Tuesday, July 28, 2009

Update on latest articles (29/7/09)

I just did my regular NCBI Pubmed search using the keywords Asherman's syndrome and intrauterine adhesions and was glad to see 2 new articles:

1. Faivre E, Deffieux X, Mrazguia C, Gervaise A, Chauveaud-Lambling A, Frydman R, Fernandez H. Hysteroscopic management of residual trophoblastic tissue and reproductive outcome: a pilot study. J Minim Invasive Gynecol. 2009 Jul-Aug;16(4):487-90.

Click here to read abstract. This one is an observational study.

2. Thomson AJ, Abbott JA, Deans R, Kingston A, Vancaillie TG. The management of intrauterine synechiae. Curr Opin Obstet Gynecol. 2009 Aug;21(4):335-41.

Click here to read abstract. This one is a review on treatment and outcomes.

I haven't read them yet but will do so as soon as I get them, and will pass on any relevant information/comments. I am particularly happy to see that the first article proposes the use of hysteroscopic guidance instead of blind surgical curettage (ie. D&C) to remove retained products of conception (trophoblastic tissue). This would certainly be a step in the right direction. Prof. Herve Fernandez has notably another publication on hysteroscopic outcomes in patients with severe Asherman's syndrome.

The group leader of the second article, A/Prof Thierry Vancaillie, practices in Sydney, Australia, where I live and is one of a handful of 'A list' Asherman's specialists from around the world who who was recommended to me by the Asherman's International Support Group. He officially diagnosed my intrauterine adhesions.

Thursday, July 23, 2009

Law suits and Asherman's syndrome: another failure for victims

You would think that if a ObGyn that performed a 'straightforward, routine' D&C which resulted in intrauterine adhesions and infertility (ie. Asheman's syndrome) you would have legal recourse. Think again. The vast majority of these cases end up with the patient not winning any damages. Incredible but, sadly, true. This is why I am so gung-ho on replacing D&Cs with drug alternatives which currently exist. It's simple madness to go through with a D&C which can decimate your fertility while the doctor gets away with it scot free. No wonder D&C continues to be such a popular surgery- there is no incentive to stop or at least be a little more discrimminating in its use when doctors are not held accountable for the outcomes. So simple too, even an intern can do it and no one will find out if it was a disaster until the damage is already done!

I would love for there to be an open list of doctors who caused Asherman's syndrome from D&Cs that were deemed to be simple and straighforward, not in any life-threatening emergency situation, for example (I'm more sympathetic to doctors who faced emergencies). This list would at least warn other women to avoid those doctors and have well-deserved repercussions on their wallets. It is afterall, their duty to care for their patients and not cause them harm and if they caused Asherman's syndrome from such a 'straightforward' procedure, they clearly breached their contract as a medical professional.

OK, I contend that it is difficult, maybe impossible, to not cause any damage from a D&C when you are poking objects into a small, soft, and fragile organ you cannot even see. But this is my point: if doctors want to continue pretending that it's acceptable to do D&Cs and stubbornly refuse to offer cheaper and less invasive drugs or a visually guided method like hysteroscopy, they should be held responsible for the consequences. As the situation stands, they continue to have their cake and eat it too. D&Cs, unlike hysteroscopy, do not require much skill (it’s hard to judge the outcome when the organ is concealed), and unlike misoprostol, it is financially rewarding to hospitals, Gyns/ObGyns, and anesthesiologists. Why would they want to work harder than they already do or earn less?

So why do these legal suits lose? One obvious reason is that medical malpractice suits have always been difficult to win because doctors are very well protected. Doctors are extremely supportive of each other and it is difficult to find a doctor who is willing to give expert medical advice in a case implicating a peer. This probably stems from reciprocity: "I'll scratch your back, if you scratch mine." Who knows if said medical expert will not face a malpractice suit (justified or not) some time in their career...

What perplexes me is that a lawyer can take on a medical case without having a medical or scientific degree or understanding basic health issues. Come to think of it, it is also somewhat disturbing that doctors don't need to be taught how to think objectively and critically to practice medicine, but I digress...

