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ASHERMAN’S SYNDROME: HOW TO IMPROVE THE RESULTS?

AAGL 5th INTERNATIONAL CONGRESS ON MINIMALLY INVASIVE GYNECOLOGY TSGE IV. ANNUAL SCIENTIFIC MEETING April 6- 10, 2011 İSTANBUL. ASHERMAN’S SYNDROME: HOW TO IMPROVE THE RESULTS?. Recai PABUÇCU, MD Ufuk University Faculty of Medicine Obstetrics and Gynecology Department.

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ASHERMAN’S SYNDROME: HOW TO IMPROVE THE RESULTS?

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  1. AAGL 5th INTERNATIONAL CONGRESS ON MINIMALLY INVASIVE GYNECOLOGY TSGE IV. ANNUAL SCIENTIFIC MEETING April 6- 10, 2011 İSTANBUL ASHERMAN’S SYNDROME: HOW TO IMPROVE THE RESULTS? Recai PABUÇCU, MD Ufuk UniversityFaculty of Medicine ObstetricsandGynecologyDepartment

  2. 1894 – HeinrichFritsch Firstdescribed a case of posttraumaticintrauterineadhesion. 1927 – Bass 1946 – Stamer 1948 – Joseph G. Asherman AshermanSyndrome has beenusedtodescribethedisease ever since. HISTORY

  3. DEFINITION • Intrauterineadhesionsare; a consequence of traumatotheendometrium, producingpartialorcompleteobliteration in theuterinecavityand/orthecervicalcanal. • Theprevelancevariesbothbydifferentpopulations as well as bythetypes of investigationusedfordiagnosis. (approximately %1,5) Al-Inany H. ActaObstetGynecolScand 2001

  4. Thecriteriaforthediagnosis of Ashermansyndrome; At leastone of thefollowingclinicalfeatures; Amenorrhea, hypomenorrhea Subfertility, infertility Recurrentpregnancyloss History of abnormalplacentation (previa, acreta…) The presence of intrauterineadhesionsbyHysteroscopyand/orhistologicallyconfirmedintrauterinefibrosis. Dan Yu et al. Fertil Steril 2008

  5. ETIOLOGY • Traumato a graviduterinecavity (%66.7) • Curettage (postpartum, postabortion, elective) • Cesareansection • Evacuation of hydatiformmole • Traumatonongravidendometrium • (Diagnosticcurettage, myomectomy, insertion of a IUD, operativehysteroscopy…) • Infection(chronicorsubacuteendometritis) • Congenitalanomaly of theuterus (esp. Septateuterus) • Geneticpredisposition Dan Yu et al. Fertil Steril 2008

  6. European Society of Gynecological Endoscopy (ESGE) 1995 Endoscopic surgery for Gynecologists, 1998 CLASSIFICATION

  7. SYMPTOMATOLOGY • Menstrualabnormalities(%68) • Infertility (%43) • Recurrentpregnancyloss • Otherpregnancycomplications • Spontaneousmiscarriage • Pretermdelivery • Abnormalplacentalimplantation • Ektopicpregnancy • IUGR-? Dan Yu et al. Fertil Steril 2008

  8. CLINICAL– PATHOLOGICALCORRELATION • The clinical features are closely associated with pathological findings in Asherman syndrome. • These pathological findings are: • The depth of fibrosis • The location of the adhesions • The extent of the pathologic changes Dan Yu et al. Fertil Steril 2008

  9. CLINICAL– PATHOLOGICALCORRELATION SYMPTOMS Variable Obstructive amenorrhea Variable Amenorrhea and infertility Obstructive amenorrhea Dan Yu et al. Fertil Steril 2008

  10. DIAGNOSIS • RadiologicalDiagnosis • Hysterosalphingography • Ultrasonography • Sonohysterography • MRI • Hysteroscopy USG H/S

  11. IU Adhesions Management • Adhesiolysis (H/S) • Lippes loop • High dose estrogen therapy • Follow up by H/S or HSG after treatment • Restoration of the uterine cavity • Prevention of recurrence • Endometrial restoration • Maintanence of the normal cavity AIM PROCEDURE

  12. TREATMENT • ExpectantManagement • Dilatation & Curettage • Hysterotomy • Hysteroscopy • Because of itsminimallyinvasivenatureandalsobecause it can be performedunderdirectvision“Hysteroscopy” is currentlythegoldstandardforthetreatment of intrauterineadhesions.

  13. HYSTEROSCOPIC ADHESIOLYSIS • Adhesiolysisusuallybeginsinferiorlyand can be advanceduntiltheuterinearchitecture has beenrestored. Inmostcasesadhesiolysis can be performedbyscissorsorgraspers but sometimeselectrosurgery is needed.

  14. Pabuçcu R., Fertil Steril, 1997 • Hysteroscopicadhesiolysis is a safeandeffectiveprocedureforrestoringthe normal menstrualpatternandfertility.

