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| == Asherman's syndrome ==
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| [[File:Uterine Fibroids.png|thumb|500px|Uterine_Fibroids]] | | [[File:Uterine Fibroids.png|thumb|500px|Uterine_Fibroids]] |
| | | Asherman's Syndrome (AS), also known as intrauterine adhesions (IUA) or intrauterine synechiae, is an acquired uterine condition characterized by the formation of scar tissue within the uterine cavity. This scar tissue can lead to the walls of the uterus sticking together, resulting in various menstrual irregularities, infertility, and pregnancy complications. |
| '''Asherman's syndrome''' ('''AS'''), is an acquired uterine condition that occurs when scar tissue ([[adhesion (medicine)|adhesion]]s) form inside the uterus and/or the cervix.<ref name=pmid28846336>{{cite journal | vauthors = Smikle C, Bhimji SS | title = Asherman Syndrome | year = 2018 | pmid = 28846336 | url = https://www.ncbi.nlm.nih.gov/books/NBK448088/ | publisher = StatPearls }}</ref> It is characterized by variable scarring inside the uterine cavity, where in many cases the front and back walls of the uterus stick to one another. AS can be the cause of menstrual disturbances, infertility, and placental abnormalities. Although the first case of intrauterine adhesion was published in 1894 by Heinrich Fritsch, it was only after 54 years that a full description of Asherman syndrome was carried out by Joseph Asherman.<ref name=pmid24373209>{{cite journal | vauthors = Conforti A, Alviggi C, Mollo A, De Placido G, Magos A | title = The management of Asherman syndrome: a review of literature | journal = Reproductive Biology and Endocrinology | volume = 11 | pages = 118 | date = December 2013 | pmid = 24373209 | pmc = 3880005 | doi = 10.1186/1477-7827-11-118 }}</ref> A number of other terms have been used to describe the condition and related conditions including: '''uterine'''/'''cervical atresia''', '''traumatic uterine atrophy''', '''sclerotic endometrium''', and '''endometrial sclerosis'''.<ref name="Palter" />
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| There isn't any one cause of AS. Risk factors can include [[myomectomy]], [[Cesarean section]], infections, age, genital tuberculosis, and obesity. Genetic predisposition to AS is being investigated. There are also studies that show that a severe pelvic infection, independent of surgery may cause AS <ref>{{Cite web | url=https://medlineplus.gov/ency/article/001483.htm |title = Asherman syndrome: MedlinePlus Medical Encyclopedia}}</ref>. AS can develop even if the woman has not had any uterine surgeries, trauma, or pregnancies. While rare in North America and European countries, genital tuberculosis is a cause of Asherman's in other countries such as India.<ref name=pmid17653564>{{cite journal | vauthors = Sharma JB, Roy KK, Pushparaj M, Gupta N, Jain SK, Malhotra N, Mittal S | title = Genital tuberculosis: an important cause of Asherman's syndrome in India | journal = Archives of Gynecology and Obstetrics | volume = 277 | issue = 1 | pages = 37–41 | date = January 2008 | pmid = 17653564 | doi = 10.1007/s00404-007-0419-0 }}</ref>
| | [[File:Hysteroscopy of Asherman's Syndrome cropped.jpg|thumb |px500|Hysteroscopy of Asherman's Syndrome]] |
| | [[Image:HSG Ashermans syndrome.jpg|thumb|[[Hysterosalpingography|HSG]] view. Note: not the same uterus as in ultrasound or hysteroscopic view; this uterus appears to be [[T-shaped uterus|T-shaped]].]] |
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| [[File:Hysteroscopy of Asherman's Syndrome cropped.jpg|thumb |px500|Hysteroscopy of Asherman's Syndrome]]
| | == History == |
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| ==Signs and symptoms==
| | The condition was first described by Heinrich Fritsch in 1894 and later extensively characterized by Israeli gynecologist Joseph Asherman in 1948. It is also referred to as Fritsch-Asherman Syndrome in recognition of both contributors. |
| It is often characterized by a decrease in flow and duration of bleeding ([[amenorrhea|absence of menstrual bleeding]], [[hypomenorrhea|little menstrual bleeding]], or [[oligomenorrhea|infrequent menstrual bleeding]])<ref name=pmid4725610>{{cite journal | vauthors = Klein SM, García CR | title = Asherman's syndrome: a critique and current review | journal = Fertility and Sterility | volume = 24 | issue = 9 | pages = 722–35 | date = September 1973 | pmid = 4725610 | doi = 10.1016/S0015-0282(16)39918-6 }}</ref> and [[infertility]]. [[Menstrual]] anomalies are often but not always correlated with severity: adhesions restricted to only the [[cervix]] or lower [[uterus]] may block [[menstruation]]. Pain during [[menstruation]] and [[ovulation]] is sometimes experienced and can be attributed to blockages.
