Original Article
Treatment of Asherman’s Syndrome in an Outpatient Hysteroscopy Setting Olga Bougie, MD, Karine Lortie, MD, FRCSC, Hassan Shenassa, MD, FRCSC, Innie Chen, MD, FRCSC, and Sukhbir S. Singh, MD, FRCSC* From the Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada (all authors).
ABSTRACT Objective: To evaluate the feasibility and success rate of treating Asherman syndrome in an outpatient hysteroscopy unit. Design: Retrospective case series (Canadian Task Force classification III). Setting: The outpatient hysteroscopy clinic at Ottawa Hospital from November 26, 2008, to January 31, 2014. Patients: Patients undergoing treatment for Asherman syndrome. Interventions: All cases of hysteroscopic adhesiolysis were reviewed. Measurements and Main Results: Demographic data were collected by a retrospective chart review including patients’ age, obstetric history, referring complaint, etiology of Asherman syndrome, antecedent treatment, and outcome measures when available. The severity of Asherman syndrome was determined based on the March classification by the operating surgeon. Analgesia used during the procedure was recorded. Twenty patients were treated for Asherman syndrome in the outpatient hysteroscopy suite. There were a total of 38 procedures (adhesiolysis or diagnostic hysteroscopies) performed for this indication in the patient set. The most common etiologies for intrauterine adhesions were previous curettage (60%) and previous missed abortion (45%). Outcomes were available for 19 patients. All of the patients had normal menses after treatment. Eighty-four percent of patients had either no adhesions or mild adhesions at their final hysteroscopy. Six patients had a spontaneous pregnancy after treatment, and 5 went on to have a term delivery to date. In terms of analgesia used for the procedure, 89% of patients had preoperative nonsteroidal anti-inflammatory drugs, 2.8% required intravenous fentanyl and midazolam, and 5.6% required oral lorazepam. Conclusion: This series showed that Asherman syndrome may be successfully treated in an outpatient hysteroscopy setting outside the operating room and without general or regional anesthesia. Journal of Minimally Invasive Gynecology (2015) 22, 446–450 Crown Copyright Ó 2015 Published by Elsevier Inc. on behalf of AAGL. All rights reserved. Keywords:
DISCUSS
Asherman syndrome; Hysteroscopic adhesiolysis; Outpatient hysteroscopy Use your Smartphone to scan this QR code and connect to the discussion forum for this article now*
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Asherman syndrome is characterized by the presence of intrauterine synechia as well as symptoms such as amenorrhea or oligomenorrhea, pelvic pain, or infertility [1,2]. Intrauterine synechia can result from trauma to the basalis The authors declare no conflict of interest. Corresponding author: Sukhbir S. Singh, MD, FRCSC, Shirley E. Greenberg Women’s Health Centre, 1967 Riverside Drive, Room 7-236-4, Ottawa, ON K1H 7W9, Canada. E-mail: [email protected] Submitted September 26, 2014. Accepted for publication December 4, 2014. Available at www.sciencedirect.com and www.jmig.org
layer of the endometrium, typically occurring after curettage, myomectomy, or intrauterine infection [3]. Pregnancy complications in patients with Asherman syndrome include ectopic pregnancy, recurrent miscarriages, preterm labor, and abnormal placentation [2]. Hysteroscopic lysis of adhesions is generally regarded as the mainstay of treatment of intrauterine adhesions and results in a high rate of resumption of normal menses [3– 5]. Adhesiolysis does carry a risk of uterine perforation, and repeat procedures may be required to achieve sustainable results [1]. Outpatient hysteroscopy is an effective method to evaluate the uterine cavity and treat intrauterine pathology.
1553-4650/$ - see front matter Crown Copyright Ó 2015 Published by Elsevier Inc. on behalf of AAGL. All rights reserved. http://dx.doi.org/10.1016/j.jmig.2014.12.006
Bougie et al.
Treatment of Asherman Syndrome
447
Procedures can be performed without regional or general anesthetic in an ambulatory setting. Large case series have reported excellent success rates with minimal complications [6–8]. Procedures such as polypectomies, directed sampling, and transcervical sterilization have been well described in the outpatient hysteroscopy setting, and some have suggested that intrauterine lysis of adhesions can also be performed in this setting [6,9,10]. Robinson et al [11] reported a case series of 24 patients in which office blunt hysteroscopic adhesiolysis with a flexible hysteroscope was performed after treatment of intrauterine adhesions in the operating room. They reported a 92% rate of improvement of disease stage after treatment. Demirol and Gurgan [12] also described the treatment of 18 cases of filmy/mild adhesions in the office setting in a study describing the use of outpatient hysteroscopy before in vitro fertilization treatment. Hysteroscopic lysis of adhesions in an office setting may offer several advantages, including reduced anesthetic risks, improved postoperative pain control, faster return to work, and decreased cost [13–15]. Although outpatient hysteroscopy has been gaining popularity worldwide, few have described its use in the treatment of intrauterine synechia.
