What Are Intrauterine Adhesions (Asherman Syndrome)? What Are the Treatment Methods?

What Are Intrauterine Adhesions (Asherman Syndrome)? What Are the Treatment Methods? We spoke with the Obstetrics and Gynecology Specialists of Hisar Hospital Intercontinental...

Intrauterine adhesions are a condition in which the uterine cavity is partially or completely closed as a result of adhesions called synechiae that form inside the uterus. They can cause menstrual irregularities, inability to conceive, or recurrent pregnancy loss. It was first described in 1948 by Joseph Asherman.

In a normal menstrual cycle, a bed for pregnancy implantation is prepared every month in the area inside the uterus called the endometrium (uterine lining). Under the influence of the hormones estrogen and progesterone, secreted by eggs developing in the ovaries, the inside of the uterus is prepared for pregnancy every month. If pregnancy does not occur, this prepared bed is shed with menstruation. Unfortunately, as a result of these adhesions inside the uterus, the menstrual cycle cannot function healthily, and because the endometrial bed cannot be prepared well, a favorable environment for pregnancy to implant or progress healthily cannot be established. Therefore, menstrual irregularities or pregnancy problems arise.

What Causes Intrauterine Adhesions?

Certain surgical procedures performed on or inside the uterus, operations, and infections that have been experienced affect the deep layer responsible for regenerating the inside of the uterus. While repairing the damage in this layer, some scar tissue forms. These layers can create adhesions, called synechiae, in various locations inside the uterus.

The risk of adhesions increases especially after sharp curettage performed for childbirth or miscarriage. In some cases, the risk is even higher when the procedure is repeated because tissue was retained inside.

Development of infection in the uterus during or after the procedure is another risk factor. Especially after curettage not performed under appropriate and sterile conditions, or after some methods used by people to induce a miscarriage on their own, an infection may develop in the uterus. If the diagnosis is not made early and treatment cannot be given, these infections are highly likely to heal with adhesions.

In addition, surgeries to remove fibroids from the uterus, infection developing during IUD (coil) use, and hysteroscopic operations performed due to uterine anomalies are other causes that can lead to adhesions in the uterus. Rarely, tuberculosis infection reaching the uterus through the bloodstream from the lungs can also cause adhesions in the uterus.

What Are the Symptoms?

The most common presentation is with menstrual problems. Menstrual bleeding may be completely absent, scant, or painful. These symptoms may vary depending on the location and density of the adhesions inside the uterus.

The second most common reason for presentation is infertility, i.e., inability to have children. Intrauterine adhesions can both cause problems with sperm passage and prevent the embryo from implanting in the uterus due to irregularities in the endometrium, i.e., the uterine lining.

In some patients, they may cause problems after pregnancy has been achieved. They can cause complications in the progression of pregnancy, leading to recurrent miscarriages. In more advanced pregnancies, they can lead to high-risk pregnancies in which the placenta attaches to the inner layer of the uterus.

How Is It Diagnosed?

Intrauterine adhesions may not always be noticed on routine ultrasound. However, in suspected cases, thinning, irregularities, and brightness in certain areas of the uterine lining may be seen. Sonohysterography, in which fluid is introduced into the uterus, can be more helpful to us.

However, a definitive diagnosis is made with hysterosalpingography (uterine film). On the film, filling defects and irregularities are seen in the area of the uterus that should be filled with radiopaque material. The uterine film also gives us information about the severity of the adhesions and whether the tubes are open.

Hysteroscopy, the procedure in which the inside of the uterus is visualized with a camera system, can both establish the diagnosis and treat the adhesions by removing them.

How Are Intrauterine Adhesions Classified?

Intrauterine adhesions can range from mild, film-like adhesions to dense, thick adhesions. They can be classified according to the area they cover inside the uterus and their density as follows (March classification);

Class

Mild

Moderate

There are adhesions in 1/4-3/4 of the uterine cavity. The upper part of the uterine cavity and the tubal ostia are partially obstructed.

Severe

There are harder, dense adhesions in more than 3/4 of the uterine cavity. The tubal ostia and the upper part of the uterine cavity are completely obstructed.

What Are the Treatment Methods?

The most effective method for removing intrauterine adhesions is hysteroscopy. While it can be performed in the office setting for mild adhesions, moderate or severe adhesions need to be treated in the operating room under anesthesia. An endoscope inserted into the uterus through the vagina allows the inside of the uterus to be observed. The structure and density of the adhesions are determined. Then, with the help of suitable instruments, the adhesions are removed. The aim is to bring the uterine cavity to sufficient width and to keep the pathway to the tubes open.

If risky conditions are suspected during the procedure or if the adhesions are very dense, it may be necessary to remove the adhesions by hysteroscopy under laparoscopic visualization of the abdomen.

Post-Treatment Considerations

Various measures are applied to prevent adhesions from recurring after treatment. These include placing an IUD (coil) in the uterus and then using hormone therapy for several months. In addition, some anti-adhesion gels placed inside the uterus after the procedure may also be used. However, it should be kept in mind that adhesions may still recur despite these measures.