Endometrial Vessels Research Articles

Evaluation of the Vascular Endothelial Growth Factor and Smooth Muscle Actin Expression With Microvessel Density and Morphometric Analysis of Endometrial Vessels in Patients With Abnormal Uterine Bleeding.

Abnormal uterine bleeding (AUB) that occurs in a structurally normal uterus with regular menstrual cycles and without other identifiable etiology is often caused by a primary endometrial disorder (AUB-E). Altered vascular morphological changes and expression of markers of angiogenesis have been implicated as an underlying cause in these cases. The study was conducted to investigate the expression of vascular endothelial growth factor (VEGF) and smooth muscle actin-alpha (SMA-α), and to perform microvessel density (MVD), andmorphometric evaluation of endometrial vessels in patients with AUB-E. Endometrial biopsies and hysterectomy specimens of 40 patients clinically diagnosed with AUB-E were included in the study with 40 age-matched controls. Immunohistochemistry (IHC) with VEGFandSMA-αwas performed, and the expression and staining pattern was recorded as the number of positive vessels per 10 high power fields and intensity scores. Morphometric analysis was performed on CD34 stained sections using Leica Application Suite, version 4.4.0 software (Leica Microsystems, Wetzlar, Germany). MVDwas calculated by the vascular hotspot method. A statistically significant increase in VEGF vessel count (p-value<0.001) and a decline in SMA-α expression (p-value=0.23) was seen in cases as compared to the control group.There was a statistically significant increase in microvessel caliber (p-value=0.01) and MVD (p-value <0.001) in cases as compared to controls. These findings support aberrant vascular proliferation and impaired vessel maturation, contributing to the pathology of AUB-E. Alterations in angiogenesis in these patients reveal potential therapeutic targets for AUB.

Cell Chirality of Micropatterned Endometrial Microvascular Endothelial Cells.

Chirality is an intrinsic cellular property that describes cell polarization biases along the left-right axis, apicobasal axis, or front-rear axes. Cell chirality plays a significant role in the arrangement of organs in the body as well as in the orientation of organelles, cytoskeletons, and cells. Vascular networks within the endometrium, the mucosal inner lining of the uterus, commonly display spiral architectures that rapidly form across the menstrual cycle. Herein, the role of endometrial-relevant extracellular matrix stiffness, composition, and soluble signals on endometrial endothelial cell chirality is systematically examined using a high-throughput microarray. Endometrial endothelial cells display marked patterns of chirality as individual cells and as cohorts in response to substrate stiffness and environmental cues. Vascular networks formed from endometrial endothelial cells also display shifts in chirality as a function of exogenous hormones. Changes in cellular-scale chirality correlate with changes in vascular network parameters, suggesting a critical role for cellular chirality in directing endometrial vessel network organization.

P-361 Is HIF-2α involved in pre-menstrual conditioning of the endometrium to ensure optimal repair and prevent heavy menstrual bleeding?

Abstract Study question Does HIF-2α play a key role in pre-menstrual conditioning of the non-pregnant endometrium to optimise menstrual breakdown/repair and prevent heavy menstrual bleeding (HMB)? Summary answer HIF-2 was higher in secretory endometrium of women with HMB versus controls, but manipulation of HIF-2α in the mouse model did not impact endometrial breakdown/repair. What is known already Hypoxia inducible factor (HIF) is the master regulator of the cellular response to hypoxia and has two common alpha isoforms (HIF-1α/HIF-2α) with overlapping but distinct target genes. We revealed that menstrual endometrial HIF-1α is necessary for normal menstrual endometrial repair. We detected HIF-2α in human endometrium exclusively during the secretory phase. The role of HIF-2α in the non-pregnant endometrium remains undetermined but was important for successful uterine implantation and lung vascular remodelling in mice. We hypothesised that endometrial HIF-2 is required for optimising the endometrial vasculature pre-menstrually to ensure appropriate vasoconstriction and endometrial repair during menstruation. Study design, size, duration HIF-2 was examined in human endometrial tissue and a mouse model of simulated menstruation. Hif2α +/- mice provided genetic reduction of HIF-2 during simulated menses versus wild-type littermates. HIF-2α was also pharmacologically inhibited during the secretory phase (PT2385 vs vehicle controls). To increase HIF-2, Hif1α +/- mice were treated with a HIF stabiliser (DMOG) during the secretory phase to increase HIF-2α followed by decreased HIF-1α at menses –mimicking human endometrial findings in women with HMB. Participants/materials, setting, methods Human secretory endometrium was collected (ethically approved and consented) from women with objectively measured HMB (n = 5) and controls (n = 4) and HIF-2 detected by Western blot. Mouse uterus was collected at the time of progesterone withdrawal (T0, decidualisation) and 8h (T8, endometrial breakdown) and 24h (T24, endometrial repair) after progesterone withdrawal. Histological endometrial repair and menstrual blood loss (MBL) were quantified. Decidualisation markers were examined by RT-qPCR. Endometrial vessel maturity and hypoxia were assessed using immunohistochemistry/immunofluorescence. Main results and the role of chance Human secretory endometrial HIF-2α protein levels were higher in those with HMB compared to controls (P &amp;lt; 0.05). Genetic reduction of HIF-2α in our mouse model of menses (Hif2α +/-) revealed no significant differences in endometrial breakdown (T8) or repair grade (T24) and no difference in MBL at T8 versus controls. There were no significant differences in expression of decidualisation markers (Prlr/Prl3c1) and vessel maturity at T0 (CD31/α-SMA immunofluorescence staining), or the presence of hypoxia at T8 (pimonidazole immunohistochemistry staining). Pharmacological inhibition of HIF-2 at the time of decidualisation also showed no significant difference in endometrial repair at T24 versus controls. Increasing pre-menstrual HIF-2 via pharmacological stabilisation of HIF-2α in Hif1α+/- mice similarly did not significantly affect endometrial breakdown (T8) or repair (T24) or MBL at T8 versus vehicle treated controls, in contrast to our findings in women with HMB. Limitations, reasons for caution Histological scoring of endometrial breakdown/repair in the menstruation mouse model may not be sensitive enough to detect subtle endometrial changes with increased HIF-2α. As HIF-1α delays endometrial repair, an additional timepoint 36h after progesterone withdrawal may better capture any delay in endometrial repair as a result of increased secretory HIF-2. Wider implications of the findings HIF-2α may play a greater role in implantation than pre-menstrual conditioning of the endometrium to optimise menstrual breakdown/repair and limit menstrual blood loss. Although endometrial breakdown was not significantly affected by HIF-2, the impact on repair warrants further investigation to fully delineate the role of HIF-2 in the non-pregnant endometrium. Trial registration number Not applicable

