Intrauterine Adhesions Research Articles

Факторы риска рецидивирования внутриматочных синехий в репродуктивном возрасте

Aim. To identify risk factors for recurrent intrauterine synechiae in women of reproductive age. Design. A comparative prospective study. Materials and methods. The study enrolled 89 female patients of reproductive age with confirmed intrauterine adhesions (IUA), according to hysteroscopy and morphology. Patients were divided into two groups depending on the course of IUA: main group (n = 45) — women with recurrent IUA (at least one episode during the year), and reference group (n = 44) — patients with IUA de novo. The mean age of patients in the main and reference groups was 36 ± 6 and 30 ± 3 years old, respectively. Results. A history of emmeniopathy was statistically more common in patients with recurrent IUA (odd ratio (OR) = 4.5; 95% confidence interval (CI): 1.7–12.3) as compared to women with IUA de novo (p < 0.05), diffuse adenomyosis (OR = 5.4; 95% CI: 2.2–13.6) (p < 0.05). Patients with morphologically confirmed chronic endometritis had a high risk of recurrent IUA (OR = 4.0; 95% CI: 1.6–9.7) (p < 0.05). The risk is several times higher after surgeries: repeated curettage of uterine cavity due to abnormal uterine bleeding (OR = 17.3; 95% CI: 5.8–51.3) (p < 0.001), a history of myomectomy due to a submucous myomatous nodule (OR = 7.4; 95% CI: 2.9–18.8) (p < 0.001), hysteroresectoscopic adhesiolysis with monopolar energy (OR = 4.4; 95% CI: 1.7–11.3) (p < 0.001). Conclusion. The mentioned risk factors of recurrent IUA make it possible to timely identify women with a high risk of the disease and undertake preventive measures. Keywords: intrauterine synechiae, recurrence, risk factors, reproductive age.

Efficacy and prognostic factors of combined administration of progesterone and estriol valerate tablets for preventing intrauterine adhesions in patients with early missed abortion following dilation and curettage.

To investigate the therapeutic efficacy and prognostic factors of combined administration of estriol valerate tablets and progesterone for the prevention of intrauterine adhesions (IUA) in patients with early missed abortion (EMA) after dilation and curettage. Clinical data of 120 EMA patients undergoing dilation and curettage at Ganzhou People's Hospital from July 2021 to June 2023 were collected for this retrospective study. The 120 enrolled patients were divided into two groups, with 70 patients in the study group receiving both estriol valerate tablets and progesterone for the prevention of IUA, and 50 in the control group undergoing no such treatments at all. The therapeutic efficacy of IUA prevention in patients was compared between the two groups. Subsequently, patients who developed IUA were categorized into the adhesion group (n = 23) and those who did not into the non-adhesion group (n = 97). The clinical data of patients were compared between the adhesion group and the non-adhesion group. Both univariate and multivariate logistic regression analyses were performed to identify the risk factors of IUA in patients with EMA after dilation and curettage. Receiver Operating Characteristic (ROC) curves were drawn to analyze the predictive value of independent risk factors for IUA in patients with EMA after dilation and curettage. The study group showed a notably higher excellent and good response rate than the control group in IUA prevention (92.00% vs. 82.00%, P = 0.035). Logistic regression analysis revealed that a history of multiple previous miscarriages (P: 0.018; OR: 0.120; 95% CI: 0.02-2.119), relatively small endometrial volume (P: 0.001; OR: 0.026; 95% CI: 0.003-0.210), relatively thin endometrial thickness (P: 0.001; OR: 32.123; 95% CI: 4.339-237.807) and lack of preventive treatment (P: 0.051; OR: 0.211; 95% CI: 0.048-0.935) were independent risk factors for the occurrence of IUA in patients with EMA after dilation and curettage. ROC curve-based analysis showed that these risk factors; encompassing, the number of previous miscarriages, endometrial volume, endometrial thickness and preventive treatment, had a notably higher efficacy in jointly predicting the occurrence of IUA in EMA patients following dilation and curettage in comparison to an individual risk factor alone. The occurrence of IUA in patients with EMA following dilation and curettage is influenced by several factors, including the number of previous miscarriages, the volume and thickness of the endometrium, and preventive treatments. To minimize the risk of IUA, it is crucial to implement proactive interventions prior to uterine surgeries. It was found that a combination therapy involving estriol valerate tablets and progesterone could effectively prevent the development of IUA in patients with EMA after dilation and curettage.

