Hysteroscopic management of uterine synechiae: a series of 102 observations

The link between intrauterine adhesions and impaired reproductive performance: a systematic review of the literature

Background

Intrauterine adhesions (IUAs) are one of the main reproductive system diseases in women worldwide. Fusion between the injured opposing walls leads to partial-to-complete obliteration of the cavity and/or cervical canal. The main clinical manifestations in case of IUAs are menstrual disturbances, cyclic pain and reproductive disorders. The reproductive outcomes of women with IUAs remain limited and inefficient compared to women without IUAs, even after adhesiolysis. An exact understanding of the underlying mechanisms and processes to explain the compromised reproductive performance and outcomes in case of IUAs are lacking.

Methods

A systematic literature review of MEDLINE-PubMed (1966 to January 2022) and EMBASE (1974 to January 2022) was performed following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Studies were included if they reported underlying causes, related mechanisms and processes to explain the association between IUAs and impaired reproductive performance, pregnancy and obstetric complications.

Results

After an extensive review of the literature, 58 articles were identified reporting underlying mechanisms to explain the association between IUAs and impaired fertility. Intrauterine scarring influences the process of fertilization, reproductive performance and ultimately reproductive outcome. IUAs can disturb the cervico-utero-tubal sperm transport and result in an avascular and unresponsive endometrium with decreased receptivity and thickness. Abnormal decidualization and abnormal trophoblastic infiltration leads to placental attachment disorders. Moreover, the risk for premature delivery, intrauterine fetal growth restriction and fetal anomalies is increased in case of IUAs.

Conclusion

The impact of IUAs on reproductive performance, even after adhesiolysis, is becoming more apparent. The postulated mechanisms to explain the association are related to sperm transport, embryo implantation and placentation. Prevention, by preserving the basal layer of the endometrium is essential. Effective and evidence-based strategies for the prevention of endometrial injury and formation of IUAs, are urgently needed.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-022-05164-2.

Postoperative reproductive results of infertile patients with intrauterine adhesions: A retrospective analysis

OBJECTIVE

To explore the reproductive outcomes after hysteroscopic separation of intrauterine adhesions (IUA) in infertile patients due to IUA.

METHODS

This retrospective study enrolled patients with fertility requirements and infertility due to IUA. Data were collected from the hospital medical records and by follow-up by telephone. The impact on pregnancy and pregnancy outcome of preoperative adhesion, menstrual conditions before and after surgery and postoperative re-adhesion was analysed.

RESULTS

A total of 106 patients (median age, 28 years) were enrolled in the study. There was a significant correlation between preoperative menstrual patterns and pregnancy rate. There were 56 pregnancies (pregnancy rate 52.83%) after the operation. Patients with improved menstruation after the operation had a significantly higher pregnancy rate (pregnancy rate 56.25%; 45 of 80 patients) compared with the patients that did not experience any improvement in their postoperative menstrual status (pregnancy rate 21.43%; three of 14 patients). Of the 56 pregnancies, 40 (71.43%) resulted in live births and six (10.71%) patients had miscarriages. A total of 54 of 56 patients (96.43%) became pregnant within 2 years.

CONCLUSION

Pregnancy after intrauterine adhesion separation has a high rate of miscarriage and obstetric complications, so close monitoring of the patient is required.

Recent Advances in Understandings Towards Pathogenesis and Treatment for Intrauterine Adhesion and Disruptive Insights from Single-Cell Analysis

Intrauterine adhesion is a major cause of menstrual irregularities, infertility, and recurrent pregnancy losses and the progress towards its amelioration and therapy is slow and unsatisfactory. We aim to summarize and evaluate the current treatment progress and research methods for intrauterine adhesion. We conducted literature review in January 2020 by searching articles at PubMed on prevention and treatment, pathogenesis, the repair of other tissues/organs, cell plasticity, and the stem cell–related therapies for intrauterine adhesion. A total of 110 articles were selected for review. Uterine cell heterogeneity, expression profile, and cell-cell interaction were investigated based on scRNA-seq of uterus provided by Human Cell Landscape (HCL) project. Previous knowledge on intrauterine adhesion (IUA) pathogenesis was mostly derived from correlation studies by differentially expressed genes between endometrial tissue of intrauterine adhesion patients/animal models and normal endometrial tissue. Although the TGF-β1/SMAD pathway was suggested as the key driver for IUA pathogenesis, uterine cell heterogeneity and distinct expression profile among different cell types highlighted the importance of single-cell investigations. Cell-cell interaction in the uterus revealed the central hub of endothelial cells interacting with other cells, with endothelial cells in endothelial to mesenchymal transition and fibroblasts as the strongest interaction partners. The potential of stem cell–related therapies appeared promising, yet suffers from largely animal studies and nonstandard study design. The need to dissect the roles of endometrial cells, endothelial cells, and fibroblasts and their interaction is evident in order to elucidate the molecular and cellular mechanisms in both intrauterine adhesion pathogenesis and treatment.

