Article| Volume 46, ISSUE 6, P965-972, June 2023

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An XGBoost predictive model of ongoing pregnancy in patients following hysteroscopic adhesiolysis

Published:January 30, 2023DOI:


      Research question

      What are the factors influencing the fertility of patients with intrauterine adhesions (IUA) after hysteroscopic adhesiolysis and which assessment system is more efficient in predicting post-operative ongoing pregnancy?


      The clinical information of 369 individuals diagnosed with and treated for IUA were obtained from the Multicentre Prospective Clinical Database for the Construction of Predictive Models on Risk of Intrauterine Adhesion (NCT05381376) and randomly divided into the training and validation cohorts. A univariate analysis was performed to identify relevant clinical indicators, followed by a least absolute shrinkage and selection operator (LASSO) regression for regularization and SHapley Additive exPlanation (SHAP) for extreme gradient boosting (XGBoost) predictive model visualization. Finally, receiver operating characteristic (ROC) curves were constructed to assess the model's efficiency.


      Univariate analysis and LASSO regression demonstrated that 12 clinical indicators were significantly associated with post-operative ongoing pregnancy in IUA patients. SHAP visualization indicated that post-operative Fallopian tube ostia, blood supply, uterine cavity shape and age had the highest significance. The area under the ROC curve (AUC) of the XGBoost model in the training and validation cohorts was 0.987 (95% CI 0.979–0.996) and 0.985 (95% CI 0.967–1), respectively. These values were significantly higher than those of the American Fertility Society (AFS) classification, the Chinese Society for Gynecological Endoscopy (CSGE) classification and endometrial thickness (all P < 0.001).


      The XGBoost model had higher accuracy in predicting post-operative reproductive outcomes in IUA patients. Clinically, the model may be useful for managing and categorizing IUA and determining optimal action to aid in pregnancy.


