Postoperative Intrauterine Adhesions Research Articles

Intrauterine interventions options for preventing recurrence after hysteroscopic adhesiolysis: a systematic review and network meta-analysis of randomized controlled trials.

Recurrence of adhesions after hysteroscopic adhesiolysis is a challenging clinical problem without a unified management approach. Therefore, we conducted a network meta-analysis that considered both direct and indirect comparisons between interventions to identify optimal strategies for preventing recurrence. We searched for research trials published up to July 2023 from PubMed, Embase and the Cochrane Database. We selected randomized controlled trials comparing the use of different interventions for the prevention of adhesion recurrence, with no language or regional restrictions. We used random-effects models to assess odds ratios (OR) and mean difference (MD) with 95% confidence intervals (CI). Adverse events associated with the interventions were also assessed. This study was registered on PROSPERO, CRD42023449068. Data from 21 randomized controlled trials involving 2406 patients were synthesized, including interventions with balloon, amnion, platelet-rich plasma (PRP), intrauterine device (IUD), hyaluronic acid (HA), platelet-rich fibrin (PRF), and granulocyte colony-stimulating factor (G-CSF). The top 5 interventions for change in AFS scores were: PRP + Balloon (MD = 5.44; 95% CI, 2.63-8.25), Amnion + Balloon (MD = 5.08; 95% CI, 2.71-7.44), IUD + Balloon (MD = 4.89; 95% CI, 2.49-7.30), HA + Balloon (MD = 3.80; 95% CI, 1.78-5.82), and G-CSF + Balloon (MD = 3.84; 95% CI, 1.05-6.63). There were no statistically significant differences between interventions in the recurrence rate of moderate-to-severe uterine adhesions and the clinical pregnancy rate. Most interventions were safe. To our knowledge, this is the most comprehensive network meta-analysis to date of interventions for preventing postoperative intrauterine adhesion recurrence. Our results indicate that PRP + Balloon seems to be the most effective approach.

Hysteroscopic Metroplasty Using Holmium: YAG Laser for Treatment of Septate Uterus

To demonstrate the safety, efficacy, and ease of hysteroscopic metroplasty using holmium:YAG (Ho:YAG) laser for treatment of septate uterus. Stepwise demonstration of surgical technique with narrated video footage. Septate uterus is the most common type of uterine anomaly. The incidence of uterine septum in women presenting with infertility and recurrent abortions is 15.4% [1,2]. Hysteroscopic septal incision is associated with improvement in live-birth rate in these women [3]. Hysteroscopic metroplasty for septate uterus can be done with the use of scissors and energy sources such as monopolar and bipolar electrosurgery and lasers. Ho:YAG laser is commonly used by urologists for various surgeries because of its "Swiss Army Knife" action of cutting, coagulation, and vaporization [4]. Ho:YAG laser is known for its precision. It causes lesser depth of tissue injury and necrosis and minimal collateral thermal damage compared with the electrosurgical devices and other lasers used for hysteroscopic surgery [5-8]. This is advantageous in hysteroscopic metroplasty given that it reduces the risk of uterine perforation during surgery and hence uterine rupture in the subsequent pregnancy. Reduced collateral damage to the surrounding endometrium helps promote early endometrial healing and prevent postoperative intrauterine adhesions. A 28-year-old patient with history of 2 spontaneous abortions came to our hospital for investigations. 3D transvaginal sonography of the patient showed presence of partial septate uterus with a fundal indentation of 1.5 cm (Supplemental video 1). Diagnostic hysteroscopy followed by septal incision using Ho: YAG laser was planned. We used a 2.9 mm BETTOCCHI Hysteroscope (Karl Storz SE & Co.) with a 5 mm operative sheath. Normal saline was used as the distending medium and the intrauterine pressure was maintained at 80 to 100 mm Hg. The procedure was done under total intravenous anesthesia using propofol injection. Vaginoscopic entry into the uterus (without any cervical dilatation) showed evidence of a partial uterine septum with tubal ostia on either side of the septum. A 400 micron quartz fiber was passed through a laser guide into the 5-Fr working channel of the operative hysteroscope. Ho:YAG laser (Auriga XL 50-Watt, Boston Scientific) with power settings of 15 watts (1500 mJ energy at 10 Hz) was used. Incision of the septum was started at the apex of the septum in the midline and continued in a horizontal manner from side to side toward the base (Supplemental video 2). Incision of the septum is continued till the tip of the hysteroscope can move freely from one ostium to the other (Supplemental video 3). The operative time was 12 minutes. There were no intra- or postoperative complications. Postoperative estrogen therapy was given for 2 months in the form of estradiol valerate 2 mg (tablet, Progynova, Zydus Cadila) 12 hourly orally for 25 days and medroxyprogesterone acetate 10 mg (tablet, Meprate, Serum Institute of India, Ltd) 12 hourly orally added in the last 5 days [9]. 3D transvaginal ultrasound was done on day 8 of menses. It showed a triangular uterine cavity with a very small fundal indentation of 0.37 cm. A second look hysteroscopy that was done on day 9 of menses showed an uterine cavity of good shape and size [10]. Few fundal adhesions were seen and they were incised using Ho:YAG laser. The patient conceived 5 months after the primary surgery and delivered by cesarean section at 38 weeks, giving birth to a healthy baby of 2860 grams. There were no complications during her pregnancy and delivery. A comparative study is essential to prove its advantages over other energy sources for this surgery. Hysteroscopic metroplasty using Ho:YAG laser for treatment of septate uterus is a simple, precise, safe, and effective procedure. VIDEO ABSTRACT.

