Endometriosis-associated infertility: aspects of pathophysiological mechanisms and treatment options

Effects of chronic particulate matter exposure on endometriosis-associated signaling pathways and disease progression

Exposure to PM2.5 (particulate matter <2.5 μm) has been implicated in increasing the risk of endometriosis and worsening its symptoms. However, the molecular mechanisms and direct associations remain unclear. This study explored whether PM2.5 contributes to the onset or progression of endometriosis using in vitro and in vivo models. Endometrial (EM) cells from women without endometriosis were cultured to the second passages (P2) with or without exposure to PM2.5 at a concentration of 200 µg/ml (N = 5 for each group). Z-stack confocal imaging confirmed PM accumulation in the nucleus and cytoplasm of exposed EM cells. Initial PM exposure at the primary passage (P0) led to decreased proliferation, migration, anti-apoptosis, and oxidative stress, accompanied by downregulation of associated pathways. However, repeated PM exposure during subculturing to P2 led to increased proliferation, enhanced anti-apoptotic activity, and elevated oxidative stress. Given the similarity of these gene expression alterations to those observed in endometriosis, an endometriosis-induced mouse model was established to assess the potential of repeated PM exposure to exacerbate the condition in vivo. To investigate the in vivo effects, an endometriosis-induced mouse model was developed using female C57BL/6 mice exposed to low (10 mg/kg/day) or high (20 mg/kg/day) doses of PM2.5 for 4 weeks (n = 6 for each group). PM exposure significantly enlarged endometriotic lesions compared to controls (no PM exposure). Upregulated gene expression in endometriotic lesions included anti-apoptotic (Bcl2/Bax), proliferative (p-ERK), inflammatory (p-NF-κB, p-c-jun, IL-6, IL-1β), and migration (MMP-2, MMP-9) markers. PM exposure altered estrogen receptor (ER) expression, resulting in a decreased ERα/ERβ ratio in both dose groups. The control group exhibited a ratio of 1.03 ± 0.09, while the low-dose and high-dose mice had ratios of 0.57 ± 0.08 (P = 0.02) and 0.46 ± 0.26 (P = 0.03), respectively. In conclusion, PM2.5 exposure alters gene expression related to cell growth, survival, oxidative stress, and migration in EM cells and exacerbates endometriotic lesions in vivo, likely through ER modulation. These findings suggest PM2.5 may contribute to other estrogen-dependent conditions, such as leiomyoma or adenomyosis, by influencing ER pathways.

Causal Relationship Between Abortion and Endometriosis: A Bidirectional Two-Sample Mendelian Randomization Study

PROBLEM

The relationship between abortion and endometriosis (EMS) has been inconsistent in previous observational studies and remains controversial. We intended to examine the causal relationship between abortion and EMS.

METHODS OF STUDY

We conducted a Mendelian randomization (MR) analysis using genome-wide association study (GWAS) summary statistics, drawing data from the FinnGen database and the UK Biobank. The primary analysis utilized the random-effects inverse variance weighted (IVW) approach, complemented by weighted median, weighted mode, and MR-Egger methods. Comprehensive sensitivity analyses were conducted, encompassing the Cochran's Q statistic for assessing heterogeneity and MR-PRESSO to detect pleiotropy. Additionally, Leave-One-Out (LOO) analysis was conducted to confirm the stability of our results.

RESULTS

The IVW method revealed no statistically significant causal association between various types of abortion and EMS. Specifically, the odds ratios (ORs) were as follows: medical abortion (OR 0.96, 95% CI: 0.78-1.18, p = 0.72), spontaneous abortion (OR 0.99, 95% CI: 0.81-1.21, p = 0.92), and other types of abortions (OR 1.01, 95% CI: 0.99-1.03, p = 0.36), indicating no significant effects on the risk of EMS. Similarly, analysis in the reverse direction showed no significant causal effects of EMS on the likelihood of experiencing any type of abortion, with ORs for medical abortion (0.97, 95% CI: 0.91-1.03, p = 0.33), spontaneous abortion (0.98, 95% CI: 0.92-1.04, p = 0.50), and other abortions (1.30, 95% CI: 0.76-2.23, p = 0.34). Sensitivity analyses supported these findings, demonstrating no evidence of horizontal pleiotropy or significant heterogeneity.

CONCLUSION

Our MR results do not support a causal relationship between abortion and EMS.

The Improved-EFI Score: A Multi-Omics-Based Novel Efficacy Predictive Tool for Predicting the Natural Fertility of Endometriosis Patients

Objective

Infertility caused by endometriosis (EM) directly affects the possibility of pregnancy in women of gestational age. This study aims to establish a prediction model to accurately predict the natural pregnancy outcome of patients with EM, providing valuable information for clinical decision-making.

Methods

We retrospectively selected a total of 496 patients who underwent their first laparoscopic surgery for infertility at the Obstetrics and Gynecology Department of Jingzhou Central Hospital from January 2016 to June 2023. An improved endometriosis fertility index (EFI) predictive model was created based on ultrasound radiomics and urinary proteomics gathered during the patient's initial admission, using two machine learning algorithms. The predictive model was evaluated for C-index, calibration, and clinical applicability through receiver working characteristic curve, decision curve analysis.

Results

The improved EFI prediction model nomogram, based on five ultrasound radiomics parameters and three urine proteomics, had AUC values of 0.921 (95% CI: 0.864-0.978) and 0.909 (95% CI: 0.852-0.966) in the training and validation sets, respectively, while the traditional EFI prediction model had AUC values of 0.889 (95% CI: 0.832-0.946) and 0.873 (95% CI: 0.816-0.930) in the training and validation sets, respectively. Additionally, the nomogram exhibited better discrimination ability and achieved an overall better benefit against threshold probability than the EFI model and decision tree in the decision curve analysis (DCA).

Conclusion

The combined ultrasound radiomics-urine proteomics model was better able to predict natural pregnancy-associated patients with EM compared to the classical EFI score. This can help clinicians better predict an individual patient's risk of natural pregnancy following a first-ever laparoscopic surgery and facilitate earlier diagnosis and treatment.

Endostatin-expressing endometrial mesenchymal stem cells inhibit angiogenesis in endometriosis through the miRNA-21-5p/TIMP3/PI3K/Akt/mTOR pathway

Endometriosis is a chronic inflammatory and neoangiogenic disease. Endostatin is one of the most effective inhibitors of angiogenesis. Mesenchymal stem cells (MSCs) have been investigated as compelling options for cell therapy. However, the effect and mechanism of action of endostatin-expressing endometrial MSCs (EMSCs) in endometriosis are unclear. Here, EMSCs were genetically modified to overexpress endostatin (EMSCs-Endo). A reduction in the angiogenic capacity of HUVECs was observed in vitro after treatment with EMSCs-Endo. EMSCs-Endo significantly suppressed endometriotic lesion growth in vivo. The limited efficacy was associated with suppressed angiogenesis. The miRNA-21-5p level and the levels of p-PI3K, p-mTOR, and p-Akt in HUVECs and mouse endometriotic lesions significantly decreased after treatment with EMSCs-Endo, whereas TIMP3 expression significantly increased. In summary, targeted gene therapy with EMSCs-Endo is feasible, and its efficacy in regulating endometriosis can be attributed to the inhibition of angiogenesis, suggesting that EMSCs could be used as promising vehicles for targeted gene therapy.

Higher oxidative balance score is associated with a decreased risk of infertility: an analysis of NHANES 2013-2020

Background

Oxidative stress plays a crucial role in the female reproductive system. The oxidative balance score (OBS) is a new measure for assessing the balance between antioxidant and pro-oxidative factors in diet and lifestyle. However, limited studies have explored the relationship between OBS and infertility.

Methods

We performed a cross-sectional study including 2,664 women aged 20-45 years, based on data from the 2013-2020 National Health and Nutrition Examination Survey (NHANES). The OBS was derived from 16 dietary components and 4 lifestyle factors. We used multivariate logistic regression analysis to examine the association between OBS and infertility.

Results

The analysis revealed a significant negative association between higher OBS and infertility risk, with an odds ratio (OR) of 0.98 (95% CI, 0.95-1.00) after full adjustment. Compared to the first quartile of OBS, the second, third, and fourth quartiles showed ORs of 0.71 (95% CI, 0.45-1.11), 0.79 (95% CI, 0.51-1.22), and 0.57 (95% CI, 0.35-0.92), respectively. Similarly, women in the highest dietary OBS and lifestyle OBS quartiles had a lower infertility risk compared to those in the lowest quartiles, with ORs of 0.60 (95% CI, 0.39-0.94) and 0.54 (95% CI, 0.32-0.93), respectively. Furthermore, subgroup analysis indicated that the association between the fourth quartile of OBS and infertility remained consistent, except among women with other ethnicities-including multi-racial, and college graduate or higher.

