Hysteroscopic Myomectomy is a safe and reliable method in patients with FIGO type 0,1 and 2 myomas

Hysteroscopic Myomectomy is a safe and reliable method in patients with FIGO type 0,1 and 2 myomas | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Hysteroscopic Myomectomy is a safe and reliable method in patients with FIGO type 0,1 and 2 myomas Özge Karaosmanoğlu, Nuri Peker, Ömür Albayrak, Ayşen Yücetürk, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6679841/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background We aimed to demonstrate feasibility and safety of hysteroscopic myomectomy in infertile patients with International Federation of Gynecology and Obstetrics (FİGO) classification type 0, type 1 and type 2 uterine fibroids. Methods Infertile patients who have FIGO type 0, 1, 2 myomas underwent hysteroscopic myomectomy before embryo transfer. Intrauterine device (IUD) was placed into the uterine cavity and adhesion barrier gel was applied after surgery. Two months later, IUD was removed and control hysterosalpingography (HSG) was performed. Embryo transfer was performed in patients who were not considered to have intrauterine adhesions (IUA) after evaluation with HSG. Results Fifty patients were enrolled the study. Thirtynine (78%) patients conceived and 21 (42%) had live birth. Second look hysteroscopy was performed in 4 (8%) patients due to intrauterine adhesions and removed by cutting cold knife via office hysteroscopy. Pregnancy was achieved in all of these patients; one had live birth, two patients had biochemical pregnancy and one patient had an abortion in the 8th week of pregnancy. No complication was occurred in any case. Conclusion Hysteroscopic myomectomy is a safe and reliable method in the treatment of FIGO type 0, 1, 2 myomas and may enhance pregnancy rate when performed before embryo transfer. Hyteroscopy myoma FIGO classification IVF intrauterine adhesion barrier gel Background Uterine fibroids are benign tumors that originate from the smooth muscle layer of the uterus and common in women of reproductive age. The most common symptom is menometrorrhagia, but it can often cause pelvic pain and infertility as well. Approximately 5–10% of patients diagnosed with infertility have uterine fibroids ( 1 ). Ultrasound is the initial method to diagnose uterine fibroids due to its’ low cost, widely use and accessibility as well as high sensitivity and specificity. Defining the size, number and location of the uterine fibroids are substantial for deciding the appropriate treatment therefore classification of myomas is of crucial importance. There are two classification methods including traditional system and FİGO classification system ( 2 ). The prior one is based on the relationship between either endometrium or uterine serosa and divided into three subgroups as submucousal, intramural and subserosal ( 2 ). According to the FIGO classification, there are nine subcategories from type 0 to type 8 in which type 0, type 1 and type 2 myomas can lead to infertility by affecting endometrial receptivity, gamet transport or hormonal milieu ( 1 , 2 ). The effect of type 3 myoma on infertility is controversial, however there are numerous studies suggesting that it is associated with lower implantation rate, pregnancy rate and live birth rate ( 3 ). Treatment of uterine fibroids is either medical or surgical, but hysteroscopic removal is recommended in patients with Figo type 0, 1, 2 myomas ( 4 , 5 ). Hystersocopy is the inspection of the uterine cavity with endoscopy, which provides opportunity to diagnose and treat intrauterine pathologies in the same session. It is a safe, reliable and effective procedure with very low complication rates ( 5 , 6 ). In a study conducted with participation of 82 hospitals, 13.600 procedures were performed and complications occurred in only 36 cases. The overall complication rate was reported as 0.28% and operative hysteroscopy has higher complication rate than diagnostic one ( 6 ). The most common complications are hemorrhage, uterine perforation and cervical laceration respectively ( 5 ). Intrauterine adhesions are late complications accounts for 18.7% ( 7 ). In our retrospective study, we aimed to demonstrate pregnancy and live birth rate in women who underwent hysteroscopic myomectomy and applied intrauterine adhesion gel after surgery. Methods This is a retrospective study conducted at Acıbadem Maslak Hospital IVF Department between January 1, 2017 and January 1, 2024. The files of 18.000 patients were retrospectively scanned and a hundred and ninety patients who received IVF treatment and had undergone hysteroscopic myomectomy were included into the study. Finally, fifty patients were enrolled the study. Patients who have Figo type 0, type 1, type 2 myomas with no previous myomectomy removal history were included into the study. Patients with a history of previous hysteroscopic myomectomy, intrauterine surgery were excluded from the study. Moreover, women aged over 38 yo, patients with recurrent pregnancy loss, history of recurrent IVF failure, men with the diagnosis of azoospermia were excluded. The study was conducted in accordance with the Declaration of Helsinki. The study involving human participants were reviewed and approved by the institutional review board and ethics committee of the Acibadem University (Acıbadem Üniversitesi ve Acıbadem Sağlık Kuruluşları Tıbbi Araştırma Etik Kurulu) with approval number: 2025/07–56. Written informed consent from the patients were not required to participate in this study in accordance with the national legislation and the institutional requirements. Description of the techniques Patients were initially evaluated with transvaginal ultrasonography (TVUSG) after taking a detailed anamnesis. Myoma number, size and type according to FIGO classification system were determined. In cases where the evaluation with TVUSG was insufficient, saline infusion sonography (SIS) was performed to better visualize and determine the location, size and the type of the myoma(s). During SIS, a sterile catheter was placed in the endometrial cavity and 10 ml of sterile saline was injected. Thus, the uterine cavity was distended and was seen in a single layer view. Finally, patients were scheduled a hysteroscopy procedure for the following day. Operative hysteroscopy was performed under general anesthesia in the operating theatre with the Storz 30 0 , 6 mm outer shift. During the procedure, fibroids were removed and sent for pathological evaluation. After the removal of myoma (s), adhesion barrier gel was applied into the endometrial cavity and IUD (Copper T 380) was inserted. The patients were discharged on the same day. Antibiotics (doxycycline 100 mg, 2*1) and estradiol + norgestrel including pills (cyclo-progynova 21 dragee) were prescribed. Two months later, patients were