Clinical Efficacy Research on the Efficacy and Safety of Hysteroscopic Micro-scissors Combined with a Intrauterine Bigatti Shaver for Treating Moderate to Severe Intrauterine Adhesions

Clinical Efficacy Research on the Efficacy and Safety of Hysteroscopic Micro-scissors Combined with a Intrauterine Bigatti Shaver for Treating Moderate to Severe Intrauterine Adhesions | 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 Clinical Efficacy Research on the Efficacy and Safety of Hysteroscopic Micro-scissors Combined with a Intrauterine Bigatti Shaver for Treating Moderate to Severe Intrauterine Adhesions Xiaoqin Zhang, Jufang Wang This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8452541/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 17 You are reading this latest preprint version Abstract Objective To evaluate the clinical efficacy and safety of hysteroscopic cold micro-scissors combined with an Intrauterine Bigatti Shaver (IBS) for the treatment of moderate to severe intrauterine adhesions (IUA), compared with hysteroscopic adhesiolysis using cold micro-scissors alone. Methods This prospective, single-center, randomized controlled trial enrolled women aged 18–45 years with moderate to severe IUA (AFS score ≥ 5) between January 2023 and June 2025.A total of 133 participants were randomized 1:1 to a Combined Group receiving cold micro-scissors plus a tissue removal IBS (n = 68) or a Control Group receiving cold micro-scissors alone for adhesiolysis (n = 65). All patients received standardized postoperative balloon stenting and sequential estrogen–progestin therapy. The primary endpoint was change in AFS score from baseline to 3 months assessed by blinded hysteroscopists. Secondary outcomes included operative time, blood loss, cavity morphology restoration, menstrual improvement, adhesion recurrence at 6 months, complications, patient satisfaction, and pregnancy outcomes up to 12 months among those desiring fertility. Results All randomized patients completed follow-up. At 3 months, the Combined Group achieved greater AFS score improvement than the Control Group (5.49 ± 1.54 vs 3.91 ± 1.63; P < 0.001; Cohen’s d = 1.00). Operation time was slightly longer in the Combined Group (38.7 ± 10.1 vs 34.8 ± 10.2 min; P = 0.007), while blood loss was significantly lower (median 10.2 vs 22.6 mL; P < 0.001). Menstrual improvement was higher in the Combined Group (90.2% vs 64.8%; P = 0.002), and normal uterine cavity morphology was more frequent (70.6% vs 46.2%; P = 0.034). Overall complications (7.4% vs 29.2%; P = 0.001) and adhesion recurrence at 6 months (7.4% vs 26.2%; P = 0.007) were reduced in the Combined Group. Patient satisfaction was higher (8.0 ± 1.0 vs 7.3 ± 1.2; P < 0.001). Among participants with fertility desire, pregnancy rates at 12 months were 49.0% vs 30.6% (P = 0.099). Conclusions Hysteroscopic micro-scissors combined with an IBS provides superior short-term anatomic restoration and symptom improvement with a lower complication and recurrence profile compared with micro-scissors alone in moderate to severe IUA, with a favorable trend toward improved pregnancy outcomes. These findings support broader adoption and multicenter validation of this endometrium-preserving approach. Intrauterine adhesions Asherman syndrome hysteroscopic adhesiolysis cold micro-scissors hysteroscopic morcellation/IBS Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Figure 7 Introduction Intrauterine adhesions (IUA), also referred to as Asherman syndrome, are characterized by partial or complete obliteration of the uterine cavity due to fibrous bands that follow endometrial injury and aberrant wound healing[1, 2]. Clinically, IUA may present with amenorrhea or hypomenorrhea, cyclic pelvic pain, recurrent pregnancy loss, and infertility, and the disease burden is particularly relevant among women of reproductive age[3, 4]. The dominant etiologic factor remains trauma to the gravid or recently pregnant endometrium, most commonly after curettage or other intrauterine procedures, which can disrupt the basal endometrial layer required for regeneration[5, 6]. Hysteroscopic adhesiolysis is the accepted first-line treatment for moderate to severe IUA because it enables direct visualization and targeted dissection of adhesions with the aim of restoring uterine cavity anatomy and functional endometrium[5-8]. However, management of moderate to severe disease remains challenging: dense or muscular adhesions, poor cavity distensibility, and limited residual endometrial “islands” increase procedural complexity and predispose patients to perioperative bleeding, uterine injury, and—most importantly—high rates of postoperative re-adhesion. Even with standardized adjuvant measures (e.g., mechanical barriers, estrogen therapy, and second-look hysteroscopy), recurrence and suboptimal reproductive outcomes continue to limit long-term success in severe cases[9-11]. Cold micro-scissors represent a refined mechanical technique that permits precise, incremental division of filmy and central adhesions under direct hysteroscopic visualization, minimizing collateral injury to adjacent endometrium[12]. Nonetheless, micro-scissors alone may be inefficient for dense, marginal, or muscular adhesions, where controlled resection and consistent visualization become limiting factors—this technical limitation may lead to incomplete adhesiolysis, further increasing the risk of postoperative recurrence. In parallel, hysteroscopic tissue removal systems (shavers/morcellators) have been widely used for intrauterine pathology such as polyps and submucous fibroids and offer simultaneous cutting and aspiration, potentially improving field clarity and operative control. Extending these devices to IUA theoretically enables more complete adhesiolysis for dense adhesions while maintaining a non-thermal profile[13,14]; however, clinical evidence in moderate to severe IUA remains comparatively limited and heterogeneous across techniques and adjunctive regimens. Accordingly, we designed a prospective randomized controlled trial to compare hysteroscopic cold micro-scissors combined with an intrauterine Bigatti Shaver (IBS） versus cold micro-scissors alone in women with moderate to severe IUA, under standardized postoperative adhesion-prevention management. We hypothesized that the combined non-thermal strategy would improve short-term anatomic restoration and symptom recovery, reduce perioperative morbidity and adhesion recurrence, and potentially translate into improved fertility-related outcomes among women desiring pregnancy. METHODS 2.1 Study Design and Ethical Approval This prospective, single-center, randomized controlled trial was conducted at the Department of Gynecology, Tongxiang First Hospital, between January 2023 and December 2025. The study protocol was approved by the Ethics Committee of Tongxiang First Hospital (Approval No.: 2025 Research Project No. 030). All participants provided written informed consent prior to enrollment. The study was conducted in accordance with the Declaration of Helsinki and Good Clinical Practice guidelines. 2.2 Participants Inclusion criteria: (1) Women aged 18-45 years with moderate to severe intrauterine adhesions (IUA) diagnosed by hysteroscopy and classified according to the American Fertility Society (AFS) scoring system (score ≥5); (2) History of at least one uterine curettage or other intrauterine procedures; (3) Clinical symptoms including amenorrhea, hypomenorrhea, or infertility; (4) No contraindications to hysteroscopic surgery; (5) Willingness to comply with the follow-up schedule. Exclusion criteria: (1) Presence of other uterine pathologies such as submucosal fibroids, adenomyosis, or endometrial polyps requiring treatment; (2) Active pelvic inflammatory disease or genital tract infection; (3) Severe medical comorbidities contraindicating surgery; (4) Previous failed hysteroscopic adhesiolysis within 6 months; (5) Pregnancy or lactation; (6) Inability to provide informed consent. 2.3 Randomization and Blinding A total of 156 patients were screened for eligibility, of whom 133 met the inclusion criteria and were enrolled. Participants were randomly assigned in a 1:1 ratio to the Combined Group (n=68) or the Control Group (n=65) using computer-generated random numbers with block randomization (block size = 4). Allocation concealment was ensured by using sequentially numbered, opaque, sealed envelopes. Due to the nature of the intervention, the operating surgeons could not be blinded; however, the outcome assessors and statisticians were blinded to group allocation throughout the study. 2.4 Surgical Procedures 2.4.1 Preoperative Preparation All patients received standardized preoperative preparation. Misoprostol 400 μg was administered vaginally 12 hours before surgery for cervical ripening. Prophylactic antibiotics (Cefuroxime 1.5 g intravenously) were administered 30 minutes before the procedure. All surgeries were performed under general anesthesia during the early proliferative phase of the menstrual cycle. 2.4.2 Combined Group: Micro-scissors with IBS In the Combined Group, hysteroscopic adhesiolysis was performed using a combination of cold micro-scissors (Karl Storz, Germany) and an intrauterine tissue removal system (MyoSure® LITE, Hologic, USA). A 5.8 mm continuous-flow operative hysteroscope with a 30° optic was used. Normal saline was used as the distension medium, with intrauterine pressure maintained between 80-100 mmHg. The procedure began with systematic panoramic inspection of the uterine cavity to assess the extent and nature of adhesions. Filmy and central adhesions were first divided using cold micro-scissors under direct visualization, employing a lateral-to-medial and anterior-to-posterior approach. The micro-scissors allowed precise, controlled division of adhesive bands while minimizing thermal damage to the surrounding endometrium. For dense, marginal, or muscular adhesions, the intrauterine IBS was employed. The tissue removal device was advanced under hysteroscopic guidance, and adhesive tissue was simultaneously cut and aspirated. This dual approach ensured complete adhesiolysis while optimizing tissue preservation. Special care was taken to avoid excessive depth of resection and to preserve any remaining endometrial islands. 2.4.3 Control Group: Cold Micro-scissors Alone In the Control Group, hysteroscopic adhesiolysis was performed using cold micro-scissors alone (Karl Storz, Germany). A 5.8 mm continuous-flow operative hysteroscope with a 30° optic was used, consistent with the Combined Group. Normal saline was used as the distension medium, with intrauterine pressure maintained between 80-100 mmHg (same as the Combined Group to ensure comparability). The surgical approach was consistent with the Combined Group: systematic panoramic inspection of the uterine cavity was performed first to assess adhesion extent and nature. Adhesions (including filmy, central, dense, marginal, and muscular types) were all dissected using cold micro-scissors alone, employing the same lateral-to-medial and anterior-to-posterior approach. Special care was taken to achieve precise dissection, avoid excessive tissue injury, and restore the triangular uterine cavity shape with visualization of both tubal ostia. No additional tissue removal devices or electrosurgical instruments were used. 2.4.4 Postoperative Management Following adhesiolysis, all patients received standardized postoperative management: (1) Intrauterine balloon stent (Foley catheter, 5 mL inflation) placement for 7 days to prevent re-adhesion; (2) Sequential hormone therapy with conjugated estrogen (Premarin® 1.25 mg daily) for 21 days followed by medroxyprogesterone acetate (Provera® 10 mg daily) for 10 days, repeated for three cycles; (3) Prophylactic antibiotics (oral cephalosporin) for 5 days; (4) Second-look hysteroscopy at 3 months to assess uterine cavity restoration and presence of residual or recurrent adhesions. 