INTRODUCTION:

Asherman’s Syndrome can strike any woman undergoing virtually any intra uterine procedure. But this condition, which can cause permanent infertility, remains largely unheard of among the public. Many specialists believe it is significantly under diagnosed and expect greater use of modern diagnostic techniques to recognize an increasing number of cases in the future.

What is Asherman’s syndrome?

Asherman's Syndrome, or intrauterine adhesions/scarring or synechiae, is an acquired uterine condition, characterized by the formation of adhesions (scar tissue) inside the uterus and/or the cervix (1,2). The adhesions can be thin or thick, spotty in location, or confluent. They are usually not vascular.

Causes:

Age and sex distribution:

· Women of any age, especially after repeated D&C or after any surgeries involving the uterus

· Individuals of all races and ethnic groups can be affected

Procedures of the uterus related with pregnancy:

· Dilation and Curettage or Dilation and Evaluation (2)

Infections involving uterus can include:

· Pelvic tuberculosis (8,9)

· Pelvic infection post-delivery, abortion or miscarriage.

· Schistosomiasis (9)

The factors below enhance the risk of adenomyosis:

· Uterine surgery: Prior surgeries involving the uterine area for example fibroid removal or C-section can lead to adenomyosis.

· Childbirth: Uterine inflammation due to child birth may result in adenomyosis.

· Congenital defects of the uterus, like septate uterus or bicornuate uterus, increase the risk for Asherman Syndrome

Stages of Asherman syndrome:

Stage I (Mild)

· Minor scarring in either the cervical canal or the uterine cavity (5).

· Unless this involves a specific area of the uterus called the isthmus, there will be little impact on normal function of the uterus and treatment is not essential.

· However if the scar involves the isthmus there can be a significant impact on the function of the endometrium and you should seek treatment.

· Most women are able to fall pregnant again.

Stage II(Moderate)

· We most frequently see patients presenting at this stage of the condition (5).

· There will be an obstruction of the inner os, a tiny part of the cervix that opens into the uterus and is easily blocked.

· In some women this obstruction involves only a fraction of a millimetre, in others it can stretch over several centimetres.

· If the scarring involves the very low end of the uterine cavity (the isthmus), there will be no production of menstrual blood and no pain.

· In some cases women might experience mild cramps with no bleeding, though this is not as common.

· Women with stage II Asherman’s syndrome have more than a 60% chance of conceiving again.

Stage III (Severe)

· The uterus will normally contract and more than 50% is blocked by scar tissue (5).

· There may also be an obstruction of one of the tubal orifices.

· The greater the extent of scar formation, the more difficult it is to treat.

· Typically, women have less than a 30% chance of successfully conceiving and delivering a child.

Stage IV (Severe)

· More than 75% of the uterus is blocked and it is smaller in size (5).

· Treatment at this stage requires multiple visits and has a low success rate.

· With the introduction of stem cell technology results may improve in the future.

Symptoms:

· During menstrual cycle (4):

· Severe cramps

· Heavy menstrual bleeding

· Prolonged cycle

· Clotting during menstrual cycle

· Other symptoms affect the abdomen area (4):

· Pressure or bloating in the area.

· Tenderness around the abdomen

Diagnosis:

Asherman Syndrome is diagnosed by the following exams and tests (3):

· Physical examination with thorough medical history evaluation, which would include an examination of the genital area

· Blood tests to rule out infections, like tuberculosis or schistosomiasis

· Hysteroscopy: By this procedure the uterine cavity can be directly examined; the scar tissue may be observed

· Hysterosalpingogram (HSG): In this procedure, a dye is injected into the uterine cavity followed by x-rays, to look for any blockage

· Hysterosonogram: Fluid is injected into the uterine cavity and an ultrasound is simultaneously performed, to look for the presence of adhesions

· Transvaginal ultrasound: This is done to measure the thickness of the inner layers of the uterus

Expectant Management:

· Cervical Probing

Cervical stenosis without damage to the uterine cavity or endometrium has been treated using cervical probing with or without ultrasound guidance [and uterine perforation has been reported after blind cervical probing. Consequently, this technique currently has a limited role.

· Dilation and Curettage

Dilation and curettage were widely used before the widespread use of hysteroscopy, and reported results included return to normal menses.

