Multiple pregnancies following induction of ovulation

Strategies for modelling endometrial diseases

Each month during a woman's reproductive years, the endometrium undergoes vast changes to prepare for a potential pregnancy. Diseases of the endometrium arise for numerous reasons, many of which remain unknown. These endometrial diseases, including endometriosis, adenomyosis, endometrial cancer and Asherman syndrome, affect many women, with an overall lack of efficient or permanent treatment solutions. The challenge lies in understanding the complexity of the endometrium and the extensive changes, orchestrated by ovarian hormones, that occur in multiple cell types over the period of the menstrual cycle. Appropriate model systems that closely mimic the architecture and function of the endometrium and its diseases are needed. The emergence of organoid technology using human cells is enabling a revolution in modelling the endometrium in vitro. The goal of this Review is to provide a focused reference for new models to study the diseases of the endometrium. We provide perspectives on the power of new and emerging models, from organoids to microfluidics, which have opened up a new frontier for studying endometrial diseases.

The link between intrauterine adhesions and impaired reproductive performance: a systematic review of the literature

Background

Intrauterine adhesions (IUAs) are one of the main reproductive system diseases in women worldwide. Fusion between the injured opposing walls leads to partial-to-complete obliteration of the cavity and/or cervical canal. The main clinical manifestations in case of IUAs are menstrual disturbances, cyclic pain and reproductive disorders. The reproductive outcomes of women with IUAs remain limited and inefficient compared to women without IUAs, even after adhesiolysis. An exact understanding of the underlying mechanisms and processes to explain the compromised reproductive performance and outcomes in case of IUAs are lacking.

Methods

A systematic literature review of MEDLINE-PubMed (1966 to January 2022) and EMBASE (1974 to January 2022) was performed following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Studies were included if they reported underlying causes, related mechanisms and processes to explain the association between IUAs and impaired reproductive performance, pregnancy and obstetric complications.

Results

After an extensive review of the literature, 58 articles were identified reporting underlying mechanisms to explain the association between IUAs and impaired fertility. Intrauterine scarring influences the process of fertilization, reproductive performance and ultimately reproductive outcome. IUAs can disturb the cervico-utero-tubal sperm transport and result in an avascular and unresponsive endometrium with decreased receptivity and thickness. Abnormal decidualization and abnormal trophoblastic infiltration leads to placental attachment disorders. Moreover, the risk for premature delivery, intrauterine fetal growth restriction and fetal anomalies is increased in case of IUAs.

Conclusion

The impact of IUAs on reproductive performance, even after adhesiolysis, is becoming more apparent. The postulated mechanisms to explain the association are related to sperm transport, embryo implantation and placentation. Prevention, by preserving the basal layer of the endometrium is essential. Effective and evidence-based strategies for the prevention of endometrial injury and formation of IUAs, are urgently needed.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-022-05164-2.

Injectable Mesenchymal Stem Cell-Laden Matrigel Microspheres for Endometrium Repair and Regeneration

Endometrial injury and intrauterine adhesions are increasingly reported in recent years; however, treatment options remain limited. Intravenous injection of mesenchymal stem cells (MSCs) for endometrium regeneration has limited effectiveness as the retention rate of transplanted cells is low. Hydrogel-based tissue-engineered solutions, such as MSC-seeded bioscaffolds, are reported to increase retention rates; however, a less invasive alternative is still desirable. 560-µm homogeneous Matrigel microspheres are fabricated, loading them with about 1500 MSCs and injecting them into the injured endometria of rats' uteri. This minimally invasive procedure is proved to significantly increase endometrium thickness by over onefold after 21 d (p < 0.0001) and fertility rates from 25% to 75% in impaired and repaired uteri (p < 0.001), respectively. This study provides a minimally invasive alternative to endometrium repair with the promise to establish a broad-spectrum technique for MSC transplantation.

The Potential Relationship Between Different Human Female Reproductive Disorders and Sperm Quality in Female Genital Tract

Spermatozoa should travel throughout the female reproductive tract to reach its ultimate goal, fertilization of the oocyte. At the ejaculation moment, millions of sperm within a few milliliters of the ejaculate are deposited at the cranial segment of vagina and make their journey to the fertilization site. This is done by means of various factors, such as sperm motility, the uterine and fallopian tubes contractility, and the ciliary movement of the lining cells. During this migration, spermatozoa interact with the female microenvironment both physically and molecularly. In this regard, the quality of the environmental conditions may affect this interaction. Therefore, some alterations in women's genital tract microenvironment, such as conditions that occur in female reproductive disorders, may have detrimental effects on sperm reproductive function. In this review, human sperm migration through the female tract is described, and the potential effects of different reproductive disorders at reproductive organs, such as vagina, uterine cervix, uterus, fallopian tubes, and ovary on sperm survival and quality, are also argued. The understanding of those conditions that may impair sperm fertility in the female genital tract can provide a more accurate diagnosis of the causes of infertility in couples. This can ultimately lead to the discovery of effective treatment approaches.