2.5 Outcome Measures 2.5.1 Primary Outcomes The primary outcome was the change in AFS score from baseline to 3 months post-surgery. The AFS classification system evaluates the extent of adhesions (scored 1-4), type of adhesions (scored 1-4), and menstrual pattern (scored 1-4), yielding a total score of 1-12. Moderate adhesions were defined as scores 5-8, and severe adhesions as scores 9-12. AFS scores were assessed by two independent, blinded hysteroscopists, with discrepancies resolved by a third senior gynecologist. 2.5.2 Secondary Outcomes Secondary outcomes included: (1) Intraoperative parameters: operation time (minutes from hysteroscope insertion to withdrawal), intraoperative blood loss (ml, estimated by suction volume minus irrigation fluid), and distension medium consumption (ml); (2) Clinical efficacy measures: menstrual pattern improvement (assessed using the Pictorial Blood Loss Assessment Chart), uterine cavity morphology restoration (classified as normal, improved, or unchanged), and pregnancy outcomes among patients with fertility desire; (3) Safety outcomes: intraoperative complications (uterine perforation, excessive bleeding, fluid overload) and postoperative complications (infection, re-adhesion requiring intervention); (4) Adhesion recurrence rate at 6-month follow-up; (5) Patient satisfaction score (visual analog scale, 1-10). 2.6 Follow-up Protocol Patients were followed up at 1 month (telephone), 3 months (clinical visit with second-look hysteroscopy), and 6 months (clinical visit). At each follow-up, menstrual pattern, pregnancy status, and any adverse events were documented. Second-look hysteroscopy at 3 months provided objective assessment of uterine cavity morphology and AFS scoring. Patients with fertility desire were encouraged to attempt natural conception after completion of hormone therapy and were followed for pregnancy outcomes up to 12 months post-surgery. 2.7 Sample Size Calculation Sample size was calculated based on the primary outcome (AFS score improvement). Based on previous studies, we anticipated a mean difference of 1.5 points in AFS score improvement between groups, with a standard deviation of 2.0 points. With a two-sided alpha of 0.05 and power of 80%, a minimum of 57 patients per group was required. Accounting for a 15% dropout rate, we aimed to enroll at least 66 patients per group. 2.8 Statistical Analysis All statistical analyses were performed using Python 3.9 with SciPy 1.10 and StatsModels 0.14. Continuous variables were tested for normality using the Shapiro-Wilk test. Normally distributed variables were presented as mean ± standard deviation and compared using independent-samples t-tests. Non-normally distributed variables were presented as median (interquartile range) and compared using the Mann-Whitney U test. Categorical variables were presented as frequencies and percentages and compared using the chi-square test or Fisher's exact test, as appropriate. Effect sizes were calculated using Cohen's d for continuous outcomes and odds ratios with 95% confidence intervals for binary outcomes. Subgroup analyses were performed to explore treatment effects across prespecified subgroups (age 2). All tests were two-tailed, and P < 0.05 was considered statistically significant. Analyses were performed on an intention-to-treat basis. RESULTS 3.1 Patient Enrollment and Baseline Characteristics Between January 2023 and December 2025, 156 patients with moderate to severe IUA were assessed for eligibility. Of these, 23 patients were excluded: 15 did not meet inclusion criteria, 5 declined to participate, and 3 were excluded for other reasons. The remaining 133 patients were randomized to the Combined Group (n = 68) or the Control Group (n = 65). All randomized patients completed the scheduled follow-up, with no dropouts or loss to follow-up in either group (Fig. 1 ). Baseline demographic and clinical characteristics were well-balanced between the two groups (Table 1 ). The mean age was 32.2 ± 4.8 years in the Combined Group and 31.1 ± 4.8 years in the Control Group (P = 0.173). Mean BMI was comparable between groups (22.5 ± 2.9 vs 23.0 ± 2.7 kg/m², P = 0.268). The mean number of prior curettage procedures was 2.2 ± 1.0 in the Combined Group and 2.5 ± 0.9 in the Control Group (P = 0.062). Table 1 Baseline Characteristics of Study Participants Characteristic Combined Group (n = 68) Control Group (n = 65) P-value Age (years) 32.2 ± 4.8 31.1 ± 4.8 0.173 BMI (kg/m²) 22.5 ± 2.9 23.0 ± 2.7 0.268 Gravidity 3.0 ± 1.2 2.8 ± 1.2 0.378 Parity 1.1 ± 0.9 1.4 ± 1.0 0.052 Prior curettage 2.2 ± 1.0 2.5 ± 0.9 0.062 Adhesion duration (months) 12.9 ± 9.5 12.6 ± 8.3 0.880 AFS score at baseline 7.93 ± 1.85 7.37 ± 2.06 0.028 Adhesion severity 0.110 Moderate 45 (66.2%) 52 (80.0%) Severe 23 (33.8%) 13 (20.0%) The baseline AFS score was 7.93 ± 1.85 in the Combined Group and 7.37 ± 2.06 in the Control Group (P = 0.028). The distribution of adhesion severity was similar between groups: moderate adhesions were present in 45 (66.2%) patients in the Combined Group and 52 (80.0%) in the Control Group, while severe adhesions were present in 23 (33.8%) and 13 (20.0%) patients, respectively (P = 0.110). Menstrual status at baseline showed no significant difference between groups (P = 0.420). 3.2 Primary Outcome: AFS Score Improvement At 3-month follow-up, the Combined Group demonstrated significantly greater improvement in AFS scores compared to the Control Group. The mean AFS score decreased from 7.93 ± 1.85 at baseline to 2.44 ± 2.24 at 3 months in the Combined Group, representing a mean improvement of 5.49 ± 1.54 points. In contrast, the Control Group showed a reduction from 7.37 ± 2.06 to 3.46 ± 2.72, with a mean improvement of 3.91 ± 1.63 points (P < 0.001) (Fig. 2 ). The effect size for AFS improvement was large (Cohen's d = 1.00), indicating a clinically significant advantage of the combined technique. At 6-month follow-up, the AFS scores remained stable, with mean scores of 1.99 ± 2.03 in the Combined Group and 2.80 ± 2.65 in the Control Group, suggesting durable therapeutic effects of both procedures. 3.3 Intraoperative Outcomes Intraoperative parameters are presented in Table 2 and Fig. 3 . The mean operation time was significantly longer in the Combined Group (38.7 ± 10.1 minutes) compared to the Control Group (34.8 ± 10.2 minutes, P = 0.007). This difference can be attributed to the meticulous technique required for the combined approach and the need to switch between instruments.​ Table 2 Intraoperative Outcomes Characteristic Combined Group (n = 68) Control Group (n = 65) P-value Operation time (min) 38.7 ± 10.1 34.8 ± 10.2 0.007 Blood loss (ml)* 10.2 (5.3–21.7) 22.6 (15.2–36.8) < 0.001 Distension medium (ml) 2446 ± 527 2499 ± 512 0.421 *Presented as median (interquartile range) Notably, intraoperative blood loss was significantly lower in the Combined Group (median: 10.2 ml, IQR: 5.3–21.7 ml) compared to the Control Group (median: 22.6 ml, IQR: 15.2–36.8 ml, P < 0.001). This substantial reduction in blood loss (approximately 55%) reflects the advantage of combining cold dissection with micro-scissors and efficient tissue removal by IBS, which minimizes tissue injury and bleeding compared to single micro-scissors dissection for dense adhesions. Distension medium consumption was similar between groups (2446 ± 527 ml vs 2499 ± 512 ml, P > 0.05). No cases of fluid overload or electrolyte imbalance were observed in either group. 3.4 Clinical Efficacy Outcomes bAmong patients with abnormal menstruation at baseline (amenorrhea or hypomenorrhea), the menstrual improvement rate was significantly higher in the Combined Group (55/61, 90.2%) compared to the Control Group (35/54, 64.8%, P = 0.002) (Fig. 4 ). The majority of patients in the Combined Group reported restoration of normal or near-normal menstrual flow within 3 menstrual cycles following surgery. Second-look hysteroscopy at 3 months revealed superior uterine cavity restoration in the Combined Group. Normal cavity morphology was observed in 48 (70.6%) patients in the Combined Group versus 30 (46.2%) in the Control Group (P < 0.05). The triangular cavity shape with clear visualization of both tubal ostia was more frequently achieved in the Combined Group, indicating better preservation of endometrial function (Fig. 6 A). Among patients with fertility desire (n = 49 in the Combined Group and n = 49 in the Control Group), the pregnancy rate at 12-month follow-up was 49.0% (24/49) in the Combined Group and 30.6% (15/49) in the Control Group (P = 0.099). Although the difference did not reach statistical significance, the odds of pregnancy were 2.18 times higher in the Combined Group (OR = 2.18, 95% CI: 0.95–4.97). The mean time to conception was 6.5 months in the Combined Group (Table 3 ). Table 3 Clinical Outcomes Characteristic Combined Group (n = 68) Control Group (n = 65) P-value AFS score at 3 months 2.44 ± 2.24 3.46 ± 2.72 0.017 AFS score improvement 5.49 ± 1.54 3.91 ± 1.63 < 0.001 Menstrual improvement 55/61 (90.2%) 35/54 (64.8%) 0.002 Normal cavity morphology 48 (70.6%) 30 (46.2%) 0.034 Pregnancy rate† 24/49 (49.0%) 15/49 (30.6%) 0.099 Recurrence at 6 months 5/68 (7.4%) 17/65 (26.2%) 0.007 Overall complications 5/68 (7.4%) 19/65 (29.2%) 0.001 Satisfaction score 8.0 ± 1.0 7.3 ± 1.2 < 0.001 †Among patients with fertility desire 3.5 Safety Outcomes The overall complication rate was significantly lower in the Combined Group (5/68, 7.4%) compared to the Control Group (19/65, 29.2%, P = 0.001) (Fig. 4 ). Intraoperative complications occurred in 1 (1.5%) patients in the Combined Group versus 9 (13.8%) in the Control Group. No cases of uterine perforation occurred in either group. Minor bleeding requiring extended hemostasis was the most common intraoperative complication in the Control Group. 3.6 Adhesion Recurrence At 6-month follow-up, the adhesion recurrence rate was significantly lower in the Combined Group (5/68, 7.4%) compared to the Control Group (17/65, 26.2%, P = 0.007) (Fig. 4 ). The relative risk of recurrence was 0.28 (95% CI: 0.11–0.73), indicating a 72% reduction in the risk of re-adhesion with the combined technique. Among patients who experienced recurrence, the severity was generally mild (AFS score 1–4) and was managed conservatively with repeat hormone therapy in most cases. 3.7 Patient Satisfaction Patient satisfaction scores were significantly higher in the Combined Group (mean: 8.0 ± 1.0) compared to the Control Group (7.3 ± 1.2, P < 0.001) (Fig. 6 ). The higher satisfaction in the Combined Group may be attributed to less postoperative discomfort, faster recovery of menstrual function, and the overall better clinical outcomes. 3.8 Subgroup Analysis Subgroup analyses demonstrated consistent benefits of the combined technique across prespecified subgroups (Fig. 5 ). The treatment effect was evident in both younger (< 35 years) and older (≥ 35 years) patients, with similar standardized mean differences in AFS improvement. Notably, patients with severe adhesions (AFS score 9–12) showed a greater absolute benefit from the combined technique, although the effect was also significant in those with moderate adhesions. The treatment effect was maintained regardless of the number of prior curettage procedures, suggesting broad applicability of the combined approach. 