Conclusion

These findings suggest that high dietary OBS and lifestyle OBS are associated with a lower risk of infertility.

Advances in the diagnosis and management of endometriosis: A comprehensive review

Endometriosis is a prevalent gynecological condition characterized by the presence of endometrial-like tissue outside the uterus, leading to chronic pelvic pain and infertility. This review aims to shed light on the latest advancements in diagnosing and managing endometriosis. It offers insight into the condition's pathogenesis, clinical symptoms, diagnostic techniques, and available treatment approaches. Furthermore, the article emphasizes innovative technologies and novel therapeutic strategies that promise to enhance patient outcomes significantly. This review aspires to empower clinicians to deliver the highest quality care to their patients affected by this challenging condition by consolidating the current understanding of endometriosis.

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

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

Bisphenol A and its potential mechanism of action for reproductive toxicity

Bisphenol A (BPA) is an organic synthetic chemical used worldwide. Billions of pounds of BPA are produced annually through industrial processes to be used in commercial products, making human exposure to BPA ubiquitous. Concerns have been raised due to the potential adverse health effects of BPA, specifically in vulnerable populations, such as pregnant persons and children. BPA is an endocrine-disrupting chemical, and through this function has been linked to reproductive toxicity. We review BPA's historical and current use, health and safety concerns and regulations, sources of exposure, and evidence for male and female reproductive toxicity. Evidence from epidemiological and animal studies idenfity that low- and high-exposure levels of BPA (prenatal, postnatal and adulthood exposure) can adversely affect male and female fertility and reproductive organs. While the cause of BPA-induced reproductive toxicity is not fully understood, we discuss BPA's estrogenic and androgenic activity, and its ability to disrupt the hypothalamic-pituitary-gonadal axis as a potential associated mechanism. There are significant differences in tolerable daily intakes of BPA set by global agencies, making interpretation of previous and emerging research findings challenging and inconsistent. Although BPA is deemed toxic by some government agencies, most do not currently consider it a health risk due to low populational exposure levels. However, we highlight evidence that even at acute, low exposure, BPA can adversely affect reproductive function. We recommend continuing research into the adverse effects of BPA on human health and revisiting the regulatory measures of BPA to limit exposure and promote public awareness of its potential to cause reproductive toxicity.

Evaluation of immunohistochemical TRPC3 and TRPC6 expression patterns in human endometriosis

BACKGROUND

Although to date the pathogenesis of endometriosis remains largely unexplained, it is known that processes of migration, proliferation and revascularization and thus calcium as a messenger substance play an important role. Consecutively, the present study examines the immunohistochemical expression of the calcium transient receptor potential channels 3 and 6 (TRPC3 and TRPC6) in ectopically located (outside the uterine cavity) endometrial tissue.

METHODS

Laparoscopically collected and histomorphologically verified endometriosis tissues from several different intraabdominal locations were examined (n = 20) and immunohistochemical stainings were performed with anti-TRPC3 and anti-TRPC6 antibodies (Alomone Labs, Jerusalem). Hereby, eutopic endometrium served as a healthy control cohort (n = 6). Staining patterns were evaluated using a modified immunoreactive score (IRS) and exploratory statistical analysis was performed, aiming to determine relations of staining intensities with associated clinical parameters such as rASRM stage and location.

RESULTS

We determined a strong cytoplasmatic TRPC3 and TRPC6 expression in all ectopic endometrial glandular formations, albeit with focally varying staining intensities. Within our cohort, we did not verify a statistically significant difference of TRPC3 and TRPC6 expression between endometriosis patients and a healthy control group or between different clinical affections (rASRM stages).

CONCLUSIONS

Our study confirms - to our knowledge for the first time - the successful immunohistochemical assessment of TRPC3 and TRPC6 in endometriosis, setting the basis for future studies aiming at evaluating not only clinical aspects of TRPC3 and TRPC6 expression but also shedding light on its function in the pathophysiological context of endometriosis.

A Narrative Review Regarding Implication of Ovarian Endometriomas in Infertility

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

Female reproductive disease, endometriosis: From inflammation to infertility

Despite the fact that endometriosis is a common gynecological disease that occurs in 10% of women of reproductive age, the pathogenesis and treatment strategy are not clear to date. Endometriosis patients are commonly characterized by adhesions in the pelvis or ovaries, which leads to prolonged inflammation in the abdominal cavity. To handle the chronic inflammation, changes of immune cells, including T cells, NK cells, and macrophage, are accompanied. Therefore, diverse cytokines and adhesions of the abdominal cavity lead to poor quality of ovarian follicles, inappropriate response to the hormone, and infertility. This review will guide researchers to summarize the molecular changes and identify new treatment strategies for endometriosis-mediated inflammation and pregnancy failure.

Dyspareunia and Biomarkers: A Case Study of Sexual Dysfunction in Moderate Endometriosis

Endometriosis, a chronic hormone-dependent condition affecting 10% of women globally, impacts pelvic organs and occasionally distant sites, causing pain, infertility, and sexual dysfunction. Biomarkers such as IL-8, IL-10, and BDNF influence inflammation, nerve sensitization, and pain. This study investigates their relationship with sexual quality of life, focusing on dyspareunia and related dysfunctions, as assessed using the Female Sexual Function Index (FSFI). Dyspareunia, a prominent symptom of endometriosis, is linked to lower FSFI scores in domains such as desire (mean 3.38), satisfaction (mean 3.28), and pain (mean 3.07). Elevated IL-8 tissue levels negatively correlated with desire (r = -0.649, p < 0.05) and satisfaction (r = -0.813, p < 0.01). Similarly, higher BDNF tissue levels were associated with increased pain (r = -0.435, p < 0.01) and reduced satisfaction (r = -0.252, p < 0.05). Patient factors such as higher endometriosis severity scores (mean 26.3, p < 0.05) and surgical history correlated with lower desire and satisfaction. Conversely, physical activity improved pain scores (p < 0.01) and enhanced desire and lubrication (p < 0.05), likely through reduced inflammation and better circulation. These findings highlight the complex interplay between biomarkers, individual factors, and sexual dysfunction in endometriosis, underscoring the need for personalized therapeutic approaches.

Ectopic endometrial stromal cell-derived extracellular vesicles encapsulating microRNA-25-3p induce endometrial collagen I deposition impairing decidualization in endometriosis

Endometrial collagen I undergoes dynamic degradation and remodelling in response to endometrial stromal cell (ESC) decidualization and embryo implantation. However, excessive collagen I deposition in the endometrium during the implantation window may impair decidualization, causing embryo implantation failure in patients with endometriosis (EMS). We found that endometrial collagen I expression during the mid-secretory phase was increased in the EMS group of patients. Collagen I stimulation resulted in decreased expression of the decidualization markers prolactin and insulin-like growth factor binding protein-1 in ESCs, impeding ESC transformation to a decidual morphology and decreasing the blastocyst-like spheroid expansion area in vitro. Treatment with extracellular vesicles (EVs) derived from the ectopic ESCs of EMS patients (EMS-EVs) increased collagen I expression in vivo and in vitro and decreased the blastocyst-like spheroid expansion area. Furthermore, EV microRNA (miRNA) sequencing revealed that there were 40 upregulated and 77 downregulated miRNAs in EMS-EVs when compared to the EVs derived from ESCs in the endometrium of control patients (CTL-EVs), including increased expression of miR-25-3p that targets phosphatase and tensin homolog (PTEN). We also found that PTEN expression was decreased and p-Akt expression was increased in the endometrium of EMS patients and EMS-EV-treated ESCs. miR-25-3p transfected ESCs exhibited increased collagen I, decreased PTEN, and increased p-Akt. Additionally, an EV uptake study further showed that EMS-EVs were preferentially taken up by ESCs rather than by endometrial epithelial cells. These results suggest that EMS-EVs encapsulating miR-25-3p might be preferentially taken up by eutopic ESCs where they may induce endometrial collagen I deposition to impair ESC decidualization in EMS.

