Decidualization potential of endometrial mesenchymal stem cells and their role in reproductive health

The establishment of a successful pregnancy depends on proper embryo development and coordinated endometrial differentiation, particularly through the process of decidualization. Mesenchymal stem/stromal cells (MSCs), especially those derived from endometrial tissue (eMSCs) and menstrual fluid (MenSCs), have emerged as critical players in regulating decidualization, trophoblast invasion, angiogenesis, and immune modulation at the maternal-fetal interface. These cells exhibit potent immunoregulatory functions, underscoring their role in establishing a tolerant yet responsive environment for implantation along with promoting angiogenesis and stromal regeneration. Dysfunctional MSCs have been linked to impaired decidualization and pregnancy disorders, including preeclampsia (PE) and fetal growth restriction. Evidence indicates that MenSCs from women with a history of PE exhibit diminished angiogenic potential, impaired trophoblast invasion support, and altered cytokine secretion, associating these alterations to disease pathogenesis. Similarly, aberrant eMSCs contribute to endometriosis by supporting ectopic implantation, impaired decidualization, and enhanced migration.Collectively, these findings highlight the central role of endometrial- and menstrual-derived MSCs in both reproductive success and pathology. They also emphasize their potential as diagnostic biomarkers and therapeutic targets in obstetrics and gynecology. In this review, we summarize current knowledge on the role of endometrial- and menstrual-derived MSCs in pregnancy establishment and related complications, and discuss their emerging promise as diagnostic tools and therapeutic strategies in reproductive medicine.