[Clinical evaluation of amniontic products after transcervical resection of intensive degree of intrauterine adhesions]

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Adjuvants to prevent reformation of adhesions following adhesiolysis for Asherman syndrome: a systematic review and meta-analysis

Two international guidelines published on the management of Asherman syndrome (AS) have made recommendations on various adjuvant methods to prevent intrauterine reformation. Nevertheless, the effectiveness of these methods when used in primary or secondary prevention settings is different. Our aim is to assess the effectiveness of various adjuvant methods for the secondary prevention of intrauterine adhesions (IUAs). Articles were considered eligible if they included subjects with AS before surgery and compared a chosen method with either a control or a comparison group (using another method). The primary outcome was the IUA reformation rate at follow-up hysteroscopy. A total of 29 studies [15 randomised controlled trials (RCTs) and 14 cohort studies] were included. Adhesion reformation with various methods to prevented IUA reformation when compared with controls were: second-look hysteroscopy: [risk ratio (RR): 0.21, 95% confidence interval (CI): 0.05-0.90 (p = 0.02)]; intrauterine contraceptive device: RR: 0.64, 95% CI: 0.36-1.12 (p = 0.12); continuous intrauterine balloon: RR: 0.18, 95% CI: 0.05-0.68 (p = 0.01); intermittent intrauterine balloon: RR: 0.50, 95% CI: 0.31-0.80 (p = 0.004); anti-adhesion gel: RR: 0.80, 95% CI: 0.58-1.10 (p = 0.17); amnion graft: RR: 0.63, 95% CI: 0.44-0.91 (p = 0.01).

Efficacy of Freeze-Dried Amnion Grafts on Cytokines in Uterine Exudates Following Hysteroscopic Adhesiolysis of Severe Intrauterine Adhesions

Background

Intrauterine adhesions (IUAs) are a benign uterine disorder that results in intrauterine adhesions and scarring. This study was conducted to assess the effects of freeze-dried amnion grafts on the concentrations of adhesion-related cytokines in uterine exudates following hysteroscopic adhesiolysis of IUAs.

Materials and Methods

This study was a prospective randomized controlled trial. Thirty patients who underwent hysteroscopic adhesiolysis for severe IUAs were enrolled. They were randomly divided into a study group (with freeze-dried amnion graft treatment after surgery, N = 15) and a control group (without a graft, N = 15). After complete separation of adhesions, a Foley balloon containing a freeze-dried amnion graft was inserted into the uterine cavity in the study group, while a Foley balloon with no graft was placed in the control group. Enzyme-linked immunosorbent assays were performed to test adhesion-related cytokine concentrations in uterine exudates, including IL-1β, TNF-α, and VEGF, at different time intervals after surgery. Second-look hysteroscopy was conducted three months after the surgery. On the basis of the American Fertility Society (AFS) scoring system, the level of adhesions was evaluated during hysteroscopy.

Results

The postoperative volume of the uterine exudates in the study group was significantly lower than that of the control group (P < 0.05). The adhesion-related cytokine concentrations of TNF-α, VEGF, and IL-1β significantly increased after surgery in both groups. Their concentrations were significantly lower in the study group than in the control group (P < 0.05). Moreover, IL-1β exhibited a long-lasting effect in the study group. AFS scores and readhesion rates were significantly lower in the study group than in the control group after hysteroscopic adhesiolysis of severe IUAs.

Conclusion

The application of freeze-dried amnion grafts is beneficial to the postoperative recovery of patients with severe IUAs and may reduce the readhesion rate after hysteroscopic adhesiolysis by lowering adhesion-related cytokines, including TNF-α, VEGF, and IL-1β.

Silicone Plate for the Prevention of Postoperative Adhesions in Patients with Asherman Syndrome

Purpose. Re-adhesion rates following hysteroscopic adhesiolysis have remained high. Accordingly, we present a case involving temporary placement of an intrauterine silicone plate to prevent re-adhesions following hysteroscopic adhesiolysis in a 36-year-old woman with Asherman syndrome. Methods. After hysteroscopic adhesiolysis, a silicone plate molded to the uterine cavity’s shape was inserted into the uterine cavity and left in place for 1 month. Results. The patient had a history of endometrial curettage for endometrial polyps. After the procedure, she developed amenorrhea and experienced infertility for 5 years despite four cycles of in vitro fertilization and embryo transfer. Following admission to our hospital, hysteroscopic examination showed a wide area of intrauterine adhesions for which hysteroscopic adhesiolysis and silicone plate insertion were performed. The silicone plate was removed after 1 month. No intrauterine adhesions were observed during the subsequent hysteroscopic examination. After a thawed embryo transfer, the patient became pregnant and delivered a healthy baby. Conclusions. A silicon plate may be considered a useful tool for preventing re-adhesion following hysteroscopic adhesiolysis without serious complications.

