Asherman's Syndrome and Fertility

Asherman's Syndrome Silently Blocks Conception

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Susan Kunin had no reason to suspect she was infertile. She'd become pregnant the first time she and her husband attempted conception, and had no other conditions or symptoms of anything amiss. Sadly, that first pregnancy miscarried and a D&C (dilatation and curretage, a common procedure in which the cervix is entered and the uterine lining is scraped) was performed. Susan didn't realize that this relatively simple procedure resulted in a severe case of Asherman's Syndrome, a cause of female infertility.

Dr. Alan Copperman, Director of the Division of Reproductive Endocrinology at the Mount Sinai Medical Center in New York and physician with Reproductive Medicine Associates of New York, is an expert in the diagnosis and treatment of Asherman's Syndrome, a condition in which the walls of the uterus adhere together to an extent where the uterine cavity itself is diminished. It is defined by uterine inflammation, adhesions, and scarring.

While the actual occurrence rate is hard to determine, Copperman says, "Any time there's a surgical procedure performed inside the uterus, there's a chance for scarring to occur." It typically results from common surgeries such as D&C following miscarriage or birth, as well as intrauterine procedures for fibroid removal, to correct structural abnormalities of the uterus, or cesarean section. Additionally, inflammation and infection from any foreign object within the uterus, such as an IUD (intrauterine device for contraception), may result in Asherman's.

The varying severity of scarring can have different levels of impact on a woman's ability to conceive and then successfully carry a pregnancy. Copperman describes, "With mild scarring, the walls of the uterus will stick to each other and the result is literally less room for menstruation and pregnancy to occur. In the case of severe scarring, all of the normal endometrium (lining of the uterus) has been removed, leaving no normal tissue in which an embryo can implant."

Women with Asherman's generally experience no uncomfortable symptoms, and in fact, may have very light or even no menstrual periods. Often, they first learn about this possible cause of infertility after speaking with a reproductive specialist.

Susan began to worry when she still had not begun menstruating several months following her miscarriage and related D&C. Eventually she was diagnosed with Asherman's and told to consider surrogacy as an option for parenthood.

"I was completely devastated," she remembers. "I cried non-stop. I was also extremely angry. I had no fertility issues a few months before, and now I was completely infertile."

Fortunately, before she had fully pursued surrogacy to have a child, Susan learned about an educational website called simply "Asherman's Syndrome" (http://www.ashermans.org) through which she joined a related support group. It was through this group that she met Dr. Copperman. While he concurred that, indeed, Susan's case was severe -- her diagnostic hysterosalpingogram (HSG) should virtually no uterine cavity because of the extent of scar tissue -- he disagreed that she needed to make arrangements for surrogacy.

While HSG is one method of diagnosing Asherman's Syndrome, Copperman states a preference for the use of hysteroscopy and 3-D ultrasound. He explains that these methods allow the physician to see adhered areas that simply aren't visible via HSG. In hysteroscopy, the patient is sedated and a tiny telescopic viewer is inserted through the cervix into the uterus, allowing the physician to have an almost direct view of the uterine interior.

Hysteroscopy is also the preferred manner for treating Asherman's, through which the physician carefully removes any scar tissue within the uterus. In some cases, a balloon catheter is placed in the uterine cavity for one to two weeks following hysteroscopy, and estrogen supplement and infection-preventing antibiotics are administered during that period of time.

The goal of treatment is not merely to remove scar tissue, but to help the uterus re-build it's endometrial lining. Inadequate endometrial lining, for any reason, can be a cause of implantation difficulty and resulting infertility.

While most women who seek treatment for Asherman's are likely doing so in order to conceive and have a baby, some women may instead be concerned about the syndrome's possible connection to the development of endometriosis, thought to be caused by retrograde (in effect, backward) menstrual flow.

In Susan's case, treatment by hysteroscopy and balloon catheter was successful -- she became pregnant several months following, and her daughter was born in May 2003. Copperman states that chances of conception after treatment for Asherman's Syndrome are related to the severity of disease. If a woman's uterus has only a few wispy bands of scar tissue, she'll likely do well in attempts to conceive after treatment. Her chances are less if the maximum endometrial thickness achieved is less than six millimeters.

Because of the unpredictable and possibly devastating results from commonly performed uterine surgeries, experts and patient advocates alike emphasize the importance of finding physicians with extensive experience in the diagnosis and, especially, treatment of Asherman's Syndrome.