the presentation of asherman's syndrome typically involves

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Asherman Syndrome

Description.

Asherman syndrome, also known as intrauterine adhesions (IUAs) or uterine synechiae, is a condition characterised by the formation of scar tissue within the uterine cavity. The adhesions may be thin or thick, spotty in location, or confluent, and may partially or completely occlude the uterine cavity. It can cause menstrual disturbances, infertility, and complications in pregnancy.

Pathogenesis

Asherman syndrome typically results from trauma to the basal layer of the endometrium, most commonly following intrauterine surgery such as dilation and curettage (D&C), particularly if performed shortly after childbirth or miscarriage. The damage to the endometrial lining can cause the uterine walls to adhere to each other, leading to the formation of intrauterine adhesions.

Asherman syndrome can be categorised by the extent of the adhesions:

• Mild : Adhesions involving less than one-third of the uterine cavity
• Moderate : Adhesions involving one-third to two-thirds of the uterine cavity
• Severe : Adhesions involving more than two-thirds of the uterine cavity

Epidemiology, Risk Factors & Associations

• The incidence of Asherman syndrome is difficult to ascertain, but it’s most commonly associated with intrauterine surgery, especially in the postpartum period or following a miscarriage.
• Other risk factors include infections of the endometrium (e.g., endometritis) and congenital malformations of the uterus.

Clinical Features

• Women with Asherman syndrome may present with amenorrhoea, hypomenorrhoea, infertility, or recurrent miscarriage.
• In severe cases, where the cervical ostia are occluded, women may present with cyclic pelvic pain due to haematometra.

Complications

• Infertility and recurrent miscarriage are the most common complications.
• Complications during pregnancy can include ectopic pregnancy, intrauterine growth restriction (IUGR), preterm birth, and placental disorders.

Pathological Features

Histopathology.

• Macroscopic : On hysteroscopy, adhesions appear as bands of scar tissue within the uterine cavity.
• Microscopic : Adhesions are composed of fibrous tissue, often with minimal vascularisation.

Radiological Features

General features.

• Characteristically demonstrates intrauterine filling defects on hysterosalpingography (HSG) or hysterosonography.

Hysterosalpingography (HSG)

• HSG can show filling defects or irregularities in the uterine cavity, suggestive of intrauterine adhesions.
• In severe cases, the uterine cavity may not be visualised at all.
• On ultrasound, a normal endometrial stripe may not be visualised. In severe cases, the uterine cavity may appear as a thin line or not be visualised at all.
• T1WI : The junctional zone might not be well visualised due to adhesions.
• T2WI : Hypointense bands within the hyperintense endometrium can be seen.
• T1 C+ : The fibrous bands do not enhance post-contrast, in contrast to the surrounding endometrium which enhances post-contrast.

The diagnosis of Asherman syndrome is typically suggested by history and clinical examination and confirmed by imaging studies such as hysterosalpingography or hysteroscopy.

Differential Diagnosis

• Endometrial polyps or submucosal fibroids : Can appear as filling defects on HSG, but are typically solitary and have a different clinical presentation.
• Congenital uterine anomalies : Can cause an abnormal appearance of the uterine cavity on imaging, but are usually diagnosed earlier in life and have a different clinical presentation.

Treatment of Asherman syndrome typically involves hysteroscopic adhesiolysis, with the goal of restoring the normal uterine cavity. Postoperative management may involve hormonal therapy to promote endometrial regrowth and prevent reformation of adhesions, as well as the use of intrauterine devices or barriers. A fertility specialist should be involved in the care of these patients due to the associated risk of infertility and recurrent pregnancy loss.

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Asherman syndrome

Asherman syndrome is the formation of scar tissue in the uterine cavity. The problem most often develops after uterine surgery.

Asherman syndrome is a rare condition. In most cases, it occurs in women who have had several dilatation and curettage (D&C) procedures.

A severe pelvic infection unrelated to surgery may also lead to Asherman syndrome.

