Asherman’s Syndrome – Signs, Treatment & Chances of Pregnancy

By (gynecologist), BSc, PhD (gynecologist), BSc, MSc (embryologist), MD, PhD (gynecologist) and (invitra staff).
Last Update: 02/14/2019

The Asherman's syndrome, or intrauterine adhesions, is a uterine disease characterised by the formation of adhesions (scar tissue) inside de uterus. In many cases the uterus walls get distorted and sometimes stuck to each other. Therefore, for its diagnosis, it is necessary to perform an ultrasound to evaluate the state of the uterus.

The extent of the adhesions defines whether the case is mild, moderate, or severe. When the uterus walls get stuck, it can lead to serious infertility issues. The adhesions can be thin or thick, spotty in location, or confluent. In other cases, adhesions only occur in a small portion of the uterus.

Causes

Asherman syndrome occurs when the normal healing process in the uterus is initiated. Most commonly, intrauterine adhesions occur after a dilation and curettage, performed because of a miscarriage. In fact, the practice of curettage after the loss of a pregnancy is the most common cause of Asherman syndrome.

Bleeding from a caesarean section or natural delivery can also cause scarring. Myomectomy or other gynecological conditions can also cause this syndrome.

These traumas cause, as in any situation, a subsequent healing process in which scar tissue is generated. This tissue has a high adhesive capacity due to its high content of fibrous filaments. The uterus walls get stuck together or get distorted. This fact compromise the uterus main function: gestate.

Asherman syndrome is, therefore, an acquired condition. Nobody is born with it, but it occurs as a result of a previous clinical case.

Diagnosis

In order to determine if the woman suffers from this disease, the gynaecologist must carry out several tests to see if there are adhesions through a series of tests detailed below.

It is very important to have the patient's clinical history in mind. It must be checked whether the patient has previously undergone curettage or gynaecological operations since, in the case of a curettage after a spontaneous abortion, there is an 8% chance of contracting Asherman syndrome. This risk may increase by up to 30% if 3 scrapes have been performed.

The medical tests necessary for the diagnosis of Asherman syndrome are:

Ultrasonography

Ultrasonography or ultrasound is a diagnostic test that takes pictures of the inside of the body. In this case, the transvaginal ultrasonography,must be inserted through the vagina and into the uterus in order to observe this cavity.

This is usually done in the first instance, as it is simple, non-invasive and can easily be performed in consultation. However, sometimes its results are not conclusive due to the difficulty in interpreting the images obtained. Therefore, it is necessary to resort to more specialised techniques.

Hysterosalpingogram (HSG)

This medical test consists of a radiograph combined with the use of a contrast medium. This fluid is essential in this test, as it is introduced into the uterus and expands throughout the cavity until it reaches the fallopian tubes and is expelled into the peritoneal space. In this way, the contrast agent "draws" the shape of the uterus and tubes. Once the contrast has been injected, an x-ray is taken.

Hysterosalpingogram is a more complete test than ultrasound, as the presence of adhesions, obstructions or alterations such as fibroids or polyps is easier to detect.

However, although it does not require anesthesia or is not very painful, it is a complicated procedure that must be scheduled and performed in a specialized unit.

Today, there is a new method for performing HSG without the need of iodinated contrast or X-rays. It consists of using the ExEm Foam Kit in a Hysterosalpingo-Foam-Sonography.

This consists of a foaming gel that is inserted through the cervix at the same time as an ultrasound scan is performed.

Hysteroscopy

Finally, if the diagnosis after the above tests remains unclear, a diagnostic hysteroscopy may be performed. This test consists of inserting a camera into the uterine cavity in order to observe it.

Using this test, the determination of the pathology is much more reliable, as the visualisation of adhesions is more direct.

Symptoms

The most common symptoms of Asherman Syndrome are:

  • Menstrual disorders: Long periods of no menstrual bleeding (amenorrhea) usually occur, mainly because adhesions block blood clots from the uterus to the vagina.
  • Pelvic or abdominal pain: As a result of the retention of menstrual bleeding, women may experience pain during periods or between periods.
  • Retrograde Menstruation: Preventing endometrial tissue from leaving can cause endometrial tissue to be released retrogressively into the abdominal cavity through the fallopian tubes. Blood released can settle into cysts or endometriomas.
  • Recurrent miscarriage: the deformation of the uterine cavity as a result of the adhesion of its walls makes the correct development of gestation impossible. If this condition is not treated, recurrent miscarriage may occur.

These symptoms are very common and may be related to many other gynaecological pathologies in addition to Asherman syndrome. Therefore, extensive testing is necessary to determine the cause of these signs.

If they occur suddenly after curettage, scraping, or other uterine surgery, it is likely to indicate Asherman syndrome.

Treatment

If the results of the above tests show that you have this syndrome, surgery is necessary, since this condition can be quite painful and have very negative consequences for a woman's fertility.

Treatment for Asherman syndrome involves the removal and cauterisation of adhesions so that the uterus regains its normal shape and size. Generally, this procedure is performed by means of a surgical hysteroscopy during which, in addition to the optical system through which the uterus is visualised, specialised microsurgical instruments are used to section the adhesions.

