Asherman's syndrome

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Asherman syndrome
Other namesIntrauterine adhesions (IUA) or Intrauterine synechiae
Ultrasound of Asherman's syndrome.jpg
Ultrasound view.
Specialty Gynaecology   OOjs UI icon edit-ltr-progressive.svg
Named after

Asherman's syndrome (AS) is an acquired uterine condition that occurs when scar tissue (adhesions) forms inside the uterus and/or the cervix. [1] It is characterized by variable scarring inside the uterine cavity, where in many cases the front and back walls of the uterus stick to one another. AS can be the cause of menstrual disturbances, infertility, and placental abnormalities. Although the first case of intrauterine adhesion was published in 1894 by Heinrich Fritsch, it was only after 54 years that a full description of Asherman syndrome was carried out by Joseph Asherman. [2] A number of other terms have been used to describe the condition and related conditions including: uterine/cervical atresia, traumatic uterine atrophy, sclerotic endometrium, and endometrial sclerosis. [3]

Contents

There is not any one cause of AS. Risk factors can include myomectomy, cesarean section, infections, age, genital tuberculosis, and obesity. Genetic predisposition to AS is being investigated. There are also studies that show that a severe pelvic infection, independent of surgery may cause AS. [4] AS can develop even if the woman has not had any uterine surgeries, trauma, or pregnancies. While rare in North America and European countries, genital tuberculosis is a cause of Asherman's in other countries such as India. [5]

History

The condition was first described in 1894 by Heinrich Fritsch (Fritsch, 1894) [6] [7] and further characterized by the Israeli gynecologist Joseph Asherman (1889–1968) [8] in 1948. [9]

It is also known as Fritsch syndrome, or Fritsch-Asherman syndrome.

Signs and symptoms

It is often characterized by a decrease in flow and duration of bleeding (absence of menstrual bleeding, little menstrual bleeding, or infrequent menstrual bleeding) [10] and infertility. Menstrual anomalies are often but not always correlated with severity: adhesions restricted to only the cervix or lower uterus may block menstruation. Pain during menstruation and ovulation is sometimes experienced and can be attributed to blockages. It has been reported that 88% of AS cases occur after a D&C is performed on a recently pregnant uterus, following a missed or incomplete miscarriage, birth, or during an elective termination (abortion) to remove retained products of conception. [11]

Causes

The cavity of the uterus is lined by the endometrium. This lining is composed of two layers, the functional layer (adjacent to the uterine cavity) which is shed during menstruation and an underlying basal layer (adjacent to the myometrium), which is necessary for regenerating the functional layer. Trauma to the basal layer, typically after a dilation and curettage (D&C) performed after a miscarriage, or delivery, or abortion, can lead to the development of intrauterine scars resulting in adhesions that can obliterate the cavity to varying degrees. In the extreme, the whole cavity can be scarred and occluded. Even with relatively few scars, the endometrium may fail to respond to estrogen.[ citation needed ]

Asherman's syndrome affects women of all races and ages equally, suggesting no underlying genetic predisposition for its development. [12] AS can result from other pelvic surgeries including cesarean sections, [12] [13] removal of fibroid tumours (myomectomy) [14] and from other causes such as IUDs, pelvic irradiation, schistosomiasis [15] and genital tuberculosis. [16] Chronic endometritis from genital tuberculosis is a significant cause of severe intrauterine adhesions (IUA) in the developing world, often resulting in total obliteration of the uterine cavity which is difficult to treat. [17]

An artificial form of AS can be surgically induced by endometrial ablation in women with excessive uterine bleeding, in lieu of hysterectomy.[ citation needed ]

Diagnosis

Hysteroscopic view of intrauterine adhesions Hysteroscopy of Asherman's Syndrome cropped.jpg
Hysteroscopic view of intrauterine adhesions
HSG showing filling defects at the adhesion sites. Additionally, this uterus appears to be T-shaped. HSG Ashermans syndrome.jpg
HSG showing filling defects at the adhesion sites. Additionally, this uterus appears to be T-shaped.

