PDF herunterladen
Semin Reprod Med 2008; 26(4): 349-355
DOI: 10.1055/s-0028-1082393
© Thieme Medical Publishers

Intrauterine Adhesions

Jay M. Berman1
  • 1Assistant Professor, Division of Gynecology, Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Hutzel Women's Hospital, Detroit, Michigan
Weitere Informationen

Publikationsverlauf

Publikationsdatum:
28. August 2008 (online)

    Lizenzen und Reprints

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
    PubMedGoogle Scholar
  • 2 Dmowski W P, Greenblatt R B. Asherman's syndrome and risk of placenta accreta.  Obstet Gynecol. 1969;  34 288-299
    PubMedGoogle Scholar
  • 3 Asherman J G. Amenorrhoea traumatica (atretica).  BJOG. 1948;  55 23-30
    PubMedGoogle Scholar
  • 4 Asherman J G. Traumatic intra-uterine adhesions.  BJOG. 1950;  57 892-896
    CrossrefPubMedGoogle Scholar
  • 5 Krolikowski A, Janowski K, Larsen J V. Asherman syndrome caused by schistosomiasis.  Obstet Gynecol. 1995;  85 898-899
    CrossrefPubMedGoogle Scholar
  • 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
    PubMedGoogle Scholar
  • 7 Practice Committee of the American Society for Reproductive Medicine . Current evaluation of amenorrhea.  Fertil Steril. 2006;  86 S148-S155
    PubMedGoogle Scholar
  • 8 March C M. Intrauterine adhesions.  Obstet Gynecol Clin North Am. 1995;  22 491-505
    PubMedGoogle Scholar
  • 9 Schenker J G. Etiology of and therapeutic approach to synechia uteri.  Eur J Obstet Gynecol Reprod Biol. 1996;  65 109-113
    CrossrefPubMedGoogle Scholar
  • 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
    PubMedGoogle Scholar
  • 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
    PubMedGoogle Scholar
  • 12 Al-Inany H. Intrauterine adhesions: an update.  Acta Obstet Gynecol Scand. 2001;  80 986-993
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 14 Simpson Jr W L, Beitia L G, Mester J. Hysterosalpingography: a reemerging study.  Radiographics. 2006;  26 419-431
    CrossrefPubMedGoogle Scholar
  • 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
    PubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 17 Letterie G S, Haggerty M F. Magnetic resonance imaging of intrauterine synechiae.  Gynecol Obstet Invest. 1994;  37 66-68
    PubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 19 Asherman J G. The myth of tubal and endometrial transplantation.  BJOG. 1960;  67 228-233
    PubMedGoogle Scholar
  • 20 March A M, Israel R, March C D. Hysteroscopic management of intrauterine adhesions.  Am J Obstet Gynecol. 1978;  130 653-657
    PubMedGoogle Scholar
  • 21 Valle R F, Sciarra J J. Intrauterine adhesions: hysteroscopic diagnosis, classification, treatment, and reproductive outcome.  Am J Obstet Gynecol. 1988;  158 1459-1470
    CrossrefPubMedGoogle Scholar
  • 22 Donnez J, Nisolle M. Hysteroscopic surgery.  Curr Opin Obstet Gynecol. 1992;  4 439-446
    PubMedGoogle Scholar
  • 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
    PubMedGoogle Scholar
  • 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
    Google Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 26 March C M, Miller C. Hysteroscopic lysis of intrauterine adhesions.  Obs Gynecol News. 2006;  41 36-37
    PubMedGoogle Scholar
  • 27 Broome J D, Vancaillie T G. Fluorscopically guided hysteroscopic dicision of adhesion in severe Asherman's syndrome.  Obstet Gynecol. 1999;  93 1041-1043
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    PubMedGoogle Scholar
  • 35 Swedarsky L, Robinson J K, Isaacson K B. Postoperative therapy for Asherman's syndrome.  J Minim Invasive Gynecol. 2005;  12(5) 34
    PubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 39 McComb P F, Wagner B L. Simplified therapy for Asherman's syndrome.  Fertil Steril. 1997;  68 1047-1050
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 42 Wu S, Kocherginsky M, Hibbard J U. Abnormal placentation: twenty-year analysis.  Am J Obstet Gynecol. 2005;  192 1458-1461
    CrossrefPubMedGoogle Scholar

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