Treatment of Asherman’s Syndrome in an Outpatient Hysteroscopy Setting

Table of Contents

• Procedure Summary
• Authors
• Youtube Video
• What is Treatment of Asherman’s Syndrome in an Outpatient Hysteroscopy Setting?
• What are the Risks of Asherman’s Syndrome in an Outpatient Hysteroscopy Setting?
• Video Transcript

Video Description

This video outlines the approach to the hysteroscopic lysis of adhesions performed to surgically manage Asherman’s Syndrome. This video uses case presentations and discusses a case series outlining how to manage this in an outpatient setting.

Presented By

Affiliations

University of Ottawa, The Ottawa Hospital

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What is Treatment of Asherman’s Syndrome in an Outpatient Hysteroscopy Setting?

Treatment of Asherman’s Syndrome in an outpatient hysteroscopy setting involves using a hysteroscope to visualize and remove intrauterine adhesions (scar tissue) that cause menstrual irregularities, infertility, and recurrent pregnancy loss. The procedure is typically performed as follows:

1. Preparation: The patient is given local anesthesia or mild sedation to minimize discomfort. They are positioned in the dorsal lithotomy position.
2. Speculum Insertion: A speculum is inserted into the vagina to access and visualize the cervix.
3. Cervical Dilation: The cervix is gently dilated if necessary to allow the hysteroscope to pass through.
4. Hysteroscope Insertion: The hysteroscope, equipped with a camera and light, is inserted through the cervix into the uterine cavity. Saline or another distension medium is used to expand the uterine cavity for better visualization.
5. Adhesion Removal: Under direct visualization, surgical instruments such as scissors or electrosurgical devices are used to carefully cut and remove the adhesions. The goal is to restore the normal shape and function of the uterine cavity.
6. Post-Procedure Care: After the adhesions are removed, the hysteroscope is withdrawn, and the patient is monitored for a short period before being discharged. Postoperative care may include antibiotics to prevent infection and hormonal therapy to promote healing of the endometrial lining.
7. Follow-Up: A follow-up hysteroscopy may be scheduled to ensure that the uterine cavity has healed properly and that no new adhesions have formed.

This minimally invasive approach allows for effective treatment of Asherman’s Syndrome with a relatively quick recovery time, enabling patients to return home the same day.

What are the Risks Asherman’s Syndrome in an Outpatient Hysteroscopy Setting?

The risks of treating Asherman’s Syndrome in an outpatient hysteroscopy setting include several potential complications related to the procedure itself and the patient’s overall health. Key risks include:

• Uterine Perforation: There is a risk that the hysteroscope or surgical instruments can accidentally create a hole in the uterine wall, which may lead to injury to surrounding organs such as the bladder or bowel.
• Infection: The procedure can introduce bacteria into the uterine cavity, leading to infection. Antibiotics may be prescribed to mitigate this risk.
• Bleeding: Excessive bleeding can occur during or after the procedure, though it is usually minimal. Severe cases may require additional medical intervention.
• Adhesion Recurrence: Despite successful removal of adhesions, there is a risk that they may recur, necessitating further treatment.
• Scarring: In rare cases, the procedure itself can cause additional scarring or exacerbate existing scar tissue.
• Anesthesia Risks: Although local anesthesia or mild sedation is typically used, there are risks associated with anesthesia, including allergic reactions and respiratory issues.
• Fluid Overload: The use of saline or other fluids to distend the uterine cavity can lead to fluid overload or electrolyte imbalances if large volumes are absorbed into the bloodstream.

Patients undergoing outpatient hysteroscopic treatment for Asherman’s Syndrome should be fully informed of these risks and receive comprehensive preoperative and postoperative care to minimize complications and ensure a successful outcome.

Video Transcript: Treatment of Asherman’s Syndrome in an Outpatient Hysteroscopy Setting?

This is a video created by the minimally invasive gynaecology group at the Ottawa Hospital, highlighting a novel management approach to treating Asherman’s syndrome. The objectives of this video are to describe a stepwise approach to treatment of Asherman’s syndrome in an outpatient hysteroscopy setting, to present three cases of hysteroscopic adhesiolysis and to highlight our experience with this management strategy.

Asherman’s syndrome is characterised by the presence of intrauterine synechiae, as well as symptoms such as amenorrhoea, pelvic pain or infertility. Hysteroscopic lysis of adhesions is regarded as the mainstay of treatment and results in high rate of resumption of normal menses. Adhesiolysis does carry a risk of uterine perforation and repeat procedures may be required to achieve sustainable results. Outpatient hysteroscopy is an effective method to evaluate the uterine cavity and treat pathology.

Procedures such as polypectomies and transcervical sterilisation can be performed without regional or general anaesthetic in an ambulatory setting. Hysteroscopic lysis of adhesions in such a setting may offer patients several advantages, including reduced anaesthetic risk and improved post-operative pain control. We employ the following approach when performing outpatient hysteroscopic places of adhesions.

Vaginoscopy is used to attain access to the uterine cavity. Patients are offered several anaesthetic options, including non-steroidal anti-inflammatories or IV sedation. Depending on the location of the adhesions, it may be reasonable to start with blunt dissection, with gentle pushing with the hysteroscope and pressure of the flowing saline to break apart the adhesions. Sharp dissection with scissors is used to break apart denser adhesions.

