MyEClinic
MyEClinic
Health Dictionary Find a Doctor

Asherman's syndrome

For patient information, click here

Editor(s)-in-Chief: Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Canan S Fornusek, Ph.D.; Associate Editor-In-Chief: Saud Khan M.D.

Overview

Overview

Editor(s)-in-Chief: Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Canan S Fornusek, Ph.D.; Associate Editor-In-Chief: Saud Khan M.D.

Overview

Asherman’s syndrome, also called “uterine synechiae” or intrauterine adhesions, presents a condition characterized by the presence of scars within the uterine cavity.

An artificial form of Asherman’s syndrome can be surgically induced by endometrial ablation in women with excessive uterine bleeding, in lieu of hysterectomy.

Historical Perspective

The Israeli gynecologist Joseph Asherman is credited with describing and characterizing the disease, hence it is called Asherman syndrome.

Classification

Classification of Asherman’s syndrome takes into account the amount of functional endometrium present, the menstrual pattern, obstetric history, and more recently the location and severity of adhesions inside the uterus. There is no data showing superiority of one system over the other.

Pathophysiology

Asherman syndrome most often is the result of vigorous scraping and damage to the basal layer of the endometrium during a dilation and curettage, which may be done for a variety of reasons. It may also occur after delivery, especially if there is uncontrolled hemorrhage, or after the elective termination of a pregnancy. Less often, it is due to sampling for endometrial cancer, or removal of endometrial polyps. It may also occur after surgery to remove uterine fibroids.

Causes

Asherman’s syndrome is most commonly linked to obstetric procedures that cause abrasion of the basal layer of the endometrium. Other causes include caesarian sections, infections or pelvic radiation therapy.

Intrauterine devices have not been linked to Asherman’s syndrome.

Differentiating Asherman’s Syndrome from other diseases

Asherman Syndrome must be differentiated from other conditions that may cause amenorrhea and pregnancy loss, and may cause infertility.

Epidiology and Demographics

Asherman’s Syndrome may occur in up to 13% of women undergoing a termination of pregnancy during the first trimester, and 30% in women undergoing a dilation and curettage (D and C) after a late spontaneous abortion. Structural placental abnormalities and previous procedures done in the uterus increase the risk.

Risk Factors

The strongest risk factors for developing Asherman Syndrome is previous obstetric curettage procedures and infections.

Screening

No screening guidelines exist for Asherman’s Syndrome.

Natural History, Complications and Prognosis

Asherman’s syndrome typically occurs after a triggering event such as an infection or a procedure, and is a cumulative process which may lead to infertility. Damage to the uterine cavity may also cause pain, congestion and endometriosis.

Historical Perspective

Historical Perspective

Editor(s)-in-Chief: Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Canan S Fornusek, Ph.D.; Associate Editor-In-Chief: Saud Khan M.D.

Overview

The Israeli gynecologist Joseph Asherman is credited with describing and characterizing the disease, hence it is called Asherman syndrome.

Historical Perspective

  • Intrauterine adhesions were first described in 1894 by Heinrich Fritsch (Fritsch, 1894)[1] and further characterized and described by the gynecologist Joseph Asherman in 1948 [2].
  • Asherman though that intrauterine adhesions may be linked to prior endometrial trauma.
  • He later published more case series of intrauterine adhesions with documented results of hysterography, with evident filling defects. It is also known as Fritsch syndrome, or Fritsch-Asherman syndrome.
  • References
  1. ↑ >Template:WhoNamedItFritsch H, Ein Fall von volligem Schwaund der Gebormutterhohle nach Auskratzung. Zentralbl Gynaekol 1894; 18:1337-1342.
  2. ↑ Asherman JG. (1948.). “Traumatic intra-uterine adhesions”. J Obstet Gynaecol Br Em. 55 (2): 2–30. Check date values in: |year= (help)


Template:WikiDoc Sources

Classification

Classification

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor-In-Chief: Saud Khan M.D.

