Autologous cell therapy with CD133+ bone marrow-derived stem cells for refractory Asherman's syndrome and endometrial atrophy: a pilot cohort study.

STUDY QUESTION: Could cell therapy using autologous peripheral blood CD133+ bone marrow-derived stem cells (BMDSCs) offer a safe and efficient therapeutic approach for patients with refractory Asherman's syndrome (AS) and/or endometrial atrophy (EA) and a wish to conceive? SUMMARY ANSWER: In the first 3 months, autologous cell therapy, using CD133+ BMDSCs in conjunction with hormonal replacement therapy, increased the volume and duration of menses as well as the thickness and angiogenesis processes of the endometrium while decreasing intrauterine adhesion scores. WHAT IS KNOWN ALREADY: AS is characterized by the presence of intrauterine adhesions and EA prevents the endometrium from growing thicker than 5 mm, resulting in menstruation disorders and infertility. Many therapies have been attempted for these conditions, but none have proved effective. STUDY DESIGN, SIZE, DURATION: This was a prospective, experimental, non-controlled study. There were 18 patients aged 30-45 years with refractory AS or EA were recruited, and 16 of these completed the study. Medical history, physical examination, endometrial thickness, intrauterine adhesion score and neoangiogenesis were assessed before and 3 and 6 months after cell therapy. PARTICIPANTS/MATERIALS, SETTING, METHODS: After the initial hysteroscopic diagnosis, BMDSC mobilization was performed by granulocyte-CSF injection, then CD133+ cells were isolated through peripheral blood aphaeresis to obtain a mean of 124.39 million cells (range 42-236), which were immediately delivered into the spiral arterioles by catheterization. Subsequently, endometrial treatment after stem cell therapy was assessed in terms of restoration of menses, endometrial thickness (by vaginal ultrasound), adhesion score (by hysteroscopy), neoangiogenesis and ongoing pregnancy rate. The study was conducted at Hospital Clínico Universitario of Valencia and IVI Valencia (Spain). MAIN RESULTS AND THE ROLE OF CHANCE: All 11 AS patients exhibited an improved uterine cavity 2 months after stem cell therapy. Endometrial thickness increased from an average of 4.3 mm (range 2.7-5) to 6.7 mm (range 3.1-12) ( ITALIC! P = 0.004). Similarly, four of the five EA patients experienced an improved endometrial cavity, and endometrial thickness increased from 4.2 mm (range 2.7-5) to 5.7 mm (range 5-12) ( ITALIC! P = 0.03). The beneficial effects of the cell therapy increased the mature vessel density and the duration and intensity of menses in the first 3 months, with a return to the initial levels 6 months after the treatment. Three patients became pregnant spontaneously, resulting in one baby boy born, one ongoing pregnancy and a miscarriage. Furthermore, seven pregnancies were obtained after fourteen embryo transfers, resulting in three biochemical pregnancies, one miscarriage, one ectopic pregnancy, one baby born and one ongoing pregnancy. LIMITATIONS, REASONS FOR CAUTION: Limitations of this pilot study include the small sample size and the lack of control group. WIDER IMPLICATIONS OF THE FINDINGS: This novel autologous cell therapy is a promising therapeutic option for patients with these incurable pathologies and a wish to conceive. STUDY FUNDING/COMPETING INTERESTS: This study was funded by the Spanish Ministry of Science and Innovation (SAF 2012-31017, Principal Investigator C.S.), Spanish Ministry of Health (EC11-299, Principal Investigator C.S.) and Regional Valencian Ministry of Education (PROMETEOII/2013/018, Principal Investigator C.S.). Four authors (X.S., I.C., A.P. and C.S.) are co-inventors of the patent resulting from this work (Application number: 62/013,121). S.C., C.A., F.R., J.F., J.P. and J.R. have no conflict of interest in relation to this work. TRIAL REGISTRATION NUMBER: This study was registered with ClinicalTrials.gov (NCT02144987).

