Abstract
Purpose
Recurrence of adhesions after hysteroscopic adhesiolysis is a challenging clinical problem without a unified management approach. Therefore, we conducted a network meta-analysis that considered both direct and indirect comparisons between interventions to identify optimal strategies for preventing recurrence.
Methods
We searched for research trials published up to July 2023 from PubMed, Embase and the Cochrane Database. We selected randomized controlled trials comparing the use of different interventions for the prevention of adhesion recurrence, with no language or regional restrictions. We used random-effects models to assess odds ratios (OR) and mean difference (MD) with 95% confidence intervals (CI). Adverse events associated with the interventions were also assessed. This study was registered on PROSPERO, CRD42023449068.
Results
Data from 21 randomized controlled trials involving 2406 patients were synthesized, including interventions with balloon, amnion, platelet-rich plasma (PRP), intrauterine device (IUD), hyaluronic acid (HA), platelet-rich fibrin (PRF), and granulocyte colony-stimulating factor (G-CSF). The top 5 interventions for change in AFS scores were: PRP + Balloon (MD = 5.44; 95% CI, 2.63–8.25), Amnion + Balloon (MD = 5.08; 95% CI, 2.71–7.44), IUD + Balloon (MD = 4.89; 95% CI, 2.49–7.30), HA + Balloon (MD = 3.80; 95% CI, 1.78–5.82), and G-CSF + Balloon (MD = 3.84; 95% CI, 1.05–6.63). There were no statistically significant differences between interventions in the recurrence rate of moderate-to-severe uterine adhesions and the clinical pregnancy rate. Most interventions were safe.
Conclusions
To our knowledge, this is the most comprehensive network meta-analysis to date of interventions for preventing postoperative intrauterine adhesion recurrence. Our results indicate that PRP + Balloon seems to be the most effective approach.
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Data availability
The data are derived from published studies.
References
Foix A, Bruno RO, Davison T, Lema B (1966) The pathology of postcurettage intrauterine adhesions. Am J Obstet Gynecol 96:1027–1033. https://doi.org/10.1016/0002-9378(66)90452-2
Asherman JG (1948) Amenorrhoea traumatica (atretica). J Obstet Gynaecol Br Emp 55:23–30. https://doi.org/10.1111/j.1471-0528.1948.tb07045.x
Lee WL, Liu CH, Cheng M, Chang WH, Liu WM, Wang PH (2021) Focus on the primary prevention of intrauterine adhesions: current concept and vision. Int J Mol Sci 22:5175. https://doi.org/10.3390/ijms22105175
Zhang Y, Zhu X, Zhang T, Zhang Y, Zhang M, Lin X (2022) Analysis of risk factors for obstetric outcomes after hysteroscopic adhesiolysis for Asherman syndrome: a retrospective cohort study. Int J Gynaecol Obstet 156:89–94. https://doi.org/10.1002/ijgo.13616
Surgery AEG (2017) AAGL practice report: practice guidelines on intrauterine adhesions developed in collaboration with the European Society of Gynaecological Endoscopy (ESGE). J Minim Invasive Gynecol 24:695–705. https://doi.org/10.1016/j.jmig.2016.11.008
Capella-Allouc S, Morsad F, Rongieres-Bertrand C, Taylor S, Fernandez H (1999) Hysteroscopic treatment of severe Asherman’s syndrome and subsequent fertility. Hum Reprod 14:1230–1233. https://doi.org/10.1093/humrep/14.5.1230
Hooker AB, de Leeuw RA, Emanuel MH, Mijatovic V, Brolmann HAM, Huirne JAF (2022) The link between intrauterine adhesions and impaired reproductive performance: a systematic review of the literature. BMC Pregn Childbirth 22:837. https://doi.org/10.1186/s12884-022-05164-2