Unveiling the fibrotic puzzle of endometriosis: An overlooked concern calling for prompt action

Endometriosis is a benign, estrogen-dependent, persistent chronic inflammatory heterogeneous condition that features fibrotic adhesions caused by periodic bleeding. The characteristic ectopic lesions are marked by a widely spread dense fibrotic interstitium comprising of fibroblasts, myofibroblasts, collagen fibers, extracellular proteins, inflammatory cells, and active angiogenesis. Fibrosis is now recognized as a critical component of endometriosis because of which current treatments, such as hormonal therapy and surgical excision of lesions are largely ineffective with severe side effects, high recurrence rates, and significant morbidity. The symptoms include dysmenorrhea (cyclic or noncyclic), dyspareunia, abdominal discomfort, and infertility. The significant lack of knowledge regarding the underlying root causes, etiology, and complex pathogenesis of this debilitating condition, hinders early diagnosis and implement effective therapeutic approaches with minimal side effects presenting substantial hurdles in endometriosis management. Emerging research offer a close relationship between endometriosis and fibrosis, which is believed to be tightly linked to pain, a primary contributor to the deterioration of the patient's quality of life. However, the underlying pathophysiological cellular and molecular signaling pathways behind endometriosis-associated fibrosis are poorly addressed. The available experimental disease models have tremendous challenges in reproducing the human characteristics of the disease limiting the treatment effectiveness. Future translational research on the topic has been hindered by the lack of an adequate fibrotic model of endometriosis emphasizing the necessity of etiological exploration. This review article focuses on recent developments in the field and highlight the necessity for novel fibrotic models for early diagnosis, a better understanding the disease's etiology and develop effective anti-fibrotic treatments. By addressing these knowledge gaps, we want to open fresh avenues for a thorough investigation and extended research in the field of endometriosis.

Combine Surgery and In Vitro Fertilization (IVF) in Endometriosis-Related Infertility: When and Why

Endometriosis is a chronic, estrogen-dependent inflammatory disease characterized by the presence of endometrial tissue outside the uterus, causing pelvic pain and infertility. Infertility arises mainly due to inflammatory mediators in the peritoneal fluid, contributing to local hypoestrogenism, which appears to exacerbate chronic inflammation and sensitize pelvic nerves. Local hypoestrogenism within endometriotic lesions contrasts with the systemic estrogen-dependent nature of the disease. This localized reduction in estrogen levels, resulting from an altered hormonal response, can contribute to the altered immune response and inflammation characteristic of endometriosis, potentially exacerbating tissue damage, promoting fibrosis, adhesions, and endometrioma formation that distort pelvic anatomy, and affecting fertility. Chronic pelvic pain and dyspareunia further complicate conception in affected women. In vitro fertilization (IVF) and laparoscopic surgical excision of endometriotic lesions are the two primary management options for endometriosis-related infertility, although current data provide limited guidance on when to prefer one approach over the other. It is generally accepted that treatment strategies must be individualized according to the patient's wishes, symptomatology, age and the preferences of the woman and the couple. Timely intervention and structured follow-up for symptomatic women wishing to conceive may maximize conception rates within two years post-surgery, while minimizing the need for repeated interventions, which should be avoided. On the other hand, first-line IVF is particularly viable in cases of unoperated deep infiltrating endometriosis in asymptomatic women, or for those ineligible for or opposed to surgery. This review aims to evaluate the most recent data on endometriosis-related infertility to identify evidence-based key points that can enhance tailored management in clinical practice.

The long road of drug development for endometriosis - Pains, gains, and hopes

Endometriosis, defined by the growth of endometrial tissues outside of the uterine cavity, is a global health burden for ∼200 million women. Patients with endometriosis usually present with chronic pain and are often diagnosed with infertility. The pathogenesis of endometriosis is still an open question; however, tissue stemness and immunological and genetic factors have been extensively discussed in the establishment of endometriotic lesions. Current treatments for endometriosis can be categorized into pharmacological management of hormone levels and surgical removal of the lesions. Both approaches have limited efficacy, with recurrences often encountered; thus, there is no complete cure for the disease or its symptoms. We review the current knowledge of the etiology of endometriosis and summarize the advancement of pharmacological management of endometriosis. We also discuss our efforts in applying DNA-encoded chemistry technology (DEC-Tec) to identify bioactive molecules for the treatment of endometriosis, offering new avenues for developing non-hormonal treatment options for those patients who seek spontaneous pregnancies.

The effects of oral nutritional supplements on endometriosis-related pain: A narrative review of clinical studies

Endometriosis is a condition that can cause significant pain and discomfort for women, and the clinical and surgical treatments available have variable efficacy and can have adverse effects. These drawbacks often lead to poor adherence and therapeutic failure. Consequently, there has been increasing interest in the use of nutritional supplements as an adjuvant therapy for endometriosis. To facilitate clinical decision-making in managing women with endometriosis, a narrative review of clinical studies was conducted to investigate the effects of oral nutritional supplements on endometriosis-related pain. A literature search of the English-language PubMed/MEDLINE database was performed using appropriate keywords to identify clinical studies involving oral nutritional supplements and reporting on endometriosis-related pain. This narrative review included 20 studies published between 2013 and 2023, comprising 12 randomized controlled trials, six non-comparative trials, and two observational studies. The studies investigated the effects of various nutritional supplements on endometriosis-related pain, including vitamins, fatty acids, probiotics, medicinal plants, and bioactive compounds. A significant decrease in endometriosis-related pain was found in three out of five studies on vitamins, four out of six studies on fatty acids, one study on probiotics, two studies on medicinal plants, and five out of six studies on bioactive compounds. These nutritional supplements exhibited diverse biological activities, such as anti-inflammatory, antioxidant, antiproliferative, and antiangiogenic effects, all of which are relevant for managing endometriosis. These findings suggest that oral nutritional supplements could be included as part of a multidisciplinary treatment for endometriosis to decrease pain and enhance overall medical treatment.

The role and potential treatment of macrophages in patients with infertility and endometriosis

Endometriosis is characterized as a macrophage-related ailment due to its strong link with immune dysfunction. Understanding the status of macrophage polarization in the context of endometriosis-related infertility is crucial for advancing diagnostic and therapeutic strategies. Our comprehensive review delves into the foundational understanding of macrophages and their profound influence on both endometriosis and infertility. Additionally, we illuminate the complex role of macrophages in infertility and endometriosis specifically. Finally, we focused on four critical dimensions: follicular fluid, the intraperitoneal environment, endometrial receptivity, and strategies for managing endometriosis. It is clear that throughout the progression of endometriosis, the diverse polarization states of macrophages play a pivotal role in the internal reproductive environment of infertile individuals grappling with this condition. Modulating macrophage polarization in the reproductive environment of endometriosis patients could address infertility challenges more effectively, offering a promising pathway for treating infertility associated with endometriosis.

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

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

A cross-sectional study on the relationship between dietary fiber and endometriosis risk based on NHANES 1999-2006

Endometriosis is a chronic inflammatory disease and an estrogen-dependent disease, so dietary factors that can modulate estrogen activity may be clinically important. Dietary fiber, widely distributed in vegetables and fruits, is closely associated with a plant-based diet. Therefore, this study aims to analyze and explore the relationship between dietary fiber intake and the risk of endometriosis providing insights for future clinical significance and treatment approaches. This cross-sectional study obtained data from the National Health and Nutrition Examination Survey (NHANES) 1999-2006 for women aged 20-54 years. A total of 2840 subjects were finally included for analysis, 2599 (91.51%) in the non-endometriosis group and 241 (8.49%) in the endometriosis group. The study used dietary fibre intake as exposure variable and endometriosis risk as outcome variable. Through the use of multiple regression modelling, subgroup analyses, smoothed curve fitting, and threshold effect tests, we uncovered a significant link between exposure and outcome. In Model 2 (Multiple regression equation model after adjusting all confounding variables), after adjusting for confounders, dietary fiber intake was negatively associated with the likelihood of developing endometriosis(OR = 0.588, 95% CI = 0.360-0.959, p = 0.041). In subgroup analyses stratified by age, race, BMI, educational level, hypertension, diabetes,and hyperlipidemia, significant interactions were visualised from smoothed fitted curves. In the cross-sectional study, a connection was observed between a higher intake of dietary fiber and a decreased risk of endometriosis.

A bird-eye view of diaphragmatic endometriosis: current practices and future perspectives

Diaphragmatic endometriosis is one of the most common localization of extra-pelvic endometriosis and may cause debilitating symptoms such as cyclic shoulder pain, right upper abdominal pain, and right-sided chest pain. Diaphragmatic endometriosis may also be asymptomatic. The exact mechanisms by which diaphragmatic endometriosis originates are unknown. The high correlation between severe pelvic endometriosis and diaphragmatic endometriosis suggests that the latter originates from endometriotic cells that reach the upper abdomen by circulating with the peritoneal fluid current. Robust evidence regarding the preoperative diagnosis and optimal management of diaphragmatic endometriosis is lacking. Most reports rely on Magnetic Resonance Imaging (MRI) for the radiologic diagnosis of diaphragmatic endometriosis. Although its sensitivity ranged between 78% and 83%, MRI was found to underestimate the extent of diaphragmatic endometriosis in comparison with the surgical findings. Accumulating evidence indicates that asymptomatic diaphragmatic endometriosis is very unlikely to progress, and therefore, could be left in situ when incidentally found. The efficiency of ablative and excisional approaches for symptomatic endometriosis has not been assessed thoroughly to date. In addition, it is unclear whether combining the laparoscopic approach with video-assisted thoracoscopy (VATS) may result in an optimized result. This gap exists due to the lack of data about the association between diaphragmatic and thoracic endometriosis. In this review, we aimed to provide a state of the art description of the current knowledge and gaps about the pathogenesis, diagnostics, and treatment modalities of diaphragmatic endometriosis.

