Postsurgical barrier strategies to avoid the recurrence of intrauterine adhesion formation after hysteroscopic adhesiolysis: a network meta-analysis of randomized controlled trials

Visualized hysteroscopic artificial intelligence fertility assessment system for endometrial injury: an image-deep-learning study

OBJECTIVE

Asherman's syndrome (AS) is a significant cause of subfertility in women from developing countries. Over 80% of AS cases in these regions are linked to dilation and curettage (D&C) procedures following pregnancy. The incidence of AS in patients with infertility and recurrent miscarriage can be as high as 10%, while the pregnancy rate in cases of moderate to severe adhesions can be as low as 34%. We aimed to establish a hysteroscopic artificial intelligence system using image-deep-learning algorithms for fertility assessment.

METHODS

This diagnostic study included 555 cases with 4922 hysteroscopic images from a Chinese intrauterine adhesions cohort clinical database (NCT05381376). The study evaluated two image-deep-learning algorithms' effectiveness in predicting pregnancy within one year, using AUCs and decision curve analysis. The models' performance was evaluated for two-year prediction via concordance index and cumulative time-dependent ROC. A quantifiable visualization panel of the system was established.

RESULTS

The proportional hazard CNN system accurately predicted conception, with AUCs of 0.982, 0.992, and 0.990 in three randomly assigned datasets, superior to the InceptionV3 framework, and achieved a net benefit of 69.4% for subfertility assessment. The system fitted well with c-indexes of 0.920-0.940 and was time-stable. The quantifiable visualization panel displayed four intrauterine pathologies intuitively. The performance was comparable to senior hysteroscopists, with a kappa value of 0.84-0.89.

CONCLUSIONS

The CNN based on the proportional hazard approach accurately assesses fertility postoperatively. The quantifiable visualization panel could assist in intrauterine pathologies assessment, optimize treatment strategies, and achieve individualized and cost-efficient practices.

Reliability of an Electronic Uterine Diagram to Standardize Intrauterine Adhesion Scoring

STUDY OBJECTIVE

To study the inter-rater reliability of an electronic complementary uterine diagram (electronic American Fertility Society [eAFS] freely available at https://bit.ly/eAFS-score) in comparison with the conventional American Fertility Society (cAFS) intrauterine adhesion (IUA) scoring system. As a secondary aim, we wanted to assess the intra-rater reliability of these tools.

DESIGN

This was an observational cross-over study with a nested test-retest design.

SETTING

Self-identified gynecologists who performed diagnostic hysteroscopy as part of their routine practice were asked to score IUA on 7 preselected videos using both cAFS and eAFS tools in 2 separate rounds. The order of use of tools was determined at random. Gynecologists who agreed to be involved in a third round were asked to use the tool they were allocated to in the first round to assess intra-rater variability.

PATIENTS

No patients were recruited for the purpose of this study.

MEASUREMENTS AND MAIN RESULTS

Inter-rater agreement between evaluators when using eAFS and cAFS for IUA scoring. Overall, the inter-rater agreement was fair (0.25; confidence interval [CI], 0.17-0.34) for cAFS and moderate (0.53; CI, 0.48-0.58) for the eAFS tool. The biggest difference between both tools was seen in the "extent of cavity involved" component, which was fair (0.28; CI, 0.21-0.35) vs substantial (0.71; CI, 0.64-0.78) for cAFS vs eAFS, respectively. Moreover, agreement coefficients were comparable among "expert" and "non-expert" evaluators with the use of the eAFS tool. In addition, intra-rater perfect agreement was higher with the use of eAFS than cAFS (38% vs 32.5%).

CONCLUSION

The current AFS IUA scoring system has fair inter-rater agreement. However, using a complementary electronic uterine diagram increased this agreement from fair to moderate overall and from fair to substantial in the "extent of adhesions" domain of the tool. The use of the electronic diagram also improved inter-rater agreement among non-experts making it comparable with that of experts.

Transcriptomics and proteomics reveal associations between myometrium and intrauterine adhesions

BACKGROUND

Intrauterine adhesions (IUAs) is a gynecological condition with a poor therapeutic prognosis, that severely threatens the fertility and the reproductive physiology and psychological health of women. Our previous research on the use of umbilical cord mesenchymal stem cells (HUCMSCs) for treating IUAs revealed that CM-Dil-labelled HUCMSCs were barely distributed in the endometrial epithelium. Instead, these cells were predominantly found in the myometrium, with no statistically significant difference in distribution compared to the endometrial stromal cells. Therefore, we aimed to explore the associations between the myometrium and IUAs.

METHODS

Eight patients with moderate and 5 severe lesional IUAs were included in the experimental group. The control group included 7 patients whose inner and outer myometrium were normal. We used H&E, Masson's trichrome and immunohistochemical staining to obtain the pathological features of the tissues. Transcriptomic and proteomic analyses were conducted to identify differentially expressed genes, proteins and enrichment pathways.

RESULTS

Both IUAs lesion tissues expressed the smooth muscle markers α-SMA and H-caldesmon, and there was no significant difference between severe IUAs tissue and normal myometrium (p > 0.05). Transcriptomic and proteomic data revealed that genes and proteins involved in cell mitosis, such as KIF14, KIF4A, and CIT, were downregulated in both IUAs lesion tissues compared with the inner myometrium (p < 0.05). Additionally, some genes or proteins that participate in activating the complement-coagulation cascade system and extracellular matrix (ECM) degradation also significantly differed (p < 0.05).

CONCLUSIONS

Transcriptomic and proteomic data revealed a correlation between endometrial injury and the myometrium. These findings preliminarily revealed that the myometrium possibly contributes to the aetiology and progression of IUAs through dual mechanisms. On the one hand, the myometrium inhibits endometrial regeneration by suppressing the cell mitogenic pathway. On the other hand, it promotes fibrosis by activating the complement-coagulation cascade system and inhibiting the ECM degradation pathway. These new findings increase our understanding of the pathogenesis of IUAs and potentially contribute to the application of precision clinical treatment for IUAs.

Comparison of hysteroscopic adhesiolysis with electrosurgery instrument or hysteroscopic scissors in the treatment of intrauterine adhesions of infertile or recurrent pregnancy loss women

OBJECTIVE

To investigate pregnancy outcomes following hysteroscopic adhesiolysis (HA) in patients with recurrent pregnancy loss (RPL) or infertility.

DESIGN

Retrospective cohort study.

SETTING

University-affiliated hospital.

SUBJECTS

According to the inclusion and exclusion criteria of this study, finally, a total of 461 subjects were included.

INTERVENTIONS

HA performed using either an electrosurgical instrument or hysteroscopic scissors.

MAIN OUTCOME MEASURES

Pregnancy outcomes post-HA.

RESULTS

A total of 461 patients were included in the study, with follow-up periods ranging from 1 to 6 years. The mean age was 29.48 ± 3.25 years. Hysteroscopic scissors demonstrated greater efficiency in restoring the uterine cavity compared to electrosurgical instruments (88.1% vs. 80.0%, p = 0.025). Post-HA, the pregnancy rate was approximately 75.3% (347/461), with a live birth rate of 55.9% (251/449). No significant differences were found between the electrosurgical instrument and hysteroscopic scissors groups regarding improvements in menstrual flow or fertility outcomes (all p > 0.05). Kaplan-Meier time-dependent cumulative curves for pregnancy and live birth rates after HA indicated that over 50% of patients achieved pregnancy within one year, with the pregnancy rate plateauing at 2 years and the live birth rate at 3 years.

CONCLUSION

Our findings suggest that HA can improve fertility outcomes for patients with RPL or infertility within 2 to 3 years following surgery. Hysteroscopic scissors proved more effective than electrosurgical instruments in restoring the uterine cavity, although no differences were observed between the techniques in terms of menstrual flow or fertility improvements. All in all, our study suggests that standardized HA procedures, the implementation of proactive intraoperative and postoperative measures to prevent the recurrence of intrauterine adhesions (IUA), and an active conception plan following HA are key factors in improving reproductive outcomes for these patients with RPL or infertility.

Strategies to avoid recurrence of intrauterine adhesions after hysteroscopic adhesiolysis

PURPOSE OF REVIEW

Intrauterine adhesions (IUA) are fibrous bands of scar tissue within the uterine cavity resulting from trauma to the endometrium. Despite treatment with hysteroscopic lysis of IUA, recurrence rates are substantial, ranging from 3 to 25%. Practice patterns can differ widely regarding intraoperative and postoperative interventions. Our goal is to review current literature that explores strategies to decrease recurrence of IUA.

RECENT FINDINGS

This literature review examines intraoperative recommendations regarding surgical technique for lysis of IUA, intrauterine placement of mechanical barriers like a balloon or an intrauterine device, and use of substances like hyaluronic acid, platelet-rich plasma, and amnion graft. Postoperative techniques including hormonal medications after lysis of IUA, medications that increase vascular flow to the uterus, and second-look hysteroscopy are also explored.

SUMMARY

Various intraoperative and postoperative interventions show promise in reducing IUA reformation after hysteroscopic lysis of adhesions. What remains to be explored are implications of preventive therapy on pregnancy rate and live birth rate. Additionally, the optimal combination of therapy for preventing IUA recurrence has yet to be established. Further research is essential to determine the most effective strategies for preventing IUA reformation and optimizing long-term reproductive health.

Narrow-band imaging offers a shorter menstrual bleeding time and a longer remission for hysteroscopic surgery in symptomatic post-cesarean scar diverticulum compared to white light

BACKGROUND

Narrow-band imaging (NBI) is a novel endoscopic imaging technology that improves the visibility of capillaries. The aim of this study was to evaluate the efficacy of NBI hysteroscopic excision in symptomatic post-cesarean scar diverticulum (PCSD) patients compared to conventional white light (WL) hysteroscopy.

METHOD

A total of 73 patients with symptomatic PCSD between January 2014 and December 2018 were enrolled. The enrolled patients were stratified into NBI and WL groups according to whether they received NBI or WL hysteroscopy. Postoperative menstrual patterns at one, six, and 12 months after the operation were collected and compared between the NBI and WL groups.

