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

Abstract

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.

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

“…For patients who agreed to join the study, an outpatient hysteroscopy was performed within 6–20 weeks from their initial USG-MVA or EVA procedure by a designated team of experienced gynaecologists with similar surgical experience who were blinded to the women’s initial surgical procedure performed for the first-trimester miscarriage. Before OPH, a pregnancy test was performed and any recent coitus was recorded [ 6 ].…”

“…IUA can be asymptomatic or manifest as menstrual disturbances such as amenorrhea or hypoamenorrhea, dysmenorrhea, recurrent miscarriages, or infertility issues. The presence of IUA can have a negative impact on future fertility, as it can affect the successful implantation of embryos [ 6 ]. Moreover, IUA increases the rate of further miscarriages, potentially lead to abnormal placentation, fetal growth restriction, preterm delivery, and post-partum haemorrhage [ 7 ].…”

Intrauterine adhesions: from pathogenesis to effective coping technologies

“…Внутриматочные спайки (ВМС) остаются одним из ключевых заболеваний репродуктивной системы женщин, реализующиеся за счет травматического повреждения/разрушения базального эндометриального компартмента [1,2]. При легком течении образуются тонкие синехии, тогда как при тяжелом проявлении ВМС происходит полная облитерация полости матки и (или) цервикального канала [3][4][5][6].…”

“…ВМС -многофакторный процесс с широким спектром предрасполагаю щих и причинно-следственных факторов [5,10,11]. Внутриматочные хирургические вмешательства (диагностические выскабливания слизистой полости матки и цервикального канала, гистерорезектоскопия, миомэктомия с вхождением в полость матки, аборты, в том числе повторные выскабливания при задержке остатков продуктов зачатия) представляют собой ключевые факторы риска и выявлены у 91% пациенток с ВМС [12][13][14][15].…”

Enhanced myometrial vascularity secondary to retained pregnancy tissue: time to stop misusing the term arteriovenous malformation

“…Ultrasonography is essential for preoperative mapping and guidance during surgical management of retained pregnancy tissue 20 . Blind tissue removal may lead to an incomplete and lengthy procedure, prolonged heavy bleeding and unnecessary scarring of the endometrial–myometrial junction associated with Asherman syndrome or perforation 21 . The exact position of the retained tissue within the uterine cavity can be deduced from the position of the EMV which underlies the retained tissue.…”