What are uterine adhesions?
These are when 2 sides of the uterus come together. The uterus is normally a hollow cavity that has a mucous lining (much like a carpet lines the floor of a room). This lining inhibits the direct adhesion between the uterine walls (much like a rubber glove does not stick when you slide it on your hand).
When the mucous membrane is damaged or disappears, the uterine cavity can stick to itself. Such adhesion can compromise successful embryo implantation and pregnancy. These adhesions can vary in extent and in importance. Significant adhesions may even impact the menstrual cycle by reducing and even stopping blood flow.
What causes uterine adhesions?
The most common reason is as a result of miscarriage (spontaneous or deliberate) with or without curettage. Uterine adhesions are not a direct result of curettage procedures. It is more likely that they are a result of changes in the mucous membrane, themselves a result of pregnancy or debris retained from pregnancy.
Uterine adhesions can also result after childbirth and sometimes even after a cesarean section. They are however most likely after a period of infection. They can result (although rare) after uterine surgery (particularly after myomectomy).
Thus uterine adhesions can result from uterine surgery, changes in the mucous membrane, or from an infection (particularly severe forms of adhesion can occur after an episode of genital tuberculosis)
How are uterine adhesions diagnosed?
During fertility checks a diagnostic hysteroscopy can pick up uterine adhesions of varying extent.
Sometimes uterine adhesion may be suspected if after surgical intervention (be it curettage, childbirth, cesarean section, or myomectomy) a patient’s normal menstrual cycle does not return (amenorrhea) or if the patient experiences much reduced cycles (hypomenorrhea).
When uterine adhesion is suspected the doctor will ensure a full check is made. This includes performing a hysterosalpingogram (HSG), a diagnostic hysteroscopy, and an ultrasound scan of the pelvic area so that: the severity of any adhesion can be established, any associated lesions can be identified, and the best treatment plan can be put together.
How are uterine adhesions treated?
Uterine adhesions are best treated via operative hysteroscopy. As with all operating hysteroscopy procedures, (cf. section operative hysteroscopy) the operating hysteroscope is inserted into the cavity. The fibrous connections between the uterus walls are seen and divided with great precision.
Les résultats, en matière de restauration de la fertilité des Traitements hystéroscopiques, dépendent de l’importance initiale de la synéchie : si les résultats sont très bons pour les synéchies peu étendues, ils deviennent plus limités pour celles qui atteignent plus des 2/3 de la cavité.
Whether or not the patient’s fertility is restored after the operative hysteroscopy depends on the initial severity of the adhesion. For adhesions that are not broadly spread the results as regards restored fertility are very good. However the results are not so positive for adhesions that impact more than 2/3 of the uterine cavity.
This type of operative hysteroscopy is one of the most difficult to performand requires a highly experienced surgeon.
If the first operative hysteroscopy fails to successfully divide an adhesion, subsequent surgical attempts are even more difficult to perform and the probability of success drops as the number of operations increases.
For adhesions that are extensive and complicated, success depends on the surgeon’s experience and the possibility of using an ultrasound scan at the same time as the operation in order to visually guide the surgeon. It is extremely difficult to navigate within a cavity when the surgeon’s view is obstructed by the adhesions. In these situations, the patient’s bladder is filled and an abdominal scan is carried out while the surgeon is performing the hysteroscopy.
Using both the endoscope camera that gives an internal view of the cavity together with the ultrasound scan images that give an external view of the cavity, the performance of the procedure is optimized. In the past, once the operation was performed, an Intra uterine device (IUD) would often be inserted. This was to prevent any subsequent adhesions. Nowadays this practice is seldom followed. Instead, diagnostic hysteroscopy procedures are performed (after the patient’s first post operation period). This way any secondary adhesions can be divided during the procedure.
It is thus very important that a diagnostic hysteroscopy to monitor the uterine cavity be scheduled for one month after the initial surgery.