Junctional Zone Research Articles

Effect of changes in the menstrual cycle and age on the signal intensity of amide proton transfer imaging in the normal uterus: a preliminary study.

To analyze the effect of changes in the menstrual cycle and age on the signal intensity of amide proton transfer (APT) imaging in normal uterine structures. Thirty-one healthy females (age: 21-50years old) underwent regular pelvic MRI and APT sequences during their menstrual cycle. The APT values of the endometrium, myometrium, and junctional zone were measured. One-way and multi-way analyses of variance were used to analyze the data. Intraindividual difference and Pearson's correlation analyses were also conducted. The APT values of the uterine structures during the menstrual, proliferative, and secretory phases were 3.413 ± 0.682%, 4.776 ± 0.829%, and 5.218 ± 0.772% for the endometrium; 2.966 ± 0.533%, 3.597 ± 0.380%, and 4.324 ± 0.583% for the myometrium; and 1.703 ± 0.393%, 2.362 ± 0.486%, and 2.779 ± 0.528% for the junctional zone. The individual variation in the APT values of the normal uterus during the three menstrual phases was 1.1-1.7%.There were no significant differences in APT values of uterine structures with age. The APT values of the endometrium were greater than those of other structures (P < 0.05).The Pearson correlation coefficients between APT values of uterine structures and menstrual cycle were 0.686, 0.743, and 0.684, respectively. The menstrual cycle had a significant effect on the APT signal intensities of the uterine structures, whereas premenopausal age had no significant effect. Changes in the uterine structures during the menstrual cycle should be considered when using APT to diagnose suspected uterine lesions.

Predicting Topographic Disease Progression and Treatment Response of Pegcetacoplan in Geographic Atrophy Quantified by Deep Learning

To identify disease activity and effects of intravitreal pegcetacoplan treatment on the topographic progression of geographic atrophy (GA) secondary to age-related macular degeneration quantified in spectral-domain OCT (SD-OCT) by automated deep learning assessment. Retrospective analysis of a phase II clinical trial study evaluating pegcetacoplan in GA patients (FILLY, NCT02503332). SD-OCT scans of 57 eyes with monthly treatment, 46 eyes with every-other-month (EOM) treatment, and 53 eyes with sham injection from baseline and 12-month follow-ups were included, in a total of 312 scans. Retinal pigment epithelium loss, photoreceptor (PR) integrity, and hyperreflective foci (HRF) were automatically segmented using validated deep learning algorithms. Local progression rate (LPR) was determined from a growth model measuring the local expansion of GA margins between baseline and 1 year. For each individual margin point, the eccentricity to the foveal center, the progression direction, mean PR thickness, and HRF concentration in the junctional zone were computed. Mean LPR in disease activity and treatment effect conditioned on these properties were estimated by spatial generalized additive mixed-effect models. LPR of GA, PR thickness, and HRF concentration in μm. A total of 31,527 local GA margin locations were analyzed. LPR was higher for areas with low eccentricity to the fovea, thinner PR layer thickness, or higher HRF concentration in the GA junctional zone. When controlling for topographic and structural risk factors, we report on average a significantly lower LPR by -28.0% (95% confidence interval [CI], -42.8 to -9.4; P = 0.0051) and -23.9% (95% CI, -40.2 to -3.0; P = 0.027) for monthly and EOM-treated eyes, respectively, compared with sham. Assessing GA progression on a topographic level is essential to capture the pathognomonic heterogeneity in individual lesion growth and therapeutic response. Pegcetacoplan-treated eyes showed a significantly slower GA lesion progression rate compared with sham, and an even slower growth rate toward the fovea. This study may help to identify patient cohorts with faster progressing lesions, in which pegcetacoplan treatment would be particularly beneficial. Automated artificial intelligence-based tools will provide reliable guidance for the management of GA in clinical practice.

Evidence From Human Placenta, Endoplasmic Reticulum-Stressed Trophoblasts, and Transgenic Mice Links Transthyretin Proteinopathy to Preeclampsia.

We have demonstrated that protein aggregation plays a pivotal role in the pathophysiology of preeclampsia and identified several aggregated proteins in the circulation of preeclampsia patients, the most prominent of which is the serum protein TTR (transthyretin). However, the mechanisms that underlie protein aggregation remain poorly addressed. We examined TTR aggregates in hypoxia/reoxygenation-exposed primary human trophoblasts (PHTs) and the preeclampsia placenta using complementary approaches, including a novel protein aggregate detection assay. Mechanistic analysis was performed in hypoxia/reoxygenation-exposed PHTs and Ttr transgenic mice overexpressing transgene-encoded wild-type human TTR or Ttr-/- mice. High-resolution ultrasound analysis was used to measure placental blood flow in pregnant mice. TTR aggregation was inducible in PHTs and the TCL-1 trophoblast cell line by endoplasmic reticulum stress inducers or autophagy-lysosomal disruptors. PHTs exposed to hypoxia/reoxygenation showed increased intracellular BiP (binding immunoglobulin protein), phosphorylated IRE1α (inositol-requiring enzyme-1α), PDI (protein disulfide isomerase), and Ero-1, all markers of the unfolded protein response, and the apoptosis mediator caspase-3. Blockade of IRE1α inhibited hypoxia/reoxygenation-induced upregulation of Ero-1 in PHTs. Excessive unfolded protein response activation was observed in the early-onset preeclampsia placenta. Importantly, pregnant human TTR mice displayed aggregated TTR in the junctional zone of the placenta and severe preeclampsia-like features. High-resolution ultrasound analysis revealed low blood flow in uterine and umbilical arteries in human TTR mice compared with control mice. However, Ttr-/- mice did not show any pregnancy-associated abnormalities. These observations in the preeclampsia placenta, cultured trophoblasts, and Ttr transgenic mice indicate that TTR aggregation is an important causal contributor to preeclampsia pathophysiology.

