New Efficient Method for Hysteroscopic Isthmoplasty: Four Simple Steps Lead to a Significant Improvement in Bleeding Status

We demonstrate an effective reduction in postmenstrual spotting after our novel hysteroscopic isthmoplasty. This study included 66 patients with isthmocele-related postmenstrual spotting confirmed by sonography and diagnostic hysteroscopy between 2000 and 2017. Our new interventions included the following four steps: (1) make a resection gradient of the distal edge of the isthmocele from the ape of the isthmocele down to the cervical outer orifice; (2) resect the distal and proximal niches of the isthmocele; (3) electrocauterize the distal and proximal sides (not only the niche bottom) of the small cave on the scar side of the isthmocele; (4) manage the isthmocele until it is largely connected to the cavity. In our results, all patients underwent extensive hysteroscopic repair of newly hysteroscopic isthmoplasty without any intra- or postoperative complications. After final hysteroscopic repair modification, prolonged menstrual spotting was significantly decreased in 98.2% (53/54) of the patients, and the total number of bleeding days per menstrual cycle significantly decreased from a mean of 15.38 ± 3.3 days to 6.4 ± 1.9 days postoperatively (p < 0.001). Our four-step hysteroscopic technique successfully resolved prolonged menstrual spotting in over 90% of the patients, exceeding the resolution rates of 60−85% achieved with other hysteroscopic techniques used to treat symptomatic isthmocele. No patients experience recurrence after long-term follow up. Four simple steps led to a significant improvement in bleeding status.

Role of hysteroscopy during conservative management of atypical endometrial hyperplasia and early-stage endometrial cancer in patients who desire pregnancy

Twenty-five percent of cases of endometrial cancer appear in women with unfulfilled reproductive desires. An adequate selection of patients and a close hysteroscopic follow-up to monitor the endometrial response to the levonorgestrel-releasing intrauterine system (LNG-IUS) may be a valid and safe option for these patients. This is a case series and review of the literature study. We included eight patients diagnosed of complex endometrial hyperplasia with atypia (CEHA) or stage 1AG1 well-differentiated endometrial cancer without myometrial invasion who desired to get pregnant and opted for a conservative treatment. Follow-up was performed with hysteroscopy and directed biopsy at 3, 6 and 12 months. Of the 854 cases of complex endometrial hyperplasia with atypia (CEHA)/endometrial cancer were diagnosed, 2.3% were candidates for conservative management. We obtained a favourable regression of 71.2% at 6 months and 57% at one year with hormonal treatment. Conservative treatment in complex endometrial hyperplasia with atypia (CEHA)/low-grade endometrial cancer in reproductive age patients with a strong desire for pregnancy is feasible.

Evaluation of Hysteroscopic Endometrectomy: A Reappraisal

Endometrial ablation can be performed using a variety of techniques, including resectoscopic or non-resectoscopic approaches. In this study, we compared 2 resectoscopic endometrial ablation techniques. The first technique was rollerball coagulation followed by endometrectomy (type A; n = 103), and the second was the reverse (type B; n = 107). Besides excessive bleeding in 4 cases, the procedures were uneventful in both groups of patients. We did not encounter uterine perforation or cervical laceration. Satisfaction rates were 97% and 99% with an overall hysterectomy rate of 2.9%. These results compared favorably with those in the literature. The results of our study show that hysteroscopic endometrectomy is effective with few associated complications.

Efficacy and safety of auto-cross-linked hyaluronic gel to prevent intrauterine adhesion after hysteroscopic electrosurgical resection: a multi-center randomized controlled trial

Background

The electrothermal effect of hysteroscopic bipolar electrosurgical resection may cause damage to the endometrium, leading to intrauterine adhesion (IUA). Although some studies have demonstrated the efficacy and feasibility of auto-cross-linked hyaluronic (ACP) gel in preventing IUAs, controversy over its use continues. In this randomized controlled multi-center 2-arm parallel trial, we aimed to examine the efficacy and safety of ACP gel in preventing IUA after hysteroscopic electrosurgical resection and facilitate pregnancy in patients.

Methods

Patients from 4 centers in China were randomly assigned (1:1) to receive an intrauterine infusion of ACP gel or nothing after hysteroscopic electrosurgical resection. The randomization assignment was generated by computer and kept in a sealed envelope. A second-look hysteroscopy was performed within 3 months of the surgery.

