Ghobrial, S., Ott, J., & Parry, J. P. (2023). An Overview of Postoperative Intraabdominal Adhesions and Their Role on Female Infertility: A Narrative Review. Journal of clinical medicine, 12(6). https://doi.org/10.3390/jcm12062263
Ghobrial S, Ott J, Parry JP. An Overview of Postoperative Intraabdominal Adhesions and Their Role on Female Infertility: A Narrative Review. Journal of clinical medicine. 2023;12(6). doi:10.3390/jcm12062263
Ghobrial, Stefan, et al. "An Overview of Postoperative Intraabdominal Adhesions and Their Role on Female Infertility: A Narrative Review." Journal of clinical medicine, vol. 12, no. 6, 2023.
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RRM Academy Synopsis
Pelvic adhesions after surgery are a common cause of infertility
A 2023 narrative review of 67 articles reports that pelvic adhesions account for 15–20% of female infertility. Up to 97% of open pelvic operations in gynecology leave adhesions. Gel barriers appeared to lower adhesion rates at second-look surgery in five high-quality studies. Their effect on pregnancy is still uncertain.
Key Findings
Pelvic adhesions account for 15–20% of female infertility, and one study suggests up to 40%. Up to 97% of open gynecologic pelvic procedures are followed by adhesions.
In a prospective study, 10.4% (12 of 115) of patients had adhesions at a first laparotomy. After a prior laparotomy, 93% (195 of 210) did.
A Cochrane review of 32 randomized trials (3492 women) estimated that gel agents would lower the chance of adhesions at second-look laparoscopy from 84% to 39–75%.
In a 1990 retrospective study of 147 women with periadnexal adhesions and otherwise unexplained infertility, pregnancy was 32% and 45% at 12 and 24 months with adhesiolysis, against 11% and 16% untreated.
After adhesiolysis of mild, filmy adhesions within 3–4 weeks of surgery, pregnancy over 6 months was 47% (9/19), against 55% (11/20) with expectant management (p > 0.05).
Interpretation
The authors searched Medline in March 2022 and summarized what they found without pooling results, so the figures come from studies of differing designs. The 15–20% share is quoted from earlier work. No official definition or standard grading of adhesions exists, which makes studies hard to compare. One Cochrane review of fluid and gel agents found their effect on clinical pregnancy uncertain. Most trials in a separate Cochrane review of barrier agents had commercial funding (13/19). The adhesiolysis pregnancy figures come from one retrospective study and one small study.
RRM Context
Restorative reproductive medicine looks for the cause of infertility. Adhesions are one cause to find and prevent. The review names avoiding unnecessary surgery as the clearest way to prevent them. It also describes microsurgical principles from fertility surgery: gentle tissue handling, careful control of bleeding, talc-free gloves, and complete excision of abnormal tissue. The authors report studies linking these principles to fewer adhesions and better fertility rates. The review lists endometriosis among the frequent causes of adhesions.
Our editorial summary of this paper, not the article's abstract.
Abstract
Postoperative intraabdominal adhesions can occur after more than 90% of gynecologic surgeries. They not only cause chronic pelvic pain and small bowel obstruction, but are also one of the main reasons for infertility. Adhesions are not only a burden for the affected patients, but are also a burden for the healthcare system, since the treatment of adhesion-associated complications costs a considerable amount of money. The gold standard for the diagnosis of adhesions is by laparoscopy, although other methods, such as transvaginal hydro-laparoscopy, are being discussed as better alternatives. Ideally, adhesions are avoided inherently, by operating carefully and by using microsurgical principles. If this is not possible, gel barriers have been shown to be successful in reducing postoperative adhesions.
