A retrospective cohort study to examine factors affecting live birth after hysteroscopic treatment of intrauterine adhesions

OBJECTIVE

To evaluate independent factors that affect the chance of live birth (LB) after hysteroscopic adhesiolysis in patients with intrauterine adhesions.

DESIGN

Retrospective cohort study.

SETTING

Hysteroscopic center of Fuxing Hospital in Beijing, China.

PATIENT(S)

Patients diagnosed with Asherman syndrome between June 2020, and February 2022.

INTERVENTION(S)

Hysteroscopic adhesiolysis is followed by a second look hysteroscopy to assess the outcome and follow-up for a year.

MAIN OUTCOME MEASURE(S)

Live birth rate (LBR) without the use of assisted reproductive technologies at 12-month follow-up.

RESULT(S)

Of the 544 women included in the cohort, the pregnancy rate at the end of 1 year of follow-up was 47.6% (95% confidence interval [CI] 45.5%-49.7%), and the LBR was 41.0% (95% CI 38.9%-43.1%). Stepwise multiple logistic regression analysis identified three independent predictors of LB in decreasing order of significance: increase in menstrual flow after surgery (odds ratio [OR] 3.69, 95% CI 1.77-8.21), postoperative endometrial thickness in the midluteal phase (OR 1.53, 95% CI 1.31-1.80), and the severity of recurred adhesion at second-look hysteroscopy (OR 0.62, 95% CI 0.50-0.76). Among subjects with good independent prognostic factors, namely, increased menstrual flow after surgery, postoperative endometrial thickness in the midluteal phase >6 mm, and no or minimal recurrence of adhesions at second-look hysteroscopy, the LBR was 69.0% (95% CI 65.4%-72.6%). On the other hand, in women (n = 26) without any of the three good prognostic factors, none had a successful LB (0).

CONCLUSION(S)

Overall, the LBR after treatment for Asherman syndrome was 41.0%. The prognosis is dependent on three outcome measures after surgery, namely, improvement in menstrual flow, postoperative endometrial thickness, and the minimal degree of recurrent adhesions at second-look hysteroscopy.

Etiology, Risk Factors, and Management of Asherman Syndrome

Asherman syndrome is characterized by a triad of symptoms including pain, menstrual abnormalities, and infertility and is a result of intrauterine scar tissue after instrumentation of a gravid uterus. Saline sonohysterogram is typically the most sensitive diagnostic tool; however, hysteroscopy is the criterion standard for diagnosis. Treatment includes hysteroscopic-guided lysis of adhesion, with restoration of the anatomy of the uterine cavity. Several modalities are used in an attempt to reduce the reformation of scar tissue after surgery; however, there is no consensus on the ideal method. Stem cells and platelet-rich plasma are being explored as means of regenerative therapy for the endometrium, but data remain limited. At present, most individuals can have restoration of menstrual function; however, lower pregnancy rates and obstetric complications are not uncommon. These complications are worse for patients with a higher grade of disease. Efforts are needed in standardizing classification, reducing uterine instrumentation of the gravid uterus, and referring patients to health care professionals with clinical expertise in this area.

Asherman Syndrome after Uterine Artery Embolization: A Cohort Study about Surgery Management and Fertility Outcomes

STUDY OBJECTIVE

To study the severity of intrauterine adhesions (IUA) after uterine arterial embolization and to evaluate fertility, pregnancy, and obstetrical outcomes after hysteroscopic treatment.

DESIGN

Retrospective cohort.

SETTING

French University Hospital.

PATIENTS

Thirty-three patients under the age of 40 years who were treated by uterine artery embolization with nonabsorbable microparticles between 2010 and 2020 for symptomatic fibroids or adenomyosis, or postpartum hemorrhage.

INTERVENTIONS

All patients had a diagnosis of IUA after embolization. All patients desired future fertility. IUA was treated with operative hysteroscopy.

