Subscribe to RSS
DOI: 10.1055/s-0028-1082393
Intrauterine Adhesions
Publication History
Publication Date:
28 August 2008 (online)
![](https://www.thieme-connect.de/media/srm/200804/lookinside/thumbnails/10.1055-s-0028-1082393-1.jpg)
ABSTRACT
Joseph Asherman first described intrauterine adhesions in 1948. It is commonly referred to as Asherman's syndrome and intrauterine synechiae. It is characterized by a spectrum ranging from amenorrhea to menstrual disturbance to normal menses. It is frequently associated with infertility. The true incidence is unknown. Most cases occur within close temporal proximity to a pregnancy, usually within 4 months and usually while the woman is in a hypoestrogenized state. Most cases are associated with trauma to the endometrium from surgical procedures, primarily curettage. Increasingly, cases are associated with myomectomy both abdominal and hysteroscopic, removal of septae, and any other intrauterine surgery. Pathology shows fibrous connective tissue bands with or without glandular tissue, although this may range from filmy to dense.
The diagnosis is primarily by history and a high index of suspicion. Confirmatory tests are increasingly saline infusion hysterography (SIS) or hysterosalpingogram (HSG), although magnetic resonance imaging has also been used. Ultimately, hysteroscopy is employed for the final diagnosis and treatment. Hysteroscopic lysis of adhesions is the main method of treatment. Dense scar tissue and difficult entry into the cervix may require laparoscopic or ultrasound guidance. Most authors use an intrauterine stent and follow treatment with sequential estrogen and progesterone therapy. Increasingly early intervention either with repeat SIS or HSG or most recently with flexible hysteroscopy has been advocated.
Treatments outcomes are difficult to assess as there are no universally agreed upon classification system. However, intrauterine pregnancies rates range from 22 to 45% and live births range from 28 to 32%. The risk of complications for those that achieve pregnancy is significant with a significant risk for placenta accreta and subsequent blood loss, transfusion, and hysterectomy. Prospective controlled studies are needed to determine the best diagnostic and treatments for intrauterine adhesions.
KEYWORDS
Intrauterine adhesions (IUAs) - intrauterine synechiae (IUS) - Asherman's syndrome
REFERENCES
- 1 Carmichael D E. Asherman's syndrome. Obstet Gynecol. 1970; 36 922-928
- 2 Dmowski W P, Greenblatt R B. Asherman's syndrome and risk of placenta accreta. Obstet Gynecol. 1969; 34 288-299
- 3 Asherman J G. Amenorrhoea traumatica (atretica). BJOG. 1948; 55 23-30
- 4 Asherman J G. Traumatic intra-uterine adhesions. BJOG. 1950; 57 892-896
- 5 Krolikowski A, Janowski K, Larsen J V. Asherman syndrome caused by schistosomiasis. Obstet Gynecol. 1995; 85 898-899
- 6 Sharma J, Roy K, Pushparaj M et al.. Genital tuberculosis: an important cause of Asherman's syndrome in India. Arch Gynecol Obstet. 2008; 277 37-41
- 7 Practice Committee of the American Society for Reproductive Medicine . Current evaluation of amenorrhea. Fertil Steril. 2006; 86 S148-S155
- 8 March C M. Intrauterine adhesions. Obstet Gynecol Clin North Am. 1995; 22 491-505
- 9 Schenker J G. Etiology of and therapeutic approach to synechia uteri. Eur J Obstet Gynecol Reprod Biol. 1996; 65 109-113
- 10 Pratt R, Robison V, Navin T, Hlavsa M, Pevzner E. Trends in tuberculosis incidence–United States, 2006 (disease/disorder overview). MMWR Morb Mortal Wkly Rep. 2007; 56 245-246
- 11 Goldrath M H, Fuller T A, Segal S. Laser photovaporization of endometrium for the treatment of menorrhagia. Am J Obstet Gynecol. 1981; 140 14-19
- 12 Al-Inany H. Intrauterine adhesions: an update. Acta Obstet Gynecol Scand. 2001; 80 986-993
- 13 Tam W H, Lau W C, Cheung L P, Yuen P M, Chung TK-H. Intrauterine adhesions after conservative and surgical management of spontaneous abortion. J Am Assoc Gynecol Laparosc. 2002; 9 182-185
- 14 Simpson Jr W L, Beitia L G, Mester J. Hysterosalpingography: a reemerging study. Radiographics. 2006; 26 419-431
- 15 Cohen J, Copperman A B. The value of 3D ultrasound in the diagnosis and treatment of Asherman's syndrome. Fertil Steril. 2005; 84(Suppl 1) S464
- 16 Soares S R, dos Reis M MBB, Camargos A F. Diagnostic accuracy of sonohysterography, transvaginal sonography, and hysterosalpingography in patients with uterine cavity diseases. Fertil Steril. 2000; 73 406-411
- 17 Letterie G S, Haggerty M F. Magnetic resonance imaging of intrauterine synechiae. Gynecol Obstet Invest. 1994; 37 66-68
- 18 Bacelar A C, Wilcock D, Powell M, Worthington B S. The value of MRI in the assessment of traumatic intra-uterine adhesions (Asherman's syndrome). Clin Radiol. 1995; 50 80-83
- 19 Asherman J G. The myth of tubal and endometrial transplantation. BJOG. 1960; 67 228-233
- 20 March A M, Israel R, March C D. Hysteroscopic management of intrauterine adhesions. Am J Obstet Gynecol. 1978; 130 653-657
- 21 Valle R F, Sciarra J J. Intrauterine adhesions: hysteroscopic diagnosis, classification, treatment, and reproductive outcome. Am J Obstet Gynecol. 1988; 158 1459-1470
- 22 Donnez J, Nisolle M. Hysteroscopic surgery. Curr Opin Obstet Gynecol. 1992; 4 439-446
- 23 The American Fertility Society classifications of adnexal adhesions, distal tubal occlusion, tubal occlusion secondary to tubal ligation, tubal pregnancies, müllerian anomalies and intrauterine adhesions. Fertil Steril. 1988; 49 944-955
