Adhesions may occur in the inner layer of the uterus after surgeries such as previous myoma surgery, abortion or cesarean section, and after uterine tuberculosis.
In these patients, there may be no menstruation, menstrual bleeding may be less than normal, or menstruation may be normal if the adhesion is less. Even if there is little adhesion, patients may not become pregnant or may have a miscarriage. The best treatment for the patient group who wants to have children is to open the adhesions with hysteroscopy. This can be done in the office or by conventional hysteroscopy. Adhesions may reoccur in patients and require repeated surgical intervention.
Adhesions formed in the uterus are one of the important reasons for not being able to get pregnant, miscarriage, and having little or no menstrual period. It is also called Asherman syndrome, after the person who first described it. It usually follows a trauma (destruction) created within the womb. The most common scenario is that after an abortion, menstrual bleeding decreases or stops, and research shows that there is an adhesion in the uterus. Other reasons following abortion include interventions made after birth due to the baby's inability to come out completely and surgeries for fibroids in the uterus. Less commonly, it may occur secondary to a tuberculosis (TB) infection in childhood. As can be understood, either an infection or a trauma is required for the formation of intrauterine adhesions. Generally, both are seen together. As a result of the damage to the basal cell layer, which is responsible for renewing the inner layer of the uterus every month after abortion, the inner layer of the uterus cannot be renewed anymore and the walls of the uterus stick together.
What are the symptoms?
The most common is abortion. After this, menstrual bleeding may stop or decrease significantly. Normally, for women who have regular menstrual periods after an abortion, menstrual bleeding is expected to occur within 4-8 weeks. If it does not come, uterine adhesions should be suspected. Less commonly, painful menstrual bleeding (dysmenorrhea), inability to become pregnant without a reason, and recurrent miscarriages may also be symptoms of intrauterine adhesions.
How is the diagnosis made?
Ultravaginal ultrasound examination for diagnosis. , uterine film (HSG), and hysteroscope pi are tools that can be used.
How is it treated?
The current standard in the treatment of intrauterine adhesions is hysteroscopic adhesion removal. Blind abortions are now a thing of the past. Hysteroscopy is the name given to inflating the uterine cavity with water by entering the uterus vaginally with a thin telescope. This procedure, which was previously performed only for the purpose of diagnosis, now also has the opportunity to perform surgery inside the uterus. Intrauterine adhesions can be opened using scissors or electrical energy.
Success is directly proportional to the degree of adhesions and the surgeon's experience. The denser the adhesions and the proportionally larger part of the uterine cavity they cover, the higher the chance of treatment failure. It is often impossible to treat adhesions, especially those that completely cover the uterine cavity. In cases where adhesions are intense, sometimes more than one attempt may be required. We have patients who underwent adhesion removal 5-6 times and eventually became pregnant.
Therefore, it is very important for the woman to be patient and not lose hope during these procedures. After hysteroscopy, a balloon may be placed in the uterus to prevent adhesion from reoccurring. However, it has not been conclusively shown that the balloon prevents the re-formation of adhesions. Although estrogen hormone therapy can be used for a short time after the procedure in severe cases, its benefit is controversial. We recommend that those with severe adhesions be examined with hysteroscopy again after menstrual bleeding after the end of hormone therapy.
What are the complications that may occur in case of pregnancy?
If pregnancy occurs, the risk of miscarriage and premature birth increases. Women who become pregnant after severe uterine adhesions may have problems caused by the abnormal positioning of the baby's partner (placenta). These are placenta previa (where the placenta comes before the baby in the birth canal) and adhesive placenta.
The placenta may not be removed during birth after the sticky placenta, called placentaaccreta or percreta, is embedded in the muscle layer of the uterus and even beyond the muscle layer to the outer membrane of the uterus. Related problems may occur. In similar cases It may even be necessary to remove the uterus
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