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The process of endometrial decidualization is a key event with direct relevance to very early pregnancy as well as subsequent pregnancy outcome. This chapter reviews the signals and pathways that control the morphological and biochemical differentiation of resident endometrial fibroblasts into secretory decidual cells. It discusses the functions of these cells at the feto-maternal interface. Decidual transformation of endometrial stromal cells can be faithfully recapitulated in culture and these in vitro studies have yielded invaluable insights into the signal pathways and downstream transcription factors that govern this differentiation process. Decidualizing stromal cells play an important role in local immunomodulation in many ways. The emergence in human beings of a cyclic decidual process has several major clinical implications; the most obvious of which is menstruation and its associated disorders. Decidualizing stromal cells and other cellular components in the superficial endometrial layer take part in menstrual shedding.
This chapter reviews the epidemiological evidence in support of a pathological link and discusses the implications for clinical management. Several epidemiological studies have investigated pregnancy outcome in singleton pregnancy after in vitro fertilisation/intracytoplasmic sperm injection (IVF/ICSI). The lack of consensus diagnostic criteria and the heterogeneous nature of contemporary infertility investigations make it difficult to define the risk of adverse pregnancy outcome in relation to specific reproductive disorders, such as endometriosis or polycystic ovary syndrome (PCOS). In humans, the formation of a functional placenta requires invasion of fetal trophoblast not only into the maternal decidua and inner myometrium (interstitial invasion) but also into the maternal spiral arteries. Progesterone support improves pregnancy outcome after IVF treatment and two recent randomised trials have reported that progesterone also markedly reduces the incidence of preterm labour in at-risk women.
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