Genetic alteration of mRNA editing enzyme APOBEC3B in the pathogenesis of ovarian endometriosis

RESEARCH QUESTION

What are the specific genetic alterations and associated network in endometriotic cells responsible for the disease pathogenesis?

DESIGN

Case control experimental study involving 45 women with endometriosis who underwent laparoscopic surgery (case) and 45 normal samples from women undergoing total abdominal hysterectomy (control). The endometrial samples were subjected to whole exome sequencing (WES) of endometriotic tissue and copy number variation analysis. Validation of gene hits were obtained from WES using polymerase chain reaction techniques, immunological techniques, in-silico tools and transgenic cell line models.

RESULTS

Germline heterozygous deletion of mRNA editing enzyme subunit APOBEC3B was identified in about 96% of endometriosis samples. The presence of germline deletion was confirmed with blood, endometrium and normal ovary samples obtained from the same patient. APOBEC3B deletions resulted in a hybrid protein that activates A1CF. APOBEC3B deletion can be a major cause of changes in the endometriotic microenvironment, and contributes to the pathogenesis and manifestation of the disease. The effect of APOBEC3B deletion was proved by in-vitro experiments in a cell line model, which displayed endometriosis-like characteristics. APOBEC3B germline deletion plays a major role in the pathogenesis of endometriosis, which is evident by the activation of A1CF, an increase in epithelial to mesenchymal transition, cellular proliferation, inflammation markers and a decrease in apoptosis markers.

CONCLUSION

The deleterious effects caused by APOBEC3B deletion in endometriosis were identified and confirmed. These results might provide a base for identifying the complete pathogenetic mechanism of endometriosis, thereby moving a step closer to better diagnosis and treatment options.

The association between serum HDL levels and infertility among American women aged 20-44 years: A retrospective cross-sectional study of NHANES, 2013-2020

BACKGROUND

Infertility is a significant national public health concern, and the World Health Organization (WHO) predicts that it will rank as the third most prevalent disease following tumors, cardiovascular and cerebrovascular diseases. The impact of dysfunctional lipoproteins on female infertility remains relatively understudied; therefore, the research focuses on exploring the relationship between serum high-density lipoprotein (HDL) concentration and infertility.

METHODS

This is a retrospective cross-sectional study where we employed multivariate logistic regression analysis to examine the association between serum HDL concentrations and female infertility. The strength of association was quantified using odds ratios (OR) along with their corresponding 95% confidence intervals and statistical significance was evaluated at a level of P < 0.05 (two-tailed).

RESULTS

The study found that there was a significant correlation between serum HDL and infertility without adjusting the model (OR = 0.62, 95%CI 0.48-0.82, P<0.001). After adjusting for covariates, a weak correlation between HDL and infertility remained (OR = 0.70, 95%CI 0.49-1.00). When HDL concentrations were divided into quartiles, there was a trend of strengthened correlation between HDL and infertility risk with the increase in HDL concentrations. Specifically, individuals in the highest concentration quartile exhibited a 44.0% lower risk of infertility compared to those in the lowest concentration quartile (95% CI 0.38-0.84). In the age-stratified analysis, after adjusting for covariates, the correlation between HDL and infertility was statistically insignificant across all age groups. Furthermore, after categorizing HDL levels into quartiles, we observed a dose-dependent trend between HDL and the reduction of female infertility risk in the adjusted models of the secondary infertility group. Specifically, in the adjusted model, the high-concentration group exhibited a 67.0% lower risk of infertility compared to the low-concentration group (OR = 0.33; 95% CI: 0.12-0.940, P = 0.04).

CONCLUSION

Our research findings suggest weak negative correlation between serum HDL and female infertility. However, upon stratified analysis by age, the correlation between HDL and infertility did not attain statistical significance. In cases of secondary infertility, a subtle dose-dependent trend was observed between serum HDL and infertility.

In Vitro Fertilization (IVF) Outcomes in Patients With Endometriosis Compared to Patients With Tubal Factor Infertility in Indonesia: A Retrospective Study

BACKGROUND

Endometriosis is a disease characterized by dysmenorrhea, chronic pelvic pain, and infertility. The pathogenesis of endometriosis and its relationship to infertility are still not fully understood. In vitro fertilization (IVF) is considered an effective treatment for patients with endometriosis-associated infertility. This study compared the pregnancy rates of endometriosis patients who underwent IVF with those of patients with tubal obstruction.

METHODS

This was a retrospective cross-sectional study of 225 patients with endometriosis and tubal factor infertility who underwent IVF at Yasmin Clinic, Dr. Cipto Mangunkusumo National General Hospital, Jakarta, Indonesia, between January 2013 and August 2021. Demographic data, anti-Mullerian hormone (AMH) levels, the initial and total dose of recombinant follicle stimulating hormone (rFSH), the total dose of recombinant luteinizing hormone (rLH), stimulation duration, oocyte maturation rates, fertilization rates, embryo cleavage rates, and pregnancy rates (biochemical, clinical and ongoing) were obtained.

RESULTS

AMH level, number of oocytes retrieved, and embryo cleavage rates were significantly lower in the endometriosis group. Initial and total doses of rFSH and total dose of rLH were higher, and the duration of stimulation was longer in the endometriosis group compared to the tubal factor group. In the endometriosis group, the biochemical (47.3% vs. 52.7%, p=0.375), clinical (43.1% vs. 56.9%, p=0.215), and ongoing (45.5% vs. 54.5%, p=0.511) pregnancy rates were lower than those in the tubal factor group. However, there were no statistically significant differences between the two groups. There was no significant difference in pregnancy rates between the short antagonist and ultra-long protocols (three months of downregulation). From multivariate analysis, only rLH supplementation was found to be significantly related to pregnancy outcomes in patients with endometriosis.

CONCLUSION

AMH levels, number of oocytes retrieved, and embryo cleavage rates were lower in patients with endometriosis. However, pregnancy rates were not significantly different from patients with tubal factors. Supplementation with rLH may improve pregnancy rates in patients with endometriosis who have undergone IVF programs.

Endometriosis and Infertility: A Bibliometric Analysis of the 100 Most-Cited Articles from 2000 to 2023

OBJECTIVES

This study aimed to conduct a bibliometric analysis of research on endometriosis and infertility, focusing on the 100 most-cited (TOP100) articles in the literature.

DESIGN

The design of this study is a bibliometric analysis.

PARTICIPANTS/MATERIALS, SETTING, METHODS

The SCOPUS database was searched using the terms "endometriosis" and "infertility." The productivity and impact of research publications by authors, countries, and journals were assessed using the following indicators: total number of publications, total number of citations (TNC), journal impact factor, and journal citation indicator. The bibliometric analysis was conducted from January 1, 2000, to December 31, 2023, using IBM SPSS™ for Windows and VOSviewer 1.6.20. VOSviewer was used to evaluate the TNC, total number of authors/coauthors, and collaboration network between countries of the TOP100 articles. VOSviewer was also used to create keyword co-occurrence networks.

RESULTS

Of the TOP100 articles, 69 were literature review articles, with a mean of 448.97 ± 513.5 citations (range: 191-2,705). The TOP100 articles were published by 479 authors (mean 5.8 ± 7.3 per study) from 40 countries in 39 high-impact journals. The keyword co-occurrence network revealed a grouping of four clusters, with terms related to pathophysiology, clinical management, assisted reproductive technology, and hormonal treatment of endometriosis.

LIMITATIONS

The main limitation of our study is the use of only one database and TNC as the main bibliometric indicator. Studies need at least 2-3 years after publication to accumulate sufficient citations for bibliometric indicators to be reliable. This means that large number of recent studies were not included in this bibliometric analysis.

CONCLUSIONS

This study revealed trends in endometriosis and infertility research, especially in the fields of immunology and genetics. It also highlights the importance of global collaboration to improve diagnostics, treatments, and outcomes.

Analysis of risk factors for postoperative anxiety and depression in endometriosis patients with reproductive intention

BACKGROUND

The occurrence of postoperative depression and anxiety in patients with endometriosis (EMS) not only causes psychological distress, but may also harm their physical health.

AIM

To explore the postoperative depression status, and its influencing factors, of EMS patients with reproductive intention.

