Abstract
Objective
To compare outcomes of operative hysteroscopy for intrauterine adhesions between single and multiple procedures.
Methods
This was a retrospective cohort in a teaching hospital including women of childbearing age treated by operative hysteroscopy for intrauterine adhesions between January 2010 and May 2020. One or more operative hysteroscopies were performed to remove intrauterine adhesions. The main outcome was occurrence of intrauterine pregnancy and live birth rate after operative hysteroscopy.
Results
A total of 454 women were included with 256 in the “single procedure” group and 198 in the “multiple procedures” group. Among these 454 women, 125 (27.5%) were lost to follow‐up. The intrauterine pregnancy rate was 44.1%, significantly lower in the “multiple procedures” group (36.7% vs. 50.0% [P = 0.02]). The mean time before pregnancy was not significantly different between groups. For women who conceived, the live birth rate was 61%, not significantly different between groups. The risk of abnormal placentation was significantly higher in the multiple procedures group (37.5% vs. 13.8% [P < 0.01]) such as the risk of postpartum hemorrhage (45.4% vs. 19.6% [P = 0.01]).
Conclusion
Repeated procedures appear to increase risks of abnormal placentation and postpartum hemorrhage but it allows some women with severe adhesions to obtain a normal uterine cavity and to become pregnant.
Keywords: Asherman syndrome, fertility, intrauterine adhesions, operative hysteroscopy, synechiae
1. INTRODUCTION
Intrauterine adhesions were first mentioned in 1894 later more accurately described by Asherman in 1948. 1 Intrauterine adhesions often occur following intrauterine procedures such as dilatation and curettage (D&C), operative hysteroscopy, and postpartum hemorrhage management including embolization or uterine compression sutures. They result from an inflammatory process that leads to endometrial fibrosis. 1
The prevalence of intrauterine adhesions is difficult to estimate, as many affected women are asymptomatic. However it appears to have increased in recent years. 1 , 2 , 3
The widespread use of diagnostic hysteroscopy and recent advancements in imaging techniques may have contributed to higher detection rate, resulting in more frequent diagnosis. 1 , 3 , 4
Women with intrauterine adhesions may present with various symptoms such as hypomenorrhea, amenorrhea, pelvic pain, infertility, or recurrent pregnancy loss. Nevertheless, some may remain asymptomatic. 1 , 3 The primary objective of treatment is to restore an normal anatomical and functional uterine cavity.
Operative hysteroscopy is considered the gold standard for surgical management. 2 , 4 Multiple procedures are sometimes necessary to achieve a functional uterine cavity. 1 , 5 , 6 , 7 The benefit of repeated procedures has been demonstrated in retrospective studies, and experts agree that further interventions are warranted when the outcome of the first procedure is suboptimal procedures need to be reiterated if an imperfect result is obtained after the first attempt. 8 , 9
However, an increased risk of obstetric complications, such as hemorrhage, abnormal placentation, 7 , 10 , 11 premature rupture of membranes 11 and preterm birth, 7 , 11 has been reported following operative hysteroscopy for intrauterine adhesions. Available data remain limited.
The aim of the present study was to compare outcomes in women undergoing single versus multiple procedures for the management of intrauterine adhesions.
2. MATERIALS AND METHODS
This retrospective cohort study, conducted in the gynecology department of a teaching hospital and referral center for the management of intrauterine adhesions, included women of reproductive age who underwent operative hysteroscopy for intrauterine adhesions between January 2010 and May 2020. Data were collected using electronic medical records.
The following information was gathered: age; medical history (including uterine surgery for myoma, congenital uterine anomalies, management of retained products of conception, infertility and pelvic inflammatory disease); obstetrical history (number of previous pregnancies, deliveries, miscarriages, terminations of pregnancy, ectopic pregnancies, vaginal deliveries, cesarean sections, and complications related to delivery or abortion such as hemorrhage or abnormal placentation); desire for pregnancy; symptoms (amenorrhea, hypomenorrhea, infertility, recurrent pregnancy loss, or incidental finding); diagnostic evaluations (diagnostic hysteroscopy, hysterosonography, magnetic resonance imaging [MRI]); operative time; number of procedures, use of energy‐based or mechanical techniques; results of second‐look diagnostic hysteroscopy; and achievement of intrauterine pregnancy (spontaneously or via assisted reproductive technology).
