It is called Asherman’s syndrome, also referred to as synechiae or simply adhesions. It is a condition where there is gluing or gumming together of the walls of the front and back of the uterus. It is most prevalent in developing countries like Nigeria due to the continued practice of unsafe abortions and following unskilled dilatation and curettage (D&C) to complete the abortion process.
It is an acquired uterine condition that occurs when irregular scar tissue (adhesions) form inside the uterus or the cervix. AS and related disorders are also described as uterine/cervical atresia, traumatic uterine atrophy, and intrauterine adhesion bands.
Uterine adhesion is responsible for about 25- 30% of the causes of infertility in Nigeria. It is present in 1-2 women out of 15 patients undergoing fertility evaluations per IVF cycle at MART.
Causes of AS
Asherman’s syndrome affects women of all races and ages equally, which suggests that it cannot be inherited.
- Following complicated Dilatation and curettage (D and C) cases
- Pelvic Inflammatory Disease (PID
- Chronic endometritis from genital tuberculosis is a significant cause of severe intrauterine adhesions (IUA) in the developing world, often resulting in total blockage of the uterine cavity, which is challenging to treat.
- Following healing after removal of fibroid tumors (myomectomy)
- Following Caesarean section (C/S) cases and manual removal of placenta
- Another form of AS can be surgically induced by endometrial ablation (surgical removal of endometrial tissue)in women with excessive uterine bleeding instead of hysterectomy (total removal of the uterus).
- Other causes include IUDs, pelvic irradiation, schistosomiasis
Sometimes it could be unexplained.
Signs and symptoms of AS include;
Asherman syndrome can present in several ways, which include:
- Infertility (most common), affecting approximately
- Disorders of the Menstrual cycle, amenorrhea (absent menses), or reduced menstrual flow.
- Cyclical/monthly pain with no actual bleeding can occur in patients with cervical adhesions/stenosis; because there is a blockage to the outflow of blood. It can lead to a backflow of blood and eventually result in endometriosis (endometrial tissue outside the uterine cavity). It is also a contributory factor to infertility in these women.
- Repeated pregnancy loss
- Disorders of placentation, including placenta accreta and previa, are relatively rare
Diagnosis
- Hysteroscopy is the gold-standard method for the diagnosis of intrauterine adhesions,
- Hysterosalpingography (HSG) – the dye test
- Sonohysterography (SHG), involving a transvaginal scan after the introduction of sterile water or saline, has a diagnostic accuracy comparable to HSG for the identification of intrauterine adhesions
- Magnetic Resonance Imaging (MRI) can be used as an additional diagnostic tool.
Treatment
- Hysteroscopicadhesiolysis- relieving the adhesions via hysteroscopy
- Ultrasound-guided dilatation and curettage (D&C) – done if hysteroscopy is unavailable.
The restoration of normal endometrium occurs with the trial of hormones, stem cells, and platelet-rich plasma (PRP). We have recently adopted the platelet-rich plasma (PRP) method at MART for patients with Asherman syndrome following adhesiolysis. We have improved endometrial growth by an average of 2mm against previous non-PRP cycles.
Prevention of AS recurrence
AS can recur after a successful adhesiolysis and prevent it intraoperatively and post-operatively.
- A pediatric Foley catheter with a 3-mL balloon can be inserted into the uterus and left in place for 7–10 days after surgery.
- Insertion of an intrauterine device (IUD) immediately after adhesiolysis is used successfully to prevent the recurrence of adhesions. However, it may not be as effective as the placement of a pediatric Foley and is no longer favored in the United States.
- Postoperative treatment with antibiotics for prevention of endometritis and exogenous estrogen supplementation to stimulate rapid endometrial regeneration is frequently used in efforts to improve outcomes,
- Oral doxycycline is commonly prescribed for the interval during which an intrauterine catheter is in place.
- Oral conjugated equine estrogens are often prescribed for a few days up to a month after surgery, in combination with oral medroxyprogesterone acetate, 10 mg daily, during the last ten days of exogenous estrogen treatment.
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