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Wang Y, Tang Z, Teng X. New advances in the treatment of thin endometrium. Front Endocrinol (Lausanne) 2024; 15:1269382. [PMID: 38745960 PMCID: PMC11092375 DOI: 10.3389/fendo.2024.1269382] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2023] [Accepted: 03/22/2024] [Indexed: 05/16/2024] Open
Abstract
Thin endometrium (TE) is defined as a mid-luteal endometrial thickness ≤7mm. TE can affect endometrial tolerance, leading to lower embryo implantation rates and clinical pregnancy rates, and is also associated with impaired outcomes from assisted reproductive treatment. Herein, we systematically review TE causes, mechanisms, and treatments. TE pathogenesis has multiple causes, with the endometrium becoming thinner with age under hormonal influence. In addition, uterine cavity factors are important, as the inflammatory environment may affect expressions of certain genes thereby inhibiting endometrial stromal cell proliferation and promoting apoptosis. Long-term oral contraceptive use or the use of ovulation-promoting drugs are also definite factors contributing to endometrial thinning. Other patients have primary factors, for which the clinical etiology remains unknown. The main therapeutic strategies available for TE are pharmacological (including hormonal and vasoactive drugs), regenerative medicine, intrauterine infusion of growth factor-granulocyte colony-stimulating factor, autologous platelet-rich plasma, and complementary alternative therapies (including traditional Chinese herbal medicine and acupuncture). However, the associated mechanisms of action are currently unclear. Clinical scholars have proposed various approaches to improve treatment outcomes in patients with TE, and are exploring the principles of efficacy, offering potentials for novel treatments. It is hoped that this will improve TE tolerance, increase embryo implantation rates, and help more couples with infertility with effective treatments.
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Affiliation(s)
- Yidi Wang
- Beijing Hospital of Traditional Chinese Medicine, Capital Medical University, Beijing, China
| | - Zunhao Tang
- College of Traditional Chinese Medicine, Shandong University of Traditional Chinese Medicine, Jinan, China
| | - Xiuxiang Teng
- Beijing Hospital of Traditional Chinese Medicine, Capital Medical University, Beijing, China
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Cai L, Jeong YW, Hwang WS, Hyun SH. Optimization of human recombinant granulocyte-colony stimulating factor supplementation during in vitro production of porcine embryos to improve the efficiency of resource utilization of poor-quality cumulus-oocyte complexes. Theriogenology 2024; 216:93-102. [PMID: 38159389 DOI: 10.1016/j.theriogenology.2023.12.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2023] [Revised: 12/11/2023] [Accepted: 12/12/2023] [Indexed: 01/03/2024]
Abstract
Granulocyte colony-stimulating factor (G-CSF), a pleiotropic cytokine, is secreted by the reproductive tract. Furthermore, our previous study indicated that human recombinant G-CSF (hrG-CSF) supplementation during porcine oocyte in vitro maturation (IVM) or during embryo in vitro culture (IVC) improved their quality and development potential when using cumulus-oocyte complexes (COCs) with more than three cumulus cell layers (CCL >3). Thus, in this study, we investigate the optimal conditions of hrG-CSF supplementation throughout the in vitro production (IVP: IVM + IVC) system to improve the embryo production efficiency of "poor-quality (CCL ≤3)" oocytes. COCs were classified into two groups according to the number of CCL (>3 and ≤3) and embryonic viability was analyzed after treatment with hrG-CSF during IVC. The mRNA transcription levels of G-CSF in COCs were compared based on their type and the period of IVM. Finally, developmental capacity and quality were evaluated after treatment with hrG-CSF for different periods of IVP. No marked effects on the developmental potential of embryos when using CCL ≤3 type COCs were observed after supplementing hrG-CSF only during IVC. Moreover, the mRNA transcription level of G-CSF increased gradually with IVM culture time and was higher in CCL ≤3 COCs than in >3. Supplementing hrG-CSF only during the IVM period resulted in the best embryo developmental potential, while supplementing hrG-CSF during the IVP period resulted in the best quality embryos, reflected in the increased total cell number and decreased apoptotic nuclei index of blastocysts. These findings indicate that "poor-quality" COCs may have a greater demand for G-CSF than "good-quality", meanwhile hrG-CSF supplementation throughout IVP improves resource utilization efficiency in poor-quality COCs.
