Severity Of Intrauterine Adhesions Research Articles

4DryField vs. hyalobarrier gel for preventing the recurrence of intrauterine adhesions – a pilot study

Introduction This was a single-center pilot study that sought to describe an innovative use of 4DryField® PH (premix) for preventing the recurrence of intrauterine adhesions (IUAs) after hysteroscopic adhesiolysis in patients with Asherman’s syndrome (AS). Material and methods Twenty-three patients with AS were enrolled and 20 were randomized (1:1 ratio) to intrauterine application of 4DryField® PH (n = 10) or Hyalobarrier® gel (n = 10) in a single-blind manner. We evaluated IUAs (American Fertility Society [AFS] score) during initial hysteroscopy and second-look hysteroscopy one month later. Patients completed a follow-up symptoms questionnaire three and reproductive outcomes questionnaire six months later. Results The demographic and clinical characteristics, as well as severity of IUAs, were comparable in both groups. The mean initial AFS score was 9 and 8.5 in the 4DryField® PH and Hyalobarrier® gel groups, respectively (p = .476). There were no between-group differences in AFS progress (5.9 vs. 5.6, p = .675), need for secondary adhesiolysis (7 vs. 7 patients, p = 1), and the follow-up outcomes. Conclusion 4DryField® PH could be a promising antiadhesive agent for preventing the recurrence of IUAs, showing similar effectiveness and safety to Hyalobarrier® gel. Our findings warrant prospective validation in a larger clinical trial. Clinical trial registry number ISRCTN15630617

Clinical efficacy analysis of laparoscopic uterine artery pre-ligation combined with hysteroscopic curettage in the treatment of type II cesarean scar pregnancy.

To explore and evaluate the clinical therapeutic effect of laparoscopic uterine artery pre-ligation combined with hysteroscopic curettage in the treatment of type II cesarean scar pregnancy. This study analyzed the clinical data of patients with cesarean scar pregnancy (CSP) in the Maternal and Child Health Hospital of Hubei Province from 2018 to 2022. A total of 134 patients with type II cesarean section were enrolled, out of which 78 patients were included in the final analysis. Treatment included either uterine artery embolization (UAE) combined with hysteroscopic curettage (n = 37 patients) or laparoscopic uterine artery pre-ligation (LUAP) combined with hysteroscopic curettage (n = 41 patients). The demographic and clinical characteristics of these two groups were recorded, and their short- and long-term complications on follow-up were compared. For patients with subsequent fertility requirements, we followed up these patients for 2 years after surgery, then collected and analyzed the compared subsequent pregnancy outcome. We found no significant discrepancies in the success rate of operation, length of hospital stay, and intraoperative blood loss between the two different operation modes. The cost of LUAP was significantly lower than that of UAE. Furthermore, the incidence of short-term postoperative complications such as fever and pelvic pain was lower in patients treated with LUAP than in those treated with UAE. In terms of long-term postoperative complications, the recovery time for menstruation in the LUAP group (49.81 ± 11.47) was earlier than that in the UAE group (34.90 ± 7.41) (p < 0.05). Additionally, 4.9% of patients in the LUAP group had decreased menstrual flow, while 59% of patients in the UAE group had a marked decrease in menstrual flow, and the incidence and severity of intrauterine adhesions were significantly lower in the LUAP group than in the UAE group(p < 0.05). Consistent with the aforementioned observations, patients treated with LUAP had better postoperative re-pregnancy outcomes than those treated with UAE. Based on the findings, LUAP combined with hysteroscopic curettage is a safe and effective surgical scheme for the treatment of type II CSPs. In addition, compared with UAE, LUAP is associated with a lower surgical cost, fewer short and long-term complications, and better postoperative pregnancy outcomes. Thus, it should be widely applied in patients with type II CSPs.

Severity of intrauterine adhesions and pregnancy success rates after treatment: Comparison of adhesions obtained from open myomectomy versus uterine curettage.

