Intrauterine Adhesions Following Miscarriage: Look and Learn

The efficacy of early office hysteroscopy in preventing intrauterine adhesions after abortion: a randomized controlled trial

BACKGROUND

Intrauterine adhesions (IUA) are a challenging clinical problem in reproductive infertility. The most common causes are intrauterine surgery and abortions. We aimed to investigate whether early second-look office hysteroscopy can prevent IUA.

METHODS

A single-center, prospective, two-armed, randomized controlled trial was designed to explore the efficacy of early office hysteroscopy after first-trimester induced abortion (suction dilatation and curettage [D&C]) and to further analyze fertility outcomes. Women aged 20-45 years undergoing suction D&C and desiring to conceive were recruited. Between October 2019 and September 2022, 66 women were enrolled, of whom 33 were allocated to group A (early hysteroscopy intervention). The women in intervention group A were planned to receive 2 times of hysteroscopies (early and late). In group B, women only underwent late (6 months post suction D&C) hysteroscopy.

RESULTS

The primary outcome was the IUA rate assessed using office hysteroscopy 6 months after artificial abortion. Secondary outcomes included menstrual amount/durations and fertility outcomes. In intervention group A, 31 women underwent the first hysteroscopy examination, and 15 completed the second. In group B (late hysteroscopy intervention, 33 patients), 16 completed the hysteroscopic exam 6 months after an artificial abortion. Twenty-one women did not receive late hysteroscopy due to pregnancy. The IUA rate was 16.1% (5/31) at the first hysteroscopy in group A, and no IUA was detected during late hysteroscopy. Neither group showed statistically significant differences in the follow-up pregnancy and live birth rates.

CONCLUSIONS

Early hysteroscopy following suction D&C can detect intrauterine lesions. IUA detected early by hysteroscopy can disappear on late examination and become insignificant for future pregnancies. Notably, the pregnancy outcomes showed a favorable trend in the early hysteroscopy group, but there were no statistically significant differences.

TRIAL REGISTRATION

ClinicalTrials.gov , ID: NCT04166500. Registered on 2019-11-10. https://clinicaltrials.gov/ct2/show/NCT04166500 .

Intrauterine adhesion in ultrasound-guided manual vacuum aspiration (USG-MVA) versus electric vacuum aspiration (EVA): a randomised controlled trial

BACKGROUND

Intrauterine adhesion (IUA) can arise as a potential complication following uterine surgery, as the surgical procedure may damage the endometrial stratum basalis. The objective of this study was to assess and compare the occurrence of IUA in women who underwent ultrasound-guided manual vacuum aspiration (USG-MVA) versus electric vacuum aspiration (EVA) for managing first-trimester miscarriage.

METHODS

This was a prospective, single-centre, randomised controlled trial conducted at a university-affiliated tertiary hospital. Chinese women aged 18 years and above who had a delayed or incomplete miscarriage of ≤ 12 weeks of gestation were recruited in the Department of Obstetrics and Gynaecology at the Prince of Wales. Recruited participants received either USG-MVA or EVA for the management of their miscarriage and were invited for a hysteroscopic assessment to evaluate the incidence of IUA between 6 and 20 weeks after the surgery. Patients were contacted by phone at 6 months to assess their menstrual and reproductive outcomes.

RESULTS

303 patients underwent USG-MVA or EVA, of whom 152 were randomised to 'USG-MVA' and 151 patients to the 'EVA' group. Out of the USG-MVA group, 126 patients returned and completed the hysteroscopic assessment, while in the EVA group, 125 patients did the same. The incidence of intrauterine adhesion (IUA) was 19.0% (24/126) in the USG-MVA group and 32.0% (40/125) in the EVA group, showing a significant difference (p < 0.02) between the two groups. No significant difference in the menstrual outcomes at 6 months postoperatively between the two groups but more patients had miscarriages in the EVA group with IUA.

CONCLUSIONS

IUAs are a possible complication of USG-MVA. However, USG-MVA is associated with a lower incidence of IUA postoperatively at 6-20 weeks. USG-MVA is a feasible, effective, and safe alternative surgical treatment with less IUA for the management of first-trimester miscarriage.

TRIAL REGISTRATION

The study was registered with the Centre for Clinical Research and Biostatics- Clinical Trials Registry (CCRBCTR), which is a partner registry of the WHO Primary Registry-Chinese Clinical Trials Registry (ChiCTR) (Unique Trial Number: ChiCTR1900023198 with the first trial registration date on 16/05/2019).

Nano-biomaterial Fibrinogen/P(LLA-CL) for prevention of intrauterine adhesion and restoration of fertility

Endometrial damage resulting from surgical procedures is a significant cause of intrauterine adhesion, thin endometrium, and subsequent miscarriage and infertility. Unfortunately, there is currently no effective clinical solution to promote endometrial regeneration after severe injury. In this study, we combined fibrinogen (Fg) and P(LLA-CL) by electrostatic spinning to form a stable nano-biomaterial Fg/P(LLA-CL), which can promote endometrial regeneration. After inducing physical injury to rat endometrium, we found that Fg/P(LLA-CL) membranes placed in the uterine cavities increased endometrial thickness and the number of glands after injury, while reducing the area of endometrial fibrosis. In addition, Fg/P(LLA-CL) increased neovascularization and decreased COL1A1 deposition. The expression of TGF-β1, a cytokine that promotes fibrosis, was down-regulated in the early stage of injury. Finally, fertility assays confirmed that Fg/P(LLA-CL) improved the pregnancy rate in rats with endometrial injury, and its safety was verified by blood tests and pathological examination of heart, liver, spleen, lung, and kidney. Therefore, Fg/P(LLA-CL) shows great potential as a safe and nontoxic biomaterial for endometrial regeneration, ultimately improving pregnancy outcomes in patients with intrauterine adhesion.

Incidence of intrauterine adhesion after ultrasound-guided manual vacuum aspiration (USG-MVA) for first-trimester miscarriages: a prospective cohort study

PURPOSE

Ultrasound-guided manual vacuum aspiration (USG-MVA) is a feasible and effective outpatient treatment to treat early pregnancy loss.

