Endometrial Disruption Research Articles

Predicting risk of endometrial failure: a biomarker signature that identifies a novel disruption independent of endometrial timing in patients undergoing hormonal replacement cycles

To propose a new gene expression signature that identifies endometrial disruptions independent of endometrial luteal phase timing and predicts if patients are at risk of endometrial failure. Multicentric, prospective study. Reproductive medicine research department in a public hospital affiliated with private fertility clinics and a reproductive genetics laboratory. Caucasian women (n = 281; 39.4 ± 4.8 years old with a body mass index of 22.9 ± 3.5 kg/m2) undergoing hormone replacement therapy between July 2018 and July 2021. Endometrial samples from 217 patients met RNA quality criteria for signature discovery and analysis. Endometrial biopsies collected in the mid-secretory phase. Endometrial luteal phase timing-corrected expression of 404 genes and reproductive outcomes of the first single embryo transfer (SET) after biopsy collection to identify prognostic biomarkers of endometrial failure. Removal of endometrial timing variation from gene expression data allowed patients to be stratified into poor (n = 137) or good (n = 49) endometrial prognosis groups on the basis of their clinical and transcriptomic profiles. Significant differences were found between endometrial prognosis groups in terms of reproductive rates: pregnancy (44.6% vs. 79.6%), live birth (25.6% vs. 77.6%), clinical miscarriage (22.2% vs. 2.6%), and biochemical miscarriage (20.4% vs. 0%). The relative risk of endometrial failure for patients predicted as a poor endometrial prognosis was 3.3 times higher than those with a good prognosis. The differences in gene expression between both profiles were proposed as a biomarker, coined the endometrial failure risk (EFR) signature. Poor prognosis profiles were characterized by 59 upregulated and 63 downregulated genes mainly involved in regulation (17.0%), metabolism (8.4%), immune response, and inflammation (7.8%). This EFR signature had a median accuracy of 0.92 (min = 0.88, max = 0.94), median sensitivity of 0.96 (min = 0.91, max = 0.98), and median specificity of 0.84 (min = 0.77, max = 0.88), positioning itself as a promising biomarker for endometrial evaluation. The EFR signature revealed a novel endometrial disruption, independent of endometrial luteal phase timing, present in 73.7% of patients. This EFR signature stratified patients into 2 significantly distinct and clinically relevant prognosis profiles providing opportunities for personalized therapy. Nevertheless, further validations are needed before implementing this gene signature as an artificial intelligence (AI)-based tool to reduce the risk of patients experiencing endometrial failure.

Mechanisms of Regeneration and Fibrosis in the Endometrium.

The uterine lining (endometrium) regenerates repeatedly over the life span as part of its normal physiology. Substantial portions of the endometrium are shed during childbirth (parturition) and, in some species, menstruation, but the tissue is rapidly rebuilt without scarring, rendering it a powerful model of regeneration in mammals. Nonetheless, following some assaults, including medical procedures and infections, the endometrium fails to regenerate and instead forms scars that may interfere with normal endometrial function and contribute to infertility. Thus, the endometrium provides an exceptional platform to answer a central question of regenerative medicine: Why do some systems regenerate while others scar? Here, we review our current understanding of diverse endometrial disruption events in humans, nonhuman primates, and rodents, and the associated mechanisms of regenerative success and failure. Elucidating the determinants of these disparate repair processes promises insights into fundamental mechanisms of mammalian regeneration with substantial implications for reproductive health.

P-521 A gene expression risk signature of endometrial failure for prognosis in In Vitro Fertilization (IVF) patients