Intrauterine adhesions (IUA) are rare. A retrospective comparative study was conducted between January 1, 2015, and December 31, 2018. Group A comprised 117 women who developed IUAs after open myomectomy, while Group B comprised 113 women who developed IUAs following uterine trauma caused by uterine instrumentation after a termination of pregnancy (TOP) or spontaneous miscarriage. The IUA grade and pregnancy rates and outcomes were compared using the March classification system. All patients underwent hysteroscopic adhesiolysis. The adhesions tended to be more severe (45/117, 38.5%) in Group A than in Group B (29/113, 25.7%); however, this difference was not statistically significant (Chi-Suare 5.047; p = .080). The period of observation was 24 months from the last hysteroscopy. The pregnancy rate in Group A (26, 22.2%) was significantly lower than in Group B (46, 40.7%) (OR: 2.403, 95% CI: 1.352-4.271; p = .003). Open myomectomy was the preceding aetiological factor in a greater proportion of women with IUA in our study. In cases where pregnancy is desired after open myomectomy, especially where the endometrial cavity is breached, postoperative hysteroscopy to exclude IUAs is recommended.

Incidence and risk factors of intrauterine adhesions after myomectomy

ObjectiveTo determine the incidence and risk factors for intrauterine adhesions (IUAs) after minimally invasive and open myomectomy and hysteroscopic myomectomy (HM).DesignRetrospective cohort study.SettingUniversity-affiliated fertility center.Patient(s)Patients aged ≥18 years undergoing robotic-assisted or conventional laparoscopic minimally invasive myomectomy, abdominal myomectomy, or HM between January 2007 and January 2017. Only patients who underwent uterine cavity evaluation within 12 months of surgery via hysteroscopy or hysterosalpingography were included. Patients were excluded if they had a history of IUA before myomectomy.Intervention(s)Not applicable.Main Outcome Measure(s)The primary outcomes of this study were the presence and severity of IUA. The secondary outcomes were the identification of risk factors for IUA formation. The severity of IUAs was scored by 2 investigators using a previously published grading system by March et al.Result(s)Of 1,315 patients who underwent myomectomy, 173 (13.2%) met the inclusion criteria. Intrauterine adhesions were identified in 9.3% of all patients, 75.0% of which were classified as minimal. The incidence of IUA did not vary by modality: 8.6%, minimally invasive myomectomy; 7.8%, abdominal myomectomy; and 11.8%, HM. There were no differences in incidence of IUA by the number or size of fibroids removed. Of patients with IUA, 87.5% had submucosal fibroids resected compared with 58.6% without IUA.Conclusion(s)The incidence of postoperative IUA in women undergoing myomectomy of any modality is relatively low (9.3%) and does not vary by modality alone. Most IUAs are of minimal degree. The presence of submucosal fibroids is associated with an increased risk of IUA in all modalities.

Evaluation of Intrauterine Adhesion After Hysteroscopic Resection of Uterine Septum

Objectives: The aim of this study was to evaluate the rate and severity of intrauterine adhesions (IUAs) and their association with septum morphology following the hysteroscopic resection of the uterine septum. Materials and Methods: This cross-sectional study was conducted on patients with septate uteri undergoing hysteroscopic septolysis with scissors. Two months after the surgery, the second look hysteroscopy was performed and the intrauterine cavity was evaluated for IUAs and residual septum. Afterward, the rate and severity of adhesions and residual septum and their association with the septal morphology were studied as well. Results: In general, 30 patients were entered into the study. The incidence rate of adhesions following septoplasty was 23.3%. It was mild and moderate in 16.7% and 6.7%, respectively. The incidence rate of adhesions was not related to the length and width of the septum (P=0.281, P=0.495). The rate of the residual septum in second-look hysteroscopy was 56.7%, which was less than 0.5 cm in most cases (33.3%). It was not more than 1 cm in any case. The possibility of the residual septum was significantly higher in long septa (P=0.045) whereas it was not related to the septum width (P=0.087). Conclusions: IUA following hysteroscopic septolysis is a possibility, especially in infertile patients which is often mild. The presence of a uterine factor in such patients may justify the risk of increased IUAs in our study in comparison to others. Therefore, it is able to perform second-look hysteroscopy in infertile patients with a septate uterus for the diagnosis and early treatment of IUAs.

