Mechanisms of Regeneration and Fibrosis in the Endometrium

Therapeutic strategies: Bioactive hydrogels oxidized sodium alginate/strontium/betamethasone for preventing intrauterine adhesion

Intrauterine adhesion (IUA) is an endometrial damage repair disorder that leads to menstrual loss, amenorrhea, and infertility in women; therefore, addressing this dilemma is a critical challenge. In this study, a multifunctional hydrogel, comprising oxidized sodium alginate (OSA), strontium carbonate (SrCO3), and betamethasone 21-phosphate sodium (BSP), was formulated to facilitate angiogenesis, reduce fibrosis, and support tissue repair in the treatment of IUA. The composite hydrogels showed significant bioactivity on human endometrial stromal cells (HESCs) and human umbilical vein endothelial cells (HUVECs), promoting the injured HESCs repair, reversing the degree of fibrosis to a certain extent, and enhancing the proliferation and migration of HUVECs. These results were also verified in the IUA model of sexually mature female rats. Compared with the model group, the selection of the appropriate hydrogel significantly increased endometrial thickness (p < 0.01), the number of glands (p < 0.001), decreased the degree of fibrosis (p < 0.05), and Vimentin (p < 0.01), CK19 (p < 0.01), CD31 (p < 0.01), and Ki67 (p < 0.01) molecular expression increased remarkably. In summary, in situ injection of this multifunctional hydrogel into the uterine cavity not only serves as a physical barrier, isolating the damaged endometrium, but also gradually releases drugs as the hydrogel degrades. This multifunctional hydrogel promotes endometrial proliferation and angiogenesis while reducing fibrosis, and provides therapeutic strategies for patients with clinical IUA.

Investigating Aging-Related Endometrial Dysfunction Using Endometrial Organoids

Ageing of the endometrium is a critical factor that affects reproductive health, yet its intricate mechanisms remain poorly explored. In this study, we performed transcriptome profiling and experimental verification of endometrium and endometrial organoids from young and advanced age females, to elucidate the underlying mechanisms and to explore novel treatment strategies for endometrial ageing. First, we found that age-associated decline in endometrial functions including fibrosis and diminished receptivity, already exists in reproductive age. Subsequently, based on RNA-seq analysis, we identified several changes in molecular processes affected by age, including fibrosis, imbalanced inflammatory status including Th1 bias in secretory phase, cellular senescence and abnormal signalling transduction in key pathways, with all processes been further validated by molecular experiments. Finally, we uncovered for the first time that PI3K-AKT-FOXO1 signalling pathway is overactivated in ageing endometrium and is closely correlated with fibrosis and impaired receptivity characteristics of ageing endometrium. Blocking or activation of PI3K by LY294002 or 740Y-P could attenuate the effect of ageing or accelerate dysfunction of endometrial organoids. This discovery is expected to bring new breakthroughs for understanding the pathophysiological processes associated with endometrial ageing, as well as treatment strategies to improve reproductive outcomes in women of advanced reproductive age.

Development and functional evaluation of recombinant type III collagen intrauterine implant gel

Intrauterine adhesion (IUA) is a prevalent complication arising from uterine surgery, significantly impacting women's fertility and overall quality of life. The conventional clinical approach involves hysteroscopic separation of uterine adhesions, though this method poses operational challenges and carries risks of postoperative re-adhesion. Alternatively, the intraoperative placement of intrauterine devices or support balloons can act as a physical barrier to prevent adhesion formation. However, its effectiveness is limited and it may result in secondary damage to the endothelial tissue. To tackle these challenges, we have engineered a temperature-responsive hydrogel incorporating Pluronic HP407/HP188 pharmaceutical excipients and recombinant type III collagen (rCol III) as a bioactive element. Upon in situ injection into the uterine cavity, this hydrogel transitions from a sol-gel phase to a gel in response to body temperature changes, thereby minimizing nonspecific distribution and prolonging the duration of treatment. In vitro studies demonstrate that rCol III temperature-responsive hydrogels exhibit favorable biocompatibility, exhibit a recruitment effect on human endometrial stromal cells, suppress the expression of the fibrotic factor transforming growth factor beta 1 and promote angiogenesis. To evaluate its efficacy in preventing IUA via in vivo experiments, we employed sexually mature female rats for IUA modeling and compared its performance with a commercially available product, cross-linked sodium hyaluronate gel. The results indicate that rCol III temperature-responsive hydrogels significantly enhance retention at the injury site, substantially promote endometrial regeneration, augment endometrial blood supply and reduce abnormal fibrin deposition. This study suggests that rCol III temperature-responsive hydrogels can effectively prevent post-surgical uterine adhesions, highlighting their potential as a promising adhesion prevention strategy.

