Prévention et traitement des synéchies endo-utérines : revue de la littérature

Effectiveness of degradable polymer film in the management of severe or moderate intrauterine adhesions (PREG-2): a randomized, double-blind, multicenter, stratified, superiority trial

OBJECTIVE

To study the effectiveness of a new intrauterine degradable polymer film (Womed Leaf) in the management of moderate to severe intrauterine adhesions (IUA).

DESIGN

PREG-2 study was a multicenter, double-blind, randomized, controlled, stratified, two-arm superiority clinical trial conducted in 16 centers in seven countries.

SETTING

Not applicable.

PATIENT(S)

Patients ≥18 years scheduled for hysteroscopic adhesiolysis because of symptomatic severe or moderate adhesions (according to American Fertility Society [AFS] IUA score) were considered eligible for the study.

INTERVENTION(S)

After adhesiolysis, patients were randomized at a 1:1 ratio to either have a Womed Leaf film inserted (intervention group) or not (control group).

MAIN OUTCOME MEASURE(S)

The primary effectiveness endpoint of the study was the change in AFS IUA score on second-look hysteroscopy (SLH), assessed by an independent evaluator, and compared with baseline. Information on the rate of no IUA and responder rate was collected as secondary effectiveness outcomes, while reported adverse events and patient-reported outcomes as safety and tolerability measures.

RESULT(S)

Between October 26, 2021, and September 28, 2023, a total of 160 women were randomized (Womed Leaf: n = 75 and controls: n = 85). The reduction in IUA AFS score on SLH was significantly higher in the intervention compared with the control group (mean 5.2 ± 2.8 vs. 4.2 ± 3.2). Similarly, the absence of adhesions on SLH was significantly higher in the intervention group (41% vs. 24%; odds ratio, 2.44; confidence interval, 1.161-5.116). None of the reported adverse events were serious or considered related to the device.

CONCLUSION(S)

Womed Leaf is effective and safe in the management of symptomatic severe or moderate IUAs.

CLINICAL TRIAL REGISTRATION NUMBER

Clinicaltrials.gov identifier: NCT04963179.

The SYNAPPH Study: Uterine Synechiae Prevalence After a Postpartum Hemorrhage, a Pilot Study

STUDY OBJECTIVE

To prospectively assess the prevalence of intrauterine synechia following medically treated postpartum hemorrhage (PPH) and to evaluate the association between synechiae formation and PPH management techniques.

DESIGN

A prospective observational cohort study.

SETTING

Angers University Hospital.

PARTICIPANTS

A total of 83 women presenting with medically treated PPH from January to December 2021 were included in the study.

INTERVENTION

Diagnostic hysteroscopy was performed twelve weeks postpartum to assess for the presence of uterine synechiae. Detailed data on PPH management techniques were collected for analysis.

MEASUREMENTS AND MAIN RESULTS

The majority of participants were primiparous and had undergone vaginal delivery. Only 7% required intrauterine balloon tamponade (IUBT), and 4% underwent uterine artery embolization. Uterine synechiae were identified in 20 women during diagnostic hysteroscopy, yielding a prevalence of 24% at 12 weeks postpartum; all classified as type I according to the ESGE classification system. IUBT was used in 15% of women with synechiae compared to 5% in the nonsynechiae group, although this difference was not statistically significant (OR 3.52, 95% CI 0.65-19.10, p = .123). Multivariate analysis identified second manual uterine examination (OR 5.00, 95% CI 1.50-16.66, p = .009) and bimanual uterine massage (OR 3.50, 95% CI 1.12-10.09, p = .020) as independent risk factors for synechiae formation.

CONCLUSION

This is the first study to evaluate the risk of intrauterine synechiae following medically treated PPH. Mild uterine synechiae were observed in one in four women in the cohort. The need for a second manual uterine examination and bimanual uterine massage were significantly associated with the development of synechiae. Further research is warranted to explore the long-term clinical consequences, including fertility outcomes, and to determine the potential role of diagnostic hysteroscopy in postpartum follow-up after PPH.