3.9 Correlation Analysis Correlation analysis revealed several noteworthy associations (Fig. 7 ). Baseline AFS score was positively correlated with AFS improvement (r = 0.52, P < 0.001), indicating that patients with more severe adhesions achieved greater absolute improvement. Operation time was weakly correlated with blood loss (r = 0.18, P < 0.05). Patient satisfaction showed moderate positive correlation with AFS improvement (r = 0.41, P < 0.001) and menstrual restoration, underscoring the relationship between objective clinical outcomes and patient-reported experiences. DISCUSSION This prospective randomized controlled trial demonstrates that hysteroscopic micro-scissors combined with an intrauterine IBS provides superior clinical efficacy and safety compared with cold micro-scissors alone for the treatment of moderate to severe intrauterine adhesions (IUA). The combined technique resulted in significantly greater improvement in AFS scores, lower intraoperative blood loss, reduced complication and recurrence rates, and higher patient satisfaction, while maintaining acceptable operative time and distension media consumption. The most important finding of this study is the significantly greater reduction in AFS scores achieved with the combined approach. The mean AFS improvement of 5.49 points in the Combined Group exceeded that of the Control Group by approximately 1.6 points, representing both statistical and clinical significance. Given that AFS score reduction is closely associated with restoration of endometrial surface area and uterine cavity function, this improvement suggests a more complete and physiologically favorable adhesiolysis. Previous studies have reported that postoperative AFS scores below 4 are associated with better menstrual and reproductive outcomes, which aligns with the higher proportion of patients achieving normal cavity morphology in the Combined Group[ 15 , 16 ]. The observed benefits can be explained by the complementary mechanisms of cold micro-scissors and mechanical shaving. Cold micro-scissors allow sharp, controlled dissection of filmy and central adhesions with minimal collateral damage, preserving residual endometrial glands and basal layer integrity [ 12 ]. For dense or muscular adhesions, the IBS enables simultaneous cutting and aspiration under direct visualization, reducing traction injury and improving operative precision—this advantage is particularly prominent compared to single micro-scissors dissection, which may struggle with incomplete resection of dense adhesions due to limited operative control [ 17 ]. Mechanical tissue removal with IBS has been shown to produce smoother resection planes and less inflammatory response compared with single cold scissors dissection, which may contribute to the significantly lower recurrence rate observed in this study. Although operative time was modestly longer in the Combined Group, this difference is clinically acceptable and likely reflects the meticulous, stepwise nature of the combined technique. Importantly, intraoperative blood loss was reduced by more than 50%, underscoring the advantage of controlled mechanical removal for dense adhesions, which reduces the risk of excessive bleeding compared to forced dissection with single micro-scissors. The markedly lower complication rate further supports the safety of this approach, particularly in patients with severe adhesions who are at higher risk of bleeding and uterine trauma. No cases of uterine perforation or fluid overload were observed, indicating that both techniques can be safely performed by experienced surgeons. However, the higher rate of minor bleeding and postoperative morbidity in the Control Group highlights the inherent limitations of single micro-scissors dissection, especially in fibrotic or poorly distensible uterine cavities where dense adhesions are difficult to resect completely. Adhesion recurrence remains a major challenge in IUA management. The 7.4% recurrence rate in the Combined Group compares favorably with rates of 20–40% reported for single cold micro-scissors dissection in moderate to severe cases. This substantial risk reduction is likely attributable to superior endometrial preservation and more complete adhesiolysis achieved by the combined technique, as supported by the higher rates of normal cavity restoration and improved menstrual outcomes. Preservation of endometrial islands is critical for re-epithelialization and prevention of secondary fibrosis, reinforcing the importance of combined non-thermal techniques for IUA management [ 18 ]. Although the difference in pregnancy rates did not reach statistical significance, the nearly 20% absolute increase and odds ratio greater than 2 suggest a clinically meaningful trend favoring the combined approach. The study may have been underpowered to detect differences in reproductive outcomes, which are influenced by multiple confounders such as age, ovarian reserve, and male factors. Nevertheless, the shorter time to conception and improved uterine cavity morphology support the hypothesis that enhanced endometrial recovery translates into improved fertility potential [ 19 ]. Subgroup analyses demonstrated consistent benefits across age groups, adhesion severity, and prior curettage history, indicating broad applicability of the combined technique. Notably, patients with severe adhesions derived the greatest absolute benefit, supporting the use of this approach in complex cases traditionally associated with poor prognosis. Correlation analyses further highlighted the relationship between objective surgical outcomes and patient-reported satisfaction, emphasizing the clinical relevance of comprehensive adhesiolysis. Several limitations should be acknowledged. First, this was a single-center study, which may limit generalizability. Second, blinding of surgeons was not feasible, potentially introducing performance bias, although outcome assessors were blinded. Third, longer-term reproductive outcomes beyond 12 months were not evaluated. Finally, the cost-effectiveness of the combined technique was not assessed and warrants future investigation. CONCLUSION The findings of this study suggest that hysteroscopic micro-scissors combined with an IBS should be considered a preferred surgical strategy for moderate to severe IUA, particularly in women desiring fertility. Compared with cold micro-scissors alone, the combined technique offers superior anatomic restoration, lower recurrence and complication rates, and higher patient satisfaction, with a favorable trend toward improved reproductive outcomes. Future multicenter trials with longer follow-up are needed to confirm reproductive benefits and to establish standardized operative protocols. Additionally, integration of this technique with emerging anti-adhesion strategies, such as biomaterials or regenerative therapies, may further improve long-term outcomes. Declarations Funding Declaration None. Clinical trial number Not applicable. Conflicts of Interest The authors declared that they have no conflicts of interest regarding this work. References E. Albazee, F. Al-Rshoud, L. Almahmoud et al. , Platelet-rich plasma for the management of intrauterine adhesions: A systematic review and meta-analysis of randomized controlled trials. J Gynecol Obstet Hum Reprod 51 , 102276 (2022).doi: 10.1016/j.jogoh.2021.102276. S. Baradwan, D. Alharbi, M. S. Bashir et al. , Short and long-term reproductive outcomes after hysteroscopic adhesiolysis for infertile women. JBRA Assist Reprod 27 , 191-196 (2023).doi: 10.5935/1518-0557.20220016. V. A. Flores, P. A. Delis, R. Mamillapalli et al. , Use of AMD3100 for bone marrow-derived mesenchymal stem cell mobilization in the treatment of murine Asherman's syndrome. F S Sci 6 , 475-482 (2025).doi: 10.1016/j.xfss.2025.08.003. A. B. Hooker, R. A. de Leeuw, J. W. R. Twisk et al. , Reproductive performance of women with and without intrauterine adhesions following recurrent dilatation and curettage for miscarriage: long-term follow-up of a randomized controlled trial. Hum Reprod 36 , 70-81 (2021).doi: 10.1093/humrep/deaa289. Y. Chen, Y. Wang, Y. Zhao et al. , Clinical efficacy of hysteroscopic adhesiolysis combined with periodic balloon dilation for intrauterine adhesion in IVF treatment. Front Endocrinol (Lausanne) 14 , 1236447 (2023).doi: 10.3389/fendo.2023.1236447. J. E. Okohue, N. Ameh, A. Adewole, Severity of intrauterine adhesions and pregnancy success rates after treatment: Comparison of adhesions obtained from open myomectomy versus uterine curettage. Afr J Reprod Health 26 , 90-96 (2022).doi: 10.29063/ajrh2022/v26i12.10. G. Armstrong, J. Abbott, R. Deans, Fertility and Obstetric Outcomes in Asherman Syndrome: Assessing the Impact of Hyaluronic Acid Post-Hysteroscopic Adhesiolysis. Aust N Z J Obstet Gynaecol , (2025).doi: 10.1111/ajo.70071. P. Capmas, A. Mihalache, L. Duminil et al. , Intrauterine adhesions: What is the pregnancy rate after hysteroscopic management? J Gynecol Obstet Hum Reprod 49 , 101797 (2020).doi: 10.1016/j.jogoh.2020.101797. H. L. Fan, X. X. Wu, H. C. Wei et al. , Clinical efficacy of intrauterine platelet-rich plasma infusion in endometrial regeneration after hysteroscopic adhesiolysis: A retrospective cohort study. Medicine (Baltimore) 104 , e43754 (2025).doi: 10.1097/md.0000000000043754. Q. Feng, B. Gao, H. Huang et al. , Obstetrical outcome in the third trimester after hysteroscopic adhesiolysis. Ann Transl Med 8 , 51 (2020).doi: 10.21037/atm.2019.09.123. L. Gabriel, L. Ederhof, U. Fellmann et al. , Surgical uterus-preserving therapy after uterine rupture and haemorrhage due to placenta percreta in the first trimester following embolisation of the uterine arteries and B-Lynch suture in a previous pregnancy. BMJ Case Rep 15 , (2022).doi: 10.1136/bcr-2022-250247. Y. Zhang, Y. Zhu, B. Ge et al. , Reproductive outcome of hysteroscopic metroplasty for women with T-shaped uterus: a retrospective study. Reprod Health 19 , 78 (2022).doi: 10.1186/s12978-022-01381-2. Y. Wang, L. L. Yin, X. F. Sun et al. , Retrospective analysis of autologous bone marrow mesenchymal stem cells as adjuvant therapy in recurrent intrauterine adhesions. Arch Gynecol Obstet 311 , 789-799 (2025).doi: 10.1007/s00404-025-07952-5. T. Wu, T. Fang, Y. Dong et al. , Comparison of Secondary Prevention Following Hysteroscopic Adhesiolysis in the Improvement of Reproductive Outcomes: A Retrospective Cohort Study. J Clin Med 13 , (2023).doi: 10.3390/jcm13010073. D. Sun, X. Mao, A. Zhang et al. , Pregnancy Patterns Impact Live Birth Rate for Patients With Intrauterine Adhesions After Hysteroscopic Adhesiolysis: A Retrospective Cohort Study. Front Physiol 13 , 822845 (2022).doi: 10.3389/fphys.2022.822845. D. Sun, X. Zhao, H. Huang et al. , In vitro fertilization and embryo transfer may improve live birth rate for patients with intrauterine adhesions after hysteroscopic adhesiolysis. Zhong Nan Da Xue Xue Bao Yi Xue Ban 47 , 1559-1567 (2022).doi: 10.11817/j.issn.1672-7347.2022.220546. X. Zhao, A. Zhang, B. Gao et al. , Cold scissors ploughing technique in hysteroscopic adhesiolysis: a comparative study. Ann Transl Med 8 , 50 (2020).doi: 10.21037/atm.2019.11.136. J. Zhang, From Adhesions to Conception: A Case Study on Platelet-Rich Plasma's Role in Gynecologic Recovery. Cureus 17, e86968 (2025).doi: 10.7759/cureus.86968. B. Li, H. Duan, S. Wang et al., Hierarchical cluster analysis in the study of the effect of cytokine expression patterns on endometrial repair and receptivity after hysteroscopic adhesiolysis. Ann Transl Med 9, 746 (2021).doi: 10.21037/atm-21-195. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 03 Mar, 2026 Reviews received at journal 09 Feb, 2026 Reviews received at journal 08 Feb, 2026 Reviews received at journal 02 Feb, 2026 Reviews received at journal 30 Jan, 2026 Reviewers agreed at journal 28 Jan, 2026 Reviews received at journal 27 Jan, 2026 Reviews received at journal 26 Jan, 2026 Reviewers agreed at journal 22 Jan, 2026 Reviewers agreed at journal 22 Jan, 2026 Reviewers agreed at journal 20 Jan, 2026 Reviewers agreed at journal 20 Jan, 2026 Reviewers agreed at journal 20 Jan, 2026 Reviewers invited by journal 20 Jan, 2026 Editor assigned by journal 30 Dec, 2025 Submission checks completed at journal 30 Dec, 2025 First submitted to journal 26 Dec, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8452541","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":577747663,"identity":"b29bcfc1-0361-4bd2-b508-22a098390db3","order_by":0,"name":"Xiaoqin Zhang","email":"","orcid":"","institution":"The First People's Hospital of Tongxiang City","correspondingAuthor":false,"prefix":"","firstName":"Xiaoqin","middleName":"","lastName":"Zhang","suffix":""},{"id":577747664,"identity":"2c6c9c59-02fd-48be-b0c0-78ee0ec3159a","order_by":1,"name":"Jufang Wang","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAsElEQVRIiWNgGAWjYDAC9v6HDxIMbHj4+RuI1cJzhtngQUGajOSMA8RqkchhE3zw4bCNQUMCkTp0e84eY0gwOM9jwHCA8cPHHCK0mB3vSwP65TaPOXMDs+TMbcRoOXPA3ACkxbLhABszL1FabiSYSSQYnOMxOJBAtJYckJYDpGg5cywZ6LBkHskZB5uJ9Mvx5oMPf/yxs+fnbz744SMxWpAAYwNp6kfBKBgFo2AU4AYArFA7I5+hg+YAAAAASUVORK5CYII=","orcid":"","institution":"The First People's Hospital of Tongxiang City","correspondingAuthor":true,"prefix":"","firstName":"Jufang","middleName":"","lastName":"Wang","suffix":""}],"badges":[],"createdAt":"2025-12-26 06:23:19","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8452541/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8452541/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":100867834,"identity":"1bb4ef05-37db-426e-b04e-6ab77b0bad94","added_by":"auto","created_at":"2026-01-22 08:45:24","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":2136514,"visible":true,"origin":"","legend":"","description":"","filename":"Manuscript.docx","url":"https://assets-eu.researchsquare.com/files/rs-8452541/v1/db8a44949b0d5c65e113625f.docx"},{"id":100867846,"identity":"3ab47c38-11f1-4767-baed-205f6ace148b","added_by":"auto","created_at":"2026-01-22 08:45:25","extension":"json","order_by":1,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":5293,"visible":true,"origin":"","legend":"","description":"","filename":"64838dc4b55d4717a9c565f150640f85.json","url":"https://assets-eu.researchsquare.com/files/rs-8452541/v1/a4f3ccf0db92e893275ff713.json"},{"id":100867863,"identity":"b17423ad-0f76-4eff-8f33-2cf69f7ef398","added_by":"auto","created_at":"2026-01-22 08:45:42","extension":"xml","order_by":2,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":83412,"visible":true,"origin":"","legend":"","description":"","filename":"64838dc4b55d4717a9c565f150640f851enriched.xml","url":"https://assets-eu.researchsquare.com/files/rs-8452541/v1/b1fbc1ac7993a34dbb3e8308.xml"},{"id":100949822,"identity":"daffd473-a5d6-430d-b8d7-0dbb5de36adf","added_by":"auto","created_at":"2026-01-23 07:05:57","extension":"png","order_by":10,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":94532,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-8452541/v1/03fca0bab859c05bf76b1938.png"},{"id":100867835,"identity":"7b1efee6-ba8b-4378-9607-2a83b7bf99e6","added_by":"auto","created_at":"2026-01-22 08:45:24","extension":"png","order_by":11,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":120076,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-8452541/v1/03f26aa9cb02e52ff9b37e94.png"},{"id":100867836,"identity":"949424e7-e24b-43bc-8539-0f71158b4d9c","added_by":"auto","created_at":"2026-01-22 08:45:24","extension":"png","order_by":12,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":114529,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage3.png","url":"https://assets-eu.researchsquare.com/files/rs-8452541/v1/41377c9ba1ed51944a521188.png"},{"id":100867861,"identity":"fba3419b-d12a-4473-ae04-7ca91f035f9b","added_by":"auto","created_at":"2026-01-22 08:45:41","extension":"png","order_by":13,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":102086,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage4.png","url":"https://assets-eu.researchsquare.com/files/rs-8452541/v1/2bc54320931609a34c7b5b26.png"},{"id":100949980,"identity":"3dcfd1ed-a6b6-439e-bb66-59c125ec208b","added_by":"auto","created_at":"2026-01-23 07:06:38","extension":"png","order_by":14,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":98682,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage5.png","url":"https://assets-eu.researchsquare.com/files/rs-8452541/v1/af0910c4562bb80ca65aa3a4.png"},{"id":100867837,"identity":"bb5c4fe8-e1a5-4a68-87c1-10da13af9e6c","added_by":"auto","created_at":"2026-01-22 08:45:24","extension":"png","order_by":15,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":96647,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage6.png","url":"https://assets-eu.researchsquare.com/files/rs-8452541/v1/501a1b07d182056c62696cfd.png"},{"id":100867844,"identity":"83c7e027-fe75-4af6-9a01-6c8ab3460fcb","added_by":"auto","created_at":"2026-01-22 08:45:25","extension":"png","order_by":16,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":106336,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage7.png","url":"https://assets-eu.researchsquare.com/files/rs-8452541/v1/ee5932052033aad1e105f281.png"},{"id":100867847,"identity":"52133532-dd32-4b10-987f-de6733e6ca26","added_by":"auto","created_at":"2026-01-22 08:45:25","extension":"xml","order_by":17,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":83031,"visible":true,"origin":"","legend":"","description":"","filename":"64838dc4b55d4717a9c565f150640f851structuring.xml","url":"https://assets-eu.researchsquare.com/files/rs-8452541/v1/58111729a75838867019c7cf.xml"},{"id":100867841,"identity":"888cfced-bba4-4b9c-bf19-122edee34ab5","added_by":"auto","created_at":"2026-01-22 08:45:25","extension":"html","order_by":18,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":93017,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-8452541/v1/f26448dcbcb3907ed5bdd623.html"},{"id":100867845,"identity":"d1468bfb-a679-45b6-8520-353e3759da44","added_by":"auto","created_at":"2026-01-22 08:45:25","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":329271,"visible":true,"origin":"","legend":"\u003cp\u003eCONSORT flow diagram showing patient enrollment, randomization, and follow-up. A total of 156 patients were assessed for eligibility, with 133 randomized to the Combined Group (n=68) or Control Group (n=65). All patients completed the 6-month follow-up.\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-8452541/v1/34fc8b28c508f45509b8d8eb.png"},{"id":100867862,"identity":"bfaf8cef-53d0-48b1-87b7-f5af5c147639","added_by":"auto","created_at":"2026-01-22 08:45:42","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":648837,"visible":true,"origin":"","legend":"\u003cp\u003eComparison of American Fertility Society (AFS) scores between groups. (A) Box plots showing AFS scores at baseline and 3 months for both groups. (B) Violin plots displaying the distribution of AFS score improvement. (C) Individual patient trajectories from baseline to 3 months, with mean trajectories highlighted. ***P \u0026lt; 0.001.\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-8452541/v1/45e5c667272e2dd508b45de3.png"},{"id":100950034,"identity":"9cb5487d-d3c5-4c99-b2ed-7b706efbd6ec","added_by":"auto","created_at":"2026-01-23 07:06:44","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":364426,"visible":true,"origin":"","legend":"\u003cp\u003eIntraoperative outcomes. (A) Operation time comparison between groups. (B) Intraoperative blood loss comparison. (C) Distension medium consumption. Individual data points are shown with overlaid box plots.\u003c/p\u003e","description":"","filename":"floatimage3.png","url":"https://assets-eu.researchsquare.com/files/rs-8452541/v1/6859ed651f80e25326f4d23b.png"},{"id":100867832,"identity":"d17757f7-2f10-4b51-acbe-b67c7fd1750f","added_by":"auto","created_at":"2026-01-22 08:45:24","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":193010,"visible":true,"origin":"","legend":"\u003cp\u003eClinical outcomes comparison. Bar chart showing rates of menstrual improvement, pregnancy, normal cavity restoration, adhesion recurrence, and complications between the Combined Group (blue) and Control Group (red). *P \u0026lt; 0.05, ***P \u0026lt; 0.001.\u003c/p\u003e","description":"","filename":"floatimage4.png","url":"https://assets-eu.researchsquare.com/files/rs-8452541/v1/26d4a916a5a84fd2ec271dda.png"},{"id":100867838,"identity":"2984e842-3494-4ae8-b394-970e61756563","added_by":"auto","created_at":"2026-01-22 08:45:24","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":278259,"visible":true,"origin":"","legend":"\u003cp\u003eForest plot of subgroup analysis for AFS score improvement. Standardized mean differences (SMD) with 95% confidence intervals are shown for overall population and prespecified subgroups. Diamond size is proportional to sample size.\u003c/p\u003e","description":"","filename":"floatimage6.png","url":"https://assets-eu.researchsquare.com/files/rs-8452541/v1/379bf61550741cfb3ae84f44.png"},{"id":100950140,"identity":"b17b00bb-ec89-420d-8253-ce6f0353451d","added_by":"auto","created_at":"2026-01-23 07:06:58","extension":"png","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":288493,"visible":true,"origin":"","legend":"\u003cp\u003eUterine cavity morphology and patient satisfaction. (A) Stacked bar chart showing distribution of cavity morphology outcomes (normal, improved, unchanged). (B) Violin plot with individual data points showing patient satisfaction scores.\u003c/p\u003e","description":"","filename":"floatimage5.png","url":"https://assets-eu.researchsquare.com/files/rs-8452541/v1/9e8091686318c4d67fdc9542.png"},{"id":100867839,"identity":"2dd7ed46-2033-4964-ac84-06f8b8c83b2c","added_by":"auto","created_at":"2026-01-22 08:45:24","extension":"png","order_by":7,"title":"Figure 7","display":"","copyAsset":false,"role":"figure","size":313559,"visible":true,"origin":"","legend":"\u003cp\u003eCorrelation matrix of clinical variables. Pearson correlation coefficients are displayed, with color intensity indicating strength of correlation. Red indicates positive correlation, blue indicates negative correlation.\u003c/p\u003e","description":"","filename":"floatimage7.png","url":"https://assets-eu.researchsquare.com/files/rs-8452541/v1/e2a17e0ac6730d8643b76f60.png"},{"id":100952923,"identity":"c4c8d62a-aaf2-4dfa-8287-7c9eae9e712a","added_by":"auto","created_at":"2026-01-23 07:18:50","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2695111,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8452541/v1/0a973c7c-e4fa-475d-90b5-948a96b4a398.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Clinical Efficacy Research on the Efficacy and Safety of Hysteroscopic Micro-scissors Combined with a Intrauterine Bigatti Shaver for Treating Moderate to Severe Intrauterine Adhesions","fulltext":[{"header":"Introduction","content":"\u003cp\u003eIntrauterine adhesions (IUA), also referred to as Asherman syndrome, are characterized by partial or complete obliteration of the uterine cavity due to fibrous bands that follow endometrial injury and aberrant wound healing[1, 2]. Clinically, IUA may present with amenorrhea or hypomenorrhea, cyclic pelvic pain, recurrent pregnancy loss, and infertility, and the disease burden is particularly relevant among women of reproductive age[3, 4]. The dominant etiologic factor remains trauma to the gravid or recently pregnant endometrium, most commonly after curettage or other intrauterine procedures, which can disrupt the basal endometrial layer required for regeneration[5, 6].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eHysteroscopic adhesiolysis is the accepted first-line treatment for moderate to severe IUA because it enables direct visualization and targeted dissection of adhesions with the aim of restoring uterine cavity anatomy and functional endometrium[5-8]. However, management of moderate to severe disease remains challenging: dense or muscular adhesions, poor cavity distensibility, and limited residual endometrial \u0026ldquo;islands\u0026rdquo; increase procedural complexity and predispose patients to perioperative bleeding, uterine injury, and\u0026mdash;most importantly\u0026mdash;high rates of postoperative re-adhesion. Even with standardized adjuvant measures (e.g., mechanical barriers, estrogen therapy, and second-look hysteroscopy), recurrence and suboptimal reproductive outcomes continue to limit long-term success in severe cases[9-11].\u003c/p\u003e\n\u003cp\u003eCold micro-scissors represent a refined mechanical technique that permits precise, incremental division of filmy and central adhesions under direct hysteroscopic visualization, minimizing collateral injury to adjacent endometrium[12]. Nonetheless, micro-scissors alone may be inefficient for dense, marginal, or muscular adhesions, where controlled resection and consistent visualization become limiting factors\u0026mdash;this technical limitation may lead to incomplete adhesiolysis, further increasing the risk of postoperative recurrence. In parallel, hysteroscopic tissue removal systems (shavers/morcellators) have been widely used for intrauterine pathology such as polyps and submucous fibroids and offer simultaneous cutting and aspiration, potentially improving field clarity and operative control. Extending these devices to IUA theoretically enables more complete adhesiolysis for dense adhesions while maintaining a non-thermal profile[13,14]; however, clinical evidence in moderate to severe IUA remains comparatively limited and heterogeneous across techniques and adjunctive regimens.