{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,8]],"date-time":"2026-09-08T00:19:15Z","timestamp":1788826755641,"version":"build-2803163510"},"reference-count":24,"publisher":"Ovid Technologies (Wolters Kluwer Health)","issue":"1","license":[{"start":{"date-parts":[[2025,8,4]],"date-time":"2025-08-04T00:00:00Z","timestamp":1754265600000},"content-version":"unspecified","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by-nc-nd\/4.0"}],"content-domain":{"domain":["lww.com","ovid.com"],"crossmark-restriction":true},"short-container-title":[],"published-print":{"date-parts":[[2026,1]]},"abstract":"\n A\n BSTRACT<\/jats:sc>\n <\/jats:title>\n \n Objectives:<\/jats:title>\n Endometriosis is a chronic, estrogen-dependent disorder characterized by the ectopic growth of endometrial-like tissue. Despite its significant impact on fertility and quality of life, the pathogenesis of endometriosis remains poorly understood. This study investigates the potential role of ovulatory follicular fluid (FF) in driving disease progression. Based on the \u201cdouble engines theory,\u201d which posits that retrograde menstruation provides the \u201cseeds\u201d for ectopic lesions while ovulation fuels their growth, we hypothesize that FF enhances endometrial cell proliferation, clonogenicity, migration, and invasion.<\/jats:p>\n <\/jats:sec>\n \n Materials and Methods:<\/jats:title>\n \n Primary eutopic and ectopic endometrial cells were isolated from infertile women and treated with 10% diluted FF collected from\n in vitro<\/jats:italic>\n fertilization patients. Cellular morphology, proliferation, clonogenicity, migration, and invasion were evaluated using colony formation, transwell, and Matrigel assays. Statistical analyses were performed to compare cellular responses between eutopic and ectopic cells.\n <\/jats:p>\n <\/jats:sec>\n \n Results:<\/jats:title>\n Morphological analysis revealed distinct adaptive changes, with ectopic cells predominantly adopting a more fibroblast-like phenotype. Ectopic cells exhibited higher clonogenicity (29.8-fold) capacities, lower proliferation (0.49-fold) and migration (0.11-fold) capacities, and similar invasion capabilities compared to eutopic cells. FF significantly enhanced proliferation (1.7-fold in eutopic and 1.3-fold in ectopic cells) and clonogenic capacity, with eutopic cells forming 31.3 times more colonies and ectopic cells showing a 1.3-fold increase. The clonogenic area expanded dramatically, increasing 261-fold in eutopic and 4.9-fold in ectopic cells. In addition, FF promoted migration (1.8-fold in eutopic and 2.9-fold in ectopic cells) and invasion (9.1-fold in eutopic and 4.8-fold in ectopic cells). These findings suggest that FF may play a pivotal role in the early establishment and progression of ectopic lesions.<\/jats:p>\n <\/jats:sec>\n \n Conclusion:<\/jats:title>\n The results highlight the critical role of FF in enhancing endometrial cell survival, proliferation, and dissemination. This supports the \u201cdouble engines theory\u201d of endometriosis, emphasizing the significant contribution of ovulation to the pathogenesis of the disease.<\/jats:p>\n <\/jats:sec>","DOI":"10.4103\/tcmj.tcmj_90_25","type":"journal-article","created":{"date-parts":[[2025,8,4]],"date-time":"2025-08-04T21:01:59Z","timestamp":1754341319000},"page":"68-74","update-policy":"https:\/\/doi.org\/10.1097\/lww.0000000000001000","source":"Crossref","is-referenced-by-count":1,"title":["Ovulatory follicular fluid promotes the clonogenicity and invasion of ectopic and eutopic endometrial cells"],"prefix":"10.4103","volume":"38","author":[{"given":"Che-Fang","family":"Hsu","sequence":"first","affiliation":[{"name":"Center for Prevention and Therapy of Gynecological Cancers, Department of Medical Research, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien, Taiwan"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Vaishnavi","family":"Seenan","sequence":"additional","affiliation":[{"name":"Center for Prevention and Therapy of Gynecological Cancers, Department of Medical Research, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien, Taiwan"},{"name":"Institute of Medical Sciences, Tzu Chi University, Hualien, Taiwan"},{"name":"Department of Biotechnology, Vel Tech High Tech Dr. Rangarajan Dr. Sakunthala Engineering College, Chennai, Tamil Nadu, India"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Swathi","family":"Manickam","sequence":"additional","affiliation":[{"name":"Center for Prevention and Therapy of Gynecological Cancers, Department of Medical Research, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien, Taiwan"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Liang-Yuan","family":"Wang","sequence":"additional","affiliation":[{"name":"Center for Prevention and Therapy of Gynecological Cancers, Department of Medical