HDlive ultrasound images in assisted reproduction treatment.

The volume ultrasound technology software known as the HDlive technique represents an innovative tool, a step towards an even more realistic anatomical visualization of pelvic organ structures. HDlive can help improve physician-patient communication with the aid of life-like images and might prove useful in the field of assisted reproduction treatment. The clinical application of this novel ultrasound technology in assisted reproduction treatment deserves scientific evaluation.

Fetal megacystis: differential diagnosis.

The purpose of our retrospective observational series was to determine whether the sonographic characteristics of fetal megacystic bladders can be used to reliably establish the most likely diagnosis in fetuses with this condition. The sonographic records of pregnant patients referred to our institutions over a 10-year period who were found on initial 2-dimensional sonography to be carrying fetuses with megacystis were examined for evidence of a keyhole sign, bladder thickness, amniotic fluid index, and fetal sex. When available, 3-/4-dimensional sonography, Doppler angiography, tomographic ultrasound imaging, virtual organ computer-aided analysis, and automatic volume calculation were used as part of the detailed fetal anatomic survey. Twenty fetuses with megacystis were identified. Seventeen were male; 2 were female; and 1 had ambiguous genitalia. All male fetuses with megacystis originally had a diagnosis of prune belly syndrome. The diagnosis for 10 male fetuses with a keyhole sign was changed to megacystis secondary to posterior urethral valves. The fetus with ambiguous genitalia had prune belly syndrome. One of the female fetuses had a diagnosis of urethral atresia, and the diagnosis for the other female fetus was megacystis-microcolon-intestinal hypoperistalsis syndrome. In conclusion, in fetuses with megacystic bladders, it is possible to distinguish between cases with prune belly syndrome, posterior urethral valves, urethral atresia, and megacystis-microcolon-intestinal hypoperistalsis syndrome by a detailed anatomic survey using 2- and 3-/4-dimensioinal sonographic techniques.

Umbilical cord cysts: evaluation with different 3-dimensional sonographic modes.

OBJECTIVE: The purpose of this series was to determine whether the use of different 3-dimensional (3D) sonographic modes allows better definition of umbilical cord cysts and pseudocysts in utero. METHODS: Two cases of umbilical cord cysts and 1 of a pseudocyst were analyzed and compared with 2-dimensional (2D), 3D, angiopower Doppler, tomographic ultrasound imaging (TUI), virtual organ computer-aided analysis (VOCAL), and automatic volume calculation (AVC) sonographic modes. All cases were followed during pregnancy. A karyotype analysis was also obtained. RESULTS: Three-dimensional sonography, TUI, and VOCAL allowed clear visualization and evaluation of the sizes, locations, and numbers of umbilical cord cysts. A clear differentiation between a pseudocyst and the yolk sac was obtained with AVC and angiopower Doppler sonography. The 3D sonographic surface mode allowed better visualization of other accompanying fetal malformations. CONCLUSIONS: Three-dimensional sonography allows for a more accurate diagnosis and provides a clearer visualization of malformations than 2D imaging. Cysts and pseudocysts can be defined much more accurately by using the different modes described here.

Three-dimensional ultrasound radiance mode imaging of a uterine lipoleiomyoma.

In this case report the diagnosis of a uterine lipoleiomyoma is depicted by means of a three-dimensional radiance mode. The advent of radiance or silhouette mode as a new tool in ultrasound diagnosis is intended to assist by generating additional realistic image visualization and a better distinction among different tissues.

Interleukin-1beta regulation of gonadotropin-releasing hormone messenger ribonucleic acid in cultured human endometrial stromal cells.

