[Treatment of synechiae related to infertility]

Synechiae are intrauterine adhesions that affect the fertility of women. They are most often of post-traumatic origin. The management of pregnancy abortions in the first trimester and post-delivery retention are the main contributing factors. Synechiae is responsible for cycle disorders and repeated pregnancy loss. Hysteroscopy is the reference method for its diagnosis and treatment. The surgical objective is the restoration of a normal sized cavity and a functional endometrium to allow fertilization and implantation. The use of small diameter (5mm) hysteroscopes and no energy or bipolar energy instruments are recommended. Echo guidance facilitates the treatment of severe synechiae and limits the risk of intraoperative perforation. The main risk of treatment is recurrence, particularly in severe cases where multiple operating times are sometimes necessary. An office hysteroscopy at 6 weeks is recommended to identify and treat these recurrences. Different physical, molecular or cellular methods are studied as primary and secondary prevention of postoperative synechiae. The objective of this review is to provide an update on the treatment of synechiae in the context of infertility.

[Trends in the use of midurethral slings after the new legislation: A nationwide survey]

INTRODUCTION

The French Department of Health published on October 23, 2020 a decree governing acts associated with mid-urethral sling (MUS) operations. The aim of this study was to evaluate the changes in practice following this new legislation.

METHODS

A cross-sectional study was carried out among French urologists and gynecologists using an online survey to collect changes in practices since the publication of the decree.

RESULTS

From January to February 2021, 436 surgeons participated in the survey. Among these surgeons, 87% were aware of the new legislation and 56% of them considered the decree as useless. The order resulted in an increase in working time in 81% of cases. Among these surgeons, 66% of the surgeons worked in tertiary referral centers for the management of incontinence, of which 55% had a multidisciplinary meeting in urogynecology. Among the surgeons, 31% considered this meeting to be useful but 80% considered that it did not lead to any change in surgical indications, even though 33% of complications of BSU were discussed there. In conclusion, 61% of surgeons felt more reluctant to schedule a BSU placement with this new legislation.

CONCLUSION

The majority of questioned surgeons considered the decree as useless. It generated few changes in practices which already respected the law on information, consultation, consent, experience and training. Most urologists and gynecologists are more reluctant to offer MUS after this new legislation.

LEVEL OF EVIDENCE

4.

Is Hysteroscopy a Good Option to Manage Severe Cesarean Scar Defect?

STUDY OBJECTIVE

To compare the outcomes of hysteroscopic management in women with a severe or nonsevere symptomatic cesarean scar defect (residual myometrium ≤3-mm vs >3-mm, respectively).

DESIGN

Retrospective cohort study.

SETTING

Gynecology department of a teaching hospital.

PATIENTS

Seventy-one women with an operative hysteroscopy for a symptomatic defect (49 with severe defects and 22 with nonsevere ones).

INTERVENTIONS

Operative hysteroscopy for cesarean scar defect in women with a severe defect (residual myometrium ≤3-mm) and with nonsevere defect (residual myometrium >3-mm).

MEASUREMENTS

The main objective was to compare success rates between the 2 groups. The secondary objectives were the comparisons of (1) the number of women who required more than 1 procedure, (2) the rate of complications, (3) the number of subsequent pregnancies, and (4) the evolution of residual myometrium thickness between the groups.

MAIN RESULTS

The success rates were not significantly different between the groups (73.5% in the severe group and 63.6% in the nonsevere group [p = .40]). The number of women requiring more than 1 procedure was also similar, as were the rate of complications and the mean increase of myometrium thickness. The rate of subsequent pregnancies in women who were infertile was significantly higher in women with a severe defect (p = .04).

CONCLUSION

The hysteroscopic approach seems to be a good way to manage cesarean scar defects even when the residual myometrium is thin. A prospective study is, however, necessary to confirm these findings.

Ulipristal acetate use in adenomyosis: A randomized controlled trial

OBJECTIVE

To evaluate the effect of a 10 mg per day 12 week treatment of ulipristal acetate (UPA) on abnormal uterine bleeding due to adenomyosis.

DESIGN

A double-blind phase 2 randomized controlled pilot study.

SETTING

From May 2015 to February 2018 in five teaching hospitals.

POPULATION

Premenopausal women with abnormal uterine bleeding (with a pictorial blood loss assessment score (PBAC) higher than 100 at inclusion) and a sonographic or MRI diagnosis of adenomyosis.

METHODS

After random allocation, either UPA 10 mg or placebo were orally administered during 12 weeks. A 3:1 ratio was used.

MAIN OUTCOME MEASURES

The primary outcome was the rate of women with a PBAC score of less than 75 as evaluated over the 28 days following the 12-week treatment. Secondary outcomes included rate of amenorrhea, evolution of pain, quality of life and tolerance.

