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Asherman Syndrome: Gradual Lysis of Adhesions

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Video Description

This video demonstrates the patient-centered approach of repeat lysis of adhesions, gradually addressing the challenges of severe Asherman Syndrome.

Presented By

 

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Dr. Craig Morton
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Dr. Ari Sanders

Affiliations

University of Calgary

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What is Asherman Syndrome?

Asherman Syndrome is a rare, acquired condition characterized by the presence of scar tissue, or adhesions, within the uterus. This scarring can lead to the partial or complete obstruction of the uterine cavity and can be associated with menstrual irregularities, reduced fertility, and complications during pregnancy.

  • The syndrome typically results from trauma to the uterine lining (endometrium) caused by surgical procedures such as dilation and curettage (D&C), particularly after a miscarriage or childbirth, or less commonly, from infections or other intrauterine interventions.
  • Women with Asherman Syndrome may experience symptoms like absent, reduced, or irregular menstrual cycles, recurrent miscarriage, and infertility. Some women may not notice any symptoms until they try to conceive.
  • Diagnosis often involves imaging techniques such as hysteroscopy, where a camera is inserted into the uterus to directly visualize the scar tissue, or through ultrasound and hysterosalpingography (HSG), which provides an x-ray view of the uterine cavity.
  • Treatment primarily involves surgical removal of the adhesions under direct visualization with hysteroscopy. Post-surgical management may include hormonal therapy to promote regrowth of the endometrium and prevent reformation of adhesions.
  • The success of treatment depends on the severity of the scarring and the response to surgical and hormonal treatments. While many women see improvements in menstrual function and fertility, others may continue to face challenges, including the risk of recurrent scarring.

This condition underscores the importance of careful surgical techniques and thorough postoperative care in preserving uterine health and function.

What are the Risks of Asherman Syndrome?

The risks of Asherman Syndrome encompass a range of complications primarily related to reproductive health but can also impact overall physical and emotional well-being. Here are some of the key risks associated with this condition:

  • Menstrual Irregularities: One of the most immediate effects of Asherman Syndrome is the disruption of normal menstrual cycles. Women may experience amenorrhea (absence of menstruation), hypomenorrhea (light or scant menstruation), or irregular periods, which can be distressing and may complicate the diagnosis of other conditions.
  • Infertility: The presence of scar tissue within the uterine cavity can significantly impair fertility. The scarring can obstruct the implantation of an embryo or, in some cases, completely prevent the conception of a pregnancy. This can be particularly challenging for women desiring to start or expand their families.
  • Recurrent Miscarriages: Even if pregnancy occurs, Asherman Syndrome can increase the risk of miscarriage. The uterine scarring can interfere with the normal growth and development of the placenta, leading to recurrent pregnancy losses.
  • Obstetric Complications: Women with Asherman Syndrome who become pregnant are at a higher risk for various obstetric complications, including placental abnormalities such as placenta accreta (where the placenta grows too deeply into the uterine wall) and preterm delivery.
  • Increased Surgical Risks: Treatment for Asherman Syndrome typically involves surgical intervention, which carries its own risks such as infection, further scarring, or damage to the surrounding uterine tissue and organs.
  • Emotional and Psychological Impact: The issues related to menstrual irregularities, infertility, and recurrent miscarriages can have significant emotional and psychological impacts, contributing to feelings of anxiety, depression, and reduced quality of life.
  • Post-Treatment Complications: Even after successful treatment, there is a risk of the reformation of adhesions, requiring additional interventions. Continuous monitoring and possibly multiple surgeries may be needed to maintain uterine health.

It is crucial for patients diagnosed with Asherman Syndrome to have a comprehensive treatment plan and follow-up care tailored to their specific condition and reproductive goals. This helps manage the risks effectively and supports overall health and well-being.

Video Transcript: Asherman Syndrome: Gradual Lysis of Adhesions

We present a case of repeat lysis of adhesions for severe Asherman syndrome.

 Our objectives are to demonstrate our experience with repeat procedures for intrauterine adhesions, to review strategies to reduce recurrence of intrauterine adhesions and to review key obstetrical risks for pregnancies following adhesiolysis.

Often used interchangeably, intrauterine adhesions refers to the presence of fibrotic tissue within the uterine cavity, resulting in adherence of opposing surfaces. Asherman syndrome includes the presence of intrauterine adhesions in addition to clinical features such as amenorrhea, hypomenorrhea, subfertility, recurrent pregnancy loss or a history of abnormal placentation.

Synechiae are thought to arise due to traumatisation of an already fragile endometrium. Procedures commonly associated with intrauterine adhesions include postpartum D&C, recurrent therapeutic abortions and D&C for routine products of conception. Caesarean section is also felt to be a risk factor, given the possibility to traumatise the gravid endometrium.

Our case involves a 40-year-old gravida one, para one with no prior history of infertility. She had a Caesarean section at 32 weeks and presented with secondary infertility. Her periods had significantly changed following her Caesarean delivery.

