Intrauterine Adhesions (IUAs) or Asherman’s Syndrome (AS) and the Stem Cells Treatment: A Systemic Review and Meta-Analysis

Background: Intrauterine Adhesions (IUAs) or Asherman’s Syndrome (AS) usually contains symptoms such as decreased menstrual flow or even amenorrhea, chronic pelvic pain, recurrent abortion and infertility. The current treatment of IUAs includes hysteroscopic adhesiolysis, oral hormone and biological barriers, but each of them has limitation. Stem cell therapy may be an expanding field seeking for therapy in IUAs. Objective: We will discuss current advances in stem cell therapy as a treatment for endometrial pathophysiology. Materials and Methods: We search on PubMed, Embase and Cochrane library and select several keywords on researches, then review the cell biology theories and animal experiments, finally do meta-analysis in human clinical trials. Results: 77 articles on PubMed, 71 articles on Embase and 17 articles on Cochrane Library, as a result, 37 articles are included under the criteria, which are intrauterine adhesions (IUAs), Asherman’s Syndrome (AS), cell therapy, stem cells, bone marrow stem cells, clinical trials, recent 10 years and human or animal experiments. The included criteria: original articles, cohort study, case control study, animal experiments, human clinical trials, high quality, 10 years recent. The excluded articles are case reports, meeting reports, low quality or more than 10 years ago. Conclusion: Stem cell may be a new therapeutic schedule for IUAs in the future clinical treatment, but it is necessary to compare it with traditional therapy such as oral hormone, also the development of random clinical tests should proceed. For clinical treatment on IUAs, stem cells could be a new choice.

Safety of menstrual blood-derived stromal cell transplantation in treatment of intrauterine adhesion

BACKGROUND Intrauterine adhesion(IUA)can cause serious damage to women’s reproductive health,yet current treatment methods are difficult to achieve satisfactory results.In our previous studies,we demonstrated that menstrual-derived stromal stem cells(MenSCs),with high proliferative capacity and self-renewal ability,have a powerful therapeutic effect in patients with severe IUA.However,safety assessment of MenSCs transplantation is essential for its further application.AIM To evaluate the short-,medium-,and long-term biosafety of MenSCs via intrauterine transplantation in a rat model of IUA,with a focus on toxicity and tumorigenicity.METHODS MenSCs were injected into the sub-serosal layer of the uterus in an IUA rat model,for 3 d,3 mo,and 6 mo separately,to monitor the corresponding acute,sub-chronic,and chronic effects.Healthy rats of the same age served as negative controls.Toxicity effects were evaluated by body weight,organ weight,histopathology,hematology,and biochemistry tests.Tumorigenicity of MenSCs was investigated in Balb/c-nu mice in vivo and by colony formation assays in vitro.RESULTS Compared with the same week-old control group,all of the IUA rats receiving MenSC transplantation demonstrated no obvious changes in body weight,mainorgan weight,or blood cell composition during the acute,sub-chronic,and chronic observation periods.At the same time,serum biochemical tests showed no adverse effects on metabolism or liver and kidney function.After 4 wk of subcutaneous injection of Men SCs in Balb/c-nu nude mice,no tumor formation or cell metastasis was observed.Moreover,there was no tumor colony formation of Men SCs during soft agar culture in vitro.CONCLUSION There is no acute,sub-chronic,or chronic poisoning,infection,tumorigenesis,or endometriosis in rats with IUA after Men SC transplantation.The above results suggest that intrauterine transplantation of Men SCs is safe for endometrial treatment.

Intrauterine transplantation of autologous bone marrow derived mesenchymal stem cells followed by conception in a patient of severe intrauterine adhesions

On a woman with severe intrauterine adhesions, hysteroscopy followed by cyclical hormone replacement therapy was tried for 5 months, for development of the endometrium. When this failed, autologous stem cells were tried as an alternative therapy. Adult autologous bone marrow mesenchymal stem cells isolated from patient’s own bone marrow and were cultured and placed in the endometrial cavity under ultrasound guidance after curettage. Patient was then given cyclical hormonal therapy. Endometrium was assessed intermittently using ultrasound. Three months later, endometrium partly recovered with improved ultrasonic echo. This resulted in spontaneous pregnancy followed by confirmation of gestational sac, yolk sac, and primitive heart tube pulse on ultrasound. Autologous bone marrow derived mesenchymal stem cells could regenerate injured endometrium not responding to conventional treatment and can be used as an alternative in females with severe Asherman’s syndrome.

