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Luo Y, Sun Y, Huang B, Chen J, Xu B, Li H. Effects and safety of hyaluronic acid gel on intrauterine adhesion and fertility after intrauterine surgery: a systematic review and meta-analysis with trial sequential analysis of randomized controlled trials. Am J Obstet Gynecol 2024; 231:36-50.35. [PMID: 38191020 DOI: 10.1016/j.ajog.2023.12.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2023] [Revised: 12/19/2023] [Accepted: 12/28/2023] [Indexed: 01/10/2024]
Abstract
OBJECTIVE This study aimed to determine the efficacy and safety of hyaluronic acid gel for the prevention of intrauterine adhesions and improved fertility after intrauterine surgery. DATA SOURCES PubMed, EMBASE, Cochrane Library, Web of science, and ClinicalTrials.gov were searched up to November 1, 2023. STUDY ELIGIBILITY CRITERIA Randomized controlled trials that reported intrauterine adhesion and fertility outcomes among women who used hyaluronic acid after intrauterine surgery. METHODS The risk of bias was assessed using criteria of the Cochrane Handbook, and the quality of the evidence was evaluated using the Grades of Recommendation, Assessment, Development, and Evaluation system. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed. A trial sequential analysis was conducted to assess the outcomes, and Stata 14 was used for sensitivity analyses and publication bias analyses. RESULTS Data from 16 randomized controlled trials involving 2359 patients were extracted and analyzed. The analysis revealed that hyaluronic acid reduced the incidence of intrauterine adhesion (risk ratio, 0.53; 95% confidence interval, 0.42-0.67; I2=48%) and improve pregnancy rates (risk ratio, 1.24; 95% confidence interval, 1.02-1.50; I2=0%). A subgroup analysis was conducted to evaluate factors that influence the effect of hyaluronic acid on the incidence of intrauterine adhesion. It was found that a small volume of hyaluronic acid reduced the incidence of intrauterine adhesions. Hyaluronic acid exhibited a protective effect among patients who underwent various intrauterine surgeries and who had different gynecologic medical histories. The protective effect was statistically significant after a follow-up of 6 to 12 weeks. The results of the trial sequential analysis indicated that the effect of hyaluronic acid on the incidence of mild intrauterine adhesions, pregnancy rates, live birth rates, and miscarriage rates after intrauterine surgery may be inconclusive and thus further evaluation is required in the form of additional clinical trials. However, the remaining effects were found to be verifiable and did not require more clinical trials for confirmation. CONCLUSION Hyaluronic acid can safely and effectively reduce the incidence of intrauterine adhesions and may improve fertility outcomes.
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Affiliation(s)
- Yan Luo
- Department of Reproductive Medicine, Xiangya Hospital, Central South University, Changsha, China; Clinical Medicine Eight-Year Program, Xiangya Hospital, Central South University, Changsha, China
| | - Yuanyuan Sun
- Department of Reproductive Medicine, Xiangya Hospital, Central South University, Changsha, China; Clinical Research Center for Women's Reproductive Health in Hunan Province, Changsha, China
| | - Bixia Huang
- Department of Reproductive Medicine, Xiangya Hospital, Central South University, Changsha, China; Clinical Research Center for Women's Reproductive Health in Hunan Province, Changsha, China
| | - Jingjing Chen
- Department of Reproductive Medicine, Xiangya Hospital, Central South University, Changsha, China; Clinical Research Center for Women's Reproductive Health in Hunan Province, Changsha, China
| | - Bin Xu
- Department of Reproductive Medicine, Xiangya Hospital, Central South University, Changsha, China; Clinical Research Center for Women's Reproductive Health in Hunan Province, Changsha, China.
| | - Hui Li
- Department of Reproductive Medicine, Xiangya Hospital, Central South University, Changsha, China; Clinical Research Center for Women's Reproductive Health in Hunan Province, Changsha, China; Hunan Key Laboratory of Molecular Precision Medicine, Department of Oncology, Xiangya Hospital, Central South University, Changsha, Hunan, China.
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Zhu Y, Zhang C, Liang Y, Shi J, Yu Q, Liu S, Yu D, Liu H. Advanced postoperative tissue antiadhesive membranes enabled with electrospun nanofibers. Biomater Sci 2024; 12:1643-1661. [PMID: 38411223 DOI: 10.1039/d3bm02038j] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/28/2024]
Abstract
Tissue adhesion is one of the most common postoperative complications, which is frequently accompanied by inflammation, pain, and even dyskinesia, significantly reducing the quality of life of patients. Thus, to prevent the formation of tissue adhesions, various strategies have been explored. Among these methods, placing anti-adhesion membranes over the injured site to separate the wound from surrounding tissues is a simple and prominently favored method. Recently, electrospun nanofibers have been the most frequently investigated antiadhesive membranes due to their tunable porous structure and high porosities. They not only can act as an essential barrier and functional carrier system but also allow for high permeability and nutrient transport, showing great potential for preventing tissue adhesion. Herein, we provide a short review of the most recent applications of electrospun nanofibrous antiadhesive membranes in tendons, the abdominal cavity, dural sac, pericardium, and meninges. Firstly, each section highlights the most representative examples and they are sorted based on the latest progress of related research. Moreover, the design principles, preparation strategies, overall performances, and existing problems are highlighted and evaluated. Finally, the current challenges and several future ways to develop electrospun nanofibrous antiadhesive membranes are proposed. The systematic discussion and proposed directions can shed light on ideas and guide the reasonable design of electrospun nanofibrous membranes, contributing to the development of exceptional tissue anti-adhesive materials in the foreseeable future.
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Affiliation(s)
- Yanting Zhu
- School of Materials and Chemistry, University of Shanghai for Science and Technology, Shanghai 200093, PR China.
| | - Chenwei Zhang
- School of Materials and Chemistry, University of Shanghai for Science and Technology, Shanghai 200093, PR China.
| | - Ying Liang
- School of Materials and Chemistry, University of Shanghai for Science and Technology, Shanghai 200093, PR China.
| | - Jianyuan Shi
- School of Materials and Chemistry, University of Shanghai for Science and Technology, Shanghai 200093, PR China.
| | - Qiuhao Yu
- School of Materials and Chemistry, University of Shanghai for Science and Technology, Shanghai 200093, PR China.
| | - Shen Liu
- Department of Orthopaedics, Shanghai Sixth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200233, PR China
| | - Dengguang Yu
- School of Materials and Chemistry, University of Shanghai for Science and Technology, Shanghai 200093, PR China.
- Shanghai Engineering Technology Research Center for High-Performance Medical Device Materials, Shanghai 200093, PR China
| | - Hui Liu
- School of Materials and Chemistry, University of Shanghai for Science and Technology, Shanghai 200093, PR China.
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Hu X, Wu H, Yong X, Wang Y, Yang S, Fan D, Xiao Y, Che L, Shi K, Li K, Xiong C, Zhu H, Qian Z. Cyclical endometrial repair and regeneration: Molecular mechanisms, diseases, and therapeutic interventions. MedComm (Beijing) 2023; 4:e425. [PMID: 38045828 PMCID: PMC10691302 DOI: 10.1002/mco2.425] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Revised: 10/21/2023] [Accepted: 10/27/2023] [Indexed: 12/05/2023] Open
Abstract
The endometrium is a unique human tissue with an extraordinary ability to undergo a hormone-regulated cycle encompassing shedding, bleeding, scarless repair, and regeneration throughout the female reproductive cycle. The cyclical repair and regeneration of the endometrium manifest as changes in endometrial epithelialization, glandular regeneration, and vascularization. The mechanisms encompass inflammation, coagulation, and fibrinolytic system balance. However, specific conditions such as endometriosis or TCRA treatment can disrupt the process of cyclical endometrial repair and regeneration. There is uncertainty about traditional clinical treatments' efficacy and side effects, and finding new therapeutic interventions is essential. Researchers have made substantial progress in the perspective of regenerative medicine toward maintaining cyclical endometrial repair and regeneration in recent years. Such progress encompasses the integration of biomaterials, tissue-engineered scaffolds, stem cell therapies, and 3D printing. This review analyzes the mechanisms, diseases, and interventions associated with cyclical endometrial repair and regeneration. The review discusses the advantages and disadvantages of the regenerative interventions currently employed in clinical practice. Additionally, it highlights the significant advantages of regenerative medicine in this domain. Finally, we review stem cells and biologics among the available interventions in regenerative medicine, providing insights into future therapeutic strategies.
