Uterine Adhesions or Asherman’s Syndrome

Uterine adhesions at a glance

  • Intrauterine adhesions are scar tissue that forms between the inner walls of the uterus.
  • Many patients experience absent, light, or infrequent menstruation; some patients are unable to get pregnant or experience recurrent miscarriages.
  • Uterine adhesions are commonly diagnosed by an x-ray procedure known as a hysterosalpingogram (HSG).
  • Surgical removal of intrauterine adhesions with hysteroscope generally is recommended to allow a full-term pregnancy.

About uterine adhesions

Intrauterine adhesions are scar tissue that forms between the inner walls of the uterus. Another term used to describe intrauterine adhesions is Asherman’s Syndrome. The most common cause of intrauterine adhesions is trauma to the uterine cavity. This may occur following dilation and curettage (D&C), an outpatient surgical procedure during which the cervix is dilated and the tissue contents of the uterus are emptied, pregnancy termination, or excess uterine bleeding after childbirth. Most often it is associated with delayed removal of the tissue and some low grade infection. The patient is usually unaware that there has been infection, and scarring is only discovered later on. Less commonly, prolonged use of an intrauterine device (IUD), infections of the endometrium (endometritis), and surgical procedures involving the uterus (such as removal of fibroids) also may lead to the development of intrauterine adhesions.

Women with intrauterine adhesions may have no obvious problems. Many patients, however, experience absent, light, or infrequent menstruation. Some patients with adhesions are unable to get pregnant or experience recurrent miscarriages. Less commonly, the adhesions block menstrual flow and cause pelvic pain or dysmenorrhea (painful menstrual periods). Moderate or even mild adhesions may be associated with no change in periods at all, but can have an adverse inflammatory effect on the remaining tissue in the uterus – interfering with embryo implantation.

An x-ray procedure known as a hysterosalpingogram (HSG) is one common method used to diagnose intrauterine adhesions. This requires a small catheter to be placed through the cervix for the delivery of fluid. However, hysteroscopy is the definitive test to diagnose adhesions. The scope is used as a guide to cut the adhesions. Because adhesions can reoccur, another test of the cavity post-operatively is needed.

Treatment of intrauterine adhesions

Surgical removal of intrauterine adhesions with hysteroscope generally is recommended; however, there are few data to show that this treatment reduces the chance of a future miscarriage, according to the American Society of Reproductive Medicine. Sometimes laparoscopy is performed to visualize the uterine surface to guard against perforating the uterus while hysteroscopic breakup of extensive adhesions is carried out. To reduce the reformation of adhesions, surgeons may prescribe hormones or NSAIDS or even recommend a structural plastic catheter placed inside the uterus to keep the walls of the uterus apart and to prevent adhesions from reforming. In severe cases, surgeons may make more than one attempt at surgical removal of the adhesions.

Pregnancies that occur after hysteroscopic breakup of intrauterine adhesions are more likely to be complicated by preterm labor, third trimester bleeding, and/or abnormal attachment of the placenta to the uterine wall.

Reproductive outcomes after adhesions

Reproductive outcomes appear to correlate with the type and extent of the adhesions, according to figures compiled by the American Society of Reproductive Medicine. After treatment, patients with mild to moderate adhesions have full-term pregnancy rates of approximately 70 percent to 80 percent, and menstrual dysfunction is frequently alleviated. Alternatively, patients with severe adhesions or extensive destruction of the endometrial lining may have full-term pregnancy rates of only 20 percent to 40 percent after treatment. Women with extensive damage to the endometrium and who are unresponsive to conventional therapy by hysteroscopy may need to consider adoption or a gestational carrier to achieve a pregnancy.