Perfusion magnetic resonance imaging in Asherman syndrome.

BACKGROUND: Microvascular scarring compromises the functionality of the endometrium, and vascular flow at the junctional zone (JZ) may be the key to understanding poor reproductive outcomes in women with Asherman syndrome (AS). AIMS: To investigate whether vascular perfusion of the uterus, measured by dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) is impaired in women with intrauterine adhesions (IUA) and AS. MATERIALS AND METHODS: A prospective observational cohort pilot study of 23 women with IUA treated with hysteroscopic synecholysis and a control group of two patients with cervix cancer were subject to DCE-MRI with gadolinium to assess uterine vascularity. Twelve regions of interest (ROIs) were allocated on the DCE-MRI image incorporating the JZ, with control ROI placed at the psoas muscle. Individual ROIs were compared to the mean total perfusion (TP) in the same uterus. Pre- and post-operative perfusion analyses were performed on five women. Receiver operator curves (ROC) were used to analyse MRI as a predictor of IUA. RESULTS: There was no significant difference in perfusion; a trend toward reduced perfusion was observed in women with IUA compared to the controls. The ROC was predictive of higher-grade and inoperable IUA. CONCLUSIONS: Reduced perfusion on DCE-MRI as assessed by ROC predicted higher-stage AS. The results of this study support further investigation of DCE-MRI as a prognostic tool for AS prior to surgical intervention to assist in providing prognostic guidance for women suffering from AS.

MRI for Diagnosing Intrauterine Adhesions.

OBJECTIVES: To prospectively assess the diagnostic accuracy of MRI and transvaginal ultrasound (TVS) as well as the prognostic value of MRI for intrauterine adhesions (IUAs), using hysteroscopy as the reference standard. DESIGN: Prospective observational study. SETTING: Tertiary medical centre. PATIENT(S): Ninety-two women with amenorrhea, hypomenorrhea, subfertility, or recurrent pregnancy loss who underwent MRI and in whom Asherman's syndrome was suspected upon TVS. INTERVENTION(S): MRI and TVS were conducted approximately 1 week before hysteroscopy. METHODS: Ninety-two patients suspected of having Asherman's syndrome were examined by MRI and TVS within 7 days of an upcoming hysteroscopy. All hysteroscopy procedures were performed during the early proliferative phase of the menstrual cycle. All hysteroscopic diagnoses were performed by an experienced expert. All MRIs were read by 2 experienced, blinded radiologists. RESULTS: MRI was highly accurate (94.57%), sensitive (98.8%), and specific (42.9%) for diagnosing IUAs with a positive predictive value of 95.5% and a negative predictive value of 75%. The diagnostic values of MRI and TVS were significantly different according to McNemar tests. Junctional zone signal and junctional zone alterations correlated with the stage of IUAs. CONCLUSION: MRI is markedly superior to TVS in terms of diagnostic accuracy for IUAs, with total agreement with hysteroscopic findings. However, the main advantage of MRI is that, unlike TVS and hysterosalpingography, it can be used to assess the risk of hysteroscopy and to predict postoperative recovery and future pregnancy based on the uterine junctional zone.

Hysterosalpingography versus hysterscopy in intrauterine pathology research of infertile patients.

BACKGROUND: The objective of the present paper is to confirm the validity and reliability of hysterosalpingography (HSG) in intrauterine pathology research of infertile female patients by comparing the hysteroscopy (HC) findings to a "gold standard" test. AIM: To analyze HSG and HC findings in infertility patients. MATERIALS AND METHODS: The research was conducted as a prospective study at the Gynecological and Obstetrics Clinic "Narodni front" in Belgrade. RESULTS: HSG indicated pathological findings in 72.5% of patients whereas HC revealed abnormalities of uterine cavity in 77.5%. In 12.5% of patients, HSG demonstrated a normal uterine cavity, and HC confirmed pathological findings, while in 7.5% of patients with filling defects and irregular shapes on HSG images, HC reported normal findings. In 22.5% of patients normal finding as well as endometrial polyps were reported; congenital malformations (anomalies) were found in 32.5%, submucosal myomas in 12.5% and Asherman's syndrome in 10%. CONCLUSION: HC finding was crucial in final diagnosing.

A rare case of Asherman's syndrome after open myomectomy: sonographic investigations and possible underlying mechanisms.

AIMS: To present a study on severe Asherman's syndrome after open myomectomy and investigate the possible reasons for this outcome. METHODS: This study involves a rare case of a 38-year-old nulliparous woman who underwent a relatively minor and straightforward open myomectomy in a university hospital setting, during which the uterine cavity was not entered and there were no post-operative complications. Post-operatively the patient had oligomenorrhoea for over a year. The patient was investigated with three-dimensional power Doppler angiography of the uterus and underwent diagnostic/operative hysteroscopy. Main outcome measures were to sonographically assess the blood flow and vascularisation throughout the uterus and to hysteroscopically confirm diagnosis of Asherman's syndrome and treat the patient at the same time. RESULTS: Sonographically there was reduced perfusion in the outer part of the uterus and the scarred areas of the endometrium. Upon hysteroscopic confirmation of diagnosis, the division of adhesions led to a normal sized uterine cavity. CONCLUSIONS: Among the predisposing and causal factors that have been implicated in post-operative adhesion formation, endometrial trauma, infection and tissue hypoxia are considered the most important. This case supports a role for tissue hypoxia in the development of Asherman's syndrome after open myomectomy.