Adhesions in the uterine cavity can also form after infection with tuberculosis or schistosomiasis. These infections are rare in the United States. Uterine complications related to these infections are even less common.

The adhesions may cause:

• Amenorrhea (lack of menstrual periods)
• Repeated miscarriages
• Infertility

However, such symptoms could be related to several conditions. They are more likely to indicate Asherman syndrome if they occur suddenly after a D&C or other uterine surgery.

Exams and Tests

A pelvic exam does not reveal problems in most cases.

Tests may include:

• Hysterosalpingography
• Hysterosonogram
• Transvaginal ultrasound examination
• Blood tests to detect tuberculosis or schistosomiasis

Treatment involves surgery to cut and remove the adhesions or scar tissue. This can most often be done with hysteroscopy. This uses small instruments and a camera placed into the uterus through the cervix.

After scar tissue is removed, the uterine cavity must be kept open while it heals to prevent adhesions from returning. Your health care provider may place a small balloon inside the uterus for several days. You may also need to take estrogen while the uterine lining heals.

You may need to take antibiotics if there is an infection.

Support Groups

The stress of illness can often be helped by joining a support group. In such groups, members share common experiences and problems.

Outlook (Prognosis)

Asherman syndrome can often be cured with surgery. Sometimes more than one procedure will be necessary.

Women who are infertile because of Asherman syndrome may be able to have a baby after treatment. Successful pregnancy depends on the severity of Asherman syndrome and the difficulty of the treatment. Other factors that affect fertility and pregnancy may also be involved.

Possible Complications

Complications of hysteroscopic surgery are uncommon. When they occur, they may include bleeding, perforation of the uterus, and pelvic infection.

In some cases, treatment of Asherman syndrome will not cure infertility.

When to Contact a Medical Professional

Call your provider if:

• Your menstrual periods do not return after a gynecologic or obstetrical surgery.
• You cannot get pregnant after 6 to 12 months of trying (See a specialist for an infertility evaluation).

Most cases of Asherman syndrome cannot be predicted or prevented.

Alternative Names

Uterine synechiae; Intrauterine adhesions; Infertility - Asherman; Asherman's syndrome

Brown D, Levine D. The uterus. In: Rumack CM, Levine D, eds. Diagnostic Ultrasound . 5th ed. Philadelphia, PA: Elsevier; 2018:chap 15.

Dolan MS, Hill CC, Valea FA. Benign gynecologic lesions: vulva, vagina, cervix, uterus, oviduct, ovary, ultrasound imaging of pelvic structures. In: Gershenson DM, Lentz GM, Valea FA, Lobo RA, eds. Comprehensive Gynecology . 8th ed. Philadelphia, PA: Elsevier; 2022:chap 18.

Turocy J, Williams Z. Early and recurrent pregnancy loss: etiology, diagnosis, treatment. In: Gershenson DM, Lentz GM, Valea FA, Lobo RA, eds. Comprehensive Gynecology . 8th ed. Philadelphia, PA: Elsevier; 2022:chap 16.

Williams Z, Scott JR. Recurrent pregnancy loss. In: Resnik R, Lockwood CJ, Moore TR, Greene MF, Copel JA, Silver RM, eds. Creasy and Resnik's Maternal-Fetal Medicine: Principles and Practice . 8th ed. Philadelphia, PA: Elsevier; 2019:chap 44.

Review Date 4/19/2022

Updated by: John D. Jacobson, MD, Department of Obstetrics and Gynecology, Loma Linda University School of Medicine, Loma Linda, CA. Also reviewed by David C. Dugdale, MD, Medical Director, Brenda Conaway, Editorial Director, and the A.D.A.M. Editorial team.

Related MedlinePlus Health Topics

• Uterine Diseases

Asherman's syndrome: current perspectives on diagnosis and management

Affiliation.

