Cause and effect of Asherman syndrome
Dr Rebecca Deans
School of Women and Children Faculty of Medicine
August 2016
Acknowledgments
Firstly, I would like to express my sincere gratitude to my main supervisor, Associate
Professor Jason Abbott. I am appreciative of his continuous support of my Ph.D study
and the related research, as well as being grateful for his patience, motivation, and
immense knowledge. His guidance helped me throughout the research and writing of
this thesis. His eternal energy and motivation is truly inspirational, and although his maddening attention to detail drove me close to insanity, I could not have imagined having a better advisor and mentor for my Ph.D.
Besides my main supervisor, I would like to also thank my co-supervisors: Professor
William Ledger and Professor Thierry Vancaillie. I am grateful for their insightful comments and encouragement, as well as their hard questions, which drove me to widen my research from various perspectives. It was truly amazing that in spite of their extremely busy lives, they selflessly gave me time and care that was sometimes all that kept me going.
My sincere thanks also goes to Dr. Daniel Moses and the team at Spectrum
Radiology, whose contribution were invaluable for the perfusion MRI study. Without
Dr Moses’ precious support, it would not have been possible to conduct this research.
Thanks also goes to Dr Toos Sachinwala, whose great mind for the vascular
pathology behind Asherman Syndrome started me along my journey towards the
causes and not just the effects of Asherman Syndrome.
ii
I thank Jinzhu Liu, who gave me endless guidance in the statistical analysis and was always happy to meet and discuss various tests and re-tests of the data at short notice.
Not only did she provide statistical advice, but she was also a great sounding board and emotional support throughout the analysis of my data.
Last but not least, I would like to thank my family: my husband James and my four children, Thomas, Oliver, Madeleine, and Jeremy – several of whom have been born
along the way. They have endured endless weekends without their wife / mother and
seen me on the brink of defeat. However, they supported me unquestioningly, and
gave me the time and space to devote myself to this very lonely and at times thankless
task. Their endless support throughout writing this thesis and my life in general is
overwhelming, and I really could not have done this without them.
iii
Table of contents
Chapter title Page
Acknowledgements iv
List of tables vii
List of figures xii
Glossary of abbreviations xv
Abstract 1
Introduction 3
Chapter 1: Literature review 6
Chapter 2: Gynaecological and obstetric outcomes following surgery for
Asherman syndrome 84
Chapter 3: Adhesions barriers and their role in Asherman syndrome 156
Chapter 4: Perfusion MRI in Asherman syndrome 226
Chapter 5: Discussion 281
Conclusions 292
References 295
Appendices 317
iv List of tables
List of tables
Table Description
1.1 Prevalence of intrauterine adhesions in different populations
1.2 Aetiology of IUA, and proportion of IUA attributable to cause
1.3 Intrauterine adhesions: Hysteroscopic diagnosis, classification, treatment and
reproductive outcome (Valle and Sciarra)
1.4 Classification of intrauterine adhesions (Wamsteker, European Society for
Hysteroscopy [ESH])
1.5 Modified classification system of European Society for Gynaecological
Endoscopy (ESGE)
1.6 The American Fertility Society classifications of adnexal adhesions, distal
tubal occlusion, tubal occlusion secondary to tubal ligation, tubal
pregnancies, Müllerian anomalies, and intrauterine adhesions
1.7 Hysteroscopic adhesiolysis of intrauterine adhesions in Asherman syndrome
(Donnez and Nisolle)
1.8 A clinicohysteroscopic scoring system of intrauterine adhesions (Nasr)
2.1 Demographic overview of cohort
2.2 Gravidity of cohort
v List of tables
2.3 Parity of cohort
2.4 Cause of intrauterine adhesions
2.5 Correlations between grade and cause of Asherman syndrome
2.6 Menstrual function of the women after diagnosis of AS, but prior to
adhesiolysis surgery
2.7 Menstrual function of the women post Asherman syndrome treatment
2.8 Pelvic pain
2.9 Fertility
2.10 Pregnancies across grades of Asherman syndrome
2.11 Pregnancies following surgery for Asherman syndrome – maternal outcomes
2.12 Pregnancies following surgery for Asherman syndrome – neonatal outcomes
2.13 Fertility outcomes following hysteroscopic treatment of intrauterine
adhesions
3.1 Mean age by group
3.2 Mean age of first and second pregnancy prior to Asherman syndrome
3.3 Gravidity by group
3.4 Parity by group
3.5 Grade of Asherman syndrome by group
vi List of tables
3.6 Gynaecological surgical procedures prior to diagnosis of intrauterine
adhesions compared between groups
3.7 Non-gynaecological surgical procedures prior to diagnosis of intrauterine
adhesions compared between groups
3.8 Responses of women in each group of their perceived cause of Asherman
syndrome
3.9 Medical conditions compared between the groups
3.10 Regular medication use compared between the groups
3.11 Number of repeat hysteroscopic resection procedures within six months of
index surgery
3.12 Repeat hysteroscopic resection procedures greater than six months following
index surgery for recurrent intrauterine adhesions
3.13 Number of pregnancies prior to the diagnosis of Asherman syndrome
3.14 Outcomes of the first pregnancy prior to the diagnosis of Asherman
syndrome
3.15 Maternal complications compared between groups
3.16 Outcomes of second pregnancy prior to the diagnosis of Asherman syndrome
3.17 The number of pregnancies defined by group prior to AS
vii List of tables
3.18 Maternal complications in live births prior to the diagnosis of Asherman
syndrome (AS)
3.19 Maternal complications in live births prior to the diagnosis of Asherman
syndrome (AS) according to grade of AS
3.20 Maternal complications in live births prior to the diagnosis of Asherman
syndrome (AS) grouped according to grade of AS
3.21 Mean age of first and second pregnancy following Asherman syndrome
3.22 Outcomes of the first pregnancy following adhesiolysis
3.23 Fetal complications following first pregnancy
3.24 Fetal complications in the second pregnancy following index surgery
3.25 Maternal complications in the second pregnancy following index surgery
3.26 Fetal complications in the third pregnancy following index surgery
3.27 Live birth weights in the first and second pregnancy following index surgery
3.28 Combined complications for pregnancies prior to AS
3.29 Maternal complication according to grade of Asherman syndrome
3.30 Sensitivity analysis
4.1 Demographic Data
viii List of tables
4.2 Summary of perfusion studies for the group of women with Asherman
syndrome
4.3 Perfusion indices according to grade of Asherman syndrome
4.4 Perfusion indices according to number of procedures
4.5 Menstrual status before surgery and perfusion indices
4.6 Analysis of perfusion indices for lower grade Asherman syndrome compared
to women with complete cavity obliteration
4.7 Analysis of perfusion indices for women with Asherman syndrome
compared to control group
4.8 Overall total perfusion (TP) vs. region of interest (ROI) in the same study
ix List of figures
List of figures
Figure Description
2.1 Tuohy needle with a bevelled edge attached to radio opaque dye
2.2 Hysteroscopy introduced with Tuohy needle in parallel
2.3 Radiographic image of the uterus where the radio opaque dye has entered the
vasculature
2.4 Radiographic image showing radio opaque dye injected into the endometrial
cavity, showing an anatomically restored endometrial cavity
2.5 Patient disposition following database identification
2.6 Grade of Asherman syndrome
2.7 Number of hysteroscopic synaechiolysis procedures required per patient to
treat their IUA for the 154 women in the cohort
2.8 Flow chart illustrating the outcomes of the 157 pregnancies following
hysteroscopic synaechiolysis
2.9 Time to pregnancy
3.1 Kaplan-Meier survival curve including only cases where pregnancies
occurred, censored for non-live birth events
x List of figures
3.2 Kaplan-Meier curve including only cases where pregnancies occurred and
including all pregnancy types with no censoring
3.3 Kaplan-Meier curve censored for live births
3.4 Kaplan-Meier curve illustrating all pregnancies in the control and
SeprafilmTM group
4.1 MRI pelvis sagittal and coronal planes used to place the four circumferential
regions of interest at the upper cavity
4.2 MRI pelvis sagittal and coronal planes used to place the four circumferential
regions of interest at the mid cavity
4.3 MRI pelvis sagittal and coronal planes used to place the four circumferential
regions of interest at the lower cavity / isthmus
4.4 Region of interest placed at the psoas in the mid uterine cavity
4.5 Perfusion image of the uterus – mean below the region of interest
4.6 Perfusion image of the uterus – mean between the region of interest
4.7 Perfusion image of the uterus – mean above the region of interest
4.8 Pregnancy outcomes in the women pregnant
4.9 ROC pre-operative total perfusion (TP), comparing Grade 4 to Grades I-III
xi List of figures
4.10 ROC pre-operative time to peak perfusion (TTP) comparing Grade IV to
Grades I-III
4.11 ROC pre-operative gradient of perfusion (GP) comparing Grade IV to
Grades I-III
4.12 ROC pre-operative rate of perfusion (RP) comparing Grade 4 to Grades I-III
4.13 ROC pre-operative total perfusion (TP) comparing inoperable IUA with all
other AS women
4.14 ROC pre-operative time to peak perfusion (TTP) comparing inoperable IUA
with other AS women
4.15 ROC pre-operative gradient of perfusion (GP) comparing inoperable IUA
with other AS women
xii Glossary
Glossary of abbreviations
Abbreviation Full term
AAGL American Society of Gynecological Laparoscopists
AB Adhesion barrier
ACP Auto cross-linked polysaccharide hyaluronic acid
ADC Apparent diffusion coefficient
AF Amniotic fluid
ART Assisted reproductive technologies
AS Asherman syndrome
ATP Adenosine triphosphate
AUB Abnormal uterine bleeding
BF Blood flow rate
CFU Colony forming unit
CMD Coronary microvascular dysfunction
CRF Case report form
D&C Dilation and curettage
DCE-MR Dynamic contrast enhanced magnetic resonance imaging
DWI Diffusion weighted imaging
ERPC Evacuated retained products of conception
ESH European Society for Hysteroscopy
ESGE European Society for Gynaecological Endoscopy
E2 Oestrogen
GnRHa Gonadotropin releasing hormone analogue
xiii Glossary
GP Gradient of perfusion
GUR Gynaecoradiologic uterine resection
HA Hyaluronic acid
HA-CMC Hyaluronic acid and carboxymethyl cellulose hCG Human chorionic gonadotropin
HSG Hysterosalpingogram
IR-GRE Inversion recovery gradient echo
IUA Intrauterine adhesions
IUD Intrauterine device
IUGR Intrauterine growth restriction
IUI Intrauterine insemination
IVF In vitro fertilisation
JA Associate Professor Jason Abbott
JZ Junctional zone
LMB Light menstrual bleeding
MRI Magnetic resonance imaging
MTT Mean transit time
MVD Microvascular density
PD Power Doppler
PLUG Pressure lavage under ultrasound guidance
POWP Prince of Wales Private Hospital, Sydney
RD Dr. Rebecca Deans
RHW Royal Hospital for Women, Sydney
RI Resistance index
ROI Region of interest
xiv Glossary
RP Rate of perfusion
RPOC Retained products of conception
SD Standard deviation
SHG Sonohystogram
SI Signal intensity
SNR Signal to noise ratio
SPSS Statistical Package for Social Sciences (Chicago, IL)
TGF Transforming growth factors
TNG Tumour necrosis factor
TP Total perfusion
TTP Time to peak perfusion
TVC Professor Thierry Vancaillie
TVUS Transvaginal ultrasound
UAE Uterine artery embolisation
VEGF Vascular endothelial growth factor
WHRIA Women’s Health & Research Institute of Australia obstetric clinic
3DUS Three dimensional ultrasound
3DSHG Three dimensional sonohysterography
xv Abstract
Abstract
Aim:
To investigate the cause and effect of intrauterine adhesions (IUA) on reproductive function in women with Asherman syndrome (AS).
Methods:
Three studies have been performed in women who have had fluoroscopically guided hysteroscopic synaechiolysis for AS in a tertiary referral unit:
i) a retrospective cohort study investigating menstrual, fertility, obstetric and
neonatal outcomes following surgery;
ii) a retrospective cohort study investigating the efficacy of SeprafilmTM
(Genzyme Corporation, Cambridge, MA) in improving menstrual fertility
and obstetric outcomes;
iii) an analysis of perfusion magnetic resonance imaging (MRI) investigating
the total perfusion, ratio of perfusion, time to peak perfusion and gradient
of perfusion to assess vascular markers of disease.
Patients:
177 women diagnosed with AS, of whom 146 were trying to conceive.
1 Abstract
Results:
The combined pregnancy rate was 106/146 (72.6%) women, and per unique woman, the live birth rate was 83/146 (56.8%), the miscarriage rate was 30/146 (20.5%) and
the perinatal mortality rate was 4/146 (2.7%). there were 166 pregnancies in total resulting in; 97 live births, 48 miscarriages, 3 perinatal mortalities, 3 terminations of
pregnancy for congenital anomalies, 4 ectopic pregnancies, and 10 ongoing
pregnancies. In total, there were 98 babies born from 97 pregnancies in 83 women (1
set of twins). Maternal and perinatal morbidity included adherent placentation in
21/146 (14%), postpartum haemorrhage in 7/146 (9%), and hysterectomy in 4/146
(3%). Neonatal morbidity and mortality included prematurity in 25/98 (26%), and
perinatal mortality in 4/98 (4%) of babies. Adhesion barriers did not improve
reproductive or obstetric outcomes. The uterine perfusion rates in women with grade
4 and above AS and inoperable IUA was significantly lower than those that had grade
1-3 AS and operable disease.
Conclusion:
Women with AS have improvement of their symptoms following surgery, including
high rates of pregnancy. However, these pregnancies are complicated by maternal and
fetal morbidity and mortality. Vascularity of the uterus may hold the key to
understanding the pathological process behind this disorder. Perfusion MRI may also
provide a prognostic tool in management of women with AS.
2 Introduction
Introduction
Amenorrhoea Traumatica (Atretica)
“Under the above name I describe a specific type of amenorrhoea
which, in spite of its prevalence has not found a fitting place in
gynaecological literature… The amenorrhoea is not functional but
organic; ovulation continues but the uterus does not react and the
endometrium remains in a state of inactivity. Hormonal therapy is
neither reasonable nor effective…” (1).
Intrauterine adhesions (IUA) resulting in secondary amenorrhoea was first reported in 1894 by Fritsch (2). Following this, 37 cases of uterine atresia were published by authors such as Bass, Wertheim, Fustner, Veit, Halban, Strassman,
Stamer, and others (3, 4), who had various explanations of their cause and effect (5).
In 1948, Asherman described 29 cases of women with amenorrhoea associated with stenosis of the internal cervical os (5). He listed curettage after delivery, miscarriage, molar pregnancy, manual removal of placenta, or uterine packing following delivery as a cause for this stenosis. Two years later he extended his description to include partial or complete obstruction of the uterine cavity by adhesions secondary to trauma of the corpus, with resulting menstrual abnormalities, cyclical lower abdominal pain, infertility, or recurrent pregnancy loss (6).
Asherman realised that this disorder required greater recognition in gynaecology. He recognised and described an endometrial quiescence associated with the pathologic intrauterine adhesions, which had not been previously reported. He
3 Introduction
termed these adhesions as organic rather than merely obstructive. He was also able to
associate these adhesions with menstrual disturbance and infertility. Asherman
produced a detailed description of the aetiology, clinical symptoms’ radiologic
features and proposed treatment of this condition. His work subsequently led to the
condition’s eponymous name: Asherman syndrome – a syndrome of intrauterine
adhesions resulting in menstrual and fertility abnormalities.
This thesis will examine the clinical manifestation of intrauterine adhesions
(IUA) causing Asherman syndrome (AS) and the effect that hysteroscopic
synaechiolysis under fluoroscopic guidance has on these symptoms. It will also
investigate the impact of a hyaluronic acid based adhesion barrier introduced to the
uterine cavity following synaechiolysis surgery, assessing long-term menstrual and
fertility outcomes. Finally, perfusion indicies on magnetic resonance imaging (MRI)
will be investigated in women with AS to assess whether uterine perfusion at the
junctional zone (JZ) is predictive of higher grade AS.
To address these focal areas, a review of the literature has been performed and
three studies have been undertaken, evaluating the effect of hysteroscopic
synaechiolysis on menstrual pain and fertility symptoms in women with AS. The
efficacy of the site-specific membrane SeprafilmTM (Genzyme Corporation,
Cambridge, MA) is also explored. SeprafilmTM is infused into the uterine cavity as a
‘slurry’ immediately following synaechiolysis of IUA in AS. Its efficacy is compared
to cases where no adhesion barrier was applied following surgery. Finally, perfusion
patterns in women with AS are investigated by using dynamic contrast enhanced
MRI.
4 Introduction
Research Questions
The research questions for the study are:
1. Does fluoroscopically guided hysteroscopic synaechiolysis improve menstrual
and pain symptoms in women with AS?
2. Does fluoroscopically guided hysteroscopic synaechiolysis improve
reproductive potential in women with AS?
3. Does the addition of SeprafilmTM (Genzyme Corporation, Cambridge, MA) as
a slurry following hysteroscopic surgery improve menstrual and fertility
outcomes in women with AS?
4. Is uterine vascular perfusion impaired in women with AS, and is this effect
more pronounced in higher grade AS?
Primary objectives:
1. To describe any changes in menstrual symptoms in AS women following
fluoroscopically guided synaechiolysis
2. To describe the difference in pain symptoms in AS women following
fluoroscopically guided synaechiolysis
3. To report the fertility outcomes in AS women following fluoroscopically
guided synaechiolysis
4. To report the obstetric and neonatal outcomes in AS women following
fluoroscopically guided synaechiolysis
5. To assess whether the addition of SeprafilmTM (Genzyme Corporation,
Cambridge, MA) improves outcomes 1-4 above
6. To assess whether there are altered vascular perfusion patterns in the uterus of
AS women, and compare low grade and high grade disease
5 Chapter 1 Literature review
Chapter 1: Literature review
This chapter reviews the literature on symptomatic intrauterine adhesions
(IUA). A historical perspective and an up-to-date account of our understanding of this
complex disorder will be covered. Electronic resources including Medline, PubMed,
CINAHL, the Cochrane Library (including the Cochrane Database of Systematic
Reviews), Current Contents and EMBASE were searched using the following MeSH
terms including all subheadings and keywords: ‘intra-uterine adhesions’, ‘Asherman
syndrome’, ‘hysteroscopy and adhesion’, ‘hysteroscopic synaechiolysis’, ‘intrauterine
septum and synaechiae’, ‘obstetric outcomes following intrauterine surgery’ and
‘hysteroscopic lysis of adhesions’. Reference lists and bibliographies of the papers
were then reviewed for any additional references.
The majority of the data were retrospective case series, with only intrauterine
adhesion barriers and incidence of IUA being assessed, in any randomised controlled manner (7, 8). This chapter will review epidemiology, pathology, classification systems and treatments. Importantly, there are seven different classification systems
described, with no universal acceptance of any system and no validation of any of
them. Hysteroscopy is the mainstay of both diagnosis and treatment, with medical
treatments having no role in management. There is a wide range of treatment
techniques with no controlled comparative studies and assessments are mainly
descriptive. Post-treatment fertility and obstetric outcomes will be reviewed in more
detail in Chapter 2.
6 Chapter 1 Literature review
SECTION 1: EPDEMIOLOGY
Terminology
Asherman syndrome (AS) and intrauterine adhesions (IUA) are terms that are
synonymously used. A syndrome refers to a cluster of signs and symptoms that
characterise a disease, and therefore, AS should only be used for women with clinical
manifestations of IUA.
The original definition of AS involved cases where IUA occurred following
curettage of the gravid uterus, and in the vast majority, IUA are related to the
pregnant uterus (9). However, it is now acknowledged that there are several
underlying causes of IUA, and therefore, as AS is defined as IUA where clinical
symptoms are present, diagnosis should not only be confined to these cases (10).
However, given that clinical symptoms are required by definition to diagnose AS, this
disease can only occur in females with a uterus, during their reproductive lifetime.
Incidence
The true incidence of IUA is unknown, as a large number of women with IUA are asymptomatic (10).
Prevalence
The prevalence of IUA varies according to population and type of investigation performed for diagnosis. The prevalence varies from 2.2%, as an
incidental finding in women presenting for hysteroscopy with or without
gynaecological symptoms (11, 12), up to 40% in women having repeat curettage or
postpartum curettage (13). Fatemi et al. more recently documented the prevalence of
7 Chapter 1 Literature review
IUA in 2% of their infertile and asymptomatic population prior to an IVF cycle in
women with a normal pelvic ultrasound (14). Table 1.1 summarises the prevalence of
hysteroscopically diagnosed IUA in different populations reported in case series.
Table 1.1 – Prevalence of intrauterine adhesions in different populations
Total No. with Prevalence Population Reference Comments cases IUA %
Secondary Jones et al 1964(15), Vutyavanich et al 487 13 2.7 amenorrhoea 1989 (16)
Yucebilgin et al 2004 (17), Taylor et al 1981 (18), Stillman and Asarkof 1985 Three studies, after (19), La Sala et al 1998 (20), Nawroth et failed IVF. Infertile women 3386 227 6.7 al 2003 (21), Preutthipan and Linasmita Diagnosed 2003 (22), Hinckley and Miliki 200 hysteroscopically 4(23), Fatemi 2010 (14)
Raizel et al 1994 (24), Ventollini et al * recurrent Recurrent 2004 (25), Toaff and Ballas 1978 (26), 374 39 10.4 miscarriage sub- miscarriage Friedler* et al 1993 (27) group
Pace 2003 (11) Hysteroscopy 9180 201 2.2 Nagelle 1996 (12)
HSG for fertility Bukar 2011 (28) 272 35 2-12.9 investigation
Women having Marty 1986 (29) 351 9 2.5 IUD placed
Adoni et al 1982 (30), Golan et al 1992 * incidence 16%, Following first (31), Friedler* et al 1993 (27), Romer 14%, and 32% after trimester 668 79 11.8 1994 (32), Tam et al 2002 (7), Dalton et first, second and third curettage al 2006 (33) curettage
Jones et al 1964 (15), Smid and Bedo Following post 1978 (34), Westendorp et al 1998 (13), 197 47 23.9 partum curettage Dalton et al 2006 (33),
RPOC Westendorp (1998) (13) 40.0
Following B Rathat 2011 (35) 37 7 19.0 lynch suture
8 Chapter 1 Literature review
Variations according to Nationality
Schenker reviewed 2981 cases of AS in 1982 and found an increased
incidence of reported cases in Israel, Greece, France, South America and Denmark
(36). However, these discrepancies may be explained by an increased awareness and
diagnosis by clinicians in these apparent high prevalence nations. In this review, the
original work conducted by Asherman himself held the largest reported single-study
sample of AS in the world, involving 350 cases of AS. Schenker’s review found a
total of 677 cases of AS across various studies were from Israel, representing 40% of
the reported cases worldwide. The fact that Asherman himself was Israeli probably
explains the increased awareness and diagnosis of AS in Israel, and perhaps has even
caused publication bias. However, it is also hypothesised that this skewing of the worldwide distribution of AS is due to higher numbers of therapeutic abortions being performed in these countries (36).
Another factor that may explain the higher incidence of AS in certain countries could be the technique used for curetting the uterus. This varies in regards to whether the curette is sharp or blunt, and whether a suction catheter is used (10). Less adhesion formation is reported with the use of blunt curette and suction catheter (37)
The higher incidence of genital tuberculosis may also contribute to the higher numbers of cases found in certain countries (36). This may be a confounding factor in
Bukar’s paper on the prevalence of IUA at hysterosalpingogram (HSG) in women presenting with infertility (28). However, genital tuberculosis is a rare form of IUA, therefore it is unlikely to significantly impact the overall number of cases.
Importantly, this national skewing of incidence has never since been replicated in subsequent studies or reviews. As Schenker’s 1982 review was published prior to commonplace use of hysteroscopy for diagnosis, HSG would have been the mode of
9 Chapter 1 Literature review
diagnosis for the majority of these cases. HSG has a high false positive rate when used as a diagnostic tool (see Chapter 1, Section 5: Diagnosis) and it is likely that this increased incidence merely reflects more investigation for AS in these countries, with
an erroneously high incidence due to the use of an inaccurate diagnostic tool.
Increasing incidence
The incidence of uterine synechiae appears to be increasing worldwide (38).
From 1894 to 1982, there were 1250 reported cases of treatment of IUA. Whereas
from 1982 to 2008, there have been over 2500 cases reported. This represents an increase from approximately 130 new cases of AS being treated per decade to over
400 new cases being treated per decade since the 1980’s. This increasing awareness of
AS has put a medicolegal burden on society in relation to retained placental tissue and
subsequent IUA being the source of an increasing number of malpractice claims (37).
Improved diagnosis of IUA is achieved by hysteroscopy and transvaginal ultrasound (TVUS). Both of these screening tools have become routine investigations in present day medical practice. Their use explains in part the apparent increasing
incidence of IUA. The increase in IUA may also be due to more uterine conserving
surgery being performed. In the past, hysterectomy may have been performed for
idiopathic menorrhagia, myomas, or postpartum haemorrhage. However, now
techniques such as uterine artery embolisation (39) and B Lynch sutures (35) have
allowed women to retain their uterus, albeit with impaired function of the organ. This
procedural shift away from performing hysterectomies may, in turn, predispose
women to the phenomenon of IUA. Furthermore, the increase in IUAs that are
asymptomatic may simply be a nuance of improved screening and publication bias,
with the true burden of AS not being raised.
10 Chapter 1 Literature review
Another explanation for the increase in incidence is an increasing world population over the past 50 years, with high-growth nations such as China and India becoming economically developed. This development is associated with higher standards in health care and the ability to investigate, treat and publish results of medical management of AS and IUA. Hence it is likely that the explanation for the apparent increasing incidence of AS and IUA is a combination of increased ability to screen and accurately diagnose, accentuated by the increasing and developing world population.
SECTION 2: PATHOLOGY
Histology
The endometrium becomes fibrosed in Asherman syndrome (AS). The
endometrial stroma is largely replaced with fibrous tissue and the glands may be
represented by an inactive cubo-columnar epithelium of the endometrial type. The
distinction between the functional and basal layer is lost, and the functional layer is replaced by an epithelial monolayer. This monolayer is unresponsive to hormonal stimulation and fibrotic synechiae form across the cavity (40). In some cases, there may be calcification or ossification in the stroma and the glands may be sparse and inactive or cystically dilated. There may be thin walled dilated telangiectatic vessels
(40), but in most cases the tissue becomes avascular.
Intrauterine adhesions (IUA) may involve different layers of the endometrium, myometrium or connective tissue. Macroscopically, these layers have distinct
qualities. Endometrial adhesions look similar to the surrounding endometrial lining at
hysteroscopy. Myofibrous adhesions are characterised by the presence of a thin layer
11 Chapter 1 Literature review
of overlying endometrium, with many glandular ostia seen at the surface. These are the most common adhesions in AS (10). Connective tissue and fibrous adhesions lack any endometrial lining. Under hysteroscopic view, they appear in stark contrast to the adjacent endometrium (10). These full thickness adhesions may comprise of collagen bundles, fibrous strips or muscle with the same characteristics as normal myometrium
(40).
When comparing the myometrium of women with IUA compared to women without, the uterine wall contains 50-80% fibrous tissue in women with IUA, compared with 13-20% in the group without adhesions (41). Occasionally fibrosis can also occur in the endometrial or myometrial layer, or at the junctional zone (JZ) in the absence of IUA (10).
The extent of damage to the endometrium may not directly correlate with
severity of symptoms. In women who have cervical adhesions obstructing the outflow
of menstruation, biopsies taken at the fundus often reveal inactive endometrium (10).
This partially explains the apparent lack of haematometra found clinically, despite the apparent blockage of the cervical os.
When angiography was performed on women with IUA, reduced myometrial blood flow was found, with widespread vascular occlusion. This explains the endometrial atrophy, poor receptivity, and recurrent miscarriage suffered in this group of women (42). Other markers for endometrial damage include a thin endometrium, as seen on ultrasound in an anteroposterior plane. Lo et al. (43) found that women with
IUA and only outlet obstruction had a thinner endometrial stripe in anteroposterior view during TVUS, in spite of the upper cavity being unaffected by adhesions.
These clinical and pathological findings differ from Asherman’s initial proposal of a neurovascular reflex between the cervical os and the endometrial lining,
12 Chapter 1 Literature review
leading to amenorrhoea. However, Asherman did recognise a relative lack of
haematometra, despite obstruction of the cervical os. The mechanism may be different
but the result is the same: an atrophic and inert endometrial lining.
SECTION 3: AETIOLOGY
Overview
Any event leading to destruction of the endometrium may lead to cicatrisation
of the mucosa, endometrial sclerosis, and subsequently, the development of synechiae between the opposing walls of the uterine cavity. There is usually a causative event on a background of a predisposing state. Table 1.2 illustrates the various causative events reported to induce IUA.
13 Chapter 1 Literature review
Table 1.2 – Aetiology of IUA, and proportion of IUA attributable to cause No. where Total Causative Population Reference Comments reported cases IUA % Hanstede 2015 (44), Yu 2008 (45), Dmowski 1969 (46), Myers 2012 (47), Klein First trimester 1973 (48), Valle and Sciarra 1988(49), Robinson 2008 (50), Pabucu 2007 (51), Tsui 856 1726 25-83 curettage 2014 (52), Xiao 2014 (53) Hanstede 2015 (44), Yu 2008 (45), Myers 2012 (47), Fernandez 2012 (54), Valle Post partum curettage 361 1650 0-50 and Sciarra 1988 (49), Robinson 2008 (50), Xiao 2014 (53) None reported Non gravid D&C Yu 2008 (45), Robinson 2008 (50), Pabuccu 2007 (51), Xiao 2014 (53) 12 863 0-6 Hanstede et al Post caesarean Rochet et al (1979) (55), Hanstede 2015 (44),Myers 2012 (47), Fernandez* 2012 42% severe IUA 37 734 3-42 delivery (54), Pabuccu 2007 (51) group* B lynch compression Senthilhes 2010 (acreta) (56), Fuglsang (RPOC and curette) (57), Rathat 2011(35), Majority case 9 61 3 sutures Ibrahim 2013 (58), Kjer 2014 (59) reports of IUA Bakri balloon Kjer 2014 (59) 1 61 2 Hysteroscopic surgery March 2011 (60), Fernandez 2012 (54), Robinson 2008 (50), Xiao 2014 (53) 15 792 1-5 / Electrosurgery Strassman procedure / Seed^ 2008 (61), Fernandez 2012 (54), Valle and Sciarra 1988 (49), Robinson 2008 ^Strassman case 11 506 0.5-11 hysterotomy (50), Pabuccu 2008 (51) report only Uterine artery Pelage 2000(62), Pron 2003(63), Davis 2002 (64), Sentilhes 2010 (65), Song 2014 20 77 8-14 embolisation (39), Fernandez 2012 (54) Pelvic infection Kjer 2014 (59), Klein 1973 (48), Valle and Sciarra 1988 (49), Pabuccu 2007 (51) 159 1018 0.5-17 48 Tuberculosis Unknown cause Yu 2008 (45), Hanstede 2015 (44), Myers 2012 (47), Fernandez 2012 (54) 23 736 2-23
14 Chapter 1 Literature review
Antecedent event
Instrumentation of the uterus
The major cause of IUA is damage to the basilar layer of the endometrium
following curettage. Tam et al. performed a well-designed prospective randomised
controlled trial comparing the incidence of IUA following surgical and non-surgical
management of incomplete miscarriage. A hysteroscopy was performed on all women
six months after treatment. The hysteroscopy found that after conservative or medical management, there were no IUA seen. However, after surgical evacuation of the
uterus, the incidence of IUA formation was 2/26 (7.7%) (7). Although the sample size
in this study was small, it is level I evidence, and it suggests that IUA follow surgical treatment of miscarriage but not medical management (7). In a review of 1856 women with IUA, 67% had undergone curettage for induced or spontaneous abortion and
22% had undergone postpartum curettage due to postpartum haemorrhage (36). In a more recent review of 683 women with IUA, pregnancy related causes accounted for
570/683 (83%(53)). In a centralised database study assessing AS, 96% of IUA were the result of instrumentation of the uterus (58% during the first trimester, and 38% postpartum) (44). More recently, the evacuation of retained products of conception has also been shown to induce IUA in case series (33, 66).
Trauma to the non-pregnant uterus may also cause IUA, although the risk of developing IUA is much lower than for the pregnant uterus. There have been reports of adhesions following myomectomy, endometrial sampling, and insertion of intrauterine devices (IUD) in the non-pregnant uterus. Schenker’s review found the rate of IUA was 1.6% following diagnostic curettage, 1.3% after abdominal myomectomy, 0.5% following cervical biopsy or polypectomy, and 0.2% after insertion of IUD (36). Table 1.2 shows the attributable cause of IUA where reported.
15 Chapter 1 Literature review
Recurrent miscarriage
IUA is also a frequent finding of women with recurrent miscarriage. IUA has been reported to occur in between 5–39% of women experiencing recurrent miscarriages (26, 46, 67-69). In these cases, it is uncertain if the adhesions are a cause or consequence of the recurrent miscarriages. Recurrent miscarriages may follow inadequate development of the endometrium, which can appear thin on transvaginal ultrasound, with reduced vascularity. In a study using pelvic angiography, there was marked reduction in myometrial vascular flow in women with hypomenorrhoea and amenorrhoea with recurrent miscarriage (70).
Postpartum haemorrhage
In women who have suffered postpartum haemorrhage, Jones et al. reported a
9% incidence of IUA (15). It is unclear whether these women had any instrumentation of the uterus in the treatment of their postpartum haemorrhage, or whether the postpartum haemorrhage was due to retained products of conception. Such products may have subsequently developed fibrosis, leading to IUA.
Curettage in the postpartum uterus
The first reported case of secondary amenorrhoea due to IUA was after postpartum curettage (2). Adhesions appear to be more severe and frequent in the second to fourth week postpartum (36). The risk of developing IUA postpartum has been quoted in various reviews of the literature as being between 21.5% (36) and 25%
(55, 71). However, Westendorp (9) reported that IUA were found in 40% of women who undergo secondary removal of placental remnants after delivery or have a repeat
16 Chapter 1 Literature review
curettage. Surprisingly, curettage in the first 48 hours postpartum appears to be less
conducive to adhesion formation. Adhesions seem to be most likely to occur if
surgery is undertaken between two to four weeks postpartum (72).
Compression suturing the postpartum uterus
The modern management of postpartum haemorrhage includes use of the B-
Lynch suture or B-Lynch procedure. This is a form of compression suture used to
mechanically compress an atonic uterus in the face of severe postpartum haemorrhage. The technique was first described in 1997 (73). It is effective in the
management of postpartum haemorrhage without the need for explorative pelvic
surgery and it preserves fertility. It is generally regarded as the first line surgical
management for controlling postpartum haemorrhage resulting from uterine atony, as
it helps in preserving the anatomical integrity of the uterus and avoids hysterectomy.
Although the uterus may be retained, effects of this procedure may include
ongoing alterations to uterine function. Following an early case report of AS
occurring after placement of a B-Lynch suture (74), Rathat et al. reviewed 37 women
who underwent uterine compression suture for postpartum haemorrhage, with 13
post-operative assessments by hysteroscopy. Synechia occurred in seven women, of
whom three had AS that could not be corrected (23% of women who desired
pregnancy and had hysteroscopic evaluation) (35). Following this, Ibrahim (58)
recorded IUA formation following the B-Lynch suturing in 5/27 women with massive
postpartum haemorrhage and compression suturing in the acute setting. Of the women
affected, 3/5 had mild adhesions, 1/5 had moderate adhesions, and 1/5 had severe
adhesions following this procedure. Interestingly, all of the women with IUA had a
caesarean delivery, supporting a theory of the open hysterotomy providing a more
17 Chapter 1 Literature review
conducive environment for adhesion formation, although the numbers in this study
were too small to make definitive conclusions. Since these early publications, a ten year retrospective study of 44 B-Lynch procedures reported IUA in one woman (2%), and this woman also underwent a postpartum curettage for retained products of conception (57). This later study indicates that initial concerning reports may have been ill founded for the risk of IUA following B-Lynch sutures, and are likely to have been affected by publication bias.
Curettage following missed miscarriage vs. incomplete miscarriage
Surgical treatment of a missed miscarriage is more likely to result in IUA compared to surgical treatment for an incomplete miscarriage, the difference being
30.9% vs. 6.4% (36). It is postulated that this increased risk is due to the extended
time that fibroblastic tissue and collagen are able to form, generated by the residual
placental tissue, before endometrial regeneration can take place in a missed, compared
to an incomplete miscarriage. If medical management of miscarriage is proposed, then
early intervention is likely to improve success of this management (75). However, if
surgery is indicated, then delays may increase the opportunity for IUA to occur, as the
interval between early fetal demise and curettage is increased. It is theorised by some
that placental remnants induce fibroblast activity and collagen formation before
endometrial regeneration occurs, and therefore some centres recommend no longer
than three weeks between diagnosis of fetal death and surgical curettage(60).
18 Chapter 1 Literature review
Curettage following molar pregnancy
Curettage following evacuation of hydatidiform mole was implicated in 11 out of 1856 cases (0.6%) in Schenker’s review of IUA (36). However, in a subsequent series, 1/31 (3%), and 1/683 (0.1%) developed IUA after evacuation of molar pregnancy (53, 76). These rates may be falsely low, due to the small number of reported cases of curettage being performed for molar pregnancy, or it may be a feature of the remnant tissue being evacuated having less likelihood of causing fibrosis. Another explanation for this finding could be the elevated level of oestradiol or human chorionic gonadotropin (hCG) being a feature of molar pregnancies. This may be protective for the development of IUA.
Repeated procedures
Women having repeated curettage have an increased incidence of IUA, with an incidence as high as 39% (26, 46). The number of procedures performed seems proportional to the frequency and severity of the IUA. In 1993, Friedler et al. reported the presence of IUA after a single miscarriage as 16%, with thin, filmy adhesions occupying less than one third of the uterine cavity, whereas after two or three miscarriages, the incidence was 14% and 32% respectively, and the area of cavity affected increased to 58% (27).
Predisposing Infections: Genital tuberculosis and schistomas
Genital tuberculosis is now a rare cause of IUA in the developed world. Cases were first described in 1956 by Netter and colleagues (77). A difference in clinical presentation is described where primary amenorrhoea is a common finding when tuberculosis is contracted prior to puberty. There is classically development of normal
19 Chapter 1 Literature review
secondary sexual characteristics with the absence of menses following childhood
infection.
Pelvic pain is a feature of this chronic infection, inevitably cyclic, and has thus been termed dysmenorrhoeic amenorrhoea. Pain also may occur during ovulation.
Chronic inflammation of the endometrium caused by miliary spread of extragenital tuberculosis or drainage of tuberculous salpingitis is thought to cause tuberculous endometritis. An end result of this chronic inflammation is IUA, often with total obliteration of the endometrial cavity. The synechiae resulting from tuberculosis characteristically extend to the tubal ostia, which are often otherwise spared in traumatic adhesions since curettes and plastic suction catheters are unable to reach the corneal areas of the uterine cavity. Characteristically, tuberculous adhesions rarely respond to intervention, with a poor prognosis for future fertility (10, 36).
Schistosomiasis has also been implicated in the development of IUA and secondary amenorrhoea with infertility. A case report has documented infection
presenting clinically in a similar fashion to genital tuberculosis. Hence, schistosomiasis should be considered in areas where infection is endemic (78).
Pelvic irradiation
Schenker found that only one woman out of 1856 women (0.05%), in a series
with AS, cited radiation therapy as a precipitating event (36). This series was
published in 1982 and the therapeutic use of radiotherapy for malignant disease of the
pelvis was not a common modality of treatment compared to current management.
Since that time, radiotherapy below the diaphragm is used therapeutically for a
number of malignant conditions such as Hodgkins disease, cervical cancer,
endometrial cancer, uterine sarcomas, and colon cancer. Radiation-induced uterine
20 Chapter 1 Literature review
damage is dose and age-dependent. The effects include atrophic endometrial, necrosis of the endometrial glands and stroma, as well as endometrial scarring (79). As the prognosis of cancer treatments improve, so too does the long term sequelae of its treatment.
Hysteroscopic surgery
Hysteroscopic resection surgery appears to predispose the uterus to IUA formation. In a prospective randomised study of 95 women undergoing uterine surgery, the frequency of IUA following surgery was 6.7% after resection of uterine septa, 31.3% after resection of a single fibroid and 45.5% after resection of multiple fibroids (80). In some reports, IUA has been proposed as the most frequent complication of resectoscopic myomectomy (81), with adhesion formation occurring in the healthy tissue of the uterine wall adjacent to the excised pathology (82). The superiority of particular types of electrical current used during surgery has also been debated, with proponents of bipolar instruments (83) reporting lower rates of IUA compared to monopolar instruments (80). More recently, a large cohort study of a new technique of cold loop hysteroscopic myomectomy has been published with lower rates (4.23%) of IUA formation. This study implicates the damaging effect of thermal spread on the endometrium and myometrium (84).
Hysteroscopic septoplasty has recently been highlighted as carrying a particularly high risk for the development of IUA (82). Adhesion formation was reported in up to 86% of women in one recent study (85).
21 Chapter 1 Literature review
Open surgery
Uncomplicated caesarean delivery has also been implicated as the only causative open surgery event for IUA in a number of studies (44, 47, 49, 50, 53-55). It is estimated that the risk of developing IUA is 2% (36). In a recent large study of AS, caesarean delivery was the only cause implicated in 3.6% (44). The prevalence of
IUA following laparotomy and full thickness myomectomy has been reported as 1.3%
(36).
Laparoscopic surgery
The laparoscopic Strassman procedure to unify a bicornuate uterus has also been described as a cause of IUA formation (61). This supports the theory that laparoscopic surgery per se is not protective against adhesion formation (86).
Devascularisation of the uterus
Case reports of AS have been described after bilateral uterine artery embolisation (UAE) (65, 87) and IUA have since been recognised as a risk factor for this procedure in myoma management (62, 63). These IUA occurred both independently and with the addition of curettage at the same time as embolisation
(39). Furthermore, the IUA resulting from UAE appear to have a poorer pregnancy prognosis compared to IUA as a result of surgical trauma (39). Adhesion formation following severe postpartum haemorrhage has also been reported (88) (44).
Presumably devascularisation of the uterus contributes to the pathogenesis of the IUA formation in caesarean and intrapartum deliveries. However, is it not described in detail within these reports (36, 44, 56).
22 Chapter 1 Literature review
Endometrial ablation techniques
IUA is a known and desired consequence of endometrial ablative techniques.
There are a number of techniques used to remove, ablate or destroy the endometrial
lining of the uterus. These include resection via hysteroscopy, electrical energy
current, thermal balloon and microwave techniques. These procedures are most often
employed for women who suffer from excessive or prolonged bleeding during their
menstrual cycle but cannot or do not wish to undergo a hysterectomy. Although these
procedures are generally reserved for women who do not desire pregnancy, and while
pregnancy is not recommended following ablation, in rare cases, conception and
pregnancy have been reported. The obstetric outcomes for such pregnancies are
similar to pregnancies following treatment of IUA, displaying higher rates of abnormal placentation, haemorrhage, and growth restriction in the fetus (89).
Predisposing state
Pregnancy
The pregnant or recently pregnant uterus is particularly susceptible to formation of IUA (10, 68). Some authors reserve AS for women who have IUA that
were caused by trauma to the endometrium in the gravid or recently gravid uterus
(44). One theory is that the low oestrogen status during pregnancy complicates recovery from surgical procedures by predisposing a woman to forming IUA, as the endometrium depends on oestrogen for regeneration (10). Gestational factors also cause a softening of the uterus, making it difficult to control the depth of curettage.
Schenker found in a series of 1856 cases of IUA, that pregnancy was a predisposing factor in 91% of cases (36). However, the majority of curettage procedures are performed when the woman has retained products of conception, at a time when the
23 Chapter 1 Literature review
level of oestrogen is actually elevated. Hence this theory lacks some biological
plausibility as the only explanation of this phenomenon.
Hypogonadism
Gonadotropin releasing hormone analogue (GnRHa) treatment has also been
associated with an increased risk of IUA formation. Fedele and Taskin et al. found the use of GnRHa prior to hysteroscopic surgery increased the risk of IUA formation (76,
80). This is supported by other authors arguing that ‘senile adhesions’ are be found in
post menopausal women (90, 91) and that there is a higher incidence of IUA after
breastfeeding for more than three months. But this effect is not proven in any
scientific studies and is “expert opinion” only (60). Reassuringly, in more recent
publications of large numbers of hysteroscopic procedures where GnRH agonists
were used, increased rates of IUA formation were not observed (84).
Intercurrent infection
The role of endometritis in the development of IUA is controversial (67, 76).
Rabau et al. (68) reported that infection was the primary cause of fibrosis and
adhesion formation in the endometrium, particularly when it is chronic or sub clinical.
He hypothesised that infection was the primum movens of adhesion formation. The
main reasons cited by Rabau (68) as evidence for infection playing a key role in the
pathogenesis of IUA are:
1. that peritubal adhesions exist, which the curette does not reach;
2. chronic or subacute endometritis was found on histological
examination; and,
24 Chapter 1 Literature review
3. there was suspected or proven infection in all cases where curettage
had been performed in their series.
Jensen and Strome (92) held an opposing view that infection is not implicated in the formation of IUA. They state that none of the women in their series had any signs of pelvic infection and that there were no detectable differences in the number of inflammatory cells, degeneration, and tissue oedema on histological examination of endometrial cells in women with IUA compared to women without IUA. When examining the role of infection after caesarean delivery, Polishuk (42) found no increased incidence of IUA in women with endometritis compared with women without evidence of infection following caesarean delivery.
The American Fertility Society states that dilation and curettage in the setting of endometritis appears to have a small, but non-significant effect on adhesion formation (93). Nevertheless, the inflammatory process may contribute to the harm caused by trauma and acts synergistically to form IUA (34, 94). Trauma and subsequent inflammation in conjunction with a low oestrogen status may potentially lead to fibrosis. It is likely that infection plays a limited role in the pathogenesis of
IUA. Infection per se is unlikely to be a primary cause of adhesions. However, infection is likely to contribute to the process of adhesion formation by the initiation of inflammation (68).
Constitutional factors
There appears to be a constitutional element which leads certain women to develop IUA where other women undergoing the same traumatic event remain unaffected (95, 96). Similarly, the level of severity of IUA can be very different
25 Chapter 1 Literature review
between women undergoing the same level of surgical trauma. Constitutional factors
may also explain the differences in the responsiveness of certain women to treatment,
such as clotting disorders or genetic variants which may lead to a defect in the
structure, production, or processing of fibrin or proteins that interact with the process
of normal scar formation. Although no target genes have been identified, some
women appear to have a predisposition to recurrent adhesion formation (10, 36).
Congenital anomaly of the uterus
Stillman and Asarkof (19) investigated 840 infertile couples and found a
significant association between AS and Müllerian duct malformations, particularly the
septate uterus (10). Of the 43 infertile women with untreated congenital
malformations of the uterus, seven of these (16%) had AS concurrently. It is not clear
whether the malformation itself predisposed the women to adhesion formation, or
whether this subset of women had had more surgical evacuation of the uterus due to
their recognised increased risk of early pregnancy loss.
Infertility
There are several possible causes of infertility in women with IUA. A
combination of endometrial insufficiency and vascular supply, and obstruction of the tubal ostia and/or endocervical canal are described as contributory factors. Although
there appears to be a relationship between infertility and the extent of the adhesive process (76), there have been reported cases of pregnancy when the endometrial
lining is minimal (42). This highlights the individual variability of fertility in women
with IUA. This is explored in more detail in Chapter 2.
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SECTION 4: PATHOLOGY AND CLINICAL MANIFESTATIONS
Overview
Clinical findings reflect the pathophysiology of this disease. These symptoms
are a useful guide to making the correct diagnosis of intrauterine adhesions (IUA).
History
Antecedent event
Traumatic insult to the uterus as a result of mechanical abrasion of the endometrium by a curette is the most common preceding event (6). The index of suspicion of Asherman syndrome (AS) should be heightened when there has been
repeated abortion or uterine curettage. The pregnant uterus is particularly susceptible
(see Chapter 1, Section 3: Aetiology). Postpartum curettage carries a higher risk for
IUA formation (13, 55, 71). Infection may contribute to the inflammatory process and
has been implicated as a cause for IUA by some authors (68). Hence, a history of
endometritis may also be important when assessing the patient.
Menstrual disturbance
Menstrual abnormalities are the most common complaint of women with AS,
although they do not correlate perfectly with the pattern of IUA. Of 2981 cases of
IUA, normal menses was reported in 179/2981 (6%) women, 1102/2981 (37%)
women described amenorrhoea, 924/2981 (31%) women reported light menstrual
bleeding, and 30/2981 (1%) reported heavy, prolonged menstrual bleeding (36). It is
likely that trauma leads to fibrosis, compounded by a lack of blood supply, making
the endometrium atrophic and inactive to hormonal simulation. Therefore menstrual
dysfunction is a hallmark of AS.
