AAGL Practice Report: Practice Guidelines for the Diagnosis and Management of Endometrial Polyps

Impaired inflammatory state of the endometrium: a multifaceted approach to endometrial inflammation. Current insights and future directions

New insights into the complex and fine-regulated inflammatory mechanisms involved in the endometrium reveal multiple facets to the problem of endometrial inflammation. However, the entity termed chronic endometritis is to date restricted to infectious etiology and managed with antibiotics. Conversely, the concept of impaired inflammatory state of the endometrium (IISE) provides a more global approach to defective endometrial inflammation, considering both infectious and non-infectious etiology. A non-systematic review was done through a search on MEDLINE, EMBASE, Global Health, The Cochrane Library, Health Technology Assessment Database and Web of Science, research registers. Pertinent original and review articles, published in English or French until December 31, 2019, were selected. A compelling body of evidence demonstrates transient, repeated and persistent IISE to be a major factor of most problematic disorders in obstetrics/gynecology, such as endometrial polyps, unexplained infertility, miscarriage, placenta-related pathology and endometrial cancer. When scheduled accordingly, hysteroscopy can play a key role in the IISE assessment. Robust data suggests the pertinence of minimal-effective anti-inflammatory regimens for therapeutic IISE targeting. This review provides a comprehensive update on the multiple facets of inflammation in the endometrial physiology and pathology. Further research is needed to improve classification, diagnosis and treatment of IISE.

An overview of the main intrauterine pathologies in the postmenopausal period

Hysteroscopy is the gold standard for evaluating the uterine cavity, diagnosing intrauterine pathology, and operative intervention for some causes of abnormal uterine bleeding. The American College of Obstetricians and Gynecologists concluded that, when the endometrium measures ≤4 mm with transvaginal ultrasonography, the likelihood that bleeding is secondary to endometrial carcinoma is less than 1% (negative predictive value 99%), and endometrial biopsy is not recommended. Endometrial sampling in this clinical scenario will likely result in insufficient tissue for evaluation and it is reasonable to consider initial management for atrophy. A thickened endometrium on transvaginal ultrasonography (>4 mm in a postmenopausal woman with postmenopausal bleeding) warrants additional evaluation with endometrial sampling. A negative tissue biopsy following 'blind' endometrial sampling in women with postmenopausal bleeding is not considered to be an endpoint, and further evaluation of the endometrial cavity with hysteroscopy to exclude focal disease is imperative.

Endometrial Scratching Effect on Clinical Pregnancy Rates in Patients Undergoing Egg Donor In Vitro Fertilization Cycles: the ENDOSCRATCH Randomized Clinical Trial (NCT03108157)

The potential benefit of endometrial scratching (ES) on embryo implantation is still a controversial subject. At present, the single retrospective study in egg donor IVF cycles concluded that ES has no beneficial effect. Our objective was to determine if there are differences in clinical pregnancy rates (CPR) in egg donor cycles when an ES is performed. This is a randomized controlled trial (RCT) in egg donor IVF patients conducted at ProcreaTec Fertility Center in Madrid. Three hundred fifty-two patients were included in total. One hundred sixty-one patients completed the protocol in group A and 172 patients in group B. Patients allocated to group A received an ES in the luteal phase of the cycle preceding the embryo transfer cycle. Group B patients did not receive any intervention. Primary outcome of this RCT was CPR. Secondary outcomes were implantation (IR), miscarriage (MR), ongoing pregnancy (OPR), multiple pregnancy (MulPR), and live birth rates (LBR). CPR was 104 of 161 (64.6%) in group A and 102 of 172 (59.3%) in group B (RR 1.09, 95% confidence interval (CI) (0.92-1.29); p = 0.378). OPR, MR, MulPR, and LBR were also comparable. No major complications were detected after ES and pregnancy complications were comparable. Our results show that there is no beneficial role of ES in egg donor IVF cycles, considering these patients as the ideal model as they share homogeneous embryo quality and endometrial preparation protocols. This trial was registered on April 5, 2017, as the ENDOSCRATCH trial (NCT03108157).

Prevention of Benign Endometrial Polyp Recurrence Using a Levonorgestrel-releasing Intrauterine System in Premenopausal Patients: A Retrospective Cohort Study

STUDY OBJECTIVE

To evaluate the levonorgestrel-releasing intrauterine system (LNG-IUS) to prevent the recurrence of endometrial polyps (EPs) after hysteroscopic polypectomies in premenopausal female patients.

DESIGN

A retrospective cohort study.

SETTING

A tertiary-care women's hospital.

PATIENTS

A total of 451 premenopausal female patients underwent hysteroscopic polypectomies between January 1, 2016, and December 31, 2017.

INTERVENTIONS

Treatment with LNG-IUS after hysteroscopic polypectomies.