Kisspeptin treatment improves fetal-placental development and blocks placental oxidative damage caused by maternal hypothyroidism in an experimental rat model.

Maternal hypothyroidism is associated with fetal growth restriction, placental dysfunction, and reduced kisspeptin/Kiss1R at the maternal-fetal interface. Kisspeptin affects trophoblastic migration and has antioxidant and immunomodulatory activities. This study aimed to evaluate the therapeutic potential of kisspeptin in the fetal-placental dysfunction of hypothyroid Wistar rats. Hypothyroidism was induced by daily administration of propylthiouracil. Kisspeptin-10 (Kp-10) treatment was performed every other day or daily beginning on day 8 of gestation. Feto-placental development, placental histomorphometry, and expression levels of growth factors (VEGF, PLGF, IGF1, IGF2, and GLUT1), hormonal (Dio2) and inflammatory mediators (TNFα, IL10, and IL6), markers of hypoxia (HIF1α) and oxidative damage (8-OHdG), antioxidant enzymes (SOD1, Cat, and GPx1), and endoplasmic reticulum stress mediators (ATF4, GRP78, and CHOP) were evaluated on day 18 of gestation. Daily treatment with Kp-10 increased free T3 and T4 levels and improved fetal weight. Both treatments reestablished the glycogen cell population in the junctional zone. Daily treatment with Kp-10 increased the gene expression levels of Plgf, Igf1, and Glut1 in the placenta of hypothyroid animals, in addition to blocking the increase in 8-OHdG and increasing protein and/or mRNA expression levels of SOD1, Cat, and GPx1. Daily treatment with Kp-10 did not alter the higher protein expression levels of VEGF, HIF1α, IL10, GRP78, and CHOP caused by hypothyroidism in the junctional zone compared to control, nor the lower expression of Dio2 caused by hypothyroidism. However, in the labyrinth zone, this treatment restored the expression of VEGF and IL10 and reduced the GRP78 and CHOP immunostaining. These findings demonstrate that daily treatment with Kp-10 improves fetal development and placental morphology in hypothyroid rats, blocks placental oxidative damage, and increases the expression of growth factors and antioxidant enzymes in the placenta.

Expulsion of Adenomyotic Lesion into Uterine Cavity after High-intensity Focused Ultrasound Ablation

A 46-year-old female, gravida 5 para 0, with a 10-year history of dysmenorrhea, was admitted to our hospital. Her symptoms worsened about 6 months before admission, affecting her sleep. Magnetic resonance imaging (MRI) showed that the uterine wall was asymmetrically thickened, with obvious thickening and an abnormal signal at junctional zone, especially the posterior wall and fundus (Fig. 1A). A diagnosis of adenomyosis was made. Because the patient had not yet given birth and wanted to preserve her uterus, she chose high-intensity focused ultrasound (HIFU) ablation.

Consensus on revised definitions of Morphological Uterus Sonographic Assessment (MUSA) features of adenomyosis: results of modified Delphi procedure.

ABSTRACTObjectivesTo evaluate whether the Morphological Uterus Sonographic Assessment (MUSA) features of adenomyosis need to be better defined and, if deemed necessary, to reach consensus on the updated definitions.MethodsA modified Delphi procedure was performed among European gynecologists with expertise in ultrasound diagnosis of adenomyosis. To identify MUSA features that might need revision, 15 two‐dimensional (2D) video recordings (four recordings also included three‐dimensional (3D) still images) of transvaginal ultrasound (TVS) examinations of the uterus were presented in the first Delphi round (online questionnaire). Experts were asked to confirm or refute the presence of each of the nine MUSA features of adenomyosis (described in the original MUSA consensus statement) in each of the 15 videoclips and to provide comments. In the second Delphi round (online questionnaire), the results of the first round and suggestions for revision of MUSA features were shared with the experts before they were asked to assess a new set of 2D and 3D still images of TVS examinations and to provide feedback on the proposed revisions. A third Delphi round (virtual group meeting) was conducted to discuss and reach final consensus on revised definitions of MUSA features. Consensus was predefined as at least 66.7% agreement between experts.ResultsOf 18 invited experts, 16 agreed to participate in the Delphi procedure. Eleven experts completed and four experts partly finished the first round. The experts identified a need for more detailed definitions of some MUSA features. They recommended use of 3D ultrasound to optimize visualization of the junctional zone. Fifteen experts participated in the second round and reached consensus on the presence or absence of ultrasound features of adenomyosis in most of the still images. Consensus was reached for all revised definitions except those for subendometrial lines and buds and interrupted junctional zone. Thirteen experts joined the online meeting, in which they discussed and agreed on final revisions of the MUSA definitions. There was consensus on the need to distinguish between direct features of adenomyosis, i.e. features indicating presence of ectopic endometrial tissue in the myometrium, and indirect features, i.e. features reflecting changes in the myometrium secondary to presence of endometrial tissue in the myometrium. Myometrial cysts, hyperechogenic islands and echogenic subendometrial lines and buds were classified unanimously as direct features of adenomyosis. Globular uterus, asymmetrical myometrial thickening, fan‐shaped shadowing, translesional vascularity, irregular junctional zone and interrupted junctional zone were classified as indirect features of adenomyosis.ConclusionConsensus between gynecologists with expertise in ultrasound diagnosis of adenomyosis was achieved regarding revised definitions of the MUSA features of adenomyosis and on the classification of MUSA features as direct or indirect signs of adenomyosis. © 2021 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Abnormal growth and morphogenesis of placenta at term is linked to adverse fetal development after perigestational alcohol consumption up to early gestation in mouse.

