Classification systems of Asherman's syndrome. An old problem with new directions

Abstract

Intrauterine adhesion (IUA) formation and the resulting Asherman's syndrome (AS) is an unfortunate clinical condition that occurs when the endometrium is damaged as a consequence of trauma, such as vigorous curettage, infection, or some Müllerian anomaly. The most frequent symptoms include hypo/amenorrhea, infertility, and adverse reproductive outcomes. Prevention of IUA formation is essential; however, when present, accurate diagnosis and surgical intervention (hysteroscopic adhesiolysis) are required. The outcome of this treatment is based on the technique and the extent of surgery performed which depends on the severity and complexity of the disease. Hence its classification becomes particularly important to determine a standardized therapy for each case and patient counseling regarding the prognosis. In this article, we aim to describe the IUAs classification systems that have been proposed comparing the merits and demerits of each one.

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Classification systems of Asherman’s syndrome.
An old problem with new directions
Rahul Manchanda, Aayushi Rathore, Jose Carugno, Luigi Della Corte, J. A. N.
Tesarik, Péter Török, George Angelos Vilos & Salvatore Giovanni Vitale
To cite this article: Rahul Manchanda, Aayushi Rathore, Jose Carugno, Luigi Della Corte, J. A.
N. Tesarik, Péter Török, George Angelos Vilos & Salvatore Giovanni Vitale (2021): Classification
systems of Asherman’s syndrome. An old problem with new directions, Minimally Invasive Therapy
& Allied Technologies, DOI: 10.1080/13645706.2021.1893190
To link to this article: https://doi.org/10.1080/13645706.2021.1893190
Published online: 04 Mar 2021.
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REVIEW ARTICLE
Classification systems of Asherman’s syndrome. An old problem with
new directions
Rahul Manchanda
a
, Aayushi Rathore
b
, Jose Carugno
c
, Luigi Della Corte
d
, J. A. N. Tesarik
e
,
P
eter T€
or€
ok
f
, George Angelos Vilos
g
and Salvatore Giovanni Vitale
h
a
Gynaecology Endoscopy Unit, PSRI Hospital, New Delhi, India;
b
VMMC & Safdarjang Hospital, New Delhi, India;
c
Department of
Obstetrics, Gynecology, and Reproductive Sciences, University of Miami Miller School of Medicine, Miami, FL, USA;
d
Department of
Neurosciences and Reproductive Sciences, School of Medicine, University of Naples Federico II, Naples, Italy;
e
MARGen Clinic,
Granada, Spain;
f
Faculty of Medicine, Institute of Obstetrics and Gynaecology, University of Debrecen, Debrecen, Hungary;
g
Department of Obstetrics and Gynecology, The Fertility Clinic, London Health Sciences Centre, Western University, London, ON,
Canada;
h
Department of General Surgery and Medical Surgical Specialties, Obstetrics and Gynecology Unit, University of Catania,
Catania, Italy
ABSTRACT
Intrauterine adhesion (IUA) formation and the resulting Asherman’s syndrome (AS) is an unfortu-
nate clinical condition that occurs when the endometrium is damaged as a consequence of
trauma, such as vigorous curettage, infection, or some M€
ullerian anomaly. The most frequent
symptoms include hypo/amenorrhea, infertility, and adverse reproductive outcomes. Prevention
of IUA formation is essential; however, when present, accurate diagnosis and surgical interven-
tion (hysteroscopic adhesiolysis) are required. The outcome of this treatment is based on the
technique and the extent of surgery performed which depends on the severity and complexity
of the disease. Hence its classification becomes particularly important to determine a standar-
dized therapy for each case and patient counseling regarding the prognosis. In this article, we
aim to describe the IUAs classification systems that have been proposed comparing the merits
and demerits of each one.