ATI-2341 TFA promotes repair of damaged endometrium by mediating the differentiation of bone marrow mesenchymal stem cells

Intrauterine adhesion (IUA) is a common complication in endometrial disorder. This study investigated the role of ATI-2341, a functionally selective allosteric regulator of CXCR4 in IUAs, and its interaction with bone marrow-derived mesenchymal stem cells (BMSCs). Following establishment of endometrial injury model, rats BMSCs were treated with ATI-2341 TFA (100 ng/mL). Endometrial tissues of rats with IUA were treated with BMSCs and estrogen, or untreated which was taken as controls. The endometrium thickness was examined and endometrial BMSC proliferation was detected by MTT assay. Levels of MMP-9, TIMP-1, CK, and VIM were determined by Western blot analysis. Treatment with ATI-2341 TFA resulted in significantly decreased level of MMP-9 (0.346±0.036 ng/mL), compared with estrogen treatment (0.467±0.029 ng/mL) and control treatment. Both BMSCs carrying ATI-2341 TFA and estrogen induced increased expression of TIMP-1 (0.734±0.034 ng/mL, 0.618±0.035 ng/mL) and enhanced endometrim growth with thicker endometrium in ATI-2341 TFA group (294.21±59.97 μm). 48 h and 72 h after treatment, ATI-2341 TFA group and estrogen group exhibited increased proliferation rate (P <0.05), and higher rate appeared upon ATI-2341 TFA treatment. Cells in ATI-2341 TFA100 ng/mL and estrogen group were greatly positive for keratin and negative for vimentin. Collectively, ATI-2341 TFA promotes the differentiation of BMSCs into endometrial epithelial cells, enhances repair of damaged endometrium, and alleviate IUA. These findings might underlie a foundation for BMSC-based treatment for endometrial disorder.

Prevalence of chronic endometritis in infertile women undergoing hysteroscopy and its association with intrauterine abnormalities: A Cross-Sectional study.

Chronic endometritis (CE) is an inflammatory condition with several different risk factors. We aimed to examine whether intrauterine abnormalities, such as endometrial polyps, submucosal myomas, intrauterine adhesions, or a septate uterus, were associated with an increased likelihood of developing chronic endometritis. A cross-sectional study was conducted on 335 infertile women who underwent hysteroscopy surgery at the Ayatollah Taleghani Hospital Infertility Center, affiliated by Shahid Beheshti University of Medical Sciences, in 2022. All participants in the study underwent hysteroscopic surgery, which allowed for direct visualization of the intrauterine cavity, and endometrial biopsies were taken for further analysis. To characterize endometritis, plasma cell infiltration was assessed. Patients with ≥5 plasma cells observed in 10 high-power fields were defined as having chronic endometritis. Endometritis was observed in 51.3% of the patients, totaling 172 individuals. Logistic regression analysis revealed that patients with endometrial polyps had 5.2 times higher odds of developing endometritis compared to patients without polyps (95% CI = 2.9, 9.2) (p-value <0.001). Similarly, patients with intrauterine adhesions had a significant increase in the odds of endometritis (OR = 4.6, 95% CI = 2.1, 10.1) (p-value <0.001). Treatment or removal of endometrial abnormalities through hysteroscopic procedures may help to reduce the risk of chronic endometritis and improve fertility outcomes. Further research is necessary.

Developing and validating a prediction model of live birth in patients with moderate-to-severe intrauterine adhesions: a new approach with endometrial morphology measurement by 3D transvaginal ultrasound.

