On hysteroscopy for infertility, a woman is found to have complete intrauterine adhesions (Asherman syndrome, Grade III-IV). Endometrial biopsy shows caseating granulomas, consistent with endometrial tuberculosis. After successful ATT, she undergoes hysteroscopic adhesiolysis. What is the recommended post-lysis treatment to promote endometrial regeneration?

• A Progestogen-only therapy to build endometrial thickness
• B High-dose oestrogen (conjugated oestrogen 2.5 mg daily for 3 months) with an intrauterine balloon stent ✓
• C Immediate IVF without hormonal preparation
• D GnRH analogue for 3 months to rest the endometrium

Explanation

After hysteroscopic adhesiolysis for severe Asherman syndrome, the endometrium is encouraged to regenerate with continuous high-dose oestrogen (CEE 2.5 mg or equivalent for 2–3 months) to promote proliferation of residual endometrial stem cells, combined with an intrauterine balloon or catheter to keep the walls apart and prevent re-adhesion. Progesterone is added in the last 10–12 days of each cycle to mimic the natural cycle. Progestogen-only therapy would cause endometrial suppression. GnRH analogues cause atrophy — the opposite of what is needed.

Reference: Shaw's Textbook of Gynaecology, 17th ed.

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Written and medically reviewed by the StethoPrep medical team.