A Rare Case of Asherman's Syndrome after Open Myomectomy: Sonographic Investigations and Possible Underlying Mechanisms

Abstract

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

Effect of myomectomy on endometrial cavity: A prospective study of 51 cases

“…[ 7 8 ] Indeed, reasonable evidence exists on the risk of development of adhesions following uterine surgery such as cesarean section or myomectomy. [ 11 12 13 ] In a large observational study of 91 patients, Fauconnier et al . [ 14 ] found a cumulative probability of conception after myomectomy to be lower when uterine sutures were required.…”

Results of centralized Asherman surgery, 2003–2013

“…Formation of adhesions or fibrosis after gynecologic surgery, of the types in these cases, is caused by removal (intentional or unintentional) or destruction of the basal layer of the endometrium, and/or hypoxia or infection. Because of the differing incidence, etiology, and prognosis, we decided to classify them as a different group (11,12). This group is very small in the Netherlands.…”

Prevalence of Intrauterine Adhesions after Myomectomy: A Prospective Multicenter Observational Study

“…Moreover, hidden risk factors, such as tissue hypoxia and ischemia, have been proposed to play a role in the adhesion formation process [8, 15, 20, 21]. Notably, intrauterine adhesions were observed in up to 14% of women after uterine artery embolization, a procedure with no surgical trauma [22, 23].…”