METHODS

This was a prospective observational study at a university-affiliated hospital. All women undergoing either a USG-MVA or electric vacuum aspiration (EVA) were invited to return 3-6 months later for follow-up at which women completed a questionnaire to document their post-evacuation menstrual and reproductive history, and underwent a hysteroscopy if they were not pregnant. The severity of intrauterine adhesion (IUA), if present, was graded (Stage I-III) according to the American fertility society classification.

RESULTS

A total of 292 women had a hysteroscopy after their initial surgical evacuation, USG-MVA 169(57.9%) versus EVA 123(42.1%). Women undergoing EVA as opposed to a USG-MVA had a 12.9% higher incidence of IUA (24.1% vs. 37.0%, p = 0.042) equivalent to 1.84 times higher risk (95% CI 1.01-3.34; p = 0.048). Women having EVA continued to show an increased but not statistically significant trend towards an increased risk of IUA after adjusting for the type of miscarriage (aOR = 1.3; 95% CI 0.66-2.50; p = 0.46).

CONCLUSION

There were no significant differences in their reproductive outcomes and fewer women post-USG-MVA complained of hypomenorrhea. IUA may still occur in women undergoing USG-MVA but it is lower than the rate in women undergoing EVA. Clinical trials registry The trial was registered with the Centre for Clinical Research and Biostatistics - Clinical Trials Registry (CCRBCTR), a partner registry of the WHO Primary Registry-Chinese Clinical Trials Registry (ChiCTR) with a Unique Trial Number: CUHK_CCRB00541 on 22 Dec 2016.

Utility of Office Hysteroscopy in Diagnosing Retained Products of Conception Following Early Pregnancy Loss After In Vitro Fertilization

OBJECTIVE

To evaluate the utility of office hysteroscopy in diagnosing and treating retained products of conception in patients with infertility who experience early pregnancy loss (EPL) after in vitro fertilization (IVF).

METHODS

We evaluated a retrospective cohort of 597 pregnancies that ended in EPL in patients aged 18-45 years who conceived through fresh or frozen embryo transfer at an academic fertility practice between January 2016 and December 2021. All patients underwent office hysteroscopy after expectant, medical, or surgical management of the EPL. The primary outcome was presence of retained products of conception at the time of office hysteroscopy. Secondary outcomes included incidence of vaginal bleeding, presence of intrauterine adhesions, treatment for retained products of conception, and duration of time from EPL diagnosis to resolution. Log-binomial regression and Poisson regression were performed, adjusting for potential confounders including oocyte age, patient age, body mass index, prior EPL count, number of prior dilation and curettage procedures, leiomyomas, uterine anomalies, and vaginal bleeding.

RESULTS

Of the 597 EPLs included, 129 patients (21.6%) had retained products of conception diagnosed at the time of office hysteroscopy. The majority of individuals with EPL were managed surgically (n=427, 71.5%), in lieu of expectant management (n=140, 23.5%) or medical management (n=30, 5.0%). The presence of retained products of conception was significantly associated with vaginal bleeding (relative risk [RR] 1.72, 95% CI 1.34-2.21). Of the 41 patients with normal pelvic ultrasonogram results before office hysteroscopy, 10 (24.4%) had retained products of conception detected at the time of office hysteroscopy. When stratified by EPL management method, retained products of conception were significantly more likely to be present in individuals with EPL who were managed medically (adjusted RR 2.66, 95% CI 1.90-3.73) when compared with those managed surgically. Intrauterine adhesions were significantly less likely to be detected in individuals with EPL who underwent expectant management when compared with those managed surgically (RR 0.14, 95% CI 0.04-0.44). Of the 127 individuals with EPL who were diagnosed with retained products of conception at the time of office hysteroscopy, 30 (23.6%) had retained products of conception dislodged during the office hysteroscopy, 34 (26.8%) chose expectant or medical management, and 63 (49.6%) chose surgical management. The mean number of days from EPL diagnosis to resolution of pregnancy was significantly higher in patients who elected for expectant management (31 days; RR 1.18, 95% CI 1.02-1.37) or medical management (41 days; RR 1.54, 95% CI 1.25-1.90) when compared with surgical management (27 days).

CONCLUSION

In patients with EPL after IVF, office hysteroscopy detected retained products of conception in 24.4% of those with normal pelvic ultrasonogram results. Due to the efficacy of office hysteroscopy in diagnosing and treating retained products of conception, these data support considering office hysteroscopy as an adjunct to ultrasonography in patients with infertility who experience EPL after IVF.

Mechanisms of Regeneration and Fibrosis in the Endometrium

The uterine lining (endometrium) regenerates repeatedly over the life span as part of its normal physiology. Substantial portions of the endometrium are shed during childbirth (parturition) and, in some species, menstruation, but the tissue is rapidly rebuilt without scarring, rendering it a powerful model of regeneration in mammals. Nonetheless, following some assaults, including medical procedures and infections, the endometrium fails to regenerate and instead forms scars that may interfere with normal endometrial function and contribute to infertility. Thus, the endometrium provides an exceptional platform to answer a central question of regenerative medicine: Why do some systems regenerate while others scar? Here, we review our current understanding of diverse endometrial disruption events in humans, nonhuman primates, and rodents, and the associated mechanisms of regenerative success and failure. Elucidating the determinants of these disparate repair processes promises insights into fundamental mechanisms of mammalian regeneration with substantial implications for reproductive health.

Comparison of the efficacy of autologous platelet gel and medical chitosan in the prevention of recurrence of intrauterine adhesions after transcervical resection of adhesion: a prospective, randomized, controlled trial

PURPOSE

Intrauterine adhesion (IUAs) in women is a debatable topic and there is no clear consensus in its management and treatment strategies. Previous treatment measures have limitations which necessitates to consider effective measures for prevention of recurrence of IUAs. Hence, the aim of this study to explore the efficacy and safety of intrauterine infusion of autologous platelet gel (APG) and medical chitosan in preventing recurrence of IUAs in females after transcervical resection of adhesion (TCRA).