Recent Advances in Understandings Towards Pathogenesis and Treatment for Intrauterine Adhesion and Disruptive Insights from Single-Cell Analysis

Intrauterine adhesion is a major cause of menstrual irregularities, infertility, and recurrent pregnancy losses and the progress towards its amelioration and therapy is slow and unsatisfactory. We aim to summarize and evaluate the current treatment progress and research methods for intrauterine adhesion. We conducted literature review in January 2020 by searching articles at PubMed on prevention and treatment, pathogenesis, the repair of other tissues/organs, cell plasticity, and the stem cell–related therapies for intrauterine adhesion. A total of 110 articles were selected for review. Uterine cell heterogeneity, expression profile, and cell-cell interaction were investigated based on scRNA-seq of uterus provided by Human Cell Landscape (HCL) project. Previous knowledge on intrauterine adhesion (IUA) pathogenesis was mostly derived from correlation studies by differentially expressed genes between endometrial tissue of intrauterine adhesion patients/animal models and normal endometrial tissue. Although the TGF-β1/SMAD pathway was suggested as the key driver for IUA pathogenesis, uterine cell heterogeneity and distinct expression profile among different cell types highlighted the importance of single-cell investigations. Cell-cell interaction in the uterus revealed the central hub of endothelial cells interacting with other cells, with endothelial cells in endothelial to mesenchymal transition and fibroblasts as the strongest interaction partners. The potential of stem cell–related therapies appeared promising, yet suffers from largely animal studies and nonstandard study design. The need to dissect the roles of endometrial cells, endothelial cells, and fibroblasts and their interaction is evident in order to elucidate the molecular and cellular mechanisms in both intrauterine adhesion pathogenesis and treatment.

Collagen-binding basic fibroblast growth factor improves functional remodeling of scarred endometrium in uterine infertile women: a pilot study

Intrauterine adhesion (IUA) is a common cause of uterine infertility and one of the most severe clinical features is endometrial fibrosis namely endometrial scarring for which there are few cures currently. Blocked angiogenesis is the main pathological change in the scarred endometrium. The fibroblast growth factor 2 (bFGF), a member of FGF family, is usually applied to promote healing of refractory ulcer and contributes to angiogenesis of tissues. In this study, the sustained-release system of bFGF 100 µg was administrated around scarred endometrium guiding by ultrasound every 4 weeks in 18 patients (2-4 times). Results showed that after treatment, the menstrual blood volume, endometrial thickness and the scarred endometrial area were improved. Histological study showed blood vessel density increased obviously. Three patients (3/18) achieved pregnancy over 20 gestational weeks. Therefore, administrating the bFGF surrounding scarred endometrium may provide a new therapeutic approach for the patients with endometrial fibrosis.

Estrogen therapy before hysteroscopic adhesiolysis improves the fertility outcome in patients with intrauterine adhesions

PURPOSES

To describe the fertility outcomes after hysteroscopic adhesiolysis combined with preoperative hormone treatment in women with intrauterine adhesion (IUA).

METHODS

This study is a retrospective cohort study. A total of 230 patients with IUA underwent hysteroscopic adhesiolysis combined with hormone treatment from Jan 2012 to Jun 2018. 148 patients who received preoperative estrogen treatment were enrolled into group A and 82 patients without preoperative estrogen treatment were enrolled into group B. All the patients underwent hysteroscopic adhesiolysis and received postoperative estrogen therapy, intrauterine indwelling device. Second or third look was performed after 2-3 months.

RESULTS

90.87% (209/230) patients complete the study. The AFS scores at baseline were higher in the group A than group B. After the preoperative E2 treatment, group A achieved the comparable AFS score to group B before the surgery. The cumulative fertility rate in group A was comparable in group B, both in the ITT analysis (49.32% vs. 52.44%, p = 0.651) and the PP analysis (54.07% vs.58.10%, p = 0.575).The mean conception time was also similar in group A and group B (8.30 ± 6.47 vs. 8.54 ± 5.68 months, p = 0.837). Besides, the surgery times in group A were less than group B. There was no difference in the rate of adverse events between two groups.