Results

From June 2018 to May 2021, 200 patients were recruited. Ultimately, 82 patients in both groups were included in the result analysis. The baseline characteristics were comparable. The outcomes were assessed by using per-protocol analysis. The incidence of IUA in the ACP gel group was lower than that in the control group [3.66% vs. 10.98%, risk ratio (RR) =0.333, 95% confidence interval (CI): 0.094-1.187, P=0.072], and the planned pregnancy rate was higher than that of the control group (60.98% vs. 40.54%, RR =1.504, 95% CI: 0.949-2.384, P=0.071), but the difference was not statistically significant. There was no significant difference in menstruation change. Menstrual volume remained unchanged in most cases (86.59% in ACP gel group vs. 89.02% in the control group, RR =0.877, 95% CI: 0.877-1.109, P=0.815). Menstrual volume decreased in 10 women in the ACP gel group and 8 in the control group (12.20% vs. 9.76%, RR =1.250, 95% CI: 0.520-3.007, P=0.617). No adverse effects were observed after the ACP administration.

Conclusions

The present study showed that the use of ACP gel appeared to reduce both the tendency of IUA and American Fertility Society (AFS) scores and improve the subsequent pregnancy rate during hysteroscopic electrosurgical resection when treating polyps, fibroids, and uterine septum. ACP might be recommended to prevent IUA after such surgery. Further studies should be conducted with larger numbers of participants.

Trial Registration

Chinese Clinical Trial Registry ChiCTR2100047165.

Endometrial Cancer in Reproductive Age: Fertility-Sparing Approach and Reproductive Outcomes

Endometrial cancer is the most common gynecologic malignancy in developed countries and approximately 7% of the women with endometrial cancer are below the age of 45. Management of endometrial cancer in young women who desire to maintain fertility presents a unique set of challenges since the standard surgical treatment based on hysterectomy and salpingo-oophorectomy is often not compatible with the patient's goals. A fertility-preserving approach can be considered in selected patients with early stage and low-grade endometrial cancer. An increasing amount of data suggest that oncologic outcomes are not compromised if a conservative approach is utilized with close monitoring until childbearing is completed. If a fertility-preserving approach is not possible, assisted reproductive technologies can assist patients in achieving their fertility goals.

Hysteroscopic Resection Followed by Adjuvant Radiotherapy: Report of a New Therapeutic Approach to Primary Cervical Diffuse Large B-Cell Lymphoma

The female genital tract can be involved as a secondary manifestation of disseminated lymphomas or leukemia but can rarely be the primary site of so-called extranodal lymphomas. Primary lymphomas of the female genital tract can affect the uterine corpus, uterine cervix, vulva, vagina or adnexa. Only about 0.008% of all cervical tumors are primary malignant lymphomas. The presenting symptoms are unspecific and also refer to much more common diseases of the female genital tract. Cervical cytology is usually negative. Preoperative diagnosis requires deep cervical biopsy. To date there is no consensus regarding optimal treatment. Radiotherapy, chemotherapy and surgery are used in different association. We report the first case reported in literature managed with an urgent hysteroscopic resection of a primary cervical diffuse large B-cell lymphoma, followed by adjuvant radiotherapy. Relevant literature was reviewed. Our conservative approach needs to be validated in the future, especially for women with pregnancy desire and for those with low performance status. To date, after 24 months from diagnosis, our patient is still disease-free.

Chronic Endometritis in Infertile Women: Impact of Untreated Disease, Plasma Cell Count and Antibiotic Therapy on IVF Outcome-A Systematic Review and Meta-Analysis

This systematic review and meta-analysis aims to evaluate the impact of chronic endometritis (CE) and its therapy on in vitro fertilization (IVF) outcome. Additionally, we aim to investigate whether various degrees of CE severity may exert a different effect on IVF outcome. Ongoing-pregnancy rate/live-birth-rate (OPR/LBR), clinical-pregnancy rate (CPR), and miscarriage rate (MR) were calculated. A total number of 4145 patients (from ten studies) were included. Women with CE had lower OPR/LBR (OR 1.97, p = 0.02) and CPR (OR 2.28, p = 0.002) compared to those without CE. CE cure increased OPR/LBR (OR 5.33, p < 0.0001) and CPR (OR 3.64, p = 0.0001). IVF outcome was comparable between women with cured CE and those without CE (OPR/LBR, CPR and MR: p = ns). Women with severe CE had lower OPR/LBR (OR 0.43, p = 0.003) and CPR (OR 0.40, p = 0.0007) compared to those mild CE. Mild CE showed no influence on the IVF outcome as compared to women without CE (OPR/LBR, CPR and MR: p = ns). Based on this data analysis, CE significantly reduces OPR/LBR and CPR in women undergoing IVF. Importantly, CE resolution after antibiotic therapy may improves IVF outcome, leading to similar OPR/LBR and CPR as compared to unaffected patients. The negative effects of CE on IVF outcome may be restricted to severe disease, whereas mild CE may have no influence on IVF success.

