Hysteroscopic metroplasty in patients with a uterine septum and otherwise unexplained infertility

Objective

To evaluate the reproductive outcomes of patients with a uterine septum and otherwise unexplained infertility who underwent hysteroscopic metroplasty, and to compare them with those of patients with the same diagnosis who did not have hysteroscopic metroplasty.

Methods

The present retrospective study included 127 patients with diagnosis of a uterine septum and otherwise unexplained infertility. The reproductive outcomes of 102 patients who underwent hysteroscopic metroplasty (group 1) and 25 patients who rejected the operation (group 2) were compared.

Results

Of the 102 patients who underwent hysteroscopic metroplasty, 44 (43.1%) were able to achieve pregnancy, as compared with 5 (20%) of the 25 patients who did not undergo the operation (P = 0.03). The abortion rate was 11.4% (5/44) in group 1, compared with 60% (3/5) in group 2 (P = 0.02). The live birth rate was 35.3% (36/102) in group 1, as compared with 8% (2/25) in group 2 (P = 0.008).

Conclusions

The results indicate that hysteroscopic metroplasty improves reproductive outcome for patients with a uterine septum and otherwise unexplained infertility.     

Reproductive outcome following resectoscope metroplasty in women having a complete uterine septum with double cervix and vagina

Objective

To evaluate reproductive outcomes in women with complete uterine septum with double cervix and vagina following resectoscope metroplasty.

Methods

The pregnancy outcomes of 21 women who underwent vaginal and uterine septum resection were compared with those of 15 untreated women with similar clinical characteristics. The Fisher exact test and the Mann-Whitney test were used for statistical analysis.

Results

Cycle fecundity was better (33.4% ± 28.5% vs 12.2% ± 4.7%; P = 0.046), the rate of term delivery significantly increased (P < 0.05), and the rate of spontaneous abortion decreased (P < 0.05) in the treatment group.

Conclusion

Resectoscope metroplasty was found to improve the pregnancy outcomes of women having primary infertility or a history of pregnancy loss associated with a complete uterine septum with double cervix and vagina.     

Hysteroscopic metroplasty: reproductive outcome in relation to septum size

Purpose

Our aim is to determine if the reproductive performance after hysteroscopic resection of partial uterine septum was related to septum size.

Methods

The retrospective and comparative cohort study was conducted in a University-affiliated Hospital. A cohort of 112 non-parous patients was treated for a partial uterine septum. The septum size was evaluated by hysteroscopy and transvaginal 3-dimensional ultrasound. The patients were stratified into two groups: group 1 (85 women) with small partial uterine septum (≤2.5 cm) and group 2 (27 women) with large partial uterine septum (>2.5 cm). They were also divided according to their obstetrics history: 39 infertile women and 73 aborters. All underwent hysteroscopic metroplasty with a resectoscope with an equatorial semicircular loop cutting 0° with monopolar energy. All septa were almost completely removed and no complications occurred.

Results

The two groups of patients with small (group 1) and large (group 2) partial uterine septum were compared in the terms of reproductive history and performance before and after surgery. In the overall population the reproductive performance after surgery is greatly improved. No significant differences in reproductive performance were evident between patients with small and large partial uterine septa. The reproductive performance was also similar in infertile patients and in aborters.

Conclusions

This study demonstrates that hysteroscopic metroplasty in cases of partial uterine septum and infertility significantly improves the reproductive performance irrespectively of septum size and that reproductive performance is independent from previous obstetrics history.     

Intrauterine device or estrogen treatment after hysteroscopic uterine septum resection

Objective

To investigate the effects on adhesion formation and pregnancy maintenance of an intrauterine device (IUD) and/or estrogen treatment after hysteroscopic septum resection.

Methods

After septum resection 100 women received either no treatment, or estrogens, or an IUD, or an IUD plus estrogens (n = 25 per group). Most were later checked hysteroscopically for uterine cavity adhesions. All pregnancies occurring during the study period were recorded.

Results

Adhesions developed in 1 of 19 (5.3%) of the untreated women, 3 of 25 (12%) of the women treated with an IUD plus estrogens, 2 of 19 (10.5%) of the women treated with an IUD only, and none of the women treated with estrogens only. None of the differences, however, were significant. Regarding pregnancy, the differences between groups were also not significant.