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Affiliation(s)
- Lian Cai
- UAE Biotech Research Center, Al Wathba, 30310, Abu Dhabi, United Arab Emirates; Laboratory of Veterinary Embryology and Biotechnology (VETEMBIO), College of Veterinary Medicine, Chungbuk National University, Cheongju, 28644, Republic of Korea; School of Veterinary Biosecurity and Protection, Chungbuk National University, Cheongju, 28644, Republic of Korea
| | - Yeon-Woo Jeong
- UAE Biotech Research Center, Al Wathba, 30310, Abu Dhabi, United Arab Emirates
| | - Woo-Suk Hwang
- UAE Biotech Research Center, Al Wathba, 30310, Abu Dhabi, United Arab Emirates; Department of Biology, North-Eastern Federal University, Yakutsk, 67707, Sakha Republic, Russia.
| | - Sang-Hwan Hyun
- Laboratory of Veterinary Embryology and Biotechnology (VETEMBIO), College of Veterinary Medicine, Chungbuk National University, Cheongju, 28644, Republic of Korea; School of Veterinary Biosecurity and Protection, Chungbuk National University, Cheongju, 28644, Republic of Korea.
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Won J, Lee D, Lee YG, Hong SH, Kim JH, Kang YJ. The therapeutic effects and optimal timing of granulocyte colony stimulating factor intrauterine administration during IVF-ET. Life Sci 2023; 317:121444. [PMID: 36731644 DOI: 10.1016/j.lfs.2023.121444] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Revised: 01/18/2023] [Accepted: 01/23/2023] [Indexed: 02/01/2023]
Abstract
Most of embryos fail to produce live offspring during In Vitro Fertilization-Embryo Transfer (IVF-ET) procedure. There is a dearth of research activity addressing this problem despite the significant population of women suffering from repeated implantation failure after transfer of high-quality of embryos. As a clinically accessible option, granulocyte colony stimulating factor (G-CSF) is often used for the treatment to improve the rates of embryo implantation. However, there are currently no evidence-based standardized protocol for the clinical use of G-CSF. G-CSF was administered into one side of mouse uterine horns and saline was infused into the other side of horns as a control. Intrauterine G-CSF administration showed maximal effects 24 h after administration in enhancing endometrial receptivity and subsequent increase of angiogenesis by demonstrating elevated integrin β3 and OPN and reduced cytotoxicity of NK cells. Furthermore, G-CSF administration 24 h prior to embryo transfer promoted the stability of attached embryos at the early stage of implantation in vitro. Our findings suggest as new consensus criteria providing a potential therapeutic strategy of the clinical use of G-CSF to achieve maximal effects of IVF-ET for patients who are suffering from repeated implantation failure with the problems with endometrial receptivity.
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Affiliation(s)
- Jieun Won
- CHA Fertility Center Bundang, 59, Yatap-ro, Bundang-gu, Seongnam-si, Gyeonggi-do, South Korea
| | - Danbi Lee
- Department of Biomedical Science, School of Life Science, CHA University, 335 Pangyo, Bundang-gu, Seongnam-si, Gyeonggi-do, South Korea
| | - Yu-Gyeong Lee
- Department of Biomedical Science, School of Life Science, CHA University, 335 Pangyo, Bundang-gu, Seongnam-si, Gyeonggi-do, South Korea
| | - Seon-Hwa Hong
- CHA Fertility Center Bundang, 59, Yatap-ro, Bundang-gu, Seongnam-si, Gyeonggi-do, South Korea
| | - Jee Hyun Kim
- CHA Fertility Center Bundang, 59, Yatap-ro, Bundang-gu, Seongnam-si, Gyeonggi-do, South Korea.
| | - Youn-Jung Kang
- Department of Biochemistry, School of Medicine, CHA University, 335 Pangyo, Bundang-gu, Seongnam-si, Gyeonggi-do, South Korea.