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Affiliation(s)
- Xulin Hu
- Clinical Medical College and Affiliated Hospital of Chengdu UniversityChengdu UniversityChengduSichuanChina
- Department of BiotherapyCancer Center and State Key Laboratory of BiotherapyWest China HospitalSichuan UniversityChengduSichuanChina
| | - Haoming Wu
- Clinical Medical College and Affiliated Hospital of Chengdu UniversityChengdu UniversityChengduSichuanChina
| | - Xin Yong
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Department of Paediatrics, West China Second University Hospital, State Key Laboratory of Biotherapy and Collaborative Innovation Center of BiotherapySichuan UniversityChengduSichuanChina
| | - Yao Wang
- Clinical Medical College and Affiliated Hospital of Chengdu UniversityChengdu UniversityChengduSichuanChina
| | - Shuhao Yang
- Department of OrthopedicsThe First Affiliated Hospital of Chongqing Medical UniversityChongqingChina
| | - Diyi Fan
- Clinical Medical College and Affiliated Hospital of Chengdu UniversityChengdu UniversityChengduSichuanChina
| | - Yibo Xiao
- Clinical Medical College and Affiliated Hospital of Chengdu UniversityChengdu UniversityChengduSichuanChina
| | - Lanyu Che
- Clinical Medical College and Affiliated Hospital of Chengdu UniversityChengdu UniversityChengduSichuanChina
| | - Kun Shi
- Department of BiotherapyCancer Center and State Key Laboratory of BiotherapyWest China HospitalSichuan UniversityChengduSichuanChina
| | - Kainan Li
- Clinical Medical College and Affiliated Hospital of Chengdu UniversityChengdu UniversityChengduSichuanChina
| | | | - Huili Zhu
- Department of Reproductive Medicine, Key Laboratory of Birth Defects and Related Diseases of Women and Children of Ministry of EducationWest China Second University Hospital of Sichuan UniversityChengduSichuanChina
| | - Zhiyong Qian
- Department of BiotherapyCancer Center and State Key Laboratory of BiotherapyWest China HospitalSichuan UniversityChengduSichuanChina
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Su Z, Xue B, Xu C, Dong X. Mussel-Inspired Calcium Alginate/Polyacrylamide Dual Network Hydrogel: A Physical Barrier to Prevent Postoperative Re-Adhesion. Polymers (Basel) 2023; 15:4498. [PMID: 38231916 PMCID: PMC10708265 DOI: 10.3390/polym15234498] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Revised: 11/17/2023] [Accepted: 11/20/2023] [Indexed: 01/19/2024] Open
Abstract
Intrauterine adhesions (IUA) has become one of the main causes of female infertility. How to effectively prevent postoperative re-adhesion has become a clinical challenge. In this study, a mussel-inspired dual-network hydrogel was proposed for the postoperative anti-adhesion of IUA. First, a calcium alginate/polyacrylamide (CA-PAM) hydrogel was prepared via covalent and Ca2+ cross-linking. Benefiting from abundant phenolic hydroxyl groups, polydopamine (PDA) was introduced to further enhance the adhesion ability and biocompatibility. This CA-PAM hydrogel immersed in 10 mg/mL dopamine solution possessed remarkable mechanical strength (elastic modulus > 5 kPa) and super stretchability (with a breaking elongation of 720%). At the same time, it showed excellent adhesion (more than 6 kPa). Surprisingly, the coagulation index of the hydrogel was 27.27 ± 4.91, demonstrating attractive coagulation performance in vitro and the potential for rapid hemostasis after surgery.
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Affiliation(s)
- Zekun Su
- School of Materials Science and Engineering, Dalian University of Technology, Dalian 116024, China; (Z.S.); (B.X.)
| | - Beibei Xue
- School of Materials Science and Engineering, Dalian University of Technology, Dalian 116024, China; (Z.S.); (B.X.)
| | - Chang Xu
- Institute of Cardio-Cerebrovascular Medicine, Central Hospital of Dalian University of Technology, Dalian 116089, China
| | - Xufeng Dong
- School of Materials Science and Engineering, Dalian University of Technology, Dalian 116024, China; (Z.S.); (B.X.)
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Guo J, Shi X, Yu F, Cao JH, Xia E, Zhai J, Mol BWJ, Li TC. Adjuvants to prevent reformation of adhesions following adhesiolysis for Asherman syndrome: a systematic review and meta-analysis. HUM FERTIL 2023; 26:797-814. [PMID: 37778374 DOI: 10.1080/14647273.2023.2254492] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2023] [Accepted: 05/15/2023] [Indexed: 10/03/2023]
Abstract
Two international guidelines published on the management of Asherman syndrome (AS) have made recommendations on various adjuvant methods to prevent intrauterine reformation. Nevertheless, the effectiveness of these methods when used in primary or secondary prevention settings is different. Our aim is to assess the effectiveness of various adjuvant methods for the secondary prevention of intrauterine adhesions (IUAs). Articles were considered eligible if they included subjects with AS before surgery and compared a chosen method with either a control or a comparison group (using another method). The primary outcome was the IUA reformation rate at follow-up hysteroscopy. A total of 29 studies [15 randomised controlled trials (RCTs) and 14 cohort studies] were included. Adhesion reformation with various methods to prevented IUA reformation when compared with controls were: second-look hysteroscopy: [risk ratio (RR): 0.21, 95% confidence interval (CI): 0.05-0.90 (p = 0.02)]; intrauterine contraceptive device: RR: 0.64, 95% CI: 0.36-1.12 (p = 0.12); continuous intrauterine balloon: RR: 0.18, 95% CI: 0.05-0.68 (p = 0.01); intermittent intrauterine balloon: RR: 0.50, 95% CI: 0.31-0.80 (p = 0.004); anti-adhesion gel: RR: 0.80, 95% CI: 0.58-1.10 (p = 0.17); amnion graft: RR: 0.63, 95% CI: 0.44-0.91 (p = 0.01).
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Affiliation(s)
- Jun Guo
- Department of Obstetrics and Gynaecology, Beijing Tongren Hospital, Capital Medical University, Beijing, China
| | - Xiaoyu Shi
- Department of Obstetrics and Gynaecology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Fei Yu
- Department of Obstetrics and Gynaecology, Beijing Tongren Hospital, Capital Medical University, Beijing, China
| | - Jing Hong Cao
- Department of Obstetrics and Gynaecology, Beijing Tongren Hospital, Capital Medical University, Beijing, China
| | - Enlan Xia
- Hysteroscopic Centre, Fuxing Hospital, Capital Medical University, Beijing, China
| | - Jianjun Zhai
- Department of Obstetrics and Gynaecology, Beijing Tongren Hospital, Capital Medical University, Beijing, China
| | - Ben W J Mol
- Department of Obstetrics and Gynaecology, Monash University, Clayton, Australia
- Aberdeen Centre for Women's Health Research, School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen, United Kingdom
| | - Tin-Chiu Li
- Hysteroscopic Centre, Fuxing Hospital, Capital Medical University, Beijing, China
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Lee KB, Chon SJ, Kim S, Kim DY, Park CW, Shin SJ, Kim SM, Lee KH, Ji YI. Using Type I Collagen Gel to Prevent Postoperative Intrauterine Adhesion: A Multicenter Retrospective Study. J Clin Med 2023; 12:jcm12113764. [PMID: 37297959 DOI: 10.3390/jcm12113764] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Revised: 05/24/2023] [Accepted: 05/24/2023] [Indexed: 06/12/2023] Open
Abstract
We evaluated the clinical outcomes of using type 1 collagen gel after therapeutic resectoscopy; overall, 150 women aged > 20 who planned to undergo therapeutic resectoscopy were enrolled. The patients were randomly assigned to either of the anti-adhesive treatment groups: the type 1 collagen gel (Collabarrier®) (study group; N = 75) or the sodium hyaluronate and sodium carboxymethylcellulose gel group (control group; N = 75) after resectoscopy. One month after applying anti-adhesive materials, postoperative intrauterine adhesions were evaluated using second-look hysteroscopy; the incidence rate of postoperative intrauterine adhesions examined through second-look hysteroscopy showed no significant differences between the groups. There were no statistical differences between the frequency and mean scores of the type and intensity of adhesions in both groups. Finally, no significant differences in adverse events, serious adverse events, adverse device effects, and serious adverse device effects were noted between the two groups; type 1 collagen gel can be effectively and safely used in intrauterine surgery to minimize postoperative adhesions, thereby eventually decreasing the prevalence of infertility, secondary amenorrhea, and recurrent pregnancy loss in reproductive women.
