Decoding the endometrial niche of Asherman's Syndrome at single-cell resolution

Abstract

Asherman's Syndrome (AS) is characterized by intrauterine adhesions, which cause infertility, menstrual abnormalities, and recurrent pregnancy loss. While AS occurs as a consequence of traumatic or infectious disruption of the endometrial cell niche, its pathophysiology remains largely unknown and treatment strategies have been restricted to recurrent hysteroscopic removal of intrauterine adhesions with limited success. We decoded the disrupted endometrial cell niche associated with AS at single cell (sc) resolution by analyzing transcriptomic data from over 230,000 cells. We sought to prove the functional relevance of our findings by incorporating scRNAseq analysis into a phase I/II clinical trial of CD133+ bone marrow-derived stem cells in AS patients (EudraCT Number: 2016–003975–23) and through in vitro analysis of AS patient-derived endometrial organoids. Our integrated analyses supported the construction of an atlas describing the dysfunctional endometrial niche of AS patients, characterized by significant differences in cell population ratios, differential gene expression, and aberrant cell–to–cell communication. Our AS atlas also highlights the existence of two unique cell types — a stressed epithelial population (AS epithelium) expressing the secretory leukocyte protease inhibitor (SLPI) and a population of smooth muscle cells expressing ACTG2 (SMC). These alterations act together to maintain a dysfunctional pro–fibrotic, pro–inflammatory, and anti–angiogenic environment; however, we describe the partial reversion of the cellular, transcriptomic, and aberrant cell to cell communication differences in vivo and in vitro (using endometrial organoids) by patient–specific cell therapy. This first description of a comprehensive functional endometrial cell atlas of AS provides a holistic view of the disrupted AS–associated endometrial niche, thereby providing insight into pathophysiology and aiding the development of advanced therapeutics.

Competing Interest Statement

C.S. & X.S are founders and shareholders of Asherman Therapy S.L. The rest of authors declare no competing interests.

Clinical Trial

This study was registered at The European Union Clinical Trials Register (EU-CTR) and The Spanish Clinical Studies Registry (Registro Espanol de Estudios Clinicos [REec]) (EudraCT Number: 2016-003975-23; Registration date: April 21st, 2021; online: https://www.clinicaltrialsregister.eu/ctr-search/trial/2016-003975-23/ES; https://reec.aemps.es/reec/estudio/2016-003975-23). The Investigational Medical Product (IMP) was designed as Orphan Drug (OD) by the European Medicines Agency (EMA) on April 20th, 2017 (EMA/OD/313/16)2 and by the Food and Drug Administration (FDA) on February 1st, 2019 (designation request number DRU-2017-6131). For the design of this clinical trial, Scientific Advice and Protocol Assistance were conducted in 2017 with the AEMPS (February 10th) and the European Medicines Agency (EMA) (September 1st), respectively.

Funding Statement

This study was jointly supported by Human Uterus Cell Atlas Project from the European Union Horizon 2020 research and innovation programme under grant agreement No. 874867, PROMETEO/2018/161 from the Valencia Government, IDI-20201142 CDTI from the Spanish Government and Carlos Simon Foundation, Spain. B.R. was supported by the H2020 funded project Human Uterus Cell Atlas (HUTER) (2020/2021) (Grant Agreement 874867). R.P. was supported by an Industrial Doctorate grant, (DIN2020-011069) from the Spanish Ministry of Science and Innovation (MICINN). N.K. was supported by PROMETEO/2018/161. J.G.F. was support by PFIS grant [FI19/00159]. I.M. was supported by a FIS project grant [PI21/00235]. F.V. was supported by a FIS project grant [PI21/00528].

Author Declarations

I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained.

Yes

The details of the IRB/oversight body that provided approval or exemption for the research described are given below:

The Clinical Research Ethics Committee at the Hospital Universitari Vall D'Hebron Barcelona, Spain gave ethical approval for this work.

I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals.

Yes

I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance).

Yes

I have followed all appropriate research reporting guidelines and uploaded the relevant EQUATOR Network research reporting checklist(s) and other pertinent material as supplementary files, if applicable.

Yes

Data Availability

All data produced in the present study are available upon reasonable request to the authors.

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