Gestation alcohol consumption produces fetal growth restriction and malformations by affecting the embryo-fetal development. Recently a relationship between abnormal placentation and fetal malformation and intrauterine growth retardation has been suggested. However, the effects of perigestational alcohol ingestion up to early pregnancy on the placenta at term and its association with fetal abnormalities are little known. In female mice, ethanol 10% in water was administered for 15 days previous and up to days 4 (D4), 8 (D8), or 10 (D10) of gestation (TF), and gestation continues without ethanol exposure. Control females (CF) received ethanol-free water. At day 18, feto-placental units and implantation sites were studied. TF had increased resorptions and only fetuses from D8-TF and D10-TF had significantly increased weights versus CF. D4 and D10-TF-placentas had significantly reduced weights. All TF had increased junctional zone (JZ) and reduced labyrinth (Lab) areas (PAS-histology and morphometry) compared with CF. Fetuses with mainly with craniofacial abnormalities and skeletal defects (Alizarin red staining), significantly increase; while the fetal bone density (alizarin color intensity, ImageJ) was reduced in D4, D8 and D10-TF versus CF. Although all TF-placentas were histo-structural affected, TF-abnormal fetuses had the most severe placental anomalies, with junctional abundant glycogenic cells into the labyrinth, disorganized labyrinthine vascularization with signs of leukocyte infiltrates and feto-maternal blood mix. Perigestational alcohol consumption up to early gestation induces at term fetal growth alterations, dysmorphology and defective skeleton, linked to deficient growth and abnormal morphogenesis of placenta, highlighting insight into the prenatal etiology of FASD.

O-232 Art of fibroid removal in patients with infertility

Abstract Aim of myomectomy in infertile patient is to preserve and improve fertility, minimising excessive bleeding and pain. Relation ship of myoma and fertility remains debatable moreover removal of all myomas may not be helpful in improving fertility outcome thus it becomes important to decide which fibroid should be removed and which one shouldn’t be touched. Principle of minimal damage and complication should be kept in mind. Mapping of fibroid is an important step in planning the route of operation.Number and site of myoma decides the approach. A preoperative meticulous TVS examination supplemented by TAS specially in large and multiple fibroids is extremely helpful in decision making. it is also important to preoperative differentiation of adenomyosis and fibroid to avoid a surprise element and excessive bleeding during removal. Use of colour flow may be helpful in differentiating. Use of 3-D is important specially in borderline sub mucous myoma. Extent of myoma in to uterine cavity is very important to decide the route of operation. various classifications have attempted to simplify the decision making but combining usg and hysteroscopy is the best way to decide. it is also important to diagnose a large intramural myoma touching the junctional zone. Instilling methylene blue before operation to outline the cavity during surgery in case of accidental entry is a good practice. using intraoperative ultrasound while tackling a large intracavitary fibroid having more than 75% extent in intra myometrial region may be helpful in complete removal. The placement of the optical and secondary ports determines the degree of ergonomic surgery performance, time and difficulty of myoma enucleation, and the ease of suturing. reducing the bleeding during enucleation, dissection in the right plane, minimal use of cautery and proper suturing and closure avoiding any haematoma formation are key points for a successful myomectomy. Use of diluted vasopressin is very effective in making the surgery blood less. So also the use of bipolar in coagulating the large blood vessels. Using bipolar diathermy, a dissecting grasper, and a suction cannula, meticulous exploration of the dissection field can more efficiently detect and coagulate any actively bleeding vessels. Slow rotation of the bevelled morcellator and good control of the bag could reduce de novo myoma and endometriosis. The surgery outcome and the risk of intraoperative complications are highly dependent on trocar placement, finding of the correct cleavage plane, haemostasis, and suturing technique. Flap technique is an innovative approach for removing small fibroid near junctional zone. Good surgery with respect to minimal destruction and handling of the healthy tissue, avoiding unnecessary organ manipulation, controlled bleeding, minimal coagulation, and reasonable operating time remain the best ways to diminish the risk of adhesion formation.It is very important to preserve the cavity, minimal adhesion formation and perfect suturing avoiding dead spaces and haematoma formation for a successful out come in infertile patient.

P-312 Effect on pregnancy outcomes of depot GnRH agonist pre-treatment before frozen-thawed embryo transfer cycles in patients with adenomyosis

