Introduction: why blog about Ashermans syndrome?

This blog is dedicated to documenting and commenting on research, attitudes and information and misinformation (past and present) relating to Asherman's syndrome and its main cause, surgical evacuation of the uterus (D&C). I will also provide information about promising alternatives to surgical evacuation, particularly misoprostol which is a safe and effective non-invasive drug. Hysteroscopy is another alternative to D&C for retained products of conception from an incomplete miscarriage or retained postpartum placenta, as it allows the surgeon a direct view inside the uterus during surgery. Both are underutilized by doctors who treat early pregnancy failure.

The misnomer of Asherman's syndrome actually refers to a frequently iatrogenic (caused by medical treatment) condition known as intra uterine adhesions or IUA (ie adhesions inside the uterus) caused by injury to the endometrium (lining of the uterus). This injury produces scars on the delicate endometrial tissue which lead to adhesions and/or fibrosis of the endometrium leading to impaired fertility and future obstetric complications if pregnancy occurs. Although estimations are difficult due to a lack of awareness about the condition by doctors and patients alike, it is thought to affect approximately 5% of women. Over 90% of cases are caused by surgical evacuation of the uterus- this includes procedures and terms such as dilation and curettage (D&C), dilation and evacuation (D&E), suction curettage/evacuation, MVA (manual vacuum aspiration), or simply curettage. For the sake of simplicity I will refer to all types of surgical evacuations of the uterus collectively as "D&C". Asherman's syndrome can be caused by any uterine surgery and rarely by endometrial tuberuculosis infection, however my focus is on D&C because this is still considered 'standard care' for miscarriage management in the US, Australia and many other countries.

All or some of these procedures continue to be used for a host of gynecological conditions and pregnancy complications including:

-postpartum retained placenta
-endometrial biopsy
-heavy/abnormal uterine bleeding
-endometrial polyps
-investigation of gynecological cancers
-Asherman's syndrome (absolutely NOT the correct treatment!!!)

There are safer and often cheaper alternatives to D&C for all of the above.

Surgical treatment for Asherman's syndrome exists (hysteroscopic adhesiolysis and estrogen therapy), however overall birthrates remain disappointing for moderate to severe cases (around 30-40%). There is also very little research on comparing treatments (e.g. stents vs IUD vs no stents, dosage and length of estrogen therapy, mechanical dissection vs electosurgery, etc.) . Meanwhile there are many randomized controlled trials (RCTs) on using misoprostol for miscarriage management. Prevention is therefore the more logical approach.

I hope to make women aware of the dangers of this procedure and the existence of alternatives. There is a lot of misinformation about the condition due to both a lack of awareness and medically unfounded over-optimism about treatment outcomes.

I feel it is important for the public to know about the existence of Asherman's syndrome, and in particular its main cause and the ways in which it can be prevented. In the past, the condition has only been discussed among sufferers hidden away from the public view with the occasional input of a handful of experts in its treatment. This is valuable but doctors' opinions may vary until further evidence is established. The information being shared between patients, as one might expect, is not always accurate. This blog goes far beyond encouraging women to acheive their personal goal of having a child after Asherman's syndrome. Given that only 40% of sufferers attain a live birth, a fixation on this outcome among sufferers is not only unrealistic and limited in scope, but unhealthy. I would like more clinicians to become interested in Asherman's syndrome and its prevention- not just its treatment. I would also like to see more doctors trained in using misoprostol for miscarriage management as well as in hysteroscopy for removal of retained products, a minimally invasive endoscopic procedure which should have long superceded the blind D&C. I would like to see researchers conduct scientifically rigorous clinical studies and clinicians taking an interest in the fundamental biology of intrauterine adhesions and its effects on fertility.  I would like to see a CHANGE in health policies so that these are based on medical evidence rather than on TRADITION. I would like to see women waking up to the situation and demanding better standards or simply more choices in the management of obstetric/gynecological problems leading to Asherman's syndrome rather than accepting the condition as inevitable or a test of faith. I would like to see women care about more than simply the fulfillment of their personal child bearing goals. I would like to see all doctors who are aware of Asherman's syndrome, its causes and consequences also speak out about it, not just to make their services known but to fulfill the oath of their profession by promoting healthcare policies and standards which protect patients instead of causing them harm.

 This blog aims to make people aware of the abuse and misuse of D&Cs. It is my hope that one day drugs and hysteroscopy will become standard care worldwide for miscarriage management.