It was an honor having Dr. Jessica Mann on The Egg Whisperer Show to talk about Asherman’s syndrome. Dr. Mann is an expert on this topic. She is a Fertility Doctor at IRMS Reproductive Medicine in New Jersey. She graduated with a Bachelor of Science in Biology and Chemistry from Florida International University before receiving her Medical Degree from the University of Florida School of Medicine. Dr. Mann is board certified in both Reproductive Endocrinology and Infertility and Obstetrics and Gynecology.
In addition to her degrees and board certifications, Dr. Mann also completed an internship at MD Anderson Cancer Center researching chemotherapy as treatment for early stage breast cancer, and then completed her residency in OBGYN at NYU Langone Medical Center. While there, she was part of the Latina Share Series to educate the community about gynecological cancers. Finally, she did a fellowship at the University of Connecticut in 2010, and that’s why she is our expert for this discussion.
Let’s get to the interview!
Dr. Aimee: Why did you become a doctor?
Dr. Mann: I envisioned a life helping others. As a college student, I was involved in various organizations which gave me exposure to the fields of healthcare, education, and service. I’ve always been fascinated by science, and medicine brought the perfect combination of all my interests. I knew firsthand being a doctor was difficult since my stepfather is a physician. I remember him practicing knot tying when I was very young. He once let me suture a portion of an artery- this was in formaldehyde of course, and I was probably 10 years old.
Dr. Aimee: What led you to become a fertility doctor specifically?
Dr. Mann: My clinical rotations gave me exposure to Obstetrics and Gynecology (OBGYN), and by the end of my third year of medical school I knew I wanted to become an OBGYN. My interest in the field of Reproductive Endocrinology and Infertility (REI) started in Florida after my REI rotation. It wasn’t until I went to NYU that I made up my mind. There have been so many advances that we have seen firsthand- when I was a student, PGT-A was limited to 5 chromosomes!
Dr. Aimee: I often get asked if I needed help getting pregnant. Do you get that question as well?
Dr. Mann: I’ve shared my story with a few patients and people that I know. There are a couple of things I share: I did have a condition called Asherman’s syndrome (which is going to be the topic of our talk today). In talking about it, I’ve shared that having a miscarriage was also part of what led me to develop Asherman’s syndrome. This is a condition that goes unrecognized, and it’s thought to be very rare. But if it’s identified early on, then it can be treated.
Dr. Aimee: What is Asherman’s syndrome?
Dr. Mann: It is an acquired uterine condition that occurs when scar tissue (adhesions) form inside the uterus and/or the cervix.
Dr. Aimee: Are there other names for it?
Dr. Mann: The other names are “Intrauterine synechiae,” which just means “scarring inside the uterus,” and the more formal name is Asherman’s Syndrome.
Dr. Aimee: What are the risk factors for Asherman’s syndrome?
Dr. Mann: Risk factors generally include a prior surgery. Say that somebody has had a difficult delivery and sometimes they’ve needed an extraction of the placenta. During manual extraction, sometimes tissue stays in the uterus and that can cause scarring. Afterwards, it heals, but it becomes calcified and it causes significant issues in the uterus.
Dr. Aimee: How is it diagnosed?
Dr. Mann: There are two ways to diagnose Asherman’s Syndrome. There’s the noninvasive way which is an HSG (hysterosalpingogram.) This is a test that is done as an outpatient, where a patient goes to a radiology facility and we’ll put a little catheter through the cervix, into the uterus. We fill the uterus up with the dye, and then we’ll take an X Ray. And so it’s an X Ray picture of the silhouette of the uterus. And that’s how we can see the scarring.
The gold standard for diagnosis is a surgery called hysteroscopy. With that, you can see it and you can actually treat it.
Dr. Aimee: Are there any symptoms to look out for?
Dr. Mann: One of the symptoms is that you don’t get periods. This sometimes happens after having had a baby or a D+C; you don’t get your period, yet you still feel what we call cyclical pain (meaning once a month you feel like you’re going to get your period, you’re bloated, but you never have a period). It can be very painful because your lining builds up and instead of coming out through the outflow track (the cervix and the vagina), it backs up and it goes into the tubes.