Clinical and investigative correlates of etiologic risk factors on treatment outcome of intrauterine adhesion in women with infertility: A descriptive study

Background: Intrauterine adhesion is a clinical entity that may present with subfertility. However, outcome of management depends on severity of intrauterine adhesion and type of treatment intervention employed. Objective: To evaluate clinical and investigative correlation of etiologic risk factors of intrauterine adhesion on fertility and pregnancy outcome following treatment. Patients and Methods: A 5 years prospective observational study. Treatment employed includes transvaginal blind intrauterine adhesiolysis, insertion of inert intrauterine device or inflated Foley’s catheter balloon and oestrogen therapy. Inclusion criteria are intrauterine adhesion as the only identifiable cause of infertility and post treatment follows up for at least a year. Results: Over a period of 5 years, 63 patients with mean age of 31.6 years and age range of 21 to 42 years were managed. Etiologic risk factors were dilatation and curettage 33 (52.4%), vacuum aspiration 13 (20.6%), myomectomy 11 (17.5%) and caesarean section in 6 (9.5%) patients. Of the 63 patients, 28 conceived giving a pregnancy rate of 44.4%. Nine out of the 28 patients that conceived had miscarriage, giving a miscarriage rate of 32.1%. The highest pregnancy rate and lowest miscarriage rate were recorded in the subgroup that had vacuum aspiration as their etiologic risk factor. Late pregnancy complications encountered are preterm contractions 5 (26.3%), placenta praevia 4 (21.1%), morbidly adherent placenta 5 (26.3%) and preterm delivery in 2 (10.5%) patients. Route of delivery was per vaginum in 13 (68.4%) patients and by caesarean section in 6 (31.6%) patients. Live birth rate was 89.5% (17/19 deliveries). There was no maternal mortality recorded. Conclusion: Compared to other risk factors, uterine vacuum aspiration was associated with higher fertility rate and better pregnancy outcome.

Diagnostic Accuracy of Hysterosalpingography in the Identification of Intrauterine Adhesions in Infertile Women in a Referral Centre, Southern Nigeria

Background: Examination of the endometrial cavity is crucial in the management of infertile women. This evaluation is done by Hysterosalpingography (HSG) in the University of Port Harcourt Teaching Hospital. The diagnostic value and accuracy of hysterosalpingography varies in various centres and has not been assessed in the University of Port Harcourt Teaching Hospital (UPTH), hence this study. Methodology: A prospective cross sectional study done among 101 infertile women at the gynaecology clinic of the UPTH from December 2018 to July 2019. Socio-demographic data of women who met the eligibility criteria were collected. Their hysterosalpingographic and outpatient hysteroscopic findings were statistically analyzed using IBM SPSS for windows version 20.0. The validity and reliability statistics of hysterosalpingography for the identification of endometrial adhesions were determined and significance was reported at p-value < 0.05. The analyzed data was presented in tables and figure. Result: The respondents were all married, 66.3% of them were nulliparous, while 54.5% were above 35 years of age. Most, 93.1% of the studied group had at least secondary education and had duration of infertility of more than 2 years. There was a moderate strength of agreement in the diagnostic accuracy of HSG with hysteroscopy in the diagnosis of intrauterine adhesions;showing sensitivity and specificity of 59.6% and 90.9% respectively. The accuracy of HSG in the identification of intrauterine adhesions in this study was 73.3%. The agreement in the diagnostic accuracy of HSG using Hysteroscopy as a gold standard for intrauterine adhesions was therefore moderately significant (k = 0.482). Conclusion: HSG had an overall fair strength of agreement with office hysteroscopy in the identification of intrauterine adhesions. It is a specific but not a sensitive predictor of intrauterine adhesion.

Expression of miR-195 in intrauterine adhesion and its relationship with TGF-β1/Smads and FGF2/FGFR1/ERK pathways

