Page 29 - WJOLS - Laparoscopic Journal

Fadare Oluwaseun O

rate and is best utilized as a screening test for IUA. 27,30 292 women in whom treatment was withheld, were
Three-dimensional sonohysterography represents a newer collated, among whom 45.5% conceived spontaneously.
diagnostic modality that can detect IUA and also estimates The unpredictable outcome of this mode of treatment has
endometrial cavity volume, which is decreased in the setting made it very unpopular amongst patients.
of Asherman’s syndrome. 31,32 Although, three-dimensional
sonohysterography is quite sensitive and specific in the Blind Dilation and Curettage
detection of intrauterine abnormalities, hysteroscopy is still Before the advent of hysteroscopy, Asherman’s syndrome
32
33% more sensitive in diagnosing IUA. Transvaginal was treated by dilation and curettage of the uterus. It is not
ultrasonography (TVS) can demonstrate hyperechogenic surprising that this method resulted in a high incidence of
areas correlating with dense adhesions. TVS has high uterine perforation and had a low success rate. This method
specificity but widely varying sensitivity. TVS that is is now considered obsolete.
performed on women of high risk for IUA formation can
have very good accuracy and is very useful as screening Hysterotomy
test prior to hysteroscopy. 33,34 Preoperative endometrial
thickness as determined by TVS appears to have prognostic Transfundal separation of the walls of endometrial cavity
by hysterotomy has been described. In an analysis of
35
value in cases of severe Asherman’s syndrome. Recent
TVS studies demonstrated very thin endometrium and 31 cases of hysterotomies compiled from a total of 12
7
reports, 52% conceived and 25.8% had term deliveries.
absence of hematometra in most women with uterine outlet
36
occlusion by IUA. Recently, it has been stated that saline The procedure is, however, seldom performed nowadays
except in very severe cases where the uterine cavity is
infusion sonography (SIS) had a higher level of correlation 41
with hysteroscopic findings than TVS. 37,38 SIS and HSG completely obliterated. Reddy and Rock had also reported
their experience with this technique in three patients who
may have similar sensitivity with high false-positive rate. 38,39
40
Magnetic resonance imaging (MRI) also represents a newer had previous unsuccessful hysteroscopic resection of
intrauterine adhesions. All three patients resumed normal
diagnostic modality for IUA, which is under evaluation as
its limited application. The main advantage of MRI is its menstruation after surgical treatment,with re-establishment
of the uterine cavity and regeneration of the endometrium.
ability to image the uterine cavity above the adhesions and
assess the endometrial remnants in the upper part of the However, this method of treatment should only be
considered in the most extreme of situations, and patients
uterine cavity, which may influence the decision and
outcome of treatment, especially in those with uterine cavity should have been counseled with regard to the implications
or cervical canal obstruction that cannot be visualized by of a laparotomy, the potential risk of bleeding with
hysteroscopy. However, the MRI-signal characteristics of hysterectomy and the risk of scar rupture during
intrauterine adhesions have not been examined in detail; it is subsequent pregnancies.
anticipated that adhesions would produce low signal intensity Hysteroscopic Adhesiolysis
40
on T2 images. Further prospective results to address these
are awaited. The extent and location of IUA are best defined Hysteroscopic surgery is now the treatment of choice for
with hysteroscopy, and they can simultaneously be treated. Asherman’s syndrome because of its minimally invasive
In addition to diagnosis and treatment, hysteroscopy is nature and it can be performed under direct vision.
required for the classification of IUA. Adhesiolysis usually begins inferiorly and can be advanced
cephalad until the uterine architecture has been normalized. 20
TREATMENT OF ASHERMAN’S SYNDROME Sometimes, the mere touch of the endoscope can be
Treatment of Asherman’s syndrome aims at restoring the sufficient to separate filmy columns of adhesions. In most
size and shape of the uterine cavity, preventing recurrence cases, adhesiolysis may be performed with the help of the
of the adhesion, promoting the repair and regeneration of hysteroscopic scissors or other cutting modalities, such as
the destroyed endometrium and restoring normal laser or diathermy. In general, filmy and central adhesions
reproductive functions. should be divided first as these are more easily distinguished;
Thus, treatment modalities in this condition are described marginal and dense adhesions are more difficult to identify,
in the following sections: and division of these adhesions carries an increased risk of
uterine perforation.
Expectant Management Hysteroscopic adhesiolysis using scissors or biopsy
42
7
In a study by Schenka and Margalioth, 23 amenorrheic forceps has the advantage that it permits dissection and
women were noted from the literature, who had not avoids complications related to energy sources, and it
undergone any surgical intervention, of whom 18 regained possibly minimizes the destruction of endometrium. Surgery
regular menses after 1 to 7 years. For fertility outcome, that uses energy sources either with the electrode or laser

34
JAYPEE