METHODS

A prospective, randomized controlled trial was conducted among 80 patients presented with moderate to severe IUAs. Patients were randomized into two groups, APG group (n = 40) and medical chitosan group (n = 40). All patients were injected with either APG or medical chitosan after TCRA.

RESULTS

The postoperative recurrence rate of adhesions in APG group was significantly lower than those in medical chitosan group (21% vs 49%). The median AFS score during the second-look hysteroscopy was significantly lower in APG group than in medical chitosan group (P = 0.008). The median AFS score reduction after TCRA surgery was significantly higher in APG group than in medical chitosan group (median, 95% CI 7.000, 6.0 to 8.3 vs. 6.000, 5.0 to 7.0, P = 0.004). Subgroup analysis of platelet concentration (1000 as cut-off value) into high- and low-dose subgroups reported no significant correlation existed between APG and baseline characteristics, recurrence rate and postoperative AFS reduction score except for previous intrauterine operation (P < 0.05).

CONCLUSION

Thus, after TCRA, intrauterine injections of APG provides better efficacy and safety compared with intrauterine injections of medical chitosan in preventing recurrence of intrauterine adhesions.

The perinatal outcomes of women treated for Asherman syndrome: a propensity score-matched cohort study

STUDY QUESTION

Do the perinatal outcomes of patients following hysteroscopic treatment for Asherman syndrome (AS) differ from that of a control population?

SUMMARY ANSWER

Perinatal complications including placental issues, high blood loss, and prematurity in women after treatment for AS should be considered as moderate to high risk, especially in patients who have undergone more than one hysteroscopy (HS) or repeated postpartum instrumental revisions of the uterine cavity (Dilation and Curettage; D&C).

WHAT IS KNOWN ALREADY

The detrimental impact of AS on obstetrics outcomes is commonly recognized. However, prospective studies evaluating perinatal/neonatal outcomes in women with AS history are sparse, and the characteristics accounting for the respective morbidity of AS patients remain to be elucidated.

STUDY DESIGN, SIZE, DURATION

We conducted a prospective cohort study utilizing data from patients who underwent HS treatment for moderate to severe AS in a single tertiary University-affiliated hospital (enrolled between 01 January 2009 and March 2021), and who consequently conceived and progressed to at least 22nd gestational week of pregnancy. Perinatal outcomes were compared to a control population without an AS history, retrospectively enrolled concomitantly at the time of delivery for each patient with AS. Maternal and neonatal morbidity was assessed as well as the characteristics-related risk factors of AS patients.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Our analytic cohort included a total of 198 patients, 66 prospectively enrolled patients with moderate to severe AS and 132 controls. We used multivariable logistic regression to calculate a propensity score to match 1-1 women with and without AS history based on demographic and clinical factors. After matching, 60 pairs of patients were analysed. Chi-square test was used to compare perinatal outcomes between the pairs. Spearman's correlation analysis was utilized to investigate the correlation between perinatal/neonatal morbidity and the characteristics-related factors of AS patients. The odds ratio (OR) for the associations was calculated by logistic regression.

MAIN RESULTS AND THE ROLE OF CHANCE

Among the 60 propensity matched pairs, the AS group more frequently experienced overall perinatal morbidity, including abnormally invasive placenta (41.7% vs 0%; P < 0.001), retained placenta requiring manual or surgical removal (46.7% vs 6.7%; P < 0.001), and peripartum haemorrhage occurrence (31.7% vs 3.3%; P < 0.001). Premature delivery (<37 gestational weeks) was reported more frequently also for patients with AS (28.3% vs 5.0%; P < 0.001). However, no increased frequency of intra-uterine growth restriction or worsened neonatal outcomes were observed in AS group. Univariable analysis of risk factors for AS group morbidity outcomes revealed that the main factor related to abnormally invasive placenta was two or more HS procedures (OR 11.0; 95% CI: 1.33-91.23), followed by two or more D&Cs preceding AS treatment (OR 5.11; 95% CI: 1.69-15.45), and D&C performed postpartum as compared to post abortion (OR 3.0; 95% CI: 1.03-8.71). Similarly, two or more HS procedures were observed as the most important factor for retained placenta (OR 13.75; 95% CI: 1.66-114.14), followed by two or more preceding D&Cs (OR 5.16; 95% CI: 1.67-15.9). Premature birth was significantly associated with the number of preceding D&Cs (OR for two or more, 4.29; 95% CI: 1.12-14.91).

LIMITATIONS, REASONS FOR CAUTION

Although the cohort of patients with AS was enrolled prospectively, a baseline imbalance was intrinsically involved in the retrospective enrolment of the control group. However, to reduce the risk of bias, confounding factors were adjusted for using propensity score matching. The limitation to the generalization of our reported results is the single institution design in which all patients were treated for AS in one tertiary medical centre.

WIDER IMPLICATIONS OF THE FINDINGS

Within our search scope, our study represents one of the first and largest prospective studies of perinatal and neonatal outcomes in moderate to severe AS patients with a prospectively analysis of the risks factors of characteristics significantly influencing reported morbidities among patients with AS.

STUDY FUNDING/COMPETING INTEREST(S)

The study was supported by the Charles University in Prague [UNCE 204065] and by the institutional grant of The General Faculty Hospital in Prague [00064165]. No competing interests were declared.

TRIAL REGISTRATION NUMBER

N/A.

The link between intrauterine adhesions and impaired reproductive performance: a systematic review of the literature

Background

Intrauterine adhesions (IUAs) are one of the main reproductive system diseases in women worldwide. Fusion between the injured opposing walls leads to partial-to-complete obliteration of the cavity and/or cervical canal. The main clinical manifestations in case of IUAs are menstrual disturbances, cyclic pain and reproductive disorders. The reproductive outcomes of women with IUAs remain limited and inefficient compared to women without IUAs, even after adhesiolysis. An exact understanding of the underlying mechanisms and processes to explain the compromised reproductive performance and outcomes in case of IUAs are lacking.