Defining optimal electrospun membranes to enhance biological activities of human endometrial MSCs

Introduction

Human endometrial mesenchymal stem cells (H-EMSCs) can inhibit endometrial fibrosis and repair damaged endometrium. However, direct cell injection into dam-aged endometrium shows limited cell survival. Cell seeding onto biomaterial-based electrospun membranes could improve H-EMSCs' survival and prolong their stay at the damaged endometrium. Polycaprolactone (PCL), silk fibroin (SF) and hyaluronic acid (HA) are synthetic or natural biomaterials used by the biomedicine field, however, their effects on the biological activities of H-EMSCs remain unclear.

Methods

In this study, CD90+CD73+CD45- H-EMSCs were extracted from human endometrium and H-EMSCs showed enhanced adhesion, proliferation on PCL-HA vs. PCL, PCL-SF, establishing the potential of the composite to address cell survival issues.

Results

H-EMSCs cultured on PCL-HA showed decreased IL-6 gene expression and increased IL-10, VEGFA, TGF-β gene expression vs. PCL-SF, establishing the potential to create a favorable micro-environment for generating vascularized endometrial tissues. PCL, PCL-SF, PCL-HA all supported CD90 and Meflin expression of the seeded H-EMSCs, establishing PCL as a platform to form enhanced biomaterial composites for endometrial repair in the future.

Discussion

This study provided significant evidence sup-porting the potential of appropriately tailored composites of PCL and HA to moder-ate inflammation and wound-healing, which can be applied for endometrial tissue repair and regeneration.

A Fibronectin (FN)-Silk 3D Cell Culture Model as a Screening Tool for Repurposed Antifibrotic Drug Candidates for Endometriosis

This study advances sustainable pharmaceutical research for endometriosis by developing in vitro 3D cell culture models of endometriotic pathophysiology that allow antifibrotic drug candidates to be tested. Fibrosis is a key aspect of endometriosis, yet current cell models to study it remain limited. This work aims to bridge the translational gap between in vitro fibrosis research and preclinical testing of non-hormonal drug candidates. When grown in a 3D matrix of sustainably produced silk protein functionalized with a fibronectin-derived cell adhesion motif (FN-silk), endometrial stromal and epithelial cells respond to transforming growth factor beta-1 (TGF-β1) in a physiological manner as probed at the messenger RNA (mRNA) level. For stromal cells, this response to TGF-β1 is not observed in spheroids, while epithelial cell spheroids behave similarly to epithelial cell FN-silk networks. Pirfenidone, an antifibrotic drug approved for the treatment of idiopathic pulmonary fibrosis, reverses TGF-β1-induced upregulation of mRNA transcripts involved in fibroblast-to-myofibroblast transdifferentiation of endometrial stromal cells in FN-silk networks, supporting pirfenidone's potential as a repurposed non-hormonal endometriosis therapy. Overall, endometrial stromal cells cultured in FN-silk networks-which are composed of a sustainably produced, fully defined FN-silk protein-recapitulate fibrotic cellular behavior with high fidelity and enable antifibrotic drug testing.