called for a check-up, IUD was removed and HSG was performed. After evaluation with HSG, hysteroscopy was performed in patients with signs of intrauterine adhesions. Embryo transfer was planned for patients with no sign of intrauterine adhesions. Statistical Analysis All data were analysed using SPSS (SPSS-IBM 2.3, Inc., Chicago, IL, USA). The Shapiro-Wilk test was used to assess data normality. Categorical variables were compared with Chi-square or Fisher’s exact test. For continuous variables, the study results were summarized as mean ± standard deviation (SD). Categorical variables were presented as frequencies and percentages. Statistical significance was set at p<0.05. Results Fifty patients were enrolled the study. Pregnancy was achieved in 39 (78%) patients, eight (16%) of them were bio-chemical pregnancies, nine (18%) of them were clinical pregnancies resulted in miscarriages and 21 (42%) patients had live birth. A second-look hysteroscopy was performed in seven patients due to either myoma(s) (n: 3) or intrauterine adhesions (n: 4). Pregnancy occurred in all patients who developed intrauterine adhesions after myomectomy and therefore underwent a second hysteroscopy. Two out of four patients had live births while the remaining patients had biochemical pregnancies. Among patients who underwent second hysteroscopic myomectomy, one had biochemical pregnancy and two patients did not conceive. Table 1 illustrates the demographic features of the patients. There was no statistically significant difference in terms of age, body mass index (BMI) and duration of infertility between patients who conceived or did not conceive. Table 2 depicts the relationship between the number and size of myomas and the pregnancy rate. There was no statistically significant relationship between the number and size of the fibroids and the pregnancy rates. Table 3 shows the relationship between the FIGO classification of the fibroids and the pregnancy rates. The results were comparable between three groups (FIGO group 0, 1 and 2) in terms of pregnancy rates. Discussion Hysteroscopy is a minimally invasive and safe procedure, which is used to evaluate the intrauterine cavity and treat in the same session ( 8 ). It is the gold standard technique in the treatment for different intrauterine pathologies including endometrial polyps, fibroids, uterine septum and intrauterine adhesions ( 8 , 9 ). The overall incidence of complication is 0.95% in which the most common one is hemorrhage fallowed by uterine perforation and cervical laceration ( 6 , 7 , 8 , 9 ). Distension media overload is a rare but serious complication with the incidence of less than 5% and can be life threatening. Later onset complications include intrauterine adhesions and pelvic infection, which are of crucial importance because they may cause infertility. Particularly, intrauterine adhesions develop after hysteroscopic myomectomy and may be related to many factors. In a study with Takasaki et al., hysteroscopic myomectomy was performed in 217 patients and the incidence of intrauterine adhesion was investigated. The patients were divided into three groups as group 1, patients with one myoma, group 2, patients having apposing myomas and group 3, fibroids that was far from each other. The incidence of IUA was reported more frequently at group 2 meaning that apposing myomas should be a risk factor in adhesion formation ( 10 ). Similarly, Yang et al. conducted a retrospective study including 132 patients and reported that the incidence of IUA after hysteroscopic myomectomy increased with the presence of apposing myomas ( 11 ). Bortoletto et al. compared IUA rate in patients who underwent abdominal myomectomy, minimally invasive myomectomy and hysteroscopic myomectomy and reported that even though IUA were higher in patients who underwent hysteroscopic myomectomy, there is no statistically significant differences. Moreover, they concluded that, the number or size of the fibroid does not affect the IUD incidence ( 12 ). In our study, we did not classified the patients regarding the location of fibroids as either apposing fibroids or fibroids far from each other, however similar with literature, we found that the size, number and the type (FİGO classification) of the fibroids dis not have relationship with the incidence of IUA formation. Different treatment methods such as hyalunoric acid gels (HAG) or intrauterine devices (IUD) have been applied to prevent the development of intrauterine adhesions after hysteroscopic resection of submucous fibroids. There are many publications supporting the use of cross-linked hyaluronic acid gels to prevent IUA. A meta-analysis assessing the effectiveness and safety of hyalunoric acid gels reported that the incidence of IUA decreased and the pregnancy rate increased after the use of HAG after hysteroscopic myomectomy ( 13 ). Similarly, Zheng et al. published a meta-analysis and suggested that the use of hyalunoric acid gel not only reduced the formation of IUA but also improved the pregnancy rates after intrauterine operations ( 14 ). On the other hand, there are many articles reporting that the use of HAG does not prevent the formation of IUA. Mmed et al. conducted a double-blinded randomized controlled trial in 245 patients evaluating the IUA recurrence and fertility score. They classified patients into two groups according to whether hyalunoric acid gel was applied or not and reported that HAG did not seem to be effective in prevention of IUAs ( 15 ). Intrauterine balloon application is another option to prevent IUAs. Yang et al. and Shi et al. reported that the incidence of IUA was reduced in patients in whom intrauterine balloon was inserted after hysteroscopic surgery ( 16 , 17 , 18 ). Recently, there have been stunning developments in biomedical engineering, thus plenty of studies conducted in the prevention and treatment of intrauterine adhesions. İn 2022, Weyers et al. carried out a multicenter study for the assessment of safety and effectiveness of a novel intrauterine degradable polymer film (DPF) to prevent IUA after hsyteroscopic myomectomy. DPF was inserted into the uterine cavity, which is totally degraded within 7 days. Twenty-three patients were enrolled into the study. It was reported that 20 out of 23 patients have no intrauterine adhesions on the second look hysteroscopy ( 19 ). In our study, we applied hyaluronic acid gel and intrauterine device after hysteroscopic myomectomy. Two months later, IUD was removed and HSG was performed to check intrauterine cavity. The IUA was occurred in four patients (8%) in our study. Preservation of fertility is the main goal after hysteroscopic surgery. Litta et al. reported a total pregnancy rate of 85.8% after hysteroscopic myomectomy. Furthermore, they reported that the classification, size and number of fibroids did not