Hysteroscopy-assisted suction curettage for early pregnancy loss: does it reduce retained products of conception and postoperative intrauterine adhesions?

To describe the feasibility of hysteroscopy-assisted suction curettage for early pregnancy loss and to investigate whether it reduces the rates of retained products of conception (RPOC) and intrauterine adhesions (IUA). Prospective single-arm cohort study. University-affiliated Department of Obstetrics and Gynecology. Women admitted for surgical evacuation of early pregnancy loss were invited to participate in the study. Vaginal misoprostol was administered for cervical ripening preoperatively. Under general anesthesia, a diagnostic hysteroscopy was performed to identify the pregnancy's implantation wall, followed by ultrasound-guided suction and curettage directed to the implantation wall, and then diagnostic hysteroscopy to verify complete uterine cavity emptying. Postoperative IUA were evaluated by follow-up office hysteroscopy. Identification of the pregnancy's implantation wall on hysteroscopy, and intra-, and postoperative complications associated with the procedure. The evaluation of postoperative IUA was limited due to the COVID-19 pandemic-related restrictions on elective procedures. Forty patients were included in the study group. Their mean age was 34.0 ± 6.6years, and their mean gestational age was 8.9 ± 1.6weeks. The implantation wall was clearly visualized on hysteroscopy in 33 out of 40 cases (82.5%). The mean operative time was 17.2 ± 8.8min, and no intraoperative complications occurred. Suspected RPOC were diagnosed intraoperatively by hysteroscopy and removed in 4 cases, and the histologic examination confirmed the presence of RPOC in three of them. Follow-up office hysteroscopy was performed in nine women: mild IUA was diagnosed in one case and a normal cavity was confirmed in eight cases. A new pregnancy was reported at the time of follow-up in 15 cases, while 12 women declined to attend the follow-up hysteroscopy and four were lost to follow-up. Hysteroscopy-assisted suction curettage for early pregnancy loss is a safe, short, and inexpensive procedure, which allows the identification of the pregnancy's wall in most cases and may reduce the rates of RPOC.

Antifouling and Injectable Granular Hydrogel for the Prevention of Postoperative Intrauterine Adhesion.