Role of 3D sonohysterography in the investigation of uterine synechiae/asherman's syndrome: pictorial assay.

Several imaging methods have been applied for evaluation of suspected uterine synechiae; however, sonohysterography is yet recognised as a valid and accurate modality. Performing three-dimensional (3D) imaging along with sonohysterography enables evaluation of the uterus in the coronal plane to detect and grade the adhesions that characterise this condition. Thus, 3D sonohysterography is a minimally invasive and cost-effective tool for investigating suspected synechiae and is particularly useful when the transvaginal sonography findings are normal.

Total adhesions treated by hysteroscopy: must we stop at two procedures?

OBJECTIVE: To study the anatomic and fertility results after treatment for Asherman syndrome involving more than two separate surgical procedures. DESIGN: Retrospective case series. SETTING: Tertiary center. PATIENT(S): Twenty-three women who had Asherman syndrome and required more than two hysteroscopic operative procedures. INTERVENTION(S): Third or higher-order operative hysteroscopy procedure. MEAN OUTCOME MEASURE(S): Fertility rate. RESULT(S): The women's mean age was 34 years (± 5.8 years) when treatment for adhesions began. All women initially had adhesions classified as severe with total amenorrhea. Twelve patients had three separate procedures to treat the adhesions, nine had four treatments, and two had five treatments. One woman was lost to follow-up. At the conclusion of treatment, more than 80% of the women had either no adhesions at all or only mild adhesions. The overall pregnancy rate was 40.9%; there were nine pregnancies and six term infants (27.2%). All but one of these pregnancies were spontaneous. The mean time to pregnancy was 10.5 months (± 4.7 months). CONCLUSION(S): The number of hysteroscopic procedures envisioned to treat Asherman syndrome should not be a limiting factor. It is appropriate to treat women, especially those younger than 35 years, until uterine anatomy permits the visualization of both ostia.

Ultrasound is the optimal choice for guidance in difficult hysteroscopy.

OBJECTIVES: To compare costs and complications associated with ultrasound-guided hysteroscopy vs laparoscopy-guided hysteroscopy vs hysteroscopy alone for the surgical repair of intrauterine septa and synechiae. METHODS: This was a retrospective cohort study. Charts of all patients undergoing reparative surgery for intrauterine synechiae or uterine septa at our academic institution between 2000 and 2008 were reviewed. A total of 159 procedures were included in the study, categorized into concurrent laparoscopic guidance (n = 69), ultrasound guidance (n = 52) or no guidance (n = 38). Data regarding billing, surgical case logs and complications were collected for these procedures. Using these data, complication rates and inflation-adjusted charges were compared between the groups. Statistical analysis was performed using Fisher's exact test and Student's t-test, as appropriate. RESULTS: A uterine perforation rate of 8.7% was observed with laparoscopic guidance vs 1.9% with ultrasound guidance (P = 0.12) and 5.3% with no guidance (P = 0.41). Analysis of billing data showed that average total costs were significantly less for ultrasound guidance than for laparoscopic guidance ($9124 vs $11 895, P < 0.001). Ultrasound guidance did not increase costs over hysteroscopy alone ($9124 vs $8242, P = 0.54). CONCLUSION: Real-time transabdominal ultrasound guidance during the resection of intrauterine synechiae or septa resulted in a trend towards reduced uterine perforation. Moreover, ultrasound guidance is less costly than laparoscopic guidance and adds no additional cost over hysteroscopy alone. Taken together, transabdominal ultrasound guidance is the optimal means of intraoperative guidance for the resection of uterine synechiae and septa.

Placenta accreta: an association with fibroids and Asherman syndrome.

OBJECTIVE: Placenta accreta is a life-threatening problem that is rising in incidence in the developed world. The increased risk of placenta accreta in women with placenta previa and 1 or more prior cesarean deliveries is well established and prompts careful sonographic evaluation. Our objective was to emphasize that accreta is also identified at sites other than cesarean scars. METHODS: Two cases of placenta accreta without placenta previa seen in association with uterine scarring from myomectomy and uterine fibroids are described. RESULTS: The sonographic and magnetic resonance imaging findings of accreta are reviewed in the classic setting of prior cesarean deliveries as well as myomectomy and uterine fibroids. CONCLUSIONS: We suggest that when the placenta overlies any uterine abnormality, a careful search for invasive placentation is warranted.

Balloon fluoroscopy as treatment for intrauterine adhesions: a novel approach.

