Asherman's Syndrome: Diagnosis, Treatment, and Prevention
Sunday, June 15, 2008
Kenneth F. Trofatter, Jr., MD, PhD
The first step to establishing the diagnosis is maintaining a high index of suspicion. It is surprising to me, for example, how often a woman will present with recurrent pregnancy loss, where she has never been asked about specific events surrounding her management and complications related to previous pregnancies and/or these previous losses (i.e., postpartum hemorrhage, D&C for retained products of conception and the timing of the same with regard to the length of time from the delivery, D&C’s for missed or incomplete miscarriages and elective abortions, prolonged bleeding, fever, infection or evidence of infection on the pathology report, length of time between the death of the baby and the actual miscarriage or medical/surgical evacuation of the uterus, complications related to the D&C’s themselves, such as hemorrhage or uterine perforation). Yet, we know that the risk of intrauterine scarring (synechiae) increases with the number of D&C’s, the duration between fetal loss and the procedure itself, and any of the other complications noted above.
Clearly, if a patient has complete absence of menstrual bleeding, a history of an intrauterine procedure and/or infection, and documented ovulation, the diagnosis is readily apparent. However, since not all Asherman’s patients will have the most extreme presentation of the condition, and since ultrasound alone is unlikely to help establish the diagnosis under these circumstances, it is probably under-diagnosed, or at best the diagnosis is delayed in many instances. Occasionally, the diagnosis can be made using sonohysterography in which fluid is used to distend the uterine cavity while performing an ultrasound, or by hysterosalpingogram in which a radio-opaque dye is instilled into the uterus to outline its contour, but by far the most efficient and reliable approach is to perform hysteroscopy in which the uterine cavity is directly visualized with the aid of a special instrument that provides light and magnification.
Interestingly, in one prospective study in which hysteroscopy was performed routinely following D&C’s for uterine evacuation of early pregnancy, intrauterine adhesions were found in 16% of women after one procedure and 32% after three or more (Friedler, et al., Hum Reprod 1993;8:442-44)! Similarly, Westendorp and colleagues (Hum Reprod 1998;13:3347-50) found that 40% of women who underwent a D&C for retained placenta longer than 24 hours after delivery, or who required a repeat D&C for incomplete abortions, had intrauterine adhesions present by hysteroscopy three months after the intervention and almost half of these had moderate to severe disease (Grade III and IV).
Although treatment for Asherman’s syndrome has had various approaches, successful treatment relies on the lysis (breakdown) of the adhesions and restoration of some degree (the more the better) of normal-appearing and functioning endometrium (the inner lining of the uterus). The gold standard at present involves surgical removal of adhesions under direct visualization using operative hysteroscopy. The success depends on the experience and skill of the surgeon and in the most severe cases (complete obliteration of the uterine cavity by scar tissue), the procedure can be quite difficult. Even in skilled hands, the risk of recurrence of scar tissue following the initial operation is very high and many surgeons try to minimize this risk by avoiding surgical techniques (such as electrocautery) that will further promote scarring. Following the procedure itself, patients are often placed on high doses of estrogen to stimulate the endometrium and in some cases, balloons, catheters, or other forms of stents are placed into the uterine cavity to help prevent adherence of the walls. Another option is to have repeated in-office hysteroscopic lysis of adhesions once the primary procedure has been performed.
Even with all these precautions, recurrence of adhesions is extremely common and success, measured in terms of restoration of fertility, is relatively low. In moderate to severe Asherman’s syndrome, recurrence rates range between 20-40% and 40-50%, respectively (Valle, et al., Am J Obstet Gynecol 1988;158:1459-70; Yu, et al., Fertil Steril 2008;89:715-22). Conception and pregnancy success depends on the success of the lysis of adhesions, the degree to which a normal endometrium can be restored, damage done to the uterus by the procedure itself and, eventually, the site of implantation of a subsequent pregnancy. As also reported in the article by Yu and colleagues noted above, “…the chances of conception in women who remained amenorrheic (2 out of 11); 18.2%) were significantly lower than in those who continued to have menses (37 out of74; 50%)…the conception rate in women who had reformation of intrauterine adhesions (2 out of 17; 11.8%) was significantly lower than that of women who had a normal cavity (26 out of 44; 59.1%)."
And, as we pointed out in our previous post, even if conception occurs, a good outcome is not guaranteed. Probably no more than one-third of women with moderate to severe adhesions will successfully carry a pregnancy and of those, there is increased risk for cervical incompetence, intrauterine growth restriction, fetal loss (early and late), placenta accreta or placenta previa, premature delivery, preeclampsia, cesarean delivery, uterine rupture, peripartum hemorrhage and hysterectomy.