MEASUREMENTS AND MAIN RESULTS

After the hysteroscopic polypectomies and placement of LNG-IUS, transvaginal ultrasounds were performed every 6 months to measure the recurrence of EPs. Overall, 5 (3.47%) of 144 patients in the LNG-IUS cohort and 49 (15.96%) of 307 patients in the control cohort experienced EP recurrence within the follow-up period of up to 3 years. The recurrence exhibited a strongly negative correlation when LNG-IUS was inserted (relative risk, 0.218; 95% confidence interval, 0.089-0.535; p <.05), but this did not significantly correlate with age, polyp size, number of polyps, previous history of polypectomy, and abnormal uterine bleeding. For the LNG-IUS and control cohorts, the recurrence in the first postoperative year was 1.39% and 6.19%, respectively, and 5.41% and 19.23% in the second postoperative year, respectively.

CONCLUSION

LNG-IUS reduces the recurrence of postoperative EPs in premenopausal patients.

Office hysteroscopy in the management of women with postmenopausal bleeding

Postmenopausal bleeding (PMB) is a relevant aspect for health-care providers in clinical practice: the first objective is to rule out potential gynecological cancer. The purpose of this narrative review is to evaluate the role of office hysteroscopy in the management of PMB. Office hysteroscopy is a minimally invasive procedure allowing direct visualization of uterine pathology without the need for general anesthesia and the use of an operating room, generating cost savings and greater compliance among patients. Here, we focus on major intrauterine diseases (polyps, submucosal myomas, endometrial hyperplasia, and cancer) as causes of PMB. Office hysteroscopy appears to be safe and feasible, and could allow accurate diagnosis of intrauterine pathologies, especially that with a focal growth pattern, otherwise misdiagnosed with blinded procedures. However, studies focusing exclusively on postmenopausal women are still few, so further research, especially randomized controlled trials, is needed.

Uterine Factor Infertility: A Clinical Review

Uterine factor infertility (UFI) may affect up to 1 in 500 reproductive age women. The uterus is an essential component of achieving pregnancy and carrying a pregnancy to term successfully. There are many etiologies of UFI which may be categorized into either congenital or acquired causes. In this review, we discuss the different causes of UFI as well as the treatment options, which now includes uterine transplant.

Do endometrial lesions require removal? A retrospective study

BACKGROUND

This study aimed to evaluate the management of asymptomatic intrauterine lesions detected by ultrasonography.

METHODS

Patients who underwent diagnostic hysteroscopy for asymptomatic lesions, including pre- and post-menopausal endometrial polyps, post-menopausal endometrial thickening (ET ≥5 mm) and reduplicative endometrial heterogeneity detected by transvaginal ultrasonography (TVUS), were recruited for this study.

RESULTS

In the 792 recruited patients, the symptom-free focal masses within the uterine cavity detected by TVUS included 558 patients with pre- or post-menopausal endometrial polyps and 234 patients with postmenopausal endometrial thickening. No pre-menopausal patient presented with carcinoma. The polyp diameter (PD) was not identified as an independent risk factor for malignancy in this study. A significant difference (P = 0.036, < 0.05) in both benign and malignant endometrial lesions was observed between two groups of post-menopausal women stratified using an endometrial thickness cut-off of ≥11 mm. The TVUS was highly sensitive (94%) for pre-menopausal polyps. This technique had a specificity and positive predictive value of 84.4 and 92.7%, respectively, for postmenopausal polyps. The TVUS was clearly valuable for ruling out polyps, as indicated by a negative likelihood ratio (LR-) of 0.087. Among postmenopausal women with endometrial thickening, the area under the receiver operating characteristic curve was 0.828 (P < 0.001). An ET cut-off value of 12.5 mm yielded a sensitivity of 72.7% and specificity of 86%.

CONCLUSION

We recommend follow-up alone for women with asymptomatic uterine polyps, particularly those who are pre-menopausal. Additionally, gynaecologists should consider risk factors such as age, obesity, polycystic ovarian syndrome, and diabetes. Prospective long-term follow-up studies should be conducted after hysteroscopic polypectomy to evaluate the recurrence rate of endometrial lesions.

Three-dimensional 3D ultrasound combined with power Doppler for the differential diagnosis of endometrial lesions among infertile women

OBJECTIVE

To assess three-dimensional (3D) ultrasound combined with power Doppler (PD) for the differential diagnosis of endometrial lesions among infertile women.

METHODS

A prospective study carried out at a reproductive medicine center in Luoyang, China, between January and December 2015. The inclusion criteria were asymptomatic infertility with normal endometrium or specific endometrial lesions. Participants were subdivided by whether they had normal endometrium (group 1, n=357), or endometrial lesions including polyps, hyperplasia, intrauterine adhesions, or endometritis (group 2, n=99). 3D PD and hysteroscopy were performed in the follicular phase. Endometrial thickness, volume, vascularization index (VI), flow index (FI), and vascularization flow index (VFI), and subendometrial VI, FI, and VFI were calculated. Endometrial lesions were confirmed by pathologic analysis.

