Transplantation of human umbilical cord blood mononuclear cells promotes functional endometrium reconstruction via downregulating EMT in damaged endometrium

Introduction

Cell transplantation is an emerging and effective therapeutic approach for enhancing uterine adhesions caused by endometrial damage. Currently, human umbilical cord blood mononuclear cells (HUCBMCs) have been extensively for tissue and organ regeneration. However, their application in endometrial repair remains unexplored. Our investigation focuses on the utilization of HUCBMCs for treating endometrial injury.

Methods

The HUCBMCs were isolated from health umbilical cord blood, and co-cultured with the injured endometrial stromal cells and injured endometrial organoids. The cell proliferation and apoptosis were measured by cck8 assays and flow cytometry. Western blotting was used to detect the expression of PTEN, AKT and p-AKT. Immunofluorescence assay revealed expression levels of epithelial-mesenchymal transition (EMT) -related markers such as E-cadherin, N-cadherin, and TGF-β1. The endometrial thickness, fibrosis level, and glandular number were examined after the intravenous injection of HUCBMCs in mouse endometrial models. Immunohistochemistry was employed to assess changes in growth factors vascular endothelial growth factor (VEGF) and insulin-like growth factor 1 (IGF-1) as well as fibrosis markers α-SMA and COL1A1. Additionally, expressions of EMT-related proteins E-cadherin and N-cadherin were evaluated.

Results

HUCBMCs significantly improved the proliferation and reduced the apoptosis of damaged endometrial stromal cells (ESCs), accompanied by up-regulation of phospho-AKT expression. HUCBMCs increased endometrial thickness and glandular count while decreasing fibrosis and EMT-related markers in mouse endometrial models. Furthermore, EMT-related markers of ESCs and endometrial organoids were significantly decreased.

Conclusions

Our findings suggest that HUCBMCs plays a pivotal role in mitigating endometrial injury through the attenuation of fibrosis. HUCBMCs may exert a reverse effect on the EMT process during the endometrium reconstruction.

Review of Asherman syndrome and its hysteroscopic treatment outcomes: experience in a low-resource setting

BACKGROUND

Asherman syndrome is one of the endometrial factors that influence a woman's reproductive capacity. However, in our context, it needs to be well-documented. This study aimed to evaluate the clinical characteristics and hysteroscopic treatment outcomes of Asherman syndrome.

METHOD

A retrospective follow-up study from January 1, 2019, to December 31, 2022, was conducted on cases of Asherman syndrome after hysteroscopic adhesiolysis at St.Paul's Hospital in Addis Ababa, Ethiopia. Clinical data were collected via telephone survey and checklist. Epidata-4.2 and SPSS-26 were employed for data entry and analysis, respectively.

RESULT

A total of 177 study participants were included in the final analysis. The mean patient age was 31 years (range: 21-39) at the initial presentation, and 32.3 years (range: 22-40) during the phone interview. The majority of the patients (97.7%) had infertility, followed by menstrual abnormalities (73.5%). Among them, nearly half (47.5%) had severe, 38.4% had moderate, and 14.1% had mild Asherman syndrome. The review identified no factor for 51.4% of the participants. Endometrial tuberculosis affected 42 patients (23.7%). It was also the most frequent factor in both moderate and severe cases of Asherman syndrome. Only 14.7% of patients reported menstrual correction. Overall, 11% of women conceived. Nine patients miscarried, three delivered viable babies, and six were still pregnant. The overall rate of adhesion reformation was 36.2%. Four individuals had complications (3 uterine perforations and one fluid overload) making a complication rate of 2.3%.

CONCLUSION

Our study revealed that severe forms of Asherman syndrome, which are marked by amenorrhea and infertility, were more common, leading to incredibly low rates of conception and the resumption of regular menstruation, as well as high recurrence rates. A high index of suspicion for Asherman syndrome, quick and sensitive diagnostic testing, and the development of a special algorithm to identify endometrial tuberculosis are therefore essential. Future multi-centered studies should focus on adhesion preventive techniques.

Chitosan-crosslinked polyvinyl alcohol anti-swelling hydrogel designed to prevent abdominal wall adhesion

Abdominal adhesion is a frequent clinical issue with a high incidence rate and consequences following intra-abdominal surgery. Although many anti-adhesion materials have been used in surgical procedures, additional research is still needed to determine which ones have the most robust wet tissue adhesion, the best anti-postoperative adhesion, and the best anti-inflammatory properties. We have developed an excellent tissue adhesion and anti-swelling polyvinyl alcohol-chitosan hydrogel (AS hydrogel). According to in vitro cell testing, AS hydrogel significantly decreased inflammation around cells and exhibited good biocompatibility. Further, we assessed how well AS hydrogel prevented intraperitoneal adhesion using a rabbit model with cecum and abdominal wall injuries. According to the data, AS hydrogel has excellent anti-inflammatory and biodegradability properties compared to the control group. It can also prevent intestinal and abdominal wall injuries from occurring during surgery. Based on these results, hydrogel appears to be a perfect new material to prevent postoperative abdominal wall adhesion.

Photobiomodulation therapy at 632 nm wavelength ameliorates intrauterine adhesion via activation of cAMP/PKA/CREB pathway

Intrauterine adhesion (IUA), a major cause of uterine infertility, is pathologically characterized by endometrial fibrosis. Current treatments for IUA have poor efficacy with high recurrence rate, and restoring uterine functions is difficult. We aimed to determine the therapeutic efficacy of photobiomodulation (PBM) therapy on IUA and elucidate its underlying mechanisms. A rat IUA model was established via mechanical injury, and PBM was applied intrauterinely. The uterine structure and function were evaluated using ultrasonography, histology, and fertility tests. PBM therapy induced a thicker, more intact, and less fibrotic endometrium. PBM also partly recovered endometrial receptivity and fertility in IUA rats. A cellular fibrosis model was then established with human endometrial stromal cells (ESCs) cultured in the presence of TGF-β1. PBM alleviated TGF-β1-induced fibrosis and triggered cAMP/PKA/CREB signaling in ESCs. Pretreatment with the inhibitors targeting this pathway weakened PBM's protective efficacy in the IUA rats and ESCs. Therefore, we conclude that PBM improved endometrial fibrosis and fertility via activating cAMP/PKA/CREB signaling in IUA uterus. This study sheds more lights on the efficacy of PBM as a potential treatment for IUA.

Yangmo decoction versus hyaluronic acid gel in women with intrauterine re-adhesion after hysteroscopic adhesiolysis: a retrospective efficacy and safety analysis

BACKGROUND

Hysteroscopic adhesiolysis is the preferred primary method for intrauterine adhesion. However, there is about a 60% of chance of re-adhesion after surgery. The objectives of the study were to evaluate the efficacy and safety of Yangmo decoction as a secondary treatment in preventing intrauterine re-adhesion against those of hyaluronic acid gel.

METHODS

Women received oral Yangmo decoction (YD cohort, n = 105) or intrauterine hyaluronic acid gel (HA cohort, n = 125) or did not receive secondary re-adhesion prevention treatments (EP cohort, n = 165) after hysteroscopic adhesiolysis for 6 months. In addition, all women have received 3 mg of oral estrogen and 20 mg oral progesterone combination after hysteroscopic adhesiolysis for 3 months. Intrauterine re-adhesion after hysteroscopic adhesiolysis after 6 months with or without secondary treatment(s) was detected using hysteroscopy. The extent of the cavity, type of adhesion, and the menstrual pattern were included to define the American Fertility Society classification of intrauterine re-adhesions (AFS) score.

