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STUDY OBJECTIVE: To prospectively assess the prevalence of intrauterine synechia following medically-treated post-partum hemorrhage (PPH) and to evaluate the association between synechiae formation and PPH management techniques. DESIGN: A prospective observational cohort study SETTING: Angers University Hospital PARTICIPANTS: A total of 83 women presenting with medically-treated PPH from January to December 2021 were included in the study. INTERVENTION: Diagnostic hysteroscopy was performed twelve weeks postpartum to assess for the presence of uterine synechiae. Detailed data on PPH management techniques were collected for analysis. MEASUREMENTS AND MAIN RESULTS: The majority of participants were primiparous and had undergone vaginal delivery. Only 7% required intrauterine balloon tamponade (IUBT), and 4% underwent uterine artery embolization. Uterine synechiae were identified in 20 women during diagnostic hysteroscopy, yielding a prevalence of 24% at 12 weeks postpartum; all classified as type I according to the ESGE classification system. IUBT was used in 15% of women with synechiae compared to 5% in the non-synechiae group, although this difference was not statistically significant (OR 3.52, 95% CI 0.65-19.10, p=0.123). Multivariate analysis identified second manual uterine examination (OR 5.00, 95% CI 1.50-16.66, p=0.009) and bimanual uterine massage (OR 3.50, 95% CI 1.12-10.09, p=0.020) as independent risk factors for synechiae formation. CONCLUSION: This is the first study to evaluate the risk of intrauterine synechiae following medically treated PPH. Mild uterine synechiae were observed in one in four women in the cohort. The need for a second manual uterine examination and bimanual uterine massage were significantly associated with the development of synechiae. Further research is warranted to explore the long-term clinical consequences, including fertility outcomes, and to determine the potential role of diagnostic hysteroscopy in postpartum follow-up after PPH SUMMATION: The study prospectively investigates the prevalence of uterine synechiae following non-surgical postpartum hemorrhage, revealing a 24% occurrence, with second manual uterine examination and bimanual massage identified as independent risk factors.
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OBJECTIVE: To update the 2010 CNGOF clinical practice guidelines for the first-line management of infertile couples. MATERIALS AND METHODS: Five major themes (first-line assessment of the infertile woman, first-line assessment of the infertile man, prevention of exposure to environmental factors, initial management using ovulation induction regimens, first-line reproductive surgery) were identified, enabling 28 questions to be formulated using the Patients, Intervention, Comparison, Outcome (PICO) format. Each question was addressed by a working group that had carried out a systematic review of the literature since 2010, and followed the Grading of Recommendations Assessment, Development and Evaluation (GRADE®) methodology to assess the quality of the scientific data on which the recommendations were based. These recommendations were then validated during a national review by 40 national experts. RESULTS: The fertility work-up is recommended to be prescribed according to the woman's age: after one year of infertility before the age of 35 and after 6months after the age of 35. A couple's initial infertility work-up includes a single 3D ultrasound scan with antral follicle count, assessment of tubal permeability by hysterography or HyFOSy, anti-Mullerian hormone assay prior to assisted reproduction, and vaginal swabbing for vaginosis. If the 3D ultrasound is normal, hysterosonography and diagnostic hysteroscopy are not recommended as first-line procedures. Chlamydia trachomatis serology does not have the necessary performance to predict tubal patency. Post-coital testing is no longer recommended. In men, spermogram, spermocytogram and spermoculture are recommended as first-line tests. If the spermogram is normal, it is not recommended to check the spermogram. If the spermogram is abnormal, an examination by an andrologist, an ultrasound scan of the testicles and hormonal test are recommended. Based on the data in the literature, we are unable to recommend a BMI threshold for women that would contraindicate medical management of infertility. A well-balanced Mediterranean-style diet, physical activity and the cessation of smoking and cannabis are recommended for infertile couples. For fertility concern, it is recommended to limit alcohol consumption to less than 5 glasses a week. If the infertility work-up reveals no abnormalities, ovulation induction is not recommended for normo-ovulatory women. If intrauterine insemination is indicated based on an abnormal infertility work-up, gonadotropin stimulation and ovulation monitoring are recommended to avoid multiple pregnancies. If the infertility work-up reveals no abnormality, laparoscopy is probably recommended before the age of 30 to increase natural pregnancy rates. In the case of hydrosalpinx, surgical management is recommended prior to ART, with either salpingotomy or salpingectomy depending on the tubal score. It is recommended to operate on polyps>10mm, myomas 0, 1, 2 and synechiae prior to ART. The data in the literature do not allow us to systematically recommend asymptomatic uterine septa and isthmoceles as first-line surgery. CONCLUSION: Based on strong agreement between experts, we have been able to formulate updated recommendations in 28 areas concerning the initial management of infertile couples.