Overview

Classification of Asherman’s syndrome takes into account the amount of functional endometrium present, the menstrual pattern, obstetric history, and more recently the location and severity of adhesions inside the uterus. There is no data showing superiority of one system over the other.

Classification of Intra Uterine Adhesions (IUA)

As severity of the condition correlates with prognosis, classification of IUA is useful for choosing the treatment method and providing a prognosis relating to fertility outcome following treatment.

Several classification systems have been proposed for Asherman’s syndrome, although none of them is currently endorsed universally.

The older systems were based on hysterosalpingography findings however with the advent of hysteroscopy modern classification systems are based on hysteroscopic diagnosis of adhesions. Those of the American Fertility Society [1], the European Society for Hysteroscopy [2]and Nasr’s proposed system, based on March et al.’s classification [3] are the most complex, taking into account several criteria. Nasr’s point based classification system includes:

Hysteroscopic findings Score
Isthmic fibrosis 2
Filmy adhesions More than 50% of the cavity 1
Less than 50% of the cavity 2
Dense adhesions Single band 2
Multiple bands 4
Tubal ostium Both visualized 0
Only one visualized 2
Both not visualized 4
Tubular cavity (sound less than 6) 10
Menstrual pattern Normal 0
Hypomenorrhea 4
Amenorrhea 8
Reproductive performance Good obstetrics history 0
Recurrent pregnancy loss 2
Infertility 4
Mild 0-4
Moderate 5-10
Severe 11-22


There is some variation between criteria used in these systems but they include

  • type of adhesions,
  • location,
  • extent of the uterine cavity affected,
  • clinical symptoms,
  • menstrual characteristics or history,
  • obstetric history.
  • The boundaries between grade subtypes are sometimes subtle.

It is important to note that none of these classification systems have been validated by clinical studies, and research reporting treatment outcomes often lack details on exact IUA grades in patients. This adds to the difficulties in comparing study outcomes in patients treated for Asherman’s syndrome.[3]

References

  1. ↑ American Fertility Society (1988). “The American Fertility Society classification of adnexal adhesions, distal tubal occlusions secondary to tubal ligation, tubal pregnancy, mullerian anomalies and intrauterine adhesions”. Fertil Steril. 49 (6): 944–55. PMID 3371491.
  2. ↑ {{cite journal |author=Wamsteker K, DeBlok SJ |title=Diagnostic hysteroscopy: technique and documentation. |journal=Endoscopic surgery for gynecologist New York:Lippincott Williams & Wilkins Publishers |pages=263-76 |year=1995
  3. ↑ 3.0 3.1 Nasr AL, AL-Inany HG, Thabet SM, Aboulghar M (2000). “A clinicohysteroscopic scoring system of intrauterine adhesions”. Gynecol Obstet Invest. 50 (3): 178–81.


Template:WikiDoc Sources

Pathophysiology

Pathophysiology

Editor(s)-in-Chief: Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Canan S Fornusek, Ph.D.; Associate Editor-In-Chief: Saud Khan M.D.

Overview

Asherman syndrome most often is the result of vigorous scraping and damage to the basal layer of the endometrium during a dilation and curettage, which may be done for a variety of reasons. It may also occur after delivery, especially if there is uncontrolled hemorrhage, or after the elective termination of a pregnancy. Less often, it is due to sampling for endometrial cancer, or removal of endometrial polyps. It may also occur after surgery to remove uterine fibroids.

Pathophysiology

The cavity of the uterus is lined by the endometrium. This lining is composed of two layers, the functional layer which is shed during menstruation and an underlying basal layer which is necessary for regenerating the functional layer. Trauma to the basal layer, typically after a dilation and curettage (D&C) performed after a miscarriage, or delivery, or for elective abortion triggers inflammation that allows adhesive bands to form from one side of the cavity to the other. The risk of developing Asherman syndrome is increased if during pregnancy, the placenta tissue burrows below the basal layer of the endometrium. The extent of the adhesions defines whether the case is mild, moderate, or severe.

