To assess the efficacy of mechanical strategies to avoid recurrence of intrauterine adhesions and to evaluate the impact on subsequent fertility after hysteroscopic adhesiolysis. To rank the available antiadhesive options.
MEDLINE, Scopus, ClinicalTrials.gov, CINAHL, Scielo, EMBASE, PROSPERO, Cochrane Library, conference proceedings and international controlled trials registries were searched without temporal, geographical and language restrictions.
Randomized trials that analyzed recurrence and/or reproductive outcomes of women undergoing hysteroscopic adhesiolysis followed by mechanical prevention of intrauterine adhesions were included. Exclusion criteria included: quasi-randomized trials and trials without randomization, studies including patients undergoing hysteroscopic surgery different from adhesiolysis.
PRISMA-NMA guidelines were followed. We performed a network meta-analysis based on random effects model for mixed multiple treatment comparisons to rank antiadhesive strategies by surface under the cumulative ranking curve (SUCRA). Quality assessment was performed using the criteria outlined in the Cochrane Handbook for Systematic Reviews of Interventions. Primary outcome was the recurrent presence of intrauterine adhesions.
Eleven studies, with data for 1596 women, were identified as applicable. Copper intrauterine device together with an intrauterine balloon (SUCRA=46.4%) or with cross-linked hyaluronic-acid gel (SUCRA=21.3%) seemed effective in preventing adhesions recurrence. Regarding fecundity, hyaluronic-acid gel demonstrated the highest pregnancy rates (SUCRA=79.8%). Greatest degrees of change in mean adhesions scores were found with hyaluronic-acid gel plus intrauterine device (SUCRA=38.9%). For postsurgical adhesions severity, hyaluronic-acid gel plus intrauterine device (SUCRA=49.9%), followed by intrauterine device alone (SUCRA=30.8%) were highest ranked. Dried amnion graft (SUCRA=53.8%) and uterine balloon (SUCRA=45%) showed greatest menstrual patterns improvement.
Cross-linked hyaluronic-acid gel, with or without insertion of a copper intrauterine device, seems the most effective approach. However, lack of a clear best therapy suggests the need for further studies to draw firm conclusions.