27 Chapter 1 Literature review
Asherman stated that menstrual disorders only occur in women suffering from cervical adhesions. He hypothesised that amenorrhoea is caused by a neurovascular reflex that inhibits the endometrium from responding to hormonal stimuli when adhesions occur in the area of the internal os (6). This theory was disputed by Netter
(77), who considered the cause for adhesions to be purely mechanical. Netter’s work demonstrated a number of cases of amenorrhoea and adhesions at the internal os with haematometra and haematosalpinx.
Hypomenorrhoea or light menstrual bleeding (LMB) (97) is commonly found in association with IUA and is thought to be due to the destruction of the endometrium. Toaff and Ballas correlated the degree and location of adhesions with the degree of alteration in menstrual function (26). The remaining endometrium may become atrophic due to limited local exposure to circulating hormones and a lack of uterine perfusion, which is a feature of AS (67). This results in myometrial fibrosis, which is significantly increased in women with IUA (41).
Pelvic pain
Pain is also described in association with IUA. Most commonly, pelvic pain is cyclical and can occur in the presence or absence of vaginal bleeding. This pain can be associated with an increase in menstrual flow, or more frequently with a decrease in or absence of flow. The mechanism of pain is thought to arise from outflow obstruction, with backflow into the fallopian tubes. This backflow creates haematosalpinx and retrograde menstruation. Pain may also arise as a result of pockets of residual endometrium responding to hormonal stimuli, with no route for egress (67).
28 Chapter 1 Literature review
Sub fertility
Secondary infertility is a common presenting symptom of women with IUA
Fertility may be impaired due to an obstructive effect, particularly when adhesions form at the level of the internal os, or tubal ostia, preventing migration of gametes and embryos within the reproductive tract (98). Implantation may also be affected in women with AS, due to the associated deficiency of endometrium hindering implantation (99). As with menstrual disturbance, the degree of symptoms do not necessarily relate to the intrauterine pathology. Taylor showed that eumenorrhoeic women with subfertility were more likely to have AS than their fertile counterparts
(18). The correlation appears higher between symptoms of infertility and degree of
IUA, compared with the correlation between symptoms of menstrual disturbance and infertility.
Recurrent miscarriage
There is a high incidence of recurrent miscarriage in AS women (36).
Therefore, a history of recurrent miscarriage should alert the clinician to the possibility of IUA. Recurrent miscarriages may be due to endometrial effects.
Polischuk postulated that defective vascularisation at the level of the denuded endometrium may inhibit effective implantation, leading to a lethal reduction in blood supply to the decidua and early embryo and fetus (42).
29 Chapter 1 Literature review
Complications of late pregnancy
If women with IUA conceive, abnormal placentation may lead to late pregnancy complications such as premature delivery, as well as placenta previa, placenta accreta, and postpartum haemorrhage (see Chapter 2) (100, 101). Placental abnormalities may follow from a defect in the basalis layer of endometrium, caused by the original trauma or subsequent adhesion formation (36). Direct implantation into the myometrial layer has also been implicated as one of the mechanisms by which this occurs (80), as has the devascularisation of the uterus that occurs as a result of the insult or subsequent healing of the endometrium and myometrium (39, 89).
Clinical examination
Clinical examination usually fails to reveal abnormalities (15, 77). However, a uterine sound passed into the cervix may reveal obstruction at the level of the internal os. This finding makes the diagnosis relatively simple when adhesions are present in the cervicoisthmic canal (77).
Summary
The main symptoms of IUA are menstrual disturbance, pelvic pain, and sub- fertility. Recurrent miscarriage and abnormal placentation are also features of IUA patients who manage to conceive. There is a spectrum of presenting features, which represent the varying pathophysiological features of this complex disease.
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SECTION 5: DIAGNOSIS
Overview
There are a number of investigations of varying sensitivity available to provide the diagnosis of Asherman syndrome (AS). These will be outlined in the following section.
Hysterosalpingogram (HSG)
Overview
Hysterosalpingogram (HSG) has been used for many years for the diagnosis of
IUA when women have symptoms suggestive of Asherman syndrome (AS) (102).
Although HSG will diagnose IUA with reasonable accuracy (see below), this technique fails to eliminate the diagnosis of endometrial sclerosis and scarring where the anatomical shape is unaltered (60).
Diagnostic features
Filling defects that can be attributed to IUA have an irregular and angulated form, with sharp contours and homogeneous opacity. These filling defects are reproducible over a number of examinations separated in time (103). In more severe cases, partial obliteration of the cavity may be observed, with blockage of one or both fallopian tubes (10). The shape, position and number of defects vary between women
(36). In severe and extensive IUA, intravascular and intralymphatic extravasations may also be seen. When complete occlusion occurs, HSG will fail to show any contrast filling of the uterine cavity (10).
31 Chapter 1 Literature review
Advantages
An advantage of this procedure is the ability to concurrently assess tubal patency. This procedure does not require an anaesthetic, and may be performed in an ambulatory setting.
Efficacy
HSG has a sensitivity of 67-100% and a specificity of 80.4% compared to
hysteroscopy in diagnosis of IUA. HSG has a positive predictive value of 50-67%
(104-106).
Disadvantages
The main limiting feature of HSG is its false positive rate, which has been
reported to be as high as 38.3% (24). This results from the inability of HSG to
distinguish between the various causes of filling defects, such as endometrial polyps.
Lower segment outflow obstruction affects the accuracy of results. In one study,
61.1% of cases which were only cervical adhesions were erroneously reported as severe IUA with complete cavity obstruction (105). There is also radiation required to perform this technique, which can be a concern for the ovary and its ongoing reproductive function.
Summary
Although HSG remains a good screening test for IUA, HSG has largely been superseded by more precise and less invasive diagnostic modalities.
32 Chapter 1 Literature review
Hysteroscopy
Overview
Hysteroscopy is established as the gold standard for diagnosis of IUA (107).
Efficacy
When compared with radiologic investigations, hysteroscopy more accurately
confirms the presence, extent and degree of adhesions, and the quality of the
endometrium. It allows a real time view of the cavity, enabling accurate description of
location and degree of adhesions, as well as classification of IUA (108).
Advantages
The major advantage of hysteroscopy is that it allows treatment at the time of
diagnosis (102). It can also be performed in theatre or in the outpatient setting (109).
Disadvantages
The main disadvantage of hysteroscopy is that it requires dedicated equipment
and qualified, experienced staff to perform the procedure. The surgical risks include
exposing the patient to infection, vasovagal syndrome, and perforation of the uterus (110).
Diagnostic features
The hysteroscopic appearances of IUA have been described by Al Inany (38)
and include:
1. the central adhesion that appears as a column with broadening ends
connecting opposite uterine walls;
33 Chapter 1 Literature review
2. the marginal adhesion, which appears like a crescent or half-drawn
curtain that can hide a cornu or side wall and create an asymmetrical
aspect to the uterine cavity – this may be easily missed; and/or,
3. complex marginal central scars, which divide the uterine cavity into
several smaller chambers, some of which may be concealed to visual
examination.
Superficial adhesions may have the same appearance as the adjacent endometrium and may be broken down by the hydrostatic pressure or simply by the hysteroscope alone. Fibrous or myometrial bands appear white, and are dense and more difficult to divide with the hysteroscope alone. Endometrial fibrosis appears as pale patches on hysteroscopy. The hysteroscopic appearance of tuberculous infection is that of a network of small alveoli coating the uterine walls, and the fundus may have a honeycomb appearance (10).
Dual modalities
Hysteroscopy may also be performed under ultrasound guidance to guide the operator when there is near complete obstruction to the uterine cavity (10).
Office hysteroscopy
Office hysteroscopy is a useful diagnostic tool. It also allows a second look follow-up after treatment of IUA. It is convenient and does not require use of an operating theatre or general anaesthesia, which add to the cost of in-patient hysteroscopy. Although dense adhesions may not be amenable to treatment during office hysteroscopy, treatment of mild adhesions during office hysteroscopy has been shown to improve clinical pregnancy rates in women with recurrent IVF failure (111).
34 Chapter 1 Literature review
Summary
Whether hysteroscopy is performed in an ambulatory setting, or in an operating theatre, it allows the operator a real time view of the endometrial cavity.
Therefore it is the investigation of choice for diagnosing IUA
Transvaginal ultrasound (TVUS)
Overview
Ultrasound has been reported as a useful method for diagnosis of IUA and uterine fibrosis (112, 113).
Advantages
Ultrasound is a non-invasive, readily available procedure that allows visualisation of the uterine cavity.
Disadvantages
TVUS may be more difficult when there is obliteration of the uterine cavity or when there are dense adhesions at the internal os. TVUS has high false positive rates of focal lesions of the endometrial cavity due to the limitations of the double layer thickness of the endometrial cavity (64). TVUS therefore can lack diagnostic accuracy
(114).
Diagnostic features
The characteristic appearances of IUA are dense echoes (hyperechoeic areas) within the endometrial cavity. When adhesions are dense, the endometrial echo may be difficult to visualise, with irregular thickness or interruptions in the lining at the
35 Chapter 1 Literature review
sites of fibrosis. In addition, there may be one or more echolucent area, with interruption of the endometrium (skip lesions) representing localised menstrual blood
in the area where functional endometrium is preserved (10).
Efficacy of TVUS
The sensitivity of TVUS has been reported as 52% and specificity of 11% in a
study that compared TVUS to sonohystogram and hysteroscopy (115).
The pre-operative endometrial thickness seen on TVUS seems to be predictive
of post-treatment prognosis. In one study, seven women who presented with
amenorrhoea and complete obliteration of the lower uterine cavity were assessed in
terms of the thickness of their endometrial lining in the upper cavity prior to and
following surgery. The women with the thinner pre-operative endometrium had a
poorer response to surgical treatment. Those women that had normal appearing
endometrium above the obstruction were more likely to resume normal menstruation
following surgical treatment (10, 113).
Power Doppler ultrasound
Doppler technology has been adopted as an adjunct to standard ultrasound in
the diagnosis and management of IUA. High resistance flows indicate poorer
prognosis for pregnancy outcomes (116)
Three dimensional ultrasound (3DUS)
The efficacy of three-dimensional ultrasound (3DUS) has been reported as
100% specific and 100% sensitive in one prospective study of 54 women. 3DUS has
36 Chapter 1 Literature review
the ability to correctly diagnose the type of adhesions as mild, moderate or severe
prior to surgery and hysteroscopy (117).
When comparing 3DUS with sonohystogram, the sensitivity has been reported
as 87%, with a specificity of 45% (118).
Sonohystogram (SHG)
This technique combines transvaginal sonography with intrauterine injection
of isotonic saline to assess the uterine cavity. In this technique, 20-30 mL of normal
saline is introduced into the uterine cavity through a catheter. Intrauterine adhesions are suspected if there are one or more echogenic areas between the anterior and posterior walls, or if full distension of the cavity is impeded by tethering of the walls by synechiae.
Sonohystogram (SHG) has been shown to be as effective as HSG in one study of 19 women with suspected diagnosis of IUA. All women in this study had a
hysteroscopy to review the suspected pathology (115). In another study of diagnostic
accuracy in 65 infertile women, SHG and HSG were both reported to have a
sensitivity of 75% with a positive predictive value of 43% for SHG and 50% for HSG
when compared to hysteroscopy (104). Similar to HSG, SHG has a high false positive
rate and is thus best utilised as a screening test for IUA. It also allows assessment of
the pelvic structures and tubal patency at the time of investigation.
37 Chapter 1 Literature review
Three dimensional sonohysterography (3DSHG)
Three dimensional sonohysterography (3DSHG) is a newer technology available for investigation of IUA. A saline infusion is instilled into the uterine cavity via a trans-cervical catheter to improve the assessment of the intracavity tissue and of
the cavity outline by contrast enhancement. The cavity is then inspected in a three
dimensional reconstruction.
Advantages
3DSHG is more reliable then TVUS for diagnosing pathology within the
endometrium. 3DSHG also makes distinguishing focal pathology and disseminated
pathology possible (119). It also allows measurement of endometrial cavity volume,
which has been shown to be decreased in the setting of AS (120, 121).
Disadvantages
The 3DSHG procedure involves cannulation of the cervix and retrograde
infusion of fluid through the uterus. It therefore is more invasive and painful for the
patient, with theoretic risks of infection to the peritoneal cavity.
Efficacy of 3DSHG
In a recent cross sectional study assessing 3DSHG, the concordance of the
finding of IUA and confirmation of pathology on hysteroscopy was 50%. Overall for
endouterine pathology, the sensitivity was 69.7%, the specificity was 85.7%, the
positive predictive value was 83%, and the negative predictive value was 73.8%
(122).
38 Chapter 1 Literature review
Magnetic resonance imaging (MRI)
Overview
MRI has been used as a diagnostic modality for AS (123-125). MRI is
particularly useful in diagnosis when there is involvement of the cervical canal (126), where hysteroscopy may be difficult or impossible to perform, especially in the case of cervical stenosis.
Advantages
The main advantage to MRI is that it allows examination of the uterine cavity cephalad to lesions causing outflow obstruction. MRI also allows assessment of the endometrial remnants in the upper part of the uterine cavity. This may influence the decision and outcome of treatment (10, 124).
A further advantage of MRI is the ability to review the basalis and superficialis layer of the endometrial lining. This provides more information on the endometrium and the junctional zone (JZ) (127).
Newer technologies also hold promise of a more dynamic assessment of the endometrium in IUA as well as endometrial and myometrial changes. These technologies include diffusion weighted imaging (DWI) with apparent diffusion coefficient (ADC) measurement and gadolinium-enhanced T1-weighted images, as used in endometrial cancer (128). This will be reviewed in more detail in Chapter 4 of this thesis. Although signal characteristics in IUA have not been examined in detail, it is anticipated that adhesions would produce low signal intensity on T2 images (126).
MRI may play a supplementary role in the diagnosis of IUA where there is complete obliteration or cervical obstruction and when this cannot be visualised on hysteroscopy (10). However, there is limited data on the use of MRI in AS.
39 Chapter 1 Literature review
Disadvantages
MRI is an expensive modality, without a necessarily improved sensitivity.
Therefore, its current role in IUA is uncertain.
Summary
HSG was the first method that allowed the uterine cavity to be inspected in detail. Since the advent of hysteroscopy, HSG has been largely superseded by this more accurate diagnostic tool, which also allows treatment of the pathological process. Various less invasive imaging techniques have also been described to
diagnose IUA. However, they all have the same propensity for false positive findings.
In the setting of IUA, they are best used as screening tests. Hysteroscopy is the
diagnostic tool of choice. It allows accurate examination of the endometrial cavity, is
minimally invasive and is able to be performed in an inpatient or outpatient setting.
40 Chapter 1 Literature review
SECTION 6: CLASSIFICATION
Overview
Hysteroscopy is required for accurate classification of Asherman syndrome
(AS) (67). X-ray and HSG have also been used in the past to classify IUA (107),
although these techniques are not widely used in current practice for diagnosis.
Grading of IUA is clinically useful as the prognosis relates to the severity of disease
(102). A number of classification systems have been proposed for AS. However, to
date there is no clear consensus as to which one to use and no classification system
has been validated.
Initial classification
March et al. were the first group to attempt to classify IUA (107).
Hysteroscopy was used to classify IUA based upon the degree of uterine cavity
involvement. This is summarised in Table 1.2 below.
Table 1.2 – Hysteroscopic classification of intrauterine adhesions (March)
Classification Involvement
< 1/4 of uterine cavity involved; thin or filmy adhesions; ostial areas and upper Minimal fundus minimally involved or clear
1/4 – 3/4 of uterine cavity involved; no agglutination of walls – ostial areas and Moderate upper fundus only partially occluded
> 3/4 of uterine cavity involved; agglutination of walls or thick bands; ostial area Severe and upper cavity occluded
41 Chapter 1 Literature review
In March’s study, X-ray findings were correlated with hysteroscopic findings.
They found a poor correlation between plain X-ray and hysteroscopy, and better correlation between HSG and hysteroscopic findings. However, HSG tended to have a higher degree of false positive results. That said, there were no cases in March’s study where HSG reported a more extensive disease than was recorded hysteroscopically.
Hamou et al. subsequently described adhesions in terms of their location
(129). However, a formal classification was not described. Adhesions were divided into isthmic, marginal, central, and severe.
Subsequent classifications
Valle and Sciarra (49) extended the classification of March et al. (107). They developed their own classification system to incorporate type of adhesion (mild, moderate or severe) and the extent of occlusion (partial or total). Their approach to classification is summarised in Table 1.3 below.
Table 1.3 – Intrauterine adhesions: Hysteroscopic diagnosis, classification, treatment
and reproductive outcome (Valle and Sciarra)
Classification Involvement / Extent
Mild Filmy adhesions composed of basal endometrium producing partial or complete
adhesions uterine cavity occlusion.
Fibromuscular adhesions that are characteristically thick; still covered with Moderate endometrium that may bleed upon division; partially or totally occluding the adhesions uterine cavity.
Severe Composed of connective tissue; lacking any endometrial lining and likely to bleed
adhesions upon division; partially or totally occluding the uterine cavity.
42 Chapter 1 Literature review
The European Society for Hysteroscopy (ESH) classification of IUA
In 1984, Wamsteker proposed a system for grading IUA (108). This system classified IUA into Grades I–IV and incorporated a combination of hysteroscopic and
HSG findings, as well as clinical symptoms. This classification is summarised in
Table 1.4 below.
Table 1.4 – Classification of intrauterine adhesions (Wamsteker, European Society for
Hysteroscopy [ESH])
Grade Extent of intrauterine adhesions
Thin or filmy adhesions easily ruptured by hysteroscope sheath alone. Cornual areas I normal.
Singular filmy adhesions connecting separate parts of the uterine cavity. Visualisation of II both tubal ostea possible. Cannot be ruptured by hysteroscope sheath.
Occluding adhesions only in the region of the internal cervical os. Upper uterine cavity II a normal.
Multiple firm adhesions connecting separate parts of the uterine cavity. Unilateral III obliteration of ostial areas of the tubes.
III a Extensive scarring of the uterine cavity wall with amenorrhea or hypomenorrhoea.
III b Combination of III and III a.
Extensive firm adhesions with agglutination of uterine walls. At least both tubal ostial IV areas occluded.
43 Chapter 1 Literature review
The European Society for Gynaecological Endoscopy (ESGE) subsequently revised the ESH classification system in 1995. Their revisions included a reduction in the sub-classification of Grade III and the inclusion of Grade V. The criteria for Grade
V incorporates endometrial scarring and fibrosis as a higher grade finding, as they recognise fibrosis to be a poor prognostic indicator. The ESGE classification system is outlined in Table 1.5 below.
Table 1.5 – Modified classification system of European Society for Gynaecological
Endoscopy (ESGE)
Grade Extent of intrauterine adhesions (IUA)
I Thin or filmy adhesions.
II Singular dense adhesion.
Occluding adhesions only in the region of the internal cervical os. Upper uterine cavity II a normal.
III Multiple dense adhesions.
IV Extensive dense adhesions with (partial) occlusion of the uterine cavity.
Extensive endometrial scarring and fibrosis in combination with Grade I or Grade II V a adhesions.
V b Extensive endometrial scarring and fibrosis.
The ESH / ESGE classification system is more precise and more prognostic than earlier classifications, such as that of March et al. (107). However, it has been criticised as being difficult to use in clinical practice (130), especially in distinguishing Grades III, III a, and III b.
44 Chapter 1 Literature review
The American Fertility Society classification
Like the European society classification, this classification is largely based
upon extent of endometrial obliteration, hysteroscopic appearance of adhesions, and menstrual characteristics of the patient. Menstrual characteristics are included as they may have an important prognostic element for fertility (93). It is hypothesised that
menstrual characteristics reflect the amount of functioning endometrium remaining in
the endometrial cavity. The scoring system can be used for direct (hysteroscopy) or
indirect (HSG) investigations. The classification is shown in Table 1.6 below. Of
note, this classification refers to stage rather than grade of IUA.
Table 1.6 – The American Fertility Society classifications of adnexal adhesions, distal
tubal occlusion, tubal occlusion secondary to tubal ligation, tubal pregnancies,
Müllerian anomalies, and intrauterine adhesions
Extent of cavity involved < 1/3 1/3 – 1/2 > 2/3
Score 1 2 4
Type of adhesions Filmy Filmy and dense Dense
Score 1 2 4
Menstrual patterns Normal Hypomenorrhoea Amenorrhoea
Score 0 2 4
The stage of disease is calculated from the Table 1.6, with Stage I (mild) scoring 1-4, Stage II (moderate) scoring 5-8, and Stage III (severe) scoring 9-12. The physician is then able to predict prognosis as excellent, good, fair or poor, based on stage, tubal patency, and clinical judgement.
45 Chapter 1 Literature review
Recent classifications
Donnez and Nisolle (131) considered location to be the most important
prognostic factor in determining post-operative pregnancy rate. Adhesions are divided
into degrees, with each degree containing two subtypes. Their classification is
summarised in Table 1.7 below.
It is unclear how the authors came to the conclusion that the higher degree was
related to the poorer prognostic value. Their classification of III refers to an inability
to perform HSG due to obstruction of the cervical canal. However, this scenario
generally has a fair prognosis for subsequent fertility when adhesions are divided.
This better prognosis is reflected in most other classification systems, where these
adhesions are given a relatively lower stage or score.
46 Chapter 1 Literature review
Table 1.7 – Hysteroscopic adhesiolysis of intrauterine adhesions in Asherman syndrome
(Donnez and Nisolle)
Degree Location
I Central adhesions (bridge-like adhesions)
II a Thin or filmy adhesions (endometrial adhesions)
II b Myofibrous or connective adhesions
II Marginal adhesions (always myofibrous or connective)
II a Ledge-like projections
II b Obliteration of one horn
III Uterine cavity ‘absent’ on hysterosalpingography
Occlusion of internal os (upper cavity normal) III a (pseudo-Asherman syndrome)
Extensive coaptation of the uterine walls (absence of the uterine cavity) III b (true Asherman syndrome)
More recently Nasr et al. described a revised classification system which incorporates both menstrual and obstetric history (130). This classification is shown in
Table 1.8 below. The classification includes pregnancies that have ended in miscarriage, as the authors believe these factors have an important prognostic value for future fertility following treatment.
47 Chapter 1 Literature review
Table 1.8 – A clinicohysteroscopic scoring system of intrauterine adhesions (Nasr)
Hysteroscopic findings Score
Isthmic adhesions 2
Filmy adhesions – few 1
– excessive (> 50% of the cavity) 2
Dense adhesions – single band 2
– multiple bands (> 50% of the cavity) 4
Tubal ostium – both visualised 0
– only one visualised 2
– both not visualised 4
Tubular cavity (sounds less than 6) 10
Menstrual pattern – Normal 0
– Hypomenorrhoea 4
– Amenorrhoea 8
Reproductive performance
– Good obstetric history 0
– Recurrent pregnancy loss 2
– Infertility 4
In this grading system, a score of 0–4 (Grade I, mild) reflects a good prognosis, a score of 5–10 (Grade II, moderate) reflects a fair prognosis, and a score of 11–22 (Grade III, severe) reflects a poor prognosis. Nasr et al. also compared their scoring system with that of March et al. (107) and Wamsteker (132) to assess the degree of similarity. They found that their scoring system correlated well for Grades I and III. However, there was much overlap in Grade II, which the investigators
48 Chapter 1 Literature review
attributed to differences in the inclusion of menstrual and reproductive performance in the assessment of these women.
Although this is not a validated system, and the study results rely on findings from a relatively small number of women, it is an innovative system. It attempts to combine hysteroscopic findings and two clinical parameters (menstrual pattern and reproductive performance) to give a prognosis for fertility after hysteroscopic lysis of adhesions.
Summary
The presence of numerous classification systems makes it difficult to interpret the studies published in the literature. This may be a reflection on the classification systems being inherently deficient, as no classification has to date received universal endorsement.
49 Chapter 1 Literature review
SECTION 7: MANAGEMENT
Overview
Following diagnosis of intrauterine adhesions (IUA), treatment is considered when there are symptoms of pain or menstrual dysfunction that are unacceptable to the woman, or more commonly when there is a history of infertility, or recurrent pregnancy loss, and the patient wishes to conceive (102). Treatment is reserved for symptomatic IUA.
The role of mild adhesions in contribution to symptoms is controversial.
However, division of these adhesions may be considered if there is a history of infertility or recurrent pregnancy loss with no other cause being found (76). When there is reproductive failure and adhesions in the cervico isthmic canal, or dense occlusion of one or both tubal ostia, surgical lysis is indicated. There appears to be a correlation between the severity of the IUA, the risk of reformation of adhesions and the success of the procedure (133). However, this is not always the case. Minimal adhesions can sometimes cause ongoing symptoms and have a high recurrence rate.
This is likely to be associated with the individual’s propensity to develop IUA (see
Chapter 1, Section 3: Aetiology).
There is no consensus as to the optimal technique for division of adhesions.
Equally there is a lack of prospective randomised controlled trials on the treatment of
Asherman syndrome (AS) (67). The aims of treatment are to restore the size and shape of the uterine cavity, treating associated symptoms, preventing recurrence of adhesions, promoting repair and regeneration of the destroyed endometrium, and restoring normal reproductive function (10).
50 Chapter 1 Literature review
Expectant management
In a historical review of the management and outcomes of women with AS,
Schenker reviewed 23 reported cases of women with AS who were amenorrhoeic and
had not undergone surgical management. Of these cases, 18 regained their regular
menses after 1–7 years of follow up. In the same review, 133 of 292 women who
desired fertility, and did not have surgical management, spontaneously conceived in
the same follow-up period (45.5%) (36). In this review, there were a large number of
women who had mild adhesions. Although this paper pre-dates the classification of
AS, in the description of the women, a large number appeared to have only mild
adhesions in the cervical canal. This is a possible explanation for the high number of
pregnancies achieved with expectant management only. Generally, pre-operative assessment of the extent of disease is imperative with either ultrasound or MRI. If no functioning endometrium is present, surgical correction is likely to be futile (60).
Cervical probing
This early technique has been described in women with cervical stenosis, without damage to the uterine cavity or endometrium. This procedure can be carried out with or without ultrasound guidance. Asherman described 29 women with cervical scarring managed by sounding the cervix (5). In some women this procedure was not sufficient to completely break down the adhesions and required a repeat procedure.
Menstruation returned in all 29 cases within one month and it was considered that mechanical irritation was sufficient to induce menstruation in those women who had incomplete lysis of IUA (5). However, given our knowledge of the pathophysiology of IUA, it is more likely that the cervical probing provided an outflow for any obstructed menstruation in this group of women.
51 Chapter 1 Literature review
Dilation and curettage
Before the introduction of hysteroscopy, blind dilation and curettage was a
technique adopted for the treatment of AS. Schenker suggested a proposed technique
of treatment for IUA, which involved vaginal lysis through dilation and curettage with
some women receiving oral oestrogens post-operatively and a majority of women
having an intrauterine device (IUD) placed following this procedure (36). Of the 137
cases performed in this manner, 116/137 (85%) reported normal menses after the
procedure, with 111/137 (81%) women conceiving after the treatment, of which
89/111 (80%) proceeded to delivery. However, 22/111 (20%) women reported miscarriages after this treatment. It is important to note that 40/137 (29%) women had
only cervical adhesions in this series, and that those women with severe IUA and
obliterated endometrial cavity were removed from this group and treated primarily
with hysterotomy with lysis.
Schenker went on to review the cases reported at that time. He found that of
1250 women treated for IUA, 1049/1250 (84%) returned to normal menses after
treatment with dilation and curettage. However, only 540/1052 (51%) of those women
who wished to conceive were able to do so, and of the pregnancies achieved, 306/559
(55%) were term pregnancies, 50/559 (9%) were premature, and 142/559 (25%)
miscarried. Placenta accreta complicated 42/559 (9%) of the pregnancies in this
cohort (36). As this review predated the advent of hysteroscopy, it is likely that the
IUA were incompletely lysed, and the authors were unable to assess their results
accurately. The presence of IUA has a higher correlation with infertility than
menstrual disturbance (18).
52 Chapter 1 Literature review
Hysteroscopy
Overview
Hysteroscopic treatment is generally regarded as the treatment of choice for
IUA (67). The procedure allows lysis of adhesions under direct vision and with a magnification that cannot be obtained during blind procedures, such as curettage, or open procedures, such as laparotomy and hysterotomy. Distension of the uterine cavity has the dual role of providing visualisation for the operator, as well as separating the uterine walls and enhancing the outcome of the procedure.
Hysteroscopic adhesiolysis involves dividing adhesions caudally first and dividing thin filmy adhesions before the denser ones. At the conclusion of the procedure, both ostia should be seen and the endometrial cavity should resemble a normal cavity.
Mild adhesions
Mild adhesions may simply be divided by fluid distension of the cavity, or blunt dissection with the tip of the hysteroscope (134). This can be done in the operating theatre or in an outpatient setting (109).
Moderate to severe IUA
Division of moderate to severe adhesions can be technically challenging.
These techniques require a continuous flow of fluid distension to allow visualisation and additional instruments are used to lyse these adhesions. Generally, adhesiolysis begins caudally and can be advanced cephalad until the uterine architecture has been restored. In general, filmy or central adhesions should be divided first, as these are
53 Chapter 1 Literature review more easily distinguished. Marginal and dense adhesions are more difficult to identify and division of these adhesions carries a higher risk of uterine perforation (10).
Hysteroscopic scissors
Semirigid 5–7 Fr scissors have been described to divide adhesions under direct vision (49, 107). Ideally, a 6.5 mm hysteroscope should be used with an operative port to accommodate scissors (67). This allows visualisation, while sparing the patient full dilatation of the cervix. It also allows dissection, avoiding complications associated with other cutting modalities, such as diathermy or laser. This theoretically minimises destruction of the endometrium (10). A recent report of a “ploughing” technique using cold scissors has also been reported to minimise the damage caused by the lateral thermal spread caused by electrosurgery for IUA (135).
Tuohy needle
An 18 gauge, 80 mm Tuohy needle (Portex Ltd., Hythe Kent, England) may be introduced in parallel with the hysteroscope, under the direct vision of the operator.
The Tuohy needle has a bevelled point, which is sharp and able to divide adhesions under direct vision. It can also be used to inject radio opaque dye (ultravist 76.9%;
Iopromide; Scherring AG, Pharmaceutical Division, Berlin Germany) into an area of dense adhesions at the point of obliteration of the cavity. An image intensifier is used to guide the operator to pockets of normal endometrium (136, 137). As this is used in parallel with the operator’s view, a 3 mm hysteroscope is adequate. This reduces additional dilation of an obliterated cervical canal and reduces the risk of false passage formation.
54 Chapter 1 Literature review
Microhysteroscopy
A report of 69 women, using a hysteroscope under carbon dioxide (CO2) insufflation has also been used to evaluate the extent and character of IUA and to perform lysis of them. In 59 women, the procedures were performed in an office setting using a CO2 hysteroscopic technique without the need for local anesthesia or cervical dilation. The severe forms of this disease remained too difficult to treat effectively with this technique. When the adhesions were severe or the procedure too painful, the operation was scheduled under general anesthesia (129).
Electrosurgery
Lysis of adhesions using monopolar electrosurgery has also been described
(49, 138-141) using powered instruments such as knife electrode. However, care needs to be taken to protect against uterine perforation, with risk of intra abdominal visceral injury (102). The risk of perforation increases when there is dissection of marginal dense adhesions (10).
The advantages of electrosurgery are that there is a precise cutting technique with good haemostasis. The disadvantages of electrosurgery are the possibility of further endometrial damage, resulting from lateral spread of electrical energy from the electrode (60, 142, 143). This may contribute to recurrence of IUA and also requires significant dilation of the cervix to accommodate the operative electrode (60). In support of avoiding electrosurgical current, some authors report a higher pregnancy rate following septum resection with scissors compared to resectoscope. Although the presence of IUA was not confirmed (144).
55 Chapter 1 Literature review
The use of Versapoint bipolar vaporisation (Versapoint Electro-Surgical
System; Gynecare Inc., Menlo Park, CA, USA) to divide IUA has been described by
Fernandez (145) and Zikopoulos (146). Being a bipolar instrument, normal saline can
be used as distension media, minimising fluid overload and electrolyte imbalances,
which can occur with glycine. As this is a closed system, there is a theoretical reduced
risk of intra abdominal injury should peroration occur (102). There is also a reduced
risk of fluid overload. However, the bipolar system is relatively costly (67)
If thermal energy is used to divide adhesions, care should be taken to use the
minimal amount of energy required to fulfil the task (10). This prevents further
damage to the endometrium. The use of a needle electrode rather than a cutting loop
has been proposed to minimise tissue exposure to the electrical current (10).
Proponents of bipolar current believe that this energy source induces less collateral damage than a monopolar electrode (52).
Laser
Vaporisation techniques such as Nd-YAG laser (neodymium-doped yttrium aluminium garnet) have also been described as a successful technique to divide IUA
(49, 141, 147). The depth of necrosis has been described as minimal in these techniques (10). However, this procedure has the same risks as electrosurgical instruments. Therefore care needs to be adopted when using laser for adhesiolysis.
56 Chapter 1 Literature review
Major risks and complications of hysteroscopic synaechiolysis
Complications during adhesiolysis include perforation of the uterus,
haemorrhage, and pelvic infection. This procedure carries the highest risk of
complication out of all operative hysteroscopic procedures reported. This procedure has a rate of 4.48% of women having complications in cross sectional data (148).
Complications were most commonly related to the entry of the uterine cavity. Uterine
perforation was the most frequently reported complication. Rates of perforation of the
uterus were as high as 9% when reviewing severe cases (10). Haemorrhage was less
commonly reported and has been reported to range from 6% to 27% in more severe
cases (10).
Blood vessels may be opened inadvertently whilst dissecting myometrium.
This obscures the operator’s view and allows rapid and excessive absorption of
distension media, such as glycine. This may cause significant electrolyte disturbances,
including hyponatraemia in the patient (149).
Repeated cervical dilation increases the risk of cervical incompetence and
complications such as mid trimester loss (140). Therefore techniques that require
cervical dilation and insertion of large resectoscopes, which are most commonly used
when electrosurgery is required, should be treated with caution.
As there is a risk of recurrence of adhesions, all women undergoing surgery
for adhesions or fibrosis must be counselled regarding repeat surgery (10). This is
particularly the case when the degree of adhesions is severe (49). Repeat surgery is
often indicated in severe cases because of the nature of the procedure and the high
rate of re-formation of adhesions (54).
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Pressure techniques
Laminara tent
A laminara tent consists of 6 cm of dried kelp stalk, approximately 2 mm in diameter, with a string attached through a hole drilled 6 mm from the larger end
(Shivata Medical Products Company, Nagoya, Japan). Insertion of a laminara tent has been described as a technique to aid difficult dense adhesions (150). The laminara is inserted pre-operatively into the short, narrow or scarred cervical canal, to enable insertion of the resectoscope. After the initial 1-2 tents have been inserted into the cervical canal for 24 hours, these are replaced by 3-4 tents into the uterine cavity and removed 24 hours later. Gentle and gradual dilation of the cervical canal follows due to fluid absorption into the laminara tent. The following day, hysteroscopy using a resectoscope under general anaesthetic is performed with dissection after initial mechanical distension of the cavity (150). In a small series of seven women with severe IUA, who had cervical priming using laminara tents and subsequent hysteroscopic adhesiolysis, there were no complications recorded and all women achieved normal menstruation and restoration of the uterine cavity was demonstrated on repeat HSG / hysteroscopy. There were also two pregnancies recorded after treatment with this method (150).
Pressure lavage under ultrasound guidance (PLUG)
This technique is based on sonohysterography, where a continuous infusion of saline solution leads to mechanical disruption of IUA. In a report by Coccia et al.
(151), which reviewed seven women, adhesiolysis was successfully performed in five women with mild adhesions. However, two women with moderate adhesions required hysteroscopy and treatment of adhesions. One out of the seven women became
58 Chapter 1 Literature review pregnant after the procedure. This technique appears to be more suited to women with mild IUA.
Hysteroscopy under guidance
Overview
Various techniques have been adopted to guide the operator during hysteroscopy for severe IUA. These include staining and scoring the endometrium, insertion of physical landmarks, fluoroscopic guidance, ultrasound guidance, and laparoscopic guidance. These techniques have been adopted as a precautionary measure to prevent perforation (146, 152, 153).
Pre treatment with GnRHa has been suggested by some authors to improve visualisation of the uterine cavity (154). However, as this treatment renders the patient hypo-oestrogenic, this may in fact predispose the uterus to adhesion formation and some authors argue that this may cause harm (60). However, there is no good evidence to support this argument.
Staining of the endometrium
Instillation of methylene blue dye to stain the endometrium and guide the operator into pockets of normal endometrium has been described by Valle and Sciarra
(49). The endometrium stains well but connective tissue and myometrium do not.
Although this helps the operator to distinguish normal endometrium from fibrosis, it does not help in the situation of complete obliteration, where the hysteroscope is surrounded by adhesions. Therefore this technique is best suited to mild and marginal adhesions.
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Myometrial scoring
An entirely different technique of dissection has been described by Protopapas
(153). This technique is termed myometrial scoring, whereby six to eight 4 mm deep incisions are created in the myometrium using an electoscope and Collins knife electrode (Valleylab Force 40; Wembley, London, U.K.) from fundus to cervix. These incisions allow widening of the uterine cavity. Capella-Allouc et al. used a similar technique in association with transverse incision at the uterine fundus in 31 women treated with 55 hysteroscopic procedures (140). Both of these techniques open up the endometrial cavity. It is hypothesised that the endometrium may regenerate over this new exposed surface area. All of the cases in the above series had severe IUA and results were favourable in restoration of the cavity in 71% (153) for Protopapas and in
51.6% (140) for Capella-Allouc et al. Pregnancies were achieved in 3/7 (42.9%) women in one study (153), and 12/31 (38.7%) women in the other study (140).
However, further studies are needed before these techniques are widely adopted.
Insertion of physical landmarks
A technique of dissection of an essentially obliterated endometrial cavity has been described whereby the dense adhesions are treated as a uterine septum. This procedure uses laparoscopic guidance due to the high risk of uterine perforation (152).
Cervical dilators are directed from the cervical canal into each of the two ostia, creating two lateral landmarks and leaving a fibrous septum, which is divided transcervically. McComb and Wagner (152) reported results following six women treated with this technique. There were two perforations and severe haemorrhage in another woman. The cavity was restored in all cases and there were five pregnancies achieved by four women, which resulted in four live births. This is a relatively high
60 Chapter 1 Literature review
pregnancy rate, which is encouraging given this group of women had severe IUA, which are difficult to manage. However, the high perforation rate is of concern. As
50% of cases had a significant complication, this technique cannot be recommended.
Fluoroscopic guidance
Fluoroscopic guidance has been described to be of assistance in preventing false passages being made in the myometrium. First described by Broome and
Vancaillie (136), and used in other large centres (44), this technique uses an
intraoperative image intensifier to guide the operator towards pockets of normal
endometrium. Radio opaque contrast media is used to identify pockets of unaffected
cavity and demarcate the myometrial boundary. Injection of radio opaque dye into the
myometrium is visualised as a vascular pattern on the image intensifier. This
technique provides a fluoroscopic view of pockets of endometrium behind an
otherwise blind ending hysteroscopic view.
Ambulatory fluoroscopic guidance
Karande and Gleicher used fluoroscopic control in an outpatient setting to
divide IUA (155). They termed their technique gynaecoradiologic uterine resection
(GUR). A specialised catheter is inserted through the cervix with a balloon attached to
its tip. Radio opaque dye is inserted through a side channel of the catheter to delineate
the cavity with its adhesions. Scissors are introduced through a central channel of the
catheter to divide adhesions.
In 13 cases of IUA, lysis was successful in all nine cases of mild adhesions.
However, in the three cases of moderate adhesions and one case of severe adhesions,
lysis was only partially successful. In cases of moderate to severe IUA, the procedure
61 Chapter 1 Literature review
was prematurely abandoned due to discomfort in one woman, visualisation difficulty
in one woman, and due to thick dense adhesions that were resistant to scissors in the two remaining women. Although a novel procedure using ambulatory care, numbers
are small and success of lysis of IUA is limited to women with mild adhesions only.
There is no published long-term follow up of this group of women.
Ultrasound guidance
Transabdominal ultrasound has been advocated as a technique to guide hysteroscopic division of IUA (52, 143, 153, 156-158). It provides efficient monitoring, guiding the scope towards the uterine cavity when the cavity appears obliterated. The authors report a significant reduction in the risk of perforation (157).
One uncontrolled study reviewed 159 mixed hysteroscopic procedures, comparing standard technique, ultrasound guidance, and laparoscopic guidance. In this review, the perforation rates were 5.2%, 1.5%, and 8.7% respectively, with the number of
women needing treatment to prevent perforation being 15. However, only 58 of these
hysteroscopic procedures were for IUA and the pre-operative assessment of level of
difficulty may have influenced the choice of guidance techniques – a possible
significant confounder to this study (158). In general, the numbers reported in these
studies are small and success depends on the operating skill of the sonographer and
the interpretation of the ultrasound view, which can be difficult due to the mobility of
the uterus during the procedure. Although it is readily available and non invasive, the
ultrasound image may give the hysteroscopist false reassurance without an accurate
view. Therefore, caution must be exercised when using hysteroscopic guidance for
lysis of IUA.
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Intracorporeal ultrasound control has been described by Tiras et al. (159),
whereby an ultrasound probe on the serosal surface of the uterus was able to guide the
surgeon into a safe plane of dissection, with the added benefit of evaluating the
adequacy of dissection. It requires the use of three modalities: hysteroscopy, laparoscopy, and ultrasound. As only one case has been reported, there is insufficient evidence for its use in the lysis of IUA.
Laparoscopic guidance
Laparoscopic guidance remains a controversial topic. Some authors advocate
its use for severe adhesions (60, 146, 152, 153, 158). Laparoscopy has the advantage
of providing directional guidance when the myometrium is unduly thin, with
transmission of light into the peritoneal cavity with a bulge over the serosal layer or a
well focused beam of light (60). This guides the hysteroscopist to cease dissection
within that area. However, perforations have been reported in 17 cases out of 174
(10%) in which laparoscopy was used (8/46, 2/6, 1/46, 0/7, 6/69) (60, 146, 152, 153).
This seemingly high perforation rate is explained in part by laparoscopic guidance
being utilised for the more severe cases of IUA. However, some authors argue that
uterine perforation has usually occurred by the time it is recognised laparoscopically
(52). Reassuringly, where perforation occurs under laparoscopic guidance, immediate
recognition and appropriate treatment ensures that extrauterine trauma is minimised,
and laparoscopic surgical management of a perforation can take place during the
procedure (10).
Another advantage of laparoscopic guidance is that detailed inspection of the
pelvic cavity can also be performed, with treatment of pathologies such as
endometriosis and pelvic adhesions. Complications such as perforation are a relatively
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rare occurrence, only seen in approximately 4.5% of cases of hysteroscopic
adhesiolysis (148). It is likely that perforation would be seen hysteroscopically, allowing laparoscopy to be performed immediately. Laparoscopy carries a significant
morbidity (160, 161) and therefore routine use of laparoscopic guidance is not
recommended for all women undergoing lysis of IUA.
Genital tuberculosis
There have only been a few reported cases of lysis of IUA resulting from
genital tuberculosis. In a study of 12 women, Bukulmez et al. reported three
perforations (20%) during the 15 attempts of hysteroscopic lysis and there was 100%
reformation rate in this group of women (162). Poor prognosis is a feature of this
condition, as highlighted by Parbucu (138) and Preutthipan and Linasmita (22), who
also reported 100% recurrence of adhesion formation following hysteroscopic
adhesiolysis. Therefore, surrogacy may be the only option for infertility patients with
IUA secondary to genital tuberculosis infection (10, 163).
Post-operative assessment
Recurrence of IUA
Recurrence of IUA and incomplete anatomical restoration after first procedure
has been reported in between 16.75% of women with moderate disease and 41.9% of
women with severe disease (164). Therefore, proponents for second look hysteroscopy (44, 129) have recommended cavity assessment within one week following lysis of adhesions (165), either in the operating theatre or by office hysteroscopy (50). Others review the cavity following a withdrawal bleed, after two to three months (102). As asymptomatic adhesions are not truly AS, it is reasonable to
64 Chapter 1 Literature review review surgically only if symptoms ensue (137). However, there is no strong evidence to guide practice either way (81) and even diagnostic hysteroscopy carries some morbidity (110, 148). Therefore a primum non nocere approach appears appropriate given the small, yet appreciable risks associated with hysteroscopic surgery.
Laparotomy and hysterotomy
Overview
Traditionally, laparotomy and hysterotomy was the treatment for severe IUA.
However, in contemporary practice, this technique is rarely used and reserved only for severe cases in which the above mentioned techniques are not practical or possible
(76).
Early techniques
In 1926, Wolff et al. were the first to describe lysis of IUA via laparotomy
(166). Asherman described a technique of blunt dissection of adhesions through the cervix or through the hysterotomy with a curette or finger (6). Netter in 1956 also reported a number of cases in which this technique was used (77).
The results of such surgical techniques were disappointing. Schenker reported four cases of severe IUA treated with anterior hysterotomy and adhesiolysis, only one of whom reported return to normal menstruation. Furthermore, none of these women were able to conceive following treatment. He reviewed the literature and found that of 31 cases treated in this manner, only 52% were able to conceive, with only 38% resulting in live births, eight of which were delivered at term (26%). Of the women who became pregnant, 31% had placenta accreta complicating their pregnancy (36).
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Recent reports
In a more recent series of three cases (167), a surgical procedure was described for lysis of adhesions in severe IUA after previous failed hysteroscopic attempts. Adhesions were divided using the blunt end of a scalpel, after the uterus was transected longitudinally from fundus to internal os. A uterine probe was then inserted cervically and a 2.0 nylon suture threaded from the fimbrial ends of the fallopian tubes, through the tubal ostia, and into the uterine cavity. The nylon thread and cervical probe were used as a guide for the surgeon to identify the boundaries of dissection. Following the dissection, the uterus was closed and a Foley catheter was placed in the cavity to prevent early adhesion reformation. Conjugated oestrogens were used post-operatively. All three women resumed normal menstruation after this surgical technique. At follow up hysteroscopy, all women had reestablishment of their uterine cavity. However, all women had residual scarring of the endometrium, and two of the three cases had mild adhesions, which were divided. Also, no pregnancies have yet been reported after these procedures. Although this technique is promising for cases where there is total obliteration of the cavity and for cases of failed hysteroscopic surgery, the number of patients remains low and there is no long term follow up reported.
Summary of laparotomy and hysterotomy
Laparotomy and hysterotomy may be reserved for lysis of adhesions when there are no landmarks available to the surgeon during the hysteroscopic approach.
The numbers of reported cases are low and the results inconclusive, particularly with regards to fertility and the risks for subsequent pregnancies.
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Ancillary treatment
Overview
Reformation of adhesions is a significant side effect of treatment of IUA.
Rates of adhesion reformation have been reported to be between 3.1% and 23.5% (22,
49), and in cases of severe AS, as high as 20% to 63% (140). Therefore a number of approaches have been suggested to reduce the risk of adhesion reformation.
Intrauterine devices
The insertion of an intrauterine device (IUD) has been proposed to provide a physical barrier between the walls of the endometrium and to reduce adhesion reformation, particularly during the initial healing phase after lysis (36, 51, 107).
Polishik and Kohane (70) were the first to use an IUD, with the Soichet device being used with only partial success in their series. Since that time, a number of studies have been performed utilising various types of IUD, including the “Massouras duck foot”
(168), Y-shaped (36), Lippes loop (51, 60, 169-173), CuT, multiload Cu 375 (45, 47,
150, 157, 173-177), Cu coil (178), and uterine-shaped IUD (179). These IUD were placed after hysteroscopic adhesiolysis and have been advocated in many studies on a number of women (49, 69, 107, 129, 134, 139, 141, 146, 157, 170, 172, 180, 181).
The type of IUD appears to affect the efficacy of the device in inducing menses for amenorrhoeic women. However, there have been no randomised, controlled trials to confirm the usefulness of the exact type and duration course of the IUD for preventing adhesion reformation after hysteroscopic lysis of IUA.
The loop IUD (e.g. Lippes loop) was considered the IUD of choice when treating IUA (10), although it is no longer available in many countries, including
Australia. San Fillipo compared IUD plus hormonal therapy with hormonal therapy
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alone and found no significant difference in reformation of adhesions (182). A
randomised controlled trial of 36 women receiving the Lippes Loop IUD after
hysteroscopic lysis of IUA found the IUD guided subsequent resection of the IUA.
However, there was no statistically significant difference in the adhesion formation
when using the IUD vs. no IUD (51).
In a prospective observational study of 48 women who were treated with a
copper IUD for secondary amenorrhoea, 40/48 (83%) resumed menses after treatment
of IUA with the device (183). The investigators attributed this effect to an
inflammatory reaction by the copper IUD as a consequence of prostaglandin and
enzyme release. Another report concerning the virtues of IUD placement after intrauterine adhesiolysis gave a recurrence rate of adhesions of only 10% (184). In a study comparing the use of IUD, Cook balloon and hyaluronic Acid gel vs. a control, findings indicated a statistically significant reduction in adhesions in the IUD and
balloon group compared to the control group (178).
