Glued from the Inside: The Truth About Asherman's Syndrome

What if your uterus looked normal on the outside—but inside, it was glued shut? In this episode of Taco Bout Fertility Tuesday, Dr. Mark Amols breaks down the rarely discussed but deeply impactful condition known as Asherman's Syndrome. From why some women are more likely to develop intrauterine adhesions (think “keloid-level healing”) to how it affects menstruation and fertility, you’ll learn everything you need to know.

We cover:

• What causes Asherman's Syndrome and who's at risk
• How to know if you have it (hint: it's often missed!)
• The difference between mild “cobweb” scarring and complete uterine cavity obliteration
• The gold-standard treatments, including hysteroscopic surgery, estrogen therapy, and balloon/IUD separation
• Emerging therapies like stem cells, PRP, and amniotic grafts
• Fertility options beyond surrogacy—including IVF and uterine transplant
• The emotional toll of Asherman’s and why psychological support matters

Whether you’re a patient, a partner, or a medical provider, this is the Asherman’s deep dive you didn’t know you needed. Don’t miss it.

Thanks for tuning in to another episode of 'Taco Bout Fertility Tuesday' with Dr. Mark Amols. If you found this episode insightful, please share it with friends and family who might benefit from our discussion. Remember, your feedback is invaluable to us – leave us a review on Apple Podcasts, Spotify, or your preferred listening platform.

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Join us next Tuesday for more discussions on fertility, where we blend medical expertise with a touch of humor to make complex topics accessible and engaging. Until then, keep the conversation going and remember: understanding your fertility is a journey we're on together.

