The uterus and fertility

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

OBJECTIVE

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

Age-related increase in live-birth rates of first frozen thaw embryo versus first fresh transfer in initial assisted reproductive technology cycles without PGT

BACKGROUND

The landscape of assisted reproductive technology (ART) has seen a significant shift towards frozen-thawed embryo transfers (FET) over fresh transfers, driven by technological advancements and clinical considerations. This study aimed to compare live birth outcomes between primary FET and fresh transfers, focusing on cycles without preimplantation genetic testing (PGT), using United States national data from the SART CORS database spanning from 2014 to 2020.

METHODS

We performed a retrospective cohort study of autologous first ART cycles without PGT comparing primary embryo transfer (frozen thaw vs. fresh) success rates from the 2014-2020 SARTCORS database. Live-birth rates (LBR) and cumulative live-birth rates (CLBR) were compared between first FET versus first fresh embryo transfer from an index retrieval. Multivariate logistic regression (MLR) determined association between live birth outcomes and method of transfer. In a subsequent sub-analysis, we compared these two embryo transfer methods among patients with either diminished ovarian reserve (DOR) or male factor infertility.

RESULTS

228,171 first ART cycles resulted in primary embryo transfer. 62,100 initial FETs and 166,071 fresh transfers were compared. Initial FETs demonstrated higher LBR and CLBR compared to fresh transfers (LBR 48.3% vs. 39.8%, p < 0.001; CLBR 74.0% vs. 60.0%, p < 0.0001). MLR indicated greater chances of live birth with FET across all age groups, with adjusted odds ratio (aOR) of live-birth incrementally increasing with advancing age groups. For DOR cycles, LBR and CLBR were significantly higher for FET compared to fresh (33.9% vs. 26.0%, p < 0.001, 44.5% vs. 37.6%, p < 0.0001), respectively. MF cycles also demonstrated higher LBR and CLBR with FET (52.3% vs. 44.2%, p < 0.001, 81.2% vs. 68.9%, p < 0.0001), respectively. MLR demonstrated that in DOR cycles, initial FET was associated with greater chance of live birth in age groups ≥ 35yo (p < 0.01), with aOR of live birth increasingly considerably for those > 42yo (aOR 2.63, p < 0.0001).

CONCLUSIONS

Overall LBR and CLBR were greater for first FET than fresh transfers with incremental increases in odds of live birth with advancing age, suggesting the presence of a more favorable age-related change in endometrial receptivity present in frozen-thawed cycles. For both DOR and MF cycles, LBR and CLBR after primary transfer were greater for first FET than fresh. However, this was particularly evident in older ages for DOR cycles. This suggests that supraphysiologic stimulation in older DOR cycles may be detrimental to endometrial receptivity, which is in part corrected for in FET cycles.

Guideline No. 447: Diagnosis and Management of Endometrial Polyps

OBJECTIVE

The primary objective of this clinical practice guideline is to provide gynaecologists with an algorithm and evidence to guide the diagnosis and management of endometrial polyps.

TARGET POPULATION

All patients with symptomatic or asymptomatic endometrial polyps.

OPTIONS

Options for management of endometrial polyps include expectant, medical, and surgical management. These will depend on symptoms, risks for malignancy, and patient choice.

OUTCOMES

Outcomes include resolution of symptoms, histopathological diagnosis, and complete removal of the polyp.

BENEFITS, HARMS, AND COSTS

The implementation of this guideline aims to benefit patients with symptomatic or asymptomatic endometrial polyps and provide physicians with an evidence-based approach toward diagnosis and management (including expectant, medical, and surgical management) of polyps.

EVIDENCE

The following search terms were entered into PubMed/Medline and Cochrane: endometrial polyps, polyps, endometrial thickening, abnormal uterine bleeding, postmenopausal bleeding, endometrial hyperplasia, endometrial cancer, hormonal therapy, female infertility. All articles were included in the literature search up to 2021 and the following study types were included: randomized controlled trials, meta-analyses, systematic reviews, observational studies, and case reports. Additional publications were identified from the bibliographies of these articles. Only English-language articles were reviewed.

VALIDATION METHODS

The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See Appendix A (Tables A1 for definitions and A2 for interpretations of strong and weak recommendations).

INTENDED AUDIENCE

Gynaecologists, family physicians, registered nurses, nurse practitioners, medical students, and residents and fellows.

TWEETABLE ABSTRACT

Uterine polyps are common and can cause abnormal bleeding, infertility, or bleeding after menopause. If patients don't experience symptoms, treatment is often not necessary. Polyps can be treated with medication but often a surgery will be necessary.

SUMMARY STATEMENTS

RECOMMENDATIONS.

Guideline No. 446: Hysteroscopic Surgery in Fertility Therapy

OBJECTIVE

To evaluate the indications, benefits, and risks of hysteroscopy in the management of patients with infertility and provide guidance to gynaecologists who manage common conditions in these patients.

TARGET POPULATION

Patients with infertility (inability to conceive after 12 months of unprotected intercourse) undergoing investigation and treatment.

BENEFITS, HARMS, AND COSTS

Hysteroscopic surgery can be used to diagnose the etiology of infertility and improve fertility treatment outcomes. All surgery has risks and associated complications. Hysteroscopic surgery may not always improve fertility outcomes. All procedures have costs, which are borne either by the patient or their health insurance provider.

EVIDENCE

We searched English-language articles from January 2010 to May 2021 in PubMed/MEDLINE, Embase, Science Direct, Scopus, and Cochrane Library (see Appendix B for MeSH search terms).

VALIDATION METHODS

The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See Appendix A (Tables A1 for definitions and A2 for interpretations of strong and conditional recommendations).

INTENDED AUDIENCE

Gynaecologists who manage common conditions in patients with infertility.

TWEETABLE ABSTRACT

When offering hysteroscopic surgery to patients with infertility, ensure it improves the live birth rate.

SUMMARY STATEMENTS

RECOMMENDATIONS.

Estimation of the prevalence of uterine infertility and its different causes in France according to data from a literature review

INTRODUCTION

Uterine infertility (UI) is defined as the complete absence of a uterus (absolute uterine infertility or AUI) or the presence of a non functional uterus (non-absolute uterine infertility or NAUI). The exact prevalence of uterine infertility is currently unknown. Our aim was to assess the number of French women concerned by Uterine Infertility according to a recent literature review.

MATERIALS AND METHODS

We have previously conducted a systematic review of the literature on UI and its various causes in the world. Based on these study and demographic data of 2022 from INSEE (Institut National de la Statistique et des Études Économiques), we attempted to estimate the number of women under 40 years of age in France affected by potential UI using direct standardization.

RESULTS AND DISCUSSION

Based on the estimation from INSEE data, approximately 2066 women of childbearing age would have MRKH syndrome in France, 380 the Androgen Insensitivity Syndrome and 3700 had an haemostasis hysterectomy in France. We did not find data on the prevalence of hysterectomies before the age of 40 in France. For the following pathologies: uterine malformations, radiation uterus, synechiae, myomas and adenomyosis there was a huge amount of missing data, which does not allow us to estimate the number of potentially infertile patients.

CONCLUSION

Prevalence of UI is poorly known. UI probably concerns several thousand patients in France. The creation of a UI registry would make enable to assess the number of patients potentially eligible for adoption, uterus transplantation or even surrogacy.

Reproductive outcomes of oocyte donation in patients with uterine Müllerian anomalies

OBJECTIVE

To evaluate live-birth rates per embryo transfer in patients with uterine Müllerian anomalies (UMAs). Secondary objectives were to compare reproductive outcomes between the normal uterus group, the different UMA types, and UMA subgroups with and without required surgery.

DESIGN

This retrospective study compared two cohorts, one with UMAs and other with normal uteri of our oocyte donation program at 12 Instituto Valenciano De Infertilidad/Reproductive Medicine Associates University affiliated clinics from January 2000 to 2020. The oocyte donation reduces confounding because of differences in embryo quality. The primary outcome was the live-birth rate per embryo transfer. Secondary outcomes included the rates of implantation, clinical pregnancy, miscarriage, and ongoing pregnancy. We calculated odds ratios with 95% confidence intervals.

