OBJECTIVE: There is limited literature on the impact of the extent of resection on short-term outcomes in patients with ulcerative colitis (UC) in an elective setting. The aim of this study was to better understand the impact of approach and extent of resection on short-term outcomes for patients undergoing total proctocolectomy (TPC) and subtotal colectomy (STC) for UC. METHODS: Patients with UC who underwent elective TPC or STC were captured from the ACS-NSQIP(R) 2011-2018 database and divided into four cohorts: Open TPC (O-TPC), Laparoscopic TPC (L-STC), Open STC (O-STC), and Laparoscopic STC (L-STC). Baseline and perioperative variables were compared between the four groups alongside 30-day mortality and 30-day complication rates. RESULTS: Of 3387 patients, 368 (10.9%) underwent O-STC, 406 (12%) underwent O-TPC, 1958 (58%) underwent L-STC, and 655 (19%) underwent L-TPC. Overall rate of prolonged length of stay (LOS) was 27% and 9% needed a blood transfusion. There was no difference in the risk of complications between open TPC and open STC. Those who had open surgery had a higher risk of complications and prolonged LOS. Patients who had L-TPC had prolonged LOS compared to patients who had L-STC, but less compared to those who had O-STC. CONCLUSION: Elective surgery for UC is associated with high rates of prolonged LOS and blood transfusion despite MIS approaches. Short-term outcomes and LOS are more impacted by the operative approach than the extent of resection. Despite this laparoscopic TPC has higher rates of prolonged LOS when compared to laparoscopic STC.

Asherman's Syndrome (AS) is an acquired condition defined by the presence of intrauterine adhesions (IUA) that cause symptoms such as menstrual abnormalities, pelvic pain, infertility, recurrent miscarriage, abnormal placentation and attendant psychological distress. Classically, AS is considered an iatrogenic disease triggered by trauma to the pregnant uterus. Different factors can cause the destruction of the endometrium, thus affecting the endometrial stem cell niche and creating IUAs. Curettage of the pregnant uterus appears to be the most common source of this destruction. Nevertheless, some AS cases have been associated with congenital uterine abnormalities and infections, and there are some idiopathic cases without any prior surgical procedures, suggesting a putative constitutional predisposition to IUA. Factors reported to cause AS share an underlying inflammatory mechanism leading to defective endometrial healing and vascularization. Interestingly, distinct genetic profiles have been observed in the endometrium of AS patients. These data suggest that AS might not just be an iatrogenic complication, but also the result of a genetic predisposition. Elucidating the possible physiopathological processes that contribute to AS will help to identify patients at risk for this condition, providing an opportunity for prevention.

OBJECTIVE: To analyze data from the hysteroscopic adhesiolysis of moderate-to-severe intrauterine adhesions (IUAs), and to review the disease etiology, changes in menstruation, uterine recovery, and reproductive prognosis of women after comprehensive therapy. METHODS: In a retrospective descriptive analysis, clinical data were assessed from 683 patients with moderate-to-severe IUAs who were treated by hysteroscopic adhesiolysis at Third Xiangya Hospital, Changsha, China, between January 2007 and December 2011. Patients underwent comprehensive treatment. After hysteroscopic adhesiolysis, a persistent balloon urinary catheter was inserted, together with an intrauterine device (IUD). Intrauterine sodium hyaluronate gel was injected to prevent adhesion reformation, and oral estrogen was administered to promote endometrial regeneration. The outcomes were menstrual changes and uterine recovery under hysteroscopy, and the reproductive prognosis of patients with fertility intentions. RESULTS: At the 3-month follow-up, the postoperative recovery of uterine shape was better than the recovery of menstruation among patients with moderate-to-severe IUAs. Among the 475 patients with fertility intentions, the pregnancy and live birth rates were 66.1% (314/475) and 64.0% (201/314), respectively. CONCLUSION: Comprehensive treatment prevented the recurrence of IUAs to a certain extent, but some severe endometrial injuries were found to be irreparable, reducing the rate of subsequent pregnancy and live birth.