There is no Correlation Between Long-Term Hysteroscopic Access to the Uterine Cavity and Menstrual Bleeding Status Following use of Water Vapor Ablation to Treat Heavy Menstrual Bleeding (HMB)

Study Objective Endometrial ablation often results in uterine cavity adhesions which preclude later evaluation and/or treatment of uterine bleeding. Prior studies of available ablation technologies have found a correlation between the severity of intrauterine adhesions and menstrual bleeding reduction. This analysis evaluates the correlation, if any, between preservation of long-term hysteroscopic access to the uterine cavity and menstrual bleeding status after water vapor endometrial ablation. Design Prospective, multicenter, observational. Setting Eight office and outpatient centers in the U.S. and Mexico. Patients or Participants 70 subjects who underwent water vapor endometrial ablation a mean of 3.9 years earlier as part of the AEGEA Pivotal Clinical Trial (NCT01979861). Interventions All subjects were screened for infection and general health risks through an IRB-approved process. Menstrual bleeding status was reported at screening prior to the hysteroscopy. Measurements and Main Results The mean duration since the endometrial ablation was 3.9 years. 27% (19/70) reported amenorrhea, 44% (31/70) light bleeding, 21% (15/70) moderate and 7% (5/70) heavy or very heavy bleeding. Overall cavity access for all subjects was 90% (63/70). The cavities were accessed in 89% of subjects reporting amenorrhea, 87% reporting light bleeding, 100% reporting moderate bleeding and 80% reporting heavy/very heavy bleeding. The Spearman Rank Correlation Coefficient was 0.19 (95% CI of -0.05 to 0.4), indicating no correlation of menstrual bleeding status with the ability to hysteroscopically access the uterine cavity. Selection bias analysis demonstrated comparability of subjects enrolled in this trial to the remaining subjects completing three-year follow-up in the Pivotal Trial. Conclusion Water vapor endometrial ablation provides lasting therapeutic effect for the treatment of HMB while preserving long-term uterine cavity access in the majority of subjects, irrespective of menstrual bleeding status.

A Simulation Curriculum for Teaching Obstetrics and Gynecology Residents the Management of Asherman's Syndrome

Study Objective To describe a simulation-based curriculum and evaluate its effect on OBGYN residents’ knowledge and confidence about the management of Asherman's Syndrome. Design A prospective cohort study. Setting A Canadian OBGYN residency program. Patients or Participants Twenty OBGYN residents. Interventions OBGYN residents participated in three targeted simulation-training sessions on the management of Asherman's Syndrome in the following sequence: didactic teaching with surgical videos and demonstration of safe dissection techniques; hysteroscopic dissection of intrauterine adhesions; insertion of intrauterine balloon to prevent adhesion reformation. Participants completed a pre-simulation and post-simulation survey assessing knowledge level of Asherman's Syndrome using a 20-point questionnaire and their self-reported confidence level in each of the simulation components using a Likert scale. (Component 1: Overall knowledge of Asherman's Syndrome; Component 2: Dissection of intrauterine adhesions; Component 3: Identifying the severity of intrauterine adhesions; Component 4: Insertion of a Cook's catheter.) Additional qualitative feedback was used to evaluate the strengths and weaknesses of the simulation curriculum. Measurements and Main Results Twenty OBGYN residents at the University of Saskatchewan participated in the study. The mean percentage of correct answers was 54.5% (+/- 18.3%) on the pre-simulation survey compared with 84.5% (+/- 12.5%) post-simulation (p Conclusion Simulation teaching is an effective method of increasing OBGYN residents’ knowledge and confidence about the management of Asherman's Syndrome.

Factors affecting pregnancy outcomes following the surgical removal of intrauterine adhesions and subsequent in vitro fertilization and embryo transfer.