You must stop and re-evaluate your location within the uterine cavity when the patient experiences sudden increase in pain or if you encountered excess bleeding. We’ll now present several cases of outpatient hysteroscopic adhesiolysis. The first patient is a 33-year-old female, a G2A2, with a history of two dilatation and curettage procedures before, following first trimester losses. She presents with oligomenorrhoea and difficulty conceiving.

Diagnostic hysteroscopy reveals an adhesion in the mid uterus. Micro scissors are introduced through a 5.8 mm operative hysteroscope. These are used to release the adhesions. Further assessment reveals some filmy adhesions near the right cornua, which are also released. At the completion of this case, a normal uterine cavity is seen. The patient conceives three months following treatment and has gone on to have an uneventful term vaginal delivery.

Although this is a low-complexity case, this example highlights the fact that a patient can avoid general or regional anaesthetic for treatment of uterine adhesions. This procedure only took seven minutes to perform and the patient was able to go home shortly after. Our second patient also presents with a similar history of post-partum curettage and subsequent amenorrhoea. Diagnostic hysteroscopy reveals thicker adhesions, in this case, in the mid uterus, resembling a uterine septum.

The micro scissors are used to release these dense adhesions. Pushing and spreading can also be performed using the scissors, as long as one is very cognisant of their location in the uterine cavity. Note that the adhesions are largely avascular and bleeding is not seen. The gentle flow of the saline allows the cavity to open up as the adhesions are released. Avascularity of the adhesions is a key clue to safety.

As the dissection approaches the myometrium layer, we would see increased bleeding. Also, the adhesions are not innervated. And therefore, patients will tolerate sharp adhesiolysis well. However, the myometrium is innervated. And once entered, patients will suddenly experience a sharp increase in pain. These two features are important in mitigating risk of uterine perforation and that it’s imperative to frequently recheck your position in the uterus and re-evaluate your progress.

At the completion of this case, we will see that once the mid uterine adhesions are released, the frontal portion of the endometrium cavity appears normal. For further reassurance, the patient is brought back for a repeat diagnostic hysteroscopy, which is not seen here. And we see maintenance of the normal shape of the uterine cavity. Our final patient is a 35-year-old female, gravida 1, para 1, who had a spontaneous vaginal delivery, complicated by a post-partum haemorrhage, requiring an immediate dilatation and curettage.

She again presents with amenorrhoea, noted after cessation of breastfeeding. Hysteroscopy reveals significant adhesions in this case obstructing the right cornua. Orientation is very difficult in this case. And again, we stress that you should frequently recheck your location within the uterus. Gentle cutting with the micro scissors is systematically performed under direct vision. The hysteroscope is also used to spread apart filmy adhesions when possible.

The fact that the use of electrosurgery is avoided, we believe may minimise the tissue inflammatory response and thereby decrease the risk of recurrent adhesions. Post-operative treatment with oestrogen is also employed for this purpose. We would like to highlight that in this difficult case, the patient received only pre-operative non-steroidal anti-inflammatory and tolerated the procedure well.

For certain patients, intravenous sedation may be used. Further reassurance provided by the surgeon and the nursing team is also imperative in decreasing pain, increasing patient comfort and satisfaction. In our case, when we see our view obstructed by the tissue cut away from the adhesions, the grasper is introduced and these adhesions are removed. At the conclusion of this case, we do see that much of the uterine cavity has been restored.

But the patient will be brought back for the repeat diagnostic hysteroscopy, with possible repeat adhesiolysis in two to three weeks. In cases of advanced adhesions, repeat procedures may be necessary. And performing repeat hysteroscopic lysis of adhesions on an outpatient basis may compound the risk reduction this treatment alternative offers patients. Lastly, we would like to share with you our results of the outpatient hysteroscopic adhesiolysis at the Ottawa Hospital.

We performed a retrospective case series looking at 20 Asherman’s patients. Baseline characteristics of patients can be seen here. 15% had mild adhesions, 50 moderate and 35% severe, according to March classification. In 35% of patients, previous hysteroscopic adhesiolysis had been attempted. This figure depicts the distribution of number of hysteroscopic treatments required, with most of our patients having one or two procedures.

Outcomes were available for 19 patients. All of the patients experienced normal menses following treatment. Seven patients achieved a spontaneous pregnancy and six have gone on to deliver to date. Two patients required a hysteroscopic adhesiolysis performed in the main operating room mainly to treat a submucosal fibroid concurrently. The most common form of analgesia used in 89% of our cases was non-steroidal anti-inflammatories.

In conclusion, Asherman’s syndrome can often present difficulty in achieving successful treatments. We present a retrospective case series demonstrating that hysteroscopic adhesiolysis for the treatment of Asherman’s syndrome is a feasible option in an outpatient setting. We suggest that outpatient hysteroscopic adhesiolysis is a viable alternative to traditional treatment of Asherman’s syndrome in the operating room, likely with a more favourable side effect profile.

Larger case series of treatment of Asherman’s syndrome in an outpatient setting should be undertaken to provide a more accurate assessment of outcome measures. We thank you for your attention and welcome any questions.