OBJECTIVE: To compare the clinical characteristics of Asherman syndrome and the outcomes of hysteroscopic adhesiolysis in women after first or second-trimester termination of pregnancy (TOP). METHODS: This was a retrospective descriptive analysis of patients with moderate-to-severe intrauterine adhesiolysis (IUAs) after TOP and treated by hysteroscopic adhesiolysis and followed by

The current treatment for Asherman syndrome is limited and not very effective. The aim of this review is to summarize the most recent evidence for stem cells in the treatment of Asherman syndrome. The advent of stem cell therapy has propagated experimentation on mice and humans as a novel treatment. The consensus is that the regenerative capacity of stem cells has demonstrated improved outcomes in terms of fertility and fibrosis in both mice and humans with Asherman syndrome. Stem cells have effects on tissue repair by homing to the injured site, recruiting other cells by secreting chemokines, modulating the immune system, differentiating into other types of cells, proliferating into daughter cells, and potentially having antimicrobial activity. The studies reviewed examine different origins and administration modalities of stem cells. In preclinical models, therapeutic systemic injection of stem cells is more effective than direct intrauterine injection in regenerating the endometrium. In conjunction, bone marrow-derived stem cells have a stronger effect on uterine regeneration than uterine-derived stem cells, likely due to their broader differentiation potency. Clinical trials have demonstrated the initial safety and effectiveness profiles of menstrual, bone marrow, umbilical cord, and adipose tissue-derived stem cells in resumption of menstruation, fertility outcomes, and endometrial regeneration.

Intrauterine adhesions (IUAs) are bands of fibrous tissue that form in the endometrial cavity and associated with the increased risk of abnormal menstruation, recurrent pregnancy loss, secondary infertility, and pregnancy complications. Physical barriers, including intrauterine device and hydrogel, were clinical available to prevent the post-operational IUAs. But physically separation of the injured endometrium relies on the own limited healing power and often ends with recurrence. In recent years, the mechanisms driving IUAs treatment has validated the application of hormones, and further stem cell therapy has also led to the development of novel therapeutic agents with promising efficacy in pre-clinical and initial clinical studies. Still, it is challenging to delivery the therpaeutic factors to the injured uterus. Herein, in this review, we discuss the traditional intervention methods for the prevention of IUAs, as well as novel therapeutics and delivery strategies that will most likely change the treatment paradigms for better clinical outcomes. The combination strategy that using physical barriers as the delivery carriers for therapeutics might provide new alternatives for the prevention of IUAs.

Intrauterine adhesions (IUA) or Asherman's syndrome is a multifaceted condition which is being diagnosed with increasing frequency. Although it usually occurs following curettage of the pregnant or recently pregnant uterus, any uterine surgery can lead to IUA. Most women with IUA have amenorrhoea or hypomenorrhoea, but some have normal menses. Those who have amenorrhoea may also have cyclic pelvic pain secondary to 'trapped' menses and the accompanying retrograde menstruation may lead to endometriosis. In addition to menstrual disorders, most women with IUA will present with infertility or recurrent spontaneous abortion. Over the last four decades hysteroscopy has become the standard method to diagnose and treat this condition. Various techniques for adhesiolysis and for prevention of scar reformation have been advocated. The most efficacious appears to be the use of miniature scissors for adhesiolysis and the placement of a balloon stent inside the uterus immediately after surgery. Post-operative oestrogen therapy is prescribed in order to stimulate endometrial regrowth. Follow-up studies to assure resolution of the IUA are mandatory before the patient attempts to conceive as is careful monitoring of pregnancies for cervical incompetence, placenta accreta and intrauterine growth restriction.

