Synechia after scraping. Intrauterine synechia and their treatment. Stages of disease development

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To begin with, let's define a new term - synechia. Synechia is a pathological fusion of the surfaces of the same organ or adjoining surfaces of different organs.

The frequency of intrauterine synechia in women with infertility is 55%. More often this pathology is combined with tubal-peritoneal factor of infertility.

The mechanism of infertility in uterine synechia

As we know, the uterine cavity is the abode of an intrauterine developing baby. Therefore, a violation of the anatomical structure of the uterus causes difficulty in the implantation of a fertilized egg and the development of pregnancy.

Causes of occurrence:

Without injury to the endometrium, the formation of synechia in the uterine cavity, even in the presence of inflammation, is almost impossible. Adhesions in the uterine cavity occur as a result of mechanical action on the basal layer of the endometrium, which most often occurs during curettage, especially in the early postpartum period. Intrauterine synechia can be the result of surgical interventions, the presence of foreign bodies in the uterus (intrauterine device, the remains of fetal fragments after an abortion), as well as irrational medical manipulations in the uterine cavity (intrauterine administration of various medications for therapeutic purposes).

The second most important factor in the formation of intrauterine synechia is chronic endometritis. In women with primary infertility and the absence of any manipulations in the uterine cavity in the past, intrauterine synechia is the result of only one specific pathological process - tuberculous endometritis.

Diagnostics

Clinical picture and complaints:

Important information for a gynecologist is the past curettage of the uterine cavity due to artificial or spontaneous abortions, as well as other medical intrauterine manipulations. Women with synechia in the uterine cavity often complain of pain in the lower abdomen, aggravated during menstruation. The intensity of pain can be different. Greater intensity of pain is achieved with synechia localized in the lower third of the uterus and the cervical canal, which makes it difficult to discharge menstrual flow. If the outflow of the menstrual discharge is not disturbed, the pain is not expressed.

Complaints about the change in the nature of menstruation are made by many patients with intrauterine synechia. Menstruation becomes less abundant and shorter. With significant lesions of the endometrium - pass in the form of a "daub". In especially severe cases, with complete infection of the uterine cavity or cervical canal, menstruation disappears (uterine form). In patients with atresia (fusion) of the cervical canal and the absence of a complete lesion of the endometrium, with normal ovarian function, there are complaints of cyclic pains in the lower abdomen that repeat every month on the days of the expected menstruation.

Instrumental research methods:

X-ray methods: performed by the method of hysterosalpingography - with the introduction of contrast into the uterine cavity and a series of radiographic images. Signs of synechia are filling defects or complete lack of filling of the uterus with contrast.

ultrasound. The diagnostic value of ultrasound for detecting intrauterine synechia is 60-70%. For women with amenorrhea and suspected intrauterine synechia, it is better to have an ultrasound scan on the days of the expected menstruation, and with a saved menstrual cycle twice: on the 8-12th day of the cycle and at the end of the cycle. With ultrasound, synechia can look like constrictions that deform the uterine cavity.

echohysterosalpingoscopy. After the expansion of the uterine cavity with a liquid medium, intrauterine synechia is visualized as hyperechoic inclusions, constrictions that deform the cavity. The diagnostic value of the method in identifying intrauterine synechia reaches 96%.

Magnetic resonance imaging. If necessary, it can be used to diagnose intrauterine synechia.

Hysteroscopy. If synechia is suspected, it is carried out in a hospital in the first phase of the menstrual cycle. During this period, against the background of a thin endometrium in the uterine cavity, intrauterine synechia is clearly visible.

Treatment

Medical preoperative preparation

Only surgical treatment is effective, however, preoperative preparation and postoperative treatment are performed with medication.

Preoperative preparation. The purpose of preoperative preparation for hysteroresectoscopy is to create reversible atrophy of the endometrium to ensure optimal conditions for surgical intervention. It is carried out by hormonally active drugs that affect the state of the endometrium. The growth and maturation of the endometrium is suppressed.

Surgical intervention
A surgical operation to eliminate the intrauterine adhesive process and restore the patency of the uterine cavity is called hysteroresectoscopy. This operation is performed with the help of special endoscopic equipment by transvaginal access.

Postoperative treatment

Early rehabilitation treatment begins from the first day of the postoperative period, using physical and medical methods.

Antibacterial therapy is indicated in the early postoperative period.

Physiotherapy improves healing processes, increases local immunity, prevents the formation of new intrauterine synechia and the development of adhesions in the pelvis. Treatment begins no later than 36 hours after surgery. They use an alternating low-frequency magnetic field, a constant magnetic field, overtone frequency currents, and laser exposure.

What treatment is prescribed after the operation?

A second course of physiotherapy begins on the 5-7th day of the menstrual cycle following the operation. The number of physiotherapy courses is determined individually. If necessary, spend up to three courses with an interval between them of at least 2 months.

Cyclic or hormone replacement therapy (HRT). It is produced in the treatment of women with intrauterine synechia that arose against the background of a chronic inflammatory process. HRT contributes to the full restoration of the uterine mucosa and its full rejection during menstruation, prevents the re-formation of synechia in the uterine cavity, improves metabolic processes in the tissues of the uterine endometrium, which creates a favorable environment for pregnancy.

Immunomodulators are selected taking into account the indicators of immune and interferon status, determined before the start of surgical and drug treatment.