This study aimed to investigate the clinical factors affecting pregnancy rates following the surgical removal of intrauterine adhesions (IUAs) and subsequent in vitro fertilization and embryo transfer (IVF-ET). We retrospectively evaluated case data from patients who had undergone hysteroscopic surgery to remove varying degrees of IUAs and who had subsequently received assisted reproductive treatments with IVF-ET (in all 140 cycles) at our hospital between January, 2011 and January, 2015. The patient data were divided into either the pregnancy or non-pregnancy groups based on the pregnancy outcomes, and a number of clinicopathological variables were compared these two groups, such as age, infertility (type and duration), the number of prior surgical treatments for and severity of IUAs, the baseline follicle-stimulating hormone/luteinizing hormone (FSH/LH) ratio and estradiol level, endometrial thickness on the day of human chorionic gonadotropin (hCG) administration, etc. We selected the variables with statistically significant differences to generate multivariate logistic regression and linear correlation analyses. We found that i) the mean endometrial thickness on the day of hCG administration was greater in the pregnancy group, and that the average gestational age was younger than that in the non-pregnancy group. The different age groups had significantly different pregnancy rates. The mean baseline FSH/LH ratio of the women in the pregnancy group was lower than that in the women in the non-pregnancy group. The number of embryos transferred in the pregnancy group was higher than that in the non-pregnancy group. However, the other variables exhibited similar values between these two groups. ii) Our multivariate logistic regression analyses revealed that age and endometrial thickness on the day of hCG administration had significant effects on the pregnancy outcome. The baseline FSH/LH ratio and the number of embryos transferred were similar between the groups. On the whole, age and endometrial thickness on the day of hCG administration are the most important predictors of pregnancy outcome in the patients undergoing IVF-ET following the surgical removal of IUAs. Importantly however, the identification of effective methods with which to improve the endometrial thickness and the ovarian response in patients with diminished ovarian reserves warrants further investigation in future research.

MiR-466 and NUS1 Regulate the AKT/Nuclear Factor kappa B (NFκB) Signaling Pathway in Intrauterine Adhesions in a Rat Model.

BackgroundIntrauterine adhesions (IUAs) are one of the most common reproductive system diseases in women worldwide. Emerging evidence has demonstrated that the upregulation or downregulation of genes plays an important role in IUAs. The aim of this study was to evaluate the role of NUS1 in IUAs in a rat model.Material/MethodsThe expression of miR-466 in intrauterine adhesions tissues was detected by using RT-qPCR assay. RT-qPCR, IHC, and Western blot were used to investigate mRNA and proteins expression, respectively, of NUS1. MTT and colony-formation assays were used to evaluate cell growth. Transwell assays were used to detect cell migration and invasion. To investigate miR-466 and NUS1 functions in vivo, we established a rat model. The level of epithelial-to-mesenchymal transition (EMT)-related markers was analyzed by Western blot assay.ResultsNUS1 was upregulated in IUAs tissues, and the high expression level of NUS1 was positively correlated with the severity of IUAs. NUS1 promoted cell proliferation in vitro. NUS1 overexpression on cell migration and invasion promoted the EMT process in vitro and in vivo. NUS1 acted as a target of miR-466 and played the stimulative role by regulating AKT/NFκB pathway.ConclusionsOur data suggest that miR-466 and NUS1 regulate proliferation and the EMT process through the AKT/NFκB pathway in IUAs in a rat model.

The role of KDR in intrauterine adhesions may involve the TGF-β1/Smads signaling pathway.

