Severity of intrauterine adhesions and pregnancy success rates after treatment: Comparison of adhesions obtained from open myomectomy versus uterine curettage

Intrauterine adhesions (IUA) are rare. A retrospective comparative study was conducted between January 1, 2015, and December 31, 2018. Group A comprised 117 women who developed IUAs after open myomectomy, while Group B comprised 113 women who developed IUAs following uterine trauma caused by uterine instrumentation after a termination of pregnancy (TOP) or spontaneous miscarriage. The IUA grade and pregnancy rates and outcomes were compared using the March classification system. All patients underwent hysteroscopic adhesiolysis. The adhesions tended to be more severe (45/117, 38.5%) in Group A than in Group B (29/113, 25.7%); however, this difference was not statistically significant (Chi-Suare 5.047; p = .080). The period of observation was 24 months from the last hysteroscopy. The pregnancy rate in Group A (26, 22.2%) was significantly lower than in Group B (46, 40.7%) (OR: 2.403, 95% CI: 1.352­4.271; p = .003). Open myomectomy was the preceding aetiological factor in a greater proportion of women with IUA in our study. In cases where pregnancy is desired after open myomectomy, especially where the endometrial cavity is breached, postoperative hysteroscopy to exclude IUAs is recommended.

Thick “Swiss Cheese” Appearance of Uterine Endometrium in Postmenopausal Women with Different Gynecologic Conditions

OBJECTIVES: To uncover gynecologic conditions with similar transvaginal sonographic findings of thick uterine endometrium with honeycomb appearance in pre-and postmenopausal women.METHODS: We retrospectively reviewed cases of patients with endometrial tissue biopsy from January 2010 to December 2016. We also collected office flexible hysteroscopic findings and surgical pathologic results. We analyzed data from 393 patients with confirmed endometrial pathology. Among these patients, 69 had transvaginal ultrasonographic images with thick uterine endometrium and honeycomb or “Swiss cheese” appearance.RESULTS: We found gynecologic conditions such as submucosal leiomyoma with degeneration, endometrial polyp, pseudocystic endometrial change associated with tamoxifen use, progesterone associated endometrial change, pyometra, retained placenta, and uterine synechiae manifested with similar thick endometrium with “Swiss cheese” appearance in transvaginal sonographic images. The most common diagnosis in postmenopausal women was atrophic endometritis, followed by endometrial cancer and endometrial polyps. The most common diagnosis in premenopausal women was abnormal uterine bleeding without pathologic conditions.CONCLUSIONS: Sonographic findings of thick uterine endometrium with “Swiss cheese” appearance need to be considered together with a thorough review of the patient's history and chief complaint before making a tentative diagnosis due to the various conditions sharing the feature.

Cerclaje, tratamiento quirúrgico conservador en embarazo ectópico cervical, tres casos. Instituto Salvadoreño del Seguro Social, Hospital Materno Infantil 1 de Mayo / Cerclage, conservative surgical treatment in cervical ectopic pregnancy, three cases. Instituto Salvadoreño del Seguro Social, Hospital Materno Infantil 1 de Mayo

Menos del 1% de los embarazos ectópicos se implantan en el canal cervical por abajo del orificio cervical interno, la etiología de esta implantación es desconocida aunque se asocia a curetaje previo, síndrome de Asherman, leiomiomas, presencia de DIU entre otras. Timor-Tritsch define el diagnóstico ecográfico como el saco coriónico implantado debajo de OCI, canal cervical dilatado, embrión con latido cardiaco o presencia de infiltración cervical confirmada por Doppler. No existe un consenso en relación al tratamiento de esta condición, se ha tratado con Metrotexate sistémico o intracervical, embolización arterial selectiva, aspiración guiada por ecografía, aunque la histerectomía fue el tratamiento en los casos de sangrado incontrolable...

Medicina natural y tradicional en el tratamiento de 3 mujeres con síndrome de Asherman / Natural and traditional medicine in the treatment of 3 women with Asherman syndrome

Se presentan 3 casos clínicos de féminas con síndrome de Asherman, procedentes del Policlínico Docente "Ramón López Peña", tratadas con medicina natural y tradicional. Se aplicaron técnicas bioenergéticas (acupuntura y microsistema de oreja, hidroterapia, dietas hipotóxicas, reflexoterapia podal) y de respiración. Todas las pacientes mejoraron su cuadro clínico, pues se le restableció el flujo menstrual y la gestación, lo cual demostró la eficacia del tratamiento empleado.