PATIENTS

Infertile women undergoing oocyte donation with UMAs.

INTERVENTION

None.

MAIN OUTCOME MEASURES

The rates of implantation, clinical pregnancy, miscarriage, ongoing pregnancy, and live birth.

RESULTS

We analyzed 58,337 cycles of oocyte donation: 57,869 patients had no uterine malformation, and 468 women had UMAs. Compared with patients with normal uteri, patients with UMAs had lower rates of live births (36.67% [32.84-40.65] vs. 38.1% [95% confidence intervals {CI}: 37.82-38.42]) and ongoing pregnancy (39.74% [35.93-43.66] vs. 41.5% [41.24-41.83]). The miscarriage rate was higher in patients with UMAs (19.5% [16.55-22.85] vs. 16.6% [16.47-16.92]). Specifically, patients with a unicornuate uterus (n=29) had lower rates of implantation (24.07% [13.49-37.64] vs. 42.85% [95% CI: 42.6-43.09]), pregnancy (41.86% [27.01-57.87] vs. 59.51% [59.22-59.81]), ongoing pregnancy (16.67% [6.97-31.36] vs. 41.54% [41.24-41.83]), and live births (16.67% [6.97-31.36] vs. 38.12% [37.83-38.42]). In addition, patients with a partial septate uterus (n=91) had a higher miscarriage rate (26.50% [18.44-34.89] vs. 16.7% [16.47-16.92]). Compared with the normal uterus group, the live-birth rates were lower in the UMA without surgery group (33.09% [27.59-38.96] vs. 38.12% [37.83-38.42]).

CONCLUSION

Among patients who received embryos derived from donated oocytes, live birth and ongoing pregnancy rates were lower in patients with UMAs compared with patients with normal uteri. A higher miscarriage rate was found in patients with UMAs. Patients with a unicornuate uterus had worse reproductive outcomes. Our results show that the uterus is less competent in patients with UMAs.

TRIAL REGISTRATION

This study was registered at clinicaltrial.gov (NCT04571671).

Validation of prognosis-based in vitro fertilization grant selection criteria

Objective

To validate a prognosis-based scoring system for in vitro fertilization (IVF) grant allocation.

Design

Retrospective cohort study.

Setting

A 501(c)(3) nonprofit foundation that awards donated IVF cycles and grants to those with demonstrated financial need. In contrast to lottery-based or subjective allocation systems, applications are scored according to medical prognostic criteria in addition to personal characteristics.

Patients

Grant recipients from 2015 to 2019.

Interventions

None.

Main outcome measures

Live birth rate (LBR) and cumulative LBR (CLBR) among grant recipients were compared with 2019 Society for Assisted Reproductive Technology (SART) national averages.

Results

A total of 435 applications were reviewed, with 59 grants awarded for 51 autologous IVF cycles, 6 donor oocyte cycles, and 2 gestational carrier cycles, resulting in 39 live births after initial embryo transfer (LBR 61.9%) and 43 CLBRs (CLBR 72.9%). Among autologous cycles, the mean (±SD=3.9 years) age was 31.8 years, and LBR and CLBR were 62.8% and 68.6% vs. 28.2% and 37.1% among all autologous SART cycles, respectively. A subanalysis of grant recipients aged <35 years (n=39) revealed LBR and CLBR of 66.7% and 74.4% vs. 40.7% and 47.8% among autologous SART cycles aged <35 years, respectively.

Conclusions

A scoring system incorporating medical criteria identified IVF grant applicants with a high likelihood of achieving a LB. Although most IVF grant programs select recipients through a lottery or personal characteristics, a prognosis-based scoring system should be considered to maximize LBR in a limited resource setting.

Nonelectric shaving of endometrial polyp by hysteroscopy - A new technique to eliminate thermal damage

OBJECTIVE

To present a new technique for complete endometrial polypectomy, using the bipolar loop hysteroscope, but without the activation of electrical energy, and follow its efficiency and safety for the patient.

STUDY DESIGN

This is a prospective descriptive study conducted at a university hospital. Forty four patients were recruited to the study according to an intra uterine polyp diagnosed by transvaginal ultrasound (TVS). Out of them 25 really had an endometrial polyp which was inspected by hysteroscopy. Eighteen were at menopause age and seven in their reproductive age. The hysteroscopic removal of the endometrial polyp was performed using the operative loop resectoscope without using electricity, meaning by cold loop. We called this unique technique SHEPH: Shaving of Endometrial Polyp by Hysteroscopy.

RESULTS

The range age was 21-77 years old. All patients with apparently endometrial polyp, underwent a complete removal of the polyp which could be directly seen through hysteroscopy. No bleeding was seen in all cases. The other nineteen patients had normal uterine cavity, so a biopsy was taken according to the indication. The specimen from all cases were sent to histological evaluation. An endometrial polyp was histologically confirmed in all cases who underwent the SHEPH technique, while fragments of an endometrial polyp was revealed by histology in six cases from the group that had normal uterine cavity. No complications were noted for the short and long periods.

CONCLUSIONS

Nonelectric Shaving of Endometrial Polyp by Hysteroscopy (SHEPH technique) is a safe and effective procedure which allows the surgeon to achieve a complete endometrial polypectomy but without using electrical energy within the body of the patient. The technique which is easy to learn, is new and unique by eliminate thermal damage in a very common gynecologic indication.

Evaluation of the relationship between ovarian reserve with congenital anomalies and intramural uterine leiomyoma among infertile women: a cross-sectional study

BACKGROUND

Ovarian reserve is a crucial indicator of a woman's fertility potential, which is determined by the quality and quantity of antral follicles and oocytes. However, certain factors such as endometriosis, pelvic inflammatory disease, myoma, and the natural process of aging can lead to a poor ovarian response to stimulation, reducing a woman's chances of conceiving.

OBJECTIVE

To evaluate the effect of uterus congenital anomalies and uterine leiomyoma are associated on ovarian reserve.

METHODS

The present cross-sectional study was performed on 321 infertile women in three groups consisted of 97 infertile women with intramural uterine leiomyoma and 81 infertile women with uterine anomalies and 143 infertile women without uterine anomalies and uterine leiomyoma during 2017-2019 in Royan Center. Sampling method was continuous and available. Data collection tool in this study was a questionnaire which was in two parts of individual variables and the second part was related to ultrasound results (number of antral follicles and ovarian volume) and laboratory tests (Anti-Mullerian Hormone (AMH) and Follicle-stimulating Hormone (FSH)). Ovarian reserve parameters were measured in three groups on the third day of the cycle in both groups. Data analysis was performed using SPSS software version 21. Quantitative variables were analyzed using t-test, qualitative variables were analyzed using chi-square test.

RESULTS

The results of in laboratory parameters showed that there was no statistically significant difference between the three groups in FSH (2.35 ± 1.55, 2.07 ± 1.81, 2.31 ± 1.93) and AMH (6.84 ± 2.75,7.52 ± 3.14,6.93 ± 3.04), respectively (P > 0.05). The results of sonographic variables also showed that the variables include number of antral follicles in right ovarian, number of antral follicles in left ovarian have statistically significant between the three groups (5.73 ± 2.69,4.84 ± 3.14,6.66 ± 3.13), respectively (P < 0.05).

CONCLUSION

The results of the present study showed that uterine abnormalities and uterine leiomyoma with different mechanisms such as reduce of antral follicle numbers and the effect on uterine and ovarian blood flow lead to a decrease in ovarian reserve and infertility. Therefore, treatment and surgery can reduce these effects and improve the fertility of the affected women.

Hysteroscopic Identification of Intrauterine Pathology in Oocyte Donation Cycles: A Retrospective Study

BACKGROUND

Hysteroscopy remains the gold standard for the diagnosis and treatment of intracavitary uterine anomalies. As for recipients where oocyte donation is mandatory, accurate evaluation of previously missed intrauterine pathology may be an important step to optimize implantation process. The aim of this study was to hysteroscopically assess the incidence of unidentified intrauterine pathology prior to embryo transfer in an oocyte recipient population.

