Thinking in context: Fibroids-to-uterine volume ratio in pre-surgical fertility evaluation for intramural fibroids

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.

Four-dimensional ultrasound guided embryo transfers improve live birth rates when compared to the clinical touch technique: a randomised controlled trial

Most aspects of in-vitro fertilisation (IVF) have changed dramatically since introduction, but embryo transfer (ET) technique remains largely unaltered. We aimed to determine whether four-dimensional ultrasound guided embryo transfers (4D UGET) could improve pregnancy rates when compared with clinical touch technique (CTT). This was a single centre open labelled randomised controlled trial in a tertiary fertility centre in the UK. 320 women were randomised on the day of single ET. The primary outcome was clinical pregnancy rate (CPR), secondary outcomes included live birth rate (LBR), biochemical pregnancy rate (BPR), miscarriage, pregnancy of unknown location (PUL) and ectopic pregnancy. 4D-UGET resulted in significantly higher CPR [50% vs 36% p = 0.02, OR 1.78 (1.12-2.84)] and LBR [41% vs 28%, p = 0.02, OR 1.77 (1.09-2.87)] when compared to CTT technique. Miscarriage (p = 0.49), PUL (p = 0.14) and ectopic pregnancy (p = 0.96) were similar between the two groups. LBR, from this trial, are significantly higher than the current UK average (41% vs 24%). 4D UGET allows for superior imaging of the uterine cavity, whilst tailoring the embryo deposition point specifically to the patient. Further RCTs are required to determine if these results can be replicated in other units and whether 4D UGET is superior to 2D UGET.

Defining recurrent implantation failure: a profusion of confusion or simply an illusion?

Recurrent implantation failure (RIF) is a poorly defined clinical scenario marked by failure to achieve pregnancy after multiple embryo transfers. The causes and definitions of implantation failure are heterogeneous, posing limitations on study design as well as the interpretation and application of findings. Recent studies suggest a novel, personalized approach to defining RIF. Here, we review the implantation physiology and definitions of the implantation rate, failure, and RIF.

Psychological Stress and Functional Endometrial Disorders: Update of Mechanism Insights

The human endometrium plays a vital role in providing the site for embryo implantation and maintaining the normal development and survival of the embryo. Recent studies have shown that stress is a common factor for the development of unexplained reproductive disorders. The nonreceptive endometrium and disturbed early maternal-fetal interaction might lead to infertility including the repeated embryo implantation failure and recurrent spontaneous abortion, or late pregnancy complications, thereby affecting the quality of life as well as the psychological status of the affected individuals. Additionally, psychological stress might also adversely affect female reproductive health. In recent years, several basic and clinical studies have tried to investigate the harm caused by psychological stress to reproductive health, however, the mechanism is still unclear. Here, we review the relationship between psychological stress and endometrial dysfunction, and its consequent effects on female infertility to provide new insights for clinical therapeutic interventions in the future.

Extracellular matrix remodeling and inflammatory pathway in human endometrium: insights from uterine leiomyomas

OBJECTIVE

To compare the expression profiles of matrix metalloproteinases (MMPs) and their inhibitors (tissue inhibitors of matrix metalloproteinases, TIMPs) in the endometrium of women with and without type 3 leiomyomas and to understand their relationship with inflammatory status.

DESIGN

Molecular and in silico studies.

SETTING

University hospital.

PATIENT(S)

Patients with type 3 leiomyomas ranging from 3 to 10 cm in diameter (n = 18) and control age-matched women undergoing surgery for ovarian cysts (n = 18) who underwent endometrial biopsies.

INTERVENTION(S)

Endometrial biopsies.

MAIN OUTCOME MEASURE(S)

To evaluate the expression levels of MMPs and TIMPs in the endometrium, quantitative reverse transcriptase polymerase chain reaction and Western blot were performed. With the use of immunofluorescence analysis, the investigated proteins were localized in the tissues. The expression levels of inflammatory mediators such as IL-1β, IL-6, IL-10, TGF, COX1, COX2, STAT3, and VEGF were evaluated by quantitative reverse transcriptase polymerase chain reaction, and their relationships were detected by the STRING approach.

RESULT(S)

The endometrium of women with type 3 leiomyomas exhibited differential expression of MMPs and TIMPs, particularly MMP2, MMP11, and MMP14, as well as different topographic distribution, suggesting that leiomyomas may influence the endometrial molecular profile. Significant decreases in IL-1β, IL-6, and IL-10 expression, along with increases in COX1 and COX2, as well as VEGF, were highlighted. The STRING approach suggests that this altered gene expression profile may affect the Th17 cell differentiation pathway.

CONCLUSION(S)

The differential expression and localization of MMPs and TIMPs observed in women with type 3 leiomyomas, along with the reported derangement in the expression of key molecules involved in the inflammatory pathway, may contribute to changes in endometrial receptivity in these patients.

