A morphological study of symptomatic uterine niche using three-dimensional models from thin-slice magnetic resonance imaging.

RESEARCH QUESTION: Is there a correlation between various morphological parameters of the uterine niche and post-menstrual spotting using three-dimensional models from thin-slice (1 mm) magnetic resonance imaging (MRI)? DESIGN: This study retrospectively identified women diagnosed with a symptomatic niche by thin-slice MRI between December 2019 and December 2021. Univariable and multivariable linear regression models assessed the correlations between morphological parameters and the duration post-menstrual spotting. Morphological differences of the niche formed by one versus two Caesarean sections were analysed by univariable and multivariable logistic analysis. RESULTS: A total of 205 women diagnosed with symptomatic niche were included in the study. The niche among most women with post-menstrual spotting was ellipsoidal, with width greater than length greater than depth, from which niche volume was estimated based on manual measurements (volume = 0.520 × length × width × depth). Manually calculated niche length (ß = 0.257, 95% confidence interval [CI] 0.040-0.473, P = 0.020) and radiomically assessed minor axis length (ß = 0.329, 95% CI 0.009-0.795, P = 0.045) both positively correlated with the duration of post-menstrual spotting, whereas the distance between the niche and external os (ß = -0.120, 95% CI -0.202 to -0.038, P = 0.004) was inversely correlated. Women with two Cesarean sections reported more days of post-menstrual spotting (8.76 ± 3.54 versus 6.68 ± 3.90 days, P < 0.001) and had increased niche length diameter (adjusted odds ratio [aOR] 1.304, 95% CI 1.190-1.429) and a smaller surface-area-to-volume ratio (aOR 0.296, 95% CI 0.129-0.680). CONCLUSIONS: Niche-associated post-menstrual spotting correlates with the length diameter of the niche and the distance between the niche and external os. Niches in women after two Caesarean sections tend to be longer in length diameter and more spherical.

Exosomal microRNAs in tubal fluid may be involved in damage to tubal reproductive function associated with tubal endometriosis.

RESEARCH QUESTION: What is the effect of tubal endometriosis on tubal epithelial ultrastructure and is there a differential expression of exosomal microRNAs (miRNAs) in tubal fluid which may affect tubal infertility? DESIGN: Human fallopian tube epithelium and tubal fluid samples were obtained from patients with and without tubal endometriosis. Scanning electron microscopy and transmission electron microscopy were used to assess ultrastructural changes. Exosomal miRNAs in tubal fluid were extracted for microarray. RESULTS: Epithelial damage was visualized in the tubal endometriosis group using electron microscopy. The number of organelles decreased (P = 0.0314), and organelle structure was destroyed. A total of 14 differentially expressed exosomal miRNAs were detected in tubal fluid (fold change >2 and P < 0.05). Four miRNAs (miR-1273f, miR-5699-5p, miR-6087 and miR-6747-5p) were validated by quantitative real-time polymerase chain reaction. Bioinformatic analysis showed that most of the target genes participated in embryo transport, regulation of cell communication, anatomical structure morphogenesis and immune system processes. CONCLUSIONS: Tubal endometriosis results in damage to the tubal epithelial ultrastructure in human specimens and the presence of differentially expressed exosomal miRNAs in tubal liquid. These findings help to clarify the pathogenesis of tubal endometriosis-associated infertility and the mechanisms driving tubal epithelial ultrastructure damage in tubal endometriosis.

Comparing levonorgestrel intrauterine system with hysteroscopic niche resection in women with postmenstrual spotting related to a niche in the uterine cesarean scar: a randomized, open-label, controlled trial.

