The effect of uterine massage and number of embryo flushing attempts on embryo recovery in mares.

The aims of this study were to determine the effect of the embryo flushing technique and the number of flushing attempts performed by operators of different experience on embryo recovery (ER). Ten non-lactating mares were inseminated with the same stallion in six cycles each (n = 60). Embryo flushing (EF) was performed 7-9 days after ovulation by three operators (OP; 20 EF cycles each): OP1 had performed >500 EF before the study, while OP2 and 3 had performed 0 EF. Each EF was performed with 2 flushing attempts (FA) using 1L of ringer's lactate "in-and-out" using two EF techniques: 1) uterine massage (UM): continuous ballottement and massage of the uterus per rectum during ringer lactate recovery, 2) gravity flow (GF): the ringer lactate was allowed to flow back without massaging the uterus. In both groups, 20 IU of oxytocin were administered at the second FA and the ringer lactate was allowed to remain in the uterus for 3 min before recovery. An extra FA was performed in each group using 0.5 L of ringer lactate and uterine massage. More embryos (P < 0.05) per ovulation were recovered in the UM (17/33, 0.51) than in the GF group (8/36, 0.22). For the UM group, 16/17 embryos (94.1 %) were recovered in the first FA, while only one embryo in the second FA (1/17, 5.9 %). In the GF group, 4 embryos were recovered in each FA. No embryo was found in the extra FA in the UM group, while seven additional embryos were found in the GF group (5/7 flushed by OP1; P < 0.05). The overall ER per cycle was 70, 40, and 45 % for OP1, 2 and 3, respectively. In conclusion, highest embryo recovery is achieved in EF performed with UM, with the majority of embryos being flushed in the first FA.

Antimicrobial efficiency of bromhexine hydrochloride against endometritis-causing Escherichia coli and Trueperella pyogenes in bovines.

In this study, the main agents associated with endometritis in cows in the state of Santa Catarina, Brazil, were identified and the resistance profile and virulence mechanisms of the bacterial isolates were evaluated. Isolates of Escherichia coli and Trueperella pyogenes were tested for their biofilm forming ability and the antimicrobial action of bromhexine hydrochloride in combination with other antimicrobials. A total of 37 uterine lavage samples were collected from cows with endometritis. Of the 55 bacteria isolated, 25.4% were identified as T. pyogenes and 16.3% as E. coli. The bacterial isolates showed greater resistance to sulfamethoxazole + trimethoprim (58.2%) and tetracycline (56.3%). Among the species, E. coli showed the highest resistance rates, with 100% of isolates showing resistance to amoxicillin, streptomycin, and gentamicin. The results of the minimum inhibitory concentration for the T. pyogenes isolates showed that 91.6% of the isolates were resistant to enrofloxacin and tetracycline, and 75% were resistant to ceftiofur and sulfamethoxazole + trimethoprim. All E. coli and T. pyogenes isolates showed biofilm forming ability. The plo, fimA, and nanH genes were identified in 100% of T. pyogenes isolates. In parallel, 100% of E. coli isolates had the fimH gene, and 11.1% had the csgD gene. Bromhexine hydrochloride showed antimicrobial activity against 100% of E. coli isolates and 66.6% of T. pyogenes isolates. Furthermore, when associated with antimicrobials, bromhexine hydrochloride has a synergistic and additive effect, proving to be an option in the treatment of endometritis in cows and an alternative for reducing the use of antimicrobials.

Inflammatory markers for differentiation of endometritis in the mare.