RESULTS

A total of 32 patients underwent NBI hysteroscopy (NBI group), while 41 patients received WL hysteroscopy (WL group). The symptom-free remission rates in the NBI group were significantly higher than in the WL group at six months and 12 months post-hysteroscopy. At the final follow-up, the menstrual bleeding duration in the NBI group was significantly shorter than in the WL group.

CONCLUSION

The use of NBI hysteroscopy in treating symptomatic PCSD resulted in shorter menstrual bleeding days and longer symptomatic remission compared to conventional WL hysteroscopy.

Targeting the lncRNA GAS5/TLR4/NLRP3 signaling cascade inhibits endometrial stromal cell pyroptosis and prevents the progression of intrauterine adhesions

Intrauterine adhesion (IUA) poses a serious threat to women's health, and its specific pathogenesis has not yet been elucidated. Our study found through high-throughput sequencing that differentially expressed genes of the endometrial tissues from healthy individuals or IUA patients were enriched in the toll-like receptor (TLR), nuclear factor-kappa B (NF-kB), and nucleotide-binding oligomerization domain-like receptor (NLR) signaling pathways. Meanwhile, we observed that compared to the controls, long non-coding RNA (lncRNA) growth arrest-specific transcripts 5 (GAS5) was significantly upregulated in the endometrial tissue of IUA patients and scratching/lipopolysaccharide (LPS)-induced IUA model mice. Subsequently, results from the functional verification assay, including hematoxylin-eosin staining, enzyme-linked immunosorbent assay, and western blot, showed that knockdown of GAS5 improved endometrial injury and uterine adhesions, decreased the levels of TIMP1, α-SMA, Vimentin, and COL1A1, but elevated MMP9 level to reduce excessive accumulation of extracellular matrix (ECM), and inhibited the expression of NLRP3, cleaved caspase-1, GSDMD, and nuclear p65 to ameliorate pyroptosis in IUA model mice. As confirmed by bioinformatics analysis and dual luciferase reporter gene system, GAS5 sponged microRNA (miR)-205-5p to upregulate TLR4, further activating the NF-kB and NLRP3 signaling in endometrial stromal cells (ESCs). The in vitro functional recovery experiments suggested that GAS5 knockdown alleviated LPS-induced activation of the NF-kB and NLRP3 signaling, pyroptotic cell death, and ECM deposition in ESCs, which was counteracted by overexpressing TLR4 and NLRP3. In a word, our study proved that targeting the GAS5/TLR4/NLRP3 signaling cascade inhibits ESCs pyroptosis and prevents the progression of IUA, providing promising therapeutic strategies for IUA disease.

Role of the collagen scaffold in preventing intrauterine adhesion from recurrence after adhesiolysis: protocol for a multicentre, randomised, controlled, parallel-group, open-label, superiority clinical trial

INTRODUCTION

Intrauterine adhesions (IUAs) are one of the most common causes of uterine infertility. Hysteroscopic adhesiolysis is the primary treatment for IUA, but the rate of IUA recurrence is high in moderate to severe cases. While traditional guidelines recommend placing a non-copper stainless steel intrauterine device (IUD) into the uterine cavity after adhesiolysis to prevent readhesion, the preventive effect is uncertain. Our preliminary trials suggested that the collagen scaffold was more effective in moderate cases. This study aims to assess the efficacy and safety of a collagen scaffold versus IUD in preventing readhesion after hysteroscopic adhesiolysis in patients with moderate IUA.

METHODS AND ANALYSIS

This multicentre, open-label, randomised controlled trial evaluates the efficacy and safety of a collagen scaffold compared with an IUD in preventing readhesion after hysteroscopic adhesiolysis in women with moderate IUA. This trial will be conducted at six teaching hospitals and plans to enrol 200 participants. The primary outcome is the non-recurrence rate of IUA 2 months after adhesiolysis. Secondary endpoints include changes in American Fertility Society scores before and after surgery and postoperative menstrual blood volume. The 95% CIs for the difference in non-recurrence rates between the two groups will be calculated. If the lower limit of this interval exceeds the superiority threshold of zero, the conclusion of superiority is confirmed.

ETHICS AND DISSEMINATION

This study has received approval from the ethics committee of the Affiliated Drum Tower Hospital of Nanjing University Medical School (2022-491-02) and the ethics committees of the participating centres. Written informed consent will be obtained from each participant before starting any study procedures. The results of this trial will be published in a peer-reviewed journal.

TRIAL REGISTRATION NUMBER

ChiCTR2300068271.

Defining optimal electrospun membranes to enhance biological activities of human endometrial MSCs

Introduction

Human endometrial mesenchymal stem cells (H-EMSCs) can inhibit endometrial fibrosis and repair damaged endometrium. However, direct cell injection into dam-aged endometrium shows limited cell survival. Cell seeding onto biomaterial-based electrospun membranes could improve H-EMSCs' survival and prolong their stay at the damaged endometrium. Polycaprolactone (PCL), silk fibroin (SF) and hyaluronic acid (HA) are synthetic or natural biomaterials used by the biomedicine field, however, their effects on the biological activities of H-EMSCs remain unclear.

Methods

In this study, CD90+CD73+CD45- H-EMSCs were extracted from human endometrium and H-EMSCs showed enhanced adhesion, proliferation on PCL-HA vs. PCL, PCL-SF, establishing the potential of the composite to address cell survival issues.

Results

H-EMSCs cultured on PCL-HA showed decreased IL-6 gene expression and increased IL-10, VEGFA, TGF-β gene expression vs. PCL-SF, establishing the potential to create a favorable micro-environment for generating vascularized endometrial tissues. PCL, PCL-SF, PCL-HA all supported CD90 and Meflin expression of the seeded H-EMSCs, establishing PCL as a platform to form enhanced biomaterial composites for endometrial repair in the future.

Discussion

This study provided significant evidence sup-porting the potential of appropriately tailored composites of PCL and HA to moder-ate inflammation and wound-healing, which can be applied for endometrial tissue repair and regeneration.

Enhanced myofibroblast differentiation of eMSCs in intrauterine adhesions

BACKGROUND

Intrauterine adhesions (IUA) is one of the most common gynecological diseases and main causes of uterine infertility. Among proposed hypotheses on IUA development, the reduced endometrial regeneration resulting from loss of functional stem cells has been proposed as the key factor affecting the IUA prognosis. However, the underlying mechanisms mostly remain unclear. Because the eMSCs (endometrial mesenchymal stem/stromal cells) play a critical role in both supporting the gland development and also preparing the environment for embryo implantation through decidualization, the characteristics and functions were compared between the eMSCs derived from IUA and non-IUA patients, to uncover the important roles of eMSCs in IUA and also the underlying mechanisms.

METHODS

Endometrium biopsies were collected from IUA patients and controls. The fibrosis features and eMSC distributions were investigated with IHC (immunohistochemistry). Then the eMSCs were isolated and their functions and characteristics were analyzed in vitro.

RESULTS

Our results indicate that the scar tissues in IUA are characterized with hyper-activation of pro-fibrotic fibroblast and myo-differentiation, along with reduced number of eMSCs. The isolated eMSCs from IUA and controls show similar functions from the perspectives of cell morphology, proliferation, colony formation, exosome secretion, positive ratio of eMSC markers and conventional MSC markers, tri-differentiation efficiency, the ability of suppressing lymphocyte proliferation, cell aging, and promoting vascular tube formation. However, the eMSCs from IUA have reduced levels of decidualization and higher levels of cell migration, invasion, and also myofibroblast differentiation. Further investigations indicate that the TGF-β pathway, which is the major inducer of myofibroblast differentiation, is up-regulated and responsible for the enhanced myofibroblast differentiation potential of eMSCs from IUA.

CONCLUSIONS

In conclusion, we have demonstrated here that the scar tissues in IUA biopsy are characterized with enhanced differentiation of pro-fibrotic fibroblast and myofibroblast. The number of eMSCs is reduced in IUA tissues, and their myofibroblast differentiation capability is increased.

4DryField vs. hyalobarrier gel for preventing the recurrence of intrauterine adhesions - a pilot study

INTRODUCTION

This was a single-center pilot study that sought to describe an innovative use of 4DryField® PH (premix) for preventing the recurrence of intrauterine adhesions (IUAs) after hysteroscopic adhesiolysis in patients with Asherman's syndrome (AS).

MATERIAL AND METHODS

Twenty-three patients with AS were enrolled and 20 were randomized (1:1 ratio) to intrauterine application of 4DryField® PH (n = 10) or Hyalobarrier® gel (n = 10) in a single-blind manner. We evaluated IUAs (American Fertility Society [AFS] score) during initial hysteroscopy and second-look hysteroscopy one month later. Patients completed a follow-up symptoms questionnaire three and reproductive outcomes questionnaire six months later.

RESULTS

The demographic and clinical characteristics, as well as severity of IUAs, were comparable in both groups. The mean initial AFS score was 9 and 8.5 in the 4DryField® PH and Hyalobarrier® gel groups, respectively (p = .476). There were no between-group differences in AFS progress (5.9 vs. 5.6, p = .675), need for secondary adhesiolysis (7 vs. 7 patients, p = 1), and the follow-up outcomes.

CONCLUSION

4DryField® PH could be a promising antiadhesive agent for preventing the recurrence of IUAs, showing similar effectiveness and safety to Hyalobarrier® gel. Our findings warrant prospective validation in a larger clinical trial.

CLINICAL TRIAL REGISTRY NUMBER

ISRCTN15630617.

The Pivotal role of hysteroscopy in diagnosing subtle uterine lesions in infertile patients: Seeing the unseen can make the difference

BACKGROUND

Subtle uterine lesions are abnormal intracavitary conditions that, while not causing significant anatomical changes, can adversely impact fertility. Identifying these "subtle" lesions is challenging due to arbitrary interpretation, varied management strategies, unclear clinical significance, and insufficient clinician training in recognizing them. Hysteroscopy offers direct visualization and the capacity to obtain targeted biopsies, making it an invaluable tool for the diagnosis and treatment of these often overlooked conditions.

