FERTILITY AND STERILITY
9, September 1973
Copyright © 1973 by The Williams & Wilkins Co.
Current Perspectives
ASHERMAN'S SYNDROME: A CRITIQUE AND CURRENT REVIEW
STEVEN M. KLEIN, M.D.,
Division of Human Reproduction, Departments of Obstetrics and Gynecology, Hospital of the University of
Pennsylvania, and the Philadelphia General Hospital, Philadelphia, Pennsylvania 19104
In this day of liberalized attitudes to-
ward termination of pregnancy, wide-
spread sexual freedom with its companion
venereal disease, and, paradoxically, the
intense interest in premium pregnancy,
there seemingly is encountered an increase
in the incidence of pathologic states. This
is not to imply the occurrence of new
diseases, but merely the reward for a
greater effort in seeking out existing condi-
tions. It was such considerations which led
to a review of the etiology, diagnosis, and
varied forms of treatment of Asherman's
syndrome.
Today, more physicians are accepting
the social challenges of these times. They
are taking termination of the unwanted
pregnancy from the "gutter" and bringing
it into the sanctuary of the hospital, where
counseling and, when indicated, proper
termination can be carried out. Abortion
has been associated with increases in sex-
ual freedom, which paradoxically have ac-
centuated the importance of the subspe-
cialty of infertility for women who hereto-
fore had little or no hope. It is apparent
that the medical profession should be re-
sponsible for ensuring that these ap-
proaches will not be disabling to reproduc-
tive function, that the population will be
protected against the ravages of venereal
disease, and that patients will have the
best possible chances for not only a wanted
pregnancy but also one nurtured in a
healthy environment.
Milroyl points out that Asherman's syn-
Vol. 24, No.
Printed in U.S.A.
AND CELSO-RAMON GARciA, M.D.
drome probably has been underdiagnosed
in the United States. Topkins 2 reports the
largest series of 25 cases. In metropolitan
Philadelphia during the last 10 years, at
four of the major hospitals with heavy ward
gynecologic populations, fewer than 20
cases were noted. The larger series are
reported from Israel, Chile, and Greece, as
well as from other parts of Europe. Some of
these reports (Asherman 3 and Louros et
al. 4) suggest a very high incidence of this
syndrome. Comninos and Zourlas 5 attrib-
ute this to the high rate of illegal abortion
in Greece. It should also be appreciated
that the incidence of tuberculosis in these
areas of the world is extremely high. An-
other factor which should be considered is
the overdiagnosis of this syndrome if only
minimal criteria are used. This is particu-
larly so if heavy emphasis is placed on
hysterosalpingography, as noted by Zondek
and Rozin. 6
It is the intent of this paper to describe
Asherman's syndrome in today's context,
to review the meaningful literature as it
relates to the description and management
of this entity, and to present the varied
forms of treatment used in our medical
center.
REVIEW OF THE LITERATURE
Definition and History
Asherman's syndrome is a complex path-
ologic state. Asherman,7 in his early publi-
cation, dealt only with the subject of intra-
722
September 1973 ASHERMAN'S SYNDROME
cervical adhesions. Today, the syndrome
which bears his name describes a variable
amount of destruction of the endometrial
cavity, diminished menstrual flow, infertil-
ity, and repeated pregnancy 10ss.8 A nu.m-
ber of synonyms have been used to desCribe
this syndrome (Table 1).
Lack of a strict definition for the syn-
drome has resulted in numerous reports in
which the patient population has an ex-
treme variance of the pathology, symp-
tomatology, and diagnosis. Many authors
believe that a history of postpartal or
postabortal curettage is enough to justify
the diagnosis even when the other criteria
are met only minimally. In its strictest
sense, Asherman's syndrome, as noted in
Table 2, presents as a permanent adher-
ence of the anterior and posterior uterine
walls. This obliteration may be partial or
complete, and the location of the adhesions
is variable. The result is a small or nonex-
istent uterine cavity characterized clini-
cally by menstrual abnormalities, infertil-
ity, and habitual abortion. 9 •
Table 3 summarizes the most salIent
reports dealing with this syndrome. Of note
are several large series of patients collected
within a relatively short period of time.
Large series are an enigma. The definition
of Asherman's syndrome has been modified
beyond the simple traumatic amenorrhea
TABLE 1. Semantic References to Asherman's
Syndrome
1. Amenorrhea traumatica (atretica)
2. Fritsch-Asherman's syndrome
3. Traumatic intrauterine adhesions or synechiae
4. Post-traumatic intrauterine synechiae
5. Endometrial sclerosis
6. Adhesive endometriosis
7. Isthmic stenosis
8. Intrauterine synechiae
9. Uterine atresia
10. Postcurettage atresia of the endometrial cavity
11. Intracervical adhesions
12. The Fritsch syndrome
13. The Asherman's syndrome
723
TABLE 2. Criteria for Definition of Asherman's
Syndrome
1. Permanent adherence of uterine walls
2. Partial or complete obliteration of uterine cavity
3. Variable placement of adhesions
4. Clinical symptoms, i.e.:
Menstrual abnormal-
ities
Infertility
Habitual abortion
and more recently has included even pa-
tients with normal menstrual habits.
Incidence and Etiology
The incidence of Asherman's syndrome
was thought to be low. However, Eriksen 10
reported a 20-25% incidence of intrauter-
ine adhesions of some degree in all pa-
tients treated with a D&C within 2 months
after delivery. The number of cases of
Asherman's syndrome reported by other
authors is unusually high (Table 3). Most
patients were first screened by hysterosal-
pingogram, and the results were then cor-
related with a retrospective history of a
D&C. Thus, the inciting factor was not
necessarily related to a pregnancy, and an
unusual emphasis was placed on the hys-
terosalpingogram alone. According to
Dmowski and Greenblatt,11 all patients
subjected to hysterosalpingograms have a
1.5% incidence of synechiae. In patients
selected for hysterosalpingograms, with the
appropriate history and physical examina-
tion, the incidence was found to be 39%.
In areas with strict abortion laws, and
also in areas with liberal ones, the fre-
quency of postpartal and postabortal cu-
rettage is markedly increased. With the
relatively recent advent ofliberalized abor-
tions in the United States and the need for
secondary curettage in some subjects, per-
haps the incidence of Asherman's syn-
drome here will also rise. Care will have to
be exercised to diagnose this entity ade-
quately and not merely to rely on a single
 -J
l:\:)
..,.
TABLE 3. Inferred Incidence and Therapeutic Approaches*

