Severe Intrauterine Adhesions Research Articles

The study on the safety and efficacy of amnion graft for preventing the recurrence of moderate to severe intrauterine adhesions

Transcervical resection of adhesion (TCRA) is the standard treatment for the intrauterine adhesions, but the recurrence of adhesions is a tough problem for the gynecologist. In addition, the therapeutic strategy after TCRA about prevention of recurrence remains controversial especially for the patients with moderate to severe intrauterine adhesions (IUAs). Hence, we designed this study to explore the safety and efficacy of fresh amnion grafts for preventing the recurrence after TCRA for patients with moderate to severe IUAs. One hundred patients with moderate to severe IUAs who presented with a history of hypomenorrhea, amenorrhea and infertility were included in the study from January 2015 to December 2017. Patients were divided into amnion group (52 patients) and chitosan group (48 patients). Fresh amnion grafts or intrauterine injections of chitosan were administered after TCRA. Transvaginal ultrasonography (TVUS) and hysteroscopy were performed at the first and third month after the operation. The surgical procedures for all patients were completed successfully without relevant complications. In amnion group, 8 patients exhibited relapse in the first month and 2 patients in three months after surgery; in chitosan group, 23 women exhibited relapse in the first month and 18 patients in three months after surgery. Statistical analysis revealed that the recurrence rate of adhesion in amnion group was significantly lower than those of chitosan group in the first and three months after surgery (P1 = 0.000, P2 = 0.000). After TCRA, fresh amnion graft plays a significant role in preventing further adhesions than injections of chitosan.

The impact of chronic endometritis on endometrial fibrosis and reproductive prognosis in patients with moderate and severe intrauterine adhesions: a prospective cohort study

To study the effect of chronic endometritis (CE) diagnosed by CD138 immunohistochemical (IHC) staining on endometrial fibrosis and reproductive prognosis in patients with moderate or severe intrauterine adhesions (IUAs). Prospective cohort study (Canadian Task Force classification II-2). University-affiliated hospital. One hundred sixty-seven women with moderate to severe IUAs. Transcervical resection of adhesions (TCRA) and endometrial biopsy were performed in all patients. According to results of IHC staining with anti-syndecan-1 antibodies to identify CD138cells, participants were classified into two groups: 78 patients with CE (CE group) and 89 women without CE (NCE group). IHC staining for fibrosis markers transforming growth factor beta 1, anti-fibrosis markers matrix metalloproteinase 9, and endometrial receptivity marker integrin alpha v beta 3 was later applied to all tissue samples. Endometrial fibrosis, endometrial receptivity, and reproductive prognosis. CE diagnosed by CD138 IHC staining has a high incidence, 46%, in moderate and severe IUAs. In the CE group, the expression of transforming growth factor beta 1 was higher than that in the NCE group, and the expression of matrix metalloproteinase 9 and alpha v beta 3 was lower than that in the NCE group. The pregnancy rate and live birth rate in the NCE group were higher than those in the CE group (42.7% vs. 31.5%, 26.9% vs. 17.9%). CE may affect the endometrial fibrosis homeostasis in IUAs. Women with CE were more likely to experience recurrence of adhesions and had poorer reproductive outcomes. NCT02744807.

Factors That Impact Fertility after Hysteroscopic Adhesiolysis for Intrauterine Adhesions and Amenorrhea: A Retrospective Cohort Study

