Intercornual Distance and Postoperative Reproductive Outcomes in Moderate-to-Severe Intrauterine Adhesions: A Retrospective Cohort Study

Abstract STUDY QUESTION Does intercornual distance (ICD), as reflected by intrauterine stent size during hysteroscopic adhesiolysis, have an association with reproductive outcomes and provide information for postoperative risk stratification in women with moderate-to-severe intrauterine adhesions? SUMMARY ANSWER A smaller ICD was independently associated with a lower likelihood of clinical pregnancy within one year of the final hysteroscopy and may offer additional information for postoperative risk stratification in women with moderate-to-severe intrauterine adhesions. WHAT IS KNOWN ALREADY Reproductive outcomes following treatment for moderate-to-severe intrauterine adhesions vary considerably. Existing severity classifications offer limited discrimination within this group. The potential association between ICD and postoperative reproductive outcomes has not been systematically evaluated. STUDY DESIGN, SIZE, DURATION Retrospective cohort study conducted at a tertiary academic center from November 2022 to October 2023. A total of 560 women were included, with up to two years of follow-up. PARTICIPANTS/MATERIALS, SETTING, METHODS Retrospective single-center cohort of women aged 18–44 years with moderate-to-severe intrauterine adhesions (American Fertility Society AFS score ≥ 5) undergoing standardized hysteroscopic management with adhesiolysis, intrauterine stent placement, and scheduled second-look hysteroscopy. ICD was reflected by intraoperatively selected stent size, categorized into ordered levels (XXXS–XXXL), and dichotomized using an XS threshold (approximately 20–22 mm). Postoperative ultrasound-derived ICD was analyzed for supportive evaluation. The primary outcome was clinical pregnancy within one year of the final hysteroscopy. Associations were examined using multivariable logistic regression with sensitivity analyses. The incremental predictive value and clinical utility of stent-size classification (≤ XS vs XS) beyond established clinical variables were evaluated using discrimination, calibration, and decision-curve analyses. MAIN RESULTS AND THE ROLE OF CHANCE Women in the ≤ XS group had lower odds of clinical pregnancy within one year of the final hysteroscopy compared with those in the XS group (adjusted odds ratio aOR = 0.447, 95% CI 0.255–0.786; P = 0.005). The association was consistent in sensitivity analyses and when postoperative ultrasound-derived ICD was analyzed as a continuous variable. Although improvements in model discrimination were modest, the difference in the probability of clinical pregnancy between the ≤ XS and XS groups was 21.2% (absolute risk difference ARD = 21.2%, 95% CI 9.6%–32.2%; P 0.001), corresponding to a number needed to benefit (NNB) of 4.7, indicating potential clinical utility for postoperative risk stratification. LIMITATIONS, REASONS FOR CAUTION This single-center retrospective study may limit generalizability and is subject to selection bias and residual confounding. Prospective multicenter validation is required. WIDER IMPLICATIONS OF THE FINDINGS ICD may provide additional information for postoperative risk stratification in women with moderate-to-severe intrauterine adhesions. STUDY FUNDING/COMPETING INTEREST(S) This study was supported by Scientific and Technological project of Furong Laboratory (Gynecological disease and reproductive health) (No.2023SK2109) and Key research project of National Key Clinical Specialties, Health Commission of Hunan Province (Z2023068), China. TRIAL REGISTRATION NUMBER N/A.