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Ferrari S, Salmeri N, He X, Schimberni M, Sangiorgi V, Bartiromo L, Tandoi I, Pagliardini L, Papaleo E, Candiani M. Thinking in context: Fibroids-to-uterine volume ratio in pre-surgical fertility evaluation for intramural fibroids. Eur J Obstet Gynecol Reprod Biol 2024; 301:194-200. [PMID: 39154514 DOI: 10.1016/j.ejogrb.2024.08.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2024] [Revised: 08/05/2024] [Accepted: 08/12/2024] [Indexed: 08/20/2024]
Abstract
OBJECTIVE To explore the utility of the total fibroids-to-uterine volume (FTUV) ratio as a simple, preoperative tool to assist in counseling patients seeking pregnancy who are undergoing myomectomy for intramural (IM) fibroids. STUDY DESIGN This is an historical cohort study on reproductive-aged patients seeking pregnancy who underwent laparotomic myomectomy for intramural fibroids from January 2017 to December 2021. Only G3 to G5 fibroids, according to the 2011 International Federation of Gynecology and Obstetrics (FIGO) classification, were included. Pre-operative transvaginal ultrasound (TVUS) was performed to measure the volume of intramural myomas (diameter1*diameter2*diameter3*0.52) and to calculate their total volume. The total fibroids-to-uterine volume (FTUV) ratio was calculated as the proportion of the uterine volume occupied by the sum of IM fibroids volumes. RESULTS A total of 166 women with pre-surgical TVUS evaluation of IM fibroids were included, with a mean age of 36.22 ± 5.15 years. The FTUV ratio was identified as a positive predictor of clinical pregnancy after surgery (adjOR, 1.04; 95 % CI, 1.02-1.06; p = 0.0001), whereas age showed a negative association (adjOR, 0.90; 95 % CI, 0.83-0.98; p = 0.012). Endometrial cavity distortion prior to surgery was also positively associated with pregnancy post-surgery (adjOR, 3.50; 95 % CI, 1.51-8.08; p = 0.003). Consistent results were found for live births, with the FTUV ratio being a significant positive predictor of live birth after surgery (adjOR, 1.03; 95 % CI, 1.01-1.05; p = 0.001) and age showing a negative association (adjOR, 0.88; 95 % CI, 0.80-0.96; p = 0.004). Parity prior to surgery also positively impacted live birth post-surgery (adjOR, 2.65; 95 % CI, 1.30-5.40; p = 0.007). An FTUV ratio threshold of 53.39 % accurately predicted clinical pregnancy in 68.46 % of cases (sensitivity of 71.70 % and specificity of 66.67 %). For live births, a higher FTUV ratio threshold of 59.21 % predicted outcomes accurately in 69.13 % of cases (sensitivity of 65.85 % and specificity of 70.37 %). CONCLUSION The use of the FTUV ratio in pre-operative ultrasound evaluation of IM fibroids may improve counseling for patients desiring to conceive after myomectomy. By providing a personalized assessment of the amount of myometrial volume occupied by fibroids, the FTUV ratio can help predict fertility outcomes after surgery, enabling better-informed decisions and treatment planning.
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Affiliation(s)
- Stefano Ferrari
- Gynecology and Obstetrics Unit, IRCCS San Raffaele Institute, 20132 Milan, Italy
| | - Noemi Salmeri
- Gynecology and Obstetrics Unit, IRCCS San Raffaele Institute, 20132 Milan, Italy.