Estrogen-regulated miRNA-27b is altered by bisphenol A in human endometrial stromal cells

MicroRNAs (miRs) are small molecules important for regulation of transcription and translation. The objective was to identify hormonally regulated miRs in human endometrial stromal cells and to determine the impact of the endocrine disruptor, bisphenol A (BPA), on those miRs. miR microarray analysis and multiple confirmatory cell preparations treated with 17β-estradiol (E2) and BPA altered miR-27b, let-7c, let-7e and miR-181b. Further, decidualization downregulated miR-27b. VEGFB and VEGFC were validated as targets of miR-27b. Identification of miR-27b target genes suggests that BPA and E2 downregulate miR-27b thereby leading to upregulation of genes important for vascularization and angiogenesis of the endometrium during the menstrual cycle and decidualization.

Cumulative Live Birth Rate in Patients With Thin Endometrium: A Real-World Single-Center Experience

Background: Studies have shown that patients with a thin endometrial thickness (EMT < 7 or 8 mm) during IVF/ICSI tend to have adverse pregnancy outcomes, and this has caused much anxiety to both patients and physicians when confronted with a thin EMT. Method: From January 2015 to December 2018, patients with a thin EMT < 7 mm on the day of hCG administration during their first GnRH agonist IVF/ICSI cycle were included. According to the hysteroscopy results, patients were classified into totally normal (Group A), normal with a specific abnormality (Group B), and adhesion before transfer (Group C). Result: For the 245 patients included, approximately 60% of the thin EMT cases were the result of an intrauterine operation. CLBR was 35.45% (67/189) in this group of patients. In regard to CLBR, there were significant differences among these three uterus condition groups irrespective of the number of oocytes retrieved (28.57 vs. 10.00 vs. 4.76%, P = 0.12 in oocyte ≤5; 61.36 vs. 44.67 vs. 23.63%, P = 0.00 in oocyte >5). In binary logistic regression analysis, age (OR = 0.09, P = 0.03), number of embryos available (OR = 1.71, P = 0.00), and uterine condition (OR = 6.77, P = 0.00 for group A; OR = 2.55, P = 0.04 for group B; Reference = group C), were significantly associated with CLBR. However, EMT and endometrial pattern had no impact on CLBR. Conclusion: An intrauterine operation was the main reason for a thin EMT. Thin EMT patients with a normal uterine cavity and endometrium had a significantly better CLBR compared with those with adhesions before transfer.

Benzo(a)pyrene inhibits endometrial cell apoptosis in early pregnant mice via the WNT5A pathway

Benzo(a)pyrene (BaP) is an endocrine-disrupting pollutant present in various aspects of daily life, and studies have demonstrated that BaP exerts reproductive toxicity. We previously showed that BaP damages endometrial morphology and decreases the number of implantation sites in early pregnant mice, but the mechanisms underlying these effects remain unclear. The endometrial function is crucial for implantation, which is associated with endometrial cell apoptosis. In this study, we focused on the effect of BaP on endometrial cell apoptosis and the role of WNT signaling during this process. Pregnant mice were gavaged with corn oil (control group) or 0.2 mg·kg^-1 ·day ^-1 BaP (treatment group) from Days 1 to 6 of pregnancy. BaP impaired endometrial function by decreasing the expression of HOXA10 and BMP2, two markers of receptivity and decidualization. WNT5A and β-catenin were activated in the BaP group. BaP affected the expression of apoptosis-related proteins and inhibited the apoptosis of endometrial stromal cells. In vitro, human endometrial stromal cells (HESCs) were treated with different concentrations of BaP (dimethyl sulfoxide (DMSO); 5, 10 µM). WNT5A and β-catenin were also upregulated in the BaP treatment group. HESC apoptosis was restrained by BaP. Inhibiting WNT5A by SFRP5 partially restored the effect of BaP on apoptosis. In summary, these results suggested that BaP exposure during early pregnancy activates WNT5A/β-catenin signaling pathway, which inhibits the endometrial cell apoptosis and potentially destroys endometrial function.

Oxytocin Administration in High-Intensity Focused Ultrasound Treatment of Myomata

Objectives

The aim of the study was to evaluate the clinical efficacy of magnetic resonance-guided High-Intensity Focused Ultrasound (HIFU) in patients with symptomatic uterine fibroids (myomata) after application of oxytocin.

Methods

156 women with symptomatic uterine fibroids were treated using MR-guided HIFU procedure. 51 patients had additional IV administration of 40 IU of oxytocin in 5% Glucose or 0,9% NaCl solution during therapy. Before and after the procedure we performed MR and measured initial perfused volume, final perfused volume, nonperfused volume (NPV), and treated volume ratio (TVR). The follow-up was up to 15 months to assess efficacy of treatment and relief of symptoms.

Results

Nonperfused volume was statistically significantly larger in oxytocin group than in control group (p=0.0019). The remaining parameters did not show significant difference between both groups.

Conclusion

Oxytocin administration seems to improve efficiency of HIFU therapy although further research is required to assess its value. This study' clinical registration number is DRKS00014794.

A Review of the Molecular Basis for Reduced Endometrial Receptivity in Uterine Fibroids and Polyps

The presence of fibroids and endometrial polyps is associated with reduced endometrial receptivity and subsequent fertility outcomes. The following review explores the molecular mechanisms behind reduced endometrial receptivity, with a focus upon homebox genes, basic transcription element binding proteins, transforming growth factor β-3, and bone morphogenetic protein 2. A better understanding of these processes is essential for future targeted therapy.

