Why would a bilateral fibriectomy (surgical removal of fibrotic tissue) fail in a female patient of reproductive age with conditions like Asherman's syndrome, despite pathology results confirming removal of the targeted tissue?

Why Bilateral Fibriectomy May Fail Despite Confirmed Tissue Removal in Asherman's Syndrome

In Asherman's syndrome, surgical removal of intrauterine adhesions (confirmed by pathology) can fail because the underlying endometrial damage persists, adhesions reform, or the fibrotic cavity remains too narrow to support normal endometrial regeneration and function. 1, 2

Primary Mechanisms of Treatment Failure

Severity of Baseline Disease

• Patients with completely obscured uterine fundus or greatly narrowed, fibrotic cavities have far worse outcomes than those with mild, endometrial-type adhesions, even after successful adhesiolysis 1
• The prognosis of severe Asherman's syndrome remains poor despite advances in hysteroscopic surgery 2
• Moderate to severe disease still poses a significant therapeutic challenge 2

Adhesion Reformation

• Intrauterine adhesions frequently recur after surgical removal, particularly in cases where the basal layer of endometrium has been extensively damaged 2, 3
• The trauma to the gravid uterine cavity that initially caused Asherman's syndrome creates conditions favorable for re-adhesion formation 2
• Prevention of adhesion reformation is as critical as initial removal for successful treatment 3

Inadequate Endometrial Regeneration

• Restoration of normal endometrial function requires more than just physical removal of adhesions - the basal endometrial layer must be capable of regeneration 1, 3
• Dense intrauterine adhesions and fibrotic tissue indicate severe endometrial damage that may not heal adequately even after surgical intervention 1
• The goal is not just cavity restoration but also promotion of the healing process and return of normal endometrial function 3

Clinical Presentation of Failure

Patients may continue to experience:

• Persistent menstrual disturbances (amenorrhea or hypomenorrhea) 2, 3
• Ongoing infertility or secondary infertility 2, 3
• Recurrent pregnancy loss if conception occurs 2

High-Risk Pregnancy Complications Post-Treatment

Even when treatment appears successful and pregnancy is achieved, women remain at elevated risk for serious complications including:

• Spontaneous abortion 2
• Preterm delivery 2
• Intrauterine growth restriction 2
• Placenta accreta or previa 2
• Uterine rupture 2

Close antenatal surveillance and monitoring are mandatory for women who conceive after treatment for Asherman's syndrome 2

Critical Pitfalls to Avoid

Assuming Pathologic Confirmation Equals Clinical Success

• Pathology confirming removal of fibrotic tissue only verifies that tissue was excised, not that the underlying endometrial function has been restored 1, 2
• The extent of baseline cavity obliteration and fibrosis predicts outcome more than the completeness of initial adhesiolysis 1

Inadequate Post-Operative Management

• Failure to implement strategies to prevent adhesion reformation (such as placement of intrauterine devices, estrogen therapy, or repeat hysteroscopy) contributes to treatment failure 3
• The healing process requires active promotion, not just passive observation after surgery 3

Underestimating Disease Severity

• Patients presenting with complete fundal obscuration or severely narrowed cavities should be counseled about poor prognosis from the outset 1
• These cases represent the greatest therapeutic challenge with outcomes substantially worse than mild disease 1