There is no reliable method to predict the live birth rate among patients with moderate-to-severe intrauterine adhesions (IUA) after second-look hysteroscopy. Therefore, we aimed to construct a practical prediction model mainly based on the features of 3D transvaginal ultrasound (3D-TVUS). and other clinical characteristics. From January 2018 to February 2020, a total of 870 IUA patients with fertility requirements were retrospectively enrolled based on the same method. First, the predictors were screened by logistic regression analysis. A nomogram was constructed based on the screened predictive factors in the derivation cohort. Next, receiver operating characteristic (ROC), calibration curve, and decision curve analysis (DCA) were used to assess the predictive accuracy and discriminability of the model. Finally, correlation analysis was performed to analyze the correlation between the results of 3D-TVUS and second-look hysteroscopy. A total of 558 (64.14%) participants had live births. Age, endometrial thickness, assisted reproductive technology, a homogeneous endometrial echo, a lower segment of scar contraction, and upper segmentation of the endometrial absence were included in the model. The predictive model showed good predictive performance in the derivation cohort (area under the curve, 0.837) and validation cohort (0.857). DCA demonstrated its clinical utility. A homogeneous endometrial echo was related to no segmentation of scar contraction (r=0.219; P<0.001) or no segmentation of the endometrial absence (r=0.226; P<0.001). Thicker endometrium was associated with no segmentation of the endometrial absence (r=-0.145; P=0.007). The proposed method can effectively predict live birth. 3D-TVUS should be an important means for evaluating the endometrium of moderate-to-severe patients with IUA preparing for pregnancy after operation.

Janus adhesive microneedle patch loaded with exosomes for intrauterine adhesion treatment.

Intrauterine adhesions (IUAs) are common sequelae of cervical mucosa damage caused by uterine curettage. Establishing an anti-adhesion barrier between the damaged endometrium with a sustained-release drug capability and hence promoting endogenous regeneration of the endometrium is an available treatment for IUA. However, current therapy lacks long-term intracavitary residence, drug-delivery permeability, and tissue anti-adhesion to the endometrium. Here, we report the design of a Janus microneedle patch consisting of two layers: an adhesive inner layer with an exosomes-loaded microneedle, which endows the patch with a tissue adhesive capability as well as transdermal drug-delivery capability; and an anti-adhesion outer layer, which prevents the intrauterine membrane from postoperative adhesion. This Janus adhesive microneedle patch firmly adhered to uterine tissue, and sustainedly released ∼80% of the total loaded exosomes in 7 days, hence promoting the expression of vascular- and endothelial-related cell signals. Furthermore, the anti-adhesive layer of the microneedle patch exhibited low cell and protein adhesion performance. In rats, the microneedle patch successfully prevented uterine adhesions, improved endometrial angiogenesis, proliferation, and hormone response levels. This study provides a stable anti-adhesion barrier as well as efficient drug-release capability treatment for intrauterine adhesion treatment.

Endometrial organoids: a reservoir of functional mitochondria for uterine repair.

Background: Asherman's syndrome (AS) is a dreadful gynecological disorder of the uterus characterized by intrauterine adhesion with severe fibrotic lesions, resulting in a damaged basalis layer with infertility. Despite extensive research on overcoming AS, evidence-based effective and reproducible treatments to improve the structural and functional morphology of the AS endometrium have not been established. Methods: Endometrial organoids generated from human or mouse endometrial tissues were transplanted into the uterine cavity of a murine model of AS to evaluate their transplantable feasibility to improve the AS uterine environment. The successful engraftment of organoid was confirmed by detection of human mitochondria and cytosol (for human endometrial organoid) or enhanced green fluorescent protein signals (for mouse endometrial organoid) in the recipient endometrium. The therapeutic effects mediated by organoid transplantation were examined by the measurements of fibrotic lesions, endometrial receptivity and angiogenesis, and fertility assessment by recording the number of implantation sites and weighing the fetuses and placenta. To explore the cellular and molecular mechanisms underlying the recovery of AS endometrium, we evaluated the status of mitochondrial movement and biogenetics in organoid transplanted endometrium. Results: Successfully engrafted endometrial organoids with similar morphological and molecular features to the parental tissues dramatically repaired the AS-induced damaged endometrium, significantly reducing fibrotic lesions and increasing fertility outcomes in mice. Moreover, dysfunctional mitochondria in damaged tissues, which we propose might be a key cellular feature of the AS endometrium, was fully recovered by functional mitochondria transferred from engrafted endometrial organoids. Endometrial organoid-originating mitochondria restored excessive collagen accumulation in fibrotic lesions and shifted uterine metabolic environment to levels observed in the normal endometrium. Conclusions: Our findings suggest that endometrial organoid-originating mitochondria might be key players to mediate uterine repair resulting in fertility enhancement by recovering abrogated metabolic circumstance of the endometrium with AS. Further studies addressing the clinical applicability of endometrial organoids may aid in identifying new therapeutic strategies for infertility in patients with AS.

