Asherman Syndrome: Intrauterine Adhesions and Fertility

There isn't a specific size used as a strict benchmark — even small fibroids can require removal if they are causing a cornual blockage, and submucous fibroids or polyps will usually require removal regardless of size. But anything bigger than roughly the equivalent of a 12–14 week pregnant uterus is a very large fibroid that definitely requires removal. On medical management: GnRH antagonists such as elagolix are used to help shrink fibroids, as are GnRH analogues/injections like leuprolide, which reduce the size of the uterus. However, submucous fibroids — the main culprits behind infertility — often will not respond well to medical management.

We need a good, plush endometrial lining, and if it isn't good we have medicines that can improve it. For example, in a recent case of severe intrauterine adhesions from a missed abortion managed elsewhere, the endometrial thickness was under 1mm in places and completely scarred. We did adhesiolysis and then gave a combination of estrogen and progesterone — estrogen helps regenerate the endometrium. It takes about 3 months for regeneration, though outcomes depend on how bad the scarring is; in some patients with very severe scarring we may not be able to regenerate a good lining at all.

We generally say at least 3 to 4 months of contraception should be used, and conception should not happen within that window.

There are now government of India guidelines on this. Strictly by those guidelines it is 50 for the woman and 55 for the man, though this used to be more liberal — we used to see people at 60–65 also getting IVF done, before the ethical question of who will care for the children led to the cutoff being tightened.

After adhesiolysis we give a combination of estrogen throughout the cycle and progesterone added in the last 14 days, and it takes about 3 months for regeneration, confirmed with transvaginal sonography for endometrial thickness before and after. Many patients start to show improvement even after about a month and a half, where the scarring and adhesions are not so severe that they have permanently damaged the endometrium.

Asherman syndrome typically follows excessive curettage, such as after a dilation and curettage for an abortion or miscarriage, or infective conditions like tuberculosis, which destroy the normal endometrium and cause the uterine walls to stick together.

Patients typically present with very light or absent menstrual flow, and the condition is confirmed through an HSG or a good 3D ultrasound with Doppler.

Treatment involves hysteroscopic adhesiolysis to separate the adhesions, followed by either a Foley catheter or a combination of estrogen and progesterone to help the endometrium regenerate.

Not always. In severe cases with extensive scarring, full endometrial regeneration may not be achievable, and outcomes vary considerably from patient to patient.