CONCLUSIONS

Hysteroscopic adhesiolysis combined with preoperative oestrogen could reduce the preoperative AFS scores and the times of surgery which yield a similar conception rate in women with less severe intrauterine adhesions.

Preliminary design of a new degradable medical device to prevent the formation and recurrence of intrauterine adhesions

Intrauterine adhesions lead to partial or complete obliteration of the uterine cavity and have life-changing consequences for women. The leading cause of adhesions is believed to be loss of stroma resulting from trauma to the endometrium after surgery. Adhesions are formed when lost stroma is replaced by fibrous tissue that join the uterine walls. Few effective intrauterine anti-adhesion barriers for gynecological surgery exist. We designed a degradable anti-adhesion medical device prototype to prevent adhesion formation and recurrence and restore uterine morphology. We focused on ideal degradation time for complete uterine re-epithelialization for optimal anti-adhesion effect and clinical usability. We developed a triblock copolymer prototype [poly(lactide) combined with high molecular mass poly(ethylene oxide)]. Comparative pre-clinical studies demonstrated in vivo anti-adhesion efficacy. Ease of introduction and optimal deployment in a human uterus confirmed clinical usability. This article provides preliminary data to develop an intrauterine medical device and conduct a clinical trial.

Detection of Asherman's syndrome after conservative management of placenta accreta: a case report

BACKGROUND

We present a case involving conservative treatment of placenta accreta, with a subsequent diagnosis of Asherman's syndrome.

CASE PRESENTATION

A 41-year-old Japanese woman (G2P0A2) delivered a healthy male infant via cesarean section due to preeclampsia. The placenta did not spontaneously separate and was manually removed. Adhesion was tight and placenta accreta was diagnosed. During the procedure, no uterine inversion or perforation, and no uterine cavity adhesion, were observed. Four months postoperatively, hysteroscopy was performed. Adhesion was detected at the fundus of her uterus where the placenta had adhered to the uterus. Asherman's syndrome was diagnosed.

CONCLUSIONS

Asherman's syndrome might occur after conservative management of placenta accreta, which may be a direct cause of placenta accreta recurrence. When Asherman's syndrome is diagnosed, the site of the placenta and adhesion should be monitored during subsequent pregnancies.

Efficacy of pelvic artery embolisation for severe postpartum hemorrhage

PURPOSE

The purpose of our study was to evaluate the outcome of selective pelvic arterial embolisation (PAE) in women with severe postpartum hemorrhage (PPH).

METHODS

We performed a retrospective, controlled, single-center cohort study. A total of 16 consecutive women with PPH who underwent therapeutic PAE were included. As historical control group, we included 22 women with similar severity of PPH who were managed without PAE. Outcome measures included necessity of surgical interventions such as postpartum hysterectomy and laparotomy after vaginal delivery, the amount of red blood cell transfusions, and hematologic findings after the procedure.

RESULTS

PAE was successful in stopping PPH and preserving the uterus in all 16 women in the study group. No woman in the PAE group required a postpartum hysterectomy, whereas postpartum hysterectomy was unavoidable in two women in the control group. Laparotomy after vaginal delivery was necessary in two women of the group without embolisation. Hematologic parameters after the treatment were better in the PAE group than in the control group, although these differences were only in part statistically significant. There were no unwarranted effects of PAE identifiable in the study group.

CONCLUSION

This is the first controlled study assessing the efficacy of PAE for the treatment of PPH. Our data suggest that PAE is effective for the treatment of severe PPH. In view of the lack of complications and unwarranted effects, clinical use of PAE in severe PPH seems justified, particularly in view of the life-threatening condition and the potential to preserve fertility in affected patients. Further evidence from well-designed prospective randomized-controlled trials would be nevertheless desirable in the future.

Dominant factors affecting reproductive outcomes of fertility-desiring young women with intrauterine adhesions

PURPOSE

To identify the dominant factors affecting reproductive outcomes of fertility-desiring young women with intrauterine adhesions (IUA) after hysteroscopic adhesiolysis.

METHODS

This prospective observational study included 104 cases of women with IUA. Logistic regression analysis was applied to analyze the value of the location and extent of adhesions, the number of previous uterine cavity surgery, menstrual patterns, and second look hysteroscopy time.

