Comparison of the localization of intrauterine adhesions in pregnant and infertile women

Intrauterine Adhesion Band Causing Fetal Leg Compression: A Case Report of a Rare Asherman Syndrome Complication in Pregnancy

Asherman syndrome (AS), characterized by intrauterine adhesions, can lead to various pregnancy complications. We report a case of a 31-year-old woman who was admitted at 29+2 weeks due to preterm premature rupture of membranes at our university hospital. The woman had a history of AS following emergency curettage. Ultrasonography revealed an adhesion band in the lower uterine segment, closely positioned to the fetus's leg. Antibiotic therapy and antenatal corticosteroids were administered to prevent infection and neonatal respiratory distress syndrome. Two weeks later, the woman developed labor contractions and pathological cardiotocography, leading to a secondary cesarean section. During surgery, the fetus was found to be in an incomplete breech position, with one leg trapped beneath the adhesion band. Delivery was achieved by releasing the other leg and cutting the adhesion band. The neonate was born with significant right leg edema, likely due to chronic intrauterine compressionby the adhesion band. Postoperatively, the neonate required intensive care. Regular orthopedic visits confirmed intact circulation, sensory, and motor function of the leg and the edema gradually resolved. This case highlights a rare pregnancy complication due to an intrauterine adhesion band and emphasizes the importance of accurate and early adhesion band detection such as the differential diagnostic exclusion of the more common amniotic band via ultrasound. It is a good example of multidisciplinary care provided by obstetricians, neonatologists and orthopedic surgeons in a perinatal care center.

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.

Ultrasound-Responsive Hydrogel Incorporated with TGF-β Mimetic Peptides for Endometrium Recovery to Restore Fertility

Unavoidable damage to the basal layer of the endometrium has a huge negative impact on a woman's reproductive health and menstrual cycle. However, it is difficult for medicine to penetrate a series of biological barriers toward the basal layer in the deeper area of the endometrium. To meet this challenge, we developed an ultrasound-responsive hydrogel incorporated with a transforming growth factor-beta (TGF-β) mimetic peptide to enhance pregnancy outcomes by restoring the function of a wounded endometrium due to its deep-tissue-penetration capability. In vitro studies revealed that the TGF-β-mimetic-peptide-loaded hydrogel could achieve 64.35% of cell migration under ultrasound stimulation even in phosphate-buffered saline of pH 6.0. Upon in situ sonication at the uterus, carboxymethyl chitosan can be released from degraded hydrogel to open tight junctions with reduced interstitial pressure by ultrasound to promote deep penetration. Rat studies revealed that the penetration capability of TGF-β-mimetic-peptide-loaded hydrogel with sonication was 1.6 times higher than that of the control group. Besides the rat uterine model, ex vivo human uterine tissue was also collected and imaged, demonstrating up to ∼700 μm of tissue penetration depth. In addition, compared to control groups, effective uterus recovery without intrauterine stenosis and endometrial cavity fluid was observed from rats with severe uterine injury treated by TGF-β-mimetic-peptide-loaded hydrogel. In addition, fertility restoration in the endometrial injury model was observed after treatment with such an ultrasound-responsive hydrogel incorporated with TGF-β mimetic peptides. Overall, this work provides an effective approach to treating endometrial injury for enhanced pregnancy outcomes.

Long-term effects of hysteroscopic adhesiolysis on postoperative pregnancy rates and fertility outcomes in patients with intrauterine adhesions

OBJECTIVE

To investigate the long-term effects of hysteroscopic adhesiolysis on postoperative pregnancy rates and fertility outcomes in patients with intrauterine adhesions (IUA).

METHODS

A retrospective analysis was conducted on 105 patients with IUA treated at Baoji Maternal and Child Health Hospital from June 2022 to December 2023. All patients underwent hysteroscopic adhesiolysis. Based on the adjunctive treatment, patients were divided into two groups: the observation group (n=55), which received adhesiolysis plus balloon uterine stent placement, and the control group (n=50), which received adhesiolysis alone. We compared clinical efficacy, changes in endometrial thickness, menstrual volume, and serum estrogen levels, including estrogen receptor (ER) and progesterone receptor (PR) levels, between the two groups. Additionally, we recorded and compared the 3-month postoperative recurrence rate of IUA, pregnancy rates and outcomes, and complications. The predictive value of ER and PR levels for postoperative pregnancy was also analyzed. We then compared the general data of patients who became pregnant after surgery with those who did not, and used multivariate logistic regression to analyze the factors influencing postoperative non-pregnancy.

RESULTS

The overall treatment efficacy was significantly higher in the observation group than in the control group (P<0.05). The observation group showed significantly greater improvements in endometrial thickness, menstrual volume, and serum estrogen levels compared to the control group (all P<0.05). The recurrence rate of adhesions during follow-up was significantly lower in the observation group than in the control group (P<0.05). The postoperative pregnancy rates and fertility outcomes were also significantly better in the observation group (both P<0.05). The sensitivity and specificity of ER levels in predicting postoperative pregnancy were 78.05% and 70.31%, respectively, with an AUC of 0.788. For PR levels, the sensitivity was 75.61%, specificity was 71.88%, and AUC was 0.834. Multivariate regression analysis indicated that age, adhesion severity, adhesion recurrence, and the use of a balloon uterine stent were independent risk factors affecting postoperative pregnancy in patients with IUA (P<0.05).

CONCLUSION

The combination of adhesiolysis and intrauterine balloon stent placement in patients with moderate to severe intrauterine adhesions significantly IUA increases endometrial thickness and volume, promotes menstrual recovery, prevents re-adhesion, and improves pregnancy outcomes. This approach is recommended for clinical application.

Intrauterine infusion of platelet-rich plasma improves fibrosis by transforming growth factor beta 1/Smad pathway in a rat intrauterine adhesion model

This study aims to elucidate the effects of Platelet-rich plasma (PRP) in fibrosis development in intrauterine adhesion (IUA), and the associated underlying mechanisms are also explored, which are expected to be a potential therapeutic scheme for IUA. In this research, PRP was obtained and prepared from the peripheral venous blood of rats. A rat model was induced by mechanical injury. Further, PRP was directly injected into the uterus for treatment. The appearance and shape of the uterus were assessed based on the tissues harvested. The fibrosis biomarker levels were analyzed. The transforming growth factor beta 1 (TGF-β1) and Mothers against decapentaplegic homolog 7 (Smad7) levels, the phosphorylation of Smad2 (p-Smad2), and the phosphorylation of Smad3 (p-Smad3) were analyzed, and the molecular mechanism was investigated by rescue experiments. It was found that PRP improved the appearance and shape of the uterus in IUA and increased endometrial thickness and gland numbers. The administration of PRP resulted in a decrease in the expressions of fibrosis markers including collagen I, α-SMA, and fibronectin. Furthermore, PRP increased Smad7 levels and decreased TGF-β1 levels, p-Smad2, and p-Smad3. Meanwhile, administration of TGF-β1 activator reversed the therapeutic effects of PRP in IUA. Collectively, the intrauterine infusion of PRP can promote endometrial damage recovery and improve endometrial fibrosis via the TGF-β1/Smad pathway. Hence, PRP can be a potential therapeutic strategy for IUA.