcomes of women with moderate to severe intrauterine adhesions after transcervical resection of adhesion: A systematic review and meta-analysis

BACKGROUND

Intrauterine adhesions (IUA) refers to the adhesion of the inner wall of the uterus, resulting in complete or partial occlusion of the uterine cavity, which causes a series of symptoms. Transcervical resection of adhesion (TCRA) is the standard surgical method for patients with IUA. However, the recurrence rate of women with moderate to severe IUA is high and it has raised a big concern about the reproductive outcomes.

METHODS

We conducted a scoping review by using 4 databases, including Google Scholar, PubMed, Scopus, Embase, and web of science, to retrieve relevant literature from September 1, 2001, to February 1, 2023, and to explore the reproductive outcomes in women with moderate to severe IUA after TCRA treatment. Following defined guidelines, data extraction was carried out by 2 researchers, and the findings were examined by 2 senior academics. The papers were evaluated by 2 reviewers using the inclusion and exclusion criteria. Using a form developed especially for this study, pertinent information was retrieved, including the first author, research design, study duration, age, intervention measurement, pregnancy rate, techniques of conception, and live birth rate. Two researchers conducted a quality assessment to determine any potential bias using the Cochrane technique and the Newcastle-Ottawa scale. RevMan 5.4.1 (The Cochrane Collaboration, London, United Kingdom) was used for data analysis, while I2 was used to evaluate heterogeneity.

RESULTS

In total, this study included 2099 participants. After a detailed systematic review and meta-analyses, the results showed that pregnancy and live birth rates were increased significantly after TCRA, and the risk difference of the pregnancy rate was 1.75 [1.17, 2.62]. Besides, in 2 retrospective studies, the risk difference of live birth rate was 2.26, with a 95% confidence interval of 1.99 to 2.58. Moreover, the menstrual status of women also was improved, and the risk difference of hypermenorrhoea and amenorrhea were -0.28 [-0.37, -0.19] and -0.06 [0.26, 0.13], respectively.

CONCLUSIONS

Taken together, TCRA is the useful strategy for the treatment of moderate to severe IUA to enhance the reproductive outcomes in women.

Chronic endometritis positively correlates with the aggravation of intrauterine adhesions but has limited effects on reproductive prognosis with antibiotic application

OBJECTIVE

To assess the effect of chronic endometritis (CE) diagnosed by CD138 staining on the aggravation of intrauterine adhesions (IUAs), and the reproductive prognosis after transcervical resection of adhesions (TCRA).

METHODS

Sixty-three patients with severe IUAs (group A) and 119 patients with moderate IUAs (group B) were included in this retrospective study. TCRA and endometrial biopsy with CD138 staining were performed. Participants in each group were classified into two subgroups: CE group and NCE group (without CE). Patients were treated with a course of oral antibiotics for 2 weeks after TCRA. Embryo transfer would be performed if patients had embryos after operations.

RESULTS

Increased incidence of CE was found in group A (18/63, 28.57%) compared with group B (18/119, 15.13%) (P = 0.030). No significant differences were found in the comparisons of chemical pregnancy rate, early miscarriage rate, or full-term pregnancy rate between the CE group and NCE group (P > 0.05), in either the subgroup analysis of group A and group B, or the total analysis.

CONCLUSION

CE has a positive correlation with the aggravation of IUAs. CE did not have a negative impact on the reproductive prognosis of patients with moderate or severe IUAs after TCRA followed by antibiotic administration.

How platelet-rich plasma (PRP) intra-uterine injection improve endometrial receptivity of intrauterine adhesions in women: A time-series-based self-controlled study

Platelet-rich plasma (PRP) treatment proven to improve fertility outcomes in patients with a poor endometrial environment. However, the mechanism is not yet clear. In this study, we recruited 6 patients with infertility due to IUA and 6 normal control women. The subjects in the IUA group collected samples before and after PRP treatment. Endometrial receptivity was improved after PRP treatment. After PRP treatment, the endometrial NK cells, CD8 T cells and Th1 cells were significantly lower than those before treatment. Functional enrichment analysis suggested that the effects of changes in microbial composition played an important role in changes in the endometrial immune environment. Among them, the most significant difference was Bacillus. Our self-controlled cohort in this study can fully describe the detailed mechanism by which PRP treatment improves the endometrial environment.

Incidence and Clinical Implications of Placenta Accreta Spectrum after Treatment for Asherman Syndrome

STUDY OBJECTIVE

To investigate the incidence, predictors, and clinical implications of placenta accreta spectrum (PAS) in pregnancies after hysteroscopic treatment for Asherman syndrome (AS).