BACKGROUND: Postmenstrual spotting and chronic pelvic pain after cesarean delivery are associated with the presence of niches. Levonorgestrel intrauterine system (52 mg) and hysteroscopic niche resection have been shown to relieve niche-related symptoms at 6 months after the intervention. OBJECTIVE: This trial aimed to compare the effectiveness of 52-mg levonorgestrel intrauterine system with that of hysteroscopic niche resection in reducing niche-related postmenstrual spotting. STUDY DESIGN: This randomized, open-label, controlled trial was conducted at a medical center in Shanghai, China. Women with symptoms of postmenstrual spotting after cesarean delivery, with a niche depth of at least 2 mm and residual myometrium of at least 2.2 mm on magnetic resonance imaging, and no intention to conceive within the next year were randomly assigned to receive treatment with 52-mg levonorgestrel intrauterine system or hysteroscopic niche resection. The primary outcome was the reduction in postmenstrual spotting at 6 months after randomization, defined as the percentage of women with a reduction of at least 50% in spotting days relative to baseline. Efficacy and safety were assessed using intention-to-treat analysis. RESULTS: Between September 2019 and January 2022, 208 women were randomized into the levonorgestrel intrauterine system group (N=104) or the hysteroscopic niche resection group (N=104). At the 6-month follow-up, a 50% reduction in spotting had occurred in 78.4% (80/102) of women in the levonorgestrel intrauterine system group and in 73.1% (76/104) of women in the hysteroscopic niche resection group (relative risk, 1.07 [95% confidence interval, 0.92-1.25]; P=.370). Spotting decreased over time (Ptrend=.001), with a stronger reduction observed in the levonorgestrel intrauterine system group (P=.001). There was also a significant interaction between time and treatment (P=.007). From 9 months onward, a more significant reduction in spotting was observed in the levonorgestrel intrauterine system group than in the hysteroscopic niche resection group (9 months, 89.2% vs 72.1%; relative risk, 1.24 [95% confidence interval, 1.08-1.42]; 12 months, 90.2% vs 70.2%; relative risk, 1.29 [95% confidence interval, 1.12-1.48]). Moreover, compared with the hysteroscopic niche resection group, the levonorgestrel intrauterine system group had significantly fewer postmenstrual spotting days and total bleeding days from 6 months onward (all P<.001), and less pelvic pain from 3 months onward (all P<.010). No intervention-related complications were reported in any group. During follow-up, 11 (10.8%) women reported hormone-related side effects, and 2 women (2.0%) in the levonorgestrel intrauterine system group had spontaneous partial expulsion. Meanwhile, 3 unintended pregnancies were reported in the hysteroscopic niche resection group. CONCLUSION: In women with niche-related postmenstrual spotting, the levonorgestrel intrauterine system was not more effective than hysteroscopic niche resection in reducing the number of spotting days by at least 50% at 6 months. However, the levonorgestrel intrauterine system was superior in reducing spotting from 9 months onward, and it reduced the absolute number of spotting days from 6 months onward and pelvic pain from 3 months onward.

The role of SK3 in progesterone-induced inhibition of human fallopian tubal contraction.

BACKGROUND: Normal motor activity of the fallopian tube is critical for human reproduction, and abnormal tubal activity may lead to ectopic pregnancy (EP) or infertility. Progesterone has an inhibitory effect on tubal contraction; however, the underlying mechanisms remain unclear. Small-conductance calcium-activated K+ channel 3 (SK3) is abundantly expressed in platelet-derived growth factor receptor α positive (PDGFRα+) cells and was reported to be important for the relaxation of smooth muscle. The present study aims to explore the expression of SK3 in the human fallopian tube and its role in progesterone-induced inhibition of tubal contraction. METHODS: We collected specimens of fallopian tubes from patients treated by salpingectomy for EP (EP group) and other benign gynecological diseases (Non-EP group). The expression of SK3 was detected by quantitative real-time polymerase chain reaction, western blot, immunocytochemistry, and immunohistochemistry analyses. Isometric tension experiments were performed to investigate the role of SK3 in progesterone-induced inhibition of tubal contraction. RESULTS: The baseline amplitude and frequency of human fallopian tube contraction were both statistically lower in the EP group compared with the non-EP group. The expression levels of SK3 in different portions of fallopian tubes from the non-EP group were significantly higher than in those from the EP group. Progesterone had an inhibitory effect on tubal contraction, mainly on the amplitude, in both groups, and SK3 as well as other calcium-activated K+ channels may be involved. SK3-expressing PDGFRα (+) cells were detected in the human fallopian tube. CONCLUSIONS: The expression of SK3 is lower in the EP group, and SK3 is involved in the progesterone-induced inhibition of human fallopian tube contraction.

Incidence and risk factors of infertility among couples who desire a first and second child in Shanghai, China: a facility-based prospective cohort study.

