Asherman's Syndrome

Asherman's Syndrome
http://www.ashermans.org/home/
"It's no longer a question of WHAT IF, but with knowledge it's answering WHAT NOW"
Welcome to our Web Site
Welcome to our site. If you are looking for information and support for Asherman's Syndrome, intrauterine adhesions/scarring, or related problems, you've found the right place.

What is Asherman's Syndrome?
Asherman's Syndrome, or intrauterine adhesions or synechiae, is an acquired uterine condition, characterized by the formation of adhesions (scar tissue) inside the uterus. In many cases the front and back walls of the uterus stick to one another. In other cases, adhesions only occur in a small portion of the uterus. The extent of the adhesions defines whether the case is mild, moderate or severe. The adhesions can be thin or thick, can be spotty in location, or can be confluent. They are usually not vascular, an important attribute that helps in treatment. Click here for more on Asherman's Syndrome grades.

Symptoms
Most patients with Asherman's have scanty or absent periods (amenorrhea) but some have normal periods. Some patients have no periods but feel pain at the time each month that their period would normally arrive. This pain may indicate that menstruation is occurring but the blood cannot exit the uterus because the cervix is blocked by adhesions. Recurrent miscarriage and infertility could also be symptoms (1).

Causes
Asherman’s syndrome occurs when trauma to the endometrial lining triggers the normal wound-healing process, which causes the damaged areas to fuse together. Most commonly, intrauterine adhesions occur after a D&C(dilation and curettage) that was performed because of a missed or incomplete miscarriage, because of retained placenta with or without hemorrhage after a delivery, or elective abortion. Pregnancy-related D&Cs have been shown to account for 90% of Asherman’s cases (2). Adhesions sometimes also occur following other pelvic surgeries such as cesarean section, surgery to remove fibroids or polyps, or in the developing world, as a result of infections such as genital tuberculosis (3) and schistosomiasis (4).

The risk of developing Asherman’s from a D&C is 25% 2-4 weeks after delivery (5-8). D&Cs also lead to Asherman’s in 30.9% of procedures for missed miscarriages(17) and 6.4% for incomplete miscarriages (2). Asherman’s risk increases with the number of D&Cs performed; after a single termination the risk is 16% however after 3 or more D&Cs the risk jumps to 32% (9). Each case of Asherman's Syndrome is different, and cause must be determined on a case-by-case basis. In some cases, Asherman's may have been caused by an "overly-aggressive" D&C. However, this is not often considered to be the case. The placenta may have attached very deeply in the endometrium or fibrotic activity of retained products of conception could have occurred both of which make it difficult to remove retained tissue without causing injury to the basal endometrium. For the most comprehensive information about D&Cs and Asherman's Syndrome, please click here to visit DandCnow.info.

There is a variant of Asherman's Syndrome that is more difficult to treat. This is a so-called "unstuck Asherman's" or endometrial sclerosis. In this condition, which may coexist with the presence of adhesions, the uterine walls are not stuck together. Instead, the endometrium has been denuded. Although curettage can cause this condition, it is more likely after uterine surgery, such as myomectomy. In these cases the endometrium, or at least its basal layer, has been removed or destroyed.

Incidence
Asherman’s is thought to be under-diagnosed because it is usually undetectable by routine diagnostic procedures such as ultrasound scan. The condition is estimated to affect 1.5% of women undergoing HSG (10), between 5 and 39% of women with recurrent miscarriage (11-13), and up to 40% of patients who have undergone D&C for retained products of conception following childbirth or incomplete abortion (14) (see Causes above).

Diagnosis
Direct visualization of the uterus via Hysteroscopyis the most reliable method for diagnosis. Other methods are sonohysterography (SHG) and hysterosalpingogram (HSG).

Prevention
Ideally, prevention is the best solution. It was suggested as early as in 1993 (9) that the incidence of IUA might be lower following medical evacuation (eg. Misoprostol) of the uterus, thus avoiding any intra-uterine instrumentation. So far, one study supports this proposal, showing that women who were treated for missed miscarriage with misoprostol did not develop IUA, while 7.7% of those undergoing D&C did(15). The advantage of misoprostol is that is can be used for evacuation not only following miscarriage, but also following birth for retained placenta or hemorrhaging. Alternatively, D&C could be performed under ultrasound guidance rather than blindly. This would enable the surgeon to end scraping the lining when all retained tissue has been removed, avoiding injury. Early monitoring during pregnancy to identify miscarriage can prevent the development of, or as the case may be, the reoccurrence of Asherman’s as adhesions are more likely to occur after a D&C the longer the period after fetal death (2). Therefore immediate evacuation following fetal death may prevent IUA. There is no evidence to suggest that suction D&C is less likely to result in adhesions than sharp D&C. Cases of Asherman’s have been reported even following manual vacuum aspiration (16) and the rate of Asherman’s has not dropped since the introduction of suction D&C.

Treatment
Asherman’s must be treated by a very experienced surgeon via hysteroscopy (sometimes assisted by Laparoscopy) Those few surgeons experienced enough in treating severe Asherman’s Syndrome recommend the avoidance of energy sources inside the uterus (this means removing scars with scissors rather than with energy-generating instruments such as resectoscopes or lasers, although not all surgeons agree with this). Adhesions have a tendency to reform especially in more severe cases. There are different methods to prevent re-scarring after surgery for Asherman´s Syndrome. Many surgeons prescribe estrogen supplementation to stimulate uterine healing respectively the growth of endometrium and place a splint or balloon to prevent apposition of the walls during the immediate post-operative healing phase. Other surgeons recommend weekly in-office hysteroscopy after the main surgery to cut away any newly formed adhesions. As yet, studies have not confirmed which method of treatment is most likely to have a successful outcome, that is one where the uterus/cervix remain scar free and fertility is restored.

Mission
This site is for a growing community of women who suffer or have suffered with Asherman's Syndrome. This site will provide information about Asherman's Syndrome, as well as personal support and shared experiences. Here, we share our hopes and despairs and talk about other options available for building our families, such as surrogacy and adoption. We will share medical and legal information, including any valuable links to other sites on the World Wide Web. We will also share our own stories as means of providing encouragement and hope.

Visit our YouTube channel to view videos about the experiences of women who have Asherman's Syndrome and the specialized doctors who treat them. We are continuously adding more videos to this channel so check it out often.

Contact Us
If you would like to join us or have any questions answered please visit our Contacts page.

If you are a medical professional and are interested in getting in touch with us, please email us for further communication. Please include the following information in your email: Name, Profession, Country, and Area of Interest in our group.

References (please click here for a complete list)