MEASUREMENTS AND MAIN RESULTS

Severity of IUA, number of operative hysteroscopies performed to obtain a normal cavity shape, pregnancy rate, and obstetrical outcomes. Of our 33 patients, 81.8% had severe IUA (state IV et V according to the European Society of Gynecological Endoscopy or state III according to the American fertility society classification). To restore fertility potential, an average of 3.4 operative hysteroscopies had to be performed [CI 95% (2.56-4.16)]. We reported a very low rate of pregnancy (8/33, 24%). Obstetrical outcomes reported are 50% of premature birth and 62.5% of delivery hemorrhage partly due to 37.5% of placenta accreta. We also reported 2 neonatal deaths.

CONCLUSION

IUA after uterine embolization is severe, and more difficult to treat than other synechiae, probably related to endometrial necrosis. Pregnancy and obstetrical outcomes have shown a low pregnancy rate, an increased risk of preterm delivery, a high risk of placental disorders, and very severe postpartum hemorrhage. Those results have to alert gynecologists and radiologists to the use of uterine arterial embolization in women who desire future fertility.

Restoring Fertility of Patients with Severe Asherman's Syndrome in the Office Setting: A Step-by-Step Recipe for Success

OBJECTIVE

To describe an effective in-office hysteroscopic strategy to restore fertility of patients with severe Asherman's syndrome.

DESIGN

A step-by-step video demonstration of the technique with an emphasis on the key portions of the procedure. A detailed narrated description of the steps is provided.

SETTING

Tertiary care University Hospital.

INTERVENTIONS

Three patients were managed by hysteroscopy performed in the office setting without anesthesia. Case 1 is a 34-year-old woman with obstetrical history of first-trimester incomplete abortion treated with Dilation and Curettage (D&C), followed by a tubal ectopic pregnancy treated with laparoscopic partial salpingectomy and a subsequent pregnancy on the tubal stump treated with uterine artery embolization. Case 2 is a 40-year-old woman with history of tubal ectopic pregnancy treated with salpingectomy, a surgical first-trimester voluntary termination of pregnancy with D&C and a full term vaginal delivery complicated with retained products of conception that were removed with D&C. Case 3 is a 35-year-old woman with two previous first-trimester spontaneous miscarriages both treated with D&C. Case 1 and 3 were treated using miniaturized mechanical instruments only; in case 2, miniaturized mechanical instruments and the 15 Fr bipolar mini-resectoscope were used. Preoperative 2D and 3D ultrasound were used to predict the complexity of the cases and to guide the surgeon during the procedure. Intrauterine lysis of adhesions was concluded when both tubal ostia were visualized, and the uterine cavity was determined to have adequate shape and volume. At the end of the procedures, hyaluronic acid-based gel was applied to prevent new intrauterine adhesion formation. Two weeks after the initial procedure, a second look diagnostic hysteroscopy was performed. Only one patient (#1) needed additional lysis of adhesions; in this case, at the end of the procedure, a Word catheter was inserted as a barrier method for the prevention of adhesion formation. Eight weeks later, the word catheter was removed, and additional lysis of adhesions was performed. All the surgical procedures were performed without complication, and a healthy endometrium was observed at the second look hysteroscopy, in all the three patients. All 3 patients conceived after the procedure. Pregnancy was achieved after one IVF cycle with the transfer of one frozen embryo in case 1 and spontaneously in cases 2 and 3. Patient 1 was delivered by elective caesarean section due to placenta previa, while the other two patients had normal vaginal deliveries. Patient 1 had Retained Products of Conception requiring hysteroscopic removal using a 27 Fr Resectoscope.

CONCLUSION

When using innovative miniaturized instruments and adequate surgical technique, hysteroscopic lysis of adhesions is a feasible and effective in-office strategy to restore fertility in patients with severe Asherman's syndrome. The use of 2D and 3D ultrasound played an important role in the preoperative workup of the patient with Asherman's syndrome.

