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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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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

Classification: as per ESGE/AAGL 2017 guidelines, classify intrauterine adhesions as prognosis is correlated with severity of adhesions.
B
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Diagnostic investigations

Diagnostic imaging: as per SOGC 2024 guidelines, consider obtaining uterine cavity evaluation by either hysteroscopy, sonohysterography, or 3D sonohysterography in patients with unexplained infertility.
C

Diagnostic procedures

Hysteroscopy: as per ESGE/AAGL 2017 guidelines, obtain hysteroscopy as the modality of choice for the diagnosis of intrauterine adhesions.
B

Medical management

Expectant management: as per ESGE/AAGL 2017 guidelines, consider offering expectant management in patients with intrauterine adhesions declining any intervention but still wishing to conceive, as subsequent pregnancy may occur but the time interval may be prolonged.
C

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 investigation should have.
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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.
B

Preventative measures

Primary prevention: as per ESGE/AAGL 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.
B
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More topics in this section

  • Secondary prevention

Follow-up and surveillance

Follow-up: as per ESGE/AAGL 2017 guidelines, obtain follow-up assessment of the uterine cavity after treatment of intrauterine adhesions, preferably with hysteroscopy.
B