Publications: Diagnosis, Classification and Treatment of Asherman's syndrome

Diagnosis of AS

Note: Hysteroscopy is the gold standard diagnostic tool for the diagnosis of Asherman’s syndrome

Kucuk T, Safali M. Chromohysteroscopy” for evaluation of endometrium in recurrent in vitro fertilization failure. J Assist Reprod Genet (2008) 25:79–82.

Knopman Copperman The value of 3D ultrasound in the management of Asherman’s syndrome The Journal of Reproductive Medicine. 2007 Nov;52(11):1016-22

Makris N, Kalmantis K, Skartados N, Papadimitriou A, Mantzaris G , Antsaklis A Three-dimensional hysterosonography versus hysteroscopy for the detection of intracavitary uterine abnormalities International Journal of Gynecology and Obstetrics (2007) 97, 6–9.

Oyinloye OI, Adesiyun OAM, Ibrahim MS, Adesina KT. Diagnosis of intracervical orifice adhesions by ultrasonography. West African Journal of Ultrasound 2006; 7:24-6.

Palter. SF, High Rates of Endometriosis in Patients With Intrauterine Synechiae (Asherman's Syndrome). Fertility and Sterility 2005; 86 (null):S471-S471. Link

Roma DA, Ubeda B, Ubeda A, et al. Diagnostic value of hysterosalpingography in the detection of intrauterine abnormalities: a comparison with hysteroscopy. AJR Am J Roentgenol. 2004;183:1405–1409. (Class III).

 Sylvestre C, Child TJ, Tulandi T, Tan SL. A prospective study to evaluate the efficacy of two- and three-dimensional sonohysterography in women with intrauterine lesions. Fertil Steril, 2003. 79(5): p. 1222-5.

Salle, B., Gaucherand P, de Saint Hilaire P, Rudigoz RC. Transvaginal sonohysterographic evaluation of intrauterine adhesions. J Clin Ultrasound, 1999; 27(3): p. 131-4.   Full article                      

Letterie, G.S. and M.F. Haggerty, Magnetic resonance imaging of intrauterine synechiae. Gynecol Obstet Invest, 1994. 37(1): p. 66-8.

Soares SR, Barbosa dos Reis MM, Camargos AF. Diagnostic accuracy of sonohysterography, transvaginal sonography and hysterosalpinography in patients with uterine cavity diseases. Fertility and sterility 2000; 73(2):406-11.

Bacelar AC, Wilcock D, Powell M, Worthington BS. The value of MRI in the assessment of traumatic intra-uterine adhesions (Asherman’s syndrome). Clin Radiol 1995;50(2):80-3.

Valle RF, Sciarra JJ. Intrauterine adhesions: hysteroscopic diagnosis, classification, treatment, and reproductive outcome. Am J Obstet Gynecol. 1988;158:1459–1470. (Class III).

Hamou J, Salat-Baroux J, Siegler A. Diagnosis and treatment of intrauterine adhesions by microhysteroscopy. Fertil Steril. 1983;39: 321–326. (Class II-3).

Classification of AS

Note: there is no universally accepted classification system

March CM, Israel R, March AD. Hysteroscopic management of intrauterine adhesions. Am J Obstet Gynecol 1978;130:653.

European Society Classification

Wamsteker K, DeBlok SJ. Diagnostic hysteroscopy:technique and documentation. In: Sutton C, Diamon M (ed.): Endoscopic surgery for gynecologist. New York: Lippincott Williams & Wilkins Publishers. 1995: 263-76.

American Fertility Society Classification

AFS. The American Fertility Society classifications of adnexal adhesions, distal tubal occlusion, tubal occlusion secondary to tubal ligation, tubal pregnancies, mullerian anomalies and intrauterine adhesions. Fertil Steril 1988;49(6):944-55.

Valle RF, Sciara JJ. Intrauterine adhesions: hysteroscopic diagnosis, classification, treatment and reproductive outcome. Am J Obstet Gynecol 1988; 158:1459-70.

Donnez J, Nisolle M. Hysteroscopic lysis of intrauterine adhesions (Asherman’ syndrome). In Donnez J (ed): Atlas of laser operative laparoscopy and hysteroscopy. New York: Press-Parthernon Publishers 1994:3-12.

