A Challenging Case Report of Severe Asherman's Syndrome: Managing Uterine Perforation During Surgery

Asherman's syndrome (AS), characterized by intrauterine adhesions (IUAs), can significantly distort uterine anatomy and complicate hysteroscopic adhesiolysis. Although hysteroscopic adhesiolysis is the standard treatment, severe adhesions increase the risk of complications such as uterine perforation.

We report a 31-year-old woman with severe AS who developed uterine perforation during hysteroscopic adhesiolysis. During dissection of dense adhesions, a small fundal perforation (0.5 cm × 0.5 cm) was suspected after sudden loss of resistance and bleeding. The procedure was immediately halted, and diagnostic laparoscopy confirmed a full-thickness fundal defect that was repaired laparoscopically. After stabilization, hysteroscopic management was resumed with placement of an amnion graft to promote endometrial regeneration. However, intraoperative bleeding recurred, and reassessment revealed enlargement of the perforation. Repeat laparoscopy confirmed a larger fundal defect, which was repaired with definitive laparoscopic hysterorrhaphy. The patient recovered uneventfully, received postoperative hormonal therapy, and resumed menstruation 1 month after surgery.

This case highlights the risk of uterine perforation during adhesiolysis in severe AS and emphasizes the importance of early recognition and prompt laparoscopic management. Adjunctive guidance techniques and combined hysteroscopic-laparoscopic approaches may improve procedural safety and help preserve uterine integrity.