Multiresponsive Microcapsules for Prevention of Intrauterine Adhesion

Intrauterine adhesion (IUA) has a significant negative impact on women's reproductive health. One of the development trends of biomaterials for prevention of IUA is improving the stability and multifaceted functions. Here, we propose a multiresponsive microcapsule (A/G-Fe3O4-Se) with an alginate (ALG) and gelatin methacryloyl (GelMA) dual-network hydrogel shell loaded with magnetic nanoparticles (Fe3O4-Se) and an ultrasound-responsive decafluoropentane core for the prevention of IUA using a microfluidic technique. The microcapsules inherited the biofriendly advantages of ALG and GelMA. The encapsulated magneto-responsive Fe3O4-Se made the microcapsule flexibly change the distribution to adapt to the irregular shape of the uterus and better exert the therapeutic effect. Besides, the A/G-Fe3O4-Se microcapsules demonstrated antioxidant, antibacterial, and pro-healing properties in vitro. Moreover, in the IUA rat models, we also observed a reduction in oxidative stress, better endometrial regeneration, and improved endometrial receptivity and pregnancy rates after treatment of the microcapsules. Consequently, the A/G-Fe3O4-Se microcapsules can be used as a promising strategy for the treatment of damaged endometrium as well as prevention of IUA.

Suture-Mediated Delivery System Reduces the Incidence of Uterine Scarring Through the TGF-β Pathway

In recent years, factors such as the postponement of childbearing and the relaxation of the childbearing policy have led to an increase in the proportion of cesarean sections and other intrauterine surgeries among pregnant women, further increasing the incidence of uterine scars. Currently, there is a lack of effective clinical treatment methods for uterine scars. In this study, a suture loaded with gene medicine was designed for the repair of uterine scars. Specifically, the non-viral vector Lipo8000 was first used to form a complex solution with the plasmid TGF-β3. Then, it was mixed and adsorbed with the surgical sutures pretreated with recombinant human type III collagen (RhCol III). In vitro experiments confirmed that RhCol III and the plasmid were successfully loaded onto the sutures and could be released and expressed. In vivo experiments were carried out using a rat model simulating uterine scars. The section results showed that compared with the scar model group, the expression level of TGF-β3 in the RhCol III+TGF-β3 group increased by 39%, the expression level of TGF-β1 decreased by 62.8%, and the fibrosis rate decreased by 16.8%, which has a positive effect on the prevention of uterine scars. This study integrates the therapeutic medicine into the sutures, ensuring that the medicine can come into contact with the wound site after suturing. Moreover, RhCol III and the gene medicine work synergistically to promote the repair of uterine wounds.

Enhanced myofibroblast differentiation of eMSCs in intrauterine adhesions

BACKGROUND

Intrauterine adhesions (IUA) is one of the most common gynecological diseases and main causes of uterine infertility. Among proposed hypotheses on IUA development, the reduced endometrial regeneration resulting from loss of functional stem cells has been proposed as the key factor affecting the IUA prognosis. However, the underlying mechanisms mostly remain unclear. Because the eMSCs (endometrial mesenchymal stem/stromal cells) play a critical role in both supporting the gland development and also preparing the environment for embryo implantation through decidualization, the characteristics and functions were compared between the eMSCs derived from IUA and non-IUA patients, to uncover the important roles of eMSCs in IUA and also the underlying mechanisms.

METHODS

Endometrium biopsies were collected from IUA patients and controls. The fibrosis features and eMSC distributions were investigated with IHC (immunohistochemistry). Then the eMSCs were isolated and their functions and characteristics were analyzed in vitro.

RESULTS

Our results indicate that the scar tissues in IUA are characterized with hyper-activation of pro-fibrotic fibroblast and myo-differentiation, along with reduced number of eMSCs. The isolated eMSCs from IUA and controls show similar functions from the perspectives of cell morphology, proliferation, colony formation, exosome secretion, positive ratio of eMSC markers and conventional MSC markers, tri-differentiation efficiency, the ability of suppressing lymphocyte proliferation, cell aging, and promoting vascular tube formation. However, the eMSCs from IUA have reduced levels of decidualization and higher levels of cell migration, invasion, and also myofibroblast differentiation. Further investigations indicate that the TGF-β pathway, which is the major inducer of myofibroblast differentiation, is up-regulated and responsible for the enhanced myofibroblast differentiation potential of eMSCs from IUA.