Anti-adhesion therapy following operative hysteroscopy for treatment of female subfertility

BACKGROUND

Observational evidence suggests a potential benefit with several anti-adhesion therapies in women undergoing operative hysteroscopy (e.g. insertion of an intrauterine device or balloon, hormonal treatment, barrier gels or human amniotic membrane grafting) for decreasing intrauterine adhesions (IUAs).

OBJECTIVES

To assess the effectiveness of anti-adhesion therapies versus placebo, no treatment or any other anti-adhesion therapy, following operative hysteroscopy for treatment of female subfertility.

SEARCH METHODS

We searched the following databases from inception to June 2017: the Cochrane Gynaecology and Fertility Group Specialised Register; the Cochrane Central Register of Studies (CRSO); MEDLINE; Embase; CINAHL and other electronic sources of trials, including trial registers, sources of unpublished literature and reference lists. We handsearched the Journal of Minimally Invasive Gynecology, and we contacted experts in the field. We also searched reference lists of appropriate papers.

SELECTION CRITERIA

Randomised controlled trials (RCTs) of anti-adhesion therapies versus placebo, no treatment or any other anti-adhesion therapy following operative hysteroscopy in subfertile women. The primary outcome was live birth. Secondary outcomes were clinical pregnancy, miscarriage and IUAs present at second-look hysteroscopy, along with mean adhesion scores and severity of IUAs.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies, assessed risk of bias, extracted data and evaluated quality of evidence using the GRADE method.

MAIN RESULTS

The overall quality of the evidence was low to very low. The main limitations were serious risk of bias related to blinding of participants and personnel, indirectness and imprecision. We identified 16 RCTs comparing a device versus no treatment (two studies; 90 women), hormonal treatment versus no treatment or placebo (two studies; 136 women), device combined with hormonal treatment versus no treatment (one study; 20 women), barrier gel versus no treatment (five studies; 464 women), device with graft versus device without graft (three studies; 190 women), one type of device versus another device (one study; 201 women), gel combined with hormonal treatment and antibiotics versus hormonal treatment with antibiotics (one study; 52 women) and device combined with gel versus device (one study; 120 women). The total number of participants was 1273, but data on 1133 women were available for analysis. Only two of 16 studies included 100% infertile women; in all other studies, the proportion was variable or unknown.No study reported live birth, but some (five studies) reported outcomes that were used as surrogate outcomes for live birth (term delivery or ongoing pregnancy). Anti-adhesion therapy versus placebo or no treatment following operative hysteroscopy.There was insufficient evidence to determine whether there was a difference between the use of a device or hormonal treatment compared to no treatment or placebo with respect to term delivery or ongoing pregnancy rates (odds ratio (OR) 0.94, 95% confidence interval (CI) 0.42 to 2.12; 107 women; 2 studies; I² = 0%; very-low-quality evidence).There were fewer IUAs at second-look hysteroscopy using a device with or without hormonal treatment or hormonal treatment or barrier gels compared with no treatment or placebo (OR 0.35, 95% CI 0.21 to 0.60; 560 women; 8 studies; I² = 0%; low-quality evidence). The number needed to treat for an additional beneficial outcome (NNTB) was 9 (95% CI 5 to 17). Comparisons of different anti-adhesion therapies following operative hysteroscopyIt was unclear whether there was a difference between the use of a device combined with graft versus device only for the outcome of ongoing pregnancy (OR 1.48, 95% CI 0.57 to 3.83; 180 women; 3 studies; I² = 0%; low-quality evidence). There were fewer IUAs at second-look hysteroscopy using a device with or without graft/gel or gel combined with hormonal treatment and antibiotics compared with using a device only or hormonal treatment combined with antibiotics, but the findings of this meta-analysis were affected by evidence quality (OR 0.55, 95% CI 0.36 to 0.83; 451 women; 5 studies; I² = 0%; low-quality evidence).

AUTHORS' CONCLUSIONS

Implications for clinical practiceThe quality of the evidence ranged from very low to low. The effectiveness of anti-adhesion treatment for improving key reproductive outcomes or for decreasing IUAs following operative hysteroscopy in subfertile women remains uncertain. Implications for researchMore research is needed to assess the comparative safety and (cost-)effectiveness of different anti-adhesion treatments compared to no treatment or other interventions for improving key reproductive outcomes in subfertile women.