Postoperative intrauterine adhesion (IUA), caused by endometrial basal layer injury, is one of the main causes of female infertility. The excessive deposition of fibrin as well as fibroblast is considered the root cause of IUA. However, few clinical strategies are effective in preventing extracellular matrix (ECM) deposition at endometrial wounds that include protein and cell deposits. Herein, the injectable granular poly(N-(2-hydroxyethyl) acrylamide) (PHEAA) hydrogel (granular PHEAA gel), which presents excellent antifouling properties and remarkably prevents protein and cell adhesions, is used to prevent postoperative IUA. The granular PHEAA gel with a jammed network structure exhibits outstanding injectability and superior stability. Compared with the IUA group, the granular PHEAA gel can promote regeneration of the endometrium while reducing the area of endometrial fibrosis. Immunohistochemical staining experiments indicate that the granular PHEAA gel can improve the proliferation of the endometrium, promote vascularization, and enhance anti-inflammatory effect in IUA rats. And the granular PHEAA gel can effectively slow down the fibrosis of uterine tissue. Importantly, the number of embryos is significantly increased after injecting granular PHEAA gel, inferring that there is an obvious reproductive function recovery of injured endometrium.

Hysteroscopic morcellation vs. curettage for removal of retained products of conception: a multicenter randomized controlled trial

To study the comparison between hysteroscopic morcellation (HM) of retained products of conception (RPOC) with ultrasound (US)-guided electric vacuum aspiration in terms of intrauterine adhesion (IUA) formation, efficacy, and complications. A randomized controlled, nonblinded trial. Three teaching hospitals and one university hospital from April 2015 to June 2022. A total of 133 women with RPOC on US, ranging from 1-4 cm, were randomized to receive either HM or electric vacuum aspiration. Hysteroscopic morcellation was performed with the TruClear System (Medtronic, Minneapolis, MN, USA). Electric vacuum aspiration was performed using an 8- or 10-mm flexible plastic Karman cannula under US guidance. Women allocated to vacuum aspiration underwent the procedure as soon as possible. In the HM group, an office diagnostic hysteroscopy was planned a minimum of 6 weeks after the end of pregnancy, followed by retained product of conception removal at least 8 weeks after the end of the pregnancy. Postoperatively, an office second-look hysteroscopy was scheduled to assess the primary outcome of IUAs. Postoperative IUAs were seen in 14.3% (9/63) of patients in the HM group and 20.6% (13/64) of patients in the vacuum aspiration group (-6% [-19.1% to 7.1%]). Significantly more RPOC were removed completely by HM compared with vacuum aspiration (95.2% vs. 82.5% (-14% [-24.9% to -3.1%]), and additional operative hysteroscopy was less frequently necessary in the HM group (12.5%) compared with the vacuum aspiration group (31.3%) (-20.1% [-34.3% to -6%]). The median operating time was shorter for vacuum aspiration compared with HM (5.80 minutes vs. 7.15 minutes). No differences were observed between HM and vacuum aspiration for the occurrence of intraoperative or postoperative complications (5.5% vs. 5.0% and 2.7% vs. 1.3%, respectively). In our randomized controlled trial, no significant differences were found in the occurrence of IUAs and complications. However, the RPOC were more often completely removed by HM than vacuum aspiration, and the HM group required fewer additional hysteroscopic treatments. NTR4923 (https://trialsearch.who.int/Trial2.aspx?TrialID=NTR4923). Date of registration: November 23, 2014, date of initial participant enrollment: January 1, 2015.

Using Type I Collagen Gel to Prevent Postoperative Intrauterine Adhesion: A Multicenter Retrospective Study.