BACKGROUND: Endometrial biopsy is required to diagnose mares with chronic endometritis and endometrial degenerative fibrosis. An increase in understanding of equine reproductive immunology could be utilised to create less-invasive, time-efficient diagnostic tools especially when evaluating mares for chronic endometritis. OBJECTIVES: To evaluate inflammatory cytokine and chemokine concentrations in uterine fluid samples collected by low-volume lavage (LVL) as a potential screening diagnostic biomarker for endometritis. STUDY DESIGN: Prospective cross-sectional clinical study. METHODS: Forty-six mares underwent a LVL and subsequently endometrial biopsy. Mares were split in three groups: healthy, acute endometritis, and chronic endometrial fibrosis (CEF) based on cytological and histological evaluation. A fluorescent bead-based multiplex assay for IFN-γ, IFN-α, IL-1ß, IL-4, IL-10, IL-17, sCD14, TNF-α, CCL2, CCL3, CCL5 and CCL11 were carried out on the LVL fluid. The endometrial biopsy was utilised for histology and qPCR of IFN-γ, IL-1ß, IL-6, IL-8, IL-17, TNF-α, CCL2 and CCL3 genes. Statistical analyses examined differences in inflammatory markers and predictive modelling for diseased endometrium. RESULTS: Secreted concentrations of IFN-γ were lower in LVL fluid from reproductively healthy mares compared with acute endometritis (p = 0.04) and CEF (p = 0.006). Additionally, IL-17, IL-10, IL-1ß, TNF-α, CCL2, CCL3, CCL5 and CCL11 were significantly increased (p ≤ 0.04) in LVL from CEF mares compared with healthy mares. Mares with CCL2 concentrations ≥550 pg/mL (14/14) had 100% probability of having CEF and/or acute endometritis. Healthy mares had lower relative abundance of IL-17 mRNA compared with mares in CEF group [median (interquartile rage) = 14.76 (13.3, 15.3) and 12.4 (10.54, 13.81)], respectively (p = 0.02). MAIN LIMITATIONS: Limited sample size: larger numbers of mares with and without endometritis are required and reference intervals in LVL samples have to be established. CONCLUSIONS: Inflammatory chemokines and cytokines concentrations differed between healthy mares and mares with acute endometritis or CEF in LVL.

Synchronous endometrial and ovarian cancer: A case report.

BACKGROUND: Synchronous endometrial and ovarian cancer (SEOC) is a rare genital tract tumor. Precise diagnosis is crucial for the disease management since prognosis and overall survival differ substantially between metastatic endometrial cancer (EC) or OC. In this review we present 2 cases of women who were diagnosed with SEOC, and discuss the clinical characteristic of SEOC, diagnostic and molecular profiling issues. Next generation sequencing of 10 gene panel was performed on cancerous tissue and uterine lavage samples. CASE SUMMARY: In our report patients with SEOC had endometroid type histology with early stage and low-grade histology for both EC and OC. They underwent surgical treatment and staging. Next-generation sequencing of 10 gene-panel identified CTNNB1, PIK3CA, and PTEN gene mutations in ovarian tissue in one case, while none of these genes were mutated in other case. Literature review in support to our data suggest a good prognosis for SEOC diagnosed at early stage. CONCLUSION: Accurate diagnosis of SEOC is essential for disease management and gene mutation analysis can be helpful as a complementary diagnostic and prognostic tool.

Proteomic analysis of uterine lavage fluid of dairy cows at different time after delivery by mass spectrometry.

Endometritis is a common disease in the reproductive system, which is the infection and inflammation of the endometrium. In severe cases, it can affect the myometrium and adversely affect the subsequent fertility of dairy cows. We used a mass spectrometry-based technique to compare proteomics of uterine lavage fluid between healthy cows and cows with cytological endometritis classified according to 100-day postpartum pregnancy results and diagnosis result. The uterine lavage fluid of dairy cows collected at 15 and 30 days after delivery was analyzed. 15 days postpartum, we identified a total of 1129 proteins in the control and cytological endometritis (CEM) groups. Among them, 160 proteins were accurately screened out. 30 days postpartum, we identified a total of 846 proteins in the control and cytological endometritis (CEM) groups. Among them, 186 proteins were accurately cytological endometritis (CEM). Endometritis is a costly reproductive disease in lactating cows, which needs to be diagnosed in time. Using proteomics method based on gel mass spectrometry, we compared the proteome of uterine lavage fluid of dairy cows with and without cytological endometritis to characterize the changes of proteomic characteristics associated with postpartum uterine disease. To provide reference for clinical application and basic research.

Human Uterine Lavage: First Live Births from In Vivo Conceived Genetically Screened Blastocysts.