PURPOSE

The lack of standardized and universally accepted terminology complicates the diagnosis and treatment of subtle uterine pathologies. A thorough understanding of how to identify and effectively manage these lesions is essential for the treatment of infertile patients. This review summarizes the critical and evolving subtle uterine lesions that clinicians frequently overlook during hysteroscopic procedures, highlighting the importance of accurate identification and its potential to improve reproductive outcomes.

METHODS

This literature review followed the Scale for the Quality Assessment of Narrative Review Articles (SANRA) guidelines. All articles discussing infertility-related issues and subtle lesions diagnosable with hysteroscopy were deemed eligible for inclusion.

RESULTS

We identified several subtle uterine lesions that are often overlooked during routine hysteroscopic evaluations but can adversely impact fertility. These include morphological abnormalities such as the T-shaped uterus, cystic lesions of the uterine wall, adenomyosis, cervicitis, cervical and tubal endometriosis, and endometrial conditions such as chronic endometritis, thin endometrium and endometrial calcifications.

CONCLUSIONS

Effective diagnosis and treatment of subtle uterine lesions is essential to fertility care. Knowing which lesions are commonly missed and understanding their endoscopic features and potential clinical implications, is crucial for enhancing the diagnostic capacity of hysteroscopy. This, in turn, may improve reproductive outcomes and the overall quality of care of infertile patients.

Extended intrauterine balloon stent use to prevent adhesion reformation after hysteroscopic adhesiolysis: a randomized trial

OBJECTIVE

To evaluate the efficacy and safety of retaining a balloon stent in the uterus for 8 weeks to prevent adhesion reformation after hysteroscopic adhesiolysis.

DESIGN

A single-center randomized controlled study.

SUBJECTS

A total of 160 women with severe intrauterine adhesions (American Fertility Society intrauterine adhesion scores ≥9 and European Society for Gynaecological Endoscopy grade ≥IV).

INTERVENTION

The participants were randomized 1:1 into two groups. In the study group, the balloon stent was left in place for 8 weeks after surgery and removed at the second-look hysteroscopy, with a third-look hysteroscopy performed 4 weeks later. In the control group, the balloon stent was maintained for 1 week, with participants undergoing second- and third-look hysteroscopies at 4 and 8 weeks postoperatively, respectively. Among 160 randomized patients, 136 (69 and 67 in the study and control groups, respectively) completed the study.

MAIN OUTCOME MEASURES

The primary outcome was the adhesion recurrence rate on third-look hysteroscopy.

RESULTS

On third-look hysteroscopy, the adhesion reformation was significantly lower in the study group than in the control group (17.4% vs. 43.3%; relative risk, 0.40; 95% confidence interval, 0.22-0.72; rate difference, -25.89%; 95% confidence interval, -40.75% to -11.04%). Additionally, the reduction in American Fertility Society adhesion scores was significantly larger in the study group than in the control group (10 vs. 7). The outcomes of the second- and third-look hysteroscopies were consistent. No safety concerns were observed regarding extended stent placement.

CONCLUSION

In this randomized controlled study, extending the balloon stent application to 8 weeks proved an effective and safe method for preventing adhesion reformation after hysteroscopic adhesiolysis for severe intrauterine adhesions.

Surgical parameters affecting procedure duration of hysteroscopic fibroid resection: results of a retrospective longitudinal study

PURPOSE

To identify and analyze the main surgical parameters affecting the operative time of hysteroscopic fibroid resection.

METHODS

This retrospective observational study included 65 cases of outpatient hysteroscopic fibroid resection performed between March 2021 and May 2023 in outpatient office setting. Patients aged 18-50 with various indications such as infertility, recurrent pregnancy loss, or abnormal uterine bleeding (AUB) were included. The operative time, fibroid size, FIGO classification, and fibroid localization were recorded and analyzed using ANOVA, Chi-square test, and linear regression models.

RESULTS

The average operative duration for all surgeries was 557.41 (± 449.52) s. A significant correlation between fibroid size and operative time was found in FIGO 0 (p = 0.0003) and FIGO 1 (p < 0.0001) subgroups, with weaker correlation in FIGO II (p = 0.039). FIGO I surgeries took significantly longer than FIGO 0 (p = 0.044), and fundal fibroids were associated with longer operative times compared to posterior fibroids (p = 0.0329).

CONCLUSION

The size and FIGO classification of fibroids significantly influence operative time during hysteroscopic resection. Smaller and more accessible fibroids (FIGO 0 and 1) are resected faster than those embedded deeper in the uterine wall (FIGO 2). Detailed preoperative evaluation of fibroid characteristics can better predict operative time, aiding in patient preparation and optimized analgesia and perioperative planning as well as optimizing the use of operating theater. Further studies with larger sample sizes are recommended to validate these findings and explore additional influencing factors.

A New Intrauterine Adhesions Classification System: The "Loddo Score"

Intrauterine adhesions (IUAs) and Asherman's syndrome (AS) have been recognized medical conditions since the late 19th and mid-20th centuries. Multiple classification systems have been proposed to better understand their severity and implications. This article aims to provide a comprehensive overview of the existing classifications for IUAs and introduces the Loddo scoring system, a novel approach for classifying these conditions. The Loddo scoring system is unique in amalgamating the strengths of previous classifications while emphasizing the importance of ultrasonographic endometrial thickness. This new system integrates various clinical parameters, offering a holistic representation of IUAs in clinical presentation and underlying structural changes. The Loddo scoring system presents a refined approach to understand and manage IUAs, providing a precise prognosis evaluation. Bridging the diagnostic and therapeutic divide seen in past systems, it offers promise for reshaping the landscape of diagnosis and treatment in women's health. Further research and validation are essential to assess its broad clinical applicability.

Non-invasive staging of endometrial fibrosis using diffusion-weighted imaging: a feasibility study

RESEARCH QUESTION

Can diffusion-weighted imaging (DWI) be used to stage endometrial fibrosis?

DESIGN

This prospective study included 41 healthy women, 30 patients with mild to moderate endometrial fibrosis (MMEF) and 102 patients with severe endometrial fibrosis (SEF). Endometrial thickness and DWI-related parameters, specifically the mean intensity (ADCROI and ADCVOI) and standard deviation (ADC-SDROI and ADC-SDVOI) of the endometrial apparent diffusion coefficient (ADC) values within a region of interest (ROI) on a mid-sagittal ADC map, and volume of interest (VOI) of the entire endometrium in the corpus uteri, were measured and analysed.

RESULTS

Endometrial thickness, endometrial ADCVOI and ADCROI were significantly higher in healthy women (11.7 mm, 1.31  ×  10-3 mm2/s and 1.36  ×  10-3 mm2/s) than MMEF patients (7.5 mm, P < 0.001; 1.23  ×  10-3 mm2/s, P = 0.001; and 1.26  ×  10-3 mm2/s, P = 0.003) and SEF patients (6.2 mm, 1.15  ×  10-3 mm2/s and 1.23  ×  10-3 mm2/s; all P < 0.001). Endometrial ADC-SDVOI and ADC-SDROI were significantly higher in SEF patients (0.24 and 0.24) than healthy women (0.16 and 0.13) and MMEF patients (0.18 and 0.16) (all P < 0.001). The degree of endometrial fibrosis was negatively correlated with endometrial thickness, endometrial ADCVOI and ADCROI (Spearman's rho = -0.662, -0.526 and -0.349) and positively correlated with endometrial ADC-SDVOI and ADC-SDROI (Spearman's rho 0.729 and 0.713) (all P < 0.001). Compared with endometrial thickness measurements, endometrial magnetic resonance imaging parameters, particularly DWI-related parameters, demonstrated excellent accuracy in distinguishing normal endometrium, MMEF and SEF (areas under the curve >0.800).

CONCLUSIONS

DWI is particularly effective for accurately staging the microstructural changes associated with endometrial fibrosis.

Effectiveness of degradable polymer film in the management of severe or moderate intrauterine adhesions (PREG-2): a randomized, double-blind, multicenter, stratified, superiority trial

OBJECTIVE

To study the effectiveness of a new intrauterine degradable polymer film (Womed Leaf) in the management of moderate to severe intrauterine adhesions (IUA).

DESIGN

PREG-2 study was a multicenter, double-blind, randomized, controlled, stratified, two-arm superiority clinical trial conducted in 16 centers in seven countries.

SETTING

Not applicable.

PATIENT(S)

Patients ≥18 years scheduled for hysteroscopic adhesiolysis because of symptomatic severe or moderate adhesions (according to American Fertility Society [AFS] IUA score) were considered eligible for the study.

INTERVENTION(S)

After adhesiolysis, patients were randomized at a 1:1 ratio to either have a Womed Leaf film inserted (intervention group) or not (control group).

MAIN OUTCOME MEASURE(S)

The primary effectiveness endpoint of the study was the change in AFS IUA score on second-look hysteroscopy (SLH), assessed by an independent evaluator, and compared with baseline. Information on the rate of no IUA and responder rate was collected as secondary effectiveness outcomes, while reported adverse events and patient-reported outcomes as safety and tolerability measures.

RESULT(S)

Between October 26, 2021, and September 28, 2023, a total of 160 women were randomized (Womed Leaf: n = 75 and controls: n = 85). The reduction in IUA AFS score on SLH was significantly higher in the intervention compared with the control group (mean 5.2 ± 2.8 vs. 4.2 ± 3.2). Similarly, the absence of adhesions on SLH was significantly higher in the intervention group (41% vs. 24%; odds ratio, 2.44; confidence interval, 1.161-5.116). None of the reported adverse events were serious or considered related to the device.

CONCLUSION(S)

Womed Leaf is effective and safe in the management of symptomatic severe or moderate IUAs.

CLINICAL TRIAL REGISTRATION NUMBER

Clinicaltrials.gov identifier: NCT04963179.