DESIGN

This is a retrospective cohort study, conducted through a telephone survey and chart review.

SETTING

Minimally invasive gynecologic surgery center in an academic community hospital.

PATIENTS

Database of 355 patients hysteroscopically treated for AS over 4 years. We identified patients who achieved pregnancy past the first trimester and evaluated the incidence and predictors for PAS as well as associated clinical implications.

INTERVENTIONS

Telephone survey.

MEASUREMENTS AND MAIN RESULTS

We identified 97 patients meeting the inclusion criteria. Among these patients, 23 (23.7%) patients had PAS. History of cesarean delivery was the only variable statistically significantly associated with having PAS (adjusted odds ratio 4.03, 95% confidence interval 1.31-12.39). PAS was diagnosed antenatally in 3 patients (14.3%), with patients having placenta previa more likely to be diagnosed (p <.01). Nine patients (39.13%) with PAS required cesarean hysterectomy, which is 9.3% of those with a pregnancy that progressed past the first trimester. Factors associated with cesarean hysterectomy were the etiology of AS (dilation and evacuation after the second trimester pregnancy or postpartum instrumentation, p <.01), invasive placenta (increta or percreta, p <.05), and history of morbidly adherent placenta in previous pregnancies (p <.05). Two patients with PAS (9.5%) had uterine rupture, and another 2 (9.5%) experienced uterine inversion.

CONCLUSION

There is a high incidence of PAS and associated morbidity in pregnancies after hysteroscopic treatment for AS. There is a low rate of antenatal diagnosis as well as a lack of reliable clinical predictors, which both stress the importance of clinical awareness, careful counseling, and delivery planning.

The UCMSC-bFGF/Scaffold System Accelerates the Healing of the Uterine Full-Thickness Injury

Severe uterine injury is a major cause of endometrial scar formation and female infertility. At present, the methods for accelerating injured uterine healing are still lacking. Genetic engineering modification of mesenchymal stem cells (MSCs) has been shown great promise in preclinical studies on regeneration. Here, we constructed a type of umbilical cord MSCs (UC-MSCs) with overexpressed basic fibroblast growth factor (UCMSC-bFGF) and investigated the effects of the UCMSC-bFGF/scaffold on functional regeneration of the full-thickness defect uterus of the rat model. At days 7, 14, and 30 after treatments, the rats were killed and the injured uterus was observed. The structural and functional change of uterine was assessed by hematoxylin and eosin staining, immunohistochemical staining, and fertility experiment. The UCMSC-bFGF/scaffold group exhibited anti-inflammatory effect, and the number of CD45⁺ cell in the UCMSC-bFGF/scaffold group was significantly less than that in UC-MSCs/scaffold group and scaffold group, but higher than sham-operated group at day 7 postmending. At day 14, the UCMSC-bFGF/scaffold group exhibited dramatically proangiogenesis efficacy compared with UC-MSCs/scaffold group and scaffold group. At day 30, the endometrial thickness, structure of myometrium, and blood vessels in the UCMSC-bFGF/scaffold were better than those of the UC-MSCs/scaffold group and scaffold group, even close to sham-operated group. Implantation rate at injury region postoperation 30 days in the UCMSC-bFGF/scaffold group (8/16) was significantly higher than that in UC-MSCs/scaffold group (1/16) and scaffold group (0/16). Taken together, the UCMSC-bFGF/scaffold system suppressed local inflammation, promoted angiogenesis, and accelerated regeneration of the defected uterine wall, and thereby greatly shortened the healing time of the injured uterus. Impact statement In this study, we used umbilical cord mesenchymal stem cells (UC-MSCs) with stably overexpressed basic fibroblast growth factor (UCMSC-bFGF) to repair the full-thickness defect uterine wall of the rat model and found that the UCMSC-bFGF/scaffold system suppressed early acute inflammation after uterus injury, promoted angiogenesis, and accelerated regeneration of the injured uterine wall.

Recurrent implantation failure: A comprehensive summary from etiology to treatment

Implantation is the first step in human reproduction. Successful implantation depends on the crosstalk between embryo and endometrium. Recurrent implantation failure (RIF) is a clinical phenomenon characterized by a lack of implantation after the transfer of several embryos and disturbs approximately 10% couples undergoing in vitro fertilization and embryo transfer. Despite increasing literature on RIF, there is still no widely accepted definition or standard protocol for the diagnosis and treatment of RIF. Progress in predicting and preventing RIF has been hampered by a lack of widely accepted definitions. Most couples with RIF can become pregnant after clinical intervention. The prognosis for couples with RIF is related to maternal age. RIF can be caused by immunology, thrombophilias, endometrial receptivity, microbiome, anatomical abnormalities, male factors, and embryo aneuploidy. It is important to determine the most possible etiologies, and individualized treatment aimed at the primary cause seems to be an effective method for increasing the implantation rate. Couples with RIF require psychological support and appropriate clinical intervention. Further studies are required to evaluate diagnostic method and he effectiveness of each therapy, and guide clinical treatment.

