Presentation in patients with Asherman’ syndrome can be menstrual irregularities, secondary amenorrhea, recurrent abortion and infertility

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Asherman’ Syndrome

Intrauterine adhesions known as Asherman’ syndrome evolve after trauma to the basal layer of the endometrium secondary to Curettge of a gravid or recently postpartum uterus. The lesion was first described by Joseph G. Asherman in 1948, and it ranges from minor to severe cohesion involving the cervical canal or uterine cavity and results in menstrual Irregularities, recurrent pregnancy losses and infertility. Other causes have been established to cause intrauterine adhesions in recent researches part from earlier  scenario.

The prevalence of Asherman’s syndrome varies from one geographic location to another, however, it is known to depend on the degree of awareness of clinicians in the area, the number of illegal and therapeutic abortions carried out in an area, the method used for the procedures, the prevalence of puerperal sepsis and genital tuberculosis as well as the criteria used for the diagnosis.
Since the description by Asherman, there has been various classification of the syndrome. For instance American Society for Reproductive Medicine developed an objective scoring system of classification that correlates the menstrual history with hysteroscopic and hysterosalpingographic findings.
Apart from trauma of the gravid endometrium from abortions and puerperal uterine evacuation, trauma to the non gravid uterus like diagnostic currettage, abdominal myomectomy, insertion of intrauterine Contraceptive Devices, cervical biopsy, polypectomy and the use of intracavitary radium, genetic predisposition to Asherman Syndrome and following congenital anomaly of the uterus are all associated to Asherman Syndrome.
Presentation in patients with Asherman’ syndrome can be menstrual irregularities, secondary amenorrhea, recurrent abortion and infertility. The menstrual Irregularities is due to destruction and subsequent sparse endometrium while the infertility might result from occlusion of tubal ostia, uterine cavity or cervical canal blocking the passage of spermatozoa.

 Investigations modalities for this condition include ultrasonographic, Hysterosalpingography, Sonohysterography, Hysteroscopy or Magnetic Resonance Imaging. Of all these, hysteroscopy can be more accurate to confirm the presence, extent, degree of adhesions and quality of the endometrium due to direct inspection of the uterine cavity.
The management of Asherman Syndrome can be expectant, blind dilatation and currettage, hysterotomy,hysteroscopic adhesiolysis or laparoscopy. Expectant management is unreliable due to uncertainty of the outcome while blind dilatation and currettage is associated with high incidence of Uterine perforation and has a low success rate. hysterotomy is too invasive and the risk of of hysterectomy during the procedure is higher.
Presently, hysteroscopic adhesiolysis is regarded as the treatment of choice because it is minimal invasive, affords direct vision, reduces risk of uterine perforation and minimises endometrial destruction during the procedure. Hysteroscopic lysis of adhesion with scissors, electrosurgery or laser can restore the size and shape of the uterine cavity, normal menstrual function and fertility. Significantly obliterated cavities may require multiple procedures to achieve a satisfactory anatomical results. Patients in whom the uterine fundus is completely obscured and those with a greatly narrowed, fibrotic cavity present the greatest therapeutic challenge.
Postoperative mechanical distention of the endometrial cavity and hormonal treatment to facilitate endometrial regrowth appear to decrease the high rate of adhesion reformation. Newer antiadhesive development can remain stunted due to scanty amount of residual functioning endometrium and fibrosis.
The outcome of hysteroscopic adhesiolysis for Asherman’s syndrome is significantly affected by recurrence of intrauterine adhesions ;conception rate in women who had reformation of intrauterine adhesions was significantly lower than that of women who had a normal cavity. Also, chances of conception in women who remained amenorrhoeic were significantly lower than those who continued to have menses.
Potential pregnancy complications especially accreta, after treatment of intrauterine adhesions should be anticipated and discussed with the patient.

Our patient earlier discussed today presented with both hypomenorrhoea and infertility. She also had history of 2 previous failed treatments by blind dilatation and currettage. This puts her as an idea candidate for hysteroscopic resection. she had stage II (moderate) Asherman with score of 5<1/3 of cavity involved, filmy and dense adhesions and hypomenorrhoea. Intrauterine Foley catheter was employed to prevent reformation of adhesion and she had hormone therapy for 3 months. She responded very well and the menstrual Irregularities was resolved paving the way to tackle the infertility.