What is the impact of simulation on the learning of hysteroscopic skills by residents and medical students? A systematic review

INTRODUCTION

Hysteroscopy is a critical procedure in gynecology for diagnosing and managing intrauterine pathology. Traditional hands-on training faces ethical and safety challenges, leading to an increased reliance on simulation training. This review systematically assesses the effectiveness of hysteroscopic simulation training in enhancing the technical skills of obstetrics and gynecology residents and medical students.

METHODS

A PRISMA-guided literature search was conducted, covering English-language articles from January 2000 to December 2023. Studies were selected based on pre-defined criteria, focusing on the impact of simulation training on the targeted educational group. Metrics for evaluating skill improvement included machine-recorded metrics, Objective Structured Assessment of Technical Skills (OSATS), and global rating scales.

RESULTS

The review included nine studies with varied designs, demonstrating significant improvements in hysteroscopic skills following simulation training. Virtual reality (VR) simulators showed substantial benefits in skill acquisition, while physical simulators provided valuable tactile feedback. However, long-term skill retention and the impact on non-technical skills were not adequately assessed.

CONCLUSIONS

Simulation-based training effectively enhances hysteroscopic skills in medical students and residents. Further research is needed to explore long-term skill retention and the development of non-technical competencies. Robust studies, including randomized trials, are required for definitive validation.

Hysteroscopy: where did we start, and where are we now? The compelling story of what many considered the "Cinderella" of gynecological endoscopy

Hysteroscopy has truly revolutionized the field of diagnostic and operative gynecology. It is presently regarded as the gold standard method for both the diagnosis and treatment of intrauterine diseases and it has fundamentally altered the way gynecologists treat patients with such conditions. These pathologies can now be diagnosed and treated in an outpatient setting, thanks to technological advancements and instrument downsizing. Two hundred years of development and notable innovation are now reflected in the present hysteroscopic practice. This review attempts to trace the boundaries-pushing history of hysteroscopy by highlighting the advancements in technology and the therapeutic and diagnostic benefits offered by this groundbreaking approach.

Emergent Hysteroscopic Removal of Retained Products of Conception Following Laparoscopic Temporary Uterine Artery Ligation

Here, we describe two cases of retained products of conception (RPOC) that were successfully managed with hysteroscopic resection after laparoscopic temporary uterine artery ligation. Both patients were diagnosed with RPOC after early miscarriages. Case 1 was urgently admitted due to massive bleeding and underwent surgery following a blood transfusion. After laparoscopic temporary bilateral uterine artery ligation, the mass was hysteroscopically removed, and the ligation was subsequently released. The patient subsequently achieved an ongoing pregnancy. Case 2 underwent semi-emergency surgery due to intermittent bleeding. Initially, hysteroscopic surgery was planned. However, bleeding resulted in poor visualization of the operative field, and laparoscopic surgery was performed. In many previous reports of RPOC with heavy bleeding, uterine artery embolization was performed. However, there are concerns regarding the effect of a long-term reduction in uterine blood flow on fertility. Our method is not expected to decrease fertility because the ischemic effect is very short.

Locationally activated PRP via an injectable dual-network hydrogel for endometrial regeneration

Enhancing the effectiveness of platelet-rich plasma (PRP) for endometrial regeneration is challenging, due to its limited mechanical properties and burst release of growth factors. Here, we proposed an injectable interpenetrating dual-network hydrogel that can locationally activate PRP within the uterine cavity, sustained release growth factors and further address the insufficient therapeutic efficacy. Locational activation of PRP is achieved using the dual-network hydrogel. The phenylboronic acid (PBA) modified methacrylated hyaluronic acid (HAMA) dispersion chelates Ca2+ by carboxy groups and polyphenol groups, and in situ crosslinked with PRP-loaded polyvinyl alcohol (PVA) dispersion by dynamic borate ester bonds thus establishing the soft hydrogel. Subsequently, in situ photo-crosslinking technology is employed to enhance the mechanical performance of hydrogels by initiating free radical polymerization of carbon-carbon double bonds to form a dense network. The PRP-hydrogel significantly promoted the endometrial cell proliferation, exhibited strong pro-angiogenic effects, and down-regulated the expression of collagen deposition genes by inhibiting the TGF-β1-SMAD2/3 pathway in vitro. In vivo experiments using a rat intrauterine adhesion (IUA) model showed that the PRP-hydrogel significantly promoted endometrial regeneration and restored uterine functionality. Furthermore, rats treated with the PRP-hydrogel displayed an increase in the number of embryos, litter size, and birth rate, which was similar to normal rats. Overall, this injectable interpenetrating dual-network hydrogel, capable of locational activation of PRP, suggests a new therapeutic approach for endometrial repair.

Injectable, degradable, and mechanically adaptive hydrogel induced by L-serine and allyl-functionalized chitosan with platelet-rich plasma for treating intrauterine adhesions

The integration of barrier materials with pharmacological therapy is a promising strategy to treat intrauterine adhesions (IUAs). However, most of these materials are surgically implanted in a fixed shape and incongruence with the natural mechanical properties of the uterus, causing poor adaptability and significant discomfort to the patients. Herein, an injectable, biodegradable, and mechanically adaptive hydrogel loaded with platelet-rich plasma (PRP) is created by L‑serine and allyl functionalized chitosan (ACS) to achieve efficient, comfortable, and minimally invasive treatment of IUAs. L‑serine induces fast gelation and mechanical reinforcement of the hydrogel, while ACS introduces, imparting a good injectability and complaint yet strong feature to the hydrogel. This design enables the hydrogel to adapt to the complex geometry and match the mechanical properties of the uterine. Moreover, the hydrogel exhibits proper degradability, sustained growth factors (GFs) of PRP release ability, and good biocompatibility. Consequently, the hydrogel shows promising therapeutic efficacy by reducing collagen fiber deposition and facilitating endometrium cell proliferation, thereby restoring the fertility function of the uterus in an IUAs model of rats. Accordingly, the combination of L‑serine and ACS-induced hydrogel with such advantages holds great potential for treating IUAs. STATEMENT OF SIGNIFICANCE: This research introduces a breakthrough in the treatment of intrauterine adhesions (IUAs) with an injectable, biodegradable and mechanically adaptive hydrogel using L‑serine and allyl functionalized chitosan (ACS). Unlike traditional surgical treatments, this hydrogel uniquely conforms to the uterus's geometry and mechanical properties, offering a minimally invasive, comfortable, and more effective solution. The hydrogel is designed to release growth factors from platelet-rich plasma (PRP) sustainably, promoting tissue regeneration by enhancing collagen fiber deposition and endometrium cell proliferation. Demonstrated efficacy in a rat model of IUAs indicates its great potential to significantly improve fertility restoration treatments. This advancement represents a significant leap in reproductive medicine, promising to transform IUAs treatment with its innovative approach to achieving efficient, comfortable, and minimally invasive therapy.

Extended balloon stent placement for reducing intrauterine adhesion recurrence: a retrospective cohort study

RESEARCH QUESTION

What are the efficacy, safety and reproductive outcomes of intrauterine balloon stent placement for 4 or 6 weeks after hysteroscopic adhesiolysis?

DESIGN

This retrospective cohort study was conducted at a university-affiliated hospital, and included 155 women with moderate to severe intrauterine adhesions who underwent hysteroscopic adhesiolysis between March 2016 and December 2019. Participants were divided according to whether the heart-shaped balloon stent was left in place for 4 (group 1) or 6 (group 2) weeks after surgery. Stents removed at the second-look hysteroscopy 4 or 6 weeks after surgery were sent for culturing of common bacteria. The incidence of adhesion reformation, adhesion score reduction, bacterial colonization of the intrauterine balloon stent, live birth rate and time to live birth were analysed.

RESULTS

Group 2 had a significantly lower adhesion reformation rate (45.7% versus 28.2%, P = 0.024) and a more significant reduction in adhesion score (5.2 ± 2.1 versus 6.3 ± 2.2, P = 0.003) compared with group 1. However, no statistical difference was observed in the percentage of bacterial colonization of the intrauterine balloon stent (55.9% versus 66.7%, P = 0.174), live birth rate (52.4% versus 42.3%, P = 0.331) or time to live birth (hazard ratio 1.09, 95% confidence interval 0.60-1.96, P = 0.778) between the two groups.

CONCLUSIONS

Extending intrauterine balloon stent use from 4 to 6 weeks further reduces the adhesion reformation rate after hysteroscopic adhesiolysis in patients with moderate to severe intrauterine adhesion. No increase in bacterial colonization of the balloon stent was observed. Extending the duration of intrauterine balloon stent placement did not significantly affect live birth rates.

Efficacy and prognostic factors of combined administration of progesterone and estriol valerate tablets for preventing intrauterine adhesions in patients with early missed abortion following dilation and curettage

OBJECTIVE

To investigate the therapeutic efficacy and prognostic factors of combined administration of estriol valerate tablets and progesterone for the prevention of intrauterine adhesions (IUA) in patients with early missed abortion (EMA) after dilation and curettage.

METHODS

Clinical data of 120 EMA patients undergoing dilation and curettage at Ganzhou People's Hospital from July 2021 to June 2023 were collected for this retrospective study. The 120 enrolled patients were divided into two groups, with 70 patients in the study group receiving both estriol valerate tablets and progesterone for the prevention of IUA, and 50 in the control group undergoing no such treatments at all. The therapeutic efficacy of IUA prevention in patients was compared between the two groups. Subsequently, patients who developed IUA were categorized into the adhesion group (n = 23) and those who did not into the non-adhesion group (n = 97). The clinical data of patients were compared between the adhesion group and the non-adhesion group. Both univariate and multivariate logistic regression analyses were performed to identify the risk factors of IUA in patients with EMA after dilation and curettage. Receiver Operating Characteristic (ROC) curves were drawn to analyze the predictive value of independent risk factors for IUA in patients with EMA after dilation and curettage.

