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Risk factors for the implementation of intrauterine adhesions in women of reproductive age
https://doi.org/10.21886/2219-8075-2022-13-2-86-90
Abstract
Childless marriages remain an important medical and social problem at present, both in our country and around the world. Infertility is a violation of the reproductive system, which has a wide range of conditions that affect one of the most important human functions – the ability to reproduce. The uterine factor of infertility occupies one of the leading positions in the formation of both primary and secondary infertility. Given the growth of acquired forms of uterine infertility, it is impossible not to turn to such a disease as intrauterine adhesions. Intrauterine synechiae is an acquired uterine disease that occurs after an injury to the endometrial mucosa. In the modern world, the prevalence of intrauterine adhesions in women of the reproductive period is increasing every year. However, it should be noted that despite modern technologies, it is impossible to accurately determine the number of women who have intrauterine adhesions. Taking into account the multifactorial development of intrauterine adhesions, as well as the low effectiveness of treatment methods, this problem occupies one of the leading positions in the structure of gynecological diseases and remains relevant. The asymptomatic course of the adhesive process leads to difficulty in diagnosis, and therefore the clinician needs to be aware of the risk factors for the development of intrauterine synechiae. The review presents risk factors for the formation of intrauterine synechiae.
For citations:
Orazov M.R., Mikhaleva L.M., Ismailzade S.Ya. Risk factors for the implementation of intrauterine adhesions in women of reproductive age. Medical Herald of the South of Russia. 2022;13(2):86-90. (In Russ.) https://doi.org/10.21886/2219-8075-2022-13-2-86-90
Prevalence
It was a gynecologist Joseph Asherman who was the author of the first publication and full description of intrauterine adhesion (IAA) in 1894 [1]. Nowadays, IAA, also known as Asherman syndrome, remains one of the urgent problems of operative gynecology. It is proved that the formation of the adhesive process in the uterine cavity occurs due to damage to the basal layer of the endometrium caused by various factors. As a result, scars and adhesions form in the endometrium, which leads to deformation of the uterine cavity and functional disorders [2][3]. It should be noted that the exact prevalence of IAA cannot be determined due to the asymptomatic or low-symptomatic course, and the frequency of recurrence cannot be determined, even taking into account modern technologies [4]. According to the academic literature, the IAA frequency ranges from 0.3% to 21.5% [5]. Approximately 25–30% of infertile women suffer from Ascherman syndrome, which is the most common cause of uterine infertility [6].
Risk factors
One of the main reasons for the development of IAAs is surgical interventions in the uterine cavity, such as artificial abortion, dilation and curettage, post-abortion bleeding followed by curettage, manual removal of the placenta, polypectomy, myomectomy, and conization of the cervix. It was also noted that pathophysiological factors such as infections, genital tuberculosis, and endometritis could lead to adhesion and occlusion of the uterine cavity, uterine isthmus, or cervical canal [7].
According to the academic literature, about 90% of the IAA cases are caused by a complicated course of pregnancy due to incomplete abortion, undeveloped pregnancy, cystic drift, postpartum bleeding, and placental tissue remnants [8]. It was found that Asherman syndrome occurred after incomplete abortion in 50%, postpartum bleeding — in 24%, and surgical abortion — in 17.5% of cases. The frequency of IAAs, depending on the etiological cause, is presented in Table 1 [3]. It should be noted that repeated intrauterine manipulations increase the likelihood of developing adhesions by 8%, and when performing surgical interventions for the third time, it reaches 30%. One of the reasons for the development of an undeveloped pregnancy is infection, which also contributes to the development of the IAA. However, the probability of adhesion has a time frame (from the moment of embryo death and its evacuation from the uterine cavity) and reaches up to 31%. Also, foreign colleagues have revealed the relationship between the imposition of compression sutures during postpartum bleeding and IAA formation [9][10].
