Endometrial-myometrial Junction Research Articles

Functional, patient-derived 3D tri-culture models of the uterine wall in a microfluidic array.

Can a functional in vitro model, containing the main cellular components of the uterine wall, be generated from cells derived from patient tissues? We present a three-dimensional (3D) physiologically relevant, organ-on-a-chip model of the uterine wall containing primary endometrial and myometrial cellular participants, generated from human uterine tissue. As a highly dynamic reproductive organ, the human uterus plays fundamental physiological roles in menstruation and childbirth. The endometrial-myometrial junction (EMJ) defines the interface between the inner mucosal layer (endometrium) and outer smooth muscle zone (myometrium) that comprises the uterine wall. The EMJ is implicit in several uterine pathologies of unknown aetiology, including adenomyosis and abnormally invasive placenta; however, despite this, no patient-derived in vitro models of the uterine wall containing all EMJ participants currently exist. We employed microfluidic technology to characterize multiple miniaturized models of the uterine wall. Protocols were tested that included variations in the seeding order of endometrial and myometrial fractions, and the addition of a low viscosity extracellular matrix to influence cell behaviour. Ultimately, functional hormone responses of patient-derived uterine wall models were assessed. Endometrial (n = 9) and myometrial biopsies (n = 4) were enzymatically dissociated to create epithelial, stromal and myometrial cellular fractions. Cell suspensions were seeded into non-adhesive poly(dimethylsiloxane) microfluidic devices containing 5 × 5 microwell arrays. The fate of individual cell types was monitored in real-time using fluorescent tracers, and cell phenotype was characterized by immunocytochemistry. Model functionality was assessed by measuring Ca2+ responses to agonist stimulation, and both insulin-like growth factor binding protein 1 (IGFBP-1) and osteopontin secretion in response to hormone stimulation. When subjected to microfluidic culture in isolation, endometrial stromal cells and smooth muscle myocytes formed compact spheroids, whilst epithelial cells produced diffuse aggregates. Tri-cultures were established by sequential seeding of individual or combined cell fractions at various ratios. Regardless of the protocol, epithelial cells localized to the outer periphery of tri-culture spheroids, which varied in morphology across the protocols. Incorporation of 5% [v/v] Matrigel® improved the reproducibility of 3D aggregates which exhibited robust self-assembly of a stromal/smooth muscle core encased in epithelium. Exposure of tri-cultures to oestradiol, medroxyprogesterone acetate and cyclic adenosine monophosphate (cAMP) increased secretion of IGFBP-1, which indicates stromal decidualization, and enhanced epithelial cell osteopontin secretion. Stimulation with endothelin-1 induced Ca2+ signalling in myocytes. Endometrial and myometrial tissue was collected from relatively few donors. Myometrial tissue was collected from pregnant donors, which may have influenced the myocyte phenotype. Furthermore, endometrial tissue sampling was from women not having a hysterectomy, thus may not include the deeper basalis region, which may limit the physiological mimicry of the final models. Our novel approach to modelling the uterine wall in 3D captures all of the main cell types in a medium-throughput system, enabling the screening of hundreds of cultures in parallel from a single biopsy. This system shows great promise for examining the cellular interplay between physiological cues and EMJ pathologies, such as the impact of uterine peristalsis and cyclical hormones on the pathogenesis of adenomyosis. C.B. was supported by an Organ-on-a-Chip Technologies Network Pump Priming Project grant. C.J.H. was supported by a Wellbeing of Women project grant (RG2137), SRI/Bayer and Wellcome Trust IFFS3. D.K.H. was supported by a Wellbeing of Women project grant (RG2137) and MRC clinical research training fellowship (MR/V007238/1). M.Z. is Director and Co-Founder of ScreenIn3D Limited. The other authors declare no conflict of interest. N/A.

P-304 Quantitative analysis of uterine peristalsis using optical flow for motion quantification in women with moderate/severe adenomyosis undergoing frozen-thawed embryo transfer following prolonged downregulation with GnRHanalogue

Abstract Study question What is the impact of prolonged downregulation with GnRH analogue (GnRHa) on uterine peristalsis in women with moderate/severe adenomyosis undergoing frozen-thawed embryo transfer? Summary answer Women with moderate/severe adenomyosis have lower coordination of uterine peristalsis and myometrial contractility; prolonged downregulation with GnRHa appears to offer benefit. What is known already Adenomyosis can adversely reduce the chance of pregnancy in women undergoing assisted conception, with altered uterine peristalsis proposed as a mechanism. We aimed to i) develop an objective tool to quantify uterine peristalsis on transvaginal sonography(TVS) using an algorithm based on optical flow for wave motion quantification, ii) compare uterine peristalsis between women with a normal uterus and women with moderate/severe adenomyosis, iii) evaluate the impact of prolonged downregulation with GnRH analogue for 6 weeks vs 1 week on uterine peristalsis in women with moderate/severe adenomyosis undergoing frozen-thawed embryo transfer within the MODA RCT (Modified Downregulation for Adenomyosis). Study design, size, duration Prospective observational cohort study(July 2021–Jan 2024) in women with moderate/severe adenomyosis(n = 26) and a normal uterus(n = 40) having TVS during assisted conception. Participants/materials, setting, methods We included women with moderate/severe adenomyosis or a normal uterus undergoing assisted conception.TVS was performed at baseline(BL),day 6-10 of ovarian stimulation(OS) and day of embryo transfer(ET)by three observers(A/B/C)to assess inter-/intra-observer agreement. TVS recordings(n = 146) were stored offline for optical flow analysis using 3D Slicer(Ver. 4.11). Pixel-level displacements for points at endometrial-myometrial junction(EMJ)and myometrium were used to compute frequency(f) and amplitude(u) by fitting to the 2D-wave equation, fit error was taken as a measure of coordination. Main results and the role of chance We recruited 66 women with moderate/severe adenomyosis (n = 26) or a normal uterus (n = 40) undergoing assisted conception. Uterine peristalsis at the EMJ in women with adenomyosis showed a significantly poorer fit with the ideal wave equation and a significantly higher fit error compared to women with normal uterus at all time points (BL (+ 0.649), OS (+ 0.630), ET (+ 0.685) (n = 66, p<0.001), indicating lower coordination of uterine peristalsis in women with adenomyosis compared to women with a normal uterus. Fit error of myometrial contractility was also significantly lower in women with adenomyosis at all time points (BL (+ 0.656), OS (+ 0.510) and ET (+ 0.639) (n = 66, p < 0.001). There was no significant difference in wave amplitude or frequency in women with adenomyosis compared to women with a normal uterus (p > 0.06). Women with moderate/severe adenomyosis exposed to prolonged downregulation with GnRH analogue for 6 weeks had lower fit error of uterine peristalsis (UP) and myometrial contractility (MC) on the day of embryo transfer compared to women receiving 1 week GnRH analogue (UP ET(+0.615) (n = 19, p = 0.058) (MC ET(+4.28) (n = 19, p < 0.05). Inter- and intra-observer agreement was found to be moderate to substantial across all wave features(ICC 0.58-0.79). Limitations, reasons for caution There is a need to recruit a larger cohort of patients and correlate wave features with clinical outcomes to increase the robustness of the conclusions drawn in this study. Wider implications of the findings Our algorithm for wave motion quantification offers an objective,reproducible measuring tool to quantify uterine peristalsis with potential for wide clinical application.Women with adenomyosis have higher fit error and lower coordination of uterine peristalsis and myometrial contractility,which may account for their reduction in chances of conception.Prolonged GnRHa appears to offer benefit. Trial registration number N/A

