answers from Dr. Putz!!!! and other questions answered

[Guest guest]

Hi,

I have just come back from Dortmund, where I had 1 1/2 hours (!!!) to

talk to one of the well known specialists for Ashermans, it was a day

trip so I had to catch up on all the messages last night. I am a little

confused what to do next, there are so many things he told me and I would

like to forward to you all and so many messages to reply to .... So this

is going to be a long e-mail NOT because it is one from Corinna :-) but

instead there is so much information.

First of all here are the answers to our questionnaire, but, please keep

in mind that it was an interview and it was in German and therefore

excuse any mistakes, don´t hesitate to ask as some details might be

misunderstood because for wrong translation ...

(I might add that he was really nice and I felt fine when being there. I

trust he really is a very good surgeon.)

1.What is the best test available to diagnose the presence of scar tissue

and therefore Ashermans? i.e. Ultrasound, HSG, hysteroscopy or

other?

a diagnostic hysteroscopy with or without anaesthesia (whatever the

patient prefers); HSG and hysterosonogram are only " second "

looks, because you look at the fluid and not at the uterine cavity

itself; and the fluid might cause infection (rare though); why should he

use HSG or hysterosonogram when being able to have a first-class-look?

The hysteroscopy should be done in the first third of the cycle because

you can see better when the endometrium has yet not grown that much.

2. It can take some doctors years to diagnose a patient with Ashermans.

What immediate signs do you think any doctor should be aware of

diagnosing a patient for Ashermans?

If a patient has had recent D & Cs after a pregnancy and can´t be

stimulated to have a period with hormones (it takes 4 weeks to find out)

then a hysteroscopy should immediately be performed, even when not

knowing about Asherman´s.

3. Do adhesions calcify over a period of time? It so, are they more

difficult to remove at that point? In your opinion, how long does it take

the adhesions to calcify and why does this occur?

Sorry, we did not talk about calcification (forgot to ask) but he said

that after a certain time (no exact frame given) they are harder to

remove.

4. Are there different types of adhesions within a uterus? It so, which

are easier to remove and which are not?

There are different types but it depends not only on the type whether

they are easy to remove or not. If they have grown across the uterus they

will be easily removed with the scissors, if they are attached to the

walls it might not be able to remove them at all as the original shape of

the cavity can´t be figured out.

5. Which surgical approach do you recommend to help the uterus regain its

best possible condition?

Hysteroscopic treatment, normally no IUD etc. He knew of Interceed

but prefers, if a device at all, a brand new developed gel. He will look

it up again for us, has used it once so far. It dissolves like interceed,

too.

During the surgery he either uses the microscissors or the laser (for

more difficult adhesions, the hot laser stops the bleeding, that occurs

when cutting the adhesions, and one of the main concerns for the surgeon

is to avoid bleeding). The laser does not damage the remaining

endometrium because it is only hot at the very tiny tip of the

" pen " .

He knew of myometrial scoring for severest cases but would consult Dr.

Gallinat in Hamburg (the one who operate me, thank God!) to make sure

before using anything like that.

He doesn´t consider adhesions in the cervix only being Asherman´s. He

said that other women with totally different stories do have them, too.

And they are no problem. They " don´t count " and can easily be

cleared with the tip of the probe.

6. What procedures and precautions do you believe a doctor should do to

avoid Ashermans? Such as: Using too sharp of an instrument during a

D & C? Doing an ultrasound at 1-2 weeks after a complicated delivery or

premature delivery? Etc.

A D & C in a recent pregnant uterus is quite difficult.

Make sure that a patient with retained placenta is covered with

antibiotics before and after the D & C. The antibiotics should also be

for the an(a)erobic bacteria!

7. Do you believe a doctor should have previous experience on Ashermans

surgeries before he/she attempts to correct the problem, or can this type

of surgery be done by any OB/GYN?

The experience is the most important factor of all when correcting

Ashermans!!!! An unexperienced doctor can make everything worse!!! Most

GYN/OBs in Germany are all not interested in graduate medical training

(i.e. for Ashermans). Once they settle down with their own office they

are only interested in how to gain more money. (He was getting really

upset at this point)

8. Do you recommend any barrier after surgery? i.e. balloon, IUD,

Interceed. State reason for preference or no preference.

see 5, a barrier could cause an infection!

9. What strength of estrogen, if any, in your opinion is considered most

effective following surgery, and why?

2 mg Estradiol 11 days, then 2 mg Estradiol + 0,5 mg Gestagen the next 10

days, then 7 days break for a period, all this for 3 to 6 months, depends

on the endometrium development

10. How quickly do adhesions reform after a hysteroscopy to lysis the

adhesions and can they continue to grow?

2 to 4 weeks (no comment on continuing growth)

11. When (time frame) and what type of test should be performed to check

for reformation of scar tissue following surgery?

a diagnostic hysteroscopy is absolutely sufficient and the best way (see

answer to question 1); the fact that there are so many HSGs done in the

USA could only be due to the fact that there is a different insurance

system and - maybe - HSGs allow to earn more money. But he is not sure,

just wondering.

