What is the best approach to manage a patient with Asherman's syndrome?

Management of Asherman's Syndrome

The cornerstone of Asherman's syndrome management is hysteroscopic adhesiolysis to restore uterine cavity anatomy, followed by measures to prevent adhesion reformation, though evidence for optimal postoperative protocols remains limited. 1, 2

Diagnostic Confirmation

• Perform saline sonohysterogram as the most sensitive initial diagnostic tool, though hysteroscopy remains the gold standard for definitive diagnosis and allows simultaneous treatment 1
• Document the extent and severity of intrauterine adhesions at the time of diagnosis, as disease grade directly correlates with pregnancy outcomes and obstetric complications 1, 3

Primary Treatment: Hysteroscopic Surgery

Hysteroscopic-guided lysis of adhesions is the definitive treatment to restore normal uterine cavity anatomy 1, 2

• Use ultrasound guidance during the procedure to ensure complete adhesiolysis and prevent uterine perforation, particularly in severe cases 3
• The goal is complete restoration of the uterine cavity architecture 1

Postoperative Adhesion Prevention

While no consensus exists on the ideal method, a comprehensive approach includes multiple modalities 1, 4:

• Place an intrauterine balloon catheter or mechanical barrier at the end of surgery to prevent opposing uterine walls from re-adhering 3
• Apply barrier gel (such as Hyalobarrier®) intraoperatively to reduce adhesion reformation 3
• Administer high-dose oral estrogen postoperatively to enhance endometrial proliferation and healing (typical regimen continues until balloon removal) 3
• Remove the balloon catheter after 5-7 days 3
• Perform second-look office hysteroscopy 4-8 weeks postoperatively to assess for adhesion recurrence and perform early lysis if needed 3

Important caveat: Despite widespread use of these postoperative measures, high-quality evidence supporting their efficacy is limited, and practices vary significantly among surgeons 4

Emerging Regenerative Therapies

• Consider stem cell therapy or platelet-rich plasma for endometrial regeneration in refractory cases with insufficient endometrial thickness, though data remain limited and these approaches are largely investigational 1, 5
• These modalities show promise for restoring adequate endometrial thickness when conventional approaches fail 5

Fertility Management

• Refer patients desiring pregnancy to reproductive endocrinology specialists with expertise in Asherman's syndrome, as most patients require assisted reproductive technology 3
• In vitro fertilization with embryo transfer may be necessary after adequate endometrial restoration (median thickness ≥7-7.5mm) 3
• Spontaneous conception is possible in milder cases after successful treatment 3

Pregnancy Monitoring and Complications

Pregnancies after Asherman's treatment are inherently high-risk and require intensive antenatal surveillance 2:

• Monitor closely for spontaneous abortion, preterm delivery, and intrauterine growth restriction 2
• Screen vigilantly for abnormal placentation including placenta previa and placenta accreta, which occur at significantly elevated rates 3, 2
• Consider delivery planning at tertiary centers with capability for managing invasive placentation 3
• Be aware of rare but serious risk of uterine rupture 2

Prognosis and Expectations

• Most patients (nearly 100%) can achieve restoration of menstrual function after treatment 1, 3
• However, pregnancy rates remain lower than normal, and obstetric complications are common, particularly in moderate-to-severe disease 1, 2
• Severe Asherman's syndrome continues to have poor reproductive prognosis despite optimal treatment 2
• The key to better outcomes is prevention: minimize unnecessary uterine instrumentation of the gravid uterus 1

Referral Considerations

Refer patients with moderate-to-severe disease to specialized centers with clinical expertise in hysteroscopic surgery and reproductive medicine, as management remains challenging and outcomes are operator-dependent 1, 2