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Semin Reprod Med 2011; 29(2): 083-094
DOI: 10.1055/s-0031-1272470
© Thieme Medical Publishers

Asherman's Syndrome

Charles M. March1
  • 1Division of Gynecology, Keck School of Medicine of the University of Southern California, Los Angeles, California
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Publication History

Publication Date:
24 March 2011 (online)

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ABSTRACT

Asherman's syndrome is being diagnosed with increasing frequency. Although it usually occurs following curettage of the pregnant or recently pregnant uterus, any uterine surgery can lead to intrauterine adhesions (IUA). Most women with IUA have amenorrhea or hypomenorrhea, but up to a fourth have painless menses of normal flow and duration. Those who have amenorrhea may also have cyclic pelvic pain caused by outflow obstruction. The accompanying retrograde menstruation may lead to endometriosis. In addition to abnormal menses, infertility and recurrent spontaneous abortion are common complaints. Hysteroscopy is the standard method to both diagnose and treat this condition. Various techniques for adhesiolysis and for prevention of scar reformation have been advocated. The most efficacious appears to be the use of miniature scissors for adhesiolysis and the placement of a balloon stent inside the uterus immediately after surgery. Postoperative estrogen therapy is prescribed to stimulate endometrial regrowth. Follow-up studies to assure resolution of the scarring are mandatory before the patient attempts to conceive as is careful monitoring of pregnancies for cervical incompetence, placenta accreta, and intrauterine growth retardation.

KEYWORDS

Asherman's syndrome - intrauterine adhesions - endometrial sclerosis - infertility - recurrent abortion