Intrauterine Levobupivacaine Instillation for Pain Control in Women Undergoing Diagnostic Hysteroscopy

Objectives

Many women experience pain and discomfort after hysteroscopic procedure. Pain and discomfort after hysteroscopic procedures can be explained by the cervical dilatation, intrauterine manipulation, and/or hydrodistension. This study designed to evaluate the efficacy of intrauterine levobupivacaine instillation for pain control in women undergoing diagnostic hysteroscopy.

Materials and Methods

One hundred and twenty (120) women scheduled for diagnostic hysteroscopy and endometrial biopsy due to uterine bleeding were included in this study and randomized either to levobupivacaine group or controls. At the end of hysteroscopy, 5 mL of 0.5% levobupivacaine was instilled intrauterine in levobupivacaine group, while 5 mL of 0.9% saline was instilled intrauterine in controls. Participants were kept in the hospital for 12 h after diagnostic hysteroscopy to detect the postoperative (PO) pain intensity using visual analog scale (VAS), and PO required analgesics.

Results

The VAS was significantly lower in levobupivacaine group compared to controls 3 h. PO (1.31 ± 1.02 vs. 1.62 ± 0.76, respectively), (P = 0.01), 6 h. PO (0.81 ± 1.24 vs. 1.53 ± 0.88, respectively), (P = 0.004), and 9 h. PO (0.55 ± 1.25 vs. 1.12 ± 0.95, respectively), (P = 0.01). The total PO required analgesics were significantly lower in levobupivacaine group compared to controls (P = 0.005).

Conclusion

The intrauterine levobupivacaine instillation was simple, and effective for pain relief after diagnostic hysteroscopy, it significantly decreased pain score assessed by VAS at 3, 6, and 9 h., PO, and it significantly decreased PO required analgesics.

A novel technique for moderate to severe intrauterine adhesions: A historical cohort study

To evaluate the feasibility and efficiency of our novel technique, ultrasound guided hysteroscopic catheter dilation (US-HCD), for the treatment of moderate to severe intrauterine adhesion (IUA). A total of 126 patients diagnosed with IUA and met the enrollment criteria were admitted in this historical cohort study from June 1, 2016 to December 31, 2018. All patients were divided into 2 groups according to the surgical techniques used. Group A (n = 68) were treated with traditional hysteroscopic adhesiolysis with scissors (THA) and Group B (n = 58) were treated with US-HCD. Their data for the next 2 years following the initial surgery were analyzed. Safety and feasibility (operation time, surgical complications and the third-look hysteroscopic surgery rate), and post-operation efficacy (reduction of American Fertility Society [AFS] scores, pregnancy and live birth rates) were evaluated between groups. Between the groups, there was no statistically significant differences in basic preoperative information and AFS scores (P > .05). While there were significant differences in the operation time of the initial surgery (P < .05) and reduction of AFS scores (P < .05). No surgical complications were recorded and only 3 patients (5.2%) received a third-look hysteroscopy in Group B, while there were 6 cases of complications and 13 cases (19.1%) of third-look hysteroscopy in Group A, indicating significant differences between Groups (P < .05). Both groups exhibited comparable pregnancy rate, live birth rate and obstetric complications (P > .05). Our new technique is a safe, feasible and effective procedure for moderate to severe IUA patients, which can be mastered more quickly and easily by surgeons and applied in areas with less affluent economy and without hysteroscopic scissors, thus worthy of further study.

Incidence and risk factors of intrauterine adhesions after myomectomy

Objective

To determine the incidence and risk factors for intrauterine adhesions (IUAs) after minimally invasive and open myomectomy and hysteroscopic myomectomy (HM).

Design

Retrospective cohort study.

Setting

University-affiliated fertility center.

Patients

Patients aged ≥18 years undergoing robotic-assisted or conventional laparoscopic minimally invasive myomectomy, abdominal myomectomy, or HM between January 2007 and January 2017. Only patients who underwent uterine cavity evaluation within 12 months of surgery via hysteroscopy or hysterosalpingography were included. Patients were excluded if they had a history of IUA before myomectomy.

Interventions

Not applicable.

Main Outcome Measures

The primary outcomes of this study were the presence and severity of IUA. The secondary outcomes were the identification of risk factors for IUA formation. The severity of IUAs was scored by 2 investigators using a previously published grading system by March et al.