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Intrauterine botulinum toxin A administration promotes endometrial regeneration mediated by IGFBP3-dependent OPN proteolytic cleavage in thin endometrium. Cell Mol Life Sci 2023; 80:26. [PMID: 36602651 PMCID: PMC9816300 DOI: 10.1007/s00018-022-04684-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2022] [Revised: 12/13/2022] [Accepted: 12/26/2022] [Indexed: 01/06/2023]
Abstract
Adequate endometrial growth is a critical factor for successful embryo implantation and pregnancy maintenance. We previously reported the efficacy of intrauterine administration of botulinum toxin A (BoTA) in improving the endometrial angiogenesis and the rates of embryo implantation. Here, we further evaluated its potent therapeutic effects on the uterine structural and functional repair and elucidated underlying molecular regulatory mechanisms. This study demonstrated that a murine model of thin endometrium was successfully established by displaying dramatically decreased endometrial thickness and the rates of embryo implantation compared to normal endometrium. Interestingly, the expressions of insulin-like growth factor binding protein-3 (IGFBP3) and an active 35 kDa-form of osteopontin (OPN) were significantly reduced in thin endometrium, which were almost fully restored by intrauterine BoTA administration. Neutralization of BoTA-induced IGFBP3 subsequently suppressed proteolytic cleavage of OPN, exhibiting un-recovered endometrial thickness even in the presence of BoTA administration, suggesting that BoTA-induced endometrial regeneration might be mediated by IGFBP3-dependent OPN proteolytic cleavage. Our findings suggest that intrauterine BoTA administration improves the endometrial environment in our murine model with thin endometrium by increasing endometrial receptivity and angiogenesis in a manner dependent on the regulatory effect of IGFBP3 on OPN proteolytic cleavage, proposing BoTA as an efficient therapeutic strategy for the patients with thin endometrium.
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Le A, Li Q, Zheng X, Yang H. P16 and P21 are involved in the pathogenesis of endometrial thinning: A cross-sectional study. Medicine (Baltimore) 2022; 101:e30987. [PMID: 36221425 PMCID: PMC9542757 DOI: 10.1097/md.0000000000030987] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
P16 plays a role in the negative regulation of cell proliferation, regulating cell apoptosis to control the growth of tumor cells. P21 is a nuclear protein that suppresses DNA synthesis and inhibits cell division. This study aimed to examine the expression and roles of P16 and P21 in endometrial thinning. Thirty cases of endometrial biopsy diagnosed as endometrial thinning were assessed by p16 and p21 immunohistochemistry from March 2014 to August 2020 in Huazhong University of Science and Technology Union Shenzhen Hospital. Another thirty cases of normal endometrium in the same period were assessed as controls. The specimens underwent histological analysis, and P16 and P21 were assessed by immunohistochemistry. There were no statistically significant differences in age, menstrual cycle, BMI, sex hormone levels, gravidity and parity between the two groups (all P > .05). In the endometrial thinning group, P16 was expressed in the endometrial adenoid nucleus, cytolymph and interstitial cell nucleus. In the normal group, P16 was mainly expressed in the endometrial adenoid nucleus, with some P16 signals detected in the endometrial interstitial nucleus. P21 expression was mainly detected in the endometrial adenoid nucleus. P16 and P21 amounts in endometrial thinning cases were significantly lower than those of the normal endometrial group. There was no correlation between p16 and p21 amounts. This study revealed aberrant expression of P16 and P21 in the endometrium might be due to a compensatory effect of the thin endometrium to increase cell proliferation and suppress cell apoptosis. However, the pathological roles of P16 and P21 in endometrial thinning and the contribution of cell senescence deserve further investigation.
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Affiliation(s)
- Aiwen Le
- Department of Gynaecology, Huazhong University of Science and Technology Union Shenzhen Hospital, Shenzhen Nanshan Peopleʼs Hospital and The Sixth Affiliated Hospital of Shenzhen University Health Science Center, Shenzhen, China
- *Correspondence: Aiwen Le, Department of Gynaecology, Huazhong University of Science and Technology Union Shenzhen Hospital, Shenzhen Nanshan Peopleʼs Hospital and The Sixth Affiliated Hospital of Shenzhen University Health Science Center, Shenzhen 518052, China (e-mail: )
| | - Qifeng Li
- Department of Pathology, Huazhong University of Science and Technology Union Shenzhen Hospital, Shenzhen Nanshan Peopleʼs Hospital and The Sixth Affiliated Hospital of Shenzhen University Health Science Center, Shenzhen, China
| | - Xianchan Zheng
- Department of Gynaecology, Huazhong University of Science and Technology Union Shenzhen Hospital, Shenzhen Nanshan Peopleʼs Hospital and The Sixth Affiliated Hospital of Shenzhen University Health Science Center, Shenzhen, China
| | - Huan Yang
- Department of Obstetrics and Gynecology, Coney Island Hospital, Brooklyn, NY, USA
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Ding J, Wang J, Cai X, Yin T, Zhang Y, Yang C, Yang J. Granulocyte colony-stimulating factor in reproductive-related disease: Function, regulation and therapeutic effect. Biomed Pharmacother 2022; 150:112903. [PMID: 35430390 DOI: 10.1016/j.biopha.2022.112903] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Revised: 03/14/2022] [Accepted: 03/27/2022] [Indexed: 11/16/2022] Open
Abstract
Granulocyte colony-stimulating factor (G-CSF) is one of the cytokines which plays important roles in embryo implantation and normal pregnancy. At the maternal-fetal interface, G-CSF can be synthesized by multiple cells, and participates in regulation of trophoblast development, endometrial decidualization, placental metabolism and angiogenesis. Moreover, as an important medium of intercellular communication, G-CSF has also been shown to exert key roles in crosstalk between cellular components at the maternal-fetal interface. Recently, our study demonstrated that G-CSF derived from M2 macrophage could promote trophoblasts invasion and migration through activating PI3K/AKT/Erk1/2 pathway, thereby involving in normal pregnancy program. Herein, we will summarize the role and regulation of G-CSF in normal pregnancy and reproductive-related disease, and the clinical applications of G-CSF in patients undergoing in vitro fertilization with thin endometrium, repeated implantation failure, and women suffered with recurrent spontaneous abortion.
