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Investigating Asherman's Syndrome

Bee Tan is an Associate Clinical Professor of Obstetrics and Gynaecology, and has been working at WMS since 2013. With a particular expertise in reproductive medicine, he is currently in the early stages of researching treatments for Asherman’s syndrome, a rare condition that can cause infertility and miscarriage. We met up with Bee to find out more about his work and what he hopes it could achieve.

What is Asherman’s syndrome?

Asherman’s syndrome is a rare condition in which there are adhesions (scarring) in the womb, with the main symptoms being infertility, miscarriage and lighter or even absent periods.

What causes the condition?

We think that the majority of cases occur when there has been a medical intervention in the womb that has stirred up the endometrium (lining of the womb) – such as a surgical evacuation following a miscarriage, termination of pregnancy, caesarean section, womb infection or when a woman has undergone imaging of the womb such as the hysterosalpingogram - a womb x-ray in which a dye that blocks x-rays is infused into the womb.

Of course, the vast majority of these procedures do not lead to the condition and the number of women affected is very small. We're still in the early stages of researching the condition so there could be other reasons why some women are affected.

How is it diagnosed?

The condition is diagnosed following a procedure called a hysteroscopy, where a camera is used to see inside the womb. This can be done under a general or a local anaesthetic. By looking inside the womb we can assess whether there are adhesions and, if so, patients are categorised as having the condition mildly, moderately or severely.

How many women are affected?

It’s very difficult to say how many women are affected, but fortunately we believe it’s a very small number. I see perhaps two cases per year. However, the fact that the condition is rare means that there isn’t much data available, making it difficult to study trends between patients and determine why certain women are affected.

What does your research involve?

Along with my research team, I am studying the endometrial stem-like cells that are present in the womb to see if we can find a way to regenerate those that are lacking in women who have Asherman’s syndrome and help them to have a successful pregnancy. IVF wouldn’t help these women to have a baby, because you need to have a sufficiently thickened womb lining in order for the egg to implant.

At the moment, the research is very much in its infancy and there are many questions we need to answer. What is the best way of using endometrial stem-like cells to regenerate the lining of the womb? These cells are known to have a relatively low immunogenicity, which means that they don’t tend to cause a big immune response when transferred between people. Could a woman therefore donate these cells as they would eggs? How would we administer the cells to the patient? Would these cells stay and develop in the womb if instilled directly into the womb? These are just a few of the questions our research aims to address.

As a Clinical Professor, I divide my time between being clinical (55%) and doing academic work/ research (45%). I find that working like this can be very helpful, as it gives me a valuable overview of both sides – so when I’m in the lab, for example, I can bear in mind how my research would impact real couples based on what I’ve seen in the clinical setting.

As well as helping women with the condition to have a baby, are there any other ways your research could help society?

Yes – our research also aims to study endometrial stem-like cells and how they could be used elsewhere in the body. There’s evidence to suggest these cells could be useful to help those with heart disease and diabetes and, in Australia, researchers have been investigating how the cells could be used to treat pelvic organ prolapse. Unlike other cells like cardiac stem cells, endometrial stem-like cells are quite easy to access, so the potential for using them to help people with other conditions is quite exciting.

If you reach the stage of being ready to start trials with women who have Asherman’s syndrome, what would need to happen in order for them to take place?

We’re a long way off getting to that point at the moment, and of course we’d need to obtain all the relevant permissions first. But if we did get to that point, we would need to establish a suitable environment in which treatments could take place – an IVF clinic could be perfect for this, as it’s already set up with the correct conditions for cell-based treatments.

Ultimately it would be great to establish a Asherman’s centre where we could bring researchers in this area together to advance our research both on treatments for Asherman’s syndrome and the use of endometrial stem-like cells for other conditions. Couples could then be referred to the centre for treatment.

What do you enjoy most about your work?

Helping couples to achieve a successful pregnancy is just so rewarding. I have children myself and it’s such a joy to me, so it’s wonderful to be able to help others experience it too.

Bee