Conclusion

Neither IUD placement, nor estrogen treatment, nor both were found to prevent intrauterine adhesions or facilitate pregnancy after hysteroscopic uterine septum resection.     

Reproductive outcome after hysteroscopic metroplasty in women with septate uterus and otherwise unexplained infertility

OBJECTIVE: To evaluate the reproductive outcome of hysteroscopic metroplasty performed in women with septate uterus and otherwise unexplained primary infertility. DESIGN: Prospective, observational study. SETTING: Tertiary center for reproductive medicine. PATIENT(S): Sixty-one patients with uterine septa and otherwise unexplained primary infertility. INTERVENTION(S): Hysteroscopic division of the uterine septum. MAIN OUTCOME MEASURE(S): Reproductive outcome after hysteroscopic metroplasty. RESULT(S): Of 61 women, 25 (41%) conceived within 8-14 (mean 11.2) months after hysteroscopic metroplasty. Of these, 18 (29.5% of the total group) had live births (13 carried to term and 5 had preterm deliveries), and 7 (11.5% of the total group) had spontaneous abortions. Cervical cerclage was performed in 9 women; only 1 (11.1%) of these patients and 4 (44.4%) of the 9 who did not have a cerclage had preterm deliveries. Twelve of the 18 women (66.6%) who had live births were delivered by cesarean section. CONCLUSION(S): Women with uterine septum and otherwise unexplained infertility might benefit from hysteroscopic metroplasty.     

Small uterine septum is an important risk variable for preterm birth

Objective(s)

To evaluate whether a uterus with a small septum (arcuate uterus or class VI according to the American Fertility Society (AFS) classification) behaves similarly to a uterus with a larger septum (septate or subseptate uterus or AFS class V).

Study design

Observational study included 826 singleton deliveries to 730 women with a history of hysteroscopic resection of the uterine septum. Data on deliveries were obtained from the National Perinatal Registry of Slovenia (NPIS). Multiple gestations were excluded. We analysed and compared perinatal outcomes before and after hysteroscopic resection in two groups of women: in women with a small uterine septum (Group A) and in those with a larger uterine septum (Group B). Data on the septum length were obtained during hysteroscopic resection by comparing the length of the 1.4-cm long yellow tip of the electric knife to the length of the resected septum. A small uterine septum was defined as having a length of 1.3–1.5 cm.

Results

The preterm birth rate in Group A (n = 420) was 33.9% before and 7.2% after hysteroscopic resection (P < 0.001); the preterm birth rate in Group B (n = 406) was 36.5% before and 8.0% after hysteroscopic resection (P < 0.001). The very preterm birth rate in Group A was 12.5% before and 3.1% after hysteroscopic resection (P < 0.001); the very preterm birth rate in Group B was 15.0% before and 2.9% after hysteroscopic resection (P < 0.001). After surgery, we registered a decreased need for neonatal intensive care, as well as a significant decrease in stillbirth and neonatal death rates in both groups of patients.

Conclusion(s)

Similarly to a large uterine septum, a small uterine septum or arcuate uterus is an important hysteroscopically preventable risk variable for preterm birth.     

Hysteroscopic findings in women with primary and secondary infertility due to genital tuberculosis

Objective

To evaluate hysteroscopic findings of infertile women with genital tuberculosis.

Method

A retrospective study of the records of 94 women who underwent diagnostic hysteroscopy for infertility at All India Institute of Medical Sciences, New Delhi, India. Genital tuberculosis was diagnosed by laboratory studies of an endometrial biopsy and/or laparoscopic findings.

Results

For women with primary or secondary infertility, respectively, the hysteroscopic findings were normal in 15 (20.5%) vs 4 (9%) cases; and adhesions were grade 2 in 11 (15.1%) vs 3 (14) cases, grade 2a in 0 vs 1 (1.4%) cases, grade 3 in 11 (15.1%) vs 9 (42.9%) cases, grade 3b in 6 (8.2%) vs 0 cases, and grade 4 in 28 (38.4%) vs 2 (9.5%) cases.

Conclusion

Genital tuberculosis causes significant pelvic morbidity due to uterine adhesions and infertility.     

