Retrospective analysis of autologous bone marrow mesenchymal stem cells as adjuvant therapy in recurrent intrauterine adhesions

doi:10.21203/rs.3.rs-4507805/v1

Download PDF

Research Article

Retrospective analysis of autologous bone marrow mesenchymal stem cells as adjuvant therapy in recurrent intrauterine adhesions

https://doi.org/10.21203/rs.3.rs-4507805/v1

This work is licensed under a CC BY 4.0 License

You are reading this latest preprint version

We aimed to retrospectively analyze the efficacy and safety of autologous bone marrow mesenchymal stem cells (BM-MSCs) as adjuvant therapy for intrauterine adhesion (IUA) and endometrial repair. All patients had menstrual cramps and significantly increased menstrual flow during three rounds of perfusions with MSC compared to before treatment. However, this effect was reversed and there was no significant difference between the menstrual flow one year after treatment vs before treatment. The IUA scores after three rounds of treatment as well as one and two years after treatments were significantly lower compared to before surgery. No IUA recurrence was observed during the 2-year follow-up. Endometrial thickness had significantly increased during treatment. During the two-year follow-up period, one patient conceived naturally. One patient was successfully implanted after invitro fertilization and embryo transfer. Intrauterine perfusion of autologous BM-MSCs, assisted by adhesiolysis, was effective in preventing postoperative IUA recurrence and partially improved the reproductive prognosis.

Amenorrhea

Bone marrow mesenchymal stem cells

Intrauterine adhesions

Infertility

Stem cell harvest

The endometrium with its remarkable ability to shed, repair, regenerate, and remodel under the influence of ovarian hormones plays an important role in human conception [1]. Functionally, the endometrium is composed of the outer functional is layer and inner basalis layer. The functional is layer contains columnar glandular tissue and loose connective stroma, which is the site of embryo implantation. It undergoes cyclic proliferation, secretion, and shedding regulated by ovarian hormones. Dense stroma and gland roots are found in the basalis layer, which does not shed but regenerates and repairs uterine wounds after menstruation and rebuilds the functionalis layer [2, 3].

Intrauterine adhesion (IUA), are bands of fibrous tissue that form in the uterine cavity often due to the failure of endometrial repair after basal layer injury [4]. IUA can result in partial or complete adhesion and atresia of the uterine cavity, decreased menstruation, amenorrhea, infertility, and repeated miscarriage [4, 5]. Although hysteroscopic adhesion dissection and numerous postoperative adjuvant programs can improve and restore the uterine cavity of patients with IUA and even increase the menstrual flow of some patients, the cure rate is low and the therapeutic outcomes and reproductive prognosis are not significantly improved. Persistent infertility and higher complication and recurrence rates remain the challenges of IUA treatment by hysteroscopic adhesiolysis [5, 6].

Stem cell therapy is a promising strategy for endometrial regeneration with bona fide cell differentiation potential; hence, it might be possible to activate endometrial stem cells or transplant stem cells from other tissue in the endometrium [4]. Studies have shown [3, 7] that transplantation of stem cells from different sources to the endometrial area induces revascularization and angiogenesis, vital for normal healing, and therefore results in increased endometrial thickness. This helps in the remodeling and improves the chances of pregnancy as reported in case studies [7, 8].

Mesenchymal stem cells (MSCs) are easy to isolate, have strong in vitro proliferation ability without alteration in their biological properties, have tissue tropism, a weak immunogenicity, secrete anti-inflammatory molecules, and cause little damage to normal cells/tissues[9, 10]. These properties are ideal for treatment methods used in tissue regenerative medicine that target conditions such as IUA.

In the current retrospective study, we analyzed the efficacy and safety of intrauterine perfusion of autologous bone marrow mesenchymal stem cells (BM-MSCs after hysteroscopic adhesiolysis for the treatment of patients with recurrent IUA. The patients of this study often had severe endometrial injury and difficulty in attaining good reproductive prognosis through conventional methods. We also looked into this treatment’s feasibility and modality.

