Asherman's Syndrome After a D&C: What the Numbers Actually Say

Asherman's syndrome is scarring inside the uterus — bands of adhesion that stick the front and back walls of the cavity together. It is one of the few genuinely under-recognised consequences of a common procedure, and also one of the most over-feared, because the internet reports the frequency of adhesions without reporting how many of them matter.

This article separates those two things: how often adhesions actually form, how often they cause a problem, what symptoms should prompt assessment, and how they are diagnosed and treated.

What is Asherman's syndrome?

The uterine cavity is normally a potential space: the front and back walls sit against each other, lined by endometrium that rebuilds itself every month. If the basal layer of that lining is damaged, the raw surfaces can heal to each other instead, forming bands of scar tissue — intrauterine adhesions, also called synechiae.

Depending on how extensive they are, they can narrow the cavity, obliterate part of it, or in severe cases close it almost entirely. The name Asherman's syndrome is usually reserved for adhesions that are actually causing symptoms, which is an important distinction, because adhesions can also be found in women who have no complaint at all.

How often does it actually happen?

The most useful figures come from the consent information given before management of miscarriage, because they are drawn from the whole population of women having the procedure rather than from women who came forward with a problem.

Intrauterine adhesions are found in around 190 in every 1,000 women after any form of management of miscarriage. Where surgical evacuation specifically is looked at, the figure is around 163 to 185 in every 1,000. Those numbers sound alarming until you read the sentence that follows them in the same guidance: over half are mild and of unknown clinical significance.

That is the crux of it. Something visible at hysteroscopy is not the same as something that affects your periods, your fertility or a future pregnancy. A great many women carry a filmy adhesion they will never know about and which will never cost them anything.

What else can a surgical evacuation cause?

Since this is the procedure most often blamed, it is worth setting out the other risks honestly and with figures, so adhesions can be seen in proportion:

Read together, these are the reasons that medical management or expectant management are offered as genuine alternatives in many situations rather than as second-best options. Where surgery is the right choice — and often it clearly is — it should be chosen for a reason rather than by default.

What causes adhesions besides a D&C?

Curettage of a pregnant uterus is the single commonest cause, and the risk appears higher when the procedure is done for retained tissue after a delivery, or repeatedly. But it is not the only route:

• Infection of the endometrium, including genital tuberculosis, which remains a relevant cause in India and can produce severe adhesions with no history of any procedure at all.
• Myomectomy, particularly where the cavity is opened to remove a fibroid.
• Hysteroscopic surgery such as division of a uterine septum, or removal of large or multiple lesions.
• Caesarean section and other uterine surgery, less commonly.

The tuberculosis point is worth emphasising in an Indian context: a woman with absent periods and infertility, with no obstetric history whatsoever, still needs the uterine cavity assessed, and genital TB considered.

What are the symptoms?

The pattern is usually recognisable if you know to look for it, because the change dates from the procedure:

Note what is not on that list: normal periods. If your cycle came back to its usual pattern after the procedure, significant adhesions are unlikely, and the anxiety many women carry about this is not usually warranted.

How is it diagnosed?

Hysteroscopy is the gold standard, for a reason worth understanding: it is the only test that looks directly at the cavity. A camera is passed through the cervix, the cavity is inspected, and adhesions are seen, graded, and very often divided in the same sitting.

Other tests have a role but do not replace it. An ultrasound may show a thin or irregular lining and is a reasonable first step, but it can be entirely normal in the presence of adhesions. A saline infusion scan, where fluid is instilled into the cavity during a scan, is more informative, because adhesions show as bands crossing the fluid. A hysterosalpingogram, done as part of a fertility work-up, may show filling defects in the cavity as an incidental finding.

Scans are arranged by referral; our page on hysteroscopy sets out what the procedure involves and where it is done.

How is it treated?

Treatment is hysteroscopic adhesiolysis: the adhesions are divided under direct vision, ideally with fine instruments rather than by blunt sweeping, so healthy endometrium is preserved. Blind curettage to break down adhesions is the wrong operation and risks making the problem worse.

The harder part is stopping them from reforming, because raw surfaces that touch each other tend to stick again. Approaches used after surgery include a physical barrier left in the cavity for a period, a course of oestrogen to encourage the lining to regrow, and a planned second-look hysteroscopy to divide anything early before it becomes dense. Which of these is used depends on how severe the adhesions were.

Outcomes track severity closely. Mild, filmy adhesions usually respond well, with periods returning and good pregnancy rates. Dense adhesions involving much of the cavity are considerably harder, may need more than one procedure, and carry a less predictable outlook.

Can I still get pregnant?

In most cases treated for mild or moderate disease, yes. Periods returning is a good practical sign that functioning endometrium has been restored.

There is one thing to know for the pregnancy itself: women who have had intrauterine adhesions treated are at increased risk of placenta accreta spectrum, where the placenta implants abnormally deeply into the uterine wall. It is not a reason to avoid pregnancy. It is a reason to tell your obstetrician about the history at the booking visit, so that the placental site is looked at carefully on the scans, and so that delivery is planned in a unit equipped for it.

If you have had a loss and are planning again, our guide to planning a pregnancy after a miscarriage covers the timing question and what is worth doing first. Where losses have been repeated, recurrent miscarriage has its own work-up, and the uterine cavity is part of it.

Can it be prevented?

Partly, and the decisions that matter are made before the procedure rather than after it:

• Consider whether surgery is needed at all. Expectant and medical management are appropriate for many early losses and carry no adhesion risk from instrumentation.
• Where surgery is chosen, gentle technique with suction rather than sharp curettage, and avoiding repeated procedures where possible, both reduce the risk.
• Treat infection properly. Endometritis left untreated is a route to adhesions in its own right.
• Ask what happens if tissue is retained. A second instrumentation carries more risk than the first, so it is worth knowing the plan.

Getting this assessed in Gurugram

If your periods changed after a procedure, that history is the important part of the consultation and it does not need any test to be taken seriously. Consultation and blood tests are done at the clinic. Scans are arranged by referral. Hysteroscopy, whether for diagnosis or for treatment, is a hospital procedure and is arranged there.

What is worth bringing: the operation note or discharge summary from the original procedure if you have it, the dates, any scan reports since, and a simple record of what your periods have actually done month by month since then. That last one is often more useful than any imaging.

Where to see us

Dr. Anam's Women Health Clinic, Sector 51 (Mayfield Garden) and Sector 56, Gurugram. Open seven days a week, including Sundays.

The bottom line

Adhesions after management of miscarriage are common as a finding and much less common as a problem. What separates the two is symptoms, and above all what your periods have done since the procedure. Normal periods are strong reassurance. Periods that vanished or became a fraction of what they were deserve a hysteroscopy conversation rather than a wait-and-see.

And if you are being offered a choice about how a miscarriage is managed, that choice is a real one. It is worth asking why surgery is being recommended, and what the alternatives would mean in your situation.