Human Platelet-Rich Plasma Facilitates Angiogenesis to Restore Impaired Uterine Environments with Asherman’s Syndrome for Embryo Implantation and Following Pregnancy in Mice

Asherman’s syndrome (AS) is caused by intrauterine adhesions and inactive endometrium from repeated curettage of the uterine endometrium. AS is a major cause of recurrent implantation failure and miscarriage and is very difficult to treat because of the poor recovery of endometrial basal cells. Platelet-rich plasma (PRP) has abundant growth factors that may induce angiogenesis and cell proliferation. Here, we demonstrate that human PRP (hPRP) significantly enhances angiogenesis to restore embryo implantation, leading to successful pregnancy in mice with AS. In mice with AS, hPRP treatment considerably reduced the expression of fibrosis markers and alleviated oligo/amenorrhea phenotypes. Mice with AS did not produce any pups, but the hPRP therapy restored their infertility. AS-induced abnormalities, such as aberrantly delayed embryo implantation and intrauterine growth retardation, were considerably eliminated by hPRP. Furthermore, hPRP significantly promoted not only the elevation of various angiogenic factors, but also the migration of endometrial stromal cells. It also increased the phosphorylation of STAT3, a critical mediator of wound healing, and the expression of tissue remodeling genes in a fibrotic uterus. PRP could be a promising therapeutic strategy to promote angiogenesis and reduce fibrosis in impaired uterine environments, leading to successful embryo implantation for better clinical outcomes in patients with AS.

Prevention of de novo adhesion formation in patients with Asherman's syndrome

OBJECTIVE

To summarize recent data and knowledge of secondary prevention of the recurrence of intrauterine adhesions in patients with Ashermans syndrome.

METHODS

Analysis of literature evidence and clinical experience of the authors.

RESULTS

Ashermans syndrome is iatrogenic disease with problematic therapy. One of the basic issues is a need for repeated surgical interventions since the recurrence of adhesions is very frequent. Secondary prevention is a crucial factor for successful therapy in these patients. The methods applied include second--look hysteroscopy, hormonal treatment and different types of barriers. To compare their efficacy is difficult and the results of meta-analysis are contradictory.

CONCLUSION

There are many different possibilities of secondary prevention of the recurrence of intrauterine adhesions; unfortunately, none of them is perfect. The usage of solid or semi-solid barriers in combination with the support of endometrium regeneration with hormonal therapy seems most reasonable.

Conservatively treated endometrial intraepithelial neoplasia/cancer: Risk of intrauterine synechiae

INTRODUCTION

To determine whether progestin type or number of dilation and curettage procedures (D&Cs) were associated with intrauterine synechiae (IS) or pregnancy outcomes in patients conservatively treated for endometrial intraepithelial neoplasia (EIN) or endometrial cancer (EC).

MATERIALS AND METHODS

We evaluated patients conservatively treated for EIN or EC from 2000 to 2017 at an academic center. IS were identified hysteroscopically. We calculated proportions for categorical variables and tested associations between D&C number, progestin, and pregnancy outcomes using Pearson chi-squared and Fisher's exact tests. A post-hoc power analysis indicated sufficient power to detect livebirth.

RESULTS

We analyzed 54 patients, 15 with EIN (28 %) and 39 with EC (72 %), with a mean age of 34 ± 1.2 years. Progestin treatment types included megestrol acetate (MA) (n = 24), MA with levonorgestrel intrauterine device (LngIUD) (n = 10), MA followed by LngIUD (n = 3), and LngIUD alone (n = 6). Mean number of D&Cs was 3.9 ± 0.9. Overall, 53 subjects underwent hysteroscopy; 10 (19 %) had IS. When D&Cs were grouped into 0-2, 3-4 and ≥5, each increase in D&C group had a 2.9 higher odds of IS (OR: 2.91, p = 0.04, CI: 1.05-10.02). LngIUD was associated with a nonsignificant 46 % decrease in the odds of IS (OR: 0.54, p = 0.66, CI: 0.08-2.87). Twenty-two women attempted pregnancy; 14 women achieved a total of 20 pregnancies and 9 women had total of 15 livebirths (41 % livebirth rate). The number of D&Cs and progestin treatment type were not associated with pregnancy outcomes.

DISCUSSION

Among 54 patients conservatively treated for EC/EIN, nearly 20 % developed IS. However, hysteroscopic and/or fertility treatments may improve pregnancy outcomes.

