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

116 Pages·2015·1.69 MB·English

Anti-adhesion therapy following operative hysteroscopy for
treatment of female subfertility (Review)
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Bosteels J, Weyers S, Kasius J, Broekmans FJ, Mol BWJ, D’Hooghe TM
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ThisisareprintofaCochranereview,preparedandmaintainedbyTheCochraneCollaborationandpublishedinTheCochraneLibrary
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2015,Issue11
http://www.thecochranelibrary.com
Anti-adhesiontherapyfollowingoperativehysteroscopyfortreatmentoffemalesubfertility(Review)
Copyright©2015TheCochraneCollaboration.PublishedbyJohnWiley&Sons,Ltd.
TABLE OF CONTENTS
HEADER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
ABSTRACT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
PLAINLANGUAGESUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
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SUMMARYOFFINDINGSFORTHEMAINCOMPARISON . . . . . . . . . . . . . . . . . . . 4
BACKGROUND . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
OBJECTIVES . . . . . . . . . . . . . . . . . . . . . . . . . .l. . . . . . . . . . . 9
METHODS . . . . . . . . . . . . . . . . . . . . . . . . . .n. . . . . . . . . . . . 9
RESULTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Figure1. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Figure2. . . . . . . . . . . . . . . . . . . . . . . O. . . . . . . . . . . . . . . 17
Figure3. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Figure4. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
Figure5. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
Figure6. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
ADDITIONALSUMMARYOFFINDINGS . . . . . . . . . . . . . . . . . . . . . . . . . . 30
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DISCUSSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
Figure7. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
AUTHORS’CONCLUSIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
ACKNOWLEDGEMENTS . . . . . . . . . . e. . . . . . . . . . . . . . . . . . . . . . 36
REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
CHARACTERISTICSOFSTUDIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
DATAANDANALYSES . . . . . . . . . .i. . . . . . . . . . . . . . . . . . . . . . . . 82
Analysis1.1.Comparison1Inserteddevicevsvnotreatment,Outcome1Livebirth. . . . . . . . . . . . . 85
Analysis1.2.Comparison1Inserteddevicevsnotreatment,Outcome2Clinicalpregnancy. . . . . . . . . . 85
Analysis1.3.Comparison1Inserteddevicevsnotreatment,Outcome3Miscarriage. . . . . . . . . . . . 86
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Analysis1.4.Comparison1Inserteddevicevsnotreatment,Outcome4Presenceofintrauterineadhesionsatsecond-look
hysteroscopy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87
Analysis2.1.Comparison2Inserteddevicevsanotherinserteddevice,Outcome1Presenceofintrauterineadhesionsat
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second-lookhysteroscopy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87
Analysis3.1.Comparison3HPormonaltreatmentvsnotreatmentorplacebo,Outcome1Livebirth. . . . . . . 88
Analysis3.2.Comparison3Hormonaltreatmentvsnotreatmentorplacebo,Outcome2Clinicalpregnancy. . . . 89
Analysis3.3.Comparison3Hormonaltreatmentvsnotreatmentorplacebo,Outcome3Miscarriage. . . . . . 90
Analysis3.4.Comparison3Hormonaltreatmentvsnotreatmentorplacebo,Outcome4Presenceofintrauterineadhesions

atsecond-lookhysteroscopy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91
Analysis4.1.Comrparison4Gelvsnotreatment,Outcome1Clinicalpregnancy. . . . . . . . . . . . . . 92
Analysis 4.2. Comparison 4 Gelvs no treatment, Outcome 2 Presence of intrauterine adhesions at second-look
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hysteroscopy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93