RESULTS

In the total 104 patients with IUA, 91 patients (87.5%) had a history of at least one previous uterine cavity surgery. Hypomenorrhoea and amenorrhoea were two most common presenting menstrual abnormalities occurring in 59 (56.7%) and 28 (26.9%) cases, respectively. The clinical pregnancy rate was 60.6% (63/104) and the live birth rate was 39.4% (41/104). Pregnancy rate was higher in patients having mild IUA (81.5%) as compared to moderate (61.3%) or severe type (20.0%) (p < 0.001). The bivariate and binary logistic regression analysis revealed that the location and extent of adhesions were the independent parameters related to the reproductive outcome after hysteroscopic adhesiolysis for fertility-desiring women with IUA (p = 0.011 and p = 0.003, respectively), but not the number of previous uterine cavity surgery, menstrual patterns, and second look hysteroscopy time (p = 0.232, p = 0.239 and p = 0.120, respectively).

CONCLUSION

The extent and location of IUA are the dominant factors affecting reproductive outcomes, which are possibly regarded as a potential predictor evaluating prognosis of IUA after hysteroscopic adhesiolysis.

Minimally invasive surgical options for congenital and acquired uterine factors associated with recurrent pregnancy loss

Recurrent pregnancy loss (RPL) is defined as two or more failed clinical pregnancies before 20 weeks' gestation and may be caused by genetic, endocrinologic, anatomic and immunologic abnormalities. Anatomic uterine anomalies include congenital malformations (bicornuate, didelphic, septate and unicornuate uteri) and acquired defects (fibroids, adenomas, adhesions and polyps). Women with septate and bicornuate uteri, intrauterine adhesions, and some adenomas and fibroids are at increased risk of RPL. Data support surgical treatment of all of these lesions except bicornuate uteri. The role of polyps in RPL is unclear. Minimally invasive options for surgical correction of intrauterine lesions include hysteroscopy, laparoscopy with and without robotic assistance and minilaparotomy.

Anti-adhesion barrier gels following operative hysteroscopy for treating female infertility: a systematic review and meta-analysis

The aim of this study was to assess the effects of any anti-adhesion barrier gel used after operative hysteroscopy for treating infertility associated with uterine cavity abnormalities. Gynecologists might use any barrier gel following operative hysteroscopy in infertile women for decreasing de novo adhesion formation; the use of any barrier gel is associated with less severe de novo adhesions and lower mean adhesion scores. Nevertheless, infertile women should be counseled that there is at the present no evidence for higher live birth or pregnancy rates. There is a lack of data for the outcome miscarriage. Preclinical studies suggest that the use of biodegradable surgical barriers may decrease postsurgical adhesion formation. Observational studies in the human report conflicting results. We searched the Cochrane Menstrual Disorders and Subfertility Specialized Register (10 April 2013), the Cochrane Central Register of Controlled Trials (The Cochrane Library 2013, Issue 1), MEDLINE (1950 to 4 April 2013), EMBASE (1974 to 4 April 2013), and other electronic databases of trials including trial registers, sources of unpublished literature, and reference lists. We handsearched the Journal of Minimally Invasive Gynecology (from 1 January 1992 to 13 April 2013); we also contacted experts in the field. We included the randomized comparisons between any anti-adhesion barrier gel versus another barrier gel, placebo, or no adjunctive therapy following operative hysteroscopy. Primary outcomes were live birth rates and de novo adhesion formation at second-look hysteroscopy. Secondary outcomes were pregnancy and miscarriage rates, mean adhesion scores, and severity of adhesions at second-look hysteroscopy. Two authors independently assessed eligible studies for inclusion and risk of bias, and extracted data. We contacted primary study authors for additional information or other clarification. Five trials met the inclusion criteria. There is no evidence for an effect favoring the use of any barrier gel following operative hysteroscopy for the key outcomes of live birth or clinical pregnancy (risk ratio (RR) 3.0, 95 % confidence interval (CI) 0.35 to 26, P = 0.32, one study, 30 women, very low quality evidence); there were no data on the outcome miscarriage. The use of any gel following operative hysteroscopy decreases the incidence of de novo adhesions at second-look hysteroscopy at 1 to 3 months (RR 0.65, 95 % CI 0.45 to 0.93, P = 0.02, five studies, 372 women, very low quality evidence). The number needed to treat to benefit is 9 (95 % CI 5 to 33). The use of auto-cross-linked hyaluronic acid gel in women undergoing operative hysteroscopy for fibroids, endometrial polyps, or uterine septa is associated with a lower mean adhesion score at second-look hysteroscopy at 3 months (mean difference (MD) -1.44, 95 % CI -1.83 to -1.05, P < 0.00001, one study, 24 women; this benefit is even larger in women undergoing operative hysteroscopy for intrauterine adhesions(MD -3.30, 95 % CI -3.43 to -3.17, P < 0.00001, one study, 19 women). After using any gel following operative hysteroscopy, there are more American Fertility Society 1988 stage I (mild) adhesions (RR 2.81, 95 % CI 1.13 to 7.01, P = 0.03, four studies, 79 women). The number needed to treat to benefit is 2 (95 % CI 1 to 4). Similarly there are less' moderate or severe adhesions' at second-look hysteroscopy (RR 0.25, 95 % CI 0.10 to 0.67, P = 0.006, four studies, 79 women). The number needed to treat to benefit is 2 (95 % CI 1 to 4) (all very low quality evidence). There are some concerns for the non-methodological quality. Only two trials included infertile women; in the remaining three studies, it is not clear whether and how many participants suffered from infertility. Therefore, the applicability of the findings of the included studies to the target population under study should be questioned. Moreover, only one small trial studied the effects of anti-adhesion barrier gels for the key outcome of pregnancy; the length of follow-up was, however, not specified. More well-designed and adequately powered randomized studies are needed to assess whether the use of any anti-adhesion gel affects the key reproductive outcomes in a target population of infertile women.

