Asherman's syndrome - AbsoluteAstronomy.com

Asherman's syndrome also called "uterine synechia

Synechia

A synechia is an eye condition where the iris adheres to either the cornea or lens . Synechiae can be caused by ocular trauma, iritis or iridocyclitis and may lead to certain types of glaucoma...

e" or intrauterine adhesions (IUA), presents a condition characterized by the presence of adhesions and/or fibrosis within the uterine cavity due to scars. A number of other terms have been used to describe the condition and related conditions including: traumatic intrauterine adhesions, uterine/cervical atresia, traumatic uterine atrophy, sclerotic endometrium, endometrial sclerosis. In this article AS and IUA are used interchangeably.

Causes and features

The cavity of the uterus

Uterus

The uterus or womb is a major female hormone-responsive reproductive sex organ of most mammals including humans. One end, the cervix, opens into the vagina, while the other is connected to one or both fallopian tubes, depending on the species...

is lined by the endometrium

Endometrium

-Function:The endometrium is the innermost glandular layer and functions as a lining for the uterus, preventing adhesions between the opposed walls of the myometrium, thereby maintaining the patency of the uterine cavity. During the menstrual cycle or estrous cycle, the endometrium grows to a...

. This lining is composed of two layers, the functional layer which is shed during menstruation

Menstruation

Menstruation is the shedding of the uterine lining . It occurs on a regular basis in sexually reproductive-age females of certain mammal species. This article focuses on human menstruation.-Overview:...

and an underlying basal layer, which is necessary for regenerating the functional layer. Trauma to the basal layer, typically after a dilation and curettage

Dilation and curettage

Dilation and curettage refers to the dilation of the cervix and surgical removal of part of the lining of the uterus and/or contents of the uterus by scraping and scooping . It is a diagnostic gynecological procedure.D&C normally is referred to a procedure involving a curette, also called sharp...

(D&C) performed after a miscarriage

Miscarriage

Miscarriage or spontaneous abortion is the spontaneous end of a pregnancy at a stage where the embryo or fetus is incapable of surviving independently, generally defined in humans at prior to 20 weeks of gestation...

, or delivery

Childbirth

Childbirth is the culmination of a human pregnancy or gestation period with the birth of one or more newborn infants from a woman's uterus...

, or for medical abortion

Abortion

Abortion is defined as the termination of pregnancy by the removal or expulsion from the uterus of a fetus or embryo prior to viability. An abortion can occur spontaneously, in which case it is usually called a miscarriage, or it can be purposely induced...

, can lead to the development of intrauterine scars resulting in adhesions that can obliterate the cavity to varying degrees. In the extreme, the whole cavity can be scarred and occluded. Even with relatively few scars, the endometrium

Endometrium

may fail to respond to estrogen

Estrogen

Estrogens , oestrogens , or œstrogens, are a group of compounds named for their importance in the estrous cycle of humans and other animals. They are the primary female sex hormones. Natural estrogens are steroid hormones, while some synthetic ones are non-steroidal...

s and rests. Often, patients experience secondary menstrual irregularities characterized by changes in flow and duration of bleeding (amenorrhea, hypomenorrhea

Hypomenorrhea

Hypomenorrhea or hypomenorrhoea, also known as short or scanty periods, is extremely light menstrual blood flow. It is the opposite of hypermenorrhea which is more properly called menorrhagia.-Overview:...

, or oligomenorrhea

Oligomenorrhea

Oligomenorrhea is infrequent menstruation. More strictly, it is menstrual periods occurring at intervals of greater than 35 days, with only four to nine periods in a year. Also, menstrual periods should have been regularly established previously before the development of infrequent flow...

