Adhesions: Effects on fertility and prevention

Abstract

Adhesions connect two or more points of organs or tissues that are normally separate and can be considered as the most common complication of abdominal and pelvic surgery. They have the potential to cause serious adverse effects such as small bowel obstruction, secondary infertility and can lead to increasingly complicated high risk operative procedures. Studies have illustrated the high burden placed on healthcare resources, with around a third of patients being readmitted for a related cause over 10 years, and upwards of an annual $2 billion inpatient expenditure on related disease in the US. Adhesions form after damage to peritoneum when a fibrin clot, produced as part of the healing process persists instead of being fully reabsorbed. Any intraperitoneal organ may become involved in adhesions, with abdominal adhesions important in relation to fertility surgery due to potential operative complications, and pelvic adhesions potentially interfering with the processes leading to fertilization and implantation. A number of scoring systems have been developed to aid comparability and prognosis, such as the American Fertility Society adhesion score. Adhesiolysis has been demonstrated to be effective in improving fertility but its benefit is limited due to high rates of reformation of divided adhesions and formation of de-novo adhesions. Prevention of adhesions would be the best solution and there is evidence from meta-analysis that some types of barrier agents reduce adhesion formation, but no evidence that they are cost-effective or have any effect on live birth rate, pelvic pain or quality of life. Clinicians are advised to be aware and to inform patients of the frequency and spectrum of complications that can result from adhesions resulting from surgery.