Abstract Study question It is possible to identify a characteristic pattern of endometrial gene expression indicative of implantation failure, which is independent of implantation window displacements? Summary answer An endometrial transcriptomic signature was able to identify patients with a > 3-fold increased risk of implantation/pregnancy failure with 95% accuracy. What is known already Implantation failure of endometrial origin is a complex and multifactorial symptom with diverse causes, diagnosed in IVF patients after repeated failures with good quality embryos. A generation of gene expression tools have assumed that Window of implantation (WOI) displacement is the principal cause of this condition, but strategies seeking to counteract this problem by adjusting the day of embryo transfer have not yielded convincing improvements in outcomes. However, it is conceivable that other forms of endometrial disruptions, relevant to embryo implantation, could exist. New endometrial diagnostic strategies are needed to understand, diagnose and potentially treat patients affected with such problems. Study design, size, duration A prospective multicenter study between January 2018 and December 2021 recruited 281 Caucasian IVF patients (mean age of 39.4±4.8 years and BMI of 22.9±3.5 kg/m2) undergoing hormone replacement therapy and encompassing 114.5±7.2 h of progesterone administration at time of endometrial biopsy. Following experimental quality controls and clinical follow up, 186 patients who had a good quality embryo transferred in the cycle after endometrial biopsy collection were included for gene discovery and prediction performance. Participants/materials, setting, methods The expression of 404 genes selected for their potential to distinguish endometrial timing and/or endometrial disruption was measured. Transcriptomic variation related to progression of the menstrual cycle was removed using transcriptomic endometrial dating (TED) and linear models. Study groups were established according to clinical and gene expression parameters through a semi-supervised artificial intelligence procedure. Gene signature discovery and a cross-validation processes were undertaken to define predictive expression patterns. Reproductive outcomes were compared between prognosis profiles. Main results and the role of chance We developed a procedure called Clinically Acute Transcriptomic Stratification (CATranS), combining clinical parameters and deep transcriptomic molecular characterisation to stratify patients according to endometrial prognosis: ‘poor’ (n = 137) or ‘good’ (n = 49). These two transcriptomic profiles were associated with differing reproductive outcomes in the single embryo transfer following biopsy: pregnancy rate (45.1% vs 79.6%, poor vs good prognosis, respectively, p = 3.8E-5); live birth rate (56.4% vs 97.5%, p = 3.0E-06); clinical miscarriage rate (27.9% vs 2.6%, p = 0.0020); biochemical pregnancy rate (20.4% vs 0%, p = 0.0023). Patients with a poor prognosis profile had 3.3-times higher relative risk of a transferred embryo failing to implant or a pregnancy not being sustained to term, compared with good prognosis patients. Initially, a reference dataset was used to build a prototype for diagnosing endometrial failure, revealing that a gene expression signature consisting of 135 genes was the most predictive. Prediction performance was estimated using a 5-fold 100-times cross-validation process, resulting in a median accuracy of 0.92, median sensitivity of 0.96, and median specificity of 0.84. From these 135 predictive genes, 122 were differentially expressed (FDR<0.05) in endometrial poor prognosis, 59 up- and 63 down-regulated, most involved in functional processes such as regulation (17%), metabolism (8.4%), immune response and inflammation (7.8%). Limitations, reasons for caution We describe a potential new strategy for evaluating endometrial competence. However, to confirm predictive value, validation using additional samples from patients independent of signature discovery set is required. Further research to identify potential treatments for patients classified as poor prognosis is needed, providing a tailored clinical pathway for these patients. Wider implications of the findings The prototype described is a novel concept, potentially leading to development of a new generation of tools for diagnosis of fertility problems related to endometrial factors. The ‘poor’ prognosis profile is not caused by asynchronies in menstrual cycle progression, opening the possibility of finding new treatment pathways for these patients. Trial registration number NA

P-298 The live birth rate of the endometriosis patient is significantly increased by high luteal phase serum progesterone in HRT-FET cycles - A cohort study

