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Rodríguez-Eguren A, Bueno-Fernandez C, Gómez-Álvarez M, Francés-Herrero E, Pellicer A, Bellver J, Seli E, Cervelló I. Evolution of biotechnological advances and regenerative therapies for endometrial disorders: a systematic review. Hum Reprod Update 2024:dmae013. [PMID: 38796750 DOI: 10.1093/humupd/dmae013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Revised: 04/12/2024] [Indexed: 05/28/2024] Open
Abstract
BACKGROUND The establishment and maintenance of pregnancy depend on endometrial competence. Asherman syndrome (AS) and intrauterine adhesions (IUA), or endometrial atrophy (EA) and thin endometrium (TE), can either originate autonomously or arise as a result from conditions (i.e. endometritis or congenital hypoplasia), or medical interventions (e.g. surgeries, hormonal therapies, uterine curettage or radiotherapy). Affected patients may present an altered or inadequate endometrial lining that hinders embryo implantation and increases the risk of poor pregnancy outcomes and miscarriage. In humans, AS/IUA and EA/TE are mainly treated with surgeries or pharmacotherapy, however the reported efficacy of these therapeutic approaches remains unclear. Thus, novel regenerative techniques utilizing stem cells, growth factors, or tissue engineering have emerged to improve reproductive outcomes. OBJECTIVE AND RATIONALE This review comprehensively summarizes the methodologies and outcomes of emerging biotechnologies (cellular, acellular, and bioengineering approaches) to treat human endometrial pathologies. Regenerative therapies derived from human tissues or blood which were studied in preclinical models (in vitro and in vivo) and clinical trials are discussed. SEARCH METHODS A systematic search of full-text articles available in PubMed and Embase was conducted to identify original peer-reviewed studies published in English between January 2000 and September 2023. The search terms included: human, uterus, endometrium, Asherman syndrome, intrauterine adhesions, endometrial atrophy, thin endometrium, endometritis, congenital hypoplasia, curettage, radiotherapy, regenerative therapy, bioengineering, stem cells, vesicles, platelet-rich plasma, biomaterials, microfluidic, bioprinting, organoids, hydrogel, scaffold, sheet, miRNA, sildenafil, nitroglycerine, aspirin, growth hormone, progesterone, and estrogen. Preclinical and clinical studies on cellular, acellular, and bioengineering strategies to repair or regenerate the human endometrium were included. Additional studies were identified through manual searches. OUTCOMES From a total of 4366 records identified, 164 studies (3.8%) were included for systematic review. Due to heterogeneity in the study design and measured outcome parameters in both preclinical and clinical studies, the findings were evaluated qualitatively and quantitatively without meta-analysis. Groups using stem cell-based treatments for endometrial pathologies commonly employed mesenchymal stem cells (MSCs) derived from the human bone marrow or umbilical cord. Alternatively, acellular therapies based on platelet-rich plasma (PRP) or extracellular vesicles are gaining popularity. These are accompanied by the emergence of bioengineering strategies based on extracellular matrix (ECM)-derived hydrogels or synthetic biosimilars that sustain local delivery of cells and growth factors, reporting promising results. Combined therapies that target multiple aspects of tissue repair and regeneration remain in preclinical testing but have shown translational value. This review highlights the myriad of therapeutic material sources, administration methods, and carriers that have been tested. WIDER IMPLICATIONS Therapies that promote endometrial proliferation, vascular development, and tissue repair may help restore endometrial function and, ultimately, fertility. Based on the existing evidence, cost, accessibility, and availability of the therapies, we propose the development of triple-hit regenerative strategies, potentially combining high-yield MSCs (e.g. from bone marrow or umbilical cord) with acellular treatments (PRP), possibly integrated in ECM hydrogels. Advances in biotechnologies together with insights from preclinical models will pave the way for developing personalized treatment regimens for patients with infertility-causing endometrial disorders such as AS/IUA, EA/TE, and endometritis. REGISTRATION NUMBER https://osf.io/th8yf/.