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| It has been reported that 88% of AS cases occur after a [[dilation and curettage|D&C]] is performed on a recently [[pregnant]] [[uterus]], following a missed or incomplete [[miscarriage]], [[birth]], or during an elective termination ([[abortion]]) to remove [[retained products of conception]].<ref name="Williams">{{cite book | first1 = John | last1 = Schorge | first2 = Joseph | last2 = Schaffer | first3 = Lisa | last3 = Halvorson | first4 = Barbara | last4 = Hoffman | first5 = Karen |last5 = Bradshaw | first6 = F. |last6 = Cunningham |name-list-format = vanc | title = Williams Gynecology|year=2008|publisher=McGraw-Hill Medical|location=New York|isbn=978-0-07-147257-9 }}{{pn|date=April 2018}}</ref> | |
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| == Causes==
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| [[Image:HSG Ashermans syndrome.jpg|thumb|[[Hysterosalpingography|HSG]] view. Note: not the same uterus as in ultrasound or hysteroscopic view; this uterus appears to be [[T-shaped uterus|T-shaped]].]]
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| [[File:Hysteroscopy of Asherman's Syndrome.jpg|thumb|[[Hysteroscopy|Hysteroscopic]] view.]] | | [[File:Hysteroscopy of Asherman's Syndrome.jpg|thumb|[[Hysteroscopy|Hysteroscopic]] view.]] |
| The cavity of the [[uterus]] is lined by the [[endometrium]]. This lining is composed of two layers, the [[Endometrium#Histology|functional layer]] (adjacent to the uterine cavity) which is shed during [[menstruation]] and an [[Endometrium#Histology|underlying basal layer]] (adjacent to the myometrium), which is necessary for regenerating the [[Endometrium#Histology|functional layer]]. Trauma to the basal layer, typically after a [[dilation and curettage]] (D&C) performed after a [[miscarriage]], or [[childbirth|delivery]], or for surgical termination of pregnancy, can lead to the development of intrauterine scars resulting in [[adhesions]] that can obliterate the cavity to varying degrees. In the extreme, the whole cavity can be scarred and occluded. Even with relatively few scars, the [[endometrium]] may fail to respond to [[estrogen]].
| | [[File:Amniotic sheet.jpg|thumb|amniotic sheet on ultrasound]] |
| | == Causes == |
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| | Asherman's Syndrome typically arises from trauma to the basal layer of the endometrium, the inner lining of the uterus. Common causes include: |
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| | * '''[[Dilation and Curettage (D&C)]]''': Procedures performed after miscarriages, childbirth, or elective abortions can damage the endometrial lining, leading to scar formation. |
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| | * '''[[Pelvic Surgeries]]''': Surgeries such as cesarean sections or myomectomies (removal of fibroids) can result in intrauterine adhesions. |
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| | * '''[[Infections]]''': Severe pelvic infections, including genital tuberculosis, can cause significant scarring within the uterus. |
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| | * '''[[Radiation Therapy]]''': Pelvic irradiation for cancer treatment may lead to endometrial damage and subsequent adhesion formation. |
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| | == Symptoms == |
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| | The clinical presentation of Asherman's Syndrome varies depending on the extent and location of the adhesions. Common symptoms include: |
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| | * '''[[Menstrual Irregularities]]''': These can range from reduced menstrual flow (hypomenorrhea) to complete absence of menstruation (amenorrhea). |
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| | * '''[[Infertility]]''': Adhesions can interfere with implantation or block the passage of sperm, leading to difficulties in conceiving. |
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| Asherman's syndrome affects women of all races and ages equally, suggesting no underlying genetic predisposition for its development.<ref name=pmid6281085>{{cite journal | vauthors = Schenker JG, Margalioth EJ | title = Intrauterine adhesions: an updated appraisal | journal = Fertility and Sterility | volume = 37 | issue = 5 | pages = 593–610 | date = May 1982 | pmid = 6281085 | doi = 10.1016/S0015-0282(16)46268-0 }}</ref> AS can result from other pelvic surgeries including [[cesarean section]]s,<ref name=pmid6281085/><ref name=pmid553931>{{cite journal | vauthors = Rochet Y, Dargent D, Bremond A, Priou G, Rudigoz RC | title = [The obstetrical future of women who have been operated on for uterine synechiae. 107 cases operated on (author's transl)] | language = fr | journal = Journal de Gynecologie, Obstetrique et Biologie de la Reproduction | volume = 8 | issue = 8 | pages = 723–6 | year = 1979 | pmid = 553931 | trans-title = The obstetrical future of women who have been operated on for uterine synechiae. 107 cases operated on }}</ref> removal of fibroid tumours ([[myomectomy]]) and from other causes such as [[IUDs]], pelvic [[irradiation]], [[schistosomiasis]]<ref name=pmid7724154>{{cite journal | vauthors = Krolikowski A, Janowski K, Larsen JV | title = Asherman syndrome caused by schistosomiasis | journal = Obstetrics and Gynecology | volume = 85 | issue = 5 Pt 2 | pages = 898–9 | date = May 1995 | pmid = 7724154 | doi = 10.1016/0029-7844(94)00371-J }}</ref> and [[Urogenital tuberculosis|genital tuberculosis]].<ref name=pmid13283012>{{cite journal | vauthors = Netter AP, Musset R, Lambert A, Salomon Y | title = Traumatic uterine synechiae: a common cause of menstrual insufficiency, sterility, and abortion | journal = American Journal of Obstetrics and Gynecology | volume = 71 | issue = 2 | pages = 368–75 | date = February 1956 | pmid = 13283012 | doi = 10.1016/S0002-9378(16)37600-1 }}</ref> Chronic endometritis from genital tuberculosis is a significant cause of severe intrauterine adhesions (IUA) in the developing world, often resulting in total obliteration of the uterine cavity which is difficult to treat.<ref name=pmid10438408>{{cite journal | vauthors = Bukulmez O, Yarali H, Gurgan T | title = Total corporal synechiae due to tuberculosis carry a very poor prognosis following hysteroscopic synechialysis | journal = Human Reproduction | volume = 14 | issue = 8 | pages = 1960–1 | date = August 1999 | pmid = 10438408 | doi = 10.1093/humrep/14.8.1960 }}</ref>
| | * '''[[Recurrent Miscarriages]]''': Scar tissue may compromise the uterine environment, increasing the risk of pregnancy loss. |
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| An artificial form of AS can be surgically induced by [[endometrial ablation]] in women with excessive uterine bleeding, in lieu of [[hysterectomy]].
