What is intrauterine synechia. Treatment of synechia in the uterine cavity. Stages of disease development

Synechia in the uterine cavity is in most cases an incomprehensible term, the meaning of which many understand only when faced with a problem. In this review, I want to help women learn more about the disease and the possibilities of getting rid of it.

Synechia is adhesions in the uterus, resulting from inflammatory, infectious and purulent processes, operations and abortions.
The main symptoms of the adhesive process are pain, impaired urination and outflow of menstrual blood.
Synechia is classified according to the degree of development, by type of tissue and by prevalence.
Adhesions are diagnosed by ultrasound.
Treatment is carried out both conservatively and surgically. When planning a pregnancy, adhesions must be removed.
In the absence of timely treatment, increased pain, uterine deformity, miscarriage and infertility are possible.

Definition

Synechiae are adhesions of connective tissue that appear in the uterus due to inflammation. They can tighten, deform the organ, close the gaps.

Symptoms

The main symptom of the adhesive process is pain, which increases in the following cases:

when filling the bladder;

during menstruation;

at rest with hypodynamia.

Urination, defecation, and the flow of menstrual blood may also be disturbed.

The reasons

Synechia in the uterus is a type of complication that can occur after:

inflammation;
infections;
suppuration;
surgery, abortion.

Classification

Synechia is subdivided depending on the composition of the tissue, location, degree of development.

Histology

Mild form - adhesions are thin and consist of epithelium.
Medium - synechiae are dense muscle formations that have grown into the endometrium. They bleed when cut.
Heavy - the tissue that makes up the synechia becomes connective and difficult to excise.

It is possible to cure the disease at any stage, only the volume of interventions is different.

By prevalence

The first type: up to 25% of the uterine cavity is affected, the orifices of the tubes are not affected.
Second: adhesions touched 25-75% of the organ and mouth, the walls do not stick together.
Third: more than 75% of the cavity, tubes are involved, the walls stick together and the uterus is deformed.

With the third type of pathology, the probability of conceiving a child is minimal.

According to the degree of damage and closure of cavities and gaps

This is a classification generally accepted by gynecologists used in surgical interventions. According to her, there are 6 degrees of damage to the uterus:

I - thin, easily dissected adhesions;
II - compacted synechia;
II-a - the location of adhesions in the internal pharynx;
III - a lot of dense synechia with damage to the mouths of the fallopian tubes;
IV - partial occlusion of the cavity;
V - scars on the walls of the organ.

Watch the video on the topic "Synechia in the uterine cavity":

Diagnostics

Synechia is easily determined by ultrasound. Ultrasound examination allows you to determine the location of their location, the degree of damage, etc.

In addition, a hysteroscopic diagnosis of the uterus is performed (if there is access to the cavity) and synechiae tissue is taken for histology.

Impact on pregnancy

Synechia most often causes problems with conception, because it can affect the cervical canal and fallopian tubes. If they are in the uterus, they prevent the attachment of the fetal egg or provoke miscarriages in the early stages of pregnancy.

During the adhesive process, the walls of the uterus are fixed at a certain distance from each other. As pregnancy develops, the organ stretches, pain and hypertonicity occur. The result may be a miscarriage or termination of pregnancy for medical reasons.

Spikes sometimes put pressure on the fetus, deform it and interfere with development. In this case, the outcome of pregnancy is the same as described above.

After the adhesions are removed, a woman can plan and carry a pregnancy.

Therapy

Treatment of synechia is carried out by several methods at once. The choice of one or another method is determined by histology, location and thickness of adhesions.

conservative

Conservative therapy includes:

Gynecological massage. It is used for thin adhesions of small size. During the massage, the synechia is stretched and the uterus returns to its normal physiological position. For those who are planning a pregnancy, this method is not suitable, because. the spike stays in place.
Microwave and UHF - therapy. Used in conjunction with massage. The action of microwaves promotes the resorption of thin adhesions and an increase in the elasticity of denser ones.
Physiotherapy. Just like massage, it is aimed at stretching small synechiae.

All conservative methods are applied in a complex with a slight development of the disease.

Radical

Radical therapy involves the excision of adhesions surgically. Sometimes it is necessary to remove them completely. Such an operation is not abdominal, since this can only enhance the adhesive process. Usually performed laparoscopically or hysteroscopically.

Laparoscopy involves the implementation of punctures of the abdominal wall, the introduction of micro-instruments and cameras into the uterine cavity and the operation.

Hysteroscopy - the introduction of a special tube into the uterus through the cervical canal. Instruments and a camera are inserted through the tube. This is the least traumatic method, and therefore more preferable.

Effects

In the absence of treatment of synechia, the following consequences are possible:

increased pain;
violation of the functions of organs located near the uterus;
deformation of the uterus, trauma and damage;
miscarriages;
problems with conception, infertility.

Intrauterine synechia (Asherman's syndrome) or the so-called adhesions inside the uterus are complete or partial infection of the uterine cavity.

Causes of synechia

To date, several theories of the formation of intrauterine synechia are known: traumatic, infectious and neurovisceral. According to the traumatic theory, the key trigger that triggers the process of synechia is traumatic damage to the basal layer of the endometrium. Mechanical trauma is possible due to difficult childbirth or frequent curettage of the uterine cavity, as well as abortions. In this case, the infection is a secondary factor in the occurrence of uterine synechia. Also, synechia of the uterine cavity can form in women whose gynecological history is aggravated by a missed pregnancy. This is possible because the remaining tissue of the placenta can contribute to the activation of fibroblasts and collagen synthesis even before the process of regeneration of the inner layer of the uterus (endometrium).

The cause of synechia, which are formed inside the uterine cavity, can be various surgical procedures and interventions on the uterus: diagnostic and therapeutic curettage of the uterine cavity, hysteroscopy, myomectomy, metroplasty. Synechia is often observed after conization of the cervix or severe endometritis. Frequent provoking factors for the formation of synechia of the uterine cavity include the introduction or removal of intrauterine contraceptives (spirals), as well as the installation of the Mirena system for therapeutic purposes.