To identify factors that affect reproductive outcomes after hysteroscopic adhesiolysis in patients with severe intrauterine adhesions (IUAs, scored between 9 and 12 according to the American Fertility Society classification) and amenorrhea. A retrospective cohort study. A university-affiliated hospital. One hundred fifty-one patients with severe IUAs and amenorrhea. Patients were diagnosed via hysteroscopy and underwent at least 1 hysteroscopic adhesiolysis between May 2012 and January 2016. Of 151 patients, 12 were lost to follow-up, and 139 were included in the study with a follow-up period ranging from 2 to 6 years. Of the 139 evaluable patients, 107 (77%) recovered with a normal uterine cavity (free of IUAs), 28 (20.1%) had improved uterine cavity (fewer IUAs), and 4 (2.9%) showed no improvement. Moreover, 79 patients (56.8%) recovered with normal menstruation, 54 (38.9%) showed increased frequency of menstruation, and 6 (4.3%) had persistent amenorrhea. Seventy-seven (55.4%) became pregnant, of whom 13 had a spontaneous miscarriage, 11 birthed prematurely (at 31-36 gestational weeks), 44 experienced term delivery, and 9 were still pregnant at the end of the study. Age >32 years (p = .002, odds ratio [OR] = 3.442), >2 surgeries (p = .027, OR = 2.969), cervical canal adhesions (p = .047, OR = 2.112), and disease course >6 months (p = .037, OR = 2.335) were risk factors for infertility in patients with severe IUAs and amenorrhea. Younger age, earlier treatment within the disease course, fewer cervical canal adhesions, and fewer surgical procedures improve the reproductive outcome in patients with severe IUAs and amenorrhea.

New Crosslinked Hyaluronan Gel, Intrauterine Device, or Both for the Prevention of Intrauterine Adhesions.

Background and Objectives:To compare the efficacy of 3 different techniques for prevention of adhesion reformation after hysteroscopic adhesiolysis in patients with moderate-to-severe intrauterine adhesions. Short-term assisted reproductive outcomes were also compared.Study Design:Total of 72 cases were randomized to Lippes loop intrauterine device (IUD) only, IUD plus a new crosslinked hyaluronan (NCH) gel, or NCH gel only following hysteroscopic adhesiolysis. All cases received hormonal therapy and a second hysteroscopy was carried out. Endometrial thickness values were measured using transvaginal ultrasonography and American Fertility Society adhesion scores were noted during first and second hysteroscopy in all groups. Reproductive outcomes were also compared for those who received in vitro fertilization treatment.Results:Transvaginal ultrasonography revealed significantly better endometrial thickness in the IUD+NCH (7.5 mm) and NCH-only groups (6.5 mm) than the IUD-only group (5 mm) (P < .001). All groups revealed enhanced but comparable American Fertility Society adhesion scores on second-look hysteroscopy. A total of 37 patients received in vitro fertilization treatment after surgical management of adhesions. Ongoing pregnancy rates after in vitro fertilization were 27%, 40%, and 36% in IUD, IUD+NCH, and NCH groups, respectively. However, the difference between the groups did not reach statistically significant difference.Conclusion:All interventions are of similar efficacy in the prevention of adhesion reformation after hysteroscopic adhesiolysis for moderate to severe intrauterine adhesions. However, better endometrial thickness values were observed in those who received NCH gel either alone or in combination with IUD. Assisted reproductive outcomes of both groups were comparable for ongoing pregnancy rates.

Porous scaffolds from droplet microfluidics for prevention of intrauterine adhesion

Severe intrauterine adhesions (IUAs) have a great negative impact on women's psychological and reproductive health. It remains a significant challenge to prevent postoperative IUAs because of the complications of various clinical preventive measures and incompatibility of uterine cavity morphology. Herein, we present a new drug-loadedporous scaffold based on a microfluidic droplet template, which combines the characteristics of the artificial biocompatible material GelMA and the natural polysaccharide material Na-alginate. By changing the containers that collect the microfluidic droplets, the porous scaffold conforming to the shape of the uterine cavity could be obtained. The porous structure, mechanical property, and flexibility impart the scaffold with compressibility and send it to the uterus through the vagina. In addition, the external–internal connected open structures could load and control the release of drugs to repair the damaged region continuously in vivo. To verify the antiadhesion and repair of drug-loaded porous scaffolds, we tested the system in the rat model of IUAs, and it was demonstrated that the system had the ability to improve neovascularization, cellularize the damaged tissue, and repair the endometrium. These features provide the drug-loaded porous scaffolds with new options for the improvement of postoperative IUAs. Statement of SignificanceIntrauterine adhesions are caused by various causes of damage to the endometrial basal layer, thus leading to part or entire adhesions in the cervical or uterine cavity. Clinically, various preventive measures reach the barrier effect through the physical barrier, which are difficult to further promote the repair of the damaged endometrium, and most of them have apparent side effects. This study aims to prepare compressible and biodegradable three-dimensional porous drug-loading biological scaffolds. GelMA and Na-alginate have desirable biocompatibility. The interconnect porous scaffolds, which were prepared through the combination of biomaterials and single emulsion microfluidics, not only have compressibility but also provide space for drug delivery and release. This system can further promote the repair of the endometrium while preventing adhesion.