Author Country Year Etiology Objective No. of

findings cases
Treatment Contribution

Fritsch' Germany 1894 D&C(PPH) Atresia 1 Dilator and First description

scalpel
Viet'· Europe 1894- 16 Additional case
Wertheim'· Europe 1927 descriptions
Halban'· Europe
Kustner'· Europe
Bass'· Germany 1927 InducedAb Isthmic stenosis 20 D&C
Stamer 7 Denmark 1946 PP; curettage Variable stenosis 24 Dilator I
Asherman 7 Israel 1948 PP; curettage Variable stenosis 29 Varied Interest and repeated II
publications
Hald' Denmark 1949 PP; curettage Variable stenosis 22 Varied HSPG
Musset" France 1953 PPandPAb; Variable stenosis 13 Varied Increased awareness I
curettage of uterine factor in i
Netter" France 1956 PP and PAb; Variable stenosis 42 Varied infertility and ~
I:)
curettage menstrual
Musset" France 1957 PPandPAb; Variable stenosis 100+ Varied irregularities
o
curettage ~
("}
Eriksen' Denmark 1960 PP; curettage Variable stenosis 61 Varied >'
Asherman 3 Israel 1960 PP and PAb; Variable stenosis 250 Varied
curettage
Topkins' United States 1962 PP; curettage Variable stenosis 25 Varied
Wood and Peria 12 Chile 1963 PPandPAb; Variable stenosis 178 Varied Estrogens
curettage
Louros et al. • Greece 1968 D&C, TAb, and Variable stenosis 80 Varied IUD
illegal Ab
Polishuk18 Israel 1969 HabitualAb CorpAdh 20 D&C;IUD IUD
Comninos and Greece 1969 TAb and illegal Intrauterine and 12 Foley catheter, Foley catheter
Zourlas' Ab endocervical Adh antibiotics,
progestins
---

* Ab, abortion; PP,\postpartum ;\PAb,\postabo rtion;\PPH,\po stpartum\ hemorrhage; TAb,\ therapeutic abortion;\HSPG , hysterogram; I Corp Adh,
corporeal
adhesions; IUD, intrauterine device; Adh, adhesions. ~
.....
~

