Be a Surgical “Multiplier” in MIGS Inspire Brilliance Through Teamwork

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Scientific Program ChairJubilee Brown, MD

Honorary ChairBarbara S. Levy, MD

PresidentMarie Fidela R. Paraiso, MD

SYLLABUSSURGICAL TUTORIAL 6:

Hot Topics in Intra-uterine Surgery

Professional Education Information

Target Audience This educational activity is developed to meet the needs of surgical gynecologists in practice and in training, as well as other healthcare professionals in the field of gynecology. Accreditation AAGL is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians. The AAGL designates this live activity for a maximum of 1.0 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Disclosure of Relevant Financial Relationships As a provider accredited by the Accreditation Council for Continuing Medical Education, AAGL must ensure balance, independence, and objectivity in all CME activities to promote improvements in health care and not proprietary interests of a commercial interest. The provider controls all decisions related to identification of CME needs, determination of educational objectives, selection and presentation of content, selection of all persons and organizations that will be in a position to control the content, selection of educational methods, and evaluation of the activity. Course chairs, planning committee members, presenters, authors, moderators, panel members, and others in a position to control the content of this activity are required to disclose relevant financial relationships with commercial interests related to the subject matter of this educational activity. Learners are able to assess the potential for commercial bias in information when complete disclosure, resolution of conflicts of interest, and acknowledgment of commercial support are provided prior to the activity. Informed learners are the final safeguards in assuring that a CME activity is independent from commercial support. We believe this mechanism contributes to the transparency and accountability of CME. Anti-Harassment Statement AAGL encourages its members to interact with each other for the purposes of professional development and scholarly interchange so that all members may learn, network, and enjoy the company of colleagues in a professional atmosphere. Consequently, it is the policy of the AAGL to provide an environment free from all forms of discrimination, harassment, and retaliation to its members and guests at all regional educational meetings or courses, the annual global congress (i.e. annual meeting), and AAGL-hosted social events (AAGL sponsored activities). Every individual associated with the AAGL has a duty to maintain this environment free of harassment and intimidation. AAGL encourages reporting all perceived incidents of harassment, discrimination, or retaliation. Any individual covered by this policy who believes that he or she has been subjected to such an inappropriate incident has two (2) options for reporting:

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Table of Contents Course Description ........................................................................................................................................ 1 Disclosure ...................................................................................................................................................... 2 Office Hysteroscopy, Set Yourself Up for Success! J.K. Robinson ................................................................................................................................................ 3 Isthmocele, Diagnosis and Hysteroscopic Management J.A. Thiel ...................................................................................................................................................... 10 Asherman’s, Management and Prevention M. Hanstede ................................................................................................................................................ 14 Cultural and Linguistics Competency .......................................................................................................... 22

Surgical Tutorial 6: Hot Topics in Intra-uterine Surgery

Moderator: Nash S. Moawad Co-Moderator: Gary N. Frishman

Faculty: Miriam Hanstede, James K. Robinson, John A. Thiel

Course Description This advanced surgical tutorial will cover state of the art office, diagnostic and operative hysteroscopy. Hysteroscopic surgery is the least invasive approach for the management of a myriad of intra-uterine structural abnormalities. This session will share tips and tricks from the Masters, to safely and efficiently perform many of these procedures in the office setting. The epidemic of C-sections has led to new entities such as Isthmocele, or cesarean scar defect, which requires highly specialized hysteroscopic skills to perform Isthmoplasty. The faculty will also navigate the diagnosis and management of Intra-uterine Adhesions or Asherman’s syndrome. One approach to decrease the risk of intra-uterine adhesions is the focused hysteroscopic resection of retained products of conception, which will be covered in this session as well.

Course Objectives At the conclusion of this activity, the participant will be able to: 1) Perform office hysteroscopy, diagnose and treat Isthmocele, Intra-uterine adhesions and retained products of conception.

Course Outline

4:10 Welcome, Introductions, and Course Overview S. Moawad, G.N. Frishman

4:12 Office Hysteroscopy, Set Yourself Up for Success! J.K. Robinson 4:27 Isthmocele, Diagnosis and Hysteroscopic Management J.A. Thiel 4:42 Asherman’s, Management and Prevention M. Hanstede 5:00 Questions & Answers All Faculty 5:10 Adjourn

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PLANNER DISCLOSURE The following members of AAGL have been involved in the educational planning of this workshop (listed in alphabetical order by last name). Art Arellano, Professional Education Director, AAGL* Linda D. Bradley, Medical Director, AAGL* Erin T. Carey Consultant: MedIQ Mark W. Dassel Contracted Research: Myovant Sciences Erica Dun* Adi Katz* Linda Michels, Executive Director, AAGL* Erinn M. Myers Speakers Bureau: Laborie Medical Technologies, Teleflex Medical Other: Unrestricted educational grant to support NC FPMRS Fellow Cadaver Lab: Boston Scientific Corp. Inc. Amy Park* Grace Phan, Professional Education Specialist, AAGL* Harold Y. Wu* Linda C. Yang Other: Ownership Interest: KLAAS LLC Gary N. Frishman* Nash S. Moawad Consultant: Boston Scientific Corp. Inc. SCIENTIFIC PROGRAM COMMITTEE Linda D. Bradley, Medical Director, AAGL* Jubilee Brown* Nichole Mahnert* Shanti Indira Mohling* Fariba Mohtashami Consultant: Hologic Marie Fidela R. Paraiso* Shailesh P. Puntambekar* Matthew T. Siedhoff Consultant: Applied Medical, Caldera Medical, CooperSurgical, Olympus Amanda C. Yunker Consultant: Olympus Linda Michels, Executive Director, AAGL*