From January 2017 to January 2020, a total of seven female eligible patients aged between 26 and 39 years, with a mean body mass index (BMI) of 23.5, received stem cell therapy. Baseline clinical characteristics of all the patients are given in Table 1. The patients had a 2 to 7 years history of IUA requiring fertility treatment. Most patients with recurrent IUA had severe endometrial injury, nil menstrual flow, and difficulty in attaining good reproductive prognosis. The patient’s sex hormone levels, husband’s sperm examination, and chromosomal karyotypes of respective couples were normal.

There was no occurrence of any adverse reactions or complications during and after bone marrow collection in all patients.

Table 1

Baseline clinical characteristics
Clinicopathological Profile
Age, years (median)	median	34
BMI (kg/m²)	median	23.5
Causes of IUA
artificial abortion	n	4
residual placenta removal	n	1
hysteroscopic endometrial polypectomy	n	1
repeated curettage	n	1
Menstrual Volume	mL	N

BMI, body mass index; IUA, intrauterine adhesion; N. none.

2.1 BM-MSC culture and flow-cytometric analysis

The mononuclear cells isolated from bone marrow was a heterogeneous mixture of a large number of lymphocytes and monocytes in addition to BM-MSCs when assessed by microscopic observation. However, for selective isolation, the cell suspension was cultured for 24 hours, and the BM-MSCs started to adhere and appear in a long spindle-shaped morphology as shown in Fig. 1A. The non-adherent cells were removed while replacing the medium as reported by another study [11]. We observed rapid growth after 6 to 10 days of continuous culture, resulting into a formation of swirling colonies (Fig. 1B). When the cells reached 80% confluence around in three days (Fig. 1C), they were passaged. After serial passage, there was a slight increase in the cell volume while the morphological appearance remained the same as shown in Fig. 1D.

Images of cells from multiple fields are provided in the Supplementary Figure. 1 (which shows cell growth at different timepoint and multiple fields). Immunophenotypic analysis by flow cytometry performed on the BM-MSC population from passages 2 to 4 showed negative expression of endothelial and hematopoietic markers CD34 (0.00%) and CD45 (0.00%), while there was positive/increased expression of primary MSC markers such as CD73 (99.37 ± 0.97%), CD90 (98.86 ± 1.84%), and CD105 (98.33 ± 2.80%), as presented in Fig. 2.

2.2 Hysteroscopic dissection of IUAs

All seven patients underwent operative hysteroscopy under general anesthesia for adhesiolysis. The operative time varied between 25 and 45 minutes. With ultrasound monitoring during the operation, blunt dissection or cold knife was employed as far as possible to separate the adhesions to reduce thermal damage to residual endometrium. Overall, we aimed to avoid perforation in the uterus and retained endometrial integrity. When required, monopolarelectrocoagulation was used to stop the bleeding. In all patients, the operation was completed efficiently without any complications, and the uterus cavity returned to its normal shape as evidenced/monitored by the hysteroscope. After the adhesiolysis, two fallopian tube openings were visible in the uterus of three patients, only one fallopian tube opening was visible in one patient. In the remaining three patients, both uterine horns were seen with normal uterus morphology but the fallopian tubes were not visible. Hysteroscopic images with description are provided in the Supplementary Fig. 3 (which shows the hysteroscopy before, after blunt separation, and before BM-MSCs perfusion.).

2.3 Changes in menstrual flow and intimal thickness after perfusion

All the patients experienced menstrual cramps after perfusion of BM-MSCs; six patients had menstrual cramps after one perfusion whereas one patient had menstrual cramps after two perfusions. A normal menstrual flow was observed in two patients, whereas the rest of the patients had less than normal menstrual flow. The menstrual flow of the patients significantly increased after treatment (t_AFP, after the first perfusion; t_ASP, after the second perfusion; t_ATP, after the third perfusion) compared to before treatment (t_AFP = 4.094, P < 0.05; t_ASP = 4.510, P < 0.05; t_ATP = 4.327, P < 0.05), but eventually decreased after one and two years of treatment (t_OYAT: one year after therapy; t_TYAT: two years after therapy) compared to before treatment (t_OYAT = 2.235, P > 0.05; t_TYAT = 1.981, P > 0.05) while amenorrhea occurred again in two patients.

