Optimal waiting period for fresh embryo transfer after hysteroscopic adhesiolysis: a retrospective cohort study

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.

Optimal timing to transfer embryos for women who underwent hysteroscopy: a systematic review and meta-analysis

OBJECTIVE

This study aimed to investigate the optimal time interval between hysteroscopy and embryo transfer.

METHODS

Electronic databases including PubMed, Embase, and Cochrane Library were searched up to Jul 2021. Two authors selected the articles independently and extracted data regarding study characteristics, quality, and results. A random-effect model was employed, and summary risk ratios (RR) at 95% confidence intervals (CI) were calculated.

RESULTS

A total of 2123 patients from 5 studies were included. Pooled results showed that no significant differences for clinical pregnancy rates within 50-day and 90-day time interval comparison groups (RR = 0.83, 95% CI 0.61-1.11, P = 0.21; and RR = 0.91, 95% CI 0.74-1.12, P = 0.38, respectively), whereas clinical pregnancy rate was significantly increased in patients with a waiting interval of ≤ 120 days (RR = 0.75, 95% CI 0.61-0.93, P = 0.009). Subgroup analysis demonstrated that transferring embryos within 50 days for patients with normal uterine cavities was associated with a higher live birth rate (RR = 0.71, 95% CI 0.54-0.95, P = 0.02).

CONCLUSION

This meta-analysis identified that performing embryo transfer within 120 days for patients who underwent adhesiolysis and polypectomy within 50 days for patients who underwent diagnostic hysteroscopy was associated with superior outcomes, respectively. These findings may provide evidence to guide clinical decisions for reproductive clinicians. The conclusions might be limited by the small publication numbers. Further studies with a larger sample size were recommended.

Pregnancy and perinatal outcomes in pregnancies following frozen embryo transfer (FET) after transcervical resection of adhesions (TCRA): A retrospective cohort study with propensity score matching analysis

OBJECTIVE

To compare the pregnancy and perinatal outcomes of frozen-thawed embryo transfer (FET) in patients following transcervical resection of adhesions (TCRA) versus patients with normal uterine morphology, and to investigate the factors influencing pregnancy outcomes in patients undergoing FET after TCRA.

METHODS

We retrospectively analyzed FET cycles from September 2014 to September 2023, comparing patients with normal uterine morphology to those with intrauterine adhesions (IUAs) treated with TCRA. Propensity score matching (PSM) adjusted for confounding factors. LASSO regression and multivariate logistic regression identified predictors of outcomes, which were visually represented in nomograms. Model performance was assessed using calibration curves, ROC curves, and DCA, with bootstrap method for internal validation.

RESULTS

Post-PSM analysis showed higher live birth rates in patients with normal uterine morphology after clinical pregnancy (75.1% vs. 61.7%, P < 0.001). No significant differences were noted in clinical pregnancy rates and perinatal outcomes between the groups. Factors influencing clinical pregnancy in FET after TCRA included basal progesterone levels, endometrial thickness, parity, infertility cause, embryo stage at transfer, number and quality of embryos transferred, IUA severity, and TCRA surgical procedures. Body mass index, basal LH levels, and day 14 HCG levels post-embryo transfer were determinants of live birth outcome.

CONCLUSION

FET cycles following TCRA showed a lower rate of successful live births, but TCRA did not increase adverse perinatal outcome risks. Our study introduces an innovative predictive model for clinical pregnancy and live birth outcomes in patients undergoing FET following TCRA, addressing a significant void in existing research.

Multimodal learning system integrating electronic medical records and hysteroscopic images for reproductive outcome prediction and risk stratification of endometrial injury: a multicenter diagnostic study

OBJECTIVE

To develop a multimodal learning application system that integrates electronic medical records (EMR) and hysteroscopic images for reproductive outcome prediction and risk stratification of patients with intrauterine adhesions (IUAs) resulting from endometrial injuries.