INTRODUCTION: We wish to report the first live births from genetically screened human euploid blastocysts obtained by uterine lavage. The embryos transferred to infertile women were previously obtained using a novel fully automated uterine lavage catheter and fluid recovery device developed for this indication. The objective of this portion of the research was to confirm embryo implantation and live births with these unique in vivo conceived blastocysts obtained by uterine lavage. METHODS: In vivo conceived embryos recovered by uterine lavage 5 days after intrauterine insemination were available for embryo donation. In vivo embryos were the result of prior controlled ovarian stimulation cycles in oocyte donors and intrauterine insemination with donor sperm. An observational case series of nine embryo transfer procedures was performed at an outpatient fertility center. One to two embryos were transferred to eight infertile women since one woman had two separate embryo transfer procedures. RESULTS: Nine embryo transfer procedures were performed with 14 blastocysts in eight women resulting in a blastocyst implantation rate of 36% (5/14) and live birth rate of 44% (4/9). Five infants have been born from the four delivered pregnancies with one set of twins. CONCLUSIONS: This is the first report of live births from genetically screened human euploid blastocysts obtained by uterine lavage. The nonsurgical uterine lavage office procedure represents the only current approach to obtain in vivo conceived embryos and can provide a benchmark for comparison to standard in vitro cultured blastocysts. Live births of in vivo conceived blastocysts represent the validation that the nonsurgical uterine lavage procedure allows simplified access to naturally conceived embryos without performing the surgical procedure of an oocyte aspiration. Owing to its simplicity, uterine lavage may be useful in screening embryos for preimplantation genetic testing for aneuploidy in fertile and infertile couples. TRIAL REGISTRATION NUMBER: ClinicalTrials.gov (Identifier NCT03426007).

The overall goal of this research was to develop a procedure that would allow collection of naturally conceived human embryos and compare them to embryos that result from the standard process of in vitro fertilization (IVF). IVF is a procedure where eggs are surgically removed from the ovaries and fertilized with sperm in a laboratory. Embryos from IVF are cultured for 3­7 days before they are placed back into a woman's uterus to establish a pregnancy. Uterine lavage is a different procedure where the sperm fertilizes an egg in the normal process of conception and the uterus is rinsed with fluid to recover the embryo before implantation. The embryos reported in this study were the first to be obtained in over 30 years owing to many improvements in the overall uterine lavage procedure. Until our initial study findings reported in 2020, the vast majority of information on embryo development was based on embryos fertilized and cultured in a laboratory. Our prior report of embryos obtained by uterine lavage compared with IVF embryos from the same women demonstrated a significantly better appearance of the embryos recovered by lavage. This current report documents the first live births from these genetically screened naturally conceived human embryos. The live births provide evidence that uterine lavage allows ready access to normal embryos without performing the surgical procedure IVF. Owing to the simplicity of uterine lavage, the procedure may improve access to genetic testing of embryos before pregnancy.

Uterine Cavity Lavage Mutation Analysis in Lithuanian Ovarian Cancer Patients.

BACKGROUND: Type II ovarian cancer (OC) is generally diagnosed at an advanced stage, translating into a poor survival rate. Current screening methods for OC have failed to demonstrate a reduction in mortality. The uterine lavage technique has been used to detect tumor-specific TP53 mutations from cells presumably shed from high-grade serous ovarian cancer (HGSOC). We aimed to pilot whether the detection of TP53 mutation in uterine cavity lavage can be used as a diagnostic method for HGSOC using an expanded gene panel. METHODS: In this study 90, uterine lavage and 46 paired biopsy samples were analyzed using next-generation sequencing (NGS) targeting TP53 as well as five additional OC-related genes: BRCA1, BRCA2, PI3KCA, PTEN, and KRAS. RESULTS: Uterine lavage was successfully applied to all patients, and 56 mutations were detected overall. TP53 mutations were detected in 27% (10/37) of cases of type HGSOC; BRCA1 and BRCA2 mutations were also frequent in this group (46%; 17/37). Overall concordance between tissue and liquid biopsy samples was 65.2%. CONCLUSION: Uterine lavage TP53 mutations in combination with other biomarkers could be a useful tool for the detection of lowly invasive HGSOC.

Uterine lavage identifies cancer mutations and increased TP53 somatic mutation burden in individuals with ovarian cancer.

