Hysteroscopy pp 697-708 | Cite as

Adhesions and Abortion



Asherman syndrome is characterized by intrauterine adhesions in association with symptoms such as infertility and menstrual irregularities. The commonest cause of Asherman syndrome is curettage of a pregnant or recently pregnant uterus. Abortions, especially unsafe abortions, constitute a major cause of Asherman syndrome. The risk of Asherman syndrome increases with the number of abortion procedures performed. While medical and surgical methods of termination of pregnancy exist, Asherman syndrome is unlikely with the medical methods and significantly reduced following a vacuum aspiration. The role of infection in causing Asherman syndrome is unclear but it is logical to believe that post-inflammatory processes could worsen a traumatic endometrial damage. Diagnostic hysteroscopy constitutes the gold standard in the diagnosis of Asherman syndrome, while therapeutic hysteroscopy constitutes the method of choice in the treatment. Female health education, liberalizing abortion laws, and training of health personnel might help in reducing abortion complications, including Asherman syndrome.


Asherman Abortion Curettage Intrauterine adhesions Hysteroscopy 


  1. 1.
    Asherman JG. Amenorrhoea traumatic (atretica). J Obstet Gynaecol Br Emp. 1948;55:23.CrossRefPubMedGoogle Scholar
  2. 2.
    Asherman JG. Traumatic intrauterine adhesions. J Obstet Gynaecol Br Emp. 1950;57:892–6.CrossRefPubMedGoogle Scholar
  3. 3.
    Yu D, Wong YM, Cheong Y, Xia E, Li TC. Asherman syndrome – one century later. Fertil Steril. 2008;89:759–79.CrossRefPubMedGoogle Scholar
  4. 4.
    Annas GJ, Elias S. Legal and ethical issues in obstetrics practice. In: Gabbe SG, Niebyl JR, Simpson JL, editors. Obstetrics: normal and problem pregnancies. 5th ed. London: Churchill Livingstone; 2007.Google Scholar
  5. 5.
    Cunningham FG, Leveno KJ, Bloom SL, Hauth JC, Rouse DJ, Spong CY. In: Williams Obstetrics, editor. Overview of obstetrics. 23rd ed. New York, NY: McGraw-Hill Medical; 2010.Google Scholar
  6. 6.
    Aimakhu UE. Abortions. Trop J Obstet Gynaecol. 1995;12(1):57–61.Google Scholar
  7. 7.
    Ahiaedeke C. Incidence of induced abortion in southern Ghana. Int Fam Plan Perspect. 2001;27(2):96–101.CrossRefGoogle Scholar
  8. 8.
    World Health Organisation (WHO). Technical and policy guidance for health systems. Geneva: World Health Organisation; 2002. WQ 440 ISBN 92 4 159034 3Google Scholar
  9. 9.
    Henshaw SK. The incidence of induced abortion in Nigeria. Int Fam Plan Perspect. 1998;24(4):156–64.CrossRefGoogle Scholar
  10. 10.
    Pazol K, Zane SB, Parker WY, Hall LR, Berg C, Cook DA, Centers for Disease Control and Prevention (CDC). Abortion surveillance—United States, 2008. MMWR Surveill Summ. 2011;60(15):1.Google Scholar
  11. 11.
    Sedgh G, Singh S, Shah IH, Ahman E, Henshaw SK, Bankole A. Induced abortion: incidence and trends worldwide from 1995 to 2008. Lancet. 2012;379(9816):625–32.CrossRefPubMedGoogle Scholar
  12. 12.
    Leke RJ. The tragedy of induced abortion in sub-Saharan Africa. In: Boniface T, editor. Contemporary health issues in maternal health care in Africa. Luxemberg: Harwood Academic; 1994. p. 281–92.Google Scholar
  13. 13.
    Bankole A, Adewale IF, Hussain R, Awolude O, Singh S, Akinyemi JO. The incidence of abortion in Nigeria. Int Perspect Sex Reprod Health. 2015;41(4):170–81.CrossRefPubMedPubMedCentralGoogle Scholar
  14. 14.
    Okonofua FE, Hammed A, Abass T, Mariga AG, Mohammed AB, Adewale A, et al. Private medical providers’ knowledge and practices concerning medical abortion in Nigeria. Stud Fam Plan. 2011;42:41–50.CrossRefGoogle Scholar
