Total adhesions treated by hysteroscopy: must we stop at two procedures?

To study the anatomic and fertility results after treatment for Asherman syndrome involving more than two separate surgical procedures.Retrospective case series.Tertiary center.Twenty-three women who had Asherman syndrome and required more than two hysteroscopic operative procedures.Third or higher-order operative hysteroscopy procedure.Fertility rate.The women's mean age was 34 years (± 5.8 years) when treatment for adhesions began. All women initially had adhesions classified as severe with total amenorrhea. Twelve patients had three separate procedures to treat the adhesions, nine had four treatments, and two had five treatments. One woman was lost to follow-up. At the conclusion of treatment, more than 80% of the women had either no adhesions at all or only mild adhesions. The overall pregnancy rate was 40.9%; there were nine pregnancies and six term infants (27.2%). All but one of these pregnancies were spontaneous. The mean time to pregnancy was 10.5 months (± 4.7 months).The number of hysteroscopic procedures envisioned to treat Asherman syndrome should not be a limiting factor. It is appropriate to treat women, especially those younger than 35 years, until uterine anatomy permits the visualization of both ostia.