METHODS

A retrospective descriptive study was conducted between 2013 and 2022 at Assisting Nature In Vitro Fertilization (IVF) Centre in Thessaloniki, Greece. The study population consisted of oocyte recipient women who underwent hysteroscopy one-three months before embryo transfer. Furthermore, oocyte recipients after repeated implantation failure were investigated as a subgroup. Any identified pathology was treated accordingly.

RESULTS

In total, 180 women underwent diagnostic hysteroscopy prior to embryo transfer with donor oocytes. The mean maternal age at the time of intervention was 38.9 (+5.2) years, while the mean duration of infertility was 6.03 (+1.23) years. Additionally, 21.7% (n=39) of the study population had abnormal hysteroscopic findings. In particular, congenital uterine anomalies (U1a: 1.1% {n=2}, U2a: 5.6% {n=10}, U2b: 2.2% {n=4}) and polyps (n=16) were the main findings in the sample population. Furthermore, 2.8% (n=5) had submucous fibroids and 1.1% (n=2) were diagnosed with intrauterine adhesions. Notably, in recipients after repeated implantation failure intrauterine pathology rates were even higher (39.5%).

CONCLUSIONS

Oocyte recipients and especially those with repeated implantation failures probably have high rates of previously undiagnosed intrauterine pathology so, hysteroscopy would be justified in these subfertile populations.

Injectable self-assembled dual-crosslinked alginate/recombinant collagen-based hydrogel for endometrium regeneration

The disadvantages of mainstream therapies for endometrial injury are difficult to resolve, herein, we suggest an omnibearing improvement strategy by introducing an injectable multifunctional self-assembled dual-crosslinked sodium alginate/recombinant collagen hydrogel. The hydrogel possessed a reversible and dynamic double network based on dynamic covalent bonds and ionic interactions, which also contributed to excellent capability in viscosity and injectability. Moreover, it was also biodegradable with a suitable speed, giving off active ingredients during the degradation process and eventually disappearing completely. In vitro tests exhibited that the hydrogel was biocompatible and able to enhance endometrial stromal cells viability. These features synergistically promoted cell multiplication and maintenance of endometrial hormone homeostasis, which accelerated endometrial matrix regeneration and structural reconstruction after severe injury in vivo. Furthermore, we explored the interrelation between the hydrogel characteristics, endometrial structure, and postoperative uterine recovery, which would benefit deep research on regulation of uterine repair mechanism and optimization of hydrogel materials. The injectable hydrogel could achieve favourable therapeutic efficacy without the need of exogenous hormones or cells, which would be of clinical value in endometrium regeneration.

The management of infertility for primary care physicians

To conduct this review of primary care, we looked for related papers in PubMed from the last 15 years. WHO's initial concept of Health defined a condition of physical, mental, and social well-being, nowadays extended to quality of life. Infertility or not being able to form a family fits perfectly into the definition. Primary care is responsible for mandatory discussions about fertility as part of a broader aspect regarding reproductive health issues. Having children is a decision taken by heterosexual couples, same sex couples, or single individuals. Understanding factors associated with infertility help guiding propedeutic. Although woman's age is one of the main factors to influence treatment success rates, multifactorial male factor may contribute to 50 percent. Infertility consultations should include partners, alleviating the accompanying stress and anxiety. Anamnesis must focus on duration of infertility, primary or secondary, sexual activity, and lifestyle habits such as smoking, alcohol consumption, diet, physical activity, use of licit and/or illicit drugs, and occupational risks. Previous treatments should be accessed. Management of infertility by primary care is mandatory, and patients requiring specialized treatments must not have their journey protracted. Strategies and couple-based interventions are essential to continuity of care and close follow-up should follow these patients.

The use of sealing hemostat patch (HEMOPATCH®) in laparotomic myomectomy: a prospective case-control study

PURPOSE

Uterine myomas are the most common gynecological disease. In these cases, a myomectomy is performed traditionally laparotomically. However, alternatives have been widely used, including laparoscopic, endoscopic, and robotic surgery. During these techniques, diffuse parenchymatous bleeding remains one of the main intraoperative and postoperative complications and sometimes requires unplanned hysterectomies. Recently, hemostatic agents and sealants have been used to prevent excessive blood loss during surgical repair.

METHODS

We propose a prospective case-control study on the use of a sealing hemostat patch (HEMOPATCH^®) on uterine sutures in laparotomic myomectomy. In the period between July 2016 and April 2017, 46 patients with symptomatic uterine fibromatosis underwent surgery. They were divided into two groups of 23 patients, with different treatments in the hemostatic phase of oozing bleeding. HEMOPATCH^® is applied in group A, and spray electrocoagulation is applied in group B.

RESULTS

In group A, we achieve faster hemostasis (p < 0.05), than in group B. We report a significantly lower C-reactive protein value on the second and third days after surgery for group A compared to group B.

CONCLUSIONS

HEMOPATCH^®, during laparotomic myomectomy, is a valid alternative solution for obtaining rapid hemostasis and consequently intraoperative and postoperative bleeding. Furthermore, we suggest that a lower inflammatory peritoneal state is probably correlated with the barrier effect of the patch on the suture.

3D bio-printed endometrial construct restores the full-thickness morphology and fertility of injured uterine endometrium

Severe damage to the uterine endometrium, which results in scar formation and endometrial dysfunction, eventually leads to infertility or pregnancy-related complications. No effective therapeutic treatment is currently available for such injuries owing to the structural complexity, internal environment, and function of the uterus. Three-dimensional (3D) bio-printing to engineer biomimetic structural constructs provides a unique opportunity for tissue regeneration. Herein, using 3D extrusion-based bioprinting (EBB), we constructed a bilayer endometrial construct (EC) based on a sodium alginate-hyaluronic acid (Alg-HA) hydrogel for functional regeneration of the endometrium. The upper layer of the 3D bio-printed EC is a monolayer of endometrial epithelial cells (EECs), while the lower layer has a grid-like microstructure loaded with endometrial stromal cells (ESCs). In a partial full-thickness uterine excision rat model, our bilayer EC not only restored the morphology and structure of the endometrial wall (including organized luminal/ glandular epithelium, stroma, vasculature and the smooth muscle layer), but also significantly improved the reproductive outcome in the surgical area after implantation (75%, 12/16, p < 0.01). Therefore, repair of the uterine endometrium using the developed 3D bio-printed bilayer EC may represent an effective regenerative treatment for severe endometrial injury. STATEMENT OF SIGNIFICANCE: Achieving structural and functional recovery of the endometrium following severe injury is still a challenge. Here, we designed a 3D bio-printed endometrial construct (EC) to mimic the native bilayer structure and cellular components of the endometrium. The bio-printed EC consists of a dense upper layer with endometrial epithelial cells and a lower layer with endometrial stromal cells. In particular, the 3D bio-printed EC significantly improved the reproductive outcome in the surgical area (75%, 12/16) compared to that of the cell-loaded non-printed group (12.5%, 2/16). This study demonstrates that a biomimetic bilayer construct can facilitate endometrial repair and regeneration. Therefore, an endometrial cells-loaded 3D-bioprinted EC is a promising therapeutic option for patients suffering from severe endometrial damage.

Role of Hysteroscopy in Patients with Previous In Vitro Fertilization Failure: An Institutional Experience in Rural Population

Objectives

(1) To evaluate the use of hysteroscopy in the assessment of uterine pathologies, not evident on ultrasonography or hystero-salpingography in women with previous one or more IVF failures and (2) to determine whether correction of such pathologies during hysteroscopy improves clinical pregnancy rates in these women.

Methods

This is a prospective randomized study. The study population included were women with primary and secondary infertility registered at our center, fit into the inclusion and exclusion criteria of this study. The total 180 patients were included.

Results

Hysteroscopies were performed in 90 patients with at least one IVF cycle failure and another 90 patients taken as control with similar demographic parameters. The average duration of infertility between both the groups was not significant. Hysteroscopy was able to detect intrauterine pathologies in around 40% of the cases, which were treated in the same treatment phase. Early ultrasound findings with gestational sac and cardiac activity were found to be significant between two groups.