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Affiliation(s)
- Kwang Beom Lee
- Department of Obstetrics and Gynecology, Gachon University Gil Medical Center, Gachon University College of Medicine, Incheon 21565, Republic of Korea
| | - Seung Joo Chon
- Department of Obstetrics and Gynecology, Gachon University Gil Medical Center, Gachon University College of Medicine, Incheon 21565, Republic of Korea
| | - Sunghoon Kim
- Department of Obstetrics and Gynecology, Women's Cancer Clinic, Institute of Women's Life Science, Yonsei University College of Medicine, Seoul 03722, Republic of Korea
| | - Dae Yeon Kim
- Department of Obstetrics and Gynecology, University of Ulsan College of Medicine, Asan Medical Center, Seoul 05505, Republic of Korea
| | - Chan Woo Park
- Department of Obstetrics and Gynecology, Fertility Center of CHA Gangnam Medical Center, CHA University School of Medicine, Seoul 13496, Republic of Korea
| | - So Jin Shin
- Department of Obstetrics and Gynecology, Keimyung University School of Medicine, Daegu 42601, Republic of Korea
| | - Seok Mo Kim
- Department of Obstetrics and Gynecology, Chonnam National University Medical School, Gwangju 61469, Republic of Korea
| | - Ki Hwan Lee
- Department of Obstetrics and Gynecology, Chungnam National University Hospital, Chungnam National University College of Medicine, Daejeon 34134, Republic of Korea
| | - Yong Il Ji
- Department of Obstetrics and Gynecology, Inje University, Haeundae Paik Hospital, Busan 48108, Republic of Korea
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Takasaki K, Henmi H, Ikeda U, Endo T, Azumaguchi A, Nagasaka K. Intrauterine adhesion after hysteroscopic myomectomy of submucous myomas. J Obstet Gynaecol Res 2023; 49:675-681. [PMID: 36404131 DOI: 10.1111/jog.15499] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Revised: 09/25/2022] [Accepted: 11/02/2022] [Indexed: 11/22/2022]
Abstract
PURPOSE To evaluate the frequency of intrauterine adhesion (IUA) after hysteroscopic myomectomy, and to analyze the association of IUA and the location of submucous myomas and the use of postoperative barrier (POB). METHODS Hysteroscopic myomectomy was performed in 217 patients with submucous myomas. The retrospective investigation was performed, and the cases were divided into three groups: cases with solitary submucous myoma (SSM; group 1), cases with apposing submucous myomas (ASMs; group 2) and cases with submucous myomas that were far from each other or not in apposition to one another (not apposing submucous myomas: NASMs; group 3). As POB, intrauterine device with oxidized regenerated cellulose and silicon sheet was inserted immediately after surgery. RESULTS IUA formation after hysteroscopic myomectomy was more frequent in group 2 than groups 1 and 3 (p = 0.03 and 0.01, respectively), despite the higher rates of POB use (p = 0.02). There was no significant difference in IUA formation in cases with POB between each group (p = 0.06 and 0.21, respectively). But in cases without POB, group 2 showed higher rates of IUA formation than group 1 (p = 0.04) and group 3 (p = 0.03). Multivariable analysis for IUA formation demonstrated that ASMs were a risk factor of IUA (hazard ratio [HR] = 27.9, p < 0.01), and the use of POB was a prognostic factor for reduction of IUA formation (HR = 0.08, p < 0.01). CONCLUSION ASMs appear to be a risk factor for IUA formation. The use of POB may be associated with preventing IUA formation after hysteroscopic myomectomy.
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Affiliation(s)
- Kazuki Takasaki
- Department of Gynecology and Reproductive Endocrinology, Tonan Hospital, Sapporo, Japan.,Department of Obstetrics and Gynecology, Teikyo University School of Medicine
| | - Hirofumi Henmi
- Department of Gynecology and Reproductive Endocrinology, Tonan Hospital, Sapporo, Japan
| | - Utako Ikeda
- Department of Gynecology and Reproductive Endocrinology, Tonan Hospital, Sapporo, Japan
| | - Toshiaki Endo
- Department of Gynecology and Reproductive Endocrinology, Tonan Hospital, Sapporo, Japan
| | | | - Kazunori Nagasaka
- Department of Obstetrics and Gynecology, Teikyo University School of Medicine
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Unanyan A, Pivazyan L, Krylova E, Obosyan L, Ishchenko A. Comparison of effectiveness of hyaluronan gel, intrauterine device and their combination for prevention adhesions in patients after intrauterine surgery: systematic review and meta-analysis. J Gynecol Obstet Hum Reprod 2022; 51:102334. [DOI: 10.1016/j.jogoh.2022.102334] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2021] [Accepted: 02/03/2022] [Indexed: 10/19/2022]
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Vatanatara J, Tingthanatikul Y, Lertvikool S, Hongsakorn W. Alginate Carboxymethylcellulose Hyaluronic Acid for Preventing Intrauterine Adhesion After Vacuum Aspiration for First-Trimester Abortion: A Prospective, Randomized Controlled Trial. J Gynecol Surg 2021. [DOI: 10.1089/gyn.2020.0196] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Jidapa Vatanatara
- Department of Obstetrics and Gynaecology and Department of Obstetrics and Gynaecology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Yada Tingthanatikul
- Reproductive Endocrinology and Infertility Unit, Department of Obstetrics and Gynaecology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Srithean Lertvikool
- Reproductive Endocrinology and Infertility Unit, Department of Obstetrics and Gynaecology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Woradej Hongsakorn
- Reproductive Endocrinology and Infertility Unit, Department of Obstetrics and Gynaecology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
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Lee WL, Liu CH, Cheng M, Chang WH, Liu WM, Wang PH. Focus on the Primary Prevention of Intrauterine Adhesions: Current Concept and Vision. Int J Mol Sci 2021; 22:ijms22105175. [PMID: 34068335 PMCID: PMC8153321 DOI: 10.3390/ijms22105175] [Citation(s) in RCA: 69] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Revised: 05/11/2021] [Accepted: 05/12/2021] [Indexed: 02/07/2023] Open
Abstract
Intrauterine adhesion (IUA), and its severe form Asherman syndrome (Asherman’s syndrome), is a mysterious disease, often accompanied with severe clinical problems contributing to a significant impairment of reproductive function, such as menstrual disturbance (amenorrhea), infertility or recurrent pregnancy loss. Among these, its correlated infertility may be one of the most challenging problems. Although there are many etiologies for the development of IUA, uterine instrumentation is the main cause of IUA. Additionally, more complicated intrauterine surgeries can be performed by advanced technology, further increasing the risk of IUA. Strategies attempting to minimize the risk and reducing its severity are urgently needed. The current review will expand the level of our knowledge required to face the troublesome disease of IUA. It is separated into six sections, addressing the introduction of the normal cyclic endometrial repairing process and its abruption causing the formation of IUA; the etiology and prevalence of IUA; the diagnosis of IUA; the classification of IUA; the pathophysiology of IUA; and the primary prevention of IUA, including (1) delicate surgical techniques, such as the use of surgical instruments, energy systems, and pre-hysteroscopic management, (2) barrier methods, such as gels, intrauterine devices, intrauterine balloons, as well as membrane structures containing hyaluronate–carboxymethylcellulose or polyethylene oxide–sodium carboxymethylcellulose as anti-adhesive barrier.