Early Second-Look Hysteroscopy: Prevention and Treatment of Intrauterine Post-surgical Adhesions

Introduction: Intra-uterine adhesion (IUA) is one of the main causes of secondary infertility. The aim of this study was to evaluate the prevalence of IUA developing in women undergoing hysteroscopic resection for submucous myomas, polyps, and intrauterine synechiae and test the efficacy of second look hysteroscopy for diagnosing and treating post-surgical adhesions.

Materials and Methods: We retrospectively collected data from reproductive age women who had a second look office hysteroscopy following hysteroscopic resection for myoma, polyp, or IUA at Foch hospital (Suresnes, France) between 2009 and 2017.

Results: Six hundred and twenty two reproductive-age women underwent hysteroscopic resection for myoma, polyp, and/or IUA. Among them, 155 women had a second look hysteroscopy. In this group, 29/155 (18.7%) had IUA formation: 17/83 (20.5%) women who underwent hysteroscopic myomectomy, 5/46 (10.9%) women who underwent hysteroscopic polypectomy, and 7/26 (26.9%) women who underwent hysteroscopic lysis of adhesions. These IUA have been lysed by the office hysteroscopy procedure in 16/29 (55.2%) patients: 11/17 (64.7%), 2/5 (40%), and 3/7 (42.9%) in women who underwent hysteroscopic myomectomy, polypectomy and lysis of adhesion, respectively.

Conclusion: IUA is a common complication of hysteroscopic surgery. Second look office hysteroscopy is an easy and effective procedure for diagnosing and removing newly formed IUA. It should be recommended for all women undergoing hysteroscopic resection for myomas, polyps, or IUA.

Live birth rate and obstetric complications following the hysteroscopic management of intrauterine adhesions including Asherman syndrome

STUDY QUESTION

What are the live birth rate and risks of obstetric complications following the surgical management of intrauterine adhesions (IUA) such as Asherman syndrome (AS)?

SUMMARY ANSWER

The live birth rate is 63.7%, and obstetric complications including placentation issues, prematurity and postpartum hysterectomy require that pregnancies in women after treatment for IUA should be considered moderate to high risk.

WHAT IS KNOWN ALREADY

Studies reviewing short-term surgical, menstrual and fertility outcomes following hysteroscopic management are reassuring, with success correlated to the severity of IUA. There are limited data reporting live birth, neonatal and maternal complications.

STUDY DESIGN, SIZE, DURATION

This retrospective study included all women treated for IUA by hysteroscopic synechiolysis under fluoroscopic guidance in two tertiary University-affiliated hospitals. All women reported at least one pre-treatment symptom including menstrual dysfunction, subfertility or pelvic pain and intended to become pregnant post-treatment. Survival curve analysis was performed for time to pregnancy, and obstetric data were collated from a National Obstetric Database for delivery and neonatal outcomes.

PARTICIPANTS/MATERIALS, SETTING, METHODS

A total of 154 women were included in the study. Surgical intervention involved hysteroscopic synechiolysis under fluoroscopic guidance until cavity restoration was confirmed. Questionnaires regarding fertility and its outcomes were sent to all women undergoing surgery, with analysis of menstrual, fertility rates and outcomes of those pregnancies including risks and complications to the woman and the offspring.

MAIN RESULTS AND THE ROLE OF CHANCE

Women were followed up for a minimum of 1 year (range: 1-14 years) from index surgery. The chance of pregnancy was 98/124 (79.0% CI: 63.6, 83.1%) in women wishing to conceive and the chance of a live birth was 79/124 (63.7% CI: 51.3, 70.7%). The chance of a miscarriage was 29/124 (23.4% CI: 18.8, 37.1%). There were 93 live births in 79 women following surgery, with detailed obstetric data available for 85 of these births. They were complicated by abnormal placentation in 15/85 (17.6% CI: 13.0, 30.2%), postpartum hysterectomy in 4/85 (4.7% CI: -0.4, 7.0%), and prematurity in 25/85 (29.4% CI: 17.0, 35.3%) women.

LIMITATIONS, REASONS FOR CAUTION

The retrospective nature of the study and extended follow-up time may cause selection and recall bias, however, pregnancy and its outcomes-particularly in women with problems of subfertility-are frequently key milestones, with birthdates readily recalled. Menstrual outcomes are more likely to be subject to recall bias.

WIDER IMPLICATIONS OF THE FINDINGS

Our surgical data are similar to the published literature with reassuring short-term outcomes for menstruation and cavity reconstruction following surgery for IUA. Long-term outcomes including pregnancy rates were higher than published data, however, the obstetric and neonatal complication rates were increased, indicating a continuation of risk beyond infertility and into pregnancy. An altered biochemical or vascular environment is a possible explanation for impaired implantation resulting in poorer reproductive obstetric and neonatal outcomes. The relative rarity of IUA-particularly severe disease-makes prospective data collection difficult. Our data suggest that women with IUA should be treated as moderate-high risk obstetric patients in subsequent pregnancy and counselled appropriately.

STUDY FUNDING/COMPETING INTEREST(S)

No funding and no competing interests.

