Hysteroscopic diagnosis and successful management of an acquired uterine arteriovenous malformation by percutaneous embolotherapy

Arteriovenous malformations are a rare but important cause of abnormal uterine bleeding in the midlife. Acquired uterine arteriovenous malformations are being increasingly diagnosed by transvaginal ultrasound, color Doppler and magnetic resonance angiography. We present a case where the suspected diagnosis was placental polyp or retained products of conception and hysteroscopy showed typical findings of uterine arteriovenous malformation, which was later, confirmed by magnetic resonance angiography. The patient underwent arterial embolization and recovered satisfactorily with resolution of hemorrhage and resumption of normal menstrual cycles. Abnormal bleeding due to arteriovenous malformations is worsened by curettage and hence its recognition is important in the management of abnormal uterine bleeding in the midlife.

Improvement in uterine artery doppler indices via hysteroscopic metroplasty

OBJECTIVE

the objective of our research was to study uterine artery doppler indices and their evolution over time after metroplasty and subsequent pregnancy in patients whose septate uterus was the only explanation for infertility.

MATERIALS AND METHODS

a retrospective study. The uterine arteries of 78 patients with septate uteri were evaluated using endovaginal color doppler ultrasound before and after metroplasty. Fifty-one patients became pregnant after metroplasty and were selected as study group, pregnancy occurred within 17 months. By comparing uterine artery doppler indices before and after metroplasty, we observed that the resistive index (RI) and pulsatility index (PI) post surgery were significantly lower compared to premetroplasty levels.

RESULTS

all pregnant women in the study group showed uterine resistive indexes within normal ranges, they all underwent scheduled cesarean in-tervention. Gestational evolution was normal in all patients (mean score of Apgar and birth weight); no neonatal complications were observed.

CONCLUSION

metroplastic intervention in women with septate uterus as the sole cause of infertility may be a plausible alternative for patients wishing to carry a pregnancy.

Endometrial pathology in breast cancer patients: Effect of different treatments on ultrasonographic, hysteroscopic and histological findings

Breast cancer patients have an increased risk of endometrial pathology. To investigate whether the incidence of endometrial abnormalities and their clinicopathological features were affected by receiving tamoxifen (TAM), non-steroidal aromatase inhibitors (AIs) or no treatment (NT), 333 peri/postmenopausal breast cancer patients, who were referred to the Department of Gynecological, Obstetrical Sciences and Reproductive Medicine for gynecological assessment, were reviewed retrospectively. Transvaginal ultrasonographic (TVUS), hysteroscopic and histological findings were investigated. Endometrial histological findings included: atrophy in 61, 94.3 and 55.6% of cases in the TAM, AIs and NT groups, respectively; polyps in 30.9, 31.4 and 42.2% of cases in the TAM, AIs and NT groups, respectively; hyperplasia in 3% of patients in the TAM group and 11.1% of patients in the NT group; and cancer in 3.8% of cases in the TAM group and 11.1% of cases in the NT group. There was a significant correlation between the duration of TAM treatment and the severity of endometrial pathology. In all groups, there was a significant correlation between hysteroscopic and histological findings with regard to the diagnosis of endometrial atrophy, polyps, hyperplasia and cancer (P<0.001). In conclusion, these data revealed that there was a higher incidence of endometrial pathology in the NT group compared with the TAM group, which was significant for endometrial hyperplasia and cancer. The chance of developing high-risk histological subtypes of endometrial cancer was independent of TAM use. Lastly, although there was no significant difference in recurrent vaginal bleeding and mean endometrial thickness between the TAM and AIs groups, patients receiving AIs did not exhibit hyperplastic, dysplastic or neoplastic changes in the endometrium. This study indicates that breast cancer patients require screening for endometrial pathology; TVUS alone is useful in asymptomatic patients, however, in patients where the endometrial line is irregular or its thickness is >3 mm, hysteroscopy with directed biopsy is the appropriate diagnostic method.

Role of diagnostic hysteroscopy in abnormal uterine bleeding and its histopathologic correlation

Aims and Objectives:

To study the accuracy of hysteroscopy in evaluation of abnormal uterine bleeding and to correlate hysteroscopic findings with histopathologic findings.

Materials and Methods:

A prospective study was carried out in the Department of Obstetrics and Gynecology at AVBRH and JNMC, Sawangi (M), Wardha, from May 2006 to September 2008. One hundred cases were selected for this study from patients of age group 18 and above, who were admitted with the history of abnormal uterine bleeding. Hysteroscopic examination was done in all patients post-menstrually, whenever possible, except in those cases where menstrual cycles were grossly irregular or patients came with continuous bleeding per vaginum. The patients then underwent dilatation and curettage and endometrium was sent for histopathologic examination. The correlation between findings on hysteroscopy and histopathologic examination was tabulated.

Results:

Following were the findings on hysteroscopy: proliferative 34%, secretary 16%, hyperplasia 18%, atrophic 8%, endometrial polyp 9%, submucous myoma 11%, carcinoma of endometrium 03%, misplaced Cu-T 1%.

Conclusion:

In patients with abnormal uterine bleeding, hyster-oscopy provides more accurate dia-gnosis than dilatation and curettage.

Reproductive performance after hysteroscopic metroplasty in women with primary infertility and septate uterus

BACKGROUND

There is enough evidence in the literature to support that removal of septum improves pregnancy rates in women with bad obstetric history. However, its role in patients with otherwise unexplained infertility is still not clear due to paucity of enough evidence.