SUMMATION

The study prospectively investigates the prevalence of uterine synechiae following nonsurgical postpartum hemorrhage, revealing a 24% occurrence, with second manual uterine examination and bimanual massage identified as independent risk factors.

Activated platelet-rich plasma accelerate endometrial regeneration and improve pregnancy outcomes in murine model of disturbed endometrium

Platelet Rich Plasma (PRP) contains high concentrations of growth factors, therefore, PRP activation results in their release, stimulating the process of healing and regeneration. The study was conducted to check whether activated platelet-rich plasma (aPRP) treatment can improve regeneration of the endometrium in an experimental model of ethanol-induced disturbed endometrium. Seventy-two female Wistar rats were randomly assigned into the control group, disturbed endometrium (DE) group and aPRP treated group. Activation of PRP was performed by adding thrombin. All the animals were sacrificed on day 1, day 3, day 6 and day 9 and samples were taken from the miduterine horn. Quantification of Cytokine and chemokine profiles of activated and non-activated PRP for CCL2, TNF- α, IL-1β, CXCL8, CXCL10, IL2, IL4, IL-6 IL-10, IL-12, IL-17A, TGF- β, IFN-γ was carried out. Functional and structural recovery of the endometrium was analyzed by hematoxylin-eosin (HE) and immunohistochemical (IHC) analyses. HE confirmed proliferated epithelial lining and stromal reconstruction with decreased fibrosis in PRP treated group compared to the DE group. Epithelial thickness in aPRP treated on day 1, day 3, day 6 and day 9 revealed an significant increase (p ≤ 0.05). Significantly stronger IHC expression of alpha smooth muscle actin, Cytokeratin 18, Cytokeratin 19, Connexin-40, E-Cadherin, Claudin-1, Zona Occludin-1was found in the aPRP treated group compared to the DE group. Furthermore, aPRP treatment was associated with birth of live pups. Our results suggest that intrauterine administration of aPRP stimulated and accelerated the regeneration of endometrium in the murine model of disturbed endometrium.

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.

Treatment strategies for intrauterine adhesion: focus on the exosomes and hydrogels

Intrauterine adhesion (IUA), also referred to as Asherman Syndrome (AS), results from uterine trauma in both pregnant and nonpregnant women. The IUA damages the endometrial bottom layer, causing partial or complete occlusion of the uterine cavity. This leads to irregular menstruation, infertility, or repeated abortions. Transcervical adhesion electroreception (TCRA) is frequently used to treat IUA, which greatly lowers the prevalence of adhesions and increases pregnancy rates. Although surgery aims to disentangle the adhesive tissue, it can exacerbate the development of IUA when the degree of adhesion is severer. Therefore, it is critical to develop innovative therapeutic approaches for the prevention of IUA. Endometrial fibrosis is the essence of IUA, and studies have found that the use of different types of mesenchymal stem cells (MSCs) can reduce the risk of endometrial fibrosis and increase the possibility of pregnancy. Recent research has suggested that exosomes derived from MSCs can overcome the limitations of MSCs, such as immunogenicity and tumorigenicity risks, thereby providing new directions for IUA treatment. Moreover, the hydrogel drug delivery system can significantly ameliorate the recurrence rate of adhesions and the intrauterine pregnancy rate of patients, and its potential mechanism in the treatment of IUA has also been studied. It has been shown that the combination of two or more therapeutic schemes has broader application prospects; therefore, this article reviews the pathophysiology of IUA and current treatment strategies, focusing on exosomes combined with hydrogels in the treatment of IUA. Although the use of exosomes and hydrogels has certain challenges in treating IUA, they still provide new promising directions in this field.

Hysteroscopic and ultrasound evaluation of a novel degradable polymer film for the prevention of intrauterine adhesion formation after hysteroscopic surgery

OBJECTIVE

To collect information on the application and behavior of a novel degradable polymeric film (DPF) developed to prevent intra-uterine adhesions (IUAs) after hysteroscopic surgery.