Hormonal support in women with Asherman syndrome does not lead to better outcomes: A randomized trial

Purpose

The purpose of the study was to investigate if adjuvant hormones after successful adhesiolysis lead to a reduction in spontaneous recurrence of adhesions and influence reproductive outcomes.

Methods

A single-blind randomized controlled trial comparing administration of oral estrogen (the usual care group) with not giving estrogen (no estrogen) in women after successful adhesiolysis for Asherman syndrome. Women were included between September 2013 and February 2017, with a follow-up of 3 years to monitor recurrences and reproductive outcomes. Analyses were based on an intention to treat analyses. This study was registered under NL9655.

Results

A total of 114 women were included. At 1 year, virtually all patients (except 3) were either having a recurrence or were pregnant. Women who did not receive estrogen did not have more recurrences of adhesions in the first year prior to pregnancy (66.1% in the usual care group, 52.7% in the no-estrogen group, p = 0.15). Of the women in usual care, 89.8% got pregnant within 3 years, and 67.8% got a living child; this was 83.6% and 60.0%, respectively, in the no-estrogen group (p = 0.33 and p = 0.39, respectively).

Conclusion

Usual care does not lead to better outcomes as compared with not giving exogenous estrogen but is associated with side effects.

Endometrial Stem Cells and Their Applications in Intrauterine Adhesion

Intrauterine adhesion (IUA), resulting from pregnancy or nonpregnant uterine trauma, is one of the major causes of abnormal menstruation, infertility, or repeated pregnancy loss. Although a few methods, including hysteroscopy and hormone therapy, are routinely used for its diagnosis and treatment, they cannot restore tissue regeneration. Stem cells, which have self-renewal and tissue regeneration abilities, have been proposed as a promising therapy for patients with severe IUAs. In this review, we summarize the origin and features of endometrium-associated stem cells and their applications in the treatment of IUAs based on animal models and human clinical trials. We expect that this information will help to elucidate the underlying mechanism for tissue regeneration and to improve the design of stem cell-based therapies for IUAs.

CRC Therapy Identifies Indian Hedgehog Signaling in Mouse Endometrial Epithelial Cells and Inhibition of Ihh-KLF9 as a Novel Strategy for Treating IUA

Intrauterine adhesion (IUA) causes menstrual disturbance and infertility. There is no effective treatment available for moderate to severe IUA cases. Stem cell-based therapy has been investigated for treating IUA but is limited in clinical applications due to issues including the precise induction of differentiation, tumorigenesis, and unclear molecular mechanisms. In our recent study, we isolated and expanded the long-term cultures of conditional reprogrammed (CR) mouse endometrial epithelial cells. Treating IUA mice with these CR cells (CRCs) restored the morphology and structure of the endometrium and significantly improved the pregnancy rate. In this study, our data with high-throughput sequencing, CRISPR knockout Ihh^-/-CRCs, and transplantation identified for the first time that the Indian hedgehog (Ihh) gene plays a critical role in the regulation of endometrial epithelial cell proliferation. We also found that aberrant activated Ihh-krüppel-like factor 9 (KLF9) signaling contributes to the inhibition of normal progesterone receptor (PR) function in IUA mice. Thus, we hypothesized that inhibition of the Ihh-KLF9 pathway may be a novel strategy to treat IUA. Our data demonstrated that treatment with the hedgehog signaling inhibitor Vismodegib restored the morphology, structure, and microenvironment of the endometrium, and greatly improved the pregnancy rate in IUA mice. This study suggests a promising application of hedgehog inhibitors as a targeted drug in the IUA clinic.

Research progress of stem cell therapy for endometrial injury

Endometrial damage is an important factor leading to infertility and traditional conventional treatments have limited efficacy. As an emerging technology in recent years, stem cell therapy has provided new hope for the treatment of this disease. By comparing the advantages of stem cells from different sources, it is believed that menstrual blood endometrial stem cells have a good application prospect as a new source of stem cells. However, the clinical utility of stem cells is still limited by issues such as colonization rates, long-term efficacy, tumor formation, and storage and transportation. This paper summarizes the mechanism by which stem cells repair endometrial damage and clarifies the material basis of their effects from four aspects: replacement of damaged sites, paracrine effects, interaction with growth factors, and other new targets. According to the pathological characteristics and treatment requirements of intrauterine adhesion (IUA), the research work to solve the above problems from the aspects of functional bioscaffold preparation and multi-functional platform construction is also summarized. From the perspective of scaffold materials and component functions, this review will provide a reference for comprehensively optimizing the clinical application of stem cells.