Results

Of 1,315 patients who underwent myomectomy, 173 (13.2%) met the inclusion criteria. Intrauterine adhesions were identified in 9.3% of all patients, 75.0% of which were classified as minimal. The incidence of IUA did not vary by modality: 8.6%, minimally invasive myomectomy; 7.8%, abdominal myomectomy; and 11.8%, HM. There were no differences in incidence of IUA by the number or size of fibroids removed. Of patients with IUA, 87.5% had submucosal fibroids resected compared with 58.6% without IUA.

Conclusions

The incidence of postoperative IUA in women undergoing myomectomy of any modality is relatively low (9.3%) and does not vary by modality alone. Most IUAs are of minimal degree. The presence of submucosal fibroids is associated with an increased risk of IUA in all modalities.

Misoprostol Administration Before Hysteroscopy Procedures - A Retrospective Analysis

OBJECTIVE

 To evaluate the use of misoprostol prior to hysteroscopy procedures regarding technical ease, the presence of side effects, and the occurrence of complications.

METHODS

 This is a retrospective, observational, analytical, case-control study, with the review of medical records of 266 patients followed-up at the Gynecological Videoendoscopy Sector of the Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto of the Universidade de São Paulo (HCFMRP - USP, in the Portuguese acronym) from 2014 to 2019, comparing 133 patients who used the drug before the procedure with 133 patients who did not.

RESULTS

 The occurrence of postmenopausal uterine bleeding was the main indication for hysteroscopy and revealed a statistical difference between groups (p < 0.001), being present in 93.23% of the patients in the study group and in 69.7% of the patients in the control group.: Only 2 patients (1.5%) in the study group reported adverse effects. Although no statistical differences were observed regarding the occurrence of complications during the procedure (p = 0.0662), a higher total number of complications was noted in the group that used misoprostol (n = 7; 5.26%) compared with the group that did not use the drug (n = 1; 0.75%), a fact that is clinically relevant. When evaluating the ease of the technique (measured by the complete performance of all steps of the hysteroscopy procedure), it was verified that although there was no difference between groups (p = 0.0586), the control group had more than twice as many incompletely performed procedures (n = 17) when compared with the group that used misoprostol previously (n = 8), which is also clinically relevant.

CONCLUSION

 The use of misoprostol prior to hysteroscopy in our service indicated that the drug can facilitate the performance of the procedure, but not without side effects and presenting higher complication rates.

Vaginal repair of cesarean section scar defects: Preoperative hysteroscopic evaluation

INTRODUCTION

Cesarean section scar defects (CSDs) are one of the long-term complications following cesarean section. They can be detected by transvaginal sonography, hysterosalpingography, sonohysterography and magnetic resonance imaging (MRI). Hysteroscopy is frequently used in evaluating endometrial disease. However, the description of CSDs by hysteroscopy is very limited. Only a few papers about hysteroscopy evaluation have been published. This is an exploratory study to compare hysteroscopic findings with myometrial thickness and post-surgical outcomes.

MATERIAL AND METHODS

From February 2019 to December 2020, 143 women with CSDs were enrolled in the observational study. All women suffered from abnormal uterine bleeding and were evaluated in a standardized way with hysteroscopy before vaginal surgery. Dome-shaped CSDs could be clearly observed in all patients under hysteroscopy. We recorded the pictures of each patient under hysteroscopy and classified them. All patients underwent outpatient review at 3 and 6 months after surgery to obtain menstrual information and CSD scar size by MRI or transvaginal sonography.

RESULTS

Pale mucosae in the defect were meager endometrial lining covering the surface of muscle layer, cyst lesions were some cyst lesions in the defect, increased local vascularization was a vascular tree with branching and irregular vascular distribution in defect, polypoid lesions were polypoid lesions in the defect, and serrated niches were two niches at the anterior uterine isthmus. The features of the CSDs observed under hysteroscopy were identified as five phenotypes: pale mucosae (90/143, 62.9%), cyst lesions (23/143, 16.1%), polypoid lesions (19/143, 13.3%), increased local vascularization (27/143, 18.9%) and serrated niches (7/143, 4.9%). The most common finding in scar defects under hysteroscopy was pale mucosae in the CSD. The results suggest that patients with increased local vascularization and serrated niches have a high risk of thinner residual myometrium before vaginal repair (p < 0.05). However, there was no significant difference in menstrual duration or in the outcome of vaginal repair for CSDs between these five phenotypes (p > 0.05).

CONCLUSIONS

Patients with the abnormal blood vessel or serration phenotypes of defects under hysteroscopy may have a thinner residual myometrium. The phenotypes of hysteroscopic findings of CSDs have no correlation with the outcome of repair.