| | * '''[[Pelvic Pain]]''': Some women may experience discomfort or pain, especially during menstruation or sexual intercourse. |
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| == Diagnosis == | | == Diagnosis == |
| The history of a [[pregnancy]] event followed by a D&C leading to secondary amenorrhea or hypomenorrhea is typical. Hysteroscopy is the gold standard for diagnosis.<ref name=pmid3381869/> Imaging by [[sonohysterography]] or [[hysterosalpingography]] will reveal the extent of the scar formation. Ultrasound is not a reliable method of diagnosing Asherman's Syndrome. Hormone studies show normal levels consistent with reproductive function.
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| === Classification ===
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| Various classification systems were developed to describe Asherman’s syndrome (citations to be added), some taking into account the amount of functioning residual endometrium, menstrual pattern, obstetric history and other factors which are thought to play a role in determining the prognoses. With the advent of techniques which allow visualization of the uterus, classification systems were developed to take into account the location and severity of adhesions inside the uterus. This is useful as mild cases with adhesions restricted to the cervix may present with amenorrhea and infertility, showing that symptoms alone do not necessarily reflect severity. Other patients may have no adhesions but amenorrhea and infertility due to a sclerotic atrophic endometrium. The latter form has the worst prognosis.
| | Accurate diagnosis is crucial for effective management. Diagnostic methods include: |
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| ==Prevention==
| | * '''[[Hysteroscopy]]''': This is the gold standard for diagnosing Asherman's Syndrome. It involves inserting a thin, lighted device into the uterus to directly visualize and assess the extent of adhesions. |
| A 2013 [[scientific review|review]] concluded that there were no studies reporting on the link between intrauterine adhesions and long-term reproductive outcome after miscarriage, while similar pregnancy outcomes were reported subsequent to surgical management (e.g. D&C), medical management or conservative management (that is, [[watchful waiting]]).<ref name=pmid24082042/> There is an association between surgical intervention in the uterus and the development of intrauterine adhesions, and between intrauterine adhesions and pregnancy outcomes, but there is still no clear evidence of any method of prevention of adverse pregnancy outcomes.<ref name=pmid24082042/>
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| In theory, the recently pregnant uterus is particularly soft under the influence of hormones and hence, easily injured. D&C (including dilation and curettage, dilation and evacuation/suction curettage and manual vacuum aspiration) is a blind, invasive procedure, making it difficult to avoid endometrial trauma. Medical alternatives to D&C for evacuation of retained placenta/products of conception exist including [[misoprostol]] and [[mifepristone]]. Studies show this less invasive and cheaper method to be an efficacious, safe and an acceptable alternative to surgical management for most women.<ref name=pmid16120856>{{cite journal | vauthors = Zhang J, Gilles JM, Barnhart K, Creinin MD, Westhoff C, Frederick MM | title = A comparison of medical management with misoprostol and surgical management for early pregnancy failure | journal = The New England Journal of Medicine | volume = 353 | issue = 8 | pages = 761–9 | date = August 2005 | pmid = 16120856 | doi = 10.1056/NEJMoa044064 }}</ref><ref name=pmid16135584>{{cite journal | vauthors = Weeks A, Alia G, Blum J, Winikoff B, Ekwaru P, Durocher J, Mirembe F | title = A randomized trial of misoprostol compared with manual vacuum aspiration for incomplete abortion | journal = Obstetrics and Gynecology | volume = 106 | issue = 3 | pages = 540–7 | date = September 2005 | pmid = 16135584 | doi = 10.1097/01.AOG.0000173799.82687.dc }}</ref> It was suggested as early as in 1993<ref name=pmid8473464/> that the incidence of IUA might be lower following medical evacuation (e.g. Misoprostol) of the uterus, thus avoiding any intrauterine instrumentation. So far, one study supports this proposal, showing that women who were treated for missed miscarriage with misoprostol did not develop IUA, while 7.7% of those undergoing D&C did.<ref name=pmid11960045>{{cite journal | vauthors = Tam WH, Lau WC, Cheung LP, Yuen PM, Chung TK | title = Intrauterine adhesions after conservative and surgical management of spontaneous abortion | journal = The Journal of the American Association of Gynecologic Laparoscopists | volume = 9 | issue = 2 | pages = 182–5 | date = May 2002 | pmid = 11960045 | doi = 10.1016/S1074-3804(05)60129-6 }}</ref> The advantage of misoprostol is that it can be used for evacuation not only following miscarriage, but also following birth for retained placenta or hemorrhaging.