Efficacy of an antiadhesive agent for the prevention of intra-abdominal adhesions after radical gastrectomy: A prospective randomized, multicenter trial

BACKGROUND

Guardix-SG is a poloxamer-based antiadhesive agent. The aim of this study was to investigate its efficacy in preventing abdominal adhesions in gastric cancer patients undergoing gastrectomy. Few clinical studies have reported that antiadhesive agent reduces the incidence of adhesion after gastrectomy.

METHODS

We conducted a multicenter trial from June 2013 and August 2015 in patients with gastric adenocarcinoma undergoing radical gastrectomy. Patients were randomly assigned to the Guardix treatment or control group. Postoperative adhesions were diagnosed based on postoperative symptoms, plain x-ray films, and computed tomography. The primary endpoint of the study was the incidence of small bowel obstruction in the first postoperative year. The secondary end-point was the safety of Guardix-SG.

RESULTS

The study included 109 patients in the Guardix group and 105 patients in the control group. The groups were similarly matched with pathological stage, operation type, anastomosis method, midline incision length, and the extent of lymph node dissection. Eight in the Guardix group and 21 in the control group experienced intestinal obstruction during the 1-year follow-up period. The cumulative incidence of small bowel obstruction was significantly lower in the Guardix group compared to that seen in the control group (4.7% vs 8.6% at 6 months and 7.3% vs 20% at 1 year; P = .007, log-rank test). There were no differences in postoperative complications and adverse events.

CONCLUSION

Guardix-SG significantly decreased the incidence of intestinal obstruction without affecting the incidence of postoperative complications.

Reproductive outcomes after surgical treatment of asherman syndrome: A systematic review

In this systematic review, we analysed the reproductive outcomes of hysteroscopic adhesiolysis in women with Asherman syndrome (AS). We searched PubMed, Web of Science and Cochrane Library (from database inception to April 2018) and selected studies that quantitatively described the reproductive outcomes. We assessed study quality and pooled rate data for each outcome. There were 54 studies (4640 women) of varying quality. The pooled rate of pregnancy was 50.7% (95% CI [confidence interval]: 49.1 to 52.3) in 53 studies, early pregnancy loss was 17.7% (95% CI: 15.9 to 19.6) in 31 studies, ectopic pregnancy (EP) was 4.2% (95% CI: 2.8 to 6.3) in 9 studies, mid-trimester loss (MTL) was 11.5% (95% CI: 7.6 to 17.8) in 7 studies, cervical incompetence was 12.5% (95% CI: 3.3 to 33.5) in 2 studies and placenta accreta syndrome was 10.1% (95% CI: 8.6 to 11.8) in 23 studies. The pregnancy rate in women with severe adhesion was significantly lower than that in women with mild adhesion (P = 0.021). These results can be used to counsel women with AS before surgical treatment and for planning antenatal care after conception.

The Relationship Between Gelatin Sponge Preparation Methods and the Incidence of Intrauterine Synechia Following Uterine Artery Embolization for Postpartum Hemorrhage

PURPOSE

To evaluate the relationship between gelatin sponge preparation methods and the incidence of intrauterine synechia following uterine artery embolization (UAE) for postpartum hemorrhage (PPH).

MATERIALS AND METHODS

In a retrospective monocentric study, we used data from 20 consecutive UAE procedures (19 patients) for PPH, performed in 2007-2016, in which gelatin sponge had been used. The gelatin sponge was processed either into a slurry by pumping it back and forth about 10 times through two syringes connected to a three-way stopcock or into pledgets using a scalpel and small scissors to obtain pieces approximately 2 × 2 × 2 mm in size. Patient information was obtained from medical records, and the data were compared between patients treated with the slurry (n = 7) or pledgets (n = 13) forms. Due to the lack of follow-up data and hysterectomy after UAE, the sample size was 6 and 12 because 1 patient with 2 procedures was excluded.

RESULTS

The rate of intrauterine synechia was significantly higher in the slurry group (5/6, 83.3%) than that in the pledgets group (0/12, 0%; P < 0.001). In contrast, there were no significant differences in population characteristics, such as the incidence of placenta accreta, non-placental diseases, and severity of shock (DIC score, shock index, or blood loss) between the groups.

CONCLUSIONS

Although non-randomization and small sample size were the two main limitations, our observations suggest that UAE using gelatin sponge slurry may be associated with a high incidence of intrauterine synechia compared to UAE using pledgets.

Intrauterine adhesion prevention after hysteroscopy: a systematic review and meta-analysis

BACKGROUND

Despite years of studies evaluating prevention strategies for intrauterine adhesion formation after operative hysteroscopy, it is still unclear which strategies are most effective.

OBJECTIVE

The objective of the study was to perform a systematic review and meta-analysis to evaluate the effectiveness of postoperative prevention strategies on intrauterine adhesion formation following operative hysteroscopy.

STUDY DESIGN

Literature searches were conducted in MEDLINE, Embase, ClinicalTrials.gov, and Cochrane Library databases. Inclusion criteria were published randomized controlled clinical trials from 1989 to 2014 comparing any postoperative preventative measures of intrauterine adhesion after hysteroscopy. The main outcome measure was a reduction in postoperative intrauterine adhesion. Heterogeneity of the studies was evaluated using a Q test and an I(2) index. Analyses were performed using a random-effects model with outcome data reported as relative risk with 95% confidence interval.

