Abstract
Intrauterine adhesion (IUA), and its severe form Asherman syndrome (Asherman’s syndrome), is a mysterious disease, often accompanied with severe clinical problems contributing to a significant impairment of reproductive function, such as menstrual disturbance (amenorrhea), infertility or recurrent pregnancy loss. Among these, its correlated infertility may be one of the most challenging problems. Although there are many etiologies for the development of IUA, uterine instrumentation is the main cause of IUA. Additionally, more complicated intrauterine surgeries can be performed by advanced technology, further increasing the risk of IUA. Strategies attempting to minimize the risk and reducing its severity are urgently needed. The current review will expand the level of our knowledge required to face the troublesome disease of IUA. It is separated into six sections, addressing the introduction of the normal cyclic endometrial repairing process and its abruption causing the formation of IUA; the etiology and prevalence of IUA; the diagnosis of IUA; the classification of IUA; the pathophysiology of IUA; and the primary prevention of IUA, including (1) delicate surgical techniques, such as the use of surgical instruments, energy systems, and pre-hysteroscopic management, (2) barrier methods, such as gels, intrauterine devices, intrauterine balloons, as well as membrane structures containing hyaluronate–carboxymethylcellulose or polyethylene oxide–sodium carboxymethylcellulose as anti-adhesive barrier.
Highlights
The endometrium contains two main structural layers: an underlying stable basal layer, named the stratum basalis, and an upper dynamic and functional layer named the stratum functionalis [1]
According to Dr Foix’s classification [60], three types of Intrauterine Adhesion (IUA) have been proposed, including (1) the most common type involves avascular fibrous strands joining the uterine wall, sometimes, thinwalled telangiectatic vessels can be found in this avascular fibrous strand and calcification or ossification can be found in the stroma area, accompanied with spare and inactive or cystically dilated glands; (2) muscular adhesion composed of collagen bundles, fibrous strips, or muscle with the same characteristics as normal myometrium, of which the percentage of fibrous tissue is more than 50–80% in the biopsy specimens; and (3) a sclerotic, atrophic endometrium [60]
The results showed that the use of hyaluronic acid gel significantly reduced the incidence of IUA with a relative risk (RR) of 0.42 (95% confidence interval (CI) 0.30–0.57, p < 0.001) [125]
Summary
The endometrium contains two main structural layers: an underlying stable basal layer (basal membrane), named the stratum basalis, and an upper dynamic and functional layer named the stratum functionalis [1]. The symptoms include intermittent spotting or persistent bleeding, inability of implantation (subfertility, infertility, repeated miscarriage, or C/S scar ectopic pregnancy), or abnormality of implantation, such as placenta previa, placenta accrete, and placenta increta [16,17,18,19,20,21,22] All of these might significantly increase the risk of pregnancy-related morbidity and mortality [19], including uterine rupture and postpartum hemorrhage (PPH). Hysteroscopy cannot evaluate the patency of tubes, and if the uterine cavity is totally obliterated, the hysteroscope cannot be inserted into the uterine cavity, and it fails to offer any informative data for IUA [27]. One issue over which there is no argument is that clinical history had better be included into the classification system, given its good correlation with prognosis [29]
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