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Affiliation(s)
- Wen-Ling Lee
- Department of Medicine, Cheng-Hsin General Hospital, Taipei 112, Taiwan;
- Department of Nursing, Oriental Institute of Technology, Taipei 220, Taiwan
- Institute of Clinical Medicine, National Yang Ming Chiao Tung University, Taipei 112, Taiwan; (C.-H.L.); (M.C.); (W.-H.C.)
| | - Chia-Hao Liu
- Institute of Clinical Medicine, National Yang Ming Chiao Tung University, Taipei 112, Taiwan; (C.-H.L.); (M.C.); (W.-H.C.)
- Department of Obstetrics and Gynecology, Taipei Veterans General Hospital, Taipei 112, Taiwan
| | - Min Cheng
- Institute of Clinical Medicine, National Yang Ming Chiao Tung University, Taipei 112, Taiwan; (C.-H.L.); (M.C.); (W.-H.C.)
- Department of Obstetrics and Gynecology, Taipei Veterans General Hospital, Taipei 112, Taiwan
| | - Wen-Hsun Chang
- Institute of Clinical Medicine, National Yang Ming Chiao Tung University, Taipei 112, Taiwan; (C.-H.L.); (M.C.); (W.-H.C.)
- Department of Obstetrics and Gynecology, Taipei Veterans General Hospital, Taipei 112, Taiwan
- Department of Nursing, Taipei Veterans General Hospital, Taipei 112, Taiwan
| | - Wei-Min Liu
- Department of Obstetrics and Gynecology, Taipei Medical University Hospital, Taipei 110, Taiwan;
| | - Peng-Hui Wang
- Institute of Clinical Medicine, National Yang Ming Chiao Tung University, Taipei 112, Taiwan; (C.-H.L.); (M.C.); (W.-H.C.)
- Department of Obstetrics and Gynecology, Taipei Veterans General Hospital, Taipei 112, Taiwan
- Female Cancer Foundation, Taipei 104, Taiwan
- Department of Medical Research, China Medical University Hospital, Taichung 404, Taiwan
- Correspondence: ; Tel.: +886-2-28757566
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Zhou Q, Shi X, Saravelos S, Huang X, Zhao Y, Huang R, Xia E, Li TC. Auto-Cross-Linked Hyaluronic Acid Gel for Prevention of Intrauterine Adhesions after Hysteroscopic Adhesiolysis: A Randomized Controlled Trial. J Minim Invasive Gynecol 2020; 28:307-313. [PMID: 32681996 DOI: 10.1016/j.jmig.2020.06.030] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Revised: 05/27/2020] [Accepted: 06/01/2020] [Indexed: 12/19/2022]
Abstract
STUDY OBJECTIVE To investigate auto-cross-linked hyaluronic acid gel for the prevention of intrauterine adhesion (IUA) recurrence after hysteroscopic adhesiolysis. DESIGN A single-center, double-blinded randomized controlled trial. SETTING A tertiary university hospital. PATIENTS Two hundred seventy-two patients with moderate-to-severe (American Fertility Society [AFS] score ≥5) IUAs underwent hysteroscopic adhesiolysis. INTERVENTIONS The patients were randomized to receive standard care along with auto-cross-linked hyaluronic acid gel after surgery (treatment group) or standard care only (control group). All patients had second-look hysteroscopy at 4 weeks and hormonal therapy for 2 cycles after surgery. MEASUREMENTS AND MAIN RESULTS Two hundred sixty patients were eligible and randomized; 245 patients successfully completed the study (n = 122 in treatment group, and n = 123 in control group). The primary outcome measure was IUA recurrence at second-look hysteroscopy. The secondary outcome measures included an improvement in the AFS score and menstrual pattern. There was no significant difference with regard to IUA recurrence (31.1% vs 39.8%) or median AFS score at second-look hysteroscopy (2, interquartile range [2-4] vs 2, interquartile range [2-4]) or improvement in the menstrual pattern at 3-month follow-up (87.7% vs 76.4%), in the treatment and control groups, respectively. CONCLUSION The application of auto-cross-linked hyaluronic acid gel did not seem to improve IUA recurrence after hysteroscopic adhesiolysis.
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Affiliation(s)
- Qiaoyun Zhou
- Department of Hysteroscopic Center, Fuxing Hospital, The Eighth Clinical Medical College, Capital Medical University, Beijing (Drs. Shi, X. Huang, R. Huang, Li, Zhou, and Zhao, and Ms. Xia)
| | - Xiaoyu Shi
- Department of Hysteroscopic Center, Fuxing Hospital, The Eighth Clinical Medical College, Capital Medical University, Beijing (Drs. Shi, X. Huang, R. Huang, Li, Zhou, and Zhao, and Ms. Xia); Assisted Reproductive Technology Unit, Department of Obstetrics and Gynaecology, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong SAR (Drs. Shi, Saravelos, and Li), China
| | - Sotirios Saravelos
- Assisted Reproductive Technology Unit, Department of Obstetrics and Gynaecology, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong SAR (Drs. Shi, Saravelos, and Li), China; IVF Unit, Hammersmith Hospital, Imperial College, London (Dr. Saravelos), United Kingdom
| | - Xiaowu Huang
- Department of Hysteroscopic Center, Fuxing Hospital, The Eighth Clinical Medical College, Capital Medical University, Beijing (Drs. Shi, X. Huang, R. Huang, Li, Zhou, and Zhao, and Ms. Xia)
| | - Yuting Zhao
- Department of Hysteroscopic Center, Fuxing Hospital, The Eighth Clinical Medical College, Capital Medical University, Beijing (Drs. Shi, X. Huang, R. Huang, Li, Zhou, and Zhao, and Ms. Xia)
| | - Rui Huang
- Department of Hysteroscopic Center, Fuxing Hospital, The Eighth Clinical Medical College, Capital Medical University, Beijing (Drs. Shi, X. Huang, R. Huang, Li, Zhou, and Zhao, and Ms. Xia)
| | - Enlan Xia
- Department of Hysteroscopic Center, Fuxing Hospital, The Eighth Clinical Medical College, Capital Medical University, Beijing (Drs. Shi, X. Huang, R. Huang, Li, Zhou, and Zhao, and Ms. Xia)
| | - Tin Chiu Li
- Department of Hysteroscopic Center, Fuxing Hospital, The Eighth Clinical Medical College, Capital Medical University, Beijing (Drs. Shi, X. Huang, R. Huang, Li, Zhou, and Zhao, and Ms. Xia); Assisted Reproductive Technology Unit, Department of Obstetrics and Gynaecology, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong SAR (Drs. Shi, Saravelos, and Li), China.
