1. Dr. Bülent Urman AMERİKAN HASTANESİ

2. Extent of cavity involved < 1/3 1/3-2/3 > 2/3 124 Type of adhesions Filmy Filmy and Dense Dense 124 Menstrual pattern Normal Hypomenor rhea Amenorrhea 024

3. Stage 1-Mild adhesions1-4 Stage 2-Moderate adhesions5-8 Stage 3-Severe adhesions9-12 HSG score: adhesions should be considered dense Hysteroscopic score

5.  Avoid overzealous curettage  Avoid curretage PP  Suction curretage by Karman aspiration whenever possible  Adjuvants

6.  Dilatation under local or general anesthesia  Curettage  Hysteroscopic lysis  Office hysteroscopy  Conventional hysteroscopy  Other methods  Pressure lavage under US guidance

7.  HSG is the single most important preoperative test  Phase of the cycle  Office hysteroscopy should be the gold standard  No indication for Misoprostol

8.  Operative scissors  Bipolar cutting current  Versapoint  Resectoscope  Laser

9. LaparoscopyUltrasoundFluoroscopy

10.  Antibiotics  Estrogen  IUD  Balloon  Adhesion barriers  Amnion grafting  Hyaluronic acid  Hyaluronic acid + CMC (Seprafilm)

11. ControlSeprafilm Number of patients 10050 No previous D&C At least 1 D&C 56443218 Pregnancy in the no D&C group at 8 mo 30/56 (54%) 32/32 (100%) Adhesion free patients at 8 mo in women who did not conceive 50%100% From Tsapanoz et al. J Biomed Mater Res 2002

12. Control Group ACP Gel Number of patients 4143 Adhesions at 6 months 32%14% Adhesion score at 6 months 6.3 to 5.3 6.2 to 2.0 Adhesion grade 25% mild 75% moderate 100% mild From Acunzo et al Hum Reprod 2003

14. BLADDER

21. A simplified treatment for Asherman’s syndrome From McComb et al. Fertil Steril 1997

22. * 41 procedures were performed by Versapoint ** 29 had a third and 10 had 4 or more procedures

23.  Normal cavity25  Abnormal cavity74  No follow-up 8

24.  Patients desiring pregnancy88  Spontaneous pregnancy21  IVF pregnancy10  No pregnancy41  No follow-up16

25. HSG and or Second-Look H/S HSG and or Second-Look H/S Type of adhesions None Mild Moderate Severe Mild (n=10)10000 Moderate (n=20)18200 Severe (n=10)4312 Total (n=40)32512 From Pabuccu et al. Fertil Steril 1997

26. Mc Comb (1997) 6 5 (83) NA Urman (2005-unpublished) 88 21 (23.8) NA Fernandez (2006) 64 28 (43.8) 21 (32.8) Modified from Capella et al. 1999

27. Pregnancy Rate Pregnancy Rate Indication for H/S Mild Moderate Severe Infertility816615 Rec Abortion948965 From Valle and Sciarra Am J Obstet Gynecol 1988

28.  Diagnosis and treatment is dictated by HSG  Ultrasound or LS guided hysteroscopic lysis is the best treatment option  Results depend upon the extent of adhesions