Defense lawyers and doctors will come up with all sorts of excuses to dismiss a valid medical case against them. This is where the Asherman's syndrome myths come in so handy. They are ‘facts’ which continue to be accepted without real evidence, often hypothesized decades ago at a time when well respected doctors in the field could formulate opinions without any scientific basis or need for clinical trials (no wonder some of them developed a ‘God complex’) and their peers believed them and even today continue to cite their published theories in the guise of ‘evidence’ in peer-reviewed medical journal articles. These opinions, in particular about Asherman’s syndrome, have over the years transformed into ‘dogma’ which medical school students are indoctrinated with. Somehow no one ever asks “Why are we blindly accepting what this doctor 50 years ago suggested when they didn’t have the advances in knowledge, diagnostic/surgical tools and understanding of evidence based medicine that we have today? ” Which leads me to wonder, as medicine is becoming more and more scientific in nature (evidence-based medicine), will this change the expected outcomes of some cases? I think it will inevitably do so. But there is still a long way to go.

I also wanted to mention a legal perspective which has always riled me in relation to Asherman's syndrome (I would think it also applies to other medical injuries affecting fertility): in a court of law where the nature of injury and of suffering are apparently graded, it makes no difference whether you had 10 children or none before the injury leading to infertility. Now, I know from the Asherman's International Support Group that such an attitude is promoted to keep the peace and encourage bonding (“we’re all in the same boat”), but to think that the law makes no distinction between someone who has been prevented from ever reproducing (a basic human right according to the United Nations charter) and someone who has done so is just plain cruel. There is no 'scientifically correct' answer to this, but one would think that the logical and instinctive answer is that the condition has more consequences for those who never had children before the injury than those who have.

It is difficult to find information about Asherman’s syndrome law suits on the internet, and judging by the number of visits this particular entry gets, it would appear to be an area that many women would like to learn more about. I have downloaded the few articles on lawsuits I have been able to find and will write another blog entry (one day) about what I find out from them. From a quick scan though, what I can say is that it appears that most of the successful lawsuits do not stem from injury of the D&C per se which caused Asherman’s syndrome, but from ‘negligence’ of a doctor to correctly identify and remove retained products of conception/placenta. It would appear that the law considers D&Cs an inherent risk, although curiously, women who give their ‘informed consent’ are rarely told of the specific risks of Asherman’s syndrome or the correct incidence rates.

The failure of justice for Asherman’s syndrome sufferers who underwent routine D&Cs for standard care is yet another argument in favour of Asherman’s syndrome prevention by replacing D&Cs with medical management or hysteroscopy…

Thursday, July 9, 2009

(Opinion) Asherman's syndrome and abortion: A convenient misconception?

In my last post I brought up the issue of abortion because usually the topic of Asherman's syndrome only gets mentioned by the public in the context of abortion which is very misleading. I just want to remind you that the intention of this blog is not about abortion, but about Asherman's syndrome, D&C safety, medical ethics and alternatives to D&C.

As I mentioned in my last post, one reason for the misconception linking Asherman's syndrome only to abortion is that doctors rarely address the point by clarifying that:

-There are ways to perform abortions without the use of surgery (D&C), therefore safely, so the point is irrelevant, and

-The same surgery as that used for abortions (D&C) is used commonly in gynecology and obstetrics.

In this
youtube clip Dr Paul Indman, who is experienced in the treatment of Asherman's syndrome, states that the condition is more often seen in women after a D&C for miscarriage or retained placenta, especially when repeated, than in women who have had a D&C for abortion.

Despite this medically known fact, this and many other myths about Asherman's syndrome continue to linger. Please watch my youtube clip.

Many women who have had Asherman’s syndrome from a D&C, myself included, feel strongly that D&Cs should not be performed, whether they are for miscarriages, diagnostic purposes or for abortion. Yet many doctors-even some Asherman's syndrome experts- are adamant that D&Cs can never be replaced, something which I as a PhD scientist and student of Public Health and Evidence Based Medicine know for a fact is untrue after having read several clinical trials on
misoprostol use for miscarriage management (1)(2)(3)(4)(5). In some parts of Europe misoprostol has gained acceptance as a valid alternative to D&C. Perhaps the absence of anti-abortion activists and strong religious influences accounts for the widespread availability of misoprostol and mifepristone in Switzerland and some parts of Europe.