Abstract Study question What is the optimal serum progesterone (P4) cut-off level for endometriosis patients undergoing hormone replacement therapy frozen embryo transfer (HRT-FET) with intensive exogenous progesterone luteal phase support? Summary answer Endometriosis patients with luteal serum P4 levels≥118nmol/l had significantly higher live birth rates (LBR) compared to patients with lower P4 levels. What is known already A low luteal serum P4 level decreases the reproductive outcome of HRT-FET cycles in the “standard” patient, and an optimal cut-off level of 10ng/ml has been suggested. Interestingly, some studies reported a negative impact of too high serum P4 levels during HRT-FET. The pathology of endometriosis is dominated by an endometrial disruption of progesterone and oestrogen signalling pathways. This results in intra-endometrial oestrogen dominance, and leads to progesterone resistance which negatively impacts endometrial receptivity and function. Until now no study explored the optimal serum P4 level in the endometriosis patient undergoing HRT-FET. Study design, size, duration A cohort study including 262 HRT-FET cycles in 179 patients, undergoing transfer of warmed blastocysts, deriving from freeze all cycles from January 2016 to august 2019. Participants/materials, setting, methods Patients were diagnosed with endometriosis either by laparoscopy or by ultrasound in cases with visible endometriomas. Pre-treatment consisted of 42 days of oral contraceptive pill and 5 days' wash-out, followed by 6 mg oral oestrogen daily. Intensive exogenous progesterone supplementation, including vaginal progesterone gel 90mg/12h commenced when the endometrium was ≥7mm. From the 4th day of progesterone patients also received intramuscular progesterone 50mg. Blastocyst transfer was scheduled for the 6th day of progesterone. Main results and the role of chance The mean P4 level was 103.1 ±44.4nmol/l and the overall positive HCG, live birth (LBR) and total pregnancy loss rates (TPLR) were 60%, 39% and 34%, respectively. The optimal serum P4 cut-off level was 118nmol/l defined as the maximum of the Youden index. No significant differences were seen between patients above or below 118nmol/l as regards age, BMI, fertilisation method or blastocyst score. In a total of 33% of cycles (86/262) the P4 level was ≥118nmol/l, and the unadjusted LBR was significantly higher in the high P4 group 51% (44/86) versus 34% (59/176) (p = 0.006) in the low P4 group. Furthermore, a non-significant difference in TPLR was found: 41% vs 25 % in favour of high P4 (p = 0.066). A logistic regression analysis showed that patients with P4 levels ≥118nmol/l were more likely to achieve a live birth compared to patients with P4 levels <118nmol/l; (odds ratio 2.1 [95% confidence interval 1.2 - 3.7] after adjusting for age, BMI, blastocyst score, blastocyst age (day 5 or day 6) and number of blastocysts transferred. Limitations, reasons for caution Cohort study with data prospectively registered and retrospectively analyzed. The estimated serum cut-off for P4 of 118nmol/l is valid for vaginal progesterone gel 90mg/12h and intramuscular progesterone 50mg from the 4th progesterone day; whether the cut-off is applicable for other progesterone regimens needs to be explored. Wider implications of the findings The optimal luteal P4 level of the endometriosis patient undergoing HRT-FET is significantly higher than that estimated for the "standard" patient due to endometrial progesterone resistance. Luteal phase P4 monitoring is mandatory to obtain the highest LBR in the endometriosis patient undergoing HRT-FET. Trial registration number 1-10-72-4-17

Minimally invasive abdominal curettage for an intramural twin pregnancy: a new twist to the traditional D&C

Less than 1% of ectopic pregnancies are intramural and are located within the myometrium without connection to the fallopian tubes or endometrial cavity. Known risk factors include prior hysterotomy, uterine instrumentation, and myometrial pathology such as adenomyosis. The timely diagnosis and treatment of intramural pregnancies is important to reduce patient morbidity. This video demonstrates the laparoscopic removal of a twin intramural pregnancy in a 32-year-old primiparous patient with a history of myomectomy eight months prior to presentation. Two gestational sacs were visualized in the right fundal myometrium surrounded by only 4-6 millimeters of myometrial tissue. One sac was empty and the other with a live embryo measuring eight weeks gestation with fetal cardiac activity. After extensive counseling, the patient desired to proceed with surgical intervention. To safely excise the pregnancy without inadvertent injury to the fallopian tubes, a reverse U-shaped incision was made with electrosurgery. Dilute vasopressin was utilized to minimize blood loss and hydro-dissection was performed to assist with myometrial separation from the gestational sac. Finally, sharp curettage was performed laparoscopically to remove any remaining products of conception from the myometrium. This unique approach to curettage laparoscopically decreases the risk of endometrial disruption and perforation of a fresh hysterotomy repair, rather than if performed vaginally. We repaired the myometrial defect in multiple layers with barbed suture to avoid uterine wall weakness, which can be associated with spontaneous uterine rupture in future pregnancy. In conclusion, this video demonstrates a minimally invasive approach to the surgical treatment of an intramural pregnancy with laparoscopic resection and curettage.

