Identification of new regenerative therapies in reproductive medicine and their application as a future therapeutic approach for endometrial regeneration

Resum

The uterus is one of the main internal organs of the female reproductive system. It is composed of three different tissue layers: perimetrium, myometrium, and endometrium. This last layer covers the intrauterine cavity and is directly responsible for embryo implantation (for which it needs a certain minimum endometrial thickness). Among the pathologies affecting the endometrium, we can distinguish, among others, endometrial atrophy (characterized by an insufficient endometrial thickness) and Asherman's syndrome (a rare disease characterized by the presence of intrauterine adhesions and fibrotic tissue), which form the common thread of this thesis, composed of four original manuscripts. In both cases, the endometrial tissue is degenerated, which hinders the correct embryo implantation, causing then fertility problems. To date, none of these pathologies has a totally effective cure. So far, one of the most promising therapeutic options is the injection of stem cells. Therefore, the first objective was to evaluate how the infusion of bone marrow-derived stem cells (isolated with the antigen CD133), which had proven effective in both a human and an animal model, was modifying the endometrium at the molecular level. Then, this work aimed to understand the paracrine mechanisms through which these cells were carrying out their therapeutic and regenerative action over the endometrial tissue. This first study revealed that these stem cells appeared to be promoting endometrial regeneration by creating an immunomodulatory scenario (down-regulation of the CXCL8 gene), which would give way to the over-expression of genes (SERPINE1, IL4, and JUN) involved in tissue regeneration. Another treatment gaining acceptance over the years is a blood derivate, platelet-rich plasma, which was the focus of the second manuscript. This work shows how this plasma, mainly derived from umbilical cord blood rather than adult peripheral blood, can promote cellular processes, such as cell migration and proliferation of different types of endometrial cells (from primary culture and from stem cell lines). These plasmas also revealed how they triggered the over-expression of certain proteins involved in regenerative events in a mouse model with induced endometrial damage. Whatever the therapeutic approach of choice, it has been hypothesized that regeneration could arise from stimulation of the stem cell niche present in the endometrium. That is why objective three involved studying those works, both murine and human models, concerning this population of endometrial stem cells. This search concluded that there are still gaps in knowledge, either in the definition of specific endometrial stem cell markers or in the contribution of the bone marrow to this endogenous endometrial stem cell niche. Finally, given the aforementioned current lack of definitive therapy for patients with endometrial atrophy or Asherman's syndrome, the last objective involved studying all those approaches that have been carried out in animal models that simulate this type of human pathology. This work concluded that although new therapies are emerging, such as those derived from bioengineering (e.g. use of decellularized scaffolds or hydrogels), there is still a need to perfect and standardize both animal and in vitro models to allow a better clinical translation of these therapies.