RESULTS

Fewer numbers of women suffered from intrauterine re-adhesion after hysteroscopic adhesiolysis in the YD cohort than those of the HA (15(14%) vs. 40(32%), p = 0.0019) and the EP (15(14%) vs. 58(35%). p = 0.0001) cohorts. Among women who developed intrauterine re-adhesion, AFS score was fewer for women of the YD cohort than those of HA (2(2-1) vs. 4(4-3), p < 0.001) and the EP (2(2-1) vs. 4(4-4), p < 0.001) cohorts. AFS score after surgery was fewer for women of the HA cohort than those of the EP cohort (p < 0.05). Higher numbers of women of the YD cohort retained pregnancies after 6-months of treatment than those of the HA (55(52%) vs. 45(36%), p = 0.0161) and EP (55(52%) vs. 35(21%), p < 0.0001) cohorts. Among women who develop re-adhesion, 10(10%) women of the YD cohort only had successful pregnancies.

CONCLUSIONS

Yangmo decoction for 6 months after hysteroscopic adhesiolysis can reduce AFS score, prevent intrauterine re-adhesion, and increases the chances of successful pregnancies of women.

LEVEL OF EVIDENCE

IV.

TECHNICAL EFFICACY

Stage 5.

Ellagic acid increases implantation rates with its antifibrotic effect in the rat model of intrauterine adhesion

Intrauterine adhesions (IUA) are defined as the adhesion of opposing endometrial tissue with dense fibrous adhesive bands within the uterine cavity. With the increase in cesarean sections and endometrial surgical procedures, intrauterine adhesions have become a problem with increasing incidence and decreasing implantation. The purpose of the study was to investigate the effect of ellagic acid (EA), a phenolic compound, on fibrosis in IUA model rats. Another goal of the study was to increase endometrial receptivity with EA. The groups in the study were planned as control, DMSO, EA, IUA, IUA+DMSO, and IUA+EA, with 8 Sprague Dawley rats in each group. EA was administered at a dose of 100 mg/kg/day for 35 days. At the end of the experiment, the uterine tissues of the rats were removed. Histochemical staining was used to validate the IUA model and determine the degree of fibrosis. The levels of some fibrosis-related genes and proteins in the obtained uterine tissues were evaluated. In addition, implantation rates were determined. In our findings, it was observed that the fibrotic structure was decreased in the treated IUA+EA group compared to the IUA group, while fibrotic improvement was supported by down-regulation of TGFβ1 activity and up-regulation of BMP7 activity. The increase in the expression of the endometrial marker LIF with EA treatment was consistent with the increase in implantation rates with treatment. As a result of the study, it can be said that EA applied as a treatment against IUA causes healing in uterine tissue by reducing fibrosis and increases implantation rates by increasing endometrial receptivity.

Salt sensitive purely zwitterionic physical hydrogel for prevention of postoperative tissue adhesion

Abdominal adhesions are a class of serious complications following abdominal surgery, resulting in a complicated and severe syndrome and sometimes leading to a Gordian knot. Traditional therapies employ hydrogels synthesized using complicated chemical formulations-often with click chemistry or thermal responsive hydrogel. The complicated synthesis process and severe conditions limit the extent of the hydrogels' applications. In this work, poly 3-[2-(methacryloyloxy)ethyl](dimethyl)-ammonio]-1-propanesulfonate (PSBMA) polymer was synthesized to self-assemble into physical hydrogels due to the inter- and intramolecular ion interactions. The strong static interaction bonding density has a substantial impact on the gelation and physicochemical properties, which is beneficial to clinical applications and offers a novel way to obtain the desired hydrogel for a specific biomedical application. Intriguingly, this PSBMA polymer can be customized into a transient network with outstanding antifouling capability depending on the ion concentration. As ion concentration increases, the PSBMA hydrogel dissociated completely, endowing it as a candidate for adhesion prevention. In the cecum-sidewall model, the PSBMA hydrogel demonstrated superior anti-adhesion properties than commercial HA hydrogel. Furthermore, we have demonstrated that this PSBMA hydrogel could inhibit the inflammatory response and encourage anti-fibrosis resulting in adhesion prevention. Most surprisingly, the recovered skins of cecum and sidewall are as smooth as the control skin without any scar and damage. In conclusion, a practical hydrogel was synthesized using a facile method based on purely zwitterionic materials, and this ion-sensitive, antifouling adjustable supramolecular hydrogel with great clinic transform potential is a promising barrier for preventing postoperative tissue adhesion. STATEMENT OF SIGNIFICANCE: The development of hydrogels with satisfactory coverage, long retention time, facile synthetic method, and good biocompatibility is vital for preventing peritoneal adhesions. Herein, we developed a salt sensitive purely zwitterionic physical hydrogel poly 3-[2-(methacryloyloxy)ethyl](dimethyl)-ammonio]-1-propanesulfonate (PSBMA) hydrogel to effectively prevent postoperative and recurrent abdominal adhesions. The hydrogel was simple to synthesize and easy to use. In the cecum-sidewall model, PSBMA hydrogel could instantaneously adhere and fix on irregular surfaces and stay in the wound for more than 10 days. The PSBMA hydrogel could inhibit the inflammatory response, encourage anti-fibrosis, and restore smoothness to damaged surfaces resulting in adhesion prevention. Overall, the PSBMA hydrogel is a promising candidate for the next generation of anti-adhesion materials to meet clinical needs.

Telocyte-Derived Exosomes Provide an Important Source of Wnts That Inhibits Fibrosis and Supports Regeneration and Repair of Endometrium

Intrauterine adhesions (IUAs) often occurred after common obstetrical and gynecological procedures or infections in women of reproductive age. It was characterized by the formation of endometrial fibrosis and prevention of endometrial regeneration, usually with devastating fertility consequences and poor treatment outcomes so far. Telocytes (TCs), as a novel interstitial cell type, present in female uterus with in vitro therapeutic potential in decidualization-defective gynecologic diseases. This study aims to further investigate the role of TC-derived Wnt ligands carried by exosomes (Exo) in reversal of fibrosis and enhancement of regeneration repair in endometrium. IUA cellular and animal models were established from endometrial stromal cells (ESCs) and mice, followed with treatment of TC-conditioned medium (TCM) or TC-derived Exo. In cellular model, fibrosis markers (collagen type 1 alpha 1 [COL1A1], fibronectin [FN], and α-smooth muscle actin [α-SMA]), angiogenesis (vascular endothelial growth factor [VEGF]), and pathway protein (β-catenin) were determined by quantitative reverse transcription polymerase chain reaction (qRT-PCR), Western blotting (WB), and immunofluorescence. Results showed that, TCs (either TCM or TC-derived Exo) provide a source of Wnts that inhibit cellular fibrosis, as evidenced by significantly elevated VEGF and β-catenin with decreased fibrotic markers, whereas TCs lost salvage on fibrosis after being blocked with Wnt/β-catenin inhibitors (XAV939 or ETC-159). Further in mouse model, regeneration repair (endometrial thickness, number of glands, and fibrosis area ratio), fibrosis markers (fibronectin [FN]), mesenchymal-epithelial transition (MET) (E-cadherin, N-cadherin), and angiogenesis (VEGF, microvessel density [MVD]) were studied by hematoxylin-eosin (HE), Masson staining, and immunohistochemistry. Results demonstrated that TC-Exo treatment effectively promotes regeneration repair of endometrium by relieving fibrosis, enhancing MET, and angiogenesis. These results confirmed new evidence for therapeutic perspective of TC-derived Exo in IUAs.