• 1 Department of Gynecology, The Juliane Marie Centre, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark, [email protected].
• PMID: 30936754
• PMCID: PMC6430995
• DOI: 10.2147/IJWH.S165474

Intrauterine adhesions with symptoms like hypomenorrhea or infertility are known under the term Asherman's syndrome. Although the syndrome has been widely investigated, evidence of both prevention of the syndrome and the ideal treatment are missing. Understanding the pathogenesis of intrauterine adherences is necessary for the prevention of the formation of intrauterine scarring. Intrauterine adhesions can develop from lesion of the basal layer of the endometrium caused by curettage of the newly pregnant uterus. The syndrome may also occur after hysteroscopic surgery, uterine artery embolization or uterine tuberculosis. For initial diagnosis the less invasive contrast sonohysterography or hysterosalpingography is useful. The final diagnosis is based on hysteroscopy. Magnetic resonance imaging is required in cases with totally obliterated uterine cavity. Intrauterine adherences are classified in accordance with different classification systems based on the hysteroscopic diagnosis of severity and localization of adherences. Classification is necessary for the planning of surgery, information on prognosis and scientific purposes. Surgery is performed in symptomatic patients with either infertility or with painful periods. Intrauterine adherences are divided with a hysteroscope using scissors or a power instrument working from the central part of the uterus to the periphery. Peroperative ultrasonography is useful in an outpatient setting for the prevention of complications. Hysteroscopy with fluoroscopy is a solution in difficult cases. Use of intrauterine devices like balloon catheters or intrauterine contraceptive devices seems to be the preferred methods for the prevention of re-occurrence of adhesions after treatment. Both primary prevention after hysteroscopic surgery or curettage and secondary prevention of new adhesions after adhesiolysis have been investigated. The aim of this review was to summarize the literature on diagnosis, classification, treatment and prevention, based on a literature search with a wide range of search terms.

Keywords: Asherman’s syndrome; genital adhesions; gynatresia; intrauterine synechia.

Publication types

Fertility & Reproductive Medicine Center

• Asherman’s syndrome

A problem that is often under diagnosed and managed by our practice frequently is Asherman’s syndrome (AS).  A number of people have questions about this, and hopefully this short FAQ will be useful.

What is AS?

Individuals with intrauterine adhesions that have signs and symptoms such as menstrual abnormalities or pain have Asherman’s syndrome.  The classic presentation is amenorrhea (complete lack of menses) following trauma to the uterus.

What causes AS?

Many patients with this disorder present with a history of recurrent pregnancy loss or infertility.  The hallmark risk factor is intrauterine surgery tied to pregnancy, including D+Cs for early pregnancy losses; it is even more likely to follow uterine curettage after term deliveries.  It may also occur from other intrauterine surgeries, like removal of fibroids.  It is rarely caused by infection.  It is probably never something that just “happens”.

How common is AS?

Classically, this syndrome has been viewed as quite rare, but it is actually more common and often overlooked.  In almost all cases of Asherman syndrome, there is a recognizable prior event that led to scar formation.  It should be considered if there are abnormalities with bleeding following surgery in the uterine cavity.

How is AS diagnosed?

There are multiple ways to do this.  The two most common tests are sonohysterography or hysteroscopy.

How is it treated?

Hysteroscopic (surgery in the uterus through a narrow sheath) is done to incise (divide) adhesions, typically performed using scissors.  Most believe it is helpful to avoid instruments that further could damage the uterine lining.  The extent of adhesions can vary dramatically and treatment of the most severe cases can be very challenging.  In difficult cases it is crucial for the surgeon to be certain where they are and when to stop the surgery.  Simultaneous transabdominal ultrasound can be very helpful.

Is it medically necessary to remove these adhesions?

In order to become pregnant or stay pregnant one must have a normal cavity and a uterine lining that is functional.  A cavity with scarring will markedly compromise chances for pregnancy and when severe, will make pregnancy impossible.  Those who have intrauterine scarring that are not having problems and have no interest it pregnancy, do not need surgery.

