Asherman’s Syndrome (AS) is a uterine condition characterized by the formation of scar tissue, known as adhesions, within the uterine cavity. These adhesions can significantly alter the normal structure of the uterus.
Understanding Asherman’s Syndrome
Asherman’s Syndrome develops when scar tissue, or adhesions, forms inside the uterus and sometimes extends into the cervix. This scarring can vary in extent, ranging from thin, filmy bands to thick, dense tissue that can partially or completely obliterate the uterine cavity. The most frequent cause of Asherman’s Syndrome is trauma to the uterine lining, particularly following uterine surgery.
Common causes include:
Dilation and curettage (D&C), especially after miscarriage, abortion, or retained placental tissue.
Cesarean sections.
Myomectomy (fibroid removal).
Operative hysteroscopy.
Severe pelvic infections, including genital tuberculosis.
Radiation treatment.
Symptoms include changes in menstrual patterns, such as very light periods (hypomenorrhea) or a complete absence of menstruation (amenorrhea). Recurrent miscarriages and difficulty conceiving are also common, as the scarred uterine environment can hinder embryo implantation and development. Some individuals may also report pelvic pain or cramping, particularly if menstrual flow is obstructed by the adhesions.
Treatment Approaches
The primary treatment for Asherman’s Syndrome involves the surgical removal of the adhesions. This procedure is typically performed using hysteroscopy, a minimally invasive technique.
During hysteroscopy, a thin, lighted telescope-like instrument called a hysteroscope is inserted through the cervix into the uterus, allowing the surgeon to visualize the adhesions directly. Specialized instruments passed through the hysteroscope are then used to carefully cut and remove the scar tissue. The goal is to restore the normal shape and size of the uterine cavity while minimizing damage to the healthy uterine lining.
In some complex cases, repeated hysteroscopic procedures may be necessary to achieve optimal results.
Following the surgical removal of adhesions, post-operative care is crucial to prevent the re-formation of scar tissue. This often involves:
Placing a temporary barrier (e.g., intrauterine balloon or Foley catheter) inside the uterus for several days to keep walls separated during healing.
Prescribing estrogen therapy to promote regrowth of a healthy uterine lining.
Administering antibiotics to prevent infection during healing.
Defining “Curability” in Asherman’s Syndrome
Curability in Asherman’s Syndrome is nuanced, meaning more than just removing physical adhesions. It implies restoring the uterine cavity to a functional state that supports normal menstrual cycles and successful pregnancy. Hysteroscopic adhesiolysis is often highly effective in achieving anatomical restoration.
Success rates for restoring normal menstrual function after treatment are high (75% to 100%). However, the ability to achieve pregnancy and a live birth varies more widely, with reported pregnancy rates from 40% to 80% and live birth rates from 30% to 70%. The severity of initial adhesions significantly impacts these outcomes, with milder cases generally experiencing higher conception rates.
Despite successful initial treatment, adhesion re-formation remains a notable challenge. Recurrence rates vary, from 3.1% to 23.5% in some studies, and up to 66% in severe cases. This often necessitates follow-up procedures, such as a second-look hysteroscopy, to address newly formed scar tissue. While physical scar tissue can often be removed, regenerating a fully functional endometrial lining or addressing the predisposition for adhesion formation can be challenging.
Prognosis and Long-Term Considerations
While treatment for Asherman’s Syndrome can significantly improve the chances of conception, long-term obstetric considerations exist for those who become pregnant. Pregnancies following Asherman’s Syndrome treatment are sometimes considered moderate to high risk.
There is an increased risk of specific pregnancy complications, including abnormal placentation such as placenta accreta, where the placenta grows too deeply into the uterine wall, or placenta previa, where the placenta partially or completely covers the cervix. Other potential complications include preterm birth and, in rare instances, uterine rupture.
Ongoing monitoring and close follow-up with a healthcare provider are important for individuals who conceive after Asherman’s Syndrome treatment. This ensures any potential complications are identified and managed promptly to support a healthy pregnancy outcome.