RESULTS

The study group showed a notably higher excellent and good response rate than the control group in IUA prevention (92.00% vs. 82.00%, P = 0.035). Logistic regression analysis revealed that a history of multiple previous miscarriages (P: 0.018; OR: 0.120; 95% CI: 0.02-2.119), relatively small endometrial volume (P: 0.001; OR: 0.026; 95% CI: 0.003-0.210), relatively thin endometrial thickness (P: 0.001; OR: 32.123; 95% CI: 4.339-237.807) and lack of preventive treatment (P: 0.051; OR: 0.211; 95% CI: 0.048-0.935) were independent risk factors for the occurrence of IUA in patients with EMA after dilation and curettage. ROC curve-based analysis showed that these risk factors; encompassing, the number of previous miscarriages, endometrial volume, endometrial thickness and preventive treatment, had a notably higher efficacy in jointly predicting the occurrence of IUA in EMA patients following dilation and curettage in comparison to an individual risk factor alone.

CONCLUSION

The occurrence of IUA in patients with EMA following dilation and curettage is influenced by several factors, including the number of previous miscarriages, the volume and thickness of the endometrium, and preventive treatments. To minimize the risk of IUA, it is crucial to implement proactive interventions prior to uterine surgeries. It was found that a combination therapy involving estriol valerate tablets and progesterone could effectively prevent the development of IUA in patients with EMA after dilation and curettage.

Pregnancy in Infertile Patient after Intrauterine Adhesiolysis by Multitherapeutic Strategy: A Case Report and Mini-review

Asherman's syndrome, characterized by intrauterine adhesions (IUAs), represents a significant challenge in the field of female infertility. Hysteroscopic adhesiolysis has emerged as the gold standard for both the diagnosis and treatment of Asherman's syndrome. Understanding the intricate relationship between Asherman's syndrome, uterine adhesiolysis, and infertility is crucial for guiding comprehensive and effective management strategies. The success of the treatment is contingent upon preventing adhesion recurrence, particularly in cases of severe IUAs. This is the first case, in which we employed a multifaceted preventive approach, utilizing hyaluronic gel, Foley balloon, hormonal therapy, and platelet-rich plasma, achieving successful pregnancy following embryo transfer despite the presence of severe IUAs. The patient, a 35-year-old female, underwent one cesarean section following in vitro fertilization and required dilation and curettage due to retained products of conception. The patient presented with oligohemorrhage, and the uterine lining was thin while using hormones for endometrial preparation. The diagnosis of severe IUAs was confirmed through ultrasound and hysteroscopic examination of the uterine cavity. The patient underwent hysteroscopic adhesiolysis with a preventive approach using a combination of methods. Subsequently, the patient underwent a second-look hysteroscopy to assess the uterine cavity and achieved successful embryo transfer. The patient carried the pregnancy to 38 weeks and underwent repeated cesarean section due to the vertex-vertex presentation of the twins.

Intrauterine chilled saline instillation reduces endometrial impairment on MRI after ultrasound-guided percutaneous microwave ablation of uterine adenomyosis

OBJECTIVE

To investigate whether intrauterine chilled saline can reduce endometrial impairment during US-guided percutaneous microwave ablation (PMWA) of adenomyosis.

METHODS

An open-label, randomized trial was conducted with sixty symptomatic adenomyosis patients who were randomly assigned (1:1) to receive PMWA treatment assisted by intrauterine saline instillation (study group) or traditional PMWA treatment alone (control group). The primary endpoint was endometrial perfusion impairment grade on post-ablation contrast-enhanced MRI. The secondary endpoints were endometrial dehydration grade, ablation rate, and intra-ablation discomfort.

RESULTS

The baseline characteristics of the two groups were similar. The incidence rates of endometrial perfusion impairment on MRI in the study and control groups were 6.7% (2/30) and 46.7% (14/30), respectively (p < 0.001). There were 28 (93.3%), 2 (6.7%), 0, and 0 patients in the study group and 16 (53.3%), 7 (23.3%), 5 (16.7%), and 2 (6.7%) in the control group (p < 0.001) who had grade 0, 1, 2, and 3 perfusion impairment, respectively. Additionally, there were 27 (90%), 3 (10%), and 0 patients in the study group and 19 (63.3%), 10 (33.3%), and 1 (3.3%) in the control group who had grade 0, 1, and 2 endometrial dehydration (p = 0.01). The ablation rates achieved in the study and control groups were 93.3 ± 17% (range: 69.2-139.6%) and 99.7 ± 15.7% (range: 71.5-129.8%), and they were not significantly different (p = 0.14). No significant difference was found in the intra-ablation discomfort.

CONCLUSION

Intrauterine chilled saline can effectively reduce endometrial impairment after PMWA treatment for adenomyosis.

CRITICAL RELEVANCE STATEMENT

This trial demonstrated that the instillation of intrauterine chilled saline reduced endometrial impairment on MRI during PMWA of adenomyosis. This approach allows more precise and safe ablation in clinical practice.

KEY POINTS

Endometrial impairment occurs in the PMWA treatment of adenomyosis. Intrauterine chilled saline can reduce endometrial impairment during PMWA for adenomyosis. An intrauterine catheter is a practical endometrial protecting method during thermal ablation.

TRIAL REGISTRATION

Chinese Clinical Trial Registry, ChiCTR2100053582. Registered 24 November 2021, www.chictr.org.cn/showproj.html?proj=141090 .

IL-4-induced M2 macrophages inhibit fibrosis of endometrial stromal cells

BACKGROUND

Intrauterine adhesions (IUA) refers to endometrial fibrosis caused by irreversible damage of the endometrial basal layer. As the key regulators in tissue repair, regeneration, and fibrosis, macrophages play an essential role in endometrial regeneration and repair during the normal menstrual cycle. However, the mechanism of macrophages involved in IUA remains unclear.

METHODS

In the late stages of proliferation, the endometrium was collected to make paraffin sections. HE and Masson staining were used to observing endometrial morphology and endometrial fibrosis. Immunohistochemistry and Western blotting were used to detect the expression level of fibrosis indexes COL1A1 and α-SMA. The macrophage infiltration was evaluated by immunohistochemistry for the expression levels of CD 206 and CD163. Next, we cultured the primary human endometrial stromal cells (HESCs), and then an IUA cell model was established with 10 ng/ml TGF-β1 for 72 h. THP 1 cells were differentiated by 100 ng/ml PMA into macrophages for 48 h, then macrophages were polarized to M2 macrophages by 20 ng/ml IL-4 for 24 h. The culture supernatants (M(IL-4) -S) of M2 macrophages were applied to the IUA cell model. The expression of fibrosis markers was then assessed using immunofluorescence and Western blotting.

RESULTS

The results show that Patients with IUA have fewer endometrial glands and significantly increased fibrosis levels. Moreover, the infiltration of CD206-positive (M2) macrophages was significantly reduced in IUA patients, and negatively correlated with the expression of endometrial fibrosis indexes α-SMA and COL1A1. In addition, the primary HESCs treated with 10 ng/ml TGF-β1 for 72 h were found to have significantly increased levels of fibrosis indexes. Furthermore, supernatants from IL4-induced M2 macrophages inhibit the TGF-β1-induced fibrosis of HESCs.

CONCLUSIONS

M2 macrophages may negatively regulate the expression of COL1A1 and α-SMA, inhibiting the TGF-β1-induced fibrosis of HESCs. Our study suggests that targeting macrophage phenotypes and promoting the polarization of macrophages to M2 may become a novel strategy for the clinical treatment of IUA.

Human amnion mesenchymal stem cells promote endometrial repair via paracrine, preferentially than transdifferentiation

BACKGROUND

Intrauterine adhesion (IUA) is one of the most severe causes of infertility in women of childbearing age with injured endometrium secondary to uterine performance. Stem cell therapy is effective in treating damaged endometrium. The current reports mainly focus on the therapeutic effects of stem cells through paracrine or transdifferentiation, respectively. This study investigates whether paracrine or transdifferentiation occurs preferentially in treating IUA.

METHODS

Human amniotic mesenchymal stem cells (hAMSCs) and transformed human endometrial stromal cells (THESCs) induced by transforming growth factor beta (TGF-β1) were co-cultured in vitro. The mRNA and protein expression levels of Fibronectin (FN), Collagen I, Cytokeratin19 (CK19), E-cadherin (E-cad) and Vimentin were detected by Quantitative real-time polymerase chain reaction (qPCR), Western blotting (WB) and Immunohistochemical staining (IHC). The Sprague-Dawley (SD) rats were used to establish the IUA model. hAMSCs, hAMSCs-conditional medium (hAMSCs-CM), and GFP-labeled hAMSCs were injected into intrauterine, respectively. The fibrotic area of the endometrium was evaluated by Masson staining. The number of endometrium glands was detected by hematoxylin and eosin (H&E). GFP-labeled hAMSCs were traced by immunofluorescence (IF). hAMSCs, combined with PPCNg (hAMSCs/PPCNg), were injected into the vagina, which was compared with intrauterine injection.

RESULTS

qPCR and WB revealed that FN and Collagen I levels in IUA-THESCs decreased significantly after co-culturing with hAMSCs. Moreover, CK19, E-cad, and Vimentin expressions in hAMSCs showed no significant difference after co-culture for 2 days. 6 days after co-culture, CK19, E-cad and Vimentin expressions in hAMSCs were significantly changed. Histological assays showed increased endometrial glands and a remarkable decrease in the fibrotic area in the hAMSCs and hAMSCs-CM groups. However, these changes were not statistically different between the two groups. In vivo, fluorescence imaging revealed that GFP-hAMSCs were localized in the endometrial stroma and gradually underwent apoptosis. The effect of hAMSCs by vaginal injection was comparable to that by intrauterine injection assessed by H&E staining, MASSON staining and IHC.

CONCLUSIONS

Our data demonstrated that hAMSCs promoted endometrial repair via paracrine, preferentially than transdifferentiation.

Intrauterine interventions options for preventing recurrence after hysteroscopic adhesiolysis: a systematic review and network meta-analysis of randomized controlled trials

PURPOSE

Recurrence of adhesions after hysteroscopic adhesiolysis is a challenging clinical problem without a unified management approach. Therefore, we conducted a network meta-analysis that considered both direct and indirect comparisons between interventions to identify optimal strategies for preventing recurrence.