The ultrasound evaluation showed significant improvement in endometrial thickness after perfusions compared with before perfusion (t_AFP = 8.042, P < 0.05; t_ASP = 21.112, P < 0.05; t_ATP = 21.015, P < 0.05; t_OYAT = 8.612, P < 0.05; t_TYAT = 9.546, P < 0.05), and there was abundant blood flow to the basal layer of the intima as evident from Fig. 3. Excluding the two pregnant patients, there was a decrease in the endometrial thickness to a varying degree on re-examination after two years of treatment as shown in Table 2. Overall, the endometrium gradually improved in thickness after every perfusion of MSCs, and the blood flow in the lower endometrial basal layer also improved (Fig. 3). The Case 6 patient, presented in Fig. 3, had an endometrial thickness of 0.78 mm in the late proliferative phase after the third perfusion. Subsequently after three months, the patient underwent invitro fertilization (IVF) and embryo transfer. Her pregnancy was successful and she delivered at term.

Table 2

Changes in endometrial thickness, menstrual flow, and intrauterine adhesion score before and after stem cell transplantation in patients
Case	Ultrasound bilayer endometrial thickness (mm)						Menstrual Volume Score(PABC)						Intrauterine Adhesion Score^*
Case	PO	AFP	ASP	ATP	OYAT	TYAT	PO	AFP	ASP	ATP	OYAT	TYAT	PO	AFP	ASP	ATP	OYAT	TYAT
1	ND	0.33	0.50	0.51	0.30	0.30	N	5	12	11	N	N	12	4	4	5	7	7
2	0.11	0.40	0.55	0.54	0.50	0.52	N	9	15	18	8	8	10	4	4	4	5	5
3	0.20	0.56	0.65	0.63	0.65	NE	N	25	35	41	34	NE	8	0	0	0	0	NE
4	ND	0.31	0.47	0.45	0.45	0.40	N	8	12	12	9	7	10	4	4	4	5	5
5	0.20	0.59	0.66	0.70	0.50	0.50	N	22	28	35	25	25	8	2	0	0	0	0
6	0.33	0.65	0.70	0.78	NE	0.75	N	25	35	35	NE	44	8	0	0	0	NE	0
7	0.10	0.30	0.45	0.44	0.30	0.30	N	6	6	7	N	N	12	4	4	4	7	7
‾X	0.13	0.45	0.57	0.58	0.45	0.46	0.00	14.29	20.43	22.72	12.67	14.00	9.71	2.57	2.29	2.43	4.00	4.00
t**		8.042	21.112	21.015	8.612	9.546		4.094	4.510	4.327	2.235	1.981		17.678	20.140	20.265	9.487	9.487
P		< 0.05	< 0.05	< 0.05	< 0.05	< 0.05		< 0.05	< 0.05	< 0.05	> 0.05	> 0.05		< 0.05	< 0.05	< 0.05	< 0.05	< 0.05

PO, pre-operation; AFP, after the first perfusion; ASP, after the second perfusion; ATP, after the third perfusion; OYAT, one year after therapy; TYAT, two years after therapy; ND, no display; N, none; NE, no examination due to pregnancy.

*1988 AFS scoring standard and classification of intrauterine adhesions.

**All mean comparisons are with pre-treatment.

2.4 Hysteroscopy and pathological evaluation

The hysteroscopy was reviewed after each perfusion, at the late stage of proliferation (the last day of oral administration of estrogen alone), and one year and two years after the operation. The treatment of stem cell perfusion in combination with estrogen–progesterone cycle therapy played an effective role in preventing the recurrence of adhesions in the uterine cavity. The adhesion score was significantly reduced after treatment when compared to before treatment (t_AFP = 17.678, P < 0.05; t_ASP = 20.140, P < 0.05; t_ATP = 20.265, P <0.05; t_OYAT = 9.487, P <0.05; t_TYAT =9.487, P < 0.05; Table 2). No new IUAs were observed in any of the patients two years after the surgery. The morphology of the uterine cavity was normal in all patients. Two patients had developed amenorrhea again after one year of treatment, however, without any new adhesions on hysteroscopic inspection. On microscopic evaluation, the morphology of the endometrium was significantly improved in comparison to preoperative observation. There was a clear reduction in the scar area on the surface of the uterine wall and an increase in endometrial thickness as seen in Fig. 4A and B. More images of endometrium before and after MSC perfusion are given in the Supplementary Fig. 2 (ultrasound images of endometrial basal layer blood flow before and after treatment for all the cases).

