What is Asherman Syndrome?
💡 Asherman syndrome = intrauterine adhesions (scar tissue inside the uterine cavity). Caused by: D&C after miscarriage/delivery, uterine surgery, endometrial TB. Symptoms: reduced or absent periods, secondary infertility. Diagnosed by hysteroscopy (gold standard) or SIS/3D USS. Treatment: hysteroscopic adhesiolysis (surgical division of adhesions). Recurrence common — prevent with post-surgical oestrogen and balloon catheter.
Asherman syndrome (intrauterine adhesions / synechia) is a condition in which fibrous scar tissue forms within the uterine cavity, causing the walls to stick together (partially or completely). It results from endometrial trauma — most commonly from dilation and curettage (D&C) procedures performed after miscarriage, retained products of conception, or postpartum haemorrhage. Asherman syndrome causes menstrual irregularities, secondary infertility, and recurrent miscarriage.
🇮🇳 India Context: Asherman Syndrome is widely assessed and treated across major Indian fertility centres including Chennai, Mumbai, Bangalore, Delhi, and Hyderabad.
What are the key characteristics of Asherman Syndrome?
- Causes: post-pregnancy uterine trauma most common — D&C for miscarriage (20–25% of cases develop adhesions); D&C for postpartum haemorrhage (highest risk — 30–35% adhesion rate); infected miscarriage; myomectomy involving cavity entry; endometrial TB (India — severe, dense adhesions)
- Severity grading (American Fertility Society): Grade I (mild — <25% cavity involved, thin filmy adhesions, normal menstruation); Grade II (moderate — 25–75% cavity, mixed dense/filmy, menstrual irregularity); Grade III (severe — >75% cavity, dense adhesions, amenorrhoea)
- Symptoms: hypomenorrhoea (scanty periods) or amenorrhoea (no periods) — caused by obliteration of endometrial glands; secondary infertility; recurrent miscarriage; cyclic pelvic pain (if adhesions trap menstrual blood)
- Diagnosis: hysteroscopy — gold standard (direct visualisation, adhesion classification, simultaneous treatment); SIS (saline infusion sonography) — adhesions appear as hyperechoic bands within fluid; 3D TVS — shows adhesion bands; HSG — irregular filling pattern, "moth-eaten" appearance
- Hysteroscopic adhesiolysis: treatment of choice; sharp dissection of adhesions with hysteroscopic scissors (not electrosurgery — risks further scarring); restore normal cavity shape; proceed systematically from anterior to posterior
- Post-adhesiolysis prevention of recurrence: high-dose oestrogen (oestradiol 4–6mg/day for 6–8 weeks) to promote endometrial regeneration; intrauterine device (IUD) or balloon catheter placed to prevent walls re-adhering; second-look hysteroscopy at 4–8 weeks
- Prognosis: Grade I/II — 80–85% live birth rate after treatment; Grade III — 20–40% live birth rate; dense TB-related adhesions — very poor prognosis; surrogacy may be the only option in complete obliteration
- TB Asherman: endometrial TB destroys the basal layer — the regenerative layer; adhesions are fibrotic and cannot be successfully divided to restore a functional endometrium; 6 months ATT + hysteroscopic adhesiolysis has limited success in advanced TB Asherman
How does Asherman Syndrome work?
Why does Asherman Syndrome matter in fertility?
Asherman syndrome is a preventable condition — the most important clinical action is prevention: performing D&C under ultrasound guidance, using suction curettage rather than sharp curettage, and avoiding unnecessary D&C procedures (medical management of miscarriage is preferred where clinically appropriate). Once established, severe adhesions are difficult to treat and carry significant risks of recurrence, placenta accreta in future pregnancies, and ongoing infertility. In India, endometrial TB-related Asherman syndrome has a very poor fertility prognosis — early diagnosis and treatment of genital TB is the most effective strategy.
What are related terms to Asherman Syndrome?
Hysteroscopy
Hysteroscopy is a procedure used to examine the inside of the uterus. A thin, li…
Adhesions (Pelvic/Intrauterine)
Adhesions are abnormal fibrous bands of scar tissue that form between organs or …
Recurrent Miscarriage
Recurrent Miscarriage means two or more pregnancy losses before 20 weeks. It aff…
Secondary Infertility
Secondary infertility is defined as the inability to achieve a clinical pregnanc…
Embryo Transfer
Embryo Transfer is the final step of the IVF process. A laboratory-cultured embr…
FAQs about Asherman Syndrome
What causes Asherman syndrome?
The most common cause is a D&C (curettage) procedure performed on a pregnant or recently pregnant uterus: D&C for miscarriage (20–25% develop adhesions); D&C for retained products after delivery (30–35% — highest risk); D&C for postpartum haemorrhage. Other causes: endometrial TB (India — causes severe, dense, irreversible adhesions); hysteroscopic surgery with cavity entry (myomectomy, septum resection); endometrial ablation. The pregnant uterus is particularly vulnerable because the basalis layer (regenerative layer) is easily damaged by curettage.
How is Asherman syndrome diagnosed?
Asherman syndrome is diagnosed by: (1) Hysteroscopy (gold standard) — camera placed inside the uterine cavity directly visualises adhesion bands; defines extent and density; allows immediate treatment; (2) SIS (saline infusion sonography) — saline injected into cavity shows adhesion bands as hyperechoic (bright) structures outlined by fluid; sensitivity ~75%; (3) 3D transvaginal ultrasound — adhesion bands may be visible in the cavity cross-sectionally; (4) HSG — shows "moth-eaten" filling defects or irregular cavity filling. Hysteroscopy is preferred as it allows diagnosis and treatment in the same procedure.
Can Asherman syndrome be treated and can I get pregnant after?
Yes — Asherman syndrome is treatable, with outcomes depending on adhesion severity: Grade I (mild, filmy adhesions): hysteroscopic adhesiolysis restores cavity in >90% of cases; 80–85% live birth rate in subsequent pregnancies. Grade II (moderate): 60–75% live birth rate after treatment. Grade III (severe, dense adhesions): 20–40% live birth rate; high recurrence rate; may require 2–3 surgical procedures. After adhesiolysis: high-dose oestrogen (4–6mg/day for 6–8 weeks) + intrauterine balloon or IUD for 4–6 weeks to prevent re-adhesion; second-look hysteroscopy to confirm cavity recovery.
Is Asherman syndrome common in India?
Yes — Asherman syndrome has a higher prevalence in India than in Western countries for two reasons: (1) Higher rates of D&C procedures — curettage is still performed for miscarriage management more commonly than medical management (misoprostol) in many centres; (2) Endometrial tuberculosis — pelvic TB is endemic in India and causes severe intrauterine adhesions by destroying the endometrial basalis layer. TB-related Asherman syndrome has a much worse prognosis than post-D&C adhesions — the basal layer is destroyed (not just covered by adhesions), so even successful adhesiolysis may not restore a functional endometrium.
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