| | - Xuemin He
- Gynecology and Obstetrics Unit, IRCCS San Raffaele Institute, 20132 Milan, Italy
| | - Matteo Schimberni
- Gynecology and Obstetrics Unit, IRCCS San Raffaele Institute, 20132 Milan, Italy
| | - Virginia Sangiorgi
- Gynecology and Obstetrics Unit, IRCCS San Raffaele Institute, 20132 Milan, Italy
| | - Ludovica Bartiromo
- Gynecology and Obstetrics Unit, IRCCS San Raffaele Institute, 20132 Milan, Italy
| | - Iacopo Tandoi
- Gynecology and Obstetrics Unit, IRCCS San Raffaele Institute, 20132 Milan, Italy
| | - Luca Pagliardini
- Gynecology and Obstetrics Unit, IRCCS San Raffaele Institute, 20132 Milan, Italy
| | - Enrico Papaleo
- Gynecology and Obstetrics Unit, IRCCS San Raffaele Institute, 20132 Milan, Italy
| | - Massimo Candiani
- Gynecology and Obstetrics Unit, IRCCS San Raffaele Institute, 20132 Milan, Italy
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Pritts TL, Ogden M, Parker W, Ratcliffe J, Pritts EA. Intramural Leiomyomas and Fertility: A Systematic Review and Meta-Analysis. Obstet Gynecol 2024; 144:171-179. [PMID: 38935974 DOI: 10.1097/aog.0000000000005661] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2024] [Accepted: 05/09/2024] [Indexed: 06/29/2024]
Abstract
OBJECTIVE To evaluate fertility outcomes based on size and number of intramural leiomyomas and outcomes after removal. DATA SOURCES Online searches: MEDLINE, ClinicalTrials.gov , PubMed, Cochrane Library, and PROSPERO Library from 1994 to 2023. METHODS OF STUDY SELECTION A total of 5,143 studies were identified, with inclusion of 13 study groups. TABULATION, INTEGRATION AND RESULTS Outcomes for size and number of leiomyomas were reported with clinical pregnancy rates and ongoing pregnancy or live-birth rates. In data sets with maximum leiomyoma diameters of less than 6 cm for study inclusion, women with leiomyomas smaller than 3 cm had lower clinical pregnancy rates than women without leiomyomas, with an odds ratio (OR) of 0.53 (95% CI, 0.38-0.76) and, for ongoing pregnancy or live-birth rates, an OR of 0.59 (95% CI, 0.41-0.86). The ORs for clinical pregnancy rates in women with intermediately-sized leiomyomas (those between 3 cm and 6 cm) were lower than in women without leiomyomas, with an OR at 0.43 (95% CI, 0.29-0.63) and, for ongoing pregnancy or live-birth rates, an OR at 0.38 (95% CI, 0.24-0.59). In data sets without exclusion for women with larger-sized leiomyomas, clinical pregnancy rates were lower for those with leiomyomas smaller than 5 cm compared with those without leiomyomas, with an OR of 0.75 (95% CI, 0.58-0.96). Women with leiomyomas larger than 5 cm showed no differences in clinical pregnancy rate compared with women without leiomyomas, with an OR of 0.71 (95% CI, 0.32-1.58). Although women with a single leiomyoma in any location had no differences in outcomes, those with more than one leiomyoma had lower clinical pregnancy rates and ongoing pregnancy or live-birth rates, with an OR of 0.62 (95% CI, 0.44-0.86) and 0.57 (95% CI, 0.36-0.88), respectively. The clinical pregnancy rate for women undergoing myomectomy for intramural leiomyomas was no different than those with intramural leiomyomas in situ, with an OR of 1.10 (95% CI, 0.77-1.59). CONCLUSION Even small intramural leiomyomas are associated with lower fertility; removal does not confer benefit. Women with more than one leiomyoma in any location have reduced fertility.