Methods All cases of hysteroscopic adhesiolysis performed in the outpatient hysteroscopy suite at Ottawa Hospital were reviewed from November 26, 2008, to November 31, 2013. The study was approved by the Ottawa Hospital Research Ethics Board, Protocol # 20130892-01H. All the procedures were performed by 2 surgeons (SS and HS). Demographic data were collected by a retrospective chart review, including patient’s age, obstetric history, referring complaint (i.e., dysmenorrhea, amenorrhea, or infertility), etiology of Asherman syndrome, antecedent treatment, and outcome measures when available. Hysteroscopy was performed with a 5.4-mm operative hysteroscope (Karl Storz Endoscopy Canada Ltd., Mississauga, Ontario, Canada) using the vaginoscopic approach [15]. Sharp adhesiolysis was performed with microscissors through the operating port. Patients were offered an opportunity to visualize the findings of their uterine cavity assessment on the screen as the procedure was performed.
Patients were brought back for repeat hysteroscopies until either no adhesions or only mild adhesions were noted (or patients declined further follow-up). This decision was made at the discretion of the surgeon. The rationale for this management approach is in keeping with the suggestion by Robinson et al [11] that repeated adhesiolysis with flexible office hysteroscope allows for the release of thin, filmy adhesions before they have the chance to become dense and/or vascularize. The standard time between treatments was 3 to 4 weeks. All patients were triaged to undergo office hysteroscopies unless a concomitant procedure that needed to be performed in the operating room was indicated. For instance, some of our patients required a hysteroscopic myomectomy and were therefore taken to the operating room. Several patients were seen for hysteroscopic adhesiolysis in the outpatient hysteroscopy clinic after an attempt had been made to perform this procedure by the referring surgeon. These patients were treated in a similar fashion as those who had not had a previous attempt at adhesiolysis. In terms of analgesia, all patients were advised to take nonsteroidal anti-inflammatories (NSAIDs) before their procedure if they had not previously experienced an adverse reaction with these medications. This approach is in keeping with the Royal College of Obstetricians and Gynecologists Best Practice in Outpatient Hysteroscopy Guidelines [16]. The patients were asked during vaginoscopy and during hysteroscopic assessment/adhesiolysis if they were satisfied with their pain control. If they expressed that their pain control was inadequate, the procedure was stopped, and additional analgesia was offered. Generally, a paracervical block (10– 20 mL 1% lidocaine with 1:200,000 epinephrine) was performed if the procedure was stopped before gaining access to the uterus; otherwise, intravenous sedation with fentanyl and midazolam was offered to the patient at the discretion of the surgeon. Analgesia used during each procedure was recorded. Intrauterine adhesions were classified according to the March classification (Fig. 1) [4]. Staging was assigned by 2 of the authors (OB and SS) after reviewing the videos of the procedures. Patients had a follow-up clinic appointment after their hysteroscopy and were questioned if they were menstruating in a normal fashion (frequency 24–38 days, lasting 4–8 days) [17]. A followup telephone call was administered by the operating surgeon to determine if patients had become pregnant. All patients had their blood pressure, heart rate, and oxygen saturation measured before the procedure and before discharge. Patients who were receiving intravenous sedation had continuous cardiovascular monitoring during the procedure. At least 1 member of
Fig. 1 March classification of intrauterine adhesions [4]. In cases in which cavity integrity has been restored but ostial occlusion still exists, a classification of moderate applies. (Adapted with permission [11].)
Minimal ¾ of uterine cavity involved; agglutination of wall or thick bands; ostial areas and upper cavity occluded
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Journal of Minimally Invasive Gynecology, Vol 22, No 3, March/April 2015
Table 1
Fig. 2
Baseline characteristics
The number of hysteroscopic adhesiolysis treatments required in the outpatient hysteroscopy suite. Number (%)
Age (median, range) 36 (27-40) Gravidity G0 4 G1 5 G2 3 G31 8 Parity P0 10 P1 10 Presenting symptom* (n, %) Infertility 11 (55) Recurrent pregnancy loss 6 (30) Postsurgical follow-up 9 (45) Menses at the time of presentation (n, %) Normal 11 (55) Oligomenorrhea 6 (30) Amenorrhea 3 (15) Previous attempt at correction in main operating room (n, %) Yes 7 (35) No 13 (65) Stage of Asherman syndrome at presentation* (n, %) Mild 3 (15) Moderate 10 (20) Severe 7 (35) SD 5 standard deviation. * Multiple responses possible.
the team caring for the patient had training in advanced cardiac life support, and appropriate resuscitation equipment was available in the surgical suite. Postoperatively, we ensured that patients’ pain was well controlled, and they met the postanesthetic recovery discharge criteria [18].
Results In total, 20 patients were identified who were treated for Asherman syndrome between November 26, 2008, and November 31, 2013, in the outpatient hysteroscopy unit. Baseline patient characteristics are presented in Table 1. The average age of women at presentation was 34.9 years. There was an equal distribution among patients who were nulliparous and multiparous. The most common presenting complaint of patients was infertility followed by postsurgical follow-up and recurrent pregnancy loss. Forty-five percent of patients described menstrual irregularities (oligomenorrhea or amenorrhea) at the time of their presentation. In 35% of patients, previous hysteroscopic adhesiolysis had been attempted in the main operating room by the referring gynecologist. In terms of the stage of Asherman syndrome at presentation, 15% had mild adhesions, 50% moderate, and 35% severe according to the March classification [4].