Therefore doctors continue to perform D&C even though it is known that complications can occur, and that there are some good alternatives including drugs for uterine evacuation (eg. miscarriage, retained placenta, abortion) and
hysteroscopy for uterine surgery (eg. fibroids, polyps) and in selected cases for miscarriage management (6). Only about 15% of US Gynecologists are trained in office hysteroscopy. The drug misoprostol, for example, is very cheap and there are no surgery related costs including anesthesia or operating room costs. Yet women in developed countries continue to have their reproductive organ-their endometrium-mutilated by the continued use of D&Cs.

Could it be that many doctors see it's in their best interest to stick to D&Cs which are more financially rewarding than prescribing drugs and less skill intensive than hysteroscopy? It may even be convenient that this whole D&C safety issue can be covered up by the abortion debate. There's nothing like a moral controversy to hide inconvenient truths. It is also a good way to deny responsibility for what is really an iatrogenic condition, avoiding law suits. In fact, doctors refrain from using the word 'iatrogenic' when describing Asherman's syndrome, yet it is more often than not the case. Their attitude towards abortion is different though. Abortion is a woman's choice, and they reason that if she chooses to have an abortion and her uterus ends up scarred by the D&C, it was the result of her own choice (not really because anyone should be given informed consent, but that is how some people might see it). They may feel it is more important to warn women about the risks of abortions- which she could (and perhaps in their mind 'should') choose not to have- than a miscarriage, which a woman has no control over. Or they may reason that women who abort should be given drugs instead of surgery to reduce the risk of infertility resulting from her own decision. I saw this inconsistent line of thinking in a paper and felt it was offensive. The medical community is doing a big disservice to women when it does not point out that these complications happen to women who never chose to miscarry, or have D&Cs imposed on them for other reasons. It is equally unacceptable for women to develop fertility and/or obstetric complications from a D&C for treating a miscarriage or for other reasons that were not of her own choice. All women need to be protected equally from potential harm.  

Whether the present situation is due to ignorance, moral confusion or denial on the part of many doctors about possible complications from D&C and alternative treatments, something needs to be done to change current mentality and awareness of the problem. Already over a century has passed since the link between Asherman's syndrome and D&C was first made (7). In some countries at least, blind surgery continues...and worst of all, possibly due to a warped argument of 'morality'.


(Please note that in medical terminology, 'abortion' is often used s a synonym for 'miscarriage' and does not refer to elective termination...which probably fuels myths among people who don't understand this.)

1. Moodliar, S, Bagratee, JS, and Moodley, J. Medical vs. surgical evacuation of first-trimester spontaneous abortion. Int J Gynaecol Obstet 2005;91(1):21-6.

2. Bique, C, Usta, M, Debora, B, Chong, E, Westheimer, E, and Winikoff, B. Comparison of misoprostol and manual vacuum aspiration for the treatment of incomplete abortion. Int J Gynaecol Obstet 2007;98(3):222-6.

3. Weeks, A, Alia, G, Blum, J, Winikoff, B, Ekwaru, P, Durocher, J et al. A randomized trial of misoprostol compared with manual vacuum aspiration for incomplete abortion. Obstet Gynecol 2005;106(3):540-7.

4. Shwekerela, B, Kalumuna, R, Kipingili, R, Mashaka, N, Westheimer, E, Clark, W et al. Misoprostol for treatment of incomplete abortion at the regional hospital level: results from Tanzania. Bjog 2007;114(11):1363-7.

5. Dao, B, Blum, J, Thieba, B, Raghavan, S, Ouedraego, M, Lankoande, J et al. Is misoprostol a safe, effective and acceptable alternative to manual vacuum aspiration for postabortion care? Results from a randomised trial in Burkina Faso, West Africa. Bjog 2007;114(11):1368-75.

6. Goldenberg, M., Schiff, E.' Achiron, R.' Lipitz, S.' Mashiach, S. Managing residual trophoblastic tissue. Hysteroscopy for directing curettage. J Reprod Med. 42(1)26-8.

7.Fritsch, H. Ein Fall von volligem Schwaund der Gebormutterhohle nach Auskratzung Zentralbl Gynaekol 1894;18:1337-1342.