· Hysteroscopy

Hysteroscopic treatment enables adhesiolysis under direct vision and with magnification. The uterine distention required for hysteroscopy may itself lyse mild adhesions and blunt dissection may be performed using only the tip of the hysteroscope (6). It can cause the greater risk of complications such as perforation.

Hysteroscopy:

· Other hysteroscopic techniques:

Myometrial scoring has been effective for creation of a cavity in women with severe asherman’s syndrome. In this technique, 6 to 8-mm deep incisions are created in the myometrium using electrosurgery with a Collins knife electrode from the fundus to the cervix. These incisions enable widening of the uterine cavity. It is performed when typical hysteroscopy directed techniques are not possible or safe.

· Additional guiding techniques for hysteroscopy

Fluorscopically-guided blunt dissection of severe adhesions has been described using a hysteroscopically directed Tuohy needle under image intensifier control with the patient under general anesthesia

Advantages:

· use of a narrow hysteroscope

· reduced risk of uterine perforation

· reduced risk of visceral damage

Disadvantages:

· costly

· Exposes the patient to ionizing radiation

· technical challenging.

· Nonhysteroscopic Methods of Treating Asherman’s syndrome

Laparotomy, hysterotomy, and subsequent blunt dissection through adhesions using a finger or curette has been a traditional treatment for severe intrauterine synechiae.

Ancillary Treatments:

Normal Uterine Physiology

· Physical barriers: Re-Adhesion Prevention

1. The Foley catheter was one of first devices developed to separate the uterine walls to prevent the recurrent adhesions. A Foley catheter can be inserted in the uterine cavity for 5 to 7 days with a bag for removing drainage from the uterus (6,7).

2. Insertion of an intrauterine device (IUD) provides a physical barrier between the uterine walls, separating the endometrial layers after lysis intrauterine synechiae (6).

3. Uterine balloon stent made from silicon and shaped to fill the uterine cavity.

4. Hyaluronic Acid gel is placed in the uterus to promote healing and help maintain a physical barrier between the front and back walls of the uterus.

· Uterus Restoration Therapy:

Hormone therapy such as estrogen therapy (6) (a daily oral dose of 2.5 mg conjugated equine estrogen with or without opposing progestin for 2 or 3 cycles) has been prescribed after surgical treatment of intrauterine adhesions. It helps to stimulate the repair of the endometrium and growth of new small vessels and reduce scar formation

· Techniques to Increase Vascular Flow to Endometrium:

Various studies have described use of medications such as aspirin, nitroglycerine, and sildenafil citrate to increase vascular perfusion to the endometrium and enable pregnancy.

· Postoperative Assessment:

The recurrence rate is as high as 1 in 3 women with mild to moderate IUAs and 2 of 3 with severe IUAs. Consequently, regardless of the surgical intervention used reassessment of the uterine cavity, usually after 2 to 3 cycles after surgery.

Investigational Therapies:

Stem cell therapies are focusing primarily on rebuilding the endometrial lining that has become damaged from adhesions and surgery (7). Early clinical trials have demonstrated that stem cell therapy is safe and may be effective in helping regeneration the uterine walls as well as helping resumption of menstruation and improving fertility. Clinical trials of stem therapy for Asherman’s syndrome are currently ongoing.

Complication:

The most important complication of asherman’s syndrome is infertility

REFERENCES:

1. https://www.topdoctors.co.uk/medical-dictionary/asherman-s-syndrome

2. https://www.ashermans.org/home/

3. http://www.dovemed.com/diseases-conditions/asherman-syndrome/

4. http://drviveksalunke.com/ashermans-syndrome-definition-causes-symptoms-treatment/

5. https://www.whria.com.au/for-patients/fertility/ashermans-syndrome/

6. https://www.aagl.org/wp-content/uploads/2013/03/aagl-Practice-Guidelines-for-Management-of-Intrauterine-Synechiae.pdf

7. https://rarediseases.org/rare-diseases/ashermans-syndrome/

8. https://www.webmd.com/women/what-is-asherman-syndrome

9. https://medlineplus.gov/ency/article/001483.htm

Received on 14.08.2021 Modified on 26.11.2021

Int. J. Nur. Edu. and Research. 2022; 10(1):87-90.

DOI: 10.52711/2454-2660.2022.00020