We evaluated the clinical outcomes of using type 1 collagen gel after therapeutic resectoscopy; overall, 150 women aged > 20 who planned to undergo therapeutic resectoscopy were enrolled. The patients were randomly assigned to either of the anti-adhesive treatment groups: the type 1 collagen gel (Collabarrier®) (study group; N = 75) or the sodium hyaluronate and sodium carboxymethylcellulose gel group (control group; N = 75) after resectoscopy. One month after applying anti-adhesive materials, postoperative intrauterine adhesions were evaluated using second-look hysteroscopy; the incidence rate of postoperative intrauterine adhesions examined through second-look hysteroscopy showed no significant differences between the groups. There were no statistical differences between the frequency and mean scores of the type and intensity of adhesions in both groups. Finally, no significant differences in adverse events, serious adverse events, adverse device effects, and serious adverse device effects were noted between the two groups; type 1 collagen gel can be effectively and safely used in intrauterine surgery to minimize postoperative adhesions, thereby eventually decreasing the prevalence of infertility, secondary amenorrhea, and recurrent pregnancy loss in reproductive women.

A new surgical approach for fertility-sparing management of diffuse endometrial G2 endometrioid adenocarcinoma: a step-by-step technique.

4% of endometrial cancers are diagnosed in young women and 70% are nulliparous. Preserve fertility in these patients is of major interest. It is demonstrated that hysteroscopic resection of focal well-differentiated endometrioid adenocarcinoma, followed by progestins achieve a complete response rate of 95.3%. Recently, fertility-sparing treatment was proposed also in case of moderately differentiated endometrioid tumors, with a relatively high remission rate. To show a new hysteroscopic approach, in case of fertility-sparing treatment of diffuse endometrial G2 endometrioid adenocarcinoma. Stepwise demonstration of the technique with narrated video footage for the fertility-sparing management of diffuse endometrial G2 endometrioid adenocarcinoma, combining the use of a 15 Fr bipolar miniresectoscope and 'three-steps' resection technique (Karl Storz, Tuttlingen, Germany) with a Tissue Removal Device (TRD) (Truclear Elite Mini, Medtronic). negative hysteroscopic assessment and endometrial biopsies at three and six months. Normal endometrial cavity and negative biopsies. Combined hysteroscopic technique, in case of diffuse endometrial G2 endometrioid adenocarcinoma, followed by double progestin therapy (Levonorgestrel releasing Intrauterine Device + Megestrole Acetate 160 mg/daily), may be associated with higher complete response rate; the use of TRD to complete the resection near tubal ostia may reduce risk of post-operative intrauterine adhesions and improve reproductive outcomes. A novel, fertility-sparing surgical approach for diffuse endometrial G2 endometroid adenocarcinoma.

Hysteroscopy for retained products of conception: a single-institution experience

BackgroundRetained products of conception can occur with induced abortion during early-term pregnancy, induction of labor during mid-term pregnancy, drug-induced abortion, miscarriage, cesarean delivery, or full-term normal delivery. Compared with traditional dilation and curettage, hysteroscopy is a safer and more effective treatment method for retained products of conception. This study aimed to report the efficacy of hysteroscopy for treating retained products of conception and to share our new clinical perspectives.MethodsThis retrospective, single-center study was conducted at a tertiary hospital in Chengdu, China. We included 36 patients with retained products of conception who underwent hysteroscopy at our hospital.ResultsOur study reported a complete removal rate of 80.5% (29/36) with one procedure. The normal menstruation recovery rate during 1 year of follow-up was 91.6% (33/36). A low rate of postoperative intrauterine adhesions (2.8% [1/36]) was also reported.ConclusionOur retrospective study elucidated the use of hysteroscopy for retained products of conception. We also shared new perspectives regarding hysteroscopy and optimal surgical methods for treating retained products of conception as well as our experience treating residual products with hysteroscopy. To our knowledge, no other study has shared similar experiences.