Endometrial disruption does not result in a reduced endometrial thickness or alter the proliferative pattern in a subsequent frozen embryo transfer cycle

Endometrial disruption does not result in a reduced endometrial thickness or alter the proliferative pattern in a subsequent frozen embryo transfer cycle

Endometrial disruption does not improve implantation in patients who have failed the transfer of euploid blastocysts.

PurposeTo assess the impact of single pass outpatient endometrial biopsy in patients at the highest risk for an endometrial cause for failed implantation; those that have failed to conceive despite the transfer of morphologically normal euploid embryos.MethodsThis is a retrospective cohort study consisting of all patients less than 42 years old who failed their first euploid blastocyst transfer and subsequently completed a second transfer cycle of euploid blastocysts. Cycles were analyzed to determine if a single pass endometrial biopsy, termed 'endometrial disruption', was performed in a cycle preceding their second embryo transfer. Transfer outcomes were analyzed and implantation rates calculated. Data analysis was performed to compare outcomes between patients who had endometrial disruption performed versus those that did not.ResultsTwo hundred ninety patients failed their first euploid embryo transfer and subsequently completed a second euploid embryo transfer and were included. Thirty-nine patients underwent endometrial disruption and 251 did not. There were no statistical differences in clinical implantation rate or sustained implantation rate between the group with endometrial disruption and subjects without any intervention (Clinical IR, 43.6 % vs. 55.0 %, p = 0.13; 38.5 % vs. 42.6 %, p = 0.60). When controlling for transfer order there was no statistical difference noted in implantation rates.ConclusionsSingle pass endometrial biopsy has no impact on endometrial receptivity in the highest risk subgroup- patient's that have failed to sustain the transfer of morphologically normal euploid embryos- as evidenced by equivalent implantation rates. It is possible that variations in technique may alter outcomes and randomized trials are needed to answer this question.

Endometrial disruption (EDrpt) does not improve endometrial receptivity in IVF: evaluation of clinical and sustained implantation rates (IR) following the transfer of euploid blastocysts

Disrupting the endometrium prior to embryo transfer has been associated with higher implantation rates. While initial studies have been encouraging, none has specifically evaluated patients at risk for impaired endometrial receptivity –i.e. those who fail to sustain implantation in spite of having optimal embryos (morphologically normal euploid blastocysts) transferred. This study seeks to investigate the relationship between endometrial disruption in this group at high risk for impaired endometrial receptivity.

A novel outpatient endometrial biopsy biospy deviceto exclude endometrial cancer

Currently there is no consensus on the best device and technique for obtaining endometrial biopsies to exclude cancer. Outpatient methods available include aspiration devices (Pipelle) and disruption devices (Tao brush). We evaluated a new device which combines Global endometrial Disruption using a brush with a built in suction Process (GDP-Tao).

Novel approach to outpatient endometrial biopsy to detect endometrial cancer.