The history of a pregnancy event followed by a D&C leading to secondary amenorrhea or hypomenorrhea is typical. Hysteroscopy is the gold standard for diagnosis. [18] Imaging by sonohysterography or hysterosalpingography will reveal the extent of the scar formation. Ultrasound is not a reliable method of diagnosing Asherman's Syndrome. Hormone studies show normal levels consistent with reproductive function.[ citation needed ]

Classification

Various classification systems were developed to describe Asherman's syndrome (citations to be added), some taking into account the amount of functioning residual endometrium, menstrual pattern, obstetric history and other factors which are thought to play a role in determining the prognoses. With the advent of techniques which allow visualization of the uterus, classification systems were developed to take into account the location and severity of adhesions inside the uterus. This is useful as mild cases with adhesions restricted to the cervix may present with amenorrhea and infertility, showing that symptoms alone do not necessarily reflect severity. Other patients may have no adhesions but amenorrhea and infertility due to a sclerotic atrophic endometrium. The latter form has the worst prognosis.[ citation needed ]

Prevention

A 2013 review concluded that there were no studies reporting on the link between intrauterine adhesions and long-term reproductive outcome after miscarriage, while similar pregnancy outcomes were reported subsequent to surgical management (e.g. D&C), medical management or conservative management (that is, watchful waiting). [19] There is an association between surgical intervention in the uterus and the development of intrauterine adhesions, and between intrauterine adhesions and pregnancy outcomes, but there is still no clear evidence of any method of prevention of adverse pregnancy outcomes. [19]

In theory, the recently pregnant uterus is particularly soft under the influence of hormones and hence, easily injured. D&C (including dilation and curettage, dilation and evacuation/suction curettage and manual vacuum aspiration) is a blind, invasive procedure, making it difficult to avoid endometrial trauma. Medical alternatives to D&C for evacuation of retained placenta/products of conception exist including misoprostol and mifepristone. Studies show this less invasive and cheaper method to be an efficacious, safe and an acceptable alternative to surgical management for most women. [20] [21] It was suggested as early as in 1993 [22] that the incidence of IUA might be lower following medical evacuation (e.g. Misoprostol) of the uterus, thus avoiding any intrauterine instrumentation. So far, one study supports this proposal, showing that women who were treated for missed miscarriage with misoprostol did not develop IUA, while 7.7% of those undergoing D&C did. [23] The advantage of misoprostol is that it can be used for evacuation not only following miscarriage, but also following birth for retained placenta or hemorrhaging.[ citation needed ]

Alternatively, D&C could be performed under ultrasound guidance rather than as a blind procedure. This would enable the surgeon to end scraping the lining when all retained tissue has been removed, avoiding injury.[ citation needed ]

Early monitoring during pregnancy to identify miscarriage can prevent the development of, or as the case may be, the recurrence of AS, as the longer the period after fetal death following D&C, the more likely adhesions may be to occur. [22] Therefore, immediate evacuation following fetal death may prevent IUA.The use of hysteroscopic surgery instead of D&C to remove retained products of conception or placenta is another alternative that could theoretically improve future pregnancy outcomes, although it could be less effective if tissue is abundant. Also, hysteroscopy is not a widely or routinely used technique and requires expertise.[ citation needed ]

There is no data to indicate that suction D&C is less likely than sharp curette to result in Asherman's. A recent article describes three cases of women who developed intrauterine adhesions following manual vacuum aspiration. [24]

Intrauterine adhesions also form after hysteroscopic surgery such as myomectomy, polypectomy or septum removal. [25] [26] Mechanical barriers such as Womed Leaf [27] or hyaluronic acid gels can be used to prevent formation of IUA after such adhesiogenic procedures or after D&C. [28] [29] [30] [31]

Treatment

Fertility may sometimes be restored by the removal of adhesions, depending on the severity of the initial trauma and other individual patient factors. Operative hysteroscopy is used for visual inspection of the uterine cavity during adhesion dissection (adhesiolysis). However, hysteroscopy is yet to become a routine gynaecological procedure and only 15% of US gynecologists perform office hysteroscopy. [32] Adhesion dissection can be technically difficult and must be performed with care in order to not create new scars and further exacerbate the condition. In more severe cases, adjunctive measures such as laparoscopy are used in conjunction with hysteroscopy as a protective measure against uterine perforation. Microscissors are usually used to cut adhesions. Electrocauterization is not recommended. [33]

