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©The Author(s) 2022. Published by Baishideng Publishing Group Inc. All rights reserved.
Surgical and nutritional interventions for endometrial receptivity: A case report and review of literature
Dinorah Hernández-Melchor, Cecilia Palafox-Gómez, Ivan Madrazo, Ginna Ortiz, America Padilla-Viveros, Esther López-Bayghen
Dinorah Hernández-Melchor, America Padilla-Viveros, Science, Technology and Society Program, Centro de Investigación y de Estudios Avanzados del Instituto Politécnico Nacional, México City 07360, CDMX, México
Dinorah Hernández-Melchor, Clinical Research, Instituto Regenera SC, México City 05320, CDMX, México
Cecilia Palafox-Gómez, Departamento de Toxicología, Centro de Investigación y de Estudios Avanzados del Instituto Politécnico Nacional, México City 07360, CDMX, México
Ivan Madrazo, Ginna Ortiz, Investigación Clínica, Instituto de Infertilidad y Genética México SC, INGENES, México City 05320, CDMX, México
Esther López-Bayghen, Departamento de Toxicología, Centro de Investigación y de Estudios Avanzados del Instituto Politécnico Nacional, Mexico City 07360, CDMX, México
Author contributions: Hernández-Melchor D, Palafox-Gómez C, and López-Bayghen E conceived the project. Ortiz G and Madrazo I performed the surgical procedures; Hernández-Melchor D and Palafox-Gómez C performed clinical data acquisition while Ortiz G and Madrazo I handled the case as the clinicians, collecting information regarding the parental history and in vitro fertilization data. López-Bayghen E, Hernández-Melchor D, and Palafox-Gómez C analyzed the data. López-Bayghen E and Hernández-Melchor D drafted the article. America Padilla critically revised the manuscript; all authors have approved the final version of the manuscript.
Supported by the National Council of Science and Technology of Mexico (CONACYT), No. 790971 (to Hernández-Melchor D), and No. 781208 to (to Palafox-Gómez C).
Informed consent statement: The patient and her partner provided written informed consent to participate in this study under the Declaration of Helsinki. Written informed consent was obtained from them for their anonymized information published in this article.
Conflict-of-interest statement: The authors have no relevant financial or non-financial interests to disclose.
CARE Checklist (2016) statement: The authors have read the CARE Checklist (2016), and the manuscript was prepared and revised according to the CARE Checklist (2016).
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:
https://creativecommons.org/Licenses/by-nc/4.0/ Corresponding author: Esther López-Bayghen, MSc, PhD, Academic Research, Departamento de Toxicología, Centro de Investigación y de Estudios Avanzados del Instituto Politécnico Nacional, Avenida Instituto Politécnico Nacional 2508, San Pedro Zacatenco, México City 07360, CDMX, México. ebayghen@cinvestav.mx
Received: June 20, 2022
Peer-review started: June 20, 2022
First decision: August 4, 2022
Revised: August 16, 2022
Accepted: October 17, 2022
Article in press: October 17, 2022
Published online: November 26, 2022
BACKGROUND
Polycystic ovary syndrome (PCOS) is an endocrine disease that combines metabolic, reproductive, and psychological dysfunctions. Ovulation disorders and impaired endometrial receptivity in PCOS can cause infertility. Insulin resistance (IR) is a pathological state of inadequate response to insulin that affects reproduction in PCOS, as damage caused by IR at the endometrial level becomes an obstacle for embryo implantation. Reversing IR resulted in spontaneous pregnancies in PCOS patients, indicating that metabolic corrections improve endometrial dysfunctions. Mesenchymal stem-cell treatment has also corrected endometrial quality and lead to pregnancies in patients with Asherman’s syndrome. We propose a combination of nutritional intervention with the surgical placement of stem cells to improve endometrial quality to achieve pregnancy in a PCOS patient undergoing in vitro fertilization (IVF) treatment.
CASE SUMMARY
After two failed IVF cycles, a metabolic intervention, consisting of a ketogenic diet with daily consumption of 50 g of carbohydrates (CH), was indicated until pregnancy. Metabolic Syndrome was assessed using the Harmonizing Definition (3 of 5 pathologies: Central obesity, hypertension, hyperglycemia, hypertriglyceridemia, and dyslipidemia), and the Homeostatic Model Assessment of IR (HOMA-IR) was used to measure the level of IR. Once IR improved, endometrial quality improved. However, two day 5-thawed embryos (euploid, donated oocyte–partner's sperm) failed to implant, suggesting endometrial quality improvement was insufficient. Therefore, transmyometrial implantation of mesenchymal stem cells from the stromal vascular fraction of adipose tissue was performed to enrich the endometrial stem cell niche. Minimal endometrial mean thickness for embryo transfer (6.9 mm) was achieved three months after stem cell treatment and continuous dietary control of IR. Two euploid-day 5-thawed embryos (donated oocyte–partner's sperm) were transferred, and embryo implantation was confirmed on day 14 by β-hCG serum levels. Currently, a 37 wk baby girl is born.
CONCLUSION
In PCOS, endometrial quality can be improved by combining nutrient-based metabolic correction with endometrial stem cell niche enrichment.
Core Tip: Polycystic ovary syndrome (PCOS) is an endocrine disease that causes infertility due to ovulation disorders and impaired endometrial receptivity related to a pathological state of insulin resistance (IR). To date, endometrial dysfunctions are the rate-limiting factor for pregnancy in PCOS patients using in vitro fertilization. Here, an overweight PCOS patient with euploid embryos available for transfer achieved pregnancy only after a continuous nutritional intervention to correct IR and metabolic parameters and the enrichment of endometrial stem cell niche with mesenchymal stem cells from adipose tissue. In this case, endometrial thickness and receptivity were improved with a combination of nutritional and surgical interventions to achieve pregnancy.
