Asherman’s syndrome is a pathology characterized by the presence of intrauterine adhesions or scarring in the uterine cavity. It usually appears after uterine curettage.
This disease has a series of consequences such as an increased risk of amenorrhea or lack of menstruation, reduced fertility, miscarriages and abnormal placentation.
Is uterine adhesions the same as Asherman’s syndrome?
When intrauterine adhesions are associated with a number of symptoms, it is Asherman’s syndrome. However, when these adhesions are found accidentally without symptoms, the term Asherman’s syndrome should be avoided and the term “asymptomatic intrauterine adhesions” should be used.
The prevalence of Asherman’s syndrome
It is difficult to determine the prevalence of this syndrome, but it generally varies between 5 and 40%. And after repeated curettage following incomplete abortion, the prevalence of uterine adhesions is between 15 and 40%.
Cause of uterine adhesions or Asherman’s syndrome
During pregnancy, the uterus is more susceptible to injury to the basal endometrial layer, which can promote the development of intrauterine adhesions.
More than 90% of cases of patients with Asherman’s syndrome occur after a pregnancy-related curettage, because it removes the basal endometrial layer. A curettage from a first trimester abortion is less serious than a curettage after delivery due to retention of placental debris.
On the other hand, intrauterine adhesions can be created in patients with:
- Uterine myoma embolization.
- Abdominal or hysteroscopic myomectomy.
- Genital tract infections.
- Surgical treatment of uterine malformations.
- After childbirth or cesarean section.
Symptoms of uterine adhesions
Among the main symptoms of uterine adhesions are the following:
- Amenorrhea or absence of menstruation
- Pelvic pain
- Repeated miscarriages
Although these symptoms are not specific to uterine adhesions, the most characteristic is the appearance of all these symptoms suddenly after a uterine curettage.
How are uterine adhesions diagnosed?
Although uterine adhesions have been known for many years, reliable non-invasive diagnostic methods are not yet available. Currently, the tests performed to diagnose them are as follows:
- Hysteroscopy: allows direct visualization and removal of adhesions.
- Hysterosalpingography.
- Vaginal ultrasound.
- Hysterosonography: consists of performing a vaginal ultrasound to visualize the uterine cavity more clearly.
- 3D ultrasound.
- Magnetic resonance imaging.
- Blood tests if infection is suspected.
How can adhesive syndrome be treated?
Intrauterine adhesions are difficult to treat, because in many cases they can reappear despite removal by hysteroscopy.
Women with Asherman’s syndrome who present should be treated:
- Infertility
- scanty menstruation
- Painful periods
In the case of the infertile woman, the treatment initially proposed is to restore the normal shape of the uterine cavity.
The treatment of choice is performed by hysteroscopy:
- It can be performed on an outpatient basis, so it does not generally require admission.
- There are few studies showing the results after adhesiolysis (release of adhesions).
- It is observed that, in 75-100% of cases, the return to menstruation is normal after treatment.
The results after hysteroscopic release of adhesions on fertility are influenced by different factors:
- The age of the patient
- The degree of the adhesions and the location
- Whether the infertility is primary or secondary
After adhesiolysis the following data have been observed:
- The pregnancy rate ranges from 25 to 76%.
- The rate of term delivery, in women who achieved pregnancy, between 25 and 79.7%.
- Formation of new adhesions is between 21 and 42% of cases.
How to prevent the appearance of new adhesions after hysteroscopic adhesiolysis
Several treatments have been investigated:
- Use of estrogens.
- Use of an intrauterine contraceptive device (IUD).
- With a Foley catheter (it is like a balloon that is placed inside the uterus).
- Intrauterine application of gel.
- Use of a special heart-shaped catheter (Cook Medical®).
In studies where estrogen alone was used, pregnancy rates were generally lower than when used in conjunction with an IUD, Foley catheter or other device, where pregnancy rates were higher. However, there are cases where it is incurable and the only option to become a mother is through surrogacy.
Complications when releasing uterine adhesions
The complications that can occur when releasing uterine adhesions are those typical of hysteroscopy such as infection, bleeding and perforation of the uterus.
Stem cell treatment of adhesive syndrome
Although research on stem cells in the treatment of adhesive syndrome or Asherman’s syndrome has already begun, more work is needed to obtain conclusive results.
Different studies have shown that, after this stem cell treatment, a large percentage of women started menstruating again and were able to achieve pregnancy.
What complications can appear after the treatment of adhesive syndrome when fertility is restored?
Mainly obstetrical complications may appear such as:
- Reduced fetal weight
- Premature delivery
- Postpartum hemorrhage