As IUA frequently reform after surgery, techniques have been developed to prevent recurrence of adhesions. Methods to prevent adhesion reformation include the use of mechanical barriers (Foley catheter, saline-filled balloon uterine stents, [34] gel barriers (Seprafilm, Spraygel, autocrosslinked hyaluronic acid gel Hyalobarrier) and mechanical barrier film (Womed Leaf) [27] to maintain opposing walls apart during healing, [35] [36] [37] thereby preventing the reformation of adhesions. Antibiotic prophylaxis is necessary in the presence of mechanical barriers to reduce the risk of possible infections. A common pharmacological method for preventing reformation of adhesions is sequential hormonal therapy with estrogen followed by a progestin to stimulate endometrial growth and prevent opposing walls from fusing together. [38] However, there have been no randomized controlled trials (RCTs) comparing post-surgical adhesion reformation with and without hormonal treatment and the ideal dosing regimen or length of estrogen therapy is not known. A recent meta analysis compared different post surgical prevention barrier strategies and concluded that there was no single clearly superior treatment. [39] Furthermore, diagnostic severity and outcomes are assessed according to different criteria (e.g. menstrual pattern, adhesion reformation rate, conception rate, live birth rate). Clearly, more comparable studies are needed in which reproductive outcome can be analysed systematically.[ citation needed ]

Follow-up tests (HSG, hysteroscopy or SHG) are necessary to ensure that adhesions have not reformed. Further surgery may be necessary to restore a normal uterine cavity. According to a recent study among 61 patients, the overall rate of adhesion recurrence was 27.9% and in severe cases this was 41.9%. [40] Another study found that postoperative adhesions reoccur in close to 50% of severe AS and in 21.6% of moderate cases. [18] Mild IUA, unlike moderate to severe synechiae, do not appear to reform.[ citation needed ]

Prognosis

Amniotic sheet on ultrasound Amniotic sheet.jpg
Amniotic sheet on ultrasound

The extent of adhesion formation is critical. Mild to moderate adhesions can usually be treated with success. Extensive obliteration of the uterine cavity or fallopian tube openings (ostia) and deep endometrial or myometrial trauma may require several surgical interventions and/or hormone therapy or even be uncorrectable. If the uterine cavity is adhesion free but the ostia remain obliterated, IVF remains an option. If the uterus has been irreparably damaged, surrogacy or adoption may be the only options.[ citation needed ]

Depending on the degree of severity, AS may result in infertility, repeated miscarriages, pain from trapped blood, and future obstetric complications [18] If left untreated, the obstruction of menstrual flow resulting from adhesions can lead to endometriosis in some cases. [3] [41]

Patients who carry a pregnancy even after treatment of IUA may have an increased risk of having abnormal placentation including placenta accreta [42] where the placenta invades the uterus more deeply, leading to complications in placental separation after delivery. Premature delivery, [38] second-trimester pregnancy loss, [43] and uterine rupture [44] are other reported complications. They may also develop incompetent cervix where the cervix can no longer support the growing weight of the fetus, the pressure causes the placenta to rupture and the mother goes into premature labour. Cerclage is a surgical stitch which helps support the cervix if needed. [43]

Pregnancy and live birth rate has been reported to be related to the initial severity of the adhesions with 93, 78, and 57% pregnancies achieved after treatment of mild, moderate and severe adhesions, respectively and resulting in 81, 66, and 32% live birth rates, respectively. [18] The overall pregnancy rate after adhesiolysis was 60% and the live birth rate was 38.9% according to one study. [45]

Age is another factor contributing to fertility outcomes after treatment of AS. For women under 35 years of age treated for severe adhesions, pregnancy rates were 66.6% compared to 23.5% in women older than 35. [42]

Epidemiology

AS has a reported incidence of 25% of D&Cs performed 1–4 weeks post-partum, [41] [13] [46] up to 30.9% of D&Cs performed for missed miscarriages and 6.4% of D&Cs performed for incomplete miscarriages. [47] In another study, 40% of patients who underwent repeated D&C for retained products of conception after missed miscarriage or retained placenta developed AS. [48]

In the case of missed miscarriages, the time period between fetal demise and curettage may increase the likelihood of adhesion formation due to fibroblastic activity of the remaining tissue. [12] [49]

The risk of AS also increases with the number of procedures: one study estimated the risk to be 16% after one D&C and 32% after three or more D&Cs. [22] However, a single curettage often underlies the condition.