Current screening methods for ovarian cancer (OC) have failed to demonstrate a significant reduction in mortality. Uterine lavage combined with TP53 ultra-deep sequencing for the detection of disseminated OC cells has emerged as a promising tool, but this approach has not been tested for early-stage disease or non-serous histologies. In addition, lavages carry multiple background mutations, the significance of which is poorly understood. Uterine lavage was collected preoperatively in 34 patients undergoing surgery for suspected ovarian malignancy including 14 patients with benign disease and 20 patients with OC (6 non-serous and 14 high grade serous-like (serous)). Ultra-deep duplex sequencing (~3000x) with a panel of common OC genes identified the tumor mutation in 33% of non-serous (all early stage) and in 79% of serous cancers (including four early stage). In addition, all lavages carried multiple somatic mutations (average of 25 mutations per lavage), more than half of which corresponded to common cancer driver mutations. Driver mutations in KRAS, PIK3CA, PTEN, PPP2R1A and ARID1A presented as larger clones than non-driver mutations and with similar frequency in lavages from patients with and without OC, indicating prevalent somatic evolution in all patients. Driver TP53 mutations, however, presented as significantly larger clones and with higher frequency in lavages from individuals with OC, suggesting that TP53-specific clonal expansions are linked to ovarian cancer development. Our results demonstrate that lavages capture cancer cells, even from early-stage cancers, as well as other clonal expansions and support further exploration of TP53 mutation burden as a potential OC risk factor.

Changes in the C-reactive protein and 13,14-dihydro-15-keto-prostaglandin F2α concentrations of uterine lavage samples after the administration of povidone-iodine in cows.

Changes in the C-reactive protein (CRP) and 13,14-dihydro-15-keto-prostaglandin F2α (PGFM) concentrations of uterine lavage fluid were examined in cows given an intrauterine povidone-iodine (PI) infusion. The mean polymorphonuclear leukocyte (PMN) ratios (the ratio of PMN to total cells) and CRP concentration of uterine lavage fluid on the day after the treatment were significantly (P<0.05) greater in the PI infusion group (PMN: 53.0 ± 32.7%, CRP: 50.2 ± 32.3 ng/mL) than in the non-treatment control group (PMN: 7.9 ± 21.9%, CRP: 17.2 ± 5.9 ng/mL), whereas there was no significant difference in the mean PGFM concentration between the two groups. The present findings suggest that the uterine CRP level is a useful biomarker of local uterine inflammation in cows.

Towards less invasive molecular diagnostics for endometrial cancer: massively parallel sequencing of endometrial lavage specimens in women attending for an office hysteroscopy.

We aimed to detect endometrial cancer (EC)-associated mutations in endometrial lavage specimens collected in an office setting and to compare the detected mutations with those identified in tissue samples. Participants included 16 women attending for an office hysteroscopy because of suspected EC between July 2020 and October 2021. Massively parallel sequencing was conducted using the targeted 72 cancer-associated genes. Endometrial lavage specimens, endometrial tissue samples, and blood samples were simultaneously sequenced to establish the concordance of genetic alterations. In this study, the vast majority of EC-associated mutations identified in lavage samples (R2 = 0.948) were identical to those detected in endometrial tissues. Of the 13 patients with EC, 12 (92.3%) had at least one mutation identified in endometrial lavage samples. Notably, no mutations in lavage samples were identified in the two patients with a previous history of EC but no actual endometrial lesions, supporting a high negative predictive value of the test. A patient previously diagnosed with EC and with current evidence of atypical hyperplasia showed persisting PTEN, PIK3R1, and KRAS mutations in her endometrial lavage specimen. PTEN was the most commonly mutated gene, followed by PIK3R1, ARID1A, PIK3CA, CTNNB1, and KRAS. In conclusions, our study provides pilot evidence on the actionability of uterine lavage samples sequencing to detect EC-associated mutations in women with suspected endometrial lesions. In a precision medicine framework, the high mutational concordance between uterine lavage samples and tissue specimens may help inform less invasive diagnostic protocols and the need for ongoing surveillance in patients with EC who wished for fertility-preserving treatment. KEY MESSAGES: • Sequencing of uterine lavage samples collected by office hysteroscopy is feasible. • Most EC mutations identified in lavage were identical to endometrial tissues. • Sequencing of uterine lavage samples may help inform diagnostic protocols for EC. • This approach can be used for recurrence surveillance in patients with EC.

Bacteria Isolated From Equine Uteri in The United Arab Emirates: A Retrospective Study.