Treatment of Intrauterine Adhesions from Phlegm and Blood Stasis Theory

Treatment of Intrauterine Adhesions from Phlegm and Blood Stasis Theory

Advances in stem cell therapy for intrauterine adhesions

Advances in stem cell therapy for intrauterine adhesions

Correlation between preoperative three-dimensional transvaginal ultrasound and postoperative pregnancy outcomes after hysteroscopic adhesiolysis.

Uterine adhesion is mainly caused by endometrial injury, leading to poor postoperative pregnancy outcome. Therefore, preoperative evaluation on uterine cavity, especially endometrial condition, is very necessary. This study aims to explore the correlation between preoperative three-dimensional transvaginal ultrasound (3D-TVS) imaging characteristics and postoperative pregnancy outcomes after hysteroscopic adhesiolysis (HA). A total of 401 patients, who underwent HA surgery from February 22, 2018 to October 31, 2018 at the Third Xiangya Hospital of Central South University or Changsha Jiangwan Hospital, were enrolled, and we collected data regarding the preoperative 3D-TVS imaging characteristics and followed up their postoperative pregnancy outcomes. Correlation analysis and univariate and multivariate logistic regression analysis were performed between imaging features and pregnancy outcomes (live and non-live birth outcomes) in patients with intrauterine adhesion. The results of correlation analysis showed that endometrial thickness, endometrial echo, visible tubal openings, endometrial blood flow, intercornual distance, and endometrial peristalsis were correlated with the live birth rate (all P<0.05). Logistic regression analysis revealed that in the HA patients with the live birth, the endometrial thickness was thicker (P<0.001), endometrial echo was more homogeneous (P<0.001), the number of tubal openings was more (P<0.001), the intercornual distance was wider (P<0.05), the endometrial blood flow, and irregular cases of endometrial peristaltic waves were more and cases of deficiency were fewer (both P<0.01) than those in the non-live birth group. Preoperative 3D-TVS imaging performance is closely related to pregnancy outcomes of HA patients, and preoperative 3D-TVS can be used to predict pregnancy outcomes after HA.

Treatment of intrauterine adhesions in rats with hypoxia-cultured BMSC-derived exosomes

