Asherman Syndrome: Diagnosis and Hysteroscopic Adhesiolysis for Gynaecologists

Intrauterine adhesions, often called Asherman syndrome when they cause symptoms, are an important and frequently missed cause of infertility, menstrual problems and recurrent pregnancy loss. Hysteroscopy is both the gold standard for diagnosis and the main treatment.

What causes intrauterine adhesions?

Adhesions form when the basal layer of the endometrium is damaged and opposing uterine walls heal together. Common causes include:

• Curettage of the pregnant or recently pregnant uterus, for example after miscarriage, retained products or postpartum haemorrhage. This is the most common cause
• Repeated uterine procedures
• Uterine surgery such as myomectomy entering the cavity, or caesarean section
• Infection, including genital tuberculosis, which is an important cause in India

Symptoms

• Scanty periods (hypomenorrhoea) or absent periods (amenorrhoea) after a uterine procedure
• Cyclical pelvic pain, which may suggest outflow obstruction
• Infertility
• Recurrent miscarriage
• Abnormal placentation in later pregnancy

Diagnosis

• Transvaginal ultrasound, especially 3D ultrasound, may show a thin or interrupted endometrial line, but it can miss adhesions
• Hysterosalpingography (HSG) may show filling defects
• Hysteroscopy allows direct visualisation and assessment of the extent, density and location of adhesions, and is the gold standard

Adhesions are commonly graded using systems such as the American Fertility Society (AFS) classification or the European Society of Gynaecological Endoscopy (ESGE) classification, which consider extent, type of adhesion and menstrual pattern. Grading helps with counselling and with comparing outcomes.

Hysteroscopic adhesiolysis: principles

The aim is to restore the normal size and shape of the uterine cavity and to preserve as much healthy endometrium as possible.

• Use the least traumatic method. Filmy adhesions can often be divided with the tip of the hysteroscope or with cold scissors. Dense adhesions may need scissors or a bipolar electrode; many surgeons prefer to limit energy use to reduce further endometrial damage
• Work methodically from the centre of the cavity towards the tubal ostia, keeping the anatomy in view
• Consider ultrasound guidance for severe adhesions, to reduce the risk of perforation
• Monitor fluid balance carefully, particularly in longer operative procedures

See our article on hysteroscopy complications and fluid management for safety thresholds.

Preventing adhesions from coming back

Re-formation is common, especially after severe disease. Approaches used include:

• Second-look or early office hysteroscopy to identify and divide new adhesions while they are still filmy
• Barrier methods such as hyaluronic acid gel, or temporary intrauterine devices or balloons
• Estrogen therapy after surgery to support endometrial regrowth

The evidence for many preventive measures is limited, and practice varies. Treatment should be individualised and the uncertainty explained to the patient.

Fertility after treatment

Outcomes depend mainly on the severity of the adhesions and the condition of the remaining endometrium. Mild disease is generally associated with better outcomes than severe disease. Pregnancies after treatment for severe adhesions should be monitored for complications such as placenta accreta spectrum.

Prevention starts earlier

Gentle technique during uterine evacuation, considering medical or vacuum aspiration where appropriate, and avoiding unnecessary repeat curettage all help to reduce the risk of adhesions in the first place.

Frequently asked questions

Which test confirms Asherman syndrome?

Hysteroscopy is the gold standard, because it shows the adhesions directly and allows treatment in the same procedure. Ultrasound and HSG can suggest the diagnosis but may miss adhesions.

Can intrauterine adhesions come back after surgery?

Yes, particularly after severe adhesions. Many surgeons perform an early second-look hysteroscopy to identify and divide new adhesions while they are still thin.

Can genital tuberculosis cause Asherman syndrome?

Yes. Genital tuberculosis can damage the endometrium and cause severe adhesions, and it should be considered in the workup, particularly in India.

Train in diagnostic and operative hysteroscopy

ReproNest's Diagnostic & Operative Hysteroscopy Surgical Training covers instrumentation, distension media, diagnostic hysteroscopy and operative techniques. Read about the role of hysteroscopy in infertility, or contact our team.

This article is educational content for healthcare professionals and trainees. It is not medical advice and does not replace clinical judgement, current guidelines or the ART (Regulation) Act 2021 and Rules 2022.