The adhesions can be thin or thick, spotty in location, or confluent. The adhesive bands are usually not vascular, an important consideration when discussing treatment options. In extreme cases, the whole cavity becomes scarred and occluded. Even with relatively few scars, the endometrium may fail to respond to estrogens and rests.

Often, patients experience secondary menstrual irregularities characterized by changes in flow and duration of bleeding (amenorrhea, hypomenorrhea, or oligomenorrhea) [1] and may develop recurrent pregnancy loss or 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 are also sometimes experienced, and can be attributed to blockages.[2]

References

  1. ↑ Klein SM, Garcia C-R (1973). “Asherman’s syndrome: a critique and current review”. Fertility and Sterility. 24 (9): 722–735. PMID 4725610.
  2. ↑ Dreisler E, Kjer JJ (2019). “Asherman’s syndrome: current perspectives on diagnosis and management”. Int J Womens Health. 11: 191–198. doi:10.2147/IJWH.S165474. PMC 6430995. PMID 30936754.


Template:WikiDoc Sources

Causes

Causes

Editor(s)-in-Chief: Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Canan S Fornusek, Ph.D.; Associate Editor-In-Chief: Saud Khan M.D.

Overview

Asherman’s syndrome is most commonly linked to obstetric procedures that cause abrasion of the basal layer of the endometrium. Other causes include caesarian sections, infections or pelvic radiation therapy.

Intrauterine devices have not been linked to Asherman’s syndrome.

Causes

Asherman’s syndrome occurs most frequently after a Dilation & Curettage (D&C) is performed on a recently pregnant uterus, following a missed or incomplete miscarriage, birth, or elective termination (abortion) to remove retained products of conception/placental remains. As the same procedure is used in all three situations, Asherman’s can result in all of the above circumstances. It affects women of all races and ages as there is no underlying predisposition or genetic basis to its development. According to a study on 1900 patients with Asherman’s syndrome, over 90% of the cases occurred following pregnancy-related curettage [1].

It is estimated that up to 5% of D&Cs result in Asherman’s. More conservative estimates put this rate at 1%. Asherman’s results from 25% of D&Cs performed 1-4 weeks post-partum [2][3][4], 30.9% of D&Cs performed for missed miscarriages and 6.4% of D&Cs performed for incomplete miscarriages. [5] In the case of missed miscarriages, the time period between fetal demise and curettage increases the likelihood of adhesion formation to over 30.9% [1][6]

Asherman’s can also result from other pelvic surgeries including Cesarean section[7], removal of fibroid tumours (myomectomy) and from other causes such as IUDs, pelvic irradiation, schistosomiasis[8] and genital tuberculosis[9]. Chronic endometritis from genital tuberculosis is a significant cause of severe IUA in the developing world, often resulting in total obliteration of the uterine cavity which is difficult to treat [10].