Analysis4.3.Comparison4Gelvsnotreatment,Outcome3Meanadhesionscoresat12weeks. . . . . . . . 94
Analysis4.4.Comparison4Gelvsnotreatment,Outcome4Mildadhesionsatsecond-lookhysteroscopy. . . . . 95
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Analysis4.5.Comparison4Gelvsnotreatment,Outcome5Moderateorsevereadhesionsatsecond-lookhysteroscopy. 96
Analysis6.1.Comparison6Graftvsnograft,Outcome1Livebirth. . . . . . . . . . . . . . . . . . 97
Analysis6.2.Comparison6Graftvsnograft,Outcome2Clinicalpregnancy. . . . . . . . . . . . . . . 97
Analysis6.3.Comparison6Graftvsnograft,Outcome3Miscarriage. . . . . . . . . . . . . . . . . 98
Analysis7.1.Comparison7Anytherapyvsnotreatmentorplacebo,Outcome1Livebirth. . . . . . . . . . 98
Analysis7.2.Comparison7Anytherapyvsnotreatmentorplacebo,Outcome2Clinicalpregnancy. . . . . . . 99
Analysis7.3.Comparison7Anytherapyvsnotreatmentorplacebo,Outcome3Miscarriage. . . . . . . . . 100
Analysis7.4.Comparison7Anytherapyvsnotreatmentorplacebo,Outcome4Presenceofintrauterineadhesionsat
second-lookhysteroscopy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101
Analysis7.5.Comparison7Anytherapyvsnotreatmentorplacebo,Outcome5Meanadhesionscores. . . . . . 102
Analysis7.6. Comparison 7Any therapyvsnotreatmentor placebo, Outcome 6Mildadhesions atsecond-look
hysteroscopy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103
Anti-adhesiontherapyfollowingoperativehysteroscopyfortreatmentoffemalesubfertility(Review) i
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Analysis7.7.Comparison7Anytherapyvsnotreatmentorplacebo,Outcome7Moderateorsevereadhesionsatsecond-
lookhysteroscopy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 104
Analysis8.1.Comparison8Anytherapyvsanyothertherapy,Outcome1Presenceofintrauterineadhesionsatsecond-
lookhysteroscopy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105
APPENDICES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105
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CONTRIBUTIONSOFAUTHORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 112
DECLARATIONSOFINTEREST . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 112
SOURCESOFSUPPORT . . . . . . . . . . . . . . . . . . . . . .l. . . . . . . . . . . 112
DIFFERENCESBETWEENPROTOCOLANDREVIEW . . . . . . . . .n. . . . . . . . . . . . 113
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Anti-adhesiontherapyfollowingoperativehysteroscopyfortreatmentoffemalesubfertility(Review) ii
Copyright©2015TheCochraneCollaboration.PublishedbyJohnWiley&Sons,Ltd.
[InterventionReview]
Anti-adhesion therapy following operative hysteroscopy for
treatment of female subfertility
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JanBosteels1,StevenWeyers2,JennekeKasius3,FrankJBroekmans3,BenWillemJMol4,lThomasMD’Hooghe5
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1BelgianBranchoftheDutchCochraneCentre,Leuven,Belgium.2ObstetricsandGynaecology,UniversityHospitalGhent,Ghent,
Belgium.3DepartmentofReproductiveMedicineandGynecology,UniversityMedicalCenter,Utrecht,Netherlands.4TheRobinson
Institute,SchoolofPaediatricsandReproductiveHealth,TheUniversityofAdelaide,Adelaide,Australia.5LeuvenUniversityFertility
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Centre,UniversityHospitalGasthuisberg,Leuven,Belgium
Contact address: Jan Bosteels, BelgianBranch of the Dutch Cochrane Centre, Kapucijnenvoer 33 blok J bus 7001, 3000 Leuven,
Leuven,[email protected]@hotmail.com.

Editorialgroup:CochraneGynaecologyandFertilityGroup. w
Publicationstatusanddate:New,publishedinIssue11,2015.
Reviewcontentassessedasup-to-date: 1March2015.
Citation: Bosteels J, Weyers S, Kasius J, Broekmans FJ,eMol BWJ, D’Hooghe TM. Anti-adhesion therapy following operative
hysteroscopyfortreatmentoffemalesubfertility.CochraneDatabaseofSystematicReviews2015,Issue11.Art.No.:CD011110.DOI:
10.1002/14651858.CD011110.pub2.
