Efficacy of high-dose estrogen and progesterone sequential assisted hysteroscopic cold knife separation versus hysteroscopic cold knife separation alone in the treatment of infertility or amenorrhea caused by severe intrauterine adhesion: a retrospective cohort study.

Introduction: To investigate the effect of high-dose estrogen and progesterone sequential assisted hysteroscopic cold knife separation surgery on the recovery of uterine cavity morphology in patients with severe intrauterine adhesions (IUA).

Methods: This was a retrospective cohort study. A total of 200 patients with severe IUA were selected as the research objects, and the selected period was from August 2020 to August 2023. According to different treatment methods, patients were divided into the surgical group (hysteroscopic cold knife separation surgery, n = 82) and the combined group (high-dose estrogen and progesterone sequential assisted hysteroscopic cold knife separation surgery, n = 118). The clinical effects and menstrual blood loss map (PBAC) scores were compared between the two groups. The uterine cavity shape recovery was observed before treatment and 2 months after treatment. Multivariate Logistic regression analysis was used to analyze the influencing factors.

Results: Compared with 79.27% in the surgical group, the effective rate of the combined group was 94.07%, which was higher (χ² = 0.035, P = 0.002). PBAC score in the combined group was significantly lower than that in the surgical group (t = 4.594, P < 0.001). After intervention, the intimal thickness, intimal volume and volume of the combined group were higher than the surgical group (t = 7.608, P < 0.001;t = 8.044, P < 0.001; t = 11.372, P < 0.001). The re-adhesion rate of the combined group was 11.02%, which was significantly lower than 29.27% of the surgical group (χ² = 10.689, P = 0.002). Compared with 6.10% and 89.02% of pregnancy rate and satisfaction rate in the surgical group, the pregnancy rate was 20.34% and the satisfaction rate was 97.46% in the combined group, which were significantly higher (χ² = 7.915, P = 0.005; χ² = 6.101, P = 0.014). Postoperative amenorrhea (OR = 1.970, 95%CI: 1.278-3.037), number of miscarriages (OR = 1.775, 95%CI: 1.344-2.344), standardized use of estrogen (OR = 1.519, 95%CI: 1.119-2.063), number of intrauterine operations (OR = 1.766, 95%CI: 1.162-2.686), and placement of balloons (OR = 3.264, 95%CI: 1.788-5.960) were independent risk factors for recurrence of IUA after treatment (P < 0.05). Besides, combination therapy (OR = 0.454, 95%CI: 0.283-0.730) was a protective factor (P < 0.05).

Conclusion: In the treatment of severe IUA, high-dose estrogen and progesterone sequential assisted hysteroscopic cold knife separation surgery can promote the recovery of uterine cavity morphology, reduce the incidence of postoperative IUA, and improve the postoperative pregnancy rate of patients. This was a retrospective study with limitations such as single sample and short follow-up time. Prospective studies with extended follow-up are needed.