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Live birth rate and obstetric complications following the hysteroscopic management of intrauterine adhesions including Asherman syndrome.
Hum Reprod. 2018 10 01; 33(10):1847-1853.HR

Abstract

STUDY QUESTION

What are the live birth rate and risks of obstetric complications following the surgical management of intrauterine adhesions (IUA) such as Asherman syndrome (AS)?

SUMMARY ANSWER

The live birth rate is 63.7%, and obstetric complications including placentation issues, prematurity and postpartum hysterectomy require that pregnancies in women after treatment for IUA should be considered moderate to high risk.

WHAT IS KNOWN ALREADY

Studies reviewing short-term surgical, menstrual and fertility outcomes following hysteroscopic management are reassuring, with success correlated to the severity of IUA. There are limited data reporting live birth, neonatal and maternal complications.

STUDY DESIGN, SIZE, DURATION

This retrospective study included all women treated for IUA by hysteroscopic synechiolysis under fluoroscopic guidance in two tertiary University-affiliated hospitals. All women reported at least one pre-treatment symptom including menstrual dysfunction, subfertility or pelvic pain and intended to become pregnant post-treatment. Survival curve analysis was performed for time to pregnancy, and obstetric data were collated from a National Obstetric Database for delivery and neonatal outcomes.

PARTICIPANTS/MATERIALS, SETTING, METHODS

A total of 154 women were included in the study. Surgical intervention involved hysteroscopic synechiolysis under fluoroscopic guidance until cavity restoration was confirmed. Questionnaires regarding fertility and its outcomes were sent to all women undergoing surgery, with analysis of menstrual, fertility rates and outcomes of those pregnancies including risks and complications to the woman and the offspring.

MAIN RESULTS AND THE ROLE OF CHANCE

Women were followed up for a minimum of 1 year (range: 1-14 years) from index surgery. The chance of pregnancy was 98/124 (79.0% CI: 63.6, 83.1%) in women wishing to conceive and the chance of a live birth was 79/124 (63.7% CI: 51.3, 70.7%). The chance of a miscarriage was 29/124 (23.4% CI: 18.8, 37.1%). There were 93 live births in 79 women following surgery, with detailed obstetric data available for 85 of these births. They were complicated by abnormal placentation in 15/85 (17.6% CI: 13.0, 30.2%), postpartum hysterectomy in 4/85 (4.7% CI: -0.4, 7.0%), and prematurity in 25/85 (29.4% CI: 17.0, 35.3%) women.

LIMITATIONS, REASONS FOR CAUTION

The retrospective nature of the study and extended follow-up time may cause selection and recall bias, however, pregnancy and its outcomes-particularly in women with problems of subfertility-are frequently key milestones, with birthdates readily recalled. Menstrual outcomes are more likely to be subject to recall bias.

WIDER IMPLICATIONS OF THE FINDINGS

Our surgical data are similar to the published literature with reassuring short-term outcomes for menstruation and cavity reconstruction following surgery for IUA. Long-term outcomes including pregnancy rates were higher than published data, however, the obstetric and neonatal complication rates were increased, indicating a continuation of risk beyond infertility and into pregnancy. An altered biochemical or vascular environment is a possible explanation for impaired implantation resulting in poorer reproductive obstetric and neonatal outcomes. The relative rarity of IUA-particularly severe disease-makes prospective data collection difficult. Our data suggest that women with IUA should be treated as moderate-high risk obstetric patients in subsequent pregnancy and counselled appropriately.

STUDY FUNDING/COMPETING INTEREST(S)

No funding and no competing interests.

Authors+Show Affiliations

School of Women's and Children's Health, University of New South Wales, Barker St, Randwick, NSW, Australia. Royal Hospital for Women, Barker, St Randwick, NSW, Australia. Genea Ltd., 321 Kent St, Sydney, NSW, Australia.School of Women's and Children's Health, University of New South Wales, Barker St, Randwick, NSW, Australia. Royal Hospital for Women, Barker, St Randwick, NSW, Australia.School of Women's and Children's Health, University of New South Wales, Barker St, Randwick, NSW, Australia. Royal Hospital for Women, Barker, St Randwick, NSW, Australia.School of Women's and Children's Health, University of New South Wales, Barker St, Randwick, NSW, Australia.School of Women's and Children's Health, University of New South Wales, Barker St, Randwick, NSW, Australia. Royal Hospital for Women, Barker, St Randwick, NSW, Australia.