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Copyright©2015TheCochraneCollaboration.PvublishedbyJohnWiley&Sons,Ltd.
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ABSTRACT
Background
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Limitedobservational evidencesuggestspotentialbenefitforsubfertilewomenundergoingoperativehysteroscopywithseveralanti-
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adhesion therapies(e.g.insertion of anintrauterine device(IUD) or balloon, hormonal treatment, barrier gelsor humanamniotic
membranegrafting)todecreaseintrauterineadhesions(IUAs).
Objectives

Toassesstheeffectivenerssofanti-adhesiontherapiesversusplacebo,notreatmentoranyotheranti-adhesiontherapyfollowingoperative
hysteroscopyfortreatmentoffemalesubfertility.
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Searchmethods
WesearchedthefollowingdatabasesfrominceptiontoMarch2015:theCochraneMenstrualDisordersandSubfertilitySpecialised
F
Register,theCochraneCentralRegisterofControlledTrials(2015,Issue2),MEDLINE,EMBASE,theCumulativeIndextoNursing
andAlliedHealthLiterature(CINAHL)andotherelectronicsourcesoftrials,includingtrialregisters,sourcesofunpublishedliterature
andreferencelists.WehandsearchedTheJournalofMinimallyInvasiveGynecology,andwecontactedexpertsinthefield.
Selectioncriteria
Randomisedcomparisonsofanti-adhesiontherapiesversusplacebo,notreatmentoranyotheranti-adhesiontherapyfollowingoperative
hysteroscopy in subfertile women. The primary outcome was live birth or ongoing pregnancy. Secondary outcomes were clinical
pregnancy,miscarriageandIUAspresentatsecondlook,alongwiththeirmeanadhesionscoresorseverity.
Datacollectionandanalysis
Tworeviewauthorsindependentlyselectedstudies,assessedriskofbias,extracteddataandevaluatedqualityoftheevidenceusingthe
GRADE(GradesofRecommendation,Assessment,DevelopmentandEvaluation)method.
Anti-adhesiontherapyfollowingoperativehysteroscopyfortreatmentoffemalesubfertility(Review) 1
Copyright©2015TheCochraneCollaboration.PublishedbyJohnWiley&Sons,Ltd.
Mainresults
Weincluded11randomisedstudiesonuse ofaninserteddeviceversusnotreatment(twostudies; 84women)or anotherinserted
device(onestudy;162women),hormonaltreatmentversusnotreatmentorplacebo(twostudies;131women),gelversusnotreatment
(fivestudies;383women)andgraftversusnograft(onestudy;43women).Thetotalnumberofwomenrandomlyassignedwas924,
but data on only 803 participants were available for analysis. Theproportion of subfertile womyen variedfrom0% (one study; 41
women),tolessthan50%(sixstudies;487women),to100%(onestudy;43women);theproportionwasunknowninthreestudies
(232women).Moststudies(9/11)wereathighriskofbiaswithrespecttooneormoremethodologicalcriteria.
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Wefoundnoevidenceofdifferencesbetweenanti-adhesiontherapyandnotreatmentornplacebowithrespecttolivebirthrates(odds
ratio(OR)0.99,95%confidenceinterval(CI)0.46to2.13,Pvalue=0.98,threestudies,150women;low-qualityevidence)andno
statisticalheterogeneity(Chi2=0.14,df=2(Pvalue=0.93),I2=0%).
O
Anti-adhesiontherapywasassociatedwithfewerIUAsatanysecond-lookhysteroscopywhencomparedwithnotreatmentorplacebo
(OR0.36, 95%CI0.20to0.64, Pvalue=0.0005, sevenstudies,528women;verylow-quality evidence).Wefoundnostatistical
heterogeneity(Chi2=2.65,df=5(Pvalue=0.75),I2=0%).Thenumberneededtotreatforanadditionalbeneficialoutcome(NNTB)
was9(95%CI6to20).