METHODS

A total of 321 EMS patients with reproductive intent were included. Using the self-rating anxiety scale and self-rating depression scale, EMS patients with anxiety or depression were distinguished. A clinical model for predicting anxiety or depression in EMS patients was constructed and evaluated using a nomogram, receiver operating characteristic curve, and calibration curve.

RESULTS

The results of the single factor analysis showed that smoking, coffee, EMS stage, chronic pelvic pain, and sexual discomfort may be related to anxiety. Further, smoking, drinking, spouse, annual household income and EMS stage may be related to depression in EMS patients. Multivariate logistic regression illustrated that smoking, coffee, chronic pelvic pain and sexual discomfort may be independent risk factors for anxiety in EMS patients, while smoking, EMS stage (Phase III and Phase IV), spouse and high annual household income may be independent risk factors for depression in EMS patients. Additionally, the models used to predict the risk of anxiety or depression in EMS patients have good predictive value.

CONCLUSION

The anxiety and depression of EMS patients may be related to many factors. In clinical treatment, additional attention should be paid to the psychological status of EMS patients.

Comparison of Time to Pregnancy in In Vitro Fertilisation between Endometriosis and Nonendometriosis

Background

This study is to compare the time to pregnancy (TTP) between patients with endometriosis and nonendometriosis undergoing in vitro fertilisation (IVF).Material and Methods.This is an observational retrospective cohort study. We included 291 patients (53 with endometriosis and 238 without endometriosis) achieving biochemical pregnancy, whether singleton or multifetal (serum beta-hCG >5 mIU/mL), between 1st January 2014 and 31st March 2020. We excluded patients with incomplete case notes and those declining participation. Time to pregnancy is the interval between the time when infertility was established to the date of confirmed biochemical pregnancy, expressed in months. Endometriosis diagnosis includes any form of endometriosis through surgical confirmation. A statistical analysis was done through the Mann-Whitney U test. Time to pregnancy was assessed through the Kaplan-Meier test. A p value <0.05 is considered statistically significant.

Results

Endometriosis patients had a shorter infertility duration (4 years vs. 5 years, p=0.024). Both groups had similar median age and body mass index at presentation. There was no significant difference in the TTP between endometriosis and nonendometriosis groups (57.7 vs. 70.9 months, p=0.060), further confirmed by a Cox regression test incorporating confounders (IVF protocol (OR: 1.482, 95% CI 0.667-3.292, and p=0.334) and type of the cycle (OR 1.071, 95% CI 0.803-1.430, and p=0.640)). The endometriosis group reached the maximum cumulative pregnancy rate at around 169 months postinfertility diagnosis, whilst the nonendometriosis group at around 255 months postinfertility diagnosis.

Conclusion

Time to pregnancy between endometriosis and nonendometriosis is not significantly different. However, infertility among patients with endometriosis tends to be shorter.

Health and socioeconomic well-being of women with endometriosis and provoked vestibulodynia: Longitudinal insights from Swedish registry data

Endometriosis and provoked vestibulodynia (PVD) are prevalent pain conditions among women of reproductive age, significantly impacting their quality of life and psychological well-being. However, comprehensive evidence regarding the lifelong health and socioeconomic outcomes for these individuals remains scarce. Additionally, many prior studies rely on limited and sometimes unrepresentative samples. This study aims to inform on the long-term consequences of these disorders by examining health, fertility, and employment outcomes in a cohort of women diagnosed with endometriosis and/or PVD, tracing their experiences from childhood to their 40s. Leveraging nationwide administrative data from Sweden and employing a matched case-control design, we investigate both similarities and differences between women with these diagnoses and those without. Our findings indicate that women diagnosed with endometriosis and/or PVD demonstrate elevated healthcare utilization patterns, commencing in their early teenage years and progressively increasing over time. Notably, disparities in labor market outcomes emerge in their 20s, showcasing lower labor earnings and a rise in sickness benefit receipt. Moreover, our results show a higher likelihood among these women to experience mental health disorders and concurrent chronic pain diseases, as well as infertility. While the association between endometriosis and infertility is well-documented, this study offers novel insights into a potential similar link between PVD and infertility. Our study informs healthcare professionals and policymakers about the considerable burden of compromised health, adverse psychosocial well-being, and reduced productivity in the labor market faced by young women with these common pain conditions. These findings underscore the urgency of addressing the multifaceted challenges encountered by individuals diagnosed with endometriosis and PVD across their lifespan.

Pain after oocyte retrieval in women with endometriosis undergoing fertility preservation or IVF

RESEARCH QUESTION

Do women with endometriosis undergoing oocyte retrieval for fertility preservation experience the same level of pain as women undergoing oocyte retrieval for IVF?

DESIGN

This retrospective cohort study included 796 cycles in women with endometriosis undergoing oocyte retrieval for fertility preservation (n = 401) or IVF (n = 395) between January 2020 and October 2022. Post-operative pain assessments were compared between the two groups using a numeric rating scale (NRS).

RESULTS

Women in the fertility preservation group were younger (32.1 ± 4.2 years versus 35.1 ± 4.1 years; P < 0.001), had a lower body mass index (22.8 ± 3.9 kg/m2 versus 24.6 ± 4.4 kg/m2; P < 0.001) and had a lower concentration of anti-Müllerian hormone (1.8 ± 1.5 ng/ml versus 2.15 ± 2.11 ng/ml; P = 0.026) in comparison with women in the IVF group. The oestrogen concentration on the day of ovulation trigger was higher in women in the fertility preservation group (2188 ± 1152 pg/ml versus 2081 ± 995 pg/ml; P = 0.004), and the prevalence rates of adenomyosis and digestive endometrial lesions were lower in women in the fertility preservation group (14% versus 29%, P < 0.001; 16% versus 25%, P = 0.003, respectively) compared with women in the IVF group. After oocyte puncture, more women in the fertility preservation group had an NRS pain score >3 (moderate to severe pain) compared with women in the IVF group (20% versus 14%; P = 0.018). The progestin-primed ovarian stimulation (PPOS) protocol was identified as an independent predictive factor of greater post-operative pain (adjusted OR 2.30, 95% CI 1.06-5.15; P = 0.039).

CONCLUSION

Women with endometriosis undergoing fertility preservation reported more intense post-operative pain in the recovery room than women undergoing IVF. The PPOS protocol was an independent risk factor of intense pain (NRS pain score >3) in women with endometriosis, but further studies are needed to confirm this result.

Endometrial E-cadherin and N-cadherin Expression during the Mid-Secretory Phase of Women with Ovarian Endometrioma or Uterine Fibroids

BACKGROUND

Endometriosis and uterine fibroids are benign conditions frequently linked to subfertility/infertility. Recent research has highlighted the importance of epithelial-mesenchymal transition between embryonic and endometrial cells in the context of embryo implantation. Additionally, the adverse endometrial environment during implantation has been proposed as a mechanism contributing to infertility in endometriosis. Nevertheless, the role of cadherin molecule alterations in relation to endometrial receptivity and embryo invasion remains a subject of controversy.

METHODS

We investigated the expression patterns of E-cadherin and N-cadherin in the endometria of women with ovarian endometrioma or uterine fibroids and assessed whether they differed from those of healthy women. We enrolled 17 women with ovarian endometrioma, 16 with uterine fibroids, and 6 healthy women. Endometrial tissues were obtained at the mid-secretory phase on days 19-24 of the menstrual cycle. The E-cadherin and N-cadherin mRNA and protein expression levels were measured using quantitative reverse transcriptase polymerase chain reaction and Western blot analysis, respectively.

RESULTS

The E-cadherin and N-cadherin mRNA expression levels were higher and lower, respectively, in the endometrium of women with ovarian endometrioma than in those of the controls. In the endometrium of women with uterine fibroids, similar patterns with higher E-cadherin and lower N-cadherin levels were observed compared with that of the controls. Protein expression showed similar patterns.

CONCLUSIONS

Our findings revealed higher E-cadherin expression and lower N-cadherin expression in the endometria of women with infertility-related diseases than in those of healthy women in the mid-secretory phase. This suggests a resistance to endometrial receptivity, potentially reflecting mesenchymal-epithelial transition properties.

Case report: Human seminal plasma allergy diagnosis for a woman with unexplained infertility

Background

Infertility is a pressing global public health concern, affecting millions worldwide, and the diagnosis of unexplained infertility poses particular challenges. Human seminal plasma allergy, a rarely diagnosed type I hypersensitivity reaction, emerges as a potential but often overlooked contributor to female infertility. With rare reported cases globally, the condition's low awareness and insufficient differential diagnosis may mask its actual prevalence.