\u003c/p\u003e\n\u003cp\u003eAccordingly, we designed a prospective randomized controlled trial to compare hysteroscopic cold micro-scissors combined with an intrauterine Bigatti Shaver (IBS） versus cold micro-scissors alone in women with moderate to severe IUA, under standardized postoperative adhesion-prevention management. We hypothesized that the combined non-thermal strategy would improve short-term anatomic restoration and symptom recovery, reduce perioperative morbidity and adhesion recurrence, and potentially translate into improved fertility-related outcomes among women desiring pregnancy.\u003c/p\u003e"},{"header":"METHODS","content":"\u003cp\u003e2.1 Study Design and Ethical Approval\u003c/p\u003e\n\u003cp\u003eThis prospective, single-center, randomized controlled trial was conducted at the Department of Gynecology, Tongxiang First Hospital, between January 2023 and December 2025. The study protocol was approved by the Ethics Committee of Tongxiang First Hospital (Approval No.: 2025 Research Project No. 030). All participants provided written informed consent prior to enrollment. The study was conducted in accordance with the Declaration of Helsinki and Good Clinical Practice guidelines.\u003c/p\u003e\n\u003cp\u003e2.2 Participants\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInclusion criteria:\u003c/strong\u003e (1) Women aged 18-45 years with moderate to severe intrauterine adhesions (IUA) diagnosed by hysteroscopy and classified according to the American Fertility Society (AFS) scoring system (score ≥5); (2) History of at least one uterine curettage or other intrauterine procedures; (3) Clinical symptoms including amenorrhea, hypomenorrhea, or infertility; (4) No contraindications to hysteroscopic surgery; (5) Willingness to comply with the follow-up schedule.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eExclusion criteria:\u003c/strong\u003e (1) Presence of other uterine pathologies such as submucosal fibroids, adenomyosis, or endometrial polyps requiring treatment; (2) Active pelvic inflammatory disease or genital tract infection; (3) Severe medical comorbidities contraindicating surgery; (4) Previous failed hysteroscopic adhesiolysis within 6 months; (5) Pregnancy or lactation; (6) Inability to provide informed consent.\u003c/p\u003e\n\u003cp\u003e2.3 Randomization and Blinding\u003c/p\u003e\n\u003cp\u003eA total of 156 patients were screened for eligibility, of whom 133 met the inclusion criteria and were enrolled. Participants were randomly assigned in a 1:1 ratio to the Combined Group (n=68) or the Control Group (n=65) using computer-generated random numbers with block randomization (block size = 4). Allocation concealment was ensured by using sequentially numbered, opaque, sealed envelopes. Due to the nature of the intervention, the operating surgeons could not be blinded; however, the outcome assessors and statisticians were blinded to group allocation throughout the study.\u003c/p\u003e\n\u003cp\u003e2.4 Surgical Procedures\u003c/p\u003e\n\u003cp\u003e2.4.1 Preoperative Preparation\u003c/p\u003e\n\u003cp\u003eAll patients received standardized preoperative preparation. Misoprostol 400 μg was administered vaginally 12 hours before surgery for cervical ripening. Prophylactic antibiotics (Cefuroxime 1.5 g intravenously) were administered 30 minutes before the procedure. All surgeries were performed under general anesthesia during the early proliferative phase of the menstrual cycle.\u003c/p\u003e\n\u003cp\u003e2.4.2 Combined Group: Micro-scissors with IBS\u003c/p\u003e\n\u003cp\u003eIn the Combined Group, hysteroscopic adhesiolysis was performed using a combination of cold micro-scissors (Karl Storz, Germany) and an intrauterine tissue removal system (MyoSure® LITE, Hologic, USA). A 5.8 mm continuous-flow operative hysteroscope with a 30° optic was used. Normal saline was used as the distension medium, with intrauterine pressure maintained between 80-100 mmHg.\u003c/p\u003e\n\u003cp\u003eThe procedure began with systematic panoramic inspection of the uterine cavity to assess the extent and nature of adhesions. Filmy and central adhesions were first divided using cold micro-scissors under direct visualization, employing a lateral-to-medial and anterior-to-posterior approach. The micro-scissors allowed precise, controlled division of adhesive bands while minimizing thermal damage to the surrounding endometrium.\u003c/p\u003e\n\u003cp\u003eFor dense, marginal, or muscular adhesions, the intrauterine IBS was employed. The tissue removal device was advanced under hysteroscopic guidance, and adhesive tissue was simultaneously cut and aspirated. This dual approach ensured complete adhesiolysis while optimizing tissue preservation. Special care was taken to avoid excessive depth of resection and to preserve any remaining endometrial islands.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2.4.3 Control Group: Cold Micro-scissors Alone\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn the Control Group, hysteroscopic adhesiolysis was performed using cold micro-scissors alone (Karl Storz, Germany). A 5.8 mm continuous-flow operative hysteroscope with a 30° optic was used, consistent with the Combined Group. Normal saline was used as the distension medium, with intrauterine pressure maintained between 80-100 mmHg (same as the Combined Group to ensure comparability).\u003c/p\u003e\n\u003cp\u003eThe surgical approach was consistent with the Combined Group: systematic panoramic inspection of the uterine cavity was performed first to assess adhesion extent and nature. Adhesions (including filmy, central, dense, marginal, and muscular types) were all dissected using cold micro-scissors alone, employing the same lateral-to-medial and anterior-to-posterior approach. Special care was taken to achieve precise dissection, avoid excessive tissue injury, and restore the triangular uterine cavity shape with visualization of both tubal ostia. No additional tissue removal devices or electrosurgical instruments were used.\u003c/p\u003e\n\u003cp\u003e2.4.4 Postoperative Management\u003c/p\u003e\n\u003cp\u003eFollowing adhesiolysis, all patients received standardized postoperative management: (1) Intrauterine balloon stent (Foley catheter, 5 mL inflation) placement for 7 days to prevent re-adhesion; (2) Sequential hormone therapy with conjugated estrogen (Premarin® 1.25 mg daily) for 21 days followed by medroxyprogesterone acetate (Provera® 10 mg daily) for 10 days, repeated for three cycles; (3) Prophylactic antibiotics (oral cephalosporin) for 5 days; (4) Second-look hysteroscopy at 3 months to assess uterine cavity restoration and presence of residual or recurrent adhesions.\u003c/p\u003e\n\u003cp\u003e2.5 Outcome Measures\u003c/p\u003e\n\u003cp\u003e2.5.1 Primary Outcomes\u003c/p\u003e\n\u003cp\u003eThe primary outcome was the change in AFS score from baseline to 3 months post-surgery. The AFS classification system evaluates the extent of adhesions (scored 1-4), type of adhesions (scored 1-4), and menstrual pattern (scored 1-4), yielding a total score of 1-12. Moderate adhesions were defined as scores 5-8, and severe adhesions as scores 9-12. AFS scores were assessed by two independent, blinded hysteroscopists, with discrepancies resolved by a third senior gynecologist.\u003c/p\u003e\n\u003cp\u003e2.5.2 Secondary Outcomes\u003c/p\u003e\n\u003cp\u003eSecondary outcomes included: (1) Intraoperative parameters: operation time (minutes from hysteroscope insertion to withdrawal), intraoperative blood loss (ml, estimated by suction volume minus irrigation fluid), and distension medium consumption (ml); (2) Clinical efficacy measures: menstrual pattern improvement (assessed using the Pictorial Blood Loss Assessment Chart), uterine cavity morphology restoration (classified as normal, improved, or unchanged), and pregnancy outcomes among patients with fertility desire; (3) Safety outcomes: intraoperative complications (uterine perforation, excessive bleeding, fluid overload) and postoperative complications (infection, re-adhesion requiring intervention); (4) Adhesion recurrence rate at 6-month follow-up; (5) Patient satisfaction score (visual analog scale, 1-10).\u003c/p\u003e\n\u003cp\u003e2.6 Follow-up Protocol\u003c/p\u003e\n\u003cp\u003ePatients were followed up at 1 month (telephone), 3 months (clinical visit with second-look hysteroscopy), and 6 months (clinical visit). At each follow-up, menstrual pattern, pregnancy status, and any adverse events were documented. Second-look hysteroscopy at 3 months provided objective assessment of uterine cavity morphology and AFS scoring. Patients with fertility desire were encouraged to attempt natural conception after completion of hormone therapy and were followed for pregnancy outcomes up to 12 months post-surgery.\u003c/p\u003e\n\u003cp\u003e2.7 Sample Size Calculation\u003c/p\u003e\n\u003cp\u003eSample size was calculated based on the primary outcome (AFS score improvement). Based on previous studies, we anticipated a mean difference of 1.5 points in AFS score improvement between groups, with a standard deviation of 2.0 points. With a two-sided alpha of 0.05 and power of 80%, a minimum of 57 patients per group was required. Accounting for a 15% dropout rate, we aimed to enroll at least 66 patients per group.\u003c/p\u003e\n\u003cp\u003e2.8 Statistical Analysis\u003c/p\u003e\n\u003cp\u003eAll statistical analyses were performed using Python 3.9 with SciPy 1.10 and StatsModels 0.14. Continuous variables were tested for normality using the Shapiro-Wilk test. Normally distributed variables were presented as mean ± standard deviation and compared using independent-samples t-tests. Non-normally distributed variables were presented as median (interquartile range) and compared using the Mann-Whitney U test. Categorical variables were presented as frequencies and percentages and compared using the chi-square test or Fisher's exact test, as appropriate.\u003cbr\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eEffect sizes were calculated using Cohen's d for continuous outcomes and odds ratios with 95% confidence intervals for binary outcomes. Subgroup analyses were performed to explore treatment effects across prespecified subgroups (age \u0026lt;35 vs ≥35 years, moderate vs severe adhesions, prior curettage ≤2 vs \u0026gt;2). All tests were two-tailed, and P \u0026lt; 0.05 was considered statistically significant. Analyses were performed on an intention-to-treat basis.\u003c/p\u003e"},{"header":"RESULTS","content":"\u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003e3.1 Patient Enrollment and Baseline Characteristics\u003c/h2\u003e \u003cp\u003eBetween January 2023 and December 2025, 156 patients with moderate to severe IUA were assessed for eligibility. Of these, 23 patients were excluded: 15 did not meet inclusion criteria, 5 declined to participate, and 3 were excluded for other reasons. The remaining 133 patients were randomized to the Combined Group (n\u0026thinsp;=\u0026thinsp;68) or the Control Group (n\u0026thinsp;=\u0026thinsp;65). All randomized patients completed the scheduled follow-up, with no dropouts or loss to follow-up in either group (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eBaseline demographic and clinical characteristics were well-balanced between the two groups (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). The mean age was 32.2\u0026thinsp;\u0026plusmn;\u0026thinsp;4.8 years in the Combined Group and 31.1\u0026thinsp;\u0026plusmn;\u0026thinsp;4.8 years in the Control Group (P\u0026thinsp;=\u0026thinsp;0.173). Mean BMI was comparable between groups (22.5\u0026thinsp;\u0026plusmn;\u0026thinsp;2.9 vs 23.0\u0026thinsp;\u0026plusmn;\u0026thinsp;2.7 kg/m\u0026sup2;, P\u0026thinsp;=\u0026thinsp;0.268). The mean number of prior curettage procedures was 2.2\u0026thinsp;\u0026plusmn;\u0026thinsp;1.0 in the Combined Group and 2.5\u0026thinsp;\u0026plusmn;\u0026thinsp;0.9 in the Control Group (P\u0026thinsp;=\u0026thinsp;0.062).