Minimal alveolar concentration of sevoflurane in combination with dexmedetomidine in patients with hysteroscopy: An up-down sequential allocation study

BACKGROUND

Dexmedetomidine is commonly used in hysteroscopy surgery due to its analgesia and sedation without respiratory depression. Many studies have shown that dexmedetomidine can reduce the consumption of sevoflurane. However, the optimal end-tidal concentration of sevoflurane when it is co-administered with dexmedetomidine has not been established. The primary purpose of this study was to investigate the minimal alveolar concentration (MAC) of sevoflurane for cervical dilatation combined with different doses of dexmedetomidine in patients with hysteroscopy surgery.

METHODS

One-hundred patients undergoing hysteroscopy surgery were enrolled in this clinical trial. All the patients were randomly assigned into four groups (C, D₁ , D₂ , D₃ ) and received a loading dose of dexmedetomidine (0, 0.6, 0.8 and 1.0 μg/kg) over 10 min before anaesthesia induction, respectively. Anaesthesia was induced in each patient with 5% sevoflurane in 100% oxygen via a facemask. A laryngeal mask (LMA) was inserted when the patient had lost consciousness and the BIS value decreased below 40. The response to cervical dilatation stimulus (movement vs non-movement) by the insert of hysteroscope was recorded. The MAC of sevoflurane was measured by up and down sequential method of Dixon and Mood and centred isotonic regression analysis.

RESULTS

The calculated MAC of sevoflurane using up-and-down method of Dixon and Mood in patients with hysteroscopy surgery was (1.90 ± 0.13)%, (1.23 ± 0.16)%, (1.03 ± 0.10)% and (0.93 ± 0.08)% in groups C, D₁ , D₂ and D₃ , respectively.

CONCLUSIONS

The administration of dexmedetomidine can significantly decrease the MAC of sevoflurane for hysteroscopy surgery. However, a ceiling effect of the reduction was observed when the dose of dexmedetomidine was higher than 0.8 μg/kg.

Uptake of outpatient hysteroscopy in Australia using Medical Benefits Scheme data: Have we fallen behind?

BACKGROUND

Hysteroscopy is a safe procedure which allows both diagnosis and management of cervical and endometrial pathology. Improving Australian women's access to outpatient hysteroscopy would improve cost efficiency and allow women a quicker recovery, negating the need for a general anaesthetic. Increasing the Medicare renumeration for outpatient hysteroscopy could incentivise provision of outpatient hysteroscopy.

AIM

We sought to review the trend and current uptake of outpatient diagnostic hysteroscopy in Medicare Benefits Scheme (MBS)-funded clinics within Australia.

MATERIALS AND METHODS

A retrospective review of Australian MBS data from 1 January 1993 to 31 December 2020.

RESULTS

Over the past 27 years, 1 319 909 hysteroscopies have been claimed from Medicare in Australia, with 39 958 (3.1%) claimed as an outpatient diagnostic procedure. Australian outpatient diagnostic hysteroscopy MBS item number use peaked in 1994 (5871 cases) representing 18.2% of all hysteroscopies claimed through the MBS that year. Uptake of the outpatient hysteroscopy item number rapidly declined after 1994 and in 2010, it represented 0.8% of all hysteroscopies claimed (426 of 49 618) and has remained below <0.5% from 2010 to 2020.

CONCLUSIONS

The lower Medicare rebate and lack of recognition of the importance of outpatient hysteroscopy has likely been a driving factor in continuing inpatient hysteroscopy. Incentivised government funding has been successfully utilised in the UK to improve outpatient hysteroscopy access. This MBS data suggests that Australia has not progressed in outpatient hysteroscopy access and support a change in the current funding model to assist in supporting the uptake of outpatient access.

Modern assessment of the uterine cavity and fallopian tubes in the era of high-efficacy assisted reproductive technology

The high efficacy of modern assisted reproductive technology (ART) and increase in the number of noninfertile patients who are using ART for family building in the United States call into question the relevance of the standard, one-size-fits-all infertility evaluation. Here, we explore whether all patients presenting for ART need uterine cavity and tubal assessment and what tests are most appropriate, efficient, and cost-effective in current times.

Reproductive Outcome of the Patients with Uterus Unicornis: Five Year Experience in a Tertiary Center

Aim

The aim is to evaluate the pregnancy outcomes of patients with uterus unicornis for 5-year experience in a tertiary center.

Material and Method

Twenty patients with uterus unicornis who were diagnosed with hysterosalpingography and/or 3D TVUSG between 2017 and 2021 and then confirmed with laparoscopy and simultaneous hysteroscopy were recruited into this retrospective study. The reproductive outcome and obstetric complications of the patients were followed up for two years postoperative period.

