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    Default Know the risks of D&C's - Asherman's Syndrome

    I was officially diagnosed with Asherman's syndrome in April 2012 after having 2 D&C's post early miscarriage in 2010 and 2011. I was completely unaware of the significant risks of this 'routine' procedure which is carried out by many FS and gynaecologists as a 1st line intervention for miscarriage management and can be acquired after a single procedure including suction evacuation. In fact it can be acquired after any type of gynaecologic surgery, however D&C's are thought to be the most common cause.

    There certainly are circumstances where a D&C might be unavoidable such as hemorrhage following delivery and retained placenta. However, understand the risks before you consent to this procedure for management of a miscarriage and ask your doctor about the option of nonsurgical intervention such as misoprostol. If the pregnancy is more advanced, a guided D&C using ultrasound or a hysteroscope will minimise the risks of scarring.

    Why is it so risky? Because the procedure consists of blindly (without ultrasound guidance or a hysteroscope) scraping away the top layer of the endometrium (the functional layer) which can vary in thickness between women but is often not thicker than a few millimeters in most parts. It is simply impossible for a doctor to know whether they have scraped too deeply into the basal endometrium which can scar the uterus and in some cases cause permanent damage. The greatest risks are posed to a recently pregnant and 'soft' uterus.

    The following information comes from http://www.ashermans.org/

    What is Asherman's Syndrome?

    Asherman's Syndrome, or intrauterine adhesions/scarring or synechiae, is an acquired uterine condition, characterized by the formation of adhesions (scar tissue) inside the uterus. In many cases the front and back walls of the uterus stick to one another. In other cases, adhesions only occur in a small portion of the uterus. The extent of the adhesions defines whether the case is mild, moderate, or severe. The adhesions can be thin or thick, spotty in location, or confluent. They are usually not vascular, which is an important attribute that helps in treatment. Click here for more on Asherman's Syndrome grades.

    Symptoms

    Most patients with Asherman's Syndrome have scanty or absent periods (amenorrhea) but some have normal periods. Some patients have no periods but feel pain at the time that their period would normally arrive each month. This pain may indicate that menstruation is occurring but the blood cannot exit the uterus because the cervix is blocked by adhesions. Recurrent miscarriage and infertility could also be symptoms (1).

    Causes

    Asherman's syndrome occurs when trauma to the endometrial lining triggers the normal wound-healing process, which causes the damaged areas to fuse together. Most commonly, intrauterine adhesions occur after a dilation and curettage (D&C) that was performed because of a missed or incomplete miscarriage, retained placenta with or without hemorrhage after a delivery, or elective abortion. Pregnancy-related D&Cs have been shown to account for 90% of Asherman's Syndrome cases(2). Sometimes adhesions also occur following other pelvic surgeries such as Cesarean section, surgery to remove fibroids or polyps, or in the developing world, as a result of infections such as genital tuberculosis(3) and schistosomiasis(4).

    There is a 25% risk of developing Asherman's Syndrome from a D&C that is performed 2 to 4 weeks after delivery(5-8). Dilation and Curettages may also lead to Asherman's Syndrome in 30.9% of procedures for missed miscarriages(17) and 6.4% of procedures for incomplete miscarriages(2). The risk of Asherman's Syndrome increases with the number of D&Cs performed; after a single termination the risk is 16%, however, after 3 or more D&Cs, the risk increases to 32%(9). Each case of Asherman's Syndrome is different, and the cause must be determined on a case-by-case basis. In some cases, Asherman's Syndrome may have been caused by an "overly aggressive" D&C. However, this is not often considered to be the case. The placenta may have attached very deeply in the endometrium or fibrotic activity of retained products of conception could have occurred, both of which make it difficult to remove retained tissue. For the most comprehensive information about D&Cs and Asherman's Syndrome, please click here to visit DandCnow.info.