STUDY DESIGN

A prospective observational study conducted in a university hospital in Naples, Italy. Women undergoing hysteroscopic myomectomy, metroplasty or adhesiolysis, were eligible for the study. Women had their uterine cavity assessed by transvaginal ultrasound scan before their hysteroscopic surgery, which was followed by the DPF insertion. Ultrasonographic and hysteroscopic assessments were undertaken immediately after insertion then at 2 h, 2-5 days, and 6 weeks postoperative. The main outcome of interest was to assess the behavior of the DPF, from insertion to degradation, by ultrasound and hysteroscopy. Other outcomes included ease of DPF insertion, any patient reported adverse events and the presence of IUAs at 6 weeks.

MEASUREMENTS AND MAIN RESULTS

A total of 15 patients were enrolled into the study. The DPF insertion was reported to be very easy in almost all the cases and was visualized immediately and 2 h after insertion in all patients. At the 2-5 day follow-up 5 and 2 of the 15 participants still had the entire or partially hydrolyzed film respectively. By 6 weeks there was no evidence of the DPF in all women. No adverse events were reported at the time of insertion or follow-up. None of the study participants had IUAs at the 6-week assessment.

CONCLUSIONS

According to this pilot study, the solid degradable polymer film, Womed Leaf, is a promising, easy to apply and well tolerated novel option for the prevention of intrauterine adhesion formation after hysteroscopic surgery.

Extracorporeal Shock Wave Therapy Combined with Platelet-Rich Plasma during Preventive and Therapeutic Stages of Intrauterine Adhesion in a Rat Model

Intrauterine adhesion (IUA) is caused by artificial endometrial damage during intrauterine cavity surgery. The typical phenotype involves loss of spontaneous endometrium recovery and angiogenesis. Undesirable symptoms include abnormal menstruation and infertility; therefore, prevention and early treatment of IUA remain crucial issues. Extracorporeal shockwave therapy (ESWT) major proposed therapeutic mechanisms include neovascularization, tissue regeneration, and fibrosis. We examined the effects of ESWT and/or platelet-rich plasma (PRP) during preventive and therapeutic stages of IUA by inducing intrauterine mechanical injury in rats. PRP alone, or combined with ESWT, were detected an increased number of endometrial glands, elevated vascular endothelial growth factor protein expression (hematoxylin-eosin staining and immunohistochemistry), and reduced fibrosis rate (Masson trichrome staining). mRNA expression levels of nuclear factor-kappa B, tumor necrosis factor-α, transforming growth factor-β, interleukin (IL)-6, collagen type I alpha 1, and fibronectin were reduced during two stages. However, PRP alone, or ESWT combined with PRP transplantation, not only increased the mRNA levels of vascular endothelial growth factor (VEGF) and progesterone receptor (PR) during the preventive stage but also increased PR, insulin-like growth factor 1 (IGF-1), and IL-4 during the therapeutic stage. These findings revealed that these two treatments inhibited endometrial fibrosis and inflammatory markers, thereby inhibiting the occurrence and development of intrauterine adhesions.

Interleukin-34 accelerates intrauterine adhesions progress related to CX3CR1+ monocytes/macrophages

Intrauterine adhesions (IUA) are characterized by endometrial fibrosis and impose a great challenge for female reproduction. IL-34 is profoundly involved in various fibrotic diseases through regulating the survival, proliferation, and differentiation of monocytes/macrophages. However, it remains unclear how IL-34 regulates monocytes/macrophages in context of IUA. Here, we showed that the expression level of IL-34 and the amount of CX3CR1+ monocytes/macrophages were significantly increased in endometrial tissues of IUA patients. IL-34 promoted the differentiation of monocytes/macrophages, which express CX3CR1 via CSF-1R/P13K/Akt pathway in vitro. Moreover, IL-34-induced CX3CR1+ monocytes/macrophages promoted the differentiation of endometrial stromal cells into myofibroblasts. Of note, IL-34 caused endometrial fibrosis and increased the amount of CX3CR1+ monocytes/macrophages in endometrial tissues in vivo. IL-34 modulated endometrial fibrosis by regulating monocytes/macrophages since the elimination of endometrial monocytes/macrophages significantly suppressed the profibrotic function of IL-34. Finally, blocking of IL-34 in the LPS-IUA model resulted in the improvement of endometrial fibrosis and decreased number of CX3CR1+ monocytes/macrophages. Our studies uncover the novel mechanism of interaction between IL-34-induced CX3CR1+ monocytes/macrophages and endometrial stromal cells in endometrial fibrosis pathogenesis, and highlight IL-34 as a critical target for treating IUA.