Recent Advances in Treatment of Recurrent Spontaneous Abortion

Importance

Recurrent spontaneous abortion (RSA) is a distressing condition experienced by approximately 1% of women trying to conceive. However, the treatment of RSA is a challenge both for clinicians and patients.

Objective

The aim of this review is to discuss the medical and surgical approach to the management of RSA, including those caused by anatomical, genetic, male, infectious, endocrine, and immune factors.

Evidence Acquisition

A literature search using MeSH terms for each topic was undertaken using PubMed, supplemented by hand searching for additional references. Retrieved articles were reviewed, synthesized, and summarized.

Results

Available treatments target hypothetical risk factors for RSA, although the effectiveness of many treatment options is controversial. Intervention should depend on the benefit-to-risk ratio of the proposed treatment.

Conclusions and Relevance

The etiology of RSA is heterogeneous, and patients often lack specific clinical manifestations, which has hindered the progress in predicting and preventing RSA to some extent. Despite intensive workup, at least 50% of couples do not have a clear underlying pathology. In addition, an evidence-based treatment is not available in most patients even if abnormal test results are present. Many new treatment directions are also still actively exploring; empirical and combined multiple treatments are still the main methods.

Target Audience

Obstetricians and gynecologists, family physicians.

Learning Objectives

After completing this activity, the learner should be better able to describe common risk factors for RSA; formulate individualized treatment plans to improve pregnancy outcomes; and propose supportive treatment recommendations for patients with unclear causes.

Correlative study of preoperative three-dimensional transvaginal ultrasound findings and ongoing pregnancy/live birth in patients with intrauterine adhesions following hysteroscopic adhesiolysis: a retrospective study

BACKGROUND

Three-dimensional transvaginal ultrasound (3D-TVUS) has recently been adopted in the gynecological sciences as it provides an accurate illustration of adhesions and the extent of cavity damage, and hence, can be used as an essential tool for the prognosis of intrauterine adhesions (IUA). This study aims to demonstrate whether preoperative 3D-TVUS features are relevant to ongoing pregnancy and live births in patients with IUA following hysteroscopic adhesiolysis (HA).

METHODS

From February 22, 2018, to October 31, 2018, a total of 401 patients with moderate to severe IUA and underwent HA were retrospectively enrolled. Preoperative 3D-TVUS diagnosed data and the patients' basic information were collected, and patients were followed up over 2 years after HA for reproductive outcomes. The correlation between each imaging variable and ongoing pregnancy or live birth was analyzed by binary logistic regression.

RESULTS

Among the 401 patients, 143 had live births, 41 patients had abortions, and 217 patients were infertile. Thick endometrium was found to be favorable for ongoing pregnancy (ongoing pregnancy group =5.4±1.95 mm, no-ongoing pregnancy group =4.7±2.24 mm, P=0.0095) and live birth (live birth group=5.6±1.92 mm, no-live birth group =4.7±2.20 mm, P=0.0029). Scar contraction was not conducive for pregnancy, while the lower segmentation was not a risk factor for ongoing pregnancy (P=0.0003). It also was a risk factor for ongoing pregnancy (P<0.0001) and live birth (P<0.0001) when the segmentation of the endometrial absence was mainly in the upper and middle segments of the uterine cavity. The area under the curves (AUCs) of the prediction model for ongoing pregnancy and live birth were 0.9116 and 0.8751, respectively, based on the meaningful variables above combined with other clinical characteristics.

CONCLUSIONS

Preoperative 3D-TVUS features have a close correlation with ongoing pregnancy and live births in patients with IUA following HA, and can be applied for predicting ongoing pregnancy and live births in IUA patients post-HA.

Decision tree model predicts live birth after surgery for moderate-to-severe intrauterine adhesions

Background

After treatment of intrauterine adhesions, the rate of re-adhesion is high and the pregnancy outcome unpredictable and unsatisfactory. This study established and verified a decision tree predictive model of live birth in patients after surgery for moderate-to-severe intrauterine adhesions (IUAs).

Methods

A retrospective observational study initially comprised 394 patients with moderate-to-severe IUAs diagnosed via hysteroscopy. The patients underwent hysteroscopic adhesiolysis from January 2013 to January 2017, in a university-affiliated hospital. Follow-ups to determine the rate of live birth were conducted by telephone for at least the first postoperative year. A classification and regression tree algorithm was applied to establish a decision tree model of live birth after surgery.

Results

Within the final population of 374 patients, the total live birth rate after treatment was 29.7%. The accuracy of the model was 83.8%, and the area under the receiver operating characteristic curve (AUC) was 0.870 (95% CI 7.699–0.989). The root node variable was postoperative menstrual pattern. The predictive accuracy of the multivariate logistic regression model was 70.3%, and the AUC was 0.835 (95% CI 0.667–0.962).

Conclusions

The decision tree predictive model is useful for predicting live birth after surgery for IUAs; postoperative menstrual pattern is a key factor in the model. This model will help clinicians make appropriate clinical decisions during patient consultations.

Platelet-rich plasma for the management of intrauterine adhesions: A systematic review and meta-analysis of randomized controlled trials

OBJECTIVE

To conduct a systematic review and meta-analysis to assess the efficacy of platelet-rich plasma (PRP) infusion after adhesiolysis in patients with intrauterine adhesions (IUAs) by establishing the evidence from published randomized controlled trials (RCTs).

METHODS

PubMed, Scopus, Web of Science, Cochrane Central Register of Controlled Trials (CENTRAL), and Google Scholar databases were screened from inception till June 2021. Risk of bias of included studies was evaluated according to the Cochrane's Collaboration tool. The efficacy endpoints were summarized as risk ratio (RR) or mean difference (MD) with 95% confidence interval (CI) under the fixed-effects model.

RESULTS

Three RCTs met the inclusion criteria, comprising a total of 260 patients (132 and 128 patients were allocated to PRP and control groups, respectively). The RCTs revealed an overall low risk of bias. Compared with the control group, the PRP group had a statistically significant higher rate of patients with IUAs grade I-II after intervention (n = 3 RCTs, RR=1.23, 95% CI [1.11 to 1.36], p<0.001), higher duration of menstrual menses after intervention (n = 3 RCTs, MD=1.13 days, 95% CI [0.86 to 1.41], p<0.001), and higher amount of menstrual menses after intervention (n = 3 RCTs, MD=2.96 pads, 95% CI [0.31 to 3.61], p<0.001). All pooled analyses were homogeneous.

CONCLUSION

PRP treatment after hysteroscopic adhesiolysis is effective in decreasing the IUA grade and improving the duration and amount of menstrual menses. Nonetheless, additional RCTs are warranted to validate these conclusions.

Effectiveness of Hyaluronic Acid Gel and Intrauterine Devices in Prevention of Intrauterine Adhesions after Hysteroscopic Adhesiolysis in Infertile Women

STUDY OBJECTIVE

To compare the recurrence rate, post-treatment American Fertility Society (AFS) score, ongoing pregnancy rate, and endometrial thickness of 3 secondary prevention therapies in preventing recurrent intrauterine adhesions (IUAs) and increasing pregnancy rates in infertile women after hysteroscopic adhesiolysis.

