576 Journal of the Royal Society of Medicine Volume 83 September 1990

Asherman's syndrome: a review of the literature, and a husband andwife's 20-year world-wide experience

Kenneth Chapman FRCOG FRACOG Roxana Chapman FRCOG FRACOG144 Harley Street, London WiN 1AH

Keywords: Asherman's syndrome; traumatic uterine synechiae; traumatic intrauterine adhesions; amenorrhoea; infertility

SummaryAsherman's syndrome is reviewed, and 27 casestreated by us in Iran, England, New Zealandand Australia over a 20-year period are analysed.Aetiological factors and treatment are discussed. Inview of the high incidence of complications insubsequent pregnancies, the need for prevention isstressed. Although more common in some countries,it is, nevertheless, of world-wide distribution and,unless looked for, will be missed.

IntroductionAsherman's syndrome, which has been well docu-mented by Israeli and French Gynaecologists, andlatterly by the Americans, is almost entirely un-reported by British and Antipodean sources. In 1957,the 17th Congress of the Federation of French-speaking Societies of Gynaecology and Obstetricsproposed the following classification of uterinesynechiae:

(1) Traumatic synechiae connected with surgical orobstetrical evacuation of the uterus.

(2) Spontaneous synechiae of tuberculous origin.(3) Synechiae occurring after myomectomy.(4) Synechiae secondary to the attack of chemical or

physical agents and, likewise, those resulting fromatrophic changes.

Most gynaecologists will have had patients who fitinto group 4. The others are less common. This paperis concerned only with the first group which is linkedwith the name of Asherman. Originally implyingtraumatic adhesions resulting from puerperal or post-abortal curettage, it has now been expanded to includeadhesions resulting from vaginal termination ofpregnancy and, in the absence of a suitable group orsub-group, we have also included four cases ofsynechiae following cone biopsy of the cervix.

ReviewFritsch in 18941 was the first to describe traumaticobliteration of the uterine cavity following puerperalcurettage. Thereafter, although several continentaland Scandinavian Gynaecologists published reports,it remained for Asherman of Israel, in several articles,to disseminate this knowledge more widely. Herecognized two distinctive types oftraumatic synechiae,although the aetiology is the same. In the first,stenosis or obliteration of the cervical canal in thevicinity of the internal os occurs2. In the second, theuterine cavity itself is partially or completelyobliterated by conglutination of the opposing walls3.Synechiae, following cone biopsy ofthe cervix, are ofdifferent aetiology4.

Most authorities believe that, ifthe decidua basalisis severely damaged, it may be replaced by granulationtissue. Should this happen, the opposing uterine wallswill adhere to form scar tissue which, later, may beinfiltrated by myometrial cells and covered byendometrium5. A somewhat similar explanation mayaccount for cervical synechiae, although Ashermanhimself believed that tetanic uterine contractionscaused circular muscle fibres around the internal osto contract around any abrasion in that region2.A further complication oftrauma is the concomitant

development of adenomyosis6. Ovulation occursnormally2'3. The endometrium either remains in-active3, or passes through the normal phases ofproliferation and secretion, but is not usually shed7.When it is, haematometra results8 and we have alsowitnessed retrograde menstruation at the time oflaparoscopy.The most common complaint is infertility5. Amenor-

rhoea is usually present29 but it is now clear thatAsherman's syndrome is also compatible with normalmenstruation'0. Dysmenorrhoea sometimes occursand may be caused by adenomyosis6 or by the devel-opment of haematometra7'8. Should pregnancy occur,there is a high incidence of recurrent abortion,premature rupture of the membranes, abnormal fetalpresentation, placenta accreta and placenta praevia5.The cervical lesion can usually be suspected if a

sound cannot be passed through the cervix into theuterine cavity. The sound can also be used to locateintrauterine adhesions.Hysterography, until recently, was always used to

