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the (71), #asherman (27), syndrome (26), and (22), that (17), for (15), adhesions (15), with (14), have (14), may (13), this (11), not (11), after (11), are (10), uterus (10), uterine (9), more (7), retained (7), intrauterine (7), miscarriage (7), cases (7), following (7), condition (6), women (6), but (6), been (6), case (6), risk (5), likely (5), there (5), other (5), such (5), which (5), only (4), international (4), association (4), who (4), information (4), any (4), those (4), however (4), than (4), periods (4), could (4), cervix (4), scarring (4), placenta (4), surgeons (4), prevent (4), surgery (4), most (4), can (4), also (4), performed (4), has (4), occur (4), under (3), ashermans (3), here (3), their (3), you (3), medical (3), result (3), pelvic (3), ultrasound (3), lower (3), either (3), although (3), lining (3), pain (3), all (3), recurrent (3), hysteroscopy (3), severe (3), healing (3), walls (3), treatment (3), would (3), one (3), iua (3), evacuation (3), missed (3), 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asherman s syndrome employer matching gift program it s no longer a question of what if but with knowledge it s answering what now welcome to our website welcome to our site if you are looking for information and support for asherman s syndrome intrauterine adhesions scarring or related problems you ve found the right place what is asherman s syndrome asherman s syndrome or intrauterine adhesions scarring or synechiae is an acquired uterine condition characterized by the formation of adhesions scar tissue inside the uterus and or the cervix in many cases the front and back walls of the uterus stick to one another in other cases adhesions only occur in a small portion of the uterus 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 they are usually not vascular which is an important attribute that helps in treatment click here for more on asherman s syndrome grades symptoms most patients with asherman s syndrome have scanty or absent periods amenorrhea but some have normal periods some patients have no periods but feel pain at the time that their period would normally arrive each month this pain may indicate that menstruation is occurring but the blood cannot exit the uterus because the cervix is blocked by adhesions recurrent miscarriage and infertility could also be symptoms 1 causes asherman s syndrome occurs when trauma to the endometrial lining triggers the normal wound healing process which causes the damaged areas to fuse together most commonly intrauterine adhesions occur after a dilation and curettage d c that was performed because of a missed or incomplete miscarriage retained placenta with or without hemorrhage after a delivery or elective abortion pregnancy related d cs have been shown to account for 90 of asherman s syndrome cases 2 sometimes adhesions also occur following other pelvic surgeries such as cesarean section surgery to remove fibroids or polyps or in the developing world as a result of infections such as genital tuberculosis 3 and schistosomiasis 4 there is a 25 risk of developing asherman s syndrome from a d c that is performed 2 to 4 weeks after delivery 5 8 dilation and curettages may also lead to asherman s syndrome in 30 9 of procedures for missed miscarriages 17 and 6 4 of procedures for incomplete miscarriages 2 the risk of asherman s syndrome increases with the number of d cs performed after a single termination the risk is 16 however after 3 or more d cs the risk increases to 32 9 each case of asherman s syndrome is different and the cause must be determined on a case by case basis in some cases asherman s syndrome may have been caused by an overly aggressive d c however this is not often considered to be the case the placenta may have attached very deeply in the endometrium or fibrotic activity of retained products of conception could have occurred both of which make it difficult to remove retained tissue there is a variant of asherman s syndrome called unstuck asherman s or endometrial sclerosis that is more difficult to treat in this condition which may coexist with the presence of adhesions the uterine walls are not stuck together instead the endometrium has been denuded although curettage can cause this condition it is more likely after uterine surgery such as myomectomy in these cases the endometrium or at least its basal layer has been removed or destroyed incidence asherman s syndrome is thought to be under diagnosed because it is usually undetectable by routine diagnostic procedures such as an ultrasound scan the condition is estimated to affect 1 5 of women undergoing a hysterosalpingogram hsg 10 between 5 and 39 of women with recurrent miscarriage 11 13 and up to 40 of patients who have undergone d c for retained products of conception following childbirth or incomplete abortion 14 see causes above diagnosis direct visualization of the uterus via