| | * '''[[Hysterosalpingography (HSG)]]''': An X-ray procedure where contrast dye is injected into the uterus and fallopian tubes to detect filling defects indicative of adhesions. |
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| Alternatively, D&C could be performed under ultrasound guidance rather than as a blind procedure. This would enable the surgeon to end scraping the lining when all retained tissue has been removed, avoiding injury.
| | * '''[[Sonohysterography]]''': An ultrasound technique that uses saline infusion to outline the uterine cavity, helping to identify irregularities. |
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| Early monitoring during pregnancy to identify miscarriage can prevent the development of, or as the case may be, the recurrence of AS, as the longer the period after fetal death following D&C, the more likely adhesions may be to occur.<ref name=pmid8473464/> Therefore, immediate evacuation following fetal death may prevent IUA.
| | * '''[[Transvaginal Ultrasound]]''': While less specific, it can provide initial clues, especially when combined with other imaging modalities. |
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| The use of hysteroscopic surgery instead of D&C to remove retained products of conception or placenta is another alternative that could theoretically improve future pregnancy outcomes, although it could be less effective if tissue is abundant. Also, hysteroscopy is not a widely or routinely used technique and requires expertise.
| | == Classification == |
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| There is no data to indicate that suction D&C is less likely than sharp curette to result in Asherman's. A recent article describes three cases of women who developed intrauterine adhesions following manual vacuum aspiration.<ref name=pmid16674955>{{cite journal | vauthors = Dalton VK, Saunders NA, Harris LH, Williams JA, Lebovic DI | title = Intrauterine adhesions after manual vacuum aspiration for early pregnancy failure | journal = Fertility and Sterility | volume = 85 | issue = 6 | pages = 1823.e1–3 | date = June 2006 | pmid = 16674955 | doi = 10.1016/j.fertnstert.2005.11.065 }}</ref>
| | Several classification systems have been developed to categorize the severity of Asherman's Syndrome based on factors such as the extent of adhesions and menstrual patterns. These classifications aid in predicting treatment outcomes and guiding management strategies. |
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| == Treatment == | | == Treatment == |
| Fertility may sometimes be restored by removal of adhesions, depending on the severity of the initial trauma and other individual patient factors. Operative [[hysteroscopy]] is used for visual inspection of the uterine cavity during adhesion dissection (adhesiolysis). However, hysteroscopy is yet to become a routine gynaecological procedure and only 15% of US gynecologists perform office hysteroscopy.<ref name=pmid12151827>{{cite journal | vauthors = Isaacson K | title = Office hysteroscopy: a valuable but under-utilized technique | journal = Current Opinion in Obstetrics & Gynecology | volume = 14 | issue = 4 | pages = 381–5 | date = August 2002 | pmid = 12151827 | doi = 10.1097/00001703-200208000-00004 }}</ref> Adhesion dissection can be technically difficult and must be performed with care in order to not create new scars and further exacerbate the condition. In more severe cases, adjunctive measures such as laparoscopy are used in conjunction with hysteroscopy as a protective measure against uterine perforation. Microscissors are usually used to cut adhesions. Electrocauterization is not recommended.<ref name=pmid17495635>{{cite journal | vauthors = Kodaman PH, Arici A | title = Intra-uterine adhesions and fertility outcome: how to optimize success? | journal = Current Opinion in Obstetrics & Gynecology | volume = 19 | issue = 3 | pages = 207–14 | date = June 2007 | pmid = 17495635 | doi = 10.1097/GCO.0b013e32814a6473 }}
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| </ref>
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| As IUA frequently reform after surgery, techniques have been developed to prevent recurrence of adhesions. Methods to prevent adhesion reformation include the use of mechanical barriers (Foley catheter, saline-filled [http://www.cookmedical.com/wh/dataSheet.do?id=4488 Cook Medical Balloon Uterine Stent], IUCD) and gel barriers (Seprafilm, Spraygel, autocrosslinked hyaluronic acid gel [[Hyalobarrier]]) to maintain opposing walls apart during healing,<ref name=pmid11787023>{{cite journal | vauthors = Tsapanos VS, Stathopoulou LP, Papathanassopoulou VS, Tzingounis VA | title = The role of Seprafilm bioresorbable membrane in the prevention and therapy of endometrial synechiae | journal = Journal of Biomedical Materials Research | volume = 63 | issue = 1 | pages = 10–4 | year = 2002 | pmid = 11787023 | doi = 10.1002/jbm.10040 }}</ref><ref name=pmid15105384>{{cite journal | vauthors = Guida M, Acunzo G, Di Spiezio Sardo