Asherman's Syndrome: The Doctor's Report - by Dr. Sony Sierra (Fall 2010)

ASHERMAN’S SYNDROME

The Doctor’s Report

by Sony Sierra, MD, MSc, FRCSC
Fall 2010

Infertility affects many couples in Canada, with estimates of up to 15% of the reproductive-aged population. While infertility has many etiologies (causes), anatomical or structural factors account for approximately 15-20% of cases. Asherman’s Syndrome, also known as intrauterine adhesions (IUA), is recognized as an uncommon but causative factor in recurrent early pregnancy loss and infertility.

Asherman’s Syndrome was first reported in 1894 and the term is used to describe partial or complete obliteration of the uterine cavity by adhesions, leading to menstrual abnormalities, infertility or recurrent pregnancy loss. It has been reported in about 1.5% of all women suffering from infertility, and in up to 39% of women with recurrent pregnancy loss.

What is it?

The adhesions or scar tissue characteristic of Asherman’s Syndrome lead to the loss of normal endometrial tissue (or uterine lining). The extent of this syndrome can vary from very minimal scar tissue to complete obliteration or loss of the normal uterine cavity.

How does it happen?

The major cause of IUA formation is trauma to the uterine lining. This can occur as a side effect of surgery or curettage of the uterus, for example, from a dilation and curettage (D&C) procedure for management of a miscarriage or retained products after delivery. In fact, the uterus is at highest risk of scar formation in the first four weeks after delivery.
Asherman’s Syndrome can also result from a severe pelvic infection contracted during surgery or post-operatively. Very rare causes of Asherman’s Syndrome include tuberculosis or schistosomiasis; these are unlikely to occur in North America, however.

How would I know if I had IUA?

Typical symptoms of this syndrome include:

Fewer, infrequent, irregular periods
Loss of periods
Cyclical pelvic pain
Recurrent early pregnancy loss
History of sharp D&C for miscarriage or for retained placenta after delivery

How is the diagnosis confirmed?

A standard investigation of infertility and recurrent miscarriage includes a structural assessment of the uterus. A pelvic ultrasound provides useful information about the exterior structure, size, and overall shape of the uterus. It detects the presence of fibroids in the muscle wall or on the exterior (serosal) surface of the uterus. Ultrasound is also an excellent way to evaluate the size of the ovaries and the presence of important follicles and/or cysts. Information about the uterine lining or endometrium requires more specialized imaging.

The best way, or “gold standard”, of investigating the endometrium is to look directly at the lining with a hysteroscope (Soures et al, 2000). This is a surgical procedure known as diagnostic hysteroscopy and it can usually be performed as an office procedure without medication. A physiologically balanced fluid is injected into the uterus while a small scope attached to a camera is inserted through the cervix into the uterine cavity. This allows the surgeon to obtain a direct view of the lining and determine the nature and extent of the scarring, or IUA.

Sonohysterography, or obtaining a sonohysterogram, is also used to diagnose IUA or Asherman’s Syndrome. This is an ultrasound-based procedure that involves taking images of the uterine lining while saline is slowly injected into the uterine cavity. When this is combined with three-dimensional sonohysterography, it can very accurately diagnose IUA, as well as measure the size of the entire uterine cavity.

Is there a way to treat IUA?

Operative hysteroscopy is the treatment of choice for IUA. The technique is similar to a diagnostic hysteroscopy. While images are being taken, a skilled reproductive surgeon uses hysteroscopic scissors, cautery or laser to sharply cut or dissect the adhesions.
In the hands of a skilled surgeon, all of these techniques result in similar outcomes (Zikopoulos et al, 2004). The anatomy of a normal uterine cavity is usually achieved after one hysteroscopic procedure; however, this doesn’t always guarantee that the lining will heal normally, nor does it guarantee a pregnancy or live birth.