The aim of this study was to investigate the role of kinase-insert domain-containing receptor (KDR) in intrauterine adhesions (IUA) and its mechanism. The Case group consisted of 92 patients diagnosed with IUA, and the Control group included 86 patients with uterine septum who had normal endometrium verified with an uteroscope. In addition, 50 rats were randomly assigned into Control, Sham, Model, NC-siRNA, and KDR-siRNA groups. Rats in the Model, NC-siRNA, and KDR-siRNA groups were induced by uterine curettage and lipopolysaccharide (LPS) treatment to establish the IUA model. Then, immunohistochemistry was applied for detection of VEGF and KDR expression, HE staining was used for observation of the endometrial morphology and gland counting, Masson staining for measurement of the degree of endometrial fibrosis, and qRT-PCR and western blot for the expression of KDR, VEGF, MMP-9, as well as TGF-β1/Smads pathway-related proteins. Compared with the Control group, the mRNA and protein expressions of KDR were significantly higher in IUA endometrial tissues, and the expression of KDR was positively correlated to the severity of IUA. In addition, the injection of si-KDR increased the number of endometrial glands, reduced the area of fibrosis, inhibited mRNA and protein expression of KDR and VEGF, up-regulated the expression of MMP-9 and Smad7, and decreased the expression level of TGF-β1, p-Smad2, p-Smad3, and Smad4 in rats with IUA. Highly-expressed KDR was related to patients' severity of IUA, and silencing KDR may prevent the occurrence and development of IUA via TGF-β1/Smads signaling pathway and up-regulating the expression of MMP-9.

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.

Anti-adhesion therapy following operative hysteroscopy for treatment of female subfertility.

Observational evidence suggests a potential benefit with several anti-adhesion therapies in women undergoing operative hysteroscopy (e.g. insertion of an intrauterine device or balloon, hormonal treatment, barrier gels or human amniotic membrane grafting) for decreasing intrauterine adhesions (IUAs). To assess the effectiveness of anti-adhesion therapies versus placebo, no treatment or any other anti-adhesion therapy, following operative hysteroscopy for treatment of female subfertility. We searched the following databases from inception to June 2017: the Cochrane Gynaecology and Fertility Group Specialised Register; the Cochrane Central Register of Studies (CRSO); MEDLINE; Embase; CINAHL and other electronic sources of trials, including trial registers, sources of unpublished literature and reference lists. We handsearched the Journal of Minimally Invasive Gynecology, and we contacted experts in the field. We also searched reference lists of appropriate papers. Randomised controlled trials (RCTs) of anti-adhesion therapies versus placebo, no treatment or any other anti-adhesion therapy following operative hysteroscopy in subfertile women. The primary outcome was live birth. Secondary outcomes were clinical pregnancy, miscarriage and IUAs present at second-look hysteroscopy, along with mean adhesion scores and severity of IUAs. Two review authors independently selected studies, assessed risk of bias, extracted data and evaluated quality of evidence using the GRADE method. The overall quality of the evidence was low to very low. The main limitations were serious risk of bias related to blinding of participants and personnel, indirectness and imprecision. We identified 16 RCTs comparing a device versus no treatment (two studies; 90 women), hormonal treatment versus no treatment or placebo (two studies; 136 women), device combined with hormonal treatment versus no treatment (one study; 20 women), barrier gel versus no treatment (five studies; 464 women), device with graft versus device without graft (three studies; 190 women), one type of device versus another device (one study; 201 women), gel combined with hormonal treatment and antibiotics versus hormonal treatment with antibiotics (one study; 52 women) and device combined with gel versus device (one study; 120 women). The total number of participants was 1273, but data on 1133 women were available for analysis. Only two of 16 studies included 100% infertile women; in all other studies, the proportion was variable or unknown.No study reported live birth, but some (five studies) reported outcomes that were used as surrogate outcomes for live birth (term delivery or ongoing pregnancy). Anti-adhesion therapy versus placebo or no treatment following operative hysteroscopy.There was insufficient evidence to determine whether there was a difference between the use of a device or hormonal treatment compared to no treatment or placebo with respect to term delivery or ongoing pregnancy rates (odds ratio (OR) 0.94, 95% confidence interval (CI) 0.42 to 2.12; 107 women; 2 studies; I² = 0%; very-low-quality evidence).There were fewer IUAs at second-look hysteroscopy using a device with or without hormonal treatment or hormonal treatment or barrier gels compared with no treatment or placebo (OR 0.35, 95% CI 0.21 to 0.60; 560 women; 8 studies; I² = 0%; low-quality evidence). The number needed to treat for an additional beneficial outcome (NNTB) was 9 (95% CI 5 to 17). Comparisons of different anti-adhesion therapies following operative hysteroscopyIt was unclear whether there was a difference between the use of a device combined with graft versus device only for the outcome of ongoing pregnancy (OR 1.48, 95% CI 0.57 to 3.83; 180 women; 3 studies; I² = 0%; low-quality evidence). There were fewer IUAs at second-look hysteroscopy using a device with or without graft/gel or gel combined with hormonal treatment and antibiotics compared with using a device only or hormonal treatment combined with antibiotics, but the findings of this meta-analysis were affected by evidence quality (OR 0.55, 95% CI 0.36 to 0.83; 451 women; 5 studies; I² = 0%; low-quality evidence). Implications for clinical practiceThe quality of the evidence ranged from very low to low. The effectiveness of anti-adhesion treatment for improving key reproductive outcomes or for decreasing IUAs following operative hysteroscopy in subfertile women remains uncertain. Implications for researchMore research is needed to assess the comparative safety and (cost-)effectiveness of different anti-adhesion treatments compared to no treatment or other interventions for improving key reproductive outcomes in subfertile women.