P-246 Exposure to oral contraceptives alters human endometrial stem cells culture media metabolomics

Abstract Study question Can oral contraceptives (OCs) influence the metabolism of endometrial stem cells (EnMSC)? Summary answer Altered metabolomic profiling in culture media may be an effect of OC hormonal properties on EnMSC metabolism. What is known already The reconstitution of the endometrial tissue relies on the presence of EnMSC, which reside in the perivascular space in the endometrium. This process can be affected by OCs by decreasing the secretory potential of the glands. In case of high dose OCs, hyperplasia of endometrial vessels and stroma atrophy of the glands may occur. However, the precise effect of OCs on the production and metabolism of EnMSCs remains unknown. Study design, size, duration This was a prospective study that included samples of menstrual blood from 5 volunteers. The study was conducted for one year and received approval from Ethics in Research Committee. Written informed consent was obtained from all participants. Participants/materials, setting, methods Five women with regular menstrual cycles were included in two groups according to the use of OCs: OC (n = 2) and non-OC (n = 3). Samples were collected by the menstrual cup on the second day of the menstrual cycle. The culture medium of EnMSC was collected from each passage. Quantitative metabolomics was performed by multiple reaction monitoring, followed by liquid chromatography mass spectrometry. Data was analyzed by PLS-DA and T-test. Potential biomarkers were assessed by ROC curve. Main results and the role of chance The cells were characterized as mesenchymal stem cells with a range of 47,4% to 85% of positive markers. From 186 metabolites quantified in the culture media of OC and non-OC groups, 15 metabolites were proposed as of high discrimination between groups by the PLS-DA, which also demonstrated a total groups separation on the statistical model. The ROC curve showed that 4 out of 15 metabolites presented more than 80% of sensitivity. These metabolites are Alanine, Phosphatidylcholine (PC) aa C30:0, Glycine and PC aa C32:2, whose concentrations were higher in the OC group than in non-OC group. The Students’ T-Test analysis confirmed that the metabolites with higher discrimination between groups presented significant p values. These metabolites have been associated with several metabolic processes, including energy production and alteration of molecular pathways related to thrombosis and cancer. Limitations, reasons for caution This study was conducted with a small number of participants and further studies are necessary to confirm the findings. Wider implications of the findings The use of OCs could affect endometrial characteristics that are crucial for reproductive success, such as endometrial receptivity. This study provides a preliminary insight into the EnMSCs response to OCs based on specific metabolite signatures, which may contribute to the development of future new reproductive therapies. Trial registration number Foundation for Coordination of Higher Education Personnel (CAPES – Brazil).