CONCLUSIONS

In conclusion, we have demonstrated here that the scar tissues in IUA biopsy are characterized with enhanced differentiation of pro-fibrotic fibroblast and myofibroblast. The number of eMSCs is reduced in IUA tissues, and their myofibroblast differentiation capability is increased.

Lower expression of colony-stimulating factor 2, an embryokine, in the endometrial epithelium of old cows

Context Infertility increases with age in various animals, including cows, owing to unknown mechanisms. The glandular and luminal epithelia of the bovine uterus synthesise and secrete colony-stimulating factor 2 (CSF2), which is a well-studied embryokine. We recently reported the possibility of fibrosis in the uteri of old cows. However, the relationship between CSF2 expression and fibrosis has not yet been clarified. Aims We tested the hypothesis that the endometrial epithelia of old cows have lower CSF2 expression compared to in heifers, and that myofibroblasts [alpha-smooth muscle actin (αSMA)-positive fibroblasts] increase near the epithelium of old cows. Methods We collected caruncle and intercaruncle samples from post-pubertal, growing, nulliparous heifers (n =6; 24.7±1.3months old) and old multiparous cows (n =6; 128.5±15.4months old). We analysed mRNA and protein expression, along with fluorescent immunohistochemistry for CSF2, anti-collagen type IV, anti-Müllerian hormone type 2 receptor, and anti-αSMA. Key results Quantitative reverse transcription polymerase chain reaction and western blot analysis revealed lower CSF2 expression in the caruncle and intercaruncle of old cows than in young heifers. Fluorescence microscopy using the same antibodies and anti-collagen type IV, anti-Müllerian hormone type 2 receptor, and anti-αSMA antibodies showed increased fibroblasts and αSMA signals near the epithelium of old cows compared to young heifers. Conclusion CSF2 expression was lower in endometrial epithelia of old cows compared to those in heifers, and myofibroblasts increased near the epithelia of old cows. Implications Lower CSF2 may play an important role in age-related infertility.

The zinc-finger transcription factor Blimp1/Prdm1 is required for uterine remodelling and repair in the mouse

The zinc finger transcription factor Blimp1/PRDM1 regulates gene expression in diverse cell types. Its activity controls the maternal decidual response at early post-implantation stages of development. The present experiments demonstrate surprisingly that Blimp1 activity in the uterus is required for tissue remodelling at sites of embryonic failure. Moreover Blimp1 mutant females are refractory to RU486 induced decidual shedding. RNA-seq together with immunostaining experiments strongly suggest that the failure to up-regulate expression of the matrix metalloprotease Mmp10 in combination with insufficient suppression of BMP signalling, likely explain Blimp1-dependent phenotypic changes. In the post-partum uterus Blimp1 together with Mmp10 are highly upregulated at sites of tissue repair following placental detachment. Conditional Blimp1 removal significantly impairs the re-epithelization process and severely impacts involution of the endometrium and luminal epithelium. Overall these results identify Blimp1 as a master regulator of uterine tissue remodelling and repair.

Melatonin improves endometrial receptivity and embryo implantation via MT2/PI3K/LIF signaling pathway in sows

BACKGROUND

Increased backfat thickness of sows in early gestation is negative to reproductive performance. Endometrial receptivity is an important determinant of reproductive success, but it is unclear whether the effect of sow backfat thickness on litter size is associated with endometrial receptivity and whether melatonin treatment may have benefits. The present study seeks to answer these questions through in vitro and in vivo investigations.

RESULTS

Excessive lipid deposition and lower melatonin levels in the uterus are detrimental to endometrial receptivity and embryo implantation in high backfat thickness sows. In cells treated with melatonin, the MT2/PI3K/LIF axis played a role in reducing lipid accumulation in porcine endometrial epithelium cells and improved endometrial receptivity. Furthermore, we found a reduction of lipids in the uterus after eight weeks of intraperitoneal administration of melatonin to HFD mice. Notably, melatonin treatment caused a significant reduction in the deposition of endometrial collagen, an increase in the number of glands, and repair of the pinopode structure, ultimately improving endometrial receptivity, promoting embryo implantation, and increasing the number of litter size of mice.