References

  1. ↑ 1.0 1.1 Schenker JG, Margalioth EJ. (1982). “Intra-uterine adhesions: an updated appraisal”. Fertility Sterility. 37 (5): 593–610. PMID 6281085.
  2. ↑ Parent B, Barbot J, Dubuisson JB. Uterine synechiae (in French). Encyl Med Chir Gynecol 1988; 140A (Suppl): 10-12.
  3. ↑ Rochet Y, Dargent D, Bremond A, Priou G, Rudigoz RC (1979). “The obstetrical outcome of women with surgically treated uterine synechiae (in French)”. J Gynecol Obstet Biol Reprod. 8 (8): 723–726. PMID 553931.
  4. ↑ Buttram UC, Turati G. (1977). “Uterine synechiae: variation in severity and some conditions which may be conductive to severe adhesions”. Int J Fertil. 22 (2): 98–103. PMID 20418.
  5. ↑ Adoni A, Palti Z, Milwidsky A, Dolberg M. (1982). “The incidence of intrauterine adhesions following spontaneous abortion”. Int J Fertil. 27 (2): 117–118. PMID 6126446.
  6. ↑ Fedele L, Bianchi S, Frontino G. Septums and synechiae: approaches to surgical correction. Clin Obstet Gynecol 2006; 49:767-788.
  7. ↑ Rochet Y, Dargent D, Bremond A, Priou G, Rudigoz RC (1979). “The obstetrical outcome of women with surgically treated uterine synechiae (in French)”. J Gynecol Obstet Biol Reprod. 8 (8): 723–726. PMID 553931.
  8. ↑ Krolikowski A, Janowski K, Larsen JV. (1995). “Asherman syndrome caused by schistosomiasis”. Obstet Gynecol. 85 (5Pt2): 898–9. doi:10.1016/0029-7844(94)00371-J. PMID 7724154.
  9. ↑ Netter AP, Musset R, Lambert A Salomon Y (1956). “Traumatic uterine synechiae: a common cause of menstrual insufficiency, sterility, and abortion”. Am J Obstet Gynecol. 71 (2): 368–75. PMID 13283012.
  10. ↑ Bukulmez O, Yarali H, Gurgan T. (1999). “Total corporal synechiae due to tuberculosis carry a very poor prognosis following hysteroscopic synechialysis”. Hum Reprod. 14 (8): 1960–1961. doi:10.1093/humrep/14.8.1960. PMID 10438408.


Template:WikiDoc Sources

Differentiating Asherman’s syndrome from other Diseases

Differentiating Asherman’s syndrome from other Diseases

Editor(s)-in-Chief: Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Canan S Fornusek, Ph.D.; Associate Editor-In-Chief: Saud Khan M.D.

Overview

Asherman Syndrome must be differentiated from other conditions that may cause amenorrhea and pregnancy loss, and may cause infertility.

Differential Diagnosis

Ashermans Syndrome must be differentiated from:


References

  1. ↑ Smikle C, Yarrarapu SNS, Khetarpal S. Asherman Syndrome. [Updated 2022 Jun 27]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK448088/
Epidemiology and Demographics

Epidemiology and Demographics

Editor(s)-in-Chief: Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Canan S Fornusek, Ph.D.; Associate Editor-In-Chief: Saud Khan M.D.

Overview

Asherman’s Syndrome may occur in up to 13% of women undergoing a termination of pregnancy during the first trimester, and 30% in women undergoing a dilation and curettage (D&C) after a late spontaneous abortion. Structural placental abnormalities and previous procedures done in the uterus increase the risk.

Epidemiology and Demographics

The true prevalence of Asherman’s syndrome is unclear. The condition is estimated to affect 1.5% of women undergoing HSG [1], between 5 and 39% of women with recurrent miscarriage [2][3][4] and up to 40% of patients who have undergone D&C for retained products of conception [5]. It may occur in up to 13% of women undergoing a termination of pregnancy during the first trimester, and 30% in women undergoing a dilation and curettage (D and C) after a late spontaneous abortion.

Women with placental abnormalities (e.g., placenta increta) may have a higher risk of developing Asherman syndrome as the placenta adheres to deeper layers within the uterus and becomes more difficult to remove. The incidence may be as high as 23.4% in patients undergoing procedures two to four weeks after the initial procedure for a vaginal delivery or missed abortion. The risk increases for patients undergoing repeated procedures for bleeding or repeated elective termination of pregnancies.