New Crosslinked Hyaluronan Gel for the Prevention of Intrauterine Adhesions after Dilation and Curettage in Patients with Delayed Miscarriage: A Prospective, Multicenter, Randomized, Controlled Trial

Study ObjectivesTo evaluate the efficacy of a new crosslinked hyaluronan (NCH) gel in reducing the formation of intrauterine adhesions (IUAs) after dilation and curettage (D&C). DesignRandomized controlled trial (Canadian Task Force classification I). SettingsSix hospitals for maternal and child healthcare in China. PatientsA total of 300 patients were randomized to undergo D&C for delayed miscarriage without previous history of D&C. Twenty-six patients (9%) were lost to follow-up and were excluded from the analysis. InterventionsWomen were randomly assigned to D&C alone (control group; n = 150) or D&C plus NCH gel application (NCH gel group; n = 150) with 1:1 allocation. Measurements and Main ResultsAll patients were evaluated using the American Fertility Society classification of IUAs during follow-up diagnostic hysteroscopy, scheduled at 3 months after D&C procedure. The primary endpoint was the number of women with IUAs at 3 months, and the secondary endpoints were adhesion scores and severity of IUAs. Postoperative efficacy data were available for 274 women (137 in each group). Intrauterine adhesion formations were observed in 13 of the 137 women (9.5%) in the NCH gel group and in 33 of the 137 women (24.1%) in the control group (p = .0012; relative risk [RR], 0.3939; 95% confidence interval [CI], 0.2107–0.7153), a difference of 14.6% (95% CI, 5.92%–23.28%) between the 2 groups. The extent of intrauterine cavity involved, type of adhesion and menstrual pattern, and cumulative adhesion scores were significantly lower in the NCH gel group compared with the control group (p = .0007, .008, .0012, and .0006, respectively). The proportion of women with moderate to severe IUAs was significantly lower in the NCH gel group than that in the control group (1 of 137 [0.7%] vs 16 of 137 [11.7%]; p = .0002; RR, 0.0625; 95% CI, 0.0084–0.4648), a difference of 11.95% (95% CI, 5.39%–16.51%) between the 2 groups. ConclusionsThe current study demonstrates that IUAs are frequently formed after D&C for delayed miscarriage in women without a previous history of D&C procedures, and the application of NCH gel significantly reduces IUA formation.

Abnormal expression of fibrosis markers, estrogen receptor α and stromal derived factor‑1/chemokine (C‑X‑C motif) receptor‑4 axis in intrauterine adhesions.