RESULTS

The overall prevalence of endometrial lesions was 99/456 (21.3%). Endometrial thickness and volume were significantly larger in group 2 than in group 1 (9.96 ± 3.24 vs 8.15 ± 2.50 mm and 3.70 ± 2.54 vs 2.42 ± 1.64 cm³ , respectively; both P<0.001). Endometrial thickness and volume were larger among women with endometrial polyps and hyperplasia; endometrial VI, FI, and VFI were lower among women with intrauterine adhesions.

CONCLUSION

Three-dimensional PD has value for the differential diagnosis of endometrial lesions among infertile women.

CLINICAL TRIAL REGISTRATION

The trial is registered in the Chinese Clinical Trial Registry as ChiCTR1800015799.

Acupuncture for uterine fibroids: Protocol for a systematic review of randomized controlled trials

BACKGROUND

Uterine fibroids represent the most common gynecological benign tumors in reproductive females. Acupuncture has been applied as a therapeutic modality in China to treat uterine fibroids. However, currently, few critical systematic reviews regarding the effect of acupuncture on uterine fibroids have been published. Our proposed review aims to evaluate the current evidence on the efficacy of acupuncture for uterine fibroids.

METHODS

A total of 7 databases were searched from their inception to December 2018, including PubMed, Medline, Embase, the Cochrane Central Register of Controlled Trials, the Chinese National Knowledge Infrastructure database, the Chinese Biomedical database, and the Wanfang database. The primary outcomes will be reduction in uterine volume and number of fibroids. Secondary outcomes are pelvic or low-back pain, assessed by Visual Analog Scale (VAS); Irregular menstrual periods; Low-abdominal pressure symptoms such as frequent or urgent urination, or constipation and adverse events. Data synthesis will be computed by RevManV.5.3.5 software when a data-analysis is allowed. Methodological quality will be evaluated with the risk of bias according to Cochrane Handbook.

RESULTS

This study will provide high-quality evidence of acupuncture for uterine fibroids.

CONCLUSION

The conclusion of this systematic review will provide evidence to judge whether acupuncture is an effective therapeutic intervention for patients with uterine fibroids.

TRIAL REGISTRATION NUMBER

PROSPERO CRD42019120484.

Identifying the superior surgical procedure for endometrial polypectomy: A network meta-analysis

OBJECTIVE

To identify the superior surgical procedure for endometrial polypectomy based on network meta-analysis.

METHOD

Literature retrieval was conducted in globally recognized databases, namely, MEDLINE, EMBASE and Cochrane Central, to address relative randomized controlled trials (RCTs) investigating the clinical effects of respective surgical procedure for endometrial polypectomy. Surgical parametric data, including operative time, success rates and complications, were quantitatively pooled and estimated based on the Bayesian theorem. The values of surface under the cumulative ranking (SUCRA) probabilities regarding each parameter were calculated and ranked by various procedures. Node-splitting analysis was performed to test the inconsistency of the main results and publication bias was assessed by examining funnel-plot symmetry.

RESULTS

After a detailed review, 8 RCTs containing 5 different procedures were finally included for network meta-analysis. The results indicated that hysteroscopic morcellation possessed the highest possibility of revealing best clinical effects on operative time (SUCRA, 0.49), success rate (SUCRA, 0.90) and complications (SUCRA, 0.50). Moreover, node-splitting analysis and funnel-plot symmetries illustrated no inconsistency or obvious publication bias in the current study.

CONCLUSIONS

Current evidence demonstrated that hysteroscopic morcellation showed optimal potential superior clinical effects for endometrial polypectomy compared to other procedures. However, high-quality large sample trials are still expected, and new investigations on other relative procedures in this field should be included in the future.

Office treatment of large endometrial polyps using truclear 5C: Feasibility and acceptability

AIM

This retrospective multicenter study was carried out to evaluate feasibility, effectiveness and patient acceptability of a small diameter hysteroscopic tissue removal system in the treatment of large endometrial polyps (≥20 mm), usually not removed in an office setting.

METHODS

Hundred and forty-six women with a single greater than 10-mm diameter polyp considered for polypectomy between April 2016 and August 2017. Sixty-five of these patients had a polyp size greater than 20 mm. All hysteroscopic polypectomy, using Hysteroscopic Tissue Removal system (TruClear 5C System Medtronic), were performed in an office setting with vaginoscopic approach.

RESULTS

Procedural success, time to complete the polypectomy and patient pain scores were evaluated. Polyps less than 20 mm were completely removed in 79/81 cases (97.53%). The completeness of greater than or equal to 20-mm polyp removal was achieved in 63/65 cases (96.92%). The median time for polypectomy was 4.19 ± 1.03 min for polyps less than 20 mm and 4.97 ± 1.30 min for polyps greater than or equal to 20 mm, respectively. Pain was minimal and brief, and the mean pain score measured on a 10-point visual analog scale at the end of polypectomy showed no significant difference between the two groups. In 4/79 (5.06%) cases with polyps less than 20 mm and in 4/63 (6.35%) cases with polyps greater than or equal to 20 mm women reported moderate pain. All specimens were adequate for pathologic measurements.