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Crosslinked Hyaluronic Acid Gels for the Prevention of Intrauterine Adhesions after a Hysteroscopic Myomectomy in Women with Submucosal Myomas: A Prospective, Randomized, Controlled Trial. Life (Basel) 2020; 10:life10050067. [PMID: 32429137 PMCID: PMC7280993 DOI: 10.3390/life10050067] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Revised: 05/10/2020] [Accepted: 05/13/2020] [Indexed: 01/12/2023] Open
Abstract
Intrauterine adhesion (IUA), fibrosis, and scarring resulting from damage to the endometrium is a rare but serious clinical disease, contributing to a significant impairment of reproductive function. Uterine instrumentation, especially that of a hysteroscopic myomectomy, has become the main cause of IUA. Therefore, a prospective randomized controlled study to assess the effectiveness and short-term safety of the use of hyaluronic acid gels in the prevention of IUA after a hysteroscopic myomectomy and an evaluation of the characteristics of IUA observed at follow-up are presented here. A total of 70 patients were analyzed at the end of 16 March 2020. The results show that the incidence of IUA in women who underwent a hysteroscopic myomectomy is 21.4% (15/70), overall. Women treated with hyaluronic acid gels have a statistically significantly lower incidence of IUAs than non-treated women (12.8% vs. 39.1%, p = 0.012). In addition, women in the anti-adhesive gel treatment group had a dramatically reduced severity of IUA than women in the no-treatment group (p = 0.002). Further analysis shows that the International Federation of Gynecology and Obstetrics (FIGO) classification type and the use of anti-adhesive gels are independent factors associated with moderate and severe degrees of IUA formation. The results here highlight the significant therapeutic benefits of the application of hyaluronic acid gels in women undergoing a hysteroscopic myomectomy, especially for those patients with a uterine myoma classified as FIGO type 2. Since the risk of IUA after a hysteroscopic myomectomy is high, especially for patients who have not received prophylactic anti-adhesive gels, the application of hyaluronic acid gels as a prevention strategy is highly recommended. More studies are encouraged to confirm our observation.
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13
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Wang YQ, Song XH, Wu SL, Huang YZ, Yan L, Li CZ. Comparison of Autocross-Linked Hyaluronic Acid Gel and Intrauterine Device for Preventing Intrauterine Adhesions in Infertile Patients: A Randomized Clinical Trial. Gynecol Minim Invasive Ther 2020; 9:74-80. [PMID: 32676284 PMCID: PMC7354758 DOI: 10.4103/gmit.gmit_103_19] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2019] [Revised: 12/04/2019] [Accepted: 12/19/2019] [Indexed: 12/16/2022] Open
Abstract
Objectives: The objective of this study is to evaluate the efficacy of autocross-linked hyaluronic acid (HA) compared with intrauterine device (IUD) for preventing intrauterine adhesions (IUAs) in infertile patients after hysteroscopic adhesiolysis. Materials and Methods: A randomized clinical trial (ChiCTR-IOR-16007746). Upon completion of adhesiolysis, 3 ml of HA gel was placed into the uterine cavity in Group A; 3 ml of HA gel and an IUD were placed in Group B; and only an IUD was placed in Group C. A second hysteroscopic examination was performed in all patients at approximately 1 month postoperatively for the evaluation of IUA. The primary outcome measure was the effective rate of IUA prevention based on the American Fertility Society (AFS) scoring system. Results: Eighty-nine women were randomly distributed into two groups for intention to treat with 30 patients in Group A, 24 patients in Group B, and 35 patients in Group C. Patients were scored and stratified into three degrees and were enrolled using the simple random sampling method. The three groups were well balanced. There were no significant differences in age, endometrial thickness, the previous number of pregnancy, and the distribution of adhesion categories across mild, moderate, and severe between the three groups. The effective rate of IUA prevention, the AFS score after therapy, and the percentage improvements of Chinese score and AFS score before and after surgery were statistically significant difference between Groups A and C. The clinical pregnancy rate in Group A was higher than those in Groups B and C, but the difference was not statistically significant. Conclusion: HA gel has an advantage over an IUD in reducing IUA recurrence and decreasing adhesions.
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Affiliation(s)
- Yu-Qing Wang
- School of medicine, Shandong University, Shandong, China.,Center for Reproductive Medicine, Reproductive Hospital Affiliated to Shandong University, Shandong, China
| | - Xiao-Hua Song
- Center for Reproductive Medicine, Reproductive Hospital Affiliated to Shandong University, Shandong, China.,Department of Obstetrics and Gynecology, Binzhou People's Hospital, Shandong, China
| | - She-Ling Wu
- Center for Reproductive Medicine, Reproductive Hospital Affiliated to Shandong University, Shandong, China.,Center for Reproductive Medicine, The third affliated hospital of Zheng Zhou University, Jinan, China
| | - Yu-Zhen Huang
- Center for Reproductive Medicine, Reproductive Hospital Affiliated to Shandong University, Shandong, China
| | - Lei Yan
- School of medicine, Shandong University, Shandong, China.,Center for Reproductive Medicine, Reproductive Hospital Affiliated to Shandong University, Shandong, China
| | - Chang-Zhong Li
- Department of Obstetrics and Gynecology, Shandong Provincial Hospital Affiliated to Shandong University, Jinan, China
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14
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Xu F, Shen X, Sun C, Xu X, Wang W, Zheng J. The Effect of Mitomycin C on Reducing Endometrial Fibrosis for Intrauterine Adhesion. Med Sci Monit 2020; 26:e920670. [PMID: 31929497 PMCID: PMC6977616 DOI: 10.12659/msm.920670] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
<strong>BACKGROUND</strong> Intrauterine adhesion (IUA) is a common reproductive system disease in women, characterized by endometrial stromal cell proliferation, increasing fibroblasts and increasing extracellular matrix secretion. The purpose of this study was to investigate the effect of mitomycin C on reducing endometrial fibrosis for IUA. <strong>MATERIAL AND METHODS</strong> Firstly, a rat IUA model was constructed by intrauterine mechanical injury. The endometrial stromal cells and fibroblasts were isolated and treated with mitomycin C. After that, Cell Counting Kit-8 (CCK-8) assay was used to investigate the endometrial stromal cell viability. Furthermore, cell cycle and apoptosis assays of endometrial stromal cells and fibroblasts were performed, respectively. Finally, the cell viability of human endometrial cells or human uterus adhesion fibroblasts treated with mitomycin C was determined using CCK-8 assay with or without estradiol. <strong>RESULTS</strong> Endometrial stromal cells were isolated from a rat IUA model. Cell cycle assay results showed that mitomycin C inhibited cell viability and promoted G1 cell cycle arrest and apoptosis in rat IUA endometrial stromal cells. Fibroblasts were also isolated from the rat IUA model. We found that mitomycin C inhibited the synthesis and secretion of collagen type I by western blotting analysis. Furthermore, mitomycin C promoted G1 cell cycle arrest and apoptosis in IUA rat uterine fibroblasts. We found that estradiol decreased the inhibitory effects of cell viability of human endometrial cells and human uterus adhesion fibroblasts by mitomycin C. <strong>CONCLUSIONS</strong> Our findings revealed that mitomycin C could reduce endometrial fibrosis for intrauterine adhesion.