Conclusion

We noticed clinical improvement in IVF success rate after hysteroscopy. Hysteroscopy may be offered to the patients with previous one or more IVF failures, as clinically some of the previously undiagnosed pathologies could be detected and treated to achieve the positive outcomes.

Trophectoderm non-coding RNAs reflect the higher metabolic and more invasive properties of young maternal age blastocysts

Increasing female age is accompanied by a corresponding fall in her fertility. This decline is influenced by a variety of factors over an individual's life course including background genetics, local environment and diet. Studying both coding and non-coding RNAs of the embryo could aid our understanding of the causes and/or effects of the physiological processes accompanying the decline including the differential expression of sub-cellular biomarkers indicative of various diseases. The current study is a post-hoc analysis of the expression of trophectoderm RNA data derived from a previous high throughput study. Its main aim is to determine the characteristics and potential functionalities that characterize long non-coding RNAs. As reported previously, a maternal age-related component is potentially implicated in implantation success. Trophectoderm samples representing the full range of maternal reproductive ages were considered in relation to embryonic implantation potential, trophectoderm transcriptome dynamics and reproductive maternal age. The long non-coding RNA (lncRNA) biomarkers identified here are consistent with the activities of embryo-endometrial crosstalk, developmental competency and implantation and share common characteristics with markers of neoplasia/cancer invasion. Corresponding genes for expressed lncRNAs were more active in the blastocysts of younger women are associated with metabolic pathways including cholesterol biosynthesis and steroidogenesis.

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

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

Efficacy of atosiban for repeated embryo implantation failure: A systematic review and meta-analysis

BACKGROUND

Repeated embryo implantation failure (RIF) posed a significant challenge in assisted reproduction. Evidence of its therapeutic effectiveness including atosiban used around embryo transfer to improve pregnancy outcomes in RIF patients undergoing in vitro fertilization-embryo transfer (IVF-ET) remained inconsistent. This study aimed to explore the efficacy of atosiban on pregnancy outcomes of patients with RIF who received IVF-ET.

METHODS

The research was designed using the PICOS format. A systematic search of four English databases, PubMed, EMBASE, Web of Science, Cochrane Library, and one Chinse database, China National Knowledge Infrastructure (CNKI) was conducted. The time range was from inception to December 10, 2022. Then trials comparing the efficacy of atosiban and control group on pregnancy outcomes in RIF patients who receive IVF-ET were included. Subgroup analysis and sensitivity analysis were performed to reduce the influence of heterogeneity between included studies. Risk ratio (RR) and 95% confidence interval (CI) were calculated. The main outcome measure was clinical pregnancy rate (CPR). For the analyses, StataMP 17.0 (Stata Corporation, USA) was used.

RESULTS

Two prospective randomized controlled trials (RCTs), one prospective cohort study and four retrospective cohort studies were included. Our results showed that atosiban was associated with higher clinical pregnancy rate (RR=1.54, 95% CI: 1.365-1.735, P < 0.001, I^{2 =} 0.0%). The results of subgroup analysis based on study types (prospective randomized controlled clinical trial, retrospective cohort study and prospective cohort study) showed that in all types of studies, CPR of atosiban group was significantly higher than controlled group. The results of subgroup analysis based upon the diagnostic criteria of number of previous embryo transfer failures showed that the intervention of atosiban improved the CPR whether in participants with 2 previous ET failures or in participants with 3 previous ET failures. Nevertheless, the incidence of ectopic pregnancy, multiple pregnancy, and miscarriages were not significantly different between the case and control groups.

CONCLUSION

For women who are undergoing IVF-ET and have experienced repeated embryo implantation failure, atosiban may be an important factor in enhancing pregnancy outcomes. To confirm this conclusion, more thorough, prospective randomized controlled studies of sizable sample sizes with well design are required.

Management of recurrent implantation failure: British Fertility Society policy and practice guideline

Recurrent implantation failure (RIF) is defined as the absence of a positive pregnancy test after three consecutive transfers of good quality embryos. There remains significant variation in clinical practice in the management of RIF. This British Fertility Society (BFS) Policy and Practice guideline analyses the evidence for investigations and therapies that are employed in RIF and provides recommendations for clinical practice and for further research. Evidence for investigations of sperm and egg quality, uterine and adnexal factors, immunological factors and thrombophilia, endocrine conditions and genetic factors and for associated therapies have been evaluated. This guideline has been devised to assist reproductive medicine specialists and patients in making shared decisions concerning management of RIF. Finally, suggestions for research towards improving understanding and management of RIF have also been provided.

Comparison of Oxytocin vs. Carbetocin Uterotonic Activity after Caesarean Delivery Assessed by Electrohysterography: A Randomised Trial

Electrohysterography has been used for monitoring uterine contractility in pregnancy and labour. Effective uterine contractility is crucial for preventing postpartum haemorrhage. The objective of our study was to compare postpartum electrohysterograms in women receiving oxytocin vs. carbetocin for postpartum haemorrhage prevention after caesarean delivery. The trial is registered at ClinicalTrials.gov with the identifier NCT04201665. We included 64 healthy women with uncomplicated singleton pregnancies at term scheduled for caesarean section after one previous caesarean section. After surgery, a 15 min electrohysterogram was obtained after which women were randomised to receive either five IU of oxytocin intravenously or 100 μg of carbetocin intramuscularly. A 30 min electrohysterogram was performed two hours after drug application. Changes in power density spectrum peak frequency of electrohysterogram pseudo-bursts were analysed. A significant reduction in power density spectrum peak frequency in the first two hours was observed after carbetocin but not after oxytocin (median = 0.07 (interquartile range (IQR): 0.87 Hz) compared to median = -0.63 (IQR: 0.20) Hz; p = 0.004). Electrohysterography can be used for objective comparison of uterotonic effects. We found significantly higher power density spectrum peak frequency two hours after oxytocin compared to carbetocin.

Uterine Factor Infertility, a Systematic Review

Uterine factor infertility (UFI) is defined as a condition resulting from either a complete lack of a uterus or a non-functioning uterus due to many causes. The exact prevalence of UFI is currently unknown, while treatments to achieve pregnancy are very limited. To evaluate the prevalence of this condition within its different causes, we carried out a worldwide systematic review on UFI. We performed research on the prevalence of UFI and its various causes throughout the world, according to the PRISMA criteria. A total of 188 studies were included in qualitative synthesis. UFI accounted for 2.1 to 16.7% of the causes of female infertility. We tried to evaluate the proportion of the different causes of UFI: uterine agenesia, hysterectomies, uterine malformations, uterine irradiation, adenomyosis, synechiae and Asherman syndrome, uterine myomas and uterine polyps. However, the data available in countries and studies were highly heterogenous. This present systematic review underlines the lack of a consensual definition of UFI. A national register of patients with UFI based on a consensual definition of Absolute Uterine Factor Infertility and Non-Absolute Uterine Factor Infertility would be helpful for women, whose desire for pregnancy has reached a dead end.

Oil-based versus water-based contrast media for hysterosalpingography in infertile women of advanced age, with ovulation disorders or a high risk for tubal pathology: study protocol of a randomized controlled trial (H2Oil2 study)

Background

In women with unexplained infertility, tubal flushing with oil-based contrast during hysterosalpingography (HSG) increases ongoing pregnancy and subsequent live birth rates when compared to tubal flushing with water-based contrast. It is currently unclear whether an HSG with oil-based contrast also results in more ongoing pregnancies and live births in women of advanced age, women with ovulation disorders, and women with potential tubal pathology when compared to an HSG with water-based contrast.

Methods

We plan an international, multicentre, open-label, randomized controlled trial (RCT) studying three groups of infertile women who have an indication for tubal patency testing according to their treating physician and additionally; (1) are 39 years of age or older, (2) have an ovulation disorder or (3) have a high risk for tubal pathology based on their medical history. Women with an allergy for iodinated contrast medium are excluded, as are women with diabetes, hyperprolactinemia or untreated hyper- or hypothyroidism, and women with a partner with severe male infertility. After informed consent, women will be randomly allocated to the intervention, tubal flushing with the use of oil-based contrast during HSG or the control group, tubal flushing with the use of water-based contrast during HSG in a 1:1 ratio by the web-based system Castor. The primary endpoint will be ongoing pregnancy leading to live birth with conception within six months after randomization. Secondary outcomes are other pregnancy outcomes, used fertility treatments, adverse events and cost-effectiveness. Based on the expected ongoing pregnancy rate of 17% in the control group and 27% in the intervention group, the sample size will be 930 women (465 per group). Study inclusion is expected to be complete in four years.

