Myometrial scoring: a new technique for the management of severe Asherman s syndrome

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1 FERTILITY AND STERILITY VOL. 69, NO. 5, MAY 1998 Copyright 1998 American Society for Reproductive Medicine Published by Elsevier Science Inc. Printed on acid-free paper in U.S.A. Myometrial scoring: a new technique for the management of severe Asherman s syndrome Athanasios Protopapas, M.D., Asher Shushan, M.D., and Adam Magos, M.R.C.O.G. Minimally Invasive Therapy Unit and Endoscopy Training Centre, University Department of Obstetrics and Gynaecology, The Royal Free Hospital, Hampstead, London, United Kingdom Objective: To describe a new hysteroscopic technique for the management of severe Asherman s syndrome. Design: Prospective observational study. Setting: Volunteers in an academic research environment. Patient(s): Seven patients with secondary infertility associated with amenorrhea or oligomenorrhea secondary to severe Asherman s syndrome. Intervention(s): Six to eight longitudinal incisions were made into the myometrium extending from the uterine fundus to the isthmus with a resectoscope fitted with a Collins knife electrode. Main Outcome Measure(s): Restoration of menses, symptomatic relief, and postoperative reproductive performance. Result(s): The amount of menstrual bleeding increased in all cases, including two women who were amenorrheic before their surgery. Pelvic pain decreased in two of the four symptomatic cases. Three to four months after surgery, hysteroscopy showed a normal sized uterine cavity in five cases. After a median follow-up of 12 months, three women conceived four pregnancies, including a missed abortion, a tubal abortion, an ongoing pregnancy currently at 7 weeks gestation, and one child delivered at 36 weeks gestation after premature rupture of the membranes. Conclusion(s): Hysteroscopic myometrial scoring enlarges uterine cavity size in cases of severe Asherman s syndrome and improves menstrual function. Reproductive performance seems to be improved also, but longer follow-up is required. (Fertil Steril 1998;69: by American Society for Reproductive Medicine.) Key Words: Intrauterine adhesions, Asherman s syndrome, hysteroscopic surgery, myometrial scoring Received September 16, 1997; revised and accepted December 3, Reprint requests: Adam Magos, Minimally Invasive Therapy Unit and Endoscopy Training Centre, University Department of Obstetrics and Gynaecology, The Royal Free Hospital, Pond Street, Hampstead, London, NW3 2QG, United Kingdom. (FAX: ) /98/$19.00 PII S (98) Asherman presented his first series of patients suffering from Amenorrhoea Traumatica in 1948 (1). Before his article, several sporadic reports appeared in the literature, describing a syndrome of amenorrhea and secondary infertility, usually associated with uterine curettage. In the years after Asherman s initial detailed description, several investigators have addressed the problem of intrauterine synechiae and have contributed to the current understanding of its etiology and clinical associations (2). Before the introduction of diagnostic hysteroscopy, the diagnosis of Asherman s syndrome relied on a history of secondary amenorrhea or oligomenorrhea frequently associated with or dysmenorrhea, which usually followed uterine curettage on a gravid uterus, or other procedures resulting in the opening of the uterine cavity (3). A positive hysterosalpingogram showing filling defects in the uterus of different and frequently bizzare shapes was considered as pathognomonic (4). Although the diagnosis of intrauterine adhesions is not difficult to make, the management of Asherman s syndrome is far from satisfactory. Several techniques have been described, but the results, especially in terms of successful reproductive outcome, have been variable (5, 6). We present myometrial scoring, a new hysteroscopic technique for the management of severe Asherman s syndrome associated with the presence of dense intrauterine adhesions and marked reduction in the size of the uterine cavity. This technique aims to restore the normal size and shape of the uterine cavity and uncover functional endometrium and was tried in seven patients who had previously under- 860

2 FERTILITY & STERILITY 861 TABLE 1 Characteristics of patients who underwent myometrial scoring. Patient no. Age (y) Parity Complaints History Previous management Secondary infertility; dysmenorrhea; Secondary infertility; dysmenorrhea Secondary infertility; amenorrhea Secondary infertility; oligomenorrhea Secondary infertility; oligomenorrhea; dyspareunia; Secondary infertility; oligomenorrhea Secondary infertility; amenorrhea; TOP ( 2); myomectomies ( 2); pelvic adhesiolysis ( 1) TOP ( 2); miscarriage ( 1); placenta accreta ( 1); ERPC ( 2) Laser surgery for twin-to-twin transfusion followed by miscarriage and ERPC ( 3) TOP ( 2); miscarriages ( 4) TOP ( 2); miscarriages ( 2) ERPC ( 2); miscarriages ( 3) LSCS ( 2); miscarriages ( 7) (blunt) with biopsy forceps D&C (blunt knife electrode) (blunt) Length of uterine cavity (cm) ESH classification of adhesions Tubal status before surgery 6 IIIb Bilateral proximal block 5 IV Bilateral proximal block 6 IIIb Unilateral proximal block Not recorded IIIa Unilateral tubal block 6 III Unilateral distal block 5 III Unilateral distal block 6 IIIa Bilateral tubal patency Note: TOP termination of pregnancy; ERPC evacuation of retained products of conception; LSCS lower segment cesarean section; ESH European Society of Hysteroscopy.