After the end of the rehabilitation treatment, an additional examination is carried out, which consists in assessing the state of the uterine cavity. According to the X-ray examination, echohysterosalpingoscopy or control hysteroscopy, an objective picture of the results achieved is compiled. In cases of incomplete separation of intrauterine synechiae, repeated surgical intervention and subsequent conservative complex treatment are performed.

In the absence of pathological changes in the uterine cavity, the patient is observed for 6 months (the period of expectation of pregnancy). Dynamic observation involves the control of ovulation and ultrasound monitoring of the state of the endometrium during the menstrual cycle.

Expectant management for 6 months is indicated if ovulation is present, the male is not infertile, and the menstrual cycle is adequate. In case of discrepancy between the ultrasonic parameters of the endometrium and the abundance of menstrual flow, it is necessary to repeat the therapeutic effect aimed at improving the trophic processes in the uterus (physiotherapy and hormonal treatment).

If ovulation defects are detected, it is stimulated for four consecutive cycles. If pregnancy has not occurred within the specified period of time, an additional examination is necessary to identify and analyze the reasons for unsuccessful treatment.

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 triggered 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!

Various pathological processes in the organs, even after their complete cure, can leave some complications and consequences. It is these unpleasant complications of inflammatory (most often) processes that include synechia, which can form in the uterine cavity.

What is synechia in the uterine cavity? Synechia is the medical name for adhesions, which are neoplasms of inextensible connective tissue that are formed as a result of inflammatory processes and are able to tighten organs, deform them, block their lumen, etc.

You can often hear that in the context of this topic, such a diagnosis as Asherman's Syndrome is mentioned. What it is? This is a disease that occurs only in women and is an adhesive process (the presence of synechia in the uterus).

Most often, this condition develops as complications after pathological and even medical processes. Among them:

1. Inflammatory processes;
2. infectious processes;
3. Processes with the formation of exudate;
4. Surgical interventions, cleanings, abortions (if we are talking about the uterus, etc.).

From a technical point of view, the process of formation of adhesions is associated with the fact that the tissue affected during the pathological process or surgical intervention begins to be replaced by another. In such processes, fibrous connective tissue is always formed (it also forms, for example, scars and scars), which does not have any functions.

This pathological process can be classified in different ways. There are several types of classifications depending on the tissue composition of synechiae, their location, and the degree of development of the process. Such a system of classifications allows doctors to better navigate the process, and is also important for determining the optimal method of treatment.

There are three types of synechia according to tissue composition. They correspond to the three stages of the syndrome.

1. The mild stage is characterized by the presence of adhesions from the epithelial tissue. They are thin and easily dissected;
2. The middle stage is characterized by the presence of more dense, fibromuscular neoplasms, densely germinated to the endometrium. They are more difficult to dissect, they bleed when damaged;
3. The severe stage is distinguished when the synechiae are dense, consist of connective tissue and are difficult to dissect.

In principle, any stage can be cured surgically, but the volume and complexity of the intervention will be different.

In this case, we are talking about how much of the cavity is involved in the process.

• The first type is characterized by the involvement of up to 25% of the uterine cavity, the orifices of the tubes are not affected;
• The second type is distinguished when from 25 to 75% of the cavity is involved, the mouths are slightly affected, there is no adhesion of the walls;
• The third type - more than 75% of the cavity is involved, the mouths are affected, there may be sticking of the walls and deformation of the organ.

From the point of view of pregnancy, any type of pathology is undesirable, however, with the third type, conception is also very unlikely.

This is an international classification used by the Association of Gynecologists-Endoscopists. According to her, 6 stages of the syndrome are distinguished.

• I - thin films that are destroyed upon contact with the hysteroscope;
• II - denser films, often single;
• II-a - localization inside the uterine os, when the upper sections are not affected;
• III - dense multiple areas, mouths are affected;
• IV - signs of the third stage are supplemented by partial occlusion of the cavity;
• V - signs of all other stages, as well as the presence of scars on the walls.

This classification is used only in the context of surgery.

Signs that synechia has formed in the uterus may be different. But most often it is a stable pain syndrome, which occurs mainly during physical exertion or placing the body in a certain position.

In addition, this is possible with a full bladder and during menstruation. The pains are sharp and sharp, of high intensity, or aching. Usually, they increase with physical inactivity - in this case, they can begin to appear even at rest.

Depending on the location of the formations, there may be problems with conception, up to infertility, urination disorders. Possible violation of the outflow of menstrual blood /. Violation of defecation, etc.

Synechiae have a density different from other uterine tissues, therefore they are easily visualized during ultrasound examination. During the ultrasound, it is possible to determine both the actual location of their location, and the degree of closeness of the organ by them, how deformed it is, etc.

If it is necessary for diagnostic purposes to take tissues of synechia for histology, then this is done during hysteroscopy. The same method can also be used to examine the uterine cavity for diagnostic purposes (if there are no obstacles to the penetration of equipment into its cavity).

Synechia in the uterine cavity is a serious problem during pregnancy. This is due to the fact that these inextensible ties actually fix the organ in a static state. Thus, the walls of the uterus are at a fixed distance from each other.

As the fetus grows, the organ enlarges and stretches, with adhesions this leads to severe pain, hypertonicity of the organ, and as a result, miscarriage or abortion for medical reasons. If such a recommendation is neglected, then theoretically even a rupture of the organ can occur.

