The human endometrium is receptive to the embryo for a specific period of time known as the window of implantation (WOI). During this period, the endometrium shows a specific gene expression profile suitable for endometrial function evaluation. ER Map is a molecular tool able to accurately predict endometrial receptivity status by transcriptomic analysis. In this retrospective study, including 2256 subfertile patients undergoing ART treatment, the clinical value of precise WOI determination is studied in detail. Results obtained when single embryo transfers (sET) were scheduled either within the WOI timeframe as established by ER Map, or deviating from this WOI, are assessed and compared. Data obtained showed that 34.18% (771/2256) of patients had a displaced WOI. Analysis of ART outcomes showed significantly higher pregnancy rates in transfers scheduled within the WOI predicted compared to transfers that deviated more than 12h from this WOI (44.35% vs 23.08%, p < 0.001). The deviation from the WOI had also an impact on the progression of pregnancy, with a significant increase in pregnancy loss (~ twofold) observed in transfers that deviated more than 12h from the WOI predicted. These results indicate that the precise determination of the WOI and personalised embryo transfer can significantly improve clinical outcomes.

Intrauterine devices (IUDs) have been widely used to prevent pregnancies with great efficacy during decades. It has been demonstrated that IUD alters the endometrial gene expression, but there is no scientific data about how copper, a metal commonly used in these devices, by itself, is able to influence the processes of endometrial receptivity and apoptosis in decidualized human endometrial stromal cells. Five endometrial samples were obtained from fertile women and processed by a standard protocol to obtain human endometrial stromal cells for in vitro studies. Stromal cells were cultured in vitro and decidualized for 8 days. At day 6, copper was added to the treatment group or camptothecin as positive control for apoptosis until day 8. Five endometrial samples were used in each group. The aim of this study was to analyze the effect of copper in apoptosis and necrosis by flow cytometry, to visualize the apoptotic microtubule network during apoptosis by immunofluorescence, and finally to determine the gene expression profile of a panel of 192 genes related to endometrial receptivity and immune system by quantitative reverse transcription PCR (RT-qPCR). Copper, compared to the decidualized group, induced changes in the gene expression by an order of magnitude in 49 genes (42 up- and 9 downregulated). This alteration in the decidualization gene signature by copper includes 19 genes involved in the endometriosis pathology and others related to other gynecological disorders such as preeclampsia and infertility. Our results indicate that copper does not increase the apoptosis level induced by the decidualization treatment. However, copper alters the gene expression of some biomarkers of endometrial receptivity and immune response.

Study question How does the presence of specific pathogenic or health-promoting microbial species in the endometrium relate to female fertility in assisted reproduction treatments (ART)? Summary answer Detection of endometrial pathogens using MicroBioMap® is associated with poor ART outcomes, whereas sterile endometria show the highest pregnancy and live birth rates. What is known already Vaginal eubiosis is characterised by low microbial diversity and dominance of Lactobacillus, which displays bioregulatory functions and prevents the growth of pathogenic microorganisms. Vaginal dysbiosis is directly linked to infertility and poor pregnancy outcomes. However, the endometrial microbiota composition and its role in fertility are more controversial. Robust reports show that chronic endometritis (CE) is highly prevalent among infertile patients, whose outcomes improve after antibiotic treatment. However, the role of Lactobacillus in this compartment, whether it also displays bioregulatory functions, or if it is essential and beneficial for women undergoing ART, is still unclear. Study design, size, duration This is a case-control retrospective study analysing the endometrial microbiota in the window of implantation (WOI) and the ART outcomes of 456 women undergoing IVF cycles in egg donation regimes with/without PGT-A (177 and 163 respectively), or using their own eggs in cycles with/without PGT-A (91 and 25 respectively), between March 2016 and April 2021 in IVF-Life Alicante (Spain). ART results after single embryo transfer (sET) of patients with different endometrial microbiota profiles were compared. Participants/materials, setting, methods Presence of 18 microbial CE pathogens and 4 Lactobacillus species was determined by high-throughput qPCR (MicroBioMap®) in 456 endometrial samples obtained during the WOI (determined by ER Map® receptivity test) of a hormone replacement therapy cycle. Clinical outcomes (clinical pregnancy, CP; live birth, LB) of sETs performed during the WOI (guided by ER Map®) were compared in relation to the endometrial microbiota profile. In PGT-A cycles, embryo ploidy was determined by NGS (VeriSeq-MiSeq) before sET. Main results and the role of chance According to the microbial profile detected by MicroBioMap®, patients were categorised as i) Lactobacillus only (L, n = 199), ii) Pathogens only (P, n = 56), iii) Lactobacillus + pathogens (L+P, n = 59) or iv) Undetected (U, n = 142). Absence of endometrial microorganisms was significantly associated to ART success. U-patients showed significantly higher CP (64.2% vs 50.8%, Fisheŕs exact p=0.046) and LB rates (52.9% vs 37.2%, p=0.03) after euploid sET than patients with microorganisms. These differences were more pronounced in patients receiving donor eggs (CP 70.2% vs 50.8%, p=0.026; LB 59.5% vs 40.2%, p=0.046). Presence of Lactobacillus in isolation in the endometrium showed a detrimental effect compared to U-environments. A trend towards statistical significance was detected, with L-patients showing lower LB rates compared to U-patients after euploid sET (38.8% vs 52.9%; p = 0.084). Detection of endometrial pathogens significantly reduced ART success rates. P-patients had significantly lower CP rates (64.2% vs 41.2%, p=0.038) after euploid sET than U-patients, and significantly lower CP (70.2% vs 36%, p=0.006) and LB rates (59.5% vs 21.7%, p=0.004) if receiving donor eggs. Interestingly, Lactobacillus dominance in pathogen-positive patients seemed to improve outcomes after euploid sET compared to pathogen-dominated patients (CP 56.7% vs 42.2%; LB 41.7% vs 31%). Limitations, reasons for caution This is a retrospective study. Randomised-control trials, non-selection studies and/or other investigations including antimicrobial treatments are needed to confirm these results and the extent of any clinical benefits. Endometrial biopsies were obtained transcervically. Although utmost care was taken, risk of contamination from the lower genital tract cannot be completely excluded. Wider implications of the findings Our results suggest that sterile endometria provide the best conditions for embryo implantation and pregnancy. Lactobacillus presence in endometrium might not be essential for pregnancy, and could even be detrimental if found in isolation. Presence of Lactobacillus as a bioregulator might only be beneficial if other pathogens co-colonise the tissue. Trial registration number Not applicable