) and become infertile. Menstrual anomalies are often but not always correlated with severity: adhesions restricted to only the cervix

Cervix

The cervix is the lower, narrow portion of the uterus where it joins with the top end of the vagina. It is cylindrical or conical in shape and protrudes through the upper anterior vaginal wall...

or lower uterus

Uterus

may block menstruation

Menstruation

. Pain during menstruation

Menstruation

and ovulation

Ovulation

Ovulation is the process in a female's menstrual cycle by which a mature ovarian follicle ruptures and discharges an ovum . Ovulation also occurs in the estrous cycle of other female mammals, which differs in many fundamental ways from the menstrual cycle...

is also sometimes experienced and can be attributed to blockages.

Asherman's syndrome, AS, occurs most frequently after a D&C

Dilation and curettage

is performed on a recently pregnant uterus

Uterus

, following a missed or incomplete miscarriage

Miscarriage

, birth

Birth

Birth is the act or process of bearing or bringing forth offspring. The offspring is brought forth from the mother. The time of human birth is defined as the time at which the fetus comes out of the mother's womb into the world...

, or elective termination (abortion

Abortion

) to remove retained products of conception. As the same procedure is used in all three situations, AS can result in all of the above circumstances. It affects women of all races and ages as there is no underlying predisposition or genetic basis to its development. According to a study on 1900 patients with AS, over 90% of the cases occurred following pregnancy-related curettage.
Depending on the degree of severity, AS may result in infertility

Infertility

Infertility primarily refers to the biological inability of a person to contribute to conception. Infertility may also refer to the state of a woman who is unable to carry a pregnancy to full term...

, repeated miscarriages, pain from trapped blood, and future obstetric complications(see Prognoses below). There is evidence that left untreated, the obstruction of menstrual flow resulting from adhesions can lead to endometriosis

Endometriosis

Endometriosis is a gynecological medical condition in which cells from the lining of the uterus appear and flourish outside the uterine cavity, most commonly on the ovaries. The uterine cavity is lined by endometrial cells, which are under the influence of female hormones...

.,

AS can also result from other pelvic surgeries including Cesarean sections, removal of fibroid tumours (myomectomy

Myomectomy

Myomectomy, sometimes also fibroidectomy, refers to the surgical removal of uterine leiomyomas, also known as fibroids. In contrast to a hysterectomy the uterus remains preserved and the woman retains her reproductive potential.-Indications:...

) and from other causes such as IUDs, pelvic irradiation

Irradiation

Irradiation is the process by which an object is exposed to radiation. The exposure can originate from various sources, including natural sources. Most frequently the term refers to ionizing radiation, and to a level of radiation that will serve a specific purpose, rather than radiation exposure to...

, schistosomiasis

Schistosomiasis

Schistosomiasis is a parasitic disease caused by several species of trematodes , a parasitic worm of the genus Schistosoma. Snails often act as an intermediary agent for the infectious diseases until a new human host is found...

and genital tuberculosis

Urogenital tuberculosis

Urogenital tuberculosis is a form of tuberculosis that affects the urogenital system.-Epidemiology:It usually strikes young adults with tuberculosis in other places of the body as well...

. Chronic endometritis from genital tuberculosis is a significant cause of severe IUA in the developing world, often resulting in total obliteration of the uterine cavity which is difficult to treat.

One study found a significant correlation

Correlation

In statistics, dependence refers to any statistical relationship between two random variables or two sets of data. Correlation refers to any of a broad class of statistical relationships involving dependence....

between Müllerian anomalies and intrauterine adhesions. This apparent correlation is attributed to women with congenital uterine anomalies being predisposed to miscarriage

Miscarriage

s, and therefore having higher rates of D&Cs

Dilation and curettage

performed than the general population, which could account for the higher rate of IUA observed. It is also feasible that women with septate uteri

Uterine septum

A uterine septum is a form of a congenital malformation where the uterine cavity is partitioned by a longitudinal septum; the outside of the uterus has a normal typical shape...

and other Müllerian defects are at a higher risk of sustaining endometrial damage after blind D&C

Dilation and curettage

due to their atypical anatomy, particularly if the doctor performing the surgery was unaware of it.