Results

Overall 20 patients who fulfilled the inclusion criterion were recruited for the study. The mean age was 28.65±5.03 years. Thirteen patients (65%) had primary infertility while the remaining seven had secondary infertility with two of them having a previous ectopic pregnancy. Rudimentary communicating uterine horn was observed in 7 (35%) of the patients. The horns were excised during laparoscopy. Overall, 14 (70%) pregnancies were achieved during the 2 years follow-up period. Twelve (85.7%) patients had a live birth (71.4% term delivery, 21.4% preterm delivery), and two (15.3%) had a first-trimester spontaneous abortion. Six (50%) of 12 patients who had a live birth received tocolytics for preterm labor.

Conclusion

Unicorn uterus is a rare anomaly diagnosed mostly during infertility work-up and might be related to the poor obstetric outcome, but early diagnosis is important for successful pregnancy results for preterm delivery especially in the secondary infertile group. In addition, rudimentary horn excision is recommended due to the high risk of obstetric complications.

Effective Doses of Nalbuphine Combined with Propofol in Painless Hysteroscopy

Purpose

Nalbuphine is becoming a common analgesic used in hysteroscopic operations. The aim of this study was to identify the median effective dose (ED50) and 95% effective dose (ED95) of nalbuphine combined with propofol in painless hysteroscopy.

Patients and Methods

Twenty-five patients aged 18–60 years with an American Society of Anesthesiologists classification of I–II who were scheduled for painless hysteroscopy were recruited. The initial dose of nalbuphine was set at 0.15 mg/kg and varied by 0.01 mg/kg according to the Dixon sequential method. The ED50/ED95 of nalbuphine combined with propofol for hysteroscopy was calculated by the probit method.

Results

The ED50 of nalbuphine was 0.122 (95% confidence interval (CI) 0.092–0.137) mg/kg, and the ED95 of nalbuphine was 0.153 (95% CI 0.138–0.361) mg/kg.

Conclusion

The ED50/ED95 values of nalbuphine combined with propofol in painless hysteroscopy are 0.122 mg/kg and 0.153 mg/kg, respectively. Nalbuphine at 0.153 mg/kg combined with propofol is effective and safe for painless hysteroscopy.

Outpatient hysteroscopy is effective for uterine cavity evaluation following failed office-based endometrial biopsy

BACKGROUND

Failure to obtain an office-based endometrial biopsy for abnormal uterine bleeding is not uncommon. Although operating room-based procedures are traditionally considered the gold standard assessment tool in these circumstances, outpatient hysteroscopy is a less invasive, more cost-effective, and safer alternative. However, there is no contemporary Canadian literature on the effectiveness of an outpatient approach for this specific population.

OBJECTIVE

We aim to evaluate the effectiveness and outcomes of outpatient hysteroscopy for uterine cavity evaluation for patients who have failed an in-office endometrial biopsy attempt.

METHODS

We conducted a retrospective cohort study of all patients referred to an academic outpatient hysteroscopy unit between January 2015 and January 2018, who underwent an outpatient hysteroscopy following failed endometrial biopsy. Data were collected from electronic medical records.

RESULTS

Of the 407 consecutive patients who underwent an outpatient hysteroscopic procedure, 68 met inclusion criteria. Postmenopausal bleeding was the most common indication for initial biopsy, and most failures were attributed to cervical stenosis. Outpatient hysteroscopies were successfully completed in 96% of cases (n = 65/68). Failure resulted from either anxiety and discomfort (n = 2), or severe intrauterine adhesions (n = 1). Overall, 10% of patients subsequently required an operating room-based hysteroscopy, either to complete a myomectomy or polypectomy, or to allow general anesthesia. Outpatient hysteroscopy identified endometrial hyperplasia and cancer in 4.5% and 3% of patients, respectively.

CONCLUSION

Outpatient hysteroscopy following unsuccessful office endometrial biopsy attempts appears to be a feasible, safe, and cost-effective investigation strategy that may prevent the need for an operating room-based procedure in 90% of cases.

See-and-treat in-office hysteroscopy versus operative hysteroscopy for the treatment of retained products of conception: A retrospective study

AIM

To compare the efficacy and safety of in-office hysteroscopy with a see-and-treat approach with that of operative hysteroscopy for the treatment of retained products of conception (RPOC).

METHODS

We retrospectively identified all consecutive patients who underwent hysteroscopic treatment of RPOC between 2015 and 2019. We excluded patients with RPOC larger than 2 cm at preoperative transvaginal ultrasounds. Between 2015 and 2017, all hysteroscopic removals of RPOC were performed by operative hysteroscopy. Between 2018 and 2019, all cases of RPOC less than 2 cm in size were hysteroscopically removed by the see-and-treat approach in the office setting. Sociodemographic, clinical, and procedure characteristics along with complications were retrieved from medical records.