Asherman's Syndrome: it may not be all our fault

Asherman's Syndrome (AS) is an acquired condition defined by the presence of intrauterine adhesions (IUA) that cause symptoms such as menstrual abnormalities, pelvic pain, infertility, recurrent miscarriage, abnormal placentation and attendant psychological distress. Classically, AS is considered an iatrogenic disease triggered by trauma to the pregnant uterus. Different factors can cause the destruction of the endometrium, thus affecting the endometrial stem cell niche and creating IUAs. Curettage of the pregnant uterus appears to be the most common source of this destruction. Nevertheless, some AS cases have been associated with congenital uterine abnormalities and infections, and there are some idiopathic cases without any prior surgical procedures, suggesting a putative constitutional predisposition to IUA. Factors reported to cause AS share an underlying inflammatory mechanism leading to defective endometrial healing and vascularization. Interestingly, distinct genetic profiles have been observed in the endometrium of AS patients. These data suggest that AS might not just be an iatrogenic complication, but also the result of a genetic predisposition. Elucidating the possible physiopathological processes that contribute to AS will help to identify patients at risk for this condition, providing an opportunity for prevention.

[Asherman's syndrome : management after curettage following a postnatal placental retention and literature review]

Asherman's syndrome (AS) is a partial or complete obliteration of the uterine cavity after intrauterine trauma. Approximately 90 % of severe AS cases occur after abortion curettage or postpartum curettage. Clinical signs and symptoms are abnormalities of the cycle (hypomenorrhoea or amenorrhoea) and fertility disorders. We have reviewed the recent literature on AS following the description of a typical clinical case. The management of AS is not easy. It must be done by experienced surgeons. Realization of several surgeries is sometimes mandatory, with the use of anti-adhesive devices between interventions. Its complex management encourages insistence on the avoidance of its risk factors.

[Intrauterine synechiae after use of monopolar resectoscope]

BACKGROUND

Uterine synechiae are defined as abnormal adhesions and fibrosis within the uterine cavity due to direct trauma or injury to the basal membrane of the endometrium.

OBJECTIVE

To identify, by routine hysteroscopy, how many patients who were treated because of intrauterine pathology developed uterine synechiae within the first six months after treatment with monopolar resectoscope.

MATERIAL AND METHOD

A descriptive, open, observational, retrospective and cross-sectional study was performed at Hysteroscopy Unit, Gynecology Service of General Hospital Manuel Gea Gonzalez, Mexico City. From January 1, 2008 to December 31, 2011, we took, from the record books of the operating rooms, the file number of those patients who were treated with monopolar resectoscopy, and subsequently underwent routine hysteroscopy within the first six months.

RESULTS

69 records were included in the study. The main diagnoses were: endometrial polyp in 48% (n=33), submucosal myoma in 45% (n=3 1); 48% (n=33) polypectomy and 45% (n=31) myomectomy. Within the first six months after the main procedure, patients underwent a routine hysteroscopy, which revealed the development of intrauterine synechiae in 5.8% (n=4) of the patients. Of the patients who underwent myomectomy, 5.8% (n=4) developed uterine synechiae; while those patients who underwent polypectomy, synechiaes were not found. Minimal synechiaes were found in 4.3% (n=3) of patients, moderate synechiaes were found in 1.4% (n=1) of patients, and severe synechiaes were found in none patient.

CONCLUSION

Uterine synechiaes were found in 5.8% of patients with intrauterine pathology and treated with monopolar resectoscopy. Minimal to moderate synechia occur more commonly after myomectomy.

Retained placental tissue as an emerging cause for malpractice claims

BACKGROUND

Removal of retained placental tissue postpartum and retained products of conception (RPOC) abortion is done by uterine curettage or hysteroscopy. Trauma to the endometrium from surgical procedures, primarily curettage, can cause intrauterine adhesions (Asherman's syndrome) and subsequent infertility. The incidence of malpractice claims relating to intrauterine adhesions is rising, justifying reevaluation of the optimal way of handling these complications.

OBJECTIVES

To review malpractice claims regarding intrauterine adhesions, and to explore the clinical approach that might reduce those claims or improve their medical and legal outcomes.

METHODS

We examined 42 Asherman's syndrome claims handled by MCI, the largest professional liability insurer in Israel. The clinical chart of each case was reviewed and analyzed by the event preceding the adhesion formations, timing and mode of diagnosis, and outcome. We also assessed whether the adverse outcome was caused by substandard care and it it could have been avoided by different clinical practice. The legal outcome was also evaluated.

