Understanding Intrauterine Adhesions (Asherman’s Syndrome) and Fertility
Intrauterine adhesions, also known as synechiae or uterine scar tissue, are bands of fibrous tissue that form inside the uterus. A healthy uterine cavity and intact endometrial lining are essential for conception and maintaining a pregnancy. Scar tissue can partially or completely block the uterine cavity, which may interfere with fertility, increase the risk of miscarriage, or cause pregnancy complications.
These adhesions can range from minor to severe. In extreme cases, they may cause the complete loss of menstrual flow, a condition known as Asherman’s syndrome.
Causes of Intrauterine Adhesions
Intrauterine adhesions often develop after trauma to the uterine lining, most commonly following a dilation and curettage (D&C) procedure. The risk increases if there is infection or inflammation during or after surgery. Other causes include uterine surgeries such as Cesarean sections or myomectomy. Multiple D&Cs increase the likelihood of scar tissue formation, especially when performed for retained placental tissue postpartum. Some studies report that the risk of Asherman’s syndrome after postpartum curettage can be as high as 25%.
Diagnosis and Treatment
Hysteroscopy, an outpatient surgical procedure, is the standard treatment for removing intrauterine adhesions. It allows the physician to directly visualize and remove scar tissue from the uterine cavity. Transabdominal ultrasound often assists during hysteroscopy to prevent uterine perforation.
Severe adhesions may require multiple hysteroscopic procedures for complete treatment. After surgery, patients are typically prescribed high doses of estrogen to promote regeneration of the endometrial lining and healing of the uterine walls. In cases of severe adhesions, an intrauterine balloon may be placed temporarily to keep the uterine walls separated during healing.
Follow-up imaging, such as a sonohysterogram or hysterosalpingogram (HSG), is usually recommended 4 to 6 weeks after surgery to confirm that the adhesions have been fully removed.
Pregnancy After Treatment
Pregnancies following the removal of severe intrauterine adhesions carry higher risks, including preterm labor, third trimester bleeding, and abnormal placental attachment. For women with extensive endometrial damage unresponsive to treatment, gestational surrogacy may be the best option to achieve a healthy pregnancy.