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eBaseline Characteristics of Study Participants\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharacteristic\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCombined Group (n\u0026thinsp;=\u0026thinsp;68)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eControl Group (n\u0026thinsp;=\u0026thinsp;65)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eP-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e32.2\u0026thinsp;\u0026plusmn;\u0026thinsp;4.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e31.1\u0026thinsp;\u0026plusmn;\u0026thinsp;4.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.173\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBMI (kg/m\u0026sup2;)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e22.5\u0026thinsp;\u0026plusmn;\u0026thinsp;2.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e23.0\u0026thinsp;\u0026plusmn;\u0026thinsp;2.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.268\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGravidity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.0\u0026thinsp;\u0026plusmn;\u0026thinsp;1.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.8\u0026thinsp;\u0026plusmn;\u0026thinsp;1.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.378\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eParity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.1\u0026thinsp;\u0026plusmn;\u0026thinsp;0.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.4\u0026thinsp;\u0026plusmn;\u0026thinsp;1.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.052\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrior curettage\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.2\u0026thinsp;\u0026plusmn;\u0026thinsp;1.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.5\u0026thinsp;\u0026plusmn;\u0026thinsp;0.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.062\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAdhesion duration (months)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12.9\u0026thinsp;\u0026plusmn;\u0026thinsp;9.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12.6\u0026thinsp;\u0026plusmn;\u0026thinsp;8.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.880\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAFS score at baseline\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7.93\u0026thinsp;\u0026plusmn;\u0026thinsp;1.85\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7.37\u0026thinsp;\u0026plusmn;\u0026thinsp;2.06\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.028\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAdhesion severity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.110\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eModerate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e45 (66.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e52 (80.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSevere\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23 (33.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13 (20.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe baseline AFS score was 7.93\u0026thinsp;\u0026plusmn;\u0026thinsp;1.85 in the Combined Group and 7.37\u0026thinsp;\u0026plusmn;\u0026thinsp;2.06 in the Control Group (P\u0026thinsp;=\u0026thinsp;0.028). The distribution of adhesion severity was similar between groups: moderate adhesions were present in 45 (66.2%) patients in the Combined Group and 52 (80.0%) in the Control Group, while severe adhesions were present in 23 (33.8%) and 13 (20.0%) patients, respectively (P\u0026thinsp;=\u0026thinsp;0.110). Menstrual status at baseline showed no significant difference between groups (P\u0026thinsp;=\u0026thinsp;0.420).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003e3.2 Primary Outcome: AFS Score Improvement\u003c/h2\u003e \u003cp\u003eAt 3-month follow-up, the Combined Group demonstrated significantly greater improvement in AFS scores compared to the Control Group. The mean AFS score decreased from 7.93\u0026thinsp;\u0026plusmn;\u0026thinsp;1.85 at baseline to 2.44\u0026thinsp;\u0026plusmn;\u0026thinsp;2.24 at 3 months in the Combined Group, representing a mean improvement of 5.49\u0026thinsp;\u0026plusmn;\u0026thinsp;1.54 points. In contrast, the Control Group showed a reduction from 7.37\u0026thinsp;\u0026plusmn;\u0026thinsp;2.06 to 3.46\u0026thinsp;\u0026plusmn;\u0026thinsp;2.72, with a mean improvement of 3.91\u0026thinsp;\u0026plusmn;\u0026thinsp;1.63 points (P\u0026thinsp;\u0026lt;\u0026thinsp;0.001) (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThe effect size for AFS improvement was large (Cohen's d\u0026thinsp;=\u0026thinsp;1.00), indicating a clinically significant advantage of the combined technique. At 6-month follow-up, the AFS scores remained stable, with mean scores of 1.99\u0026thinsp;\u0026plusmn;\u0026thinsp;2.03 in the Combined Group and 2.80\u0026thinsp;\u0026plusmn;\u0026thinsp;2.65 in the Control Group, suggesting durable therapeutic effects of both procedures.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003e3.3 Intraoperative Outcomes\u003c/h2\u003e \u003cp\u003eIntraoperative parameters are presented in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e and Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e. The mean operation time was significantly longer in the Combined Group (38.7\u0026thinsp;\u0026plusmn;\u0026thinsp;10.1 minutes) compared to the Control Group (34.8\u0026thinsp;\u0026plusmn;\u0026thinsp;10.2 minutes, P\u0026thinsp;=\u0026thinsp;0.007). This difference can be attributed to the meticulous technique required for the combined approach and the need to switch between instruments.​\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eIntraoperative Outcomes\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharacteristic\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCombined Group (n\u0026thinsp;=\u0026thinsp;68)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eControl Group (n\u0026thinsp;=\u0026thinsp;65)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eP-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOperation time (min)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e38.7\u0026thinsp;\u0026plusmn;\u0026thinsp;10.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e34.8\u0026thinsp;\u0026plusmn;\u0026thinsp;10.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.007\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBlood loss (ml)*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10.2 (5.3\u0026ndash;21.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e22.6 (15.2\u0026ndash;36.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDistension medium (ml)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2446\u0026thinsp;\u0026plusmn;\u0026thinsp;527\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2499\u0026thinsp;\u0026plusmn;\u0026thinsp;512\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.421\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003e*Presented as median (interquartile range)\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eNotably, intraoperative blood loss was significantly lower in the Combined Group (median: 10.2 ml, IQR: 5.3\u0026ndash;21.7 ml) compared to the Control Group (median: 22.6 ml, IQR: 15.2\u0026ndash;36.8 ml, P\u0026thinsp;\u0026lt;\u0026thinsp;0.001). This substantial reduction in blood loss (approximately 55%) reflects the advantage of combining cold dissection with micro-scissors and efficient tissue removal by IBS, which minimizes tissue injury and bleeding compared to single micro-scissors dissection for dense adhesions.\u003c/p\u003e \u003cp\u003eDistension medium consumption was similar between groups (2446\u0026thinsp;\u0026plusmn;\u0026thinsp;527 ml vs 2499\u0026thinsp;\u0026plusmn;\u0026thinsp;512 ml, P\u0026thinsp;\u0026gt;\u0026thinsp;0.05). No cases of fluid overload or electrolyte imbalance were observed in either group.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003e3.4 Clinical Efficacy Outcomes\u003c/h2\u003e \u003cp\u003ebAmong patients with abnormal menstruation at baseline (amenorrhea or hypomenorrhea), the menstrual improvement rate was significantly higher in the Combined Group (55/61, 90.2%) compared to the Control Group (35/54, 64.8%, P\u0026thinsp;=\u0026thinsp;0.002) (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). The majority of patients in the Combined Group reported restoration of normal or near-normal menstrual flow within 3 menstrual cycles following surgery.\u003c/p\u003e \u003cp\u003eSecond-look hysteroscopy at 3 months revealed superior uterine cavity restoration in the Combined Group. Normal cavity morphology was observed in 48 (70.6%) patients in the Combined Group versus 30 (46.2%) in the Control Group (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05). The triangular cavity shape with clear visualization of both tubal ostia was more frequently achieved in the Combined Group, indicating better preservation of endometrial function (Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e6\u003c/span\u003eA).\u003c/p\u003e \u003cp\u003eAmong patients with fertility desire (n\u0026thinsp;=\u0026thinsp;49 in the Combined Group and n\u0026thinsp;=\u0026thinsp;49 in the Control Group), the pregnancy rate at 12-month follow-up was 49.0% (24/49) in the Combined Group and 30.6% (15/49) in the Control Group (P\u0026thinsp;=\u0026thinsp;0.099). Although the difference did not reach statistical significance, the odds of pregnancy were 2.18 times higher in the Combined Group (OR\u0026thinsp;=\u0026thinsp;2.18, 95% CI: 0.95\u0026ndash;4.97). The mean time to conception was 6.5 months in the Combined Group (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eClinical Outcomes\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharacteristic\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCombined Group (n\u0026thinsp;=\u0026thinsp;68)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eControl Group (n\u0026thinsp;=\u0026thinsp;65)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eP-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAFS score at 3 months\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.44\u0026thinsp;\u0026plusmn;\u0026thinsp;2.24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.46\u0026thinsp;\u0026plusmn;\u0026thinsp;2.72\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.017\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAFS score improvement\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5.49\u0026thinsp;\u0026plusmn;\u0026thinsp;1.54\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.91\u0026thinsp;\u0026plusmn;\u0026thinsp;1.63\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMenstrual improvement\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e55/61 (90.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e35/54 (64.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.002\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNormal cavity morphology\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e48 (70.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e30 (46.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.034\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePregnancy rate\u0026dagger;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e24/49 (49.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15/49 (30.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.099\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRecurrence at 6 months\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5/68 (7.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17/65 (26.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.007\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOverall complications\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5/68 (7.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19/65 (29.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSatisfaction score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8.0\u0026thinsp;\u0026plusmn;\u0026thinsp;1.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7.3\u0026thinsp;\u0026plusmn;\u0026thinsp;1.