In addition, adhesions can be placed in such a way that they deform the fetus, allow it to grow, and put pressure on it. The resolution of pregnancy in this case will be the same as described above. Although most often in the presence of adhesions, the onset of pregnancy is difficult.

If they are present in the uterus, then the fetus is poorly attached, and if it is attached, then miscarriages occur in the early stages. But more often there are problems even at the stage of conception - the cervical canal or fallopian tubes can be closed by adhesions.

However, after the removal of synechia, pregnancy can be planned. Usually, depending on the individual characteristics of the body and the volume of the operation, the doctor recommends starting attempts at conception six months to a year after removal.

Treatment of this condition is carried out in several ways and, most often, in a complex way, that is, several of them are used at once. All methods can be divided into two large groups - radical and conservative.

The following conservative methods of influence are most often used:

• Gynecological massage. The method is especially good for thin adhesions, which have minimal elasticity and are small in size. During the massage, they are mechanically stretched, as a result of which the organ and / or its parts return to their normal physiological positions, the organ lumens open. That is, in fact, the spike remains in place, but no longer causes discomfort. The method is not suitable for those who are going to give birth in the future, and is also ineffective when adhesions are located in the mouths of the fallopian tubes, cervical canal, etc .;
• Physiotherapy by methods of microwave and / or UHF exposure is indicated in the same cases as gynecological massage. Often these two methods are used together. Exposure to microwaves leads to the fact that small adhesions dissolve, those that are larger become more elastic and stretch more during the massage. The method is used as an additional method for both radical and conservative treatment;
• Therapeutic gymnastics is a special set of physical exercises that is developed by a physiotherapy doctor and is aimed at gradually stretching small adhesions so that they no longer cause discomfort. That is, this method, according to the principle of action, is similar to gynecological massage. In addition, it has the same indications, contraindications and scope. Most often, physiotherapy, gymnastics and massage are prescribed together with a slight degree of development of the pathology.

All methods of conservative therapy are used in combination with a mild severity of the process. They are not suitable for those who are planning a pregnancy after the removal of synechiae in the uterus, since they do not actually remove adhesions, but only make them so that they do not cause discomfort for a given organ size.

But with an increase in the uterus, they will again make themselves felt. An exception can be called physiotherapy - in rare cases, this method contributes to the complete resorption of small adhesions, but often its effectiveness is not enough to completely cure.

The radical method of treatment involves surgical intervention. It involves the introduction of a scalpel into the uterus and direct dissection of the adhesions. In some cases, their complete removal is also necessary.

Such an intervention may have a different level of severity depending on which method it was performed, and the choice of method, in turn, depends on the structural features of the uterus, the location of adhesions in it, their size, etc.

Such an intervention is almost never performed laparotomically, since in most cases it is pointless, because as a result of such an operation, new adhesions can form. Sometimes it is performed laparoscopically, when micro-instruments and a camera are inserted through punctures in the abdominal wall and the wall of the uterus with a diameter of 1.5 cm, and with the help of them, an operation is performed on the image from the camera that appears on the screen.

The least traumatic and most desirable method is hysteroscopic incision, during which the hysteroscope tube is inserted into the uterine cavity through the cervical canal. Instruments and a camera are inserted through the tube and an intervention is performed. While this method is preferred, it may not be suitable for all adhesion locations.

Such a dissection of synechia in the uterus is usually supplemented by a course of physiotherapy. Also, therapeutic exercises and gynecological massage can be used during the recovery period and after it.

What happens if treatment is not carried out? The following consequences are possible:

1. Persistent pain syndrome;
2. Violation of the work of organs and systems located nearby;
3. Deformation of the organ;
4. His injuries and injuries;
5. Synechia in the uterus during pregnancy leads to miscarriage or abortion for medical reasons;
6. Infertility.

What is intrauterine synechia (fusion)

There are several theories as to why intrauterine synechia occurs. They are conditionally divided into:

1. Traumatic. Here are considered the reasons that led to the mechanical trauma of the uterine cavity. It can be difficult childbirth, abortion, various operations on the uterus. If an infection still penetrates here, then it becomes a secondary factor influencing the development of the disease. If a woman had a "frozen" pregnancy, then the disease is also possible, since the placenta could not completely leave the uterus, which contributes to various processes before the regeneration of the endometrium (the inner layer of the uterus).

Other mechanical damage to the walls of the uterus include the following reasons: hysteroscopy, various therapeutic or diagnostic curettage, myomectomy, conization of the cervix, metroplasty, severe endometritis, insertion or removal of intrauterine devices, installation of the Mirena system.

1. Neurovisceral.
2. Infectious. If an infection enters the uterine cavity, then an inflammatory process develops. The exudate becomes viscous, appears in large quantities, "glues" the uterus and forms strands. Tuberculosis is one of the most common infections.

Depending on the tissues due to synechia, the following types of synechia are distinguished:

• The lungs are the mucous membranes of the basal layer, which have a filmy appearance, thin and very tender.
• Medium - consist of epithelial cells, muscle and fibrous fibers.
• Heavy - the most dense, because they consist of connective tissue.

Dangerous periods are considered a few weeks after childbirth and abortion, when the endometrium is restored against the background of an extensive wound. The placenta comes out, the uterine cavity is restored. If there are no various damages, then the process ends favorably.

The most dangerous is a “frozen” pregnancy, since there are both curettage processes and a long period of placenta release, which partially remains and starts the painful process.

