Dou Yuya, Yu Tingting, Li Zhen, Wang Jingjing, Jiang Yuting, Liu Yu
Department of Obstetrics and Gynecology of the Southwest Hospital of Army Medical University, People's Liberation Army of China, Shapingba district Chongqing China (Dr. Dou and Dr. Li, Ms. Wang and Ms. Jiang).
Department of Obstetrics and Gynecology of the People's hospital of Wenjiang Chengdu, Sichuan Province China (Dr. Yu).
J Minim Invasive Gynecol. 2022 Aug;29(8):934-942. doi: 10.1016/j.jmig.2022.05.006. Epub 2022 May 13.
To systematically evaluate the role of hyaluronic acid (HA) gel and its derivatives in the postoperative prevention of intrauterine adhesions (IUA) and to assess whether HA gel could improve the pregnancy rate.
A structured search was performed in PubMed, Cochrane, Scopus, Web of Science, and Embase on February 2, 2022.
We chose medical subject headings and relevant terms from other articles for the database search. The following intervention was selected: HA gel or related derivatives vs placebo in randomized controlled trials (RCTs). The following outcomes were selected: the rate and severity of IUA after intrauterine operations and pregnancy rate. After the full-text screening, 12 articles were included in the final analysis. The study quality and risk of bias were assessed with the Cochrane tool (www.training.cochrane.org/handbook).
TABULATION, INTEGRATION, AND RESULTS: Data from 12 articles on 1579 patients were extracted and analyzed by 2 independent reviewers. According to the meta-analysis, HA gel could decrease the risk of IUA (risk ratio [RR], 0.50; 95% confidence interval [CI], 0.37-0.67; p = .005; I = 59%) after intrauterine operations. Subgroup analysis revealed a significant positive impact of HA gel on both groups receiving dilatation and curettage (RR, 0.42; 95% CI, 0.30-0.59; p = .86; I = 0) or hysteroscopic surgery (RR, 0.55; 95% CI, 0.38-0.80; p = .007; I = 66%). The sensitivity analysis showed that heterogeneity could be improved significantly by removing one study. The severity of IUA (mean difference = -0.92; 95% CI, -1.49 to -0.34; p <.00; I = 89%) was lower in the intervention group. Subgroup and sensitivity analyses did not significantly improve the heterogeneity. When the studies are classified by the volume of HA gel, 10 mL (RR, 0.40; 95% CI, 0.27-0.60; p = .96; I = 0) and 5 mL (RR, 0.34; 95% CI, 0.14-0.82; p = .36; I = 0) were effective in treating IUA. In contrast, HA gel <5 mL was not sufficient to prevent IUA (RR, 0.66; 95% CI, 0.43-1.01; p = .02; I = 71%; p = .05). The pregnancy rate was also improved by the use of HA gel (RR, 1.39; 95% CI, 1.13-1.72; p = .37, I = 0).
HA gel helps prevent IUA and decreases the severity of IUA after intrauterine surgery. A greater volume (≥5 mL) of HA gel is recommended to prevent IUA, according to this analysis. Moreover, HA gel can increase the pregnancy rate after intrauterine surgery. However, these conclusions should be interpreted with caution because of the inadequate quality of some RCTs with relatively small sample sizes and sample heterogeneity. Large RCTs are required to verify these conclusions in the future.
系统评价透明质酸（HA）凝胶及其衍生物在预防子宫内粘连（IUA）术后的作用，并评估HA凝胶是否能提高妊娠率。
于2022年2月2日在PubMed、Cochrane、Scopus、Web of Science和Embase进行了结构化检索。
我们从数据库搜索中选择医学主题词和其他文章中的相关术语。选择的干预措施如下：随机对照试验（RCT）中HA凝胶或相关衍生物与安慰剂对比。选择的结局如下：子宫内手术后IUA的发生率和严重程度以及妊娠率。经过全文筛选，最终分析纳入12篇文章。使用Cochrane工具（www.training.cochrane.org/handbook）评估研究质量和偏倚风险。
制表、整合与结果：由2名独立审阅者提取并分析了12篇文章中1579例患者的数据。根据荟萃分析，HA凝胶可降低子宫内手术后发生IUA的风险（风险比[RR]，0.50；95%置信区间[CI]，0.37 - 0.67；p = 0.005；I² = 59%）。亚组分析显示，HA凝胶对接受刮宫术（RR，0.42；95% CI，0.30 - 0.59；p = 0.86；I² = 0）或宫腔镜手术（RR，0.55；95% CI，0.38 - 0.80；p = 0.007；I² = 66%）的两组均有显著的积极影响。敏感性分析表明，剔除一项研究后异质性可显著改善。干预组IUA的严重程度较低（平均差 = -0.92；95% CI，-1.49至 -0.34；p < 0.00；I² = 89%）。亚组分析和敏感性分析并未显著改善异质性。按HA凝胶的用量对研究进行分类时，10 mL（RR，0.40；95% CI，0.27 - 0.60；p = 0.96；I² = 0）和5 mL（RR，0.34；95% CI，0.14 - 0.82；p = 0.36；I² = 0）对治疗IUA有效。相比之下，HA凝胶<5 mL不足以预防IUA（RR，0.66；95% CI，0.43 - 1.01；p = 0.02；I² = 71%；p = 0.05）。使用HA凝胶也提高了妊娠率（RR，1.39；95% CI，1.13 - 1.72；p = 0.37，I² = 0）。
HA凝胶有助于预防IUA，并降低子宫内手术后IUA的严重程度。根据该分析，建议使用更大体积（≥5 mL）的HA凝胶来预防IUA。此外，HA凝胶可提高子宫内手术后的妊娠率。然而，由于一些样本量相对较小且样本存在异质性的RCT质量不足，这些结论应谨慎解读。未来需要大型RCT来验证这些结论。