Objective:To investigate the expression of miR-195 in intrauterine adhesion(IUA)and its relationship with TGF-β1/Smads and FGF2/FGFR1/ERK pathways.Methods:118 cases of IUA patients who underwent hysteroscopic treatment in our hospital between September 2017 and February 2019 were regarded as IUA group,80 cases of dysfunctional uterine bleeding patients who underwent hysteroscopic curettage in our hospital during the same period were regarded as control group.Differences in the expression levels of miR-195 as well as TGF-β1/Smads and FGF2/FGFR1/ERK signaling pathway-related molecules in the focal tissues obtained by hysteroscopy were compared between the two groups.Pearson test was used to evaluate the correlation of miR-195 expression in the intrauterine adhesion tissues with TGF-β1/Smads and FGF2/FGFR1/ERK pathways in IUA patients.Results:miR-195 expression in intrauterine adhesion tissues of IUA group was higher than that in endometrial tissues of control group(P<0.05).TGF-β1,Smad2 and Smad3 mRNA expression in intrauterine adhesion tissues of IUA group were higher than those in endometrial tissues of control group;FGF2,FGFR1 and ERK mRNA expression in intrauterine adhesion tissues were higher than those in endometrial tissues of control group(P<0.05).Pearson test showed that the miR-195 expression in intrauterine adhesion tissues of IUA group was positively correlated with the TGF-β1/Smads pathway-related molecules TGF-β1,Smad2 and Smad3 mRNA expression,and positively correlated with the FGF2/FGFR1/ERK pathway-related molecules FGF2,FGFR1 and ERK mRNA expression(P<0.05).Conclusion:miR-195 is highly expressed in IUA lesion tissues and may promote disease progression by activating TGF-β1/Smads and FGF2/FGFR1/ERK signaling pathways.

Clinical Study of Changmaile II Combined with Estrogen and Progesterone in Preventing and Treating Intrauterine Adhesion

Purpose: To explore the clinical efficacy of Changmaile II combined with cyclic estrogen/progesterone therapy in treating hypomenorrhea caused by intrauterine adhesion (IUA) and its effect on the endometrium after the separation procedure for intrauterine adhesion. Methods: Sixty patients with IUA confirmed by hysteroscopy in the Second People’s Hospital of Fujian University of Traditional Chinese Medicine from March 2020 to December 2020 were selected and randomly divided into the control group and the observation group, with 30 cases in each group. After the separation procedure for intrauterine adhesion, the observation group underwent the cyclic estrogen/progesterone therapy alone, while the observation group was administered the in-hospital preparation of Changmaile II in addition to the therapy of the observation group. Menstrual recovery, endometrial thickness, and the diagnostic grading scores of IUA after 3 menstrual cycles were measured in both groups. Results: After the treatment for 3 menstrual cycles, the total effective rate was higher in the observation group (73.33%) than in the control group (53.33%) (P < 0.05). The period flow was heavier in the observation group than in the control group (P < 0.05). The endometrial thickness of both groups was thicker than before treatment (P < 0.05), nonetheless the difference between the groups was not statistically significant (P > 0.05). After treatment, the diagnostic grading scores of IUA were higher in the observation group than in the control group (P < 0.05). Conclusions: Changmaile II combined with estrogen and progesterone artificial cycle therapy could increase the menstrual volume and endometrial thickness of patients with intrauterine adhesion, while promoting the endometrial repair, with better efficacy than artificial cycle therapy alone.

Correlation of FoxF2 expression with MMPs, ADAMs and TGF-β1 pathway in intrauterine adhesions

Objective: To study the correlation of forkhead box F2 (FoxF2) expression with matrix metalloproteinases (MMPs), a disintegrin and metalloproteases (ADAMs), transforming growth factor-β1 (TGF-β1) pathway in intrauterine adhesions. Methods: The patients who underwent hysteroscopic surgery and were diagnosed with intrauterine adhesions according to postoperative pathology results in our hospital between March 2015 and January 2018 were selected as the IUA group, and the patients who underwent surgical resection and were diagnosed with uterine fibroid according to postoperative pathology results in our hospital during the same period were selected as the control group. The intrauterine adhesion tissues of the IUA group and the normal endometrial tissues of the control group were collected to measure the expression levels of FoxF2, MMPs and ADAMs-related molecules as well as TGF-β1 pathway molecules. Results: FoxF2, ADAM15, ADAM17, TIMP1, TGF-β1, Smad2, Smad3 and CTGF mRNA expression in the intrauterine adhesion tissues of IUA group were significantly higher than those of control group whereas MMP9 mRNA expression was significantly lower than that of control group;FoxF2 mRNA expression in the intrauterine adhesion tissues of IUA group was negatively correlated with MMP9 mRNA expression, and positively correlated with ADAM15, ADAM17, TIMP1, TGF-β1, Smad2, Smad3 and CTGF mRNA expression. Conclusion: The high expression of FoxF2 in intrauterine adhesions can inhibit protease activity and enhance TGF-β1 pathway function.