METHODS

We searched for research trials published up to July 2023 from PubMed, Embase and the Cochrane Database. We selected randomized controlled trials comparing the use of different interventions for the prevention of adhesion recurrence, with no language or regional restrictions. We used random-effects models to assess odds ratios (OR) and mean difference (MD) with 95% confidence intervals (CI). Adverse events associated with the interventions were also assessed. This study was registered on PROSPERO, CRD42023449068.

RESULTS

Data from 21 randomized controlled trials involving 2406 patients were synthesized, including interventions with balloon, amnion, platelet-rich plasma (PRP), intrauterine device (IUD), hyaluronic acid (HA), platelet-rich fibrin (PRF), and granulocyte colony-stimulating factor (G-CSF). The top 5 interventions for change in AFS scores were: PRP + Balloon (MD = 5.44; 95% CI, 2.63-8.25), Amnion + Balloon (MD = 5.08; 95% CI, 2.71-7.44), IUD + Balloon (MD = 4.89; 95% CI, 2.49-7.30), HA + Balloon (MD = 3.80; 95% CI, 1.78-5.82), and G-CSF + Balloon (MD = 3.84; 95% CI, 1.05-6.63). There were no statistically significant differences between interventions in the recurrence rate of moderate-to-severe uterine adhesions and the clinical pregnancy rate. Most interventions were safe.

CONCLUSIONS

To our knowledge, this is the most comprehensive network meta-analysis to date of interventions for preventing postoperative intrauterine adhesion recurrence. Our results indicate that PRP + Balloon seems to be the most effective approach.

Intrauterine adhesion

Intrauterine adhesions (IUA) occurred in the reproductive-age women are a big economic and health problem, resulting in severe impairment of social, psychological and physical function of the female genital organs. IUA-related symptoms or signs are varied greatly from free of symptoms or ambiguous symptoms (an incidental finding during the intervention) to ceased menstruation and loss of fecundability. The underlying pathophysiology is not completely understood, but intrauterine damage with broken basal layers of the endometrium formatting scar tissues or fibrosis in the endometrium with subsequently causing partial or complete occlusion of the uterine cavity may be a well-accepted hypothesis. Previously, infection is the most common cause to develop IUA, but now, intrauterine surgery may be a critical cause contributing to the majority of cases of IUA. In the current review, update information about the etiology, epidemiology, pathophysiology, sequelae and prevention of IUA will be renewed. We emphasize the importance of awareness of IUA, and primary prevention should be considered in the routine clinical practice if intrauterine surgery has been applied, based on uncertainty of ideal treatment for the established IUA and unpredictable outcomes after IUA treatment. So far, evidence supports that hyaluronic acid with/without other strategy is the most valuable and effective method to reduce the formation and re-formation of IUA as well as to achieve the best fertility outcome.

Fertility and anatomical outcomes following hysteroscopic adhesiolysis: An 11-year retrospective cohort study to validate a new classification system for intrauterine adhesions (Urman-Vitale Classification System)

OBJECTIVE

To propose a new classification system (Urman-Vitale Classification System) for intrauterine adhesions (IUAs) and to evaluate anatomical and fertility outcomes after hysteroscopic adhesiolysis accordingly.

METHODS

A retrospective analysis of consecutive patients treated over 11 years by a single operator in a tertiary care hospital. Women with sonographic suspicion of IUAs were scheduled for hysterosalpingography (HSG) and hysteroscopy for confirmation and treatment. IUAs were divided into five classes according to symptoms, ultrasound, HSG findings, and postsurgical hysteroscopic appearance. Hysteroscopic adhesiolysis was performed using a bipolar cutting electrode in an office setting. Evaluated outcomes were restoration of the uterine cavity, clinical pregnancy, pregnancy loss, and live birth rates.

RESULTS

A total of 227 patients (479 procedures) were included. Mean number of hysteroscopies increased in frequency with class of adhesions from Class 1 to Class 5 (1.0 ± 0.2 vs 2.3 ± 0.5; P = 0.001). Full restoration of the cavity was achieved in 100% of patients with Class 1 compared with 18.5% for Class 5 (43/43 vs 5/27; P = 0.001). Clinical pregnancy (Class 1 vs Class 4: P = 0.034; 1 vs 5: P = 0.006; 2 vs 5: P = 0.024) and live birth (Class 1 vs Class 4: P = 0.001; 1 vs 5: P = 0.006; 2 vs 4: P = 0.007; 2 vs 5: P = 0.0208) rates decreased with increasing severity of IUAs. Pregnancy loss rate was related to IUA severity (Class 1 vs Class 4: P = 0.012; 1 vs 5: P = 0.003: 2 vs 4: P = 0.014; 2 vs 5: P = 0.021).

CONCLUSION

A classification based on symptoms, imaging findings, and postsurgical macroscopic appearance of the uterine cavity could be useful in predicting prognosis and fertility in women with IUAs.

Short-term reproductive outcomes analysis and prediction of the modified uterine stent treatment for mild to moderate intrauterine adhesions: experience at a single institution

BACKGROUND

To evaluate the efficacy of modified uterine stent in the treatment of mild-to-moderate intrauterine adhesions and explore the relative indicators affecting prognosis prediction.

METHODS

A total of 115 patients with mild-to-moderate intrauterine adhesions received a modified uterine stent placement after hysteroscopy adhesiolysis. The second-look hysteroscopy operated after 3 months surgery, and the third-look hysteroscopy operated after 6 months surgery if necessary. The stent was removed when the cavity shape was repaired, then the reproductive outcomes were followed up one year.

RESULTS

Menstrual blood volume, endometrial thickness and volume had increased significantly after 3 months surgery. The rates of cavity repaired were 86.96% (100/115) after 3 months surgery and 100% (115/115) after 6 months surgery cumulatively. Endometrial thickness after 3-months surgery was positively associated with uterine cavity shape repaired (P<0.01). The receive operating characteristic (ROC) curve showed the rate of uterine cavity shape repaired predicted by the model was 0.92, based on the endometrial thickness after 3-months surgery. The rate of pregnancy was 86.09% (99/115) in one year, while the rate of miscarriage accounted for 26.26% (26/99). The median time interval between stent removal and subsequent conception was 3 months. It showed adhesion recurrence was the risk factor for subsequent pregnancy (P<0.01).

CONCLUSIONS

A modified uterine stent placement under hysteroscopy was an effective approach for mild-to-moderate intrauterine adhesions, which is easy to operate and worthy for clinical promotion. Endometrial thickness measured by ultrasonography probably has predictive value in adhesion recurrence and subsequent pregnancy.

TRIAL REGISTRATION

ChiCTR2100051524. Date of registration (retrospectively registered): 26/09/2021.

Human umbilical cord-derived mesenchymal stem cells and auto-crosslinked hyaluronic acid gel complex for treatment of intrauterine adhesion

OBJECTIVE

The purpose of this study was to explore the therapeutic characteristics of mesenchymal stem cells generated from human umbilical cord (hUC-MSCs) when utilized in conjunction with auto-crosslinked hyaluronic acid gel (HA-gel) for the management of intrauterine adhesion (IUA). The goal was to see how this novel therapy could enhance healing and improve outcomes for IUA patients.

METHODS

In this study, models of intrauterine adhesion (IUA) were established in Sprague-Dawley (SD) rats, which were then organized and divided into hUC-MSCs groups. The groups involved: hUC-MSCs/HA-gel group, control group, and HA-gel group. Following treatment, the researchers examined the uterine cavities and performed detailed analyses of the endometrial tissues to determine the effectiveness of the interventions.

RESULTS

The results indicated that in comparison with to the control group, both HA-gel, hUC-MSCs, and hUC-MSCs/HA-gel groups showed partial repair of IUA. However, in a more notable fashion transplantation of hUC-MSCs/HA-gel complex demonstrated significant dual repair effects. Significant outcomes were observed in the group treated with hUC-MSCs and HA-gel, they showed thicker endometrial layers, less fibrotic tissue, and a higher number of endometrial glands. This treatment strategy also resulted in a significant improvement in fertility restoration, indicating a profound therapeutic effect.

CONCLUSIONS

The findings of this study suggest that both HA-gel, hUC-MSCs, and hUC-MSCs/HA-gel complexes have the potential for partial repair of IUA and fertility restoration caused by endometrium mechanical injury. Nonetheless, the transplantation of the hUC-MSCs/HA-gel complex displayed exceptional dual healing effects, combining effective anti-adhesive properties with endometrial regeneration stimuli.

Uterine cervical stenosis: from classification to advances in management. Overcoming the obstacles to access the uterine cavity

BACKGROUND

To date hysteroscopy is the gold standard technique for the evaluation and management of intrauterine pathologies. The cervical canal represents the access route to the uterine cavity. The presence of cervical stenosis often makes entry into the uterine cavity difficult and occasionally impossible. Cervical stenosis has a multifactorial etiology. It is the result of adhesion processes that can lead to the narrowing or total obliteration of the cervical canal.

PURPOSE

In this review, we summarize the scientific evidence about cervical stenosis, aiming to identify the best strategy to overcome this challenging condition.

METHODS

The literature review followed the scale for the quality assessment of narrative review articles (SANRA). All articles describing the hysteroscopic management of cervical stenosis were considered eligible. Only original papers that reported data on the topic were included.

RESULTS

Various strategies have been proposed to address cervical stenosis, including surgical and non-surgical methods. Medical treatments such as the preprocedural use of cervical-ripening agents or osmotic dilators have been explored. Surgical options include the use of cervical dilators and hysteroscopic treatments.

CONCLUSIONS

Cervical stenosis can present challenges in achieving successful intrauterine procedures. Operative hysteroscopy has been shown to have the highest success rate, particularly in cases of severe cervical stenosis, and is currently considered the gold standard for managing this condition. Despite the availability of miniaturized instruments that have made the management of cervical stenosis more feasible, it remains a complex task, even for experienced hysteroscopists.

