Endometrial adhesions are a serious cause of infertility, both in terms of difficulty in conception and in the completion of pregnancy, as they are responsible for miscarriage rates of up to 80%. Responsible for infertility, repeated miscarriages, secondary amenorrhoea (absence of menstruation) and oligomenorrhoea (less than normal amount of blood during menstruation), hematomas (filling of the endometrial cavity with blood), endometrial adhesions are caused by several factors.
What are adhesions?
The uterine cavity is lined by the endometrium. This “lining” consists of two layers: the functional layer, which is shed during menstruation, and an underlying basal layer, which is necessary for the regeneration of the functional layer. Trauma to the basal layer, usually after a dilation and curettage, after a miscarriage, or after an abortion, may cause the development of intrauterine scars which become adhesions and may eliminate the endometrial cavity to varying degrees. Menstrual disorders, amenorrhea, hypo menorrhea and oligomenorrhea are the known symptoms of adhesions within the uterus. Period abnormalities are often, but not always, correlated with severity, e.g. adhesions in the cervix block menstruation. Pain during menstruation and ovulation can also be attributed to adhesions. Depending on how serious it is, it can lead to infertility, recurrent miscarriages, ectopic pregnancy, obstetric complications, and pain from blood trapped in the uterus. And of course, the “trapped” uterine blood inside the uterus caused by adhesions can lead to endometriosis.
Asherman’s syndrome, which is characterized by an extensive fusion of the walls of the uterine cavity, results in the absence of a uterine cavity and the absence of a period. Asherman described in 1948 as ‘traumatic amenorrhoea’ the secondary amenorrhoea resulting from traumatic uterine abruption following childbirth, abortion or septic abortions. Restoration of the uterine cavity by lysis of adhesions in Asherman’s syndrome is extremely difficult, if not impossible.
The adhesions are treated hysteroscopically. Before surgery, a careful preoperative assessment by the surgeon with endovaginal ultrasound and hysterosalpingography is needed to determine the extent of adhesions to avoid possible complications (uterine perforation) at the time of surgery. Treatment of the condition is done immediately and the patient is discharged after 1-2 hours. Of course, the results of the resolution of adhesions depend on the extent, location, thickness, and morphology of the adhesions (thin and transparent, or firm and fibrous), with mild to moderate adhesions usually being successfully treated. Extensive involvement of the uterine cavity or the phalangeal ducts and deep lesions of the myometrium and endometrium may require several surgical interventions. In any case, after surgery, a cycle of estrogen therapy is administered to enhance the re-growth of the uterine surface. After surgery and hormone therapy, the results in terms of the return of normal menstruation and thus the achievement of pregnancy are usually excellent.
adhesions and pregnancy
In order for a woman to become pregnant after the removal of adhesions, IVF must be performed, unless the uterus is completely destroyed, in which case pregnancy will not be possible even with IVF. Now if there is pregnancy after treatment of endometrial adhesions, there is an increased risk of abnormal placental formation and possible placental abruption. It also happens that the cervix can no longer support the increased weight of the fetus, the pressure can cause the placenta to rupture and premature labour can occur. In this case, it is advisable to perform a cervical ligation.