"f" I>
September 1973 ASHERMAN'S SYNDROME 725

criterion. Further confusion may result TABLE 4. Etiologic Factors

since traumatic uterine synechiae could be
1. Congenital-(hypothetical)-no reported cases"
a consequence of spontaneous abortion, 2. Trauma"
although they also may have been present A. Characteristics
as a result of other conditions associated 1. Usually multiple (if not puerperal)
with infertility which may still persist at 2. Mainly isthmic
the time of the investigation. 12 3. Usually extensive
B. Forms
The etiology could be considered from 1. D&C (diagnostic)
three viewpoints. As noted in Table 4, the 2. Evacuation of moles
first etiology is congenital. This must be 3. Myomectomies
considered theoretical, since there are no 4. C-sections
known case reports. 18 The second etio- 5. Caustic abortifacients
6. Packing
logic factor is infection. In Europe, tuber- 7. Posthysterotomy (trauma)
culosis is present in relative abundance 8. Diagnostic endometrial biopsy
and may explain those adhesions arising 9. Postpartum D&C
without an antecedent history of trauma. 10. Postabortal D&C
Septic abortions are still equivocal. The 3. Infection
A. Trauma
third cause is traumatic. Most common is 1. May precede (PROM)
the puerperal D&C. Cases have been re- 2. May result from (septic abortion)
ported posthysterotomy, mainly for myo- B. No trauma
mectomy. The diagnostic endometrial 1. Tuberculosis
biopsy or D&C has been implicated, but 2. PID
4. Timing of trauma
the data are less convincing. 14 A. Bergman'"-puerperal D&C; spontaneous in-
Most authors agree that trauma is the complete abortion
common denominator. Whether an en- B. Eriksen '·-(between first and fourth week post-
dometritis exists prior to or is caused by partum)
the trauma, usually in the form of a D&C, 5. Individual susceptibility'?
is conjectural. 15 Without an antecedent
surgical history, however, one must con- duce this syndrome by vigorous curettage
sider a tubercular or a pelvic inflammatory within the first 48 hr. of the puerperium
disease origin. However, Asherman's syn- failed, and it was assumed that factors such
drome is the result of more than just an as infection and individual susceptibility
overly vigorous D&C of the gestational might be at fault. 17 Other investigators 19
uterus or the denudation down to the have attempted unsuccessfully to produce
myometrium. Asherman's syndrome.
Bergman, 16 in 1961, presented a series in Asherman originally reported that adhe-
which Asherman's syndrome occurred sions formed secondarily to the mechanical
more often after puerperal D&C than after forces, but Rabau and David 20 maintained
D&C for incomplete abortion. Eriksen 10 that the "primum movens" is infection,
noted that D&C during the second, third, and as an example they pointed to the
and fourth weeks postpartum leads to a cornual adhesions noted where the curet
higher incidence of intrauterine adhesions, was unable to reach but where infection
with greater severity, than does D&C dur- could easily spread. Active infection in the
ing the first or after the fourth week post- uterine cavity at the time of the traumatic
partum. From these observations by Erik- D&C could not be proved either on the
sen,10 postpartum curettage within the basis of fever or through peripheral white
first 48 hr. should be less disposed to adhe- counts in most patients described by some
sion formation. Indeed, attempts to pro- of these authors. Those patients curetted
726 KLEIN AND GARciA
between 1 and 4 weeks postpartum who did
develop Asherman's syndrome had the
same pathologic appearance-an increased
number of inflammatory cells, with degen-
eration and tissue edema-as those who
did not develop Asherman's syndrome.
Bacteriologic results were not available. It
had also been postulated that the endome-
trium of those who did develop Asherman's
syndrome during this time may have been
refractory to estrogens. Exogenous estro-
gens given at the time of curettage and
then maintained did not prevent Asher-
man's syndrome. It is likely, however, that
the endometrium responds to estrogens,
either exogenous or endogenous, immedi-
ately postpregnancy. Moreover, even
gentle suction curettage was found to be
as provocative as sharp curettage. 21
In summary, curettage done 1-4 weeks
postpartum or postabortion may result in
production of intrauterine adhesions with
or without cervical stenosis. 21 Immediate
postpartal curettage will not cause trau-
matic intrauterine adhesions; the uterus
must be in a vulnerable phase. Diagnostic
D&C will not cause Asherman's syndrome;
rarely will prompt D&C for early spontane-
ous abortion cause it.
Pathophysiology
Table 5 summarizes the more important
theories of the pathophysiology. Asherman
believed that sustained myometrial con-
tractions cause narrowing of the isthmus,
resulting in adhesions between opposing
endometrial surfaces. Thus, a neural com-
TABLE 5. Summary of Proposed Pathophysiology
1. Permanent contraction of uterine muscles-neural
component-narrowing isthmus, resulting in
adhesions of opposite surfaces""
2. Basalis trauma = granular tissue-bridges of scar
tissue infiltrated by myometrium and covered
by endometrium
3. Formation of adenomyosis-25%'°
4. Abnormal response of uterus to normal cyclic
hormonal stimuli·
Vol. 24
ponent is implied. 7. 9 Most authors believe
that trauma is induced in the basal endo-
metrium, causing granular tissue to form
on opposing walls which bridge to form scar
tissue that eventually may be infiltrated by
myometrium and covered by endome-
trium. Development of adenomyosis is a
common concomitant event which proba-
bly accounts for the pelvic pain experi-
enced by 25% of the patients with Asher-
man's syndrome. 10 What is affected, there-
for, is the reaction of the endometrium to
the normal uninterrupted cyclic hormonal
stimuli. 3 The adhesions are scars resulting
from the healing of a wound, and they