In closing, let us just mention a few thoughts on prevention of Asherman’s syndrome. Based on several reports, the risk of Asherman’s could be reduced significantly if pregnancy-related D&C procedures could be minimized or done less traumatically. To that end, in recent years, the prostaglandin drug, misoprostol, has been used effectively even in first trimester uterine evacuations and compared to D&C is clearly associated with a reduction in risk for adhesions (Tam, et al., J Am Assoc Gynecol Laparoscop 2002;9:182-5). When given the option of instruments to use for D&C, a plastic suction curette is probably (but not completely) less traumatic than a sharp metal curette and efforts should be made to reduce the degree to which the endometrium is denuded by either. Prophylactic antibiotics, although rarely used when a D&C is performed, unless there is frank evidence of infection, might be considered in patients who opt to defer uterine evacuation following fetal loss in preference to awaiting spontaneous abortion. I think if I learned nothing else from this review myself, it was the fact that the risk of Asherman’s appears to go up dramatically with the length of time from fetal death to uterine evacuation although the factors that contribute to this risk are not entirely clear.
Labels: Asherman's syndrome, cervical incompetence, IUGR, placenta accreta, placenta previa, recurrent pregnancy loss
18 Comments:
At Tue Jun 17, 05:23:00 PM 2008,
Julia Mangan said…
Thank you for the post! This is information women that are offered D&C's should definitely know about! I had 2 in a months time and, even I repeatedly asked about the risks, was never told about this condition.
At Sat Jun 21, 06:16:00 PM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To Julia: thank you for being such a great reader! The risk are relatively low, but they are real. Dr T
At Mon Jun 30, 08:07:00 PM 2008,
cm in toronto said…
I wish I had known about Asherman's a year ago. I had miscarriage at 5.5 months (twins), D&C 2 weeks later with infection (I was hospitalized for over a week). Initally I was shocked that my OB didn't follow-up after the whole ordeal. I was diagnosed with mild Asherman's in May of this year after being refered to a specialist by my GP and will have a hysteroscopy on July 4th. I'm really worried about the estrogen therapy following surgery (~4mg/day for ~4 weeks) and its long-term effects. Although my specialist is well-trained and has reassured me repeatedly, I still have that feeling of doubt (which is throwing off my husband since I'm usually a strong and optimistic person).
Your article is a great read and will hopefully help those avoid the situation that I'm currently in.
At Tue Jul 01, 06:37:00 PM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To CM: It sounds like you are in good hands. Thank you for reading and for the kind remarks! Best wishes to you too! Dr T
At Thu Jul 03, 04:47:00 PM 2008,
Anonymous said…
Dr. T
Thank you so much for your article. I have severe Asherman's Syndrome after a D and C for retained placenta and hemmorhage (3 weeks after the birth of my daughter). I am trying to raise awareness about D and Cs and that they should not be used following miscarriage or childbirth due to the high (although overlooked) risk of the procedure at this time as you mentioned above. Medical or expectant management should be used or hysteroscopy in place of the BLIND D and C procedure. I hope that fewer women will be robbed of their future fertility as I have been. Thank you again.
At Thu Jul 10, 05:19:00 PM 2008,
Anonymous said…
Dr. Trofatter,
I want to see that you think of my results from the ultrasound and one blood test. I am 37 years old, 162 lbs, first pregnancy, conceived naturally. I had a myomectomy for 3 fibroids last year. my results:
NT: 1.08 MoM
PAPP-A: .29 MoM
hcg: 1.05 MoM
DS risk: 1:42.
I am very nervous about the results--especially since the ultrasound was very good. Please let me know what you think!
At Thu Jul 10, 06:28:00 PM 2008,
Anonymous said…
Thank you for your article. I wish more doctors paid this much attention to the literature out there. I chased my tail for a year with 4 different Drs. saying they had no ideas. It took a Dr. saying "we even looked on th internet" for me to go online and find my symptoms-self Dx and then I contacted an RE who Dx me with severe AS 5 min. into our visit. It's amazing what the GOOD Dr. can do! Keep up the good work!
At Sat Jul 12, 08:43:00 PM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To anonymous July 3: Thanks for your comments and the kind words. Best wishes....Dr T
At Sat Jul 12, 08:46:00 PM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To anonymous July 10: Even though your Down's risk is elevated, it is being driven mostly by the low PAPP-A. In view of your history of fibroids, this may simply reflect a suboptimal placental insertion site. We usually would recommend an invasive diagnostic procedure under these circumstances anyway, but the final choice on that is entirely yours. Best of luck. Dr T
At Sat Jul 12, 08:47:00 PM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To anonymous July 10: Thanks for sharing your story and the kind words! They are greatly appreciated. Dr T
At Mon Sep 08, 09:14:00 PM 2008,
Anonymous said…
Dr. Trofatter,
This is a little bit off the subject of Asherman's Syndrome, but I didn't know where else on your blog to post my questions/comments.
I have a friend who lost a baby at approx. 5 months due to placenta abruptio. She has none of the typical risk factors for placenta abruptio, i.e. high blood pressure, drug use, etc. She was, however, diagnosed during her pregnancy with a urinary tract infection that turned into a kidney infection. After the placenta abruptio, she subsequently had a D & E. She has an 11 year old daughter and had no placental problems with that pregnancy. About a year after the miscarriage, she was diagnosed with stage 4 endometriosis and has since had two surgeries to remove cysts as well as her left tube.