    There is a variant of Asherman's Syndrome called "Unstuck Asherman's or endometrial sclerosis that is more difficult to treat. In this condition, which may coexist with the presence of adhesions, the uterine walls are not stuck together. Instead, the endometrium has been denuded. Although curettage can cause this condition, it is more likely after uterine surgery, such as myomectomy. In these cases the endometrium, or at least its basal layer, has been removed or destroyed.

    Incidence

    Asherman's Syndrome is thought to be under-diagnosed because it is usually undetectable by routine diagnostic procedures such as an ultrasound scan. The condition is estimated to affect 1.5% of women undergoing a hysterosalpingogram (HSG) (10), between 5 and 39% of women with recurrent miscarriage (11-13), and up to 40% of patients who have undergone D&C for retained products of conception following childbirth or incomplete abortion (14) (see Causes above).

    Diagnosis

    Direct visualization of the uterus via Hysteroscopy is the most reliable method for diagnosis. Other methods are sonohysterography (SHG) and hysterosalpingogram (HSG).

    Prevention

    Ideally, prevention is the best solution. It was suggested as early as in 1993 (9) that the incidence of intrauterine adhesions (IUA) might be lower following medical evacuation (eg., misprostol) of the uterus, thus avoiding any intrauterine instrumentation. So far, one study supports this proposal, showing that women who were treated for missed miscarriage with misoprostol did not develop IUA, while 7.7% of those undergoing D&C did(15). The advantage of misoprostol is that is can be used for evacuation not only following miscarriage, but also for retained placenta or hemorrhaging following birth. Alternatively, D&C could be performed under ultrasound guidance rather than blindly. This would ensure that the surgeon stops scraping the lining when all retained tissue has been removed, thereby avoiding injury. Early monitoring during pregnancy to identify miscarriage can prevent the development of, or as the case may be, the reoccurrence of Asherman's Syndrome as adhesions are more likely to occur after a D&C the longer the period after fetal death (2). Therefore, immediate evacuation following fetal death may prevent IUA. There is no evidence to suggest that suction D&C is less likely to result in adhesions than sharp D&C. Cases of Asherman's Syndrome have been reported even following manual vacuum aspiration, (16) and the rate of Asherman's Syndrome has not dropped since the introduction of suction D&C.

    Treatment

    Asherman's Syndrome must be treated by a very experienced surgeon via hysteroscopy (sometimes assisted by laparoscopy) Those few surgeons experienced enough in treating severe Asherman's Syndrome recommend the avoidance of energy sources inside the uterus (this means removing scars with scissors rather than with energy-generating instruments such as resectoscopes or lasers, although not all surgeons agree with this). Adhesions have a tendency to reform, especially in more severe cases. There are different methods to prevent re-scarring after surgery for Asherman´s Syndrome. Many surgeons prescribe estrogen supplementation to stimulate uterine healing and place a splint or balloon to prevent apposition of the walls during the immediate post-operative healing phase. Other surgeons recommend weekly in-office hysteroscopy after the main surgery to cut away any newly formed adhesions. As of yet, studies have not confirmed the method of treatment that is most likely to have a successful outcome, which would be one where the uterus/cervix remains scar-free and fertility is restored.

    Non Reproductive Consequences of Asherman’s Syndrome


    The reproductive consequences of Asherman’s Syndrome, including infertility, recurrent miscarriage, intrauterine growth restriction, placenta accreta and others, are well known. However, for all women with intrauterine scarring and amenorrhea, including those who may have completed childbearing, there are other concerns. Although the lack of menstrual periods could be secondary to hormonal abnormalities, it is more likely caused by either complete destruction of the uterine lining or by obstruction of the cervix or lower portion of the uterus; thus, menses are either retained in the uterus (leading to pelvic pain and a condition called hematometra) or flow into the abdominal cavity leading to endometriosis. Women with Asherman’s Syndrome may develop uterine cancer, either before or after menopause. This risk is NOT increased and may be lower than in the general population. However, the usual warning sign of uterine cancer is excessive uterine bleeding: those with obstructed menstrual flow cannot have that symptom even if they harbor a uterine growth. Therefore, pelvic ultrasound should be a routine part of their annual gynecologic visit.
    Last edited by Starf1sh; 16-03-2013 at 06:29.