Recent Advances in Uterine Fibroid Etiology

Uterine fibroids, also known as uterine leiomyoma (UL), are monoclonal tumors of the smooth muscle tissue layer (myometrium) of the uterus. Although ULs are considered benign, uterine fibroids are the source of major quality-of-life issues for approximately 25% of all women, who suffer from clinically significant symptoms of UL. Despite the prevalence of UL, there is no treatment option for UL which is long term, cost-effective, and leaves fertility intact. The lack of understanding about the etiology of UL contributes to the scarcity of medical therapies available. Studies have identified an important role for sex steroid hormones in the pathogenesis of UL, and have driven the use of hormonal treatment for fibroids, with mixed results. Dysregulation of cell signaling pathways, miRNA expression, and cytogenetic abnormalities have also been implicated in UL etiology. Recent discoveries on the etiology of UL and the development of relevant genetically modified rodent models of UL have started to revitalize UL research. This review outlines the major characteristics of fibroids; major contributors to UL etiology, including steroid hormones; and available preclinical animal models for UL.

Endometrial Expression of Homeobox Genes and Cell Adhesion Molecules in Infertile Women With Intramural Fibroids During Window of Implantation

This study was designed to examine the expression and cellular distribution of homeobox ( HOX) genes ( HOXA10 and HOXA11) and cell adhesion molecules (E-cadherin, N-cadherin, and β-catenin) during the window of implantation in infertile women with noncavity-distorting intramural (IM) fibroids (n = 18) and in fertile controls (n = 12). Quantitative real-time polymerase chain reaction and immunohistochemistry were used to evaluate the messenger RNA (mRNA) levels and protein expression, respectively. When compared to fertile controls, reduced HOXA10 and HOXA11 transcript and protein levels were observed in infertile women. However, changes only in the expression of HOXA10 mRNA (-1.72-fold; P = .03) and stromal protein ( P = .001) were statistically significant. Significantly lower E-cadherin mRNA (-10.97-fold; P = .02) and protein levels were seen in infertile patients. E-cadherin immunostaining was significantly reduced both in the luminal ( P = .048) and in the glandular ( P = .014) epithelium of endometrium from infertile patients when compared to controls. No significant change was observed either in the mRNA levels or in the immunoexpression of N-cadherin and β-catenin. However, a trend toward lower N-cadherin expression in the luminal epithelium ( P = .054) and decreased β-catenin expression in the glandular epithelium ( P = .070) was observed in infertile patients. The present findings suggest that altered endometrial HOXA10 and E-cadherin mRNA and protein expression observed in infertile women with IM fibroids during the mid-secretory phase might impair endometrial receptivity leading to infertility in these patients.

Potential causes of subfertility in patients with intramural fibroids

BACKGROUND

Intramural leiomyomas have been long debated as a potential cause of infertility and pregnancy loss.

FINDINGS

Previous research has linked intramural fibroids to defective implantation, as well as to abnormal peristaltic events of the uterine smooth muscle. Previous reports describe the effects of intramural fibroids on normal human fertility and early pregnancy loss, specifically in regards to implantation failure.

CONCLUSION

A thorough understanding of prior research may direct new research focus, leading to better understanding of leiomyoma-associated infertility.

Effect of myomectomy on endometrial glutathione peroxidase 3 (GPx3) and glycodelin mRNA expression at the time of the implantation window

BACKGROUND

In fertile women, glycodelin and glutathione peroxidase 3 (GPx3) genes expression rises during the luteal phase, with a peak occurring during the implantation window. The expression of these genes decreases in women with myomas. To determine whether myomectomy would reverse glycodelin and GPx3 expression, we evaluated the transcript levels of these genes in the endometrium of patients before and after myomectomy.

METHODS

Expression of glycodelin and GPx3 genes were examined prospectively during the midluteal phase in the endometrium obtained from infertile women with myoma (n = 12) before and three months after myomectomy. Endometrial expression of these genes was evaluated using quantitative real-time RT-PCR.

RESULTS

Endometrial glycodelin mRNA expression levels (normalized to 18S rRNA expression) were increased significantly in endometrium of patients after myomectomy (P = 0.02). GPx3 mRNA expression was increased insignificantly after myomectomy (P = 0.43).

CONCLUSION

The results showed that myomectomy increased endometrial glycodelin (significantly) and GPx3 (not significantly) gene expression after 3 months. Study at different times and detecting expression of these genes can reveal more details.

Uterine factors

Uterine anomalies are one of the most common parental causes of recurrent pregnancy loss, occurring in about 19% of patients. Congenital uterine anomalies are most likely caused by HOX gene mutations, although the mechanism is probably polygenic. There are no known environmental causes other than estrogenic endocrine disruptors such as diethylstilbestrol. Acquired uterine anomalies may result from uterine trauma (adhesions) or benign growths of the myometrium (fibroids) or endometrium (polyps). Although randomized controlled trials are lacking, surgical treatment is recommended for repair of uterine septa, and for removal of severe adhesions and submucosal fibroids, especially if no other causes are identified.