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?

Women 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 women 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.  Women with 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 women 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.