P-277 Focal rather than diffuse nature of adenomyosis might be more detrimental to IVF outcomes after single euploid embryo transfer

Abstract Study question Is the nature of adenomyosis a factor to consider after a single euploid embryo transfer? Summary answer Focal adenomyosis was associated with lower live birth rate per transfer when compared to diffuse adenomyosis. What is known already Adenomyosis is widely described to hamper reproductive potential of women who suffer it. This uterine pathology has a detrimental impact on in vitro fertilization (IVF) clinical outcomes, as described by a series of recent metanalysis. Nevertheless, there is scarce evidence regarding clinical studies that address the impact of adenomyosis depending either on its diffuse or focal nature. Study design, size, duration A multicenter retrospective cohort study in which 229 patients undergoing IVF treatment were included. Patients with single embryo transfer (SET) in blastocyst stage after pregestational testing for aneuploidy (PGT-A) between years 2015 and May 2023 were divided into two groups: diffuse adenomyosis (n = 167) and focal adenomyosis (n = 62). Participants/materials, setting, methods Inclusion criteria consisted of patients in a PGT-A program who had a cryotransfer of a single euploid blastocyst-stage embryo. Patients were diagnosed within our facilities using transvaginal ultrasonography (TVUS) prior to their IVF cycle. Diffuse adenomyosis was diagnosed when irregular endometrial-myometrial junction, increased uterine volume, ill-defined myometrial heterogeneity, presence of anechoic round myometrial cysts, hyperechoic islands, fan-shaped shadows and/or echogenic subendometrial lines were detected. Focal adenomyosis was diagnosed when foci with adenomyotic characteristics were observed. Main results and the role of chance Clinical pregnancy rate per embryo transfer was 81/167 (48.5%) in those women diagnosed with diffuse adenomyosis versus 23/62 (37.1%) in the focal adenomyosis group (OR = 0.63 95% CI [0.33-1.18], NS). Differences found in clinical miscarriage rate were not statistically significant, being 33/81 (40.7%) for diffuse adenomyosis and 14/23 (60.1%) for the focal adenomyosis group (OR = 2.24 95% CI [0.79-6.63], NS). A lower live birth rate per euploid embryo transfer was observed in women diagnosed with focal adenomyosis, being 9/62 (14.5%) and 48/167 (28.7%) for women who presented diffuse adenomyosis (OR = 0.42 95% CI [0.17-0.95], p=0.027). There were no statistically significant differences between childbirth delivery method (vaginal versus caesarean section). Furthermore, means of gestational age at the time of delivery, newborn size and weight and incidences of low birth weight did not differ between the two groups. Limitations, reasons for caution The retrospective nature of this observational study implies that possible confounders cannot be completely excluded. Also, the accurate diagnostic of adenomyosis is not without complexity and although gynecologists were equally trained to identify direct and indirect markers, different criteria may have been used Wider implications of the findings To our knowledge this is the first study to use an euploid model to assess the impact of the focal versus diffuse nature of adenomyosis in IVF patients. This model permits to correct for numerous covariables attributed to patient’s age and embryo genetic constitution. Trial registration number Not applicable

Comprehensive transcriptional atlas of human adenomyosis deciphered by the integration of single-cell RNA-sequencing and spatial transcriptomics.

Adenomyosis is a poorly understood gynecological disorder lacking effective treatments. Controversy persists regarding "invagination" and "metaplasia" theories. The endometrial-myometrial junction (EMJ) connects the endometrium and myometrium and is important for diagnosing and classifying adenomyosis, but its in-depth study is just beginning. Using single-cell RNA sequencing and spatial profiling, we mapped transcriptional alterations across eutopic endometrium, lesions, and EMJ. Within lesions, we identified unique epithelial (LGR5+) and invasive stromal (PKIB+) subpopulations, along with WFDC1+ progenitor cells, supporting a complex interplay between "invagination" and "metaplasia" theories of pathogenesis. Further, we observed endothelial cell heterogeneity and abnormal angiogenic signaling involving vascular endothelial growth factor and angiopoietin pathways. Cell-cell communication differed markedly between ectopic and eutopic endometrium, with aberrant signaling in lesions involving pleiotrophin, TWEAK, and WNT cascades. This study reveals unique stem cell-like and invasive cell subpopulations within adenomyosis lesions identified, dysfunctional signaling, and EMJ abnormalities critical to developing precise diagnostic and therapeutic strategies.