CONCLUSION

Hysteroscopic treatment of polyps greater than or equal to 20 mm in size with TruClear 5C is feasible and well tolerated in an office setting with no significant difference regarding completeness compared to polyps less than 20 mm, but with a minimal increase in procedure times.

Hysteroscopic Endometrial Polypectomy with Manual Vacuum Aspiration Compared to Mechanical Morcellation

STUDY OBJECTIVE

To examine the effectiveness of hysteroscopy plus manual vacuum aspiration (MVA) for endometrial polypectomy compared with hysteroscopic morcellation.

DESIGN

Retrospective cohort study (Canadian Task Force classification II-2).

SETTING

Duke University Medical Center database.

PATIENTS

Women who underwent hysteroscopic removal of endometrial polyps performed by Duke Fertility Center faculty physicians between January 1, 2015, and January 29, 2018, using either hysteroscopy plus MVA or hysteroscopic morcellation.

INTERVENTIONS

The 2 groups were compared using the χ² or Fisher's exact test, Student's t test, and multivariable regression analysis.

MEASUREMENTS AND MAIN RESULTS

The primary outcome was the duration of the procedure. Secondary outcomes were fluid deficit, rate of complete polyp resection, estimated blood loss, and operative complications. A total of 102 women undergoing endometrial polypectomy were identified. Patients in whom polyps were removed using only a hysteroscopic grasper and/or scissors (n = 31); patients who underwent an additional simultaneous procedure, such as laparoscopy (n = 12); and patients in whom the duration of the procedure was not recorded (n = 2) were excluded. Among the remaining 57 patients, 28 underwent hysteroscopy plus MVA and 29 underwent hysteroscopic morcellation. The mean duration of procedure was longer for hysteroscopic morcellation compared with hysteroscopy plus MVA (32 ± 10 minutes vs 20 ± 6 minutes; p = .04), and this difference remained significant after adjusting for age, body mass index, surgeon, and number and size of polyps. Mean fluid deficit was greater for morcellation than for hysteroscopy plus MVA (277 ± 204 mL vs 51 ± 97 mL; p < .001). Complete polyp resection was possible in all patients; however, the use of a hysteroscopic scissors and grasper was required for 1 patient in the MVA group. Estimated blood loss was minimal in all cases, and there were no operative complications.

CONCLUSION

Hysteroscopy plus MVA is an effective method for removing large or multiple endometrial polyps, with outcomes comparable to hysteroscopic morcellation.

Usefulness of Cryoprobe in Office Hysteroscopy for Removal of Polyps and Myomas

Hysteroscopy is a gold standard in 21^st-century gynaecology for both diagnosis and treatment procedures of intrauterine pathologies. Miniaturisation of the equipment and better techniques of performing this procedure allowed it to become the gold standard. Nevertheless, hysteroscopy has its limitations, which is the size of the endometrial polyps or submucous myomas. We have invented a new device for the 5Fr working channel hysteroscopes for possessing and resecting intrauterine structures: the cryoprobe. The retrospective cryobiopsy study presented here was conducted at the Department of Gynaecology and Oncological Gynaecology, Military Institute of Medicine in Warsaw, Poland, from October 2017 to January 2018. Its purpose was to assess the usefulness of the new device in office hysteroscopy for the removal of polyps and myomas with a diameter over 10 mm. Thirteen patients with an initial diagnosis of an endometrial polyp or submucous myoma were enrolled in the trial. All procedures took place in day-surgery settings, with a total resection of the pathological intrauterine structure, without complications. The application of the cryoprobe may enhance the usefulness of office hysteroscopy, without extending the procedure. The cryoprobe efficiency is still under research in a bigger group.

Incidence of intrauterine abnormalities in Pakistani women with unexplained infertility diagnosed via saline infusion sonography

To determine the frequency of intrauterine abnormalities in women with unexplained infertility using saline infusion sonography. This was a retrospective cohort study conducted at Aziz medical centre, Karachi, Pakistan between January and December 2015. The study population comprised of women with unexplained infertility who underwent saline infusion sonography as a part of their diagnostic workup. The frequency of uterine abnormalities in these women was determined and the relationship between these pathologies and patient age and body mass index was assessed. Of the 769 women included, 202 (26.3%) had uterine abnormalities. Endometrial polyp (118 cases, 15.3%) was the most common abnormality, followed by submucous fibroids (54, 7%), intrauterine adhesions (20, 2.6%), and septae (10, 5%). Intrauterine pathologies were more common in women with primary infertility (71.8% versus 28.2%, p = 0.002). Uterine abnormalities were most common in the age group 30-34 years ( n = 80, 39.6%) and in overweight patients ( n = 95, 47%). The distribution of abnormalities differed significantly in various age groups ( p = 0.009) and among women with different BMI ( p = 0.029). A significant number of women with unexplained infertility present with unsuspected uterine abnormalities; therefore an assessment of the uterine cavity should be performed in all cases.