REFERENCES

  • 1 Fritsch H. Ein fall von volligen Schwund der Gebarmutterhohle nach Auskratzung.  Zentralbl Gynakol. 1894;  18 1337-1339
    PubMedGoogle Scholar
  • 2 Asherman J G. Amenorrhoea traumatica (atretica).  J Obstet Gynaecol Br Emp. 1948;  55 (1) 23-30
    CrossrefPubMedGoogle Scholar
  • 3 Foix A, Bruno R O, Davison T, Lema B. The pathology of postcurettage intrauterine adhesions.  Am J Obstet Gynecol. 1966;  96 (7) 1027-1033
    PubMedGoogle Scholar
  • 4 Hamou J, Salat-Baroux J, Siegler A M. Diagnosis and treatment of intrauterine adhesions by microhysteroscopy.  Fertil Steril. 1983;  39 (3) 321-326
    PubMedGoogle Scholar
  • 5 Shokeir T A, Fawzy M, Tatongy M. The nature of intrauterine adhesions following reproductive hysteroscopic surgery as determined by early and late follow-up hysteroscopy: clinical implications.  Arch Gynecol Obstet. 2008;  277 (5) 423-427
    CrossrefPubMedGoogle Scholar
  • 6 Schenker J G, Margalioth E J. Intrauterine adhesions: an updated appraisal.  Fertil Steril. 1982;  37 (5) 593-610
    CrossrefPubMedGoogle Scholar
  • 7 Taskin O, Sadik S, Onoglu A et al. Role of endometrial suppression on the frequency of intrauterine adhesions after resectoscopic surgery.  J Am Assoc Gynecol Laparosc. 2000;  7 (3) 351-354
    CrossrefPubMedGoogle Scholar
  • 8 Eriksen J, Kaestel C. The incidence of uterine atresia after post-partum curettage. A follow-up examination of 141 patients.  Dan Med Bull. 1960;  7 50-51
    PubMedGoogle Scholar
  • 9 Buttram Jr V C, Turati G. Uterine synechiae: variations in severity and some conditions which may be conducive to severe adhesions.  Int J Fertil. 1977;  22 (2) 98-103
    PubMedGoogle Scholar
  • 10 Adoni A, Palti Z, Milwidsky A, Dolberg M. The incidence of intrauterine adhesions following spontaneous abortion.  Int J Fertil. 1982;  27 (2) 117-118
    PubMedGoogle Scholar
  • 11 Massouras H G. Intrauterine adhesions: a syndrome of the past with the use of the Massouras duck's foot No. 2 intrauterine contraceptive device.  Am J Obstet Gynecol. 1973;  116 (4) 576-578
    PubMedGoogle Scholar
  • 12 Stillman R J, Asarkof N. Association between mullerian duct malformations and Asherman syndrome in infertile women.  Obstet Gynecol. 1985;  65 (5) 673-677
    PubMedGoogle Scholar
  • 13 Polishuk W Z, Anteby S O, Weinstein D. Puerperal endometritis and intrauterine adhesions.  Int Surg. 1975;  60 (8) 418-420
    PubMedGoogle Scholar
  • 14 Rabau E, David A. Intrauterine adhesions: etiology, prevention and treatment.  Obstet Gynecol. 1963;  22 626-629
    PubMedGoogle Scholar
  • 15 Netter A P, Musset R, Lambert A, Salomon Y. Traumatic uterine synechiae: a common cause of menstrual insufficiency, sterility, and abortion.  Am J Obstet Gynecol. 1956;  71 (2) 368-375
    PubMedGoogle Scholar
  • 16 Polishuk W Z, Sadovsky E. A syndrome of recurrent intrauterine adhesions.  Am J Obstet Gynecol. 1975;  123 (2) 151-158
    PubMedGoogle Scholar
  • 17 Toaff R, Ballas S. Traumatic hypomenorrhea-amenorrhea (Asherman's syndrome).  Fertil Steril. 1978;  30 (4) 379-387
    PubMedGoogle Scholar
  • 18 Polishuk W Z, Siew F P, Gordon R, Lebenshart P. Vascular changes in traumatic amenorrhea and hypomenorrhea.  Int J Fertil. 1977;  22 (3) 189-192
    PubMedGoogle Scholar
  • 19 Taylor P J, Cumming D C, Hill P J. Significance of intrauterine adhesions detected hysteroscopically in eumenorrheic infertile women and role of antecedent curettage in their formation.  Am J Obstet Gynecol. 1981;  139 (3) 239-242
    PubMedGoogle Scholar