OBJECTIVE

To assess reproductive performance in women with septate uterus and otherwise unexplained infertility after hysteroscopic metroplasty.

MATERIALS AND METHODS

72 women with septate uterus and otherwise unexplained primary infertility were included in the study. All these women underwent hysteroscopic septal resection. Reproductive performance of these women within one year of surgery was studied and analysed.

RESULT

33 women (45.83%) conceived within one year of surgery. Only 4 women (12%) had spontaneous abortions and only 5 (15%) had preterm delivery.

CONCLUSION

Hysteroscopic metroplasty in women with septate uterus significantly improves the reproductive performance.

Digital Management of a Hysteroscopy Surgery Using Parts of the SNOMED Medical Model

This work describes a hysteroscopy surgery management application that was designed based on the medical information standard SNOMED. We describe how the application fulfils the needs of this procedure and the way in which existing handwritten medical information is effectively transmitted to the application's database.

Preprocedure patient preferences and attitudes toward permanent contraceptive options

OBJECTIVE

To determine patient preference for laparoscopic tubal occlusion or hysteroscopic tubal occlusion, two common sterilization interventions, and the acceptability of a postprocedure confirmation test for a hysteroscopic approach.

PARTICIPANTS AND METHODS

A total of 100 patients were offered two procedures. A description of each procedure was developed and read to each patient by a research nurse on site. Patients were then asked to respond to a questionnaire concerning options. Final informed consent, procedure review, and procedural date determination were provided by a physician upon completion of the questionnaire. Patients were not allowed to change their questionnaire responses after completion. No interviewer or physician input was allowed during the questionnaire. The study was completed in English or Spanish, as per patient request, by a bilingual/fluent speaker. Physicians completing informed consent were unaware of the questionnaire responses. Patients were not financially incentivized.

RESULTS

Of 100 participants, 93 (93%) preferred hysteroscopic sterilization to laparoscopy. The reasons were as follows: fear of general anesthesia (24/93 [26%]), fear of incision (25/93 [27%]), cost (32/93 [34%]), and time (12/93 [13%]) to return to routine activity. All 93 viewed "office-based location" as the main advantage over laparoscopy; 88/93 (94.6%) considered a confirmation test to be a benefit of the procedure. After informed consent was obtained, one additional patient switched from a laparoscopic decision to hysteroscopy (total = 94/100); 89/94 (95%) hysteroscopic decisions underwent hysteroscopic sterilization; 4/6 (67%) laparoscopic decisions proceeded to that surgery. The remainder (N = 7) cancelled due to lack of financial resources.

CONCLUSION

A nonincisional, office-based approach to sterilization has high patient acceptability. Patients viewed a confirmatory test for tubal occlusion as a benefit after sterilization.

Antibiotic prophylaxis in gynaecologic procedures

OBJECTIVE

To review the evidence and provide recommendations on antibiotic prophylaxis for gynaecologic procedures.

OUTCOMES

Outcomes evaluated include need and effectiveness of antibiotics to prevent infections in gynaecologic procedures.

EVIDENCE

Medline and The Cochrane Library were searched for articles published between January 1978 and January 2011 on the topic of antibiotic prophylaxis in gynaecologic procedures. Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies. Searches were updated on a regular basis and incorporated in the guideline to June 2011. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology assessment-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies.

VALUES

The quality of evidence obtained was rated using the criteria described in the Report of the Canadian Task Force on Preventative Health Care (Table 1).

BENEFITS, HARMS, AND COSTS

Guideline implementation should result in a reduction of cost and related harm of administering antibiotics when not required and a reduction of infection and related morbidities when antibiotics have demonstrated a proven benefit.

RECOMMENDATIONS

(1) All women undergoing an abdominal or vaginal hysterectomy should receive antibiotic prophylaxis. (I-A) (2) All women undergoing laparoscopic hysterectomy or laparoscopically assisted vaginal hysterectomy should receive prophylactic antibiotics. (III-B) (3) The choice of antibiotic for hysterectomy should be a single dose of a first-generation cephalosporin. If patients are allergic to cephalosporin, then clindamycin, erythromycin, or metronidazole should be used. (I-A) (4) Prophylactic antibiotics should be administered 15 to 60 minutes prior to skin incision. No additional doses are recommended. (I-A) (5) If an open abdominal procedure is lengthy (e.g., > 3 hours), or if the estimated blood loss is > 1500 mL, an additional dose of the prophylactic antibiotic may be given 3 to 4 hours after the initial dose. (III-C) (6) Antibiotic prophylaxis is not recommended for laparoscopic procedures that involve no direct access from the abdominal cavity to the uterine cavity or vagina. (l-E) (7) All women undergoing surgery for pelvic organ prolapse and/or stress urinary incontinence should receive a single dose of first-generation cephalosporin. (III-B) (8) Antibiotic prophylaxis is not recommended for hysteroscopic surgery. (II-2D) (9) All women undergoing an induced (therapeutic) surgical abortion should receive prophylactic antibiotics to reduce the risk of post-abortal infection. (I-A) (10) Prophylactic antibiotics are not suggested to reduce infectious morbidity following surgery for a missed or incomplete abortion. (I-E) (11) Antibiotic prophylaxis is not recommended for insertion of an intrauterine device. (I-E) However, health care professionals could consider screening for sexually transmitted infections in high-risk populations. (III-C) (12) There is insufficient evidence to support the use of antibiotic prophylaxis for an endometrial biopsy. (III-L) (13) The best method to prevent infection after hysterosalpingography is unknown. Women with dilated tubes found at the time of hysterosalpingography are at highest risk, and prophylactic antibiotics (e.g., doxycycline) should be given. (II-3B) (14) Antibiotic prophylaxis is not recommended for urodynamic studies in women at low risk, unless the incidence of urinary tract infection post-urodynamics is > 10%. (1-E) (15) In patients with morbid obesity (BMI > 35 kg/m²), doubling the antibiotic dose may be considered. (III-B) (16) Administration of antibiotics solely to prevent endocarditis is not recommended for patients who undergo a genitourinary procedure. (III-E).