MATERIALS AND METHODS

EMR and 5014 revisited hysteroscopic images of 753 post hysteroscopic adhesiolysis patients from the multicenter IUA database we established were randomly allocated to training, validation, and test datasets. The respective datasets were used for model development, tuning, and testing of the multimodal learning application. MobilenetV3 was employed for image feature extraction, and XGBoost for EMR and image feature ensemble learning. The performance of the application was compared against the single-modal approaches (EMR or hysteroscopic images), DeepSurv and ElasticNet models, along with the clinical scoring systems. The primary outcome was the 1-year conception prediction accuracy, and the secondary outcome was the assisted reproductive technology (ART) benefit ratio after risk stratification.

RESULTS

The multimodal learning system exhibited superior performance in predicting conception within 1-year, achieving areas under the curves of 0.967 (95% CI: 0.950-0.985), 0.936 (95% CI: 0.883-0.989), and 0.965 (95% CI: 0.935-0.994) in the training, validation, and test datasets, respectively, surpassing single-modal approaches, other models and clinical scoring systems (all P<0.05). The application of the model operated seamlessly on the hysteroscopic platform, with an average analysis time of 3.7±0.8 s per patient. By employing the application's conception probability-based risk stratification, mid-high-risk patients demonstrated a significant ART benefit (odds ratio=6, 95% CI: 1.27-27.8, P=0.02), while low-risk patients exhibited good natural conception potential, with no significant increase in conception rates from ART treatment (P=1).

CONCLUSIONS

The multimodal learning system using hysteroscopic images and EMR demonstrates promise in accurately predicting the natural conception of patients with IUAs and providing effective postoperative stratification, potentially contributing to ART triage after IUA procedures.

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.

Benefits of antibiotics and the optimal time interval between biopsy and the next embryo transfer in patients with chronic endometritis

This study evaluated the effects of antibiotics on the implantation rate (IR) as well as the optimal time interval from endometrial biopsy to subsequent embryo transfer (ET) to explore proper chronic endometritis (CE) management. We retrospectively analyzed the clinical data of patients who had failed 1 or 2 ET cycles and underwent hysteroscopy. CE was diagnosed when 3 or more cluster of differentiation138 - positive plasma cells were found per high-power field. We divided the patients into 3 groups: those with CE who received antibiotics (group 1), those with CE who did not receive antibiotics (group 2), and those without CE (group 3). We found that IR was significantly higher in Group 1 than in Group 2. Furthermore, while the IR in Groups 1 and 3 was significantly higher when the time interval was < 6 months than when the time interval was > 6 months, there were no significant differences in the IR when the time interval was < 2 months or ≥ 2 months but < 6 months. Postbiopsy oral antibiotic therapy significantly improved IR in patients with CE, whereas increasing the time interval from biopsy to ET reduced IR. This study may help to find a higher potential for success in the medical management of patients with CE.

Hysteroscopic metroplasty for the treatment of the dysmorphic uterus: A SWOT analysis

Introduction

Dysmorphic uterus or T-shaped uterus is an increasingly frequent diagnosis among the infertile population that has been associated to worse reproductive results. Hysteroscopic metroplasty is a safe and simple procedure that can improve the reproductive outcomes in this group of patients, although the benefits of this procedure remains controversial due to the lack of adequate scientific evidence.

Objective

To analyze the hysteroscopic metroplasty using the SWOT (Strengths, Weaknesses, Opportunities and Threats) methodology.

Data sources

An electronic search from inception each database up to December 2021 including the following databases was conducted: PubMed-MEDLINE, EMBASE, Web of Science, The Cochrane Library, and Google Scholar.

Methods of study selection

Studies reporting outcomes of patients undergoing hysteroscopic metroplasty were included.

Tabulation

Not applicable.

Integration and Results

Clinical evidence from the included studies suggests an improvement in reproductive results after performing hysteroscopic metroplasty especially in women with recurrent pregnancy loss and previous infertility, but all of them have relevant methodological limitations. For this reason, benefits, risks and alternatives of this intervention should be considered with caution.

Conclusions

Evidence from published data shows a probable association between dysmorphic uterus and poor reproductive outcomes. Hysteroscopic metroplasty in patients with dysmorphic uterus could improve pregnancy outcomes, but there is need of properly designed prospective controlled studies to determine the benefits of this technique.

