June 25, 2024
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Case Study

Mrs X, a 32-year-old woman, has a history of one natural vaginal delivery seven years ago and a medical abortion five years ago, followed by D&C for retained products. She has been trying to conceive for four years. An ultrasound shows an 18 mm follicle on day 13 of her cycle but reveals an endometrial thickness of only 5 mm with irregular margins. She has experienced scanty menstrual flow during periods for the last three years. Hysterosalpingography (HSG) indicates bilateral patent fallopian tubes, and her partner’s semen analysis is normal.

Asherman’s Syndrome (AS)

Asherman’s Syndrome involves the presence of intrauterine adhesions (IUA) and is characterized by symptoms such as amenorrhea, hypomenorrhea, recurrent pregnancy loss, infertility, and a history of abnormal placentation. The prevalence of AS in women with impaired fertility ranges from 2.8% to 45.5%.

Risk Factors

  • Over 90% of AS cases occur after pregnancy-related curettage, as the basal layer is destroyed.
  • Incidence of IUA after one curettage is 10%.
  • Incidence increases to 30.6% with at least two curettages.

Diagnosis

Transvaginal Ultrasound

  • Thin endometrium with irregular margins.
  • Echo dense pattern.
  • Endometrium interrupted by one or more translucent “cyst-like” areas.
  • Unenhanced transvaginal ultrasonography alone has low sensitivity and positive predictive value as low as 0%.
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Hysterosalpingography (HSG)

  • Filling defects described as homogeneous opacity surrounded by sharp edges.
  • Simultaneous evaluation of fallopian tubes.
  • High false positive rate.

Sonohysterography (SHG)

  • Improves accuracy significantly, with an accuracy rate of 50.3% in HSG group and 81.8% in SHG group.

Three-Dimensional Sonohysterography (3D-SHG)

  • Sensitivity and specificity are 91.1% and 98.8%.

MRI

  • Useful when the uterine cavity is totally obliterated.
  • IUA are visualized as low signal intensity on T2 weighted images.
  • Expensive, but remains the gold standard for assessing AS.

Management and Treatment of Asherman’s Syndrome

Treatment Strategy

  1. Dilatation and Curettage (D&C) and Hysteroscopy
  2. Prevention of Re-Adhesion
    • Intrauterine device (IUD)
    • Uterine balloon stent
    • Foley’s catheter
    • Anti-adhesion barriers
  3. Restoring Normal Endometrium
    • Hormonal treatment
    • Stem cells
  4. Post-Operative Assessment
    • Repeat surgery
    • Diagnostic hysteroscopy
    • Ultrasound

Hysteroscopic Surgery Principles

  • Flimsy Lesions: Tip of the hysteroscope and uterine distension enough to break down adhesions – “no touch technique.”
  • Removal Technique: Start from the lower part of the uterus, progressing toward the upper part.
  • Dense Adhesions: Treat at the end due to the greater risk of uterine perforation and bleeding.
  • Cold-Knife Approach: Preferred over electric surgery to prevent potential damage to the residual endometrium.
  • Bipolar over Monopolar Surgery: More focal tissue effect and safer electrolyte-containing uterine distension media.
  • Laser Surgery: Higher costs and increased uterine damage.

Prevention of Adhesion Recurrence

  • IUD: Separates anterior and posterior uterine walls, aiding endometrial regeneration. Some concerns about inflammatory responses.
  • Foley Catheter: Higher conception rate compared to IUD. Complications include uterine perforation and infection.
  • Intrauterine Balloon Stent: Fits the uterine cavity shape, showing promising pregnancy rates. Requires more safety and efficacy data.
  • Hyaluronic Acid: Forms a temporary barrier, aiding in tissue repair and preventing adhesions.

Restoration of Normal Endometrium

  • Estrogen Supplementation: Encourages endometrial growth and prevents new scar formation. The ideal dosage and route (vaginal or oral) are still under study.
  • Stem Cell Therapy: Shows promise in endometrial regeneration but requires more research for clinical application.

Complications of AS

  • Obstetric Complications: Lower birth weight, increased incidence of preterm delivery, and retained placenta (placenta accreta in 10.7% of patients).

Success of Hysteroscopy

  • Overall pregnancy rates from 40% to 63% after hysteroscopic adhesiolysis.

Second-Look Hysteroscopy

  • Recommended one to two months post-treatment to assess uterine cavity and manage recurrence.
  • Studies show improved pregnancy and live birth rates with second-look hysteroscopy.

Resistant Thin Endometrium

  • Drugs to Increase Endometrial Blood Flow: Pentoxyfilline, tocopherol, sildenafil, L-arginine, and low-dose aspirin. However, these therapies have not met with much success.

Canadian Fertility and Androgyny Society Guidelines