ARTICLE HISTORY
Received 7 December 2020
Accepted 16 February 2021
KEYWORDS
Asherman’s syndrome;
intrauterine adhesions;
hysteroscopy; classifica-
tion system
Introduction
Intrauterine adhesions (IUAs) were first described by
Heinrich Fritsch in 1894 in a patient who developed
secondary amenorrhea after a postpartum curettage
[1]. In 1948, Joseph Asherman of the Hadassah
Hospital of Tel Aviv published the first article on the
pathology of this condition which he named
‘Amenorrhoea Traumatica’[2]. He described in detail
the etiology, anatomy, differential diagnosis, and
prognosis of this disease. Later, in 1950, he also
described a treatment by laparotomy and the use of
intrauterine catheters to prevent its recurrence [3].
Currently, the term IUAs is often used inter-
changeably with Asherman’s syndrome (AS).
Nevertheless, while IUAs defines the presence of
fibrotic bands or synechiae formed between the uter-
ine walls, AS is a spectrum which encompasses the
clinical manifestations of this disease including men-
strual dysfunction, cyclical abdominal pain, infertility,
and poor reproductive outcomes, as well as the ana-
tomical distortion caused by these synechiae.
Endometrial injury (especially of the gravid uterus)
leads up to the development of AS as damage to the
basal layer of the endometrium results in its subse-
quent replacement with the fibrous tissue generating
intrauterine adhesions [4]. The most common causes
contributing to the development of AS include curet-
tage of the postpartum or post abortus uterus, some
M€
ullerian anomalies, infections, uterine surgeries, and
the utilization of compressive sutures for postpartum
hemorrhage [5].
The purpose of this review is to describe the vari-
ous classification systems of AS that have been pro-
posed over the years and to compare the merits and
demerits of each one.
Material and methods
The data research was carried out using the following
databases MEDLINE, EMBASE, Web of Sciences,
Scopus, and Cochrane Library querying for all articles
related to AS from the inception of the database up
CONTACT Rahul Manchanda drrahulmanchanda@rediffmail.com Gynaecology Endoscopy Unit, PSRI Hospital, New Delhi, India
ß2021 Society of Medical Innovation and Technology
MINIMALLY INVASIVE THERAPY & ALLIED TECHNOLOGIES
https://doi.org/10.1080/13645706.2021.1893190

to September 2020. Studies describing classification
systems of this condition were selected for analysis.
Results
Diagnosis of Asherman’s syndrome
Hysterosalpingography (HSG)
Historically, the diagnosis of AS was primarily made
using radiographic techniques such as
Hysterosalpingogram (HSG). The findings suggestive
of AS on HSG are as follows:
Marginal or centrally located intrauterine fill-
ing defects
Partial obliteration of the uterine cavity
Complete distortion of the uterine cavity
Absence of contrast filling inside the uterine cavity
(due to lower uterine cavity obliteration)
Although HSG is an invasive investigation, its role
is of particular importance in cases of infertility asso-
ciated with AS because of its ability to demonstrate
tubal patency as well as tubal contour. The drawback
of HSG is that it is not useful in cases of lower uter-
ine cavity adhesions, given the inability to fill the
endometrial cavity with contrast solution. The sensi-
tivity of HSG is 75% in the detection of IUAs while
its positive predictive value (PPV) is 50% [6].
Ultrasound
Ultrasonography (USG) is a non-invasive diagnostic
investigation that is commonly used as the first-line
diagnostic imaging modality in symptomatic patients
with gynecologic pathology. IUAs appear as dense
echoes within the endometrial cavity with an irregu-
lar, thin endometrium. USG is especially useful in
women with dense lower uterine cavity adhesions
where the role of HSG is limited. The sensitivity and
specificity of transvaginal USG are 52% and 11%,
respectively. Currently, 3D USG is also used to detect
IUAs with a specificity of 45% [6,7].
Sonohysterography
Sonohysterography (SHG) combines the advantages
of both HSG and USG. In this procedure, saline solu-
tion is instilled into the uterus to distend the endo-
metrial cavity. The visualization of echogenic areas
within the saline-filled cavity denotes the presence of
IUAs. The sensitivity of SHG has been reported to be
75% and PPV of 42.9%, which is comparable to that
of HSG [6].
