Asherman syndrome is characterized by intrauterine adhesions that impair fertility. Which of the following is the most common iatrogenic cause of this condition?

Explanation

## Asherman Syndrome: Intrauterine Adhesions ### Definition and Pathophysiology **Key Point:** Asherman syndrome is the formation of fibrous bands (adhesions) within the uterine cavity that obliterate the normal endometrial architecture, leading to amenorrhea, hypomenorrhea, and infertility. ### Causes of Asherman Syndrome | Cause | Mechanism | Frequency | | --- | --- | --- | | **Dilation and curettage (D&C)** | Mechanical trauma to basal endometrium during evacuation of products of conception | Most common (70–80%) | | Hysteroscopic myomectomy | Instrumentation and tissue removal | 5–10% | | Endometrial ablation | Intentional destruction of endometrium | 5–10% | | Uterine artery embolization | Ischemic endometrial necrosis | Rare | | Tuberculosis (TB) | Granulomatous destruction of endometrium | Common in endemic areas | | Schistosomiasis | Chronic inflammation and fibrosis | Endemic regions | **High-Yield:** Dilation and curettage (D&C) for evacuation of molar pregnancy, retained products of conception, or therapeutic abortion is the **single most common iatrogenic cause** of Asherman syndrome in developed countries. ### Risk Factors for Asherman Syndrome Post-D&C 1. **Multiple D&C procedures** (cumulative trauma) 2. **Aggressive curettage** (removal of basal layer) 3. **Post-molar pregnancy evacuation** (high risk due to invasive trophoblastic tissue) 4. **Postpartum D&C** for retained placenta or placental fragments **Clinical Pearl:** Even a single D&C can cause adhesions, but risk increases significantly with repeated procedures or aggressive instrumentation. ### Clinical Presentation - Amenorrhea or hypomenorrhea (most common) - Secondary infertility - Recurrent pregnancy loss (if partial adhesions) - Dysmenorrhea (if partial obstruction) **Mnemonic:** **ASHERMAN** — **A**dhesions, **S**econdary amenorrhea, **H**ysterectomy (iatrogenic), **E**vacuation (D&C), **R**etained products, **M**olar pregnancy, **A**bortion (therapeutic), **N**ormal uterus (on imaging), **M**anagement (hysteroscopic lysis) [cite:Textbook of Obstetrics & Gynaecology (Hiralal Konar) Ch 15]