İNTRAUTERİN ADEZYONLAR

Dr. Bülent Urman

AMERİKANHASTANESİ

AFS Classification for IU adhesions

Extent of cavity involved

< 1/3 1/3-2/3 > 2/3

1 2 4

Type of adhesions

Filmy Filmy and Dense

Dense

1 2 4

Menstrual pattern

Normal Hypomenorrhea

Amenorrhea

0 2 4

Prognostic classification

Stage 1-Mild adhesions 1-4Stage 2-Moderate adhesions 5-8Stage 3-Severe adhesions 9-12

HSG score: adhesions should be considered denseHysteroscopic score

Frequency of intrauterine adhesions after D&C for

different indicationsIndication for D&C

Percent Author

Incomplete Ab 6.4 Adoni

Elective Ab 2.9 Kraji, Lavric

PP hemorrhage 3.7 Bergaman

PP hem (late) 23.4 Eriksen

Missed Ab 30.9 Adoni

Prevention of IU adhesions

Avoid overzealous curettage Avoid curretage PP Suction curretage by Karman aspiration

whenever possible Adjuvants

Treatment

Dilatation under local or general anesthesia Curettage Hysteroscopic lysis

Office hysteroscopyConventional hysteroscopy

Other methodsPressure lavage under US guidance

Preoperative preparation

HSG is the single most important preoperative test

Phase of the cycle Office hysteroscopy should be the gold

standard No indication for Misoprostol

Operative techique

Operative scissors Bipolar cutting current Versapoint Resectoscope Laser

Guidance

LaparoscopyUltrasoundFluoroscopy

Adjuvants Antibiotics Estrogen IUD Balloon Adhesion barriers

Amnion graftingHyaluronic acidHyaluronic acid + CMC (Seprafilm)

The role of Seprafilm in the prevention of IU adhesions in women with missed abortions

Control Seprafilm

Number of patients 100 50

No previous D&CAt least 1 D&C

5644

3218

Pregnancy in the no D&C group at 8 mo

30/56 (54%) 32/32 (100%)

Adhesion free patients at 8 mo in women who did not conceive

50% 100%

From Tsapanoz et al. J Biomed Mater Res 2002

Auto-cross-linked hyaluronic acid gel in theprevention of intrauterine adhesions after

hysteroscopicadhesiolysis: a prospective, randomized, controlled

study

Control Group ACP Gel

Number of patients 41 43

Adhesions at 6 months

32% 14%

Adhesion score at 6 months

6.3 to 5.3 6.2 to 2.0

Adhesion grade 25% mild75% moderate

100% mild

From Acunzo et al Hum Reprod 2003

ULTRASOUND GUIDANCE

BLADDER

GRADE 1-2 ADEZYONLAR

GRADE 3 ADEZYONLAR

A simplified treatment for Asherman’s syndrome

From McComb et al. Fertil Steril 1997

Treatment of severe IU adhesions by resectoscopic* lysis under TA

ultrasound guidance Number of patients Percent

Severe Adh 107 100

Total rest of the cavity

50 46.7

Partial rest of the cavity

57 53.3

Complications 2 1.8

Laparoscopy 4 3.7

Second HS 70** 65.4

* 41 procedures were performed by Versapoint** 29 had a third and 10 had 4 or more procedures

Postoperative HSG control

Normal cavity 25 Abnormal cavity 74 No follow-up 8

Fertility outcome

Patients desiring pregnancy 88 Spontaneous pregnancy 21 IVF pregnancy 10 No pregnancy 41 No follow-up 16

Results at second look H/S or HSG after hysteroscopic adhesiolysis

HSG and or Second-Look H/SType of adhesions None Mild Moderate Severe

Mild (n=10) 10 0 0 0

Moderate (n=20) 18 2 0 0

Severe (n=10) 4 3 1 2

Total (n=40) 32 5 1 2

From Pabuccu et al. Fertil Steril 1997

Mc Comb (1997) 6 5 (83) NAUrman (2005-unpublished) 88 21 (23.8) NAFernandez (2006) 64 28 (43.8) 21 (32.8)

Modified from Capella et al. 1999

Fertility after hysteroscopic adhesiolysis

Pregnancy RateIndication for H/S Mild Moderate Severe

Infertility 81 66 15

Rec Abortion 94 89 65

From Valle and Sciarra Am J Obstet Gynecol 1988

IU adhesions-conclusions

Diagnosis and treatment is dictated by HSG

Ultrasound or LS guided hysteroscopic lysis is the best treatment option

Results depend upon the extent of adhesions