title: Intrauterine adhesion prevention after hysteroscopy: a systematic review and meta-analysis.
abstract: BACKGROUND
  Despite years of studies evaluating prevention strategies for intrauterine adhesion formation after operative hysteroscopy, it is still unclear which strategies are most effective.
  
  
  OBJECTIVE
  The objective of the study was to perform a systematic review and meta-analysis to evaluate the effectiveness of postoperative prevention strategies on intrauterine adhesion formation following operative hysteroscopy.
  
  
  METHODS
  Literature searches were conducted in MEDLINE, Embase, ClinicalTrials.gov, and Cochrane Library databases. Inclusion criteria were published randomized controlled clinical trials from 1989 to 2014 comparing any postoperative preventative measures of intrauterine adhesion after hysteroscopy. The main outcome measure was a reduction in postoperative intrauterine adhesion. Heterogeneity of the studies was evaluated using a Q test and an I(2) index. Analyses were performed using a random-effects model with outcome data reported as relative risk with 95% confidence interval.
  
  
  RESULTS
  Twelve studies were included in the systematic review. Eight studies compared similar treatment methods and were included in the meta-analysis. Three studies evaluated hyaluronic acid gel, of which 2 reported a significant decrease in intrauterine adhesion with treatment. The meta-analysis demonstrated a significant reduction of intrauterine adhesion when using hyaluronic acid gel. Two studies evaluated polyethylene oxide-sodium carboxymethylcellulose gel, 1 of which demonstrated a decrease in intrauterine adhesion with treatment. A meta-analysis showed a significant reduction of intrauterine adhesion with polyethylene oxide-sodium carboxymethyl cellulose gel. However, these 3 studies demonstrating a benefit of the gels in preventing adhesion formation were all conducted by the same research group. Other research groups have not confirmed these results. A sensitivity analysis excluding these trials from this single group demonstrated no benefit to adhesion prevention with either gel formation. Three studies investigated oral estrogen therapy after hysteroscopy and found no difference in intrauterine adhesion. A meta-analysis showed no decrease in intrauterine adhesion with estrogen therapy after hysteroscopy. Data were lacking to perform metaanalyses on the use of intrauterine balloon, intrauterine device, and other adhesion prevention barriers in preventing intrauterine adhesion.
  
  
  CONCLUSIONS
  There was a lack of definitive evidence to conclude that any treatment is effective in preventing posthysteroscopy uterine adhesion formation. The available literature has significant heterogeneity and a high risk of bias, making any definitive conclusions difficult.
authors.affiliation: Program in Reproductive and Adult Endocrinology, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD; Department of Obstetrics and Gynecology, Walter Reed National Military Medical Center, Bethesda, MD. Electronic address: mae.healy@mail.nih.gov.
authors.forename: Mae Wu
authors.initials: MW
authors.lastname: Healy
authors.affiliation: Uniformed Services University of Health Sciences, Bethesda, MD.
authors.forename: Brian
authors.initials: B
authors.lastname: Schexnayder
authors.affiliation: Program in Reproductive and Adult Endocrinology, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD; Department of Obstetrics and Gynecology, Walter Reed National Military Medical Center, Bethesda, MD.
authors.forename: Matthew T
authors.initials: MT
authors.lastname: Connell
authors.affiliation: National Institutes of Health Library, National Institutes of Health, Bethesda, MD.
authors.forename: Nancy
authors.initials: N
authors.lastname: Terry
authors.affiliation: Program in Reproductive and Adult Endocrinology, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD.
authors.forename: Alan H
authors.initials: AH
authors.lastname: DeCherney
authors.affiliation: Program in Reproductive and Adult Endocrinology, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD; Department of Obstetrics and Gynecology, Walter Reed National Military Medical Center, Bethesda, MD.
authors.forename: John M
authors.initials: JM
authors.lastname: Csokmay
authors.affiliation: Program in Reproductive and Adult Endocrinology, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD; Department of Obstetrics and Gynecology, Walter Reed National Military Medical Center, Bethesda, MD.
authors.forename: Belinda J
authors.initials: BJ
authors.lastname: Yauger
authors.affiliation: Program in Reproductive and Adult Endocrinology, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD; Department of Obstetrics and Gynecology, Walter Reed National Military Medical Center, Bethesda, MD.
authors.forename: Micah J
authors.initials: MJ
authors.lastname: Hill
mesh_terms: D005260:Female; D006801:Humans; D015907:Hysteroscopy / Q000009:adverse effects*; D011183:Postoperative Complications / Q000517:prevention & control*; D000267:Tissue Adhesions / Q000209:etiology / Q000517:prevention & control; D014591:Uterine Diseases / Q000209:etiology / Q000517:prevention & control*
keywords: intrauterine adhesion; meta-analysis; operative hysteroscopy; prevention strategy