NoevidencesuggesteddifferencesbetweenanIUDandanintrauterineballoonwithrespecttoIUAsatsecond-lookhysteroscopy(OR
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1.23,95%CI0.64to2.37,Pvalue=0.54,onestudy,162women;verylow-qualityevidence).
Authors’conclusions
Implicationsforclinicalpractice e
Thequalityoftheevidenceretrievedwasloworverylowforalloutcomes.Clinicaleffectivenessofanti-adhesiontreatmentforimproving
keyreproductiveoutcomesorfordecreasingIUAsfollowingoperativehysteroscopyinsubfertilewomenremainsuncertain.
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Implicationsforresearch v
Additionalstudiesareneededtoassesstheeffectivenessofdifferentanti-adhesiontherapiesforimprovingreproductiveoutcomesin
subfertilewomentreatedbyoperativehysteroescopy.
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PLAIN LANGUAGE SUMMARY
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Anti-adhesiontreatmentafterhysteroscopyforwomenhavingdifficultybecomingpregnant
Reviewquestion
Toassesstheeffectsoftreatm entsforpreventionofscartissueaftersurgicaltreatmentforlesionsofthewombinwomenhavingdifficulty
becomingpregnant.
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Background
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Thepresentpracticeusedtopreventscartissueformationaftersurgeryofthecavityofthewombisbasedontraditionalorobservational
studies.
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Searchdate
Evidenceiscurrentto1March2015.
Studycharacteristics
We searchedfor studies thatrandomly compared any treatmentversusno treatment, placeboor any other intervention in women
havingdifficultybecomingpregnantaftersurgeryforabnormalitiesofthecavityofthewomb.Outcomeswerelivebirthorongoing
pregnancy,clinicalpregnancy,miscarriageandpresenceorseverityofscartissueatthesecond-lookprocedure.
Studyfundingsources
Sixstudiesreceivednoexternalfunding,thegovernmentfundedonestudyandfourstudiesprovidedunclearinformationonfunding.
Keyresults
Anti-adhesiontherapyfollowingoperativehysteroscopyfortreatmentoffemalesubfertility(Review) 2
Copyright©2015TheCochraneCollaboration.PublishedbyJohnWiley&Sons,Ltd.
Wefound11studies.Treatmentsincludedinsertionofadevicecomparedwithnotreatment(twostudies;84women)orinsertionof
anotherdevice(onestudy;162women),intakeofhormonaltabletsaftersurgery(twostudies;131women),useofstickygels(five
studies;383women)andapplicationofmembranesoftheafterbirthofnewbornbabies(onestudy;43women).Investigatorsrandomly
assigned924women,butdataononly803womenwereavailableforanalysis.Theproportionofwomenhavingdifficultybecoming
pregnantvariedfrom0%(onestudy;41women),tolessthan50%(sixstudies;487women),to100%(onestudy;43women);the
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proportionwasnotknowninthreestudies(232women).Moststudies(9/11)wereathighriskofbiasinoneormoreareas.Noproof
showsbenefitwithanyanti-adhesiontreatmentforincreasingthechanceofalivebornbaby(threestudies;150women).Useofsticky
gels(fivestudies;383women)candiminishthepresenceofscartissue:Wewouldexpectthlatoutof1000womentreatedbysurgery
ofthewomb,between120and316woulddevelopscartissueafterusingstickygels,conmparedwith454womenwhennogelswere
used.Noproofindicatesthatinsertingacontraceptivecoilmaydecreasescartissuebetterthaninsertingaballoon.
Qualityoftheevidence
O
Theoverallqualityofstudyevidenceisloworverylowforalloutcomes.Moreresearchisneededbeforeanti-adhesiontreatmentcan
beroutinelyofferedafterhysteroscopictreatmenttowomenhavingdifficultybecomingpregnant.

