Adjuvants to prevent reformation of adhesions following adhesiolysis for Asherman syndrome: a systematic review and meta-analysis

Two international guidelines published on the management of Asherman syndrome (AS) have made recommendations on various adjuvant methods to prevent intrauterine reformation. Nevertheless, the effectiveness of these methods when used in primary or secondary prevention settings is different. Our aim is to assess the effectiveness of various adjuvant methods for the secondary prevention of intrauterine adhesions (IUAs). Articles were considered eligible if they included subjects with AS before surgery and compared a chosen method with either a control or a comparison group (using another method). The primary outcome was the IUA reformation rate at follow-up hysteroscopy. A total of 29 studies [15 randomised controlled trials (RCTs) and 14 cohort studies] were included. Adhesion reformation with various methods to prevented IUA reformation when compared with controls were: second-look hysteroscopy: [risk ratio (RR): 0.21, 95% confidence interval (CI): 0.05-0.90 ( p  = 0.02)]; intrauterine contraceptive device: RR: 0.64, 95% CI: 0.36-1.12 ( p  = 0.12); continuous intrauterine balloon: RR: 0.18, 95% CI: 0.05-0.68 ( p  = 0.01); intermittent intrauterine balloon: RR: 0.50, 95% CI: 0.31-0.80 ( p  = 0.004); anti-adhesion gel: RR: 0.80, 95% CI: 0.58-1.10 ( p  = 0.17); amnion graft: RR: 0.63, 95% CI: 0.44-0.91 ( p  = 0.01).