Visualized hysteroscopic artificial intelligence fertility assessment system for endometrial injury: an image-deep-learning study

Asherman’s syndrome (AS) is a significant cause of subfertility in women from developing countries. Over 80% of AS cases in these regions are linked to dilation and curettage (D&C) procedures following pregnancy. The incidence of AS in patients with infertility and recurrent miscarriage can be as high as 10%, while the pregnancy rate in cases of moderate to severe adhesions can be as low as 34%. We aimed to establish a hysteroscopic artificial intelligence system using image-deep-learning algorithms for fertility assessment. This diagnostic study included 555 cases with 4922 hysteroscopic images from a Chinese intrauterine adhesions cohort clinical database (NCT05381376). The study evaluated two image-deep-learning algorithms’ effectiveness in predicting pregnancy within one year, using AUCs and decision curve analysis. The models’ performance was evaluated for two-year prediction via concordance index and cumulative time-dependent ROC. A quantifiable visualization panel of the system was established. The proportional hazard CNN system accurately predicted conception, with AUCs of 0.982, 0.992, and 0.990 in three randomly assigned datasets, superior to the InceptionV3 framework, and achieved a net benefit of 69.4% for subfertility assessment. The system fitted well with c-indexes of 0.920–0.940 and was time-stable. The quantifiable visualization panel displayed four intrauterine pathologies intuitively. The performance was comparable to senior hysteroscopists, with a kappa value of 0.84–0.89. The CNN based on the proportional hazard approach accurately assesses fertility postoperatively. The quantifiable visualization panel could assist in intrauterine pathologies assessment, optimize treatment strategies, and achieve individualized and cost-efficient practices.