12. When the scar tissue is down to the muscle wall of the uterus,

can surgery or hormone intake or even Viagra encourage the growth of new

endometrium or only increase the growth of existing endometrium? If the

latter were correct, would this cause a problem during pregnancy?

Estrogen will only help if there is any endometrium in the uterus left.

It may then also grow again in those areas that have been severely

damaged.

13. If the cavity is still small after surgery does this tend to mean

that there are still lots of adhesions left inside the uterus?

Normally, yes.

14. Once an Ashermans patient has become pregnant following successful

surgery or treatment, what cautions and care should be taken to continue

this success?

once the pregnancy continues after the first 8 weeks, none, but high risk

of losing the embryo within the first 8 weeks; very rarely there is

placenta accreta;

15. Apart from getting the endometrium to thicken, which other factors

play a vital role in maintaining a pregnancy to full term in Ashermans

cases?

Complete removal of adhesions (same answer as Dr. Valle), because there

will be the risk of membrane rupture (amniotic sac) if adhesions are

still left; this is like a balloon being clued at one point and then

being blown up, it will tear a lot easier. Furthermore there is not as

much endometrium in the cavity if there are adhesions left; therefore

abnormal placenta might take place.

16. Once Ashermans is treated, what would you consider the minimum

" safe " endometrium thickness for a successful pregnancy? 3, 7

mm on each side should be fine. He has experienced term deliveries with

much less.

17. Can further D & C's or surgeries to an Ashermans sufferer worsen

their situation? e.g. after a miscarriage, fibroids etc. attempt at

removal of further adhesions?

Only, if again the surgeon is scrapping too hard (but as already stated

it can happen in a recent pregnant uterus); but " once an Ashermans

patient, always an Ashermans patient " is certainly not correct.

18. When a patient is admitted to hospital with retained placenta and an

infection, is it better to treat the infection first and then remove

placenta or the other way round? Or does this not make a difference?

The retained placenta and the infection relate to each other; the lochia

is a very nutrient solution for any bacteria (it should in fact be used

in the labs :-)); so both need to be treated, but at least antibiotics

should be given at once even when the surgery is scheduled the next

morning;

19. Is there research being done on repairing or regenerating the

endometrium within the uterus?

Yes, but very rarely.

20. Is it dangerous to leave Ashermans untreated, if someone in not

intending to get pregnant? For example, if one gets a menstrual flow and

is not being passed through the cervix because it is closed shut from

scarring, could this blood leak backwards and out through the fallopian

tubes and in time

cause endometriosis?

No, as long as there is no cyclic pain. Back leave of blood can occur in

some patients but they usually develop pain. (exactly same answer as Dr.

Valle) This is then called Haematometra (spelling?).

21. Does having had Asherman's, or even just having a small amount of

scar tissue present in the uterus, affect the estrogen receptors in the

uterus in any way, so that the endometrium does not respond to the

effects of estrogen and thus does not thicken properly, even when

supplemental estrogen hormones are given? Can this be determines and/or

treated?

No.

22. Does having had Asherman's, even if minor and well corrected, every

in any way decrease blood supply to the uterus/endometrium? Can this be

determined and/or treated? Can decreased blood supply also affect

endometrial growth/thickness?

No.

___________

Further questions asked and following answers:

a) Does nursing a child (and therefore lower estrogen level) interfere

with the healing of the endometrium after apostpartum D & C?

Well, purely in theory it could, but this is only a hypothesis. It is NOT

worth it to stop nursing the child just to go along this

hypothesis!!!

Is a cervical cerclage or baby aspirin useful for a pregnancy after

Asherman´s? No.

c) Should one try to use IVF to place the embryo in a not damaged area of

the uterus? This is not possible. You can´t predict even with IVF where

the embryo will attach.

d) If there are placenta pieces left, is this gross negligence? It

depends on the size of the placenta pieces; when they are bigger than or

5 cm big it is considered gross negligence and you should be able to sue

successfully.

e) Why would the surgeon not be able to reconstruct the uterine cavity

100%? In severe cases adhesions are left because the surgeon can not find

the original shape of the cavity.

f) Do you think there are two different groups of Asherman´s patients:

one where the adhesions reoccur and several surgeries are necessary and

pregnancies are at very high risk and one with

only a one step surgery necessary and more chances of term deliveries?

No.

g) How long can it take after the estrogen treatment is finished to have

a normal cycle? 1 to 3 months, if then a period does not appear, you

should see the RE again.

h) How serious is a perforation of the uterus? Nothing serious at all. It

can happen (rare though) but it is sewed and that´s it. It does not at

all make a following pregnancy more complicated, don´t worry! (Poly, how

about this?)

h) Whom can you recommend for surgeries on Asherman´s in Europe? Dr. van

der Pas in Rotterdam and Dr. A. Gallinat in Hamburg. They are both

" Popes of Hysteroscopies " .

_______

I will post this to all of you first, and then send another e-mail

tonight or tomorrow with other thoughts and replies (Poly). Corinna