Yu D, Li TC, Xia E, Huang X, Liu Y, Peng X (2008) Factors affecting reproductive outcome of hysteroscopic adhesiolysis for Asherman’s syndrome. Fertil Steril 89:715–722. https://doi.org/10.1016/j.fertnstert.2007.03.070
Yu D, Wong YM, Cheong Y, Xia E, Li TC (2008) Asherman syndrome—one century later. Fertil Steril 89:759–779. https://doi.org/10.1016/j.fertnstert.2008.02.096
Johary J, Xue M, Zhu X, Xu D, Velu PP (2014) Efficacy of estrogen therapy in patients with intrauterine adhesions: systematic review. J Minim Invasive Gynecol 21:44–54. https://doi.org/10.1016/j.jmig.2013.07.018
Ma J, Zhan H, Li W, Zhang L, Yun F, Wu R, Lin J, Li Y (2021) Recent trends in therapeutic strategies for repairing endometrial tissue in intrauterine adhesion. Biomater Res 25:40. https://doi.org/10.1186/s40824-021-00242-6
Vitale SG, Riemma G, Carugno J, Perez-Medina T, Alonso Pacheco L, Haimovich S, Parry JP, Di Spiezio Sardo A, De Franciscis P (2022) Postsurgical barrier strategies to avoid the recurrence of intrauterine adhesion formation after hysteroscopic adhesiolysis: a network meta-analysis of randomized controlled trials. Am J Obstet Gynecol 226:487–498e488. https://doi.org/10.1016/j.ajog.2021.09.015
Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, Shamseer L, Tetzlaff JM, Akl EA, Brennan SE, Chou R, Glanville J, Grimshaw JM, Hrobjartsson A, Lalu MM, Li T, Loder EW, Mayo-Wilson E, McDonald S, McGuinness LA, Stewart LA, Thomas J, Tricco AC, Welch VA, Whiting P, Moher D (2021) The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ 372:n71. https://doi.org/10.1136/bmj.n71
Sterne JAC, Savovic J, Page MJ, Elbers RG, Blencowe NS, Boutron I, Cates CJ, Cheng HY, Corbett MS, Eldridge SM, Emberson JR, Hernan MA, Hopewell S, Hrobjartsson A, Junqueira DR, Juni P, Kirkham JJ, Lasserson T, Li T, McAleenan A, Reeves BC, Shepperd S, Shrier I, Stewart LA, Tilling K, White IR, Whiting PF, Higgins JPT (2019) RoB 2: a revised tool for assessing risk of bias in randomised trials. BMJ 366:l4898. https://doi.org/10.1136/bmj.l4898
Acunzo G, Guida M, Pellicano M, Tommaselli GA, Di Spiezio Sardo A, Bifulco G, Cirillo D, Taylor A, Nappi C (2003) Effectiveness of auto-cross-linked hyaluronic acid gel in the prevention of intrauterine adhesions after hysteroscopic adhesiolysis: a prospective, randomized, controlled study. Hum Reprod 18:1918–1921. https://doi.org/10.1093/humrep/deg368
Mortada E, Ahmed MIA, Ahmed WE (2021) Platelet rich plasma following hysteroscopic adhesolysis: a randomized clinical trial. Int J Reprod Contracept Obstet Gynecol 10:433–438
Amer MI, Abd-El-Maeboud KH, Abdelfatah I, Salama FA, Abdallah AS (2010) Human amnion as a temporary biologic barrier after hysteroscopic lysis of severe intrauterine adhesions: pilot study. J Minim Invasive Gynecol 17:605–611. https://doi.org/10.1016/j.jmig.2010.03.019
Amer MIMAM-E-SKR (2018) The value of using platelet rich plasma after hysteroscopic analysis of severe intrauterine adhesions (a randomized controlled trial). Egypt J Hosp Med 71:2869–2874
Amer MGR, Oraby A, AbdelHaleem M (2021) Intrauterine use of autologous platelet-rich plasma in management of Asherman syndrome: a randomized controlled trial. Evid Based Womens Health 11:56–67
Gan L, Duan H, Sun FQ, Xu Q, Tang YQ, Wang S (2017) Efficacy of freeze-dried amnion graft following hysteroscopic adhesiolysis of severe intrauterine adhesions. Int J Gynaecol Obstet 137:116–122. https://doi.org/10.1002/ijgo.12112
Guo Y, Shi X, Song D, Liu Y, Huang X, Xiao Y, Yang L, Xia E, Li TC (2022) The efficacy of auto-cross-linked hyaluronic acid gel in addition to oestradiol and intrauterine balloon insertion in the prevention of adhesion reformation after hysteroscopic adhesiolysis. Reprod Biomed Online 45:501–507. https://doi.org/10.1016/j.rbmo.2022.04.017