OBJECTIVE: To assess the rate of complications of surgical interventions delayed more than 24 h after delivery in women suspected of placental remnants. METHODS: A retrospective review was performed to analyse complications of delayed surgical interventions. Women were identified from the operation database and their medical records were reviewed to determine the rate of immediate and long-term complications, including reproductive outcome. RESULT: A total of 127 women were evaluated. The median interval between delivery and surgery was 42 days. Immediate complications were registered in 22.0% and re-interventions in 16.5%. Placental remnants were histologically confirmed in 63.8%. Intrauterine adhesions (IUAs), only of the severe type, were recorded in 20.5%, although a minority of women was hysteroscopically revised. The difference between women treated by dilatation and curettage (D&C) and hysteroscopy was not statistically significant. Similar reproductive outcomes were encountered in women treated by D&C and hysteroscopy and in women with and without IUAs, although the samples were small. CONCLUSION: Identification of placental remnants remains difficult while delayed interventions are associated with significant immediate and long-term complications. The impact on reproductive performance remains unclear. Further research is necessary to examine treatment options in relation to complications and reproductive outcome.

Intrauterine adhesions (IUA) can occur after mechanical or infectious injury to the endometrium. Normal endometrial repair occurs without scar formation; however, in some women, these normal repair mechanisms are aberrant, resulting in IUA formation. The exact alteration in repair mechanisms is not well understood; however, it likely involves hypoxia, reduced neovascularization, and altered expression of adhesion-associated cytokines. The prevalence of IUA varies by the type of injury and ranges from 16 to 24% in women undergoing pregnancy-related curettage and 31 to 45% after hysteroscopic myomectomy. The presence of IUA may result in infertility and/or pregnancy complications; thus, hysteroscopic adhesiolysis is typically recommended before conception. Sharp dissection rather than cautery to resect adhesions and postoperative treatment with an IUA barrier and estrogen may decrease the likelihood of recurrence. Menstrual history before hysteroscopic repair and endometrial thickness after surgical repair may be useful in assessing endometrial receptivity and the likelihood of conception.

Intrauterine adhesions with symptoms like hypomenorrhea or infertility are known under the term Asherman's syndrome. Although the syndrome has been widely investigated, evidence of both prevention of the syndrome and the ideal treatment are missing. Understanding the pathogenesis of intrauterine adherences is necessary for the prevention of the formation of intrauterine scarring. Intrauterine adhesions can develop from lesion of the basal layer of the endometrium caused by curettage of the newly pregnant uterus. The syndrome may also occur after hysteroscopic surgery, uterine artery embolization or uterine tuberculosis. For initial diagnosis the less invasive contrast sonohysterography or hysterosalpingography is useful. The final diagnosis is based on hysteroscopy. Magnetic resonance imaging is required in cases with totally obliterated uterine cavity. Intrauterine adherences are classified in accordance with different classification systems based on the hysteroscopic diagnosis of severity and localization of adherences. Classification is necessary for the planning of surgery, information on prognosis and scientific purposes. Surgery is performed in symptomatic patients with either infertility or with painful periods. Intrauterine adherences are divided with a hysteroscope using scissors or a power instrument working from the central part of the uterus to the periphery. Peroperative ultrasonography is useful in an outpatient setting for the prevention of complications. Hysteroscopy with fluoroscopy is a solution in difficult cases. Use of intrauterine devices like balloon catheters or intrauterine contraceptive devices seems to be the preferred methods for the prevention of re-occurrence of adhesions after treatment. Both primary prevention after hysteroscopic surgery or curettage and secondary prevention of new adhesions after adhesiolysis have been investigated. The aim of this review was to summarize the literature on diagnosis, classification, treatment and prevention, based on a literature search with a wide range of search terms.

