Hashimoto's Thyroiditis Negatively Influences Intracytoplasmic Sperm Injection Outcome in Euthyroid Women on T4 Substitution Therapy: A Retrospective Study.

OBJECTIVE: The objective of this study was to analyze the impact of thyroid autoimmunity (TAI) on reproductive outcome parameters of intracytoplasmic sperm injection (ICSI) cycles as compared to TAI-negative ICSI cycles. DESIGN: In this single in vitro fertilization (IVF) center retrospective study, 86 infertile women with elevated thyroid peroxidase or TGAb levels, but euthyroid after thyroxine replacement (study group), were compared to 69 female patients with no thyroid abnormalities (controls). Following ICSI treatment fertilization rate (FR), clinical pregnancy rate (CPR), miscarriage rate (MR), and live birth rate (LBR) were analyzed. MATERIALS, SETTING, METHODS: All subjects with various infertility factors were treated with ICSI in university-based IVF center. Patients in the study group received thyroxine replacement and were euthyroid at IVF treatment. Before the IVF cycles, endocrinological parameters were uniformly assessed: thyroid function and antibodies, reproductive hormones (anti-Müllerian hormone [AMH], follicular stimulating hormone [FSH], luteinizing hormone, E2, PRL, testosterone, DHEAS, 17-OHP, AD) and OGTT (0-60-120 min glucose and insulin). Following descriptive comparison of laboratory parameters, age-adjusted analyses of FR, CPR, MR, and LBR were performed. RESULTS: TAI-positive women were older (mean age 35.31 ± 4.95 vs. 32.15 ± 4.87 years; p = 0.002), had higher FSH (8.4 ± 3.4 vs. 7.4 ± 2.32 U/L; p = 0.024), higher E2 (53.94 ± 47.61 vs. 42.93 ± 18.92 pg/mL; p = 0.025) levels, while AMH (2.88 ± 2.62 vs. 3.61 ± 1.69 ng/mL; p = 0.0002) was lower. There were no differences in TSH levels (1.64 ± 0.96 vs. 1.66 ± 0.65 µIU/mL; p = 0.652) between the two groups. FT3 (2.63 ± 0.58 vs. 2.98 ± 0.55 pg/mL; p = 0.002) was lower and FT4 (1.3 ± 0.29 vs. 1.13 ± 0.21 ng/dL; p = 0.0002) was higher in the TAI-positive group, reflecting clinically irrelevant differences. Egg cell counts (6 ± 3.8 vs. 7.5 ± 3.95; p = 0.015) were lower in TAI and remained so following age adjustment. Although the overall ICSI FR did not differ (62.9% vs. 69.1%, p = 0.12), it was lower for patients under 35 with TAI showing decreasing differences in line with age. The CPR (36.04% vs. 69.56%; p < 0.001) and LBR (23.25% vs. 60.86%; p < 0.001) were lower, the MR (35.48% vs. 12.5%; p = 0.024) was higher in the TAI group, and these differences remained after age adjustment. LIMITATIONS: Since the higher age of the study group may interfere with the effect of TAI, age adjustment calculations were necessary to perform to eliminate this confounding factor. CONCLUSION: Despite optimal thyroid supplementation in clinical or subclinical hypothyroidism, the presence of TAI negatively influences CPR and is connected to a higher MR, thus resulting in a lower LBR after ICSI. Decreased FR with ICSI in TAI patients may also contribute to poorer outcomes, especially in younger women.

Uterine cervical stenosis: from classification to advances in management. Overcoming the obstacles to access the uterine cavity.