connect the anterior to the posterior uter-
ine wall.15 The endometrial cavity is re-
duced in size.
Symptomatology and Diagnosis
The main symptoms are infertility, sec-
ondary amenorrhea, cyclic painful hypo-
menorrhea, menstrual irregularities, and
habitual abortion. Of all the symptoms re-
lated to Asherman's syndrome, the most
common is infertility (Table 6). This, of
course, is noted in conjunction with dis-
turbances of menstrual function. Various
theories for the etiology of the infertility
have been proposed. Adhesions may im~
pede sperm migration. They also may cre-
ate an unsuitable endometrial environ-
ment for the blastocyst and, in addition,
actually may obstruct implantation me-
chanically. Adhesions may cause an occult
TABLE 6. Symptoms
1. Infertility
2. Menstrual irregularities
3. Pregnancy abnormalities
A. Spontaneous habitual abortion (first trimester)
B. Missed abortion (second trimester)
C. Intrauterine fetal demise (third trimester)
D. Premature labor
E. Ectopic pregnancy
F. Obstetric complications:
Accreta
Previa
 September 1973 ASHERMAN'S SYNDROME
abortion, a missed abortion, or an intrauter-
rine fetal demise. Other consequences, as
noted by Forssman,23 include a 33% abor-
tion rate of established pregnancies, a 33%
rate of premature labor, and approxi-
mately a 33% rate of ectopic pregnancies,
placenta accretas, and placenta previae.
Secondary amenorrhea occurs when the
lower uterine segment is obliterated or
when the endometrial cavity is severely
sclerosed. Hypomenorrhea occurs more of-
ten, especially with scattered corporeal ad-
hesions. Other symptoms include menor-
rhagia, metrorrhagia, pelvic pain, and
dysmenorrhea. 15 As noted in Table 7, the
symptoms and signs may be related to the
degree of atresia. If the isthmic obstruction
is sufficient, hematometra and hematosal-
pinx may result. A failure among patients
with amenorrhea or hypomenorrhea to re-
spond to hormonal therapy is quite charac-
teristic. Carmichael 10 maintained that
there may be no signs or symptoms except
those noted at hysterosalpingography.
Others do not share this view. Zondek and
Rozin 6 have demonstrated the reversal of
the hysterosalpingographic findings by
uterine denervation only. Therefore, the
diagnosis of Asherman's syndrome cannot
be made by hysterosalpingography alone.
Hald, then Asherman, attempted to
make this syndrome known in medical cir-
TABLE 7. Correlation of Signs and Symptoms with
Extent of Disease
Signs and symptoms with objective findings of
Cervical and/or
Corporeal adhesions Total atresia
isthmic stenosis
Secondary Amen- Hypomenorrhea Secondaryamen-
orrhea orrhea
Pelvic pain Menometrorrhagia Infertility-no
pregnancies
Dysmenorrhea No symptoms (diag-
Hematometra nosis on basis of
hysterogram)
Hematosalpinx Infertility-usually
Unresponsive to takes form of ha-
hormones bitual abortion
Infertility-no and/or problems
pregnancies with pregnancy
727
cles as a cause of secondary infertility.
However, in the United States it may not
have been diagnosed consistently, since it
has been listed infrequently in the differ-
ential diagnostic reviews. In many in-
stances, cases are viewed as dysfunctional
uterine bleeding secondary to gonadal or
gonadotrophic disturbances and even have
been treated with hormones. 12 If hormonal
therapy follows a D&C for diagnosis (even
though the tissue report not uncommonly
reads "quantity not sufficient"), sponta-
neous cures sometimes may seem appar-
ent, at least for a period of time. This lulls
the practitioner into a false sense of
security, but the patient's infertility still
persists and often her menstrual habit soon
reverts to an abnormal one.
Asherman's syndrome is characterized
by rather definite symptoms relating to
menstrual changes following mechanical
curettage. It is discouraging that, in view of
such precise signs of menstrual irregularity
which appear immediately after instru-
mental curettage, a correct diagnosis is
seldom made. 12
In establishing the diagnosis of a single
cause for infertility, the existence of other
factors, organic and functional, must also
be investigated. The differential diagnosis
of Asherman's syndrome includes postpar-
tum gonadotropic failure, hypothalamic
amenorrhea, and premature menopause,
among other more exotic conditions. 24
The final diagnosis may be facilitated
with the aid of the criteria listed in Table 8,
as described below.
Hysterosalpingogram. Asherman's syn-
drome has been reported in 5% of all
hysterosalpingograms done for habitual
TABLE 8. Diagnostic Methods
1. lIysterosalpingograrn
2. Sounding
3. lIorrnonal withdrawal tests
4. lIistory
5. Pathologic histology
728 KLEIN AND GARCiA
abortion (Rabau and David 20 ). Of note is
the lacunar pattern of sharply angulated or
straight, but definitely not rounded, filling
defects. These defects may be single or
multiple. They are variable in size and are
irregular in shape. They may be central or
peripheral and must be differentiated from
filling artifacts whose appearance is more
variable in serial films. It is suggested that
only 2 ml. of radiopaque material be used
for the first film, because an excess may
obscure the adhesions. 15 False positive hys-
terosalpingograms may be seen with sub-
mucous myomas, endometrial polyps, in-
trauterine septae, physiologic contractions,
and air bubbles; therefore, the use of image
intensification and fluoroscopy is invalua-
ble. As a radiation hazard, 30 sec. of
fluoroscopy are equal to only one routine
abdominal film.lO If adhesions are exten-
sive enough, vaginal leakage and intravas-
cular and intra lymphatic extravasation are
common 22; but this is not pathognomonic,
since extravasation is seen in 0.4-4.7% of
all hysterosalpingograms. 11
Uterine Sounding. Exploration with a
cannula, with a sound, or with a curet to
locate the adhesions is imperative. 15
Hormone Withdrawal Test. Failure to