The most common reason for Asherman syndrome was a previous history of curettage, which was noted in 60% of patients. Other contributing causes included missed abortion (45%), retained placenta (20%), abdominal myomectomy (20%), and hysteroscopic myomectomy (10%). In our case series, patients who presented with oligo- or amenorrhea were treated with estrogen therapy (Estrace [Actavis, Mississauga, Ontario, Canada] 2 mg for 14 days) after hysteroscopic adhesiolysis [5]. There were 9 of 19 patients who received postoperative estrogen treatment. No patient received an intrauterine device or balloon after adhesiolysis. Figure 2 depicts the distribution of the number of hysteroscopic adhesiolysis treatments patients required. Thirtyfive percent of the patients had only 1 procedure, 40% had 2, 20% had 3, and 5% had 4 procedures. The outcomes available after hysteroscopic adhesiolysis are depicted in Table 2. Outcomes were available for 19 patients. The average length of follow-up was 17.3 months (range, 4–53 months). All of the patients experienced normal menses after completion of their treatments. Eighty-four percent of patients had either mild adhesions or no adhesions at their final hysteroscopy. Six patients (32%) experienced a
Table 2 Outcome of hysteroscopy treatment of Asherman syndrome
Outcome Menses Mild or no adhesions at final hysteroscopy Spontaneous pregnancy Term delivery Failed assisted reproductive attempt Requirement for treatment in main operating room * Outcome unavailable for 1 patient.
Number of patients (n 5 19)* (%) 19 (100) 16 (84) 6 (32) 5 (26) 4 (21) 2 (10)
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Table 3 Analgesia used during procedures Analgesia method (N 5 37)
Frequency use (%)
NSAID IV fentanyl/midazolam None Unknown Tylenol Lorazepam PO Paracervical block
32 (89) 1 (2.8) 2 (5.6) 2 (5.6) 2 (5.6) 1 (2.8) 0
IV 5 intravenous; NSAID 5 nonsteroidal anti-inflammatory drug; PO 5 by mouth.
spontaneous pregnancy, and 5 of these proceeded to have a term delivery to date. One patient is currently 27 weeks’ pregnant. Four patients (21%) did experience failed assisted reproductive attempts. The presenting stage of Asherman syndrome did not influence pregnancy outcomes (p 5 .16). Two patients (10%) required hysteroscopic adhesiolysis performed in the main operating room for further treatment. These 2 patients required a hysteroscopic myomectomy as an adjunct procedure, which could not be performed in the office setting. The analgesia methods used during each procedure are listed in Table 3. The most common form of analgesia used was NSAID administration preoperativately, which was used in 89% of cases. Intravenous sedation with the use of fentanyl and midazolam was only used in 1 case, and there were no paracervical blocks used. The relative risk of requiring intravenous sedation based on nulliparity versus multiparity was 3.33 (95% confidence interval, 0.14–76.76). Discussion It is often difficult to achieve successful treatments in patients with Asherman syndrome. Hysteroscopic adhesiolysis is generally regarded as the mainstay of treatment [5]; however, repeat treatments are expected, increasing surgical risks such as uterine perforations and the risk of general anesthetic. Recurrence rates of intrauterine adhesions are estimated to range between one third to two thirds depending on the severity of adhesions (moderate to severe) [3,19–21]. We present a retrospective case series showing that hysteroscopic adhesiolysis for the treatment of Asherman syndrome is feasible in an outpatient setting. In our series, all patients reported normal menstrual cycles after treatment, and 84% had either no adhesions or only mild adhesions at their final hysteroscopy. There were 6 spontaneous pregnancies and 5 term deliveries in the group of 19 patients (not all patients were attempting to conceive). In terms of the analgesia used for outpatient hysteroscopic adhesiolysis, this was most commonly limited to preoperative NSAIDs
(89%). Only 1 case required intravenous sedation, and none required a paracervical block. There is a paucity of literature describing this treatment approach for the management of Asherman syndrome. Our findings are an extension of those previously described by Robinson et al [11], who described using serial outpatient flexible hysteroscope procedures to prevent recurrence of intrauterine adhesions after sharp hysteroscopic adhesiolysis. Demirol and Gurgan [12] also suggested that outpatient hysteroscopic adhesiolysis may be performed for patients undergoing infertility investigations, but they provide little details with respect to these procedures. We are the first to present a case series describing the management of Asherman syndrome exclusively in an outpatient setting. Hysteroscopic lysis of adhesions with cold scissors without general or regional anesthetic is a novel approach for the treatment of intrauterine adhesions that warrants further analysis. Our study is limited by its sample size and retrospective nature. Because this was a retrospective series, we could not control for variations in management with each patient (e.g., the postoperative use of estrogen therapy). The fact that repeat office hysteroscopies were performed at the discretion of the surgeon could impact the interpretation of the results. Also, we could not ascertain how many of our patients were actively trying to conceive or using artificial reproductive technologies to assist in conception. It is possible that some patients had additional factors impacting their fertility potential. However, because this is a novel approach to the management of a condition that continues to provide challenges in treatment, we believe that this study can serve as a stepping stone in the development of a prospective compassion trial of standard versus outpatient management of Asherman syndrome. Although surgical techniques and postoperative management of Asherman syndrome are difficult to study, recent American Association of Gynecologic Laparoscopists guidelines suggest that high-quality studies are necessary to improve the management of this condition [5]. Outpatient hysteroscopy presents an alternative to traditional hysteroscopy performed in the operating room and offers advantages in terms of reduced anesthetic risks, improved postoperative pain control, faster return to work, and decreased cost [13– 15]. Patients generally report high satisfaction with their procedures performed in an outpatient setting [22,23]. Although outpatient hysteroscopy has been gaining popularity rapidly, little data have been reported on the treatment of Asherman syndrome in an outpatient setting. We suggest that outpatient hysteroscopic adhesiolysis is a viable alternative to traditional treatment of Asherman syndrome in the operating room, likely with a more favorable side effect profile. Larger case series of the treatment of Asherman syndrome in the outpatient setting should be undertaken to provide a more accurate assessment of outcome measures.