Nasr, AL, Al-Inany, HG, Thabet, SM, and Aboulghar, M. A clinicohysteroscopic

scoring system of intrauterine adhesions. Gynecol Obstet Invest 2000;50(3):178-81.

Treatment of AS

See also review articles for a summary. Note: I’ve left out older papers using outdated techniques. Although I’ve included papers on the use of electosurgery, endometrial biopsy treatment and myometrial scoring, there are concerns about these techniques with regards to preservation of fertility.  

Summary and guidelines

AAGL: Practice Report: Practice Guidelines for Management of Intrauterine Synechiae, The Journal of Minimally Invasive Gynecology Vol. 17, No.1 2010.  For abstract Click here.

Hysteroscopic adhesiolysis/synechiolysis

Piketty M, Lesavre M, Prat-Ellenberg L, Benifla JL.[Surgical management of intrauterine adhesions: is benefice bigger than risk?] Gynecol Obstet Fertil. 2010 ;38(9):547-9. For abstract Click here.

Frey C, Chanelles O, Poncelet C.[How to prevent postoperative intrauterine adhesions?] Gynecol Obstet Fertil. 2010 ;38(9):550-2. For abstract Click here.

Barash A, Granot I, Fieldust S, Or Y. .Successful pregnancy and delivery of a healthy baby after endometrial biopsy treatment in an in vitro fertilization patient with severe Asherman syndrome.  Fertil Steril 2009;

Hayasaka S,Murakami T, Arai M, Ugajin T, Nabeshima H, Yuki H, Terada Y, and Yaegashi N, A Method for Safe Hysteroscopic Synechiolysis in Patients with Asherman Syndrome Volume 25, Number 4, 2009 147-152.

Taniguchi F, Suginami H. Pregnancy and delivery following sonohysterographic lysis to treat recurrence after hysteroscopic lysis of severe intrauterine adhesions: a case report. Clin Exp Obstet Gynecol. 2008;35(3):215-7. For abstract Click here.

Pabuccu R, Onalan G, Kaya C, et al. Efficiency and pregnancy outcome of serial intrauterine device–guided hysteroscopic adhesiolysis of intrauterine synechiae. Fertil Steril. 2008;90:1973–1977. (Class I).

Revaux A, Ducarme G, Luton D.  [Prevention of intrauterine adhesions after hysteroscopic surgery] Gynecol Obstet Fertil. 2008 ;36(3):311-7.For abstract Click here.  [Article in French]

Thomson A, Abbott J, Kingston A, Lenart M, Vancaillie T. Fluoroscopically guided synechiolysis for patients with Asherman’s syndrome: menstrual and fertility outcomes. Fertil Steril 2007;87:405-10. For abstract Click here.

Chason RJ, Levens ED, Yauger BJ, Payson MD, Cho K, Larsen FW. Balloon fluoroscopy as treatment for intrauterine adhesions: a novel approach. Fertil Steril. 2008 Nov;90(5):2005.e15-7.  For abstract Click here. 

Robinson, JK, Colimon, LM, and Isaacson, KB. Postoperative adhesiolysis therapy for intrauterine adhesions (Asherman's syndrome). Fertil Steril 2008;90(2):409-14. For abstract Click here.  

Shokeir, T.A., M. Fawzy, and M. Tatongy, The nature of intrauterine adhesions following reproductive hysteroscopic surgery as determined by early and late follow-up hysteroscopy: clinical implications. Arch Gynecol Obstet, 2008. 277(5): p. 423-7.

Pabuccu R, Onalan G, Kaya C, Selam B, Ceyhan T, Ornek T, Kuzudisli E. Efficiency and pregnancy outcome of serial intrauterine device-guided hysteroscopic adhesiolysis of intrauterine synechiae. Fertil Steril. 2008 Nov;90(5):1973-7. For abstract Click here.  

Yasmin H, Nasir A, Noorani KJ. Hysteroscopic management of Asherman’s syndrome. Pak Med Assoc 2007;57(11):553-5.
Bifulco G, Di Spiezio Sardo A, Guido M, Nappi C. Prevenzione delle aderenze in ginecologia endoscopica. Ginecologo 2006; 1(3):154-61.

Fernandez H, Al-Najjar F, Chauvenaud-Lambling A, Frydman R and Gervaise A. Fertility after treatment of Asherman’s syndrome stage 3 and 4. J Minim Invas Gynecol 2006;13:398-42.