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CoAn SUMMARY OF FINDINGS FORwTHE MAIN COMPARISON [Explanation]
pyrti-a
ight©dhesio
2n e
015the Anyanti-adhesiontherapyfollowingoperativehysteroscopyfortreatmentoffemalesubfertilityvsnotreatmentorplacebo
Thrap
ey Patientorpopulation:womentreatedbyoperativehysteroscopyforuterinepathologyassociatedwithsubfertilityoradversepregnancyoutcome
Cfo i
ochraneCllowingop ICSnoetemttripnvaegrnsi:tsioosinnn::ganlenoycteraennattrtiem-a-ednHhteyossritoepnrloatschceeobrapopyyUnitvorDepartmentofObstetricsandGynaecologyofauniversityornon-universitytertiarycarehospital
ollaboerativ Outcomes Illustrativeecomparativerisks* Relativeeffect Numberofparticipants Qualityoftheevidence Comments
re
ation.Publishysteroscop P(A9s5sr%umCeId) risk Correspondingrisk (95%CI) (studies) (GRADE)
hy
edfo Notreatment Anti-adhesiontreatment
br
ytr
Johneatm Livebirth Average-riskpopulationa OR0.99 150 ⊕⊕(cid:13)(cid:13)
Wen (0.46to2.13) (3studies) Lowb,c,d,e
ileytof r338per1000 292per1000
&fe (182to469)
Sm o
onsale
,Lsu Presenceofintrauterine Low-riskpopulationf OR0.37 383 ⊕(cid:13)(cid:13)(cid:13)
td.bfer adheFsions at any sec- (0.20to0.67) (5studies) Verylowe,g,h
tility ond-look hysteroscopy 0per1000 0per1000
(R - anti-adhesion barrier
ev gels Medium-riskpopulationf
ie
w (second-
)
lookhysteroscopyat4to 454per1000 194per1000
12 weeks after operative (120to316)
hysteroscopy)
High-riskpopulationf
875per1000 374per1000
(231to608)
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pyrti-a
ight©dhesio Presenceofintrauterine Low-riskpopulationf OR0.14 145 ⊕⊕(cid:13)(cid:13)
2n adhesions at any sec- e (0.01to2.72) (2studies) Lowe,i,j,k,l,m
015the ond-look hysteroscopy 0per1000 0per1000
Thrap - other anti-adhesion
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Cochranefollowing t(ohsneedcr-a-lopoykhysteroscopyat M45e4dipuemr-1r0is0k0povpuilationf 66per1000
Collabooperativ 4tivteoh8yswteereoksscaofpteyr)opera- e (3to1250)
ration.Pehystero H87ig5rhp-reirsk10p0o0pulationf 127per1000
ublisscop P (7to2410)
hy
edfo
byrtr *Thebasisfortheassumedriskisprovidedinfootnotes.Thecorrespondingrisk(andits95%confidenceinterval)isbasedonassumedriskinthecomparisongroupandtherelativeeffect
Johneatm oftheintervention (andits95%CI).
We CI:Confidenceinterval;OR:Oddsratio.
n
ileytof r
&fe GRADEWorkingGroupgradesofevidence.
Sm o
onsale Highquality:Furtherresearchisveryunlikelytochangeourconfidenceintheestimateofeffect.
,Lsu Moderatequality:Furtherresearchislikelytohaveanimportantimpactonourconfidenceintheestimateofeffectandmaychangetheestimate.
td.bfer LowFquality:Furtherresearchisverylikelytohaveanimportantimpactonourconfidenceintheestimateofeffectandislikelytochangetheestimate.
tility Verylowquality:Weareveryuncertainabouttheestimate.
