Intrauterine Adhesions

Publication Date: August 1, 2017
Last Updated: March 14, 2022

Guidelines

Diagnosis of Intrauterine Adhesions

Hysteroscopy is the most accurate method for diagnosis of IUAs and should be the investigation of choice when available. (B)
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If hysteroscopy is not available, HSG and SHG are reasonable alternatives. (B)
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Magnetic resonance imaging should not be used for diagnosis of IUAs outside of clinical research studies. (C)
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Classification of Intrauterine Adhesions

Intrauterine adhesions should be classified as prognosis is correlated with severity of adhesions. (B)
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The various classification systems make comparison between studies difficult to interpret. This may reflect inherent deficiencies in each of the classification systems. Consequently, it is currently not possible to endorse any specific system. (C)
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Primary Prevention of Intrauterine Adhesions

The risk for de novo adhesions during hysteroscopic surgery is impacted by the type of procedure performed with those confined to the endometrium (polypectomy) having the lowest risk and those entering the myometrium or involving opposing surfaces a higher risk. (B)
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The method of pathology removal may impact the risk of de novo adhesions. The risk appears to be greater when electrosurgery is used in the non-gravid uterus and for blind versus vision-guided removal in the gravid uterus. (C)
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The application of an adhesion barrier following surgery that may lead to endometrial damage significantly reduces the development of IUAs in the short term, although limited fertility data are available following this intervention. (A)
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Surgical Management of Intrauterine Adhesions

Hysteroscopic lysis of adhesions by direct vision and a tool for adhesiolysis is the recommended approach for symptomatic IUAs. (B)
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There is no evidence to support the use of blind cervical probing. (C)
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There is no evidence to support the use of blind dilation and curettage. (C)
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For women with IUAs who do not wish any intervention but still want to conceive, expectant management may result in subsequent pregnancy, however the time interval may be prolonged. (C)
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Adjunctive interventions to aid adhesiolysis include ultrasound, fluoroscopy, and laparoscopy. There are no data to suggest that these prevent perforation or improve surgical outcomes and are likely dependent on clinical skills and availability. However, when such an approach is used in appropriately selected patients it may minimize the consequences if perforation occurs. (B)
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In the presence of extensive or dense adhesions, treatment should be performed by an expert hysteroscopist familiar with at least one of the methods described. (C)
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Secondary Prevention of Intrauterine Adhesions

The use of an IUD, stent or catheter appears to reduce the rate of postoperative adhesion reformation. There are limited data regarding subsequent fertility outcomes when these barriers are used. (A)
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The risk of infection appears to be minimal when a solid barrier is used compared with no treatment. (A)
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There is no evidence to support or refute the use of preoperative, intraoperative, or postoperative antibiotic therapy in surgical treatment of IUAs. (C)
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If an IUD is used postoperatively, it should be inert and have a large surface area such as a Lippes loop. Intrauterine devices that contain progestin or copper should not be used after surgical division of IUAs. (C)
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Semi-solid barriers such as hyaluronic acid and auto-cross-linked hyaluronic acid gel reduce adhesion reformation. At this time, their effect on post-treatment pregnancy rates is unknown. (A)
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Following hysteroscopic-directed adhesiolysis, postoperative hormone treatment using estrogen, with or without progestin, may reduce recurrence of IUAs. (B)
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The role of medications designed as adjuvants to improve vascular flow to the endometrium has not been established. Consequently, they should not be used outside of rigorous research protocols. (C)
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Stem cell treatment may ultimately provide an effective adjuvant approach to the treatment of Asherman syndrome; however, evidence is very limited and this treatment should not be offered outside of rigorous research protocols. (C)
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Postoperative Assessment After Treatment of Intrauterine Adhesions

Follow-up assessment of the uterine cavity after treatment of IUAs is recommended, preferably with hysteroscopy. (B)
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Recommendation Grading

Overview

Title

Intrauterine Adhesions

Authoring Organization

Publication Month/Year

August 1, 2017

Last Updated Month/Year

January 17, 2024

Document Type

Guideline

External Publication Status

Published

Country of Publication

US

Inclusion Criteria

Female, Adult, Older adult

Health Care Settings

Ambulatory, Hospital, Operating and recovery room

Intended Users

Surgical technologist, physician, nurse, nurse practitioner, physician assistant

Scope

Assessment and screening, Prevention, Management, Treatment

Diseases/Conditions (MeSH)

D007434 - Intrauterine Devices

Keywords

Intrauterine Adhesions, Hysteroscopic lysis, Hysteroscopic synechiolysis, Intrauterine septum and synechiae, hysteroscopy, Hysterosalpinography, Sonohysterography