Uterine Synechiae: Diagnosis and Treatment

What is it?

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. Among the most frequent changes are the IUA (abbreviations in Intrauterine Adhesions), a kind of scars (adhesions) resulting from attacks inside the uterus, such as post-curettage. Abortion, endometritis, intrauterine surgery to eliminate fibroids, correction of structural defects of the uterus, or cesarean section.

Heinrich Fritsch first described these adhesions in 1894 and Ashermann in 1948, who told “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 in 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 work).

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 remain controversial, there is insufficient evidence that surgical correction of certain defects, including intrauterine adhesions, can significantly improve the reproductive result of 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 into 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 blocked hole, composed only of dense connective tissue.

Endometrial adhesions can be broken even during diagnosis with the device itself and have an excellent prognosis. The fibrous adhesions (covering many uterine cavities) are only removed with a resectoscope or laser.

The most significant 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 decreasing the uterine endometrial cavity, besides insufficient to supply the necessary vascularization for 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 method has greater sensitivity and specificity and provides 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.

The treatment can be simple or complex in uterine adhesions, depending on its degree. Only simple cases in which the reference points are clear should be treated in the office. Due to the risk of uterine rupture, others 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, the highest degree of uterine synechia, has an easy diagnosis but a problematic treatment. This treatment aims to restore the size and shape of the uterine cavity, to return to the normal functioning of the endometrium, and pregnancy may be possible. Good adhesions are easily treated (sometimes with simple distension), with good results.

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.