Conversely, in a randomised controlled trial assessing IUA formation following resection of uterine septum, the study arms where copper containing IUDs
were used showed a higher rate of IUA formation, compared to the control or
oestrogen only scenarios in the post-operative phase (185). Although this effect was
not statistically significant, it gives weight to the argument that a copper containing
IUD is unlikely to prevent adhesion formation. Furthermore, March in his review
(186) concluded that a T shaped IUD may have too small a surface area and that IUDs
containing copper induce an excessive inflammatory response, and therefore are not
advisable in women with IUA. The progestogen impregnated IUD prevents
endometrial proliferation and is thought to contribute to the formation of adhesions.
Therefore this device is generally not recommended (60, 187, 188).
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There is a theoretical risk of infection when an IUD is introduced into the uterus immediately following adhesiolysis, which has been quantified as 8% in one series (49, 170, 175). Urinary tract infection has also been reported in connection with this (170, 174). However, large series show no increase in upper genital tract infection in the absence of cervical symptoms (189). Based on this possible risk of endometritis, some authors advocate the use of antibiotics after adhesiolysis and IUD formation (67). Perforation of the cavity at the time of insertion is the other risk associated with the use of an IUD (10, 49, 174, 177). There is insufficient evidence for the efficacy of an IUD following lysis of IUA.
Balloon catheters
The use of a Foley catheter has been favoured by some authors to act as an intrauterine foreign body providing separation between the walls and acting as a physical barrier to the formation of IUA after surgical lysis of IUA (107, 138, 155,
170, 172, 178). Asherman used a soft catheter following resection of adhesions via laparotomy and anterior hysterotomy, which was left in situ for three days, draining into the vagina, in an attempt to prevent contact between the uterine walls (6). In more contemporary reports, the balloon catheter is placed after hysteroscopic lysis of adhesions and left for several days post-operatively in an effort to reduce the likelihood of adhesion reformation.
Concerns have been expressed by some authors about the use of Foley
catheters leading to cervical incompetence and uterine infection (36). However, this is
not reported in other series.
Orhue et al. compared the use of a paediatric Foley catheter inflated and
placed in the uterus of 59 women for ten days as opposed to a second group of 51
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women, who had three months of IUD placement following adhesiolysis over a four
year period. In the Foley group, 48/59 (81%) had restoration of normal menses
compared to 32/51 (62%) in the IUD group, which was not significant. HSG
investigation showed that reformation of adhesions was significantly lower in the
Foley group. The conception rate after treatment in the Foley group was 20/59 (34%)
compared to 14/51 (28%) in the IUD group. Overall, there was a better rate for return
to menses, higher pregnancy rates with fewer complications, and less sepsis in the
Foley catheter group. The authors concluded that this was a safe and effective
technique for forming a mechanical barrier to stimulate endometrial growth after
adhesiolysis (170).
Another prospectively controlled study investigated Foley catheter placement
after operative hysteroscopy as a preventative for IUA reformation. This study used a
10F Foley catheter inflated with 3.5 mL of saline, with its stem cut above the cervix
and left in situ for one week in 32 women. These women were compared to 18
women without the balloon. Formation of adhesions at diagnostic hysteroscopy was
found in 7/32 (22%) women with the balloon and in 9/18 (50%) without the balloon,
(p = 0.04). In women with IUA, reformation of adhesions after balloon placement was
found in 4/12 (33%) women in the balloon group versus 5/8 (63%) women without the balloon, (p = 0.199) (190). Although the intervention did not reach significance for reduction of IUA after adhesiolysis, the authors concluded that the Foley catheter was effective for prevention of IUA. However, the numbers of this study are small and no long-term follow up of these groups was reported.
More recently, the Cook balloon uterine stent has been placed into the uterus immediately after adhesiolysis. This device has a triangular shape which conforms to the configuration of the normal uterus and maintains separation at the margins of the
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uterine cavity, where adhesion reformation is likely to occur (60). A study of 12 women with severe IUA treated with post resection triangular uterine balloon fitting, followed by post-operative removal and replacement with a copper IUD, reported
100% resumption of menses and 67% pregnancy rate (47). A more recent retrospective study compared the copper coil IUD, to the Cook balloon catheter and hyaluronic acid gel in 28, 20, and 18 women respectively. The study also had a control arm of 41 women. This study found that the balloon and IUD arms had statistically significant results of fewer adhesions forming post-operatively compared to the hyaluronic acid and control groups. The study also found that the balloon group
had statistically significant lower adhesion scores than the IUD group (178). There
was no information about clinically relevant outcomes such as menstruation, fertility,
and pregnancy rates, although these results do show promise.
Consensus on IUD and balloon catheters
The use of post-operative IUD and catheters are not universally endorsed (36,
102) and some authors believe that they may in fact do more harm than good (60,
191). The IUD string and the stem of the Foley catheter carry a theoretical risk of ascending infection from the vagina. Orhue et al. found a higher risk of infection in the IUD group, when comparing IUD to Foley catheter. Both techniques involve a foreign body placed in an immediate post-operative site (170). Randomised controlled data showed a reduction in post-operative adhesion formation but no long term data on symptoms of pregnancy have been reported. The over distended balloon of the
Foley catheter increases pressure on the uterine walls, which may result in decreased perfusion, affecting endometrial regeneration. This technique can also cause some
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discomfort for the patient (10). Finally, the optimum timing for the IUD or catheter removal is not consistent amongst published studies (178).
Amnion grafts
Novel techniques such as Amnion grafts have been used to prevent IUA after hysteroscopic lysis. In an early study of 25 women with moderate to severe AS,
hysteroscopic adhesiolysis was followed by a fresh amnion graft placed over an
inflated Foley catheter balloon and left in the uterine cavity for two weeks. Repeat hysteroscopy showed adhesion reformation in 48% of women with severe adhesions.
However, all of these reformed adhesions were minimal (192). A more recent, well-
designed, randomised controlled study compared fresh amnion, dried amnion, and
intrauterine balloon alone in women with severe IUA. This study found adhesion
grades were significantly reduced in the amnion graft group vs. the balloon group,
with a trend towards better outcomes for fresh grafts. There was twice the pregnancy
rate in the amnion graft group, but this did not reach statistical significance (95). It is postulated that human amnion epithelial cells produce factors for tissue regeneration and repair by stimulating endogenous stem cells (192), as well as antibacterial and antiviral properties (193). However, no long-term data reporting reproductive outcomes is available for this technique.
Oral mucosal epithelial sheets
In a recent rodent study, oral mucosa placed into the uterus has been investigated following trauma to the endometrium. In the transplanted group, there were no adhesions, compared to marked IUA in the control group using hysterogram and micro-CT imaging (194). These investigations propose insight into the
72 Chapter 1 Literature review mechanism behind the development of IUA, with statistically significant reduction in the neutrophil count and inflammatory markers during the early phases of endometrial healing in the transplant arm (194). Although this preliminary animal model is promising, human studies have not yet been published to date.
Hormonal treatment
Wood and Pena first used oestrogen therapy to stimulate the regeneration of the endometrium and promote re-epithelisation of the endometrium following surgical treatment (195). Early observation of rapid endometrial growth was made in a woman with IUA (36).
Oestrogen has been described in the pre-operative and post-operative uterus to enhance endometrial proliferation (47). However, most studies describe use in the post-operative period to promote re-epithelialisation of the endometrium in an effort to form a functional separation of the uterine walls.
In the pre-operative phase, the use of oestrogen therapy is controversial.
Romer stated that there were no benefits of pre-operative oestrogen therapy (196).
However, others have opposed this opinion and endorsed its use to stimulate the endometrium (102, 197) and it has also been reported for use in the treatment of severe IUA (47). The difficulty with using oestrogen pre-operatively is the impact this has on the visualisation of the endometrial cavity during hysteroscopy, making the surgery more challenging for the operator (198).
In post-operative treatment, it has been postulated that oestrogen is required to stimulate the endometrial regeneration and epithelialise the denuded layer prior to the formation of fibroblast adhesions, which is supported by the American Association of
Gynecological Laparoscopists (AAGL) practice guideline for IUA to reduce the
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recurrence of adhesion formation (199). Certainly the endometrium was thicker and
spiral artery resistive index lower in one study investigating post-operative oestrogen
therapy in women with IUA (116).
One randomised controlled study focused on 60 women following dilation and
curettage during their first trimester of pregnancy, who received post-operative
oestrogen and progestin therapy. This study found a statistically significant greater
endometrial thickness (0.84 cm vs. 0.67 cm) and endometrial volume (3.85 cm3 vs.
1.97 cm3) in these woman compared to a control group (200). The authors concluded
that oestrogen and progestin therapy increase endometrial thickness and volume.
Although these are encouraging and biologically plausible results, there are no
randomised controlled trials to confirm the efficacy of hormonal treatment on the
reduction or reformation of IUA, or on pregnancy outcomes, and papers are
confounded by varying surgical techniques, other adjuvant use, and differences in
severity of adhesions, making comparison and true assessment of the effect of
oestrogen a difficult undertaking (198). Despite this, oestrogen is widely used as a post-operative treatment to stimulate the endometrial lining to proliferate following the fresh excision of adhesions (76).
Varying regimes have been identified including sequential treatment, with or without progestin, for two to three cycles. A typical regime is 2.5 mg conjugated equine oestrogen daily for 30 days, given with medroxyprogesterone acetate during the last 10 days (67).
The side effects of oestrogen treatment include nausea. In high doses, oestrogen treatment may lead to serious events such as thrombo-embolism, although there have not been any reported serious adverse events from oestrogen use following surgery for IUA. The most common regimes are low dose oestrogen for a short time
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interval, which is unlikely to cause significant side effects. The added benefit of
progestogens is uncertain at this time.
Antibiotics
As some authors suggest chronic subclinical infection as a predisposing factor for adhesion formation, antibiotic administration has been recommended by some authors before, during and after treatment (68). In his original work, Asherman recommended the use of an antibiotic (penicillin) soaked gauze being placed into the uterine cavity. Although the use of routine prophylactic antibiotics is advocated by some (13, 201-203), this practice is not currently universally recommended (36, 67).
There is a theoretic risk of infection secondary to instrumentation of the uterus. Such infection may contribute to reformation of adhesions and therefore in practice, many women receive pre-operative or an intra-operative dose of intravenous
antibiotics. Tuberculous endometritis is a specific condition, which should be treated
with antibiotics prior to surgery, and with combination drug therapy for at least nine
months after diagnosis (67).
Adhesion barriers
Modified hyaluronic acid (HA) has been used as a barrier to adhesion
formation and has been studied by several investigators (8, 178, 179, 204, 205). HA is
a natural component of the extracellular matrix and has been proposed as a barrier
agent to prevent adhesion formation after abdominal or pelvic surgery (206). The anti-
adhesive effects of HA depend on the preparation’s molecular weight and
concentration (207). Modified HA products include SeprafilmTM (Genzyme
Corporation, Cambridge MA) and auto-cross-linked HA (ACP) gel (Hyalobarrier gel;
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Baxter, Pisa Italy). Both have been investigated as a means of reducing IUA after
hysteroscopic synaechiolysis (208).
SeprafilmTM is a bio-absorbable membrane made from chemically modified
HA and carboxylmethyl cellulose. SeprafilmTM has been shown to reduce IUA in a
prospective single blinded randomised controlled trial of 150 women, who underwent
suction curettage after incomplete, missed or recurrent miscarriage (8). There were no
reported adverse reactions using SeprafilmTM in the endometrial cavity and ultrasound did not show any abnormalities during the follow up of these women. In this study there was no declaration of funding stated and authors did not declare any conflict of interest in reporting these findings (8).
Auto-cross-linked hyaluronic acid gel (ACP) appears to be particularly suitable for preventing IUA because of a higher sensitivity and prolonged residency time on the injured surface, compared to unmodified HA (209). Acunzo et al. studied
84 women with AS in a prospective randomised controlled trial, comparing ACP gel
(Hyalobarrier gel; Baxter) with no treatment, following lysis of IUA (204).
Although some of these trials yield promising results (8, 179, 204, 205), their numbers were small and these encouraging results have not been replicated in other studies (178, 210). More data is required before the use of these adhesion barriers is adopted in routine practice. See Chapter 3 of this thesis for more details on this subject.
Techniques to increase vascular flow to endometrium
Case reports have described various techniques designed to increase vascular perfusion to the endometrium, using asprin, nitroglycerin, and sildenafil citrate (211-
215). Although pregnancies have been reported with these techniques (215), further
76 Chapter 1 Literature review research is required to accurately assess the effect of these treatments ancillary to endometrial development following lysis of IUA.
Stem cells
Stem cell technology is gaining momentum in all areas of medical science and the uterus is no exception. The first evidence of the existence of adult stem cells in human endometrium was the demonstration of small populations of colony-forming unit (CFU) activity. This indicates a capacity for self renewal, differentiation and proliferation (216).
Transplants of fully dissociated, unfractionated, human endometrial epithelial and stromal cell suspensions have been placed directly beneath the kidney capsule in mice undergoing bilateral oophorectomy and oestrogen supplementation. This stem cell population reconstructed human endometrium and responded to cyclical sex steroid hormone replacement, forming glands, and decidualised stroma, with large blood filled cysts following hormonal withdrawal (216).
Subsequent reconstruction of epithelial and stromal cells was also shown in mice (217). In a recent rodent model investigating stem cell therapy in AS mesenchymal stem cells derived from adipose tissues of two male rats were placed into the uterine cavity and subsequently thrice into the peritoneal cavity at five day intervals. The arms of the study included stem cell alone, ostrogen alone, and stem cells plus oestrogen vs. control. The animals treated with stem cells had less fibrosis of the endometrium, less inflammation, and better vascular proliferation when compared to controls (218).
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In humans, autologous CD40 and CD90 bone marrow cells have been instilled into the uterus on day two of the cycle after curettage for a patient with AS with thin dysfunctional endometrium, who failed to respond to oestrogen. High doses of oestrogen were administered during four artificial cycles and IVF, and a clinical pregnancy was achieved after embryo transfer (219). Other reports of bone marrow derived stem cells show a potential application to the endometrium (220). A further case report described some success with direct placement of non characterised mononuclear stem cells into the subendometrial zone with a needle (221). Most recently, a human study using autologous cell therapy with CD133+ bone marrow derived stem cells has shown encouraging results in humans with AS and endometrial atrophy (222). The stem cells were derived from peripheral blood of each treated woman and were injected into their spiral arterioles through the femoral route.
Despite these women being refractory to treatment by other modalities, such as surgery and hormone therapy, three of the sixteen women became pregnant spontaneously, and a subsequent seven pregnancies followed using assisted reproductive technologies (ART). Two live births have been reported thus far. Other long-term pregnancy outcomes are pending.
The ability to reconstruct human endometrial cells in vivo suggests a potential use of stem cells therapy for treating endometrial sclerosis, atrophy and IUA.
However, cases are few and safety data has not yet been established.
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Prevention
Primary prevention
To prevent IUA, it is imperative that trauma to the uterus be minimised or
avoided. This is especially the case in the highly predisposed pregnant or postpartum state. The following principals may reduce the likelihood of IUA:
a) From a public health perspective, contraceptive advice and access is
paramount to prevent unwanted pregnancies and the need for induced
abortion.
b) Correct diagnosis of retained products of conception (RPOC) is important
when assessing persistent bleeding following delivery and miscarriage.
Saline infused sonohysterography enhances the efficacy of ultrasound to
investigate RPOC (223). Colour velocity imaging and pulsed Doppler will
also help to distinguish retained trophoblastic tissue from residual blood clots
(224). Using these additional techniques, one may be able to select women
who may be suitable for conservative management, thereby reducing the
need for unnecessary instrumentation of the uterus.
c) Expectant management of miscarriage is as effective and acceptable to
patients as surgical evacuation of the uterus (225) and should be considered a
the first line treatment where possible.
d) Medical management of miscarriage should also be used where possible (7,
10). In a large, multicentre, randomised controlled trial supported by the
World Health Organisation (WHO), which compared intramuscular
prostaglandin E2 (PGE2) with vacuum evacuation for management of
miscarriage, the frequency of complete miscarriage was 91% in the PGE2
group, compared to 94% in the vacuum curettage group (226). In a long term
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follow up, excellent pregnancy rates were reported following non-surgical
management of miscarriage (227).
e) Medical management of therapeutic termination of pregnancy is increasing in
many countries with the introduction of the anti-progestin abortifacient
medication (mifepristone) in combination with a prostaglandin E1 analogue,
with high efficacy and low complication rates (228, 229).
f) Hysteroscopy is considered an effective method for diagnosis and treatment
of RPOC. By using an operative hysteroscope with a cutting loop as a
curette, adherent retained tissue may be removed thereby avoiding
interference with the rest of the endometrial lining, and may be preferable to
conventional blind curettage (139). It has been shown to be a superior
technique for the management of residual trophoblastic tissue compared to
ultrasound-guided curettage (230). This is a technique that may be adopted
for particular high risk clinical situations such as RPOC postpartum or when
repeat curettage is necessary. The AAGL have published guidelines for
prevention of IUA (231) which recommend this approach.
g) Postpartum curettage should be avoided where possible. Some authors
advocate close inspection of the placenta postpartum to ensure that it is
complete. If there is suspicion of retention of placental tissue, uterine
examination should be performed as this time when there is a lower risk of
development of IUA, avoiding the critical time of one to four weeks
postpartum, where IUA are more likely to occur (36).
h) If surgical curettage is necessary then this should be performed gently with a
suction catheter or blunt curettage, rather then a sharp instrument (45)
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i) Hysteroscopy and targeted removal of products to avoid excessive trauma to
the endometrial lining should be considered (139).
j) Increasing concerns about the formation of IUA as a result of hysteroscopic
myomectomy and uterine septum resection has prompted early intervention
to be proposed by some authors. Such intervention includes early
hysteroscopy to distend the endometrial cavity and prevent fibroplasia,
following myoma resection (232), or following lysis of IUA to maintain
patency of the uterine cavity (50, 165).
k) The use of electrical current is controversial in its contribution to the
pathogenesis to IUA. However, some authors recommend cold loop resection
(84) and avoidance of excessive use of current with the associated thermal
spread in patients where ongoing fertility may be a concern.
Secondary prevention
The use of ancillary techniques as detailed above may reduce the reformation
of adhesions. However, all of the studies have only examined primary prevention as an outcome measure. Hormonal therapy, antibiotics, adhesion barriers and mechanical
methods such as IUD or balloon catheter may also prevent reformation of IUA. There
is no definitive evidence to support any of these measures. Therefore clinicians should
consider all cases individually and make an individual assessment as to the best
means of preventing reformation of IUA.
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Outcomes of treatment
The outcomes of treatment will be considered in more detail in Chapter 2.
However, a summary is provided below.
Anatomical restoration
Surgical success can be judged by the restoration of normal anatomy of the uterine cavity. Women should be warned that they may require multiple procedures before an adequate size and shape of cavity can be achieved (67, 137). Some authors advocate repeat hysteroscopy to assess surgical success, and the combined rate of anatomical restoration reported amongst these centres is 640/815 (78.5%, range 44 –
93) (11, 44, 76, 233). However, the rate is lower for the more severe adhesions, with rates of anatomical restoration reported as only 31/71 (44%) in women with Grade 3 and 4 AS (233). However, even with restoration of the cavity, the function of the endometrium may not be fully restored and fibrosis will have a significant impact on the reproductive capacity of the uterine cavity. Therefore anatomical and functional results need to be considered when assessing the success of a therapeutic procedure.
Menses
Resumption of normal menses is cited as a surrogate measure for endometrial function, and more centres rely upon and report clinical outcomes as a measure of surgical success. When compiling the results of 24 studies of mixed severity of IUA, a rate of improvement of menstruation was 1668/2513 (66.4%) (39, 44, 45, 47, 50, 53,
54, 67, 116, 133, 137, 140, 143, 150, 151, 153, 172, 174-176, 192, 233, 234).
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Fertility
To date, pregnancy data have been reported in 53 studies after hysteroscopic lysis of IUA (see Table 2.13). In the subset of women who wished to conceive in these studies, the combined pregnancy rate was 2393/3907 (61%), the miscarriage rate of the women who did conceive was 363/2393 (16%), and the live birth rate of those who achieved pregnancy was 1826/2393 (76%). This is outlined in more detail in the discussion section of Chapter 2 of this thesis.
The chance of pregnancy appears to be influenced by the severity of the IUA in an inverse relationship. Thomson (137), Yu (45), and Roy (176) showed that the conception rates in women with IUA differ according to the severity of adhesion.
Their results had the following conception rates respectively:
• 66%, 64.7%, and 58% for mild adhesions;
• 43%, 53.6%, and 30% for moderate adhesions; and
• 57%, 32.5%, and 33.3% for severe adhesions.
Live births also appear to follow the same pattern. In some studies, women with severe adhesions were unable to conceive (51, 116, 176, 235, 236). For women with recurrent miscarriage, the pregnancy rate has been reported as 121/135 (90%) and the live birth rate as 104/135 (77%) after treatment (10).
83 Chapter 2 Reproductive outcomes
Chapter 2: Gynaecological and reproductive outcomes following surgery for Asherman syndrome
Background
The presenting symptoms of Asherman syndrome (AS) include menstrual disturbance, pain, altered fertility, recurrent pregnancy loss, and obstetric complications. Medical signs include the presence of synaechia during investigation via imaging or hysteroscopy. Large-scale retrospective studies report menstrual restoration and anatomic results as generally favourable after surgery for intrauterine adhesions (IUA). The aim of surgery is restoration of the uterine cavity with both ostia clearly visualised at the end of the procedure. Repeat surgery is either performed routinely to assess the cavity, or based upon menstrual symptoms. In a recent, large ten year retrospective study, Hanstede et al. reported resumption of menstruation in
98% of their 638 cases (44). However, 126/638 (20%) required repeat surgery to restore the uterine cavity, and re-formation of IUA occurred in 174/606 (29% of women). Increasing grade of disease is associated with poorer surgical outcomes (76,
133).
Reproductive function following surgery is generally poorer than surgical outcomes. The limited success of any kind of treatment is related to deficiency in the residual endometrium and fibrosis in the myometrium, which might decrease the vascular flow of steroids to the endometrial tissue (41), or alter the endometrial
84 Chapter 2 Reproductive outcomes biochemical milieu, affecting implantation. Hence restoration of a normal uterine cavity and regular menstruation is not always followed by normal endometrial receptivity and fertility. The largest retrospective series recently tabulated within a review paper purported a clinical pregnancy rate of 761/1240 (62%) and a live birth rate of 674/1240 (54%) (60). Historical series describe a correlation between the extent of uterine adhesions and subsequent term pregnancy rates at 81% correlation for women with mild disease, 66% for those with moderate disease, and only 32% for women with severe IUA (49).
In this chapter, the symptoms and signs of AS are investigated before and after surgery for IUA. Surgical outcomes, including anatomic success of the procedure, number of procedures, and complication rates are investigated. Post surgical symptoms including pain, menstruation, fertility, pregnancy, and obstetric outcomes are explored through a 3-15 year follow up of women with AS in a tertiary referral hospital campus.
Overview
The research questions are as follows:
1. What are the menstrual outcomes before and after fluoroscopically guided
synaechiolysis for women with AS?
2. What are the reproductive outcomes before and after fluoroscopically
guided synaechiolysis for women with AS?
3. What are the obstetric outcomes before and after fluoroscopically guided
synaechiolysis for women with AS?
4. What are the neonatal outcomes following pregnancy in women with AS?
85 Chapter 2 Reproductive outcomes
The primary objectives are as follows:
1. To compare overall gynaecological symptoms following fluoroscopically
guided synaechiolysis and to compare them to symptoms before surgery.
2. To review fertility rates (pregnancy, miscarriage rates and live birth rates)
in women having fluoroscopically guided synaechiolysis.
3. To review maternal obstetric outcomes in women who have had
fluoroscopically guided synaechiolysis.
4. To review neonatal outcomes in babies born following fluoroscopically
guided synaechiolysis.
5. To assess the time to pregnancy in women who have had fluoroscopically
guided synaechiolysis for AS.
86 Chapter 2 Reproductive outcomes
Methods
Approval for the study was obtained from the NSW Government, South Eastern
Sydney Local Health District (HREC No. 07/207). The ethics letter is included as
Appendix A.
Inclusion criteria:
To be considered for entry into the study, women had to fulfil the following criteria:
1. Has suspected or proven IUA based on hysteroscopic assessment
2. Has undergone fluoroscopically guided synaechiolysis for AS between
January 1 2000 and 30 June 2014 at The Royal Hospital for Women or
Prince of Wales Private Hospital.
3. Is English speaking or has adequate interpreter available
4. Was between the ages of 18–51 years at the time of surgery
5. Is capable of providing informed consent
Exclusion criteria:
Women were excluded from the study if any of the following criteria were encountered:
1. Suspected diagnosis of gynaecological malignancy or its precursors.
2. Post menopausal
3. Pre-existing condition of tuberculosis
4. No hysteroscopic confirmation of IUA at the time of index surgery
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Previous medical or surgical treatment for IUA was not a contra-indication to entry into the study.
Women were recruited from either the outpatient department of the Royal
Hospital for Women, or the private consulting rooms of Associate Professor
Thierry Vancaillie (TVC), or Associate Professor Jason Abbott (JA). Women
were referred from three areas to the clinic or rooms:
1. general practitioners from the immediate local area;
2. other specialist gynaecologists from within the hospital; or
3. tertiary referrals from outside the hospital area.
As these surgeons were known to have some expertise in the surgical division of IUA, the surgeons were referred a number of women who had failed treatment elsewhere.
At the time of admission, each women had a full history and physical examination completed by a resident medical officer, not involved with the study.
Surgery was undertaken by one of seven surgeons: two consultant gynaecologists
(TVC and JA) and five fellows training in minimal access surgery, using a standardised technique previously described (136) by all seven surgeons. The senior consultant was present at all procedures to ensure standardisation as set out below:
. A 4 mm 30° diagnostic hysteroscope (Stortz, Tuttlingen Germany) in a
5 mm sheath was introduced into the cervical canal and distension
obtained using 1.5% glycine (Baxter Medical, Melbourne Australia).
. Mild adhesions were simply divided by fluid distension of the cavity, or
blunt dissection with the tip of the hysteroscope.
. For moderate to severe adhesions, the intraoperative image intensifier
(Phillips BV 25, CD 145 Compact Video Imager; Medical Systems Best,
88 Chapter 2 Reproductive outcomes
Eindhoven, The Netherlands) was then positioned over the pelvis so that
the hysteroscope was seen at the inferior margin of the field of view.
. An 18 gauge, 80 mm Tuohy needle (Portex Ltd., Hythe Kent, England)
was introduced in parallel with the hysteroscope, in view of the operator.
Radio opaque dye (ultravist 76.9%; Iopromide; Schering AG,
Pharmaceutical Division, Berlin Germany) was injected at intervals
through the needle while the surgeon probed behind the adhesion under
fluoroscopic control.
Figure 2.1 – Tuohy needle with a bevelled edge attached to radio opaque dye
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Figure 2.2 – Hysteroscopy introduced with Tuohy needle in parallel
. If the needle was within an adhesion, free flow of contrast away from the
needle tip would not be seen; if it was in a pocket of normal
endometrium, there would be free flow, and a radio opaque pocket. If
contrast flowed through the fallopian tubes, this confirmed the location of
the needle tip in the endometrial cavity. If the needle tip was buried in the
myometrium, it would show a vascular pattern of the venous plexus.
Under the guidance of the image intensifier and hysteroscopy, areas of
normal endometrium were sought, and fibrous adhesions lysed by
sweeping the needle or with the aid of hysteroscopic scissors.
. This process was repeated until the normal anatomy of the uterine cavity
was restored. The technique has the added benefit of assessing tubal
patency.
90 Chapter 2 Reproductive outcomes
. The procedure was abandoned after 60 minutes or if there was positive
fluid balance of greater than one litre.
. If an adhesion barrier was being utilised, SeprafilmTM (Genzyme
Corporation, Cambridge, MA) was inserted into the cavity after
synaechiolysis. The sheet was sliced into 1-2 x 3-4 mm strips and drawn
up into a syringe of 10 mL of sterile water. The cervix was then
cannulated and the solution instilled into the uterine cavity by slow push
of the solution from the 10 mL syringe into the uterine cavity as a slurry.
. Photographs were taken intermittently during the procedure
hysteroscopically and via the image intensifier. These images were
printed or uploaded onto an external electronic device.
Figure 2.3 – Radiographic image of the uterus where the radio opaque dye has entered the vasculature
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Figure 2.4 – Radiographic image showing radio opaque dye injected into the endometrial cavity, showing an anatomically restored endometrial cavity
During the hysteroscopic adhesiolysis, the ESH grade (108), location, extent, and type of adhesions would be recorded. Any complications (e.g. uterine perforation or haemorrhage) were also noted in the operative report and medical records. The
ESH grade was used throughout the entire series, as this was the classification system by which the first cases were graded in the historical cohort. As there is no identified superior classification system, the aim was to maintain consistency across the entirety of women in the study.
Following surgery, all women left the operating theatre with intravenous fluids and were taken to recovery. Once they had completed their initial post-operative recovery, the patients were moved to the day surgery waiting room. Here the surgeon would meet the patient and explain the operative findings.
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The operative notes were kept with the patient. These notes recorded the following:
The ESH grading (108) as described earlier in Chapter 1
Any other intra operative findings
The surgery that was undertaken
Post-operative directions for the patients
Women recovered for two to three hours, until they could eat, drink, mobilise and void. As routine, women took a post-operative course of oral oestradiol (2.5 mg daily, for three weeks) to stimulate recovery of the endometrium. Women were also prescribed antibiotics (doxycyline for 100 mg twice / day for 10 days) prophylactically.
Study participants were seen post-operatively in the outpatients’ clinic or the private consulting rooms, where the surgery and symptoms were discussed. The first appointment occurred between four to six weeks following adhesiolysis. Women were asked about their symptoms to assess the success of the procedure. If there were ongoing symptoms, a second post-operative visit was planned to occur three months after their surgery.
Women who reported ongoing symptoms underwent a second-look hysteroscopy to check for recurrence of adhesions. Repeat hysteroscopy and repeat adhesiolysis were routine practice for women who report ongoing symptoms after initial adhesiolysis. The extent and location of subsequent adhesions were documented in the operative record. Any adhesions that were identified were resected intraoperatively. Women then returned for a subsequent post-operative visit. Surgical complications were recorded at the post-operative visit or at any time in the post- operative period. If the patient experienced recurrent symptoms or had no pregnancy
93 Chapter 2 Reproductive outcomes in the three to six months following surgery when attempting conception, a repeat hysteroscopy was performed to review the cavity for recurrent IUA.
Statistics
As this is a descriptive study, the sample size was not pre calculated, and was determined by the number of patients available from the database having had surgery for AS from January 2000 – June 2014. SPSS 22.0 statistical software was used to analyse the clinical data. Descriptive analysis was performed, including frequency of each variable and prevalence. Data were checked for normal distribution and compared to independent t test or analysis of variance. Data that was not normally distributed were compared with non-parametric tests. Contingency table analysis was used for comparison of categorical variables. Association of dichotomous measures between the groups were assessed by utilising the Pearson chi-square test and Fisher's exact test for an expected count in each cell of less than five. Comparisons of continuous variables were undertaken using a student t-test unless otherwise indicated. Time to pregnancy was analysed and recorded using an inverse Kaplan-
Meier estimate to measure the fraction of women still not pregnant after a certain amount of time following treatment. The time starts from a defined point (date of surgery) to the occurrence of pregnancy, and 50 months is considered the final time point. Losses to follow up were assumed to be non-pregnant (excluding censored observations). For women who reported pregnancy, but the time to pregnancy was unknown, the maximum of 50 months was assumed. A p value of <0.05 was considered as statistically significant.
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Results
The results with respect to the clinical evaluations in this chapter are presented in the following sections:
Demographics
Association of IUA with antecedent event
Questionnaire
Symptom outcomes
Fertility outcomes
Obstetric outcomes
176 women were identified from the hospital patient database. Medical records and contact details were unable to be found for four women. There were also three women in the database who were recorded twice under different names, such as a maiden and married surname. Figure 2.5 below summarises recruitment and losses to follow up.
Figure 2.5 – Patient disposition following database identification
No notes / medical records (4) Repeated names (3) Women excluded from study: (6) –>51 years (3) Unique women (169) –No IUA on hysteroscopy (2) –No uterine fundus (1)
Met inclusion criteria (163) Identifed from Lost to follow up (9) database (176) Women with some obstetric information in questionnaire or notes (154) Did not answer questionnaire (23)
Responded to at least 1 questionnaire (131)
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The medical records of the 169 remaining women were reviewed to confirm treatment of IUA and that the women met inclusion criteria. Six women were excluded from analysis. Three of the excluded women were found to be post menopausal or greater than 51 years of age. One of these post-menopausal women had received treatment of a rectal cancer, with IUA secondary to pelvic radiotherapy.
A further two women were excluded as while they were investigated for AS, at hysteroscopy no IUA were found. Both of these women were investigated for infertility after HSG was suggestive of IUA. The final woman excluded from the study was found to have no uterine fundus. This was due to a partial hysterectomy having previously been performed in another country without her consent. This woman had been unaware of her prior surgery.
In the remaining 163 women, information was collected including date of birth, date of first procedure, stage of AS, presenting symptoms, previous treatments, past medical history, number of procedures, complications of treatment, and post- operative outcomes.
Having met the entry criteria, a letter was sent to the 163 women informing them of the study and inviting them to participate. Women were informed that their medical care would not be compromised if they did not take part, or respond to the questionnaire, or if they withdrew from the study at any time.
The questionnaire asked women to provide demographic data, gravidity and parity, gynaecologic and menstrual history, symptoms of pain, fertility history including time taken to conceive following treatment, and infertility treatments (see patient letter in Appendix B). Women were asked to recall their symptoms pre treatment, post treatment, and presently. They were asked about pregnancies and deliveries after treatment, and any obstetric complications that they may have
96 Chapter 2 Reproductive outcomes encountered. Finally they were asked to comment on their satisfaction with the procedure.
After the initial mail out of 163 questionnaires, 38 women responded immediately. A second questionnaire was mailed out with a reminder letter. An email was also sent to women who had given their email addresses, with the questionnaire attached. This increased the response rate to a total of 70 women. The remaining 93 women were contacted with a courtesy phone call, reiterating that they were not obliged to participate. Three subsequent phone calls and questionnaire contacts were made to update the database during the follow-up period of up to fifteen years, achieving an additional 61 participants. Nine women were lost to follow up, reducing the possible sample size from 163 to 154. In total, 131/154 women responded to at least one questionnaire (85%). For the remaining 23 women (15%), information was ascertained from the medical records where it was available. If contact had been made by the woman to inform the clinic about pregnancy or delivery, this was included in the medical records and incorporated into the database. Letters from treating obstetricians were reviewed to assess whether obstetric and gynaecological information could be gathered from this source. Finally, referring doctors were contacted to assess whether women had sought fertility services or become pregnant after discharge from the gynaecological service. Information was gathered on 154 women who were included in the final dataset.
97 Chapter 2 Reproductive outcomes
Demographics
Age and past obstetric history
Women were asked about their past obstetric history. Their medical records were reviewed for demographic data and information relating to their past medical history.
Table 2.1 – Demographic overview of cohort
Age:
Age (years), (n=154) mean (SD) 35.7 (5.0)
Range 19 – 51
Previous pregnancies:
Gravidity (n=142) median (range) 5 (0-10)
Parity (n=91) median (range) 1 (0-3)
Early pregnancy loss: miscarriage (n=82)
median (range) 2 (1-3)
Mode of delivery: Vaginal delivery (n=60)
median (range) 1 (1-4) Caesarean delivery (n=31) median (range) 1 (1-2)
Postpartum history: ERPC for RPOC postpartum (n=43) median (range) 1 (1-2)
Repeated ERPC for RPOC (n=5) median (range) 1 (1-2)
N.B. information available for number of women in parenthesis in first column ERPC = evacuation of retained products of conception RPOC = retained products of conception
98 Chapter 2 Reproductive outcomes
The median age of the surveyed woman at the time of their surgery was 36 years. Hence, a large number of the women in the cohort were of advanced maternal age upon entry into the study. Table 2.2 and 2.3 outline the gravidity and parity of the group. The majority of the cohort had been pregnant at least once before, with only five having developed IUA in the non-pregnant uterus. Gravida one, two or three accounted for 75% of the sample in relatively equal proportions. Despite the high gravidity, most women (38%) had never had a pregnancy beyond 20 weeks gestation.
Overall, 119/154 women (77.3%) stated that they hoped to conceive prior to surgery.
Table 2.2 – Gravidity of cohort
Gravidity Number (%)
0 6 (3.9) 1 42 (27.3) 2 40 (26.0) 3 37 (24.0) 4 7 (4.5) 5 9 (5.8) 6 4 (2.6) 7 1 (0.6) 9 1 (0.6) 10 1 (0.6) Unknown 6 (3.9) Total 154 (100.0)
Table 2.3 – Parity of cohort
Parity Number (%)
0 59 (38.3) 1 43 (27.9)
2 35 (22.7) 3 13 (8.4) Unknown 4 (2.6) Total 154 (100.0)
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Grade of Asherman syndrome
At initial surgery, the ESG grading of AS was noted on the operation record.
In 154 cases, the grade of AS was recorded on the operative notes. In three cases it was unknown or not recorded. The grading method used was a simplified ESG classification (see Chapter 1). The subgroups for IIa, IIIa and IIIb were not always distinguished in the records. Instead for analysis, classification was only divided into
Grade I, II, III and IV. The majority of women had Grade II or III adhesions, as shown in Figure 2.6. This is representative of the population base being referred to the two senior gynaecologists who performed the majority of the procedures while working at a tertiary referral unit.
Figure 2.6 – Grade of Asherman syndrome
Asherman Grade n=154
Grade 1, 32 (20.8%)
Grade 2, 52 (33.8%)
Grade 3 41 (26.6%)
Grade 4, 26 (16.9%)
Unknown / not recorded, 3 (1.9%)
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Cause of AS
Where the initiating event that preceded AS was known, it was recorded.
There were 10 (6%) women who reported developing AS following intervention to a non-pregnant uterus: 6/10 from dilation and curettage in a non-pregnant uterus, 2/10 from cone biopsy and curettage for pre malignant or malignant disease of the cervix, and 2/10 following hysteroscopic myomectomy. In a separate five women, the cause of IUA was unknown or not recorded. Table 2.4 overviews the causes of IUA in the cohort.
Table 2.4 – Cause of intrauterine adhesions
Cause of IUA Number %
Curettage post miscarriage 71 46.1 Curettage post delivery once 43 27.9 Curettage post delivery twice 5 3.2 Caesarean delivery 9 5.8 Curettage post termination of pregnancy 7 4.5 Curettage whilst not pregnant 6 3.9 Curettage at ectopic pregnancy 2 1.3 Following cone biopsy for cancer 2 1.3 Following hysteroscopic myomectomy 2 1.3 Curettage for molar pregnancy 1 0.6 Curettage post second trimester miscarriage 1 0.6 Unknown 5 3.2
Total 154 100
Of the 139 cases of AS that were pregnancy related, 81/139 (58.3%) were due to curettage during the first trimester following miscarriage, termination of pregnancy, ectopic and molar pregnancy. One case of AS – 1/139 (0.7%) – occurred during the second trimester, and no cases were reported to have occurred during the third trimester. Intrapartum causes were implicated in 9/139 women (6.5%) and
101 Chapter 2 Reproductive outcomes postpartum causes accounted for 48/139 (34.5%) of these cases. Of these 48 cases,
43/139 (30.9%) cases were reported after single curettage during the postpartum period, and 5/139 (3.6%) women reported AS following multiple postpartum curettage procedures for retained products of conception (RPOC).
Other relevant past medical history
Eight women reported previous uterine surgery. Of these eight, three had had hysteroscopic surgery, including septoplasty and myomectomy, and a further five had had other uterine surgery, including laparoscopic or open myomectomy. It was uncertain from the medical records if the myomectomies were full thickness excision of the fibroids. It was also unclear whether there had been penetration of the endometrium during surgery.
Intervention
The median number of hysteroscopic synaechiolysis procedures performed for women was one (range one to six). In 114 (74%) women, no adhesion barrier was used and in 40 (26%) of the cases, SeprafilmTM (Genzyme Corporation, Cambridge,
MA) was infused into the endometrial cavity following resection of the IUA as a slurry. The effect of the adhesion barrier is assessed in more detail in Chapter 3 of this thesis.
The number of procedures required for treatment of IUA is illustrated in
Figure 2.7. Only one procedure was required in the majority of women – 87/154
(56.5%). For other women, two procedures were required, which occurred for 44/154
(28.6%) women; three procedures were required for 12/154 (7.8%) women; four procedures were required for 8/154 (5.2%) of the women; five procedures were
102 Chapter 2 Reproductive outcomes required for 2/154 (1.3%) of the women; and one woman required six procedures to treat IUA.
Figure 2.7 – Number of hysteroscopic synaechiolysis procedures required per patient to treat their IUA for the 154 women in the cohort
Hysteroscopic synechiolysis 100 90 80 70 60 50 40
Number of patients of Number 30 20 10 0 123456 Number of procedures required for treatment of IUA
Concurrent surgery
At the time of index surgery, eleven women had a concurrent procedure performed. All except one of these procedures were laparoscopies to investigate coexisting pathology for pelvic pain or infertility. The final woman had a uterine septum that was resected at the time of surgery. All of the women undergoing laparoscopy had hydrotubation performed to assess their tubal patency and in all cases the fallopian tubes were patent. At laparoscopy, six of the ten women (60%) had biopsy proven endometriosis and all macroscopic disease was removed during this procedure. One of these women had severe r-FAS Stage IV endometriosis, which was excised completely. Two of the ten women (20%) who had laparoscopies had no
103 Chapter 2 Reproductive outcomes pathology found at laparoscopy. In these two cases, hydrotubation was performed, which revealed normal fill and spill from both tubes in these women. One of these woman (10%) had pelvic adhesions, which were divided. She subsequently had a tubal dye test, which showed patent fallopian tubes. The final woman had an ovarian cyst that was excised completely.
Co-existing pathology found hysteroscopically
In five women undergoing hysteroscopic synaechiolysis, co-existing pathology was diagnosed. One woman had a submucous fibroid, two women were found to have uterine septum and two other women were diagnosed as having a bicornuate uterus.
The fibroid and one of the uterine septum were not treated at the index surgery due to concerns regarding recurrent IUA.
Complications of hysteroscopic synaechiolysis
Out of 259 procedures in 154 women, there were 8/259 complications, which is a complication rate of 3.1%. A further 6/259 (2.3%) procedures were incompletely performed due to: positive fluid balance (2), excessive time (1), or perforation (3).
Late intrauterine infection affected two women. For the two procedures that were prematurely ceased due to a positive fluid balance of greater than 1 litre of 1.5% glycine (NH2CH2COOH), an amino acid in fluid form was used as distention media during the hysteroscopic surgery to allow visualisation whilst being non-conductive.
However, the intraoperative absorption of this electrolyte-free fluid can cause hyponatraemia, hypoosmolality, hyperglycinaemia and volume overload, including pulmonary oedema. These women that had a positive fluid balance had serum
104 Chapter 2 Reproductive outcomes electrolytes checked intraoperatively and six hours after the procedure to ensure hyponatraemia did not ensue, in accordance with the current guideline (149). The serum electrolytes were normal in both cases and the procedure was re-scheduled for the following month and completed successfully at this time. The procedure ceased prematurely due to operative time exceeding 60 minutes was also re-scheduled in the following month and completion of the synaechiolysis was achieved at the second hysteroscopy.
In 3/259 (1.2%) of the surgeries, full thickness perforation with the hysteroscope was noted at the time of the procedure. Laparoscopy was performed in one of these cases, as it was planned prior to surgery for symptoms of dysmenorrhoea. There was no bleeding or damage to adjacent organs as a result of the uterine perforation. However, the woman had r-FAS stage II endometriosis, which was treated with excision of visible disease. In the other two cases, laparoscopy was not performed as the perforation was recognised immediately and no electrosurgery or sharp instruments had been used. Both women stayed overnight for observation, recovered well, and were discharged the following day. In all of these cases, repeat surgery was re-scheduled six weeks after index surgery, and in two of the three cases with perforation, uterine anatomy was restored at subsequent hysteroscopy. In the final case, the uterus was found to be completely obliterated with no endometrial pockets seen on HSG. Subsequent MRI confirmed an atrophic uterine corpus, with no endometrium visualised, and the woman was counselled that surgical intervention was no longer possible.
The overall rate of perforation for this procedure is 3/259 or 1.1%. Two of these cases had Grade II AS and perforation was at the posterior uterus when the
105 Chapter 2 Reproductive outcomes operator was dividing dense adhesions in the cervical canal. In the third case, the woman had Grade III AS and perforation was at the posterior uterus.
Intrauterine infection complicated 2/154 (1.3%) cases and this infection was treated with antibiotics. In both cases the women presented with abdominal pain following the procedure. One woman was also febrile and had malodourous discharge. Both women were treated empirically with antibiotics, although low and high vaginal swabs failed to culture any pathological microbes. The woman without an elevated temperature was treated with oral broad-spectrum antibiotics and the woman with elevated temperatures was admitted to hospital for intravenous antibiotics for 48 hours, followed by a course of oral antibiotics for one week. Both women had a hysteroscopy in the month following their presumed intrauterine infection, and no additional synechiae were noted.
Association between antecedent event and grade of AS
In order to assess whether there was a correlation between the antecedent event and grade of IUA, a number of variables were assessed against AS Grades III and IV to assess predictors for AS. These variables include:
ERPC for miscarriage
ERPC for termination of pregnancy
ERPC for postpartum RPOC
Repeated procedures for RPOC
Hysteroscopic surgery
Other uterine surgery
106 Chapter 2 Reproductive outcomes
No one antecedent event was predictive for development of Grade 3 and 4
AS. However, this is likely to be reflective of the small number of cases in each individual category.
The causes were then re-grouped into three categories for analysis: non- pregnant causes, postpartum causes, and pregnancy related causes. Table 2.5 below summarises the number of cases that occurred within each grade of AS. Grade IV AS was significantly associated with postpartum curettage, 2 = 14.293, p = 0.027.
Table 2.5 – Correlations between grade and cause of Asherman syndrome
Grade AS Cause Total I II III IV Number 2 3 2 0 7 Non pregnant % within cause 28.6 42.9 28.6 0.0 100.0 % within grade AS 6.3 5.9 4.9 0.0 4.8 Number 8 14 20 15 57 Postpartum % within cause 14.0 24.6 35.1 26.3 100.0 % within grade AS 25.0 27.5 48.8 65.2 38.8 Number 22 34 19 8 83 Early % within cause 26.5 41.0 22.9 9.6 100.0 pregnancy % within grade AS 68.8 66.7 46.3 34.8 56.5 Number 32 51 41 23 147 Total % within cause 21.8 34.7 27.9 15.6 100.0 % within grade AS 100.0 100.0 100.0 100.0 100.0
Questionnaire findings
Questionnaires were assessed according to symptoms the women experienced before and after their surgery – see Appendix C for a complete questionnaire. The main symptoms assessed were:
menstrual disturbance;
pelvic pain; and
infertility.
107 Chapter 2 Reproductive outcomes
Symptoms pre treatment
In the questionnaire, women were asked to recall their symptoms prior to treatment. Table 2.6 outlines the results for menstrual function, and Table 2.8 outlines the pelvic pain symptoms after diagnosis of AS but prior to treatment.
Fertility dysfunction was the most commonly reported symptom in the cohort pre-operatively, with 124/154 (80.5%) women stating that they had tried and had difficulties conceiving prior to surgery. The next most common symptom was menstrual disturbance, with 87/154 (56.5%) women complaining of light or irregular cycles or no period. Pelvic pain was also experienced by a large number of women pre-operatively, and 59/154 (38.3%) women complained of pelvic pain.
Women were asked about their periods prior to the development of AS. Patient responses indicated that 94/154 (61%) had regular cycles, while 58/154 (37.7%) had no periods or infrequent periods. Further information was not recorded regarding menstrual symptoms prior to the development of AS.
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Table 2.6 – Menstrual function of the women after diagnosis of AS, but prior to adhesiolysis surgery
Summary of patient symptoms prior to treatment
Regularity and flow of women’s periods: Regular, normal flow, % (n) 33.7 (67) Irregular, normal flow% (n) 17.5 (10) Light / reduced flow, % (n)* 18.8 (29)*
Periods but regularity / flow not known % (n) 0.6 (1) No periods, % (n) 48.1 (74) Unknown, % (n) 1.3 (2)
For women having periods (n=80): Menses length (days) mean (SD) 4.1 (3.8) Range 1 – 33
For women not having periods: (n = 74) Amenorrhoea length (months) mean (SD) 18.2 (18.9) Range 2 – 96 *inclusive of LMB in regular and irregular categories
Menstrual symptoms
The questionnaire also asked women to recall their menstrual cycle immediately following treatment and record their menstrual cycle ‘now’. The results are shown in Table 2.7
Prior to surgery, 74/154 (48.1%) women reported amenorrhoea and 78/154
(50.6%) of the women reported some menstruation (and in two women this was unknown). Of those that had periods, 67/78 (85.9%) reported regular cycles, 10/78
(12.8%) reported irregular cycles, and in 1/78 (1.3%) this was unknown or not reported despite reporting ‘having periods’. The symptom of amenorrhoea was associated with higher grade pathology, with Grade IV AS having a statistically significant increase in amenorrhoea rates before surgery, 2 = 8.728, p = 0.033.