[Treatment of synechiae related to infertility]

Synechiae are intrauterine adhesions that affect the fertility of women. They are most often of post-traumatic origin. The management of pregnancy abortions in the first trimester and post-delivery retention are the main contributing factors. Synechiae is responsible for cycle disorders and repeated pregnancy loss. Hysteroscopy is the reference method for its diagnosis and treatment. The surgical objective is the restoration of a normal sized cavity and a functional endometrium to allow fertilization and implantation. The use of small diameter (5mm) hysteroscopes and no energy or bipolar energy instruments are recommended. Echo guidance facilitates the treatment of severe synechiae and limits the risk of intraoperative perforation. The main risk of treatment is recurrence, particularly in severe cases where multiple operating times are sometimes necessary. An office hysteroscopy at 6 weeks is recommended to identify and treat these recurrences. Different physical, molecular or cellular methods are studied as primary and secondary prevention of postoperative synechiae. The objective of this review is to provide an update on the treatment of synechiae in the context of infertility.

Construction and Optimization of an Endometrial Injury Model in Mice by Transcervical Ethanol Perfusion

This study aimed to establish a stable animal model of intrauterine adhesion (IUA) using a minimally invasive method that recapitulates the clinicopathologic characteristics of IUA. Mice were randomly divided into groups based on the ethanol treatment time (the EtOH-10 s, EtOH-20 s, EtOH-40 s, EtOH-1 min, and sham operation groups), and after the cervix was relaxed with phloroglucinol, the uterine horn was perfused with 95% ethanol through the cervix to induce endometrial injury. Eight days after the procedure, routine biochemical assays were performed to assess liver and kidney function; HE and Masson staining were used to assess uterine morphology and fibrosis; and immunohistochemistry was performed to evaluate the expression of CD31 and F4/80 in the endometrium. Furthermore, the fertility of mice in the EtOH-40 s group and the sham operation group was compared. As expected, the ethanol treatment time was positively correlated with the degree of uterine damage and kidney dysfunction in mice. In particular, the endometria of mice in the EtOH-40 s group were significantly thinner than those of mice in the sham operation group and exhibited severe necrosis, glandular loss, incomplete epithelial and glandular epithelial cell structure, severe tissue fibrosis, an activated inflammatory response, and a significant decrease in the number of fetuses, consistent with the clinical characteristics of severe IUA. In conclusion, this study resulted in successful establishment, by a minimally invasive transcervical ethanol perfusion technique, of a mouse model of endometrial injury, which could support an in-depth study of IUA pathogenesis and further promote the development of IUA therapies.

In Vivo Evaluation of the Efficacy and Safety of a Novel Degradable Polymeric Film for the Prevention of Intrauterine Adhesions

STUDY OBJECTIVE

To study the safety of a degradable polymeric film (DPF) and its efficacy on reducing the risk of intrauterine-adhesion (IUA) formation in a rat model.

DESIGN

A series of case-control studies relying on random allocation, where feasible.

SETTING

University and good practice animal laboratories.

ANIMALS

The animal models comprised female and male Oncins France Strain A and female Wistar rats.

INTERVENTION(S) AND MEASUREMENTS

The Oncins France Strain A rats were used for in vivo evaluation of the impact of the DPF on endometrial thickness and its effect on fertility. For in vivo evaluation of the biologic response, 40 Wistar rats were randomly allocated to intervention and control groups, with matched sampling time after surgery. Finally, for the in vivo evaluation of the DPF's efficacy on IUA prevention, a total of 24 Wistar rats were divided into 3 groups: 1 treated with the DPF, 1 treated with hyaluronic acid gel, and a sham group.

