Asherman syndrome is scar tissue (called intrauterine adhesions) that forms inside the womb, usually after a D&C, other surgery on the womb or an infection such as genital tuberculosis. The scar tissue can make periods very light or stop them altogether, cause pain around the time a period is due, and lead to infertility or repeated miscarriage. It does not go away on its own, but it can be treated by removing the scar tissue through a thin telescope passed into the womb (hysteroscopy). At Yaal Fertility Centre in Chennai, Dr. Rukkayal Fathima and our team diagnose and treat Asherman syndrome and plan the safest route to pregnancy afterwards.
What Is Asherman Syndrome?
The inside of the womb is lined by the endometrium. It has two layers:
- The functional layer, which thickens each month and sheds as your period.
- The basal layer, a thin deeper layer that regrows the functional layer after every period.
If the basal layer is injured, it may heal with scar tissue instead of healthy lining. Bands of scar tissue can then join the front and back walls of the womb together, like two sides of a pocket stuck shut. Depending on how much of the cavity is affected, there may be less lining to bleed each month and less healthy space for an embryo to implant.
Asherman syndrome is acquired: you are not born with it. It almost always follows an injury or infection, which also means it can often be prevented.
How Scar Tissue Forms in the Womb
When the basal layer is scraped away or badly inflamed, the tissue underneath heals the way skin does after a deep cut, with tough fibrous bands rather than soft, blood-rich lining. Over weeks these bands mature and can pull the walls of the womb together, close part of the cavity and reduce blood flow to the surrounding lining.
Early Warning Signs
The clearest clue is a change in your periods after a procedure on the womb:
- Bleeding that drops to light spotting, or stops completely, after a D&C or delivery.
- Monthly cramping or pelvic pain around the expected period date, but little or no bleeding. This can mean blood is trapped behind scar tissue.
- Normal pre-period signs, such as breast tenderness or mood changes, but no period. This suggests your hormones are cycling normally and the problem is in the womb itself.
What Causes Asherman Syndrome?
D&C After Miscarriage or Delivery
The most common cause is a D&C (dilation and curettage), a procedure in which the lining of the womb is removed, done:
- after a miscarriage, especially an incomplete one,
- for retained placenta after delivery,
- for a termination of pregnancy.
The risk is highest when the womb has recently been pregnant, because its walls are soft and rich in blood vessels and the basal layer is easily injured. The risk also rises with repeated procedures. In South India, a D&C after a miscarriage is still very common. It is worth asking your doctor whether a D&C is needed in your case.
Other Surgery on the Womb
Less often, scarring follows other operations that involve the cavity, such as:
- fibroid removal (myomectomy), particularly when a fibroid sits inside the cavity,
- a caesarean section,
- surgery for polyps or a septum.
See our guide to fibroids and fertility for how fibroid surgery is planned to protect the lining.
Genital Tuberculosis and Other Infections
In India, genital tuberculosis is an important cause of severe Asherman syndrome, and it can cause scarring even without any previous surgery. TB can damage both the womb lining and the fallopian tubes, often silently. Read more in our guide to genital TB and infertility.
Severe infection of the womb lining after a delivery, a miscarriage or a procedure, and pelvic inflammatory disease, can also lead to scarring. When infection and a recent procedure happen together, the risk of dense scarring is higher.
Symptoms of Asherman Syndrome
Changes in Your Periods
Because the ovaries usually keep working normally, you still ovulate and make normal hormones. But with scar tissue in place of healthy lining, there is less lining to build up and shed. This causes:
- Hypomenorrhoea: much lighter periods than before, sometimes only spotting.
- Amenorrhoea: no periods at all.
| Asherman syndrome | Normal changes after a procedure | |
|---|---|---|
| Periods | Much lighter or absent, and stay that way | Slightly lighter for one or two cycles, then back to normal |
| Hormone cycle | Normal ovulation; pre-period signs but little or no bleeding | Ovulation may be delayed for a cycle by stress or healing |
| Pain | Monthly cramping with little or no bleeding | Mild cramping in the first days of recovery that settles |
| Lining on scan | Thin or patchy and does not respond well to hormones | Recovers within a few weeks |
Unlike hormonal causes of light or missed periods, such as PCOS or high prolactin, hormone blood tests are usually normal in Asherman syndrome. For other reasons periods change, see irregular periods: causes and when to worry.
Infertility and Miscarriage
An embryo needs a thick, healthy, blood-rich lining to implant and grow. Scar tissue is a poor place for this, so Asherman syndrome can cause:
- difficulty conceiving, often as secondary infertility after an earlier pregnancy,
- repeated miscarriage,
- problems with the placenta in a later pregnancy.