Operative hysteroscopies for intrauterine adhesions were performed in the operating room under general or epidural anesthesia. The objective of this surgery was to remove intrauterine adhesions. Two Pozzi tenacula were systematically used to facilitate the introduction of the hysteroscope and minimize the risk of uterine perforation. Ultrasound guidance could also be employed to further reduce this risk. No cervical dilatation was performed at the beginning of the procedure. A 5 mm hysteroscope with an operative channel (Bettochi, Karl Storz, Germany or Easycare, Delmont, France) was used. Adhesiolysis was performed mechanically or with bipolar energy when necessary. The distension medium was saline solution. The procedure was concluded once the uterine cavity was restored, or in the event of complications such as excessive bleeding, fluid imbalance, or uterine perforation. It was primarily planned as outpatient surgery. Three experienced surgeons, assisted by trainees, carried out the surgeries. Recorded data included adhesion severity, visibility of tubal ostia, and endometrial trophicity. The location, extent and type of adhesions were documented and classified according to the European Society of Gynecological Endoscopy (Table 1).
TABLE 1.
European Society of Gynecological Endoscopy (ESGE) classification of intrauterine adhesions.
| Grade | Extent of intrauterine adhesions |
|---|---|
| I | Thin or filmy adhesions. Easily ruptured by hysteroscopic sheath alone. Cornual areas normal |
| II | Singular dense adhesion. Connecting separate area of the uterine cavity. Visualization of both ostia possible. Cannot be ruptured by hysteroscopic sheath alone |
| IIa | Adhesions affect only the cervico‐isthmic area. Furthermore, cavity is normal with visualization of both ostia |
| III | Multiple dense adhesions. Connecting separate areas of the uterine cavity. Unilateral obliteration of ostial area of the tubes |
| IV | Extensive dense adhesions with (partial) occlusion of the uterine cavity. Both tubal ostial areas (partially) occluded |
| Va | Adhesions grade I or II with amenorrhea or hypomenorrhea |
| Vb | Dense or extensive adhesions grade III or IV with amenorrhea |
The following data related to surgical procedures were collected: use of ultrasound guidance during surgery, type of hysteroscope, use of bipolar energy, associated surgical procedure, occurrence of intraoperative complications, fluid balance, shape of the uterine cavity at the end of the procedure, number of visible tubal ostia, appearance of the endometrium, and use of barrier agents to prevent adhesion reccurence.
A follow‐up office hysteroscopy was systematically scheduled four to six weeks after the operative procedure.
The objective of surgery was to restore a triangular‐shaped uterine cavity of adequate size. Repeated procedures were performed when necessary to achieve this outcome. The number of surgeries required to obtain a triangular uterine cavity was recorded. Indication for repeat procedures included progressive improvement in cavity morphology and gradual endometrial re‐epithelialization, which led to the decision to perform an additional intervention. Fertility outcomes following treatment were also documented, including desire for pregnancy, use of assisted reproductive technologies (ART), achievement of pregnancy, time to conception, and pregnancy outcomes (vaginal delivery or cesarean section, preterm delivery, miscarriage, ectopic pregnancy, voluntary termination of pregnancy, medical termination, and any complications such as hemorrhage, infection, or abnormal placentation).
Women were contacted to collect follow‐up fertility data, pregnancy outcomes, and associated complications. Only the first pregnancy occurring after surgery was considered for analysis.
The primary endpoint was the comparison of intrauterine pregnancy rates between the single‐procedure group and the multiple‐procedure group (including both spontaneous and ART‐pregnancies). An intrauterine pregnancy was defined as a pregnancy located within the uterine cavity during the first trimester. Outcomes included miscarriage (early or late), aborption, live birth, intra‐uterine fetal death, or medically indicated termination.
Secondary endpoints included the comparison uterine cavity shape observed during postoperative office hysteroscopy, normalization of menstruation in cases of initial amenorrhea, and complications occurring during the subsequent pregnancy.
Descriptive statistical analysis was performed using Stata software (STATA/SE release 14.2; Texas, USA). Categorical variables are reported as numbers (percentages) and continuous variables as means with 95% confidence intervals (CIs). Comparisons were conducted using a Chi‐square test for categorical variables and a student's t‐test for continuous variables. Survival analysis was performed using the Nelson‐Aalen cumulative hazard function for graphical representation and a Cox proportional hazards model was used to estimate hazard ratios.
A sensitivity analysis was conducted using a logistic regression model after multiple imputation for missing data concerning the occurrence of intrauterine pregnancy following hysteroscopic treatment.
Ethical approval for the study was obtained from the ethics committee (CEROG 2015‐GYN‐0701). All women were informed and provided oral consent for inclusion.
