Asherman’s Syndrome (AS) is characterized by the formation of scar tissue, known as intrauterine adhesions (IUA), within the uterine cavity or cervix. This scarring causes the uterine walls to stick together, reducing functional space and interfering with the normal uterine lining. While AS impacts reproductive health, modern medical interventions offer high rates of successful treatment, often restoring the uterine cavity and fertility. Management depends heavily on the severity of the adhesions and the approach taken to remove them and prevent their return.
Understanding the Causes and Symptoms
Asherman’s Syndrome results from trauma to the basal layer of the endometrium, the deep, regenerative layer of the uterine lining. When this layer is damaged, the opposing uterine walls can fuse together, creating scar tissue. The most common cause is a Dilation and Curettage (D&C) procedure, especially when performed following a miscarriage, retained placental tissue, or an abortion. The risk is higher when the D&C is performed on a recently pregnant uterus. Severe pelvic infections or other uterine surgeries, such as a myomectomy, can also lead to scar tissue development. Adhesions range from thin and filmy to thick and dense, sometimes obliterating the entire cavity in severe cases.
Intrauterine adhesions disrupt the menstrual and reproductive cycles, leading to distinct symptoms. The most frequent symptom is amenorrhea (absence of menstrual periods) or hypomenorrhea (a significant decrease in menstrual flow). Because scar tissue can block blood flow, some patients experience monthly pelvic pain without external bleeding. AS is also a major contributor to female infertility and recurrent pregnancy loss, as the uterine lining cannot properly support embryo implantation and growth.
How Asherman’s Syndrome is Diagnosed
Diagnosis usually begins when a patient presents with reduced menstrual flow or difficulty conceiving following a uterine procedure. Doctors use specialized imaging techniques to visualize the extent of scarring. A Hysterosalpingogram (HSG) involves injecting dye through the cervix and taking X-ray images to detect blockages or irregularities in the uterine cavity and fallopian tubes. A specialized ultrasound, such as a sonohysterogram, uses saline instilled into the uterus to identify scar tissue.
The gold standard for confirming diagnosis and assessing severity is the diagnostic hysteroscopy. This minimally invasive procedure involves inserting a thin, lighted instrument through the cervix to directly visualize the uterine cavity. Direct visualization allows the surgeon to accurately map the location, extent, and type of adhesions, which grades the syndrome as mild, moderate, or severe. This grading is necessary for planning surgical treatment and providing an accurate prognosis for fertility restoration.
Surgical Management and Adhesion Removal
The primary treatment for Asherman’s Syndrome is hysteroscopic lysis of adhesions. This surgical procedure is performed under direct visualization using a hysteroscope, allowing the surgeon to work precisely within the uterine cavity without external incisions. The goal is to carefully cut the scar tissue to restore the normal shape and volume of the uterus. Specialized miniature instruments, such as scissors, electrosurgical tools, or lasers, are passed through the hysteroscope to divide the adhesions.
Care is taken to avoid further damage to the remaining healthy basal layer of the endometrium, which is necessary for future menstrual function and pregnancy. In complex cases involving severe scarring, the procedure may be guided by a simultaneous laparoscopy to monitor the outside of the uterus for safety. Extensive or dense adhesions often require multiple surgical sessions for complete restoration. Success relies on the surgeon’s expertise in distinguishing scar tissue from the healthy uterine wall. After removal, the cavity is fully distended to confirm separation of the uterine walls and clear openings to the fallopian tubes.
Success Rates and Preventing Recurrence
The long-term outcome depends highly on the initial severity of the adhesions. Patients with mild adhesions often have an excellent prognosis, with successful cavity restoration in over 90% of cases. For women with moderate to severe adhesions, the prognosis is more guarded, and recurrence remains a significant challenge.
To mitigate the risk of re-scarring, an immediate post-operative regimen is implemented. This typically involves high-dose estrogen therapy, sometimes combined with progesterone, for several weeks to stimulate the regrowth of a healthy endometrial lining. Simultaneously, a physical barrier is temporarily placed inside the uterus to prevent the newly separated walls from fusing again. These barriers include a small intrauterine balloon or a specific type of intrauterine device (IUD), removed after a short healing period.
Following successful treatment, pregnancy rates for women previously infertile range from 40% to 80%, with live birth rates between 30% and 70%. Subsequent pregnancies may be considered high-risk due to an elevated likelihood of placental complications, such as placenta accreta, requiring close monitoring.