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        • Wamsteker K.
        • De Blok S.J.
        Diagnostic hysteroscopy: technique and documentation.
        in: Sutton C. Diamon M. Endoscopic Surgery for Gynecologists. Lippincott Williams & Wilkins Publishers, New York1995: 263-276
        • Bhandari S.
        • Bhave P.
        • Ganguly I.
        • Baxi A.
        • Agarwal P.
        Reproductive outcome of patients with Asherman's syndrome: a SAIMS experience.
        J. Reprod. Infertil. 2015; 16: 229-235
        • Cao M.
        • Pan Y.
        • Zhang Q.
        • You D.
        • Feng S.
        • Liu Z
        Predictive value of live birth rate based on different intrauterine adhesion evaluation systems following TCRA.
        Reprod. Biol. Endocrinol. 2021; 19: 13
        • Chen L.
        • Zhang H.
        • Wang Q.
        • Xie F.
        • Gao S.
        • Song Y.
        • Dong J.
        • Feng H.
        • Xie K.
        • Sui L.
        Reproductive outcomes in patients with intrauterine adhesions following hysteroscopic adhesiolysis: experience from the largest women's hospital in China.
        J. Minim. Invasive Gynecol. 2017; 24: 299-304
        • Chinese Society for Gynecological Endoscopy
        [Expert consensus on the diagnosis and management of intrauterine adhesions in China].
        Zhonghua Fu Chan Ke Za Zhi. 2015; 50: 881-887
        • Deans R.
        • Vancaillie T.
        • Ledger W.
        • Liu J.
        • Abbott J.A
        Live birth rate and obstetric complications following the hysteroscopicmanagement of intrauterine adhesions including Asherman syndrome.
        Hum. Reprod. 2018; 33: 1847-1853
        • Di Guardo F.
        • Della Corte L.
        • Vilos G.A.
        • Carugno J.
        • Török P.
        • Giampaolino P.
        • Manchanda R.
        • Vitale S.G.
        Evaluation and treatment of infertile women with Asherman syndrome: an updated review focusing on the role of hysteroscopy.
        Reprod. Biomed. Online. 2020; 41: 55-61
        • Dreisler E.
        • Kjer J.J.
        Asherman's syndrome: current perspectives on diagnosis and management.
        Int. J. Womens Health. 2019; 11: 191-198
        • Fernandez H.
        • Al-Najjar F.
        • Chauveaud-Lambling A.
        • Frydman R.
        • Gervaise A.
        Fertility after treatment of Asherman's syndrome stage 3 and 4.
        J. Minim. Invasive Gynecol. 2006; 13: 398-402
        • Friedler S.
        • Margalioth E.J.
        • Kafka I.
        • Yaffe H
        Incidence of post-abortion intra-uterine adhesions evaluated by hysteroscopy – a prospective study.
        Hum. Reprod. 1993; 8: 442-444
        • Guo E.J.
        • Chung J.P.W.
        • Poon L.C.Y.
        • Li T.C.
        Reproductive outcomes after surgical treatment of Asherman syndrome: a systematic review.
        Best Pract. Res. Clin Obstet. Gynaecol. 2019; 59: 98-114
        • Handelman G.S.
        • Kok H.K.
        • Chandra R.V.
        • Razavi A.H.
        • Lee M.J.
        • Asadi H.
        eDoctor: machine learning and the future of medicine.
        J. intern. Med. 2018; 284: 603-619
        • Hooker A.B.
        • de Leeuw R.A.
        • Twisk J.W.R.
        • Brölmann H.A.M.
        • Huirne J.A.F
        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. 2021; 36: 70-81
        • Jiang X.
        • Chen X.
        • Li J.
        • Wang W.
        • Li J
        Clinical application of three-dimensional transvaginal ultrasonography in the diagnosis of intrauterine adhesions.
        J. Int. Med. Res. 2021; 493000605211024520
        • Lee W.L.
        • Liu C.H.
        • Cheng M.
        • Chang W.H.
        • Liu W.M.
        • Wang P.H.
        Focus on the primary prevention of intrauterine adhesions: current concept and vision.
        Int. J. Mol. Sci. 2021; 22: 5175
        • Li B.
        • Duan H.
        • Wang S.
        • Wu J.
        • Li Y
        Gradient boosting machine learning model for defective endometrial receptivity prediction by macrophage–endometrium interaction modules.
        Front. Immunol. 2022; 13842607
        • Li B.
        • Zhang Q.
        • Sun J.
        • Lai D
        Human amniotic epithelial cells improve fertility in an intrauterine adhesion mouse model.
        Stem Cell Res. Ther. 2019; 10: 257
        • Lo S.T.
        • Ramsay P.
        • Pierson R.
        • Manconi F.
        • Munro M.G.
        • Fraser I.S
        Endometrial thickness measured by ultrasound scan in women with uterine outlet obstruction due to intrauterine or upper cervical adhesions.
        Hum. Reprod. 2008; 23: 306-309
        • Luo H.
        • Xu G.
        • Li C.
        • He L.
        • Luo L.
        • Wang Z.
        • Jing B.
        • Deng Y.
        • Jin Y.
        • Li Y.
        • Li B.
        • Tan W.
        • He C.
        • Seeruttun S.R.
        • Wu Q.
        • Huang J.
        • Huang D.W.
        • Chen B.
        • Lin S.B.
        • Chen Q.M.
        • Yuan C.M.
        • Chen H.X.
        • Pu H.Y.
        • Zhou F.
        • He Y.
        • Xu R.H.
        Real-time artificial intelligence for detection of upper gastrointestinal cancer by endoscopy: a multicentre, case-control, diagnostic study.
        Lancet Oncol. 2019; 20: 1645-1654
        • Malhotra N.
        • Bahadur A.
        • Kalaivani M.
        • Mittal S
        Changes in endometrial receptivity in women with Asherman's syndrome undergoing hysteroscopic adhesiolysis.
        Arch. Gynecol. Obstet. 2012; 286: 525-530
        • March C.M.
        Management of Asherman's syndrome.
        Reprod Biomed Online. 2011; 23: 63-76
        • Olawale B.B.
        • Ademola A.O.
        • Gbadebo A.G.
