Successful Pregnancy After Thermal Balloon Endometrial Ablation

Endometrial ablation: postoperative complications

Endometrial ablation as a treatment for abnormal uterine bleeding has evolved considerably over the past several decades. Postoperative complications include the following: (1) pregnancy after endometrial ablation; (2) pain-related obstructed menses (hematometra, postablation tubal sterilization syndrome); (3) failure to control menses (repeat ablation, hysterectomy); (4) risk from preexisting conditions (endometrial neoplasia, cesarean section); and (5) infection. Physicians performing endometrial ablation should be aware of postoperative complications and be able to diagnose and provide treatment for these conditions.

Treatment with methotrexate of a cornual pregnancy following endometrial resection

OBJECTIVES

Endometrial resection is a procedure often performed for treatment of menorrhagia. Despite the fact that amenorrhoea frequently ensues, some normal endometrium can remain present and become the implantation site of a pregnancy. Such an event is uncommon (0.7%); however, the likelihood of an ectopic pregnancy is increased. This case report calls the reader's attention to the risk of intra- and extrauterine pregnancies and the necessity for contraception after endometrial resection, even in cases where amenorrhoea supervenes.

CASE

A 46-year-old woman with prior endometrial resection and subsequent amenorrhoea, was diagnosed with a cornual pregnancy. She was successfully treated with systemic methotrexate, which was given in an outpatient clinic.

CONCLUSION

Clinicians should be aware of the increased likelihood of an ectopic pregnancy after endometrial resection. All women submitting to this procedure should be counselled about the need for contraception, even in cases where amenorrhoea develops.

Pregnancy following endometrial ablation: a review article

This review summarises the 70 pregnancies reported following endometrial ablation by various techniques, including a those in a case report from the authors' own experience. Thirty-one viable pregnancies resulted, with a high proportion of complications. These included a perinatal mortality rate of 12.9% (4 cases), and an overall prematurity rate of 42%, which reduced to 31% after excluding iatrogenic deliveries performed for other complications. Eight (26%) cases had a morbidly adherent placenta and a further two cases required a manual removal of placenta. Seven (39%) of the term births were reported as having malpresentations and 71% of the total births were by caesarean section. The complications are discussed and a comparison is made with Asherman's Syndrome. In addition, the various factors that may be relevant to fertility after endometrial ablation are discussed.

Thermal balloon endometrial ablation: a systematic review

OBJECTIVE

The aim of our study is to review the role of thermal balloon endometrial ablation (TBEA) as an alternative in treating abnormal uterine bleeding.

METHODS

Articles relevant to our review and relevant references from the initially identified articles on the field that were archived by May 2007, were retrieved from Pubmed.

RESULTS

Success rates ranged from 83 up to 94%, with patient's satisfaction ranging from 57 up to 94%. Persisted menorrhagia could reach 17% in some studies.

CONCLUSION

TBEA is an effective alternative method used in the treatment of menorrhagea which results in a significant reduction in menstrual bleeding and high satisfaction rates. However, a longer follow-up is required to determine the role of such a treatment.

The occurrence and outcome of 39 pregnancies after 1621 cases of transcervical resection of endometrium

BACKGROUND

To evaluate the outcomes and management of pregnancy after transcervical resection of the endometrium (TCRE).

METHODS

Retrospective study of 39 pregnancies after 1621 procedures of TCRE.

RESULTS

Among 1621 women who were successfully followed up after TCRE, there were 39 pregnancies in 32 women, including five ectopic pregnancies (12.8%) and 34 intrauterine pregnancies (87.2%). The majority of pregnancies (84.6%) occurred within the first 2 years. In the first year after TCRE, the incidence of pregnancy was 1.5%. In women who had amenorrhoea after TCRE, the chances of conception (2/676; 0.3%) were significantly (P < 0.001) lower than for those who continued to have period (30/945; 3.2%). Thirty-two cases with intrauterine pregnancy were terminated under ultrasound guidance with two difficult procedures. Only one pregnancy in our study resulted in spontaneous miscarriage which was managed by suction curettage. One term pregnancy had placenta increta resulting in Caesarean hysterectomy.

CONCLUSIONS

Pregnancies after TCRE are associated with increased risk, and clinicians should be aware of the various complications of pregnancy that may occur after TCRE, including an increased risk of ectopic pregnancy. Surgical termination of pregnancy after TCRE is potentially a difficult procedure and should be carried out under ultrasound guidance.

Cost-effectiveness of treatments for dysfunctional uterine bleeding in women who need contraception

OBJECTIVE

This study aims to compare the cost-effectiveness of oral contraceptives (OCs), the levonorgestrel-releasing intrauterine system (LNG-IUS) and surgical management in treating dysfunctional uterine bleeding (DUB) in women not desiring additional children.

METHOD

A Markov model was constructed from the perspective of the health services payers for a 5-year period. Treatment costs, DUB treatment success rates and contraception success rates were obtained through a literature review.