bleed, after proper estrogen priming, pro-
gesterone conversion, and withdrawal, is
very important to the diagnosis of end
organ failure. 15 Biphasic basal body tem-
perature curves without evidence of endo-
crinopathy are significant.7 Such patients
with ovarian function and amenorrhea
probably represent the more severe forms
of this syndrome.
Clinical History. A careful history may
be almost diagnostic. Occasional spotting
or absence of menses is noted. Cyclic lower
abdominal pain or low back discomfort,
without flow, is suggestive. The timing of
the puerperal or postabortal curettage is
important, as has been noted by Jensen
and Stromme. 21 In the usual situation, the
curettage had taken place :>ome 21/2 weeks
Vol. 24
after delivery or after abortion, and the
pathology report most often presents find-
ings of basal endometrium with significant
amounts of deciduitis, myometrial frag-
ments, and degenerated placental villi, as
well as endocervical and cervical tissue.
The important historic feature is post-
gravid endometrial infection. 20
Pathologic Anatomy of the Diagnostic
Biopsy or D&C. On section, synechiae are
noted between the myometrial walls. A
core of endometrial stroma with fibrosis is
noted as a fibromuscular band surrounded
by superficial epithelial cells. Rarely, calci-
fied bodies are seen. Myometrium may be
found in the adhesions with or without
inflammatory cells such as those found in
granulomas, i.e., plasma cells, white blood
cells, and lymphocytes.
Twenty-five per cent of the patients are
reported to have normal endometria with
round cell stromal infiltration in addition
to synechiae. 15 These may be the "inflam-
matory adhesions" that may form without
trauma.
There are variable amounts of mucoid,
fibrous, and muscle tissue and atrophic
endometrium. 4 Although Netter et al. 22
warn us not to overlook the authentic
infectious causes of amenorrhea, e.g., tu-
berculosis, evidence that the diagnosis has
been considered, through culture or even
history of pulmonary tuberculosis, is not
noted in the large series.
No endometrial tissue was found in ex-
tirpated uteri in cases of complete uterine
cavity atresia. 11 In cases of moderate cor-
poreal involvemept, chronic round cell in-
filtration with a normal glandular pattern is
sometimes noted. In advanced cases, one
notes atrophy, fibrosis, loss of stromal
edema, and lymphocytic infiltration in the
luteal phase. Round cells are seen in all
gradations except in the most severe cases.
The fallopian tubes may be involved sec-
ondarily to the primary infectious process
and, as such, tubal pregnancy may result. 20
September 1973 ASHERMAN'S SYNDROME
Treatment
Treatment may be indicated for various
reasons. Therapy may be necessary to
restore menses, to correct infertility, to
correct habitual abortions, to cure dys-
menorrhea and, in rare circumstances, to
treat hematometra. The basic therapies
described in the literature include cervical
dilatation, lysis of adhesions by curettage,
exogenous hormonal therapy, and, in some
instances, abdominal hysterotomy. 14
Table 9 summarizes the various treat-
ment methods described by a number of
different authors reporting in the world
literature. This varied spectrum in itself
connotes the enigma which therapy for this
condition presents today.
Prognosis
Bergman 16 believed that a woman with
severe intrauterine adhesions had a poor
likelihood of eventually giving birth to a
living child. Only 30% will conceive, and of
these only 50% will carry to term.
Dmowski and Greenblatt l l pointed out
that there are known cases of term preg-
nancy coincidental with uterine synechiae.
Therefore, the causal relationship between
sterility and adhesions is often difficult to
establish, and other factors must be ex-
cluded, such as the tubal factor.
Spontaneous recovery may occur but
may take months or years.21 No documen-
tation of spontaneous resolution of adhe-
sions has been made; hence, these reported
fertility rates are suspect. 14 Forssman 23
noted a better prognosis if the primary
insult was a postabortal D&C. Cervico-
isthmic adhesions alone give the best
results. 11 Wood and Peiia 12 reported a 63%
menstrual success rate and a 58% preg-
nancy success rate, but only 40% of those
patients had a normal delivery. Immediate
evidence of anatomic restitution of the
endometrial cavity and the fallopian tubes
does not necessarily portend a satisfactory
long term result. The prognostic determi-
729
TABLE 9. Various Treatment Methods
Historical interest
Spontaneous (Bergman 25)
Chemico-therapeutic agents (Asherman 9 , 12, 14)
Allow early gestation 10, 21
Present modalities
Limited effectiveness
Transplants
Fallopian tubes 15
Donor endometrium 25
Fetal membranes 10, 15
Decidua 10, 15
Placenta 10, 15
Denervation (Zondek and Rozin 6 )
Pseudopregnancy (progestins) 5, 11, 25, 27
Spasmolytics'
Probable effectiveness
D&C', 5, 28
Hysterotomy
Dilate cervix from above (Bergman 16, 29)
With hematometra and/or hematosalpinx
(N etter et al. 22)
Antibiotics 1, 5, 10, 12
Steroids 20, 30
Prostheses
Polyethylene tubing 1, 5, 10
Catheters 10
Drains 10
Balloons 10
Intrauterine device" 31, 32
Hormones (estrogens) 1, " 5,10, 12, 14, 27, 31
nants include: (1) initial disease state, (2)
type of therapy applied, (3) duration of
follow-up, and (4) involvement of other
causes for the infertility. 12. 13
MATERIAL AND METHODS
Eleven patients with Asherman's syn-
drome presenting as intrauterine distortion
and diminished menstrual flow were
treated by the staff of the Department of
Obstetrics and Gynecology of the Univer-
sity of Pennsylvania, at the Hospital of the
University of Pennsylvania or at the Phila-
delphia General Hospital, during the inter-
val between July 1968 and June 1972
(Table 10).
The patients ranged in age from 22 to 37
years (mean, 29.1 years). Six were referred
for infertility, and 5 were diagnosed during
730 KLEIN AND GARCiA Vol. 24