BACKGROUND: To date hysteroscopy is the gold standard technique for the evaluation and management of intrauterine pathologies. The cervical canal represents the access route to the uterine cavity. The presence of cervical stenosis often makes entry into the uterine cavity difficult and occasionally impossible. Cervical stenosis has a multifactorial etiology. It is the result of adhesion processes that can lead to the narrowing or total obliteration of the cervical canal. PURPOSE: In this review, we summarize the scientific evidence about cervical stenosis, aiming to identify the best strategy to overcome this challenging condition. METHODS: The literature review followed the scale for the quality assessment of narrative review articles (SANRA). All articles describing the hysteroscopic management of cervical stenosis were considered eligible. Only original papers that reported data on the topic were included. RESULTS: Various strategies have been proposed to address cervical stenosis, including surgical and non-surgical methods. Medical treatments such as the preprocedural use of cervical-ripening agents or osmotic dilators have been explored. Surgical options include the use of cervical dilators and hysteroscopic treatments. CONCLUSIONS: Cervical stenosis can present challenges in achieving successful intrauterine procedures. Operative hysteroscopy has been shown to have the highest success rate, particularly in cases of severe cervical stenosis, and is currently considered the gold standard for managing this condition. Despite the availability of miniaturized instruments that have made the management of cervical stenosis more feasible, it remains a complex task, even for experienced hysteroscopists.

Distinguishing the Uterine Artery, the Ureter, and Nerves in Laparoscopic Surgical Images Using Ensembles of Binary Semantic Segmentation Networks.

Performing a minimally invasive surgery comes with a significant advantage regarding rehabilitating the patient after the operation. But it also causes difficulties, mainly for the surgeon or expert who performs the surgical intervention, since only visual information is available and they cannot use their tactile senses during keyhole surgeries. This is the case with laparoscopic hysterectomy since some organs are also difficult to distinguish based on visual information, making laparoscope-based hysterectomy challenging. In this paper, we propose a solution based on semantic segmentation, which can create pixel-accurate predictions of surgical images and differentiate the uterine arteries, ureters, and nerves. We trained three binary semantic segmentation models based on the U-Net architecture with the EfficientNet-b3 encoder; then, we developed two ensemble techniques that enhanced the segmentation performance. Our pixel-wise ensemble examines the segmentation map of the binary networks on the lowest level of pixels. The other algorithm developed is a region-based ensemble technique that takes this examination to a higher level and makes the ensemble based on every connected component detected by the binary segmentation networks. We also introduced and trained a classic multi-class semantic segmentation model as a reference and compared it to the ensemble-based approaches. We used 586 manually annotated images from 38 surgical videos for this research and published this dataset.

Risk of endometrial cancer in asymptomatic postmenopausal women in relation to ultrasonographic endometrial thickness: systematic review and diagnostic test accuracy meta-analysis.

