Asherman's Syndrome
Tuesday, June 10, 2008
Kenneth F. Trofatter, Jr., MD, PhD
Julia Mangan has left a new comment on your post "Request to My Readers...":
Thank you for all your work on the blog and answering our comments!
I would love for you to address Asherman's Syndrome at some point and the risks of D&C's.
So be it Julia! See my response to the reader below and the comments that follow addressing Asherman's syndrome.
Dr T
At Thu Jun 05, 09:33:00 AM 2008, Anonymous said…
I had a miscarriage at 11-12 weeks of pregnancy in Nov 2008 due to some unknown infection. I had slight spotting in the 5th and 6th week then again in 11th week… the spotting increased to bleeding and 2 days before the miscarriage I had fever, chills and vomiting…and had a very painful miscarriage and the doctor did a D&C.
Now I am trying again for the past 2 months. This month my period has been delayed by 5 days and I had spotting like its a beginning of period….However, I do not have any pregnancy symptom this time expect that my period is delayed…I am worried that the first miscarriage due to infection could have affected my fallopian tube although the doctor said in most cases it won’t…Why do I have spotting? Does it mean that my uterus not strong enough? Could a doctor please reply to my question….
At Sat Jun 07, 08:21:00 AM 2008, Kenneth F. Trofatter, Jr., MD, PhD said…
To anonymous June 5: If you have not had a normal period since the D&C, and are just spotting, I am concerned that you either are not yet ovulating normally, or that you might have developed "Asherman's syndrome." This is scarring of the lining of the uterus that can occur if you have a D&C that is preceded by infection inside the uterus. If you do not have a normal period within the next couple of months, you need to discuss this possibility with your doctor. If you develop Asherman's syndrome, it is very hard to get pregnant unless you get some help. Dr T
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J.G. Asherman described the syndrome that now bears his name in a 1948 publication in what was then known as the Journal of Obstetrics and Gynecology of the British Empire. The condition he termed “amenorrhea traumatica (atretica),” basically, the absence of menstrual bleeding following trauma (specifically, D&C – dilatation and curettage) to the inner lining of the uterus, was further defined in a subsequent paper in the same journal (1950;57:892-96). Earlier descriptions in case studies were discussed in the 1890’s by several physicians, including Heinrich Fritsch in 1894, and the condition can be found occasionally referenced as the Fritsch-Asherman syndrome.
So, what is Asherman’s syndrome; under what conditions does it come about; what problems does it cause; how is it diagnosed; and, what can be done about it? To help understand this condition, let’s first discuss the uterine anatomy. The innermost lining of the uterus is called the endometrium. It contains the tissues (blood vessels and glands) that proliferate in the early stages (estrogen-dependent) of the menstrual cycle and then becomes conditioned (decidualized) following ovulation (progesterone-dependent) to facilitate the implantation of the egg should it become fertilized on its journey down the fallopian tube. If fertilization does not occur (or the embryo does not implant), the upper portion of the endometrium (the functional layer) sheds and regresses with the bleeding that accompanies the menstrual period. Normally, when tissues are damaged and bleed, they tend to adhere to each other in the presence of blood clot and begin to form scar tissue. However, one very important characteristic of the innermost endometrial layer is that this does NOT usually occur – in other words, one key role of the endometrium must be to keep the inside of the uterus from sticking together and closing up!
In Asherman’s syndrome, on the other hand, that’s exactly what happens – the uterine cavity becomes obstructed by scar tissue (intrauterine synechiae) and if this is severe enough, there may not be sufficient endometrium remaining to cycle normally, resulting in very light periods (hypomenorrhea) or even the complete absence of periods (amenorrhea). There are several conditions that are together associated with more than 90% of all cases of Asherman’s syndrome (Schenker, et al., Fertility Sterility 1982;37:593-610): pregnancy, intrauterine infection, and trauma (usually by D&C) to the endometrium. This triad of conditions can lead to an intense inflammatory response and denuding of the endometrium into the deeper (basalis) layer, or into the stromal connective tissue, or the muscle (myometrium) of the uterus itself, which do not have the same regenerative capabilities as the innermost layer of the endometrium, nor the same capacity to prevent activation of pathways that can lead to the formation of scar tissue. Although Asherman’s syndrome probably complicates no more than about 1% of D&C's done electively and in the absence of infection, it has been estimated to occur in about 25% of these procedures that are done one to four weeks following pregnancy (Buttram, et al., In J Fertil 1977;22:98-103) and as many as 30% of missed spontaneous abortions with the length of time between fetal demise and the D&C itself being directly correlated with the risk of adhesion formation (Adoni, et al., Int J Fertil 1982;27:117-18).