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Affiliation(s)
- Taïna Laurore Pritts
- University of Wisconsin and the Wisconsin Fertility Institute, Madison, Wisconsin; and the University of California, San Diego, San Diego, and Advanced Fertility Associates Medical Group, Santa Rosa, California
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Donnez J, Taylor HS, Marcellin L, Dolmans MM. Uterine fibroid-related infertility: mechanisms and management. Fertil Steril 2024; 122:31-39. [PMID: 38453041 DOI: 10.1016/j.fertnstert.2024.02.049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2024] [Accepted: 02/29/2024] [Indexed: 03/09/2024]
Abstract
Fibroids are a common pathology and increasingly observed in women seeking medical treatment for infertility. The longer reproductive horizon because of improvements in medical care and current trend for women to postpone childbearing are making fibroid-related infertility increasingly common. This review aimed to critically analyze the association between uterine fibroids and infertility, mechanisms by which uterine fibroids may impair fertility, and management of myoma-related infertility. The association of fibroids with infertility is a source of controversy. As the focus of this review is infertility, it is crucial to analyze the mechanisms by which fertility may be impaired by the presence of fibroids. Current management strategies involve mainly surgical interventions, including myomectomy by hysteroscopy, laparotomy, or laparoscopy, and nonsurgical approaches, such as uterine artery embolization and focused ultrasound performed under radiologic or echographic guidance. The risks and benefits of each option should be discussed with patients, and several factors need to be considered, including the skills of surgeons and availability of different resources in various centers. Concerning the efficacy of oral gonadotropin-releasing hormone antagonists (i.e., elagolix, relugolix, and linzagolix), they were shown to have a rapid impact on heavy menstrual bleeding (HMB) in >70% of women. When used without add-back therapy, these drugs cause a significant reduction in fibroid volume, namely, approximately 50% from baseline to week 24. Further studies are required to determine the best protocol and optimal dosage if a reduction in myoma volume is the main goal, as in case of myoma-related infertility.
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Affiliation(s)
- Jacques Donnez
- Université Catholique de Louvain, Ottignies-Louvain-la-Neuve, Belgium; Society for Research into Infertility (SRI), Brussels, Belgium.
| | - Hugh S Taylor
- Department of Obstetrics, Gynecology and Reproductive Sciences, Yale School of Medicine, New Haven, Connecticut
| | - Louis Marcellin
- Département de Gynécologie Obstétrique II et Médecine de la Reproduction, Université Paris Cité, Assistance Publique-Hôpitaux de Paris (AP-HP), Centre Hospitalier Universitaire (CHU) Cochin, Hôpital Universitaire Paris Centre (HUPC), Paris, France
| | - Marie-Madeleine Dolmans
- Pôle de Recherche en Gynécologie, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain (UCL), Brussels, Belgium; Gynecology Department, Cliniques Universitaires Saint-Luc, Brussels, Belgium
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Favilli A, Mazzon I, Etrusco A, Dellino M, Laganà AS, Tinelli A, Chiantera V, Cicinelli E, Gerli S, Vitagliano A. The challenge of FIGO type 3 leiomyomas and infertility: Exploring therapeutic alternatives amidst limited scientific certainties. Int J Gynaecol Obstet 2024; 165:975-987. [PMID: 38009829 DOI: 10.1002/ijgo.15260] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Revised: 10/28/2023] [Accepted: 11/08/2023] [Indexed: 11/29/2023]
Abstract
Uterine leiomyomas (ULs) are non-cancerous tumors composed of smooth muscle cells that develop within the myometrium and represent the most prevalent pathological condition affecting the female genital tract. Despite the volume of available research, many aspects of ULs remain unresolved, making it a "paradoxical disease" where the increase in available scientific literature has not been matched by an increase in solid evidence for clinical management. Fertility stands at the top of the list of clinical issues where the role of ULs is still unclear. The leiomyoma subclassification system, released by the International Federaion of Gynecology and Obstetrics (FIGO) in 2008, introduced a new and more effective way of categorizing uterine fibroids. The aim was to go beyond the traditional classification "subserosal, intramural and submucosal", facilitating a detailed examination of individual ULs impact on the female reproductive system. The "type 3 UL" is a special type of myoma, characterized by its complete myometrial development while encroaching the endometrium. It is a unique "hybrid" between a submucous and an intramural UL, that may exert a detrimental "double hit" mechanism, which is of particular interest in patients wishing pregnancy. To date, no robust evidence is available regarding the management of type 3 ULs. The aim of this narrative review is to provide a comprehensive overview of the physiopathological mechanisms that type 3 UL may exert on fertility, and to present new perspectives that may help us to better understand both the need for and the methods of treating this unique type of fibroid.