3 TABLE 2 European Society of Hysteroscopy classification of intrauterine adhesions. Grade I II IIa III IIIa IIIb IV Extent Thin or filmy adhesions; easily ruptured by hysteroscope alone; cornual areas normal Singular firm adhesions connecting separate parts of the uterine cavity; cannot be ruptured by hysteroscope sheath alone; visualization of both tubal ostia possible Occluding adhesions only in the region of the internal cervical os; upper uterine cavity normal Multiple firm adhesions connecting separate parts of the uterine cavity; unilateral obliteration of ostial areas of the tubes Extensive scarring of the uterine cavity wall; with amenorrhea or pronounced hypomenorrhea Combination of III and IIIa Extensive firm adhesions with agglutination of uterine walls; at least both tubal ostial areas occluded gone conventional hysteroscopic procedures that were unsuccessful. MATERIALS AND METHODS All patients had a history of uterine curettage either for termination of pregnancy or for the evacuation of retained products of conception after a spontaneous abortion or postpartum hemorrhage (Table 1). Two patients had a history of uterine surgery, including myomectomy or lower segment cesarean section, that predated their current symptoms. All patients were referred because of infertility. Additional complaints included amenorrhea or light menses, dysmenorrhea, cyclical or constant abdominal pain, and dyspareunia. All but one of the women had tubal disease in addition to the Asherman s syndrome, and four also had ovulatory dysfunction. The diagnosis of Asherman s syndrome was suggested by an abnormal hysterosalpingogram and was confirmed by a diagnostic hysteroscopy. Before their referral, all seven women had at least one attempt at hysteroscopic division of the adhesions with hysteroscopic scissors, biopsy forceps, blunt dissection, or electrosurgery. All presented with dense intrauterine adhesions that caused partial obliteration or excessive narrowing and distortion of the uterine cavity. The cervical canal either was obliterated completely or severely stenosed in most cases. The cases were classified as grade III, IIIa, IIIb, or IV according to the intrauterine adhesions classification of the European Society of Hysteroscopy (Table 2) (7). Myometrial scoring was performed under general anesthesia with a standard 26F continuous flow resectoscope fitted with a Collins knife electrode at a power setting of 100 watts of pure cutting current (Valleylab Force 40; Wembley, London, United Kingdom). Sterile 1.5% glycine solution was used for uterine distension, and irrigation was controlled with a HAMOU Endomat (all endoscopic equipment manufactured by Karl Storz GmBH, Tuttlingen, Germany). The cervix was dilated to Hegar no. 10 under ultrasound control in cases of cervical stenosis. Scoring involved making six to eight, 4-mm-deep longitudinal incisions into the myometrium extending from the uterine fundus to the isthmus (Fig. 1). In all but the last case, surgery was monitored by simultaneous laparoscopy or abdominal ultrasound. At the end of the procedure, the cervix was dilated up to Hegar no to reduce the likelihood of postoperative cervical stenosis. An intrauterine contraceptive device was inserted in two patients (nos. 5 and 6) who had severe conglutination of the uterine walls; these patients also were given antibiotics for 5 days after their surgery. Oral estrogens were prescribed for all the women for 3 months postoperatively; they received either mg of conjugated equine estrogens daily (Premarin; Wyeth Laboratories, Berkshire, United Kingdom) or 30 g daily of ethinyl estradiol. They were reviewed 3 4 months after their surgery to determine any changes in menstruation. A check hysteroscopy and endometrial biopsy was performed in some cases. In the case of patient 2, a repeat hysterosalpingography was performed to check the state of the proximal fallopian tubes. Repeat hysteroscopic surgery was performed if there was persistent oligomenorrhea after the first procedure. RESULTS We treated seven women by myometrial scorings, and four have undergone a repeat procedure (Table 3). There were no operative complications. The mean fluid absorption was 357 ml (range, 0 1,000), and the mean blood loss was 60 ml (range, ). The mean procedure time was 27.5 FIGURE 1 The resectoscope is withdrawn toward the isthmus with the knife electrode remaining continuously out of the sheath. 862 Protopapas et al. Myometrial scoring for Asherman s syndrome Vol. 69, No. 5, May 1998

