Dose-Effect Relationship of Chitosan and Danshen Combined Injection for Fallopian Tube Recanalization

Objectives: This study examined the dose-effect relationship of chitosan and danshen combined injections on the long-term prevention of fallopian tube re-obstructions, with increased pregnancy rates in infertile women.

Methods: High-performance liquid chromatography was used to determine the content changes of combined chitosan and danshen injection. Two hundred and eighty patients with fallopian tube obstructions were randomly assigned to four groups. Group A (control group, saline), Group B (2 ml chitosan, 4 ml danshen), Group C (2 ml chitosan, 10 ml danshen), and Group D (1 ml chitosan, 10 ml danshen). Injections were administered after tubal recanalization.

Results: The effective constituent of chitosan and danshen injection was stable. Tubal patency rate was 94.2% and 87.3% in Group C after 1 and 3 years, respectively, which was significantly higher than Groups A (38.6%, 31.5%), B (73.5%, 64.1%), and D (68.5%, 50.7%). Intrauterine pregnancy rates were 61.8% and 79.4% in Group C after 1 and 3 years, respectively, and were significantly higher than Groups A (31.8%, 34.8%), B (40.1%, 62.5%), and D (38.5%, 58.5%) (p < 0.05).

Conclusion: Combined Chitosan and danshen injections prevented tubal obstruction and increased pregnancy rates for long periods using an optimal ratio of 1 part chitosan and 5 parts danshen.

1 Introduction

Chitosan, a polysaccharide acquired from the shells of marine creatures, is a non-toxic, biocompatible, and biodegradable material with mucoadhesion and permeation enhancements (Gao et al., 2021). Carboxymethyl chitin is the primary active ingredient. Chitosan has desirable antimicrobial properties, promotes wound healing and is used in various clinical applications. Research (Kou et al., 2022) has shown that the “molecular chain configuration” model should be used to explain the possible interactive mechanisms among the different molecular weight chitosan molecules. With these beneficial bioactivities in mind, chitosan can be used in surgery and tissue engineering and is becoming an important medical polymer.

Danshen comes from the dried roots and rhizomes of Salvia miltiorrhiza Bge and is a traditional Chinese medicinal. The chemical constituents of Danshen include salvianolic acid A and protocatechualdehyde, as well as several other chemicals. Our previous research (Huang et al., 2019) has shown that combined chitosan and danshen injections could decrease tubal re-occlusion post-injection in infertile women with fallopian tube occlusions, increasing pregnancy rates for brief periods.

Infertility occurs in approximately 15% of reproductive-aged couples worldwide (Hanson et al., 2017). Fallopian tube obstruction can lead to reduced fertility among women, accounting for 25–∼ 45% of all causes of infertility (Fields et al., 2013; Practice Committee of the American Society for Reproductive M, 2015). Although microsurgery is becoming more common (leading to a reduction in adhesions caused by intraabdominal cavity laparotomy), adhesions cannot be completely prevented through the microsurgical technique (Xiao et al., 2014).

Interventional fallopian tube recanalization (FTR) is extremely effective for treating tubal obstruction in cases of infertility with a technical success rate as high as 90% (Ikechebelu et al., 2018; Gao et al., 2019). One-year pregnancy rate following FTR is approximately 41% (Kohi, 2021). FTR is an alternative to vitro fertilization (IVF) and intracytoplasmic sperm injection (ICSI) and should be top-of-mind in the setting of infertility due to fallopian tube obstruction (Kohi, 2021). FTR is a safe treatment option in patients with fallopian tube obstruction, with high technical success rate and increased chances of pregnancy. It is prior to more invasive and expensive treatments (Anil et al., 2011).

FTR had become the universally accepted therapeutic option of fallopian tube obstruction in the last 2 decades (Verma et al., 2009; Anil et al., 2011). However, more than 20% of patients have poor outcomes following interventional recanalization (Shen et al., 2020). Niuniu Sun showed that fallopian tube recanalization by ozone perfusion could effectively increase the postoperative pregnancy rate, but there was no significant difference in the recanalization success rate by ozone perfusion (Sun et al., 2017).

In previous clinical studies, we have showed that chitosan and danshen combined injection maybe reduce the rate of tubal postoperative re-occlusion preliminarily (Huang et al., 2019).In this study, we examined the curative rates and dose effects of combined injections in the prevention of fallopian tube re-obstruction after recanalization.

