Intrauterine adhesions and Asherman syndrome — structured SAQ (15 marks)

(a) Diagnosis, pathophysiology and confirmatory investigation (3 marks)

One mark per point, maximum three.^[4]

• Diagnosis: intrauterine adhesions / Asherman syndrome — hypomenorrhoea with subfertility after sharp curettage, with a normal endocrine screen and a negative pregnancy test.^[4]
• Pathophysiology: sharp curettage damaged the basal layer (basalis) of the endometrium; healing proceeded by dysregulated inflammation, impaired angiogenesis and excessive fibrotic repair. Because the functionalis regenerates from the basalis each cycle, basal destruction prevents cyclical regeneration and leaves collagen-rich adhesions.^[4]
• Confirmatory investigation: hysteroscopy — the diagnostic gold standard, which visualises the adhesions directly, stages severity (e.g. Nasr score), and allows concurrent adhesiolysis.^[4]

(b) Procedure-specific risks and recurrence rate (3 marks)

One mark per figure with the source.^[3]

• Procedure-specific new-onset IUA (Munro 2025): about 17% after evacuation for early pregnancy loss, about 16% after hysteroscopic myomectomy, and about 28% after hysteroscopic metroplasty for septum.^[3]
• Recurrence after adhesiolysis without adjuvants: about 35% (95% CI 24–46%) — the rationale for mandatory postoperative prevention.^[3]
• Causal demonstration: the Hooker PAPA follow-up showed auto-crosslinked hyaluronic acid gel after recurrent D&C reduced IUA to 13% from 31% (relative risk 0.43), confirming the index procedure is the modifiable driver.^[8]

(c) Surgical treatment and prevention strategies with evidence (6 marks)

One mark per point, maximum six. Marks are lost for "adhesiolysis" without a prevention plan.^[3]

• Definitive treatment: hysteroscopic adhesiolysis (transcervical resection of adhesions, TCRA) — divide adhesions under direct vision to restore a single cavity; staged where severe.^[4]
• Prevention of recurrence is mandatory: because adhesions reform in about a third without adjuvants, every adhesiolysis carries a prevention plan and a second-look.^[3]
• Hyaluronic acid gel: reduces IUA incidence (risk ratio 0.53, 95% CI 0.42–0.67) and may improve pregnancy rates (RR 1.24) — Luo 2024 meta-analysis of 16 RCTs.^[5]
• Estrogen — standard, not high-dose: high-dose oral oestradiol (10 mg) added no benefit over standard dose (4 mg) for adhesion scores or conception (Liu 2019); benefit concentrates in moderate-to-severe disease.^[7]
• Estrogen-releasing intrauterine device: outperformed oral estrogen plus Foley balloon — 93.3% versus 58.6% adhesion reduction at 60 days (Feng 2024 RCT).^[6]
• Second-look hysteroscopy: to detect and divide reformed adhesions early; a strategy, not a substitute for primary prevention. Physical barriers (balloon, IUD) alone do not abolish recurrence (about 43% in pooled data).^[3]

(d) Reproductive prognosis and obstetric surveillance (3 marks)

One mark per point, maximum three.^[8]

• Reproductive prognosis: treatment restores anatomy but does not fully restore performance — women with identified and treated adhesions after recurrent D&C achieved fewer ongoing pregnancies and live births, with a prolonged time to live birth, compared with women without IUA (Hooker 2021).^[8]
• Obstetric surveillance: even after treatment, an IUA history carries excess preterm birth, placenta accreta spectrum, placenta praevia, peripartum haemorrhage and hysterectomy — plan a consultant-led pregnancy with surveillance.^[3]
• Counsel honestly: most women with mild-to-moderate disease regain normal menses; severe disease is less predictable; and recurrence after adhesiolysis is common unless prevention is applied.^[3]