Cellular heterogeneity and dynamics of the human uterus in healthy premenopausal women.

The human uterus is a complex and dynamic organ whose lining grows, remodels, and regenerates in every menstrual cycle or upon tissue damage. Here we applied single-cell RNA sequencing to profile more the 50,000 uterine cells from both the endometrium and myometrium of 5 healthy premenopausal individuals, and jointly analyzed the data with a previously published dataset from 15 subjects. The resulting normal uterus cell atlas contains more than 167K cells representing the lymphatic endothelium, blood endothelium, stromal, ciliated epithelium, unciliated epithelium, and immune cell populations. Focused analyses within each major cell type and comparisons with subtype labels from prior studies allowed us to document supporting evidence, resolve naming conflicts, and to propose a consensus annotation system of 39 subtypes. We release their gene expression centroids, differentially expressed genes, and mRNA patterns of literature-based markers as a shared community resource. We find many subtypes show dynamic changes over different phases of the cycle and identify multiple potential progenitor cells: compartment-wide progenitors for each major cell type, transitional cells that are upstream of other subtypes, and potential cross-lineage multipotent stromal progenitors that may be capable of replenishing the epithelial, stromal, and endothelial compartments. When compared to the healthy premenopausal samples, a postpartum and a postmenopausal uterus sample revealed substantially altered tissue composition, involving the rise or fall of stromal, endothelial, and immune cells. The cell taxonomy and molecular markers we report here are expected to inform studies of both basic biology of uterine function and its disorders. SIGNIFICANCE: We present single-cell RNA sequencing data from seven individuals (five healthy pre-menopausal women, one post-menopausal woman, and one postpartum) and perform an integrated analysis of this data alongside 15 previously published scRNA-seq datasets. We identified 39 distinct cell subtypes across four major cell types in the uterus. By using RNA velocity analysis and centroid-centroid comparisons we identify multiple computationally predicted progenitor populations for each of the major cell compartments, as well as potential cross-compartment, multi-potent progenitors. While the function and interactions of these cell populations remain to be validated through future experiments, the markers and their "dual characteristics" that we describe will serve as a rich resource to the scientific community. Importantly, we address a significant challenge in the field: reconciling multiple uterine cell taxonomies being proposed. To achieve this, we focused on integrating historical and contemporary knowledge across multiple studies. By providing detailed evidence used for cell classification we lay the groundwork for establishing a stable, consensus cell atlas of the human uterus.

Cellular atlas of the human ovary using morphologically guided spatial transcriptomics and single-cell sequencing.

The reproductive and endocrine functions of the ovary involve spatially defined interactions among specialized cell populations. Despite the ovary's importance in fertility and endocrine health, functional attributes of ovarian cells are largely uncharacterized. Here, we profiled >18,000 genes in 257 regions from the ovaries of two premenopausal donors to examine the functional units in the ovary. We also generated single-cell RNA sequencing data for 21,198 cells from three additional donors and identified four major cell types and four immune cell subtypes. Custom selection of sampling areas revealed distinct gene activities for oocytes, theca, and granulosa cells. These data contributed panels of oocyte-, theca-, and granulosa-specific genes, thus expanding the knowledge of molecular programs driving follicle development. Serial samples around oocytes and across the cortex and medulla uncovered previously unappreciated variation of hormone and extracellular matrix remodeling activities. This combined spatial and single-cell atlas serves as a resource for future studies of rare cells and pathological states in the ovary.

Total fertilization failure with in vitro fertilization-intracytoplasmic sperm injection related to WEE2 mutation highlights emerging importance of genetic causes of in vitro fertilization failure.

Objective: To report a unique case of total fertilization failure (TFF) after in vitro fertilization with intracytoplasmic sperm injection related to homozygous WEE2 gene mutation and summarize the current literature and management of TFF. Design: Case report. Setting: Academic fertility center. Patients: A 25-year-old woman and her 35-year-old partner with a history of near-complete fertilization failure after 2 cycles of in vitro fertilization/intracytoplasmic sperm injection. Interventions: Consultation with medical and commercial genetic testing for WEE2, PLCZ1, and TLE6. Main Outcome Measures: Oocyte fertilization. Results: The patient was homozygous for WEE2 pathogenic variant impacting oocyte activation and resulting in infertility. Conclusions: In the setting of TFF, early consideration should be given to genetic testing to assist couples in clinical decision-making and help limit the financial and emotional burden associated with unsuccessful fertility intervention.