confirm the presence of corporeal adhesions". Itis not totally reliable and, for this reason, it ispreferable that an oil-soluble contrast medium beinjected, for this will not only be less likely than awater-soluble medium to yield a false-positive result,but it may also enhance subsequent fertilityl213.Hysterography is very limited in its ability todiagnose the cervical lesion. Hysteroscopy wouldappear to be the ideal method for confirming thepresence of corporeal synechiae'4.In the vast majority of cases, the upper cervical

lesion can be cured by the passage of a probe andsubsequent dilatation ofthe cervix. Adhesions of theuterine body are much more difficult to treat. Vaginal,abdominal and vagino-abdominal operations have allbeen employed. Hysteroscopic lysis of the adhesionspromises to be the method of choice in the future'5-'8.Unfortunately, treatment is not always complete andrecurrences are frequent. Even after division ofadhesions through the hysteroscope, most operatorsstill advise the insertion of an intrauterine contra-ceptive device or Foley's catheter to keep the wallsapart while endometrial regeneration takes place.

0141-0768/90/090576-05/$02.00/0©1990The RoyalSociety ofMedicine

Journal of the Royal Society of Medicine Volume 83 September 1990 577

The value of oestrogens, progestogens and corti-costeroids, as adjuncts to treatment, is in dispute, butmost gynaecologists favour the use of sequentialoestrogen-progestogen therapy.

Case analysisWe have analysed 27 cases treated by us during thelast 20 years in four different countries. These wehave divided into three groups, namely corporealadhesions, and those associated with adhesions in thevicinity of the internal os which we have calledisthmic adhesions, to distinguish them from thosefollowing cone biopsy of the cervix which we havenamed cervical adhesions. Their distribution in ourseries was as follows:

* In Iran (1967-1971) we treated three patients withcorporeal and one with isthmic (upper cervical)adhesions.* In England (1971-1975) we treated one patientwith corporeal and one with"cervical synechiae.* In New Zealand (1975-1978) we treated two caseswith corporeal adhesions, four with isthmic and twowith cervical synechiae.* In Australia (1978-1987) we treated six withcorporeal, six with isthmic and one with cervicaladhesions.

The six patients whom we treated in Iran andEngland have already been reported elsewhere4. Ofthe total patients, 12 had corporeal adhesions, 11 hadisthmic stenosis and, in four cases, cervical stenosishad followed cone biopsy of the cervix.Asherman's syndrome has no respect ofrace. Ofthe

27 cases, which we have reported, 10 were Australian,five were New Zealanders, four were Iranian, twowere English and there was one German, one Maltese,one Pakistani, one Indian, one Philippino and oneCook Islander. The age range was from 18 to 43 years,except for a post-menopausal patient who had had acone biopsy ofthe cervix and was 74 years old. Siteenofthem were 30 years old or less. Parity ranged from0 to 10, but seven ofthem were primiparous and therewas one nulliparous patient who had-had a cervicalcone biopsy. The duration of their presentingsymptom, which, in 20 cases, was amenorrhoea,varied between 6 weeks and 13 years. Ten of themhad had symptoms for-more than 3 years.Eight patients developed adhesions following post-

abortal curettage, seven following curettage forsecondary postpartum haemorrhage, one following asecond curettage after expulsion of a hydatidiformmole, seven following termination of pregnancy andfour following cone biopsy of the cervix.Jensen and Stromme in 197219 noted that curettage

during the second, third and fourth week postpartumled to a higher incidence of intrauterine adhesions.Of our 16 cases who had had puerperal or post abortalcurettage or curettage following evacuation of ahydatidiform mole, 6 fell into that category. Theoverall scatter varied from a few hours to 8 weeks.Of the 12 patients with corporeal adhesions,

curettage at the time of definitive treatment failedto yield curettings in five. Of the others, two hadsecretory endometrium, two proliferative, there wasone resting phase, one with necrotic tissue suggestiveof an old abortion, and one with adenocercinoma.Ofthe 11 patients with isthmic synechiae, five had