Discussion

This multicentre RCT will establish whether, for women of advanced age, women with ovulatory disease, and women who have a high risk for tubal pathology, there is a fertility enhancing effect of tubal flushing with oil-based contrast during HSG and whether the use of this contrast medium is cost-effective.

Trial Registration The study was prospectively registered in the Netherlands Trial Register on August 1st 2019 as ‘H2Oil2’ (reference number NL7925, https://www.trialregister.nl/trial/7925).

Supplementary Information

The online version contains supplementary material available at 10.1186/s12905-022-01707-z.

Exosomes Derived From CTF1-Modified Bone Marrow Stem Cells Promote Endometrial Regeneration and Restore Fertility

Background: Thin endometrial tissue is a leading cause of embryo transfer failure, potentially contributing to sustained infertility and associated adverse outcomes. The application of exosomes derived from autologous or allogeneic bone marrow-derived stem cells (BMSCs) has been used to promote uterine repair following injury, and there is also prior evidence that stem cell transplantation can bolster fertility. Genetic modifications represent a primary approach to enhancing exosomal therapy strategies. The present study thus explored the effects of Cardiotrophin-1 (CTF1)-modified BMSCs-exo on fertility-related outcomes.

Methods: An adenoviral vector was used to generate CTF1-overexpressing BMSCs (C-BMSCs), after which exosomes were isolated from control BMSCs (BMSC-exos) and C-BMSCs (C-BMSC-exos). The angiogenic effects of C-BMSC-exo treatment were assessed through analyses of endothelial cell proliferation and tube formation. Model rats exhibiting endometrial thinning were administered C-BMSCs-exo, after which the effects of such treatment were assessed through H&E staining, Masson’s trichrome staining, and immunofluorescence analyses. The mechanistic basis for the proangiogenic effects of CTF1 as a driver of endometrial regeneration was additionally explored.

Results: C-BMSC-exo treatment of HUVECs was associated with enhanced neovascularization, as evidenced by improved in vitro proliferation, migration, and tube formation. Importantly, such treatment was also linked to tissue regeneration, neovascularization, and the suppression of localized tissue fibrosis in vivo. Regenerated endometrial tissue exhibited higher embryo receptivity and was associated with higher birth rates in treated rats. The upregulation of the JAK/PI3K/mTOR/STAT3 signaling pathways in C-BMSC-exo-treated rats may underscore the mechanistic basis whereby CTF1 can positively impact endometrial angiogenesis and regeneration.

Conclusion: Our data suggest that exosomes produced by CTF1-modified BMSCs can more effectively promote the regeneration of endometrial and myometrial tissues, driving neovascularization in a manner that improves endometrial receptivity in a rat model system, highlighting the therapeutic promise of this approach for patients diagnosed with endometrial thinning.

Pregnancy outcome after in-vitro fertilization/intracytoplasmic sperm injection in women with congenital uterus didelphys

OBJECTIVE

To investigate the pregnancy and obstetric outcomes of patients with congenital uterus didelphys who achieved clinical pregnancy after in-vitro fertilization (IVF)/intracytoplasmic sperm injection (ICSI).

METHODS

This was a retrospective matched-cohort study of 83 infertile patients with uterus didelphys who underwent IVF/ICSI and achieved clinical pregnancy from January 2005 to December 2018 at our center. For each patient in the study group, three control patients with normal uterine morphology who underwent IVF/ICSI in 2018 were selected randomly. Patients in the two groups were matched for number of gestational sacs, maternal age, infertility type, cause of infertility, fertilization method, endometrial thickness 1 day before embryo transfer and number of embryos transferred. The classification of congenital uterine anomalies was based on the American Fertility Society system (1988). The pregnancy and obstetric outcomes of the didelphic and control groups were compared separately for singleton and twin pregnancies, and for all pregnancies combined.

RESULTS

In singleton pregnancies, women with uterus didelphys had increased risk of preterm birth (odds ratio (OR), 4.68; rate difference (RD), 0.14; P < 0.001), Cesarean section (OR, 2.80; RD, 0.17; P = 0.016) and birth weight < 2500 g (OR, 4.06; RD, 0.10; P = 0.017) compared to women with normal uterine morphology. In twin pregnancies, the presence of uterus didelphys was associated with increased risk of preterm delivery (OR, 4.79; RD, 0.37; P = 0.006), perinatal mortality (OR, 3.16; RD, 0.19; P = 0.043) and birth weight < 2500 g (OR, 9.57; RD, 0.35; P = 0.001).

CONCLUSIONS

The presence of uterus didelphys was associated with significantly increased risk of some adverse pregnancy outcomes compared to pregnancies with normal uterine morphology in women who underwent IVF/ICSI. A twin pregnancy in women with uterus didelphys was associated with worse perinatal outcome. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.

Birth rate after major trauma in fertile-aged women: a nationwide population-based cohort study in Finland

Background

To date, only a few small studies have assessed the effects of major orthopedic traumas on the subsequent birth rate in fertile-aged woman. We assessed the incidences of traumatic brain injury (TBI) and fractures of the spine, pelvis, and hip or thigh and evaluated their association with the birth rate in fertile-aged woman.

Methods

In this retrospective register-based nationwide cohort study, data on all fertile-aged (15–44 years of age) women who sustained a TBI or fracture of the spine, pelvis, hip or thigh between 1998 and 2013 were retrieved from the Care Register for Health Care. A total of 22,780 women were included in TBI group, 3627 in spine fracture group, 1820 in pelvic fracture group, and 1769 in hip or thigh fracture group. The data were subsequently combined with data from the National Medical Birth Register. We used Cox regression model to analyze the hazard for a woman to give birth during 5-year follow-up starting from a major trauma. Women with wrist fractures (4957 women) formed a reference group. Results are reported as hazard ratios (HR) with 95% confidence intervals (CI).

Results

During 5-year follow-up after major trauma, 4324 (19.0%) women in the TBI group, 652 (18.0%) in the spine fracture group, 301 (16.5%) in the pelvic fracture group, 220 (12.4%) in the hip or thigh fracture group, and 925 (18.7%) in the wrist fracture group gave birth. The cumulative birth rate was lower in the hip or thigh fracture group in women aged 15–24 years (HR 0.72, CI 0.58–0.88) and 15–34 years (HR 0.65, CI 0.52–0.82). Women with pelvic fracture aged 25–34 years also had a lower cumulative birth rate (HR 0.79, CI 0.64–0.97). For spine fractures and TBIs, no reduction in cumulative birth rate was observed. Vaginal delivery was the primary mode of delivery in each trauma group. However, women with pelvic fractures had higher rate of cesarean section (23.9%), when compared to other trauma groups.

Conclusions

Our results suggest that women with thigh, hip, or pelvic fractures had a lower birth rate in 5-year follow-up. Information gained from this study will be important in clinical decision making when women with previous major trauma are considering becoming pregnant and giving birth.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12978-022-01387-w.

To date, only a few small studies have assessed the effects of major orthopedic traumas on the subsequent birth rate in fertile-aged woman. We assessed the incidences of traumatic brain injury (TBI) and fractures of the spine, pelvis, and hip or thigh and evaluated their association with the birth rate in fertile-aged woman.

Data on all fertile-aged (15–44 years of age) women who sustained a TBI or fracture of the spine, pelvis, hip or thigh between 1998 and 2013 were retrieved from the Care Register for Health Care and the data was then subsequently combined with data from the National Medical Birth Register.

