Asherman’s syndrome is a syndrome that follows postpartum or postarbortal curettage, it may present with menstrual abnormalities such as oligomenorrhea, amenorrhea, hematometra, recurrent abortions, with the commonest presentation being infertility [1], This was evident to our case as she presented with amenorrhea for 12 months with no symptoms pelvic pain suggestive of hematometra. This pathology arises as a result of partial or complete adherence of the anterior and posterior wall of the uterus due to disruption of the basalis layer of the endometrium which can occur following postarbortal curettage, caesarian section, multiparty or myomectomy [2], however, most of the mentioned risk factors were not explaining the problem in our case, the only caesarian section was highly associated with Asherman’s syndrome.

In approximately 90% of cases, intrauterine adhesions are due to curettage for pregnancy complications, such as missed or incomplete abortion or retained products of conception [3], however, this was not the case in our patient as she had no history of curettage, no previous uterine scars or uterine surgery, only a full-term pregnancy baby caesarian section in January 2021. Surgical intervention of the uterus leads to scarring during the healing process, for the case of the Caesarian section, the sewing of the uterine tissue leaves a scar in the endometrium, this inappropriate Scar healing can lead to a post-Caesarean niche (isthmocele), which is visible in ultrasound as a triangular hypoechoic area, however, these findings were not evident via transabdominal ultrasound, this interruption of the endometrium is believed to occur due to insufficiency scar healing especially at the placenta bed [4].

The diagnosis of Asherman’s syndrome can be made using Hysterosalpingography and transvaginal hydroultra-sonography but they have a high false-positive rate because polyps and minor fibroids can be misdiagnosed as adhesions, Hysterosalpingography was used in our case but it was unable to confirm the diagnosis of Asherman syndrome due to complete blockage of the internal os by fibrotic bands which contrasted to a throwback. For accurate diagnosis it is important to use hysteroscopy which is termed as a gold standard [5], however, this modality was not available in the facility. Other studies show Hysterosalpingography to have a sensitivity and specificity of 80% as a hysteroscope, the only advantage of the hysteroscope is its ability to report on the location and extent of the disease [6] which help to determine treatment outcome. Asherman syndrome should be considered in patients with a history of a Caesarian section presenting with amenorrhea/hypomenorrhea and infertility because trauma itself leads to an impaired ability for implantation, the synechia can also lead to tubal occlusion and thus to infertility [7]. The diagnosis of Asherman’s syndrome was reached using intraoperative findings which revealed partial endometrial cavity obliteration with adhesions intracavitary, cervical canal occlusion by adhesion band blocking the internal os and cervical canal, there was no evidence of hematometra.

To avoid over treatment of Asherman’s syndrome the difference between intrauterine adhesion and Asherman’s syndrome should be made as Intrauterine Adhesion only presents with adhesions with no symptoms, while Asherman’s syndrome presents with both adhesions and symptoms such as hematometra, pelvic pain, amenorrhea, hypomenorrhea and infertility as it presented in our case, secondly it might give a chance of conservative treatment for Intrauterine Adhesion if fertility is desired while Asherman's syndrome needs surgical intervention such as adhesiolysis hysteroscopic then the intrauterine device of copper T and estrogen to stimulate endometrial proliferation and epithelization [8]. After primary hysteroscopic adhesiolysis, the formation of new adhesions is very frequent, and several modalities have been studied and suggested for the prevention of new adhesions such as hyaluronic acid gel, Intrauterine contraceptive devices such as copper T, foley catheter balloon for 7-14 days, and estrogen from day 7 for 8-10 weeks which help to stimulate endometrium hyperplasia, and aid in re-epithelization of the basalis layer [9] which was previously distorted. The initial goal of treatment is the restoration of a normal calibrated uterine cavity covered with endometrial lining and free tubal Ostia, Overall restoration of normal menstruation is observed in 75%–100% [10], as in our case menses resumed after 3 months post-surgery and a month after stopping combined oral contraceptive.