Of the three conditions, the presence of infection perhaps contributes the most to the onset of adhesion formation. The result, in the most severe cases, is that the entire uterine cavity may be completely fused together. In the developing world, chronic endometritis from pelvic tuberculosis (Netter, et al., Am J Obstet Gynecol 1956;71:368-75) and schistosomiasis (Krolikowski, et al., Obstet Gynecol 1995;85:898-9) are major causes of intrauterine synechiae. Other uterine procedures, such as removal of fibroids (myomectomies) and even cesarean section have been associated with Asherman’s syndrome, but these are less common causes.
Other than light or absent periods, the primary complications related to Asherman’s syndrome are recurrent miscarriages and infertility. Patients at risk for or suspected of having Asherman’s syndrome, who still have pain occurring at the expected time of menstruation in the absence of significant or any menstrual flow, may have obstruction of the cervix by scar tissue and are then at risk for accumulating menstrual blood and tissues within the uterine cavity (hematometra) and also may develop endometriosis as a secondary consequence of this. In addition to the risk of miscarriage when pregnancy occurs, women with intrauterine adhesions are at risk for later pregnancy complications related to abnormalities of placentation, either small placentas with poor blood supply or a placenta accreta (placentation into the deeper basalis layer and the myometrium). These conditions increase risk for cervical incompetence, poor fetal growth (intrauterine growth restriction), fetal demise, preeclampsia, early delivery, cesarean section, uterine rupture, postpoartum hemorrhage, and peripartum hysterectomy.
In our next post on this subject, we will discuss the diagnosis, treatment, and prevention of Asherman’s syndrome….
54 Comments:
At Wed Jun 11, 08:13:00 PM 2008,
Julia Mangan said…
Thanks for the post! I didn't realize that having an infection and failed pregnancy put one at higher risk after a D&C procedure for Ashermans.
At Tue Jun 17, 08:14:00 AM 2008,
Anonymous said…
I am a healthy 36 year old who very recently (last week) had a suction curettage therapeutic abortion at 13.0 week gestation without complication. I was not informed of the potential Asherman's risk and am very concerned for future fertility. I would not have undergone the procedure had I known the risk (what is the approximate Asherman's risk for me...I am unclear the incidence rate from the data). I had a previous full term C-section birth without complication 2 years ago. I was on a regular 28 day cycle prior to this termination, with no prior fertility issues. Before I attempt to conceive in the future, perhaps I should undergo a hysteroscopy to assess the degree of scarring if there is any? Should I wait to see if my period appears normal before I seek help? I am very concerned and regret not being fully informed prior to making the difficult decision to terminate. Thanks.
At Thu Jun 19, 04:02:00 AM 2008,
Anonymous said…
I would like to point out that although 2 infections are known to cause Asherman's syndrome by themselves (endometrial tuberculosis and schistosomiasis- both found mostly in the developing world) infection is not necessary for the development of Asherman's syndrome after D&C (see Jensen and Stromme, 1972 and Polishuk et al, 1975). There is no evidence to date to suggest that antibiotics prevent adhesion formation after D&C. Furthermore, Schenker and Margalioth (1982)reported that 90% of the Asherman's cases resulted from D&C following miscarriage, abortion, or delivery, with no mention of infection being present.
Lastly, I have not seen any reports of pre-eclampsia being a pregnancy complication following treatment for Asherman's syndrome.
Thank you.
At Sat Jun 21, 04:45:00 PM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To anonymous June 17: There is probably no more than a 1% chance of significant adhesions following an uncomplicated elective procedure. I would not recommend a hysteroscopy unlesss you develop menstrual abnormalities or have other problems with your fertility. Odds are in your favor that you will do just find. Best wishes. Dr T
At Sat Jun 21, 04:59:00 PM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To anonymous June 19: Thanks for your comments. I am not sure that those earlier articles realy prove that subclinical infection or some degree of inflammation doesn't contribute to Asherman's, although I truly appreciate the references and will look them up. Regardless, although it wasn't worded well, I did not say that infection was ncesssary. I do know that the worst cases of Asherman's that I have seen have been those associated with midtrimester septic abortions and later pregnancy chorioamnionitis/endomyometritis in which a D&C was performed at some delayed point following a delivery - and the remarkable thing in some of those cases was that the operator took precautions to prevent the same. I was not proposing that antibiotics be given at routine D&C and if given after the fact, I would not imagine they would help. I was just wondering if giving them to women who chose to delay uterine evacuation following a pregnancy loss might benefit if they eventually came down to a D&C - was thinking something like doxycycline or azithromycin. There are enough women who choose the option to "let nature take its course" that it might not be too hard to do a prospective study in that regard. And, lastly, even though there are no published articles of which I am aware that address preeclampsia in women who have had Asherman's I can testify to the numerous patients who end up with abnormalities of placentation following myomectomies, uterine septum removal, and treatment for Asherman's who, if they develop IUGR and/or placenta accreta, go on to develop preeclampsia with those pregnancies. Perhaps that is another subgroup that would lend itself to analysis in that regard. Again, thanks for writing and kind regards. Love the 'professsional feedback'! Dr T
At Sun Jun 22, 12:16:00 AM 2008,
Tammy said…
I believe that I have Asherman's syndrome. Why are doctors so reluctant to diagnois you or even do the neccessary,although slightly evasive, but easy to do test, to either confirm or deny Asherman's?