2 Materials and Methods

2.1 Synergistic Research on Combined Chitosan and Danshen Injection

Chitosan (12080311, China Pharmaceutical and Biological Products Inspection Institute, China) and danshen (110855-200809, China Pharmaceutical and Biological Products Inspection Institute, China) were combined. The available contents of these natural remedies were evaluated using high-performance liquid chromatography (DGU-20a5, Shimadzu, Japan) immediately and after 10 min.

Chromatographic conditions used were as follows: Inertsil C18 column = 4.6 × 250 mm, 5 μm; flow rate = 1.0 ml/min; dual wavelength detection = 210–280 nm; sample quantity = 10 μl; mobile phase elutions included (A) 1% phosphoric acid, and (B) methanol gradient elution.

Chitosan (1 ml) and danshen injections (5 ml) were combined with ultrapure water at 1 and 5 ml and diluted 2 times into the liquid phase at 0, 10, 30 min. The main ingredients were sodium danshen, protocatechuic aldehyde, and carboxymethyl chitin and recorded as peak times and peak areas on the chromatograph chart. Each condition was assessed at least in triplicate.

2.2 Combined Chitosan and Danshen Injections in Fallopian Tube Recanalization

This prospective study was conducted at our hospital between 2014 and 2018. The study was approved by the medical ethics committee of Guangzhou Panyu Central Hospital (Reference number: P20140042). Informed consent was obtained from all patients prior to participation in the study.

The Inclusion criteria were 1) females of childbearing age (between 22 and 45 years), and 2) a Fallopian tube isthmus or interstitial obstruction diagnosed without adhesions of the fimbriated tubal extremity, determined on laparoscopic examination or salpingography. The exclusion criteria were 1) pelvic infection, congenital physiological defects or malformations, infertility caused by genetic factors, endocrine factors [follicle-stimulating hormone (FSH) or luteinizing hormone [LH] or other hormones] or immune factors, 2) endometriosis, uterine myoma, uterine hypoplasia, tubal ligation, or pelvic tuberculosis, 3) male partners were diagnosed with reproductive dysfunction (Huang et al., 2019; Shen et al., 2020).

A total of 280 eligible patients were enrolled between 2014 and 2018. Patients were randomized into four groups of 70 patients each, including Group A group (control group, saline only), Group B (2 ml chitosan and 4 ml danshen [1:2]), Group C (2 ml chitosan and 10 ml danshen [1:5]), and Group D group (1 ml chitosan and 10 ml danshen [1:10]). The groups were blinded to the nature of the anti-adhesion agents they had received. All groups underwent coaxial catheterizations either alone (Groups A) or after followed chitosan and danshen combined injections (Groups B, C, and D).

First, specific reproductive hormone levels (FSH, LH, estrogen, and progesterone) were measured and assessed. Interventional recanalizations were performed within 3–7 days after the end of menstruation. The procedures were performed under digital subtraction angiography (DSA) with an OEC 9600 C-arm X-ray machine (General Electric, United States). A 20 ml dose of the contrast agent (Iopromide, Ultravist, Bayer, Germany) was injected into the uterine cavity to identify the uterine shape and position of the cornu uteri, as well as to confirm the obstructed portion(s) of the fallopian tube. Then, the guidewire and catheter were directed to the cornu uteri on the affected side. Finally, a saline solution (10 ml) was administered to patients in Group A. For Groups B, C, and D, a 2 ml chitosan, 4 ml danshen solution, a 2 ml chitosan, 10 ml danshen solution, and a 1 ml chitosan and 10 ml danshen solution were administered, respectively.

Through preoperative salpingography, 400 obstructed fallopian tubes were discovered.All the patients were followed for 1 and 3 years to assess tubal patency maintenance using salpingography. Ultrasound was used to ascertain pregnancy, which was also determined to be intrauterine pregnancy rather than ectopic pregnancy during the 1- and 3 year follow-up times. Patients who did not return for follow-up examinations were contacted by telephone.

2.2.1 Salpingography Definitions

i. Unobstructed: Huang et al. (2019) both sides of the fallopian tubes are clearly shown during the procedure and visible contrast agent can be seen diffusing through the pelvic cavity.

ii. Completely obstructed: Partial or no development of the middle and distal end of the fallopian tube, and no contrast agent can be seen diffusing through the pelvic cavity.

iii. Partially obstructed: The contrast agent is seen passing through the fallopian tube with partial flow into the pelvic cavity in a heterogeneous manner. Additionally, fallopian tubes often form irregular configurations.