Can this always be fixed?

Repair of significant adhesions may require more than one surgery.  Most cases can be repaired and most women with this problem will ultimately be successful.  Some will have disease that cannot be repaired and they may need to pursue other treatment options like using a gestational carrier.

Is this preventable?

There is no question that the number of cases of AS could be reduced if people would be able to avoid operative intervention in the uterus.  The best way to do this is to utilize medical options or expectant (wait for it to happen) management for early pregnancy losses.  However, sometimes that is not possible.  These choices do not always work, they may not be desirable, and sometimes patients are bleeding so heavily that surgery is the only choice.

To schedule a consultation with the Fertility & Reproductive Medicine Center to discuss Asherman’s Syndrome, please call 314-286-2400 .

• Male Factor
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• Diminished Ovarian Reserve
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• Your Medical History
• Endometriosis
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• Recurrent Pregnancy Loss

Asherman Syndrome

• First Online: 11 October 2014

Cite this chapter

• Line Engelbrechtsen MD 2 &
• Olav Istre MD, PhD, DMSc 3  

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Asherman syndrome (AS) was first reported in 1894 by Heinrich Fritz, however it was not until 1948 that Joseph Asherman described the syndrome, frequency, and etiology based on a series of cases of intrauterine adhesions following curettage of a gravid uterus in 29 women with secondary amenorrhea (Asherman 1948; 1950).

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Engelbrechtsen, L., Istre, O. (2015). Asherman Syndrome. In: Istre, O. (eds) Minimally Invasive Gynecological Surgery. Springer, Berlin, Heidelberg. https://doi.org/10.1007/978-3-662-44059-9_4

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Asherman’s Syndrome

Asherman’s syndrome is where  adhesions  (sometimes called  synechiae ) form  within the uterus , following damage to the uterus.

Usually Asherman’s syndrome occurs after a pregnancy-related  dilatation and curettage procedure , for example in the treatment of  retained products of conception  (removing placental tissue left behind after birth). It can also occur after uterine surgery (e.g. myomectomy) or several pelvic infection (e.g.  endometritis ).

Endometrial curettage (scraping) can damage the basal layer of the endometrium . This damaged tissue may heal abnormally, creating scar tissue (adhesions) connecting areas of the uterus that are generally not connected. There may be adhesions binding the uterine walls together, or within the endocervix, sealing it shut.

These adhesions form physical obstructions and distort the pelvic organs, resulting in menstruation abnormalities, infertility and recurrent miscarriages. 

Adhesions may be found incidentally during hysteroscopy. Asymptomatic adhesions are not classified as Asherman’s syndrome.

Presentation

Asherman’s syndrome typically presents following recent dilatation and curettage, uterine surgery or endometritis with:

• Secondary amenorrhoea (absent periods)
• Significantly lighter periods
• Dysmenorrhoea (painful periods)

It may also present with infertility.

There are several options for establishing a diagnosis of intrauterine adhesions:

• Hysteroscopy  is the gold standard investigation, and can involve dissection and treatment of the adhesions
• Hysterosalpingography , where contrast is injected into the uterus and imaged with xrays
• Sonohysterography , where the uterus is filled with fluid and a pelvic ultrasound is performed

Management is by dissecting the adhesions during hysteroscopy. Reoccurrence of the adhesions after treatment is common.

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The Diagnosis and Management of Asherman's Syndrome Developed after Cesarean Section and Reproductive Outcome

Pinar ozcan cenksoy.

Department of Obstetrics and Gynecology, Yeditepe University, 34752 Istanbul, Turkey

Cem Ficicioglu

Mert yesiladali, ozge kizilkale.