3. RESULTS
From January 2010 to May 2020, 521 women who underwent at least one procedure were recorded. A total of 454 women were included with 256 in the single‐procedure group (56.4%) and 198 in the multiple‐procedures group (43.6%). After surgery, 125 women were lost to follow‐up—74 in the single‐procedure group (28.9%) and 51 in the multiple‐procedures group (25.8%). These data are presented in the flow chart in Figure 1.
FIGURE 1.
Flow chart.
The characteristics of the women and the etiology of intrauterine adhesions are shown in Tables 2 and 3. The mean age of women was 35.6 years old (95% CI [35.1–36.1]). A higher proportion of women in the multiple‐procedures group had living children compared to those in the single‐procedure group (57.5% vs. 51.6%, P < 0.01).
TABLE 2.
Characteristics of included women depending on the number of procedures.
| Characteristics | Total procedures N = 454 | Single procedure N = 256 | Multiple procedure N = 198 | |
|---|---|---|---|---|
| Age – average – 95% CI | 35.6 [35.1–36.1] | 36.0 [35.3–36.6] | 35.1 [34.4–35.8] | P = 0.07 |
| Age over 38 at first surgery | 172 (37.9) | 98 (38.3) | 74 (37.4) | P = 0.84 |
| Gravidity, n (%) | ||||
| 0 | 75 (16.5) | 42 (16,4) | 33 (16,7) | P = 0.02 |
| 1 | 131 (28.8) | 62 (24,2) | 69 (34,9) | |
| ≥2 | 248 (54.6) | 152 (59,4) | 96 (48,5) | |
| Parity, n (%) | ||||
| 0 | 208 (45.8) | 124 (48.4) | 84 (42.4) | P < 0.01 |
| 1 | 150 (33.0) | 66 (25.8) | 84 (42.4) | |
| ≥2 | 96 (21.2) | 66 (25.8) | 30 (15.1) | |
| Medical history, n (%) | ||||
| Manual uterine exploration after delivery | 107 (23.6) | 48 (18.8) | 59 (29.8) | |
| Retained products of conception | 98 (21.6) | 46 (18) | 52 (26.3) | |
| Pregnancy loss in the first trimester excluding abortion (miscarriage, molar pregnancy) | 176 (38.8) | 103 (40.2) | 73 (36.9) | |
| Surgical abortion | 69 (15.2) | 49 (19.1) | 20 (10.1) | |
| Medical abortion | 53 (11.7) | 31 (12.1) | 22 (11.1) | |
| Embolization | 33 (7.3) | 9 (3.5) | 24 (12.1) | |
| History of hysteroscopy for intrauterine adhesions (prior to current support) | 121 (26.6) | 33 (12.9) | 88 (44.4) | |
| Open myomectomy | 62 (13.7) | 38 (14.8) | 24 (12.1) | |
| Hysteroscopic myomectomy | 53 (11.7) | 36 (14.1) | 17 (8.6) | |
| Other hysteroscopies (polypectomy, endometrectomy, surgery of uterine malformation) | 32 (7.1) | 18 (7.0) | 13 (6.6) | |
Abbreviation: CI, confidence interval.
TABLE 3.
Characteristics of included women depending on the severity of adhesions.
| Characteristics | Total procedures N = 454 | Moderate adhesions N = 264 | Severe adhesions N = 190 | |
|---|---|---|---|---|
| Age – average – 95% CI | 35.6 [35.1–36.1] | 35.4 [34.8–36.0] | 35.9 [35.1–36.7] | NS |
| Gravidity, n (%) | ||||
| 0 | 75 (16.5) | 35 (13.3) | 40 (21.0) | P = 0.06 |
| 1 | 131 (28.8) | 83 (31.4) | 48 (25.3) | |
| ≥2 | 248 (54.6) | 146 (55.3) | 102 (53.7) | |
| Parity, n (%) | ||||
| 0 | 208 (45.8) | 114 (43.2) | 94 (49.5) | NS |
| 1 | 150 (33.0) | 96 (36.4) | 54 (28.4) | |
| ≥2 | 96 (21.2) | 54 (20.4) | 42 (22.1) | |
| Medical history, n (%) | ||||
| Manual uterine exploration after delivery | 107 (23.6) | 70 (26.5) | 37 (19.5) | |
| Retained products of conception | 98 (21.6) | 70 (26.5) | 28 (14.7) | |
| Pregnancy loss in the first trimester excluding abortion (miscarriage, molar pregnancy) | 176 (38.8) | 108 (40.9) | 68 (35.8) | |
| Surgical abortion | 69 (15.2) | 35 (13.3) | 34 (17.9) | |
| Medical abortion | 53 (11.7) | 27 (10.2) | 26 (13.7) | |
| Embolization | 33 (7.3) | 21 (8.0) | 12 (6.3) | |
| History of hysteroscopy for intrauterine adhesions (prior to current support) | 121 (26.6) | 76 (28.8) | 45 (23.7) | |
| Open myomectomy | 62 (13.7) | 42 (14.8) | 20 (12.1) | |
| Hysteroscopic myomectomy | 53 (11.7) | 32 (12.1) | 21 (11.1) | |
| Other hysteroscopies (polypectomy, endometrectomy, surgery of uterine malformation) | 32 (7.1) | 15 (5.7) | 17 (9.0) | |
Abbreviations: CI, confidence interval; NS, not significant.
