The impact of caesarean scar niche on fertility - a systematic review.

BACKGROUND: The trend of increasing caesarean section (CS) rates brings up questions related to subfertility. Research regarding the influence of CS on assisted reproduction techniques (ART) is conflicting. A potential mechanism behind CS-induced subfertility is intra uterine fluid resulting from a caesarean scar defect or niche. The vaginal microbiome has been repeatedly connected to negative ART outcomes, but it is unknown if the microbiome is changed in relation to a niche. METHODS: This systematic review describes literature investigating the effect of a niche on live birth rates after assisted reproduction. Furthermore, studies investigating a difference in microbial composition in subfertile persons with a niche compared to no niche are evaluated. Pubmed, Embase and Web of Science were searched on March 2023 for comparative studies on both study questions. Inclusion criteria were i.e., English language, human-only studies, availability of the full article and presence of comparative pregnancy data on a niche. The quality of the included studies and their risk of bias were assessed using the Newcastle-Ottawa scale for cohort studies. The results were graphically displayed in a forest plot. RESULTS: Six retrospective cohort studies could be included on fertility outcomes, with a total of 1083 persons with a niche and 3987 without a niche. The overall direction of effect shows a negative impact of a niche on the live birth rate (pooled aOR 0.58, 95% CI 0.48-0.69) with low-grade evidence. Three studies comparing the microbiome between persons with and without a CS could be identified. CONCLUSION: There is low-grade evidence to conclude that the presence of a niche reduces live birth rates when compared to persons without a niche. The theory that a caesarean has a negative impact on pregnancy outcomes because of dysbiosis promoted by the niche is interesting, but there is no sufficient literature about this.

The increasing number of caesarean deliveries has raised concerns about how it might affect a woman's ability to get pregnant afterwards. Some studies suggest that having a caesarean section (CS) could make it harder to conceive, particularly through in vitro fertilisation (IVF). The reason could be the scar or niche from a previous caesarean. This niche can cause fluid inside the uterus. We also know that the mix of bacteria in the vagina, called the vaginal microbiome, can affect a woman's chances of getting pregnant, especially with treatments like IVF. But we are not sure if having a caesarean affects the vaginal microbiome.To understand this better, van den Tweel's team looked at studies on whether having a niche from a caesarean affects a woman's chance of having a baby through IVF. They also looked at studies comparing the bacteria in the vagina of women who have had a caesarean with those who have not. They found that having a caesarean niche makes it harder for a woman to have a baby through IVF. However, the evidence from these studies is not very strong. We still do not know enough about whether having a caesarean niche affects the bacteria in the vagina.

The Vaginal Microbiome Changes During Various Fertility Treatments.

This study aimed to investigate the influence of hormonal treatment on the vaginal microbiome during fertility treatments. Bacterial vaginosis (BV) could affect fecundity, particularly in the in vitro fertilization (IVF) population, where negative effects on pregnancy outcomes have been reported. It is hypothesized that the hormone treatment during fertility treatments could influence the abundance of Lactobacilli, with negative effects on the pregnancy results. A total of 53 couples attending a fertility clinic in the Netherlands between July 2019 and August 2022 were included in this prospective cohort study. Vaginal samples were collected at start of treatment, oocyte retrieval or insemination from subjects undergoing intra uterine insemination (IUI) with mild ovarian stimulation, and IVF or intra cytoplasmatic sperm injection (ICSI) with controlled ovarian hyperstimulation. AmpliSens® Florocenosis/Bacterial vaginosis-FRT qPCR and 16S rRNA gene-based amplicon sequencing were performed on all samples. In total, 140 swabs were analyzed, with a median of two swabs per person. 33 (24%) tested qPCR BV positive. Lactobacilli percentage decreased during fertility treatments, leading to changes in the vaginal microbiome. Shannon diversity index was not significantly different. Of the total of 53 persons, nine switched from qPCR BV negative to positive during treatment. The persons switching to qPCR BV positive had already a (not significant) higher Shannon diversity index at start of treatment. If the vaginal microbiome of persons deteriorates during fertility treatments, timing of following treatments, lifestyle modifications, or a freeze all strategy could be of possible benefit.

The relationship between vaginal pH and bacterial vaginosis as diagnosed using qPCR in an asymptomatic subfertile population.

