Is platelet-rich plasma (PRP) injection effective after hysteroscopy and adhesiolysis in the management of Asherman's syndrome?

PRP Injection After Hysteroscopy and Adhesiolysis in Asherman's Syndrome

Based on the highest quality randomized controlled trial evidence, PRP injection after hysteroscopic adhesiolysis does NOT improve endometrial thickness, menstrual patterns, adhesion recurrence rates, or pregnancy outcomes in Asherman's syndrome patients compared to standard treatment alone. 1, 2

Evidence from Clinical Trials

The two available RCTs directly addressing this question show consistently negative results:

• No improvement in endometrial thickness: In a 2021 RCT of 30 patients with moderate-severe Asherman's syndrome, intrauterine PRP infusion (0.5-1 mL) administered immediately after hysteroscopic adhesiolysis showed no statistically significant difference in endometrial thickness change compared to saline control (PRP: 1.4 mm increase vs control: 1.0 mm increase, p=0.78) 1

• No improvement in pregnancy rates: The same study found no difference in predicted likelihood of pregnancy between PRP (0.53) and control groups (0.67, p=0.45) 1

• No reduction in adhesion recurrence: A 2020 non-randomized clinical trial of 30 women found that PRP injection could not change the menstrual pattern or prevent development of post-surgical adhesions as evaluated by follow-up hysteroscopy at 8-10 weeks 2

• No change in intrauterine adhesion stage: The intrauterine adhesion stage (per American Society for Reproductive Medicine scoring) was similar in both PRP and control groups before and after treatment (p=0.2) 2

Theoretical Mechanism vs Clinical Reality

While PRP theoretically delivers concentrated growth factors that promote angiogenesis, cell migration, proliferation, and collagen deposition through platelet α-granules 3, 4, this biological mechanism has not translated into clinical benefit for Asherman's syndrome patients in human trials.

Important caveat: Animal studies show promising results - mouse models with Asherman's syndrome treated with human PRP demonstrated restored fertility, reduced fibrosis markers, and enhanced angiogenesis 5. However, these preclinical findings have not been replicated in human clinical trials.

What Actually Works for Asherman's Syndrome

The evidence supports that hysteroscopic adhesiolysis alone significantly improves reproductive outcomes:

• Term delivery rates improve from 18.3% pre-operatively to 68.6% post-operatively with hysteroscopic adhesiolysis 6
• Success rates reach 64% in women with two previous unsuccessful pregnancies and 75% in those with three or more 6
• The key determinant of success is preventing adhesion reformation, not adding adjunctive therapies 7

Critical Factors Affecting Outcomes

Menstrual pattern restoration is the most important prognostic indicator:

• Women who remain amenorrheic after adhesiolysis have only 18.2% conception rates 7
• Women who resume menses have 50% conception rates 7

Adhesion recurrence is the primary obstacle:

• Women with normal cavity at second-look hysteroscopy: 59.1% conception rate 7
• Women with adhesion reformation: only 11.8% conception rate 7

Standardization Problems with PRP

The field suffers from critical methodological issues that undermine PRP efficacy 8, 3:

• Lack of standardization in preparation methods, platelet concentration, activation protocols, and dosing
• Variations in centrifugation protocols (g-force, duration) significantly affect platelet yields, purity, and viability
• Clinical trials conducted without clear quantification of PRP biological properties
• These factors likely contribute to the negative clinical results despite theoretical promise

Clinical Recommendation

Do not routinely use PRP injection after hysteroscopic adhesiolysis for Asherman's syndrome. Focus instead on:

1. Optimal hysteroscopic technique to minimize trauma during adhesiolysis 6, 7
2. Prevention of adhesion reformation through appropriate post-operative management 7
3. Second-look hysteroscopy at 8-12 weeks to detect and treat recurrent adhesions early 2, 7
4. Estrogen therapy as standard post-operative management 1

While PRP is well-tolerated with no reported adverse effects 1, 2, the lack of demonstrated clinical benefit does not justify its routine use in this population.