Auto-Cross-Linked Hyaluronic Acid Gel for Prevention of Intrauterine Adhesions after Hysteroscopic Adhesiolysis: A Randomized Controlled Trial.

STUDY OBJECTIVE: To investigate auto-cross-linked hyaluronic acid gel for the prevention of intrauterine adhesion (IUA) recurrence after hysteroscopic adhesiolysis. DESIGN: A single-center, double-blinded randomized controlled trial. SETTING: A tertiary university hospital. PATIENTS: Two hundred seventy-two patients with moderate-to-severe (American Fertility Society [AFS] score ≥5) IUAs underwent hysteroscopic adhesiolysis. INTERVENTIONS: The patients were randomized to receive standard care along with auto-cross-linked hyaluronic acid gel after surgery (treatment group) or standard care only (control group). All patients had second-look hysteroscopy at 4 weeks and hormonal therapy for 2 cycles after surgery. MEASUREMENTS AND MAIN RESULTS: Two hundred sixty patients were eligible and randomized; 245 patients successfully completed the study (n = 122 in treatment group, and n = 123 in control group). The primary outcome measure was IUA recurrence at second-look hysteroscopy. The secondary outcome measures included an improvement in the AFS score and menstrual pattern. There was no significant difference with regard to IUA recurrence (31.1% vs 39.8%) or median AFS score at second-look hysteroscopy (2, interquartile range [2-4] vs 2, interquartile range [2-4]) or improvement in the menstrual pattern at 3-month follow-up (87.7% vs 76.4%), in the treatment and control groups, respectively. CONCLUSION: The application of auto-cross-linked hyaluronic acid gel did not seem to improve IUA recurrence after hysteroscopic adhesiolysis.

Asherman syndrome and insufficient endometrial thickness: A hypothesis of integrated approach to restore the endometrium.

Asherman syndrome consists in an acquired condition characterized by the development of fibrous intrauterine adhesions involving until two-thirds of the uterine cavity. Common signs of the syndrome are represented by alterations of regular menses, hypomenorrhea and amenorrhea. Moreover, women affected by Asherman syndrome, often struggle with fertility problems such as difficulty in spontaneous conceiving as well as complications including recurrent pregnancy loss and invasive placentation. The abnormality of the endometrial line consisting in insufficient thickness and/or endometrial trauma damaging the decidua basalis, are characteristic elements of the disease. Several studies have been conducted during the last ten years to find a solution restoring the regular endometrial line solving the fertility issue in Asherman women. Hormonal therapy as well as the use of stem cells seem to represent valid options to regenerate the endometrium opening a new scenario in the fertility treatment of these women. In this context, the presented study proposes an integrated approach to reach an adequate endometrial reconstitution and consequentially optimal fertility outcomes.

Comprehensive management of severe Asherman syndrome and amenorrhea.

OBJECTIVE: To describe a comprehensive approach to women with severe Asherman syndrome and amenorrhea, including preoperative, operative, and postoperative care and subsequent resumption menses, and pregnancy. DESIGN: Retrospective case series. SETTING: Tertiary care teaching hospital. PATIENT(S): Twelve women with severe Asherman syndrome and amenorrhea. INTERVENTION(S): Preoperative administration of prolonged preoperative and postoperative oral E(2) to enhance endometrial proliferation, intraoperative abdominal ultrasound-directed hysteroscopic lysis of uterine synechia to ensure that the dissection is performed in the proper tissue plane, placement of a triangular uterine balloon catheter during surgery, and postoperative removal with placement of a copper intrauterine device (IUD) to maintain separation of the cavity and mechanically lyse newly formed adhesions during removal. MAIN OUTCOME MEASURE(S): Resumption of menses, pregnancy, and delivery. RESULT(S): All women resumed menses, although 5 of 12 had a preoperative maximal endometrial thickness of 4 mm or less, with follow-up ranging from 6 months to 10 years. Six of nine women less than age 39 years (67%) became pregnant, and four of six achieved a term or near-term delivery. CONCLUSION(S): Comprehensive management provides the best possible outcomes in poor-prognosis women with severe Asherman syndrome.

Successful use of vaginal sildenafil citrate in two infertility patients with Asherman's syndrome.

Vaginal sildenafil citrate (Viagra, Pfizer, Inc., New York, NY) has been shown to be useful in increasing endometrial thickness and achieving pregnancy in women with varied uterine disorders. However, it failed to demonstrate favorable results in the setting of Asherman's syndrome, a condition characterized by the presence of uterine synechiae. We have successfully applied this treatment in two women noted to have inadequate endometrium after surgical resection of uterine synechiae. Both patients had a history of a postpartum uterine curettage with subsequent secondary infertility. Asherman's syndrome was surgically demonstrated and treated in both patients. Postoperatively, both patients were noted to have a thin endometrium and failed to conceive despite fertility treatment. Subsequently, these women achieved pregnancy in the first treatment cycle with vaginal sildenafil citrate. Using transvaginal ultrasound, endometrial thickness was noted to improve when sildenafil citrate was administered. It is suspected that this medication causes selective vasodilatation, resulting in improved endometrial development.