Ultrasound-Guided Hysteroscopic Lysis of Adhesions in Severe Asherman’s Syndrome

INTRODUCTION: Intrauterine adhesions can form inside the uterus due to injury of the basalis layer of the endometrium. The exact prevalence is unknown as many patients are asymptomatic and diagnosis often requires invasive procedures. Estimates of prevalence range from 1.5% of women undergoing hysterosalpingograms, to 21.5% of women who have a postpartum dilation and curettage, to 45% of women who have hysteroscopic myomectomy of multiple fibroids. The clinical presentation can include abnormal uterine bleeding, secondary amenorrhea, infertility, recurrent pregnancy loss, and pelvic pain. When symptomatic, these adhesions are called Asherman’s syndrome. Hysteroscopic lysis of adhesions is the primary treatment and often multiple procedures are required to serially treat recurrent adhesions. Postoperative estrogen therapy and intrauterine balloons have been studied as methods to prevent recurrent adhesions, but the data is inconclusive regarding their benefits. Hysteroscopic procedures rely on intrauterine landmarks, such as tubal ostia, to guide the dissection and reach the goal of a normal cavity contour. In severe Asherman’s syndrome, intrauterine landmarks may be obscured, or the cavity can be completely obliterated, making these procedures technically challenging. OBJECTIVE: To demonstrate ultrasound-guided hysteroscopic surgical techniques used to manage a case of severe, refractory Asherman’s syndrome. METHODS: Step-by-step educational video reviewing Asherman’s syndrome, presenting a clinical case, and demonstrating a complex ultrasound-guided hysteroscopic lysis of adhesions. RESULTS: A hysteroscopic lysis of adhesions is performed in this video under ultrasound. guidance. The procedure took place in the operating room with the following key steps: (1) backfilling the bladder for optimal ultrasound views, (2) developing the intrauterine cavity cephalad on a horizontal plane, (3) developing the lateral walls of the uterine cavity to create expected, triangular cavity contour, (4) using continuous ultrasound imaging to confirm the uterine axis and correct depth of dissection, (5) intermittently assessing the developed cavity from the internal os, and (6) placing an intrauterine pediatric Foley catheter. The patient removed the Foley 7 days postoperatively, took 4 mg estradiol twice a day, and had a planned repeat office hysteroscopy 4 weeks after the procedure. This hysteroscopy demonstrated maintenance of the surgically developed cavity and new growth of pink endometrial tissue. The left lateral aspect of the cavity required additional adhesiolysis, and the patient will follow up in another 4 weeks for office hysteroscopy. CONCLUSIONS: Severe Asherman’s syndrome can be challenging to manage. Intraoperative ultrasound guidance is useful to guide the hysteroscopic dissection when intrauterine landmarks are absent. Providers should consider the use of estrogen therapy and an intrauterine balloon in severe or refractory cases of Asherman’s syndrome. Repeat hysteroscopy is important to assess endometrial regrowth, recurrent adhesions, and to serially lyse adhesions until the cavity is normalized.