Methods

A systematic literature review of MEDLINE-PubMed (1966 to January 2022) and EMBASE (1974 to January 2022) was performed following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Studies were included if they reported underlying causes, related mechanisms and processes to explain the association between IUAs and impaired reproductive performance, pregnancy and obstetric complications.

Results

After an extensive review of the literature, 58 articles were identified reporting underlying mechanisms to explain the association between IUAs and impaired fertility. Intrauterine scarring influences the process of fertilization, reproductive performance and ultimately reproductive outcome. IUAs can disturb the cervico-utero-tubal sperm transport and result in an avascular and unresponsive endometrium with decreased receptivity and thickness. Abnormal decidualization and abnormal trophoblastic infiltration leads to placental attachment disorders. Moreover, the risk for premature delivery, intrauterine fetal growth restriction and fetal anomalies is increased in case of IUAs.

Conclusion

The impact of IUAs on reproductive performance, even after adhesiolysis, is becoming more apparent. The postulated mechanisms to explain the association are related to sperm transport, embryo implantation and placentation. Prevention, by preserving the basal layer of the endometrium is essential. Effective and evidence-based strategies for the prevention of endometrial injury and formation of IUAs, are urgently needed.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-022-05164-2.

An Acellular Scaffold Facilitates Endometrial Regeneration and Fertility Restoration via Recruiting Endogenous Mesenchymal Stem Cells

Severe intrauterine adhesions (IUAs), characterized by inadequate endometrial repair and fibrosis, can lead to infertility. Stem cell-based therapies, which deliver mesenchymal stem cells (MSCs) to the wound site, hold a considerable promise for endometrium regeneration. However, some notable hurdles, such as stemness loss, immunogenicity, low retention and survival rate, limit their clinical application. Evidence shows a strategy of mobilizing endogenous MSCs recruitment can overcome the traditional limitations of exogenous stem cell-based therapies. Here, an acellular biomaterial named stromal derived factor-1 alpha (SDF-1α)/E7-modified collagen scaffold (CES) is explored. CES based on harnessing the innate regenerative potential of the body enables near-complete endometrium regeneration and fertility restoration both in a rat endometrium acute damage model and a rat IUA model. Mechanistically, the CES implantation promotes endogenous MSCs recruitment via a macrophage-coordinated strategy; then the homing MSCs exert the function of immunomodulation and altered local microenvironments toward regeneration. To conclude, CES, which can harness endogenous MSCs and overcome the traditional limitations of cell-based therapies, can serve as a clinically feasible and cell-free strategy with high therapeutic efficiency for IUA treatment.

In situ delivery of apoptotic bodies derived from mesenchymal stem cells via a hyaluronic acid hydrogel: A therapy for intrauterine adhesions

Stem cell-based and stem cell-derived exosome-based therapies have shown promising potential for endometrial regeneration and the clinical treatment of intrauterine adhesions (IUAs). Evidence shows that apoptosis occurs in a majority of grafted stem cells, and apoptotic bodies (ABs) play a critical role in compensatory tissue regeneration. However, the therapeutic potential of AB-based therapy and its mechanism have not been explored in detail. Here, a cell-free therapeutic strategy was developed by incorporating mesenchymal stem cell-derived ABs into a hyaluronic acid (HA) hydrogel to achieve endometrial regeneration and fertility restoration. Specifically, we found that the ABs could induce macrophage immunomodulation, cell proliferation, and angiogenesis in vitro. The HA hydrogel promoted the retention of ABs and facilitated their continuous release. In a murine model of acute endometrial damage and a rat model of IUAs, in situ injection of the AB-laden HA hydrogel could efficiently reduce fibrosis and promote endometrial regeneration, resulting in the fertility restoration. Consequently, ABs show good potential as therapeutic vesicles, and the AB-laden HA hydrogel appears to be a clinically feasible and cell-free alternative for endometrial regeneration and IUA treatment.

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Human umbilical cord derived apoptotic bodies induce macrophage immunomodulation, cell proliferation and angiogenesis

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A strategy of apoptotic bodies associated with hyaluronic acid hydrogel promotes apoptotic bodies retention and continuous release

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The implantation of the apoptotic body-laden hyaluronic acid hydrogel into uterine cavity effectively promoted endometrial regeneration and fertility restoration in a rodent model of intrauterine adhesion

Safety and efficacy of manual vacuum aspiration under local anesthesia compared to general anesthesia in the surgical management of miscarriage: a retrospective cohort study

Background

In Japan, dilatation & curettage (D&C) has been performed under general anesthesia as a surgery for an early pregnancy miscarriage for a long time. In 2016, manual vacuum aspiration (MVA) under general anesthesia was introduced at our hospital and has been used as a surgical treatment for first-trimester pregnancy miscarriage, with its utility to date being reported here. In July 2018, our hospital introduced the MVA procedure under local anesthesia. In this study, we evaluated the efficacy and safety of MVA under general and local anesthesia in first-trimester pregnancy miscarriage surgery in Japanese women.

Methods

In this retrospective observational cohort study, we enrolled 322 pregnant women at less than 12 weeks of gestation, who underwent MVA surgery under local anesthesia (n = 166) or conventional general anesthesia (n = 156). The duration of surgery, blood loss volume, quantity of anesthesia, presence or absence of retained products of conception, and clinical complications were evaluated. In addition, the intraoperative pain and treatment satisfaction were assessed using the visual analog scale (VAS).

Results

The duration of surgery was significantly shorter in the local anesthesia group. No significant differences were observed between both groups in terms of the blood loss volume and incidence of retained products of conception. In addition, no serious complications were observed in either group. No significant differences were noted between the two groups in the VAS scores for pain and treatment satisfaction.

Conclusions

In this retrospective study, the use of MVA under local anesthesia for early pregnancy miscarriage surgery was found to be equally safe and effective when performed under conventional general anesthesia. This technique allowed the achievement of appropriate pain control with excellent patient satisfaction.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13037-022-00328-7.