I'm a 38 year old woman. I gave birth vaginal to 1 son in 2005 no problem. Resumed normal menstruation, charting and confirmed ovulation.
I got pregnant in August 2007 after 6 months of try. Miscarried in october 2008 at 8 weeks. The baby died only a 1-2 days before the U/S. I had a fever the night before and bad cramps. My dr. insisted on D&C less then 24 hours after the baby died.
This was October 2007. Since the D&C, I do not have periods, merely light spotting and each month it gets lighter. I have bad cramping around the time when my period should be. I temp chart and it shows ovulation along with all other system, eggwhite mucus, sharp ovualtion pains ect.
Since this has been going on for 9 months, I've seen my dr. who did the D&C. He confirmed that I had a lining, but not "where he'd like it to be" and sent me off to keep trying and refused to do any tests. He could not explain why I was having no period even though I had lining.
I then went to see another dr. He did another U/S. It showed only lining at the top of uterus and nothing nothing going down the sides.
Again I asked for the Hysteroscopy and he doesn't want to do it. He first wants to test my hormones (had it done exactly 12 months ago and all EXCELLENT, like an old 20 yr), then if that's normal he wants to do high does of estrogen to see if it'll help, and then if it doesn't may be do a hysteroscopy.
WHY THE WAIT??? I fit the criteria, I'm still trying to get pregnant, which may be dangerous for me or the baby (assuming I can conceive) if I do get pregnant and have asherman's.
i've had 2 D&C s in my life, I had unexplained bleeding for the first trimester of my son's pregnancy and small placenta.
why won't doctors be more aggressive in ruling out Ashermans????
At Sun Jun 22, 01:27:00 AM 2008,
Anonymous said…
Thanks Dr Trofatter I appreciate your feedback. To date the role of unspecified infection in IUA development remains controversial (reviewed in Kodaman and Arici, 2007). It may be of your opinion that infection plays a bigger role than presently accepted and I look forward to seeing any papers reporting conclusive evidence that infection affects either the onset or severity of adhesions. I know of cases which occured despite the use of prophylactic antibiotics following miscarriage exactly as you describe.
I'd be interested to see the first reported study of a statistically significant correlation between preeclampsia and Asherman's syndrome. Of course the study would also need to take into account the presence of other factors known to predispose to preeclampsia in order to determine if the correlation is real.
I also wanted to draw the attention of your readers to the fact that incompetent cervix is thought to occur from dilation of the cervix associated with D&C and hysterosocopy to treat the Asherman's syndrome than from the intrauterine adhesions per se.
Many thanks.
At Mon Jul 28, 06:37:00 AM 2008,
Anonymous said…
Hi, I had a D&C in mid-May. I bled afterwards moderately for 4 weeks. Then developed an infection (symptom was a high temperature and the bleeding started having an odour). It was treated by antibiotics. One week later I had a massive bleed with lots of clots.About 1 week after this I stopped bleeding.My first period after the D&C arrived this Saturday just passed - 26th July.
It was a very strange period. As it was moderate for 1 day (not spotting but not as heavy as usual). Yesterday I only had spotting. Today it's over.
My Dr. seems to think my body's just getting back into the rhythm of things. I am worried I have Ashermans. What do you advise? I am very worried
At Mon Jul 28, 04:04:00 PM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To anonymous July 28: I am worried to. My suggestion would be to see how things go over the next 3-4 cycles. I do not recommend trying to get pregnant in the interim. Please check back in with us to give us an update. Good luck. Dr T
At Thu Aug 14, 01:21:00 PM 2008,
Anonymous said…
thanks for this interesting article. i had a d&c last oct. due to a missed m/c, and haven't been able to get pregnant since. (been trying for 7 months now, the last one with clomid) the problem is that in the last few cycles my period is lighter than usual. only 3 days, while in the past, and the first few months after the m/c i had a normal 6 days period.
could it be possible that i have Asherman's Syndrome even though i had normal periods after the d&c, for 4 months? all the data i found indicate a sustained change in periods since the d&c and not normal-then-light pattern.
thanks for your help
At Sat Aug 16, 07:44:00 PM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To anonymous Aug 14: You could have any number of things contributing to your secondary "infertility" but part of the assessment for that is an evaluation of the uterine cavity. In your case a sonohysterogram and/or hysteroscopy will tell you whether or not Asherman's may be a contributing factor. Dr T
At Mon Aug 25, 09:58:00 AM 2008,
TXan said…
Dr. T,
My question is at the end, but I need to explain my situation:
I am a healthy, thin, 36.5 year old, but has been diagnosed as hypogonadatrophic (no history of eating disorders or excessive exercise/athletics) and have PCOS (no IR that I am aware of but am on Metformin). I went to an RE for a stimulation meds cycle, but was a strong responder to fertility meds, and switched to IVF since I was at risk for higher order multiples (also developed OHSS). Even with my strong response (high e2 levels and MANY follicles), my lining was only around 5mm. I did become pregnant with the first IVF attempt, but miscarried at 8 weeks (only 6 week growth), had a D&C, and the diagnosis was chromosonal (Trisomy 10). The second IVF was not successful. Lining was also right around 5mm.