A, Bifulco G, Piccoli R, Pellicano M, Cerrota G, Cirillo D, Nappi C | title = Effectiveness of auto-crosslinked hyaluronic acid gel in the prevention of intrauterine adhesions after hysteroscopic surgery: a prospective, randomized, controlled study | journal = Human Reproduction | volume = 19 | issue = 6 | pages = 1461–4 | date = June 2004 | pmid = 15105384 | doi = 10.1093/humrep/deh238 | doi-access = free }}</ref><ref name=pmid16147625>{{cite journal | vauthors = Abbott J, Thomson A, Vancaillie T | title = SprayGel following surgery for Asherman's syndrome may improve pregnancy outcome | journal = Journal of Obstetrics and Gynaecology | volume = 24 | issue = 6 | pages = 710–1 | date = September 2004 | pmid = 16147625 | doi = 10.1080/01443610400008206 }}</ref> thereby preventing the reformation of adhesions. Antibiotic prophylaxis is necessary in the presence of mechanical barriers to reduce the risk of possible infections. A common pharmacological method for preventing reformation of adhesions is sequential hormonal therapy with [[estrogen]] followed by a progestin to stimulate endometrial growth and prevent opposing walls from fusing together.<ref name=pmid8730623/> However, there have been no [[randomized controlled trials]] (RCTs) comparing post-surgical adhesion reformation with and without hormonal treatment and the ideal dosing regimen or length of estrogen therapy is not known. The absence of prospective RCTs comparing treatment methods makes it difficult to recommend optimal treatment protocols. Furthermore, diagnostic severity and outcomes are assessed according to different criteria (e.g. menstrual pattern, adhesion reformation rate, conception rate, live birth rate). Clearly, more comparable studies are needed in which reproductive outcome can be analysed systematically.
| | The primary goal of treatment is to restore the normal anatomy and function of the uterine cavity. Treatment options include: |
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| Follow-up tests (HSG, hysteroscopy or SHG) are necessary to ensure that adhesions have not reformed. Further surgery may be necessary to restore a normal uterine cavity. According to a recent study among 61 patients, the overall rate of adhesion recurrence was 27.9% and in severe cases this was 41.9%.<ref name=pmid17681324>{{cite journal | vauthors = Yu D, Li TC, Xia E, Huang X, Liu Y, Peng X | title = Factors affecting reproductive outcome of hysteroscopic adhesiolysis for Asherman's syndrome | journal = Fertility and Sterility | volume = 89 | issue = 3 | pages = 715–22 | date = March 2008 | pmid = 17681324 | doi = 10.1016/j.fertnstert.2007.03.070 }}</ref> Another study found that postoperative adhesions reoccur in close to 50% of severe AS and in 21.6% of moderate cases.<ref name=pmid3381869/> Mild IUA, unlike moderate to severe synechiae, do not appear to reform.
| | * '''[[Surgical Adhesiolysis]]''': Hysteroscopic surgery is performed to cut and remove adhesions, restoring the uterine cavity's normal structure. |
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| | * '''[[Post-Surgical Measures]]''': To prevent reformation of adhesions, methods such as the insertion of intrauterine devices (IUDs), application of barrier gels, or estrogen therapy may be employed to promote healing of the endometrial lining. |
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| | * '''[[Hormonal Therapy]]''': Estrogen therapy is often prescribed post-surgery to stimulate endometrial regeneration and prevent the walls of the uterus from sticking together during the healing process. |
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| == Prognosis == | | == Prognosis == |
| [[File:Amniotic sheet.jpg|thumb|amniotic sheet on ultrasound]]
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| The extent of adhesion formation is critical. Mild to moderate adhesions can usually be treated with success. Extensive obliteration of the uterine cavity or fallopian tube openings ([[Ostium of Fallopian tube|ostia]]) and deep endometrial or myometrial trauma may require several surgical interventions and/or hormone therapy or even be uncorrectable. If the uterine cavity is adhesion free but the ostia remain obliterated, [[IVF]] remains an option. If the uterus has been irreparably damaged, [[surrogacy]] or [[adoption]] may be the only options. | | The success of treatment largely depends on the severity of the adhesions and the promptness of intervention. Mild to moderate cases often have favorable outcomes with restored menstrual function and the potential for successful pregnancies. Severe cases, especially those with extensive scarring, may have a guarded prognosis, and fertility may remain compromised. |
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| | == Prevention == |
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| | Preventative strategies focus on minimizing uterine trauma and include: |
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| | * '''[[Gentle Surgical Techniques]]''': Utilizing careful and minimally invasive methods during uterine surgeries to reduce endometrial damage. |