Abstract Study question Is there any difference between using or not using depot GnRH agonist pre-treatment on pregnancy outcomes in patients with adenomyosis before frozen-thawed embryo transfer cycles? Summary answer GnRH agonist pre-treatment before frozen-thawed embryo transfer has no effect on pregnancy outcomes in adenomyosis patients. What is known already Uterine adenomyosis negatively affects implantation and clinical pregnancy rates and also increases the risk of early pregnancy loss. Increased inflammatory markers and increased myometrial peristalsis are thought to decrease the rate of implantation. Depot GnRH agonist pre-treatment is thought to increase implantation rate by both decreasing myometrial contractility and reducing inflammatory marker production. Study design, size, duration This retrospective cohort study was conducted at ART and Reproductive Genetics Centre, Memorial Sisli Hospital, Istanbul, Turkey. Patients with adenomyosis undergoing a FET cycle between 2011 and 2021 were evaluated. Patients between 25-45 years old with good and top-quality blastocysts were included and preimplantation genetic diagnosis (PGD) was applied to patients who were &amp;gt;37 years old. A total of 144 frozen embryo transfer cycles were examined. Participants/materials, setting, methods Diagnosis of adenomyosis was made using transvaginal ultrasound and/or pelvic magnetic resonance imaging which revealed an asymmetrically thickening between the anterior and posterior uterine walls, focal adenomyosis, myometrial cysts and irregular/interrupted junctional zone of the endometrium. 65 patients in the study group (Group I) who received depot GnRH agonist pre-treatment for minimum 2 and maximum 6 months and 79 patients without GnRH agonist pre-treatment (Group 2) were evaluated. Main results and the role of chance There was no significant difference in patient characteristics such as age, endometrial thickness on embryo transfer day, BMI, infertility duration, and anti mullerian hormone levels between groups 1 and 2. Endometrial preparation was done using artificial cycle in the depot agonist group, whereas both artificial and modified natural cycle were used in patients without depot GnRH agonist pre-treatment.The pregnancy rate was 53.8%(n = 35) in group 1 and 54.4%(n = 43) in group 2. The clinical pregnancy loss rate was 20% (n = 9) in group 1 and 15.7% (n = 6)in group 2. The live birth rate was 40% (n = 26) in group I and 39.2. (n = 31) in group II. There were no statistically significant differences in pregnancy rates, clinical pregnancy losses, and live birth rates between the groups. Limitations, reasons for caution The limitation of the study is its retrospective nature. Wider implications of the findings The lack of any statistically significant differences in pregnancy outcomes in this study suggests the need for further evaluation of the value/effectiveness of GnRHa treatment in adenomyosis patients before embryo transfer cycles. Trial registration number not applicable

P-333 The influence of hormonal stimulation on uterine peristalsis measured by ultrasound speckle tracking in women with IVF/ICSI treatment compared to normal ovulating women

Abstract Study question To investigate possible effects of ovarian stimulation during IVF/ICSI on uterine peristalsis features using ultrasound speckle tracking compared to normal ovulating women. Summary answer Patients with a normal uterus treated with exogenous hormones during IVF/ICSI treatment show significantly increased contraction amplitude and power parameters compared to normal ovulating women. What is known already Uterine peristalsis plays a role in procreation. Subjective visual inspection of uterine peristalsis is extensively researched throughout the menstrual cycle. Studies on uterine peristalsis in IVF/ICSI patients show higher frequency of uterine contractions during the periovulatory phase. Recently, a new automated quantitative method was validated to objectively analyse uterine strain using speckle tracking. Besides objective insight in frequency, also information on amplitude, power and coordination of motion is available. The effect of exogenous hormones on uterine contraction features has not objectively been studied using this new method. Study design, size, duration This multicentre prospective observational cohort study was performed between 2020 and 2022 in the Catharina Hospital in Eindhoven, the Netherlands, Embryolab Fertility Centre in Thessaloniki, Greece and University of Naples, Federico II in Naples, Italy. 30 normal ovulating patients served as controls. The primary outcomes were the contraction features frequency, amplitude, direction, velocity, power and coordination in women undergoing IVF/ICSI on the day of follicle aspiration compared to controls on cycle day 9 – 14. Participants/materials, setting, methods 19 women undergoing IVF/ICSI were included regardless of the treatment cycle number and stimulation protocol. Indication for IVF/ICSI treatment was male subfertility (n = 8), idiopathic subfertility (n = 5), tubal factor (n = 2), primary ovarian insufficiency (n = 2) or combined (n = 2), all women had normal uteri on transvaginal ultrasound. The control group consisted of 30 healthy pre-menopausal women with normal uteri on ultrasound and spontaneous regular cycles. Main results and the role of chance Each patient underwent a 2.5 – 4 minute transvaginal ultrasound of the uterus in mid-sagittal plane. The various contraction features were extracted using a quantitative dedicated speckle tracking algorithm analysis studying motion of the subendometrial junctional zone. Mean age of IVF/ICSI patients was 32.7 years and mean BMI was 25.6. Mean age of healthy controls was 33.8 years, BMI was 23.4, and cycle length was 27.44 days. Characteristics of IVF/ICSI patients and healthy volunteers showed no statistically significant differences. Both groups predominantly consisted of nulliparous women. In IVF/ICSI patients the contraction amplitude was significantly higher compared to controls (0.062 vs 0.040; p &amp;lt; 0.001). The contraction power (combination of amplitude and frequency) appeared to be significantly higher in IVF/ICSI patients compared to controls (1528.18 vs 683.44; p &amp;lt; 0.001). No significant differences were found in contraction frequency and coordination. Even though the mean coordination did not show statistically significant differences, the values were less scattered in IVF/ICSI patients, with a much smaller range of coordination values (1.04 – 3.06) compared to healthy volunteers (1.02 – 50.33). Limitations, reasons for caution The reported difference between IVF/ICSI patients and controls in contraction amplitude and power may not solely be attributed to the administration of exogenous hormones. The difference may also be due to an underlying cause for infertility in these patients. Another limitation of this study is the small sample size. Wider implications of the findings Future research should explore which uterine contraction profile is associated with viable pregnancy: during the natural menstrual cycle, or when treated with hormones. The question arises whether it is preferred to transfer the embryo in the stimulated cycle or implement a freeze-all policy and transfer during the natural menstrual cycle. Trial registration number NCT02310802

P-324 Effectiveness of letrozole in symptomatic women with adenomyosis undergoing IVF: An overview of clinical features, sonographic characteristics, and reproductive outcome

