Asherman’s syndrome is one of the lesser-known but significant causes of fertility issues that can profoundly affect a woman’s ability to conceive and successfully carry a child to term. This condition is characterized by the formation of intrauterine adhesions—bands of scar tissue that connect the walls of the uterus, causing deformation of its cavity and impairing its functions.
These adhesions can partially or completely obstruct the uterine cavity, complicating or making embryo implantation impossible. This can also lead to complications during pregnancy, such as miscarriage or preterm labor, and may be accompanied by menstrual cycle disturbances, including reduced flow or complete absence of menstrual bleeding.
Asherman’s syndrome typically develops after surgical interventions on the uterus, such as dilation and curettage (D&C) or cesarean section, especially if these procedures were complicated by infections or other negative factors.
The formation of intrauterine adhesions can severely hinder the normal progression of pregnancy, often resulting in miscarriages, preterm births, or even infertility. These adhesions can complicate the embryo implantation process, restrict fetal growth, and cause various placental developmental anomalies. Therefore, early diagnosis and appropriate treatment of Asherman’s syndrome are crucial for maintaining a woman’s reproductive health.
What is Asherman’s Syndrome
Asherman’s syndrome is a pathological condition in which the uterine cavity is filled with connective tissue adhesions, leading to its obliteration (closure). The primary symptom of this condition is amenorrhea, which is the absence of menstrual periods. Asherman’s syndrome can cause serious fertility issues, such as miscarriage, infertility, and significant menstrual cycle disturbances. Additionally, the adhesions may hinder embryo implantation and normal fetal development, increasing the risk of complications during pregnancy.
Classification of Asherman’s Syndrome
In clinical practice, there are several types of classifications for intrauterine adhesions based on various methods of study. According to histological structure, Asherman’s syndrome is classified into three degrees:
- Mild Degree: Membranous adhesions that can be easily dissected using a hysteroscopic instrument. These are formed from cells of the basal layer of the endometrium and are considered a less severe form of Asherman’s syndrome.
- Moderate Degree: Characterized by fibromuscular growths that may bleed during dissection.
- Severe Degree: Connective tissue intrauterine adhesions that are difficult to dissect and require more complex treatment.
Depending on the extent of uterine involvement, Asherman’s syndrome is categorized into three degrees of severity:
- First Degree: Adhesions cover up to 25% of the internal cavity of the uterus. They have a thin structure and do not involve the fundus of the uterus or the openings of the fallopian tubes.
- Second Degree: Adhesions encompass 25% to 75% of the internal cavity of the uterus, with partial closure of the uterine fundus and the openings of the fallopian tubes.
- Third Degree: More than 75% of the uterine cavity is filled with adhesions, indicating complete or nearly complete obliteration of the organ.
The most commonly used classification of Asherman’s syndrome was developed by the European Society of Gynecological Endoscopy. This classification is based on data obtained during hysteroscopy, which is considered the “gold standard” for diagnosing this condition.
There are five stages of the disease:
- Mild adhesions: Thin and delicate adhesions that can be easily cut. The openings of the fallopian tubes are clearly visible.
- Single adhesions: Adhesions that connect separate areas of the uterus and cannot be cut with a hysteroscope. The openings of the fallopian tubes remain visible.
- Multiple adhesions: Adhesions that connect different parts of the uterus, with partial filling of the openings of the fallopian tubes on one side.
- Partial obliteration: Obliteration of the openings of both fallopian tubes and partial filling of the uterine cavity with adhesions.
- Severe stage: A combination of fibrous formation and scarring of the endometrium with any degree of Asherman syndrome, caused by disruption of the menstrual cycle.
Risk Factors
In gynecology, the occurrence of intrauterine adhesions is associated with the influence of infectious agents, trauma, and neurovisceral factors. The most common cause of Asherman syndrome is mechanical trauma to the basal layer of the endometrium that has occurred previously. Injury to the endometrium can be caused by:
- Surgical termination of pregnancy;
- The use of intrauterine contraceptives;
- Diagnostic curettage of the uterine cavity due to uterine bleeding or endometrial polyps;
- Surgical procedures on the uterine cavity.
Endometrial damage may worsen with the onset of infection. Additionally, several factors may contribute to the development of intrauterine adhesions:
- Genital tuberculosis;
- Intrauterine instillations;
- Radiation therapy for the treatment of uterine and ovarian tumors;
- Missed miscarriage accompanied by remnants of placental tissue, which stimulate fibroblast activity and early collagen formation before the complete regeneration of the endometrium.
Signs and Clinical Manifestations of Asherman Syndrome
The symptoms of Asherman syndrome can vary depending on the severity of intrauterine adhesions:
- Hypomenstrual syndrome or secondary amenorrhea: Menstrual irregularities may occur, manifesting as a reduction in menstrual blood volume or a complete absence of menstruation.