Immunohistochemical expression of hormone receptors, Ki-67, endoglin (CD105), claudins 3 and 4, MMP-2 and -9 in endometrial polyps and endometrial cancer type I

Objective

The aim of this study was to investigate the malignant potential of endometrial polyps (EP) by assessing the immunoexpressions of both estrogen receptor (ER) and progesterone receptor (PR), Ki-67 cell proliferation index, neovascularization network (endoglin – CD105), cellular adhesion molecules (claudins 3 and 4), and extracellular matrix proteins (MMP-2 and -9) in both EP and endometrioid adenocarcinoma (type I) in comparison with the normal endometrium.

Study design

This is a cross-sectional comparative study. Patients were identified from the database of Botucatu Medical School, São Paulo State University (BMS-UNESP) Clinical Pathology Laboratory.

Setting

The study was conducted using a convenience sample of patients attending the Sectors of Gynecologic Endoscopy and Family Planning and Gynecologic Oncology of the Department of Gynecology and Obstetrics of BMS-UNESP, Brazil.

Patients

A total of 90 women were allocated into the following three groups: EP without atypia (EP, n=30), endometrioid endometrial cancer (EC, n=30), and normal endometrium (control, n=30).

Methods

Epidemiological and clinical data were obtained by reviewing medical records. Adenocarcinoma and control cases were assessed using the tissue microarray technique. The immunoexpressions of ER, PR, Ki-67, CD105, claudins 3 and 4, and MMP-2 and -9 were assessed in paraffin blocks containing sections of the largest polyploid lesion fragment and tissue microarray recipient blocks.

Major results

Compared to the control group, significant differences in the expression of ER (P<0.001), PR (P<0.05), Ki-67 (P<0.001), CD105 (P<0.001), and claudin 3 (P<0.001) were observed in EP and EC. No significant differences were found between EP and EC (P≥0.05). MMP-2 and -9 expression were nearly absent in all groups.

Conclusion

The malignant potential of EP could not be determined through the immunohistochemical parameters used in this study. No MMP-2 or -9 expression was observed in any endometrial tissue sample. Further studies are necessary for a better understanding of the biomolecular mechanisms underlying endometrial carcinogenesis.

Resectoscopic Surgery for Polyps and Myomas: A Review of the Literature

Resectoscopic surgery is routinely performed to remove endometrial polyps and uterine myomas. A search of Medline, PubMed, and the Cochrane Library was conducted through November 2016 for studies written in English, regardless of sample size or study type. The studies were then filtered by selecting those evaluating resectoscopic surgery. An analysis of peer-reviewed, published literature was performed to examine the clinical application of this treatment modality on patients requiring polypectomy and myomectomy. Different surgical techniques were also compared: hysteroscopy with scissors, forceps, or a cold loop; resectoscopy with radiofrequency energy; and mechanical resection. The literature finds that operative time during resectoscopic surgery is significantly longer than with mechanical resection. Resectoscopic myomectomy, however, may be necessary for removal of larger or more deeply embedded myomas. Ultimately, both techniques result in symptom resolution and a low recurrence rate.

Office Operative Hysteroscopy: An Update

Hysteroscopy is considered the gold standard for the evaluation of intracavitary pathology in both premenopausal and postmenopausal patients associated with abnormal uterine bleeding, as well as for the evaluation of infertile patients with suspected cavity abnormalities. Office-based operative hysteroscopy allows patients to resume activities immediately and successfully integrates clinical practice into a "see and treat" modality, avoiding the added risks of anesthesia and the inconvenience of the operating room. For 2017, the Centers for Medicare and Medicaid Services has provided a substantial increase in reimbursement for a select number of office-based hysteroscopic procedures. This review provides an update on the indications, equipment, and procedures for office hysteroscopy, as well as the management of complications that may arise within an office-based practice.

Diagnostic Office Vaginohysteroscopy in Evaluation of Infertility Prior to IVF: A Retrospective Analysis of 1000 Cases

AIM

The aim of this study was to analyze the utility of routine use of diagnostic office vaginohysteroscopy in the evaluation of uterine cavity in infertility patients prior to IVF-ET.

MATERIALS AND METHODS

We conducted a retrospective analysis of 1000 women who had undergone routine diagnostic office vaginohysteroscopy as an institutional protocol in the evaluation of infertility prior to IVF-ET cycle at a tertiary care hospital. They were divided into two groups: primary infertility (group I) and secondary infertility (group II). The primary outcome was the finding of an abnormal uterine cavity (congenital abnormality vs acquired abnormality).

RESULTS

One thousand women underwent routine diagnostic office vaginohysteroscopy in the evaluation of infertility prior to IVF-ET. There were no intraoperative or postoperative complications. Vaginohysteroscopy revealed an abnormal uterine cavity in 13.8% (1000 patients) of women. Primary infertility group (I) had 13.19% (811 patients), and secondary infertility group (II) had 16.4% (189 patients) abnormal uterine cavities.

