Intrauterine adhesions and Asherman syndrome — structured oral station (12 minutes)

Opening prompt — "What is the diagnosis and how do you confirm it?"

Model response — say it in this order:^[1]

• "The likely diagnosis is intrauterine adhesions — Asherman syndrome. The clue is the hypomenorrhoea and subfertility following a sharp curettage, with a normal endocrine screen and a negative pregnancy test. The hormonal axes are intact; the endometrium is not."^[1]
• "The pathophysiology is damage to the basal layer of the endometrium from the sharp curettage, healing by dysregulated inflammation, impaired angiogenesis and fibrosis. The functionalis regenerates from the basalis, so when the basalis is destroyed, cyclical regeneration fails and adhesions form."^[1]
• "I would confirm it with hysteroscopy — the diagnostic gold standard — which visualises the adhesions directly, stages severity, and allows concurrent treatment. I might start with 3D ultrasound or saline infusion sonography as a less-invasive first step."^[1]

Probe 1 — "She is anxious. How common is this, and was it caused by the curettage?"

• "It is a recognised and important complication of uterine instrumentation. In the Munro 2025 systematic review, the risk of new-onset adhesions was about 17% after evacuation for early pregnancy loss, 16% after hysteroscopic myomectomy, and 28% after septum metroplasty."^[2]
• "Yes, the curettage is the cause — and importantly, sharp curettage confers a higher risk than vacuum aspiration, particularly when repeated. That is the mechanistic basis for preferring vacuum aspiration and image guidance when we do these procedures."^[1]

Probe 2 — "You take her to hysteroscopic adhesiolysis. What is the problem you most need to prevent afterwards, and how?"

• "Recurrence. Adhesions reform in about 35% of women after adhesiolysis performed without adjuvants — that figure comes from the Munro 2025 review. So adhesiolysis is never the end of the operation; I need a prevention plan and a second-look."^[2]
• "My prevention options are hyaluronic acid gel, estrogen, and physical barriers. Hyaluronic acid gel reduces adhesion incidence with a risk ratio of about 0.53, per the Luo 2024 meta-analysis. For estrogen, I would use a standard dose, not high-dose — the Liu 2019 cohort found 10 mg added no benefit over 4 mg for adhesion scores or conception."^[3][5]
• "If available, an estrogen-releasing intrauterine device outperformed oral estrogen plus a Foley balloon in the Feng 2024 randomised trial — 93% versus 59% adhesion reduction at 60 days. And I would plan a second-look hysteroscopy to catch and divide any reformed adhesions early."^[4]

Probe 3 — "What if this is severe and keeps recurring despite your best efforts?"

• "For severe or refractory Asherman after repeated adhesiolysis, regenerative therapies are emerging — mesenchymal stromal cells loaded onto collagen scaffolds. The Hou 2025 double-blind randomised trial tested these in refractory thin endometrium and saw a signal of benefit — live birth in about 27% versus 8% — but it was not statistically significant in a small, underpowered sample."^[7]
• "I would frame these as options of last resort on early evidence, not standard care, and I would involve a specialist centre and a multidisciplinary team before offering them."^[7]

Probe 4 — "She asks whether she will be able to have a baby. What do you tell her?"

Rapport and respect are scored domains — counsel out loud and honestly:^[1]

• "I would tell her, plainly and at her eye level, that most women with mild-to-moderate disease regain normal periods and can conceive after treatment — but that treatment restores the anatomy, it does not fully guarantee restored fertility."^[6]
• "The honest evidence is that women with identified and treated adhesions after recurrent curettage achieved fewer ongoing pregnancies and live births, with a longer time to live birth, than women without adhesions. So I will support her actively, but I will not over-promise."^[6]
• "And I will tell her that even after successful treatment, her pregnancies will be watched a little more closely — women with an adhesion history have higher rates of preterm birth, placenta accreta, placenta praevia and peripartum haemorrhage. We will plan consultant-led care for her pregnancies."^[2]

Probe 5 — "How would you prevent this happening to the next patient?"

• "Prevention first. For uterine evacuation I would prefer vacuum aspiration over sharp curettage, and use image guidance. Sharp, repeated or unguided curettage is the modifiable risk factor."^[1]
• "For adhesiogenic hysteroscopic surgery — myomectomy, metroplasty — I would apply an anti-adhesion gel barrier. The Munro 2025 review found gel barriers reduced primary adhesion risk with relative risks of 0.45 after pregnancy-loss evacuation, 0.38 after myomectomy, and 0.29 after septum metroplasty."^[2]
• "And I would counsel any woman undergoing these procedures about the small but real adhesion risk, so she can report menstrual change early."^[1]