RESULTS

Thirty women were included in the UPA group and 10 in the placebo group. No woman in the placebo group versus 95.24 % of women in the UPA group had a PBAC score under 75 during the 28 day period following the 12-week treatment (p < 0.01). A significant decrease in pain was noticed between inclusion and 13 weeks in the UPA group (p < 0.01). At 6 months, there was no significant difference in PBAC score or pain between groups. No serious adverse event was recorded.

CONCLUSION

UPA could be an interesting option for treatment of abnormal uterine bleeding related to adenomyosis in women wishing to preserve their fertility.

Benefits of using a simulator in the initial training for transvaginal ultrasound examination in gynecologic emergency unit

PURPOSE

Transvaginal ultrasound examination is decisive in Gynecologic emergency unit. This study's aim was to evaluate benefits of using a simulator for initial training of medical student for transvaginal ultrasound examination.

METHOD

A multicenter randomized trial was conducted. Medical student were randomized in two groups: in the intervention group, students took part in a simulation session in addition to the companionship-training while in the control group, they were only trained by companionship. To evaluate their progression, the quality of ultrasound pictures performed in real conditions before (pre-test) and after (post-test) the training by the students of both groups were evaluated and compared. Evaluation was performed according to predefined quality criterias for each ultrasound examination using a score of 20 points. Mean scores of students in both groups were compared for the pre and post-test.

RESULTS

Fifty six medical students were included. Mean scores of the 56 students were significantly better at the post-test than at the pre-test: 10,61/20 [9,62-11, 59] vs 6,35/20 [5,48-7,24], p < 0,001. Mean scores were significantly better at the post-test for students in the intervention group (n = 29) than in the control group (n = 27) 11,79/20 [7,72-10,94] vs 9,33/20 [7,72-10,94], p = 0,01. All the students in the intervention group were satisfied or highly satisfied to take part in this program.

CONCLUSIONS

Using a simulator for medical student was beneficial in the initial training of transvaginal ultrasound examination.

National survey of surgical practices: Sacropexy in France in 2019

INTRODUCTION AND HYPOTHESIS

Sacropexy is a reference surgical treatment for pelvic organ prolapse in women. The great variability in surgical techniques for this procedure is a source of bias that complicates analysis of the results of trials assessing it. Using the French guidelines issued in 2016 by the SCGP, AFU, SIFUD-PP, and CNGOF as a reference, we sought to inventory the surgical practices of the surgeons who perform these procedures.

METHODS

In November 2018, a questionnaire about the technical aspects of this procedure was distributed by email to the French physicians performing it. It was distributed to members of several professional societies (CNGOF, SCGP, and SIFUD) and to gynecologists practicing in clinics owned by the ELSAN group.

RESULTS

Of the 273 responders, 92% reported that they perform most operations laparoscopically. Overall, 83% of gynecologic surgeons used polypropylene prostheses (mesh); 38% routinely placed a posterior mesh, while the rest did so only in cases of clinical rectocele with anorectal symptoms. A concomitant hysterectomy was performed by 51% of respondents when the uterus was bulky and/or associated with substantial uterine prolapse. Finally, half the surgeons suggested the placement of a suburethral sling for women with stress urinary incontinence.

CONCLUSIONS

Although practices are largely consistent with the most recent guidelines, surgical techniques vary widely between surgeons, both in France and internationally.

Guidelines for minimal report in gynaecologic sonography: Are they useful for emergency department resident physicians?

OBJECTIVES

This study aimed to evaluate the impact of Collège National des Gynécologues et Obstétriciens Français (CNGOF) guidelines on the minimal sonographic reports generated by emergency department resident physicians.

MATERIAL AND METHODS

This prospective observational study was conducted in the gynaecologic emergency unit of a teaching hospital from November 2016 to May 2017. We analysed sonographic reports generated by residents during gynaecological emergencies before and after training on the minimal report standards. An analysis of the evaluated items was carried out. We also compared residents according to their specialities and seniority.

RESULTS

A total of 240 reports were analysed, 120 before and 120 after the training. Half of the reports concerned women with an early pregnancy while the others concerned women with negative hCG. All residents significantly improved their practice after the training, as shown by the increase in ratings of the evaluated items (38 % before training vs 44.8 % after, p < 0.01). General practitioners had greater improvement (48.1 % of evaluated items), whereas older residents reported fewer items before or after the training (43.5 %) than younger residents. Finally, all residents improved their practice with a conclusion that followed the guidelines in 92.5 % of cases (versus 68.3 % before the training; p < 0.01).

CONCLUSION

Training on the CNGOF minimal sonographic report guidelines significantly improved the emergency sonographic reports generated by residents. Wider dissemination of this training, particularly to young residents, would probably improve the quality of sonographic reports performed at gynaecological emergencies.