Abstract Study question Is letrozole pre-treatment a cost-effective option in improving symptoms, sonographic features, and reproductive outcomes in women with adenomyosis, undergoing IVF treatment? Summary answer Only two months of low dose letrozole pre-treatment is as effective as GnRH-agonist in symptomatic adenomyosis while significantly reducing the cost of treatment. What is known already About 20%–25% of women undergoing IVF present with adenomyosis and many of them suffer from dysmenorrhea and menorrhagia. Adenomyosis is often underdiagnosed and neglected uterine pathology which has a major bearing on the quality of life and fertility. Since adenomyosis is an estrogen-dependent disorder, letrozole, an aromatase inhibitor (controls estrogen production) is reported to be effective in improving symptoms of adenomyosis similar to GnRH-agonist but its role as before treatment IVF is unclear. Although GnRH-agonist is an established and effective pre-treatment option, is expensive and comes with the concerns like menopausal symptoms, increased gonadotropin doses, and duration of stimulation. Study design, size, duration This longitudinal, randomized cohort study was conducted at a tertiary-care hospital during June-2019 and November-2021. 194 adenomyosis women with symptoms undergoing fresh-cycle IVF, were screened and 147 recruited. These women were resistant to OCPs/progestins for symptomatic relief. 72 patients were treated with letrozole and 75 with GnRH-agonist for 2 months, and changes in their sonographic features and symptoms were evaluated before and after treatment. Reproductive outcomes were also compared between the treatment groups after IVF. Participants/materials, setting, methods Adenomyosis was diagnosed on 2D-TVS according to MUSA criteria. Among them, 72 patients were treated with 2.5 mg letrozole (only thrice weekly instead of conventional 2.5mg/daily) and 75 women were treated with GnRH-agonist depot (3.6mg/month) for 2 months. Patients were evaluated before and after 2 months of treatment for improvements in dysmenorrhea (VAS score) and menorrhagia (PBAC score), and quantitative scoring of sonographic features. Reproductive outcomes were also compared after both treatment. Main results and the role of chance The majority of women had 3-4 sonographic criteria on TVS (median of 3), such as irregular or interrupted junctional zone (79.49%), asymmetrical thickening of the myometrium (71.15%), globular uterus (43.59%), and myometrial cyst (33.33%). Significant reductions in the sonographic severity scores for diffuse adenomyosis, adenomyoma, and asymmetry in myometrial thickness were observed following both the treatment (p &amp;lt; 0.05). The effects of both the treatments were comparable in terms of severity of sonographic features (p &amp;gt; 0.05). Significant decreases in dysmenorrhea (letrozole: pre-7.76±1.6, post-1.74±0.58; GnRH-agonist: pre-7.92±2.1, post-0) and menorrhagia (letrozole: pre-169±31, post-73±18; GnRH-agonist: pre-171±25, post-12±6) were observed after 2 months in both the treatment (p &amp;lt; 0.05). Since GnRH-agonist treated women experienced cessation of menstruation, the VAS and PBAC scores were not directly comparable between the groups after treatment. All fresh cycle IVF women were included to understand the effect of pre-treatment of these women. Following fresh cycle IVF, clinical pregnancy (23.61%, 25.33%), miscarriage rate (35.29%, 36.84%), and live birth rate (12.5%, 13.33%), respectively for letrozole and GnRH-agonist groups were comparable (p &amp;gt; 0.05). The cost of the treatment was 19 times less with letrozole pre-treatment when compared with GnRH-agonist, while a comparable reduction in symptoms and IVF outcome parameters were observed. Limitations, reasons for caution A possible limitation is the lack of a proper blinding due to different routes of administration of the therapies. In the absence of a standardized classification of severity, we have used the TVS based scoring proposed by Lazzeri et al (2018), which is not universally accepted or independently validated. Wider implications of the findings Low-dose letrozole pre-treatment for 2 months is an attractive option before IVF for symptoms relief and comparable reproductive outcome to that of GnRH-agonist but with lower cost and without over-suppression of pituitary. This protocol may also be extended to women in general who are suffering from symptomatic adenomyosis. Trial registration number CTRI/2019/01/016919 [04/01/2019]

P-418 The effect of subendometrial injection of autologous platelet rich plasma treatment on refractive endometrium during frozen embryo transfer

Abstract Study question Will subendometrial injection of autologous platelet rich plasma (PRP) enhance the implantation by improving endometrial thickness (ET) and vascularity in frozen embryo transfers (FET)? Summary answer In this study it was observed that subendometrial injection of autologous PRP enhances implantation by improving ET and vascularity. What is known already Reports on evaluating effectiveness of injecting PRP hysteroscopically at the endomyometrial junction are limited. PRP has more effect on angiogenic growth cells as it contains high concentrations of vascular endothelial growth factor, epidermal growth factor, platelet derived growth factor, leukemia inhibiting factor, beta 3 integrin, transforming growth factor and cytokines which are essential for the endometrial proliferation. Previous reports suggest that these factors are inadequately expressed in a deficient endometrium and they are enhanced after PRP. Study design, size, duration From December 2019 to December 2021, 172 women with ET less than or equal to 7mm were included in the study and underwent PRP instillation. Patients with Asherman’s syndrome were excluded from the study. The endometrial vascularity zone as per Applebaum criteria was noted. Informed written consent obtained from all participants.The comparison of ET and vascularity before and after PRP was carried out by paired t test. This study was approved by Institutional ethical committee. Participants/materials, setting, methods 8 ml of autologous PRP was instilled at the junctional zone hysteroscopically from day 6-10 of menstrual cycle. After allowing 8 weeks for the endometrium to regenerate, ET and vascularity were measured and prepared for FET. The statistical significance was tested by comparing ET and vascularity before and after PRP using Paired T-test at 5% level of significance. FET was done for 109 women and the outcome was analysed. Main results and the role of chance Based on paired ‘t’test, it is concluded that there is statistically significant effective difference on ET after PRP at 0.05 significance level and vascularity following PRP at CI (-0.663± 0.11). T statistic = 1.653813 p value = 0.000282 and CI (-0.33±0.092),T statistic=1.653813, p value= 0.000254 respectively. Out of 172 women, ET increased in 130, decreased in 22 and remained the same in 20. Mean ET before and after PRP were 5.9mm and 6.6mm respectively which showed significant difference. Endometrial vascularity improved for 56 women decreased for 9 remained the same for 107. Of 172 women, 109 had underwent FET 44 showed positive BHCG value (40.3%) and 38 showed a clinical pregnancy rate (CPR) corresponding to 34.8%. Two others are awaited for the first scan Other two had blighted ovum, missed abortion respectively. CPR was observed to be 34.09% in the group with increased and 33.3% in the group with decreased and 44.4% in the group with no change in ET. Similarly the CPR was 30% in women with increased and 50% in those with decreased and 36% in the group with no change in vascularity. Limitations, reasons for caution The embryo quality and synchrony could have an effect on the pregnancy rate. It involves invasive procedure at a higher cost. It can cause infections and anaesthesia related complications. Wider implications of the findings we can assume that subendometrial injection of PRP is effective in improving the ET and vascularity and there by improve the pregnancy outcome. More studies are needed to confirm the effect of PRP in improving the endometrial thickness and vascularity and thereby implantation. Trial registration number N/A