An obstetrical etiology for intrauterine adhesions was identified in 68.5% of cases (311/454): 67.6% in the single‐procedure group (173/256) and 69.7% in the multiple‐procedures group (138/198).
Infertility was the main symptom leading to the diagnosis of intrauterine adhesions, reported in 51.5% of cases (234/454): 44.1% in the single‐procedure group (113/256) and 61.1% in the multiple‐procedures group (121/198) (P = 0.04).
Menstrual history prior to treatment was available for 61.9% of women (281/454). Among them, amenorrhea or hypo‐menorrhea was reported in 64.4% of cases (181/281): 53.8% in the single‐procedure group (77/143) and 75.4% in the multiple‐procedures group (104/138). Intrauterine adhesions were significantly more severe in the multiple‐procedures group, according to the ESGE classification, with a higher prevalence of type 2 and 3 adhesions in the single‐procedure group and type 4 and 6 in the multiple‐ procedures group (P < 0.01). A desire for pregnancy was expressed by 88.7% of women (360/454).
In the multiple‐procedures group, the average number of was 3.34 (95% CI [3.11–3.57]) (Figure 2).
FIGURE 2.
Number of procedures (multiple procedures group (N = 198)).
Bipolar energy was required in 46.0% of cases across both groups, while mechanical dissection using scissors was performed in the remaining cases. Ultrasound guidance was significantly more frequently used in the multiple‐procedures group: 29.3% (58/198) versus 15.2% (39/256) (P < 0.01). Similarly, the use of barrier agents to prevent recurrence was more common in the multiple‐procedures group: 32.8% (65/198) versus 23.8% (61/256) (P = 0.03). A surgical complication occurred in 10.6% of all procedures (48/454), the most common being uterine perforations, reported in 6.0% of cases (27/454). The rate of uterine perforation was significantly higher in the multiple‐procedures group (12.1%, 24/198) compared to the single‐procedure group (1.2%, 3/256).
For the 198 women in the multiple‐procedures group, the mean interval between the first and the last operative hysteroscopies was 9 months and 14 days (95% CI: 7 months and 15 days–11 months and 8 days).
Among the 454 included women, 283 postoperative office hysteroscopies were performed (62.3%). There was no significant difference in the rate of postoperative office hysteroscopy between the single‐procedure and the multiple‐procedures groups. Additionally, undergoing an office hysteroscopy was not significantly associated with the likelihood of achieving pregnancy.
The rate of recurrence or persistence of intrauterine adhesions was significantly higher in the multiple‐procedures group: 42.9% (54/126) compared to 29.3% (46/157) in the single‐procedure group (P < 0.01).
An intrauterine pregnancy was achieved in 145 out of 329 women with a documented pregnancy outcome (44.1%), with a significant difference between groups: 50.0% in the single‐procedure group (91/182) versus 36.7% (54/147) in the multiple‐procedures group (P = 0.02). Undergoing multiple procedures was associated with a significantly lower likelihood of achieving pregnancy (odds ratio [OR] 0.55, 95% CI [0.35–0.88], P = 0.01).
A univariate survival analysis was conducted to assess the time to intrauterine pregnancy, with a maximum follow‐up of 36 months. The Nelson‐Aalen cumulative hazard function is graphically represented in Figure 3. Both univariate and multivariate analyses were performed using a Cox proportional hazards model. The corresponding results are presented in Table 4.
FIGURE 3.
Survival analysis for obtention of intrauterine pregnancy within the 36 months following management of an intrauterine pregnancy using a Nelson‐Aalen cumulative hazard function.
