Asherman's Syndrome and Miscarriage

Asherman's syndrome, characterized by scarring in the uterus, is a condition most often associated with a common surgical procedure called dilation and curettage (D&C). The D&C may be used to remove excess tissue for any number of reasons, including:

• To resolve abnormal uterine bleeding
• To sample an abnormally thick lining as can happen in women with PCOS, endometrial hyperplasia, or endometrial cancer
• To remove tissue not totally expelled after a missed miscarriage, incomplete miscarriage, or delivery
• To terminate a pregnancy or remove tissue not totally expelled after a missed miscarriage, incomplete miscarriage, or delivery

Following a D&C, uterine tissues can sometimes stick together abnormally and form adhesions. Fibrosis, the thickening, and scarring of connective tissue are also involved. Depending on the extent and severity of the scarring, Asherman's syndrome may result in miscarriage, infertility, pain caused by trapped blood, and other obstetric complications.

While a D&C is the predominant cause of Asherman's syndrome, other conditions can lead to uterine scarring, including pelvic radiation and the use of intrauterine devices (IUDs).

Symptoms

Asherman's syndrome often causes no symptoms aside from a difficulty in conceiving or maintaining a pregnancy. The formation of adhesions and fibrosis typically reduces blood flow to the uterus. When this happens, some women may have extremely light periods or have no periods (amenorrhea). If blockages develop, they can often cause pain during ovulation or menstruation.

Diagnosis

The gold standard for diagnosing Asherman's syndrome is a procedure called a hysteroscopy in which a thin, lighted scope is inserted into the vagina to examine the cervix and uterus. Doctors may also order X-rays, transvaginal ultrasound, and biopsy to evaluate the severity and extent of scarring and to help determine the course of treatment.

Risk Factors and Outcomes

The risk of Asherman's syndrome is often associated with the number of D&C procedures a woman undergoes.

Treatments

The surgical removal of adhesions can significantly improve the odds of having a successful pregnancy. With that being said, it can be a technically difficult procedure and needs to be performed with care to prevent the formation of additional scars. Hysteroscopy is typically involved. Laparoscopy (commonly referred to as keyhole surgery) may also be used in more complicated cases.

After the surgery, some doctors will recommend the placement of an intrauterine balloon to keep tissues from sticking together. Oral estrogen may also be prescribed to help induce the regeneration of uterine tissue and promote healing.