FACULTY DISCLOSURE The following have agreed to provide verbal disclosure of their relationships prior to their presentations. They have also agreed to support their presentations and clinical recommendations with the “best available evidence” from medical literature (in alphabetical order by last name). Gary N. Frishman* Miriam Hanstede* Nash S. Moawad Consultant: Boston Scientific Corp. Inc. James K. Robinson Consultant: Karl Storz John A. Thiel Consultant: AbbVie, Hologic Contracted Research: Allergan Stock Ownership: Aurora Cannabis Inc., Valens Growork Corp. Content Reviewer has nothing to disclose. Asterisk (*) denotes no financial relationships to disclose.

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Office Hysteroscopy, Set Yourself Up for Success!

James K Robinson, MD, MS, FACOG

Director, Minimally Invasive Gynecologic Surgery (MIGS)

Associate Program Director AAGL MIGS Fellowship

National Center for Advanced Pelvic Surgery

MedStar Washington Hospital Center

Washington, DC

DisclosuresConsultant: Karl Storz

Objectives

• Review the indications for office hysteroscopy

• Illustrate the evidence supporting office hysteroscopy

• Describe the approach to vaginoscopy and pain management in office hysteroscopy

• Summarize the costs and reimbursement for office hysteroscopy

Why is this important?

BETTER FOR PATIENTS BETTER FOR HOSPITALS

BETTER FOR PHYSICIANS

BETTER FOR THE HEALTH CARE SYSTEM

What’s Involved?

The Medical Team

Patient Selection

• Indications

• contraindications

Patient Preparation

• Timing

• Premedication

• Analgesia

Office Set‐up

Procedure

Postprocedure

It takes a village

Authorization specialist

Scheduling specialist

Medical Assistant

Physician team (I include residents, students, and fellows)

Nursing  ‐ Is ideal but not necessary

Billing specialist

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Indications for office hysteroscopy

• AUB

• Vaginal or cervical evaluation

• Infertility and evaluation of abnormal SIS/HSG

• Intrauterine scarring

• Mullerian anomalies

• Evaluation of foreign body

• Retained products of conception

• Isthmocele

• Preop and postop evaluation

• Endometrial sampling/biopsy

• Hysteroscopic polypectomy

• Simple hysteroscopic myomectomy

• Adhesiolysis

• Septoplasty

• Removal of foreign body

Diagnostic Operative

Hysteroscopic Findings in Patients with AUB

• 50% will have a structural abnormality

All Premenopausal Patients

• 90% will have a structural abnormality (Vercillini et al)

All Ovulatory Premenopausal Patients

• On HRT: 50% with structural abnormality off HRT: 88% with structural abnormality

Postmenopausal Patients

AUB – OH vs SIS

Similar time requirements

Significantly lower pain scores if vaginoscopic 

approach

Better patient satisfaction

Patient tolerance 

78% preferred flexible office hysteroscopy

No significant difference in detecting 

pathology

In patients with a structural abnormality it can often be addressed at the time of an office hysteroscopy

Senapati et al 2008 Fertil Steril Endometrial Cancer or Hyperplasia Outpatient TVUS + office HSC + EMB 

Inpatient HSC / D&C 

Equivalent detection rates

Outpatient procedures well tolerated

Tahir, M, et al. 1999;106(12), 1259‐64.

Patient Selection

• Patient is motivated to avoid the OR and undergo a “see and treat” procedure

• Procedure can be accomplished with no more than 5 Fr. Instruments in under 10 minutes

• Patient tolerates an office examination

• Viable pregnancy

• Acute Pelvic Infection

• Known cancer

Indications

Contraindications

Procedural Timing 

• Cycle day 4‐11

Early Proliferative phaseEarly Proliferative phase

• In anovulatory patients

3 weeks after starting a 10 day progestin withdrawal3 weeks after starting a 10 day progestin withdrawal

• When you just cant make the timing work

After 3 weeks of continuous progestinAfter 3 weeks of continuous progestin

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Procedural Timing

• Good Timing

• Bad Timing

It must be very painful

Pain During Flexible Office HysteroscopyLinda D. Bradley et al.

1 = easily accepted discomfort 34.4%

2 = acceptable discomfort 22.2%

3 = tolerable discomfort 27.4%

4 = barely tolerable pain 12.4%

5 = intolerable pain 3.6 %

387 patients without anesthesia and 3.6 mm flexible hysteroscope29 patients of 417 could not be done in the office

Pain Management

High Dose NSAIDs 1 hour prior to procedure

In patients where anxiety or history of difficult exams exist:

• Lorazepam 1 mg 1 hour prior to procedure

• Tramadol 50 mg 1 hour prior to procedure

Avoid dilation and tenaculum

VAGINOSCOPY for rigid and select flexible procedures

Verbal anesthesia –competence is the key

Paracervical block only if dilation is necessary

• Narrow canal

• Premedicate with Misoprostol

• 200mg PV night prior and morning of procedure

• Especially for nulliparous or postmenopausal stenotic cervices

The equipment must be veryintimidating

Standard GYN Room with a Monitor

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High Tech Fluid Management

Miscellaneous items

Under buttock drape

Squeeze ball Chux Pads

Pressure Bag with tubing

SpeculumMayo Stand

What are my options?