450
Acknowledgments We would like to express our sincerest appreciation to Karen Deme, RN, and the nursing team in the Minimally Invasive Gynecology Suite at Ottawa Hospital for their outstanding contribution to patient care. References 1. Yu D, Wong YM, Cheong Y, Xia E, Li TC. Asherman syndrome: one century later. Fertil Steril. 2008;89:759–779. 2. Schenker JG, Margalioth EJ. Intrauterine adhesions: an updated appraisal. Fertil Steril. 1982;37:593–610. 3. Valle RF, Sciarra JJ. Intrauterine adhesions: hysteroscopic diagnosis, classification, treatment, and reproductive outcome. Am J Obstet Gynecol. 1988;158:1459–1470. 4. March CM, Israel R, March AD. Hysteroscopic management of intrauterine adhesions. Am J Obstet Gynecol. 1978;130:653–657. 5. AAGL Advancing Minimally Invasive Gynecology Worldwide. AAGL practice report: practice guidelines for management of intrauterine synechiae. J Minim Invasive Gynecol. 2010;17:1–7. 6. Bettocchi S, Ceci O, Nappi L, et al. Operative office hysteroscopy without anesthesia: Analysis of 4863 cases performed with mechanical instruments. J Am Assoc Gynecol Laparosc. 2004;11:59–61. 7. Cicinelli E, Parisi C, Galantino P, Pinto V, Barba B, Schonauer S. Reliability, feasibility, and safety of minihysteroscopy with a vaginoscopic approach: experience with 6,000 cases. Fertil Steril. 2003;80:199–202. 8. Van Kerkvoorde TC, Veersema S, Timmermans A. Long-term complications of office hysteroscopy: analysis of 1028 cases. J Minim Invasive Gynecol. 2012;19:494–497. 9. Bettocchi S, Nappi L, Ceci O, Selvaggi L. What does ‘diagnostic hysteroscopy’ mean today? The role of the new techniques. Curr Opin Obstet Gynecol. 2003;15:303–308. 10. Di Spiezio Sardo A, Bettocchi S, Spinelli M, et al. Review of new office-based hysteroscopic procedures 2003-2009. J Minim Invasive Gynecol. 2010;17:436–448.
Journal of Minimally Invasive Gynecology, Vol 22, No 3, March/April 2015 11. Robinson JK, Swedarsky Colimon LM, Isaacson KB. Postoperative adhesiolysis therapy for intrauterine adhesions (Asherman’s syndrome). Fertil Steril. 2008;90:409–414. 12. Demirol A, Gurgan T. Effect of treatment of intrauterine pathologies with office hysteroscopy in patients with recurrent IVF failure. Reprod Biomed Online. 2004;8:590–594. 13. Marsh F, Kremer C, Duffy S. Delivering an effective outpatient service in gynaecology. A randomised controlled trial analysing the cost of outpatient versus daycase hysteroscopy. Br J Obstet Gynecol. 2004; 111:243–248. 14. Marsh FA, Rogerson LJ, Duffy SR. A randomised controlled trial comparing outpatient versus daycase endometrial polypectomy. Br J Obstet Gynecol. 2006;113:896–901. 15. Cooper N, Smith P, Khan K, Clark T. Vaginoscopic approach to outpatient hysteroscopy: a systematic review of the effect on pain. Br J Obstet Gynecol. 2010;117:532–539. 16. Royal College of Obstetricians and Gynaecologists. Green-top Guideline No. 59: Best Practice in Outpatient Hysteroscopy. London: RCOG; 2011. 17. Fritz MA, Speroff L. Clinical Gynecologic Endocrinology and Infertility. Philadelphia, PA: Wolters Kluwer; 2010. 18. Aldrete JA. Post- recovery score. J Am Coll Surg. 2007;205:e3–e4. 19. Capella-Allouc S, Morsad F, Rongieres-Bertrand C, Taylor S, Fernandez H. Hysteroscopic treatment of severe Asherman’s syndrome and subsequent fertility. Hum Reprod. 1999;14:1230–1233. 20. Preutthipan S, Linasmita V. A prospective comparative study between hysterosalpingography and hysteroscopy in the detection of intrauterine pathology in patients with infertility. J Obstet Gynaecol Res. 2003;29: 33–37. 21. Siegler A, Valle R. Therapeutic hysterosocpic procedures. Fertil Steril. 1988;50:685–701. 22. van Dongen H, Timmermans A, Jacobi CE, Elskamp T, de Kroon CD, Jansen FW. Diagnostic hysteroscopy and saline infusion sonography in the diagnosis of intrauterine abnormalities: an assessment of patient preference. Gynecol Surg. 2011;8:65–70. 23. Bougie O, Wang V, Lortie K, Shenassa H, Singh SS. High patient satisfaction with office hysteroscopy using tailored analgesia protocols. J Gynecol Surg. 2014;30:100–104.