When I switched REs, the Dr. did an operative hysteroscopy, and said my uterus was "shut down" and "bald" and he diagnosed with mild Asherman's per paperwork (not sure if having a dormant uterus and lack of hormones is part of Asherman's). To encourage gland growth he did a ploughing procedure, followed with antibiotics and high estrogen therapy to heal. During the subsequent mock cycle, an endometrial biopsy was done, and I was "in phase," or within one day of that part of the cycle.
We just completed a stimulation cycle with IUI, and my lining got to around 7mm, so definitely an improvement. On September 3, 2008 I go in for my beta. If this cycle is successful, my Dr. wants to put me on HSG to encourage placenta growth and adequate blood supply, since he thinks my lining is still on the thin side. (I am also now taking baby aspirin everye day.) Will this therapy put me more at risk for placenta accretia or other placental issues later in pregnancy? Is there anything else I should be aware of? I appreciate any insight you could offer.
At Tue Aug 26, 12:39:00 PM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To TXan: You hit the nail on the head. You probably are at increased risk for a placenta accreta because of all that has been done and the thiness of the endometrium. Placenta accretas also increase your risk for small babies (intrauterine growth restriction), preeclampsia, and early delivery - often by cesarean section, as well as hemorrhage and possible hysterectomy at delivery. But with all that doom and gloom, you still have a very good chance that NONE of that will happen. Best of luck to you nad thanks for reading! Dr T
At Tue Aug 26, 01:40:00 PM 2008,
TXan said…
Thanks Dr. T for your prompt response. I take it from the increased risk if I am pregnant, I should see a high risk/fetal maternal specialist? Are there things I should be looking for the Dr. to track to make sure I don't develop these issues? I know I am early in the process to think about next steps, but I want to be as proactive as possible. Do you have any advise on what I should look for in a specialist? Too bad you aren't in Dallas, TX, or else I'd come to you! :)
At Wed Aug 27, 09:08:00 AM 2008,
Anonymous said…
Hi, I am anonymous from Mon Jul 28 and had been worried as my first period after the D&C was very light and only lasted 24 hours.
However, I am now on day 3 of my 2nd period after the D&C. It seems reasonably heavy, and like how my periods were before the d&c. Maybe a little lighter. Do you think it is OK to start TTC after this cycle?
Thanks for all your help!
At Wed Sep 03, 06:33:00 AM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To anonymous Aug 27: If YOU are ready, then go for it and good luck! Dr T
At Wed Sep 03, 11:37:00 AM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To TXan: there is nothing you can really do to prevent an abnormality of placentation except to say your little prayers! We are getting better at detecting placenta accretas by ultrasound during pregnancy to at least forwarn us of a possible problem and to better prepare for delivery. There are lots of great doctors in Dallas, so you don't need me, but thanks for asking! Dr T
At Tue Sep 09, 03:54:00 PM 2008,
Anonymous said…
I am nearly 40 with a large family. I have had three miscarriages in the last three years. I had a D&C at 10 wks for missed miscarriage on 6-12 and then proceeded to bleed of and on for nearly 3 months. I thought I had an infection because there was a strange yellow matter discharged along with small clots and blood. The doc prescribed flagyl. I thought it was my period but the HCG was not 0 until nearly three months after the D&C. On 8-26 I passed a large clot that showed blood w/fibrin and foci of acute inflammation and necrosis. It contained chorionic villi and there were calcifications. Since then, I have stopped bleeding. I wonder what could have caused this problem and why I am having repeated miscarriages after so many successful pregnancies. My doctor says it is just bad luck. Genetic testing showed MTHFR A1298C mutation, he has proscribed Foltab and prenatal vitamins. He said we could do a hysteroscopy to check for scaring. I don't know what to do. After reading your article, I wonder if I should be concerned about Asherman's. Thank You for writing such a clear explanation of Asherman's. It is nearly impossible to find info of this quality especially when it involves pathology.
At Thu Sep 11, 09:15:00 AM 2008,
annrb said…
I just read your notes on ashermans syndrome .I had a miscarriage the first week in may this year due to a subchronic heamatoma.The baby died at 9 weeks i had a DnC the next day. I bleed for 5 weeks and returned to the hospital they put me on antibiotics for a week and told me it wasnt retained tissue. I still bleed and 7 weeks after the first DnC i had to have another one. This time they told me i had retained tissue. Now 11 weeks past the SEcond DnC my periods have not returned. I got my hormone levels checked and i have ovulated. I have had 2 episodes of back pain one at 6 weeks and one at 10 weeks.