PURPOSE: Bacterial vaginosis (BV) is a dysbiosis of the vaginal microbiome and a condition found in 20-30% of all women. Literature describing the possible link between BV and subfertility is increasing. Newer techniques such as quantitative polymerase chain reactions (qPCR) detect BV more accurately than traditional methods but come with high costs. The association between pH and BV as diagnosed using traditional methods is well-established in a symptomatic population. This study is the first to investigate the association between pH and BV diagnosed by qPCR in an asymptomatic subfertile population and to examine the usefulness of pH as a means of cost reduction. METHODS: Data of 170 pH-qPCR combinations were used from a prospective cohort study examining bacterial vaginosis in a subfertile population. 102 women received a vaginal swab and pH measurement at baseline and subsequent advanced reproductive technology (ART) treatments. The swabs are analysed using the AmpliSens®Florocenosis/Bacterial vaginosis-FRT qPCR kit. RESULTS: pH is strongly associated with BV as diagnosed by qPCR (OR 3.06, p = 0.000, CI 1.65-5.68). The cut-off point for pH ≥ 4.7 maximised diagnostic performance [AUC 0.74 (CI 0.66-0.83), sensitivity 76%] and reduced costs by 60%. CONCLUSION: This study shows that the vaginal pH for a multi-ethnic, asymptomatic population of women attending fertility clinics is strongly associated with BV qPCR outcome. Using the cut-off of pH of 4.7 has a high sensitivity for diagnosis of BV by qPCR and can be achieved at a cost reduction of 60%.

Comparing negative health indicators in male and female veterans with the Canadian general population.

INTRODUCTION: Sex-based information on differences between Canadian veterans and the general population is important to understand veterans' unique health needs and identify areas requiring further research. This study compared various health indicators in male and female veterans with their Canadian counterparts. METHODS: Health indicators for recent-era Regular Force veterans (released between 1998 and 2015) were obtained from the 2016 Life After Service Survey and compared with the general population in the 2015-16 Canadian Community Health Survey using a cross-sectional approach. Age-adjusted rates and 95% CIs were calculated for males and females separately. RESULTS: Compared with Canadians, veterans (both sexes) reported higher prevalence of fair or poor health and mental health, needing help with one or more activity of daily living, lifetime suicidal ideation and being diagnosed with mood and anxiety disorders, post-traumatic stress disorder, migraines, back problems, chronic pain, arthritis, ever having cancer, hearing problems, chronic pain and gastrointestinal problems. A higher prevalence of cardiovascular disease (all types) and high blood pressure was observed in male veterans compared with their Canadian counterparts. Within veterans only, males reported a higher prevalence of diagnosed hearing problems and cardiovascular disease compared with females; conversely females reported a higher prevalence of diagnosed migraines, mood, anxiety and gastrointestinal disorders, and needing help with activities of daily living. These sex differences are similar to the Canadian general population. Some similarities in reporting prevalence between male and female veterans (eg, fair or poor mental health, lifetime suicidal ideation, arthritis, asthma, lifetime cancer incidence, chronic pain and diabetes) were not observed in other Canadians. CONCLUSION: Male and female veterans differed from comparable Canadians, and from each other, in various areas of health. Further research is needed to explore these findings, and veteran-based policies and services should consider sex differences.

Increased cAMP levels in stimulated neutrophils inhibit their adhesion to human bronchial epithelial cells.

Bronchial epithelial cells express the intercellular adhesion molecule-1 that mediates binding of activated neutrophils via interaction with Mac-1 and/or leukocyte function-associated antigen-1. In this study, we examined whether increased intracellular levels of adenosine 3',5'-cyclic monophosphate (cAMP) affected neutrophil adhesion to the human bronchial epithelial cells. It was found that the N-formylmethionyl-leucyl-phenylalanine (fMLP)-stimulated neutrophil adhesion was concentration dependently inhibited when the cAMP analogs dibutyryl adenosine 3',5'-cyclic monophosphate or 8-bromoadenosine 3',5'-cyclic monophosphate were present. The beta-adrenergic receptor agonists isoprenaline and salmeterol, in the presence of the phosphodiesterase inhibitor 3-isobutyl-1-methylxanthine (IBMX), were also able to inhibit the fMLP-stimulated adhesion of neutrophils to bronchial epithelial cells. These agonists in combination with IBMX significantly increased the intracellular cAMP level in both neutrophils and epithelial cells. Preincubation of neutrophils with the long-acting beta2-adrenergic receptor agonist salmeterol (in the presence of IBMX) inhibited their fMLP-stimulated adhesion to epithelial cells, whereas pretreatment of epithelial cells did not influence the adhesion process. When ethanol-fixed epithelium was used, salmeterol pretreatment also diminished the adhesion of stimulated neutrophils. Moreover, combinations of salmeterol or isoprenaline with IBMX inhibited fMLP-upregulated Mac-1 expression. Therefore, we conclude from these data that elevation of intracellular cAMP in the neutrophil inhibits stimulated neutrophil adhesion to bronchial epithelial cells via Mac-1.

LFA-1, and not Mac-1, is crucial for the development of hyperreactivity in a murine model of nonallergic asthma.

