1. Asherman Syndrome Hormoz Dabirashrafi M.D.

2. Heinrich Fritsch (1927) Stamen (1946) 1948 (Joseph G.Ashenman) The focus of research in the initial: Prevalence, Etiology and Pathology The focus of research has now: Diagnosis, Treatment and Reproductive Outcomes

3. Definition Asherman.Sy: curettage of the gravid uterus Syndrome: a group of symptoms… Asymptomatic intrauterine adhesions Intrauterine fibrosis

4. Prevalence Israel, Greece, South America 1- Degree of awareness 2- The number of therapeutic or illegal – ab 3- Sharp, blunt or suction curettage… 4- Incidence of G.Tub 5- Criteria Used for diagnosis of…

5. Etiology A- Truma: 1- Truma to a gravid uterine cavity 66.7% post abortion /miscarriage curettage – 21.5% postpartum curettage 2% after CS - 0.6% after mole… Explanation: a) low estrogen status b) The uterus could be in a vulnerable state 2- Truma to non-gravid uterus Diagnostic curettage (1.6%) – abdominal myomectomy (1.3%) Cervical biopsy or Polypectomy (0.5%) - Use Of radium (0.02%) - Insertion of IUD (0.2%)

6. B- Post Hysteroscopy 6.7% resection of septa 31.3% resection of solitary fibroid and multiple fibromas. A case of adhesion after UAE. After endometrial ablation (with thermal balloon) 36.4%

7. C- Infection: Uterine truma and subsequent inflammation in conjunction with a low estrogen status may potentially lead to fibrosis. 1856 case – 74 case TB D- Congenital anomaly of the uterus 43 malformations 7 had Ashenman.Synd (16%) E- Genetic predisposition: Gentle suction curettage No apparent reason

8. Symptomatology Atretic amenorrhea. 43% infertility (lack of sufficient amount of normal end – defective vascularization). spontaneous miscarriage 40%, preterm-d 23%, placenta accrete 13%, ectopic p 12%, IUGR. No limb amputation

9. Endometrial Ablation 70 pregnancies: 1.4% EP - 21% Spontaneous miscarriage. 18.6% premature D 4%IUGR - adherent placenta 14.3%- A case of fetal malformations (limbs abnormality, Scoliosis….) Endometrial malignancy Asherman.Sy and end adenocarcinoma can exist simultaneously….

10. Investigations HSG: Prospective study: HSG was comparable with Hysteroscopy It remains an important screening procedure Limitations: not detect end fibrosis – limitation in defining the nature of identified intrauterine adhesions-minor filmy adhesions- air bubbles- differential diagnosis

11. Ultrasonography: Uterine cavity (not possible by HSG or hysteroscopy) Sensitivity and specificity is low Ultrasonography before hysteroscopy Sonohysterography As accurate as HSG – The sensitivity of SHG 100% - HSG 100% - TVS=52% MRI Supplementary role cannot visualize by hysteroscopy

12. Treatment Restoring the size and shape –preventing recurrence-promoting the repair-restoring normal reproductive functions 1)Expectant management (23-18 regular mense) 292-133 conserved spontaneously 2) Blind D&C, high incidence of uterine perforation +low success 3) Hysterotomy nowadays –very severe cases. 3 cases-most extreme of situations

13. 4) Hysteroscopy Adhesiolysis: Method of choice (minimally invasive under vision) Scissors, Unipolar, Bipolar, Laser No diff in outcome between Scissors, resectoscope and laser. Guide: laparoscopy (often too late…) fluoroscopy, Gynecoradiologic uterine resection, Transabdominal ultrasound. laminaria tent. Sonohysterography. Conversion to septum division-repeat surgery. Genital TB Total uterine synechia – poor prognosis –surrogacy.

14. Complication Perforation, Hemorrhage, Pelvic infection

15. Prevention of recurrence (1.3% - 23.5%) 1) IUD (the loop IUD the best choice) No randomized study? 2) Foley balloon catheter Foley cath (for 10 days) safer, more effective than IUD (3 month) Prospective controlled study (balloon & no splint) Stem not coming out of the cervix 3.5 c.c very important 3) Amnion graft 4) Hyaluronic acid (very effective) Seprafilm - auto – cross – linked HA (ACP)

16. 5)Hormone Treatment: No objective evidence, on the reduction of reformation of adhesion.

17. Prevention 1) Curettage in the postpartum or post abortion period should be avoided – hysteroscopy 2) Perform gentle curettage (suction or blunt curette) 3) Select medical management

18. Conclusion - The management of moderate to severe Disease still poses a challenge, and the prognosis of severe disease remains poor - repeat surgery may be necessary without desired out come - In pregnancy after treatment, careful surveillance… -future research: cellular and molecular aspects of endometrial tissue regeneration, prevention of postsurgical adhesion formation

19. END