Prediction of Endometrial Pathology by Endometrial Cut-Off Thickness in Patients with Abnormal Uterine Bleeding

Aim: To determinecut-off endometrial thickness for prediction of endometrial pathology in patients with abnormal uterine bleeding. Study design: Cross-sectional study Place and duration of study: Department of Obstetrics &amp; Gynaecology, Niazi Medical &amp; Dental College, Sargodha from 1st October 2021 to 30th September 2022. Methodology: Seventy perimenopausal women who were above the age of 40 years and were suffering from acute urinary bleeding were enrolled. Transvaginal ultrasound was conducted. Uterus as well as adnexa were scanned longitudinally ad transversally. Doppler was activated and hemodynamic-parameters were bilaterally examined from the main dominant uterine arteries branch to the cervical-corporal section of uterus. Endometrial vessels color flow examination detected number, size, as well as vessel regularity of branching. Three different vascular patterns were observed. Results: The mean age of the women in Group I was 44.25 ± 2.69 years where as in Group II cases it was mean 47.16 ± 3.25 years. Transvaginal ultrasound endometrial thickness cut-off was determined as &gt;10.5mm. Comorbidities were higher in the Group II with neoplastic changes observed. The value of obesity, age, hypertension and diabetes as well as endometrial thickness &gt;10.5 were significantly higher in mltivariant analysis whereas age, obesity and ET&gt;10.5 was increased in the univariate analysis as well. Transvaginal ultrasound-endometrial thickness &gt;10.5mm was having highest value of sensitivity and specificity Conclusion: Perimenopausal women suffering with abnormal uterine bleeding should undergo histopathological examination if they have a transvaginal ultrasound-endometrial thickness value greater than 10.5mm.The main risk factors towards increased risk of endometrial pathology development are age and obesity. Keywords: Abnormal uterine bleeding, Endometrial carcinoma, Histopathology

The effects of melatonin and metformin on histological characteristics of the ovary and uterus in letrozole-induced polycystic ovarian syndrome mice: A stereological study.

Polycystic ovarian syndrome (PCOS) with anovulation, hyperandrogenism, ovarian and uterine histological changes, menstrual irregularities, etc. signs is an infertility type. It seems that melatonin and metformin can improve these abnormalities. To evaluate the effects of melatonin and metformin on the ovary and uterus in PCOS-induced mice using stereological methods. Seventy-two adult female BALB/c mice (8-wk-old, 20-30 gr) were randomly divided into control (distilled water, gavage), PCOS (90 µg/kg letrozole, gavage), PCOS+metformin (500 mg/kg, gavage), PCOS+melatonin (10 mg/kg, intraperitoneal injection), and PCOS+melatonin control (0.5% ethanol saline) groups (n = 12/each). Another PCOS group was kept for a month to ensure that PCOS features remained. Finally, a stereological evaluation of the uterus and ovary was carried out, and vaginal cytology and serum testosterone levels were assessed. PCOS mice treated with metformin and melatonin had lower testosterone levels, body weight, and more regular estrus cycles than the PCOS group (p 0.001). A significant decrease in conglomerate and daughter gland numbers, and primary, secondary, atretic, and cystic follicles numbers with a significant increase in primordial and Graafian follicles, and corpus luteum numbers (p 0.001) was seen in these treated mice. Also, endometrial vessels' volume and length significantly increased, but ovarian, endometrial, myometrial, stromal, and glands volume, and endometrial and myometrial thickness dramatically declined (p 0.001). It appears that metformin and melatonin could restore the PCOS phenotype including estrus cycle irregularity, high testosterone level, and ovarian and uterine micromorphology to the control levels. However, the 2 treatments had similar effects on the examined parameters.

Effects of stem cells and amniotic fluid on uterus and ovaries in a rat model of abdominal adhesions: a controlled study

Objective:This study aimed to compare the effects of human umbilical cord mesenchymal stem cells (hUCMSCs), amniotic fluid (AF), and a combination of both on the uterus and ovaries in a rat model of abdominal adhesions.Material and Methods:This study was designed as a controlled study. Four groups, each consisting of six rats, were randomly formed. One group was designated as the control (CNT). hUCMSCs - applied (hUCSC), AF-applied (AMN), and a combination of both (hUCSC + AMN) were the experimental groups. All rats were given intraperitoneal talc powder to create adhesions. After 21 days, animals in experimental groups were further treated with hUCMSC, AF or a combination of these.Results:There was a statistically significant difference in primordial follicle count, endometrial gland number, and endometrial blood vessel count (p<0.05). AMN provided the best results in the endometrial vessel and primordial follicle count. The average endometrial gland count in AMN and hUCSC + AMN was similarly higher than CNT and hUCSC alone.Conclusion:There were significantly higher for counts for endometrial glands, endometrial blood vessels, and primordial follicles in the hUCSC, AMN and hUCSC + AMN groups compared to controls. Animals in the AMN group had the best result for endometrial vessel and highest primordial follicle count.

Endometrial Cut Off Thickness as Predictor of Endometrial Pathology in Perimenopausal Women with Abnormal Uterine Bleeding: A Cross-Sectional Study.