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| | * '''[[Prompt Treatment of Infections]]''': Early and effective management of pelvic infections to prevent the development of scar tissue. |
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| | * '''[[Alternative Management of Miscarriages]]''': Considering medical management or expectant management of miscarriages when appropriate, to reduce the need for surgical interventions like D&C. |
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| | == Epidemiology == |
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| Depending on the degree of severity, AS may result in [[infertility]], repeated [[miscarriages]], pain from trapped blood, and future obstetric complications<ref name=pmid3381869>{{cite journal | vauthors = Valle RF, Sciarra JJ | title = Intrauterine adhesions: hysteroscopic diagnosis, classification, treatment, and reproductive outcome | journal = American Journal of Obstetrics and Gynecology | volume = 158 | issue = 6 Pt 1 | pages = 1459–70 | date = June 1988 | pmid = 3381869 | doi = 10.1016/0002-9378(88)90382-1 }}</ref> If left untreated, the obstruction of [[menstrual]] flow resulting from [[adhesions]] can lead to [[endometriosis]] in some cases.<ref name="Palter">{{cite journal | vauthors = Palter SF |title=High Rates of Endometriosis in Patients With Intrauterine Synechiae (Asherman's Syndrome) |journal=Fertility and Sterility |volume=86 |issue=Suppl 1 |pages=S471 |year=2005 |doi=10.1016/j.fertnstert.2005.07.1239 }}</ref><ref name=pmid20418>{{cite journal | vauthors = Buttram VC, Turati G | title = Uterine synechiae: variations in severity and some conditions which may be conducive to severe adhesions | journal = International Journal of Fertility | volume = 22 | issue = 2 | pages = 98–103 | year = 1977 | pmid = 20418 }}</ref>
| | The exact prevalence of Asherman's Syndrome is challenging to determine due to underdiagnosis. However, it is estimated that up to 25% of women who undergo D&C after a miscarriage or delivery may develop intrauterine adhesions. The risk increases with the number of uterine surgeries performed. |
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| Patients who carry a [[pregnancy]] even after treatment of IUA may have an increased risk of having abnormal placentation including [[placenta accreta]]<ref name=pmid16962521>{{cite journal | vauthors = Fernandez H, Al-Najjar F, Chauveaud-Lambling A, Frydman R, Gervaise A | title = Fertility after treatment of Asherman's syndrome stage 3 and 4 | journal = Journal of Minimally Invasive Gynecology | volume = 13 | issue = 5 | pages = 398–402 | year = 2006 | pmid = 16962521 | doi = 10.1016/j.jmig.2006.04.013 }}</ref> where the placenta invades the [[uterus]] more deeply, leading to complications in placental separation after delivery. Premature delivery,<ref name=pmid8730623>{{cite journal | vauthors = Roge P, D'Ercole C, Cravello L, Boubli L, Blanc B | title = Hysteroscopic management of uterine synechiae: a series of 102 observations | journal = European Journal of Obstetrics, Gynecology, and Reproductive Biology | volume = 65 | issue = 2 | pages = 189–93 | date = April 1996 | pmid = 8730623 | doi = 10.1016/0301-2115(95)02342-9 }}</ref> second-trimester pregnancy loss,<ref name=pmid10325268>{{cite journal | vauthors = Capella-Allouc S, Morsad F, Rongières-Bertrand C, Taylor S, Fernandez H | title = Hysteroscopic treatment of severe Asherman's syndrome and subsequent fertility | journal = Human Reproduction | volume = 14 | issue = 5 | pages = 1230–3 | date = May 1999 | pmid = 10325268 | doi = 10.1093/humrep/14.5.1230 | doi-access = free }}</ref> and uterine rupture<ref name=pmid2729381>{{cite journal | vauthors = Deaton JL, Maier D, Andreoli J | title = Spontaneous uterine rupture during pregnancy after treatment of Asherman's syndrome | journal = American Journal of Obstetrics and Gynecology | volume = 160 | issue = 5 Pt 1 | pages = 1053–4 | date = May 1989 | pmid = 2729381 | doi = 10.1016/0002-9378(89)90159-2 }}</ref> are other reported complications. They may also develop [[incompetent cervix]] where the cervix can no longer support the growing weight of the fetus, the pressure causes the placenta to rupture and the mother goes into premature labour. [[Cerclage]] is a surgical stitch which helps support the cervix if needed.<ref name=pmid10325268/>
| | == Complications == |
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| Pregnancy and live birth rate has been reported to be related to the initial severity of the adhesions with 93, 78, and 57% pregnancies achieved after treatment of mild, moderate and severe adhesions, respectively and resulting in 81, 66, and 32% live birth rates, respectively.<ref name=pmid3381869/> The overall pregnancy rate after adhesiolysis was 60% and the live birth rate was 38.9% according to one study.<ref name=pmid3053254>{{cite journal | vauthors = Siegler AM, Valle RF | title = Therapeutic hysteroscopic procedures | journal = Fertility and Sterility | volume = 50 | issue = 5 | pages = 685–701 | date = November 1988 | pmid = 3053254 | doi = 10.1016/S0015-0282(16)60300-X }}