If you have had several losses after a procedure, our recurrent miscarriage care includes a check of the womb cavity.
How Is Asherman Syndrome Diagnosed?
Hysteroscopy: The Most Accurate Test
Hysteroscopy is the best way to diagnose Asherman syndrome. A thin telescope with a camera is passed through the cervix, and the womb is gently filled with fluid so the doctor can see inside. It shows where the scar tissue is, how dense it is, how much of the cavity is affected and whether the openings to the tubes are clear. Often, mild scar tissue can be treated in the same sitting. Read more about hysteroscopy for fertility and our hysteroscopy service.
HSG, Saline Scan and 3D Ultrasound
Other tests help as a first step or alongside hysteroscopy:
- HSG: an X-ray test with dye. Scar tissue shows as areas the dye cannot fill ("filling defects"). It also shows whether the tubes are open, but it cannot always tell scar tissue apart from mucus or a polyp. See our HSG test guide.
- Saline infusion scan: an ultrasound while a little sterile fluid is passed into the womb, which outlines the cavity.
- 3D ultrasound: shows the shape of the cavity and the thickness of the lining in more detail than a standard scan.
A routine 2D ultrasound may show a thin or irregular lining but often misses thin bands of scar tissue, so a normal scan does not rule Asherman syndrome out.
What Doctors Look At
To judge how severe it is, doctors assess:
- How much of the cavity is affected.
- The type of scar tissue: thin and filmy, or thick and dense.
- Whether the tube openings are blocked.
- Your period pattern and history.
Severity of Asherman Syndrome
| Severity | How much of the cavity is affected | Type of scar tissue |
|---|---|---|
| Mild | Less than a third | Thin, filmy bands; the top of the cavity and tube openings are clear |
| Moderate | A third to two-thirds | Thicker, fibrous bands; parts of the walls stuck together |
| Severe | More than two-thirds | Dense scarring; the walls may be largely joined and the tube openings blocked |
Mild
Thin bands affect a small part of the cavity, and most of the lining is healthy. These are usually the easiest to treat, and the lining often recovers well.
Moderate
Thicker bands affect a larger area, and one or both tube openings may be partly blocked. Treatment needs careful surgery and follow-up to help the lining regrow evenly.
Severe
Dense scar tissue fills most of the cavity, and the walls may be largely fused. Restoring the cavity may need more than one operation, and the chance of the lining recovering fully is lower.
Asherman Syndrome vs Thin Endometrium
The two are often confused because both can show a thin lining on a scan.
| Asherman syndrome | Thin endometrium without scarring | |
|---|---|---|
| What it is | Scar tissue inside the womb | A lining that does not grow thick enough |
| Usual cause | D&C, surgery, infection or TB | Low estrogen, poor blood flow, some medicines, sometimes mild injury |
| Periods | Often much lighter or absent after a procedure | Often normal or slightly light |
| Best test | Hysteroscopy | Serial ultrasound scans through the cycle |
| Main treatment | Hysteroscopic removal of scar tissue, then hormones | Hormone treatment and support for blood flow |
For a thin lining without scarring, see our guide on how to increase endometrial thickness.
Asherman Syndrome Treatment
Hysteroscopic Adhesiolysis
The standard treatment is hysteroscopic adhesiolysis, which simply means cutting and removing the scar tissue through a hysteroscope. The surgeon divides the bands carefully, usually with fine scissors or other instruments, until the normal shape of the cavity is restored. Heat-based instruments are used sparingly, because heat can damage the healthy lining that is left. It is done as a day procedure, through the cervix, with no cuts on the tummy.
Stopping the Scar Tissue Coming Back
Freshly treated surfaces inside the womb tend to stick together again while they heal. To reduce this, your doctor may use one or more of the following:
- A balloon or other device placed in the womb for a short time to keep the walls apart.
- Estrogen treatment for a few weeks to help the remaining lining grow over the treated areas, followed by progesterone to bring on a period.
- A gel placed in the cavity at the end of surgery to reduce sticking.
- A second-look hysteroscopy a few weeks later to check the cavity and gently divide any new thin bands before they harden.
Recovery
Most women go home the same day. Mild cramping and light bleeding for a few days are common. Your doctor will plan follow-up scans to watch the lining grow, and will tell you when it is safe to try for a pregnancy. Moderate and severe cases often need more than one procedure.
Pregnancy After Asherman Syndrome
When Can You Try to Conceive?
Most doctors advise waiting for a few cycles after treatment, until a scan or second-look hysteroscopy shows that the cavity is open and the lining is growing well. If you are having IVF, the embryo transfer is planned once the lining reaches a good thickness.