Parallelly, the endometrial pathology was also obtained for each hysteroscopy and the histopathological results were: proliferative endometrium (20/33; Fig. 5), secretory endometrium (6/33), mild endometrium hyperplasia with secretory reaction (3/33), and proliferative endometrium with focal fibrosis (3/33). At the end of the two-year follow-up after treatment, no atypical hyperplasia was found in the endometrial pathology of any of the patients.

In one patient (Case 3), the endometrium was covered before and after, and no obvious scar tissue and fibrous bands were found.

2.5 Follow-up of reproductive outcome

All patients were followed up for two years. One patient had a successful pregnancy and natural delivery following IVF and embryo transfer five months after perfusion. One patient had natural pregnancy and successful delivery 15 months after perfusion. Embryo implantation was not successful in three patients who had undergone IVF embryo transfer 1 to 4 months after the end of the treatment.

The hysteroscopic adhesiolysis is currently the most common and effective option in the treatment of IUA [12], but even if the patient's uterine cavity returns to normal shape after surgery, it does not significantly improve the reproductive prognosis. Moreover, in about 30–62.5% of patients, adhesions reoccur after the separation surgery [13].

Currently, the treatment modality used to promote endometrial repair after separation of IUAs is the sequential application of estrogen and progesterone, and the methods of preventing re-adhesion include intrauterine balloon placement [14], intrauterine device [15], sodium hyaluronate gel [13], etc. However, there was either no significant therapeutic improvement or varying degrees of fertility outcomes with complications with these treatment modalities and they may potentially aggravate the preexisting endometrial injury [15–18]. IUAs are still a challenge, especially when correlated with infertility. So, there is a strong unmet need for effective therapies for the treatment of IUAs.

The potential role of stem cells in endometrium was established as early as 1978 itself, and Prianishnikov proposed the endometrial repair and its long-term self-renewal under the influence of estradiol and progesterone [19]. The use of allogenic embryonic stem cells has limitations such as immune rejection, a high risk for tumorigenesis, and ethics restricting its clinical application[20]. On contrary, the use of adult stem cells has fewer restriction in terms of legal and ethical issues [21]. The currently available data suggest that the reconstruction of the endometrium by stem cells especially in IUA may be facilitated by (i) mobilization of stem cells to the damaged endometrium regulated by chemokines and (ii) accumulation of undifferentiated stem cells in the damaged endometrial area, followed by the release of anti-inflammatory cytokines, growth factors with immunomodulatory properties and factors promoting angiogenesis in the injured area while also regulating the local mesenchymal stem cells in the tissue to promote endometrial regeneration [22–24].

The mesenchymal stem cells can be derived from various tissues in the required quantity with ease [21]. The available literature from animal and human studies suggests that the BM-MSCs can differentiate into endometrial cells and hence could have a convincing application prospect in the treatment of IUAs [24–26]. In the present study, the patients had amenorrhea and recurrent IUA even after they had undergone one or more IUA separation surgery indicating a severely affected endometrium. It is difficult to achieve the desired therapeutic effect with the existing conventional treatments for IUA; hence, we recommended autologous BM-MSC therapy. We successfully harvested and cultured the patient’s own bone marrow stem cells from all seven patients without any adverse effects to the patients. Our treatment approach achieved a very significant outcome in preventing IUAs as no recurrent IUAs were observed in any of the patients during the follow-up. The endometrial thickness had significantly (P < 0.05) increased after the perfusion of stem cells as compared to before treatment. Conversely, the blood flow to the basal layer of the endometrium was also significantly (P < 0.05) improved after perfusions/treatment. All the patients experienced menstrual cramps after perfusion suggesting BM-MSCs combined with hormone supplements promoted the repair of the endometrium. It is imperative to note that in our study, the patients had severe IUA complicated with amenorrhea suggesting nonresponsive, damaged endometrium. The procedure involving bone marrow aspiration and subsequent intrauterine perfusion is simple, reliable, can avoid infections or bleeding due to possible physical injury, and could be safely performed by the practitioner.