  • 20 Confino E, Friberg J, Giglia R V, Gleicher N. Sonographic imaging of intrauterine adhesions.  Obstet Gynecol. 1985;  66 (4) 596-598
    PubMedGoogle Scholar
  • 21 Soares S R, Barbosa dos Reis M M, Camargos A F. Diagnostic accuracy of sonohysterography, transvaginal sonography, and hysterosalpingography in patients with uterine cavity diseases.  Fertil Steril. 2000;  73 (2) 406-411
    CrossrefPubMedGoogle Scholar
  • 22 March C M, Israel R, March A D. Hysteroscopic management of intrauterine adhesions.  Am J Obstet Gynecol. 1978;  130 (6) 653-657
    PubMedGoogle Scholar
  • 23 The American Fertility Society . The American Fertility Society classifications of adnexal adhesions, distal tubal occlusion, tubal occlusion secondary to tubal ligation, tubal pregnancies, müllerian anomalies and intrauterine adhesions.  Fertil Steril. 1988;  49 (6) 944-955
    PubMedGoogle Scholar
  • 24 Nasr A L, Al-Inany H G, Thabet S M, Aboulghar M. A clinicohysteroscopic scoring system of intrauterine adhesions.  Gynecol Obstet Invest. 2000;  50 (3) 178-181
    CrossrefPubMedGoogle Scholar
  • 25 Lancet M, Mass N. Concomitant hysteroscopy and hysterography in Asherman's syndrome.  Int J Fertil. 1981;  26 (4) 267-272
    PubMedGoogle Scholar
  • 26 Zhang J, Gilles J M, Barnhart K, Creinin M D, Westhoff C, Frederick M M. National Institute of Child Health Human Development (NICHD) Management of Early Pregnancy Failure Trial . A comparison of medical management with misoprostol and surgical management for early pregnancy failure.  N Engl J Med. 2005;  353 (8) 761-769
    CrossrefPubMedGoogle Scholar
  • 27 Smith L FP, Ewings P D, Quinlan C. Incidence of pregnancy after expectant, medical, or surgical management of spontaneous first trimester miscarriage: long term follow-up of miscarriage treatment (MIST) randomised controlled trial.  BMJ. 2009;  339 b3827
    CrossrefPubMedGoogle Scholar
  • 28 Fontanarosa M, Galiberti S, Fontanarosa N. Fertility after non-surgical management of the symptomatic first-trimester spontaneous abortion.  Minerva Ginecol. 2007;  59 591-594
    PubMedGoogle Scholar
  • 29 Tam W H, Lau W C, Cheung L P, Yuen P M, Chung T K. Intrauterine adhesions after conservative and surgical management of spontaneous abortion.  J Am Assoc Gynecol Laparosc. 2002;  9 (2) 182-185
    CrossrefPubMedGoogle Scholar
  • 30 Wieringa-de Waard M, Vos J, Bonsel G J, Bindels P J, Ankum W M. Management of miscarriage: a randomized controlled trial of expectant management versus surgical evacuation.  Hum Reprod. 2002;  17 (9) 2445-2450
    CrossrefPubMedGoogle Scholar
  • 31 Golan A, Raziel A, Pansky M, Bukovsky I. The role of manual removal of the placenta in forming intrauterine adhesions.  J Am Assoc Gynecol Laparosc. 1995;  2 (Suppl 4) S18
    PubMedGoogle Scholar
  • 32 Lurie S, Appelman Z, Katz Z. Curettage after midtrimester termination of pregnancy. Is it necessary?.  J Reprod Med. 1991;  36 (11) 786-788
    PubMedGoogle Scholar
  • 33 de Vries J I, van der Linden R M, van der Linden H C. Predictive value of sonographic examination to visualize retained placenta directly after birth at 16 to 28 weeks.  J Ultrasound Med. 2000;  19 (1) 7-12; quiz 13–14
    PubMedGoogle Scholar
  • 34 Wolman I, Altman E, Fait G et al. Evacuating retained products of conception in the setting of an ultrasound unit.  Fertil Steril. 2009;  91 (4 Suppl) 1586-1588
    CrossrefPubMedGoogle Scholar
  • 35 Cohen S B, Kalter-Ferber A, Weisz B S et al. Hysteroscopy may be the method of choice for management of residual trophoblastic tissue.  J Am Assoc Gynecol Laparosc. 2001;  8 (2) 199-202
    CrossrefPubMedGoogle Scholar
