ASHERMAN’S SYNDROME AND ADHESIONS

What is Asherman syndrome and what are uterine adhesions?

Uterine adhesions, also known as intrauterine adhesions, are abnormal bands of tissue that form within the uterine cavity and may partially or completely fuse its walls. They usually occur as a result of damage to the basal layer of the endometrium, leading to irregular healing and the formation of internal scar tissue that alters the uterine anatomy. This condition can affect menstruation, embryo implantation and the normal progression of pregnancy.

We refer to Asherman syndrome when these intrauterine adhesions are associated with clinical symptoms such as reduced or absent menstruation, infertility, recurrent miscarriage or obstetric complications. Although both terms are often used interchangeably, it is important to distinguish that uterine adhesions describe the anatomical lesion, whereas Asherman syndrome refers to the clinical condition that may result from it.

What are the symptoms of Asherman syndrome?

Symptoms vary depending on the location and extent of the adhesions, but the most common include:

• reduced menstrual bleeding (hypomenorrhea);

• absence of menstruation (amenorrhea);

• infertility;

• recurrent miscarriage;

• cyclical pelvic pain in some cases;

• pregnancy complications.

From a reproductive perspective, adhesions may hinder sperm transport, alter the architecture of the uterine cavity and compromise endometrial receptivity. In more severe cases, fibrosis may affect uterine vascularisation, reducing the endometrium’s ability to regenerate properly and support implantation.

What are the causes of Asherman syndrome?

The most common cause is endometrial damage following procedures performed inside the uterus. The main associated factors include:

• uterine curettage, especially if repeated or performed after miscarriage, childbirth or retained tissue;

• hysteroscopic surgery, such as myomectomy, polypectomy or septum resection;

• procedures that damage the basal layer of the endometrium;

• less frequently, uterine infections or endometritis.

In women wishing to conceive, any treatment that may affect the uterine cavity or endometrial perfusion should be carefully evaluated, as it may worsen reproductive prognosis.

How is Asherman syndrome diagnosed?

Hysteroscopy remains the gold standard for diagnosing Asherman syndrome, as it allows direct visualisation of the uterine cavity, assessment of the location and severity of adhesions, evaluation of the endometrium and, in many cases, planning or performing treatment.

Transvaginal ultrasound also plays an important role in suspicion and follow-up. It may suggest abnormalities in the uterine cavity, areas of fibrosis, endometrial irregularities or findings compatible with adhesions. In specialised centres, advanced transvaginal ultrasound (3D ultrasound) can provide valuable information before hysteroscopy and after treatment.

In some cases, additional tests may be used to study the uterine cavity, although diagnosis is usually confirmed by hysteroscopy. Assessing severity is important as it influences both prognosis and treatment strategy.

What is the treatment for Asherman syndrome?

The main treatment is hysteroscopy with adhesiolysis, performed by a gynaecologist experienced in complex uterine pathology. The aim is to restore the uterine cavity as close to normal as possible, release adhesions and preserve functional endometrium.

In mild cases, correction is usually straightforward. In moderate or severe cases, specialised instruments, careful technique and sometimes more than one procedure may be required to achieve adequate reconstruction. Recurrence remains one of the main challenges, making follow-up essential.

After treatment, measures are often used to reduce adhesion recurrence. Among them, anti-adhesion gels based on hyaluronic acid have shown usefulness in reducing recurrence during follow-up hysteroscopy.

Prognosis and fertility

In many patients, treatment helps restore menstruation and improve fertility. However, prognosis depends on several factors, including age, severity of adhesions, underlying cause, recurrence and the endometrium’s ability to regenerate. The greater the fibrosis or scarring, the more guarded the reproductive prognosis.

Pregnancy with Asherman syndrome

Yes, pregnancy is possible after treatment, either naturally or through assisted reproductive techniques. However, these pregnancies are considered higher risk, especially in patients with a history of extensive adhesions or complex uterine surgery.

Endometrial alterations, uterine cavity changes or placentation issues may persist. Therefore, there is an increased risk of complications such as abnormal placental implantation, placenta accreta, postpartum haemorrhage, miscarriage or preterm birth. For this reason, pregnancy should be closely monitored with individualised care.

New strategies and emerging treatments

In recent years, complementary strategies have been studied to promote endometrial regeneration and reduce adhesion recurrence after hysteroscopic surgery. One of the most promising approaches is platelet-rich plasma (PRP), administered intrauterinely and, in some protocols, subendometrially.

Recent evidence suggests that PRP may improve endometrial repair, reduce recurrence of moderate or severe adhesions and enhance parameters such as endometrial thickness, menstrual recovery and clinical pregnancy rates. However, studies remain heterogeneous and it is not yet considered a standard treatment, nor has it consistently demonstrated improvement in live birth rates. Therefore, its use should be considered complementary and limited to selected cases.

Other biological and regenerative strategies, including cell-based therapies, are also under investigation and remain limited to highly specialised settings.

Frequently asked questions about Asherman syndrome

What happens if I have a scar in the uterus?
It depends on its location, extent and depth. Some scars may be asymptomatic, while others deform the uterine cavity, alter endometrial elasticity, affect vascularisation and impair menstruation or implantation. When scar tissue forms bridges within the uterus, these are called adhesions or synechiae.

How can I know if I have uterine adhesions?
Suspicion usually arises from symptoms such as reduced or absent menstruation, infertility, recurrent miscarriage or a history of curettage or uterine surgery. Initial evaluation includes medical history and transvaginal ultrasound, with confirmation usually by hysteroscopy.

How can I know if I have Asherman syndrome?
Diagnosis is considered when compatible symptoms coexist with a history of uterine procedures or endometrial damage. Ultrasound can guide assessment, but hysteroscopy is the most useful tool to confirm diagnosis, evaluate extent and plan treatment.

What is the difference between uterine adhesions and synechiae?
In clinical practice, both terms are used to describe the same anatomical lesion: abnormal bands within the uterine cavity. The term Asherman syndrome is reserved for cases where these adhesions are associated with symptoms or reproductive impact.

Comprehensive treatment at Instituto Bernabeu

The management of Asherman syndrome requires experience, appropriate technology and individualised follow-up. In moderate or severe cases, more than one hysteroscopy may be necessary to restore the uterine cavity and reduce recurrence risk.

At Instituto Bernabeu, we have high-precision hysteroscopy equipment and gynaecologists specialised in intrauterine adhesions, complex uterine pathology and reproductive medicine. Our goal is to achieve the best possible anatomical and functional recovery of the uterine cavity, optimising both gynaecological and reproductive outcomes for each patient.