Intrauterine adhesions: Adjunctive strategies beyond hysteroscopic lysis and reconstruction

Restoration of the uterine cavity after hysteroscopic adhesiolysis should be evaluated as a combined anatomical and functional endpoint. Anatomical normalization is a necessary prerequisite for implantation, but functional recovery of the endometrium (re-epithelialization, glandular regeneration, vascularization, and hormone responsiveness) is equally critical for reproductive success. Contemporary data show that pregnancy and live birth rates correlate closely with the degree of postoperative cavity restoration, underscoring the prognostic relevance of anatomical repair, while established adjuncts and emerging regenerative therapies are designed to target the biological processes that govern functional endometrial recovery rather than cavity patency alone. In this narrative review, we appraise the current standard of care and the adjuncts proposed to improve it, including postoperative estrogen, mechanical barriers, anti-adhesion gels, platelet-rich plasma, mesenchymal stem cells, exosomes, and bioactive scaffolds. We argue that these interventions should be judged by their ability to achieve durable anatomical restoration coupled with functional endometrial recovery, particularly in moderate-to-severe disease, with reproductive outcomes serving as the ultimate validation. Although biologically plausible and supported by encouraging surrogate and preclinical data, these adjuncts have not yet demonstrated a reproducible improvement in live birth across adequately powered, independently validated trials. We provide a clinically meaningful framework for interpreting current evidence and for guiding future trial design in women with intrauterine adhesions.