The United Arab Emirates (UAE) presents a unique environment in which to breed horses with a non-physiological breeding season coupled with high temperatures and humidity for much of the year. This study aimed to describe bacterial isolates from the uteri of mares in the UAE and compare them to those reported elsewhere in the world. Bacterial antibiotic resistance was also analyzed to give a starting point for future monitoring. A total of 2,022 swabs taken over five breeding seasons from the endometrium (n = 1,350) or from uterine lavages (n = 672) were submitted for microbiological culture and antibiotic sensitivity testing. At 48 hours post-inoculation 616 of 2,022 (30.5%) of cultures showed microbial growth from which 690 isolates were identified. Most positive plates (548 of 616; 89%) grew one isolate; 68 cultures had two (62 of 616; 10.1%) or three (6 of 616; 1%) isolates. The most frequently isolated bacteria were ß-hemolytic Streptococcus (36.5%; 252 of 690), E. coli (10.6%; 73 of 690), P. aeruginosa (10.1%; 70 of 690), K. pneumoniae (8.8%; 61 of 690) and Aeromonas hydrophila (4.1%; 28 of 690). The lowest level of antibiotic susceptibility for all isolates was shown by trimethoprim-sulphonamide (36.4%; 198 of 544), with amikacin showing the highest (76.1%; 271 of 356). A significant decrease in susceptibility to doxycycline, enrofloxacin, and erythromycin, but a significant increase for amoxicillin with clavulanic acid, was seen for ß-hemolytic Streptococcus. Decreasing susceptibility of trimethoprim-sulphonamide between two time periods was seen for E. coli. Compared to other studies UAE-based mares had a high incidence of P. aeruginosa and K. pneumoniae isolates, whereas E. coli was represented far less frequently as an isolate.

Infectious Endometritis in Mares: Microbiological Findings in Field Samples.

Endometritis is a major cause of infertility and subfertility in the mare. Early diagnosis and identification of the pathogens involved in infectious endometritis are crucial to initiate correct treatments in time, in order to optimize fertility and reduce the risk of bacterial resistance development. In this retrospective study (from 2014 to 2018), 394 samples (uterine swabs and lavages) obtained from mares before breeding, regardless of clinical history of endometritis were analyzed. Our bacteriological procedure included the subculturing from the enrichment in Brain Heart Infusion Broth of the samples resulted negative after direct smearing. A total of 386 microorganisms were isolated from 230 positive samples (58%). At least one microorganism was isolated from 33% of the samples after direct smearing and from another 25% after enrichment. The results, obtained from both direct smearing and enrichment, also show a significative difference between positive uterine lavages (80%) and swabs (53%). The most frequently isolated bacteria were α-haemolytic Streptococcus (27%), Escherichia coli (27%), ß-haemolytic Streptococcus (26.1%) and Staphylococcus spp. (19.1%). In monoculture, the most common isolated microorganisms were α-haemolytic Streptococcus (13%), Staphylococcus spp. (12.2%), ß-haemolytic Streptococcus (11.4%) and Escherichia coli (9.8%). Focusing on the samples with a pure culture, Gram-negative bacteria grew preferably after direct smearing, while Gram-positive after enrichment. In conclusion, the present study shows that uterine lavage with high volume of fluid statistically significantly increased the sensitivity of the bacteriological examination and highlights the key role of the enrichment step in the routine bacteriological laboratory procedure by increasing the isolation rate.

Extracellular vesicles in low volume uterine lavage and serum: novel and promising biomarker for endometritis in Arabian mares.

BACKGROUND: Extracellular vesicles (EVs) are a promising biomarker and play a vital role in cell-cell communication. This study aimed (I) to identify and characterize EVs from low volume uterine lavage (LVL) and serum in mares with endometritis, compared to healthy controls and (II) to measure serum levels of interleukin 6 (IL-6), and prostaglandins (PGF2α and PGE2). Mares were divided into 30 sub-fertile (endometritis) and 20 fertile (controls). Serum and LVL was collected for EV isolation, and determination of serum levels of inflammatory mediators. Characterization and visualization of EVs were done by electron microscopy, dynamic light scattering and flow cytometry. RESULTS: Serial ultracentrifugation of LVL and use of a commercial kit for serum were strategies for EVs isolation. Mares with endometritis released higher amounts of larger size EVs. The EVs from mares with endometritis differentially expressed CD9 and CD63, compared to controls. Mares suffering from endometritis evoked higher levels of inflammatory mediators. CONCLUSIONS: Thus, EVs could be used for a better understanding the regulatory mechanisms associated with developing endometritis in mares.