  2. The Following 9 Users Say Thank You to Starf1sh For This Useful Post:

    Buttoneska  (13-04-2012),Frostysmum  (15-04-2012),helenmac  (11-07-2012),KaraB  (13-04-2014),mamakatd  (31-12-2014),Marga  (04-07-2012),Mod-Uniquey  (04-03-2014),SimpsonDesert  (12-04-2012),wishmeluck  (13-04-2012)

  3. #2
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    Starf1sh,

    I'm so sorry that you are battling Ashermans, and that every time you clear one hurdle another presents itself . So not fair .

    It sounds like your AS specialist can make miracles happen and I hope your treatment sees you become another post-AS success story.

    Thanks so much for sharing your story and spreading the word. You are truly amazing for thinking of others at such a difficult time for you .

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    Starf1sh  (13-04-2012)

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    Thanks again Starf1sh for sharing this important information and making this a separate thread. I hope the moderators can make this a sticky. If you could share the details of the AS specialist that will be great, just in case I need that in the future.

    If there's any kharma in this world you will be blessed with the babies you so dearly want. You have been a wonderful source of hope to so many women on Bubhub.

    Wish

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    Starf1sh  (13-04-2012)

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    Wishmeluck I hope you don't mind me reposting your original message here. I know you don't have this diagnosis currently, however your experience gives another perspective on potential complications of AS and how others may come to hear of it. Thanks for sharing your experience Will PM you details for Asherman's specialist and provide more info below.

    Quote Originally Posted by wishmeluck View Post

    I only heard of Asherman's recently as it was briefly mentioned in a conversation by my FS. Although losing my little girl at 15 weeks pregnant was traumatic and painful, I was fortunate that King Edward Memorial Hospital in Perth where I went to deliver my little girl, as a matter of routine now, try and talk all ladies in my position (between 14-20 weeks) to consider medical termination (misopristol) rather than surgical (D&C). Unfortunately for me, I developed an infection about 9 days after the birth and ended up having a D&C for retained product as it was still tethered and getting a blood supply. Incredibly, 2 weeks after that at a follow-up scan my FS found more retained product and I required a second D&C. Although she consulted numerous specialists, the consensus was that it may take up to 9 months to clear on its own, if at all, because they think I had placenta accreta. How I got that I don't know, as prior to this pregnancy, I hadn't had any D&Cs or other pregnancies. I'm now terrified of what scarring has been done, and in addition, wondering about how to cope with the anxiety around birth consequences of the accreta.

    Anyway, sorry to ramble, just wanted to say that I think it is so important you get your message out there as D&Cs are becoming more and more routine. Perhaps start a thread "What you need to know before you have a D&C" and ask the moderators to make it a sticky?

    Once again, so sorry for your losses. All the very best of luck to you.

    Wish

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    If you suspect you may have acquired Asherman's following a D&C I would highly recommend going to see a specialist in this area. Dr Thierry Vancaillie is the only A list Asherman's specialist in Australia and is the Doctor who is treating me http://www.whria.com.au/page.aspx?docid=90 He is based in Sydney.

    However there are other B and C list doctors in Australia with some experience treating Ashermans. The list can be obtained by joining the Yahoo Asherman's Australia support group http://groups.yahoo.com/group/AshermansAustralia

    I know of people in Australia have been successfully treated by their gynaecologist or FS BUT would strongly encourage you to interview them regarding their experience with treating AS. The following list of questions may be a helpful guide to ask your Doctor before going ahead with a diagnostic hysteroscopy. A cautionary note: I did ask my FS many of these questions and he agreed only to use microscissors not an energy source in my uterus but still my Asherman's wasn't appropriately diagnosed or treated post surgery and I wasn't prescribed preventative measures (estrogen supplementation) to stop the scarring reforming.

