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Journal of Minimally Invasive Gynecology (2006) 13, 398 – 402 Fertility after treatment of Asherman’s syndrome stage
3 and 4

Hervé Fernandez, MD, Fadheela Al-Najjar, MD, Aurélia Chauveaud-Lambling, MD,
René Frydman, MD, and Amélie Gervaise, MD

From the Department of Obstetrics and Gynecology, Hôpital Antoine Béclère, Assistance Publique-Hôpitaux de Paris,Clamart cedex, France (all authors). KEYWORDS:
STUDY OBJECTIVE: To evaluate the efficacy of hysteroscopic adhesiolysis and subsequent fertility
in patients with adhesions stage 3 and 4.
DESIGN: A retrospective cohort study (Canadian Task Force classification II-2).
SETTING: A tertiary referral center for hysteroscopic surgery.
PATIENTS: Seventy-one patients with intrauterine permanent adhesions.
INTERVENTIONS: Hysteroscopic surgery with monopolar energy (n ϭ 31) or bipolar energy (n ϭ
40). Uterine cavity with at least one free ostial area was restored after one (n ϭ 31), two (n ϭ 20), three(n ϭ 15), or four or more (n ϭ 5) surgical procedures RESULTS: Sixty-four patients were followed. Evaluation of the uterine cavity after surgery has been
performed by hysteroscopy for all the patients. All patients had resumption of menses, except for twopatients with a history of uterine artery embolization. Pregnancy index rate after the procedure was 28(43.8%) of 64, and the live birth rate was 21 (32.8%) of 64. In patients 35 years of age or younger, 20of 30 (66.6%) conceived compared with 8 of 34 (23.5%) in patients older than 35 years (p ϭ .01). Threepatients had either hysterectomy (n ϭ 2) or hypogastric arteries ligation for placenta accreta withuneventful postoperative course.
CONCLUSIONS: Hysteroscopic adhesiolysis can be performed for severe adhesions stage 3 and 4
with safety and efficacy. Age is the main predictive factors of success: the pregnancies were at risk ofabnormal placentation.
2006 AAGL. All rights reserved.
Asherman’s syndrome is defined by the presence of and 40% of uterine synechia are found after intrauterine permanent adhesions, obliterating the uterine repeated curettage for incomplete abortion or retained pla- cavity partially or completely. The prevalence is 3.7% to In addition, a prevalence of 2.7% has been report- 23.4% in women with a history of postpartum hemorrhag ed in women undergoing hysterosalpingography for infer- with curettage and 5% to 39% in women with recurrent Women with Asherman’s syndrome may have menstrual Corresponding author: Professeur Hervé Fernandez, MD, Service de disturbance, while subfertility may be there main complaint.
Gynécologie-Obstétrique, Hôpital Antoine Béclère, Assistance Publique- Hysteroscopic surgery currently is the optimal approach, Hôpitaux de Paris (AP-HP), 157 rue de la Porte-de-Trivaux. 92141 Clamart which has allowed rapid improvement in the diagnosis and treatment of total or partial uterine adhesions. However, there are very few studies concerning the treatment and fertility Submitted November 17, 2005. Accepted for publication April 24, prognosis of patients with severe adhesions.
1553-4650/$ -see front matter 2006 AAGL. All rights reserved.
doi:10.1016/j.jmig.2006.04.013 Etiology of intrauterine adhesions and symptoms at initial consultation D&C for missed or incomplete abortion Subfertility and recurrent pregnancy loss D&C ϭ dilatation and curettage.
We previously published a study of 31 patients with Eight patients (11.3%) were referred to our tertiary care reproductive center after first inefficient procedure. There factors increased subsequent fertility: the role of age (Ͻ 35 was no case of tuberculosis endometritis in this series.
years) and the interest to repeat the procedures to restore a Of the 71 patients, 31 patients (43.6%) reported amen- normal cavity. Since this first short-term study, we intro- orrhea, 19 (26.7%) profound hypomenorrhea, and 21 duced a new surgical technique with Versapoint electrode (29.7%) normal cycles (exclusively in cases of stage 3).
