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Prof. Dr Osama Shawki, M.D.Sponsors
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In order to outline the prognosis and results of the treatment, a classification of intrauterine adhesions is most useful. There are many classifications based on histology, hysterography, symptomatology and hysteroscopy. The important factor that seem to correlate with the final outcome are the extent of uterine cavity occlusion and the type and severity of adhesions involved.
Table 1: March et al, classification, 1978 of IUA by Hysteroscopic Findings.
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Grade
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Findings
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Severe
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More than 3/4 of uterine cavity involved.
Agglutination of walls or thick bands
Ostial areas or upper cavity occluded
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Moderate
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Between 1/4-3/4 of the uterine cavity involved
No agglutination of walls, adhesions only
Ostial areas and upper cavity only partially occluded
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Minimal
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Less than 1/4 of uterine cavity involved:- thin or filmy adhesions
Fundus, ostial areas are clear
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Valle & Sciarra ,1988 classification of IUA :
Mild adhesions:
Filmy adhesions composed of basal endometrium producing partial or complete uterine cavity occlusion.
Moderate adhesions:
Fibromuscular adhesions that are characteristically thick, still covered by endometrium that may bleed on division, partially or totally occluding the uterine cavity.
Severe adhesions:
composed of connective tissue with no endometrial lining and likely to bleed upon division, partially or totally occluding the uterine cavity.
Table 2: Donnez and Nisolle 1994, Classification according to the location and the aspect of the adhesions:-
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Degree
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Location
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I
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Central adhesions
a)thin filmy adhesions (endometrial adhesions)
b)myofibrous (connective adhesions)
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II
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Marginal adhesions (always myofibrous or connective)
a)wedge like projection
b)obliteration of one horn
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III
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Uterine cavity absent on HSG
a)occlusion of the internal os (upper cavity normal)
b)extensive coaptation of the uterine walls (absence of the uterine cavity) (True Asherman’s syndrome)
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Table 3: European Society for Hysteroscopy (ESH) 1989, Classification of IUA :-
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Grade
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Extent of intrauterine adhesions
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I
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Thin or filmy adhesions
easily ruptured by hysteroscope sheath alone
cornual areas normal
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II
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Singular firm adhesions
connecting separate parts of the uterine cavity
visualisation of both tubal ostia possible
cannot be ruptured by hysteroscope sheath alone
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IIa
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Occluding adhesions only in the region of the internal cervical os
Upper uterine cavity normal
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III
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Multiple firm adhesions
connecting separate parts of the uterine cavity
unilateral obliteration of ostial areas of the tubes
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IIIa
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Extensive scarring of the uterine cavity wall with amenorrhoea or hypomenorrhoea
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IIIb
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Combination of III and IIIa
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IV
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Extensive firm adhesions with agglutination of uterine walls
At least both tubal ostial areas occluded
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The American Fertility Society Classification Of Intrauterine Adhesions,1988.
The American Fertility Society,1988, has proposed a classification of intrauterine adhesions based on the findings at hysterosalpingography and hysteroscopy and the correlation with menstrual patterns. Because this classification has not been used uniformly when reporting reproductive outcome following treatment of intrauterine adhesions, assessment and comparisons of the different reports and their outcomes has been difficult.
Table 4:- American Fertility Society, 1988 Classification of IUA
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Extent of cavity involved
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< 1/3
1
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1/3 - 2/3
2
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> 2/3
4
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Type of adhesions
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Filmy
1
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Filmy&Dense
2
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Dense
4
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Menstrual pattern
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Normal
0
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Hypomenorrhea
2
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Amenorrhoea
4
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Prognostic classification HSG* Hysteroscopy
score score
Stage I (mild) 1-4 ........ ..........
Stage II (Moderate) 5-8 ........ ..........
Stage III (severe) 9-12 ........ ..........
*All adhesions should be considered dense
Additional findings ......................................