Prevalence, intensity, impact on quality of life and insights of dysmenorrhea among French women: A cross-sectional web survey

OBJECTIVE

Determine prevalence and intensity of primary dysmenorrhea in a sample of French women and assess impact on daily life and Quality of Life, care pathway and pain management METHODS: This cross-sectional web-based survey was conducted from December 19th2018 through January 10th2019 among a representative sample of 3001 French women aged 16 to 50.

RESULTS

2375 women (79%) reported having pain during menstruation, currently or in the past. 52% reported being currently affected, 27% had been affected in the past and 21% never suffered. Among younger women under 24, 66% reported current dysmenorrhea. Mean rating of pain intensity, evaluated on a visual analog scale from 0 to 10, was 6 + 1.9 in women presently having dysmenorrhea and 42% reported rating between 7 and 10. The impact on daily life was strong and there was a significant reduction of SF-36 scores in women experiencing dysmenorrhea. Among the 79% of women affected by dysmenorrhea, (current or past) 53% never used any medication and respectively 58% and 66% never sought medical advice.

CONCLUSION

Dysmenorrhea is very frequent in France with a significant impact on daily life and Quality of Life. There is a real inadequacy in the recognition and the management of this pathology, too often considered as common by the patients. There is a strong need for better information of the women and to raise the awareness of first line health-care professionals that any dysmenorrhea and especially severe dysmenorrhea must be accurately assessed and managed with the available therapeutic means.

Activation of Toll-Like Receptors Differentially Modulates Inflammation in the Human Reproductive Tract: Preliminary Findings

The female reproductive tract (FRT) is the main site of entry of sexually transmitted infections (STIs). Toll-like receptors (TLRs) that recognize pathogenic motifs are widely expressed in the FRT. TLR stimulation induces immune activation and local production of inflammatory mediators. In the FRT, this response should also be compatible with reproductive functions and symbiosis with host microbiota. With a view to develop efficient mucosal vaccines to prevent STI acquisition, the role of TLR ligands in the FRT needs to be explored. We have therefore investigated the cytokine profiles of the different compartments of the FRT (vagina, endocervix, ectocervix, and uterus) before and after stimulation of mononuclear cells from human tissue specimens. The comparison with PBMCs allowed us to highlight the FRT specificities. We first characterized the main immune cell populations in each compartment and observed that their distribution was different through the compartments. The CD45⁺ cells represented a maximum of 11% in the FRT in contrast to 96% in PBMCs. We identified two main populations among the CD45⁺ cells in the four compartments of the FRT: CD3⁺ T cells (CD4⁺ and CD8⁺) and CD14⁺ APCs. B cell populations (CD19⁺) were much less frequent than T cells in all the FRT regions and were equally distributed. NK CD56⁺ cells were detected in all compartments and were more abundant in the uterus. Stimulation of the mononuclear cells was then performed with TLR agonists: R848 for TLR7/8, Poly I:C for TLR3, LPS for TLR4 and ODN CpG for TLR9. Cytokine levels in unstimulated cultures of cells isolated from all FRT compartments were higher than in cultures of unstimulated PBMCs. In contrast, after stimulation with TLR agonists, cytokine responses induced by TLR agonists were moderate in the FRT and significantly lower than in PBMCs. These responses were varied with different TLR ligands and FRT compartments. The cytokine profile induced by TLR activation in the FRT supports the role of these tissues in genital anti-microbial immunity and in the control of inflammation while allowing maintenance of its reproductive function.

Cost-effectiveness analysis of medical management versus conservative surgery for early tubal pregnancy

STUDY QUESTION

Is conservative surgery (laparoscopic salpingotomy) cost-effective, using fertility as the endpoint compared with medical management (Methotrexate) in women with an early tubal pregnancy?

SUMMARY ANSWER

Conservative surgery appeared slightly, but not statistically significantly, more effective than medical management but also more costly.

WHAT IS KNOWN ALREADY

Women with an early tubal pregnancy treated with medical therapy (Methotrexate) or conservative surgery (laparoscopic salpingotomy) have comparable future intrauterine pregnancy rates by natural conception. Also, cost-minimisation studies have shown that medical therapy was less expensive than conservative surgery, but there is no cost-effectiveness study comparing these two treatments with fertility as the endpoint.

STUDY DESIGN, SIZE, DURATION

A multicentre randomised controlled trial-based (DEMETER study) cost-effectiveness analysis of conservative surgery compared with medical therapy in women with an early tubal pregnancy was performed.

PARTICIPANTS/MATERIALS, SETTINGS, METHODS

Included women had an ultrasound that confirmed an early tubal pregnancy. They were randomly allocated to conservative surgery or to medical therapy. The study clinical outcome was the intrauterine pregnancy rate. The payer's perspective was considered. Costs of conservative surgery and medical therapy were compared. The analysis was performed according to the intention-to-treat principle. Missing variables were imputed using the fully conditional method. To characterise uncertainty and to provide a summary of it, a non-parametric bootstrap resampling was executed and cost-effectiveness accessibility curves were constructed.