In an attempts to estimate the prevalence of AS in the general population, it was found in 1.5% of women undergoing hysterosalpingography HSG, [50] and between 5 and 39% of women with recurrent miscarriage. [51] [52] [53]

After miscarriage, a review estimated the prevalence of AS to be approximately 20% (95% confidence interval: 13% to 28%). [19]

Related Research Articles

Dilationand curettage (D&C) refers to the dilation of the cervix and surgical removal of sections and or layers of the lining of the uterus and or contents of the uterus such as an unwanted fetus, remains of a non viable fetus, retained placenta after birth or abortion as well as any abnormal tissue which may be in the uterus causing abnormal cycles by scraping and scooping (curettage). It is a gynecologic procedure used for treatment and removal as well as diagnostic and therapeutic purposes, and is the most commonly used method for first trimester abortion or miscarriage.

<span class="mw-page-title-main">Endometrium</span> Inner mucous membrane of the mammalian uterus

The endometrium is the inner epithelial layer, along with its mucous membrane, of the mammalian uterus. It has a basal layer and a functional layer: the basal layer contains stem cells which regenerate the functional layer. The functional layer thickens and then is shed during menstruation in humans and some other mammals, including other apes, Old World monkeys, some species of bat, the elephant shrew and the Cairo spiny mouse. In most other mammals, the endometrium is reabsorbed in the estrous cycle. During pregnancy, the glands and blood vessels in the endometrium further increase in size and number. Vascular spaces fuse and become interconnected, forming the placenta, which supplies oxygen and nutrition to the embryo and fetus. The speculated presence of an endometrial microbiota has been argued against.

<span class="mw-page-title-main">Uterus</span> Female sex organ in mammals

The uterus or womb is the organ in the reproductive system of most female mammals, including humans, that accommodates the embryonic and fetal development of one or more fertilized eggs until birth. The uterus is a hormone-responsive sex organ that contains glands in its lining that secrete uterine milk for embryonic nourishment.

<span class="mw-page-title-main">Ectopic pregnancy</span> Female reproductive system health issue

Ectopic pregnancy is a complication of pregnancy in which the embryo attaches outside the uterus. Signs and symptoms classically include abdominal pain and vaginal bleeding, but fewer than 50 percent of affected women have both of these symptoms. The pain may be described as sharp, dull, or crampy. Pain may also spread to the shoulder if bleeding into the abdomen has occurred. Severe bleeding may result in a fast heart rate, fainting, or shock. With very rare exceptions, the fetus is unable to survive.

Heavy menstrual bleeding (HMB), previously known as menorrhagia or hematomunia, is a menstrual period with excessively heavy flow. It is a type of abnormal uterine bleeding (AUB).

<span class="mw-page-title-main">Adenomyosis</span> Extension of endometrial tissue into the myometrium

Adenomyosis is a medical condition characterized by the growth of cells that proliferate on the inside of the uterus (endometrium) atypically located among the cells of the uterine wall (myometrium), as a result, thickening of the uterus occurs. As well as being misplaced in patients with this condition, endometrial tissue is completely functional. The tissue thickens, sheds and bleeds during every menstrual cycle.

<span class="mw-page-title-main">Vaginal bleeding</span> Medical condition

Vaginal bleeding is any expulsion of blood from the vagina. This bleeding may originate from the uterus, vaginal wall, or cervix. Generally, it is either part of a normal menstrual cycle or is caused by hormonal or other problems of the reproductive system, such as abnormal uterine bleeding.

<span class="mw-page-title-main">Hysteroscopy</span> Medical procedure

Hysteroscopy is the inspection of the uterine cavity by endoscopy with access through the cervix. It allows for the diagnosis of intrauterine pathology and serves as a method for surgical intervention.

<span class="mw-page-title-main">Gynecologic ultrasonography</span> Application of medical ultrasonography to the female pelvic organs

Gynecologic ultrasonography or gynecologic sonography refers to the application of medical ultrasonography to the female pelvic organs as well as the bladder, the adnexa, and the recto-uterine pouch. The procedure may lead to other medically relevant findings in the pelvis.This technique is useful to detect myomas or mullerian malformations.

