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Hysteroscopic Management
https://t.me/med1917
ofUterine Synechiae
JudeEhiabhiOkohue, AngeloB.Hooker,
andPreyeOwenFiebai
1 Introduction
Intrauterine adhesions (IUAs) or uterine synechiae describe situations where scar tissues
develop within the uterine cavity. This eventually leads to partial or complete agglutination
between the uterine walls and can result in clinical manifestations. It was rst described and
published by a German gynaecologist, named
Henrich Fritsch in 1894 following postpartum
dilatation and curettage (D&C) [1]. This condition however was characterized by Joseph
Asherman, who in 1948, identied the aetiology
and frequency of this syndrome, since known as
the Asherman syndrome. He described a series
of 29 cases with intrauterine cavity involvement
J. E. Okohue (*)
Assisted Reproduction Unit, Department of
Obstetrics and Gynaecology, Gynescope Specialist
Hospital and Madonna University, Port Harcourt,
Rivers State, Nigeria
e-mail: jude.okohue@npmcn.edu.ng
A. B. Hooker
Department of Obstetrics and Gynaecology, Zaans
Medical Centre, Zaandam, Netherlands
P. O. Fiebai
Department of Obstetrics and Gynaecology,
University of Port Harcourt Teaching Hospital,
Port Harcourt, Rivers State, Nigeria
e-mail: preye.abai@uniport.edu.ng
following hysterography and linked endometrial
trauma and adhesions to menstrual irregularities
and infertility [2].
The terms IUAs and Asherman syndrome are
often used interchangeably, although the syndrome, as described by Asherman, requires signs
and symptoms: when IUAs become associated
with menstrual irregularities or infertility.
Sometimes the same symptoms are present, but
the cause of the IUA is not pregnancy-related.
While some authors believe the term Asherman
syndrome can still be used in such situations, others suggest it should be restricted to cases of
IUAs resulting from endometrial damage related
to a gravid uterus [3].
2 Aetiology
Intrauterine adhesion formation is multifactorial
with multiple predisposing and causal factors,
while the pathogenetic mechanism is still poorly
understood. The true prevalence of IUAs remains
unknown; the condition is considered rare in the
general population. Intrauterine adhesions are
thought to develop following trauma to the uterine cavity. The damage to the basal layer of the
endometrium results in the formation of granulation tissue on the opposing surfaces of the uterine
cavity. Once these coalesce, adhesions form,
© The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature
Switzerland AG 2022
J. E. Okohue et al. (eds.), Gynaecological Endoscopic Surgery,
https://doi.org/10.1007/978-3-030-86768-3_29
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J. E. Okohue et al.
leading to a partial or total obliteration of the
uterine cavity. Hooker and colleagues recently
performed a systematic review of the literature
and reported a prevalence of 19.1% among 912
women hysteroscopically evaluated within
12months following a spontaneous miscarriage
or after medical or surgical management, 86% of
the patients following D&C [4]. In a study of
1856 women with Asherman syndrome, Schenker
and Margaloith found that 90.8% of the cases
were pregnancy-related, following termination of
pregnancy, miscarriage, vaginal birth, or caesarean section [5]. Dilatation and curettage of a
pregnant or recently pregnant uterus, therefore,
appear to be the most common predisposing factor for uterine synechiae.
Other causes of uterine synechiae or IUAs
include myomectomy, the use of the B-lynch compression sutures, the use of intrauterine devices,
uterine artery embolization, infections such as
tuberculosis of the genital tract, and following surgeries for Mullerian abnormalities [6–8].
3 Classication
A variety of classication systems exist, but
none have been validated or linked to reproductive performance. To date, no comparative anal-
ysis of studies has been performed, making a
comparison between different studies difcult
to interpret. The internationally most used classication systems are those of March etal., the
American Fertility Society (AFS), and the
European Society of Gynecological Endoscopy
(ESGE).
In the classication system of March etal.
