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Between the stages of menarche and menopause, women of reproductive age undergo monthly cycles of hormone-regulated endometrial proliferation, differentiation, and subsequent shedding in preparation for pregnancy in a process known as menstruation1,2. Such physical modifications of the human endometrium are necessary for proper embryo implantation into the uterine wall1. Alterations of the endometrium, including both morphological and biochemical adaptations, are mediated throughout the menstrual cycle via ovarian steroid hormones estrogen and progesterone (P4)3,4,5. Within the proliferative (or follicular) phase, preovulatory estrogen levels increase, initiating endometrium thickening. Following ovulation, the secretory (or luteal) phase promotes a significant rise in P4 concentrations, inducing the morphological transformation of endometrial stromal cells (ESC) from fibroblast-like appearance to rounded, epithelial-like decidual cells in a process known as decidualization4,6. Improper decidualization has been established as a root cause for implantation failure and subsequent early embryo miscarriage4,7,8. Therefore, understanding the molecular mechanisms underlying decidualization is advantageous to the diagnosis and treatment of early pregnancy loss.
Currently, several methodologies are utilized to explore the underlying effects of decidualization on endometrial stromal cells. In vivo, the mouse uterus can be artificially induced for decidualization via mechanical stimulation (i.e.,, scratching) or oil injection in a hormonally primed uterus9. Distinct from humans, this synthetic stimulation promotes the differentiation of the uterine lumen by providing the appearance of blastocyst presence, a step that is required for the initiation of decidualization in rodents10,11. Accordingly, due to the translational complications associated with animal models and the ethical dilemmas surrounding in vivo based studies in humans, decidualization based models are most successfully studied in vitro.
In this study, subjects are recruited through the placement of advertisements in both local English and Spanish newspapers. Subjects identified as suitable candidates for this study are brought in to meet with the research coordinator, in which a full disclosure of potential risks are discussed. Upon confirmation of a complete understanding of potential risks involved, subjects' consent is attained in both written and verbal forms. Subject consent includes permission to (1) undergo phlebotomy (2) long-term storage of their tissues for future research purposes and (3) agree to the creation of primary cultures from collected tissue specimens. Following consent, subjects are given a form to complete in which permitted self-identification of race/ethnicity and/or the right for nondisclosure. A subsequent visit is scheduled to attain the endometrium biopsy based on the subject's menstrual cycle. Volunteers recruited to this study reflect both the ethnic and racial demographics of the St. Louis metropolitan region as documented by the 2012 Census and did not involve the participation of any vulnerable population including pregnant women, fetuses, embryos, children under 18 years of age, or other vulnerable groups. Eligibility requirements for participation in the biopsy sample collection include (1) being between the ages of 18-45 years (2) having regular menstrual cycles (25-32 days) (3) having no current pregnancy or use of hormonal/intrauterine device contraceptives for 30 days prior to enrollment (4) having no current vaginal infection or sexually transmitted diseases (5) having no current antibiotic treatments, and (6) having no current abnormal Pap smear.
Within this study, human endometrial stromal cells (HESC) are cultured and artificially induced to undergo in vitro decidualization through the supplementation of hormones (estradiol (E2), medroxyprogesterone acetate (MPA), and cyclic adenosine monophosphate (cAMP)) to the medium. In this method, the degree of decidualization is altered based on the total number of days of hormonal treatment. In conjunction with cytoskeletal rearrangement, hormonal supplementation induces biochemical adaptations in which the decidual cells experience secretory-like qualities2,4. The expression of hallmark genes, such as prolactin (PRL) and insulin-like growth factor binding protein 1 (IGFBP1), can be utilized to confirm and quantify the degree of HESC decidualization5,12,13,14. Importantly, the viability of this protocol to conduct gene specific knockdown is also demonstrated.