Asherman Syndrome and Fertility: Intrauterine Adhesions, Hysteroscopy, and Pregnancy Planning

Asherman syndrome refers to symptomatic intrauterine adhesions—scar tissue inside the uterine cavity associated with menstrual changes, pain, infertility, or pregnancy loss. Hysteroscopy is the reference standard for diagnosis and allows treatment under direct vision. Blind dilation and curettage is not the preferred way to treat adhesions.

What intrauterine adhesions are

Intrauterine adhesions (IUAs) are bands of scar tissue that partially or extensively join surfaces inside the uterine cavity. “Asherman syndrome” is generally used when adhesions are accompanied by symptoms such as reduced or absent menstrual flow, cyclic pain, infertility, or recurrent loss.

A common history is uterine instrumentation after pregnancy, miscarriage, retained placenta, or postpartum bleeding, but adhesions can also occur after other uterine procedures or infection.

Clues that justify a cavity evaluation

A dramatic reduction in menstrual flow after a uterine procedure is a classic clue. Other patients have infertility or repeated pregnancy loss without obvious menstrual change. Ultrasound, HSG, or saline sonography may suggest adhesions, but none provides the same direct cavity view as hysteroscopy.

If an HSG report mentions filling defects, an irregular cavity, or incomplete filling, ask whether hysteroscopy or saline sonography is appropriate before assuming the finding is definitive.

Why hysteroscopy is central

AAGL/ESGE guidelines describe hysteroscopy as the criterion standard for diagnosis. When treatment is indicated, hysteroscopic adhesiolysis allows scar tissue to be divided under direct vision. This matters because blind procedures can miss adhesions and can injure remaining healthy endometrium.

Severe or dense adhesions are technically different from a small filmy band. Extensive disease is best managed by a clinician with specific hysteroscopic experience.

Preventing recurrence after treatment

Adhesions can reform. Postoperative strategies may include a temporary intrauterine barrier or catheter, hyaluronic-acid gel, and hormonal treatment in selected cases. Evidence is stronger for reducing adhesion reformation than for proving that every adjunct improves live birth.

Many specialists perform a second-look cavity assessment after treatment, especially when adhesions were moderate or severe. Ask what your clinic uses to confirm that the cavity is open before trying to conceive or transferring an embryo.

Pregnancy after Asherman treatment

Pregnancy is possible after successful treatment, but reproductive outlook depends heavily on adhesion severity, the amount of functional endometrium, age, and other fertility factors. A history of significant IUAs can also matter later in pregnancy because abnormal placentation may be more likely in some patients.

The practical goal is not merely to make a hysteroscopy look normal. It is to restore a functional cavity and then plan conception with realistic counseling about recurrence and obstetric follow-up.

Severity is about more than the word “adhesions”

Intrauterine adhesions range from a few filmy bands to dense scarring that partially or almost completely obliterates the cavity. The reproductive impact depends on how much normal endometrium remains, where the adhesions are located, whether the tubal ostia are accessible, and whether the cavity can be restored without repeated injury.

Clue	Why it deserves attention
Periods became much lighter or stopped after uterine surgery	Raises concern that scarring has reduced the functional cavity or outflow.
Cyclic pain with little bleeding	Can suggest trapped menstrual flow or outflow obstruction.
Repeated thin endometrium	Adhesions are one possible structural cause, especially with a risk history.
Repeated implantation failure or pregnancy loss	Not specific for adhesions, but can lower the threshold for cavity reassessment.

Risk history matters

Common antecedents include dilation and curettage after pregnancy, postpartum procedures, retained products of conception, hysteroscopic myomectomy or other uterine surgery, and less commonly infection such as genital tuberculosis in regions where it occurs. The same procedure does not create adhesions in everyone, so symptoms and imaging still matter.

What each test can and cannot do

HSG can show filling defects, an irregular cavity or poor filling, but it does not directly visualize scar tissue. Saline infusion sonography can outline the cavity and detect bridging bands. Three-dimensional ultrasound may provide additional structural information. Hysteroscopy is the reference standard because it lets the clinician see the cavity directly and treat adhesions at the same session.

Practical point: if the history strongly suggests adhesions, a reassuring routine pelvic ultrasound does not necessarily settle the question. A normal outer uterine shape does not prove the cavity is normal.

Why repeat procedures sometimes happen

Moderate and severe adhesions can recur after adhesiolysis. For that reason, management often includes a plan to keep cavity surfaces separated while healing and to encourage endometrial recovery. Strategies vary by clinician and severity and can include temporary balloons or other barriers, postoperative estrogen, and scheduled second-look hysteroscopy. Evidence for individual adjuncts is not equally strong, so ask what the proposed step is intended to accomplish.

Fertility prognosis after treatment

Pregnancy is possible after successful treatment, especially when the cavity is restored and healthy endometrium remains. Prognosis is less predictable with dense, extensive disease because scarring may recur and basal endometrium can be damaged. That is why a simple statement such as “the adhesions were removed” is not enough; the post-treatment cavity and lining response matter.

Before surgery

Ask how severe the adhesions appear.
Clarify whether both tubal ostia can be seen.
Ask whether ultrasound suggests remaining functional endometrium.
Discuss fertility timing before repeated procedures.

After surgery

Know the recurrence-prevention plan.
Ask when the cavity will be reassessed.
Track menstrual flow changes.
Clarify when trying or embryo transfer can resume.

Pregnancy care may need extra attention

A history of significant intrauterine adhesions and adhesiolysis can be associated with abnormal placentation and other obstetric complications in some patients. Once pregnant, tell the obstetric team about the diagnosis and prior hysteroscopic procedures so they can decide whether additional placental surveillance is appropriate.

Evidence reality check: hysteroscopy is the central diagnostic and therapeutic tool for intrauterine adhesions. Prevention of recurrence is a major part of treatment because the cavity can scar again, particularly after moderate or severe disease.

Frequently asked questions

What causes Asherman syndrome?

It often follows uterine injury, particularly procedures related to pregnancy, but the exact history varies.

Can an HSG diagnose Asherman syndrome?

It can suggest adhesions, but hysteroscopy is the reference standard because it directly visualizes the cavity.

Can adhesions come back after surgery?

Yes. Recurrence is possible, especially with severe disease, which is why postoperative prevention and reassessment may be discussed.

Sources and evidence checked

Medical disclaimer: This article is for general educational purposes and is not medical advice, diagnosis, or a treatment recommendation. Fertility evaluation and treatment should be individualized with a qualified reproductive endocrinologist, reproductive urologist, gynecologic surgeon, or other appropriate clinician.