Purpose We aim to determine the predictive value of endometrial thickness by transvaginal ultrasonography (TVS) in diagnosing endometrial pathology and to evaluate whether Doppler complements its diagnostic efficacy in perimenopausal women with abnormal uterine bleeding. Methods This cross-sectional observational study was conducted among 70 perimenopausal women with AUB who underwent TVS measurement of endometrial thickness (ET) and Doppler flow indices followed by endometrial sampling and histopathological examination (HPE). Results In HPE, 51 (73%) women had normal diagnosis while 19 (27%) women had neoplastic histology either benign or malignant. They were categorised into group I and group II, respectively. There was a significant difference in age (P=0.001) and incidence of obesity (P=0.01) between the two groups. The ETs measured in group I and group II were 7.89 ± 2.62 mm and 14.07 ± 3.96 mm, respectively, with significant difference (P < 0.001). A TVS-ET of 10.5 mm had the highest sensitivity and specificity of 89.5% and 86.3%, respectively, PPV of 70.68%, NPV of 95.68%, LR+ of 6.52, and LR− of 0.12. Doppler flow velocimetric study of endometrial and uterine vessels did not demonstrate a significant difference. Conclusions Women in perimenopause with AUB should be offered to undergo endometrial sampling for histopathological examination if TVS ET ≥10.5 mm. The coexisting risk factors especially higher age (>45 years) and obesity (BMI>30) significantly escalate the chances of developing endometrial pathology.

3D stem cell-laden artificial endometrium: successful endometrial regeneration and pregnancy

Thin endometrium lining or severe endometrial injury which may occur during artificial abortion can cause defective endometrial receptivity and subsequent infertility. Therefore, much effort has been devoted toward regenerating thin or damaged endometrial lining by applying multiple types of stem cells. Even though there are some positive preliminary outcomes, repairing the injured endometrium with stem cells is considerably challenging, due to the lack of an adequate microenvironment for the administrated stem cells within the tissues and subsequent poor therapeutic efficiency. In this context, as an alternative, we fabricated a 3D stem cell-laden artificial endometrium by incorporating several biodegradable biomaterials (collagen and hyaluronic acid) and multiple cellular components of endometrium (endometrial stem cells, stromal cells, and vessel cells) to properly recapitulate the multicellular microenvironment and multilayered structure. Agarose was used as an inert filler substrate to enhance the mechanical integrity of the three-layered artificial endometrium. Various mechanical characteristics, such as morphology, compression properties, swelling, and viscosity, have been evaluated. Various biological features, such as steroid hormone responsiveness, specific endometrial cell-surface marker expressions, and the secretion of multiple growth factors and steroid hormones, as well as the viability of encapsulated endometrial cells are relatively well maintained within the artificial endometrium. More importantly, severe tissue injuries were significantly relieved by transplanting our 3D artificial endometrium into endometrial ablation mice. Remarkably, artificial endometrium transplantation resulted in a successful pregnancy with subsequent live birth without any morphological or chromosomal abnormalities.

Superovulation with gonadotropin-releasing hormone agonist or chorionic gonadotropin for ovulation trigger differentially affects leukocyte populations in the peri-implantation mouse uterus

To investigate the effect of superovulation with human chorionic gonadotropin (hCG) or gonadotropin-releasing hormone agonist (GnRHa) trigger on leukocyte density and expression of leukocyte-specific genes in the peri-implantation period in the mouse uterus. Laboratory research. University laboratory facility. Female mice were mated to fertile male mice in one of three protocols: (1) natural mating or mating following injection with pregnant mare serum gonadotropin followed by trigger with (2) GnRHa or (3) hCG. Female mice were killed prior to implantation, 3 days after ovulation (E3.5), and the ovaries and uterine tissue were collected. Total RNA was isolated and assayed using quantitative reverse transcription polymerase chain reaction, and the uterine tissue was stained for histologic analysis of immune cell markers. Endometrial leukocyte (CD45) and vessel density (CD31) by immunohistochemical staining; expression of leukocyte markers CD11b, CD335, and CD22, by quantitative reverse transcription polymerase chain reaction in the whole uterine tissue. Superovulation decreased (compared with controls) the endometrial leukocyte density, based on the number of cells staining for CD45, and endometrial vessel density, based on the number of cells staining for CD31. Leukocyte density was additionally decreased in the GnRHa trigger group compared with that in the hCG trigger group. Superovulation with hCG and GnRHa triggers decreased the uterine expression of the B-cell marker CD22 compared with controls. The expression of the natural killer cell marker CD11b was decreased by the hCG trigger but not by the GnRHa. Abundance of mRNA encoding the CD335 natural killer cell marker was not affected by superovulation or trigger agent. In mice, superovulation with the GnRHa trigger compared with that with the hCG trigger differentially alters key immunologic factors in the uterine peri-implantation. These altered immunologic factors have roles in angiogenesis that may assist in elucidating the effects of assisted reproductive technologies on implantation efficiency and fetal growth and development.

Human endometrial perivascular stem cells exhibit a limited potential to regenerate endometrium after xenotransplantation.