RESULTS

Forty-seven percent of the cases occurred following vaginal delivery, 19% followed cesarean section, 28% were RPOC following a first-trimester pregnancy termination, and 2% followed a second-trimester pregnancy termination.

CONCLUSIONS

It is apparent that due to the lack of an accepted management protocol for cases of RPOC, it is difficult to legally defend those cases when the complication of Asherman syndrome develops.

Post-traumatic amenorrhea: the role of diagnostic and operative hysteroscopy in the prevention, diagnosis, differential diagnosis and treatment

AIM

The aim of the study was to evaluate the clinical usefulness of the selective removal of residual intrauterine trophoblastic tissue by using a hysteroscopic procedure, especially in the prevention of the Intra-Uterine Adhesion's Syndrome.

METHODS

Seventy-six patients had an Asherman's Syndrome: 5 cases after laparotomic myomectomy, 1 after caesarean section, 2 after hysteroscopic myomectomy, 10 after VIP, 1 with a severe vaginal endometriosis, 1 after conisation, 4 after a post-partum hemorrhage due to coagulopathy or uterine atony, 20 cases after D&C because of PPH due to placental retention, 26 after repetitive D&Cs because of AUB due to post abortion chorial residues' retention, 6 cases after D&C for post menopausal AUB. Thirty-six patients presented AUB due to chorioplacental residues retention: 14 cases after a vaginal delivery or a caesarean section, 4 after VIP, 18 cases after repetitive D&Cs for incomplete or internal spontaneous abortion. Complete physical examination, transvaginal ultrasonography and operative hysteroscopy was offered as first treatment to all patients. Surgical treatment of IUA depends on the type (I-IV) and is based on the section of synechiae, liberation of the uterine cavity and tubal recesses, recovery of the residual endometrium to restore the physiology of the reproductive tract. Our technique to remove the chorioplacental residues is based on: correct use of loops and electric currents, enucleation by cold loops of the base of the placental implant, and to single out the level of miometrial infiltration.

RESULTS

After treatment we have noticed: two hysterectomies (for persistent AUB after myomectomy and for severe bleeding after dehiscence of a C. section), restoration of regular menstruations in 94.6% of patients (6 women in menopause), disappearance of pelvic pain and dysmenorrhea in all cases (100%), 8 pregnancies of the 9 women who were wanting child after hysteroscopic synechiolysis (88.9%).

CONCLUSION

According to the present study, the best way to prevent IUA is to make D&C for abortion, avoiding waiting longer than 24 hours, perform a D&C and then a diagnostic hysteroscopy after PPH in symptomatic women, reserve D&Cs only for a PPH, or an incomplete abortion, limit to only one D&C, always make a diagnostic hysteroscopy after D&C and uterine plugging for PPH.

The management of Asherman syndrome: a review of literature

Asherman syndrome is a debatable topic in gynaecological field and there is no clear consensus about management and treatment. It is characterized by variable scarring inside the uterine cavity and it is also cause of menstrual disturbances, infertility and placental abnormalities. The advent of hysteroscopy has revolutionized its diagnosis and management and is therefore considered the most valuable tool in diagnosis and management. The aim of this review is to explore the most recent evidence related to this condition with regards to aetiology, diagnosis management and follow up strategies.

Pregnancy after endometrial ablation. A report of three cases

BACKGROUND

Pregnancies after endometrial ablation (EA) are rare and are associated with high morbidity, especially in the second and third trimesters.

CASE

We report 3 cases of pregnancy after EA in which severe complications occurred during the first trimester. The first case concerns an unexpected pregnancy after EA in a 50-year-old woman. Hysterectomy via laparotomy was needed because of heavy bleeding and severe anemia. Pathology showed a complete hydatidiform mole without invasion. Ultrasound-guided in situ methotrexate injection could be a nonsurgical alternative to terminate an intrauterine pregnancy after EA when the pregnancy is located within uterine synechiae, as shown by the second case. The third case presented as an accreta placentation mimicking hyperplastic myometrial invasion in a 46-year-old patient.

