Treatment of Intrauterine Adhesions

Intrauterine adhesions (scar tissue), also called Asherman syndrome, can cause infertility, menstrual irregularities (light or absent menses) and recurrent pregnancy losses. In a previous blog, I have discussed the causes of Intrauterine adhesions. In this blog, we will discuss the treatment of intrauterine adhesions.

Most cases of mild intrauterine adhesions (solitary band of scar tissue) can be easily treated via hysteroscopy. The scar tissue can be cut with scissors, electric current (Versapoint) or laser. All three modalities are equally effective and the choice is based on the surgeon’s preference.

Severe Asherman syndrome, however, can be clinically challenging. These are patients with dense scar tissue that affects at least two-thirds of the uterine cavity and these patients have light or absent menses. The problem with these patients is that the adhesions often recur and may require multiple surgical procedures.

What is the most effective treatment of intrauterine adhesions?

Doctors Myers and Hurst from the Carolinas Medical Center in Charlotte, North Carolina, discussed this very issue in a recent paper (Fertil Steril 2012;97:160-4). They utilized a comprehensive approach for treatment of severe intrauterine adhesions. The details were a follows:

Prior to surgery

• A hysterosalpingogram, hysterosonogram or a hysteroscopy was performed to confirm diagnosis and identify extent of the adhesions.
• Transvaginal ultrasound to assess “baseline” uterine lining (endometrial) thickness and evaluate pelvic anatomy
• Patients were treated with estrogen for 2 – 8 weeks to stimulate development of the endometrium (4 – 6 mg orally daily). This was done to facilitate visualizing the uterine lining by abdominal ultrasound during hysteroscopy. They liked the endometrial thickness to be at least 4 mm.

During surgery

• Hysteroscopy was done with a full bladder to facilitate monitoring with an abdominal ultrasound.
• Cervical dilators were then inserted under ultrasound guidance to dilate the cervix and the uterine cavity.
• The adhesions were cut with hysteroscopy scissors inserted through the operative channel of the hysteroscope. Ultrasound helped direct the cutting of the adhesions, which was continued till the cavity was completely adhesion free.
• A triangular balloon catheter was inserted under ultrasound guidance and the balloon inflated to hold the two surfaces of the uterine cavity apart. Mechanical separation of the two surfaces is supposed to prevent the adhesions from recurring. The catheter was removed 3 – 7 days after the surgery.

After surgery

• The oral estrogen tablets were continued for 4 – 10 weeks after surgery. This facilitated maximal growth of the uterine lining to cover the denuded uterine cavity.
• The triangular balloon catheter was removed 7 – 10 days later and replaced by a copper intrauterine device (IUD). The copper IUD is left in place for a couple of months. The IUD once again helps with mechanical separation of the two surfaces. The copper in the IUD helps promote healing of the uterine lining.
• The uterine cavity was then reassessed by hysterosalpingography, hysterosonography or hysteroscopy.

The authors reported their experience in 12 women with severe intrauterine adhesions and absent menses. Using the above protocol, all 12 women resumed menses although the uterine lining was less than 4 mm in 5 of the 12 women. Six of nine women less than age 39 years (67%) became pregnant, and four of six achieved a term or near-term delivery.

Other authors have used hyaluronic acid (HA) to prevent recurrence of the adhesions. Seprafilm, a bioresorbable membrane from chemically modified HA (sodium hyalronate) and methyl cellulose, has been shown to significantly reduce intrauterine adhesions.

Women who get pregnant after treatment of Asherman syndrome still have a high risk of pregnancy complications, including miscarriage, premature delivery, abnormal placentation (placenta gets deeply embedded in the uterine musculature and can cause bleeding and other problems), intrauterine growth restriction (IUGR), and uterine rupture during pregnancy or delivery.

To see a Board Certified physician who has been successfully treating intrauterine adhesions for many years, make an appointment at one of InVia's four Chicago area fertility clinics.