In the presented cases, though the stem cell treatment improved endometrial thickness and menstrual flow during the treatment period, there was a varying degree of decline in the improvements observed after the treatment was stopped. Out of the seven patients, amenorrhea reappeared in two patients after one year of treatment, suggesting that the duration of effect of this treatment method is limited. This indicates that BM-MSCs perfusion adjuvant therapy might need further modifications or improvements for treating patients with severe IUAs. Additionally, understanding the mechanism of endometrial repair by mesenchymal stem cells and optimal treatment plans might also help in further improving the therapeutic outcomes. Given the limited duration of effects of this therapy, it will be beneficial for the patients to seek assisted reproductive treatment in the early stages after BM-MSCs perfusion. In our study, a total of four patients received IVF embryo transfer during the two-year follow-up. Among them, one patient successfully implanted leading to term delivery, three patients did not implant but one patient conceived spontaneously and delivered at term about a year later. Taken together, our results suggest that perfusion of autologous BM-MSCs in the patients, severely affected by IUAs, improves the endometrial thickness potentially by rejuvenating the basal layer of the endometrium but the effect may not be long-lasting without continuous treatment.

In preliminary study, the application of patients’ own bone marrow stem cells for the treatment of IUA may have eliminated the possible host immune reaction [27] helping in better integration in the uterus. However, intrauterine perfusion of stem cells has its limitation such as low retention rate, low survival rate, and less activity that limit their clinical application. Further research would be needed to understand the mechanism underlying the therapeutic effects of this treatment and to further explore its potential in the treatment of IUAs in a larger number of patients.

Our study exhibited the effectiveness of bone marrow-derived stem cell adjuvant therapy in preventing the recurrence of IUAs by possibly promoting the repair of damaged endometrium. Bone marrow aspiration and intrauterine perfusion is simple and can be safely executed by a skillful hand. Significant improvement in required parameters observed among all enrolled patients and two full-term pregnancies achieved are very encouraging outcomes warranting further exploration of the efficacy and safety of BM-MSCs in the treatment of IUAs by optimizing the treatment modality in a larger cohort.

5.1 Study design and setting

This is a retrospective, single-center, interventional preliminary study. Patients who were enrolled at Shengjing Hospital Affiliated to China Medical University from January 2017 to January 2020 for the treatment of infertility and diagnosed with recurrent IUA as confirmed by hysteroscopy were included. Additionally, patients with at least one history of hysteroscopic adhesiolysis, failure to respond to estrogen and progesterone, no contraindication to the use of estrogen and progesterone, no contraindication of perfusion/hysteroscopic adhesiolysis on the vital organs, no record of blood transfusion within three months before perfusion were included in the study. Patients with infections such as hepatitis, HIV, syphilis, and severe allergic reaction or with contraindications for bone marrow aspiration were excluded.

5.2 Ethical consideration

This study was approved by the Medical Ethics Committee of Shengjing Hospital affiliated to China Medical University (ethical approval no: 2015PS31J). All the patients provided informed written consent for bone marrow aspiration and intrauterine perfusion of stem cells. This study was conducted in accordance with the principles of the Declaration of Helsinki.

5.3 Extraction and preparation of BM-MSCs

Reagents: Following reagents were used: Sample Density Separation Solution (Tianjin Haoyang Biological Co., Ltd.); DMEM/F12 Medium (Gibco, USA); 0.25% Trypsin-EDTA (Gibco, USA); Ultroser G Serum Replacement (Pall, USA); PE/Dazzle 594 anti-human CD34, PerCP anti-human CD45, PE/Cy7 anti-human CD73, FITC anti-human CD90, PE anti-CD105 (Endoglin) flow antibody (BioLegend, USA). Progynova (Bayer, Germany).

Bone marrow harvesting

The patient’s own bone marrow was collected under standard conditions, with patients in the prone position, under local intradermal anesthesia with 2% lidocaine in the operating room. Under aseptic conditions following the “Standards of clinical-grade mesenchymal stromal cell preparation and quality control” [28], 50 mL of the patient's own bone marrow was aspirated by conventional methods from a posterior superior iliac spine through a biopsy needle and gently mixed with 1% heparin saline medium[29].