REUSABLE DISPOSABLE

Disposable

LiNA Single‐Use OperaScope Cooper Surgical Endosee

Disposable Instruments Reusable

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Reusable Semi‐Rigid Instruments

• Semirigid in nature

• Greater stability for direction and cutting

• 5 F in diameter and 35 cm in length

• Scissors (blunt or sharp tipped)

• Alligator forceps

• Biopsy forceps

• Tenaculum

• Screw

Vaginoscopy

Position the patient in dorsal lithotomy

Place under‐buttocks drape with a pouch to collect fluid media during hysteroscopy

1000‐3000cc normal saline bag in a pressure bag hung on a tall IV pole with standard IV tubing

Clean the cervix and vagina with a small diameter swab dipped in Betadine (povidone‐iodine) or alternative (chlorhexidine gluconate) if allergic

Have sterilized camera, light cord and scope attached and functioning properly

Vaginoscopy Technique

• Scope:  30 degrees

• Image display reflects what is above the tip of the instrument

• i.e. – with the scope angle positioned anteriorly,  if the cervical canal looks like it is straight ahead, the scope is actually digging in posteriorly.

Vaginoscopy Tips

Practice in the OR makes this an invaluable office approach

• Sterilization

• Polypectomy

• Adhesiolysis

• Drainage of hematometra

• IUD retrieval

Continuous in‐flow ‐ passive outflow

• Pressure bag and cystoscopy tubing

• High pressure setting on the fluid management system

30 degree optic looking up

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Procedural Complications – Have a plan

Vasovagal episode

• Smelling salts

• O2 and Atropine 5 mg IM

Local anesthesia toxicity

• Max dose 4 mg/kg 1% lidocaine

Uterine perforation (without energy)

• Where did it occur?

Uterine hemorrhage

• 30 cc Foley balloon

What does it cost?  What does it pay?

Cost

• Cooper Endosee $150.00

• Cooper rechargeable handpiece $

• LiNA OperaScope $200.00

• LiNA Instruments $

• Storz Telepack Camera System $15,000.00

• Storz Camera and Light Cord $4500.00

• Storz Flexible scope/case $8,000.00

• Storz Bettocchi rigid scope/case $7,000.00

• Semirigid Instrument $900.00

• Total initial investment $35,400.00

Disposable

Reusable

Reimbursement

• 58555   Diag Hyst 272.76 157.92

• 58558   Hyst polyp 1382.12 214.18

• 58559   Hyst LOA 299.60 297.17

• 58561  Hyst myo 458.67 449.34

• 58562  Hyst FB 345.98 238.31

CPT Proc Office Facility

The Elephant in the Room

Full Sterilization

• Recommended by all vendors

• Each scope can only be used once/day

• Requires access to sterilization facility

• Often requires equipment transport with associated wear and tear

Cidex IPA

• Utilized successfully for many years by many providers.

• Allows instruments to be cleaned in the office (using a dirty room) and reused multiple times per day.

• Decreases total equipment investment and wear and tear

• Requires staff training

Why isn’t everyone doing this?

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References

• Angioni, S, Loddo, A, Milano, F, et al.  Detection of benign intracavitary lesions in postmenopausal women with abnormal uterine bleeding: a prospective comparative study on outpatient hysteroscopy and blind biopsy. Journal of MinimallyInvasive Gynecology, 2008;15(1), 87‐91.

• Loffer, F D. Hysteroscopy with selective endometrial sampling compared with D&C for abnormal uterine bleeding: the value of a negative hysteroscopic view. Obstetrics and gynecology, 1989;73(1), 16‐20.

• Pluchino, N, Ninni, F, Angioni, S, et al. Office vaginoscopic hysteroscopy in infertile women: effects of gynecologist experience, instrument size, and distention medium on patient discomfort. Journal of Minimally Invasive Gynecology, 2010; 17(3), 344‐50.   

• Siristatidis, C,  Chrelias, C. Feasibility of office hysteroscopy through the "see and treat technique" in private practice: a prospective observational study. Archives of gynecology and obstetrics, 2011 Apr;283(4):819‐23.

References

• Svirsky, Ran, Smorgick, N, Rozowski, Uri, et al. Can we rely on blind endometrial biopsy for detection of focal intrauterine pathology?. American journal of obstetrics and gynecology, 2008;199(2), 115‐3.

• Tahir, M M, Bigrigg, M A, Browning, J J, et al.  A randomised controlled trial comparing transvaginal ultrasound, outpatient hysteroscopy and endometrial biopsy with inpatient hysteroscopy and curettage. British journal of obstetrics and gynaecology, 1999;106(12), 1259‐64.