Use of clomiphene citrate in infertile women: a committee opinion

This committee opinion describes the use of clomiphene citrate, including indications, use, monitoring, and side effects. There is also a discussion of adjuvants and alternatives to clomiphene citrate therapy.

The need for repeat evacuation of retained products of conception: how common is it?

Evacuation of retained products of conception with suction curettage is a widely used method for the management of missed miscarriage, incomplete miscarriage and termination of pregnancy. This procedure carries a risk of incomplete evacuation, which may lead to a further repeat evacuation. There are limited data on the incidence of repeat evacuation for suspected retained products. We undertook a retrospective audit on patients who underwent suction curettage for retained products of conception between January 2006 and February 2008, in order to evaluate the rate of repeat evacuation. Our study showed 3.1% (17 of 541) of patients underwent a repeat evacuation for suspected retained products. Suction curettage remains a safe and common procedure, however, it is important to minimise the recurrence of repeat evacuations through the use of medical management, improved training and local guidelines. This in turn should lower the risk of further complications associated with a surgical procedure.

Effects of α and β recombinant FSH (Gonal-F, Puregon) and progesterone upon human endometrial cell proliferation in-vitro: a preliminary study

Endometrial proliferation or regeneration during menstrual cycle is regulated by sexual hormones. However, the effect of gonadotrophins on the endometrial cell growth remains obscure. Herein, we aimed to investigate the effects of r-FSH (Gonal-F, Puregon) and progesterone on the proliferation of human endometrial cells in-vitro. According as gonadotrophin concentrations, the follicular-phase endometrial cells were divided into six groups: (1) 0 (controls), (2) 1; (3) 10; (4) 100; (5) 1000; (6) 100,000 μIU/ml. The cell countings with microscopy and cell proliferation kit assay were used to assess the endometrial cell proliferations. In Gonal-F groups, the cell absorptions (%) after 24/48 h culture were: (1) 100/100; (2) 103.8/102.3; (3) 104.8/102.8; (4) 102.3/101.3; (5) 96.3/94.2; (6) 86.8/84.3. In Puregon groups, the cell absorptions were: (1) 100/100; (2) 102.8/101.9; (3) 103/102.3; (4) 103.9/103.5; (5) 102.9/102.4; (6) 103.7/103.2 (non-different). In progesterone groups, the cell absorptions were: (1) 100/100; (2) 99.1/101.9; (3) 83.5/80.4; (4) 80.7/82.4. Higher dosage of Gonal-F (100,000 μIU/ml) and progesterone (10, 100 μg/ml) appeared the significant inhibition upon endometrium. We conclude that lower dosages of Gonal-F, Puregon, and progesterone appear the non-significant influence upon endometrium. Higher dosage of Gonal-F (10,000 μIU/ml) and progesterone (10, 100 μg/ml), but not Puregon, might interfere with the endometrial proliferation during follicular phase.