Desogestrel versus danazol as preoperative treatment for hysteroscopic surgery: a prospective, randomized evaluation

Rapid and random-start endometrial preparation before outpatient hysteroscopic polypectomy in patients of perimenopausal age

OBJECTIVE

This study aimed to assess the efficacy of randomly started oral dienogest/ethinylestradiol (DNG/EE) for swift endometrial preparation prior to outpatient hysteroscopic polypectomy in perimenopausal women.

METHOD

A multicenter, prospective, randomized controlled trial was conducted in university hospitals. Eighty perimenopausal women scheduled for outpatient hysteroscopic polypectomy between January 2023 and March 2024 were randomly assigned to either intervention (n = 40) or control (n = 40) groups. Exclusion criteria included concomitant endometrial pathologies, recent therapy and adnexal diseases. The intervention group received oral DNG/EE 2 mg/0.03 mg/day started on any day of the menstrual cycle for 14 days. The control group underwent polypectomy between menstrual cycle days 8 and 11 without pharmacological treatment.

RESULTS

Pre-procedure (p < 0.001) and post-procedure (p < 0.001) endometrial thickness were significantly reduced in the intervention group, along with a higher incidence of hypotrophic/atrophic endometrial patterns (p < 0.001). Surgical parameters also differed significantly between groups.

CONCLUSION

DNG/EE treatment offers rapid, cost-effective endometrial preparation, enhancing surgical outcomes and patient satisfaction during outpatient polypectomy.

TRIAL REGISTRATION

ClinicalTrials.gov NCT06316206.

The use of hormonal contraceptives in fertility treatments: a committee opinion

The use of hormonal contraception can be considered to aid in the timing of assisted reproductive technology cycles, reduce the risk of ovarian cysts at in vitro fertilization cycle initiation, and optimize visualization before hysteroscopy.

The Modulatory Effect of Adipose-Derived Stem Cells on Endometrial Polyp Fibroblasts

Endometrial polyps (EPs) are benign overgrowths of the endometrium, with the potential to cause severe complications, ranging from discomfort to inflammation and infertility. Dysfunction of endometrial fibroblasts may be a critical component leading to the development of polyps. While surgical intervention is the common remedy for severe cases, it comes with drawbacks, including infection, bleeding, and risk of damage to the cervix and adjacent tissues. Adipose-derived mesenchymal stromal cells (ASCs) are at the focus of modern medicine, as key modulators of tissue homeostasis, inflammation and tissue repair, rendering them prime candidate agents for tissue regeneration and cell-based therapies. In the current work, endometrial polyps were isolated from patients admitted to the OB/GYN department at the Galilee Medical Center and extracted fibroblasts (EPFs) were isolated and characterized. ASCs were isolated from healthy patients. The effect of EPF- and ASC-conditioned media (CM) on polyp-derived fibroblasts was evaluated, in both 2D and 3D assays, as well as on the expression of matrix-related gene expression. Herein, EPFs exposed to ASC-CM exhibited reduced migration, invasion, contraction of hydrogels, and extracellular matrix deposition, compared to those exposed to EPF-CM. Altogether, the current work suggests that ASCs may have a modulating effect on fibroblasts involved in forming endometrial polyps and may serve as the basis for conservative treatment strategies aimed at treating severe cases of EPs.

Fertility-Sparing Approach in Women Affected by Stage I and Low-Grade Endometrial Carcinoma: An Updated Overview

Endometrial cancer (EC) is a deleterious condition which strongly affects a woman's quality of life. Although aggressive interventions should be considered to treat high-grade EC, a conservative approach should be taken into consideration for women wishing to conceive. In this scenario, we present an overview about the EC fertility-sparing approach state of art. Type I EC at low stage is the only histological type which can be addressed with a fertility-sparing approach. Moreover, no myometrium and/or adnexal invasion should be seen, and lymph-vascular space should not be involved. Regarding the pharmaceutical target, progestins, in particular medroxyprogesterone acetate (MPA) or megestrol acetate (MA), are the most employed agent in conservative treatment of early-stage EC. The metformin usage and hysteroscopic assessment is still under debate, despite promising results. Particularly strict and imperious attention should be given to the follow-up and psychological wellbeing of women, especially because of the double detrimental impairment: both EC and EC-related infertility consequences.