A total of 22,780 women were included in TBI group, 3627 in spine fracture group, 1820 in pelvic fracture group, 1769 in hip or thigh fracture group, and 4957 in wrist fracture group, which was used as control group. Of these, 4324 (19.0%) women in the TBI group, 652 (18.0%) in the spine fracture group, 301 (16.5%) in the pelvic fracture group, 220 (12.4%) in the hip or thigh fracture group, and 925 (18.7%) in the wrist fracture group gave birth during the 5-year follow-up.

Our results suggest that women with thigh, hip, or pelvic fractures had a lower birth rate in 5-year follow-up. Information gained from this study will be important in clinical decision making when women with previous major trauma are considering becoming pregnant and giving birth.

Developmental exposure to phytoestrogens found in soy: New findings and clinical implications

Exposure to naturally derived estrogen receptor activators, such as the phytoestrogen genistein, can occur at physiologically relevant concentrations in the human diet. Soy-based infant formulas are of particular concern because infants consuming these products have serum genistein levels almost 20 times greater than those seen in vegetarian adults. Comparable exposures in animal studies have adverse physiologic effects. The timing of exposure is particularly concerning because infants undergo a steroid hormone-sensitive period termed "minipuberty" during which estrogenic chemical exposure may alter normal reproductive tissue patterning and function. The delay between genistein exposure and reproductive outcomes poses a unique challenge to collecting epidemiological data. In 2010, the U.S. National Toxicology Program monograph on the safety of the use of soy formula stated that the use of soy-based infant formula posed minimal concern and emphasized a lack of data from human subjects. Since then, several new human and animal studies have advanced our epidemiological and mechanistic understanding of the risks and benefits of phytoestrogen exposure. Here we aim to identify clinically relevant findings regarding phytoestrogen exposure and female reproductive outcomes from the past 10 years, with a focus on the phytoestrogen genistein, and explore the implications of these findings for soy infant formula recommendations. Research presented in this review will inform clinical practice and dietary recommendations for infants based on evidence from both clinical epidemiology and basic research advances in endocrinology and developmental biology from mechanistic in vitro and animal studies.

Cell-Specific Expression Pattern of Toll-Like Receptors and Their Roles in Animal Reproduction

Toll-like receptors (TLRs), a part of the innate immune system, have critical roles in protection against infections and involve in basic pathology and physiology. Secreted molecules from the body or pathogens could be a ligand for induction of the TLR system. There are many immune and non-immune types of cells that express at a least single TLR on their surface or cytoplasm. Those cells may be a player in a defense system or in the physiological regulation mechanisms. Reproductive tract and organs contain different types of cells that have essential functions such as hormone production, providing an environment for embryo/fetus, germ cell production, etc. Although lower parts of reproductive organs are in a relationship with outsider contaminants (bacteria, viruses, etc.), upper parts should be sterile to provide a healthy pregnancy and germ cell production. In those areas, TLRs bear controller or regulator roles. In this chapter, we will provide current information about physiological functions of TLR in the cells of the reproductive organs and tract, and especially about their roles in follicle selection, maturation, follicular atresia, ovulation, corpus luteum (CL) formation and regression, establishment and maintenance of pregnancy, sperm production, maturation, capacitation as well as the relationship between TLR polymorphism and reproduction in domestic animals. We will also discuss pathogen-associated molecular patterns (PAMPs)-induced TLRs that involve in reproductive inflammation/pathology.

Histopathological profile of women who had previously failed IVF and the association to the outcome in the subsequent IVF cycle

Objective

To evaluate the endometrial histopathological profile of patients undergoing curettage and the association of the histopathological profile with the pregnancy outcome during the subsequent IVF cycle.

Methods

In this retrospective cohort study, a total of 248 women with at least one failed attempt of IVF and who underwent curettage and a subsequent IVF were included. Demographic data, endometrial histopathological records, stimulation information, and pregnancy outcomes were collected and analyzed.

Results

The histopathological analysis of endometrial tissues showed that 130 women (52.4%) had endometrial pathologies. Of these women, 103 (41.5%) had endometrial polyps, 22 (8.9%) had chronic endometritis, and five (2.0%) had both polyps and endometritis. No statistical difference was observed between the normal histopathology group and the abnormal histopathology group in the outcome of the subsequent IVF cycle. Subgroup analyses were performed to further characterize and compare women with normal histopathology and women with endometrial polyps (polyp subgroup) or chronic endometritis (endometritis subgroup). No statistical differences were found among the three groups in the rates of pregnancy (44.1% vs. 49.5% vs. 45.5%, P=0.72), biochemical pregnancy loss (13.5% vs. 15.7% vs. 20.0%, P=0.86), clinical pregnancy loss (25.0% vs. 31.4% vs. 30.0%, P=0.77), and live birth (27.1% vs. 26.2% vs. 22.7%, P=0.91) during the subsequent IVF cycle.

Conclusion

Women with previously failed IVF and abnormal endometrial histopathology treated with curettage had the same outcome in the subsequent IVF cycle as women with normal endometrial histopathology.

The effects of hysteroscopic morcellation of endometrial polyps on frozen embryo transfer outcomes

OBJECTIVE(S)

To determine if hysteroscopic removal of endometrial polyps, specifically via morcellation of polyps, affects implantation rate (IR), clinical pregnancy rate (CPR), spontaneous abortion (SAB) rate, and live birth rate (LBR) in first frozen embryo transfer (FET) cycles.

STUDY DESIGN

Retrospective chart review, with data abstracted from the charts of all first autologous oocyte frozen embryo transfer (FET) cases (n = 135) at a single fertility center from January 2018 through June 2020. Subjects were grouped into (A) hysteroscopic polypectomy prior to first FET (n = 25) or (B) no hysteroscopic polypectomy prior to first FET (n = 110). The primary outcome was live birth rate (LBR). Secondary outcomes were implantation rate (IR), clinical pregnancy rate (CPR), and spontaneous abortion (SAB) rate.

RESULTS

We found no difference between the groups in terms of the primary outcome (LBR) or the secondary outcomes IR, CPR, and SAB rate.

CONCLUSION(S)

The data analyzed here suggest that hysteroscopic morcellation of endometrial polyps has no adverse effect on IR, SAB rate, CPR, or LBR among first FET cases after this type of polypectomy.

Evaluation of artificial intelligence using time-lapse images of IVF embryos to predict live birth

RESEARCH QUESTION

Can artificial intelligence (AI) improve the prediction of live births based on embryo images?

DESIGN

The AI system was created by using the Attention Branch Network associated with deep learning to predict the probability of live birth from 141,444 images recorded by time-lapse imaging of 470 transferred embryos, of which 91 resulted in live birth and 379 resulted in non-live birth that included implantation failure, biochemical pregnancy and clinical miscarriage. The possibility that the calculated confidence scores of each embryo and the focused areas visualized in each embryo image can help predict subsequent live birth was examined.

RESULTS

The AI system for the first time successfully visualized embryo features in focused areas that had potential to distinguish between live and non-live births. No visual feature of embryos were visualized that were associated with live or non-live births, although there were many images in which high-focused areas existed around the zona pellucida. When a cut-off level for the confidence score was set at 0.341, the live birth rate was significantly greater for embryos with a score higher than the cut-off level than for those with a score lower than the cut-off level (P < 0.001). In addition, the live birth rate of embryos with good morphological quality and confidence scores higher than 0.341 was 41.1%.

CONCLUSIONS

The authors have created an AI system with a confidence score that is useful for non-invasive selection of embryos that could result in live birth. Further study is necessary to improve selection accuracy.

Successful Outcome Following Hysteroscopic Septoplasty in a Woman with Seven Consecutive Pregnancy Losses

Anomalies of the reproductive tract are common and present in about 3%–5% of the general population and in about 3% of infertile women. In general, they are asymptomatic, but they can also be associated with recurrent abortions or infertility. This is the case of a 27-year-old nulliparous woman presenting with the history of seven consecutive first trimester spontaneous abortions. Since her marriage 10 years back she conceived on repeated times but all the pregnancies ended in spontaneous miscarriage at around 10–12 weeks. Hysterosalpingography revealed a bicornuate/septate uterus. Hysteroscopic septoplasty with concurrent laparoscopy was planned after normalization of the endocrine parameters. She conceived spontaneously 7 months after the surgery. She had luteal phase support with progesterone, cervical cerclage and management of gestational diabetes, and pregnancy-induced hypertension. At 37 weeks of gestation, elective caesarean section was done with the delivery of a healthy female baby.

