Prevention of intra uterine adhesion following hysteroscopy procedure: a review of literature

Back ground: Intra uterine adhesions have been recognised as a cause of secondary amenorrhoea since the end of 19th century 1. IU adhesions are a rare but significant cause of menstrual disturbances and secondary infertility 2. They are likely to form after any endo- uterine surgery via deregulated activation of coagulation chain linked to the inflammatory process 3.
Objective: The purpose of this review was to perform a systematic study and analysis to evaluate the effectiveness of post operative prevention strategies on intra uterine adhesion formation following operative hysteroscopy.
Materials and Method: Systematic computer based literature search was conducted to provide a survey of the various measures used in hysteroscopy surgery to prevent adhesions in accordance with PRISMA (preferred reporting items for systematic reviews and meta analysis) guidelines.
Searches were conducted in Medline, Pub Med, Cochrane Library, ErMed, Scopus and World of science databases using the keywords ‘prevention’, ‘intrauterine Adhesions’, ‘asherman syndrome’, ‘post operative’, ‘uterine synechae’, ‘endo uterine surgery’. The search included studies from the earliest publication from 1985 date to publication 2016 in English literature.
Inclusion criteria were studies preferably randomised control studies or observational studies (prospective or retrospective cohort) comparing any preventive measures of intrauterine adhesions after hysteroscopy were included in review. The main outcome measure was a reduction in post operative intrauterine adhesion.
Results: Five studies evaluated intra uterine devices and three studies evaluated hyaluronic acid gel, 3 studies evaluated hormones and other medications and 5 studies evaluated effect of stem cells in re generation of uterine endometrial layers. The results of our study shows that (1) surgical techniques which uses less electro cautery should be preferred over others (2) non copper containing barrier are the most widely used methods and gel barrier have been proven to have significant clinical effect (3) early second look hysteroscopy would appear to be an effective preventive strategy before the adhesions settles down. (4) the role of hormones and antibiotics have been used in combination with other methods so efficacy if the individual substance is difficult to evaluate (5) Autologous stem cells are showing very promising results and will be effective tool in future.
Conclusions: There is lack of definite evidence to conclude that any particular treatment is effective in preventing post hysteroscopic uterine adhesion formation 4. Robust and high quality randomised trials are still needed to assess the effectiveness of different anti adhesion therapies before any of these strategies may be strongly recommended for improving clinical outcomes in women treated by operative hysteroscopy5.