OBJECTIVE: This study aimed to evaluate the risk of endometrial carcinoma and atypical endometrial hyperplasia in asymptomatic postmenopausal women concerning the endometrial thickness measured by stratified threshold categories used for performing subsequent endometrial sampling and histologic evaluation. DATA SOURCES: MEDLINE, Scopus, ClinicalTrials.gov, SciELO, Embase, the Cochrane Central Register of Controlled Trials, LILACS, conference proceedings, and international controlled trials registries were searched without temporal, geographic, or language restrictions. STUDY ELIGIBILITY CRITERIA: Studies were selected if they had a crossover design evaluating the risk of atypical endometrial hyperplasia and endometrial carcinoma in postmenopausal asymptomatic women and calculated the diagnostic accuracy of transvaginal ultrasonography thresholds (at least 3.0 mm) confirmed by histopathologic diagnosis. METHODS: This was a systematic review and diagnostic test accuracy meta-analysis according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses of Diagnostic Test Accuracy and Synthesizing Evidence from Diagnostic Accuracy Tests guidelines. Endometrial thickness thresholds were grouped as follows: from 3.0 to 5.9 mm; between 6.0 and 9.9 mm; between 10.0 and 13.9 mm; and ≥14.0 mm. Quality assessment was performed using the Quality Assessment Tool for Diagnostic Accuracy Studies 2 tool. Publication bias was quantified using the Deek funnel plot test. Coprimary outcomes were the risk of atypical endometrial hyperplasia or endometrial carcinoma according to the endometrial thickness and diagnostic accuracy of each threshold group. RESULTS: A total of 18 studies provided the data of 10,334 women who were all included in the final analysis. Overall, at an endometrial thickness threshold of at least 3.0 mm, the risk of atypical endometrial hyperplasia or endometrial carcinoma was increased 3-fold relative to women below the cutoff (relative risk, 3.77; 95% confidence interval, 2.26-6.32; I2=74%). Similar degrees of risk were reported for thresholds between 3.0 and 5.9 mm (relative risk, 5.08; 95% confidence interval, 2.26-11.41; I2=0%), 6.0 and 9.9 mm (relative risk, 4.34; 95% confidence interval, 1.68-11.23; I2=0%), 10.0 and 13.9 mm (relative risk, 4.11; 95% confidence interval, 1.55-10.87; I2=86%), and ≥14.0 mm (relative risk, 2.53; 95% confidence interval, 1.04-6.16; I2=78%) with no significant difference among subgroups (P=.885). Regarding diagnostic accuracy, the pooled sensitivity decreased from thresholds below 5.9 mm (relative risk, 0.81; 95% confidence interval, 0.49-0.85) to above 14.0 mm (relative risk, 0.28; 95% confidence interval, 0.18-0.40). Furthermore, the specificity increased from 0.70 (95% confidence interval, 0.61-0.78) for endometrial thickness between 3.0 and 5.9 mm to 0.86 (95% confidence interval, 0.71-0.94) when the endometrial thickness is ≥14.0 mm. For 3.0 to 5.9 mm and 10.0 to 13.9 mm thresholds, the highest diagnostic odds ratios of 10 (95% confidence interval, 3-41) and 11 (95% confidence interval, 2-49), with areas under the curve of 0.81 (95% confidence interval, 0.77-0.84) and 0.82 (95% confidence interval, 0.79-0.86), respectively, were retrieved. The summary point analysis revealed that the 3.0 to 5.9 mm cutoff point was placed higher in the summary receiver operator curve space than the other subgroups, indicating increased endometrial carcinoma or atypical endometrial hyperplasia diagnosis using these cutoffs. CONCLUSION: Both low and high endometrial thickness thresholds in postmenopausal asymptomatic women seem equally effective in detecting endometrial carcinoma and atypical endometrial hyperplasia. However, although using a 3.0 to 5.9 mm cutoff results in a lower specificity, the offsetting improvement in sensitivity may justify using this cutoff for further endometrial evaluation in patients with suspected endometrial malignancy.

Effects of transdermal versus oral hormone replacement therapy in postmenopause: a systematic review.

PURPOSE: To summarize available evidence comparing the transdermal and the oral administration routes of hormone replacement therapy (HRT) in postmenopausal women. METHODS: We performed a systematic review of the literature on multiple databases between January 1990 and December 2021. We included randomized controlled trials and observational studies comparing the transdermal and oral administration routes of estrogens for HRT in postmenopausal women regarding at least one of the outcomes of interest: cardiovascular risk, venous thromboembolism (VTE), lipid metabolism, carbohydrate metabolism, bone mineral density (BMD), and risk of pre-malignant and malignant endometrial lesions, or breast cancer. RESULTS: The systematic literature search identified a total of 1369 manuscripts, of which 51 were included. Most studies were observational and of good quality, whereas the majority of randomized controlled trials presented a high or medium risk of bias. Oral and transdermal administration routes are similar regarding BMD, glucose metabolism, and lipid profile improvements, as well as do not appear different regarding breast cancer, endometrial disease, and cardiovascular risk. Identified literature provides clear evidence only for the VTE risk, which is higher with the oral administration route. CONCLUSIONS: Available evidence comparing the transdermal and oral administration routes for HRT is limited and of low quality, recommending further investigations. VTE risk can be considered the clearest and strongest clinical difference between the two administration routes, supporting the transdermal HRT as safer than the oral administration route.

Fertility-Sparing Strategies for Early-Stage Endometrial Cancer: Stepping towards Precision Medicine Based on the Molecular Fingerprint.

Endometrial cancer represents the fifth most common cancer in women, and the most common gynecological malignancy in developed countries [...].

Reproductive outcomes after expectant and surgical management for tubal pregnancy: a retrospective study.