Color Doppler analysis of pelvic arteries following bilateral internal iliac artery ligation for severe postpartum hemorrhage

Objective

To compare Doppler blood flow characteristics of the uterine, arcuate, and ovarian arteries of women who underwent bilateral internal iliac artery ligation with those of controls.

Methods

Thirteen women who underwent bilateral internal iliac artery ligation for severe postpartum hemorrhage (PPH) were matched with 15 healthy women of reproductive age. Transvaginal color and pulsed (duplex) Doppler modes were used to visualize the pelvic arteries. The pulsatility index, the resistance index, the systolic/diastolic blood flow ratio, the peak systolic velocity, and the end-diastolic velocity were measured.

Results

The mean age was 26.1 ± 5.2 years in the study group and 27.0 ± 5.4 years in the control group. All participants had regular menstrual periods. There were no significant differences between the groups regarding each of the vascular indices for the uterine, arcuate, and ovarian arteries.

Conclusion

These findings are consistent with published data demonstrating that pelvic circulation is not compromised after bilateral internal iliac artery ligation.     

A comparison of reproductive outcomes following hysteroscopic management versus dilatation and curettage of retained products of conception

Objective

To compare the reproductive outcome of women who underwent blind dilatation and curettage (D&C) with those who underwent hysteroscopic resection of pathologically confirmed retained products of conception (RPOC).

Methods

Medical records of women who underwent either D&C or hysteroscopic resection of RPOC at Assaf Harofeh Medical Center, Israel, between 2000 and 2010 were retrospectively reviewed.

Results

A total of 177 women with pathologically confirmed RPOC underwent either D&C (n = 94, 53.1%) or hysteroscopy (n = 83, 46.9%). Mean time to conception was significantly shorter after hysteroscopy than after D&C (7.4 ± 7 vs 12.9 ± 16.8 months, P = 0.037). Rate of occurrence of a newly diagnosed infertility problem was significantly higher following D&C than hysteroscopy (23 [24.5%] vs 10 [12.0%]; P = 0.034). Etiology of the new problem was mechanical, including tubal occlusion and intrauterine adhesions. Logistic regression comparing both methods revealed that hysteroscopic resection was associated with a significant reduction in the occurrence of a new infertility problem compared with D&C (OR 0.42; 95% CI, 0.18–0.96, P = 0.04).

Conclusion

Hysteroscopic removal of RPOC is associated with a shorter mean time to further conception and a lower rate of occurrence of newly diagnosed infertility problems than D&C.     

Abdominal electromyography may predict the response to tocolysis in preterm labor

Objective

To determine whether abdominal electromyography can predict the response to tocolysis in pregnant women in preterm labor.

Study design

This study was carried out at the Department of Obstetrics and Gynecology, Menofyia University Hospital in Egypt. Fifty pregnant women in preterm labor who fulfilled the inclusion criteria were enrolled. Baseline abdominal electromyography was performed. Tocolysis in the form of hexoprenaline sulphate infusion was started for all women and electromyography was repeated after 24 h in responders but only after 6 h in non responders. The receiver operating characteristics curve was drawn to calculate specificity of the electromyography at 100% sensitivity. Results were tabulated and statistically analyzed.

Results

Forty women responded to tocolysis by delaying delivery for more than 48 h. There was a significant reduction in the frequency of uterine contractions after tocolysis (3.76 ± 0.92 versus 2.32 ± 2.05 contractions per 10 min; P < 0.001). Similar significant reductions affected the duration and amplitude of uterine action potentials (25.08 ± 9.74 versus 14.4 ± 17.16 s; P < 0.001, 40.8 ±  25.89 versus 28.32 ± 29.38 mV; P < 0.001). At a sensitivity of 100% and using ROC curve, abdominal electromyography of amplitude of 82 mV lasting for 30 s or more had a specificity of 90%, positive and negative predictive values of 67% and 95%, and a diagnostic accuracy of 88% in predicting preterm labor.

Conclusion

Abdominal electromyography may predict the response to tocolysis in preterm labor.     

Improved quality of life is partly explained by fewer symptoms after treatment of fibroids with mifepristone

Objective

To examine mediators of mifepristone treatment on improvements in health-related quality of life (HRQOL) among women with symptomatic fibroids.