An artificial form of AS can be surgically induced by endometrial ablation

Endometrial ablation

Endometrial ablation is a medical procedure that is used to remove or destroy the endometrial lining of a uterus. This technique is most often employed for people who suffer from excessive or prolonged bleeding during their menstrual cycle but cannot or do not wish to undergo a hysterectomy. ...

in women with excessive uterine bleeding, in lieu of hysterectomy

Hysterectomy

A hysterectomy is the surgical removal of the uterus, usually performed by a gynecologist. Hysterectomy may be total or partial...

Incidence

AS has been reported to result from 25% of D&Cs performed 1–4 weeks post-partum, up to 30.9% of D&Cs performed for missed miscarriages and 6.4% of D&Cs performed for incomplete miscarriages. In another study, 40% of patients who underwent repeated D&C for retained products of conception after missed miscarriage or retained placenta developed AS.

In the case of missed miscarriages, the time period between fetal demise and curettage may increase the likelihood of adhesion formation due to fibroblastic activity of the remaining tissue

The risk of AS also increases with the number of procedures: one study estimated the risk to be 16% after one D&C and 32% after 3 or more D&Cs, however a single curettage often underlies the condition.

Prevalence in the general population

The true prevalence of AS is unclear as many doctors are unaware of the symptoms or diagnosis. It is estimated that up to 5% of D&Cs result in AS. More conservative estimates put this rate at 1% , however, this seems an underestimate given the incidence of IUA following curettage reported in prospective studies and the number of D&Cs performed annually.Increased awareness about the condition and its diagnosis is also expected to reveal a higher frequency than previously reported. The condition was found in 1.5% of women undergoing HSG, and between 5 and 39% of women with recurrent miscarriage.

Diagnosis

The history of a pregnancy

Pregnancy

Pregnancy refers to the fertilization and development of one or more offspring, known as a fetus or embryo, in a woman's uterus. In a pregnancy, there can be multiple gestations, as in the case of twins or triplets...

event followed by a D&C leading to secondary amenorrhea or hypomenorrhea is typical. Hysteroscopy is the gold standard for diagnosis. Imaging by sonohysterography or hysterosalpingography

Hysterosalpingography

Hysterosalpingography is a radiologic procedure to investigate the shape of the uterine cavity and the shape and patency of the fallopian tubes. It entails the injection of a radio-opaque material into the cervical canal and usually fluoroscopy with image intensification...

will reveal the extent of the scar formation. Ultrasound is not a reliable method of diagnosing Asherman's Syndrome. Hormone studies show normal levels consistent with reproductive function.

Classification

Various classification systems were developed to describe Asherman’s syndrome (citations to be added), some taking into account the amount of functioning residual endometrium, menstrual pattern, obstetric history and other factors which are thought to play a role in determining the prognoses. With the advent of techniques which allow visualization of the uterus, classification systems were developed to take into account the location and severity of adhesions inside the uterus. This is useful as mild cases with adhesions restricted to the cervix may present with amenorrhea and infertility, showing that symptoms alone do not necessarily reflect severity. Other patients may have no adhesions but amenorrhea and infertility due to a sclerotic atrophic endometrium. The latter form has the worst prognosis.

Treatment

Fertility may sometimes be restored by removal of adhesions, depending on the severity of the initial trauma and other individual patient factors. Operative hysteroscopy

Hysteroscopy

Hysteroscopy is the inspection of the uterine cavity by endoscopy with access through the cervix. It allows for the diagnosis of intrauterine pathology and serves as a method for surgical intervention .-Method:...

is used for visual inspection of the uterine cavity during adhesion dissection (adhesiolysis).However, hysteroscopy is yet to become a routine gynaecological procedure and only 15% of US gynecologists perform office hysteroscopy {Isaacson, 2002}. Adhesion dissection can be technically difficult and must be performed with care in order to not create new scars and further exacerbate the condition. In more severe cases, adjunctive measures such as laparoscopy are used in conjunction with hysteroscopy as a protective measure against uterine perforation. Microscissors are usually used to cut adhesions. Electrocauterization is not recommended.