You can also have lighter periods, where you can become pregnant, and it can lead to miscarriage, because you have a scar in your uterus due to Asherman’s Syndrome.
Anybody who has had a history of a D+C, or has a concern that something is changing, it’s not a bad idea to discuss this with your doctor because there are different parts within the uterus or the lower uterine segment that can be scarred and essentially closed.
Dr. Aimee: Are there changes in your cervical mucus that you would notice if you had Asherman’s syndrome?
Dr. Mann: Usually, cervical mucus is thinner, around the middle of the cycle, and with Asherman’s it might present that way. So you don’t have the clear egg white mucus like you usually see. I think that the cervical mucus is more of a sign of an underlying issue. I know that some people have suggested taking guaifenesin (Mucinex) to help with this, but it doesn’t address the syndrome. If it does anything, it’s only changing mucus.
Dr. Aimee: How is Asherman’s syndrome treated?
Dr. Mann: I will typically perform a hysteroscopy and resection/removal of the scarring. Some patients may require an intrauterine stent or a balloon in the uterus to prevent reformation of the scarring, but that’s a decision I like to make during the surgery. Estrogen may also be used post-op to prevent scar tissue from reforming.
Dr. Aimee: What are some novel therapies for Asherman’s syndrome?
Dr. Mann: I’ve heard of using Neupogen, but to be honest, I’ve never needed to resort to this. There’s also fresh amnion grafting, but with any of these procedures you must weigh the risks. I have used Viagra and Aspirin post-surgery, to improve uterine flow.
Dr. Aimee: Are there any supplements patients can take?
Dr. Mann: Vitamin E can help improve uterine flow. It’s something I ask my patients to consider: taking 400 IU daily.
Dr. Aimee: Can Acupuncture help?
Dr. Mann: I think it’s worth a try. I have seen studies that suggest that acupuncture can improve the lining of the uterus. If it’s too expensive, and it causes more stress for you to be having to pay for it, then maybe it’s not worth it.
But if it’s something that you can handle and you would like to try it? A lot of things in terms of acupuncture and stress reduction can also be helpful. I have seen some studies about improving uterine blood flow.
Dr. Aimee: What kind of things should a woman who has Asherman’s syndrome be counseled about related to pregnancy? Are there any particular pregnancy complications that could come about from having it?
Dr. Mann: Yes. We know that one of the issues could be difficulty with the placenta detaching at delivery. There can also be an issue with the placenta invading into the wall of the uterus called the myometrium. This can cause a problem called placenta accreta.
Dr. Aimee: What was the hardest part about having Asherman’s syndrome for you?
Dr. Mann: We are always told you don’t want to be your own doctor. I thought I knew what might be going on, but I didn’t want to be my own doctor, and that was difficult. I had retained placental tissue after I had my first baby, and when I got pregnant again I had a miscarriage. And after the miscarriage, I had retained tissue again. I was an REI fellow at the time and was able to have my mentors take care of me, and they did a hysteroscopy to remove the scar tissue. I immediately got pregnant with my second child. The placenta took a long time to come out, and when it finally did, I still had in the back of my mind that something wasn’t right. This process repeated with my third child, and throughout my experience I ended up having around six surgeries.The pain, and the number of surgeries I had were very challenging for me.
Dr. Aimee: What about your experiences as a patient has helped you as a Doctor?
Dr. Mann: My experiences with the my own diagnosis and treatment for Asherman’s have made me the best advocate for my patients. I also believe that you can’t be too thorough!
Dr. Aimee: In closing, do you have anything else you want to share with our audience?
Dr. Mann: I completely agree with the philosophy that you have to find a problem before you can treat it. I make sure I listen to my patients and get their full history so that I can guide their care and provide the best possible outcome for them.
Dr. Aimee: Where can patients find you?
Dr. Aimee: Thank you so much Dr. Mann for joining me for this conversation and for sharing so much of your expertise and personal journey with Asherman’s syndrome.
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