influence the pregnancy and delivery rate ( 20 ). Similarly, Yang et al. reported a total pregnancy rate of 89.2% and live birth rate of 70.7% in a study published in 2021 ( 21 ). In our study, the pregnancy and live birth rate was 78% and 42% respectively. The overall pregnancy rate was similar with literature, however live birth rate was significantly lower. We attribute this to the fact that, the population in our study was consisted of infertile patients and factors other tan uterine fibroids may have affected the live birth rate for instance embryo quality, sperm quality and oocyte quality as well. Moreover, the classification, size and the number of fibroids did not change the pregnancy and live birth rate. The first limitation of our study is it’s retrospective nature. The second limitation is the absence of control group in the study, but in our clinic embryo transfer is not performed to patients with FIGO type 0, 1, 2 groups without removing the myomas. Therefore, a control group could not be provided. The third limitation is that small numbers of patients were included into the study. However, we evaluated the pregnancy rates after hysteroscopic myomectomy, so we excluded all independent factors that may reduce pregnancy rates. Conclusion In conclusion, FIGO type 0, 1, 2 fibroids can reduce pregnancy rates in patients who undergo embryo transfer, thus removal via hysteroscopy is recommended. In our study, we demonstrated the safety and feasibility of the procedure. Abbreviations International Federation of Gynecology and Obstetrics (FIGO), intrauterine adhesions (IUA), Intrauterine device (IUD), hysterosalpingography (HSG), transvaginal ultrasonography (TVUSG), saline infusion sonography (SIS), body mass index (BMI) Declarations Ethics approval and consent to participate The study was conducted in accordance with the Declaration of Helsinki. The study involving human participants were reviewed and approved by the institutional review board and ethics committee of the Acibadem University (Acıbadem Üniversitesi ve Acıbadem Sağlık Kuruluşları Tıbbi Araştırma Etik Kurulu) with approval number: 2025/07-56. Written informed consent from the patients were not required to participate in this study in accordance with the national legislation and the institutional requirements. Consent for publication not applicable Availability of data and material The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. Competing interests The authors declare that they have no competing interests Funding There is no funding. Authors' contributions Ö.K and Ö.A collected patient’s data N.P, İ.Ö.A and B.T wrote the main manuscript task A.Y prepared tables and the statistics of the study All authors reviewed the manuscript Acknowledgements Not applicable References Guo XC, Segars JH. The impact and management of fibroids for fertility: an evidence-based approach. Obstet Gynecol Clin North Am. 2012: 39(4): 521-33. doi: 10.1016/j.ogc.2012.09.005. PMID: 23182558; PMCID: PMC3608270. Palheta MS, Medeiros FDC, Severiano ARG. Reporting of uterine fibroids on ultrasound examinations: an illustrated report template focused on surgical planning. Radiol Bras. 2023: 56(2): 86-94. doi: 10.1590/0100-3984.2022.0048. PMID: 37168038; PMCID: PMC10165971. Favilli A, Etrusco A, Chiantera V, Laganà AS, Cicinelli E, Gerli S, Vitagliano A. Impact of FIGO type 3 uterine fibroids on in vitro fertilization outcomes: A systematic review and meta-analysis. Int J Gynaecol Obstet. 2023; 163(2): 528-539. doi: 10.1002/ijgo.14838. Epub 2023 May 15. PMID: 37183601. Piecak K, Milart P. Hysteroscopic myomectomy. Prz Menopauzalny. 2017; 16(4): 126-128. doi: 10.5114/pm.2017.72757. Epub 2017 Dec 30. PMID: 29483854; PMCID: PMC5824682. Jansen FW, Vredevoogd CB, van Ulzen K, Hermans J, Trimbos JB, Trimbos-Kemper TC. Complications of hysteroscopy: a prospective, multicenter study. Obstet Gynecol. 2000; 96(2): 266-70. doi: 10.1016/s0029-7844(00)00865-6. PMID: 10908775. Elahmedawy H, Snook NJ. Complications of operative hysteroscopy: an anaesthetist's perspective. BJA Educ. 2021; 21(7): 240-242. doi: 10.1016/j.bjae.2021.03.001. Epub 2021 May 6. PMID: 34178379; PMCID: PMC8212159. Sebbag L, Even M, Fay S, Naoura I, Revaux A, Carbonnel M, Pirtea P, de Ziegler D, Ayoubi JM. Early Second-Look Hysteroscopy: Prevention and Treatment of Intrauterine Post-surgical Adhesions. Front Surg. 2016: 16; 6:50. doi: 10.3389/fsurg.2019.00050. PMID: 31475154; PMCID: PMC6706867. Aas-Eng MK, Langebrekke A, Hudelist G. Complications in operative hysteroscopy - is prevention possible? Acta Obstet Gynecol Scand. 2017; 96(12): 1399-1403. doi: 10.1111/aogs.13209. Epub 2017 Sep 27. PMID: 28832907. Etrusco A, Laganà AS, Chiantera V, Vitagliano A, Cicinelli E, Mikuš M, Šprem Goldštajn M, Ferrari F, Uccella S, Garzon S, Gerli S, Favilli A. Feasibility and Surgical Outcomes of Hysteroscopic Myomectomy of FIGO Type 3 Myoma: A Systematic Review. J Clin Med. 2023; 12(15): 4953. doi: 10.3390/jcm12154953. PMID: 37568356; PMCID: PMC10419844. Takasaki K, Henmi H, Ikeda U, Endo T, Azumaguchi A, Nagasaka K. Intrauterine adhesion after hysteroscopic myomectomy of submucous myomas. J Obstet Gynaecol Res. 2023; 49(2): 675-681. doi: 10.1111/jog.15499. Epub 2022 Nov 20. PMID: 36404131. Yang JH, Chen MJ, Wu MY, Chao KH, Ho HN, Yang YS. Office hysteroscopic early lysis of intrauterine adhesion after transcervical resection of multiple apposing submucous myomas. Fertil Steril. 2008; 89(5): 1254-1259. doi: 10.1016/j.fertnstert.2007.05.027. Epub 2007 Aug 8. PMID: 17686478. Bortoletto P, Keefe KW, Unger E, Hariton E, Gargiulo AR. Incidence and risk factors of intrauterine adhesions after myomectomy. F S Rep. 2022; 3(3): 269-274. doi: 10.1016/j.xfre.2022.05.007. PMID: 36212555; PMCID: PMC9532880. Luo Y, Sun Y, Huang B, Chen J, Xu B, Li H. Effects and safety of hyaluronic acid gel on intrauterine adhesion and fertility after intrauterine surgery: a systematic review and meta-analysis with trial sequential analysis of randomized controlled trials. Am J Obstet Gynecol. 2024; 231(1): 36-50.35. doi: 10.1016/j.ajog.2023.12.039. Epub 2024 Jan 6. PMID: 38191020. Zheng F, Xin X, He F, Liu J, Cui Y. Meta-analysis on the use of hyaluronic acid gel to prevent intrauterine adhesion after intrauterine operations. Exp Ther Med. 2020; 19(4): 2672-2678. doi: 10.3892/etm.2020.8483. Epub 2020 Feb 3. PMID: 32256748; PMCID: PMC7086218. Zhou Q, Shi X, Saravelos S, Huang X, Zhao Y, Huang R, Xia E, Li TC. Auto-Cross-Linked Hyaluronic Acid Gel for Prevention of Intrauterine Adhesions after Hysteroscopic Adhesiolysis: A Randomized Controlled Trial. J Minim Invasive Gynecol. 2021; 28(2): 307-313. doi: 10.1016/j.jmig.2020.06.030. Epub 2020 Jul 15. PMID: 32681996. Yang X, Liu Y, Li TC, Xia E, Xiao Y, Zhou F, Song D, Zhou Q. Durations of intrauterine balloon therapy and adhesion reformation after hysteroscopic adhesiolysis: a randomized controlled trial. Reprod Biomed Online. 