MRI
Magnetic resonance imaging (MRI) is another non-
invasive imaging modality that can be used in cases
of suspected AS. It is frequently used in cases of
dense adhesions as it can evaluate the uterine cavity
above the adhesions and thus helps in the evaluation
of post-treatment prognosis of the disease. It is also
useful in cases where the diagnosis of AS is difficult
using HSG and USG due to dense adhesions and
lower uterine cavity obliteration. Low-intensity signals
on T2 weighted images reveal the presence of IUAs
on MRI. However, its role in routine clinical practice
remains limited because of its high cost [6].
Hysteroscopy
Hysteroscopy is currently the gold standard diagnostic
and therapeutic modality for the diagnosis of AS, gener-
ating only minimal patient discomfort, and allowing the
accurate diagnosis and treatment in only one interven-
tion in an office setting in selected cases, thus improv-
ing patient compliance and cost-effectiveness [8].
Management of Asherman’s syndrome
Surgical management, performing intrauterine lysis of
adhesions, is the cornerstone therapy for patients
diagnosed with AS. Joseph Asherman in his initial
reports described how a simple dilatation and curet-
tage (D&C) of the endometrial cavity resolved the
symptoms of abnormal menstruation in the majority
of the cases. Later, he also described that laparotomy
could also be used for its treatment. However, with
the introduction of minimally invasive surgeries, hys-
teroscopic lysis of intrauterine adhesions, over the
years, has gained popularity and is now the gold
standard treatment of AS.
Post-operative adjuvant therapies to prevent refor-
mation of adhesions include the use of barriers such
as inert intrauterine devices, Foley’s catheter, hyalur-
onic acid gel with or without the addition of estro-
gen-based medical treatments. Once adhesiolysis is
performed, the patient undergoes a second-look hys-
teroscopy after the next menstrual cycle [6]. The
second-look hysteroscopy is not only diagnostic, but
also allows the treatment of newly formed adhesions.
It could be repeated several times, if needed to pre-
vent more dense adhesion forming [9].
Classification of Asherman syndrome
The prognosis of AS relies on the severity of the con-
dition determined by both the degree of distortion of
2 R. MANCHANDA ET AL.

the uterine cavity and the severity of associated symp-
toms. Hence, an appropriate classification of this dis-
ease was deemed necessary. Initially, the classification
systems were only based on the severity of the intra-
uterine adhesions, but it was soon realized that it was
essential to create a more holistic categorization sys-
tem which also included clinical symptoms. This also
helped in directing the efforts towards standardization
of classification systems for easy global comparison of
findings and success of therapy. However, the search
for an ideal classification system is still ongoing and
further validation is required through large-scale
observational and randomized studies to determine
the most appropriate classification system.
The classification systems developed to date are
listed chronologically in Table 1. They comprise an
HSG-based classification system (Toaff and Ballas,
1978), hysteroscopy-based classification systems
(March classification, 1978, Hamou classification,
1983, Valle classification, 1988, Donnez and Nisolle
classification, 1994, Manchanda Endoscopy classifica-
tion, 2016), and clinico-hysteroscopic classification
systems (American Fertility Society [AFS] classifica-
tion, 1988, European Society of Hysteroscopy [ESH]
classification, 1989, Nasr classification, 2000).
In their 2017 Guidelines for Classification of AS,
the American Association of Gynecologic
Laparoscopists (AAGL) and the European Society for
Gynecological Endoscopy (ESGE) stated that
there was the need for a classification system of
intrauterine adhesions because the severity of this
condition affects the prognosis (Level B);
the different available classification systems com-
pared studies difficult to analyze. This could reflect
inherent deficiencies in each of the classification
systems. Consequently, it is currently not possible
to endorse any specific system (Level C) [10].
Classification based on HSG
Toaff and Ballas classification. Toaff and Ballas were
the first to classify AS in 1978 [11]. An HSG was per-
formed in all patients with suspected AS. They classify
the cases of AS as follows:
Grade 1: a single, small, filling defect within the
uterine cavity, occupying up to about one-tenth
(1/10) of the uterine cavity.
