Intrauterine adhesions

Abstract

Intrauterine adhesions (IUA) also referred to as Asherman's syndrome or intrauterine synechiae is a well-defined clinical entity, manifested by anatomic obliteration of the uterine cavity by adhesions. It may be caused by surgical trauma to the basal layer of the endometrium, usually secondary to curettage of the postpartum uterus, elective termination of early pregnancies, and genital tuberculosis, and may culminate in a spectrum of disorders ranging from menstrual disturbances to normal menses, infertility, recurrent pregnancy loss, and possibly, endometriosis. Several diagnostic techniques, such as transvaginal sonography (TVS), hysterosalpingography (HSG), saline infusion hysterography (SIS), sonohysterography, saline contrast hysterosonography (SCHS), 3D ultrasound, sonohysterosalpingography, 3D hysterosonography, hydrosonography, and rarely, magnetic resonance imaging, have been used for screening IUA. However, though these techniques are noninvasive and cost-effective with a short learning curve and may accurately assess most intrauterine pathology with a high specificity, they have limited accuracy for the detection of IUA with a high false-positive diagnosis rate and have to fall back on hysteroscopy as the reference standard owing to its higher sensitivity.Combined with history and a high index of suspicion, operative hysteroscopy is the gold standard for the accurate diagnosis, classification, and treatment of IUA. Adhesiolysis followed by the use of anti-adhesive barriers to prevent reformation and combined with cyclic estrogen therapy to stimulate endometrial growth is the therapy of choice. Several techniques, such as hysteroscopic adhesiolysis with scissors, electrosurgery or laser, ultrasound-directed hysteroscopic adhesiolysis, fluoroscopically guided hysteroscopic synechiolysis and balloon hysteroplasty, laparoscopic intracorporeal ultrasound-guided hysteroscopic adhesiolysis, pressure lavage under ultrasound guidance (PLUG), and sonohysterographic (SHG) adhesiolysis, have been proposed for the treatment of IUA. Hysteroscopic adhesiolysis is a unanimously recognized safe and effective first choice for restoring menstrual function and fertility even in women with severe adhesions and postmenopausal women with highly favorable pregnancy and live birth rates. Intraoperative ultrasonography, as an adjunct, has a significant role in hysteroscopic adhesiolysis in coordinating images of the endometrial cavity, uterine wall, and the tip of the hysteroscope, directing and ensuring dissection in the proper tissue plane, thus avoiding the possibility of inadvertent uterine perforation, and in examining the endometrial pattern and predicting the surgical and clinical outcome in women with severe Asherman's syndrome and in extensive, recurrent adhesions. Fluoroscopically guided hysteroscopic synechiolysis and PLUG are minimally invasive and cost-effective alternatives compared to labor-intensive, expensive endoscopic techniques with a high potential for restoration of menses and fertility, and PLUG enables complete lysis in mild to moderate IUA obviating the need for operative hysteroscopy. However, their efficacy must be explored further. Hence, while ultrasonography may have a limited role in the diagnosis of IUA compared to hysteroscopy, it has a significant role in guiding the surgical management of IUA.