Pub Type(s)

Journal Article
Multicenter Study

Language

eng

PubMed ID

30239778

Citation

Deans, Rebecca, et al. "Live Birth Rate and Obstetric Complications Following the Hysteroscopic Management of Intrauterine Adhesions Including Asherman Syndrome." Human Reproduction (Oxford, England), vol. 33, no. 10, 2018, pp. 1847-1853.
Deans R, Vancaillie T, Ledger W, et al. Live birth rate and obstetric complications following the hysteroscopic management of intrauterine adhesions including Asherman syndrome. Hum Reprod. 2018;33(10):1847-1853.
Deans, R., Vancaillie, T., Ledger, W., Liu, J., & Abbott, J. A. (2018). Live birth rate and obstetric complications following the hysteroscopic management of intrauterine adhesions including Asherman syndrome. Human Reproduction (Oxford, England), 33(10), 1847-1853. https://doi.org/10.1093/humrep/dey237
Deans R, et al. Live Birth Rate and Obstetric Complications Following the Hysteroscopic Management of Intrauterine Adhesions Including Asherman Syndrome. Hum Reprod. 2018 10 1;33(10):1847-1853. PubMed PMID: 30239778.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Live birth rate and obstetric complications following the hysteroscopic management of intrauterine adhesions including Asherman syndrome. AU - Deans,Rebecca, AU - Vancaillie,Thierry, AU - Ledger,William, AU - Liu,Jinzhu, AU - Abbott,Jason A, PY - 2017/02/21/received PY - 2018/9/22/pubmed PY - 2019/5/31/medline PY - 2018/9/22/entrez SP - 1847 EP - 1853 JF - Human reproduction (Oxford, England) JO - Hum. Reprod. VL - 33 IS - 10 N2 - STUDY QUESTION: What are the live birth rate and risks of obstetric complications following the surgical management of intrauterine adhesions (IUA) such as Asherman syndrome (AS)? SUMMARY ANSWER: The live birth rate is 63.7%, and obstetric complications including placentation issues, prematurity and postpartum hysterectomy require that pregnancies in women after treatment for IUA should be considered moderate to high risk. WHAT IS KNOWN ALREADY: Studies reviewing short-term surgical, menstrual and fertility outcomes following hysteroscopic management are reassuring, with success correlated to the severity of IUA. There are limited data reporting live birth, neonatal and maternal complications. STUDY DESIGN, SIZE, DURATION: This retrospective study included all women treated for IUA by hysteroscopic synechiolysis under fluoroscopic guidance in two tertiary University-affiliated hospitals. All women reported at least one pre-treatment symptom including menstrual dysfunction, subfertility or pelvic pain and intended to become pregnant post-treatment. Survival curve analysis was performed for time to pregnancy, and obstetric data were collated from a National Obstetric Database for delivery and neonatal outcomes. PARTICIPANTS/MATERIALS, SETTING, METHODS: A total of 154 women were included in the study. Surgical intervention involved hysteroscopic synechiolysis under fluoroscopic guidance until cavity restoration was confirmed. Questionnaires regarding fertility and its outcomes were sent to all women undergoing surgery, with analysis of menstrual, fertility rates and outcomes of those pregnancies including risks and complications to the woman and the offspring. MAIN RESULTS AND THE ROLE OF CHANCE: Women were followed up for a minimum of 1 year (range: 1-14 years) from index surgery. The chance of pregnancy was 98/124 (79.0% CI: 63.6, 83.1%) in women wishing to conceive and the chance of a live birth was 79/124 (63.7% CI: 51.3, 70.7%). The chance of a miscarriage was 29/124 (23.4% CI: 18.8, 37.1%). There were 93 live births in 79 women following surgery, with detailed obstetric data available for 85 of these births. They were complicated by abnormal placentation in 15/85 (17.6% CI: 13.0, 30.2%), postpartum hysterectomy in 4/85 (4.7% CI: -0.4, 7.0%), and prematurity in 25/85 (29.4% CI: 17.0, 35.3%) women. LIMITATIONS, REASONS FOR CAUTION: The retrospective nature of the study and extended follow-up time may cause selection and recall bias, however, pregnancy and its outcomes-particularly in women with problems of subfertility-are frequently key milestones, with birthdates readily recalled. Menstrual outcomes are more likely to be subject to recall bias. WIDER IMPLICATIONS OF THE FINDINGS: Our surgical data are similar to the published literature with reassuring short-term outcomes for menstruation and cavity reconstruction following surgery for IUA. Long-term outcomes including pregnancy rates were higher than published data, however, the obstetric and neonatal complication rates were increased, indicating a continuation of risk beyond infertility and into pregnancy. An altered biochemical or vascular environment is a possible explanation for impaired implantation resulting in poorer reproductive obstetric and neonatal outcomes. The relative rarity of IUA-particularly severe disease-makes prospective data collection difficult. Our data suggest that women with IUA should be treated as moderate-high risk obstetric patients in subsequent pregnancy and counselled appropriately. STUDY FUNDING/COMPETING INTEREST(S): No funding and no competing interests. SN - 1460-2350 UR - https://www.unboundmedicine.com/medline/citation/30239778/Live_birth_rate_and_obstetric_complications_following_the_hysteroscopic_management_of_intrauterine_adhesions_including_Asherman_syndrome_ L2 - https://academic.oup.com/humrep/article-lookup/doi/10.1093/humrep/dey237 DB - PRIME DP - Unbound Medicine ER -