Classification of intrauterine synechia

In practice, gynecologists use a special classification in which synechia are divided according to the prevalence and degree of involvement in the pathological process of the uterus:

I degree is characterized by the involvement of no more than 1/4 of the volume of the uterine cavity in the pathological process, intrauterine adhesions of a thin diameter, and the bottom of the uterus and the mouth of the fallopian tubes are free.
II degree - intrauterine synechia extend to at least 1/4 and not more than 3/4 of the volume of the uterine cavity. The walls of the uterus do not stick together, there are only thin adhesions that partially overlap the bottom of the uterus and the mouth of the fallopian tubes.
III degree is characterized by the involvement in the pathological process of more than 3/4 of the volume of the entire uterine cavity.

Clinical manifestations of intrauterine synechia

The clinic of synechias located inside the uterine cavity depends on the extent of the lesion by the pathological process of the uterine cavity. The most common clinical manifestations of intrauterine synechia are amenorrhea or hypomenstrual syndrome. The result of a long and neglected process of being inside the uterine cavity is infertility, or the inability to bear a child. In those cases when there is an infection of the lower sections of the uterus with a normally functioning internal endometrium in the upper sections, a cavity filled with blood (hematometra) may form. With a significant infection of the uterine cavity and a poorly functioning inner layer of the uterus, it makes it difficult for the embryo to implant into the uterine cavity. Also, intrauterine synechia of even a small diameter can cause ineffective in vitro fertilization.

Diagnosis of intrauterine synechia

To remove synechia, it is necessary to clearly establish their localization and the degree of damage to the uterine cavity by synechia. For the diagnosis of synechia, the following research methods are used:

Hysterosalpingography;
Ultrasound examination of the pelvic organs;
Hydrosonography;
Diagnostic hysteroscopy.

Examination for the presence of intrauterine synechia begins in cases where there are problems with conception. To date, there is no specific developed plan for examining such women. Many practitioners believe that it is better to start diagnosing intrauterine synechia with hysteroscopy, and if a questionable result is obtained, hysterosalpingography should be performed.

Diagnostic hysteroscopy

Hysteroscopy today in practical gynecology is a key method for diagnosing synechia inside the uterine cavity. In the course of this study, intrauterine synechiae are presented as white strands without vessels of various lengths. These pathological adhesions of a dense consistency, located throughout between the walls of the uterus, can cause a decrease in its size due to complete or partial obliteration of the uterine cavity. Synechia can also be localized in the cervical canal, which causes infection of the cervical canal and difficulty in entering the uterine cavity. Intrauterine synechia of a thin diameter are presented in the form of pale pink strands, sometimes they look like a web, in which the vessels passing through it are visible.

Hysterosalpingography

With hysterosalpingography, the signs of synechia of the uterine cavity clearly depend on their nature and distribution. As a rule, intrauterine synechia on hysterosalpingography is presented in the form of single or multiple filling defects that have an irregular shape. More often, synechia of the uterine cavity manifests itself as lacunar defects of various sizes. Intrauterine synechiae have a dense consistency, divide the uterus into numerous chambers of different sizes, which are connected to each other only by ducts of small diameter. This configuration of the uterine cavity is not fully visualized during diagnostic hysteroscopy, since during this research method only a few first centimeters of the lower uterus are examined. While with hysterosalpingography, a viscous contrast agent bypasses all the complex labyrinths of the uterine cavity affected by synechia and non-obliterated uterine spaces. This method of X-ray examination also has negative qualities. It can give false positive results arising from remnants of the inner layer of the uterus (endometrium), mucus, or deformation of the synechia of the uterine cavity.

Ultrasound examination of the pelvis

At present, even advanced ultrasound equipment, when detecting intrauterine synechia, does not provide complete information about the state of the uterine cavity, and the doctor does not receive an objective picture of what is happening. In some cases, it is possible to visualize the fuzzy contours of the inner layer of the uterus, and in the presence of a hematometer, an anechoic formation is detected that completely fills the uterine cavity. With hydrosonography, single synechia of the uterine cavity can be determined when there is no complete obstruction in the lower segment of the uterus. Dense intrauterine synechia are characterized as white strands of dense consistency, which are localized more often along the side walls. In the central part of the uterus, they are located very rarely. A large number of transverse synechia lead to partial or complete infection of the uterine cavity in the form of numerous cavities of different sizes. These cavities are sometimes mistaken for the mouths of the fallopian tubes.

Treatment of intrauterine synechia

Today, the only correct solution for the treatment of synechia of the uterine cavity is the dissection of synechia under the careful control of a hysteroscope, which does not injure the remnants of the endometrium, which is important for normalizing the menstrual cycle and maintaining the reproductive function of a woman. The volume of operations for the separation of synechia and its effectiveness depends on the type of synechia and the degree of obstruction of the uterine cavity by synechia.

Intrauterine synechia, which are localized in the central part of the uterus, can only be dissected in a blunt way, using the body of the hysteroscope. Also, special endoscopic scissors and forceps are used to separate synechiae. At the same time, a hysteroresectoscope with an electrode (“electroknife”) is used to completely dissect the synechiae of the uterine cavity.

In order to prevent perforation of the uterus, the dissection of synechia is performed under constant and careful control of ultrasound equipment. Such separation of synechia is possible only with partial obstruction of the uterine cavity. While with complete or significant occlusion by synechia of the uterine cavity, control over the course of the operation is performed through laparoscopic access using special equipment.

Despite the great effectiveness of hysteroscopic treatment, a recurrence of the pathological process is possible. More often, intrauterine synechia can recur with compacted adhesions, as well as uterine tuberculosis. After separation of the synechiae, each patient individually, the doctor prescribes hormonal therapy (oral contraceptives in large dosages). This therapy is prescribed for 3-6 months to restore normal menstrual function.