Intrauterine adhesions (IUAs) are mainly derived from fibrous tissue formation following endometrial damage. The aim of the present study was to assess whether fibrosis markers, estrogen receptor (ER)α and the stromal derived factor (SDF)-1/C-X-C chemokine receptor type 4 (CXCR-4) axis are abnormally expressed in IUA endometrium. A total of 76 human endometrial biopsy samples (normal, n=20; mild-to-moderate IUAs, n=40; and severe IUAs, n=16) were employed, and Sprague-Dawley rat IUA models at different time points were constructed. Subsequently, the expression of transforming growth factor (TGF)-β1, matrix metalloproteinase (MMP)-9, ERα and the SDF-1/CXCR-4 axis was evaluated in human and rat IUAs using histology, immunohistochemistry, reverse transcription quantitative polymerase chain reaction and western blotting. In patients and rats with IUA formation, the expression of TGF-β1, MMP-9 and ERα was significantly higher compared with the control group at the mRNA and protein levels (P<0.05); in addition, in patients, the TGF-β1, MMP-9 and ERα levels were significantly higher in severe IUAs compared with those in mild-to-moderate IUA endometrium (P<0.05). Although the chemokine SDF-1 level in rats increased significantly during the early postoperative phase (reaching a peak at the second estrus phase) in rat endometrium (P<0.05), its special receptor CXCR-4 expression did not differ significantly compared with the control group in rats or patients (P>0.05). Our findings indicated that aberrant activation of fibrosis and expression of ERα may be involved in the pathology of IUA formation. The role of the SDF-1/CXCR-4 axis in IUAs as inflammatory medium in the short-term or special homing factors for bone marrow mesenchymal stem cells requires further verification in in vivo animal models.

Transdermal estrogen gel and oral aspirin combination therapy improves fertility prognosis via the promotion of endometrial receptivity in moderate to severe intrauterine adhesion.

Intrauterine adhesion (IUA) is one of the most common gynecological diseases in women of reproductive age. IUA, particularlyin moderate to severe forms, accounts for a large percentage of infertility cases. Clinically, the first-line treatment strategy for IUA is transcervical resection of adhesion (TCRA), followed by adjuvant postoperative treatment. Estrogen is one of the classic chemotherapies used following TCRA and contributes to preventing re-adhesion following surgery. However, estrogen has limited effects in promoting pregnancy, which is the ultimate goal for IUA management. In the present study, a transdermal estrogen gel and oral aspirin combination therapy was used in patients with IUA following TCRA. Compared with in the control group (transdermal estrogen only therapy), the combination therapy significantly increased endometrial receptivity marker (αvβ٣ and laminin) expression in endometrium tissues. Additionally, ultrasonic examination revealed the pulsatility index and resistant index of the uterine artery were lower in the combination therapy group. Combination therapy promoted angiogenesis and prevented fibrosis following TCRA more effectively than estrogen-only therapy. Collectively, the evaluation indices, including American Fertility Society score, endometrial parameters and pregnancy rate, indicated that patients with combination therapy had better prognoses in endometrial repair and pregnancy. In conclusion, postoperative combination therapy with transdermal estrogen gel and oral aspirin may be more efficacious in enhancing endometrial receptivity by increasing uterine blood and angiogenesis, contributing to improved fertility prognosis. The findings of the present study may provide novel guidance to the clinical treatment of IUA.

A cohort study comparing 4 mg and 10 mg daily doses of postoperative oestradiol therapy to prevent adhesion reformation after hysteroscopic adhesiolysis

This is a retrospective cohort study conducted in a national training centre for hysteroscopy between January 2012 and December 2014 to compare the clinical outcome of two doses of oestradiol valerate (4 mg and 10 mg daily) in the prevention of recurrence of adhesions after hysteroscopic adhesiolysis. A total of 176 women who suffered from Asherman syndrome with moderate to severe intrauterine adhesions were included: 91 subjects received a 10 mg daily dose of oestradiol and 85 subjects received a 4 mg daily dose of oestradiol in the postoperative period. Second look hysteroscopy was performed 4–6 weeks after the initial surgery. There was no difference in age and preoperative American Fertility Society (AFS) adhesion score between the two groups. The proportion of women in whom menstruation had returned to normal in the 10 mg group (49/91 = 53.8%) was significantly (p < 0.05) higher than that of subjects in the 4 mg group (35/85 = 41.2%). However, there was no difference in AFS scores at second look hysteroscopy between the two groups or in the conception rate and miscarriage rate between the two groups. The findings do not support the use of high-dose postoperative oestrogen therapy following hysteroscopic adhesiolysis.