| | If left untreated, Asherman's Syndrome can lead to several complications: |
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| Age is another factor contributing to fertility outcomes after treatment of AS. For women under 35 years of age treated for severe adhesions, pregnancy rates were 66.6% compared to 23.5% in women older than 35.<ref name=pmid16962521/>
| | * '''[[Chronic Pelvic Pain]]''': Ongoing discomfort due to trapped blood or menstrual debris. |
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| ==Epidemiology==
| | * '''[[Endometriosis]]''': Retrograde menstruation caused by blocked menstrual flow can lead to the development of endometrial tissue outside the uterus. |
| AS has a reported [[Incidence (epidemiology)|incidence]] of 25% of D&Cs performed 1–4 weeks post-partum,<ref name=pmid20418/><ref name=pmid553931/><ref>{{cite journal | vauthors = Parent B, Barbot J, Dubuisson JB |title=Synéchies utérines |trans-title=Management of Uterine synechiae |language=fr |journal=Encyclopédie Medico-Chirurgicale, Gynécologie |year=1988 |volume=140A |issue=Suppl |pages=10–12 }}</ref> up to 30.9% of D&Cs performed for missed miscarriages and 6.4% of D&Cs performed for incomplete miscarriages.<ref name=pmid6126446>{{cite journal | vauthors = Adoni A, Palti Z, Milwidsky A, Dolberg M | title = The incidence of intrauterine adhesions following spontaneous abortion | journal = International Journal of Fertility | volume = 27 | issue = 2 | pages = 117–8 | year = 1982 | pmid = 6126446 }}</ref> In another study, 40% of patients who underwent repeated D&C for retained products of conception after missed miscarriage or retained placenta developed AS.<ref name=pmid9886512>{{cite journal | vauthors = Westendorp IC, Ankum WM, Mol BW, Vonk J | title = Prevalence of Asherman's syndrome after secondary removal of placental remnants or a repeat curettage for incomplete abortion | journal = Human Reproduction | volume = 13 | issue = 12 | pages = 3347–50 | date = December 1998 | pmid = 9886512 | doi = 10.1093/humrep/13.12.3347 | doi-access = free }}</ref>
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| In the case of missed miscarriages, the time period between fetal demise and curettage may increase the likelihood of adhesion formation due to fibroblastic activity of the remaining tissue.<ref name=pmid6281085/><ref name=pmid17082672>{{cite journal | vauthors = Fedele L, Bianchi S, Frontino G | title = Septums and synechiae: approaches to surgical correction | journal = Clinical Obstetrics and Gynecology | volume = 49 | issue = 4 | pages = 767–88 | date = December 2006 | pmid = 17082672 | doi = 10.1097/01.grf.0000211948.36465.a6 }}</ref>
| | * '''[[Obstetric Complications]]''': Increased risks during pregnancy, such as abnormal placentation (e.g., placenta accreta), preterm labor, and uterine rupture. |
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| The risk of AS also increases with the number of procedures: one study estimated the risk to be 16% after one D&C and 32% after 3 or more D&Cs.<ref name=pmid8473464>{{cite journal | vauthors = Friedler S, Margalioth EJ, Kafka I, Yaffe H | title = Incidence of post-abortion intra-uterine adhesions evaluated by hysteroscopy--a prospective study | journal = Human Reproduction | volume = 8 | issue = 3 | pages = 442–4 | date = March 1993 | pmid = 8473464 | doi = 10.1093/oxfordjournals.humrep.a138068 }}</ref> However, a single curettage often underlies the condition.
| | == Research and Future Directions == |
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| In an attempts to estimate the [[prevalence]] of AS in the general population, it was found in 1.5% of women undergoing [[hysterosalpingography]] HSG,<ref name=pmid5816312>{{cite journal | vauthors = Dmowski WP, Greenblatt RB | title = Asherman's syndrome and risk of placenta accreta | journal = Obstetrics and Gynecology | volume = 34 | issue = 2 | pages = 288–99 | date = August 1969 | pmid = 5816312 }}</ref> and between 5 and 39% of women with recurrent miscarriage.<ref name=pmid14082285>{{cite journal | vauthors = Rabau E, David A | title = Intrauterine Adhesions: Etiology, Prevention, and Treatment | journal = Obstetrics and Gynecology | volume = 22 | pages = 626–9 | date = November 1963 | pmid = 14082285 }}</ref><ref name=pmid5940506>{{cite journal | vauthors = Toaff R | title = [Some remarks on post-traumatic uterine adhesions] | journal = Revue Francaise de Gynecologie et d'Obstetrique | volume = 61 | issue = 7 | pages = 550–2 | year = 1966 | pmid = 5940506 }}
| | Ongoing research aims to improve the understanding and management of Asherman's Syndrome. Areas of interest include: |
| </ref><ref name=pmid15809790>{{cite journal | vauthors = Ventolini G, Zhang M, Gruber J | title = Hysteroscopy in the evaluation of patients with recurrent pregnancy loss: a cohort study in a primary care population | journal = Surgical Endoscopy | volume = 18 | issue = 12 | pages = 1782–4 | date = December 2004 | pmid = 15809790 | doi = 10.1007/s00464-003-8258-y }}</ref>