  • 36 Candiani G B, Vercellini P, Fedele L, Garsia S, Brioschi D, Villa L. Argon laser versus microscissors for hysteroscopic incision of uterine septa.  Am J Obstet Gynecol. 1991;  164 (1 Pt 1) 87-90
    PubMedGoogle Scholar
  • 37 Rock J A, Singh M, Murphy A A. A modification of technique for hysteroscopic lysis of severe uterine adhesions.  J Gynecol Surg. 1993;  9 191-193
    CrossrefPubMedGoogle Scholar
  • 38 Protopapas A, Shushan A, Magos A. Myometrial scoring: a new technique for the management of severe Asherman's syndrome.  Fertil Steril. 1998;  69 (5) 860-864
    CrossrefPubMedGoogle Scholar
  • 39 Duffy S, Reid P C, Sharp F. In-vivo studies of uterine electrosurgery.  Br J Obstet Gynaecol. 1992;  99 (7) 579-582
    PubMedGoogle Scholar
  • 40 Panayotidis C, Weyers S, Bosteels J et al. Intrauterine adhesions (IUA): has there been any progress in understanding and treatment over the last 20 years?.  Gynecol Surg. 2009;  6 197-211
    CrossrefPubMedGoogle Scholar
  • 41 Ikeda T, Morita A, Imamura A, Mori I. The separation procedure for intrauterine adhesion (synechia uteri) under roentgenographic view.  Fertil Steril. 1981;  36 (3) 333-338
    PubMedGoogle Scholar
  • 42 Karande V, Levrant S, Hoxsey R, Rinehart J, Gleicher N. Lysis of intrauterine adhesions using gynecoradiologic techniques.  Fertil Steril. 1997;  68 (4) 658-662
    CrossrefPubMedGoogle Scholar
  • 43 Broome J D, Vancaillie T G. Fluoroscopically guided hysteroscopic division of adhesions in severe Asherman syndrome.  Obstet Gynecol. 1999;  93 (6) 1041-1043
    CrossrefPubMedGoogle Scholar
  • 44 Coccia M E, Becattini C, Bracco G L, Pampaloni F, Bargelli G, Scarselli G. Pressure lavage under ultrasound guidance: a new approach for outpatient treatment of intrauterine adhesions.  Fertil Steril. 2001;  75 (3) 601-606
    CrossrefPubMedGoogle Scholar
  • 45 Reddy S, Rock J A. Surgical management of complete obliteration of the endometrial cavity.  Fertil Steril. 1997;  67 (1) 172-174
    CrossrefPubMedGoogle Scholar
  • 46 Polishuk W Z, Adoni A, Aviad I. Intrauterine device in the treatment of traumatic intrauterine adhesions.  Fertil Steril. 1969;  20 (2) 241-249
    PubMedGoogle Scholar
  • 47 Robinson J K, Colimon L M, Isaacson K B. Postoperative adhesiolysis therapy for intrauterine adhesions (Asherman's syndrome).  Fertil Steril. 2008;  90 (2) 409-414
    CrossrefPubMedGoogle Scholar
  • 48 Friedman A, DeFazio J, DeCherney A. Severe obstetric complications after aggressive treatment of Asherman syndrome.  Obstet Gynecol. 1986;  67 (6) 864-867
    CrossrefPubMedGoogle Scholar
  • 49 Jewelewicz R, Khalaf S, Neuwirth R S, Vande Wiele R L. Obstetric complications after treatment of intrauterine synechiae (Asherman's syndrome).  Obstet Gynecol. 1976;  47 (6) 701-705
    PubMedGoogle Scholar
  • 50 Yu D, Wong Y-M, Cheong Y, Xia E, Li T C. Asherman syndrome—one century later.  Fertil Steril. 2008;  89 (4) 759-779
    CrossrefPubMedGoogle Scholar
  • 51 Valle R F, Sciarra J J. Intrauterine adhesions: hysteroscopic diagnosis, classification, treatment, and reproductive outcome.  Am J Obstet Gynecol. 1988;  158 (6 Pt 1) 1459-1470
    CrossrefPubMedGoogle Scholar
  • 52 Capella-Allouc S, Morsad F, Rongières-Bertrand C, Taylor S, Fernandez H. Hysteroscopic treatment of severe Asherman's syndrome and subsequent fertility.  Hum Reprod. 1999;  14 (5) 1230-1233
    CrossrefPubMedGoogle Scholar
  • 53 March C M. Acquired intrauterine adhesions: Asherman's syndrome. In:, Adashi E Y, Rock J A, Rosenwaks Z, eds. Reproductive Endocrinology, Surgery and Technology. Philadelphia, PA: Lippincott-Raven; 1996: 1474-1487