Once the scar tissue has been removed, it is important that the uterine cavity remains expanded to prevent the recurrence of adhesions. There are several methods available:

  • Intrauterine balloon: is a small probe that is inserted into the uterus and, once positioned inside, expands, keeping the uterine walls separate, while they heal.
  • Oestrogen Treatment: Oestrogen-based pharmacological treatment may also be necessary during the days following surgical hysteroscopy. This hormone stimulates the natural growth of the initially damaged endometrial tissue, preventing the growth of the tissue causing the adhesions.
  • Continuous hysteroscopies: some doctors recommend more exhaustive check-ups for women who have suffered this syndrome since they have a greater predisposition to suffer it again.

Moreover, as the Dr Pilar Alamá says:

Currently, there is a regenerating therapy of endometrial stem cells that may allow an adequate growth of the endometrium in these cases of synergies.

Endometrial sclerosis

There’s a variety of Asherman that is difficult to treat. This variety is known as endometrial sclerosis.

This condition may coexist with the formation of adhesions and what happens isn’t that the uterine walls are glued to each other, but the endometrium has been torn out.

Even though dilation and curettage may cause it, it’s more common after a uterine surgery such as myomectomy. In these cases, because the endometrium, or at least its basal root, has been removed or destroyed, the amenorrhea that results from this situation is not because menstrual bleeding is retained, but because there is no tissue to expel during menstruation.

In the most severe cases of incurable Asherman, the only option to become a mother may be surrogacy. You can learn more about this here: What Is Surrogacy? – Definition & Types.

FAQs from users

Can I know if I have Asherman’s syndrome by just checking my hormone levels?

By José Antonio Duque Gallo BSc, PhD (gynecologist).

No, it can be suspected by ultrasound, and diagnosed by hysteroscopy.

What are the causes of Asherman syndrome?

By Dr. Joel G. Brasch (gynecologist).

Asherman syndrome is a rare condition that presents as the formation of scar tissue in the uterine cavity. The problem most often develops after uterine surgery, especially in women who have had several dilation and curettage (D&C) procedure. Other cause of AS include a severe pelvic infection unrelated to surgery, infection with tuberculosis or schistosomiasis. Uterine complications related to these infections are even less common.

Can Asherman syndrome be completely cured?

By Victoria Moliner BSc, MSc (embryologist).

It depends on the degree of the condition, the more severe it is, the more likely the adhesions will reappear in the patient.

Can intrauterine adhesions appear after a cesarean section?

By Victoria Moliner BSc, MSc (embryologist).

Yes, cesarean section may be a reason for intrauterine adhesions to develop because it is a surgical procedure that requires healing after the incisions made to extract the baby.

Is a pregnancy viable with Asherman Syndrome?

By Victoria Moliner BSc, MSc (embryologist).

The presence of intrauterine adhesions seriously compromises the fact that a pregnancy can develop normally. To do this, it is necessary to remove the tissues before the woman becomes pregnant.

Can Asherman syndrome be the cause of endometriosis?

By Victoria Moliner BSc, MSc (embryologist).

It is possible that blood clots retained by the adhesions can be evacuated retrograde into the abdominal cavity, landing on the tubes or ovaries and forming cysts. Suffering from Asherman syndrome may be a reason to develop endometriosis, as the retrograde menstruation mechanism results precisely from it.

Our editors have made great efforts to create this content for you. By sharing this post, you are helping us to keep ourselves motivated to work even harder.

References

Authors and contributors

Dr. Joel G. Brasch
Dr. Joel G. Brasch
Gynecologist
Dr. Joel Brasch is the Medical Director of Chicago IVF, founded in 2005. He is board certified by the American Board of Obstetrics and Gynecology, and has over 25 years of direct experience in fertility treatment and reproductive care. He is also the Director of Mount Sinai Medical Center’s Division of Reproductive Endocrinology and Infertility. More information about Dr. Joel G. Brasch
 José Antonio Duque Gallo
José Antonio Duque Gallo
BSc, PhD
Gynecologist
Bachelor's Degree in Medicine and Surgery from the University of Valencia. Specialist in Obstetrics & Gynecology. He has an extensive experience in the field of Human Reproduction. he has been Head of Human Reproduction Service at the Miguel Servet University Hospital of Zaragoza ans is currently the Medical Director of the GOBEST Clinic in Zaragoza. More information about José Antonio Duque Gallo
Licence: 505005367
 Neus Ferrando Gilabert
Neus Ferrando Gilabert
BSc, MSc
Embryologist
Bachelor's Degree in Biology from the University of Valencia (UV). Postgraduate Course in Biotechnology of Human Assisted Reproduction from the Miguel Hernández University of Elche (UMH). Experience managing Embryology and Andrology Labs at Centro Médico Manzanera (Logroño, Spain). More information about Neus Ferrando Gilabert
Dr. Pilar Alamá Faubel
Dr. Pilar Alamá Faubel
MD, PhD
Gynecologist
Bachelor's Degree in Medicine from the University of Valencia (UV). PhD in Medicine and Surgery with the highest qualification from the University of Valencia. She works as an OB/GYN specialized in Reproductive Medicine at IVI Valencia, where she is the Director of the Egg Donation Program as well. As regards her experience as a teacher, she is a professor at the Biotechnology of Reproduction course of IVI and the Master's Degree in Human Reproduction. More information about Dr. Pilar Alamá Faubel
License: 464619335
Adapted into english by:
 Marie Tusseau
Marie Tusseau
inviTRA Staff
Editorial Director of Babygest magazine in French and English More information about Marie Tusseau

Find the latest news on assisted reproduction in our channels.