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Affiliation(s)
- Alessandro Favilli
- Section of Obstetrics and Gynecology, Department of Medicine and Surgery, University of Perugia, Perugia, Italy
- Center of Perinatal and Reproductive Medicine, University of Perugia, Perugia, Italy
| | | | - Andrea Etrusco
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (PROMISE), University of Palermo, Palermo, Italy
| | - Miriam Dellino
- 1st Unit of Obstetrics and Gynecology, Department of Interdisciplinary Medicine (DIM), University of Bari, Bari, Italy
| | - Antonio Simone Laganà
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (PROMISE), University of Palermo, Palermo, Italy
| | - Andrea Tinelli
- Department of Obstetrics and Gynecology, CERICSAL (CEntro di RIcerca Clinico SALentino), Veris delli Ponti Hospital, Scorrano, Italy
| | - Vito Chiantera
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (PROMISE), University of Palermo, Palermo, Italy
- Unit of Gynecologic Oncology, National Cancer Institute - IRCCS - Fondazione "G. Pascale", Naples, Italy
| | - Ettore Cicinelli
- 1st Unit of Obstetrics and Gynecology, Department of Interdisciplinary Medicine (DIM), University of Bari, Bari, Italy
| | - Sandro Gerli
- Section of Obstetrics and Gynecology, Department of Medicine and Surgery, University of Perugia, Perugia, Italy
- Center of Perinatal and Reproductive Medicine, University of Perugia, Perugia, Italy
| | - Amerigo Vitagliano
- 1st Unit of Obstetrics and Gynecology, Department of Interdisciplinary Medicine (DIM), University of Bari, Bari, Italy
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Kleinstein J. Laparoskopie bei Infertilität, Tubenpathologie, Endometriose und vor ART. GYNAKOLOGISCHE ENDOKRINOLOGIE 2021. [DOI: 10.1007/s10304-021-00424-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Intramural myomas more than 3-4 centimeters should be surgically removed before in vitro fertilization. Fertil Steril 2021; 116:945-958. [PMID: 34579828 DOI: 10.1016/j.fertnstert.2021.08.016] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Accepted: 08/06/2021] [Indexed: 12/29/2022]
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Dolmans MM, Cacciottola L, Donnez J. Conservative Management of Uterine Fibroid-Related Heavy Menstrual Bleeding and Infertility: Time for a Deeper Mechanistic Understanding and an Individualized Approach. J Clin Med 2021; 10:4389. [PMID: 34640407 PMCID: PMC8509802 DOI: 10.3390/jcm10194389] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Revised: 09/22/2021] [Accepted: 09/23/2021] [Indexed: 12/17/2022] Open
Abstract
(1) Background: Uterine fibroids are the most common form of benign uterine tumors, causing heavy menstrual bleeding (HMB), pelvic pain, infertility and pressure symptoms. Almost a third of women with uterine fibroids seek treatment. The objective of this review is to understand the mechanisms linking fibroids to these symptoms and evaluate different options for their management, particularly the place of gonadotropin-releasing hormone (GnRH) antagonist. (2) Methods: We gathered the most recent and relevant papers on the main fibroid-related symptoms and medical and surgical therapy for their treatment. Those reporting use of oral GnRH antagonists were investigated in detail. (3) Results: The mechanisms explaining myoma-related HMB and infertility were reviewed, as they are essential to a deeper mechanistic understanding and oriented approach. The choice of treatment depends on the number, size, and location of fibroids, and is guided by the patient's age and desire to preserve her fertility. Economic impacts of myomas in terms of direct costs, lost workdays, and complications were found to be significant. Medical, surgical, and non-surgical strategies were analyzed in this context. Novel medical approaches with GnRH antagonist were explored and found to represent an effective new option. (4) Conclusion: The need for alternatives to surgical intervention is very real, especially for women seeking to preserve their fertility. New options now exist, with GnRH antagonists proven to treat fibroid symptoms effectively, opening the door to novel strategies for the management of myomas.