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Table 2.7 – Menstrual function of the women post AS treatment
Summary of patient menstruation after their last treatment
Regularity of periods following last treatment: Regular, % (n) 77.3 (119) Irregular, % (n) 10.4 (16) Light / reduced flow, % (n)* 5.2 (8)* No periods, % (n) 6.5 (10) Unknown, % (n) 5.8 (9)
If yes to periods, menses length (days) mean (SD) 3.9 (2.6) range 1 – 21
If yes to irregular period, cycle length (days) mean (SD) 28.2 (10.4) range (months) 12 – 42
Current status of periods: Regular, % (n) 65.6 (101) Irregular, % (n) 11.7 (18) Light / reduced flow, % (n)* 12.3 (19)* No periods currently (including started then stopped), % (n) 2.6 (4) Not applicable (pregnant, breastfeeding or hysterectomy), % (n) 9.1 (14) Unknown, % (n) 5.8 (9)
If yes to periods, menses length (days) mean (SD) 3.6 (1.8) range (days) 0.5 – 10
If periods now irregular, cycle length (days) mean (SD) 28.5 (9.8) range (days) 14 – 43 *number inclusive of LMB in regular and irregular categories n = 2 missing information on length of irregular period post treatment. n = 4 missing information on length of current irregular period.
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In the immediate post surgical period, 135/154 (87.7%) women reported menstruation, 10/154 (12.3%) did not, and in 9/154 (5.8%) cases this was not known.
Of those menstruating, 119/135 (88.1%) reported regular cycles, 16/135 (11.9%) reported irregular cycles, and 8/154 (5.2%) reported light bleeding. In 9/154 (5.8%) cases, menstrual activity was not reported. There were no statistically significant differences in the rate of amenorrhoea between all the ESG grades of AS, 2 = 1.231, p = 0.746. However, Grade IV had a significantly higher rate of irregular bleeding pattern following surgery then the other stages, 2 = 21.108, p = 0.0001, with irregular bleeding reported in 36.4% of Grade 4 patients, relative to 10.4% across entire cohort.
There were no differences in the rate of regular periods prior to and immediately following surgery, 2 1.347, p = 0.246. However, regular periods were statistically significantly lower in women with Grade 4 following surgery, 2 =
17.668, p = 0.001.
In an effort to assess long term menstrual function and possible return of IUA, women were asked about their periods ‘now’. As this was a longitudinal study, this follow up time could have been from 6 months post treatment to 14 years following final surgery. In total 124/154 (80.5%) women were menstruating at the time of the questionnaire. Of those menstruating, 101/124 (81.5%) reported regular cycles, and
18/124 (14.5%) reported irregular cycles. There were 19/124 (15.3%) women who had a light menstrual flow (regular or irregular). There were 4/154 women (2.6%) who reported periods starting following surgery and then stopping. Periods were not applicable in fourteen women, nine were currently pregnant or breastfeeding, and five women reported having had a hysterectomy (four of whom had postpartum
111 Chapter 2 Reproductive outcomes hysterectomies and one had had a hysterectomy unrelated to pregnancy due to dysmenorrhoea). In nine cases (5.8%), menstrual activity ‘now’ was unknown.
When comparing pre treatment periods overall to ESG grade of AS, there was no statistically significant difference in having periods with grade of AS, 2 = 6.783, p = 0.079. When looking at regular cycles, there was no correlation between regular cycles, and grade of AS, p = 0.485.
Light menstrual bleeding
Reduced flow or light menstrual bleeding (LMB) (97) is a subjective measure, and was defined as periods that were light, ‘spotting’, or periods that were less than two days in duration. Women may have had regular cycles despite this reduction in flow. LMB prior to treatment was reported in 29 (31.8%) of the women, where as in the immediately post-operative phase, only eight women reported this symptom
(5.2%). At the time of the questionnaire, there was an increase to 19 women (12.3%) reporting LMB. As a percentage of the 124 who were menstruating, this was 15.3%.
However, this still represented a reduction of this symptom when compared to the pre-operative rate. When assessing as a sub group of only those women who had
LMB pre treatment to these symptoms post treatment, there was a statistically significant improvement in symptoms, 2 = 11.064, p = 0.001. This difference is more pronounced if comparing LMB pre treatment to LMB now, 2 = 15.746, p<0.0001.
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Amenorrhoea
Amenorrhoea or an absence of menstrual bleeding was reported by 74/154
(48.1%) women pre surgery, whereas after surgery it was only reported by 10/154
(6.5%) women. The difference in amenorrhoea before and after were assessed and there was no statistically significant difference in the number of women reporting amenorrhoea after surgery compared to before, 2 0.664, p = 0.313, nor the number of women reporting amenorrhoea now compared to the rate reported prior to surgery, 2
0.438, p = 0.390.
Combined outcomes for abnormal periods
When combining outcomes for abnormal periods and analysing the correlation between abnormal periods (light, irregular and absent periods) before treatment and after treatment, a 2 analysis was performed. This revealed that there were no statistically significant differences between these groups before and after treatment (p = 0.548).
When analysing the correlation between abnormal periods (light, irregular and absent periods) before treatment and periods at present, a 2 analysis showed no significant difference between these groups after treatment (p = 0.316).
Pelvic pain
Women were asked to comment on their pelvic pain since their procedure. A summary of the results is provided below in Table 2.8.
Prior to surgery, 59/154 (39.0%) women complained of pelvic pain, 61/154
(39.6%) reported no pain and 33/154 (21.4%) did not comment on pelvic pain prior to surgery. There were no differences in the symptom of pain across the grades of AS,
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2 = 1.761, p = 0.623. For women with period pain, the mean length of time pain was experienced was 10 months (SD 10.7), with a range of 1-96 months.
After surgery, only 29/154 (18.8%) women were still suffering from pelvic pain, 95/154 (61.7%) had no pain and 29/154 (18.8%) did not comment on this symptom. There were no differences in the rates of pelvic pain between the grades of
AS, 2 = 1.761, p = 0.623. Of the 59 women who reported pain before surgery, 25/59 still had pain after surgery and 34/59 reported no pain post-operatively. Of the 61 women that had no pain before surgery, 3/61 developed pain following surgery and
58/61 remained pain free. There were significantly fewer women who reported pain after surgery, compared to before surgery, 2 = 23.520, p = 0.0001.
Table 2.8 – Pelvic pain
Status of pain Pain present post Pain absent post operative operative % (n) % (n)
Pain present pre operative (n = 59) 42.4 (25) 57.6 (34)
Pain absent pre operative (n=61) 4.9 (3) 95.1 (58)
No comment on pain (n=62) 21.4 (33) 18.8 (29)
Fertility
Women were asked if they were trying to conceive prior to their surgery. In total, 119/154 (77.3%) women reported trying to conceive prior to undergoing surgery, 23/154 (14.9%) women stated they were not hoping to be pregnant and in
12/154 (7.8%) cases, this was not recorded. For those women actively trying to conceive, the mean time trying to conceive, as reported in the questionnaire, was
10.73 months (SD 14.4), and the range was 2–96 months prior to undertaking adhesiolysis surgery.
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After surgery, the women were asked to comment on whether they were still hoping to conceive. 124/154 (80.5%) women subsequently stated they were trying to conceive following surgery, the same 23/154 women (14.0%) were not actively trying to conceive, and 7/154 (4/5%) made no comment in the questionnaire. Table
2.9 below illustrates their outcomes.
Table 2.9 – Fertility
Fertility
Trying/hoping to conceive? % (n) 80.5 (124)
If trying to conceive, time until successful, % (n) less than 3 months 7.3 (9) 3 to 6 months 49.2 (61) 6 to 12 months 27.4 (34) 12 to 24 months 2.4 (3) > 24 months / still trying without success 13.7 (17)
Had fertility treatment (ART) to achieve a pregnancy, % (n) 32.3 (40) IVF 27.4 (34) Donor oocyte 1.6 (2) Frozen embryo transfer (FET) only 1.6 (2) Intrauterine insemination (IUI) 1.6 (2) E2 patch 4.0 (5) Aspirin 0.8 (1) Herbal 0.8 (1)
Pregnant since surgery? % (n) 79 (98)* If yes, how many times? mean (SD) 1.5 (0.7) Range 1 – 7
Notes: One individual said no to trying to conceive, but yes to ART. * One pregnancy achieved in a woman who did not try to become pregnant Numbers in parenthesis indicate number of women who had these outcomes rather than number of births
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In total, 98/124 (79%) women who were trying to conceive were successful.
These women collectively had 157 pregnancies subsequent to index surgery. Figure
2.8 illustrates the outcomes of the pregnancies.
Assisted reproductive technologies (ART) were utilised in 40/124 (32.3%) of the women, 78/124 (62.9%) did not access or require ART, and in 6/124 (4.8%) cases this was not indicated. Of the ART utilised, 34/40 (85%) used IVF or intracytoplasmic sperm injection (ICSI), 2/40 (5%) used intrauterine insemination
(IUI), 1/40 (2.5%) used clomiphene citrate, and 2/40 (5%) women used a donor oocyte with ART. In one case of donor egg, the pregnancy was successful and in the other women, this treatment was unsuccessful. The use of IVF in two women was due to a male factor for infertility and these women required IVF for their pregnancies prior to the diagnosis of AS. In the remainder of the women, the indication for IVF was not stated. Other fertility treatments used include a hormone patch to augment endometrial thickness in 5/40 (12.5%) women and aspirin in 1/40 woman (2.5%).
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Figure 2.8 – Flow chart illustrating the outcomes of the 157 pregnancies following hysteroscopic synaechiolysis
157 pregnancies
Trimester 1 Trimester 2 Trimester 3 Post partum
1 subsequent 47 miscarriages complications 5 T2 deliveries 91 T3 live births hysterectomy
3 ectopic 1 short cervix T3 2 T2 live births 3 mid trimester 4 years post 25 premature complications pregnancies delivery 26/40 loss / SB partum for pain
2 TOP for 1 pPROM T2 1 patient 20/40 7 placenta congenital 7 placenta previa 13 MROP /RPOC 13 PPH 1 vasa previa delivery and 21/40 loss accreta malformations
1 required 9 ongoing 4 post partum uterine packing pregnancies hysterctomies 3 days
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Live births
The live birth rate per woman was 79/124 (63.7%) women and of the 98 women who achieved pregnancy, 79/98 (80.6%) had a live birth. Sixty-three women had one live birth, thirteen women had two live births, and one woman had three live births. Two women reported a live birth, however the outcomes of the livebirths were not recorded. One woman finally achieved a live birth following six miscarriages post surgery. Her seventh pregnancy was an IVF conception, which resulted in a twin pregnancy. One woman reported two live births. However, obstetric data revealed that she had two mid trimester losses at 20 and 21 weeks gestation, which resulted in neonatal deaths. The babies weighed 262 grams and 300 grams respectively. These pregnancies were excluded from the live birth data analysed. There were nine ongoing pregnancies at the time of analysis, which accounted for women who reported pregnancy beyond the first trimester, and were then lost to follow up for obstetric and neonatal outcomes.
Miscarriage
In total there were 47 miscarriages in 29 women; 19 women had one miscarriage, six women had two miscarriages, two women had three miscarriages, and one woman had four and one woman had six miscarriages.
Other early pregnancy complications
There were three (3.1%) ectopic pregnancies reported following surgery for
IUA, one of which was an ovarian ectopic. Two pregnancies (2%) were terminated for congenital anomalies.
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One woman conceived despite reporting that she was ‘not wanting to conceive’ and another woman reported ‘no’ to trying to conceive prior to treatment, but had assisted reproductive technologies after treatment. These may have been due to unplanned pregnancy, or a change of mind regarding pregnancy after treatment, or due to the questionnaire being erroneously completed.
The pregnancy according to grade of AS was calculated. The results of this are illustrated in Table 2.10 below. This data was created using patients where there was information recorded about both grade and pregnancy. There was no statistically significant difference in the chance of pregnancy between the grades, with 2 5.618, and p = 0.132.
Table 2.10 – Pregnancies across grades of Asherman syndrome
Grade of AS 1 2 3 4 Total
Pregnant? No 7 6 9 9 31 % 25.0 14.3 25.0 40.9 24.2 % pregnant Yes 21 36 27 13 97 / grade % 75.0 85.7 75.0 59.1 75.8 Total 28 42 36 22 128 100.0 100.0 100.0 100.0 100.0 Note: 3 cases grade of AS unknown
Time to pregnancy
The time to pregnancy is illustrated in the inverse Kaplan Meier survival curve in Figure 2.9. This curve illustrates pregnancies achieved of all the women who were hoping to become pregnant prior to treatment. In total, 98/124 women trying to conceive (79%) were successful.
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Initially the time to pregnancy was assessed using a time range, such as 0-3 months and 3-6 months (see Appendix C questionnaire). In the questionnaire, many women also wrote an exact number of months required to conceive, or such data was recorded in the medical records. In order to make the data collection uniform throughout the duration of follow up, the exact number of months were ascertained where possible. This also allowed analysis using the Kaplan Meier curve. Where information was only available for women within a time range, then the longer time was used, to minimise the effect of bias in this data. For example, when 0-3 months was selected in the questionnaire, 3 months was assumed.
Figure 2.9 – Time to pregnancy
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Obstetric outcomes
Table 2.11 illustrates the total number of pregnancies resulting in deliveries for the women who achieved a live birth following surgery. Complete records for obstetric and fetal data were recorded in 85 of the 93 live births in pregnancies following surgery. This equates to 72 complete sets of data for neonatal outcomes in the first live birth following AS due to one set of twins.
Table 2.11 – Pregnancies following surgery for Asherman syndrome – maternal outcomes
First live birth Second live birth Third live birth Overall following surgery following surgery following surgery n (% of total n (% of total births) n (% of total births) n (% of total births) births)
Number of births 71* (83.5) 13 (15.3) 1 (1.2) 85 (100)
Caesarean 49 (57.6) 8 (9.4) 1 (100) 58 (68.2) delivery
Antepartum 2 (2.4) 0 (0) 0 (0) 2 (2.4) bleeding
Placenta previa 6 (7.1) 1 (1.2) 0 (0) 7 (8.2)
Placenta acreta 6 (7.1) 0 (0) 1 (1.2) 7 (8.2)
Vasa previa 1 (1.2) 0 (0) 0 (0) 1 (1.2)
Manual removal 12 (14.1) 1 (1.2) 0 (0) 13 (15.3) of placenta
Postpartum 12 (14.1) 1 (1.2) 0 (0) 13 (15.3) haemorrhage
Blood transfusion 3 (3.5) 1 (1.2) 0 (0) 4 (4.7)
Prolonged postpartum 1 (1.4) 0 (0) 0 (0) 1(1.2) bleeding >6 weeks
Postpartum 3 (3.5) 1 (1.2) 0 (0) 4 (4.7) hysterectomy * 1 set of twins, 72 neonates
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Two pregnancies were complicated with antepartum haemorrhage and sub- chorionic haemorrhage was diagnosed on ultrasound. Both of these pregnancies progressed to term and the women had vaginal deliveries. The rate of caesarean delivery was high in this population, at nearly 60% of deliveries following index surgery. The caesarean delivery was complicated in two women, with one having an extension of the hysterotomy into the broad ligament, which was repaired at the time of surgery, and another woman having an adherent placenta, which was difficult to remove abdominally. Her adherent placenta was eventually removed completely without the need for a hysterectomy. Postpartum haemorrhage was defined as blood loss of greater then one litre at delivery. Postpartum haemorrhage complicated 13/85
(15.3%) pregnancies in the study, with blood transfusions required in 4/85 (4.7%) of the women. The rate of placenta previa was also high for the population, occurring in
7/85 (8.2%) of the pregnancies, with a further 13/85 (15.3%) of the women having a placenta that did not separate spontaneously. One woman had a pregnancy complicated with a vasa previa that led to a postpartum haemorrhage, but no blood transfusion was required. Of the women with adherent placentas, 11 of the 13
(84.6%) also had postpartum haemorrhage. One woman was found to have retained products of conception on investigation of her postpartum haemorrhage, and another women had prolonged bleeding for 16 weeks after her delivery, which resolved spontaneously. One woman who suffered postpartum haemorrhage required uterine packing for three days following her delivery to treat profuse bleeding, but managed to retain her uterus. In total, four women required a hysterectomy immediately following delivery, representing 4/85 (4.7%) of the deliveries following AS.
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Neonatal outcomes
The mean weight in the first live birth was 3.1 kg (range 0.9-4.4 kg). There were 2/72 (2.7%) babies born under 1 kg, 7/72 (9.7%) babies born between 1.1 and
2.0 kg; and 12/72 (16.7%) babies born under 2.5 kg for the cohort. The rate of prematurity was 25/86 (29.1%). The gestational age in this group ranged from 26 to
36 weeks, with two women delivering extremely prematurely at 26 weeks gestation.
All other women delivered at greater than 30 weeks gestation. One woman had premature rupture of membranes at 18 weeks, and subsequently delivered at 26 weeks gestation. The baby survived after a neonatal intensive care unit admission, and was discharged at term corrected age.
The neonatal outcomes were slightly better for women who had a second live birth following surgery. These women were likely to have a better prognosis as a group, having already achieved one successful live birth. However, one neonatal death did occur in this group. There was only one case of a third live birth following surgery.
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Table 2.12 – Pregnancies following surgery for Asherman syndrome – neonatal outcomes
First live Second live Third live birth birth birth Overall following following following surgery surgery surgery
Number of babies 72* (83.7) 13 (15.1) 1 (1.2%) 86 (100) n (% of total babies)
Mean weight 3.08 3.13 3.32# 3.08 n in kg (range) (0.9–4.35) (2–3.85) (0.9–4.35)
Preterm pre- labour rupture of membranes 1 (1.2) 0 0 1 (1.2) n (% of total babies)
Preterm birth <37 weeks gestation 23 (26.7) 2 (2.3) 0 25 (29.1) n (% of total babies)
Preterm birth <30 weeks gestation 3 (3.5) 0 (0) 0 (0) 3 (3.5) n (% of total babies)
Mean gestation of premature births # weeks 31 (20–36) 34 0 (0) 31 (20–36) n (range)
Neonatal deaths 1 (1.2) 1 (1.2) 0 (0) 2 (2.4) n (% of total births) Notes: *72 babies of 71 births due to 1 twin pregnancy # Only 1 baby in this group
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Satisfaction
Formal satisfaction analysis did not form part of the questionnaire. However women were simply asked if they were ‘satisfied’ and whether they would ‘have the procedure again’. These questions are detailed in Appendix C Questionnaire. Of the
94 women who responded to this question, 76/94 (80.8%) stated they were satisfied with the procedure, 2/94 women were dissatisfied (2.1%), and 3/94 (3.2%) women were undecided. When asked whether they would have the procedure again, 72/94
(76.6%) of the women stated that they would have the procedure again, 6/94 (6.4%) stated they would not have the procedure again, and 3/94 (3.2%) of the women were
‘not sure anymore’.
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Discussion
Introduction
This series represents a historical cohort of 154 women treated for Asherman syndrome (AS) over 14 years, with a 3-15 year follow up of menstrual pain, fertility and obstetric outcomes. In total, 259 fluoroscopically guided hysteroscopic adhesiolyses were performed. Subsequent surgery was based on symptoms, such as persistent abnormal bleeding or infertility, rather then routine second look laparoscopy. The post-operative function of the endometrium was assessed by menstrual symptoms, pregnancy and subsequent obstetric outcomes. Resumption of menstruation following treatment occurred in 89% of women. This compared favourably with data from other sources, which had resumption of menstruation in a range of 67-98% of women, depending on the specific study (49, 50, 103, 137, 172,
175). Pelvic pain was similarly reduced post surgery, with a reduction from 33% experiencing pain to 18% post-operatively. Pregnancy rates achieved were 79%, which was higher than in the largest other series with data available, which reported
61% (60). However, major obstetric complications occurred in 4 (4.7%) of the pregnancies, which required postpartum hysterectomy. One third of the live births were premature and 17% were delivered with a low birth weight.
Causation
There is conflicting opinion regarding the definition of AS, and whether intrauterine adhesions (IUA) caused by an intervention in the non-gravid uterus are a result of the same pathogenic pathway as those formed in the gravid uterus. Hence some authors have elected to exclude IUA from non-gravid interventions in their
126 Chapter 2 Reproductive outcomes definition of AS (44). Certainly the pregnant uterus is more susceptible to formation of IUA. This is purportedly due to the hormonal milieu at the time of traumatic intervention. All women in our series were cases that had been referred to our centre with IUA between January 2000-June 2014. Only 10/154 (6.5%) were unrelated interventions in the pregnant uterus, with 2/154 (1.3%) cases the result of hysteroscopic myomectomy with electrosurgery. In these cases of myomectomy,
GnRH agonists (GnRHa) were not used to prime the endometrial lining prior to surgery. It is difficult to determine whether the causation following hysteroscopic myomectomy was a result of a breach of the endometrium, or the effect of electrosurgery. The most common cause for AS as reported by the women in our study, and in the literature, was following evacuation of retained products of conception (ERPC) for miscarriage. This accounted for over half of the sample.
Curettage in the first trimester was the most common time that ERPC occurred.
However, the first trimester is also the most common time for miscarriage and indeed curettage. Therefore, it is difficult to analyse whether this association accounts for the greater occurrence of this procedure. Alternatively, perhaps a pathogenic process or the hormonal environment account for this procedure occurring more frequently during the first trimester. Proponents of early surgical intervention cite the increased incidence of IUA following a missed miscarriage compared to an incomplete miscarriage (30) as being due to the increase in fibroblast activity and collagen formation before endometrial regeneration occurs. Furthermore, some centres use an arbitrary cut off of three weeks between diagnosis of miscarriage and surgery if products of conception are not spontaneously expelled (60). However, there is no evidence for this protocol minimising IUA formation during the first trimester.
Medical management is as efficacious as curettage in assuring complete evacuation
127 Chapter 2 Reproductive outcomes of retained products of conception (237, 238). There are no data reporting the incidence of IUA following medical management of miscarriage. However, as per the pathogenic condition described by Joseph Asherman in his seminal paper, avoidance of any initiating traumatic event should minimise the risk of developing pathological
IUA.
Intrapartum causes at caesarean delivery accounted for 9/154 (5.8%) cases, with complications such as difficulty removing a placenta, or the management of postpartum haemorrhage. This is compared to the 3.6% reported in the Dutch series
(44). Intrapartum causative factors have not been reported in other series. No cases in our series were directly associated with the utilisation of the B Lynch compression sutures. This contrasts a series by Rathat (35), which reported on the results of 37 women who underwent uterine compression sutures for postpartum haemorrhage.
From this group, Rathat conducted 13 post-operative assessments by hysteroscopy, which found synechia in seven women, of whom three had AS. Uterine artery embolisation (UAE) was also not a cause found in our series, despite it being reported as having particularly poor prognosis for reproductive outcomes (39). This data reports a historical series, and routine use of UAE was not common practice in the referring centres during the time of recruitment.
Concurring with the literature, postpartum causes accounted for a disproportionate number of cases at 48/154 (31.2%), which was also statistically significantly associated with higher grade adhesions in our data, 2 = 14.293, p =
0.027. Hanstede et al. reported this same association (44). The Dutch group also found a correlation between recurrences of higher grades of AS, which was not replicated in our cohort. However, this may merely be due to the relative small numbers of women with high grade AS in our data and other reported series (44).
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Despite these differences in causes for IUA, the proportion of each grade of adhesions in our series was most similar to the Dutch group, with a weighting towards higher grades of disease. Our series reports 60.4% having Grade 2 and 3 pathology, and 16.9% Grade 4, compared to 71% Grade 2 and 3, and 25.3% having
Grade 4 and 5 in Hanstede’s series. Although differences in the grading systems utilised (pre and post modified ESGE) makes these studies difficult to compare, their similar grade proportions most likely reflect the similarity of the units being tertiary referral centres for the more complex IUA.
Abnormal uterine bleeding
The most obvious manifestation of endometrial dysfunction is menstrual abnormalities, and surgery was effective for improving symptoms of abnormal uterine bleeding (AUB). Amenorrhoea (or absent periods) affected 78/154 (50.6%) of the women in our sample prior to surgery. Women with higher grades of disease were statistically significantly more likely to report amenorrhoea compared to lesser grades at the time of diagnosis. Amenorrhoea may represent outlet obstruction, or may be due to the atrophic effect that IUA have on the entire uterine cavity.
There were no differences in the rate of regular periods prior to and immediately following surgery, 2 1.347, p = 0.246. However, regular periods were statistically significantly lower in women with Grade 4 disease following surgery, 2
17.668, p = 0.001. These findings may be accounted for by the high number of women who were amenorrhoeic prior to surgery in the Grade IV group. This group may have had periods return following surgery, but reported abnormalities in their cycle, and a failure to return to their normal menstrual pattern. Following surgery,
87% of women with amenorrhea had resumption of menstruation. This finding was
129 Chapter 2 Reproductive outcomes similar to recent and historical series, where resumption of menstruation is reported to occur in 67.7–98% of women (44, 49, 50, 103, 137, 172, 175). When comparing amenorrhoea rates before and after surgery, there was no statistically significant difference in these rates in our study. There were 74 women who reported amenorrhoea before surgery and only ten women who reported this symptom after surgery. Of these ten women, two who were not amenorrhoeic prior to surgery became amenorrhoeic post-operatively. This statistical nuance accounts for the lack of significance in a series with relatively small numbers. However, if the resumption of menstruation indicates return to fertility, then these numbers, although small, are certainly clinically significant.
Of those women who reported menstruation at the time of diagnosis of AS, various patterns of menstrual flow were reported including light menstrual bleeding
(LMB), short menstrual bleeding, and infrequent bleeding cycles. Higher grade AS was associated with alterations in frequency of cycles prior to surgery.
Following surgery, there was a statistically significant improvement in the symptom of LMB / short menstrual bleeding, compared to the proportion of women who reported this symptom prior to surgery. However, LMB / short menstrual bleeding was still persistent in some women, despite normalisation of the uterine cavity. The improvement in menstrual symptoms is biologically plausible, with surgical release of obstructed haematometra allowing egress of menstruation though the uterine cervix. However, the long-term effect on the endometrium may persist, despite anatomical restoration of the endometrial cavity. Lo et al. (43) found that women with IUA and only outlet obstruction had a thinner endometrial thickness in the unaffected upper uterine cavity, in spite of the upper cavity being unaffected by adhesions. This may represent a primary endometrial vascular alteration persisting
130 Chapter 2 Reproductive outcomes beyond the perceived outlet obstruction, or indeed ongoing cicitrisation effect of the endometrium that is not visible macroscopically at the time of hysteroscopy.
Pelvic pain
Pain is an associated symptom of AS, considered to be a result of obstructed menstruation in pockets throughout the uterine cavity. Despite this, many series do not provide information relating to pain in women with this condition (44, 60). In our cohort, 59/154 (38%) women who were questioned about pelvic pain reported this symptom prior to index surgery. Following surgery, 25/154 (16%) women still reported pain. In contrast to women with obstructed Müllerian structures (uterine horns with the presence of active endometrium without an associated cervix or upper vagina), women with persistent pelvic pain often require laparoscopic resection of the unilateral or bilateral obstructed uterine structures (239). There appears to be less pain then expected in this cohort, given half of the women were in fact amenorrhoeic due to AS. The relative quiescence of the endometrium, which is a feature of this pathological process, may explain in part the lack of pain associated with this phenomenon. In women with AS, where there are cervical adhesions obstructing the outflow of menstruation, biopsies taken at the fundus have revealed inactive endometrium (10). This explains the apparent lack of haematometra found clinically, despite the blockage to the cervical os for, at times, many months. It also explains the obstructive cause for the amenorrhoea.
All women were thoroughly assessed for other gynaecological conditions prior to undergoing synaechiolysis surgery. Ten women also underwent laparoscopy for symptoms or signs suggestive of endometriosis, such as pelvic pain, or other pathology seen on ultrasound, such as an ovarian cyst. Six of these women (3.9% of
131 Chapter 2 Reproductive outcomes the whole cohort) had histologically proven endometriosis, which was resected at the time of index hysteroscopic surgery. The presence of other gynaecological pathological findings may also have contributed to the symptom of pelvic pain reported at the time of diagnosis.
Women with obstructed menstruation due to Müllerian anomalies are commonly found to have endometriosis secondary to retrograde menstruation, which presents as dysmenorrhea or chronic pelvic pain. In most cases, surgical excision of the uterine horn results in resolution of the endometriosis (240). This also adds weight to the relative endometrial inactivity seen in AS, with relatively few women having concurrent endometriosis or indeed obstruction related pelvic pain.
Three women in our cohort described no pain prior to surgery, yet reported symptoms of pain post-operatively. This reported symptom of pain following surgery may have been due to resumption in menstruation as a cause for pelvic pain, recall, or related to the surgical procedure itself.
The symptom of pain occurred at a relatively low rate in our data. One would expect that if menstrual obstruction were to be the cause of pelvic pain in AS, then this would occur with higher frequency than seen in this study and in the literature.
This low rate supports the suggestion that the endometrium becomes atrophic in the unaffected uterine cavity in AS, avoiding uterine distension.
Complications
Hysteroscopic surgery has a complication rate of <0.5%. However, IUA accounts for the highest incidence of complications in hysteroscopic surgery, with rates reported as high as 4.5% in large cross sectional studies (148). Fluid overload is reported as the most common procedure complication in hysteroscopic surgery.
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Surgical complications generally relate to uterine perforation, which most commonly occurs during entry into the uterine cavity via the cervix. In our series, three adhesions were incompletely resected due to fluid balance or excessive surgical time required to resect the synechiae. However, subsequent surgery completed the synaechiolysis in all three cases. In three (1.1%) procedures, full thickness perforation was noted. This low complication rate reflects the nature of the technique of fluoroscopically guided synaechiolysis, where the use of fluoroscopy guides the operator towards pockets of ‘normal’ endometrium, minimising the risk of perforation. This approach was similar to a Dutch group, who also used fluoroscopic guidance, with no complications reported (44).
Reproductive outcomes
Successful pregnancy relies on early embryonic implantation. This unique biological phenomenon, where the blastocyst comes into contact with the endometrium and forms the placenta provides the interface between the growing fetus and the maternal circulation. Despite the encouraging results reported for anatomical restoration of the uterine cavity (11, 44, 76, 140, 233), and subsequent menstrual resumption, pregnancy and live births following surgery still remain low.
Successful reproductive outcome are seen more frequently in women with a history of previous pregnancies than those with primary infertility, even if the pregnancies included miscarriage (231). Women with IUA due to genital tuberculosis appear to have a particularly poor prognosis (36). Success of treatment relates to the type of procedure. In historical series, prior to hysteroscopic resection, pregnancy rates after treatment were reported at 51% (540 out of 1052) This pregnancy rate was only slightly higher than that of untreated women, which was 46% (133 out of 292)
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(36). Treatment for mild to moderate adhesions included blind passage of a sound through the cervix, or curettage. Reproductive results following laparotomy for severe grade disease reported a pregnancy rate of 52% and live birth rate of 25% (36).
However, in more recent reports, there have been no pregnancies achieved in cases of severe disease treated by laparotomy after failed hysteroscopy (167).
Since the advent of hysteroscopic synaechiolysis by Wamsteker et al. (60,
103), successful pregnancy outcomes have substantially increased. Pregnancy results since hysteroscopy are summarised in Table 2.13 below. These results have an overall pregnancy rate of 61% (2393/3907), and of women who conceived, live birth rates when combining reported data are 47% (1828/3907), and 76% (1828/2393) of those who achieved pregnancy.
Reproductive success is related to the severity of adhesions. Valle and Sciarra report pregnancy rates of 93%, 78% and 57% after treatment of mild, moderate, and severe adhesions respectively, with live birth rates of 81%, 66%, and 32% respectively after hysteroscopic lysis of IUA (49).
Successful implantation requires receptive endometrium, a functioning blastocyst and a synchronized dialogue between the maternal and the embryonic tissues. Implantation has three established stages: apposition, adhesion and penetration (241). Apposition is an unstable adhesion of the embryo to the endometrium. This is followed by the adhesion stage, where the adhesion is sufficiently intimate as to resist dislocation from the endometrial lumen. The final stage is penetration, where the embryo invades through the endometrial lumen into the stroma to establish a relationship with the maternal vasculature. This process is mainly controlled by the trophoblast. However, the decidua also limits the extent of
134 Chapter 2 Reproductive outcomes invasion (242). Therefore there are multiple potential explanations for the alteration in normal implantation for women with AS, which may affect reproductive outcomes.
The effect of thin endometrium (as seen on ultrasound in an anteroposterior plane, defined as a diameter of < 8 mm) may have a negative impact on the reproductive success of the uterus (243, 244). Large, historical, prospective cohort studies describe little influence of thin endometrium on cumulative pregnancy rates
(245). Subsequently large series have reported success of implantation being based upon thickness of the lining and proliferative pattern of the endometrium, as seen on ultrasound scanning (246). The pattern of the endometrium has also been studied as an independent and important factor for prediction of implantation at IVF cycles.
Furthermore, the pattern of the endometrium has been shown to be predictive of pregnancy where endometrial thickness was not (247). Lo et al. (43) found that women with IUA and only outlet obstruction had a thinner endometrium, in spite of the upper cavity being unaffected by adhesions. Although endometrial thickness was not formally assessed in our study, a number of women who had restoration of menstruation reported LMB/short menstrual flow. Of the women who underwent IVF cycles within our series, in either fresh or frozen embryo transfer, 12.5% required agents to augment the thickness of the endometrium, despite the fact that management of a thin endometrial lining is controversial in the IVF literature.
Local dysregulation of the normal expression of cytokines has also been implicated in recurrent implantation failure in women who do not have AS.
Alterations such as elevated natural killer (NK) cells, dysregulation of interleukin
(IL) 12, 15 and 18 (248), high IL-1beta, and low interferon gamma and IL-10 (249) are found in women who have had recurrent implantation failure in embryo transfer cycles. High levels of aromatase P450 mRNA (250), changes in pinopode expression
135 Chapter 2 Reproductive outcomes
(251), and high matrix metalloproteinases (249) have been associated with recurrent implantation failure. Alteration in local cytokine expression could occur at any time during the lifecycle of IUA, from the initial endometrial trauma, during subsequent healing in the fibrotic phase or at re-operation to restore the uterine cavity.
Receptor expression may also be altered in women with IUA. In a recent study, the expression of progesterone receptors in the epithelial and stromal cells of fertile and infertile women were compared, and an endometrial thickness and endometrial biopsy was obtained on the seventh or eighth postovulatory day (252).
Immunohistochemistry was performed to measure percentage of positive nuclei, intensity of staining PgRs (A + B), as well as Type B PgRs, in epithelial and stromal cells. Expression of progesterone receptors was significantly lower in the epithelial cells of infertile women. No significant difference was observed in stromal cells. This study concluded that expression levels of PgR (A + B) as well as Type B receptors are significantly lower in the epithelial cells of infertile women during the implantation window (252). They also concluded that the correlation of expression levels to endometrial thickness supported the hypothesis that the process affecting implantation lies at an endometrial biochemical level, rather than a crude measure of endometrial thickness based on ultrasound alone.
Altered endometrial and myometrial perfusion may also be implicated in the process of implantation, affecting the reproductive success of women with AS. (253).
Evaluating uterine receptivity by means of assessment of endometrial blood flow was introduced by Applebaum (254). Salle (255) subsequently proposed a uterine score calculated in the secretory phase of the menstrual cycle preceding IVF. Among other parameters, the presence or absence of color in the sub-endometrial region was determined. The vascularisation was considered as positive if more than three vessels
136 Chapter 2 Reproductive outcomes could be seen penetrating the outer hypoechogenic area surrounding the endometrium. The uterine score seemed to be a useful predictor of implantation (255). More recently, in a prospective, nonrandomized observational study, a total of 165 women undergoing their first frozen embryo transfer cycle were evaluated for subendometrial-endometrial blood flow by 2D Power Doppler (PD) once the endometrium was ≥ 7 mm thick. Pregnancy rates were significantly higher in the presence of subendometrial-endometrial blood flow than in its absence (256)
(35.43% vs. 15.78%, p = 0.02). When angiography was performed on women with
IUA, myometrial blood flow was found to be reduced, with widespread vascular occlusion. This may explain the endometrial atrophy, poor receptivity, and recurrent miscarriage suffered in this group of women (42).
Other fertility factors affecting reproductive outcomes
During the investigation and treatment of IUA, other fertility factors such as endocrine profile, tubal patency and semen analysis should be assessed in order to exclude other causes of infertility. In a study by Roge of the 44% of patients who had persistent infertility after treatment, 60% had additional infertility factors (143).
Indeed, ART were accessed by nearly one third of couples in this study. In two cases,
ART were specifically required for male factor infertility, and the couples had only conceived after utilising ART in their pregnancies before the diagnosis of AS. Donor oocytes were utilised by two women, and for one couple this resulted in a successful pregnancy. However, this highlights that other factors associated with infertility (such as oocyte or embryo quality) may have affected the couple’s fertility, and confounded the reproductive outcomes in this study.
137 Chapter 2 Reproductive outcomes
In our present series, ten (6.5%) women had concurrent laparoscopies at the time of hysteroscopic adhesiolysis. These laparoscopies were performed for signs or symptoms of other disease such as endometriosis. Of these ten women, six cases had endometriosis proven histologically, and two of these six women subsequently achieved pregnancy. In two cases where laparoscopy was performed, an ovarian cyst was excised and in one of these two cases, pregnancy ensued. In the final two laparoscopies, adhesiolysis for peritoneal adhesions were performed for past pelvic inflammatory disease, and one of these women also achieved pregnancy. The women who had pathology requiring laparoscopy as well as hysteroscopic synaechiolysis had a pregnancy rate of 4/10 (40%), which was lower than our cohort as a whole.
Two cases of uterine septum were diagnosed at hysteroscopy. In a third case, a submucous fibroid was found during hysteroscopic surgery. In one of the cases of the septum, this was resected at index surgery, and in the other two cases (one fibroid, and one septum), this pathology was not treated to avoid further formation of IUA with electrosurgery. The woman with the uterine septum treated concurrently achieved a pregnancy, whereas the other two women did not. The decision to perform concurrent intrauterine surgery was made intraoperatively by the surgical team with little evidence to guide either decision. Although treating intrauterine pathology certainly did not affect reproductive outcomes in our series, the numbers are to small to make firm conclusions about the management of intrauterine pathology at the time of synaechiolysis.
138 Chapter 2 Reproductive outcomes
Table 2.13 – Fertility outcomes following hysteroscopic treatment of intrauterine adhesions
Pregnancy of those Miscarriage Live birth Premature delivery Author and year Obstetric complications trying to conceive (%) (%) (%) n (%)
March and Israel 1981(186) 38/38 (100)* 8/38 (21) 33/38 (87) Neurith 1982 14/27 (52) - 13/27 (48) 0 Hamou et al 1983(129) 20/39 (52) 5/20 (13) 15/20 (75) 0 Wamsteker 1984(108) 17/36 (63) - 12/17 (71) - Fedele 1986(76) 22/22 (100) 10/22 (45) 9/22 (41) 3 cases including placenta increta, uterine Friedman 1986 (257) 24/30 (80) 1/24 (4) 23/24 (96) - sacculation, and a paper-thin uterine fundus 1 placenta accreta requiring hysterectomy Valle and Sciarra 1988 (49) 143/187 (76) 26/143 (18) 114/143 (80) 3/114 (3) 2% ectopic pregnancy Parent 1988 (71) 107/169 (63) - 91/107 (85) Spontaneous uterine rupture at 25 weeks, Deaton 1989 (258) 1/1 (100)* 0/1 (0) 1/1 (100) caesarean hysterectomy for uncontrolled bleeding Hulka 1990 (259) 1/1 (100)* 0/1 (0) 1/1 (100) 0 Uterine rupture in pregnancy Carp 1992 (99) 1/1 (100)* 0/1 (0) 1/1 (100) Barbot 1994 (260) 33/73 (45) - 23/33 (70)
139 Chapter 2 Reproductive outcomes
Note: Table 2.13 continues
140 Chapter 2 Reproductive outcomes
Table 2.13 [continued] – Fertility outcomes following hysteroscopic treatment of intrauterine adhesions
Pregnancy of those Miscarriage Live birth Premature delivery Author and year Obstetric complications trying to conceive (%) (%) (%) n (%) Fraser et al 1995 (156) 3/6 (50) 0 (0) 3/3 (100) 0 Goldenberg et al 1995 11/24 (46) - - - (261) Roge et al 1995 28/52 (54) 10/28 (36) 18/28 (64) 7/18 (39) 2 partial placental accreta Bellingham 1996 (157) 8/17 (47) - - 1 perinatal mortality following premature Katz et al 1996 (181) 66/72 (92) 15/66 (23) 46/66 (70) 6/46 (13) delivery Chapman & Chapman 1996 1/1 (100)* 0 1/1 (100) (141)
Roge 1996 (143) 28/50 (56) 10/28 (36) 24/28 (86) same data set as Roge 1995
Pistofidis 1996 (262) 30/86 (35) - 21/30 (70) McComb and Wagner 1997 5/6 (83) 1/5 (20) 4/5 (80) 2/4 (50) 1 x placenta praevia (152) Pabuccu et al 1997 (133) 34/40 (85) 11/34 (32) 23/34 (68) Chen 1997 (150) 3/4(75) 1/3 (33) 2/3 (67)
141 Chapter 2 Reproductive outcomes
Hysterectomy following delivery for placenta Protopas 1998 (153) 3/7 (43) 1/3 (33) 1/3 (33) accreta, 1 ongoing pregnancy
Note: Table 2.13 continues
142 Chapter 2 Reproductive outcomes
Table 2.13 [continued] – Fertility outcomes following hysteroscopic treatment of intrauterine adhesions
Pregnancy of those Miscarriage Live birth Premature delivery Author and year Obstetric complications trying to conceive (%) (%) (%) n (%) Capella-Allouc et al 1999 12/28 (43) 3/12 (25) 9/12 (75) 2 abnormal placenta (140) Villos (263) 2/2 (100) * 0/2 (0) 1/2 (5) 145/156 Feng 1999 (174) 156/186 (84) 11/156 (7) 4 abnormal placenta, 3 accreta (92.9) 50/50 (100) *, 62 Nasr 2000 (130) 13/50 (26) 35/50 (70) 9/35 (26) 4 NND, 2 ectopic, 2 placenta accreta pregnancies Preutthipan and Linasmita 16/45 (36) - 16/16 (100) 2000 (22) Coccia 2001 (151) 2/3 (67) 1/2 (50) Sher 2001 (214) 2/2 (100) * Sidenafil treatment Zikopolous et al 2004 (175) 20/46 (43) - 20/20 (100) 2 hysterectomy for placenta accreta Shiau 2005 (101) 1/1 (100)* 0/1 (0) 1/1 (100) Uterine rupture in subsequent pregnancy Fernandez et al 2006 (233) 31/40 (78) - 10/31 (32) Knopman and Copperman 45/50 (90) 10/45 (22) 35/45 (78) 2005 (117)
143 Chapter 2 Reproductive outcomes
Note: Table 2.13 continues
144 Chapter 2 Reproductive outcomes
Table 2.13 [continued] – Fertility outcomes following hysteroscopic treatment of intrauterine adhesions
Pregnancy of those Miscarriage Live birth Premature delivery Author and year Obstetric complications trying to conceive (%) (%) (%) n (%) Yasmin et al 2007 (172) 2/20 (10) 1/2 (50) 1/2 (50) Thomson et al 2007 (137) 9/17 (53) 1/9 (11) 8/9 (89) 1/8 (13) 1 bleeding requiring caesarean hysterectomy 2 x caesarean hysterectomy for accreta 3 x Yu et al 2008 (45) 39/85 (46) 8/39 (21) 25/39 (64) 2/25 (8) manual removal; Robinson 2008 (50) 10/24 (42) 1/10 (10) 6 (60) 1/6 (17) 3 ongoing pregnancies Pabucu 2008 (264) 28/71 (39) 11/28(39) 17/28 (61) Taniguchi 2008 (265) 1/1 (100)* 0/1 (0) 1/1 (100) Dawood 2010 (234) 22/43 (51) 8/22 (36) 14/22 (64) Roy et al 2010 (176) 36/89 (40) 5/36 (14) 31/36 (86) 4 post partum haemorrhage for adherent placenta Amer 2010 (95) 10/43 (23) 6/10 (60) live birth and ongoing included in 4/10 preg 764/1240 (62), and 807 1 ectopic, 13 cervical incompetence, 13 acreta, 4 March 2011 (60) 126/764 (16) 674/764 (88) 47/674 (7) pregnancies hysterectomy, 3 Intrauterine growth restriction all patients > 2 procedures 2004-2010 so may be Fernandez et al 2012 (54) 9/22 (41) 3/9 (33) 6/9 (67) - represented Fernandez paper 2006
Note: Table 2.13 continues
145 Chapter 2 Reproductive outcomes
Table 2.13 [continued] – Fertility outcomes following hysteroscopic treatment of intrauterine adhesions
Pregnancy of those Live birth Premature delivery Author and year Miscarriage (%) Obstetric complications trying to conceive (%) (%) n (%) Myers & Hurst 2012 (47) 6/8 (75) 3/6 (50) 3/6 (50) 2/3 (66) all severe AS Malhotra 2012 (116) 5/40 (13) 2/5 (40) 2/5 (40) 1 ongoing pregnancy Kjer 2014 (59) 29/58 (50) No pregnancy outcome data Tsui 2014 (52) 4/4 (100) * 2/4 (50) 2/4 (50) - 1 placenta previa, 1 placenta abruption Xiao 2014 (53) 314/475 (66) 201/314 (64) Song 2014 (39) 20/76 (26) 5/20 (25) 12/20 (70) 1 ectopic pregnancy, 2 ongoing. 1 MROP Huang 2016 (127) 46/92 (50) 15/46 (33) 21/46 (46) 10 ongoing pregnancies 98/124 (79), and 157 Our data 29/124 (23) 79/124 (62) 25/98 (25) 4 caesarean hysterectomy, 6 placenta accreta pregnancies
TOTAL 2393/3907 363/2393 1828/2393 105/917 3 placenta increta, 29 placenta accreta, 3 % (61) (16) (76) (12) uterine rupture, 16 hysterectomy * reported only those women who became pregnant
Notes: (1) Thompson paper excluded, as this is included in our current data (2) Fernandez 2000 paper superseded by 2006 (therefore earlier paper excluded) (3) Roge 1996 same dataset as 1995 (numbers counted only once) (4) Ventolini paper excluded as pregnancy rate reported was for mixed pathology so uncertain pregnancy rate of IUA
146 Chapter 2 Reproductive outcomes
Time to pregnancy
In our series, 70% of women achieved their pregnancy within ten months of trying to conceive post surgery. Beyond this time point, there was a diminishing return to achieve this desired outcome. This is longer than the only other series to
report this outcome, which had 46 women with no other fertility factors, where a
mean time to delivery was 12.2 months (146).
Miscarriages
The rate of early miscarriage appears to be reduced in AS patients after
treatment of adhesions, with a reduction from 78% to 43% and with an average time
to conception after adhesiolysis of 18-21 months (139). In the series that reported
miscarriages as an outcome following hysteroscopic management of IUA, the miscarriage rate was 363/2393 (16%) of the women who conceived (45, 47, 49, 54,
60, 76, 129, 133, 137, 140, 143, 152, 153, 172, 174, 176, 181, 186, 257). This is
shown in Table 2.13 above. In our series, the rate of miscarriage following surgery
was 47 miscarriages in 157 total pregnancies (30%) following synaechiolysis, which
is higher than the rate of miscarriage in the community at 15-20% (10). This
implicates the fibrosed uterus as a less receptive organ for implantation. Recurrent
miscarriage has been reported to be as high as 25% after treatment for IUA (36). Four
women (4%) in our series also reported recurrent miscarriage following treatment (>2
miscarriages), with one woman (0.6%) reporting 6 miscarriages following synaechiolysis surgery before a successful live birth was achieved. However, it is difficult to distinguish whether this was a cause or effect of AS, given 46.1% of women in our cohort developed IUA following single or multiple curettages for miscarriage prior to diagnosis.
147 Chapter 2 Reproductive outcomes
Extrauterine pregnancies
Ectopic pregnancies occurred in three (1.9%) women in our series, with one woman having an ovarian ectopic pregnancy. Although this rate of ectopic pregnancy is within that expected for conception, particularly in women accessing ART, it may also represent a tendency of the early embryo to implant outside of the affected endometrial cavity. Certainly cervical ectopic pregnancies have been described in a case report (266), which may be a result of the relatively hostile endometrium to intrauterine implantation of the early blastocyst.
