Asherman’s syndrome is a condition in which mechanical damage to the endometrium or infection results in intrauterine adhesions (IUAs) and thinning of the endometrium, leading to menstrual abnormalities, such as hypomenorrhea, amenorrhea, and menstrual pain, as well as infertility due to implantation failure. Asherman’s syndrome is usually characterized by light menstrual periods. IUAs were first reported in 1895 by Fritsch, and the condition known as Asherman’s syndrome was first described by Asherman in 1950[2,3]. In > 90% of reported cases, Asherman’s syndrome develops following dilation and curettage (D&C); however, it has also been frequently reported after myomectomy, intrauterine infection, radiotherapy, and uterine arterial embolization (UAE) and is reportedly present in 4.6% of patients with infertility.
Hysteroscopic adhesion removal surgery is indicated to treat Asherman’s syndrome if symptoms such as menstrual disorders and infertility are caused by uterine cavity adhesions. Monitoring during hysteroscopic surgery is required to reduce the risk of uterine perforation. In addition to surgery, the treatment of Asherman’s syndrome involves appropriate postoperative management to prevent additional causes of infertility. Herein, we report the use of hysteroscopic adhesiolysis under laparoscopic monitoring to make intrapelvic observations and reduce the risk of intraoperative uterine perforation in a woman with Asherman’s syndrome who subsequently gave birth successfully.
A 40-year-old gravida 3 para 0 (3020) woman presented to our hospital for specialist care with a desire to carry a pregnancy to term. She had attained menarche at 13 years of age, with a regular, 28-d menstrual cycle.
History of present illness
She had previously undergone six sessions of D&C for a hydatidiform mole and persistent trophoblastic disease, followed by chemotherapy (methotrexate). She had also become pregnant twice; however, both pregnancies ended in spontaneous miscarriages.
History of past illness
She had also become pregnant twice; however, both pregnancies ended in spontaneous miscarriages.
Personal and family history
She had attained menarche at 13 years of age, with a regular, 28-d menstrual cycle.
Hysteroscopic adhesiolysis with concurrent laparoscopy was performed, and Asherman’s syndrome was diagnosed.
The uterine adhesions covered the area from the internal cervical os to the uterine fundus.
Postoperative Kaufmann therapy was administered, and endometrial regeneration was confirmed using hysteroscopy.
Here, we describe a case involving a 40-year-old woman with Asherman’s syndrome who could conceive and successfully give birth after hysteroscopic adhesiolysis under laparoscopic monitoring. We believe that this case is unique because surgery was performed under laparoscopic monitoring. The use of a laparoscope for women with Asherman’s syndrome who wish to conceive both prevents uterine perforation during surgery and allows investigation of the abdominal cavity to determine the cause of infertility during surgery. Moreover, to prevent the recurrence of adhesions, we inserted an IUD at the end of the surgery and administered Kaufmann therapy 1 mo postoperatively.
Asherman’s syndrome is characterized by partial or widespread adhesions in the uterine cavity, which are associated with menstrual abnormalities, infertility, and placental abnormalities. The syndrome develops when the endometrium is damaged due to trauma or ischemia. If this damage extends beyond the functional layer of the endometrium into the basal layer, the endometrial epithelium cannot regenerate, and endometrial surface adhesions form. This presentation is caused by surgical abortion in many cases, although it may also develop owing to other causes, including myomectomy, intrauterine infections, radiotherapy, or UAE. The absence of part or all of the endometrial tissue and the resulting IUAs prevent normal thickening of the endometrium during the menstrual cycle, causing uterine amenorrhea or uterine infertility.
In terms of its effect on pregnancy, in particular, Asherman’s syndrome is responsible for high rates of infertility, miscarriage, implantation failure during assisted reproduction, and placental abnormalities[6-8]. We considered that our patient had developed severe Asherman’s syndrome due to repeated D&C for a hydatidiform mole and persistent trophoblastic disease.