Treatment of Asherman’s Syndrome in an Outpatient Hysteroscopy Setting Olga Bougie, MD, Karine Lortie, MD, FRCSC, Hassan Shenassa, MD, FRCSC, Innie Chen, MD, FRCSC, and Sukhbir S. Singh, MD, FRCSC* From the Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada (all authors).
ABSTRACT Objective: To evaluate the feasibility and success rate of treating Asherman syndrome in an outpatient hysteroscopy unit. Design: Retrospective case series (Canadian Task Force classification III). Setting: The outpatient hysteroscopy clinic at Ottawa Hospital from November 26, 2008, to January 31, 2014. Patients: Patients undergoing treatment for Asherman syndrome. Interventions: All cases of hysteroscopic adhesiolysis were reviewed. Measurements and Main Results: Demographic data were collected by a retrospective chart review including patients’ age, obstetric history, referring complaint, etiology of Asherman syndrome, antecedent treatment, and outcome measures when available. The severity of Asherman syndrome was determined based on the March classification by the operating surgeon. Analgesia used during the procedure was recorded. Twenty patients were treated for Asherman syndrome in the outpatient hysteroscopy suite. There were a total of 38 procedures (adhesiolysis or diagnostic hysteroscopies) performed for this indication in the patient set. The most common etiologies for intrauterine adhesions were previous curettage (60%) and previous missed abortion (45%). Outcomes were available for 19 patients. All of the patients had normal menses after treatment. Eighty-four percent of patients had either no adhesions or mild adhesions at their final hysteroscopy. Six patients had a spontaneous pregnancy after treatment, and 5 went on to have a term delivery to date. In terms of analgesia used for the procedure, 89% of patients had preoperative nonsteroidal anti-inflammatory drugs, 2.8% required intravenous fentanyl and midazolam, and 5.6% required oral lorazepam. Conclusion: This series showed that Asherman syndrome may be successfully treated in an outpatient hysteroscopy setting outside the operating room and without general or regional anesthesia. Journal of Minimally Invasive Gynecology (2015) 22, 446–450 Crown Copyright Ó 2015 Published by Elsevier Inc. on behalf of AAGL. All rights reserved. Keywords:
DISCUSS
Asherman syndrome; Hysteroscopic adhesiolysis; Outpatient hysteroscopy Use your Smartphone to scan this QR code and connect to the discussion forum for this article now*
You can discuss this article with its authors and with other AAGL members at: http://www.AAGL.org/jmig-22-3-JMIG-D-14-00483
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Asherman syndrome is characterized by the presence of intrauterine synechia as well as symptoms such as amenorrhea or oligomenorrhea, pelvic pain, or infertility [1,2]. Intrauterine synechia can result from trauma to the basalis The authors declare no conflict of interest. Corresponding author: Sukhbir S. Singh, MD, FRCSC, Shirley E. Greenberg Women’s Health Centre, 1967 Riverside Drive, Room 7-236-4, Ottawa, ON K1H 7W9, Canada. E-mail: [email protected] Submitted September 26, 2014. Accepted for publication December 4, 2014. Available at www.sciencedirect.com and www.jmig.org
layer of the endometrium, typically occurring after curettage, myomectomy, or intrauterine infection [3]. Pregnancy complications in patients with Asherman syndrome include ectopic pregnancy, recurrent miscarriages, preterm labor, and abnormal placentation [2]. Hysteroscopic lysis of adhesions is generally regarded as the mainstay of treatment of intrauterine adhesions and results in a high rate of resumption of normal menses [3– 5]. Adhesiolysis does carry a risk of uterine perforation, and repeat procedures may be required to achieve sustainable results [1]. Outpatient hysteroscopy is an effective method to evaluate the uterine cavity and treat intrauterine pathology.