Such adhesions can be congenital in nature, when the pathology develops already in the womb. In this case, the causes of the development of synechia can be choanal atresia and syphilis, adhesions are formed on the back wall of the nasal passages.

Adhesions (synechia) can form in different parts of the nasal cavity and in the nasal passages. It is noteworthy that if the fusion is small, then no complaints are received from a sick person. But if synechia captures a large area of ​​​​the nasal cavity, then the symptoms will be:

• constant tinnitus;
• persistent nasal congestion;
• lack or partial decrease in sense of smell;
• constant formation of crusts on the mucous membrane in the nasal passages.

Against the background of synechia in the nose, pharyngitis, pneumonia, bronchitis and other diseases of the respiratory system can develop. Spikes close the nasal passages, which provokes complete nasal congestion. The result of this is breathing through the mouth - dirty and cold air, passing through the throat, causes the development of laryngitis and tonsillitis, which occur in a chronic form.

Diagnosis of synechia in the nasal cavity is based not only on the patient's complaints - the symptoms of this disease are too non-specific. The doctor will be able to make an accurate diagnosis only after performing rhinoscopy, probing the nasal cavity and probing the nasopharynx.

Synechia in girls

This disease most often occurs in girls, can solder together not only the labia, but also the entrance to the vagina. If the labia are completely fused together, then the urethra will also close - problems with urination in girls will be guaranteed.

Synechia of the labia, vulva and vagina occurs against the background of inflammatory and / or infectious diseases of the internal and external genital organs, excessive or insufficient hygiene, and an allergic reaction.

Regarding violations of hygiene rules, it should be emphasized that not only the insufficiency of procedures leads to synechia, but also excessiveness. The fact is that in girls the vulva is covered with a very delicate layer of a protective “film”, and its friction leads to the formation of microtraumas. Such damage is a direct path to the penetration of infection.

The allergy factor in the development of the disease in question "works" only if the girl is allergic to some products or substances, and they are constantly present in her life - the external genitalia swell, become more vulnerable.

Synechia of the vagina, labia and vulva is considered a rather dangerous disease, because it has the ability to quickly turn into a chronic form of the course. The result of this will be the improper development of the genital organs, and in the future this may affect the reproductive function.

Synechia in boys

Quite often in boys, the appearance of synechia between the glans penis and the foreskin is noted. In principle, doctors do not attribute this phenomenon to some dangerous pathologies and prefer not to treat, but to take a wait-and-see attitude.

Due to synechia, boys have problems with exposing the glans penis - many parents mistake this for phimosis, but doctors quickly differentiate these two diseases. At the age of 3-4 months, boys begin to produce smegma - a whitish discharge that accumulates under the foreskin.

Please note: normally, synechia in boys disappear by adolescence - at 11-12 years old, the tissue of these adhesions becomes loose and the glans penis is freely exposed.

According to statistics, synechia in boys does not lead to any serious consequences.

In an adult woman, synechia can form in the uterine cavity - there is an fusion between the walls of this hollow organ. Such a disease is usually diagnosed against the background of frequent abortions and diagnostic curettage, after a difficult birth and surgical interventions on the uterus.

The primary symptoms of synechia in the uterine cavity will be menstrual irregularities and pain during or after intercourse. These signs are nonspecific and are not a reason for diagnosing exactly synechia.

The doctor will send the woman for a full examination and during the ultrasound examination, the adhesions will be confirmed. The size, extent of adhesions in the uterine cavity can be determined using hysterosalpingography.

If synechia in the uterus was diagnosed in a woman who has not yet given birth, then this can become an obstacle to conception and the normal course of pregnancy.

Intrauterine synechia (fusion), or the so-called Asherman's syndrome, consists in partial or complete infection of the uterine cavity.

There are infectious, traumatic, neuro-visceral theories of the occurrence of intrauterine synechia. The main factor is considered to be mechanical trauma to the basal layer of the endometrium after childbirth or abortion (wound phase), and infection serves as a secondary factor.

The occurrence of intrauterine synechia is most likely in patients with missed pregnancy. After curettage of the uterine cavity, they are more likely than patients with incomplete abortion to develop intrauterine synechia, which is associated with the fact that the remnants of placental tissue can cause fibroblast activation and collagen formation before endometrial regeneration. Intrauterine synechia develops in 5-40% of patients with recurrent miscarriages.

Intrauterine synechia can occur after surgical interventions on the uterus: myomectomy, metroplasty or diagnostic curettage of the uterine mucosa, conization of the cervix, as well as after endometritis. This pathology can also provoke an intrauterine contraceptive.

Classification. There are several classifications of intrauterine synechia.

According to the histological structure, O. Sugimoto (1978) distinguishes 3 types of intrauterine synechia:

• lungs - synechia in the form of a film, usually consisting of a basal endometrium, are easily dissected with the tip of a hysteroscope;
• medium - fibromuscular, covered with endometrium, bleed during dissection;
• heavy - connective tissue, dense synechiae, usually do not bleed during dissection, are dissected with difficulty.

According to the prevalence and degree of involvement of the uterine cavity, C. March, R. Israel (1981) proposed the following classification:

• I degree - less than 1/4 of the uterine cavity is involved, thin adhesions, the bottom and mouths of the tubes are free;
• II degree - from 1/4 to 3/4 of the uterine cavity is involved, there is no adhesion of the walls, only adhesions, the bottom and mouths of the tubes are partially closed;
• III degree - more than 3/4 of the uterine cavity is involved.