    Questions to Ask Your Doctor

    Treatment Questions

    How do you recommend treating Asherman's? What type of surgery, hormone treatments, barrier method?
    Are there any treatments or ways in which I can improve my chances of success with overcoming Ashermans?
    If you don’t recommend surgery, what potential problems may I encounter?
    Is there a problem with my cervix being shut if I don’t have surgery? Am I at greater risk of developing endometriosis?
    Is there an increased risk of uterine or cervical cancer if my AS is untreated? How would I know if I had these types of cancer?
    Will my scarring get worse over time? Will it be more difficult to remove in the future?
    (If applicable) The scan showed a hematometra i.e. stale trapped fluid in my cavity – once this is released from my uterine cavity will there be a risk that my uterine walls will fuse together with scar tissue while it is healing? If there is a risk is there something you can do to prevent this from happening e.g. a barrier method etc?
    Is the first hysteroscopy planned strictly a diagnostic procedure?
    If you do find extensive scarring in my uterine cavity, would you consider leaving this alone (if beyond surgeon’s experience level) and discuss with me what my options are next or will you attempt to remove it then and there?
    If you attempt to remove it how confident are you that you will be successful? Would you consider referring me to an A-list doctor who routinely treats Asherman’s patients, to give me the best possible chance of recovery?
    If there is scarring and after answering these questions we decide you are the best person to remove it, how will you prevent it from reforming? Will you use a barrier method like a balloon or will you do in-office hysteroscopies to remove any further scar tissue that is reforming?

    Doctor Background Questions

    Have you treated cases similar to mine? As severe? Did these women go on to have successful pregnancies?
    How many Asherman’s patients have you treated (via surgery) in an average year? What types of surgery do you perform most frequently?
    What procedures do you use to avoid uterine punctures?

    Diagnosis Questions

    What caused my Asherman’s Syndrome?
    Was this preventable?
    How often does Asherman's Syndrome occur in women?
    Can scarring be caused by an infection?
    What tests/hormone treatments would you recommend to make a proper diagnosis?
    What severity of Asherman’s do I have? (This and the other questions below assume you have been diagnosed.)
    What percentage of my cavity is open?
    Where is most of the scarring?
    What type of scarring do I have? Flat scarring (on walls of uterus) or adhesions holding the sides of the walls together? Is the scarring difficult or easy to remove?
    Can you tell if my scar tissue is very dense, calcified or difficult to remove?
    Can you tell if the scarring is covering my tubes? How difficult is it to remove the scarring in this area? Is there a risk of doing irreparable damage to my tubes?
    How is my endometrium? Is it continuous or one that has parts missing?
    How thin or thick is my endometrium?
    What methods would you recommend to increase the thickness or amount of endometrium? Baby aspirin? Viagra? Acupuncture? Herbal treatments?
    Is the hysteroscopy planned the best course of treatment at this current stage based on the information we have in front of us or is an HSG or SHG to determine Asherman’s a possibility?

    Surgery Questions

    If I am a candidate for surgery, how would you handle my case? How do you treat women from out of state/country? Do you work with doctors here in my state/country?
    What will you do if you find the scar tissue is very dense, calcified or difficult to remove?
    Do you use the balloon method or other barrier methods post surgery to prevent the adhesions from reforming? Will you prescribe an antibiotic while the barrier is inside my uterus?
    Some doctors don’t use antibiotics after hysterscopic surgery unless a barrier method like a balloon has been placed inside the uterine cavity. However, considering all I have been through would you consider putting me on antibiotics to safe guard against infection anyway?
    How long does it take to schedule surgery?
    How long does it take to recover from surgery?
    What post-operative follow-up care do you recommend? When does this occur?
    How many surgeries would I need to correct my Asherman’s?
    How will you know if you have removed all of my scarring?
    What is the average price of surgery? Do most insurance companies pick up these expenses?
    What are the potential side effects/risks of doing surgery? Will my Asherman’s get worse?
    Is there a risk you would need to perform a hysterectomy?
    What instrument will you be using in my surgery? I understand that there are three types that are typically used, micro scissors, yag laser, and resectoscope (electrocautery). Please explain the benefits and risks of the type of instrument that you will use during my surgery. Is one of the above mentioned instruments more safe than another?