Once the adhesions are cut, the next step in treatment involves prevention of future adhesions, or the reformation of IUA. This is a particular risk if the adhesions were extensive and there is very little normal endometrial lining to regenerate and line the newly formed cavity. Post-operative adhesion formation occurs in almost 50% of severe cases and 22% of moderate cases (Valle & Sciarra, 1988). The science behind preventing these adhesions is not clear on which is the better method, but your doctor can choose between hormonal therapies, mechanical methods or both in an attempt to prevent future scarring.

If hormonal therapy is used, the objective is to stimulate endometrial development and healing after adhesions are cut. There are several options for treatment, but a standard approach often involves twice-daily doses of oral estrogens for anywhere from 2 weeks to 30 days, with or without the addition of progesterone or a synthetic progestin during the last 10-14 days of estrogen therapy.

Mechanical methods include the insertion of an IUD for about 30 days (Zikopoulous et al, 2004) or the insertion of a Foley catheter (or intrauterine balloon) for 1-2 weeks (Orhue et al, 2003).

What are the success rates after treatment?

The overall pregnancy rate after lysis (removal) of adhesions is approximately 60%, with a live birth rate of 40%. These figures come from a comprehensive review of 800 women with Asherman’s Syndrome who were treated with hysteroscopic surgery (Sieglar & Valle, 1988).
In women with recurrent pregnancy loss, after surgery the rates of early loss decrease from 86% to 43% (Goldenberg et al, 1995).

When presented with infertility, it is always important to evaluate all possible causes, even in the case of known intrauterine adhesions. While most women conceive after surgery for IUA, there are some that continue to face infertility. In one study, almost 60% of women in a group who did not conceive after treatment of IUA actually had other causes for infertility (Roge et al, 1996).

Intrauterine adhesions can be a reason for infertility, especially in women who have undergone multiple uterine surgeries or uterine procedures in the postpartum period. Proper diagnosis and management in the hands of skilled reproductive surgeons can result in the return of normal menstrual and reproductive function.

For more information, or for support and other resources, visit www.ashermans.org

About the author
Dr. Sierra practices Gynecologic Reproductive Endocrinology & Infertility in Toronto, where she is co-founder of First Steps Fertility Inc. She graduated from Medicine and a residency in Obstetrics & Gynecology at the University of Toronto. She then specialized in Infertility and Recurrent Miscarriage through further training in a Royal College of Canada accredited fellowship program at the University of British Columbia and the University of Chicago. After completion, she was appointed Assistant Professor, Clinician Investigator in the Department of Obstetrics & Gynecology at the University of Toronto. She is currently enrolling patients with a history of recurrent pregnancy loss and recurrent implantation failure after IVF in a study to document the expression of genes in the endometrial lining.

References
Goldenberg, M., Sivan, E., Sharabi, Z., et al. (1995) Reproductive outcome following hysterocopic management of intrauterine septum and adhesions. Human Reproduction; 10: 2663-5.

Orhue A.A., Aizken, M.E., Igbefoh, J.O. (2003). A comparison of two adjunctive treatments for intrauterine adhesions follow lysis. International Journal of Gynecology and Obstetrics; 82: 49-56.

Roge, P., D’Ercole, C., Cravello, L., et al (1996). Hysteroscopic management of uterine synechiae: a series of 102 observations. European Journal Obstetrics Gynecology and Reproductive Biology; 65: 189-193.

Sieglar, A.M., Valle, R.F. (1988). Therapeutic hysteroscopic procedures. Fertility and Sterility; 50: 685-701.

Soures, S.R., Barbosa dos Reis, M.M., Camargos, A.F. (2000). Diagnostic accuracy of sonohysterography, transvaginal sonography, and hysterosalpingography in patients with uterine cavity diseases. Fertility and Sterility; 72: 406-411.

Valle, R.F., Sciarra, J.J. (1988). Intrauterine adhesions: hysterocopic diagnosis, classification, treatment and reproductive outcome. American Journal of Obstetrics and Gynecology; 158: 1459-1470.

Zikopoulos, D.A., Kolibianakis, E.m., Platteau, P. Et al. (2004). Live delievery rates in subfertile women with Asherman’s syndrome after hysteroscopic adhesiolysis using the resectoscope or the Versapoint system. RBM Online; 8 :723-725.