Successful intrauterine pregnancy after endometrial ablation

The frequency of pregnancy after endometrial ablation is reported in the literature to be 0.7%, with a variety of complications and adverse outcomes for the fetus. A 30-year-old woman underwent rollerball endometrial ablation for menometrorrhagia. Her menses returned to normal and she conceived 16 months later. The pregnancy was uncomplicated apart from diet-controlled gestational diabetes and cesarean delivery for a transverse lie. To our knowledge, this is the first literature report of a viable pregnancy after rollerball ablation.     

Successful pregnancy after microwave endometrial ablation: case report

We present details of a 39-year-old para 3 woman, who was treated with microwave endometrial ablation (MEA) for menorrhagia after previous failed medical treatments. She then presented at 8 weeks after the procedure and was confirmed to have an 8-week viable intrauterine pregnancy. She was counselled, but, based on the fact that there was no published literature about the effects of MEA on pregnancy, she decided to have a medical termination and she subsequently got pregnant again and had a healthy baby girl. There was no complication in pregnancy and delivery.     

Successful planned pregnancy following endometrial ablation with the YAG laser

In selected patients who previously have undergone YAG laser ablation of the endometrium and who have demonstrated normal intrauterine architecture, pregnancy as a planned event may be a reasonable and safe option.     

Artificial sapphire contact probes in Nd:YAG endometrial ablation: a quantitative in vitro and in vivo study

Artificial sapphire contact probes offer theoretical advantages in Nd:YAG endometrial ablation. To examine this, an in vitro and in vivo study of laser-tissue interaction was performed. In vitro, a linear correlation was found between applied energy and total depth of effect, that is, photovaporization and photocoagulation. Using a Round (MTR 1.5) contact probe, an applied energy of 30 joules gave a depth of myometrial effect of 3.3 mm. In vivo, there was a significant reduction in tissue effect (p less than 0.001) compared to in vitro. Difficulty of manipulation of the contact laser probe within the uterus also caused a significant reduction (p less than 0.001) in depth of tissue ablation achieved on the posterior uterine wall compared with that achievable at the uterine fundus, but this may be counteracted by increasing applied energy.     

Five-year follow-up of endometrial ablation: endometrial coagulation versus endometrial resection

OBJECTIVE: A randomized, controlled trial was performed to compare the patient complication rate, effectiveness, and satisfaction rate of transcervical hysteroscopic endometrial coagulation versus endometrial resection in the treatment for heavy dysfunctional bleeding. METHODS: One hundred and twenty women requiring endometrial ablation for the treatment of heavy bleeding disorders entered the study. All patients were offered a clinical examination 24 months postoperatively and had a questionnaire by mail 5 years after the initial treatment. The number of complications during and after the operation, re-ablations, and hysterectomies were registered. A bleeding index and the patient satisfaction rate were stated. RESULTS: Sixty-one patients were treated by endometrial coagulation, and 59 were treated by endometrial resection. No differences between the two groups were observed concerning fluid absorption, bleeding, perforation, and infection. At the 5-year follow-up, 64% of the patients had only one ablation, 15% were treated twice, 15% had a hysterectomy, and 6% were lost to follow-up. After 5 years, the bleeding index was halved in patients with menses. Seventy-nine percent of the women would recommend the treatment to their best female friend. CONCLUSION: We found no significant differences in the frequency of complications. Only 15% of the women had a hysterectomy after 5 years. No significant difference was observed with respect to bleeding reduction and patient satisfaction in the two groups.     