<span class="mw-page-title-main">Uterine malformation</span> Female birth defect in which the uterus forms abnormally

A uterine malformation is a type of female genital malformation resulting from an abnormal development of the Müllerian duct(s) during embryogenesis. Symptoms range from amenorrhea, infertility, recurrent pregnancy loss, and pain, to normal functioning depending on the nature of the defect.

<span class="mw-page-title-main">Endometrial polyp</span> Mass on the interior lining of the uterus

An endometrial polyp or uterine polyp is a mass in the inner lining of the uterus. They may have a large flat base (sessile) or be attached to the uterus by an elongated pedicle (pedunculated). Pedunculated polyps are more common than sessile ones. They range in size from a few millimeters to several centimeters. If pedunculated, they can protrude through the cervix into the vagina. Small blood vessels may be present, particularly in large polyps.

<span class="mw-page-title-main">Uterine myomectomy</span> Surgical removal of uterine fibroid

Myomectomy, sometimes also called fibroidectomy, refers to the surgical removal of uterine leiomyomas, also known as fibroids. In contrast to a hysterectomy, the uterus remains preserved and the woman retains her reproductive potential. It still may impact hormonal regulation and the menstrual cycle.

<span class="mw-page-title-main">Vacuum aspiration</span> Gynaecological procedure

Vacuum or suction aspiration is a procedure that uses a vacuum source to remove an embryo or fetus through the cervix. The procedure is performed to induce abortion, as a treatment for incomplete spontaneous abortion or retained fetal and placental tissue, or to obtain a sample of uterine lining. It is generally safe, and serious complications rarely occur.

<span class="mw-page-title-main">Endometrial ablation</span> Medical procedure

Endometrial ablation is a surgical procedure that is used to remove (ablate) or destroy the endometrial lining of the uterus. The goal of the procedure is to decrease the amount of blood loss during menstrual periods. Endometrial ablation is most often employed in people with excessive menstrual bleeding, who do not wish to undergo a hysterectomy, following unsuccessful medical therapy.

<span class="mw-page-title-main">Placenta accreta spectrum</span> Medical condition

Placenta accreta occurs when all or part of the placenta attaches abnormally to the myometrium. Three grades of abnormal placental attachment are defined according to the depth of attachment and invasion into the muscular layers of the uterus:

  1. Accreta – chorionic villi attached to the myometrium, rather than being restricted within the decidua basalis.
  2. Increta – chorionic villi invaded into the myometrium.
  3. Percreta – chorionic villi invaded through the perimetrium.
<span class="mw-page-title-main">Unicornuate uterus</span> Birth defect in which only one uterine horn fully develops

A unicornuate uterus represents a uterine malformation where the uterus is formed from one only of the paired Müllerian ducts while the other Müllerian duct does not develop or only in a rudimentary fashion. The sometimes called hemi-uterus has a single horn linked to the ipsilateral fallopian tube that faces its ovary.

<span class="mw-page-title-main">Arcuate uterus</span> Concave variant of uterine cavity shape

The arcuate uterus is a form of a uterine anomaly or variation where the uterine cavity displays a concave contour towards the fundus. Normally the uterine cavity is straight or convex towards the fundus on anterior-posterior imaging, but in the arcuate uterus the myometrium of the fundus dips into the cavity and may form a small septation. The distinction between an arcuate uterus and a septate uterus is not standardized.

Müllerian duct anomalies are those structural anomalies caused by errors in Müllerian duct development as an embryo forms. Factors contributing to them include genetics and maternal exposure to substances that interfere with fetal development.

<span class="mw-page-title-main">T-shaped uterus</span> Medical condition

A t-shaped uterus is a type of uterine malformation wherein the uterus is shaped resembling the letter T. This is typically observed in DES-exposed women. It is recognised in the ESHRE/ESGE classification, and is associated with failed implantation, increased risk of ectopic pregnancy, miscarriage and preterm delivery. There is a surgical procedure to correct the malformation.

