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WJOLS

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

Adhesion reformation has been a major limiting step to presence of fibrosed endometrium, which impairs successful
the success of the operation. The reformation of intrauterine implantation. Thus, pregnancies in women with a history
adhesions appears to be directly related to the severity of of Asherman’s syndrome should be considered to be high
the adhesions. It has been reported that the recurrence rate risk. Careful monitoring during the antenatal period, especially
for intrauterine adhesions ranges from 3.1 to 23.5% among the third trimester, should be undertaken. Also, the
all cases of intrauterine adhesions and from 20 to 62.5% in importance of preventing Asherman’s syndrome cannot be
those with severe adhesions. Repeat surgery for those who overemphasized. Such preventive measures include the need
have adhesion reformation may be worthwhile as there have to avoid postpartum or postabortal curettage; the need for
been case reports of conception and delivery after repeated gentle curettage, if surgical evacuation is needed; and
surgical adhesiolysis. 50 preference for medical management of miscarriages.
Another outcome measure of the procedure is restoration
of normal menses. The return of menstruation has been CONCLUSION
reported to range from 52.4 to 88.2%. From five available Asherman’s syndrome is a worldwide disease and
studies; we can conclude that, of 625 women who hysteroscopy remains the method of choice in the
underwent surgical treatment of Asherman’s syndrome, investigation and treatment of the condition. The
84.5% regained normal menstruation. management of moderate to severe disease remains a
Finally, in women who present with infertility or challenge, while the prognosis of severe disease remains
recurrent pregnancy loss, the outcome may be measured in poor. In those who succeed in achieving pregnancy after
terms of pregnancy rate and live birth rate. Pace et al 61 treatment of the condition, careful surveillance of the
reported that in women with Asherman’s syndrome, pregnancy is essential because a number of obstetrics
pregnancy rate varied from 28.7% before surgery to 53.6% complications may occur. Large prospective controlled
after hysteroscopic treatment. In a study of women with studies are needed to determine the best diagnostic and
62
two or more previous unsuccessful pregnancies, the treatment modalities for intrauterine adhesions.
operative success as measured by live birth rate improved
from 18.3% preoperatively to 68.6% postoperatively. In REFERENCES
the literature, the pregnancy rate after hysteroscopic lysis 1. Fritsch H. Ein Fall von volligem Schwund der Gebormutterhohle
of intrauterine adhesions in women who wanted to have a nach Auskratzung. Zentralbl Gynaekol 1894;18:1337-42.
child has been about 74%, which is much higher than found 2. Asherman JG. Amenorrhoea Traumatica (Atretica). J Obstet
Gynaecol Br Emp 1948;55:23-30.
in untreated women (46%). The pregnancy rate after 3. Asherman JG. Traumatic intrauterine adhesions. BJOG
treatment in women with infertility is about 45.6%; the 1950;57:892-96.
successful pregnancy rate after treatment in severe cases 4. Taylor PJ, Cummings DC, Hill PJ. Significance of intrauterine
is reported to be consistently lower at 33%. For women adhesions detected hysteroscopically in eumenorrhoeic infertile
with previous pregnancy wastage, both the pregnancy rate women and the role of antecedent curettage in their formation.
Am J Obstet Gynecol 1981;139:239-42.
and the live birth rate after treatment are reasonably high— 5. Practice Committee of the American Society for Reproductive
89.6 and 77.0% respectively. Medicine. Current evaluation of amenorrhea. Fertil Steril
Women who conceive after treatment of Asherman’s 2006;86:S148-55.
syndrome still have a high risk of pregnancy complications, 6. AAE Orhue, ME Aziken, JO Igbefoh. A comparison of two
including spontaneous abortion, premature delivery, adjunctive treatments for intrauterine adhesions following lysis.
International Journal of Gynecology and Obstetrics 2003;82:49-
abnormal placentation, intrauterine growth restriction 56.
(IUGR) and uterine rupture during pregnancy or delivery. 7. Schenker JG, Margalioth EJ. Intrauterine adhesions: An updated
63
Everett reported that, in the general population, in 550 appraisal. Fertil Steril 1982;37:593-610.
women who conceived, bleeding occurred before the 20th 8. Chapman K, Chapman R. Asherman’s syndrome: A review of
the literature, and a husband and wife’s 20-year world-wide
week in 117 patients (117 out of 550; 21%), and 67 experience. J R Soc Med 1990;83:576-80.
pregnancies (67 out of 550; 12%) ended in miscarriage. 9. Toaff R, Ballas S. Traumatic hypomenorrhea-amenorrhea
The spontaneous miscarriage rate after treatment of (Asherman’s syndrome). Fertil Steril 1978;30:379-87.
intrauterine adhesions was around 20% (94 out of 477). 10. March CM, Israel R, March AD. Hysteroscopic management
It is unclear whether this represents an increase in the risk of intrauterine adhesions. Am J Obstet Gynecol 1978;130:
653-57.
of early miscarriage after treatment of Asherman’s 11. Valle RF, Sciarra JJ. Intrauterine adhesions: Hysteroscopic
syndrome, as the likelihood of miscarriage in the general diagnosis, classification, treatment, and reproductive outcome.
population (about 15 to 20%) is rather close to this figure. Am J Obstet Gynecol 1988;158:1459-70.
Continued collection of data is required to determine if the 12. Donnez J, Nisolle M. Hysteroscopic lysis of intrauterine
adhesions (Asherman’s syndrome). In: Donnez J (Ed). Atlas of
miscarriage rate after treatment of Asherman’s syndrome laser operative laparoscopy and hysteroscopy. New York: Press
is increased. This increased rate could be related to the Parthenon 1994:305-22.

World Journal of Laparoscopic Surgery, January-April 2011;4(1):31-39 37