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Affiliation(s)
- Jinli Ding
- Reproductive Medical Center, Renmin Hospital of Wuhan University & Hubei Clinic Research Center for Assisted Reproductive Technology and Embryonic Development, Wuhan 430060, China
| | - Jing Wang
- Reproductive Medical Center, Renmin Hospital of Wuhan University & Hubei Clinic Research Center for Assisted Reproductive Technology and Embryonic Development, Wuhan 430060, China
| | - Xiaopeng Cai
- Department of Gastrointestinal Surgery, Zhongnan Hospital of Wuhan University & Hubei Key Laboratory of Tumor Biological Behaviors & Hubei Cancer Clinical Study Center & The Clinical Medical Research Center of Peritoneal Cancer of Wuhan, Wuhan 430071, China
| | - Tailang Yin
- Reproductive Medical Center, Renmin Hospital of Wuhan University & Hubei Clinic Research Center for Assisted Reproductive Technology and Embryonic Development, Wuhan 430060, China
| | - Yan Zhang
- Department of Clinical Laboratory, Renmin Hospital of Wuhan University, Wuhan 430060, China.
| | - Chaogang Yang
- Department of Gastrointestinal Surgery, Zhongnan Hospital of Wuhan University & Hubei Key Laboratory of Tumor Biological Behaviors & Hubei Cancer Clinical Study Center & The Clinical Medical Research Center of Peritoneal Cancer of Wuhan, Wuhan 430071, China.
| | - Jing Yang
- Reproductive Medical Center, Renmin Hospital of Wuhan University & Hubei Clinic Research Center for Assisted Reproductive Technology and Embryonic Development, Wuhan 430060, China.
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Wu W, Xu GF, Hu YJ. The therapeutic effect of granulocyte colony stimulating factor (G-CSF) on potential biochemical pregnancy in patients with unexplained repeated transplantation failure (RIF): a case series and literature review. Gynecol Endocrinol 2022; 38:443-447. [PMID: 35244509 DOI: 10.1080/09513590.2022.2036716] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
BACKGROUND Biochemical pregnancy is a type of embryo transfer failure, patients with unexplained repeated implantation failure (RIF) also have higher biochemical pregnancy rate. Our study intends to evaluate the effect of granulocyte colony-stimulating factor (G-CSF) in patients with unexplained RIF with low hCG levels in early pregnancy. METHODS Unexplained RIF patients with low hCG levels after embryo transfer were allocated. G-CSF were administrated from the ninth days after embryo transfer. Clinical pregnancy, miscarriage and live birth rates were evaluated. RESULTS The clinical pregnancy and live birth rates were 52.5% and 30%. CONCLUSION G-CSF is an effective treatment for potential biochemical pregnancy in unexplained RIF patients.