RESULTS

In women not responding to an initial trial of OCs, surgical management was more effective than the LNG-IUS (95.5% vs. 92%) but at higher cost (US$4853 vs. US$2796 per woman). Among responders to OCs, continuing treatment with the LNG-IUS instead of OCs was more effective (92% vs. 90.4%) and less expensive (US$2796 vs. US$4711). For women naïve to medical therapy, the LNG-IUS and OCs had similar effectiveness, but cost for the LNG-IUS was lower (US$2796 vs. US$4895). In all scenarios, surgery followed if medical therapy failed; rates of primary method failure were 62.5% with OCs and 34% with the LNG-IUS at 12 months.

CONCLUSIONS

Treatment strategies employing the LNG-IUS are the most cost-effective in managing DUB, regardless of whether a woman has previously tried OC therapy.

Concomitant Essure®⁎ ⁎Essure® Permanent Birth Control System, Conceptus Inc., San Carlos, California. tubal sterilization and Thermachoice®† †Balloon Uterine Therapy System IIIC, Gynecare Thermachoice®, Ethicon, Inc., Somerville, New Jersey. endometrial ablation: feasibility and safety

OBJECTIVE

To evaluate the feasibility and safety of combining endometrial ablation (EA) with a thermal balloon endometrial ablation system (Gynecare Thermachoice IIIC Uterine Balloon Therapy System; Ethicon Inc., Somerville, NJ) and transcervical sterilization by intratubal insert (Essure Permanent Birth Control System; Conceptus, San Carlos, CA).

DESIGN

Feasibility and safety studies.

SETTING

University hospital in Chihuahua, Mexico.

PATIENT(S)

There were 40 volunteers in the feasibility study and 9 in the safety study, all requiring hysterectomies for benign uterine bleeding.

INTERVENTION(S)

In the feasibility study, both procedures were performed just before hysterectomy; in the safety study, thermocouples were inserted under the tubal serosa to assess heat transmission from the intratubal insert devices to the tubes and surrounding organs during EA.

MAIN OUTCOME MEASURE(S)

Completeness of EA and possible device dislodgement in the feasibility study; temperature readings in the safety study.

RESULT(S)

No disturbance of the intratubal insert devices was noted, and EA by the thermal balloon endometrial ablation system was complete visually and histologically, although small areas near the tubal ostia exhibited less endometrial destruction. Mean tubal temperatures ranged from 37.1 degrees C to 37.5 degrees C and did not reach the critical temperature of 45 degrees C. No damage to the tubes was noted.

CONCLUSION(S)

Performance of EA and sterilization with these two systems in a one-step approach is safe for women who require EA and permanent contraception.

Pregnancy after endometrial ablation: English literature review and case report

Endometrial ablation is an effective treatment for dysfunctional uterine bleeding. The incidence of pregnancy after endometrial destruction is low and is reported to be 0.7%. We report what is to the best of our knowledge the first case of pregnancy after microwave endometrial ablation and review the outcomes of 74 pregnancies after various methods of endometrial destruction.

Contraceptive information after endometrial ablation

We reviewed the records of the patients considered "fertile" in a consecutive series of 206 patients treated by intrauterine balloon ablation for dysfunctional uterine bleeding, and three pregnancies were observed among 58 patients (5.2%), with two spontaneous abortions and a placenta accreta at 26 weeks. These findings lead us to conclude that balloon ablation is not contraceptive and that use of a supplemental contraceptive method should be planned. Hysteroscopic endometrial ablation and nonhysteroscopic endometrial thermal ablation are the first-line conservative surgical treatments for dysfunctional uterine bleeding. Their use reduces the rate of hysterectomies for this common problem. Because of their effects on the endometrium and uterine cavity (synechiae), these treatments are indicated only for patients who do not wish to remain fertile.

Menorrhagia, mechanisms and targeted therapies

PURPOSE OF REVIEW

Efficient treatment options for the increasing complaint of heavy menstrual bleeding are required to avoid the morbidity associated with major surgery. This review summarizes recent developments in the nonsurgical approach to treating menorrhagia.

RECENT FINDINGS

Even though the mechanism of menstruation has still not been fully elucidated, there have been promising developments in the attempt to reduce menstrual blood loss. The levonorgestrel-releasing intrauterine system has proven very efficient, and there is a frameless device suitable for enlarged uterine cavities. The side effect of breakthrough bleeding has been the main reason for discontinuing treatment. Recent studies have investigated options of concomitant therapy with antiprogestogens to counter this effect. Another group of novel compounds are selective progesterone receptor modulators, which thus far have been shown to reduce menstrual bleeding without the unwanted effect of unscheduled bleeding episodes.

SUMMARY

As menorrhagia is largely a subjective complaint, it is important for successful therapy to be based on an informed patient's choice. Currently, lack of evidence-based practice, poor compliance and unpleasant side effects limit the success of medical therapies contributing to the amount of major surgery performed for this indication. If concomitant therapies succeeded in minimizing the episodes of breakthrough bleeding with the levonorgestrel-releasing intrauterine system, its recommendation as a first choice treatment may be confounded. Further research is needed into efficiency and safety of selective progesterone receptor modulators, which appear to have great potential in reducing menstrual blood loss.