Research, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien, Taiwan"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Yin-Chen","family":"Chang","sequence":"additional","affiliation":[{"name":"Center for Prevention and Therapy of Gynecological Cancers, Department of Medical Research, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien, Taiwan"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ying-Hsi","family":"Chen","sequence":"additional","affiliation":[{"name":"Center for Prevention and Therapy of Gynecological Cancers, Department of Medical Research, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien, Taiwan"},{"name":"Institute of Medical Sciences, Tzu Chi University, Hualien, Taiwan"},{"name":"Department of Obstetrics and Gynecology, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien, Taiwan"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Dah-Ching","family":"Ding","sequence":"additional","affiliation":[{"name":"Institute of Medical Sciences, Tzu Chi University, Hualien, Taiwan"},{"name":"Department of Obstetrics and Gynecology, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien, Taiwan"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Pao-Chu","family":"Chen","sequence":"additional","affiliation":[{"name":"Department of Obstetrics and Gynecology, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien, Taiwan"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Tang-Yuan","family":"Chu","sequence":"additional","affiliation":[{"name":"Center for Prevention and Therapy of Gynecological Cancers, Department of Medical Research, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien, Taiwan"},{"name":"Institute of Medical Sciences, Tzu Chi University, Hualien, Taiwan"},{"name":"Department of Obstetrics and Gynecology, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien, Taiwan"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"276","published-online":{"date-parts":[[2025,8,4]]},"reference":[{"key":"R1-20260116","doi-asserted-by":"crossref","first-page":"1244","DOI":"10.1056\/NEJMra1810764","article-title":"Endometriosis","volume":"382","author":"Zondervan","year":"2020","journal-title":"N Engl J Med"},{"key":"R2-20260116","doi-asserted-by":"crossref","first-page":"2807","DOI":"10.1016\/j.cell.2021.04.041","article-title":"Endometriosis: Etiology, pathobiology, and therapeutic prospects","volume":"184","author":"Saunders","year":"2021","journal-title":"Cell"},{"key":"R3-20260116","doi-asserted-by":"crossref","first-page":"511","DOI":"10.1016\/j.fertnstert.2012.06.029","article-title":"Pathogenesis and pathophysiology of endometriosis","volume":"98","author":"Burney","year":"2012","journal-title":"Fertil Steril"},{"key":"R4-20260116","doi-asserted-by":"crossref","first-page":"327","DOI":"10.1016\/j.fertnstert.2018.10.013","article-title":"Pathogenesis of endometriosis: The genetic\/epigenetic theory","volume":"111","author":"Koninckx","year":"2019","journal-title":"Fertil Steril"},{"key":"R5-20260116","first-page":"1465348","article-title":"Endometriosis malignant transformation: Epigenetics as a probable mechanism in ovarian tumorigenesis","author":"He","year":"2018","journal-title":"Int J Genomics 2018"},{"key":"R6-20260116","doi-asserted-by":"crossref","first-page":"564","DOI":"10.1093\/humupd\/dmz018","article-title":"The endometrial immune environment of women with endometriosis","volume":"25","author":"Vallv\u00e9-Juanico","year":"2019","journal-title":"Hum Reprod Update"},{"key":"R7-20260116","doi-asserted-by":"crossref","first-page":"1134663","DOI":"10.3389\/fimmu.2023.1134663","article-title":"Peritoneal immune microenvironment of endometriosis: Role and therapeutic perspectives","volume":"14","author":"Chen","year":"2023","journal-title":"Front Immunol"},{"key":"R8-20260116","doi-asserted-by":"crossref","first-page":"1738","DOI":"10.1095\/biolreprod.103.024109","article-title":"Clonogenicity of human endometrial epithelial and stromal cells","volume":"70","author":"Chan","year":"2004","journal-title":"Biol Reprod"},{"key":"R9-20260116","doi-asserted-by":"crossref","first-page":"2282","DOI":"10.1210\/en.2019-00314","article-title":"Estrogen signaling drives ciliogenesis in human endometrial organoids","volume":"160","author":"Haider","year":"2019","journal-title":"Endocrinology"},{"key":"R10-20260116","doi-asserted-by":"crossref","first-page":"100737","DOI":"10.1016\/j.xgen.2024.100737","article-title":"Single-cell and spatial transcriptomic profiling revealed niche interactions sustaining growth of endometriotic lesions","volume":"5","author":"Liu","year":"2025","journal-title":"Cell Genom"},{"key":"R11-20260116","doi-asserted-by":"crossref","first-page":"1403","DOI":"10.3390\/biomedicines10061403","article-title":"The double engines and single checkpoint theory of endometriosis","volume":"10","author":"Hsu","year":"2022","journal-title":"Biomedicines"},{"key":"R12-20260116","doi-asserted-by":"crossref","first-page":"1419","DOI":"10.1093\/carcin\/bgv132","article-title":"Mutagenic, surviving and