Management of Asherman's syndrome

Intrauterine adhesions (IUA) or Asherman's syndrome is a multifaceted condition which is being diagnosed with increasing frequency. Although it usually occurs following curettage of the pregnant or recently pregnant uterus, any uterine surgery can lead to IUA. Most women with IUA have amenorrhoea or hypomenorrhoea, but some have normal menses. Those who have amenorrhoea may also have cyclic pelvic pain secondary to 'trapped' menses and the accompanying retrograde menstruation may lead to endometriosis. In addition to menstrual disorders, most women with IUA will present with infertility or recurrent spontaneous abortion. Over the last four decades hysteroscopy has become the standard method to diagnose and treat this condition. Various techniques for adhesiolysis and for prevention of scar reformation have been advocated. The most efficacious appears to be the use of miniature scissors for adhesiolysis and the placement of a balloon stent inside the uterus immediately after surgery. Post-operative oestrogen therapy is prescribed in order to stimulate endometrial regrowth. Follow-up studies to assure resolution of the IUA are mandatory before the patient attempts to conceive as is careful monitoring of pregnancies for cervical incompetence, placenta accreta and intrauterine growth restriction.