(By Dr.Arvind Vaid IVF Specialist Indira IVF Hospital, New Delhi)
Somya(34), was not having regular menstrual cycles for over 4 months and difficulty in getting pregnant but used to feel pain at the same time that her period would normally arrive each month. A complete uterus examination using hysteroscope confirmed the presence of adhesions that was blocking the cervix from bleeding. She was immediately operated and a balloon was placed in the uterus to prevent apposition of the walls during the immediate post-operative healing phase. Estrogen supplements were also given for healing of the uterine walls and restoring fertility. Soon with the help of IVF she was able to conceive.
Asherman's Syndrome is an acquired uterine condition, characterized by the formation of adhesions (scar tissue) inside the uterus (intrauterine Adhesions) and/or the cervix. In most of the cases, the front and back walls of the uterus stick to one another, or portion of it in some cases. The extent of the adhesions defines whether the case is mild, moderate, or severe. The adhesions can be thin or thick, spotty in location, or confluent. They are usually not vascular, which is an important attribute that helps in treatment
Recurrent miscarriage and infertility are the most common symptoms. Most patients with Asherman's Syndrome have scanty or absent periods (amenorrhea) and some patients have no periods but feel pain at the time that their period would normally arrive each month. This pain may indicate that menstruation is occurring but the blood cannot exit the uterus because the cervix is blocked by adhesions.
Asherman's syndrome occurs when trauma to the endometrial lining triggers the normal wound-healing process, which causes the damaged areas to fuse together. Sometimes adhesions also occur following other pelvic surgeries such as Cesarean section, surgery to remove fibroids or polyps, or in the developing world, as a result of infections such as genital tuberculosis and schistosomiasis.
Direct visualization of the uterus via Hysteroscopy is the most reliable method for diagnosis.
Hysteroscopy is a procedure that allows looking inside the uterus in order to diagnose and treat causes of abnormal bleeding. Hysteroscopy is done using a hysteroscope, a thin, lighted tube that is inserted into the vagina to examine the cervix and inside of the uterus. Hysteroscopy can be either diagnostic or operative. Diagnostic hysteroscopy is used to diagnose problems of the uterus. Operative hysteroscopy is used to correct an abnormal condition that has been detected during a diagnostic hysteroscopy. If an abnormal condition was detected during the diagnostic hysteroscopy, an operative hysteroscopy can often be performed at the same time, avoiding the need for a second surgery. During operative hysteroscopy, small instruments used to correct the condition are inserted through the hysteroscope.
Compared with other, more invasive procedures, hysteroscopy has a lot more advantages a recovery time is short and a shorter hospital stay is required. Post operative recovery and pain is less.
Adhesions have a tendency to reform, especially in more severe cases. There are different methods to prevent re-scarring after surgery for Asherman´s Syndrome. Prescription of estrogen supplementation to stimulate uterine healing and placement of a splint or balloon to prevent apposition of the walls during the immediate post-operative healing phase. By this the uterus/cervix remains scar-free and fertility is restored.
The reproductive consequences of Asherman’s Syndrome, including infertility, recurrent miscarriage, intrauterine growth restriction, placenta accreta and others, are well known. However, for all women with intrauterine scarring and amenorrhea, including those who may have completed childbearing, there are other concerns. Although the lack of menstrual periods could be secondary to hormonal abnormalities, it is more likely caused by either complete destruction of the uterine lining or by obstruction of the cervix or lower portion of the uterus; thus, menses are either retained in the uterus (leading to pelvic pain and a condition called hematometra) or flow into the abdominal cavity leading to endometriosis. Women with Asherman’s Syndrome may develop uterine cancer, either before or after menopause.