  15. Pabuçcu R., Fertil Steril, 1997 • Fortywomenwithrecurrentpregnacylossorinfertilityresultingfromintrauterineadhesions. • Afterhysteroscopicadhesiolysis; • In 16 infertilecases; • %63 (n:10) conceived, • %37 (n:6) termorviablepretermdelivery • In 24 caseswithrecurrentpregnancyloss; • %71 termorviablepretermdelivery

  16. HYSTEROSCOPIC ADHESIOLYSIS • Hysteroscopicadhesiolysisusingscissorsorbiopsyforceps has theadvantages of; • Avoidingcomplicationsrelatedtoenergysources, • Minimizingthefurtherdestruction of theendometrium, • Decreasingtherecurrentadhesionformation. Fedele L, ActaEurFertil 1986 Feng ZC, GynaecolEndosc 1999

  17. HYSTEROSCOPIC ADHESIOLYSIS • Hysteroscopicsurgeryusingenergysourcessuch as laservaporizationorelectrodesprovideseffectiveandprecisecutting as well as betterhemostasis. But there is a possibility of furtherendometrialthermaldamage Duffy S, J ObstetGynaecol 1992 Roge P, GynaecolEndosc 1997 • However, otherauthorssuggestthatthere is no differencebetweentheuse of scissorsandresectoscope. Alsoelectrosurgeryachievesbetterhemostasis, thusproviding an improvedclarity of theoperativefield. De Cherney A, ObstetGynecol 1983 Cararach M, HumanReproduction 1994

  18. Reproductive outcome following hysteroscopic adhesiolysis in patients with fertility due to Asherman’s syndrome • 89 patientswithinfertilityduetoAshermansyndrome • Retrospectiveclinicalanalysis • Hysteroscopicadhesiolysisbymonopolarelectrodeknife • A secondlookofficehysteroscopywasperformed in allcasesafter 2 months Roy K et al. Arch Gynecol Obstet, 2010

  19. Reproductiveoutcomefollowinghysteroscopicadhesiolysis in patientswithfertilityduetoAsherman’ssyndrome • 12 patientsshowedreformation of adhesionsandneeded a repeatprocedure • Conception rate 40.4 % • Livebirth rate 86.1 % • Miscarriage rate 11.1 % • Hysteroscopicadhesiolysis is safeandeffectiveforrestoringmenstrualfunctionandfertility. Roy K et al. Arch Gynecol Obstet, 2010

  20. HYSTEROSCOPIC ADHESIOLYSIS ***

  21. HYSTEROSCOPIC ADHESIOLYSIS ***

  22. HYSTEROSCOPIC ADHESIOLYSIS ***

  23. HYSTEROSCOPIC ADHESIOLYSIS • Hysteroscopicmanagement of theintrauterineadhesions, especiallythe severe and dense ones; • May be technicallydifficult, • Alsocarries a significant risk of uterineperforation. • Perforationusuallyoccursduringthedilatation of thecervicalcanalor / andtheintroduction of thehysteroscope.

  24. HYSTEROSCOPIC ADHESIOLYSIS • Inordertoimprovethesafetyandefficiency of thehysteroscopicadhesiolysis, andalsoto minimize the risk of uterineperforationtheprocedure can be guidedbyone of thefollowingmethods: • Laparoscopy • Transabdominalultrasonography • Fluoroscopiccontrol • Gynecoradiologicuterineresection

  25. PREVENTION OF RECURRENT ADHESIONS • Because of thehigh rate of reformation of theadhesions (%3.1- 23.5), esp. the severe ones (%20-62.5) preventionaftersurgery is essential. • The risk is directlycorrelatedwiththetypeandtheetiology of adhesions.

  26. PREVENTION OF RECURRENT ADHESIONS • Prevention of recurrentadhesionsaftersurgery is essentialfor a successfultreatment • Methodsusedforprevention: • Second / Thirdlookhysteroscopicadhesiolysis • BarrierMethods (Sepra film, hyaluronicacid gel, amniongraft) • MechanicalMethods (IUD, Lippesloop, Foleybaloon) • HormoneTreatment (estrogen, progestin, GnRHanalogues, danazole) • PharmacologicAgents (antibiotics, NSAID, Caantagonists, antihistaminics)

  27. PREVENTION OF RECURRENT ADHESIONS • Serial hysteroscopic adhesiolysis after primary treatment of intrauterine adhesions, is an effective method for the maintenance of the cavity as well as the prevention of recurrence. 1) SERIAL HYSTEROSCOPY Robinson JK et al. Fertil Steril 2008 Wheeler et al. Fertil Steril 1993

  28. AIM: Toevaluatepostoperativebluntadhesiolysisaftersharpadhesiolysisforthetreatment of intrauterineadhesions. • DESIGN: Retrospectiveanalysis of 24 patientstreatedwithprimaryhysteroscopicadhesiolysisfollowedbyhormonetherapyandserialflexibleofficehysteroscopy. Robinson JK et al. Fertil Steril 2008

  29. Initialpostoperativeofficehysteroscopieswereperformedwithin 2 weeks of theprimarysurgery. Subsequenthysteroscopieswereperformedevery 1-3 weeksuntil minimal to no diseaseremained . • RESULTS: • Improvement in menstrual flow in 95%, • Relief of dysmenorrhea in 92% and, • %46 of fertilitypatientswereactivelypregnantor had deliveredviableinfants. Robinson JK et al. Fertil Steril 2008

