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BMC Women’s Health
Yangmo decoction versus hyaluronic acid
gel inwomen withintrauterine re-adhesion
afterhysteroscopic adhesiolysis: aretrospective
ecacy andsafety analysis
Jiaxin Dan1 and Yi Cao1*
Abstract
Background Hysteroscopic adhesiolysis is the preferred primary method for intrauterine adhesion. However, there
is about a 60% of chance of re-adhesion after surgery. The objectives of the study were to evaluate the efficacy
and safety of Yangmo decoction as a secondary treatment in preventing intrauterine re-adhesion against those
of hyaluronic acid gel.
Methods Women received oral Yangmo decoction (YD cohort, n = 105) or intrauterine hyaluronic acid gel (HA
cohort, n = 125) or did not receive secondary re-adhesion prevention treatments (EP cohort, n = 165) after hystero-
scopic adhesiolysis for 6 months. In addition, all women have received 3 mg of oral estrogen and 20 mg oral pro-
gesterone combination after hysteroscopic adhesiolysis for 3 months. Intrauterine re-adhesion after hysteroscopic
adhesiolysis after 6 months with or without secondary treatment(s) was detected using hysteroscopy. The extent
of the cavity, type of adhesion, and the menstrual pattern were included to define the American Fertility Society clas-
sification of intrauterine re-adhesions (AFS) score.
Results Fewer numbers of women suffered from intrauterine re-adhesion after hysteroscopic adhesiolysis in the YD
cohort than those of the HA (15(14%) vs. 40(32%), p = 0.0019) and the EP (15(14%) vs. 58(35%). p = 0.0001) cohor ts.
Among women who developed intrauterine re-adhesion, AFS score was fewer for women of the YD cohort
than those of HA (2(2–1) vs. 4(4–3), p < 0.001) and the EP (2(2–1) vs. 4(4–4), p < 0.001) cohorts. AFS score after surgery
was fewer for women of the HA cohort than those of the EP cohort (p < 0.05). Higher numbers of women of the YD
cohort retained pregnancies after 6-months of treatment than those of the HA (55(52%) vs. 45(36%), p = 0.0161)
and EP (55(52%) vs. 35(21%), p < 0.0001) cohorts. Among women who develop re-adhesion, 10(10%) women
of the YD cohort only had successful pregnancies.
Conclusions Yangmo decoction for 6 months after hysteroscopic adhesiolysis can reduce AFS score, prevent intrau-
terine re-adhesion, and increases the chances of successful pregnancies of women.
Level ofevidence IV.
Technical Ecacy Stage 5.
Keywords Amenorrhea, Hormone, Hyaluronic acid, Hysteroscopic adhesiolysis, Hysteroscopy, Yangmo decoction
*Correspondence:
Yi Cao
js202037@163.com
Full list of author information is available at the end of the article
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Page 2 of 8
Danand Cao BMC Women’s Health (2023) 23:480
Background
Intrauterine adhesions (Asherman’s syndrome) have
resulted from lesions of the endothelial basement that
is caused by various reasons, for example, intrauterine
operations and/ or infections [1]. Due to the surgical
repair process, the endometrium forms scars and adhe-
sions in the uterine cavity that cause an abnormal uter-
ine morphology [2, 3]. ere are several other clinical
manifestations of intrauterine adhesion, for example,
recurrent miscarriage, menstrual reduction, amenor-
rhea (abnormal menstrual), infertility, and recurrent
lower abdominal pain those are serious issues in wom-
en’s health [4]. Hysteroscopic adhesiolysis is the pre-
ferred primary method for the treatment of intrauterine
adhesion. However, there is about a 60% of chance of
intrauterine re-adhesion after surgery (hysteroscopic
adhesiolysis) [5]. It is necessary to control intrauterine
re-adhesion after surgery [6–8]. Hormones, intrauter-
ine balloons, amniotic membranes, and intrauterine
devices have a vital role in preventing intrauterine re-
adhesion [9]. However, they have no significant effects
on clinical manifestations of intrauterine re-adhesion
[6–8]. At present, the intrauterine hyaluronic acid gel
is the preferred secondary method of intrauterine re-
adhesions after hysteroscopic adhesiolysis [10, 11]. e
hyaluronic acid gel is well-established for the preven-
tion of re-adhesion after surgery [1, 12]. Oral estrogen
and progesterone combination is the most common
treatment for the prevention of intrauterine re-adhe-
sion after hysteroscopic adhesiolysis but it has limita-
tions that this combination cannot increase the rate
of fertility of victim women [13]. Yangmo decoction
(a traditional Chinese medicine) has better therapeu-
tic action in the treatment of intrauterine re-adhesion
after hysteroscopic adhesiolysis than that of estrogen
and progesterone combination [13, 14]. Yangmo decoc-
tion consists of Sanchi flower, Ginseng flower, Snow
lotus, Daidai flower, Licorice, and so on [13]. Yangmo
decoction is a common and registered treatment for
adhesions prevention in China.