OBJECTIVE: To investigate the role of interleukin-1beta (IL-1beta) in regulating GnRH mRNA expression in cultured human endometrial stromal cells using a modified semiquantitative competitive reverse transcription and polymerase chain reaction (PCR). DESIGN: A controlled study. SETTING: Clinical and academic research setting in a university medical center. PATIENT(S): Women undergoing hysterectomy for nonmalignant indications. INTERVENTION(S): Confluent stromal cell cultures treated with steroid hormones were stimulated with IL-1beta and attenuated by anti-IL-1beta antibody or IL-1 receptor antagonist. MAIN OUTCOME MEASURE(S): The human endometrial stromal cell expression of GnRH and its receptor were determined by PCR. Interleukin-1beta-mediated regulation of stromal cell GnRH mRNA expression was determined by quantitative competitive PCR. RESULT(S): The GnRH and GnRH receptor mRNA expression were amplified in cultured stromal cells by PCR and two rounds of nested PCR, respectively. Treatment with IL-1beta stimulated stromal cell GnRH mRNA expression at concentrations of IL-1beta above 10 IU/mL. Recombinant IL-1 receptor antagonist and anti-IL-1beta antibody attenuated the increase of gene expression of GnRH initiated by IL-1beta. CONCLUSION(S): These results provide indirect evidence that IL-1beta may play a crucial role at the level of embryo-maternal interaction by regulating stromal cell expression of GnRH and its receptor, both known to be important in mediating trophoblast invasion and placental hormone regulation.

HDlive 3D ultrasound and follicular development.

Two-dimensional (2D) ultrasonography is the fundamental technology on which diagnosis, management, and control in reproductive medicine depends. Over the years there have been efforts to improve 2D ultrasound image quality. In recent years, a series of software has appeared that has generated enormous interest. The goal of these modes has been to improve image quality and diagnostic accuracy. HDlive incorporates a movable virtual adjustable light source which, as it penetrates, produces selective illumination with respective shadows that result from the structures where light is reflected. This combination of light and shadow results in spectacular images which appear much more real than those obtained with conventional 3D ultrasonography.

Endometrial receptivity: evaluation with ultrasound.

An adequate endometrial receptivity is a crucial factor for embryo implantation. We describe endometrial morphology (endometrial appearance or pattern, endometrial thickness, volume, and delimitation), based on the concepts and possibilities of the new ultrasound modalities (3-dimensional/4-dimensional ultrasound, automatic volume calculation, virtual organ computer-aided analysis, tomographic ultrasound image, inverse mode, and 3-dimensional Doppler angiography) as markers of endometrial receptivity.

Multimodality 3-dimensional volumetric ultrasound in obstetrics and gynecology with an emphasis in HDlive technique.

HDlive (high-definition live or real-time US), a new ultrasound software, combines a movable virtual adjustable light source in a software that calculates the proportion of light reflecting through surface structures, depending on light direction. The light source can be manually positioned to illuminate the desired area of interest. The ultrasound technician can control light intensity to create shadows that enhance image quality. HDlive is an innovation that will render even more realistic images of fetal anatomy and of gynecologic lesions. The full potential of this new technology is yet to be determined and deserves scientific evaluation.

Expression of vascular endothelial growth factor receptors in the endometrium of septate uterus.

OBJECTIVE: To compare the messenger RNA (mRNA) expression of vascular endothelial growth factor (VEGF) receptors (KDR, Flt-1, and sflt) in the different endometrial locations of septate uterus and normal uterus. DESIGN: Prospective, observational study. SETTING: University teaching hospital. PATIENT(S): Twelve women with complete septate uterus undergoing hysteroscopic metroplasty and 12 women with normal uterus. INTERVENTION(S): Endometrial tissue samples were obtained from the endometrium covering the septum and the endometrium lining the lateral wall of the uterus. Moreover, endometrial samples were obtained from patients with normal uterus. MAIN OUTCOME MEASURE(S): Differences in the mRNA expression of VEGF receptors between the endometrial samples of septate and normal uterus. RESULT(S): The mRNA expression of VEGF receptors, both KDR and Flt-1, was significantly lower in the endometrium lining the septum as compared with the endometrium covering the lateral wall of septate and normal uterus. Conversely, no differences were observed in mRNA expression in the soluble receptor sflt between the different endometrial samples studied. CONCLUSION(S): The results suggest that a local defect of both VEGF transmembranous receptors (KDR and Flt-1) in the endometrium covering the septal area may be responsible for the clinical comportment of this müllerian anomaly.