Long noncoding RNAs regulate intrauterine adhesion and cervical cancer development and progression

Intrauterine adhesion, one of reproductive system diseases in females, is developed due to endometrial injury, such as infection, trauma, uterine congenital abnormalities and uterine curettage. Intrauterine adhesion affects female infertility and causes several complications, including amenorrhoea, hypomenorrhoea, and recurrent abortion. Cervical cancer is one of the common gynecological tumors and the fourth leading cancer-related death in women worldwide. Although the treatments of cervical cancer have been improved, the advanced cervical cancer patients have a low survival rate due to tumor recurrence and metastasis. The molecular mechanisms of intrauterine adhesion and cervical tumorigenesis have not been fully elucidated. In recent years, long noncoding RNAs (lncRNAs) have been known to participate in intrauterine adhesion and cervical carcinogenesis. Therefore, in this review, we will summarize the role of lncRNAs in regulation of intrauterine adhesion development and progression. Moreover, we will discuss the several lncRNAs in control of cervical oncogenesis and progression. Furthermore, we highlight that targeting lncRNAs could be used for treatment of intrauterine adhesion and cervical cancer.

Nano-biomaterial Fibrinogen/P(LLA-CL) for prevention of intrauterine adhesion and restoration of fertility

Endometrial damage resulting from surgical procedures is a significant cause of intrauterine adhesion, thin endometrium, and subsequent miscarriage and infertility. Unfortunately, there is currently no effective clinical solution to promote endometrial regeneration after severe injury. In this study, we combined fibrinogen (Fg) and P(LLA-CL) by electrostatic spinning to form a stable nano-biomaterial Fg/P(LLA-CL), which can promote endometrial regeneration. After inducing physical injury to rat endometrium, we found that Fg/P(LLA-CL) membranes placed in the uterine cavities increased endometrial thickness and the number of glands after injury, while reducing the area of endometrial fibrosis. In addition, Fg/P(LLA-CL) increased neovascularization and decreased COL1A1 deposition. The expression of TGF-β1, a cytokine that promotes fibrosis, was down-regulated in the early stage of injury. Finally, fertility assays confirmed that Fg/P(LLA-CL) improved the pregnancy rate in rats with endometrial injury, and its safety was verified by blood tests and pathological examination of heart, liver, spleen, lung, and kidney. Therefore, Fg/P(LLA-CL) shows great potential as a safe and nontoxic biomaterial for endometrial regeneration, ultimately improving pregnancy outcomes in patients with intrauterine adhesion.

Endometrium procurement and transplantation restores fertility in rats

RESEARCH QUESTION

Can rat endometrium be successfully procured and transplanted, and can a similar method be used to procure human endometrium?

DESIGN

Rat endometrium was procured using an endometrium stripping method and transplanted into female Sprague-Dawley rats. Macroscopic and histological changes, endometrial receptivity-related protein concentrations and fertility were assessed. Additionally, a preliminary experiment was conducted to procure human endometrium using a similar method.

RESULTS

Endometrium was successfully procured from both rats and humans, which contained intact endometrium and parts of the adjacent inner annulus myometrium. Endometrium auto-transplantation was conducted in rats and the procedure lasted a total of 41.3 ± 5.7 min with a mean blood loss of 0.09 ± 0.04 g. The transplanted endometrium survived well, but a fibrotic zone formed between the transplant and recipient tissue. Compared with sham rats, those with endometrium transplantation had similar endometrial thickness and endometrial gland numbers but reduced vascular density at 8 weeks after surgery. Endometrium transplantation also retained expression of the endometrial receptivity-related proteins leukaemia inhibitory factor and vascular endothelial growth factor. In contrast to non-pregnancy in the stripped horn, a mean of 5.0 ± 2.7 fetuses developed in the transplanted horn, and full-term live fetuses were conceived in the horns with transplanted endometrium.

CONCLUSIONS

Endometrium procurement by stripping method can obtain an intact and functional endometrium, and endometrium transplantation can reconstruct the uterine cavity and restore fertility in rats.

Guideline No. 446: Hysteroscopic Surgery in Fertility Therapy

OBJECTIVE

To evaluate the indications, benefits, and risks of hysteroscopy in the management of patients with infertility and provide guidance to gynaecologists who manage common conditions in these patients.

TARGET POPULATION

Patients with infertility (inability to conceive after 12 months of unprotected intercourse) undergoing investigation and treatment.

BENEFITS, HARMS, AND COSTS

Hysteroscopic surgery can be used to diagnose the etiology of infertility and improve fertility treatment outcomes. All surgery has risks and associated complications. Hysteroscopic surgery may not always improve fertility outcomes. All procedures have costs, which are borne either by the patient or their health insurance provider.

EVIDENCE

We searched English-language articles from January 2010 to May 2021 in PubMed/MEDLINE, Embase, Science Direct, Scopus, and Cochrane Library (see Appendix B for MeSH search terms).

VALIDATION METHODS

The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See Appendix A (Tables A1 for definitions and A2 for interpretations of strong and conditional recommendations).

INTENDED AUDIENCE

Gynaecologists who manage common conditions in patients with infertility.

TWEETABLE ABSTRACT

When offering hysteroscopic surgery to patients with infertility, ensure it improves the live birth rate.

SUMMARY STATEMENTS

RECOMMENDATIONS.

Mesenchymal Stem Cell Derived Exosomes Repair Uterine Injury by Targeting Transforming Growth Factor-β Signaling

Intrauterine adhesions (IUA) refer to adhesions within the uterine cavity and cervix caused by injuries from uterine surgery. They are a significant cause of female infertility. Exosomes derived from mesenchymal stem cells (MSCs) play an active role in the treatment of IUA. However, the mechanism by which they reduce fibrosis in the damaged endometrium remains unclear. In this paper, we demonstrate that exosomes derived from placental mesenchymal stem cells (PMSCs) can restore uterine functions and improve the fertility rate of injured animals. This is achieved by promoting cell proliferation, increasing endometrial thickness, and reversing fibrosis. Regarding the molecular mechanism behind these therapeutic effects, we identify three specific miRNAs, namely, miR-125b-5p, miR-30c-5p, and miR-23a-3p, enriched in PMSC-exosomes, as the key players in the treatment of IUA. Specifically, miR-125b-5p/miR-30c-5p and miR-23a-3p inhibit the expression of smad2 and smad3 by targeting their 3'-untranslated regions, resulting in the downregulation of the transforming growth factor-β (TGF-β)/smad signaling pathway and the reversal of fibrosis. Notably, the safety of PMSC-exosomes in intrauterine treatment was also been confirmed. In conclusion, we illustrate that exosomes derived from PMSCs possess the capability to repair endometrial damage and enhance fertility in injured animals by regulating the TGF-β/smad pathway via miR-125b-5p, miR-30c-5p, and miR-23a-3p. This provides insights into the precision treatment of IUA through exosome-based cell-free therapy.

Effect of autologous bone marrow stem cells-scaffold transplantation on the ongoing pregnancy rate in intrauterine adhesion women: a randomized, controlled trial

Intrauterine adhesion is a major cause of female reproductive disorders. Although we and others uncontrolled pilot studies showed that treatment with autologous bone marrow stem cells made a few patients with severe intrauterine adhesion obtain live birth, no large sample randomized controlled studies on this therapeutic strategy in such patients have been reported so far. To verify if the therapy of autologous bone marrow stem cells-scaffold is superior to traditional treatment in moderate to severe intrauterine adhesion patients in increasing their ongoing pregnancy rate, we conducted this randomized controlled clinical trial. Totally 195 participants with moderate to severe intrauterine adhesion were screened and 152 of them were randomly assigned in a 1:1 ratio to either group with autologous bone marrow stem cells-scaffold plus Foley balloon catheter or group with only Foley balloon catheter (control group) from February 2016 to January 2020. The per-protocol analysis included 140 participants: 72 in bone marrow stem cells-scaffold group and 68 in control group. The ongoing pregnancy occurred in 45/72 (62.5%) participants in the bone marrow stem cells-scaffold group which was significantly higher than that in the control group (28/68, 41.2%) (RR=1.52, 95%CI 1.08-2.12, P=0.012). The situation was similar in live birth rate (bone marrow stem cells-scaffold group 56.9% (41/72) vs. control group 38.2% (26/68), RR=1.49, 95%CI 1.04-2.14, P=0.027). Compared with control group, participants in bone marrow stem cells-scaffold group showed more menstrual blood volume in the 3rd and 6th cycles and maximal endometrial thickness in the 6th cycle after hysteroscopic adhesiolysis. The incidence of mild placenta accrete was increased in bone marrow stem cells-scaffold group and no severe adverse effects were observed. In conclusion, transplantation of bone marrow stem cells-scaffold into uterine cavities of the participants with moderate to severe intrauterine adhesion increased their ongoing pregnancy and live birth rates, and this therapy was relatively safe.

Comparison of clinical outcomes and second-look hysteroscopy of the complete and incomplete septate uterus after hysteroscopic septoplasty

PURPOSE

Septate uterus is the most common congenital uterine malformation. This retrospective cohort study compared clinical outcomes and second-look hysteroscopy findings in patients with complete and incomplete septate uteri after septoplasty.

METHODS

We reviewed the medical records of patients with a septate uterus who underwent hysteroscopic septoplasty and second-look hysteroscopy at the West China Second University Hospital between September 2013 and September 2021. Information regarding pregnancy outcomes was collected through telephone interviews. The independent samples t-test, Mann-Whitney U test, Pearson's chi-square test, and Fisher's exact test were used to explore the differences between the complete and incomplete septate uterus groups.

RESULTS

A total of 64 patients were enrolled in this study. There was no significant difference in intrauterine adhesion (IUA) rates (16.7% and 32.1%), pregnancy rates (44.1% and 42.9%), term delivery rates (35.3% and 32.1%), premature delivery rates (2.9% and 0), placenta previa rates (2.9% and 3.6%), placenta implantation/adhesion rates (5.9% and 3.6%), and premature rupture of membranes rates (2.9% and 0) between the complete and the incomplete group after hysteroscopic septoplasty (P > 0.05). Endometrial polyps in the septate uterus were common, with an incidence of 33.3% and 25% in the complete and incomplete groups, respectively (P > 0.05).