In this study, we investigated the importance of the beta 2-integrins for the development of tracheal hyperreactivity in a murine model for nonallergic asthma. The response was induced by skin sensitization with dinitrofluorobenzene (DNFB) followed by an intranasal challenge with the same hapten. Twenty-four hours after the challenge, tracheal hyperreactivity, a decrease in T cells in the blood, and increased neutrophil numbers in bronchoalveolar lavage fluid (BALF) and blood were observed. Monoclonal antibodies (mAbs) directed against the alpha-chains of LFA-1 (FD441.8) and Mac-1 (M1/70) were injected intravenously 2 h before and 2 h after the challenge. Treatment with anti-LFA-1 mAb totally inhibited the development of tracheal hyperreactivity measured 24 h after the challenge, whereas anti-Mac-1 mAb had only a partial effect on this response. The decrease in T cells in the blood, which was also evident 24 h after the challenge, was totally inhibited by treatment with anti-LFA-1, whereas anti-Mac-1 had little effect. The increase in the number of neutrophils in BALF at this time point was completely inhibited by both anti-LFA-1 and anti-Mac-1. In summary, evidence presented in this report highlights the possible importance of the adhesion molecule LFA-1 in the development of tracheal hyperreactivity. Our results suggest that LFA-1 present on T cells may play an integral role in this response.

Stimulation of both human bronchial epithelium and neutrophils is needed for maximal interactive adhesion.

It has become clear that the bronchial epithelium is not just a passive barrier but plays an active role in inflammation. It can produce several inflammatory mediators and does express cell adhesion molecules of which intercellular adhesion molecule (ICAM)-1 can be upregulated by cytokines like interferon (IFN)-gamma. In the present study, we analyzed in detail the interaction of neutrophils with human bronchial epithelial cells, both primary cultured cells and the bronchial epithelial cell line BEAS-2B. Confluent monolayers of epithelial cells were incubated with freshly isolated 51Cr-labeled neutrophils for 30 min at 37 degrees C; then the nonadherent cells were removed by washing gently. Stimulation of the epithelial cells with IFN-gamma or the combination of IFN-gamma and tumor necrosis factor-alpha (TNF-alpha) (which doubles the ICAM-1 expression) increased neutrophil adhesion. Activation of the neutrophils themselves with N-formylmethionyl-leucyl-phenylalanine (fMLP), platelet-activating factor, or TNF-alpha also caused a profound enhancement of the adhesion. A significant additional increase was found when the epithelial cells had been exposed to IFN-gamma and the neutrophils were stimulated with fMLP simultaneously. This effect was even more pronounced with epithelium preincubated with IFN-gamma and TNF-alpha. With the use of monoclonal antibodies against CD18 and ICAM-1, it was demonstrated that the increased adhesion was mainly mediated by the ICAM-1/beta 2-integrin interaction. This study highlights that both the activation state of the bronchial epithelial cells and the activation state of the neutrophils are critical for their interactive adhesion.

Adhesion molecules: a new target for immunoliposome-mediated drug delivery.

The anti-ICAM-1 monoclonal antibody F10.2 was conjugated to liposomes to target to cells expressing the cell adhesion molecule ICAM-1. We demonstrate that F10.2 immunoliposomes bind to human bronchial epithelial cells (BEAS-2B) and human umbilical vein endothelial cells (HUVEC) in a specific, dose- and time-dependent manner. It appears that the degree of ICAM-1 expression is the limiting factor in the degree of immunoliposome binding to the cells. These results are a first step in the strategy for specific drug delivery to target sites characterised by increased expression of adhesion molecules.

Expression and modulation of adhesion molecules on human bronchial epithelial cells.

Epithelial damage in the airways is a feature often observed in patients with asthma and is probably caused by the interaction of epithelial cells with leukocytes. As adhesion molecules are thought to be important in this interaction, we analyzed the expression and modulation of adhesion molecules on primary cultured human bronchial epithelial cells and the bronchial epithelial cell lines BEAS-2B and NCI-H292. E-selectin, P-selectin, and VCAM-1 were absent under basal and stimulated conditions. The adhesion molecules ICAM-1 (CD54), LFA-3 (CD58), and CD44 (H-CAM) were expressed basally on primary cultured human bronchial epithelial cells and the BEAS-2B and NCI-H292 cell lines. CD44 and LFA-3 expression did not change after stimulation with IFN-gamma or TNF-alpha. In contrast, ICAM-1 expression on human bronchial epithelial cells and BEAS-2B cells could be increased by incubation with PMA, IFN-gamma, TNF-alpha, and especially with the combination of IFN-gamma and TNF-alpha. The maximal ICAM-1 expression on both epithelial cell types was obtained with the combination of TNF-alpha and IFN-gamma after 48 h of incubation. The NCI-H292 cell line was different in that it only showed increased ICAM-1 expression after stimulation with PMA and IFN-gamma and not by the combination of IFN-gamma and TNF-alpha or with TNF-alpha alone. In conclusion, the bronchial epithelial cells tested express several adhesion molecules, but only ICAM-1 expression was influenced by inflammatory cytokines.