Zooming in on the endometrial factor of recurrent implantation failure

Recurrent implantation failure (RIF) is a major limiting factor in the success rates of in-vitro fertilisation despite the remarkable clinical and technological advancement made at improving assisted reproductive technology. The primary purpose of the endometrium is to provide a receptive site for the implantation of the blastocyst and support its growth and subsequent development. Endometrial pathologies such as endometrial polyps, adenomyosis, Asherman's syndrome, chronic endometritis, and congenital Müllerian ducts defect negatively influence the integrity and receptivity of the endometrium, as well as the implantation of the embryo. This review highlights the implications of these endometrial pathologies and their association with RIF.

Potential Molecular Mechanism of Guishen Huoxue Decoction against Intrauterine Adhesion Based on Network Pharmacology

Objective

Intrauterine adhesion (IUA) represents an endometrial repair disorder that is associated with menstrual disorders, recurrent pregnancy loss, and infertility. This study aimed to explore the underlying biological mechanisms of Guishen Huoxue decoction for the treatment of IUA based on network pharmacology.

Methods

The selection of active compounds for Guishen Huoxue decoction and prediction of relevant targets were performed by the TCMSP and Swiss Target Prediction databases, respectively. The targets of IUA were obtained by three databases, including Online Mendelian Inheritance in Man (OMIM), DisGeNET, and GeneCards. The drug-disease regulatory network was constructed via Cytoscape software, following the acquisition of common genes of active compounds of drug Guishen Huoxue decoction and disease IUA, which was carried out through Venny software. Protein-protein interaction (PPI) network and function enrichment analyses were performed.

Results

According to the data obtained from TCMSP, a total of 200 potential active compounds of Guishen Huoxue decoction and their related targets (1068) were screened by the Swiss Target Prediction database. 1303 disease targets and 134 common targets were identified. The drug-disease regulatory network showed that 165 active compounds were found to be involved in the treatment of IUA. Among 134 common targets, AKT1, SRC, TP53, VEGFA, and IL-6 were predicted as core genes against IUA. PI3K-Akt, Rap1, Ras, and AGE-RAGE were the main signaling pathways that participated in the treatment of Guishen Huoxue decoction for IUA.

Conclusion

The active compounds of Guishen Huoxue decoction confer therapeutic effects against IUA by regulating fibrosis, inflammation, and oxidative stress through major signaling pathways such as PI3K-Akt and AGE-RAGE.

Mycobiome Dysbiosis in Women with Intrauterine Adhesions

The vaginal microbiota dysbiosis is closely associated with the development of reproductive diseases. However, the contribution of mycobiome to intrauterine adhesion (IUA) disease remains unknown. Harnessing 16S and ITS2 rDNA sequencing analysis, we investigate both bacterial and fungal microbiota compositions across 174 samples taken from both cervical canal (CC) and middle vagina (MV) sites of IUA patients. Overall, there is no significant difference in microbial diversity between healthy subjects (HS) and IUA patients. However, we observe the IUA-specific bacterial alterations such as increased Dialister and decreased Bifidobacterium and enriched fungal genera like increased Filobasidium and Exophiala. Moreover, site-specific fungal-bacterial correlation networks are discovered in both CC and MV samples of IUA patients. Mechanistic investigation shows that Candida parapsilosis, other than Candida albicans and Candida maltosa, prevents the exacerbation of inflammatory activities and fibrosis, and modulates bacterial microbiota during IUA progression in a rat model of IUA. Our study thus highlights the importance of mycobiota in IUA progression, which may facilitate the development of therapeutic target for IUA prevention. IMPORTANCE Intrauterine adhesion (IUA) often leads to hypomenorrhea, amenorrhea, repeat miscarriages, and infertility. It has been prevalent over the last few decades in up to 13% of women who experience pregnancy termination during the first trimester, and 30% of women undergo dilation and curettage after a late, spontaneous abortion. However, the pathogenesis of IUA remains unclear. Despite reports of microbiota dysbiosis during IUA progression, there is little information on the effect of fungal microbiota on the development of IUA. This study not only enhances our understanding of the mycobiome in IUA patients but also provides potential intervention strategies for prevention of IUA by targeting mycobiome.