1553-4650/$ - see front matter Crown Copyright Ó 2015 Published by Elsevier Inc. on behalf of AAGL. All rights reserved. http://dx.doi.org/10.1016/j.jmig.2014.12.006
Bougie et al.
Treatment of Asherman Syndrome
447
Procedures can be performed without regional or general anesthetic in an ambulatory setting. Large case series have reported excellent success rates with minimal complications [6–8]. Procedures such as polypectomies, directed sampling, and transcervical sterilization have been well described in the outpatient hysteroscopy setting, and some have suggested that intrauterine lysis of adhesions can also be performed in this setting [6,9,10]. Robinson et al [11] reported a case series of 24 patients in which office blunt hysteroscopic adhesiolysis with a flexible hysteroscope was performed after treatment of intrauterine adhesions in the operating room. They reported a 92% rate of improvement of disease stage after treatment. Demirol and Gurgan [12] also described the treatment of 18 cases of filmy/mild adhesions in the office setting in a study describing the use of outpatient hysteroscopy before in vitro fertilization treatment. Hysteroscopic lysis of adhesions in an office setting may offer several advantages, including reduced anesthetic risks, improved postoperative pain control, faster return to work, and decreased cost [13–15]. Although outpatient hysteroscopy has been gaining popularity worldwide, few have described its use in the treatment of intrauterine synechia.
Methods All cases of hysteroscopic adhesiolysis performed in the outpatient hysteroscopy suite at Ottawa Hospital were reviewed from November 26, 2008, to November 31, 2013. The study was approved by the Ottawa Hospital Research Ethics Board, Protocol # 20130892-01H. All the procedures were performed by 2 surgeons (SS and HS). Demographic data were collected by a retrospective chart review, including patient’s age, obstetric history, referring complaint (i.e., dysmenorrhea, amenorrhea, or infertility), etiology of Asherman syndrome, antecedent treatment, and outcome measures when available. Hysteroscopy was performed with a 5.4-mm operative hysteroscope (Karl Storz Endoscopy Canada Ltd., Mississauga, Ontario, Canada) using the vaginoscopic approach [15]. Sharp adhesiolysis was performed with microscissors through the operating port. Patients were offered an opportunity to visualize the findings of their uterine cavity assessment on the screen as the procedure was performed.
Patients were brought back for repeat hysteroscopies until either no adhesions or only mild adhesions were noted (or patients declined further follow-up). This decision was made at the discretion of the surgeon. The rationale for this management approach is in keeping with the suggestion by Robinson et al [11] that repeated adhesiolysis with flexible office hysteroscope allows for the release of thin, filmy adhesions before they have the chance to become dense and/or vascularize. The standard time between treatments was 3 to 4 weeks. All patients were triaged to undergo office hysteroscopies unless a concomitant procedure that needed to be performed in the operating room was indicated. For instance, some of our patients required a hysteroscopic myomectomy and were therefore taken to the operating room. Several patients were seen for hysteroscopic adhesiolysis in the outpatient hysteroscopy clinic after an attempt had been made to perform this procedure by the referring surgeon. These patients were treated in a similar fashion as those who had not had a previous attempt at adhesiolysis. In terms of analgesia, all patients were advised to take nonsteroidal anti-inflammatories (NSAIDs) before their procedure if they had not previously experienced an adverse reaction with these medications. This approach is in keeping with the Royal College of Obstetricians and Gynecologists Best Practice in Outpatient Hysteroscopy Guidelines [16]. The patients were asked during vaginoscopy and during hysteroscopic assessment/adhesiolysis if they were satisfied with their pain control. If they expressed that their pain control was inadequate, the procedure was stopped, and additional analgesia was offered. Generally, a paracervical block (10– 20 mL 1% lidocaine with 1:200,000 epinephrine) was performed if the procedure was stopped before gaining access to the uterus; otherwise, intravenous sedation with fentanyl and midazolam was offered to the patient at the discretion of the surgeon. Analgesia used during each procedure was recorded. Intrauterine adhesions were classified according to the March classification (Fig. 1) [4]. Staging was assigned by 2 of the authors (OB and SS) after reviewing the videos of the procedures. Patients had a follow-up clinic appointment after their hysteroscopy and were questioned if they were menstruating in a normal fashion (frequency 24–38 days, lasting 4–8 days) [17]. A followup telephone call was administered by the operating surgeon to determine if patients had become pregnant. All patients had their blood pressure, heart rate, and oxygen saturation measured before the procedure and before discharge. Patients who were receiving intravenous sedation had continuous cardiovascular monitoring during the procedure. At least 1 member of
Fig. 1 March classification of intrauterine adhesions [4]. In cases in which cavity integrity has been restored but ostial occlusion still exists, a classification of moderate applies. (Adapted with permission [11].)
