Asherman’s Syndrome and Infertility

Dr Richa Sharma , Dr Amit Basnotra
Womb health status and its assessment is one of the key factors while planning pregnancy as it not only serves as a passage for the transfer of sperm from the vagina and cervix, into the fallopian tube, but also has the very important function of growing the embryo to fetus to term. The importance of assessing the uterine cavity cannot be underestimated in an infertile patient. To lose a pregnancy after assisted reproduction due to a preventable or correctable uterine factor is indeed a tragedy!
Womb can be affected in approximately 5 percent of cases of Infertility
What Role Womb Has ?
Womb or uterus is a hollow pear shared organ located in lower abdomen and it has the endometrial layer which sheds every month but also is the fertile implantation site to nurture the embryo to a full term baby. So it needs to have good health and strength to carry the pregnancy to term but unfortuantely in some cases there can be various issues which can hamper the functioning so creating difficulty in carrying pregnancy so adding to one of the factors for subfertility and infertility
Uterine pathology (fibroids, congenital anomalies, polyps, etc.) are more often associated with miscarriages than with infertility so its more of the sub fertility than Infertility
What could be the hindrances in Pregnancy ?
There can be various factors which can be – Non Genetic and Genetic
Non Genetic factors can be anatomical or functional-
Anatomical can be the space occupying lesions and obstructions with severity varying as per the status
* Intrauterine adhesions
* Fibroids
* Endometrial polyps
* Adenomyosis
* Genital tuberculosis
* Luteal phase defect
* Thin-non receptive endometrium
* Defects at the Receptor level
Genetic Factors- which include Congenital uterine defects
Adhesions(Asherman’s Syndrome)-
Asherman’s syndrome or Intrauterine adhesions (IUA) in which the scar tissue makes the walls of womb,cervix etc stick together and reduces the size of the womb.
Adhesions in the womb can happen secondary to some events happened locally and are responsible for infertility, somewhat like can happen following endometrial curettage after a spontaneous, incomplete or elective abortion, postpartum hemorrhage and even post infection in the womb.It is the scar tissue in the uterine cavity ultimately which affects implantation, as well as increases the risk of miscarriage. Asherman’s syndrome is defined by the National Fertility Association, as the presence of scar tissue within the endometrial cavity.
To summarize the causes of adhesions can be –
* Scar tissue from uterine surgery like dilation and curettage (D&C)- cause of more than 90% cases
* Scar tissue after a Cesarean section or from sutures used to stop hemorrhages
* Endometriosis
* Infections of the reproductive organs
* Radiation treatment
Types of intrauterine adhesions –
* Mild-thin, filmy; consisting mostly of endometrial tissue
* Moderate-thick fibromuscular, covered by endometrial tissue
* Severe-dense connective tissue
Further it can be –
* Less than 1/4th of uterine cavity involved
* 1/4th to 3/4th of uterine cavity involved
* More than 3/4th of uterine cavity involved
Asherman’s syndrome is a rare disease especially the severe form and many times it may go undiagosed.Some studies say it can happen in nearly 20% of women who have had dilation and curettage (D&C) after pregnancy complications.
How will the patient know ?
Patient may be symptomatic with even normal menstrual periods but various symptoms which they can elicit are-
* Hypomenorrhoea- Scanty menstrual periods
* Secondary Amenorrhoea- Absence of menstrual periods
* Dysmenorrhoea- Painful menstrual periods
* Recurrent Pregnancy losses
* Repeated ART failures like IUI,IVF
* Irregular menstrual periods with fluctuations in the flow pattern over a period of time
How will the doctor know ?
Patient will be diagnosed with this conditional after knowing clinical details along with examination supported with certain varied set of investigations starting from basics and sometimes it can be an Incidental finding also
For example-
* Woman with significant intrauterine adhesions may complain of oligomenorrhea or amenorrhea
* Prior surgery on the uterus
* History of tuberculosis/exposure to the infection
* Previous H/o peritonitis, appendicectomy with slow healing, pleurisy, prolonged illness in childhood, family H/o tuberculosis and childhood contact
What can be done ?
Management depends on the severity and extent of the damage and can be treatable one to a permanent damage.Its better that treating physician should give clear transparent picture to the couple in first go itself with cafeteria approach with their informed consent and understanding
Success Rates post treatment-
Intrauterine pregnancies rates range from 22 to 45% and live births range from 28 to 32% after treatment of intrauterine adhesions.
What Complications can happen ?
The risk of complications for those that achieve pregnancy is significant with an increased risk for placenta accreta and subsequent blood loss, transfusion, and hysterectomy
Last resort – is surrogacy and adoption which further governed by the law of land and ICMR guidelines for India and specific ones for the particular nations
Womb or Uterus is one of the important components rather the way to final destination so cannot be taken lightly or kept as last in queue.Proper information from authenticated source definitely helps couples to take a more lucid and firm decision.
(The authors are Senior IVF Consultant Delhi NCR and Senior Gastroentrologist)