Secondary Prevention of Morbus Asherman
Evaluation of endometrium stimulation with estrogen gestagen post hysteroscopic adhesiolysis

The prevalence of M. Asherman varies widely depending on the trauma caused to
the uterus. The true incidence of this condition is difficult to determine,
ranging from 1.5% of patients referred for fertility testing up to 40% of
women following secondary removal of placental tissue or repeat curettage after
a missed abortion. There is almost universal support that surgical treatment is
the criterion standard in management of Asherman syndrome, and there is no role
for medical treatments. There is no consensus as to the optimal technique of
division of adhesions. The most used technique is according to the methods
described by Broome and Vancaillie in 1999 .
There is a lack of prospective randomized controlled trials on the secondary
prevention of Asherman syndrome. Insertion of an IUD provides a physical
barrier between the uterine walls, separating the endometrial layers after
lysis of intrauterine adhesions the effectivesness has been studied in one
study from 1982 . The addition of medication in period after the surgical
restore is poorly investigated. In 1964, Wood and Pena described estrogen
therapy to stimulate regeneration of the endometrium and promote
reepithelization of the endometrium after surgical treatment of intrauterine
adhesions. Various regimens have been described for postoperative treatment
with estrogens (e.g., a daily dose of 2.5 mg of conjugated equine estrogen)
with or without opposing progesterone for 2 to 3 cycles. No comparative studies
have been performed on effectiveness, dosage, administration, or combination of
hormones in pateintes with m. Asherman. The question is wheather endometrium
stimulations with exogene substitution of oestogen en progesterone is a better
prevention of secondary adhesiolysis after succesvol hysteroscopic adhesiolysis
in patients with M. Asherman than the endogene production of hormones,

We want to stuudy if exogenous hormone administration (oral administration of
estrogen and gestagen) starting immediately after successful hysteroscopic
adhesiolysis, in patients with M. Asherman reduces or prevents the incidence
and severity (ESGE score/classification) of intra-uterine re-adhesions better
then the endogen production of hormones.

Singlecentre randomized controlled trial.

Consented patients undergoing hysteroscopic adhesiolysis will be randomly
allocated to receive secondary prevention of M. Asherman with exogene hormonal
support to stimulate the endometrium post operative adhesiolysis (intervention)
group or surgery alone (control) group.

Nature and extent of the burden

The patients who are treated at the Spaarne hospital for M. Asherman at this
moment, who had a succesfull adhesiolysis receive a IUD and hormone secudule
post operative. After 3 months they get an appointment for an office
hysteroscopy. The extra burden will be completing teh CRf and questionairs at
2,6-9 and 12 months.