tumorigenic effects of follicular fluid in the context of p53 loss: Initiation of fimbria carcinogenesis","volume":"36","author":"Huang","year":"2015","journal-title":"Carcinogenesis"},{"key":"R13-20260116","doi-asserted-by":"crossref","first-page":"101085","DOI":"10.1016\/j.neo.2024.101085","article-title":"Ovulation sources ROS to confer mutagenic activities on the TP53 gene in the fallopian tube epithelium","volume":"59","author":"Subramani","year":"2025","journal-title":"Neoplasia"},{"key":"R14-20260116","doi-asserted-by":"crossref","first-page":"597","DOI":"10.1016\/j.ebiom.2019.01.061","article-title":"IGF-axis confers transformation and regeneration of fallopian tube fimbria epithelium upon ovulation","volume":"41","author":"Hsu","year":"2019","journal-title":"EBioMedicine"},{"key":"R15-20260116","doi-asserted-by":"crossref","first-page":"1123","DOI":"10.1016\/j.neo.2021.09.006","article-title":"Ovulation sources coagulation protease cascade and hepatocyte growth factor to support physiological growth and malignant transformation","volume":"23","author":"Huang","year":"2021","journal-title":"Neoplasia"},{"key":"R16-20260116","doi-asserted-by":"crossref","first-page":"1417","DOI":"10.1002\/mc.23586","article-title":"Insulin-like growth factor (IGF) and hepatocyte growth factor (HGF) in follicular fluid cooperatively promote the oncogenesis of high-grade serous carcinoma from fallopian tube epithelial cells: Dissection of the molecular effects","volume":"62","author":"Chu","year":"2023","journal-title":"Mol Carcinog"},{"key":"R17-20260116","doi-asserted-by":"crossref","first-page":"424","DOI":"10.1186\/s12935-024-03614-9","article-title":"Epidermal growth factor receptor ligands enriched in follicular fluid exosomes promote oncogenesis of fallopian tube epithelial cells","volume":"24","author":"Khine","year":"2024","journal-title":"Cancer Cell Int"},{"key":"R18-20260116","doi-asserted-by":"crossref","first-page":"468","DOI":"10.3390\/cancers13030468","article-title":"Ovulatory follicular fluid facilitates the full transformation process for the development of high-grade serous carcinoma","volume":"13","author":"Hsu","year":"2021","journal-title":"Cancers (Basel)"},{"key":"R19-20260116","doi-asserted-by":"crossref","first-page":"231","DOI":"10.1186\/s12935-024-03406-1","article-title":"Human peritoneal fluid exerts ovulation- and nonovulation-sourced oncogenic activities on transforming fallopian tube epithelial cells","volume":"24","author":"Hsu","year":"2024","journal-title":"Cancer Cell Int"},{"key":"R20-20260116","doi-asserted-by":"crossref","first-page":"e0158266","DOI":"10.1371\/journal.pone.0158266","article-title":"Platelet-derived growth factor in the ovarian follicle attracts the stromal cells of the fallopian tube fimbriae","volume":"11","author":"Yeh","year":"2016","journal-title":"PLoS One"},{"key":"R21-20260116","first-page":"286","article-title":"Experimental hepatocerebral disease. Astrocytic changes in the globus pallidus of rats with carbon tetrachloride induced cirrhosis","volume":"84","author":"Hasson","year":"1967","journal-title":"Arch Pathol"},{"key":"R22-20260116","doi-asserted-by":"crossref","first-page":"550","DOI":"10.3390\/jcm13020550","article-title":"Deep infiltrating endometriosis in adolescence: Early diagnosis and possible prevention of disease progression","volume":"13","author":"Martire","year":"2024","journal-title":"J Clin Med"},{"key":"R23-20260116","doi-asserted-by":"crossref","first-page":"443","DOI":"10.1021\/pr070277z","article-title":"Proteomic analysis of human follicular fluid using an alternative bottom-up approach","volume":"7","author":"Hanrieder","year":"2008","journal-title":"J Proteome Res"},{"key":"R24-20260116","first-page":"CD001019","article-title":"Oral contraceptives for pain associated with endometriosis","volume":"18","author":"Davis","year":"2007","journal-title":"Cochrane Database Syst Rev"}],"container-title":["Tzu Chi Medical Journal"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.ovid.com\/10.4103\/tcmj.tcmj_90_25","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,8,26]],"date-time":"2026-08-26T19:41:01Z","timestamp":1787773261000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.ovid.com\/10.4103\/tcmj.tcmj_90_25"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2025,8,4]]},"references-count":24,"journal-issue":{"issue":"1","published-print":{"date-parts":[[2026]]}},"URL":"https:\/\/doi.org\/10.4103\/tcmj.tcmj_90_25","relation":{},"ISSN":["1016-3190","2223-8956"],"issn-type":[{"value":"1016-3190","type":"print"},{"value":"2223-8956","type":"electronic"}],"subject":[],"published":{"date-parts":[[2025,8,4]]},"assertion":[{"value":"2025-03-12","name":"received","label":"Received","group":{"name":"publication_history","label":"Publication History"}},{"value":"2025-05-05","name":"accepted","label":"Accepted","group":{"name":"publication_history","label":"Publication History"}}]}}