Endometrial Scarring/Adhesions - Asherman’s Syndrome

The obliteration of the uterine cavity secondary to trauma to the uterine body was described in 1950 as Asherman's syndrome. In 1989, the American Fertility Society classified intrauterine adhesions (IUA) from stage I to III based on the extent and type of adhesions and the menstrual pattern.

Intrauterine adhesions are caused by an insulting event to the endometrium that engenders adhesion of the myometrium to the opposing uterine wall. The most common antecedent events are either uterine curettage to a vulnerable gravid uterus or a uterine infection from a variety of microorganisms. Genital tuberculosis in particular can cause intrauterine adhesions (IUA) which are associated with uterine cavity obliteration in more than half of the cases.

Hysteroscopy, which is the gold standard for the diagnosis, has identified IUA present in approximately in 3 to 16% of women before their first IVF attempt and in 7 to 21.8% of women with recurrent pregnancy loss.

The reproductive outcome of women with IUA is generally poor. Studies have reported pregnancies in approx. 45% of women with IUA who did not receive treatment before attempting to conceive. Of these pregnancies, around 40% end in spontaneous abortion and another 23% in preterm deliveries.

Subfertility in patients with intrauterine adhesions may be caused by complete or partial occlusion of the tubal ostia, uterine cavity, or the cervical canal, preventing the migration of sperm or the implantation of the embryo. Severe destruction of the endometrium may also lead to defective or absent implantation.

Hysteroscopic Adhesiolysis/Synechiolysis

The blind lysis (cutting) of adhesions by curettage can cause trauma to the basal layer of the endometrium and may promote adhesion reformation. Therefore, hysteroscopic adhesiolysis is favored, that is performed using forceps, scissors, or knife electrode under direct visualization.

To reduce the chance of recurrent IUA, the use of hormone therapy (estrogen with or without a progestin), intrauterine stents, intrauterine devices, and antibiotics have been advocated.

The mean term live birthrate of published series of hysteroscopic adhesiolysis in infertile women using various techniques is 33%. The rates of first- and second-trimester pregnancy loss in these series were 11% and 14%, respectively. A correlation between the extent of uterine adhesions and subsequent pregnancy outcome following therapy has been observed in the largest study that classified IUA. This study reported a term pregnancy rate following hysteroscopic adhesiolysis of 81.3% among women with mild disease, 66.0% among women with moderate disease, and 31.9% of those with severe disease.

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Dr Eleftherios Meridis