Does uterine artery ligation, performed because of a severe postpartum hemorrhage, alter fertility?

26 04 2011

To the Editor:

We read with interest the case series report by Blanc et al. that highlights the risk of synechia after uterine-sparing procedures (1). The authors concluded that their “results suggest that triple ligation (TUAL), with or without haemostatic multiple square suturing (HMSS), exposes patients to the risk of subsequent abnormalities of the uterine cavity.” (1).

Regarding HMSS, we could not agree more with the authors, as we have been attempting to alert physicians to the possible hidden mid-term or long-term effects of uterine compression sutures (2–6), although these procedures were adopted promptly throughout the world.

Regarding TUAL, consisting of a bilateral (i) uterine artery, (ii) utero-ovarian and (iii) round ligament ligation (3), we have major concerns on reading the article by Blanc et al. First, almost no information is reported regarding the uterine-sparing surgical procedures, which were performed on the five women in whom an abnormal hysteroscopy finding was found. It is only mentioned that one of these 5 women had undergone both TUAL and HMSS (1). As 76.8% of the women had undergone both TUAL and HMSS due to a failure of TUAL [this failure rate of uterine artery ligation being extraordinarily higher than that reported in the literature (3, 7)], one can speculate that the number of women who had a synechia following TUAL alone (i.e., without HMSS) is very limited.

Second, in order to support the opinion that TUAL may be a risk factor of synechia, the authors mentioned inadequately two previous studies where no synechia was found following TUAL alone (7-8): in the first series, no amenorrhea or synechia was reported on the 20 women who underwent a bilateral uterine artery ligation whether or not associated with utero-ovarian ligament ligation (7); in the second one, Asherman syndrome occurred in a woman who underwent both bilateral uterine artery ligation and B-Lynch suture (8).

Third, bilateral artery uterine ligation has been found to have no impact on the rhythm, duration and amount of menstrual bleeding in 45 women (9), as well as on endometrium in an animal study (10).

We do believe that the results of Blanc et al, such as they reported (1), do not allow these authors to suggest that TUAL is a risk factor of subsequent abnormal hysteroscopy findings.

Loïc Sentilhes, M.D., Ph.D.
Philippe Descamps, M.D., Ph.D.
Department of Obstetrics and Gynecology
Angers University Hospital
Angers, France

References
1. Blanc J, Courbière B, Desbriere R, Bretelle F, Boubli L, D’Ercole C, et al. Is uterine-sparing surgical management of persistent postpartum hemorrhage truly a fertility-sparing technique? Fertil Steril 2011 Feb 10. doi:10.1016/j.fertnstert.2011.01.021

2. Sentilhes L, Gromez A, Razzouk K, Resch B, Verspyck E, Marpeau L. B-Lynch suture for persistent massive postpartum hemorrhage following vessel ligation. Acta Obstet Gynecol Scand 2008; 87:1020-6.

3. Sentilhes L, Gromez A, Descamps P, Marpeau L. Why stepwise uterine devascularization should be the first-line conservative surgical treatment to control severe postpartum hemorrhage? Acta Obstet Gynecol Scand 2009;88:490-2.

4. Sentilhes L, Gromez A, Trichot C, Ricbourg-Schneider A, Descamps P, Marpeau L. Fertility after B-lynch suture and stepwise uterine devascularization. Fertil Steril 2009;91:934.e5-9.

5. Sentilhes L, Gromez A, Marpeau L. Fertility after pelvic arterial embolization, stepwise uterine devascularization, hypogastric artery ligation and B-Lynch suture. Int J Gynaecol Obstet 2010;108:249.

6. Sentilhes L, Marpeau L, Descamps P. Has B-Lynch suture hidden long-term effects? Fertil Steril 2010;94:e62.

7. Sentilhes L, Trichot C, Resch B, Sergent F, Marpeau L, Verspyck E. Fertility and pregnancy outcomes following uterine devascularization for postpartum hemorrhage. Hum Reprod 2008; 23:1087-92.

8. Goojha CA, Case A, Pierson R. Development of Asherman syndrome after conservative surgical management of intractable postpartum hemorrhage. Fertil Steril 2010;94:1098.e1–5.

9. O’Leary JA. Effects of bilateral ligation of the uterine and ovarian vessels in dogs. Int J Gynaecol Obstet 1980;17:460–461.

10. AbdRabbo S. Stepwise uterine devascularization: a novel technique for management of uncontrollable postpartum hemorrhage with preservation of the uterus. Am J Obstet Gynecol 1994;171:694–700.

Published online in Fertility and Sterility doi:10.1016/j.fertnstert.2011.04.085

The Authors Respond:

We thank Sentilhes and Descamps for their interest and comments regarding our paper (1).