e objectives of the current retrospective study were
to evaluate the effectiveness and safety of oral Yangmo
decoction in preventing intrauterine re-adhesion after
hysteroscopic adhesiolysis (surgery, primary treatment)
against those of intrauterine hyaluronic acid gel in Chi-
nese women.
Methods
Inclusion criteria
A total of 20–40 years of women before hysteroscopic
adhesiolysis desire to have a pregnancy (according to
records of institutes) and who underwent hysteroscopic
adhesiolysis (cutting by scissors) for intrauterine adhe-
sion were included in the study.
Exclusion criteria
Women with heart, liver, and/ or kidney disease(s) and
women with severe motor disabilities were excluded
from the study. Cases of incomplete adhesiolysis were
excluded from the analyses. Allergic to one of component
of Yangmo decoction and hyaluronic acid were excluded
from analyses.
Cohorts
Women who received oral Yangmo decoction after hyst-
eroscopic adhesiolysis for 6 months for secondary treat-
ment of intrauterine re-adhesion [13] were included in
the YD cohort (n = 105). e pharmacological bases,
dosage, and dose are based on empirical bases. Women
who received intrauterine hyaluronic acid gel after hyst-
eroscopic adhesiolysis for 6 months using a 15cm cath-
eter for secondary treatment of intrauterine re-adhesion
[15] were included in the HA cohort (n = 125). Intrau-
terine hyaluronic acid gel was applied on monthly basis.
Women return to the hospital for this treatment. Women
who did not receive secondary re-adhesion prevention
treatments after hysteroscopic adhesiolysis for 6 months
[16] were included in the EP cohort (n = 165). All women
have received 20 mg twice a day cefixime for 4 days after
hysteroscopic adhesiolysis. In addition, all women have
received 3mg of oral estrogen and 20 mg oral proges-
terone combination after hysteroscopic adhesiolysis for
3 months [16]. Selection of treatment was the choice of
women because Chinese rule provides rights to patients
for the selection of Chinese traditional medicine(s) for
their treatment(s) of disease(s).
Outcome measures
Hysteroscopy
Intrauterine re-adhesion after hysteroscopic adhesiolysis
after 6 months with or without secondary treatment(s)
was detected using hysteroscopy. Hysteroscopy was car-
ried out using a hysteroscope, with a light and camera at
the end. e hysteroscope had 3–5mm diameter. Images
were sent to a monitor for diagnosis [17].
The american Fertility Society classication ofintrauterine
adhesions (AFS) score
AFS score was used for classifications of intrauterine re-
adhesion severity. e extent of the cavity, type of adhe-
sion, and the menstrual pattern were included to define
intrauterine adhesion severity. e extent of the cavity,
type of intrauterine adhesion, and the menstrual pat-
tern was graded as per Table1. A score of 1–4 is con-
sidered mild intrauterine re-adhesion, a score of 5–8 is
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Danand Cao BMC Women’s Health (2023) 23:480
considered intrauterine moderate re-adhesion, and a
score of 9 or more is considered severe intrauterine re-
adhesion [9]. e extent of the cavity and type of intrau-
terine adhesion was evaluated using a hysteroscope and
the menstrual pattern was self-reported.
The density ofendometrial glands
e biopsy performed at the base of the nongravid uter-
ine horn and the other biopsy performed from beneath
the conceptus. Computer assisted morphometric analysis
was used to evaluate samples to determine the density of
endometrial glands.
Statistical analysis
InStat 3.01 GraphPad Software, San Diego, CA, USA
was used for statistical analysis purposes. Linear and
ordinal variables are depicted as mean ± standard error
of the mean (SEM), not linear, and ordinal variables are
depicted as median (Q3–Q1), and constant variables are
depicted as frequency (percentages). e chi-square test
with Yate’s corrections (χ2-test) or Fisher’s exact test was
used for the statistical analysis of categorical variables.