Methods

The study sample included women with symptomatic uterine fibroids who were treated with 5 mg or 2.5 mg of mifepristone or placebo. Assessments of uterine size (ultrasound), pain (McGill pain questionnaire), bleeding (diary), anemia (gm/dL), and HRQOL measured using the uterine fibroid symptom quality of life scale were done at baseline, 3 months, and 6 months. The improvements in HRQOL that could be explained by changes in these clinical factors were assessed.

Results

The final sample included 62 women. Treatment with mifepristone was associated with significant improvement in HRQOL, which was explained in part by reduction in pain (28%, P < 0.001) and bleeding (18%, P < 0.001). Reduction in uterine volume was of marginal significance (P = 0.05) and was associated with a decrease in HRQOL (7%). Much of the impact of treatment on HRQOL (61%) remained unexplained in this model.

Conclusions

Improvements in HRQOL after treatment with mifepristone are partly explained by improvements in pain and bleeding, but not uterine size. However, most of the improvement in HRQOL is not explained by improvements in these clinical parameters.     

Bilateral uterine artery ligation plus B-Lynch procedure for atonic postpartum hemorrhage with placenta accreta

Objective

To assess the effectiveness of bilateral uterine artery ligation followed by B-Lynch compression suturing in women with atonic postpartum hemorrhage and placental site bleeding due to adherent placenta accreta.

Method

This protocol was followed in 26 women undergoing cesarean delivery for placenta accreta.

Results

Two women died from disseminated intravascular coagulopathy. In the remaining 24 women, placental remnants completely disappeared within 8 months and ovulation resumed after a mean ± SD of 51.6 ± 3.2 days. Moreover, 18 women (75%) became pregnant within 12 months.

Conclusion

Atonic postpartum hemorrhage and placental site bleeding due to adherent placenta accreta can be safely controlled by bilateral uterine artery ligation followed by B-Lynch compression suturing in women who desire to remain fertile.     

Immunohistochemical expression of estrogen and progesterone receptors and outcomes in patients with newly diagnosed uterine leiomyosarcoma

Objective

We assessed the IHC expression of ER and PR and their prognostic significance in uterine leiomyosarcoma (LMS).

Methods

We identified 43 “high-grade” uterine LMS cases from 7/82-7/07 for whom ER/PR IHC analysis was performed at initial diagnosis at our institution.

Results

Disease was confined to the uterine body in 20/43 (47%). Eighteen (42%) of 43 were ER(+); 17/42 (41%) were PR(+). At last follow-up, 33 (77%) had recurred or progressed, and 23 (54%) had died. PR expression was associated with improved progression-free survival (PFS; P = 0.002) and overall survival (OS; P = 0.03) overall; ER expression was not. After adjusting for stage, ER expression was associated with PFS (P = 0.01), not OS (P = 0.3), and PR expression maintained a significant association with PFS (P = 0.002) and approached a significant association with OS (P = 0.05). Neither ER nor PR expression was associated with outcome in cases with disease outside the uterine body. In cases with confined disease, median PFS for ER(+) or PR(+) cases was not reached compared to 16.9 months for ER(−) cases (95% CI: 8.1-25.7; P = 0.03) and 13.5 months for PR(−) cases (95% CI: 5.9-21.1; P = 0.001). Only 1/10 PR(+) cases recurred and died; 9/10 PR(−) cases recurred, and 5 died. Two of 9 ER(+) cases recurred and died; 8/11 ER(−) cases recurred, and 4 died.

Conclusion

ER/PR expression is associated with survival outcomes in patients with high-grade uterine LMS confined to the uterine body. PR expression seems capable of identifying cases confined to the uterine body, which have better outcomes.     

Uterosacral-cardinal ligament stretching prior to vaginal hysterectomy increases uterine descent: a novel technique

Objective

To examine the effect of uterosacral-cardinal ligament complex stretching prior to vaginal hysterectomy on uterine descent.

Study design

A prospective trial of 25 consecutive women undergoing vaginal hysterectomy. Pre-operative, apical, anterior and posterior wall POP-Q measurements were recorded for each patient before and after uterosacral-cardinal ligament complex stretching during general anesthesia.