It is found in 1.5% of women evaluated with a hysterosalpingogram (HSG) for infertility, between 5 and 39% of women with recurrent miscarriage. Asherman’s Syndrome may occur in 31% of women after the initial hysteroscopic resection of leiomyoma, and up to 46% after the second hysteroscopic resection.[6][7]

References

  1. ↑ Dmowski WP, Greenblatt RB. (1969). “Asherman’s syndrome and risk of placenta accreta”. Obstet Gynecol. 34 (2): 288–299. PMID 5816312.
  2. ↑ Rabau E, David A. (1963). “Intrauterine adhesions:etiology, prevention, and treatment”. Obstet Gynecol. 22: 626–629. PMID 14082285.
  3. ↑ Toaff R. (1966). “Some remarks on posttraumatic uterine adhesions.in French”. Rev Fr Gynecol Obstet. 61 (7): 550–552. PMID 5940506.
  4. ↑ Ventolini G, Zhang M, Gruber J. (2004). “Hysteroscopy in the evaluation of patients with recurrent pregnancy loss: a cohort study in a primary care population”. Surg Endosc. 18 (12): 1782–1784. doi:10.1007/s00464-003-8258-y. PMID 15809790.
  5. ↑ Westendorp ICD, Ankum WM, Mol BWJ, Vonk J. (1998). “Prevalence of Asherman’s syndrome after secondary removal of placental remnants or a repeat curettage for incomplete abortion”. Hum Reprod. 13 (12): 3347–3350. doi:10.1093/humrep/13.12.3347. PMID 9886512.
  6. ↑ Chikazawa K, Imai K, Liangcheng W, Sasaki S, Horiuchi I, Kuwata T; et al. (2018). “Detection of Asherman’s syndrome after conservative management of placenta accreta: a case report”. J Med Case Rep. 12 (1): 344. doi:10.1186/s13256-018-1869-7. PMC 6245912. PMID 30454053.
  7. ↑ Tchente NC, Brichant G, Nisolle M (2018) [Asherman’s syndrome : management after curettage following a postnatal placental retention and literature review.] Rev Med Liege 73 (10):508-512. PMID: 30335256


Template:WikiDoc Sources

Risk Factors

Risk Factors

Editor(s)-in-Chief: Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Canan S Fornusek, Ph.D.; Associate Editor-In-Chief: Saud Khan M.D.

Overview

The strongest risk factors for developing Asherman Syndrome is previous obstetric curettage procedures and infections.

Risk Factors

The risk of Asherman’s 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 [1]. Other risk factors may include

Women may be predisposed to intrauterine adhesions if they are of increased age, poor nutritional status during pregnancy, and have experienced intrauterine or genital infectious processes. However, such factors are not supported in the literature, where the dominant factor seems to be surgical trauma (frequent hysteroscopic surgery, repeat curettages and infection).[2]


References

  1. ↑ Friedler S, Margalioth EJ, Kafka I, Yaffe H. (1993). “Incidence of postabortion intra-uterine adhesions evaluated by hysteroscopy: a prospective study”. Hum Reprod. 8 (3): 442–444. PMID 8473464. Text “doi” ignored (help)
  2. ↑ Di Spiezio Sardo A, Calagna G, Scognamiglio M, O’Donovan P, Campo R, De Wilde RL (2016). “Prevention of intrauterine post-surgical adhesions in hysteroscopy. A systematic review”. Eur J Obstet Gynecol Reprod Biol. 203: 182–92. doi:10.1016/j.ejogrb.2016.05.050. PMID 27337414.


Template:WikiDoc Sources

Screening

Screening


Editor-in-Chief: Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor-in-Chief: Saud Khan M.D.

Screening for Asherman’s Syndrome

No screening guidelines exist for Asherman’s Syndrome.

References


Template:WikiDoc Sources

Natural History, Complications and Prognosis

Natural History, Complications and Prognosis

Editor(s)-in-Chief: Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Canan S Fornusek, Ph.D.; Associate Editor-In-Chief: Saud Khan M.D.

Overview

Asherman’s syndrome typically occurs after a triggering event such as an infection or a procedure, and is a cumulative process which may lead to infertility. Damage to the uterine cavity may also cause pain, congestion and endometriosis.