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Affiliation(s)
- Adolfo Rodríguez-Eguren
- IVIRMA Global Research Alliance, IVI Foundation, Instituto de Investigación Sanitaria La Fe (IIS La Fe), Valencia, Spain
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale School of Medicine, New Haven, CT, USA
| | - Clara Bueno-Fernandez
- IVIRMA Global Research Alliance, IVI Foundation, Instituto de Investigación Sanitaria La Fe (IIS La Fe), Valencia, Spain
- Department of Paediatrics, Obstetrics and Gynecology, Faculty of Medicine, University of Valencia, Valencia, Spain
| | - María Gómez-Álvarez
- IVIRMA Global Research Alliance, IVI Foundation, Instituto de Investigación Sanitaria La Fe (IIS La Fe), Valencia, Spain
| | - Emilio Francés-Herrero
- IVIRMA Global Research Alliance, IVI Foundation, Instituto de Investigación Sanitaria La Fe (IIS La Fe), Valencia, Spain
- Department of Paediatrics, Obstetrics and Gynecology, Faculty of Medicine, University of Valencia, Valencia, Spain
| | - Antonio Pellicer
- Department of Paediatrics, Obstetrics and Gynecology, Faculty of Medicine, University of Valencia, Valencia, Spain
- IVIRMA Global Research Alliance, IVI Rome, Rome, Italy
| | - José Bellver
- IVIRMA Global Research Alliance, IVI Foundation, Instituto de Investigación Sanitaria La Fe (IIS La Fe), Valencia, Spain
- Department of Paediatrics, Obstetrics and Gynecology, Faculty of Medicine, University of Valencia, Valencia, Spain
- IVIRMA Global Research Alliance, IVI Valencia, Valencia, Spain
| | - Emre Seli
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale School of Medicine, New Haven, CT, USA
- IVIRMA Global Research Alliance, IVIRMA New Jersey, Basking Ridge, NJ, USA
| | - Irene Cervelló
- IVIRMA Global Research Alliance, IVI Foundation, Instituto de Investigación Sanitaria La Fe (IIS La Fe), Valencia, Spain
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Lacconi V, Massimiani M, Carriero I, Bianco C, Ticconi C, Pavone V, Alteri A, Muzii L, Rago R, Pisaturo V, Campagnolo L. When the Embryo Meets the Endometrium: Identifying the Features Required for Successful Embryo Implantation. Int J Mol Sci 2024; 25:2834. [PMID: 38474081 DOI: 10.3390/ijms25052834] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2024] [Revised: 02/22/2024] [Accepted: 02/27/2024] [Indexed: 03/14/2024] Open
Abstract
Evaluation of the optimal number of embryos, their quality, and the precise timing for transfer are critical determinants in reproductive success, although still remaining one of the main challenges in assisted reproduction technologies (ART). Indeed, the success of in vitro fertilization (IVF) treatments relies on a multitude of events and factors involving both the endometrium and the embryo. Despite concerted efforts on both fronts, the overall success rates of IVF techniques continue to range between 25% and 30%. The role of the endometrium in implantation has been recently recognized, leading to the hypothesis that both the "soil" and the "seed" play a central role in a successful pregnancy. In this respect, identification of the molecular signature of endometrial receptivity together with the selection of the best embryo for transfer become crucial in ART. Currently, efforts have been made to develop accurate, predictive, and personalized tests to identify the window of implantation and the best quality embryo. However, the value of these tests is still debated, as conflicting results are reported in the literature. The purpose of this review is to summarize and critically report the available criteria to optimize the success of embryo transfer and to better understand current limitations and potential areas for improvement.