CONCLUSION

Because of the high morbidity of these pregnancies that could still occur after EA, patients need contraception after EA, and concomitant hysteroscopic sterilization should be proposed at the same time.

[Epidemiological profile, etiological diagnosis and prognosis of uterine synechias: report of 86 cases]

BACKGROUND

Uterine synechias may pose real problems for fertility prognosis. It depends mainly on its etiology.

AIM

To study the epidemiological profile of patients, describe the circumstances of discovery of uterine synechias, specify the diagnostic procedures for pelvic ultrasound, hysterography and hysteroscopy and estimate the benefits on fertility.

METHODS

A retrospective study over a period of 10 years from 1 January 2000 to December 31, 2009 in the department of obstetrics gynecology B Charles Nicolle's Hospital in Tunis.

RESULTS

We collected 86 patients. The age average was 35.42 years, gestit average of 1.36 with 37.2% of nulligeste and an average parity of 0.67. The uterine revision was the main etiology (55.8%). The main circumstance of discovery was the exploration of infertility (60%). Hysterosalpingography showed a luminal filling defect in 79% of patients mostly fundic location (37.3%). Faced with data from the hysteroscopy sensitivity of HSG was 78% and positive predictive value was 100%. For the seat of the synechia its sensitivity is only 40%. The surgical procedure took place in one time in 74 cases. Our complication rate is 8.14%: 2 uterine perforations, 2 falseroads and 3 cases of hemorrhage stopping surgery.

CONCLUSION

The main etiology is a history of uterus revision. The main circumstance of discovery is the exploration of infertility. Anatomic results were generally good as testified hysteroscopy control.

[Asherman's syndrome I--history, prevalence, histopathology, classification, ethiology, symtomatology and investigations]

OBJECTIVE

To describe the current knowledge of Ashermanes syndrome--its history, prevalence, histopathology, classification, ethiology, symtomatology and investigations.

DESIGN

Review article.

RESULTS

There is presented the history of definition of Asherman's syndrome. The origin of Asherman's syndrome is in a fibrotisation of endometrium--the ethiologic factors are: an intrauterine trauma in connection with pregnancy, the trauma on nongravid uterus is in minority. There is not certificated that the inflammation without trauma can cause Asherman's syndrome, exception the cases with genital TBC and schistosomiasis. The prevalence of Asherman's syndrome depends on various factors: number of therapeutic and illegal abortions, on incidence of genital inflammation and TBC, on criteria used for diagnosis of IUA and etc. The typical symptomatology of this syndrome consisted of: menstrual abnormalities (hypomenorrhea, amenorrhoea), infertility, repeated pregnancy loss and pregnancy complications. There were described a lot of classifications developed in relation with chosen diagnostic method. The gold standard in diagnosis and therapy is the hysteroscopy, the sonohysterography is very promissing diagnostic method.

CONCLUSION

The Asherman's syndrome is very complicated and severe disease that can significantly influence a possibility of woman conceive and give birth to a healthy child.

[Intrauterine adhesions--Asherman's syndrome]

Intrauterine adhesions known as Asherman's syndrome evolve after trauma to the basal layer of the endometrium usually secondary to curettage of a recently pregnant uterus. The lesions range from minor to severe cohesive adhesions that affect menstrual function and fertility. Operative hysteroscopy is the mainstay of diagnosis, classification and treatment of the intrauterine adhesions. Significantly obliterated cavity may require multiple hysteroscopic adhesiolysis to achieve a satisfactory anatomical and functional result. Operative hysteroscopy for selective curettage of residual trophoblastic tissue instead of nonselective conventional curettage may prevent intrauterine adhesions.

Intra-uterine adhesions and fertility outcome: how to optimize success?

PURPOSE OF REVIEW

To review the etiology, diagnosis, and clinical manifestations of intra-uterine adhesions and to address treatment with a specific focus on fertility outcome.