Isolation of BM-MSCs, passage, and surface antigen detection

The harvested bone marrow was transferred to a 50-mL centrifuge tube and centrifuged at 800g for 10 minutes. The supernatant was discarded and the cell pellet was resuspended in 45 mL of normal saline. As per the manufacturer’s instruction/protocol (Tianjin Haoyang Biological Co., Ltd.), 15 mL of peripheral blood lymphocyte sample density separation solution was taken in a 50-mL centrifuge tube. The bone marrow cell suspension was slowly layered on the separation solution and centrifuged at 935g for 20 minutes, accelerate 1 and decelerate 1. A white band of mononuclear cells was formed at the interface of the separation solution and bone marrow solution. The band of cells was aspirated and 50 mL of physiological saline was added to resuspend. The cells were mixed and centrifuged at 170g for 10 minutes, the resultant supernatant was discarded and 10 mL of universal serum-free medium containing 2% serum substitute was added, and mixed well. The cells were examined using an inverted phase contrast microscope (Leica, DMi1, Germany) under an objective lens 5x and eyepiece 10x. Images were captured using an image acquisition digital camera (Leica MC170 HD, Germany), and image acquisition software (Leica LAS EZ, Germany). The cells were counted and cell density was adjusted to 2×10⁷/mL for seeding.

The medium was changed for 3 to 4 days, and when the cells were confluent to about 80%, it was trypsinized for passage. The cells that expanded in 2 to 4 passages were determined for cell count and viability before taken for CD34, CD45, CD73, CD90, and CD105 surface antigen detection by flow cytometry[30]. The detailed steps are given in the Supplementary data 1 (complete steps in the methods of BM harvesting and BM-MSC isolation).

5.4 Hysteroscopic adhesion separation surgery and intrauterine perfusion of stem cells

The patients were admitted to the hospital for hysteroscopic transcervical resection of adhesions (TCRA)[31] in the early proliferative phase of the menstrual cycle. TCRA was performed under general anesthesia using ultrasound monitoring, and IUA was dissected with blunt dissection or cold knife to separate the adhesions. When required, electrocoagulation was applied to stop the bleeding. The patients were then given the first intrauterine perfusion of BM-MSCs on the same day of surgery and after surgery for the second or third perfusion on the fifth day of the menstrual cycle. For the first perfusion, 1 mL of bone marrow mesenchymal stem cell suspension (2 × 10⁷/mL) was perfused into the uterine cavity immediately after the operation on the day of surgery. Patients were given an injection of antibiotic (cefmetazole sodium, 1 g, intravenous infusion, twice a day) on the day of operation and were discharged after 24 hours of surgery.

Patients received estrogen tablet (Progynova 2 mg orally, twice a day) 3 days before operation to 40 days after perfusion. Post procedure on the 31st day, orally active progesterone tablet (Duphaston 10 mg, twice a day) was added and continued for the next 10 days. The treatment of both estrogen and progesterone was stopped at the same time. If there were changes in menstruation within 10 days of drug withdrawal, then the second round of intrauterine perfusion of stem cell suspension (2 × 10⁷/mL) was carried out on the fifth day of the menstrual cycle. The third perfusion was performed following similar steps as the second perfusion and the patient was given oral estrogen on the day of each perfusion and followed the same treatment regimen as the first perfusion.

5.5 Follow-up

Patients were followed up with the sequential treatment of estrogen and progesterone after each perfusion. Color Doppler ultrasonography was used to detect endometrial thickness on the 30th day of oral estrogen administration before combining with progesterone. Outpatient hysteroscopy was performed on the same day to examine endometrial pathology and confirm IUA and endometrial repair. After the third perfusion and improvement in the menstrual cycle, the patients were followed up once a year, for up to two years. During the follow-up, color Doppler ultrasonography was used to detect the thickness of the intima. The changes in menstrual flow and reproductive outcomes were recorded. IUAs were evaluated according to the 1988 American Fertility Society (AFS) scoring standard for IUAs[32]. Observation of menstrual flow and scoring was done according to the pictorial blood loss assessment chart (PBAC) method[33].

Ethics approval and consent to participate

This study was approved by the Medical Ethics Committee of Shengjing Hospital affiliated to China Medical University (ethical approval no.2015PS31J). All the patients provided informed written consent for bone marrow aspiration and intrauterine perfusion of stem cells. This study was conducted in accordance with the principles of the Declaration of Helsinki.

