Techniques and instrumentation

FERTILITY AND STERILITY ~

Copyright c 1997 American Society for Reproductive Medicine

Vok 67, No. 1, January 1997

Printed on acid-free paper in U. S. A.

Surgical management of complete endometrial cavity

Obliteration of the

Sujatha Reddy, M.D. John A. Rock, M.D.

Department of Co,necology and Obstetrics, Enzor:y University School of Medicine, Atlanta, Georgia

Objective:.To describe a technique for surgical management of complete obliteration of the endometrial cavity.

Design: A report of a series of three patients. Setting: A university-based hospital. Patient(s): Three patients with complete obliteration of the endometrial cavity. Intervent ion(s ) : Transfundal scar removal using stents in the fallopian tubes to serve as

landmarks. Main O u t c o m e Measure(s): Regular withdrawal bleeding. Result(s): Regular menses in all three patients. Conclus ion(s ) : The technique described here shows promise for establishing uterine cavity

integrity in cases of complete endomehial obliteration where there are no landmarks in the uterine cavity. Fertil Steril e 1997;67:172-4

Key Words: Asherman's Syndrome, uterine synechiae, secondary amenorrhea, uterine scar- ring, endometrial sclerosis

Asherman's Syndrome is defined as "regional obliteration of the uterine cavity due to partial con- glutination of the uterine cavity." In its most severe form the entire endometrial cavity is obliterated. We describe our technique for treating complete obliter- ation of the cavity by uterine synechiae through transfundal separation of the walls of the endome- trial cavity. To date three patients have had their uterine walls separated with this technique and all three continue to have regular menses.

CASE REPORT

All patients received informed consent for laparos- copy-hysteroscopy and laparotomy. All patients had at least one "prior attempt at hysteroscopic resection of synechiae. The obliteration of the endometrial

Received May 14, 1996; revised and accepted August 21, 1996. Reprint requests: John A. Rock, M.D., Department of Gynecol-

ogy and Obstetrics, Emory University School of Medicine, 1639 Pierce Drive, Room 4208 WMB, Atlanta, Georgia 30322 (FAX: 404-727-8609).

cavity resulted from postpartum hemorrhage, uter- ine packing, and subsequent dilatation and curet- tage in two patients. The etiology of cavity oblitera- tion was unknown in one patient. Each operative procedure began with a concomitant hysteroscopy and laparoscopy. In each case the uterine cavity was obliterated completely by adhesions. The hystero- scopic portion of the procedure was terminated be- cause the uterine walls could not be separated with- out significant risk of perforation. An exploratory laparotomy was performed. The uterus was brought through the incision and was transected longitudi- nally to the level of the internal os (Fig. 1A). What could be identified as uterine cavity was fibrosed and scarred. To delineate the borders of the cavity, a uterine sound was placed in the cavity transcervi- cally to identify clearly the internal os. To demarcate the cornual areas, which were obliterated completely by scar, 2.0 nylon suture was threaded through the fimbria to pass through into the uterus. In some instances the 2-0 nylon suture may be palpated to assist in the location of the cavity. Using the scalpel handle, the walls of the uterus were separated

172 Reddy and Rock Techniques and instrumentation Fertility and Sterility ®

B

F i g u r e 1 (A) The uterus is divided to the level of the internal os; (B) by using the handle of a scalpel, the walls of the u terus are separated and the cavity is created.

bluntly, being careful to avoid injury and denudation of the myometrium, and a normal uterine cavity con- tour was established (Fig. 1B). The nylon sutures in the cornua and the uterine sound were used to establish the outer borders of the uterine cavity. The sutures were left in the tubes as stents. The intra- uterine sound was now removed and replaced with an 8-F Foley catheter. With the balloon inflated with 3 mL of saline, the ends of the suture in the endome- trial cavity were now sutured to the tip of the Foley catheter (Fig. 2). This was done so that when the Foley was removed, the stents would follow. The uterus was now closed in four layers. Initially two layers of 2.0 vicryl were used to close the muscularis. The anterior and posterior walls of the uterine cavity were closed by alternating suture placement similar to a uterine closure after abdominal metroplasty for

F i g u r e 2 I l lustrat ion showing the Foley catheter within the uter ine cavity. A nylon 2-0 suture has been placed through the lumen of each fallopian tube.

F i g u r e 3 The uterus is closed using 2-0 vicryl suture. Sutures are placed in an a l te rna t ing fashion to close in anter ior and poste- rior walls of the cavity.

removal of a uterine septum (Fig. 3). Next horizontal mat t ress sutures of 3.0 vicryl were placed (Fig. 4A). Finally a subserosal baseball stitch of 4.0 vicryl was placed (Fig. 4B). Each patient was started on 2.5 mg of conjugated estrogen (Premarin; Wyeth-Ayerst Laboratories, Philadelphia, PA) on postoperative day 1 to enhance endometrial proliferation. The pa- tients received preoperative cefazolin and intraoper- ative gentamicin and clindamycin. The catheter was left in place for 5 to 8 days.