The last episode i ended up in A&E .The doctor there thought i was anxious to get pregnant, But i just want to be normal and not get these monthly cycles of pain. I do Believe that i now have ashermans and that it must be bad enough. What aare your thoughts on this , i have been driving my self mad .
At Fri Sep 19, 03:55:00 PM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To anonymous Sept 9: I agree that a hysteroscopy and perhaps a sonohysterogram are warranted. This should help you find out if Asherman's is present. If the results do not provide any answers, you might want to seek a 'second opinion' with a specialist in Reproductive Endocrinology and Infertility. Good luck and please let us know what you find out. Dr T
At Fri Sep 19, 03:57:00 PM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To annrb: Your history is certainly a 'set up' for Asherman's. I would recommend a sonohysterogram and hysteroscopy. If your docctor does not have a lot of experience with those procedures, ask for a referral to a specialist in reproductive endocrinology and infertility - he/she would be in the best position to help you if Asherman's or any other reason for infertility is found. Dr T
At Sun Sep 21, 04:18:00 AM 2008,
Anonymous said…
I am wondering about the likelihood of Asherman's or something similar following a caesarian. I am having difficulty conceiving a second child: the most obvious explanation is age (I've just turned 44), but I'm also wondering if other explanations are possible as I conceived my first child rather easily just after my 42nd birthday. My FSH is 6 and day 21 progesterone confirms ovulation, but I have had very much lighter periods than pre-pregnancy ever since stopping breastfeeding around 9 months ago - only a couple of days of quite moderate flow, they were much heavier at the time I got pregnant. I there is any potentially remediable cause for not conceiving since then, I would like to find out and am wondering whether uterine ultrasound or hysteroscopy are worthwhile investigations before giving up! Obviously I feel very blessed to have managed one thriving child at this late stage, but if we have any chance of a second, I'd like to maximise this!
Many thanks
At Sun Sep 21, 06:16:00 PM 2008,
Anonymous said…
I had a severe case of Asherman's Syndrome after a D and C for retained placenta. I would like to let people know of a great resource called www.ashermans.org, where there is also a support group that you can join. I had two surgeries with a world class Asherman's Specialist and now have a uterus with uniform endometrium between 7.5-8.5 mm and only a left tube blocked. There is hope if you see a doctor that treats this condition routinely. Thank you Dr. T for helping women find answers. Asherman's really isn't that rare!
At Tue Sep 23, 12:17:00 PM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To anonymous Sept 9: Reprise - at your age, the losses may well have been the result of fetal chromosomal abnormalities as well. If you lose another pregnancy, ask to have chromosome studies done on the products of conception. Dr T
At Sat Oct 04, 05:15:00 PM 2008,
LadyMinister said…
I am scheduled for hysteroscopy to correct Asherman's this month. My husband and I are eager to TTC after such my MC in July.
I wasn't told the severity of the adhesions but assuming it to be mild to moderate when is it likely that I will be able to resume fertility treatments.
I am 38 (39 in December) and my one and only pregnancy ended in a second trimester loss.
At Sun Oct 05, 05:39:00 PM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To anonymous Sept 21 04:18 I think it is unlikely that you have Asherman's from your c/section, but a hysteroscopy and/or sonohysterogram might still be warranted to rule out an obstructive process. The greater likelihood is that your age is catching up with you. My suggestion would be to find a good reproductice endocrinologist to see waht he/she is willing to do to enhance your prospects for another pregnancy. Good luck!
Dr T
At Sun Oct 05, 05:40:00 PM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To anonymous Sept 21 06:16: Thanks for the resource link and for the kind words! Regards, Dr T
At Tue Oct 07, 05:44:00 PM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To ladyminister: I know everyone who reads your note will be praying for you to have a good result. Best wishes and thank you for reading! Dr T
At Thu Oct 09, 07:53:00 AM 2008,
Anonymous said…
My doctor suspects Ashermans. I have had 6 pregnancies with 3 live births and 3 D&C's after no fetal life was detected. My last pregnancy was 8 years ago and resulted in a live healthy birth, with the use of progesterone to help conceive and retain the fetus until 12 weeks. I have been on the pill since then due to heavy periods, and missed periods due to cysts on the ovaries. This did help regulate menstruation and made my periods manageable. However, I stopped taking the pill 4 months ago and coinicidently stopped having a period with my last week of the pill. I have been checked for thyroid,(normal) and cysts, ultrasound found none, however my uterus is "big" but my lining thickness normal. She did find very small fibroids. My Dr wants to try me on hormones to see if that jump starts my period. If it does he said that should rule out Ashermans (?) If I have Ashermans and I do not want anymore children (I am 45) what is the procedure? Is it ok to leave things as they are?