Correlation of the changes of TLR4/NF-κB pathway function in intrauterine adhesion tissue with the characteristics of cytokine secretion and collagen metabolism

Objective:To study the correlation of the changes of Toll-like receptor 4 (TLR4) / nuclear factorκB (NF-κB) pathway function in intrauterine adhesion (IUAs) tissue with the characteristics of cytokine secretion and collagen metabolism.Methods:The patients with IUAs who were treated in our hospital between February 2015 and March 2018 were selected as the IUAs group, and the patients who underwent hysteroscopy due to infertility and were pathologically confirmed to have normal endometrium during the same period were selected as the control group. The expression levels of TLR4/NF-κB pathway molecules and collagen metabolism genes as well as the contents of cytokines and collagen metabolism markers in the adhesion tissues of IUAs group and the normal endometrial tissue of control group were measured.Results: TLR4, NF-κB, a disintegrin and metalloproteinase 15 (ADAM15), ADAM17, matrix metalloproteinase 9 (MMP9) and plasminogen activator inhibitor 1 (PAI-1) mRNA expression as well as transforming growth factor-β1 (TGF-β1), Smad2/3, insulin-like growth factor 1 (IGF-1), IGF-1 receptor (IGF-1R), basic fibroblast growth factor (bFGF), periostin/osteoblast-specific factor 2 (Postn), type I collagen (Col-I) and actin-α (α-SMA) contents in the adhesion tissues of IUAs group were significantly higher than those of control group while urokinase-type plasminogen activator (uPA) mRNA expression was significantly lower than that of control group;TLR4 and NF-κB mRNA expression were positively correlated with TGF-β1, Smad2/3, IGF-1, IGF-1R, bFGF, Postn, Col-I,α-SMA, ADAM15, ADAM17, MMP9 and PAI-1, and negatively correlated with uPA.Conclusion:The excessive activation of TLR4/NF-κB pathway in IUAs is associated with the cytokine secretion and collagen metabolism abnormalities.

The Clinical Value of Ultrasound Image Texture Analysis in the Diagnosis of Uterine Adhesions

Purpose: This review examines the diagnostic value of transvaginal 3D ultrasound image texture analysis for the diagnosis of uterine adhesions. Materials and Methods: The total clinical data of 53 patients with uterine adhesions diagnosed by hysteroscopy and the imaging data of transvaginal three-dimensional ultrasound from the Second Affiliated Hospital of Chongqing Medical University from June 2022 to August 2023 were retrospectively analysed. Based on hysteroscopic surgical records, patients were divided into two independent groups: normal endometrium and uterine adhesion sites. The samples were divided into a training set and a test set, and the transvaginal 3D ultrasound was used to outline the region of interest (ROI) and extract texture features for normal endometrium and uterine adhesions based on hysteroscopic surgical recordings, the training set data were feature screened and modelled using lasso regression and cross-validation, and the diagnostic efficacy of the model was assessed by applying the subjects’ operating characteristic (ROC) curves. Results: For each group, 290 texture feature parameters were extracted and three higher values were screened out, and the area under the curve of the constructed ultrasonographic scoring model was 0.658 and 0.720 in the training and test sets, respectively. Conclusion Relative clinical value of transvaginal three-dimensional ultrasound image texture analysis for the diagnosis of uterine adhesions.

宫腔镜冷刀微剪分离术应用于重度IUA患者中的疗效及对其血清指标的影响

目的:分析宫腔镜冷刀微剪分离术应用于重度宫腔粘连(IUA)患者中的疗效及对其血清指标的影响。方法:采取便利抽样的方法选取2022年1月—2023年1月黄冈市黄州区人民医院妇产科收治的80例重度IUA患者作为研究对象,根据随机数表法将患者分为对照组与观察组,各40例。对照组予以宫腔镜电切手术,观察组予以宫腔镜冷刀微剪分离术,比较两组临床疗效、月经改善情况、子宫内膜动脉血流、子宫内膜厚度及血清指标。结果:观察组总有效率为95.0%,高于对照组的77.5%,差异有统计学意义(P<0.05);观察组月经恢复总有效率为90.0%,高于对照组的72.5%,差异有统计学意义(P<0.05);术后30 d、90 d,两组子宫内膜动脉血流与子宫内膜厚度较术前显著改善,两组术后90 d优于术后30 d,且观察组阻力指数(RI)、搏动指数(PI)低于对照组,而子宫内膜厚度高于对照组,差异有统计学意义(P<0.05);术后30 d、90 d,两组血清指标较术前显著改善,两组术后90 d优于术后30 d,且观察组血清转化生长因子-β_(1)(TGF-β_(1))、白细胞介素-6(IL-6)及纤溶酶原激活物抑制因子-1(PAI-1)水平均低于对照组,而基质金属蛋白酶-9(MMP-9)水平高于对照组,差异有统计学意义(P<0.05)。结论:宫腔镜冷刀微剪分离术应用于重度IUA患者可取得显著效果,不仅能提升临床疗效及月经改善效果,还能促进子宫内膜动脉血流与子宫内膜厚度恢复,有效改善血清指标。