Use of Versapoint to refashion the cervical canal to overcome unusually difficult embryo transfers and improve in-vitro fertilization-embryo transfer outcome: A case series

BACKGROUND

Smooth atraumatic embryo transfer is paramount for the success of in-vitro fertilization (IVF). In difficult cases, cervical canal manipulation may be required.

AIM

To see if surgical correction of the cervical canal or cervical canal refashioning could improve ease of embryo transfer.

SETTING

Private infertility and IVF hospital.

DESIGN

Prospective study.

MATERIALS AND METHODS

PATIENTS

11 women with failed 1-3 IVF cycles with history of extremely difficult embryo transfers (ETs) despite undergoing cervical dilatation in the cycle prior to IVF.

INTERVENTIONS

Operative hysteroscopy using Versapoint for refashioning of the cervical canal.

MAIN OUTCOME MEASURES

Ease of ET in the subsequent IVF cycle. Secondary outcome measure was to assess reproductive outcome.

RESULTS

Easy and atraumatic ET in the IVF cycle after procedure in 100% patients. PR was 46.5%.

CONCLUSIONS

Use of Versapoint for refashioning the cervical canal can improve the quality of ET and PR.

Site-specific endometrial injury improves implantation and pregnancy in patients with repeated implantation failures

BACKGROUND

To test whether a site-specific hysteroscopic biopsy-induced injury in the endometrium during the controlled ovarian hyperstimulation cycle improves subsequent embryo implantation in patients with repeated implantation failure, a total of 30 patients who have had good responses to controlled ovulation stimulation but have failed to achieve pregnancy after two or more transfers of good-quality embryos were recruited in this prospective study.

METHODS

A single, site-specific hysteroscopic biopsy-induced injury was generated on the posterior endometrium at midline 10-15 mm from the fundus during the D4-D7 period of the ongoing controlled ovarian hyperstimulation cycle in six patients.

RESULTS

Patients received endometrial biopsy protocol achieved a pregnancy rate of 100%. By contrast, only 46% of patients with similar clinical characteristics (N = 24) achieved pregnancy without the hysteroscopic biopsy-induced endometrium injury (p < 0.05).

CONCLUSIONS

Our proof-of-concept study demonstrates that a site-specific hysteroscopic endometrium injury performed during the ongoing in vitro fertilization (IVF) cycle, instead of injuries received during prior cycles, significantly improves clinical outcomes in patients with repeated implantation failure.

Reproductive outcome of septate uterus following hysteroscopic septum resection

OBJECTIVE

To evaluate the reproductive outcome following hysteroscopic septum resection in patients with primary and secondary (recurrent pregnancy loss [RPL] and bad obstetric history [BOH]) infertility.

STUDY DESIGN

Retrospective study.

MATERIALS AND METHODS

Hysteroscopic septum resection was performed on 26 patients with a history of either recurrent pregnancy loss, BOH or infertility. The septum resection was performed using a bipolar versapoint system. Reproductive performance of these patients after septum resection was analyzed. The main outcome measures were clinical pregnancy and live birth rates.

RESULTS

Hysteroscopic septum resection was performed on seven patients with the history of secondary infertility. Post operatively, the pregnancy rate was 86% (n=6), and the live birth rate was 67% (n=4). After septum resection in 19 primary infertile patients, 6 (32%) patients conceived which resulted in live birth rates of 67% (n=4).

CONCLUSION

Hysteroscopic septum resection using bipolar versapoint system is an effective and safe approach for the removal of septum. Hysteroscopic septum resection in women with septate uterus significantly improves the live birth rates and future fertility is not impaired.

Endometrial osseous metaplasia: Clinicopathological study of a case and literature review

Endometrial osseous metaplasia is an uncommon clinical entity with the presence of bone in the endometrium. Most of the cases clinically present with secondary infertility following an abortion. Various theories have been proposed and the most accepted theory is metaplasia of the stromal cells into osteoblastic cells that produce the bone. It is important to distinguish this condition from the mixed mullerian tumor of the endometrium to avoid hysterectomy. Removal of these bony bits leads to spontaneous conception. We present one such case in a 25-year-old female patient presented with secondary infertility.

A randomized trial of vaginal misoprostol for cervical priming before hysteroscopy in postmenopausal women

OBJECTIVE

To perform hysteroscopy the cervix needs to be dilated and in nullipara and postmenopausal women this is sometimes difficult. Well-known, entry-related complications during hysteroscopy include cervical tear, creation of false tract, bleeding, uterine perforation, scarring, and subsequent anatomical stenosis.

