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- Asherman syndrome (AS) is the term used to describe infertility or secondary amenorrhea associated with intrauterine adhesions (IUAs) or development of scar tissue within the endometrium.
- The extent of IUAs can range from mild disease causing thin, filmy adhesions from the anterior uterine wall to the posterior uterine wall to complete obliteration of the intrauterine cavity due to large thick adhesions comprised largely of dense connective tissue.
- The severity to which these adhesions cause symptoms of infertility or abnormal menses will dictate the level of disease.
- The manifestations of IUA include decrease in menstrual flow, infertility, recurrent miscarriage, placenta accreta, amenorrhea, and so forth, which significantly influence the reproductive health.
- The leading risk factor for IUAs and AS is intrauterine trauma associated with a surgical instrumentation or manipulation.
- Treatment is indicated by the extent of disease and consists of lysis of adhesions and preventative measures.
As intrauterine adhesive disease is rare and generally asymptomatic, true incidence and prevalence is difficult to measure.
Prevalence has been cited as
Etiology and Pathophysiology
- The etiology of this disorder is trauma to a pregnant uterus, especially after postpartum curettage or after D&C for missed abortion (2).
- When curettage is done during 2nd, 3rd, and 4th postpartum week, a higher incidence of IUA is associated with this procedure (3).
- Endometrial injury from procedures unrelated to pregnancy has also been implicated in the disease process, that is, myomectomy or curettage performed in the nonpregnant uterus.
- Infectious processes have also been found as a cause of adhesive disease within the endometrium. Although studies have shown conflicting evidence, genital tuberculosis is one of the main etiologic factors of this condition, whereas chronic endometritis has also been associated with IUA.
- After endometrial injury, impaired endometrial repair is thought to be the pathogenesis behind IUA (4).
- Intrauterine surgery or infection may cause damage to the basal layer of endometrium, leading to the impaired regeneration of epithelial cells (4).
- The basalis layer of endometrium is damaged, causing inactive regeneration of endometrial cells and glands leading to poor endometrial repair signaling and defective angiogenesis.
- The absence of vascular regeneration causing interruption in the endometrium causes formation of fibrous scar and adhesion between anterior and posterior walls (4).
- Endometrial curettage up to 4 weeks postpartum
- Recurrent miscarriages and D&C procedures
- Congenital (septate uterus or bicornuate uterus) and acquired intrauterine abnormalities (polyps or fibroids) have been identified more frequently in woman with IUA (5).
- Women with more than one miscarriage generally have more IUAs compared with women with one miscarriage (5).
- Avoiding repeated intrauterine curettage for early pregnancy loss by opting for expectant and medical management especially in women with history of previous uterine instrumentation
- Other measures have been proposed, such as routine estrogen therapy, after uterine curettage and using hyaluronic acid as an adhesion barrier; however, no studies have demonstrated clinical benefit from these approaches.
Commonly Associated Conditions
- Associated with müllerian duct malformations, especially with septate uterus
- Patients with remaining areas of normally functioning endometrium may have increased risk of developing endometrial adenocarcinoma (6).
- Endometriosis from backflow of menstrual fluid