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Postsurgical antiadhesive barriers to reduce the risk of recurrence after hysteroscopic adhesiolysis: a reply

Published:February 17, 2022DOI:https://doi.org/10.1016/j.ajog.2022.02.015
      We would like to thank He et al
      • He X.
      • Sun X.
      • Qu T.
      Postsurgical barrier strategies to avoid the recurrence of intrauterine adhesion formation after hysteroscopic adhesiolysis: a comment.
      for their interest in our network meta-analysis evaluating the efficacy of postsurgical antiadhesive barriers to reduce the risk of recurrence after hysteroscopic adhesiolysis.
      • Vitale S.G.
      • Riemma G.
      • Carugno J.
      • et al.
      Postsurgical barrier strategies to avoid the recurrence of intrauterine adhesion formation after hysteroscopic adhesiolysis: a network meta-analysis of randomized controlled trials.
      The authors expressed their concern regarding the lack of the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) criteria to assess the certainty of the evidence of the evaluated outcomes, especially for the primary outcome (intrauterine adhesions recurrence). He et al
      • He X.
      • Sun X.
      • Qu T.
      Postsurgical barrier strategies to avoid the recurrence of intrauterine adhesion formation after hysteroscopic adhesiolysis: a comment.
      concluded that the lack of the GRADE criteria could deliver misleading conclusions.
      It is indeed true, and we agree with He et al
      • He X.
      • Sun X.
      • Qu T.
      Postsurgical barrier strategies to avoid the recurrence of intrauterine adhesion formation after hysteroscopic adhesiolysis: a comment.
      that the use of the GRADE criteria would have been an added value to validate the reported evidence.
      • He X.
      • Sun X.
      • Qu T.
      Postsurgical barrier strategies to avoid the recurrence of intrauterine adhesion formation after hysteroscopic adhesiolysis: a comment.
      However, it should be acknowledged that our approach for study selection adopted extremely strict criteria, which resulted in including only high-quality, with low risk of bias, articles in the quantitative synthesis and network meta-analysis. In addition, to confirm the considerability of the evaluated evidence for both direct and indirect comparisons, the Separating Indirect from Direct Evidence–splitting method was used. This approach enhances the possibility that the considerability of results is related to the effects of the interventions rather than randomness.
      • Mbuagbaw L.
      • Rochwerg B.
      • Jaeschke R.
      • et al.
      Approaches to interpreting and choosing the best treatments in network meta-analyses.
      At the same time, there was no inconsistency reported for both direct and indirect comparisons among the study outcomes, which also increases the validity of the main findings.
      Considering all the aforementioned elements, although agreeing with He et al
      • He X.
      • Sun X.
      • Qu T.
      Postsurgical barrier strategies to avoid the recurrence of intrauterine adhesion formation after hysteroscopic adhesiolysis: a comment.
      regarding the importance of implementing GRADE criteria, we believe that the conclusions of our network meta-analysis must be considered appropriate. As we stated in our article and its conclusions, because of the lack of a superior approach among the analyzed barrier strategies, it is necessary to carry out further research to validate and confirm these findings. We hope with our article to encourage the research community to perform the needed additional studies to provide clinicians with valuable information on this fascinating topic.

      References

        • He X.
        • Sun X.
        • Qu T.
        Postsurgical barrier strategies to avoid the recurrence of intrauterine adhesion formation after hysteroscopic adhesiolysis: a comment.
        Am J Obstet Gynecol. 2022; 226: 869-870
        • Vitale S.G.
        • Riemma G.
        • Carugno J.
        • et al.
        Postsurgical barrier strategies to avoid the recurrence of intrauterine adhesion formation after hysteroscopic adhesiolysis: a network meta-analysis of randomized controlled trials.
        Am J Obstet Gynecol. 2022; 226: 487-498.e8
        • Mbuagbaw L.
        • Rochwerg B.
        • Jaeschke R.
        • et al.
        Approaches to interpreting and choosing the best treatments in network meta-analyses.
        Syst Rev. 2017; 6: 79

      Linked Article

      • Postsurgical barrier strategies to avoid the recurrence of intrauterine adhesion formation after hysteroscopic adhesiolysis: a comment
        American Journal of Obstetrics & GynecologyVol. 226Issue 6
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          In this network meta-analysis (NMA), Vitale et al1 compared antiadhesive strategies for women undergoing hysteroscopic adhesiolysis followed by mechanical prevention of intrauterine adhesions. The authors used the surface under the cumulative ranking (SUCRA) method to rank the interventions. Based on the SUCRA scores, the study concluded a copper intrauterine device together with an intrauterine balloon (46.4%), hyaluronic acid gel (79.8%), hyaluronic acid gel plus intrauterine device (49.9%), and dried amnion graft (53.8%) ranked the highest for preventing adhesions recurrence, improving fecundity, postsurgical adhesion severity, and menstrual pattern improvement, respectively.
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