Intrauterine Adhesions (Asherman) · Hysteroscopic Adhesiolysis

Step-by-step decision

Choose step by step as prompted; reaching an endpoint gives the management recommendation. You can go back a step or restart anytime.

Full pathway

1. [Decision] Symptoms + severity + fertility need
   Symptomatic? Adhesion severity? Fertility need? (Severity by AFS/ESGE grade; dense/severe cases warrant ultrasound or laparoscopic guidance to lower perforation risk, often staged.)
   • Symptomatic (hypomenorrhea/amenorrhea, infertility, recurrent loss, cyclic pelvic pain) → Symptomatic → hysteroscopic lysis + re-adhesion prevention
   • Asymptomatic, incidentally found mild adhesions → Asymptomatic mild → observe
   • Severe/dense extensive adhesions → Severe dense → staged + guidance
2. [End] Symptomatic → hysteroscopic lysis + re-adhesion prevention
   Symptomatic → hysteroscopic adhesiolysis (mechanical/energy lysis under direct vision, preserving residual normal endometrium); prevent re-adhesion: intrauterine barrier (balloon stent/IUD/hyaluronic acid gel) + estrogen (± cyclic progestogen) for endometrial regeneration + planned second-look hysteroscopy to lyse early re-adhesions.
3. [End] Asymptomatic mild → observe
   Asymptomatic, incidental mild adhesions, no fertility need → may leave alone and follow up; reassess if menstrual abnormality or a fertility need arises.
4. [End] Severe dense → staged + guidance
   Severe/dense extensive adhesions → staged hysteroscopic lysis with intraoperative ultrasound/laparoscopic guidance to lower perforation; aggressive re-adhesion prevention + estrogen + multiple second-looks; counsel fully that menstrual and fertility recovery prognosis is poorer with high re-adhesion rates.

Source guidelines & references

• Intrauterine adhesion (Asherman) management (AAGL/ESGE consensus; hysteroscopic adhesiolysis + re-adhesion prevention + estrogen + second-look)

This pathway is our own synthesis of the decision logic in the guidelines above (not the guideline verbatim); thresholds and workflows change as guidelines update — in practice follow the latest guideline, your institution's protocol and the individual patient.

Other pathways