hysteroscopy is the most reliable method for diagnosis other methods are sonohysterography shg and hysterosalpingogram hsg prevention ideally prevention is the best solution it was suggested as early as in 1993 9 that the incidence of intrauterine adhesions iua might be lower following medical evacuation eg misprostol of the uterus thus avoiding any intrauterine instrumentation so far one study supports this proposal showing that women who were treated for missed miscarriage with misoprostol did not develop iua while 7 7 of those undergoing d c did 15 the advantage of misoprostol is that is can be used for evacuation not only following miscarriage but also for retained placenta or hemorrhaging following birth alternatively d c could be performed under ultrasound guidance rather than blindly this would ensure that the surgeon stops scraping the lining when all retained tissue has been removed thereby avoiding injury early monitoring during pregnancy to identify miscarriage can prevent the development of or as the case may be the reoccurrence of asherman s syndrome as adhesions are more likely to occur after a d c the longer the period after fetal death 2 therefore immediate evacuation following fetal death may prevent iua there is no evidence to suggest that suction d c is less likely to result in adhesions than sharp d c cases of asherman s syndrome have been reported even following manual vacuum aspiration 16 and the rate of asherman s syndrome has not dropped since the introduction of suction d c treatment asherman s syndrome must be treated by a very experienced surgeon via hysteroscopy sometimes assisted by l aparoscopy those few surgeons experienced enough in treating severe asherman s syndrome recommend the avoidance of energy sources inside the uterus this means removing scars with scissors rather than with energy generating instruments such as resectoscopes or lasers although not all surgeons agree with this adhesions have a tendency to reform especially in more severe cases there are different methods to prevent re scarring after surgery for asherman s syndrome many surgeons prescribe estrogen supplementation to stimulate uterine healing and place a splint or balloon to prevent apposition of the walls during the immediate post operative healing phase other surgeons recommend weekly in office hysteroscopy after the main surgery to cut away any newly formed adhesions as of yet studies have not confirmed the method of treatment that is most likely to have a successful outcome which would be one where the uterus cervix remains scar free and fertility is restored non reproductive consequences of asherman s syndrome the reproductive consequences of asherman s syndrome including infertility recurrent miscarriage intrauterine growth restriction placenta accreta and others are well known however for all women with intrauterine scarring and amenorrhea including those who may have completed childbearing there are other concerns although the lack of menstrual periods could be secondary to hormonal abnormalities it is more likely caused by either complete destruction of the uterine lining or by obstruction of the cervix or lower portion of the uterus thus menses are either retained in the uterus leading to pelvic pain and a condition called hematometra or flow into the abdominal cavity leading to endometriosis women with asherman s syndrome may develop uterine cancer either before or after menopause this risk is not increased and may be lower than in the general population however the usual warning sign of uterine cancer is excessive uterine bleeding those with obstructed menstrual flow cannot have that symptom even if they harbor a uterine growth therefore pelvic ultrasound should be a routine part of their annual gynecologic visit references references may be found here international asherman s association is a 501 c 3 non profit corporation fein 27 4442769 material herein is provided for informational purposes only it is general information that may not apply to you as an individual and is not a substitute for your own doctor s medical care or advice no warranties are given in relation to the medical information provided and that no liability will accrue to the international asherman s association or any of its board members in the event that a user is damaged in any way as a result of reliance upon the information international ashermans association follow ashermansorg the silent syndrome this book is dedicated to telling stories of women who were given no hope by their doctors but ended up with babies click here to order your copy of the silent syndrome 14 99 hrvatski en español work in progress en français versione italiana german română português do brasil conditions of third party use contents from this website may be reprinted only under the condition that the content is credited to international ashermans association and a url link i e http www ashermans org is included