(Re aAssumedriskforaverage-riskpopulationistheriskoflivebirthinpooledcontrolgroupsofthe3includedstudies.
v
iew bTwo studies at highriskof bias, and thethird study at low risk of bias; asensitivity analysis onthe choice to includeall 3studies
)
regardlessofstudyqualitycomparedwiththesinglestudyatlowriskofbiasrevealednosubstantialchangeindirectionormagnitudeof
effectsizeandintestsofstatisticalsignificance.
cIndirectnessofevidence:Onlyaportionofparticipantssufferedfromsubfertilityin2includedstudies.
dResultsof2studiesimprecise,givenwideconfidenceintervals.
eFormalstudyofreportingbiasnotpossible.
fAssumed riskfor low/medium/high-riskpopulationbased onpresenceofintrauterine adhesions followinghysteroscopic removalof
endometrialpolyps/meanprevalenceofIUAs/removalofuterineseptum,respectively,basedonfindingsofaprospectivecohortstudy.
gDesignofthe5studieshadseveralmainlimitations.
hSubstantial indirectnessofavailableevidence:in2of4Italiantrials,<50%ofparticipantssufferedfromsubfertility;in2otherItalian
studies,subfertilewomenwereincludedevenafterclarifyingwithprimarystudyauthors;andinthefifthtrialfromIsrael,onlywomen
withprovenfertilitywereincluded.
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CoAn iSmallstudywithnoeventsresultinginundeterminedtreatmenwteffects.
pyrti-a jHigh risk of performance and detection bias because participants, personnel and outcome assessors were not blinded. Moreover,
ight©2dhesion tchoenicnetrenrvseunrtrioonungdrsouimpb(1al7a/n3c1e)itnhabnasinelitnheecchoanrtarocltegrriostueicps(1b0e/tw31e)e.ncomparisongroups;theproportionofwomenwithIUAswashigherin
015the kNotclearwhethersubfertilewomenwereincluded,andifso,howmany.
Thrap lIndirectnessofavailableevidence:only34%ofparticipantssufferingfromsubfertility.
eCyfo mImprecision:confidenceintervalsofeffectestiimateverywide.
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Cop
ollaboerativ e
re
ation.Phystero r
ublisscop P
hy
edfo
br
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Johneatm
We
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ileytof r
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Sm o
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tility
(R
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)
6
BACKGROUND (Revaux 2008) despite several hypotheses on the origin of cells
forendometrialregeneration(Okulicz2002).Endometrialstem
or progenitor cells, present in the human and in rodents, may
Descriptionofthecondition haveanimportantfunctionforendometrialregenerationinnor-
mal menstrual cycles and after delivery; this holds promise for
Intrauterineadhesions(IUAs)arefibrousstringsatopposingwalls y
newtreatmentsforsubfertilityassociatedwithIUAsorAsherman’s
oftheuterus.ThespectrumofseverityofIUAsrangesfrommin-
syndrome (Deane 2013). The duration of endometrial wound
imal to complete obliteration of the uterine cavity. Any trauma
healingdependson thle typeof pathology present, according to
to the endometrium (the inner layer of the uterus) can lead to
aprospectivecohortnstudy of163 womenundergoing operative
formation of IUAs; in daily clinical practice, nearly 90% of all
hysteroscopy (Yang 2013); these investigators reported that the
IUAs are associated with postpartum or postabortion dilatation
time needed for complete recovery of the endometrium ranges
andcurettage(Nappi2007).Theaetiologicalroleofinfectionin
fromonetotOhreemonthsfollowinghysteroscopicremovalofen-
theformationofIUAsiscontroversial,withtheexceptionofgen-
dometrialpolypsandsubmucousfibroids,respectively.
italtuberculosis(Deans2010).IUAformationisthemajorlong-
IUAs are associated with poor reproductive outcomes. This is
termcomplication of hysteroscopicsurgery inwomen ofrepro-
dueinparttoinfertility,withprevalenceashighas43%(922of
ductiveage.