DESIGN

A retrospective study.

SETTING

A private fertility hospital.

PATIENTS

A total of 200 consecutive infertile women, with the desire to have a baby and were diagnosed as having IUAs detected by hysterosalpingogram, who underwent hysteroscopic adhesiolysis for IUAs from January, 2018 to May, 2020.

INTERVENTIONS

Women who underwent hysteroscopic adhesiolysis received hormone therapy, and one of the 3 secondary preventions: hyaluronic acid (HA) gel alone, intrauterine devices (IUDs) alone, or HA gel + IUD.

MEASUREMENTS AND MAIN RESULTS

Of the 200 women included in the final analysis, 121 received HA alone, 59 were treated with IUD alone, and 20 received HA gel + IUD combination. The mean post-treatment AFS score for IUAs was significantly lower in the HA gel + IUD group than the HA alone or the IUD alone groups (adjusted p = .01 and p = .02, respectively). Multivariable analysis revealed a significantly lower recurrence rate in the women after treatment with HA gel + IUD than HA alone (adjusted odds ratio, 0.19; 95% credible interval [CreI], 0.03-0.88). Women treated with HA gel + IUD also had reduced post-treatment AFS scores compared with HA alone (β coefficients, -0.83; 95% CreI, -1.64 to -0.01). For ongoing pregnancy rates after in vitro fertilization, the adjusted odds ratio for HA gel + IUD vs HA alone was 2.03 (95% CreI, 0.44-11.00) and for IUD alone vs HA alone was 1.13 (95% CreI, 0.41-3.29), indicating nonsignificant differences. There were no differences observed in endometrial thickness on the day of embryo transfer among the 3 groups.

CONCLUSION

The investigation of the primary outcome in reducing the recurrence rate IUA after treatment demonstrated that a combination of HA gel + IUD provides greater prevention of recurrent IUAs and may decrease post-treatment AFS scores for infertile women undergoing hysteroscopic adhesiolysis. However, for the secondary outcome of increasing pregnancy rates, there was no improvement in the ongoing pregnancy rates after in vitro fertilization.

The efficacy of amniotic membrane-mediated sequential double-barrier therapy for the treatment of postoperative intrauterine adhesions

To study the efficacy of using amniotic membrane, balloon and intrauterine device (IUD) as barrier therapy to prevent re-adhesion after hysteroscopic adhesiolysis.A total of 45 patients diagnosed with intrauterine adhesions in Changzhou Maternal and Child Health Hospital from June 2014 to December 2017 were included in this retrospective case control study. According to different postoperative isolation barrier methods, the patients were divided into group A (Foley balloon + fresh amniotic membrane Day1 + IUD Day7) (22 cases) and group B (Foley balloon Day1 + IUD Day7) (23 cases). Three months after the surgery, the second hysteroscopy was performed to observe the condition of the uterine cavity and the improvement of menstruation, and to monitor the thickness of the endometrium.The efficacy of hysteroscopic procedure in group A was significantly higher than that of group B (P < .05). After 3 months of treatment, the improvement rate of menstruation was significantly higher in group A than in group B (P < .05). Endometrial thickness in both group A and B was significantly increased compared with that before the surgery (P < .05). The postoperative endometrium of group A was significantly thicker than that of group B (P < .05).Amniotic membrane-mediated sequential double-barrier method is clinically feasible for preventing recurrent intrauterine adhesions.

Biodegradable Zwitterionic Cream Gel for Effective Prevention of Postoperative Adhesion

Postoperative peritoneal adhesions were frequent complications for almost any types of abdominal and pelvic surgery. This led to numerous medical problems and huge financial burden to the patients. Current anti-adhesion strategies focused mostly on physical barriers including films and hydrogels. However, they can only alleviate or reduce adhesions to certain level and their applying processes were far from ideal. This work reported the development of a biodegradable zwitterionic cream gel presenting a series of characters for an idea anti-adhesion material, including unique injectable yet malleable and self-supporting properties, which enabled an instant topical application, no curing, waiting or suturing, no hemostasis requirement, protein/cell resistance and biodegradability. The cream gel showed a major advancement in anti-adhesion efficacy by completely and reliably preventing a primary and a more severe recurrent adhesion in rat models.

si-SNHG5-FOXF2 inhibits TGF-β1-induced fibrosis in human primary endometrial stromal cells by the Wnt/β-catenin signalling pathway

Background

Intrauterine adhesions (IUAs) are manifestations of endometrial fibrosis characterized by inflammation and fibrinogen aggregation in the extracellular matrix (ECM). The available therapeutic interventions for IUA are insufficiently effective in the clinical setting for postoperative adhesion recurrence and infertility problems. In this study, we investigated whether si-SNHG5-FOXF2 can serve as a molecular mechanism for the inhibition of IUA fibrosis ex vivo.

Methods

FOXF2, TGF-β1 and collagen expression levels were measured by microarray sequencing analysis in three normal endometrium groups and six IUA patients. We induced primary human endometrial stromal cells (HESCs) into myofibroblasts (MFs) to develop an IUA cell model with various concentrations of TGF-β1 at various times. Downstream target genes of FOXF2 were screened by chromatin immunoprecipitation combined with whole-genome high-throughput sequencing (ChIP-seq). We investigated ECM formation, cell proliferation and Wnt/β-catenin signalling pathway-related proteins in primary HESCs with FOXF2 downregulation by quantitative reverse transcription-polymerase chain reaction (qRT-PCR), western blotting (WB), immunohistochemistry (IHC), flow cytometry, ethylenediurea (EdU) and CCK8 assays. We identified long noncoding RNAs (lncRNA) SNHG5 as the upstream regulatory gene of FOXF2 through RNA immunoprecipitation (RIP), RNA pulldown and fluorescence in situ hybridization (FISH). Finally, we examined FOXF2 expression, ECM formation, cell proliferation and Wnt/β-catenin signalling pathway-related proteins in primary HESCs upon FOXF2 downregulation.

Results

FOXF2 was highly expressed in the endometrium of patients with IUA. Treatment of primary HESCs with 10 ng/ml TGF-β1 for 72 h was found to be most effective for developing an IUA cell model. FOXF2 regulated multiple downstream target genes, including collagen, vimentin (VIM) and cyclin D2/DK4, by ChIP-seq and ChIP-PCR. FOXF2 downregulation inhibited TGF-β1-mediated primary HESC fibrosis, including ECM formation, cell proliferation and Wnt/β-catenin signalling pathway-related protein expression. We identified lncRNA SNHG5 as an upstream gene that directly regulates FOXF2 by RIP-seq, qRT-PCR, WB and FISH. SNHG5 downregulation suppressed FOXF2 expression in the IUA cell model, resulting in synergistic repression of the Wnt/β-catenin pathway, thereby altering TGF-β1-mediated ECM aggregation in endometrial stromal cells ex vivo.

Conclusions

Regulation of the Wnt/β-catenin signalling pathway and ECM formation by si-SNHG5-FOXF2 effectively inhibited the profibrotic effect of TGF-β1 on primary HESCs. This finding can provide a molecular basis for antagonizing TGF-β1-mediated fibrosis in primary HESCs.