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Affiliation(s)
- Fang Xu
- Department of Obstetrics and Gynecology, Wenzhou People's Hospital, Wenzhou, Zhejiang, China (mainland)
| | - Xiaolu Shen
- Department of Obstetrics and Gynecology, Wenzhou People's Hospital, Wenzhou, Zhejiang, China (mainland)
| | - Congcong Sun
- Laboratory of Obstetric, Wenzhou People's Hospital, Wenzhou, Zhejiang, China (mainland)
| | - Xiaomin Xu
- Laboratory of Obstetric, Wenzhou People's Hospital, Wenzhou, Zhejiang, China (mainland)
| | - Wenhuan Wang
- Laboratory of Obstetric, Wenzhou People's Hospital, Wenzhou, Zhejiang, China (mainland)
| | - Jiayong Zheng
- Laboratory of Obstetric, Wenzhou People's Hospital, Wenzhou, Zhejiang, China (mainland)
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15
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Azumaguchi A, Henmi H, Saito T. Efficacy of silicone sheet as a personalized barrier for preventing adhesion reformation after hysteroscopic adhesiolysis of intrauterine adhesions. Reprod Med Biol 2019; 18:378-383. [PMID: 31607798 PMCID: PMC6780041 DOI: 10.1002/rmb2.12294] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2019] [Revised: 07/28/2019] [Accepted: 07/29/2019] [Indexed: 12/25/2022] Open
Abstract
PURPOSE To evaluate the efficacy of silicone sheet as a new type of barrier for preventing adhesion reformation following hysteroscopic adhesiolysis of intrauterine adhesions (IUAs). METHODS Hysteroscopic adhesiolysis was performed for 36 patients with IUAs. The adhesion reformation rate was retrospectively compared between 26 patients treated with silicone sheet (group 1) and 10 patients treated with an intrauterine device wrapped in oxidized regenerated cellulose as a barrier (group 2). For patients in group 1, a 1-mm-thick silicone sheet was cut to fit the size and shape of the individual uterine cavity as a personalized barrier. RESULTS The size and shape of each silicone sheet used for patients in group 1 differed significantly. The adhesion reformation rate was significantly lower in group 1 (4/26, 15.4%) than in group 2 (4/10, 40.0%; P = 0.03), although the pregnancy rate (14/20, 70.0% vs. 5/10, 50.0%; P = 0.28) and miscarriage rate (2/14, 14.3% vs. 1/5, 20.0%; P = 0.72) were not significantly different. CONCLUSION Use of silicone sheets appears to be effective for preventing adhesion reformation following hysteroscopic adhesiolysis of IUAs. This is the first study to investigate the efficacy of silicone sheet used as a personalized barrier for preventing IUAs.
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Affiliation(s)
| | - Hirofumi Henmi
- Department of Gynecology and Reproductive Endocrinology, National Public Service Mutual Aid AssociationTonan HospitalSapporoJapan
| | - Tsuyoshi Saito
- Department of Obstetrics and GynecologySapporo Medical UniversitySapporoJapan
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16
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Ohta S, Toda T, Inagaki F, Omichi K, Shimizu A, Kokudo N, Hasegawa K, Ito T. The Prevention of Hepatectomy-Induced Adhesions by Bilayer Sponge Composed of Ultrapure Alginate. J Surg Res 2019; 242:286-295. [PMID: 31125842 DOI: 10.1016/j.jss.2019.04.063] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2018] [Revised: 03/28/2019] [Accepted: 04/24/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND Adhesion formation is a critical issue in surgery, particularly in hepatectomy. The present study aimed to develop a bilayer adhesion barrier comprising alginate (Alg) of different molecular weight (Mw). It was expected that a slowly dissolving layer remains on the cut surface, functioning as a physical barrier, whereas a rapidly dissolving layer widely distributes in the peritoneal cavity to prevent de novo adhesions. METHODS Bilayer Alg sponges were fabricated using low Mw Alg for the upper layer and high Mw Alg for the bottom layer. The dissolution behavior of each layer was evaluated in vitro in peritoneum-like environments. We constructed a Pean crush hepatectomy-induced adhesion model in rats. The effects of the bilayer sponge on cut surface and de novo adhesions were separately evaluated in terms of their extent and grade. RESULTS The Alg sponge layer with low Mw dissolved faster than that with high Mw in vitro. One week after the hepatectomy, although no significant decrease in adhesion extent on the cut surface was observed in rats that received Seprafilm and Interceed, treatment with Alg bilayer sponge significantly decreased the adhesion extent to 38% of that without treatment. Moreover, a significant decrease in de novo adhesion extent was observed in the Alg bilayer sponge compared with the Interceed group. CONCLUSIONS The Alg bilayer sponge was effective for preventing both cut surface and de novo adhesions in the rat Pean crush hepatectomy model. The simple yet functional design of the Alg bilayer sponge can facilitate its use in future clinical practice.
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Affiliation(s)
- Seiichi Ohta
- Center for Disease Biology and Integrative Medicine, The University of Tokyo, Tokyo, Japan
| | - Takeo Toda
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Fuyuki Inagaki
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Kiyohiko Omichi
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Atsushi Shimizu
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Norihiro Kokudo
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Kiyoshi Hasegawa
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Taichi Ito
- Center for Disease Biology and Integrative Medicine, The University of Tokyo, Tokyo, Japan.
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17
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Bosteels J, Weyers S, D'Hooghe TM, Torrance H, Broekmans FJ, Chua SJ, Mol BWJ. Anti-adhesion therapy following operative hysteroscopy for treatment of female subfertility. Cochrane Database Syst Rev 2017; 11:CD011110. [PMID: 29178172 PMCID: PMC6486292 DOI: 10.1002/14651858.cd011110.pub3] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
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.
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Affiliation(s)
- Jan Bosteels
- Cochrane BelgiumAcademic Centre for General PracticeKapucijnenvoer 33blok J bus 7001LeuvenBelgium3000
- University Hospital GhentObstetrics and GynaecologyDe Pintelaan 185GhentBelgium9000
| | - Steven Weyers
- University Hospital GhentObstetrics and GynaecologyDe Pintelaan 185GhentBelgium9000
| | - Thomas M D'Hooghe
- University Hospital GasthuisbergLeuven University Fertility CentreHerestraat 49LeuvenBelgium3000
| | - Helen Torrance
- University Medical CenterDepartment of Reproductive Medicine and GynecologyHeidelberglaan 100UtrechtNetherlands3584 CX
| | - Frank J Broekmans
- University Medical CenterDepartment of Reproductive Medicine and GynecologyHeidelberglaan 100UtrechtNetherlands3584 CX
| | - Su Jen Chua
- The University of AdelaideAdelaideAustraliaSA5005
| | - Ben Willem J Mol
- The University of AdelaideDiscipline of Obstetrics and Gynaecology, School of Medicine, Robinson Research InstituteLevel 3, Medical School South BuildingFrome RoadAdelaideSouth AustraliaAustraliaSA 5005
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Yan Y, Xu D. The Effect of Adjuvant Treatment to Prevent and Treat Intrauterine Adhesions: A Network Meta-Analysis of Randomized Controlled Trials. J Minim Invasive Gynecol 2017; 25:589-599. [PMID: 28893657 DOI: 10.1016/j.jmig.2017.09.006] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2017] [Revised: 09/01/2017] [Accepted: 09/04/2017] [Indexed: 12/29/2022]
Abstract
Intrauterine adhesions (IUAs) can lead to partial or complete closure of the uterine cavity, which may result in symptoms including abnormal menstruation, infertility, and pelvic pain. A network meta-analysis was performed to assess the effect of adjuvant therapy on the prevention and treatment of IUAs. We searched electronic databases, including PubMed, Embase, and the Cochrane Library, up to May 5, 2017, without language restrictions. The primary outcomes in the present analysis were the rate of IUAs for prevention and the rate of IUA recurrence for treatment. The secondary outcomes included the IUA score and the rate of severity of IUAs. The treatments were then ranked by the surface under the cumulative ranking curve (SUCRA). We included 20 articles that involved a total of 1891 patients in our analysis. In the outcomes of prevention-related studies, an alginate hyaluronate-carboxymethylcellulose membrane (ACH) (n = 10, SUCRA score = 93.3%) was the adjuvant treatment that most effectively reduced IUA incidence. It was followed by intercoat (n = 10, SUCRA score = 74.7%) and misoprostol (n = 10, SUCRA score = 68.6%). In addition, auto-cross-linked hyaluronic acid (ACP) (n = 3, SUCRA score = 83.2%) and intercoat (n = 3, SUCRA score = 66.4%) each corresponded to a relatively high preventive effect against severe IUAs. In the treatment-related studies, ACP plus a balloon (n = 4, SUCRA score = 96.3%) and a freeze-dried amnion graft plus a balloon (n = 4, SUCRA score = 62.7%) most effectively reduced IUA recurrence and had a high probability of most effectively reducing IUA scores. Therefore, according to the prophylactic analysis, ACH and intercoat were most likely to prevent IUA development. In our analysis of agents used to prevent severe IUAs, we found that ACP and intercoat provided significant advantages and had high reliability. In our analysis of treatments, ACP plus a balloon and freeze-dried amniotic agents plus a balloon were most likely to reduce IUA recurrence and IUA scores after adhesiolysis.