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Affiliation(s)
- Wei Wu
- Department of Reproductive Endocrinology, Women's Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Gu-Feng Xu
- Department of Reproductive Endocrinology, Women's Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Department of Obstetrics, Gynecology and Reproductive Biology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Yan-Jun Hu
- Department of Reproductive Endocrinology, Women's Hospital, Zhejiang University School of Medicine, Hangzhou, China
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Zhang Y, Chen X, Chen S, Wei C, Li B, Wang Z, Shen X, Lin X. OUP accepted manuscript. Hum Reprod 2022; 37:725-733. [PMID: 35147195 DOI: 10.1093/humrep/deac023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2021] [Revised: 12/03/2021] [Indexed: 11/13/2022] Open
Affiliation(s)
- Yanling Zhang
- Assisted Reproduction Unit, Department of Obstetrics and Gynecology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, P. R. China
- Key Laboratory of Reproductive Dysfunction Management of Zhejiang Province, Hangzhou, P. R. China
| | - Xuanyu Chen
- Department of Obstetrics and Gynecology, Wenzhou People's Hospital, Wenzhou, Zhejiang Province, P. R. China
| | - Sijia Chen
- Assisted Reproduction Unit, Department of Obstetrics and Gynecology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, P. R. China
- Key Laboratory of Reproductive Dysfunction Management of Zhejiang Province, Hangzhou, P. R. China
| | - Cheng Wei
- Assisted Reproduction Unit, Department of Obstetrics and Gynecology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, P. R. China
- Key Laboratory of Reproductive Dysfunction Management of Zhejiang Province, Hangzhou, P. R. China
| | - Baijia Li
- Assisted Reproduction Unit, Department of Obstetrics and Gynecology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, P. R. China
- Key Laboratory of Reproductive Dysfunction Management of Zhejiang Province, Hangzhou, P. R. China
| | - Zilian Wang
- Assisted Reproduction Unit, Department of Obstetrics and Gynecology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, P. R. China
- Key Laboratory of Reproductive Dysfunction Management of Zhejiang Province, Hangzhou, P. R. China
| | - Xiaolu Shen
- Department of Obstetrics and Gynecology, Wenzhou People's Hospital, Wenzhou, Zhejiang Province, P. R. China
| | - Xiaona Lin
- Assisted Reproduction Unit, Department of Obstetrics and Gynecology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, P. R. China
- Key Laboratory of Reproductive Dysfunction Management of Zhejiang Province, Hangzhou, P. R. China
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Wen J, Hou B, Lin W, Guo F, Cheng M, Zheng J, He P, Ji W. 3D-printed hydrogel scaffold-loaded granulocyte colony-stimulating factor sustained-release microspheres and their effect on endometrial regeneration. Biomater Sci 2022; 10:3346-3358. [DOI: 10.1039/d2bm00109h] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
After injury, the endometrium cannot self-repair or regenerate because damages of the basal layer of the uterine, which often lead to intrauterine adhesions (IUAs), which can cause serious problems such...
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Human Acellular Amniotic Matrix with Previously Seeded Umbilical Cord Mesenchymal Stem Cells Restores Endometrial Function in a Rat Model of Injury. Mediators Inflamm 2021; 2021:5573594. [PMID: 34531703 PMCID: PMC8438588 DOI: 10.1155/2021/5573594] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2021] [Revised: 06/24/2021] [Accepted: 08/03/2021] [Indexed: 12/17/2022] Open
Abstract
Background Abnormal endometrial repair after injury results in the formation of intrauterine adhesions (IUA) and a thin endometrium, which are key causes for implantation failure and infertility. Stem cell transplantation offers a potential alternative for some cases of severe Asherman's syndrome that cannot be treated with surgery or hormonal therapy. Umbilical cord-derived mesenchymal stem cells (UCMSCs) have been reported to repair the damaged endometrium. However, there is no report on the effects of UCMSCs previously seeded on human acellular amniotic matrix (AAM) on endometrial injury. Methods Absolute ethanol was injected into rat uteri to damage the endometrium. UCMSCs previously seeded on AAM were surgically transplanted. Using a variety of methods, the treatment response was assessed by endometrial thickness, endometrial biomarker expression, endometrial receptivity, cell proliferation, and inflammatory factors. Results Endometrial thickness was markedly improved after UCMSC-AAM transplantation. The expression of endometrial biomarkers, namely, vimentin, cytokeratin, and integrin β3, in treated rats increased compared with untreated rats. In the UCMSC-AAM group, the VEGF expression decreased, whereas that of MMP9 increased compared with the injury group. Moreover, in the AAM group, the MMP9 expression increased. The expression of proinflammatory factors (IL-2, TNFα, and IFN-γ) in the UCMSC-AAM group decreased compared with the untreated group, whereas the expression of anti-inflammatory factors (IL-4, IL-10) increased significantly. Conclusions UCMSC transplantation using AAM as the carrier can be applied to treat endometrial injury in rats. The successful preparation of lyophilized AAM provides the possibility of secondary infectious disease screening and amniotic matrix quality detection, followed by retrospective analysis. The UCMSC-AAM complex may promote the better application of UCMSCs on the treatment of injured endometrium.
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