Diode Laser Hysteroscopic Metroplasty for Dysmorphic Uterus: a Pilot Study

This paper aims to study the efficacy and safety of diode laser hysteroscopic metroplasty for dysmorphic uterus and the impact on reproductive outcomes. This is a retrospective, single-center pilot study with prospective follow-up. The study was performed at a university-affiliated, tertiary hospital. From February 2018 to February 2020, all nulliparous women with a 3D ultrasound diagnosis of T-shaped or Y-shaped dysmorphic uterus and diagnosis of infertility, recurrent implantation failure, or recurrent pregnancy losses were referred for hysteroscopic metroplasty. Diode laser hysteroscopic metroplasty was performed under general anesthesia in an ambulatory setting. Main outcome measures included operative time, complications, hysteroscopic appearance of the cavity in a follow-up hysteroscopy, and reproductive outcomes in terms of pregnancy and live birth. A total of 25 infertile women with mean duration of infertility of 56.6 ± 36.1 months underwent hysteroscopic metroplasty. No complications were reported, and subsequent 3D ultrasound and follow-up hysteroscopic appearance were satisfactory in all cases. Maximum follow-up was 32 months (mean ± standard deviation 11.5 ± 9.2 months). Fifteen nulliparous women returned for fertility treatments in our institute, among whom nine conceived (60% pregnancy rate). The rate of deliveries and ongoing pregnancies (pregnancies beyond 24 weeks of gestation) was 78% (7/9), with six successful liveborn deliveries at 36-38 weeks and one ongoing pregnancy. One had spontaneous abortion at week 19 and one had a spontaneous abortion at week 7. Hysteroscopic metroplasty in an ambulatory setting, using diode laser, is a safe and effective procedure, improving reproductive outcomes in cases of T-shaped or Y-shaped uterus.

A comparative clinical trial of vaginal misoprostol versus intracervical normal saline infiltration as a cervical ripening agent at time of hysteroscopy

Cervical status has a great impact on the duration and success of its dilatation especially during hysteroscopy, so cervical ripening employed before the procedure can increase the success rate and minimize the complications.

AIM

To compare the efficacy of vaginal misoprostol and intracervical normal saline infiltration as cervical ripening agents.

METHODS

A randomized comparative clinical trial had been conducted in AL Yarmouk Teaching Hospital involving two methods for cervical ripening before the hysteroscopic procedure. One Hundred women were enrolled in the study, fifty of them were those who used preoperative vaginal misoprostol and the other fifty patients were those who had been submitted to intracervical normal saline infiltration during surgery. Basal cervical dilatation, time to achieve 8 mm cervical dilatation, difficulties, and complications encountered during the procedure were evaluated and compared for both groups.

RESULTS

The participants had been admitted for hysteroscopy for the following indications: Abnormal uterine bleeding, missed loop, infertility, polypectomy, endometrial resection, and myomectomy. Regarding operative findings, the basal cervical dilatation was not significantly different between them, the time required to achieve the required dilatation was significantly shorter for the normal saline infiltration group, 66.95 sec. ± 10.85 than for the misoprostol group which was 87.9 sec. ± 13.11. There was more difficulty in dilatation with more complications in the misoprostol group than in the normal saline infiltration group.

CONCLUSIONS

Normal saline infiltration is a simple, readily available at the time of surgery and with fewer complications and shorter time of dilatation in comparison to vaginal misoprostol for a comparable efficacy.

The Impact of Spinal Anesthesia and Use of Oxytocin on Fluid Absorption in Patients Undergoing Operative Hysteroscopy: Results from a Prospective Controlled Study

Objective

The aim of this study was to determine if combining intravenous oxytocin infusion and spinal anesthesia will reduce the amount of glycine absorption in patients undergoing operative hysteroscopy.

Patients and Methods

A prospective controlled study was conducted in premenopausal patients who had hysteroscopic surgery including endometrial resection, endometrial polypectomy, myomectomy resection and uterine septal resection. The effect of combined spinal anesthetic with oxytocin infusion on fluid deficit was studied.

Results

A total of 88 patients were studied. Sixty-two cases were done under general anesthesia (control group) and 26 cases were performed with spinal anesthesia and the use of oxytocin infusion (study group). There was a statistically significant less mean fluid deficit in the study group than control group in the endometrial polypectomy patients (220±36 mL vs 392±178 mL, respectively, P value 0.010, 95% C.I.: 163–276) and the myomectomy patients (308±66 mL vs 564±371 mL, respectively, P value 0.003, 95% C.I.: 239–378). In the endometrial resections, there was also a statistically significant less mean fluid deficit in the study than the control group (P value ˂ 0.001). Regarding septal resection, there was no statistically significant difference in the mean fluid deficit between the two groups (P value 0.833).

Conclusion

Spinal anesthesia combined with intravenous oxytocin infusion in operative hysteroscopy results in a statistically significant reduction in the glycine fluid deficit than the general anesthesia. We also recommend studying the effects of this combination in operative hysteroscopy using bipolar devices with isotonic solutions.