2020; 40(4): 539-546. doi: 10.1016/j.rbmo.2019.11.017. Epub 2019 Dec 10. PMID: 32199799. Shi X, Saravelos SH, Zhou Q, Huang X, Xia E, Li TC. Prevention of postoperative adhesion reformation by intermittent intrauterine balloon therapy: a randomised controlled trial. BJOG. 2019; 126(10): 1259-1266. doi: 10.1111/1471-0528.15843. Epub 2019 Jul 18. PMID: 31207009. Luo Y, Liu Y, Xiao Y, Zhou Q, Zhang Z, Li X. Extended intrauterine balloon stent use to prevent adhesion reformation after hysteroscopic adhesiolysis: a randomized trial. Fertil Steril. 2025: S0015- 0282(25)00051-2. doi: 10.1016/j.fertnstert.2025.01.024. Epub ahead of print. PMID: 39884334. Weyers S, Capmas P, Huberlant S, Dijkstra JR, Hooker AB, Hamerlynck T, Debras E, De Tayrac R, Thurkow AL, Fernandez H. Safety and Efficacy of a Novel Barrier Film to Prevent Intrauterine Adhesion Formation after Hysteroscopic Myomectomy: The PREG1 Clinical Trial. J Minim Invasive Gynecol. 2022; 29(1): 151-157. doi: 10.1016/j.jmig.2021.07.017. Epub 2021 Jul 31. PMID: 34343712. Litta P, Conte L, De Marchi F, Saccardi C, Angioni S. Pregnancy outcome after hysteroscopic myomectomy. Gynecol Endocrinol. 2014; 30(2): 149-52. doi: 10.3109/09513590.2013.863861. Epub 2013 Dec 5. PMID: 24303914. Yang Y, Yang Y, You M, Chen L, Sun F. Observation of pregnancy outcomes in patients with hysteroscopic resection on submucous myomas. J Obstet Gynaecol Res. 2022; 48(2): 360-365. doi: 10.1111/jog.15125. Epub 2021 Dec 12. PMID: 34897915. Tables Table 1: Demographic characteristics of patients Pregnancy Number (n) Mean Std. Deviation Std. Error Mean Age 0 11 34.18 3.710 1.119 1 39 33.64 3.240 .519 BMI 0 11 25.073 5.9621 1.7976 1 39 24.372 4.2014 .6728 Duration of Infertility 0 11 7.27 4.839 1.459 1 39 6.23 4.158 .666 0: non pregnant, 1: pregnant Table 2: The relationship between the number and size of myomas and the pregnancy rate Pregnancy (n) Non pregnant n (%) Pregnant, n (%) Total n (%) Number of fibroids 1 7 (19.4%) 29 (80.6%) 36 (72%) 2 4 (33.3%) 8 (66.7%) 12 (24%) 3 or more 0 (0%) 2 (100%) 2 (4%) Size of fibroids (mean) 15.91+3.743 15.08+1.639 Table 3: The relationship between the FIGO classification of the fibroids and the pregnancy rates Pregnancy Non pregnant N (%) Pregnant N (%) Total N (%) Type of fibroids (FIGO classification) Type 0 0 (0%) 4 (100%) 4 (8%) Type 1 5 (21.7%) 18 (78.3%) 23 (46%) Type 2 4 (21.1%) 15 (78.9%) 19 (38%) Type 1+2 2 (50%) 2 (50%) 4 (8%) 11 (22%) 39 (78%) 50 (100%) Additional Declarations No competing interests reported. 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The most common symptom is menometrorrhagia, but it can often cause pelvic pain and infertility as well. Approximately 5\u0026ndash;10% of patients diagnosed with infertility have uterine fibroids (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). Ultrasound is the initial method to diagnose uterine fibroids due to its\u0026rsquo; low cost, widely use and accessibility as well as high sensitivity and specificity. Defining the size, number and location of the uterine fibroids are substantial for deciding the appropriate treatment therefore classification of myomas is of crucial importance. There are two classification methods including traditional system and FİGO classification system (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). The prior one is based on the relationship between either endometrium or uterine serosa and divided into three subgroups as submucousal, intramural and subserosal (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). According to the FIGO classification, there are nine subcategories from type 0 to type 8 in which type 0, type 1 and type 2 myomas can lead to infertility by affecting endometrial receptivity, gamet transport or hormonal milieu (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). The effect of type 3 myoma on infertility is controversial, however there are numerous studies suggesting that it is associated with lower implantation rate, pregnancy rate and live birth rate (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). Treatment of uterine fibroids is either medical or surgical, but hysteroscopic removal is recommended in patients with Figo type 0, 1, 2 myomas (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eHystersocopy is the inspection of the uterine cavity with endoscopy, which provides opportunity to diagnose and treat intrauterine pathologies in the same session. It is a safe, reliable and effective procedure with very low complication rates (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). In a study conducted with participation of 82 hospitals, 13.600 procedures were performed and complications occurred in only 36 cases. The overall complication rate was reported as 0.28% and operative hysteroscopy has higher complication rate than diagnostic one (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). The most common complications are hemorrhage, uterine perforation and cervical laceration respectively (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). Intrauterine adhesions are late complications accounts for 18.7% (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn our retrospective study, we aimed to demonstrate pregnancy and live birth rate in women who underwent hysteroscopic myomectomy and applied intrauterine adhesion gel after surgery.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eThis is a retrospective study conducted at Acıbadem Maslak Hospital IVF Department between January 1, 2017 and January 1, 2024. The files of 18.000 patients were retrospectively scanned and a hundred and ninety patients who received IVF treatment and had undergone hysteroscopic myomectomy were included into the study. Finally, fifty patients were enrolled the study. Patients who have Figo type 0, type 1, type 2 myomas with no previous myomectomy removal history were included into the study. Patients with a history of previous hysteroscopic myomectomy, intrauterine surgery were excluded from the study. Moreover, women aged over 38 yo, patients with recurrent pregnancy loss, history of recurrent IVF failure, men with the diagnosis of azoospermia were excluded. The study was conducted in accordance with the Declaration of Helsinki. The study involving human participants were reviewed and approved by the institutional review board and ethics committee of the Acibadem University (Acıbadem \u0026Uuml;niversitesi ve Acıbadem Sağlık Kuruluşları Tıbbi Araştırma Etik Kurulu) with approval number: 2025/07\u0026ndash;56. Written informed consent from the patients were not required to participate in this study in accordance with the national legislation and the institutional requirements.