In vitro fertilization and embryo transfer may improve live birth rate for patients with intrauterine adhesions after hysteroscopic adhesiolysis

OBJECTIVES

The prevalence of intrauterine adhesion (IUA) increased gradually, which seriously affected female reproductive health and fertility. This study aims to analyze the clinical features of pre-, intra-, and post hysteroscopic adhesiolysis (HA) and to identify the main risk factors for non-live birth and other factors affecting pregnancy outcome in patients with IUA.

METHODS

A total of 486 IUA patients with reproductive needs, who underwent HA in the third Xiangya Hospital of Central South University from January 2017 to May 2018, were retrospectively included. The follow-up period was 2-3 years after operation. Univariate analysis and multivariate logistic regression analysis were used to explore the relationship between clinical features and live birth rate in patients with IUA. Pre-operative clinical indicators included age, gravidity, parity, abortion, IUA recurrence, menstrual patterns, and disease course. Intraoperative clinical features assessed in the last operation were uterine cavity length, IUA appearance, IUA area, number of visible uterine cornua, number of visible tubal ostia, and American Fertility Society (AFS) scores. The relationship between clinical indicators and postoperative live birth rate was investigated by univariate analysis and multivariate logistic regression analysis. Pregnancy pattern was the main variable.

RESULTS

Among the 486 IUA patients included in this study, there were 256 (52.67%) live births and 230 (47.33%) non-live births. Univariate analysis and multivariate logistic regression showed that the live birth rate of in vitro fertilization and embryo transfer (IVF-ET) after HA was higher than that of spontaneous pregnancy (OR=0.557, 95% CI 0.361 to 0.861, P=0.008). When the bilaterally fallopian tube ostia were invisible in the last operation (OR=0.322, 95% CI 0.104 to 0.997, P=0.049), patients were more likely to have live birth. The older the patient was, the lower the live birth rate was (OR=1.081, 95% CI 1.034 to 1.131, P<0.001). The live birth rate would be low when the last AFS score was moderate (OR=2.973, 95% CI to 1.541 to 5.738, P<0.010).

CONCLUSIONS

Based on the outcome of the first pregnancy after HA, IUA patients' pregnancy patterns, age, number of visible tubal ostia, and AFS scores noted by a second-look hysteroscopy, are the factors influencing the prognosis for the live birth rate in IUA patients. IVF-ET may improve live birth rate for patients with IUA after HA.

Pregnancy Patterns Impact Live Birth Rate for Patients With Intrauterine Adhesions After Hysteroscopic Adhesiolysis: A Retrospective Cohort Study

Objective

The pregnancy patterns and other factors of live birth for patients with intrauterine adhesions (IUAs) were identified by analyzing the clinical features of pre-, intra-, and post-hysteroscopic adhesiolysis (HA).

Design

A total of 742 patients with IUAs who wanted to become pregnant underwent HA from January 2017 to May 2018 at the Third Xiangya Hospital of Central South University. The patient follow-up period was 2 years post-HA. A logistic regression was performed to analyze the clinical characteristics associated with a live birth for patients with IUAs. Pre-operative clinical indicators included age, gravidity, parity, abortion, IUA recurrence, menstrual patterns, disease course. Intraoperative clinical features assessed in the last operation were uterine cavity length, IUA appearance, IUA area, number of visible uterine cornua, number of visible tubal ostia, AFS scores. Pregnancy patterns were post-hysteroscopic adhesiolysis features.

Results

Among the 742 IUA patients, 348 (46.9%) had a live birth and 394 (53.1%) did not. A bivariate and binary logistic regression analysis showed that IUA patients’ pregnancy patterns, age, number of visible tubal ostia noted by a second-look hysteroscopy, and American Fertility Society (AFS) scores were significantly related to the live birth rate (P < 0.05).

Conclusions

Pregnancy patterns, age, number of visible tubal ostia, and AFS scores were significantly related to the live birth rate and may be considered potential predictors of the live birth rate in IUA patients. The indications of assisted reproductive technology (ART) might be a better choice for patients with recurrent IUAs.