TABLE 10. Findings in 11 Patients with Asherman's Syndrome with Corporeal Adhesions*
Duration No. of
of men- Additional
Patient Age Parity Etiology D&C's Tissue treatment
strual diagnosis Follow-up
elsewhere- used
symptoms HUP
yr.
Severe
disease
A.U. 26 3/2 (Ab) 3 yr., Am PAbH;D&C 0-1 Scattered None Pregnancy
glands
J. B. 23 1/1 1yr., Am P Septic Ab 0-1 Synechiae IUD NP
with D&C
S.J. 34 2/1 7mo.,Am P Septic Ab O-Lippes QNS IUD Amenorrhea
with D&C loop
L.S. 34 0/2 3 yr., Am PAb;D&C 4-3 QNS Decadron and NP(husband
Phenergan factor)
L.M. 21 1/0 1 yr., Am PPH;D&C Endome- QNS Decadron and Pregnancy
trial Phenergan (2 Ab)
biopsy-S'
Z.B. 33 0/2 6mo.,Am PAb; D&C 0-2 Prolif. En. Decadron and Pregnancy
Phenergan
M.B. 37 1/0 1yr., Am SIP C-section 2-3 QNS Laparotomy Pregnancy
for
periadnexal
adhesions
Moderate
disease
E.M. 22 0/1 1 yr., Hypo P Septic Ab 0-2 Prolif. En. None NP (tubal
with D&C factor)
A.T. 33 1/0 2yr., Hypo PPH;D&C 0-1 QNS None Pregnancy
D.M. 30 0/1 1 yr., Hypo PAb; D&C; 0-1 Scattered Laparotomy Pregnancy
infection glands for
Peri adnexal
adhesions
D.T. 27 0/2 7yr., Hypo P Septic Ab
with D&C
0-1
IS':::'~'Y None Periadnexal
adhesions;
myoma