Effect of autologous bone marrow stem cells-scaffold transplantation on the ongoing pregnancy rate in intrauterine adhesion women:a randomized,controlled trial

Intrauterine adhesion is a major cause of female reproductive disorders.Although we and others uncontrolled pilot studies showed that treatment with autologous bone marrow stem cells made a few patients with severe intrauterine adhesion obtain live birth,no large sample randomized controlled studies on this therapeutic strategy in such patients have been reported so far.To verify if the therapy of autologous bone marrow stem cells-scaffold is superior to traditional treatment in moderate to severe intrauterine adhesion patients in increasing their ongoing pregnancy rate,we conducted this randomized controlled clinical trial.Totally 195 participants with moderate to severe intrauterine adhesion were screened and 152 of them were randomly assigned in a 1:1 ratio to either group with autologous bone marrow stem cells-scaffold plus Foley balloon catheter or group with only Foley balloon catheter(control group)from February 2016 to January 2020.The per-protocol analysis included 140 participants:72 in bone marrow stem cells-scaffold group and 68 in control group.The ongoing pregnancy occurred in 45/72(62.5%)participants in the bone marrow stem cells-scaffold group which was significantly higher than that in the control group(28/68,41.2%)(RR=1.52,95%CI 1.08–2.12,P=0.012).The situation was similar in live birth rate(bone marrow stem cells-scaffold group 56.9%(41/72)vs.control group 38.2%(26/68),RR=1.49,95%CI 1.04–2.14,P=0.027).Compared with control group,participants in bone marrow stem cells-scaffold group showed more menstrual blood volume in the 3rd and 6th cycles and maximal endometrial thickness in the 6th cycle after hysteroscopic adhesiolysis.The incidence of mild placenta accrete was increased in bone marrow stem cells-scaffold group and no severe adverse effects were observed.In conclusion,transplantation of bone marrow stem cells-scaffold into uterine cavities of the participants with moderate to severe intrauterine adhesion increased their ongoing pregnancy and live birth rates,and this therapy was relatively safe.

HAMSCs移植联合G-CSF有效修复IUA大鼠子宫内膜损伤并抑制其纤维化

目的探讨人羊膜间充质干细胞(HAMSCs)联合粒细胞集落刺激因子(G-CSF)对宫腔粘连(IUA)大鼠子宫内膜损伤后的修复及纤维化抑制的影响。方法酶消化法提取HAMSCs体外培养,取P3代细胞通过生长特征、免疫荧光鉴定表面标记分子和三系分化能力进行鉴定。32只动情期SD大鼠随机均分为IUA组、HAMSCs组、G-CSF和H+G组。乙醚麻醉后行背部开口,IUA组从近卵巢端向左侧子宫腔内注射1 mL无水乙醇作用90 s,1 mL生理盐水冲刷子宫2次,右侧子宫注射等体积生理盐水作为假手术自身对照(Sham对照)。在造模后第7天和第10天进行2次治疗,每次注射体积均为0.2 mL。其中IUA组注射PBS,HAMSCs组宫腔灌注含1×106个细胞的PBS;G-CSF组灌注含20μg G-CSF的PBS;H+G组则在G-CSF灌注后再行HAMSCs灌注。各组大鼠在第2次治疗结束7 d后处死取子宫角备用。HE、Masson染色法检测各组大鼠子宫内膜的修复情况;qRT-PCR和免疫组化法检测各组大鼠子宫中TGF-β1、SMAD3、SMAD7、β-catenin、孕酮受体(PR)及雌激素受体(ER)的表达情况;另取32只大鼠同样分组造模后与正常雄鼠交配,计算其怀孕率和胚胎数。结果所获细胞经生长特性、细胞表面分子和分化能力的鉴定符合MSCs特征。IUA组大鼠子宫出现水肿、充血等现象,其余各组大鼠子宫形态均在一定程度上得以恢复,子宫内膜厚度和腺体数目从高到低依次为Sham对照、H+G组、HAMSCs组、G-CSF组、IUA组。Masson染色结果显示,在纤维化面积占整个子宫内膜面积的比例上,从高到低依次为IUA组、G-CSF组、HAMSCs组、H+G组、Sham对照。qRT-PCR结果显示,Sham对照TGF-β1、SMAD3和β-catenin mRNA最低,在IUA组中表达最高(P<0.05)。与IUA组相比,HAMSCs、G-CSF和H+G处理不同程度降低TGF-β1、SMAD3和β-catenin mRNA表达,尤其H+G组的表达水平接近于Sham对照水平(P<0.05)。SMAD7、PR和ER mRNA的表达趋势则与TGF-β1、SMAD3、β-catenin相反(P<0.05)。免疫组化结果显示,与IUA组相比,HAMSCs、G-CSF和H+G处理可以降低TGF-β1、SMAD3和β-catenin表达而升高SMAD7、PR和ER表达(P<0.05)。怀孕率和胚胎数计数结果显示,IUA组怀孕率为0,HAMSCs、G-CSF、H+G可以提高怀孕率和胚胎数(P<0.05)。结论HAMSCs移植及G-CSF宫腔灌注可能通过TGF-β1/SMAD3/β-catenin信号促进IUA大鼠子宫内膜损伤后的修复并抑制其纤维化,并且H+G处理的治疗效果优于单一的HAMSCs和单一G-CSF处理。