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Affiliation(s)
- Marie-Madeleine Dolmans
- Gynecology Department, Cliniques Universitaires St-Luc, Avenue Hippocrate 10, 1200 Brussels, Belgium;
- Gynecology Research Unit, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Avenue Mounier 52, 1200 Brussels, Belgium;
| | - Luciana Cacciottola
- Gynecology Research Unit, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Avenue Mounier 52, 1200 Brussels, Belgium;
| | - Jacques Donnez
- Université Catholique de Louvain, 1200 Brussels, Belgium
- Société de Recherche pour l’Infertilité (SRI), 143 Avenue Grandchamp, 1150 Brussels, Belgium
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Donnez J. Uterine Fibroids and Progestogen Treatment: Lack of Evidence of Its Efficacy: A Review. J Clin Med 2020; 9:jcm9123948. [PMID: 33291422 PMCID: PMC7762035 DOI: 10.3390/jcm9123948] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Revised: 11/17/2020] [Accepted: 12/02/2020] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND The objective of this review is to determine the evidence or, conversely, the absence of evidence regarding the effectiveness of progestogens in treating premenopausal women with uterine fibroids. In particular, the goal is to address recurring questions as to whether they are effective or not for managing symptoms commonly attributed to fibroids. METHODS A review of the most relevant papers (n = 63) on the efficacy of progesterone and progestogens as medical therapy for uterine fibroids. RESULTS Having reviewed the most significant papers on the relationship between uterine fibroids and progesterone/progestogens, it is clear that there is biochemical, histological and clinical evidence that progesterone and progestogens play a critical role in the pathogenesis of myomas. CONCLUSION Since progesterone is already implicated in the pathogenesis of this entity, using progestogens to manage fibroids is like constantly adding fuel to the fire, rendering this treatment ineffective.
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Affiliation(s)
- Jacques Donnez
- Société de Recherche pour l’Infertilité (SRI), 1150 Brussels, Belgium;
- Université Catholique de Louvain, 1200 Brussels, Belgium
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9
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Donnez J, Dolmans MM. Hormone therapy for intramural myoma-related infertility from ulipristal acetate to GnRH antagonist: a review. Reprod Biomed Online 2020; 41:431-442. [PMID: 32703756 DOI: 10.1016/j.rbmo.2020.05.017] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Revised: 05/15/2020] [Accepted: 05/29/2020] [Indexed: 12/30/2022]
Abstract
Uterine fibroids may cause infertility, depending on their size and location according to the International Federation of Gynecology and Obstetrics classification. In this review, infertility relating to intramural myomas is evaluated. The mechanisms linking uterine fibroids and infertility are numerous: uterine cavity distortion (fibroids types 0, 1, 2, 2-5); impaired endometrial and myometrial blood supply; increased uterine contractility; hormonal, paracrine and molecular changes; impaired endometrial receptivity in gene expression (decrease in homeobox 10 [HOXA-10] expression); and thicker capsule. The negative effect of intramural myoma is related to myoma size and proximity of the uterine cavity. Therefore, a medical approach could be proposed to reduce the size of the myoma and push it back deep into the myometrium. The relevant medical treatments, including selective progesterone receptor modulator and gonadotrophin releasing hormone antagonist are reviewed. Even if the mystery surrounding intramural myomas remains, the development of new algorithms for intramural myoma-related infertility, and evaluation of the place of medical treatment as a primary approach are urgently needed. An algorithm, taking into account the mechanisms linking uterine fibroids and infertility, is proposed.
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Affiliation(s)
- Jacques Donnez
- Catholic University of Louvain and Société de Recherche pour l'Infertilité (SRI) 143 Avenue Grandchamp, Brussels B-1150, Belgium.
