Document Type : Pictorial Review
Asherman’s syndrome (AS) was first described
by Heinrich Fritsch in 1894 (
Trauma to the basal layer due to dilation and
curettage (D&C), after a miscarriage, delivery
and medical abortion are the most common predisposing factors for AS (
There are various classification systems to describe AS. Classification systems have been developed to describe the location and severity of adhesions inside the uterus. For instance, mild cases with adhesions restricted to the cervix may present with amenorrhea and infertility, it shows that symptoms alone do not indicate the severity of condition.
Early diagnosis and appropriate treatment by
the removal of adhesion improve reproductive
outcome of infertile women and resolve abnormal
uterine bleeding (AUB) complications. According
to the American Society of Reproductive Medicine (ASRM), the type and severity of the adhesions correlates with the two following reproductive outcomes: i. After removing mild to moderate
uterine adhesions, patient has 70 to 80% full-term
pregnancy success rates, while normal menstruation is restored in over 90% of patients (
The objective of this pictorial essay is to depict various appearance of intrauterine adhesion which is taken by hysterosalpingography.
In AS, destruction of endometrium causes scar
in the endometrium, followed by rapid expansion
of scar tissue band or synechiae within the uterine
cavity. Scarring may be minor, affecting a small
area of the uterine wall, or be extensive with diffuse involvement and obliteration of the uterine
cavity. Synechiae may be found anywhere in the
uterine cavity. They can also involve adjacent
structures, causing stenosis of tubal ostia in the
corneal region or stenosis of the endocervical canal near the internal cervical canal (
Symptoms related to AS are as follows: infertility, recurrent pregnancy loss, menstrual irregularity specially amenorrhea, as well as cyclic pelvic pain, indicating that mensturation is occurring, but the blood cannot exit the uterus because the cervix is blocked by adhesions.
The American Fertility Society (AFS) classifies
intrauterine synechia involvement by applying the
combination of hysterosalpingographic, hysteroscopic and menstrual changes (
AS is identified through application of the following techniques: two dimensional ultrasonography (2DUS) and 3DUS trans vaginal sonography (TVS), hystrosonography, hysterosalpingography (HSG), as well as hysteroscopy.
Hysteroscopy is the gold standard for the diagnosis of severe intrauterine adhesions (
Figure 1 shows an ultrasound scan of a patient
with AS showing a mixed picture of the endometrial line; however, the line in some parts cannot be
visualized, while in other parts, the endometrium
appears normal. Other appearances are adhesions,
which are observed as endometrial irregularities
Ultrasound shows irregular endometrial contour with typical adhesion appearnace.
Three dimensional ultrasound (3DUS) is a
good supplement to TVS which only obtains
images in two planes. The third plane can depict
the extent and location of synechiae, more thoroughly (
phy findings, there may be
echogenic bands traversing distended endometrial
canal extending side to side of uterine wall. Distention of uterine cavity with saline infusion may
be done hardly (
In sonohysterography there are echogenic fibrotic bands, distended endometrium side to side wall of the uterus and superior to inferior in sagital and coronal plane which is shows typic adhesion.
The extent and location of the synechiae can be identified through HSG; however, patients may feel pain during contrast medium injection due to poor distansibility of cavity.
The radiographic appearance of intrauterine adhesions varies with the sites involved and the severity of scares (
Synechiae appears as filling defects distorting
the contour of the uterine cavity; although, they
typically have an irregular, multiple angulated
lacunar-shaped and immobile intracavity filling
A 24 years old woman with history of three curettages. HSG detected a small filling defect with totally sharp contour and typical synechiae. The adhesion involves less than ¼ of uterine cavity.
(A and B): 32 and 40 years old women with history of two curettages, each. HSG shows multiple irregular and angulated filling defects with sharp border involving ½ of uterine cavity (moderate synechiae).
A 25-years-old woman with history of three curettages. HSG result shows that configuration of uterine cavity is totally disturbed. Multiple defects in uterine wall and cavity, considered as secondary to extensive adhesion, involve more than ¾ of the uterine cavity volume (severe synechiae).
They are easily defined because the uterine walls are adhered, while the contrast material does not completely
surround the defects (
A 35 year old lady with a history of 5 year of infertility and family tuberculosis history.HSG shows Small irregular hypo plastic uterine cavity. (Dwarf uterus) Spillage of contrast media up to isthmus region of both tubes, under pressure is detected. Pipe-like appearance is detected bilaterally. All of the mentioned features could be considered in genital tuberculosis.
In this situation, a history of previous trauma or disease, as well as clinical and sonographic signs will be
helpful to diagnose adhesions (
A 28-year-old woman with history of three curettages. HSG shows spindle shape cervical canal with normal appearance. There is obliteration of the isthmus and uterine cavity, considered as secondary to multiple curettages. In obtained image series, there is no filling of contrast in uterine cavity. Intravasation of contrast media into surrounded ventricular plexus is observable due to severe force of injection (Finger glove’s appearance).
Asymmetrical obliteration in uterine cavity with
unicorn involvement resembles unicorn (pseudo
unicorn-uterus) appearances (
A 20 years old woman with history of one curettage. HSG shows spindle shape uterus with unicorn appearance in left pelvic cavity. Previous HSG shows normal uterus,but now, there is no filling of contrast in right corn due to adhesion. Uterus is appeared as a unicorn which is known as pseudo-unicorn uterus.
A 29-year-old woman with history of seven curettages. HSG shows irregular contour of uterine cavity and asymmetry in both corn and adhesion in right corn. Due to adhesive changes, result reveals an image mimicking bicorne or septate uterus
Ultrasound is not a reliable method for diagnosing AS compared to HSG. One study reported that transvaginal sonography showed low sensitivity
and PPV for this kind of diagnosis (
TVS shows normal appearance (A), but sonohysterography depicts IUA (B).
The gold standard is to look directly at the
uterine cavity and scar tissue using hysteroscopy (