At Mon Oct 20, 10:56:00 AM 2008,
Anonymous said…
I am a 49 yr, who has had several procedures done to treat my uterine fibroids. I had a U.A.E., which didn't work for me. I had a Ovarian Artery Embolization done approx. 6 mos. later. The bleeding and anemia continued. The gyne then recommended doing a hysteroscopic resection and an ablation (rollerball). Ten days post, I ended up with endometritis and was treated with IV antibiotics. After the oral antibiotics were finished, I had another unspecified uterine infection and this continued for approx. 6 mos. Finally got rid of the infection!! I have had no bleeding however, each cycle I get cramps and pelvic pain. I also feel that I may have some adhesions from these procedures - I feel pain during exercise (abs. particularly!). I have also recently had an abnormal pap. I am concerned. Any comments or suggestions will be appreciated.
At Tue Oct 21, 01:20:00 PM 2008,
Anonymous said…
My husband and I have being trying to concieve for the past 18 months. We are currently undergoing fertility investigation. I am currently awaiting a HSG scan and feel extremely apprehensive about the procedure and the results, as I had a D&C 4 years ago after an un-wanted pregnancy. My periods are relatively heavy, I am always regular and after the D&C my periods returned to normal, however i feel convinced that I may have some scar tissue. Is this likely? I have tried to talk yo my GP about it but he was extremely dismissive that this is the problem. Please help as I feel that there is no-one I can talk to.
At Wed Oct 22, 06:43:00 PM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To anonymous Oct 20: There comes a time when hysterectomy looks very inviting - you may not want one for some reason, but if the current list of complications continues, you may eventually absolutely need one and my thoughts would be it is better to do it before you get to that point. Best wishes! Dr T
At Fri Oct 24, 06:38:00 AM 2008,
Anonymous said…
Thank you Dr. T.for your prompt reply. The reason behind not having a hysterectomy to me was, why loose an important organ for a benign condition (fibroids)? I was also trying to avoid a major surgery especially if less invasive methods could work. However, in my particular case you may be right. I am extremely grateful to you.
At Tue Oct 28, 09:26:00 PM 2008,
Anonymous said…
Hi Dr T. I have a friend who has Asherman's and she was going in to schedule surgery to correct it and found out she is unexpectantly pregnant. As a friend I want to be as supportive for her as I can. So I have been researching this. But I haven't been successful at really finding anything about anyone having a successful pregnancy while actually having Asherman's. She is almost 5 weeks along...I guess what I am getting at is, what are her chances of having a viable pregnancy with Asherman's?
Thank you
At Wed Oct 29, 07:12:00 PM 2008,
Myra said…
Hi Dr T. My friend was diagnosed with Asherman's after 2 miscarriages, one involving a D&C. She was due to go in for surgery next week to remove the scar tissue build up. But had to cancel it because last week she found out she was unexpently pregnant. She is really scared and don't know what will happen. What are her chances of carrying the baby to term or as close to it with this condition?
At Mon Nov 10, 08:20:00 AM 2008,
Anonymous said…
from anonymous Sept 9
Even though the pathologist scared me with the possibility of a molar pregnancy. It seems, for the time being that Asherman's has been ruled out. Once the clot passed, everything seems to have returned to normal. Except for the fact that I haven't become pregnant. This was a very traumatic ordeal. (I will certainly never go through a d&c without anesthesia again.) Thanks for your kind reply and the information, at least I learned a little through all this craziness. Guess it is bad luck and old age together!
At Mon Dec 08, 05:25:00 PM 2008,
Tammy said…
It probably depends on how bad the scaring is in teh uterus and how well the placenta can grow...
another Asherman's woman with 98% scarring got pregnant. the zygote or embryo landed in the 2% that was clear. however she miscarried at about 8 weeks...most likely the placenta could grow.
so hopefully you friend will be luck and she'll go to term
At Fri Dec 12, 07:18:00 PM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To Myra Oct 28/29: I JUST got this comment this week. Women with varying degrees of Asherman's syndrome can carry pregnancies. The chances depend on how severe is the scarring and where the pregnancy implanted. Even if she is successful, she will be at increased risk for placenta accreta if the pregnancy implanted in an area of scarring. Now that it has been 6 weeks since you have written, why don't you tell ME how things are going. Best wishes! Dr T
At Fri Jan 02, 07:12:00 PM 2009,
Anonymous said…
Back in February 2008 I had to have a D&C due to the fact that I had been on my period for three months. My doctor told me if I didn't have a D&C I would bleed for another three months. Since having the D&C I have not had a period. I was 42 at the time of the D&C. My doctor said that I was just going through menopause. But after reading articles on Asherman's Syndrome I believe that is what I have. Can it be reversed and if I took fertility drugs could I get pregnant
At Mon Jan 05, 09:15:00 AM 2009,
Anonymous said…
Three months ago (at the age of 53) I had a hysteroscopic resection of my endometrium. The procedure was done because I was experiencing what felt like uterine contractions - ultrasound revealed what looked like a small polyp. (Three years previous I had a D &C and an endometrium ablation because of frequent periods and excessive bleeding.) After the surgery this time I have experienced a lot of pain and have been told that I likely have Asherman's syndrome and was given Naprosyn to help with the pain. The gynecologist I saw also suggested that I might consider taking progesterone agents (tests suggest I'm not in menopause yet although I haven't had a period for 2 1/2 years, perhaps due to the ablation?). The other alternative appears to be a hysterectomy. I'm wondering what might be the best alternative?