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eDescription of the techniques\u003c/h2\u003e \u003cp\u003ePatients were initially evaluated with transvaginal ultrasonography (TVUSG) after taking a detailed anamnesis. Myoma number, size and type according to FIGO classification system were determined. In cases where the evaluation with TVUSG was insufficient, saline infusion sonography (SIS) was performed to better visualize and determine the location, size and the type of the myoma(s). During SIS, a sterile catheter was placed in the endometrial cavity and 10 ml of sterile saline was injected. Thus, the uterine cavity was distended and was seen in a single layer view. Finally, patients were scheduled a hysteroscopy procedure for the following day. Operative hysteroscopy was performed under general anesthesia in the operating theatre with the Storz 30\u003csup\u003e0\u003c/sup\u003e, 6 mm outer shift. During the procedure, fibroids were removed and sent for pathological evaluation. After the removal of myoma (s), adhesion barrier gel was applied into the endometrial cavity and IUD (Copper T 380) was inserted. The patients were discharged on the same day. Antibiotics (doxycycline 100 mg, 2*1) and estradiol\u0026thinsp;+\u0026thinsp;norgestrel including pills (cyclo-progynova 21 dragee) were prescribed. Two months later, patients were called for a check-up, IUD was removed and HSG was performed. After evaluation with HSG, hysteroscopy was performed in patients with signs of intrauterine adhesions. Embryo transfer was planned for patients with no sign of intrauterine adhesions.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eStatistical Analysis\u003c/h2\u003e \u003cp\u003eAll data were analysed using SPSS (SPSS-IBM 2.3, Inc., Chicago, IL, USA). The Shapiro-Wilk test was used to assess data normality. Categorical variables were compared with Chi-square or Fisher\u0026rsquo;s exact test. For continuous variables, the study results were summarized as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation (SD). Categorical variables were presented as frequencies and percentages. Statistical significance was set at p\u003c0.05.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eFifty patients were enrolled the study. Pregnancy was achieved in 39 (78%) patients, eight (16%) of them were bio-chemical pregnancies, nine (18%) of them were clinical pregnancies resulted in miscarriages and 21 (42%) patients had live birth. A second-look hysteroscopy was performed in seven patients due to either myoma(s) (n: 3) or intrauterine adhesions (n: 4). Pregnancy occurred in all patients who developed intrauterine adhesions after myomectomy and therefore underwent a second hysteroscopy. Two out of four patients had live births while the remaining patients had biochemical pregnancies. Among patients who underwent second hysteroscopic myomectomy, one had biochemical pregnancy and two patients did not conceive.\u003c/p\u003e\n\u003cp\u003eTable \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e illustrates the demographic features of the patients. There was no statistically significant difference in terms of age, body mass index (BMI) and duration of infertility between patients who conceived or did not conceive.\u003c/p\u003e\n\u003cp\u003eTable\u0026nbsp;2 depicts the relationship between the number and size of myomas and the pregnancy rate. There was no statistically significant relationship between the number and size of the fibroids and the pregnancy rates.\u003c/p\u003e\n\u003cp\u003eTable \u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e shows the relationship between the FIGO classification of the fibroids and the pregnancy rates. The results were comparable between three groups (FIGO group 0, 1 and 2) in terms of pregnancy rates.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eHysteroscopy is a minimally invasive and safe procedure, which is used to evaluate the intrauterine cavity and treat in the same session (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). It is the gold standard technique in the treatment for different intrauterine pathologies including endometrial polyps, fibroids, uterine septum and intrauterine adhesions (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). The overall incidence of complication is 0.95% in which the most common one is hemorrhage fallowed by uterine perforation and cervical laceration (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). Distension media overload is a rare but serious complication with the incidence of less than 5% and can be life threatening. Later onset complications include intrauterine adhesions and pelvic infection, which are of crucial importance because they may cause infertility. Particularly, intrauterine adhesions develop after hysteroscopic myomectomy and may be related to many factors. In a study with Takasaki et al., hysteroscopic myomectomy was performed in 217 patients and the incidence of intrauterine adhesion was investigated. The patients were divided into three groups as group 1, patients with one myoma, group 2, patients having apposing myomas and group 3, fibroids that was far from each other. The incidence of IUA was reported more frequently at group 2 meaning that apposing myomas should be a risk factor in adhesion formation (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). Similarly, Yang et al. conducted a retrospective study including 132 patients and reported that the incidence of IUA after hysteroscopic myomectomy increased with the presence of apposing myomas (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). Bortoletto et al. compared IUA rate in patients who underwent abdominal myomectomy, minimally invasive myomectomy and hysteroscopic myomectomy and reported that even though IUA were higher in patients who underwent hysteroscopic myomectomy, there is no statistically significant differences. Moreover, they concluded that, the number or size of the fibroid does not affect the IUD incidence (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). In our study, we did not classified the patients regarding the location of fibroids as either apposing fibroids or fibroids far from each other, however similar with literature, we found that the size, number and the type (FİGO classification) of the fibroids dis not have relationship with the incidence of IUA formation.