What are the localization, characteristics and potential for tissue regeneration of two perivascular stem cells, namely CD34+ adventitial cells and CD146+ pericytes, in human endometrium? Human endometrial CD34+ adventitial cells (located in the outermost layer of blood vessels and mainly in the basal layer) and CD146+ pericytes showed mesenchymal stem cell (MSC) phenotypes in in vitro culture, but presented limited potential to regenerate endometrium. Periodic endometrial regeneration is considered to be maintained by MSCs. Blood vessel wall, regarded as stem cell niche, harbors a large reserve of progenitor cells that may be integral to the origin of MSCs. However, a lack of validated markers has hampered the isolation of putative endometrial MSCs. Currently, CD146+ pericytes and Sushi Domain Containing 2 (SUSD2) positive cells have been identified in the endometrial perivascular region as sharing MSCs characteristics. The locations of adventitial cells and pericytes in the human endometrium were identified by immunofluorescence staining (n = 4). After CD34+CD146-CD45-CD56-CD144- adventitial cells and CD146+CD34-CD45-CD56-CD144- pericytes were isolated from the endometrium of normal women (n = 6) by fluorescence-activated cell sorting, their characteristics were investigated in culture. Adventitial cells and pericytes were induced to differentiate, respectively, into vascular endothelial-like cells or endometrial stromal-like cells in vitro, with their potential explored by in vivo xenotransplantation (n = 2 in each group) and eutopic transplantation (n = 2 in each group). CD34+ adventitial cells and CD146+ pericytes were cultured in the inducing medium to differentiate into endothelial-like cells in vitro, and then analyzed for CD31, von Willebrand factor immunofluorescent staining and tube formation. They were also cultured to differentiate into endometrial stromal cells in vitro, with the expression of vimentin and CD13 being detected by western blot before and after induction, and the expression of prolactin and insulin-like growth factor-binding protein 1 being determined as well. Single dispersed CD34+ adventitial cells and CD146+ pericytes were respectively transplanted under the kidney capsule of NOG mice to investigate their differentiation potential in vivo. A eutopic transplantation model was constructed by grafting recellularized uterine matrix loaded up with CM-Dil labeled adventitial cells or pericytes into the injury region of nude rat's uterus. CD34+ adventitial cells were mainly located at the outmost layer of endometrial large vessels, while CD146+ pericytes were found surrounding the inner endothelial cells of microvessels. A small proportion of CD34+ adventitial cells expressed SUSD2. The number of adventitial cells was ∼40 times higher than that of pericytes in the endometrium. Both adventitial cells and pericytes showed MSC phenotypes after in vitro culture. After in vitro induction into endometrial endothelial-like cells and stromal-like cells, adventitial cells showed higher plasticity than pericytes and a closer correlation with stromal-like cells. In the mouse xenotransplantation model, vimentin+ cells, CD31+ endothelial-like cells and CD146+ pericyte-like cells could be observed after adventitial cells were transplanted. CM-Dil-labeled adventitial cells or pericytes could survive in the immunocompromised nude rats after eutopic transplantation, and vimentin+ cells were detected. In addition, CM-Dil-labeled adventitial cells or pericytes did not express α-smooth muscle actin or E-cadherin after transplantation. N/A. CD34 was chosen as a novel marker to isolate adventitial cells from human endometrium according to previous literature. The association of endometrial CD34+ adventitial cells and SUSD2+ MSCs should be further investigated. The decellularized uterine matrix model might be useful in endometrial stem cell therapy. L.D. is supported by grants from National Key Research and Development Program of China (2018YFC1004700), Nature Science Foundation of China (81871128, 81571391) and Nanjing Medical Science Development Project (ZKX16042). H.S. is supported by a grant from Jiangsu Province Social Development Project (BE2018602). X.Z. was supported by grants from the Postgraduate Innovative Project of Jiangsu Province (KYCX19-1177). The authors declare no conflict of interest.

Green urine sign after laparoscopic chromopertubation as an effect of severe contrast intravasation: a report of three cases

Tubal diseases are responsible for 25% to 35% of female infertility. Laparoscopic chromopertubation is the gold standard for assessing tubal patency when female infertility is suspected. Intravasation is a complication of intrauterine procedures involving the passage of fluid filling the uterine cavity into the bloodstream through endometrial vessels (from the myometrial veins to the uterine venous plexuses). This complication has been described during hysterosalpingography and sonohysterosalpingography. We herein present a report of three cases in which severe intravasation occurred during laparoscopic chromopertubation using methylene blue as a contrast agent. The intravasation manifested as green urine (i.e., the “green urine sign”). The presence of methylene blue in the urine and blood was confirmed by laboratory tests. All three patients had risk factors for intravasation as described in the literature (unilateral or bilateral tubal obstruction, endometriosis, and previous intrauterine procedures for Mullerian duct anomalies and Asherman’s syndrome). The green urine sign appeared a few hours after laparoscopic chromopertubation and spontaneously resolved after 24 hours. Cystoscopy was performed to rule out bladder injury. All three patients required only clinical observation.

