ASHERMAN’S SYNDROME AND INFERTILITY (Part 1)

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Asherman’s Syndrome simply refers to the presence of scar tissue in the uterus (womb) or cervix (the opening of the uterus). It can also be called Intra uterine adhesions/scarring, Intrauterine Synechiae, Uterine Synechiae (Synechiae means adhesions).

Asherman’s Syndrome is an acquired uterine condition that happens when scar tissues form inside the womband or the cervix. This scar tissue or adhesions formed are in most cases due to some form of trauma. This scar tissue makes the uterine wall stick together and also reduces the size of the uterus.

Stages of Asherman’s Syndrome

The extent/degree of the adhesions determines if the case is mild, moderate, or severe. The scar tissues can either be thin or thick, spotty in location, or confluent. They are usually not vascular, which is an important attribute that helps in its diagnosis and treatment.

Stage 1 – the scarring involves a mild scar in either the cervical canal or uterine cavity. The scar may or may not involve the very low end of uterine cavity which might result in significant impact in the function of the endometrium. However, if the low end of the uterine cavity is not involved, there would be a little impact on normal function of the uterus.

Stage 2 – the scarring involves a moderate scar at the very low end of uterine cavity. There will be no production of menstrual blood and no pain, meanwhile some women may experience little cramps with no bleeding at all

Stage 3 – in this case, more than half of the uterus is blocked by scar tissue, also one of the fallopian tubes may also be obstructed. It is much more difficult to achieve clinical pregnancy in this stage.

Stage 4 – the scarring occupies more than half of the uterus and causes a reduction in the size of the uterus. It is almost impossible to achieve clinical pregnancy in this stage and treatment might include multiple corrective surgeries. This is usually referred to as Unstuck Ashermans and is usually caused by endometrial changes (sclerosis) more than D and C.

Causes

Asherman’s Syndrome is relatively common in women who have had several Dilatation and Curettage (D&C) procedures either as elective abortion or because of a missed or incomplete miscarriage, retained placenta which could be accompanied with or without bleeding after a delivery. Most often develops after uterine surgeries with scar tissues formed after some pelvic surgeries such as: Caesarean Section, Myomectomy (Surgery for Uterine Fibroid Removal) and Polyps Surgery (Removal of abnormal tissue growth on a mucous membrane).

A severe pelvic infection (infection of the reproductive organs) or inflammation unrelated to surgery such asgenital tuberculosis (tuberculosis affecting fallopian tubes) and Schistosomiasis (an infection caused by parasitic worms e.g. Tape worm) may also lead to Asherman’s syndrome.

It may be caused by after effect of radiation treatment(any form of treatment done via radiation e.g. treatment of cancer by chemotherapy)

Symptoms

Most women with Asherman syndrome suffer Hypomenorrhea (very light periods), or Amenorrhea (Having no periods at all.)Some women have pain at the time that their period should be due, but don’t have any bleeding. This could indicate that they are menstruating, but that the blood is unable to leave the uterus/womb because the exit is blocked by scar tissue.Severe cramping or pain, unable to achieve/ sustain pregnancy and have live birth of healthy babies are some of the symptoms of severe Asherman’s.

Sparse, irregular, or absent menses, may be due to other condition, such as: Obesity, over exercising,sudden weight loss, stress, contraceptive pill use, polycystic ovary syndrome (PCOS), menopause, pregnancy.

If your periods stop or become very infrequent, you need to see your doctor. They can use diagnostic tests to identify the cause and begin treatment as appropriate.

Asherman’s Syndrome and Infertility

Asherman’s Syndrome may lead to primary or secondary infertility depending on the degree and causes in any individual. Relationship between Asherman Syndrome and infertility includes but not limited to the under listed:

The scar tissue formed makes the walls of the uterus stick together and causes reduction in the size of the uterus which may affect the ability to achieve clinical pregnancy.

It causes menstrual disturbances such as very light or totally absent periods.

Inability to stay pregnant i.e. recurrent miscarriages.

Growth restrictions within the uterus i.e. intrauterine restrictions of growth of babies.

Uterine cancer could also be a rare complication which could be seen in non-menopausal and menopausal women thereby preventing the ability to get pregnant.

Placenta accreta i.e. the placenta grows too deeply into the wall of the uterus which could cause heavy bleeding after delivery resulting into serious complications.

Asherman’s Syndrome and Pregnancy

A major concern for women with Asherman’s syndrome is whether or not they will be able to sustain a pregnancy to full term. This likelihood of a full-term pregnancy depends on diverse factors such as the class of the scarring, skill and expertise of the surgeon, the amount of healthy endometrium (inner lining of the womb) left after surgery. For example a thin or patchy endometrium, which mostly occurs as a result of an aggressive or poorly conducted Dilation and Curettage (D & C) procedure, may result in inability to achieve pregnancy……..to be continued