Dilation and curettage (D and C) is a common surgical procedure in which the lining of the womb (endometrium) is scraped away. It is carried out after a miscarriage (often routinely), after elective termination or caesarean section.
Sometimes it is also carried out after manual removal of the placenta after birth or to remove polyps or other growths from the uterus.
Despite the widespread use of D and C, women are not warned that it can result in Asherman’s Syndrome and infertility.
What is Asherman’s Syndrome?
Asherman’s Syndrome is a scarring of the uterus. In severe cases the walls of the uterus stick together or the uterus completely fills up with scar tissue and becomes solid.
The woman’s menstrual period usually becomes milder or stops altogether as the cervix is blocked up by scar tissue so there is nowhere for the menstrual blood to exit.
Infertility is a natural consequence of this.
Some women experience monthly abdominal pain as a result of retained menstrual blood but others have no symptoms.
Having a D and C after childbirth increases the likelihood of having Asherman’s Syndrome because during pregnancy, the hormone progesterone suppresses the ability of the endometrium to repair injury. The tissue, that normally grows rapidly and then sheds when a woman has a period, slows down its growth during gestation.
This means that its ability to regenerate itself after trauma is limited, putting a woman at extra risk during the post-partum period. The same is true for women who have terminations.
One study suggested that as many as 40 percent of women may develop Asherman’s Syndrome after a post-natal D and C, particularly if it was a repeat procedure. Other studies suggest one in 100 women will have the syndrome afterwards.
Whatever figure is the nearest, both figures are high enough for the syndrome to receive a great deal more public attention and for women to be informed of its possibility prior to consenting to a D and C.
Jen, who developed Asherman’s Syndrome and infertility after a D and C to remove a polyp, shares her experiences to help other women:
“My Ashermans journey began the day I went in for a routine Dilation & Curettage to remove a polyp. I was 32 years old at the time. I had no children and never had any pregnancies. I always wanted children and finally found the man of my dreams that I wanted to have children with. I do remember my OB/GYN talking to me about the procedure and said there were very little risks with the surgery. Honestly I do not even remember if Asherman’s was even mentioned. I didn’t really take any of those risks seriously.
"That day I didn’t realize that a simple procedure could drastically and permanently change my life both physically and mentally. After my D&C months went by and I had no period. Before the D&C I always had a period every month like clockwork. I questioned my doctor and asked why I was not having one. He blamed it on my birth control. Many months later still nothing. He did blood work to look at my hormone levels. Everything came back normal. Finally he decided to do a Hystosalpinagram. He made several attempts to do the procedure but could not. He told me it was because my uterus was tilted and there was nothing to be concerned about.
"One day my sister called me to let me know that her Dr told her about having an Endrometrial Ablation to keep her from having periods. Her periods were very heavy and affected her life day to day. This was an option for her seeing she was finished having children. She asked me if I think that is what happened to me. That really got me thinking. I went off the birth control pill and I started looking for a new OB/GYN. One that I hoped would listen to me.
"I found one and made an appointment with him and within 30 minutes of letting him know my history I was getting answers. He told me about this rare condition sometimes caused by an over aggressive D&C among other complications: Ashermans Syndrome. He told me not to worry and that one day he will deliver my baby. He sent me for a Hydro-sonogram to look at my uterus.
"That day was the scariest day of my life. The technician doing the procedure seemed to be having problems. They were whispering to each other and saying maybe we need to get a doctor. They kept apologizing as they were trying to force the catheter into my cervix. She called another technician in to try. The pain was intense. They said they have never seen this before. Finally, they called a doctor in to try. After several failed attempts they told me they could not get into my cervix.
"He told me that I did indeed have Asherman’s Syndrome and that my uterus is completely scarred shut. He set me up to go to a well-known fertility clinic where I was given estrogen treatments for months to try and build up my endometrial lining.
"My final visit with the Reproductive Endocrinologist was when he coldly told me I would never have children. He said I should have a hysterectomy. He said it as if it was not a big deal. I was so crushed. I couldn’t stop crying. How could this be? Why is it so difficult?
"I found Ashermans.org and a doctor who specialized in treating Asherman’s but I no longer had trust in any doctor. I also realized that the doctor that caused my AS knew something was wrong and so did the doctor that took over his patients. I was so angry with the doctor and the one that took his place as well as the first Reproductive Endocrinologist I met with. I felt guilt about being so angry with the doctor that caused my AS, but I was. He lied to me. They knew what was wrong and I was 35 years old and probably would not ever have my own children!”
Jen did go on to have a daughter, Isabella, by caesarean after receiving the correct treatment from a specialist, but has since had to have a hysterectomy due to complications of the Asherman’s.
It is very important after being diagnosed with Asherman's Syndrome to seek help from a specialist who is expert in the field, to maximize your chances of recovery. This will be discussed in a subsequent article.
Thank you to Poly from www.ashermans.org and to Jen for sharing her story with me.
International Asherman’s Association, Medical Description. Web. 26 March 2012. http://www.ashermans.org/information/medical-description
Asherman’s Syndrome Leaflet, Endo-Gynaecology 2005. Web. 26 March 2012. http://www.asherman.de/fileadmin/downloads/Dr_Vancaillie_s_pamphlet.pdf
Prevalence of Asherman's syndrome after secondary removal of placental remnants or a repeat curettage for incomplete abortion. Hum Reprod. 1998 Dec;13(12):3347-50.
Reviewed March 26, 2012
by Michele Blacksberg RN
Edited by Jody Smith