Prevalence of intrauterine adhesions after the application of hyaluronic acid gel after dilatation and curettage in women with at least one previous curettage: short-term outcomes of a multicenter, prospective randomized controlled trial

To examine whether intrauterine application of auto-crosslinked hyaluronic acid (ACP) gel, after dilatation and curettage (D&C), reduces the incidence of intrauterine adhesions (IUAs). Multicenter; women and assessors blinded prospective randomized trial. University and university-affiliated teaching hospitals. A total of 152 women with a miscarriage of <14weeks with at least one previous D&C for miscarriage or termination of pregnancy. Women were randomly assigned to either D&C plus ACP gel (intervention group) or D&C alone (control group). A follow-up diagnostic hysteroscopy was scheduled 8-12weeks after the D&C procedure. The primary outcome was the number of women with IUAs and the secondary outcome was the severity of IUAs. Outcomes were available for 149 women: 77 in the intervention group and 72 in the control group. The IUAs were observed in 10 (13.0%) and 22 women (30.6%), respectively (relative risk, 0.43; 95% confidence interval 0.22-0.83). Mean adhesion score and the amount of moderate-to-severe IUAs were significantly lower in the intervention group according to the American Fertility Society (AFS) and European Society of Gynecological Endoscopy classifications systems of adhesions. Intrauterine application of ACP gel after D&C for miscarriage in women with at least one previous D&C seems to reduce the incidence and severity of IUAs but does not eliminate the process of adhesion formation completely. Future studies are needed to confirm our findings and to evaluate the effect of ACP gel on fertility and reproductive outcomes. NTR3120.

Oxidized, Regenerated Cellulose Adhesion Barrier Plus Intrauterine Device Prevents Recurrence After Adhesiolysis for Moderate to Severe Intrauterine Adhesions

Study ObjectiveTo compare the efficacy of an oxidized, regenerated cellulose adhesion barrier (Interceed; Ethicon, Somerville, NJ) combined with an intrauterine device (IUD) versus an IUD alone for preventing adhesion recurrence following hysteroscopic adhesiolysis for moderate to severe intrauterine adhesions (IUAs). DesignRetrospective case series (Canadian Task Force classification III). SettingTertiary care teaching hospital. PatientsPatients undergoing treatment for moderate to severe IUAs. The severity of IUA was determined based on the American Fertility Society scoring system (mild, moderate, or severe). InterventionsAll cases of hysteroscopic adhesiolysis were reviewed. Measurements and ResultsSeventy-six women with moderate to severe IUAs treated between March 2009 and August 2015 were included. After hysteroscopic adhesiolysis, 35 patients were treated with an IUD alone (group 1), and 41 patients were treated with Interceed plus an IUD (group 2). A second hysteroscopy was performed in all cases three months after the initial hysteroscopy and both groups achieved significant reduction in adhesion scores and grade, especially in group 2 (scores, p < .001; grade, p = .039). Compared with group 1, menstruation dysfunction, pregnancy rate, and live birth rate in group 2 improved with no statistical difference (menstruation improvement, p = .764; pregnancy rate, p = .310; live birth rate, p = .068). However, an adhesion-free uterine cavity was regained significantly owing to the fewer operations in group 2 compared with group 1 (median, 3 vs 4; p = .001). The interval from initial hysteroscopy to conception was significantly shorter in group 2 (median, 12 months vs 51 months; p < .001). ConclusionsFor moderate to severe IUAs, Interceed combined with an IUD may be an alternative approach for reducing adhesion recurrence after hysteroscopic adhesiolysis.

