Lysis of mid-uterine central adhesions has lower recurrence risk.

Abstract

Intrauterine adhesions are most likely to occur following a postpartum dilatation and curettage (D&C) for the management of haemorrhage as a result of retained products of conception. Less common causes include myomectomy, first-trimester D&C, non-pregnancy related D&C, and uterine infection. Currently, we have no data on the optimal technique to lyse these adhesions or prevent the recurrence of adhesions. Techniques used to lyse intrauterine scar tissue include radiofrequency energy, mechanical morcellation, sharp curettage, and lysis with cold scissors under direct visualisation. Likewise, efforts used to prevent recurrence after the initial lysis included oestrogen therapy, mechanical barriers such as intrauterine devices, balloons, blunt dissection, instillation of hylauronate, transplantation of stem cells (Neeta Singh et al. J Hum Reprod Sci 2014;7:93–98), and recurrent postoperative lysis with outpatient hysteroscopy (Robinson et al. Fertil Steril 2008;90:409–414). Yang and colleagues describe their results of preventing recurrent intrauterine scar tissue by repeat outpatient hysteroscopy and blunt dissection with a flexible hysteroscope every 2 weeks until there was no scar tissue remaining. The authors retrospectively evaluated 140 patients with intrauterine adhesions and categorised the adhesions into four groups: groups 1–3 (mid-uterine, corneal, and cervical isthmic, respectively), which were central and had space between the adhesions and the sidewall; and group 4, which had dense occlusion of part of the uterine cavity. Group 1 required fewer postoperative therapies than groups 2–4. Several questions arise from the design of the study, which affects the applicability of the clinical findings. Firstly, although 140 women were initially included in the cohort, 25 were excluded because of thick scar tissue that could not be completely lysed. The authors did not explain why this group was not offered the same postoperative therapy. Secondly, the primary outcome measure was complete absence of recurrent intrauterine scar tissue. This is an unusual primary end point because clinical measures, such as reduction in pain, return to normal menses, or successful fertility, and live birth rates are more commonly assessed. Pregnancy information was however reported as a secondary outcome in 42/73 women (42 of the original cohort of 115 women were lost to follow-up), in whom there were 24 live births. The fertility success reported by Yang and colleagues is similar to other reported treatments for Asherman's syndrome (Deans & Abbot JMIG 2010;17:555). Lastly, although D&C was reported to be the cause of the adhesions in 93% of the patient population reported on by Yang et al., no information was given about the indications for the D&Cs. This is important because postpartum D&Cs can result in the genesis of scar tissue that is most difficult to treat. The use of repeated outpatient hysteroscopic adhesiolysis may be unfamiliar to many gynaecologists. Yang and colleagues argue that this strategy should be adopted in the absence of effective preventative strategies for use at the time of primary hysteroscopic surgery. They have demonstrated that it takes fewer postoperative outpatient hysteroscopies to minimise intrauterine scar tissue recurrence in patients with mid-uterine central adhesions. None declared. Completed disclosure of interests form available to view online as supporting information.