Prevention of de novo adhesion formation in patients with Asherman's syndrome

Authors: Boudová B.;  Lisá Z.;  Richtárová A.;  Kužel D.;  Mára M.
Authors‘ workplace: Gynekologicko-porodnická klinika 1. LF UK a VFN v Praze
Published in: Ceska Gynekol 2021; 86(4): 273-278
Category: Review article
doi: 10.48095/cccg2021273


Objective: To summarize recent data and knowledge of secondary prevention of the recurrence of intrauterine adhesions in patients with Asherman‘s syndrome. Methods: Analysis of literature evidence and clinical experience of the authors. Results: Asherman‘s syndrome is iatrogenic disease with problematic therapy. One of the basic issues is a need for repeated surgical interventions since the recurrence of adhesions is very frequent. Secondary prevention is a crucial factor for successful therapy in these patients. The methods applied include second--look hysteroscopy, hormonal treatment and different types of barriers. To compare their efficacy is difficult and the results of meta-analysis are contradictory. Conclusion: There are many different possibilities of secondary prevention of the recurrence of intrauterine adhesions; unfortunately, none of them is perfect. The usage of solid or semi-solid barriers in combination with the support of endometrium regeneration with hormonal therapy seems most reasonable.


Asherman‘s syndrome – hysteroscopy – intrauterine adhesions – prevention


1. Fritsch H. Ein Fall von volligen Schwund der Gebaumutterhohle nach Auskratzung. Zentralbl Gynaekol 1894; 18: 1337–1342.

2. Asherman JG. Amenorrhoea traumatica (atretica). J Obstet Gynaecol Br Emp 1948; 55 (1): 23–30. doi: 10.1111/j.1471-0528.1948.tb07045.x.

3. Asherman JG. Traumatic intra-uterine adhesions. J Obstet Gynaecol Br Emp 1950; 57 (6): 892–896. doi: 10.1111/j.1471-0528.1950.tb06053.x.

4. Asherman JG. Traumatic intrauterine adhesions and their effects on fertility. Int J Fertil 1957; 2: 49–54.

5. Schenker JG. Etiology of and therapeutic approach to synechia uteri. Eur J Obstet Gynecol Reprod Biol 1996; 65 (1): 109–113. doi: 10.1016/0028-2243 (95) 02315-j.

6. Schenker JG, Margalioth EJ. Intrauterine adhesions: an updated appraisal. Fertil Steril 1982; 37 (5): 593–610. doi: 10.1016/s0015-0282  (16) 46268-0.

7. Hrazdirová L, Kužel D, Žižka Z. Ashermanův syndrom I – historie, prevalence, histopatologie, klasifikace, etiologie, symptomatologie a vyšetřovací metody. Ceska Gynekol 2010; 75 (6): 492–498.

8. Sebbag L, Even M, Fay S et al. Early second-look hysteroscopy: prevention and treatment of intrauterine post-surgical adhesions. Front Surg 2019; 6: 50. doi: 10.3389/fsurg.2019.00 050.

9. Mara M, Horak P, Kubinova K et al. Hysteroscopy after uterine fibroid embolization: evaluation of intrauterine findings in 127 patients. J Obstet Gynaecol Res 2012; 38 (5): 823–831. doi: 10.1111/j.1447-0756.2011.01782.x.

10. March CM. Management of Asherman‘s syndrome. Reprod Biomed Online 2011; 23 (1):  63–76. doi: 10.1016/j.rbmo.2010.11.018.

11. Yu D, Wong YM, Cheong Y et al. Asherman syndrome – one century later. Fertil Steril 2008; 89 (4): 759–779. doi: 10.1016/j.fertnstert. 2008.02.096.

12. Hrazdirová L, Kužel D, Žižka Z. Ashermanův syndrom II – terapie, asistencní metody, prevence readhezí, komplikace a výsledky lécby. Ceska Gynekol 2010; 75 (6): 499–506.

13. Dreisler E, Kjer JJ. Asherman‘s syndrome:  current perspectives on dia­gnosis and management. Int J Womens Health 2019; 11: 191–198. doi: 10.2147/IJWH.S165474.

14. Hanstede MM, van der Meij E, Goedemans L et al. Results of centralized Asherman surgery, 2003–2013. Fertil Steril 2015; 104 (6): 1561–1568. doi: 10.1016/j.fertnstert.2015.08.039.

15. Li C, Wei ML, Lin XN et al. Effects of early intervention of second-look office hysteroscopy in the prevention of adhesion reformation for moderate-severe Asherman‘s syndrome. Zhonghua Yi Xue Za Zhi 2013; 93 (45): 3617–3619.

16. Xu W, Zhang Y, Yang Y et al. Effect of early second-look hysteroscopy on reproductive outcomes after hysteroscopic adhesiolysis in patients with intrauterine adhesion, a retrospective study in China. Int J Surg 2018; 50:  49–54. doi: 10.1016/j.ijsu.2017.11.040.

17. Wood J, Pena G. Treatment of traumatic uterine synechias. Int J Fertil 1964; 9: 405–410.

18. AAGL Elevating Gynecologic Surgery. AAGL practice report: practice guidelines on intrauterine adhesions developed in collaboration with the European Society of Gynaecological Endoscopy (ESGE). Gynecol Surg 2017; 14 (1): 6. doi: 10.1186/s10397-017-1007-3.

19. Guo J, Li TC, Liu Y et al. A prospective, randomized, controlled trial comparing two doses of oestrogen therapy after hysteroscopic adhesiolysis to prevent intrauterine adhesion recurrence. Reprod Biomed Online 2017; 35 (5): 555–561. doi: 10.1016/j.rbmo.2017.07. 011.