  15. 15.
    ACOG. ACOG practice bulletin. Clinical management guidelines of obstetrician-gynecologists number 67. Medical management of abortion. Obstet Gynecol. 2005;106:871.CrossRefGoogle Scholar
  16. 16.
    Bracken H, Dabash R, Tsertsvadze G, Posohova S, Shah M, Hajri S, et al. A two-pill sublingual outpatient regimen following mifepristone for medical abortion through 70 days’ LMP: a prospective comparative open-label trial. Contraception. 2014;89(3):181–6.CrossRefPubMedGoogle Scholar
  17. 17.
    Greene MF, Drazen JM. A new label for mifepristone. N Engl J Med. 2016;374:2281.CrossRefPubMedGoogle Scholar
  18. 18.
    Fjerstad M, Trussell J, Sivin I, Lichtenberg S, Cullins V. Rates of serious infection after changes in regimens for medical abortion. N Engl J Med. 2009;361:145.CrossRefPubMedPubMedCentralGoogle Scholar
  19. 19.
    Darney PD. Deaths associated with medication abortion. Contraception. 2005;72:319.CrossRefPubMedGoogle Scholar
  20. 20.
    Creinin MD, Vittingghoff E, Keder L, Darney PD, Tiller G. Methotrexate and misoprostol for early abortion: a multicenter trial. I. Safety and efficacy. Contraception. 1996;53(6):321–7.CrossRefPubMedGoogle Scholar
  21. 21.
    Enabudoso EJ, Gharoro EP, Ande ABA, Ekpe UP, Okohue JE. Five year review of complicated induced abortions in university of Benin teaching hospital, Benin City. Benin J Postgrad Med. 2007;9(1):13–21.Google Scholar
  22. 22.
    Sawaya GF, Grady D, Kerlikowske K, Grimes DA. Antibiotics at the time of induced abortion: the case for universal prophylaxis based on a meta-analysis. Obstet Gynecol. 1996;87:884.PubMedGoogle Scholar
  23. 23.
    ACOG Committee on Practice Bulletins. ACOG practice bulletin no. 74. Antibiotic prophylaxis for gynecologic procedures. Obstet Gynecol. 2006;108:225.CrossRefGoogle Scholar
  24. 24.
    Van Eyk N, van Schalkwyk J, Infectious Diseases Committee. Antibiotic prophylaxis in gynaecologic procedures. J Obstet Gynaecol Can. 2012;34:382.CrossRefPubMedGoogle Scholar
  25. 25.
    Kapp N, Whyte P, Tang J, Jackson E, Brahmi D. A review of evidence for safe abortion care. Contraception. 2013;88:350.CrossRefPubMedGoogle Scholar
  26. 26.
    Creinin MD, Schreiber CA, Bednarek P, Lintu H, Wahner MS, Meyn LA. Mifepristone and misoprostol administered simultaneously versus 24 hours apart for abortion: a randomized controlled trial. Obstet Gynecol. 2007;109:885.CrossRefPubMedGoogle Scholar
  27. 27.
    Creinin MD, Fox MC, Teal S, Chen A, Schaff EA, Meyn LA. A randomized comparison of misoprostol 6 to 8 hours versus 24 hours after mifepristone for abortion. Obstet Gynecol. 2004;103:851.CrossRefPubMedGoogle Scholar
  28. 28.
    Ulmann A, Silvestre L, Chemama L, Rezvani Y, Renault M, Aguillaume CJ, et al. Medical termination of early pregnancy with mifepristone (RU 486) followed by a prostaglandin analogue. Study in 16,369 women. Acta Obstet Gynecol Scand. 1992;71:278.CrossRefPubMedGoogle Scholar
  29. 29.
    Wen J, Cai QY, Deng F, Li YP. Manual versus electric vacuum aspiration for first-trimester abortion: a systematic review. BJOG. 2008;115:5.CrossRefPubMedGoogle Scholar
  30. 30.
    Srofenyoh EK, Addison M, Dortey B, Kuffour PA. Intrauterine retained fetal bones as a cause of secondary infertility. Ghana Med J. 2006;40(3):105–9.PubMedPubMedCentralGoogle Scholar
  31. 31.
    Kelly T, Suddes J, Howel D, Hewison J, Robson S. Comparing medical versus surgical termination of pregnancy at 13-20 weeks of gestation: a randomised controlled trial. BJOG. 2010;117:1512.CrossRefPubMedGoogle Scholar
  32. 32.
