MVA, Asherman’s and hysteroscopy
Did you have any uterine procedures and your periods disappeared or are less frequent? You may have developed Asherman’s syndrome 😣🕸♀
Dr. Arturo Valdés, Creafam’s fertility expert, explains how even simple treatments such as aspiration (MVA) can cause Asherman’s syndrome (Adhesions) if not carried out carefully. Solving this problem requires a hysteroscopy.
Good morning, today we are going to talk about a hysteroscopy and we are going to see a video of a patient that we just operated on, she is a patient who underwent an MVA, right now we are going to explain a little about this, but remember #KnowEsPower
The patient needs to know in advance what she should do, how she can have a diagnosis and, above all, what treatment is appropriate to improve and solve assisted reproduction problems. I saw this patient just two weeks ago, on the 14th she came. 25 years old with a history of a spontaneous pregnancy 7 months ago, but her pregnancy was stopped, which everyone knows as an anembryonic, that is, the gestational sac was formed, but an embryo never developed inside this gestational sac, so the patient, they decided to do an MVA, MVA is called Endo-Uterine Myometral Aspiration, they are little cannulas that go from 1 mm to 10 mm in diameter and then what they do is aspirate by means of a vacuum, however, at the tip they have a kind of sore or little sharp lesion that is where all the tissue they are aspirating passes through, then, when you do a kind of curettage with the same MVA, it is when these lesions or these inflammatory alterations occur, then, Asherman’s syndrome is: the superior cavity with inferior and no longer allows that endometrium to grow.
She came to the clinic due to a secondary amenorrhea
In other words, she started with menstrual cycles, she got pregnant, but after the MVA, curiously, six months without menstruating, but she was referring to the questioning, which is something very fundamental and very basic when you ask the patient, “Hey, and month after month do you have discomfort or pain? “Yes doctor, every month I have inflammation, it hurts much more than it hurt before and I don’t have any spotting or bleeding.”
So, when I do a vaginal ultrasound, I realize that the ultrasound shows a normal uterus without alterations but the endometrial cavity is cut. The endometrium was perfectly well formed in the entire upper part and nothing was visible in the lower part, when trying to introduce a small cannula… With which we normally do a transfer test, we wanted to put that small cannula through the hole and it did not happen, so, we had to confirm the diagnosis of Asherman’s syndrome with hysteroscopy. We must remember that the hysteroscopy is a metallic tube that has an optical fiber but we can put water through it and we can pass small surgical forceps to do some correction procedure, right now they will see it in the video, it looks super good because we entered. .. It is called a vaginoscopy, that is, we do not insert my vaginal mirror, but with the pure operating channel we enter, we see the cervical orifice, we introduce the tube or the hysteroscope and it is perfectly clear how the cervical canal is, but when we reach the The space where we have to go into the cavity, which is called the internal cervical os, is completely covered. So we did an abdominal ultrasound to visualize where our hysteroscope was, where the uterus is, and also avoid one of the complications that is perforating the uterus.
The surgery begins
We are going to start with a 25-year-old patient, she came to us for a diagnosis of secondary amenorrhea, that is, the patient had not presented her menstrual cycle for four months as an important history, she had a curettage due to an anembryonic pregnancy with a device called MVA , which does not curette, but is like an aspiration, I will explain later, but look here we are with a hysteroscopy, this is the vagina, the cervical canal Here is the cervical os, this is the upper lip, posterior lip, the entire duct or canal cervical, there is a little bit of bleeding. But what I want to show you is: That’s as far as the conduit goes. In other words, we have a small obstruction here, which surely occurred after the MVA.
It must be remembered that MVA is not innocuous, that is, we often think that performing a curettage is more complicated, or has more risks, but MVA can also often generate both cervical and internal adhesions, in this case this patient will we did a vaginal ultrasound and she clearly had the upper third cavity fully formed, but the lower third was not. So, the idea is that we have to go slowly because in these small surgeries there may also be a perforation, because the hole is not identified, so we are going to go slowly to see if we can enter. This part over there is the one that seems to be the most…
In this case we choose to guide ourselves with an abdominal ultrasound, precisely because since we don’t know where we are, the idea of this is to try not to perforate. That’s it, I think we’ve already entered because if you look, a little bit of mucus with blood is coming out. There was the adherence. There it is, we are already entering the cavity surely. And in this case the most important thing is to go very slowly. and preferably, wait for the cavity to open by itself as we cut. Because if we force, we can make a slightly larger perforation, unlike if we go in slowly, if it perforates, it’s not so harmful. We are already inside, this is the cavity. There we have the uterine fundus, which also has a small subseptum or septum. There is the cavity, right now it flattens out a bit because obviously since the entrance is wide, well, this is the ostium on the patient’s right side, see the ostium peeks out a little, it seems to be permeable, the entire uterine fundus cannot be seen no aspiration and the ostium on the left side. There is your ostium, very nice, it also seems to be permeable. This is how a cavity should look, slightly… Well, bone-colored or pink, without any apparent inflammatory lesion, we are going to make a few small cuts in the fundus of the uterus that seemed to have a partition, or a small subseptum.
The anembryonic procedure, remember that the subseptum does not cause anembryonic, hey! Anembryonic is generally a genetic cause, but being able to cut the uterine fundus a bit is with the idea that the patient has that cavity wider and improves the issue of implantation and reproduction of it. We have practically finished the problem, this patient, of having had secondary amenorrhea due to the MVA surgical process, because right now we have solved her amenorrhea problems. As you can see, the visualization suddenly begins to blur because there are some small vessels around the bottom, they are somewhat bloody, they are small, but we have already opened the uterine fundus a little, the cavity is wide, the lateral side is the one that is a little. .. A little tight, but the adhesions were definitely in the lower third. They are left with the confidence of “It’s just that it’s plastic”, yes, but it also causes adhesions. There, the ideal is that you only do it with suction, that is, do not scratch. The pure aspiration We’re done – Already? Now you’re going to be able to menstruate – “Mhmm” And obviously, get pregnant. So, Asherman’s syndrome is not so frequent, but it is a pathology that the patient should know that if after having had an abortion and they do an MVA or a curettage and after this she no longer has menstrual cycles, the safest thing is If you have adhesion syndrome or Asherman’s syndrome, that’s where we tell patients: Come call Creafam. We generally make the diagnosis on the first day of the consultation with the pure examination and the pure interrogation, we go to the diagnosis and the resolution is immediate.
We have just entered this little patient, the process lasts 20-25 minutes, but what is the advantage of this woman? She will no longer have infertility or amenorrhea, that is, she will be able to have her menstrual cycles again, she will surely get pregnant easily, because she is 25 years old and she also got pregnant spontaneously and the third and most important thing is that the problem without the need for a complication. Ambulatory, 25 minutes now the patient is going to walk, in a week we will check her.