Successful Outcome in a Middle-Aged Woman With Secondary Infertility Using Donor Oocyte In Vitro Fertilization: A Case Report From a Rural Infertility Clinic

We present the case of a 42-year-old (gravida 2, abortion 2 (G2A2)) infertile woman who visited an infertility clinic with her husband (aged 42 years). She had been married for eight years and had two abortions during this time. After the second abortion, dilatation and curettage (D&C) was done at her hometown hospital. This is a case of secondary infertility. Before coming to our center, she visited another center for infertility treatment, where in vitro fertilization (IVF) was done using self-oocyte, but intracytoplasmic sperm injection (ICSI) was not done. Unfortunately, the treatment did not succeed. On hysteroscopy, adhesions were found in the cavity, which were possibly formed due to the D&C procedure performed for past abortions. This condition is known as Asherman’s syndrome. Hence, hystero-adhesiolysis was done on January 20, 2021. Her latest report showed an anti-Mullerian hormone (AMH) value of 0.252 ng/dL, which was very low. Low AMH was indicative of low ovarian reserve. Her follicle-stimulating hormone (FSH) was 23 mIU/mL, which was too high, suggestive of poor egg quality. The antral follicular count was assessed through transvaginal ultrasound; the total count was three (one on the right, and two on the left). Ovum pick-up was done on March 15, 2021. Only one oocyte was retrieved from the patient (MI grade). The husband’s sperm count was 12 million/mL with low motility, which is known as oligoasthenozoospermia; hence, ICSI was performed. However, the embryo could not be formed. Therefore, on April 1, 2021, oocytes were retrieved from the donor, and ICSI was done using the semen sample of the husband. On April 6, 2021, two embryos at the day six stage were transferred to the patient’s uterus. Before the embryo transfer, tablet estrogen 2 mg was administered thrice daily. This was started from day two of menses till day 14th. After 14 days, the patient was given a progesterone injection for six days daily. After embryo transfer, tablet estrogen 2 mg was given thrice daily, and tablet progesterone 2 mg twice daily was given as support. After 14 days of embryo transfer, a beta-human chorionic gonadotrophic hormone (βhCG) test was done. Her βhCG was positive, and the couple was delighted. Diagnostic challenges occurred due to previous abortions, previous failure of IVF, history of hypothyroidism, AMH value of 0.252 ng/dL, and presence of adhesions. This is a case of secondary infertility with cavity adhesions with low AMH and low antral follicular count. The outcome was favorable at our fertility clinic. Because the patient is a known case of hypothyroidism, levothyroxine tablets were also prescribed.

Association of Intrauterine Microbes with Endometrial Factors in Intrauterine Adhesion Formation and after Medicine Treatment

Intrauterine adhesions (IUAs) have caused serious harm to women’s reproductive health. Although emerging evidence has linked intrauterine microbiome to gynecological diseases, the association of intrauterine microbiome with IUA, remains unknown. We performed metagenome-wide association, metabolomics, and transcriptomics studies on IUA and non-IUA uteri of adult rats to identify IUA-associated microbial species, which affected uterine metabolites and endometrial transcriptions. A rat model was used with one side of the duplex uterus undergoing IUA and the other remaining as a non-IUA control. Both 16S rRNA sequencing and metagenome-wide association analysis revealed that instead of Mycoplasmopsis specie in genital tract, murine lung pathogen Mycoplasmopsispulmonis markedly increased in IUA samples and displayed a distinct positive interaction with the host immune system. Moreover, most of the IUA-enriched 58 metabolites positively correlate with M.pulmonis, which inversely correlates with a mitotic progression inhibitor named 3-hydroxycapric acid. A comparison of metabolic profiles of intrauterine flushing fluids from human patients with IUA, endometritis, and fallopian tube obstruction suggested that rat IUA shared much similarity to human IUA. The endometrial gene Tenascin-N, which is responsible for extracellular matrix of wounds, was highly up-regulated, while the key genes encoding parvalbumin, trophectoderm Dkkl1 and telomerase involved in leydig cells, trophectoderm cells, activated T cells and monocytes were dramatically down-regulated in rat IUA endometria. Treatment for rat IUA with estrogen (E2), oxytetracycline (OTC), and a traditional Chinese patent medicine GongXueNing (GXN) did not reduce the incidence of IUA, though inflammatory factor IL-6 was dramatically down-regulated (96–86%) with all three. Instead, in both the E2 and OTC treated groups, IUA became worse with a highly up-regulated B cell receptor signaling pathway, which may be associated with the significantly increased proportions of Ulvibacter or Staphylococcus. Our results suggest an association between intrauterine microbiota alterations, certain uterine metabolites, characteristic changes in endometrial transcription, and IUA and the possibility to intervene in IUA formation by targeting the causal factors, microbial infection, and Tenascin-like proteins.

