Table of contents
Intrauterine adhesions
What's new
Added 2024 SOGC and 2017 AAGL/ESGE guidelines for the diagnosis and management of intrauterine adhesions.
Background
Overview
Definition
Intrauterine adhesions are bands of fibrous tissue forming inside the uterus, often leading to adhesion between the uterine walls.
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Pathophysiology
The pathophysiology of intrauterine adhesions involves trauma to the endometrium, often after surgical procedures such as dilation and curettage or manual vacuum aspiration. This trauma can lead to loss of stroma, which is replaced by fibrous tissue, resulting in adhesion formation.
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Epidemiology
The highest incidence of intrauterine adhesions has been reported after curettage for the removal of retained products of conception, hysteroscopic myomectomy, and uterine compressive sutures for postpartum hemorrhage.
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Risk factors
Risk factors for intrauterine adhesions include multiple pregnancy terminations, uterine infections, and certain surgical procedures, including dilation and curettage, uterine evacuation, hysteroscopic surgery, and uterine artery embolization.
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Disease course
Clinically, intrauterine adhesions can present with menstrual abnormalities, infertility, and recurrent pregnancy loss. Menstrual abnormalities are present in a significant proportion of patients, and the condition can lead to both primary and secondary infertility.
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Prognosis and risk of recurrence
The prognosis of intrauterine adhesions can vary based on the severity of the adhesions. While some patients may experience significant fertility issues, others may have milder symptoms. With appropriate treatment, such as hysteroscopic adhesiolysis, the condition is generally manageable. No adhesion-preventing substance, material, or barrier is unequivocally effective in all clinical situations.
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Guidelines
Key sources
The following summarized guidelines for the evaluation and management of intrauterine adhesions are prepared by our editorial team based on guidelines from the Society of Obstetricians and Gynaecologists of Canada (SOGC 2024), the European Society of Human Reproduction and Embryology (ESHRE 2018), the European Society of Gastrointestinal Endoscopy (ESGE/AAGL 2017), and the American Association of Gynecologic Laparoscopists (AAGL 2012).
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Classification and risk stratification
Diagnostic investigations
Diagnostic procedures
Medical management
Surgical interventions
Hysteroscopic adhesiolysis
As per SOGC 2024 guidelines:
Perform hysteroscopic adhesiolysis to increase the likelihood of conception in patients with infertility or recurrent pregnancy loss diagnosed with intrauterine adhesions on routine evaluation.
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Perform hysteroscopic adhesiolysis to improve the likelihood of a live birth in patients planning to conceive and known to have intrauterine adhesions.
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Preventative measures
Primary prevention: as per AAGL/ESGE 2017 guidelines, recognize that the risk for de novo adhesions during hysteroscopic surgery is impacted by the type of procedure performed, with those confined to the endometrium (polypectomy) having the lowest risk and those entering the myometrium or involving opposing surfaces a higher risk.
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More topics in this section
Secondary prevention