Case report

This case report presents the clinical case of a 29-year-old woman with unexplained infertility who underwent two unsuccessful IVF procedures and was subsequently diagnosed with human seminal plasma allergy. The patient, known for bronchial asthma and allergic rhinitis exacerbated by inhalant allergens, exhibited eosinophilia and a history of local allergy symptoms (burning sensation, vulvar pruritus, edema, and general discomfort) as well as sneezing and nasal congestion following unprotected intercourse-symptoms compatible with human seminal plasma allergy. Molecular allergy diagnostics revealed pronounced sensitization to dust mites and Can f 5, a canine-specific allergen. A positive skin prick test using her partner's sperm confirmed the diagnosis of human seminal plasma allergy. The patient's medical history also includes mild endometriosis, raising questions about the interplay between allergic conditions and fertility. Treatment options such as barrier contraception, antihistamine therapy, and sperm desensitization are discussed.

Conclusion

Highlighting the need for increased awareness among healthcare professionals, this case emphasizes the significance of reporting and sharing clinical experiences to enhance our understanding of this rare condition. As researchers continue to accumulate relevant information, a more comprehensive understanding of human seminal plasma allergy and its potential impact on female fertility will contribute to improved diagnostic protocols and expanded treatment options. This case report contributes to the growing body of knowledge surrounding this rare allergy, serving as a reminder of possible intricate relationships between allergic conditions and reproductive health.

Exploring the Influence of IL-8, IL-10, Patient-Reported Pain, and Physical Activity on Endometriosis Severity

Endometriosis is known to be a chronic, debilitating disease. The pathophysiological mechanisms of endometriosis development include local chronic inflammation and a certain degree of local immune deficit. We investigated the relationship between the endometriosis severity, IL-8, IL-10, BDNF, VEGF-A serum and tissue levels, patient-related pain, and physical activity in a cohort of 46 patients diagnosed with endometriosis who underwent surgery. The same panel of biomarkers was investigated in a control group of 44 reproductive-aged patients with non-endometriotic gynecological pathology who underwent surgical intervention. Our data show a high statistical significance between tissue expression of IL-8, IL-10, patient-related pain, and the severity of endometriosis. No relationship was identified between serum or tissue levels of VEGF-A and BDNF and the severity of endometriosis. These results validate the presence of local chronic inflammation and immune deficit, thereby creating, alongside other studies in the field, an opportunity for the development of innovative and personalized treatment approaches in endometriosis.

Analysis of factors affecting pregnancy outcomes in patients with adenomyosis after high intensity focused ultrasound ablation: a retrospective study

OBJECTIVES

To investigate all pregnancies and analyze the factors influencing pregnancy outcomes in patients with adenomyosis after high intensity focused ultrasound (HIFU).

MATERIALS AND METHODS

A total of 231 patients with adenomyosis who completed HIFU and wished to conceive were enrolled. The symptom improvement and information of pregnancy were recorded during the follow-up period. Factors influencing pregnancy outcomes were analyzed using multivariate regression analysis and survival analysis.

RESULTS

After HIFU, 100 of 231 (43.3%) patients became pregnant within 96 months, including 77 (77/194, 39.7%) in natural and 23 (23/37, 62.2%) in vitro fertilization and embryo transfer (IVF-ET) pregnancies following gonadotropin-releasing hormone agonist (GnRHa). Among the 108 (46.8%, 108/231) infertile patients (defined as the failure to achieve pregnancy after 12 months of regular unprotected sexual intercourse, 40 primary infertility and 68 secondary infertility), 31 (28.7%) became pregnant. At the end of the follow-up, 70 successfully delivered 71 healthy babies. No uterine rupture occurred during pregnancy and delivery. Patients with pelvic adhesion and infertility history had a lower pregnancy chance than that of patients without pelvic adhesion and infertility history (OR < 1, p < 0.05). Patients with small adenomyotic lesion volume had a greater pregnancy chance than that of patients with large lesion volume (OR < 1, p < 0.05). IVF-ET following GnRHa had a better pregnancy chance (p < 0.05).

CONCLUSIONS

HIFU seems to have a beneficial effect on fertility of patients with adenomyosis. Pelvic adhesion, infertility history, and large adenomyotic lesion volume have adverse effects on pregnancy, but IVF-ET following GnRHa after HIFU could increase the pregnancy chance.

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

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

Cannabidiol as a possible treatment for endometriosis through suppression of inflammation and angiogenesis

BACKGROUND

Endometriosis is associated with a wide variety of signs and symptoms and can lead to infertility, embryo death, and even miscarriage. Although the exact pathogenesis and etiology of endometriosis is still unclear, it has been shown that it has a chronic inflammatory nature and angiogenesis is also involved in it.

OBJECTIVE

This review aims to explore the role of inflammation and angiogenesis in endometriosis and suggest a potential treatment targeting these pathways.

FINDINGS

Among the pro-inflammatory cytokines, studies have shown solid roles for interleukin 1β (IL-β), IL-6, and tumor necrosis factor α (TNF-α) in the pathogenesis of this condition. Other than inflammation, angiogenesis, the formation of new blood vessels from pre-existing capillaries, is also involved in the pathogenesis of endometriosis. Among angiogenic factors, vascular endothelial growth factor (VEGF), hypoxia-inducible factor 1α (HIF-1α), transforming growth factor β1 (TGF-β1), and matrix metalloproteinases (MMPs) are more essential in the pathogenesis of endometriosis. Interestingly, it has been shown that inflammation and angiogenesis share some similar pathways with each other that could be potentially targeted for treatment of diseases caused by these two processes. Cannabidiol (CBD) is a non-psychoactive member of cannabinoids which has well-known and notable anti-inflammatory and antiangiogenic properties. This agent has been shown to decrease IL-1β, IL-6, TNF-α, VEGF, TGFβ, and MMPs in different animal models of diseases.

CONCLUSION

It seems that CBD could be a possible treatment for endometriosis due to its anti-inflammatory and antiangiogenic activity, however, further studies are needed.

Comparison of ovarian preservation versus oophorectomy on fertility outcomes in patients with endometriosis post-laparoscopic surgery: A prospective study

BACKGROUND

Endometriosis is a chronic inflammatory condition affecting a significant proportion of women of reproductive age. Although laparoscopic surgery is commonly the preferred treatment, the decision to preserve or remove the ovaries remains controversial. Previous studies have yielded inconsistent results regarding the impact of ovarian preservation vs oophorectomy on fertility outcomes and disease recurrence. This prospective study aimed to address this knowledge gap by comparing the effects of these surgical approaches on spontaneous pregnancy rates, time to pregnancy, recurrence rates, and postoperative pain in patients with endometriosis.

AIM

To compare the reproductive outcomes and recurrence rates between ovarian preservation and oophorectomy in women undergoing laparoscopic surgery for endometriosis.

METHODS

This study was conducted at a tertiary care hospital between January 2019 and December 2023. A total of 312 women aged 18 to 40 years, diagnosed with endometriosis and undergoing laparoscopic surgery, were included. The patients were categorized into the ovarian preservation group (n = 204) and the oophorectomy group (n = 108). The primary outcome measure was the achievement of spontaneous pregnancy within 24 months post-surgery. Secondary outcomes included time to spontaneous pregnancy, recurrence rates, and postoperative pain scores.

RESULTS

The ovarian preservation group exhibited a significantly higher spontaneous pregnancy rate than that in the oophorectomy group (43.6% vs 28.7%, P = 0.006). Moreover, the median time to spontaneous pregnancy was shorter in the ovarian preservation group (8.2 months vs 11.4 months, P = 0.018). Nonetheless, endometriosis recurrence was more prevalent in the ovarian preservation group (22.1% vs 11.1%, P = 0.014). The postoperative pain scores demonstrated similar improvements in both groups, with no significant differences observed. Subgroup analyses indicated that the benefit of ovarian preservation on spontaneous pregnancy rates was more evident among younger women (≤ 35 years) and those with advanced-stage endometriosis.

CONCLUSION

Ovarian preservation is associated with a high spontaneous pregnancy rate and a short time to pregnancy. However, because of the increased risk of recurrence, the decision should be based on age, fertility aspirations, and disease severity.

Diagnostic Value of Menstrual Blood Lipidomics in Endometriosis: A Pilot Study

Endometriosis is a prevalent chronic inflammatory disease characterized by a considerable delay between initial symptoms and diagnosis through surgery. The pressing need for a timely, non-invasive diagnostic solution underscores the focus of current research efforts. This study examines the diagnostic potential of the menstrual blood lipidome. The lipid profile of 39 samples (23 women with endometriosis and 16 patients in a control group) was acquired using reverse-phase high-performance liquid chromatography-mass spectrometry with LipidMatch processing and identification. Profiles were normalized based on total ion counts. Significant differences in lipids were determined using the Mann-Whitney test. Lipids for the diagnostic model, based on logistic regression, were selected using a combination of variance importance projection filters and Akaike information criteria. Levels of ceramides, sphingomyelins, cardiolipins, triacylglycerols, acyl- and alkenyl-phosphatidylethanolamines, and alkenyl-phosphatidylcholines increased, while acyl- and alkyl-phosphatidylcholines decreased in cases of endometriosis. Plasmenylphosphatidylethanolamine PE P-16:0/18:1 and cardiolipin CL 16:0_18:0_22:5_22:6 serve as marker lipids in the diagnostic model, exhibiting a sensitivity of 81% and specificity of 85%. The diagnostic approach based on dried spots of menstrual blood holds promise as an alternative to traditional non-invasive methods for endometriosis screening.