3 Statistical Analyses

The data from each group were collected and analyzed using SPSS 11.5 software (IBM SPSS China, Shanghai, China). The enumeration data were checked and corrected using the Chi-square test (x²), whereas the measurement data were calculated as the mean (X) ± standard deviation. The one-tailed t-test was also used, and significant differences were only identified if the p-value was < 0.05.

4 Results

4.1 The Relative Effective Constituents of Chitosan and Danshen Injections Were Stable

Chromatographic readings were detected as shown in Figure 1; Table 1. Peak area ratios between main danshen and chitosan ingredients were shown in Table 2. Table 3 showed the results after statistical analysis (t-tests); no statistical significance was found between the groups. The chitosan and danshen mixture before and after 0 and 10 min had no significant differences between the content of each ingredient, as shown in Table 3.

FIGURE 1

FIGURE 1. Chromatogram Chart. (A). The 210 nm wavelength shows the peak for carboxymethyl chitin (a). (B). The 280 nm wavelength shows peaks for salvianic acid A sodium (b) and protocatechualdehyde (c).

TABLE 1

TABLE 1. Precision table.

TABLE 2

TABLE 2. Peak area ratios between the main ingredients of danshen and medicinal chitosan injections alone and combined.

TABLE 3

TABLE 3. Statistical analysis of the contents of the main ingredients (t-test).

4.2 Combined Chitosan and Danshen Injections Prevent Tubal Re-Obstructions and Increase Pregnancy Rates

Two hundred and sixty-three of them completed 3 years of follow-up. There were no statistically significant differences in the mean ages of the study groups (p > 0.05). The differences in the hormone levels (estrogen and progesterone, FSH, and LH) were not statistically different before surgery (p > 0.05). No statistical differences were also found among the groups regarding the location of the fallopian tube obstruction or the positions of those obstructions (one or both sides) preoperatively (p > 0.05). Baseline patient characteristics are listed in Table 4.

TABLE 4

TABLE 4. Patient characteristics.

Seventeen of the enrolled patients were lost to follow-up, including 4 in Group A group, six in Group B, 2 in Group C, and 5 in group D (Figure 2). No statistically significant differences were found between the patients who had completed the study and those who were lost to follow-up with respect to age, hormone level, obstruction location, and obstruction position preoperatively (one or both sides of the fallopian tube).

FIGURE 2

FIGURE 2. Flow chart illustrating patient recruitment and analysis.

4.2.1 Tubal Patency Rates in Non pregnant Patients at 1- and 3 years Post-Injection

A total of 526 fallopian tubes were evaluated in 263 patients with salpingography preoperatively. 400 fallopian tubes were obstructed after follow-up. The tubal recanalization rates were highest in Group C (2 ml chitosan and 10 ml danshen, 97.1%), but the differences were not statistically significant (p = 0.17, p > 0.05, Table 5). Figure 3 shows a representative patient from each of the four treatment groups at the preoperative stage, 1 day after interventional recanalization.

TABLE 5

TABLE 5. Analysis of fallopian tube recanalization rates 1 day after treatment.

FIGURE 3

FIGURE 3. Pre- and post-injection salpingography. (A). Control group. (A1), The right fallopian tube completely obstructed at the preoperative stage. (A2), The right fallopian tube partially unobstructed 1 day after interventional recanalization. (B). Chitosan and danshen combined injection group (Group 2, 1:2 ratio) (B1), The right fallopian tube completely obstructed at the pre-injection stage. (B2), The right fallopian tube unobstructed 1 day after interventional recanalization. (C). Chitosan and danshen combined injection group (Group C, 1:5 ratio) (C1), The left fallopian tube completely obstructed at the preoperative stage. (C2), The left fallopian tube unobstructed 1 day after interventional recanalization. (D). Chitosan and danshen combined injection group (Group D, 1:10 ratio) (D1), The left fallopian tube completely obstructed at the pre-injection stage. D2, The left fallopian tube unobstructed 1 day after interventional recanalization.

The tubal patency rate for patients receiving the combination of 2 ml chitosan and 10 ml danshen injection (Group C group, 1:5 mixture) at 1 year post-injection was substantially higher than that for Groups A, B, and D (94.2% vs. 38.6%, 73.5%, 68.5%), respectively; these differences were statistically significant (p = 0.0001, p < 0.05), as shown in Table 6. Figure 4 shows a representative patient from each of the four treatment groups 1 year after interventional recanalization.

TABLE 6

TABLE 6. Analysis of tubal patency rates (in non-pregnant patients) 1-year post-injection (PI).

