Intrauterine adhesions and Asherman syndrome

A 29-year-old had a sharp curettage for a missed miscarriage six months ago. Her periods, which were always regular, have dwindled to two days of light staining, and she has not conceived since. Her FSH, LH, oestradiol, prolactin and TSH are normal, and she is not pregnant. The diagnosis is in the history — the instrumentation that damaged the basalis — and the question that follows is how to confirm it, restore the cavity, and stop the adhesions coming back. Asherman rewards the candidate who prevents first, resects precisely, and prevents again.[3][5]

Overview and definition

Intrauterine adhesions are fibrous bands within the uterine cavity, formed when trauma to the basal layer of the endometrium heals by scarring rather than regeneration. Asherman syndrome is the clinical syndrome that results — menstrual disturbance (hypomenorrhoea or amenorrhoea) and/or impaired fertility, including recurrent pregnancy loss, in a woman with intrauterine adhesions and a history of uterine instrumentation. Not every woman with adhesions has the syndrome; some are asymptomatic and are found on investigation.[1][4]

Three ideas anchor the topic. First, IUA is overwhelmingly iatrogenic — the dominant cause is trauma to the basalis, most often from curettage. Second, the basalis is the key structure: the functional endometrium regenerates from it each cycle, so its destruction breaks cyclical regeneration and leaves collagen-rich, poorly vascularised adhesions. Third, prevention outperforms treatment — the procedures that cause adhesions are the ones we can make safer, and the adhesiolysis we perform to treat them is itself adhesiogenic unless we add prevention.[3][4]

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