e16522 Background: Currently there is no consensus on the best device and technique for obtaining endometrial biopsies to rule out cancer. Outpatient methods available include aspiration devices (Pipelle) and disruption devices (Tao brush). This study evaluated a new device which combines Global endometrial Disruption using a brush with a built in suction Process (GDP-Tao). Methods: After IRB approval, endometrial specimens were collected using the GDP-Tao from fresh uteri after completion of hysterectomies. Endometrial pathology results from the new device were compared to the final hysterectomy diagnosis by blinded review. Results: Patients (n = 33) were 29-86 years old (median 56), 67% obese, 52% menopausal. Uterine sounds were 2.5-11cm (median 6.6 cm), weight 45-3500g (median 238g), 15% of cervical os were stenotic but all allowed the device to pass without other instrumentation with overall diagnostic rate of 91% (30/33) 15/15 pathologically confirmed malignant specimens were correctly identified by the new device including 2 GDP-Tao specimens with atypical hyperplasia (AH) and hysterectomy pathology with AH and focal adenocarcinoma. Classifying any atypia from the GDP-Tao as “positive” then the detection rate for malignancy was 100% (PPV). 11/11 samples were benign in GDP-Tao and final pathology. There were 3 non-diagnostic (ND) samples from GDP-Tao with final pathology of benign endometrium. One specimen was ND due to absence of tissue from prior endometrial ablation. There was one device result of “proliferative endometrium” with final pathology of focal complex atypical hyperplasia and one device result of “rare atypical cells” with final diagnosis of endometrial polyp. Sensitivity and specificity were 94% and 92%, and negative predictive value was 82% for the identification of both atypical hyperplasia and malignancy. When stratified by uterine size, benign or malignant, the results were similar. Conclusions: Our validation study showed encouraging data thatthis new endometrial sampling device, which combines tissue disruption and aspiration into a single process, provides a reliable mean of obtaining adequate sample to accurately detect endometrial cancer with a high negative and positive predictive value.

Effects of Embryo Transfer Catheters on the Endometrial Surface Noted at Hysteroscopy

Study ObjectiveTo assess the effects on the endometrial surface of embryo transfer catheters using hysteroscopy with ultrasound guidance. DesignProspective descriptive study (Canadian Task Force classification III). SettingUniversity-based clinical practice. PatientsTwenty patients with a documented difficult trial transfer (TT). InterventionAll patients underwent an intraoperative TT using an Edwards-Wallace catheter (n = 10), a Soft-Pass catheter with obturator (n = 2), or an Echosight Patton catheter with a coaxial wire (n = 8), with placement assured using ultrasound. This was followed by hysteroscopy and cervical surgical correction. Measurements and Main ResultsA 5-mm hysteroscope was used to visualize, assess, and document TT catheter placement and effects on the endometrial cavity. The Wallace catheter caused the least trauma (20%). The Soft-Pass catheter with obturator (100%) resulted in linear grooves in the endometrial surface. The most traumatic effects occurred with use of the coaxial catheter (38%), which caused shaving with petechial bleeding past the point of obstruction. In addition, 3 of the Wallace catheters were improperly placed (cannulation of tubal ostia, n = 2) and coiled back (n =1). ConclusionDespite ultrasound guidance, endometrial disruption and catheter displacement occurs with difficult embryo transfer catheter placement, which may suggest an explanation for lower pregnancy rates in these difficult cases. Greater attention to correction of cervical disease before an in vitro fertilization–embryo transfer cycle may improve clinical outcomes.

P-322: Partial introduction of the ET catheter into uterine cavity at the time of USG guided trial transfer improves ART outcome

In recent years use of Hysteroscopy offered a unique insight into the effects of Embryo Transfer on endometrial integrity and suggested that clinical perception of ease of transfer does not correlate well with the degree of endometrial disruption. Endometrial lesions caused by the ET catheters were directly visualized and documented on micro hysteroscopy. Some of these observed lesions appear to be capable of compromising the success of ET. We also know that microbial contamination at embryo transfer may influence implantation rates .

Assessment of endocervical and endometrial damage inflicted by embryo transfer trial: a hysteroscopic evaluation

The aim was to assess the endocervical and endometrial damage inflicted by embryo transfer trial using office hysteroscopy. Seventy-five consecutive infertile women who underwent office hysteroscopy were enrolled. Hysteroscopy was performed immediately after embryo transfer trial. The relationship between clinical perception of easiness of transfer, presence of blood on the catheter, degree of endocervical and endometrial damage was examined. In the difficult transfer group, minor and moderate endocervical lesions were noted in 35% and 24% of the cases, respectively. The respective figures for the easy transfer group were 19% and 3% (P > .05). There was a statistically significant concordance between the perceived difficulty of transfer and degree of endometrial damage ( P < 0.05). Of interest, in the easy transfer group, 32% of the patients had minor, 3% moderate and 65% no endometrial damage. The respective figures were 42%, 29% and 29% in the difficult transfer group. There was blood on the catheter in 25%, 56% and 71% of the easy, moderate and difficult transfer groups, respectively. There was a statistically significant concordance between the perceived difficulty of embryo transfer and presence of blood on the catheter ( P < 0.05). These results suggest that clinical perception of difficulty of transfer and the presence of blood on the catheter are directly associated with endometrial disruption.