MAIN RESULTS

The DPF did not have a significant impact on endometrial thickness, and there were no significant differences in the number of conceived or prematurely terminated pregnancies, confirming its noninferiority to no treatment. The DPF did not induce irritation at 5 days and 28 days. Finally, the DPF significantly reduced the likelihood of complete IUA formation compared with hyaluronic acid gel- and sham-implanted animals, where only 27% of the animals had their uterine cavity obliterated compared with 80% and 100%, respectively.

CONCLUSION

The DPF is a safe film that is effective in preventing IUA formation after intrauterine curettage in rats.

Intrauterine adhesions: What is the pregnancy rate after hysteroscopic management?

OBJECTIVE

To evaluate the rate of pregnancy following hysteroscopic management of intrauterine adhesions.

DESIGN

Retrospective study.

SETTING

From June 2009 to December 2014 in a teaching hospital.

PATIENTS

Women treated by operative hysteroscopy for intrauterine adhesions.

INTERVENTION

Operative hysteroscopy to manage intrauterine adhesions.

MAIN OUTCOME MEASURE

rate of intrauterine pregnancy after hysteroscopic management of intrauterine adhesions.

RESULTS

Out of the 202 women whom benefit from hysteroscopic adhesiolysis, 112(55%) had an effective pregnancy desire. Among them, an intrauterine pregnancy was obtained for 58 women (52%) with a trend to a lower rate for type IV and Vb intrauterine adhesions management (40.5%, p = 0.09). Pregnancy rates were similar for women undergoing one or more procedures.

CONCLUSION

Hysteroscopic management of intrauterine adhesions seems useful as it leads to a pregnancy rate of 52%. However, this rate is lower in case of type IV and Vb intrauterine adhesions. Repeated procedures don't seem to lead to less pregnancy; however, a more powerful prospective study should be performed to answer this specific question.

Diagnosis and treatment of cervical incompetence combined with intrauterine adhesions

Background

Cervical insufficiency (CI) with concomitant intrauterine adhesions (IUAs) is a common clinical phenomenon among CI patients. But there are neither published reports regarding the difference in diagnosis and treatment of such patients compared to those with CI only, nor any report about their prognosis. This study aimed to preliminary the alteration in diagnostic and curative aspects of these patients, so as to provide a certain reference for the clinical management of such conditions.

Methods

Ten patients with CI combined with moderate to severe IUAs were diagnosed, treated and followed up at the Third Xiangya Hospital of Central South University from September 2017 to August 2019, their medical records and the pregnancy outcomes were retrospectively analyzed.

Results

All 10 patients had a previous history of typical painless cervical dilatation during the second trimester. All patients were moderate to severer IUAs, and the mean AFS score of IUAs was 9.80±1.08 (range, 8 to 12). Preoperatively, in 6 patients, the No. 7 Hegar dilator was able to pass through the internal cervical os before surgery without resistance. In the other 4 patients, the Hegar dilator could not be inserted before surgery due to the adhesions of the cervical canal and the lower uterine segment; the diagnoses of these patients were further confirmed at 3 months after hysteroscopic adhesiolysis (HA) when the No. 7 Hegar dilator was able to pass through the internal cervical os without resistance. There were 9 patients underwent pre-pregnancy laparoscopic cervical cerclage after HA. The remaining 1 patient exceptionally underwent laparoscopic cervical cerclage prior to HA, as the cervix was too loose to retain and be treated with an intrauterine device (IUD) or distended Foley's catheter balloon; which essentially prevent postoperative adhesion reformation. The patients were followed-up for 3 months to 2 years. The pregnancy rate was 60%, and the live birth rate was 100%.

Conclusions

In patients with CI and concomitant cervical or lower uterine segment IUAs, it is necessary to separate the adhesion prior to evaluating the cervical competency with the No. 7 Hegar dilator, to confirm the diagnosis. However, when the cervix is too loose, laparoscopic cervical cerclage is exceptionally carried out first and then IUAs is treated. Pre-pregnancy laparoscopic cervical cerclage has a good prognosis in patients with CI complicated by moderate to severe IUAs.