FIGURE 4

FIGURE 4. Selective salpingography showed fallopian tubes obstructed 1 year post-injection. (A), Control group; (B), Chitosan and Danshen combined injection group (1:2); (C), Chitosan and Danshen injection group (1:5); and (D), Chitosan and Danshen combined injection group (1:10). The yellow arrow shows the tube recanalized.

The tubal patency rate in Group C (1:5 mixture of chitosan and danshen) at 3 years post-injection was also higher than that in Groups A, B, and D (87.3%vs. 31.5%, 64.1%, 50.7%), respectively; these differences were statistically significant (p = 0.0001, p < 0.05), as shown in Table 7. Figure 5 shows a representative patient from each of the four treatment groups 3 years after the interventional recanalization.

TABLE 7

TABLE 7. Analysis of tubal patency rates (excluding pregnant patients) 3 years post-injection (PI).

FIGURE 5

FIGURE 5. Selective salpingography showed fallopian tubes partially obstructed 3 years post-injection. (A), Control group; (B), Chitosan and Danshen combined injection group (1:2); (C), Chitosan and Danshen combined injection group (1:5); and (D), Chitosan and Danshen combined injection group (1:10). The blue arrow shows the tube partially recanalized.

4.2.2 Pregnancy Rates at 1- and 3 years Post-Injection

The pregnancy rates at 1- and 3 years post-injection in Group C were 61.8% and 79.4%, respectively. These rates were higher than those of Group A (control group) (31.8% and 34.8%), as well as the other treatment groups. The differences were statistically significant (p = 0.0032 [year 1] and p = 0.0001 [year 3], p < 0.05), as shown in Table 8.

TABLE 8

TABLE 8. Analysis of pregnancy rates in the patients 1- and 3 years post-injection (PI).

5 Discussion

Chitosan is composed of arbitrarily distributed β-(1-4)-linked d-glucosamine (deacetylated unit) and N-acetyl-d-glucosamine (acetylated unit), which exhibits impressive characteristics, including mucoadhesive, biodegradable, and biocompatible properties. Chitosan has emerged as an essential element in the development of a nano-particulate delivery vehicle (Abolhasani et al., 2020; Babicheva et al., 2020; Palomino-Durand et al., 2020; Majcher et al., 2021; Yee Kuen and Masarudin, 2022).

Chitosan nanoparticles have loaded methylprednisolone sodium succinate to prolong the residence time and considerably inhibited the production of inflammatory cytokines, such as TNF-α and IL-6 (Ding et al., 2022). Great efficacy was found in the healing of diabetic skin wounds with alginate-and chitosan-based scaffolds (Cai and Li, 2020; Gaissler et al., 2021). Chitosan has also been shown to form a thermosensitive injectable hydrogel, and chitosan hydrogel-encapsulated mesenchymal stem cell exosomes show great potential in tissue repair (Wu et al., 2021). The redox-sensitive chitosan matrices can be used to realize synergistic photothermal-chemo therapy (Zhu et al., 2022). Celastrol-chitosan oligosaccharide (CSO) has also been found to be a promising delivery system for pancreatic cancer therapy (Zeng et al., 2022).

Tubal obstruction is one of the most common causes of female infertility, accounting for approximately 14%–45% of all female infertilities (Hanson et al., 2017; Shen et al., 2020). The recanalization rate of traditional tubal interventional procedures is approximately 90% (Knuttinen et al., 2014; Ikechebelu et al., 2018). But a high post-injection re-occlusion rate of 20–50% (Knuttinen et al., 2014) has been seen, as well as a low pregnancy rate of about 30% (Ikechebelu et al., 2018; Huang et al., 2019; Shen et al., 2020).

In this study, we developed a combined chitosan and danshen injection (China Invention Patent Number: ZL201510973669.3) Supplementary Figure S1. Chitosan, in correct proportions, can allow the release of drugs more slowly (Iftime et al., 2020). It can also inhibit inflammatory responses effectively (Liu et al., 2020), prevent post-injection adhesions (Liu et al., 2017) and fibrosis (Chung et al., 2016; Hassan et al., 2019), enhance collagen synthesis, promote revascularization (Shukla et al., 2021), and promote fallopian tube cilia repair. Cross-linked medium molecular weight chitosan nanoparticles are nontoxic, well-tolerated, and could, therefore, be a good candidate as a novel drug delivery system for improved therapeutic effects (Sethi et al., 2021). Especially, when the chitosan and danshen injection were combined, the effective constituent of chitosan and danshen injection was stable in our study.

