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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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Cheng M, Chang WH, Yang ST, Huang HY, Tsui KH, Chang CP, Lee WL, Wang PH. Efficacy of Applying Hyaluronic Acid Gels in the Primary Prevention of Intrauterine Adhesion after Hysteroscopic Myomectomy: A Meta-Analysis of Randomized Controlled Trials. Life (Basel) 2020; 10:life10110285. [PMID: 33203159 PMCID: PMC7697815 DOI: 10.3390/life10110285] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Revised: 11/12/2020] [Accepted: 11/13/2020] [Indexed: 12/15/2022] Open
Abstract
Intrauterine adhesion (IUA), which mainly occurs after intrauterine surgery or an inflammatory process, is an important but often neglected condition in women of reproductive age. The presentation of IUA varies greatly, ranging from symptom-free to severe, with amenorrhea or infertility. With much advanced development of intrauterine instruments, more intrauterine diseases can be successfully cured by hysteroscopic surgery. Among these, submucosal myoma is one of the best examples. Submucosal myomas are often related to abnormal bleeding, anemia, and possible infertility or miscarriage. However, submucosal myoma after hysteroscopic myomectomy may be complicated by IUA in various grades of severity, and its incidence and prevalence might be nearly one-quarter to one-third of patients, suggesting an urgent need for efforts to decrease the risk of developing IUA after hysteroscopic myomectomy. Many strategies have been reported to be useful for this purpose, and intrauterine application of anti-adhesive gels, such as polyethylene oxide–sodium carboxymethylcellulose (PEO-NaCMC) or auto-crosslinked hyaluronic acid (ACHA), has become increasingly popular in routine clinical practice. This meta-analysis is aimed at investigating the effect of ACHA on the primary prevention of IUA formation after hysteroscopic myomectomy. A pooled analysis of three studies (hysteroscopic surgeries for fibroids, polyps, and septum) including 242 women showed that using PEO-NaCMC or ACHA gel decreased the IUA rate with an odds ratio (OR) of 0.364 (95% confidence interval (CI) 0.189–0.703, p = 0.03). Pooled analysis of two studies that limited the use of ACHA in 119 women showed that the application of ACHA gel for the primary prevention of IUA in patients after hysteroscopic myomectomy led to a statistically significant reduction of the development of IUA postoperatively (OR 0.285, 95% CI 0.116–0.701, p = 0.006). All of this suggests that the use of ACHA gel in patients after hysteroscopic myomectomy could significantly reduce de novo IUA, although more evidence is needed.
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Affiliation(s)
- Min Cheng
- Department of Obstetrics and Gynecology, Taipei Veterans General Hospital, Taipei 112, Taiwan; (M.C.); (W.-H.C.); (S.-T.Y.); (C.-P.C.)
- Institute of Clinical Medicine, National Yang-Ming University, Taipei 112, Taiwan;
- Department of Obstetrics and Gynecology, National Yang-Ming University, Taipei 112, Taiwan
| | - Wen-Hsun Chang
- Department of Obstetrics and Gynecology, Taipei Veterans General Hospital, Taipei 112, Taiwan; (M.C.); (W.-H.C.); (S.-T.Y.); (C.-P.C.)
- Institute of Clinical Medicine, National Yang-Ming University, Taipei 112, Taiwan;
- Department of Nursing, Taipei Veterans General Hospital, Taipei 112, Taiwan
| | - Szu-Ting Yang
- Department of Obstetrics and Gynecology, Taipei Veterans General Hospital, Taipei 112, Taiwan; (M.C.); (W.-H.C.); (S.-T.Y.); (C.-P.C.)
- Institute of Clinical Medicine, National Yang-Ming University, Taipei 112, Taiwan;
- Department of Obstetrics and Gynecology, National Yang-Ming University, Taipei 112, Taiwan
| | - Hsin-Yi Huang
- Biostatics Task Force, Taipei Veterans General Hospital, Taipei 112, Taiwan;
| | - Kuan-Hao Tsui
- Institute of Clinical Medicine, National Yang-Ming University, Taipei 112, Taiwan;
- Department of Obstetrics and Gynecology, National Yang-Ming University, Taipei 112, Taiwan
- Department of Obstetrics and Gynecology, Kaohsiung Veterans General Hospital, Kaohsiung 813, Taiwan
- Department of Pharmacy and Master Program, College of Pharmacy and Health Care, Tajen University, Pingtung County 907, Taiwan
| | - Chia-Pei Chang
- Department of Obstetrics and Gynecology, Taipei Veterans General Hospital, Taipei 112, Taiwan; (M.C.); (W.-H.C.); (S.-T.Y.); (C.-P.C.)
- Institute of Clinical Medicine, National Yang-Ming University, Taipei 112, Taiwan;
- Department of Obstetrics and Gynecology, National Yang-Ming University, Taipei 112, Taiwan
| | - Wen-Ling Lee
- Institute of Clinical Medicine, National Yang-Ming University, Taipei 112, Taiwan;
- Department of Medicine, Cheng-Hsin General Hospital, Taipei 112, Taiwan
- Department of Nursing, Oriental Institute of Technology, New Taipei City 220, Taiwan
- Correspondence: (W.-L.L.); (P.-H.W.); Tel.: +886-2-2873-4400 (W.-L.L.); +886-2-2875-7566 (P.-H.W.)
| | - Peng-Hui Wang
- Department of Obstetrics and Gynecology, Taipei Veterans General Hospital, Taipei 112, Taiwan; (M.C.); (W.-H.C.); (S.-T.Y.); (C.-P.C.)
- Institute of Clinical Medicine, National Yang-Ming University, Taipei 112, Taiwan;
- Department of Obstetrics and Gynecology, National Yang-Ming University, Taipei 112, Taiwan
- Cancer Female Foundation, Taipei 104, Taiwan
- Department of Medical Research, China Medical University Hospital, Taichung 404, Taiwan
- Correspondence: (W.-L.L.); (P.-H.W.); Tel.: +886-2-2873-4400 (W.-L.L.); +886-2-2875-7566 (P.-H.W.)
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