The treatment strategy of AS could be summarized in four main steps:
- Treatment (Dilatation and curettage, hysteroscopy, hysterotomy)
- Re-adhesion prevention (Intrauterine device, Uterine balloon stent, Foley’s catheter, anti-adhesion barriers)
- Restoring normal endometrium (Hormonal treatment, stem cells)
- Post-operative assessment (Repeat surgery; diagnostic hysteroscopy; ultrasound).
Few cases of AS treatment using an open-surgery approach with transfundal separation of scarring uterine walls have been mentioned: in some cases an adequate restoration of menstruation and fertility was obtained. It has been superseded by hysteroscopic techniques, so today this strategy may be adopted only in extremely complex situation, when the hysteroscopic approach is not possible or unlikely to succeed, and only by expert surgeons. The patient should be informed about the risk of the procedure, and warmed that the successful restoration of the cavity may not be obtained, not even with such an aggressive approach.
Dilatation and curettage
Before the introduction of hysteroscopy, the blind dilation and curettage (D&C) was the treatment of choice. Nevertheless blind D&C is associated with a high risk of uterine perforation as well as being a relatively poor diagnostic tool, with the result that this technique should be considered obsolete.
Hysteroscopic surgery has revolutionized the treatment of intrauterine adhesion and it is the established gold standard technique. The magnification and the direct view of the adhesions allow for a precise and safe treatment. When the lesions are filmy, the tip of the hysteroscope and uterine distension may be enough to break down the adhesions. Thus, in favourable cases the restoration of cavity can be obtained through “no touch” hysteroscopy in out-patient setting without general anaesthesia.
Nevertheless, the treatment of the severe and dense adhesion remains more challenging: in these cases, the cavity may be completely occluded or too narrow to allow the insertion of hysteroscopic sheath inside the cervix. Moreover, multiple procedures may be required because of post-surgical recurrence of the adhesions. In these situations, it is recommended to offer a proper counselling regarding the lower rate of success and the higher risk of complications.
According to many experts, the removal of the adhesions should start form the lower part of the uterus and progress toward the upper part. Any central and filmy adhesions should be separated initially in order to allow adequate distension of the uterine cavity. Dense and lateral adhesions should be treated at the end, bearing in mind the greater risk of uterine perforation and bleeding.
A wide range of mechanical or electric equipment has been adopted during hysteroscopic adhesiolysis. Even the use of a sharp needle (Touhy needle) has showed a good rate of success. Specifically, 55 patients were treated with a 16-gauge, 80-mm Touhy needle introduced alongside a 5-mm hysteroscope under fluoroscopical guidance. All women regained a normal menstruation pattern but no data about fertility outcome was collected in this study. A cold-knife approach is supposed to prevent thermal damage of the residual endometrium and reduce the rate of perforation during the procedure. The use of powered instruments (electric surgery or laser) has also proven efficient for hysteroscopic adhesiolysis. Nevertheless the use of electric surgery is associated with potential damage to the residual endometrium.
Monopolar surgery has provided results as satisfactory as bipolar one. However, one of the advantages of the latter is that the tissue effect is more focal and the use of electrolyte-containing uterine distension media means that electrolyte changes are less likely to be clinically serious in cases of fluid overload.
The treatment with laser vaporization using an Nd-YAG (neodymium-doped yttrium aluminium garnet) and KTP (potassium-titanyl-phosphate) laser has also been described in the treatment of AS. However, it is characterized by higher costs and increased uterine damages, and does not offer significant advantages over other electric equipment. Therefore its use in hysteroscopic adhesions has been increasingly abandoned.
The most difficult cases to treat are those with severe AS stage characterized by a complete obliteration of cavity and no apparent endometrium visible at hysteroscopy. It can be impossible to dissect the adhesions with standards hysteroscopic techniques. In these difficult circumstances, several innovative hysteroscopic strategies have been suggested in medical literature.