Transcervical resection of adhesion (TCRA) is the standard treatment for the intrauterine adhesions, but the recurrence of adhesions is a tough problem for the gynecologist. In addition, the therapeutic strategy after TCRA about prevention of recurrence remains controversial especially for the patients with moderate to severe intrauterine adhesions (IUAs). Hence, we designed this study to explore the safety and efficacy of fresh amnion grafts for preventing the recurrence after TCRA for patients with moderate to severe IUAs. One hundred patients with moderate to severe IUAs who presented with a history of hypomenorrhea, amenorrhea and infertility were included in the study from January 2015 to December 2017. Patients were divided into amnion group (52 patients) and chitosan group (48 patients). Fresh amnion grafts or intrauterine injections of chitosan were administered after TCRA. Transvaginal ultrasonography (TVUS) and hysteroscopy were performed at the first and third month after the operation. The surgical procedures for all patients were completed successfully without relevant complications. In amnion group, 8 patients exhibited relapse in the first month and 2 patients in three months after surgery; in chitosan group, 23 women exhibited relapse in the first month and 18 patients in three months after surgery. Statistical analysis revealed that the recurrence rate of adhesion in amnion group was significantly lower than those of chitosan group in the first and three months after surgery (P 1 = 0.000, P 2 = 0.000). After TCRA, fresh amnion graft plays a significant role in preventing further adhesions than injections of chitosan.

OBJECTIVE: Intrauterine adhesions (IUAs) are a problematic complication after termination of pregnancy, but their incidence is unknown. Our objective was to assess the incidence of IUAs following induced termination of pregnancy and the risk factors for IUAs. DESIGN: Retrospective cohort study. SETTING: A nationwide registry study. SAMPLE: All women undergoing induced termination of pregnancy (n = 80 015) in Finland between 2000 and 2008. METHODS: The data were retrieved from the Finnish Abortion Registry and the Hospital Discharge Registry. The diagnosis of IUAs or complications was based on the diagnostic codes (International Statistical Classification of Diseases and Related Health Problems 10th Revision, ICD-10) and operative codes according to the Nordic Medico-Statistical Committee (NOMESCO) Classification of Surgical Procedures (NCSP). IUAs were defined as ICD-10 code N85.6 or operative code LCG02. A subanalysis of IUA cases and five matched controls was performed. MAIN OUTCOME MEASURES: The incidence of and risk factors for IUAs. RESULTS: A total of 12 (1.5 per 10 000) IUA diagnoses were identified from 79 960 eligible induced terminations of pregnancy. The rate of IUAs was 1.5 and 2.0 cases per 10 000 terminations of pregnancy following medically and surgically induced termination of pregnancy, respectively (P = 0.19). In a subgroup analysis of IUA cases and five matched controls, surgical treatment of the remaining products of conception following termination of pregnancy significantly increased the risk of IUAs (odds ratio, OR 5.50; 95% confidence interval, 95% CI 1.46-20.79; P = 0.012). CONCLUSION: IUAs that require further treatment are rare after an induced termination of pregnancy. Surgical evacuation following medical or surgical termination of pregnancy was a risk factor for the diagnosis of IUAs. These results suggest that trauma to a recently pregnant uterus is an important risk factor for IUAs. TWEETABLE ABSTRACT: IUA is rare after induced termination of pregnancy (iTOP), but surgical evacuation is a risk factor for IUAs.

OBJECTIVE: Hysteroscopic removal of retained products of conception (RPOC) may allow complete removal of RPOC and decreased rates of intrauterine adhesions (IUA) when compared to the traditional blind curettage. The aim of this meta-analysis is to examine the current evidence regarding the use of hysteroscopy for treatment of RPOC. STUDY DESIGN: A literature search was conducted in December 2012 using MEDLINE and ClinicalTrials. The study selection criteria were use of the standard hysteroscopic technique for removal of RPOC in 5 or more cases, in any study design. We reviewed 11 studies, of which 5 retrospective studies met the selection criteria (comprising 326 cases). The rates of incomplete RPOC removal, surgical complications, post-operative IUA and subsequent pregnancies were abstracted and weighted events rates using a fixed meta-analysis model were calculated. RESULTS: Only one study compared the rates of IUA following hysteroscopy and curettage, precluding a meta-analysis comparison of the two techniques. There were no cases of incomplete RPOC removal. Three perioperative complications occurred (uterine perforation, infection, and vaginal bleeding). IUA on follow-up hysteroscopy were found in 4/96 women (weighted rate of 5.7%, 95% CI 2.4%, 13.0%). Of the 120 women desiring a subsequent pregnancy 91 conceived (weighted rate of 75.3%, 95% CI 66.7%, 82.3%). CONCLUSIONS: The lack of traditional curettage comparison groups in most studies precludes the conclusion that hysteroscopy is superior to traditional curettage, but this procedure does appear to have low complication rates, low rates of IUA, and high rates of subsequent pregnancies.