        Tubal abnormalities in patients with intrauterine adhesion: evaluation using hysterosalpingography.
        Ann. Afr. Med. 2014; 13: 179-183
        • Park M.Y.
        • Hastie T
        Penalized logistic regression for detecting gene interactions.
        Biostatistics. 2008; 9: 30-50
        • Roy K.K.
        • Baruah J.
        • Sharma J.B.
        • Kumar S.
        • Kachawa G.
        • Singh N
        Reproductive outcome following hysteroscopic adhesiolysis in patients with infertility due to Asherman's syndrome.
        Arch. Gynecol. Obstet. 2010; 281: 355-361
        • Schild R.L.
        • Knobloch C.
        • Dorn C.
        • Fimmers R.
        • van der Ven H.
        • Hansmann M.
        Endometrial receptivity in an in vitro fertilization program as assessed by spiral artery blood flow,endometrial thickness, endometrial volume, and uterine artery blood flow.
        Fertil. Steril. 2001; 75: 361-366
        • Sharma J.B.
        • Roy K.K.
        • Pushparaj M.
        • Gupta N.
        • Jain S.K.
        • Malhotra N.
        • Mittal S.
        Genital tuberculosis: an important cause of Asherman's syndrome in India.
        Arch. Gynecol. Obstet. 2008; 277: 37-41
        • Shen H.
        • Cai M.
        • Chen T.
        • Zheng D.
        • Huang S.
        • Zhou M.
        • He W.
        • Li Y.
        • Tan Q
        Factors affecting the success of fallopian tube recanalization in treatment of tubal obstructive infertility.
        J. Int. Med. Res. 2020; 48300060520979218
        • Shen M.
        • Duan H.
        • Lv R.
        • Lv C.
        Efficacy of autologous platelet-rich plasma in preventing adhesion reformation following hysteroscopic adhesiolysis: a randomized controlled trial.
        Reprod. Biomed. Online. 2022; 45: 1189-1196
        • Smit J.G.
        • Kasius J.C.
        • Eijkemans M.J.C.
        • Koks C.A.M.
        • van Golde R.
        • Nap A.W.
        • Scheffer G.J.
        • Manger P.A.P.
        • Hoek A.
        • Schoot B.C.
        • van Heusden A.M.
        • Kuchenbecker W.K.H.
        • Perquin D.A.M.
        • Fleischer K.
        • Kaaijk E.M.
        • Sluijmer A.
        • Friederich J.
        • Dykgraaf R.H.M.
        • van Hooff M.
        • Louwe L.A.
        • Kwee J.
        • de Koning C.H.
        • Janssen I.
        • Mol F.
        • Mol B.W.J.
        • Broekmans F.J.M.
        • Torrance H.L.
        Hysteroscopy before in-vitro fertilisation (inSIGHT): a multicentre, randomised controlled trial.
        Lancet. 2016; 387: 2622-2629
        • Sun D.
        • Mao X.
        • Zhang A.
        • Gao B.
        • Huang H.
        • Burjoo A.
        • Xu D.
        • Zhao X.
        Pregnancy patterns impact live birth rate for patients with intrauterine adhesions after hysteroscopic adhesiolysis: a retrospective cohort study.
        Front. Physiol. 2022; 13822845
        • The American Fertility Society
        The American Fertility Society classifications of adnexal adhesions, distal tubal occlusion, tubal occlusion secondary to tubal ligation, tubal pregnancies, müllerian anomalies and intrauterine adhesions.
        Fertil. Steril. 1988; 49: 944-955
        • Xu J.
        • Zhang S.
        • Jin L.
        • Mao Y.
        • Shi J.
        • Huang R.
        • Han X.
        • Liang X.
        • Zhang C.
        The effects of endometrial thickness on pregnancy outcomes of fresh IVF/ICSI embryo transfer cycles: an analysis of over 40,000 cycles among five reproductive centers in China.
        Front. Endocrinol. (Lausanne). 2021; 12788706
        • Yu D.
        • Li T.C.
        • Xia E.
        • Huang X.
        • Liu Y.
        • Peng X
        Factors affecting reproductive outcome of hysteroscopic adhesiolysis for Asherman's syndrome.
        Fertil. Steril. 2008; 89: 715-722
        • Yu D.
        • Wong Y.M.
        • Cheong Y.
        • Xia E.
        • Li T.C.
        Asherman syndrome – one century later.
        Fertil. Steril. 2008; 89: 759-779
        • Zhao J.
        • Chen Q.
        • Cai D.
        • Duan Z.
        • Li X.
        • Xue X
        Dominant factors affecting reproductive outcomes of fertility-desiring young women with intrauterine adhesions.
        Arch. Gynecol. Obstet. 2017; 295: 923-927
        • Zhao J.
        • Zhang Q.
        • Wang Y.
        • Li Y.
        Endometrial pattern, thickness and growth in predicting pregnancy outcome following 3319 IVF cycle.
        Reprod. Biomed. Online. 2014; 29: 291-298
        • Zhao X.
        • Liu Y.
        • Zhang A.
        • Gao B.
        • Feng Q.
        • Huang H.
        • Zhu X.
        • Sun X.
        • Xu D
        Logistic regression analyses of factors affecting fertility of intrauterine adhesions patients.
        Ann. Transl. Med. 2020; 8: 49
        • Zhu R.
        • Duan H.
        • Wang S.
        • Gan L.
        • Xu Q.
        • Li J.
        Decision tree analysis: a retrospective analysis of postoperative recurrence of adhesions in patients with moderate-to-severe intrauterine.
        Biomed. Res. Int. 2019; 20197391965


      Hua Duan is the Director of the Department of Minimally Invasive Gynecology, Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing, China. She is also President of the Gynecologic Endoscopy Training Institute of the Chinese Medical Doctor Association, and Vice-President of the Chinese Society of Gynecology Endoscopy (CSGE).
      Key message
      This study found 12 clinical indicators that significantly influence the fertility of patients with intrauterine adhesions following hysteroscopic adhesiolysis. An XGBoost model was constructed; these have excellent clinical value in predicting post-operative ongoing pregnancy compared to AFS and CSGE classifications and endometrial thickness.