Human Platelet-Rich Plasma Facilitates Angiogenesis to Restore Impaired Uterine Environments with Asherman’s Syndrome for Embryo Implantation and Following Pregnancy in Mice

Asherman’s syndrome (AS) is caused by intrauterine adhesions and inactive endometrium from repeated curettage of the uterine endometrium. AS is a major cause of recurrent implantation failure and miscarriage and is very difficult to treat because of the poor recovery of endometrial basal cells. Platelet-rich plasma (PRP) has abundant growth factors that may induce angiogenesis and cell proliferation. Here, we demonstrate that human PRP (hPRP) significantly enhances angiogenesis to restore embryo implantation, leading to successful pregnancy in mice with AS. In mice with AS, hPRP treatment considerably reduced the expression of fibrosis markers and alleviated oligo/amenorrhea phenotypes. Mice with AS did not produce any pups, but the hPRP therapy restored their infertility. AS-induced abnormalities, such as aberrantly delayed embryo implantation and intrauterine growth retardation, were considerably eliminated by hPRP. Furthermore, hPRP significantly promoted not only the elevation of various angiogenic factors, but also the migration of endometrial stromal cells. It also increased the phosphorylation of STAT3, a critical mediator of wound healing, and the expression of tissue remodeling genes in a fibrotic uterus. PRP could be a promising therapeutic strategy to promote angiogenesis and reduce fibrosis in impaired uterine environments, leading to successful embryo implantation for better clinical outcomes in patients with AS.

Treating intrauterine adhesion using conditionally reprogrammed physiological endometrial epithelial cells

Background

There is unmet need for effective therapies of intrauterine adhesions (IUAs) that are common cause of menstrual disturbance and infertility, since current clinical procedures do not improve prognosis for patients with moderate to severe IUA, with a recurrence rate of 23–50%. Stem cell-based therapy has emerged as a therapeutic option with unsolved issues for IUA patients in the past few years. Primary endometrial epithelial cells for cell therapy are largely hampered with the extremely limited proliferation capacity of uterine epithelial cells. This study was to evaluate whether IUA is curable with conditionally reprogrammed (CR) endometrial epithelial cells.

Methods

Mouse endometrial epithelial cells (MEECs) were isolated from C57BL female mice, and long-term cultures of MEECs were established and maintained with conditional reprogramming (CR) method. DNA damage response analysis, soft agar assay, and matrigel 3D culture were carried out to determine the normal biological characteristics of CR-MEECs. The tissue-specific differentiation potential of MEECs was analyzed with air–liquid interface (ALI) 3D culture, hematoxylin and eosin (H&E) staining, Masson’s trichrome and DAB staining, immunofluorescence assay. IUA mice were constructed and transplanted with CR-MEECs. Repair and mechanisms of MEECs transplantation in IUA mice were measured with qRT-PCR, Masson’s trichrome, and DAB staining.

Results

We first successfully established long-term cultures of MEECs using CR approach. CR-MEECs maintained a rapid and stable proliferation in this co-culture system. Our data confirmed that CR-MEECs retained normal biological characteristics and endometrium tissue-specific differentiation potential. CR-MEECs also expressed estrogen and progesterone receptors and maintained the exquisite sensitivity to sex hormones in vitro. Most importantly, allogeneic transplantation of CR-MEECs successfully repaired the injured endometrium and significantly improved the pregnancy rate of IUA mice.

Conclusions

Conditionally reprogrammed physiological endometrial epithelial cells provide a novel strategy in IUA clinics in a personalized or generalized manner and also serve as a physiological model to explore biology of endometrial epithelial cells and mechanisms of IUA.