  30. PREVENTION OF RECURRENT ADHESIONS 2) BARRIER METHODS • Seprafilm, is a bioresobable membrane of chemically modified hyaluronic acid and carboxymethylcellulose, was shown to be effective in reducing adhesion formation. • Tsapanos et al. reported that, • Placement of Seprafilm; into the both cervical canal and endometrial cavity after suction evacuation or curettage for incomplete, missed and recurrent abortion, effectively prevents adhesion formation. Tsapanos et al. J Biomed Mater Res 2002

  31. PREVENTION OF RECURRENT ADHESIONS 2) BARRIER METHODS • Auto-cross linked hyaluronic acid (ACP) gel • Hyaluronic acid is a natural component of the extracellular matrix and has been suggested as a possible adhesion barrier • After hysteroscopic adhesiolysis intracavitary ACP gel application, effectively prevents postoperative adhesion formation. • De Iaco et al., Fertil Steril 1998 Acunzo G et al. Hum Reprod 2003 Guida M et al. Hum Reprod 2004

  32. PREVENTION OF RECURRENT ADHESIONS 2) BARRIER METHODS • Amnion Graft • Hysteroscopic adhesiolysis was followed by introduction of a fresh amnion graft draped over an inflated Foley catheter balloon in 25 patients. • Repeat hysteroscopy showed further adhesion formation in 48% but all these were minimal. • Long-term data are not available. Amer MI et al, J Obset Gynecol Res, 2006

  33. PREVENTION OF RECURRENT ADHESIONS • Some studies reported that the application of a 8 – 10 F Foley catheter into the uterine cavity with an inflated balloon for several days after adhesiolysis may prevent recurrence. 3) MECHANICAL METHODS Orhue AA et al. Int J Gynaecol Obstet 2003 Amer MI et al. MEFS J 2005

  34. PREVENTION OF RECURRENT ADHESIONS • In a comparative study, after lysis of adhesions either a 10 F Foley catheter balloon, inflated with 3,5 ml of saline was left in the uterine cavity for 10 days or Lippes loop was placed for 3 months. • Foley catheter resulted in a greater proportion of women achieving normal menses(81% vs 63%), higher conception rates (34% vs 23%)and a reduced need for reoperation. 3) MECHANICAL METHODS Orhue AA et al. Int J Gynaecol Obstet 2003

  35. PREVENTION OF RECURRENT ADHESIONS • For many years, the placement of an IUD into the uterine cavity for 3 months has been considered the standard method of maintaining the uterine cavity after surgery. • However, the copper-bearing IUDs might induce an excessive inflammatory reaction and T-shaped coils may have a too small surface area to maintain the uterine cavity. • Some authors suggested that larger inert devices such as Lippes-loop is effective in the prevention of recurrent adhesions. 3) MECHANICAL METHODS March CM. Obstet Gynecol Clin North Am 1995 Orhue AA et al. Int J Gynaecol Obstet 2003 Pabuccu et al., Fertil Steril 2008

  36. Prospective, randomized trial to highlight the efficiency of Lippes loop guidance during hysteroscopic adhesiolysis for severe adhesions. 71 subfertilepatientswith severe intrauterineadhesions. Patientswererandomizedinto 2 groups; Group 1: Justafterhysteroscopicadhesiolysis, IUD wasinsertedand 1 weeklater a secondlook H/S wasperformedforfurtherlysisbytheguidance of IUD. (n=36) Group 2: Just after hysteroscopic adhesiolysis, IUD was inserted and the patients were given estrogen+progesterone for 2 months.(n=35) Pabuccu et al., Fertil Steril 2008

  37. An IUD-guidedtherapeuticapproachsimplifieshysteroscopicadhesiolysisfor severe intrauterineadhesions. TheLippesloop IUD probablyenlargesthecavityandcreatesbits of endometrium, whichsimplifiestheprocedureforadhesiolysis. Pabuccu et al., Fertil Steril 2008

  38. However, spontaneouspregnancyandlivebirthratesbetweenthetwogroupswere not statisticallysignificant. Pabuccu et al., Fertil Steril 2008

  39. IUD-GUIDED HYSTEROSCOPIC ADHESIOLYSIS***

  40. PREVENTION OF RECURRENT ADHESIONS 4) HORMONE TREATMENT • Estrogen-progestin therapy significantly increases endometrial thickness and volume, but there is no objective evidence based on randomized, controlled trials to confirm the efficacy of hormone treatment on the reduction of reformation of intrauterine adhesions. Dan Yu et al. Fertil Steril 2008

  41. CONCLUSION “HYSTEROSCOPY” is thegoldstandardfordiagnosisandtreatment of intrauterineadhesions. Prevention of recurrentadhesionsaftersurgery is essentialfor a successfultreatment. There is still no singlemodalityprovento be unequivocallyeffective in preventingpostoperativeadhesionformationafterhysteroscopicsurgery.

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