TABLE 4.
Results of Cox proportional hazards model univariate and multivariate analysis for obtention of intrauterine pregnancy after management of intrauterine adhesions.
| Univariate analysis | Multivariate analysis | |||
|---|---|---|---|---|
| HR [95% CI] | P value | HR [95% CI] | P value | |
| Age | 0.93 [0.90–0.96] | <0.01 | 0.65 [0.46–0.94] | <0.01 |
| Unique or multiple procedure | 0.70 [0.49–1.01] | 0.05 | 0.93 [0.90–0.96] | 0.02 |
Abbreviations: CI, confidence interval; HR, hazard ratio.
A sensitivity analysis was performed following multiple imputations for missing data related to the occurrence of intrauterine pregnancy. The imputation model incorporated variables such as number of procedures (single vs. multiple), presence of complications, and woman age. Using a simple Chi‐square test, the intrauterine pregnancy rate was estimated at 48.0% in the single‐procedure group and 39.0% in the multiple‐procedure group. A logistic regression model further confirmed that undergoing multiple procedures and a higher age were independently associated with a lower likelihood of intrauterine pregnancy (OR = 0.88 [95% CI: 0.87–0.88] for age, and OR = 0.55 [95% CI: 0.50–0.62] for multiple procedures).
The interval between the last procedure and subsequent pregnancy was similar between groups, with a mean duration of 15.1 months (range: 11.7–18.5 months). Women aged over 38 at the time of procedure had a significantly lower pregnancy rate (OR = 0.3 [95% CI: 0.2–0.4], P < 0.01). ART was used in 32 of 145 women (22.1%), with no significant difference between groups. Early spontaneous miscarriage occurred in 36 of 145 pregnancies (24.8%), and late fetal loss in nine of 145 pregnancies (6.2%), again without a significant difference between groups.
A live birth occurred in 89 of 145 pregnancies (61.4%), with similar rates between the two groups. After adjusting for single versus multiple procedures, there was no significant difference in pregnancy rates based on the use of cold scissors versus energy. In a logistic regression model, the use of energy was not associated with a significantly different pregnancy rate (OR = 0.88 [95% CI: 0.57–1.37], P = 0.58).
Postpartum hemorrhage was reported in 27 of 89 deliveries (30.3%), occurring more frequently in the multiple‐procedures group (15/33, 45.5%) compared to the single‐procedure group (11/56, 19.6%), P = 0.01. Placenta accreta was diagnosed in 21 of 105 pregnancies (20.0%) that progressed beyong 12 weeks' gestation, with a significantly higher rate in the multiple‐procedures group (14/40, 35.0%) compared to the single‐procedure group (6/65, 9.2%), P < 0.01. Emergency hysterectomy due to uncontrolled postpartum bleeding was performed in five of 89 live births (5.6%): three of 33 cases (9.1%) in the multiple‐procedures group and two of 56 cases (3.6%) in the single‐procedure group.
4. DISCUSSION
The intrauterine pregnancy rate was 44.1%, significantly higher in the single‐procedure group. The live birth rate was 61% in both groups. Postpartum hemorrhages and placenta accreta occurred significantly more frequently in the multiple‐procedures group.
Intrauterine pregnancy rates vary widely across published studies. Guo et al. reported an overall intrauterine pregnancy rate of 50.7% (1871/3690 cases) based on data from 54 studies, with rates ranging from 10.5% to 100%. 11 The initial severity of intrauterine adhesions is a key factor in predicting reproductive outcomes, with more severe adhesions being associated with lower conception rates. 3 , 6 , 11 , 12 , 13 , 14 The relatively high proportion of severe adhesions in our cohort may account for the lower pregnancy rate observed. Furthermore, both literature and expert consensus indicate that multiple surgical procedures are often required to fully restore a normal uterine cavity in cases of severe adhesions. 3 , 6 , 11 , 12 , 13 , 14
Our live birth rate is comparable to previously published data. Guo et al. reported a live birth rate of 64.1% among 1543 pregnancies accross 41 published articles. 11
However, published data directly comparing outcomes between single and multiple procedures remain limited. One study involving 32 women reported 12 pregnancies (37.5%), with four occurring in women who underwent a single procedure and eight in those who had two or more procedures. The live birth rate in that cohort was 75.0% (9/12). 5 Another study of 102 women reported that 68.6% underwent a single procedure while 31.4% had multiple procedures; among 50 women followed, the overall pregnancy rate was 56%. 15
A third study involving 71 women with stage III and IV intrauterine adhesions reported that 31 women (43.6%) underwent a single procedure, while 40 women (56.4%) had multiple procedures. 8 The intrauterine pregnancy rate in this cohort was 43.8%, with a live birth rate 32.8%. Another study of 23 women with severe adhesions requiring more than one procedure reported a pregnancy rate of 39% and a live birth rate of 27.3%. 9 Additionally, a study of 85 women—75% having a single procedure and 25% multiple procedures—reported an intrauterine pregnancy rate of 64.7%. 14 None of these studies provided direct comparisons between single and multiple procedures groups.