Prognosis for synechia inside the uterine cavity

A positive result after hysteroscopic dissection of synechia depends on the duration and prevalence of intrauterine synechia. For example, the more the uterine cavity is obturated with synechia, the less effective the treatment is. The worst results in normalizing the menstrual function and restoring the reproductive function of a woman are observed with synechia of the uterine cavity of a tuberculous nature.

Women who underwent surgical treatment of synechia in history during pregnancy are at risk for the occurrence of complications during pregnancy, delivery and the course of the early postpartum period. In 35% of pregnant women who have synechia inside the uterine cavity, spontaneous abortion is observed. 30% go into labor prematurely, while the remaining 35% of pregnant women develop placental pathology (tight or partial attachment of the placenta or placenta previa).

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Intrauterine synechia are fusions of the tissues of the cavity with each other, which entails partial or complete infection of the entire uterus. It is imperative to eliminate such a problem, otherwise a woman is unlikely to be able to become pregnant and bear a healthy fetus. Therefore, the removal of synechia in the uterus must be done promptly and with the help of a qualified doctor.

Reasons for the formation of synechia

There are a number of specific factors that can provoke the formation of synechia in the uterine cavity of any woman.

We list these reasons:

Mechanical damage. They can be provoked by abortion (rough curettage of the fetus), severe pregnancy, removal of benign formations, conization of the cervix, metroplasty, surgery on the walls of the uterus, improper placement of the intrauterine device, etc.
Infectious and inflammatory processes. Endometritis, the chronic course of the development of chlamydia and other diseases will become a clear reason for the degeneration of the endometrial layer and the formation of synechia.
Frozen pregnancy. Remnants of placental tissue cause fibroblast activation and collagen formation to produce synechia in the uterine cavity.

As you can see from the list, there are plenty of reasons for getting such an unpleasant ailment. But most importantly, the initial stage of the formation of synechia is invisible to a woman and it is very important to contact the clinic at the first unpleasant symptoms to provide qualified medical care.

Symptoms of the disease

It is possible to identify the fusion of uterine tissues with the help of a preventive gynecological examination, so every woman should not neglect the golden rule: 2 times a year, you must definitely visit a gynecologist. Also, one of the visible symptoms of the disease is the meager course of menstruation or its complete absence. The cessation of the menstrual cycle threatens with the accumulation of menstrual blood in the uterus, which will lead to disastrous consequences.

Also, the last stages of the course of the disease, a woman may feel unpleasant pain in the abdomen.

Stages of disease development

It is used in the treatment of synechia to identify a varying degree of prevalence and employment of the uterine cavity.

There are 3 stages of the development of the disease:

There are thin adhesions, ¼ of the volume of the uterine cavity is involved.
Adhesions have a denser structure, but there is no adhesion of the walls yet, up to ¾ of the uterine cavity is involved.
Dense adhesions are observed, more than ¾ of the uterine cavity is involved.

The last stage is very dangerous and threatens the woman with infertility.

Diagnostics

It is possible to start treatment of synechia only after their thorough diagnosis. The patient will need to perform an ultrasound, hysterosalpingography (x-ray of the uterus) and hysteroscopy (examination of the uterus with a tiny video camera that is inserted into the woman's vagina). After receiving all the results of the study, the doctor will prescribe the correct and effective treatment.

Treatment

Removal of synechia in the uterus occurs using a hysteroscope or endoscopic instruments. Removal of synechia of the uterine cavity is a painless procedure.

The hysteroscope is used if the synechiae have the first degree of damage to the uterine cavity. The hysteroscope is inserted into the vagina and thin and tender adhesions are carefully dissected with the body of the device. In this case, the procedure is very safe, painless and not accompanied by bleeding.

Endoscopic instruments, such as microscissors, are used by the doctor when removing grade 2 and 3 synechiae. Medical manipulation does not require the use of general anesthesia. The essence of the procedure is as follows: microscissors are passed through the channels of the endoscopic installation and, with special care, so as not to cause additional harm to the uterus, the neoplasms are dissected. Such an operation requires a high qualification of the attending physician, since the dissection of synechia of the 2nd and 3rd degree is fraught with the occurrence of profuse bleeding.

In order to avoid recurrences at the end of the procedure, a special gel-like filler is injected into the uterine cavity of women. It will help to avoid re-growth of the walls and the formation of adhesions. Hysteroresectoscopy of synechia in the uterine cavity is performed on the eve of menstruation.

Postoperative period

In the postoperative period, it is mandatory to take antimicrobial drugs to prevent the onset of an inflammatory and infectious process. Also, the attending physician, in addition to antibiotics, will prescribe hormonal therapy for the fastest recovery of the female body without the appearance of unwanted side effects.

After a short time after the procedure, a woman will need to visit a gynecologist without fail for a second hysteroscopy. It will help determine the condition of the uterine cavity after removal of synechiae, evaluate the results of treatment and avoid recurrence.

Do I need to remove intrauterine synechia? Of course yes! And the faster the better. In whom synechia of the uterine cavity was found, reviews after the treatment always turn into two strips on the gavidar test!

Intrauterine adhesions (IUDs) are still a major medical and social problem with a poor prognosis in terms of fertility and quality of life, in particular in patients of reproductive age. The true incidence of IUDs is still unknown, because the range of clinical manifestations is too wide - from menstrual dysfunction to infertility.
The trigger mechanism for the formation of the IUD is an injury to the basal layer of the endometrium, which can be caused by various factors. The main one is interventions during pregnancy or in the postpartum period. Due to the development of intrauterine surgery, resectoscopic interventions are increasingly being used to treat IUDs: myomectomy, removal of the intrauterine septum, etc. Hysteroscopy is used as the main method for diagnosing and treating IUDs in order to normalize the menstrual cycle and restore fertile function. When pregnancy occurs after the treatment of Asherman's syndrome, there remains a high risk of such formidable complications as spontaneous miscarriage, premature birth, intrauterine fetal growth retardation, placental pathology, etc. recurrence of the IUD after their separation.