Estrogen attenuates TGF-β1-induced EMT in intrauterine adhesion by activating Wnt/β-catenin signaling pathway

Although estrogen has crucial functions for endometrium growth, the specific dose and underlying molecular mechanism in intrauterine adhesion (IUA) remain unclear. In this study, we aimed to investigate the effects of estrogen on epithelial-mesenchymal transition (EMT) in normal and fibrotic endometrium, and the role of estrogen and Wnt/β-catenin signaling in the formation of endometrial fibrosis. CCK-8 and immunofluorescence assay were performed to access the proliferation of different concentrations of estrogen on normal human endometrial epithelial cells (hEECs). qRT-PCR and western blot assay were utilized to explore the effect of estrogen on EMT in normal and fibrotic endometrium, and main components of Wnt/β-catenin signaling pathway in vitro. Hematoxylin and eosin and Masson staining were used to evaluate the effect of estrogen on endometrial morphology and fibrosis in vivo. Our results indicated that the proliferation of normal hEECs was inhibited by estrogen at a concentration of 30 nM accompanied by upregulation of mesenchymal markers and downregulation of epithelial markers. Interestingly, in the model of transforming growth factor β1 (TGF-β1)-induced endometrial fibrosis, the same concentration of estrogen inhibited the process of EMT, which might be partially mediated by regulation of the Wnt/β-catenin pathway. In addition, relatively high doses of estrogen efficiently increased the number of endometrial glands and reduced the area of fibrosis as determined by the reduction of EMT in IUA animal models. Taken together, our results demonstrated that an appropriate concentration of estrogen may prevent the occurrence and development of IUA by inhibiting the TGF-β1-induced EMT and activating the Wnt/β-catenin pathway.

Experience with Hysteroscopy in a Private Specialist Hospital in Nigeria

Background

Hysteroscopy is a standard method for the evaluation and treatment of various gynecological disorders. Its availability and accessibility are limited in our setting owing to resource constraints. Nevertheless, the utilization is on the increase mostly in private health institutions in Nigeria and as an adjunct in infertility management.

Objectives

The objective is to document the experience and outcome of hysteroscopy surgeries at a private specialist-assisted reproduction and endoscopy unit.

Materials and Methods

A retrospective review of all hysteroscopic procedures conducted at the unit was undertaken. Relevant sociodemographic and clinical information were extracted for analysis. In addition, outcomes of the procedure and outcome for those who eventually had in vitro fertilization (IVF) treatment were documented for analysis.

Results

A total of 106 patients had hysteroscopy over the study period. The age of patients ranged from 24 to 55 years. The most common indication for hysteroscopy was uterine synechiae (50%) others were preparatory for IVF (30.2%), uterine fibroid/polyp (10.4%), and abnormal uterine bleeding (9.4%), respectively. The major findings at hysteroscopy were intrauterine adhesions 68.9%. Therapeutic adhesiolysis was done using the scissors in most cases (83%) while two patients (1.9%) had adhesiolysis and resection of uterine polyp. A complication of noncardiogenic pulmonary edema was recorded from fluid overload. Overall most had return to normal menses (65.1%). Thirty-nine (38.8%) women had IVF treatment after hysteroscopy of which outcome was successful in 16 (41%) women.

Conclusion

The utilization of hysteroscopic surgeries in management of endometrial pathologies is increasing. It offers a safe and effective treatment and is a useful adjunct for improving IVF outcome especially for those with repeated failed treatment.

Transforming growth factor-β1 in intrauterine adhesion

Intrauterine adhesion (IUA), led by trauma to the basal layer, can prevent the endometrium from growing, resulting in complications in females, such as infertility and amenorrhea. Transforming growth factor-β1 (TGF-β1) plays a crucial role in inducing and promoting the differentiation and proliferation of mesenchymal cells, in the secretion of extracellular matrix-associated components, and is a major cytokine in initiating and terminating tissue repair downstream of the TGF-β/Smad signaling pathway. Some evidence supports that TGF-β1 is closely associated with the occurrence and development of IUA, and is regarded as an early risk factor of disease recurrence. Furthermore, the role of TGF-β1 has been demonstrated to be potentially regulated by a variety of cytokines, hormones, enzymes, and microRNAs. This review provides an overview of the expression, function, and regulation of TGF-β1 in IUA, with a brief discussion and perspectives on its future clinical implications on the diagnosis and treatment of IUA.

Prevention of Benign Endometrial Polyp Recurrence Using a Levonorgestrel-releasing Intrauterine System in Premenopausal Patients: A Retrospective Cohort Study

STUDY OBJECTIVE

To evaluate the levonorgestrel-releasing intrauterine system (LNG-IUS) to prevent the recurrence of endometrial polyps (EPs) after hysteroscopic polypectomies in premenopausal female patients.

DESIGN

A retrospective cohort study.

SETTING

A tertiary-care women's hospital.

PATIENTS

A total of 451 premenopausal female patients underwent hysteroscopic polypectomies between January 1, 2016, and December 31, 2017.

INTERVENTIONS

Treatment with LNG-IUS after hysteroscopic polypectomies.

MEASUREMENTS AND MAIN RESULTS

After the hysteroscopic polypectomies and placement of LNG-IUS, transvaginal ultrasounds were performed every 6 months to measure the recurrence of EPs. Overall, 5 (3.47%) of 144 patients in the LNG-IUS cohort and 49 (15.96%) of 307 patients in the control cohort experienced EP recurrence within the follow-up period of up to 3 years. The recurrence exhibited a strongly negative correlation when LNG-IUS was inserted (relative risk, 0.218; 95% confidence interval, 0.089-0.535; p <.05), but this did not significantly correlate with age, polyp size, number of polyps, previous history of polypectomy, and abnormal uterine bleeding. For the LNG-IUS and control cohorts, the recurrence in the first postoperative year was 1.39% and 6.19%, respectively, and 5.41% and 19.23% in the second postoperative year, respectively.

CONCLUSION

LNG-IUS reduces the recurrence of postoperative EPs in premenopausal patients.

A prospective randomized controlled trial comparing two different treatments of intrauterine adhesions

RESEARCH QUESTION

Intrauterine adhesions (IUA) are primarily caused by trauma to the endometrium, and hysteroscopy is presently the main treatment for IUA. However, high rates of post-operative adhesion re-formation remain a problem. In this study, the combination of an intrauterine device (IUD) with a Foley catheter and the balloon uterine stent were investigated to evaluate their efficacy in preventing adhesion re-formation and the subsequent reproductive outcomes in patients with moderate to severe adhesions.

DESIGN

A prospective randomized controlled study was conducted in a university-affiliated hospital. A total of 171 women with Asherman's syndrome were initially recruited between August 2016 and December 2017 and were randomized to undergo either balloon uterine stent insertion or placement of a contraceptive IUD plus a Foley catheter after hysteroscopic adhesiolysis. Reduction of adhesion scores, incidence of adhesion re-formation, changes in menstrual flow and reproductive outcomes were analysed.

RESULTS

A total of 118 participants were eligible for analysis. The American Fertility Society (AFS) scores were not significantly different between groups before hysteroscopic adhesiolysis. At the second-look hysteroscopy, the AFS scores and adhesion recurrence rates were significantly higher in the balloon uterine stent group compared with the combination group (P < 0.01 and P = 0.024, respectively). There were no statistically significant differences in pregnancy and live birth rates between the two groups.

CONCLUSIONS

The combination of an IUD and a Foley balloon catheter had better efficacy in preventing adhesion re-formation than the balloon uterine stent alone; however, it did not produce better reproductive outcomes.