Vascular endothelial growth factor 165 inhibits pro-fibrotic differentiation of stromal cells via the DLL4/Notch4/smad7 pathway

Endometrial fibrosis is the main pathological feature of Asherman’s syndrome (AS), which is the leading cause of uterine infertility. Much is known about the expression of VEGF165 in luminal/glandular epithelial cells and stromal cells of the endometrium in normal menstrual cycles; however, less is known about the role and mechanism of VEGF165 in endometrial fibrosis. Herein, we report that VEGF165 is a key regulator in endometrial stromal cells to inhibit α-SMA and collagen 1 expression. Compared to human control subjects, patients with AS exhibited decreased VEGF165 expression in the endometrium along with increased fibrotic marker expression and collagen production. A fibrotic phenotype was shown in both mice with conditional VEGF reduction and VEGF165-deleted endometrial stromal cells. Exogenous VEGF165 could suppress TGFβ1-induced α-SMA and collagen 1 expression in human primary endometrial stromal cells. However, this beneficial effect was hindered when the expression of smad7 or Notch4 was inhibited or when Notch signaling was blocked, suggesting that smad7 and Notch4 are essential downstream molecules for VEGFA functioning. Overall, our results uncover a clinical targeting strategy for VEGF165 to inhibit pro-fibrotic differentiation of stromal cells by inducing DLL4/Notch4/smad7, which paves the way for AS treatment.

Early Second-Look Hysteroscopy: Prevention and Treatment of Intrauterine Post-surgical Adhesions

Introduction: Intra-uterine adhesion (IUA) is one of the main causes of secondary infertility. The aim of this study was to evaluate the prevalence of IUA developing in women undergoing hysteroscopic resection for submucous myomas, polyps, and intrauterine synechiae and test the efficacy of second look hysteroscopy for diagnosing and treating post-surgical adhesions.

Materials and Methods: We retrospectively collected data from reproductive age women who had a second look office hysteroscopy following hysteroscopic resection for myoma, polyp, or IUA at Foch hospital (Suresnes, France) between 2009 and 2017.

Results: Six hundred and twenty two reproductive-age women underwent hysteroscopic resection for myoma, polyp, and/or IUA. Among them, 155 women had a second look hysteroscopy. In this group, 29/155 (18.7%) had IUA formation: 17/83 (20.5%) women who underwent hysteroscopic myomectomy, 5/46 (10.9%) women who underwent hysteroscopic polypectomy, and 7/26 (26.9%) women who underwent hysteroscopic lysis of adhesions. These IUA have been lysed by the office hysteroscopy procedure in 16/29 (55.2%) patients: 11/17 (64.7%), 2/5 (40%), and 3/7 (42.9%) in women who underwent hysteroscopic myomectomy, polypectomy and lysis of adhesion, respectively.

Conclusion: IUA is a common complication of hysteroscopic surgery. Second look office hysteroscopy is an easy and effective procedure for diagnosing and removing newly formed IUA. It should be recommended for all women undergoing hysteroscopic resection for myomas, polyps, or IUA.

Preliminary design of a new degradable medical device to prevent the formation and recurrence of intrauterine adhesions

Intrauterine adhesions lead to partial or complete obliteration of the uterine cavity and have life-changing consequences for women. The leading cause of adhesions is believed to be loss of stroma resulting from trauma to the endometrium after surgery. Adhesions are formed when lost stroma is replaced by fibrous tissue that join the uterine walls. Few effective intrauterine anti-adhesion barriers for gynecological surgery exist. We designed a degradable anti-adhesion medical device prototype to prevent adhesion formation and recurrence and restore uterine morphology. We focused on ideal degradation time for complete uterine re-epithelialization for optimal anti-adhesion effect and clinical usability. We developed a triblock copolymer prototype [poly(lactide) combined with high molecular mass poly(ethylene oxide)]. Comparative pre-clinical studies demonstrated in vivo anti-adhesion efficacy. Ease of introduction and optimal deployment in a human uterus confirmed clinical usability. This article provides preliminary data to develop an intrauterine medical device and conduct a clinical trial.