BACKGROUND: With the implementation of the two-child policy in China, more couples have expressed the desire to have another child. We conducted this study to evaluate the incidence of infertility and risk factors in couples intending to have a first and second child. METHODS: From 2013 to 2017, a prospective cohort study was conducted at the pre-pregnancy center of the International Peace Maternal and Child Health Hospital. The participants were selected by screening and random sampling couples who came to the pre-pregnancy center. Data regarding patient sociodemographic characteristics, reproductive and gynecological history, male disease history, and laboratory and imaging examination results were collected. Couples were followed up every 3 months until pregnancy or for 12 months, whichever came first. Multi-factor logistic regression was used to analyze risk factors for infertility. Adjusted odds ratios (aORs) and corresponding 95% confidence intervals (CIs) were calculated and adjusted for potential confounding factors. RESULTS: The overall infertility incidence was 16.95% (369/2177). The infertility incidence of "first child intention" and "second child intention" was 19.30% (355/1839) and 4.14% (14/338), respectively. This study found great differences in both infertility rate (P < 0.001) and risk factors between the two groups. Risk factors for "first child intention" infertility included advanced age (> 35 years) (aOR = 1.70, 95% CI 1.27-2.28), abnormal body mass index (BMI) (aOR = 1.58, 95% CI 1.31-6.26), longer menstrual periods (aOR = 4.47, 95% CI 2.25-8.88), endometrial polyps (aOR = 2.52, 95% CI 1.28-4.97), polycystic ovarian syndrome (PCOS) (aOR = 6.72, 95% CI 1.79-7.39), salpingostomy (aOR = 3.44, 95% CI 1.68-7.07), and history of mycoplasma (aOR = 1.54, 95% CI 1.09-2.40). However, in the "second child intention" group, clinical risk factors slightly differed and included leiomyoma (aOR = 5.60, 95% CI 1.06-29.76), and higher age (> 40 years) (aOR = 7.36, 95% CI 1.01-53.84). CONCLUSION: The overall infertility rate in Shanghai is similar to that of other large cities in China. Marriage at advanced ages has become increasingly common. As such, the government must consider subsidies to encourage childbirth at childbearing ages, which can improve fertility levels.

Infertility is defined as pregnancy failure after at least 12 months of regular unprotected sexual intercourse. Few researchers have investigated the infertility rate in Shanghai in the past 15 years, and little attention has been paid to the infertility of couples hoping to have a second child. We conducted a prospective cohort study in Shanghai to evaluate infertility incidence and risk factors in couples intending to have a first or second child. The investigators administered a questionnaire survey to the participants and followed them for 1 year. Finally, 1839 couples intending to have a first child and 338 couples intending to have a second child were included in this study. The overall infertility incidence was 16.95% (369/2177). However, the infertility incidence of the "first child intention" and "second child intention" groups was 19.30% (355/1839) and 4.14% (14/338), respectively. Risk factors for "first child intention" infertility included advanced age (> 35 years), abnormal body mass index (BMI), longer menstrual periods, endometrial polyps, polycystic ovarian syndrome (PCOS), salpingostomy, and history of mycoplasma; in the "second child intention" group, clinical risk factors slightly differed and included leiomyoma and advanced age (> 40 years). Since studies have shown large differences in infertility risk factors between the two groups, early and targeted intervention for couples in different high-risk groups can help reduce infertility.

miR-4443 Contained Extracellular Vesicles: A Factor for Endometriosis Progression by PI3K/AKT/ACSS2 Cascade in-vitro.