Future Screening Prospects for Ovarian Cancer.

Current diagnostic tools used in clinical practice such as transvaginal ultrasound, CA 125, and HE4 are not sensitive and specific enough to diagnose OC in the early stages. A lack of early symptoms and an effective asymptomatic population screening strategy leads to a poor prognosis in OC. New diagnostic and screening methods are urgently needed for early OC diagnosis. Liquid biopsies have been considered as a new noninvasive and promising method, using plasma/serum, uterine lavage, and urine samples for early cancer detection. We analyzed recent studies on molecular biomarkers with specific emphasis on liquid biopsy methods and diagnostic efficacy for OC through the detection of circulating tumor cells, circulating cell-free DNA, small noncoding RNAs, and tumor-educated platelets.

Effect of Endometrial Sampling Procedures on Subsequent Pregnancy Rate of Cattle.

Endometrial infections are a common cause of reproductive loss in cattle. Accurate diagnosis is important to reduce the economic losses caused by endometritis. A range of sampling procedures have been developed which enable collection of endometrial tissue or luminal cells or uterine fluid. However, as these are all invasive procedures, there is a risk that sampling around the time of breeding may adversely affect subsequent pregnancy rate. This systematic review compared the pregnancy rates (PR) of cattle which underwent uterine lavage (UL), cotton swab (CS), cytobrush (CB), cytotape (CT), or endometrial biopsy (EB) sampling procedures with those that were not sampled. Using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) protocol, relevant databases, including Pubmed, Web of Science, CAB Abstracts, VetMed Resource-Ruminants, and Scopus, were searched. The outcome measured was the pregnancy rate after the collection of endometrial sample(s). Seven studies, involving a total of 3693 cows, fulfilled the inclusion criteria for the systematic review and allowed the comparison of PR between sampled (n = 1254) and non-sampled cows (n = 2409). The results of the systematic review showed that endometrial sampling procedures can be performed before breeding or shortly after insemination without adversely affecting pregnancy rates in cattle. However, further studies are needed to validate this information.

Isolation and Characterization of Equine Uterine Extracellular Vesicles: A Comparative Methodological Study.

Extracellular vesicles (EVs) have been identified in the uterine fluid in different species and have been pointed as key players in the embryo-maternal dialogue, maternal recognition of pregnancy and establishment of pregnancy. However, little is known about the uterine EVs in the mare. Therefore, the present study aimed at characterizing EVs from uterine lavage of cyclic mares by comparing five EVs isolation methods and the combination of them: (1) ultracentrifugation (UC); (2) concentration of lavage volume by Centricon ultrafiltration (CE); (3) the use of CE with different washing steps (phosphate-buffered saline with or without trehalose); (4) size-exclusion chromatography with iZON-qEV columns, and (5) a combination of the methods with best results based on EVs yield, purity, and protein cargo profiles. Transmission electron microscopy and Western blotting confirmed the isolation of EVs by all methods but with quantitative and qualitative differences. Mass spectrometry provided differences in protein profiles between methods, number of identified proteins, and protein classes. Our results indicate that the combination of CE/trehalose/iZON/UC is an optimal method to isolate equine uterine EVs with good yield and purity that can be applied in future studies to determine the role of equine uterine EVs in embryo-maternal interactions.

Occurrence of Intrauterine Purulent Concrements in a Maiden Mare-A Case Report.

Pyometra is an uncommon condition in mares associated with various symptoms. Here, we report a case of a 13-year-old Icelandic barren maiden mare with recurrent vaginal discharge. Ultrasonographically, the mare displayed intrauterine spherical masses of inhomogenous texture, which were identified as purulent concrements in hysteroscopy. The purulent concrements were successfully removed via uterine lavage after endoscope-assisted comminution. Microbiologic examination of the concrements revealed growth of Streptococcus equi subspecies zooepidemicus, Actinobacillus species, Pseudomonas aeruginosa, Staphylococcus intermedius, Pseudomonas fulva, Citrobacter freundii, and Chryseobacterium species. Systemic antibiotic treatment with trimethoprim-sulfadiazine and additional uterine lavages were performed for 10 days. A follow-up examination revealed absence of intrauterine masses but reoccurrence of pyometra due to an impatent cervical canal. The pyometra condition was resolved by insertion of a cervical stent for prevention of intrauterine fluid accumulation. In conclusion, uterine masses, which may severely impact fertility, are best diagnosed by hysteroscopy. Intrauterine purulent concrements should be considered as an atypical form of equine pyometra.