    Hooker AB, Lemmers M, Thurkow AL, Heymans MW, Opmeer BC, Brolmann HA, et al. Systematic review and meta-analysis of intrauterine adhesions after miscarriage: prevalence, risk factors and long term reproductive outcome. Hum Reprod Update. 2014;20(2):262.CrossRefPubMedGoogle Scholar
  33. 33.
    Harick H, Akin O, Sala E, Ascher SM, Levine D. Diagnostic imaging gynecology. 1st ed. Amyris Inc: Salt Lake City, UT; 2007. p. 68–77.Google Scholar
  34. 34.
    March CM. Asherman’s syndrome. Semin Reprod Med. 2011;29(2):83–94.CrossRefPubMedGoogle Scholar
  35. 35.
    Rasheed SM, Amin MM, Abo Ellah AH, Abo Elhassan AM, El Zahry MA, Wahab HA. Reproductive performance after conservative surgical treatment of postpartum haemorrhage. Int J Gynaecol Obstet. 2014;124(3):248–52.CrossRefPubMedGoogle Scholar
  36. 36.
    Schenker JG, Marghioth EJ. Intra-uterine adhesions: an updated appraisal. Fertil Steril. 1982;37:593–610.CrossRefPubMedGoogle Scholar
  37. 37.
    Fedele L, Bianchi S, Frontino G. Septums and synechiae: approaches to surgical correction. Clin Obstet Gynecol. 2006;49(4):767–88.CrossRefPubMedGoogle Scholar
  38. 38.
    Friedler S, Margalioth EJ, Kafka I, Yaffe H. Incidence of post-abortion intra-uterine adhesions evaluated by hysteroscopy – a prospective study. Hum Reprod. 1993;8:442–4.CrossRefPubMedGoogle Scholar
  39. 39.
    Tam WH, Lan WC, Cheung LP, Yuen PM, Chung TK. Intrauterine adhesions after conservative and surgical management of spontaneous abortion. J Am Assoc Gynecol Laparosc. 2002;9(2):182–5.CrossRefPubMedGoogle Scholar
  40. 40.
    Gilman Baber AR, Rhone SA, Fluker MR. Curettage and Asherman’s syndrome- lessons to (re-)learn? J Obstet Gynaecol. 2014;36(11):997–1001.Google Scholar
  41. 41.
    Okonofua FE. Induced abortion, a risk for infertility in Nigerian women. J Obstet Gynaecol. 1994;14:272–6.CrossRefGoogle Scholar
  42. 42.
    Sai F. An overview of unsafe abortion in Africa. Forward. Afr J Fertil Sex Reprod Heal. 1996;1(1):2–3.Google Scholar
  43. 43.
    Ajayi AI, Nwokocha EE, Akpan W, Adeniyi OV. Use of non-emergency contraceptive pills and concoctions as emergency contraception among Nigerian University students: results of a qualitative study. BMC Public Health. 2016;16(1):1046.CrossRefPubMedPubMedCentralGoogle Scholar
  44. 44.
    Coelho HL, Teixeira AC, Santos AP, Forte EB, Morais SM, La Vecchia C, Tognoni G, Herxheimer A. Misoprostol and illegal abortion in Fortaleza Brazil. Lancet. 1993;341(8855):1261–3.CrossRefPubMedGoogle Scholar
  45. 45.
    Barbosa RM, Arilha M. The Brazilian experience with cytotec. Stud Fam Plan. 1993;24(4):236–40.CrossRefGoogle Scholar
  46. 46.
    Kodaman PH, Arici AA. Intrauterine adhesions and fertility oucome: how to optimize success? Curr Opin Obstet Gynecol. 2007;19(3):207–14.CrossRefPubMedGoogle Scholar
  47. 47.
    Fedele L, Vercellini P, Viezzoli T, Ricciardiello O, Zamberleti D. Intra uterine adhesions: current diagnostic and therapeutic trends. Acta Eur Fertil. 1986;17:31–7.Google Scholar
  48. 48.
    Deans R, Abbott J. Review of intrauterine adhesions. J Minim Invasive Gynecol. 2010;17(5):555–69.CrossRefPubMedGoogle Scholar
  49. 49.
    Rabau E, David A. Intrauterine adhesions: etiology, prevention and treatment. Obstet Gynecol. 1963;22:626–9.Google Scholar
  50. 50.
    Jensen P, Stromme W. Amenorrhoea secondary to puerperal curettage (Asherman syndrome). Am J Obstet Gynecol. 1972;113:150.CrossRefPubMedGoogle Scholar
  51. 51.
    The American Fertility Society. The American Fertility Society classification of adnexal adhesions, distal tubal occlusion, tubal occlusion secondary to tubal ligation, tubal pregnancies, mullerian anomalies and intrauterine adhesions. Fertil Steril. 1988;49:944–55.CrossRefGoogle Scholar