Reducing blood loss at myomectomy with use of a gelatin-thrombin matrix hemostatic sealant.

OBJECTIVE: To evaluate the hemostatic efficacy and handling of gelatin-thrombin matrix in abdominal myomectomy. DESIGN: Prospective and randomized trial. SETTING: University teaching hospital. PATIENT(S): Women (n = 50) with uterine fibroids with a uterine size equivalent to > or =16 weeks gestation. INTERVENTION(S): Gelatin-thrombin matrix (FloSeal Matrix; Baxter Healthcare Corp., Fremont, CA) was delivered to the site of the uterine bleeding during myomectomy. MAIN OUTCOME MEASURE(S): Patient age, parity, number of myomas, operative time, blood loss, transfusion, intraoperative and postoperative complications, and length of hospitalization were evaluated. RESULT(S): The average blood loss during surgery was 80 +/- 25.5 mL for the FloSeal group and 625 +/- 120.5 mL for the control group. Intraoperative blood transfusion was necessary in five patients from the control group. Postoperative blood loss was 25 +/- 5 mL for the FloSeal group and 250 +/- 75 mL for the control group. Length of the postoperative hospital stay was 2.5 +/- 1.2 days for FloSeal group and 4.5 +/- 1.3 for the control group. No major immediate or delayed complications were observed in either group. CONCLUSION(S): Reductions in hemorrhage in FloSeal-treated women undergoing a myomectomy are encouraging, and provide evidence for the ability of gelatin-thrombin matrix to reduce blood loss when applied immediately and directly to bleeding uterine tissue.

Cotyledonoid dissecting leiomyoma of the uterus.

We describe a cotyledonoid dissecting leiomyoma in a 33-year-old nulliparous woman treated by laparoscopy.

Gonadotropin-releasing hormone (GnRH)-I regulation of interleukin (IL)-1b and IL-1 receptor antagonist expression in cultured human endometrial stromal cells.

AIM: Human endometrium is an active site of cytokine production and action. Among these cytokines, the interleukin-1 (IL-1) system seems to be relevant to the embryonic implantation process. We have previously reported the production of GnRH-I by human blastocyst, as well as the presence of GnRH-I receptor in human endometrium. This suggests a close interaction between the immune and endocrine systems through these cytokine mediators in embryonic implantation. METHODS: To test the relevance of this interaction during embryonic implantation, we investigated GnRH-I regulation of IL-1b and IL-1ra mRNA and protein expression in human endometrial stromal cells using quantitative competitive polymerase chain reaction and ELISA. RESULTS: IL-1b mRNA and protein expression in cultured human endometrial stromal cells was significantly enhanced by GnRH-agonist in comparison to control groups. IL-1ra mRNA and protein was significantly decreased by GnRH-agonist in comparison to control groups. In contrast, the GnRH-antagonist ablated the regulatory effects of GnRH agonist in 1b and IL-1ra mRNA and protein levels in a dose-dependent manner. CONCLUSIONS: In conclusion, these results suggest a possible close interaction between the immune and endocrine systems in human embryonic implantation through the classical neuropeptide hormone GnRH and its receptor.

Prenatal diagnosis of congenital cystic adenomatoid malformation using three-dimensional inversion rendering: a case report.

We report a case of a congenital cystic adenomatoid malformation of the lung (CCAM). At 12 weeks of gestation, an echogenic lung associated to a hydrothorax was detected. Despite the results of the combined test that informed of a high risk of chromosomopathy, normal karyotype was confirmed after an amniocentesis. The three-dimensional ultrasound inversion mode depicted all the cysts within the fetal lungs as opaque areas that were seen concurrently together, which was compatible with CCAM. After parental counseling, the patient opted to terminate the pregnancy at 18 weeks. Pathological analysis of the lungs confirmed the diagnosis of a CCAM type II. The recent advent of the three-dimensional ultrasound inversion mode opens many diagnostic options until now unavailable or difficult to attain sonographically and therefore it may help us to increase the sonographic detection rates of congenital cystic adenomatoid malformation.

