In a retrospective case report series, we evaluated the efficacy of hysteroscopic adhesiolysis in patients with severe Asherman's syndrome. In 31 patients with permanent severe adhesions, hysteroscopic treatment was performed. In all patients, uterine cavity with at least one free ostial area was restored after one (n = 16), two (n = 7), three (n = 7), and four (n = 1) surgical procedures. All previously amenorrhoeic patients (n = 16) had resumption of menses. Twenty-eight patients were followed-up with a mean time of 31 months (range 2-84). Fifteen pregnancies were obtained in 12 patients and the outcomes were the following: two first trimester missed abortions, three second trimester fetal losses, one second trimester termination of pregnancy for multiple fetal abnormalities and nine live births in nine different patients. Pregnancy rate after treatment was 12/28 (42.8%) and live birth rate was 9/28 (32.1%). In patients </=35 years, 10 out of 16 conceived (62.5%) versus two out of 12 (16.6%) in patients >35 years (P = 0. 01). Three patients were lost to follow-up and their results omitted. In nine patients with live births, one Caesarean hysterectomy for placenta accreta and one hypogastric arteries ligation for severe haemorrhage and placenta accreta were performed. Hysteroscopic treatment of severe Asherman's syndrome appeared to be effective for the reconstruction of a functional uterine cavity with a 42.8% pregnancy rate. However, these pregnancies were at risk for haemorrhage with abnormal placentation.