RECENT FINDINGS

Intra-uterine adhesions can cause recurrent pregnancy loss and infertility. The gravid or recently postpartum uterus is particularly susceptible to adhesion formation following instrumentation. While sonohysterography and hysterosalpingography are useful as screening tests of intra-uterine adhesions, hysteroscopy remains the mainstay of diagnosis and treatment. Hysteroscopic lysis of adhesions with scissors, electrosurgery, or laser can restore the size and shape of the endometrial cavity. Significantly obliterated cavities may require multiple procedures to achieve a satisfactory anatomical result. Postoperative mechanical distention of the endometrial cavity and hormonal treatment to facilitate endometrial regrowth appear to decrease the high rate of adhesion reformation. Newer antiadhesive barriers may also prevent the recurrence of intra-uterine adhesions. Endometrial development can remain stunted due to a scant amount of residual functioning endometrium and fibrosis. Potential pregnancy complications, especially placenta accreta, after the treatment of intra-uterine adhesions should be anticipated and discussed with the patient.

SUMMARY

Diagnosis and treatment of intra-uterine adhesions are integral to the optimization of fertility outcomes. Favorable results in terms of pregnancy and live birth rates can be expected after hysteroscopic adhesiolysis.

Genital tuberculosis: an important cause of Asherman's syndrome in India

OBJECTIVE

To demonstrate the association between genital endometrial tuberculosis and Asherman's syndrome.

MATERIALS AND METHODS

A total of 28 women who underwent hysteroscopy with or without laparoscopy for suspected Asherman's syndrome from symptoms (amenorrhoea or oligomenorrhoea, and or primary or secondary infertility) and who were found to have genital tuberculosis on endometrial biopsy (histopathology or culture) or positive polymerase chain reaction (PCR) on endometrial aspirate or positive findings of tuberculosis on laparoscopy or hysteroscopy were enrolled in this retrospective study.

RESULTS

The mean age and parity were 26.5 years and 0.3, respectively. There was past history of TB in 67.8% women. All women had menstrual dysfunction, with oligomenorrhoea and hypomenorrhoea in 16 (57%) women and amenorrhoea in 12 (42.8%). All women had primary (n = 19, 67.8%) or secondary (n = 9, 32%) infertility. On hysteroscopy, there were various grades of adhesions in all women, with grade I in 17.8%, grade II in 28.5%, grade III in 28.5% and grade IV in 17.5% women. Only four women (14.3%) had open ostia, while others had bilateral (28.5%) or unilateral (21.3%) blocked ostia or inability to see ostia (28.5%). On laparoscopy performed on 18 women, there were varying grades of adhesions in 16 (88.8%) women, with beading (33.3%), tubercles (33.3%), caseation (11.1%) and tubo-ovarian masses (11.1%). The diagnosis of genital TB was made by histopathology (tuberculous granuloma) on endometrial biopsy in 28.6%, positive culture in 3.6%, positive polymerase chain reaction (PCR) in 46.4% and observation of tubercles, beading or caseation on laparoscopy in 17.8% or shaggy cavity with caseation on hysteroscopy in 3.6% women.

CONCLUSION

Genital tuberculosis appears to be an important and common cause of Asherman's syndrome in India, causing oligomenorrhoea or amenorrhoea with infertility.

Appendico-vesicostomy in tile management of complex vesico-vaginal fistulae

Complex vesico-vaginal fistulae (VVFs) continue to complicated prolonged obstructed labour in this country. Recently a young lady presented to us with a huge VVF, associated with loss of the urethra and bladder neck, severe gynaetresia and recto-vaginal fistula. Her VVF was successfully managed by an appendico-vesiscostomy.

Intrauterine adhesions after manual vacuum aspiration for early pregnancy failure

OBJECTIVE

To describe the occurrence of intrauterine adhesions after manual vacuum aspiration for early pregnancy failure.

DESIGN

Case series.

SETTING

Tertiary care center.

PATIENT(S)

Three women with intrauterine adhesions after manual vacuum aspiration for the treatment of early pregnancy failure.

INTERVENTION(S)

Chart review.

MAIN OUTCOME MEASURE(S)

Hysteroscopic diagnosis of intrauterine adhesions after manual vacuum aspiration.

RESULT(S)

Three cases of symptomatic intrauterine adhesions after manual vacuum aspiration.

CONCLUSION(S)

Intrauterine adhesion formation may follow manual vacuum aspiration for early pregnancy loss.

