Decoding uterine contractility: from physiology to pathology, through emerging technologies

Uterine contractility has emerged as a potential key element in the orchestration of female reproductive functions, with specific motility patterns seemingly aligning with hormonal fluctuations throughout the menstrual cycle. These dynamic contractility profiles appear to facilitate various stages of conception, underscoring the importance of maintaining physiological uterine kinetics for fertility. Altered uterine contractility might thus contribute to cases of unexplained infertility. By offering a comprehensive reappraisal of uterine contractility across both physiological and pathological contexts, this review has been undertaken to challenge conventional fertility paradigms. The review outlines uterine anatomy and details the genesis and regulation of uterine contractions, emphasizing the electrophysiological role of uterine pacemaker cells, namely interstitial Cajal-like cells. It also provides a thorough overview of current methodologies for assessing uterine contractility, focusing on non-invasive ultrasound-based approaches, and discussing both innovative applications of established techniques and entirely novel diagnostic methods. The review then evaluates the various physiological uterine contractility patterns observed across the menstrual cycle, and finally presents evidence supporting potential causal links between impaired uterine contractility and fertility-threatening uterine pathologies. Since the directionality of this association remains uncertain, longitudinal studies are needed to determine whether alterations in uterine contractility precede or are a consequence of uterine disease. This is a distinction with critical implications for both treatment and prevention strategies in reproductive medicine.