Your chances depend mainly on how severe the scarring was and how well the lining recovers. Many women with mild to moderate Asherman syndrome go on to conceive after treatment. When the lining has been badly damaged, the chances are lower and treatment may take longer.
Why Pregnancy Needs Closer Care
After Asherman syndrome, some pregnancies have a higher risk of:
- Placenta problems, including a placenta that grows too deeply into the wall of the womb (placenta accreta). This needs planning for a safe delivery.
- Miscarriage or early labour.
- The baby growing less well if the placenta is not well attached.
For this reason, pregnancies after treatment are usually followed more closely, with detailed scans. Our high-risk pregnancy care team provides this monitoring.
When the Womb Cannot Recover
In a small number of women, the lining cannot regrow enough despite surgery and hormone treatment. In that case, IVF with a gestational carrier is an option for having a genetically related child. See surrogacy for how this works and the rules in India.
Can Asherman Syndrome Be Prevented?
Not always, but the risk can be lowered:
- Ask about alternatives to a D&C. For an early miscarriage, waiting, medicines or gentle suction may be suitable. Your doctor will advise what is safe for you.
- Choose gentle techniques when a procedure is needed. Suction rather than sharp scraping, and ultrasound guidance, reduce injury to the lining.
- Treat infection promptly after a delivery, miscarriage or procedure.
- Watch your periods afterwards. If your period has not returned, or is much lighter, about 6 to 8 weeks after a D&C, miscarriage or delivery, see a doctor. Scar tissue is softer and easier to treat when found early.
Questions to Ask Your Doctor
If you are being checked for Asherman syndrome, these questions can help:
- How severe is the scarring, and how much healthy lining is left?
- Can it be treated in one procedure, or might I need more than one?
- What will you do to stop the scar tissue coming back?
- When can I start trying for a pregnancy, and should I try naturally or with treatment?
- Could genital TB be the cause, and should I be tested?
- What extra care will I need if I become pregnant?
When to See a Doctor
Book an appointment if:
- Your period has not come back, or has become much lighter, 6 to 8 weeks after a D&C, miscarriage, delivery or surgery on the womb.
- You have monthly pelvic pain or cramps with little or no bleeding.
- You have not conceived after 6 to 12 months of trying following an earlier pregnancy or a procedure on the womb.
- You have had two or more miscarriages after a procedure.
Frequently Asked Questions About Asherman Syndrome
Can Asherman syndrome go away on its own?
No. Once scar tissue has formed inside the womb, it does not dissolve by itself. Hysteroscopy is needed to remove it.
Can you get pregnant with Asherman syndrome?
Yes, many women conceive after treatment, especially when the scarring was mild or moderate. Pregnancy is less likely with severe scarring, and closer monitoring is needed once you are pregnant.
Does Asherman syndrome show on ultrasound?
A standard scan may show a thin or irregular lining but often misses scar tissue. A saline scan, 3D ultrasound or hysteroscopy is needed for an accurate diagnosis.
Is the treatment painful?
Treatment is usually done under sedation or anaesthesia as a day procedure, so you should not feel pain during it. Mild cramps and light bleeding for a few days afterwards are common.
How long after Asherman surgery can I try to conceive?
Usually after a few cycles, once your doctor has confirmed that the cavity is open and the lining is growing well.
Can scar tissue come back after treatment?
Yes, especially after moderate or severe scarring. Devices, estrogen treatment and a second-look hysteroscopy help reduce this.
What is the difference between Asherman syndrome and a thin endometrium?
Asherman syndrome is physical scar tissue inside the womb. A thin endometrium is a lining that does not grow thick enough, often for hormonal or blood-flow reasons, without scar tissue.
Can Asherman syndrome happen without a D&C?
Yes. Infections, including genital tuberculosis, and other surgery on the womb can also cause it.
Asherman Syndrome Care at Yaal Fertility Centre, Chennai
At Yaal Fertility Centre, our team led by Dr. Rukkayal Fathima, MRCOG (UK) looks at your history, period pattern and scans, uses hysteroscopy to confirm the diagnosis and treat scar tissue, and then plans your path to pregnancy, whether that is trying naturally, IUI or IVF.
You can see our team at any of our eight centres across Chennai: Kilpauk, Mylapore, Thiruvanmiyur, Pallikaranai, Madipakkam, Red Hills, Velappanchavadi and Tambaram.
If your periods have become much lighter after a procedure, or you are struggling to conceive after a D&C, a female fertility evaluation will look for the cause. Book a consultation with Yaal Fertility Centre.
Written by
Dr. Rukkayal Fathima
Specialist at Yaal Fertility Centre, Chennai. Providing expert guidance on fertility and women's health.