1 cm and IUA-OLs can aggravate reproductive outcomes, resulting in the need for reoperation. New criteria for diagnosing a uterine septum according to the European Society of Human Reproduction and Embryology (ESHRE) and European Society for Gynaecological Endoscopy (ESGE) have been suggested (ESHRE-ESGE criteria). Autocross-linked hyaluronic acid gel (autocross-linked polysaccharide) has an antiadhesive effect. STUDY DESIGN, SIZE, DURATION: A prospective, observational cohort study was performed with 96 women consecutively enrolled between 2007 and 2012. PARTICIPANTS/MATERIALS, SETTING, METHODS: Women who had uterine septum and previous miscarriage or infertility presented for evaluation at a university hospital, private hospital or private medical center were included. Preoperative septal width, length and surface area were determined with three-dimensional sonohysterography. Women were treated by hysteroscopy in a standardized manner with three- or four-dimensional transrectal ultrasound guidance (complete resection). Patients received either no adhesion barrier (49 patients) or adhesion barrier with autocross-linked polysaccharide (47 patients). Anatomic results were assessed with three-dimensional sonohysterography and second-look hysteroscopy. Healing-dependent ARs were reported using both American Society of Reproductive Medicine (ASRM) criterion of RS length >1 cm (ASRM>1 cm criterion) and ESHRE-ESGE criteria. Univariate and multivariate logistic regression were used to identify predictors of RS, IUA-OLs and ARs. MAIN RESULTS AND ROLE OF CHANCE: In patients who had no adhesion barrier, ARs were diagnosed in 11 of 49 patients (23%) using the ASRM > 1 cm criterion and in 20 of 49 patients (41%) using the ESHRE-ESGE criteria for RS [odds ratio (OR)ESHRE-ESGE:ASRM, 2.4, P = 0.05]. In the patients who had autocross-linked polysaccharide, ARsASRM > 1 cm were diagnosed in 2 of 47 patients (4%) and ARsESHRE-ESGE in 4 of 47 patients (9%). RSESHRE-ESGE was diagnosed significantly more often than RSASRM > 1 cm 19 of 96 (20%) versus 5 of 96 (5%) in all patients (ORESHRE-ESGE:ASRM > 1 cm = 4.5, P 1 cm and ESHRE-ESGE criteria showed that the width and surface area were predictors of ARs. Models adjusted by patient group confirmed the significance of width as a predictor of ARsASRM > 1 cm [OR for width, 3.5 (P 1 cm [OR for surface area, 1.5 (P 1 cm (septal width, 3.42 cm; septal surface area, 4.68cm(2)) and ARsESHRE-ESGE (septal width, 3.42 cm; septal surface area, 3.51cm(2)). LIMITATIONS AND REASONS FOR CAUTION: Patients were enrolled in the adhesion barrier group in a time-dependent, consecutive and non-randomized manner. WIDER IMPLICATIONS OF THE FINDINGS: A wide septum and large surface area may be indications for adhesion barrier. The use of autocross-linked polysaccharide reduces the risk of ARs. The ESHRE-ESGE criteria may cause greater frequency of recognition of RS than the ASRM > 1 cm criterion, which could result in more frequent reoperations with use of the ESHRE-ESGE criteria, possibly without any significant effect on reproductive performance. STUDY FUNDING/COMPETING INTEREST(S): This work was supported by Jagiellonian University (grant no. K/ZDS/003821). The authors have no competing interest to declare.]]>