Introduction: Endometriosis (EM) is an estrogen-dependent benign gynecologic disease affecting approximately 10% of reproductive-age women with a high recurrence rate, but lacks reliable biomarkers. No previous studies have investigated the possible use of extracellular vesicle (EV)-associated micro RNAs (miRNAs) from menstrual blood (MB) as candidate diagnostic or prognostic markers of EM. Methods: Specimens were obtained from endometriosis and non-endometriosis patients at the International Peace Maternity and Child Health Hospital in Shanghai. Microarray was used to screen differentially expressed miRNAs among peritoneal fluid (PF), fallopian tube fluid (FF), and MB. Dual-luciferase reporter gene assay was carried out to verify the relationship between miR-4443 and ACSS2. Cell proliferation and Transwell invasion assays were performed in vitro after intervention on miR-4443 and ACSS2 in hEM15A human endometrial stromal cells and primary human endometrial stromal cells (hESCs). Spearman correlation analysis, receiver operating characteristic (ROC) curve analysis, and survival analysis were applied to clinical data, including severity of symptoms and relapse of EM among EM patients. Results: EV-associated miR-4443 was abundant in MB of endometriosis patients. ACSS2 knockdown and miR-4443 overexpression promoted cell proliferation and migration via the PI3K/AKT pathway. miR-4443 levels in MB-EVs were positively correlated with the degree of dyspareunia (r=0.64; P<0.0001) and dysmenorrhea (r=0.42; P<0.01) in the endometriosis group. ROC curve analyses showed an area under the curve (AUC) of 0.741 (95% CI 0.624-0.858; P<0.05) for miR-4443 and an AUC of 0.929 (95% CI 0.880-0.978; P<0.05) for the combination of miR-4443 and dysmenorrhea. Conclusion: MB-derived EV-associated miR-4443 might participate in endometriosis development, thus providing a new candidate biomarker for the noninvasive prediction of endometriosis recurrence.

Colony-stimulating factor 1 positive (CSF1+ ) secretory epithelial cells induce excessive trophoblast invasion in tubal pregnancy rupture.

Tubal ectopic pregnancy (TEP) occurs when an embryo aberrantly implants in the fallopian tube, leading to abortive or ruptured tubal ectopic pregnancy (AEP or REP). Poor outcomes of REP include maternal infertility or mortality. Current studies on the prevention and treatment of ruptured tubal ectopic pregnancy (REP) are unfortunately hampered by a lack of the cell spectrum and cell-cell communications in the maternal-foetal interface. Here, we investigate the mechanisms of tubal rupture through single-cell transcriptome profiling of the fallopian tube-trophoblast interface in REP, AEP and intrauterine pregnancy patients. In REP, extravillous trophoblast (EVTs) cells form a dominant cell population, displaying aggressive invasion and proliferation, with robust differentiation into three subsets. Cell communication analysis identified colony-stimulating factor 1 (CSF1), overexpressed by fallopian tube secretory epithelial cells in REP, with CSF1R on EVTs and macrophages, as a ligand/receptor pair that stimulates EVT invasion and macrophage accumulation. CSF1+ secretory epithelial cells stimulate EVTs migration and invasion, leading to a tubal rupture in REP. These results provide a mechanistic context and cellular milieu leading to tubal rupture, facilitating further study and development of therapeutics for REP in early pregnancy.

Trophoblastic infiltration of tubal pregnancy may have an association with chronic inflammation of the fallopian tube.

OBJECTIVE: To explore the factors associated with trophoblastic infiltration in ampullary pregnancy from the perspective of clinical and pathologic characteristics. METHODS: A single-center, retrospective, clinicopathologic cohort study was conducted in women who were diagnosed with tubal pregnancy and underwent salpingectomy in the International Peace Maternal and Child Health Care Hospital from January 2018 to June 2021. RESULTS: A total of 333 eligible women diagnosed with ampullary pregnancy were included in the analysis. Multivariate logistic analysis showed that preoperative ß-human chorionic gonadotropin greater than 3000 IU/L (adjusted odds ratio [aOR] 3.77, 95% confidence interval [CI] 2.02-7.03), and vascular remodeling phenomenon (aOR 4.34, 95% CI 2.41-7.83) were positively correlated with the infiltration of extravillous trophoblasts into serosa, while presence of chronic inflammation of the fallopian tube was a negatively corellated factor (aOR 0.49, 95% CI 0.29-0.85). CONCLUSION: The depth of trophoblastic infiltration in tubal pregnancy may be related to the presence of chronic inflammation in the fallopian tube. A tubal pregnancy in a tube with chronic salpingitis is more likely to develop into an abortive ectopic pregnancy; whereas in a fallopian tube without chronic inflammation, the risk of it developing into a ruptured ectopic pregnancy increases. Hence, early identification is needed to properly address this dangerous pregnancy situation.

Comparative effectiveness of transvaginal repair vs. hysteroscopic resection in patients with symptomatic uterine niche.

