Hysteroscopic treatment of the septate uterus

Twelve patients with symptomatic septate uteri underwent hysteroscopic division of the uterine septum, monitored by concomitant laparoscopy, over a six-year period. The preoperative reproductive performance included 42 pregnancies, with only three viable deliveries. Ten of the 12 patients conceived within one year after therapy, and eight of these patients delivered a live infant at term. Two patients had a spontaneous abortion at six and eight weeks after therapy, respectively, but in each, a subsequent pregnancy was carried to term. Three patients are currently pregnant (eight, 12, and 18 weeks). Two patients have not as yet conceived. Two patients required a second hysteroscopic operation because a partial residual septum was observed on the posttreatment hysterogram.     

Hysteroscopic treatment of septate uterus with Neodymium-YAG laser.

OBJECTIVE: To determine the effectiveness of Neodymium-YAG (Nd-YAG) laser for hysteroscopic transection of the septate uterus to improve pregnancy outcome. DESIGN: Patients treated for recurrent pregnancy loss and/or infertility were evaluated for before versus after treatment pregnancy outcomes. SETTING: All patients were referred to a University Reproductive Endocrine and Infertility practice from 1986 through 1990. PATIENTS, PARTICIPANTS: Nineteen patients underwent hysteroscopic transection of uterine septa after exclusion of other factors that may cause recurrent fetal wastages and/or infertility. They were allowed to conceive 8 weeks after surgery after a postoperative hysterosalpingogram. Fourteen women attempted conception during a time span of 11 to 42 months; 3 patients declined to conceive, and 2 were lost to follow-up. INTERVENTIONS: Hysteroscopic transection of the uterine septum with a Nd-YAG laser was performed in all patients. The Nd-YAG laser delivered via a 600-microns bare fiber or an 800-microns sculpted fiber through operative hysteroscopy. MAIN OUTCOME MEASURES: To evaluate the success and complications of this new laser technique. RESULTS: (1) Thirteen patients conceived; 10 delivered a live infant at term; (2) 87% of the postoperative pregnancies were considered successful as compared with 11% preoperative; (3) complications included a small perforation of the uterus (no treatment needed) and development of uterine adhesions (1 case only). CONCLUSIONS: Hysteroscopic metroplasty with the Nd-YAG laser is a valuable alternative new technique for the treatment of uterine septum.     

Hemostasis and cold knife cone biopsy: a prospective randomized trial comparing a suture versus non-suture technique

Two methods of obtaining hemostasis after cold knife cone biopsy were compared in a prospective randomized trial involving 200 patients. One method relied primarily on hemostatic sutures, and the other involved the use of a styptic solution (Monsel's solution) and vaginal pack, thus avoiding the use of sutures altogether. The short- and long-term morbidity in these two groups were compared and 12-month follow-up was completed. The use of sutures did not reduce the incidence of primary hemorrhage. Secondary hemorrhage was twice as frequent in the suture group, although this trend did not quite reach statistical significance. During long-term follow-up, significantly more patients in the suture group developed menstrual symptoms, cervical stenosis, and unsatisfactory colposcopy, requiring further operative intervention as a result.     

A study of hysteroscopic metroplasty in 141 women with a septate uterus

141 patients who had a hysteroscopic septum resection of a partial uterine septum (class Vb, American Society for Reproductive Medicine, ASRM) were divided into two groups: Group I (69 patients) presented with infertility and Group II (72 patients) with recurrent abortion. The mean±SD post-operative follow up period was 36±19.5 months. Thiry-six Group I patients (52.1%) and 38 Group II patients (52.7%) achieved pregnancy, with respective abortion rates of 20% and 25%. Received: 18 April 2001 / Accepted: 11 June 2001     

宫腔镜子宫纵隔切开术治疗纵隔子宫

诊断纵隔子宫的金标准仍然是宫腔镜联合腹腔镜手术。文章阐述宫腔镜子宫纵隔切开术的手术技巧,回顾分析190例纵隔子宫患者术后的妊娠结局。宫腔镜下子宫纵隔切开术可减少流产率,提高活产率。宫腔镜下子宫纵隔矫形手术安全,并发症少,可明显改善纵隔子宫合并不良孕产史患者的妊娠结局。     

Oral versus intramuscular progesterone for in vitro fertilization: a prospective randomized study