Three case reports of females with Asherman syndrome, belonging to "Ramón López Peña" Teaching Polyclinic, treated with natural and traditional medicine are presented. Bioenergetic techniques (acupuncture and ear microsystem, hydrotherapy, hipotoxic diets, foot reflex therapy) and breathing techniques were applied. All the patients improved their clinical pattern, because the menstrual flow and pregnancy were reestablished, which demonstrated the effectiveness of the treatment.

Achados histeroscópicos na cavidade endometrial após ablação endometrial / Hysteroscopic appearance of the endometrial cavity after endometrial ablation

OBJETIVO: Verificar o aspecto da cavidade uterina após a ablação endometrial histeroscópica, a prevalência de sinéquias após o procedimento e, com isso, avaliar a importância da histeroscopia realizada no pós-operatório dessas pacientes. MÉTODOS: Foram avaliados, retrospectivamente, os laudos dos exames de 153 pacientes que haviam sido submetidas à histeroscopia ambulatorial após ablação do endométrio devido a sangramento uterino anormal de causa benigna, no período entre janeiro de 2006 e julho de 2011. As pacientes foram divididas em dois grupos: HIST≤60 (n=90), com pacientes submetidas ao exame no período de 40 a 60 dias após o procedimento, e grupo HIST>60 (n=63), das que foram examinadas entre 61 dias e 12 meses. RESULTADOS: No grupo HIST≤60, 30% das pacientes apresentavam algum grau de sinéquia; aderências grau I foram descritas em 4,4%; grau II em 6,7%; grau IIa em 4,4%; grau III em 7,8%; e 2,2% apresentavam grau IV. No HIST>60, sinéquias foram descritas em 53,9% dos casos, 3,2% tinham sinéquias grau I; 11,1%, grau II; 7,9%, grau IIa; 15,9%, grau III; e 4,8%, grau IV. Hematometra foi descrito em 2,2% dos casos do HIST≤60 e em 6,3% no HIST>60. CONCLUSÕES: A cavidade uterina de pacientes submetidas à histeroscopia ambulatorial até 60 dias após a ablação endometrial mostrou menor número de sinéquias quando comparada com as cavidades uterinas de pacientes que foram submetidas ao exame após 60 dias. Acompanhamento em longo prazo é necessário para avaliar plenamente o impacto da histeroscopia ambulatorial após a ablação endometrial. .

PURPOSE: To examine the aspect of the uterine cavity after hysteroscopic endometrial ablation, to determine the prevalence of synechiae after the procedure, and to analyze the importance of hysteroscopy during the postoperative period. METHODS: The results of the hysteroscopic exams of 153 patients who underwent outpatient hysteroscopy after endometrial ablation due to abnormal uterine bleeding of benign etiology during the period from January 2006 to July 2011 were retrospectively reviewed. The patients were divided into two groups: HIST≤60 (n=90) consisting of patients undergoing the exam 40-60 days after the ablation procedure, and the group HIST>60 (n=63) consisting of patients undergoing the exam between 61 days and 12 months after the procedure. RESULTS: In the HIST≤60 group, 30% of the patients presented some degree of synechiae: synechiae grade I in 4.4% of patients, grade II in 6.7% , grade IIa in 4.4%, grade III in 7.8%, and grade IV in 2.2%. In the HIST>60 group, 53.9% of all cases had synechiae, 3.2% were grade I, 11.1% grade II, 7.9% grade IIa, 15.9% grade III, and 4.8% grade IV. Hematometra was detected in 2.2 % of all cases in group HIST≤60 and in 6.3% of all cases in group HIST>60. CONCLUSIONS: The uterine cavity of the patients submitted to diagnostic hysteroscopy up to 60 days after endometrial ablation showed significantly fewer synechiae compared to the uterine cavity of patients who underwent the exam after 60 days. Long-term follow-up is necessary to fully evaluate the importance of outpatient hysteroscopy after endometrial ablation regarding menstrual patterns, risk of cancer and prevalence of treatment failure. .

The management of Asherman syndrome in gynecology.

