The number of hysteroscopic procedures to achieve an adhesion-free cavity following hysteroscopic adhesiolysis: an explorative systematic review

Objective: Intrauterine adhesions (IUAs) are associated with menstrual disturbances, infertility and adverse reproductive outcomes. Hysteroscopic adhesiolysis (HA) is the standard treatment, but adhesion reformation is common. The number of HA-procedures required to achieve an adhesion-free uterine cavity is clinically relevant because of burden and healthcare costs but remains unclear. This systematic review and meta-analysis aimed to determine the number of procedures required to achieve an adhesion-free uterine cavity in women with IUAs. Methods: Pubmed was searched from inception until November 2025 for studies evaluating women with IUAs treated by HA. Studies were included if IUAs were diagnosed by hysteroscopy and postoperatively the uterine cavity was systematically evaluated for recurrence of IUAs. The primary outcome was the number of HA-procedures required to achieve an adhesion-free uterine cavity. Secondly, we try to identify risk factors. Results: In total 9 studies were included with 1716 participants. The severity of IUAs was reported in 86.3%. After the first HA-procedure, an adhesion-free uterine cavity was achieved in 67.9%. There was no significant difference in the recurrence rate according to IUAs severity. The recurrence rate after one and two HA-procedures was respectively 30.4% and 45.0%. A lower recurrence rate was reported when an intrauterine device (IUD) was placed following HA when compared to intrauterine ballon placement. Mechanical dissection leads to a significant lower recurrence rate when compared to energy base dissection. Conclusions: Recurrent IUAs are common in women with IUAs following HA; 30.4% required more than one HA-procedure and after a second procedure, recurrence occurred in 44.6%. It was not possible to determine the exact number of HA-procedures to achieve an adhesion-free uterine cavity in women with IUAs. Future studies should use broader search strategies to determine the number of HA-procedures.