Hysteroscopic findings after laparoscopic and open myomectomy with or without uterine cavity breach: historical cohort study

Introduction The aim of this study was to evaluate hysteroscopic findings after laparoscopic and laparotomic myomectomy with a focus on the presence of postoperative intrauterine adhesions in groups of patients with and without perioperative uterine cavity breach (UCB). Material and methods This is a historical cohort study. Our database was searched to identify patients with UCB during myomectomy and matched the same number of patients after myomectomy without UCB to create a control group. All relevant data were retrieved from our medical records. In both groups, the results of follow-up hysteroscopy were analyzed. Results Low prevalence of intrauterine adhesions after myomectomy was observed in only 3.5% of the 170 patients in our samples. No significant difference in the occurrence of synechiae between the patients with and without UCB was found (2 vs. 4, RR 0.5, 95% CI 0.1–2.7, p = .341), nor was the difference in other hysteroscopic findings. Follow-up hysteroscopy was performed with slender optics and expandable casing system without need of any anesthesia in 87.1% of cases. Conclusions According to our findings, the prevalence of post-myomectomy intrauterine adhesions after myomectomy is low. Our study did not demonstrate that UCB during myomectomy is a risk factor for the formation of intrauterine synechiae.

Hysteroscopy Assisted Suction Curettage for Early Miscarriage: Does It Reduce Rpocn and Postoperative Intrauterine Adhesions?

<h3>Study Objective</h3> To describe the feasibility of hysteroscopy assisted suction curettage for early pregnancy loss and to investigate whether it reduces the rates of retained products of conception (RPOC) and intrauterine adhesions (IUA). <h3>Design</h3> Prospective single-arm cohort study. <h3>Setting</h3> University-affiliated department of Obstetrics and Gynecology. <h3>Patients or Participants</h3> Women admitted for surgical evacuation in cases of early pregnancy loss. <h3>Interventions</h3> Vaginal misoprostol was administered for cervical ripening preoperatively. Under general anesthesia, hysteroscopy was performed to identify the pregnancy's implantation wall, followed by ultrasound-guided suction and curettage directed to the implantation wall, and hysteroscopy to verify uterine cavity emptying. Postoperative IUA were evaluated by follow-up hysteroscopy. <h3>Measurements and Main Results</h3> Identification of the pregnancy's implantation wall on hysteroscopy, and intra- and postoperative complications associated with the procedure. The evaluation of postoperative IUA was limited due to the COVID-19 pandemic restrictions. Main Results: 40 patients, with early pregnancy loss were studied. In 33 out of 40 cases (82.5%), the implantation wall was clearly visualized on hysteroscopy. In 4 cases, suspected RPOC were diagnosed intraoperatively by hysteroscopy and removed. The histology examination confirmed the presence of RPOC in 3 out of 4 cases. Follow-up office hysteroscopy was performed in 9 women, diagnosing mild IUA in one out of 9 cases. In 15 cases, a new pregnancy was reported at time of follow-up. <h3>Conclusion</h3> Hysteroscopy assisted suction curettage for early pregnancy loss is safe procedure, which allows the identification of the pregnancy's implantation wall in most cases and may reduce the rates of RPOC and IUA. By identification of uterine anomalies, the procedure may offer a potential benefit in terms of reproductive outcomes for hypo-fertile patients.

Postpartum retained products of conception: Is it possible to avoid postpartum curettage?

Removal of retained products of conception (RPOC) by suction curettage or hysteroscopy may be required in the postpartum period, possibly causing intrauterine adhesions. We investigated whether rates of suction curettage, hysteroscopy, and postoperative intrauterine adhesions have changed over time. Parturients considered at risk for RPOC were followed in a specialized postpartum clinic with sequential ultrasound scans. We compared the rates of women requiring surgical procedures for RPOC removal and rates of postoperative intrauterine adhesions between two 2-year periods: 2011-2012 ("early period") and 2016-2017 ("late period"). The overall rates of women requiring a surgical procedure for removal of RPOC did not differ between the early and late periods (38/762 [5.0%] vs 41/732 [5.6%], respectively, P=0.595). However, removal of RPOC by suction curettage decreased significantly over time whereas removal by hysteroscopy increased (P=0.022). Intrauterine adhesions were diagnosed in 7 of 38 women (18.4%) who underwent a surgical procedure for RPOC removal in the early period, but none of the patients operated on in the late period developed intrauterine adhesions (P=0.004). Removal of RPOC in postpartum women may be completed by hysteroscopy in most cases, significantly reducing the need for postpartum curettage and the rates of postoperative intrauterine adhesions.

