Asherman’s Syndrome (AS), often referred to as intrauterine adhesions, involves scar tissue inside the uterus. This condition is typically acquired following a trauma to the uterine lining, such as a dilation and curettage (D&C) procedure performed after a miscarriage or delivery. The scar tissue, or synechiae, causes the walls of the uterus to stick together, which can partially or completely block the uterine cavity. While AS presents a significant barrier to conception, pregnancy is generally possible. However, achieving a successful pregnancy usually requires specialized medical intervention to remove the scar tissue and restore the uterine environment.
Understanding Asherman’s Syndrome and Fertility
The physical presence of scar tissue directly impairs fertility by distorting the uterine cavity’s normal shape and size. This anatomical change makes it difficult for a fertilized embryo to find a suitable space for successful implantation. The scar tissue also reduces the amount of healthy, functional endometrial tissue, which is the specialized lining required to nourish a developing pregnancy.
The degree to which fertility is affected depends on the severity of the adhesions, which are typically classified as mild, moderate, or severe. In mild cases, the adhesions may be thin and sparse, offering a better prognosis for natural conception. Severe cases, where the uterine walls are extensively or completely fused, often result in a complete obstruction, making conception nearly impossible without intervention.
Even if conception occurs with existing adhesions, the compromised uterine environment significantly raises the risk of pregnancy loss. The scar tissue can limit the blood flow to the developing embryo, increasing the likelihood of early miscarriage. The damaged endometrial lining can also prevent the placenta from developing correctly, leading to recurrent pregnancy loss. Women with AS may also experience very light or absent menstrual periods, which is a sign of reduced functional endometrial tissue.
Treatment for Asherman’s Syndrome
The primary intervention is a minimally invasive surgical procedure called hysteroscopic adhesiolysis, which is performed using a hysteroscope. This thin, lighted instrument is inserted through the vagina and cervix, allowing the surgeon to visualize and meticulously cut away the scar tissue.
The goal of this surgery is to restore the uterine cavity to its normal anatomical shape. The procedure is typically performed under anesthesia and usually takes about 30 minutes. After the adhesions are removed, post-operative care prevents the raw surgical surfaces inside the uterus from sticking back together.
To keep the uterine walls separated and encourage healing, a temporary physical barrier, such as a balloon catheter or an intrauterine device (IUD), is often placed inside the cavity for a few weeks. This separation technique is combined with high-dose estrogen therapy, sometimes followed by progesterone, to stimulate the regrowth of the endometrial lining. This hormonal regimen helps regenerate the tissue necessary for future embryo implantation.
In cases of moderate to severe adhesions, multiple surgical procedures may be required to fully restore the uterine environment. Follow-up diagnostic hysteroscopy or specialized imaging is often performed to confirm the uterine cavity is fully open and the endometrial lining has adequately regrown before a woman attempts to conceive. The success of the treatment is often correlated with the return of a normal menstrual flow and a healthy postoperative endometrial thickness.
Navigating Pregnancy After Successful Treatment
Once the uterine cavity has been successfully restored, the likelihood of conception significantly improves, though success rates vary based on the initial severity of the condition. Overall pregnancy rates following hysteroscopic adhesiolysis are reported to be around 50.7%, with live birth rates in the range of 32% to 41%. Women who had milder adhesions generally have higher conception rates, as do those younger than 35.
However, a pregnancy after AS treatment is typically managed as high-risk due to the underlying damage to the uterine lining. Even with successful surgical removal of the scar tissue, the basal layer of the endometrium, which is responsible for regeneration, may have been permanently affected. This previous trauma increases the risk for specific placental complications during the subsequent pregnancy.
The most concerning risks involve abnormal placentation, including Placenta Previa and Placenta Accreta. Placenta Previa occurs when the placenta partially or completely covers the cervix, while Placenta Accreta involves the placenta implanting too deeply into the uterine wall. The incidence of Placenta Accreta after AS treatment is estimated to be around 10%. These conditions can lead to severe hemorrhage during delivery, often requiring a specialized delivery plan and close monitoring by a Maternal-Fetal Medicine specialist. The risk of preterm labor and recurrent miscarriage also remains elevated, necessitating careful management.