Asherman Syndroom Behandeling in Nederland Het Effect van

Asherman Syndroom Behandeling in Nederland Het Effect van Centralisatie 2003 -2013 Mark Hans Emanuel MD Ph. D Miriam Hanstede MD VVOG maart 2014 Spaarne Ziekenhuis Haarlem/Heemstede/Hoofddorp Universiteit van Amsterdam en Vrije Universiteit

Belangenverstrengeling Geen in relatie tot het onderwerp van de voordracht VVOG 2014 Mark Hans Emanuel m@emanuel. nl

Asherman Syndrome Fritsch N=1 1894 Bass N=20 1927 Stamer N=24 1946 VVOG 2014 Mark Hans Emanuel m@emanuel. nl Asherman N=29 1948

Definition 2 criteria 1. intra-uterine adhesions due to trauma of the endometrium of gravid or non gravid uterus 2. presence of symptoms VVOG 2014 Mark Hans Emanuel m@emanuel. nl

What do we know about Asherman Syndrome? • • rare highest level hysteroscopic surgery no RCT’s high outcome variation VVOG 2014 Mark Hans Emanuel m@emanuel. nl

What do we know about Asherman Syndrome? • • rare highest level hysteroscopic surgery no RCT’s high outcome variation VVOG 2014 Mark Hans Emanuel m@emanuel. nl

What do we know about Asherman Syndrome? • • rare? highest level hysteroscopic surgery no RCT’s high outcome variation VVOG 2014 Mark Hans Emanuel m@emanuel. nl

Centralized Care in The Netherlands • • • small geographical area small language area only 1000 gynecologists 16. 8 mio citizens social media /chat sites VVOG 2014 Mark Hans Emanuel m@emanuel. nl

• Retrospective Cohort 2003 -2013 • total 638 patients baseline n % 537 84. 2 Subfertility 44 6. 9 Both 42 6. 6 Amenorrhea 413 64. 7 Hypomenorrhea 190 29. 8 35 5. 5 Symptoms Menstrual abnormalities Menstrual pattern • mean age 35 years Eumenorrhea VVOG 2014 Mark Hans Emanuel m@emanuel. nl

causal procedures First Trimester procedures % 56. 9 2. 9 Caesarean section Post partum procedures No causal procedure (genital TB) VVOG 2014 Mark Hans Emanuel m@emanuel. nl 37. 0 0. 6

Treatment Protocol Hysteroscopy with Fluoroscopic Control IUD & Hormonal Medication 6 weeks Second Look Hysteroscopy 2 months ASHERMAN E X P E R T I S E C E N T R E RESEARCH, TREATMENT AND EXPERTISE VVOG 2014 Mark Hans Emanuel m@emanuel. nl

Hysteroscopy with Fluoroscopic Control • Wamsteker, de Blok and Emanuel used since 1990 described in 1997 • Broome and Vancaillie 1999 VVOG 2014 Mark Hans Emanuel m@emanuel. nl

VVOG 2014 Mark Hans Emanuel m@emanuel. nl

Grade of Intra Uterine Adhesions ESGE 2 2 a 3 Internal cervical os Uterine cavity 4 Uterine cavity 5 Uterine cavity VVOG 2014 Mark Hans Emanuel m@emanuel. nl

grade n 1 st attempt % success 1 25 100 2 27 100 2 a 218 99. 1 100 3 201 80. 6 95. 5 100 4 106 60. 4 94, 3 97. 1 5 50 16. 0 44. 0 60. 0 VVOG 2014 Mark Hans Emanuel m@emanuel. nl 2 nd attempt % success 3 rd attempt % success

VVOG 2014 Mark Hans Emanuel m@emanuel. nl grade n 1 st attempt % success 2 nd attempt % success 3 rd attempt % success 1 25 100 2 27 100 2 a 218 99. 1 100 3 201 80. 6 95. 5 100 4 106 60. 4 94, 3 97. 1 5 50 16. 0 44. 0 60. 0 n % 594 94. 7 Incomplete 7 1. 1 Drop-out 26 4. 1 total in 1 to 3 attempts Complete

VVOG 2014 Mark Hans Emanuel m@emanuel. nl Yu et. al. Fertil Steril 2008 Total in 1 to 3 attempts No. % Complete 594 94. 7 Incomplete 7 1. 1 Drop-out 26 4. 1

627 incomplete 125 (19. 9%) 112 incomplete 33 (5. 2%) 20 incomplete 7(1. 1%) VVOG 2014 Mark Hans Emanuel m@emanuel. nl

Spontaneous Recurrence of Adhesions grade n adhesion recurrence % 1 5/25 20. 0 2 5/27 18. 5 2 a 39/217 18. 0 3 41/201 20. 4 4 32/104 30. 8 5 7/28 25. 0 total 129/602 21. 4 VVOG 2014 Mark Hans Emanuel m@emanuel. nl

Spontaneous Recurrence of Adhesions Yu et. al. Fertil Steril 2008 VVOG 2014 Mark Hans Emanuel m@emanuel. nl

Primary Prevention 1 st trimester post-partum VVOG 2014 Mark Hans Emanuel m@emanuel. nl

Recommendations for Future Research VVOG 2014 Mark Hans Emanuel m@emanuel. nl

Secondary Prevention RCT’s • SEPA I – Adjunctive Hormones vs. None • SEPA II – IUD vs. Foley/Cook catheter vs. Hyalobarrier VVOG 2014 Mark Hans Emanuel m@emanuel. nl

Life time Follow up Database I-follow up study database • approximately 1500 patients • starting 1989 VVOG 2014 Mark Hans Emanuel m@emanuel. nl

Take to Work Messages • Best Treatment in our hands Hysteroscopy with Fluoroscopic Control • Centralization for achieving higher Success Rates • Primary Prevention should be focused on Post- partum Procedures • Need for EBM treatment for Secondary Prevention VVOG 2014 Mark Hans Emanuel m@emanuel. nl

Follow us http: //www. asherman. nl VVOG 2014 Mark Hans Emanuel m@emanuel. nl

Thank You m@emanuel. nl VVOG 2014 Mark Hans Emanuel m@emanuel. nl