Kolmogorov and Smirnov test was used to check the lin-
earity of continuous and ordinal variables. One-way anal-
ysis of variance (ANOVA) was used for linear continuous
and ordinal variables for statistical analysis. Kruskal-Wal-
lis’ test (nonparametric ANOVA) was used for not linear
continuous and ordinal variables for statistical analysis.
Tukey or Dann’s multiple comparison tests were used for
post hoc analysis. Univariate following multivariate analy-
sis was performed for detecting independent parameters
for intrauterine re-adhesion. All results were considered
significant at a 95% confidence interval (Cl) if the p-value
was less than 0.05.
Results
Study population
From January 2019 to 15 January 2021, a total of 401
women underwent hysteroscopic adhesiolysis for
intrauterine adhesion at the First Affiliated Hospital of
Chongqing Medical University, Chongqing, China, and
the referring hospitals. Among them, one woman had
heart disease(s), one woman had liver disease(s), three
women had kidney diseases, and one woman had severe
motor disabilities. erefore, data from these women
(n = 6) were excluded from the analysis. Results of hyst-
eroscopy and the AFS score after surgery of a total of 395
women were included in the analysis. e summary chart
of the study is presented in Fig.1.
Demographical andclinical characters
All cohorts had a mean AFS score of 4 before hystero-
scopic adhesiolysis (Q3–Q1 range: 4–4). Age, body mass
index, before surgery location of intrauterine adhesion,
AFS score (mild intrauterine re-adhesion), and ethnicity
of women were comparable among cohorts (p > 0.05 for
all, Table2). Women were arrived at institute for 2 years
in follow-up time for pregnancy outcomes.
Hysteroscopic adhesiolysis characters
Surgery time, postoperative hysteroscopy observation
room, stays, and total hospital stays of women were com-
parable among cohorts (p > 0.05 for all, Kruskal-Wallis’
test).
Hysteroscopy
Hysteroscopy results after 6 months of treatment(s)
revealed that 15 (14%), 40 (32%), and 58 (35%) women of
the YD, the HA, and the EP cohorts, respectively suffered
from intrauterine re-adhesion after hysteroscopic adhe-
siolysis. Fewer numbers of women suffered from intrau-
terine re-adhesion after hysteroscopic adhesiolysis in
the YD cohort than those of the HA (p = 0.0019, 95% Cl:
0.3364 to 0.8359 (using the approximation of Katz.), Fish-
er’s exact test) and the EP (p = 0.0001, 95% Cl: 0.2794 to
0.7241, Fisher’s exact test) cohorts. ere was no statisti-
cal significance difference between women who suffered
from intrauterine re-adhesion after hysteroscopic adhe-
siolysis between the EP and the HA cohorts (p = 0.6171,
Fisher’s exact test). e details of hysteroscopy results are
reported in Table3.
Obstetrics parameters
A total of 135 (34%) women with successful pregnancies
after 6 months of treatment. Pregnancies were successful
in 55 (52%), 45 (36%), and 35 (21%) women of the YD, the
HA, and the EP cohorts, respectively. Higher numbers
of women in the YD cohort retained pregnancies after
6 months of treatment than those of the HA (p = 0.0161,
Fisher exact test) and EP (p < 0.0001, Fisher exact test)
cohorts. Higher numbers of women in the HA cohort
Table 1 Grading of the extent of the cavity, type of intrauterine
adhesion, and menstrual pattern
1–4: mild re-adhesion, 5–8: moderate re-adhesion, and ≥ 9: severe re-adhesion
Score Extent of cavity Type of
intrauterine
adhesion
Menstrual pattern
1<
1
/
3
Filmy Normal
2
1
/
3
–
2
/
3
Dense filmy Hypomenorrhea
4>
2
/
3
Dense Amenorrhea
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Danand Cao BMC Women’s Health (2023) 23:480
Fig. 1 The summary chart of the study. AFS: American Fertility Society classification of intrauterine adhesions
Table 2 Demographical and clinical characters of women before hysteroscopic adhesiolysis
Variables are depicted as mean ± SEM (standard error of the mean) or median (Q3–Q1) or frequency (percentages)
A p-value less than 0.05 was considered signicant
Df Degree of freedom, N/A Not applicable
Characters Total Cohorts Comparisons