Since 1995, the classification adopted by the European Association of Gynecologists-Endoscopists (ESH) has been used in Europe, with the allocation of 5 degrees of intrauterine synechia based on hysterography and hysteroscopy data, depending on the condition and length of synechia, occlusion of the orifices of the fallopian tubes and the degree of damage to the endometrium:

• I degree. Thin or delicate synechia - easily destroyed by the body of the hysteroscope, the area of ​​​​the mouth of the fallopian tubes is free.
• II degree. Single dense synechia - connecting separate, isolated areas of the uterine cavity, the mouths of both fallopian tubes are usually visible, cannot be destroyed only by the body of the hysteroscope.
  • IIa degree. Synechia only in the area of ​​the internal pharynx, the upper parts of the uterine cavity are normal.
• III degree. Multiple dense synechia - connecting separate isolated areas of the uterine cavity, unilateral obliteration of the area of ​​​​the mouths of the fallopian tubes.
• IV degree. Extensive dense synechia with (partial) occlusion of the uterine cavity - the mouths of both fallopian tubes are partially closed.
  • Va degree. Extensive scarring and fibrosis of the endometrium in combination with I or II degree - with amenorrhea or obvious hypomenorrhea.
  • VB degree. Extensive scarring and fibrosis of the endometrium in combination with III or IV degree - with amenorrhea.

Classification of uterine adhesions

Light (look like films),

Medium (consist of muscle fibers),

Heavy (dense, from connective tissue).

1 degree: occupy less than 1/4 of the organ cavity; the mouths of the pipes, the bottom is not overgrown;

Grade 2: adhesions filled up to 3/4 of the cavity; pipe mouths, the bottom is partially closed;

Grade 3: uterine synechia occupy more than 3/4 of the organ cavity or the entire organ.

With the last degree, pathology of the placenta is noted, if there is a pregnancy. It is manifested by presentation and tight attachment. This leads to a great risk in childbirth, often considered the issue of caesarean section.

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

• I degree is characterized by the involvement in the pathological process of no more than 1/4 of the volume of the uterine cavity, 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.

They consist of a thin layer of basal endometrium.

They consist of endometrial-covered tissues of the fibrous and muscular layer of the uterine membranes, tightly attached to the endometrium.

Strong strands consist of connective tissue, have a dense structure, and are difficult to dissect during surgical procedures.

Classification of the process according to the degree of involvement of the structures of the uterus:

• No more than ¼ of the internal area of ​​the organ is involved in the pathological process, the bottom and passages of the fallopian tubes are free;
• Synechiae occupy 3/4 of the internal cavity of the uterus, the walls of the organ stick together, partial occlusion is observed in the openings of the fallopian tubes;
• The entire uterine cavity is affected by the pathological process.

International classification according to the degree of damage and the level of cavity filling, used in surgical endoscopic intervention:

• Thin synechia, easily destroyed during hysteroscopy;
• Single dense films;
• 2a. Synechia is localized in the uterine pharynx, the upper part of the uterine cavity is not affected;
• A large number of dense areas are diagnosed, the mouths of the fallopian tubes are involved in the process;
• In addition to the above signs, partial occlusion of the uterine cavity is diagnosed;
• The above symptoms are accompanied by scars on the inner walls of the organ.

In rare cases, single adhesions are diagnosed, located randomly in different parts of the uterus.

The most common symptom that a pathological process has arisen in the uterus is pain. They intensify during exercise, during menstruation and during the adoption of a certain posture.

The pain has a different character, it can be sharp or aching, aggravated by movement or physical inactivity. Additionally, urination and defecation disorders, infertility or problems with carrying a pregnancy in the early stages are diagnosed.

In most cases, synechiae are formed in the uterine cavity as a result of injury to the basal layer of the endometrium. After an injury, a response occurs - the main connective tissue protein collagen is synthesized in large quantities and fibroblasts are activated.

Causes of mechanical or other effects that provoke the formation of synechia:

• Scraping;
• The consequences of surgery;
• The presence of the Navy;
• Remains of the fetal egg left after an abortion;
• Intrauterine administration of drugs.

In addition, adhesions and synechia in the uterine cavity occur as a complication of chronic or tuberculous endometritis.

As a result of the formation of synechia, the menstrual and reproductive functions of the female body are disturbed. The following abnormalities of cyclic bleeding from the norm are most often diagnosed:

• Violation of the intensity and duration of menstruation;
• Complete absence of menstruation;
• The formation of a hematometra (accumulation of blood) in the uterus when the opening of the cervical canal is blocked and the endometrium remains active, accompanied by cramping pain and a feeling of heaviness in the lower abdomen;
• The development of the inflammatory process (pyometra, endometritis).

Reproductive disorders:

• Difficulties with implantation of the embryo due to a deficiency in the uterine cavity of a normally functioning endometrium;
• The impossibility of fertilization of the egg by spermatozoa during fusion of the mouths of the fallopian tubes;
• Obstetric complications during pregnancy: placenta previa, spontaneous abortion, premature birth;
• Problems during IVF due to changes in the functional layer of the endometrium and a decrease in its area.

Violation of the normal course of pregnancy occurs due to the fact that synechia prevent an increase in the uterine cavity, fixing it in the same position. Since the fetus grows, and the uterus does not stretch, this circumstance leads to the appearance of severe pain, hypertonicity of the uterus.