Transcript

0:01

Today we talk about asherman syndrome. I'm Dr. Mark Amols, and this is Taco about Fertility Tuesday. Today we're going to be talking about a topic that may never affect you or anyone. You know, it's actually not that common. But for the people it does affect, it's devastating. Asherman's syndrome is one of those diagnoses that can be missed, mismanaged, or misunderstood. Yet it holds profound consequences for fertility, menstruation and emotional well being. So in today's episode of Talk About Fertility Tuesday, we're going to cover what it is, what causes it, and how severe it can get. How, do you know if you have it? Well, that's what we're going to talk about. We'll also break down what are the treatments, what the merging treatments, and what you can do if you're facing this diagnosis. So the first question is, what causes Asherman's syndrome? Asherman'syndrome the most common cause is a procedure called a dilation and curage. Sometimes people call it that D and C, particularly after a miscarriage or after delivery, basically associated with pregnancy. Now, during the dnc, the urine lining is scraped, so it's traumatically scraped to remove retained tissue. Now, in most people, this procedure heals without any complications. But for a subset of women, what we might call hyperhalers, the healing response goes overboard. Instead of regrowing the normal lining, scar tissue forms. A great example of this would be people who develop keloids. Have you ever noticed on some people's ears they have this swollen tissue around their ears? Well, that's because they have keloid development. Their body doesn't just heal. It over heals well. Similarly, in these patients and other patients, the uterus responds by generating adhesions that stick the front and the back walls of the uterus together, creating problems in the future for pregnancy. And analogy, I would think of is a sleeping bag. Normally, you unzip it, you climb in, and you have room to move. But imagine if a bunch of glue got inside the sleeping bag and parts of the sleeping bag started sticking together. Maybe the top layer sticks to the bottom where the sides stick to each other. From the outside. You look at that bag and go, yeah, looks like a normal sleeping bag. Everything looks great. But when you try to climb inside of the sleeping bag, there's no room. It's stuck shut. You can't get your legs in, you can't get anything in, but yet the cavity still is there. That's what Ashman does to uterine cavity. It causes it to stick together, and that then prevents a pregnancy from developing in there. Now, it's not only dncs that cause this, but that is the common cause. And that's because during pregnancy or around the time of pregnancy, there's that hyperhaling that can occur. So you have to be very careful when you do a D and C when someone is pregnant or just recently pregnant. Less commonly, ashermentss can also result from intrauterine surgery, such as fibroid surgery, or endometrial ablations, or uterine infections that occur inside there, or even radiation to the uterus. But the key takeaway is not everyone's scars like this. It's the rare, unluckly few who respond to trauma with excessive intrauteder adhesion formation. So the question then is, who's at risk? Basically, anyone who has undergone a dnc, particularly after a miscarriage or retained placenta, are at the top of the list. This risk is going to increase if multiple procedures are done, especially in short succession. It'also seen in patients with recurrent miscarriages, again, because of multiple procedures. Complicated deliveries can cause it, or even uterine surgeries such as submicosal myomectomies. And although very rare in the United States, tuberculosis can also cause uterine scarring in other parts of the world. Now, one thing I've noticed is some people will call everything asherments, and I really want to break down the severity, because not all aserin cases are created equal. Mild cases of aserins can involve very thin, filmy adhesions, which are called syecii. These might slightly reduce menstrual flow. They might be found during a fertility workup. But these are like complwebs. They're very easy to remove and usually have a very good prognosis. Most of the time, women don't even know they have them. Now, in the moderate cases, there are thicker adhesions. These usually have flow within adhesions, not cobwebs. And they can reduce thensruional flow and absolutely impact implantation. A lot of times women will notice that their period is a little bit different after their dnc. Let's say not say completely gone, but just different. Think of it like just a little bit of glue got into the sleeping bag. And so you can still get in it, but you really can't get in very well, but you can still get in it. Basically, the urine cavity has usable space. The parts of it are still stuck together, whereas in the mild case, you can just kind of push those little stuck parts out of the way, because glue is not very strong in those areas. Those are the cobwebs. But what about severe cases when these situations? Urterine cavity can be completely obliterated. Women will have no menstrual bleeding at all. And the chance the pregnancy without any intervention is very slim. And this is a scary part because everyone is called Asherins. And so if you read this, you'll think, oh, my God, I'm never going to have a kid again. And that's why it's important to determine what type you have. Do you have a severe case or do you have a mild case with cobwebs that you can just treat very easily? If you have a severe case, then that sleeping bag has been sealed shut. You technically still have a sleeping bag, but functionally it's unusable. And that's the same thing when it comes to uterus. If it's completely stuck together and you have complete Asherman syndrome, you have a slim chance of becoming pregnant unless you have some type of intervention done to fix it. So how do you even know if you have it? Well, this is one of the trickiest aspects of Asherman syndrome. It's often missed unless you're specifically looking for it. But the question is, what are the signs? Well, first thing is looking at the menstrual patterns. If all of a sudden, after your dnc, theres a sudden drop in your menstrual flow or complete absence of your period, then you know thats a red flag, something is wrong. You might also notice increased cramping or very little bleeding, or as I mentioned, no bleeding at all. The other thing is fertility. If you had the procedure in the past, and now you're struggling to conceive, but before you weren't, or you're having, let's say, early miscarriages, potentially, you may have adhesions, have been silently hanging on your uterus without knowing about it from a diagnostic standpoint. The way we're able to figure it out is we look at things like a Sono histogram. This is where we put water in the uterus, where we can fill it up and, we can determine if there's any irregularities inside the uterus. A, histosypingogram, also called an hsg, is where we put dye into the uterus, and that can show filling defects, but it can sometimes be erroneous because if you push the dye too fast, you won't catch those irregularities. But the gold standard is going to be a hysteroscopy, a hysteroscopy is going to be where we put