RESULTS

Between 2015 and 2019, 119 women underwent hysteroscopic removal of RPOC equal to or smaller than 2 cm: 53 patients by in-office hysteroscopy, and 66 by operative hysteroscopy. The two groups were similar in preoperative characteristics. Although the time required to complete the RPOC removal was similar, the total procedure and assistant time were significantly higher in the operative hysteroscopy group (p < 0.001). Moreover, operative hysteroscopy was associated with a higher proportion of cases complicated by excessive bleeding, cervical tear, or uterine perforation (p = 0.016). Failure to complete the procedure was similarly reported in the two groups (p = 0.58).

CONCLUSIONS

In-office hysteroscopy with the see-and-treat approach for RPOC equal to or smaller than 2 cm appears as effective as operative hysteroscopy, but safer. In-office hysteroscopy may be considered the first choice for treating RPOC equal to or smaller than 2 cm.

The management of caesarean scar pregnancy with or without a combination of methods prior to hysteroscopy: ovarian reserve trends and patient outcomes

STUDY OBJECTIVE

This study compared the efficacy and safety of a combination of uterine artery embolization or methotrexate before hysteroscopy in the treatment of cesarean scar pregnancy.

METHODS

We divided 276 cesarean scar pregnancy patients into three groups. Group A underwent direct hysteroscopy; Group B received uterine artery embolization plus hysteroscopy; Group C received the systemic administration of methotrexate prior to hysteroscopy.

RESULTS

The patients in Group A lost significantly more blood than those in Groups B (P < 0.05). There were no significant differences between the three groups with regards to massive hemorrhage and transfusion (P > 0.05). None of the patients required hysterectomy. Group A was also associated with a significantly shorter period of hospitalization, reduced medical costs, and fewer adverse events than either Group B or C (P < 0.05). Moreover, among women of advanced age (≥35y), the levels of serum anti-Mullerian hormone in Group B were significantly lower than those of the baseline group (P<0.05), which were significantly lower than those in Group A after surgery (4.22 ± 2.35 vs 2.78± 1.89 ng/ml, P < 0.05).

CONCLUSION

Direct hysteroscopy is a reliable treatment option for most early type I cesarean scar pregnancy patients with a gestational sac. A combination of methotrexate and uterine artery embolization before hysteroscopy in these patients has limited remedial effects. uterine artery embolization may reduce ovarian reserve in patients aged ≥35y.

Laparoscopic Fluorescence Guided Detection of Uterine Niche-The Next Step in Surgical Diagnosis and Treatment

(1) Background: Uterine niche is a frequent condition in patients with a history of cesarean section. Although the relation to uterotomy seems to be clear, the exact pathogenesis is not fully understood. Uterine niche can easily be diagnosed by transvaginal ultrasound. It can be related to symptoms like dysmenorrhea, bleeding disorders, dysuria and dyspareunia. Uterine niche can be the cause of scar pregnancy, a rare form of ectopic pregnancy which can be related to severe complications; (2) Methods: We present a series of nine cases with different uterine niche related findings and discuss the diagnostic and therapeutic options reviewing the current literature and introduce a novel intrauterine ICG use for laparoscopic niche detection in one case; (3) Results: Most of uterine niche related symptoms and complications can be treated by a minimally invasive approach. Laparoscopic fluorescence guided niche detection is feasible; (4) Conclusions: Hysteroscopic and laparoscopic techniques allow the treatment of uterine niche related symptoms and complications. Intrauterine ICG application during fluorescence guided laparoscopy may allow easy niche detection.

Endometrial Cancer Management in Young Women

Endometrial cancer (EC) rarely develops in young women. Most cases are associated with known risk factors: BMI > 30, history of Polycystic Ovary Syndrome (PCOs), and race differentiation. The molecular EC classification based on The Cancer Genome Atlas Research Network divides these heterogeneous cancers into four types: Polymerase Epsilon Mutation (POLE), Microsatellite Instability (MSI), Copy Number Low (CNL), and Copy Number High (CNH). This division was introduced to allow for early assessment of neoplastic changes and clinical management, including targeted therapies. The basic technique for imaging endometrium changes is transvaginal sonography. Hysteroscopy is the standard for obtaining endometrial material for histological evaluation. The MRI result permits assessment of the extent of EC cancer infiltration. In young women who want to preserve fertility, apart from surgery, conservative management is often implemented after strict selection based on clinical and pathological data. This pharmacological treatment involves the administration of progestogens MPA (medroxyprogesterone acetate) and MA (megestrol acetate). The use of metformin may increase the effectiveness of such treatment. An alternative option is to apply progestogens locally—via the levonorgestrel-releasing intrauterine device. In addition to pharmacological treatment, hysteroscopic resection may be used—part of the uterine muscle adjacent to the pathologically changed endometrium may also undergo resection. An alternative is the administration of estrogen receptor modulators (e.g., SERMs) or aromatase inhibitors, or GnRH agonists.

