Asherman’s Syndrome – Grading, Symptoms, Causes & Fertility

The Asherman syndrome or Asherman's syndrome, also known as uterine synechiae, is a uterine disorder characterized by the presence of pelvic or intrauterine scarring and adhesions.

Uterine adhesions are located in the walls of the uterus, and cause the uterus to narrow. This causes injury to the endometrium and in most cases leads to female infertility.

The treatment of uterine synechiae involves surgery to remove intrauterine adhesions. However, the most severe causes can cause permanent sterility in the woman, thereby preventing her from getting pregnant. In such cases, the treatment option to have a child is surrogacy, as one shall see below.

Grading

Asherman's syndrome can be detected in any woman who has undergone some type of surgical procedure involving the manipulation of the uterus.

The incidence rate of this uterine condition ranges between 6 and 30% of all abortions, and reaches 25% in those who undergo a D&C procedure following childbirth.

Normal uterus vs. uterine adhesions

Given that this syndrome affects women of childbearing age by damaging her ability of getting pregnant and carrying a child until labor, it is considered a serious condition.

Nonetheless, the extent and location of uterine synechiae determine the severity of the disease. We can classify them into three grades of severity in accordance with Valle and Sciarra's (1988):

Mild

Thin endometrial adhesions that block the passage through the uterine cavity, either partially or totally.

Moderate

Fibromuscular, thick adhesions composed of endometrial tissue that cause a total or partial occlusion of the uterine cavity.

Severe

Composed of connective tissue, without endometrial lining, partially or totally blocking the uterine cavity.

The most severe type, known as known as true Asherman or unstuck Asherman, can lead to the extensive agglutination of the uterine walls, that is, the front and back walls of the uterus stick to each other. This prevents embryo implantation and subsequent fetal development in the womb. It affects tubal patency as well.

Causes

Asherman's syndrome is an acquired uterine condition that occurs after causing trauma to the endometrial lining. As a consequence, it triggers a wound-healing process that causes the damaged areas to fuse together.

Damage to the endometrium usually occurs after an open surgical procedure, although uterine adhesions can be triggered by other causes, including:

• D&C after a miscarriage or abortion
• Retained placenta after baby's birth
• Postpartum bleeding (bleeding after delivery)
• C-section
• Fibroid or endometrial polyp surgery
• Hysteroscopic myomectomy
• Severe pelvic inflammatory disease (PID)
• IUD insertion
• Genital tuberculosis and schistosomiasis (a.k.a. snail fever and bilharzia)

In general, in all cases where Dilation & Curettage (D&C) is required, the chances for intrauterine adhesions to develop are higher.

It should be noted that the risk of developing Asherman's syndrome increases after several D&C procedures.

Causes of Asherman's syndrome

Symptoms

The most frequent symptom in women with Asherman's syndrome are irregularities in their menstrual periods. However, some of these women have normal menstrual periods.

The following are some of the most common symptoms of the disease:

• Scanty periods, with brown menstrual blood, or absent periods (amenorrhea)
• Painful menstrual periods due to the presence of menstrual clots
• Endometriosis
• Recurrent pregnancy loss
• Infertility
• Vaginal bleeding in the most severe cases

It should be noted that these symptoms are not exclusive of the Asherman's syndrome. They can appear for other reasons as well. Doing an appropriate diagnosis is necessary for determining the precise cause.

However, if the symptoms appear suddenly after a D&C or after a surgical procedure, the most common is that they are associated with the Asherman syndrome.

Diagnosis

If you start noticing common Asherman's syndrome symptoms such as absence of menstrual periods or pain after D&C, you should visit your gyneacologist to undergo some diagnostic tests.

Routine tests such as a pelvic exams or transvaginal ultrasounds are insufficient to reveal the presence of uterine synechiae. However, an ultrasound scan allows us to determine the endometrial thickness and/or identify other potential causes of infertility.