Fertility preservation in endometrial cancer patients: options, challenges and perspectives

Several different approaches have been designed by physicians in order to preserve fertility in younger patients with endometrial carcinoma. There are various options offering different advantages, but hysteroscopic resection of pathologic endometrial tissue with placement of a Levonorgestrel Intrauterine Device has proven to be the most successful in allowing patients to conceive and give birth afterwards. However, conservative treatments should only be considered in patients with low-grade and low-stage endometrial tumours. There are many published studies which have sought out a preferable approach to treating endometrial cancer whilst preserving fertility. However, more research on this matter is needed to allow a better understanding as to which techniques/approaches are optimal. In this review, we will summarise the current available treatment options for endometrial cancer in patients of reproductive age.

Effect of hysteroscopic septum resection on preterm delivery rate in singleton pregnancies

INTRODUCTION

Uterine septum is the most common uterine anomaly and is often found during the work-up in primary infertile women. In this study, we aimed to evaluate the potential effect of hysteroscopic septum resection (HSR) on preterm delivery (PTD) in primary infertile women who had singleton pregnancies.

MATERIAL AND METHODS

We analyzed 420 singleton pregnancies after primary infertility treatment and compared the PTD rates in women who underwent previous HSR (cases) and women who did not undergo previous operative hysteroscopy or cervical dilation (controls), regardless of the modality of conception (spontaneous or by in vitro fertilization).

RESULTS

We did not find significant differences between cases and controls for the incidence of overall PTD rate (p = .237), PTD before 32 gestational weeks (p = .848), and between 32 and 37 gestational weeks (p = .324), premature rupture of membranes (p = .419), and neonatal birth weight (p = .129). Overall, the risk of spontaneous PTD <37 gestational weeks after HSR was not found to be significantly higher compared to controls (RR 1.29, 0.61-2.73 95% CI; p = .561).

CONCLUSION

According to our results, previous HSR could be not considered a risk factor for PTD in singleton pregnancies, regardless of the modality of conception (spontaneous or by in vitro fertilization).

From hysteroscopy to laparoendoscopic surgery: what is the best surgical approach for symptomatic isthmocele? A systematic review and meta-analysis

PURPOSE

To investigate the effectiveness and risks of different surgical therapies for isthmocele in symptomatic women with abnormal uterine bleeding, infertility, or for the prevention of obstetric complications, considering safety and surgical complications.

METHODS

PubMed/MEDLINE, Scopus, Embase, Science Direct, and Cochrane Library were systematically searched (n° CRD4201912035) for original articles on the surgical treatment of isthmocele published between 1950 and 2018. Data synthesis was completed using MedCalc 16.4.3. The body of evidence was assessed using the GRADE methodology.

RESULTS

We retrieved 33 publications: 28 focused on a single surgical technique, and five comparing different techniques. Meta-analysis showed an improvement of symptoms in 85.00% (75.05-92.76%) of women after hysteroscopic correction, 92.77% (85.53-97.64%) after laparoscopic/robotic correction, and 82.52% (67.53-93.57%) after vaginal correction. Hysteroscopic surgery was associated with the lowest risk of complications (0.76%, 0.20-1.66%).

CONCLUSIONS

We found adequate evidence supporting the use of surgery for the treatment of symptomatic isthmocele, as it was found to improve the bleeding symptoms in more than 80% of patients. Differently, we found a lack of evidence regarding the role of surgery with the purpose of improving fertility or reducing the risk of obstetric complications in women with asymptomatic isthmocele. The hysteroscopic correction of isthmocele may be the safest and most effective strategy in those patients with adequate residual myometrial thickness overlying the isthmocele. Laparoscopic and vaginal surgeries may be the preferred options for patients with a thinner residual myometrium over the defect (< 2.5 mm) and when hysteroscopic treatment is inconclusive.

Endometrial polyps: Pathogenesis, sequelae and treatment

Endometrial polyps are overgrowths of endometrial glands that typically protrude into the uterine cavity. Endometrial polyps are benign in nature and affect both reproductive age and postmenopausal women. Although endometrial polyps are relatively common and may be accompanied by abnormally heavy bleeding at menstruation. In asymptomatic women, endometrial polyps may regress spontaneously, in symptomatic women endometrial polyps can be treated safely and efficiently with hysteroscopic excision.

Use of pre-operative imaging for symptomatic uterine myomas during pregnancy: a case report and a systematic literature review

PURPOSE

Uterine fibroids (UFs) occur in 10% of pregnancies and may lead to severe maternal-fetal complications, mainly depending on UFs characteristics and the distance to the uterine cavity (UC). When symptomatic, UFs are managed medically. Nevertheless, in about 2% of cases, surgery becomes necessary. Entry into the UC should be avoided during myomectomy. Consequentially, pre-operative assessment of this risk could be beneficial. Ultrasonography (US) represents the gold standard for UFs assessment; however, scarce evidence has been produced to assess the role of magnetic resonance imaging (MRI). The aim of the present study was to summarize current evidence about the pre-operative use of imaging techniques for UFs during pregnancy.