MATERIALS AND METHODS

This study was done to investigate the priming effect of vaginal misoprostol on cervical dilatation in postmenopausal women, before hysteroscopy, to prevent such complications. Two hundred micrograms of misoprostol was inserted into the vagina at least 12 hours before the procedure and the control group did not receive any cervical priming agent. Pre-procedural dilatation, additional dilatation required, and time taken for dilatation was noted in each case.

OBSERVATIONS

The study showed a significant difference between the study group (7.7 ± 1.7 mm) and the control group (4.5 ± 1.8 mm) in terms of pre-procedural cervical width and the number of women requiring a dditional dilatation (7 / 25 versus 22 / 25), and hence, the time required for dilatation (4.7 ± 8 seconds versus 20.6 ± 9.3 seconds).

CONCLUSION

The pre-procedural cervical width was significantly more in the study group as compared to that in the control group. We found significant differences between the study and control groups with respect to the number of women who required cervical dilatation. To conclude, this study helps derive a conclusion that vaginal misoprostol as a cervical priming agent in postmenopausal women appears to be safe, effective, and inexpensive, with mild side effects.

The effectiveness of reproductive surgery in the treatment of female infertility: facts, views and vision

BACKGROUND

The role of reproductive surgery is declining due to the widespread availability of assisted reproductive technology, but an evidence-based fundament for this decline is lacking. We therefore performed a systematic review of the literature.

METHODS

We searched MEDLINE, EMBASE and the Cochrane Library for randomised trials evaluating laparoscopic or hysteroscopic interventions in subfertile women, studying pregnancy or live birth rates. We present an overview of the results and quality of the detected studies.

RESULTS

The methodological quality of the 63 detected studies was mediocre. The laparoscopic treatment of minimal/ mild endometriosis might increase the pregnancy rate but the two major studies report conflicting results. Excision of the endometriotic cyst wall increases the spontaneous conception rate (RR 2.8, 95% CI 1.4-5.5). Laparoscopic ovarian drilling results at least in equal pregnancy rates as gonadotropin treatment (RR 1.0, 95% CI 0.83-1.2) but decreases the multiple pregnancy rate (RR 0.16, 95% CI 0.04-0.58). Laparoscopic tubal surgery for hydrosalpinx prior to IVF increases the pregnancy rate (RR 1.9, 95% CI 1.4-2.7). Removal of polyps prior to IUI increases the pregnancy rate (RR 2.2, 95% CI 1.6-3.1). Myomectomy for submucosal fibroids results in higher pregnancy rates (RR 2.2, 95% CI 1.6-2.9). The removal of intramural/ subserosal fibroids shows a beneficial trend, albeit not statistically significant (RR 1.2, 95% CI 0.75-1.9). Hysteroscopy in patients with recurrent IVF failure increases the pregnancy rates even in the absence of pathology (RR 1.6, 95% CI 1.3-1.9).

CONCLUSIONS

Although the limited evidence indicates a positive role for some surgical reproductive interventions, we should be very cautious in providing guidelines for clinical practice in reproductive surgery since more research is needed.

Hysteroscopy in postmenopausal bleeding

OBJECTIVES

1) To study the etiology of postmenopausal bleeding (PMB). 2) To study the significance of hysteroscopy in evaluation of the etiopathogenic factors. 3) Correlating the diagnosis after transvaginal sonography (TVS), hysteroscopy and histopathologic diagnosis. 4) Feasibility of conservative management with hysteroscopy in PMB.

DESIGN

Prospective study from January 2008 to June 2009.

SETTING

Department of Obstetrics and Gynecology of Ruby Hall Clinic, Pune.

PATIENTS

Sixty postmenopausal women with complaint of bleeding per vaginum.

INTERVENTIONS

Clinical and sonographic evaluation, followed by diagnostic and/or therapeutic hysteroscopy and guided biopsy. Hysteroscopic images were analyzed and compared with histopathologic results.

MEASUREMENTS AND MAIN RESULTS

On hysteroscopy, endometrium was classified as suggestive of normal, atrophic, endometrial hyperplasia or endometrial carcinoma. Histopathologic diagnosis is taken as a gold standard to determine the efficacy of hysteroscopy in diagnosing endometrial pathologies. The sensitivity and specificity of hysteroscopy in diagnosing endometrial pathologies was assessed.

CONCLUSIONS

In women with PMB, hysteroscopy is the basic tool that allows precise diagnosis of various endouterine pathologies. The average sensitivity of hysteroscopy was 97% in our study and the specificity was 98.66%. Hence, we can conclude that it is highly accurate for evaluating endometrial pathologies. For obvious benign lesions, it also provides treatment in the same sitting, therefore avoiding an extensive, morbid, and expensive procedure like hysterectomy.

Building decision trees for diagnosing intracavitary uterine pathology

OBJECTIVES

To build decision trees to predict intrauterine disease, based on a clinical data set, and using mathematical software.

METHODS

Diagnostic algorithms were built and validated using the data of 402 consecutive patients who underwent grey scale ultrasound, followed by colour Doppler, saline infusion sonography (SIS), office hysteroscopy and endometrial-- sampling. The "final diagnosis" was classified as "abnormal" in case of endometrial polyps, hyperplasia or malignancy or intracavitary myoma. "Pre-test parameters" included patient's age, weight, length, parity, menopausal status, bleeding symptoms and cervical cytology; "post-test parameters" included ultrasound-, color Doppler-, SIS-, hysteroscopy- findings and histology results after endometrial sampling. Decision Tree #1 was built using both "pre-test" and "post-test" parameters; Tree #2 was only based on "post-test" parameters; Tree #3 was designed without using the hysteroscopy variables. The Waikato Environment for Knowledge Analysis (Weka) software was used for the development of decision trees.

