Treatment

Unfortunately, there aren’t methods of Asherman`s syndrome treatment which would perfectly save reproductive function. Basically the treatment involves surgery during which the doctor must remove the uterine synechiae in less traumatic way which helps to restore normal menstrual function. The main treatment involves two stages.

The first stage is the surgery during which the doctor removes adhesions. This is the first and the main step in treatment of Asherman`s disease. The surgeon removes synechiae via hysteroscope. The removal of adhesions can be difficult therefore the doctor must conduct this procedure with extreme care because postoperative cicatrix can exacerbate medical condition in future.

The second stage is to prevent synechiae from growing after the surgery. It’s the most difficult part of the treatment because after a while adhesion can quickly return after the procedure. Results of the surgery can be positive if the patient has mild stage of disease. If the patient has severe stage of the Asherman`s syndrome than she may require several repeated hysteroscopic surgeries. Thus, it’s needed to prevent synehiae from repeated growing. In order to avoid progression of the disease the doctor can:

  • prescribe estrogen which reverses normal growing of uterine lining. In addition, estrogen prevents the growth of scars after the surgery;
  • place balloon-mounted catheter which prevents synehiae development;
  • conduct repeated hysteroscopy if it’s needed in order to remove new synechiae.

Medical community doesn’t have particular treatment of Asherman`s syndrome with successful outcome yet. The surgery doesn’t mean that patient`s uterus will stay without scars and female fertility will be absolutely restored. Unfortunately, Asherman`s syndrome undermines reproductive function of woman. If woman is failed to conceive in a natural way and IVF attempts aren’t crowned with success patient should think about surrogacy or adoption to have children.

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During the last 20 years, the opportunity to explore the inside of the uterus, provided by the new endoscopic procedures, has revolutionized diagnosis and management of AS. AS and IUA should be suspected in every woman presenting menstrual problems (hypomenorrhea or amenorrhea) and/or infertility with history of curettage or other intrauterine surgery. AS cannot be diagnosed by simple bimanual pelvic examination, therefore an accurate diagnosis is only possible with imaging of the uterine cavity.

Historically, hysterosalpingography (HSG) has represented the most widespread diagnostic tool. It is a cost-effective method to assess tubal patency in women who suffer from infertility. Usually, AS is characterized by filling defects described as homogeneous opacity surrounded by sharp edges. In the worst cases, the uterine cavity appears completely distorted and narrowed, and ostial occlusion may also be evident. However, the information provided by an HSG is relatively crude, and it is important to bear in mind that the investigation has a high false positive rate.

Transvaginal ultrasound has a high compliance, and in many countries it is often used “in office” during gynaecological consultation. The ultrasounds image of AS is characterized by an echo dense pattern with difficult visualization of endometrium interrupted by one or more translucent “cyst like” areas. Although, the diagnostic accuracy of ultrasound has been reported to be low, it does allow visualization of the uterine cavity when a complete obstruction of the cervix precludes HSG or hysteroscopy. Ultrasound imaging seems to be significantly influenced by ovulatory cyclical phase of menstrual cycle; therefore some authors suggest that the best time for the evaluation of endometrium is during luteal phase of the menstrual cycle.

Ultrasound control can also be useful during hysteroscopic adhesiolysis, in order to prevent uterine injury. Compared with laparoscopy, ultrasound monitoring is cheaper, with no difference in the incidence of uterine perforation. In addition, some authors have reported its value to predict the outcome of surgical repair by allowing assessment of residual endometrium: if little or no endometrium is seen during transvaginal scan, the likelihood of a successful outcome is greatly decreased.

Data regarding the value of three-dimensional (3D) ultrasound in the detection of intrauterine adhesions are limited. Preliminary data in 2003 showed a specificity of 45%. In a case series of 54 subjects with a high suspicion of AS, a significantly higher sensitivity of 3D ultrasound method was showed. However, until further data becomes available, the high cost of 3D ultrasound does not justify its use in clinical practice.

The use of saline infusion during the ultrasound scan (Sonohysterography or SHG) has also been investigated. Salle et al. reported comparable sensitivity and specificity with the standard HSG. More recently, in a retrospective study involving 149 cases with intrauterine anomalies, Acholonu et al. demonstrated a significant difference in general accuracy (50.3% in HSG group and 81.8% in SHG group).

Another technique combining 3D ultrasound and intrauterine saline infusion (Three-dimensional sonohysterography, 3D-SHG) has recently been proposed for the diagnosis of intrauterine lesions. 3D-SHG, carried out in combination with 3D power Doppler (3-DPD), was found to have sensitivity and specificity of 91.1% and 98.8% respectively for all kinds of intrauterine lesion including synechiae. Abou-Salem et al. confirmed these preliminary results showing comparable diagnostic efficacy with hysteroscopy.

Magnetic resonance imaging (MRI) can be helpful as a supplementary diagnostic tool, especially when the adhesions involve the endocervix. IUA are visualized as low signal intensity on T2 weighed-image inside the uterus.

Despite the above developments, hysteroscopy remains the gold standard in the assessment of AS. Table 2 illustrates the accuracy of transvaginal ultrasound, HSG and SHG compared with gold standard hysteroscopic imaging (Table 1).

Table 1

Approach Sensitivity (%) Specificity (%) PPV (%) NPV (%)
Ultrasound 0.5 95.2 0.0 95.2
Sonohysterography 75 93.4 42.9 98.3
Hysterosalpingography 75 95.1 50 98.3

 

Hysteroscopy provides a real time view of the uterine cavity, allowing for a meticulous definition of the site, extent and character of any adhesions, and it is the optimum tool for assessing the endometrium. Currently, this technique can be performed in ambulatory setting with less discomfort than a blind HSG. Hysteroscopy also makes immediate treatment possible in some favourable cases.


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