OBJECTIVE: To report a unique fluoroscopically guided approach to treat severe intrauterine adhesions and cervical stenosis using balloon hysteroplasty. DESIGN: Case report. SETTING: Military-based fertility center. PATIENT(S): A 33-year-old woman undergoing assisted reproductive technology whose uterus could not be cannulated because of the development of intrauterine synechiae and cervical stenosis after a post-IUI infection that was further complicated by a prominent lower uterine segment-filling defect in the location of a prior cesarean delivery scar. INTERVENTION(S): Fluoroscopic cannulation and balloon uterine dilation. MAIN OUTCOME MEASURE(S): Resolution of synechiae by hysterosalpingogram and successful uterine cannulation. RESULT(S): A postprocedure hysterosalpingogram demonstrated a normalized uterine cavity with the exception of a persistent prominent lower uterine segment-filling defect from a prior cesarean delivery. A frozen ET cycle was performed successfully. CONCLUSION(S): Hysteroplasty, using standard interventional radiographic techniques, may provide an alternative treatment modality for patients with intrauterine adhesions and lower uterine defects from prior cesarean deliveries in select cases. While treating intrauterine adhesions improves pregnancy outcome, the effect of lower uterine segment-filling defects from cesarean deliveries on pregnancy outcome in assisted reproductive technology cycles warrants further investigation.

Endometrial thickness measured by ultrasound scan in women with uterine outlet obstruction due to intrauterine or upper cervical adhesions.

BACKGROUND: A subgroup of women with Asherman's syndrome has adhesions of limited extent completely blocking the lower uterine cavity or upper cervix, whereas the upper endometrium remains normal. Haematometra are rarely found in these women. We tested the hypothesis that women with localized adhesions occluding the uterine outlet (but not affecting the upper uterine cavity) will have much thinner endometrium than controls. METHODS: Twenty-six women with Asherman's syndrome (16 with limited outlet adhesions only) and 50 with normal menstrual cycles underwent transvaginal ultrasound scan where endometrial double thickness was measured precisely and the cycle phase assessed. The presence of any fluid in the uterine cavity was noted. RESULTS: The endometrium in women with Asherman's syndrome, in whom uterine outlet blockage was the sole abnormality (subgroup 3), was substantially thinner (mean +/- SEM: 3.9 +/- 0.4 mm) than controls (8.5 +/- 0.05; P < 0.001), and haematometra were very uncommon (1 of 16). Endometrial thickness at all stages of the ovarian/menstrual cycle in all three subgroups of Asherman's syndrome was significantly less than in normal menstruating controls. CONCLUSIONS: Non-invasive ultrasound measurements have demonstrated very thin endometrium and absence of haematometra in most women with uterine outlet occlusion by adhesions. This unusual phenomenon of failure of cyclical endometrial growth and breakdown in the sole presence of cervical occlusion by adhesions merits further study.

Value of 3D ultrasound in the management of suspected Asherman's syndrome.

OBJECTIVE: To assess the value of 3-dimensional (3D) ultrasound in the management of patients with suspected Asherman's syndrome. STUDY DESIGN: A case series of 54 infertile patients who presented to a tertiary care center between 1998 and 2004 with suspected Asherman's syndrome underwent both hysterosalpingography and 3D ultrasound prior to hysteroscopy. Sensitivity and the ability to attain fertility postoperatively were calculated. RESULTS: Intrauterine adhesions (IUAs) were demonstrated on 3D ultrasound and HSG in all cases and confirmed by hysteroscopy. However, 3D ultrasound had a sensitivity of 100% and HSG a sensitivity of 66.7% for correctly grading the extent of IUAs. In 61.1% of cases in which HSG results were inconsistent with hysteroscopy, lower uterine segment outflow obstruction was present, and HSG misclassified findings as severe Asherman's with complete cavity obstruction. Postoperatively, 90% of patients conceived. CONCLUSION: 3D ultrasound provides a more accurate depiction of adhesions and extent of cavity damage than HSG in patients with suspected Asherman's syndrome, particularly when differentiating severe IUAs from lower uterine segment outflow obstruction. Therefore, grading systems utilizing HSG to classify severity of disease should be revised to include 3D ultrasound findings.

Vaginal calculus secondary to vaginal outlet obstruction.

Primary vaginal stones are extremely rare and are often mistaken for bladder calculi on plain radiography. However, intravenous pyelography and sonography can help differentiate between the two. We report a case of a large vaginal stone in a 21-year-old woman referred for apareunia and difficult micturation. The clinical findings of vaginal outlet obstruction and a hard mass anterior to the rectum made us suspect a bladder calculus; however, sonography of the pelvis indicated that the mass was in the vagina. Further examination using a probe to physically define the stone's location confirmed it to be a vaginal calculus. Surgery was performed to repair the outlet obstruction and remove the stone, which permitted the woman to urinate normally and engage in normal sexual relations.