(1978), the adhesions are categorized in minimal, moderate, and severe groups based on a
combination of the type of adhesions and cavity
involvement. The AFS classication (1988) is
based on the extent of cavity involvement, type
of adhesions, and menstrual pattern. Cumulative
scores determine the severity ranging from
stage I to III.The ESGE classication emerged
from the European Society of Hysteroscopy;
both classications are based on a combination
of the type of adhesions, site, and extent of cavity involvement and the presence of amenorrhea or pronounced hypomenorrhoea. The
severity of the adhesion is classied into seven
grades.
The European Society of Hysteroscopy
classication of intrauterine adhesions is presented in Table1, while the American Fertility
Society classication system is presented in
Table2.
Table 1 European Society of Hysteroscopy classication of intrauterine adhesions
Grade Extent of intrauterine adhesions
I Thin or lmy adhesions easily ruptured by hysteroscope sheath alone, cornual areas
II Singular rm adhesions connecting separate parts of the uterine cavity, visualization of
IIA Occluding adhesions only in the region of the internal cervical os. Upper uterine cavity
III Multiple rm adhesions connecting separate parts of the uterine cavity, unilateral
IIIA Extensive scarring of the uterine cavity wall with amenorrhea or hypomenorrhoea
IIIB Combination of III and IIIA
IV Extensive rm adhesions with agglutination of the uterine walls. Both tubal ostial areas
normal
both tubal ostia possible, cannot be ruptured by hysteroscope sheath alone
normal
obliteration of ostial areas of the tubes
occluded
Hysteroscopic Management ofUterine Synechiae
https://t.me/med1917
The American Fertility Society (AFS) classication of intrauterine adhesions
Table 2
Adhesion score
Extent of cavity involved
(Score)
Type of adhesions
(Score)
Menstrual pattern
(Score)
Prognostic classication
Disease severity
Stage I (mild) 1–4
Stage II (moderate) 5–8
Stage III (severe) 9–12
a
Disease severity is staged based on cumulative score
a
<1/3
(1)
Filmy
(1)
Normal
(0)
Scores
1/3–2/3
(2)
Filmy and dense
(2)
Hypomenorrhoea
(2)
4 Presentation
Patients with IUAs can be asymptomatic, and
therefore the diagnosis can remain undetected. It
is uncertain whether the reproductive performance of asymptomatic women is inuenced by
the presence of IUAs.
Women with IUAs or Asherman syndrome
can present with the following symptoms:
309
>2/3
(4)
Dense
(4)
Amenorrhoea
(4)
• Hypomenorrhoea/amenorrhea
• Cyclical lower abdominal/pelvic pain
• Recurrent pregnancy loss
• Infertility
5 Diagnosis
The diagnosis of intrauterine adhesion is made
based on the clinical presentations and assessment of the endometrial cavity. The following
investigative modalities assist in establishing a
diagnosis of intrauterine adhesions:
5.1 Hysteroscopy
Hysteroscopy is still considered the gold standard for establishing and conrming the diagnosis of uterine synechiae or IUAs (Figs.1, 2, 3, 4,
and 5). Hysteroscopy enables visualization of
the uterine cavity: the extent, localization, and
Fig. 1 Intrauterine adhesions
Fig. 2 Adhesions on the left uterine wall
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degree of IUAs can be accurately determined,
while other intrauterine abnormalities can also
be detected. Furthermore, there is the possibility
to perform adhesiolysis in the same session. In
case hysteroscopy is not available or cannot be
performed, other diagnostic modalities can be
considered. Because of the high frequency of
false-positive and diagnostic errors, hysterosalpingography, ultrasonography, and sonohysterography are less suitable for accurate detection
of IUAs.
Fig. 3 Column of adhesion just proximal to the internal os
Fig. 4 Another column of intrauterine adhesions
5.2 Hysterosalpingography
Hysterosalpingography can show lling defects
within the endometrial cavity and in severe
cases might show complete obliteration of the
uterine cavity. It can be performed as an ofce
procedure.