Huang XW, Lin MM, Zhao HQ, Powell M, Wang YQ, Zheng RR, Ellis LB, Xia WT, Lin F (2020) A prospective randomized controlled trial comparing two different treatments of intrauterine adhesions. Reprod Biomed Online 40:835–841. https://doi.org/10.1016/j.rbmo.2020.02.013
Lin XN, Zhou F, Wei ML, Yang Y, Li Y, Li TC, Zhang SY (2015) Randomized, controlled trial comparing the efficacy of intrauterine balloon and intrauterine contraceptive device in the prevention of adhesion reformation after hysteroscopic adhesiolysis. Fertil Steril 104:235–240. https://doi.org/10.1016/j.fertnstert.2015.04.008
Mao X, Tao Y, Cai R, Zhang J, Gao H, Chen Q, Kuang Y, Zhang S (2020) Cross-linked hyaluronan gel to improve pregnancy rate of women patients with moderate to severe intrauterine adhesion treated with IVF: a randomized controlled trial. Arch Gynecol Obstet 301:199–205. https://doi.org/10.1007/s00404-019-05368-6
Pabuccu EG, Kovanci E, Sahin O, Arslanoglu E, Yildiz Y, Pabuccu R (2019) New crosslinked hyaluronan gel, intrauterine device, or both for the prevention of intrauterine adhesions. JSLS 23:e00108. https://doi.org/10.4293/JSLS.2018.00108
Shen M, Duan H, Lv R, Lv C (2022) Efficacy of autologous platelet-rich plasma in preventing adhesion reformation following hysteroscopic adhesiolysis: a randomized controlled trial. Reprod Biomed Online 45:1189–1196. https://doi.org/10.1016/j.rbmo.2022.07.003
Wang S, Duan H, Li B, Wang Y, Guo Z, Zhu X (2022) Efficacy of freeze-dried amnion grafts on cytokines in uterine exudates following hysteroscopic adhesiolysis of severe intrauterine adhesions. Int J Gen Med 15:1703–1713. https://doi.org/10.2147/IJGM.S333836
Wang X, Duan H (2016) Clinical evaluation of amniotic products after transcervical resection of intensive degree of intrauterine adhesions. Zhonghua Fu Chan Ke Za Zhi 51:27–30. https://doi.org/10.3760/cma.j.issn.0529-567X.2016.01.007
Wang Y, Zhao Y, Ge Y, Cen J, Liao Y, Xu G (2022) 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. EClinicalMedicine 43:101200. https://doi.org/10.1016/j.eclinm.2021.101200
Wang Z, Yang M, Mao L, Wang X, Wang S, Cui G, Hou Z, Yang M, Cui L, Bai W (2021) Efficacy and safety of autologous platelet-rich fibrin for the treatment of infertility with intrauterine adhesions. J Obstet Gynaecol Res 47:3883–3894. https://doi.org/10.1111/jog.14964
Wang YQ, Song XH, Wu SL, Huang YZ, Yan L, Li CZ (2020) 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 9:74–80. https://doi.org/10.4103/GMIT.GMIT_103_19
Xiao S, Wan Y, Zou F, Ye M, Deng H, Ma J, Wei Y, Tan C, Xue M (2015) Prevention of intrauterine adhesion with auto-crosslinked hyaluronic acid gel: a prospective, randomized, controlled clinical study. Zhonghua Fu Chan Ke Za Zhi 50:32–36
Zhang X, Liu W, Zhou Y, Qiu J, Sun Y, Li M, Ding Y, Xi Q (2021) Comparison of therapeutic efficacy of three methods to prevent re-adhesion after hysteroscopic intrauterine adhesion separation: a parallel, randomized and single-center trial. Ann Palliat Med 10:6804–6823. https://doi.org/10.21037/apm-21-1296
Zhang Y, Chen X, Chen S, Wei C, Li B, Wang Z, Shen X, Lin X (2022) Intrauterine administration of G-CSF for promoting endometrial growth after hysteroscopic adhesiolysis: a randomized controlled trial. Hum Reprod 37:725–733. https://doi.org/10.1093/humrep/deac023