We found an optimal 1:5 ratio of chitosan and danshen for injection that had a better efficacy to prevent tubal re-occlusion and improve the probability of a resultant pregnancy. We studied the stability of the 1:5 combined chitosan and danshen injection with high-performance liquid chromatography to determine the content changes of chitosan before and after mixing with danshen. We found that a ratio of 1:5 chitosan to danshen was more stable and produced better efficacy than the other ratios.

Compared with Group B (1:2 mixture), Group C with the 1:5 mixture was better at preventing post-injection fallopian tube re-adhesions. The analytic results might be due to the complex spatial structure of the chitosan macromolecule compound that can act as a carrier for the effective danshen compounds. With low doses of danshen, even if enough carrier is present, not enough danshen is available to provide a therapeutic effect on the fallopian tube.

Compared with Group D (1:10 mixture), Groups C and B were better at preventing post-injection fallopian tube re-adhesion with increasing doses of chitosan. The analytic results suggested that danshen itself reduces tissue adhesions; however, compared with Group C (1:5 mixture) and Group D (without enough chitosan to be effective as a carrier), danshen injections would be quickly metabolized. Danshen does not stay in the body for long periods, which would reduce its time in the fallopian tube and affect the overall prevention of fallopian tube re-adhesion. In addition, a large release of danshen in a short time could cause mucosal edema and hyperemia in fallopian tubes and slow down local microcirculation as seen in Group D, which is not conducive to the recovery of tubal function, with decreased patency rates seen 3 years after injection.

The tubal patency and pregnancy rates of Group C (1:5) were 87.3% and 79.4%, respectively, at 3 years post-injection and were significantly higher than those of the other groups. These results indicate that the combination of chitosan and danshen injection at a 1:5 ratio had positive effects on the probability of tubal patency and pregnancy after a long post-injection period.

Traditional Chinese medicine combined with interventional recanalization has a better effect on tubal obstruction than interventional recanalization alone, which may be caused by the regulation of inflammatory factors and the inhibition of fallopian tube inflammation (Liu et al., 2021). In addition, we found that the chitosan and danshen combined injection had a certain anti-inflammatory effect on the mucosa of fallopian tube in the pre-clinical study. Therapeutic Mechanism maybe promote the maturation of follicular cells by the TGF-β/SMAD and BMP/SMAD signaling pathways and increase the pregnancy rate (Liu et al., 2021). The new research (Marlow et al., 2021) showed the intrauterine pregnancy rate only was 31.4% with interventional recanalization alone and 59% using ozone treatment (He and Ma, 2015).The pregnancy rates of Group C (1:5) were 79.4% at 3 years post-injection in our study, which was higher than the other treatment. So combined chitosan and danshen injections observably increased pregnancy rates.

6 Conclusion

Combined chitosan and danshen injections are effective at preventing tubal re-obstruction and increasing pregnancy rates. The optimal concentration at 1:5 chitosan to danshen appears better than the other concentrations in treating and preventing fallopian tube obstruction.

Data Availability Statement

The original contributions presented in the study are included in the article/Supplementary Material, further inquiries can be directed to the corresponding authors.

Ethics Statement

The studies involving human participants were reviewed and approved by the medical ethics committee of Guangzhou Panyu Central Hospitalt. The patients/participants provided their written informed consent to participate in this study.

Author Contributions

CH conceived and wrote the paper. QW and JL executed the experimental tests. QW and XH took care of all the statistical aspects.QW,YX and YL took care of sample collection. JS and YT took care of text critical revision. All authors read and approved the final manuscript.

Funding

This work was supported by Guangzhou Science and Technology Planning Project (202103000002), Guangdong Medical Science and Technology Research Foundation (B2021376) and Panyu Major Science and Technology Planning Project (2020-Z04-002). This work was supported by department of minimally invasive interventional radiology, Guangzhou Panyu Central Hospital.

Conflict of Interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Publisher’s Note

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

Supplementary Material

The Supplementary Material for this article can be found online at: https://www.frontiersin.org/articles/10.3389/fphar.2022.935117/full#supplementary-material

References

Abolhasani, A., Heidari, F., and Abolhasani, H. (2020). Development and Characterization of Chitosan Nanoparticles Containing an Indanonic Tricyclic Spiroisoxazoline Derivative Using Ion-Gelation Method: an In Vitro Study. Drug Dev. Ind. Pharm. 46, 1604–1612. doi:10.1080/03639045.2020.1811304

