The extent of any adhesions and its impact on female reproduction should be evaluated where AS is suspected. The ideal classification system should include a comprehensive description of the adhesions which should be graded in terms of severity. Finally, it ought to provide a practical guide for clinicians to achieve optimum treatment and likely outcome.
Since Asherman original description, there have been many attempts to find the most accurate classification for IUAs. Toeff and Ballas (1978) were the first authors who tried to classify AS on the basis of hysterosalpingographic findings (Table 1). In the same year, March et al. introduced for the first time a hysteroscopic classification of AS (Table 2). This classification is still used for its simplicity although it is considered insufficiently prognostic.
|Type 1||Atresia of the internal ostium, without concomitant corporal adhesions.|
|Type 2||Stenosis of internal ostium, causing almost complete occlusion without concomitant corporal adhesions.|
|Type 3||Multiple small adhesions in the internal ostium isthmic region.|
|Type 4||Supra isthmic diaphragm causing complete separation of the main cavity form its lower segment.|
|Type 5||Atresia of the internal ostium with concomitant corporeal adhesions.|
|Mild||Filmy adhesion occupying less than one-quarter of uterine cavity. Ostial areas and upper fundus minimally involved or clear.|
|Moderate||One-fourth to three fourth of cavity involved. Ostial areas and upper fundus partially involved. No agglutination of uterine walls.|
|Severe||More than three fourth of cavity involved. Occlusion of both ostial area and upper fundus. Agglutination of uterine walls.|
Finally, the widely used classification developed on behalf of the American Fertility Society took into account the extent of the disease, menstrual pattern and the morphological feature of the adhesions. Both hysteroscopy and HSG could be used for this kind of scoring system (Table 3).
|Cavity involved||<1-3||1/3 – 2/3||>2/3|
|Type of adhesions||Filmy||Filmy and Dense||Dense|
|Menstrual pattern||Normal||Hypo menorrhea||Amenorrhea|
|PrognosticClassification||HSG score||Hysteroscopy score|
|Stage I (Mild)||1-4|
|Stage II (Moderate)||5-8|
|Stage III (Severe)||9-12|
More recently, the classification published in 2000 by Nasr et al. illustrated an innovative way to classify AS (Table 4). This scoring system included not only the menstrual symptoms but also the obstetric history of the woman. According to this group, clinical history plays a more important role than the extent of the adhesions. The results were compared with the classifications of March and the ESH showing a good correlation in women with mild or severe disease, but not in those with moderate adhesions.
|Filmy adhesions||More than 50% of the cavity||1|
|Less than 50% of the cavity||2|
|Dense adhesions||Single band||2|
|Tubal ostium||Both visualized||0|
|Only one visualized||2|
|Both not visualized||4|
|Tubular cavity(sound less than 6)||10|
|Reproductive performance||Good obstetrics history||0|
|Recurrent pregnancy loss||2|