Intrauterine adhesions (IUAs) frequently occur as a result of trauma to the basal layer of endometrium following pregnancy-related curettage such as incomplete abortion (33,3%), postpartum hemorrhage (37,5%), and elective abortion (8,3%). Hysterotomy, myomectomy, Cesarean section, hysteroscopic procedures, such as resection of submucosal leiomyomata or uterine septae, and endometrial ablation are less common etiologic factors resulting in IUA formation. Patients with Asherman's syndrome usually present with menstrual disturbances, infertility, or recurrent pregnancy loss. A successful treatment of infertility could be achieved by restoration of the uterine cavity, prevention of IUA reformation, and promotion of healing process. We presented the diagnosis and management of a case that suffers from menstrual disturbances and secondary infertility resulted from IUA formation developed after Cesarean section.

1. Introduction

Intrauterine adhesions (IUAs) were first described by Fritsch in 1894 and then further studied by gynecologist Asherman [ 1 , 2 ]. They frequently occur as a result of trauma to the basal layer of endometrium following pregnancy-related curettage such as incomplete abortion (33,3%), postpartum hemorrhage (37,5%), and elective abortion (8,3%) [ 3 ]. Basal layer damage leads to partial or complete obliteration of the uterine cavity with surface deficiencies of the endometrium by fibrous bridges between the uterine walls [ 4 ]. Patients with Asherman's syndrome usually present with menstrual disturbances such as amenorrhea or hypomenorrhea, infertility, or recurrent pregnancy loss [ 5 ].

Hysterotomy, myomectomy, Cesarean section, hysteroscopic procedures, such as resection of submucosal leiomyomata or uterine septae, and endometrial ablation are less common etiologic factors resulting in IUA formation. The development of IUA after Cesarean section is uncommon and estimated at approximately 2–2.8% [ 4 ]. It may be more likely to result from chorioamnionitis or postpartum endometritis, postpartum curettage, and uterine compression sutures for postpartum haemorrhage [ 6 ].

We presented the diagnosis and management of a case that suffers from with menstrual disturbances and secondary infertility resulted from IUA formation developed after Cesarean section.

2. Case History

A 34-year-old woman, gravida 1, parity 1, with a previous Caesarean section history of 11 years ago, has applied to Yeditepe University ART Center with secondary amenorrhea and desire for pregnancy. Although she started seeing menstruation again three months after caeserian section, she presented with oligomenorrhea followed by amenorrhea for the last four years. Her vaginal examination and transvaginal USG revealed no abnormalities. Hysterosalphingography (HSG) was planned to evaluate tubal patency and uterine cavity. HSG revealed multiple filling defects in uterine cavity and bilateral tubal occlusion ( Figure 1 ). An operative hysteroscopy was performed to distinguish between varying etiologies of filling defects. Hysteroscopy revealed the extent of endometrial cavity obliteration with dense, multiple adhesions, especially located on isthmus and previous Caesarean incision, and hysteroscopic adhesiolysis was performed ( Figure 2 ). Postoperative intrauterine device and hormonal treatment (4 mg/day estrogen) was applied to prevent the reformation of IUA. A second-look office hysteroscopy was performed to evaluate the endometrial cavity 2 months after the initial procedure. At the second-look hysteroscopy, there was no reformation of adhesions and an adequate uterine cavity was achieved for pregnancy. Patient had resumption of normal menses 3 months after the initial procedure, and IVF treatment was performed 6 months after the initial procedure because of tubal factor. The patient has an ongoing pregnancy.