RESULTS

Twelve studies were included in the systematic review. Eight studies compared similar treatment methods and were included in the meta-analysis. Three studies evaluated hyaluronic acid gel, of which 2 reported a significant decrease in intrauterine adhesion with treatment. The meta-analysis demonstrated a significant reduction of intrauterine adhesion when using hyaluronic acid gel. Two studies evaluated polyethylene oxide-sodium carboxymethylcellulose gel, 1 of which demonstrated a decrease in intrauterine adhesion with treatment. A meta-analysis showed a significant reduction of intrauterine adhesion with polyethylene oxide-sodium carboxymethyl cellulose gel. However, these 3 studies demonstrating a benefit of the gels in preventing adhesion formation were all conducted by the same research group. Other research groups have not confirmed these results. A sensitivity analysis excluding these trials from this single group demonstrated no benefit to adhesion prevention with either gel formation. Three studies investigated oral estrogen therapy after hysteroscopy and found no difference in intrauterine adhesion. A meta-analysis showed no decrease in intrauterine adhesion with estrogen therapy after hysteroscopy. Data were lacking to perform metaanalyses on the use of intrauterine balloon, intrauterine device, and other adhesion prevention barriers in preventing intrauterine adhesion.

CONCLUSION

There was a lack of definitive evidence to conclude that any treatment is effective in preventing posthysteroscopy uterine adhesion formation. The available literature has significant heterogeneity and a high risk of bias, making any definitive conclusions difficult.

Optimal uterine anatomy and physiology necessary for normal implantation and placentation

The authors review aberrations of uterine anatomy and physiology affecting pregnancy outcomes with IVF. In the case of endometriosis and hydrosalpinx, pathologies outside of the uterus alter the uterine endometrium. In the case of endometriosis, Dominique de Ziegler outlines the numerous changes in gene expression and the central role of inflammation in causing progesterone resistance. With endometriosis, the absence of ovarian function inherent in deferred transfer, with or without a more lengthy suppression of ovarian function, appears to be sufficient to restore normal function of eutopic endometrium. Because laparoscopy is no longer routine in the evaluation of infertility, unrecognized endometriosis then becomes irrelevant in the context of assisted reproductive technology. With hydrosalpinx and submucus myomas, the implantation factor HOXA-10 is suppressed in the endometrium and, with myomas, even in areas of the uterus not directly affected. Daniela Galliano reviews various uterine pathologies, the most enigmatic being adenomyosis, where the endometrium also manifests many of the changes seen in endometriosis and deferred transfer with extended suppression appears to provide the best outcomes. Ettore Cicinelli's group has extensively studied the diagnosis and treatment of endometritis, and although more definitive diagnosis and care of this covert disorder may await techniques such as sequencing of the endometrial microbiome, it undoubtedly is an important factor in implantation failure, deserving our attention and treatment.

Ovarian thrombosis and uterine synechiae after arterial embolization for a late postpartum haemorrhage

Background

We report two unusual separate complications after uterine artery embolization for a late postpartum haemorrhage. This report appeared important to us in view of the apparent absence of any other publications on this topic.

Case presentation

We report the case of a 25-year-old woman, gravida 3, para 1, admitted for uterine bleeding 7 days after a spontaneous delivery at term, in our university hospital. A suction curettage and then, after persistent bleeding, uterine artery embolization were necessary. Immediately after the embolization, a bilateral ovarian thrombosis occurred, subsequently followed by amenorrhea, due to uterine synechiae, and depression. Hysteroscopic surgery was performed to remove the adhesions. A complete work-up for thrombophilia showed a heterozygous mutation of the factor V gene R506Q. The pathology examination found subinvolution of the placental bed. One month after treatment of the synechiae (and insertion of a copper IUD for contraception), the woman's menstrual cycle returned to normal. Her clinical examination 19 months later was normal.

Conclusions

This case teaches us that one rare complication can hide another! It is important to consider the diagnosis of subinvolution of the placental bed in cases of late PPH and to know the complications associated with vascular artery embolization in order to provide the most rapid and least invasive treatment.

•

Arterial embolization is associated with ovarian thrombosis.

•

Do not forget the subinvolution of the placental bed in late postpartum haemorrhage.

•

Suction curettage can lead to uterine synechiae.

Efficacy of intrauterine device in the treatment of intrauterine adhesions

The primary purpose of this paper is to assess the efficacy of the use of the intrauterine device (IUD) as an adjunctive treatment modality, for intrauterine adhesions (IUAs). All eligible literatures were identified by electronic databases including PubMed, Scopus, and Web of Science. Additional relevant articles were identified from citations in these publications. There were 28 studies included for a systematic review. Of these, 5 studies were eligible for meta-analysis and 23 for qualitative assessment only. Twenty-eight studies related to the use of IUDs as ancillary treatment following adhesiolysis were identified. Of these studies, 25 studies at least one of the following methods were carried out as ancillary treatment: Foley catheter, hyaluronic acid gel, hormonal therapy, or amnion graft in addition to the IUD. There was one study that used IUD therapy as a single ancillary treatment. In 2 studies, no adjunctive therapy was used after adhesiolysis. There was a wide range of reported menstrual and fertility outcomes which were associated with the use of IUD combined with other ancillary treatments. At present, the IUD is beneficial in patients with IUA, regardless of stage of adhesions. However, IUD needs to be combined with other ancillary treatments to obtain maximal outcomes, in particular in patients with moderate to severe IUA.