If these symptoms are ignored, miscarriage occurs, in difficult cases - uterine rupture. In the period before the onset of a miscarriage or before a medical abortion, synechia and adhesions deform the fetal egg, limiting its growth, interfering with full development.

Treatment of intrauterine synechia

When the doctor makes a diagnosis: synechia, treatment depends on the classification of adhesions, the patient's planning for pregnancy, and the age of the patient. It is taken into account that in severe form, the strands are so dense that it is very difficult to dissect.

The middle stage of the disease is characterized by profuse bleeding during dissection. At the same time, the muscle fibers that make up the adhesions of this stage are easily dissected. The films characteristic of the initial stage are easily dissected with only one tip of the hysteroscope and do not bleed.

This pathology appears, as a rule, in adult women, it is rare in young girls. A form of tuberculous etiology has a not very optimistic prognosis. In other cases, the restoration of the endometrium is possible in 90% of women.

Treatment and prognosis of the disease depends on the nature of intrauterine adhesions. Depending on the structure of the tissue, synechiae are light (in the form of films), medium (muscle fibers) and heavy (formed from connective tissue).

With complaints from the patient and suspicion of the presence of intrauterine synechia, the following methods are used for diagnosis:

1. Hysteroscopy. The procedure allows you to install white cords of different lengths and densities.
2. Ultrasound of the uterus and its appendages.
3. X-ray of the uterine cavity.

When making a diagnosis of synechia of the uterine cavity, the results of a gynecological examination are taken into account, which allows to establish the size of the uterus and its appendages, their mobility and soreness.

The main method of treating intrauterine synechia is their dissection and removal using a hysteroscope, electric knife or laser. The procedure is carried out under ultrasound guidance. In the case of severe adhesions, more serious surgical intervention is required to separate them.

Unfortunately, excision of intrauterine synechia does not always guarantee a complete cure. Very often, relapses, the appearance of new adhesions are possible. To restore the normal structure and functioning of the endometrium, women are prescribed a course of hormone therapy.

The drugs are taken for 6 months to prevent the appearance of new synechia of the uterine cavity. Treatment is supplemented with antibiotics if the cause of the development of adhesions was inflammatory processes in the body.

Most women are concerned about the question of how quickly after treatment for synechia of the uterine cavity, pregnancy can occur. The normal menstrual cycle and the ability to fertilize are resumed quite quickly, however, it is necessary to take into account the degree of restoration of the endometrium.

In women of reproductive age, synechia in the uterus leads to severe complications and leaves negative consequences.

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.

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.

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.

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.

In the treatment of intrauterine synechia, the only method is used - dissection of the cords. This is done with the help of hysteroscopy, when the surgeon penetrates the uterine cavity by instrumental means and removes damaged cells by dissecting them.

It is easy enough to treat the first degree of synechia, which are tender in the form of films. The average degree of synechia is removed, but after them there is some bleeding. The severe degree of synechia is dissected very hard, but they do not bleed.

After the operation, a repeated hysteroscopic diagnosis is made after some time to determine the success of the operation. If new synechiae have not appeared, and the corners of the uterus are free, where the fallopian tubes enter, then the woman is considered cured.

Most often, the disease in question can be cured by therapeutic methods, but in some cases only surgical intervention can correct the situation. Of course, doctors will prescribe an individual treatment regimen, we will only cover the general principles of getting rid of such adhesions:

1. If synechia has formed in the nasal cavity, then the doctor will insist on surgical treatment - the specialist will simply excise the adhesions. Moreover, the sooner such a cardinal treatment is carried out, the faster the patient's health will be restored. The most effective treatment will be getting rid of synechia with a laser - in the postoperative period, scars form very quickly and the risk of relapse is reduced significantly.
   Note:if nasal congestion has appeared and there are suspicions of the formation of synechia, then in no case should you carry out procedures for washing the nasal cavity and use vasoconstrictor drops to facilitate breathing - this will lead to the growth of the mucosa and a greater spread of synechia. Vasoconstrictor drops with synechia in the nasal cavity can lead to impaired functionality of the organs of vision and the brain.
2. Treatment of synechia in the uterine cavity is possible only with a surgical method. - hysteroscope excision of synechiae. As a rule, within 2 months after the surgical treatment, the woman's menstrual cycle is restored and the state of health is normalized. Relapses are extremely rare.
3. Synechia in girls can occur against the background of infectious and inflammatory processes, so doctors first conduct a complete examination of the child and prescribe (if necessary) a course of antibacterial or antiviral therapy . If the parents promptly sought qualified medical help for synechia, then the treatment will be as follows:
   • the introduction of solutions of antibacterial drugs into the vagina;
   • carrying out hygiene procedures with a decoction of medicinal chamomile or a solution of potassium permanganate;
   • use only soap from the "children's" category - it should not contain fragrances and other chemical additives;
   • treatment of the external genitalia after hygiene procedures with pumpkin, almond or grape seed oil.

If therapeutic methods in the treatment of synechia of the vulva, vagina and labia do not work, then the doctor will resort to surgical treatment, which is performed under local anesthesia.

Most often, doctors encounter synechia of the vagina, vulva and labia in girls. It is not surprising that for such a case there are several remedies from the category of "traditional medicine", which can be used in each specific case only in the field of consultation with a doctor.