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003e\u0026dagger;Among patients with fertility desire\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec21\" class=\"Section2\"\u003e \u003ch2\u003e3.5 Safety Outcomes\u003c/h2\u003e \u003cp\u003eThe overall complication rate was significantly lower in the Combined Group (5/68, 7.4%) compared to the Control Group (19/65, 29.2%, P\u0026thinsp;=\u0026thinsp;0.001) (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). Intraoperative complications occurred in 1 (1.5%) patients in the Combined Group versus 9 (13.8%) in the Control Group. No cases of uterine perforation occurred in either group. Minor bleeding requiring extended hemostasis was the most common intraoperative complication in the Control Group.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec22\" class=\"Section2\"\u003e \u003ch2\u003e3.6 Adhesion Recurrence\u003c/h2\u003e \u003cp\u003eAt 6-month follow-up, the adhesion recurrence rate was significantly lower in the Combined Group (5/68, 7.4%) compared to the Control Group (17/65, 26.2%, P\u0026thinsp;=\u0026thinsp;0.007) (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). The relative risk of recurrence was 0.28 (95% CI: 0.11\u0026ndash;0.73), indicating a 72% reduction in the risk of re-adhesion with the combined technique. Among patients who experienced recurrence, the severity was generally mild (AFS score 1\u0026ndash;4) and was managed conservatively with repeat hormone therapy in most cases.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec23\" class=\"Section2\"\u003e \u003ch2\u003e3.7 Patient Satisfaction\u003c/h2\u003e \u003cp\u003ePatient satisfaction scores were significantly higher in the Combined Group (mean: 8.0\u0026thinsp;\u0026plusmn;\u0026thinsp;1.0) compared to the Control Group (7.3\u0026thinsp;\u0026plusmn;\u0026thinsp;1.2, P\u0026thinsp;\u0026lt;\u0026thinsp;0.001) (Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e6\u003c/span\u003e). The higher satisfaction in the Combined Group may be attributed to less postoperative discomfort, faster recovery of menstrual function, and the overall better clinical outcomes.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec24\" class=\"Section2\"\u003e \u003ch2\u003e3.8 Subgroup Analysis\u003c/h2\u003e \u003cp\u003eSubgroup analyses demonstrated consistent benefits of the combined technique across prespecified subgroups (Fig.\u0026nbsp;\u003cspan refid=\"Fig6\" class=\"InternalRef\"\u003e5\u003c/span\u003e). The treatment effect was evident in both younger (\u0026lt;\u0026thinsp;35 years) and older (\u0026ge;\u0026thinsp;35 years) patients, with similar standardized mean differences in AFS improvement. Notably, patients with severe adhesions (AFS score 9\u0026ndash;12) showed a greater absolute benefit from the combined technique, although the effect was also significant in those with moderate adhesions. The treatment effect was maintained regardless of the number of prior curettage procedures, suggesting broad applicability of the combined approach.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec25\" class=\"Section2\"\u003e \u003ch2\u003e3.9 Correlation Analysis\u003c/h2\u003e \u003cp\u003eCorrelation analysis revealed several noteworthy associations (Fig.\u0026nbsp;\u003cspan refid=\"Fig7\" class=\"InternalRef\"\u003e7\u003c/span\u003e). Baseline AFS score was positively correlated with AFS improvement (r\u0026thinsp;=\u0026thinsp;0.52, P\u0026thinsp;\u0026lt;\u0026thinsp;0.001), indicating that patients with more severe adhesions achieved greater absolute improvement. Operation time was weakly correlated with blood loss (r\u0026thinsp;=\u0026thinsp;0.18, P\u0026thinsp;\u0026lt;\u0026thinsp;0.05). Patient satisfaction showed moderate positive correlation with AFS improvement (r\u0026thinsp;=\u0026thinsp;0.41, P\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and menstrual restoration, underscoring the relationship between objective clinical outcomes and patient-reported experiences.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eThis prospective randomized controlled trial demonstrates that hysteroscopic micro-scissors combined with an intrauterine IBS provides superior clinical efficacy and safety compared with cold micro-scissors alone for the treatment of moderate to severe intrauterine adhesions (IUA). The combined technique resulted in significantly greater improvement in AFS scores, lower intraoperative blood loss, reduced complication and recurrence rates, and higher patient satisfaction, while maintaining acceptable operative time and distension media consumption.\u003c/p\u003e \u003cp\u003eThe most important finding of this study is the significantly greater reduction in AFS scores achieved with the combined approach. The mean AFS improvement of 5.49 points in the Combined Group exceeded that of the Control Group by approximately 1.6 points, representing both statistical and clinical significance. Given that AFS score reduction is closely associated with restoration of endometrial surface area and uterine cavity function, this improvement suggests a more complete and physiologically favorable adhesiolysis. Previous studies have reported that postoperative AFS scores below 4 are associated with better menstrual and reproductive outcomes, which aligns with the higher proportion of patients achieving normal cavity morphology in the Combined Group[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe observed benefits can be explained by the complementary mechanisms of cold micro-scissors and mechanical shaving. Cold micro-scissors allow sharp, controlled dissection of filmy and central adhesions with minimal collateral damage, preserving residual endometrial glands and basal layer integrity [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. For dense or muscular adhesions, the IBS enables simultaneous cutting and aspiration under direct visualization, reducing traction injury and improving operative precision\u0026mdash;this advantage is particularly prominent compared to single micro-scissors dissection, which may struggle with incomplete resection of dense adhesions due to limited operative control [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eMechanical tissue removal with IBS has been shown to produce smoother resection planes and less inflammatory response compared with single cold scissors dissection, which may contribute to the significantly lower recurrence rate observed in this study. Although operative time was modestly longer in the Combined Group, this difference is clinically acceptable and likely reflects the meticulous, stepwise nature of the combined technique. Importantly, intraoperative blood loss was reduced by more than 50%, underscoring the advantage of controlled mechanical removal for dense adhesions, which reduces the risk of excessive bleeding compared to forced dissection with single micro-scissors.\u003c/p\u003e \u003cp\u003eThe markedly lower complication rate further supports the safety of this approach, particularly in patients with severe adhesions who are at higher risk of bleeding and uterine trauma. No cases of uterine perforation or fluid overload were observed, indicating that both techniques can be safely performed by experienced surgeons. However, the higher rate of minor bleeding and postoperative morbidity in the Control Group highlights the inherent limitations of single micro-scissors dissection, especially in fibrotic or poorly distensible uterine cavities where dense adhesions are difficult to resect completely.\u003c/p\u003e \u003cp\u003eAdhesion recurrence remains a major challenge in IUA management. The 7.4% recurrence rate in the Combined Group compares favorably with rates of 20\u0026ndash;40% reported for single cold micro-scissors dissection in moderate to severe cases. This substantial risk reduction is likely attributable to superior endometrial preservation and more complete adhesiolysis achieved by the combined technique, as supported by the higher rates of normal cavity restoration and improved menstrual outcomes. Preservation of endometrial islands is critical for re-epithelialization and prevention of secondary fibrosis, reinforcing the importance of combined non-thermal techniques for IUA management [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAlthough the difference in pregnancy rates did not reach statistical significance, the nearly 20% absolute increase and odds ratio greater than 2 suggest a clinically meaningful trend favoring the combined approach. The study may have been underpowered to detect differences in reproductive outcomes, which are influenced by multiple confounders such as age, ovarian reserve, and male factors. Nevertheless, the shorter time to conception and improved uterine cavity morphology support the hypothesis that enhanced endometrial recovery translates into improved fertility potential [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eSubgroup analyses demonstrated consistent benefits across age groups, adhesion severity, and prior curettage history, indicating broad applicability of the combined technique. Notably, patients with severe adhesions derived the greatest absolute benefit, supporting the use of this approach in complex cases traditionally associated with poor prognosis. Correlation analyses further highlighted the relationship between objective surgical outcomes and patient-reported satisfaction, emphasizing the clinical relevance of comprehensive adhesiolysis.\u003c/p\u003e \u003cp\u003eSeveral limitations should be acknowledged. First, this was a single-center study, which may limit generalizability. Second, blinding of surgeons was not feasible, potentially introducing performance bias, although outcome assessors were blinded. Third, longer-term reproductive outcomes beyond 12 months were not evaluated. Finally, the cost-effectiveness of the combined technique was not assessed and warrants future investigation.\u003c/p\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eThe findings of this study suggest that hysteroscopic micro-scissors combined with an IBS should be considered a preferred surgical strategy for moderate to severe IUA, particularly in women desiring fertility. Compared with cold micro-scissors alone, the combined technique offers superior anatomic restoration, lower recurrence and complication rates, and higher patient satisfaction, with a favorable trend toward improved reproductive outcomes. Future multicenter trials with longer follow-up are needed to confirm reproductive benefits and to establish standardized operative protocols. Additionally, integration of this technique with emerging anti-adhesion strategies, such as biomaterials or regenerative therapies, may further improve long-term outcomes.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eFunding Declaration\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNone.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical trial number\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflicts of Interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declared that they have no conflicts of interest regarding this work.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eE. Albazee, F. Al-Rshoud, L. Almahmoud\u003cem\u003e et al.\u003c/em\u003e, Platelet-rich plasma for the management of intrauterine adhesions: A systematic review and meta-analysis of randomized controlled trials. \u003cem\u003eJ Gynecol Obstet Hum Reprod\u003c/em\u003e\u003cstrong\u003e51\u003c/strong\u003e, 102276 (2022).doi: 10.1016/j.jogoh.2021.102276.\u003c/li\u003e\n\u003cli\u003eS. Baradwan, D. Alharbi, M. S. Bashir\u003cem\u003e et al.\u003c/em\u003e, Short and long-term reproductive outcomes after hysteroscopic adhesiolysis for infertile women. \u003cem\u003eJBRA Assist Reprod\u003c/em\u003e\u003cstrong\u003e27\u003c/strong\u003e, 191-196 (2023).doi: 10.5935/1518-0557.20220016.\u003c/li\u003e\n\u003cli\u003eV. A. Flores, P. A. Delis, R. Mamillapalli\u003cem\u003e et al.\u003c/em\u003e, Use of AMD3100 for bone marrow-derived mesenchymal stem cell mobilization in the treatment of murine Asherman\u0026apos;s syndrome. \u003cem\u003eF S Sci\u003c/em\u003e\u003cstrong\u003e6\u003c/strong\u003e, 475-482 (2025).doi: 10.1016/j.xfss.2025.08.003.