Ultrasound demonstrated a thin endometrium with multiple cystic spaces. Sonohysterogram was attempted, but the catheter could not be advanced through the cervical os. Asherman syndrome was suspected and hysteroscopic adhesiolysis was planned. Other modalities for diagnosis include a hysterosalpingogram and 3D ultrasound.

Initial cavity entry can be challenging as adhesions can involve the upper portion of the cervix. A bimanual exam is paramount prior to commencing. Direct entry into the cervix is preferred to decrease perforation or false passage. In this case, you can see the camera is maintained in a midline orientation. A series of twisting motions with gentle cephalad pressure is used to help traverse the narrow cervix. Additionally, pressurised saline is used to aid with hydrodissection.

 Our preferred approach is to use a 5.5 mm operative hysteroscope and a combination of scissors and graspers. This is preferred over the use of electrosurgery to minimise injury to existing endometrium. In this case, a blinded cavity is encountered. Scissors are used to interrogate the tissue, followed by a push-spread-cut series of movements. Care is taken to minimise axial deviation.

In this video from another case, axis deviation to one side results in perforation. Because there was no suspicion of intraperitoneal injury and the site was haemostatic, the hysteroscope was able to be reoriented and the case finished.

Dissection is carried cephalad towards the fundus and laterally towards the ostia. Dissection is also carried into the lateral walls of the cavity. For mild and moderate disease, these cases can be performed in an outpatient setting, and often with no systemic sedation.

When severe disease is expected, our preference is to perform these in the operating room, as the procedure can be upwards of 30 minutes, and the patient will still get some discomfort if dissection is carried into the innervated myometrium, which helps with identifying and remaining in the appropriate trajectory.

Shown here, vessels indicate entry into the myometrium. Hysteroscopic graspers can be used to extract excess fibrotic tissue. At the end, both tubal ostia should be visible from the internal cervical os.

The rate of recurrence is reported as high as 22% for moderate cases and 65% for severe cases. In order to decrease the rate of recurrence, two important concepts are of interest.

First, the endometrium should be separated to avoid agglutination. Most commonly used and our preferred approach is the placement of an intrauterine Foley catheter for seven days. While evidence is limited, placement of an IUD has also been described.

A less common method is intermittent distension of the cavity every one to two weeks, with office hysteroscopy. A fourth method which has increasing evidence is placement of an adhesion barrier, most commonly hyaluronic acid gel, which is not readily available in Canada at this time.

The second important principle is endometrial regeneration. Because the basalis layer has often been destroyed, regeneration of the endometrium can be challenging. Several approaches have been described. The most common and our preferred is hormone therapy, with an extended treatment of oestrogen followed by progesterone. The use of postoperative amnion grafts have also been described.

Two newer approaches involve the use of platelet-rich plasma or menstrual stem cells. Both of these have promising results in recent small, randomised trials. These products are still experimental. In our experience, endometrial regeneration is cumulative and progressive over the course of multiple procedures.

In patients who are planning pregnancy, sonohysterograms are routinely arranged one to four months following their initial procedure. Shown here is a repeat sonohysterogram for our patient. Shown in yellow is an area of persistent adhesion near the fundus. Shown in red, although less obvious, is limited cavity distension, which suggests persistent adhesions in the lower uterine segment. It is important to note that imaging findings do not always correlate well with hysteroscopic findings.

On second look, the endometrium appears much more healthy, consistent with the progressive regeneration of endometrium. Based on preoperative imaging, lower uterine adhesions are expected. Again, a seemingly short cavity is encountered. The upper border of this is probed with the tip of the hysteroscope, and eventually the fundal portion of the uterine cavity is entered.

Scissors are then used to divide adhesions, both at the fundus and in the lower uterine segment, in order to completely open up the cavity. Notably, at the end of this procedure, there appears to be a much more functional endometrium. A paediatric Foley catheter is then placed at the end of the procedure for seven days, along with 21 days of oestradiol and seven days of medroxyprogesterone acetate.

Three months following the procedure, our patient spontaneously conceived. She is currently at 28 weeks gestation, with a complete anterior placenta previa and no evidence of placenta accreta.

The most common reason for treatment is desired pregnancy. Data on pregnancy outcomes are retrospective and heterogeneous. Clinical pregnancy rates range from 44% up to 64%, and live birth rates range from 62% to 75%. Importantly, there are some high-risk features of these pregnancies, including spontaneous abortion, ectopic pregnancy, mid-trimester loss, and perhaps most importantly, placenta accreta. For these reasons, it is important to involve maternal foetal medicine in the care of patients with previous hysteroscopic adhesiolysis.

In summary, we have presented a case of hysteroscopic adhesiolysis for severe Asherman’s, where a repeat procedure resulted in a good outcome. We have described an approach to optimise success, including direct cervical entry, hydrodistension, gentle interrogation of tissue and awareness of axial deviation. We’ve described approaches to decrease incidence and severity of recurrence by promoting endometrial separation and regeneration.

It’s important to remember for both physicians and patients that persistence pays off, and recurrence should be expected and planned for in severe cases. Finally, pregnancies after hysteroscopic adhesiolysis for severe Asherman’s come with significantly elevated risks, particularly of placenta accreta.