BACKGROUND: Wilson's disease, first described by Samuel Wilson in 1912, is an autosomal recessive metabolic disorder resulting from mutations in the ATP7B gene. The disease develops as a consequence of copper accumulating in affected tissues. There is no gold standard for the diagnosis of Wilson's disease, which is often delayed due to the non-specific clinical features and the need for a combination of clinical and laboratory tests for diagnosis. This delay may in turn affect clinical outcome and has implications for other family members in terms of diagnosis. The Leipzig criteria were established to help standardise diagnosis and management. However, it should be emphasised that these criteria date from 2003, and many of these have not been formally evaluated; this review examines the evidence behind biochemical testing for Wilson's disease. OBJECTIVES: To determine the diagnostic accuracy of three biochemical tests at specified cut-off levels for Wilson's disease. The index tests covered by this Cochrane Review are caeruloplasmin, 24-hour urinary copper and hepatic copper content. These tests were evaluated in those with suspected Wilson's disease and appropriate controls (either healthy or those with chronic liver disease other than Wilson's). In the absence of a gold standard for diagnosing Wilson's disease, we have used the Leipzig criteria as a clinical reference standard. To investigate whether index tests should be performed in all individuals who have been recommended for testing for Wilson's disease, or whether these tests should be limited to subgroups of individuals. SEARCH METHODS: We identified studies by extensive searching of, e.g. the Cochrane Central Register of Controlled Trials (CENTRAL), PubMed, Embase, the Web of Science and clinical trial registries (29 May 2019). Date of the most recent search of the Cochrane Cystic Fibrosis and Genetic Disorders Inborn Errors of Metabolism Register: 29 May 2019. SELECTION CRITERIA: We included prospective and retrospective cohort studies that assessed the diagnostic accuracy of an index test using the Leipzig criteria as a clinical reference standard for the diagnosis of Wilson's disease. DATA COLLECTION AND ANALYSIS: Two review authors independently reviewed and extracted data and assessed the methodological quality of each included study using the QUADAS-2 tool. We had planned to undertake meta-analyses of the sensitivity, specificity at relevant cut-offs for each of the biochemical tests for Wilson's, however, due to differences in the methods used for each biochemical index test, it was not possible to combine the results in meta-analyses and hence these are described narratively. MAIN RESULTS: Eight studies, involving 5699 participants (which included 1009 diagnosed with Wilson's disease) were eligible for inclusion in the review. Three studies involved children only, one adults only and the four remaining studies involved both children and adults. Two evaluated participants with hepatic signs and six with a combination of hepatic and neurological signs and symptoms of Wilson's disease, as well as pre-symptomatic individuals. The studies were of variable methodological quality; with high risk if bias for participant selection and the reference standard used being of greatest methodological concern. Key differences between studies include differences in assay methodology, different cut-off values for diagnostic thresholds, different age and ethnicity groups. Concerns around study design imply that diagnostic accuracy figures may not transfer to populations outside of the relevant study. INDEX TEST: caeruloplasmin Five studies evaluated various thresholds of caeruloplasmin (4281 participants, of which 541 had WD). For caeruloplasmin a cut-off of 0.2 g/L as in the Leipzig criteria achieved a sensitivity of 77.1% to 99%, with variable specificity of 55.9% to 82.8%. Using the cut-off of 0.1 g/L of the Leipzig criteria seemed to lower the sensitivity overall, 65% to 78.9%, while increasing the specificity to 96.6% to 100%. INDEX TEST: hepatic copper Four studies evaluated various thresholds of hepatic copper (1150 participants, of which 367 had WD). The hepatic copper cut-off of 4 mumol/g used in the Leipzig criteria achieved a sensitivity of 65.7% to 94.4%, with a variable specificity of 52.2% to 98.6%. INDEX TEST: 24-hour urinary copper Three studies evaluated various thresholds of 24-hour urinary copper (268 participants, of which 101 had WD). For 24-hour urinary copper, a cut-off of 0.64 to 1.6 mumol/24 hours used in the Leipzig criteria achieved a variable sensitivity of 50.0% to 80.0%, with a specificity of 75.6% to 98.3%. AUTHORS' CONCLUSIONS: The cut-offs used for caeruloplasmin, 24-hour urinary copper and hepatic copper for diagnosing Wilson's disease are method-dependent and require validation in the population in which such index tests are going to be used. Binary cut-offs and use of single-test strategies to rule Wilson's disease in or out is not supported by the evidence in this review. There is insufficient evidence to inform testing in specific subgroups, defined by age, ethnicity or clinical subgroups.