CONCLUSIONS

Collectively, the finding reveals the harmful effects of high backfat thickness sows on embryo implantation and highlight the role of melatonin and the MT2/PI3K/LIF axis in improving endometrial receptivity by enhancing metabolism and reducing the levels of uterine lipids in obese animals.

In Situ Sprayed Hydrogel Delivers Extracellular Vesicles Derived from Human Endometrial Organoids for Uterine Function Preservation and Fertility Restoration

Impaired endometrial function and reduced receptivity remain significant causes of female infertility. Here, a sprayable hydrogel combined with human endometrial organoid extracellular vesicles (HEO-EVs) is developed to enhance uterine function preservation and fertility restoration. The peptide amphiphile hydrogel (labeled CPA) is engineered by conjugating a collagen-binding peptide with glutathione to impart its biocompatible adhesive and antioxidant properties. The therapeutic EVs are isolated and purified from human endometrial organoids that have been stably passaged long-term using a bioreactor-culture system. The resulting HEO-EVs-loaded CPA (CPA@HEO-EVs) rapid gelation, triggered by salt-ion interactions, occurs when the fluid is sprayed onto the uterine lining. The ex vivo studies demonstrate that CPA@HEO-EVs promote cell proliferation, scavenges free radicals, and increases tube formation in human umbilical vein endothelial cells. In vivo experiments further validate that in situ spraying with the CPA@HEO-EVs can promote neovascularization, prevent localized endometrial fibrosis, and effectively enhance fertility in a mouse model of endometrial injury. These findings highlight the promising clinical application of in situ sprayed CPA@HEO-EVs hydrogel for targeted endometrial therapy.

Gene Therapy for Inflammatory Cascade in Intrauterine Injury with Engineered Extracellular Vesicles Hybrid Snail Mucus-enhanced Adhesive Hydrogels

Early hyper-inflammation caused by intrauterine injury triggered subsequent intrauterine adhesion (IUA). STAT1-mediated M1 macrophages are confirmed to secrete pro-inflammatory cytokines to accelerate inflammatory cascade and IUA formation by multi-omics analysis and experimental verification. However, clinically used hyaluronic acid (HA) hydrogels are prone to slip out of injury sites due to poor bio-adhesion properties. Therefore, there are still challenges in applying hydrogels for M1 macrophage intervention in IUA treatment. Herein, an engineered extracellular vesicles (EVs) hybrid snail mucus (SM)-enhanced adhesive hydrogels to improve bio-adhesion property is fabricated and M1 macrophage intervention through targeting delivery and STAT1 silencing is achieved. First, inspired by the high bio-adhesion capacity of SM, SM and gelatin methacrylate (GelMA) solution are mixed to construct GelMA/SM (GS) hydrogel. Then, folic acid-modified extracellular vesicles (FA-EVs) are synthesized for targeting the delivery of STAT1-siRNA. Upon injection of FA-EVs hybrid GS hydrogel into the uterine cavity, a protective hydrogel layer forms on the surface of injury sites and sustains the release of STAT1-siRNA-loaded FA-EVs to curtail M1 macrophages generation through inhibiting STAT1 phosphorylation, resulting in reduction of myofibroblasts activation and collagen deposition. In addition, the pregnancy rate and the number of fetuses in rats treated with this hydrogel were much higher than those in other groups, suggesting that the hydrogel could promote functional endometrial regeneration and restore fertility. Overall, this study presents a promising strategy for employing FA-EVs hybrid adhesive hydrogel with superior bio-adhesion properties and M1 macrophage targeting delivery for IUA treatment and uterus recovery.