Surgery is indicated for treating patients with Asherman’s syndrome whose IUAs are causing symptoms such as menstrual irregularities and infertility, with hysteroscopic adhesiolysis considered the gold standard treatment. IUAs have the gross appearance of white, fibrous, granulation tissue, but this appearance changes to red or pink-colored uterine muscle tissue if the hysteroscope enters the normal muscle layer; therefore, the device must be advanced cautiously when detaching the adhesions. During the procedure, it is of paramount importance to avoid blind manipulation and to stay constantly aware of the device’s orientation within the uterine cavity, using the fallopian tube orifices as a landmark, taking care not to perforate the uterus. Recent studies have reported that transabdominal ultrasonography and laparoscopy are useful for monitoring during hysteroscopic surgery[9,10]. Although laparoscopy is more surgically invasive and expensive than ultrasonography, we performed hysteroscopic adhesiolysis under laparoscopic observation to prevent complications such as endometriosis, evaluate the fallopian tubes (for patency and surrounding adhesions), and prevent the uterus from rotating. Keeping the hysteroscope’s light source visible under laparoscopic observation enables safe and effective resection of IUAs.
However, adhesions commonly recur after adhesiolysis. Indeed, the more severe the adhesions, the higher the recurrence rate. Therefore, care must be taken to prevent this from occurring. Methods of preventing the recurrence of adhesions include the following: (1) IUD insertion or the temporary placement of a Foley catheter within the uterus as a physical barrier to prevent contact with the damaged endometrium; (2) coating the damaged endometrium with hyaluronic acid gel or carboxymethyl cellulose as an adhesion barrier; (3) hormone therapy to promote endometrial regeneration; and (4) second-look hysteroscopy early after surgery[11-15].
For our patient, our efforts to prevent the recurrence of adhesions included IUD insertion at the end of the surgery and Kaufmann therapy which was started 1 mo postoperatively. Given that the IUD insertion should last for 3 mo, we considered that re-evaluation while the IUD was in place would be challenging; therefore, a second-look hysteroscopy was conducted 3 mo postoperatively.
The IUAs in the present case were widespread and severe. However, postoperative hysteroscopy showed that endometrial regeneration was apparent throughout the uterine cavity. Furthermore, the endometrium had thickened from 4–5 mm preoperatively to 8–9 mm postoperatively, indicating a good postoperative course.
Careful monitoring of the course of pregnancy after surgery for Asherman’s syndrome is necessary. Deans et al reviewed the data of 696 women who delivered a child after adhesiolysis. The authors found that 17 of the women exhibited placental abnormalities such as placenta accreta or placenta previa, 8 required total hysterectomy, and 2 had uterine rupture. Furthermore, the premature birth rate was 40%–50%. Guo et al also reported higher ectopic pregnancy rates, cervical insufficiency, placenta previa, placenta accreta, premature separation of normally implanted placenta, premature rupture of membranes, stillbirth, and neonatal death in women who became pregnant after intrauterine adhesion removal, compared to the general female population[3,5]. Our patient was diagnosed with cervical insufficiency at 22 wk of gestation, and cervical cerclage was performed. Subsequently, the pregnancy was unproblematic, and MRI performed at 34 wk of gestation showed no obvious signs of placenta accreta or morphological abnormalities, such as thinning of the uterine wall. Regarding the described patient, we deliberated whether her baby should be delivered vaginally or by cesarean section. We decided to perform an elective cesarean section to ensure rapid and flexible management of placenta accreta, if present, and avoid uterine rupture. During the cesarean section, careful manual manipulation was required to detach the placenta because placental adhesions (placenta increta) were present. The manual detachment may have been more difficult after vaginal birth; therefore, a cesarean section was indeed the most appropriate option for this patient. Pregnancy and delivery outcomes post-treatment for Asherman’s syndrome remain unclear, and decisions concerning the delivery method are at the individual’s discretion. Further studies involving larger numbers of patients are needed to determine indicators for the methods of managing pregnancy and delivery in women with Asherman’s syndrome.