| | - Marie-Madeleine Dolmans
- Gynecology Department, Cliniques Universitaires St-Luc, Avenue Hippocrate 10, 1200 Brussels, Belgium: Pôle de Gynécologie, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Avenue Mounier 52, bte B1.52.02, Brussels 1200, Belgium
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Moridi I, Mamillapalli R, Kodaman PH, Habata S, Dang T, Taylor HS. CXCL12 Attracts Bone Marrow-Derived Cells to Uterine Leiomyomas. Reprod Sci 2020; 27:1724-1730. [PMID: 32020550 DOI: 10.1007/s43032-020-00166-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2019] [Accepted: 01/23/2020] [Indexed: 01/02/2023]
Abstract
Uterine leiomyomas, also known as fibroids or myomas, are a common benign gynecologic tumor found in women of reproductive age. Though advances have been made in understanding leiomyomas, the etiology and pathogenesis of this disease are not fully characterized. Current evidence supports a role of putative human uterine stem/progenitor cells in the onset of uterine disease such as uterine myomas. In this study, we report that increased expression of CXCL12 in leiomyomas recruits bone marrow-derived cells (BMDCs) that may contribute to leiomyoma growth. Tissue was collected from leiomyomas or control myometrium from women with or without leiomyomas. qRT-PCR analysis showed increased expression of CXCL12 and decreased CXCR4 expression in the leiomyoma and myometrium of women with leiomyoma compared with normal myometrium. Increased CXCL12 protein secretion from cultured myoma cells was confirmed by ELISA. Further, we found that BMDCs migration was increased toward leiomyoma conditioned medium compared with conditioned medium from normal myometrium. CXCR4 antagonist AMD3100 completely blocked this migration. Engraftment of BMDCs significantly increased in myoma of mouse uteri treated with CXCL12 compared with placebo. We conclude that CXCL12 may play a role in leiomyomas growth by attracting bone marrow-derived cells to leiomyoma. Therefore, CXCL12 and its receptors are novel targets for leiomyoma therapy.
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Affiliation(s)
- Irene Moridi
- Department of Obstetrics, Gynecology and Reproductive Sciences, Yale School of Medicine, 333 Cedar Street, New Haven, CT, 06520, USA
| | - Ramanaiah Mamillapalli
- Department of Obstetrics, Gynecology and Reproductive Sciences, Yale School of Medicine, 333 Cedar Street, New Haven, CT, 06520, USA.
| | - Pinar H Kodaman
- Department of Obstetrics, Gynecology and Reproductive Sciences, Yale School of Medicine, 333 Cedar Street, New Haven, CT, 06520, USA
| | - Shutaro Habata
- Department of Obstetrics, Gynecology and Reproductive Sciences, Yale School of Medicine, 333 Cedar Street, New Haven, CT, 06520, USA
| | - Tran Dang
- Department of Obstetrics, Gynecology and Reproductive Sciences, Yale School of Medicine, 333 Cedar Street, New Haven, CT, 06520, USA
| | - Hugh S Taylor
- Department of Obstetrics, Gynecology and Reproductive Sciences, Yale School of Medicine, 333 Cedar Street, New Haven, CT, 06520, USA
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Corachán A, Ferrero H, Escrig J, Monleon J, Faus A, Cervelló I, Pellicer A. Long-term vitamin D treatment decreases human uterine leiomyoma size in a xenograft animal model. Fertil Steril 2019; 113:205-216.e4. [PMID: 31739978 DOI: 10.1016/j.fertnstert.2019.09.018] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Revised: 09/02/2019] [Accepted: 09/12/2019] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To study the effects of short- and long-term vitamin D treatment on uterine leiomyomas in vivo through cell proliferation, extracellular matrix (ECM) degradation, and apoptosis. DESIGN Preclinical study of human leiomyoma treatment with vitamin D in an nonhuman animal model. SETTING Hospital and university laboratories. PATIENT(S)/ANIMAL(S) Human leiomyomas were collected from patients and implanted in ovariectomized NOD-SCID mice. INTERVENTION(S) Mice were treated with vitamin D (0.5 μg/kg/d or 1 μg/kg/d) or vehicle for 21 or 60 days. MAIN OUTCOME MEASURE(S) Vitamin D effect in xenograft tissue was assessed by monitoring tumor size (18F-FDG positron-emission tomography/computerized tomography and macroscopic examination), cell proliferation (immunohistochemistry and quantitative real-time polymerase chain reaction [qRT-PCR]), ECM (Western blot), transforming growth factor (TGF) β3 (qRT-PCR), and apoptosis (Westrn blot and TUNEL). RESULT(S) Short-term treatment with vitamin D did not appear to alter leiomyoma size, based on in vivo monitoring and macroscopic examination. However, long-term high-dose treatment induced a significant reduction in leiomyoma size. Cell proliferation was not decreased in the short term, whereas 1 μg/kg/d vitamin D in the long term significantly reduced proliferation compared with control. Although collagen-I and plasminogen activator inhibitor 1 were not modified by short-term treatment, they were both significantly reduced by long-term high-dose vitamin D. Similarly, long-term high-dose vitamin D significantly reduced TGF-β3 expression. Finally, apoptosis significantly increased with both short- and long-term high-dose vitamin D treatment. CONCLUSION(S) Long-term vitamin D acts as an antiproliferative, antifibrotic, and proapoptotic therapy that provides a safe, nonsurgical therapeutic option for reducing uterine leiomyoma size without side-effects.
