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
American Association of Gynecologic Laparoscopists
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