Avoiding Asherman’s syndrome: refining our approach to uterine evacuation
VOLUME 116, ISSUE 4, P961-962
Martin F. Freedman, M.D., William D. Schlaff, M.D.
As fertility specialists, we frequently see patients who present to our office complaining of secondary amenorrhea or a significant reduction in menstrual bleeding after dilatation and curettage (D and C). These patients typically relate a history of excessive bleeding or presumed retained products of conception after a delivery, termination, or failed pregnancy. The diagnosis in such cases is presumed to be intrauterine synechiae, or Asherman’s syndrome (dubbed “amenorrhea traumatica” by Asherman). This can be a clinically devastating condition for the patient who wishes to have more children. In a related vein, we are also commonly required to counsel patients who present with an anembryonic pregnancy or, even more sadly, a failed pregnancy after previously identifying fetal cardiac motion. Our advice to these patients usually includes the options of expectant management (i.e., awaiting spontaneous miscarriage), medical treatment, or surgical evacuation by manual vacuum aspiration or D and C. In some cases, the decision may be influenced by the urgency required to obtain tissue for genetic analysis. In most other cases, these options are presented as similarly acceptable, and the decision is left to the patient. The juxtaposition of these two clinical scenarios leaves us contemplating the wisdom of our approach to our patients with an early pregnancy loss. We wonder if this “balanced” counsel, predicated on the assumption that these treatment options have essentially equal implications for short-term complications and future outcomes, may be putting our patients at unnecessary risk of becoming the next patient we see with Asherman’s syndrome.