a camera inside the uterus, and in real time, we have diagnostic evaluation where we can look at the cavity. We can see, are they cobwebs, are they very small? Syakii or is this a complete ablation? The other benefit from hystercopy is you can then plan how you're going to treat it. With the other test, you may know there's a problem, but the severity isn't as easy to tell because you're inferring it from the test. But with the hysteroscopy, you see with your eyes, and you know what you're going to need to do to repair it. So here's the good news. Treatment does exist, and it's somewhat effective when done by experts. The gold standard is hysoscopic adhesiolysis. That's just a fancy word of saying we're going to remove the scar tissue. Picture a little camera going into the uterus, and then using surgical tools, like little type of, scissors, we can then dissect and remove the sclerar tissue. Now, it's important to know that you can only remove it if you can see it, right? So there has to be tissue going in between the top and the back of the uterus, or front and back, or side to side. But if it's obliterated where there is no cavity, then you have to recreate the cavity. That becomes a very difficult surgery because you have to do it under, ultrasound guidance sometimes, or even have to do a laparoscopy while doing a hysteroscopy. That way you're watching where to go with the hysteroscopy. But surgery is just one step in the process. The real challenge is keeping adhesions from coming back, because they usually do. If you ever see any with keloids, once they fix them, they'll just go away. Sometimes they come right back and even worse. So one of the things we do is we'll give people estrogen therapy to stimulate the regrowth of the endometrium. Sometimes we even want to prevent the sides from sticking together. So we'll put a balloon or some type of IUD to keep the uterine walls apart while they're healing. And there are even newer things such as adhesion barriers. And these gels that have hyaluronic acid in it can be put into the uterus, and they sit in there, preventing the walls from touching each other. But again, you have to have something to cut to remove it. If it's obliterated, it becomes very difficult. One of the things a lot of surgeons will do is what's called a second look hysteroscopy a few weeks later after the surgery. What this does is it says, hey, let's make sure those stuck sleeping backag flaps haven't glued themselves shut again. We're basically making sure the uterus has been repaired. I think one thing that's important is if you do have the obliterated uterus, it is very important you see one of the best surgeons. That is extremely difficult surgery and there are very few people who can do it well. So now let's talk about cutting edge therapies. Stem cell therapy, whether from the bone marrow, menstrual blood or even end theomettrial tissue, is being explored to rebuild the uterine lining in cases where it won't regrow on its own. Platelet rich plasma, also known as prp, is another buzzword already popular in the sports medicine and dermatology. PRP can stimulate and heal and regenerate when injected into endometrium. There is also fascinating research into biological scaffolds where amnioc membranes or hydrogels are put into the uterus to provide structure for new tissue group. Keep in mind these are still experimental but represent a real shot at restoring function for women with severe disease. Without this, they may never be able to carry a pregnancy on their own. When I was at the most recent ASRM conference, there was one company that actually takes stem cells from the blood and then basically turns them into super stem cells and then re injjects them back into blood to get to the uterus. Per their data, they had very good results. But again, this is very experimental. But it's good to know that people are out there trying to treat this devastating disease. So what happens when traditional treatments don't work well, for some women, repeat surgery with a specialist may still offer improvement. For those who doesn't. A lot of women will undergo IVF and then they will use a surrogate. Although it's not the path you originally wanted to take, it does give you the ability to still have a child of your own. And surrogacy is not the only option. For some, there are alternatives like adoption. And for people who are on the experimental frontier, there's uterine transplantation. It's not widely available and it's not without risk, but it has resulted in successful pregnancies for women with absolute uterine factor infertility. The point is, even when traditional treatments don't work, there still is a way to have your child. I think one important thing we need to talk about is Aschherman syndrome is not just a physical diagnosis, it's also an emotional one. Imagine, losing your periods, your ability to conceive, your sense of normalcy all at once. It'grief, its confusion and frustration all rolled into one. It's part of being a woman. And then all of a sudden it's gone. When patients get Asherman syndrome, they often experience anxiety, depression, even post traumatic stressor syndrome. That's why psychological support is just as important as the surgical skill. If you'someone going through this, it's not unreasonable to undergo counseling, fertility coaching, mindful based therapies, and even sometimes peer support groups. All those are valuable tools to use. Keep in mind, healing isn't linear. It's not just about clearing scar tissue. It's about reclaiming hope. I can tell you, in my experience, I've had many patients with Asherman syndrome, all the way from mild to the most severe. For most patients with mild or moderate, they end up going on to have live births without issues. So for the patients who have severe, it is a struggle. I would say about 50% of the patients I did surgery on ended up having a live birth and the ones with complete ablation where there was no cavity at all. Unfortunately, most of them had to use the surrogate. Asherman'syndrome is daunting, but it's not the end. As I mentioned before, if you have this, make sure you get the right diagnosis and make sure you get the right treatment from the right doctor. If you have severe Asherman syndrome, it's very important to see a specialist in Asherman'syndrome and remember, there are new therapies always coming out. So even if other ones didn't work, keep the hope because there are new therapies coming every day. I hope none of you have Asherman's syndrome, but if you do, hopefully this episode helped you understand it a little bit more. Maybe you had that DNC in the past. Your periods have been irregular and you may think you may have it. If you do, definitely follow up with a doctor. And as I discussed, if you have the condition, make sure you go to the right doctor to treat it. If you know someone who might have this, please tell them about our podcast and they might find this episode quite helpful. As always, I greatly appreciate everyone who listens to this podcast. I appreciate all the emails I get and the suggestions for future topics. If you love this podcast, give us a five star review on your favorite medium and tell everyone about us. But most of all, I look forward to talking to you again next week on Talk About Fertility Tuesday.