    Post-Surgery Questions


    What is the prescription for hormones aftercare and how long will I be on them? Can I call the office for any questions or problems I may have with these hormones afterwards?
    When will I know if the operation has been successful?
    How/when will I find out if the scarring has reoccurred? Will it grow back after a year or if it's not there after a few months does that mean it's gone for good?
    When can we start trying to conceive again?
    Is there an advantage to becoming pregnant speedily or is it okay to try ourselves and wait without having fertility treatment?
    What diagnostic test do I need to find out if my tubes are open or if the AS has caused endometriosis/ damage to tubes/ovaries? When can I have this after this surgery?
    Would you recommend having a 3d ultrasound scan to check for scarring over having another hysteroscopy?
    How soon can we have intercourse?
    What do I do, and how can I tell, if I get an infection after surgery?
    Do I have antibiotics after the operation?
    Can I reach you by phone if I need anything after the operation?
    How do I know if my lining has improved - how is this measured?
    What percentage of my cavity was open?
    What percentage of my cavity is now open?
    Was the scar tissue dense, calcified, difficult to remove?
    Am I scar free?
    If not, why hasn’t all the scarring been removed?
    Is my endometrium continuous?
    Were the Fallopian Tubes obstructed?
    Have they been free from obstruction?
    Can you say that it was the D&C that caused my AS?
    What post-operative follow-up care do you recommend?
    For how long will I bleed?
    What post-surgery symptoms that I may develop that I should be concerned about?
    When can I go back to exercise?
    When is it safe to have sex again?
    Did you use a barrier?
    If so, which method did you use and why?
    How effective are barriers in preventing re-scarring?
    How long should the barrier stay?
    Can any gynaecological doctor remove it?
    Will you provide instructions?
    Does the barrier pose a risk of infection?
    How do you address the risks of using a barrier?
    Will I re-scar?
    Will I need another surgery?
    What are my chances of having a child?
    Do I take contraceptives? Which one? Why? For how long?
    Do I take hormones, antibiotics? Which one? Why? For how long?
    What methods would you recommend to increase the thickness or amount of endometrium?
    When should I expect my period?
    When should I have the HSG?
    Would you recommend natural conception or IVF?
    When can I start IVF?
    What are the chances of conception with IVF?

    Questions Regarding Hormonal Therapy Post-surgery


    What can I expect re my cycle and bleeding while on the estrogen?
    What kind of side effects can I expect from estrogen?
    How long will I be on hormone therapy for?
    When will my cycle return to normal?
    Will it ever be normal?
    Do I ovulate on the estrogen?
    When will I bleed after stopping the estrogen?
    Can I expect my bleed to be painful?
    What happens if I do not respond to the estrogen? Are there other options?
    Some of the girls are on progesterone. What is this for and why? Will I need it too?

    Questions Regarding Additional Surgeries (if necessary)


    Where the scarring is, is this where a healthy embryo would more than likely try to attach itself?
    How long will the next surgery be?
    How does the laparoscopy work?
    What happens after the next surgery? When will we know my Asherman’s has been successfully treated?
    Will you do an HSG to check? Or another diagnostic procedure?
    Do you do in-office hysteroscopies where general anesthesia is not needed?
    Should I think about taking baby aspirin to help with lining growth?
    What happens if we are not successful with the next surgery?