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Affiliation(s)
- Yu Yan
- Departments of Obstetrics, Chongqing Health Center for Women and Children, Chongqing, China
| | - Dongmei Xu
- Department of Reproductive Endocrinology, Chongqing Health Center for Women and Children, Chongqing, China.
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Smorgick N, Levinsohn-Tavor O, Ben-Ami I, Maymon R, Pansky M, Vaknin Z. Hysteroscopic removal of retained products of conception following first trimester medical abortion. Gynecol Minim Invasive Ther 2017; 6:183-185. [PMID: 30254910 PMCID: PMC6135206 DOI: 10.1016/j.gmit.2017.05.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2016] [Revised: 03/15/2017] [Accepted: 05/23/2017] [Indexed: 11/28/2022] Open
Abstract
Study Objective: To investigate the use of operative hysteroscopy instead of traditional curettage in women with retained products of conception (RPOC) following first trimester medical abortion, with the aim of reducing post-operative intrauterine adhesions. Design: Retrospective study. Setting: Gynecology department in a University affiliated hospital. Patients: All women treated by hysteroscopy for RPOC following first trimester medical abortion using the mifepristone-misoprostol protocol for pregnancy termination or the misoprostol protocol for early missed abortion from January 2013 to August 2016. Intervention: Operative hysteroscopy for removal of RPOC. Post-operative intrauterine adhesions were assessed by diagnostic office hysteroscopy after 6–8 weeks. Measurements and Main Results: 50 cases were identified. The mean time from medication administration to the operative hysteroscopy was 1.7 ± 0.7 months. Operative hysteroscopy with blunt use of the resectoscopic loop was used to remove all specimens, and all procedures were completed without intra-operative complications. Two patients (4.0%) were readmitted for fever. Pathology confirmed the presence of RPOC in 45 (90.0%) cases. On follow-up office hysteroscopy, a normal uterine cavity without evidence of intrauterine adhesions was seen in 29/29 (100%) women. Conclusion: Hysteroscopy for removal of RPOC following medical abortion is associated with low rates of complications and post-operative intrauterine adhesions.
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Affiliation(s)
- Noam Smorgick
- Department of Obstetrics and Gynecology, Assaf Harofeh Medical Center, Affiliated with Tel-Aviv University, Sackler School of Medicine, Israel
| | - Orna Levinsohn-Tavor
- Department of Obstetrics and Gynecology, Assaf Harofeh Medical Center, Affiliated with Tel-Aviv University, Sackler School of Medicine, Israel
| | - Ido Ben-Ami
- Department of Obstetrics and Gynecology, Assaf Harofeh Medical Center, Affiliated with Tel-Aviv University, Sackler School of Medicine, Israel
| | - Ron Maymon
- Department of Obstetrics and Gynecology, Assaf Harofeh Medical Center, Affiliated with Tel-Aviv University, Sackler School of Medicine, Israel
| | - Moty Pansky
- Department of Obstetrics and Gynecology, Assaf Harofeh Medical Center, Affiliated with Tel-Aviv University, Sackler School of Medicine, Israel
| | - Zvi Vaknin
- Department of Obstetrics and Gynecology, Assaf Harofeh Medical Center, Affiliated with Tel-Aviv University, Sackler School of Medicine, Israel
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AAGL Practice Report: Practice Guidelines on Intrauterine Adhesions Developed in Collaboration With the European Society of Gynaecological Endoscopy (ESGE). J Minim Invasive Gynecol 2017; 24:695-705. [PMID: 28473177 DOI: 10.1016/j.jmig.2016.11.008] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2016] [Accepted: 11/15/2016] [Indexed: 11/15/2022]
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AAGL practice report: practice guidelines on intrauterine adhesions developed in collaboration with the European Society of Gynaecological Endoscopy (ESGE). ACTA ACUST UNITED AC 2017; 14:6. [PMID: 28603474 PMCID: PMC5440524 DOI: 10.1186/s10397-017-1007-3] [Citation(s) in RCA: 54] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2017] [Accepted: 03/23/2017] [Indexed: 11/22/2022]
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Intrauterine adhesion prevention after hysteroscopy: a systematic review and meta-analysis. Am J Obstet Gynecol 2016; 215:267-275.e7. [PMID: 27173082 DOI: 10.1016/j.ajog.2016.05.001] [Citation(s) in RCA: 93] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2016] [Revised: 04/22/2016] [Accepted: 05/02/2016] [Indexed: 11/27/2022]
Abstract
BACKGROUND Despite years of studies evaluating prevention strategies for intrauterine adhesion formation after operative hysteroscopy, it is still unclear which strategies are most effective. OBJECTIVE The objective of the study was to perform a systematic review and meta-analysis to evaluate the effectiveness of postoperative prevention strategies on intrauterine adhesion formation following operative hysteroscopy. STUDY DESIGN Literature searches were conducted in MEDLINE, Embase, ClinicalTrials.gov, and Cochrane Library databases. Inclusion criteria were published randomized controlled clinical trials from 1989 to 2014 comparing any postoperative preventative measures of intrauterine adhesion after hysteroscopy. The main outcome measure was a reduction in postoperative intrauterine adhesion. Heterogeneity of the studies was evaluated using a Q test and an I(2) index. Analyses were performed using a random-effects model with outcome data reported as relative risk with 95% confidence interval. RESULTS Twelve studies were included in the systematic review. Eight studies compared similar treatment methods and were included in the meta-analysis. Three studies evaluated hyaluronic acid gel, of which 2 reported a significant decrease in intrauterine adhesion with treatment. The meta-analysis demonstrated a significant reduction of intrauterine adhesion when using hyaluronic acid gel. Two studies evaluated polyethylene oxide-sodium carboxymethylcellulose gel, 1 of which demonstrated a decrease in intrauterine adhesion with treatment. A meta-analysis showed a significant reduction of intrauterine adhesion with polyethylene oxide-sodium carboxymethyl cellulose gel. However, these 3 studies demonstrating a benefit of the gels in preventing adhesion formation were all conducted by the same research group. Other research groups have not confirmed these results. A sensitivity analysis excluding these trials from this single group demonstrated no benefit to adhesion prevention with either gel formation. Three studies investigated oral estrogen therapy after hysteroscopy and found no difference in intrauterine adhesion. A meta-analysis showed no decrease in intrauterine adhesion with estrogen therapy after hysteroscopy. Data were lacking to perform metaanalyses on the use of intrauterine balloon, intrauterine device, and other adhesion prevention barriers in preventing intrauterine adhesion. CONCLUSION There was a lack of definitive evidence to conclude that any treatment is effective in preventing posthysteroscopy uterine adhesion formation. The available literature has significant heterogeneity and a high risk of bias, making any definitive conclusions difficult.
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Di Spiezio Sardo A, Calagna G, Scognamiglio M, O’Donovan P, Campo R, De Wilde RL. Prevention of intrauterine post-surgical adhesions in hysteroscopy. A systematic review. Eur J Obstet Gynecol Reprod Biol 2016; 203:182-92. [DOI: 10.1016/j.ejogrb.2016.05.050] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2015] [Revised: 05/18/2016] [Accepted: 05/31/2016] [Indexed: 10/21/2022]
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Bosteels J, Weyers S, Kasius J, Broekmans FJ, Mol BWJ, D'Hooghe TM. Anti-adhesion therapy following operative hysteroscopy for treatment of female subfertility. Cochrane Database Syst Rev 2015:CD011110. [PMID: 26559098 DOI: 10.1002/14651858.cd011110.pub2] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
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.