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| After miscarriage, a [[scientific review|review]] estimated the prevalence of AS to be approximately 20% (95% [[confidence interval]]: 13% to 28%).<ref name=pmid24082042>{{cite journal | vauthors = Hooker AB, Lemmers M, Thurkow AL, Heymans MW, Opmeer BC, Brölmann HA, Mol BW, Huirne JA | title = Systematic review and meta-analysis of intrauterine adhesions after miscarriage: prevalence, risk factors and long-term reproductive outcome | journal = Human Reproduction Update | volume = 20 | issue = 2 | pages = 262–78 | year = 2013 | pmid = 24082042 | doi = 10.1093/humupd/dmt045 | doi-access = free }}</ref>
| | * '''[[Stem Cell Therapy]]''': Investigating the potential of stem cells to regenerate damaged endometrial tissue. |
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| == History ==
| | * '''[[Novel Surgical Techniques]]''': Developing advanced minimally invasive procedures to reduce the risk of adhesion formation. |
| The condition was first described in 1894 by [[Heinrich Fritsch]] (Fritsch, 1894)<ref>{{WhoNamedIt|synd|1521}}</ref><ref>{{cite journal | vauthors = Fritsch H |title=Ein Fall von volligem Schwaund der Gebormutterhohle nach Auskratzung |trans-title=A case of complete disappearance of the uterine cavity after extraction | language = German |journal=Zentralblatt für Gynäkologie |year=1894 |volume=18 |pages=1337–42 }}</ref> and further characterized by the [[Czechs|Czech]]-[[Israelis|Israeli]] gynecologist [[Joseph Asherman]] (1889–1968)<ref>[http://www.britishfibroidtrust.org.uk/adhesions.php Adhesions & Asherman's Syndrome]</ref> in 1948.<ref name=pmid14804168>{{cite journal | vauthors = Asherman JG | title = Traumatic intra-uterine adhesions | journal = The Journal of Obstetrics and Gynaecology of the British Empire | volume = 57 | issue = 6 | pages = 892–6 | date = December 1950 | pmid = 14804168 | doi = 10.1111/j.1471-0528.1950.tb06053.x }}</ref>
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| It is also known as Fritsch syndrome, or Fritsch-Asherman syndrome.
| | * '''[[Biomaterials]]''': Exploring the use of new barrier materials to prevent adhesion reformation after surgery. |
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| == References == | | == See Also == |
| {{Reflist}}
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| == External links ==
| | * '''[[Endometrial ablation]]''' |
| | * '''[[Hysteroscopic surgery]]''' |
| | * '''[[Uterine synechiae]]''' |
| | * '''[[Fertility preservation]]''' |
| | * '''[[Reproductive surgery]]''' |
| | * '''[[Menstrual disorders]]''' |
| | * '''[[Pelvic Inflammatory Disease]]''' |
| | * '''[[Gynecological imaging]]''' |
| | * '''[[Minimally invasive gynecology]]''' |
| | * '''[[Women's health]]''' |
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| {{commons category}}
| | == External Links == |
| Articles
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| * [https://www.mirror.co.uk/life-style/real-life/2010/04/29/the-secret-syndrome-leaving-women-infertile-115875-22219119/ The secret syndrome leaving women infertile] [[Sophie Blake]] talks about being diagnosed with Asherman's syndrome (Daily Mirror UK)
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| * The hidden threat to fertility (Times Online) www.timesonline.co.uk/tol/life_and_style/health/features/article3025016.ece (copy and paste into web browser)
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| * [http://www.mailonsunday.ie/health/article-1086020/The-great-news-I-thought-I-deliver-TV-newsreader-Kate-Gerbeau.html The great news I thought I would never deliver, by TV newsreader Kate Gerbeau]
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| * [https://web.archive.org/web/20051225074945/http://health.ivillage.com/gyno/gynomal/0,,10t,00.html Overview] at [[iVillage]]
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| * [http://ashermansprevention.blogspot.com/2010/02/how-as-causes-infertility-or.html How Asherman's syndrome causes infertility or miscarriages] from [http://ashermansprevention.blogspot.com/ Blog: Asherman's Syndrome Watch] (awareness, education, prevention)
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| | * '''[https://www.ashermans.org/ Asherman's Syndrome Support Group]''' |
| | * '''[https://www.acog.org/ The American College of Obstetricians and Gynecologists]''' |
| | * '''[https://www.rcog.org.uk/ Royal College of Obstetricians and Gynaecologists]''' |
| | * '''[https://www.who.int/ World Health Organization - Women's Health]''' |
| | * '''[https://www.endofound.org/ Endometriosis Foundation of America] |
| {{Diseases of the pelvis, genitals and breasts}} | | {{Diseases of the pelvis, genitals and breasts}} |
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| {{DEFAULTSORT:Asherman's Syndrome}} | | {{DEFAULTSORT:Asherman's Syndrome}} |
| [[Category:Fertility]] | | [[Category:Fertility]] |