Berberine prevents primary peritoneal adhesion and adhesion reformation by directly inhibiting TIMP-1

Peritoneal adhesions are fibrous tissues that tether organs to one another or to the peritoneal wall and represent the major cause of postsurgical morbidity. Enterolysis at repeat surgeries induces adhesion reformation that is more difficult to prevent than primary adhesion. Here we studied the preventive effects of different approaches of berberine treatment for primary adhesion, and its effects on adhesion reformation compared to Interceed. We found the primary adhesion was remarkably prevented by berberine through intraperitoneal injection 30 min before abrasive surgery (pre-berberine) or direct addition into injured cecum immediately after the surgery (inter-berberine). Rats with adhesion reformation had a more deteriorative collagen accumulation and tissue injury in abrasive sites than rats with primary adhesion. The dysregulated TIMP-1/MMP balance was observed in patients after surgery, as well as adhesion tissues from primary adhesion or adhesion reformation rats. Inter-berberine treatment had a better effect for adhesion reformation prevention than Interceed. Berberine promoted the activation of MMP-3 and MMP-8 by directly blocking TIMP-1 activation core, which was reversed by TIMP-1 overexpression in fibroblasts. In conclusion, this study suggests berberine as a reasonable approach for preventing primary adhesion formation and adhesion reformation.

Evaluation and treatment of infertile women with Asherman syndrome: an updated review focusing on the role of hysteroscopy

Asherman syndrome is a rare acquired clinical condition resulting in the obliteration of the uterine cavity causedby the presence of partial or complete fibrous intrauterine adhesions involving at least two-thirds of the uterine cavity potentially obstructing the internal cervical orifice. Common reported symptoms of the disease are alterations of the menstrual pattern with decreased menstrual bleeding leading up to amenorrhoea and infertility. Hysteroscopy is currently considered the gold standard diagnostic and therapeutic approach for patients with intrauterine adhesions. An integrated approach, including preoperative, intraoperative and postoperative therapeutic measures, however, are warranted owing to the complexity of the syndrome. This review aims to summarize the most recent evidence on the recommended preoperative, intraoperative and postoperative procedures to restore the uterine cavity and a functional endometrium, as well as on the concomitant use of adjuvant therapies to achieve optimal fertility outcomes.

A preliminary study on a patented intrauterine stent in the treatment of recurrent intrauterine adhesions with poor prognosis

Background

Management of intrauterine adhesions (IUAs) is challenging, mainly because there is no ideal method to prevent its recurrence. Recurrence of moderate to severe IUAs after conventional treatments entails a poorer prognosis in these patients. This study aimed to assess the safety and effectiveness of a patented intrauterine stent as a barrier in the treatment of recurrent IUAs with poor prognosis.

Methods

This was a retrospective, observational study of 13 women with IUAs, admitted to the Third Xiangya Hospital of Central South University from June 2018 to September 2019. After conventional treatments, moderate to severe adhesions were still evident. Then a patented intrauterine stent was used as a barrier to prevent the reformation of adhesions after hysteroscopic adhesiolysis (HA). All cases received a second-look hysteroscopy after 2-3 menstrual cycles. American Fertility Society (AFS) scores were noted for all cases. Menstrual pattern, recurrence of adhesions, and reproductive outcomes were also evaluated.

Results

The mean number of previous HA of the 13 patients was 2.7, and mean AFS score after conventional treatments was still 8.7. Before the use of the stent, 46.2% of the patients had amenorrhea caused by IUAs. After using the intrauterine stent as a barrier, the mean AFS score was 1.7. The menstrual improvement rate was 100%, while the rate of resumption of normal menstrual volume was 53.8%. The second-look hysteroscopy revealed a correct position of the stents and no obvious recurrence of IUAs in all cases. After the removal of the stent, the patients were followed up for 2-13 months (mean: 7 months), and no amenorrhea was observed, the recurrence rate of IUAs was 25.0% and one patient got pregnant.

Conclusions

Even in the recurrent IUAs patients with very poor prognosis, the patented intrauterine stent has been proved to be very effective in preventing the recurrence of adhesions, on condition that its correct position inside the uterine cavity is achieved. Due to the extremely poor nature of the studied population, the recurrent rate of IUAs and pregnancy rate after the removal of the stent is still discouraging, although the improvement in menstruation is inspiring.

Logistic regression analyses of factors affecting fertility of intrauterine adhesions patients

Background

Intrauterine adhesion (IUA) prevalence is difficult to measure, but appears to have increased over the last few decades. The reproductive outcomes following hysteroscopic adhesiolysis (HA) for moderate-severe IUAs were unsatisfactory, and few studies have analyzed the clinical characteristics pre-, intra- and post-HA to determine the main risk factors for infertility in patients with IUAs.

Methods

This retrospective observational study included 406 patients, desiring fertility, who had undergone HA between January 1st, 2016 to May 31st, 2017, and had moderate-to-severe IUA [5-12 on the American Fertility Society (AFS) classification scale]. Logistic regression was performed to analyze the data of the clinical characteristics associated with IUA.

Results

A total of 406 IUA patients were initially collected. Twenty-six [26] were lost during follow-up or excluded by other criteria; 380 were included in the study with a follow-up period ranging from 2 to 3 years. There were 215 patients (56.6%) that became pregnant, of whom 18 spontaneously miscarried, 5 birthed prematurely (31-36 gestational weeks), 182 delivered at term, and 10 were pregnant at the end of the study. A bivariate and binary logistic regression analysis showed that an age of >30 years, cohesive IUA, lack of increased menstrual volume, and more than 2 times undergoing HA procedure were the risk factors for infertility in IUA patients (P<0.05).

Conclusions

Age, severity of IUA, increased menstrual volume, and HA procedures were the dominant factors affecting reproductive outcomes and may be regarded as potential predictors for evaluating IUA prognosis.

Effects of uterus derived mesenchymal stem cells and their exosomes on asherman's syndrome

Asherman's syndrome has become a growing problem with the incidence of cesarean and endometrial surgical procedures. A surgical procedure that can damage to the basal layer of the endometrium is formed as intrauterine adhesion and can cause asherman's syndrome. Mesenchymal stem cells (MSCs) are characterized by some characteristics such as non-immunogenic, angiogenic, antifibrotic, antiapoptotic and antiinflammatory properties, also they support tissue repair by secretion of various factors and chemokines in cellular therapy. Exosomes are active paracrine components with a great potential for repairing damaged tissue. Exosomes include many paracrine factors responsible for regeneration and angiogenesis. In this study, 10 newborn Wistar rats were used to obtain MSCs. A total of 24 adult Wistar rats were also used. The rats were divided into 4 groups: untreated control group; asherman control group; asherman + uterine-derived MSCs group; asherman + uterine-derived MSCs-exosomes group. At the end of the experiment, uterine tissues were evaluated by histochemical and immunohistochemical. As a result of MSCs and exosomes treatments, proliferation and vascularization in uterine tissue was increased. It was also shown to reduce fibrosis with masson's trichrome staining. MMP-2 and MMP-9 expression was enhanced by MSC and exosomal therapy; in addition, TIMP-2 expression was decreased. In our study, it was shown that proliferation and vascularization increased and fibrosis decreased in uterus as a result of MSC and exosome treatments. Our results indicate that the exosomal treatment restored the damage of asherman's syndrome at tissue at a shorter time than the MSCs group.