2430 Placental Site Trophoblastic Tumor—Unusual Cause of Nodular Regenerative Hyperplasia and Portal Hypertension: Case Report

INTRODUCTION: There are various causes of non-cirrhotic portal hypertension which can be classified as pre hepatic, intra hepatic and post hepatic. One of the causes of idiopathic non cirrhotic portal hypertension is nodular regenerative hyperplasia (NRH). There are various disorders which are associated with NRH. We report a case of placental site trophoblastic tumor as a cause of NRH and portal hypertension. CASE DESCRIPTION/METHODS: A 36 years old Caucasian female with no known medical illness presented with progressive abdominal swelling of 5 months duration. She had a normal vaginal delivery to a healthy baby one year back. She gained almost 40 pounds since she started to notice abdominal distention. She has no history of alcohol intake or medication use. On physical examination she had markedly distended abdomen, with fluid wave and small umbilical hernia. She had Pitting edema of 3+ in the extremities. Investigations revealed that the platelet count was 114, Sodium 124, ALT 41, AST 46 and albumin 2.6. Otherwise white cell count, hemoglobin, bilirubin, PT and INR values were within normal limit. Viral hepatitis panel and work up for other causes of chronic liver disease were unrevealing. Abdominal ultrasound showed ascites and mild splenomegaly. It also showed a normal liver echotexture, no ductal dilatation and a patent portal vein. Ascitic fluid analysis was suggestive of portal hypertension with SAAG of 2. Transjugular liver biopsy was suggestive of nodular regenerative hyperplasia. Portal pressure was elevated at 11 mmHg. On abdominal CT scan an incidental enlarged heterogeneous uterus with prominent sub endometrial and parametrial vessels was noted. Serum HCG was high (762). Subsequent hysteroscopy and endometrial biopsy revealed trophoblastic maturation suggestive of trophoblastic tumor. PET scan showed that the disease was limited to the uterus. The patient underwent total hysterectomy with bilateral salpingectomy. She was also treated with three cycles of chemotherapy. The patient experienced total resolution of here symptoms. Four months after her surgery the patient continues to be symptom free with resolution of ascites and leg swelling without any medications. DISCUSSION: Idiopathic non cirrhotic portal hypertension can be associated with a variety of conditions including hematologic, neoplastic, immunogenic and medication related. To our knowledge, this is the first report of nodular regenerative hyperplasia associated with trophoblastic tumor.

Endometrial and Subendometrial Vessels in Cases of Unexplained Infertility (Case Control Study)

AbstractBackground: Infertility defined as failure to conceive after 12 months of unprotected regular intercourse. Unex-plained infertility describes couples with infertility in whom standard investigations including semen analysis, tests of ovulation, and tubal patency have no gross abnormality.Aim of Study: To evaluate the endometrial and suben-dometrial blood flow in mid-luteal phase after measuring serum progesterone level in unexplained infertility patients and compare those parameters with fertile women in order to reveal the role of the uterine perfusion in unexplained infertility.Patients & Methods: In this study, we collected 100 participants presented to the outpatient clinic in Kasr El-Aini maternity hospital, we classify them into two groups: Group A: 50 women presented with unexplained infertility either primary or secondary (the case group). Group B: 50 women who had no history of infertility and at least have one child who came for any gynecological procedure (the control group) Primary outcome measures (VI) (FI) & (VFI) of endometrial and subendmetrial areas using (VOCAL) in mid luteal phase after measurement of serum progesterone level in both groups.Results: As regards endometrial vascularity index (VI), it was higher in control group (0.64±0.05) than in case group (0.51±0.09), Sub endometrial (VI) also was higher in control group (2.34±0.13) than in case group (1.92±0.22), endometrial flow index (FI), it was higher in control group (29.26±1.98) than in case group (24.47±4.19), sub endometrial flow index (FI), it was higher in control group (36.29±3.10) than in case group (30.52±2.52), endometrial vascular flow index (VFI), it was higher in control Group (0.36±0.05) than in case group (0.25±0.04) & subendometrial vascular flow index (VFI), it was higher in control group (1.13±0.25) than in case group (0.83±0.07) all of that are statistically significant. As regards to serum progesterone level it was higher in control group (12.87±2.47) than in case group (12.66±3.17) which was statistically insignificant.Conclusion: From our study we found that impairment of uterine perfusion could have a role in cases of unexplained infertility.

Endometrial vascular development in heavy menstrual bleeding: altered spatio-temporal expression of endothelial cell markers and extracellular matrix components.