Mid-pregnancy poly(I:C) viral mimic disrupts placental ABC transporter expression and leads to long-term offspring motor and cognitive dysfunction

Limited information is available about the effect of mid-pregnancy viral infections on the placental expression of efflux transporters and offspring behavior. We hypothesized that maternal exposure to polyinosinic-polycytidylic acid [poly(I:C)], a synthetic double-stranded RNA viral mimic, would impair placental cell turnover, the expression of selected ABC transporters and adult offspring behavior. C57BL/6 mice were administered poly(I:C) (10 mg/Kg;ip) or vehicle at gestational day (GD) 13.5 (mid-pregnancy). Dams were euthanized for blood collection 4 h after injection, fetal and placental collection at GD18.5 or allowed to deliver spontaneously at term. At GD 13.5, poly(I:C) induced an acute pro-inflammatory response characterized by an increase in maternal plasma levels of IL-6, CXCL-1 and CCL-2/MCP-1. At GD 18.5, poly(I:C) decreased cell proliferation/death in the labyrinthine and increased cell death in the junctional zones, characterizing a disruption of placental cell turnover. Abca1 and Abcg1 immunolabelling was decreased in the labyrinthine zone, whereas Abca1, Abcg1 and breast cancer resistance transporter (Bcrp) expression increased in the junctional zone. Moreover, adult offspring showed motor and cognitive impairments in the Rotarod and T-water maze tests. These results indicate that viral infection during mid-pregnancy may disrupt relevant placental efflux transporters, as well as placental cell turnover and offspring behavior in adult life.

Long-Term Pregnancy Outcomes of Patients with Diffuse Adenomyosis after Double-Flap Adenomyomectomy.

Although many studies show that patients with diffuse adenomyosis who underwent fertility-sparing surgery can have a successful pregnancy, their pregnancy outcomes are still controversial. The objective of this study was to determine long-term pregnancy outcomes and possible influencing factors after double-flap adenomyomectomy for patients with diffuse adenomyosis. A total of 137 patients with diffuse adenomyosis who underwent double-flap adenomyomectomy between January 2011 and December 2019 were studied, and correlations between pregnancy outcomes and clinical data, including age and junctional zone measured by magnetic resonance imaging (JZmax-A), were analyzed. The results show that 56 patients (40.9%, 56/137) had 62 pregnancies, including 35 natural pregnancies and 27 assisted reproduction pregnancies, after operation. A univariate regression analysis showed that the pregnancy outcomes were related to age at surgery, visual analog scale (VAS) score of preoperative dysmenorrhea, parity experience, length of infertility, and postoperative JZmax-A. A multivariate regression analysis showed that age at surgery, VAS score of preoperative dysmenorrhea, and postoperative JZmax-A were the independent indicators correlated with pregnancy outcomes. A receiver operating characteristic curve analysis showed that postoperative JZmax-A was the most valuable indicator for predicting pregnancy outcomes. Cumulative pregnancy rates during the first 3 years were 70.1% and 20.9% in the postoperative JZmax-A ≤ 8.5 mm and the postoperative JZmax-A > 8.5 mm groups, respectively. In conclusion, double-flap adenomyomectomy could improve fertility for diffuse adenomyosis, and postoperative JZmax-A might be a promising indicator for predicting pregnancy outcomes.

The Effect of Pegcetacoplan Treatment on Photoreceptor Maintenance in Geographic Atrophy Monitored by Artificial Intelligence–Based OCT Analysis