RESULTS

All trees started with an imaging technique: hysteroscopy or SIS. The diagnostic accuracy was 88.3%, 88.3% and 84.0% for Tree #1, #2 and #3 respectively, the sensitivity and specificity was 95.5% and 82%, 97.7% and 80.0, 93.2 and 76.0%, respectively.

CONCLUSION

The method used in this study enables the comparison between different decision trees containing multiple tests.

Role of hysteroscopy prior to assisted reproductive techniques

BACKGROUND

There have been numerous advances in the area of assisted reproduction. Among the various reasons of implantation failure, intrauterine lesions play an important role.

OBJECTIVE

The aim of the present study is to evaluate the role of hysteroscopy prior to any assisted reproductive technique.

MATERIALS AND METHODS

It is a retrospective study of 292 women who attended our infertility clinic over a period of 18 months, who had a variable number of failed IVF cycles previously.

RESULTS

Out of the 292 women studied, in 74 women, that is 25%, intrauterine pathology was detected, which when rectified by hysteroscopy, gave a considerable increase in pregnancy rate.

CONCLUSION

According to this study it can be concluded that evaluating the uterine cavity is an important step before any assisted reproductive procedures.

Does self-administered vaginal misoprostol result in cervical ripening in postmenopausal women after 14 days of pre-treatment with estradiol? Trial protocol for a randomised, placebo-controlled sequential trial

OBJECTIVE

To compare the impact of 1000 micrograms of self-administered vaginal misoprostol versus self-administered vaginal placebo on preoperative cervical ripening after pre-treatment with estradiol vaginal tablets at home in postmenopausal women prior to day-care operative hysteroscopy.

DESIGN

Randomised double-blind placebo-controlled sequential trial. The boundaries for the sequential trial were calculated on the primary outcomes of a difference of cervical dilatation > or = 1 millimetre, with the assumption of a type 1 error of 0.05 and a power of 0.95.

SETTING

Norwegian university teaching hospital.

POPULATION

Postmenopausal women referred for day-care operative hysteroscopy.

METHODS

The women were randomised to either 1000 micrograms of self-administered vaginal misoprostol or self-administered vaginal placebo the evening before day-care operative hysteroscopy. All women had administered a 25-microgram vaginal estradiol tablet daily for 14 days prior to the operation.

MAIN OUTCOME MEASURES

Preoperative cervical dilatation (difference between misoprostol and placebo group, primary outcome), difference in dilatation before and after administration of misoprostol or placebo, number of women who achieve a preoperative cervical dilatation > or = 5 millimetres, acceptability, complications and side effects (secondary outcomes).

RESULTS

Intra-operative findings and distribution of cervical dilatation in the two treatment groups: values are given as median (range) or n (%). Difference in dilatation before and after administration of misoprostol and placebo: values are given as median (range) of intraindividual differences. Percentage of women who achieve a cervical dilatation of > or = 5 mm, percentage of women who were difficult to dilate. Acceptability in the two treatment groups: values are given as completely acceptable n (%), fairly acceptable n (%), fairly unacceptable n (%), completely unacceptable n (%). Pain in the two treatment groups: pain was measured with a visual analogue scale ranging from 0 (no pain) to 10 (unbearable pain): values are given as median (range). Occurrence of side effects in the two treatment groups. Values are given as n (%). Complications given as n (%).

FUNDING SOURCES

No pharmaceutical company was involved in this study. A research grant from the regional research board of Northern Norway has been awarded to finance Dr K.S.O.'s leave from Hammerfest hospital as well as travel expenses between Hammerfest and Oslo, and research courses. The research grant from Prof B.I.N. (Helse Øst) funded the purchase of estradiol tablets, the manufacturing costs of misoprostol and placebo capsules from the hospital pharmacy, as well as the costs incurred for preparing the randomisation schedule and distribution of containers containing capsules to hospital. Prof B.I.N.'s research grant also funded insurance for the study participants.

CONCLUSIONS

Estimated completion date 31 December 2008.

Hysteroscopy as a standard procedure for assessing endometrial lesions among postmenopausal women

CONTEXT AND OBJECTIVES

Endometrial cancer is the most prevalent type of malignant neoplasia of the genital tract. The objective of this study was to calculate the sensitivity, specificity, accuracy and positive and negative predictive values for diagnostic hysteroscopy, in comparison with histopathological tests, for all lesions of the endometrial cavity.

DESIGN AND SETTING

Retrospective descriptive study at the public tertiary-level university hospital of Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo.

METHODS

Diagnostic hysteroscopy was indicated in the following instances: endometrial thickness > 4 mm in asymptomatic patients; postmenopausal bleeding; and irregular endometrium or endometrium difficult to assess from ultrasound, with or without vaginal bleeding. Ultrasound evaluations were carried out no more than three months prior to hysteroscopy.

RESULTS

There were 510 patients, with a mean age of 61.1+/-2.0 years and mean time elapsed since the menopause of 12.7+/-2.5 years. Endometrial biopsies were performed on 293 patients (57.5%). Histopathological analysis showed that 18 patients presented endometrial carcinoma or typical or atypical hyperplasia, and none of them presented endometrial thickness of less than 8 mm. No significant differences were found between the median thicknesses of the various benign lesions (p > 0.05). In our data, the sensitivity, specificity, accuracy and positive and negative predictive values for cancer or hyperplasia were 94.4%, 97.0%, 96.8%, 68% and 99.6%, respectively.

