Hysteroscopic Lysis Of Adhesions Research Articles

Surgical Management of Intrauterine Adhesions

Intrauterine adhesions, also known as Asherman’s syndrome, can have an impact on both reproductive outcomes and gynaecologic symptoms. Surgical management with hysteroscopic lysis of adhesions is the gold standard for treatment. The following techniques are described in this presentation for cases with severe occlusive cavity and should be performed by experienced surgeons. 1. The use of 3D ultrasound played an important role in the preoperative workup of the patient, it could be used to evaluate the severity of intrauterine adhesion and predict the complexity of the cases. 2. Transabdominal 2D ultrasound guidance can help to delineate the location and extent of the adhesions and reduce the risk of uterine perforation and the formation of false passage. Laparoscopic guidance for severe cases has been advocated for immediate treatment of uterine perforation and minimizing extrauterine trauma. 3. In patients with severe intrauterine adhesion, a “myometrial scoring technique” could be used by bipolar electrode need with score 6 to 8, 4-mm-deep incisions from the fundus to the cervix and a transverse incision at the uterine fundus. Or the “ploughing technique” could be used by scissors, both methods aim to remove the fibrotic tissue, expose any underlying healthy basal endometrial tissue capable of regeneration. It remains to be seen whether “ploughing technique” using cold scissors or a “myometrial scoring technique” by bipolar electrode produces similar or different results, which could only be resolved by RCT in the future. 4. Surgical management offers favourable fertility outcomes and is often successful in restoring menstruation. Endometrial thickness and volume assessed by 3D-TVUS may have important predictive value for pregnancy after hysteroscopic adhesiolysis. 5. Prevention of reformation of adhesions remains challenging and no single method for preventing recurrence has shown superiority.

Restoring Fertility of Patients with Severe Asherman's Syndrome in the Office Setting: A Step-by-Step Recipe for Success

To describe an effective in-office hysteroscopic strategy to restore fertility of patients with severe Asherman's syndrome. A step-by-step video demonstration of the technique with an emphasis on the key portions of the procedure. A detailed narrated description of the steps is provided. Tertiary care University Hospital. Three patients were managed by hysteroscopy performed in the office setting without anesthesia. Case 1 is a 34-year-old woman with obstetrical history of first-trimester incomplete abortion treated with Dilation and Curettage (D&C), followed by a tubal ectopic pregnancy treated with laparoscopic partial salpingectomy and a subsequent pregnancy on the tubal stump treated with uterine artery embolization. Case 2 is a 40-year-old woman with history of tubal ectopic pregnancy treated with salpingectomy, a surgical first-trimester voluntary termination of pregnancy with D&C and a full term vaginal delivery complicated with retained products of conception that were removed with D&C. Case 3 is a 35-year-old woman with two previous first-trimester spontaneous miscarriages both treated with D&C. Case 1 and 3 were treated using miniaturized mechanical instruments only; in case 2, miniaturized mechanical instruments and the 15 Fr bipolar mini-resectoscope were used. Preoperative 2D and 3D ultrasound were used to predict the complexity of the cases and to guide the surgeon during the procedure. Intrauterine lysis of adhesions was concluded when both tubal ostia were visualized, and the uterine cavity was determined to have adequate shape and volume. At the end of the procedures, hyaluronic acid-based gel was applied to prevent new intrauterine adhesion formation. Two weeks after the initial procedure, a second look diagnostic hysteroscopy was performed. Only one patient (#1) needed additional lysis of adhesions; in this case, at the end of the procedure, a Word catheter was inserted as a barrier method for the prevention of adhesion formation. Eight weeks later, the word catheter was removed, and additional lysis of adhesions was performed. All the surgical procedures were performed without complication, and a healthy endometrium was observed at the second look hysteroscopy, in all the three patients. All 3 patients conceived after the procedure. Pregnancy was achieved after one IVF cycle with the transfer of one frozen embryo in case 1 and spontaneously in cases 2 and 3. Patient 1 was delivered by elective caesarean section due to placenta previa, while the other two patients had normal vaginal deliveries. Patient 1 had Retained Products of Conception requiring hysteroscopic removal using a 27 Fr Resectoscope. When using innovative miniaturized instruments and adequate surgical technique, hysteroscopic lysis of adhesions is a feasible and effective in-office strategy to restore fertility in patients with severe Asherman's syndrome. The use of 2D and 3D ultrasound played an important role in the preoperative workup of the patient with Asherman's syndrome.