OBJECTIVE: To evaluate the efficacy of oral micronized progesterone compared with IM progesterone in oil for luteal support in patients undergoing IVF who are treated with a GnRH agonist. DESIGN: Randomized prospective clinical trial. SETTING: University-based IVF center. PATIENT(S): Women <40 years of age who were undergoing IVF with luteal GnRH pituitary down-regulation. INTERVENTION(S): Patients were randomized to receive either oral micronized progesterone (200 mg three times daily) or IM progesterone (50 mg daily). MAIN OUTCOME MEASURE(S): Progesterone levels at standardized days 21 and 28, and pregnancy and embryo implantation rates. RESULT(S): Day 21 progesterone levels were 77.6+/-13.2 ng/mL in the IM group and 81.5+/-16.2 ng/mL in the oral group. Day 28 progesterone levels were 76.3+/-15.0 ng/mL in the IM group and 53.6+/-10.1 ng/mL in the oral group. The clinical pregnancy rates were 57.9% and 45.8% for the IM and oral groups, respectively. The implantation rate per embryo was significantly higher in the IM group (40.9%) than in the oral group (18.1%). CONCLUSION(S): When used according to our protocols, oral progesterone and IM progesterone result in comparable levels of circulating progesterone. However, oral progesterone results in a reduced implantation rate per embryo.     

Zona-intact versus zona-free blastocyst transfer: a prospective,randomized study

OBJECTIVE: To compare the outcome of zona-intact versus zona-free blastocyst transfer. DESIGN: Prospective, randomized study. SETTING: Tertiary care private hospital IVF center. PATIENT(S): A total of 240 patients undergoing blastocyst stage ET (119 zona intact and 121 zona free). INTERVENTION(S): In vitro culture of embryos to the blastocyst stage was followed by random allocation to zona-intact or zona-free transfer. MAIN OUTCOME MEASURE(S): Treatment cycle characteristics, implantation, and pregnancy rates. RESULT(S): Transfer of zona-free blastocysts was associated with a higher implantation rate. Subgroup analysis, however, indicated that better outcome was achieved only in the group that received poor-quality blastocysts. Patients undergoing blastocyst transfer for the first time did not seem to benefit from zona-free blastocyst transfer. CONCLUSION(S): Zona-free blastocyst transfer increases the success of blastocyst-stage transfer in patients with poor-quality blastocysts.     

Carbon dioxide versus normal saline as a uterine distension medium for diagnostic vaginoscopic hysteroscopy in infertile patients: a prospective,randomized, multicenter study

OBJECTIVE: To evaluate the satisfaction rate, efficacy, and complication rate of carbon dioxide (CO(2)) versus normal saline as a uterine distension medium for outpatient diagnostic vaginoscopic hysteroscopy in infertile patients. DESIGN: Prospective, randomized multicenter study. SETTING: Hysteroscopy units in two university hospitals and in a private center. PATIENT(S): One hundred eighty-nine infertile women undergoing outpatient hysteroscopy. INTERVENTION(S): Outpatient hysteroscopy was performed with CO(2) (group A) or normal saline (group B) and with endometrial biopsy when indicated. MAIN OUTCOME MEASURE(S): Quality of the visualization of the uterine cavity, procedure time, complications, patient discomfort, and satisfaction rate. RESULT(S): Significantly lower abdominal and shoulder tip pain and a lower incidence of vasovagal reactions were observed in group B in comparison with group A. A higher satisfaction rate and a lower operative time were obtained in the normal saline group in comparison with the CO(2) group. Moreover, group A required significantly more analgesics after the procedure than group B. CONCLUSION(S): Uterine distension with normal saline seems to have less adverse effects and is better tolerated by patients. Moreover, it allows operative procedures to be performed with the new bipolar instruments.     

Complications of hysteroscopy: a prospective, multicenter study

OBJECTIVE: To estimate the incidence of complications of diagnostic and operative hysteroscopic procedures in the Netherlands and describe their nature. METHODS: Data on complications were recorded by 82 hospitals in 1997. Participating hospitals had a 100% response rate. Any unexpected events that required intraoperative or postoperative intervention were defined as complications in two groups: approach (entry-related) and technique-related (caused by surgical instruments). RESULTS: Thirty-eight complications occurred among 13,600 hysteroscopic procedures (rate 0.28%). Diagnostic hysteroscopic procedures had a significantly lower complication rate (0.13%) than operative procedures (rate 0.95%; P <.01). Fluid overloads of distention medium were recorded five times (rate 0.20%). The most frequent surgical complication was perforation of the uterine cavity (rate 0.76%). Approximately half the perforations (18 of 33) were entry-related. Bleeding caused by perforation was seen in 0.16% of cases. Incidences of complications were: intrauterine adhesiolysis 4.48%, endometrium resection 0.81%, myomectomy 0.75%, and removal of a polyp 0.38%. CONCLUSION: Diagnostic hysteroscopic procedures had very low complication rates, so are safe procedures with which to evaluate intrauterine pathology. Operative hysteroscopic procedures were more risky, but the removal of polyps had a very low complication rate (12 times lower than synechiolysis). Half the complications were entry-related, so attention has to be paid to the method of entry with the hysteroscope (ie, no unnecessary dilation of cervix and introduction of the scope under direct vision). The other half of complications were related to surgeons' experience and type of procedure.     

