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

Abstract

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