PubMed Abstract | CrossRef Full Text | Google Scholar

Anil, G., Tay, K. H., Loh, S. F., Yong, T. T., Ong, C. L., and Tan, B. S. (2011). Fluoroscopy-guided, Transcervical, Selective Salpingography and Fallopian Tube Recanalisation. J. Obstet. Gynaecol. 31, 746–750. doi:10.3109/01443615.2011.593647

PubMed Abstract | CrossRef Full Text | Google Scholar

Babicheva, T. S., Konduktorova, A. A., Shmakov, S. L., and Shipovskaya, A. B. (2020). Formation of Liesegang Structures under the Conditions of the Spatiotemporal Reaction of Polymer-Analogous Transformation (Salt → Base) of Chitosan. J. Phys. Chem. B 124, 9255–9266. doi:10.1021/acs.jpcb.0c07173

PubMed Abstract | CrossRef Full Text | Google Scholar

Cai, H., and Li, G. (2020). Efficacy of Alginate-And Chitosan-Based Scaffolds on the Healing of Diabetic Skin Wounds in Animal Experimental Models and Cell Studies: A Systematic Review. Wound Repair Regen. 28, 751–771. doi:10.1111/wrr.12857

PubMed Abstract | CrossRef Full Text | Google Scholar

Chung, Y. J., An, S. Y., Yeon, J. Y., Shim, W. S., and Mo, J. H. (2016). Effect of a Chitosan Gel on Hemostasis and Prevention of Adhesion after Endoscopic Sinus Surgery. Clin. Exp. Otorhinolaryngol. 9, 143–149. doi:10.21053/ceo.2015.00591

PubMed Abstract | CrossRef Full Text | Google Scholar

Ding, Y., Lv, B., Zheng, J., Lu, C., Liu, J., Lei, Y., et al. (2022). RBC-hitchhiking Chitosan Nanoparticles Loading Methylprednisolone for Lung-Targeting Delivery. J. Control Release 341, 702–715. doi:10.1016/j.jconrel.2021.12.018

PubMed Abstract | CrossRef Full Text | Google Scholar

Fields, E., Chard, J., James, D., and Treasure, T. (2013). Fertility (Update): Summary of NICE Guidance. BMJ 346, f650. doi:10.1136/bmj.f650f650

PubMed Abstract | CrossRef Full Text | Google Scholar

Gaissler, V., Antunes, F. T. T., Willand, E., Duarte, S. B. S., Pires, C. S., Machado, R. N. F., et al. (2021). The Effects of Brazilian Chitosan-Based Biomaterials on Wound Healing in Rats. Tissue Cell 69, 101476. doi:10.1016/j.tice.2020.101476

PubMed Abstract | CrossRef Full Text | Google Scholar

Gao, X., Liu, N., Wang, Z., Gao, J., Zhang, H., Li, M., et al. (2021). Development and Optimization of Chitosan Nanoparticle-Based Intranasal Vaccine Carrier. Molecules 27, 27. doi:10.3390/molecules27010204

PubMed Abstract | CrossRef Full Text | Google Scholar

Gao, Y. B., Yan, J. H., Yang, Y. D., Sun, J., Dong, J. Y., and Cui, G. H. (2019). Diagnostic Value of Transvaginal Four-Dimensional Hysterosalpingo-Contrast Sonography Combined with Recanalization in Patients with Tubal Infertility. Niger. J. Clin. Pract. 22, 46–50. doi:10.4103/njcp.njcp_376_17

PubMed Abstract | CrossRef Full Text | Google Scholar

Hanson, B., Johnstone, E., Dorais, J., Silver, B., Peterson, C. M., and Hotaling, J. (2017). Female Infertility, Infertility-Associated Diagnoses, and Comorbidities: a Review. J. Assist. Reprod. Genet. 34, 167–177. doi:10.1007/s10815-016-0836-8

PubMed Abstract | CrossRef Full Text | Google Scholar

Hassan, R., Tammam, S. N., Safy, S. E., Abdel-Halim, M., Asimakopoulou, A., Weiskirchen, R., et al. (2019). Prevention of Hepatic Stellate Cell Activation Using JQ1- and Atorvastatin-Loaded Chitosan Nanoparticles as a Promising Approach in Therapy of Liver Fibrosis. Eur. J. Pharm. Biopharm. 134, 96–106. doi:10.1016/j.ejpb.2018.11.018

PubMed Abstract | CrossRef Full Text | Google Scholar

He, C., and Ma, X. (2015). Distal Fallopian Tube Recanalization Using Ozone Treatment: a Clinical Study in Two Hundred Tubal Obstruction Chinese Patients. Int. J. Clin. Exp. Med. 8, 2958–2961.