Therapeutic Effects and Repair Mechanism of HGF Gene-Transfected Mesenchymal Stem Cells on Injured Endometrium

There are many studies on the advantages of using mesenchymal stem cells (MSCs) that secrete various paracrine factors for repairing endometrial injury. However, the stability and effectiveness of MSCs require improvement to become a viable therapy. Hepatocyte growth factor (HGF), one of the cytokines secreted by MSCs, promotes vascular repair and mesenchymal to epithelial transformation (MET). Therefore, HGF likely promotes the repair process of the endometrium. We prepared MSCs transfected with the HGF gene to explore its repair effects and mechanism using a damaged endometrium mouse model. HGF gene-transfected MSCs were prepared by electroporation. The transfected MSCs retained their cellular characteristics and significantly increased the expression of HGF ( $P<0.01$ ). HGF gene-transfected MSCs helped damaged endometrium to recover its morphological characteristics, improved proliferation and decreased apoptosis of endometrial cells, increased the expression of endometrial vascular growth-related factors, and activated phosphorylated c-Met and AKT in the mouse endometrial damage model ( $P<0.05$ ). Compared with normal MSCs, HGF gene-transfected MSCs produced a more significant effect on damaged endometrial epithelium repair by activating the HGF/c-Met and downstream signaling pathways. Our results indicate that HGF gene-transfected MSCs provide an effective and promising tool for injured endometrium therapy.

Genetically engineered FGF1-sericin hydrogel material treats intrauterine adhesion and restores fertility in rat

Endometrial injury can cause intrauterine adhesions (IUA) and induce the formation of endometrial fibrosis, leading to infertility and miscarriage. At present, there is no effective treatment method for severe IUA and uterine basal injury with adhesion area larger than 1/3 of the uterus. In this study, we prepared FGF1 silk sericin hydrogel material (FGF1-SS hydrogel) to treat endometrial injury and prevent endometrial fibrosis. Compared with the silk sericin hydrogel material (WT-SS hydrogel), FGF1-SS hydrogel significantly promotes the cell migration and infiltration ability of endometrial stromal cells (ESCs). More importantly, FGF1-SS hydrogel can release FGF1 stably for a long time and inhibit The ESCs injury model forms fibrosis through the TGF-β/Smad pathway. In the IUA rat model, FGF1-SS hydrogel treatment effectively restored the number of uterine glands and uterine wall thickness in rats, with a fertility rate of 65.1 ± 6.4%. The results show that FGF1-SS hydrogel is expected to be a candidate to prevent IUA.

Extracorporeal Shock Wave Therapy Combined with Platelet-Rich Plasma during Preventive and Therapeutic Stages of Intrauterine Adhesion in a Rat Model

Intrauterine adhesion (IUA) is caused by artificial endometrial damage during intrauterine cavity surgery. The typical phenotype involves loss of spontaneous endometrium recovery and angiogenesis. Undesirable symptoms include abnormal menstruation and infertility; therefore, prevention and early treatment of IUA remain crucial issues. Extracorporeal shockwave therapy (ESWT) major proposed therapeutic mechanisms include neovascularization, tissue regeneration, and fibrosis. We examined the effects of ESWT and/or platelet-rich plasma (PRP) during preventive and therapeutic stages of IUA by inducing intrauterine mechanical injury in rats. PRP alone, or combined with ESWT, were detected an increased number of endometrial glands, elevated vascular endothelial growth factor protein expression (hematoxylin-eosin staining and immunohistochemistry), and reduced fibrosis rate (Masson trichrome staining). mRNA expression levels of nuclear factor-kappa B, tumor necrosis factor-α, transforming growth factor-β, interleukin (IL)-6, collagen type I alpha 1, and fibronectin were reduced during two stages. However, PRP alone, or ESWT combined with PRP transplantation, not only increased the mRNA levels of vascular endothelial growth factor (VEGF) and progesterone receptor (PR) during the preventive stage but also increased PR, insulin-like growth factor 1 (IGF-1), and IL-4 during the therapeutic stage. These findings revealed that these two treatments inhibited endometrial fibrosis and inflammatory markers, thereby inhibiting the occurrence and development of intrauterine adhesions.

Decision tree model predicts live birth after surgery for moderate-to-severe intrauterine adhesions

Background

After treatment of intrauterine adhesions, the rate of re-adhesion is high and the pregnancy outcome unpredictable and unsatisfactory. This study established and verified a decision tree predictive model of live birth in patients after surgery for moderate-to-severe intrauterine adhesions (IUAs).

Methods

A retrospective observational study initially comprised 394 patients with moderate-to-severe IUAs diagnosed via hysteroscopy. The patients underwent hysteroscopic adhesiolysis from January 2013 to January 2017, in a university-affiliated hospital. Follow-ups to determine the rate of live birth were conducted by telephone for at least the first postoperative year. A classification and regression tree algorithm was applied to establish a decision tree model of live birth after surgery.

Results

Within the final population of 374 patients, the total live birth rate after treatment was 29.7%. The accuracy of the model was 83.8%, and the area under the receiver operating characteristic curve (AUC) was 0.870 (95% CI 7.699–0.989). The root node variable was postoperative menstrual pattern. The predictive accuracy of the multivariate logistic regression model was 70.3%, and the AUC was 0.835 (95% CI 0.667–0.962).