Cellular heterogeneity of human fallopian tubes in normal and hydrosalpinx disease states identified using scRNA-seq.

Fallopian tube (FT) homeostasis requires dynamic regulation of heterogeneous cell populations and is disrupted in infertility and ovarian cancer. Here, we applied single-cell RNA-seq to profile 59,738 FT cells from four healthy, pre-menopausal subjects. The resulting cell atlas contains 12 major cell types representing epithelial, stromal, and immune compartments. Re-clustering of epithelial cells identified four ciliated and six non-ciliated secretory epithelial subtypes, two of which represent potential progenitor pools: one leading to mature secretory cells and the other contributing to either ciliated cells or one of the stromal cell types. To understand how FT cell numbers and states change in a disease state, we analyzed 17,798 cells from two hydrosalpinx samples and observed shifts in epithelial and stromal populations and cell-type-specific changes in extracellular matrix and TGF-ß signaling; this underscores fibrosis pathophysiology. This resource is expected to facilitate future studies aimed at expanding understanding of fallopian tube homeostasis in normal development and disease.

A review of fertility preservation in patients with breast cancer.

Breast cancer remains the most common cancer diagnosed in women and causes more lost disability-adjusted life years (DALYs) than any other cancer worldwide; however, improvements in therapies have led to increased survival and therefore a new focus on quality of life following treatment. Fertility is an important concern among cancer survivors of reproductive age. The purpose of this article is to contextualize the importance of oncofertility services for women with breast cancer and review options for fertility preservation, including oocyte/embryo cryopreservation, GnRH agonist therapy, and ovarian tissue cryopreservation. We also discuss special considerations for preimplantation genetic testing for women with germline pathogenic mutations associated with breast cancer, as well as issues related to endocrine therapy. Finally, we review barriers to accessing fertility preservation services, including cost of treatment and lack of referral to reproductive care providers or fertility preservation programs.

Outcomes of Fertility Preservation Consults for Women at Risk for Primary Ovarian Insufficiency Due to History of Cancer Treatment or Mosaic Turner Syndrome.

Adolescents and young adults (AYAs) at risk of primary ovarian insufficiency (POI) often request fertility preservation consultation. We report consult/treatment outcomes for 21 cancer survivors and 3 mosaic Turner syndrome (TS) patients (mean age 21.6 at consult, 3 with POI). Ten AYAs (9 survivors, 1 mosaic TS) attempted ovarian stimulation; 4 cancelled for poor response. Of completed cycles, mean 3.8 mature oocytes were retrieved, with mean anti-Müllerian hormone 0.653 ng/mL. Ovarian stimulation for mosaic TS AYA and survivors is possible, even with diminished ovarian reserve. Further study is needed to establish guidelines for patient selection, treatment timing, and stimulation protocols.

Ovarian Reserve Testing: A Review of the Options, Their Applications, and Their Limitations.

Ovarian reserve refers to the number of oocytes remaining in a woman's ovaries that have the potential to yield a pregnancy. This is a concept based on the fact that the number of oocytes within a woman's ovaries and her ability to achieve pregnancy decline over time. There are 2 overlapping but distinct interpretations and utilizations of ovarian reserve testing (ORT)-biological and clinical. Given the increasing incorporation of ORT into clinical practice, care must be taken to ensure that patients and providers understand the limitations affecting ORT interpretation. Here, we will review commonly used tests of ovarian reserve and offer guidance on interpretation (biology) and application (clinical practice) of results.

Opiate Prescribing Practices in the Postpartum Unit.