Objective: To perform intrauterine adhesion modeling, and to investigate the repair effect of hypoxic treated bone marrow mesenchymal stem cells (BMSC) and their derived exosomes (BMSC-exo) on endometrial injury. Methods: BMSC and their exosomes BMSC-exo extracted from rats' femur were cultured under conventional oxygen condition (21%O2) or hypoxia condition (1%O2). Intrauterine adhesion modeling was performed on 40 healthy female SD rats by intrauterine injection of bacterial lipopolysaccharide after curettage. On the 28th day of modeling, 40 rat models were randomly divided into five groups, and interventions were performed: (1) NC group: 0.2 ml phosphate buffered solution was injected into each uterine cavity; (2) BMSC group: 0.2 ml BMSC (1×106/ml) with conventional oxygen culture was injected intrauterine; (3) L-BMSC group: 0.2 ml of hypoxic cultured BMSC (1×106/ml) was injected intrauterine; (4) BMSC-exo group: 0.2 ml of BMSC-exo cultured with conventional oxygen at a concentration of 500 μg/ml was injected into the uterine cavity; (5) L-BMSC-exo group: 0.2 ml hypoxic cultured BMSC-exo (500 μg/ml) was injected intrauterine. On the 14th and 28th day of treatment, four rats in each group were sacrificed by cervical dislocation after anesthesia, and endometrial tissues were collected. Then HE and Masson staining were used to observe and calculate the number of glands and fibrosis area in the endometrium. The expressions of angiogenesis related cytokines [vascular endothelial growth factor A (VEGFA) and CD31], and fibrosis-related proteins [collagen-Ⅰ, collagen-Ⅲ, smooth muscle actin α (α-SMA), and transforming growth factor β1 (TGF-β1)] in endometrial tissues were detected by western blot. Results: (1) HE and Masson staining showed that the number of endometrial glands in L-BMSC group, BMSC-exo group and L-BMSC-exo group increased and the fibrosis area decreased compared with NC group on the 14th and 28th day of treatment (all P<0.05). Noteworthily, the changes of L-BMSC-exo group were more significant than those of BMSC-exo group (all P<0.05), and the changes of BMSC-exo group were greater than those of BMSC group (all P<0.05). (2) Western blot analysis showed that, compared with NC group, the expressions of collagen-Ⅲ and TGF-β1 in BMSC group, L-BMSC group, BMSC-exo group and L-BMSC-exo group decreased on the 14th and 28th day of treatment (all P<0.05). As the treatment time went on, the expressions of fibrosis-related proteins were different. Compared with BMSC group, the expressions of collagen-Ⅲ, α-SMA and TGF-β1 in the BMSC-exo group and L-BMSC group decreased on the 28th day (all P<0.05). Moreover, the expressions of collagen-Ⅲ and TGF-β1 in L-BMSC-exo group were lower than those in BMSC-exo group on the 28th day (all P<0.05). And the expressions of collagen-Ⅰ, α-SMA and TGF-β1 in L-BMSC-exo group were lower than those in L-BMSC group on the 28th day (all P<0.05). (3) The results of western blot analysis of VEGFA and CD31 showed that, the expressions of VEGFA and CD31 in BMSC group, L-BMSC group, BMSC-exo group and L-BMSC-exo group increased on the 14th and 28th day of treatment compared with NC group (all P<0.05). Treatment for 28 days, the expressions of VEGFA and CD31 in BMSC-exo group and CD31 in L-BMSC group were higher than those in BMSC group (all P<0.05). Moreover, the expressions of VEGFA and CD31 in L-BMSC-exo group were higher than those in BMSC-exo group and L-BMSC group on the 28th day (all P<0.05). Conclusions: Treatment of BMSC and their exosomes BMSC-exo with hypoxia could promote endometrial gland hyperplasia, inhibit tissue fibrosis, and further repair the damaged endometrium in rats with intrauterine adhesion. Importantly, hypoxic treatment of BMSC-exo is the most effective in intrauterine adhesion rats.

Synergistic effects of electroacupuncture and bone marrow mesenchymal stem cell transplantation on rat intrauterine adhesion： an observation.

To investigate the effects of electroacupuncture(EA) combined with bone marrow mesen-chymal stem cells(BMSCs) transplantation on the endometrium of rats with intrauterine adhesions(IUA), so as to explore the possible mechanisms underlying their combined therapeutic effects. Forty adult female SD rats were randomly divided into control, model, cell, and combined groups. The IUA rat model was established using a dual injury method of mechanical scratching and lipopolysaccharide infection. After successful modeling, on days 1, 3, and 7, rats in the model group received tail vein injection of phosphate buffered solution, while rats in the cell group received tail vein injection of BMSCs suspension for BMSCs transplantation；and rats in the combined group received BMSCs transplantation combined with EA treatment (2 Hz/15 Hz, 1-2 mA), targeting the "Guanyuan"(CV4), bilateral "Zusanli"(ST36) and "Sanyinjiao"(SP6) for 20 min daily for 3 consecutive estrous cycles. After intervention, uterine tissue was collected from 5 rats in each group. Histological analysis was performed using hematoxylin and eosin staining to evaluate endometrial thickness and glandular number. Masson staining was used to assess endometrial fibrosis area. Immunohistochemistry was performed to detect the positive expressions of vascular endothelial growth factor(VEGF), proliferating cell nuclear antigen(PCNA), and estrogen receptor(ER). Western blot analysis was conducted to determine the protein expressions of homeobox A10(HoxA10) and leukemia inhibitory factor(LIF), both key regulators of endometrial receptivity. The remaining 5 rats in each group were co-housed with male rats, and the uterine function recovery was evaluated by assessing the number of embryo implantations. Compared with the control group, the model group showed thinning endometrium(P<0.001), decreased glandular number(P<0.001), increased endometrial fibrosis area(P<0.001), reduced positive expressions of VEGF, PCNA, ER, expressions of HoxA10 and LIF, and decreased embryo implantation number (P<0.001) on the injured side of the uterus. Compared with the model group, the combined group showed a reversal of the aforementioned indicators(P<0.001, P<0.01)；the cell group exhibited thicker endometrium(P<0.001) and reduced endometrial fibrosis area(P<0.001). Compared with the cell group, the combined group showed increased endometrial thickness(P<0.01), elevated glandular number(P<0.05), significantly decreased endometrial fibrosis area(P<0.05), enhanced positive expressions of VEGF, PCNA and ER, expressions of HoxA10 and LIF in the endometrium, and a significant increase in embryo implantation number (P<0.001, P<0.05, P<0.01) on the injured side of the uterus, indicating better results than the cell group. The combination of EA and BMSCs synergistically promotes the repair of damaged endometrium, improves endometrial morphology, reduces fibrosis levels, enhances vascular regeneration and matrix cell proliferation, improves endometrial receptivity, which ultimately facilitates embryo implantation.

