Asherman Syndrome

What is Asherman Syndrome?

Any scar formation in the endometrial cavity of the uterus can cause adhesion in the membrane of the soft tissue termed as Asherman syndrome.

Clinically it has great importance, as endometrial lining of the normal uterine cavity is important for carrying a fetus and delivering a child. In Asherman syndrome,  due to adhesion inside the uterine cavity causes partial or complete destruction of the normal cavity and can hinder the conception, or enhance the possibility of miscarriage or creates additional difficulties of the later stage of the pregnancy. ^(1,2,3)

Symptoms

In some cases, the Asherman syndrome does not show any symptom (asymptomatic). But the following symptoms may observed depending upon the intensity of the  scaring, which affect the uterine cavity.

• Irregularity of the menstrual cycle
• Hypomenorrhea (very mild bleeding and short duration of the menstrual cycle)
• Amenorrhea (Complete absence of menstrual cycle) Above symptoms arise due to scaring cause inadequate endometrium discard during menstrual cycle.
• Infertility
• Recurrent miscarriage (pregnancy loss)
• Pain in pelvic region due to blockage of the steady flow of the menstrual blood
• Nausea

If the above mentioned symptoms suddenly arise just after a dilation and curettage (D&C) procedure  or other surgical intervention in the uterine cavity. ^(1,2,3)

Causes

Any traumatic procedure in the uterine cavity due to pregnancy or non-pregnancy related can cause  Asherman syndrome.

Pregnancy related

• If any placental tissue retained in the uterine cavity after delivery of a child or post-partum complication which need to conduct curettage
• Surgical abortion, any retained tissue fragments after medical abortion or miscarriage may need to conduct dilation and curettage (D&C) or dilation and evacuation (D&E)

The above pregnancy related instrumentation can cause scarring of the uterine tissue, which leads to Asherman syndrome.

Non-pregnancy related

• In some cases, heavy bleeding needs dilation and curettage
• Other complications like fibroid tumors need uterine surgery, which include myomectomy or cesarean section.

Genital infections

Rarely it has observed that some genital infections can cause the Asherman’s syndrome, these include:

• Post-partum infection or pelvic infection arises after abortion or miscarriage
• Genital tuberculosis is another possible cause of intrauterine scarring in underdeveloped or developing countries.
• Schistosomiasis infection is also has a role in the development of Asherman’s syndrome.

In some cases, Asherman’s syndrome developed without any predisposing factors. ^(2,3)

Possibility of Development

Surveys and different studies provide the estimated amount of Asherman’s syndrome in respect of possible cause

• Approximately 1% intrauterine scarring is due to D&Cs, whereas conducting multiple D&Cs potentially increases the possibility for development of the scar tissue in the uterus.
• The purpose of conduction of D & C also influence the incidence rate of Asherman’s syndrome. For example, D & C conducted for removal of the retained placental tissue after delivery may increase the possibility of the development of the Asherman’s syndrome. It has been estimated almost 25% of Asherman’s syndrome is caused by postpartum curettage. ⁽²⁾

Pathophysiology

The different approaches are made by various researchers to draw a pathophysiology of the Asherman’s syndrome, though the exact etiology is not confirmed.

• Considerable sub-cellular alterations like missing of the ribosome, vascular shutting due to mitochondrial inflammation and cellular alterations due to hypoxia in the endometrial ghiandolar cells.
• Endometrial trauma followed of the endometrial vascularity modification. Pelvic angiography showed damaged vascularity in the endometrium and myometrium.
• In intrauterine adhesion other contributory factors are platelet derived growth factor, b-fibroblast growth factor and transforming growth factor type 1 and play an important role in the development of the Asherman’s syndrome.
• Any endometrial traumatic stimulation, which influence the development of the fibrotic tissue can cause Asherman’s syndrome.

The amalgamation of inflammation and ischemia  persuaded by invasive trauma may comprise the major cause of intrauterine adhesion development and progress of the Asherman’s syndrome. ⁽⁴⁾

Diagnosis

Initially a pelvic examination is proceed to evaluate the clinical condition. The diagnostic gold standard for detecting the Asherman’s syndrome is a hysteroscopy.