Obstetrical Outcomes Among Asherman's Syndrome Patients: Comparing Classification Systems and Developing a Novel Calculator

Study Objective To compare the March Classification and ASRM Classification of Asherman's Syndrome as predictors of pregnancy and live birth, and to develop an obstetrical outcomes calculator. Design Cross-sectional observational study. Setting Outpatient minimally invasive gynecological surgery (MIGS) clinic Patients or Participants Asherman's Syndrome patients (n=127). Interventions Office hysteroscopic lysis of adhesions (LOA). Measurements and Main Results Patients were classified as “mild,” “moderate,” or “severe,” following both the March and ASRM classifications. Inconsistencies between March and ASRM classifications were found in 37.8% of patients. Model fit was assessed using Akaike information criterion (AIC), where lower AIC indicated better fit. Based on multivariable logistic regression analyses and controlling for confounding, the March Classification model was a stronger predictor of both pregnancy (AIC: 117.6 vs. 178.6) and live birth (AIC: 178.6 vs 178.9) following office hysteroscopic LOA than the ASRM Classification model. To address these discrepancies, patient medical history and obstetric/gynecologic history, presumed etiology, and cavity involvement were used to develop new models for pregnancy (AIC: 112.1) and live birth (AIC: 173.0). Using the estimates from the logistic regression, an Asherman's Syndrome obstetrical outcomes calculator was created to predict the probability of pregnancy and live birth following office hysteroscopic LOA. Conclusion First, this study underscores discrepancies between the March and ASRM classification systems regarding association with obstetrical outcomes; because of such inconsistency, these classification systems may have limited predictive ability and, thus, limited clinical utility. This study then offers a novel model for predicting obstetrical outcomes among Asherman's Syndrome patients who have undergone office hysteroscopic LOA, and we present it as a proof-of-concept calculator. This calculator has promising potential as a clinical tool. Limitations and areas to build upon include larger sample size and accounting for potential confounders.

Patient Reported Menstrual and Obstetrical Outcomes Following Office Based Hysteroscopic Lysis of Adhesions for Asherman's Syndrome

Study Objective To understand the impact of hysteroscopic adhesiolysis on menstrual and obstetrical outcomes amongst Asherman's syndrome patients when stratified by disease severity using the March classification system. Design A retrospective cohort study. Setting A community teaching hospital affiliated with a large academic medical center. Patients or Participants A total of 355 Asherman's syndrome patients who underwent hysteroscopic adhesiolysis from 01/01/2015 - 03/01/2019. Interventions Hysteroscopic adhesiolysis followed by telephone survey to determine menstrual and obstetrical outcomes. Measurements and Main Results A total of 150 (42.3%) patients completed the telephone survey with a mean follow-up of 2.21 years. They were representative of the clinic population, and comprised of 40.6% with mild, 52.7% with moderate, and 6.7% with severe Asherman's syndrome. Amenorrhea was reported at initial evaluation in 23.8% of all patients, with no significant difference by March classification. However, there was a significant difference in the resolution of amenorrhea with 93.7%, 85.0%, and 50.0% of mild, moderate, and severe Asherman's syndrome patients endorsing a return of menstruation following treatment. The cumulative pregnancy rate was 81.9%. There was no significant difference in live birth rate with 50.9%, 54.6%, and 16.7% amongst the mild, moderate and severe Asherman's syndrome patients. March classification was not a predictor for ≥1 pregnancy or ≥1 live births when adjusted for confounders using multivariable logistic regression modeling. March classification was a predictor of ≥1 miscarriage in moderate disease when compared to mild cases (95% CI 0.1 - 0.8, P-value Conclusion The patient reported return of menstruation as well as the pregnancy rate following hysteroscopic adhesiolysis of Asherman's syndrome patients are both promising, however not well predicted by the March classification system.