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Affiliation(s)
- Valentina Lacconi
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Via Montpellier 1, 00133 Rome, Italy
- Saint Camillus International University of Health Sciences, Via di Sant'Alessandro 8, 00131 Rome, Italy
| | - Micol Massimiani
- Saint Camillus International University of Health Sciences, Via di Sant'Alessandro 8, 00131 Rome, Italy
| | - Ilenia Carriero
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Via Montpellier 1, 00133 Rome, Italy
| | - Claudia Bianco
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Via Montpellier 1, 00133 Rome, Italy
| | - Carlo Ticconi
- Department of Surgical Sciences, Section of Gynaecology and Obstetrics, University of Rome Tor Vergata, Via Montpellier 1, 00133 Rome, Italy
| | - Valentina Pavone
- Reproductive Sciences Laboratory, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy
| | - Alessandra Alteri
- Obstetrics and Gynaecology Unit, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy
| | - Ludovico Muzii
- Department of Maternal and Child Health and Urological Sciences, "Sapienza" University of Rome, Policlinico Umberto I, 00161 Rome, Italy
| | - Rocco Rago
- Physiopathology of Reproduction and Andrology Unit, Sandro Pertini Hospital, Via dei Monti Tiburtini 385/389, 00157 Rome, Italy
| | - Valerio Pisaturo
- Department of Maternal and Child Health and Urological Sciences, "Sapienza" University of Rome, Policlinico Umberto I, 00161 Rome, Italy
| | - Luisa Campagnolo
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Via Montpellier 1, 00133 Rome, Italy
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Melado L, Lawrenz B, Vitorino RL, Patel R, Ruiz F, Marques LM, Bayram A, Elkhatib I, Fatemi H. Clinical and laboratory parameters associated with pregnancy outcomes in patients undergoing frozen euploid blastocyst transfer. Reprod Biomed Online 2023:S1472-6483(23)00153-0. [PMID: 37062636 DOI: 10.1016/j.rbmo.2023.02.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2022] [Revised: 01/03/2023] [Accepted: 02/27/2023] [Indexed: 03/09/2023]
Abstract
RESEARCH QUESTION Which factors impact on clinical pregnancy rate (CPR) and live birth rates (LBR) in euploid frozen embryo transfer (eFET) cycles? DESIGN Retrospective observational study including 1660 eFET cycles with 2439 euploid blastocysts, from November 2016 to December 2020. The impact of clinical and laboratory parameters on CPR, biochemical miscarriage rate (BMR), clinical miscarriage rate (CMR) and LBR was evaluated. RESULTS CPR per transfer was 63.4%, LBR per transfer 51.6%. CPR and LBR were significantly higher when double embryo transfer (DET) was performed (71.6% versus 57.7%, P < 0.001; 55.2% versus 49.1%, P = 0.016, respectively). However, pregnancy loss was significantly higher in the DET group (28.8% versus 22.8%, P = 0.02). When patients were classified by body mass index (BMI), no differences were observed for CPR, but CMR was lower (P < 0.001) and LBR higher (p = 0.031) for the normal BMI group. The natural cycle protocol revealed lower CMR (P < 0.001) and lower pregnancy loss (P < 0.001); subsequently, higher LBR (57.6%, 48.8%, 45.0%, P = 0.001) compared with hormonal replacement protocol and stimulated cycle. Day of trophectoderm biopsy affected CPR (P < 0.001) and LBR (P < 0.001), yet no differences were observed for BMR, CMR or pregnancy loss. The multivariate analysis showed that day 6/7 embryos had lower probabilities for pregnancy; overweight and obesity had a negative impact on LBR, and natural cycle improved LBR (adjusted odds ratio 1.445, 95% confidence interval 0.519-0.806). CONCLUSIONS Day of biopsy affected CPR, while BMI and endometrial preparation protocol were associated with LBR in eFET. DET should be discouraged as it will increase the risk of pregnancy loss. Women with higher BMI should be aware of the higher risk of pregnancy loss and lower LBR even though a euploid blastocyst is transferred.
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del Carmen Nogales M, Cruz M, de Frutos S, Martínez EM, Gaytán M, Ariza M, Bronet F, Garcia-Velasco JA. Association between clinical and IVF laboratory parameters and miscarriage after single euploid embryo transfers. Reprod Biol Endocrinol 2021; 19:186. [PMID: 34906128 PMCID: PMC8670289 DOI: 10.1186/s12958-021-00870-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Accepted: 11/24/2021] [Indexed: 01/29/2023] Open
Abstract
BACKGROUND The goal of this study was to investigate which factors, excluding embryo aneuploidies, are associated with miscarriage in patients who have undergone a single euploid blastocyst transfer. METHODS Retrospective, observational and multicenter study with 2832 patients undergoing preimplantational genetic testing for aneuploidies (PGT-A) due to repeated implantation failure, recurrent pregnancy loss, advanced maternal age or severe male factor were transferred one single euploid embryo. RESULTS One of the main findings was a significant relationship between body mass index (BMI) and miscarriage rates (13.4% in underweight women, 12.1% in normal weight, 14.5% in overweight, and 19.2% in obese women, odds ratio [OD] 1.04; 95% confidence interval [CI], 1.01-1.07 p = 0.006). Endometrial thickness (OD 0.65; 95%, 0.52-0.77 p = 0.04) and type of endometrial preparation (natural cycle or hormone replacement cycle) (OD 0.77; 95%, 0.52-0.77, p = 0.04) were also associated with miscarriage rates. CONCLUSIONS BMI was strongly associated to miscarriage rates. We also observed a weaker association with endometrial thickness and with the type of endometrial preparation (natural cycle or hormone replacement cycle). None of the other studied variables (biopsy day, maternal and male age, duration of infertility, cycle length, previous miscarriages, previous live births, previous In Vitro Fertilization (IVF) cycles, endometrial pattern and/or diagnosis) were associated with miscarriage rates.