secretory endometrium, four proliferative, in one no

curettings were obtained, and in one curettage wasnot performed because haematometra was discovered.Haematometra was also present in three ofthe othercases in which curettage was performed. Ofthese, twowere found to have secretory endometrium and oneproliferative. In other words, in four of the 11 casesof isthmic synechiae, haematometra was present. Itis noteworthy that, of the 11 patients with isthmicstenosis, six ofthem were attributable to terminationofpregnancy, ofwhich all but one had been performedby suction curettage.Haematometra was present in two of the four

patients who had developed cervical synechiaefollowing cone biopsy of the cervix. It was absent inone and the fourth patient was post-menopausal.Treatment of the first two patients with corporeal

adhesions, whom we saw in Iran, was by dilatationof the cervix and attempted division of adhesionswith the curette, followed by sequential oestrogen-progestogen therapy. Menstruation returned tempor-arily, but ceased soon after treatment was dis-continued. The third patient was treated by acombined vagino-abdominal operation, followed bythe insertion of a Lippes loop. Normal menstruationwas re-established.The patient whom we saw in England had normal

resumption ofmenses following separation ofadhesionsby the vaginal route and the insertion of a Saf-T-coil.Of the two patients with corporeal adhesions seen

by us in New Zealand, one had only a temporaryreturn of menstruation following attempted vaginalseparation of adhesions and the insertion of a Lippesloop, but the second one became pregnant after ourtreatment and gave birth to a premature infant whosurvived.We treated six patients in Australia with corporeal

adhesions. In five cases, we attempted to separate theadhesions by the vaginal route, either with the curetteor, latterly, with laparoscopy scissors, which weinsrted through the cervix (Figures 1 and 2). In mostofthese cases, we subsequently inserted a Lippes loop

Figure 1. Hysterosalpingogram (HSG) of patient withwidespread corporeal synechiae

578 Journal of the Royal Society of Medicine Volume 83 September 1990

Figure 2. HSG of same patient as Figure 1 after vaginaldivision of adhesions

and/or used sequential oestrogen-progestogen therapy.In all cases, menstruation was re-established. Onesubsequently requested sterilization and was treatedby hysterectomy (Figures 3 and 4). Three of the sixpatients became pregnant. One had two subsequentabortions (Figures 1 and 2). One, who had sufferedin the past from recurrent abortion, had a furtherabortion. The third patient had two prematuredeliveries. The first resulted in a neonatal death andthe second infant survived. She was pregnant againwhen we left Australia. The sixth patient was foundto have an endometrial adenocarcinoma; she wastreated with radiotherapy followed by pelvic clearance.We should have liked to have used the hysteroscopein the treatment ofthese patients but the instrumentwas not available. Since returning to the UnitedKingdom, we have had access to this instrument andcan report a successful pregnancy following treatmentthrough the hysteroscope of a patient with synechiaeproduced by previous myomectomy and also apregnancy achieved by means of in vitro fertilizationin a patient who had had tuberculou endometritis(and salpingitis) and had developed corporealadhesions.The 11 patients with isthmic synechiae were all.

treated by dilatation ofthe cervix (Figure 5). Normalmenstruation followed in every case and threepregnancies are known to have resulted. One imaginesthat further pregnancies occurred, but.these patientstended to be lost sight of once their symptoms hadbeen cured.In three of the four patients who developed- cer-vical

synechiae, following cone biopsy of the 6cervix, thesmallest probe could not be passed (Figure 6). Furtherconization might have relieved the mechanicalblockage, but other considerations led us to carry outhysterectomy. The fourth patient was cured of herhaematometra by dilatation of the cervix.

DiscussionThe foregoing analysis of our cases makes it clearthat, whereas isthmic (upper cervical) synechiae arecomparatively easily cured, corporeal adhesions arenot only difficult to treat, but are likely to recur.