CONCLUSIONS

Our results suggest that hysteroscopy is valuable as a diagnostic tool for malignant/hyperplastic and benign lesions, except for submucous myomas, for which the sensitivity was only 52.6%.

Hysteroscopic resection of the vaginal septum in uterus didelphys with obstructed hemivagina: a case report

Uterus didelphys with obstructed hemivagina and ipsilateral renal agenesis is a rare congenital anomaly. Excision of the obstructed vaginal septum is the treatment of choice for symptom relief and the preservation of reproductive capability. A 14-yr-old girl complained of persistent vaginal spotting following each menstruation. Pelvic magnetic resonance imaging revealed a uterus didelphys with left hematocolpos and ipsilateral renal agenesis. Instead of conventional transvaginal excision of the vaginal septum, we used hysteroscopic excision under transabdominal ultrasonographic guidance to preserve the integrity of the hymen. The postoperative course was uneventful, and clinical symptoms were completely resolved after this intervention. Resectoscopic excision of the vaginal septum was found to be easy, safe, effective, and appropriate for young women as it preserved hymen integrity. We believe that this is the first Korean report on the use of a hysteroscopy for vaginal septum resection in a patient with uterus didelphys with obstructed hemivagina.

Comparison of transvaginal sonography and saline contrast sonohysterography in women with abnormal uterine bleeding: correlation with hysteroscopy and histopathology

BACKGROUND

Transvaginal ultrasound is used conventionally as initial investigation of patients with abnormal uterine bleeding but saline contrast sonohysterography is a better technique to reliably distinguish focal from diffuse endometrial lesions. This study was performed to compare the ability of transvaginal ultrasonography and saline infusion sonohysterography as initial modality for the diagnosis of endometrial abnormalities in women with abnormal uterine bleeding.

PATIENTS AND METHODS

In a prospective study, 100 women with abnormal uterine bleeding were submitted to sequential examination by transvaginal ultrasound, and sonohysterography. The presence of focal endometrial lesions and the type of lesion (endometrial hyperplasia, polyp, submucous myoma, or malignancy) were noted. Predictive values were calculated by correlating the results with final diagnosis reached by hysteroscopy and endometrial biopsy.

RESULTS

The sonohysterography had 92.9% sensitivity and 89.7% specificity compared to 71.4% sensitivity and 67.7% specificity achieved by transvaginal sonography. There was 91% agreement between saline contrast sonohysterography and hysteroscopy as compared to 69% for TVS (p = 0.002). The diagnostic performance of sonohysterography for 3 main endometrial abnormalities (i.e. endometrial hyperplasia, polyps and submucous myoma) was better than transvaginal sonography. The best results were seen in cases of submucous myoma where sensitivity and specificity of sonohysterography reached to 100% as compared to TVS (61.55 and 97.7% respectively).

CONCLUSION

Our results have substantiated that sonohysterography is a better tool than transvaginal sonography for the assessment of endometrial intra-cavity lesions. By providing accurate differentiation between focal and diffuse endometrial lesions, it can help in decision making regarding selection of cases for hysteroscopy and directed biopsy. We recommend that saline contrast sonohysterography should be used as an initial investigation in cases of abnormal uterine bleeding.

Outpatient hysteroscopic emptying of a submucosal uterine cystic lesion

BACKGROUND

Uterine cystic neoformations are rare, but they should always be investigated to differentiate a benign from a malignant pathology. Transvaginal ultrasonography, MRI, and blood tests are the main investigations for diagnosing these lesions, avoiding over- or undertreatment. Hysteroscopy might represent a helpful tool both for its diagnostic and therapeutic properties.

METHODS

We report the hysteroscopic emptying of a cystic-degenerated leiomyoma with a 5-Fr flexible needle inserted through the operative channel of a 5-mm continuous-flow operative office hysteroscope in an outpatient setting.

RESULTS

The cystic lesion was successfully emptied. The hystopathological result of the target biopsies performed on the cystic wall was cystic degeneration of a leiomyoma.

CONCLUSION

This needle is normally used in gynecology to instill intrauterine local anesthesia under a hysteroscopic view. We adapted it to drain a fluid-filled lesion, identifying a further application of this instrument.

The Greenberg hysteroscopy speculum: a new instrument for hysteroscopy

OBJECTIVES

Although the ubiquitous Graves speculum (open-sided or closed) is versatile and familiar, its shortest length is often too long for comfortable manipulation of the newer, pliable, flexible hysteroscopes. The Greenberg speculum is a modification of a Graves speculum with an open side to allow for the removal of instruments while they are still in the vagina. Whereas a standard mediumsized, open-sided Graves speculum measures 110 mm in maximum length, the Greenberg speculum measures only 74 mm. Although the difference between the speculums is only 36 mm in maximum length, this alteration can add considerable ease to placement of both flexible and rigid hysteroscopes in the office or operating room. In this study, we sought to quantify the benefit of this new device by demonstrating that this speculum brings the patient's cervix closer to the provider and reduces the length of unsupported hysteroscope shaft entering the cervical canal.

METHODS

We measured the intraspeculum distance from the operator-side opening of the speculum to the external cervical os by using first a standard medium open-sided Graves speculum and then a Greenberg speculum.