• Vercellini, P, Vendola, N, Ragni, G, et al. (1993). Abnormal uterine bleeding associated with iron‐deficiency anemia. Etiology and role of hysteroscopy. Journal of reproductive medicine, 1993;38(7), 502‐4.

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Isthmocoele: Diagnosis and Hysteroscopic Management

John Thiel MD, FRCSC

Clinical Professor of Obstetrics and Gynecology

University of Saskatchewan

Regina, Saskatchewan

Surgical Tutorial 6: Hysteroscopy48th AAGL Global Congress on Minimally Invasive Gynecology

Vancouver BCNovember 12, 201

Disclosures

• Consultant: AbbVie, Hologic

• Contracted Research: Allergan

• Stock Ownership: Aurora Cannabis Inc., Valens Growork Corp.

Objectives

• Identify the possible origins and causes of the uterine niche

• Outline options for diagnosis and investigation

• Discuss methods of hysteroscopic treatment

Patient Presentation

• 39 year old G2P2, LSCS x 2

• One year history of worsening pain and heavy menstrual bleeding

• Intermenstrual bleeding associated with pain

• Coital spotting without much dyspareunia

• Unresponsive to medical management

• First reported in 2001 as a filling defect noted on SIS

• Alternate terms include Caesarian scar defect, deficient Caesarian scar, diverticulum, pouch 

• Imaging described with sonography, contrast sonography (both saline and gel), hysteroscopy and HSG

• No gold standard for detection or for measurement

Monteagudo et al, J Ultrasound Medicine 2001

• Triangular anechoic space with a depth of at least 2 mm at the site of the LSCS scar

• Scar is almost always visible and is reflected as a hypoechoic indentation of the myometrium

• These can sometimes be reported as one in the same finding

• No standard as to size, shape or other characteristics

• No relation to presentation or symptoms

van der Voet et al, BJOG 2014

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• Based on 4 studies of women with one or more LSCS, prevalence ranges from 24 to 70 per cent

• Most studies will report the niche as larger if using SIS/GIS vs TVU

• Can also be seen with hysteroscopy, having a 100% correlation to SIS/GIS

Bij de Vaate et al, Ultrasound Obstet Gynecol, 2014

• 27 RCTs in Cochrane review

• Assess surgical technique for uterine incision and uterine closure, sharp vs blunt entry, different suture materials, continuous vs interuptted closure, single vs double layer closure

• No difference in short term outcomes

• 20 RCTs

• Evaluate single vs double layer closure in relation to adverse outcomes and prevalence of uterine scar defects

• Single layer closure resulted in significantly thinner residual myometrial thickness (‐2.6mm) assessed 6 to 12 weeks post LSCS

Dodd et al, Cochrane Database Sys Rev, 2014

Roberge et al AJOG, 2014

Bij de Vaate et al, Ultrasound Obstet Gynecol, 2014

• Cervical location of uterine incision

• Development of the lower segment

• Wound healing

• Maternal factors

Vervoort et al, Human Reprod 2015

How does the niche declare itself

• Postmenstrual spotting ‐ 34%

• Dysmenorrhea – 53%

• Chronic pelvic pain – 37%

• Dyspareunia – 18%

• IUCD migration

Bij de Vaate et al, Ultrasound Obstet Gynecol, 2014

• Prolonged menstrual bleeding– 30% of women with a niche have postmenstrual spotting >2 days versus 15% of women without a niche

• Intermenstrual spotting and pain–Mechanism not well understood

– Accumulated blood that passes after menstrual flow

– Fibrotic tissue may affect contractility at the site of the niche

– Newly formed fragile vessels may leak

– Pain does not usually respond to hormonal medications

Vervoort et al, BMC Women’s Health, 2015

• Niche acts as a small reservoir as a result of poor contractility of the overlying myometrium

• Menstrual blood can be seen in the niche in the early proliferative phase which is manifest as postmenstrual spotting

• May also create an area of inflammation with an “endometriosis” like effect resulting in dysmenorrhea and dyspareunia

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Tower and Frishman JMIG, 2013

Surgical Approach• Hysteroscopic repair

– Resection loop and roller ball– Removes the edges which should allow for easier drainage of retained contents, but does not increase the thickness of overlying myometrium – importance of this not known

– Need to know the thickness of residual overlying myometrium prior to starting

– Ultrasound– Improved AUB in 87%, pain improved in 97%– >3mm residual myometrium there is significant improvement in spotting and pain vs no treatment

van der Voet, BJOG 2014

Vervoort et al, BJOG, 2018 

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Laparoscopic repair

• 96.9% report complete resolution of symptoms• Significant increase in the residual myometrial thickness, although the clinical relevance is unknown

• Hysteroscopic guidance• One versus two layer closure does not seem to affect the outcome

• No need to repair endometrium as a separate layer• Avoid excessive tension to reduce ischaemia during healing of the repair

Api et al, JMIG 2015

van der Voet, BJOG 2014

• Fertility

–78 women reported fertility problems, 72 conceived after treatment

• 67 hysteroscopic repair

• 4 laparoscopic repair

• 1 vaginal repair

–4 had miscarriage, 58 delivered by elective LSCS

–No evidence regarding labour on a surgically reconstructed niche even though the measured myometrial thickness after repair is about 8 mm

van der Voet, BJOG 2014

Future of the niche• LSCS is not likely to become a less common operation thus the importance of investigating the potential morbidity of the resultant scar, both in future labour and in the non‐pregnant woman

