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Here we review the endocrine, paracrine, and autocrine cues that tightly govern this differentiation process.
In response to activation of various signaling pathways and genome-wide chromatin remodeling, evolutionarily conserved transcriptional factors gain access to the decidua-specific regulatory circuitry.
In his book, , published in 1826, he describes the role of the decidua as follows: “Soon after the ovum [embryo in modern parlance; author's comment] is deposited within the cavity of the uterus, we find it connected through the whole extent of its surface, with the internal face of this organ.
Both uterus and ovum contribute to this end; on the part of the womb, we find it produces a soft spongy substance called decidua; on the part of the ovum, we discover its external covering or chorion shooting out innumerable vascular fibers — and both, when united, serve as the bond of union between ovum and uterus” (2).
The burden of abnormal menstruation and menstruation-associated disorders, such as endometriosis, in terms of health, quality of life, and socioeconomic cost, is immense.
However, the intra- and interobserver variability inherent in dating the product of the -the endometrium-has led to the current situation, in which, in approximately 20% of cases, variability attributed to the pathologist alone is determinant of whether a given biopsy in “in phase” or out of phase (ie, an assigned postovulatory date that is at least 2 days behind the chronologic date).
This concept is predicated on the ability of decidualizing stromal cells to respond to individual embryos in a manner that either promotes implantation and further development or facilitates early rejection.
Furthermore, menstruation and cyclic regeneration involves stem cell recruitment and renders the endometrium intrinsically capable of adapting its decidual response to maximize reproductive success.
From an evolutionary perspective, the acquisition of maternal control over the decidual process must have been essential for reproductive fitness to justify the expenditure and cost to the mother imposed by cyclic menstruation (10).
This notion was not lost on William Potts Dewees, who wrote, “I adopt the opinion that the menstrual discharge is a genuine secretion; and that the internal face or lining of this organ is the portion which furnishes it; now it will be evident, that whenever this part is in any way deranged, its product must also be impaired; but the injury does not consist so much in the imperfect elaboration of the menstrual fluid, as in the inability of this surface to furnish a healthy decidua after impregnation has taken place; for there can be but little doubt that the same apparatus furnishes both one and the other.
For example, decidualization can be very shallow or deep, depending on the degree of placental trophoblast invasion in a given species (5).