Analysis of clinical data of different endometrial pathological types in perimenopausal women with abnormal uterine bleeding.

Early detection and diagnosis are important for improving the therapeutic effect and quality of life in patients with endometrial cancer (EC). This study aimed to analyze the clinical data of different endometrial pathological types in perimenopausal women with abnormal uterine bleeding (AUB) in order to provide evidence for the prevention and early diagnosis of EC. A total of 462 perimenopausal women with AUB were enrolled in this prospective observational study. Endometrial biopsy was performed in patients with suspected endometrial lesions. According to the pathological examination results, the patients were divided into endometrial polyp group (EP) (n = 71), endometrial hyperplasia without atypia group (EH) (n = 59), atypical endometrial hyperplasia (AEH) (n = 36), and EC group (n = 27). The history risk factors and ultrasonic imaging characteristics of endometrium among the four groups were compared. Twenty-seven women were diagnosed with EC (5.84%). The prevalence rate of AEH and EC in the group of 51- to 55-year-old women was significantly higher than that in the groups of 40- to 45-year-old women and of 46- to 50-year-old women (P < 0.05). The age, body mass index, and history of diabetes gradually increased with the development of endometrial pathological types. In addition, the correlation index of endometrial blood flow increased gradually, and the proportion of uneven endometrial echo, unclear endometrial-myometrial junction (EMJ), and ovarian cyst also increased gradually. However, no statistically significant difference was found when comparing endometrial thickness (ET) and endometrial volume (EV) among endometrial pathological groups (P > 0.05). The ET, EV, endometrial vascularization index, endometrial flow index, and vascularization flow index in the ovarian cyst group were significantly higher (P < 0.05), and the proportion of uneven endometrium echo and unclear EMJ were significantly higher compared with that in the non-ovarian cyst group (P < 0.05). The most common cause of perimenopausal women with AUB was benign endometrial lesions. However, women aged 51-55 years old with endometrial high risk factors and ovarian cyst should be alert to AEH and EC. Endometrial biopsy needs to be performed to determine endometrial malignancy in necessity.

Ultrasound-guided percutaneous microwave ablation for adenomyosis with abnormal uterine bleeding: clinical outcome and associated factors

Objective To investigate the factors affecting the efficacy of ultrasound (US)-guided percutaneous microwave ablation (PMWA) for adenomyosis with abnormal uterine bleeding (AUB-A). Methods Baseline data of patients with AUB-A who underwent US-guided PMWA treatment between October 2020 and October 2021, including demography characteristics, laboratory and imaging examination results were retrospectively analyzed. 3D reconstruction of magnetic resonance imaging (MRI) was applied to quantitatively assess the local treatment responses, including ratio of non-perfusion volume to adenomyosis volume (NPVr), ablation rate of the endometrial-myometrial junction (EMJ), and surface area (SA) of the ablated part of the EMJ. Patients were followed up at 3, 6, and 12 months after treatment, and divided into two groups: group with complete relief (CR), and group with partial relief (PR) or no relief (NR). Data were compared between them. Results Thirty-one patients were analyzed with a mean age of 38.7 ± 6.8 years (range: 24–48): 48.4% (15/31), 63.3% (19/30), and 65.5% (19/29) achieved CR at 3, 6, and 12 months, respectively. In univariate analysis, compared with the PR/NR group, serum CA125 levels were significantly lower in CR group at 3 months, while ablation rates of EMJ and SA of the ablated part of the EMJ were significantly higher at the three time points. Other baseline characteristics and NPVr did not differ between the two groups. Conclusion Baseline CA125 and ablation rate of the EMJ and SA of the ablated part of the EMJ are associated with the outcome of AUB-A patients after US-guided PMWA treatment.

Adenomyosis and Infertility: A Literature Review.

Background and Objectives: Adenomyosis (the presence of ectopic endometrial glands and stroma below the endometrial-myometrial junction) is a benign condition which is increasingly diagnosed in younger women suffering from infertility. The aim of this narrative review was to study the pathophysiology and prevalence of adenomyosis, the mechanisms causing infertility, treatment options, and reproductive outcomes in infertile women suffering from adenomyosis. Materials and Methods: A literature search for suitable articles published in the English language was performed using PubMed from January 1970 to July 2022. Results: The literature search retrieved 50 articles that met the purpose of this review and summarized the most recent findings regarding the accuracy of diagnostic methods, pathophysiology, and the prevalence of adenomyosis and optimal strategies for the treatment of infertile women with adenomyosis. Conclusions: Adenomyosis is a common gynecological disorder, affecting women of reproductive age. It negatively affects in vitro fertilization, pregnancy and the live birth rate, as well as increases the risk of miscarriage. With the advent of non-invasive diagnoses with MRI and TVUS, the role of adenomyosis in infertility has been better recognized. Overall, more randomized controlled trials (RCTs) are needed to provide strong data on the accuracy of diagnostic methods, the pathophysiology and the prevalence of adenomyosis, the fertility outcomes of patients and the optimal strategy for the treatment.

A differentiated approach to the management of patients with hyperplastic diseases of the uterus complicated by abnormal uterine bleeding

The purpose: to justify a differentiated approach to the management of patients with hyperplastic uterine diseases complicated by abnormal uterine bleeding (AUB) based on the study of the morpho-functional features of the endo- and myometrium. It has been shown that PgR expression is low in patients with combined lesions of the endometrium and myometrium complicated by AMC. The degree of PgR expression has a strong negative correlation with pathological changes of the endometrial-myometrial junction (r=-0.71), which made it possible to consider these criteria in the creation of a differentiated algorithm for the management of patients taking into account clinical and morphological pathogenetic variants of the disease. The use of differentiated approaches to the treatment of patients with combined hyperplastic processes of the uterus, taking into account the clinical and morphological features of the disease, made it possible to reduce the number of recurrences of AMC and achieve a long-term clinical effect in comparison with traditional treatment.