Consent for publication

Not applicable

Data availability

All data generated or analyzed during this study are included in this published article and its supplementary information file.

Evans J, Salamonsen LA, Winship A, Menkhorst E, Nie G, Gargett CE et al (2016) Fertile ground: human endometrial programming and lessons in health and disease. Nat Rev Endocrinol 12:654–667
Ochoa-Bernal MA, Fazleabas AT (2020) Physiologic Events of Embryo Implantation and Decidualization in Human and Non-Human Primates. Int J Mol Sci 21:1973
Azizi R, Aghebati-Maleki L, Nouri M, Marofi F, Negargar S, Yousefi M (2018) Stem cell therapy in Asherman syndrome and thin endometrium: Stem cell- based therapy. Biomed Pharmacother 102:333–343
Deshmukh S Understanding Intrauterine Adhesions: Hysteroscopic Evaluation.:15
Dreisler E, Kjer JJ (2019) Asherman’s syndrome: current perspectives on diagnosis and management. Int J Womens Health 11:191–198
Lee W-L, Liu C-H, Cheng M, Chang W-H, Liu W-M, Wang P-H (2021) Focus on the Primary Prevention of Intrauterine Adhesions: Current Concept and Vision. Int J Mol Sci 22:5175
Nagori CB, Panchal SY, Patel H (2011) Endometrial regeneration using autologous adult stem cells followed by conception by in vitro fertilization in a patient of severe Asherman’s syndrome. J Hum Reprod Sci 4:43–48
Zhao Y, Wang A, Tang X, Li M, Yan L, Shang W et al (2013) Intrauterine transplantation of autologous bone marrow derived mesenchymal stem cells followed by conception in a patient of severe intrauterine adhesions. OJOG 03:377–380
Ding D-C, Shyu W-C, Lin S-Z (2011) Mesenchymal stem cells. Cell Transpl 20:5–14
Chen X, Huang J, Wu J, Hao J, Fu B, Wang Y et al (2021) Human mesenchymal stem cells. Cell Prolif. ;e13141
Neagu M, Suciu E, Ordodi V, HUMAN MESENCHYMAL STEM, CELLS AS BASIC TOOLS FOR TISSUE ENGINEERING : ISOLATION AND CULTURE.:6
Yang L, Wang L, Chen Y, Guo X, Miao C, Zhao Y et al (2021) Cold scissors versus electrosurgery for hysteroscopic adhesiolysis: A meta-analysis. Med (Baltim) 100:e25676
Zhou Q, Shi X, Saravelos S, Huang X, Zhao Y, Huang R et al (2021) Auto-Cross-Linked Hyaluronic Acid Gel for Prevention of Intrauterine Adhesions after Hysteroscopic Adhesiolysis: A Randomized Controlled Trial. J Minim Invasive Gynecol 28:307–313
Chen Y, Liu L, Luo Y, Chen M, Huan Y, Fang R (2017) Effects of Aspirin and Intrauterine Balloon on Endometrial Repair and Reproductive Prognosis in Patients with Severe Intrauterine Adhesion: A Prospective Cohort Study. Biomed Res Int 2017:8526104
Haimov-Kochman R, Doviner V, Amsalem H, Prus D, Adoni A, Lavy Y (2003) Intraperitoneal levonorgestrel-releasing intrauterine device following uterine perforation: the role of progestins in adhesion formation. Hum Reprod 18:990–993
Zhou Q, Shi X, Saravelos S, Huang X, Zhao Y, Huang R et al (2021) Auto–Cross-Linked Hyaluronic Acid Gel for Prevention of Intrauterine Adhesions after Hysteroscopic Adhesiolysis: A Randomized Controlled Trial. J Minim Invasive Gynecol 28:307–313
Preutthipan S, Linasmita V (2000) Reproductive outcome following hysteroscopic lysis of intrauterine adhesions: a result of 65 cases at Ramathibodi Hospital. J Med Assoc Thai 83:42–46
Valle RF, Sciarra JJ (1988) Intrauterine adhesions: hysteroscopic diagnosis, classification, treatment, and reproductive outcome. Am J Obstet Gynecol 158:1459–1470
Prianishnikov VA (1978) On the concept of stem cell and a model of functional-morphological structure of the endometrium. Contraception 18:213–223
