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Intrauterine Adhesions

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Ultrasound Imaging in Reproductive Medicine

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Abstract

Intrauterine adhesions (IUA) also referred to as Asherman’s syndrome or intrauterine synechiae is a well-defined clinical entity, manifested by anatomic obliteration of the uterine cavity by adhesions. It may be caused by surgical trauma to the basal layer of the endometrium, usually secondary to curettage of the postpartum uterus, elective termination of early pregnancies, and genital tuberculosis, and may culminate in a spectrum of disorders ranging from menstrual disturbances to normal menses, infertility, recurrent pregnancy loss, and, possibly, endometriosis.

Several diagnostic techniques, such as transvaginal sonography (TVS), hysterosalpingography (HSG), saline infusion hysterography (SIS), sonohysterography, saline contrast hysterosonography (SCHS), 3D ultrasound, sonohysterosalpingography, 3D hysterosonography, hydrosonography, and, rarely, magnetic resonance imaging, have been used for screening IUA. MR might give additional information with the use of DW and T2W high-resolution images. The uterine cavity must be evaluated as the place where the embryo is implanted and where pregnancy is developed. Any occupation of the cavity can thwart embryo development. Although MR hysterosalpingography can properly evaluate these abnormalities, standard MR examinations also can be of value. Intrauterine adhesions or synechiae may be secondary to pregnancy, curettages, surgeries, or earlier infections. They might be identified as hypointense linear images that cross the endometrial cavity in T2-weighted images. However, though these techniques are noninvasive and cost-effective with a short learning curve and may accurately assess most intrauterine pathology with a high specificity, they have limited accuracy for the detection of IUA with a high false-positive diagnosis rate and have to fall back on hysteroscopy as the reference standard owing to its higher sensitivity. Combined with history and a high index of suspicion, operative hysteroscopy is the gold standard for the accurate diagnosis, classification, and treatment of IUA.

Adhesiolysis followed by the use of anti-adhesive barriers to prevent reformation and combined with cyclic estrogen therapy to stimulate endometrial growth is the therapy of choice. Auto-cross-linked hyaluronic acid (ACP) gel, obtained by condensation of hyaluronic acid, is a reabsorbable agent that can be applied to the uterine cavity for the prevention of IUAs. Approximately 7 days after the application, ACP is completely reabsorbed. Prevention of IUAs is essential, and application of ACP gel may be considered to reduce the incidence and severity of IUAs. Perivascular stem cells (PVSCs) are recently proposed as the origin of all mesenchymal stem cells, and PVSCs from human umbilical cords (HUCs) are known to be the most effective cells to respond rapidly in intrauterine injuries. PVSCs transplantation gives us a promising option to facilitate restoration processes of impaired endometrium and improve poor pregnancy outcomes in the uterus with intrauterine adhesions based on murine research. Several techniques, such as hysteroscopic adhesiolysis with scissors, electrosurgery or laser, ultrasound-directed hysteroscopic adhesiolysis, fluoroscopically guided hysteroscopic synechiolysis and balloon hysteroplasty, laparoscopic intracorporeal ultrasound-guided hysteroscopic adhesiolysis, pressure lavage under ultrasound guidance (PLUG), and sonohysterographic (SHG) adhesiolysis, have been proposed for the treatment of IUA. Hysteroscopic adhesiolysis is a unanimously recognized safe and effective first choice for restoring menstrual function and fertility even in women with severe adhesions and postmenopausal women with highly favorable pregnancy and live birth rates. Intraoperative ultrasonography, as an adjunct, has a significant role in hysteroscopic adhesiolysis in coordinating images of the endometrial cavity, uterine wall, and the tip of the hysteroscope, directing and ensuring dissection in the proper tissue plane, thus avoiding the possibility of inadvertent uterine perforation, and in examining the endometrial pattern and predicting the surgical and clinical outcome in women with severe Asherman’s syndrome and in extensive, recurrent adhesions. Fluoroscopically guided hysteroscopic synechiolysis and PLUG are minimally invasive and cost-effective alternatives compared to labor-intensive, expensive endoscopic techniques with a high potential for restoration of menses and fertility, and PLUG enables complete lysis in mild to moderate IUA obviating the need for operative hysteroscopy. However, their efficacy must be explored further.

Hence, while ultrasonography may have a limited role in the diagnosis of IUA compared to hysteroscopy, it has a significant role in guiding the surgical management of IUA.

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Authors and Affiliations

  1. Reproductive Endocrinology & IVF, Millennium Medical Center IVF, Jumeirah, Dubai, UAE

    Gautam Nand Allahbadia

  2. Reproductive Endocrinology & IVF, Bourn Hall IVF, Jumeirah, Dubai, UAE

    Gautam Nand Allahbadia

  3. Reproductive Endocrinology & IVF, Orchid Fertility & Andrology Services, DHCC, Dubai, UAE

    Gautam Nand Allahbadia

  4. Reproductive Endocrinology & IVF, Dr. Amal Elias Fertility Center, Dubai, UAE

    Gautam Nand Allahbadia

  5. Reproductive Endocrinology & IVF, Canadian Specialist Hospital, Abu Hail, Dubai, UAE

    Gautam Nand Allahbadia

  6. Reproductive Endocrinology & IVF, Indo Nippon IVF, Mumbai, India

    Gautam Nand Allahbadia

  7. Rotunda – The Center For Human Reproduction, Mumbai, India

    Gautam Nand Allahbadia

  8. Medical Education & Research, ISRME, Mumbai, India

    Gautam Nand Allahbadia

  9. Medical Education & Research, Indira IVF, Udaipur, India

    Gautam Nand Allahbadia

  10. Indira IVF, New Delhi, India

    Akanksha Allahbadia Gupta

  11. Millennium Medical Center IVF, Dubai, UAE

    A. H. Maham

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Editors and Affiliations

  1. The Jones Institute for Reproductive Medicine, Eastern Virginia Medical School, Norfolk, VA, USA

    Laurel A. Stadtmauer

  2. Institute for Human Reproduction, Chicago, IL, USA

    Ilan Tur-Kaspa

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Allahbadia, G.N., Gupta, A.A., Maham, A.H. (2019). Intrauterine Adhesions. In: Stadtmauer, L., Tur-Kaspa, I. (eds) Ultrasound Imaging in Reproductive Medicine. Springer, Cham. https://doi.org/10.1007/978-3-030-16699-1_11

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