Fedele, L, Bianchi, S, and Frontino, G. Septums and synechiae: approaches to surgical correction. Clin Obstet Gynecol 2006;49(4):767-88.

Soliman N, Singh SS, Nevin A, Leyland N. The management of intrauterine adhesions. 2006, UWOMJ 75(1):S11-13.

Zikopoulos, KA, Kolibianakis, EM, Platteau, P, de Munck, L, Tournaye, H, Devroey, P et al. Live delivery rates in subfertile women with Asherman's syndrome after hysteroscopic adhesiolysis using the resectoscope or the Versapoint system. Reprod Biomed Online 2004;8(6):720-5.

Tiras MB, Oktem M, Noyan V. Laparascopic intracorporeal ultrasound guidance during hysteroscopic adhesiolysis. 2003;European Journal of Obstetrics and Gynaecology and Reproductive Biology (80-84).

Dickey KW. Cervical stenosis and uterine synechiae: Evaluation and treatment with interventional methods. Seminars in Interventional Radiology 2000; 17(3):309-14.

Fernandez H, Gervaise A, de Tayrac R. Operative hysteroscopy for infertility using normal saline solution and a coaxial bipolar electrode: a pilot study. Hum Reprod 2000,15:1773-5.

Broome, JD and Vancaillie, TG. Fluoroscopically guided hysteroscopic division of

adhesions in severe Asherman syndrome. Obstet Gynecol 1999;93(6):1041-3.

Capella-Allouc, S, Morsad, F, Rongieres-Bertrand, C, Taylor, S, and Fernandez, H.

Hysteroscopic treatment of severe Asherman's syndrome and subsequent fertility.

Hum Reprod 1999;14(5):1230-3.

ChapmanR, Chapman K. The value of two stage laser treatment for severe Asherman’s syndrome. BJOG. 1996; 103:1256-8.

Protopapas, A, Shushan, A, and Magos, A. Myometrial scoring: a new technique

for the management of severe Asherman's syndrome. Fertil Steril 1998;69(5):860-4.

McComb, PF and Wagner, BL. Simplified therapy for Asherman's syndrome. Fertil

Steril 1997;68(6):1047-50.

Pabuccu, R, Atay, V, Orhon, E, Urman, B, and Ergun, A. Hysteroscopic treatment

of intrauterine adhesions is safe and effective in the restoration of normal menstruation and fertility. Fertil Steril 1997;68(6):1141-3.

Reddy S, Rock JA. Surgical management of complete obliteration of the endometrial cavity. Fertility and Sterility 1997; 67:172-4.

Karande V, Levrant S, Hoxsey R, Rinehart J, Gleicher N. Lysis of intrauterine adhesions using gynecoradiologic techniques. Fertil Steril. 1997;68:658–672. (Class II-2).

Bellingham R. Intrauterine adhesions: hysteroscopic lysis and adjunctive methods. Aust NZ Obstet Gynaecol. 1996;36:171–174. (Class III).

Fraser IS, Song JY, Jansen RPS, Ramsay P. Hysteroscopic lysis of intrauterine adhesions under ultrasound guidance. Gynaecol Endosc. 1995;4: 35–40. (Class III).

Neuwirth RS.Asherman’s syndrome. Gynecologic surgery and adhesions prevention 1993; 187-190.

Fedele L, Vercellini P, Viezzoli T, Ricciardiello O, Zamberleti D. Intrauterine adhesions: current diagnostic and therapeutic trends. Acta Eur Fertil. 1986;17:31–37. (Class III).

Hamou J, Salat-Baroux J, Siegler A. Diagnosis and treatment of intrauterine adhesions by microhysteroscopy. Fertil Steril. 1983;39: 321–326. (Class II-3).

March C, Israel R. Gestational outcomes following hysteroscopic lysis of adhesions. Fertil Steril 1981, 36:455-9.

March, CM, Israel, R, and March, AD. Hysteroscopic management of intrauterine

adhesions. Am J Obstet Gynecol 1978;130(6):653-7.

Sugimoto, O. Diagnostic and therapeutic hysteroscopy for traumatic intrauterine

adhesions. Am J Obstet Gynecol 1978;131(5):539-47.