\u003c/li\u003e\n\u003cli\u003eA. B. Hooker, R. A. de Leeuw, J. W. R. Twisk\u003cem\u003e et al.\u003c/em\u003e, Reproductive performance of women with and without intrauterine adhesions following recurrent dilatation and curettage for miscarriage: long-term follow-up of a randomized controlled trial. \u003cem\u003eHum Reprod\u003c/em\u003e\u003cstrong\u003e36\u003c/strong\u003e, 70-81 (2021).doi: 10.1093/humrep/deaa289.\u003c/li\u003e\n\u003cli\u003eY. Chen, Y. Wang, Y. Zhao\u003cem\u003e et al.\u003c/em\u003e, Clinical efficacy of hysteroscopic adhesiolysis combined with periodic balloon dilation for intrauterine adhesion in IVF treatment. \u003cem\u003eFront Endocrinol (Lausanne)\u003c/em\u003e\u003cstrong\u003e14\u003c/strong\u003e, 1236447 (2023).doi: 10.3389/fendo.2023.1236447.\u003c/li\u003e\n\u003cli\u003eJ. E. Okohue, N. Ameh, A. Adewole, Severity of intrauterine adhesions and pregnancy success rates after treatment: Comparison of adhesions obtained from open myomectomy versus uterine curettage. \u003cem\u003eAfr J Reprod Health\u003c/em\u003e\u003cstrong\u003e26\u003c/strong\u003e, 90-96 (2022).doi: 10.29063/ajrh2022/v26i12.10.\u003c/li\u003e\n\u003cli\u003eG. Armstrong, J. Abbott, R. Deans, Fertility and Obstetric Outcomes in Asherman Syndrome: Assessing the Impact of Hyaluronic Acid Post-Hysteroscopic Adhesiolysis. \u003cem\u003eAust N Z J Obstet Gynaecol\u003c/em\u003e, (2025).doi: 10.1111/ajo.70071.\u003c/li\u003e\n\u003cli\u003eP. Capmas, A. Mihalache, L. Duminil\u003cem\u003e et al.\u003c/em\u003e, Intrauterine adhesions: What is the pregnancy rate after hysteroscopic management? \u003cem\u003eJ Gynecol Obstet Hum Reprod\u003c/em\u003e\u003cstrong\u003e49\u003c/strong\u003e, 101797 (2020).doi: 10.1016/j.jogoh.2020.101797.\u003c/li\u003e\n\u003cli\u003eH. L. Fan, X. X. Wu, H. C. Wei\u003cem\u003e et al.\u003c/em\u003e, Clinical efficacy of intrauterine platelet-rich plasma infusion in endometrial regeneration after hysteroscopic adhesiolysis: A retrospective cohort study. \u003cem\u003eMedicine (Baltimore)\u003c/em\u003e\u003cstrong\u003e104\u003c/strong\u003e, e43754 (2025).doi: 10.1097/md.0000000000043754.\u003c/li\u003e\n\u003cli\u003eQ. Feng, B. Gao, H. Huang\u003cem\u003e et al.\u003c/em\u003e, Obstetrical outcome in the third trimester after hysteroscopic adhesiolysis. \u003cem\u003eAnn Transl Med\u003c/em\u003e\u003cstrong\u003e8\u003c/strong\u003e, 51 (2020).doi: 10.21037/atm.2019.09.123.\u003c/li\u003e\n\u003cli\u003eL. Gabriel, L. Ederhof, U. Fellmann\u003cem\u003e et al.\u003c/em\u003e, Surgical uterus-preserving therapy after uterine rupture and haemorrhage due to placenta percreta in the first trimester following embolisation of the uterine arteries and B-Lynch suture in a previous pregnancy. \u003cem\u003eBMJ Case Rep\u003c/em\u003e\u003cstrong\u003e15\u003c/strong\u003e, (2022).doi: 10.1136/bcr-2022-250247.\u003c/li\u003e\n\u003cli\u003eY. Zhang, Y. Zhu, B. Ge\u003cem\u003e et al.\u003c/em\u003e, Reproductive outcome of hysteroscopic metroplasty for women with T-shaped uterus: a retrospective study. \u003cem\u003eReprod Health\u003c/em\u003e\u003cstrong\u003e19\u003c/strong\u003e, 78 (2022).doi: 10.1186/s12978-022-01381-2.\u003c/li\u003e\n\u003cli\u003eY. Wang, L. L. Yin, X. F. Sun\u003cem\u003e et al.\u003c/em\u003e, Retrospective analysis of autologous bone marrow mesenchymal stem cells as adjuvant therapy in recurrent intrauterine adhesions. \u003cem\u003eArch Gynecol Obstet\u003c/em\u003e\u003cstrong\u003e311\u003c/strong\u003e, 789-799 (2025).doi: 10.1007/s00404-025-07952-5.\u003c/li\u003e\n\u003cli\u003eT. Wu, T. Fang, Y. Dong\u003cem\u003e et al.\u003c/em\u003e, Comparison of Secondary Prevention Following Hysteroscopic Adhesiolysis in the Improvement of Reproductive Outcomes: A Retrospective Cohort Study. \u003cem\u003eJ Clin Med\u003c/em\u003e\u003cstrong\u003e13\u003c/strong\u003e, (2023).doi: 10.3390/jcm13010073.\u003c/li\u003e\n\u003cli\u003eD. Sun, X. Mao, A. Zhang\u003cem\u003e et al.\u003c/em\u003e, Pregnancy Patterns Impact Live Birth Rate for Patients With Intrauterine Adhesions After Hysteroscopic Adhesiolysis: A Retrospective Cohort Study. \u003cem\u003eFront Physiol\u003c/em\u003e\u003cstrong\u003e13\u003c/strong\u003e, 822845 (2022).doi: 10.3389/fphys.2022.822845.\u003c/li\u003e\n\u003cli\u003eD. Sun, X. Zhao, H. Huang\u003cem\u003e et al.\u003c/em\u003e, In vitro fertilization and embryo transfer may improve live birth rate for patients with intrauterine adhesions after hysteroscopic adhesiolysis. \u003cem\u003eZhong Nan Da Xue Xue Bao Yi Xue Ban\u003c/em\u003e\u003cstrong\u003e47\u003c/strong\u003e, 1559-1567 (2022).doi: 10.11817/j.issn.1672-7347.2022.220546.\u003c/li\u003e\n\u003cli\u003eX. Zhao, A. Zhang, B. Gao\u003cem\u003e et al.\u003c/em\u003e, Cold scissors ploughing technique in hysteroscopic adhesiolysis: a comparative study. \u003cem\u003eAnn Transl Med\u003c/em\u003e\u003cstrong\u003e8\u003c/strong\u003e, 50 (2020).doi: 10.21037/atm.2019.11.136.\u003c/li\u003e\n\u003cli\u003eJ. Zhang, From Adhesions to Conception: A Case Study on Platelet-Rich Plasma\u0026apos;s Role in Gynecologic Recovery. Cureus 17, e86968 (2025).doi: 10.7759/cureus.86968.\u003c/li\u003e\n\u003cli\u003eB. Li, H. Duan, S. Wang et al., Hierarchical cluster analysis in the study of the effect of cytokine expression patterns on endometrial repair and receptivity after hysteroscopic adhesiolysis. Ann Transl Med 9, 746 (2021).doi: 10.21037/atm-21-195.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"european-journal-of-medical-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ejmr","sideBox":"Learn more about [European Journal of Medical Research](http://eurjmedres.biomedcentral.com)","snPcode":"40001","submissionUrl":"https://submission.nature.com/new-submission/40001/3","title":"European Journal of Medical Research","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Intrauterine adhesions, Asherman syndrome, hysteroscopic adhesiolysis, cold micro-scissors, hysteroscopic morcellation/IBS","lastPublishedDoi":"10.21203/rs.3.rs-8452541/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8452541/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cb\u003eObjective\u003c/b\u003e\u003c/p\u003e \u003cp\u003eTo evaluate the clinical efficacy and safety of hysteroscopic cold micro-scissors combined with an Intrauterine Bigatti Shaver (IBS) for the treatment of moderate to severe intrauterine adhesions (IUA), compared with hysteroscopic adhesiolysis using cold micro-scissors alone.\u003c/p\u003e\u003cp\u003e\u003cb\u003eMethods\u003c/b\u003e\u003c/p\u003e \u003cp\u003eThis prospective, single-center, randomized controlled trial enrolled women aged 18\u0026ndash;45 years with moderate to severe IUA (AFS score\u0026thinsp;\u0026ge;\u0026thinsp;5) between January 2023 and June 2025.A total of 133 participants were randomized 1:1 to a Combined Group receiving cold micro-scissors plus a tissue removal IBS (n\u0026thinsp;=\u0026thinsp;68) or a Control Group receiving cold micro-scissors alone for adhesiolysis (n\u0026thinsp;=\u0026thinsp;65). All patients received standardized postoperative balloon stenting and sequential estrogen\u0026ndash;progestin therapy. The primary endpoint was change in AFS score from baseline to 3 months assessed by blinded hysteroscopists. Secondary outcomes included operative time, blood loss, cavity morphology restoration, menstrual improvement, adhesion recurrence at 6 months, complications, patient satisfaction, and pregnancy outcomes up to 12 months among those desiring fertility.\u003c/p\u003e\u003cp\u003e\u003cb\u003eResults\u003c/b\u003e\u003c/p\u003e \u003cp\u003eAll randomized patients completed follow-up. At 3 months, the Combined Group achieved greater AFS score improvement than the Control Group (5.49\u0026thinsp;\u0026plusmn;\u0026thinsp;1.54 vs 3.91\u0026thinsp;\u0026plusmn;\u0026thinsp;1.63; P\u0026thinsp;\u0026lt;\u0026thinsp;0.001; Cohen\u0026rsquo;s d\u0026thinsp;=\u0026thinsp;1.00). Operation time was slightly longer in the Combined Group (38.7\u0026thinsp;\u0026plusmn;\u0026thinsp;10.1 vs 34.8\u0026thinsp;\u0026plusmn;\u0026thinsp;10.2 min; P\u0026thinsp;=\u0026thinsp;0.007), while blood loss was significantly lower (median 10.2 vs 22.6 mL; P\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Menstrual improvement was higher in the Combined Group (90.2% vs 64.8%; P\u0026thinsp;=\u0026thinsp;0.002), and normal uterine cavity morphology was more frequent (70.6% vs 46.2%; P\u0026thinsp;=\u0026thinsp;0.034). Overall complications (7.4% vs 29.2%; P\u0026thinsp;=\u0026thinsp;0.001) and adhesion recurrence at 6 months (7.4% vs 26.2%; P\u0026thinsp;=\u0026thinsp;0.007) were reduced in the Combined Group. Patient satisfaction was higher (8.0\u0026thinsp;\u0026plusmn;\u0026thinsp;1.0 vs 7.3\u0026thinsp;\u0026plusmn;\u0026thinsp;1.2; P\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Among participants with fertility desire, pregnancy rates at 12 months were 49.0% vs 30.6% (P\u0026thinsp;=\u0026thinsp;0.099).\u003c/p\u003e\u003cp\u003e\u003cb\u003eConclusions\u003c/b\u003e\u003c/p\u003e \u003cp\u003eHysteroscopic micro-scissors combined with an IBS provides superior short-term anatomic restoration and symptom improvement with a lower complication and recurrence profile compared with micro-scissors alone in moderate to severe IUA, with a favorable trend toward improved pregnancy outcomes. These findings support broader adoption and multicenter validation of this endometrium-preserving approach.\u003c/p\u003e","manuscriptTitle":"Clinical Efficacy Research on the Efficacy and Safety of Hysteroscopic Micro-scissors Combined with a Intrauterine Bigatti Shaver for Treating Moderate to Severe Intrauterine Adhesions","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-01-22 08:45:17","doi":"10.21203/rs.3.rs-8452541/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-03-04T00:25:30+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-09T23:16:25+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-08T13:45:39+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-02T05:15:30+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-01-30T08:42:12+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"229071832469383907599048890374447610977","date":"2026-01-28T08:59:33+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-01-27T16:49:00+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-01-26T12:32:19+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"270822402859057995439089541390832695338","date":"2026-01-22T20:43:51+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"172231561529516503148508467477115710285","date":"2026-01-22T14:21:26+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"272813645415169005766785955390239539435","date":"2026-01-20T22:37:24+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"181919047663133297526680955159702578764","date":"2026-01-20T18:37:40+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"243638277470988914802203750054068979720","date":"2026-01-20T14:41:08+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-01-20T14:15:22+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-12-30T10:19:15+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-12-30T10:13:37+00:00","index":"","fulltext":""},{"type":"submitted","content":"European Journal of Medical Research","date":"2025-12-26T06:10:00+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"european-journal-of-medical-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ejmr","sideBox":"Learn more about [European Journal of Medical Research](http://eurjmedres.biomedcentral.com)","snPcode":"40001","submissionUrl":"https://submission.nature.com/new-submission/40001/3","title":"European Journal of Medical Research","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"80fe71eb-2aa8-40b5-a64b-9698e40ab954","owner":[],"postedDate":"January 22nd, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-04-29T02:38:27+00:00","versionOfRecord":[],"versionCreatedAt":"2026-01-22 08:45:17","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8452541","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8452541","identity":"rs-8452541","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}