Figure 3. HSG ofpatient with a solitary, thick intrauterineadhesion

-Fure J etomy specimen ofsame patient as Figure 3indicatingthat attempted vaginal division ofthe adhesion hadbeen unsuccessfuL The synechia was found histologically toconiitofparalel orientited bands offibro-leiomyomatous tissuecontinuous with the leiomyomatous fibres ofthe uterine corpusand covered with endometrial tissue on its exposed surfaces

Fertility, too, even in the apparently adequatelytreated case, is still likely to be impaired20.Jewelewicz et al. writing from Columbia University,

New York, in 197621, diagnosed 36 patients as havingAsherman's syndrome. Treatment was followed by a50% conception rate, but only 17% had uncomplicatedfull-term deliveries. Lancet and Mass, in 198116,described their regimen with the hysteroscope supple-mented by insertion of Lippes loop and cyclicalhormone therapy. Of 56 patients treated, 53 were

Journal of the Royal Society of Medicine Volume 83 September 1990 579

Figure 5. HSG of patient with isthmic (upper cervical)synechiae. Minor abnormality only was noted but corporealadhesions were excluded (Undoubtedly, manipulativeprocedures prior to or at the time ofinjection ofradio-opaquedye damage the synechiae and make it valueless as adiagnostic procedure)

Figure 6. Radiograph ofhysterectomy specimen ofpatient whohad had a cone biopsy. Radio-opaque dye has been injectedinto the uterine cavity to outline the cervical canal which couldnot be located with the finest probe

subsequently found to have a regular uterine cavityand they claimed that the obstetric performance wasimproved from 31.9%, with the old blind method ofseparation of adhesions, to 64.9%, by using thehysteroscope. Valle and Sciarra of NorthwesternUniversity Medical School, in 198822, reported theevaluation and treatment by hysteroscopy of 187patients over a 10-year period. Of these patients,76.4% subsequently achieved pregnancy and 79.9%

of them went to term. They -showed that thereproductive outcome correlated with thickness oftheadhesions and the extent of the uterine cavityocclusion, ranging from a term pregnancy rate of81.3% in patients with mild disease, to 31.9% inpatients with severe disease.In our previous paper, we suggested that Asherman's

syndrome is more prevalent in Iran than Britain,because gynaecologists there use a sharp curette forpuerperal and post-abortal evacuations23, whereas inBritain a blunt curette was normally used. Asecondary factor, possibly, is the higher incidence ofpuerperal infection24.Traumatic uterine synechiae, in our experience, are

also more common in New Zealand and Australia thanin Britain. Intrauterine infection might have been acontributing factor in three ofthe 13 Australian cases.Almost certainly, however, the sharp curette, whichappears to be commonly employed in both countries, ismore likely to be primarily incriminated. One mustalso note that the suction curette is capable ofcausingsynechiae, usually, however, in the region of theinternal os. It goes without saying that, in vieBw oftheseriousness of the sequelae, the best management isprevention, and all hospital dilatation and curettagesets should include two or three blunt curettes ofdifferent sizes.The suggestion that a pack be inserted through the

cervix after puerperal and post-abortal curettage, ora catheter after cone biopsy of the cervix, and left insitu for 24 hours to discourage the formation ofsynechiae, does not commend itself to us. Such aprocedure would increase the risk of adhesionformation from trauma2 and infection24.Needless to say, all patients must be followed up

and, ifamenorrhoea persists, a sound should be passedthrough the cervix. Such a simple measure might beexpected to break down all but corporeal adhesions.

ConclusionAsherman's syndrome is of world-wide distributionand, with the liberalization of abortion, is likely to-become more common25. Prevention is of paramountimportance, but, unless it is recognized by gynaecolo-gists as a not uncommon clinical entity, it willcontinue to be missed.