METHODS

A systematic research of the literature was conducted in Scopus, PubMed/MEDLINE, ScienceDirect and the Cochrane Library, including case reports and case series. A case report was also discussed. We collected data regarding patients, imaging assessment, UFs characteristics, surgical information, timing and modality of delivery.

RESULTS

According to our search strategy, 66 articles were selected and 210 patients were included. US assessment was reported in 36 (17%) cases. MRI was reported in 10 (4.7%) cases. Only in one case, MRI was used to measure the distance between UFs and UC.

CONCLUSION

US allows an adequate pre-operative evaluation of anterior, submucosal or pedunculated symptomatic UFs in pregnancy. However, compared to US, MRI may provide a more accurate evaluation of multiple, large, intramural or posterior UFs and could measure the distance between UFs and UC more accurately.

Management of Cesarean Scar Pregnancy: A Single-Institution Retrospective Review

Objective

Cesarean scar pregnancy (CSP) is a rare condition that occurs when the pregnancy implants in a cesarean scar. An early diagnosis and a proper management are fundamental to prevent maternal complications. We review and discuss the different treatment employed in our unit to reduce morbidity, preserve fertility, and predict possible complications.

Methods

The reported treatment has been expectant management, operative hysteroscopy approach, and intramuscular injection of 50 mg methotrexate (MTX), followed by cervical dilation and manual vacuum aspiration (D&S) with a Karman cannula under ultrasound guidance, uterine artery embolization (UAE), and manual vacuum aspiration under ultrasound guidance and uterine artery embolization before surgical laparotomic resection.

Results

Complications were more frequent in women with a history of three or more cesarean section deliveries and with a myometrial thickness thinner than 2 mm. MTX and D&S treatment appear to be most effective and safe at the early age of pregnancy, while UAE and D&S are related to the highest risk of complication in any age of pregnancy.

Conclusion

An appropriate preoperative diagnostic evaluation, the identification of cases at higher risk, and those eligible for a conservative treatment are fundamental to reduce complications.

Fertility sparing surgery for stage IA type I and G2 endometrial cancer in reproductive-aged patients: evidence-based approach and future perspectives

Fertility-sparing surgery (FSS) in reproductive-age patients affected by endometrial cancer (EC) gained growing attention in the last decade, although the first reports were already published in 1990-2000s. Nevertheless, only few patients undergoing FSS for stage I, type I EC had been reported in each case series, without a robust multicenter study. In the available literature there are even fewer reported cases of conservative treatment of Stage IA and G2 EC. Considering these important gaps in our current knowledge, the purpose of this review was to summarize the available evidence about conservative treatments for stage IA type I and G2 EC, to improve the pretreatment counseling for reproductive-age patients. According to our overview, women who have low-risk disease (G1 or G2, endometrioid histotype confined to the endometrium) are candidates for progestin therapy. In addition, FSS could be considered a valid option for reproductive-aged patients with stage IA type I and G2 EC. Nevertheless, we solicit new trials to clarify the medium- and long-term outcomes in this kind of patients.

Dienogest as preoperative treatment of submucous myomas for hysteroscopic surgery: a prospective, randomized study

The aim of this single-center, prospective, randomized, parallel-group study was to compare Dienogest and Danazol as endometrial preparation in patients who have to undergo hysteroscopic surgery for submucous myomas. We enrolled 80 consecutive eligible patients, in reproductive age, affected by submucous myomas. Pre- and posttreatment characterization of endometrium was performed by hysteroscopic visual observation and histologic confirmation. The enrolled patients were randomly assigned to two groups: 40 were treated with 2 mg of Dienogest/die, 40 with 100 mg of Danazol/die, both orally for 5 weeks, starting on day 1 of menstruation. Posttreatment comparison of endometrial patterns showed a significant more marked effect of Dienogest, respect to Danazol, in atrophying endometrium ("normotrophic non-responders" versus "hypotrophic"-"atrophic", p = 0.028). Intraoperative data showed no significant difference between the two groups for cervical dilatation time (p = 0.326), while in the Dienogest group, we found a significant reduction of operative time (p = 0.001), infusion volume (p = 0.001), and severity of bleeding (p = 0.042). Moreover, Dienogest caused less side effects (p = 0.008). According to our data analysis, Dienogest, respect to Danazol, is more effective for the preparation of the endometrium in patients who have to undergo hysteroscopic surgery for submucous myomas, and causes less side effects.