Grade 2: a single, medium-sized filling defect
occupying one-fifth (1/5) of the uterine cavity, or
several smaller defects adding up to the same
degree of involvement, located within the uterine
cavity, whose outline may show minor indenta-
tions but no gross deformation.
Grade 3: a single, large or several smaller, filling
defects involving up to about one-third (1/3) of
the uterine cavity, which is distorted or asymmet-
rical due to marginal adhesions.
Grade 4: large-sized filling defects occupying most
of the severely deformed uterine cavity.
The authors correlated these radiographic findings
with the degree of menstrual dysfunction in 64 patients
and graded the menstrual pattern of patients as:
1:slight, but noticeable reduction in quantity and
duration of the menstrual flow.
11:reduction in menstrual flow quantity and
duration to half of the usual flow.
111:scant menstrual flow for 1 or 2 d followed
by brown spotting
1111:only brown spotting for 1 or 2 d
Table 1. Classification systems for Asherman’s syndrome/intrauterine adhesions (IUAs).
Classification Year Summary of classification
Toaff and Ballas 1978 Classifies the IUAs into four grades based on HSG findings to determine the impact of the extent
of IUA as well as their location in the uterus on the menstrual pattern of patients
March 1978 IUA were classified as minimal, moderate, or severe based on hysteroscopic assessment of the
degree of uterine cavity involvement
Hamou 1983 IUAs were classified as isthmic, marginal, central, or severe based on hysteroscopic assessment
Valle 1988 IUAs were classified as mild, moderate or severe based on hysteroscopic assessment and extent
of occlusion (partial or total) at HSG
American Fertility Society 1988 Complex scoring system of mild, moderate and severe IUAs based on extent of endometrial
cavity obliteration, appearance of adhesions, and patient menstrual characteristics based on
hysteroscopy or HSG assessment
European Society for Hysteroscopy 1989 Complex system classifies IUAs as grades I through IV with several subtypes based on a
combination of hysteroscopic and HSG findings and clinical symptoms
Donnez and Nisolle 1994 IUAs were classified into six grades based on their location determined by hysteroscopy or HSG
and postoperative pregnancy rate being the primary clinical outcome
Nasr 2000 Complex system generating a prognostic score by incorporating menstrual and obstetric history
with findings at hysteroscopic assessment
MEC 2016 Simple and easy to use system dividing AS into mild, moderate, and severe grade based on the
extent of uterine involvement at hysteroscopy
MINIMALLY INVASIVE THERAPY & ALLIED TECHNOLOGIES 3

In this case series the following correlation
was drawn:
Grade 1 adhesions: asymptomatic, fortuit-
ous findings
Grade 2 adhesions: mostly asymptomatic, in some
cases results in moderate to severe hypo-menorrhea
Grade 3 and Grade 4 adhesions: always symptom-
atic and cause severe menstrual dysfunction.
In light of this, it was understood that the HSG-
based classification system could be useful to correlate
the degree of menstrual dysfunction with the severity
of intrauterine adhesions.
Hysteroscopy-based classification systems
Over the subsequent years, there was an increase use
of hysteroscopy when IUAs were suspected, for both
diagnostic and therapeutic purposes with the advan-
tage of direct visualization of the uterine cavity as
compared to other diagnostic imaging modalities.
Hence hysteroscopy-based classification systems were
subsequently developed.
March classification. The first attempt to classify
IUAs based on hysteroscopic findings was made by
March et al. in 1978. The extent of adhesions present
in the endometrial cavity and the degree of its occlu-
sion was used to grade the severity of AS. They cate-
gorized them into minimal, moderate, and severe.
This classification system is still used because it is
simple to use and easy to remember (Table 2). It is
important to highlight that hysteroscopy-based classi-
fication systems are better to compare the efficacies of
various techniques used for adhesiolysis which was
assessed by performing a second look hysteroscopy.
Thus, the comparison of postoperative outcomes of
such techniques was much easier and convenient.