[The surgical treatment of severely injured vagina]

OBJECTIVE

To investigate the surgical methods of treating severely injured vagina.

METHODS

A retrospective study was carried out on the clinical materials and results of 7 patients suffered from severe vaginal injury.

RESULTS

Different surgical approaches such as trans-suprapubic, transperineal or both approaches were applied according to the position of the atresia, meanwhile, different surgical methods such as skin graft, free flap transplantation, vaginal mucous flap advancement, direct anastomosis of the two ends, "Z" plasty was used to repair the vagina according to the different defect of the vagina, except for 1 case complicated with vaginorectus fistula, all the other cases were achieved satisfactory results.

CONCLUSIONS

The accurate judgment of the severity of the vaginal injury and the understanding of the changed anatomy around the injured vagina was the key points to the success of the surgical treatment of traumatic vaginal atresia.

Vaginal calculus secondary to vaginal outlet obstruction

Primary vaginal stones are extremely rare and are often mistaken for bladder calculi on plain radiography. However, intravenous pyelography and sonography can help differentiate between the two. We report a case of a large vaginal stone in a 21-year-old woman referred for apareunia and difficult micturation. The clinical findings of vaginal outlet obstruction and a hard mass anterior to the rectum made us suspect a bladder calculus; however, sonography of the pelvis indicated that the mass was in the vagina. Further examination using a probe to physically define the stone's location confirmed it to be a vaginal calculus. Surgery was performed to repair the outlet obstruction and remove the stone, which permitted the woman to urinate normally and engage in normal sexual relations.

Unusual late complications after two previous cesarean deliveries: a case report

BACKGROUND

Women with multiple previous cesarean deliveries (CDs) risk the development of uterine synechiae and ventral fixation of the uterus to the abdominal wall.

CASE

A para 2, gravida 2 women who had two prior CDs experienced prolonged menstrual bleeding with persistent cramps, both of which became more severe after insertion of an intrauterine contraceptive device that was subsequently removed. Pelvic ultrasound revealed an enlarged uterus with fibroids. After a failed attempt to perform a dilation and curettage because of uterine synechiae, the patient underwent a total abdominal hysterectomy. During surgery, the gynecologist observed a total dehiscence of the previous uterine incision, with ventral fixation of the uterus to the lower anterior abdominal wall and marked elongation of the portio cervix.

CONCLUSION

Dysmenorrhea in a patient with multiple previous CDs, mainly of the classical type, should be carefully evaluated and, in addition, when such patient requires a dilation and curettage, the possibility of cervical stenosis and uterine synechiae should be kept in mind. Having had a number of previous CDs may have an adverse impact on the uterine complication rate.

Intravesical Lippes loop following insertion for the treatment of Asherman's syndrome: a case report

A case report of a 36-year-old Para 6+0 (1 alive) civil servant who developed Asherman's syndrome following repair of ruptured uterus is presented. She had adhesiolysis and insertion of Lippes loop. She defaulted 3 months after presentation and was seen 1 year after with intravesical translocation of the IUCD. This was successfully removed using a forward biting bladder biopsy forceps under direct cystoscopic view.

Prevalence of Asherman's syndrome after secondary removal of placental remnants or a repeat curettage for incomplete abortion

This prospective study assesses the prevalence of intrauterine adhesions among women undergoing secondary removal of placental remnants after delivery, or a repeat curettage for incomplete abortions, and evaluates risk factors associated with the presence of intrauterine adhesions. In 50 women, undergoing either a secondary removal of placental remnants more than 24 h after delivery, or a repeat curettage for incomplete abortions, ambulatory hysteroscopy was performed 3 months after the intervention. Intrauterine adhesions were found in 20 of the women (40%): five patients had Asherman's syndrome grade I, six had grade II, six had grade III and three had grade IV. In women with menstrual disorders a statistically significant 12-fold increased risk for Asherman's syndrome grade II-IV was found. Previous abortion as well as infection during surgery were associated with a mildly but non-significant increased risk. Based on our findings, hysteroscopy is recommended only in those patients who develop menstrual disorders, either after secondary intervention for placental remnants after delivery or after a repeat curettage.