Asherman syndrome is an acquired condition characterized by the formation of adhesions in the uterine cavity. This condition is often caused by trauma to the endometrium, which mostly happens after currettage or post-partum, and can produce several complications such as menstrual disturbances, infertility, or recurrent abortion. The management of Asherman syndrome requires complete actions which can be summarized with the acronym PRACTICE, consisting of prevention, anticipation, comprehensive therapy, timely surveillance of subsequent pregnancies, investigation and continuing education. The prevention and anticipation aspects can be performed through reduction of invasive methods of therapy such as currettage, prophylactic therapy for adhesions such as antibiotics and post-estrogen therapy for high risk patients, and the use of instruments that do less damage to the uterine walls. The comprehensive therapy that become the method of choice is operative lysis using hysteroscopy, which provides direct visualization of the adhesion. To prevent reccurrence, especially to patients planning to have subsequent pregnancies, timely surveillance of the next pregnancies for high risk patients should be performed at hospital, with complete work-ups. Lastly, evaluation of operative results and continuing education to explain prognoses to the patient should be also performed.

Diagnosis of intracavitary uterine diseases in postmenopausal women by hysteroscopy

To reveal the hysteroscopic findings among postmenopausal women who were subjected to diagnostic hysteroscopy method. This is a descriptive study which was conducted at King Hussein Medical Center within the period from January 2008 to January 2010, on a total of 215 postmenopausal women. Mean age of the study group was 58 years [range 46-70]. Hysteroscopy was carried out to detect intracavitary disease, either by hysteroscopic view or using histopathological biopsies for other diseases. Simple descriptive statistics [frequency, mean age and percentage] were used to describe the study variables. The histopathological and hysteroscopic findings were as follows: polyps in 122 [56.7%] patients, atrophic endometrium in 44 [20.5%] patients, synechia in 22 [10.2%] patients, fibroid in 13 [4.6%] patients, endometrial hyperplasia in seven [3.3%] patients, focal thickening seven [3.3%] patients. The most frequent findings at hysteroscopy for postmenopausal women with bleeding were benign lesions. Hysteroscopy using biopsy is a selective method for detecting intracavitary uterine disease

True unicornuate uterus- Pseudounicornuate uterus

A 27 year old patient presented with primary infertility of 3 years' duration and also a history of myomectomy [5 years ago] was referred to our infertility clinic for investigation of infertility. The latest Hysterosalpingography [HSG] revealed an obstructed left fallopian tube with apparently a unicornuate uterus with luminal contour irregularity and normal left fallopian tube [Figure 1]. Significant information in her past medical history revealed that she had another HSG two years before and her first hysterosalpingography [HSG] showed a apparently unicornuate uterus. Additional significant information in comparison with second HSG revealed that both fallopian tubes were opacified [Figure 2]. In this case medical history also included hysteroscopic diagnosis of adhesion following open myomectomy at the age of 22. Comparison of previous graphies and hysteroscpic findings lead to a suggestion of pseudounicornuate uterus. Intrauterine adhesions develop after trauma to the basal layer of the endometrium. Unilateral excessive scarring of the uterus may lead to an obliteration of the uterine lumen resulting in an image that can mimic a unicornuate uterus [pseudounicornuate uterus] [1]. A true unicornuate uterus should be excluded from pseudounicornuate uterus by a] horizontally oriented in its long axis due to deficient development of mullerian ducts b] smooth or regular contour c] with one tube. While pseudounicornuate uterus look like acquired lesion and cicatrisation leads to a usually irregular contour and uterus is more vertical in its long axis [2]. Obtaining an accurate history, comparison of previous sonographic or laparoscopic findings, and awareness about this image of synechiae are the critical steps in differentiating a pseudounicornuate uterus from true unicornuate uterus

Síndrome Asherman / Síndrome Asherman

El síndrome de Asherman también llamado sinequias uterinas o adherencias uterinas es una condición que se caracteriza por la presencia de adherencias y/o fibrosis en la cavidad uterina debido a cicatrices. Se han utilizado otros términos para referirse esta entidad como adherencias intrauterinas traumáticas, atresia cervical/uterina, esclerosis endometrial, y otros...