At Fri Jan 23, 08:08:00 AM 2009,
Anonymous said…
Hi Dr. T... I had an uncomplicated D&C in June (7 months ago). My period resumed as usual and 3 months later I was pregnant again. Unfortunately I m/c naturally at 7 weeks. Since then I have had 3 periods- the 1st was a usual 5 day period, but the two since then have been only 1 day of heavy flow followed by 1 day of moderate flow and then 2 days of spotting which is lighter than usual for me. Is it possible that I developed Ashermans after the D&C in June?
At Fri Jan 30, 12:58:00 PM 2009,
Anonymous said…
I am a 31 yr old that was diagnosed with Asherman's Syndrome.
December 2006 I gave birth to my baby girl with no issues - 9 days later I was hemorrhaging due to retained placenta. I still have not had what anyone would call "a normal period". I've had 2 surgeries to remove "scar tissue". My uterine lining measures .46 (same measurement from a year ago). I have been on estrogen and progestrogen medicine. In the mean time I discovered I have hypothyroidism and now on Syntroid 88 mcg for that. I STILL am NOT having what one would call a period. My doctor now believes I am not ovulation and this so called period I am having in me just shedding the lining (minus an egg). Do you have any suggestions?
I have read about something called Sheehan's Syndrome - does that always show up in blood work? Would it show up immediately or over time? Should I ask the doctor to scan my pituatary gland?
Now it's 2009...still no "normal" period (I mean its hardly anything each day I am on my so called period). My doctor is having me to use ovulation kits this next month to prove to him that I am not ovulating.
Please if you have any suggestions on what to look at...please let me know.
~B
At Sun Feb 22, 11:23:00 AM 2009,
Anonymous said…
I have so much to ask, dont know where to start. I had a m/c in September 08 - went in for my 12 week ultrasound in early September and found out baby died at 9 weeks. I took four separate doses of misoprotol but apparently still had remanants of the baby in my system so I was sent for a D/C. Got that on Oct 1/08. I have not had a period since.
I had received no real direction from OBGYN, but thanks to the net, had diagnosed myself as having asherman's. I went in for a sonohysterogram on February 12, but the Dr. couldnt get the cathedar into my cervix despite many attempts with different caths of differing sizes. The Dr "strongly suspected asherman's". I am no scheduled to go in for a hysteroscopy in a week or so.
Despite not having ANY blood present for the last 4+ months, I have started spotting over the last couple of days - about one week after my SHG.
I have no idea why this is happening - but i am experiencing alot of cramping pains along with the spotting. I should also mention that since December, I have had strong and sharp shooting pains for at least 2 days in a row (dont know if it is at the time i am supposed to be menstruating since i havent bled in quite a while).
I have no idea what is going on - have resigned myself to fact that I have asherman's but am confused about the recent spotting and the continued sharp shooting pains. Can anyone provide some insight? Is it possible that I have Endomitriosis in addition to Asherman's?? Medical innsight would be greatly appreciated.
At Sat Mar 14, 07:50:00 PM 2009,
Anonymous said…
Thanks for the post! I just want to say I had D&C procedures when I 33year of age. I am now 46yrs old and I have been trying to get pregnant from the past up to present with no luck. The doctors says I have endometrium problems They also mentioned that I dont need surgery to remove fibroids because the size is too small and its unnecessary. Even though I have lots of chronic lower back pains almost all the time because of the fibroids. It is something I have to live with until after menopause when fibroids vanishes. So based on my experience future fertility problems does comes with the price. And I wish I had known better. It will take some divine power to intervine the process if pregnancy does become possible. I just have to keep my fingers crossed. Good Luck to All.!!!Thank you
At Tue Mar 24, 05:13:00 PM 2009,
Anonymous said…
I'm concerned that I may have Asherman's Syndrome. I had a D&C in Feb 2008 and had a light but normal period for 8 months however; in November of 2008 my menstral cycle changed completely. My period in November lasted for only 1 day and it was extremely light.
Since November my period has become non-existent and occurs later and later every month. My period used to start at the 8th of the month and over a 5 month period has moved to the 24th of the month.
I do have some light spotting for a day or two but its extremely light.
I've had FSH tests, Thyroid and Hormone testing and it has come back normal.
Could I have Asherman's Syndrome after 8 months of having a somewhat normal period?