As IUA frequently reform after surgery, techniques have been developed to prevent recurrence of adhesions. Methods to prevent adhesion reformation include the use of mechanical barriers (Foley catheter, saline-filled Cook Medical Balloon Uterine Stent, IUCD) and gel barriers (Seprafilm, Spraygel, autocrosslinked hyaluronic acid gel Hyalobarrier

Hyalobarrier

Hyalobarrier is a substance to keep tissue apart post surgery and therefore prevent adhesions. It contains autocross-linked hyaluronan. Highly viscous due to condensation. Hyaluronan is present in cartilage and skin hence there is a natural metabolic pathway for it...

) to maintain opposing walls apart during healing {Tsapanos, 2002}; {Guida, 2004};{Abbott, 2004}, thereby preventing the reformation of adhesions. Antibiotic prophylaxis is necessary in the presence of mechanical barriers to reduce the risk of possible infections. A common pharmacological method for preventing reformation of adhesions is sequential hormonal therapy with estrogen

Estrogen

followed by a progestin to stimulate endometrial growth and prevent opposing walls from fusing together {Roge, 1996}. However there have been no RCTs comparing post-surgical adhesion reformation with and without hormonal treatment and the ideal dosing regimen or length of estrogen therapy is not known. The absence of prospective randomized controlled trials (RCTs) comparing treatment methods makes it difficult to recommend optimal treatment protocols. Furthermore, diagnostic severity and outcomes are assessed according to different criteria (e.g. menstrual pattern, adhesion reformation rate, conception rate, live birth rate). Clearly, more comparable studies are needed in which reproductive outcome can be analysed systematically.

Follow-up tests (HSG, hysteroscopy or SHG) are necessary to ensure that adhesions 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%. Another study found that postoperative adhesions reoccur in close to 50% of severe AS and in 21.6% of moederate cases. Mild IUA, unlike moderate to severe synechiae, do not appear to reform.

Prognosis

The extent of adhesion formation is critical. Mild to moderate adhesions can usually be treated with success. Extensive obliteration of the uterine cavity or fallopian tube openings (ostia

Ostium of Fallopian tube

The ostium of the Fallopian tube may refer to the proximal or distal opening of the tube.The proximal tubal opening is located within the uterus at the uterotubal junction and accessible via hysteroscopy...

) and deep endometrial or myometrial trauma may require several surgical interventions and/or hormone therapy or even be uncorrectable. If the uterine cavity is adhesion free but the ostia remain obliterated, IVF remains an option. If the uterus has been irreparably damaged, surrogacy

Surrogacy

Surrogacy is an arrangement in which a woman carries and delivers a child for another couple or person. This woman may be the child's genetic mother , or she may carry the pregnancy to delivery after having an embryo, to which she has no genetic relationship whatsoever, transferred to her uterus...

or adoption

Adoption

Adoption is a process whereby a person assumes the parenting for another and, in so doing, permanently transfers all rights and responsibilities from the original parent or parents...

may be the only options.

Patients who carry a pregnancy

Pregnancy

even after treatment of IUA may have an increased risk of having abnormal placentation including placenta accreta

Placenta accreta

Placenta accreta is a severe obstetric complication involving an abnormally deep attachment of the placenta, through the endometrium and into the myometrium...

where the placenta invades the uterus

Uterus

more deeply, leading to complications in placental separation after delivery. Premature delivery, second-trimester pregnancy loss, and uterine rupture are other reported complications. They may also develop incompetent cervix where the cervix can no longer support the growing weight of the fetus, the pressure causes the placenta to rupture and the mother goes into premature labour. Cerclage is a surgical stitch which helps support the cervix if needed.

Pregnancy and live birth rate has been reported to be related to the initial severity of the adhesions with 93, 78, and 57% pregnancies achieved after treatment of mild, moderate and severe adhesions, respectively and resulting in 81, 66, and 32% live birth rates, respectively. The overall pregnancy rate after adhesiolysis was 60% and the live birth rate was 38.9% according to one study.