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Affiliation(s)
| | - María Cruz
- IVI Madrid, Av. del Talgo, 68, 28023 Madrid, Spain
| | | | | | - María Gaytán
- IVI Madrid, Av. del Talgo, 68, 28023 Madrid, Spain
| | - Marta Ariza
- IVI Madrid, Av. del Talgo, 68, 28023 Madrid, Spain
| | | | - Juan A. Garcia-Velasco
- IVI Madrid, Av. del Talgo, 68, 28023 Madrid, Spain
- Rey Juan Carlos University, Madrid, Spain
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Endometrial factor testing is a useful tool in clinical infertility management. Reprod Biomed Online 2021; 44:953-960. [DOI: 10.1016/j.rbmo.2021.12.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Revised: 12/10/2021] [Accepted: 12/16/2021] [Indexed: 11/15/2022]
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Ruiz-Alonso M, Valbuena D, Gomez C, Cuzzi J, Simon C. Endometrial Receptivity Analysis (ERA): data versus opinions. Hum Reprod Open 2021; 2021:hoab011. [PMID: 33880420 PMCID: PMC8045472 DOI: 10.1093/hropen/hoab011] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Indexed: 12/14/2022] Open
Abstract
This article summarises and contextualises the accumulated basic and clinical data on the ERA test and addresses specific comments and opinions presented by the opponent as part of an invited debate. Progress in medicine depends on new technologies and concepts that translate to practice to solve long-standing problems. In a key example, combining RNA sequencing data (transcriptomics) with artificial intelligence (AI) led to a clinical revolution in personalising disease diagnosis and fostered the concept of precision medicine. The reproductive field is no exception. Translation of endometrial transcriptomics to the clinic yielded an objective definition of the limited time period during which the maternal endometrium is receptive to an embryo, known as the window of implantation (WOI). The WOI is induced by the presence of exogenous and/or endogenous progesterone (P) after proper oestradiol (E2) priming. The window lasts 30-36 hours and, depending on the patient, occurs between LH + 6 and LH + 9 in natural cycles or between P + 4 and P + 7 in hormonal replacement therapy (HRT) cycles. In approximately 30% of IVF cycles in which embryo transfer is performed blindly, the WOI is displaced and embryo-endometrial synchrony is not achieved. Extending this application of endometrial transcriptomics, the endometrial receptivity analysis (ERA) test couples next-generation sequencing (NGS) to a computational predictor to identify transcriptomic signatures for each endometrial stage: proliferative (PRO), pre-receptive (PRE), receptive (R) and post-receptive (POST). In this way, personalised embryo transfer (pET) may be possible by synchronising embryo transfer with each patient's WOI. Data are the only way to confront arguments sustained in opinions and/or misleading concepts; it is up to the reader to make their own conclusions regarding its clinical utility.