Objective: To compare the efficacy of transvaginal repair and hysteroscopic resection in improving niche associated postmenstrual spotting. Methods: The improvement rate of postmenstrual spotting in women who underwent transvaginal repair or hysteroscopic resection treatment was assessed retrospectively in patients accepted at the Niche Sub-Specialty Clinic in International Peace Maternity and Child Health Hospital between June 2017 and June 2019. Postoperative spotting symptom within one year after surgery, pre- and postoperative anatomical indicators, women' satisfaction with menstruation and other perioperative parameters were compared between the two groups. Results: 68 patients in the transvaginal group and 70 patients in the hysteroscopic group were included for analysis. The improvement rate of postmenstrual spotting in the transvaginal group at the 3rd, 6th, 9th, and 12th months after surgery was 87%, 88%, 84%, and 85%, significantly higher than 61%, 68%, 66%, and 68% in the hysteroscopic group, respectively (P < 0.05). The total days of spotting improved significantly at the 3rd month after surgery but did not change over time within one year in each group (P > 0.05). After surgery, the disappearance rates of the niche are 68% in transvaginal group and 38% in hysteroscopic group, however, hysteroscopic resection had shorter operative time and hospitalization duration, less complications, and lower hospitalization costs. Conclusion: Both treatments can improve the spotting symptom and anatomical structures of uterine lower segments with niches. Transvaginal repair is better in thickening the residual myometrium than hysteroscopic resection, however, hysteroscopic resection has shorter operative time and hospitalization duration, less complications, and lower hospitalization costs.

Fertility outcomes after hysteroscopic niche resection compared with expectant management in women with a niche in the uterine cesarean scar.

OBJECTIVE: To determine whether hysteroscopic niche resection (HNR) and expectant management are suitable in women with fertility desire and a niche with a residual myometrium thickness (RMT) ≥ 2.5 mm. STUDY DESIGN: This retrospective cohort study was conducted at International Peace Maternity and Child Health Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China between September 2016 and December 2021. We reported the fertility outcomes between women (with fertility desire and a niche with RMT ≥ 2.5 mm) who received HNR or expectant management. RESULTS: We studied 166 women, of whom 72 accepted HNR and 94 accepted expectant management. The HNR group included more symptomatic women, in terms of postmenstrual spotting or infertility. No differences were found regarding niche measures before treatment. The live birth rate was comparable in both groups (HNR versus expectant management as 55.5% versus 45.7%, risk ratio = 1.48, 95% Cl 0.80-2.75, p = 0.21). The pregnancy rate was higher in HNR group than that in expectant management group (n = 72.2% versus n = 56.4%, risk ratio = 2.01, 95% CI 1.04-3.88, p = 0.04). In a subgroup of women with infertility before entry in the study, HNR resulted in a significant higher live birth rate (p = 0.04) and pregnancy rate (p = 0.01). CONCLUSION: In women with infertility with a symptomatic niche with RMT ≥ 2.5 mm, HNR may be superior to expectant management. This retrospective cohort biased selection against a randomized study, our results still need to be validated in the future with larger clinical multicenter randomized controlled trials.

The effect of a hysteroscopic niche resection compared with Levonorgestrel-releasing intrauterine device on postmenstrual spotting in patients with a symptomatic niche in the uterine cesarean scar: A prospective cohort study.

OBJECTIVE: To compare the effect of a hysteroscopic niche resection with a Levonorgestrel-releasing intrauterine device (LNG-IUD, 52 mg) on postmenstrual spotting duration in patients with a symptomatic niche in the uterine cesarean scar. STUDY DESIGN: This prospective cohort study was conducted at the International Peace Maternity and Child Health Hospital, School of Medicine, Shanghai Jiaotong University, China. Patients with postmenstrual spotting symptomatic niches were allocated to hysteroscopy group or LNG-IUD group based on the shared medical decision-making approach, and were followed up for 1 year after treatment. MAIN OUTCOME MEASURES: The primary outcome was reduced postmenstrual spotting days at 6th month after treatment. Secondary outcomes were effectiveness rate (proportion of patients with spotting days reduced by at least 50% from baseline), menstrual characteristics, menstruation satisfaction, direct medical costs, complications and side effects. RESULTS: 78 out of the 82 eligible patients were included, 36 patients in both group finished 1-year follow-up. Reduced spotting days at the 6th month was 7 days in LNG-IUD group, significantly higher than 5 days in hysteroscopy group, P = 0.004; The effectiveness rate increased over time within 1 year after the insertion of LNG-IUD (63.89%, 83.33%, 88.89%, 88.89%, P for trend = 0.006), while no trend change was observed in hysteroscopy group (71.05%, 71.05%, 66.67%, 61.11%, P for trend = 0.77). The mean direct medical costs were 817[785,856] $ in the hysteroscopy group and 243[239,255] $ in the LNG-IUD group (p＜0.001). 2 patients removed IUD and 2 patients reported weight gain of more than 5 kg and breast distended pain in LNG-IUD group; 2 patients got pregnant in hysteroscopy group. No serious complications were observed in both groups. CONCLUSIONS: LNG-IUD is more effective in the treatment of postmenstrual spotting from the 6th month onwards than a hysteroscopic niche resection in patients with a symptomatic niche at lower direct costs.