3. Discussion

IUA would undoubtedly affect the reproductive outcomes but especially if no other etiology for reproductive failure can be found, a successful treatment of infertility could be achieved by restoration of the uterine cavity via lysis of adhesions under direct vision with hysteroscopy, prevention of IUA reformation, promotion of healing process with intrauterine stent and hormonal treatment, and finally performing a follow-up architecture hysteroscopy or hysterosalpingography. On the other hand, even for women who has Asherman's syndrome with additional infertility factors, it is important to restore the uterine cavity and endometrium before IVF treatment. General consensus on the management of Asherman's syndrome exists on the necessity of hysteroscopic adhesiolysis followed by hormone therapy [ 4 ]. Particularly in patients with severe Asherman's syndrome, multiple procedures may be required to achieve adequate uterine cavity. Valle and Sciarra reported the postoperative pregnancy rates as 93% in those with minimal disease; term pregnancy rates as 55.6% in patients with severe adhesions and 87.5% in patients with mild adhesions [ 7 ]. A recent study found that the severity of intrauterine adhesions before hysteroscopic adhesiolysis affects the conception rates after hysteroscopic adhesiolysis; and the conception rates in women with mild, moderate, and severe adhesions were 64.7%, 53.6%, and 32.5%, respectively [ 8 ].

Although Cesarean section is a less common etiologic factor for IUA formation, Asherman's syndrome should be considered in patients with history of Cesarean section presenting with menstrual disturbances such as amenorrhea or hypomenorrhea and infertility, like the present case. To the best of our knowledge, that situation has infrequently been previously reported in the literature. A case reported that woman who presented with dysmenorrhea developed uterine synechiae on the previous uterine incision after previous cesarean deliveries and underwent a total abdominal hysterectomy after failure of a dilation and curettage because of uterine synechiae [ 9 ]. Another case presented with secondary infertility showed that severe Asherman's syndrome occurred following a Cesarean section and pregnancy complicated to premature labor and abnormal adherent placentation as placenta increta was achieved through a subsequent intracytoplasmic sperm injection after hysteroscopic adhesiolysis and a cesarean hysterectomy was performed because of placenta increta [ 10 ]. A case of a 19-year-old patient who developed secondary amenorrhea after Cesarean section and severe postpartum hemorrhage also demonstrated that severe intrauterine adhesions caused by trauma to the decidua caused by currettage and the decrease in blood flow related to uterine artery ligation because of severe postpartum hemorrhage [ 11 ].

In the present case, we considered Asherman's syndrome resulting from Cesarean section as an etiological factor for infertility and secondary amenorrhea because of the history of Cesarean section, HSG findings, and the absence of another etiologic factors causing Asherman's syndrome. It is probably related to an adhesive endometrial fibrous process between the uterine walls due to previous Cesarean incision. Because the extent of endometrial cavity obliteration was dense, multiple adhesions, especially located on isthmus and previous Caeserian incision, could be demonstrated by hysteroscopy. We confirmed the diagnosis of IUA formation under direct vision with hysteroscopy which is the gold standard method. Our case was classified as severe Asherman's syndrome according to the modified classification based on the European Society of Hysteroscopy (ESH) and European Society of Gynaecological Endoscopy (ESGE) classification of intrauterine adhesions (1995 version) [ 12 ]. We successfully treated the patient with single hysteroscopic adhesiolysis followed by a postoperative hormone therapy. Second-look office hysteroscopy was performed to evaluate the endometrial cavity 2 months after the initial procedure. At the second look hysteroscopy, there was no reformation of adhesions and an adequate uterine cavity was achieved for pregnancy. Patient had resumption of normal menses 3 months after the initial procedure, and an IVF treatment was performed 6 months after the initial procedure because of tubal factor. The patient had an ongoing pregnancy.

4. Conclusion

As the present case, even with no history of chorioamnionitis or postpartum endometritis, postpartum curettage, uterine compression sutures, the probability of Asherman's syndrome should be kept in mind in patients with history of Cesarean section presenting with menstrual disturbances such as amenorrhea or hypomenorrhea and infertility because women with previous cesarean deliveries tend to develop uterine synechiae and that uterine synechiae may have an adverse impact on fertility and the uterine complication rate; therefore, the management of infertility puts forward the evaluation of uterine cavity. Moreover, even if there are additional infertility factors, in the patients with Asherman's syndrome, for the success of IVF procedure it is important to restore the uterine cavity and endometrium. It is also important to realize the high risk involved in such cases during the pregnancy course, and careful perinatal management should be required.