Are there any phenotypic and structural/architectural changes in the vessels of endometrium and superficial myometrium during the normal menstrual cycle in healthy women and those with heavy menstrual bleeding (HMB)? Spatial and temporal differences in protein levels of endothelial cell (EC) markers and components of the extracellular matrix (ECM) were detected across the menstrual cycle in healthy women and these are altered in HMB. HMB affects 30% of women of reproductive age with ~50% of cases being idiopathic. We have previously shown that the differentiation status of endometrial vascular smooth muscle cells (VSMCs) is altered in women with HMB, suggesting altered vessel maturation compared to controls. Endometrial arteriogenesis requires the co-ordinated maturation not only of the VSMCs but also the underlying ECs and surrounding ECM. We hypothesized that there are spatial and temporal patterns of protein expression of EC markers and vascular ECM components in the endometrium across the menstrual cycle, which are altered in women with HMB. Biopsies containing endometrium and superficial myometrium were taken from hysterectomy specimens from both healthy control women without endometrial pathology and women with subjective HMB in the proliferative (PP), early secretory (ESP), mid secretory (MSP) and late secretory (LSP) phases (N = 5 for each cycle phase and subject group). Samples were fixed in formalin and embedded in paraffin wax. Serial sections (3μm thick) were immunostained for EC markers (factor VIII related antigen (F8RA), CD34, CD31 and ulex europaeus-agglutinin I (UEA-1) lectin), structural ECM markers (osteopontin, laminin, fibronectin and collagen IV) and for Ki67 to assess proliferation. Immunoreactivity of vessels in superficial myometrium, endometrial stratum basalis, stratum functionalis and luminal region was scored using either a modified Quickscore or by counting the number of positive vessels. In control samples, all four EC markers showed a dynamic expression pattern according to the menstrual cycle phase, in both endometrial and myometrial vessels. EC protein marker expression was altered in women with HMB compared with controls, especially in the secretory phase in the endometrial luminal region and stratum functionalis. For example, in the LSP expression of UEA-1 and CD31 in the luminal region decreased in HMB (mean quickscore: 1 and 5, respectively) compared with controls (3.2 and 7.4, respectively) (both P = 0.008), while expression of F8RA and CD34 increased in HMB (1.4 and 8, respectively) compared with controls (0 and 5.8, respectively) (both P = 0.008). There was also a distinct pattern of expression of the vascular structural ECM protein components osteopontin, laminin, fibronectin and collagen IV in the superficial myometrium, stratum functionalis and stratum basalis during the menstrual cycle, which was altered in HMB. In particular, compared with controls, osteopontin expression in HMB was higher in stratum functionalis in the LSP (7.2 and 11.2, respectively P = 0.008), while collagen IV expression was reduced in stratum basalis in the MSP (4.6 and 2.8, respectively P = 0.002) and in stratum functionalis in the ESP (7 and 3.2, respectively P = 0.008). The protein expression of vascular EC markers and ECM components was assessed using a semi-quantitative approach in both straight and spiral arterioles. In our hospital, HMB is determined by subjective criteria and levels of blood loss were not assessed. Variation in the protein expression pattern between the four EC markers highlights the importance of choice of EC marker for investigation of endometrial vessels. Differences in expression of the different EC markers may reflect developmental stage dependent expression of EC markers in endometrial vessels, and their altered expression in HMB may reflect dysregulated vascular development. This hypothesis is supported by altered expression of ECM proteins within endometrial vessel walls, as well as our previous data showing a dysregulation in VSMC contractile protein expression in the endometrium of women with HMB. Taken together, these data support the suggestion that HMB symptoms are associated with weaker vascular structures, particularly in the LSP of the menstrual cycle, which may lead to increased and extended blood flow during menstruation. This study was funded by Wellbeing of Women (RG1342) and Newcastle University. There are no competing interests to declare. Not applicable.

A Review and Reconsideration of Nonneoplastic Myometrial Pathology.

From 1861 to 1962, clinicopathologic research tried to explain the association of abnormal uterine bleeding with uterine enlargement. The etiology was theorized as metropathy, suggesting that myometrial dysfunction may predispose to abnormal uterine bleeding. Research reached a nadir in 1962, when a major review dismissed myometrial hypertrophy as a plausible explanation after prior rejections of the theories of chronic myometritis, fibrosis uteri, and subinvolution as causes of bleeding. Subsequent to this arose a crusade against unnecessary hysterectomies in the 1970s. Although myometrial hyperplasia was proposed in 1868, it is only in the past 25 years that tangible evidence has supported that idea. It now appears that clinically enlarged uteri are due to globoid outward bulging of the uterus, caused by increased intramural pressure-often unrelated to either uterine weight or myometrial thickness. Abnormal (dysfunctional) uterine bleeding may often be due to spontaneous rupture of thrombosed dilated endometrial vessels, due to the combined effects of obstructed venous drainage by increased intramural pressure, and Virchow's triad. Despite a century-old known association of parity with naturally occurring outer wall myometrial scars (fibrosis uteri with elastosis), it was not previously suggested that these may reflect healing reactions to muscle tears during labor and delivery. We now suggest that smaller, similar inner wall elastotic scars in the nerve-rich inner myometrium may explain many cases of pelvic pain. This review suggests that diverse pressure-related lesions may be present in clinically abnormal uteri that have been called "normal" since the crusade against unnecessary hysterectomy.