Fifty patients experienced infertility (70.4%), and 21 pa- Menlo Park, CA ) without cervical dilatation.
tients (29.6%) suffered recurrent pregnancy loss. Diagnosis The aim of this study was to evaluate the safety and was made by hysterosalpingography and confirmed by hys- efficacy of this new hysteroscopic adhesiolysis surgical technique in the treatment of 40 new patients and to eval-uate the results of 71 consecutive patients with severe Ash- Surgical technique
erman’s syndrome by observing the complete elimination ofall synechia in the uterine cavity, postoperative resumptionof menses, and pregnancy rate in a retrospective case report Hysteroscopy was performed under general or epidural anesthesia in the early proliferative phase of the menstrualcycle in the patients who were menstruating.
For 31 patients (43%) operated on from 1990 through 1997, a 9-mm resectoscope equipped with hysteroscopic Materials and methods
monopolar knife (Karl Storz GmbH, Tuttlingen, Germany)was introduced into the blind reduced cavity, obtained after From January 1990 through December 2003, 302 pa- prudent dilatation of the cervix by Hegar’s dilators. Glycine tients underwent hysteroscopy treatment for intrauterine ad- was used as distending medium. Starting in 1998, we used hesions (IUA). We reviewed all operative reports and se- Versapoint bipolar electrode exclusively with normal saline lected all patients with severe adhesions, with partial solution to distend the uterine cavity (n ϭ 40 [57%]). No agglutination of uterine wall (stage 3) or total agglutination cervical dilatation was needed with Versapoint 5F elec- (stage 4) and both ostial area occluded (stage 3 and 4 trode. In both methods, fluid balance was recorded in all according to the European Society of Sev- enty-one patients (23%) were selected according to these Treatment was performed by making several myometrial incisions 4-mm deep: two or three lateral incisions from the Median age was 36.1 years Ϯ 6.1 (range 26 – 47). Mean fundus to the isthmus on both sides and two or three trans- parity was 0.6 Ϯ 0.9 (range 0 –3). Risk factors for cavity versal incisions of the fundus. Procedure was stopped at that obliteration were the following: history of at least one di- point, even if ostial areas were not visible. A simultaneous latation and curettage (D&C) (range 1–5) for elective abor- laparoscopy was performed only in three patients with a tion in the first trimester (30 patients [42.3%]); at least one history of pelvic inflammatory disease or ectopic preg- D&C (range 1– 4) for missed abortion or incomplete abor- nancy, to observe the distal tubal status. In our large expe- tion in the first trimester (18 patients [25.4%]); and D&C for rience, ultrasound and laparoscopic control are not used to postpartum hemorrhage (5 patients [7%]). One patient avoid uterine perforation with hysteroscopy, due to absence (1.4%) had curettage for molar pregnancy. Fifteen patients of usefulness in monitoring this surgery. Prophylactic anti- (21.1%) had myomectomy involving hysterotomy, with six biotics amoxicillin and clavulanic acid at the dose of 2 g of them performed in another hospital, and two patients (SmithKline Beecham, Nanterre, France) were given rou- (2.8%) underwent uterine embolization for fibroid uterus in tinely at the induction of anesthesia. No intrauterine con- absence of rational indication . The interval be- traceptive device was inserted, because no significant ad- tween the causal procedure and hysteroscopy treatment of vantages has been noted when compared with hormonal IUA unfortunately was not available.