• More robust data on potential risk factors in development

• Risk to future pregnancy and fertility

• Interventional trials to correct abnormal bleeding and/or pain

• ?should GIS after LSCS become part of the routine assessment in determining the safety of a trial of labour

References1. Monteagudo A, Carreno C, Timor‐Tritsch IE. Saline infusion sonohysterography in nonpregnant women 

with previous cesarean delivery: the "niche" in the scar. J Ultrasound Med. 2001 Oct;20(10):1105‐152. van der Voet LF, Bij de Vaate AM, Veersema S, Brölmann HA, Huirne JA. Long‐term complications of 

caesarean section. The niche in the scar: a prospective cohort study on niche prevalence and its relation to abnormal uterine bleeding. BJOG. 2014 Jan;121(2):236‐44. 

3. van der Voet LF, Vervoort AJ, Veersema S, BijdeVaate AJ, Brölmann HA, Huirne JA. Minimally invasive therapy for gynaecological symptoms related to a niche in the caesarean scar: a systematic review. BJOG. 2014 Jan;121(2):145‐56.

4. Dodd JM, Anderson ER, Gates S, Grivell RM. Surgical techniques for uterine incision and uterine closure at the time of caesarean section. Cochrane Database Syst Rev. 2014 Jul 22;(7):CD004732. doi: 10.1002/14651858.CD004732.pub3.

5. Roberge S, Demers S, Berghella V, Chaillet N, Moore L, Bujold E. Impact of single‐ vs double‐layer closure on adverse outcomes and uterine scar defect: a systematic review and metaanalysis. Am J Obstet Gynecol.2014 Nov;211(5):453‐60.

6. Vervoort AJ, Uittenbogaard LB, Hehenkamp WJ, Brölmann HA, Mol BW, Huirne JA. Why do niches develop in Caesarean uterine scars? Hypotheses on the aetiology of niche development. Hum Reprod. 2015 Dec;30(12):2695‐702.

7. Vervoort AJ, Van der Voet LF, Witmer M, Thurkow AL, Radder CM, van Kesteren PJ, Quartero HW, Kuchenbecker WK, Bongers MY, Geomini PM, de Vleeschouwer LH, van Hooff MH, van Vliet HA, Veersema S, Renes WB, van Meurs HS, Bosmans J, Oude Rengerink K, Brölmann HA, Mol BW, Huirne JA. The HysNiche trial: hysteroscopic resection of uterine caesarean scar defect (niche) in patients with abnormal bleeding, a randomised controlled trial. BMC Womens Health. 2015 Nov 12;15:103. doi: 10.1186/s12905‐015‐0260‐8.

8. Tower AM, Frishman GN. Cesarean scar defects: an underrecognized cause of abnormal uterine bleeding and other gynecologic complications. J Minim Invasive Gynecol. 2013 Sep‐Oct;20(5):562‐72. 

9. Api M, Boza A, Gorgen H, Api O. Should Cesarean Scar Defect Be Treated Laparoscopically? A Case Report and Review of the Literature. J Minim Invasive Gynecol. 2015 Nov‐Dec;22(7):1145‐52.

Page #13

AAGL Vancouver Surgical Tutorial 

Hot topics in Intra‐Uterine Surgery Tuesday 12 November 2019

Asherman’s, management and prevention

MIR I AM  HANST EDE  M . D .  

A SHERMAN EXPERT I S E   C ENT ER

SPAARNE GASTHU I S HAAR L EM

THE NETHER LANDS  

Disclosure slide

• I have no financial relationships to disclose

Objective

• Discuss the management and prevention of Asherman’s

Introduction

H.Fritsch

N=1

1894

B.Bass

N=20

1927

S.Stamer

N=61

1946

J.Asherman

N=29

1948

Causal procedure

5

Trauma to the endometrium

Page #14

Hypoxia of the endometriumETHIOPATHOGENESIS

INFLAMMATION

G EN E T I C

LOW

E2INFECTION

POOR VASCULARISATION

MULLERIAN DUCT

 MALFORMATIONS

HYPOXIA ARTERIAL FIBROSIS

SEPTATED UTERUS 

VULNERABLE ENDOMETRIUM 

DEFECTIVE ENDOMETRIAL HEALING

INTRA UTERINE 

ADHESIONS 

ENDOMETRITIS

TRANSITORY• LNG-IUD• BREAST FEEDING

• MISCARRIAGE• IATROGENIC• CS• CURETTAGE • IUD

D I A G N O S I S

         TRAUMA           TO THE ENDOMETRIUM 

HYSTEROSCOPYGRAVID UTERUS

DIAGNOSIS

SYMPTOMSFORMATON 

OF IUA

1 3 5

2 4

DIRECT TRAUMASEVERE HYPOXIAINFECTION

GOLDSTANDARD

MENSTRUAL PROBLEMSINFERTILITY PREGNANCY LOSSPELVIC PAIN

ASHERMAN SYNDROME

Definition

ESGE Classification of intra uterine adhesions

ASF‐score

Page #15

G r a d e 2 A G r a d e 3

Grade  4 Grade  5

Treatment

Hysteroscopy with Fluoroscopy

IUD

&

Hormone schedule

Hysteroscopic control 

After 2 months

Hysteroscopy with fluoroscopy

• Wamsteker 1990 published 1997

• Broome and Vancaillie published 1999

Page #16

Fluoroscopy Fluoroscopie

• Is not to restore the uterine anatomyand to perform a successful adhesiolysis

• but to prevent the spontaneous recurrence of adhesions

The great challenge with Asherman syndrome patients 

Grade ESGE %

1,2,2a 20‐25

3 30

4,5 39‐42

Hanstede M et al. Results of centralized Asherman surgery, 2003‐2013. Fertil Steril. 2015 Dec;104(6):1561,1568. 