Background: The management of ectopic pregnancy is widely debated. Salpingectomy, salpingostomy, and expectant management are widely performed, but the best approach in terms of keeping good future spontaneous fertility chances is yet to be determined. Material and methods: We performed a retrospective analysis (Clinical Trial ID: NCT05479786) of the medical records of patients with an ultrasonographic or surgical diagnosis of tubal ectopic pregnancy that were admitted to the University of Debrecen Clinical Centre between 2012 and 2020. Results: A total of 312 patients were included in the analysis. Patients managed expectantly and patients treated with salpingostomy had significantly higher rates of clinical pregnancy than patients treated with salpingectomy. Pregnancy outcomes and recurrence rates were comparable between the study groups. Salpingectomy was found to decrease the likelihood of conceiving spontaneously by 65%. A stratified analysis based on serum ß-HCG levels demonstrated that all treatment modalities carry the same reproductive opportunities for patients presenting with ß-HCG levels ≤ 1745 IU/L. Conclusion: Salpingectomy was found to decrease the patient's chance of achieving a natural conception. Conservative approaches should be considered with caution only when the patient's clinical condition permits, and the patient is appropriately counseled.

Post-restoration grassland management overrides the effects of restoration methods in propagule-rich landscapes.

Grassland restoration is gaining momentum worldwide to tackle the loss of biodiversity and associated ecosystem services. Restoration methods and their effects on ecological community reassembly have been extensively studied across various grassland types, while the importance of post-restoration management has so far received less attention. Grassland management is an important surrogate for natural disturbances, with which most ancient grasslands have coevolved. Thus, without the reintroduction of management-related disturbance, restoration targets are unlikely to be achieved in restored grasslands. In this study, we aimed to explore how 20 yr of management by mowing once a year or light cattle grazing affects restoration success in Palearctic meadow-steppe grasslands restored by either sowing native grasses (sown sites), applying Medicago sativa as a nurse plant (Medicago sites), or allowing spontaneous succession (spontaneous sites). We found that, following mowing, sown sites maintained long-lasting establishment limitation, while Medicago sites experienced a delay in succession. These limitations resulted in low total and target species richness, low functional redundancy, and distinct species and functional composition compared to reference data from ancient grasslands. Spontaneous sites that were mowed reached a more advanced successional stage, although they did not reach reference levels regarding most vegetation descriptors. Sown and Medicago sites that were grazed had higher total and target species richness than those that were mowed, and showed restoration success similar to that of spontaneous sites, on which grazing had only moderate further positive effects. Grazed sites, irrespective of the restoration method, were uniformly species rich, functionally diverse, and functionally redundant, and thus became important biodiverse habitats with considerable resilience. We conclude that an optimally chosen post-restoration management may have an impact on long-term community reassembly comparable to the choice of restoration method. Restoration planners may, therefore, need to put more emphasis on future management than on the initial restoration method. However, our findings also imply that if local constraints, such as potentially high invasive propagule pressure, necessitate the application of restoration methods that could also hinder the establishment of target species, the long-term recovery of the grassland can still be ensured by wisely chosen post-restoration management.

Is there proof of transferability of laparoscopic psychomotor skills from the simulator laboratory to the operating room? Results from a systematic review.

This systematic review aims to understand better the translation of laparoscopic psychomotor skills, acquired in dry lab training, into a direct patient benefit in actual clinical practice in the operating room. The review was performed according to PRISMA guidance, searching database-specific filters for controlled trials: 'laparoscopy', 'simulator', 'surgical training', 'dry lab', 'psychomotor skills'. We included only RCTs in which the study population was the surgical trainee or novice surgeon with no prior simulation training, and the intervention was simulation training in laparoscopic surgery, regardless of subspecialty. Ten studies were included in this systematic review. The mean performance score was higher compared to the control groups. Fewer errors were noted in the intervention groups. No clinical patient outcomes (mortality, morbidity, quality of life) were addressed in these studies. All the trials were at high risk of bias. Training outside the operating room may lead to better surgical performance and less operative time. Nevertheless, additional studies with better designs are needed to provide more robust evidence.

Pain Management during Office Hysteroscopy: An Evidence-Based Approach.

