Reply of the authors

Abstract

We thank Sentilhes and Descamps for their interest and comments regarding our article (1Blanc J. Courbiere B. Desbriere R. Bretelle F. Boubli L. d’Ercole C. et al.Is uterine-sparing surgical management of persistent postpartum hemorrhage truly a fertility-sparing technique?.Fertil Steril. 2011; https://doi.org/10.1016/j.fertnstert.2011.01.021Abstract Full Text Full Text PDF PubMed Scopus (16) Google Scholar). We acknowledge that the rate of patients in our series who had triple uterine ligation (TUAL) complemented by haemostatic multiple square suturing (HMSS) is unusually high and needs to be discussed (2AbdRabbo S.A. Stepwise uterine devascularization: a novel technique for management of uncontrolled postpartum hemorrhage with preservation of the uterus.Am J Obstet Gynecol. 1994; 171: 694-700Abstract Full Text PDF PubMed Google Scholar, 3Sentilhes L. Trichot C. Resch B. Sergent F. Roman H. Marpeau L. et al.Fertility and pregnancy outcomes following uterine devascularization for severe postpartum haemorrhage.Hum Reprod. 2008; 23: 1087-1092Crossref PubMed Scopus (74) Google Scholar). According to our institution protocol, HMSS was only performed after failure of TUAL technique. However, we observed a trend toward a reduction of HMSS combined with TUAL over the years. In complement to TUAL, HMSS was significantly less often performed after 2006 than during the 2001-2006 period: 11 (57.9%) vs. 32 (86.5%), respectively (P=0.023). One can therefore speculate that some of the earlier HMSS procedures may have been done unnecessarily. This probably reflects the learning curve which we felt necessary to feel confident with the TUAL technique and does not indicate compromised efficacy. Concerns about the exact uterine sparing procedure that had been previously performed on the five women in whom an abnormal hysteroscopy finding was found are legitimate. However, as reported in our article, “only endometritis was found to have statistically significant impact on the risk of an abnormal diagnostic hysteroscopy examination: 2 (40%) vs. 0 (P=0.033)” (1Blanc J. Courbiere B. Desbriere R. Bretelle F. Boubli L. d’Ercole C. et al.Is uterine-sparing surgical management of persistent postpartum hemorrhage truly a fertility-sparing technique?.Fertil Steril. 2011; https://doi.org/10.1016/j.fertnstert.2011.01.021Abstract Full Text Full Text PDF PubMed Scopus (16) Google Scholar). Among these five women, whereas 4 (23.5%) were previously managed using the combination of TUAL and HMSS, one (50%) had undergone TUAL alone, (P=0.395). Interestingly, this woman did not develop endometritis following TUAL. We could therefore not identify any other factor but TUAL that may have explained the abnormal hysteroscopic finding. None of our references were inadequately cited. We referred to two studies (3Sentilhes L. Trichot C. Resch B. Sergent F. Roman H. Marpeau L. et al.Fertility and pregnancy outcomes following uterine devascularization for severe postpartum haemorrhage.Hum Reprod. 2008; 23: 1087-1092Crossref PubMed Scopus (74) Google Scholar, 4Goojha C.A. Case A. Pierson R. Development of Asherman syndrome after conservative surgical management of intractable postpartum hemorrhage.Fertil Steril. 2010; 94: 1098.e1-1098.e5Abstract Full Text Full Text PDF Scopus (36) Google Scholar) to support the opinion that, as other uterine-sparing procedures, TUAL may be a risk factor of synechia. They confirm that similar complications have been previously described as a possible consequence of other uterine-sparing procedures. We were referring to all uterine-sparing procedures in general without focusing on TUAL. However, we do not believe that the absence of amenorrhea or synechia after bilateral uterine artery ligation with or without utero-ovarian ligation (3Sentilhes L. Trichot C. Resch B. Sergent F. Roman H. Marpeau L. et al.Fertility and pregnancy outcomes following uterine devascularization for severe postpartum haemorrhage.Hum Reprod. 2008; 23: 1087-1092Crossref PubMed Scopus (74) Google Scholar) is a strong argument enough to refute our conclusions. Neither is the fact that bilateral uterine artery ligation was not found to have any impact on menstrual bleeding in 45 women (5O’Leary J.A. Pregnancy following uterine artery ligation.Obstet Gynecol. 1980; 55: 112-113PubMed Google Scholar) or in the endometrium in an animal model (2AbdRabbo S.A. Stepwise uterine devascularization: a novel technique for management of uncontrolled postpartum hemorrhage with preservation of the uterus.Am J Obstet Gynecol. 1994; 171: 694-700Abstract Full Text PDF PubMed Google Scholar). Amenorrhea possibly related to uterine synechia has been reported after 5.6% of pelvic arterial embolization alone (I.E. without uterine-sparing surgery) (6Hardeman S. Decroisette E. Marin B. Vincelot A. Aubard Y. Pouquet M. et al.Fertility after embolization of the uterine arteries to treat obstetrical hemorrhage: a review of 53 cases.Fertil Steril. 2010; 94: 2574-2579Abstract Full Text Full Text PDF PubMed Scopus (53) Google Scholar). This would support the hypothesis of synechia occurring because of the interruption of blood flow in uterine arteries only. Interestingly, when reporting the follow up of 58 patients who underwent pelvic arterial embolization alone, Sentilhes et al. reported 11 (19%) cases of amenorrhea or decreased menstrual flow of whom 6 were attributed to synechia (7Sentilhes L. Gromez A. Clavier E. Resch B. Verspyck E. Marpeau L. Fertility and pregnancy following pelvic arterial embolisation for postpartum haemorrhage.BJOG. 2009; 117: 84-93Crossref Scopus (71) Google Scholar). Finally, as none of the patients with abnormal hysteroscopy reported a desire of pregnancy, the only legitimate concern regarding our finding is to know whether or not these abnormal hysteroscopic findings would be responsible for subsequent infertility. Does uterine artery ligation, performed because of a severe postpartum hemorrhage, alter fertility?Fertility and SterilityVol. 95Issue 8PreviewWe read with interest the case series reporting by Blanc et al. (1), which highlights the risk of synechia after uterine-sparing procedures. The authors concluded their “results suggest that triple ligation (TUAL), with or without haemostatic multiple square suturing (HMSS), exposes patients to the risk of subsequent abnormalities of the uterine cavity” (1). Regarding HMSS, we could not agree more with the authors as we have been attempting to alert physicians to the possible hidden mid-term or long-term effects of uterine compression sutures (2–6), although these procedures were adopted promptly throughout the world. Full-Text PDF