YD HA EP
Secondary re-adhesion preventions Yes/ No Yangmo decoction Intrauterine
hyaluronic acid
gel
None
Numbers of women 395 105 125 165 p-value Df
Age (years) 30.14±0.25 30.77±0.47 29.82±0.48 29.98±0.35 0.2898 (ANOVA) N/A
Body mass index (kg/ m2) 22(23–21) 22(24–21) 22(23–21) 22(23–21) 0.2861 (Kruskal-Wallis’ test) N/A
Before surgery location
of intrauterine adhesion Middle cavity 249(62) 65(62) 79(63) 105(64) 0.8669 (χ2-test) 6
Fundus and cornua 81(21) 21(20) 28(23) 32(19)
Entire cavity 43(11) 11(10) 14(11) 18(11)
Cervico-isthmic 22(6) 8(8) 4(3) 10(6)
Before surgery American Fertility Society clas-
sification of intrauterine adhesions score 4(4–4) 4(4–4) 4(4–4) 4(4–4) 0.161 (Kruskal-Wallis’ test) N/A
Ethnicity Han Chinese 349(88) 96(91) 111(88) 142(86) 0.854 (χ2-test) 6
Mongolian 38(10) 7(7) 11(9) 20(12)
Tibetan 5(1) 1(1) 2(2) 2(1)
Uyghur Muslim 3(1) 1(1) 1(1) 1(1)
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Danand Cao BMC Women’s Health (2023) 23:480
retained pregnancies after 6 months of treatment than
those of the EP cohort (p = 0.0077, Fisher exact test).
Gynecological parameters
Among women who developed intrauterine re-adhesion
after hysteroscopic adhesiolysis, AFS score was fewer for
women of the YD cohort than those of HA (2 (2–1) vs.
4 (4–3), p < 0.001, Kruskal-Wallis’ test/ Dann test) and
the EP (2 (2–1) vs. 4 (4–4), p < 0.001, Kr uskal-Wallis’
test/ Dann test) cohorts. AFS score was fewer for women
of the HA cohort than those of the EP cohort (p < 0.05,
Kruskal-Wallis’ test/ Dann test).
Endometrial thickness was statistically the same
among women of all cohorts. Among women who
develop intrauterine re-adhesion, only 10 (10%) women
of the YD cohort had successful pregnancies after treat-
ment of intrauterine re-adhesion. None of women from
the HA and the EP cohorts had successful pregnancies
after treatment of intrauterine re-adhesion. e den-
sity of endometrial glands was higher in women of the
YD cohort than in the HA and the EP cohorts (p < 0.05
for both, Kruskal-Wallis’ test/ Dann test). e details of
women after hysteroscopic adhesiolysis Table4.
Parameters forintrauterine re-adhesion
Before surgery AFS score was > 5 and before surgery, the
location of intrauterine adhesion at the fundus and cor-
nua, entire cavity, or cervical-isthmic was the independ-
ent parameter of intrauterine re-adhesion. e details of
parameters for intrauterine re-adhesion are presented in
Table5.
Discussion
e study showed the lowest number of women with
intrauterine re-adhesion after hysteroscopic adhesiolysis
if they have taken Yangmo decoction. Traditional Chinese
medicine Yangmo decoction has a superior effect than 3
months of estrogen and progesterone combinations only
[13, 14] because kidney deficiency and blood stasis are
the main reasons for women with intrauterine adhesions,
and the treatment for that is to nourish the kidney and
activate blood circulation [18]. Ingredients of Yangmo
decoction nourish the kidney and activate blood circu-
lation [13]. Yangmo decoction for 6 months can prevent
intrauterine re-adhesion after hysteroscopic adhesiolysis.
e study showed women had comparatively fewer
post-surgery AFS scores if they have taken Yangmo
decoction in cases of intrauterine re-adhesion occur-
rence after hysteroscopic adhesiolysis. e AFS score is
evaluated from the scope, type, and menstrual flow of
intrauterine adhesions [9]. Yangmo decoction improves
menstrual flow and prevents intrauterine re-adhesion
after hysteroscopic adhesiolysis. is would lead to
improving the AFS score of women. e results of the
association of the AFS score of women in the current
study are parallel with those of a retrospective analysis
[13]. Yangmo decoction reduces the AFS score of women
in cases of intrauterine re-adhesion occurrence after hys-
teroscopic adhesiolysis.
e density of endometrial glands was reported higher
in women of the YD cohort. e absence of endome-
trial glands and increased fibrosis are associated with
intrauterine adhesions [19]. e density of endometrial
glands is associated with endometrial functions [20, 21].