MAIN RESULTS AND THE ROLE OF CHANCE

At baseline, costs per woman in the conservative surgery group and in the medical therapy group were 2627€ and 2463€, respectively, with a statistically significant difference of +164€. Conservative surgery resulted in a marginally, but non-significant (P = 0.46), higher future intrauterine pregnancy rate compared to medical therapy (0.700 vs. 0.649); leading, after bootstrap, to an incremental cost-effectiveness ratio of 1299€ (95% CI = -29 252; +29 919). Acceptability curves showed that conservative surgery could be considered a cost-effective treatment at a threshold of 3201€ for one additional future intrauterine pregnancy.

LIMITATIONS, REASONS FOR CAUTION

A limitation was that monetary valuation was carried out using 2016 euros while the DEMETER study took place from 2005 to 2009. Anyway, the results would not have been very different given the marginal changes in the health insurance reimbursement tariffs during this period.

WIDER IMPLICATIONS OF THE FINDINGS

Conservative surgery can be considered a cost-effective treatment, if the additional cost of 3201€ per additional future intrauterine pregnancy is an acceptable financial effort for the payer.

STUDY FUNDING/COMPETING INTEREST(S)

None.

TRIAL REGISTRATION NUMBER

NCT 00137982.

Intrauterine adhesions: What is the pregnancy rate after hysteroscopic management?

OBJECTIVE

To evaluate the rate of pregnancy following hysteroscopic management of intrauterine adhesions.

DESIGN

Retrospective study.

SETTING

From June 2009 to December 2014 in a teaching hospital.

PATIENTS

Women treated by operative hysteroscopy for intrauterine adhesions.

INTERVENTION

Operative hysteroscopy to manage intrauterine adhesions.

MAIN OUTCOME MEASURE

rate of intrauterine pregnancy after hysteroscopic management of intrauterine adhesions.

RESULTS

Out of the 202 women whom benefit from hysteroscopic adhesiolysis, 112(55%) had an effective pregnancy desire. Among them, an intrauterine pregnancy was obtained for 58 women (52%) with a trend to a lower rate for type IV and Vb intrauterine adhesions management (40.5%, p = 0.09). Pregnancy rates were similar for women undergoing one or more procedures.

CONCLUSION

Hysteroscopic management of intrauterine adhesions seems useful as it leads to a pregnancy rate of 52%. However, this rate is lower in case of type IV and Vb intrauterine adhesions. Repeated procedures don't seem to lead to less pregnancy; however, a more powerful prospective study should be performed to answer this specific question.

Vaginal posterior isthmic sling: A report of 53 cases

INTRODUCTION

Sacrospinofixation is used for fundic vaginal vault's prolapse or to prevent mid-level or posterior prolapse. It can lead to complications such as dyspareunia, chronic pain, and quality of life impairment. Anchoring a posterior isthmic sling to the two sacrospinous ligaments is an alternative to classic Richter's sacrospinofixation. Objective of this study is to report the first cases of vaginal posterior isthmic slings.

METHODS

This study is retrospective and unicentric. It includes women who had posterior isthmic sling at the time of a surgery with a mesh for anterior prolapse by vaginal way between 2010 and 2016 in the gynecologic department of a teaching hospital. Report of efficacy and tolerance was performed.

RESULTS

Between 2010 and 2016, 53 women were included with a posterior isthmic sling and a mesh for an anterior prolapse. POP-Q evolution during the follow-up in the posterior isthmic sling group assess of a good efficacy of the sling. Four women (7.5%) required second surgery in 28 months following initial surgery (only 1 for excision). Four women (7.5%) had a prolapse recurrence in a mean time of 30 months without recurrent surgery. Women's satisfaction level was high (8.0/10 [7,1-8,8]).

CONCLUSION

Efficacy and tolerance of the posterior isthmic sling seems good. It might then be an option for mid-level prolapses in case of vaginal surgery with mesh for anterior prolapse. A non-inferiority trial should be performed to be able to conclude on the place of this alternative to Richter's sacrospinofixation.

What does non-eligibility for myoma surgery mean in the context of sequential prescription of ulipristal acetate?

Ulipristal Acetate (UPA) is the only selective progesterone receptor modulator currently approved for medical management of myomas. Following several cases of liver toxicity during UPA treatment, new recommendations of PRAC (Pharmacovigilance Risk Assessment Committee) and EMA (European Medicines Agency) have been proposed, including a pre-therapeutic assessment of liver function and a close monitoring during treatment. Repeated courses of UPA have also been restricted to women who are defined as "non-eligible" for surgery. This article raises important questions and tries to provide clarification about the concept of 'non-eligibility' for myoma surgery.