Sunday, July 5, 2009

Opinion: Abortion debate masks real issues on D&C safety

Unfortunately, I have become all too aware of the distortion of medical facts and findings since being diagnosed with Asherman' syndrome in 2007 following a D&C for incomplete miscarriage (I have never had an abortion). High on the list of misinformation about Asherman's syndrome, a complication of D&C, is that it is caused only by abortion. One can never repeat enough that Asherman's syndrome as well as other complications result from D&C, NOT 'abortion' per se. Abortion is just a 'reason' for performing the D&C, the same way a miscarriage, or retained placenta for example, are. As I explained in the introductory blog, D&C is (unfortunately) used commonly in gynecology and obstetrics to treat everything from fibroids and polyps to miscarriage and postpartum hemorrhage. There is sufficient evidence in the medical literature (and I will provide this in a future post) that the incidences of Asherman's syndrome are roughly the same or even lower following D&C performed for termination, than those following miscarriage and delivery.

It is well known that women who undergo repeated dilation and curettage (or even a single dilation of over 12 mm) are at a high risk of cervical incompetence (cervical insufficiency) which is thought to account for second trimester pregnancy loss in women with a history of Asherman's syndrome (1). This particular complication is not caused by the endometrial damage itself (ie. adhesions or fibrosis of Asherman's syndrome) but as a by-product of the stretching or dilating (as in 'dilation and curettage of D&C) of the cervix during D&C (which caused the Asherman's syndrome) and also during corrective surgery to remove adhesions (hysteroscopic adhesiolysis).

 Prolife proponents will often twist medical research findings to benefit their own anti-abortion agenda. Whenever a study shows increased obstetric or fertility complications following D&C, the message blaring from these lobbyists will be that abortion (not the medical technique of dilation and curettage) is the cause. As such, they completely ignore these risks apply equally to women who have a D&C for other causes, such as miscarriage, retained post partum placenta or other indications. By associating the procedure with such a highly contentious topic, all reasonable debate about the medical safety of the medical procedure is overtaken by an emotional moral debate about people's personal opinions regarding a woman's right to choose versus an embryos right to life.

For example, an oral presentation given at the recent 25th annual meeting of ESHRE (European Society of Human Reproduction and Embryology) in Amsterdam (28 June-1 July 2009. Click here to read the original press release on the oral presentation) "Complications early in pregnancy or in previous pregnancies adversely affect existing or subsequent pregnancies" summarized that:

"The researchers found that a history of one or more miscarriages nearly doubled the risk in an ongoing pregnancy of preterm premature rupture of the membrane that surrounds the baby in the womb, and increased the risk of premature or very premature delivery."


"Recurrent miscarriages (three or more miscarriages) increased the risk in a subsequent pregnancy of all of these conditions; in addition, it increased the risk of placenta praevia (where the placenta partially or completely blocks the cervix) six-fold and congenital malformations nearly two-fold."

Then there is the logical mention of abortion since the two are linked to D&C:

"If a previous pregnancy had to be terminated for any reason, this increased the risk of premature rupture of the membrane, premature and very premature delivery in subsequent pregnancies."

It seems obvious that the reason for these complications is that D&Cs are often used to treat miscarriages AND for terminations. Hence, women who have been exposed to D&Cs for either miscarriages or abortion would both be at a risk for D&C-related complications.

Yet prolife proponents insist on interpreting medical data as above with a moral view instead of a scientifically rigorous one. This is demonstrated by the scientifically illogical reasoning of Josephine Quintavalle, of the campaign group Comment On Reproductive Ethics, in response to the above findings:

"There's a logic. The body is protecting a healthy baby. By producing an abortion, you destroy that protection and make the cervix - the neck of the womb - more vulnerable.
And if you make the cervix more vulnerable, you are more at risk of a premature baby."

The problem with that explanation is that the cervix is weakened whether or not there is a 'baby' (healthy or not) in the womb because cervical dilation (D&C stands dilation and curettage) stretches the cervix open so that instruments can access the uterus. If the cervix had some sort of 'moral' sensor as Ms Quintavalle seems to believe, D&Cs and dilations for reasons other than abortion should not lead to cervical insufficiency or preterm births. The medical fact however is that the same complications occur after an abortion as after repeated dilation even if there is a dead baby inside (ie. a miscarriage) or the remains of a miscarriage, or polyps, or for any reason a D&C is used, or a cervix is mechanically stretched. 