- Hematometra: If the lower sections of the uterus are obliterated, but the endometrium is preserved in the upper sections, blood can accumulate in the uterus.
- Implantation complications: Severe intrauterine adhesions may hinder the implantation of the fertilized egg due to the absence of a functional endometrium.
- Infertility: Obliteration of the fallopian tubes can prevent fertilization.
- Miscarriage: The condition can lead to difficulties in maintaining a pregnancy.
- Ineffectiveness of in vitro fertilization (IVF): Even mildly expressed adhesions can cause problems with IVF success due to obstacles to embryo implantation.
These symptoms can range from mild to severe and require different diagnostic and treatment approaches.
Diagnostic Methods for Asherman Syndrome
The primary and most accurate method for diagnosing Asherman syndrome is hysteroscopy, which is considered the “gold standard” in this case. This modern medical procedure allows for a visual examination of the internal cavity of the uterus using a special instrument called a hysteroscope. The hysteroscope is a thin tube with a camera and light at the end, which is inserted through the vagina and cervix into the uterine cavity.
Hysteroscopy enables tissue biopsy for further examination, the removal of remnants of the fertilized egg, the elimination of adhered intrauterine devices, and the determination of the optimal surgical intervention method for subsequent operations.
Additional methods, such as hysterosalpingography, can assess the degree of scarring formation in the uterus. Ultrasound is not reliable for confirming Asherman syndrome, as its accuracy in this context is limited.
Asherman syndrome is characterized by the following signs:
- Negative results from hormonal tests, particularly the absence of menstruation even after the administration of estrogen and progesterone.
- Diagnosis may include a Pipelle biopsy, which allows for tissue samples to be obtained without further traumatizing the endometrium.
Features of Treatment for Asherman Syndrome
The primary goal of treating Asherman syndrome is to minimally invasively remove intrauterine adhesions, restore normal menstrual function, and regain fertility.
The treatment strategy includes several stages:
- Operative Hysteroscopy: The first stage involves the cutting of adhesions under visual control. Various instruments are used for this purpose, depending on the degree of development of the intrauterine adhesions, including endoscopic scissors, forceps, hysteroscopic resectoscopes, and lasers.
- Monitoring for Uterine Perforation: To prevent complications during the procedure, monitoring is performed using ultrasound (US) or laparoscopy.
- Hormonal Therapy: After the operation, the patient is prescribed cyclical hormone therapy with estrogens and progestins to stimulate the recovery of the endometrium and its cyclical transformation.
- Antibacterial Therapy: In cases of infectious etiology, bacteriological examination of smears and vacuum biopsy materials is conducted, along with antibacterial therapy.
Combined oral contraceptives are not recommended, as these medications can cause atrophic changes in the endometrium.
Does the Presence of Intrauterine Adhesions Affect Pregnancy
The presence of intrauterine adhesions can significantly impact fertility and the course of pregnancy. Adhesions complicate the conception process, lead to infertility, and increase the risk of miscarriage and preterm labor.
Is It Possible to Get Pregnant with Intrauterine Adhesions
It is possible to get pregnant with intrauterine adhesions; however, this depends on the severity of the condition and the location of the adhesions. In mild cases, pregnancy can occur, and it may progress successfully. In severe cases, where the uterine cavity is significantly deformed or covered by adhesions, the likelihood of conception is greatly reduced.
Treatment for Asherman syndrome significantly increases the chances of successful conception and carrying a pregnancy to term. According to research, the effectiveness of treatment varies depending on the severity of the case:
- In mild cases, after treatment, the chances of becoming pregnant are 75-80%.
- In severe cases, this rate drops to 20-30%.
Course of Pregnancy
After treatment for Asherman syndrome, the course of pregnancy usually has a positive prognosis. In most cases, pregnancy proceeds without complications, and women successfully carry their babies to term. However, even after effective treatment, certain complications may still arise. These can include an increased likelihood of miscarriage or preterm labor, especially in cases of severe adhesions. Therefore, it is essential to ensure careful medical monitoring and adhere to the doctor’s recommendations throughout the pregnancy.
How to Prevent the Development of Asherman Syndrome in Women
Following simple recommendations can reduce the risk of developing Asherman syndrome and help maintain reproductive health:
- Timely treatment of gynecological infections and inflammatory processes.
- Avoiding trauma and surgeries.
- Regular medical check-ups with a gynecologist.
- Using barrier-type contraceptives.
- Preparing for pregnancy.
- Preventing abortions.
Conclusion
Asherman syndrome is a serious gynecological condition that affects fertility by complicating conception and increasing the risk of miscarriage or preterm birth.
Without timely treatment, Asherman syndrome can lead to infertility, as adhesions limit the normal functioning of the uterus. Therefore, early detection and treatment of Asherman syndrome are crucial for preserving fertility. The foundation of treatment includes the surgical removal of adhesions and subsequent medical monitoring. Prompt treatment significantly enhances the chances of successful conception and a healthy pregnancy.