Efficacy of estrogen therapy in patients with intrauterine adhesions: systematic review

Hysteroscopic adhesiolysis has become the preferred option for management of intrauterine adhesions (IUA). Use of estrogen as perioperative adjuvant therapy has been suggested for preventing recurrent adhesions. The primary objective of this article was to review the literature for evidence of the efficacy of estrogen therapy in the management of IUA. All eligible studies were identified using computerized databases (PubMed, Scopus. and Web of Science) from their earliest publication date to July 2013. Additional relevant articles were identified from citations in these publications. Twenty-six studies were identified that reported use of hormone therapy as ancillary treatment after adhesiolysis. Of these studies, 19 used at least one of the following methods: intrauterine device, Foley catheter, hyaluronic acid gel, or amnion graft, in addition to hormone therapy as ancillary treatment. In 7 studies, hormone therapy was used as a single ancillary treatment. In 2 studies, no adjunctive therapy was used after adhesiolysis. Meta-analysis could not be performed because of the differences in treatment methods in these articles. There was a wide range of reported menstrual and fertility outcomes. Better menstrual and fertility outcomes were associated with use of estrogen in combination with other methods of ancillary treatment. At present, hormone therapy, in particular estrogen therapy, is beneficial in patients with IUA, regardless of stage of adhesions. However, estrogen therapy needs to be combined with ancillary treatment to obtain maximal outcomes, in particular in patients with moderate to severe IUA.

Hysteroscopic adhesiolysis for patients with Asherman's syndrome: menstrual and fertility outcomes

Purpose

Most patients with Asherman's syndrome present with infertility and menstrual problems. In this retrospective clinical study, we analyzed patients with Asherman's syndrome who underwent hysteroscopic adhesiolysis to examine their associated symptoms, disease etiologies, and fertility outcomes.

Methods

Twenty-seven patients with Asherman's syndrome that were diagnosed using hysteroscopy were recruited. The chief complaints were infertility, hypomenorrhea, and amenorrhea. Each case of Asherman's syndrome was classified according to the American Fertility Society classification. Hysteroscopic adhesiolysis was performed in all cases and concomitant transabdominal ultrasonography was conducted in cases with extensive and dense adhesions.

Results

There were no complications associated with the hysteroscopic procedure. Normal menstrual cycles resumed in all cases. Of the 16 infertile patients, 9 conceived. Three patients achieved term deliveries and one patient is currently pregnant. None of the patients had obstetric complications. Two patients had spontaneous abortions, one had an ectopic pregnancy, one had an abortion at 16 weeks' gestation due to cervical incompetence, and one had a molar pregnancy and required uterine artery embolization for uncontrolled hemorrhaging during a dilatation and curettage procedure.

Conclusions

Hysteroscopic adhesiolysis with transabdominal ultrasonography is a suitable treatment method for Asherman's syndrome. Subfertile patients with Asherman's syndrome undergoing adhesiolysis should be appropriately informed about the risk of associated life-threatening complications and preterm delivery.

Postpartum hemorrhage: what every radiologist needs to know

Postpartum hemorrhage is among the most common causes of maternal morbidity and mortality. Postpartum hemorrhage is defined as a blood loss of greater than 500 mL or any amount that, if not replaced, could cause shock or death in the mother. The most common cause of postpartum hemorrhage is uterine atony. This occurs when the normal myometrium fails to contract after delivery of the placenta. The initial treatment involves the administration of intravenous oxytocin and uterine massage. If the initial maneuvers fail to stop the postpartum hemorrhage, other techniques, such as uterine packing, suture techniques, uterine or hypogastric artery ligation, can be considered. In the last 30 years, a new angiographic approach for treatment of postpartum hemorrhage has emerged. Pelvic arterial embolization, after emerging as a treatment option to control and prevent pregnancy-related hemorrhage, has been established to be safe and effective. The goal of treatment for all causes of postpartum hemorrhage is cessation of bleeding in a timely fashion, before the onset of consumptive coagulopathy and end organ damage.

Efficacy of a polyethylene oxide-sodium carboxymethylcellulose gel in prevention of intrauterine adhesions after hysteroscopic surgery

STUDY OBJECTIVES

To assess the efficacy of a polyethylene oxide-sodium carboxymethylcellulose gel (Intercoat; Gynecare, division of Ethicon, Inc., Somerville, NJ) in preventing the development of de novo intrauterine adhesions (IUAs) after hysteroscopic surgery and to rate the patency of the internal uterine ostium at 1-month follow-up diagnostic hysteroscopy.

DESIGN

Randomized controlled study (Canadian Task Force classification I).

SETTING

University hospital.

PATIENTS

One hundred ten patients diagnosed during office hysteroscopy as having single or multiple lesions suitable for surgical treatment or resistant dysfunctional uterine bleeding requiring endometrial ablation.

