Oral Presentation AGES XXVIII Annual Scientific Meeting 2018

Aim:
Magnetic resonance imaging (MRI) is increasingly being used as a diagnostic modality for Asherman syndrome (AS), and the appearance of the junctional zone shows promise as a marker for severity of intrauterine adhesions (IUA). This provides information beyond the visualisation of the endometrium afforded by hysteroscopy. Newer MRI technology includes dynamic studies using gadolinium-enhanced T1-weighted images. These have been used in endometrial and cervical cancer. There is a no information regarding the role of vascular perfusion MRI for AS and IUA. This study explores using MRI as a non-invasive modality to assess microvascular perfusion of the uterus in women with IUA.

Methods:
This is a proof of concept study. This study has 2 main objectives:

• To assess perfusion patterns in women with AS, using the total perfusion (TP), ratio of perfusion (RP), time to peak (TTP) and gradient of perfusion (GP) to assess vascular markers of disease.
• To compare uterine perfusion in women with differing stages of AS. Receiver operator curves (ROC) were used to analyse the value of perfusion of MRI as a test for severity of AS

Patients:
23 women diagnosed with AS.  All had preoperative scans, and 5 women had post-operative scans. Six women had Grade IV AS, and 4 women had incomplete/inoperable disease.

Results:
There were no differences between the perfusion indicies performed; TP, RP, TTP and GP across Grade of disease. Using a ROC to assess GP of Grade IV vs other Grades; the area under the curve was 0.823 when the gradient was < 11 mL/sec. When assessing inoperable disease with TP, the area under the curve showed a value of 0.855, mean uterine perfusion studies in the pre-operative uterus were highly predictive of uterine cavity obliteration vs. lower grade disease.

Conclusion:
The uterine perfusion in women with Grade IV and inoperable IUA was significantly lower than those that had lower Grade AS. Vascularity of the uterus may hold the key to understanding the pathological process behind AS. Perfusion MRI may provide a prognostic tool to assess vascularisation, and aid in the management of women with IUA. Future applications of this technique may include development of imaging methods to predict success of surgery, given the relatively high rates of complication following hysteroscopic synechiolysis or indeed the impaired reproductive function of the uterus following surgery, despite objective visual normalisation of the endometrial cavity.