Mechanistic insights into intrauterine adhesions

Intrauterine adhesions (IUA), also known as Asherman's syndrome, arise from damage to the basal layer of the endometrium, frequently caused by intrauterine interventions. This damage leads to nonregenerative healing of endometrium resulting in replacement by fibrous connective tissue, which bring about the adherence of opposing endometrium to render the uterine cavity and/or cervical canal partially or completely obliterated. IUA is a common cause of the refractory uterine infertility. Hysteroscopy is the gold standard for diagnosis of IUA. However, the method of accurately predicting the likelihood of achieving a live birth in the future remains established. Classical treatments have shown limited success, particularly in severe cases. Therefore, utilizing new research methods to deepen the understanding of the pathogenesis of IUA will facilitate the new treatment approaches to be found. In this article we briefly described the advances in the pathogenesis of IUA, with focus on inflammation and parenchymal cellular homeostasis disruption, defects in autophagy and the role of ferroptosis, and we also outlined the progress in IUA therapy.

Current advances in understanding endometrial epithelial cell biology and therapeutic applications for intrauterine adhesion

The human endometrium is a highly regenerative tissue capable of undergoing scarless repair during the menstruation and postpartum phases. This process is mediated by endometrial adult stem/progenitor cells. During the healing of endometrial injuries, swift reepithelization results in the rapid covering of the wound surface and facilitates subsequent endometrial restoration. The involvement of endogenous endometrial epithelial stem cells, stromal cells, and bone marrow-derived cells in the regeneration of the endometrial epithelium has been a subject of prolonged debate. Increasing evidence suggests that the regeneration of the endometrial epithelium mainly relies on epithelial stem cells rather than stromal cells and bone marrow-derived cells. Currently, no consensus has been established on the identity of epithelial stem cells in the epithelial compartment. Several markers, including stage-specific embryonic antigen-1 (SSEA-1), sex-determining region Y-box 9 (SOX9), neural-cadherin (N-cadherin), leucine-rich-repeat-containing G-protein-coupled receptor 5 (LGR5), CD44, axis inhibition protein 2 (Axin2), and aldehyde dehydrogenase 1A1 (ALDH1A1), have been suggested as potential candidate markers for endometrial epithelial stem cells. The identification of endometrial epithelial stem cells contributes to our understanding of endometrial regeneration and offers new therapeutic insights into diseases characterized by regenerative defects in the endometrium, such as intrauterine adhesion. This review explores different perspectives on the origins of human and mouse endometrial epithelial cells. It summarizes the potential markers, locations, and hierarchies of epithelial stem cells in both human and mouse endometrium. It also discusses epithelial cell-based treatments for intrauterine adhesion, hoping to inspire further research and clinical application of endometrial epithelial stem cells.

Thermosensitive hydrogel as a sustained release carrier for mesenchymal stem cell-derived extracellular vesicles in the treatment of intrauterine adhesion

Intrauterine adhesion (IUA), a prevalent etiology of female infertility, is attributed to endometrial damage. However, conventional therapeutic interventions for IUA are plagued by high recurrence rates. Human umbilical cord mesenchymal stem cell-derived extracellular vesicles (hUCMSC-EVs) demonstrate the promising therapeutic effects on IUA, but the current efficacy of extracellular vesicles (EVs) is hindered by lower retention and bioavailability. In this study, a thermosensitive hydrogel was utilized as a prolonged release carrier to improve the retention and bioavailability of hUCMSC-EVs in IUA treatment. The hydrogel-EVs complex effectively prolonged EVs retention in human endometrial stromal cells and an IUA mouse model. The complex exhibited superior protection against cellular injury, significantly alleviated endometrial damage, inhibited fibrosis, suppressed inflammation, and improved fertility compared to EVs alone. The results indicated that thermosensitive hydrogel enhanced the therapeutic capacity of EVs for IUA by prolonging their retention in the uterine environment. The hydrogel-EVs complex provides a novel strategy for the sustained release of hUCMSC-EVs in the treatment of IUA.