Here are my questions:
First, is there a correlation between endometriosis and placenta abruptio? Could she have had undiagnosed endo that caused the placenta to separate? Second, could the kidney infection have caused the placenta abruptio? Third, if she is even able to get pregnant again, what preventative measures can be taken to ensure that the same situation does not occur?
Thanks for your time!
Concerned Friend
At Tue Sep 23, 12:10:00 PM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To anonymous Sept 8: Pregnancy tends to suppress endometriosis, however, if she had it then perhaps it led to an abnormality of placentation that set her up for a placental abruption. The greater likelihood is that the abruption occurred as the result of the urinary tract infection and perhaps secondary infection of the placenta and membranes. Do you know if she had pathology performed on the placenta to look for evidence of infection? Thanks for your questions and your concern for your friend. Dr T
At Tue Sep 23, 09:59:00 PM 2008,
Anonymous said…
Dr. T,
I don't believe that my friend had any tests performed on the placenta to look for evidence of infection, but I will have to ask her to be sure. I know they performed an autopsy on the baby but I am not sure about the placenta.
We have always suspected that the placenta abruptio was caused by the UTI/Kidney infection but none of her doctors have been willing to confirm that. We think that she was suffering from a UTI/kidney infection for a while and was quite sick from it, but the doctors did not diagnose it as quickly as they possibly should have and that is why they have always been reluctant to say that the infection caused the placenta abruptio.
Given that hindsight is 20/20 and there is nothing that can be done about the loss of her previous pregnancy... if she should get pregnant again, what precautions/monitoring should occur in order to ensure that a UTI and possible placenta abruptio does not happen again?
Thanks,
Concerned Friend
(anonymous Sept 8)
At Sun Sep 28, 06:25:00 AM 2008,
tamarajohnsonmft said…
Dr T,
Thank you for your article and your interactions here with the women who post!
I had a fertility doc 22 years ago who couldn't perform an endometrial biopsy in office because my cervix was stenosed (sp?). He opted for a D&C.
Last October, I had an out-of-phase pap and my gynecologist wanted to do another biopsy. I refused because of fear -- remembering that first horrendous experience. So, my gyn opted to do it under general anesthesia.
What he found was severe ashermann's. He said he could hardly get the instruments into my uterus, and when he did, he was able to sample very little endometrial tissue -- mostly scar tissue.
I'm 42 years old and have replaced my baby-hunger with a darling little Shih Tzu that I adore.
Here's my question. This month, my period was so light that I really consider it nothing. Just one little light presentation of blood.
Are there any complications that I should be concerned about since I don't care about becoming pregnant any more?
Thank you so much,
Tamara
At Wed Oct 01, 01:53:00 PM 2008,
Anonymous said…
Dr. T-
I had a missed miscarriage 2 weeks ago. I was given the option of D & C, I asked about risks and was not told about possible Asherman's. But, here is my problem. I am so ashamed of the fact that I have had 3 abortions that I didn't tell my doctor I had them , mostly because if my current partner found out he would probably hate me (like im sure all the people on this blog will). All of them were at 5-6weeks and no infection and no complications, and regular periods after. Now I am scared that the 3 abortions and the d&c have runed my ability to have a baby, which I desperately want. Previously, I was irresponsable and in abusive relationships. Some would say I got what I deserve. Please help. What are the chances that I have Asherman's. My follow up is tommorrow and I plan on telling my doctor and asking for hysteroscopy.
At Mon Oct 06, 06:02:00 PM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To concerned friend: It is routine to culture for evidence of urinary tract infection with the New OB exam. In your friend's case, I would suggest doing that every 4-6 weeks throughout the pregnancy, even if she is asymptomatic, and then treating any infections aggressively and following up the treatment with prophylactic 'suppressive' therapy with a low dose antibiotic taken every day. Even after that she should continue to be cultured every 4-6 weeks to screen for evidence of an infection that is resistant to the antibiotics she is taking. Hope this helps! Dr T
At Mon Oct 06, 06:07:00 PM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To Tamara: Have you been having periods regularly (even if they have been light) up til now? Or did you just have one after the doctor did the recent procedure and found the scar tissue? You could be undergoing ovarian failure (menopause) or there could be so little endometrium there that you will never have any more than very light bleeding. That probably puts you at very low risk for developing endometrial cancer. I know that doesn't answer your question, but chances are you will not have any problems related to your uterus. Dr T
At Mon Oct 06, 06:12:00 PM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To anonymous Oct 1: It would be a good idea to have a frank chat with your doctor. It is our responsibility and promise to you to keep such conversations confidential. You might not need a hysteroscopy at this point if this loss was the first with your current partner. I would suggest, however, that you seriously consider counseling related to the guilt you feel about the abortions. This is the ideal time to do that because of the recent miscarriage and the feelings that has brought out. Odds are in your favor that you will have the family you want, but you need to take care of yourself too! Kind regards, Dr T
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