4 TABLE 3 Postoperative results for patients who underwent myometrial scoring. Patient no. No. of procedures Size of uterine cavity after procedure Menses Pain Tubal patency after surgery Endometrial biopsy Duration of follow-up (mo) Pregnancies/outcome 1 2 Normal Improved* No change Not checked Not done 30 Referred for IVF-ET; not suitable 2 2 Normal Normal* No change Both tubes patent Inactive glands 20 One missed abortion at 7 weeks; one liveborn baby; elective LSCS after PROM at 36 wk 3 2 Normal Normal* No Unilateral block Secretory 15 Treated with clomiphene 4 2 Normal Normal* No Not checked Inactive glands 12 One tubal abortion 5 1 Normal Normal Decreased Not checked Proliferative 4 Trying for pregnancy 6 1 Normal Improved No Not checked Dense stroma; scanty glands 4 Ongoing pregnancy; 7wk 7 1 Normal Normal Decreased Not checked Not done 2 Trying for pregnancy Note: PROM preterm rupture of membranes. * Menstruating after first procedure. Scoring repeated as endometrial thin on ultrasound. minutes (range, minutes). All patients were discharged from the hospital on the day of surgery or the following day. One of the two patients in whom an intrauterine contraceptive device was inserted intraoperatively (no. 5) developed symptoms suggestive of pelvic infection shortly after the procedure and was treated with further courses of antibiotics. As of this writing, the median follow-up time was 12 months (range, 2 30). Four patients underwent myometrial scoring twice. Menstruation improved in all cases after one or two procedures. The two women with secondary amenorrhea both started to menstruate. The other five patients with oligomenorrhea had longer and heavier periods. Follow-up diagnostic hysteroscopy was performed on five women, and showed a uterine cavity of normal size and shape in all cases. Endometrial biopsy in five cases showed normal functional endometrium in two. The repeat hysterosalpingogram on the patient with bilateral cornual blocks before the hysteroscopic adhesiolysis (no. 2) showed that both tubes became patent after the surgery. During the follow-up period, three of the women conceived a total of four pregnancies. After ovulation induction with Pergonal (Sanofi Winthrop, Guildford, United Kingdom), patient 4 had a tubal abortion that was treated conservatively. Patient 2 had two pregnancies after her hysteroscopic surgery. The first was a missed abortion at 7 weeks gestation for which she underwent suction curettage. She conceived again 3 months later, and this pregnancy continued until 36 weeks gestation when she had preterm rupture of membranes and underwent cesarean section. The placenta was morbidly adherent and could be removed only partially at the time of the delivery. Three days later she underwent hysterectomy for persistent postpartum hemorrhage. Patient 6 got pregnant shortly after the procedure and was now in her 37th week of gestation at the time of this writing. DISCUSSION Severe Asherman s syndrome is easy to diagnose but difficult to treat. Any treatment has essentially three aims: to restore the size and shape of the uterine cavity, to return normal endometrial function, and to make pregnancy possible. Our preliminary results show that making longitudinal cuts into the myometrium achieves all three aims to a certain extent. Hysteroscopy showed that the internal dimensions of the uterine cavity had increased and seemed normal after one or two procedures (Fig. 2). Menstruation recommenced in the two women who were amenorrheic and became heavier and longer in those with oligomenorrhea. These effects may not necessarily be synonymous with normal endometrial function, but it is noteworthy that all three women who conceived still had abnormal endometrial histology after their surgery. Tubal disease, ovulatory dysfunction, age, and a relatively short follow-up may be the principal reasons why the other patients did not conceive. How does myometrial scoring compare with the other methods for treating severe Asherman s syndrome? There is good evidence that hysteroscopic adhesiolysis is an effective and safe treatment for mild adhesive disease and should be considered as the current standard of care (8 10). Hysteroscopy becomes more complicated, particularly if the uterine fundus is obliterated, and is less successful when there are dense fibrous adhesions. For instance, Valle and Sciarra (6) reported a term pregnancy rate of 31.9% after hysteroscopic adhesiolysis for severe adhesions, in contrast with 81.3% when operating on mild disease. Sugimoto (11), reporting on FERTILITY & STERILITY 863