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.

Molecular implication of ADAM-15 and 17 in intrauterine adhesions

ObjectivesTo investigate the regulation of the proteins ADAM-15 and ADAM-17 in intrauterine adhesions (IUA). Study design68 patients were found to have IUA in a study performed at our Department of Gynecology, and 18 control volunteer participants were recruited in the study. The patients with IUA were assigned to three groups according to the classification of March et al.: IUA-I (n=28), IUA-II (n=22), and IUA-III (n=18). All the volunteers were assigned to the control group (Con, n=18). The expression of ADAM-15 and ADAM-17 in the adhesive band tissue in patients and the endometrium in volunteers was detected by western blot, real-time PCR, and immunohistochemistry. ResultsThe expression of ADAM-15 and ADAM-17 was significantly upregulated in both protein level and transcript level in IUA patients compared to that in controls. ADAM-15 expression was significantly higher in IUA-III (4.59±0.15) compared to IUA-II (3.18±0.12) and IUA-I (2.11±0.17; P<0.01). ADAM-17 expression was also significantly higher in IUA-III (3.25±0.11) compared to IUA-II (2.21±0.15) and IUA-I (1.78±0.21; P<0.01). The transcript levels of ADAM-15 and ADAM-17 showed similar patterns, and were markedly higher in grade III IUA patients compared to grade II and grade I. The severity of IUA was positively correlated to the protein and transcript expression level of ADAM-15 and ADAM-17 in uterine tissue. ConclusionsThe development of IUA is associated with regulation of ADAM15 and ADAM-17, which may be potential biological markers for evaluating the severity of intrauterine adhesions.

Intérêt du gel d’acide hyaluronique dans la prévention des synéchies intra-utérines après hystéroscopie opératoire

To evaluate the efficacy of auto-cross-linked hyaluronic acid gel in the prevention of adhesions after operative hysteroscopy using a case-control study.Fifty-four patients with an intrauterine lesion (myoma, polyp, uterine septa and adhesions) undergoing hysteroscopic surgery were divided into two groups: group A (30 patients) with intrauterine application of hyaluronic acid gel at the end of the surgical procedure and group B, which was considered as control (24 patients). The rate of adhesion formation, the score and the adhesion severity were estimated for each group using American Fertility Society (AFS) classification, by diagnostic hysteroscopy two months after surgery. No other treatment was associated.Age, weight, parity, hysterometry were comparable in the two groups. Surgery indications were polyp(s), myoma(s), uterine septa, and adhesions (11, 8, 1, and 10 patients in group A and 6, 6, 4, and 8 patients in group B, respectively). No difference was observed in intrauterine adhesion formation between the two groups (33.3% for group A and B; p = NS). The median adhesion scores using AFS were comparable in the two groups (1.30+/-2.35 vs 1.42+/-2.47; respectively, p = NS). The severity of the adhesions showed no significant difference between the two (70% stage I, mild adhesions; 20% stage II, moderate adhesions; 10% stage III, severe adhesions and 62.5% stage I; 25% stage II; 12.5% stage III in the group A and B, respectively). No adverse effect with the ACP gel was detected.ACP gel does not reduce the incidence and the severity of intrauterine adhesions after hysteroscopic surgery.

