What is the treatment for Asherman's syndrome?

Treatment of Asherman's Syndrome

Hysteroscopic adhesiolysis is the definitive treatment for Asherman's syndrome, and should be performed repeatedly until both tubal ostia are visualized, regardless of the number of procedures required. 1, 2

Surgical Management

Primary Treatment Approach

• Hysteroscopic adhesiolysis is the gold standard treatment for Asherman's syndrome, as it allows both diagnosis and therapeutic intervention under direct visualization 3, 4
• Surgery should be performed using hysteroscopic scissors or power instruments, working systematically from the central uterine cavity toward the periphery 4
• The goal is complete restoration of the uterine cavity with visualization of at least one (preferably both) tubal ostia 1, 2

Multiple Procedures Strategy

• Do not limit treatment to one or two procedures—continue operative hysteroscopy until adequate cavity restoration is achieved 2
• In severe cases, patients may require 3-5 separate surgical procedures to achieve optimal anatomic results 1, 2
• More than 80% of patients can achieve either complete resolution or only mild residual adhesions after multiple procedures 2
• **Younger patients (<35 years) should be treated more aggressively**, as they have significantly better pregnancy outcomes (62.5% vs 16.6% in those >35 years) 1

Surgical Adjuncts

• Peroperative ultrasonography should be used during outpatient procedures to prevent complications like uterine perforation 4
• Hysteroscopy with fluoroscopy can be employed in particularly difficult cases with severe obliteration 4
• MRI may be necessary preoperatively when the uterine cavity is totally obliterated to guide surgical planning 4

Post-Surgical Prevention of Re-Adhesion

Mechanical Barriers

• Intrauterine devices (IUDs) or balloon catheters should be placed after adhesiolysis to prevent reformation of adhesions 4
• These devices serve as physical barriers during the critical healing period when re-adhesion risk is highest 4

Hormonal Support

While not explicitly detailed in the highest-quality evidence for Asherman's syndrome specifically, estrogen therapy is commonly used post-operatively to promote endometrial regeneration, though the evidence base requires further investigation 3

Expected Outcomes

Anatomic Success

• Functional uterine cavity restoration can be achieved in 100% of severe cases with persistent surgical treatment 1
• All previously amenorrheic patients should experience resumption of menses after successful treatment 1

Fertility Outcomes

• Overall pregnancy rates after treatment range from 40-43% in severe cases 1, 2
• Live birth rates are approximately 27-32% after treatment of severe disease 1
• Mean time to pregnancy is approximately 10.5 months after final procedure 2
• Most pregnancies occur spontaneously without assisted reproductive technology 2

Critical Obstetric Considerations

High-Risk Pregnancy Monitoring

Pregnancies after Asherman's treatment are inherently high-risk and require intensive antenatal surveillance due to the following complications 1, 3:

• Placenta accreta occurs with significant frequency—requiring preparation for potential Cesarean hysterectomy 1
• Placenta previa risk is elevated 3
• Increased rates of spontaneous abortion (both first and second trimester) 1
• Preterm delivery and intrauterine growth restriction 3
• Rare but catastrophic risk of uterine rupture 3

Delivery Planning

• Multidisciplinary delivery planning with maternal-fetal medicine and availability of blood products is essential 1
• Surgical expertise for managing placental abnormalities (including potential hysterectomy or hypogastric artery ligation) must be immediately available 1

Prognostic Factors

Age is the most significant prognostic factor—patients ≤35 years have nearly 4-fold higher conception rates compared to those >35 years 1

Rare Spontaneous Resolution

While Asherman's syndrome has been documented to resolve spontaneously in extremely rare cases, this should never be relied upon for management, as the pregnancy outcomes in such cases are generally poor and the syndrome typically requires active intervention 5