\u003c/p\u003e \u003cp\u003eDifferent treatment methods such as hyalunoric acid gels (HAG) or intrauterine devices (IUD) have been applied to prevent the development of intrauterine adhesions after hysteroscopic resection of submucous fibroids. There are many publications supporting the use of cross-linked hyaluronic acid gels to prevent IUA. A meta-analysis assessing the effectiveness and safety of hyalunoric acid gels reported that the incidence of IUA decreased and the pregnancy rate increased after the use of HAG after hysteroscopic myomectomy (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). Similarly, Zheng et al. published a meta-analysis and suggested that the use of hyalunoric acid gel not only reduced the formation of IUA but also improved the pregnancy rates after intrauterine operations (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). On the other hand, there are many articles reporting that the use of HAG does not prevent the formation of IUA. Mmed et al. conducted a double-blinded randomized controlled trial in 245 patients evaluating the IUA recurrence and fertility score. They classified patients into two groups according to whether hyalunoric acid gel was applied or not and reported that HAG did not seem to be effective in prevention of IUAs (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). Intrauterine balloon application is another option to prevent IUAs. Yang et al. and Shi et al. reported that the incidence of IUA was reduced in patients in whom intrauterine balloon was inserted after hysteroscopic surgery (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). Recently, there have been stunning developments in biomedical engineering, thus plenty of studies conducted in the prevention and treatment of intrauterine adhesions. İn 2022, Weyers et al. carried out a multicenter study for the assessment of safety and effectiveness of a novel intrauterine degradable polymer film (DPF) to prevent IUA after hsyteroscopic myomectomy. DPF was inserted into the uterine cavity, which is totally degraded within 7 days. Twenty-three patients were enrolled into the study. It was reported that 20 out of 23 patients have no intrauterine adhesions on the second look hysteroscopy (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). In our study, we applied hyaluronic acid gel and intrauterine device after hysteroscopic myomectomy. Two months later, IUD was removed and HSG was performed to check intrauterine cavity. The IUA was occurred in four patients (8%) in our study.\u003c/p\u003e \u003cp\u003ePreservation of fertility is the main goal after hysteroscopic surgery. Litta et al. reported a total pregnancy rate of 85.8% after hysteroscopic myomectomy. Furthermore, they reported that the classification, size and number of fibroids did not influence the pregnancy and delivery rate (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). Similarly, Yang et al. reported a total pregnancy rate of 89.2% and live birth rate of 70.7% in a study published in 2021 (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). In our study, the pregnancy and live birth rate was 78% and 42% respectively. The overall pregnancy rate was similar with literature, however live birth rate was significantly lower. We attribute this to the fact that, the population in our study was consisted of infertile patients and factors other tan uterine fibroids may have affected the live birth rate for instance embryo quality, sperm quality and oocyte quality as well. Moreover, the classification, size and the number of fibroids did not change the pregnancy and live birth rate.\u003c/p\u003e \u003cp\u003eThe first limitation of our study is it\u0026rsquo;s retrospective nature. The second limitation is the absence of control group in the study, but in our clinic embryo transfer is not performed to patients with FIGO type 0, 1, 2 groups without removing the myomas. Therefore, a control group could not be provided. The third limitation is that small numbers of patients were included into the study. However, we evaluated the pregnancy rates after hysteroscopic myomectomy, so we excluded all independent factors that may reduce pregnancy rates.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn conclusion, FIGO type 0, 1, 2 fibroids can reduce pregnancy rates in patients who undergo embryo transfer, thus removal via hysteroscopy is recommended. In our study, we demonstrated the safety and feasibility of the procedure.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eInternational Federation of Gynecology and Obstetrics (FIGO), intrauterine adhesions (IUA), Intrauterine device (IUD), hysterosalpingography (HSG), transvaginal ultrasonography (TVUSG), saline infusion sonography (SIS), body mass index (BMI)\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was conducted in accordance with the Declaration of Helsinki. The study involving human participants were reviewed and approved by the institutional review board and ethics committee of the Acibadem University (Acıbadem \u0026Uuml;niversitesi ve Acıbadem Sağlık Kuruluşları Tıbbi Araştırma Etik Kurulu) with approval number: 2025/07-56. Written informed consent from the patients were not required to participate in this study in accordance with the national legislation and the institutional requirements.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u0026nbsp;\u003c/strong\u003enot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and material\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e The authors declare that they have no competing interests\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u0026nbsp;\u003c/strong\u003eThere is no funding.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026Ouml;.K and \u0026Ouml;.A collected patient\u0026rsquo;s data\u003c/p\u003e\n\u003cp\u003eN.P, İ.\u0026Ouml;.A and B.T wrote the main manuscript task\u003c/p\u003e\n\u003cp\u003eA.Y prepared tables and the statistics of the study\u003c/p\u003e\n\u003cp\u003eAll authors reviewed the manuscript\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u0026nbsp;\u003c/strong\u003eNot applicable\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eGuo XC, Segars JH. The impact and management of fibroids for fertility: an evidence-based approach. Obstet Gynecol Clin North Am. 2012: 39(4): 521-33. doi: 10.1016/j.ogc.2012.09.005. PMID: 23182558; PMCID: PMC3608270.\u003c/li\u003e\n\u003cli\u003ePalheta MS, Medeiros FDC, Severiano ARG. Reporting of uterine fibroids on ultrasound examinations: an illustrated report template focused on surgical planning. Radiol Bras. 2023: 56(2): 86-94. doi: 10.1590/0100-3984.2022.0048. PMID: 37168038; PMCID: PMC10165971.\u003c/li\u003e\n\u003cli\u003eFavilli A, Etrusco A, Chiantera V, Lagan\u0026agrave; AS, Cicinelli E, Gerli S, Vitagliano A. Impact of FIGO type 3 uterine fibroids on in vitro fertilization outcomes: A systematic review and meta-analysis. Int J Gynaecol Obstet. 2023; 163(2): 528-539. doi: 10.1002/ijgo.14838. Epub 2023 May 15. PMID: 37183601.\u003c/li\u003e\n\u003cli\u003ePiecak K, Milart P. Hysteroscopic myomectomy. Prz Menopauzalny. 2017; 16(4): 126-128. doi: 10.5114/pm.2017.72757. Epub 2017 Dec 30. PMID: 29483854; PMCID: PMC5824682.\u003c/li\u003e\n\u003cli\u003eJansen FW, Vredevoogd CB, van Ulzen K, Hermans J, Trimbos JB, Trimbos-Kemper TC. Complications of hysteroscopy: a prospective, multicenter study. Obstet Gynecol. 