Broad spectrum of hysteroscopic surgery / 대한산부인과학회지

OBJECTIVE: To evaluate the spectrum of hysteroscopic surgery to be extended. METHODS: Total 1101 women who had undergone hysteroscopic operations with Urione(R) solution and Normal saline as distension media between Feberary 2001 and December 2008 were selected. Clinical characteristics, laboratory data and postoperative result were retrospectively analyzed. RESULTS: Hysteroscopic myomectomy was 884 cases. hysteroscopic polypectomy was 447 cases. Hysteroscopic adhesiolysis was 89 cases. Hysteroscopic adenomyomectomy or adenomyolysis was 66 cases. Hysteroscopic IUD removal was 31 cases. Hysteroscopic ablation for DUB and endometrial hyperplasia was 32 cases. Hysteroscopic septolysis was 18 cases. Hysteroscopic conceptus removal was 6 cases. Mean size of myoma was 3.4 cm. Mean operation time was 47 minutes. Mean deficit of distension media was 193 cc. Average duration of hospitalization was 4.9 days. Average change of Hb. was 1.5 g/dL. Complications of hysteroscopic operation were 16 cases. That is uterine perforation (n=9), hyponatremia (n=2), pulmonary edema (n=2), delayed bleeding (n=2) and bladder perforation (n=1). CONCLUSION: The indication of hysteroscopic op. can be very extended. Pure intramural myoma, subserosal myoma, endometrial polyps, adenomyosis, uterine synechiae, uterine septum, endometrial hyperplasia, DUB and ectopic conceptus can be resected by hysteroscopic operation. Intraoperative ultrasonographic guidance is very important. It makes the complication and morbidity rate to be lower.

Analysis of 81 cases of congenital anomalies of the vagina / 南方医科大学学报

<p><b>OBJECTIVE</b>To investigate the types, clinical features and therapeutic approaches of congenital anomalies of the vagina.</p><p><b>METHODS</b>The clinical data of 81 patients with congenital anomalies of the vagina were analyzed retrospectively.</p><p><b>RESULTS</b>There were 5 types in these 81 patients, and 16 (19.7%) patients showed absence of the vagina, 15(18.5%) had vaginal obstruction, 10 (12.3%) had transverse vaginal septum,14(17.2%) had longitudinal vaginal septae,18(22.2%) had septum obliquus, and 8 (9.8%) had imperforate hymen. Forty-eight (59.2%) patients presented with primary amenorrhea, and 22(27.1%) complained of irregular pelvic pain. Fifteen of the patients with absent vagina underwent amnion artificial vaginoplasty, and the others were treated with incising and removing the septum, all having good clinical outcomes.</p><p><b>CONCLUSION</b>Amnion artificial vaginoplasty is a good option for treatment of absent vagina.</p>

The surgical treatment of severely injured vagina / 中华整形外科杂志

<p><b>OBJECTIVE</b>To investigate the surgical methods of treating severely injured vagina.</p><p><b>METHODS</b>A retrospective study was carried out on the clinical materials and results of 7 patients suffered from severe vaginal injury.</p><p><b>RESULTS</b>Different surgical approaches such as trans-suprapubic, transperineal or both approaches were applied according to the position of the atresia, meanwhile, different surgical methods such as skin graft, free flap transplantation, vaginal mucous flap advancement, direct anastomosis of the two ends, "Z" plasty was used to repair the vagina according to the different defect of the vagina, except for 1 case complicated with vaginorectus fistula, all the other cases were achieved satisfactory results.</p><p><b>CONCLUSIONS</b>The accurate judgment of the severity of the vaginal injury and the understanding of the changed anatomy around the injured vagina was the key points to the success of the surgical treatment of traumatic vaginal atresia.</p>

Estudio del factor uterino como causa de infertilidad femenina / Study of the uterine factor as a cause of female infertility

Se realizó un estudio retrospectivo de 478 pacientes, durante el período 1968-1998, procedentes de la consulta de infertilidad del ISMM "Dr. Luis Díaz Soto", portadoras de factor uterino. Se encontró que el mioma predominó entre las causas (78 porciento), seguido del síndrome de Asherman (11 porciento), las malformaciones uterinas (10 porciento) y los pólipos endometriales (0,8 porciento). Mencionamos las técnicas quirúrgicas más empleadas según enfermedades, obtuvimos normalización de las menstruaciones en el 97,2 porciento, así como un alto índice de embarazos (63,7 porciento)

Síndrome de Asherman: diagnóstico y manejo simplificado / Syndrome of Asherman: diagnosis and simplified handling

Objetivo: determinar la utilidad de la sonohisterografía y la dilatación uterina en el diagnóstico y manjeo del síndrome de Asherman. Método y pacientes: se incluyeron 10 pacientes: seis tenían antecedente de legrado postaborto, dos con legrado postparto, una con endometritis y legrado postparto y una con cirugía de Strassman. Resultados: en las 10 pacientes la sonohisterografía mostró la sinequia y ubicación; en 7 pacientes el desprendimiento de las adherencias intrauterinas con dilatadores de Hegar fue exitosa, en una paciente con adherencias gruesas y ubicadas en la parte superior de la cavidad endometrial, la dilatación no fue posible y 2 pacientes prefirieron no somerterse a tratamiento. Conclusiones: la sonohisterografía es un recurso diagnóstico efectivo en pacientes con síndrome de Asherman y el desprendimiento de las adherencias intrauterinas con dilatadores de Hegar para su manejo