Archimetra: imaging aspects of combined pathology of the endometrium and myometrium

Objectives: evaluation of changes in the endometrial-myometrial junction (EMJ) in the combined pathology of the endometrium and myometrium.Materials and methods. 50 perimenopausal women with combined pathology of the endometrium and myometrium (main group) were examined. The control group consisted of 30 practically healthy women of the same age who were examined for the male factor of infertility. All patients underwent a comprehensive examination, which included clinical and paraclinical research methods.Patients were examined using transvaginal ultrasound. The DEERS (Diseases of Endometrium – Evaluation and Risk scoring System) index was used for the integral assessment of the endometrium and myometrium state.Results. The average age of women was 43.4 ± 1.2 years. The combination of endometrial hyperplasia (EH) and intramural uterine myoma was found in 58.0% of cases, EH and submucous uterine myoma – in 14.0%, EH and endometrial polyps – in 10.0%, EH and external peritoneal endometriosis – in 12.0%, EH and adenomyosis – in 4.0%, EH, adenomyosis and uterine fibroids – in 2.0%.The blood flow rate in the uterine arteries in the main group was 38.8 ± 0.6 cm/s, resistance index – 0.8 ± 0.04, pulsation index – 1.3 ± 0.1. In the control group the blood flow rate in the uterine arteries was 42.2 ± 0.8 cm/s without a clear difference of the sides, the resistance index – 0.9 ± 0.1, the pulsation index – 1.2 ± 0.1 (p &gt; 0.05).The total DEERS score in the main group was 13.2 ± 0.4 points, in the control group it was 7.3 ± 0.7 points. In the vast majority of cases (88.0%) EMJ was not involved in the pathological process. The average thickness of the EMJ in women from the control group was 0.45 ± 0.05 cm, in the main group – 0.42 ± 0.03 cm. At the same time, 36 (72.0%) women with combined pathology of the endometrium and myometrium had signs of hypomobility EMJ.Conclusions. EMJ was not involved in the pathological process in the vast majority of patients with combined pathology of the endometrium and myometrium. At the same time, some women with combined pathology of the endometrium and myometrium showed signs of hypomobility of the EMJ.

Autologous bone marrow-derived nucleated cell (aBMNC) transplantation improves endometrial function in patients with refractory Asherman's syndrome or with thin and dysfunctional endometrium.

The purpose was to evaluate the effect of intrauterine injection of aBMNC on the endometrial function in patients with refractory Asherman's syndrome (AS) and/or thin and dysfunctional endometrium (TE). This is a prospective, experimental, non-controlled study MATERIAL AND METHODS: The study was carried out between December 2018 and December 2020 on 20 patients, who were of age < 45 years and had oligo/amenorrhea and primary infertility due to refractory AS and/or TE. One hundred ml BM was extracted. aBMNC cells were separated according to generic volume reduction protocol by using the Cell Separation System SEPAX S-100 table top centrifuge system. We have evaluated CD34+, mononuclear cell (MNC), and total nucleated cell (TNC) counts. The transplantation aBMNC was performed by two intrauterine injections at an interval of one week, transvaginally into the endometrial-myometrial junction by an ovum aspiration needle. Midcyclic endometrial thickness (ET) and gestations after transplantation were evaluated. The mean TNC, MNC, and CD34+ cells were 11.55 ± 4.7 × 108, 3.85 ± 2.01 × 108, and 7.00 ± 2.88 × 106 at first injection, respectively, and 6.85 ± 2.67 × 108, 2.04 ± 1.11 × 108, and 3.44 ± 1.31 × 106 at second injection, respectively. The maximum posttransplantation ET was significantly higher than the maximum pretransplantation ET: 2.97 ± 0.48 vs. 5.76 ± 1.19 (mean ± standard deviation, p < 0.01). Twelve patients had frozen-thaw embryo transfers after the study. In 42% (n = 5 of 12) of the patients, pregnancy was achieved. One of the five patients delivered a healthy baby at term. Autologous BMNC transplantation may contribute to endometrial function in patients with AS and/or TE.

Clinical, Sonographic, and Hysteroscopic Features of Endometrial Carcinoma Diagnosed after Hysterectomy in Patients with a Preoperative Diagnosis of Atypical Hyperplasia: A Single-Center Retrospective Study.

atypical endometrial hyperplasia (AEH) is a precancerous condition implying a high risk of concurrent endometrial cancer (EC), which might be occult and only diagnosed at postoperative histopathological examination after hysterectomy. Our study aimed to investigate potential differences in preoperative clinical, sonographic, and hysteroscopic characteristics in patients with AEH and postoperative diagnosis of EC. a retrospective single-center study was carried out on a case series of 80 women with AEH undergoing diagnostic workup, including ultrasonography and hysteroscopy, with subsequent hysterectomy. Women with AEH confirmed at the histopathological examination were compared with patients with a postoperative diagnosis of EC. in our population, EC was diagnosed in 53 women, whereas the preoperative diagnosis of AEH was confirmed in 27 cases. At ultrasonography, women with occult EC showed greater endometrial thickness (20.3 mm vs. 10.3 mm, p 0.001) and size of the endocavitary lesion (maximum diameter 25.2 mm vs. 10.6 mm, p 0.001), and a higher prevalence of irregular endometrial-myometrial junction (40.5% vs. 6.7%, p 0.022) and endouterine vascularization at color Doppler (64.2% vs. 34.6%, p 0.017). At hysteroscopy, patients with occult EC showed a higher prevalence of necrosis (44.2% vs. 4.2%, p 0.001) and atypical vessels (70.6% vs. 33.3%, p 0.003), whereas true AEH mainly presented as a protruding intracavitary lesion (77.8% vs. 50.9%, p 0.029). In EC, subjective assessment by the operator was more frequently indicative of cancer (80.0% vs. 12.5%). No difference was found for clinical variables. occult EC in AEH may exhibit some differences in ultrasonographic and hysteroscopic patterns of presentation compared with real AEH, which could prompt a more significant suspect for the possible presence of concurrent EC at preoperative diagnostic workup.