Reproductive outcomes and reproductive tract microbiota shift in women with moderate-to-severe intrauterine adhesions following 30-day post-hysteroscopic placement of balloon stents or intrauterine contraceptive devices: A randomized controlled trial

BACKGROUND

Intrauterine adhesions (IUA) develop in up to 20% of women with a history of abortion. After hysteroscopic adhesiolysis, balloon stents are usually placed for seven days to prevent recurrence. The efficacy of prolonged use (30 days) of balloon stents has not been determined.

METHODS

The trial was conducted from June 2019 to March 2021. Ninety-one patients who underwent hysteroscopic adhesiolysis for moderate or severe IUA were randomized to receive a 30-day placement of a balloon stent (n = 44) or an intrauterine device (IUD) (n = 47). The primary outcomes were the ongoing pregnancy and miscarriage rates assessed at 15-19 months. The secondary outcomes were the recurrence of IUA and the American Fertility Society (AFS) intrauterine adhesion scores at the first and second hysteroscopies, the diagnosis of new chronic endometritis at the second-look hysteroscopy, and the vaginal/uterine microbiome assessed using 16S rRNA sequencing. The trial was registered at Chinese Clinical Trial Registry (ChiCTR1900023306).

FINDINGS

The ongoing pregnancy rates (balloon 56·4% versus IUD 57·1%) and miscarriage rates (balloon 10·3% versus IUD 22·9%) were not significantly different between the groups. No differences in the recurrence of IUA, reduction of AFS scores, or new endometritis rates were detected. The bacterial load in the uterus and vagina increased in the IUD group but not in the balloon group.

INTERPRETATION

Balloon placement has a similar effect on ongoing pregnancy rates as intrauterine device (IUD) placement. Patients who underwent balloon placement had a lower miscarriage rate, although the difference was not significant. There were no differences in the recurrence rate of IUA, reduction of American Fertility Society scores, or rate of new chronic endometritis. The balloon stent has less effects on the uterine microbiota.

FUNDING

National Natural Science Foundation of China (81802593).

Making More Womb: Clinical Perspectives Supporting the Development and Utilization of Mesenchymal Stem Cell Therapy for Endometrial Regeneration and Infertility

The uterus is a homeostatic organ, unwavering in the setting of monthly endometrial turnover, placental invasion, and parturition. In response to ovarian steroid hormones, the endometrium autologously prepares for embryo implantation and in its absence will shed and regenerate. Dysfunctional endometrial repair and regeneration may present clinically with infertility and abnormal menses. Asherman's syndrome is characterized by intrauterine adhesions and atrophic endometrium, which often impacts fertility. Clinical management of infertility associated with abnormal endometrium represents a significant challenge. Endometrial mesenchymal stem cells (MSC) occupy a perivascular niche and contain regenerative and immunomodulatory properties. Given these characteristics, mesenchymal stem cells of endometrial and non-endometrial origin (bone marrow, adipose, placental) have been investigated for therapeutic purposes. Local administration of human MSC in animal models of endometrial injury reduces collagen deposition, improves angiogenesis, decreases inflammation, and improves fertility. Small clinical studies of autologous MSC administration in infertile women with Asherman's Syndrome suggested their potential to restore endometrial function as evidenced by increased endometrial thickness, decreased adhesions, and fertility. The objective of this review is to highlight translational and clinical studies investigating the use of MSC for endometrial dysfunction and infertility and to summarize the current state of the art in this promising area.

Recent developments in bio-scaffold materials as delivery strategies for therapeutics for endometrium regeneration

Intrauterine adhesions (IUAs) refer to the repair disorder after endometrial injury and may lead to uterine infertility, recurrent miscarriage, abnormal menstrual bleeding, and other obstetric complications. It is a pressing public health issue among women of childbearing age. Presently, there are limited clinical treatments for IUA, and there is no sufficient evidence that these treatment modalities can effectively promote regeneration after severe endometrial injury or improve pregnancy outcome. The inhibitory pathological micro-environment is the main factor hindering the repair of endometrial damaged tissues. To address this, tissue engineering and regenerative medicine have been achieving promising developments. Particularly, biomaterials have been used to load stem cells or therapeutic factors or construct an in situ delivery system as a treatment strategy for endometrial injury repair. This article comprehensively discusses the characteristics of various bio-scaffold materials and their application as stem cell or therapeutic factor delivery systems constructed for uterine tissue regeneration.

Identifying the risk factors and incidence of Asherman Syndrome in women with post-abortion uterine curettage

AIM

To evaluate the risk factors and incidence of Asherman Syndrome in women with post-abortion uterine evacuation and curettage.

METHODS

A total of 2546 patients who had surgical abortion (uterine evacuation and curettage) before the 20th gestational week with indications of missed abortion, anembryonic pregnancy, incomplete abortion, and elective curettage in a tertiary antenatal care center were recruited. The patients were called and surveyed for their symptoms; including infertility, oligo-amenorrhea and recurrent pregnancy loss, preterm birth and intrauterine growth retardation and abnormal placentation as criteria of Asherman Syndrome. Diagnostic (office) hysteroscopy was performed for 177 who had one of those complaints.

RESULTS

The incidence of Asherman Syndrome was 1.6% (n = 43/2546). History of ≥3 abortions was the main factor that increased the risk of Asherman Syndrome for by 4.6 times. Use of vacuum aspiration or sharp curettage, premedication for cervical priming, and having a pregnancy >10th gestational weeks were not risk factors for Asherman Syndrome.

CONCLUSION

When the diagnosis was based on presence of symptoms who underwent uterine instrumentation, the incidence of Asherman Syndrome was found to be 1.6%. Repeated abortions were the main risk factor for Asherman Syndrome and avoiding from repeated uterine instrumentations may have a role in prevention.

Patient-reported menstrual and obstetric outcomes following hysteroscopic adhesiolysis for Asherman syndrome

Objective

Review the menstrual and obstetric outcomes among Asherman syndrome patients when stratified by disease severity.

Design

Retrospective cohort study.

Setting

A community teaching hospital affiliated with a large academic medical center.