Uterine Fibroids and Infertility

Infertility is a disease of the reproductive system defined by the failure to achieve a clinical pregnancy after 12 months or more of regular unprotected sexual intercourse. Uterine fibroids are the most common tumor in women, and their prevalence is high in patients with infertility. Fibroids may be the sole cause of infertility in 2–3% of women. Depending on their location in the uterus, fibroids have been implicated in recurrent pregnancy loss as well as infertility. Pregnancy and live birth rates appear to be low in women with submucosal fibroids; their resection has been shown to improve pregnancy rates. In contrast, subserosal fibroids do not affect fertility outcomes and their removal does not confer any benefit. Intramural fibroids appear to reduce fertility, but recommendations concerning their treatment remain unclear. Myomectomy should be discussed individually with the patient; other potential symptoms such as dysmenorrhea or bleeding disorders should be included in the indication for surgery.

Three-dimensional microengineered vascularised endometrium-on-a-chip

STUDY QUESTION

Can we reconstitute physiologically relevant 3-dimensional (3D) microengineered endometrium in-vitro model?

SUMMARY ANSWER

Our representative microengineered vascularised endometrium on-a-chip closely recapitulates the endometrial microenvironment that consists of three distinct layers including epithelial cells, stromal fibroblasts and endothelial cells in a 3D extracellular matrix in a spatiotemporal manner.

WHAT IS KNOWN ALREADY

Organ-on-a-chip, a multi-channel 3D microfluidic cell culture system, is widely used to investigate physiologically relevant responses of organ systems.

STUDY DESIGN, SIZE, DURATION

The device consists of five microchannels that are arrayed in parallel and partitioned by array of micropost. Two central channels are for 3D culture and morphogenesis of stromal fibroblast and endothelial cells. In addition, the outermost channel is for the culture of additional endometrial stromal fibroblasts that secrete biochemical cues to induce directional pro-angiogenic responses of endothelial cells. To seed endometrial epithelial cells, on Day 8, Ishikawa cells were introduced to one of the two medium channels to adhere on the gel surface. After that, the microengineered endometrium was cultured for an additional 5–6 days (total ∼ 14 days) for the purpose of each experiment.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Microfluidic 3D cultures were maintained in endothelial growth Medium 2 with or without oestradiol and progesterone. Some cultures additionally received exogenous pro-angiogenic factors. For the three distinct layers of microengineered endometrium-on-a-chip, the epithelium, stroma and blood vessel characteristics and drug response of each distinct layer in the microfluidic model were assessed morphologically and biochemically. The quantitative measurement of endometrial drug delivery was evaluated by the permeability coefficients.

MAIN RESULTS AND THE ROLE OF CHANCE

We established microengineered vascularised endometrium-on-chip, which consists of three distinct layers: epithelium, stroma and blood vessels. Our endometrium model faithfully recapitulates in-vivo endometrial vasculo-angiogenesis and hormonal responses displaying key features of the proliferative and secretory phases of the menstrual cycle. Furthermore, the effect of the emergency contraception drug levonorgestrel was evaluated in our model demonstrating increased endometrial permeability and blood vessel regression in a dose-dependent manner. We finally provided a proof of concept of the multi-layered endometrium model for embryo implantation, which aids a better understanding of the molecular and cellular mechanisms underlying this process.

LARGE SCALE DATA

N/A.

LIMITATIONS, REASONS FOR CAUTION

This report is largely an in-vitro study and it would be beneficial to validate our findings using human primary endometrial cells.

WIDER IMPLICATIONS OF THE FINDINGS

Our 3D microengineered vascularised endometrium-on-a-chip provides a new in-vitro approach to drug screening and drug discovery by mimicking the complicated behaviours of human endometrium. Thus, we suggest our model as a tool for addressing critical challenges and unsolved problems in female diseases, such as endometriosis, uterine cancer and female infertility, in a personalised manner.

STUDY FUNDING/COMPETING INTEREST(S)

This work is supported by funding from the National Research Foundation of Korea (NRF) grant funded by the Korea government (MSIT) to Y.J.K. (No. 2018R1C1B6003), to J.A. (No. 2020R1I1A1A01074136) and to H.S.K. (No. 2020R1C1C100787212). The authors report no conflicts of interest.

Management of endometrial polyps in infertile women: A mini-review

Considerable disagreement exists regarding whether endometrial polyps should be removed before attempting natural pregnancy and before pregnancy via intrauterine insemination (IUI) or in vitro fertilization (IVF). Through a literature review, we obtained information on the impact of endometrial polyps and polypectomy on fertility outcomes. Several observational studies have suggested that women with unexplained infertility may benefit from endometrial polypectomy for a future natural pregnancy. A few studies reported benefits from endometrial polypectomy in infertile women who plan to undergo IUI. However, no strong evidence supports polypectomy as a way to improve the pregnancy rate in infertile women who plan to undergo IVF or polypectomy during controlled ovarian stimulation for IVF. Although no studies have defined criteria for the polyp size that should be removed in infertile women, clinicians should be aware that small endometrial polyps (<10 mm) sometimes regress spontaneously. Endometrial polypectomy is currently justified in patients with repeated IVF failure, but more studies are needed to verify that endometrial polypectomy itself will eventually increase the pregnancy rate. Although several mechanisms by which endometrial polyps exert a negative effect on fertility have emerged, there is no consensus about the proper management of endometrial polyps in infertile women. Therefore, the management of endometrial polyps should be individualized depending on the patient's situation and clinician’s preference.

A Comprehensive Review on the Applications of Exosomes and Liposomes in Regenerative Medicine and Tissue Engineering

Tissue engineering and regenerative medicine are generally concerned with reconstructing cells, tissues, or organs to restore typical biological characteristics. Liposomes are round vesicles with a hydrophilic center and bilayers of amphiphiles which are the most influential family of nanomedicine. Liposomes have extensive research, engineering, and medicine uses, particularly in a drug delivery system, genes, and vaccines for treatments. Exosomes are extracellular vesicles (EVs) that carry various biomolecular cargos such as miRNA, mRNA, DNA, and proteins. As exosomal cargo changes with adjustments in parent cells and position, research of exosomal cargo constituents provides a rare chance for sicknesses prognosis and care. Exosomes have a more substantial degree of bioactivity and immunogenicity than liposomes as they are distinctly chiefly formed by cells, which improves their steadiness in the bloodstream, and enhances their absorption potential and medicinal effectiveness in vitro and in vivo. In this review, the crucial challenges of exosome and liposome science and their functions in disease improvement and therapeutic applications in tissue engineering and regenerative medicine strategies are prominently highlighted.

Recurrent implantation failure - an overview of current research

BACKGROUND

Recurrent implantation failure (RIF) can be defined as a failure to achieve a clinical pregnancy after transfer of at least four embryos of good quality in a minimum of three fresh or frozen cycles in women under the age of 40. RIF is often a complex problem with a wide variety of etiologies and mechanisms as well as treatment options.

SUMMARY

Anatomical conditions of the uterus, thrombophilia, genetic abnormalities, or immunological factors are only a few examples which could be responsible for RIF. The recommendations for women with RIF vary depending on the source of their problem. There is not just one treatment option, but many depending on the etiology and the severity of the problem.

KEY MESSAGE

However, it would help to establish a set of standardized examinations and tests to use, in order to do a preliminary evaluation on each patient, which would then hopefully direct the approach of treatment for each individual couple.

The Rare, Unexpected Condition of a Twisted Leiomyoma in Mayer-Rokitansky-Küster-Hauser (MRKH) Syndrome: Etiopathogenesis, Diagnosis and Management. Our Experience and Narrative Review of the Literature

Uterine leiomyomas are a common finding in medical practice, but their frequency changes drastically when contextualized in a syndrome, as in the following case. A 50-year-old woman with a known Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome presented at our clinic with abdominal pain located in the lower quadrants and scarcely responsive to analgesic therapy. A twisted gynecological pelvic mass was diagnosed, and management for prompt resolution was adopted. Histologically the mass was described as a leiomyoma. The aim of the present study is to share our experience and to review the literature to compare different manifestation of the disease and different approach used in the various centers. The additional novelty of the paper is the immunohistochemical study we carried out on the leiomyoma that is contrasted with the current etiopathogenetic theories.

