We report a case of severe Ashermann’s syndrome. This is an extremely uncommon occurrence following postpartum haemorrhage for which vigorous surgical evacuation of the uterus is almost always implicated . In this case, when the initial IUCD was inserted 6 weeks post-partum, it was felt that a false passage had been created. Concordant amenorrhoea raised the possibility of Ashermann’s syndrome, which was confirmed at initial hysteroscopy and hysterosalpingogram [2, 3]. When this woman underwent subsequent hysteroscopy and division of endometrial adhesions, it was done with the objective of recreating a functional endometrial cavity which would be receptive to a further pregnancy, either spontaneous or through assisted conception [4, 5, 6]. Later hysteroscopy revealed a narrow and tubular endometrial cavity without identifiable tubal ostia which was also almost certainly unsuitable for embryo transfer.
A retrospective case study in France evaluated the efficacy of hysteroscopic adhesiolysis in patients with severe Ashermann’s syndrome . They restored uterine cavity with one functional ostium. All previously amenorrhoeic patients had resumption of menses. A pregnancy rate of 42% was obtained with a live birth rate 32%. These pregnancies were at high risk of haemorrhage with abnormal placentation, premature labour, uterine sacculations and a paper-thin uterine fundus.
An Australian study found safe and effective hysteroscopic division of adhesions difficult, if not impossible, in patients with severe Ashermann’s syndrome . There is also a suggestion that in patients with intrauterine adhesions severe enough to produce amenorrhoea, biologically active endometrium can undergo malignant change .
An Egyptian study attempted to show the possibility of an association between Mullerian duct malformations and Ashermann’s syndrome ; the association was highly significant (p<0.005), especially for those patients with a septate uterus (p<0.001). This predicament, though uncommon, brings to the forefront the importance of surgical evacuation of uterus for retained products following delivery.
The possibility of Ashermann’s syndrome, although rare, should always to be borne in mind. If it is severe, as in the case illustrated, it can render a young woman essentially infertile, which will obviously have serious psychological squealae. Hysteroscopic recavitation is not only complex surgery, but it is also associated with potential problems even when successful, so realistic counselling is essential.