2000; 96(2): 266-70. doi: 10.1016/s0029-7844(00)00865-6. PMID: 10908775.\u003c/li\u003e\n\u003cli\u003eElahmedawy H, Snook NJ. Complications of operative hysteroscopy: an anaesthetist\u0026apos;s perspective. BJA Educ. 2021; 21(7): 240-242. doi: 10.1016/j.bjae.2021.03.001. Epub 2021 May 6. PMID: 34178379; PMCID: PMC8212159.\u003c/li\u003e\n\u003cli\u003eSebbag L, Even M, Fay S, Naoura I, Revaux A, Carbonnel M, Pirtea P, de Ziegler D, Ayoubi JM. Early Second-Look Hysteroscopy: Prevention and Treatment of Intrauterine Post-surgical Adhesions. Front Surg. 2016: 16; 6:50. doi: 10.3389/fsurg.2019.00050. PMID: 31475154; PMCID: PMC6706867.\u003c/li\u003e\n\u003cli\u003eAas-Eng MK, Langebrekke A, Hudelist G. Complications in operative hysteroscopy - is prevention possible? Acta Obstet Gynecol Scand. 2017; 96(12): 1399-1403. doi: 10.1111/aogs.13209. Epub 2017 Sep 27. PMID: 28832907.\u003c/li\u003e\n\u003cli\u003eEtrusco A, Lagan\u0026agrave; AS, Chiantera V, Vitagliano A, Cicinelli E, Miku\u0026scaron; M, \u0026Scaron;prem Gold\u0026scaron;tajn M, Ferrari F, Uccella S, Garzon S, Gerli S, Favilli A. Feasibility and Surgical Outcomes of Hysteroscopic Myomectomy of FIGO Type 3 Myoma: A Systematic Review. J Clin Med. 2023; 12(15): 4953. doi: 10.3390/jcm12154953. PMID: 37568356; PMCID: PMC10419844.\u003c/li\u003e\n\u003cli\u003eTakasaki K, Henmi H, Ikeda U, Endo T, Azumaguchi A, Nagasaka K. Intrauterine adhesion after hysteroscopic myomectomy of submucous myomas. J Obstet Gynaecol Res. 2023; 49(2): 675-681. doi: 10.1111/jog.15499. Epub 2022 Nov 20. PMID: 36404131.\u003c/li\u003e\n\u003cli\u003eYang JH, Chen MJ, Wu MY, Chao KH, Ho HN, Yang YS. Office hysteroscopic early lysis of intrauterine adhesion after transcervical resection of multiple apposing submucous myomas. Fertil Steril. 2008; 89(5): 1254-1259. doi: 10.1016/j.fertnstert.2007.05.027. Epub 2007 Aug 8. PMID: 17686478.\u003c/li\u003e\n\u003cli\u003eBortoletto P, Keefe KW, Unger E, Hariton E, Gargiulo AR. Incidence and risk factors of intrauterine adhesions after myomectomy. F S Rep. 2022; 3(3): 269-274. doi: 10.1016/j.xfre.2022.05.007. PMID: 36212555; PMCID: PMC9532880.\u003c/li\u003e\n\u003cli\u003eLuo Y, Sun Y, Huang B, Chen J, Xu B, Li H. Effects and safety of hyaluronic acid gel on intrauterine adhesion and fertility after intrauterine surgery: a systematic review and meta-analysis with trial sequential analysis of randomized controlled trials. Am J Obstet Gynecol. 2024; 231(1): 36-50.35. doi: 10.1016/j.ajog.2023.12.039. Epub 2024 Jan 6. PMID: 38191020.\u003c/li\u003e\n\u003cli\u003eZheng F, Xin X, He F, Liu J, Cui Y. Meta-analysis on the use of hyaluronic acid gel to prevent intrauterine adhesion after intrauterine operations. Exp Ther Med. 2020; 19(4): 2672-2678. doi: 10.3892/etm.2020.8483. Epub 2020 Feb 3. PMID: 32256748; PMCID: PMC7086218.\u003c/li\u003e\n\u003cli\u003eZhou Q, Shi X, Saravelos S, Huang X, Zhao Y, Huang R, Xia E, Li TC. Auto-Cross-Linked Hyaluronic Acid Gel for Prevention of Intrauterine Adhesions after Hysteroscopic Adhesiolysis: A Randomized Controlled Trial. J Minim Invasive Gynecol. 2021; 28(2): 307-313. doi: 10.1016/j.jmig.2020.06.030. Epub 2020 Jul 15. PMID: 32681996.\u003c/li\u003e\n\u003cli\u003eYang X, Liu Y, Li TC, Xia E, Xiao Y, Zhou F, Song D, Zhou Q. Durations of intrauterine balloon therapy and adhesion reformation after hysteroscopic adhesiolysis: a randomized controlled trial. Reprod Biomed Online. 2020; 40(4): 539-546. doi: 10.1016/j.rbmo.2019.11.017. Epub 2019 Dec 10. PMID: 32199799.\u003c/li\u003e\n\u003cli\u003eShi X, Saravelos SH, Zhou Q, Huang X, Xia E, Li TC. Prevention of postoperative adhesion reformation by intermittent intrauterine balloon therapy: a randomised controlled trial. BJOG. 2019; 126(10): 1259-1266. doi: 10.1111/1471-0528.15843. Epub 2019 Jul 18. PMID: 31207009.\u003c/li\u003e\n\u003cli\u003eLuo Y, Liu Y, Xiao Y, Zhou Q, Zhang Z, Li X. Extended intrauterine balloon stent use to prevent adhesion reformation after hysteroscopic adhesiolysis: a randomized trial. Fertil Steril. 2025: S0015- 0282(25)00051-2. doi: 10.1016/j.fertnstert.2025.01.024. Epub ahead of print. PMID: 39884334.\u003c/li\u003e\n\u003cli\u003eWeyers S, Capmas P, Huberlant S, Dijkstra JR, Hooker AB, Hamerlynck T, Debras E, De Tayrac R, Thurkow AL, Fernandez H. Safety and Efficacy of a Novel Barrier Film to Prevent Intrauterine Adhesion Formation after Hysteroscopic Myomectomy: The PREG1 Clinical Trial. J Minim Invasive Gynecol. 2022; 29(1): 151-157. doi: 10.1016/j.jmig.2021.07.017. Epub 2021 Jul 31. PMID: 34343712.\u003c/li\u003e\n\u003cli\u003eLitta P, Conte L, De Marchi F, Saccardi C, Angioni S. Pregnancy outcome after hysteroscopic myomectomy. Gynecol Endocrinol. 2014; 30(2): 149-52. doi: 10.3109/09513590.2013.863861. Epub 2013 Dec 5. PMID: 24303914.\u003c/li\u003e\n\u003cli\u003eYang Y, Yang Y, You M, Chen L, Sun F. Observation of pregnancy outcomes in patients with hysteroscopic resection on submucous myomas. J Obstet Gynaecol Res. 2022; 48(2): 360-365. doi: 10.1111/jog.15125. Epub 2021 Dec 12. PMID: 34897915.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTable 1: Demographic characteristics of patients\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"594\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003ePregnancy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003eNumber (n)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003eMean\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003eStd. Deviation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003eStd. Error Mean\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003eAge\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e34.18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e3.710\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e1.119\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e39\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e33.64\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e3.240\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e.519\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003eBMI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e25.073\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e5.9621\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e1.7976\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e39\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e24.372\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e4.2014\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e.6728\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003eDuration of Infertility\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e7.27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e4.839\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e1.459\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e39\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e6.23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e4.158\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e.666\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e0: non pregnant, 1: pregnant\u003c/p\u003e\n\u003cp\u003eTable 2: The relationship between the number and size of myomas and the pregnancy rate\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"571\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"4\" valign=\"top\" style=\"width: 446px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Pregnancy (n)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003eNon pregnant\u003c/p\u003e\n \u003cp\u003en (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003ePregnant,\u003c/p\u003e\n \u003cp\u003en (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003eTotal\u003c/p\u003e\n \u003cp\u003en (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003eNumber of fibroids\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003e7 (19.