~ S ~ T S

Regular withdrawal bleeds confirmed the re-es- tabl ishment of the uterine cavity with regeneration of endometrium. Postoperative hysterogram in each patient revealed some residual endometrial scar- ring. Two patients required hysteroscopy to lyse mild postoperative uterine synechiae. Each patient continues to have regular periods. Endometrial bi- opsy was not obtained. A 10-mm endometrial stripe was documented on the last patient by ultrasound.

DISCUSSION

Since Heinrich Fritsch (1) first described intra- uterine adhesions in 1894 and Asherman (2) brought this entity into the public eye in 1948, advances in

A B

F i g u r e 4 (A) Horizontal mat t ress sutures are placed; (B) the final layer in the closure is a subserosal suture.

Vol. 67, No. 1, J a n u a r y 1997 Reddy and R o c k Techniques and instrumentation 173

the pathogenesis , t r ea tmen t , and diagnosis have been made. About 90% of pa t ien ts with u te r ine sy- nechiae will give a his tory of a pos tpa r tum cure t tage or postabortal infection; however, 10% will give no similar h is tory (as in our pat ient) (3). Ferenczy et al. (4) showed tha t af ter normal mens t rua l shedding, the basalis ep i the l ium resurfaces the s t roma in 24 hours. This occurs on cycle day 1 when es t rogen lev- els are known to be low. This process therefore would seem to be estrogen independent . Ini t ial ly this re- pair may be secondary to cell migrat ion. As repai r cont inues and the estrogen levels rise, the multipli- cation of these migra t ing cells is probably estrogen dependent . Thus we can ext rapola te tha t in s ta tes of low estrogen this repai r might be r e t a rded and adhesions may form. This repai r also may be im- peded by infection. The t r e a t m e n t of Asherman ' s Syndrome was revolut ionized in the 1970s by hyster- oscopy. Hysteroscopic lysis of adhesions followed by high-dose estrogen has become the most common method of t r ea tment .

The obstetric outcome of pat ients with Asherman ' s Syndrome who have been t rea ted with hysteroscopy has been reported. Valle and Sciarra (5) repor ted a series of 187 pat ients over 10 years . The repor ted incidence for res tora t ion of menses was 88%. There were also 143 pregnancies with a t e rm delivery ra te of 80% and an 18% spontaneous abort ion rate. Pa- t ients with mild disease had a t e rm pregnancy ra te of 81% whereas pat ients with severe disease had a t e rm pregnancy ra te of only 32%, suggest ing tha t the reproduct ive outcome correlated with the extent of the adhesions. Pa t ien ts with severe adhesions had

a recur rence ra te of 35% af te r t r ea tmen t . Pa t i en t s with modera te adhes ions had only a 5% recur rence rate.

Our exper ience suggests t h a t cyclic m e n s t r u a t i o n may be re-es tabl ished in women with complete oblit- era t ion of the u te r ine cavity. Pa t i en t s should be aware of the obstetr ic complicat ions and a reduced pregnancy ra te is associated with t r e a t m e n t of se- vere Asherman ' s Syndrome (6).

The operat ive technique described shows promise for re-es tabl ishing the in tegr i ty of the u te r ine cavity in cases of complete endometr ia l obl i tera t ion where there are no l a n d m a r k s to guide the surgeon in his or her efforts to separa te the cavity walls. Longer follow-up of our pa t ien ts is needed to de t e rmine if this technique will allow pregnancy. There is usual ly a poor prognosis for successful ferti l i ty.

R E F E R E N C E S

1. Flitsch, H. Ein Fall von volligen Schwund der gebarmutter Hohle nach Auskratzung. Contralbl F Gynak 1894; 18:1337- 9.

2. Asherman, JG. Amenorrhea traumatica (atretical. J Obstet Gynaeco] Br Empire 1948;55:23-30.

3. Neuwirth RS. Gynecologic surgery and adhesion prevention. Asherman's Syndrome. Prog Clin Bio] Res 1993;381:187- 90.

4. Ferenczy A, Bertrrand G, Gelfand MM. Proliferation kinetics of human endometrium during the normal menstrual cycle. Am J Obstet Gynecol 1979; 133:859-67.

5. Valle RF, Sciarra JJ. Intrauterine adhesions: hysteroscopic diagnosis, classification, treatment, and reproductive out- come. Am J Obstet Gynecol 1988;158:1459-70.

6. Friedman A, DeFazio J, DeCherney A. Severe obstetric com- plications after aggressive treatment of Asherman Syn- drome. Obstet Gynecol 1986;67:864-7.

174 Reddy and Rock Techniques and instrumentation Fertility and Sterility~