2151 women)accordingtoalargereviewofobservational stud-
Severalintrauterineanomalieshavebeenlinkedwithfemalesub-
ies(Schenker1982).Pooroutcomesalsoresultfromtheclinical
w
fertility(Bosteels2015).Endometrialpolypsarebenign,endome-
problem of recurrent miscarriage, ranging from 5% to 39% in
trial,stalk-likemassesprotrudingintotheuterinecavity.Fibroids
womenwithIUAs,accordingtoareviewofobservationalstudies
areexcessivegrowthsoriginatingfromthemuscularportionofthe
(Kodaman2007),andfrommajor and attimesdevastating ob-
uterine cavity. A septate uterus is a congenital malformation in
estetricalcomplications,forexample,placentaaccretaorincreta,as
whichthelongitudinal bandseparatingleftandrightMüllerian
wellashigherrisksforpretermdelivery,uterineruptureandperi-
ducts, which form the uterus in the human female foetus, has
partumhysterectomyastheendpointofsuccessfulhysteroscopic
notbeenentirelyresorbed. Hysteroscopyallowsdirectvisualisa-
itreatmentforsevereIUAs(Deans2010).
tion of the uterine cavity through a rigid, semi-rigid or flexible
v
endoscope.Thehysteroscopeconsistsofarigidtelescopewitha
proximaleyepieceandadistalobjectivelensthatmaybeangled
Descriptionoftheintervention
at 0 degrees to allow direct viewing, or offseet at various angles
to provide a fore-oblique view. Operative hysteroscopy requires Several observational studies have suggested different anti-ad-
adequatevisualisationthroughcontinuousfluidcirculationusing hesion strategies for preventing IUAs following operative hys-
inflow and outflow channels. The sherath system of the opera- teroscopy.
tive hysteroscope contains one or two 1.6- to 2.0-mm working
P
channelsforinsertionofasmallgraspingorbiopsyforceps,scis-
Intrauterinedevice
sors,myomafixationinstruments,retractionloops,morcellators
Anintrauterinedevice(IUD)mayprovideaphysicalbarrierbe-
(surgicalinstrumentsusedtodivideandremovetissueduringen-
tweentheuterinewalls,separatingtheendometriallayersafterly-
doscopic surgery) and aspi ration cannulae or unipolar or bipo-
sisofIUAs.Itsinsertionasanadjuncttherapyfortheprevention
larelectrodiathermyinstruments.Operativehysteroscopicproce-
r
ofIUAshasbeenrecommendedinatleast13observationalstud-
dures require a complex instrumentation setup, special training
ies(Deans2010). The use of aFoley catheterballoon has been
of the surgeon andoappropriate knowledge and management of
reportedasanalternative,forsimilarpurposes,ineightobserva-
complications. Removalofendometrialpolypsbyanendoscope
tionalstudies(Deans2010).
iscalledhysteroscopicpolypectomy.Hysteroscopicmyomectomy
istheprocedFurebywhichafibroidisremovedbyhysteroscopy.
Removalofauterineseptumistermedhysteroscopicseptoplasty Hormonaltherapy
orseptumresection.RemovalofIUAsiscalledhysteroscopicad-
In1964, Woodand Penasuggested useof oestrogentherapyto
hesiolysisorsynechiolysis.Adiagnosticoroperativehysteroscopy
stimulate regeneration of the endometrium after surgical treat-
followinganoperativehysteroscopyistermedasecond-lookhys-
mentforIUAs(Wood1964).
teroscopy.
Arandomisedcontrolledtrial(RCT)reportedthefollowingnum-
bers for the incidence of postsurgical IUAs at second-look hys- Barriergels
teroscopy:3.6%afterpolypectomy,6.7%afterresectionofuter- Hyaluronicacid(HA)orhyaluronanisawater-soluble polysac-
ine septa, 31.3% after removal of asolitary myoma and45.5% charidethatconsistsofmultipledisaccharideunitsofglucuronic
afterresectionofmultiplemyomas(Taskin2000).Mechanismsof acidandN-acetylglucosamineboundtogetherbyaβ1-3-typeglu-
tissue repair in thehumanendometrium arepoorly understood cosidebond.SolutionsofHAhaveviscoelasticpropertiesthathave
Anti-adhesiontherapyfollowingoperativehysteroscopyfortreatmentoffemalesubfertility(Review) 7
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