Results

Uterosacral-cardinal ligament complex stretching yielded a significant increase in mean stage of uterine and anterior wall descent (2.6 ± 0.6 vs. 3.2 ± 0.6 cm, p < 0.001, and 2.5 ± 0.8 vs. 2.9 ± 0.8 cm, respectively, p < 0.004). There was no significant change in posterior wall prolapse measurements (1.3 ± 0.7 vs. 1.4 ± 0.8 cm, p = 0.05).

Conclusion

Uterosacral-cardinal ligament complex stretching prior to vaginal hysterectomy increase uterine descent.     

Doppler study of uterine hemodynamics in women with unexplained infertility

Objective

To evaluate uterine artery blood flow using pulsed Doppler, and endometrial and subendometrial microvascularization using three-dimensional (3D) power Doppler, in women with unexplained infertility.

Study design

In a prospective clinical trial at a university teaching hospital, 40 women with unexplained infertility were compared to 40 fertile parous controls. In the mid-luteal (peri-implantation) phase, the endometrial thickness and volume, uterine artery pulsatility index (PI) and resistance index (RI), endometrial and subendometrial 3D power Doppler vascularization index (VI), flow index (FI), and vascularization flow index (VFI), and serum estradiol and progesterone levels were measured in both groups.

Results

The uterine artery PI (P = 0.003) and RI (P = 0.007) were significantly increased and the endometrial VI (P = 0.029), FI (P = 0.031), and VFI (P = 0.001) and subendometrial VI (P = 0.032), FI (P = 0.040), and VFI (P = 0.005) were significantly decreased in the unexplained infertility group. The endometrial thickness and volume and serum estradiol and progesterone levels, however, were not significantly different between the two groups.

Conclusion

Peri-implantation endometrial perfusion is impaired in women with unexplained infertility: Doppler study of uterine hemodynamics should therefore be considered in infertility work-up.     

Urodynamic findings in women with pelvic organ prolapse and obstructive voiding symptoms

Objective

To determine whether obstructive voiding symptoms in women with advanced pelvic organ prolapse (POP) were associated with objective bladder outflow tract obstruction.

Methods

We reviewed preoperative data from patients with advanced POP who underwent surgical correction at the Department of Obstetrics and Gynecology, Carmel Medical Center, Haifa, Israel, between December 1, 2005, and November 30, 2007. Obstructive voiding symptoms were recorded from Pelvic Floor Distress Inventory-20 questionnaires.

Results

Of the 81 women aged 44-80 years who were included in the study, 40 (49.4%) reported incomplete bladder emptying preoperatively. There was no significant difference between these women and asymptomatic women in terms of demographic and clinical parameters such as age, parity, and stage of prolapse. Furthermore, there was no significant difference with regard to postvoid residual bladder volume (52.8 ± 65.8 vs 41.6 ± 41.2 mL), maximal (23.8 ± 11 vs 21.9 ± 9.6 mL/second) and average (10.3 ± 6.2 vs 9.3 ± 4 mL/second) urinary flow velocities, prevalence of increased postvoid residual volume (10.0% vs 4.8%), or obstructive urinary flow (17.5% vs 7.3%).

Conclusion

Almost half of all women with advanced POP experienced incomplete bladder emptying; however, this symptom did not correlate with objective urodynamic bladder outflow tract obstruction.     

Doppler analysis of uterine perfusion and ovarian stromal blood flow in polycystic ovary syndrome

Objective

To investigate blood flow velocity in the ovarian stromal artery and uterine artery in women with polycystic ovary syndrome (PCOS) and to correlate these velocities with clinical and biochemical parameters.

Methods

A prospective study was carried out in 55 patients with PCOS and 42 age-matched women who did not have PCOS. Clinical, biochemical, and hormonal characteristics, and utero-ovarian Doppler ultrasound blood flow parameters were determined, and correlations between the parameters were evaluated.

Results

Ovarian stromal blood flow was higher (P < 0.01) and uterine perfusion was lower (P < 0.01) in women with PCOS compared with women who did not have PCOS. Ovarian stromal artery pulsatility index (PI) was inversely correlated with levels of dehydroepiandrosterone sulfate (DHEAS) and insulin-like growth factor-1, and with the luteinizing hormone/follicle-stimulating hormone ratio. There was a positive correlation between uterine artery PI and DHEAS level.