First of all, it is important to dismiss the presence of other pathologies that can lead to irregular periods. By doing this, performing more technically challenging or invasive tests such as the ones we will find below may be unnecessary, saving considerable discomfort to the patient:

Hysterosalpingography (HSG)

It is a form of X-ray using a radiographic contrast medium (dye) injected into the uterine cavity to see the uterine and Fallopian tube anatomy. It allows us to see if the uterine walls are stick to one another and if there exists a blockage in the tubes.

Sonohysterography (SHG)

Also called ultrasound of the uterus or saline infusion sonography, it is a type of ultrasound in which a salt (saline) solution is put in the uterus for a clearer image.

Hysteroscopy (HSC)

It is the most accurate method for the diagnosis of uterine adhesions in the uterus. It allows the specialist to inspect the uterine cavity by endoscopy with access through the cervix.

Treatment

The only effective method that can be used for the removal of uterine adhesions is surgery. In fact, the specialist may do it while performing a diagnostic HSC.

In case uterine synechiae were located within the uterus, they can be cut and cauterized using small tools. Another possibility is to separate the uterine adhesions by HSC as well.

After the treatment, uterine adhesions may continue to occur, especially in the most severe cases. With the purpose of preventing this from happening, estrogen supplements may help in the healing process while allowing the endometrial lining to grow normally.

During the first days of the healing process, inserting an intrauterine balloon is another possibility. The goal is to prevent the uterine walls from adhering to each other again in the future.

Treatment of Asherman syndrome

Finally, your physician will schedule post surgery periodic hysteroscopies in order to evaluate if uterine adhesions have grown back or not.

In any case, the purpose of every treatment for the Asherman's syndrome is to have a normal uterus, without the presence of adhesions and/or scarring, able to maintain an ongoing pregnancy.

Unstuck Asherman's & using a surrogate

Endometrial sclerosis, commonly called unstuck Asherman's, is a severe type of Asherman's syndrome, considered an end-stage disease.

Contrary to what we have explained previously, endometrial sclerosis is more likely to develop after surgical procedures such as myomectomy instead of D&C.

In this type of Asherman's, the basalis layer of the endometrium has been severely damaged or even removed, which makes pregnancy not possible. Uterine adhesions may appear as well, but the woman will lack menstrual periods.

In these cases, the only way through which a woman can have a child is by means of surrogacy. This infertility treatment involves the use of another woman (the surrogate) to carry the child of a childless woman (the intended mother).

Get more info by clicking the following link: What Is IVF Surrogacy? – Process, Success Rates & Cost.

FAQs from users

What are the causes of Asherman syndrome?

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.

Is treatment of Asherman's syndrome covered on NHS?

Yes, a hysteroscopy to treat pelvic adhesions is covered on NHS to treat conditions and problems such as intrauterine adhesions, as well as for removing fibroids, polyps, displaced IUDs, etc. Also, to diagnose conditions and investigate symptoms or problems.

Are pelvic adhesions dangerous?

Yes, as they can lead to other problems such as obstructed tubes, pelvic tenderness, painful intercourse, chronic pelvic pain... The most appropriate would be to visit your physician in order to have the adequate diagnostic tests done and see what would be the most adequate treatment to prevent that uterine adhesions get worse.

Can you get pregnant with Asherman's syndrome?

Yes, pregnancy is not impossible in women with Asherman's syndrome. However, the presence of uterine adhesions and reduced space in the uterus compromise embryo development to a large extent. The risk of miscarriage is high.

Moreover, getting pregnant with Asherman's syndrome or even after treating the disease has an elevated risks for developing complications of the placenta (placenta previa or placenta accreta), or cervical insufficiency.

Can pelvic adhesions cause bloating and nausea?

Even though intrauterine adhesions are asymptomatic in most cases, they may come along with other warning signs such as bloating, nausea, vomiting and constipation. Moreover, these symptoms can point to a bowel obstruction.

Suggested for you

In case you want to learn more about surrogacy or surrogate motherhood as a treatment option in cases of severe Asherman's syndrome, visit the following guide: What Is Surrogacy & How Does It Work? – Everything You Should Know.