RESULTS

Use of the Greenberg speculum reduced the mean minimum intraspeculum distance from the extended fingertips grasping a hysteroscope to the external cervical os by an average of 28 mm or 34% compared with a Graves speculum.

CONCLUSIONS

We believe this new speculum offers a subtle but distinct advantage over standard speculums for hysteroscopy.

The incidence of retained fetal bone revealed in 2000 diagnostic hysteroscopies

Three of 2000 diagnostic hysteroscopies revealed residual fetal bony fragments in women with abnormal uterine bleeding. Removal of bony fragments by hysteroscopy is associated with therapeutic success.

1000 office-based hysteroscopies prior to in vitro fertilization: feasibility and findings

BACKGROUND AND OBJECTIVES

Hysteroscopy offers diagnostic accuracy and the ability to treat uterine pathology, but practitioners may be reluctant to perform it without a high index of suspicion because it traditionally requires an operating room. This study reviews the findings and feasibility of office-based diagnostic and operative hysteroscopy in an unselected in vitro fertilization (IVF) population to evaluate whether first-line hysteroscopy should be recommended.

METHODS

One thousand consecutive infertile patients scheduled for in vitro fertilization underwent office hysteroscopy. A rigid 20-degree 5-mm hysteroscope, with an operative channel for grasping forceps, scissors, or coaxial bipolar electrode was used. Operative findings, complications, and patient tolerance were noted.

RESULTS

Sixty-two percent of patients had a normal uterine cavity. Thirty-two percent had endometrial polyps. Other pathology included submucous fibroids (3%), intrauterine adhesions (3%), polypoid endometrium (0.9%), septum (0.5%) retained products of conception (0.3%), and bicornuate uterus (0.3%). The pathology was treated in all patients without complication.

CONCLUSIONS

When hysteroscopy is routinely performed prior to in vitro fertilization, a significant percentage of patients have uterine pathology that may impair the success of fertility treatment. Patient tolerance, safety, and the feasibility of simultaneous operative correction make office hysteroscopy an ideal procedure.

Ultrasound-guided unification of noncommunicating uterine cavities

BACKGROUND

The benefits of ultrasound-guided hysteroscopic metroplasty have been well described in the management of the partial septate uterus. The use of ultrasonography at the time of hysteroscopy provides visualization of the intrauterine instruments within the uterine cavity. This report describes a case where ultrasound-guidance was used to enter a noncommunicating uterine cavity hysteroscopically.

METHODS

A 22-year-old female after her third miscarriage experienced worsening dysmenorrhea. The patient underwent a laparoscopy and hysteroscopy to further evaluate the cause of pelvic pain and to treat the Müllerian anomaly. Under ultrasound-guidance, the 2 uterine cavities were unified by hysteroscopic metroplasty.

RESULTS

Postoperative sonohysterography demonstrated unification of the 2 cavities.

CONCLUSIONS

This unique application of ultrasound-guidance in hysteroscopic surgery may aid the surgeon in entering a noncommunicating uterine cavity.

Hysteroscopy: an analysis of 2-years' experience

BACKGROUND

Over the years, hysteroscopy has been increasingly performed for various gynecological disorders. In this study, we present a review of hysteroscopic procedures performed over a 2-year period analyzing the complications associated with it.

METHODS

Seven hundred twenty-six hysteroscopic procedures performed at the Department of Gynecology and Obstetrics, University of Kiel over a period of 2 years were reviewed retrospectively using the GynReg database in the department. Indications, intraoperative diagnoses, and complications were particularly highlighted.

RESULTS

The most common indications for the procedure were abnormal vaginal bleeding, endometrial ablation, polypectomy, and myomectomy. The most common findings were uterine polyps, submucous myoma, and hyperplastic endometrium. The complication rate was 1.65% of total hysteroscopies. False passage and uterine perforation were the most common acute complications. No late complications occurred.

CONCLUSIONS

Correlating our data with that found elsewhere, we find hysteroscopy to be a safe, minimally invasive procedure with a very low rate of complications.

Hysteroscopic endometrial destruction, optimum method for preoperative endometrial preparation: a prospective, randomized, multicenter evaluation

OBJECTIVE

To compare the outcome and cost-effectiveness of various forms of preoperative endometrial preparation prior to hysteroscopic endometrial destruction for abnormal uterine bleeding.

METHODS

This was a multicenter, prospective, comparative, randomized study conducted in a tertiary care hospital in Cairo, Egypt and 2 academic tertiary care teaching hospitals in the United States. One hundred thirty-one premenopausal women, who had completed childbearing, mean age of 45.7 years, with abnormal uterine bleeding refractory to medical management without histologic evidence of endometrial neoplasia were studied. The 131 patients were randomized for preoperative preparation for hysteroscopic endometrial destruction into 1 of 5 groups as follows: Group I, dilation and curettage (D & C) (39); Group II, gonadotropin-releasing hormone analogue (GnRHa) for 1 month (23); Group III, GnRHa for 3 months (26); Group IV, danazol for 3 months (26); and Group V, medroxyprogesterone acetate (MPA) 15 mg for 3 months (27). The choice of endometrial ablation or endometrial resection was left to the surgeon.

