Uterine Synechiae: Diagnosis and Treatment


What is it?

The infertility affects about one in five couples who want to become pregnant and there are several causes in the female part that can determine pregnancy failure. The cause of uterine infertility is one of them and among the most frequent changes are the IUA (abbreviations in Intrauterine Adhesions), a kind of scars (adhesions) as a result of attacks inside the uterus, such as post-curettage. abortion, endometritis, intrauterine surgery for the elimination of fibroids, correction of structural defects of the uterus or by cesarean section.

These adhesions were first described by Heinrich Fritsch in 1894, and Ashermann in 1948, who described “traumatic amenorrhea”, the result of extensive intrauterine synechia , characterizing the syndrome that bears his name. Although it is usually asymptomatic, its main symptoms are menstrual changes such as amenorrhea and hypomenorrhea, infertility, and 15% to 50% of cases, habitual abortion, which occurs due to the reduction of the surface of the endometrium for the implantation of the embryo and the difficulty of expansion of the uterine cavity. However, when pregnancy occurs, they may have problems such as premature labor, placenta previa, and accumulation (often causing bleeding at the onset of labor).

It is harmful to the reproductive health of women

Although the direct cause and effect between some types of alterations of the uterine cavity with recurrent pregnancy loss remains controversial, there is insufficient evidence that surgical correction of certain defects, including intrauterine adhesions, can provide significant improvement in the reproductive result in the patients. When the adhesions disappear, it is observed that the pregnancy rate increases to a great extent, but this improvement depends on the type of synechiae and the severity with which the uterine cavity is affected.

The uterine synechiae can be classified in three stages: mild adhesions, which are composed of membranes of endometrial tissue, and can be partial or total; moderate adhesions formed by fibromuscular tissue of the endometrium still characteristically coated, which may prevent the uterine cavity partially or totally; and severe adhesions, it has a partially or totally blocked cavity, composed only of dense connective tissue.

Endometrial adhesions can be broken even during diagnosis with the device itself and have an excellent prognosis. As for the fibrous adhesions (which cover a large part of the uterine cavity) they are only removed with a resectoscope or laser.

The greatest impact of the Synechiae is the change in reproductive health , in particular it leads to infertility. The mechanism by which adhesions can cause sterility is the mechanical obstruction factor of the tubes to prevent the migration of sperm or the implantation of the blastocyst. The habitual abortion can be explained by the decrease of the uterine endometrial cavity, besides insufficiency to supply the necessary vascularization for the embryonic and fetal growth. Of the patients with uterine pathology is infertility of which 25% had uterine adhesions.

Diagnosis and treatment

The diagnosis of UIA is mainly carried out by hysteroscopy, because this is the method that has greater sensitivity and specificity, in addition to providing more detail as an extension of synechiae, location, type and degree of belonging. The HSG can also be used, but the sensitivity is low, failing to diagnose all cases.

In uterine adhesions, depending on its degree, the treatment can be simple or complex. Only simple cases, in which the reference points are clear, should be treated in the office. Others, due to the risk of uterine rupture, require combining hysteroscopy and laparoscopic treatment, and should not be treated in the office. The elimination of the synechia can be done with scissors or bipolar energy, using a cutting electrode.

Positive results vary with the type and severity of the scar. Asherman syndrome , which is the highest degree of uterine synechia, has an easy diagnosis, but a difficult treatment. This treatment aims to restore the size and shape of the uterine cavity, to return to normal functioning of the endometrium and pregnancy may be possible. Fine adhesions are easily treated (sometimes with simple distension), with good results after treatment.

The surgery lasts about 30 minutes, and the patient can be discharged the same day. Depending on the case, there is the possibility of using hormones additionally.