IETA Ultrasonic Features Combined with GI-RADS Classification System and Tumor Biomarkers for Surveillance of Endometrial Carcinoma: An Innovative Study.

Objectives: We were the first to combine IETA ultrasonic features with GI-RADS and tumor biomarkers for the surveillance of endometrial carcinoma. The aim was to evaluate the efficacy of single IETA ultrasonography GI-RADS classification and combined tumor biomarkers in differentiating benign and malignant lesions in the uterine cavity and endometrium. Methods: A total of 497 patients with intrauterine and endometrial lesions who had been treated surgically between January 2017 and December 2021 were enrolled; all of them had undergone ultrasound examinations before surgery. We analyzed the correlation between the terms of ultrasonic signs of the uterine cavity and endometrial lesions defined by the expert consensus of IETA and the benign and malignant lesions and then classified these ultrasonic signs by GI-RADS. In addition, the tumor biomarkers CA125, CA15-3, CA19-9 and HE4 were combined by adjusting the classification. The results of the comprehensive analysis were compared with pathological results to analyze their diagnostic efficacy. Results: (1) The statistic analysis confirmed that there were seven independent predictors of malignant lesions, including thickened endometrium (premenopause ≥ 18.5 mm, postmenopause ≥ 15.5 mm), non-uniform endometrial echogenicity (heterogeneous with irregular cysts), endometrial midline appearance (not defined), the endometrial-myometrial junction (interrupted or not defined), intracavitary fluid (ground glass or "mixed" echogenicity), color score (3~4 points) and vascular pattern (focal origin multiple vessels or multifocal origin multiple vessels). (2) In traditional ultrasound GI-RADS (U-T-GI-RADS), if category 4a was taken as the cut-off value of benign and malignant, the diagnostic sensitivity, specificity, PPV, NPV and diagnostic accuracy were 97.2%, 65.2%, 44.0%, 98.8% and 72.2%, respectively, and the area under the ROC curve (AUC) was 0.812. If 4b was taken as the cut-off value, the diagnostic sensitivity, specificity, PPV, NPV diagnostic accuracy and AUC were 88.1%, 92.0%, 75.6%, 96.5% and 91.2%, 0.900, respectively. The diagnostic sensitivity, specificity, PPV, NPV diagnostic accuracy and AUC were 75.2%, 98.5%, 93.2%, 93.4%, 93.4% and 0.868, respectively, when taking category 5 as the cutoff point. In modified ultrasound GI-RADS (U-M-GI-RADS), if 4a was taken as the cut-off value, The diagnostic efficacy was the same as U-T-GI-RADS. If 4b was taken as the cut-off value, the diagnostic sensitivity, specificity, PPV, NPV, diagnostic accuracy and AUC were 88.1%, 92.3%, 76.2%, 96.5%, 91.3% and 0.902, respectively. If 4c was taken as the cutoff point, the diagnostic sensitivity, specificity, PPV, NPV diagnostic accuracy and AUC were 75.2%, 98.7%, 94.3%, 93.4%, 93.6% and 0.870, respectively. The diagnostic sensitivity, specificity, PPV, NPV diagnostic accuracy and AUC were 66.1%, 99.7%, 98.6%, 91.3%, 92.4% and 0.829, respectively, if taking category 5 as the cutoff point. (3) In the comprehensive diagnostic method of U-T-GI-RADS combined tumor biomarkers results, the AUC of class 4a, 4b and 5 as the cutoff value was 0.877, 0.888 and 0.738, respectively. The AUC of class 4a, 4b, 4c and 5 as the cutoff value in the comprehensive diagnostic method of U-M-GI-RADS combined tumor biomarkers results was 0.877, 0.888, 0.851 and 0.725, respectively. There was no significant difference in diagnostic efficiency between the two comprehensive diagnostic methods. Conclusions: In this study, no matter which diagnostic method was used, the best cutoff value for predicting malignant EC was ≥GI-RADS 4b. The GI-RADS classification had good performance in discriminating EC. The tumor biomarkers, CA125, CA19-9, CA15-3 and HE4, could improve the diagnostic efficacy for preoperative endometrial carcinoma assessment.

Ultrasound features of endometrial pathology in women without abnormal uterine bleeding: results from the International Endometrial Tumor Analysis study (IETA3).

