A commentary on ‘Cold scissors ploughing technique versus electrosurgical excision for hysteroscopic adhesiolysis: a multicenter randomized controlled trial’

Dear Editor, We read with great interest the recent study by Liu et al, published in the International Journal of Surgery, which compares two methods of hysteroscopic separation in treating intrauterine adhesion (IUA) and improving fertility. It is the first multicenter RCT to compare the efficacy, recurrence rate, and pregnancy outcomes. However, we seek to outline several limitations and considerations in this study, which could significantly improve the quality of this study and its guiding value for clinical practice. 1. Concerns on randomization methods Although the Resman central randomization system was applied, the randomization method was not explicitly described (simple randomization, stratified randomization, block randomization), different randomization methods may contribute to large biases in the results[1]. We suggest adding details such as whether randomization was stratified on the basis of baseline patient characteristics (adhesion severity, age)[2], were provided to ensure balance between groups. 2. Evaluation of exclusion criteria The study population was strictly screened, such as age restricted to 20-40 years, American Fertility Society (AFS) score ≥3, normal ovarian reserve, and patients with a history of multiple surgeries were excluded. However, the recurrence rates of auto-cross-linked hyaluronic acid (ACP) gel and intrauterine Foley balloons in the two groups were still as high as 27.5% and 30.6%. And other literature has reported IUA recurrence rates reach from 30% to 66%[3]. By including only primary patients, the recurrence rate of adhesions in the study sample may be lower than the true data, leading to a bias of the results toward a more optimistic assessment of efficacy. Such exclusion criteria would overestimate the treatment effect in the population, and the conclusions would apply only to lower risk patients. 3. Selection of postoperative adjuvant therapy methods The study applied conventional hormone therapy, ACP gel and a Foley balloon. However, studies have reported that conventional methods do not solve the problem of endometrial regeneration and only result in limited effects and long treatment cycles[4]. Charles et al also pointed out that there are some concerns regarding the use of balloons[5]. Recently, biological barriers such as amniotic membrane, urinary bladder matrix, platelet-rich plasma and small intestine submucosa, have demonstrated significant potential in the treatment of IUAs[4]. Thus, novel intervention methods for people with different degrees of IUA are worth discussing. In conclusion, the effective treatment of IUAs is still a tough and hot research area. The study by Liu et al provides compelling evidence in choosing methods of transcervical resection of adhesions. We believe through these suggestions could enhance the readability and clinical significance of the article, and the implementation of this evidence is a possible IUA management model. Therefore we strongly recommend consideration of our proposed approach.