To investigate the therapeutic effect of intravitreal pegcetacoplan on the inhibition of photoreceptor (PR) loss and thinning in geographic atrophy (GA) on conventional spectral-domain OCT (SD-OCT) imaging by deep learning-based automated PR quantification. Post hoc analysis of a prospective, multicenter, randomized, sham (SM)-controlled, masked phase II trial investigating the safety and efficacy of pegcetacoplan for the treatment of GA because of age-related macular degeneration. Study eyes of 246 patients, randomized 1:1:1 to monthly (AM), bimonthly (AEOM), and SM treatment. We performed fully automated, deep learning-based segmentation of retinal pigment epithelium (RPE) loss and PR thickness on SD-OCT volumes acquired at baseline and months 2, 6, and 12. The difference in the change of PR loss area was compared among the treatment arms. Change in PR thickness adjacent to the GA borders and the entire 20° scanning area was compared between treatment arms. Square-root transformed PR loss area in μm or mm, PR thickness in μm, and PR loss/RPE loss ratio. A total of 31 556 B-scans of 644 SD-OCT volumes of 161 study eyes (AM 52, AEOM 54, SM 56) were evaluated from baseline to month 12. Comparison of the mean change in PR loss area revealed statistically significantly less growth in the AM group at months 2, 6, and 12 than in the SM group (-41 μm ± 219 vs. 77 μm ± 126; P= 0.0004; -5 μm ± 221 vs. 156 μm ± 139; P < 0.0001; 106 μm ± 400 vs. 283 μm ± 226; P= 0.0014). Photoreceptor thinning was significantly reduced under AM treatment compared with SM within the GA junctional zone, as well as throughout the 20° area. A trend toward greater inhibition of PR loss than RPE loss was observed under therapy. Distinct and reliable quantification of PR loss using deep learning-based algorithms offers an essential tool to evaluate therapeutic efficacy in slowing disease progression. Photoreceptor loss and thinning are reduced by intravitreal complement C3 inhibition. Automated quantification of PR loss/maintenance based on OCT images is an ideal approach to reliably monitor disease activity and therapeutic efficacy in GA management in clinical routine and regulatory trials.

Diagnostic Accuracy of Ultrasound and MRI for Diagnosis of Adenomyosis Taking Histopathology as Gold Standard

Objective: To determine the diagnostic accuracy of Magnetic Resonance Imaging (MRI) and ultrasonography to detect adenomyosis, keeping histopathology as the gold standard.&#x0D; Study Design: Cross-sectional study.&#x0D; Place and Duration of Study: Radiology and Gynecology departments of the Combined Military Hospital, Quetta Pakistan, from Aug 2019 to Aug 2021.&#x0D; Methodology: One hundred sixty-two patients were enrolled in this study after taking written and informed consent. After taking history, all patients were assessed by Magnetic resonance imaging and transvaginal ultrasonography. The magnetic resonance imaging and transvaginal ultrasound findings were noted on a predesigned proforma. All the patients underwent a hysterectomy, and a Biopsy specimen was sent for histological confirmation of adenomyosis. The accuracy of diagnosis was assessed in both initial modalities.&#x0D; Results: A total of 162 patients were enrolled in the study. The mean age of the females and junctional zone diameter (JZmax) in mm on MRI was 38.56 years and 12.54.9 mm. In terms of parity, 32 (19.8%) females were nulliparous, 68 (42%) females had low multi-parity, and 62 (38.2%) females had high multi-parity. On magnetic resonance imaging, adenomyosis was present in 112 (69.1%) females. On transvaginal ultrasound, it was present in 97 (59.9%) females, and on histopathology, it was present in 105 (64.8%) females, out of which 36 (34%) had diffuse adenomyosis and 32 (30.8%) had focal adenomyosis. The sensitivity, specificity, positive predictive value, negative predictive value and diagnostic accuracy of Magnetic resonance imaging was 86.7%, 36.9%, 81.3%, 71.8% and 78.4% respectively and of transvaginal ultrasound it was 65.7%, 50.9%,.............

MRI and Adenomyosis: What Can Radiologists Evaluate?

Uterine adenomyosis is a common benign condition defined by the presence of heterotopic endometrial glands and stroma within the myometrium. Adenomyosis is often related to infertility and other adverse pregnancy outcomes. Modern imaging techniques allow the non-invasive diagnosis of adenomyosis and, in this framework, Magnetic Resonance Imaging (MRI) has assumed a central role due to its high diagnostic accuracy in the detection of adenomyosis. Currently, there is still a lack of international consensus on adenomyosis diagnostic criteria and classification, despite the fact that an agreed reporting system would promote treatment outcomes and research. This review aims to emphasize the important contribution of MRI to the diagnosis of adenomyosis and to highlight how, thanks to the great tissue differentiation provided by MRI, it is possible to identify the main direct (cystic component) and indirect (junctional zone features) signs of adenomyosis and to distinguish its various subtypes according to different MRI-based classifications. We also explored the main MRI criteria to identify the most common pitfalls and differential diagnoses of adenomyosis, whose features should be considered to avoid misdiagnosis.

Altered expression of Notch signaling, Tlr receptors, and surfactant protein expression after prostaglandin inhibition may be associated with the delayed labor in LPS-induced mice.

This study aims to investigate whether indomethacin (IND) delays preterm birth by regulating the Notch pathway, Tlr receptors, and Sp-A in the placenta in lipopolysaccharide (LPS)-induced preterm labor (PTL) model. CD-1 mice were distributed to the pregnant control (PC), Sham, PBS, IND (2 mg/kg; i.p.), LPS (25 μg/100 μl; intrauterine), and LPS + IND groups. The injections were performed on day 14.5 of pregnancy. Placentae were collected on day 15.5 of pregnancy, and immunohistochemical analyzes were performed. Differences in staining intensities between the Cox-1, Notch-1 (N1), Dll-1, Jagged-2 (Jag-2), Tlr-2, and Tlr-4 proteins were compared. Preterm labor rates were 100% and 66% (preterm delivery delayed 5 h) in the LPS and LPS + IND groups, respectively. In LPS-treated mice, a general morphological deterioration was observed in the placenta. Total placental mid-sagittal measurement was significantly reduced in the LPS-treated group, while it was similar to the PC group in the LPS + IND group. Cox-1 expression in the LZ increased, and Sp-A expression decreased after LPS injection, and IND administration diminished this increase. N1 expression increased in the labyrinth zone (LZ) and the junctional zone (JZ). Dll-1 and Jag-2 expression increased in the JZ after LPS injection (p < 0.0001). IND administration diminished Tlr-2 expression in the LZ and Tlr-4 expression in the JZ after LPS injection. In conclusion, PG (prostaglandin) inhibition may alter Notch signaling, Tlr, and Sp-A protein expression and may be associated with delayed labor in LPS-induced mice.

