Comparison Of Scissors Versus Electrosurgical Excision For Hysteroscopic Adhesiolysis And Pregnancy Outcome After IVF/ICSI Fresh Embryo Transfer

Background:Intrauterine adhesions,also known as Asherman’s syndrome,is a consequence of trauma to the endometrium,producing partial or complete obliteration of the uterine cavity and/or the cervical canal,manisfested as menstrual abnormalities,infertility,and recurrent pregncancy loss.Transerervical resection of adhesions(TCRA)is currently the most important surgical procedure for the treatment of intrauterine adhesions(IUA).Hysteroscopy can accurately confirm the presence,nature,extent of adhesions providing references for the assessment and prognosis of the disease because uterine cavity can be directly inspected.Hysteroscopic surgery is the main choice of treatment for IUA beacause it can be performed under direct vision,reducing the risk of uterine perforation.Adhesiolysis may be performed with the help of the hysteroscopic scissors or eclectrode needle or loop currently.Electrosurgery system can provide effective and precise cutting as well as good hemostasis maintaing a clear operative field and reducing the risk,but there is a theoretical possibility of further endometrial damage.The damage of residual endometrium aside adhesions will affect the endometrial healing.In addition,increased inflammatory factors promote the reformation of adhesions.Hysteroscopic adhesiolysis using scissors has the advantage that it permitts dissection and avoids complications related to energy sources,and it possibly minimizes the destruction endometrium.But the disadvantage is that it is more difficult to seperate dense,marginal adhesions with a scissor and without good hemostasis.This will carry a increased risk of perforation.The area of residual endometrium is fundamental basis for endometrial repair,and reformation of adhesion is also an important factor affecting wound healing.Treatment of IUA aims at restoring the normal size and shape of the uterine cavity,preventing recurrence of the adhesion,promoting the repair and regeneration of the destroyed endometrium,and ultimately improving the patient’s reprodctive outcome.Whether hysteroscopic adhesiolysis using scissors or a electrosurgery system is better for IUA is unkown.Further research is needed to provide evidence for the selection of surgical methods and improvement of reprductive outcome.Objective:To analyze retrospectively clinical features of patients with intrauterine adhesions,and to evaluate the efficacy,pregnancy outcomes after different methods of hysteroscopic adhesiolysis and influencing factors of pregnacncy outcome,thus provide evidence for the selection of surgical methods.Method:A total of 456 infertile women aged from 20 to 45 years old who diagnosed with intrauterine adhesion underwent hysteroscopic adhesiolysis followed by IVF/ICSI-ET in the affiliated reproductive hospital of Shandong University from January 2014 to July 2018.There were 378 cases in electrode knife group and 78 cases in scissor group.Estrogen treatment was administered postoperatively for 2 months in both groups.A second-look hysteroscopy was carried out 1 month after the surgery.The clinical baseline data including age,body mass index,AFS score before and after surgery,ovarian stimulation procedure and reproductive outcome were collected.Endometrial thickness and reproductive outcome were compared.And factors influecing pregnancy outcomes were analyzed by univariate and multivariate Logistic regression model.Results:65.4%(298/456)of IUA cases had pregnancy-related predisposing factors and 58.1%(265/456)had a history of pregnancy-related intrauterine operations.There were significant differences in the number of intrauterine operations between different degrees of intrauterine adhesion.The number of intrauterine operations in patients with moderate IUA was significantly higher than that in patients with mild IUA(p<0.01).The postoperative AFS scores of the electrode knife group and the scissor group were significantly lower than those before surgery(P<0.01)and there was no significant difference in postoperative AFS sore between both groups.There was no significant differences in age,BMI,basal endocrine level and ovulation-induced baseline data between electrode knife group and scissor group.The mean endometrial thickness and thin endometrial rate of electrode kinfe group were 0.90±0.20cm and 11.1%,wheras 0.87±0.18cm and 14.1%in scissor group and no statistical significance was found between two groups(p>0.05).Baseline data of both groups were similar,except IUA are more severe in knife group than that in scissor group.There was no significant difference in biochemical pregnancy rate,clinical pregnancy rate,ongoing pregnancy rate,live birth rate,biochemical pregnancy abortion rate,clinical pregnancy abortion rate between electrode knife and scissor group considering the mixed effects of severity of IUA(p>0.05).Logistic regression analysis showed that the independent influencing factors of clinical pregnancy were endometrial thickness on HCG trigger day(OR 5.6 14,95%CI 1.746-18.048),age(OR 0.570,95%CI 0.369-0.881),AMH(OR 1.192,95%CI 1.092-1.301)are the independent factors that affect the clinial pregnancy rate.And the number of intrauterine operations(OR 0.726,95%CI 0.598-0.881),endometrial thickness on HCG trigger day(OR 5.655,95%CI 1.653-19.343),BMI(OR 0.431,95%CI 0.266-0.699),AMH(OR 1.181,95%CI 1.091-1.279)are the independent influencing factors of live birth rate.Conclusion:1.Pregnancy is the dominating predisposing factor of the formation of intrauterine adhesions.As the number of intrauterine operation increases,the degree of intrauterine adhsion will increase.2.Hysteroscopic adhesiolysis is an effective and safe operation for the treatment of IUA.Different methods of operation do not influence the efficacy and reproductive outcome of IUA patient who received IVF/ICSI-ET after hysteroscopic adhesiolysis.Prospective studies with more samples are needed to provide guidance for clinical practice.3.Endometrial thickness on HCG trigger day,age,AMH are independent factors of clinial pregnancy in patients with intrauterine adhesions who received IVF/ICSI-ET postoperatively.Number of intrauterine operations,Endometrial thickness on HCG trigger day,BMI,AMH are independent factors of live birth in patients with intrauterine adhesions who received IVF/ICSI-ET postoperatively.