Maternal age
Maternal age has a profound impact on reproductive success, elegantly highlighted in a classic study reporting pregnancy rates following cessation of contraception. This study showed infertility rates in different age categories following attempted spontaneous conception to be 6% at 20-24, 9% at 25-29, 15% at 30-34,
30% at 35-39, and 64% at 40-44 years(267). Similarly, spontaneous miscarriage rates increase with advancing maternal age in ART cycles (268), even after the presence of fetal cardiac activity, with rates of 14% in 35 year olds, 19% at 35-37 years, 25% at
38-40 years, and 40% in women older then 40 who achieved pregnancy (269).
Similarly, the conception rates following lysis of IUA are more favourable in women under the age of 35 years (76), with pregnancy rates threefold higher in women under
35 compared to women older than 35 years of age (145). With a median age of 36 years in the women in our study, rates of both infertility and spontaneous miscarriage would be affected by age alone. Our group represented a slightly older cohort compared to the recently published Dutch series (44) and certainly older than historic series reported in the late 20th century. The Dutch series reported a mean age of 34
148 Chapter 2 Reproductive outcomes
years, although no reproductive data was included. Unfortunately, in the largest series
reporting fertility and obstetric outcomes, the maternal age was not reported (60).
Obstetric complications
Various pregnancy complications have been described after treatment of AS
(10, 36, 76). These include premature delivery, intrauterine growth restriction (IUGR) and uterine rupture during pregnancy or delivery (10, 258).
Placenta accreta and increta
The risk of developing placenta accreta in subsequent pregnancies has been described by a number of authors (10, 45, 49, 138, 143, 146, 152, 153, 257). Placenta increta has also been reported in one paper (174). Schenker collated fertility outcomes
in women with AS and found that the rate of placenta accreta was 8% in this group of
women after treatment (36). He concluded that this was probably due to abnormal
placentation at the sites of severed adhesions adjacent to the myometrium, where the
lack of decidua basalis is most evident. This group of women were treated prior to the
advent of hysteroscopic lysis of adhesions.
Table 2.13 above summarises the fertility outcomes of women treated with hysteroscopic adhesiolysis. In 1828 births, there were 29 cases of placenta abnormalities, including placenta accreta and increta (2%). This rate is lower following the advent of hysteroscopy compared with blind division of adhesions (49).
However, this rate is significantly higher than the background risk of 0.5% (270).
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Other placental abnormalities
Retained placenta and placental sacculation over the placental site have also been reported in pregnancies following hysteroscopic lysis of adhesions (257). One case of abnormal placentation led to severe intrauterine growth restriction (IUGR) as a consequence, with delivery at 29 weeks gestation (172).
Second trimester pregnancy loss
An increased incidence of second trimester pregnancy loss has also been reported in this group of women after treatment of IUA. It is postulated that this is due to cervical incompetence arising from multiple cervical dilatations. Treatment with prophylactic cervical cerclage appears to benefit women with this complication (140).
March reports a high frequency of cervical incompetence in his series. The cervix may be affected by IUA, as it is the most common location of IUA in AS (60).
Hormonal dysfunction and inflammatory mechanisms may play an important role in degrading the cervical extracellular matrix and promoting cervical insufficiency.
Cervical ripening is induced by PGE2, IL-1, platelet-activating factor, mechanical stretch, and migration of macrophages and neutrophils (271). Similarly, repeat hysteroscopic procedures requiring dilation may alter the collagen matrix, altering the balance responsible for cervical competence.
Primary prevention of the complication of cervical incompetence is to avoid multiple cervical dilatations to a high gauge to treat IUA.
Premature delivery
The risk of premature delivery is increased in women with IUA, with rates initially estimated at 9% in a series reviewing 1053 women with IUA (36). Other
150 Chapter 2 Reproductive outcomes more recent reports indicate much higher rates of 40–50% following synaechiolysis
(140, 146, 152, 153). However when combined data was pooled from studies where this outcome was reported, the rate was 105/917 (12%), and this is shown on table
2.13. The reason for this complication is likely to be similar to the reasons for other obstetric complications: that disruption of the basalis layer of the endometrium leads to abnormal placentation following initial IUA and fibrosis replacing endometrium, or inefficient endometrial function despite anatomical restoration (143, 146). There have also been reported cases of perinatal mortality secondary to premature delivery in our series and in others (181).
Low birth weight
According to the Australian perinatal data (272), around 6% of live born babies are of low birth weight (less than 2.5 kg). In this series treating AS, this rate was substantially higher at 16.7% (272). The mechanisms are likely to be associated with an altered hormonal or inflammatory environment associated with early embryo implantation (248, 249, 252), or a poorly vascularised endometrium and myometrium
(221, 273, 274).
Uterine rupture
Uterine rupture has been described after hysteroscopic surgery for AS (10,
101, 258, 259), and may be a result of a weakened and scarred myometrium, especially if perforation occurs during the index procedure. Freidman also cautions regarding uterine rupture, with 1 case of a paper thin myometrium found at the uterine fundus at the time of delivery in a subsequent pregnancy (257).
151 Chapter 2 Reproductive outcomes
For one woman following AS treatment, spontaneous uterine rupture occurred at 25 weeks gestation. The patient’s background included surgical correction of IUA, which was complicated with uterine perforation at the time of hysteroscopic adhesiolysis (258). The patient required a caesarean hysterectomy due to bleeding from an adherent low lying placenta. However, at the time of emergency caesarean delivery, it was noted that there were two actively bleeding puncture sites separate to the adherent placenta, and the fundus was extremely thin. There was 1000 mL of blood in the peritoneal cavity from the bleeding points. This case was complicated by two obstetric factors: abnormal placentation and a thin myometrium following treatment for AS.
Caesarean hysterectomy
There were 16 (0.87%) hysterectomies from 1828 births reported following hysteroscopic lysis of adhesions, as per Table 2.13 above. These hysterectomies were performed for antepartum, intrapartum, or postpartum haemorrhage, as well as placental abnormalities. Our data showed a slightly higher rate, with 4/85 deliveries
(4.7%). This increased figure is likely to be due to the extended length of follow up reported within our series. It also may be skewed by the relatively high number of women actually achieving a pregnancy within our series, with a rate of 98/124 (79%).
Indeed our sample may represent a number of women who were unable to even achieve pregnancy using other surgical techniques. Although once pregnancy is achieved, the endometrium may be inherently altered as a result of their AS, leading to this ultimate obstetric outcome.
152 Chapter 2 Reproductive outcomes
Possible explanation for the reproductive and obstetric outcomes of women with AS
Despite anatomical restoration of the uterine cavity, IUA seem to have a negative impact on pregnancy from implantation until delivery. Many women who present with AS have either required an intervention for a miscarriage (at times repeated curettage for recurrent miscarriage), or postpartum intervention for an adherent placenta. It is therefore difficult to distinguish the contribution of the intervention compared to cicatrisation of the endometrium or myometrium, or indeed
the woman’s own susceptibility to IUA leading to adverse obstetric outcomes.
Confounding this is the time taken to diagnose and manage IUA, which contributes to advancement of maternal age. Indeed the poor reproductive outcomes may be a product of the adhesions themselves, the predisposing factor or advanced maternal age (231).
Increasing evidence shows that hormonal aberrations and the hyperinflammatory state may lead to derangements of the immune-endocrine cross talk among endometrium, myometrium and cervix, and between decidua and trophoblast, predisposing women to pregnancy complications. Pathogenic mechanisms that contribute to IUA may impair pregnancy outcomes through common pathways associated with inflammation.
The abnormal endometrial milieu due to IUA or surgery may lead to suboptimal uterine receptivity due to inflammatory mechanisms. The establishment and development of successful pregnancy requires coordinated implantation of the embryo and trophoblast invasion into the receptive decidua. This process is followed by remodelling of the spiral arteries, proliferation, migration and invasion of trophoblastic cells into the maternal endometrium. These are essential steps and
153 Chapter 2 Reproductive outcomes failure of one of these due to endometrial dysfunction may be a basis for the development of obstetric complications.
Hormonal abnormalities, including altered endometrial receptor expression, are present in other gynaecological disorders such as endometriosis and polycystic ovarian syndrome. These hormone abnormalities drive endometrial dysfunction, leading to altered trophoblast and decidual invasion. Women with endometriosis also have been shown to have abnormal oestrogen receptor (ER) and progesterone receptor
(PR) mediated signalling pathways associated with progesterone resistance (275).
Apart from the sex steroids, abnormal decidual/trophoblast interaction may also be driven by metabolic dysfunction. Lower glycodelin may contribute to a more pro inflammatory environment in women with polycystic ovarian syndrome and endometriosis during early gestation, impairing trophoblast invasion (276). These alterations may lead to epigenetic changes in endometrium that persist long after the insult is removed or corrected. Widespread alterations in endometrial gene methylation, and therefore gene expression, affect endometrial function (277). Similar mechanisms such as receptor alterations and alterations in sex steroids may also be at play in the endometrium of women with IUA. These may affect initial implantation, which is responsible for laying the foundations for the subsequent gestation.
Activation of inflammatory pathways are also associated with immune and vascular dysfunction of the placenta and decidua. Wound healing is an intricate process, where body tissue repairs itself after injury. Following endometrial trauma, an orchestrated cascade of biochemical events is quickly set into motion to repair the damage. This process is divided into predictable phases: blood clotting hemostasis, inflammation, the growth of new tissue (proliferation), and the remodeling of tissue
(maturation). Inflammation aids the expulsion of bacteria and other pathogens or
154 Chapter 2 Reproductive outcomes
debris via phagocytosis. Platelet derived growth factors are released that signal
migration and division of cells during the proliferative phase. In angiogenesis,
vascular endothelial cells form new blood vessels. In fibroplasia and granulation
tissue formation, fibroblasts grow and form a new, provisional extracellular matrix by
excreting collagen and fibronectin. Maturation (remodeling) occurs as collagen is
realigned along tension lines, and cells that are no longer needed are removed by apoptosis.
Although inflammation is essential in normal wound healing (278), local
inflammatory pathways and reactive oxygen species are implicated in altered cell proliferation, apoptosis, increased oxidative stress and increased endometrial prostaglandin production with expression of cyclooxygenase 2 (COX2). This may impact on decidualisation, reducing endometrial receptivity. Inflammation may be enhanced by the altered ratio of progesterone receptor (PR) isoform A or PR isoform
B in eutopic endometrium (279). Uterine cavities containing leiomyomas show excess inflammation, with up-regulation of MMP’s and inflammatory cytokines such as IL-1, transforming growth factor B and tumour necrosis factor A (TNF A). These can contribute to pre term birth (280)
Deep to the endometrium, the myometrium is similarly affected by inflammatory markers. TNF A and IL-1 B increase the expression of COX-2 and the production of PGE2 by myometrial cells, while IL-6 up-regulates the expression of oxytocin receptors in the myometrial cells in vitro (281) (282). This may in part explain the alterations in menstrual function and fertility despite normalisation of macroscopic anatomy.
155 Chapter 2 Reproductive outcomes
Placentation
Abnormal placentation is a major cause of poor obstetric outcomes and potential placental mechanisms underlying the association between adverse pregnancy outcomes and reproductive disorders. The endometrial-myometrial junctional zone
(JZ) plays a critical role in human placentation and women with AS have defective deep placentation due to defective remodelling of the spiral arteries. In the absence of adequate decidual transformation, endovascular trophoblast cells arrest at the level of the endometrial-myometrial junctional zone and fail to progress into the myometrial spiral arteries. This may contribute to the vascular resistance in pPROM and preterm birth. Defective endovascular trophoblast invasion may also be secondary to absence of natural killer cells in the thickened myometrial JZ that are responsible for the depth of trophoblast invasion (283).
Inflammatory mechanisms such as syncytiotrophoblast apoptosis and shedding of products that extensively damage endothelial integrity can decrease utero-placental flow and activate molecular effects leading to hypoxia, thrombosis, and endothelial cell disruption. Excessive oxidative stress and complement activation can lead to placental damage, abnormal placental development, generalised endothelial activation and release of angiogenic factors (284). Thrombin up-regulates pro-inflammatory chemokines, resulting in endothelial dysfunction or inappropriate cell activation,
enhanced cell permeability or platelet aggregation.
156 Chapter 2 Reproductive outcomes
Conclusions
Intrauterine adhesions (IUA) are associated with the risk of obstetric complications. Affected women often require surgery, and multiple intrauterine procedures. Recurrent pregnancy loss, ART and advanced maternal age are confounding factors. The challenge is to dissect causation and confounders in determining how IUA predispose women to poor pregnancy outcomes.
Beyond surgical intervention for IUA, a major difficulty in the management of the woman with Asherman syndrome (AS) is to manage the pregnancy complications associated with the AS and minimise the associated adverse obstetric outcomes.
Revisiting the research questions
1. Is there a difference in menstrual outcomes before and after
fluoroscopically guided synaechiolysis for women with Asherman
syndrome (AS)?
2. What are the reproductive outcomes before and after fluoroscopically
guided synaechiolysis for women with AS?
3. What are the obstetric outcomes before and after fluoroscopically guided
synaechiolysis for women with AS?
157 Chapter 2 Reproductive outcomes
Summary
One should always consider pregnancies in women with a history of IUA as
high risk. Obstetric complications in this cohort of women are higher than the general population (257). Careful monitoring during the antenatal period is recommended, particularly in the third trimester. Understanding the inflammatory, endocrine and metabolic mechanisms responsible for the increased incidence of obstetric complications associated with IUA are important for treating doctors. Peri-conceptual counselling and prenatal guidelines should be developed to minimise risk factors.
These guidelines should also be used to alert health care professionals about the high- risk status of the pregnancy for the mother and neonate, in order to optimise pregnancy outcomes overall.
158 Chapter 3: Adhesion Barriers, and their role in Asherman Syndrome
Chapter 3: Adhesion barriers and their role in
Asherman syndrome
The reformation of intrauterine adhesions (IUA) remains a challenge for
surgeons caring for women with Asherman syndrome (AS). Despite achieving an
anatomically normal cavity following surgery, rates of adhesion reformation have been reported to be between 3.1–23.5% (22, 49) for mild to moderate adhesions, and
20–63% for severe adhesions (140). A number of approaches have been suggested to
reduce the risk of adhesion formation and recurrence, including hormonal or
antibacterial management (13, 201-203), stents and intrauterine devices (IUDs) (36,
107, 133), balloon catheters (47, 51, 60, 155, 170, 172), and adhesion barriers (204,
205, 285-287).
Hyaluronic acid (HA) is a water-soluble polysaccharide. It consists of multiple
disaccharide units of glucuronic acid N-acetylglucosamine bound together by a ß1-3
type glucoside bond. It is a natural component of the extracellular matrix and amniotic
fluid (AF). Hyaluronic acid (HA) is hypothesised to be an important ingredient in scar
free wound healing, promoting rapid re-epithelialisation of fetal skin (288). In a
recombinant form (289), HA has also been proposed as a barrier agent to prevent
adhesion formation after abdominal or pelvic surgery, with variable success to date.
HA forms a physical barrier between adjacent tissue surfaces and has biochemical
properties to minimise abnormal wound healing and adhesion formation (206). In
humans, exogenous HA is cleared from the surgical site within hours of deposition,
and rapid degradation is the biggest problem with its use. Therefore, chemically
159 Chapter 3: Adhesion Barriers, and their role in Asherman Syndrome modified forms have been developed to combat this issue. These forms have longer residence at the target tissue site, as the anti-adhesive effects depend on the preparation’s molecular weight and concentration (207). Minimising degradation time provides a mechanical separation of the uterine walls and allows the innate properties of hyaluronan to promote healing to the adjoining tissue (290). Preparations such as auto-crosslinked polysaccharide (ACP), hyaluronate and carboxymethylcellulose
(HA-CMC) gel and membranes have been developed in such a way. Preclinical studies report the effectiveness of ACP (86, 291-297), HA-CMC gel (298, 299), and membranes (300, 301). Although encouraging, in early murine (291, 300) and leporine (302-304) research, differences are evident in the endometrial properties of animals compared to human models (290). One rodent study shows HA-CMC to be persistent for seven days following application (304), which is far longer then it’s expected residence time in humans (290). These findings in animal studies have not been validated in the closest nonhuman primate models (305), nor in humans.
Following these early, reassuring, pre clinical trials, application of modified hyaluronic acid entered the human arena, with uptake in both research and clinical settings. The application has taken many forms in gynaecological surgery. Hyaluronic acid sheets have been applied to open peritoneal surfaces (306-308), and in a gel or powder form in laparoscopic surgery (208, 285, 309, 310). It has also been used in hysteroscopic surgery in primary prevention for intrauterine adhesions (IUA), with success reported in some studies (8, 204, 205, 311) and no difference to controls shown in others (178, 210). Observational studies have generally been small, with methodological flaws and only short-term follow up for clinically significant outcomes. Although meta-analyses have reported a reduction in adhesion formation in the gel form of hyaluronic acid, there was substantial heterogeneity between the
160 Chapter 3: Adhesion Barriers, and their role in Asherman Syndrome studies included which combined both hysteroscopic and laparoscopic surgery (310).
Human studies have generally only reported adhesion reformation or surrogate markers for this, such as mechanical separation at the walls of the uterus, as defined by ultrasound. Only one study in the human literature to date has reported early pregnancy data (286). No publications use live birth as a primary or secondary outcome. Publications are also marred with reporting and publication bias, with potential conflicts of interest also affecting the quality of the literature available.
In this chapter, the efficacy of the site-specific membrane SeprafilmTM
(Genzyme Corporation, Cambridge, MA) will be explored, infused into the uterine cavity as a ‘slurry’ immediately following synaechiolysis of IUA in AS versus no adhesion barrier applied following surgery. Menstrual, reproductive and obstetric outcomes are assessed in the immediate post-operative period, and at a follow-up period of greater than four years.
161 Chapter 3: Adhesion Barriers, and their role in Asherman Syndrome
Methods
Background
The research questions for this study are as follows:
1. Is there a difference in menstrual outcomes when using a SeprafilmTM
adhesion barrier after fluoroscopically guided synaechiolysis versus
fluoroscopically guided synaechiolysis alone for women with Asherman
syndrome (AS)?
2. Is there a difference in reproductive outcomes when using a SeprafilmTM
adhesion barrier after fluoroscopically guided synaechiolysis versus
fluoroscopically guided synaechiolysis alone for women with AS?
3. Is there a difference in obstetric outcomes when using a SeprafilmTM adhesion
barrier after fluoroscopically guided synaechiolysis versus fluoroscopically
guided synaechiolysis alone for women with AS?
Primary objectives (beyond Chapter 2) are as follows:
1. To compare overall gynaecological symptoms following fluoroscopically
guided synaechiolysis with an adhesion barrier compared to fluoroscopically
guided synaechiolysis alone (historical controls).
2. To compare fertility rates (pregnancy, miscarriage rates and live birth rates) in
women having fluoroscopically guided synaechiolysis with an adhesion
barrier compared to fluoroscopically guided synaechiolysis alone.
3. To compare obstetric outcomes in women who have had fluoroscopically
guided synaechiolysis with an adhesion barrier compared to fluoroscopically
guided synaechiolysis alone.
162 Chapter 3: Adhesion Barriers, and their role in Asherman Syndrome
Secondary objectives:
1. To compare any differences in fetal outcomes in babies born following
fluoroscopically guided synaechiolysis with an adhesion barrier compared to
fluoroscopically guided synaechiolysis alone.
2. To report any post-operative side effects and/or adverse reactions from using a
SeprafilmTM adhesion barrier immediately following fluoroscopically guided
synaechiolysis.
Approval for the study was obtained from the Bellberry Human Research Ethics
Committee (HREC) (study number 2012-03-687). The ethics approval letter is included as Appendix D. As part of the ethics committee’s approval for the study, a number of points were highlighted:
1) The importance of establishing the role of surgery for AS and the need for such
a rigorously performed study.
2) That there had been no adverse effects with the use of SeprafilmTM to date in the
body of literature, suggesting that SeprafilmTM was relatively safe for use.
3) That patients were sent out information prior to the consent process to be
allowed time to consider the information, and consent without coercion.
Following consent the questionnaire may be mailed or emailed to the patients or
a telephone interview may be performed.
163 Chapter 3: Adhesion Barriers, and their role in Asherman Syndrome
Literature Review
A literature review was performed using the Ovid Medline. Embase, and
PubMed databases, using medical subject headings Asherman Syndrome, intrauterine adhesions, adhesion barriers, Seprafilm, fertility, and pregnancy to obtain a comprehensive list of articles published between 1960 and 2016. To date, 621 papers were identified, including review articles and primary findings, when a search of adhesion barriers and uterus were used as headings. When this search was combined with Asherman syndrome or intrauterine adhesion, this limited the search to 70 papers. Upon reading the existing literature, the reference list was reviewed to capture any further relevant papers published in this area to provide a complete review of this area in the literature.
Women were recruited from the outpatient department of the Royal Hospital for Women, or the private consulting rooms of Professor Thierry Vancaillie (TVC), or
Associate Professor Jason Abbott (JA). Women were referred from three areas to the clinic or rooms:
1. general practitioners from the immediate local area;
2. other specialist gynaecologists from within the hospital; and
3. tertiary referrals from outside the hospital area.
Women were invited to participate in the study once inclusion and exclusion criteria were met. As these surgeons were known to have some expertise in the surgical division of adhesions, the surgeons were referred a number of women who had failed treatment elsewhere.
164 Chapter 3: Adhesion Barriers, and their role in Asherman Syndrome
Inclusion criteria
To be considered for entry into the study, women had to fulfil the following criteria:
1. Has proven intrauterine adhesions (IUA) based on hysteroscopic
assessment
2. Has undergone fluoroscopically guided synaechiolysis for Asherman
syndrome (AS) between 1 January, 2000 and 30 June, 2011. Long-term
outcomes such as pregnancy and obstetric factors were measured as part
of the study.
3. Is English speaking
4. Was over the age of 18 years at the time of surgery
5. Is capable of providing informed consent
6. Is living in Australia or New Zealand
Exclusion criteria
Women were excluded from the study if any of the following criteria were encountered:
1. Suspected diagnosis of gynaecological malignancy or its precursors.
2. Documented iodine allergy
3. Current pregnancy
4. Pre-existing condition of tuberculosis
165 Chapter 3: Adhesion Barriers, and their role in Asherman Syndrome
Previous medical or surgical treatment for IUA was not a contra-indication to
study entry. Women requiring surgical intervention for AS from January 2000 to June
2011 were offered fluoroscopically guided hysteroscopic synaechiolysis as described in Chapter 2.
From June 2008, one surgeon (TVC) introduced the application of an adhesion barrier as part of standard operative technique. The SeprafilmTM (Genzyme
Corporation, Cambridge, MA) slide membrane is cut into multiple pieces of
approximately 2 mm x 5 mm, and mixed with 10 mL of sterile water to form a slurry.
A 10 mL luer lock syringe is placed on the operative table. The plunger is removed
from the barrel. The SeprafilmTM solution was then poured into the finger flange end
of the syringe, while placing a finger or stopper at the tip to prevent leakage of the
fluid. The plunger is then re-attached and any air is pushed out of the barrel so that the
fluid fills the body of the syringe. The solution is then ready for installation into the
uterine cavity. The tip of the syringe is placed into the external cervical os and using
hand pressure, the plunger is driven into the barrel of the syringe, releasing the slurry through the cervical canal and into the endometrial cavity. The installation of the slurry was made immediately following the fluoroscopically guided synaechiolysis if the patient had no contraindications to its use. If the patient agreed with the use of the
adhesion barrier, a note was made in the medical records and in the operative report.
From June 2008, one surgeon routinely utilised this technique with all women with no
contraindications and its application was recorded in the operative report.
166 Chapter 3: Adhesion Barriers, and their role in Asherman Syndrome
All women having fluoroscopically guided synaechiolysis from January 2000 to June 2011 were invited to participate in the research study. Further information regarding the study was given to them by the primary researcher and included the following:
a. The format of the study, which compares the same procedure either with
or without the use of a SeprafilmTM (Genzyme Corporation, Cambridge,
MA) adhesion barrier.
b. That participation in the trial was voluntary and their medical care would
not be affected in any way if they did not participate.
c. That they would be given written information regarding the study (see
Appendix E) and could discuss their participation with their partner,
family or medical practitioner.
d. That if they consented to the study, they would be contacted by phone or
email, and undergo a telephone interview which would involve
approximately 20 minutes of their time.
e. That some of the questions on the questionnaire would be of a personal
nature relating to their reproductive organs, pregnancy and information
about any children they have.
Having met the entry criteria, women who consented to participate in the study
were contacted by telephone with a questionnaire obtaining demographic data, parity,
gynaecologic and menstrual history, medical and surgical history, previous treatments
and surgeries, fertility and infertility treatments, as well as pregnancies and obstetric
history.
167 Chapter 3: Adhesion Barriers, and their role in Asherman Syndrome
The medical records of those who consented were then audited for demographic data, parity, gynaecologic and menstrual history, medical and surgical history, previous treatments and surgeries, fertility and infertility treatments, as well as pregnancies and obstetric outcomes (before and after surgery for IUA). If there was a discrepancy between the medical records and the patients’ recollection, a second contact was made with the patient (either by telephone or by electronic mail) to seek clarification about the item in question and the patients’ recollection was used for data analysis. Patients were advised that they could withdraw from the study at any time without their medical care being affected in any way.
Intervention groups were as follows:
Historical controls (control group):
Those patients with confirmed IUA who had fluoroscopically guided
synaechiolysis as previously described in Chapter 2, with surgery being
performed between January 2000 and June 2011.
Adhesion barrier group (AB group):
Those patients who had fluoroscopically guided synaechiolysis with the
addition of SeprafilmTM following division of their IUA. Generally these
patients had had their procedure with TVC between June 2008 and June
2011.
168 Chapter 3: Adhesion Barriers, and their role in Asherman Syndrome
Surgical intervention
At the time of admission, each women had a full history and physical examination
completed by a resident medical officer, who was not involved with the study.
Surgery was undertaken by one of five surgeons: two consultant gynaecologists (TVC and JA) and five fellows training in minimal access surgery. All seven surgeons used a standardised technique. The technique has been described in more detail Chapter 2. Following surgery, all patients left the operating theatre with intravenous fluids and were taken to the recovery room. Once they had completed their initial post-operative recovery, the patients were moved to the day surgery waiting room, where the surgeon would meet the patient and explain the operative findings.
The operative notes were kept with the patient. These notes recorded the following:
the ESH grade (132) and written description of the location of the IUA;
any other intra operative findings;
the nature and extent of the surgery that was undertaken;
any complications of the surgery; and
post-operative directions for the patients.
Women recovered for two to three hours until they could eat, drink, mobilise and void. As routine, subjects took a post-operative course of antibiotics (100 mg of doxycycline twice daily for ten days) to prevent infection and oral oestradiol (2.5 mg daily, for three weeks) to stimulate recovery of the endometrium.
169 Chapter 3: Adhesion Barriers, and their role in Asherman Syndrome
Study participants were seen in the outpatients’ clinic or the private consulting rooms, where the surgery and symptoms were discussed. At the first post-operative appointment, occurring four to six weeks following adhesiolysis, AS subjects were asked about their symptoms to assess success of the procedure.
As per the protocol outlined in Chapter 2 of this thesis, only women who reported ongoing symptoms underwent a second-look hysteroscopy and concurrent synaechiolysis to review recurrence of adhesions. Repeat hysteroscopy and repeat adhesiolysis were routine practice for women who reported ongoing symptoms after their initial adhesiolysis. Any surgical complications were recorded at this visit or any time in the post-operative period. For the purposes of analysis, the index surgical intervention was assigned as the first surgical correction procedure undertaken by
TVC, JA or the associated fellow in one of the study centres.
Statistics
The sample size for this study was determined by the number of women available from the database, who had had surgery for AS between January 2000 and
June 2011. Group tables of variables for analysis were inspected to ascertain whether the control group and adhesion barrier (AB) group were similar. Association of dichotomous measures between the groups were assessed by using the chi-square test, or Fisher's exact test where the numbers were too small to be analysed using chi- square. Comparisons of continuous variables were undertaken using an analysis of variables test unless otherwise indicated. A p value of <0.05 was considered statistically significant.
170 Chapter 3: Adhesion Barriers, and their role in Asherman Syndrome
Results
The results with respect to the clinical evaluations in this thesis are presented in the following sections:
Overview
Assessment of similarity or differences between groups, and demographic
data
Menstrual comparison pre and post-operatively between the groups
Pregnancy and obstetric comparisons between the groups
Time to pregnancy analysis
Maternal complications comparison between the two groups
Fetal outcome comparison between the two groups
Overview
After reviewing hospital and clinician databases, 128 women with AS were identified as having had surgery performed between January 2000 and June 2011. Of these women, 87 women were identified as having had fluoroscopic guided synaechiolysis without the use of an adhesion barrier (control group), and forty-one women were identified as having had surgery with SeprafilmTM instilled immediately after resection of the IUA (adhesion barrier group).
In the control group (n= 87), five women were excluded due to miscoding and being identified as not truly having AS. Attempts were made to contact the remaining
82 women. Of these, 27 women were unable to be contacted, despite telephone and email contact. A further 20 were contacted by telephone, and agreed to review the study information, but never returned the consent form. Four were contacted by phone
171 Chapter 3: Adhesion Barriers, and their role in Asherman Syndrome but declined participation in the study and another eight gave written consent, but were not contactable to complete the telephone questionnaire. The remaining 23 completed the questionnaires, of which one was removed during analysis due to substantially incomplete data. This left a final number of 22 women with complete datasets for analysis in the control group.
In the adhesion barrier (AB) group (n=41), eight were unable to be contacted, and a further eleven were contactable and agreed to review the study documents but did not return the consent form. One woman declined participation. In the final analysis, there were 21 completed consents and questionnaires for the AB group.
Demographic data between the groups
Age, gravidity, and parity for the control group and AB group is summarised in Tables 3.1, 3.2, 3.3, and 3.4 below. There were no statistically significant differences in any of these factors between the two groups. As age can have a significant impact on chances of pregnancy, the two groups were assessed according to age of first and second pregnancy prior to and following surgery for AS (see Table
3.2). Using a chi-squared test, there were no statistically significant differences between the groups.
Table 3.1 – Mean age by group
Control Adhesion barrier
Age in years at diagnosis of AS: 33 (6.9) 30.5 (5.3) mean (SD)
172 Chapter 3: Adhesion Barriers, and their role in Asherman Syndrome
The mean age at the first and second pregnancies prior to AS were compared between the groups and the results are shown in Table 3.2. There was no statistical significance between the groups.
Table 3.2 – Mean age of first and second pregnancy prior to Asherman syndrome
Mean age
Pregnancy Control group AB group p value
First 30.2 31.05 0.60 Second 34.9 32.64 0.29
The time it took to achieve pregnancy in the first pregnancy prior to AS was assessed. This was similar in the two groups, with a mean time in the control group of
18.18 (SD 19.26) months, and a mean time in the AB group of 15.95 (SD 22.38) months (p = 0.729).
The groups were also similar with regard to the number of their pregnancies, as shown in Table 3.3. Most women were gravida three at the time of recruitment into the study. This likely reflects the nature of AS, with pregnancy a causative factor. One woman in each group was gravida zero. These two women had non-pregnancy related causes for AS, and never achieved pregnancy despite treatment. One woman in each group was gravida seven.
173 Chapter 3: Adhesion Barriers, and their role in Asherman Syndrome
Table 3.3 – Gravidity by group
Group Gravidity Total Control AB
0 1 1 2 1 2 2 4 2 3 2 5 3 8 6 14
4 1 4 5 5 5 3 8 6 1 2 3 7 1 1 2
Total 22 21 43
The majority of women in the study had a parity of two across both groups, with a relatively fewer number women para zero and para three. No patient had greater then three births prior to enrolment in the trial. These results are shown in
Table 3.4 below.
Table 3.4 – Parity by group
Group Parity Total Control AB
0 1 3 4 1 6 7 13
2 10 7 17 3 5 4 9
Total 22 21 43
174 Chapter 3: Adhesion Barriers, and their role in Asherman Syndrome
The grade of AS for the two groups is summarised in Table 3.5 below. Both cohorts have a high proportion of Grade III and IV AS. This is representative of the patients referred to the surgeons in this study, who would often have had failed treatment elsewhere for the IUA and be referred for a second opinion to the unit. The proportion of women with Grade 3 or 4 AS in the control group was 50%, whereas the proportion was 43% in the AB group.
Table 3.5 – Grade of Asherman syndrome by group
Group Grade Total Control (%) AB (%)
1 4 (18) 4 (19) 8 2 7 (32) 8 (38) 15
3 6 (27) 7 (33) 13 4 5 (23) 2 (10) 7
Total 22 21 43
Women were asked about prior gynaecological surgery, as this may have had an
impact on their fertility potential or even precipitated IUA. The types and number of procedures in the two groups are shown in Table 3.6 below. The groups were similar in terms of number of previous procedures.
175 Chapter 3: Adhesion Barriers, and their role in Asherman Syndrome
Table 3.6 – Gynaecological surgical procedures prior to diagnosis of intrauterine adhesions compared between groups
Group Gynaecological Procedures Total Control AB
No previous gynaecological 0 1 1 procedures
D&C not related to pregnancy 2 0 2
Myomectomy 1 0 1 Laparoscopy 2 1 3 Hysteroscopy 0 2 2
D&C post delivery 5 5 10
Synaechiolysis with another 2 0 2 technician
Cone biopsy/cervical 2 1 3 diathermy/LLETZ
D&C post miscarriage 4 8 12
Total 18 18 36 D&C = dilation and curettage
Complications of surgery such as uterine infection may contribute to developing IUA or indeed the severity of IUA. Study participants were asked about surgical complications, and a review of the medical record assessed complications in both groups. There was only one complication from a prior a gynaecological procedure reported in a woman within the control group, and the complication reported was intrauterine infection.
Women were asked if they had ever had any prior non-gynaecological surgical procedures in the patient questionnaire and the types and numbers of these other ‘non gynaecological’ operations are shown in Table 3.7 below.
176 Chapter 3: Adhesion Barriers, and their role in Asherman Syndrome
Table 3.7 – Non-gynaecological surgical procedures prior to diagnosis of intrauterine adhesions compared between groups
Group Surgical procedures Total Control AB
None 16 17 33 Appendectomy 2 1 3 Back surgery 0 1 1 Knee surgery 2 0 2 Cosmetic surgery to face 0 2 2
Ganglion removed from hand 1 0 1
Colonoscopy 1 0 1
Total 22 21 43
Cause of Asherman syndrome
AS is generally caused by a surgical intervention (36). However, many of the women in the study had had a number of surgical procedures prior to their diagnosis of AS. Therefore women were asked specifically in the questionnaire which procedure was the initiating event prior to the diagnosis of AS. The results of responses to this question are shown in Table 3.8 below. The majority of cases occurred in the pregnant or recently postpartum uterus. In the control group, pregnancy related causes accounted for 18/22 (82%), and in the adhesion barrier group, the rate was slightly higher at 18/21 (86%). Indeed the most common cause of adhesion formation was as a result of curettage or intervention postpartum (36% and
42% in control and adhesion barrier groups respectively). There were also a high number of IUA that occurred as a result of curettage for miscarriage (31% and 38% in control and adhesion barrier groups respectively). As expected, the occurrence of IUA whilst not pregnant was uncommon in our cohort. In the control group (historical
177 Chapter 3: Adhesion Barriers, and their role in Asherman Syndrome cohort), two woman developed IUA following a hysteroscopic myomectomy. This surgical technique was less common in the recent cohort, with the AB group having no women report myomectomy related AS. In the AB group, one woman developed
IUA following a cone biopsy and laparoscopic excision of endometriosis. The adhesions were persistent at the internal os / isthmus. Another two women developed
AS following an endometrial biopsy unrelated to pregnancy.
Table 3.8 – Responses of women in each group of their perceived cause of Asherman syndrome
Group Cause of AS Total Control AB
D&C postpartum 8 (36%) 9 (42%) 3
Causes D&C post miscarriage 7 (31%) 8 (38%) 15 related to D&C at time of ectopic 1 (5%) 0 (0%) 1 pregnancy pregnancy At caesarean delivery 1 (5%) 0 (0%) 1 D&C post TOP 1 (5%) 1 (5%) 2 Causes not D&C not related to pregnancy 0 (0%) 2 (10%) 2 related to pregnancy Hysteroscopic myomectomy 2 (9%) 0 (0%) 2 Cone biopsy 0 (0%) 1 (5%) 14
Cause unknown 2 (9%) 0 2
Total 22 21 43 D&C = dilation and curettage
Women were asked about their past medical history to assess if there were any similarities or differences between the groups. The results are shown in Table 3.9 below. No women in either group reported tuberculosis in their past medical history.
178 Chapter 3: Adhesion Barriers, and their role in Asherman Syndrome
Table 3.9 – Medical conditions compared between the groups
Group Past medical conditions Total Control AB
None 18 16 34 Raynaud’s syndrome 1 0 1 Asthma 1 0 1 Hypothyroidism 1 1 1 Coeliac disease 1 0 1 PCOS 1 3 4 Precancerous lesion of the cervix 0 1 1
Total 23 21 43
Women were asked about their regular medications to assess whether there were any similarities or differences between the groups. The results are shown in
Table 3.10 below. Most women were not taking any regular medications at the time of questionnaire.
Table 3.10 – Regular medication use compared between the groups
Group Medication Total Control AB
None 11 16 27 Low dose aspirin 1 0 1 Pregnancy vitamins 7 2 9 Inhalants for asthma 1 0 1
Thyroxine 1 0 1 Biguanide (Metformin) 1 1 2 Naturopathic herbs 0 1 1 Unknown 0 1 1
Total 22 21 43
179 Chapter 3: Adhesion Barriers, and their role in Asherman Syndrome
No women in the adhesion barrier group reported any known drug allergies. In the control group, four women reported allergies to each of the following respectively: metronidazole, cefalexin, metoclopramide (maxalon), and penicillin.
A number of women required multiple hysteroscopic procedures for complete synaechiolysis and normalisation of the cavity. Table 3.11 below shows the number of repeat procedures (excluding the index procedures) that were required between the groups in the first six months following index procedure.
Table 3.11 – Number of repeat hysteroscopic resection procedures within six months of
index surgery
Group Number of repeat Total procedures Control AB
0 14 11 25 1 6 8 14 2 1 1 2 4 1 1 2
Total 22 21 43
Women were reviewed regarding hysteroscopic procedures within six months of
the index surgery. This generally indicated recurrence of adhesions. In total, 8/22
(36.4%) women in the control group required a repeat procedure and 10/21(47.6%)
required a repeat procedure. A statistical analysis comparing those who did need a
repeat procedure versus those who did not require a repeat procedure was performed,
and a 2 analysis showed no statistically significant difference between the groups (p
= 0.46).
180 Chapter 3: Adhesion Barriers, and their role in Asherman Syndrome
The recurrence rate of adhesions requiring repeat surgery was similar in both groups. In the control group, two women required one procedure, and another two women required two procedures for recurrence. In the AB group, a total of four women had recurrence of adhesions, whereby one required one subsequent synaechiolysis, and three women needed two procedures to resect recurrent adhesions and normalise the cavity. All women in the AB group for the index surgery also had an adhesive barrier applied for subsequent revisions. No women in the control group had an adhesive barrier applied in any of their subsequent surgeries.
Table 3.12 – Repeat hysteroscopic resection procedures greater than six months
following index surgery for recurrent intrauterine adhesions
Group Number of Total procedures Control AB
0 18 17 35 1 2 1 3 2 2 3 5
Total 22 21 43
As there were only a small number of women who needed surgery > 6 months
from index procedure (four in each group), a statistical analysis could only be
performed using Fischer’s exact test, and there was no statistically significant differences between these groups (p = 0.94).
181 Chapter 3: Adhesion Barriers, and their role in Asherman Syndrome
Menstrual Outcomes
Menstruation prior to treatment
Amenorrhoea is an established symptom of AS. The amenorrhoea rate prior to
index surgery was similar between the groups, with 13/22 (59%) in the control group,
and 12/21 (57%) in the AB group.
Of those women that reported menstrual bleeding prior to index surgery, all
9/9 in the control group (100%) reported regular cycles. Whereas in the AB group,
7/10 (70%) stated their periods were regular.
Menstruation six months after surgery
Six months after treatment, 2/22 (9%) women in the control group reported amenorrhoea, where one woman had persistent amenorrhoea, and in another woman the type of menstruation was unknown. In the AB group, all women reported return of
their menstruation.
Of those that reported menstruation in the control group, 19/21 (90%) reported
regular cycles, and in 2/21 (10%) cases the bleeding pattern was unknown. In the 21
women in the AB group who reported return to menstruation, 20/21 (95%) reported
regular cycles, and 1/21 (5%) reported having an irregular cycle.
The days of bleeding were assessed between the groups and there were no
significant differences between the groups (p = 0.513).
182 Chapter 3: Adhesion Barriers, and their role in Asherman Syndrome
Pregnancy
Planning pregnancy
For many of the women diagnosed with AS, treatment is sought to facilitate pregnancy. In this cohort, 21/22 (95%) women in the control group wished to conceive prior to undergoing surgery, and all of the 21 women in the AB arm were planning pregnancy prior to undertaking the index surgery.
The number of pregnancies prior to AS was similar in each group, with the exception of one woman in the control group who had seven pregnancies prior to the diagnosis of AS. This number is different to the reported gravidity shown in Table
3.13, which reports gravidity (pregnancies before and after surgery) at the time of study entry.
Table 3.13 – Number of pregnancies prior to the diagnosis of Asherman syndrome
Group Number of Total Pregnancies Control AB
0 2 2 4 1 11 7 18 2 7 8 16 3 0 2 2 4 1 2 3 7 1 0 1
Total 22 21 43
Overall, pregnancies and their outcomes prior to AS were compared between
the groups. The results are shown in the Tables 3.14 – 3.20. There were no statistically significant differences between the groups (p = 0.342).
183 Chapter 3: Adhesion Barriers, and their role in Asherman Syndrome
First pregnancy prior to Asherman syndrome
Women were asked about the outcome of their first pregnancy prior to the diagnosis of IAU. The results are displayed in Table 3.14 below.
Table 3.14 – Outcomes of the first pregnancy prior to the diagnosis of Asherman
syndrome
Group Outcome of first pregnancy Total before AS Control AB
Live birth 10 9 19 Miscarriage 5 8 13 Termination of pregnancy 5 1 6 Stillbirth twin gestation 0 1 1 Ectopic 1 0 Not pregnant 1 2 4
Total 22 21 43
The groups were similar in the types of pregnancies that occurred in the first
pregnancy before AS, with the exception of the termination of pregnancy for five
women in the control group, and one in the AB group, who reported a prior
termination of pregnancy. In the AB group, eight women had a prior miscarriage, and
only five had in the control group. However, there were no statistically significant
differences between these groups using a 2 test (p = 0.342).
The age at first pregnancy was similar between the groups. The mean age in the control group was 30 years (range 18-40), and the age of the first pregnancy in the adhesion barrier group was 31 years (range 23-42). There was no difference between the groups using students t test (p = 0.604).
184 Chapter 3: Adhesion Barriers, and their role in Asherman Syndrome
The birth weights for the live births prior to AS across the two groups were compared for the first births. The mean birth weight for single births was 3.5 kg
(range 2.8–4.3 kg) in the control group and 3.6 kg (range 2.95–5 kg) in the AB group.
There was one set of twins in the AB group, with a mean weight of 2 kg.
Mode of delivery for first pregnancy prior to AS
The vaginal birth rate was 7/10 (70%) of those who delivered in the control group, and 5/9 (55%) in the AB group. Conversely, the caesarean rate in the control
group was 3/10 (30%), and in the AB group it was 4/9 (45%).
Maternal complication during pregnancies prior to AS
Maternal complications for the first pregnancy prior to AS across the groups are shown in Table 3.15. These were assessed to review whether this was similar between the control and AB groups, or whether other maternal factors were confounding the obstetric outcomes following synaechiolysis surgery.
More women in the control group had uncomplicated pregnancies prior to AS.
Intrauterine infection only occurred in one woman in the control group. However, one woman in the AB group experienced a febrile illness postpartum (endometritis was not confirmed). Retained products occurred in equal numbers across the groups.
Manual removal of the placenta was only required in one woman in the AB group.
185 Chapter 3: Adhesion Barriers, and their role in Asherman Syndrome
Table 3.15 – Maternal complications compared between groups
Group Maternal complication Total Control AB
None 11 5 16 Infection 1 0 1 Febrile illness 0 1 1
Retained products/Ongoing 8 8 16 Bleeding
Manual Removal of Placenta 0 1 1 Pelvic bone injury 0 1 1 Unknown / Not applicable 2 5 7
Total 22 21 43
Second pregnancy prior to Asherman syndrome
Table 3.16 summarises the results for the women who had a second pregnancy prior to the diagnosis of AS.
The mean age for the control group was 35 years (range 28-42) and 32 years
(range 23-37) in the AB group, with no statistically significant difference between the groups (p = 0.291)
Table 3.16 – Outcomes of second pregnancy prior to the diagnosis of Asherman syndrome
Group Outcome of second pregnancy Total Control AB
Live birth 5 3 8 Miscarriage 5 5 10 Termination 0 2 2 Still birth 0 1 1 Not pregnant 12 10 22
Total 22 21 43
186 Chapter 3: Adhesion Barriers, and their role in Asherman Syndrome
The birth weights for the live births in second pregnancies prior to AS across the two groups were compared. The mean birth weight in the control group was
2.4 kg (range 0.8–2.7 kg) and 3.2 kg (range 3.0–3.4 kg) in the AB group.
Of the five live births in the control group, there were two vaginal deliveries
(40%) and two caesarean deliveries. In one case, the method of delivery was unknown. In the AB group, there was one vaginal delivery and two caesarean deliveries.
Two babies were born prematurely in the control group. There were no fetal complications in the AB group.
Maternal complications were similar for the second pregnancies across the groups. There were five live births in the control group, and of these 3/5 (60%) had retained products of conception. Of those that had a miscarriage in the second pregnancy of the control group, 3/5 (60%) suffered from retained products. All three of the women who had a live birth in the AB group had retained products following their deliveries (100%), and a further 4/7 (57%) who had a miscarriage or termination also had retained products. In the AB group, there was one stillbirth at 29 weeks gestation, which also resulted in retained products.
Third pregnancy prior to Asherman syndrome
There were two women in the control group who had three pregnancies prior to AS. The outcome of both of these pregnancies was early miscarriage, and one of these women had retained products of conception.
There were three women in the AB group who had three pregnancies prior to
AS. In their third pregnancy, two women had an early miscarriage and one woman had a live birth delivered vaginally weighing 3 kg.
187 Chapter 3: Adhesion Barriers, and their role in Asherman Syndrome
Greater than third pregnancy pre Asherman syndrome
There was one woman in the control group who had more then three pregnancies. The outcome of her fourth pregnancy was a live birth delivered vaginally, weighing 3.7 kg. This pregnancy was complicated by retained products of conception, which ultimately caused her AS.
There were three women in the AB group who had more then three pregnancies before AS. One woman had two stillbirths consecutively in her third and fourth pregnancies, and developed IUA after curettage following delivery of her fourth stillbirth. The other two women had first trimester miscarriages, and in one case, the woman had a total of seven miscarriages prior to diagnosis and surgery for
AS.
Table 3.17 – The number of pregnancies defined by group prior to AS
Group Number of pregnancies Total Control AB prior to AS n (%) n (%) n (%)
0 2 (9) 2 (10) 4 (9) 1 11 (50) 7 (33) 18 (42) 2 7 (32) 8 (37) 16 (37) 3 0 (0) 1 (5) 1 (2) 4 1 (5) 2 (10) 3 (7) 7 1 (5) 1 (5) 1 (2)
Total 22 21 43
The majority of women had one pregnancy prior to AS in the control group, and in the AB group the majority had two pregnancies prior to AS.
188 Chapter 3: Adhesion Barriers, and their role in Asherman Syndrome
Overall in the control group, prior to AS, there were 34 pregnancies in 22 women; 16 (47%) live births, 12 (35%) miscarriages, 5 (15%) terminations, no stillbirths and 1 (3%) ectopic pregnancy.
Overall in the AB group, prior to AS, there were 39 pregnancies in 21 women;
13 (33%) live births, 19 (49%) miscarriages, 3 (8%) terminations, 4 (10%) stillbirths,
and no ectopic pregnancies.
Groups were assessed to determine whether there were any differences in
maternal complications during or after pregnancies proceeding AS. An analysis was
also performed to assess if an increase in the maternal complications during
pregnancy led to a higher grade of AS. This analysis did not show any increase in
subsequent grade of AS related to particular types of complications. However, this
may be due to the fact that the numbers in the sample were too small to ascertain a
difference. The results are tabulated below in Tables 3.18, 3.19 and 3.20.