Wedge metroplasty for the septate uterus: an update

Twenty-one patients with septate uteri and 2 patients with a T-shaped uterine anomaly and recurrent abortions underwent wedge metroplasty during the period from September 1978 to August 1983. Thirteen patients had a characteristic history of one or more abortions associated with the septate uterus and absence of other metabolic and endocrine abnormalities. Ten other patients, including the two with a T-shaped uterine anomaly, either had one or more abortions of an uncharacteristic nature with absence of other abnormalities or had one or more characteristic abortions in addition to the presence of other metabolic, endocrine, or surgically correctable disease. The application of wedge metroplasty for the surgical reconstruction of the uterus yielded equally gratifying results in both groups with approximately two thirds of the patients having a term delivery or carrying a pregnancy in the third trimester.     

An immunohistochemical study of metroplastic surgical specimens from patients with a septate uterus

Purpose  

To elucidate the etiology of recurrent pregnancy loss in patients with congenital uterine anomalies, an immunohistochemical technique was used to quantitatively evaluate the vascular arrangement of septate uteri with respect to vascular density and morphology.     

Unification of a septate uterus: Mahgoub's operation.

A simple surgical technique for unification of a septate uterus is described. The septum and a small strip of fundus are removed with scissors inserted through two small fundal stabs, and the opening is closed with one mattress suture, which forms an anteroposterior suture line no more than 1 cm long. At the end of the operation an intrauterine contraceptive device is inserted to prevent uterine adhesions. The operation has several advantages: (a) it leaves a capacious uterine cavity of normal appearance, (b) it avoids large uterine incisions, and thus the possibility of postoperative adhesions or weak uterine scars, and (c) it avoids possible injury to the cornual ends of the Fallopian tubes. This article reports favorable results in 17 women treated with this surgical technique.     

Laparoscopic supracervical hysterectomy versus laparoscopic total hysterectomy: a prospective randomized study

AIM: The aim of this study was to compare surgical complications and clinical outcomes after supracervical versus total laparoscopic hysterectomy for the control of abnormal uterine bleeding or symptomatic uterine leiomyomata. METHODS: We conducted a prospective randomized trial on 141 patients who had laparoscopic hysterectomy for symptomatic uterine leiomyomata, abnormal bleeding refractory to hormonal treatment, or both. Patients were randomly assigned to receive a supracervical or total laparoscopic hysterectomy. We compared surgical complications and clinical outcomes for 2 years after randomization. RESULTS: Seventy-one participants were assigned to supracervical laparoscopic hysterectomy (SLH) and 70 to total laparoscopic hysterectomy (TLH). Hysterectomy by either techniques led to statistically significant reductions in most symptoms, including pelvic pain or pressure, back pain and urinary incontinence. Patients assigned to SLH tended to have more hospital readmissions than those randomized to TLH. There were no statistically significant differences in the rate of complications, degree of symptoms improvement, or activity limitation. Participants weighing more than 100 kg at study entry were more than twice as likely to be readmitted to the hospital during the 2-year of follow-up (OR 2.48, 95% CI 0.11; 1.91, P=0.04). CONCLUSIONS: We did not observe statistically significant differences between SLH and TLH in surgical complications and clinical outcomes during the 2-years of follow-up.     

Day 3 versus day 5 embryo transfer: a prospective randomized study

Transfer of embryos at the blastocyst stage has been associated with exceptionally high implantation rates. There are, however, only a few prospective randomized studies comparing day 3 versus day 5 embryo transfer. Furthermore, the number of embryos replaced in the day 3 group transfer is often higher than the number of blastocysts replaced, thereby affecting implantation rates. A total of 118 patients undergoing standard IVF/intracytoplasmic sperm injection who had developed at least three 8-cell embryos showing <20% extracellular fragmentation on day 3 were randomized for day 3 or day 5 transfer. A maximum of two embryos were replaced. In this prospective, randomized study the implantation and pregnancy potential of embryos transferred on day 3 or day 5 were compared. Equal numbers of embryos were replaced in the two groups. There was no statistically significant difference between day 3 and day 5 transfer regarding positive human chorionic gonadotrophin rates (70 versus 67%), clinical pregnancy rates (61 versus 51%), implantation rates (44 versus 37%), twinning rates (42 versus 41%) and rates of early pregnancy loss (15 versus 29%). Transfer of embryos on day 3 or 5 showed similar implantation rates when equal numbers of embryos were transferred. Embryo transfer at the blastocyst stage seems to have no advantage over day 3 transfer in patients with more than two 8-cell embryos showing less than 20% fragmentation on day 3.     

Sublingual versus vaginal misoprostol for cervical ripening before hysteroscopy: a randomized clinical trial

Purpose

To evaluate the efficacy of two routes of misoprostol (sublingual and vaginal) for cervical ripening before hysteroscopy.