First, you need to adjust the girl's diet. It is highly desirable to exclude from the menu products that can allegedly cause an attack of an allergic reaction - chocolate, eggs, honey, cocoa, oranges, red berries / fruits.

But you need to introduce foods rich in vitamin C into the diet - persimmons, tomatoes, broccoli, apricots and others. Even official medicine recommends excluding or limiting the use of foods rich in calcium - these include milk and sour-milk products.

Important! Treatment of synechia in girls with folk remedies should not be a priority, it is of an auxiliary nature. Allowed only after consultation with a doctor.

Secondly, after evening hygiene procedures, you can independently separate the synechia. To do this, gently spread the girls' labia to the sides with two fingers, exposing the entrance to the vagina, and drip 2 drops of pumpkin or almond oil into the resulting space.

Be sure to remember that for the treatment of synechia in girls, not essential, but vegetable oil is used! During this procedure, it is highly desirable not to come into contact with the delicate mucosa.

Please note: the famous and useful sea buckthorn oil for the treatment of synechia in girls is not suitable. It is in childhood that this product often provokes the development of a powerful allergic reaction.

Thirdly, you can give the girl baths twice a day with a decoction of chamomile officinalis (1 tablespoon of chamomile flowers per glass of boiling water, insist for 1 hour). And after the procedure, you need to lubricate the external genital organs and the place of synechia with internal pork fat.

There is another option - lotions with infusion of calendula. Usually they are made to girls at the age of 2-3 years, when they can lie down for 10-15 minutes. First, an infusion is prepared from 200 ml of boiling water and a tablespoon of calendula flowers (leak for 30 minutes).

Methods of instrumental diagnostics and removal of synechia

Before starting the treatment of strands and adhesions in the uterine cavity, it is necessary to clarify the diagnosis, because the clinical picture of the pathology does not differ in specific symptoms that are unique to this disease.

X-ray of the uterine cavity with contrast, with the disease, defects in the filling of the organ are fixed.

Not the most reliable method, its information content is only 65%.

The accuracy of the method is 96%, synechiae are visualized as hyperechoic inclusions.

It can be used as a diagnostic and therapeutic manipulation at the same time, it is carried out in the first phase of the menstrual cycle against the background of a thin endometrium.

The main method by which the pathology is treated radically is the removal of synechiae surgically. The peculiarity of such an operation is that additional trauma to the endometrial mucosa can lead to a deterioration in the patient's condition.

Synechia is removed during hysteroscopy under visual control of the endoscope. The cords are dissected using an electric or laser knife, hystero- or resectoscope, surgical scissors.

After surgical procedures, the endometrium is restored with hormonal preparations based on a combination of progestogen and estrogen. The inflammatory process is treated with antibiotics, selected after diagnosing the sensitivity of microflora to them. Immunomodulators based on interferon are used to increase immunity.

Stretches thin adhesions, eliminating discomfort, not effective for infertility.

Physiotherapy with high frequency currents.

Promotes stretching of medium ligaments and resorption of thin synechiae.

Exercises are mastered under the guidance of a doctor, help stretch thin synechiae and eliminate discomfort.

6 months after the removal of synechiae and a follow-up examination, pregnancy can be planned. In this case, 4 cycles of normal ovulation should be recorded, and ultrasound of the uterus confirms the normal state and functioning of the endometrium.

Hysteroscopy

Hysterosalpingography.

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.

Application of the hysteroscope

Dissection of adhesions is carried out only with visual control. This is possible with the help of a hysteroscope. The device does not give complications in the form of injury to the remaining intact sections of the endometrium. The working element is flexible scissors.

In addition to this equipment, a neodymium laser is used. The device cuts with a laser using the contact method. The appearance of adhesions is possible again with dense strands. After their dissection, recurrence is possible in 60% of cases.

Causes and symptoms

Intrauterine adhesions are called adhesions located inside the uterus. Another name for this disease is Asherman's syndrome. The consequence of such changes is the infection of the uterus, which leads to infertility or spontaneous abortions.

What is it

Synechia is a pathological fusion of the surface of an organ or the adjacent surfaces of different organs. If they appear in the uterus, then its walls are soldered together and cause its deformation.

Synechiae are formed in the basal layer of the uterus. Its peculiarity is that it contains connective tissue fibers, due to which the mucous membrane is extensible and elastic.

If the patient has this pathology, this can lead to menstrual dysfunction and infertility. Even if pregnancy occurs, there is a high probability of losing a child.

Reasons for the appearance

In most women, adhesions in the uterus appear due to mechanical injuries in which the basal layer is affected. The epithelium of this layer of the uterus reacts to damage and tries to restore its integrity. It begins to grow, involving other fibers in this process. Because of this, strands are formed. Gradually, these formations "contract" the walls of the uterus, because of which it is deformed. In the most severe cases, the uterine cavity is completely closed.

The endometrium can be damaged:

• during an abortion;
• when the uterus is scraped, if the woman has uterine bleeding or had polyps;
• due to intrauterine contraceptives;
• during operations that affect the uterine cavity.

If an infection joins the injury, the mucous layer is damaged even more. Contribute to the appearance of this disease genital tuberculosis, missed pregnancy and radiation therapy, carried out due to a tumor of the ovaries or uterus.

