Pregnancy-related intrauterine adhesions: Prevalence, risk factors and prevention strategies

Intrauterine adhesions (IUAs), first described in the nineteenth century, represent an acquired condition. IUAs are characterized by intrauterine scarring leading to obliteration of the endometrial surface. As pregnancy-related IUAs account for more than 90% of all IUA cases, this thesis focuses on pregnancy-related IUAs. The pathophysiological process leading to pregnancy-related IUA formation remains undetermined. IUAs can be asymptomatic and remain undiscovered, but women may experience menstrual abnormalities, secondary infertility, and recurrent miscarriages. The exact prevalence of IUAs remains undetermined, and the reported prevalence in the literature varies considerably; mainly symptomatic women are included with different diagnostic modalities. In current practice, IUAs remain a difficult medical condition; the management of women with IUAs remains a clinical challenge. The work presented in the studies in this thesis evaluated different aspects of pregnancy related IUAs and prevention strategies. The first part focuses on the prevalence of pregnancy-related IUAs, etiological and risk factors, and (long-term) complications. The second part describes the effects of a strategy for preventing pregnancy-related IUAs in high-risk women and its impact on reproductive performance. The third part focuses on the relationship between pregnancy-related IUAs and reproductive performance and describes underlying mechanisms and processes that may lead to impaired reproductive performance in the case of IUAs. In this thesis, pregnancy-related IUAs were encountered in one in five women after miscarriage, TOP and RPOC. D&C was identified as the most important risk factor. It is of the utmost importance to limit the number of D&C procedures as much as possible. D&C should be performed only in cases of clinical necessity, and the application of an adhesion barrier such as APC should be considered, particurarly in women with a high risk for IUA formation, as IUAs are associated with impaired reproductive performance and an increase in obstetric complications.