Patients

A total of 355 Asherman syndrome patients stratified by March classification who underwent hysteroscopic adhesiolysis.

Interventions

Telephone survey, analyzed with multivariable analysis.

Main Outcome Measures

Return of menstruation. Pregnancy, miscarriage, and live birth rate.

Results

A total of 355 patients underwent hysteroscopic adhesiolysis. Of these, 150 (42.3%) patients completed the telephone survey with a mean follow-up of 2.21 years. Additionally, 40.7% had mild, 52.7% had moderate, and 6.6% had severe disease. Furthermore, 25.3% of patients reported amenorrhea at presentation, with mild disease patients having the highest rate of returning menstruation (93.8%) following treatment. The cumulative pregnancy rate was 81.9%, and the cumulative live birth rate was 51.2%, with no statistical differences identified by the classification group.

Conclusion

Asherman syndrome disease severity predicted returning menstruation but not pregnancy or live birth rate.

Mini-Review of the New Therapeutic Possibilities in Asherman Syndrome-Where Are We after One Hundred and Twenty-Six Years?

Asherman syndrome is a multifaceted condition describing the partial or complete removal of the uterine cavity and/or cervical canal. It is a highly debatable topic because of its pronounced influence on both reproductive outcomes and gynaecologic symptoms. The latest reports demonstrated that trauma to the endometrium is the main cause of intrauterine adhesion formation. Left untreated, such adhesions gradually lead to a range of repercussions ranging from mild to severe. Considering the lack of non-invasive approaches, the advent of hysteroscopy has revolutionized the entire field, being otherwise considered the most efficient tool offering new directions and amplifying the chances of treating the Asherman syndrome.

Asherman's Syndrome: it may not be all our fault

Asherman's Syndrome (AS) is an acquired condition defined by the presence of intrauterine adhesions (IUA) that cause symptoms such as menstrual abnormalities, pelvic pain, infertility, recurrent miscarriage, abnormal placentation and attendant psychological distress. Classically, AS is considered an iatrogenic disease triggered by trauma to the pregnant uterus. Different factors can cause the destruction of the endometrium, thus affecting the endometrial stem cell niche and creating IUAs. Curettage of the pregnant uterus appears to be the most common source of this destruction. Nevertheless, some AS cases have been associated with congenital uterine abnormalities and infections, and there are some idiopathic cases without any prior surgical procedures, suggesting a putative constitutional predisposition to IUA. Factors reported to cause AS share an underlying inflammatory mechanism leading to defective endometrial healing and vascularization. Interestingly, distinct genetic profiles have been observed in the endometrium of AS patients. These data suggest that AS might not just be an iatrogenic complication, but also the result of a genetic predisposition. Elucidating the possible physiopathological processes that contribute to AS will help to identify patients at risk for this condition, providing an opportunity for prevention.

Foxf2 and Smad6 co-regulation of collagen 5A2 transcription is involved in the pathogenesis of intrauterine adhesion

The replacement of normal endometrial epithelium by fibrotic tissue is the pathological feature of intrauterine adhesion (IUA), which is caused by trauma to the basal layer of the endometrium. COL5A2 is a molecular subtype of collagen V that regulates collagen production in fibrotic tissue. Here, we investigated the roles of Foxf2 and Smad6 in regulating the transcription of COL5A2 and their involvement in the pathogenesis of IUA. Small interference‐mediated Foxf2 (si‐Foxf2) silencing and pcDNA3.1‐mediated Smad6 (pcDNA3.1‐Smad6) up‐regulation were performed in a TGF‐β1‐induced human endometrial stromal cell line (HESC) fibrosis model. Assessment of collagen expression by Western blotting, immunofluorescence and qRT‐PCR showed that COL5A2, COL1A1 and FN were significantly down‐regulated in response to si‐Foxf2 and pcDNA3.1‐Smad6. Transfection of lentivirus vector‐Foxf2 (LV‐Foxf2) and pcDNA3.1‐Smad6 into HESCs and qRT‐PCR showed that Foxf2 promoted COL5A2 expression and Smad6 inhibited Foxf2‐induced COL5A2 expression. Co‐immunoprecipitation, chromatin immunoprecipitation and dual‐luciferase reporter assays to detect the interaction between Foxf2 and Smad6 and their role in COL5A2 transcription showed that Foxf2 interacted with Smad6 and bond the same promoter region of COL5A2. In a rat IUA model, injection of ADV2‐Foxf2‐1810 and ADV4‐Smad6 into the uterine wall showed that Foxf2 down‐regulation and Smad6 up‐regulation decreased fibrosis and the expression of COL5A2 and COL1A1, as detected by haematoxylin/eosin, Masson trichrome staining and immunohistochemistry. Taken together, these results suggested that Foxf2 interacted with Smad6 and co‐regulated COL5A2 transcription in the pathogenesis of IUA, whereas they played opposite roles in fibrosis.

Establishment of an animal model of intrauterine adhesions after surgical abortion and curettage in pregnant rats

Background

Intrauterine adhesion (IUA), also referred to as Asherman syndrome, is a complication with partial or complete adhesion of the uterine cavity due to fibrotic proliferation after endometrial and uterine wall injury of the newly pregnant uterus. Currently, all IUA research models are based on non-pregnant animals which are ill-suited in mimicking its pathogenesis. This study aimed to establish an animal IUA model caused by surgical abortion and curettage in pregnant rats that is more in line with clinical etiology, and to provide a more ideal animal model for further exploration of the pathogenesis and treatment for IUA.

Methods

Fifteen, 13-to-15-day pregnant Sprague-Dawley (SD) rats aged 10 weeks were selected. After incising and removing the embryos, we randomly selected one side of the uterine cavity as the study group (n=15) and scraped it with a curette; the contralateral side of the uterine cavity that underwent no special procedures was used for inclusion in the control group (n=15). Five rats were euthanized and dissected on the 3rd, 7th, and 14th day after surgery respectively. The changes in tissue morphology, the number of endometrial glands, the ratio of endometrial fibrotic area, and the expression level of the transforming growth factor beta (TGF-β) in the endometrium were compared between the 2 groups.

