Millions of Britons suffer from adhesions, a form of internal scarring after surgery that causes organs and tissues to stick together. It can be linked to infertility and miscarriage as Rebecca McAra, 36, from Northampton, discovered. She tells her story to ANGELA BROOKS.
When I became pregnant in 2005, my husband and I were delighted. But a few weeks later I had a ‘missed’ miscarriage – when you lose the baby but it stays in the womb, so you don’t realise it’s happened.
It was only when I had a routine scan that I found out the awful news. I was told it could take six weeks for my body to deal with this naturally – the alternative was a D&C (dilatation and curettage), an operation to clear the womb.
There was a risk of damage to the womb lining, but I was assured this was rare.
I had the operation, as it seemed the best option, and was told it had gone well.
By November 2006 I was pregnant again but, after seven weeks, miscarried and had to have another D&C.
Devastated, I began to wonder if I had an underlying medical problem. I made an appointment at a private recurrent miscarriage clinic.
They put a camera into my womb to check for adhesions that could have been caused by the miscarriages and D&Cs.
The doctor explained that adhesions are internal scar tissue that forms around the surgery site, gluing the tissues together. When they form in the womb, they’re known as Asherman’s Syndrome.
There’s a 25 per cent chance of developing Asherman’s two to four weeks after a D&C, although I didn’t know that.
Apparently, I had a moderate degree of Asherman’s, so the doctor snipped the adhesions away on the spot. He fitted me with a contraceptive coil, which sounds odd as I was trying for a baby, but he said it would keep the walls of the womb apart so the tissue healed, and so it was hard for the adhesions to re-form.
This was taken out eight weeks later and I soon got pregnant – only to miscarry yet again. Desperate, I scoured the internet and came across Mr Geoffrey Trew, reproductive medicine and surgery specialist at the Hammersmith Hospital, London. I saw him the following month.
He suspected I still had some residual adhesions, as it can take more than one procedure to clear.
He arranged a special X-ray where they run a dye through your fallopian tubes and womb to highlight any adhesions. This showed there were still some at the top of my womb where the tubes deliver the egg – they were preventing the egg from implanting properly, which is why I kept miscarrying.
Mr Trew said I would need surgery to have them cut away. He would put a camera into my womb so he could see them all properly. It would be the same operation I’d had before, but as there were so few of them, he felt sure it would resolve the problem.
I had the operation in 2008 under a general anaesthetic. I became pregnant straight away, but bled for 14 weeks at the start of the pregnancy. That is normal for women who’ve had womb adhesions – but it’s scary. You’re living in constant fear of losing the baby.
I didn’t let myself believe I was in the clear until I held our baby boy for the first time.
Mr Geoffrey Trew is a consultant in reproductive medicine and surgery at the Hammersmith Hospital, London.
Around 93 per cent of surgical patients, both men and women, develop adhesions afterwards – they are a huge problem.
Adhesions most commonly form in the abdomen – particularly the bowel – and in the pelvis after gynaecological procedures. But conditions such as endometriosis and pelvic inflammatory disease can also cause them, leading to inflammation and scar tissue.
Adhesions in this area can cause infertility and miscarriage – when you consider the womb is usually only the size of a pear, it’s easy to see how adhesions in such a small space can interfere with pregnancy.
The biggest cause of womb adhesions is miscarriage, particularly where the foetus dies before 24 weeks and is not expelled by the body. The miscarriage itself – but also the D&C afterwards – can leave parts of the womb lining raw; the ideal environment for this scar tissue to form.
While all adhesions are very distressing, as they can cause medical complications and pain, womb adhesions are particularly upsetting as they are commonly overlooked.
Astonishingly, most fertility clinics don’t check for them at the outset, even though they are a significant cause of infertility. The ultrasound scans they do flag up only severe adhesions rather than the mild-to-moderate ones which Rebecca had.
We often see women who have not only wasted thousands of pounds on pointless IVF treatments, but they’ve also lost one or two years. At our clinic, we scrupulously check for adhesions using an X-ray and dye.
If adhesions are present, we bring patients in for hysteroscopy – where we insert a tube with a tiny camera attached into the womb – to confirm the diagnosis and tackle the adhesions at the same time.
Through another channel in the tube, we flush a special fluid into the area; this gives us excellent views of the adhesions as they are held taut by the fluid. Rebecca’s were filmy, almost like cling-film, but depending on the severity they can be like pillars stretching from side to side or, in the worst cases, can completely stick down much of the womb.
To remove the adhesions we feed tiny micro-scissors into the tube and cut them away.
During surgery, patients are given antibiotics intravenously to help prevent adhesions re- forming (this works by reducing the chance of infection and therefore minimise further inflammation which can set the whole process off again).
Most patients are then fitted with two contraceptive coils which keep the surfaces apart while the tissues heal.
As Rebecca’s were minor, we felt this wasn’t necessary. Most women will also be given a daily oestrogen tablet which stimulates the growth of healthy tissue to line the womb – and to seal the raw surfaces.
After a month, we will add a daily progesterone tablet – this helps to shed the lining in the same way a period would, and spurs the growth of more healthy lining tissue.
With minor-to-moderate disease, we have virtually a 100 per cent success rate with this operation.
Even with severe adhesions, we can restore a healthy womb cavity in well over 90 per cent of patients, which should allow a natural pregnancy. If patients don’t conceive within a few months, and if they’re worried about their biological clock ticking away, they can then return for IVF treatment.
This surgery has to be done with scrupulous care to avoid further damaging the delicate lining of the womb – preferably by a surgeon with a good track record who’s doing at least one of these procedures each month.