CONCLUSION

Diagnostic office vaginohysteroscopy has a definite role in the uterine cavity evaluation in infertility patients prior to IVF, but routine use should not be recommended considering the low incidence of abnormal uterine cavity findings. Moreover, the majority of these uterine cavity abnormalities can be detected by less invasive tests such as HSG, TVS, SSG and 3D ultrasound.

Management of endometrial polyps incidentally diagnosed during IVF: a case-control study

An endometrial polyp is a frequently encountered abnormality of the uterine cavity that may interfere with normal embryo implantation. In this case-control study, we enrolled 56 women in whom endometrial polyps were incidentally diagnosed by transvaginal ultrasound and office hysteroscopy during IVF (Group 1), and 112 age-matched IVF controls randomly selected from the same time period (group 2). Cryopreserved embryos were transferred in group 1 whereas fresh embryos were transferred in group 2, which is a limitation of the study. Hysteroscopic polypectomy was carried out for those in group 1, followed by vitrified-warmed embryo transfer 1-7 months later. Results revealed that the clinical pregnancy rate was higher in group 1 than in group 2 (63% versus 41%, P = 0.009), but the embryo implantation rates were not different between the two groups (26% versus 20%). In group 1, pregnancy rates (64%, 69%, and 53% respectively) and embryo implantation rates (30%, 24%, and 23%, respectively) were similar among women that received vitrified-warmed embryo transfer at 1, 2, and 3 months or over after hysteroscopic polypectomy. We conclude that, for women with endometrial polyps incidentally diagnosed during IVF, pregnancy outcomes are not compromised after hysteroscopic polypectomy followed by vitrified-warmed embryo transfer.

A Prospective Multicenter Registry of Patients Undergoing Hysteroscopic Morcellation of Uterine Polyps and Myomas

Background: Hysteroscopic morcellation removes uterine pathology under direct visualization with continuous real-time tissue fragment removal. Objective: The aim of this study was to explore the feasibility of hysteroscopic morcellation across a diverse set of facilities, including both surgical and office-based settings. Design: This was a prospective, single-arm, multicenter registry development (Canadian Task Force classification II-3). Materials and Methods: Thirty-four U.S. obstetrics and gynecology facilities enrolled subjects into the registry. Inclusion criteria were women ages 18–65 with indications for hysteroscopic myomectomy and/or polypectomy who were treated with the MyoSure® Hysteroscopic Tissue Removal System (Hologic Inc., Marlborough, MA). Intrauterine lesion type/size and removal parameters, adverse events (AEs), and physician satisfaction ratings were recorded. Results: A total of 559 pathologies (187 fibroids; 372 polyps) were removed from 278 registered subjects (mean age: 43.9 ± 9.0 years), with 250 procedures (89.9%) performed in an ambulatory surgery center or hospital outpatient setting and 28 (10.1%) in a gynecologic office setting. Most patients (n = 206, 74.1%) were treated for abnormal uterine bleeding, and 42 (15.1%) were treated for infertility. Mean fibroid diameter was 2.2 ± 1.2 cm. Mean polyp diameter was 1.3 ± 1.0 cm. Overall mean percentage of pathology removed was 95.4% (polyps 99.3%, fibroids 86.8%). Five AEs included four incidents of blunt cervical trauma and a single postoperative case of pedal edema; all were considered mild and resolved spontaneously. Postprocedure surveys indicated that 95% of reporting physicians were “satisfied” or “highly satisfied” with device performance. Conclusions: Hysteroscopic morcellation of intrauterine pathology was accomplished safely with a high degree of physician satisfaction in 278 patients treated in diverse healthcare settings that are reflective of general community practice in the United States. (J GYNECOL SURG 32:318)

Structured imaging technique in the gynecologic office for the diagnosis of abnormal uterine bleeding

The aim in the diagnosis of abnormal uterine bleeding (AUB) is to identify the bleeding cause, which can be classified by the PALM-COEIN (Polyp, Adenomyosis, Leiomyoma, Malignancy (and hyperplasia), Coagulopathy, Ovulatory disorders, Endometrial, Iatrogenic and Not otherwise classified) classification system. In a gynecologic setting, the first step is most often to identify structural abnormalities (PALM causes). Common diagnostic options for the identification of the PALM include ultrasonography, endometrial sampling, and hysteroscopy. These options alone or in combination are sufficient for the diagnosis of most women with AUB. Contrast sonography with saline or gel infusion, three-dimensional ultrasonography, and magnetic resonance imaging may be included.

AIM

The aim of this article is to describe how a simple structured transvaginal ultrasound can be performed and implemented in the common gynecologic practice to simplify the diagnosis of AUB and determine when additional invasive investigations are required. Structured transvaginal ultrasound for the identification of the most common endometrial and myometrial abnormalities and the most common ultrasound features are described. Moreover, situations where magnetic resonance imaging may be included are described. This article proposes a diagnostic setup in premenopausal women for the classification of AUB according to the PALM-COEIN system. Moreover, a future diagnostic setup for fast-track identification of endometrial cancer in postmenopausal women based on a structured evaluation of the endometrium is described.