Embryoscopic diagnostics of endometrial defects in missed abortion after IVF

High incidence of missed abortion induces to search for its causes. Apart from genetic and anatomic uterine factors, the state of the decidual endometrium and implantation zone of chorionic structures of the gestational sac are of particular interest. Direct visualization of the intact decidual endometrium is possible with embryoscopy, however, there is lack of presented data of normal and pathological signs of the endometrium during pregnancy. This paper describes the changes of the endometrium in missed abortion obtained by hysteroscopy in 160 women with nonprogressive pregnancy after ART protocols. High incidence of vascular disorders is determined, namely perivascular hemorrhage (70%), thrombosis of small-caliber endometrial vessels (36.9%), necrosis of the decidual endometrium and areas of the endometrium ejection beyond the implantation zone as a source of vaginal bleeding (10%). In addition, a high incidence of capsular decidual membrane defects are detected, namely, dystrophy, thinning and necrosis (60.6%).

Placenta Accreta and Placenta Increta: An Approach to Pathogenesis Based on the Trophoblastic Differentiation Pathway.

Morbid adherence remains a puzzling disease. This paper suggests that normal and morbidly adherent placentation may be viewed best in terms of trophoblastic stem cells and the mutually exclusive branches of the trophoblastic differentiation pathway-villous trophoblast (VT), interstitial and endovascular nonvillous trophoblast (NVT) at the implantation site, and a positional variation in the chorion. Based on cases of hysterectomies for morbid adherence seen over 30 years at a community hospital, analyzed with routine keratin stains, with actin and trichrome stains as indicated, and with attempts at ultrasonography-pathology correlation, we present selected observations. In true accreta, the site of morbid adherence was to dilated basal plate vessels infiltrated by endovascular NVT, with scant interstitial NVT, and normal myometrium. It appeared that excess blood flow into the placenta was due to excessively deep keratin-positive endovascular NVT that spread-independently of interstitial NVT-in an angiocentric fashion in both accreta and increta. Retroplacental abnormalities were due to myometrial destruction by interstitial NVT in increta, sometimes requiring actin stains for detection; and to an admixture of markedly dilated endometrial glands and vessels in true accreta, best appreciated with keratin stains. Variations of depth and extent in increta may be due to variations in myometrial tone, and in the protease-antiprotease balance. Morbidly adherent fetal membranes are described, and the role of caesarean section scars in incretas is addressed.

Equine endometrial vascular pattern changes during the estrous cycle examined by Narrow Band Imaging hysteroscopy

The aim of this study was to evaluate the uterine blood supply and endometrial vessel architecture, during the equine estrous cycle. Narrow Band Imaging (NBI) hysteroscopy was used for evaluating changes in the endometrial vasculature during the estrous cycle [six mares, d 0 (representing the day of ovulation), d 6 and 11 in four locations]. In addition, endometrial biopsy samples were used for immunodetection of markers for angiogenesis (Vascular Endothelial Growth Factor A, its receptor 2, as well as angiopoietin-2 and its receptor-tyrosine-kinase Tie2) during the estrous cycle (three mares, d 0, 5 and 10; one biopsy per mare). Detailed analysis of hysteroscopic images revealed an increase in the vascular density from estrus towards diestrus. In contrast, microscopic specimens prepared from biopsies revealed no evidence for changes in the endometrial vessel number during the estrous cycle. Studies on expression of angiogenesis markers indicated that cyclic changes in the endometrial vascular density observed by NBI-hysteroscopy were not due to formation of new vessels. It is concluded that vessels are involved in blood supply of a smaller area during diestrus, facilitating better distribution of nutrients during this phase.

Human CD133+ bone marrow-derived stem cells promote endometrial proliferation in a murine model of Asherman syndrome

To investigate the engraftment and proliferation of superparamagnetic iron oxide nanoparticles (SPIOs)-labeled human CD133(+) bone marrow-derived stem cells (BMDSCs) in an animal model of Asherman syndrome (AS). Prospective experimental animal study. University research laboratories. Nonobese diabetic mice (strain code 394; NOD.CB17- Prkdc(scid)/NcrCrl) in which AS was induced according to a published protocol. Human CD133(+) BMDSCs were obtained from patients undergoing autologous cell therapy in refractory AS and endometrial atrophy, labeled with SPIOs and injected either intrauterinely (n = 5) or systemically through the tail vein (n = 5) in the animal model. Accumulation of collagen and glycosaminoglycan deposits detected by trichrome staining. Percentage and localization of engrafted human SPIOs-labeled CD133(+) BMDSCs by Prussian blue staining. Cell proliferation assay using Ki67 and reverse transcriptase-polymerase chain reaction (PCR) for specific paracrine factors. The induction of the AS in the murine model was demonstrated by the accumulation of collagen and glycosaminoglycan deposits in the damaged horns by trichrome staining. Human SPIOs labeled CD133(+) BMDSCs homing represents 0.59% and 0.65% of total number of cells present in the horns after intrauterine or tail vein injections, respectively. Engrafted cells were localized around endometrial blood vessels, inducing proliferation in surrounding cells based on Ki67 and regulation of the paracrine factors thrombospondin 1 and insulin-like growth factor 1. The injection of human SPIOs labeled CD133(+) BMDSCs in a murine model of AS confirms that these cells engraft around endometrial vessels, inducing proliferation of surrounding cells through paracrine molecules such as thrombospondin 1 and insulin-like growth factor 1. NCT02144987.