Yangmo decoction hinders fibrosis and promotes the
regeneration of endometrial glands.
Only Yangmo decoction was successful in pregnancies
in women with intrauterine re-adhesion that occurred
after hysteroscopic adhesiolysis on treatment. A higher
density of endometrial glands can promote pregnancies
[20, 21]. Yangmo decoction improves the blood supply
and uniform blood flow of the endometrium and uterus
are beneficial to pregnancy outcomes [22]. Yangmo
decoction improves the chances of pregnancies in
women with intrauterine re-adhesion after hysteroscopic
adhesiolysis.
Table 3 Hysteroscopy results
Variables are depicted in frequency (percentages)
χ2-test was used for statistical analysis
A p-value less than 0.05 was considered signicant
DfDegree of freedom
Characters Total Cohorts Comparisons among
cohorts
YD HA EP
Secondary re-adhesion
preventions Yes/ No Yangmo decoction Intrauterine hyaluronic
acid gel None
Numbers of women 395 105 125 165 p-value Df
Intrauterine re-adhesion 113(29) 15(14) 40(32) 58(35) 0.0006 2
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Danand Cao BMC Women’s Health (2023) 23:480
Before surgery, AFS score > 5 was associated with
intrauterine re-adhesion. e results of the association of
AFS score with intrauterine re-adhesion are parallel with
those of a retrospective analysis [13]. e moderate and
severe AFS scores of females have always high intrauter-
ine re-adhesion after surgery [23]. Women with severe or
moderate AFS scores (> 5) have difficulties in resolving
intrauterine adhesion.
Before surgery, the location of intrauterine adhesion at
the fundus and cornua, entire cavity, or cervical-isthmic
was the independent parameter of intrauterine re-adhe-
sion. e results of the association of the original location
of intrauterine adhesion with occurrences of intrauter-
ine re-adhesion are parallel with those of a retrospective
observational study [24]. Besides the extent, the original
location of intrauterine adhesion is also associated with
intrauterine re-adhesion.
Only 34% women reported successful pregnancies after
6 months of treatment. e results of successful preg-
nancies are inconsistent with domestic research [25] and
Table 4 The details of women after hysteroscopic adhesiolysis
Variables are depicted in frequency (percentages) or median (Q3–Q1)
AFS American Fertility Society classication of intrauterine adhesions
A p-value less than 0.05 was considered signicant
Cl Condence Interval, N/A Not applicable
Characters Cohorts Comparisons between
HA and EP
YD HA EP
Secondary
re-adhesion
preventions
Yangmo
decoction Intrauterine
hyaluronic
acid gel
Comparisons between YD
and HA None Comparisons between YD
and EP
Numbers
of women 105 125 p-value Cl 165 p-value Cl p-value Cl
Successful
pregnancies 55(52) 45(36) 0.0161 1.080
to 1.893 35(21) <0.0001 1.650
to 2.933 0.0077 1.140 to 1.913
Numbers
of women
who develop
re-adhesion
15(14) 40(32) 0.0019 0.2794
to 0.7241 58(35) 0.0001 0.2794
to 0.7241 0.6171 N/A
Postoperative
AFS score
of women
who develop
re-adhesion
2(2–1) 4(4–3) <0.001
(Krushal-
Wallis’ test)
N/A 4(4–4) <0.001
(Krushal-
Wallis’ test)
N/A <0.05
(Krushal-
Wallis’ test)
N/A
Successful
pregnancies
after re-
adhesion
10(67) 0(0) <0.0001
(Fisher exact
test)
1.990
to 2.695 0(0) <0.0001
(Fisher exact
test)
5.433
to 29.222 N/A N/A
Endometrial
thickness
(mm)
3(3.4–2.8) 3.45(4.1–
2.85) >0.05 (one-
way ANOVA/
Tukey test)
N/A 3.05(3.5–2.8) >0.05 (one-
way ANOVA/
Tukey test)
N/A >0.05
(one-way
ANOVA/
Tukey test)
N/A
Table 5 Parameters for intrauterine re-adhesion
Multivariate analysis
An odd ratio of more than 1 and a p-value less than 0.05 was considered signicant
Cl Condence Interval
a Responsible parameter for intrauterine re-adhesion
Parameters Odd ratio 95% Cl p-value
Age (<30 years vs. ≥30 years) 0.8951 0.8621–0.9821 0.0821
Before surgery AFS score (>5avs.<5) 1.8521 1.2451–1.9522 0.0412
Before surgery location (other avs. Middle cavity) 1.5222 0.7541–1.8952 0.0221
Body mass index (>23 vs. ≤23) 0.7421 0.6214–0.8241 0.0852
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Page 7 of 8
Danand Cao BMC Women’s Health (2023) 23:480
foreign research [26]. e clinical, demographical, and
operational parameters also affect successful pregnancies
[25]. It is difficult for women for intrauterine adhesion to
return to normal reproductive function.
