Asherman’s Syndrome

What is Asherman’s Syndrome?

Asherman’s syndrome is a condition in which adhesions or scar tissue develops inside the uterus, sticking the front wall to the back wall of the uterus, obstructing or obliterating the endometrial cavity where a pregnancy develops.

Asherman’s syndrome usually develops after a surgical procedure on the uterus such as a D&C (Dilatation and curettage), termination of pregnancy, evacuation of retained products of conception after a miscarriage or retained placenta or more extensive surgery such as a myomectomy (operation to remove a fibroid).  It is usually made worse if there is an infection, and is much more common than many doctors accept.  It is not always caused by poor surgical technique and is an unfortunate consequence of some procedures.

How do you know you have Asherman’s syndrome?

Most women with Asherman’s syndrome will notice that their periods become much lighter than they were before the operation and sometimes the periods stop altogether.  Many women also experience significant cramping  and pain at the expected time of their period, especially if they don’t see any loss at all.

How Common is Asherman’s Syndrome?

Asherman’s syndrome is much more common than many doctors think and many are not prepared to consider the diagnosis as a result.  The estimates of the proportion of D&C procedures that cause it vary from less than 1% to up to 5%.  If you have had surgery and your periods are lighter than they were before it is certainly worth checking it out.

How is Asherman’s Syndrome diagnosed?

The easiest way to diagnose Asherman’s syndrome is by a hysterosalpingogram, an xray examination in which contrast medium is introduced into the womb which shows up on xray and will show an absence of contrast medium or a filling defect in areas of the cavity which are obstructed  by adhesions.

How does Asherman’s Syndrome affect fertility?

In the worst case, Asherman’s syndrome can affect fertility by obliterating the cavity so there is nowhere for the embryo to develop, or it can make the endometrium so thin that implantation cannot occur.  Adhesions can also block off the Fallopian tube so that sperm cannot gain access to the egg to fertilise it.

How is Asherman’s Syndrome treated?

The diagnosis is confirmed by hysteroscopy and can also be treated by hysteroscopy using microscissors to divide the adhesions.  It is best if this procedure is done by a surgeon who has plenty of experience in treating Asherman’s syndrome, since it can be made much worse if the hysteroscope is introduced in the wrong place, creating a false passage which is surprisingly easy to do.  The more experienced surgeons will do this under xray or ultrasound control to ensure that they are in the true cavity of the uterus.

Unfortunately the adhesions often come back and it is essential to have high dose oestrogen treatment to encourage regrowth of the endometrium after the adhesions have been divided to reduce this risk.  A stent or contraceptive coil is also often left in the uterus to help to prevent adhesions from regrowing and to break them down when the coil is removed.

We also support the use of acupuncture which seems to have a beneficial effect on the endometrium.  The mechanism is unclear but may be mediated through beneficial effects on uterine blood flow.  This link takes you to a video of Alison, one of our patients who tells the moving story of her journey involving Asherman’s treatment who was supported by Emma Cannon, with whom we work very closely.

The prognosis for most women with Asherman’s syndrome is good and we can improve the uterus in most cases.  Sometimes however the uterus is so badly damaged that the endometrium has been completely lost.  In these cases the only option is to resort to surrogacy.