羊膜细胞外基质与膀胱细胞外基质材料修复大鼠子宫内膜损伤

背景:大量研究已证实,羊膜细胞外基质与膀胱细胞外基质材料均可作为干细胞载体用于子宫内膜损伤的治疗,但是有关两种材料的比较研究相对少见。目的:对比羊膜细胞外基质与膀胱细胞外基质材料作为干细胞载体治疗子宫内膜损伤的差异。方法:采用全骨髓贴壁法分离纯化SD大鼠骨髓间充质干细胞。分别制备SD大鼠羊膜细胞外基质与膀胱细胞外基质材料,然后将骨髓间充质干细胞分别接种于两种材料表面,检测细胞增殖与黏附情况。将40只SD大鼠随机分为4组(n=10),除假手术组外,子宫内膜损伤组、羊膜细胞外基质组、膀胱细胞外基质组均通过机械干预的方式建立子宫内膜损伤模型,分别将羊膜细胞外基质/骨髓间充质干细胞复合物、膀胱基质细胞外基质/骨髓间充质干细胞复合物移植至羊膜细胞外基质组、膀胱细胞外基质组大鼠损伤内膜部位,移植后14,28 d取材检测,苏木精-伊红染色观察大鼠子宫内膜组织形态,酶联免疫吸附法分析子宫内膜组织中碱性成纤维细胞生长因子、胰岛素样生长因子1与血管内皮生长因子水平,免疫组化染色分析子宫内膜组织中波形蛋白与CD34表达。结果与结论:(1)两种细胞外基质材料均有利骨髓间充质干细胞的增殖,相较于膀胱细胞外基质材料,羊膜细胞外基质材料可促进骨髓间充质干细胞的黏附;(2)相较于假手术组,子宫内膜损伤组碱性成纤维细胞生长因子、胰岛素样生长因子1与血管内皮生长因子水平降低(P <0.01),子宫内膜组织形态发育不良,内膜厚度与腺体数量减少,波形蛋白与CD34阳性表达减少(P <0.01);相较于子宫内膜损伤组,羊膜细胞外基质组、膀胱细胞外基质组碱性成纤维细胞生长因子、胰岛素样生长因子1与血管内皮生长因子水平均升高(P <0.05或P <0.01),子宫内膜组织形态明显改善,内膜厚度与腺体数量增加,波形蛋白与CD34阳性表达增加(P <0.05或P <0.01),并且羊膜细胞外基质组的改善作用优于膀胱细胞外基质组(P <0.05);(3)结果表明,相较于膀胱细胞外基质材料,羊膜细胞外基质材料作为骨髓间充质干细胞的载体可进一步促进损伤子宫内膜的修复。