5.3 Saline Infusion Sonography
This is performed in an ofce setting using saline,
instilled via a special intrauterine catheter.
5.4 Transvaginal Ultrasound Scan
Versatile sonologists might be able to establish a
diagnosis of uterine synechiae with the help of a
transvaginal scan. This should not be considered
an accurate diagnostic modality.
5.5 Magnetic Resonance Imaging
Fig. 5 Severe intrauterine adhesions
It is less frequently used because of the exorbitant cost.
5.6 3D Ultrasonography
This may also be helpful in diagnosing intrauterine synechiae and seems a promising diagnostic
modality. Further research is necessary.
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6 Treatment
Hysteroscopic adhesiolysis is considered the
appropriate treatment method for IUAs. Since the
availability of hysteroscopy which allows a
proper visualization of IUAs within the cavity,
blind adhesiolysis has been relegated [9].
Hysteroscopic adhesiolysis aims at restoring
the normal anatomy of the uterine cavity, while at
the same time steps are taken towards preventing
recurrence. Randomized controlled trials comparing different treatment modalities are lacking,
and treatment, therefore, is essentially based on
the personal experience of the gynaecologist,
case series, and case reports, channelled towards
the individual needs of the patient.
The rigid hysteroscope is the most used treatment modality for the treatment of IUAs. Over
the years, developments in hysteroscopic equipment have occurred: renement in optic and
bre-optic technology with newer accessories,
which have led to an improvement in both visual
resolution and surgical techniques [10].
The rst hysteroscopes had diameters of about
5.5–6mm but were associated with a reduction in
quality of vision. Much later, the 2.9–4 mm
diameter hysteroscopes were manufactured.
Hysteroscopes with diameters less than 2mm are
now available, with good quality of vision.
The hysteroscopes are attached to inner and
outer irrigation and suction sheaths, respectively,
ensuring a continuous ow of uid. Also attached is
a 5 F operating channel through which hysteroscopic handheld instruments such as scissors and
graspers can be introduced. In case of cervical stenosis, intravaginal misoprostol can be administered,
facilitating dilatation of the cervical canal [11, 12].
Mild adhesions can be separated either because
of the pressure effect of the distension medium or
with the use of the tip of the hysteroscope [13].
Hysteroscopic scissors introduced through the
operating channel is usually used for adhesiolysis
(Fig.6a–c). The scissors are preferred for this purpose as it is believed to be associated with less
injury to the endometrium compared with the use
of an energy source [14, 15]. In the vast majority
of cases, the use of energy is not required.
In cases where energy is used, there is the
choice between the monopolar and bipolar
energy. While the monopolar energy uses hypotonic non-electrolyte-containing and therefore
non- conductive uids like 1.5% glycine, the
bipolar uses isotonic, conductive uids such as
normal saline and lactated Ringer solution. It
must be borne in mind that strict assessment and
documentation of uid input and output are
essential for patient safety.
While a uid decit of up to 2.5 L can be
allowed when using normal saline, the procedure
needs to be stopped following a decit of 1 L
with 1.5% glycine and hence monopolar energy.
It is important to have a clear eld with the
lowest intrauterine pressure possible. Manual
pressure cuffs and automated pumps are readily
available for delivering uids during hysteroscopy. Visualization is improved by the use of lowpressure and high-ow uid delivery system
rather than a high-pressure, low-ow system [16].
Intrauterine adhesions, centrally located
within the uterine cavity, are dealt with rst
before treating those located at the periphery of
the cavity [16]. Hysteroscopic adhesiolysis can
be performed under ultrasound scan or simultaneous laparoscopy guidance, especially in cases
where the anatomy is unclear, to minimize perforation. Fluoroscopy is another modality that can
offer the needed guidance during hysteroscopic
adhesiolysis. Fluoroscopy can identify unseen
areas of the endometrial cavity inaccessible to the
hysteroscope [17].