Hysteroscopy

The hysteroscopy is conducted in a hospital or clinic, as it involves a small surgical process. Doctor insert a small magnifying camera inside the uterine cavity through the cervix. The inserted medical device helps to provide magnifying images of uterine tissue and can detect the presence of scar tissue. It is also estimated that the complete or partial invasion of the adhesion in the uterine cavity.

Other possible tests are:

Hysterosalpingogram

In this X-ray image of the uterine cavity is obtained.  To conduct this test dye is injected into the uterine cavity, which is followed by an X-ray.

Sonohysterogram

In this test, sufficient amount of fluid is injected into the uterine cavity and then ultrasonographic imaging technique is applied to get the clue of the existence of intrauterine scar tissue.

Transvaginal ultrasound

This test is conducted for evaluation and estimation of the width of the of the endometrial membrane by the presence of endometrial stripe.

Endometrial biopsy

This test is conducted if any suspicion of tissue growth obtains during the above mentioned test. In this test a small sample of the uterine lining is sent to a lab for detection of the presence of the abnormal endometrium. ^(2,4,5,6)

Treatment

Usually the treatment process for Asherman’s syndrome is involved in two stages:

Scar tissue removal

Surgical intervention is required to conduct the removal of the scar tissue. Hysteroscope is used to perform the operation. Minor surgery is required for removal and may need not to require a hospital stay  also depending upon the patient response. The surgery is followed a quick revival with minimal usage of analgesic medications.

If the small and not extended scar tissue is obtained, which can easily locate, then doctors take the measure to break up the adhesion during the initial hysteroscopy procedure.

Avert recurrence of adhesion

The chance of recurrence of the adhesion is common after initial lysis and for prevention, which include estrogen therapy after surgical removal, periodic break up of form scar tissue,  insertion of balloon in the uterine cavity.

• Estrogen Therapy:usually after surgical intervention, estrogen therapy is prescribed for one month, this therapy promote the development of the normal uterine membrane and assisting in the prevention of  the re-growth of the scar tissue.
• Repeat office hysteroscopy: Periodic hysteroscopy test is recommended to   The standard recommendation is first test should be conducted within 7 to 14 days after the initial removal procedure, and this can be repeat for two more times with the same gaping for the duration. Generally the cycle should not be conducted more than 3 times at a instance.
• Placement of an intrauterine balloon: After the initial removal of adhesions, some doctors put an puffed up balloon or an IUD (intrauterine device) within the uterine cavity for prevention of recurrence of scar tissue.
• Antibiotic therapy: Antibiotic therapy is recommended for tuberculosis or schistosomiasis infection is detected. ^(2,4,5,6)

References

1. Sylvie Capella-Allouc,  Fadila Morsad, Catherine Rongières-Bertrand, Sabine Taylor and Hervé Fernandez (1998); Hysteroscopic treatment of severe Asherman’s syndrome and subsequent fertility; doi: 10.1093/humrep/14.5.1230; Retrieve from: http://humrep.oxfordjournals.org/content/14/5/1230.full
2. Richard Sherbahn; Intrauterine Adhesions, Asherman’s Syndrome – Scar TissueIn Uterine Cavity; Retrieve from: http://www.advancedfertility.com/uterineadhesions.htm
3. Asherman’s Syndrome Causes, Symptoms & Treatment; Newton-Wellesley Hospital; Retrieve from: http://www.nwh.org/departments-and-services/migs/conditions-treated/ashermans-syndrome/
4. Alessandro Conforti, Carlo Alviggi, Antonio Mollo, Giuseppe De Placido and Adam Magos; The management of Asherman syndrome: a review of literature; Retrieve from: http://rbej.biomedcentral.com/articles/10.1186/1477-7827-11-118
5. Asherman’s Syndrome; Retrieve from: http://www.adhesions.org/asherman.htm
6. Kenneth F. Trofatter, Jr., Asherman’s Syndrome: Diagnosis, Treatment, and Prevention; Retrieve from: http://www.healthline.com/health-blogs/fruit-womb/ashermans-syndrome-diagnosis-treatment-and-prevention