The primary aim of this study was to describe the ultrasound features of various endometrial and other intracavitary pathologies in women without abnormal uterine bleeding (AUB) using the International Endometrial Tumor Analysis (IETA) terminology. The secondary aim was to compare our findings with published data on women with AUB. This was a prospective observational study of women presenting at one of seven centers specialized in gynecological ultrasonography, from 2011 until 2018, for indications unrelated to AUB. All patients underwent transvaginal ultrasound using the IETA examination and measurement techniques. Ultrasonography was performed as part of routine gynecological examination or follow-up of non-endometrial pathology, or as part of the work-up before undergoing treatment for infertility, uterine prolapse or ovarian pathology. Ultrasound findings were described using the IETA terminology. Endometrial sampling was performed after the ultrasound scan. The histological endpoints were endometrial atrophy, proliferative or secretory endometrium, endometrial hyperplasia without atypia, endometrial polyp, intracavitary leiomyoma, endometrial intraepithelial neoplasia (EIN), endometrial cancer (EC) and insufficient tissue. The findings in our cohort of women without AUB were compared with those in a published cohort of women with AUB who were examined with transvaginal ultrasound between 2012 and 2015 using the same IETA examination technique and terminology. In this study (IETA3), we included 1745 women without AUB who underwent a standardized transvaginal ultrasound examination followed by either endometrial sampling with histological diagnosis (n = 1537) or at least 1 year of clinical and ultrasound follow-up (n = 208). Of these, 858 (49.2%) women were premenopausal and 887 (50.8%) were postmenopausal. Histology showed the presence of EC and/or EIN in 29 (1.7%) women, endometrial polyps in 1028 (58.9%), intracavitary myomas in 66 (3.8%), proliferative or secretory changes or hyperplasia without atypia in 144 (8.3%), endometrial atrophy in 265 (15.2%) and insufficient tissue in five (0.3%). Most cases of EC or EIN (25/29 (86.2%)) were diagnosed after menopause. The mean endometrial thickness in women with EC or EIN was 11.2 mm (95% CI, 8.9-13.6 mm), being on average 2.4 mm (95% CI, 0.3-4.6 mm) thicker than their benign counterparts. Women with malignant endometrial pathology manifested more frequently non-uniform echogenicity (22/29 (75.9%)) than did those with benign endometrial pathology (929/1716 (54.1%)) (difference, +21.8% (95% CI, +4.2% to +39.2%)). Moderate to abundant vascularization (color score 3-4) was seen in 31.0% (9/29) of cases with EC or EIN compared with 12.8% (220/1716) of those with a benign outcome (difference, +18.2% (95% CI, -0.5% to +36.9%)). Multiple multifocal vessels were recorded in 24.1% (7/29) women with EC or EIN vs 4.0% (68/1716) of those with a benign outcome (difference, +20.2% (95% CI, +4.6% to +35.7%)). A regular endometrial-myometrial junction was seen less frequently in women with EC or EIN (19/29 (65.5%)) vs those with a benign outcome (1412/1716 (82.3%)) (difference, -16.8% (95% CI, -34.2% to +0.6%)). In women with endometrial polyps without AUB, a single dominant vessel was the most frequent vascular pattern (666/1028 (64.8%)). In women with EC, both in those with and those without AUB, the endometrium usually manifested heterogeneous echogenicity, but the endometrium was on average 8.6 mm (95% CI, 5.2-12.0 mm) thinner and less intensely vascularized (color score 3-4: difference, -26.8% (95% CI, -52.2% to -1.3%)) in women without compared to those with AUB. In both pre- and postmenopausal women, asymptomatic endometrial polyps were associated with a thinner endometrium, and they manifested more frequently a bright edge, a regular endometrial-myometrial junction and a single dominant vessel than did polyps in symptomatic women, and they were less intensely vascularized. We describe the typical ultrasound features of EC, polyps and other intracavitary histologies using IETA terminology in women without AUB. Our findings suggest that the presence of asymptomatic polyps or endometrial malignancy may be accompanied by thinner and less intensely vascularized endometria than their symptomatic counterparts. © 2022 International Society of Ultrasound in Obstetrics and Gynecology.

P-314 Quantitative analysis of uterine peristalsis using optical flow for motion quantification

Abstract Study question Do women with adenomyosis have altered uterine peristalsis? Summary answer Women with adenomyosis have altered uterine peristalsis on transvaginal sonography (TVS), as measured using optical flow for motion quantification. What is known already Adenomyosis can reduce the chance of clinical pregnancy in women undergoing assisted conception, with altered uterine peristalsis proposed as a mechanism. Uterine peristalsis can be visualised by TVS and is thought to play an important role in sperm transport and embryo implantation. Ultrastructural myometrial abnormalities in adenomyosis cause a disturbance in normal myocyte contractility with subsequent loss of normal rhythmic contraction. We aimed to develop an objective tool to quantify uterine peristalsis on TVS using an algorithm based on optical flow for wave motion quantification in women with adenomyosis. Study design, size, duration Prospective observational cohort study, July - December 2021, of women with moderate/severe adenomyosis (n = 16) and a normal pelvis (n = 21), having TVS during assisted conception. TVS was performed in the mid-sagittal plane for 4 minutes at baseline (BL), day 6-12 of ovarian stimulation (OS) and day of embryo transfer (ET). Recordings were stored offline for analysis using 3D Slicer (Ver. 4.11) and sampled at constant intervals to achieve a set of frames for optical flow analysis. Participants/materials, setting, methods We recruited women with moderate/severe adenomyosis or normal uterus on TVS. Optical flow was used to track pixels over successive TVS frames. Pixel-level displacements for points at endometrial-myometrial junction were used to compute time-period(inverse of frequency, 1/f) and amplitude(u) by fitting to the 2D-wave equation. Fit error was taken as a measure of coordination of wave at endometrial-myometrial junction(uterine peristalsis - up). Myometrial zone standard deviation quantifies spread, a measure of coordination of myometrial contractility(mc). Main results and the role of chance The observed wave of uterine peristalsis (up) at the endometrial-myometrial junction in women with adenomyosis showed a significantly poorer fit with the ideal wave equation compared to women with a normal uterus at all time points (BL (+ 0.725), OS (+ 0.612) and ET (+ 0.627) (n = 37, p &amp;lt; 0.001)), indicating lower coordination of uterine peristalsis in women with adenomyosis compared to women with a normal uterus. Coordination of myometrial contractility was also significantly lower in women with adenomyosis compared to women with a normal uterus at all time points (BL (+ 0.656) , OS (+ 0.510) and ET (+ 0.639) (n = 37, p &amp;lt; 0.001). Statistically significant difference was not found in wave amplitude or frequency between groups (p &amp;gt; 0.06 for both). Limitations, reasons for caution Optical flow for motion quantification has been used here to quantify uterine peristalsis in women with adenomyosis and women with a normal uterus and would require validation prior to use in other uterine pathology. Wider implications of the findings Women with adenomyosis have altered uterine peristalsis and myometrial contractility, which may account for their reduction in chances of conception. The proposed approach for wave motion quantification is an objective tool to quantify uterine peristalsis, with potential for wide clinical application in the gynaecology and assisted conception setting. Trial registration number Not applicable

A Novel Nomogram Based on 3-dimensional Transvaginal Ultrasound for Differential Diagnosis Between Severe and Mild-to-Moderate Intrauterine Adhesions