Zhou Q, Shi X, Saravelos S, Huang X, Zhao Y, Huang R, Xia E, Li TC (2021) Auto-cross-linked hyaluronic acid gel for prevention of intrauterine adhesions after hysteroscopic adhesiolysis: a randomized controlled trial. J Minim Invasive Gynecol 28:307–313. https://doi.org/10.1016/j.jmig.2020.06.030
Cecerska-Heryc E, Goszka M, Serwin N, Roszak M, Grygorcewicz B, Heryc R, Dolegowska B (2022) Applications of the regenerative capacity of platelets in modern medicine. Cytokine Growth Factor Rev 64:84–94. https://doi.org/10.1016/j.cytogfr.2021.11.003
Dohan DM, Choukroun J, Diss A, Dohan SL, Dohan AJ, Mouhyi J, Gogly B (2006) Platelet-rich fibrin (PRF): a second-generation platelet concentrate. Part I: technological concepts and evolution. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 101:e37-44. https://doi.org/10.1016/j.tripleo.2005.07.008
Lubkowska A, Dolegowska B, Banfi G (2012) Growth factor content in PRP and their applicability in medicine. J Biol Regul Homeost Agents 26:3S-22S
Zhou Y, Shen H, Wu Y, Zhao X, Pei J, Mou Z, Dong J, Hua X (2020) Platelet-rich plasma therapy enhances the beneficial effect of bone marrow stem cell transplant on endometrial regeneration. Front Cell Dev Biol 8:52. https://doi.org/10.3389/fcell.2020.00052
Jang HY, Myoung SM, Choe JM, Kim T, Cheon YP, Kim YM, Park H (2017) Effects of autologous platelet-rich plasma on regeneration of damaged endometrium in female rats. Yonsei Med J 58:1195–1203. https://doi.org/10.3349/ymj.2017.58.6.1195
Kim JH, Park M, Paek JY, Lee WS, Song H, Lyu SW (2020) Intrauterine infusion of human platelet-rich plasma improves endometrial regeneration and pregnancy outcomes in a murine model of Asherman’s syndrome. Front Physiol 11:105. https://doi.org/10.3389/fphys.2020.00105
Albazee E, Al-Rshoud F, Almahmoud L, Al Omari B, Alnifise M, Baradwan S, Abu-Zaid A (2022) Platelet-rich plasma for the management of intrauterine adhesions: a systematic review and meta-analysis of randomized controlled trials. J Gynecol Obstet Hum Reprod 51:102276. https://doi.org/10.1016/j.jogoh.2021.102276
Korany S, Baradwan S, Badghish E, Talat Miski N, Alshahrani MS, Khadawardi K, Baradwan A, Alanwar A, Labib K, Dahi AA, Hamed WM, Abdallah KM, Badawy MA, Kamel M, Abbas AM, Ahmaro M, Abdelhakim AM, Sileem SA (2022) Value of intrauterine platelet-rich concentrates in patients with intrauterine adhesions after hysteroscopy: a systematic review and meta-analysis of randomized controlled trials. Eur J Obstet Gynecol Reprod Biol 271:63–70. https://doi.org/10.1016/j.ejogrb.2022.01.030
Zhu R, Duan H, Gan L, Wang S (2018) Comparison of intrauterine suitable balloon and Foley balloon in the prevention of adhesion after hysteroscopic adhesiolysis. Biomed Res Int 2018:9494101. https://doi.org/10.1155/2018/9494101
Louros NC, Danezis JM, Pontifix G (1968) Use of intrauterine devices in the treatment of intrauterine adhesions. Fertil Steril 19:509–528. https://doi.org/10.1016/s0015-0282(16)36723-1
Lin X, Wei M, Li TC, Huang Q, Huang D, Zhou F, Zhang S (2013) A comparison of intrauterine balloon, intrauterine contraceptive device and hyaluronic acid gel in the prevention of adhesion reformation following hysteroscopic surgery for Asherman syndrome: a cohort study. Eur J Obstet Gynecol Reprod Biol 170:512–516. https://doi.org/10.1016/j.ejogrb.2013.07.018
Uriu-Adams JY, Scherr RE, Lanoue L, Keen CL (2010) Influence of copper on early development: prenatal and postnatal considerations. BioFactors 36:136–152. https://doi.org/10.1002/biof.85
Ahmadian E, Dizaj SM, Eftekhari A, Dalir E, Vahedi P, Hasanzadeh A, Samiei M (2020) The potential applications of hyaluronic acid hydrogels in biomedicine. Drug Res (Stuttg) 70:6–11. https://doi.org/10.1055/a-0991-7585