Platelet-rich plasma improves therapeutic effects of menstrual blood-derived stromal cells in rat model of intrauterine adhesion

Background

Intrauterine adhesion (IUA) is a major cause of female secondary infertility. We previously demonstrated that menstrual blood-derived stromal cell (MenSC) transplantation helped severe IUA patients have pregnancy and endometrium regeneration. We also initiated platelet-rich plasma (PRP) acted as a beneficial supplement in MenSC culturing and a potential endometrial receptivity regulator. Here, we investigated the therapeutic effect of combined transplantation of MenSCs with PRP in rat IUA models and the mechanisms of MenSCs in endometrium regeneration.

Methods

Rat IUA models were established by intrauterine mechanical injured. Nine days later, all rats were randomly assigned to four groups received different treatment: placebo, MenSC transplantation, PRP transplantation, and MenSCs + PRP transplantation. The traces of MenSCs were tracked with GFP label. Endometrial morphology and pathology, tissue proliferation, inflammation, pregnancy outcomes, and mechanism of MenSCs in the regeneration of endometrium were investigated.

Results

Notably, at days 9 and 18 post-treatment, MenSC transplantation significantly improved endometrial proliferation, angiogenesis, and morphology recovery and decreased collagen fibrosis and inflammation in the uterus. MenSCs had lesion chemotaxis, colonized around the endometrial glands. Gene expression of human-derived secretory protein IGF-1, SDF-1, and TSP-1 was detected in the uterus received MenSCs at day 18. The three treatments can all improve fertility in IUA rats. Moreover, gene expressions of cell proliferation, developmental processes, and other biological processes were induced in MenSC transplantation group. Hippo signaling pathway was the most significantly changed pathway, and the downstream factors CTGF, Wnt5a, and Gdf5 were significantly regulated in treatment groups. PRP enhanced these parameters through a synergistic effect.

Conclusions

In summary, MenSCs could effectively improve uterine proliferation, markedly accelerate endometrial damage repairment and promote fertility restoration in IUA rats, suggesting a paracrine restorative effect and Hippo signaling pathway stimulation. Our results indicate MenSCs, a valuable source of cells for transplantation in the treatment intrauterine adhesion. Combined with PRP, this cell therapy was more effective.

Electronic supplementary material

The online version of this article (10.1186/s13287-019-1155-7) contains supplementary material, which is available to authorized users.

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

BACKGROUND

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).

OBJECTIVES

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.

SEARCH METHODS

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.

SELECTION CRITERIA

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.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies, assessed risk of bias, extracted data and evaluated quality of evidence using the GRADE method.

MAIN RESULTS

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).

AUTHORS' CONCLUSIONS

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.

[Complications of termination of pregnancy]

The legalization of abortion in France allowed to disappear almost maternal deaths caused by induced abortions. Nevertheless, the practice of abortion in a medical framework is encumbered with a number of immediate complications. Similarly, the late consequences of the practice of surgical abortion have generated an abundant literature, which it is important to analyse, both to meet the legitimate concerns of patients as to prevent any spread of false ideas under the influence of movements opposed to abortion.

Autologous menstrual blood-derived stromal cells transplantation for severe Asherman's syndrome

STUDY QUESTION

Does autologous transplantation of menstrual blood-derived stromal cells (menSCs) regenerate endometrium to support pregnancy in patients with severe Asherman's syndrome (AS)?

SUMMARY ANSWER

Autologous menSCs transplantation significantly increases endometrial thickness (ET) for women with severe AS.

WHAT IS KNOWN ALREADY

AS is a major cause of secondary infertility in women. Cell transplantation has been tried in a few clinical cases with encouraging results.

STUDY DESIGN, SIZE, DURATION

In this experimental, non-controlled and prospective 3-year clinical study involving seven patients with AS, autologous menSCs were isolated and cultured from menstrual blood of each patient within ~2 weeks and then transplanted back into their uterus. Endometrial growth and pregnancy were assessed after cell therapy.

PARTICIPANTS/MATERIALS, SETTING, METHOD

Infertile women, aged 20-40 years, diagnosed with severe AS (Grade III-V) by hysteroscopy and with menstrual fluid were recruited at the Shengjing Hospital affiliated to China Medical University. Autologous menSCs transplantation was conducted followed by HRT. Endometrial thickness was monitored with frozen embryo transfer (FET) as needed.