The value of hysteroscopic biopsy in the diagnosis of endometrial polyps

Several studies have demonstrated that the combination of hysteroscopy with endometrial biopsy is more accurate in differentiating endometrial polyps from endometrial hyperplasia and cancer. However, blind biopsy not always confirms hysteroscopic findings due to high rates of inadequate or insufficient material. The objective of this clinical, prospective, and comparative study was to establish a correlation between the histological results of office-based endometrial biopsies (hysteroscopically guided and blind) with the surgical polypectomy specimens. We evaluated 82 patients with hysteroscopic diagnosis of endometrial polyp, who randomly underwent hysteroscopically guided biopsy or blind biopsy, referred for surgical resection. A total of 36 women (43.9%) underwent hysteroscopically guided biopsy and 46 women (56.1%) underwent blind biopsy. The sensitivity of hysteroscopically guided biopsy for the diagnosis of endometrial polyps ranged between 35.3 and 36.8%, when carried out at the apex and base of the lesion, compared with 29.2% for blind biopsy. Specificity was 33.3, 50, and 60%, respectively, for each biopsy. The positive predictive values were 75, 77.8, and 87.5%, and negative predictive values were 8.3, 14.3, and 8.1% respectively, compared with surgical polypectomy specimens. The office-based endometrial biopsies had low diagnostic accuracy for endometrial polyps compared with surgical polypectomy specimens.

Clinical Study of Endometrial Polyp and Role of Diagnostic Hysteroscopy and Blind Avulsion of Polyp

INTRODUCTION

Endometrial polyp is one of the common causes of Abnormal Uterine Bleeding (AUB) in the reproductive age group as well as postmenopausal age group.

AIM

To study the clinical features of endometrial polyp and the safety and feasibility of blind polypectomy following diagnostic hysteroscopy.

MATERIALS AND METHODS

Total of 256 women who were diagnosed to have endometrial polyp by transvaginal ultrasound and underwent diagnostic hysteroscopy and blind polypectomy by simple avulsion in the period of January 2008 to December 2014 were included in our study. Polyp was confirmed by the histopathology.

RESULTS

The prevalence of polyp among women who underwent diagnostic hysteroscopy and blind polypectomy was more common in the age group of 40-49years. Polyps manifested as AUB in 45.6% of our study population. The mean size of the polyp was not significantly different between premenopausal and postmenopausal women and single and multiple polyps. Histopathological study of the polyp showed two malignant polyps in our study population. Premalignant lesions i.e., endometrial hyperplasia without atypia and with atypia was found in 33 women. There was one uterine perforation, one cervical tear; one false passage and one patient had mild bleeding after the procedure. In our study, in the mean follow-up period of 37.57±28.12 months, 3.9% (7 women) had recurrence. In the follow-up period of 16.56±18.96 months, 78.9% women didn't have recurrence.

CONCLUSION

Diagnostic hysteroscopy and blind polypectomy has low complication rate and recurrence rate and technically feasible for the practicing gynaecologists which don't need much training and is cost-effective also.

A randomised controlled trial of Outpatient versus inpatient Polyp Treatment (OPT) for abnormal uterine bleeding

BACKGROUND

Uterine polyps cause abnormal bleeding in women and conventional practice is to remove them in hospital under general anaesthetic. Advances in technology make it possible to perform polypectomy in an outpatient setting, yet evidence of effectiveness is limited.

OBJECTIVES

To test the hypothesis that in women with abnormal uterine bleeding (AUB) associated with benign uterine polyp(s), outpatient polyp treatment achieved as good, or no more than 25% worse, alleviation of bleeding symptoms at 6 months compared with standard inpatient treatment. The hypothesis that response to uterine polyp treatment differed according to the pattern of AUB, menopausal status and longer-term follow-up was tested. The cost-effectiveness and acceptability of outpatient polypectomy was examined.

DESIGN

A multicentre, non-inferiority, randomised controlled trial, incorporating a cost-effectiveness analysis and supplemented by a parallel patient preference study. Patient acceptability was evaluated by interview in a qualitative study.

SETTING

Outpatient hysteroscopy clinics and inpatient gynaecology departments within UK NHS hospitals.

PARTICIPANTS

Women with AUB - defined as heavy menstrual bleeding (formerly known as menorrhagia) (HMB), intermenstrual bleeding or postmenopausal bleeding - and hysteroscopically diagnosed uterine polyps.

INTERVENTIONS

We randomly assigned 507 women, using a minimisation algorithm, to outpatient polypectomy compared with conventional inpatient polypectomy as a day case in hospital under general anaesthesia.