Maternal complications prior to AS were compared between AB and control
groups. There were three groupings made; complications relating to infection (pelvic
infection and fever); complications relating to placentation (retained products of
conception, manual removal of placenta, placenta abruption, placenta accreta,
antepartum haemorrhage, postpartum haemorrhage, and hysterectomy), and finally
other complications were grouped (pelvic bone injury, gestational diabetes, perennial
tears). The results are shown of the women who reported complications in
pregnancies prior to AS, and the results are displayed in Table 3.18. There were no
statistically significant differences between the groups.
189 Chapter 3: Adhesion Barriers, and their role in Asherman Syndrome
Table 3.18 – Maternal complications in live births prior to the diagnosis of Asherman syndrome
Group Total Complication Control AB n (p value) n (%) n (%)
No complications 11 (55) 5 (33) 16 (0.460) Complications relating to infection 1 (5) 1 (7) 2 (0.460)
Complications relating to placentation 8 (40) 8 (53) 16 (0.395) Other complications 0 (0) 1 (7) 1 (0.168)
Total 20 15 35
Table 3.19 – Maternal complications in live births prior to the diagnosis of Asherman syndrome (AS) according to grade of AS
Grade I Grade II Grade III Grade IV Total Complication n (%) n (%) n (%) n (%) n (p value)
No complications 3 (50) 7 (50) 3 (33.3) 3 (50) 16 (45.7) Infection 1 (16.7) 0 (0) 1 (11.1) 0 (0) 2 (5.7) Placentation 1 (16.7) 7 (50) 5 (55.6) 3 (50) 16 (45.7) related Placentation 1 (16.7) 0 (0) 0 (0) 0 (0) 1 (2.9) unrelated
Total 6 14 9 6 35
Table 3.20 – Maternal complications in live births prior to the diagnosis of Asherman syndrome (AS) grouped according to grade of AS
Grouped AS grade Complication Total Grade I & II Grade III & IV
No complication 10 6 16 Infection 1 1 2
Placentation related 8 8 16 Placentation unrelated 1 0 1
Total 20 15 35
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There were no significant differences in the groups when combining lower grade and
higher grade AS, when related to maternal complications prior to AS using a chi-
squared test (p = 0.73). This is shown in Table 3.20.
Pregnancies following surgery
Pregnancies following adhesiolysis surgery
Following hysteroscopic synaechiolysis, 21 women in each arm reported trying to conceive. The woman who did not try to conceive after surgery was in the control group and following seven previous miscarriages had elected to accept childlessness.
In the control group, of those who tried to conceive, 13/21 (62%) tried to
conceive immediately after synaechiolysis, and 8/21 (38%) waited at least one month
following surgery. Fewer women in the AB group tried to conceive immediately, with
9/21 (43%) trying immediately, and 12/21 (57%) waiting at least one month prior to
attempting conception.
The age of pregnancy was assessed across the groups and it was found that
there were no significant differences between the groups (see Table 3.21 below).
Table 3.21 – Mean age of first and second pregnancy following Asherman syndrome
Mean age of group
n (p value)
Pregnancy Control group AB group
First 34.88 (0.76) 34.47 (0.76) Second 36.00 (0.86) 35.73 (0.86)
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Pregnancy 1 following synaechiolysis surgery
The age of pregnancy has an impact on the chance of conception (267). The mean age of first pregnancy following index surgery for AS in the control group was
35 years (range 27-44), and in the AB group was 34 years (range 28-41). There was no statistically significant difference between the groups (p = 0.757).
The time to pregnancy was assessed between the groups (of those women who managed to conceive). The mean time taken for the control group was 4.3 months, and the mean time to achieve pregnancy in the AB group was 3.5 months. There was no statistically significant difference between the groups (p = 0.729).
Upon first attempt of pregnancy, 11/21 (52%) women who tried to conceive in the control group, and 10/21 (48%) in the AB group, achieved a live birth. The miscarriage rate was equal in both groups, at 6/21 (29%). There was one termination of pregnancy in the AB group for a congenital anomaly in the fetus.
Of the 11 live births in the control group, 4/11 (36%) had a vaginal delivery, and 7/11 (64%) had a caesarean delivery. In the AB group, there were 5/10 (50%) vaginal births and 5/10 (50%) caesarean deliveries.
Table 3.22 – Outcomes of the first pregnancy following adhesiolysis
Group
Pregnancy outcome Control AB Total n (%) n (%)
Live birth 11 (50) 10 (48) 21 Miscarriage 6 (27) 6 (27) 12
Termination of pregnancy 0 (0) 1 (5) 1 Not pregnant 5 (23) 4 (20) 9
Total 22 21 43
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Mean birth weight in the control group for first birth following surgery was
3.3 kg (range 1.3–4.3 kg), and in the AB group the mean birth weight was 3.4 kg
(range 2.8–4 kg). There were no significant differences between the groups (p =
0.266).
The fetal complications that were reported in these pregnancies have been
tabulated below. There was no statistically significant difference in the complication
rate or types of complications between the groups. However, the overall fetal
complication rates for these pregnancies were high compared to the general
population (272).
Table 3.23 – Fetal complications following first pregnancy
Group
Complication Control AB Total n (%) n (%)
No complications 6 (55) 6 (60) 12 Admission to NICU 2 (18) 1 (10) 3 Intrauterine growth restriction 1 (9) 0 (0) 1 Breech 1 (9) 1 (10) 2 Preterm 2 (18) 2 (20) 4 Cephalohaematoma 1 (9) 0 (0) 1 Total number of complications (more then one complication in some 13 10 23 pregnancies)
Maternal complications arose in pregnancies from both groups. In the control group, retained products following delivery were reported in 1/11(9%), and a further one woman suffered from a postpartum haemorrhage. Another woman had a severe placenta accreta and required a hysterectomy following her delivery. The baby was delivered pre-term and required admission to the NICU. However, the baby survived
193 Chapter 3: Adhesion Barriers, and their role in Asherman Syndrome
without ongoing issues. In the AB group, there was a similar rate of complications.
There was 1/10 (10%) woman who reported retained products following delivery and there was another woman, 1/10 (10%), who reported postpartum haemorrhage. One woman required a manual removal of placenta – 1/10 (10%). There was also one reported case of placenta accreta, which did not require a hysterectomy and a separate woman who required a hysterectomy in her first pregnancy following surgery for IUA
due to postpartum haemorrhage.
Although there were no statistically significant differences in the complication
rate or types of complications between the groups, the overall maternal complication
rates in both groups were high compared to the general population (272).
Second pregnancy following synaechiolysis surgery
In the control group, there were 11 women who had two pregnancies after
surgery for AS. Of those that had a pregnancy, three were miscarriages (27%), seven
were live births (64%), and one had a termination of pregnancy for Trisomy 21 (9%).
Of the live births in the control group, two were delivered vaginally and five by
caesarean. In the AB group, there were also 11 pregnancies; four miscarriages (36%),
six live births (55%), and one stillbirth. There were equal numbers of vaginal deliveries and caesarean deliveries in the AB group.
Of the live births in the second pregnancy, the mean gestational weight in the control group was 3.4 kg (range 2.8–4.3 kg). Of the live births in the AB group, the mean gestational weight was 2.8 kg (range 1.8–3.3 kg). There were no statistically significant differences between the groups (p = 0.054).
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Table 3.24 – Fetal complications in the second pregnancy following index surgery
Group
Complication Control AB Total n (%) n (%)
Pregnant, no complication 5 (23) 4 (19) 9 NICU 2 (9) 0 (0) 2 Breech 1 (5) 0 (0) 1
Premature 0 (0) 1* (5) 1 Intrauterine growth restriction 0 (0) 1* (5) 1 Hypospadias 0 (0) 1 (5) 1 Not applicable / not pregnant 14 (64) 15 (71) 29
Total 22 22 * 43
Note *1 woman had 2 complications
The maternal complications for the second pregnancy are shown in Table
3.25. There was one woman who required manual removal of placenta following delivery, and another woman who had a placental abruption following a vaginal delivery at term for a 3.1 kg baby. This baby went to the NICU but otherwise had no complications.
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Table 3.25 – Maternal complications in the second pregnancy following index surgery
Group
Complication Control AB Total n (%) n (%) Pregnant, no complications 10 (45) 10 (48) 20 Manual removal of placenta 1 (5) 0 (0) 1
Placental abruption 1 (5) 0 (0) 1 Not applicable 10 (45) 11 (52) 21
Total 22 21 43
Third pregnancy following synaechiolysis surgery
In the control group there were five women who had three pregnancies following surgery for AS, four of which were live births, and one was a miscarriage.
In the AB group, there were four women who had three pregnancies following surgery, with only one live birth, and three miscarriages.
The mean birth weight in the control group was 2.98 kg (range 1.97-3.4 kg), and in the AB group, the birth weight of the only live birth was 3.85 kg.
Table 3.26 – Fetal complications in the third pregnancy following index surgery
Group
Complication Control AB Total n (%) n (%)
None 4 (18) 1 (5) 5 NICU 1* (5) 0 (0) 1
Premature 1* (5) 0 (0) 1 Not applicable 17 (77) 20 (95) 37
Total 23* 21 44
Note * complication occurring in the same pregnancy
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There were no maternal complications reported in the third pregnancies for either group.
Fourth pregnancy following synaechiolysis surgery
There were two women in both groups who had fourth live births, and two
women in each group that had miscarriages in their fourth pregnancy following
surgery. The mean age of fourth pregnancy in the control group was 37 years, and 34 years in the AB group. Both miscarriages were in the first trimester. In the control
group, the live birth was delivered by caesarean delivery. The baby was premature but
did not require admission to the NICU, and the pregnancy was only complicated by
antepartum haemorrhage. In the AB group, the baby was delivered vaginally with no
maternal or fetal complications.
Live births following surgery
When comparing live birth weights, there were no statistically significant
differences between the groups when comparing the first and second live births
following treatment for AS. This is shown in Table 3.27.
Table 3.27 – Live birth weights in the first and second pregnancy following index
surgery
Number of live Mean birth weight p value births kg (SD)
First live Control 11 2.97 (0.90) 0.27 birth AB 8 3.37 (0.43) 0.22
Second live Control 7 3.44 (0.47) 0.05 birth AB 6 2.82 (0.60) 0.06
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Differences in groups for combined complications were assessed, and there were no differences in the types of complications leading to AS between control and
AB groups. Complications relating to ‘placentation’ were grouped, including: retained products of conception, manual removal of placenta, placenta abruption, placenta accreta, antepartum haemorrhage, postpartum haemorrhage, and hysterectomy. There were no significant differences between the groups. This is shown in Table 3.28.
Table 3.28 – Combined complications for pregnancies prior to AS
Group Total Complications Control AB (p value) n (%) n (%)
None 2 (10) 2 (9) 4 (0.98) Others 10 (45) 10 (48) 20 (0.98) Placentation related 10 (45) 9 (43) 19 (0.88)
Total 22 21 43
Pregnancies following IUA
Pregnancies following AS have an increased risk of maternal and fetal
complications, mainly related to placentation. Therefore these complications were
assessed independently from the other reported complications (such as breech presentation) for statistical purposes. The two groups were then compared see if the use of AB increased or reduced the likelihood of these complications. Maternal
complications were divided into two groups: group one concerned placenta related
complications (retained products of conception, manual removal of placenta, placental
abruption, placenta accreta, postpartum haemorrhage, and hysterectomy), and group
two contained all other complications. When comparing the two groups using the 2
test, there were no differences in the occurrence of these complications relating to
198 Chapter 3: Adhesion Barriers, and their role in Asherman Syndrome
infection (p = 0.726), nor placental complications (p = 0.641), or the other
complications assessed as a group (p = 0.704).
Fetal complications relating to abnormal placentation were also separately
assessed. The complications that were grouped were: potentially placental related
(prematurity, intrauterine growth restriction, low birth weight, and admission to
NICU). Other complications were also grouped for the purpose of statistical analysis.
On comparing the groups using the 2 test, there were no statistical differences
between the groups for these placental complications (p = 0.758), and the other
complications (p = 0.747).
Assisted reproductive technologies (ART)
In the control group, 6/22 (27%) required in vitro fertilisation (IVF) or
intracytoplasmic sperm injection (ICSI) to assist conception. Three of these women
(50%) never achieved a pregnancy, despite ART. One woman conceived a live birth
only after the use of donor oocytes (having had two miscarriages with her own eggs
prior to this). Another woman conceived but had an early miscarriage. There was therefore only one woman (17%) who had a successful live birth with her own eggs following ART.
In the AB group, there were 7/21 (33%) women who utilised IVF or ICSI to
assist conception. Of this group, two required IVF to conceive prior to the diagnosis
of AS – one for male factor infertility and for the other woman, the reason was
unknown. However, advanced maternal age is likely to have contributed in this latter
case, as she was over 40 years of age at the diagnosis of AS. Of the 7/21 women, five
(71%) were successful in conceiving after synaechiolysis surgery, and two (29%)
were unsuccessful. Of the five women who achieved pregnancy, four (80%) resulted
199 Chapter 3: Adhesion Barriers, and their role in Asherman Syndrome
in live births, and one (20%) woman had a stillbirth. Following the stillbirth, in a subsequent pregnancy, the same woman had a termination of pregnancy for a congenital anomaly.
Time to pregnancy analysis
The time to pregnancy between the groups was compared by an inverted
Kaplan-Meier survival curve. The Kaplan-Meier is a non-parametric statistic and is generally used to measure survival from lifetime data. The analysis involves a series of increasing horizontal steps. The method takes into account ‘censored’ data, such as
‘right censoring’, where women may have achieved a pregnancy but it was not a live
birth. On the plot, these are shown as tick-marks, which indicate individual women
whose event has been right censored. The other important piece of information
required to generate the Kaplan-Meier estimate is the time required to achieve the
event occurrence (pregnancy).
Four analyses were performed on the study data. The initial two analyses
included only the women who had ever achieved a pregnancy during the study follow
up period. The final two analyses included all women in the cohort. This required re-
coding of those women who never achieved a pregnancy to a time for achieving the
event outside of the follow up period, making the assumption that they were still
trying to achieve pregnancy at the end of the study duration.
Overall, there were seventeen women that achieved a pregnancy in each
group. The analyses were only performed for the first pregnancy following treatment.
Of the seventeen pregnancies in the control group, there were six miscarriages
and eleven live births. The median time to pregnancy was three months, with a range
of one to twelve months. In the AB group, there were also seventeen pregnancies,
200 Chapter 3: Adhesion Barriers, and their role in Asherman Syndrome
including six miscarriages, one termination of pregnancy and ten live births. The
median time to pregnancy was two months, with a range of one to seventeen months
to achieve pregnancy.
Analysis A – incorporating only those who achieved a pregnancy with
censoring for live birth
Cumulative number and proportion of time was utilised to generate the graph
below in Figure 3.1. In Analysis A, all pregnancies were included in the analysis.
However, if the pregnancy resulted in an outcome other then a live birth, the case was
censored in the curve. The aim in this analysis was to only represent live birth
outcomes.
Figure 3.1 – Kaplan-Meier survival curve including only cases where pregnancies occurred, censored for non-live birth events
201 Chapter 3: Adhesion Barriers, and their role in Asherman Syndrome
The break points (tick marks) seen illustrated within the curve indicate the pregnancies that were achieved, and resulted in an outcome other then a live birth. An example of an outcome other than a live birth being the final pregnancy that occurred in the AB group, which resulted in a termination of pregnancy.
Analysis B – incorporating only those who achieved a pregnancy without
censoring for live birth
This analysis included all pregnancies that occurred in each cohort, which did not censor / exclude the pregnancies other then live births. Cumulative number and proportion of time was utilised to generate the graph below in Figure 3.2.
Figure 3.2 – Kaplan-Meier curve including only cases where pregnancies occurred and
including all pregnancy types with no censoring
202 Chapter 3: Adhesion Barriers, and their role in Asherman Syndrome
In Analysis B, both groups reached 100%, as only the women who achieved this outcome were included. All pregnancies whether they resulted in live birth, miscarriage, or termination were treated in a similar fashion for the purpose of this analysis.
Analysis C – all women pregnant or not with censoring
The entire cohort of women, including those that never achieved a pregnancy during follow up were included in this analysis. In order to run the Kaplan Meyer test, a set time of 50 months was allocated to the women who never achieved a pregnancy
(which was outside the follow up period for the study). The ‘non-pregnant’ group could then be included in the analysis.
In Figure 3.3 below, the entire cohort of women were included. However, only those who achieved a live birth were uncensored from the analysis. This curve reflects the live birth rate in the first pregnancy following AS. This rate was slightly lower then the overall 14/21 (66.7%) live births in the control group, and 15/22 (68.2%) live births in the AB group.
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Figure 3.3 – Kaplan-Meier curve censored for live births
Analysis D – the entire cohort without censoring
Analysis D was run whereby all cases in the cohort were included and the results were not censored for just live birth outcomes. This is representative of the first pregnancy that occurred following surgery for AS, whether it resulted in a live birth, miscarriage, ectopic pregnancy, or termination of pregnancy. The graph for
Analysis D is depicted in Figure 3.4 below.
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Figure 3.4 – Kaplan-Meier curve illustrating all pregnancies in the control and
SeprafilmTM group
This curve shows a pregnancy rate for the first pregnancy only, which is
slightly lower then the 77% pregnancy rate in the controls, and 81% in the AB group
as a whole. This is discussed in more detail below.
Summary of pregnancies by group
The overall pregnancy rate in the control group was 17/22 (77%). A number of
women had more then one pregnancy following surgery. There were 22 live births in
15 women: nine women had a single live birth after surgery, five women had two live
births, and one woman had three live births following surgery for AS. There were a
total of twelve miscarriages in eight women within the control group: five had a single
205 Chapter 3: Adhesion Barriers, and their role in Asherman Syndrome miscarriage, two women had two miscarriages, and one woman had three miscarriages. There was one termination of pregnancy due to congenital anomaly, and there were no stillbirths. However, one woman had a live birth of a premature baby weighing 2 kg. This woman required a hysterectomy due to placenta accreta postpartum, and subsequently lost her baby at two months of age due to sudden infant death syndrome (SIDs).
The overall pregnancy rate in the AB group was 17/21 (81%). A number of women had a more then one pregnancy outcome. There were 18 live births in 15 women: thirteen (87%) women had a single live birth after surgery, two (13%) women had two live births, and no women had three or more live births following surgery. There was a total of 17 miscarriages in 10 women within the AB group: four had a single miscarriage, three women had two miscarriages, one woman had three miscarriages, and one woman had four miscarriages. There were three terminations of pregnancy due to congenital anomalies, and there was one stillbirth in this group.
Overall analysis of the study population
Analysis was performed to assess if certain maternal complications in pregnancies before AS were associated with higher grade of AS, to test whether placental complications predisposed them to a higher grade of AS. The results are shown in Table 3.29 below. A 2 test was unable to be performed due to the small number of cases in each group. However, on inspection of the data, the spread of complications was similarly distributed across the grades of disease.
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Table 3.29 – Maternal complication according to grade of Asherman syndrome
Grade I Grade II Grade III Grade IV Maternal complication Total n (%) n (%) n (%) n (%)
None 3 (50) 7 (50) 3 (33) 3 (50) 16 Infection 1 (16.7) 0 (0) 1 (11) 0 (0) 2 (5.7%)
Placentation 1 (16.7) 7 (50) 5 (56) 3 (50) 16 (45.7%) Other complication 1 (16.7) 0 (0) 0 (0) 0 (0) 1 (2.9%)
Total 6 14 9 6 35
The pregnancy rate was 34/42 (79%) following surgery in the overall sample.
The overall maternal complication rate was 19/34 (56%) and the overall fetal
complication rate was 16/34 (47%) of the pregnancies.
Sensitivity analysis
A sensitivity analysis was performed on the study cohort to assess the impact of the losses to follow up and the direction and magnitude of the treatment effect.
Sensitivity analysis was performed within the group and between the groups. In an effort to incorporate the most accurate data and minimise the effect of the losses to follow up, the medical records of all the patients were reviewed. Information was gathered by assessing medical records of the two private clinics (WHRIA and Alana), and two hospital obstetric databases (RHW and POWP) to capture any subsequent admissions or pregnancies, which may have occurred following surgery. Where there was referral back to a specialist for assisted reproductive technologies or pregnancy, the consulting rooms of the specialists were contacted to gain information about those women that were lost to follow up. A new database was created which included non- questionnaire derived information that had been gathered from the medical record audit where it was available.
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In the control group, there were 83 unique women identified as having had surgery for AS over a time span of eleven years. One woman was excluded due to insufficient information. Of the 82 women, 22 (27%) participated in the study and completed interviews according to the study protocol. Of the 60 women who did not participate in the study: 28 were lost to follow up with no contact information available, 20 agreed to participate verbally but did not return the consent form, 8 consented but were then unable to be reached for the telephone interview and 4 women declined participation. However, in 25 cases, there was some information relating to pregnancy data following surgery within their medical records, hospital records, or by contacting referring gynaecologists’ and obstetricians’ private consulting rooms. In the other 35 cases, no follow up information was available.
In the AB group, 40 cases were identified, and 21 women participated (53%).
Of those lost to follow up, 6 records contained information relating to pregnancy, and
in 13 cases there was no follow up information available, despite extensive searches
through hospital records and medical records.
In order to run a sensitivity analysis, the information gathered from records was
included as either ‘true information’, and then a ‘best case’ and ‘worst case’ of particular outcomes were included for the purposes of running statistical analysis.
Items where ‘best’ and ‘worst’ case outcomes were included are pregnancy, miscarriage, live birth, maternal complications, and fetal complications. These outcomes were treated as dichotomous variables. This analysis was performed to assess whether the participants of the study were representative of the entire AB and control group. Between group analysis was run including women who participated, lost to follow up with some information in the medical records, and ‘best’ and ‘worst’ case (allocating them as a positive and a negative result for the purposes of analysis).
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Within group analysis was also performed to analyse if the participant group was the same as the loss to follow up group for the same arm in the study for ‘best’ case and
‘worst’ case outcomes.
Table 3.30 – Sensitivity analysis
Group Yes No Unknown
n (%) n (%) n (%)
Control 40 (48.8) 6 (7.3) 36 (43.9) True LB Adhesion barrier 21 (52.5) 9 (22.5) 10 (25.0) Control 18 (21.9) 17 (20.7) 47 (57.3) True M/C Adhesion barrier 9 (22.5) 14 (35.0) 17 (42.5)
True maternal Control 14 (17.1) 30 (36.6) 38 (46.3) complication Adhesion barrier 8 (20) 21 (52.5) 11 (27.5)
True fetal Control 18 (21.9) 26 (31.7) 38 (46.3) complication Adhesion barrier 8 (20) 21 (52.5) 11 (27.5)
Best case Control 76 (92.7) – – (all unknown LB) Adhesion barrier 40 (100) – – Worst case Control 40 (48.8) – – (all unknown no LB) Adhesion barrier 21 (52.5) – – LB = live birth M/C = miscarriage
Between group analysis
The outcome of whether the women ever had a live birth was compared between the AB and control groups, incorporating information from the medical records. When comparing outcomes in this way, there was no difference between the
AB group and the control group in live births (p = 0.069), or miscarriage rates (p =
0.479). For maternal and fetal complications, the groups were similar with p values of
0.873 and 0.532 respectively.
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When allocating all women to a best case live birth outcome, where all subjects were allocated an affirmative result where data was missing, there was a statistically significant difference between the AB and control groups, with a p value of 0.017 in favour of the control group. When assessing the worst case scenario, where all subjects that had missing data were allocated a negative outcome for live birth, the analysis yielded no statistical significance, with a p value of 0.700.
Within group analysis was also performed, comparing the participants of the study to the rest of their group. In the AB group, the live birth outcomes comparing
the subjects where information was gathered from the records to the study participants
showed no differences between these groups (p = 0.794). For miscarriage, the
comparison of those where there was information available to the participants showed
no statistical differences between the groups (p = 0.136). For maternal and fetal
complications, the groups were also similar, with p = 0.292 and p = 1.00 respectively.
In the ‘best case’ analysis and ‘worst case’ analysis within the AB group, there
was no statistically significant differences for the best case analysis, with a p value
0.334. However, in the worst case analysis, the p value reached significance at 0.012.
In the control group, the ‘best case’ analysis and ‘worst case’ analysis within the
group were assessed. In the best case analysis, where all women that were lost to
follow up had a positive outcome, there was a highly statistically significant result,
with a p value 0.00 when comparing the losses to follow up to participants. In the
worst case analysis, the p value also reached significance at 0.004.
210 Chapter 3: Adhesion Barriers, and their role in Asherman Syndrome
Discussion
Hyaluronic acid (HA) is a water-soluble polysaccharide that has favourable
viscoelastic properties and biological plausibility in preventing intrauterine adhesion
(IUA) formation. However, is it limited by its residence time when applied to surgical sites. To combat its rapid absorption, chemically modified derivatives of HA have been manufactured. Two such modified HA products are SeprafilmTM (Genzyme
Corporation, Cambridge MA), and auto-cross-linked HA (ACP) gel (Hyalobarrier gel;
Baxter, Pisa Italy). These two products have been developed to circumvent the
disadvantages of HA and allow longer residence at the target surgical site.
In our study, SeprafilmTM (Genzyme Corporation, Cambridge, MA), a sodium
hyaluronate-based bioresorbable membrane was sliced and inserted as a slurry into
the uterine cavity. Despite the findings that modified HA based adhesion barriers
show a reduction in IUA in short term surgical studies (204, 205, 285, 287, 310), in
our study, SeprafilmTM was not associated with improved fertility or obstetric
outcomes compared to controls in women with pre-existing AS, nor was it shown to
reduce ongoing symptoms or repeat surgical intervention for adhesion recurrence.
This highlights a valid criticism of short-term studies reporting surgical findings. The outcome measured may not be that which is clinically relevant to the patient. The presence of IUA that occur visually at hysteroscopy may not be clinically meaningful and it could be argued that these adhesions are not true AS.
211 Chapter 3: Adhesion Barriers, and their role in Asherman Syndrome
The lack of statistical difference between the groups in our study for reproductive outcomes is likely multifactorial:
1. The patient numbers in our study may not be large enough to show
an improvement in reproductive outcomes, in the light of the
excellent overall outcomes following surgical division of adhesions
as described in Chapter 2.
2. Substantial losses to follow up in the control group, particularly due
to the long-term nature of this study spanning eleven years.
3. Published data commonly reports primary prevention of IUA
following hysteroscopic surgery, rather than secondary prevention in
women with pre-existing AS, which is a different group entirely.
4. Aside from two studies (8, 286), published data to date have not
reported pregnancy or live birth data, and reduction of adhesions
may not have an impact on these outcomes
With that in mind, there was no poorer outcome in using the AB, and there were no adverse reactions reported from the use of the SeprafilmTM (Genzyme
Corporation, Cambridge, MA) in our study.
Modified HA has been used as a barrier to IUA formation, and has been
studied by several investigators (8, 204, 205) for primary prevention of IUA following
curettage and hysteroscopic surgery. Modified HA such as SeprafilmTM (Genzyme
Corporation, Cambridge MA), and auto-cross-linked HA (ACP) gel (Hyalobarrier gel;
Baxter, Pisa Italy), have been developed to circumvent the disadvantages of HA and
to allow longer residence at the target surgical site. Halogel has been shown in a meta-
analysis of three randomised, controlled trials to prevent adhesion formation following hysteroscopic surgery. It remains in situ for five to six days (290, 303, 312),
212 Chapter 3: Adhesion Barriers, and their role in Asherman Syndrome
and is excreted from the body after 28 days. The exact mechanism by which HA-
CMC and APC reduce adhesion formation is not entirely understood. However, a
‘hydroflotation’ or ‘siliconisation’ effect on the endometrial lining has been proposed
(290). These early findings held promise for modified HA in preventing primary IUA
reformation. Subsequent to these early studies, larger trials have been undertaken
comparing two derivatives of modified HA. However, both of these larger trials
lacked a control arm and only had short term outcomes being reported (313). All of
these studies examined adhesion formation on ultrasound, or via post procedure
hysteroscopy, and no clinically relevant information such as live birth data was
provided. There are substantial differences in this population compared to our study
population, which was a group of women who already had AS by definition.
In secondary prevention of IUA, Acunzo et al. studied 84 women with AS in a prospective randomised controlled trial, comparing ACP gel (Hyalobarrier gel;
Baxter) to no treatment following lysis of IUA (205). ACP gel was introduced into the
uterine cavity at the end of the adhesiolysis procedure and infusion was considered
complete when the gel appeared to fill the cavity from tubal ostia to internal os.
Ultrasound was the outcome measure used to show whether the walls of the uterine
cavity remained separated for at least 72 hours after the treatment. Investigators
performed a second look hysteroscopy at three months post procedure and found the
presence of IUA was statistically significantly reduced in those women who received the adhesion barrier, with only 6/43 (14%) having recurrence of IUA, in comparison
with the control group, which had 13/41 (32%) p<0.05 (204). This patient population
was similar to our own. However, follow up was short term, and no clinical outcomes
were reported such a menstrual flow, reproductive capacity, and number of live births.
213 Chapter 3: Adhesion Barriers, and their role in Asherman Syndrome
Although these trials yield positive results, with few adverse outcomes (204,
205, 285), the numbers of participants in these studies remain small, and the encouraging data have not been replicated in all studies (178). No declaration of funding was stated in some publications, and the authors did not always declare any conflict of interest in reporting their findings (8). Publication bias is likely to
influence the available literature. Furthermore, no studies had long-term data available
with regards to menstrual, reproductive or obstetric outcomes following these
techniques.
Our study does not concur with the available literature, with generally
positive findings seen in published studies, and no improvement shown in our trial.
Possible reasons for this lack of concurrence is the overall small numbers in our study
and substantial losses to follow up, despite all efforts made to minimise these losses.
Overall in the control group, 27% of the total group participated, and in the AB group,
50% of the total group participated. Our groups were otherwise similar groups. The
only difference was based on the time of surgery, as the control group represented a
‘historical’ group that had surgery performed in an earlier time frame. The surgical
technique and adjuvant treatments used remained the same across the entire study cohort. There was the same referral base and same lead surgeons. The only intervention difference between groups was the addition of an adhesion barrier.
The impact of this loss to follow up was assessed in part by the sensitivity
analysis to ascertain the direction and magnitude of this effect. In order to achieve
this, all lost for follow up women were allocated to a ‘best case’ live birth outcome,
and the findings were that there was indeed a statistically significant difference
between the AB and control groups, with a p value of 0.017 in favour of the control
group. However, when assessing the ‘worst case’ scenario, where all subjects that
214 Chapter 3: Adhesion Barriers, and their role in Asherman Syndrome
were lost to follow up were allocated no live birth, the analysis yielded no statistical significance, with a p value of 0.700. This effect in favour of the control group is most likely to be due to the high loss to follow up rate in this group compared to the AB group. These data are difficult to interpret, however, it is likely, based upon these findings, that the losses to follow up would have contributed to a statistically significant difference in our results. This is an unfortunate consequence of all long term follow up studies, and as expected, the larger proportion of loss was seen in the women who had surgery at an earlier date, suggesting that the time between surgery
and data analysis had the greatest influence on the rate of loss to follow up.
The overall maternal and fetal complication rates cannot be ignored in our discussion and are certainly higher than that expected in the general population (272).
This higher overall morbidity is in keeping with that reported in Chapter 2. It is likely to be reflective of the higher risks of pregnancy seen in women with AS compared to the population as a whole, and not a consequence of the AB intervention.
What is becoming increasing clear is that women with AS are likely to represent a different group of women than those assessed in previous studies undergoing hysteroscopic surgery or curettage. Women with AS display altered wound healing patterns as an innate factor, or following substantial tissue trauma. The reasons for adhesion formation and altered wound healing will be explored in more detail below.
Wound healing is a natural restorative response to tissue injury. Healing is the interaction of a complex cascade of cellular events that generates resurfacing, reconstitution, and restoration of the tensile strength of injured tissue. The endometrium is a unique anatomical tissue that is exquisitely sensitive to its hormonal
215 Chapter 3: Adhesion Barriers, and their role in Asherman Syndrome environment, and typically undergoes a shedding cycle every month, termed the menstrual cycle.
The endometrium is the innermost glandular layer and functions as a lining for the uterus, preventing adhesions between the opposed walls of the myometrium, thereby maintaining the patency of the uterine cavity. It’s sole purpose each month is to prepare the uterus for implantation of the embryo. It consists of a single layer of columnar epithelium plus the stroma on which it rests (314). The stroma is a layer of connective tissue that varies in thickness according to hormonal influences. Simple tubular uterine glands reach from the endometrial surface through to the base of the stroma, which also carries a rich blood supply of spiral arteries (315). In a woman of reproductive age, two layers of endometrium can be distinguished histologically and on imaging (315). The functional layer is adjacent to the uterine cavity. This layer begins to thicken after the end of menstruation, during the first part of the menstrual cycle. Proliferation is predominantly induced by oestrogen (termed the follicular phase of the menstrual cycle). Later changes in this layer are due to progesterone following ovulation from the corpus luteum (termed the luteal phase) (314). It is adapted to provide an optimum environment for the implantation and growth of the embryo by providing a thick, blood vessel-rich, glandular tissue layer (315), which acts as a receptive environment for the implantation of a blastocyst upon its arrival in the uterus. This layer is completely shed during menstruation. Conversely, the basal layer, which is adjacent to the myometrium, is not shed at any time during the menstrual cycle, and from it the functional layer develops (316). In the absence of progesterone, the arteries supplying blood to the functional layer constrict, so that cells in that layer become ischaemic and necrotic, leading to menstruation (317).
Newer research in rodent and human models supports the theory that endometrial
216 Chapter 3: Adhesion Barriers, and their role in Asherman Syndrome
stem/progenitor stem cells play a key role in endometrial regeneration in the normal
menstrual cycle and after delivery (318).
During normal pregnancy, the glands and blood vessels in the endometrium
further increase in size and number. Vascular spaces fuse and become interconnected,
forming the placenta, which supplies oxygen and nutrition to the embryo or fetus
(315).
It is generally considered that an insult to the endometrium is responsible for
the development of AS (36). This insult can occur through surgical trauma, by
denuding the endometrium beyond the functional layer, with possible surgical
involvement of the basal layer and myometrium (60). This insult may also be due to
events at delivery, such as massive blood loss and subsequent hypovolaemia, and
hypoxia to the tissues locally, mechanical compression from haemostatic sutures to
the uterus or even the application of tamponading balloons (73). IUA may also be the
result of pelvic infection affecting the uterine cavity (78, 162). The hormonal
environment plays a role, as evidenced by the atraumatic adhesions of the post-
menopausal woman termed ‘senile’ adhesions by some authors (90, 91), and the
increased incidence of the formation of adhesions in the post-partum, and poorly
estrogenised uterus (13, 15, 319). Emerging data suggests abnormalities in
endometrial stem/progenitor stem cells in their location and function may contribute to pathological processes such as endometriosis and AS.
217 Chapter 3: Adhesion Barriers, and their role in Asherman Syndrome
Normal wound healing
Many extrinsic and intrinsic factors affect normal wound healing, which has traditionally been divided into four distinct and overlapping phases:
1. haemostasis,
2. inflammation,
3. proliferation, and
4. remodeling (320, 321).
Following tissue insult, platelets play a crucial role in clot formation during haemostasis, while inflammatory cells debride injured tissue during the early inflammatory phase. Epithelialisation, fibroplasia, and angiogenesis occur during the proliferative phase. Meanwhile, granulation tissue forms and the wound begins to contract. Finally, during the remodeling phase, collagen forms tight cross-links to other collagen and to protein molecules, increasing the tensile strength of any scar.
Although the process of wound healing may be presented as a series of separate events, in actuality, the entire process is much more complicated, as cellular events that lead to scar formation overlap, and many aspects of wound healing have yet to be elucidated (322).
From injury until around day four to day six, haemostasis and inflammation occur. Collagen exposed during wound formation activates the clotting cascade
(intrinsic and extrinsic pathways). After injury, the cell membranes release the potent vasoconstrictors thromboxane A2 and prostaglandin 2 alpha (322). Clots, made of collagen, platelets, thrombin and fibronectin, are organised and these factors release cytokines and growth factors (323). The fibrin clot acts as a buttress for signalled cells, such as neutrophils, monocytes, fibroblasts and endothelial cells (324), and also
concentrates the cytokines and growth factors (325).
218 Chapter 3: Adhesion Barriers, and their role in Asherman Syndrome
Immediately after the clot is formed a cellular signal is sent out and neutrophils are the first line respondents. As inflammatory mediators and prostaglandins accumulate, the nearby blood vessels vasodilate to allow for increased cellular traffic, as neutrophils are drawn into the injured area by interleukin 1 (IL-1), tumour necrosis factor alpha (TNF-α), transforming growth factor beta (TGF-ß), platelet factor-4 (PF-4), and the bacterial products (326, 327). Monocytes in nearby tissues and in the blood will be attracted to the area and transform to macrophages, usually around 48 to 96 hours following tissue injury. Activation of the inflammatory mediators, such as macrophages, are critical for this stage. An activated macrophage will mediate angiogenesis, fibroplasia, and synthesize nitrous oxide (323).
Neutrophils enter the wound and begin the process of phagocytosis of invading bacteria and cellular debris. The neutrophils release proteolytic enzymes that will digest bacteria and non-viable tissue. The next cells present are the leukocytes.
Numerous enzymes and cytokines are secreted by the macrophages, including collagenases, which debride the wound; and ILs and TNF, which stimulate fibroblasts by producing collagen and promoting angiogenesis.
From day four to day fourteen, the proliferative phase of wound healing occurs. Epithelialisation, angiogenesis, granulation tissue formation, and collagen deposition are the principal steps in the construction phase of wound healing.
Epithelialisation occurs early in wound repair. The basement membrane remains intact, and epithelial cells migrate upward in the normal pattern. The epithelial progenitor cells remain intact below the wound, and the endometrium is restored in two to three days. If the basement membrane has been destroyed the columnar epithelial cells, located at the edge of the injury, send out projections to re-establish a protective barrier (328, 329). Angiogenesis, stimulated by TNF alpha, is marked by
219 Chapter 3: Adhesion Barriers, and their role in Asherman Syndrome endothelial cell migration and capillary formation. The migration of capillaries into the wound bed is critical for proper wound healing. The granulation phase and tissue deposition requires nutrients supplied by capillaries. Bone marrow-derived leukocytes have recently been proposed to have particular importance in repairing endometrial injury, rather than in normal cyclic regeneration (330).
From day eight to one year following tissue injury, maturation and remodelling occur. The main feature of this phase is deposition of collagen in an organised and well-mannered network. Matrix deposition problems can occur, causing a weakening of the scar. Net collagen synthesis will occur for four to five weeks after the initial trauma. The increased rate of collagen synthesis during wound healing is not only due to the increase in the number of fibroblasts but also a net increase in the collagen production in the cell (331, 332). The collagen in the scar will never be as organised as collagen found in uninjured tissue (322).
IUA may involve different layers of the endometrium, myometrium, or connective tissue. Macroscopically, these layers have distinct qualities. Endometrial adhesions look similar to the surrounding endometrial lining at hysteroscopy.
Myofibrous adhesions are characterised by the presence of a thin layer of overlying endometrium, with many glandular ostia seen at the surface. These are the most common adhesions in AS (10). Connective tissue and fibrous adhesions lack any endometrial lining and under hysteroscopic view appear in stark contrast to the adjacent endometrium. These full thickness adhesions comprise collagen bundles, fibrous strips, or muscle with the similar characteristics as normal myometrium (40).
220 Chapter 3: Adhesion Barriers, and their role in Asherman Syndrome
Factors affecting wound healing
Other local factors can greatly influence wound healing, such as tissue ischaemia, foreign bodies, infection, and contamination. Trauma to the endometrial basalis and junctional zone from curettage, in a setting of low circulating estrogen, hinders endometrial regeneration. Any remaining endometrial stem/progenitor cells may survive a low oestrogen environment, but their adjacent cells require this steroid.
When infection and inflammation also occur, the inflammatory products may damage endometrial stem/progenitor cells, critically reducing their numbers and limiting their
capacity to regenerate sufficient endometrium (333).
Healing is an energy dependent process and requires an adequate supply of adenosine triphosphate (ATP). Anaerobic conditions cause ATP to be synthesised by glycolysis (334). The proliferative phase of healing requires an increased metabolism and protein synthesis, requiring much larger quantities of ATP via oxidative phosphorylation. This demands a rich blood supply to provide glucose and oxygen.
Hypoxia, and decreased glucose, have the potential to slow or halt the healing process. The physiologic response of the vascular endothelium to localised hypoxia precipitates vasodilation, stimulating fibrin deposition and an increase in pro- inflammatory activity, inducing capillary leak and neovascularisation. The endothelial
cell response to sustained hypoxia is a TNF alpha induction of apoptosis. Sustained
hypoxia will result in endothelial cell apoptosis. Wound neutrophil activity is
impaired in lower oxygen tensions identified in wounds. Low temperature, low pH
and elevated glucose concentrations also limit leukocyte function (335). Fibroblasts
exposed to longer periods of hypoxia may not participate in the formation of the
extracellular matrix, thus delaying healing (336).
221 Chapter 3: Adhesion Barriers, and their role in Asherman Syndrome
Local wound infection and foreign bodies affect healing, prolonging the inflammatory phase. If the bacterial count of the wound exceeds 105 organisms per
gram of tissue, or if beta haemolytic streptococcus is present, the wound will not heal
by any means. The bacteria prolong the inflammatory phase and interfere with
epithelialisation and collagen deposition (321). The endotoxins stimulate
phagocytosis and the release of collagenase, which contributes to collagen
degradation and destruction of surrounding, previously normal tissue. Wound
contamination, which may occur as a result of necrotic retained products of
conception, or can be introduced vertically, may be associated with tissue hypoxia and
potentially suppresses macrophage-regulated fibroblast proliferation (337).
Foreign bodies, such as retained products of conception, act as a physical
obstacle to wound healing and an asylum to bacteria. Foreign bodies prolong the
inflammatory phase. They also alter the ability of the wound to repopulate the area
with capillaries and completely epithelialise. Necrotic tissue will prevent the wound from healing at all until the necrotic tissue is removed (338). Therefore advocates of early management of miscarriage or retained products of conception post birth generally aim to intervene within three weeks (60) of the diagnosis to prevent alteration of the maturation and remodelling phase
Oedema and locally raised pressures are associated with ischaemic tissue injury and can further compromise perfusion. Mast cells in skeletal muscle have been demonstrated to produce most of the nitric oxide associated with ischaemia- reperfusion injury (339), and these mast cells stimulate release of numerous cytokines and histamines responsible for an intense inflammatory reaction and oedema. Raised tissue pressure induces capillary closure. Cellular function is compromised due to prolonged severe hypoxia leading to cell death and necrosis of the endometrium,
222 Chapter 3: Adhesion Barriers, and their role in Asherman Syndrome
basalis, and potentially the myometrium. This may occur as a result of B-Lynch
suturing, which is implicated in AS (58, 73). Uterine artery embolisation induces such tissue hypoxia and injury with an aim to minimise menstrual blood flow. However, the consequences may be IUA and subsequent poorer reproductive function compared to adhesions secondary to surgical trauma (39).
The role of oestrogen
Oestrogen plays a crucial role in wound healing generally, and supplemental
oestrogen has been shown to improve rates of skin healing in post menopausal women
(340). A low oestrogen environment contributes to the formation of IUA, and this in
part explains the high incidence of adhesions in the immediate postpartum period (13,
72), or the increased incidence seen following GnRH agonists pre-treatment for
hysteroscopic myomectomy (60). Low circulating oestrogen levels hinder endometrial
healing at the cellular level. Although the stem cells themselves are not reliant on this
hormonal milieu, their niche cells are reliant on an oestrogen rich environment, and
these supporting cells are responsible for activation of the progenitor cells critical in
endometrial regeneration (333).
Pooled data for oestrogen replacement following hysteroscopic surgery in
women with IUA has shown a reduction in the formation of IUA, and improvement in
subjective measures such as menstrual resumption in those treated with oestrogen
(198). Stromal and epithelial cells in the endometrium also respond to oestrogen by
alterations in gene expression. Oestrogen moves passively into intracellular
compartments and exerts an effect by binding with its receptor (341, 342). The sex
hormones also have an important role in initiating and maintaining the growth of the
superficalis level following menstruation via angiogenesis. Angiogenic growth factors
223 Chapter 3: Adhesion Barriers, and their role in Asherman Syndrome
such as vascular endothelial growth factor (VEGF) and permeability factor, fibroblast
growth factor and transforming growth factor B1 are reliant on the sex hormones for
amplification (343). The angiogenic growth factors enhance cell proliferation,
migration and the development of new capillaries. Low VEGF levels result in poor
angiogenesis, with the follow on effect of decreased blood flow to the endometrium
(344). Therefore, the hormonal environment is critical for the normal menstrual cycle and alterations to it are likely to contribute to abnormal wound healing.
Tissue injury due to surgery, infection or ischaemia initiates an inflammatory reaction that increases endometrial fluid production, including protein and cells. The
fibrinous exudate leads to the formation of fibrin (345) by activation of the coagulation cascade, which transforms prothrombin (Factor II) into thrombin (Factor
IIa). Thrombin then triggers the conversion of fibrinogen into monomers of fibrin, which interact and polymerase. The initially soluble polymer becomes insoluble by coagulation factors such as Factor XIIIa and is deposited on the wound surface (346).
Within the fibrinous exudate, polymorphonuclears (PMN), macrophages, fibrinoblasts, and mesothelial cells migrate, proliferate and/or differentiate.
Macrophages increase in number and change functions, such as increased accuracy in
phagocytosis and greater secretion of a variety of substances that recruit mesothelial
cells onto the injured surface. Mesothelial cells form islands throughout the injured
area, proliferate, and cover the denuded area. All of these cells release a variety of
substances such as plasminogen system components, arachidonic acid metabolites,
reactive oxygen species (ROS), cytokines and growth factors such as interleukins
(IL), tumour necrosis factor alpha (TNF-α), and transforming growth factors alpha and beta (TGF-α and TGF-β). These factors modulate the process of healing and
adhesion formation at different stages.
224 Chapter 3: Adhesion Barriers, and their role in Asherman Syndrome
The balance between fibrin deposition and degradation is critical in determining normal healing or adhesion formation. If fibrin is completely degraded, normal healing of the basalis occurs following surgical trauma. If fibrin is not completely degraded, it will serve as a scaffold for fibroblasts and capillary growth.
Fibroblasts will invade the fibrin matrix and extra-cellular matrix, and scarring will be produced and deposited (347). During healing, cell-cell interactions between the mesothelial cells, macrophages and fibroblasts contribute to the healing of the peritoneum. Adhesion fibroblasts develop a specific phenotype. Compared with normal peritoneal fibroblasts, adhesion fibroblasts have increased basal levels of collagen I, fibronectin, MMP-1, tissue MMP-1, TGF-β, PA-1, and IL-10 and decreased levels of tPA (348). A similar alteration in vascular perfusion has been proposed as a consequence of the abnormal healing at the transformation zone and basalis layer of the uterus (116). Finally it has been demonstrated in vitro that free radicals contribute to the formation of cross-linked proteins that may serve as initial scaffolding for the development of adhesions seen frequently in joints (349).
Fetal wound healing and hyaluronic acid
Tissue repair in the mammalian fetus is fundamentally different from postnatal healing. In adult humans, injured tissue is repaired by collagen deposition, collagen remodelling, and eventual scar formation. In contrast, fetal wound healing seems to be a more regenerative process, with minimal to no scar formation (350). Seibert et al. examined fetal wounds histologically and biochemically and found that they contained a small amount of collagen identical to that found in exudate from wounds in adults (type II collagen but no type I). The fetal wound matrix was also rich in hyaluronic acid, which has been associated experimentally with decreased postnatal
225 Chapter 3: Adhesion Barriers, and their role in Asherman Syndrome scarring. Rowsell (351) suggests that the collagen present in fetal wounds is structural rather than scar tissue collagen. The fetal pattern of wound healing is characterised, at least in the early fetus, by the deposition of glycosaminoglycans at the wound site, in which rapidly proliferating mesenchymal cells of all types migrate, differentiate and mature (352). The fetal wound matrix contains predominantly hyaluronic acid (353,
354). This has prompted and supported research into hyaluronic acid as a medium with anti-adhesive properties in the adult human model (312).
Human amniotic fluid (AF) contains factors that appear to minimize scarring
(355). It is interesting that a fetal incision made early in gestation will heal without a scar, whereas one made in late gestation heals with scar formation. Two theories predominate: the first is that hyaluronic acid, which is found in high levels in amniotic fluid (AF), inhibits collagen synthesis. This hyaluronic acid-rich environment is due to a relative lack of hyaluronidase in AF and due to the presence of hyaluronic acid- stimulating factor in AF. In one study, looking at the effect of AF on proteases important to wound healing, human AF was shown to enhance collagenase activity, but to inhibit activities of hyaluronidase, elastase, and cathepsin (356). The second theory is that TGF, which is absent from AF early in gestation but present late in gestation, plays a major role in scar formation (357). Disagreement remains as to whether healing occurs without scar formation during early pregnancy because of a favorable fetal environment (i.e. fetal serum and AF) or because of the properties of fetal skin. Hyaluronic acid is a key component in the adhesion barrier SeprafilmTM
(Genzyme Corporation, Cambridge, MA), which was examined in this study.
