Reveals apoptosis enrichment and proliferative-program suppression in intrauterine adhesion, with exploratory stromal mapping

Background Intrauterine adhesion (IUA/Asherman syndrome) is a leading cause of acquired infertility in women, characterized by dysregulated apoptosis and fibrosis of endometrial stromal cells (ESCs). Bioelectrical stimulation (ES) holds potential for tissue repair, but its cytological mechanism for regulating ESC apoptosis remains unclear. Methods Transcriptomic data from GEO dataset GSE224093 were used for differential gene expression (DEG) analysis, GO/KEGG enrichment, WGCNA co-expression networks, PPI network construction, and GSEA. Public single-cell data were used for ESC subpopulation annotation and apoptosis scoring. An H 2 O 2 -induced ESC injury model was established; low-frequency ES (1 Hz, 2 mA, 12 h/day) was applied, and cell viability, apoptosis rate, mitochondrial membrane potential and Bcl-2/Bax/Cleaved-Caspase-3 proteins were measured. RT-PCR verified mRNA expression. Results GSE224093 analysis identified 892 DEGs. Hallmark GSEA revealed strong inflammatory enrichment in IUA (Interferon Gamma Response: NES = +1.89, FDR = 0.001; Myogenesis: NES = +1.90, FDR = 0.001) and broad suppression of proliferative programs (Myc Targets V1: NES = −3.80; E2F Targets NES = −3.73; G2-M Checkpoint: NES = −3.46; all FDR = 0.001). Single-cell data revealed stromal-state differences between AS-Pre and WOI control libraries that are interpretable as exploratory given preparation imbalance. In vitro experiments confirmed ES reduced the ESC apoptosis rate from 38.2% to 14.7% (P < 0.001), upregulated Bcl-2 (2.8-fold), and downregulated Bax (0.48-fold) and Cleaved Caspase-3 (0.37-fold). RT-PCR results were highly consistent with protein-level findings (Spearman r = 0.92, P < 0.001). Conclusion Bioelectrical stimulation significantly inhibits pathological apoptosis of ESCs in IUA by activating the Bcl-2/Bax/Caspase-3 anti-apoptotic axis and stabilizing MMP, thereby promoting endometrial repair. The integrated transcriptomic and in vitro evidence presented here provides a cytological basis for ES as an adjuvant treatment for IUA, pending prospective clinical validation.