CONCLUSION

The pregnancy outcomes of complete and incomplete septate uteri after hysteroscopic septoplasty were similar. There was no statistical difference in IUAs after surgery. Different treatment strategies may not be required for complete or incomplete septate uteri.

Hysteroscopy-assisted suction curettage for early pregnancy loss: does it reduce retained products of conception and postoperative intrauterine adhesions?

OBJECTIVE

To describe the feasibility of hysteroscopy-assisted suction curettage for early pregnancy loss and to investigate whether it reduces the rates of retained products of conception (RPOC) and intrauterine adhesions (IUA).

DESIGN

Prospective single-arm cohort study.

SETTING

University-affiliated Department of Obstetrics and Gynecology.

PATIENTS

Women admitted for surgical evacuation of early pregnancy loss were invited to participate in the study.

INTERVENTION

Vaginal misoprostol was administered for cervical ripening preoperatively. Under general anesthesia, a diagnostic hysteroscopy was performed to identify the pregnancy's implantation wall, followed by ultrasound-guided suction and curettage directed to the implantation wall, and then diagnostic hysteroscopy to verify complete uterine cavity emptying. Postoperative IUA were evaluated by follow-up office hysteroscopy.

MAIN OUTCOME MEASURE

Identification of the pregnancy's implantation wall on hysteroscopy, and intra-, and postoperative complications associated with the procedure. The evaluation of postoperative IUA was limited due to the COVID-19 pandemic-related restrictions on elective procedures.

RESULTS

Forty patients were included in the study group. Their mean age was 34.0 ± 6.6 years, and their mean gestational age was 8.9 ± 1.6 weeks. The implantation wall was clearly visualized on hysteroscopy in 33 out of 40 cases (82.5%). The mean operative time was 17.2 ± 8.8 min, and no intraoperative complications occurred. Suspected RPOC were diagnosed intraoperatively by hysteroscopy and removed in 4 cases, and the histologic examination confirmed the presence of RPOC in three of them. Follow-up office hysteroscopy was performed in nine women: mild IUA was diagnosed in one case and a normal cavity was confirmed in eight cases. A new pregnancy was reported at the time of follow-up in 15 cases, while 12 women declined to attend the follow-up hysteroscopy and four were lost to follow-up.

CONCLUSIONS

Hysteroscopy-assisted suction curettage for early pregnancy loss is a safe, short, and inexpensive procedure, which allows the identification of the pregnancy's wall in most cases and may reduce the rates of RPOC.

Comparison of Secondary Prevention Following Hysteroscopic Adhesiolysis in the Improvement of Reproductive Outcomes: A Retrospective Cohort Study

Intrauterine adhesion (IUA) is primarily caused by endometrial injury, and hysteroscopic adhesiolysis is presently the main treatment. However, postoperative recurrence and poor pregnancy outcomes remain intractable. In this study, we aim to assess the effects of different treatments on clinical symptoms and reproductive outcomes in IUA. This retrospective study was conducted in a tertiary university-affiliated women's hospital. The study included 1449 consecutive women who desired to have a baby and were diagnosed with IUA through hysteroscopy from January 2016 to December 2021. Patients with IUA underwent hysteroscopic electric resection (E) or cold scissors separation (C), as well as hormone therapy and one or both of the following secondary prevention measures: intrauterine devices (IUD) and hyaluronic acid gel (HA). The pregnancy rate (PR) was significantly higher in the E + IUD + HA (90.23% CI: 85.82, 94.64%) than in other groups (p = 0.000) groups. The rates of full-term birth (p = 0.000) and live birth (p = 0.000) were significantly higher in the E + IUD + HA (67.82% and 68.97%, respectively) and E + HA (62.41% and 63.91%, respectively) groups. Multivariate logistic regression analysis revealed a significantly higher PR in women who received second-look hysteroscopy (OR 1.571, 95% CI: 1.009-2.224, p = 0.013) and E + IUD + HA (OR 4.772, 95% CI: 2.534-8.987, p = 0.000). Combining hysteroscopic electric resection with IUDs and HA gel could prevent adhesion recurrence and improve postoperative pregnancy and live birth outcomes in IUA. Furthermore, postoperative second-look hysteroscopy may increase the PR and shorten the waiting period.

Diode laser use in hysteroscopic surgery: current status and future perspectives

Recent advances in surgical technology and innovative techniques have revolutionized surgical gynecology, including transcervical hysteroscopic procedures. Surgical lasers (Nd-Yag, Argon, diode, and CO2 lasers) have been promoted to remove a variety of gynecological pathologies. For hysteroscopic surgery, the diode laser represents the most versatile and feasible innovation, with simultaneous cut and coagulate action, providing improved hemostasis compared with CO2 laser. The newest diode laser devices exhibit increased power and a dual wavelength, to work precisely with reduced thermal dispersion and minimal damage to surrounding tissues. Their efficacy and safety have been validated both in the hospitals as well as in the office setting. Updated evidence reports that several hysteroscopic procedures, including endometrial polypectomies, myomectomies and metroplasties can be successfully performed with a diode laser. Therefore, this review aimed to give a deeper understanding of the role of laser energy in gynecology and subsequently in hysteroscopy in order to safely incorporate this technology into clinical practice.

The use of intrauterine balloon therapy in reproductive medicine and surgery: a guidance for practice

The use of balloon therapy in obstetric practice especially in postpartum haemorrhage (PPH) is well established and has recently been reviewed. However, little attention has been drawn regarding the use of intrauterine balloon (IUB) in gynaecological practice. This study focuses on the various usage of IUB in gynaecological practice. An electronic literature search through Medline, EMBASE and Clinicaltrial.gov from inception to August 2022 was conducted. The study focuses on the three following areas: (1) Indications: prevention and removal of intrauterine adhesions, management of ectopic pregnancy, facilitation of endoscopic surgery and other clinical usages; (2) Practical aspects of balloon therapy including ultrasound guidance, choice of balloon, inflation volume, duration of balloon therapy; and (3) Potential complications including pain, infection, uterine rupture and how they can be avoided. IUB therapy is a simple, inexpensive and effective method that can be applied in various gynaecological conditions ranging from IUA to intrauterine haemorrhage. Complications are rare, but in most cases can be avoided with correct use.

Etiology, Risk Factors, and Management of Asherman Syndrome

Asherman syndrome is characterized by a triad of symptoms including pain, menstrual abnormalities, and infertility and is a result of intrauterine scar tissue after instrumentation of a gravid uterus. Saline sonohysterogram is typically the most sensitive diagnostic tool; however, hysteroscopy is the criterion standard for diagnosis. Treatment includes hysteroscopic-guided lysis of adhesion, with restoration of the anatomy of the uterine cavity. Several modalities are used in an attempt to reduce the reformation of scar tissue after surgery; however, there is no consensus on the ideal method. Stem cells and platelet-rich plasma are being explored as means of regenerative therapy for the endometrium, but data remain limited. At present, most individuals can have restoration of menstrual function; however, lower pregnancy rates and obstetric complications are not uncommon. These complications are worse for patients with a higher grade of disease. Efforts are needed in standardizing classification, reducing uterine instrumentation of the gravid uterus, and referring patients to health care professionals with clinical expertise in this area.

Integrative analysis links autophagy to intrauterine adhesion and establishes autophagy-related circRNA-miRNA-mRNA regulatory network

BACKGROUND

Intrauterine adhesion (IUA) is a troublesome complication characterized with endometrial fibrosis after endometrial trauma. Increasing number of investigations focused on autophagy and non-coding RNA in the pathogenesis of uterine adhesion, but the underlying mechanism needs to be further studied.

METHODS

mRNA expression profile and miRNA expression profile were obtained from Gene Expression Omnibus database. The autophagy related genes were low. Venn diagram was used to set the intersection of autophagy genes and DEGs to obtain ARDEGs. Circbank was used to select hub autophagy-related circRNAs based on ARDEMs. Then, the differentially expressed autophagy-related genes, miRNAs and circRNAs were analyzed by functional enrichment analysis, and protein-protein interaction network analysis. Finally, the expression levels of hub circRNAs and hub miRNAs were validated through RT-PCR of clinical intrauterine adhesion samples. In vitro experiments were investigated to explore the effect of hub ARCs on cell autophagy, myofibroblast transformation and collagen deposition.

RESULTS

11 autophagy-related differentially expressed genes (ARDEGs) and 41 differentially expressed miRNA (ARDEMs) compared between normal tissues and IUA were identified. Subsequently, the autophagy-related miRNA-mRNA network was constructed and hub ARDEMs were selected. Furthermore, the autophagy-related circRNA-miRNA-mRNA network was established. According to the ranking of number of regulated ARDEMs, hsa-circ-0047959, hsa-circ-0032438, hsa-circ-0047301 were regarded as the hub ARCs. In comparison of normal endometrial tissue, all three hub ARCs were upregulated in IUA tissue. All hub ARDEMs were downregulated except has-miR-320c.

CONCLUSIONS

In the current study, we firstly constructed autophagy-related circRNA-miRNA-mRNA regulatory network and identified hub ARCs and ARDEMs had not been reported in IUA.

Update on antiadhesion barriers and therapeutics in gynecological surgery

PURPOSE OF REVIEW

Postoperative adhesions remain a clinical challenge to both patients and providers, as they are associated with significant complications and a high economic burden. This article provides a clinical review of currently available antiadhesive agents and promising new therapies that have advanced past animal studies.

RECENT FINDINGS

Several agents have been investigated on their ability to reduce adhesion formation; however, there is no widely acceptable option. The few available interventions are barrier agents and while low-quality evidence suggests that they may be more effective than no treatment, there is no general agreement on their overall efficacy. There is an abundance of research on new solutions; however, their clinical efficacy is yet to be determined.

SUMMARY

Although a wide range of therapeutics have been investigated, majority are halted in animal models with only a select few being studied in humans and ultimately available in the market. Many agents have shown effectiveness in reducing adhesion formation, however, that has not been translated to improvement in clinically relevant outcomes; hence the need for high-quality large randomized trials.