Adhesions: Can Sterility Be Avoided?

Adhesions are kind of “strings” of connective tissue, which are formed as result of inflammation or surgical interventions and stretch from organ to organ. If adhesions are located in pelvic cavity or in abdominal cavity, they can interfere with conception, so it`s very important to detect and eliminate them in time.

Organs of abdominal cavity and pelvis (uterus, fallopian tubes, ovaries, bladder, rectum) are covered on outside with thin, shiny membrane – peritoneum. Smoothness of peritoneum in combination with small amount of fluid in abdominal cavity provides good mobility of loops of intestine, uterus, fallopian tubes. Therefore, normally work of intestine doesn`t interfere with capture of egg by fallopian tube, and growth of uterus during pregnancy doesn`t interfere with normal functioning of intestine and bladder.

Inflammation of peritoneum – peritonitis – is very dangerous disease. And it is all more dangerous, larger space in abdominal cavity or in pelvis. But in body there is mechanism that limits spread of peritonitis, formation of adhesions. With development of inflammatory process in pelvis, tissues in focus of inflammation become edematous, and surface of peritoneum is covered with adhesive coating containing fibrin (protein that forms basis of blood clot).

Inflammatory process in abdominal cavity doesn`t always lead to formation of adhesions. If treatment is started on time and carried out correctly, likelihood of adhesions is reduced. Adhesions are formed when acute process becomes chronic and healing process stretches over time.

Adhesions can interfere with normal functioning of internal organs. Impaired mobility of intestinal loops can lead to intestinal obstruction. Adhesions affecting fallopian tubes, uterus, ovaries, disrupt ingestion of egg into fallopian tube, sperm movement through fallopian tube, meeting of sperm and egg, advance of embryo after conception to place of attachment to uterine cavity. In gynecology, adhesions can cause infertility and pelvic pain.

Reasons for formation of adhesions

Main causes of adhesions in pelvic organs are:

  • Inflammatory diseases.
  • Surgical operations.
  • Endometriosis – disease in which inner lining of uterus grows in places uncharacteristic for this.
  • Blood in abdominal cavity.

Adhesions resulting from inflammation

Fallopian tubes, uterus and ovaries can be involved in adhesion process that occurs with inflammation of neighboring organs (appendicitis – inflammation of appendix), as well as with lesions of small and large intestines. In this case, genitals themselves suffer little: adhesion process almost doesn`t violate their internal structure. If inflammation occurs inside genitals, not only formation of adhesions occurs, but also damage to genitals themselves.

The most unprotected in this regard is fallopian tube – one of most delicate and delicately arranged smooth muscle organs. She plays key role in ensuring conception and supporting pregnancy at its onset. Sperm that enter vagina are filtered through mucus of cervix, pass through uterine cavity and enter fallopian tube. Peristalsis is movement of fallopian tube – it helps sperm to get into outer third (ampoule) of fallopian tube, where process of conception takes place. During ovulation release of egg from ovary – fallopian tube “sucks” mature egg.

If sperm cells are there at time egg enters fallopian tube, fertilization occurs, and resulting embryo moves within a few days to uterine cavity, where it will be immersed in uterine mucosa (implantation). Delivery of embryo to uterine cavity is provided by movements of fallopian tube and active work of cilia of fallopian tube.

Postoperative adhesions

With surgical interventions, adhesions are formed due to:

  • Tissue hypoxia or ischemia – insufficient supply of blood and oxygen to tissues.
  • Drying tissues during surgery.
  • Gross manipulation of tissue.
  • Presence of foreign bodies.
  • Presence of blood.
  • Separation of former adhesions.

Foreign bodies that cause formation of adhesions often include talc particles from doctor’s gloves, small cotton fibers from gauze or tampons, and suture material. Adhesions are formed with endometriosis. During menstruation, small amount of menstrual blood containing living cells of uterine mucosa (endometrium) can enter abdominal cavity through fallopian tubes. Normally, these cells are removed using their own immune system, but if there are any problems, they take root and form functioning islets of endometrium, which menstruate inside abdominal cavity. Around these foci, commissures form.

Diagnosis

Presence of adhesions in abdominal cavity can be suspected in patients who have undergone pelvic inflammatory diseases, surgery on pelvic organs and abdominal cavity, and women suffering from endometriosis in past.

However, only half of patients with more than two risk factors for development of adhesions have history of adhesions during laparoscopy (operations during which small holes are made in anterior abdominal wall through which optical device is inserted to allow examination of cavity and special surgical instruments).

The main diagnostic method for adhesions is laparoscopy method. It allows not only to detect presence of adhesions and assess severity of adhesive process, but also to conduct treatment.

There are 3 stages of adhesion process according to laparoscopy:

  • Stage I: adhesions are located around fallopian tube, ovary or in another area, but don`t interfere with capture of egg.
  • Stage II: adhesions are located between fallopian tube and ovary or between these organs and other structures and can interfere with capture of egg.
  • Stage III: there is either torsion of fallopian tube, or its blockage by adhesions, or complete blockage of egg capture.

Treatment

Main treatment for adhesions is laparoscopy. Using special micromanipulators, adhesiolysis is performed – dissection and removal of adhesions. Adhesion separation methods include laser therapy (laser adhesion dissection), aquadissection (adhesion dissection using pressurized water), and electrosurgery (electric knife dissection).

Following methods can be used to prevent formation of new postoperative adhesions during laparoscopy:

  • Introduction into spaces between anatomical structures of various barrier fluids (dextran, povidin, mineral oils, etc.).
  • Wrapping of fallopian tubes and ovaries with special polymer absorbable films.

In addition, after laparoscopy in recent years, control diagnostic laparoscopy several months after first laparoscopy has become more widespread.