To develop and validate a nomogram for differentiating severe intrauterine adhesions (IUAs) from mild-to-moderate IUAs preoperatively on the basis of 3-dimensional transvaginal ultrasound (3D-TVUS). Retrospective observational study. University-affiliated hospital. A dataset of 413 patients who had undergone hysteroscopic adhesiolysis and 3D-TVUS examination before hysteroscopic adhesiolysis between March 2019 and December 2020. Not applicable. A total of 212 patients with mild-to-moderate IUAs and 201 patients with severe IUAs were enrolled. Intercornual distance, endometrial thickness, number of visible fallopian tubal ostia, echoes of the endometrial-myometrial junction zone, and endometrial blood flow grade differed significantly between the severe and mild-to-moderate IUAs groups. The area under the receiver operating characteristic curve of the nomogram was 0.880 (95% confidence interval, 0.843-0.918) in the training set and 0.878 (95% confidence interval, 0.818-0.939) in the validation set, revealing reliable discrimination. The calibration curve and Hosmer-Lemeshow test showed strong calibration, and decision curve analysis indicated that the nomogram had a high net benefit and a wide range of threshold probabilities. This nomogram, which was developed on the basis of 3D-TVUS, can accurately distinguish severe IUAs from mild-to-moderate IUAs preoperatively.

Molecular Insights into Endometrial Cancer in Mice

Pluripotent, very small embryonic-like stem cells (VSELs) and the 'progenitors' endometrial stem cells (EnSCs) along with associated molecular changes in endometrial cancer, that developed seven months after neonatal exposure to estradiol in one of the sixty mice, were studied in the present study. Endocrine disruption affected both endometrium and myometrium, there was accumulation of endometrial fluid and significant hyperplasia. Disrupted endometrial-myometrial junction resulted in mobilization of myometrial cells into endometrium and epithelial andstromal cells into myometrium suggestive of adenomyosis. Markers specific for VSELs/ EnSCs (OCT-4, NANOG, SSEA-1, SCA-1, c-KIT) showed increased expression in uterine sections and marked upregulation of corresponding transcripts (Oct-4A, Oct-4, Sox-2, Nanog, Sca-1, c-Kit) was noted in RNA extracted from both uterine tissue and stem cells enriched from endometrial fluid. Hormonal receptors (ER-α, ER-β, PR, FSHR) were upregulated in both tumor sections and in endometrial fluid. ER-β and FSHR (Fshr3) expression was prominent suggesting a major role in endometrial cancer. Cancer cells showed global hypomethylation (reduced expression of 5-methyl cytosine), reduced expression of tumor suppressor gene (PTEN) and increased expression of cancer stem cells marker (CD166)which suggested dysregulation and aberrant oncogenic events. Increased expression of PCNA, Ki67, SOX-9 suggested excessive proliferation and hyperplasia which are predominant signs of endometrial cancer. Results suggest that VSELs increase in numbers and possibly transform into cancer stem cells (co-express CD166 and OCT-4) in endometrial cancer. Expression of OCT-4, CD133, ALDHA1 and CD166 in side-population cells from human endometrial cancer samples suggests a possible role of VSELs in human endometrial cancer as well.

Аномальные маточные кровотечения. Анализ результатов ультрасонографии по системе IETA

Objective. To study the features of the uterine cavity echo and the prognostic value of ultrasound signs of endometrial pathology in patients with abnormal uterine bleeding based on the terminology and recommendations of IETA. Patients and methods. The study included 196 women with abnormal uterine bleeding in the late reproductive period and premenopause and 54 patients with postmenopausal bleeding and/or ultrasound signs of endometrial pathology. All ultrasonography results were interpreted according to the IETA classification and terminology and were subsequently verified by histological examination. Results. In patients with endometrial intraepithelial neoplasia (EIN), the thickness of the endometrium was in the range of 9–19 mm and, according to this criterion, did not differ from endometrial hyperplasia without atypia. Only in some patients with EIN, the endometrial-myometrial junction was characterized by unevenness (16.7% in the reproductive period/premenopause and 22.2% in postmenopause). Compared with endometrial hyperplasia, EIN was dominated by uneven, heterogeneous echogenicity without cystic inclusions with a color scale 2–3 points. In endometrial cancer, the endometrial-myometrial junction was interrupted in 77.8–100% of cases, and the color score reached 4 points. Conclusion. Modern possibilities of ultrasonography allow improving the principles of early diagnosis of EIN and preinvasive endometrial carcinoma. Key words: ultrasound, IETA, endometrial cancer, endometrial intraepithelial neoplasia

ULTRASOUND BASED ENDOMETRIAL RECEPTIVITY SCORING ACCURATELY IDENTIFIES IVF CYCLES WITH LOW PROBABILITY OF PREGNANCY

Ultrasonographic endometrial thickness (ET) measurements have become a clinical standard for cycle selection in IVF. However, large studies on the effectiveness of midsagittal ET measurements as a predictor of cycle outcome are contradictory. Quantitative and qualitative ultrasound based endometrial receptivity assessment (usER; Matris™, Synergyne Imaging Technology, Inc, Saskatoon, SK) for cycle selection has recently been demonstrated to improve pregnancy rates over standard of care ET measurements. usER analysis is conducted on transverse ultrasonographic images of the endometrium acquired 10–15 mm from the endometrial-myometrial junction at the uterine fundus. Over 40 parameters are extracted from the image attributes and numerical endometrial receptivity scores from 0 – 10 (0 poor receptivity – 10 optimal receptivity) characterizing virtual histology are calculated. Patients with usER scores of 7.0 and higher are recommended to proceed to single embryo transfer (SET), while cycles scoring 6.5 or lower are recommended for deferral based on low probability of pregnancy. Embryos from deferred cycles are conserved for future optimal cycles. We assessed the interrelationships among ET, usER score and pregnancy outcome. Our objective was to test the hypotheses that: 1) diagnostic usER testing facilitates identification of cycles in which probability of pregnancy is low; and, 2) usER scores are not correlated with ET. All IVF cycles conducted at a tertiary ART clinic which had usER scores, ET measurements, and outcome data available were considered (n=2274). Data were acquired from a review of deidentified patient files from 2014 – 2019. We conducted general linear [logistic] models multivariate regression analyses of the relationships between ET, usER score, and pregnancy. ET and usER score showed negligible correlation (R2=0.30). ET measurements ranged from 2.9 mm to 23.0 mm (mean 9.9 mm ± 2.56 mm SD). usER scores ranged from 0.5 to 9.5 (mean 7.5 ± 1.5 SD). 1695 (74.5 %) cycles had usER scores of 7.0 or above (recommended to proceed to SET). Pregnancy outcomes of the 2274 cycles were: 835 pregnant (47% per SET), 954 not pregnant (53% per SET), 485 no embryo transfer. Of the 579 cycles which received usER scores of 6.5 or lower (deferral recommended), 179 proceeded to embryo transfer against recommendation. Regression analysis of the 179 low usER scores (< 6.5) reliably predicted the outcome of ‘not pregnant’(p=0.020). ET measurements and usER diagnostic are fundamentally different. ET was not a significant predictor of pregnancy outcome (p=0.132). Deferral of cycles with low usER scores also resulted in the conservation of 310 embryos.