* The severity of disease was determined at operation and by hysterosalpingogram. HUP, Hospital of the
University of Pennsylvania; P, post-; S, septic; Ab, abortion; Hypo, hypomenorrhea; Am, amenorrhea; PAbH,
postabortion hemorrhage; NP, normal periods; PPH, postpartum hemorrhage; QNS, quantity not sufficient.
Unless otherwise specified, treatment at HUP refers to that outlined in the text.

the course of delivery of primary care. In all
cases there was associated trauma subse-
quent to pregnancy, and most had docu-
mented intrauterine infections at the time
of the traumatic event. The diagnosis of
intrauterine adhesions was supported in
each instance by the five diagnostic criteria
listed above. Of pertinence is the fact that
7 patients presented with amenorrhea
which was associated with extensive oblit-
eration of the uterine cavity. Four patients
had hypomenorrhea with less severe uter-
ine deformity. The results of the patho-
logic examination of curettage specimens
were variable. All patients sought help for
secondary infertility. .c.
Table 11 lists the therapeutic regimens
which were used for most of these patients.
The approach consisted of careful sounding
of the uterine cavity, followed by dilatation
and curettage with histologic examination.
A pediatric Foley catheter was inserted
September 1973 ASHERMAN'S SYNDROME
into the uterine cavity and the bag was
to a 3-ml. volume. Conjugated estro-
gens were given at dosages of 5.0-7.5 mg.
daily in divided doses. In the event of
breakthrough bleeding, the estrogen dose
was increased. Broad-spectrum antibiotics
were initiated preoperatively in most in-
stances. The Foley catheter was removed
after 5-7 days. Antibiotics were continued
for a week to 10 days. The estrogens were
continued for 21 days with medroxyproges-
terone acetate, 5 mg./day for the last 5
days, to simulate a 28-day cycle. 33 This
regimen was repeated, starting either 1
week later or on Day 5 of flow, for at least 1
additional cycle, depending upon the men-
strual response. In the event of failure of
return of normal flow patterns, the patient
was followed, and the therapeutic regimen
with uterine cavity dissection was repeated
some 6 months later. Except for 2 patients
treated with an intrauterine device and
those treated additionally with dexameth-
asone and promethazine, all patients were
treated similarly. The dexamethasone and
promethazine regimen has been added re-
cently, since these agents possibly aid in
the prevention of the recurrence of adhe-
sions through their anti-inflammatory ac-
tions and other properties. Three subjects
were so treated. Dexamethasone, 20 mg.,
was given intramuscularly 6 hr. and again
at 3 hr. prior to surgery. Concomitantly,
but in a separate intramuscular injection,
promethazine, 25 mg., also was given.
These drugs were continued postopera-
tively every 4 hr. for nine doses. This is the
regimen now used routinely in our clinic for
those patients undergoing laparotomy for
abdominal adhesions. In those patients in
whom the menstrual habit was not im-
proved within some 6 months or in whom
pregnancy did not ensue, and when the
patient permitted, corrective treatment
was repeated after re-evaluation of the
endometrial cavity. In those instances in
which menstrual habit was normalized and
pregnancy did not occur, pursuit of other
731
TABLE 11. Treatment Schedules
1. Start antibiotics (broad-spectrum) and continue
for 7-10 days
2. Estrogens (conjugated) 5.0-7.5 mg. daily for 28
days for 2 cycles
3. D&C
4. Foley catheter (pediatric 3-ml. Foley catheter) for
3 days
5. Progesterone (medroxyprogesterone acetate), 5
mg. daily, Days 24-28, to cause regular shedding
6. Start dexamethasone, 20 mg. in-
tramuscularly every 4 hr. for 36 hr. )TO pr~vent
7. Start promethazine, 25 mg. in- adheSIOn
tramuscularly every 4 hr. for 36 hr. reformation
factors was initiated as circumstances per-
mitted.
RESULTS
The observations on the 11 patients are
summarized in Table 10 and are listed
according to severity of their presenting
symptoms. It was possible to re-establish
normal menstrual patterns in 6 (86%) of
the 7 women with severe disease. The
single exception was a patient in whom a
Lippes loop was inserted as a variant of the
usual D&C routine. Pregnancies were es-
tablished in 4 of these patients (57%). One
pregnancy did not go to term; there has
since been an additional spontaneous abor-
tion in the first trimester.
In patients with moderate disease, a
return to normal menstrual habit occurred
in all instances. However, only 2 estab-
lished a pregnancy. One pregnancy went to
term, and the other is still in progress at
the time of this writing.
When considering the 11 patients as a
group instead of in categories of severe or
moderate disease, 6 of the 11 patients
established pregnancies (56%). All but two
of the pregnancies have gone to term, a 36%
term pregnancy rate. All but 1 patient
either showed a return to normal menstrual
habit or established a pregnancy after one
or more series of treatments. This patient
remained amenorrheic following the re-
732 KLEIN AND GARCfA
moval of the Lippes loop and, unfortu-
nately, was lost to follow-up.
DISCUSSION
All 11 patients presented in this series
had a prior puerperal or postabortal infec-
tion, and a related uterine instrumentation
was the most probable etiologic antecedent
event. Although uterine tuberculosis can
produce a similar picture, no patient had
any indication of such in her evaluation.
The fact that they had established a preg-
nancy initially supported this contention,
although initially it did not exclude the
diagnosis of tuberculosis entirely. None
had prior uterine surgery, e.g., metroplas-
ty, myomectomy, etc., which potentially
might have predisposed to partial uterine
cavity obliteration. None had a cervical
stenosis or an isthmic occlusion alone.
None presented with hematometra.
Criminal termination of pregnancy is
associated with infection and with an in-
crease in the incidence of the Asherman's
syndrome. Five (46%) of the women in this
series acquired intrauterine distortion as a
result of such intervention. With the
acceptability of pregnancy termination
and the resulting increased frequency with
which women tum to this method, it is
imperative that the technic of the abortion
procedures be meticulous, since otherwise
the future reproductive capabilities of the
individual may be compromised. It is
hoped that an increase in the incidence of
this syndrome will not parallel the in-
creased frequency of pregnancy termina-
tion.
The therapy of patients presented in this
series was directed initially to re-establish-
ing and maintaining the integrity of the
endometrial cavity. Infection was ruled out
and broad-spectrum antibiotic therapy was
used to reduce the possibility of introduc-
tion of bacteria during the course of trans-
vaginal intrauterine manipulations. In an
attempt to prevent the recurrence of adhe-
sions, separation of the uterine walls with
Vol. 24
an inflated pediatric Foley catheter was
accomplished. Exogenous estrogens to in-
duce endometrial growth, hopefully with
lateral extension, were used as adjuvant
therapy.
The use of the Lippes loop does not
appear to be an effective supportive meas-
ure. In one patient in whom it was used,
amenorrhea returned following its removal.
In another patient, a Lippes loop inserted
at another institution produced similar
results. Subsequently, multiple treatments
with the prescribed approach produced a
functional uterine cavity. If pregnancy
does not follow within 12-18 months after
the endometrial cavity has been restored,
attention should be turned to the tubal
factor. Since primary tubal surgery cannot
be expected to help in the presence of an
inadequate nidation environment, the re-
verse approach is not recommended. There
may be some merit to the laparoscopic
assessment of the adnexa at the time of the
intrauterine exploration and dissection of
adhesions. A severe degree of intrauterine
occlusion is not necessarily associated with
periadnexal involvement. Laparoscopy is
not only helpful in assessing the intra-
abdominal status but also permits dissec-
tion of extensive intrauterine adhesions
with concomitant transabdominal moni-
toring of this manipulation. In the absence
of massive pelvic adhesions, the excursions
of the uterine sound and of the curet can be
observed through the laparoscope by an
assistant.
The success· of therapeutic modalities
can be evaluated only through comparison
of results in patients with a similar state.
In the main, most series do not report their
results in terms of extent of the intraute-
rine involvement. Perhaps a grading of
severity according to the five diagnostic
criteria (Table 8) would be helpful. In any
event, it is reasonable to state that the
cases of amenorrhea with normal ovulatory
function represent a more or less compara-
ble and certainly a severe form of this syn-
 September 1973 ASHERMAN'S SYNDROME 733