Wu DC, Boyd AS, Wood KJ (2007) Embryonic stem cell transplantation: potential applicability in cell replacement therapy and regenerative medicine. Front Biosci 12:4525–4535
Ding D-C, Shyu W-C, Lin S-Z (2011) Mesenchymal stem cells. Cell Transpl 20:5–14
Gargett CE, Ye L (2012) Endometrial reconstruction from stem cells. Fertil Steril 98:11–20
Lapidot T, Petit I (2002) Current understanding of stem cell mobilization: the roles of chemokines, proteolytic enzymes, adhesion molecules, cytokines, and stromal cells. Exp Hematol 30:973–981
Cervelló I, Gil-Sanchis C, Santamaría X, Cabanillas S, Díaz A, Faus A et al (2015) Human CD133(+) bone marrow-derived stem cells promote endometrial proliferation in a murine model of Asherman syndrome. Fertil Steril. ;104:1552–1560.e1-3
Alawadhi F, Du H, Cakmak H, Taylor HS (2014) Bone Marrow-Derived Stem Cell (BMDSC) transplantation improves fertility in a murine model of Asherman’s syndrome. PLoS ONE 9:e96662
Li-hong Q, Jia-qun Y (2016) Differentiation of bone marrow mesenchymal stem cells into endometrial epithelial cells in vitro. Chin J Tissue Eng Res 20:2770
Khan SA, Moreb JS (2005) Reversal of severe graft-versus-host disease after nonmyeloablative matched unrelated donor stem cell transplant by infusion of backup autologous peripheral blood stem cells. Bone Marrow Transpl 36:267–268
Shuanglin Xiang WG, Shuanglin Xiang WG (2021) Standards of clinical-grade mesenchymal stromal cell preparation and quality control (2020 China Version). J Neurorestoratology 8:197–216
Lyu T, Wang Y, Li D, Yang H, Qin B, Zhang W et al (2021) Exosomes from BM-MSCs promote acute myeloid leukemia cell proliferation, invasion and chemoresistance via upregulation of S100A4. Exp Hematol Oncol 10:24
Dominici M, Le Blanc K, Mueller I, Slaper-Cortenbach I, Marini FC, Krause DS et al (2006) Minimal criteria for defining multipotent mesenchymal stromal cells. The International Society for Cellular Therapy position statement. Cytotherapy 8:315–317
Wang Y, Yao Z, Zhao H, Yue C, Yu Q, Zhang Y et al (2021) Reproductive Outcomes of In Vitro Fertilization-Intracytoplasmic Sperm Injection after Transcervical Resection of Adhesions: A Retrospective Cohort Study. J Minim Invasive Gynecol 28:1367–1374
The American Fertility (1988) Society classifications of adnexal adhesions, distal tubal occlusion, tubal occlusion secondary to tubal ligation, tubal pregnancies, müllerian anomalies and intrauterine adhesions. Fertil Steril 49:944–955
Higham JM, O’Brien PM, Shaw RW (1990) Assessment of menstrual blood loss using a pictorial chart. Br J Obstet Gynaecol 97:734–739

Supplementaryfile.docx

Download PDF

Reviewers agreed at journal
17 Aug, 2024
Reviewers invited by journal
17 Aug, 2024
Editor invited by journal
12 Aug, 2024
Editor assigned by journal
26 Jun, 2024
First submitted to journal
26 Jun, 2024

You are reading this latest preprint version

Retrospective analysis of autologous bone marrow mesenchymal stem cells as adjuvant therapy in recurrent intrauterine adhesions

Status:

Version 1

Abstract

Figures

1. Introduction

2. Results

2.1 BM-MSC culture and flow-cytometric analysis

2.2 Hysteroscopic dissection of IUAs

2.3 Changes in menstrual flow and intimal thickness after perfusion

2.4 Hysteroscopy and pathological evaluation

2.5 Follow-up of reproductive outcome

3. Discussion

4. Conclusions

5. Experimental procedures

5.1 Study design and setting

5.2 Ethical consideration

5.3 Extraction and preparation of BM-MSCs

5.4 Hysteroscopic adhesion separation surgery and intrauterine perfusion of stem cells

5.5 Follow-up

Declarations

References

Supplementary Files

Status:

Version 1