95%

5%

Successful

Not succesfull

Causale Procedure

‐1st trimester procedure

‐post partum procedure

Spontaneous recurrence and grade of adhesions

Grade ESGE %

1 20.8

2 22.7

2a 25

3 29.1

4 38.5

5 41.9

Grade AFS %

Mild 22.9

Moderate 25

Severe 36.5

Outcome

Restoring uterine anatomy

Year

Author n %

1986 Fedele et al.  31 62.5

1999 Capella‐Allouc et al.  31 51.6

2003 Pace et al.  75 93.3

2006 Fernandez et al.  71 43.6

2015 Hanstede 606 98.0

Page #17

Spontaneous recurrence

Year Author n %1986 Fedele et al. 

1988 Valle and Sciarra 44/187 23.5

1997 Pabuccu et al 8/40 20

1999 Feng et al  10/12 83 severe adhesions

2006 Caplella‐Allouc et al. 10/16 62.5

2015 Hanstede 34.8 28.7

Hanstede et al. Recurrence and grade of adhesions

Grade ESGE %

1 20.8

2 25.0

2a 22.7

3 29.1

4 38.5

5 41.9

Grade AFS %

Mild 22.9

Moderate 22.7

Severe 36.5

Pregnancy outcome after adhesiolysis  

Total group At least one life birth 

(n(%))

No life birth        

(n(%))

P value

Number of patients (n) 500 336(67.2) 164 (32.8)

At least one life birth before  

Occurrence of AS

Yes

No

305

195

190(62.3)

146(74.9)

115(37.7)

49(25.1)

0.000

At least one miscarriage 

before   Occurrence of AS

Yes

No

370

130

265(71.6)

71(54.6)

105(28.4)

59(45.4)

0.000

Asherman classification ESGE  Grade1

Grade 2

Grade 2a

Grade 3

Grade4

Grade 5

16

15

183 

183 

74

29 

13 (81.2)

12(80.0)

137 (74.9)

118 (64.5)

44 (59.5)

12 (41.4)

3 (18.8)

3 (20.0)

46 (25.1)

65 (35.5)

30 (40.5)

17 (58.6)

0.000

Asherman classification ASF  Mild

Moderate

Severe

31

183

286

25 (80.6)

137 (74.9)

174 (60.8)

6 (19.4)

46 (25.1)

112 (39.2)

0.000

Putative cause of Asherman 

syndrome 

First trimester procedure

Post partum procedure

327

173

241 (73.7)

95  (54.9)

86 (26.3)

78 (45.1)

0.000

Spontaneous recurrence of 

IUAs after adhesiolysis

Yes

No

No complete resection

171

317

12

104 (60.8)

232 (73.2)

0 (0)

67 (39.2)

85 (26.8)

12 (100)

0.431

At least one miscarriage after 

adhesiolysis

Yes 

No

148

352

78 (52.7)

258 (73.3)

70 (47.3)

94 (26.7)

0.000

THBR 

N=336

TAKE HOME BABYRATE 67.2%

N=164

NO CHILDREN 32.8%

Take Home Baby Rate=THBR

Grade of adheions

LBB LOWERS WHEN THE GRADE OF ADHESIONS RISES

GRADE 5: 41% LBB

Causal procedure

FIRST TRIMESTER PROCEDURES LBB 73.7%

POST PARTUM PROCEDURES LBB 55%

Page #18

Spontaneous recurrence

NO RECURRENCE LBB 73.2% SPONTANEOUS RECURRENCE LBB 60.8%

At least one obstetrical complication

Number (n (%)) 

Total number of women, n (%) 348 (100)

Pregnancy Complications

Yes

No

Unknown

71 (21.8)

255 (78.2)

22 Placenta Implantation problems 

Yes 

No

Unknown

63 (19.2)

263 (80.7)

22Post partum problem

Yes 

No 

Unknown

133 (40.8)

193 (59.2)

22

Premature Deliveries

GRADE OF  ADHESIONS

MILD/MODERATE VS. SEVERE

1.74 (1.02-2.96) 

P 0.041

SPONTANEOUS RECURRENCE OF ADHESIONS

1.68 (1.01-2.79)

P 0.045

Abnormal Invasive Placenta

1ST TRIMESTER PROCEDURE

LESS RISK OF AIP

POST PARTUM PROCEDURES 

2.69 (1.54‐4.69) P <0.001

Post Partum problems 

SEVERE ADHESIES 

1.64 (1.01-2.69) P 0.048

POST PARTUM PROCEDURES

2.49 (1.35-4.26)  P 0.004

Prevention

• PRIMARY, prevention of intentional treatment

• SECUNDARY, prevention of formation of intra uterine adhesions after intentional treatment

• TERTIARY, prevention of recurrence of adhesions

Page #19

Primary Prevention AS1st trimester Treatment Year author

Expective management 1997

Blohm et al.