Keywords: intrauterine synechia, Asherman's syndrome, infertility, hysteroscopy, amenorrhea.

For citation: Popov A.A., Manannikova T.N., Alieva A.S., Fedorov A.A., Bespalova A.G. Intrauterine synechia: a century later // RMJ. Mother and child. 2017. No. 12. pp. 895-899

Intrauterine synechiae: a century later
Popov A.A., Manannikova T.N., Alieva A.S., Fedorov A.A., Bespalov A.G.

Moscow Regional Research Institute of Obstetrics and Gynecology

Intrauterine synechia is still a major medical and social problem with a disappointing prognosis of fertility and quality of life, particularly in women of reproductive age. The true frequency of the occurrence of the IUS is not known up to the present time, as the range of its clinical manifestations is too wide - from the violation of menstrual function to infertility. Any triggers of intrauterine synechia lead to the emergence of this condition by a common mechanism involving injury of the basal layer of the endometrium and trauma of the pregnant uterus, which cause IUS. In connection with the development of intrauterine surgery, intrauterine synechia has been increasingly associated with resectoscopic interventions such as myomectomy, removal of the intrauterine septum, and others. Hysteroscopy is used as the main method of diagnosis and treatment of the IUS aiming at normalizing the menstrual cycle and restoring fertility. At the onset of pregnancy after the treatment of Asherman's syndrome there remains a high risk of such severe complications as spontaneous abortion, premature birth, intrauterine growth retardation, placental pathology, etc.The use of an anti-adhesive gel containing hyaluronic acid and carboxymethyl cellulose (Antiadhesin) helps to reduce the risk of recurrence of intrauterine synechia after separation.

key words: intrauterine synechia, Asherman's syndrome, infertility, hysteroscopy, amenorrhea.
For quote: Popov A.A., Manannikova T.N., Alieva A.S. et al. Intrauterine synechiae: a century later // RMJ. 2017. No. 12. P. 895–899.

The article is devoted to the problem of intrauterine synechia

Introduction

For the first time, intrauterine synechia (IUD) was described in 1894 by Fritsch H. in a patient with secondary amenorrhea that developed after curettage in the postpartum period. After 33 years, Bass B. diagnosed cervical atresia in 20 out of 1500 women examined after a medical abortion. In 1946, Stamer S. added 24 cases from his own experience to the 37 cases described in the literature. In 1948, Joseph Asherman published a number of articles in which he first indicated the frequency of the IUD, described in detail the etiology, symptoms, and also presented the X-ray picture of the IUD. After his publications, the term "Asherman's syndrome" has been used to describe the IUD until the present day. Despite the fact that more than a century has been known about synechia, the problem still remains unresolved, and work is currently underway to find measures for the prevention, diagnosis and treatment of this pathology.
The trigger for the formation of the IUD is an injury to the basal layer of the endometrium, which can be caused by various factors. The main one is interventions during pregnancy or in the postpartum period. Despite the fact that Asherman's syndrome has been described after curettage for obstetric conditions, other causes of IUDs have now been established. Thus, an increase in the number of intrauterine interventions for submucosal myomatous nodes, anomalies in the development of the uterus, etc., gave another group of patients predisposed to the formation of an IUD.
The role of infection in the development of the IUD is controversial. While some authors believe that infections are not involved in the formation of the IUD, others argue that the main cause of this pathology is infection, especially with histologically confirmed chronic or subacute endometritis, even without a clinical picture (fever, leukocytosis, purulent discharge).
In patients with IUDs, the picture during hysteroscopy (HS) can be different: from loose, single adhesions to complete obliteration of the uterine cavity with dense synechiae. A number of authors claim that the critical period during which adhesions appear is from 3 to 5 days after surgery. This process is enhanced by a number of factors that disrupt physiological fibrinolysis: ischemia, post-traumatic inflammation, the presence of blood, foreign bodies. Adhesions may involve different layers of both the endometrium and the myometrium. Adhesions of these tissues hysteroscopically manifest a characteristic pattern: endometrial adhesions are similar to the surrounding healthy tissue, myofibral adhesions are the most common, characterized by a superficial thin layer of the endometrium with multiple glands.
Menstrual dysfunction, including hypomenorrhea and amenorrhea, remain common clinical manifestations of IUDs. With IUD, amenorrhea can be caused by various etiological factors: endocervical adhesions leading to obstruction of the cervical canal, extensive adhesions in the uterine cavity due to destruction of the basal layer of the endometrium. With obstructive amenorrhea, patients experience cyclic discomfort or pain in the lower abdomen, hematometer, and even hematosalpinx. Dysmenorrhea and infertility are also noted. Compared with amenorrhea and infertility, miscarriage is a milder complication of the IUD. Possible etiological factors include: reduction of the uterine cavity, lack of sufficient normal endometrial tissue for implantation and support of the placenta, inadequate vascularization of the functioning endometrium due to fibrosis, etc. In a study by Schenker J.G., Margalioth E.J. 165 pregnancies were observed in women with untreated Asherman's syndrome. The frequency of spontaneous miscarriage was 40%, preterm birth 23%, timely delivery occurred in 30% of cases, pathological attachment of the placenta was observed in 13% of women, ectopic pregnancy - in 12% of patients.
Clinical manifestations are closely related to such pathological changes as the depth of fibrosis, the location of adhesions (Fig. 1), and are divided into 3 types.