drome. Table 12 lists the comparison of re-
sults of cases presenting with amenorrhea
for whom sufficient data were reported in
the literature to permit a comparison with
the experience in our department. The
treatment used by Milroy 1 did not differ
significantly from that described in this
paper. However, only 1 case is presented
by that author. Wider and Marsha1l 31 were
also unsuccessful in 1 case in which a Tef-
lon intrauterine device was used.
The use of the Lippes loop has been
advocated, but it is not supported in prac-
tice or in theory. The Lippes loop is known
to produce a local foreign body reaction
and may well serve as an afferent pathway
of infection. Moreover, the ridges produced
by the indwelling intrauterine device do
not adequately serve to separate the walls
of the uterine cavity. The Foley catheter,
while presenting much the same inflamma-
tory potential, does separate the walls of
the uterine cavity. It is believed that the
antibiotics and estrogens given during the
retention of the inflated Foley catheter
significantly alter the pathologic response
and promote an epithelialization of the
denuded areas. Perhaps a less reactive
inflatable device, such as one made of
silicone, might better serve this purpose.
Asherman 29 used hysterotomy to lyse
intracervical and intrauterine adhesions
without adjuvant therapy with antibiotics,
estrogens, or the like. The addition of this
adjuvant therapy represents a major step
forward in the definition and treatment of
the entity which bears his name. There is
rare need for hysterotomy today, even for
patients with extensive intrauterine adhe-
sions.
In an enlightened society, most patients
seek early treatment. Early treatment is

TABLE 12. Comparison of Therapy in Cases with Amenorrhea

Normal
Author Method of treatment· No. of Term Successful
menses Pregnancy
cases pregnancy pregnancy
restored

%
Milroy' D&C, Foley catheter, antibiotics, es- 1 0 0 0 0
trogens
Louros et a1. • D&C, IUD, spasmolytics, estrogens 8 8 1 ? ?
Comninos and D&C, Foley catheter, antibiotics, pro- 12 6 2 1 8
Zourlas· gestins
Asherman" Hysterotomy 7 7 0 0 0
Gibbs" Uterine pack, estrogens 1 1 1 1 100
Dmowski and D&C, combination hormones, ster- 6 3 1 1 17
Green blatt 11 oids, antibiotics
Griinberger·· Endometrial transplants, combination 2 1 1 1 50
hormones
Jensen and No treatment in 10 cases; others: D&C 17 13 5 2 12
Stromme" and/or IUD, hysterotomy
Wider and Hysterotomy, IUD, estrogens, tubal 1 1 0 0 0
Marshall" repair
Asherman' Sounding and/or D&C 29 18 10 2 7
Polishuk13 D&C,IUD 1 1 0 0 0
DeRozada et a1. .. D&C,IUD 7 7 0 0 0
Wood and Peiia 12 D&C, estrogens, antibiotics, postopera- 9 5 4 2 22
tive dilatation
University of Penn- Noted in text 7 6 4 3 43
sylvania (1968-
1973)

* IUD, intrauterine device.

734 KLEIN AND GARciA
believed to yield a better prognosis 7 ; we
could not deduce this from our limited
experience. However, persistence in treat-
ment, with repeated procedures, has pro-
duced an improved reproductive potential
in all but 1 patient who was lost to follow-
up. It is acknowledged that sweeping clini-
cal conclusions cannot be drawn on the
basis of 11 patients, 7 of whom presented
with amenorrhea. In arriving at our present
conclusions, however, an extensive review
of the opinions and experiences of many
have supplemented our own clinical expe-
rience.
CONCLUSIONS
The variations in incidence as reported
in the literature may reflect a lack of strict
definition of criteria used for diagnosis.
However, since those countries with an
increased incidence in genital tuberculosis
have an unusually high rate of intrauterine
disease, such factors should not be over-
looked. With the increase in acceptability
of termination of pregnancy, subsequent
increases in intrauterine pathology may be
observed.
In reviewing causal factors, it would
appear that, in addition to trauma and
infection, a third critical etiologic compo-
nent is the duration and the extent of the
inflammatory response to the necrosing
products of conception.
The success of treatment has varied, as
have the criteria for diagnosis. After
searching diligently for the syndrome and
for coexisting factors affecting fertility,
success is enhanced by maintaining a thor-
oughness and persistence in therapy while
supporting the patient and encouraging the
enthusiasm of the couple. If reproductive
function is desired, it is not enough to
re-establish menses. Persistence in therapy
with repeated dissection of the cavity is
recommended in stubborn cases. Laparos-
copy is a helpful procedure in assessing
concomitant intrapelvic factors which may
affect fertility.
Vol. 24
SUMMARY
Asherman's syndrome has been defined;
its incidence, etiology, and pathophysi-
ology have been reviewed. Recognition of
the entity has been supported through the
use of specific diagnostic criteria and cate-
gorization of signs and symptoms. Treat-
ment and prognosis have been reviewed,
and 11 cases of Asherman's syndrome have
been presented. The preponderance of a
postabortal curettage etiology of this syn-
drome, which has a devastating prognosis
for reproduction, points once again to the
grave responsibility which is entrusted to
those caring for the pregnant woman. A
plea is made for vigil in preventive efforts
which may avoid the need for postabortal
and postpartal curettage and sepsis. Vigor-
ous efforts in diagnosis and treatment are
needed, since the potential of Asherman's
syndrome is still before us.
Acknowledgments. The authors wish to ex-
press their appreciation to Dr. John P. Emich,
Dr. Luigi Mastroianni, Jr., and Dr. Edward
Wallach for permission to inc! ude several of
their patients in this report.
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