Human umbilical cord mesenchymal stem cells improve uterine incision healing after cesarean delivery in rats by modulating the TGF-β/Smad signaling pathway

OBJECTIVE

Although human umbilical cord-derived mesenchymal stem cells (HU-MSCs) have attracted increasing attention because of their pivotal functions in the process of wound healing, the underlying molecular mechanisms have been poorly understood. It has been shown that the TGF-β/Smad signaling pathway plays an important role in the process of scar formation. The present study focused on exploring whether HU-MSCs improve uterine incision healing after cesarean delivery in rats via the TGF-β/Smad signaling pathway.

STUDY DESIGN

Pregnant rats were randomly assigned to three groups, including the NP group, incision-injected group (HU-MSCs1 group), and tail vein-injected group (HU-MSCs2 group), and 30 days after cesarean section, sampling was carried out to further explore the specific mechanisms from tissue and protein levels.

RESULTS

HU-MSCs secretion could inhibit the fibrosis of scar tissue. We observed that the TGF-β induced expression of TGF-β1, Smad2, and Smad3 was attenuated upon HU-MSCs treatment in scar tissue, while the decrease in TGF-β3 expression was enhanced by HU-MSCs. Furthermore, HU-MSCs treatment accelerated wound healing and attenuated collagen deposition in a damaged uterine rat model, leading to the promoting of uterine incision scarring. In addition, the expression of alpha-smooth muscle actin (a-SMA) was enhanced by HU-MSCs treatment.

CONCLUSION

HU-MSCs transplantation promotes rat cesarean section uterine incision scar healing by modulating the TGF-β/Smad signaling pathway.

Hypoxia and the endometrium: An indispensable role for HIF-1α as therapeutic strategies

Hypoxia-inducible factor 1 alpha (HIF-1α) is a major molecular mediator of the hypoxic response. In the endometrium, local hypoxic conditions induced by hormonal fluctuations and endometrial vascular remodeling contribute to the production of HIF-1α, which plays an indispensable role in a series of physiological activities, such as menstruation and metamorphosis. The sensitive regulation of HIF-1α maintains the cellular viability and regenerative capacity of the endometrium against cellular stresses induced by hypoxia and excess reactive oxygen species. In contrast, abnormal HIF-1α levels exacerbate the development of various endometrial pathologies. This knowledge opens important possibilities for the development of promising HIF-1α-centered strategies to ameliorate endometrial disease. Nonetheless, additional efforts are required to elucidate the regulatory network of endometrial HIF-1α and promote the applications of HIF-1α-centered strategies in the human endometrium. Here, we summarize the role of the HIF-1α-mediated pathway in endometrial physiology and pathology, highlight the latest HIF-1α-centered strategies for treating endometrial diseases, and improve endometrial receptivity.

Intrauterine adhesion

Intrauterine adhesions (IUA) occurred in the reproductive-age women are a big economic and health problem, resulting in severe impairment of social, psychological and physical function of the female genital organs. IUA-related symptoms or signs are varied greatly from free of symptoms or ambiguous symptoms (an incidental finding during the intervention) to ceased menstruation and loss of fecundability. The underlying pathophysiology is not completely understood, but intrauterine damage with broken basal layers of the endometrium formatting scar tissues or fibrosis in the endometrium with subsequently causing partial or complete occlusion of the uterine cavity may be a well-accepted hypothesis. Previously, infection is the most common cause to develop IUA, but now, intrauterine surgery may be a critical cause contributing to the majority of cases of IUA. In the current review, update information about the etiology, epidemiology, pathophysiology, sequelae and prevention of IUA will be renewed. We emphasize the importance of awareness of IUA, and primary prevention should be considered in the routine clinical practice if intrauterine surgery has been applied, based on uncertainty of ideal treatment for the established IUA and unpredictable outcomes after IUA treatment. So far, evidence supports that hyaluronic acid with/without other strategy is the most valuable and effective method to reduce the formation and re-formation of IUA as well as to achieve the best fertility outcome.