However, its use was not found in this study to improve fertility or reproductive outcomes compared to a control group who received no adhesion barrier.
226 Chapter 3: Adhesion Barriers, and their role in Asherman Syndrome
Syndromes associated with abnormal wound healing
There are a number of syndromes associated with altered would healing, including Cutis Laxa and Ehlers Danlos syndrome, which has ten identifiable phenotypes/clinical subtypes with autosomal dominant and recessive inheritance patterns. Homocystinuria and osteogenesis imperfecta similarly have altered wound
healing associated with the different collagen types (321). Keloid scars extend beyond
the wound edge and tend to occur at times of rapid growth, typically between ages 10-
30 years, with a peak in the teenage years. After a traumatic event, the keloid forms
because the fibroblasts haphazardly lay down collagen. This can occur anywhere on
the body (358, 359). This and other altered wound healing states may explain in part
why certain individuals may be predisposed to the development of IUA, at different
ages, alongside hormonal influences. It is uncertain whether the women with AS have
a predisposition for altered endometrial wound healing, and form a subgroup of
individuals, which have altered wound healing.
227 Chapter 3: Adhesion Barriers, and their role in Asherman Syndrome
Summary
Abnormal healing and the mechanism for the scar formation are important in
our understanding of adhesion formation, and may explain in part why women with
AS represent a unique cohort of women. It is important to dissect out the differences in the findings of IUA on short-term surgical studies, compared to the long-term reproductive outcomes reported in our findings. Despite the high incidence of IUA seen in women following curettage, the reproductive outcomes are not reported (7).
Therefore it is difficult to extrapolate primary prevention data to recurrence of adhesions in those who already have pathology. In the only secondary prevention studies of women with existing IUA, clinical outcomes were not reported. To date, this is the only study reporting the effect of adhesion barriers on women with AS, reporting clinically relevant data.
228 Chapter 4: Perfusion MRI in Asherman syndrome
Chapter 4: Perfusion MRI in Asherman syndrome
Background
Magnetic resonance imaging (MRI) has been used as a diagnostic modality for
Asherman syndrome (AS) (124, 360). MRI is particularly useful where there is involvement of the cervical canal (126). The main advantage of MRI for AS diagnosis is that it allows examination of the uterine cavity cephalad to intrauterine lesions. This allows visual access to the endometrial remnants in the upper uterine cavity, which may influence the decision and outcome of treatment (10). The architecture of the junctional zone shows promise as a marker for severity of intrauterine adhesions
(IUA) and pregnancy outcomes (127).
Furthermore and importantly, MRI has the ability to review the basalis and superficialis layers of the endometrial lining. This provides information beyond the visualisation of the endometrium afforded by hysteroscopy. Newer technologies include conducting dynamic studies with MRI using gadolinium-enhanced T1- weighted images. These have been used in endometrial and cervical cancer (128) and are now being utilised in other areas of uterine pathology, as microvascular perfusion at the level of the capillaries can be assessed in detail. Although signal characteristics in IUA have not been examined, it is anticipated that adhesions would produce low signal intensity on T2 images (126). However, there is a no information regarding the role of vascular perfusion MRI for AS and IUA.
229 Chapter 4: Perfusion MRI in Asherman syndrome
Pelvic angiography has been performed on women with AS. This has revealed reduced myometrial blood flow, with widespread vascular occlusion (42). Other markers for endometrial damage include the endometrial thickness, as seen on ultrasound in an anteroposterior plane. Lo et al. (43) found that women with IUA and only outlet obstruction had reduced endometrial thickness, in spite of the upper cavity being unaffected by adhesions. This endovascular phenomenon may explain the ongoing effects of IUA, whereby the vascular bed of the endometrium and myometrium are affected by trauma to or hypoxia of the uterine cavity. Alternatively, deranged vascularity may have predisposed a patient to IUA in the first instance.
The rates of anatomical restoration of the uterine cavity achieved from a patient’s first procedure to treat the IUA have been reported to range from 52% to
95% (11, 44, 76, 140, 233). However, even with restoration of the cavity, the function of the endometrium may not be fully competent and fibrosis is likely to have a serious impact on the reproductive capacity of the uterine cavity. These contribute to the poor obstetric and neonatal outcomes seen in our data and in other published series (see
Chapter 2) (49, 50, 172, 175). Therefore, functional and clinical results need to be considered when assessing the success of any therapeutic procedure.
With a deeper understanding of the pathophysiological process of AS being a primary vascular phenomenon, this chapter explores the potential for using MRI as a non-invasive modality to assess microvascular perfusion of the endometrium in women with IUA.
230 Chapter 4: Perfusion MRI in Asherman syndrome
Overview
This is a proof of concept study. Results from this study will be used to inform future studies, appropriately powered by this study’s data. This study has four main objectives:
1. To assess perfusion patterns in women with Asherman syndrome (AS) by
using Dynamic Contrast Enhanced MRI (DCE-MR)
2. To compare operative findings with perfusion at regions of interest (ROI)
in the endometrial / myometrial junctional zone (JZ), and to assess the
perfusion at areas of pathology compared to areas with relatively little
scarring in the same uterus
3. To assess the effect of surgery on perfusion by performing DCE-MR
before and after surgery
4. To compare uterine perfusion in women with differing stages of AS
5. To compare perfusion indices in AS with a control group
The aim is to test the feasibility of DCE-MR to detect endometrial and myometrial fibrosis. Perfusion imaging is a recently developed tool used in cardiac and cerebral MRI to detect alterations in microvascular supply and intramuscular fibrosis (361). MRI studies of AS are currently limited to case studies with poor quality images (124, 126, 360). The uterus with IUA has never been comprehensively documented using dynamic MRI techniques. The development of new imaging methods in gynaecology and cardiology now make it possible to visualise the vasculature of the pelvis in greater detail (125, 361-363). Histopathological specimens following hysterectomy in women with IUA show a marked increase in uterine wall fibrosis (41). A major benefit of dynamic MRI is the ability to visualise the entire uterus, including both the endometrium and myometrium. This allows for gross
231 Chapter 4: Perfusion MRI in Asherman syndrome patterns of fibrosis to be seen. With the addition of gadolinium, the micro-vascularity of these tissues may also be assessed. Perfusion MRI may shed light on the poorly understood mechanism of adhesion formation and re-formation. Future applications of this technique may include development of imaging methods to predict success of surgery, given the relatively high rates of complication following hysteroscopic synaechiolysis (148) or indeed the impaired reproductive function of the uterus following surgery, despite objective visual normalisation of the endometrial cavity. It is also hoped this technique will help to explain, in part, the poor obstetric and neonatal outcomes reported in cases of AS. Perfusion MRI evidence may support the hypothesis that the scarring in AS affects the entire cavity, not simply the endometrium.
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Methods
Approval for the study was obtained from the NSW Government, South
Eastern Sydney Local Health District (HREC No. 14/202/POWH/517). The ethics approval letter is included as Appendix G. This study followed Chapter 2 and 3 of this thesis, and therefore it reports a new cohort of women with AS.
Inclusion criteria
To be considered for entry into the study, women had to fulfill the following criteria:
1. Established or suspected IUA on past hysteroscopy or imaging
2. English speaking
3. Over 18 years of age at time of presentation to clinic, and pre menopausal
4. An understanding of the conditions of the study and willingness to
participate for the length of the prescribed term of follow-up
5. Capable of giving informed consent
Exclusion criteria
Women were excluded from the study if any of the following criteria were encountered:
1. Current pregnancy
2. Diagnosed gynaecological malignancy
3. Previous hysterectomy
4. Post menopausal
5. Psychological disorders and/or may be unduly stressed by inclusion
6. Renal impairment or failure
7. Previous IV contrast reaction
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The women were recruited from one of seven centres involved in the study:
(i) Royal Hospital for Women (RHW), (ii) the private rooms of Dr. Rebecca Deans
(RD), (iii) the private rooms of Professor Thierry Vancaillie (TVC) and (iv) the private rooms of Associate Professor Jason Abbott (JA). Participants underwent MRI at (v) Prince of Wales Hospital and (vi) Spectrum Imaging. Women with AS were scheduled for surgical excision of IUA at RHW or (vii) Prince of Wales Private
Hospital (POWP).
The women were informed that they were free to refuse participation in this study without compromising their medical care, and that if they chose to participate, they could withdraw from the study at any time. Women were also informed of the possibility of detecting incidental abnormalities (e.g. congenital uterine abnormalities, neoplastic changes) through the MRI scan. If any abnormalities were detected, a radiologist would review the abnormalities and provide a written report to the study coordinator, who would arrange follow-up treatment with relevant specialists with the permission of the patient.
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Study Groups
There were three study groups:
1 a. Pre-operative AS group: A cohort of all eligible women with AS
syndrome confirmed with IUA on hysteroscopy who were scheduled for
hysteroscopic synaechiolysis
1 b. Post-operative AS group: A cohort of the same group of AS women
following synaechiolysis as performed according to the protocol described
in Chapter 2 of this thesis.
2. Control group: A cohort of women who were having MRI scans with
gadolinium for other indications (such as malignancy).
This is a proof of concept study. Potential participants in the AS group
(women who were booked for adhesiolysis between August 2014 and August 2015) were invited by their treating physician (RD, TVC or JA) to undergo DCE-MR with contrast to study microvascular perfusion and identify the presence or absence of endometrial and myometrial fibrosis, and vascular perfusion markers. Following informed consent, the MRI was scheduled to occur within the six weeks prior to hysteroscopic adhesiolysis to assess whether the IUA were visualised on MRI anatomically, and to review whether adhesion location hysteroscopically correlated with MRI findings. The IUA were all graded according to the ESH (108), and specific anatomical regions of scarring were also documented in the medical records. Women were also approached to return for a follow up MRI six weeks after complete surgical excision of IUA (Group 1b).
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Potential participants in the control group were approached before their scheduled pelvic MRI with contrast to obtain permission to use their de-identified images and gynaecological history in the study.
Within six weeks of MRI scanning, AS women underwent hysteroscopic synaechiolysis under fluoroscopic guidance, and were then discharged on the same day if no intraoperative complications occurred. The surgical protocol used was as described in Chapter 2 of this thesis. Following surgery, all women were given intravenous fluids and were taken to the recovery area. Once they had completed their initial post-operative recovery, the patients were moved to the day surgery waiting room, where the surgeon would meet the patient and explain the operative findings.
The operative notes were kept with the patient. These notes recorded the following:
• The ESH grading (132)
• Anatomical description of the adhesion location
• Any other intra operative findings
• The surgery that was undertaken
• Complications at surgery
• Post-operative directions for the patients
Women recovered for two to three hours, until they could eat, drink, mobilise and void. As routine, women were given a post-operative course of oral oestradiol
(conjugated ethinyl oestrodiol 2.5 mg daily, for three weeks), to stimulate recovery of the endometrium, and prophylactic antibiotics (doxycycline 100 mg twice / day for 10 days).
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At the first post-operative appointment, four to six weeks following adhesiolysis, AS subjects were asked about their symptoms, as per the protocol described in Chapter 2 of this thesis. If their symptoms persisted, a repeat hysteroscopy was performed to review incomplete or recurrent adhesions. These were subsequently divided. This process was repeated until cavity restoration ensued or the procedure was felt to place the woman at unacceptably high risk of complications, such as uterine perforation. Surgical complications were recorded in the medical records at the post-operative visit or at any time in the post-operative period, ideally in the luteal phase of the menstrual cycle, if the woman was aware of her phase in the menstrual cycle.
The post-operative MRI procedure was identical to the pre-operative MRI procedure and was performed a minimum of six weeks following the final synaechiolysis procedure.
As each woman with AS was scanned before and after hysteroscopic synaechiolysis, each woman acted as her own control and was assessed pre- operatively (Group 1a) and post-operatively (Group 1b).
MRI protocol
Image acquisition
MRI images were performed using one of two 3 T magnets: Phillips (the
Netherlands), and GE (USA) with a body phased-array coil. The 3 T magnet offers better spatial resolution than the 1.5 T magnet to accommodate for different types of uterine motion (363). Under quiet respiration, the midsagittal plane of the uterus is scanned using the different sequences.
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Screening of the pelvis is first performed on MRI with sagittal T2-weighted images, T1-weighted images, and axial T2-weighted images, to assess for uterine pathology, such as fibroids. The number and size of any pathology (such as uterine myomas) was recorded.
Perfusion images were then acquired 10–15 seconds after administration of IV gadolinium contrast (0.15 mmol/kg) via an IV cannula, using an inversion-recovery gradient-echo (IR-GRE) sequence. Constant adjustment of inversion time (between
200–400 ms) nulls the myometrium so scar tissue can be seen as hyper-enhancement.
As perfusion is the steady state delivery of blood to a tissue, and reflects the capillary blood flow, it is a marker for blood volume, blood velocity, and blood oxygenation
(364). This technique is also widely referred to as permeability MRI, and is based on the acquisition of serial T1-weighted images before, during and after administration of extracellular low-molecular-weight MRI contrast media, such as a gadolinium-based contrast agent. Differing from conventional (static contrast-enhanced, T1-weighted),
DCE-MR perfusion imaging depicts the wash-in, plateau, and washout contrast kinetics of the tissue, thereby providing insight into the nature of the bulk tissue properties at the microvascular level. Most often, DCE-MR perfusion imaging is based on a two-compartmental (plasma space and extravascular-extracellular space) pharmacokinetic model. In order for perfusion to be assessed, the technique includes:
• performing baseline T1 mapping,
• acquiring DCE-MR perfusion images,
• converting signal intensity data to gadolinium concentration,
• determining the vascular input function, and
• performing pharmacokinetic modeling.
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With pharmacokinetic modeling of DCE-MR, perfusion data can be achieved and plotted (365, 366). When there is very high permeability, the flux of gadolinium- based contrast agent is limited only by flow, and thus perfusion mainly reflects blood flow at the capillary region. In situations in which there is very low permeability, the gadolinium-based contrast agent cannot leak easily into the extravascular-extracellular space. It is anticipated that in scar tissue, the micro-vascularity is impaired, and therefore indices of perfusion to this tissue are lower than non-scarred tissue.
Image analysis
There is no precedent for evaluation of extent of uterine adhesion / fibrosis in perfusion imaging of the uterus, and thus no recognised methods exist for describing these changes. Areas of hyper-enhancement were mapped in order to find the best way to describe the changes.
Two groups of images were evaluated: (i) screening images, and (ii) gadolinium enhanced perfusion images. On the screening images, organic lesions in the uterus and surrounding region were evaluated. Regional perfusion data were obtained from dynamic enhanced series, taken over fixed time points. Twelve regions of interest (ROI) were assigned in the same z plane (head to foot) in the following locations: upper superior (US), upper right (UR), upper inferior (UI), upper left (UL), middle superior (MS), middle right (MR), middle inferior (MI), middle left (ML), lower superior (LS), lower right (LR), lower inferior (LI), lower left (LL). The ROI area was kept consistent throughout the uterus and each ROI was 38.4 mm2. This was based on a ‘best fit’ to incorporate the junctional zone (JZ) in the cross sectional locations (upper, middle, and lower cavity). Mean perfusion across all of the twelve
ROIs throughout the imaging sequence was then calculated. See Figures 4.1, 4.2 and
4.3 below.
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To avoid signal intensity (SI) variations between women, and between imaging studies, ratios of perfusion were calculated by comparing the perfusion of the uterine muscle at the JZ to the psoas muscle in the right and left pelvis during the same study (see Figure 4.4). This was performed in the last five time points where it is assumed that there was stable contrast within each organ, and that this perfusion was a good reflection of the organ at equilibrium. This technique has been described in other organs, such as cardiac muscle where the heart signal intensity is measured against skeletal muscle and a ratio of >2 is reflective of increased fibrosis at the location of infarct (367). Calculating the ratio of perfusion (RP) corrects for interscan and interpatient SI variability, and allows an internal marker of perfusion. This can then be compared from woman to woman across time points and studies. RPs were compared between higher grade disease and lower grade disease to allow analysis between the groups. The ROI for the psoas was kept uniform at an area of 285.1 mm2.
Comparisons were performed using each woman as her own control (Groups
1a and 1b). Following surgery, the location of endometrial scarring was noted hysteroscopically, and assigned to the relevant ROI on the perfusion images. This
ROI was then compared with the mean uterine ROI in the same patient for the entire study sequence. If there were greater than six involved locations where endometrial adhesions were noted, then this comparison was not performed, as the area of
‘abnormality’ exceeds ‘normality’. For those women where there was recurrence of
IUA at a particular anatomical location, an analysis of this particular ROI was compared with the mean perfusion across the same uterus as a whole to examine if there was a primary vascular alteration in this location predisposing the patient to the reformation of adhesions.
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Figure 4.1 – MRI pelvis sagittal and coronal planes used to place the four circumferential regions of interest at the upper cavity
Figure 4.2 – MRI pelvis sagittal and coronal planes used to place the four circumferential regions of interest at the mid cavity
241 Chapter 4: Perfusion MRI in Asherman syndrome
Figure 4.3 – MRI pelvis sagittal and coronal planes used to place the four circumferential regions of interest at the lower cavity / isthmus
Figure 4.4. – Region of interest placed at the psoas in the mid uterine cavity
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Semi-quantitative evaluation of the first-pass perfusion images was used to calculate the indexed ratio of perfusion-time intensity curve upslopes. This was used as a measure of myometrial perfusion reserve index in response to vasodilator stress.
Alterations in perfusion of the uterus throughout the cycle have been demonstrated in MRI (368, 369). In an effort to analyse the sample’s perfusion, an initial decision was made to study the uterus in the proliferative / follicular phase.
However, after three women were imaged, it became evident that the endometrial and myometrial junction was less clear during this phase and subsequent imaging was performed in the luteal phase, where the architecture of the tissue could be defined and locations for ROI could be confidently placed and analysed. This is in keeping with other centres’ experiences with pelvic imaging (125, 362). Similarly, a number of women in the study were amenorrhoeic at recruitment and therefore the time of their cycle was difficult to establish. In some cases, the women could give an indication of their expected menstruation using symptoms of pain, or other premenstrual symptoms, and the MRI was then planned for a time as close to the luteal phase as possible to improve image quality for allocation of the ROI. No information was available relating to the phase of the menstrual cycle for women in the control group (Group 2). Further contact between the investigators and control group women after their single MRI scan, in order to obtain menstrual cycle data, was not permitted by the ethics committee.
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Four measures were considered worthwhile for comparison:
1. ‘total perfusion’ (TP), the mean of all twelve ROIs for the uterus
throughout all time points (mL/100 gm/sec),
3. a ‘ratio of perfusion’ (RP) of the uterus compared to skeletal muscle
(psoas muscle) in the same woman during the same study,
4. the ‘time to peak’ perfusion (TTP) in seconds, and
5. the ‘gradient’ of perfusion (GP) in mL/sec.
Four research questions were then developed, namely, does impaired perfusion secondary to junctional zone fibrosis cause vascular changes at the tissue which result in:
i) an overall reduction in TP at an ROI where adhesions are seen
hysteroscopically,
ii) a reduction in RP,
iii) a slower TTP, and
iv) a lower GP, compared to unscarred tissue?
The gradient was calculated by finding the ratio of the "vertical change" to the
"horizontal change" for two distinct points on the line, the so-called "rise over run".
The graph was reviewed for the point at which the peak occurred and the gradient was calculated using the peak perfusion (x axis) and time to peak (y axis).
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Statistical Methods
As this was a proof of concept study, no sample size estimates were made. A study-specific case report form (CRF) was designed and all data from the CRF was entered into an electronic database using Statistical Package for Social Sciences, version 20 (SPSS, Chicago, IL). Subsequent statistical analyses were undertaken with the same software. Demographics for the population are expressed as mean and standard deviation (SD), or median and range, appropriate to the distribution of the data.
Alterations in perfusion were assessed using mean perfusion for the entire uterus at all time frames during the study, perfusion ratios, perfusion at ROIs for all time frames during the same study, time to peak for gadolineum infusion (TTP) and rate of the perfusion (gradient) of gadolinium in myometrium at the junctional zone.
The SPSS 22.0 statistical software was used to analyse the clinical data.
Descriptive analysis was performed, including frequency of each variable and prevalence. Data were checked for normal distribution and compared to independent t test or analysis of variance. Data that was not normally distributed were compared with non-parametric tests. Contingency table analysis was used for comparison of categorical variables. Association of dichotomous variables, such as perfusion measures between the groups, were assessed by utilising the Pearson chi-square test and Fisher's exact test used for expected count in each cell less than five.
Comparisons of continuous variables were undertaken using a student t-test unless otherwise indicated. Paired t-tests were used for analysis where each woman acted as her own control. A receiver operator curve was used to assess the area under the curve for the technique as a test. The measurements were subject to intra-observer reliability testing using a weighted kappa coefficient (Cohen’s kappa). A p value of <0.05 was considered as statistically significant.
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Results
The results with respect to the clinical evaluations in this chapter are presented in the following sections:
• Demographics and risk factors
o Association of IUA with antecedent event
o Recurrence of adhesion and recurrent surgery
o Menstrual symptom outcomes
• Perfusion changes within the uterus in the same woman using a specific
ROI
• Perfusion changes comparing low grade to high grade AS
• Perfusion changes pre- and post-operatively in the same patient
(comparison of Group 1a and 1b)
• Perfusion changes in AS women compared to controls (Group 2)
As this is a proof of concept study, there was no literature available to guide analysis of the perfusion of the uterus. Therefore the uterus was assessed in the coronal plane in the mid sagittal region, where the cervix was able to be visualised and the junctional zone (between the myometrium and endometrium) could be seen on anatomical imaging, as described in the methods section of this chapter. See
Figures 4.1– 4.3.
Once the perfusion studies were run for the overall uterine cavity, and at various ROIs where there was intrauterine pathology noted hysteroscopically, these values were plotted on a graph to look at overall perfusion of the mean compared to the ROI. Various graphs were assessed and differing values were seen. Figures 4.5,
4.6, and 4.7 below show various situations where the mean uterine perfusion was plotted compared to the ROI. In some instances, the ROI where pathology was noted
246 Chapter 4: Perfusion MRI in Asherman syndrome was lower than the mean perfusion of the entire uterus. There were instances where the pathological ROI(s) sat between the twelve ROIs for the uterus, and in some instances the pathological ROI(s) was plotted above the mean perfusion of the uterus.
Figure 4.5 – Perfusion image of the uterus – mean below the region of interest
Average LS_Im mean LL_Im mean LI_Im mean LR_Im mean
Figure 4.6 – Perfusion image of the uterus – mean between the region of interest
Mean MR mean MI mean ML mean MS mean
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Figure 4.7 – Perfusion image of the uterus – mean above the region of interest
1200
1000
800
600
400
200
0 012345678
All mean LI mean LL mean LR mean LS mean
An analysis was then undertaken to review the affect of scarring on the perfusion of the uterus. The perfusion curves were assessed using a semi-log plot to visualise the data that were related according to an exponential relationship. One axis was plotted on a logarithmic scale. This plot was useful as it covers a large range of values in one axis (perfusion/flow) and the other has only a restricted range (time).
The advantage of this plot was that it could display features in the data that would not easily be seen if both variables had been plotted linearly. An exposure–response relationship was produced, which describes the change in effect of the uterine perfusion caused by an exposure of gadolinium given intravenously after a certain exposure time to the uterus. Dose–response relationships generally depend on the exposure time and exposure route (intravenous). The MRI perfusion screening was performed every four seconds until traces of gadolinium were seen entering the uterine cavity. This screening time was based on studies of the heart and prostate in similar perfusion studies.
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Table 4.1 – Demographic Data
Demographic information: Median (range)
Age (years) 36 (30-42) Gravidity 2 (0-4) Parity 1 (0-2) Number of procedures 2 (1-5)
Cause of AS: Number (%)
Curette first trimester miscarriage 7 (30.4) Curette second trimester miscarriage 2 (8.7) Postpartum curette 4 (17.4) Caesarean delivery 4 (17.4) Copper containing IUD 1(4.3) Non pregnant hysteroscopy and curettage 1 (4.3) TOP in first trimester 1 (4.3) Postpartum haemorrhage / B lynch suture 1 (4.3) Laparotomy and myomectomy 1 (4.3) Laparoscopic myomectomy 1 (4.3)
Total 23
Other medical conditions: Number (%)
Hydrosalpinx 1 (4.3) Pelvic organ prolapse 1 (4.3) Perimenopausal 1 (4.3)
TOP = Termination of pregnancy
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In total there were 23 women with AS, and 2 controls who had MRI pre operatively, and 5 had both pre and post-operative scans. Table 4.1 illustrates the demographic data. Grades of AS were as follows; four with grade I, three with grade
II, ten with grade III, and six with grade IV, of which four were inoperable. The median age was advanced, which was in keeping with the results in our earlier cohort of women (Chapter 2 and 3). In this study, there were four cases where complete resection of the IUA was deemed impossible. In three of these four cases, the adhesions were found to be dense with no pockets of normal endometrium found on fluoroscopic assessment. In the fourth case, there had been an extensive abdominal myomectomy performed, leading to her AS. After resection in this case, the upper cavity was found to have been completely dissected with the fundal fibroid.
Histopathological assessment of the original myomectomy specimen confirmed that a large area of endometrium was removed with the original myoma specimen.
The majority of the women in this cohort had been pregnant at least once, with
11/23 (43%) being Para 0, 7/23 (30%) being Para 1, and 5/23 (22%) being Para 2.
There were ten causes for AS in this group, and there were no statistically significant differences between the causes for AS (p = 0.072). The range of conditions predisposing women to AS were broader than that seen in Chapter 2 of this thesis. As a number of women underwent an MRI due to expected high grade disease, this group also represents a higher risk population compared to the cohort reported in Chapter 2 of this thesis.
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Analysis 1 – Relationships between perfusions and demographic data
Overall the perfusion was calculated for the entire uterus. Table 4.2 describes
TP, RP, TTP and GP for the group pre-operatively and post-operatively.
Summary of perfusion studies
Table 4.2 – Summary of perfusion studies for the group of women with Asherman syndrome
Pre- or Perfusion Standard post- Number Minimum Maximum Mean measure deviation operative Pre- 23 545.02 2111.36 937.54 334.15 TP Post- 5 556.69 1241.56 851.02 290.17 Pre- 23 2.816 1.41 4.69 0.80 RP Post- 5 1.31 4.30 2.47 1.15 Pre- 22 30.00 120.00 38.18 21.58 TTP Post- 5 20.00 36.00 29.20 5.76 Pre- 22 2.64 30.15 15.50 6.01 GP Post- 5 7.25 27.39 15.12 8.28
The perfusion with the grade of AS was compared, and the results are shown in Table 4.3 below. There were no differences between the groups. The perfusion with the number of procedures was also compared, and the results are shown in Table 4.4 below. There were no statistically significant differences between the perfusion indices compared to number of procedures required.
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Grade of AS
Table 4.3 – Perfusion indices according to grade of Asherman syndrome
Mean time to peak perfusion Mean gradient of perfusion Mean total perfusion (TP) Mean ratio of perfusion (RP) Grade of AS (TTP) (GP) (SD) (SD) (N pre- and (SD) (SD) post-op) Pre-operative Post-operative Pre-operative Post-operative Pre-operative Post-operative Pre-operative Post-operative
765.21 2.68 52.50 12.87 I (4, 1) 1241.56 4.3 30.00 27.39 (292.36) (0.54) (45.00) (8.17) 1023.31 2.38 40.00 28.00 16.99 13.12 II (3, 1) 1063.32 1.78 (228.07) (0.85) (17.32) (11.31) (3.32) (8.30) 845.12 696.77 2.65 2.05 35.00 12.86 III (10, 2) 30.00 13.46 (195.22) (70.56) (0.48) (1.04) (15.00) (1.64) 1163.58 3.41 32.50 20.47 IV (6, 1) 556.69 2.19 30.00 8.49 (493.99) (1.17) (6.12) (7.33)
p value 0.190 0.154 0.201 0.552 0.525 0.997 0.065 0.610
N= number of women in each group
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Number of procedures
Table 4.4 – Perfusion indices according to number of procedures
Mean time to peak perfusion Mean gradient of perfusion Number of Mean total perfusion (TP) Mean ratio of perfusion (RP) (TTP) (GP) procedures (SD) (SD) (SD) (SD) (n pre- and post-op) Pre-operative Post-operative Pre-operative Post-operative Pre-operative Post-operative Pre-operative Post-operative
888.23 1241.56 2.80 3.04 48.33 28.67 14.18 17.88 1 (10, 2) (263.44) (126.04) (0.83) (1.78) (31.62) (8.08) (5.16) (10.12) 467.91 1063.32 2.70 2.05 31.88 15.49 2 (8, 2) 30.00 13.46 (467.91) (70.56) (0.71) (1.04) (5.30) (6.59) 847.66 3.10 18.43 3 (4, 1) 696.77 2.19 30.00 (0) 30.00 8.49 (140.50) (1.15) (7.98) 5 (1) 730.28 556.69 2.76 – 30.00 – 15.75 –
p value 0.572 0.062 0.891 0.798 0.353 0.984 0.738 0.746
N= number of women in each group
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Menstrual status
Women were asked about their menstrual status, and the results are illustrated in Table 4.5 below. The menstruation status is a subjective symptom described by the patients during their consultation before and after surgery. Prior to surgery, ten (43%) women reported normal flow of periods, nine (39%) reported amenorrhoea, and four (17%) reported light menstrual bleeding. In the analysis in
Table 4.5, the pre-operative menstrual status is assessed against the pre and post- operative perfusion indices. There were only five post-operative scans performed, and none of these women reported normal menstruation pre-operatively.
There was a statistically significant lower post-operative TP amongst the women with menstrual symptoms. However, the other perfusion indices were no different between the groups when comparing pre-operative symptoms.
When comparing post-operative menstrual status, 21 women reported normal periods (91%), two (9%) reported amenorrhoea and no women reported LMB. The
TP, TTP, and RP were similar between the groups (p = 0.07, 0.964, 0.850 respectively). The GP was statistically significantly lower in the women with amenorrhoea.
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Table 4.5 – Menstrual status before surgery and perfusion indices
Mean time to peak perfusion Mean gradient of perfusion Menstrual Mean total perfusion (TP) Mean ratio of perfusion (RP) (TTP) (GP) pattern (SD) (SD) (SD) (SD) (n pre- and post-op) Pre-operative Post-operative Pre-operative Post-operative Pre-operative Post-operative Pre-operative Post-operative
Normal 929.03 2.92 35.00 14.32 – – – – (10, 21) (248.10) (0.48) (15.00) (3.46) No period 1000.97 1152.44 2.67 3.04 45.00 28.67 17.49 17.88 (9, 2) (468.40) (126.04) (0.96) (1.78) (30.0) (8.08) (8.54) (10.12) LMB 816.11 650.08 2.87 2.09 30.00 30.00 13.69 10.98 (4, 0) (130.86) (95.03) (1.22) (0.73) (0) (0) (2.42) (3.52)
p value 0.671 0.014 0.804 0.451 0.455 0.839 0.449 0.440
N= number of women in each group
LMB = light menstrual bleeding
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Pregnancies
All 23 women undertook surgery with an intention to conceive. Following surgery, two women had incomplete resection, and stated that they were no longer actively trying to conceive and had accepted childlessness. One of these two women actually conceived 12 months following treatment. However, this pregnancy ended in a first trimester miscarriage. In total for this group, there were nine pregnancies in eight women, which is a pregnancy rate of 8/23 (35%) for the group. Figure 4.8 illustrates the pregnancy outcomes. The mean live birth weight was 3.5 kg (range 3.4–
3.8 kg)
Figure 4.8 – Pregnancy outcomes in the women pregnant
9 pregnanies in 8 women
1 ongoing 1 termination 1 4 livebirths 1 stillbirth 1 unknown for congenital spontaneous outcome anomaly miscarriage
(11% of (11.1% of (11.1% of (44.4% of (11.1% of (11.1% of pregnancies) pregnanies) pregnanies) pregnancies) pregnacies) regnancies)
There were no statistically significant differences in pre-operative perfusion indices between those who became pregnant and these who did not conceive following the procedure, with p values for TP, RP, TTP and GP at 0.695, 0.468,
0.515, and 0.331 respectively. However, the numbers of cases were small, with only eight women achieving a pregnancy.
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Four women had a live birth following surgery, and one woman had a stillbirth. The stillbirth occurred following premature rupture of membranes at 22 weeks gestation, and chorioamnionitis, which led to the premature delivery. The perfusions indices were not different between women who had live births compared to the one who did not, with p values for TP, RP, TTP and GP at 0.600, 0.705, 0.685, and 0.539 respectively. There were a total of two complications of pregnancy reported: one of the nine pregnancies had pre-eclampsia (11%) and another one pregnancy had an adherent placenta (11%). Statistical analyses were not performed due to the small numbers in these groups.
Analysis 2 – High grade vs. low grade AS
A receiver operator curve (ROC) was utilized to assess perfusion as a test for high grade IUA (Grade IV) and total cavity obliteration. Pre-operative TP, PR, TTP,
GP were the indices compared. There were 6 women with Grade IV AS compared to
17 with Grades I-III.
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Figure 4.9 – ROC pre-operative total perfusion (TP), comparing Grade IV to Grades I-
III
The area under the curve was 0.765, indicating that this was a good marker for
Grade IV AS, where the total perfusion (TP) was < 683 mL/100 g/sec.
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Figure 4.10 – ROC pre-operative time to peak perfusion (TTP) comparing Grade IV to
Grades I-III
The area under the curve is 0.474. The time to peak perfusion (TTP) was a poor predictor of Grade IV AS.
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Figure 4.11 – ROC pre-operative gradient of perfusion (GP) comparing Grade IV to
Grades I-III
The area under the curve is 0.823. The GP was highly predictive of Grade IV
AS when the gradient was < 11 mL/sec. Therefore gradients below this were predictive of Grade IV AS.
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Figure 4.12 – ROC pre-operative rate of perfusion (RP) comparing Grade IV to Grades
I-III
The area under the curve is 0.716, indicating that when allowing for inter scan variability (by using a ratio), the test is still very sensitive for predicting Stage IV disease. The ratio that was found to be predictive of Grade IV AS is a ratio of < 2.3 of total perfusion of the uterus for the mean of the 12 ROI during a study, compared to one ROI in each right and left psoas muscle in the same patient during the same study.
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A subgroup of women in the study had complete cavity obliteration. In these cases, surgery was incompletely performed or abandoned, with no pockets of endometrium being found, despite multiple attempts. In total, there were four such women within this cohort with inoperable IUA. ROC curves were analysed to assess whether the perfusion studies would be predictive of inoperable disease, and whether these women had altered perfusion indices compared to the other women where surgery was able to be performed
Figure 4.13 – ROC pre-operative total perfusion (TP) comparing inoperable IUA with all other AS women
The area under the curve showed a value of 0.855, indicating that mean uterine perfusion studies in the pre-operative uterus were highly predictive of uterine cavity obliteration vs. lower grade disease. The total perfusion that was found to be predictive of inoperable disease is a TP of < 660 mL/100 g/sec.
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The second analysis was mean time to peak perfusion (TTP), which was also analysed using a ROC curve. The results are shown in Figure 4.14 below.
Figure 4.14 – ROC pre-operative time to peak perfusion (TTP) comparing inoperable
IUA with other AS women
The area under the curve was 0.521 indicating that the time to peak perfusion
(TTP) was less predictive of cavity obliteration compared to the TTP of lower grade
AS. This was similar to the findings analysing Grade IV compared to the lower grades of AS.
The third analysis was the gradient of the curve for perfusion (GP), where women with complete cavity obliteration were compared to all other women.
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Figure 4.15 – ROC pre-operative gradient of perfusion (GP) comparing inoperable IUA with other AS women
The area under the curve was 0.792, indicating the gradient of the curve for perfusion (GP) was predictive of cavity obliteration compared with lower grade disease. The GP that was found to be predictive of inoperable AS was < 11 mL/sec.
There was a highly statistically significant difference in the mean perfusion and GP when comparing operable AS with those women who had complete cavity obliteration and inoperable disease. However, there was no difference in time to peak perfusion between the groups. See Table 4.6 below. This correlates with the findings seen on the ROC curves indicating that TP, RP, and GP are the better analysis metrics, and that TTP was less predictive of high grade AS.
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Table 4.6 – Analysis of perfusion indices for lower grade Asherman syndrome compared to women with complete cavity obliteration
Standard Standard p value Number Mean deviation error (2 tailed)
Pre- Lower grades AS 19 856.81 217.27 49.85 0.008 operative TP Cavity obliteration 4 1321.03 546.09 273.04 Post- Lower grades AS 5 851.02 290.17 129.77 – operative TP Cavity obliteration 0 – – – – Pre- Lower grades AS 18 39.17 23.66 5.58 0.661 operative TTP Cavity obliteration 4 33.75 7.50 3.75 Post- Lower grades AS 5 29.20 5.76 2.58 – operative TTP Cavity obliteration 0 – – – – Pre- Lower grades AS 18 13.91 4.17 0.98 0.005 operative GP Cavity obliteration 4 22.67 8.38 4.19 – Post- Lower grades AS 5 15.12 8.28 3.70 – operative GP Cavity obliteration 0 – – – –
Analysis 3 – AS compared with controls (Group 2)
This analysis aimed to compare the MRI perfusion studies of all women with
AS (Group 1a) against a sample of women who did not have AS (Group 2). This comparison analysed each group’s pre-operative TP, RP, TTP and GP. No post- operative comparisons could be performed, as no control women (Group 2) had post- surgical scans. As per ethical requirements, the women used as controls were already having a pelvic scan with gadolinium for other indications. A total of six controls were identified. However, only two met inclusion criteria, as the others were excluded due to being post-menopausal. The two controls used were women with cervical cancer. However, the cancer was confined to the cervix in both instances, and there was no involvement seen in the uterine body on MRI.
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Table 4.7 – Analysis of perfusion indices for women with Asherman syndrome compared (Group 1a) to control group (Group 2)
Standard Standard Number Mean p value deviation error
Pre- AS 23 937.54 334.15 69.67 0.673 operative TP Control 2 1410.99 425.51 300.88 Pre- AS 23 2.82 0.80 0.17 0.239 operative RP Control 2 3.72 1.05 0.75 Pre- AS 22 38.18 21.58 4.60 0.364 operative TTP Control 2 29.25 3.182 2.25 Pre- AS 22 15.50 6.01 1.28 0.239 operative GP Control 2 26.59 11.10 7.85
There were only a small number of women in the control arm (2). The AS women had a lower TP, lower PR, slower TTP and lower GP. However, these results did not reach statistical significance, as shown in Table 4.7.
Analysis 4 – Mean vs. ROI
This assessment involved analysis of perfusion at particular ROIs where endometrial scarring was noted intraoperatively. Statistical analysis used each woman’s mean uterine perfusion as her own control. In these analyses, we compared the mean perfusion across the uterine cavity to the ROI perfusion in the same study, using a paired t test.
The mean uterine perfusion was compared with the ROI for the same women.
Up to six ROIs were identified and recorded in the operative notes. If there were greater then six ROIs involved, the pair of results was excluded from the analysis, due to confounding, as the majority of the uterine cavity was visually affected by disease
(> 50% cavity involvement).
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Pre and post-operative mean analyses were used to compare the pre and post- operative ROI for the same person. Pre-operative mean values were compared with pre-operative ROIs and post-operative means were compared to post-operative ROIs, as shown in Table 4.8 below.
Table 4.8 – Overall total perfusion (TP) vs. region of interest (ROI) in the same study
Standard p value Number Mean deviation (2 tailed)
Pair 1 TP and ROI 2 17 59.69 115.80 0.049
Pair 2 Pre- TP and ROI 3 16 81.90 107.98 0.008 Pair 3 operative TP and ROI 4 15 54.98 114.56 0.084 Pair 4 TP and ROI 5 5 -15.64 113.30 0.773 Pair 5 TP and ROI 1 5 5.87 88.56 0.889
Pair 6 Post- TP and ROI 2 4 -51.82 29.85 0.040 Pair 7 operative TP and ROI 3 4 -34.08 38.97 0.179 Pair 8 TP and ROI 5 2 -39.10 5.53 0.062
Statistical significance was reached in three of the eight pairs, when assessing perfusion indices’ mean values compared to post ROI in one paired group. The relevance of this is not known
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Discussion
Hysteroscopy is the diagnostic tool of preference in cases of AS. MRI has only been advocated for assessment of AS where there is obliteration of the cervical os
(10). However, MRI has the benefit of visualising the uterine cavity above the level of adhesions and identification of any remaining endometrium, particularly in higher grade disease (126). Other benefits include observation of the wider uterine anatomy
(such as the myometrium and junctional zone) and visualisation of pathology extending into the myometrium. This study has attempted to determine whether there may be a wider role for MRI in the clinical assessment of women with AS.
There are limited reports in the literature concerning the use of MRI in AS.
All published studies have used T2 weighted images and a T1.5 magnet (124, 126,
360). Imaging from these studies is available but the resolution is poor. Dykes et al.
(360) reported loss of normal endometrial and junctional zone signals and luminal obliteration in a 31-year-old woman who presented with amenorrhoea following curettage for retained placental fragments. Bacelar (126) subsequently undertook imaging in a further four cases, of which one showed a loss of trilaminar pattern in the lower part of the uterine cavity. In two cases, low signal bands were seen in the uterine cavity and two cases showed partial obliteration of the uterine cavity.
Hysteroscopy was not undertaken, as the cervical os was impenetrable in all cases.
Hence MRI findings were not confirmed. Letterie & Haggerty (124) compared hysterosalpingography (HSG) and MRI in two women with amenorrhoea and IUA.
They correlated low intensity signals with sites of adhesions demonstrated on HSG.
However, the images were of a very low resolution.
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In more recent studies, a review was conducted on the use of MRI with contrast imaging of benign uterine pathologies. In this review, Wolfman et al. (125) described the appearance of synaechiae as low T2 signal bands traversing the uterine cavity, which were enhanced after gadolinium contrast was added. Bands were more clearly visible in this study owing to use of higher resolution MRI and contrast administration. In a recent retrospective cohort study (n=91), Huang et al. (127) investigated the relationship between degree of injury to the junctional zone (JZ), visualised on MRI, and fertility outcomes at 12 months after hysteroscopic adhesiolysis. Their findings suggested that JZ damage on static imaging was correlated to a higher grade of AS and poorer pregnancy outcomes. There were no pregnancies in women with an indeterminate JZ (severe adhesions). This study represents the first of its kind, correlating MRI findings to clinical outcomes.
More rapid imaging has made it possible to measure perfusion (368, 370, 371).
This minimally invasive technique is now available to study the microvascular pattern of the uterus in a relatively non-invasive way. In dynamic MRI, calculating perfusion relies on the regional blood volume within a tissue volume of interest. Blood supply of this tissue is quantified via the parameters of blood flow rate (BF) and perfusion, measured as BF mL/min /W (tissue mass (g)). Another important parameter is the mean transit time (MTT), which is the mean time required for a tracer to pass through the tissue. A typical MTT is a few seconds (364). In order to probe the properties of the blood, circuit tracers (such as gadolinium) are injected into the blood and its passage is observed at a point of interest. For MRI, a contrast agent is used to induce a strong local relaxation rate change and significant susceptibility (DSC), and then perfusion measurements are used. In order to achieve sufficient volume coverage, combined with temporal sampling rate that allows the determination of dynamic perfusion parameters, fast sequences with a repetition rate of 1.5–2 seconds are used.
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After contrast agent administration, the signal time course is plotted (bolus measurement). The strong susceptibility effects of a passing bolus of the contrast agent causes a substantial drop in the T2 weighted signal of the sequence (372).
Perfusion of the ‘normal’ uterus on MRI has been examined at various time points throughout the menstrual cycle (368), and although perfusion MRI has been studied in the myomatous uterus (373), to date ours is the first study exploring perfusion of the uterus affected by IUA. Studies in the past have merely looked at perfusion of the organ. This study provides a framework for a protocol for perfusion imaging of the uterus of women with AS, and perhaps other pathological processes such as a thin endometrium and infertility. The total perfusion and perfusion ratio with gradient of perfusion of the uterus were found to be the best predictors of higher grade AS and indeed inoperable IUA. This provides important new information for treating physicians, with an ability to predict poor prognosis prior to surgical intervention. Prediction modeling for poor reproductive function was unable to be performed due to the small number of pregnancies in this group. However, it is hoped this technique may be utilised in larger cohorts, and with differing pathogenesis for their IUA or infertility.
Dynamic contrast-enhanced MRI (DCE-MRI) is increasingly used to assess the vascular environment of tumours and other intrauterine pathologies. It involves the acquisition of serial T1W images before, during and after IV injection of a low molecular weight contrast medium, such as gadolinium. DCE-MRI provides information about tissue microvasculature, perfusion and vessel permeability (374,
375). Current applications in the uterus are primarily oncological, including tumour detection and staging, pre treatment prediction of therapeutic outcome and response assessment to anticancer treatments (374, 376, 377). As a technique, MRI has been widely used in pelvic pathology (378, 379) and has been shown to be a better
270 Chapter 4: Perfusion MRI in Asherman syndrome predictor than ultrasound in staging cancers in the reproductive tract (380-383). DCE-
MRI is reported to increase detection of myometrial invasion by endometrial cancer when compared with T2W imaging, with accuracy ranges from 85–93%, compared with 58–77% for static T2W imaging (376, 377). DCE-MRI parameters have also demonstrated correlation with tissue characteristics, including degree of stromal cellularity and fibrosis, tumour proliferation and angiogenesis (374, 384, 385).
Perfusion MRI techniques for exploring the microvascular dysfunction of the cardiac muscle have been examined. These are termed coronary microvascular dysfunction (CMD) and defined as abnormal responses to perfusion testing of endothelial and non-endothelial macro and micro vascular pathways. In perfusion
MRI for CMD, correlation has been identified between abnormal perfusion pathways and coronary adverse events (361, 386). A growing body of evidence supports the presence of CMD in men and women with signs and symptoms of ischaemia in the absence of obstructive coronary artery disease. It has been postulated that CMD encompasses a spectrum of disorders of coronary endothelial and non-endothelial disorders dependent on vascular reactivity (361, 387). A multitude of factors have been suggested as causative in CMD including risk factors for atherosclerotic disease, hormonal and structural factors. CMD is hypothesised to be a generalised process that may result in patchy or more or less generalised subendothelial myocardial ischaemia, as opposed to the highly regional localisation of ischaemia resulting from obstructive coronary artery disease that can be assessed using angiography (386, 388). Cardiac
MRI has a better ability to perform tissue characterisation than other imaging techniques and it allows one to distinguish between healthy and fibrotic myocardial tissue and assess the spatial distribution of the vascular defects.
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Perfusion MRI has also been used in cerebral imaging to assess cerebral blood flow in patients with Alzheimer’s disease, stroke and tumours. Correlations could be found between cerebral atrophy and perfusion values, with a reduction in cortical thickness in those with neurodegenerative disease (364, 389). Hypoperfusion in the brain may be a consequence of the neuronal dysfunction. Alternatively, the process of hypoperfusion may lead to the neuronal dysfunction seen on DCE-MRI. The use of a ratio of perfusion to correct the effects of the signal intensity variability have also been established in other organs and shown to be an appropriate method to overcome the inter-scan and inter-patient variability (390, 391).
There is increasing evidence that women with IUA have reduced vascular supply to both myometrium and endometrium (116). Reported subjects with a vascular cause for their IUA, such as following UAE, have a particularly poor prognosis both surgically and reproductively (39). Foix, in his classic histology paper, reported that the endometrium becomes fibrosed in AS, with loss of the distinction between the functional and basal layer, and replacement of the functional layer with an epithelial monolayer, which is unresponsive to hormonal stimulation. Fibrotic synechiae then form across the cavity (40). In some cases, there may be calcification or ossification of the stroma and the glands may be sparse and inactive or cystically dilated. There may be thin walled, dilated vessels, but in most cases the tissue becomes avascular (40).
IUA may involve different layers of the endometrium, myometrium, or connective tissue. Macroscopically, these layers have distinct qualities, even when endometrial adhesions look similar to the surrounding endometrial lining at hysteroscopy. Myofibrous adhesions are characterised by the presence of a thin layer of overlying endometrium, with many glandular ostia seen at the surface. Myofibrous adhesions are the most common adhesions in AS (10). Connective tissue and fibrous
272 Chapter 4: Perfusion MRI in Asherman syndrome adhesions lack any endometrial lining and at hysteroscopic view, appear in stark contrast to the adjacent endometrium (10). Full thickness adhesions may comprise of collagen bundles, fibrous strips, or muscle with the same characteristics as normal myometrium (40).
When comparing the histopathological findings of the myometrium of women with IUA with women without AS, the myometrium has been found to contain 50–
80% fibrous tissue in women with IUA, compared with 13-20% in the group without adhesions (41). The extent of damage to the endometrium may not directly correlate with severity of symptoms. In women with cervical adhesions obstructing the outflow of menstruation, biopsies taken at the fundus often reveal inactive endometrium (10).