Symptoms

Symptoms of intrauterine synechia depend on the condition of the uterus and the degree of the disease. Many patients may develop hypomenstrual syndrome. With it, menstruation becomes not as plentiful as before, less long, sometimes it comes in the form of a daub, and in some it disappears altogether. If the endometrium in the upper layers is not affected, a pathological condition (hematomera) may develop, in which the outflow of menstrual blood is difficult. This creates favorable conditions for the development of inflammation and other complications. The patient complains of weakness, dizziness, may lose consciousness, later complaints of pain appear.

Kinds

There are several types of intrauterine synechia:

1. Lungs: fragile, easily dissected by a hysteroscope; derived from basal endometrial cells.
2. Medium: denser, they include fibers of muscle and fibrous tissue; they are firmly soldered to the mucous membrane of the uterus and bleed when cut.
3. Heavy: the most dense, made of coarse connective tissue, difficult to dissect.

Degrees

Patients may have a different number of synechiae, different degrees of infection of the uterine cavity. This affects the course of the disease and treatment. There are 3 degrees of the disease:

1. The first one is the easiest. Adhesions occupy a small area of ​​the mucosa (less than 25%), they are absent at the bottom of the uterus and at the mouth of the fallopian tubes. Formations are thin.
2. Second. The pathological process captured more than 25% of the uterus, but less than 75%. The adhesions partially overlap the bottom of the uterus and the mouths of its tubes, but the walls of the organ are free, do not stick together.
3. Third. Almost the entire endometrium (more than 75%) suffered from the adhesive process. The resulting synechiae are dense, they splice the walls of the uterus together.

Synechia and pregnancy

Intrauterine synechia and pregnancy are closely related. It is intrauterine synechia that is considered as the main cause of infertility. Because of them, menstruation may be absent, the body becomes unprepared for fertilization. But, even if the critical days come on time, there are difficulties with the implantation of the fetal egg. It is useless for women with a similar diagnosis to do IVF, it will be ineffective.

If the patient is able to become pregnant, there is a high risk of losing a child (1/3 of patients with a similar diagnosis experience spontaneous miscarriages). Complications are also possible during pregnancy, during childbirth and in the postpartum period (premature birth, placental pathology, etc.). Therefore, women who dream of a child must first undergo a course of treatment, and only then plan a pregnancy.

Diagnostics

The doctor may suspect the presence of this pathology if the patient cannot become pregnant or menstrual function is disturbed after abortions, curettage, or other intrauterine manipulations. But he will not be able to immediately diagnose "intrauterine synechia", diagnostics are necessary. 2 examinations help to detect this disease:

1. Hysterosalpingography. This is an X-ray examination of the fallopian tubes and uterus using a contrast agent. Sometimes this study gives a false positive result if there are endometrial scraps, mucus and curvature in the uterus.
2. Hysteroscopy. A hysteroscope is inserted into the patient through the vagina, which helps the doctor to examine the uterine mucosa and see synechia. They appear as avascular strands of light shades of various lengths and densities.

Additional examinations are also possible: ultrasound of the small pelvis or hormonal tests. Moreover, ultrasound is almost useless; it can only be used to examine irregular contours of the mucous membrane.

Treatment

How to treat intrauterine synechia to get rid of them forever? There is only one method of treatment - mechanical dissection of synechiae. The easiest way to remove thin formations, the hysteroscope can easily cope with this. If they are denser and not easily removed, endoscopic scissors, forceps, laser, etc. are used. In order not to damage the uterus, the doctor controls the operation using ultrasound or laparoscopy.

After dissection, a hysteroscopic examination is necessary. It should show that there are no synechiae, the corners of the uterus are free, near which the fallopian tubes are located. This completes the initial stage of treatment, but with intrauterine synechia this is not enough, it is necessary to restore the work of the endometrium. Therefore, the patient needs cyclic hormonal therapy, which can last about 3-6 months.

If the disease is complicated by infection, antimicrobial therapy is prescribed. Treatment with folk remedies for intrauterine synechia is ineffective, because no herbs will help remove adhesions formed in the uterus. But if desired, a woman, after consulting a doctor, can drink fortifying decoctions that will help her recover faster.

Important! After the treatment, the patient can quickly become pregnant. But doctors advise not to rush. If a woman wants her pregnancy and childbirth to proceed without complications, it is better to wait until the body recovers completely.

Prevention

Even after successful treatment, a relapse of the disease is possible; in 60% of patients, dense synechiae can form again. To exclude this, doctors recommend putting an intrauterine device at least for a month.

Prevention of this disease:

• Refusal of abortions, use of contraceptives;
• Timely treatment of genital infections;
• Complete examination for menstrual irregularities.

Intrauterine synechia can appear in any woman due to damage to the endometrium of the uterus. Often this leads to infertility or causes miscarriages, early births, etc. This disease is treated, especially if you do not delay the visit to the doctor. The patient will eventually be able to become pregnant and give birth to a child. However, the management of pregnancy should be carried out by an experienced obstetrician-gynecologist, who will take into account all possible risks.

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 used for the treatment of 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 terrible complications as spontaneous miscarriage, premature birth, intrauterine growth retardation of the fetus, placental pathology, etc. The use of an anti-adhesion gel containing hyaluronic acid and carboxymethylcellulose (Antiadgesin®) helps to reduce 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 synechia has been known for more than a century, 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 IUD 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 are hysteroscopically manifested by a characteristic picture: 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%, premature 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, GS 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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