Comparison of Secondary Prevention Following Hysteroscopic Adhesiolysis in the Improvement of Reproductive Outcomes: A Retrospective Cohort Study.

Intrauterine adhesion (IUA) is primarily caused by endometrial injury, and hysteroscopic adhesiolysis is presently the main treatment. However, postoperative recurrence and poor pregnancy outcomes remain intractable. In this study, we aim to assess the effects of different treatments on clinical symptoms and reproductive outcomes in IUA. This retrospective study was conducted in a tertiary university-affiliated women's hospital. The study included 1449 consecutive women who desired to have a baby and were diagnosed with IUA through hysteroscopy from January 2016 to December 2021. Patients with IUA underwent hysteroscopic electric resection (E) or cold scissors separation (C), as well as hormone therapy and one or both of the following secondary prevention measures: intrauterine devices (IUD) and hyaluronic acid gel (HA). The pregnancy rate (PR) was significantly higher in the E + IUD + HA (90.23% CI: 85.82, 94.64%) than in other groups (p = 0.000) groups. The rates of full-term birth (p = 0.000) and live birth (p = 0.000) were significantly higher in the E + IUD + HA (67.82% and 68.97%, respectively) and E + HA (62.41% and 63.91%, respectively) groups. Multivariate logistic regression analysis revealed a significantly higher PR in women who received second-look hysteroscopy (OR 1.571, 95% CI: 1.009-2.224, p = 0.013) and E + IUD + HA (OR 4.772, 95% CI: 2.534-8.987, p = 0.000). Combining hysteroscopic electric resection with IUDs and HA gel could prevent adhesion recurrence and improve postoperative pregnancy and live birth outcomes in IUA. Furthermore, postoperative second-look hysteroscopy may increase the PR and shorten the waiting period.

A cost-effectiveness analysis of intrauterine spacers used to prevent the formation of intrauterine adhesions following endometrial cavity surgery

Aim To assess, from a United States (US) payer’s perspective, the cost-effectiveness of gels designed to separate the endometrial surfaces (intrauterine spacers) placed immediately following intrauterine surgery. Materials and Methods A decision tree model was developed to estimate the cost-effectiveness of intrauterine spacers used to facilitate endometrial repair and prevent the formation (primary prevention) and reformation (secondary prevention) of intrauterine adhesions (IUAs) and associated pregnancy- and birth-related adverse outcomes. Event rates and costs were extrapolated from data available in the existing literature. Sensitivity analyses were conducted to corroborate the base case results. Results In this model, using intrauterine spacers for adhesion prevention led to net cost savings for US payers of $2,905 per patient over a 3.5-year time horizon. These savings were driven by the direct benefit of preventing procedures associated with IUA formation ($2,162 net savings) and the indirect benefit of preventing pregnancy-related complications often associated with IUA formation ($3,002). These factors offset the incremental cost of intrauterine spacer use of $1,539 based on an assumed price of $1,800 and the related increase in normal deliveries of $931. Model outcomes were sensitive to the probability of preterm and normal deliveries. Budget impact analyses show overall cost savings of ‍$19.96 per initial member within a US healthcare plan, translating to $20 million over a 5-year time horizon for a one-million-member plan. Limitations There are no available data on the effects of intrauterine spacers or IUAs on patients’ quality of life. Resultingly, the model could not evaluate patients’ utility related to treatment with or without intrauterine spacers and instead focused on costs and events avoided. Conclusion This analysis robustly demonstrated that intrauterine spacers would be cost-saving to healthcare payers, including both per-patient and per-plan member, through a reduction in IUAs and improvements to patients’ pregnancy-related outcomes.