    Google Scholar
  • 54 Beuker J M, Erwich J JHM, Khong T Y. Is endomyometrial injury during termination of pregnancy or curettage following miscarriage the precursor to placenta accreta?.  J Clin Pathol. 2005;  58 (3) 273-275
    CrossrefPubMedGoogle Scholar
  • 55 Asch R H, Zuo W L, Garcia M, Ramzy I, Laufe L, Rojas F P. Intrauterine release of oestriol in castrated rhesus monkeys induces local but not peripheral oestrogenic effects: a possible approach for the treatment and prevention of Asherman's syndrome.  Hum Reprod. 1991;  6 (10) 1373-1378
    PubMedGoogle Scholar
  • 56 Takasaki A, Tamura H, Miwa I, Taketani T, Shimamura K, Sugino N. Endometrial growth and uterine blood flow: a pilot study for improving endometrial thickness in the patients with a thin endometrium.  Fertil Steril. 2010;  93 (6) 1851-1858
    CrossrefPubMedGoogle Scholar
  • 57 Acharya S, Yasmin E, Balen A H. The use of a combination of pentoxifylline and tocopherol in women with a thin endometrium undergoing assisted conception therapies—a report of 20 cases.  Hum Fertil (Camb). 2009;  12 (4) 198-203
    CrossrefPubMedGoogle Scholar
  • 58 Abbott J, Thomson A, Vancaillie T. SprayGel following surgery for Asherman's syndrome may improve pregnancy outcome.  J Obstet Gynaecol. 2004;  24 (6) 710-711
    CrossrefPubMedGoogle Scholar
  • 59 Amer M I, Abd-El-Maeboud K H. Amnion graft following hysteroscopic lysis of intrauterine adhesions.  J Obstet Gynaecol Res. 2006;  32 (6) 559-566
    CrossrefPubMedGoogle Scholar
  • 60 Tsapanos V S, Stathopoulou L P, Papathanassopoulou V S, Tzingounis V A. The role of Seprafilm bioresorbable membrane in the prevention and therapy of endometrial synechiae.  J Biomed Mater Res. 2002;  63 (1) 10-14
    CrossrefPubMedGoogle Scholar
  • 61 Acunzo G, Guida M, Pellicano M et al. Effectiveness of auto-cross-linked hyaluronic acid gel in the prevention of intrauterine adhesions after hysteroscopic adhesiolysis: a prospective, randomized, controlled study.  Hum Reprod. 2003;  18 (9) 1918-1921
    CrossrefPubMedGoogle Scholar
  • 62 Jones W E. Traumatic intrauterine adhesions. A report of 8 cases with emphasis on therapy.  Am J Obstet Gynecol. 1964;  89 304-313
    PubMedGoogle Scholar
  • 63 Nawroth F, Foth D, Schmidt T. Minihysteroscopy as routine diagnostic procedure in women with primary infertility.  J Am Assoc Gynecol Laparosc. 2003;  10 (3) 396-398
    CrossrefPubMedGoogle Scholar
  • 64 Rochet Y, Dargent D, Bremond A, Priou G, Rudigoz R C. The obstetrical future of women who have been operated on for uterine synechiae. 107 cases operated on.  [author's translation] J Gynecol Obstet Biol Reprod (Paris). 1979;  8 (8) 723-726
    PubMedGoogle Scholar
  • 65 Bergman P. Traumatic intra-uterine lesions.  Acta Obstet Gynecol Scand. 1961;  40 (Suppl 4) 1-39
    PubMedGoogle Scholar
  • 66 Kralj B, Lavric V. Cervico isthmic incompetence. In:, Andolsek L, ed. The Ljubljana Abortion Study 1971–1973. Bethesda, MD: National Institutes of Health; 1974: 28-31
    Google Scholar
  • 67 Westendorp I CD, Ankum W M, Mol B WJ, Vonk J. Prevalence of Asherman's syndrome after secondary removal of placental remnants or a repeat curettage for incomplete abortion.  Hum Reprod. 1998;  13 (12) 3347-3350
    CrossrefPubMedGoogle Scholar
  • 68 Friedler S, Margalioth E J, Kafka I, Yaffe H. Incidence of post-abortion intra-uterine adhesions evaluated by hysteroscopy—a prospective study.  Hum Reprod. 1993;  8 (3) 442-444
    CrossrefPubMedGoogle Scholar

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