The Prevalence and Severity of Intrauterine Adhesions in an Infertile Population Undergoing Office Hysteroscopy

In the evaluation of the uterine cavity, hysteroscopy couples diagnostic accuracy with the potential for simultaneous treatment of identified pathology. Studies that have addressed the prevalence of intrauterine adhesions in the infertile population have been retrospective in nature and subject to the limitations of this design. The aim of the present study is to prospectively define the risk factors and examine the prevalence and severity of intrauterine adhesions at office hysteroscopy in patients with a history of infertility.

Incidence of post-abortion intra-uterine adhesions evaluated by hysteroscopy--a prospective study.

A prospective study was conducted on the incidence of intra-uterine pathology diagnosed by hysteroscopy in 147 women who underwent dilatation and sharp curettage due to spontaneous first trimester abortion. The diagnostic hysteroscopies were performed 4-6 weeks after the miscarriage, using CO2 as medium for uterine distention. In 38 patients (25.9%), uterine pathology was found, of whom 28 patients (19%) had intra-uterine adhesions (IUA). The incidence of IUA following only one abortion was 16.3% (16 out of 98 cases), all were of mild extent and filmy consistency, occupying less than one-quarter of the uterine cavity. The incidence of IUA after two abortions was 14% (3/21) but the incidence after three or more spontaneous abortions was significantly elevated (32%, 9/28), (P < 0.05, chi-square test). In addition, 58% of IUA diagnosed in the latter two groups were of a more severe extent. After a first miscarriage, occurrence of post-abortion IUA was not related to the serum oestrogen concentration on the day of curettage, nor was it related to any of the oestrogen treatment modalities used in this study. Although in most of these cases normal recovery of the endometrium was the rule, the high incidence of IUA diagnosed in this prospective study stresses the need for preventive treatment and close follow-up of patients after sharp curettage due to spontaneous abortion. Obviously oestrogen treatment alone did not prove to be effective and other treatment methods should be evaluated. The high incidence and severity of IUA in habitual aborters clearly justifies the performance of a diagnostic hysteroscopy as a standard evaluation.

The heart in combined syphilitic aortic valvulitis and rheumatic heart disease: Lisa, J. R., Solomon, C., and Eckstein, D.: Arch. Path. 33: 37, 1942

To compare the efficacy of an oxidized, regenerated cellulose adhesion barrier (Interceed; Ethicon, Somerville, NJ) combined with an intrauterine device (IUD) versus an IUD alone for preventing adhesion recurrence following hysteroscopic adhesiolysis for moderate to severe intrauterine adhesions (IUAs).Retrospective case series (Canadian Task Force classification III).Tertiary care teaching hospital.Patients undergoing treatment for moderate to severe IUAs. The severity of IUA was determined based on the American Fertility Society scoring system (mild, moderate, or severe).All cases of hysteroscopic adhesiolysis were reviewed.Seventy-six women with moderate to severe IUAs treated between March 2009 and August 2015 were included. After hysteroscopic adhesiolysis, 35 patients were treated with an IUD alone (group 1), and 41 patients were treated with Interceed plus an IUD (group 2). A second hysteroscopy was performed in all cases three months after the initial hysteroscopy and both groups achieved significant reduction in adhesion scores and grade, especially in group 2 (scores, p < .001; grade, p = .039). Compared with group 1, menstruation dysfunction, pregnancy rate, and live birth rate in group 2 improved with no statistical difference (menstruation improvement, p = .764; pregnancy rate, p = .310; live birth rate, p = .068). However, an adhesion-free uterine cavity was regained significantly owing to the fewer operations in group 2 compared with group 1 (median, 3 vs 4; p = .001). The interval from initial hysteroscopy to conception was significantly shorter in group 2 (median, 12 months vs 51 months; p < .001).For moderate to severe IUAs, Interceed combined with an IUD may be an alternative approach for reducing adhesion recurrence after hysteroscopic adhesiolysis.