PubMed Abstract | Google Scholar

Huang, C., He, X., Luo, W., Chen, H., and Huang, Y. (2019). Combined Chitosan and Dan-Shen Injection for Long-Term Tubal Patency in Fallopian Tube Recanalization for Infertility. Drug Deliv. Transl. Res. 9, 738–747. doi:10.1007/s13346-018-00611-0

PubMed Abstract | CrossRef Full Text | Google Scholar

Iftime, M. M., Dobreci, D. L., Irimiciuc, S. A., Agop, M., Petrescu, T., and Doroftei, B. (2020). A Theoretical Mathematical Model for Assessing Diclofenac Release from Chitosan-Based Formulations. Drug Deliv. 27, 1125–1133. doi:10.1080/10717544.2020.1797242

PubMed Abstract | CrossRef Full Text | Google Scholar

Ikechebelu, J. I., Eleje, G. U., Bhamare, P., Joe-Ikechebelu, N. N., Okafor, C. D., and Akintobi, A. O. (2018). Fertility Outcomes Following Laparoscopy-Assisted Hysteroscopic Fallopian Tube Cannulation: A Preliminary Study. Obstet. Gynecol. Int. 2018, 7060459. doi:10.1155/2018/7060459

PubMed Abstract | CrossRef Full Text | Google Scholar

Knuttinen, M. G., Jajko, R., and Scoccia, B. (2014). Fluoroscopic Tubal Recanalization in Tubal Factor Related Infertility. Semin. Interv. Radiol. 31, 269–271. doi:10.1055/s-0034-1382797

PubMed Abstract | CrossRef Full Text | Google Scholar

Kohi, M. P. (2021). Interventional Radiologist's Approach to Fallopian Tube Recanalization. Tech. Vasc. Interv. Radiol. 24, 100736. doi:10.1016/j.tvir.2021.100736

PubMed Abstract | CrossRef Full Text | Google Scholar

Kou, S. G., Peters, L., and Mucalo, M. (2022). Chitosan: A Review of Molecular Structure, Bioactivities and Interactions with the Human Body and Micro-organisms. Carbohydr. Polym. 282, 119132. doi:10.1016/j.carbpol.2022.119132

PubMed Abstract | CrossRef Full Text | Google Scholar

Liu, C., Qiu, H., Huang, R., Chai, H., Yuan, G., and Shan, S. (2021). Therapeutic Mechanism and Clinical Observation of Traditional Chinese Medicine Combined with Interventional Recanalization for Tubal Infertility. Evid. Based Complement. Altern. Med. 2021, 2842250. doi:10.1155/2021/2842250

CrossRef Full Text | Google Scholar

Liu, F., Li, H. Y., Wang, Z., Zhang, H. N., Wang, Y. Z., and Xu, H. (2020). Carboxymethyl Chitosan Reduces Inflammation and Promotes Osteogenesis in a Rabbit Knee Replacement Model. BMC Musculoskelet. Disord. 21, 775. doi:10.1186/s12891-020-03803-3

PubMed Abstract | CrossRef Full Text | Google Scholar

Liu, J., Zeng, Q., Ke, X., Yang, Y., Hu, G., and Zhang, X. (2017). Influence of Chitosan-Based Dressing on Prevention of Synechia and Wound Healing after Endoscopic Sinus Surgery: A Meta-Analysis. Am. J. Rhinol. Allergy 31, 401–405. doi:10.2500/ajra.2017.31.4469

PubMed Abstract | CrossRef Full Text | Google Scholar

Majcher, M. J., Babar, A., Lofts, A., Leung, A., Li, X., Abu-Hijleh, F., et al. (2021). In Situ-gelling Starch Nanoparticle (SNP)/O-carboxymethyl Chitosan (CMCh) Nanoparticle Network Hydrogels for the Intranasal Delivery of an Antipsychotic Peptide. J. Control Release 330, 738–752. doi:10.1016/j.jconrel.2020.12.050

PubMed Abstract | CrossRef Full Text | Google Scholar

Marlow, J. A., Picus, D., Gould, J., Connolly, S., and Mani, N. B. (2021). Outcomes after Successful Fallopian Tube Recanalization: A Single Institution Experience: Observational Retrospective Study. Clin. Imaging 76, 70–73. doi:10.1016/j.clinimag.2020.12.010