Postsurgical barrier strategies to avoid the recurrence of intrauterine adhesion formation after hysteroscopic adhesiolysis: a network meta-analysis of randomized controlled trials

OBJECTIVE

To assess the efficacy of mechanical strategies to avoid the recurrence of intrauterine adhesions, to evaluate the impact on subsequent fertility after hysteroscopic adhesiolysis and to rank the available antiadhesive options.

DATA SOURCES

MEDLINE, Scopus, ClinicalTrials.gov, CINAHL, Scielo, EMBASE, PROSPERO, Cochrane Library, conference proceedings, and international controlled trials registries were searched without temporal, geographic, and language restrictions.

STUDY ELIGIBILITY CRITERIA

Randomized trials that analyzed the recurrence, reproductive outcomes, or both in women undergoing hysteroscopic adhesiolysis followed by mechanical prevention of intrauterine adhesions were included. The exclusion criteria included the following: quasi-randomized trials and trials without randomization and studies including patients undergoing hysteroscopic surgery that was different from adhesiolysis.

STUDY APPRAISAL AND SYNTHESIS METHODS

The Preferred Reporting Items for Systematic reviews and Meta-Analyses extension statement for network meta-analyses guidelines were followed. We performed a network meta-analysis based on the random effects model for mixed multiple treatment comparisons to rank the antiadhesive strategies by surface under the cumulative ranking curve area. Quality assessment was performed using the criteria outlined in the Cochrane Handbook for Systematic Reviews of Interventions. The primary outcome was the recurrent presence of intrauterine adhesions.

RESULTS

Eleven studies with data for 1596 women were identified as applicable. A copper intrauterine device together with an intrauterine balloon (surface under the cumulative ranking curve area=46.4%) or with cross-linked hyaluronic acid gel (surface under the cumulative ranking curve area=21.3%) seemed effective in preventing adhesions recurrence. Regarding the fecundity, hyaluronic acid gel demonstrated the highest pregnancy rates (surface under the cumulative ranking curve area=79.8%). The greatest degrees of change in the mean adhesions scores were found with the use of hyaluronic acid gel plus an intrauterine device (surface under the cumulative ranking curve area=38.9%). For postsurgical adhesion severity, hyaluronic acid gel plus intrauterine device (surface under the cumulative ranking curve area=49.9%) followed by intrauterine device alone (surface under the cumulative ranking curve area=30.8%) was ranked the highest. Dried amnion graft (surface under the cumulative ranking curve area=53.8%) and uterine balloon (surface under the cumulative ranking curve area=45%) showed the greatest menstrual pattern improvement.

CONCLUSION

Cross-linked hyaluronic acid gel, with or without insertion of a copper intrauterine device, seems to be the most effective approach. However, the lack of a clear best therapy suggests the need for further studies to draw firm conclusions.

Second look hysteroscopy following hysteroscopic septum resection improves reproductive outcomes in patients undergoing ICSI

The aim of this study was to compare the reproductive outcomes between infertile women who underwent hysteroscopic uterine septum resection and those who required a second look hysteroscopy due to residual septum prior to intracytoplasmic sperm injection (ICSI) cycles with selective single 'Grade A' embryo transfer (ET). All second look hysteroscopies were performed due to partial remnant septum in a control three dimensional transvaginal ultrasonography (3D TVUSG) after the first hysteroscopic resection. Miscarriage and biochemical pregnancy rates were not different between the groups while clinical pregnancy and live birth rates were significantly higher in Group 2 than in Group 1. Second look hysteroscopic metroplasty performed to restore remnant septum significantly improves live birth rate as well as clinical pregnancy rates while it appears not to alleviate abortion and biochemical pregnancy rates in women undergoing ICSI-ET.IMPACT STATEMENTWhat is already known on this subject? The effect of hysteroscopic septum resection on reproductive outcomes in IVF treatment in infertile patients with uterine septum is not clearly known.What do the results of this study add? With the selective single ET strategy, complete or partial hysteroscopic correction of the uterine septum before ICSI and subsequent resection of the residual septum with control hysteroscopy significantly increases the live birth rates in the infertile population.What are the implications of these findings for clinical practice and/or further research? In the group of infertile patients with uterine septum, second control hysteroscopy should be performed 1 month later for residual septum or adhesions after hysteroscopic septum resection performed once.