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Affiliation(s)
- Jan Bosteels
- Belgian Branch of the Dutch Cochrane Centre, Kapucijnenvoer 33 blok J bus 7001, 3000 Leuven, Leuven, Belgium
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Thubert T, Dussaux C, Demoulin G, Rivain AL, Trichot C, Deffieux X. Influence of auto-cross-linked hyaluronic acid gel on pregnancy rate and hysteroscopic outcomes following surgical removal of intra-uterine adhesions. Eur J Obstet Gynecol Reprod Biol 2015; 193:65-9. [PMID: 26246163 DOI: 10.1016/j.ejogrb.2015.06.025] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2015] [Revised: 05/11/2015] [Accepted: 06/30/2015] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To 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 DESIGN An 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. RESULTS Pregnancy (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). CONCLUSION Application 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.
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Affiliation(s)
- T Thubert
- AP-HP, Service de Gynécologie-Obstétrique et Médecine de la Reproduction, Hôpital Antoine Béclère, Clamart, France
| | - C Dussaux
- AP-HP, Service de Gynécologie-Obstétrique et Médecine de la Reproduction, Hôpital Antoine Béclère, Clamart, France
| | - G Demoulin
- AP-HP, Service de Gynécologie-Obstétrique et Médecine de la Reproduction, Hôpital Antoine Béclère, Clamart, France
| | - A-L Rivain
- AP-HP, Service de Gynécologie-Obstétrique et Médecine de la Reproduction, Hôpital Antoine Béclère, Clamart, France
| | - C Trichot
- AP-HP, Service de Gynécologie-Obstétrique et Médecine de la Reproduction, Hôpital Antoine Béclère, Clamart, France
| | - X Deffieux
- AP-HP, Service de Gynécologie-Obstétrique et Médecine de la Reproduction, Hôpital Antoine Béclère, Clamart, France.
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Warembourg S, Huberlant S, Garric X, Leprince S, de Tayrac R, Letouzey V. Prévention et traitement des synéchies endo-utérines : revue de la littérature. ACTA ACUST UNITED AC 2015; 44:366-79. [DOI: 10.1016/j.jgyn.2014.10.014] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2014] [Revised: 10/16/2014] [Accepted: 10/23/2014] [Indexed: 12/25/2022]
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Hysteroscopy: guidelines for clinical practice from the French College of Gynaecologists and Obstetricians. Eur J Obstet Gynecol Reprod Biol 2014; 178:114-22. [PMID: 24835861 DOI: 10.1016/j.ejogrb.2014.04.026] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2014] [Revised: 04/18/2014] [Accepted: 04/22/2014] [Indexed: 01/02/2023]
Abstract
The objective of this study was to provide guidelines for clinical practice from the French College of Obstetrics and Gynecology (CNGOF), based on the best evidence available, concerning hysteroscopy. Vaginoscopy should be the standard technique for diagnostic hysteroscopy (Grade A) using a miniature (≤3.5mm sheath) (Grade A) rigid hysteroscope (Grade C), using normal saline solution distension medium (Grade C), without any anaesthesia (conscious sedation should not be routinely used), without cervical preparation (Grade B), without vaginal disinfection and without antibiotic prophylaxy (Grade B). Misoprostol (Grade A), vaginal oestrogens (Grade C), or GnRH agonist routine administration is not recommended before operative hysteroscopy. Before performing hysteroscopy, it is important to purge the air out of the system (Grade A). The uterine cavity distention pressure should be maintained below the mean arterial pressure and below 120mm Hg. The maximum fluid deficit of 2000ml is suggested when using normal saline solution and 1000ml is suggested when using hypotonic solution. When uterine perforation is recognized during operative hysteroscopy using monopolar or bipolar loop, the procedure should be stopped and a laparoscopy should be performed in order to eliminate a bowel injury. Diagnostic or operative hysteroscopy is allowed when an endometrial cancer is suspected (Grade B). Implementation of this guideline should decrease the prevalence of complications related to hysteroscopy.
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Conforti A, Alviggi C, Mollo A, De Placido G, Magos A. The management of Asherman syndrome: a review of literature. Reprod Biol Endocrinol 2013; 11:118. [PMID: 24373209 PMCID: PMC3880005 DOI: 10.1186/1477-7827-11-118] [Citation(s) in RCA: 123] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2013] [Accepted: 12/19/2013] [Indexed: 12/13/2022] Open
Abstract
Asherman syndrome is a debatable topic in gynaecological field and there is no clear consensus about management and treatment. It is characterized by variable scarring inside the uterine cavity and it is also cause of menstrual disturbances, infertility and placental abnormalities. The advent of hysteroscopy has revolutionized its diagnosis and management and is therefore considered the most valuable tool in diagnosis and management. The aim of this review is to explore the most recent evidence related to this condition with regards to aetiology, diagnosis management and follow up strategies.
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Affiliation(s)
- Alessandro Conforti
- University Department of Obstetrics, Gynaecology, Urology and Reproductive Medicine, University of Naples Federico II, Via Sergio Pansini n. 6, Naples 80100, Italy
| | - Carlo Alviggi
- University Department of Obstetrics, Gynaecology, Urology and Reproductive Medicine, University of Naples Federico II, Via Sergio Pansini n. 6, Naples 80100, Italy
| | - Antonio Mollo
- University Department of Obstetrics, Gynaecology, Urology and Reproductive Medicine, University of Naples Federico II, Via Sergio Pansini n. 6, Naples 80100, Italy
| | - Giuseppe De Placido
- University Department of Obstetrics, Gynaecology, Urology and Reproductive Medicine, University of Naples Federico II, Via Sergio Pansini n. 6, Naples 80100, Italy
| | - Adam Magos
- University Department of Obstetrics and Gynaecology, Royal Free Hospital, London NW3 2QG, UK
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[Prevention of the complications related to hysteroscopy: guidelines for clinical practice]. ACTA ACUST UNITED AC 2013; 42:1032-49. [PMID: 24210234 DOI: 10.1016/j.jgyn.2013.09.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To provide clinical practice guidelines (CPGs) from the French college of obstetrics and gynecology (CNGOF), based on the best evidence available, concerning the adverse events related to hysteroscopy. MATERIALS AND METHODS Review of literature using following Keywords: hysteroscopy; vaginoscopy; infection; perforation; intrauterine adhesions RESULTS Vaginoscopy should be the standard technique for outpatient hysteroscopy (grade A) using a miniature (≤ 3.5mm sheath) (grade A) rigid hysteroscope (grade C), using normal saline solution distension medium (grade C), without any anesthesia (conscious sedation should not be routinely used), without cervical preparation (grade B), without vaginal disinfection and without antibiotic prophylaxy (grade B). Misoprostol (grade A), vaginal estrogens (grade C), or GnRH agonist routine administration is not recommended before operative hysteroscopy. Before performing hysteroscopy, it is important to purge the air out of the system (grade A). The uterine cavity distention pressure should be maintained below the mean arterial pressure and below 120 mmHg. The maximum fluid deficit of 2000 mL is suggested when using normal saline solution and 1000 mL is suggested when using hypotonic solution. When uterine perforation is recognized during operative hysteroscopy using monopolar or bipolar loop, the procedure should be stopped and a laparoscopy should be performed in order to eliminate a bowel injury. Diagnostic or operative hysteroscopy is allowed when an endometrial cancer is suspected (grade B). CONCLUSION Implementation of this guideline should decrease the prevalence of complications related to office and operative hysteroscopy.
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Alkhamesi NA, Schlachta CM. The role of aerosolized intraperitoneal heparin and hyaluronic acid in the prevention of postoperative abdominal adhesions. Surg Endosc 2013; 27:4663-9. [DOI: 10.1007/s00464-013-3102-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2013] [Accepted: 07/02/2013] [Indexed: 12/11/2022]
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