Amorphous curcumin-based hydrogels to reduce the incidence of post-surgical intrauterine adhesions

The incidence of intrauterine adhesions (IUA) has increased with the rising utilization of intrauterine surgery. The postoperative physical barrier methods commonly used, such as balloons and other fillers, have limited effectiveness and may even cause further damage to the remaining endometrial tissue. Herein, we developed an injectable thermosensitive hydrogel using Pluronic F127/F68 as pharmaceutical excipients and curcumin as a natural active molecule. The hydrogel effectively addresses solubility and low bioavailability issues associated with curcumin. In vitro, drug release assays revealed that the amorphous curcumin hydrogel promotes dissolution and sustained release of curcumin. In vitro experiments reveal high biocompatibility of the hydrogel and its ability to enhance vascular formation while inhibiting the expression of fibrotic factor TGF-β1. To assess the effectiveness of preventing IUAs, in vivo experiments were conducted using IUA rats and compared with a class III medical device, a new-crosslinked hyaluronic acid (NCHA) gel. According to the study, curcumin hydrogel is more effective than the NCHA group in improving the regeneration of the endometrium, increasing the blood supply to the endometrium and reducing the abnormal deposition of fibrin, thus preventing IUA more effectively. This study provides a promising strategy for treating and preventing IUA.

MALAT1/miR-7-5p/TCF4 Axis Regulating Menstrual Blood Mesenchymal Stem Cells Improve Thin Endometrium Fertility by the Wnt Signaling Pathway

Thin endometrium (TE) is a significant factor contributing to fertility challenges, and addressing this condition remains a central challenge in reproductive medicine. Menstrual blood-derived mesenchymal stem cells (MenSCs) play a crucial role in tissue repair and regeneration, including that of TE. The Wnt signaling pathway, which is highly conserved and prevalent in eukaryotes, is essential for cell proliferation, tissue development, and reproductive functions. MALAT1 is implicated in various transcriptional and molecular functions, including cell proliferation and metastasis. However, the combined effects of the Wnt signaling pathway and the long non-coding RNA (lncRNA) MALAT1 on the regulation of MenSCs' regenerative capabilities in tissue engineering have not yet been explored. To elucidate the regulatory mechanism of MALAT1 in TE, we analyzed its expression levels in normal endometrium and TE tissues, finding that low expression of MALAT1 was associated with poor clinical prognosis. In addition, we conducted both in vitro and in vivo functional assays to examine the role of the MALAT1/miR-7-5p/TCF4 axis in cell proliferation and migration. Techniques such as dual-luciferase reporter assay, fluorescent in situ hybridization, and immunoblot experiments were utilized to clarify the molecular mechanism. To corroborate these findings, we established a TE model and conducted pregnancy experiments, demonstrating a strong association between MALAT1 expression and endometrial fertility. In conclusion, our comprehensive study provides strong evidence supporting that lncRNA MALAT1 modulates TCF4 expression in the Wnt signaling pathway through interaction with miR-7-5p, thus enhancing MenSCs-mediated improvement of TE and improving fertility.

Breaking the silence: The role of extracellular vesicles in unraveling the diagnosis and treatment of endometriosis

Cell-to-cell communication is believed to be facilitated by membrane-bound vesicles called extracellular vesicles (EVs), which are released by cells. Protein, lipids, and nucleic acids are major cargo of EVs and are transported in these vesicles. Depending on the parent and recipient cell types, they can affect a wide variety of biological processes in the tissues to which they are delivered. EVs are essential for embryo implantation and endometriosis, and they are located in the uterine cavities of different species, where they promote blastocyst and endometrial preparation for implantation. This review focuses on what is currently understood regarding pathologic and diagnostic characteristics, and the potential therapeutic value of EVs in the context of endometriosis, where they can be used for drug delivery and targeted therapy due to their ability to carry bioactive molecules to specific cells or tissues. The findings of this review highlight the potential for a wide range of clinical applications that involve endometrial EVs in the areas of treatment, such as surgical and pharmacological, diagnostic biomarker development, and drug delivery systems, all with the ultimate goal of improving pregnancy success rates.