Female genital tuberculosis (FGTB) is caused by Mycobacterium tuberculosis (rarely Mycobacterium bovis and/or atypical mycobacteria) being usually secondary to TB of the lungs or other organs with infection reaching through haematogenous, lymphatic route or direct spread from abdominal TB. In FGTB, fallopian tubes are affected in 90 per cent women, whereas uterine endometrium is affected in 70 per cent and ovaries in about 25 per cent women. It causes menstrual dysfunction and infertility through the damage of genital organs. Some cases may be asymptomatic. Diagnosis is often made from proper history taking, meticulous clinical examination and judicious use of investigations, especially endometrial aspirate (or biopsy) and endoscopy. Treatment is through multi-drug antitubercular treatment for adequate time period (rifampicin, isoniazid, pyrazinamide, ethambutol daily for 60 days followed by rifampicin, isoniazid, ethambutol daily for 120 days). Treatment is given for 18-24 months using the second-line drugs for drug-resistant (DR) cases. With the advent of increased access to rapid diagnostics and newer drugs, the management protocol is moving towards achieving universal drug sensitivity testing and treatment with injection-free regimens containing newer drugs, especially for new and previously treated DR cases.

STUDY OBJECTIVE: To evaluate the prevalence and impact of chronic endometritis (CE) in patients with intrauterine adhesions (IUAs). DESIGN: Prospective cohort study (Canadian Task Force classification II-2). SETTING: University-affiliated hospital. PATIENTS: Eighty-two women with moderate to severe IUAs. INTERVENTIONS: Transcervical resection of adhesions (TCRA) and endometrial biopsy were performed in all patients. According to results of the endometrial biopsy, participants were classified into 2 groups: 29 patients with CE (CE group) and 53 women without CE (NCE group). Second-look hysteroscopy assessed the impact of TCRA using the American Fertility Society classification system. MEASUREMENTS AND MAIN RESULTS: Prevalence of CE, reformation of adhesions, and reduction of adhesion score were studied. Thirty-one women (37.8%) presented with visual signs of CE at hysteroscopy, confirmed by histology in 29 of 82 patients (35.4%). In hysteroscopic diagnosis of CE, sensitivity and specificity were 79.3% (23/29) and 84.9% (45/53), respectively. At second-look hysteroscopy, the recurrence of adhesions in the CE group was significantly higher than in the NCE group (44.8% vs 20.8%, respectively; p = .022). The median reduction of adhesion score was significantly greater in the NCE group (median, 8; range, 0-12) than in the CE group (median, 5; range, 0-10). CONCLUSION: CE in women with IUAs may be a contributing factor in higher adhesion recurrence, indicating chronic inflammation may play a role in IUA recurrence. (Clinical Trial Registration No.: NCT02744807.).

In developed countries Asherman's syndrome is almost always the result of a prior intrauterine operative trauma. This is often asymptomatic but may result in hypo- or amenorrhea and can contribute to infertility and pregnancy complications. We review their etiology, clinical implications, and systems proposed to classify their extent. The numerous methods reported for performing lysis of intrauterine adhesions are summarized along with clinical results. Current strategies to prevent recurrence of intrauterine adhesions have not been conclusively shown to be clinically effective, but the potential for endometrial regeneration using stem cells is an exciting modality under investigation.