RESULTS

Improvement in bleeding patterns, amenorrhea, operative times, complications, and relative cost were the measured outcomes. The mean follow-up time was 1 year from the time of the procedure. Overall, in Group I, 39/39 (100%) improved and 7/39 (18.0%) experienced amenorrhea; in Group II, 21/23 (91.3%) improved and 9/23 (39.1%) experienced amenorrhea; in Group III, 24/26 (92.3%) improved and 10/26 (38.5%) experienced amenorrhea; in Group IV, 24/26 (92.3%) improved and 9/26 (34.6%) experienced amenorrhea; and in Group V, 23/27 (85.1%) improved and 7/27 (25.9%) experienced amenorrhea.

CONCLUSION

Endometrial destruction whether by the ablation or resection technique, regardless of the type of surgical pretreatment is a safe and effective surgical approach for treating abnormal uterine bleeding. D & C or MPA appear to be the most cost-effective pretreatment regimens. MPA pretreatment may confer the added advantage of decreasing blood flow and allowing better hysteroscopic visualization than D & C pretreatment.

The effect of endometrial polyps on outcomes of in vitro fertilization (IVF) cycles

PURPOSE

Our purpose was to investigate the effect of endometrial polyps on pregnancy outcome in an in vitro fertilization (IVF) program.

METHODS

Endometrial polyps less than 2 cm in diameter were suspected by transvaginal ultrasound before oocyte recovery in 83 patients. Forty-nine women (Group I) had standard IVF-embryo transfer, while in 34 women (Group II) hysteroscopy and polypectomy were performed immediately following oocyte retrieval, the suitable embryos were all frozen, and the replacement cycle took place a few months later.

RESULTS

Of the 32 hysteroscopies, a polyp was diagnosed in 24 cases (75%) and polypoid endometrium in another 5 patients (15.6%). An endometrial polyp was confirmed by histopathological examination in 14 women (58.3%). The pregnancy rate in group I was similar to the general pregnancy rate of our unit over the same period (22.4 vs 23.4%) but the miscarriage rate was higher (27.3 vs 10.7%, P = 0.08). In Group II, the pregnancy and miscarriage rates were similar to those of the frozen embryo cycles at Bourn Hall (30.4 and 14.3 vs 22.3 and 12.1%, respectively).

CONCLUSIONS

Small endometrial polyps, less than 2 cm, do not decrease the pregnancy rate, but there is a trend toward increased pregnancy loss. A policy of oocyte retrieval, polypectomy, freezing the embryos, and replacing them in the future might increase the "take-home baby" rate.

Operative ultrasonography for upper genital tract pathology

PURPOSE

A procedure using transvaginal sonohysterography (SHG) to perform operative intrauterine biopsies and resections is described.

METHODS

Seven women, six with intrauterine pathology noted on diagnostic SHG and one with a thickened endometrium noted on transvaginal ultrasonography, underwent attempted operative SHG. The indications were peri- and postmenopausal bleeding (n = 4) and infertility requiring assisted reproduction (n = 3). Access to the uterine cavity was accomplished with a 9-F cervical access catheter (CAC) with a 3-ml balloon (BEI Medical Systems, ZSI Gynecology Products Division, Chatsworth, CA), which was placed in the cervical canal or lower uterine segment. Depending on the position of the noted uterine pathology, a 6-F uterine ostial access catheter (UOAC) (BEI Medical Systems, ZSI Gynecology Products Division) was placed through the CAC. The uterine cavity was distended with 5-10 ml of 1% Lidocaine and a 3-F loop grasper or finger-like biopsy grasper was then passed through the UOAC or a 5-F operative instrument directly within the CAC with attempted resection under ultrasound guidance. Biopsied samples were sent to pathology for definitive diagnosis. Office hysteroscopy was then performed to confirm adequate resection.

RESULTS

Three of six patients had adequate resection or biopsy of intrauterine pathology, while the seventh patient successfully had a directed biopsy of the fundal cavity under ultrasound guidance. In one case, the visualized lesion could not be grasped. In the other two cases, each patient had severe cervical stenosis and declined in-office cervical dilation precluding the procedure. Each procedure was well tolerated, with an average time from start to finish of about 25 min (range, 18-43 min) without complications.

CONCLUSIONS

Operative SHG makes it possible to resect and biopsy intrauterine pathology often missed on Pipelle sampling. If found to be as effective as hysteroscopy, operative SHG would provide a cost-effective alternative. Further study is ongoing to perfect the existing instruments to allow removal of larger lesions both safe and possible.

Safe and effective fluid management by automated gravitation during hysteroscopy

OBJECTIVE

The automated gravitational Vario Flow system with weighing-based electronic fluid deficit indicator was used in order to reduce the risk of fluid intravasation during continuous flow hysteroscopic procedures. Early experiences are reported.

METHODS

Between August 1996 and July 1997, the Vario Flow with fluid deficit indicator and alarm system was used in 203 hysteroscopic operations. Between January 1994 and August 1996 the Vario Flow without fluid deficit indicator was used in 240 hysteroscopic operations. In all, there were 443 hysteroscopic operations: 301 metroplasties, 20 endometrial ablations, 10 cases of lysis of synechiae, 58 myomectomies and 54 polypectomies. The data on fluid deficit before and after the introduction of the electronic fluid deficit indicator were similar.

RESULTS

Fluid deficit indicator was proved highly efficient in 203 operations. It provided the information on fluid deficit at any moment during hysteroscopic operations. Besides intrauterine pressure, the actual fluid deficit has become one of the leading parameters during our continuous flow hysteroscopic procedures.

CONCLUSIONS

We therefore conclude that by using an automated gravitational system with fluid deficit indicator and alarm system, the safety for patients during hysteroscopic procedures has been increased.