Endometriosis: A Comprehensive Analysis of the Pathophysiology, Treatment, and Nutritional Aspects, and Its Repercussions on the Quality of Life of Patients

Endometriosis is a chronic proinflammatory pathology characterized by the growth of tissue similar to the endometrium outside the uterus, affecting approximately 5 to 15% of women worldwide. Suffering from endometriosis entails a complex pathophysiological process, significantly impacting the quality of life and reproductive function of affected women; therefore, it must be addressed in a personalized and comprehensive manner, as its management requires a multidisciplinary approach. This article aims to conduct a comprehensive literature review of endometriosis, not only as a pathophysiological condition but also as a significant factor impacting the social, nutritional, and mental well-being of those who experience it. Emphasis is placed on the importance of understanding and assessing the impact of the pathology to provide a better and more comprehensive approach, integrating various alternatives and strategic treatments for the factors involved in its development. The aim is to provide a complete overview of endometriosis, from its pathophysiology to its impact on the quality of life of patients, as well as a review of current treatment options, both pharmacological and alternative, in order to broaden the perspective on the pathology to improve the care of patients with this disease.

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

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

Endometriosis is a disease of immune dysfunction, which could be linked to microbiota

Background: Endometriosis, characterized by extrauterine endometrial tissue, leads to irregular bleeding and pelvic pain. Menstrual retrograde theory suggests fragments traverse fallopian tubes, causing inflammation and scar tissue. Prevalent among infertile women, risk factors include fewer pregnancies, delayed childbirth, irregular cycles, and familial predisposition. Treatments, medication, and surgery entail side effects. Studies link gut microbiota alterations to endometriosis, necessitating research to establish causation. We used Mendelian randomization to investigate the potential link between endometriosis and gut microbiota through genetic variants. Methods: Two-sample Mendelian randomization analyzed gut microbiota's potential causal effects on endometriosis. Instrumental variables, robustly associated with exposures, leveraged GWAS data from MiBioGen for gut microbiota and FinnGen R8 release for endometriosis. SNPs strongly associated with exposures were instrumental variables. Rigorous assessments ensured SNP impact scrutiny on endometriosis. Results: At the genus level, Anaerotruncus, Desulfovibrio, Haemophilus, and Holdemania showed causal association with endometriosis. Specific gut microbiota exhibited causal effects on different endometriosis stages. Holdemania and Ruminococcaceae UCG002 exerted reversible, stage-specific impacts. Conclusion: Mendelian randomization provides evidence for the causal link between specific gut microbiotas and endometriosis, emphasizing the pivotal role of gut microbiota dysbiosis. Modulating gut microbiota emerges as a promising strategy for preventing and treating endometriosis.

Analysis of factors affecting pregnancy rate after laparoscopic surgery for infertility associated with endometriosis

OBJECTIVE

To analyze the factors that might influence the pregnancy rate in patients with infertility related to endometriosis (EMs) after undergoing laparoscopic surgery, providing guidance for our clinical diagnostic and therapeutic decision-making.

METHODS

A retrospective analysis was conducted on clinical records and 1-year postoperative pregnancy outcomes of 335 patients diagnosed with endometriosis-related infertility via laparoscopic surgery, admitted to our department from January 2018 to December 2020.

RESULTS

The overall pregnancy rate for patients with endometriosis (EMs) related infertility 1-year post-surgery was 57.3 %, with the highest pregnancy rate observed between 3 to 6 months after surgery. Factors such as Body Mass Index (BMI) (P = 0.515), presence of dysmenorrhea (P = 0.515), previous pelvic surgery (P = 0.247), type of EMs pathology (P = 0.893), and preoperative result of serum carbohydrate antigen 125 (CA125)（P = 0.615）had no statistically significant effect on postoperative pregnancy rates. The duration of infertility (P = 0.029), coexistence of adenomyosis (P = 0.042), surgery duration (P = 0.015), intraoperative blood loss (P = 0.050), preoperative result of serum anti-Müllerian hormone (AMH) (P = 0.002) and age greater than 35 (P = 0.000) significantly impacted postoperative pregnancy rates. The post-surgery pregnancy rate in patients with mild (Stage I-II) EMs was notably higher than those with moderate to severe (Stage III-IV) EMs (P = 0.009). Age (P = 0.002), EMs stage (P = 0.018), intraoperative blood loss (P = 0.010) and adenomyosis (P = 0.022) were the factors that affected the postoperative live birth rate.

CONCLUSION

For patients with EMs-related infertility undergoing laparoscopic surgery, factors such as age > 35 years, infertility duration > 3 years, concurrent adenomyosis, severe EMs, surgery duration ≥ 2 h, intraoperative blood loss ≥ 50 ml, and low AMH before surgery are detrimental for the pregnancy rate within the first postoperative year. However, BMI, dysmenorrhea, past history of pelvic surgery, EMs pathology types (ovarian, peritoneal, deep infiltrating),and preoperative result of serum CA125 barely show any statistical difference in their effect on postoperative pregnancy rates. In terms of postoperative live birth rate, age > 35 years, severe EMs, intraoperative blood loss ≥ 50 ml, and adenomyosis were adverse factors.

The Known, the Unknown and the Future of the Pathophysiology of Endometriosis

Endometriosis is one of the most common causes of chronic pelvic pain and infertility, affecting 10% of women of reproductive age. A delay of up to 9 years is estimated between the onset of symptoms and the diagnosis of endometriosis. Endometriosis is currently defined as the presence of endometrial epithelial and stromal cells at ectopic sites; however, advances in research on endometriosis have some authors believing that endometriosis should be re-defined as "a fibrotic condition in which endometrial stroma and epithelium can be identified". There are several theories on the etiology of the disease, but the origin of endometriosis remains unclear. This review addresses the role of microRNAs (miRNAs), which are naturally occurring post-transcriptional regulatory molecules, in endometriotic lesion development, the inflammatory environment within the peritoneal cavity, including the role that cytokines play during the development of the disease, and how animal models have helped in our understanding of the pathology of this enigmatic disease.

MR Relaxometry for Discriminating Malignant Ovarian Cystic Tumors: A Prospective Multicenter Cohort Study

BACKGROUND

Endometriosis-associated ovarian cancer (EAOC) is a well-known type of cancer that arises from ovarian endometrioma (OE). OE contains iron-rich fluid in its cysts due to repeated hemorrhages in the ovaries. However, distinguishing between benign and malignant tumors can be challenging. We conducted a retrospective study on magnetic resonance (MR) relaxometry of cyst fluid to distinguish EAOC from OE and reported that this method showed good accuracy. The purpose of this study is to evaluate the accuracy of a non-invasive method in re-evaluating pre-surgical diagnosis of malignancy by a prospective multicenter cohort study.

METHODS

After the standard diagnosis process, the R2 values were obtained using a 3T system. Data on the patients were then collected through the Case Report Form (CRF). Between December 2018 and March 2023, six hospitals enrolled 109 patients. Out of these, 81 patients met the criteria required for the study.

RESULTS

The R2 values calculated using MR relaxometry showed good discriminating ability with a cut-off of 15.74 (sensitivity 80.6%, specificity 75.0%, AUC = 0.750, p < 0.001) when considering atypical or borderline tumors as EAOC. When atypical and borderline cases were grouped as OE, EAOC could be distinguished with a cut-off of 16.87 (sensitivity 87.0%, specificity 61.1%).

CONCLUSIONS

MR relaxometry has proven to be an effective tool for discriminating EAOC from OE. Regular use of this method is expected to provide significant insights for clinical practice.

Association between dietary inflammation index and female infertility from National Health and Nutrition Examination Survey: 2013-2018

Objective

To investigate the relationship between dietary inflammatory index (DII) scores and infertility in US adults aged 18 to 45.

Methods

Data were gathered from the 2013-2018 National Health and Nutrition Examination Survey (NHANES). In total, 3496 women were included in the study. To examine the relationship between DII, EDII and infertility, a weighted multivariable logistic regression analysis using continuous factors or categorical variables grouped by quartiles was conducted. Using subgroup analysis stratified based on DII and infertility features, the association between DII and infertility has been further studied. In order to determine whether there was a nonlinear relationship between DII and infertility, restricted cubic spline (RCS) analysis was carried out.

