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WJOLS

Reproductive Outcome following Hysteroscopic Adhesiolysis in Patients with Asherman’s Syndrome

are rather complex and difficult to use. More recently, an curettage at the time of treatment of adhesions was
improved classification system has been developed that takes secretory in 80%, proliferative in 12%, atrophic in 5%
20
into account clinical presentations, hysteroscopic findings and hyperplastic in 3%. It appears that dense fibrous
15
and past reproductive performance. This scoring system adhesions without glands carry the worst prognosis for
is attractive because of its potential to predict reproductive patients in terms of both menses and fertility, as lack of
outcome. None of these classification systems, however, evidence at pathophysiological level makes the choice
have been validated by clinical studies, and no one has used of an effective treatment more difficult.
them uniformly when reporting reproductive outcome after
treatment of intrauterine adhesions. Thus, comparison DIAGNOSIS
among the different reports that include outcomes is Women with IUA seeking help from the gynecologists may
difficult. present different clinical manifestations from menstrual
disorder, dysmenorrhea to subfertility and pregnancy
ETIOLOGY
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complications. In Schenker and Margalioth’s study, it was
The etiology of Asherman’s syndrome is not clear as the further reported that, among 165 pregnancies in women
pathophysiology of the regeneration of the endometrial layers with untreated Asherman’s syndrome, the rate of
is not well understood. However, its causes can largely be spontaneous miscarriage was 40%, preterm delivery was
grouped into: 23%, term delivery was 30%, placenta accreta was 13%
1. Mechanical and iatrogenic complications with excessive and ectopic pregnancy was 12%. The pregnancy
local destruction beyond the basal layer of the complication rates in this group of patients appeared to be
endometrium into the ‘compact zone’ covering the high, although there was no proper control group.
myometrium. Examples include curettage for The presence of IUA can be suspected, taking into
miscarriage, evacuation of retained products for account relevant information from a thorough personal
incomplete miscarriages, manual removal of placenta, patient history aimed to identify previous gynecological
hysteroscopic resection of polyps or multiple submucous infections, pelvic inflammatory disease, iatrogenic correlated
uterine fibroids, abdominal myomectomy with opening complications, obstetrical complications and history of
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of the uterine cavity, uterine artery embolization and pelvic tuberculosis. Other causes of amenorrhea and
uterine septum resection. 18 menstrual disturbances should be ruled out. Pregnancy is
2. Pathophysiological disturbance, such as endometritis, the most frequent cause of amenorrhea in this age group
complete miscarriage, septic abortion as well as uterine and should be assessed prior to any other work-up.
tuberculosis. Genital tuberculosis, which appears to be Secondary amenorrhea of course is associated with many
an important and common cause of Asherman’s causes including polycystic ovarian syndrome, hypothalamic
syndrome in India, 19,20 carries a rather poor prognosis amenorrhea, ovarian failure and hyperprolactinemia.
21
with treatment. Other causes include schistosomiasis, 22 Asherman’s syndrome should be considered in any patient
Müllerian malformations, atrophy due to a long period with a recent history of trauma to the uterine cavity.
23
of lactation or menopause. 24 Laboratory evaluation should consist of serum pregnancy
3. Idiopathic cause when no apparent reason is found. The test, complete blood count, and depending on the history
findings of Asherman’s syndrome vary considerably and physical examination, follicle-stimulating hormone,
from complete obliteration to minimal adhesions. There thyroid stimulating hormone (TSH) and prolactin. In almost
can also be filmy, fluffy adhesions or dense adhesions all cases of IUAs, the physical examination will be normal.
that are difficult to cut with hysteroscopic scissors. The Hysteroscopy represents the gold standard for the
extent of findings at hysteroscopy includes adhesion of diagnosis of IUA, since it offers a direct view of IUA.
the cavity ranging from filmy to severe, total atresia and Comparatively, sonohysterography and hysterosalpingo-
cervicoisthmic adhesions. Adhesions in the cavity are graphy have a sensitivity of 75% with positive predictive
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the most common, whereas total atresia and values of about 43 and 50%, respectively. A recent study
20
cervicoisthmic adhesions are rare. A subgroup of comparing hysterosalpingography with hysteroscopy found
women with Asherman’s syndrome due to uterine outlet a sensitivity and specificity of 81.2 and 80.4% respectively,
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obstruction from intrauterine or cervical adhesions was for hysterosalpingography. Hysterosalpingography is
demonstrated to have substantially thinner albeit normal limited by its high false-positive rate, which stems from its
endometrium with very uncommon finding of inability to distinguish between varying etiologies of filling
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hematometra. The histologic appearance is variable defects; hysterosalpingography, therefore represents a good
and can be endometrial, myometrial or connective tissue. screening test for IUA with the added benefit of its ability
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Most frequent are fibromuscular bands, sometimes lined to assess tubal patency. Like hysterosalpingography,
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with endometrium. Endometrium obtained by sonohysterography is also limited by its high false-positive
World Journal of Laparoscopic Surgery, January-April 2011;4(1):31-39 33