Endometriosis and infertility: the hidden link between endometritis, hormonal imbalances and immune dysfunctions preventing implantation!

Molecular Profile (Estrogen Receptor, Progesterone Receptor, Bcl-2 and Ki-67) of the Ectopic Endometrium in Patients with Endometriosis

Endometriosis is characterized by alterations of the action and control mechanisms that lead to the development of ectopic endometrial tissue. This study aimed to analyze the molecular profile of ectopic endometrium by evaluating the expression of several biomarkers [estrogen receptor (ER), progesterone receptor (PR), anti-apoptotic protein Bcl-2, and Ki-67 antigen] in relation to the stage of the disease and symptoms. A prospective study over a period of one year, consisting of 14 patients with endometriosis, was performed. All patients received laparoscopic surgical treatment for excision of the lesions and staging of the disease. The expression of the aforementioned biomarkers was assessed in the ectopic endometrial tissue from the excised lesions using immunohistochemistry to determine their expression in the glandular epithelium and stroma. The mean expression of biomarkers in the epithelial and stromal levels did not differ significantly based on disease stage. Epithelial ER expression was significantly positively correlated with stromal ER, epithelial PR, and stromal PR. Stromal ER was significantly positively correlated with epithelial PR and stromal Ki-67. Epithelial Bcl-2 was significantly positively correlated with stromal Bcl-2. Epithelial Ki-67 was significantly positively correlated with stromal Ki-67. Finally, epithelial Bcl-2 expression was significantly positively correlated with the intensity of dyspareunia. The correlation between epithelial Bcl-2 expression and the intensity of dyspareunia highlights a potential molecular link to the severity of symptoms in endometriosis. These results suggest that further exploration of these biomarkers could lead to improved understanding of their clinical implications and more personalized therapies for patients with endometriosis.

Decoding immune tolerance in infertility: Exploring immune pathways and non-coding RNAs as pioneering biomarkers and therapeutic targets

Infertility, impacting a significant number of couples, is characterized by the failure to conceive after one year of consistent, unprotected sexual intercourse. It is multifactorial, with etiological contributors including ovulatory dysfunction, male reproductive anomalies, and tubal patency issues. Approximately 15% of infertility cases are classified as "unexplained," highlighting the complexity of this condition. Lifestyle determinants such as obesity and smoking further complicate reproductive outcomes, while infertility can also indicate underlying chronic health conditions. A specialized category, immune infertility, arises from a breakdown of immunological tolerance, an essential aspect for conception and the maintenance of pregnancy. The role of various immunological components, including immune cells, cytokines, chemokines, factors like HLA-G, etc., is pivotal in this context. Moreover, non-coding RNAs (ncRNAs) have emerged as critical regulators of immune tolerance within the reproductive axis. This review synthesizes the complex immunological pathways vital for successful implantation and the early stages of pregnancy alongside the regulatory roles of ncRNAs in these processes. Offering an integrated view of molecular and immunological interactions associated with infertility seeks to enhance our understanding of potential strategies to facilitate successful conception and sustain early pregnancy.

Peri-implantation treatment with TNF-α inhibitor for endometriosis and/or adenomyosis women undergoing frozen-thawed embryo transfer: A retrospective cohort study

PROBLEM

Endometriosis and adenomyosis have common pathogenesis and close relationship, with multi-factors involved in related infertility and IVF failure. They lead to anatomical changes, ovarian reserve reduction, endocrine abnormalities, altered endometrial receptivity and immunological dysfunction. Collective evidence indicate that abnormal function of immune cells and secretion of cytokines are closely related to reproductive outcomes among the women. Some studies showed that increased secretion of tumor necrosis factor alpha (TNF-α) led a key role in pro-inflammatory response in women with endometriosis/adenomyosis.TNF-a is embrryotoxic and receptivity impairing. Therefore, immunotherapy is a targeted therapeutic strategy apart from routine treatment. TNF-α inhibitors such as etanercept and adalimumab were shown to reduce the embryotoxic and anti-inflammatory effects to increase IVF pregnancy rates in recurrent implantation failure or endometrioma patient. However, there's no evidence about the use of adalimumab for patients with endometriosis and/or adenomyosis undergoing Frozen embryo transfer(FET).

METHOD OF STUDY

A retrospective analysis of 141 women with endometriosis and/or adenomyosis undergoing FET from January 2021 to Jun 2023 was conducted.They were 20-42 years old, with or without previous implantation failure. Endometriosis was diagnosed by laparoscopy during their infertility workup and adenomyosis was confirmed by vaginal ultrasound screening. GnRH agonist and hormone replacement treatment (HRT) or HRT were taken for endometrium preparation according to doctor's evaluation and preference. Before and after embryo transfer, 84 women were treated with Adalimumab and 57 patients were untreated. Implantation rate, clinical pregnancy rate, ongoing pregnancy rate and live birth rate were compared between the two groups.

RESULTS

The demographics and baseline characteristics between the two groups were comparable. Stage of embryo transferred and number of embryo transferred were comparable between the two groups (p = 0.227 and p = 0.204 separately). The regimen of endometrium preparation was similar too(p = 0.907). The implantation rate was significantly improved in study group (28.09 % vs 49.18 %, X2=9.515, P = 0.002). The clinical pregnancy rate was much lower in control group comparing with TNF-α inhibitor treatment group (42.11 % vs 60.71 %, X2=4.723, P = 0.029). There was no significant difference between the two groups as for ongoing pregnancy rate (38.60 % vs 52.38 %, X2=2.591, P = 0.107)and live birth rate (36.84 % vs 47.62 %, X2=1.606, P = 0.205). Following adjustment for age, BMI, number of prior failed transfer, stage of embryo transferred in a multiple logistic analysis, patients treated without TNF-α inhibitor had a significant lower CPR (ORadj 0.45, 95 %CI 0.22-0.92, p = 0.029) and a similar probability for OPR (ORadj 0.56, 95 %CI 0.28-1.12) and LBR (ORadj 0.62, 95 %CI 0.31-1.26) as compared with patients with TNF-α inhibitor treatment. However, an obvious trend of improvement of LBR was observed and it's clinical relevant for the patients.

CONCLUSION

In women with endometriosis and/or adenomyosis, peri-implantation treatment with TNF-α inhibitor increased implantation rate and clinical pregnancy rate significantly compared with control group in FET cycles. The ongoing pregnancy rate and live birth rate were not significant different, while the difference was clinical relevant.

Impact of cesarean scar defect on reproductive outcomes after assisted reproductive technology

In the last twenty years, the cesarean section rate has been rising in China, leading to an increased prevalence of cesarean scar defect (CSD) and secondary infertility. CSD decreases receptivity of endometrium, induces adenomyosis and endometriosis, disrupts uterine micro-environment and causes difficulties in embryo transplant operation as well as has further pregnancy complications. For women undergoing assisted reproductive technology (ART), CSD significantly reduces live birth rate, clinical pregnancy rate and embryo implantation rate. CSD can be effectively treated by hysteroscopic surgery, laparoscopic surgery and transvaginal surgery to increase the pregnancy rate. This article reviews the research progress on the impact of CSD on the reproductive outcomes of ART, the potential factors and related treatments, and provides a reference for the management of CSD patients undergoing ART.