Adjuvent treatments:

Barriers (mechanical barriers, gels, amnion)

(Note: see also  AAGL Practice Report under AS treatment and Tsapanos et al under prevention of Asherman’s syndrome. Follow link)

Amer MI, Abd-El-Maeboud KH, Abdelfatah I, Salama FA, Abdallah AS. Human amnion as a temporary biologic barrier after hysteroscopic lysis of severe intrauterine adhesions: pilot study. J Minim Invasive Gynecol. 2010 Sep-Oct;17(5):605-11. . http://www.ncbi.nlm.nih.gov/pubmed/20576472

Goorah B, Tulandi T. Uterine Rupture Resulting From the Pressure of an Intrauterine Balloon. J Obstet Gynaecol Can 2009;31(7):649–651.

Amer, MI and Abd-El-Maeboud, KH. Amnion graft following hysteroscopic lysis of intrauterine adhesions. J Obstet Gynaecol Res 2006;32(6):559-66.

Guida, M, Acunzo, G, Di Spiezio Sardo, A, Bifulco, G, Piccoli, R, Pellicano, M etal. Effectiveness of auto-crosslinked hyaluronic acid gel in the prevention of intrauterine adhesions after hysteroscopic surgery: a prospective, randomized, controlled study. Hum Reprod 2004;19(6):1461-4.

Abbott, J, Thomson, A, and Vancaillie, T. SprayGel following surgery for Asherman's syndrome may improve pregnancy outcome. J Obstet Gynaecol 2004;24(6):710-1.

Orhue, A.A., M.E. Aziken, and J.O. Igbefoh, A comparison of two adjunctive treatments for intrauterine adhesions  following lysis. Int J Gynaecol Obstet, 2003. 82(1): p. 49-56.

Vesce F, Jorrizo G, Biancotto A, Gotti G. Use of intrauterine device in the management of secondary amenorrhea. Fertil Steril 2000;73:162-5.

March, CM. Update: Intrauterine adhesions. Fertil News 1996;XVIV(No.1 Forum).

Roge, P, D'Ercole, C, Cravello, L, Boubli, L, and Blanc, B. Hysteroscopic

management of uterine synechiae: a series of 102 observations. Eur J Obstet

Gynecol Reprod Biol 1996;65(2):189-93.

Stem cells

(No articles relating to treatment of Asherman’s syndrome using stem cells as of yet. Please see future Miscellaneous Articles section for information about endometrial stem cells).

Endometrium (drugs and hormones to improve endometrial perfusion and thickness)

Note:  For more general articles on endometrial stimulation see future Miscellaneous Articles section.

Acharya S, Yasmin E, Balen AH. The use of a combination of pentoxifylline and tocopherol in women with a thin endometrium undergoing assisted conception therapies--a report of 20 cases. Hum Fertil (Camb). 2009;12(4):198-203. Link

Zinger M, Liu JH, Thomas MA. Successful use of vaginal sildenafil citrate in two infertility patients with Asherman's syndrome. J Womens Health (Larchmt). 2006 May;15(4):442-4. For abstract Click here.   

Takasaki A, Tamura H, Miwa I, Taketani T, Shimamura K, Sugino N.Endometrial growth and uterine blood flow: a pilot study for improving endometrial thickness in the patients with a thin endometrium. Fertil Steril. 2010 Apr;93(6):1851-8. Epub 2009 Feb 6. For abstract Click here.

Ledee-Bataille N, Oliviennes F, Lefaix, J-L., Chaouat G, Frydman R, Delanian S. Combined treatment by pentoxifylline and tocopherol for recipient women with a thin endometrium enrolled in an oocyte donation programme. Hum. Reprod. (2002) 17 (5): 1249-1253.  For full article Click here. 

Sher G, Fisch D. Effect of vaginal sildenafil on the outcome of in vitro fertilization (IVF) after multiple IVF failures attributed to poor endometrial development. Fertil Steril 2002; 78(5):10073-6.

Sher G and Fisch JD. Vaginal sildenafil (Viagra): a preliminary report of a novel method to improve uterine artery blood flow and endometrial development in patients undergoing IVF. 2000;Human Reproduction 15(4):806-9.

Sanfilippo, J.S., et al., Asherman's syndrome. A comparison of therapeutic methods. J Reprod Med, 1982. 27(6): p. 328-30.