Conclusions

The decision tree predictive model is useful for predicting live birth after surgery for IUAs; postoperative menstrual pattern is a key factor in the model. This model will help clinicians make appropriate clinical decisions during patient consultations.

Reproductive outcomes and reproductive tract microbiota shift in women with moderate-to-severe intrauterine adhesions following 30-day post-hysteroscopic placement of balloon stents or intrauterine contraceptive devices: A randomized controlled trial

BACKGROUND

Intrauterine adhesions (IUA) develop in up to 20% of women with a history of abortion. After hysteroscopic adhesiolysis, balloon stents are usually placed for seven days to prevent recurrence. The efficacy of prolonged use (30 days) of balloon stents has not been determined.

METHODS

The trial was conducted from June 2019 to March 2021. Ninety-one patients who underwent hysteroscopic adhesiolysis for moderate or severe IUA were randomized to receive a 30-day placement of a balloon stent (n = 44) or an intrauterine device (IUD) (n = 47). The primary outcomes were the ongoing pregnancy and miscarriage rates assessed at 15-19 months. The secondary outcomes were the recurrence of IUA and the American Fertility Society (AFS) intrauterine adhesion scores at the first and second hysteroscopies, the diagnosis of new chronic endometritis at the second-look hysteroscopy, and the vaginal/uterine microbiome assessed using 16S rRNA sequencing. The trial was registered at Chinese Clinical Trial Registry (ChiCTR1900023306).

FINDINGS

The ongoing pregnancy rates (balloon 56·4% versus IUD 57·1%) and miscarriage rates (balloon 10·3% versus IUD 22·9%) were not significantly different between the groups. No differences in the recurrence of IUA, reduction of AFS scores, or new endometritis rates were detected. The bacterial load in the uterus and vagina increased in the IUD group but not in the balloon group.

INTERPRETATION

Balloon placement has a similar effect on ongoing pregnancy rates as intrauterine device (IUD) placement. Patients who underwent balloon placement had a lower miscarriage rate, although the difference was not significant. There were no differences in the recurrence rate of IUA, reduction of American Fertility Society scores, or rate of new chronic endometritis. The balloon stent has less effects on the uterine microbiota.

FUNDING

National Natural Science Foundation of China (81802593).

Peptidome analysis of human intrauterine adhesion tissues and the identification of antifibrotic peptide

Intrauterine adhesion (IUA) is a common clinical endometrial disease, which can severely damage the fertility and quality of life in women. This study aims to find the differentially expressed endogenous peptides and their possible roles in IUA. Liquid chromatography-mass spectrometry was used to identify the peptidomic profiling of IUA tissues, and the differentially expressed peptides were screened out. Using real-time quantitative PCR, Western blotting, and immunocytochemistry staining, the function of six endogenous peptides was verified in vitro. It was found that peptide 6 (T6) (peptide sequence: TFGGAPGFPLGSPLSSVFPR) could inhibit the expression of TGF-β1-induced cell fibrosis in human endometrial stromal cell line and primary human endometrial stromal cell at a concentration of 50 μmol/L. This study provides new targets for further clarifying the formation and prevention of IUA.

Stem cells technology as a platform for generating reproductive system organoids and treatment of infertility-related diseases

In recent years, stem cells have known as a helpful biological tool for the accurate diagnosis, treatment and recognition of diseases. Using stem cells as biomarkers have presented high potential in the early detection of many diseases. Another advancement in stem cell technology includes stem cell derived organoids model that could be a promising platform for diagnosis and modeling different diseases. Furthermore, therapeutic capabilities of stem cell therapy have increased hope in the face of different disability managements. All of these technologies are also widely used in reproductive related diseases especially in today's world that many couples encounter infertility problems. However, with the aid of numerous improvements in the treatment of infertility, over 80% of couples who dreamed of having children could now have children. Due to the fact that infertility has many negative effects on personal and social lives of young couples, many researchers have focused on the treatment of male and female reproductive system abnormalities with different types of stem cells, including embryonic stem cells, bone marrow mesenchymal stem cells (MSCs), and umbilical cord-derived MSCs. Also, design and formation of reproductive system organoids provide a fascinating window into disease modeling, drug screening, personalized therapy, and regeneration medicine. Utilizing these techniques to study, model and treat the infertility-related diseases has drawn attention of many scientists. This review explains different applications of stem cells in generating reproductive system organoids and stem cell-based therapies for male and female infertility related diseases treatment.