Story of Management of a Challenging Case of a Fibrotic Uterine Cavity

Abstract

ABSTRACTAimOur aim is to highlight the emerging trends of management of a moderate-to-severe degree of Asherman's syndrome/fibrotic uterine cavity in the form of either relook hysteroscopic surgery or postoperative hormonal therapy.BackgroundAsherman's syndrome also known as Fritsch syndrome or Fritsch–Asherman syndrome is a condition where iatrogenic intrauterine adhesions (IUA) develop and it occurs most commonly following dilatation and curettage or pelvic infections, e.g., endometrial tuberculosis. Diagnosis is based on the history and a high index of suspicion followed by confirmation by saline infusion sonography (SIS) or hysterosalpingography (HSG). Hysteroscopy is the gold standard for both diagnosis and treatment of Asherman's syndrome. This case highlights the importance of hysteroscopic management of a known case of Asherman's syndrome/IUA and also highlights how important are relook hysteroscopic surgeries and their interval from primary surgery and gradually decreasing the dose of postoperative hormonal therapy to cure the same and to improve the clinical outcome.Case descriptionWe present a case where a patient underwent curettage after retained products leading to fibrosis of the uterine cavity. Multiple surgeries abroad were unsuccessful to correct the problem. Then patient came to our institute where hysteroscopic adhesiolysis and lateral wall metroplasty along with laparoscopic adhesiolysis and right-sided ovarian cystectomy followed by intrauterine contraceptive device (IUCD) insertion, i.e., multiload without copper was done followed by two more relook hysteroscopic procedures leading to reformation of a normal uterine cavity. The authors discuss the stepwise management of a known case of Asherman's syndrome through this successful and challenging case.ConclusionIUA develop most commonly after vigorous curettage or endometrial tuberculosis. Diagnosis is based on the history and a high index of suspicion and confirmation by SIS and HSG. The hysteroscopic management of IUA is a safe and effective method. It is a surgical pearl for both diagnostic and therapeutic purposes. Sequential estrogen and progesterone therapy and a splint are found to be helpful, but further studies are needed to assess their efficacy. Relook hysteroscopy acts as an adjunctive method to improve the outcome. We emphasize on relook hysteroscopy and its interval from the primary surgery which is usually after next menses when the patient resumes menses as it helps to get a better and long-term clinical outcome.Clinical significanceHysteroscopy acts as both a diagnostic and therapeutic tool for the management of fibrotic uterine cavity. Relook hysteroscopic surgery is useful to manage a moderate-to-severe degree of fibrotic uterine cavity along with insertion of IUCD without copper to prevent further adhesions. Gradually decreasing the dose of hormonal therapy (estrogen plus progesterone) helps to regenerate the endometrium and to resume normal menses.How to cite this articleJain N, Kausar H, Manchanda R,et al.Story of Management of a Challenging Case of a Fibrotic Uterine Cavity. J South Asian Feder Obst Gynae 2020;12(6):432–435.