Medical research and reproductive medicine in an ethical context: a critical commentary on the paper dealing with uterine lavage published by Munné et al.

A recent study published in Human Reproduction claimed that uterine lavage offers a non-surgical, minimally invasive strategy for the recovery of human embryos from fertile women who do not want or need IVF for medical reasons but who desire preimplantation genetic testing (PGT) for embryos. To prove this hypothesis, the researchers recruited dozens of young Mexican women. The prospective oocyte donors underwent ovarian stimulation to induce the production of multiple mature oocytes. Subsequently, these women were inseminated by donor semen. A few days later, the developing embryos were collected by uterine lavage (uterine flushing) and subjected to genetic testing for aneuploidies (PGT-A). Oocyte donors with persistently elevated hCG levels, indicating the implantation of one or more embryos after uterine lavage, had to undergo uterine curettage and/or treatment with methotrexate. A critical opinion paper discussing the aforementioned study was published by De Santis and colleagues and has raised critical issues that are largely technical in nature. However, this opinion paper neglects-from our point of view-critical issues of the Mexican study regarding ethical principles and moral standards in human research. These aspects are summarized below.

Diagnostic and Treatment Practices of Equine Endometritis-A Questionnaire.

Endometritis is a major cause for impaired fertility in mares. The objectives of this study were to collect information on diagnostic and treatment practices performed by veterinarians and to investigate possible effects of professional experience, caseload, and geographical location on the practitioners' management of endometritis cases. For this purpose, equine practitioners (n = 680) were asked to fill out an online survey (34 questions). The online survey yielded 117 responses by veterinarians practicing in all parts of Germany. Most respondents came from Lower Saxony and managed <20 mares per year. For the diagnosis of chronic infectious endometritis, uterine sampling for microbiological examination was performed manually with a swab by the majority of practitioners whereas only few used the speculum technique. The incidence of antibiotic resistant pathogens was reported to be <5% by almost all respondents. Most practitioners relied on systemic antibiotic treatment with trimethoprim-sulfadiazine. Only occasionally veterinarians used intrauterine antibiotic therapy. Uterine lavages were performed routinely by almost half of the respondents in case of positive uterine cultures, mostly with 0.9% saline solution. Irritant solutions (e.g., iodine, chlorhexidine, kerosene) were used less often. Collection of an endometrial culture after completion of the treatment was common practice. While only a very limited association of the geographical location of practitioner (e.g., on selection of mares for endometrial culture, p < 0.05) was observed, the number of managed mares affected the answers notably (e.g., for use of irritating intrauterine treatment, p < 0.05). The management of persistent breeding induced endometritis (PBIE) was influenced by the number of managed mares (e.g., for use of oxytocin, p < 0.05) and 29.6% of respondents administered antibiotics as part of their PBIE management. In summary, treatment strategies in the field vary considerably and include also non-evidence-based methods, but most German practitioners apply the recommended suitable treatments. Following the guidelines for antibiotic usage, most veterinarians administer antibiotics dependent on endometrial culture results but do not use cytology, low-volume lavage, or biopsy routinely. Antibiotic resistant uterine pathogens are reported to be isolated infrequently and equine practitioners prefer systemic to local antibiotic treatment of endometritis.

Uterine lavage: ethics of research and clinical applications.

Uterine lavage is presented as a way to perform aneuploidy screening without IVF. The feasibility of this method was tested in a research study. This study combined a number of highly contentious ethical issues: the creation of embryos for research (very early), abortion and (moderate) payments to research participants. It is concluded that the study largely fulfils the criteria of ethical research but that the researchers should have avoided a number of steps. These steps were the inclusion of infertility patients, the performance of the research in a middle-income country and the double destination of the embryos. The next question then becomes whether it would be acceptable to apply the method in a clinical setting. Two elements complicate the introduction in the clinic: low success rate of embryo collection and risk of unintended pregnancy. The application of the method in the clinic may lead to very complicated ethical and legal situations for which both patients and doctors should be prepared.