Mini-Review of the New Therapeutic Possibilities in Asherman Syndrome—Where Are We after One Hundred and Twenty-Six Years?

Abstract

Asherman syndrome is a multifaceted condition describing the partial or complete removal of the uterine cavity and/or cervical canal. It is a highly debatable topic because of its pronounced influence on both reproductive outcomes and gynaecologic symptoms. The latest reports demonstrated that trauma to the endometrium is the main cause of intrauterine adhesion formation. Left untreated, such adhesions gradually lead to a range of repercussions ranging from mild to severe. Considering the lack of non-invasive approaches, the advent of hysteroscopy has revolutionized the entire field, being otherwise considered the most efficient tool offering new directions and amplifying the chances of treating the Asherman syndrome.

Focus on the Primary Prevention of Intrauterine Adhesions: Current Concept and Vision

“…The classification of AFS for IUA (1988) used three items, including the extent of the cavity involved, the type of adhesions, and the menstrual pattern (Table 1), to produce the following prognostic classification: stage I (mild), II (moderate) and III (severe) [53]. The ESGE IUA classification includes grade I (thin or filmy adhesion, easily ruptured by hysteroscopic sheath alone and normal cornual area), II (singular dense adhesion that cannot be ruptured by the hysteroscopic sheath, but a uterine cavity connected to a separate space, and visualization of both tubal ostia), IIa (occluding adhesion only in the region of the internal cervical os with normal upper uterine cavity), III (multiple dense adhesions connected to a separate space of the uterine cavity and unilateral obliteration of tubal ostia), IV (extensive dense adhesion with partial occlusion of the uterine cavity and tubal ostia), Va (extensive endometrial scarring and fibrosis in combination with grade I or II adhesions, accompanied by amenorrhea or pronounced hypomenorrhea), and Vb (extensive endometrial scarring and fibrosis in combination with grade III or IV adhesion, accompanied with amenorrhea), based on hysteroscopic and hysterographic findings [27][28][29][30]54], and this classification was modified in 2017 [55]. Besides the aforementioned classification of IUA based on AFS and ESGE, there are at least six additional classification systems available for clinical practice [55], and these have been reported by the following authors: March et al [27,56]; Hamou et al [57]; Valle and Sciarra [58]; Donnez and Nisolle [59]; Nasr et al [52].…”

“…The exact prevalence or real incidence of IUA is unknown, and may be underestimated, partly because of a lack of symptoms or the presence of vague symptoms, and partly because of neglect leading to the disease not being discovered even in those patients with clear symptoms [ 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 ]; as well as partly because of the uncertain predisposing and causal factors [ 30 , 35 ]. Additionally, IUA varies with geographic location, study population, and the availability of investigations for diagnosis [ 29 , 36 ].…”

“…Additionally, IUA varies with geographic location, study population, and the availability of investigations for diagnosis [ 29 , 36 ]. Many review articles are available in the literature to describe the prevalence of IUA according to the various clinical presentations and surgeries [ 26 , 27 , 28 , 29 , 30 ]. The occurrence of IUA may be low as 1–2% in patients with secondary amenorrhea; 1–4% in patients after C/S; 3–4% in women undergoing postpartum dilation and curettage (D&C); 6–7% of patients receiving D&C for early spontaneous abortion; 6–7% in patients with infertility; 6–24% in women treated with hysteroscopic metroplasty; 10–20% in patients with spontaneous abortion occurring less than twice; 10–20% in patients undergoing D&C of elective abortion; 20–30% in patients with postpartum D&C occurring more than twice; 20–30% in patients requiring uterine instrumentation performed between the second and fourth postpartum weeks [ 27 , 30 , 37 , 38 , 39 , 40 , 41 , 42 ].…”

“…In cases of extreme severity, the endometrial lining might be partially or totally absent, contributing to the approximation and fusion of surfaces of opposing uterine walls. As a result, IUA or Asherman syndrome (Asherman’s syndrome) develops [ 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 ].…”

Efficacy of Applying Hyaluronic Acid Gels in the Primary Prevention of Intrauterine Adhesion after Hysteroscopic Myomectomy: A Meta-Analysis of Randomized Controlled Trials

“…Women with IUA may present with various kinds of symptoms, and some are persistent. These symptoms include abnormal uterine bleeding, amenorrhea, dysmenorrhea, infertility, abnormal placentation, and recurrent miscarriage [ 1 , 2 , 4 , 7 , 8 , 9 , 24 , 25 , 26 , 27 , 28 , 29 ]. As there is continuous progression in hysteroscopic surgeries and they are widely performed for the treatment of various kinds of intrauterine lesions, there is increased concern about IUA-associated morbidities and the subsequent significant impairment of reproductive performance in women of reproductive age [ 3 , 5 , 7 , 30 , 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 ].…”