What has been happening for decades is that complications of D&C are being hijacked by those on the prolife side of the abortion debate as 'arguments' against abortion. They also hope it can be used to scare women from terminating pregnancies. This simplistic argument overlooks the fact that there are ways to abort without surgery: mifepristone (RU486) and misoprostol (Cytotec), to name the most popular drugs which can be used instead of D&C. (Note: Not surprisingly, the prolifers in the know about this also disseminate false information about the risks of these drugs to scare women). They are also behind the movement banning these drugs from being carried by most pharmacies or prescribed by private doctors. Unfortunately, this fixation on the rights of embryonic life is at the expense of the thousands, if not millions, of women who are only given the option of D&C for other indications. It seems that to these prolifers, it is more important to prevent abortion than to prevent all women, even those who miscarry or have delivery complications, from being subjected to the risks and complications of D&C including future infertility and/or life-threatening obstetric complications such as placenta accreta. In other words, they consider an embryo to have have more of a right to life than an adult woman. The biggest irony, however, is that these drugs which can replace D&C are often only available in abortion clinics but not to women who miscarry! As a society, we should be asking ourselves why this is so.

Meanwhile, I frequently hear from those on the prochoice side of the abortion debate, denials about the risks associated with abortion probably because they do not want to have this 'inconvenient truth' tarnish women's 'freedom of choice'. Presumably they are also unaware that drugs can replace D&C so the argument is invalid to begin with. What they also fail to realize is that D&Cs are hardly a 'feminist'option. Consider what the procedure is: a doctor inserts sharp and/or an extremely powerful suctioning instrument into a sexual reproductive organ which contains fragile tissue (the endometrium) necessary for implantation and a normal pregnancy and then scrapes at it without even being able to see what they are doing! On top of this, the doctor usually doesn't tell them that complications are not uncommon and that if he makes a mistake and renders them infertile, chances are he will get away with it ($1,000 richer). In my opinion, a woman's right includes the right to be accurately informed about the true risks of a procedure and the right to be given other available options regarding what is done to her body.

So the real issue here-that is, the health and fertility risks of blind surgery (D&C)- is being clouded by the abortion debate. Who benefits from this? Certainly NOT women.

As someone who developed Asherman's syndrome after a D&C for incomplete miscarriage, I feel that the myth that only abortion causes complications should be actively dispelled. Firstly, it stigmatizes all women who have Asherman's syndrome by associating their condition with the highly controversial issue of abortion. It suggests that any woman with Asherman's syndrome is 'responsible' for her situation when in truth she may have done nothing of her choosing to cause it. It may also be one of the reasons that women with Asherman's syndrome often prefer to stay anonymous about it. The second reason it must be dispelled is because it is a distraction from the real issue-the risks of D&C. It hides the fact that in the 21st century, women are being subjected to blind surgery of the reproductive organs, which causes injury (possibly impairing fertility) in up to 31% of cases (2) DESPITE THE EXISTENCE OF SAFE, NON-INVASIVE, EFFECTIVE ALTERNATIVES. The uninformed view that only abortion causes complications will come as a rude shock to women who get these complications from D&Cs (or uterine surgery) for other reasons. But it is too late for them. The third and most important reason it must be debunked in particular is that the misinformation about risks is the reason why D&Cs continue to be performed for all types of reasons and why complications from them continue to occur. Prevention is not being practiced even though use of drugs could significantly reduce the number of D&Cs and subsequent complications.

There is undoubtedly much ignorance in the public arena concerning gynecological procedures and what they are used for unless people have undergone it themselves or have a medical or paramedical background. This explains in part why these false ideas continue to flourish. What is less clear is why the medical community does not step forward to dismiss these so-called arguments. Could this possibly be because D&Cs are one of the most common procedures on women of reproductive age and that admitting that all D&Cs carry a risk would mean this veritable 'industry' of blind surgery (and associated income)? Little experience is needed to perform D&Cs, unlike hysteroscopy, and if drugs such as misoprostol can replace D&Cs, the money will go to the pharmaceutical companies that produce it, instead of the ObGyn, Hospital and Anesthesiologist. Also, could an uneasiness with performing terminations be the reason why medical management is used for abortions but not for miscarriages? In other words, do doctors themselves, or medical bodies feel it is 'unethical' to perform abortions and so prefer to gain as little from it as possible or play a less active role in the procedure than with a D&C?