Advances in endometrial ablation

The evolution of the surgical treatment of dysfunctional uterine bleeding has resulted in the design and manufacture of instrumentation that is minimally invasive, has a low risk profile, and is technically simple to operate. Whereas hysterectomy was the only definitive surgical option before 1981, operative hysteroscopy with transcervical resection of the endometrium and rollerball ablation of the endometrium gained favor in the mid-1980s and 1990s. During the past 10 years, devices dedicated entirely to the ablation (or destruction) of the endometrium have been designed, modeled, tested, and approved for clinical use in the United States. This review describes the methods by which the technologies are evaluated and approved for clinical use by the Food and Drug Administration. In addition, the reported efficacy of each approved device is reviewed. The complications associated with the devices, as well as the potential long-term risks of endometrial ablation, also are reported. Finally, the cost for device disposables and nondisposables is presented. TARGET AUDIENCE: Obstetricians & Gynecologists, Family Physicians LEARNING OBJECTIVES: After completion of this article, the reader will be able to list the various FDA-approved uterine ablation devices, compare the effectiveness of the various uterine ablation devices, and summarize the various adverse events associated with the use of the uterine ablation devices.     

Outpatient endometrial ablation

The simplicity of use and short treatment times of second-generation ablation techniques have increased the likelihood of acceptable treatment under local anaesthetic. Once treatment under local anaesthesia +/- conscious sedation has become accepted, the next step is to explore the viability of moving ablation out of theatre. Whilst there are many series reports of treatment under local anaesthetic, few well-constructed trials have evaluated acceptability and success rates. A reliable anaesthetic regime is available with low failure rates, although problems exist with unpredictable post-operative discomfort and nausea. The optimal treatment package, which will guarantee acceptable treatment with no failures and a quick recovery time allowing for early discharge, is not known. This, along with equipment requirements, safety issues and the need for well-trained support staff, will make outpatient ablation unattractive at present for all but the most determined gynaecologists who have supportive and dynamic staff.     

Second-generation endometrial ablation: an overview

Various methods exist to destroy the endometrium as a treatment for menorrhagia. This chapter discusses the rationale, evidence, indications, and long-term safety and efficacy of the current techniques. It also discusses endometrial ablation in the context of its clinical utility in comparison with the existing alternative treatments.     

Second-generation endometrial ablation treatment: Novasure

The Novasure endometrial ablation system consists of a single-use device and a radiofrequency controller. It is a three-dimensional, triangular-shaped bipolar ablation device. The generator functions at 500 kHz and has a power cut-off limit set at a tissue impedance of 50 Ohms. The self-terminating procedure is based on tissue impedance or time. A cavity assessment system works to detect perforations in the uterine cavity. No pretreatment is necessary. Randomized controlled trials have shown that the Novasure system has an amenorrhoea rate of 44-56% at 1-year follow-up, and the 5-year results of a randomized trial will be published shortly. Prospective observational studies show even higher amenorrhoea rates of up to 58-75% up to 5-year follow-up. Hysterectomy rates in the prospective trial were very low (4%). In summary, the Novasure endometrial ablation system is an effective second-generation ablation technique, resulting in a high percentage of amenorrhoea.     

Prognostic factors that predict success in office endometrial ablation: a retrospective study

The objective of the cohort study was to identify clinical factors that influence the rate of further surgical intervention in women who had endometrial ablation. Electronic databases and patient records were scrutinised to obtain examination, investigative and procedural data considered to be potentially predictive of the need for further surgical intervention after endometrial ablation in the office setting. A total of 391 consecutive women were identified who received endometrial ablation in the office setting between July 2005 and December 2012, with an average follow-up of 4.3 years. Univariable and multivariable logistic regressions were used to estimate the influence of these variables on prognosis. Factors predictive of further surgical treatment were dysmenorrhea (odds ratio [OR] 4.01; 95 % CI 1.63 to 9.91) and a uterine cavity length >9 cm (OR 2.65; 95 % CI 1.33 to 5.27). In conclusion, dysmenorrhoea before treatment or a uterine cavity length >9 cm was associated with the need for further surgical interventions after office endometrial ablation. These findings should help inform clinician and patient upon decision-making when considering treatment options for heavy menstrual bleeding.     