Prenatal alcohol exposure contributes to negative pregnancy outcomes by altering fetal vascular dynamics and the placental transcriptome

BackgroundPrenatal alcohol exposure (PAE) has been shown to alter fetal blood flow in utero and is also associated with placental insufficiency and intrauterine growth restriction (IUGR), suggesting an underlying connection between perturbed circulation and pregnancy outcomes.MethodsTimed‐pregnant C57/BL6NHsd mice, bred in‐house, were exposed by gavage on gestational day 10 (GD10) to ethanol (3 g/kg) or purified water, as a control. Pulse‐wave Doppler ultrasound measurements for umbilical arteries and ascending aorta were obtained post‐gavage (GD12, GD14, GD18) on 2 fetuses/litter. RNA from the non‐decidual (labyrinthine and junctional zone) portion of placentas was isolated and processed for RNA‐seq and subsequent bioinformatic analyses, and the association between transcriptomic changes and fetal phenotypes assessed.ResultsExposure to ethanol in pregnant mice on GD10 attenuates umbilical cord blood flow transiently during gestation, and is associated with indices of IUGR, specifically decreased fetal weight and morphometric indices of cranial growth. Moreover, RNA‐seq of the fetal portion of the placenta demonstrated that this single exposure has lasting transcriptomic changes, including upregulation of Tet3, which is associated with spontaneous abortion. Weighted gene co‐expression network analysis (WGCNA) identified erythrocyte differentiation and homeostasis as important pathways associated with improved umbilical cord blood flow as gestation progresses. WGCNA also identified sensory perception of chemical stimulus/odorant and receptor activity as important pathways associated with cranial growth.ConclusionOur data suggest that PAE perturbs the expression of placental genes relevant for placental hematopoiesis and environmental sensing, resulting in transient impairment of umbilical cord blood flow and, subsequently, IUGR.

Gq Signaling in the Placental Syncytiotrophoblast Layer During Preeclampsia

Preeclampsia is a pregnancy‐associated cardiovascular disorder characterized by hypertension and proteinuria after 20 weeks of gestation. Generalized cellular ‘stress’ (oxidative, mitochondrial, etc.) within the syncytiotrophoblast (STB) layer of placenta is theorized to drive its pathogenesis. Hormones implicated in preeclampsia such as angiotensin, endothelin, and vasopressin signal via receptors that typically couple to the Gq second‐messenger cascade, and Regulator of G protein Signaling‐2 (RGS2) buffers this signaling. We have published that RGS2 expression is decreased in human preeclamptic placenta, and reducing RGS2 expression in placenta is sufficient to cause development of key features of this disorder in mice. Unpublished in situ hybridization data indicate that in both humans and mice, RGS2 is present in the STB layer – and that RGS2 expression in the STB layer is reduced during preeclampsia in humans. Collectively, these findings lead us to generally hypothesize that excess Gq signaling specifically within the STB layer, whether due to excessive hormonal activation or loss of RGS2‐mediated buffering, causes STB‐Stress and thereby contributes to the pathogenesis of preeclampsia. Therefore, the objective of this study was to test whether artificial, exogenous activation of Gq signaling only within STB cells is sufficient to induce placental and maternal phenotypes of preeclampsia in mice.CAG‐FLEX‐hM3Dq+/+ (Gαq DREADD, Jax 026943) or C57BL/6J dams were bred with Gcm1‐Cre+/‐ sires (Jax 026625) or non‐transgenic littermates to elicit STB‐restricted hM3Dqexpression in ≍50% or 0% of placentas. The synthetic DREADD ligand clozapine N‐oxide (CNO) or saline vehicle was administered (2 mg/kg/d, ip) mid‐gestation (GD 12.5‐14.5). Placental and maternal phenotypes were compared between Cre– and Cre+ placentas within a dam, CNO‐ vs saline‐injected double‐transgenic dams, and double‐ vs single/non‐transgenic dams treated with CNO. Activation of Gq in the STB layer caused maternal proteinuria (n=4‐9, 49±6 mg/day vs 28±4 mg/day; p=0.01). Labyrinth vascularization, assessed by percentage of CD31+ area, was reduced with Gq activation (n=5, Cre+ 21±1%, Cre– 27±2%; p=0.01), while other regions remained unaffected (Decidua: Cre+ 14±4%, Cre– 14±3%; Junctional Zone: Cre+ 11±4%, Cre– 12±3%). Possible reductions in placental mass (n=5 Cre+ 0.12±0.01g, Cre– 0.15±0.01g; p=0.06), and placental vascular endothelial growth factor protein levels (n=6‐7 117±67 ng/g vs 151±12 ng/g; p=0.06) were noted, but no obvious trend in fetal growth restriction was observed (n=5 Cre+ 0.21±0.06g, Cre– 0.29±0.04g). These data support the pathological significance of excess Gq signaling specifically within the STB layer. Ongoing studies are aimed at further characterizing maternal phenotypes (blood pressure, circulating factors) in these models, and the synergistic effects of simultaneous STB‐specific deletion of RGS2 upon sensitivity to Gq stimulation in this cell type.