Collagen-binding basic fibroblast growth factor improves functional remodeling of scarred endometrium in uterine infertile women: a pilot study

Intrauterine adhesion (IUA) is a common cause of uterine infertility and one of the most severe clinical features is endometrial fibrosis namely endometrial scarring for which there are few cures currently. Blocked angiogenesis is the main pathological change in the scarred endometrium. The fibroblast growth factor 2 (bFGF), a member of FGF family, is usually applied to promote healing of refractory ulcer and contributes to angiogenesis of tissues. In this study, the sustained-release system of bFGF 100 µg was administrated around scarred endometrium guiding by ultrasound every 4 weeks in 18 patients (2-4 times). Results showed that after treatment, the menstrual blood volume, endometrial thickness and the scarred endometrial area were improved. Histological study showed blood vessel density increased obviously. Three patients (3/18) achieved pregnancy over 20 gestational weeks. Therefore, administrating the bFGF surrounding scarred endometrium may provide a new therapeutic approach for the patients with endometrial fibrosis.

Exosomes derived from mesenchymal stem cells reverse EMT via TGF-β1/Smad pathway and promote repair of damaged endometrium

Background

Intrauterine adhesion (IUA) is one of the most serious complications in patients with endometrial repair disorder after injury. Currently, there is no effective treatment for IUA. Stem cell is the main candidate of new therapy, which functions mainly through paracrine mechanism. Stem-derived exosomes (Exo) play an important role in tissue injury. Here, we mainly aim to study the effect of bone marrow mesenchymal stem cell (BMSC)-derived Exo on repairing endometrium of IUA animal models and its effect on TGF-β1 induced EMT in endometrial epithelial cells (EECs).

Methods

Totally, 64 female rabbits were randomly divided into Sham operation group, model group, BMSC treatment group, and Exo treatment group. EMT in EECs was induced by TGF-β1. Then, EECs were treated with Exo (25 μg/ml, 50 μg/ml, 100 μg/ml) for 24 h. HE staining and Masson staining were used to evaluate the changes in glandular number and fibrosis area. The expression levels of CK19 and VIM were detected by immunohistochemistry. Western blotting was used to detect the expression of CK19, VIM, FSP-1, E-cadherin, TGF-β1, TGF-β1R, Smad 2, and P-Smad 2. RT-PCR was used to detect mRNA expression levels of CK19, VIM, FSP-1, E-cadherin, TGF-β1, TGF-β1R, and Smad 2.

Results

Compared with the model group, the number of endometrial glands was significantly increased and endometrial fibrosis area was significantly decreased in BMSC and Exo groups (P < 0.05). CK19 level significantly increased whereas VIM level significantly decreased after treatment of BMSCs and Exo (P < 0.05). Additionally, the expressions of TGF-β1, TGF-β1R, and Smad2 mRNA were all significantly decreased after BMSC and Exo treatment (P < 0.05). Besides, phosphorylation levels of TGF-β1, TGF-β1R, and Smad2 were also significantly decreased in BMSC and Exo treatment groups (P < 0.05). Furthermore, there was no significant difference between BMSC and Exo treatment groups (P > 0.05). EMT was induced in EECs by 60 ng/ml TGF-β1 for 24 h. After Exo treatment for 24 h, mRNA expressions of CK-19 and E-cadherin increased, while those of VIM, FSP-1, TGF-β1, and Smad2 decreased. Additionally, protein expressions of CK-19 and E-cadherin increased, while those of VIM, FSP-1, TGF-β1, Smad2, and P-Smad2 decreased.

Conclusions

BMSC-derived Exo is involved in the repair of injured endometrium, with similar effect to that of BMSC, and can reverse EMT in rabbit EECs induced by TGF-β1. BMSC-derived Exo may promote endometrial repair by the TGF-β1/Smad signaling pathway.

Comparison of Intrauterine Suitable Balloon and Foley Balloon in the Prevention of Adhesion after Hysteroscopic Adhesiolysis

Objective

To compare the effect of intrauterine suitable balloon (ISB) and Foley balloon (FB) in the prevention of adhesion after hysteroscopic adhesiolysis in patients with intrauterine adhesions (IUAs).

Methods

A retrospective study was conducted on 150 women with moderate and severe IUAs, who underwent hysteroscopic adhesiolysis. According to the postoperative placement of the ISB or FB, the cohort was divided into the ISB group and the FB group. A second-look hysteroscopy was performed at 3 months postsurgery. The scoring system proposed by the American Fertility Society (AFS) was used to evaluate the adhesion during hysteroscopy. Subgroup analysis was carried out based on the degree of IUAs.

Results

(1) In the ISB group, only 25% (19/76) women presented adhesion reformation after surgery, while, in the FB group, the adhesion reformation was observed in 35.1% (26/74) patients; however, the difference was not statistically significant (P>0.05). Subsequently, the adhesion reformation rate (29.5%, 13/44) after surgery with an ISB for severe intrauterine adhesions was significantly lower as compared to that (53.6%, 15/28) with FB (P<0.05). (2) In the ISB group, the reduction in the adhesion score after surgery was 8 points, which was significantly higher than the 7 points in the FB group (P<0.05).

Conclusion

The ISB is better than the FB in preventing the adhesion reformation and reducing the AFS score after hysteroscopic adhesiolysis in severe IUAs. Also, it can effectively prevent the adhesion reformation in severe IUAs with a similar effect on moderate IUAs.

Clinico-hysteroscopic analysis of severe intrauterine adhesions among Nigerian infertile women

Introduction

Severe intrauterine adhesions are difficult to manage and are associated with poor reproductive outcomes following treatment. The objective was to study the clinical presentation and hysteroscopic findings of severe intrauterine adhesions seen at hysteroscopy in two fertility/gynaecological endoscopy units in Nigeria.

Methods

A prospective study of 19 out of 76 women managed for intrauterine adhesions in our units. Data were analyzed with STATA software, version 12.0 SE (Stata Corporation, TX, USA).

Results

Severe intrauterine adhesion accounted for 19 (25.0%) of 76 cases of intrauterine adhesions managed during the period. This constituted 11.9% of 160 infertile women who had diagnostic hysteroscopies in our units over the study period. The mean duration of symptom was 4.2 years +/-3.2. Amenorrhea in association with infertility (68.4%) was the main presenting complaint. Secondary dysmenorrhea and cyclical abdominal pain were found in 10.8% and 31.6% of the women respectively. The main aetiological events were complicated caesarean section (42.1%) and abdominal myomectomy (26.3%). The adhesions were mainly dense (52.6%) and multiple (94.7%) with complete involvement of the uterine cavity in all the cases. Obliterative lesions were seen in 63.2% of the women.

Conclusion

The main clinical presentation of severe IUA was amenorrhea and infertility while the major risk factors were complicated caesarean section and myomectomy. The adhesions were mainly multiple, dense, obliterative and complete.

Dominant factors affecting reproductive outcomes of fertility-desiring young women with intrauterine adhesions

PURPOSE

To identify the dominant factors affecting reproductive outcomes of fertility-desiring young women with intrauterine adhesions (IUA) after hysteroscopic adhesiolysis.

METHODS

This prospective observational study included 104 cases of women with IUA. Logistic regression analysis was applied to analyze the value of the location and extent of adhesions, the number of previous uterine cavity surgery, menstrual patterns, and second look hysteroscopy time.