However, the shortcoming of this classification sys-
tem is that there is no correlation with clinical symp-
toms and the post-treatment success was not
defined [12].
Hamou classification system. In 1983, the concept of
hysteroscopy-based classification system was further
refined by Hamou et al., who also included the extent
and histologic nature of the adhesions as well as the
evaluation of the surrounding glandular endometrium
along with the degree of cavity distortion. They used a
micro-hysteroscope (4 mm diameter and 30-degree
fore-oblique lens) with CO
2
distension media for adhe-
siolysis. After examining the endometrial cavity with a
panoramic view of the uterine cavity and determining
the amount of uterine cavity affected with adhesions,
contact hysteroscopy was done for assessment of size
and histologic nature of adhesions under 20magnifi-
cation. The thickness, extension, and glandular epithe-
lium of the surrounding endometrium were also
visualized under 60and 150magnification (after
methylene blue staining) (Table 3)[13].
The three different types of adhesions described in
his study are as follows:
Endometrial adhesions: white, vascularization simi-
lar to the surrounding endometrium
Fibrous or connective tissue adhesions: transpar-
ent, bridge-like and poorly vascularized
Myometrial adhesions: highly vascular and exten-
sive adhesions
Valle classification. In an attempt to reduce the short-
comings of the previous classification systems, in 1988,
Valle et al. suggested that success of treatment, identified
by improvement in menstrual pattern, and reproductive
outcomes, also had to be correlated with the severity of
disease. They reported that great results were obtained
in cases of mild adhesions and partial occlusion of the
endometrial cavity and less satisfactory results were
achieved with severe adhesions and complete obliter-
ation of the cavity. This classification system thus
included both the extent of endometrial cavity involve-
ment as well as the type of adhesions (Table 4)[14].
The different types of adhesions identified were
as follows:
Mild: filmy adhesions, composed of endometrial
tissue causing partial or complete endometrial cav-
ity occlusion.
Table 2. Detailed classification of Asherman’s syndrome by
March, 1978.
Classification Involvement
Severe >3/4 of the uterine cavity involved, agglutination of walls or
thick bands, tubal ostium areas, and upper
cavity occluded
Moderate 1
=
4–3/4 of the uterine cavity involved, no agglutination of
walls- adhesions only, tubal ostium areas and upper
fundus only partially occluded
Minimal <1/4 of the uterine cavity involved, thin or filmy adhesions,
tubal ostium areas, and upper fundus minimally involved
or clear
Table 3. Classification of Asherman’s syndrome by
Hamou, 1983.
Location of the adhesions Isthmic
Marginal
Central
Size of the adhesions <1cm
2
>1cm
2
Type of adhesions Endometrial adhesions
Fibrous/ connective tissue adhesions
Myometrial adhesions
4 R. MANCHANDA ET AL.

Moderate: fibromuscular adhesions, made up of
endometrium causing partial or total occlusion of
the endometrial cavity, can bleed on adhesiolysis.
Severe: dense connective tissue adhesions, lack
endometrial tissue and causing partial or total
occlusion of the endometrial cavity, not likely to
bleed on adhesiolysis.
Donnez and Nisolle classification. In 1994, Donnez
and Nisolle re-emphasized the importance of using
HSG in the classification of AS along with hystero-
scopic finding and proposed a classification system
based on both modalities. They broadly divided AS
into three groups and six subgroups depending on
the type of adhesion and the extent of uterine
involvement as described in Table 5 [15].
MEC classification. In 2016, the Manchanda’s
Endoscopic Centre (MEC) classification system was
proposed in India, which categorized AS as mild,
moderate, and severe disease owing to the extent of
the endometrial cavity involvement. It encompasses
both dense and flimsy adhesions in all categories. Its
advantage is of being relatively simple and easy to use
in clinical practice [16](Table 6).
The reproductive outcomes based on this classifica-
tion system were correlated with the severity of the
adhesions in a retrospective analysis performed in
2018 by Sharma et al., who reported an increased
number of live births after adhesiolysis in the moder-
ate and severe categories of adhesions. The direction
and degree of adhesiolysis performed by hysteroscopy
were guided by preoperative assessment of myome-
trial thickness of fundal, anterior, and posterior uter-
ine walls using the ‘RR’method in this study [17].