Type 1. Amenorrhea develops due to adhesions or stenosis of the cervical canal. In such cases, as a rule, a normal uterine cavity is detected above the adhesions, the prognosis is quite favorable.
Type 2. Adhesions are detected in the uterine cavity. This most common form of IUD has 3 degrees of severity: central intrauterine synechia without narrowing of the cavity, partial obliteration with reduction and complete obliteration of the uterine cavity. The prognosis after treatment directly depends on the degree of damage. In patients with a central IUD and preserved normal endometrium and uterine cavity, the treatment prognosis is quite favorable. The prognosis of treatment is often unsatisfactory in patients with partial or complete atresia of the uterine cavity.
Type 3. Adhesions can be detected both in the cervical canal and in the cavity of the uterine body.

IUD Diagnostics

Hysterosalpingography (HSG) before the invention of the hysteroscope was and still is the method of choice for many gynecologists. HSG is able to assess the shape of the uterine cavity and the condition of the fallopian tubes. Wamsteker K. described the HSG picture in IUD as filling defects with sharply defined boundaries, with a centralized and / or parietal location.
Due to its non-invasiveness, ultrasound is widely used both for diagnostic and, intraoperatively, with an auxiliary purpose.
Sonohysterography combines ultrasound with intrauterine administration of isotonic saline. If one or more echogenic areas are identified between the anterior and posterior walls of the uterine cavity, an IUD can be suspected.
The main advantage of MRI is the visualization of proximal adhesions in the uterine cavity and the assessment of the state of the endometrium, which is necessary to resolve the issue of further management of the patient. MRI plays a supporting role in diagnosing complete obliteration of the uterine cavity when hysteroscopic imaging is not possible.
Thanks to direct imaging in HS, it is possible to more accurately confirm the presence and assess the degree of adhesions in the uterine cavity. Al-Inany H. described various types of intrauterine adhesions that are visualized with a hysteroscope: 1) central adhesions look like columns with expanded ends and connect opposite walls of the uterine cavity; 2) parietal adhesions look like a crescent and a curtain, hiding the bottom or side walls, they can give the uterine cavity an asymmetric shape; 3) multiple adhesions that divide the uterine cavity into several smaller cavities.
None of the IUD classifications take into account clinical manifestations, features of menstrual function. Of all the known classifications, the classification of the American Fertility Society (AFS) of 1988 is currently considered the most objective, although it is somewhat complex and cumbersome (Table 1) .

According to this classification, the stage of the IUD is determined by the sum of points:
1) stage I - 1–4 points;
2) stage II - 5–8 points;
3) stage III - 9–12 points.

Treatment

Treatment of Asherman's syndrome is aimed at restoring the size and shape of the uterine cavity, menstrual and reproductive function, and preventing the recurrence of adhesions. Over the past century, various treatments have been described.
1. Expectant tactics. Schenker and Margalioth followed up 23 women with amenorrhea who did not receive surgical treatment, 18 of them recovered a regular menstrual cycle in the period from 1 to 7 years.
2. Blind dilation and curettage. It is known that this method is fraught with a high risk of complications and is ineffective.
3. Hysterotomy. For the first time, D. Asherman proposed hysterotomy to separate the IUD. In the analysis of 31 cases of hysterotomy, 16 women (52%) became pregnant, 8 (25.8%) of whom delivered safely. However, this treatment method should only be considered in the most extreme situations.
4. Hysteroscopy(GS) is currently the method of choice for Asherman's syndrome due to its low invasiveness and the possibility of repeated execution in case of relapse. When using scissors or forceps to destroy synechia, there is a lower risk of perforation of the uterus and destruction of the basal layer of the endometrium compared with the use of various types of energy. However, energy-assisted intrauterine surgery can enable efficient and precise cutting as well as guarantee hemostasis by providing optical transparency to the operating field.
The efficacy and safety of surgical treatment of Asherman's syndrome can be improved if GS is combined with one of the control methods: fluoroscopy, laparoscopy, transabdominal ultrasound. The disadvantage of fluoroscopy is the radiation exposure. Laparoscopy is widely used to control hysteroscopic adhesiolysis and makes it possible to assess the condition of the pelvic organs and perform surgical treatment for various pathologies. Transabdominal ultrasound is increasingly being used for hysteroscopic separation of intrauterine adhesions and significantly reduces the risk of uterine perforation.
Surgical success can be judged by the restoration of the normal anatomy of the uterine cavity, the restoration of menstrual function, the onset of pregnancy and live birth. It is noted that the restoration of the normal uterine cavity after the first procedure is 57.8–97.5%. However, the reproductive outcome depends not only on the state of the uterine cavity, but also on the state of the endometrium.
According to the literature, the pregnancy rate after hysteroscopic lysis of intrauterine adhesions in women was about 74% (468 out of 632), which is much higher than in non-operated women. IUD recurrence is the main factor in the failure of the operation and is directly related to the prevalence of adhesions. It was noted that the frequency of relapses in the range of 3.1–28.7% is typical for all cases of adhesions and 20–62.5% for widespread adhesions.
Since IUD recurrence occurs in the early postoperative period, prophylaxis after surgery is important and is carried out by various methods.