  52. 52.
    Chen Y, Chang Y, Yao S. Role of angiogenesis in endometrial repair of patients with severe intrauterine adhesions. Int J Chin Exp Pathol. 2013;11:1343–50.Google Scholar
  53. 53.
    Malhotra N, Bahadur A, Kalaivani M, Mittal S. Changes in endometrial receptivity in women with Asherman’s syndrome undergoing hysteroscopic adhesiolysis. Arch Gynecol Obstet. 2012;11:525–30.CrossRefGoogle Scholar
  54. 54.
    Okohue JE, Onuh SO, Ebeigbe P, Shaibu I, Wada I, Ikimalo JI, Okpere EE. The effect of endometrial thickness on in vitro fertilization (IVF)-ET/intracytoplasmic sperm injection (ICSI) outcome. Afr J Reprod Health. 2009;13(1):113–21.PubMedGoogle Scholar
  55. 55.
    Polishuk WZ, Siew FP, Gordon R, Lebenshart P. Vascular changes in traumatic amenorrhoea and hypomenorrhoea. Int J Fertil. 1977;22:189–92.PubMedGoogle Scholar
  56. 56.
    Dmowski WP, Greenblatt R. Asherman’s syndrome and risk of placenta acreta. Obstet Gynecol. 1969;34:288–99.PubMedGoogle Scholar
  57. 57.
    Toaff R, Ballas S. Traumatic hypomenorrhoea-amenorrhoea (Asherman’s syndrome). Fertil Steril. 1978;30:379–87.CrossRefPubMedGoogle Scholar
  58. 58.
    Ventolini G, Zhang M, Gruber J. Hysteroscopy in the evaluation of patients with recurrent pregnancy loss. Surg Endosc. 2004;18:1782–4.CrossRefPubMedGoogle Scholar
  59. 59.
    Soares SR, Barbosa dos Reis MM, Camargos AF. Diagnostic accuracy of sonohysterography, transvaginal sonography and hystersalpingography in patients with uterine cavity diseases. Fertil Steril. 2000;73(2):406.CrossRefPubMedGoogle Scholar
  60. 60.
    Shalev J, Meizner I, Bar-Hava I, Dicker D, Mashiach R, Ben-Rafael Z. Predictions value of transvaginal sonography performed before routine diagnostic hysteroscopy for evaluation of infertility. Fertil Steril. 2000;73(2):412.CrossRefPubMedGoogle Scholar
  61. 61.
    Magos A. Hysteroscopic treatment of Asherman’s syndrome. Reprod BioMed Online. 2002;4(Supp 3):46–51.CrossRefPubMedGoogle Scholar
  62. 62.
    Bhandari S, Bhave P, Ganguly I, Baxi A, Agarwal P. Reproductive outcome of patients with Asherman’s syndrome. A SAIMA experiment. J Reprod Infertil. 2015;16(4):229–35.PubMedPubMedCentralGoogle Scholar
  63. 63.
    Okohue JE, Onuh SO, Akaba GO, Shaibu I, Wada I, Ikimalo JI. A 3 years review of hysteroscopy in a private hospital in Nigeria. World J Laparosc Surg. 2009;2(2):26.CrossRefGoogle Scholar
  64. 64.
    Levine RU, Neuwirth RS. Simultaneous laparoscopy and hysteroscopy for intrauterine adhesions. Obstet Gynecol. 1973;42(3):441.PubMedGoogle Scholar
  65. 65.
    Hanstede MM, Van der Meij E, Goedemans L, Emanuel MH. Results of centralized Asherman surgery 2003–2013. Fertil Steril. 2015;104(6):1561–8.CrossRefPubMedGoogle Scholar
  66. 66.
    Oppegaard KS, Wesheim BI, Istre O, Qvigstad E. Comparison of self administered misoprostol versus placebo for cervical ripening prior to operative hysteroscopy using a sequential design. BJOG. 2008;115(5):663–e9.CrossRefPubMedPubMedCentralGoogle Scholar
  67. 67.
    Al-Fozan H, Firwana B, Alkadri H, Hassan S, Tulandi T. Preoperative ripening of the cervix before operative hysteroscopy. Cochrane Database Syst Rev. 2015;23(4):CD005998.Google Scholar
  68. 68.
    Sugimoto O. Diagnostic and therapeutic hysteroscopy for traumatic intrauterine adhesions. Am J Obstet Gynecol. 1978;131:539–47.CrossRefPubMedGoogle Scholar
  69. 69.
    Emanuel MH. New development in hysteroscopy. Best Pract Res Clin Obstet Gynecol. 2013;27:421–9.CrossRefGoogle Scholar