Adenomyosis pathogenesis: insights from next-generation sequencing.

BACKGROUNDAdenomyosis, characterized by the presence of islands of endometrial tissue surrounded by hypertrophic smooth muscle cells within the myometrium, is one of the most challenging uterine disorders in terms of diagnosis and management. Adenomyosis presents with pelvic pain, excessive uterine bleeding, anemia and infertility. The relative contributions of abnormal endometrial tissue and myometrial smooth muscle cells to the development and growth of adenomyosis are not well understood. Moreover, there is continuing debate on the origins of adenomyosis; two competing theories describe the invagination of basal endometrium into the myometrium or the metaplastic differentiation of remnant endometrial stem/progenitor cells within the myometrium.OBJECTIVE AND RATIONALEA recent series of next-generation sequencing (NGS) studies have provided the best scientific evidence thus far regarding the cellular origins of adenomyosis and the contributions of new signaling pathways to its pathogenesis, survival, and growth. These seminal studies on endometrium, adenomyosis and endometriosis demonstrate or support the following key points. (i) Mutations of KRAS map to both intracavitary endometrial tissue and proximally located adenomyotic samples, supporting the invagination theory of pathogenesis. Driver mutations found in smooth muscle cells of uterine fibroids are absent in adenomyosis. (ii) KRAS and other less frequent mutations are limited to endometrial-type epithelial cells. They are also observed in endometriosis, indicating that the disease process in adenomyosis is similar to that in endometriosis and distinct from that of uterine fibroids. (iii) Activating mutations of KRAS stimulate specific pathways to increase cell survival and proliferation and are associated with progesterone resistance in adenomyosis. Together, these findings suggest that distinct cell populations in eutopic endometrial tissue play key roles in the etiology of adenomyosis. Dependence on ovarian steroids and ovulatory cycles for disease severity is a unique feature of adenomyosis. In this context, common patterns of aberrant gene expression have been reported both in adenomyosis and endometriosis. These include pathways that favor increased estrogen biosynthesis, decreased estradiol metabolism, a unique estrogen receptor beta (ESR2)-driven inflammatory process, and progesterone resistance due to decreased progesterone receptor expression. Since adenomyosis exhibits a uniquely estrogen-driven inflammatory process and progesterone resistance, we discuss the interactions between these molecular characteristics and signaling pathways induced by the newly discovered KRAS mutations.SEARCH METHODSWe conducted a comprehensive search using PubMed for human and animal studies published until 2020 in the following areas: adenomyosis, endometriosis, endometrium, NGS, whole-exome sequencing, whole-genome sequencing, RNA sequencing, targeted deep sequencing, epigenetics, driver mutation, KRAS, progesterone resistance, estrogen action and steroid production.OUTCOMESTargeted deep sequencing analyses of epithelial cells in adenomyosis and adjacent basalis endometrial glands demonstrated recurring KRAS mutations in both cell types. This finding suggests that adenomyosis originates from basalis endometrium. Epithelial cells of the endometrium, adjacent adenomyosis and co-occurring endometriosis also share identical KRAS mutations. These findings suggest both adenomyosis and endometriosis are oligoclonal tissues that arise from endometrial cell populations carrying a specific driver mutation that most commonly affects the KRAS gene.WIDER IMPLICATIONSAdenomyosis usually follows an event such as pregnancy that has disrupted the integrity of the endometrial–myometrial junction followed by repetitious menstrual episodes that increase the likelihood of the entrapment of the basalis endometrium within the myometrium. Glandular epithelial cells carrying KRAS mutations and located within the deep crypts of basalis endometrium may become entrapped and invade myometrial tissue to give rise to adenomyosis. Evidence suggests that KRAS mutations may be responsible, in part, for previously observed phenomena such as prolonged cell survival and progesterone resistance in adenomyosis.

Sonographic Criteria for Uterine Curettage: Suspecting Endometrial Neoplasia.

The aim of the work is to determine the Suspicious sonographic findings associated with endometrial hyperplasia or cancer in premenopausal and perimenopausal women requiring uterine curettage other than endometrial thickness. Transvaginal ultrasonography examinations of premenopausal and perimenopausal women were reported here. These women underwent endometrial biopsy based on abnormal uterine bleeding or discharge and sonographic endometrial abnormalities. Histologically, hyperplasia was found in PCOS patients, endometrial cancer on top of tamoxifen therapy was found in others. The highly related ultrasound criteria are thick irregular endometrium, ill-defined endometrial myometrial junction, myometrial invasion with pseudowidening of the endometrium, turbid intrauterine fluid collection, associated complex adnexal masses, and cystic areas in the endometrium. Endometrial stripe abnormality by transvaginal ultrasonography is considered to be important in the recommendation of endometrial biopsy to exclude cancer along with positive complains in addition to thickness abnormalities.