-
24 Wamsteker K, de Blok S.
Diagnostic hysteroscopy: technique and documentation . In: Sutton C, Diamond M Endoscopic Surgery for Gynaecologists. London, England; WB Saunders Company Ltd 1998: 511-524 - 25 Nasr A LA, Al-Inany H G, Thabet S M, Aboulghar M. A clinicohysteroscopic scoring system of intrauterine adhesions. Gynecol Obstet Invest. 2000; 50 178-181
- 26 March C M, Miller C. Hysteroscopic lysis of intrauterine adhesions. Obs Gynecol News. 2006; 41 36-37
- 27 Broome J D, Vancaillie T G. Fluorscopically guided hysteroscopic dicision of adhesion in severe Asherman's syndrome. Obstet Gynecol. 1999; 93 1041-1043
- 28 Coccia M E, Becattini C, Bracco G L, Pampaloni F, Bargelli G, Scarselli G. Pressure lavage under ultrasound guidance: a new approach for outpatient treatment of intrauterine adhesions. Fertil Steril. 2001; 75 601-606
- 29 Protopapas A, Shushan A, Magos A. Myometrial scoring: a new technique for the management of severe Asherman's syndrome. Fertil Steril. 1998; 69 860-864
- 30 Yu D, Li T-C, Xia E, Huang X, Liu Y, Peng X. Factors affecting reproductive outcome of hysteroscopic adhesiolysis for Asherman's syndrome. Fertil Steril. 2008; 89(3) 715-722
- 31 Orhue A AE, Aziken M E, Igbefoh J O. A comparison of two adjunctive treatments for intrauterine adhesions following lysis. Int J Gynaecol Obstet. 2003; 82 49-56
- 32 Amer M I, Abd-El-Maeboud K H. Amnion graft following hysteroscopic lysis of intrauterine adhesions. J Obstet Gynaecol Res. 2006; 32 559-566
- 33 Abbott J, Thomson A, Vancaillie T. SprayGel following surgery for Asherman's syndrome may improve pregnancy outcome. J Obstet Gynaecol. 2004; 24 710-711
- 34 Fumino T, Teranishi A, Wakimoto E, Hamai H, Kuwata A, Shigeta M. Early second-look flexible hysteroscopy is effective for the treatment of asherman's syndrome. Fertil Steril. 2007; 88(Suppl 1) S224
- 35 Swedarsky L, Robinson J K, Isaacson K B. Postoperative therapy for Asherman's syndrome. J Minim Invasive Gynecol. 2005; 12(5) 34
- 36 Pabuccu R, Atay V, Orhon E, Urman B, Ergun A. Hysteroscopic treatment of intrauterine adhesions is safe and effective in the restoration of normal menstruation and fertility. Fertil Steril. 1997; 68 1141-1143
- 37 Fedele L M, Bianchi S M, Frontino G M, Article M. Septums and synechiae: approaches to surgical correction. Clin Obstet Gynecol. 2006; 49 767-788
- 38 Fernandez H, Al-Najjar F, Chauveaud-Lambling A, Frydman R, Gervaise A. Fertility after treatment of Asherman's syndrome stage 3 and 4. J Minim Invasive Gynecol. 2006; 13 398-402
- 39 McComb P F, Wagner B L. Simplified therapy for Asherman's syndrome. Fertil Steril. 1997; 68 1047-1050
- 40 Capella-Allouc S, Morsad F, Rongieres-Bertrand C, Taylor S, Fernandez H. Hysteroscopic treatment of severe Asherman's syndrome and subsequent fertility. Hum Reprod. 1999; 14 1230-1233
- 41 Miller D A, Chollet J A, Goodwin T M. Clinical risk factors for placenta previa-placenta accreta. Am J Obstet Gynecol. 1997; 177 210-214
- 42 Wu S, Kocherginsky M, Hibbard J U. Abnormal placentation: twenty-year analysis. Am J Obstet Gynecol. 2005; 192 1458-1461
Jay M BermanM.D. F.A.C.O.G.
Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Hutzel Women's Hospital
7 Brush North, Box 166, 3990 John R, Detroit, MI 48201
Email: jberman@med.wayne.edu