therapy Postoperative estrogen therapy (estradiol 4 Journal of Minimally Invasive Gynecology, Vol 13, No 5, September/October 2006 ing cervical dilatation (n ϭ 4) or during the procedure (n ϭ 3). No perforation occurred during the first surgery using Versapoint electrode. If perforation occurred, the procedure was terminated, and patients were operated on 2 months later without any difficulty, and no difference in subsequent A completed elimination of all synechia was obtained after the initial procedure by outpatient control hysteros- copy in 31 patients (43.6%), and these patients were al- lowed to attempt pregnancy; nevertheless in 16 of these 31patients (51.6%), filmy adhesions easily ruptured duringpostoperative hysteroscopy. In the remaining 40 patients,postoperative hysteroscopy diagnosed the persistence of mg daily; Laboratories Cassenne, Puteaux, France) was moderate or severe IUA and justified a second operative given to all patients for 2 months to plan postoperative hysteroscopy with direct synechialysis. No difference was observed between the two surgical techniques.
The anatomic result defined by complete elimination of Finally reconstruction of normal uterine cavity was real- synechia with restoration of normal size and shape of the ized after one (n ϭ 31), two (n ϭ 20), three (n ϭ 15), or four uterus was checked in all patients by an outpatient hyster- or more (n ϭ 5) surgical procedures despite the heteroge- oscopy without anesthesia. Hysteroscopy, even if it misses neous quality of endometrium mucosa.
small areas of adhesions, conversely to hysterosalpingogra- Menstruation was restored in all patients with history of phy visualizes the restoration of endometrium—the cavity amenorrhea and oligomenorrhea, with the exception of two that appears to be the main prognostic factor—and can patients who underwent uterine artery embolization for uter- easily rupture filmy adhesion during this procedure. Subse- quent fertility was studied by calling all patients by tele- Seven patients were lost to follow-up after control hys- phone. We considered only the first pregnancy after index teroscopy. The median follow-up time was 41 months (range 6 – 86) for the remaining 64 patients. The results in We evaluated the results between the two surgical tech- accordance with surgical techniques are presented in niques. The ␹2, test modified by Yates correction when appropriate, and Fisher’s exact test were used for statistical Twenty-eight index pregnancies were obtained in 64 evaluation, and p Ͻ.05 was considered to be statistically patients (43.8%) with no difference between surgical tech- significant. Where appropriate, we used means, standard niques, and the outcomes were as follows: 3 had first tri- deviation, and CIs for normally distributed data; and for mester missed abortions, 4 had second trimester fetal losses, skewed data, we used medians and ranges.
and 21 (32.8%) had live births. Three out of four secondtrimester losses occurred after resectoscope technique. Allpatients conceived spontaneously with the exception of three who underwent a first cycle of in vitro fertilization andembryo transfer .
Seventy-one patients underwent a total of 136 hystero- Nine (42.9%) of 21 patients with a history of pregnancy scopic procedures. The mean operating time for the proce- loss and 12 (24%) of 50 patients with infertility had live dure was 25.4 Ϯ 6.2 minutes (95% CI 24.35–26.45). All births. In patients aged 35 years or younger, 20 out of 30 patients were discharged from the hospital on the day of conceived (66.6%) compared with 8 out of 34 (23.5%) in surgery. Complications were noted in seven patients (5.1%) patients aged more than 35 years (p Ͻ.05) . In 21 of 136 hysteroscopies involving perforation occurring dur- patients with live births, there were 12 vaginal deliveries at Obstetrical history and pregnancy outcome after synechialysis with subsequent pregnancy and live birth rate Obstetrical history and recent obstetric outcome after synechialysis Current pregnancy fetal loss in second trimester term and 9 cesarean sections (CS). Three CS were per- ine myomas who continue to have amenorrhea. Coccia et al formed for breech presentation with fetal distress, and an- achieved a 33.3% pregnancy at term rate by using pressure other three CS were performed for fetal distress with ce- lavage under ultrasound guidance in adhesiolysis. The new phalic presentation. Caesarean sections were performed in Versapoint technique has been used in the last few years and two patients with previous one and two CS, respectively, for demonstrated its efficacy in treating intrauterine patholo- placenta accreta. The last CS was performed for chorioam- We observed only 1 out of 40 second trimester fetal losses with Versapoint, whereas the rate was 3 out of Severe complications occurred in 3 (14.3%) of 21 pa- 31 after resectoscope techniques. Versapoint could prevent tients. Two patients had hysterectomy for placenta accreta iatrogenic cervical incompetence due to cervical dilatation (patients with previous one and two CS, respectively) with- realized for resectoscope techniques. This difference can be out postoperative complications. The third patient had CS due to absence of cervical dilatation and/or less mucosa for Candida albicans chorioamnionitis at 30 weeks’ gesta- tion, after preterm rupture of membrane. Hemostasis was From the above studies, the rate of pregnancy at term obtained by hypogastric arteries ligation with an uneventful after synechialysis was almost the same among the various postoperative course. The newborn required respiratory techniques of hysteroscopic surgery . All these support initially. The pregnancy rate was 14 (48.4%) of 31, series can be compared because, whatever the classification 10 (50%) of 20, and 4 (20%) of 20, respectively, after one, used in each of these series, we always considered severe two, and three or more surgical procedures.