Age is another factor contributing to fertility outcomes after treatment of AS. For women under 35 years of age treated for severe adhesions, pregnancy rates were 66.6% compared to 23.5% in women older than 35.

Prevention

The recently pregnant uterus is particularly soft under the influence of hormones and hence, easily injured. D&C (including dilation and curettage, dilation and evacuation/suction curettage and manual vacuum aspiration) is a blind, invasive procedure, making it difficult to avoid endometrial trauma. Medical alternatives to D&C for evacuation of retained placenta/products of conception exist including misoprostol

Misoprostol

Misoprostol is a drug that is used for the prevention of non steroidal anti inflammatory drug induced gastric ulcers, for early abortion, to treat missed miscarriage, and to induce labor. The latter use is controversial in the United States. Misoprostol was invented and marketed by G.D...

and mifepristone or RU486. Studies show this less invasive and cheaper method to be an efficacious, safe and an acceptable alternative to surgical management for most women. It was suggested as early as in 1993 that the incidence of IUA might be lower following medical evacuation (e.g. Misoprostol) of the uterus, thus avoiding any intrauterine instrumentation. So far, one study supports this proposal, showing that women who were treated for missed miscarriage with misoprostol did not develop IUA, while 7.7% of those undergoing D&C did. The advantage of misoprostol is that it can be used for evacuation not only following miscarriage, but also following birth for retained placenta or hemorrhaging.

Alternatively, D&C could be performed under ultrasound guidance rather than as a blind procedure. This would enable the surgeon to end scraping the lining when all retained tissue has been removed, avoiding injury.

Early monitoring during pregnancy to identify miscarriage can prevent the development of, or as the case may be, the recurrence of AS, as the longer the period after fetal death following D&C, the more likely adhesions may be to occur. Therefore immediate evacuation following fetal death may prevent IUA.

The use of hysteroscopic surgery instead of D&C to remove retained products of conception or placenta is another alternative, although it could be less effective if tissue is abundant. Also, hysteroscopy is not a widely or routinely used technique and requires expertise.

There is no data to indicate that suction D&C is less likely than sharp curette to result in Asherman's. A recent article describes three cases of women who developed intrauterine adhesions following manual vacuum aspiration.

History

It was first described in 1894 by Heinrich Fritsch

Heinrich Fritsch

Heinrich Fritsch was a German gynecologist and obstetrician who was a native of Halle an der Saale.He studied medicine at the Universities of Tübingen, Würzburg and Halle, where in 1869 he earned his medical doctorate. Afterwards he remained at Halle as an assistant at the clinic of obstetrics...

(Fritsch, 1894) and further characterized by the gynecologist Joseph Asherman in 1948.

It is also known as Fritsch syndrome, or Fritsch-Asherman syndrome.

External links

Articles

The secret syndrome leaving women infertile Sophie Blake
Sophie Blake
Sophie Blake , is an English television presenter and former model.-Career:Blake studied drama, and then travelled working in bars and restaurants for a few years. She did some modelling, and put a home-made show-reel together which United Sports picked up, and got her interviewing footballers in...

talks about being diagnosed with Asherman's syndrome (Daily Mirror UK)
The hidden threat to fertility (Times Online) www.timesonline.co.uk/tol/life_and_style/health/features/article3025016.ece (copy and paste into web browser)
The great news I thought I would never deliver, by TV newsreader Kate Gerbeau
Overview at iVillage
IVillage
iVillage, Inc. is a media company that is owned by NBCUniversal. The site focuses on categories targeted at women, including Food, Health, Entertainment, Family, Beauty & Style. Additional businesses and brand extensions within iVillage Networks include iVillage UK, NBC Digital Health Network,...
How Asherman's syndrome causes infertility or miscarriages from Blog: Asherman's Syndrome Watch (awareness, education, prevention)

Support Group

Ashermans.org Patient support group run by patients.

Videos

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