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003e29 (80.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e36 (72%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003e4 (33.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003e8 \u0026nbsp; \u0026nbsp;(66.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e12 (24%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e3 or more\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003e0 (0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003e2 \u0026nbsp; \u0026nbsp;(100%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e2 \u0026nbsp; (4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003eSize of fibroids (mean)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003e15.91+3.743\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 115px;\"\u003e\n \u003cp\u003e15.08+1.639\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp\u003eTable 3: The relationship between the FIGO classification of the fibroids and the pregnancy rates\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 97px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 300px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Pregnancy\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 97px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003eNon pregnant\u003c/p\u003e\n \u003cp\u003eN (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 101px;\"\u003e\n \u003cp\u003ePregnant\u003c/p\u003e\n \u003cp\u003eN (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 97px;\"\u003e\n \u003cp\u003eTotal\u003c/p\u003e\n \u003cp\u003eN (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"4\" valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003eType of fibroids (FIGO classification)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 97px;\"\u003e\n \u003cp\u003eType 0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e0 (0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 101px;\"\u003e\n \u003cp\u003e4 (100%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 97px;\"\u003e\n \u003cp\u003e4 (8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 97px;\"\u003e\n \u003cp\u003eType 1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e5 (21.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 101px;\"\u003e\n \u003cp\u003e18 (78.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 97px;\"\u003e\n \u003cp\u003e23 (46%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 97px;\"\u003e\n \u003cp\u003eType 2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e4 (21.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 101px;\"\u003e\n \u003cp\u003e15 (78.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 97px;\"\u003e\n \u003cp\u003e19 (38%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 97px;\"\u003e\n \u003cp\u003eType 1+2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e2 (50%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 101px;\"\u003e\n \u003cp\u003e2 \u0026nbsp; (50%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 97px;\"\u003e\n \u003cp\u003e4 \u0026nbsp; \u0026nbsp;(8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 234px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e11 (22%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 101px;\"\u003e\n \u003cp\u003e39 (78%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 97px;\"\u003e\n \u003cp\u003e50 \u0026nbsp;(100%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Hyteroscopy, myoma, FIGO classification, IVF, intrauterine adhesion, barrier gel","lastPublishedDoi":"10.21203/rs.3.rs-6679841/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6679841/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eWe aimed to demonstrate feasibility and safety of hysteroscopic myomectomy in infertile patients with International Federation of Gynecology and Obstetrics (FİGO) classification type 0, type 1 and type 2 uterine fibroids.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eInfertile patients who have FIGO type 0, 1, 2 myomas underwent hysteroscopic myomectomy before embryo transfer. Intrauterine device (IUD) was placed into the uterine cavity and adhesion barrier gel was applied after surgery. Two months later, IUD was removed and control hysterosalpingography (HSG) was performed. Embryo transfer was performed in patients who were not considered to have intrauterine adhesions (IUA) after evaluation with HSG.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eFifty patients were enrolled the study. Thirtynine (78%) patients conceived and 21 (42%) had live birth. Second look hysteroscopy was performed in 4 (8%) patients due to intrauterine adhesions and removed by cutting cold knife via office hysteroscopy. Pregnancy was achieved in all of these patients; one had live birth, two patients had biochemical pregnancy and one patient had an abortion in the 8th week of pregnancy. No complication was occurred in any case.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eHysteroscopic myomectomy is a safe and reliable method in the treatment of FIGO type 0, 1, 2 myomas and may enhance pregnancy rate when performed before embryo transfer.\u003c/p\u003e","manuscriptTitle":"Hysteroscopic Myomectomy is a safe and reliable method in patients with FIGO type 0,1 and 2 myomas","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-06-03 16:33:05","doi":"10.21203/rs.3.rs-6679841/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"432b4e35-cb8f-459a-a7b1-dee6cbbdbfa6","owner":[],"postedDate":"June 3rd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-06-23T10:53:56+00:00","versionOfRecord":[],"versionCreatedAt":"2025-06-03 16:33:05","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6679841","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6679841","identity":"rs-6679841","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}