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Affiliation(s)
- Ana Corachán
- Fundación IVI, Instituto Universitario IVI, Universidad de Valencia, Valencia, Spain; Departamento de Pediatría, Obstetricia y Ginecología, Universidad de Valencia, Valencia, Spain
| | - Hortensia Ferrero
- Fundación IVI, Instituto Universitario IVI, Universidad de Valencia, Valencia, Spain; Instituto de Investigación Sanitaria INCLIVA, Valencia, Spain.
| | - Julia Escrig
- Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | - Javier Monleon
- Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | - Amparo Faus
- Fundación IVI, Instituto Universitario IVI, Universidad de Valencia, Valencia, Spain
| | - Irene Cervelló
- Fundación IVI, Instituto Universitario IVI, Universidad de Valencia, Valencia, Spain
| | - Antonio Pellicer
- Fundación IVI, Instituto Universitario IVI, Universidad de Valencia, Valencia, Spain; Departamento de Pediatría, Obstetricia y Ginecología, Universidad de Valencia, Valencia, Spain
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Rasheedy R, Makled A, Abou-Gamrah A, Giuma H. Intrauterine Instillation of Tranexamic Acid in Hysteroscopic Myomectomy: A Double-Blind, Placebo-Controlled, Parallel-Group Randomized Clinical Trial. J Minim Invasive Gynecol 2019; 27:1264-1272.e2. [PMID: 31536837 DOI: 10.1016/j.jmig.2019.09.773] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2019] [Revised: 08/28/2019] [Accepted: 09/09/2019] [Indexed: 11/16/2022]
Abstract
STUDY OBJECTIVE To evaluate the hemostatic effect of intrauterine instillation of tranexamic acid (TXA) with the distention medium during hysteroscopic myomectomy. DESIGN Prospective, parallel-group, double-blind, placebo-controlled randomized clinical trial. SETTING Early Cancer Detection Unit in Ain Shams University Maternity Hospital, Cairo, Egypt. PATIENTS Eighty women with type 0 or I submucous myoma undergoing hysteroscopic myomectomy using unipolar resectoscope. INTERVENTIONS The participants were randomly assigned to receive either 1 g of TXA for every 1000 mL of the distending medium (intervention group) or 10 mL of placebo (10 mL of 1.5% glycine) in the same form inside every 1000 mL of the distention medium. MEASUREMENTS AND MAIN RESULTS The primary outcome was a change in hemoglobin level 24 hours after surgery compared with preoperative values, and the secondary outcomes were the surgeon's rating of intraoperative bleeding and the quality of operative view, the duration of surgery, the volume of injected media, intraoperative complications, and the completion of myomectomy in 1 procedure. The mean difference in hemoglobin level was 1.11 ±.58 g/dL in the TXA group and 1.46 ± 0.61 g/dL in the placebo group (p = .015). The quality of hysteroscopic view was better in the TXA group (p = .001), with good operative view in 23 (60.5%) cases in TXA vs 8 (20.5%) in the placebo group. The surgeon's rating of bleeding as excessive was reported in 1 (2.6%) case in the TXA group and in 9 (23.1%) cases in the placebo group. There was no difference between the groups regarding the duration of surgery, the volume of injected media, completion of myoma resection in 1 session, and intraoperative complications. Three cases of uterine perforation with the thermal loop were reported, and all were associated with poor operative field in the placebo group. CONCLUSION Intrauterine instillation of TXA with the distention medium during hysteroscopic myomectomy resulted in a statistically significant decrease in hemoglobin level 24 hours after surgery, albeit with minimal clinical significance. TXA resulted in better visualization of the field throughout the procedure.