Methods

One hundred and ten perimenopausal women who were referred to a tertiary hospital for surgical hysteroscopy enrolled in this double-blind randomized clinical trial. They were divided into two groups to receive 400 mg misoprostol either sublingually or vaginally 6 h before hysteroscopy. The duration of dilatation, Hegar number inserted into the cervix without resistance, and hysteroscopic and drug complications were recorded for all cases.

Results

Forty-nine women in sublingual and 51 in vaginal group participated in the study. Dilatation time was significantly lower in sublingual group (P < 0.001). Median Hegar number passed into the cervix without resistance was 5 in sublingual versus 4 in vaginal group (P = 0.002). Cramp followed by vomiting and diarrhea were the most common side effects of misoprostol in the sublingual group, while cramp followed by vomiting was the most frequent side effect in the vaginal group. Diarrhea was not reported in the vaginal group (P = 0.008).

Conclusion

Sublingual route of misoprostol could be considered as an effective medication before surgical hysteroscopy in perimenopausal women.     

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

The aim of this single-center, prospective, randomized, parallel-group study was to compare desogestrel and danazol as preoperative endometrial preparation for hysteroscopic surgery. We enrolled 200 consecutive eligible patients, in reproductive age, with endouterine diseases. Pre- and post-treatment characterization of endometrium was performed by hysteroscopic visual observation and histologic confirmation. The enrolled patients were randomly assigned to two groups: 100 were treated with 75?μg of desogestrel/die, 100 with 100?mg of danazol/die, both orally for 5?weeks, starting on Day 1 of menstruation. We recorded intraoperative data (cervical dilatation time, operative time, infusion volume and severity of bleeding) and drugs' side effects. Post-treatment comparison of endometrial patterns showed a significant more marked effect of desogestrel, respect to danazol, in atrophying endometrium (“normotrophic non-responders” versus “hypotrophic”—“atrophic”, p?=?0.031). Intraoperative data showed no significant differences between the two groups for cervical dilatation time (p?=?0.160), while in the desogestrel group we found a significant reduction of operative time (p?=?0.020), infusion volume (p?=?0.012), and severity of bleeding (p?=?0.004). Moreover, desogestrel caused less side effects (p?=?0.031). According to our data analysis, desogestrel showed most marked effect in inducing endometrial atrophy, allowed a better intraoperative management and caused less side effects during treatment.     

Vaginal versus abdominal reconstructive surgery for the treatment of pelvic support defects: A prospective randomized study with long-term outcome evaluation

OBJECTIVES: Our purpose was to determine whether a vaginal or abdominal approach is more effective in correcting uterovaginal prolapse. STUDY DESIGN: Eighty-eight women with cervical prolapse to or beyond the hymen or with vaginal vault inversion >50% of its length and anterior vaginal wall descent to or beyond the hymen were randomized to a vaginal versus abdominal surgical approach. Forty-eight women underwent a vaginal approach with bilateral sacrospinous vault suspension and paravaginal repair, and 40 women underwent an abdominal approach with colposacral suspension and paravaginal repair. Ancillary procedures were performed as indicated. Detailed pelvic examination was performed postoperatively by the nonsurgeon coauthor yearly up to 5 years. The women were examined while standing during maximum strain. Surgery was classified as optimally effective if the woman remained asymptomatic, the vaginal apex was supported above the levator plate, and no protrusion of any vaginal tissue beyond the hymen occurred. Surgical effectiveness was considered unsatisfactory if the woman was symptomatic, the apex descended >50% of its length, or the vaginal wall protruded beyond the hymen. RESULTS: Eighty women (vaginal 42, abdominal 38) were available for evaluation at 1 to 5.5 years (mean 2.5 years). The groups were similar in age, weight, parity, and estrogen status, and 56% had undergone prior pelvic surgery. There was no significant difference between the groups in morbidity, complications, hemoglobin change, dyspareunia, pain, or hospital stay. The vaginal group had longer catheter use, more urinary tract infections, more incontinence, decreased operative time, and lower hospital charge. Surgical effectiveness was optimal in 29% of the vaginal group and 58% of the abdominal group and was unsatisfactory leading to reoperation in 33% of the vaginal group and 16% of the abdominal group. The reoperations included procedures for recurrent incontinence in 12% of the vaginal and 2% of the abdominal groups. The relative risk of optimal effectiveness by the abdominal route is 2.03 (95% confidence interval 1.22 to 9.83), and the relative risk of unsatisfactory outcome using the vaginal route is 2.11 (95% confidence interval 0.90 to 4.94). CONCLUSIONS: Reconstructive pelvic surgery for correction of significant pelvic support defects was more effective with an abdominal approach. (Am J Obstet Gynecol 1996;175:1418-22.)