  70. 70.
    McComb PF, Wagner BL. Simplified therapy for Asherman’s syndrome. Fertil Steril. 1997;11:1047–50.CrossRefGoogle Scholar
  71. 71.
    Munro MG, Abbott JA, Bradley LD, Howard FM, Jacobs VR, Sokol AI, Gallinat A, Isaacson KB, Thomson AJ, Valle RF. AAGL practice report: practice guideline for management of intrauterine synechiae. J Minim Invasive Gynecol. 2010;17(1):1–7.CrossRefGoogle Scholar
  72. 72.
    Protopapas A, Shushan A, Magos A. Myometrial scoring: a new technique for the management of Asherman’s syndrome. Fertil Steril. 1998;69:860–4.CrossRefPubMedGoogle Scholar
  73. 73.
    Lippes Loop. Ortho stops marketing Lippes Loop; cites economic factors. Contracept Technol Update. 1985;6(11):149–52.Google Scholar
  74. 74.
    Vesce F, Jorizzo G, Bianciotto A, Gotti G. Use of intrauterine device in the management of secondary amenorrhoea. Fertil Steril. 2000;73:162–5.CrossRefPubMedGoogle Scholar
  75. 75.
    March C, Israel R. Gestational outcomes following hysteroscopic lysis of adhesions. Fertil Steril. 1981;36:455–9.CrossRefPubMedGoogle Scholar
  76. 76.
    Orhue AA, Aziken ME, Igbefoh JO. A comparison of two adjunctive treatments for intrauterine adhesions following lysis. Int J Gynaecol Obstet. 2003;82:49–56.CrossRefPubMedGoogle Scholar
  77. 77.
    Lin X, Wei M, Li TC, Huang Q, Huang D, Zhou F, Zhang S. A comparison of intrauterine balloon, intrauterine contraceptive device and hyaluronic acid gel in the prevention of adhesion reformation following hysteroscopic surgery for Asherman syndrome: a cohort study. Eur J Obstet Gynecol Reprod Biol. 2013;170:512–6.CrossRefPubMedGoogle Scholar
  78. 78.
    Acunzo G, Guida M, Pellicaro M, Ga T, Di SpiezioSardo A, Bifulco G. Effectiveness of auto crosslinked hyaluronic acid gel in the prevention of intrauterine adhesions after hysteroscopic adhesiolysis: a prospective randomized controlled study. Hum Reprod. 2003;18(9):1918–21.CrossRefPubMedGoogle Scholar
  79. 79.
    Hearly MW, Schexnayder B, Connell MT, Terry N, Decherney AH, Csokmay JM, et al. Intrauterine adhesion prevention after hysteroscopy: a systematic review and meta-analysis. Am J Obstet Gynecol. 2016;215(3):267.CrossRefGoogle Scholar
  80. 80.
    Hurst BS, Bhojwani J, Marshburn P. Low dose aspirin does not improve ovarian stimulation endometrial response or pregnancy rates for in vitro fertilization. J Exp Clin Assist Reprod. 2005;31:8–13.CrossRefGoogle Scholar
  81. 81.
    Hsieh Y, Tsai H, Chang C. Low dose aspirin for infertile women with thin endometrium receiving intra-uterine insemination: a prospective randomized study. J Assist Reprod Genet. 2000;17:174–7.CrossRefPubMedPubMedCentralGoogle Scholar
  82. 82.
    Zackrisson U, Brannstrome M, Granberg S. Acute effects of a transdermal nitric oxide donor on perifollicular and intrauterine blood flow. Ultrasound Obstet Gynecol. 1998;12:50–5.CrossRefPubMedGoogle Scholar
  83. 83.
    Sher G, Fisch D. Effect of vaginal sildenafil on the outcome of invitro fertilization (IVF) after multiple IVF failures attributed to poor endometrial development. Hum Reprod. 2001;15:806–9.CrossRefGoogle Scholar
  84. 84.
    Nagori CB, Panchal SY, Patel H. Endometrial regeneration using autologous adult stem cells followed by conception by in vitro fertilization in a patient of severe Asherman’s syndrome. J Hum Reprod Sci. 2011;4(1):43–8.CrossRefPubMedPubMedCentralGoogle Scholar

Copyright information

© Springer International Publishing AG 2018

Authors and Affiliations

  1. 1.Gynescope Specialist Hospital/Madonna UniversityPort HarcourtNigeria

Personalised recommendations