INTERVENTIONS

Patients were randomized to 2 groups. Group 1 underwent hysteroscopic surgery plus intrauterine application of Intercoat gel, and group 2 underwent hysteroscopic surgery only (control group). Follow-up office hysteroscopy was performed at 1 month after surgery to assess the rate and severity of IUA formation and to rate the patency of the internal uterine ostium after the surgical intervention.

MEASUREMENTS AND MAIN RESULTS

Compared with the group 2, group 1 demonstrated a significant reduction in the incidence (6% vs 22%; p <.05) of de-novo IUAs. Application of the gel seemed to reduce the severity of IUAs, with fewer moderate and severe IUAs at follow-up in group 1 in comparison with group 2 (33% vs 92%). Furthermore, group 1 demonstrated significant improvement in the degree of patency of the internal uterine ostium (41.9% of cases) in comparison with diagnostic office hysteroscopy performed at enrollment (p <.05). In contrast, in group 2, worsening of patency of the internal uterine ostium was recorded in 18.2% of cases (p <.05).

CONCLUSIONS

Intercoat gel seems to prevent de novo formation of IUAs and to improve the patency of the internal uterine ostium at follow-up hysteroscopy. However, larger studies are needed to confirm these findings.

Review of intrauterine adhesions

This article has been produced to review the literature on symptomatic and asymptomatic intrauterine adhesions. Electronic resources including Medline, PubMed, CINAHL, The Cochrane Library (including the Cochrane Database of Systematic Reviews), Current Contents, and EMBASE were searched using the Medical Subject Headings (MeSH), including all subheadings, and the keywords "Asherman syndrome," "Hysteroscopic lysis of adhesions," "Hysteroscopic synechiolysis," "Hysteroscopy and adhesion," "Intrauterine adhesions," "Intrauterine septum and synechiae," and "Obstetric outcomes after intrauterine surgery." The vast majority of evidence in the literature consists of uncontrolled case series, with only intrauterine adhesion barriers being assessed in a randomized controlled format. This article reviews epidemiology, pathologic features, classification systems, and treatments. Seven classification systems are described, with no universal acceptance of any one system and no validation of any of them. Hysteroscopy is the mainstay of both diagnosis and treatment, with medical treatments having no role in management. There is a wide range of treatment techniques with no controlled comparative studies, and assessments are descriptive and report fertility and menstrual outcomes, with more severe adhesions having the worst clinical outcomes. One of the most important features of treatment is prevention of recurrence, with the best available evidence demonstrating that newly developed adhesion barriers such as hyaluronic acid show promise for preventing new adhesions.

Human amnion as a temporary biologic barrier after hysteroscopic lysis of severe intrauterine adhesions: pilot study

STUDY OBJECTIVE

To estimate the efficacy of fresh and dried amnion graft after hysteroscopic lysis of severe intrauterine adhesions in decreasing its recurrence and encouraging endometrial regeneration.

DESIGN

Pilot prospective randomized comparative study (Canadian Task Force classification I).

SETTING

Ain Shams Medical School, Cairo, Egypt.

PATIENTS

Forty-five patients with severe intrauterine adhesions. Primary symptom was infertility with or without menstrual disorders such as amenorrhea or hypomenorrhea.

INTERVENTIONS

Patients were randomized preoperatively using a computer-generated randomization sheet into 3 groups of 15 patients each. Allocation to any group was concealed in an opaque envelope, which was opened at the time of operation. Hysteroscopic lysis of intrauterine adhesions was followed by insertion of an intrauterine balloon only (group 1) or either fresh amnion graft (group 2) or dried amnion graft (group 3) for 2 weeks. Diagnostic hysteroscopy was performed at 2 to 4 months postoperatively.

MEASUREMENTS AND MAIN RESULTS

Adhesion grade, menstruation, uterine length, complications, and reproductive outcome were determined. There was significant improvement in adhesion grade with amnion graft vs intrauterine balloon alone (p = .003). Improvement was greater with fresh amnion than with dried amnion (p = .01). Normal menstruation occurred in 4 patients (28.6%) in group 1, 5 (35.7%) in group 2, and 7 (46.7%) in group 3. Of 43 patients, 41 (95.3%) were treated in 2 endoscopic sessions (95.3%), and 2 patients (4.7%) were treated in 3 endoscopic sessions. Uterine perforations occurred in 2 patients (4.7%), and cervical tears in 3 (7.0%). Ten patients (23.3%) achieved pregnancy, 8 (80%) after amnion graft and 2 (20%) without amnion. Six of the 10 patients (60%) miscarried, and 4 (40%) were either still pregnant or delivered at term without complications.

CONCLUSION

Hysteroscopic lysis of severe intrauterine adhesions with grafting of either fresh or dried amnion is a promising adjunctive procedure for decreasing recurrence of adhesions and encouraging endometrial regeneration.

Reproductive outcome following hysteroscopic adhesiolysis in patients with infertility due to Asherman's syndrome

OBJECTIVES

To evaluate the outcome of hysteroscopic adhesiolysis in patients with infertility due to Asherman's syndrome.