However, the Versapoint technique has improved safety by avoiding the complication of fluid overload and cervical Discussion
laceration or uterine perforation due to cervical dilatation inpatients with stenosed cervix or nullipara and we Management of uterine synechia improved progressively observed no perforation with this technique. Moreover, the during the last 10 years by the widespread use of hystero- risk of excessive fluid absorbed is theoretically possible but scopic surgery, which helps in diagnosis of uterine synechia the short time of the procedure, always less than 30 minutes, and restoration of normal size and shape to the uterus, which decreases the risk of this complication.
is essential to carry a pregnancy to term. With this largest There are probably few indications left for laparotomy, series published of patients with severe adhesions, we con- even in the treatment of severe IUA. Repeated hystero- firmed the role of age and the interest to repeat the proce- scopic procedures as and in our series al- dures until restoration a normal cavity are predictive factors lowed the re-establishment of a normal cavity in all patients, of subsequent fertility. Moreover, in 90% of pregnancies in and 20% fertility after three or more procedures in spite of our series occurred by natural means.
a higher risk of uterine perforation, whichever surgical tech- Various hysteroscopic adhesiolysis techniques were de- nique was used during the repeat procedures.
scribed and published in the last decades, either division of Many studies fail to present their results according to the adhesion by hysteroscopic or by using the resecto- severity of the adhesion. Therefore different techniques are In our study, pregnancy to term was achieved in difficult to compare. So in our study we treated severe 32.8% patients, and normal uterine cavity and menstruation Asherman synechia stage 3 and 4, and we obtained a 32.8% were achieved in all patients with the exception of two live birth rate after adhesiolysis. The live birth rate observed patients with history of uterine artery embolization for uter- demonstrates the difficulty of having a normal endometrium Delivery rate after adhesiolysis using various hysteroscopic methods Valle and 47 Resectoscope with scissors 15 (31.9)Chen et 23 Resectoscope with Laminaria (MedGyne, Lombard, IL) 8 (34.9)Capella-Allouc et 28 Monopolar knife 9 (32.1)Coccia et 3 Pressure lavage under ultrasound guidance 1 (33.3)Our series (2004) Journal of Minimally Invasive Gynecology, Vol 13, No 5, September/October 2006 suitable for nidation even after restoration of a normal chance of parenthood in a substantial proportion of infertile uterine cavity in patients with stage 4 adhesions, which couples. However, these patients with IUA undergoing ad- corresponds to what was reported by Valle and Scierr hesiolysis should be appropriately informed about the oc- where the severity of adhesions affected the chance of currence of life-threatening complications if they became pregnant and should be managed appropriately in a tertiary When the patient’s age was considered, we found that 20 care center. Moreover, performance of repeat procedures is (66.6%) of 30 patients aged 35 years or younger conceived, not indicated in patients older than 35 years.
compared with 8 (23.5%) of 34 patients older than 35 years.
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adhesions with safety and efficacy, which offers a real


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