Fluoroscopically guided hysteroscopic division of adhesions in severe Asherman syndrome

Severe Asherman syndrome that is stage III disease according to the American Fertility Society, with obliteration of the uterine cavity and the inability to visualize isolated pockets of the intrauterine cavity, makes safe and effective hysteroscopic division of adhesions difficult, if not impossible.

A 16-gauge, 80-mm Tuohy needle is introduced into the endocervical canal alongside a 5-mm diagnostic hysteroscope. The surgeon probes the area beyond the adhesion with the needle. Ultravist 76.9% is injected through the needle under fluoroscopic and hysteroscopic control. Hidden pockets of endometrium can be located radiographically, a passageway is created using the needle, and subsequent division of adhesions is performed under direct vision with hysteroscopic scissors.

Since 1984, approximately 55 women with severe Asherman syndrome have undergone this procedure. All patients required at least two procedures, and one woman required six. There have been two cases of uneventful perforation with the Tuohy needle, and all women resumed menstruation. No serious complications have occurred.

This technique provides an intraoperative fluoroscopic view of pockets of endometrium behind an otherwise blind-ending endocervical canal in women with severe Asherman syndrome, allowing guided division of adhesions and reducing the likelihood of perforation and formation of false passageways.