A comprehensive review of Asherman's syndrome: causes, symptoms and treatment options

Intrauterine adhesions, also known as Asherman's syndrome, can have an impact on both reproductive outcomes and gynaecologic symptoms. Understanding the cause of intrauterine adhesions and the common clinical presentation will increase awareness of the condition and guide the patient to appropriate therapy. Surgical management offers favourable fertility outcomes and is often successful in restoring menstruation. Surgical management with hysteroscopic lysis of adhesions is the gold standard for treatment and adopting an office-based approach offers several advantages. Prevention of reformation of adhesions remains challenging and no single method for preventing recurrence has shown superiority. Cell-based therapies using endometrial stem/progenitor cells hold promise for future use in regenerating inadequate endometrium. Increased awareness of the symptoms suggestive of intrauterine adhesive disease, as well as recognition of common causes and preceding events, is crucial for early diagnosis, patient counselling and treatment. VIDEO ABSTRACT: http://links.lww.com/COOG/A36.

Severe Asherman's Syndrome and Amenorrhea

In patients with Asherman's syndrome, standardized postoperative treatment after hysteroscopic lysis of adhesions with sequential use of an intrauterine foley balloon and copper intrauterine device may increase pregnancy rates.

Intrauterine Adhesions

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.

Intra-uterine adhesions and fertility outcome: how to optimize success?

To review the etiology, diagnosis, and clinical manifestations of intra-uterine adhesions and to address treatment with a specific focus on fertility outcome. Intra-uterine adhesions can cause recurrent pregnancy loss and infertility. The gravid or recently postpartum uterus is particularly susceptible to adhesion formation following instrumentation. While sonohysterography and hysterosalpingography are useful as screening tests of intra-uterine adhesions, hysteroscopy remains the mainstay of diagnosis and treatment. Hysteroscopic lysis of adhesions with scissors, electrosurgery, or laser can restore the size and shape of the endometrial cavity. Significantly obliterated cavities may require multiple procedures to achieve a satisfactory anatomical result. Postoperative mechanical distention of the endometrial cavity and hormonal treatment to facilitate endometrial regrowth appear to decrease the high rate of adhesion reformation. Newer antiadhesive barriers may also prevent the recurrence of intra-uterine adhesions. Endometrial development can remain stunted due to a scant amount of residual functioning endometrium and fibrosis. Potential pregnancy complications, especially placenta accreta, after the treatment of intra-uterine adhesions should be anticipated and discussed with the patient. Diagnosis and treatment of intra-uterine adhesions are integral to the optimization of fertility outcomes. Favorable results in terms of pregnancy and live birth rates can be expected after hysteroscopic adhesiolysis.

Gestational outcome following hysteroscopic lysis of adhesions

Thirty-eight infertile women conceived 43 times following treatment for intrauterine adhesions (IUA). Adhesions were classified as being minimal in 7 women, moderate in 20 others, and extensive in 11. All women underwent hysteroscopy with division of all adhesions utilizing miniature scissors and high-dose estrogen treatment for 2 months. In addition 35 of the 38 women had either an intrauterine contraceptive device or a Foley catheter placed to prevent readherence of the walls, and 31 women had the uterine cavity investigated again prior to attempting a pregnancy. Prior to treatment for IUA only 16.7% of all pregnancies in those women with no other cause for pregnancy loss resulted in the delivery of a living infant. However, following treatment 87.2% of these pregnancies resulted in the delivery of a viable infant (P less than 0.001). No instances of placenta accreta occurred, and manual removal of the placenta was not required. Division of adhesions under hysteroscopic control together with the adjunctive measures utilized is superior to all other methods of therapy for IUA and should replace them.