Results

For statistical analysis, a total of 3496 individuals - 367 patients with infertility and 3129 persons without infertility - were included. A multivariable logistic regression study revealed a positive relationship between DII and infertility. A significant difference in subgroup analysis was shown in age group and race, although RCS analysis demonstrated nonlinear relationship between the DII and infertility.

Conclusion

For participants aged 18-45 years, higher DII scores were positively correlated with infertility. In addition, anti-inflammatory diets might improve infertility outcomes.

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.

Endometriosis diagnosed by ultrasound is associated with lower live birth rates in women undergoing their first in vitro fertilization/intracytoplasmic sperm injection treatment

OBJECTIVE

To study the cumulative live birth rate (CLBR) after the first in vitro fertilization (IVF) or intracytoplasmic sperm injection (ICSI) treatment in women with or without deep-infiltrating endometriosis (DIE) and/or endometrioma diagnosed by transvaginal ultrasonography (TVUS), using the International Deep Endometriosis Analysis (IDEA) group definitions.

DESIGN

Prospective observational cohort study at a university hospital.

PATIENTS(S)

In total, 1,040 women with subfertility aged 25 to ≤39 years were undergoing their first IVF/ICSI treatment between January 2019 and October 2022. Of these, 234 (22.5%; 95% confidence interval [CI], 20.0-25.0) women were diagnosed with DIE and/or endometrioma at systematic TVUS before starting their treatment.

INTERVENTION(S)

All women underwent their first IVF or ICSI treatment. Fresh and/or frozen embryos from the first cycle were used until pregnancy was achieved or no embryos remained.

MAIN OUTCOME MEASURE(S)

Cumulative live birth rate after the first IVF/ICSI cycle in women with or without DIE and/or endometrioma.

RESULT(S)

The CLBR after the first IVF/ICSI treatment in the total cohort of women was 426/1,040 (41.0%; 95% CI, 38.0-44.0). Women with DIE and/or endometrioma had a lower CLBR (78/234, 33.3%; 95% CI, 27.3-39.4) than women without the disease (348/806, 43.2%; 95% CI, 39.8-46.6). The crude relative risk (RR) for cumulative live birth for women with DIE and/or endometrioma was 0.77; 95% CI, 0.63-0.94, and after adjustments were made for age, body mass index, s-antimüllerian hormone, stimulation protocol, and day for embryo transfer, the adjusted RR was 0.63; 95% CI, 0.48-0.82. There was no difference in the number of retrieved mature oocytes, fertilization rate, or good quality embryos between the 2 groups.

CONCLUSION

The presence of DIE and/or endometrioma diagnosed by TVUS lowers the chance of live birth in women undergoing their first IVF/ICSI treatment.

Ovarian reserve markers of women with superficial endometriosis

OBJECTIVE

Endometriosis affects up to 10% of reproductive age women and is associated with pelvic pain and subfertility. While previous studies have shown an association between deep and ovarian endometriosis to reduced ovarian reserve, there is no data on the effect of superficial endometriosis on ovarian reserve markers. Hence, we aimed to compare ovarian reserve markers of women with superficial endometriosis to that of women without endometriosis.

METHODS

This was a case control study in a tertiary medical center. The study group included women aged 18-40 with surgically and histopathology-proven superficial endometriosis with no deep lesions or ovarian involvement. The control group included women with no known or suspected endometriosis and was matched to the study group by age, BMI and parity. We excluded women with other known risk factors for ovarian failure and with other gynecological disorders. Participants completed a questionnaire with demographic, medical and gynecological data. Each patient underwent anti-Mullerian hormone (AMH) testing and an ultrasound to assess their antral follicular count (AFC). AMH and AFC were then compared between groups.

RESULTS

A total of 124 women participated in the study. Of these, 50% (n = 62) had surgically proven superficial endometriosis and 50% (n = 62) were without known or suspected endometriosis. Mean AMH levels of women with and without superficial endometriosis was 3.0 ± 2.8 ng/mL and 2.8 ± 1.9 ng/mL, respectively (P = 0.71). AFC also did not differ between groups (women with superficial endometriosis: 12.0 ± 6.6; women without endometriosis: 10.2 ± 5.0, P = 0.15).

CONCLUSIONS

In our cohort, superficial endometriosis was not associated with diminished ovarian reserve. While further studies are needed, to date, it does not appear to be justified to assess ovarian reserve for patients with superficial endometriosis.

Society of Radiologists in Ultrasound Consensus on Routine Pelvic US for Endometriosis

Endometriosis is a prevalent and potentially debilitating condition that mostly affects individuals of reproductive age, and often has a substantial diagnostic delay. US is usually the first-line imaging modality used when patients report chronic pelvic pain or have issues of infertility, both common symptoms of endometriosis. Other than the visualization of an endometrioma, sonologists frequently do not appreciate endometriosis on routine transvaginal US images. Given a substantial body of literature describing techniques to depict endometriosis at US, the Society of Radiologists in Ultrasound convened a multidisciplinary panel of experts to make recommendations aimed at improving the screening process for endometriosis. The panel was composed of experts in the imaging and management of endometriosis, including radiologists, sonographers, gynecologists, reproductive endocrinologists, and minimally invasive gynecologic surgeons. A comprehensive literature review combined with a modified Delphi technique achieved a consensus. This statement defines the targeted screening population, describes techniques for augmenting pelvic US, establishes direct and indirect observations for endometriosis at US, creates an observational grading and reporting system, and makes recommendations for additional imaging and patient management. The panel recommends transvaginal US of the posterior compartment, observation of the relative positioning of the uterus and ovaries, and the uterine sliding sign maneuver to improve the detection of endometriosis. These additional techniques can be performed in 5 minutes or less and could ultimately decrease the delay of an endometriosis diagnosis in at-risk patients.

A systematic review of the mechanistic actions of microRNAs within integrated traditional Chinese medicine and western medical treatment for endometriosis

Endometriosis (EM), also known as Zhengjia in traditional Chinese medicine, is a common disease that significantly impacts women's health. An integrated treatment approach combining traditional Chinese medicine (TCM) and western medicine has demonstrated significant clinical efficacy in the management of this condition. Specifically, it has been effective in addressing blood circulation and other diseases. MicroRNAs (miRNAs), which are molecules important in gene regulation, have been implicated in various physiologic and pathologic processes. In this review, we systematically summarized the potential mechanisms underlying the integrated EM treatment, with a focus on the role of microRNAs (miRNAs). Current research suggests that integrated TCM and western medicine treatment may exert their therapeutic effects on EM by influencing the expression of miRNAs. Through miRNA modulation, such a treatment approach may inhibit the growth of ectopic lesions and alleviate clinical symptoms. This review will shed light on the specific miRNAs that have been implicated in the integrated treatment of EM, as well as their potential mechanisms of action. By consolidating the existing evidence, we aim to provide clinicians and researchers with a clearer understanding of the therapeutic benefits of the integrated approach and potentially identify new avenues for improving clinical treatment outcomes. Ultimately, this review will contribute to the growing body of knowledge in this field, providing a basis for further research and the development of more targeted and efficient treatment strategies for EM.

Exosomes from ectopic endometrial stromal cells promote M2 macrophage polarization by delivering miR-146a-5p

BACKGROUND

Ectopic endometrial stromal cells (ESCs) and M2 macrophages co-exist in the lesions of endometriosis and participate in the occurrence and progression of endometriosis. However, the interaction between ectopic ESCs and M2-type macrophage polarization is poorly understood. This study aims to investigate the effect of exosomes released from ectopic ESCs on M2 macrophage polarization and the potential mechanism.

METHODS

Human THP-1 monocytic cells induced macrophage differentiation (M0) and M2 polarization. Ectopic ESCs and their exosomes were used to stimulate M2 macrophages. M2 macrophage polarization was examined by detecting CD163 and ARG1 expression. Exosomal microRNAs were analyzed by small-RNA sequencing.

RESULTS

Our in vitro results suggest that exosomes of ectopic ESCs promoted M2 macrophage polarization. Meanwhile, The miR-146a-5p level was highly increased in ectopic ESCs and their exosomes and promoted the role of exosomes in M2 macrophage polarization. As a target, TRAF6 overexpression inhibits the function of miR-146a-5p mimic on M2 macrophage polarization. In the rat model, exosomes from ectopic ESCs contribute to the development of endometriosis.

CONCLUSIONS

It was suggested that exosomes derived from ectopic ESCs promote the M2 macrophage polarization by delivering miR-146a-5p targeting TRAF6 in the pathological process of endometriosis.