Repeated implantation failure (RIF) is the repeated failure of the embryo to implant onto the side of the uterus wall following IVF treatment. Implantation happens at 6–7 days after conception and involves the embedding of the growing embryo into the mothers uterus and a connection being formed. A successful implantation can be determined by using an ultrasound to view the sac which the baby grows in, inside the uterus.

References

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  2. ↑ Conforti A, Alviggi C, Mollo A, De Placido G, Magos A (December 2013). "The management of Asherman syndrome: a review of literature". Reproductive Biology and Endocrinology. 11: 118. doi: 10.1186/1477-7827-11-118 . PMC   3880005 . PMID   24373209.
  3. 1 2 Palter SF (2005). "High Rates of Endometriosis in Patients With Intrauterine Synechiae (Asherman's Syndrome)". Fertility and Sterility. 86 (Suppl 1): S471. doi: 10.1016/j.fertnstert.2005.07.1239 .
  4. ↑ "Asherman syndrome". MedlinePlus Medical Encyclopedia. National Library of Medicine, National Institutes of Health, U.S. Department of Health and Human Services.
  5. ↑ Sharma JB, Roy KK, Pushparaj M, Gupta N, Jain SK, Malhotra N, Mittal S (January 2008). "Genital tuberculosis: an important cause of Asherman's syndrome in India". Archives of Gynecology and Obstetrics. 277 (1): 37–41. doi:10.1007/s00404-007-0419-0. PMID   17653564. S2CID   23594142.
  6. ↑ synd/1521 at Who Named It?
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  8. ↑ "Adhesions & Asherman's Syndrome". BritishFibroidTrust.
  9. ↑ Asherman JG (December 1950). "Traumatic intra-uterine adhesions". The Journal of Obstetrics and Gynaecology of the British Empire. 57 (6): 892–896. doi:10.1111/j.1471-0528.1950.tb06053.x. PMID   14804168. S2CID   72393995.
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  15. ↑ Krolikowski A, Janowski K, Larsen JV (May 1995). "Asherman syndrome caused by schistosomiasis". Obstetrics and Gynecology. 85 (5 Pt 2): 898–899. doi:10.1016/0029-7844(94)00371-J. PMID   7724154. S2CID   24103799.
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  17. ↑ Bukulmez O, Yarali H, Gurgan T (August 1999). "Total corporal synechiae due to tuberculosis carry a very poor prognosis following hysteroscopic synechialysis". Human Reproduction. 14 (8): 1960–1961. doi: 10.1093/humrep/14.8.1960 . PMID   10438408.
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  21. ↑ Weeks A, Alia G, Blum J, Winikoff B, Ekwaru P, Durocher J, Mirembe F (September 2005). "A randomized trial of misoprostol compared with manual vacuum aspiration for incomplete abortion". Obstetrics and Gynecology. 106 (3): 540–547. doi:10.1097/01.AOG.0000173799.82687.dc. PMID   16135584. S2CID   30899930.
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  25. ↑ Gambadauro P, Gudmundsson J, Torrejón R (2012). "Intrauterine Adhesions following Conservative Treatment of Uterine Fibroids". Obstetrics and Gynecology International. 2012: 853269. doi: 10.1155/2012/853269 . PMC   3236427 . PMID   22190959.
  26. ↑ Sebbag L, Even M, Fay S, Naoura I, Revaux A, Carbonnel M, et al. (2019-08-16). "Early Second-Look Hysteroscopy: Prevention and Treatment of Intrauterine Post-surgical Adhesions". Frontiers in Surgery. 6: 50. doi: 10.3389/fsurg.2019.00050 . PMC   6706867 . PMID   31475154.
  27. 1 2 "How to treat intrauterine adhesions". How to treat intrauterine adhesions. Archived from the original on 2022-01-14. Retrieved 2022-01-14.
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  29. ↑ Guida M, Acunzo G, Di Spiezio Sardo A, Bifulco G, Piccoli R, Pellicano M, et al. (June 2004). "Effectiveness of auto-crosslinked hyaluronic acid gel in the prevention of intrauterine adhesions after hysteroscopic surgery: a prospective, randomized, controlled study". Human Reproduction. 19 (6): 1461–1464. doi: 10.1093/humrep/deh238 . PMID   15105384.
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