Is scar tissue inside your uterus causing infertility or miscarriage? Maybe! In todays
episode of infertilityTV, I will explain how to find and treat this hidden problem.
First, some definitions and clarifications. Today we are talking about scar tissue INSIDE
the uterus which is completely different from scar tissue OUTSIDE of the uterus. Scar tissue
outside of the uterus is referred to as pelvic adhesions. Scar tissue inside of the uterus
is called intrauterine adhesions. You may also hear it referred to as Asherman’s syndrome
The inside of the uterine cavity is lined with a layer of special cells called the endometrium. In
certain situations, these cells can be damaged or destroyed causing scar tissue to be left behind.
Which situations would cause scar tissue to form inside the uterus? Number 1 - Bacterial
Infection that affects the uterine lining. Number 2 - Surgery performed on the inside of the uterus.
For example, a procedure to remove a polyp or fibroid can result in scarring. Another type of
surgical procedure called a D&C or dilation and curretage can also cause scar tissue.
It is most likely to cause a problem if a D&C had to be performed after a delivery or a miscarriage
because there was placental tissue that remained in the uterus. Number 3 - Rarely,
the presence of an intrauterine device may result in adhesions within the uterus.
There are different categories of intrauterine adhesions. Category 1 is called a band adhesion.
This type of adhesion is a single piece of tissue that runs from one wall of the uterus
to another. It can be very thin which is called a filmy adhesion or it can be thicker and even
have blood vessels running inside. This is known as a vascular adhesion. Category 2
is called a contact adhesion. In this type, the walls of the uterus have gotten
stuck together. The affected area is usually larger than is seen with a band adhesion.
Category 3 is when the entire uterine cavity has been affected. Really, this type of adhesion is a
more severe version of category 2. Doctors will refer to this as uterine cavity obliteration.
How can you determine if you have scar tissue in the uterus? The first method is to assess your
menstrual bleeding. Lets say that your periods used to come every month, last for 4 to 5 days
with 4 heavy days and one light day but then you had a miscarriage and a D&C. Afterwards,
your periods were still coming every month but now it lasts only two days and is not as heavy.
This situation would be very suspicious for scar tissue in the uterine cavity. In some cases,
a person's periods may stop completely. This is suspicious for complete cavity obliteration.
Keep in mind that if you have adhesions that only affect a small area of the uterus,
you may not notice any change in your periods. In some cases, changes in your
bleeding can be due to other causes like failure to ovulate. Menstrual bleeding,
therefore, is not a perfect method for assessing for intrauterine adhesions.
What sort of tests can a fertility doctor perform to look for adhesions?
There are three. The first test is called a saline ultrasound or hysterosonogram. During this test,
a catheter is inserted into the uterus and salt water is squirted inside. A vaginal ultrasound
is then performed. The salt water pushes the walls of the uterus apart so that scar tissue can be
seen with the ultrasound. A second test is called a hysterosalpingogram or HSG for short. This test
is similar except that the fluid being squirted inside the uterus is contrast which shows up on
x-rays. Instead of using ultrasound, an x-ray is used to view the uterus. The third test is
different. It is called hysteroscopy. During this test, a small fiberoptic scope is inserted
into the uterus. Instead of using ultrasound or x-ray, the doctor looks inside directly.
If scar tissue is identified, then hysteroscopy is also used to get rid of it.
This type of hysteroscopy, called operative hysteroscopy,
is usually performed under anesthesia so the patient is asleep. The fertility doctor inserts
an instrument through the scope and into the uterus. Scar tissue can then be cut or vaporized.
Sometimes scar tissue in the uterus can come back. The general rule of thumb is that the more scar
tissue you have, the greater the chance it might return after surgery. Your doctor may try a few
tricks to reduce the chances that the scar tissue will recur. One option is to leave a balloon
in the uterine cavity for a few days after the surgery. Another is to use hormone medications to
help the normal uterine lining grow more quickly to cover the areas where the scarring was removed.
In some severe cases, it might require more than one surgery
to finally get rid of scar tissue in the uterus. In some really severe cases,
it might not be possible to reconstruct a normal uterine cavity and those patients
may need to use a gestational carrier or surrogate to carry a pregnancy for them.
Our Infertility TV Bottom Line is this. Scar tissue inside the uterine cavity can affect
your ability to become pregnant and increase your risk for miscarriage. Your fertility
doctor has a number of options to diagnose and fix this problem - be sure to ask about it.