Conversely, one study involving 89 women reported no pregnancies among the 12 women who underwent multiple procedures. 16 A recent retrospective study of 423 women, who had between one and five procedures, found no significant association between the number of procedures and the rate of intrauterine pregnancy (OR = 1.01 [95% CI: 0.87–1.18]). 13
These findings suggest that pregnancy is possible after multiple procedures; however, no published studies have directly compared outcomes between single and multiple procedure groups. The strength of the present study lies not only in comparing these pregnancy rates between groups but also in reporting obstetrical complications.
Although the live birth rate did not differ significantly between the single‐procedure and the multiple‐procedures groups, the intrauterine pregnancy rate was significantly higher in the single‐procedure group. The lack of a significant difference in live birth rate may be attributed to the limited statistical power of the study.
Regarding the risk of operative complications, repeated surgeries naturally increase this risk, particularly the risk of uterine perforation, which is approximately 2% in intrauterine adhesion management but can rise to 9% in case of severe adhesions. 3 The complication rate observed in the present study aligns with these published data.
The primary concern in managing intrauterine adhesions is the risk of recurrence, generally estimated between 20.0% to 23.5%, but increasing to 48.9%–62.5% in cases of severe adhesions. 2 , 3 In the present study, the reccurence rate was higher in the multiple procedures group, which also included women with more severe adhesions.
Regarding obstetrical complications, previous studies have reported an increased risk following the surgical treatment of intrauterine adhesions. 11 , 12 Specifically, postpartum hemorrhage rates have been reported between 8.9% and 11.4%. 10 , 11 In the present study, the rate of postpartum hemorrhage was higher, which may be explained by differing definitions: some studies define postpartum hemorrhage as blood loss exceeding 1000 mL, 11 whereas the French standard defines it as blood loss over 500 mL.
Reported rates of placenta accreta range from 8.2% to 14.3%. 8 , 9 , 11 A comparative study between women treated for intrauterine adhesions and healthy controls demonstrated a significantly higher risk of placental abnormalities following adhesions management (33.6% vs. 2.7%), with placenta accreta occurring in 24.7% of cases compared to 2.1% in controls. 10 Consistent with these findings, the present study also reports an elevated risk of postpartum hemorrhage after intrauterine adhesion treatment, particularly following multiple procedures.
The main limitation of the present study was its retrospective design, which introduces potential confounding bias and missing data. Nevertheless, it remains one of the largest studies published on this topic and among the first to directly compare outcomes after single versus mutiple procedures. The lost to follow‐up rate of 27.5% is acceptable, considering the retrospective data collection spanning 10 years. A key strength of this study is that all surgeons performing the procedures were trained and utilized standardized operating techniques.
5. CONCLUSION
To the best of our knowledge, this is the first study to directly compare the management of intrauterine adhesions between single and multiple procedures. We found that the intrauterine pregnancy rate was lower in the multiple‐procedures group, while the risks of postpartum hemorrhage and placentation abnormalities were higher. Although repeated procedures may improve the chances of restoring a satisfactory uterine cavity in cases of severe adhesions, they also increase the risk of postpartum complications.
Consistent with previous published studies, pregnancies following intrauterine adhesion treatment should be considered high‐risk and managed accordingly.
AUTHOR CONTRIBUTIONS
Conception: H. Fernandez and P. Capmas. Patient recruitment: E. Debras, A. G. Pourcelot, H. Fernandez and P. Capmas. Statistical analysis: C. Bleas and P. Capmas. Manuscript writing: C. Bleas and P. Capmas. Manuscript reading: E. Debras, A. G. Pourcelot and H. Fernandez.
FUNDING INFORMATION
None.
CONFLICT OF INTEREST STATEMENT
H. Fernandez declares interests with Delmont. The other authors have no conflict of interest.
DATA AVAILABILITY STATEMENT
Research data are not shared.
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Associated Data
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Data Availability Statement
Research data are not shared.