The efficacy of amniotic membrane-mediated sequential double-barrier therapy for the treatment of postoperative intrauterine adhesions.

To study the efficacy of using amniotic membrane, balloon and intrauterine device (IUD) as barrier therapy to prevent re-adhesion after hysteroscopic adhesiolysis.A total of 45 patients diagnosed with intrauterine adhesions in Changzhou Maternal and Child Health Hospital from June 2014 to December 2017 were included in this retrospective case control study. According to different postoperative isolation barrier methods, the patients were divided into group A (Foley balloon + fresh amniotic membrane Day1 + IUD Day7) (22 cases) and group B (Foley balloon Day1 + IUD Day7) (23 cases). Three months after the surgery, the second hysteroscopy was performed to observe the condition of the uterine cavity and the improvement of menstruation, and to monitor the thickness of the endometrium.The efficacy of hysteroscopic procedure in group A was significantly higher than that of group B (P < .05). After 3 months of treatment, the improvement rate of menstruation was significantly higher in group A than in group B (P < .05). Endometrial thickness in both group A and B was significantly increased compared with that before the surgery (P < .05). The postoperative endometrium of group A was significantly thicker than that of group B (P < .05).Amniotic membrane-mediated sequential double-barrier method is clinically feasible for preventing recurrent intrauterine adhesions.

Is Hysteroscopy the Best Surgical Approach for Removal of Retained Products of Conception Following Surgical Termination of Pregnancy?

To investigate the rates of intrauterine adhesion following hysteroscopy for removal of RPOC associated with surgical termination of pregnancy. We conducted a retrospective cohort study of all cases of removal by hysteroscopy of RPOC associated with surgical termination of pregnancy carried out at the Yitzhak Shamir (Assaf Harofe) Medical Center from January 2013 to December 2018. The rates of postoperative intrauterine adhesion were assessed by follow-up hysteroscopy. Our study involved 85 cases of removal by hysteroscopy of RPOC associated with surgical termination of pregnancy. The mean size of the RPOC was 1.9 ± 0.9 cm, and the mean time from termination of pregnancy to hysteroscopy was 1.5 ± 0.9 months. Two patients (2.4%) were readmitted for postoperative complications (fever). Postoperative follow-up information was available for 49 cases (57.6%). A total of 47 of these women had a normal uterine cavity (95.9%) while 2 women (4.1%) were diagnosed with mild intrauterine adhesions. Hysteroscopy for removal of RPOC following surgical termination of pregnancy is associated with low rates of postoperative intrauterine adhesions. Additional studies may determine whether this is the procedure of choice in these cases.

Two-step hysteroscopy for management of morbidly adherent retained products of conception.

Retained products of conception (RPOC) may occur as the result of a morbidly adherent placenta. In these cases, the hysteroscopic removal of RPOC may be technically challenging, and may require more than one hysteroscopic procedure. We sought to compare the clinical, surgical, and postoperative characteristics of cases managed by either a one-step hysteroscopy procedure or a two-step hysteroscopy approach. A retrospective review of all RPOC cases managed by hysteroscopy from 1/2013 to 3/2018. We included cases of RPOC occurring following delivery and medical or surgical pregnancy terminations. The rates of postoperative intrauterine adhesions were assessed by office hysteroscopy. A two-step procedure was required in 11 (3.9%) of the 358 women who underwent hysteroscopy for removal of RPOC during the study period. Comparison between the two-step and the one-step procedure groups revealed that the women in the two-step group were significantly older and the mean RPOC size was significantly larger (35.5 ± 4.1years versus 30.7 ± 5.9years, respectively, p = 0.01, and 38.6 ± 9.8mm versus 22.3 ± 7.5mm, p < 0.001, respectively). While the rates of intraoperative complications were similar between groups, readmission for postoperative fever was more common in the two-step group (18.2% versus 2.0%, respectively, p = 0.03). Postoperative intrauterine adhesions were diagnosed in 20.0% and 5.2%, respectively (p = 0.05). The two-step hysteroscopic approach enabled the complete removal of larger RPOC masses without the use of uterine curettage. The women who underwent the two-step procedure, however, were at increased risk for postoperative fever and postoperative intrauterine adhesions.