Surgery- and complications from that surgery-do not discrimminate between what is morally 'right' or 'wrong'- people do. Science cannot answer whether it is ethical to terminate a pregnancy but it can frame the debate by showing that complications from D&C exist, regardless of the moral context in which it is used. For the informed person, the issue should not be 'should abortions must be banned because of possible complications?' but 'should the medical community continue to perform D&Cs on women-for any reason- when these complications exist and alternatives are available?'


(1) Capella-Allouc S, Morsad F, Rongieres-Bertrand C, et al. (1999). "Hysteroscopic treatment of severe Asherman's syndrome and subsequent fertility". Hum Reprod 14 (5): 1230–1233.
PMID 10325268
(2) Adoni A, Palti Z, Milwidsky A, Dolberg M. (1982). "The incidence of intrauterine adhesions following spontaneous abortion". Int J Fertil. 27 (2): 117–118.

Friday, July 3, 2009

Introduction: why blog about Asherman's syndrome?

This blog is dedicated to documenting and commenting on information and misinformation relating to Asherman's syndrome and its main cause, surgical evacuation of the uterus. I will also document information and misinformation about promising alternatives to surgical evacuation, particularly misoprostol which is a safe and effective non-invasive drug. Hysteroscopy is another alternative to D&C for retained products of conception from an incomplete miscarriage or retained postpartum placenta, as it allows the surgeon a direct view inside the uterus during surgery. Both are underutilized by doctors who treat early pregnancy failure.

The misnomer of Asherman's syndrome actually refers to a frequently iatrogenic (caused by medical treatment) condition known as intra uterine adhesions or IUA (ie adhesions inside the uterus) caused by injury to the endometrium (lining of the uterus). This injury produces scars on the delicate endometrial tissue which lead to adhesions and/or fibrosis of the endometrium leading to impaired fertility and future obstetric complications if pregnancy occurs. Although estimations are difficult due to a lack of awareness about the condition by doctors and patients alike, it is thought to affect approximately 5% of women. Over 90% of cases are caused by surgical evacuation of the uterus- this includes procedures and terms such as dilation and curettage (D&C), dilation and evacuation (D&E), suction curettage/evacuation, MVA (manual vacuum aspiration), or simply curettage. For the sake of simplicity I will refer to all types of surgical evacuations of the uterus collectively as "D&C". Asherman's syndrome can be caused by any uterine surgery and rarely by endometrial tuberuculosis infection, however my focus is on D&C because this is still considered 'standard care' for miscarriage management in the US, Australia and many other countries.

All or some of these procedures continue to be used for a host of gynecological conditions and pregnancy complications including:

-postpartum retained placenta
-endometrial biopsy
-heavy/abnormal uterine bleeding
-endometrial polyps
-investigation of gynecological cancers
-Asherman's syndrome (absolutely NOT the correct treatment!!!)

There are safer and often cheaper alternatives to D&C for all of the above.

Surgical treatment for Asherman's syndrome exists (hysteroscopic adhesiolysis and estrogen therapy), however overall birthrates remain disappointing for moderate to severe cases (around 30-40%). There is also very little research on optimizing and comparing treatments. Meanwhile there are many randomized controlled trials (RCTs) on using misoprostol for miscarriage management. Prevention is therefore the more logical approach.

I hope to make women aware of the dangers of this procedure and the existence of alternatives. There is a lot of misinformation about the condition due to both a lack of awareness and medically unfounded over-optimism about treatment outcomes.

Over the years women have become aware of the abuse and misuse of hysterectomies and alternatives thanks to activism. This blog aims to make people aware of a similar situation occurring with D&C. It is my hope that one day drugs will replace D&C worldwide for miscarriage management, or at least be offered as a first line of treatment.