Feasibility analysis of treating severe intrauterine adhesions by transplanting menstrual blood-derived stem cells.

Intrauterine adhesions (IUA) are associated with the loss of stem cells in the endometrium. Menstrual blood‑derived stem cells (MenSCs) can be isolated from the menstrual blood and differentiated into endometrial cells. To check the transplantation feasibility of MenSCs for the treatment of severe IUA, MenSCs were isolated from menstrual blood, cultured in Dulbecco's modified Eagle's medium (DMEM), identified by immunocytochemistry and flow cytometry, differentiated into endometrial cells invitro, and finally transplanted into the axillary subcutaneous tissue of non‑obese diabetic/severe combined immunodeficiency (NOD‑SCID) mice to create endometrial tissue. Additionally, the cloning efficiency and POU domain class5 transcription factor1 (OCT‑4) positivity of MenSCs from patients with severe IUA were compared with those from healthy women. Immunocytochemistry and flow cytometry results showed that 95.1±0.8% cells were OCT‑4‑positive, 0.9±0.4% were cluster of differentiation (CD)45‑positive, 1.8±0.9% were STRO‑1‑positive and 1.0±0.4% were human leukocyte antigen‑antigen D related‑positive. Following differentiation invitro, the results of immunocytochemistry, reverse transcription‑polymerase chain reaction and western blot analysis showed that the expression of cytokeratin(CK) and vimentin (VIM) was increased in MenSCs compared with that in control subjects. Subsequent to transplantation in mice administered with sequential 17β‑estradiol and progesterone, CK, VIM, estrogen receptor and progesterone receptor were expressed in the transplantation regions, suggesting that MenSCs could differentiate into endometrial tissues invivo. The cloning efficiency and OCT‑4 positivity of MenSCs from patients with severe IUA was significantly decreased. In conclusion, to the best of our knowledge, this is the first study in which MenSCs could differentiate into endometrial cells invitro and create endometrial tissue in NOD‑SCID mice invivo, with impaired cloning efficiency and OCT‑4 expression of MenSCs from patients with IUA. This study will provide a theoretical basis for the treatment of IUA with MenSCs.

Endometrial stem cell-derived granulocyte-colony stimulating factor attenuates endometrial fibrosis via sonic hedgehog transcriptional activator Gli2.

Intrauterine adhesion (IUA) is characterized by endometrial fibrosis, which ultimately leads to menstrual abnormalities, infertility, and recurrent miscarriages. The Shh/Gli2 pathway plays a critical role in tissue fibrogenesis and regeneration; Gli2 activation induces profibrogenic effects in various tissues, such as the liver and kidney. However, the role of Gli2 in endometrial fibrosis remains unknown. The purpose of this study was to test the hypothesis that activated Gli2 promotes endometrial fibrosis. Endometrial samples from moderate and severe IUA patients exhibited significantly enhanced expression of Gli2 compared with normal endometrial samples and mild IUA samples. Transfection with overactive Gli2 plasmids induced higher fibrosis-related protein expression, while blocking Gli2 signaling with cyclopamine caused the opposite effect in endometriotic stromal cells (ESCs), including inducing cell-cycle arrest. Menstrual-derived stem cell conditioned medium (MenSCs-CM) reduced endometrial fibrosis by reducing Gli2 protein levels and causing cell-cycle arrest in ESCs through granulocyte-colony stimulating factor (G-CSF). The effect was weakened after neutralization with a G-CSF antibody. Gli2 overexpression reduced the effects of MenSC-CM and G-CSF on fibrosis and cell-cycle progression in vitro. The antifibrotic effect of G-CSF was also observed in murine model. These findings demonstrate that Gli2 signaling promotes endometrial fibrosis, and the inhibition of Gli2 through MenSCs-secreted G-CSF may be of therapeutic value for managing endometrial fibrosis.