Rosuvastatin exposure in female Wistar rats alters uterine contractility and do not show evident (anti)estrogenic effects

Statins are 3-hydroxy-3-methyl-glutaryl-CoA (HMG-CoA) reductase inhibitor drugs that lead to serum-cholesterol-lowering effects. Rosuvastatin, a third-generation statin, has shown better results in reducing cholesterol concentrations when compared to other widely prescribed statins. Recent studies by our group reported that rosuvastatin impairs reproductive function in rats possibly by disrupting the reproductive-endocrine axis. In this study, we evaluated whether rosuvastatin presents estrogenic or antiestrogenic effects, by an in vivo uterotrophic assay in rats, and investigated the direct effect of this drug upon rat uterine tissue contractility both in non-gravid and gravid periods. Rosuvastatin exposure in vivo at doses of 0 (control), 3, and 10 mg/kg/d was not associated with estrogenic or antiestrogenic effects on uterine tissue. However, in vivo (doses of 0, 3, and 10 mg/kg/d) and ex vivo (concentrations of 0, 1, 10, and 100 µg/mL) exposures to this drug were related to alterations in uterine basal contraction pattern. Furthermore, in vivo and ex vivo rosuvastatin exposures potentially modulate the action of uterine contraction inducers carbachol, norepinephrine, and prostaglandin E2. Thus, rosuvastatin can affect uterine physiology not necessarily by an endocrine mechanism related to the estrogen signaling, but possibly by its pleiotropic effects, with indirect tissue and cellular interactions, since in vivo and ex vivo exposures of uterine fragments to rosuvastatin presented different responses in uterine contractile parameters, which require further studies upon the precise mechanism of action of this drug in female reproductive function.

Fertility outcomes after hysteroscopic removal of intrauterine leiomyomas and polyps

INTRODUCTION

Thanks to the progress of science, it is now understood that a successful implantation not only depends on the quality of the embryo, but also on having a receptive endometrium. During the years, several authors have reviewed the important role of the uterine factor, ranging from the congenital anomalies, such as uterine septa and subsepta, and acquired conditions such as endometrial polyps and submucous myomas. Currently, hysteroscopy has proved to be a powerful and accurate tool for visualizing the uterine cavity and treating intrauterine pathologies.

EVIDENCE ACQUISITION

This review of the literature aims to report the current available data on the effects of the two most common endouterine pathologies (i.e. endometrial polyps and submucous myomas) and the impact of hysteroscopic removal on fertility outcomes.

EVIDENCE SYNTHESIS

To date, the low number of randomized controlled trials available does not yet make it possible to give a definitive answer on what are the reproductive outcomes following treatment of endometrial polyps and leiomyomas. Nevertheless, existing evidence points to a benefit of removal of this two pathologies in infertile women, mostly when they have a history of recurrent pregnancy loss.

CONCLUSIONS

Further studies are needed to demonstrate that surgical treatments of endometrial polyps and myomas could improve not only the morphology but also the function of the uterine cavity before undergoing any assisted fertility treatment.

Clinical outcomes analysis of infertile women with unicornuate uterus in IVF-ET

PURPOSE

To explore the pregnancy outcomes, and neonatal status, arising from embryo transfer in unicornual uterine infertility patients.

METHODS

We analyzed 2499 cycles of clinical data from in vitro fertilization/intracytoplasmic sperm injection-embryo transfer (IVF/ICSI-ET) from 1st May 2016 to 1st May 2018 in the Reproductive Center of the Third Affiliated Hospital of Zhengzhou University, including 109 women with unicornuate uterus (the observation group) and 2390 women with normally shaped uterus (the control group).

RESULTS

There were no significant differences in embryo implantation rate, clinical pregnancy rate or miscarriage rate (41.88 % VS 42.36 %, P = 0.904; 48.62 % VS 55.94 %, P = 0.133; 11.01 % VS 8.99 %, P = 0.474) between the two groups. The live birth rate in the observation group was lower than that in the control group (35.78 % VS 45.82 %, P = 0.040). The fetal birth weight of the observation group was lower than that of the control group among single-born live births (3009.12 ± 430.59 g VS 3413.40 ± 492.25 g, P = 0.017), but the differences were not observed in the sex ratio at birth, premature birth rate, low birth weight infant (LBW) rate and macrosomia rate (P > 0.05). The fetal birth weight of the observation group was lower than that of the control group among twins live births (2480.00 ± 190.32 g VS 2606.02 ± 471.59 g), but the difference between the groups did not reach statistical significance (P > 0.05)．Logistic regression analysis showed that age, number of embryos transplanted and uterine morphology were independent influencing factors of live birth.

CONCLUSION

Compared with women with normal uterus, the live birth rate of women with unicornuate uterus is low, and the birth weight of newborns with single birth is reduced.

Hysteroscopy as An Investigational Operative Procedure in Primary and Secondary Infertility: A Systematic Review

Background

The aim of this study is to review current indications to diagnostic and/or operative hysteroscopy in primary and secondary infertility, as well as to determine its efficacy in improving fertility.

Materials and Methods

We gathered available evidence about the role of hysteroscopy in the management of vari- ous infertility conditions. Literature from 2000 to 2020 that pertained to this topic were retrieved and appropriately selected.

Results

Hysteroscopy does not appear as a first line diagnostic procedure for every clinical scenario. However, its di- agnostic sensitivity and specificity in assessing intrauterine pathology is superior to all other non-invasive techniques, such as saline infusion/gel instillation sonography (SIS/GIS), transvaginal sonography (TVS) and hysterosalpingog- raphy (HSG). Hysteroscopy allows not only a satisfactory evaluation of the uterine cavity but also, the eventual treat- ment of endocavitary pathologies that may affect fertility both in spontaneous and assisted reproductive technology (ART) cycles.

Conclusion

Hysteroscopy, due to its diagnostic and therapeutic potential, should be regarded as a necessary step in infertility management. However, in case of suspected uterine malformation, hysteroscopy should be integrated with other tests [three-dimensional (3D) ultrasound or magnetic resonance imaging (MRI)] for diagnostic confirmation.

Diagnostic yield and therapeutic outcome of hysteroscopy in women with infertility in a referral clinical setting: a Port Harcourt, Nigeria experience

Introduction

intrauterine pathologies were traditionally evaluated by blind dilatation and curettage along with hysterosalpingography. Hysteroscopy is a veritable tool for evaluation of uterine cavity pathologies with an increasing availability in Nigeria. The study aims to report the diagnostic yield and therapeutic outcome of hysteroscopy in women with infertility from a Nigerian metropolis.

Methods

a retrospective cross-sectional study of consecutive cases of infertile women referred for hysteroscopy to an ambulatory care endoscopy facility in Port Harcourt, Nigeria. The variables collated included age, parity, past gynaecological history, indication, hysteroscopy findings and interventions. Statistical analysis was performed using SPSS version 25.

Results

included in study were 75 patients undergoing a total of 124 hysteroscopic procedures. The age range of patients was 25 to 56 years (mean 40.7 ± 5.9 years). A positive diagnostic yield of 93.3% with non-visualization of intracavitary uterine pathology in 5 patients was recorded. The most common pathologies were submucous myoma-25(31.3%), endometrial polyps- 18(22.5%) and intrauterine adhesions-18(22.5%). There was no statistical difference between the mean age of patients with or without polyp, myoma and intrauterine adhesions (P = 0.185, P = 0.510 and P = 0.619 respectively) but a non-linear relationship between age and polyp detection (Eta2 = 0.024). Operative hysteroscopies were all performed on out- patient basis but staged in 30(40.0%) patients.

Conclusion

benign uterine growths and intrauterine adhesions are frequent causes of uterine factor infertility. A high successful completion rate of hysteroscopic interventions was achieved.