Asherman's syndrome surgery
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor-In-Chief: Saud Khan M.D.
Overview
Hysteroscopy is diagnostic and therapeutic for Asherman's syndrome. In severe cases, laparoscopy is used to protect against perforation of the uterus.
Surgery
Fertility can be restored by removal of adhesions. Fluoroscopically guided operative hysteroscopy is used for visual inspection of the uterine cavity and dissection of scar tissue (adhesiolysis). In more severe cases, laparoscopy is used in addition to hysteroscopy as a protective measure against uterine perforation. Microscissors are usually used to cut adhesions. Electrocauterization is not recommended [1]. Devices to prevent the apposition of the uterine walls may be placed intraoperatively to reduce scar formation. Sometimes a balloon stent (Foley catheter or Cook stent) filled with saline is inserted in the uterus for up to 3 weeks to keep the walls of the uterus apart as they heal to prevent the reformation of adhesions. These may however, cause the unintended side effect of wall atrophy due to pressure.
Experimental protocols to rebuild the endometrium by infusing stem cells derived from the patient's blood cells, fresh or freeze-dried amniotic tissue may be used in the future. However, these remain untested. Although adhesive gels containing synthetic hyaluronidase have been studied and show promise.
Reevaluation one to two weeks postoperatively may allow earlier identification of recurrent adhesions while small and allow resection before these adhesions worsen. Follow-up testing is necessary to ensure that scars have not reformed. Further surgery may be necessary to restore a normal uterine cavity.
According to a recent study among 61 patients, the overall rate of adhesion recurrence was 27.9% and in severe cases this was 41.9%. [2] Another study found that postoperative adhesions reoccur in close to 50% of severe Asherman's and in 21.6% of moederate cases [3]. Mild IUA unlike moderate to severe synechiae do not appear to reform.
References
- ↑ Kodaman PH, Arici AA. (2007). "Intra-uterine adhesions and fertility outcome: how to optimize success?". Curr Opin Obstet Gynecol. 19 (3): 207–214. PMID 17495635.
- ↑ Yu D, Li T, Xia E, Huang X, Peng X. (2008). "Factors affecting reproductive outcome of hysteroscopic adhesiolysis for Asherman's syndrome". Fertility and Sterility. 89 (3): 715–722. doi:10.1016/j.fertnstert.2007.03.070. PMID 17681324.
- ↑ Valle RF, Sciarra JJ. Intrauterine adhesions: hysteroscopic diagnosis, classification, treatment, and reproductive outcome. Am J Obstet Gynecol 1988; 158:1459-1470.