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Affiliation(s)
- Maria Ruiz-Alonso
- Igenomix Foundation-INCLIVA, Valencia, Spain
- Igenomix SL, Valencia, Spain
| | - Diana Valbuena
- Igenomix Foundation-INCLIVA, Valencia, Spain
- Igenomix SL, Valencia, Spain
| | | | | | - Carlos Simon
- Igenomix Foundation-INCLIVA, Valencia, Spain
- Department of Pediatrics, Obstetrics & Gynecology, University of Valencia, Valencia, Spain
- Department of Obstetrics and Gynecology, BIMDC, Harvard University, Boston, MA, USA
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Embryo transfer strategy and therapeutic options in infertile patients with thin endometrium: a systematic review. J Assist Reprod Genet 2019; 36:2217-2231. [PMID: 31502111 DOI: 10.1007/s10815-019-01576-w] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2019] [Accepted: 08/28/2019] [Indexed: 10/26/2022] Open
Abstract
Human endometrium has a key role in implantation process. The measurement of endometrial thickness is the most commonly used in clinical practice. Managing patients with thin endometrium still represents a major challenge for clinicians. The objective of this systematic review was to investigate all available interventions to improve endometrial thickness (EMT) in women with history of thin endometrium undergoing fresh or frozen-thawed embryo transfers (ET). We performed a comprehensive search of relevant studies from January 1978 to February 2018. The different strategies were categorized as hormonal, vascular, and growth factor approaches and specifically analyzed according to the type of ET. Thirty-one studies were included. Overall, quality of the evidence ranged from very low to moderate, with only few randomized controlled trials that support the use of either GnRH analogues in fresh ET or sildenafil in frozen ET for enhancing endometrial growth. Besides, intensified estradiol administration is a common approach that might improve EMT in frozen ET. The present review evidences the paucity of reliable data regarding the efficiency of different interventions aiming at increasing EMT before fresh or frozen-thawed ET. Robust and high-quality randomized controlled trials are still needed before guidelines can be established.
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Abstract
PURPOSE OF REVIEW To review recent findings related to possible causes of recurrent implantation failure of endometrial origin in normal uterus. RECENT FINDINGS Recent evidences suggest that in apparently normal endometria, RIF may associate with molecular and functional changes in the uterus such as abnormal endometrial microbiota, including the presence of chronic endometritis, poor synchronization between the blastocyst and endometrium, and/or excessive uterine peristalsis. An altered endometrial microbiota detected by molecular techniques has been recently related to poorer embryo implantation, even in apparently normal endometria. The use of the endometrial receptivity analysis test to obtain an objective signature of endometrial receptivity has shown to improve the reproductive performance in RIF patients. The diagnosis of uterine peristalsis, however, remains challenging since the usual evaluation by transvaginal ultrasound is not accurate, and drugs tested to reduce uterine peristalsis and enhance embryo implantation have not been clearly beneficial. Finally, endometrial injury to improve implantation rates remains controversial being definitive well-designed trials needed to assess its benefit, if any. SUMMARY In recurrent implantation failure of endometrial origin an altered pattern of the microbial endometrial ecosystem, a displaced window of implantation leading to desynchronization between the blastocyst and the endometrium, or an altered pattern of uterine contractions during embryo transfer may be factors to consider in our attempt to solve this clinical issue. New diagnostics for assessing these conditions and new therapies to improve these dysfunctional situations are currently under investigation to be presumably included in the near future in the work-up of affected patients.
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The thin endometrium in assisted reproductive technology: An ongoing challenge. MIDDLE EAST FERTILITY SOCIETY JOURNAL 2018. [DOI: 10.1016/j.mefs.2017.12.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
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Kudesia R, Kuokkanen S. Thin endometrium after radiation therapy as an unresolved treatment challenge: a case report. Gynecol Endocrinol 2016; 32:701-703. [PMID: 27129096 DOI: 10.1080/09513590.2016.1177813] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Abstract
Receptive endometrium is essential for successful implantation and ongoing pregnancy. Significant health issues and associated therapies, especially oncologic therapies, have potential to negatively impact future fertility in young women. Irradiation and chemotherapeutic alkylating agents are known to cause ovarian failure in most females; however, less well is characterized the impact of irradiation on uterine development and integrity. With an increasing number of cancer survivors, women are seeking infertility treatment after such therapies. Here, we present a young woman who developed ovarian failure after the treatment of acute myeloid leukemia with bone marrow transplant and preceding irradiation and chemotherapy and who was diagnosed with thin endometrial lining while seeking infertility therapy.
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Affiliation(s)
- Rashmi Kudesia
- a Montefiore Medical Center/Albert Einstein College of Medicine , Bronx , NY , USA
- c RMA NY, Icahn School of Medicine , NY , USA
| | - Satu Kuokkanen
- a Montefiore Medical Center/Albert Einstein College of Medicine , Bronx , NY , USA
- b Long Island IVF , Melville , NY , USA , and
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Strategies to manage refractory endometrium: state of the art in 2016. Reprod Biomed Online 2016; 32:474-89. [DOI: 10.1016/j.rbmo.2016.02.001] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2016] [Revised: 02/07/2016] [Accepted: 02/09/2016] [Indexed: 01/01/2023]
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