At Thu Mar 26, 10:20:00 AM 2009,
Anonymous said…
My wife and I are confused about her case and are wondering if you have any thoughts to share. History: molar pregnancy 3 1/2 years ago, resulting in D&C. Since unsuccessful at conception, so went to see a fertility specialist recently. HSG indicated salpingitis in both fallopian tubes. Negative for chlamydia and gonnorhea. Ultrasound indicated some uterine scarring. Doc tried saline sonogram but could not get any uterine dilation. We will have a hysteroscopy and laparascopy next month, but are at a loss for understanding what's going on. Signs look like PID, but we can't identify an underlying infection, and my wife hasn't experienced any pelvic pain. Could also be Asherman's, but she still has normal menstrual cycle.
Any thoughts on questions we should be asking our doc, or other factors we need to look at? Thank you in advance for your assistance
At Sat Apr 04, 12:22:00 AM 2009,
Anonymous said…
Hi Dr Trofatter,
I was wondering why you often advise women to undergo both hysteroscopy and a sonohysterogram to diagnose Asherman's syndrome. A hysteroscopy is sufficient to detect cervical and/or uterine adhesions.
I also wanted to stress that older women should not be discouraged to undergo diagnosis for AS, under the assumption that infertility is due to age. Women's fertility should be assesed not only by their age but also according to their individual hormonal factors and fertility history. I too was told that my light periods after a D&C for a miscarriage were due to age (by a top AS doctor) but insisted on a hysteroscopy which revealed stage III AS. My advice to women is to follow their instincts as they know their bodies best, and if they are willing to pay for a test, no doctor has the right to refuse them. Of course I would recommend that the hysteroscope be performed by an expert in AS.
At Thu Apr 16, 09:02:00 PM 2009,
Tammy said…
I am a 43 and my doctor tells me I am menopausal. I started having problems in 2002 after miscarriage and a d and c. My periods would come only every two or three months. I would hurt during intercourse. The doctor did say that I had scar tissue. He gave me something to make my period start. I had a couple of periods and then they ceased again for several months. It has been 2 years and I hurt every month as though I am going to have a period. I finally had one and went to the doctor and he done a uterine biopsy and a blood test. he said that my fsh is too high. I continue to cramp and have pain in my ovaries. I have not had hot flashes and no vaginal dryness. Do you think I should ask him about Asherman's?
At Fri Apr 24, 02:52:00 PM 2009,
Blue said…
Dear TXan,
My new RE (also in Dallas) recommended I undergo the ploughing procedure, although I was not diagnosed with Ashermans. Can I discuss this further with you? Many thanks!
At Fri May 08, 10:18:00 PM 2009,
Michelle L. said…
I have many questions regarding Asherman's. I had a miscarriage in June 2008 that showed fetal demise at 9 weeks 1 day during my 10th week of pregnancy. I had a suction D&C with no known complications. In July 2008, I had a laproscopy to diagnose Endometriosis where they found Stage 3. Doctor recommended 6 months treatment on Lupron Depot. I had one menstrual cycle in August 2008 after both surgeries, which was very light, I thought it was due to the Lupron. I finished treatment with Lupron early Feb 2009 and was expecting a period 6-8 weeks later. I still have not had a cycle yet even after 10 days of Progesterone. I am currently on day 10 of a Clomid cycle which was given to me to induce ovulation and hopefully start a period. I am now with a RE who wants to do a hysteroscopy to see in there is any scarring that has prevented my period to resume. I am just learning about Asherman's and am so fearful that I may have it. What is the possibility of becoming pregnant again with Asherman's Syndrome? Please help...
At Tue Jun 09, 07:47:00 AM 2009,
anonymous said…
I am a 26 year old healthy woman. i fell pregnant in February this year.(first time)
I had very regular periods then.
When i went for my second scan at 9 weeks, the doc said baby had no heartbeat and had stopped growing, (missed miscarriage)i went straight away for an evacuation on 4/4/09. I went for a check up on 4 may as i bled heavy all of a sudden, diagnosis retained tissue, was on cytotec to remove tissue, unsuccesful, went for a d&c to remove residue on 9 May 09, doc said histological results displayed placenta tissue and presence of inflamation. was on antibiotics day before second op. I still havent gotten my period and im worried.
Last wknd, 31st May 09, had bad period pains and only one spot of blood, pelvic pain as well then it subsided. Do i have anything to worry bout or shall i wait? its been a month since second op and 2 months since first
plz assist
thx so much
At Mon Jun 15, 06:48:00 PM 2009,
Kenneth F. Trofatter, Jr., MD, PhD said…
To anonymous June 9: If you have not had a normal period in the next 6-12 weeks, you should be further evaluated. You might have Asherman's, not be ovulating, or even be pregnant at that point.
Dr T
At Tue Jun 16, 12:40:00 AM 2009,
Anonymous said…
Thank you for the response Dr T.When exactly does the 6-12 weeks start to run from?from the second operation (d&c) or from the day i stopped bleeding which was a week thereafter?thanks again
At Sun Jun 21, 04:49:00 PM 2009,
Kenneth F. Trofatter, Jr., MD, PhD said…
To anonymous June 16: It really doesn't matter. That's just a very general time frame.
Dr T
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