Prevention of IUD recurrence

Intrauterine contraceptives have been widely used as a method to prevent recurrence of the IUD. In a literature review March C.M. concluded that T-shaped intrauterine devices have too little surface area to prevent adhesion of the walls of the uterine cavity. There is evidence in the literature on the use of a Foley catheter inserted into the uterine cavity for several days after adhesion lysis to prevent recurrence. In a prospective controlled study, Amer M.I. et al. evaluated the effectiveness of this method by leaving the Foley catheter in the uterine cavity for one week after surgery in 32 patients. Diagnostic HS was performed within 6 to 8 weeks. after operation. IUDs were found in 7 patients in the balloon group (7 of 32; 21.9%) compared with 9 patients in the non-balloon group (9 of 18; 50%). However, the use of a balloon creates an "open gate" into the uterine cavity for infection from the vagina. A large balloon increases intrauterine pressure, which can lead to reduced blood flow to the uterine wall and adverse effects on endometrial regeneration. In addition, this method can create significant discomfort for the patient.
J. Wood and G. Pena proposed the use of estrogen to stimulate the regeneration of the endometrium on injured surfaces. In a randomized trial, 60 women underwent uterine curettage during the first trimester of pregnancy and estrogen-progestin therapy after adhesiolysis. In this group of patients, the thickness (0.84 cm vs. 0.67 cm; P1/4.02) and endometrial volume (3.85 cm2 vs. 1.97 cm2) were statistically significantly greater than in the control group. These data suggest that hormone replacement therapy significantly increases the thickness and volume of the endometrium, stimulating repair and cyclic transformation.
In the recommendations of the Royal College of Obstetricians and Gynecologists on the prevention of adhesions, it is noted that any surgical intervention on the organs of the abdomen and pelvis leads to the formation of adhesions and related complications in the long-term period. To avoid such risks, the use of anti-adhesion barrier agents is necessary. Hyaluronic acid (HA) derivatives are recognized as the most effective antiadhesion agents in obstetrics and gynecology. The American Association of Laparoscopic Gynecological Surgeons recommends the use of barrier antiadhesions (gels), which include HA, after any intrauterine interventions, since it has been proven that these agents significantly reduce the risk of adhesions in the uterine cavity.
The use of gel forms of antiadhesion agents is most preferred in intrauterine surgery, since the gel is evenly distributed over the entire sphere, filling congruent surfaces and hard-to-reach areas in the uterine cavity. The gels are easy to use, they form a thin film on the surface of the organ, which acts as an anti-adhesion barrier during intensive tissue healing. Therefore, to prevent recurrence after adhesiolysis, gel-like fillers are introduced into the uterine cavity, preventing the contact of its walls, thus preventing the formation of an IUD. The most widely used barriers are made of biodegradable materials, which are completely excreted from the body.
The main component of such barriers is HA (a disaccharide molecule), it is present in the body as a natural component of the extracellular matrix. HA has been proposed as a barrier agent to prevent adhesion and has shown beneficial biological properties for the body. The mechanism of action of HA is realized at a very early stage of tissue healing (the first 3-4 days) by suppressing the adhesion of fibroblasts and platelets, the activity of macrophages, as well as by inhibiting the formation of fibrin and creating a protective barrier on the damaged tissue area. The half-life of HA is about 1-3 days. Completely split in the body within 4 days with the help of the enzyme hyaluronidase.
Another anti-adhesive component called carboxymethyl cellulose (CMC) is a high molecular weight polysaccharide that also serves as an effective anti-adhesion agent. CMC is non-toxic, non-carcinogenic. In the food industry, it is used as a thickener, filler and food additive. In surgery, CMC is used as a substrate for fixing and prolonging the action of HA on the tissue surface. Acts as a mechanical barrier.
The combination of highly purified sodium salt of HA with CMC in the form of a gel (Antiadgesin® (Genuel Co., Ltd., Korea)) is intended for the prevention of adhesion formation after any operations on organs and tissues where there is a risk of adhesion formation, including after intrauterine operations. According to a prospective randomized study by J.W. Do et al., development of intrauterine adhesions after 4 weeks. after interventions, it was noted 2 times less often in the group with postoperative use of Antiadhesin than in the control group: 13% versus 26%, respectively. The anti-adhesion gel has favorable characteristics: convenience and ease of use, the possibility of using it for intrauterine, open and laparoscopic intervention, the duration of the anti-adhesion effect (up to 7 days), the ability to resolve (biodegradation), safety, immunocompatibility, inertness (the gel is not a focus of infection, fibrosis, angiogenesis, etc.), has a barrier (delimiting) effect. In addition, Antiadhesin® gel has an optimal degree of fluidity and viscosity, which allows it to envelop anatomical formations of any shape, creating a gel film fixed to the wound surface, and also does not affect the normal regeneration processes and meets all established quality standards.
It should be remembered that IUD prevention is always more useful and easier than treatment. To this end, it is important to avoid any injury to the uterus, especially during pregnancy and the postpartum period. In the presence of changes in the uterine cavity in the postpartum period or after abortion, HS should be considered as an effective method for diagnosis and treatment control, since it is preferable to conventional uncontrolled, blind curettage.

Case Study #1

Patient Ya., 28 years old. Complaints of cyclic pain in the lower abdomen, secondary amenorrhea during the year. From the anamnesis: in February 2014 - urgent spontaneous delivery, manual separation of the placenta. In March 2014, curettage of the walls of the uterine cavity was performed due to uterine bleeding and remnants of placental tissue. After 2 weeks ultrasound revealed the remains of placental tissue, in connection with which the repeated curettage of the walls of the uterine cavity was performed. After 5 months there were cyclic pains in the lower abdomen, menstruation was absent. Ultrasound revealed massive synechia of the uterine cavity, signs of hematometra. In March 2015, HS was performed under endotracheal anesthesia, resection of extensive intracervical and intrauterine synechiae. The procedure was performed under ultrasound guidance. During the restoration of the uterine cavity, a section of the functioning endometrium was identified in the region of the left tubal angle. During the period of the expected menstruation, the patient noted the appearance of spotting spotting. With the control office HS after 2 months. a recurrence of synechiae was revealed only in the uterine cavity, and they were dissected. In order to prevent the formation of synechia, cyclic hormone therapy was prescribed using drugs for menopausal hormone therapy (dydrogesterone + estradiol, 2/10). In a subsequent patient, 3 office HSs were performed with an interval of 2 months, during which the adhesions of the uterine cavity were dissected using endoscopic scissors. Upon completion of the operation, Antiadhesin® gel was injected into the uterine cavity. The patient noted the restoration of the normal menstrual cycle. According to ultrasound, no pathology of the uterine cavity was found. During the control office GS, the uterine cavity had a normal shape, the mouth of the left fallopian tube was visualized without features, the mouth of the right fallopian tube was not clearly visualized. The endometrium corresponded to the phase of the menstrual cycle. After 6 months after an office HS, a spontaneous pregnancy occurred, which ended with a planned caesarean section at the 38th week due to complete placenta previa.