    Summary Questions

    What are my next steps? Where do we go from here?
    Would you recommend a third opinion?
    Do you know of any other Asherman’s Syndrome Support Groups other than the Yahoo online group?

    FROM http://www.ashermans.org/

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    Great post Starfish - I am also an Ashermans sufferer due to multiple d&c procedures. After trying for over 3 years with IVF I am 12 weeks pregnant and if I knew know what I knew then I would not have so easily agreed to those procedures. It needs to be more common knowledge in all my D & C procedures Ashermans syndrome was not once mentioned by any doctor.

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    Starf1sh  (15-04-2012)

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    Congratulations Petrult on your post Asherman's pregnancy

    Do you mind if I ask you how you were diagnosed and what treatment you received for your AS?

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    Quote Originally Posted by Starf1sh View Post
    Congratulations Petrult on your post Asherman's pregnancy

    Do you mind if I ask you how you were diagnosed and what treatment you received for your AS?
    Thanks Starf1sh, my Asherman's was diagnosed by my FS after we did a full IVF cycle which all went well and had one embryo put back which failed to implant. We then went on to do a FET not long after and was cancelled due to the lining scan being only 3cm. I then had a hysteroscopy and laporoscopy as my FS had thought from the beginning I was at risk of Ashermans due to the D&C's that I had previously. It was found that one of my tubes is closed due to scarring and also that my uterus was scarred closed and it was very bare with not much lining left. He removed the scarring that he could and then left it to see what would happen with time. I was told to wait 6 months then had another op so he could have another look inside. The scarring had not come back the lining was still a bit bleak but better. I then waited a few more months and did another FET with a lining at 5cm, both embryos failed to take again. In both my failed FET cycles I was on estrogen high dose to grow the lining. I then had another break of 3 months but this time FS put me on a more natural cycle - no estrogen but this time it was a stimulated cycle similar to clomid. I responded well with at least half a dozen follies and my lining was 7cm at my scan then had an injection to ensure that I ovulated and stimulated my lining further. I then had two transferred and both implanted however twin A stopped growing at about 7 weeks. My FS was extremely happy that both implanted that shows that my lining has recovered on it's own with the time it was given.
    That's my story in a nutshell, and I feel for you in a way that most people will never understand, we even looked into surrogacy as a last option its a horrible feelling to never know what the outcome will be, but give it everything you have and when you think it's never going to happen it just may. I am still terrified having a post Asherman pregnancy and miscarriage, I won't relax until the end when I have a healthy baby in my arms.
    All the best in your journey.

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    Quote Originally Posted by petrult View Post
    That's my story in a nutshell, and I feel for you in a way that most people will never understand, we even looked into surrogacy as a last option its a horrible feelling to never know what the outcome will be, but give it everything you have and when you think it's never going to happen it just may. I am still terrified having a post Asherman pregnancy and miscarriage, I won't relax until the end when I have a healthy baby in my arms.
    Thank you so much Petrult for sharing your story. One of my reasons for wanting to raise awareness of AS is that the gravity of the situation and what might have been done differently often doesn't come home to you until you get the diagnosis. Your experience with repeated thin linings was similar to mine, although I'm glad your FS was more switched on to the possibility of Asherman's than mine.

    There is a wonderful woman on the Over 35's thread who is about to deliver her post AS baby full term and her story is quite inspirational if you haven't already seen it.

    I wish you all the best with your pregnancy. I will be you on and crossing my fingers for you also for a full term delivery

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    Thanks Starf1sh I'm very happy with my FS, he was our second opinion and luckily we didn't waste alot of time on the first FS he just didn't seem interested. Nothing like this one, he even suggested having a look in the uterus before we started IVF as it was what he thought from the very start. We live a fair way from any specialists and he is an extra 200 kms away than our first FS was but well worth it.
    Where are you at with your treatment at the moment if you don't mind me asking and has there been any improvement as yet ?


 

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