Intrauterine adhesions (IUA) are the most common cause of uterine infertility and are caused by endometrium fibrotic regeneration following severe damage to the endometrium. Although current stem cell treatment options using different types of autologous stem cells have exhibited some beneficial outcomes in IUA patients, the reported drawbacks include variable therapeutic efficacies, invasiveness and treatment unavailability. Therefore, the development of new therapeutic stem cell treatments is critical to improving clinical outcomes. Twenty-six patients who suffered from infertility caused by recurrent IUA were enrolled in this prospective, non-controlled, phase I clinical trial with a 30-month follow-up. During the procedure, 1 × 107 umbilical cord-derived mesenchymal stromal cells (UC-MSCs), loaded onto a collagen scaffold, were transplanted into the uterine cavity following an adhesion separation procedure. Medical history, physical examination, endometrial thickness, intrauterine adhesion score and the biological molecules related to endometrial proliferation and differentiation were assessed both before and 3 months after cell therapy. No treatment-related serious adverse events were found. Three months after the operation, the average maximum endometrial thickness in patients increased, and the intrauterine adhesion score decreased compared to those before the treatment. A histological study showed the upregulation of ERα (estrogen receptor α), vimentin, Ki67 and vWF (von Willebrand factor) expression levels and the downregulation of ΔNP63 expression level, which indicates an improvement in endometrial proliferation, differentiation and neovascularization following treatment. DNA short tandem repeat (STR) analysis showed that the regenerated endometrium contained patient DNA only. By the end of the 30-month follow-up period, ten of the 26 patients had become pregnant, and eight of them had delivered live babies with no obvious birth defects and without placental complications, one patient in the third trimester of pregnancy, and one had a spontaneous abortion at 7 weeks. Transplanting clinical-grade UC-MSCs loaded onto a degradable collagen scaffold into the uterine cavity of patients with recurrent IUA following adhesiolysis surgery is a safety and effective therapeutic method. Clinicaltrials.gov . NCT02313415 , Registered December 6, 2014.

Significance: Thin endometrium is the most common reason for uterine infertility and refractory gynecological diseases due to its complexity in pathogenesis and adverse pregnancy outcomes. Here, we profile cells from normal and thin endometrium at single-cell resolution to investigate the sophisticated alterations in the local microenvironment that occur in thin endometrium. Increased cellular senescence, collagen overdeposition, and significant down-regulation of gene expression related to cell proliferation are observed and confirmed. Moreover, we demonstrate aberrant activation of the SEMA3 pathway accompanied by dampened EGF, PTN, and TWEAK signaling pathways in thin endometrium. These findings aid in understanding the mechanisms of thin endometrium and provide new tools to rejuvenate the atrophic endometrium for female fertility preservation and successful pregnancy.

Does the transplantation of adipose-derived stem cells (ADSCs) on soluble collagen scaffolds (collagen/ADSCs) have better therapeutic effect than transplantation of ADSCs alone, to treat premature ovarian insufficiency (POI) in a rat model induced by Tripterygium Glycosides (TG)? The transplantation of collagen/ADSCs increased the short-term retention of ADSCs in ovaries and contributed to long-term restoration of ovarian function, as well as the fertility of rats with TG-induced ovarian damage. About 50% of young women in China, who have been treated with TG, have subsequently developed ovarian insufficiency. Rats exhibit similar symptoms to these patients when given an equivalent dose of TG. Transplantation of ADSCs improves ovarian function impaired by chemotherapy in rodent models. After the administration of TG, 54 POI model rats were randomly assigned to 4 groups: phosphate buffered saline (PBS) (n = 14), collagen (n = 11), ADSCs (n = 16) and collagen/ADSCs (n = 13). Seventeen normal rats were assigned as control group. The retention of ADSCs in ovaries was confirmed immediately or at 3, 7, 14 and 28 days after transplantation (n = 9). Four weeks after transplantation, ovarian function was evaluated from estrous cycle, estradiol level, the follicle number, granulosa cell proliferation and a fertility test. To establish the POI model, rats were administered 60 mg TG/kg/day intragastrically for 50 days. The estrous cycles were assessed by vaginal smear. The concentration of plasma estradiol in diestrus stage was measured using a radioimmunoassay kit. Disordered estrous cycles and low serum estradiol levels indicated the successful establishment of the POI model. Four types of suspensions (PBS, collagen, ADSCs and collagen/ADSCs) were transplanted directly into the core of the ovaries. The short-term retention of ADSCs in ovaries was evaluated by small-animal positron emission tomography images immediately after transplantation of ¹⁸F-Fluorodeoxyglucose (¹⁸F-FDG) labeled ADSCs. The long-term retention of ADSCs in ovaries was observed by immunohistochemistry after transplantation of green fluorescent protein (GFP)-labeled ADSCs. Serial sections of ovaries were prepared for histological analysis, follicle counting, and immunohistochemistry for Ki67 and Cleaved-Caspase-3. For the assessment of fertility, rats were mated with proven fertile male rats for 10 days. The ¹⁸F-FDG signal decreased more slowly in ovaries injected with collagen/ADSCs than in ovaries with injected with ADSCs alone. Significantly more GFP-positive cells were observed in ovaries injected with collagen/GFP-ADSCs than in ovaries injected with GFP-ADSCs alone up to 14 days after the injection. However, in both groups very few GFP-positive cells were present at 4 weeks after transplantation. The collagen/ADSCs and ADSCs groups both showed better estrous cycle recovery than the PBS and collagen groups. The estradiol (E₂) level in the collagen/ADSCs group was significantly increased compared with that of the PBS group (P < 0.05). The number of antral follicles in the collagen/ADSCs group and the ADSCs group significantly increased compared with the PBS group (P < 0.05). The granulosa cell proliferation in the collagen/ADSCs group was better than in the PBS group (P < 0.01). The mating rates of the collagen/ADSCs group (88.9%) and the ADSCs group (90.9%) were higher than that of PBS group (60%, P < 0.05). The pregnancy rates of the collagen/ADSCs group (77.8%) and the ADSCs group (72.7%) were higher than the PBS group (50%, P < 0.05). We chose ADSCs for their accessibility, convenience and safety. We did not use other cells or materials for POI treatments to show that the collagen/ADSCs are the most promising materials. Soluble collagen scaffolds may be useful in stem cells transplantation therapy for POI. This work is supported by grants from the ‘Strategic Priority Research Program’ of the Chinese Academy of Sciences (XDA01030000); Maternal-Fetal Medicine from Jiangsu Province Health Department of China (XK2011027); Clinical Center of Obstetric, Gynecologic and Genetic Diseases, Nanjing Health Department of Jiangsu Province, China; Fundamental Research Funds for the Central Universities (20620140652). The authors declare no competing financial interests. Not applicable.

Asherman’s syndrome (AS) is a common disease that presents endometrial regeneration disorder. However, little is known about its molecular features of this aregenerative endometrium in AS and how to reconstruct the functioning endometrium for the patients with AS. Here, we report that ΔNp63 is significantly upregulated in residual epithelial cells of the impaired endometrium in AS; the upregulated-ΔNp63 induces endometrial quiescence and alteration of stemness. Importantly, we demonstrate that engrafting high density of autologous bone marrow mononuclear cells (BMNCs) loaded in collagen scaffold onto the uterine lining of patients with AS downregulates ΔNp63 expression, reverses ΔNp63-induced pathological changes, normalizes the stemness alterations and restores endometrial regeneration. Finally, five patients achieved successful pregnancies and live births. Therefore, we conclude that ΔNp63 is a crucial therapeutic target for AS. This novel treatment significantly improves the outcome for the patients with severe AS.