Minimal ¾ of uterine cavity involved; agglutination of wall or thick bands; ostial areas and upper cavity occluded
448
Journal of Minimally Invasive Gynecology, Vol 22, No 3, March/April 2015
Table 1
Fig. 2
Baseline characteristics
The number of hysteroscopic adhesiolysis treatments required in the outpatient hysteroscopy suite. Number (%)
Age (median, range) 36 (27-40) Gravidity G0 4 G1 5 G2 3 G31 8 Parity P0 10 P1 10 Presenting symptom* (n, %) Infertility 11 (55) Recurrent pregnancy loss 6 (30) Postsurgical follow-up 9 (45) Menses at the time of presentation (n, %) Normal 11 (55) Oligomenorrhea 6 (30) Amenorrhea 3 (15) Previous attempt at correction in main operating room (n, %) Yes 7 (35) No 13 (65) Stage of Asherman syndrome at presentation* (n, %) Mild 3 (15) Moderate 10 (20) Severe 7 (35) SD 5 standard deviation. * Multiple responses possible.
the team caring for the patient had training in advanced cardiac life support, and appropriate resuscitation equipment was available in the surgical suite. Postoperatively, we ensured that patients’ pain was well controlled, and they met the postanesthetic recovery discharge criteria [18].
Results In total, 20 patients were identified who were treated for Asherman syndrome between November 26, 2008, and November 31, 2013, in the outpatient hysteroscopy unit. Baseline patient characteristics are presented in Table 1. The average age of women at presentation was 34.9 years. There was an equal distribution among patients who were nulliparous and multiparous. The most common presenting complaint of patients was infertility followed by postsurgical follow-up and recurrent pregnancy loss. Forty-five percent of patients described menstrual irregularities (oligomenorrhea or amenorrhea) at the time of their presentation. In 35% of patients, previous hysteroscopic adhesiolysis had been attempted in the main operating room by the referring gynecologist. In terms of the stage of Asherman syndrome at presentation, 15% had mild adhesions, 50% moderate, and 35% severe according to the March classification [4].
The most common reason for Asherman syndrome was a previous history of curettage, which was noted in 60% of patients. Other contributing causes included missed abortion (45%), retained placenta (20%), abdominal myomectomy (20%), and hysteroscopic myomectomy (10%). In our case series, patients who presented with oligo- or amenorrhea were treated with estrogen therapy (Estrace [Actavis, Mississauga, Ontario, Canada] 2 mg for 14 days) after hysteroscopic adhesiolysis [5]. There were 9 of 19 patients who received postoperative estrogen treatment. No patient received an intrauterine device or balloon after adhesiolysis. Figure 2 depicts the distribution of the number of hysteroscopic adhesiolysis treatments patients required. Thirtyfive percent of the patients had only 1 procedure, 40% had 2, 20% had 3, and 5% had 4 procedures. The outcomes available after hysteroscopic adhesiolysis are depicted in Table 2. Outcomes were available for 19 patients. The average length of follow-up was 17.3 months (range, 4–53 months). All of the patients experienced normal menses after completion of their treatments. Eighty-four percent of patients had either mild adhesions or no adhesions at their final hysteroscopy. Six patients (32%) experienced a
Table 2 Outcome of hysteroscopy treatment of Asherman syndrome
Outcome Menses Mild or no adhesions at final hysteroscopy Spontaneous pregnancy Term delivery Failed assisted reproductive attempt Requirement for treatment in main operating room * Outcome unavailable for 1 patient.
Number of patients (n 5 19)* (%) 19 (100) 16 (84) 6 (32) 5 (26) 4 (21) 2 (10)
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Treatment of Asherman Syndrome
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Table 3 Analgesia used during procedures Analgesia method (N 5 37)
Frequency use (%)
NSAID IV fentanyl/midazolam None Unknown Tylenol Lorazepam PO Paracervical block
32 (89) 1 (2.8) 2 (5.6) 2 (5.6) 2 (5.6) 1 (2.8) 0
IV 5 intravenous; NSAID 5 nonsteroidal anti-inflammatory drug; PO 5 by mouth.