While all the above are meant to prevent uterine perforation, hysteroscopic adhesiolysis still
remains the procedure with the greatest risk of
perforation of the uterus [18]. If a perforation is
suspected, the management should depend on the
source of the perforation. Those caused by the
introduction of the hysteroscope, scissors, or
grasping forceps can be managed conservatively
as severe intra-abdominal bleeding or bowel perforation would rarely occur [16]. Perforation
caused by an energy device requires an emergency laparoscopy. The site of the perforation
should be inspected, and severe haemorrhage
ruled out. The bowel should also be inspected for
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a
b
c
Fig. 6 (a–c) Hysteroscopic adhesiolysis with scissors
any sign of injury, although this might not be
immediately apparent.
Other reported modes of management of IUAs
include the use of NdYAG (neodymium-doped
yttrium aluminium garnet) and KTP (potassiumtitanyl- phosphate) LASER, which are said to
cause damage to the endometrium as well as
being exorbitant [19].
Mccomb and Wagner reported their management of six cases with severe IUAs [20]. The
uterine wall was separated into two hemi-cavities
by inserting a 13F Pratt cervical dilator. Under
laparoscopic control, the brotic septum formed
was cut up to the fundus with hysteroscopic scis-
sors. The technique is associated with high morbidity and is therefore largely abandoned.
Another hysteroscopic technique was
described by Protopapas and colleagues [21].
They described making 6–8 longitudinal incisions, 4mm long into the myometrium from the
fundus to the isthmus using a resectoscope tted
with a Collins knife electrode.
They aimed to enlarge the uterine cavity with
the intention of uncovering functional endometrium. They reported an increase in menstrual
bleeding in all cases. Hysteroscopic morcellation
is emerging as a possible treatment modality in
cases of IUAs.
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In the management of IUAs, stem cell therapy
is gaining popularity. Stem cells could proliferate
and differentiate into matured specialized cells
both in vivo and invitro [22]. The use of stem
cells in a patient with severe Asherman syndrome
led to the development of endometrial thickness
up to 8 mm with a subsequent successful IVF
treatment [23].
7 Prevention ofAdhesion
Reformation
Numerous modalities have been employed with
the aim of reducing the recurrence of uterine synechiae which should be considered an important
problem, occurring in approximately 27% following adhesiolysis [3]. The available evidence
on this subject remains limited.
7.1 Intrauterine Device (IUD)
This separates the walls of the endometrium following the completion of hysteroscopic adhesiolysis. Originally, the Lippes loop was used, but
its manufacture was stopped for economic reasons [24]. The copper contained in the copper T
IUD causes an unwanted endometrial inammatory reaction, while the small surface area constitutes another disadvantage.
7.2 Intrauterine Foley Catheter
This also prevents the walls of the endometrium
from colliding together thereby reducing the
adhesion recurrence rate. A non-randomized
study comparing the use of Foley’s catheter for
10 days with IUD insertion for 3 months following adhesiolysis found fewer infections and
a lower recurrence rate in the Foley catheter
group [25]. Wrapping the Foley catheter balloon with fresh amnion has been shown to
improve healing [26].
7.3 Intrauterine Balloon Stent
This acts in the same manner as a Foley catheter.
Because of its triangular shape, it conforms to the
shape of the endometrial cavity. Its use was
recently found to be associated with a reduction
in adhesions recurrence rate, compared with an
IUD or hyaluronic acid [27].
7.4 Re-absorbable Agents:
Intrauterine Gel
There are several re-absorbable agents that can be
applied into the uterine cavity for the prevention
of IUAs. Hyaluronic acid, a naturally occurring
component of peritoneal uid that aids in tissue
lubrication and structural integrity, is an agent that
is registered for the prevention of IUAs. It was
found in a systematic review and meta-analysis to
be effective in preventing adhesion formation,
although the evidence is limited [28].