Operative hysteroscopy for retained products of conception: Efficacy and subsequent fertility

Retained product of conception complicates nearly 1% of pregnancies and can lead to synechiae and compromise ulterior fertility. The aim of this study is to evaluate efficiency of operative hysteroscopy in management of retained products of conception (RPOC). Secondary objectives are assessments of intra-uterine adhesions rate and later fertility.This unicentric retrospective study includes women who undertook an operative hysteroscopy for retained products of conception between January 2012 and March 2014. Assessment of the efficiency of operative hysteroscopy is defined by a complete resection of retained products of conception confirmed by office hysteroscopy.One hundred fourteen women were included in the study. Efficiency of operative hysteroscopy for retained products of conception is 91% for women with a postoperative office hysteroscopy. The authors observed a 7.5% rate of postoperative intra-uterine adhesions. Fertility rate was 83% (30 women out of 36 with a desired pregnancy).Hysteroscopic resection of retained products of conception is an efficient procedure and seems to be a real alternative.

Efficacy and Safety of Hyaluronic Acid Gel for the Prevention of Intrauterine Adhesion: A Meta-Analysis of Randomized Clinical Trials

Background: The aim of this study is to assess the clinical effectiveness and safety of hyaluronic acid gel for the prevention of postoperative intrauterine adhesions (IUAs). Methods: PubMed, Cochrane Library, Embase and ClinicalTrials.gov databases were searched for randomized controlled trials. Results: Six RCTs with a total of 564 patients met the inclusion criteria. The meta-analysis showed that, compared to no other treatment method, hyaluronic acid gel significantly reduced the rate of any IUA (risk ratio [RR] 0.68; 95% CI 0.53–0.86; p = 0.03; I² = 64%) and adhesion score (standard mean difference = –2.90; 95% CI –4.61 to –1.49; p < 0.00001; I² = 98%) following intraperitoneal or intrauterine surgery. Treatment lowered the rate of IUAs classified as moderate (RR 0.26; 95% CI 0.13–0.52; p = 0.13; I² = 0%), but not those deemed mild (RR 0.86; 95% CI 0.62–1.21; p = 0.39; I² = 3%) or severe (RR 0.33; 95% CI 0.03–3.09; p = 0.33; I² = 0). Compliance with hyaluronic acid gel treatment was low. Conclusion: Hyaluronic acid gel can prevent IUAs, particularly those with moderate severity and a lower adhesion score.

Hysteroscopic removal of retained products of conception following first trimester medical abortion.

Study Objective:To investigate the use of operative hysteroscopy instead of traditional curettage in women with retained products of conception (RPOC) following first trimester medical abortion, with the aim of reducing post-operative intrauterine adhesions.Design:Retrospective study.Setting:Gynecology department in a University affiliated hospital.Patients:All women treated by hysteroscopy for RPOC following first trimester medical abortion using the mifepristone-misoprostol protocol for pregnancy termination or the misoprostol protocol for early missed abortion from January 2013 to August 2016.Intervention:Operative hysteroscopy for removal of RPOC. Post-operative intrauterine adhesions were assessed by diagnostic office hysteroscopy after 6–8 weeks.Measurements and Main Results:50 cases were identified. The mean time from medication administration to the operative hysteroscopy was 1.7 ± 0.7 months. Operative hysteroscopy with blunt use of the resectoscopic loop was used to remove all specimens, and all procedures were completed without intra-operative complications. Two patients (4.0%) were readmitted for fever. Pathology confirmed the presence of RPOC in 45 (90.0%) cases. On follow-up office hysteroscopy, a normal uterine cavity without evidence of intrauterine adhesions was seen in 29/29 (100%) women.Conclusion:Hysteroscopy for removal of RPOC following medical abortion is associated with low rates of complications and post-operative intrauterine adhesions.