Conclusion

Doppler analysis of the uterine and intraovarian arteries may provide additional information about the etiopathogenesis of PCOS and partly explain the clinical implications of the condition.     

HDL concentration, lipid transfer to HDL, and HDL size in normolipidemic nonobese menopausal women

Objective

To determine the impact of menopause on lipid transfer from donor lipoproteins to high-density lipoproteins (HDLs)—a process that is related to the protective function of HDL—and the size of HDL particles.

Method

Plasma from 22 premenopausal and 18 postmenopausal nonobese, normolipidemic women paired for age (40-50 years) was incubated in an artificial nanoemulsion labeled with radioactive lipids. Then the HDL fraction was assessed for radioactivity; the percentage of radioactive lipids transferred from the nanoemulsion to HDL was determined; and the size of HDL particles was measured by laser light scattering.

Results

There were no differences between the 2 groups in serum concentration of HDL cholesterol (61 ± 12 mg/dL vs 61 ± 14 mg/dL) or apolipoprotein A₁ (1.5 ± 0.3 g/L vs 1.5 ± 0.2 g/L); lipid transfer to HDL; or size of HDL particles (8.8 ± 0.8 vs 9.0 ± 0.5 nm).

Conclusion

Menopause was not found to affect HDL cholesterol plasma concentration, lipid transfer to HDL, or size of HDL particles in normolipidemic nonobese women.     

Apnea-hypopnea index in nonobese women with polycystic ovary syndrome

Objective

To assess the influence of polycystic ovary syndrome (PCOS) on respiratory events during sleep in nonobese Taiwanese women.

Method

Overnight polysomnography was recorded in 18 nonobese women with PCOS who had not received treatment (body mass index [BMI] 21.7 ± 0.57, age 29.1 ± 1.43 years) and in 10 age- and BMI-matched women without PCOS (BMI 20.9 ± 0.58, age 31.6 ± 3.87 years).

Results

The nonobese women with PCOS had a higher total apnea-hypopnea index (AHI) especially during the non-rapid eye movement stage (AHI_NREM) than the women who did not have PCOS. The women with PCOS had higher serum levels of high-sensitivity C-reactive protein (hsCRP) and this was positively correlated with AHI_REM. Total testosterone level was positively correlated with AHI_NREM, and androstenedione was negatively correlated with AHI_NREM.

Conclusion

PCOS was directly linked to increased obstructive respiratory events during sleep in nonobese women in Taiwan.     

The value of hysteroscopy in diagnosis of chronic endometritis in patients with unexplained recurrent spontaneous abortion

Objectives

We performed this study in order to investigate the role of chronic endometritis (CE) in unexplained recurrent spontaneous abortion (RSA) and to determine the correlation between hysteroscopic and histologic findings of CE in patients with unexplained RSA. We also tried to find out the relation between CE and primary vs. secondary RSA.

Study design

One hundred and forty-two consecutive patients with unexplained RSA and 154 fertile women were enrolled in this study. All the patients and controls underwent hysteroscopy and, at the same time, endometrial biopsy. CE was suspected when hysteroscopy revealed signs of focal or diffuse endometrial hyperemia or endometrial endopolyps (less than 1 mm in size). Histopathologic diagnosis of CE was based on superficial stromal edema, increased stromal density, and pleomorphic stromal inflammatory infiltrate dominated by lymphocytes and plasma cells. Results were compared between cases and controls as well as those with primary (n = 61) and secondary (n = 81) RSA.

Results

Patients with RSA had a significantly higher incidence of CE both hysteroscopically (67.6% vs. 27.3%; p < 0.0001) and pathologically (42.9% vs. 18.2%; p < 0.0001). The sensitivity, specificity, positive predictive value and negative predictive value of hysteroscopy in the diagnosis of CE were found to be 98.4%, 56.23%, 63.5% and 97.82% respectively. Patients with secondary RSA had a higher prevalence of CE both pathologically (83.9% vs. 45.9%; p < 0.0001) and hysteroscopically (58.1% vs. 24.6%; p < 0.0001).

Conclusion

CE is associated with unexplained RSA. Hysteroscopy, with high sensitivity and acceptable specificity, is suitable for the diagnosis of CE in those with unexplained RSA. CE should be taken into consideration in those with secondary unexplained RSA.