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Affiliation(s)
- Radwa Rasheedy
- Obstetrics and Gynecology Department, Faculty of Medicine, Ain Shams University, Cairo, Egypt (all authors)..
| | - Ahmed Makled
- Obstetrics and Gynecology Department, Faculty of Medicine, Ain Shams University, Cairo, Egypt (all authors)
| | - Amgad Abou-Gamrah
- Obstetrics and Gynecology Department, Faculty of Medicine, Ain Shams University, Cairo, Egypt (all authors)
| | - Hajer Giuma
- Obstetrics and Gynecology Department, Faculty of Medicine, Ain Shams University, Cairo, Egypt (all authors)
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Corachán A, Ferrero H, Aguilar A, Garcia N, Monleon J, Faus A, Cervelló I, Pellicer A. Inhibition of tumor cell proliferation in human uterine leiomyomas by vitamin D via Wnt/β-catenin pathway. Fertil Steril 2018; 111:397-407. [PMID: 30458994 DOI: 10.1016/j.fertnstert.2018.10.008] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2018] [Revised: 09/27/2018] [Accepted: 10/05/2018] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To assess the effect of vitamin D (VitD) on human uterine leiomyomas through Wnt/β-catenin pathway inhibition, apoptosis induction, and cell growth arrest. DESIGN A prospective study comparing leiomyoma vs. myometrium tissues. Paired design study comparing human uterine leiomyoma primary (HULP) cells treated with or without VitD. SETTING University hospital. PATIENT(S) Human uterine leiomyoma and myometrium were collected from women (aged 35-52 years) without hormonal treatment. INTERVENTION(S) Samples were collected from women undergoing surgery due to symptomatic uterine leiomyoma pathology. MAIN OUTCOME MEASURE(S) Uterine leiomyoma and myometrium tissues were analyzed by western blot (WB) to determine proliferation, Wnt/β-catenin, and apoptosis pathways. HULP cells were used to study VitD effect in cell proliferation (WB), cell cycle (flow cytometry), Wnt/β-catenin and apoptosis genes (polymerase chain reaction arrays), Wnt-related proteins (protein array), and apoptosis (terminal deoxynucleotidyl transferase-mediated dUTP nick end-labeling [TUNEL] assay). RESULTS Human leiomyoma tissues compared with matched myometrium showed higher proliferation (fold change = 8.16; P=.0006) and altered Wnt/β-catenin pathway (fold change = 5.5; P<.0001), whereas no differences in apoptosis were observed. VitD induced cell growth arrest and decreased proliferation in HULP cells (fold change = 0.74; P=.007). Moreover, VitD decreased Wnt-pathway expression in HULP cells at gene (activity score = -0.775; P<.001) and protein levels. However, VitD did not induce apoptosis expression. CONCLUSION Increased proliferation and Wnt/β-catenin pathway deregulation play a role in the development and growth of leiomyomas, whereas apoptosis appears not to contribute. VitD exerts an antiproliferative action on HULP cells through cell growth arrest and Wnt/β-catenin pathway inhibition, but not through apoptosis regulation, suggesting VitD as an effective therapy to stabilize leiomyoma size and prevent its growth.
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Affiliation(s)
- Ana Corachán
- Fundación IVI, Instituto Universitario IVI, Universidad de Valencia, Valencia; Departamento de Pediatría, Obstetricia y Ginecología, Universidad de Valencia, Valencia, Spain
| | - Hortensia Ferrero
- Fundación IVI, Instituto Universitario IVI, Universidad de Valencia, Valencia; Instituto de Investigación Sanitaria INCLIVA, Valencia, Spain.
| | | | - Nuria Garcia
- Hospital Universitario y Politécnico La Fe, Valencia
| | | | - Amparo Faus
- Fundación IVI, Instituto Universitario IVI, Universidad de Valencia, Valencia
| | - Irene Cervelló
- Fundación IVI, Instituto Universitario IVI, Universidad de Valencia, Valencia
| | - Antonio Pellicer
- Fundación IVI, Instituto Universitario IVI, Universidad de Valencia, Valencia; Hospital Universitario y Politécnico La Fe, Valencia
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