Comparing levonorgestrel intrauterine system versus hysteroscopic resection in patients with postmenstrual spotting related to a niche in the caesarean scar (MIHYS NICHE trial): protocol of a randomised controlled trial.

INTRODUCTION: Recently, the rate of caesarean sections (CS) worldwide has risen and CS-associated complications such as niche have increased substantially. Until now, evidence-based clinical guidelines for the treatment of niche-related symptoms remain absent. In patients with postmenstrual spotting, it has not been studied if the effect of levonorgestrel 52 mg intrauterine system (LNG-IUS 52 mg) is superior to that of hysteroscopy. This study will answer the question of whether LNG-IUS 52 mg is more effective in improving postmenstrual spotting than hysteroscopic niche resection in women with niche-related spotting at 6 months after randomisation. METHODS AND ANALYSIS: This is a randomised controlled trial. A total of 208 women with postmenstrual spotting related to niche in the caesarean uterine scar of at least 2 mm and residual myometrium of at least 2.2 mm evaluated by MRI will be included. Women desiring to conceive within 1 year, with contraindications for LNG-IUS 52 mg or hysteroscopic surgery will be excluded. After informed consent is obtained, eligible women will be randomly allocated to LNG-IUS 52 mg or hysteroscopic niche resection at 1:1. The primary outcome is the efficacy in reducing postmenstrual spotting at 6 months after randomisation. The secondary outcomes include menstrual pattern, total days of blood loss per month, rate of amenorrhoea, side effects and complications.We will use a Visual Analogue Scale for chronic pelvic pain, urological symptoms and women's satisfaction (five-point Likert scale). ETHICS AND DISSEMINATION: The study was approved by the local medical ethics committee and by the Institutional Review Board of the International Peace Maternity and Child Health Hospital, Shanghai, China (No. GKLW 2019-08). Participants will sign a written informed consent before participation. The results of this study will be submitted to a peer-reviewed journal for publication. TRIAL REGISTRATION NUMBER: ChiCTR1900025677.

Fertility intentions among couples in Shanghai under COVID-19: A cross-sectional study.

OBJECTIVE: To evaluate fertility intensions among couples in Shanghai under the novel coronavirus infection (COVID-19) pandemic against the backdrop of persistently low fertility. METHODS: A cross-sectional study was carried out using data from studies conducted before the COVID-19 pandemic. Data were collected regarding sociodemographic characteristics, history of reproduction and gynecology, fertility intention before and after the COVID-19 pandemic, female psychological state, and the impact of the COVID-19 pandemic on daily life. RESULTS: Under the influence of COVID-19, 296/447 (66.2%) participants did not change their original fertility intention to have children, while 151/447 (33.8%) of participants were affected by the outbreak. Participants who believed in government and hospital control policies were less likely to change their intention to become pregnant (P < 10-3 , P < 10-3 ). In contrast, concerns about the impact of COVID-19 on female and fetal health led participants to cancel their original pregnancy plans (P < 10-3 ). CONCLUSION: Three in ten couples of childbearing age, who originally expressed their intention of becoming pregnant, canceled their pregnancy plans after the COVID-19 outbreak. The COVID-19 outbreak has brought new challenges to people's physical and mental health. Effective policies and measures can help to improve people's fertility intentions with respect to having children.