Treatment of intrauterine adhesions and subsequent pregnancy outcomes in an in vitro fertilization population

• Published in: American journal of obstetrics and gynecology 2024-11, Vol.231 (5), p.536.e1-536.e10
• Main Authors: Mortimer, Roisin M., Lanes, Andrea, Srouji, Serene S., Waldman, Ian, Ginsburg, Elizabeth
• Format: Article
• Language: English
• Subjects: Asherman’s syndrome; hysteroscopy; placenta accreta spectrum disorder
• ISSN: 0002-9378; 1097-6868; 1097-6868
• DOI: 10.1016/j.ajog.2024.05.026

Asherman syndrome refers to the presence of intrauterine adhesions, which have clinical implications, including infertility. There are few studies assessing the effect of serial hysteroscopies for adhesiolysis on reproductive and pregnancy outcomes among women who subsequently undergo in vitro fertilization, and none have looked at maternal, neonatal, or placental pregnancy complications. This study aimed to explore the effect of hysteroscopic adhesiolysis among a cohort of patients who subsequently undergo in vitro fertilization. This was a retrospective cohort study of all patients who underwent hysteroscopic adhesiolysis for intrauterine adhesions at our center between 2005–2020 and subsequently attempted conception by in vitro fertilization. A control group of patients who underwent in vitro fertilization for nonuterine factor infertility and had no history of intrauterine adhesions was chosen for comparison. There were 691 patients included in this study, of whom 168 were intrauterine adhesion cases. The implantation rate (41.3% in both groups) and live birth rate (adjusted relative risk, 0.93 [95% confidence interval, 0.76–1.14]) were not statistically different between cases and controls. When grouped by number of previous adhesiolysis surgeries, patients who underwent ≥2 adhesiolysis surgeries had a lower live birth rate than controls (adjusted relative risk, 0.53 [95% confidence interval, 0.28–0.99]). Endometrial thickness before the transfer was significantly reduced in cases vs controls (8.23 vs 10.25 mm; adjusted relative risk, 0.84 [95% confidence interval, 0.78–0.90]). Adverse placental outcomes, including placenta accreta spectrum, placenta previa, or vasa previa, were significantly more likely to occur in cases than controls (adjusted relative risk, 2.08 [95% confidence interval, 1.25–3.46]). When grouped by the number of adhesiolysis surgeries, the risk appeared to increase as the number of prior surgeries increased. This is likely because of the increased severity of these adhesions. Overall, patients with a history of treated intrauterine adhesions have the same live birth rate as patients undergoing in vitro fertilization for nonuterine factor indications. However, the subgroup of patients who require multiple surgeries for correction of intrauterine adhesions had a lower live birth rate after in vitro fertilization than controls. Patients with a history of treated intrauterine adhesions are at significantly greater risk of placenta acc