The incidence of post-operative adhesion following transection of uterine septum: a cohort study comparing three different adjuvant therapies

ObjectiveTo investigate the clinical efficacy of postoperative estrogen therapy, intrauterine device (IUD) and intrauterine balloon in preventing intrauterine adhesions after transcervical resection of septum (TCRS). Study design238 patients who underwent TCRS in our hospital from March 2012 to December 2013 were allocated into one of four groups. In Group 1 (50 patients), women received postoperative estrogen therapy. In Group 2 (59 patients), an intrauterine contraceptive device (IUD) was placed into the uterine cavity at the end of the operation. In Group 3 (75 patients), a Foley catheter with the balloon inflated with 4ml of normal saline solution was placed into the uterine cavity at the end of the operation for five days. In Group 4 (54 patients), women did not receive any of the above treatment (comparison group). All subjects underwent two further hysteroscopy, one and three months after the initial surgery. ResultsThe intrauterine adhesion rates among the four groups at one month were 22.0%, 28.81, 26.7% and 24.1% (p>0.05); and at the third month were 0%, 1.7%, 1.3% and 3.4%, respectively (p>0.05). ConclusionsThe use of postoperative estrogen therapy, IUD or intrauterine balloon did not appear to have any benefit in reducing the incidence of postoperative intrauterine adhesion formation.

Value of herbal medicine in prevention of postoperative intrauterine adhesions (Misurata experience)

Value of herbal medicine in prevention of postoperative intrauterine adhesions (Misurata experience)

Influence of auto-cross-linked hyaluronic acid gel on pregnancy rate and hysteroscopic outcomes following surgical removal of intra-uterine adhesions

ObjectiveTo determine the effect of the use of auto-cross-linked hyaluronic acid (ACP) gel following hysteroscopic surgery on the prevention of intra-uterine adhesions (IUAs) and the pregnancy rate. Study designAn observational retrospective study of 90 patients who underwent hysteroscopic removal of IUAs was conducted between 2008 and 2013 at a tertiary university care centre. Thirty-two patients received ACP gel during hysteroscopic removal of IUAs, and the remaining 58 patients did not receive ACP gel. Controls were matched to cases according to infertility and severity of IUAs using the American Society for Reproductive Medicine (ASRM) score. Four to six weeks after surgery, patients underwent diagnostic hysteroscopy to determine the re-occurrence of IUAs or the presence of adhesions. The patients were contacted by telephone to answer a questionnaire concerning their fertility. The main outcomes were pregnancy rate and postoperative IUAs. ResultsPregnancy (viable or not) rates were not influenced by the use of ACP gel. The viable pregnancy rate was eight of 24 (33.3%) in the ACP gel group and 12 of 49 (24.5%) in the control group (p=0.427). The mean interval between surgery and pregnancy was 11.8 [standard deviation (SD) 10.5] months in the ACP group compared with 13.4 (SD 14.1) months in the control group (p=0.744). The mean ASRM score after surgery (hysteroscopic diagnosis at 4–6 weeks postoperatively) was equivalent in the two groups: 2.7 (SD 3.0) in the ACP gel group vs 2.6 (SD 3.2) in the control group (p=0.854). The mean follow-up was 45.2 months (interquartile range 33.2–52.7), with a loss to follow-up of 25% in the ACP gel group compared with 15.5% in the control group (p=0.817). ConclusionApplication of ACP gel did not prevent recurrence of IUAs and was not associated with an increased pregnancy rate. ACP gel should be used with caution pending assessment in a randomized control trial in a larger population.