spontaneous pregnancy, and 5 of these proceeded to have a term delivery to date. One patient is currently 27 weeks’ pregnant. Four patients (21%) did experience failed assisted reproductive attempts. The presenting stage of Asherman syndrome did not influence pregnancy outcomes (p 5 .16). Two patients (10%) required hysteroscopic adhesiolysis performed in the main operating room for further treatment. These 2 patients required a hysteroscopic myomectomy as an adjunct procedure, which could not be performed in the office setting. The analgesia methods used during each procedure are listed in Table 3. The most common form of analgesia used was NSAID administration preoperativately, which was used in 89% of cases. Intravenous sedation with the use of fentanyl and midazolam was only used in 1 case, and there were no paracervical blocks used. The relative risk of requiring intravenous sedation based on nulliparity versus multiparity was 3.33 (95% confidence interval, 0.14–76.76). Discussion It is often difficult to achieve successful treatments in patients with Asherman syndrome. Hysteroscopic adhesiolysis is generally regarded as the mainstay of treatment [5]; however, repeat treatments are expected, increasing surgical risks such as uterine perforations and the risk of general anesthetic. Recurrence rates of intrauterine adhesions are estimated to range between one third to two thirds depending on the severity of adhesions (moderate to severe) [3,19–21]. We present a retrospective case series showing that hysteroscopic adhesiolysis for the treatment of Asherman syndrome is feasible in an outpatient setting. In our series, all patients reported normal menstrual cycles after treatment, and 84% had either no adhesions or only mild adhesions at their final hysteroscopy. There were 6 spontaneous pregnancies and 5 term deliveries in the group of 19 patients (not all patients were attempting to conceive). In terms of the analgesia used for outpatient hysteroscopic adhesiolysis, this was most commonly limited to preoperative NSAIDs
(89%). Only 1 case required intravenous sedation, and none required a paracervical block. There is a paucity of literature describing this treatment approach for the management of Asherman syndrome. Our findings are an extension of those previously described by Robinson et al [11], who described using serial outpatient flexible hysteroscope procedures to prevent recurrence of intrauterine adhesions after sharp hysteroscopic adhesiolysis. Demirol and Gurgan [12] also suggested that outpatient hysteroscopic adhesiolysis may be performed for patients undergoing infertility investigations, but they provide little details with respect to these procedures. We are the first to present a case series describing the management of Asherman syndrome exclusively in an outpatient setting. Hysteroscopic lysis of adhesions with cold scissors without general or regional anesthetic is a novel approach for the treatment of intrauterine adhesions that warrants further analysis. Our study is limited by its sample size and retrospective nature. Because this was a retrospective series, we could not control for variations in management with each patient (e.g., the postoperative use of estrogen therapy). The fact that repeat office hysteroscopies were performed at the discretion of the surgeon could impact the interpretation of the results. Also, we could not ascertain how many of our patients were actively trying to conceive or using artificial reproductive technologies to assist in conception. It is possible that some patients had additional factors impacting their fertility potential. However, because this is a novel approach to the management of a condition that continues to provide challenges in treatment, we believe that this study can serve as a stepping stone in the development of a prospective compassion trial of standard versus outpatient management of Asherman syndrome. Although surgical techniques and postoperative management of Asherman syndrome are difficult to study, recent American Association of Gynecologic Laparoscopists guidelines suggest that high-quality studies are necessary to improve the management of this condition [5]. Outpatient hysteroscopy presents an alternative to traditional hysteroscopy performed in the operating room and offers advantages in terms of reduced anesthetic risks, improved postoperative pain control, faster return to work, and decreased cost [13– 15]. Patients generally report high satisfaction with their procedures performed in an outpatient setting [22,23]. Although outpatient hysteroscopy has been gaining popularity rapidly, little data have been reported on the treatment of Asherman syndrome in an outpatient setting. We suggest that outpatient hysteroscopic adhesiolysis is a viable alternative to traditional treatment of Asherman syndrome in the operating room, likely with a more favorable side effect profile. Larger case series of the treatment of Asherman syndrome in the outpatient setting should be undertaken to provide a more accurate assessment of outcome measures.
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Acknowledgments We would like to express our sincerest appreciation to Karen Deme, RN, and the nursing team in the Minimally Invasive Gynecology Suite at Ottawa Hospital for their outstanding contribution to patient care. References 1. Yu D, Wong YM, Cheong Y, Xia E, Li TC. Asherman syndrome: one century later. Fertil Steril. 2008;89:759–779. 2. Schenker JG, Margalioth EJ. Intrauterine adhesions: an updated appraisal. Fertil Steril. 1982;37:593–610. 3. Valle RF, Sciarra JJ. Intrauterine adhesions: hysteroscopic diagnosis, classification, treatment, and reproductive outcome. Am J Obstet Gynecol. 1988;158:1459–1470. 4. March CM, Israel R, March AD. Hysteroscopic management of intrauterine adhesions. Am J Obstet Gynecol. 1978;130:653–657. 5. AAGL Advancing Minimally Invasive Gynecology Worldwide. AAGL practice report: practice guidelines for management of intrauterine synechiae. J Minim Invasive Gynecol. 2010;17:1–7. 6. Bettocchi S, Ceci O, Nappi L, et al. Operative office hysteroscopy without anesthesia: Analysis of 4863 cases performed with mechanical instruments. J Am Assoc Gynecol Laparosc. 2004;11:59–61. 7. Cicinelli E, Parisi C, Galantino P, Pinto V, Barba B, Schonauer S. Reliability, feasibility, and safety of minihysteroscopy with a vaginoscopic approach: experience with 6,000 cases. Fertil Steril. 2003;80:199–202. 8. Van Kerkvoorde TC, Veersema S, Timmermans A. Long-term complications of office hysteroscopy: analysis of 1028 cases. J Minim Invasive Gynecol. 2012;19:494–497. 9. Bettocchi S, Nappi L, Ceci O, Selvaggi L. What does ‘diagnostic hysteroscopy’ mean today? The role of the new techniques. Curr Opin Obstet Gynecol. 2003;15:303–308. 10. Di Spiezio Sardo A, Bettocchi S, Spinelli M, et al. Review of new office-based hysteroscopic procedures 2003-2009. J Minim Invasive Gynecol. 2010;17:436–448.
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