The contribution of vascular pathologies to the aetiology of AS has not been fully elucidated. On pelvic angiography in twelve AS women with amenorrhoea (n=2) and hypomenorrhoea (n=10), seven had widespread vascular occlusion of myometrial vessels (42). A prospective observational study of 40 women with AS and infertility demonstrated high impedance of the spiral artery on Doppler ultrasound (116).
Although 55% of this cohort had genital tuberculosis, there was no statistical difference in impedance when compared with women in whom genital tuberculosis was excluded. Additionally, development of severe IUA secondary to uterine devascularisation as a result of bilateral uterine artery ligation and/or a B-Lynch suture has also been described (39, 57, 65, 74, 392). However, DCE-MRI has not previously been used in this context and may provide new information about blood flow at a microvascular level that could improve understanding of AS.
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Generally, when using MRI, normal uterine anatomy is best displayed on sagittal T2-weighted (T2W) images. In premenopausal women in the luteal phase, there is a characteristic trilaminar appearance with an innermost region of high signal intensity corresponding to the endometrium, a hypointense junctional zone (the innermost layer of the myometrium anatomically) and a region of intermediate signal intensity corresponding to the outermost layer of the myometrium (125, 362). The thickness of the endometrium shows cyclic variation and women should ideally be scheduled for imaging during the second half of the menstrual cycle for better visualisation of zonal anatomy (362).
Findings from the current study demonstrate that differential perfusion responses occur in the junction zone at the regions of interest directly adjacent to areas of endometrial fibrosis. The current studies findings also indicate that women with higher ESG grade disease have poorer mean uterine perfusion compared to women with lower grade disease. This study’s findings also support the use of DCE-
MRI for prediction of higher-grade disease. This predictive effect is more pronounced in cases where incomplete or unsuccessful surgical outcomes eventuated. This altered perfusion may explain the poor obstetric outcomes reported in women with AS, despite adequate anatomical restoration and return to menstruation. Parallels may be made to the irradiated uterus for abdominal or pelvic malignancies, with endometrial atrophy, poor response to hormonal stimulation (393), necrosis of endometrial glands and stroma, endometrial scarring and a reduction in uterine volume. Similar changes have also been seen in MRI imaging of the uterus in these women (394). Radiation to the uterus can interfere with implantation and uterine growth during pregnancy, which can result in poor obstetric outcomes, with an increase in rates of miscarriage, premature delivery and low birth weight reported in the literature (395) and in
Chapter 2 of this thesis. There are various mechanisms by which this may occur,
274 Chapter 4: Perfusion MRI in Asherman syndrome including a reduced endometrial thickness (as seen on ultrasound), reduced uterine volume, and diminished uterine flow, particularly in women who have been treated with total body irradiation in the pre pubertal years (396). These effects are likely to be the result of disrupted vasculature following insult to the pelvic organs from radiotherapy. Most authors report that these effects are irreversible (393, 396), although others have reported improvements in endometrial thickness through the use of exogenous hormones (397).
Vascular function and perfusion lie at the core of the ability of the uterus to accept an implantation. Early failures of uterine transplantation (398, 399) occurred due to the lack of perfusion to the transplanted tissues, and subsequent success has been achieved by using larger lateral vascular anastamosis of uterine vessels. This allows greater perfusion to this unique organ (400). However, the pregnancies have still been complicated by prematurity, pre-eclampsia, and low birthweight (401).
Classic studies carried out in the 1960’s using 133-xenon and hydrogen clearance have established the vascular patterns of the myometrium and endometrium in the normal and pathological uterus (402, 403). These techniques relied on invasive measures of blood flow assessment within the macro and microvascular supply. The main findings were that there is collateral circulation involving varying sizes of vessels supplying the myometrium, which is also ultimately responsible for perfusion of the endometrial tissue. Due to the intimate association of the endometrial perfusion with that of the myometrium, fibrosis of the endometrium leading to IUA may also affect the uterine muscle / implantation. This may predispose patients to the poor obstetric outcomes seen in women with AS, as described in detail in Chapter 2 of this thesis, and indeed the extra nine pregnancies reported in this chapter, where an additional stillbirth occurred.
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In the pathological uterus, alterations in vascular density have been purported to be responsible for heavy menstrual bleeding in women with uterine myomas (373).
When examining scar tissue, the vascular pattern of any area adjacent the fibrosis in the endometrium is likely to represent a localised expansion of the myometrial vasculature, with the vessels oriented in the direction of the muscle cell bundles, as shown in histological and x-ray injection models (404). The differences in myovascular density in the myometrium may represent differences in angiogenesis and vascular remodeling in the vascular beds. One or both of two mechanisms may explain this. The differences may result either from a complex differential angiogenic promoter or inhibitor signals on myometrium at this location, or it may be that fibrosis in the end arterioles induces vascular changes within the myometrium.
Angiogenesis and vascular remodeling occur in the endometrium throughout the menstrual cycle, which is critical for endometrial function. Disruption of angiogenesis in mice using AGM-1470 results in endometrial atrophy (405). There are three established peaks of endometrial cell proliferation activity. The first occurs in the early proliferative phase during repair after menstruation, and the second is associated with the rising circulating concentration of oestradiol seen during the mid follicular phase. The third peak of endometrial cell proliferation activity accompanies the growth of the spiral arterioles during the luteal phase (406). Vascular endothelial growth factor (VEGF) stimulates cell proliferation and increases vascular permeability, involving two key receptors that bind to VEGF with high affinity (407).
Disruption of the genes encoding VEGF or its receptors results in failure of cell differentiation and angiogenesis in the murine model (408-411). Steroids regulate the level of VEGF. However, oxygen tension is also an important determinant of expression (242). Relative hypoxia at the time of menstruation is a potent upregulator of secretion of VEGF at the glandular and stromal cells of the human endometrium
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(242), potentially playing a crucial role in the subsequent endometrial modeling and remodeling. This modeling is critical to successful implantation of the early embryo.
An additional effect of VEGF on the vasculature is the vasodilatory properties mediated through nitrous oxide (NO) released from the endothelial cells. Nitrous oxide also stimulates release of prostacyclin, another vasoconstricting agent, via the release of the arachidonic acid, which modulates contractility of spiral arterioles and alters menstrual blood loss (412).
VEGF and microvascular density (MVD) have been correlated with DCE-MRI contrast kinetics in an oncological setting (374). A number of clinical studies have demonstrated a relationship between enhancement on MRI and immunohistochemical
MVD measurement (413, 414), though some authors found no correlation (415, 416).
Recently, VEGF has been demonstrated to also influence T1 MRI signal enhancement. Knopp et al. (414) found VEGF expression in breast tumours (n=27) correlated with vascular permeability at MRI, independently of MVD. However, Su et al. (415) found no statistical correlation between VEGF and enhancement in a similar study. Notably, the histological type of tumour was varied in both studies.
Impaired angiogenesis and revascularisation is hypothesised to contribute to the failure of endometrial regeneration and resultant IUA (116). In a study of 36 women with AS who underwent hysteroscopic adhesiolysis, endometrial VEGF and
MVD were quantified from specimens obtained at hysteroscopy intra-operatively and at a three month follow up (50). Although there was no statistical difference between
VEGF and MVD expression before and after adhesiolysis, VEGF expression was significantly higher (p 0.012) in patients responding to surgery (3.55, n=16) than in those who did not respond to surgery (3.24, n=5). Though data are not available in an
AS cohort, several studies have similarly demonstrated that low VEGF leads to decreased endometrial blood flow and thin endometrium (417-419). Miwa et al. (344)
277 Chapter 4: Perfusion MRI in Asherman syndrome demonstrated that low VEGF is associated with blood flow impedance in the radial artery, and that uterine and radial artery impedance correlate negatively with endometrial thickness. VEGF may represent a prognostic tool for women undergoing surgery for AS. Application of DCE-MRI could allow for non-invasive prognostic assessment and monitoring of treatment response.
Blood flow impedance of the uterine and radial artery has been measured using computerised vaginal ultrasonography with an integrated pulsed Doppler in women with thin endometrium, and correlated with tissue samples (344). The radial artery is at the lower extremity of the uterine artery, and appears to be the most useful in assessing blood flow to the endometrium. Resistance index (RI) was calculated for women of a normal thickness and thin endometrium, and correlation was found between thin endometrium and radial artery RI throughout the menstrual cycle. The growth of glandular epithelium was also impaired in the women with a thin endometrium on histological sampling. On evaluating VEGF in the same samples, the protein expression was significantly lower in the thin ET group. This led the investigators to conclude that thin endometrium is characterised by poor growth of the glandular epithelium, high uterine blood flow resistance, decreased VEGF, and poor vascular development (344).
Menstrual disorders including dysmenorrhoea, heavy menstrual bleeding, abnormal uterine bleeding and endometriosis are thought to be associated with dysregulation of endometrial blood flow (420, 421). Similarly, an adequate blood supply appears an important determinant of endometrial receptivity during assisted reproductive therapies (422, 423). This inadequacy may be represented in a proportion of women with apparently unexplained infertility or uterine factor with decreased uterine and endometrial perfusion (424, 425). More recently, women with
AS have been shown to have alterations in Doppler blood flow of uterine spiral
278 Chapter 4: Perfusion MRI in Asherman syndrome arteries, as shown in ultrasound studies (116). Many of these women acquired AS from tuberculosis infection. This study showed that there was high impedance of the spiral artery and improvement following hysteroscopic adhesiolysis (116). Hence improved methods of monitoring uterine blood flow and tissue remodeling are important to improve characterisation of the physiological and pathophysiological changes and to define etiologies or to assess future therapeutic strategies.
A thin endometrium has been recognised as an independent and critical factor for implantation failure (243, 246, 426, 427). It is hypothesised that a thin endometrium is caused by an impairment of the normal process of endometrial growth
(344). Angiogenesis is essential to promote endometrial growth after menstruation and to provide a vascular receptive endometrium for implantation (412, 428). Uterine blood flow is important in controlling endometrial growth and is closely associated with vascular development of the endometrium (211)
Some data were lost from this study because of poor quality data and artefacts in the images such as bowel gas. A reduction in susceptibility artefacts was achieved by changing the protocol to perform imaging in the secretory (luteal) phase of the menstrual cycle, when there is less contractility of the uterus (429, 430), and the JZ may also be more readily identified for allocating ROIs. By making this change in the scanning protocol, there is a potential reduction in consistency of the data, as it is possible that the hormonal environment may alter the perfusion of the JZ, a phenomenon which has not to date been described. However, this change was necessary to achieve precise locations of the regions of interest, and being a proof of concept study, this effect did not become apparent until interim analyses of the images. Another reason for the loss of data was the low in-plane resolution, which made differentiating endometrial and myometrial tissue difficult, particularly when the endometrium was thin – which is a key feature of this disease process. The
279 Chapter 4: Perfusion MRI in Asherman syndrome principle reason for the low in-plane resolution was to maintain an adequate signal to noise ratio (SNR) over the uterine region. This study used a body coil, but dedicated phased array pelvic coil or using higher magnetic field strength would allow better in- plane resolution achieved from the gain in SNR. Improvements in the spatial resolution would allow for the JZ to be separated from the surrounding tissues and increase the accuracy of the measurements in the endometrium as a larger number of pixels in the ROI can be used.
All of these images have been performed on a 3T MRI system, which can produce double SNR and higher T2 contrast. These advantages can be utilised for reduction in acquisition time or increasing temporal resolution in dynamic resolution
(100-102). However, imaging at higher magnetic field is accompanied by larger chemical shift, larger susceptibility effect, worsened radiofrequency inhomogeneity, and increased power deposition (383, 431, 432), which are the main disadvantages of
T3. However, this is less likely to affect perfusion imaging as an endpoint.
Routine contractility of the uterus must also be taken into consideration when assessing the female pelvis. The uterine myometrium is known to contract, leading to local decreased blood flow during the menstrual phase (433). Although uterine artery vascular perfusion may alter during the menstrual cycle (368), the perfusion of the radial artery has been shown to be relatively stable. This phenomenon has been demonstrated in recent Doppler ultrasound studies (434, 435). The radial artery is now considered to offer the best representation of the perfusion of the endometrium (344).
Radial artery perfusion has been associated with positive prediction of pregnancy in
IVF studies (436, 437). Perfusion MRI sequences assess the vascular density at the capillary level. Therefore lower perfusion indices, particularly lower ratio of perfusion of the uterus, are due to either less contrast in the capillaries, or less volume in the extracellular space. This means that there are fewer capillaries, or the extracellular
280 Chapter 4: Perfusion MRI in Asherman syndrome space is smaller in women with higher grade AS. The main question this raises is whether there is an innate alteration of vascularity in the uterus of women who develop AS or whether this effect is due to scarring or fibrous changes secondary to trauma in this group of women.
The importance of an appropriate control group should be reemphasised.
There is a paucity of published data defining what is normal uterine perfusion using this technique in premenopausal women. MRI is a useful tool for evaluating IUA and is inseparable from improvements in hardware and software. These improvements not only increase the signal to noise ratio (SNR) for conventional imaging, but also make it possible to investigate feasibility of novel imaging such as perfusion of the uterine tissue. Although research of these techniques is still underway, rapid progress in recent technology is likely to benefit both clinicians and women.
Due to ethical concerns regarding gadolinium use and potential contrast reactions to ‘normals’, only women undergoing pelvic scans for other indications where gadolinium was already being used could be included as the control group.
Unfortunately, this led to only two women in this arm of the study that met inclusion criteria. This is likely to have had an impact on the statistical analysis. Similarly, the women who were our controls had cervical cancer, which may have confounded the perfusion levels, as there are no data comparing the uterine perfusion of women with cervical cancer to that of women without any uterine pathology. Although there was no statistical significance reached in comparing the AS women vs. controls, there was a trend towards a lower TP, RP, TTP and GP in the AS women. This supports my hypothesis that IUA and fibrous change at the JZ reduces uterine perfusion, which affects the functional capacity of this unique reproductive organ.
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Other limitations of the study include the small sample size as a whole. This is a rare condition, and recruitment for additional investigations in women undergoing a number of procedures even before referral to our unit affected sample size. Other limitations include the two phases where the perfusion images were taken in the menstrual cycle. In such a small sample size, this could certainly have had an impact on the results.
The data from this study demonstrate that perfusion imaging of the uterus may detect endometrial microvascular disease of the uterus. These findings have implications for the management of women who have persisting reproductive impairment with an anatomically restored endometrial cavity. Importantly, the methodology utilised standard equipment and protocols that are available in most tertiary institutions. Further work is required to define myometrial and endometrial perfusion reserve in this population to optimally identify women with abnormalities of endothelial and non-endothelial microvascular function. Additional long term follow up is needed to determine whether endothelial microvascular function or dysfunction lead to impaired obstetric outcomes and placental anomalies, which are too often associated with women with IUA.
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Summary
Functional magnetic resonance imaging of the uterus is an emerging technique and no standardised imaging protocols or reference ranges for normal tissues are available. Nonetheless, these results hold promise for improving understanding of underlying pathology in AS, as well as the mechanisms that contribute to recurrence and on going infertility in certain women. In the future, this may provide a basis for non-invasive prognostic investigations to help inform treatment decisions, and perhaps reproductive expectations, which is vital information for women with AS.
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Chapter 5: Discussion
“Also, hysteroscopy, which is so often mentioned in the literature and just as
often discarded, may perhaps be of use for this purpose. If it were possible to
see the adhesions, and to loosen them instrumentally, using the eye as a guide,
the ideal method would have been found…”(6).
Asherman predicted the future treatment of intrauterine adhesions (IUA) causing amenorrhoea and infertility. Half a century later, we now recognise that diagnosis and
treatment is best achieved by hysteroscopy. However, the nature of the endometrial and
myometrial adhesions makes each case individual. The prognosis seems to be related to the
type and location of the adhesions, as well as the individual’s constitution and susceptibility
to adhesion formation. Although hysteroscopic management has improved the outcomes in terms of anatomical restoration of the uterine cavity, pain, menstrual disturbance and sub- fertility, this condition still remains problematic and pregnancies are high risk for women with this condition.
At the conclusion of this treatise, there appear to be more questions than answers.
Despite the advent of the use of the eye as a guide, no universally endorsed classification
system has been developed, making comparison of studies difficult. Management techniques differ and outcomes range from favourable to poor, particularly for the women with higher
grade IUA. Infertility and recurrent miscarriage remain the most challenging symptoms to
manage. Once pregnant, the patient is at increased risk of placental abnormalities and its
284 Chapter 5: Discussion subsequent sequelae, including fetal growth restriction, prematurity, maternal haemorrhage, and hysterectomy.
Asherman himself felt that his eponyomous disorder required greater recognition in gynaecology. He described an endometrial quiescence associated with the pathologic IUA, which had not been previously reported. He termed these adhesions organic rather than merely obstructive. In so doing, he was able to delve into the heart of the pathophysiology.
The level of disruption is likely to go beyond merely the endometrial lining as a result of altered blood flow or signalling pathways at the cellular level of the endometrium.
Importantly, Asherman associated these adhesions with menstrual and fertility disturbance
(6), indicating that IUA without symptoms are unlikely to be of any clinical consequence.
This indicates that it is the clinical phenomenon that makes the condition pathological.
Initial attempts to try to formulate this thesis lead to a number of broader questions about this pathological process of AS, namely the reason for IUA, why certain individuals are predisposed to IUA, how do IUA occur and how do we best manage this condition?
Similarly, why are anatomical restoration and menstrual function rates high with fair pregnancy rates, yet obstetric and fetal outcomes remain poor following surgical management of this condition? Therefore, the hypothesis moved towards searching for a deeper understanding of this condition extending beyond the endometrium, and affecting the myometrium and junctional zone. For example, the vascular phenomenon associated with
IUA may lead to the clinically significant abnormal placentation and reproductive outcomes seen in this condition. Furthermore, it led to questioning if there is a way to prevent the recurrence of adhesions, and questioning if the encouraging outcomes reported for adhesion barriers translate to improved pregnancy and neonatal outcomes for these women. A number of studies have been published on IUA reporting adhesion score following hysteroscopic
285 Chapter 5: Discussion
investigation. Little has been published regarding the long-term follow up of women with
this disorder and even less on the fetal and neonatal outcomes.
Menstrual dysfunction is the most obvious presenting symptom in women with AS.
Deranged menstruation and absence of vaginal bleeding affected nearly a half of our cohort.
However, there was excellent menstrual restoration in our cohort following fluoroscopically
guided synaechiolysis. Menstruation was present in 48% of the women in our study prior to
surgery, in 87% of the women in the immediate post-operative phase, and in 81% of the
women in the long-term analysis. This finding concurred with recent large published series
(44). The reason for the amenorrhoea may be due to physical obstruction, although it is noteworthy that a majority of women with AS have a thin endometrial lining beyond the direct area of pathology, and that the condition tends to affect the uterus as a whole. If amenorrhoea were simply a by-product of obstructed menstruation, then the islands of endometrium would produce a thickened lining on TVUS. Yet in fact, the opposite occurs.
Therefore, could the presence of adhesions affect the vascular flow to the endometrium, impacting capillary perfusion at the spiral arterioles? Once women were surgically corrected, the mechanism for recurrence of adhesions in the absence of trauma or pregnancy is also unknown. Reformation of IUA is a problem highlighted in most papers reporting surgical outcomes in women with AS. Could aberrant vascularity be the underlying reason for the recurrence of IUA?
Furthermore, if menstrual obstruction represents the key mechanism leading to amenorrhea, pelvic pain would present as a more prominent feature of this condition.
Contrary, pelvic pain is only reported in a few studies on AS. In our cohort, pain affected one third of women (39%). This rate is higher than most reported series. This may be due to the lack of direct questioning about this particular symptom. However, if the menstrual dysfunction is indeed a direct result of menstrual obstruction, one would consider that this
286 Chapter 5: Discussion
would be a key feature of AS, as it is in Müllerian anomalies. However, this does not appear
to be the case for AS, and the description of the cases reported in the literature. In the women
in our study who reported pelvic pain, a significant number had marked improvement in this
symptom post-operatively. This indicates that there may have been an element of obstructed menstruation causing their symptoms, or indeed this may be due to the altered contractile function of the uterus, which is responsive to changes in the hormonal environment. Altered contractility has been elegantly demonstrated in pelvic ultrasound and MRI cine sequences
(438-440). Contraction of the uterus is a direct cause of dysmenorrhoea and the change in contractile patterns due to the presence of scar tissue may adversely affect the pain receptors in the uterine cavity. The presence of fibrosis may alter the pattern of contraction or promote an asynchronous contraction. As a number of women were amenorrhoeic, and pain is a subjective symptom, it was difficult to assess whether their pain was uterine, ovarian,
musculoskeletal or visceral, and whether their pain was associated with the cyclical hormonal
milieu, including progestogens in the luteal phase causing lower abdominal bloating or
altered gastrointestinal function.
Impaired fertility is a common complaint of women with AS. The mechanism behind
this may be a physical barrier to fertilisation by complete obstruction of the reproductive
tract, or the adhesions themselves may form a foreign body effect, or uterine scarring which
alters the myometrial contractility or endometrial molecular environment may contribute.
High rates of pregnancy post-operatively were demonstrated in our cohort. This concurs with
large series in tertiary referral centres worldwide (60). Chapter 2 presents the pregnancy data
for Chapters 2 and 3, while Chapter 4 reports a new cohort of women, with a weighting
towards higher grade AS. The combined results represent 177 women with AS and surgery,
of whom 146 were trying to conceive. Although the pregnancy rates were reassuring, these pregnancies were marred by obstetric complications. The combined pregnancy rate for the
287 Chapter 5: Discussion
thesis was 106/146 (72.6%). The live birth rate according to number of women was 83/146
(56.8%), the miscarriage rate was 30/146 (20.5%), and the perinatal mortality was 4/146
(2.7%). In total, there were 166 pregnancies resulting in 98 babies born from 97 pregnancies in 83 women (1 set of twins). There were 97 live births, 48 miscarriages, 4 perinatal mortalities, 3 terminations of pregnancy for congenital anomalies, 4 ectopic pregnancies, and
10 ongoing pregnancies. However, maternal morbidity cannot be ignored, with adherent placentation in 21/146 (14%), postpartum haemorrhage in 7/146 (9%), and hysterectomy in
4/146 (3%) of women.
This data represents the largest series reporting long-term fetal and neonatal outcomes to date in women with AS. The main obstetric complications relate to placentation or the dysfunction associated with it, including obstetric haemorrhage, placenta previa and placenta accreta. This has secondary repercussions for the fetus. There is a paucity of long-term fetal outcomes in the AS literature. The rates of prematurity in our cohort were very high, with one quarter (26%) of all deliveries born prematurely following surgery for AS, compared to population rates of 8.6% born prematurely in Australia wide databases (272). The fetal weight was also adversely affected in the babies born, with the average fetal weight of the
cohort being 3.1 kg vs. 3.6 kg in the general population. Extremely low birth weight, defined
as delivery under 1 kg affected 2.8% of our patients compared to 0.4% of the general
population (272). The two neonatal deaths and 2 stillbirths in our data were certainly
alarming at 2.3% compared to 0.3% in the population at large. Furthermore, in the Australian
population-wide perinatal statistics, congenital anomalies account for a majority of the causes
of perinatal death (272), and neither of the two neonatal losses were associated with such
conditions, with prematurity identified as the principal cause in both cases in our data. An
algorithm has been developed (Appendix L) to assist treating doctors in the management of
women with AS.
288 Chapter 5: Discussion
The ultimate test of the function of the uterus is pregnancy and the achievement of a live birth. Indeed this is the most important outcome for women desirous of pregnancy.
These data provide meaningful and clinically significant outcomes to treating physicians and their patients. This study represents the largest number of long-term pregnancy and fetal
outcomes in the AS literature. Vascular function and perfusion lie at the core of the ability of
the uterus to accept an implantation. Uterine transplantation poses an interesting parallel.
Early surgical failures (398, 399) occurred due to poor perfusion to the transplanted tissues,
and subsequent success was achieved using increased, larger, lateral vascular anastamosis of
uterine vessels allowing adequate perfusion to this unique organ, which has a vascular
requirement beyond it’s own metabolic function but a role of supporting the metabolic requirements of an embryonic graft. Interestingly, despite anatomical success of the transplanted organ, pregnancies following this technique are still complicated by prematurity, pre-eclampsia, and low birthweight (401). This indicates that vascularity is likely to be at the
core of these poor obstetric outcomes.
These initial concerning obstetric and neonatal outcomes directed my research
towards prevention of the reformation of IUA as the principal cause for the poor obstetric outcomes. If the current literature on adhesion barriers was correct, with a true reduction in
AS not merely IUA, then perhaps the prevention of IUA using adhesion barriers may lead to
improved reproductive and ultimately neonatal outcomes. Therefore the second new study in this thesis was performed to assess whether adhesion barriers improved clinical outcomes,
rather than simply improving adhesion scores, as seen in animal and human models.
However, despite their promise in adhesion formation for primary and secondary prevention,
our findings did not support the published world literature, which support positive findings
for adhesion barriers in AS in the majority of papers. This is likely to be explained by the
outcome measures assessed in this thesis. These measures were different to most other well-
289 Chapter 5: Discussion
designed published studies, which report short-term adhesion score, and not clinically
relevant long-term symptoms. The aim of my thesis was to provide clinically meaningful
information to clinicians and patients about AS, including its cause and treatment options.
There was a lack of any difference in reproductive fertility and obstetric data in our cohort with the addition of the site-specific membrane SeprafilmTM (Genzyme Corporation,
Cambridge, MA) following surgery for secondary prevention of IUA in women who were having synaechiolysis for diagnosed IUA. The main reasons for this lack of difference are likely to be twofold: firstly that asymptomatic IUA do not constitute AS and are of limited clinical relevance, and secondly, that the outcomes for pregnancy following surgery were already favourable without an adhesion barrier, hence it is difficult to reach statistical significance in the small cohort that was represented in this study. This highlights one of the
key difficulties with long-term surgical studies, that losses to follow up are common, and the
relative improvement would need to be so great as to be powered to achieve a true
improvement in symptoms. This calls for collaboration between centres that have experience
in AS to undertake larger scale, adequately powered studies to answer these important
clinical questions.
Finally, the investigation became a quest for the true pathogenesis and causality of
IUA, which underpins the idiosyncratic nature of this condition. IUA alter the ability of the
endometrium to respond appropriately to the hormonal environment and facilitate successful
embryonic implantation, and if no pregnancy ensues, menstrual shedding. Could this same
pathological process be the root cause of the excessively high rates of maternal and fetal
morbidity? It is biologically plausible that disorders of placentation lead to the cascade of
obstetric haemorrhage, hysterectomy impaired fetal growth, prematurity and perinatal
mortality, and that this may be due to the altered implantation environment, or impaired
ability of the organ to provide ongoing support to the growing fetus in the first instance.
290 Chapter 5: Discussion
Therefore the final section of this thesis investigates the alterations in vascular perfusion in the uterus to assess whether this phenomenon may explain and unite all of the components of this enigmatic disorder; a loss of menstrual function, poor embryonic receptivity and a defective uterine environment for the ultimate growth and development of the fetus.
Certainly in our data and others, higher-grade disease is associated with poorer reproductive prognosis in AS, and in a recent MRI study, an ill identified JZ was strongly associated with no pregnancy in women with IUA (127). In addition, once the seminal cause could be identified, then perhaps women may be able to be more appropriately counselled about their true chance of a healthy take home baby, defined by their extent of endometrial perfusion.
No studies to date have looked at perfusion using MRI as an investigative tool. The advantage of dynamic MRI sequences is the ability to read the ‘wash in’ and ‘wash out’ of radiolucent contrast, mimicking and paralleling the vascular perfusion at the end arterioles and at the capillary level. It is this microvascular perfusion that needs to be investigated to truly assess the vascular receptive state of the endometrium. As is well recognised, the process of implantation requires a nutrient rich environment to adequately provide the cell adhesion molecules, cytokines and inflammatory cells required for effective implantation.
These are signalled via appropriate endocrine and paracrine pathways. Predictive models for effective implantation, such as the endometrial thickness measured on TVUS prior to embryo transfer, have been used for decades to assess receptivity of the endometrium. Recent studies support the benefits of a minimal threshold thickness for implantation success. This crude measure is but a surrogate marker for the true pathological process, which is the ability of the endometrium to read and respond to the various hormones, cell adhesion molecules and cytokines to provide a receptive domicile for the embedding embryo. Trophoblastic invasion is reliant on angiogenesis. However, this invasion phase is entirely reliant on the vascular rich maternal bed. If this environment is insufficient, then surely this leads to failure or
291 Chapter 5: Discussion aberrant implantation. Could this truly be the mechanism behind symptoms experienced by women with AS? There were no normal studies on DCE-MRI in the uterus outside of the oncological literature. Therefore the third part of this thesis attempted to explore this hypothesis by developing a proof of concept study to assess the vascular perfusion of women with AS using DCE-MRI technology. This was performed in the endometrial cavity in the same way tumour activity is assessed in the uterine corpus. The JZ is integral to the implantation of the embryo, as the essential anatomical link between the myometrial and endometrial layers. Therefore, the JZ was selected as the area to be investigated in women with AS. Models used to guide the study design included investigation of the myocardioum following hypoxic ischaemic injury following infarct, and the brain in Alzheimer’s disease.
These models were used as a template to develop the perfusion study of the myometrium.
This MRI data augments the increasing body of literature in power Doppler ultrasound in early implantation and its failure. The finding of the lower perfusion threshold in higher grade AS is important as it may provide a new non-invasive test to guide women as to the severity of their pathological process prior to resection. The higher predictability (area under curve = 0.855) of total perfusion of < 660 mL/100 g/sec in women who had inoperable disease is also extremely relevant for treating surgeons. It may alter treatment plans, rather than continuing to persevere with adhesiolysis with poor outcomes expected and an increasing risk of iatrogenic injury, and perhaps ultimately, pregnancies which are destined to be deleterious to the mother and baby.
The evidence in this thesis shows that Grade IV AS women have a lower chance of pregnancy and a higher risk of obstetric complications. This can be predicted on MRI.
Therefore, should we consider performing MRI in these women? Once severe vascular incompetence is seen on imaging, should they consider other options for pregnancy such as surrogacy? Just because anatomical restoration is possible, is this in fact the best
292 Chapter 5: Discussion management option for these women, who ultimately are likely to develop serious obstetric morbidity and neonatal mortality? Ultimately, primum non nocere needs to be considered by clinicians treating women, and especially when IUA are concerned, as the implications for anatomical restoration of the uterine cavity can affect not only the woman herself, but the life of the unborn fetus.
Future directions
As our understanding of this complex disorder develops, one can only hope that fertility and obstetric outcomes improve. More research is required to explore the risk factors for development of IUA, techniques of instrumenting the uterus in a minimally traumatic fashion, and medical management of miscarriage, to reduce the likelihood of adhesion formation, and if IUA do occur, to guide the optimal surgical technique to treat AS.
The work in this thesis is limited by the relatively small number of women presenting with a heterogenous range of symptoms defined as AS. Increasing awareness of this condition is obvious with the larger sample size of the studies being published in this area, with a view to primary prevention of IUA or secondary prevention of the re-formation of
IUA once this cascade of events has occurred. Adhesion barriers may still hold promise in this field and more well powered studies with large numbers of women against a control arm will help to answer this important research question before the routine use of adhesion barriers are adopted.
The role of perfusion MRI as a diagnostic tool in predicting location and extent of endometrial and myometrial fibrosis needs to be explored in greater depth. The small numbers in this study may provide a basis for which adequately powered control matched studies can be performed to help answer the question of whether perfusion MRI may also be utilised as a predictor of grade of disease and surgical success, or indeed the chance of
293 Chapter 5: Discussion
recurrence of adhesion, and a healthy pregnancy and live birth. Women with a high degree of
uterine scarring and impaired uterine microvascular supply may respond poorly to
hysteroscopic synaechiolysis, even after repeated attempts. In light of the high rate of
perforation and other complications of hysteroscopic synaechiolysis (12), identification of
women who may not benefit from the procedure is of clinical relevance. MRI may also shed light on the reduced reproductive function of the uterus following AS, despite anatomical normalisation of the endometrial cavity, and the poor obstetric outcomes reported in these
women. Perfusion MRI evidence may support the hypothesis that the scarring in AS affects
the entire cavity, not simply the endometrium, and that AS may represent but a component of
the spectrum of disease which encompasses implantation failure in women with poorly responsive and thin endometrium, or placental pathologies leading to fetal growth restriction.
There may exist the possibility that these women have disordered vascularity to the uterus, and may also have altered perfusion, which is now measurable on DCE-MRI. Finally, one must ask whether the women with AS are indeed predisposed to the development of IUA following their traumatic or hypoxic event, or whether instead of implicating the event itself, they may have an innate vascular phenomenon within their uterus which leads to AS. If the latter is the case, this predisposition needs to be explored in greater depth.
Compared to the era when Asherman first described his syndrome, hysteroscopy is now the mainstay of management. Many referral centres have the skills and experience necessary to resect IUA with good results using a number of techniques. However, higher grade IUA remain problematic. Is this treatment recommended for all women with AS? Can we stratify those that will have a good outcome, compared to those who stand a poor chance of pregnancy or safe delivery? Or are there better options available for these women? Stem cells certainly hold great promise, with the most recent human study using autologous cell therapy with CD133+ bone marrow derived stem cells reporting encouraging results in
294 Chapter 5: Discussion women with AS and endometrial atrophy refractory to other management, including adhesiolysis surgery (222). The peripheral blood derived stem cells injected into the spiral arterioles through the femoral route yielded 3/16 spontaneous pregnancies, and seven subsequent pregnancies with ART. Although two live births have been reported thus far, other long-term pregnancy outcomes are eagerly awaited. This may represent the next major development in the treatment of women with AS since simply using the eye as a guide in hysteroscopic adhesiolysis.
295 Chapter 5: Discussion
Conclusion
Asherman syndrome (AS) is likely to represent a spectrum of disease. Although
various aetiological factors have been identified, constitutional factors are also likely to play a role. The pregnant state is certainly a predisposing factor to the formation of intrauterine adhesions (IUA). This may be due to hormonal or vascular changes that occur within the uterus at this unique time. Treatments have improved outcomes over the last half a century, with the advent of hysteroscopic synaechiolysis. Studies that report adhesion score show a marked reduction of IUA following surgical adhesiolysis. Clinical symptoms such amenorrhoea and pain are also improved following adhesiolysis but to a lesser extent.
Pregnancy remains problematic in women with higher-grade AS. Fertility rates are encouraging in the literature and in our series. However, these pregnancies have high obstetric and perinatal complication rates. Women with AS have decidual senescence, leading to hormonal aberrations and vascular anomalies that impair pregnancy success. This may lead to an increased risk of preterm birth, fetal growth restriction, and placental pathologies. The altered endometrium may cause hormonal aberrations or inflammation, which may act on the endometrium, myometrium, cervix, and during implantation and pregnancy. These women should be recognised as high risk for poor obstetric outcomes and pregnancies should be monitored with specialised follow-up.
Moving into the next century of management, treatments should focus on non- invasive options for women with AS, with targeted therapy to individualise care. Vascular derangement is likely to be at the core of the causality of this phenomenon. Therefore MRI or other vascular assessments hold promise for the prognosis of women with AS. These may also help to guide doctors towards the safest and most effective treatment for women with this enigmatic disease.
296 Chapter 5: Discussion
Management should focus on preventative care measures for women to avoid the occurrence of this disease in the first instance. However, as more women are being effectively treated, giving them the opportunity of pregnancy, there is a real need for the development of evidenced-based recommendations for clinical management and specific obstetric care pathways for women with AS.
297 References
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320 Appendices
Appendices
A Ethics letter (Chapter 2) 317
B Patient letter (Chapter 2) 318
C Patient questionnaire (Chapter 2) 319
D Ethics approval letter (Chapter 3) 322
E Patient consent form (Chapter 3) 324
F Patient questionnaire (Chapter 3) 326
G Ethics approval letter (Chapter 4) 332
H Asherman patient’s consent form (Chapter 4) 334
I Control patient’s consent form (Chapter 4) 343
J Patient questionnaire (Chapter 4) 352
K Checklist for normals (Chapter 4) 363
321 Appendices
Appendix A: Ethics letter (Chapter 2)
322 Appendices
Appendix B – Patient letter (Chapter 2)
323 Appendices
Appendix C: Patient questionnaire (Chapter 2)
NAME:
QUESTIONS: (please place a cross in appropriate boxes)
Immediately prior to any treatment on our unit were you having periods?
YES If yes: were they REGULAR IRREGULAR Number of days bleeding each period ______ NO If no: for how long had you had no periods ______(months)
Prior to any treatment on our unit were you experiencing significant pelvic pain or pain around your periods?
YES If yes: for how long had pain been a problem ______(months) NO
Prior to any treatment on our unit were you trying to / hoping to become pregnant?
YES If yes: for how long had you wanted to become pregnant ______(months) NO
After your last treatment on our unit what were your periods like (in the first 3 to 6 months)?
No periods following treatment Irregular periods (how many days bleeding ______: how often ______) Regular periods (how many days bleeding ______)
What are your periods like now?
No periods since procedure Periods started but then stopped since procedure Irregular periods (how many days bleeding ______: how often ______) Regular periods (how many days bleeding ______)
After your last treatment on our unit were you experiencing significant pelvic pain or pain around your periods (3-6 months after treatment)?
YES NO
324 Appendices
Appendix C: Patient questionnaire (Chapter 2) [continued]
325 Appendices
Appendix C: Patient questionnaire (Chapter 2) [continued]
If you have been pregnant since your treatment on our unit – what was the pregnancy complicated by the following? (if more than once insert number)
Caesarean delivery Premature delivery less than 37 weeks at delivery (No of weeks______) low lying placenta operation / procedure to remove placenta heavy bleeding after the birth blood transfusion Other ______
Were you satisfied with the procedure?
YES NO
Would you have this treatment again?
YES NO
Do you have any other comments? ______
Thank you
326 Appendices
Appendix D – Ethics approval letter (Chapter 3)
327 Appendices
Appendix D – Ethics approval letter (Chapter 3) [continued]
328 Appendices
Appendix E – Patient consent form (Chapter 3)
329 Appendices
Appendix E – Patient consent form (Chapter 3) [continued]
330 Appendices
Appendix F – Patient questionnaire (Chapter 3)
331 Appendices
Appendix F – Patient questionnaire (Chapter 3) [continued]
Patient History Prior to any treatment (before t=0) (For more details refer to Q20)
1. Gravidy _____ Parity_____ Miscarriage(s) ______Termination(s)______
2. Has the patient had gynaecological procedures previously? (Inc. D+C –post delivery/miscarriage – coded seperately) Yes ____ Please specify ______No _____ Were there any complications? (Including Ashermans – Ask about Cause of Asherman’s Syndrome) Yes ____ Please specify ______No _____
3. Has the patient had other surgical procedures previously? Yes ____ Please specify ______No ____
a. Were there any complications? Yes ____ Please specify ______No _____
4. Has the patient been diagnosed with genital tuberculosis? Yes ____ No ____
5. Has the patient received treatment for any gynecological cancers? Yes ___ Please specify ______No ____
6. Did the patient have any pre-existing medical conditions? Yes ___ Please specify ______No ____
7. Was the patient taking any medications/supplements? Yes ___ Please specify ______No ____
8. Did the patient receive pre-op oestrogen? Yes ___ Please specify ______No ____
9. Any documented allergies? Yes ___ Please specify ______No ____
version 1 – April 2, 2012 2
332 Appendices
Appendix F – Patient questionnaire (Chapter 3) [continued]
During time of treatment (t=0)
10. Date/ Time for corrective surgery of Asherman’s syndrome: ______
11. Staging of Asherman’s syndrome ______
12. Did the patient receive Seprafilm as part of their treatment? Yes ___ No ____
13. Did the patient experience any adverse reactions to the treatment? Yes ___ Please specify ______No ____
14. Were there any complications during the surgery? Yes ___ Please specify ______(proce ed to Q14a) No ____
a. How were the complications resolved? ______
Within 6 months from the treatment (t=6)
15. Did the patient require another procedure? Yes ___ Please specify how many?______No ____
More than 6 months from the treatment (t>6)
16. Did the patient require another procedure? Yes ___ Please specify how many?______No ____
version 1 – April 2, 2012 3
333 Appendices
Appendix F – Patient questionnaire (Chapter 3) [continued]
II Menstrual cycle Prior to any treatment (before t=0)
17. Was the patient having periods? Yes ___ (proceed to Q1a,b) No ___ (proceed to Q1c) Was the patient breastfeeding at diagnosis? _____
a. Were they Regular ___ or Irregular ____? b. Number of days each bleeding period lasted for? ____ days c. How long did the patient have amenorrhea? ______months
Within 6 months from the treatment (t=6)
18. Was the patient having periods? Yes ___ (proceed to Q20a,b) No ___ (proceed to Q20c) Was the patient pregnant before menstruation could begin? a. Were they Regular ___ or Irregular ____? b. Number of days each bleeding period lasted for? ____ days c. How long did the patient have amenorrhea? ______months
Comments______
version 1 – April 2, 2012 4
334 Appendices
Appendix F – Patient questionnaire (Chapter 3) [continued]
III Pregnancy/ Fertility Prior to any treatment (before t=0)
19. Was the patient hoping to become pregnant? Yes ___ (proceed to Q19a) No ___
a. How long did the patient want to become pregnant?
20. Has the patient been pregnant before? (Refer to Q1) Yes____if more than 1 insert number____ (proceed to Q20a) No ____ Age at conception? (yrs) a. What was the outcome of the pregnancy? Live birth ___ i. What was the weight of the baby at birth? ___ kg ii. What was the method of delivery? ______iii. Were there any fetal abnormalities or complications? Yes ___ Please specify?______No ____ iiii. Maternal Complications? (Bleeding, infection, surgery, retained products etc)
Miscarriage___ Ectopic pregnancy___ Termination___ (REPEAT FOR SUBSEQUENT PREGNANCIES) Comments______
version 1 – April 2, 2012 5
335 Appendices
Appendix F – Patient questionnaire (Chapter 3) [continued]
Within 6 months from the treatment (t=6)
21. Did the patient try to become pregnant? Yes ___ (proceed to Q16a) No ____
a. When did the patient start trying to become pregnant since the surgery(t=0)? i.e. Straight away = 1 Or after 1 or more menses = 2 b. How long did it take the patient to get pregnant after beginning to try? (months)
22. Did the patient become pregnant (positive result for pregnancy test)? Yes ___if more than 1 insert number______(proceed to Q22a) No ____ Age at conception? (yrs) a. What was the outcome of the pregnancy? Live birth ___ i. What was the weight of the baby at birth? ___ kg ii. What was the method of delivery? ______iii. Were there any fetal abnormalities or complications? Yes ___ Please specify?______No ____ iiii. Maternal Complications? (Bleeding, infection, surgery, retained products etc)
Miscarriage ____ Ectopic pregnancy ____ Termination ____ (REPEAT FOR SUBSEQUENT PREGNANCIES) Comments______
23. Did the patient receive any fertility treatments during this time? Yes ___ Please specify the kind of treatment (ovulation induction, IVF etc)______(proceed to Q19a.b) No ____
a. How many times(frequency) did the patient require the treatment? ______b. How long did the treatment(duration) last for (please specify for each cycle? ______
24. Was the patient taking any other medications to supplement the treatment ?(hormones, antibiotics, herbal etc) Yes ___ Please specify ______No ____
version 1 – April 2, 2012 6
336 Appendices
Appendix G – Ethics approval (Chapter 4)
337 Appendices
Appendix G – Ethics approval (Chapter 4) [continued]
338 Appendices
Appendix H – Patient consent form – Asherman patients (Chapter 4)
339 Appendices
Appendix H – Patient consent form – Asherman patients (Chapter 4) [continued]
340 Appendices
Appendix H – Patient consent form – Asherman patients (Chapter 4) [continued]
341 Appendices
Appendix H – Patient consent form – Asherman patients (Chapter 4) [continued]
342 Appendices
Appendix H – Patient consent form – Asherman patients (Chapter 4) [continued]
343 Appendices
Appendix H – Patient consent form – Asherman patients (Chapter 4) [continued]
344 Appendices
Appendix H – Patient consent form – Asherman patients (Chapter 4) [continued]
345 Appendices
Appendix H – Patient consent form – Asherman patients (Chapter 4) [continued]
346 Appendices
Appendix H – Patient consent form – Control patients (Chapter 4) [continued]
347 Appendices
Appendix I – Patient consent form – Control patients (Chapter 4)
348 Appendices
Appendix I – Patient consent form – Control patients (Chapter 4) [continued]
349 Appendices
Appendix I – Patient consent form – Control patients (Chapter 4) [continued]
350 Appendices
Appendix I – Patient consent form – Control patients (Chapter 4) [continued]
351 Appendices
Appendix I – Patient consent form – Control patients (Chapter 4) [continued]
352 Appendices
Appendix I – Patient consent form – Control patients (Chapter 4) [continued]
353 Appendices
Appendix I – Patient consent form – Control patients (Chapter 4) [continued]
354 Appendices
Appendix I – Patient consent form – Control patients (Chapter 4) [continued]
355 Appendices
Appendix I – Patient consent form – Control patients (Chapter 4) [continued]
356 Appendices
Appendix J – Patient questionnaire (Chapter 4)
357 Appendices
Appendix J – Patient questionnaire (Chapter 4) [continued]
358 Appendices
Appendix J – Patient questionnaire (Chapter 4) [continued]
359 Appendices
Appendix J – Patient questionnaire (Chapter 4) [continued]
360 Appendices
Appendix J – Patient questionnaire (Chapter 4) [continued]
361 Appendices
Appendix J – Patient questionnaire (Chapter 4) [continued]
362 Appendices
Appendix J – Patient questionnaire (Chapter 4) [continued]
363 Appendices
Appendix J – Patient questionnaire (Chapter 4) [continued]
364 Appendices
Appendix J – Patient questionnaire (Chapter 4) [continued]
365 Appendices
Appendix J – Patient questionnaire (Chapter 4) [continued]
366 Appendices
Appendix J – Patient questionnaire (Chapter 4) [continued]
367 Appendices
Appendix K – Checklist for normals (Chapter 4)
MRI Asherman’s
CHECKLIST: NORMALS
PRINCIPAL INVESTIGATOR: DR REBECCA DEANS
(Study reference number:)
Subject Initials: (3 initials where applicable)
Subject Identification Number:
Version 1. Last updated 10/06/14 1
368 Appendices
Appendix K – Checklist for normals (Chapter 4) [continued]
Part A – Demographics Today’s Date: __/__/__ Date of Birth: _ _/_ _/_ _ _ _ Age (years): MRN: Initials: OR STICKER
LMP ______Days ago
Unknown
Mirena
IUD
OCP Cycling (exclude) – SHOULD WE EXCLUDE BASED ON OCP???
Cycle pattern Regular Irregular Duration of cycle in days ______
Medical history Has the patient been diagnosed with the Yes SHOULD NOT No following? NEED TO EXCLUDE?
Fibroids Yes No
Polycystic Ovarian Syndrome Yes No
Endometriosis Yes No
Drugs Is the patient taking any of the following Yes (???Exclude) No medications? Anticholinergic drugs Yes No
Oral Contraceptive Pill Yes No
Hormone replacement therapy Yes No
369 Appendices
Appendix K – Checklist for normals (Chapter 4) [continued]
Previous surgery Has the patient had any Yes No previous surgery? C-section Yes No
Number: Myomectomy Yes (Exclude) No
??? IS THIS Yes (Exclude) No RELEVANT?Surgical TOP Number: Endometrial ablation Yes (Exclude) No
Uterine artery Yes (Exclude) No embolization
370 Appendices
Appendix L – Recommendations for management of women with Asherman Syndrome
o Menstrual and pain symptoms o Hormone profile to establish ovulation o Pelvic ultrasound to assess endometrial thickness o Hysteroscopy to diagnose intrauterine adhesions. o If anatomy is unclear or surgeons are not familiar with advanced operative hysteroscopy, refer to a centre with extensive experience to avoid false passage formation and perforation o Pregnancies following surgical division of intrauterine adhesions o Repeat hysteroscopy if symptoms recur or the woman is not pregnant within 6 months o Investigate other causes of infertility after 6-12 months for women under 35, and earlier if older than 35 years of age o If IVF is required, single embryo transfer only. o Antenatal Care o Once pregnant, women should have antenatal care and delivery in a unit that provides surgical back up for delivery, and comprehensive neonatal services o Early and accurate ultrasound to confirm gestation, identify (spontaneous) multiple pregnancy and exclude anomalies o Detailed ultrasound at 18-20 weeks to assess placentation and any evidence of placenta accreta o Consider MRI if ultrasound is suspicious for morbid adhesion of placenta o Delivery o Delivery should be attempted vaginally unless the woman has contraindications o Delivery in a unit with maternal and neonatal high dependence and intensive care. o Placenta accreta or percreta should have a planned elective caesarean delivery with surgical back up considering the high risk of hysterectomy in this situation o Blood should be cross matched for delivery especially where there is abnormal placentation
371