An experimental model: intrauterine adhesion versus subendometrial fibrosis

Background: Intrauterine adhesions (IUA) remain a major cause of infertility. The prevalence of IUA varies geographically and keeps increasing over the last few decades due to increased hysteroscopic surgeries. Therefore, IUA management has received considerable attention. However, the management of IUAs still presents a big challenge: the recurrence rate could be up to 62.5% in severe IUAs. Intrauterine adhesion (IUA) occurs as a result of endometrial destruction by surgical interventions or infection causing obliteration of uterine cavity by the adhesions which interfere with embryonic implantation. Sub endometrial fibrosis may occurs, which causes narrowing of uterine cavity so no enough space for fetal growth. This leads to recurrent abortion. Aim: We aim in this experiment to apply a method for two models of IUA and or fibrosis by intrauterine injections of two different doses of trichloroacetic acid. Method: This experimental study was performed on 30 albino adult rats which were divided into three groups (n=10 rats/group) as follows, group 1: normal control rats, group 2: induced IUA and/or fibrosis that received low dose trichloroacetic acid, group 3: induced fibrosis that received high dose trichloroacetic acid, the extent of fibrosis, vascularization and inflammation were evaluated by; qRTPCR for IL-6, TNF, VEGF and TG-β immunohistochemistry examination for VEGF and TGF-β and histological assessment. Results: We found significant increase in IL-6, TNF and TGF in high dose group and significant decrease in VEGF in high dose group compared to normal group and low dose group (p<0.05). Discussion: The reproductive cells are the most sensitive to toxic environmental materials. In this study, we found that group II rats (IUAs), unlike control rats, had impaired endometrial epithelial cells, a lower number of endometrial glands, higher inflammatory cell infiltration, poor vascularity, and a severe narrowing of the uterine cavity with dense endometrial fibrosis as confirmed by H&E and Masson’s trichrome staining.

Analysis of clinical efficacy of moderate and severe intrauterine adhesions following uterine arterial embolization

Objective To evaluate the efficacy of moderate and severe intrauterine adhesion (IUA) following uterine arterial embolization (UAE) after hysteroscopic adhesiolysis. Methods A analysis of clinical efficacyl was performed. According to American Fertility Society (AFS) scoring system, 60 cases following UAE were used for the observation group, 60 cases without following UAE were used for the control group. Hysteroscopic adhesiolysis was performed in two groups. Second-look hysteroscopic examination was performed to all patients at 3 months postoperatively for evaluation of IUA. Primary endpoint was the reduction rate of IUA at 3months afer hysteroscopic adhesiolysis. The secondary endpoint includes total AFS score, and score of each individual AFS category. Results At 3 months after surgery, the observasion group resulted in significantly lower effective rate for reduction of adhesion, the effctive rate were 37.04% (20/54) and 82.46% (47/57)(P<0.05); the tatal AFS score of the observation group (6.06±3.18), and significantly lower than that of the control group (3.88±3.01, P<0.05), meanwhile, with regard to their adhension area, adhension type, menstrual pattern, the score of the observation group (1.78±1.37, 2.50±1.51, 1.78±0.74), and significantly lower than that of the control group (1.12±0.93, 1.89±1.51, 0.86±0.99) (P=0.004, 0.037, 0.01). The observation group had singnificantly lower proportion than that of the control group (P<0.05). Conclusions The women with moderate and severe intrauterine adhesion following UAE had singnificantly the lower effective rate for reduction of adhesion, the higher rate of re adhesion and the poorer outcome of regerenation after hysteroscopic adhesiolysis. Gynecologist strictly grasps indications of uterine arterial embolization. Key words: Embolization, therapeutic/AE; Uterine diseases/ET/TH; Tissue adhesions/ET/TH

Hysteroscopic Intrauterine Adhesiolysis Using a Blunt Spreading Dissection Technique With Double-action Forceps