20. Liu L, Huang X, Xia E et al. A cohort study comparing 4 mg and 10 mg daily doses of postoperative oestradiol therapy to prevent adhesion reformation after hysteroscopic adhesiolysis. Hum Fertil (Camb) 2019; 22 (3): 191–197. doi: 10.1080/14647273.2018.1444 798.

21. Conforti A, Alviggi C, Mollo A et al. The mana­gement of Asherman syndrome: a review of literature. Reprod Biol Endocrinol 2013; 11: 118. doi: 10.1186/1477-7827-11-118.

22. Vesce F, Jorizzo G, Bianciotto A et al. Use of the copper intrauterine device in the mana­gement of secondary amenorrhea. Fertil Steril 2000; 73 (1): 162–165. doi: 10.1016/s0015- 0282 (99) 00475-6.

23. Tonguc EA, Var T, Yilmaz N et al. Intrauterine device or estrogen treatment after hysteroscopic uterine septum resection. Int J Gynaecol Obstet 2010; 109 (3): 226–229. doi: 10.1016/j.ijgo.2009.12.015.

24. Amer MI, El Nadim A, Hassanein K. The role of intrauterine baloon after operative hysteroscopy in the prevention of intrauterine adhesion: a prospective controlled study. MEFS J 2005; 10: 125–129.

25. Orhue AA, Aziken ME, Igbefoh JO. A comparison of two adjunctive treatments for intrauterine adhesions following lysis. Int J Gynaecol Obstet 2003; 82 (1): 49–56. doi: 10.1016/s0020-7292 (03) 00030-4.

26. Lin XN, Zhou F, Wei ML et al. Randomized, controlled trial comparing the efficacy of intrauterine balloon and intrauterine contraceptive device in the prevention of adhesion reformation after hysteroscopic adhesiolysis. Fertil Steril 2015; 104 (1): 235–240. doi: 10.1016/j.fertnstert.2015.04.008.

27. Zhu R, Duan H, Gan L et al. Comparison of intrauterine suitable balloon and foley bal­loon in the prevention of adhesion after hysteroscopic adhesiolysis. Biomed Res Int 2018; 2018: 9494101. doi: 10.1155/2018/9494 101.

28. Amer MI, Abd-El-Maeboud KH. Amnion graft following hysteroscopic lysis of intrauterine adhesions. J Obstet Gynaecol Res 2006; 32 (6): 559–566. doi: 10.1111/j.1447-0756.2006.00 454.x.

29. Amer MI, Abd-El-Maeboud KH, Abdelfatah I et al. Human amnion as a temporary bio­logic barrier after hysteroscopic lysis of severe intrauterine adhesions: pilot study. J Minim Invasive Gynecol 2010; 17 (5): 605–611. doi: 10.1016/j.jmig.2010.03.019.

30. Peng X, Li T, Zhao Y et al. Safety and efficacy of amnion graft in preventing reformation of intrauterine adhesions. J Minim Invasive Gynecol 2017; 24 (7): 1204–1210. doi: 10.1016/j.jmig.2017.08.005.

31. Kužel D, Mára M. Prevence tvorby adhezí a jejich léčba. Ceska Gynekol 2011; 76 (1):  73–76.

32. Acunzo G, Guida M, Pellicano M et al. Effectiveness of auto-cross-linked hyaluronic acid gel in the prevention of intrauterine adhesions after hysteroscopic adhesiolysis: a prospective, randomized, controlled study. Hum Reprod 2003; 18 (9): 1918–1921. doi: 10.1093/humrep/deg 368.

33. Lin X, Wei M, Li TC et al. 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 (2): 512–516. doi: 10.1016/j.ejogrb.2013.07. 018.

34. Fei Z, Bin Z, Xin X et al. Meta-analysis on the use of hyaluronic acid gel to prevent recur­rence of intrauterine adhesion after hysteroscopic adhesiolysis. Taiwan J Obstet Gynecol 2019; 58 (6): 731–736. doi: 10.1016/j.tjog.2019.09. 002.

35. Javaheri A, Kianfar K, Pourmasumi S et al. Platelet-rich plasma in the management of Asherman‘s syndrome: an RCT. Int J Reprod Biomed 2020; 18 (2): 113–120. doi: 10.18502/ijrm.v18i2.6423.

36. Chen Y, Liu L, Luo Y et al. Effects of aspirin and intrauterine balloon on endometrial repair and reproductive prognosis in patients with severe intrauterine adhesion: a prospective cohort study. Biomed Res Int 2017; 2017: 8526104. doi: 10.1155/2017/8526104.

37. Chen L, Qu J, Xiang C. The multi-functional roles of menstrual blood-derived stem cells in regenerative medicine. Stem Cell Res Ther 2019; 10 (1): 1. doi: 10.1186/s13287-018-1 105-9.

38. Liu F, Hu S, Yang H et al. Hyaluronic acid hydrogel integrated with mesenchymal stem cell-secretome to treat endometrial injury in a rat model of Asherman‘s syndrome. Adv Healthc Mater 2019; 8 (14): e1900411. doi: 10.1002/adhm.201900411.

39. Benor A, Gay S, DeCherney A. An update on stem cell therapy for Asherman syndrome. J Assist Reprod Genet 2020; 37 (7): 1511–1529. doi: 10.1007/s10815-020-01801-x.

40. Zhao Y, Luo Q, Zhang X et al. Clinical efficacy and safety of stem cell-based therapy in treating asherman syndrome: a system review and meta-analysis. Stem Cells Int 2020; 2020: 8820538. doi: 10.1155/2020/8820538.

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