Case Study #2

Patient A., 34 years old , was admitted to the clinic with complaints of hypomenorrhea, recurrent miscarriage. From the anamnesis: in 2010 - urgent spontaneous delivery. The postpartum period was complicated by endometritis, in connection with which the walls of the uterine cavity were scraped. The menstrual cycle was restored after 2 months. type of hypomenorrhea. In 2015, for a period of 5–6 weeks. a non-developing pregnancy was diagnosed, for which curettage of the walls of the uterine cavity was performed. After 2 months Ultrasound revealed synechia of the cervical canal and uterine cavity. Performed hysteroresectoscopy (HRS), dissection of synechia of the cervical canal and uterine cavity. Subsequently, two office HSs were made with an interval of 1 month, during which the IUD was dissected. A month later, a spontaneous pregnancy occurred, but in the period of 7-8 weeks. was again diagnosed as non-developing, in connection with which the patient underwent another curettage of the walls of the uterine cavity. In our clinic, the patient underwent office HS, dissection of the IUD, followed by the introduction of anti-adhesion gel Antiadhesin®. After 2 months spontaneous pregnancy occurred, which at full term ended in a planned caesarean section due to the transverse position of the fetus and the low location of the placenta.

Case Study #3

Patient T., 37 years old, was admitted to the clinic with complaints of pain in the lower abdomen, lack of menstruation. From the anamnesis: the patient underwent 2 emergency caesarean sections for pregnancies that occurred through IVF (male factor). The postpartum period of the last pregnancy was complicated by hematometra, suspected endometritis, in connection with which diagnostic curettage was performed. Menstrual function was not restored, there were cyclic pains in the lower abdomen. The patient underwent HRS, excision of the synechia of the uterine cavity and cervical canal with the appointment of hormone therapy for 3 months. Restored menstruation - meager, within 1-2 days. At the next 2 control office GS after excision of recurrent synechiae, antiadhesion gel Antiadhesin® was introduced into the uterine cavity. Currently, the patient has no complaints, menstruation is regular for 4 days, pregnancy is not planned.

Conclusion

During the century, great progress has been made in the diagnosis and treatment of IUDs, as a result of which HS has become the "gold standard" for the diagnosis and treatment of IUDs. In other cases, repeated (third, fourth, etc.) interventions may be required, which do not always end with the desired result. The use of an anti-adhesion gel based on hyaluronic acid and carboxymethylcellulose in combination with hormonal treatment is a modern innovative method for preventing intrauterine adhesion formation with a high success rate. Women who become pregnant after IUD treatment are subject to close monitoring due to the high risk of a number of obstetric complications. Future research should focus on the cellular and molecular aspects of endometrial regeneration, as well as measures to prevent primary and recurrent postoperative IUDs.

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Intrauterine synechia - adhesions in the uterine cavity.

The appearance of synechia in the uterine cavity leads to atrophic changes in the endometrium, which entails a violation of menstrual function. In addition, intrauterine synechia is a mechanical obstacle to the advancement of spermatozoa, as a result of which a woman suffers from infertility. There are also poor conditions for the implantation of the fetal egg, which leads to spontaneous abortion.

The trigger for the formation of intrauterine synechia is damage to the basal layer of the endometrium, which, in turn, can be caused by various factors. The most common factors include:

surgical termination of pregnancy;
a previous frozen pregnancy, in which possible remnants of the placenta in the uterine cavity contribute to the formation of collagen fibers;
the presence of intrauterine contraceptives;
diagnostic curettage of the uterine cavity, carried out with endometrial polyps, fibroids, uterine bleeding, and so on;
endometritis - an inflammatory disease that affects the endometrium;
genital tuberculosis;
radiation therapy for malignant tumors of the uterus or ovaries.

With timely detection, the prognosis of the disease is favorable, in most cases it is possible to restore menstrual and reproductive function. An unfavorable outcome is observed with intrauterine synechia of tuberculous etiology. In this case, it is extremely rare to restore the state of the endometrium. In addition, after dissection and removal of synechia of any origin, there is a risk of the formation of new ones. Since intrauterine synechia is a mechanical obstacle to the advancement of spermatozoa, women often suffer from infertility. In this regard, such patients are offered assisted reproductive technologies, including in vitro fertilization. However, unfortunately, in some cases, even with the help of assistive technology, women fail to bear a fetus. In this case, it is proposed to consider the option of bearing a fetus with the help of surrogate motherhood.

Symptoms

As a rule, the presence of intrauterine synechia is manifested by the development of hypomenstrual syndrome. This syndrome is characterized by the following:

rare and short menstruation;
small blood loss during menstruation compared with the physiological norm.

In rare cases, women who have intrauterine synechia have secondary amenorrhea (a pathological condition characterized by prolonged absence of menstruation in women who used to menstruate). With obliteration of the lower parts of the uterine cavity during menstruation, a hematometer can form - an accumulation of blood in the uterine cavity, resulting from a violation of its outflow. This phenomenon is accompanied by the appearance of pain in the lower abdomen. In most cases, the pain has a cramping character.

Since the presence of intrauterine adhesions prevents implantation of the ovum, women often suffer from infertility or miscarriage. The formation of synechia in the fallopian tubes makes the fertilization process impossible, which also leads to infertility. In such cases, artificial insemination techniques can be used, however, unfortunately, the presence of even the smallest synechia in the uterine cavity disrupts the implantation process, which can cause ineffective in vitro fertilization.

Diagnostics

Diagnosis begins with the clarification of the patient's complaints, in particular, the assessment of menstrual and reproductive function. You should also find out if the woman had a history of abortions, intrauterine manipulations, for example, curettage of the endometrium, inflammatory diseases of the reproductive organs. This is important to know, since it is these factors that often cause the development of intrauterine adhesions.