Study ObjectiveTo demonstrate step-by-step the technique of hysteroscopic adhesiolysis (HA) by means of a blunt spreading technique using double-action forceps to dissect and restore the layer between the anterior and posterior uterine walls in a patient with severe intrauterine adhesions (IUAs), particularly in cases in which the endometrial lining is obscured on ultrasound imaging and the endometrial cavity is completely occluded on hysteroscopy. DesignA step-by-step explanation of the technique using videos and pictures (educative video) (Canadian Task Force Classification III). SettingA university-affiliated hospital. PatientA 36-year-old, gravida 3, para 1, abortus 2 woman presenting with amenorrhea for 5 months after surgical termination of a 53-day intrauterine pregnancy. She had no cyclic lower abdominal pain. Ultrasound revealed an obscure endometrial stripe and no obvious hematometra. Both the urine human chorionic gonadotropin test and the progesterone withdrawal test were negative. One month before admission, hysteroscopic adhesiolysis failed because the uterine cavity was inaccessible because of adhesions completely occluding the lower uterine cavity. Additionally, the uterine cavity could not be explored with a probe because the anatomic layer of the endometrial lining could not be easily identified by transabdominal ultrasound. InterventionHA using a blunt spreading dissection technique with double-action forceps to restore the uterine cavity followed by “ploughing” of the intrauterine scar tissue using cold scissors [1]. Measurements and Main ResultsAn intraoperative technique with commentary highlighting tips for a successful dissection. The uterine cavity was successfully restored using the blunt spreading dissection technique. There were no complications, including false uterine wall passage, uterine perforation, or fluid overload. Postoperative hysteroscopy at 1 month revealed an almost normal uterine cavity. ConclusionsHA using a blunt spreading dissection technique to restore the uterine cavity is a simple, effective, and safe hysteroscopic skill, especially when the endometrial stripe is obscured on ultrasound imaging and exploring the uterine cavity by means of a probe has failed. Furthermore, this technique may serve as an alternative to resectoscopic techniques because it uses cold forceps and scissors, which provide better protection for the endometrium.

352 - Comprehensive Treatment of Moderate and Severe Intrauterine Adhesions in Reproductive Age Woman

352 - Comprehensive Treatment of Moderate and Severe Intrauterine Adhesions in Reproductive Age Woman

238 - Grade 3 Asherman Following Unabsorbed Suture Material Post LSCS in Office Setting

The most common cause of IUA are iatrogenic trauma to the uterine cavity or infection. This patient is previous LSCS with secondary amenorrhoea. Suspecting Uterine pathology, Office hysteroscopy was done using 2.9 mm Bettocchi scope with low pressure setting(80–100 mmHg). During procedure we found severe intrauterine adhesion with obliteration of left ostia(Stage 3). Adhesiolysis was done using semi-rigid scissors, bipolar needle was used for thick adhesions. During the procedure we created small cavity and found a non absorbable suture material and removed it. TB- PCR was negative. In the susequent sitting, fundal adhesions were removed. Finally we could see patches of endometrium being formed, entire endometrium can be regenerated even with an island of endometrium.The patient resumed menses after hormonal therapy. Office hysteroscopy is safe with the patient's pain threshold being the end point for the procedure.

391 - A Clinical Observation of Preoperative Adjuvant Therapy for Intrauterine Adhesions

Study Objective: To study the clinical observation of estrogen, progesterone and vasodilator in the treatment of moderate to severe intrauterine adhesions.

Safety and Efficacy of Amnion Graft in Preventing Reformation of Intrauterine Adhesions