聚己内酯-透明质酸静电纺丝膜联合间充质干细胞修复子宫内膜损伤

背景:人子宫内膜间充质干细胞能够直接修复受损的子宫内膜,促进血管生成、恢复子宫形态结构,然而将干细胞直接注入受损子宫内膜后的细胞存活率低、滞留时间短,修复效果有限。目的:观察聚己内酯-透明质酸静电纺丝膜复合人子宫内膜间充质干细胞修复大鼠子宫内膜损伤的效果。方法:①细胞实验:采用胶原酶消化法提取人子宫内膜间充质干细胞,静电纺丝技术制备聚己内酯-透明质酸静电纺丝膜。将人子宫内膜间充质干细胞分别接种于聚苯乙烯培养板与聚己内酯-透明质酸静电纺丝膜上,通过DNA定量分析、WST-1细胞活性实验、鬼笔环肽染色、扫描电镜观察细胞的增殖与黏附能力,qRT-PCR检测静电纺丝膜上细胞CD90、Meflin的mRNA表达。②动物实验:取27只处于动情期的雌性SD大鼠,通过机械搔刮法建立宫腔粘连模型后随机分为3组,每组9只:空白对照组不进行任何治疗,对照组将聚己内酯-透明质酸静电纺丝膜植入宫腔损伤部位,实验组将聚己内酯-透明质酸静电纺丝膜/人子宫内膜间充质干细胞补片植入宫腔损伤部位。术后第3,7,14天取材,采用苏木精-伊红染色观察子宫形态结构及腺体数量,qRT-PCR和免疫荧光染色观察子宫组织CD31、血管内皮生长因子的表达。结果与结论:①细胞实验:与聚苯乙烯培养板相比,聚己内酯-透明质酸静电纺丝膜可促进人子宫内膜间充质干细胞的增殖与黏附,并且聚己内酯-透明质酸静电纺丝膜支持人子宫内膜间充质干细胞基因CD90和Meflin的表达;②动物实验:苏木精-伊红染色显示,聚己内酯-透明质酸静电纺丝膜/人子宫内膜间充质干细胞补片可促进子宫内膜损伤后形态结构的恢复,术后第14天的内膜厚度与腺体数量均多于空白对照组、对照组(P<0.05);qRT-PCR和免疫荧光染色检测显示,实验组术后第7,14天的CD31、血管内皮生长因子mRNA与蛋白表达均高于空白对照组、对照组(P<0.05);③结果表明:聚己内酯-透明质酸静电纺丝膜可以提高干细胞的存活率、延长干细胞与受损组织的接触时间,二者复合移植可更好地修复受损子宫内膜组织。

滋肾化瘀汤在IUA治疗中的效果及对SOCS3和ER表达的影响

目的探讨滋肾化瘀汤应用在子宫宫腔手术后腔内粘连(IUA)的临床疗效以及对细胞因子信号转导抑制因子3(SOCS3)及雌激素受体(ER)表达的影响。方法行宫腔操作的64例患者根据入院顺序随机分为试验组和对照组,每组32例,对照组采用口服雌激素预防宫腔粘连,试验组采用滋肾化瘀汤预防宫腔粘连,由同一中医师随访2组患者治疗前后中医证候改善情况,治疗后子宫内膜厚度,比较宫腔镜查看粘连分度、例数及总的发生率,应用免疫组化的方法检测2组患者的宫腔粘连组织中SOCS3和ER的表达状况。结果治疗后,试验组患者的中医证候改善、月经恢复、子宫内膜厚度、宫腔再发粘连等与对照组比较,差异有统计学意义(P<0.05);试验组患者的SOCS3和ER的表达明显低于对照组,差异有统计学意义(P<0.05)。结论滋肾化瘀汤在预防宫腔术后腔内粘连、促进子宫内膜功能恢复、抑制SOCS3和ER的表达等等各个方面具有明显的优势,值得临床应用。

Advanced Role of Hippo Signaling in Endometrial Fibrosis： Implications for Intrauterine Adhesion

Objective： Intrauterine adhesion （IUA） is a major health problem that causes infertility, menstrual irregularities, and recurrent pregnancy losses in women. Unfortunately, treatments for IUA are limited, and there are currently no effective strategies for preventing IUA recurrence. In this review, we introduced the role of Hippo signaling in the normal endometrium and IUA and described the mechanisms by which the Hippo pathway integrates with the Wnt and transforming growth factor-β （TGF-β） signaling pathways to form an intricate network governing the development of fibrosis. Data Sources： Original research articles in English that were published until July 2017 were collected from the PubMed database. Study Selection： Literature search was conducted using the search terms ＂endometrial fibrosis OR fibrosis AND or OR intrauterine adhesion OR Asherman syndrome OR IUA,＂ ＂Hippo AND or OR Hippo/TAZ,＂ ＂TGF-β,＂ and ＂Wnt.＂ Related original research articles were included in the comprehensive analysis. Results： Endometrial fibrosis is recognized as a key pathological event in the development of IUA, which is characterized by epithelial/fibroblast-myofibroblast transition. Myofibroblasts play crucial roles in the pathogenesis of fibrous scarring, and myofibroblast differentiation can be triggered by multiple signaling pathways. H ippo signaling is a critical regulator of the epithelial/fibroblast-myofibroblast transition and α-smooth muscle actin, which exhibits a specific spatiotemporal expression in the endometrium. Conclusions： Hippo signaling plays a critical role in fibrous diseases and participates in cross talks with Wnt and TGF-β signaling. Our findings not only contributed to knowledge on the pathogenesis of endometrial fibrosis, but can also serve as a useful resource for developing specific molecular inhibitors for IUA treatment and prevention.

