The introduction of hysteroscopic technology has led to a significant improvement in the diagnosis of several diseases, among which is hysterocutaneous adhesions. However, for every patient diagnosed with uterine adhesions, there is a lot more heaviness, and the serious consequences of this disorder are not taken seriously by the majority of patients and doctors, who have encountered several cases that remained undiagnosed after 1-2 years, delaying the timing of treatment. Today, I read an article about the surgery of complete cavity adhesions, and I would like to tell our first doctors to pay attention to patients who do not return to menstruation for several months after miscarriage.
Number of hysteroscopic procedures for complete uterine adhesions
Preamble.
Uterine adhesions are a phenomenon recognized in the late 19th century, dating back to its first description by H. Fritsch in 1894.Joseph G.
Asherman studied uterine adhesions in depth and defined them as: intrauterine adhesions due to trauma or narrowing over the internal cervical opening.
Uterine adhesions are usually due to damage to the uterine mucosa. The causes of uterine adhesions are varied and are usually post-pregnancy adhesions and non-pregnancy intrauterine adhesions. The main causes of post-pregnancy adhesions are: scraped or unscraped uterus after abortion, postpartum scraping, post-abortion or post-partum endometritis, local ischemia of the uterus due to postpartum bleeding, and uterine artery embolism. Intrauterine adhesions after non-pregnancy include adhesions after hysteroscopic surgery (e.g., fibroid removal, endometrial polyp removal, endometrial septum removal, hyperplastic endometrial removal, etc.) and uterine adhesions after genital tuberculosis infection.
The incidence of uterine adhesions is on the rise. A total of 1250 cases of uterine adhesions were reported in the literature during a total of 88 years from 1894-1982, while a total of 2500 cases of uterine adhesions were reported in the literature during a total of 26 years from 1982-2008. The rapidly increasing incidence is undoubtedly associated with the use of diagnostic hysteroscopy and 3D ultrasound, which are the best tools for the diagnosis of uterine adhesions.
Some uterine adhesions are very complex and severe and can lead to amenorrhea, recurrent miscarriage, infertility, placenta previa or implantation. The treatment of these complex uterine adhesions requires several hysteroscopic procedures. How many hysteroscopic procedures are appropriate and what is the impact on reproduction? This has been studied retrospectively by several French experts. The literature was published in Fertility and Sterility in October 2012.
STUDY OBJECTIVE; To investigate the uterine anatomical changes and reproductive outcomes after more than 2 separate hysteroscopic procedures for Asherman syndrome.
STUDY DESIGN: Retrospective case study.
CASE SELECTION: From January 2004 to August 2010, 258 hysteroscopic procedures for intrauterine adhesions were performed at two hospitals affiliated with the same university, and patients with >2 hysteroscopic procedures were selected. These patients all initially had severe Asherman syndrome leading to amenorrhea, stage IV and above according to ESHRE staging and stage III according to AFS staging. 23 patients met the above inclusion criteria.
Intervention: 3 or more hysteroscopic procedures.
Main observation: fertility rate.
Results.
A total of 83 hysteroscopic procedures were performed in 23 patients, with an average of 3.6 procedures per patient. Four of the patients had intraoperative perforation due to severe uterine adhesions, and each patient completed treatment anyway because the perforation occurred near the end of the procedure. one of the 23 patients was lost to follow-up after the last hysteroscopic procedure.
The mean age of the patients at the start of treatment for uterine adhesions was 34 (24-41) years, and the age at the final completion of hysteroscopic separation of uterine adhesions was 35.7 (29-42) years, with a mean duration of treatment of 20.8�12 months. All patients initially had severe uterine adhesions leading to complete amenorrhea.
The etiology of uterine adhesions was post-abortion and post-partum curettage in 52% (12 cases). All patients were infertile, 21 (91.3%) of the 23 patients had secondary infertility and 2 (8.7%) had primary infertility. Some patients had a combination of other causes of infertility: two cases of oligospermia in the male partner, one case of uterine fibroid, one case of T-shaped uterus, two cases of pelvic endometriosis, and one case of polycystic ovary syndrome.
After two hysteroscopic procedures in 23 patients, 14 patients (60.8%) still had amenorrhea, 8 patients (34.7%) had hypomenorrhea, and only 1 patient (4.3%) had normal menstruation.
Twelve of the 23 patients had 3 hysteroscopic treatments, 9 had 4 hysteroscopic treatments and 2 had 5 hysteroscopic treatments. Hysteroscopic evaluation at the end of treatment was normal in 13 patients (59%) with normal uterine mucosa and 9 patients (41%) with atrophic uterine mucosa. ≥Normal menstrual cycles were obtained in 17 patients (77.3%), hypomenorrhea in 2 patients (9.2%) and amenorrhea in 3 patients (13.7%).
The mean follow-up after treatment was 25.4 months (3-27 months) in 22 patients. Pregnancy was desired in all patients after treatment. The overall pregnancy rate was 40.9%, with 9 pregnancies and 6 full-term births (27.2%), all but one spontaneous pregnancy (88.9%), and 3 cases of spontaneous abortion.
One of the four patients with uterine perforation during hysteroscopy was pregnant, three of the eight patients with post-abortion uterine adhesions were pregnant at the end of treatment, and all four patients with post-partum uterine adhesions were pregnant after hysteroscopic surgery. The mean time until pregnancy after treatment was 10.5�4.7 months. The pregnancy rate at the end of treatment was 50% in patients with normal uterine mucosa and only 20% in patients with atrophic uterine mucosa. The pregnancy rate was 45.5% in patients with 3 hysteroscopic treatments (5 out of 11), 37.5% in patients with 4 hysteroscopic treatments (3 out of 8) and 50% in patients with 5 hysteroscopic treatments (1 out of 2), with no significant difference in the pregnancy rate between the three groups (P=1). Pregnancy rate was 50% in patients ≤35 years old (6 of 12 cases) and 30% in patients >35 years old (3 of 10 cases), but the difference was not significant (P=.66). This may be related to the small number of cases in this study. In general, age is an important factor in determining the prognosis of pregnancy.
Conclusion.
Hysteroscopy is now the best option for the diagnosis and treatment of uterine adhesions; however, many of them are complex. Restoration of normal uterine anatomy and optimal function requires multiple hysteroscopic procedures. The number of hysteroscopic procedures for Asherman’s syndrome should not be limited, and it is reasonable for patients with Asherman’s syndrome, especially those younger patients ≤35 years of age, to undergo hysteroscopic treatment as many times as necessary until the uterine cavity is completely normalized. Hysteroscopic procedures should preferably be performed under ultrasound guidance to reduce the risk of uterine perforation.