What is Asherman’s Syndrome?
Intrauterine adhesions (IUA) or Asherman’s syndrome is a condition characterized by the presence of severe intrauterine adhesions (synechiae) that often destroy most of the basal layer of the endometrium from which, under the influence of the hormones estrogen and progesterone, the uterine lining (endometrium) develops. When most of the basal endometrium is incapacitated so that virtually no regeneration of the endometrium can take place, amenorrhea (cessation of menstruation) and infertility follow.
What Causes IUA or Asherman’s Syndrome?
IUA most commonly results from post-partum or post-abortal inflammation/infection involving the uterine lining (endometritis), but it can also occur following uterine surgery, such as removal of fibroid tumors (myomectomy) or overzealous scraping at the time of D & C, that encroach upon, or penetrate into the uterine cavity.
The diagnosis of IUA/Asherman’s syndrome can be quite difficult to establish and should always be entertained when someone has a history of prior uterine surgery, especially if associated with infection. The patient will describe a “defining event” (e.g. a termination of pregnancy with an associated infection), followed by a noticeable change in her menstrual pattern; for example, from a heavy flow for 4-5 days down to a scant flow for 1-2 days and in some cases, even a complete absence of menstrual flow in the months following this event. Filling defects can be seen on HSG (dye test). Sometimes, the only way to make the diagnosis is at the time of a hysteroscopy. If a hysteroscopy is undertaken, the surgeon should be ready to remove (lyse) the adhesions at the same time, because it does not make sense to end the procedure and tell the patient adhesions have been found, only to tell them that another hysteroscopy is needed again in order to remove them. Even a small number of adhesions can significantly interfere with pregnancy potential because the adhesions act like an IUD (intrauterine device) and also diminish the available endometrium for successful implantation to take place. However, it is also prudent to bear in mind that attempts to remove adhesions can actually make the situation worse, by causing more adhesions to develop. Therefore, experience with HSC and judgment on the part of the doctor are very important.
Treatment involves a procedure called hysteroscopic lysis of adhesions, whereby a telescope-like instrument is introduced via the vagina and cervix into the uterine cavity, to allow direct surgical resection of as much scar tissue as possible. The objective is to remove as much scar tissue as possible and to free adhesions that fuse the walls of the uterine cavity together, so as to uncover and enable viable basal endometrium to resume growth and progressively cover as much of the surface of the uterine cavity as possible. Post-operatively, a small balloon is often placed in the uterine cavity for a day or two, to keep the opposing surfaces separated in the hope of preventing recurrence of adhesion formation. The woman usually receives supplemental estrogen to stimulate endometrial growth. It may be necessary to repeat this procedure to completely reset the scar tissue.
Endometritis of a severity sufficient to produce IUA usually scars and blocks the uterine entrance to the fallopian tubes. However sometimes, one or both tubes remain open (although there is usually some degree of damage to the inner lining). While in such cases, the uterus is often incapable of allowing proper embryo implantation, a pregnancy could implant in a fallopian tube leading to an ectopic pregnancy.
Since the blood flow to the uterine lining is often damaged with the presence of adhesions, it may be necessary to assist endometrial development at the time of an assisted reproductive cycle. This can be accomplished with estrogen supplementations or the use of Viagra vaginal suppositories to improve blood flow and hence the delivery of estrogen to the endometrium. The response to these interventions and the determination as to whether the endometrium will develop adequately comes down to the blood flow dynamics and the amount of scar tissue.
Unfortunately, in some cases of IUA, there can be such widespread destruction of the basal endometrium (from which fresh endometrial cells must be generated), that improving blood flow with Viagra is often unsuccessful in improving estrogen-mediated endometrial development sufficient to achieve adequate improvement in endometrial growth. In such cases, the women should consider other options such as gestational surrogacy.
This blog is intended as an aid to provide patients with general information. As science is rapidly evolving, some new information may not be presented here. It is not intended to replace or define evaluation and treatment by a physician.
At RISE Fertility, our goal is to provide seamless and elevated fertility treatment. If you are experiencing symptoms of IUA or Asherman’s Syndrome, and you are trying to get pregnant, contact us today for a fertility assessment. Our team is standing by and waiting to assist you on your fertility journey – we are with you every step of the way!