BACKGROUND: Louisiana is significantly impacted by the opioid epidemic. In preparation for a quality improvement project aimed at decreasing postpartum narcotics prescriptions, we evaluated routine prescribing practices on a postpartum unit and the number of patient-initiated encounters for postpartum pain. METHODS: We conducted a retrospective medical record review of all vaginal deliveries occurring at Ochsner Baptist Medical Center in New Orleans, LA in December 2016 and January 2017. We collected patient demographics, inpatient and outpatient pain medications, and the number of postpartum pain-related encounters prior to the scheduled postpartum visit. We evaluated the cohort for inpatient medication usage and for postpartum encounters for pain. RESULTS: After exclusions, 187 of 369 patients were included in the analysis: 78 patients had no perineal laceration, 40 had a first-degree laceration, and 69 had a second-degree laceration. The no-laceration (P=0.007) and second-degree laceration (P=0.011) groups had a significantly higher mean morphine milligram equivalent (MME) per patient during hospitalization than the first-degree group. Sixty-four patients were primiparous, and 123 were multiparous. Parity decreased as the severity of the laceration increased. Multiparous patients had a higher mean MME than primiparous patients (34.5 vs 30.0, respectively) during hospitalization, but the difference was not significant. In the no-laceration group, multiparous patients used significantly more narcotics during hospitalization (mean 41.4 MME) than primiparous patients (mean 22.5 MME) (P=0.029). A total of 3,635 narcotic pills were prescribed for our cohort at discharge, an average of 19.4 pills per patient. Overall, the mean number of postpartum encounters for pain was 0.19 per patient, with no difference between groups. CONCLUSION: Despite a high number of outpatient narcotics prescriptions, approximately 1 in 5 patients initiated an encounter to address pain after vaginal delivery. Parity may play a role in postpartum inpatient narcotic usage, possibly because multiparous patients have had prior exposure to narcotics use in postpartum care.

Hemorrhagic Stroke Resulting From Venous Malformation at 20 Weeks of Pregnancy.

BACKGROUND: Stroke in the pregnant patient is not a common occurrence. Despite its relative rarity, stroke during pregnancy is associated with high morbidity and mortality for both mother and infant. We report the case of a patient who experienced a hemorrhagic stroke during pregnancy because of venous cavernoma. CASE REPORT: A 34-year-old patient, gravida 5 para 1-0-3-1, presented to labor and delivery triage at 21 weeks, 0 days' gestation with the concern of sudden-onset right-sided facial, arm, and leg numbness and weakness. Intracranial imaging via magnetic resonance imaging demonstrated a small left midbrain venous cavernoma in the periaqueductal region of the posterior lateral cerebral peduncle area with evidence of edema and focal hemorrhage. During a 3-day hospital admission, the patient's deficits slowly improved, and she was discharged home. She subsequently delivered vaginally without incident. Six days postpartum, the patient presented with symptoms that were similar to her initial presentation. She was correctly diagnosed with migraine with aura after the appropriate neuroimaging studies did not show an acute stroke. CONCLUSION: This case demonstrates the similarities between the perilous diagnosis of stroke and the more routine diagnosis of migraine. The case also highlights the need for caution and for a multidisciplinary treatment approach when the diagnosis of stroke is considered, particularly in the pregnant patient.

Obstetrical Outcomes of Ultrasound Identified Uterine Fibroids in Pregnancy.

Objective We aimed to determine if fibroids in pregnancy, categorized by size, are associated with adverse obstetrical outcomes. Study Design Demographic, clinical, and delivery data were collected from charts of women with singleton gestations who delivered at >20 weeks gestation with fibroids identified at routine anatomy scan and their randomly selected age-matched controls. Largest fibroid diameter was used to categorize small fibroids (≤5 cm) and large fibroids (>5 cm). Results We included 450 patients: 264 patients with fibroids (174 small, 90 large fibroids) and 186 age-matched controls. Women with large fibroids had significantly greater blood loss than women with small fibroids and women with no fibroids (p-value <0.0001 and <0.0001 after adjusting for delivery mode). When fibroid size was compared individually, there was a significantly higher rate of primary cesarean section in both small and large fibroid groups when compared with women with no fibroids (p-values 0.044 and 0.003 after adjusting for body mass index). Conclusion Women with fibroids in pregnancy have higher rates of primary cesarean delivery and are at significant risk for increased blood loss at the time of delivery.