Ascherman syndrome

Ascherman syndrome, or intrauterine synechiae, is a pathological condition characterized by the formation of adhesions and outgrowths of the endometrium with its sclerosis and fibrosis. The disease is also known as Fritch syndrome, traumatic endometrial atrophy or endometrial sclerosis. The disease is named after the gynecologist who described and investigated this pathology in detail, Joseph Asherman. The syndrome was first described in 1894 by the German gynecologist Heinrich Fritsch.

The content of the article:
Classification of Ascherman syndrome
Morbidity
Intrauterine synechiae and pregnancy
Causes of intrauterine synechiae formation
Symptoms of Ascherman syndrome
Diagnosis of Ascherman syndrome
Treatment of Ascherman syndrome (intrauterine synechiae)
Prognosis in the treatment of Ascherman syndrome
Prevention of Ascherman syndrome
Ascherman syndrome
Classification of Ascherman syndrome
Depending on the degree of damage to the basal layer of the endometrium, adhesions can be of different nature and extent. Basically , there are 3 degrees of severity of the disease:

mild degree: the splices consist of a thin tissue of the basal layer, are easily destroyed by contact with the working part of the endoscope, occupy less than 25% of the uterine cavity;
medium degree: fibromuscular adhesions, firmly soldered to the uterine mucosa, occupy most of the uterine cavity;
severe degree: the joints are dense, consist of sclerosed connective tissue, fill more than 75% of the uterine cavity, block the mouth of the fallopian tubes, the bottom of the uterus.
Morbidity
Ascherman syndrome occurs in women of all races with the same frequency. After curettage of the uterine cavity in women who have given birth, the risk of the disease is 25%. An undeveloped or frozen pregnancy more often leads to the occurrence of this pathology and accounts for up to 30% of cases. With a normal miscarriage with a delay of parts of the fetal membranes and subsequent curettage, the risk of the disease does not exceed 7%.

The longer the period of delay of the fetal membranes after childbirth or miscarriage, the higher the likelihood of the disease. The number of procedures also matters: after a single curettage, the risk is 16%, and 3 or more procedures increase the likelihood of Ascherman syndrome to 32%.

Intrauterine synechiae and pregnancy
In Ascherman syndrome, the reproductive function is seriously affected. Due to synechiae, the uterine cavity is obliterated and the patency of the fallopian tubes is disrupted. In severe cases, the entire uterine cavity is blocked by splices, the walls stick together, which leads to the impossibility of conception and implantation of the embryo. Moreover, the endometrium loses its ability to respond to cyclical fluctuations in estrogen levels, resulting in secondary infertility and possible amenorrhea, that is, the absence of menstruation.

Synechiae in the cervix area lead to accumulation and delay of menstrual secretions in the uterine cavity. This is evidenced by pain and poor discharge during menstruation (oligomenorrhea). Possible violations of the menstrual cycle usually indicate a severe form of the disease.

Depending on the severity of the disease, the effect on reproductive function can vary from complicated pregnancy to repeated spontaneous abortions, miscarriages and secondary infertility. Premature birth, late uterine rupture, true placental increment and other pregnancy pathologies are possible.

Causes of intrauterine synechiae formation
The uterus is a hollow muscular organ consisting of 3 layers. From the outside it is covered with a peritoneum. The uterine wall is formed by smooth muscle tissue. The uterine cavity is lined with the endometrium, which consists of the superficial functional and deep basal layers. The endometrium under the influence of female sex hormones undergoes cyclic changes depending on the phase of the menstrual cycle. Closer to the ovulation phase, when the probability of conception is highest, the uterine mucosa thickens. The cells of the endometrium are actively synthesizing nutrients and biologically active substances. When a fertilized egg enters, implantation occurs — the embryo is immersed in the thickness of the uterine mucosa. The contact of the embryo shells with the normal endometrium is an important condition for the successful start of pregnancy. If pregnancy has not occurred, the functional layer is completely rejected during menstruation. With the beginning of a new cycle, it begins to grow anew, regenerating with the help of stem cells of the basal layer.

Intrauterine synechiae are outgrowths, or adhesions, of the sclerosed endometrium that violate the normal anatomy and physiology of the uterine mucosa.

The main cause of Ascherman syndrome is damage and trauma to the basal layer during gynecological procedures (dilation of the uterine cavity, therapeutic and diagnostic curettage of the uterine cavity, cesarean section, operations on the uterus). Less often, intrauterine synechiae are formed after endometritis — inflammation of the uterine mucosa.