Results

The endometrial granular cell number in the study group on the 7th and 14th day postoperatively was 3.87±0.72 & 2.59±0.90 in each visual field (×100) respectively, which was significantly lower than that of the control group (6.48±0.96 & 7.53±1.10; P<0.05). The ratio of the endometrial stromal fibrotic area in the study group was significantly higher than that of the control group post-operatively on the 3rd day (0.0974±0.0430 vs. 0.0584±0.05110), 7th day (0.1551±0.0348 vs. 0.0328±0.0152), and 14th day (0.1518±0.0477 vs. 0.0311±0.0128) (P<0.05). The endometrial TGF-β expression in the study group was positive on the 14th day postoperatively while weakly expressed in the control group, and the integrated optical density (IOD) value (5,608.8±2,887.3) was higher than that of the control group (388.3±98.6) (P<0.05). The endometrial TGF-β expression in the study group and control group was relatively weak on the 3rd and 7th day after surgery, and there was no significant difference when compared with that of the control group (P>0.05).

Conclusions

The establishment of an animal model of IUA after surgical abortion and curettage in pregnant rats was successful and is thus feasible for further studies; the model may be a more effective mimic for the generation of human IUA.

Using 17β-estradiol heparin-poloxamer thermosensitive hydrogel to enhance the endometrial regeneration and functional recovery of intrauterine adhesions in a rat model

Mechanical damage or infection to the endometrium can lead to the formation of adhesions in the uterine cavity, which may result in reduced reproductive outcome and/or pregnancy complications. The prognosis of this disease is poor due to few effective treatments and the complex environment of endometrium. Heparin-Poloxamer Hydrogel (HP hydrogel) is a nontoxic and biodegradable biomaterial, which has been commonly used as a sustained-release delivery system. In this study, we applied a mini-endometrial curette to scrape the endometrium of rats to mimic the process of curettage in patients. After the establishment of IUA model in rats, we injected the thermo-sensitive hydrogel(E₂-HP hydrogel) into the injured uterine cavity and evaluated the therapeutic effect of E₂-HP hydrogel on the recovery of IUA. Our results showed that E₂-HP hydrogel can significantly facilitate the regeneration of injured endometrium along with inhibiting the cell apoptosis in IUA model. Furthermore, we revealed that E₂-HP hydrogel on the recovery of IUA was closely associated with the upregulation of kisspeptin through activating the ERK1/2 and MAPKs p38 pathways. In conclusion, E₂-HP hydrogel can effectively transfer E₂ into the injured endometrium and it can be considered as a promising therapeutic method for the women with intrauterine adhesions.

No. 360-Induced Abortion: Surgical Abortion and Second Trimester Medical Methods

OBJECTIVE

This guideline reviews evidence relating to the provision of surgical induced abortion (IA) and second trimester medical abortion, including pre- and post-procedural care.

INTENDED USERS

Gynaecologists, family physicians, nurses, midwives, residents, and other health care providers who currently or intend to provide and/or teach IAs.

TARGET POPULATION

Women with an unintended or abnormal first or second trimester pregnancy.

EVIDENCE

PubMed, Medline, and the Cochrane Database were searched using the key words: first-trimester surgical abortion, second-trimester surgical abortion, second-trimester medical abortion, dilation and evacuation, induction abortion, feticide, cervical preparation, cervical dilation, abortion complications. Results were restricted to English or French systematic reviews, randomized controlled trials, clinical trials, and observational studies published from 1979 to July 2017. National and international clinical practice guidelines were consulted for review. Grey literature was not searched.

VALUES

The quality of evidence in this document was rated using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology framework. The summary of findings is available upon request.

BENEFITS, HARMS, AND/OR COSTS

IA is safe and effective. The benefits of IA outweigh the potential harms or costs. No new direct harms or costs identified with these guidelines.

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

Transcervical resection of adhesion (TCRA) is the standard treatment for the intrauterine adhesions, but the recurrence of adhesions is a tough problem for the gynecologist. In addition, the therapeutic strategy after TCRA about prevention of recurrence remains controversial especially for the patients with moderate to severe intrauterine adhesions (IUAs). Hence, we designed this study to explore the safety and efficacy of fresh amnion grafts for preventing the recurrence after TCRA for patients with moderate to severe IUAs. One hundred patients with moderate to severe IUAs who presented with a history of hypomenorrhea, amenorrhea and infertility were included in the study from January 2015 to December 2017. Patients were divided into amnion group (52 patients) and chitosan group (48 patients). Fresh amnion grafts or intrauterine injections of chitosan were administered after TCRA. Transvaginal ultrasonography (TVUS) and hysteroscopy were performed at the first and third month after the operation. The surgical procedures for all patients were completed successfully without relevant complications. In amnion group, 8 patients exhibited relapse in the first month and 2 patients in three months after surgery; in chitosan group, 23 women exhibited relapse in the first month and 18 patients in three months after surgery. Statistical analysis revealed that the recurrence rate of adhesion in amnion group was significantly lower than those of chitosan group in the first and three months after surgery (P ₁  = 0.000, P ₂  = 0.000). After TCRA, fresh amnion graft plays a significant role in preventing further adhesions than injections of chitosan.

Efficacy of a New Crosslinked Hyaluronan Gel in the Prevention of Intrauterine Adhesions

Background and Objectives:

The authors sought to assess the effect of the use of a new crosslinked hyaluronan (NCH) gel on the prevention of intrauterine adhesions (IUAs) in women underwent curettage in the second trimester.

Methods:

Between June 2016 and September 2017, 60 patients who underwent curettage for retained placental tissue after medically induced or spontaneous pregnancy loss in the second trimester were enrolled in the study. The patients were randomly assigned to 1 of 2 groups: Group 1 patients received curettage plus NCH gel (intervention group), and group 2 patients received curettage alone (control group). The main outcomes were the rate and severity of IUA formation, which were assessed by follow-up hysteroscopy performed in the ensuing 2–6 months.

