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\begin{document}

\title{BJOG-23-0761.R1. Prevention, the way to go}



\author[1]{Angelo Hooker}%
\affil[1]{Zaans Medical Center (ZMC)}%


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  \date{May 23, 2024}


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\textbf{Prevention, the way to go.}

\emph{Angelo B. Hooker, M.D., Ph.D.}

\emph{Zaans Medical Center (ZMC),}

\emph{Department of Obstetrics and Gynaecology}

\emph{Koningin julianaplein 58. P.O. Box 210.}

\emph{1500 EE Zaandam, the Netherlands.}

\textbf{Prevention, the way to go.}

Intrauterine adhesions (IUAs), characterized by partial to complete
obliteration of the uterine cavity and/or cervical canal, is one of the
main reproductive system diseases with menstrual disturbances, cyclic
pain and reproductive disorder as the main clinical manifestations
(Deans et al. \emph{J Minim Invasive Gynecol} 2010;17:555--69).
Hysteroscopic adhesiolysis (HA) is the standard treatment to improved
menstrual pattern and reproductive performance.

Xiaocui and co-workers conducted a retrospective matched control study;
women with a history of HA were categorized as exposed and women without
as controls. The potential impact of age, parity, mode of conception,
prior history of abortion and BMI were eliminated as exposed women were
matched with four controls by propensity score matching. Ultimately, 780
exposed and 3010 matched control pregnancies were analyzed. Women with a
history of HA had a higher risk for developing pre-eclampsia, there was
an increased risk for placenta accreta spectrum and previa, postpartum
hemorrhage and preterm birth. There was no association with newborn
birth weights. The risk of obstetrical complications increased with the
number of hysteroscopic interventions.

IUAs formation is multifactorial with multiple predisposing and causal
factors. In up to 91\% pregnancy-related intrauterine surgery is the
predisposing risk factor (Schenker et al. \emph{Fertil
Steril}1982;37:593--610). The formation of IUAs seems to be the ultimate
result of an abnormal response to inflammation leading to a defective
endometrium with substandard vascularization by disruption of the basal
layer (Saed et al. \emph{Fertil Steril} 2002;78:137--43). The
development of IUAs is still poorly understood but IUAs have an impact
on female reproduction, adversely affecting reproductive and obstetric
outcomes. IUAs has a debilitating impact on quality of life.

Although this retrospective registry-based study has a large sample
size, important data could not be retrieved due to data inaccessibility.
The number of prior abortions are reported but the number and type of
intrauterine interventions, classification of IUAs and adjuvant
treatment following HA, could not be assessed: crucial factors in the
interpretation of the results. Moreover, the use of propensity score
matching increases the risk of initial selection bias. Despite, Xiaocui
et al. must be complimented for the way they conducting this study and
the comprehensive assessment of potential confounders. The results of
this cohort study are clinical relevant.

Prevention was not mentioned in the current study. The current treatment
methods for IUAs are not optimal, the reproductive and obstetric
outcomes remain limited and inefficient compared to women without IUAs,
even after adhesiolysis. Prevention is essential and starts with
preserving the basal layer of the endometrium and residing stem cells by
preventing trauma. Intrauterine interventions should be prevented as
much as possible and when there is a necessity, surgery should be
performed in the gentlest manner, avoiding unnecessary trauma. Adhesion
formation and the increased risk of adverse obstetric outcomes should be
taken into account when treatment options are discussed. The more
intrauterine interventions there are, the more destruction of the
endometrium there will be. Prevention is crucial and the way to go.

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