The ‘RR method’is named after the two main authors
of this paper and refers to the measurement of myo-
metrial thicknesses both at the fundus of the uterus
and at anterior/posterior uterine walls, that guides the
amount and the direction of hysteroscopic adhesioly-
sis [17].
Clinico-hysteroscopic classification
American Fertility Society (AFS) classification.
Historically, the focus has primarily been on how to
make the diagnosis of AS, whereas the presenting
clinical symptoms of patients have been overlooked
and not included in the proposed grading systems. In
1988, the AFS introduced a comprehensive classifica-
tion system that became the most widely accepted
IUAs classification system across the globe. It
included the clinical symptoms (menstrual pattern) as
an indicator of disease severity, which was considered
important as it gives an estimate about the amount of
endometrium which was available for potential regen-
eration post-adhesiolysis and serves as an important
marker for defining the prognosis post-treatment,
thus helping in pre-treatment patient counseling.
Scoring points (1–3) were given to each of the
included characteristics and staging of AS was done
(stage I/II/III: mild/moderate/severe) according to the
score obtained. Additionally, a prognostic score to
each patient was for the first time assigned by a clas-
sification system and hence it became a more object-
ive way of classification (Table 7)[18].
European Society of Hysteroscopy (ESH). Another
classification system was proposed by the European
Society of Hysteroscopy (ESH) in 1989, incorporating
the menstrual pattern of women with AS. However,
the reproductive outcome of patients, which is one of
the important aspects in cases of AS, was not
included. Another disadvantage of this classification
system was that, despite it being a very comprehen-
sive system for grading, its complexity makes it
Table 4. Classification of Asherman’s
Syndrome by Valle, 1988.
Type of adhesion Mild
Moderate
Severe
Extent of uterine cavity occlusion Partial
Total
Table 5. Classification of Asherman’s syndrome by Donnez
and Nisolle, 1994.
Degree Location
I Central adhesion
a. Thin filmy adhesion (endometrial adhesions)
a. Myofibrous (connective adhesions)
II Marginal adhesions (always myofibrous or connective)
a. Wedge like projection
a. Obliteration of one horn
III Uterine cavity absent on HSG
a. Occlusion of the internal os (upper cavity normal)
a. Extensive coaptation of the uterine walls
(absence of the uterine cavity, true Asherman’s syndrome)
Table 6. MEC classification of Asherman’s syndrome.
Grade Category Characteristics
Grade 1 Mild Less than one-third of the uterine cavity is obliterated (filmy/dense adhesions)
Grade 2 Moderate 1/3–2/3 of the uterine cavity obliterated (filmy/dense adhesions)
Grade 3 Severe More than two-thirds of the uterine cavity obliterated (filmy/dense adhesions)
MINIMALLY INVASIVE THERAPY & ALLIED TECHNOLOGIES 5

difficult to remember and use in clinical practice,
thus limiting its utility (Table 8)[19].
Nasr classification. Nasr et al. (2000) described a
very comprehensive scoring system including the clin-
ical symptoms (both menstrual pattern and repro-
ductive outcomes) of the patients and the
hysteroscopic findings along with providing a prog-
nostic correlation. This system gives greater emphasis
on the type of adhesions and the ability to visualize
the tubal ostium over the involvement of the rest of
the endometrial cavity. Adhesions were pathologically
classified into three categories: filmy/dense/tubular.
The latter, which is the most severe form of the dis-
ease, indicates dense adhesions obliterating the entire
uterine cavity, thereby obscuring both the tubal ostia.
Isthmic fibrosis was identified as a separate entity and
was given special importance as it could initiate a
neuroendocrine reflex and cause endometrial deacti-
vation and amenorrhea even when the rest of the cav-
ity is free of adhesions [20].