Embryo transfer: hysteroscopic assessment of transfer catheter effects on the endometrium

So far as is known, this is the first series to report the effects of embryo transfers on endometrial integrity as assessed by direct hysteroscopic visualization. Subjects ( n = 30) were patients of reproductive age undergoing diagnostic hysteroscopy. A mock embryo transfer was performed by a single clinician, immediately followed by saline hysteroscopy using a 2.7 mm hysteroscope. Hegar dilators or uterine sounds were not used. Representative video clips were recorded for independent assessment of endometrial integrity. (The movie sequence may be purchased for viewing on the internet at www.rbmonline.com/Article/1040; it is free to web subscribers.) Outcomes measured were ease of transfer (easy, moderate, difficult, very difficult) and details of the transfer technique. Endometrial damage was independently assessed and graded as follows: none, minor, moderate or severe. Of the easy transfers, 54% showed no endometrial damage. However, there 37% showed moderate to severe damage in the easy transfer group. Of the moderately difficult transfers, there was no clear association between perceived difficulty of transfer and amount of endometrial damage. Clinical perception of ease of transfer does not correlate well with the degree of endometrial disruption ( P = 0.41). Use of hysteroscopy offers a unique insight into the effects of embryo transfer on endometrial integrity.

Diabetes-associated endometrial disruption in the Chinese hamster: structural changes in relation to progressive hyperglycemia.

The relationship between progressive diabetes and endometrial structure was examined in genetically diabetic Chinese hamsters. Uterine samples were collected from animals exhibiting prediabetic to overt diabetic conditions and from matched control animals. In controls (with blood glucose levels less than or equal to 145 mg/dl) the endometrium was typified by an intact luminal epithelium, a thin underlying basement membrane and a well-organized stroma layer. In contrast, mildly diabetic (150-250 mg/dl) animals exhibited a compressed luminal epithelium which was embedded in a thickened basement membrane infiltrated with phagocytic blood elements. The stromal layer contained several irregular cells which were characterized by cytoplasmic vacuolization and collagen fiber separation by an amyloid-like, intercellular ground substance. In overt diabetic animals (greater than or equal to 300-500 mg/dl), the luminal epithelial cells were located over a greatly thickened basement membranes which was infiltrated by phagocytic blood elements and degenerating stromal cell membranes. The lumens of the glands were closed and the stromal cells were separated by an increased intercellular space occupied by an amyloid-like ground substance. Many stromal cells exhibited cytoplasmic vacuolization. These studies demonstrate that uterine involution associated with diabetes occurs in a sequential manner and is temporally related to progressive elevations in blood glucose levels.

Diabetes-associated endometrial disruption in the ketonuric, diabetic Chinese hamster.

The effects of the ketonuric-diabetic (KD) condition on uterine endometrial morphology were studied in the genetically diabetic Chinese hamster. All KD hamsters were matched for age, body weight and cyclic state with nondiabetic control animals. All KD hamsters were reproductively acyclic as compared to controls. The uterine epithelium of KD hamsters was devoid of surface microvilli, secretory activity, and exhibited a height reduction as compared to controls. The basal lamina underlying the luminal epithelium was 2-5 times as thick in the KD condition than control. The endometrial stroma was disrupted in the KD hamsters, with the endometrium composed of rounded cells surrounded by a thickened intercellular matrix. This was in marked contrast to the stroma of controls which consisted of an orderly array of fibroblasts and collagen fibers. Stromal vessels had a thickened basement membrane in diabetic animals. The results of this study indicate that epithelial and stromal disruption are associated with the KD state in the Chinese hamster and are probably causally associated with reproductive failure.