Таблица / Table 1
Частота встречаемости внутриматочных адгезий в зависимости от этиологического фактора
The frequency of intrauterine adhesions depending on the etiological factor
|
Этиологический фактор / Etiological factor |
Частота / Frequency |
|
Кесарево сечение / Cesarean section |
2-2,8% |
|
Самопроизвольный выкидыш / Spontaneous miscarriage |
5-39% |
|
Рассечение внутриматочных перегородки / Dissection of the intrauterine septum |
6% |
|
Хирургический аборт / Surgical abortion |
17,5% |
|
Эмболизация маточных артерий / Embolization of the uterine arteries |
14% |
|
Компрессионный шов на матке / Compression suture on the uterus |
18,5% |
|
Выскабливание полости матки после родов / Curettage of the uterine cavity after childbirth |
37,5% |
|
Резектоскопия, миомэктомия / Resectoscopy, myomectomy |
35% |
|
Неполный аборт / Incomplete abortion |
50% |
|
Аблация эндометрия / Ablation of the endometrium |
36,4% |
In recent years, the issue of genetic predisposition to the formation of IAAs has been studied. A deeper understanding of risk factors and etiology will help to further develop a strategy for the prevention and treatment of the IAA [11].
Complications and patient management tactics
The endometrium contains two main structural layers: the underlying stable layer (the basement membrane), called the basal layer, and the upper dynamic layer, called the functional layer [12]. The above-mentioned factors lead to damage to the basal layer of the endometrium, which plays an important role in the repair of the damaged layer [13][14].
The IAA is often clinically asymptomatic, but there are complications such as chronic pain syndrome, infertility, habitual miscarriage, pregnancy complications, and amenorrhea, which leads to a decrease in the quality of life [15–19].
The severity of the IAA varies from minimal to complete obliteration of the uterine cavity and/or the walls of the cervical canal due to the formation of adhesions [20].
Actually, the IAA is an acquired disease of the uterus that occurs after an injury to the mucous membrane of the endometrium. The search for cellular and molecular mechanisms underlying the pathogenesis of the disease is relevant for the prognosis of IAA development and effective treatment [21].
Although Ascherman syndrome has been described for more than a century and its impact on a woman's reproductive health is well known, it was the introduction of hysteroscopy that revolutionized its treatment, becoming the standard method of diagnosis and treatment of IAAs. However, the effectiveness of hysteroscopic treatment in restoring the anatomy of the uterine cavity and, most importantly, the reproductive potential of the patient and prognostic factors affecting the outcome of treatment have not been fully elucidated [22][23].
Despite the fact that the effectiveness of surgical treatment of intrauterine synechiae is 85–90%, reproductive function is restored in only 23–35% of women. The severity of intrauterine synechiae affects the probability of pregnancy and is 64.7% in mild patients, 53.6% in medium, and 32.5% in severe patients [25][26].
Primary prevention is the most important issue for women in need of surgical intervention on the uterus, especially for women of reproductive age suffering from intrauterine lesions. Many data suggest that the risk of developing the IAA can be reduced using the above-mentioned strategies, but it is well known that it is impossible to completely avoid the formation of adhesions [27-29].
Conclusion
The intensive development of modern medicine and the use of minimally invasive technologies to reduce the traumatic nature of surgical interventions did not contribute to reducing the IAA prevalence. Primary prevention and the study of risk factors are important aspects of overcoming IAA formation and the complications caused by them. It should be noted that currently there is no single method of IAA treatment and prevention that would be sufficiently effective. Therefore, it is necessary to take a comprehensive approach to solving the problem and conduct further research in this area to improve the effectiveness of measures.
References
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About the Authors
M. R. Orazov
People’s Friendship University of Russia
Russian Federation
Russian Federation
Mekan R. Orazov, Dr. Sci. (Med.), Professor of the Department of Obstetrics and Gynecology with the course of Perinatology of the Medical Institute
Moscow
L. M. Mikhaleva
Avtsyn Research Institute of Human Morphology
Russian Federation
Russian Federation
Lyudmila M. Mikhaleva, Dr. Sci. (Med.), Professor, Director of the Institute of Morphology
Moscow
S. Ya. Ismailzade
People’s Friendship University of Russia
Russian Federation
Russian Federation
Ismailzade Sevinj Yadulla kyzy, post–graduate student of the Department of Obstetrics and Gynecology with a course in perinatology at the Medical Institute
Moscow
Review
For citations:
Orazov M.R., Mikhaleva L.M., Ismailzade S.Ya. Risk factors for the implementation of intrauterine adhesions in women of reproductive age. Medical Herald of the South of Russia. 2022;13(2):86-90. (In Russ.) https://doi.org/10.21886/2219-8075-2022-13-2-86-90
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