Asherman syndrome-HSG

A 25 year old lady being investigated for  infertility with history of previous D&C. The HSG shows grossly reduced capacity of the uterus with incapability to inject more than 10 cc contrast with no evidence of reflux. In addition it shows multiple mixed opacities with longitudinal radio lucencies interspersed with opacities, along with beaded and tortuous tubular component on the right  possibly representing the right tube. The left tube has not been visualized. There is no peritoneal spill. The features suggest adhesions and fibrotic endometrium, representing Asherman syndrome. Case submitted by Dr MGK Murthy, Dr Srujana & Mr Venkat.

Teaching points :

·         Also known as Fritsch’s syndrome / uterine synechiae. Occasionally normal longitudinal uterine folds can mimic the findings.

·         Incapable of contrast injection beyond 10 cc is typical. Usually follows aborted pregnancy with associated D&C. Trauma to the basal layer of endometrium is considered as responsible factor, including after miscarriages. The longer miscarriage stays in the uterus, more is the possibility of adhesions.

·         Obliterating of the uterine canal is obvious on HSG. Associated with Mullerian anomalies. Infertility is highly possible following development of synechiae.

·         Treatment  is usually attempted with adhesiolysis with micro scissors. Electrocautery is usually contraindicated.