Symptoms of Ascherman syndrome
The clinic of Ascherman syndrome usually does not affect the general condition and well-being of patients. The main symptoms are associated with the adhesive process and its effect on the function of the reproductive system. Among them are:

Algodismenorrhea, that is, disorders of menstrual function: painful, prolonged, abundant or meager periods.
Oligomenorrhea, hypomenorrhea, in severe cases amenorrhea: a decrease in the number and duration of menstruation.
Hematometer, or hematosalpings — accumulation of menstrual secretions in the uterine cavity or fallopian tubes due to adhesions in the cervix, blocking the cervical canal. As a result, a pronounced pain syndrome that occurs during menstruation is possible. The ingress of blood through the fallopian tubes into the abdominal cavity causes severe pain, resembling a picture of an acute abdomen.
Habitual miscarriage, repeated miscarriages without cause, secondary infertility.
Ascherman syndrome may be accompanied by endometriosis (adenomyosis) of varying severity. Endometriosis is an ectopic growth of the functional layer of the endometrium outside the uterine cavity. This combination worsens the prognosis and prospects of treatment and has a stronger effect on reproductive function.

Diagnosis of Ascherman syndrome
Basically, instrumental research methods are used for diagnosis, allowing to visualize the uterine cavity from the inside. To search in the right direction, it is necessary to take into account the data of obstetric history — the number of pregnancies, births, abortions and other medical procedures.

Ultrasound is traditionally considered to be the most accessible and non-invasive method of examining the pelvic organs. A more informative sonography option is transvaginal ultrasound. For an accurate diagnosis, it is necessary to conduct a study in different phases of the menstrual cycle.

The gold standard for the diagnosis of intrauterine synechiae is endoscopic examination of the uterine cavity or hysteroscopy. An endoscope is inserted into the uterine cavity through the cervical canal, which allows you to see the state of the endometrium in real time on the monitor. In addition, diagnostic hysteroscopy may precede direct endoscopic intervention to remove the splices. This is the best way to assess the extent of the process and determine the nature of the adhesions and the possibility of their removal.

In some cases, hysterosalpingography is performed. This method is mainly used to assess the patency of the fallopian tubes.

The results of the study should be combined with the clinic, previous treatment attempts and obstetric history, which allows you to predict the results and effectiveness of treatment.

Treatment of Ascherman syndrome (intrauterine synechiae)
Mild and moderate severity of the disease usually responds well to treatment. In severe cases, Ascherman syndrome and the resulting infertility can be overcome only with the help of surrogate motherhood. In some cases (when synechiae are located on a limited area of the uterus), in vitro fertilization is effective.

Removal (dissection) of synechiae is performed by operative hysteroscopy. The method does not require general anesthesia and has no complications typical of conventional operations. Micro-tools can be carried out through the channels in the endoscopic installation. Removal and dissection of synechiae with microknives is carried out with caution due to the likelihood of additional injuries. Perforation of the uterine wall during the operation is particularly dangerous. Technically, this is not an easy operation. In severe cases, synechiae fill the entire uterine cavity and are tightly fused to the walls, and bleed when dissected.

The percentage of relapses is high. In some patients, intrauterine fusion occurs again after surgical treatment. To prevent relapse, gel-like fillers are injected into the uterine cavity after surgery, preventing contact of the walls and the formation of adhesions. The average recurrence rate after surgical treatment is 28%.

In the postoperative period, antibiotics are prescribed to prevent infectious complications. Drug treatment in the postoperative period is necessarily supplemented with hormone therapy. Cyclic administration of estrogens and progestins is carried out to stimulate the growth of the endometrium.

Some time after the operation, repeated hysteroscopy is performed to assess the results of treatment and timely diagnosis of relapse.

Prognosis in the treatment of Ascherman syndrome
The average indicators of the effectiveness of treatment correlate with the frequency of pregnancy. With a mild degree of the disease, pregnancy is observed in 93% of patients, with an average — in 78%. Treatment of severe Ascherman syndrome makes it possible for 57% of women to become pregnant. However, the birth of a healthy child is observed in 81, 66 and 32% of cases, respectively, of the severity of the disease.

The age of the patients also has a prognostic value. 66% of women under 35 years of age with severe Ascherman syndrome are able to conceive a child after treatment. However, in women over 35, this figure does not exceed 24%.

Prevention of Ascherman syndrome
Scraping of the uterine cavity with an acute gynecological curette or vacuum aspiration are procedures carried out almost blindly, the doctor relies only on his feelings during manipulations. Endometrial tissues under the action of estrogens during pregnancy are soft and easily injured. As a result, therapeutic or diagnostic curettage is almost always accompanied by damage to the basal layer of the endometrium to one degree or another.

An alternative to curettage during abortions or miscarriages is the use of medications to stimulate labor (therapeutic abortion). However, the effectiveness of this method is 80-85%. In 10-15% of cases, after therapeutic abortion, parts of the fetal membranes are delayed, which again requires curettage.

It is possible that the safety and effectiveness of therapeutic and diagnostic curettage of the uterine cavity can be increased if the procedure is carried out under the control of ultrasound.

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