Objective: To establish and validate a decision tree model to predict the recurrence of intrauterine adhesions (IUAs) in patients after separation of moderate-to-severe IUAs. Design: A retrospective study. Setting: A tertiary hysteroscopic center at a teaching hospital. Population: Patients were retrospectively selected who had undergone hysteroscopic adhesion separation surgery for treatment of moderate-to-severe IUAs. Interventions: Hysteroscopic adhesion separation surgery and second-look hysteroscopy 3 months later. Measurements and Main Results: Patients' demographics, clinical indicators, and hysteroscopy data were collected from the electronic database of the hospital. The patients were randomly apportioned to either a training or testing set (332 and 142 patients, respectively). A decision tree model of adhesion recurrence was established with a classification and regression tree algorithm and validated with reference to a multivariate logistic regression model. The decision tree model was constructed based on the training set. The classification node variables were the risk factors for recurrence of IUAs: American Fertility Society score (root node variable), isolation barrier, endometrial thickness, tubal opening, uterine volume, and menstrual volume. The accuracies of the decision tree model and multivariate logistic regression analysis model were 75.35% and 76.06%, respectively, and areas under the receiver operating characteristic curve were 0.763 (95% CI 0.681-0.846) and 0.785 (95% CI 0.702-0.868). Conclusions: The decision tree model can readily predict the recurrence of IUAs and provides a new theoretical basis upon which clinicians can make appropriate clinical decisions.

Asherman syndrome is a rare acquired clinical condition resulting in the obliteration of the uterine cavity causedby the presence of partial or complete fibrous intrauterine adhesions involving at least two-thirds of the uterine cavity potentially obstructing the internal cervical orifice. Common reported symptoms of the disease are alterations of the menstrual pattern with decreased menstrual bleeding leading up to amenorrhoea and infertility. Hysteroscopy is currently considered the gold standard diagnostic and therapeutic approach for patients with intrauterine adhesions. An integrated approach, including preoperative, intraoperative and postoperative therapeutic measures, however, are warranted owing to the complexity of the syndrome. This review aims to summarize the most recent evidence on the recommended preoperative, intraoperative and postoperative procedures to restore the uterine cavity and a functional endometrium, as well as on the concomitant use of adjuvant therapies to achieve optimal fertility outcomes.

Background: Management of intrauterine adhesions (IUAs) is challenging, mainly because there is no ideal method to prevent its recurrence. Recurrence of moderate to severe IUAs after conventional treatments entails a poorer prognosis in these patients. This study aimed to assess the safety and effectiveness of a patented intrauterine stent as a barrier in the treatment of recurrent IUAs with poor prognosis. Methods: This was a retrospective, observational study of 13 women with IUAs, admitted to the Third Xiangya Hospital of Central South University from June 2018 to September 2019. After conventional treatments, moderate to severe adhesions were still evident. Then a patented intrauterine stent was used as a barrier to prevent the reformation of adhesions after hysteroscopic adhesiolysis (HA). All cases received a second-look hysteroscopy after 2-3 menstrual cycles. American Fertility Society (AFS) scores were noted for all cases. Menstrual pattern, recurrence of adhesions, and reproductive outcomes were also evaluated. Results: The mean number of previous HA of the 13 patients was 2.7, and mean AFS score after conventional treatments was still 8.7. Before the use of the stent, 46.2% of the patients had amenorrhea caused by IUAs. After using the intrauterine stent as a barrier, the mean AFS score was 1.7. The menstrual improvement rate was 100%, while the rate of resumption of normal menstrual volume was 53.8%. The second-look hysteroscopy revealed a correct position of the stents and no obvious recurrence of IUAs in all cases. After the removal of the stent, the patients were followed up for 2-13 months (mean: 7 months), and no amenorrhea was observed, the recurrence rate of IUAs was 25.0% and one patient got pregnant. Conclusions: Even in the recurrent IUAs patients with very poor prognosis, the patented intrauterine stent has been proved to be very effective in preventing the recurrence of adhesions, on condition that its correct position inside the uterine cavity is achieved. Due to the extremely poor nature of the studied population, the recurrent rate of IUAs and pregnancy rate after the removal of the stent is still discouraging, although the improvement in menstruation is inspiring.