Results:

The hysteroscopic findings were available for 20 patients in group 1 and 28 patients in group 2. IUAs were observed in 6 patients in group 2, while no IUAs was observed in group 1 (P = .007). IUAs were staged as mild in 4 patients (14.28%) and moderate in 2 patients (7.14%) in group 2 according to the American Fertility Society classification of IUAs.

Conclusions:

Our study demonstrates that NCH gel appears to be able to reduce the formation of IUAs in women who undergo curettage in the second trimester, although larger controlled, randomized, multicenter studies are needed to confirm these results.

A comprehensive review of Asherman's syndrome: causes, symptoms and treatment options

PURPOSE OF REVIEW

Intrauterine adhesions, also known as Asherman's syndrome, can have an impact on both reproductive outcomes and gynaecologic symptoms. Understanding the cause of intrauterine adhesions and the common clinical presentation will increase awareness of the condition and guide the patient to appropriate therapy. Surgical management offers favourable fertility outcomes and is often successful in restoring menstruation.

RECENT FINDINGS

Surgical management with hysteroscopic lysis of adhesions is the gold standard for treatment and adopting an office-based approach offers several advantages. Prevention of reformation of adhesions remains challenging and no single method for preventing recurrence has shown superiority. Cell-based therapies using endometrial stem/progenitor cells hold promise for future use in regenerating inadequate endometrium.

SUMMARY

Increased awareness of the symptoms suggestive of intrauterine adhesive disease, as well as recognition of common causes and preceding events, is crucial for early diagnosis, patient counselling and treatment. VIDEO ABSTRACT: http://links.lww.com/COOG/A36.

Office Operative Hysteroscopy: An Update

Hysteroscopy is considered the gold standard for the evaluation of intracavitary pathology in both premenopausal and postmenopausal patients associated with abnormal uterine bleeding, as well as for the evaluation of infertile patients with suspected cavity abnormalities. Office-based operative hysteroscopy allows patients to resume activities immediately and successfully integrates clinical practice into a "see and treat" modality, avoiding the added risks of anesthesia and the inconvenience of the operating room. For 2017, the Centers for Medicare and Medicaid Services has provided a substantial increase in reimbursement for a select number of office-based hysteroscopic procedures. This review provides an update on the indications, equipment, and procedures for office hysteroscopy, as well as the management of complications that may arise within an office-based practice.

Three-dimensional structure micelles of heparin-poloxamer improve the therapeutic effect of 17β-estradiol on endometrial regeneration for intrauterine adhesions in a rat model

Intrauterine adhesions (IUA) frequently occur after infectious or mechanical injury to the endometrium, which may lead to infertility and/or pregnancy complications. There are few effective treatments due to the complex function of endometrium and shortage of native materials. 17β-estradiol (E₂) is commonly used as an ancillary treatment in IUA patients, but it is limited by its poor solubility in aqueous solutions and low concentrations at the injured sites. In this research, a mini-endometrial curette was used to injure the rat’s endometrium to form an IUA model. 17β-estradiol was encapsulated into the micelles of heparin-poloxamer and a thermosensitive hydrogel (E₂-HP hydrogel) was formed. This sustained releasing system was applied to restore the structure and function of the injured uterus. E₂-HP hydrogel was constructed and relevant characteristics including gelation temperature and micromorphology were evaluated. Sustained release of 17β-estradiol from HP hydrogel was performed both in vitro and in vivo. Ultrasonography measurement and pathologic characteristics on the IUA rats were performed to evaluate the therapeutic effect of E₂-HP hydrogel. Endoplasmic reticulum (ER) stress-related apoptosis was analyzed to explore the possible mechanisms in IUA recovery. E₂-HP hydrogel showed a prolonged release of E₂ at the targeting region and more effective endometrium regeneration in IUA rats. Significant improvements in both gland numbers and fibrosis area were observed in the E₂-HP hydrogel group. We also demonstrated that E₂-HP hydrogel in the recovery of IUA was closely related to the suppression of ER stress signals via the activation of downstream signals, PI3K/Akt and ERK1/2. HP hydrogel might be an effective approach to deliver E₂ into the injured endometrium. Therapeutic strategies targeting ER stress using E₂-HP hydrogel might be a promising solution for the treatment of women with intrauterine adhesions.

Human amniotic mesenchymal stromal cell transplantation improves endometrial regeneration in rodent models of intrauterine adhesions

BACKGROUND AIMS

Intrauterine adhesion (IUA) is a common uterine cavity disease characterized by the unsatisfactory regeneration of damaged endometria. Recently, stem cell transplantation has been proposed to promote the recovery process. Here we investigated whether human amniotic mesenchymal stromal cells (hAMSCs), a valuable resource for transplantation therapy, could improve endometrial regeneration in rodent IUA models.

METHODS

Forty female Sprague-Dawley rats were randomly assigned to five groups: normal, sham-operated, mechanical injury, hAMSC transplantation, and negative control group. One week after intervention and transplantation, histological analyses were performed, and immunofluorescent and immunohistochemical expression of cell-specific markers and messenger RNA expression of cytokines were measured.

RESULTS

Thicker endometria, increased gland numbers and fewer fibrotic areas were found in the hAMSC transplantation group compared with the mechanical injury group. Engraftment of hAMSCs was detected by the presence of anti-human nuclear antigen-positive cells in the endometrial glands of the transplantation uteri. Transplantation of hAMSCs significantly decreased messenger RNA levels of pro-inflammatory cytokines (tumor necrosis factor-α and interleukin-1β), and increased those of anti-inflammatory cytokines (basic fibroblast growth factor, and interleukin-6) compared with the injured uterine horns. Immunohistochemical expression of endometrial epithelial cells was revealed in specimens after hAMSC transplantation, whereas it was absent in the mechanically injured uteri.

CONCLUSIONS

hAMSC transplantation promotes endometrial regeneration after injury in IUA rat models, possibly due to immunomodulatory properties. These cells provide a more easily accessible source of stem cells for future research into the impact of cell transplantation on damaged endometria.