Retracted: Comparison of the Effects of Hysteroscopic Cold Broad Sword Play Combined with Estrogen and Progestin Sequential Therapy and Drospirenone and Ethinylestradiol Tablets in Patients with Severe Intrauterine Adhesion.

[This retracts the article DOI: 10.1155/2022/9898228.].

Value of 2D ultrasonography in the diagnosis and evaluation of intrauterine adhesions – a prospective study

Research questionWhat is the value of 2D ultrasonography in the diagnosis and assessment of intrauterine adhesions (IUA)? DesignThis was a prospective study conducted at a hysteroscopy centre. ResultsOf a total of 600 subjects recruited, 41 dropped out and 559 were finally enrolled and analysed. The observed 2D ultrasonography features, in decreasing order of frequency, were ‘irregular endometrium’ (37.9%), ‘broken endometrial echo’ (23.4%), ‘thin endometrium’ (13.7%), ‘loss of endometrial echo’ (13.1%,), ‘hyperechoic focus’ (12.5%) and ‘fluid in the cavity’ (8.8%). The sensitivity of individual ultrasound features ranged from 8.8% to 37.9%, whereas the specificity of individual ultrasound features ranged from 78.9% to 100%. When all the six ultrasound features were considered together, the sensitivity and specificity were 71.7% and 66.2% respectively. The sensitivity, specificity and accuracy of ultrasound diagnosis in the mid-proliferative phase, peri-ovulatory phase and mid-luteal phase did not appear to be significantly different statistically, although the results in the mid-proliferative phase appeared to be consistently higher than those in the mid-luteal phase. In women confirmed to have IUA, the likelihood of the adhesions being severe in nature in the presence of zero, one, two or three or more ultrasound features was 8.7%, 23.0%, 40.2% and 80.5%, respectively (P < 0.001). ConclusionsThe findings in this study support the notions that ultrasonography examination in women suspected to have IUA cannot replace hysteroscopy in the diagnosis of the condition. However, it does provide useful clinical information regarding severity and could help in the planning of hysteroscopy to optimize management.

The Clinical Application of Platelet-Rich Plasma in the Female Reproductive System: A Narrative Review.

Platelet-rich plasma is an autologous plasma containing platelets prepared from fresh whole blood drawn from a peripheral vein. Through processing, it can be prepared to contain supraphysiologic levels of platelets at three to five times greater than the level of normal plasma. PRP has been explored both in vivo and ex vivo in the human endometrium model in its ability to harness the intrinsic regenerative capacity of the endometrium. Intrauterine autologous PRP infusions have been shown to increase endometrial thickness and reduce the rate of intrauterine adhesions. In the setting of recurrent implantation failure, intrauterine infusion of PRP has been shown to increase clinical pregnancy rate. PRP also appears to hold a potential role in select patients with premature ovarian insufficiency, poor ovarian responders and in improving outcomes following frozen-thawed transplantation of autologous ovarian tissue. Further studies are required to explore the potential role of PRP in reproductive medicine further, to help standardise PRP protocols and evaluate which routes of administration are most effective.