Engineering self-healing adhesive hydrogels with antioxidant properties for intrauterine adhesion prevention

Intrauterine adhesion (IUA) is the fibrosis within the uterine cavity. It is the second most common cause of female infertility, significantly affecting women’s physical and mental health. Current treatment strategies fail to provide a satisfactory therapeutic outcome for IUA patients, leaving an enormous challenge for reproductive science. A self-healing adhesive hydrogel with antioxidant properties will be highly helpful in IUA prevention. In this work, we prepare a series of self-healing hydrogels (P10G15, P10G20, and P10G25) with antioxidant and adhesive properties. Those hydrogels exhibit good self-healing properties and can adapt themselves to different structures. They possess good injectability and fit the shape of the human uterus. Moreover, the hydrogels exhibit good tissue adhesiveness, which is desirable for stable retention and therapeutic efficacy. The in vitro experiments using P10G20 show that the adhesive effectively scavenges ABTS+, DPPH, and hydroxyl radicals, rescuing cells from oxidative stress. In addition, P10G20 offers good hemocompatibility and in vitro and in vivo biocompatibility. Furthermore, P10G20 lowers down the in vivo oxidative stress and prevents IUA with less fibrotic tissue and better endometrial regeneration in the animal model. It can effectively downregulate fibrosis-related transforming growth factor beta 1 (TGF-β1) and vascular endothelial growth factor (VEGF). Altogether, these adhesives may be a good alternative for the clinical treatment of intrauterine adhesion.

The study on the safety and efficacy of amnion graft for preventing the recurrence of moderate to severe intrauterine adhesions

Transcervical resection of adhesion(TCRA)is the standard treatment for the intrauterine adhesions,but the recurrence of adhesions is a tough problem for the gynecologist.In addition,the therapeutic strategy after TCRA about prevention of recurrence remains controversial especially for the patients with moderate to severe intrauterine adhesions(IUAs).Hence,we designed this study to explore the safety and efficacy of fresh amnion grafts for preventing the recurrence after TCRA for patients with moderate to severe IUAs.One hundred patients with moderate to severe IUAs who presented with a history of hypomenorrhea,amenorrhea and infertility were included in the study from January 2015 to December 2017.Patients were divided into amnion group(52 patients)and chitosan group(48 patients).Fresh amnion grafts or intrauterine injections of chitosan were administered after TCRA.Transvaginal ultrasonography(TVUS)and hysteroscopy were performed at the first and third month after the operation.The surgical procedures for all patients were completed successfully without relevant complications.In amnion group,8 patients exhibited relapse in the first month and 2 patients in three months after surgery;in chitosan group,23 women exhibited relapse in the first month and 18 patients in three months after surgery.Statistical analysis revealed that the recurrence rate of adhesion in amnion group was significantly lower than those of chitosan group in the first and three months after surgery(P1=0.000,P2=0.000).After TCRA,fresh amnion graft plays a significant role in preventing further adhesions than injections of chitosan.

In situ delivery of apoptotic bodies derived from mesenchymal stem cells via a hyaluronic acid hydrogel:A therapy for intrauterine adhesions

Stem cell-based and stem cell-derived exosome-based therapies have shown promising potential for endometrial regeneration and the clinical treatment of intrauterine adhesions(IUAs).Evidence shows that apoptosis occurs in a majority of grafted stem cells,and apoptotic bodies(ABs)play a critical role in compensatory tissue regeneration.However,the therapeutic potential of AB-based therapy and its mechanism have not been explored in detail.Here,a cell-free therapeutic strategy was developed by incorporating mesenchymal stem cell-derived ABs into a hyaluronic acid(HA)hydrogel to achieve endometrial regeneration and fertility restoration.Specifically,we found that the ABs could induce macrophage immunomodulation,cell proliferation,and angiogenesis in vitro.The HA hydrogel promoted the retention of ABs and facilitated their continuous release.In a murine model of acute endometrial damage and a rat model of IUAs,in situ injection of the AB-laden HA hydrogel could efficiently reduce fibrosis and promote endometrial regeneration,resulting in the fertility restoration.Consequently,ABs show good potential as therapeutic vesicles,and the AB-laden HA hydrogel appears to be a clinically feasible and cell-free alternative for endometrial regeneration and IUA treatment.