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Cited by 55Gynecological conditions and treatmentsIntestinal and Peritoneal AdhesionsReproductive Health and Contraception

Ultrasound and intrauterine adhesions: a novel structured approach to diagnosis and management

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Amin, T. N., Saridogan, E., Jurkovic, D.·2015·Ultrasound in Obstetrics & Gynecology
DOI 10.1002/uog.14927
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Abstract

In anatomical terms, the uterus is often perceived as a simple organ that is easily accessible on clinical examination and can be evaluated in great detail using various diagnostic modalities. It therefore comes as a surprise that there are still many uncertainties regarding the effects of congenital and acquired uterine abnormalities on women's reproductive health. Intrauterine adhesions (IUAs), which involve both the myometrial and the endometrial layers, are relatively rare in comparison with other abnormalities such as uterine fibroids and adenomyosis, and our understanding of their causes and clinical significance is particularly sparse. IUAs were first described by Heinrich Fritsch in the late 19th century1, but it was Joseph Asherman who, in 1948, further defined this eponymous condition as a traumatic amenorrhea caused by obstruction of the internal cervical os following complicated labor or abortion requiring intrauterine instrumentation2. The terms 'Asherman syndrome' and 'intrauterine adhesions' are often used interchangeably, although the original definition of the syndrome includes amenorrhea, with or without cyclical abdominal pain. Over the past 70 years there have been a number of studies focusing on IUAs, but there remain many unanswered questions regarding their etiology, prevalence and effect on reproductive outcomes3. Historically, hysterosalpingography (HSG) has been the main tool for the diagnosis of IUAs. With the development and widespread use of endoscopic techniques, hysteroscopy is now considered the 'gold standard' for diagnosis of this condition and also enables us to treat it4, 5. High-resolution ultrasound has, in recent years, largely replaced diagnostic hysteroscopy as the primary tool for assessment of the uterine cavity. Although ultrasound is one of the most commonly used diagnostic tests in gynecology, there is a paucity of data regarding its value for the detection and management of IUAs. The recent advent of three-dimensional (3D) ultrasound has further enhanced the role of ultrasound in the diagnosis of uterine anomalies, as it enables imaging of the uterus in planes that cannot be obtained on standard two-dimensional (2D) imaging. In this Editorial, we review current thinking on the etiology and prevalence of IUAs, and propose a novel structured ultrasound-based approach to the diagnosis and management of this complex condition. The prevalence of IUAs is difficult to determine with certainty, but it is thought to vary between 0.3% and 21.5%, with the highest rates being reported in Israel, Greece and South America6. These geographical variations could be explained by the differences in the number of women receiving surgical treatment for miscarriage or surgical termination of pregnancy, prevalence of puerperal infection/genital tuberculosis and the diagnostic methods used to detect IUAs7. A recent meta-analysis found that the prevalence of IUAs following a miscarriage varied between 3% and 38%, with a pooled prevalence of 19%8. IUAs were significantly more frequent in women with a history of multiple miscarriages. There were no cases of IUAs in women who underwent conservative management of miscarriage, and the authors hypothesized that repeated uterine curettage is the most important risk factor for formation of IUAs. One of the main limitations in determining the prevalence of IUAs is the reliance on invasive diagnostic methods such as HSG and hysteroscopy to detect them. These tests tend to be offered selectively to women with a history of menstrual symptoms or infertility, while asymptomatic adhesions remain undetected. In view of this, it is likely that the prevalence of IUAs is underestimated and their clinical significance overstated. The endometrium consists of a basal layer, adjacent to the myometrium, and a superficial functional layer. The functional layer responds to the cyclical changes in the secretion of ovarian sex hormones. The increased hormone production during the proliferative phase of the cycle stimulates endometrial growth, while its decrease in the late luteal phase causes endometrial shedding and menstruation. The basal layer is not shed at any time during the menstrual cycle and provides the basis for regeneration of the functional layer, which is completed without formation of adhesions. Endometrial injury that results in the loss of stroma is believed to be the key event leading to the development of IUAs. Lost stroma is replaced by fibrous tissue, which causes the opposing endometrial surfaces to bond to one another, resulting in the formation of IUAs. The distinction between the functional and basal layers of the endometrium is lost and they are both replaced by an avascular and atrophic epithelial monolayer that is unresponsive to hormonal stimulation7. Injury to the gravid uterus is the main risk factor for developing IUAs. A literature review including 1856 women with IUAs found that 67% of them had undergone uterine curettage for ter

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  • The inclusion of saline infusion with the 3D ultrasound assessment may be particularly useful for the diagnosis of intrauterine adhesions if these are suspected based on the clinical history.

    “The inclusion of saline infusion with the 3D ultrasound assessment may be particularly useful for the diagnosis of intrauterine adhesions if these are suspected based on the clinical history (e.g.prior surgical management of miscarriage with subsequent oligomenorrhoea).148”

    From Recurrent MiscarriageGreen‐top Guideline No. 17 (2023) · cites this paper as [148]

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Authors
Amin, T. N., Saridogan, E., & Jurkovic, D.
Affiliations
  • University College London (GB)
  • Institute for Women's Health University College London London UK
Corresponding author
Jurkovic, D.
ORCID
Venue
Ultrasound in Obstetrics & Gynecology
Publisher
Wiley
Published
2015-07-20
Volume
46
Issue
2
Pages
131-139
ISSN
  • 0960-7692 (ISSN-L)
  • 1469-0705
DOI
10.1002/uog.14927
OpenAlex
W1891683364
Cited by
55
References
53
Citations by year
2026: 4 · 2025: 6 · 2024: 10 · 2023: 4 · 2022: 7 · 2021: 5 · 2020: 8 · 2018: 2 · 2017: 5 · 2016: 2
FWCI
0.44
Type
journal article
Language
en
Open access
Licence
onlinelibrary.wiley.com/termsAndConditions#vor (vor)
Locations
  • Ultrasound in Obstetrics and Gynecology (publishedVersion)
  • PubMed (publishedVersion)
  • UCL Discovery (University College London) (submittedVersion)
Topics
  • Health Sciences › Medicine › Obstetrics and Gynecology › Gynecological conditions and treatments
  • Health Sciences › Medicine › Surgery › Intestinal and Peritoneal Adhesions
  • Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Reproductive Health and Contraception
Keywords
intrauterine adhesions, uterine ultrasound, 3D ultrasound, hysterosalpingography, hysteroscopy, endometrial injury, endometrial regeneration, endometrial ablation, endometrial scratching
MeSH terms
Tissue Adhesions, Female, Humans, Hysterosalpingography, Ultrasonography, Uterine Diseases, Uterus, Hysteroscopy

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