We acknowledge that the rate of patients in our series who had triple uterine ligation (TUAL) complemented by hemostatic multiple square suturing (HMSS) is unusually high and needs to be discussed (2, 3). According to our institution protocol, HMSS was only performed after failure of TUAL technique. However, we observed a trend toward a reduction of HMSS combined with TUAL over the years. In complement to TUAL, HMSS was significantly less often performed after 2006 than during the 2001-2006 period: 11 (57.9%) vs. 32 (86.5%), respectively (p=0.023). One can therefore speculate that some of the earlier HMSS procedures may have been done unnecessarily. This probably reflects the learning curve, which we felt necessary to feel confident with the TUAL technique and does not indicate compromised efficacy.

Concerns about the exact uterine sparing procedure that had been previously performed on the five women in whom an abnormal hysteroscopy finding was found are legitimate. However, as reported in our article, “only endometritis was found to have statistically significant impact on the risk of an abnormal diagnostic hysteroscopy examination: 2 (40%) vs. 0 (p=0.033)” (1). Among these five women, whereas 4 (23.5%) were previously managed using the combination of TUAL and HMSS, one (50%) had undergone TUAL alone, (p=0.395). Interestingly, this woman did not develop endometritis following TUAL. We could therefore not identify any other factor but TUAL that may have explained the abnormal hysteroscopic finding.

None of our references were inadequately cited. We referred to two studies (3, 4) to support the opinion that, as other uterine-sparing procedures, TUAL may be a risk factor of synechia. They confirm that similar complications have been previously described as a possible consequence of other uterine-sparing procedures. We were referring to all uterine-sparing procedures in general without focusing on TUAL. However, we do not believe that the absence of amenorrhea or synechia after bilateral uterine artery ligation with or without utero-ovarian ligation (3) is a strong enough argument to refute our conclusions. Neither is the fact that bilateral uterine artery ligation was not found to have any impact on menstrual bleeding in 45 women (5) or in the endometrium in an animal model (2).

Amenorrhea possibly related to uterine synechia has been reported after 5.6% of pelvic arterial embolization alone (i.e., without uterine-sparing surgery) (6). This would support the hypothesis of synechia occurring because of the interruption of blood flow in uterine arteries only. Interestingly, when reporting the follow up of 58 patients who underwent pelvic arterial embolization alone, Sentilhes et al. reported 11 (19%) cases of amenorrhea or decreased menstrual flow, of whom 6 were attributed to synechia (7).

Finally, as none of the patients with abnormal hysteroscopy reported a desire of pregnancy, the only legitimate concern regarding our finding is to know whether or not these abnormal hysteroscopic findings would be responsible for subsequent infertility.

Xavier Carcopino, M.D.1, 2
Julie Blanc, M.D.1
Blandine Courbiere, M.D., Ph.D.2,3
Raoul Desbriere, M.D.1
Florence Bretelle, M.D., Ph.D.1, 2
Léon Boubli, M.D.1, 2
Claude d’Ercole, M.D.1, 2

1Service de Gynécologie Obstétrique
Assistance Publique Hôpitaux de Marseille (APHM)
Hôpital Nord
Marseille, France
2Faculté de Médecine de Marseille
Université de la Méditerranée
Marseille, France
3Service de Gynécologie Obstétrique
Assistance Publique Hôpitaux de Marseille (APHM)
Hôpital de la Conception
Marseille, France

References
1. Blanc J, Courbiere B, Desbriere R, Bretelle F, Boubli L, d’Ercole C et al. Is uterine-sparing surgical management of persistent postpartum hemorrhage truly a fertility-sparing technique? Fertility and sterility 2011.

2. AbdRabbo SA. Stepwise uterine devascularization: a novel technique for management of uncontrolled postpartum hemorrhage with preservation of the uterus. American journal of obstetrics and gynecology 1994;171:694-700.

3. Sentilhes L, Trichot C, Resch B, Sergent F, Roman H, Marpeau L et al. Fertility and pregnancy outcomes following uterine devascularization for severe postpartum haemorrhage. Human reproduction (Oxford, England) 2008;23:1087-92.

4. Goojha CA, Case A, Pierson R. Development of Asherman syndrome after conservative surgical management of intractable postpartum hemorrhage. Fertility and sterility 2010;94:1098 e1- e5.

5. O’Leary JA. Pregnancy following uterine artery ligation. Obstetrics and gynecology 1980;55:112-3.

6. Hardeman S, Decroisette E, Marin B, Vincelot A, Aubard Y, Pouquet M et al. Fertility after embolization of the uterine arteries to treat obstetrical hemorrhage: a review of 53 cases. Fertility and sterility 2010.

7. Sentilhes L, Gromez A, Clavier E, Resch B, Verspyck E, Marpeau L. Fertility and pregnancy following pelvic arterial embolisation for postpartum haemorrhage. Bjog 2009;117:84-93.

Published online in Fertility and Sterility doi:10.1016/j.fertnstert.2011.04.086

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