PubMed Abstract | CrossRef Full Text | Google Scholar

Palomino-Durand, C., Lopez, M., Marchandise, P., Martel, B., Blanchemain, N., and Chai, F. (2020). Chitosan/Polycyclodextrin (CHT/PCD)-Based Sponges Delivering VEGF to Enhance Angiogenesis for Bone Regeneration. Pharmaceutics 12, 12. doi:10.3390/pharmaceutics12090784

PubMed Abstract | CrossRef Full Text | Google Scholar

Practice Committee of the American Society for Reproductive M (2015). Diagnostic Evaluation of the Infertile Female: a Committee Opinion. Fertil. Steril. 103, e44–50. doi:10.1016/j.fertnstert.2015.03.019

PubMed Abstract | CrossRef Full Text | Google Scholar

Sethi, A., Ahmad, M., Huma, T., and Ahmad, W. (2021). Pharmacokinetic Variables of Medium Molecular Weight Cross Linked Chitosan Nanoparticles to Enhance the Bioavailability of 5-fluorouracil and Reduce the Acute Oral Toxicity. Drug Deliv. 28, 1569–1584. doi:10.1080/10717544.2021.1944398

PubMed Abstract | CrossRef Full Text | Google Scholar

Shen, H., Cai, M., Chen, T., Zheng, D., Huang, S., Zhou, M., et al. (2020). Factors Affecting the Success of Fallopian Tube Recanalization in Treatment of Tubal Obstructive Infertility. J. Int. Med. Res. 48, 300060520979218. doi:10.1177/0300060520979218

PubMed Abstract | CrossRef Full Text | Google Scholar

Shukla, A., Choudhury, S., Chaudhary, G., Singh, V., Prabhu, S. N., Pandey, S., et al. (2021). Chitosan and Gelatin Biopolymer Supplemented with Mesenchymal Stem Cells (Velgraft®) Enhanced Wound Healing in Goats (Capra hircus): Involvement of VEGF, TGF and CD31. J. Tissue Viability 30, 59–66. doi:10.1016/j.jtv.2020.12.002

PubMed Abstract | CrossRef Full Text | Google Scholar

Sun, N., Wei, L., Chen, D., Gao, W., Niu, H., and He, C. (2017). Clinical Observation of Fallopian Tube Obstruction Recanalization by Ozone. Pak J. Med. Sci. 33, 290–294. doi:10.12669/pjms.332.11961

PubMed Abstract | CrossRef Full Text | Google Scholar

Verma, A., Krarup, K., and Donuru, A. (2009). Selective Salpingography and Fallopian Tube Catheterisation by Guidewire. J. Obstet. Gynaecol. 29, 315–317. doi:10.1080/01443610902888469

PubMed Abstract | CrossRef Full Text | Google Scholar

Wu, D., Qin, H., Wang, Z., Yu, M., Liu, Z., Peng, H., et al. (2021). Bone Mesenchymal Stem Cell-Derived sEV-Encapsulated Thermosensitive Hydrogels Accelerate Osteogenesis and Angiogenesis by Release of Exosomal miR-21. Front. Bioeng. Biotechnol. 9, 829136. doi:10.3389/fbioe.2021.829136

PubMed Abstract | CrossRef Full Text | Google Scholar

Xiao, L., Liu, D., Song, Y., and Huang, W. (2014). Reproductive Outcomes after Operative Laparoscopy of Patients with Tubal Infertility with or without Hydrosalpinx. Chin. Med. J. Engl. 127, 593–594.

PubMed Abstract | Google Scholar

Yee Kuen, C., and Masarudin, M. J. (2022). Chitosan Nanoparticle-Based System: A New Insight into the Promising Controlled Release System for Lung Cancer Treatment. Molecules 27, 27. doi:10.3390/molecules27020473

CrossRef Full Text | Google Scholar

Zeng, X., Zhu, X., Tian, Q., Tan, X., Sun, N., Yan, M., et al. (2022). Celastrol-conjugated Chitosan Oligosaccharide for the Treatment of Pancreatic Cancer. Drug Deliv. 29, 89–98. doi:10.1080/10717544.2021.2018521

PubMed Abstract | CrossRef Full Text | Google Scholar

Zhu, X., Li, L., Tang, J., Yang, C., Yu, H., Liu, K., et al. (2022). Cascade-responsive Nano-Assembly for Efficient Photothermal-Chemo Synergistic Inhibition of Tumor Metastasis by Targeting Cancer Stem Cells. Biomaterials 280, 121305. doi:10.1016/j.biomaterials.2021.121305

PubMed Abstract | CrossRef Full Text | Google Scholar