背景:宫腔粘连(IUAs)是世界范围内妇女的主要生殖系统疾病之一。受伤的相对壁之间的融合导致腔和/或宫颈管的部分至完全闭塞。IUA的主要临床表现是月经紊乱,周期性疼痛和生殖障碍。与没有IUA的妇女相比,有IUA的妇女的生殖结果仍然有限且效率低下,即使在粘连松解术后。缺乏对潜在机制和过程的确切理解,以解释在IUA的情况下受损的生殖性能和结果。
方法:MEDLINE-PubMed(1966年至2022年1月)和EMBASE(1974年至2022年1月)的系统文献综述遵循系统评价和荟萃分析(PRISMA)指南的首选报告项目。如果研究报告了潜在的原因,相关的机制和过程来解释IUAs与生殖性能受损之间的关联,妊娠和产科并发症。
结果:在对文献进行广泛回顾之后,确定了58篇文章,报告了解释IUA与生育率下降之间关联的潜在机制。宫内疤痕影响受精过程,生殖性能和最终的生殖结果。IUA会干扰宫颈-子宫-输卵管精子的运输,并导致无血管和无反应的子宫内膜,容受性和厚度降低。异常蜕膜化和异常滋养细胞浸润导致胎盘附着障碍。此外,早产的风险,宫内胎儿生长受限和胎儿异常在IUA的情况下增加。
结论:IUA对生殖性能的影响,即使在粘连松解术后,变得越来越明显。解释这种关联的假定机制与精子运输有关,胚胎植入和胎盘形成。预防,通过保留子宫内膜的基底层是必不可少的。预防子宫内膜损伤和IUA形成的有效和循证策略,迫切需要。
BACKGROUND: Intrauterine adhesions (IUAs) are one of the main reproductive system diseases in women worldwide. Fusion between the injured opposing walls leads to partial-to-complete obliteration of the cavity and/or cervical canal. The main clinical manifestations in case of IUAs are menstrual disturbances, cyclic pain and reproductive disorders. The reproductive outcomes of women with IUAs remain limited and inefficient compared to women without IUAs, even after adhesiolysis. An exact understanding of the underlying mechanisms and processes to explain the compromised reproductive performance and outcomes in case of IUAs are lacking.
METHODS: A systematic literature
review of MEDLINE-PubMed (1966 to January 2022) and EMBASE (1974 to January 2022) was performed following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Studies were included if they reported underlying causes, related mechanisms and processes to explain the association between IUAs and impaired reproductive performance, pregnancy and obstetric complications.
RESULTS: After an extensive
review of the literature, 58 articles were identified reporting underlying mechanisms to explain the association between IUAs and impaired fertility. Intrauterine scarring influences the process of fertilization, reproductive performance and ultimately reproductive outcome. IUAs can disturb the cervico-utero-tubal sperm transport and result in an avascular and unresponsive endometrium with decreased receptivity and thickness. Abnormal decidualization and abnormal trophoblastic infiltration leads to placental attachment disorders. Moreover, the risk for premature delivery, intrauterine fetal growth restriction and fetal anomalies is increased in case of IUAs.
CONCLUSIONS: The impact of IUAs on reproductive performance, even after adhesiolysis, is becoming more apparent. The postulated mechanisms to explain the association are related to sperm transport, embryo implantation and placentation. Prevention, by preserving the basal layer of the endometrium is essential. Effective and evidence-based strategies for the prevention of endometrial injury and formation of IUAs, are urgently needed.