Unfortunately, ultrasound of the pelvic organs in this case is an uninformative study, since it is possible to indirectly judge the presence of intrauterine synechia only by irregular contours of the endometrium. The presence of a hematometer is well visualized on ultrasound, which is expressed as an anechoic formation in the uterine cavity. The most informative are the following studies:

hysteroscopy is an endoscopic examination method that allows you to examine the uterine cavity using a hysteroscope. In the future, if necessary, not only diagnostic manipulations, but also therapeutic ones can be carried out. Intrauterine synechiae are visualized as whitish avascular strands. These strands have different density and length, connect the walls of the uterus. Due to their presence, deformation or obliteration of the uterine cavity is noted;
hysterosalpinography is an X-ray examination method that allows you to assess the patency of the uterus and fallopian tubes. However, it is worth noting that in some cases this study gives a false positive result due to the presence of mucus in the uterine cavity, fragments of the endometrium, and so on.

Hormonal tests may also be prescribed, which are assessed by the presence of menstrual-like bleeding in response to taking estrogen and progesterone. Under this condition, the hormonal test will be negative. In addition, the level of sex hormones is assessed, which is within the normal range, which indicates the normogonadotropic nature of amenorrhea.

Treatment

The main task of treatment is to eliminate existing intrauterine synechia, thereby restoring menstrual and reproductive function.

Undoubtedly, the most effective method is to conduct an operating hysteroscopy, during which the adhesions are dissected under the control of an optical device. Hysteroresectoscopy allows you to eliminate the existing problem without resorting to more complex interventions. Since this manipulation is considered minimally invasive, as a rule, the development of any complications is extremely rare in the future.

After a surgical procedure, a woman is prescribed hormone therapy, the action of which is aimed at stimulating the restoration of the endometrium, as well as its cyclic transformation. It is important to note that in no case should combined oral contraceptives be used, since these drugs act on the endometrium, causing atrophic changes in it.

Since the formation of synechia in the uterine cavity is often associated with inflammatory diseases of the genital organs, it is important to use antibacterial agents, the action of which is aimed at destroying pathogenic microflora. To avoid the development of a chronic form of an inflammatory disease, which is often the cause of intrauterine synechia, it is necessary to carefully follow all the doctor's recommendations during the treatment of the acute form of the disease. You should also be careful while taking antibiotics, in particular, in no case should you independently cancel the drug or adjust the dosage and frequency of administration. In addition, after stopping the acute inflammatory process, physiotherapy is prescribed, which reduces the possibility of adhesion formation in the small pelvis. The following types of physiotherapy are used:

UHF - a physiotherapeutic method of treatment based on the use of an electromagnetic field of ultrahigh frequency;
magnetotherapy - a physiotherapeutic procedure based on the impact on the body of a magnetic field;
electrophoresis with magnesium, zinc or hyaluronidase - the introduction of a drug through the skin or mucous membranes using a direct electric current;
diadynamic therapy is a method of physiotherapeutic treatment based on the use of electric currents of various frequencies and powers.

Medications

As you know, the main method of treatment of intrauterine synechia is their dissection and removal during hysteroresectoscopy. After this surgical procedure, the woman is prescribed hormone therapy, which helps to restore the endometrium. The selection of hormonal drugs is carried out by a specialist strictly individually in each individual case. While taking hormonal drugs, you should carefully follow all the doctor's recommendations, and also not self-medicate, in particular, do not adjust the dose of drugs and do not stop taking them without the knowledge of your doctor. In no case should combined oral contraceptives be used, since these drugs, on the contrary, cause atrophic changes in the endometrium.

With the infectious nature of the disease, antibacterial agents are prescribed, the action of which is aimed at the destruction of pathogenic microflora. The choice of a specific group of antibiotics is based on the results of the study of scrapings from the cervical canal and cervix. Based on this study, it is possible to isolate the pathogenic microorganisms that caused the development of an inflammatory disease, as well as to determine their sensitivity to the antibiotics used. As a rule, until the results of the study are obtained, preference is given to broad-spectrum antibacterial drugs that act on both gram-positive and gram-negative microflora.

Folk remedies

Folk remedies are not used in the treatment of intrauterine synechia, however, their use can be encountered in the treatment of inflammatory diseases of the reproductive system, since they are often the cause of the adhesive process. In this case, traditional medicine based on plant components are used for prophylactic purposes. It is also worth noting that these funds should be used solely as an adjunct to the main treatment prescribed by a qualified specialist. We bring to your attention the following recipes, before using which you should consult with your doctor:

to prepare the infusion you will need: 1 tablespoon of chamomile, 2 tablespoons of marshmallow leaves and 1 tablespoon of sweet clover herb. Mix the listed components thoroughly and pour 1 cup of boiling water, let it brew for 20 minutes, then strain through a strainer. It is recommended to take ¼ cup 2 times a day after meals;
mix 6 tablespoons of oak bark and 4 tablespoons of linden flowers. From the resulting collection for the preparation of the infusion, you will need 4 tablespoons of raw materials, which are poured with 1 liter of boiling water and infused for 5 minutes, after which the infusion is carefully filtered. It is recommended to use for douching 2 times a day;
take 4 tablespoons of dried chamomile flowers, pour them with 1 cup of boiling water, let it brew for 10 - 20 minutes. The infusion becomes ready for use after careful straining. It is recommended to take orally ½ cup 2 times a day;
take 1 tablespoon of pre-prepared plantain leaves, pour two cups of boiling water, let it brew for 15 - 20 minutes, then strain through a strainer. The resulting infusion is used 1 tablespoon 3-4 times a day.

The information is for reference only and is not a guide to action. Do not self-medicate. At the first symptoms of the disease, consult a doctor.