Study ObjectiveTo determine the safety and efficacy of amnion grafts in preventing the recurrence of intrauterine adhesions after hysteroscopic adhesiolysis in women with severe intrauterine adhesions. DesignA retrospective matched cohort study including 120 patients treated during 62 months (Canadian Task Force classification II-2). SettingA tertiary referral center. PatientsA total of 120 patients who underwent intrauterine adhesiolysis for severe intrauterine adhesions: 40 patients in the treatment group and 80 patients in the control group matched for age and adhesion scores. The mean duration of follow-up was 14.6 months. InterventionA Foley balloon with/without a fresh amnion graft was introduced into the uterine cavity after hysteroscopic adhesiolysis. Measurements and Main ResultsIn both groups, the balloon was kept in place for 7 days, cyclic hormone treatment was given for 3 months, and second-look and third-look hysteroscopies were performed 1 and 3 months after the operation. Outcome measures included the incidence of the recurrence of intrauterine adhesions, the score of intrauterine adhesions (if present), and the impact of the surgery on the amount of menstrual flow. In the study group, the menstrual score at the end of 3 months was significantly higher, and the intrauterine adhesion score at third-look hysteroscopy was significantly lower compared with those in the control group. The incidences of the recurrence of intrauterine adhesions at third-look hysteroscopy in the treatment and control groups were 30% and 48.7%, respectively (p = .05). The adhesion scores at third-look hysteroscopy in the treatment and control groups were 1.3 and 2.1, respectively (p < .05). ConclusionThe use of an amnion graft after intrauterine adhesiolysis appears to be beneficial in improving menstruation and reducing the recurrence of adhesion reformation.

Efficacy of freeze-dried amnion graft following hysteroscopic adhesiolysis of severe intrauterine adhesions.

To evaluate the efficacy of freeze-dried amnion graft for prevention of intrauterine adhesion (IUA) reformation after hysteroscopic adhesiolysis. A prospective randomized controlled trial was conducted among 88 women with severe IUAs who underwent hysteroscopic adhesiolysis at Beijing Obstetrics and Gynecology Hospital between July 15, 2015, and July 1, 2016. All participants had a balloon inserted into the uterine cavity for 1week. Sterilized freeze-dried amnion graft covered the balloon portion of the Foley catheter among patients allocated to the amnion group (n=44), whereas patients in the control group (n=44) did not receive the graft. Follow-up hysteroscopy was performed 3months after surgery. Preoperative and postoperative IUA scores, menstruation scores, and pregnancy rates were assessed. Both groups exhibited reductions in IUA scores and improvements in menstruation scores following treatment (P<0.001 for each measure). Compared with the control group, the amnion group had a lower IUA score (P=0.032) and a higher menstruation score (P<0.001) at follow-up. By contrast, the rates of IUA reformation and pregnancy were not significantly different between the two groups. Use of freeze-dried amnion graft was effective in reducing IUA reformation and improving menstruation (according to pictorial blood-loss assessment chart) following hysteroscopic adhesiolysis of severe IUAs. ClinicalTrials.gov: (NCT02496052).

Clinico-hysteroscopic analysis of severe intrauterine adhesions among Nigerian infertile women.

IntroductionSevere intrauterine adhesions are difficult to manage and are associated with poor reproductive outcomes following treatment. The objective was to study the clinical presentation and hysteroscopic findings of severe intrauterine adhesions seen at hysteroscopy in two fertility/gynaecological endoscopy units in Nigeria.MethodsA prospective study of 19 out of 76 women managed for intrauterine adhesions in our units. Data were analyzed with STATA software, version 12.0 SE (Stata Corporation, TX, USA).ResultsSevere intrauterine adhesion accounted for 19 (25.0%) of 76 cases of intrauterine adhesions managed during the period. This constituted 11.9% of 160 infertile women who had diagnostic hysteroscopies in our units over the study period. The mean duration of symptom was 4.2 years +/-3.2. Amenorrhea in association with infertility (68.4%) was the main presenting complaint. Secondary dysmenorrhea and cyclical abdominal pain were found in 10.8% and 31.6% of the women respectively. The main aetiological events were complicated caesarean section (42.1%) and abdominal myomectomy (26.3%). The adhesions were mainly dense (52.6%) and multiple (94.7%) with complete involvement of the uterine cavity in all the cases. Obliterative lesions were seen in 63.2% of the women.ConclusionThe main clinical presentation of severe IUA was amenorrhea and infertility while the major risk factors were complicated caesarean section and myomectomy. The adhesions were mainly multiple, dense, obliterative and complete.