5 FIGURE 2 (A), Drawing of a transverse section of the uterus showing a narrow uterine cavity. (B), The myometrial incisions are 4 mm in depth, extending from point A to point B and are performed in a radial fashion. (C), The cavity size is increased at the end of the procedure as the edges of the incisions at point B separate. 11 patients with marginal connective tissue adhesions similar to our cases, could not treat six hysteroscopically even after repeated attempts. Two of these cases ultimately underwent abdominal hysterotomy. An abdominal approach to the management of intrauterine adhesions has been shown to have variable success rates. Asherman (12) treated five women by laparotomy and hysterotomy after cervical dilatation and curettage had previously failed in four. Two of these patients subsequently conceived. Tomkins (13) also reported four cases of Asherman s syndrome of variable severity treated with abdominal synechiotomy. Only one patient had a successful pregnancy, and she was delivered by elective cesarean section. One patient aborted spontaneously at 6 weeks, the third did not get pregnant, and the fourth was lost to follow-up. More recently, Freedman et al. (14) managed 3 of 33 women who were not considered suitable for hysteroscopic adhesiolysis by transfundal adhesiolysis. Menses was restored in all patients, and two became pregnant and were delivered of viable infants. In their extensive review, Schenker and Margalioth (5) compiled 31 cases of abdominal synechiotomy from a total of 12 reports. Sixteen (52%) patients conceived, but only half of these pregnancies ended in the delivery of a healthy infant. In four cases cesarean hysterectomy was necessary because of placenta accreta. Recently, Reddy and Rock (15) reported the cases of three patients with complete obliteration of the endometrial cavity by dense adhesions, who were managed with the use of a technique of transfundal separation of the uterine walls and subsequent metroplasty. All patients resumed regular menstruation, but no pregnancy was achieved. Unfortunately, many studies fail to present their results according to the severity of the adhesions, and comparisons between different methods of management are very difficult to make (2, 5, 6). It would seem from the available evidence that a transfundal approach may be the only option when there is complete obliteration of the uterine cavity by dense adhesions. Our preliminary data suggest that hysteroscopic adhesiolysis with myometrial scoring can be effective in the management of moderate to severe Asherman s syndrome when the cavity of the uterus is at least partially preserved. Whether the addition of myometrial scoring to conventional hysteroscopic adhesiolysis improves outcome remains to be proved by larger numbers and perhaps randomized trials, but it is noteworthy that all our patients had undergone at least one unsuccessful hysteroscopic procedure previously. In view of our favorable results, it would seem logical to offer myometrial scoring to such patients as well as to those with a greatly reduced uterine cavity volume. References 1. Asherman JG. Amenorrhoea traumatica (atretica). J Obstet Gynaecol 1948;55: Shaffer W. Role of uterine adhesions in the cause of multiple pregnancy losses. Clin Obstet Gynecol 1986;29: Butram UC, Turati G. Uterine synechiae: variation in severity and some conditions which may be conductive to severe adhesions. Int J Fertil 1977;22: Sweeney WJ. Intrauterine synechiae. Obstet Gynecol 1966;27: Schenker JG, Margalioth EJ. Intrauterine adhesions: an updated appraisal. Fertil Steril 1982;37: Valle RF, Sciarra JJ. Intrauterine adhesions: hysteroscopic diagnosis, classification, treatment, and reproductive outcome. Am J Obstet Gynecol 1988;158: Wamsteker K, De Blok S. Diagnostic hysteroscopy: technique and documentation. In: Sutton C, Diamond M, editors. Endoscopic surgery for gynaecologists. London: Saunders, 1993: March CM. Intrauterine adhesions. Obstet Gynecol Clin North Am 1995;22: Roge P, D Ercole L, Cravello L, Boubli L, Blanc B. Hysteroscopic management of uterine synechiae: a series of 102 observations. Eur J Obstet Gynecol Reprod Biol 1996;65: Bellingham FR. Intrauterine adhesions: hysteroscopic lysis and adjunctive methods. Aust NZ J Obstet Gynaecol 1996;36: Sugimoto O. Diagnostic and therapeutic hysteroscopy for traumatic intrauterine adhesions. Am J Obstet Gynecol 1978;131: Asherman JG. Traumatic intrauterine adhesions. J Obstet Gynaecol Br Emp 1950;57: Topkins PT. Traumatic intrauterine synechiae. Am J Obstet Gynecol 1962;83: Friedman A, DeFazio J, DeCherney A. Severe obstetric complications after aggressive treatment of Asherman syndrome. Obstet Gynecol 1986;67: Reddy S, Rock JA. Surgical management of complete obliteration of the endometrial cavity. Fertil Steril 1997;67: Protopapas et al. Myometrial scoring for Asherman s syndrome Vol. 69, No. 5, May 1998