Randomised controlled trial of bipolar radio-frequency endometrial ablation and balloon endometrial ablation

OBJECTIVE: To compare the effectiveness of two second-generation ablation techniques, bipolar radio-frequency impedance-controlled endometrial ablation (NovaSure) and balloon ablation (ThermaChoice), in the treatment of menorrhagia. DESIGN: Double-blind, randomised, controlled trial. SETTING: A large teaching hospital with 500 beds in The Netherlands. POPULATION: Women suffering from menorrhagia referred by their general practitioner. METHODS: Women suffering from menorrhagia, without intracavitary abnormalities, were randomly allocated to bipolar radio-frequency ablation (bipolar group) and balloon ablation (balloon group) in a 2:1 ratio. At follow up, both women and observers were unaware of the type of treatment that had been performed. MAIN OUTCOME MEASURES: The main outcome measure was amenorrhea at 3, 6 and 12 months after randomisation. RESULTS: One hundred and twenty-six women were included in the study, of which 83 were allocated to the bipolar group, and 43 to the balloon group. No complications occurred in either of the treatment groups. At the one-year follow up stage, amenorrhea rates were 43% (34/83) in the bipolar group and 8% (3/43) in the balloon group (treatment effect in time P < 0.001). At this stage, 90% of the patients in the bipolar group were satisfied with the result of the treatment against 79% in the balloon group (treatment effect in time P= 0.003). CONCLUSION: The bipolar radio-frequency impedance-controlled endometrial ablation system is more effective than balloon ablation in the treatment of menorrhagia.     

Microwave endometrial ablation versus endometrial resection: a randomized controlled trial

OBJECTIVE: To compare menstrual status, satisfaction, and acceptability of microwave endometrial ablation with transcervical endometrial resection for the treatment of heavy menstrual bleeding. METHODS: Women were randomized to either endometrial ablative method. Menstrual status, satisfaction, acceptability, and changes in health-related quality of life were obtained by a self-completed questionnaire. Case note review and personal communication identified further surgery rates at 2 years after each procedure. RESULTS: Among the original 263 women who underwent endometrial ablation, 249 (95%) returned questionnaires at 2 years. Menstrual status in both groups was similar, although the amenorrhea rate was higher after microwave endometrial ablation. Seventy-nine percent of women were either completely or generally satisfied after microwave ablation compared with 67% after transcervical endometrial resection. Health-related quality-of-life scores remained higher than at recruitment for both treatments. Hysterectomy rates were similar at 2 years (11.6% after microwave endometrial ablation and 12.7% after transcervical endometrial resection), and no repeat endometrial ablative procedures were required. CONCLUSION: Microwave endometrial ablation is an effective alternative to transcervical endometrial resection for dysfunctional uterine bleeding.     

Hysterectomy after endometrial ablation

OBJECTIVES: Our purpose was to determine the number of women undergoing hysterectomy after endometrial ablation and the indications for the subsequent surgery. STUDY DESIGN: Forty-two premenopausal women, who had severe menorrhagia associated with a clinically normal examination result, underwent rollerball endometrial ablation between November 1990 and December 1991. Thirty-seven women whom we gave ongoing care were evaluated by chart review. Four women who received care elsewhere were interviewed by telephone. One woman was lost to follow-up. Patients were followed up a minimum of 4 years. Age, parity, operating time, endometrial preparation, preablation sterilization, and preablation dysmenorrhea were assessed in regard to subsequent hysterectomy. Patient satisfaction was assessed at 24 months. Life-table analysis was performed to determine cumulative probability of hysterectomy. RESULTS: Fourteen of the 41 women (34%) underwent hysterectomy within 5 years after rollerball endometrial ablation. Continued abnormal menstrual bleeding and menstrual pain were significantly associated with subsequent hysterectomy. Eleven of the 14 cases of hysterectomy were associated with gross abnormality such as myomas, adenomyosis, endometriosis, and chronic hematosalpinx. A linear relationship between hysterectomy and time was noted. CONCLUSION: On the basis of our findings one third of women undergoing rollerball endometrial ablation for menorrhagia can expect to have a hysterectomy within 5 years. If the linear relationship noted during the first 5 years is extrapolated, theoretically, all women may need hysterectomy by 13 years. Most patients undergo hysterectomy because of significant pelvic abnormality. Further studies with long-term follow-up are needed to define the role of endometrial ablation for menorrhagia. (Am J Obstet Gynecol 1996;175:1432-7.)