8 Endometrial Preparation
Various agents are used with the intention of stimulating residual growth of the endometrium following hysteroscopic adhesiolysis. One of such
agents is oestrogens. There are few comparative
studies investigating estrogen dosage and route of
administration. A recent comparative study did
not nd any difference between using a daily oral
dose of 2mg, compared to 6mg [29]. Other medications that increase blood ow such as aspirin,
nitroglyceride, and sildenal citrate have also
been tried. Unfortunately, the number of women
treated with these modalities to date remains
small, while there are no large studies in which
the modalities are examined.
The use of autologous platelet-rich plasma
(PRP) has been shown to improve endometrial
thickness in women with refractory thin endometrium and may play a role in the healing process
following adhesiolysis [30]. About 1mL of PRP
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is prepared and administered within the endometrial cavity. A transvaginal ultrasound scan is performed after 48–72h, measuring the endometrial
thickness. If found to be less than 7mm, the PRP
is again administered.
9 Follow-Up
Patients are usually assessed in order to detect
any recurrence. This can be done via ofce hysteroscopy, saline infusion sonography, and hysterosalpingography. The aim is to detect a
recurrence and offer treatment.
Learning Points
• Uterine synechiae are rare in the general
population.
• The most important risk factor is pregnancy.
• There are no comparative analyses of the different classication systems.
• Hysteroscopy is the gold standard in the diagnosis and treatment of uterine synechiae.
• Hysteroscopic adhesiolysis remains the procedure with the greatest risk of uterine
perforation.
• Available evidence on the prevention of adhesion reformation is limited.
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Hysteroscopic Myomectomy
https://t.me/med1917
SundayOmaleOnuh, PhilipsUcheEkpe,
andRaisS.Ibraheem
1 Introduction
Uterine leiomyoma or broids are benign tumours
of the uterine muscle which are of monoclonal
origin and rank the commonest tumour of the
female reproductive system [1]. Based on location, uterine broids could be subserosal, intramural or submucosal. While submucosal broids
constitute only 5.5–16.6% of all broids, they
cause the most severe symptoms [2]. Most of the
symptoms of submucosal broids are related to
anatomical distortion of the endometrial cavity,
manifesting as heavy menstrual bleeding (HMB),
infertility and pregnancy loss among others [3].
Hysteroscopic myomectomy has now become
the mainstay in the management of submucosal
broids. Hysteroscopic myomectomy was rst
performed in 1976 by Neuwirth and Amin [4].
Over the last three decades, advances in instrument and techniques have continued to improve
the possibility and ease of surgical removal of
submucosal broid using the hysteroscope and
S. O. Onuh (*)
Department of Obstetrics and Gynecology,
Deda Hospital, Abuja, Nigeria
P. U. Ekpe
Department of Obstetrics and Gynaecology, Asokoro
District Hospital, Abuja, Nigeria
R. S. Ibraheem
Department of Obstetrics and Gynaecology, IVF
Center National Hospital, Abuja, Nigeria
thus joining the ranks of minimally invasive surgery (MAS) [5].
In current practice, hysteroscopic myomectomy
could be achieved via mechanical means with cold
scissors, graspers or morcellators, or by the use of
energy like monopolar, bipolar, radio frequency
and laser energy [6]. Most cases of hysteroscopic
myomectomy are performed in the operating theatre under anaesthesia; however, a few cases can be
performed as ofce procedures [6].
2 Classication ofSubmucosal
Fibroids
There are varied classications of submucosal
broids which help in appropriate surgical management with resultant elimination or reduction
in the attendant morbidities. The most popular
classication is that by the European Society for
Gynaecological Endoscopy (ESGE) [7]. This
classies submucosal broids into three groups
as shown in Table1 and Fig.1.
There exists other methods of classication,
notable among them is the STEPW Lasmar classication [8], which uses trans-vaginal ultrasound scan (TVUS) or magnetic resonance
imaging (MRI) to assess the following parameters: size, topography, extension of the myoma
base, depth of myoma penetration and lateral
wall involvement.
© The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature
Switzerland AG 2022
J. E. Okohue et al. (eds.), Gynaecological Endoscopic Surgery,
https://doi.org/10.1007/978-3-030-86768-3_30
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