Expression pattern of progesterone receptor, integrinbeta(3), cyclooxygenase-2 ( COX-2 ) in human endometrium of patient with the disease related implantation / 대한산부인과학회잡지

OBJECTIVE: We compared the expression pattern of progesterone receptor, integrin 3, cyclooxygenase-2 (COX-2) in in-phased endomerium of patient with the disease related implantation and control group, and tried to confirm the clinical efficacy of the immunohistochemical markers for discrimination of occult uterine receptivity defect in in-phase endometrium. STUDY DESIGN: Endometrial tissues were obtained from 60 women with normal (group 1; n = 20), uterine synechiae (group 2; n = 15), and endometriosis (group 3; n = 25). On 7 ~ 8 days after ovulation (POD 7 ~ 8), sex hormone levels were measured and immunohistochemical staining of PR, integrin 3, and COX-2 expression were performed. RESULTS: PR was decreased in the group 2 and increased in the group 3 comparing with the group 1. integrin 3 expression was significantly decreased in the group 2 and 3. COX-2 expression was significantly decreased in the group 2. But, in the group 3, COX-2 expression was slightly increased in glandular epithelial cells, and significantly increased in stromal cells. CONCLUSIONS: In-phase biopsies from patients with endometriosis and uterine synechiae showed different expression pattern of integrin 3, COX-2, and PR compared to the control. The aberrant expression of immunohistochemical markers be associated with occult uterine receptivity defect and produce the useful diagnostic method.

MR Imaging of Asherman's Syndrome in Patients With and Without Uterine Anomalies: Comparison withHysterosalpingography

PURPOSE: To assess the role of MR imaging in the detection of Asherman's syndrome, especially whenthis is associated with a congenital uterine anomaly. MATERIALS AND METHODS: MR images were obtained in thesemicoronal plane parallel to the long axis of the uterus in 11 patients. Dilatation and curettage involving thein-sertion of an intrauterine device was performed in all patients, and transabdominal metroplasty was performedin four with uterine anomaly. MR imaging findings we r e compared with those of hyste rosalpingograhy in all patients and compared with sur-gical findings in four. RESULTS: The MR findings of uterine synechiademonstrated in nine of 11 patients were focal thickening of the uterine junctional zone (n=2), hypointense fociin the en-dometrium (n=1), or both these findings (n=6). Seven of the 11 patients had associat-ed uterineanomalies, which were demonstrated in all seven by MR imaging. In four of the seven, HSG failed to demonstratethese anomalies. CONCLUSION: MR imaging satisfactorily demonstrated intrauterine lesions in nine of 11 patientswith Asherman's syndrome, and was especially helpful in demonstrating associated uterine anomalies.

The Use of Sonohysterography in Infertile Patients / 대한산부인과학회잡지

OBJECTIVE: The purpose of this study was to assess the usefulness of sonohysterography in the detection of abnormalities of the uterine cavity in infertile patients, compared with other diagnostic methods, such as transvaginal sonography, hysterosalpingography and hysteroscopy. METHODS: Three intrauterine pathologies including intrauterine synechiae, endometrial polyp and submucosal myoma, that could be possible causes of infertility were diagnosed. RESULTS: Transvaginal ultrasonography and hysterosalpingography were able to detect 41.7% and 83.3% of uterine pathologies respectively comparing with sonohysterography to detect all of the uterine pathologies. CONCLUSION: Our results show that sonohysterography is easy, inexpensive, well-tolerated and non-invasive technique with high sensitivity in the detection of uterine pathologies. Therefore the use of sonohysterography for the diagnosis of intrauterine pathologies in infertile patients is highly recommended.

Successful pregnancy outcome after hysteroscopic adhesiolysis in Asherman's syndrome

Asherman's syndrome is an uncommon finding at hysterosalpingography for infertility. Modern day management entails hysteroscopic confirmation and adhesiolysis. We present one such case of a young woman who had secondary infertility after dilatation and curettage, and who was diagnosed and treated with a successful outcome.