e study showed that intrauterine hyaluronic acid
gel was not successful to prevent intrauterine re-adhe-
sion, to decrease AFS scores, and to establish fortunate
pregnancies. e obstetrics and gynecological results of
the current study are parallel with those of a trial [27].
e intrauterine hyaluronic acid gel does not aberrantly
reduce the incidence of secondary intrauterine re-adhe-
sion. In the presence of independent parameters for
intrauterine re-adhesion, hyaluronic acid gel would not
much successful to prevent intrauterine re-adhesion.
e limitations of the study, for example, retrospec-
tive analysis with small sample size. In the current study,
hysteroscopy was used instead of hysterosalpingography
for the detection of intrauterine re-adhesion after hyst-
eroscopic adhesiolysis. e possible justification for the
same is that AFS scores would be vigorous if it would
be detected using hysteroscopy. e study is underpow-
ered to detect significant differences for the investigated
parameters because the study did not perform any “a
priori” sample size calculation based on the primary
outcome. Yangmo decocticion is not a registered drug
in EU. In the future, well-designed, carefully conducted
randomized controlled trial are needed, with a particular
focus on the live birth rate after hysteroscopic adhesioly-
sis followed by Yangmo solution and other safety indexes.
Conclusions
According to current study results Yangmo decoction
for 6 months can reduce the American Fertility Society
classification of intrauterine adhesions score and prevent
intrauterine re-adhesion of women after hysteroscopic
adhesiolysis. Yangmo decoction hinders fibrosis and pro-
motes the regeneration of endometrial glands. Yangmo
decoction improves the chances of pregnancies in women
with intrauterine re-adhesion after hysteroscopic adhesi-
olysis. Women with severe or moderate (> 5) American
Fertility Society classification of intrauterine adhesions
score have difficulties in resolving intrauterine adhesion.
Abbreviations
SEM Standard error of the mean
χ2-test Chi-square test
ANOVA Analysis of variance
Cl Confidence Interval
Q3 Third Quartile
Q1 First Quartile
AFS American Fertility Society classification of intrauterine adhesions
YD cohort Women received oral Yangmo decoction after hysteroscopic
adhesiolysis for 6 months
HA cohort Women received intrauterine hyaluronic acid gel after hystero-
scopic adhesiolysis for 6 months using a 15 cm catheter
EP cohort Women did not receive secondary re-adhesion prevention treat-
ments after hysteroscopic adhesiolysis
Acknowledgements
The authors are thankful for the medical and non-medical staff of the First
Affiliated Hospital of Chongqing Medical University, Chongqing, China.
Authors’ contributions
Both authors have read and approved the manuscript for publication. JD was
the project administrator and contributed to the conceptualization, investiga-
tion, supervision, resources, methodology, and literature review of the study.
YC contributed to the literature review, validation, methodology, formal analy-
sis, and data curation of the study, and drafted, and edited the manuscript for
intellectual content. Both authors agree to be accountable for all aspects of
work ensuring integrity and accuracy.
Funding
This research did not receive any specific grant from funding agencies in the
public, commercial, or not-for-profit sectors.
Availability of data and materials
The datasets were used and analyzed during the current study available from
the corresponding author on reasonable request.
Declarations
Ethics approval and consent to participate
The study was approved by the ethics committee of Chongqing Medical
University (approval No. fhCMU dated 17 January 2023) and the gynecological
society of China. The study follows the law of China and the v2008 Declaration
of Helsinki. Informed consent of all subjects and/ or their legal guardian(s)
waived by the ethics committee of the Chongqing Medical University
(because of retrospective analysis).
Consent to participate
Not applicable.
Competing interests
The authors declare no competing interests.
Author details
1 Department of Gynecology of Jinshan Campus, the First Affiliated Hospital
of Chongqing Medical University, No. 1 Youyi Road, Yuzhong District, Chong-
qing 400016, China.
Received: 28 April 2023 Accepted: 10 August 2023
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