Asherman Syndrome (AS), also known as intrauterine adhesions or synechiae, is a condition characterized by the formation of scar tissue inside the uterine cavity, often leading to menstrual abnormalities, infertility, or recurrent pregnancy loss. It is commonly associated with postpartum curettage, abortion, uterine infections, or pelvic surgeries.

Modern minimally invasive techniques, particularly hysteroscopy and laparoscopy, have revolutionized the diagnosis and management of Asherman Syndrome. By combining these approaches, surgeons can safely remove adhesions, restore uterine anatomy, and improve reproductive outcomes.

Dr. R. K. Mishra, a pioneer in laparoscopic surgery, has emphasized the integration of laparoscopy and hysteroscopy to ensure safe, precise, and effective management of Asherman Syndrome.

Etiology and Pathophysiology

Asherman Syndrome primarily results from trauma to the basal layer of the endometrium, leading to fibrous adhesions. Common causes include:

Postpartum or post-abortal curettage

Infections, such as endometritis or tuberculosis

Uterine surgeries, including myomectomy or cesarean section

Radiation therapy

The adhesions can vary in severity from thin, filmy bands to dense fibrotic tissue, potentially obliterating the uterine cavity and impairing endometrial function. Symptoms often include:

Hypomenorrhea or amenorrhea

Infertility

Recurrent pregnancy loss

Pelvic pain in severe cases

Diagnosis

Accurate diagnosis is essential before planning surgical management:

Hysterosalpingography (HSG): Can suggest intrauterine adhesions but lacks precision in detailing their extent.

Sonohysterography (Saline Infusion Sonography): Improves visualization of cavity irregularities.

Hysteroscopy: Gold standard for both diagnosis and treatment, allowing direct visualization of adhesions and the uterine cavity.

Laparoscopy: Provides external uterine and pelvic assessment, particularly useful in complex cases or when endometriosis or other pelvic pathology is suspected.

Hysteroscopic Management

Hysteroscopic adhesiolysis is the cornerstone of Asherman Syndrome treatment. Key steps include:

Cervical Dilation and Entry: Under anesthesia, a hysteroscope is introduced after gentle cervical dilation.

Visualization of Adhesions: The uterine cavity is inspected for filmy or dense adhesions.

Adhesiolysis: Adhesions are removed using scissors, bipolar energy, or laser, taking care to preserve healthy endometrium.

Cavity Reconstruction: Restoration of a normal cavity shape is the goal to optimize fertility outcomes.

Postoperative Measures: Placement of intrauterine devices (IUDs) or balloons may prevent re-adhesion, and postoperative estrogen therapy promotes endometrial regeneration.

Hysteroscopy alone may be sufficient for mild adhesions, but laparoscopic guidance is often used for moderate to severe cases.

Role of Laparoscopy

Laparoscopy complements hysteroscopy by providing:

Uterine and Pelvic Assessment: Ensures there are no concomitant pathologies such as endometriosis, fibroids, or adhesions outside the cavity.

Safety during Adhesiolysis: Reduces the risk of uterine perforation, especially in dense adhesions or a thin uterine wall.

Real-time Monitoring: The laparoscope allows surgeons to monitor the uterus externally while hysteroscopic instruments dissect adhesions.

Dr. R. K. Mishra emphasizes laparoscopic assistance particularly in severe Asherman Syndrome or repeat adhesiolysis, as it enhances safety and precision.

Postoperative Management and Fertility Outcomes

Postoperative care is crucial to prevent recurrence of adhesions:

Hormonal Therapy: Estrogen promotes endometrial regeneration.

Mechanical Barriers: IUDs or intrauterine balloons maintain cavity patency.

Follow-Up Hysteroscopy: Re-evaluation ensures complete removal of adhesions and monitors healing.

Fertility outcomes after combined laparoscopic and hysteroscopic management are promising:

Restoration of normal menstruation in 70–90% of cases

Pregnancy rates improving significantly, especially in women with mild to moderate adhesions

Reduced risk of recurrent adhesion formation with careful follow-up

Advantages of Combined Laparoscopic and Hysteroscopic Approach

Enhanced Safety: Minimizes risk of uterine perforation.

Accurate Assessment: Detects coexisting pelvic pathology.

Precise Adhesiolysis: Preserves functional endometrium.

Improved Fertility Outcomes: Optimizes uterine environment for conception.

Dr. Mishra’s approach has set a global standard in minimally invasive management of Asherman Syndrome, ensuring both anatomical and functional restoration.

Conclusion

Asherman Syndrome poses significant challenges in gynecology, particularly in women seeking fertility. The integration of hysteroscopic and laparoscopic techniques offers a safe, effective, and minimally invasive solution. Hysteroscopy provides direct visualization and targeted adhesiolysis, while laparoscopy ensures safety, external assessment, and management of associated pelvic conditions.

Under the guidance of experts like Dr. R. K. Mishra, surgeons can achieve:

Restoration of normal uterine anatomy

Improved menstrual and reproductive outcomes

Reduced recurrence of adhesions

This combined approach represents the modern gold standard for managing Asherman Syndrome, balancing safety, precision, and optimal fertility outcomes for patients.