References1 Fritsch H. A case ofcomplete atrophy ofthe uterine cavity

after curettage. Zentralbl GynkJol 1894;18:1337-92 Asherman JG. Amenorrhoea traumatica (atretica). J

Obstet Gynaecol Br Emp 1948;55:23-303 Asherman JG. Traumatic intra-uterine adhepions. J

Obstet Gynaecol Br Emp 1950;57:892-64 Karimi R, Chapman K. Traumatic uterine synechiae. IrJ Med Sci 1974;143:319-24

5 Klein SM, Garcia. Asherman's syndrome: a critique andcurrent review. Fertil Steril 1973;24:722-35

6 Carmichael DE. Asherman's syndrome. Obstet Gynecol1970;36:922-8

7 Netter AP, Musset R, Lambert A, Salomon Y. Traumaticuterine synechiae: a common cause of menstrual in-suffilciency, sterility and abortion. Am JObstet Gynecol1956;71:368-'75

8 Stainer S. Partial and total atresia of the uterus aft;erexcochleation. Acta Obstet Gzynecol Scand 1946;26:263-97

9 Musset R, Salomon Y. Traumatic menstrual insufficiencysecondary to surgical and obstetrical evacuation of theuterus. Rev Fr Gyndcol ObstSt 1953;48:311-53

580 Journal of the Royal Society of Medicine Volume 83 September 1990

10 Asherman JG. Uterine synechiae of traumatic origin.Bull Fed Soc Gynecol Obstet Fr 1957;9supplement:490-6

11 Dellenbach P, Walter JP, Szwarcberg R, Houyet PH,Alaoui T. Hysterographic diagnosis ofuterine synechiae.J Radiol Electrol 1971;52:519-22

12 De Cherney AH, Kort H, Barney JB, De Vore GR.Increased pregnancy rate with oil-soluble hystero-salpingography dye. Fertil Steril 1980;33:407-10

13 Schwabe MG, Shapiro SS, Haning RV. Hysterosalping-ography with oil contrast medium enhances fertility inpatients with infertility of unknown etiology. FertilSteril 1983;40:604-6

14 Levine RV, Neuwirth RS. Simultaneous laparoscopy andhysteroscopy for intrauterine adhesions. Obstet Gynecol1973;42:441-5

15 March CM, Israel R, March AD. Hysteroscopicmanagement of intrauterine adhesions. Am J ObstetGynecol 1978;130:653-7

16 Lancet M, Mass N. Concomitant hysteroscopy andhysterography in Asherman's syndrome. Int J Fertil1981;26:267-72

17 San Filippo JS, Fitzgerald MR, Badawy SZ, NussbaumML, Yussman MA. Asherman's syndrome. A comparisonof therapeutic methods. JReprod Med 1982;27:328-30

18 Valle RF. Therapeutic hysteroscopy in infertility. Int JFertil 1984;29:143-8

19 Jensen PA, Stromme WB. Amenorrhoea secondary topuerperal curettage (Asherman's syndrome). Am JObstet Gynecol 1972;113:150-4

20 Asherman JG. Traumatic intrauterine adhesions andtheir effects on fertility. Int J Fertil 1957;2:49-61

21 Jewelewicz R, Khalaf S, Neuwirth RS, Vande Wiele RL.Obstetric complications after treatment ofintrauterinesynechiae (Asherman's syndrome). Obstet Gynecol1976;47:701-5

22 Valle RF, Sciarra JJ. Intrauterine adhesions: hystero-scopic diagnosis, classification, treatment, and repro-ductive outcome. AmJ Obstet Gynecol 1988;158:1459-67

23 Elgueta H, Pefia G. Nov Congr Chil Obstet Ginecol1961;1:71 cited by Foix A, Bruno RO, Davison T, Lema B.The pathology ofpost curettage intrauterine adhesions.Am J Obstet Gynecol 1966;96:1027-33)

24 Dalsace J. Uterine synechiae. Progr MWd (Paris)1955;83:195-9

25 March CM, Israel R. Intrauterine adhesions secondaryto elective abortion. Hysteroscopic diagnosis andmanagement. Obstet Gynecol 1976;48:422-4

(Accepted 11 April 1990)

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