2009

Smith et al.

Misoprostol treatment 2017

Kim et al. Cochrane review

2018

WHO Geneva

Delayed‐surgical treatment  2008

Adoni et al. 

Hysteroscopic treatment 201420112001

Ben‐Ami et al .Rein et al.Cohen et al.

Post partum Treatment Year author

Hysteroscopic treatment 2013

Hamerlynck et al.

2001

Cohen et al.

Delayed‐surgical treatment 2008

Adoni et al.

Secondary Prevention

First trimester 

• Adhesion barriers Hooker

Post partum 

• Adhesion barriers

Post partum Year author

Discontinuation of Breastfeeding 1977

Buttram and Turati

Curettage with ultrasound guidance 2009

Wolman et al.

1st trimester Treatment Year author

Hylaluronic acid gel  after dilation and curettage in women with at least one previous curettage

2017

Hooker

Tertiary prevention

Treatment Year author

Intermittent intra uterine balloon dilatation therapy 2019 Shi et al.

Anti‐adhesion barriers 2013 Lin et al.

Cu‐IUD 2015 Lin et al. 

Intra uterine balloon (folley balloon, intra uterine suitable balloon) 2018 Zhu et al.

Early intervention second look office hysteroscopy  2013 Li et al.

Stemm cells 2018 Aziz et al.

Amnion graft 20182017

Zheng et al Gan et al.

•What works better endogenous or exogenous hormones?

Estrogen stimulates endometrial development, stimulates regeneration of endometrium and promoting re‐epithelialisation of the scarred surface after adhesiolysis

Exogenous

Endogenous

Te r t i a r y p r e v en t i o n

40

conclusion

41

•Does not influences the endometrial thickness•Does not influence the chance of recurrence of adhesions•Does not influence the miscarriage rate•Does not influence life birth rate

Hormonal adjuvant treatment after Asherman surgery:

TAKE TO WORK MESSAGE

01 02

03 04

Management 2

Use guidance methodManagement 1

Use non electro-surgery Preferable conventional instruments

Tertiary Prevention Prevention of recurrence of adhesions 

Any barrier will help to prevent recurrenceHormonal suppletion is not always necessary 

Primary prevention Think of non-surgical and expectivemanagement first if possible 

Asherman’s, management and prevention

Page #20

Acknowledgment

• Prof. M.H. Emanuel

• Dr B.Veersema

• Dr M. Rijken

• Prof. K. Bloemenkamp

• Dr E van der Meij

• Els Hijmans

• Dr K Vollebregt

• Dr JFM Molkenboer

References

• 1 Schenker JG, Margalioth EJ. Intrauterine adhesions: an updated appraisal. Fertil Steril. 1982;37:593–610

• 2 Hanstede MMF, van der Meij E, Goedemans L, Emanue MH. Centralized Asherman’s surgery 2003‐2013: Ferti Steril 2015 

• 3 K. Wamsteker and S. De Block, “Diagnostic hysteroscopy: technique and documentation,” in Endoscopic Surgery for Gynecologists, C. Sutton and M. Diamond, Eds., pp. 511–524, Saunders, London, UK, 1998. 

• 4 American Fertility Society classifications of adnexal adhesions, distal tubal occlusion, tubal occlusion secondary to tubal ligation, tubal pregnancies, mullerian anomalies and intrauterine adhesions. Fertil Steril.1988;49:944–955

• 5 Yu D, Wong Y, Cheong Y, Xia E, Li T. Asherman syndrome: one century later. Fertil Steril, 2008;89. 759–779

• 6 Fedele L, Vercellini P, Viezzoli T, Ricciardiello O, Zamberletti D. Intrauterine adhaesions: current diagnostic and therapeutic trends. Acta EurFertil 1986;17:317.

• 7 Capella‐Allouc S, Morsad F, Rongieres‐Bertrand C, Taylor S, Fernandez H. Hysteroscopic treatment of severe Asherman’s syndrome and subsequent fertility. Hum Reprod 1999;14:1230–3.

• 8 Pace S, Stentella P, Catania R, Palazzetti PL, Frega A. Endoscopic treatment of intrauterine adheiosn. Clin Exp Obstet Gynecol 2003;30:26‐8.

• 9 Fernandez H, Al Najjar F, Chauvenaud‐Lambling et al. (2006). "Fertility after treatment of Asherman's syndrome stage 3 and 4". J Minim Invasive Gynecol 13 (5): 398–402.

• 10 Blohm, F., Hahlin, M., Nielsen, S., Milsim, I., 1997. Fertility after a randomised trial of spontaneous abortion managed by surgical evacuation or expectant treatment. Lancet 349, 995. 

