Asherman's Syndrome, Miscarriage and Infertility

   Miscarriage or any form of early pregnancy loss, even when it may have come from personal choice, can leave many women confused and worried when trying to conceive again.  That's because it seems that the more they try, the more trouble they have getting pregnant again…or that another miscarriage follows.

     It is common to have a Dilation and Curettage (D&C) with a miscarriage, especially when the fetal or placental tissue is unable to completely pass on its own.  When this happens, the uterus is unable to completely collapse, leaving the inside open, which in turn prevents the uterine arteries from closing down.  This produces continued bleeding and hemorrhage.  Once the uterus is empty again the bleeding will stop.  The process used for D&C with miscarriage is the exact same process used during elective terminations or induced abortions.  There are many reasons why women miscarry or involuntarily abort their pregnancies, and it is important to look into all of those areas. 

     
    Some women do not have problems getting pregnant, but do have problems holding onto the pregnancy after conception.  They worry it could be damage from the previous  D&C's.   

    Asherman's Syndrome, or intrauterine adhesions/scarring (or synechiae), is an acquired uterine condition, characterized by the formation of adhesions (scar tissue) inside the uterus. In many cases the front and back walls of the uterus stick to one another. In other cases, adhesions only occur in a small portion of the uterus. The extent of the adhesions defines whether the case is mild, moderate, or severe. The adhesions can be thin or thick, encompassing the entire uterine contents or may be just localized to one area.

    Most patients with Asherman's Syndrome have scanty or absent periods (amenorrhea) but some have normal periods. Some patients have no periods but feel pain at the time that their period would normally arrive each month. This pain may indicate that menstruation is occurring, but the blood cannot exit the uterus because the cervix is blocked by adhesions. Recurrent miscarriage and infertility could also be symptoms.  If periods are normal and not painful, then it is unlikely that uterine scarring or Asherman's Syndrome is present.

     There is a 25% risk of developing Asherman's Syndrome from a D&C that is performed 2 to 4 weeks after delivery.  Dilation and Curettages may also lead to Asherman's Syndrome in 30.9% of procedures for missed miscarriages and 6.4% of procedures for incomplete miscarriages. The risk of Asherman's Syndrome increases with the number of D&Cs performed.  After a single termination, the risk is 16%, however, after 3 or more D&Cs, the risk increases to 32%.

    In order to know for sure if someone has this, ultrasound is not useful.  We have to use direct visualization of the uterus with Hysteroscopy - the best method for diagnosis.  There are other methods like sonohysterography (SHG) and hysterosalpingogram (HSG).

     The creation of scarring is why we try to avoid a D&C if possible. It was suggested as early as 1993 that the incidence of intrauterine adhesions (IUA) might be lower following medical evacuation using cytotec (or misprostol), thus avoiding any intrauterine instrumentation. So far, one study supports this proposal, showing that women who were treated for missed miscarriage with misoprostol did not develop IUA, while 7.7% of those undergoing D&C did. The advantage of misoprostol is that it can be used for evacuation following miscarriage, but also for retained placenta or hemorrhaging following regular term birth.

     Asherman's Syndrome must be treated hysteroscopically with the patient under anesthesia, in order to look inside and remove the intrauterine adhesions. These adhesions have a tendency to reform, especially in more severe cases, so continued monitoring is recommended.  There are some real reproductive consequences of Asherman’s Syndrome, including infertility, recurrent miscarriage, intrauterine growth restriction, placenta accreta and others.

     The most important thing to remember is to pay attention to your cycles and the amount of flow.  This is one of the best ways to know your female organs are functioning normally.