Prevalent classification adopted in the world
Although a variety of classification systems have been
developed so far to categorize Asherman syndrome,
we could not find any literature on the comparison of
these classification systems in terms of their prognos-
tic significance. The use of HSG to classify Asherman
syndrome has now become obsolete with the begin-
ning of hysteroscopy. Having said that, in our view
clinico-hysteroscopic classification as given by AFS is
currently the best method of classification and is
being widely used in the Indian clinical settings.
Moreover, the hysteroscopic classification given by
March et al. and the recently introduced MEC classi-
fication system remains the most convenient and easy
to remember classifications in operating rooms.
Conclusion
The diagnosis of AS should be taken into account in
case of alterations of the menstrual flow and poor
reproductive outcomes in women with a history of
endometrial ‘trauma’. Classifying AS is important
because it represents the basis for understanding how
to manage a patient according to the severity of
the disease.
While previously radiographic findings of HSG
were used to classify this disease, later direct visualiza-
tion of the endometrial cavity by hysteroscopy became
a favored approach and focus was thus shifted to for-
mulate an ideal classification system which should be
both comprehensive and easy to use, including the
disease symptoms along with the extent adhesions
inside the uterine cavity. Although numerous classifi-
cation systems have been proposed over the years, the
search is still ongoing and none of the available classi-
fication systems specify the influence of its severity on
the reproductive outcome. Additionally, these systems
still need to be validated with larger randomized stud-
ies and clinical application of these classification sys-
tems have to be further evaluated.
Main points
Classification systems are necessary to evaluate the
extent of intra-uterine adhesions, selecting the best
treatment option and analyzing the postoperative
success of adhesiolysis.
The various classification systems include HSG-
based classification, hysteroscopy-based classifica-
tion, and clinico-hysteroscopic classification.
HSG-based classifications have become by and
large obsolete.
The most widely accepted among these is the AFS
classification, which is a clinico-hysteroscopic
classification.
Table 7. Classification of Asherman’s syndrome by American
Fertility Society (AFS), 1988.
Characteristics
Extent of cavity involved <1/3 <1/3–2/3 >2/3
12 4
Type of adhesions Flimsy Filmy and Dense Dense
12 4
Menstrual pattern Normal Decreased Amenorrhoea
02 4
Prognostic classification HSG score Hysteroscopy
score
Stage I (Mild) 1–4
Stage II (Moderate) 5–8
Stage III (Severe) 9–12
Table 8. Classification of Asherman’s syndrome by European
Society of Hysteroscopy (ESH) 1989.
Grade Extent of intrauterine adhesion
I Thin or filmy adhesion
The adhesions are easily broken using only the
hysteroscope sheath
The cornual areas are normal
II Single firm adhesion
Connecting separate parts of the uterine cavity
Visualization of each tubal ostium is possible
Cannot be broken by hysteroscope sheath alone
IIa Occluding adhesions only in the region of internal cervical os
The upper uterine cavity normal
III Multiple firm adhesions
Connecting separate parts of the uterine cavity
Unilateral obliteration of tubal ostium areas
IIIa Extensive scarring of the uterine cavity with
amenorrhea or decreased menstrual flow
IIIb Combination of III and IIIa
IV Extensive firm adhesions with agglutination of the uterine walls
At least both tubal ostium areas are occluded
6 R. MANCHANDA ET AL.

Nasr has developed the most comprehensive classi-
fication system in 2000, which is the most ideal
one, to include prognostic scoring as well as the
reproductive outcome of the patients.
The most recent classification system has been
developed in 2016 in India, known as MEC classi-
fication, which is hysteroscopy-based and is rela-
tively simple and easy to implement under
clinical settings.
Further clinical studies are required to validate the
clinical application of these classification systems
and to prognosticate post-treatment reproductive
outcomes according to the severity of
the condition.
Declaration of interest
The authors report no conflicts of interest.
ORCID
Rahul Manchanda http://orcid.org/0000-0002-6367-3005
Luigi Della Corte http://orcid.org/0000-0002-0584-2181
Salvatore Giovanni Vitale http://orcid.org/0000-0001-
6871-6097
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