MATERIALS AND METHODS

This was a retrospective clinical analysis of 89 patients who underwent hysteroscopic adhesiolysis by monopolar electrode knife. A second-look office hysteroscopy was performed in all cases after 2 months. On second-look hysteroscopy, 12 patients showed reformation of adhesions and needed a repeat procedure.

RESULTS

The mean age of the patient was 28.4 years. In the majority (64%) of patients, the possible cause of Asherman's syndrome was previous curettage on gravid uterus. The overall conception rate was 40.4% after hysteroscopic adhesiolysis. The mean conception time after surgery was 12.8 months. There was no conception in patients who needed repeat adhesiolysis. The conception rate was higher (58%) in mild Asherman's syndrome compared to 30% conception rate in moderate and 33.3% conception rate in severe cases. There was no significant association between conception rate and preoperative menstrual pattern. There was significant higher likelihood of conception rate (44.3%) in those who continued to have improved menstrual pattern compared to only 10% likelihood of conception in those who continued to have amenorrhea after adhesiolysis. The live birth rate was 86.1% and miscarriage rate was 11.1%. Cumulative pregnancy rate showed that 97.2% patients conceived within 24 months. There was increased incidence (43.8%) of cesarean section. Four (12.5%) patients had postpartum hemorrhage for adherent placenta.

CONCLUSION

Hysteroscopic adhesiolysis for Asherman's syndrome is a safe and effective method of choice for restoring menstrual function and fertility.

Menses recovery and fertility after artery embolization for PPH: a single-center retrospective observational study

To evaluate long-term effects of arterial embolization (AE) for postpartum hemorrhage (PPH) on menses recovery and subsequent pregnancies. One hundred thirteen consecutive patients, recruited from 1999 to 2006, who had undergone AE for severe PPH were evaluated in a retrospective monocentric study. As embolization agents, pledgets of absorbable gelatine sponge (Curaspon) were used in 106 cases, Curaspon powder in 3 cases, and inert microparticles in 4 cases. In 111/113 cases (98.1%), AE was successful in controlling PPH. In two cases (1.7%), the AE was unsuccessful and required a total abdominal postembolization hysterectomy. Concerning fertility, 6 patients were lost to follow-up and 107 were available. The average time to follow-up was 46.4+/-21.8 months. Of the 107 patients, 99 had recovery of menses (92.5%). Of the 107 (61%) patients, 66 reported regular menstruation with normal delay after the delivery. Thirty-three patients (31%) reported subjective changes in the frequency and amount of menses. Six patients (5.6%) had documented amenorrhea after AE and developed diffuse uterine synechiae at the hysteroscopic investigation. Out of 29 patients who desired and attempted conception, 18 patients (62%) reported a total of 19 pregnancies at the end of the follow-up. One miscarriage at 12 weeks of gestation was reported. The 18 pregnancies at term were uneventful until delivery, but 3 cases of further PPH (15%) occurred due to abnormal placentation requiring a further AE. All full-term newborns were healthy. AE is a feasible, safe, and reproducible technique to control PPH, allowing a very high resumption of menses and subsequent pregnancies; in these cases, considering the elevated incidence of further PPH due to abnormal placentation, an accurate ultrasonographic monitoring during pregnancy seems appropriate.

[Prevention of intrauterine adhesions after hysteroscopic surgery]

Intrauterine adhesions are the most frequent complications after hysteroscopic surgery in women of reproductive age. The prevalence of intrauterine adhesions after hysteroscopic surgery is correlated to intrauterine pathology (myoma, polyp, or adhesions). Few clinical trials have demonstrated the efficiency of barrier agents developed in order to prevent adhesions after operative hysteroscopy. Adhesion barriers are mechanic agent (intrauterine device), fluid agents (Seprafilm, Hyalobarrier) and postoperative systemic treatment (estroprogestative treatment). In this article, we evaluate the efficiency of these barrier agents for adhesion prevention in hysteroscopic surgery, undertaking a review of clinical trials published. The most frequent published studies evaluate the anatomic efficiency of antiadhesion agents after hysteroscopic surgery in order to evaluate the fertility. Data are still insufficient to evaluate them for clinical use. There is a need for other randomised controlled trials.

Prevalence of uterine synechia after abortion evacuation curettage

CONTEXT AND OBJECTIVE

Intrauterine adhesion (IUA) is a possible complication of uterine curettage following abortion. Because IUA is an important cause of infertility, some investigators have been advocating its inclusion in the routine investigational workup after every abortion curettage procedure. The aim of this study was to evaluate the uterine cavity of patients subjected to abortion curettage, in order to ascertain the prevalence of IUA and its association with social and clinical factors.

DESIGN AND SETTING

This was a cross-sectional study at the Human Reproduction Unit, Department of Obstetrics and Gynecology, Universidade Estadual de Campinas (Unicamp).

METHODS

A total of 109 women were enrolled. The investigators searched the records of Unicamp's hospital for patients who had been subjected to uterine curettage following abortion. The hysteroscopy was performed 3 to 12 months after the curettage. The correlations between patients' characteristics and the prevalence of IUA were assessed by means of chi-squared and Fisher's exact test calculations.