Natural History

Usually occurring after vigorous intrauterine procedures such as Dilation and Curettage, Asherman’s syndrome manifests as amenorrhea and uterine congestion. Over time, due to the uterine cavity being damaged by adhesions, infertility may occur.

Complications

Depending on the degree of severity, Asherman’s syndrome may result in infertility, repeated miscarriages, pain from trapped blood, and high risk pregnancies [1]. There is evidence that left untreated, the obstruction of menstrual flow resulting from scarring can lead to endometriosis[2].

Prognosis

The extent of scar formation is critical. Small scars can usually be treated with success. Extensive obliteration of the uterine cavity or fallopian tube openings (ostia) may require several surgical interventions or even be uncorrectable. In this case surrogacy, IVF or adoption may be advised.

Patients who carry a pregnancy after correction of Asherman’s syndrome may have an increased risk of having abnormal placentation including placenta accreta [3]where the placenta invades the uterus more deeply, leading to complications in placental separation after delivery. Premature delivery [4], second-trimester pregnancy loss[5], and uterine rupture[6] 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[5].

The overall pregnancy rate after adhesiolysis (removal of adhesions) was 60% and the live birth rate was 38.9% according to one study [7]. Success is related to the 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 [1].

Age is another factor contributing to fertility outcomes after treatment of Asherman’s. 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 [3].

References

  1. ↑ 1.0 1.1 Valle RF, and Sciarra JJ (1988). “Intrauterine adhesions: Hystreoscopic diagnosis, classification, treatment and reproductive outcome”. . Am J Obstet. 158 (6Pt1): 1459–1470. PMID 3381869.
  2. ↑ Buttram VC, Turati, G (1977). “Uterine synechiae: variations in severity and some conditions which may be conducive to severe adhesions”. Int J Fertil. 22 (2): 98–103. PMID 20418.
  3. ↑ 3.0 3.1 Fernandez H, Al Najjar F, Chauvenaud-Lambling; et al. (2006). “Fertility after treatment of Asherman’s syndrome stage 3 and 4”. J Minim Invasive Gynecol. 13 (5): 398–402. doi:10.1016/j.jmig.2006.04.013. PMID 16962521.
  4. ↑ Roge, P (1996). “Hysteroscopic management of uterine synechiae: a series of 102 observations”. Eur J Obstet Gynecol Reprod Biol. 65 (2): 189–193. doi:10.1016/0301-2115(95)02342-9. PMID 8730623. Unknown parameter |authro= ignored (help)
  5. ↑ 5.0 5.1 Capella-Allouc S, Morsad F, Rongieres-Bertrand C; et al. (1999). “Hysteroscopic treatment of severe Asherman’s syndrome and subsequent fertility”. Hum Reprod. 14 (5): 1230–1233. doi:10.1093/humrep/14.5.1230. PMID 10325268.
  6. ↑ Deaton JL, Maier D, Andreoli J. (1989). “Spontaneous uterine rupture during pregnancy after treatment of Asherman’s syndrome”. Am J Obstet Gynecol. 160 ((5Pt1)): 1053–1054. PMID 2729381.
  7. ↑ Siegler AM, Valle RF. (1988). “Therapeutic hysteroscopic procedures”. Fertil Steril. 50 (5): 685–701. PMID 3053254.


Template:WikiDoc Sources

Diagnosis

Diagnosis

History and Symptoms | Physical Examination | Laboratory Findings | Ultrasound | Other imaging findings | Other diagnostic studies

Treatment

Treatment

Medical therapy | Surgery | Primary prevention | Secondary prevention | Cost-Effectiveness of Therapy | Future or Investigational Therapies

Case Studies

Case Studies

Case #1

Template:WH Template:WS

Looking for the patient version?

Back to the patient-friendly article

Imprint

Privacy Policy

Terms and Conditions

© 2026 MyEClinic – IFTM Institut für Telematik in der Medizin GmbH