Asherman's syndrome natural history, complications and prognosis
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Asherman's syndrome typically occurs after a triggering event such as an infection or a procedure, and is a cumulative process which may lead to infertility. Damage to the uterine cavity may also cause pain, congestion and endometriosis.
Usually occurring after vigorous intrauterine procedures such as Dilation and Curettage, Asherman's syndrome manifests as amenorrhea and uterine congestion. Over time, due to the uterine cavity being damaged by adhesions, infertility may occur.
Depending on the degree of severity, Asherman's syndrome may result in infertility, repeated miscarriages, pain from trapped blood, and high risk pregnancies . There is evidence that left untreated, the obstruction of menstrual flow resulting from scarring can lead to endometriosis.
The extent of scar formation is critical. Small scars can usually be treated with success. Extensive obliteration of the uterine cavity or fallopian tube openings (ostia) may require several surgical interventions or even be uncorrectable. In this case surrogacy, IVF or adoption may be advised.
Patients who carry a pregnancy after correction of Asherman's syndrome may have an increased risk of having abnormal placentation including placenta accreta where the placenta invades the uterus more deeply, leading to complications in placental separation after delivery. Premature delivery , second-trimester pregnancy loss, and uterine rupture are other reported complications. They may also develop incompetent cervix where the cervix can no longer support the growing weight of the fetus, the pressure causes the placenta to rupture and the mother goes into premature labour. Cerclage is a surgical stitch which helps support the cervix if needed.
The overall pregnancy rate after adhesiolysis (removal of adhesions) was 60% and the live birth rate was 38.9% according to one study . Success is related to the severity of the adhesions with 93, 78, and 57% pregnancies achieved after treatment of mild, moderate and severe adhesions, respectively and resulting in 81, 66, and 32% live birth rates, respectively .
Age is another factor contributing to fertility outcomes after treatment of Asherman's. For women under 35 years of age treated for severe adhesions, pregnancy rates were 66.6% compared to 23.5% in women older than 35 .
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