RESULTS

The prevalence of IUA was 37.6%. The number of previous abortions and curettage procedures did not correlate with the presence of IUA. Most of the women (56.1%) presented IUA grade I.

CONCLUSIONS

In the present study, 37.6% of the women subjected to curettage following abortion had IUA, which was mostly mucous and grade I. None of the demographic and clinic characteristics evaluated were found to be associated with IUA. From this study, there is no firm evidence to justify carrying out routine diagnostic hysteroscopy following abortion evacuation.

Intra-uterine adhesions and fertility outcome: how to optimize success?

PURPOSE OF REVIEW

To review the etiology, diagnosis, and clinical manifestations of intra-uterine adhesions and to address treatment with a specific focus on fertility outcome.

RECENT FINDINGS

Intra-uterine adhesions can cause recurrent pregnancy loss and infertility. The gravid or recently postpartum uterus is particularly susceptible to adhesion formation following instrumentation. While sonohysterography and hysterosalpingography are useful as screening tests of intra-uterine adhesions, hysteroscopy remains the mainstay of diagnosis and treatment. Hysteroscopic lysis of adhesions with scissors, electrosurgery, or laser can restore the size and shape of the endometrial cavity. Significantly obliterated cavities may require multiple procedures to achieve a satisfactory anatomical result. Postoperative mechanical distention of the endometrial cavity and hormonal treatment to facilitate endometrial regrowth appear to decrease the high rate of adhesion reformation. Newer antiadhesive barriers may also prevent the recurrence of intra-uterine adhesions. Endometrial development can remain stunted due to a scant amount of residual functioning endometrium and fibrosis. Potential pregnancy complications, especially placenta accreta, after the treatment of intra-uterine adhesions should be anticipated and discussed with the patient.

SUMMARY

Diagnosis and treatment of intra-uterine adhesions are integral to the optimization of fertility outcomes. Favorable results in terms of pregnancy and live birth rates can be expected after hysteroscopic adhesiolysis.

Successful use of vaginal sildenafil citrate in two infertility patients with Asherman's syndrome

Vaginal sildenafil citrate (Viagra, Pfizer, Inc., New York, NY) has been shown to be useful in increasing endometrial thickness and achieving pregnancy in women with varied uterine disorders. However, it failed to demonstrate favorable results in the setting of Asherman's syndrome, a condition characterized by the presence of uterine synechiae. We have successfully applied this treatment in two women noted to have inadequate endometrium after surgical resection of uterine synechiae. Both patients had a history of a postpartum uterine curettage with subsequent secondary infertility. Asherman's syndrome was surgically demonstrated and treated in both patients. Postoperatively, both patients were noted to have a thin endometrium and failed to conceive despite fertility treatment. Subsequently, these women achieved pregnancy in the first treatment cycle with vaginal sildenafil citrate. Using transvaginal ultrasound, endometrial thickness was noted to improve when sildenafil citrate was administered. It is suspected that this medication causes selective vasodilatation, resulting in improved endometrial development.

Myometrial scoring: a new technique for the management of severe Asherman's syndrome

OBJECTIVE

To describe a new hysteroscopic technique for the management of severe Asherman's syndrome.

DESIGN

Prospective observational study.

SETTING

Volunteers in an academic research environment.

PATIENT(S)

Seven patients with secondary infertility associated with amenorrhea or oligomenorrhea secondary to severe Asherman's syndrome.

INTERVENTION(S)

Six to eight longitudinal incisions were made into the myometrium extending from the uterine fundus to the isthmus with a resectoscope fitted with a Collins knife electrode.

MAIN OUTCOME MEASURE(S)

Restoration of menses, symptomatic relief, and postoperative reproductive performance.

RESULT(S)

The amount of menstrual bleeding increased in all cases, including two women who were amenorrheic before their surgery. Pelvic pain decreased in two of the four symptomatic cases. Three to four months after surgery, hysteroscopy showed a normal sized uterine cavity in five cases. After a median follow-up of 12 months, three women conceived four pregnancies, including a missed abortion, a tubal abortion, an ongoing pregnancy currently at 7 weeks' gestation, and one child delivered at 36 weeks gestation after premature rupture of the membranes.

CONCLUSION(S)

Hysteroscopic myometrial scoring enlarges uterine cavity size in cases of severe Asherman's syndrome and improves menstrual function. Reproductive performance seems to be improved also, but longer follow-up is required.

Endoscopic surgery. The end of classic surgery?

Gynecological endoscopy is now a well-established procedure and it has been proved that the laparoscopic surgical technique can be used in the management of most gynecological disorders thus replacing conventional laparotomic procedures. The latest indications apply to such functional pathologic conditions as urinary incontinence and genital prolapse, and oncology (radical hysterectomy, lymphadenectomy). Hysteroscopy has afforded an easier surgical approach to certain pathologies such as septate uterus and endometrial ablation. Indications of conventional surgery are getting fewer. Yet conventional surgery should be part of the training of the gynecologist surgeon as the laparotomic approach is still the only solution in the most difficult cases.