• 11 Smith, L.F.P., Ewings, P.D., Quinlan, C., 2009. Incidence of pregnancy after expectant, medical, or surgical management of spontaneous first trimester miscarriage: long term follow‐up of miscarriage treatment (MIST) randomised controlled trial. Br. Med. J. 339, 3827 

• 12 Cohen, S.B., Kalter‐Ferber, A., Weisz, B.S., Zalel, Y., Seidman, D.S., Mashiach, S., Lidor, A.L., Zolti, M., Goldenberg, M., 2001. Hysteroscopy may be the method of choice for management of residual trophoblastic tissue. J. Am. Assoc. Gynecol. Laparosc. 8, 199–202. 

• 13 Wolman, I., Altman, E., Fait, G., Har‐Toov, J., Gull, I., Amster, R., Jaffa, A., 2009. Evacuating retained products of conception in the setting of an ultrasound unit. Fertil. Steril. 91, 1586–1588. 

• 14 Rein DT, Schmidt T, Hess AP, Volkmer A, Schöndorf T, Breidenbach M. Hysteroscopic management of residual trophoblastic tissue is superior to ultrasound‐ guided curettage. J Minim Invasive Gynecol. 2011;18(6):774‐778. 

• 15 Hooker AB, Aydin H, Brölmann HAM, Huirne JAF. Long‐term complications and reproductive outcome after the management of retained products of conception: A systematic review. Fertil Steril. 2016;105(1):156‐164e2. 

• 16 Ben‐Ami I, Melcer Y, Smorgick N, Schneider D, Pansky M, Halperin R. A comparison of reproductive outcomes following hysteroscopic management versus dilatation and curettage of retained products of conception. Int J Gynecol Obstet. 2014;127(1):86‐89. 

• 17 Hamerlynck TWO, Van Vliet HAAM, Beerens A‐S, Weyers S, Schoot BC. Hysteroscopic Morcellation Versus Loop Resection for Removal of Placental Remnants: A Randomized Trial. J Minim Invasive Gynecol. 2016;23:1172‐1180. 

• 18 Liu C, Lu Q, Zhang Z, et al. HyaRegen A randomized controlled trial on the efficacy and safety of a new crosslinked hyaluronan gel in reducing adhesions after gynecologic laparoscopic surgeries. J Minim Invasive Gynecol. 2015;22(5):853–863

• 19 Li X, Wu L, Zhou Y, et al. New crosslinked hyaluronan gel for the prevention of intrauterine adhesions after dilation and curettage in patients with delayed miscarriage: A prospective, multicenter, randomized, controlled trial. J Minim Invasive Gynecol. 2019;26(1):94–99. 

Vragen

• http://www.asherman.nl

Page #21

CULTURAL AND LINGUISTIC COMPETENCY Governor Arnold Schwarzenegger signed into law AB 1195 (eff. 7/1/06) requiring local CME providers, such as

the AAGL, to assist in enhancing the cultural and linguistic competency of California’s physicians

(researchers and doctors without patient contact are exempt). This mandate follows the federal Civil Rights Act of 1964, Executive Order 13166 (2000) and the Dymally-Alatorre Bilingual Services Act (1973), all of which

recognize, as confirmed by the US Census Bureau, that substantial numbers of patients possess limited English proficiency (LEP).

California Business & Professions Code §2190.1(c)(3) requires a review and explanation of the laws

identified above so as to fulfill AAGL’s obligations pursuant to California law. Additional guidance is provided by the Institute for Medical Quality at http://www.imq.org

Title VI of the Civil Rights Act of 1964 prohibits recipients of federal financial assistance from

discriminating against or otherwise excluding individuals on the basis of race, color, or national origin in any of their activities. In 1974, the US Supreme Court recognized LEP individuals as potential victims of national

origin discrimination. In all situations, federal agencies are required to assess the number or proportion of LEP individuals in the eligible service population, the frequency with which they come into contact with the

program, the importance of the services, and the resources available to the recipient, including the mix of oral

and written language services. Additional details may be found in the Department of Justice Policy Guidance Document: Enforcement of Title VI of the Civil Rights Act of 1964 http://www.usdoj.gov/crt/cor/pubs.htm.

Executive Order 13166,”Improving Access to Services for Persons with Limited English

Proficiency”, signed by the President on August 11, 2000 http://www.usdoj.gov/crt/cor/13166.htm was the genesis of the Guidance Document mentioned above. The Executive Order requires all federal agencies,

including those which provide federal financial assistance, to examine the services they provide, identify any

need for services to LEP individuals, and develop and implement a system to provide those services so LEP persons can have meaningful access.

Dymally-Alatorre Bilingual Services Act (California Government Code §7290 et seq.) requires every

California state agency which either provides information to, or has contact with, the public to provide bilingual

interpreters as well as translated materials explaining those services whenever the local agency serves LEP members of a group whose numbers exceed 5% of the general population.

~

If you add staff to assist with LEP patients, confirm their translation skills, not just their language skills.

A 2007 Northern California study from Sutter Health confirmed that being bilingual does not guarantee competence as a medical interpreter. http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=2078538.

US Population

Language Spoken at Home

English

Spanish

AsianOther

Indo-Euro

California

Language Spoken at Home

Spanish

English

OtherAsian

Indo-Euro

19.7% of the US Population speaks a language other than English at home In California, this number is 42.5%

Page #22