Alta definición ecográfica en tiempo real (HDLive US) en Obstetricia y Ginecología

Los ultrasonidos de alta definición en tiempo real (HDLive US) incorporan un software que calcula la propagación de la luz a través de superficies y en relación con la dirección de la misma. Esta fuente de luz puede ser posicionada libremente con el fin de iluminar las áreas de interés deseadas, permitiendo así imágenes de mejor calidad, una mayor sensación de profundidad y una visión más sencilla de superficies fetales. Mostramos casos de embriones y fetos normales, así como algunas malformaciones para señalar las posibilidades de esta nueva tecnología. El auténtico potencial de esta nueva tecnología esta aún por revelar. La HDLive representa, en nuestra opinión, una verdadera innovación y un paso más hacia una visión anatómica mucho más realista de estructuras normales y patológicas fetales.

High definition real time ultrasound (HDLive US) incorporates software that calculates the propagation of light through surface structures in relation to light direction. This light source can be freely positioned in order to illuminate the desired area of interest allowing better image quality, better sensation of deepness and easier visualization of fetal surfaces. Cases of normal embryos, fetuses and common fetal malformations are shown. The full potential of this new technology is still to be revealed. HDlive represents, in our opinion, an innovative tool and a step towards an even more realistic anatomical visualization of normal and malformed fetuses.

MRI and multiplanar 3D ultrasound compared in the prenatal assessment of enlarged posterior fossa.

Our aim was to compare the diagnostic capabilities of the multiplanar mode of 3D ultrasound (3D US) and MRI in the assessment of a fetal enlarged cisterna magna. Two fetuses showing an enlarged posterior fossa by conventional two-dimensional ultrasound at 24 and 29 weeks of pregnancy were assessed using both diagnostic methods. One fetus was found to have Dandy-Walker syndrome malformation. In the other, the syndrome was ruled out using both methods. Our results suggest that multiplanar 3D US is able to achieve similar results as does MRI when observing the fetal brain.

Androgen insensitivity syndrome: in utero diagnosis by four-dimensional sonography and amniotic fluid karyotype.

We describe a fetus with androgen insensitivity syndrome diagnosed at 16 weeks' gestation with two-dimensional (2D) and four-dimensional (4D) sonography and karyotype analysis in a 37-year-old pregnant woman. Two-dimensional (2D) sonography revealed a female phenotype. Karyotype analysis revealed an unremarkable 46,XY chromosomal complement. Repeat 4D sonography confirmed a female phenotype with edematous labia majora, consistent with androgen insensitivity syndrome.

Two-dimensional and three-dimensional sonography of conjoined twins.

PURPOSE: The aim of this study was to evaluate and compare the diagnostic capabilities of 2-dimensional (2D) and 3-dimensional (3D) sonography for the study of conjoined twins. METHODS: Four pregnant women with an initial 2D sonographic diagnosis of conjoined twins were examined with color Doppler sonography, 3D multiplanar sonography, and orthogonal plane imaging and 3D surface rendering. RESULTS: All 4 cases of conjoined twins were initially diagnosed with either transvaginal or transabdominal 2D sonography. 3D sonography afforded more realistic views and demonstrated more clearly the linking areas and surface anomalies, but 2D and color Doppler sonography provided more definitive and specific information about shared organs. CONCLUSIONS: Although 2D sonography is the primary modality for diagnosing and evaluating conjoined twins, color Doppler and 3D sonography can sometimes provide additional information that assists in the clinical management of these twins. 3D sonography also provides images that are easier for parents to understand, which can help them with decision making.