The link between intrauterine adhesions and induced termination of pregnancy remains a challenge.

Abstract

Termination of pregnancy (TOP) or induced TOP is one of the most commonly performed interventions on women of reproductive age: it is estimated that 30–50% of women will undergo at least one TOP during their lifetime (Templeton et al. N Engl J Med 2011;365:2198–204). Intrauterine adhesions (IUAs) are thought to develop following the destruction of the basal layer of the endometrium: during the healing process opposing walls of the uterus adhere together (Schenker Eur J Obstet Gynecol Reprod Biol 1996;65:109–13). There is a link between induced TOP and IUA, but data concerning the incidence of IUA are conflicting. Mentula and co-workers conducted a retrospective nationwide registry cohort study. The rate of IUAs in 79 960 eligible induced TOPs were assessed: 1.5 and 2.0 cases of IUA per 10 000 TOPs following medically and surgically induced TOPs, respectively. Surgical evacuation of the remaining products of conception was significantly related to the risk of IUA formation (odds ratio, OR, 5.50; 95% confidence interval, 95% CI, 1.5–20.8). Although the authors should be complemented for conducting one of the largest studies on this topic, the results should be interpreted with caution. The authors included a wide range of diagnostic and operation codes to include as many cases of IUA as possible. Nevertheless, the reported incidence should be regarded as an underestimation of the real incidence. Women were retrieved by linking TOP registry data with hospital discharge registry data. The diagnosis of IUA was based on diagnostic and operation codes. Women with IUA who were asymptomatic remained undiscovered. Furthermore, the most severe cases of IUA requiring treatment were detected. The data in the TOP registry reported only the first attempted method for TOP. The method of TOP in women who received both treatment options was only classified by the primary method. Induced TOPs from 2000 to 2008 were analysed (representing an 8-year period). The question remains whether the treatment methods were comparable during the years included. In this registry-based study, detailed information on how medical or surgical treatment was performed throughout the period of study was not available. Nevertheless, there seems to have been differences across the years, as the rate of IUA significantly differed: 10 of the 12 IUA cases (83.3%) were diagnosed in the period 2000–2003, and only two IUA cases (16.7%) were diagnosed in the period 2004–2008 (P < 0.01). Furthermore, the overall re-evacuation rates after surgical management varied significantly, ranging from 11.8% in 2000 to 4.6% in 2008 (P < 0.001). Despite the reported limitations, Mentula and co-workers must be complimented for conducting this study on a clinically relevant topic. IUA formation is multifactorial, and can result in menstrual disturbances, infertility, and miscarriage. If pregnancy occurs, the risk of fetal growth restriction and placental implantation disorders is increased (Schenker et al. Fertil Steril 1982:37;593–610). Treatment of women with IUA remains a challenge, with the prognosis of moderate and severe adhesion remaining unsatisfactory. Even after hysteroscopic adhesiolysis, reproductive performance remains unsatisfactory (March Obstet Gynecol Clin North Am 1995:22;491–505). IUA should be considered a surrogate indicator, as long-term fertility, reproductive outcome, and obstetric complications are clinically relevant. As a result of the possible implications of IUA, the prevention of IUA is crucial. None declared. The completed disclosure of interest form is available to view online as supporting information. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.