Dou Y, Yu T, Li Z, Wang J, Jiang Y, Liu Y (2022) Short- and long-term outcomes of postoperative intrauterine application of hyaluronic acid gel: a meta-analysis of randomized controlled trials. J Minim Invasive Gynecol 29:934–942. https://doi.org/10.1016/j.jmig.2022.05.006
Akle CA, Adinolfi M, Welsh KI, Leibowitz S, McColl I (1981) Immunogenicity of human amniotic epithelial cells after transplantation into volunteers. Lancet 2:1003–1005. https://doi.org/10.1016/s0140-6736(81)91212-5
Zheng F, Zhu B, Liu Y, Wang R, Cui Y (2018) Meta-analysis of the use of amniotic membrane to prevent recurrence of intrauterine adhesion after hysteroscopic adhesiolysis. Int J Gynaecol Obstet 143:145–149. https://doi.org/10.1002/ijgo.12635
Thomas J, Liu F, Link DC (2002) Mechanisms of mobilization of hematopoietic progenitors with granulocyte colony-stimulating factor. Curr Opin Hematol 9:183–189. https://doi.org/10.1097/00062752-200205000-00002
Rahmati M, Petitbarat M, Dubanchet S, Bensussan A, Chaouat G, Ledee N (2014) Granulocyte-colony stimulating factor related pathways tested on an endometrial ex-vivo model. PLoS One 9:e102286. https://doi.org/10.1371/journal.pone.0102286
Gleicher N, Kim A, Michaeli T, Lee HJ, Shohat-Tal A, Lazzaroni E, Barad DH (2013) A pilot cohort study of granulocyte colony-stimulating factor in the treatment of unresponsive thin endometrium resistant to standard therapies. Hum Reprod 28:172–177. https://doi.org/10.1093/humrep/des370
Lin X, Zhang Y, Pan Y, He S, Dai Y, Zhu B, Wei C, Xin L, Xu W, Xiang C, Zhang S (2018) Endometrial stem cell-derived granulocyte-colony stimulating factor attenuates endometrial fibrosis via sonic hedgehog transcriptional activator Gli2. Biol Reprod 98:480–490. https://doi.org/10.1093/biolre/ioy005
Chen JM, Huang QY, Chen WH, Lin S, Shi QY (2022) Clinical evaluation of autologous and allogeneic stem cell therapy for intrauterine adhesions: a systematic review and meta-analysis. Front Immunol 13:899666. https://doi.org/10.3389/fimmu.2022.899666
Azumaguchi A, Henmi H, Saito T (2019) Efficacy of silicone sheet as a personalized barrier for preventing adhesion reformation after hysteroscopic adhesiolysis of intrauterine adhesions. Reprod Med Biol 18:378–383. https://doi.org/10.1002/rmb2.12294
Pang WJ, Zhang Q, Ding HX, Sun NX, Li W (2022) Effect of new biological patch in repairing intrauterine adhesion and improving clinical pregnancy outcome in infertile women: study protocol for a randomized controlled trial. Trials 23:510. https://doi.org/10.1186/s13063-022-06428-0
Funding
Funding provided by Shaanxi Provincial Health Commission (Grant number: 2021D022) and Second Affiliated Hospital of Harbin Medical University (Grant number: 2021LCYJ035).
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X. H. W. and R. N. T. conceived and designed the study. R. N. T., X.F.X. and W. L. Z. selected articles and extracted the data. R. N. T. and W. Y. L. analyzed the data. R. N. T., W. L. Z., and X. X. C. wrote the manuscript. X. H. W., X.F.X. and W.Y.L. contributed to the writing of final version of the manuscript. All authors agreed and reviewed the final version of the manuscript.
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Tang, R., Zhang, W., Xiao, X. et al. Intrauterine interventions options for preventing recurrence after hysteroscopic adhesiolysis: a systematic review and network meta-analysis of randomized controlled trials. Arch Gynecol Obstet 309, 1847–1861 (2024). https://doi.org/10.1007/s00404-024-07460-y
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DOI: https://doi.org/10.1007/s00404-024-07460-y