Exosomes in the management of intrauterine adhesions: a systematic review of regenerative mechanisms and clinical translational evidence

To systematically evaluate current preclinical and clinical evidence on the role of exosomes in the management of intrauterine adhesions (IUAs), with emphasis on regenerative mechanisms, molecular signaling pathways, and translational clinical outcomes. A PRISMA-guided systematic search of PubMed, Scopus, Embase, and Web of Science (inception to October 2025) was conducted to identify preclinical and clinical studies reporting histologic, molecular, or reproductive outcomes related to exosome-based interventions in IUAs. Sixteen studies (14 preclinical and 2 clinical) met the inclusion criteria. Mesenchymal stem cell–derived exosomes were associated with enhanced angiogenesis, epithelial regeneration, and attenuation of fibrosis through pathways including PI3K/AKT, Wnt/β-catenin, and VEGF signaling. Limited early clinical data suggested improvements in endometrial thickness and a potential reduction in adhesion recurrence when exosome-based approaches were used as adjuncts to standard hysteroscopic adhesiolysis. Current evidence indicates that exosomes exhibit regenerative and anti-fibrotic properties relevant to the management of intrauterine adhesions. Nevertheless, heterogeneity in study design and the paucity of robust clinical trials underscore the need for standardized protocols and well-designed randomized controlled studies before clinical implementation can be established.