RESULTS

In the total 104 patients with IUA, 91 patients (87.5%) had a history of at least one previous uterine cavity surgery. Hypomenorrhoea and amenorrhoea were two most common presenting menstrual abnormalities occurring in 59 (56.7%) and 28 (26.9%) cases, respectively. The clinical pregnancy rate was 60.6% (63/104) and the live birth rate was 39.4% (41/104). Pregnancy rate was higher in patients having mild IUA (81.5%) as compared to moderate (61.3%) or severe type (20.0%) (p < 0.001). The bivariate and binary logistic regression analysis revealed that the location and extent of adhesions were the independent parameters related to the reproductive outcome after hysteroscopic adhesiolysis for fertility-desiring women with IUA (p = 0.011 and p = 0.003, respectively), but not the number of previous uterine cavity surgery, menstrual patterns, and second look hysteroscopy time (p = 0.232, p = 0.239 and p = 0.120, respectively).

CONCLUSION

The extent and location of IUA are the dominant factors affecting reproductive outcomes, which are possibly regarded as a potential predictor evaluating prognosis of IUA after hysteroscopic adhesiolysis.

Management of endometrial polyps incidentally diagnosed during IVF: a case-control study

An endometrial polyp is a frequently encountered abnormality of the uterine cavity that may interfere with normal embryo implantation. In this case-control study, we enrolled 56 women in whom endometrial polyps were incidentally diagnosed by transvaginal ultrasound and office hysteroscopy during IVF (Group 1), and 112 age-matched IVF controls randomly selected from the same time period (group 2). Cryopreserved embryos were transferred in group 1 whereas fresh embryos were transferred in group 2, which is a limitation of the study. Hysteroscopic polypectomy was carried out for those in group 1, followed by vitrified-warmed embryo transfer 1-7 months later. Results revealed that the clinical pregnancy rate was higher in group 1 than in group 2 (63% versus 41%, P = 0.009), but the embryo implantation rates were not different between the two groups (26% versus 20%). In group 1, pregnancy rates (64%, 69%, and 53% respectively) and embryo implantation rates (30%, 24%, and 23%, respectively) were similar among women that received vitrified-warmed embryo transfer at 1, 2, and 3 months or over after hysteroscopic polypectomy. We conclude that, for women with endometrial polyps incidentally diagnosed during IVF, pregnancy outcomes are not compromised after hysteroscopic polypectomy followed by vitrified-warmed embryo transfer.

Prevalence and Impact of Chronic Endometritis in Patients With Intrauterine Adhesions: A Prospective Cohort Study

STUDY OBJECTIVE

To evaluate the prevalence and impact of chronic endometritis (CE) in patients with intrauterine adhesions (IUAs).

DESIGN

Prospective cohort study (Canadian Task Force classification II-2).

SETTING

University-affiliated hospital.

PATIENTS

Eighty-two women with moderate to severe IUAs.

INTERVENTIONS

Transcervical resection of adhesions (TCRA) and endometrial biopsy were performed in all patients. According to results of the endometrial biopsy, participants were classified into 2 groups: 29 patients with CE (CE group) and 53 women without CE (NCE group). Second-look hysteroscopy assessed the impact of TCRA using the American Fertility Society classification system.

MEASUREMENTS AND MAIN RESULTS

Prevalence of CE, reformation of adhesions, and reduction of adhesion score were studied. Thirty-one women (37.8%) presented with visual signs of CE at hysteroscopy, confirmed by histology in 29 of 82 patients (35.4%). In hysteroscopic diagnosis of CE, sensitivity and specificity were 79.3% (23/29) and 84.9% (45/53), respectively. At second-look hysteroscopy, the recurrence of adhesions in the CE group was significantly higher than in the NCE group (44.8% vs 20.8%, respectively; p = .022). The median reduction of adhesion score was significantly greater in the NCE group (median, 8; range, 0-12) than in the CE group (median, 5; range, 0-10).

CONCLUSION

CE in women with IUAs may be a contributing factor in higher adhesion recurrence, indicating chronic inflammation may play a role in IUA recurrence. (Clinical Trial Registration No.: NCT02744807.).

Oxidized, Regenerated Cellulose Adhesion Barrier Plus Intrauterine Device Prevents Recurrence After Adhesiolysis for Moderate to Severe Intrauterine Adhesions

STUDY OBJECTIVE

To compare the efficacy of an oxidized, regenerated cellulose adhesion barrier (Interceed; Ethicon, Somerville, NJ) combined with an intrauterine device (IUD) versus an IUD alone for preventing adhesion recurrence following hysteroscopic adhesiolysis for moderate to severe intrauterine adhesions (IUAs).

DESIGN

Retrospective case series (Canadian Task Force classification III).

SETTING

Tertiary care teaching hospital.

PATIENTS

Patients undergoing treatment for moderate to severe IUAs. The severity of IUA was determined based on the American Fertility Society scoring system (mild, moderate, or severe).

INTERVENTIONS

All cases of hysteroscopic adhesiolysis were reviewed.

MEASUREMENTS AND RESULTS

Seventy-six women with moderate to severe IUAs treated between March 2009 and August 2015 were included. After hysteroscopic adhesiolysis, 35 patients were treated with an IUD alone (group 1), and 41 patients were treated with Interceed plus an IUD (group 2). A second hysteroscopy was performed in all cases three months after the initial hysteroscopy and both groups achieved significant reduction in adhesion scores and grade, especially in group 2 (scores, p < .001; grade, p = .039). Compared with group 1, menstruation dysfunction, pregnancy rate, and live birth rate in group 2 improved with no statistical difference (menstruation improvement, p = .764; pregnancy rate, p = .310; live birth rate, p = .068). However, an adhesion-free uterine cavity was regained significantly owing to the fewer operations in group 2 compared with group 1 (median, 3 vs 4; p = .001). The interval from initial hysteroscopy to conception was significantly shorter in group 2 (median, 12 months vs 51 months; p < .001).

CONCLUSIONS

For moderate to severe IUAs, Interceed combined with an IUD may be an alternative approach for reducing adhesion recurrence after hysteroscopic adhesiolysis.

Factors Influencing the Recurrence Potential of Benign Endometrial Polyps after Hysteroscopic Polypectomy

Background

An endometrial polyp is a frequently encountered gynecologic disease with abnormal uterine bleeding and infertility being the two common presenting problems, and hysteroscopic polypectomy is an effective method to remove them. The postoperative polyp recurrence might result in reappearance of abnormal uterine bleeding or infertility, whereas factors influencing the postoperative recurrence potential have limited data.

Methods

This case-series report included 168 premenopausal women who suffered from endometrial polyps and underwent hysteroscopic polypectomy. All of them were awaiting a future pregnancy. Office hysteroscopy was done before and after hysteroscopic polypectomy, in which preoperative hysteroscopy examined the number, type, and location of endometrial polyps, and postoperative hysteroscopy checked the polyp recurrence. Surgical indications, either infertility or the presentation of abnormal uterine bleeding, and follow-up duration were recorded.

Results

Seventy-three out of 168 (43%) women had polyp recurrence after hysteroscopic polypectomy. Multivariate logistic regression analysis revealed that more endometrial polyps (P = 0.015) and longer duration of follow-up (P = 0.004) were significantly associated with an increased risk of postoperative polyp recurrence. The type of endometrial polyps was not correlated with polyp recurrence potential, whereas pedunculated type endometrial polyps were closely related to the presentation of abnormal uterine bleeding (P = 0.001).

Conclusions

A higher number of endometrial polyps and longer follow-up duration are associated with a greater potential of polyp recurrence after hysteroscopic polypectomy.