MAIN OUTCOME MEASURES

The primary outcome was successful treatment at 6 months, determined by the woman's assessment of her bleeding. Secondary outcomes included quality of life, procedure feasibility, acceptability and cost per quality-adjusted life-year (QALY) gained.

RESULTS

At 6 months, 73% (166/228) of women who underwent outpatient polypectomy were successfully treated compared with 80% (168/211) following inpatient polypectomy [relative risk (RR) 0.91, 95% confidence interval (CI) 0.82 to 1.02]. The lower end of the CIs showed that outpatient polypectomy was at most 18% worse, in relative terms, than inpatient treatment, within the 25% margin of non-inferiority set at the outset of the study. By 1 and 2 years the corresponding proportions were similar producing RRs close to unity. There was no evidence that the treatment effect differed according to any of the predefined subgroups when treatments by variable interaction parameters were examined. Failure to completely remove polyps was higher (19% vs. 7%; RR 2.5, 95% CI 1.5 to 4.1) with outpatient polypectomy. Procedure acceptability was reduced with outpatient compared with inpatient polyp treatment (83% vs. 92%; RR 0.90, 95% CI 0.84 to 0.97). There were no significant differences in quality of life. The incremental cost-effectiveness ratios at 6 and 12 months for inpatient treatment were £1,099,167 and £668,800 per additional QALY, respectively.

CONCLUSIONS

When treating women with AUB associated with uterine polyps, outpatient polypectomy was non-inferior to inpatient polypectomy at 6 and 12 months, and relatively cost-effective. However, patients need to be aware that failure to remove a polyp is more likely with outpatient polypectomy and procedure acceptability lower.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN 65868569.

FUNDING

This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 19, No. 61. See the NIHR Journals Library website for further project information.

Antibiotic Prophylaxis for Gynecologic Procedures prior to and during the Utilization of Assisted Reproductive Technologies: A Systematic Review

The use of assisted reproductive technologies (ART) has increased steadily. There has been a corresponding increase in the number of ART-related procedures such as hysterosalpingography (HSG), saline infusion sonography (SIS), hysteroscopy, laparoscopy, oocyte retrieval, and embryo transfer (ET). While performing these procedures, the abdomen, upper vagina, and endocervix are breached, leading to the possibility of seeding pelvic structures with microorganisms. Antibiotic prophylaxis is therefore important to prevent or treat any procedure-related infections. After careful review of the published literature, it is evident that routine antibiotic prophylaxis is generally not recommended for the majority of ART-related procedures. For transcervical procedures such as HSG, SIS, hysteroscopy, ET, and chromotubation, patients at risk for pelvic infections should be screened and treated prior to the procedure. Patients with a history of pelvic inflammatory disease (PID) or dilated fallopian tubes are at high risk for postprocedural infections and should be given antibiotic prophylaxis during procedures such as HSG, SIS, or chromotubation. Antibiotic prophylaxis is recommended prior to oocyte retrieval in patients with a history of endometriosis, PID, ruptured appendicitis, or multiple prior pelvic surgeries.

Diagnostic methods for fast-track identification of endometrial cancer in women with postmenopausal bleeding and endometrial thickness greater than 5 mm

OBJECTIVE

This study aims to evaluate the diagnostic efficiency of pattern recognition by transvaginal ultrasonography (TVS) and gel infusion sonography (GIS) for identifying endometrial pathology and to compare this setup with a standard setup of endometrial sampling (ES), hysteroscopy with pattern evaluation (HY(pattern)), or magnetic resonance imaging (MRI).

METHODS

This study used a prospective cohort of 174 women with postmenopausal bleeding and endometrial thickness of 5 mm or greater. Resectoscopic biopsy (hysteroscopy with biopsy) samples or hysterectomy served as reference standard. Malignant and benign endometrial patterns were evaluated with TVS, GIS and HY(pattern) were then added. The efficiency of each diagnostic strategy, including ES and MRI findings (n = 83), was compared and evaluated against the reference standard.

RESULTS

ES, TVS, GIS, and HY(pattern) had high diagnostic efficiency (area under the curve) for malignancy diagnosis (ES, 0.90; TVS, 0.88; GIS, 0.92; HY(pattern), 0.91). When insufficient samples were incorporated, ES was less efficient than the other techniques. ES was not more efficient in the subgroup of women without localized lesions than in the subgroup of women with localized lesions. MRI and HY(pattern) added limited efficiency, whereas hysteroscopy with biopsy was most efficient.

CONCLUSIONS

As a first-line technique, pattern recognition on TVS, GIS, and HY(pattern) correctly identifies 9 of 10 women with malignancy and is superior to pattern recognition on ES when insufficient samples are included. Endometrial pattern evaluated with TVS and GIS is a fast and efficient first-line diagnostic tool that outperforms ES in women with or without localized lesions. Malignant patterns on TVS/GIS should warrant fast-track evaluation, whereas women with benign patterns may be selected for office or operative hysteroscopy. A fast-track diagnostic setup based on pattern recognition is presented.