#87 : Intrauterine Adhesion in Ultrasound-Guided Manual Vacuum Aspiration (USG-MVA) Versus Electric Vaccum Aspiration (EVA): A Randomized Controlled Trial

Background and Aims: Intrauterine adhesion (IUA) is a possible complication after uterine surgery, especially after sharp curettage for miscarriages as it destroys the endometrial stratum basalis. This study aimed to determine and compare the IUA in women who underwent ultrasound-guided manual vacuum aspiration (USG-MVA) as opposed to traditional surgical evacuation (EVA) for the management of their first-trimester miscarriage. Methods: This was a prospective single-centre, randomised controlled trial conducted in a university-affiliated tertiary hospital. Chinese women aged [Formula: see text]18 years with a delayed miscarriage [Formula: see text]12 weeks of gestation or incomplete miscarriage attending the hospital were randomized to either USG-MVA or EVA for the management of their miscarriage. They were invited to come back for a hysteroscopic assessment for IUA at 6-20 weeks post-surgery to assess the incidence of IUA. Patients were contacted by phone at 6 months to assess their menstrual and reproductive outcomes. Results: 303 patients underwent surgical evacuation, of whom 152 were randomized to the ‘USG-MVA’ and 151 patients to the ‘EVA’. 126 from the USG-MVA group and 125 from the EVA group returned and completed the hysteroscopic assessment. The incidence of the IUA from USG-MVA was 19.0% (n=24/126) and was significantly lower compared to EVA, which was at 32.0% (n=40/125). There was no significant difference in menstrual outcomes at 6 months postoperatively between the two groups, but more patients had miscarriages in the EVA group with IUA. Conclusions: IUAs are a possible complication of USG-MVA. However, USG-MVA is associated with a lower incidence of IUA postoperatively at 6-20 weeks. USG-MVA is a feasible, effective, and safe alternative surgical treatment with less IUA for the management of first-trimester miscarriage.

Surgical Management of Intrauterine Adhesions

Intrauterine adhesions, also known as Asherman’s syndrome, can have an impact on both reproductive outcomes and gynaecologic symptoms. Surgical management with hysteroscopic lysis of adhesions is the gold standard for treatment. The following techniques are described in this presentation for cases with severe occlusive cavity and should be performed by experienced surgeons. 1. The use of 3D ultrasound played an important role in the preoperative workup of the patient, it could be used to evaluate the severity of intrauterine adhesion and predict the complexity of the cases. 2. Transabdominal 2D ultrasound guidance can help to delineate the location and extent of the adhesions and reduce the risk of uterine perforation and the formation of false passage. Laparoscopic guidance for severe cases has been advocated for immediate treatment of uterine perforation and minimizing extrauterine trauma. 3. In patients with severe intrauterine adhesion, a “myometrial scoring technique” could be used by bipolar electrode need with score 6 to 8, 4-mm-deep incisions from the fundus to the cervix and a transverse incision at the uterine fundus. Or the “ploughing technique” could be used by scissors, both methods aim to remove the fibrotic tissue, expose any underlying healthy basal endometrial tissue capable of regeneration. It remains to be seen whether “ploughing technique” using cold scissors or a “myometrial scoring technique” by bipolar electrode produces similar or different results, which could only be resolved by RCT in the future. 4. Surgical management offers favourable fertility outcomes and is often successful in restoring menstruation. Endometrial thickness and volume assessed by 3D-TVUS may have important predictive value for pregnancy after hysteroscopic adhesiolysis. 5. Prevention of reformation of adhesions remains challenging and no single method for preventing recurrence has shown superiority.

#366 : Adjuvants to Prevent Reformation of Adhesions Following Adhesiolysis for Asherman Syndrome

Background and aims: 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). Methods: 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 IUA reformation rate at follow-up hysteroscopy. Results: A total of 29 studies [15 randomised controlled trial (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 to 0.90 (P=0.02)];intrauterine contraceptive device: RR: 0.64, 95% CI: 0.36 to 1.12 (P=0.12);continuous intrauterine balloon: RR: 0.18, 95% CI: 0.05 to 0.68 (P=0.01);intermittent intrauterine balloon: RR: 0.50, 95% CI: 0.31 to 0.80 (P=0.004);anti-adhesion gel: RR: 0.80, 95% CI: 0.58 to 1.10 (P=0.17);amnion graft:RR:0.63, 95% CI:0.44 to 0.91 (P=0.01). Conclusions: In conclusion, among various adjuvant therapies in secondary prevention of IUA, second look hysteroscopy and IUB can be considered as an option to reduce adhesion recurrence.