MAIN RESULTS AND THE ROLE OF CHANCE

We successfully cultured menSCs from seven patients and transferred the autologous cells back to their uterus. Our results showed that the ET was significantly (P = 0.0002) increased to 7 mm in five women, which ensured embryo implantation. Four patients underwent FET and two of them conceived successfully. One patient had spontaneous pregnancy after second menSCs transplantation.

LIMITATIONS, REASONS FOR CAUTION

Limited sample size, lack of rigorous controls or knowledge of underlying mechanism.

WIDER IMPLICATIONS OF THE FINDINGS

Autologous menSCs transplantation is a potential option for treating women with severe AS.

STUDY FUNDING/COMPETING INTERESTS

This study was supported by Liaoning Provincial Science and Technology Program. The sponsor and authors declare no conflicts of interest.

TRIAL REGISTRATION NUMBER

Registered in the Chinese Clinical Trial Registry (ChiCTR-ONB-15007464).

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

BACKGROUND

Limited observational evidence suggests potential benefit for subfertile women undergoing operative hysteroscopy with several anti-adhesion therapies (e.g. insertion of an intrauterine device (IUD) or balloon, hormonal treatment, barrier gels or human amniotic membrane grafting) to decrease intrauterine adhesions (IUAs).

OBJECTIVES

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.

SEARCH METHODS

We searched the following databases from inception to March 2015: the Cochrane Menstrual Disorders and Subfertility Specialised Register, the Cochrane Central Register of Controlled Trials (2015, Issue 2), MEDLINE, EMBASE, the Cumulative Index to Nursing and Allied Health Literature (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.

SELECTION CRITERIA

Randomised comparisons 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 or ongoing pregnancy. Secondary outcomes were clinical pregnancy, miscarriage and IUAs present at second look, along with their mean adhesion scores or severity.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies, assessed risk of bias, extracted data and evaluated quality of the evidence using the GRADE (Grades of Recommendation, Assessment, Development and Evaluation) method.

MAIN RESULTS

We included 11 randomised studies on use of an inserted device versus no treatment (two studies; 84 women) or another inserted device (one study; 162 women), hormonal treatment versus no treatment or placebo (two studies; 131 women), gel versus no treatment (five studies; 383 women) and graft versus no graft (one study; 43 women). The total number of women randomly assigned was 924, but data on only 803 participants were available for analysis. The proportion of subfertile women varied from 0% (one study; 41 women), to less than 50% (six studies; 487 women), to 100% (one study; 43 women); the proportion was unknown in three studies (232 women). Most studies (9/11) were at high risk of bias with respect to one or more methodological criteria.We found no evidence of differences between anti-adhesion therapy and no treatment or placebo with respect to live birth rates (odds ratio (OR) 0.99, 95% confidence interval (CI) 0.46 to 2.13, P value = 0.98, three studies, 150 women; low-quality evidence) and no statistical heterogeneity (Chi(2) = 0.14, df = 2 (P value = 0.93), I(2) = 0%).Anti-adhesion therapy was associated with fewer IUAs at any second-look hysteroscopy when compared with no treatment or placebo (OR 0.36, 95% CI 0.20 to 0.64, P value = 0.0005, seven studies, 528 women; very low-quality evidence). We found no statistical heterogeneity (Chi(2) = 2.65, df = 5 (P value = 0.75), I(2) = 0%). The number needed to treat for an additional beneficial outcome (NNTB) was 9 (95% CI 6 to 20).No evidence suggested differences between an IUD and an intrauterine balloon with respect to IUAs at second-look hysteroscopy (OR 1.23, 95% CI 0.64 to 2.37, P value = 0.54, one study, 162 women; very low-quality evidence).

AUTHORS' CONCLUSIONS

Implications for clinical practiceThe quality of the evidence retrieved was low or very low for all outcomes. Clinical effectiveness of anti-adhesion treatment for improving key reproductive outcomes or for decreasing IUAs following operative hysteroscopy in subfertile women remains uncertain. Implications for researchAdditional studies are needed to assess the effectiveness of different anti-adhesion therapies for improving reproductive outcomes in subfertile women treated by operative hysteroscopy.