Background and Objectives: Hysteroscopy is a reliable technique which is highly useful for the evaluation and management of intrauterine pathology. Recently, the widespread nature of in-office procedures without the need for anesthesia has been requesting validation of practical approach in order to reduce procedure-related pain. In this regard, we performed a comprehensive review of literature regarding pain management in office hysteroscopic procedures. Materials and Methods: MEDLINE, EMBASE, The Cochrane Library (Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, Cochrane Methodology Register), Global Health, Health Technology Assessment Database and Web of Science, other research registers (for example Clinical Trials database) were searched. We searched for all original articles regarding pain relief strategy during office hysteroscopy, without date restriction. Results have been collected and recommendations have been summarized according to the Appraisal of Guidelines for Research and Evaluation (AGREE) tool. Moreover, the strength of each recommendation was scored following the Grading of Recommendations Assessment (GRADE) system, in order to present the best available evidence. Results: Both pharmacological and non-pharmacological strategies for pain management are feasible and can be applied in office setting for hysteroscopic procedures. The selection of strategy should be modulated according to the characteristics of the patient and difficulty of the procedure. Conclusions: Accumulating evidence support the use of pharmacological and other pharmacological-free strategies for reducing pain during office hysteroscopy. Nevertheless, future research priorities should aim to identify the recommended approach (or combined approaches) according to the characteristics of the patient and difficulty of the procedure.

Hystero-salpingo scintigraphy for fallopian tubal patency assessment: results from a prospective study.

OBJECTIVE: To evaluate the diagnostic accuracy of a bygone method, hystero-salpingo-scintigraphy (HSSG), for tubal patency assessment of infertile women. MATERIAL AND METHODS: Prospective cohort study involving women in the infertility workup at the University of Debrecen, Hungary. Seventy infertile patients were scheduled to either basic dynamic HSSG, post-purge dynamic HSSG, or post-purge dynamic HSSG followed by SPECT/CT for reducing tracer contamination. The primary endpoint was the evaluation of the diagnostic accuracy of HSSG for the three methods. RESULTS: During the basic dynamic group, the examination yielded a sensitivity of 87.5%, with a specificity of 71.7%, while positive and negative predictive values were 31.8%, and 97.4% respectively. Using post purge dynamic HSSG, it resulted in a sensitivity of 87.5%, a specificity of 88.7%, a positive predictive value of 53.8%, and a negative predictive value of 97.9%. Adding SPECT/CT to post-purge dynamic HSSG increased diagnostic accuracy with 100% sensitivity and 88.7% specificity, while positive and negative predictive values were 57.1% and 100%, respectively. CONCLUSION: HSSG is a non-invasive and well-tolerated technique for tubal patency. It could be used initially to predict tubal patency in case of infertility. Its diagnostic accuracy is higher when it is carried out by adding SPECT/CT to the post-purge dynamic method.

Distension media delivery systems in hysteroscopy: past, present and future.

To examine the uterine cavity and/or to perform hysteroscopic surgery, one has to access the uterine cavity through the cervix, distend the cavity with a fluid (liquid or gas) to visualize it with a telescope and/or a camera system and use energy (mechanical or thermal) to affect and/or remove tissue. Distension of the uterine cavity then is an important component of hysteroscopy, and during the last century, numerous attempts have been made to achieve an undistorted and unobstructed panoramic view of the uterine cavity. In order to achieve this goal, the uterine cavity has been distended with fluids using a variety of techniques, including gravity-assisted systems, pressure cuffed systems, and electronic pumps. Excessive fluid intravasation during hysteroscopy can lead to significant complications, and hence, automated fluid delivery systems have been developed recently to provide a safe and more efficient method of fluid delivery. This review aims to describe the evolution of distension media delivery systems chronologically from the 1900s to the present day.

Hysteroscopy for Assessing Fallopian Tubal Obstruction: A Systematic Review and Diagnostic Test Accuracy Meta-analysis.

OBJECTIVE: To assess the diagnostic accuracy of hysteroscopy compared with that of laparoscopic chromopertubation for the detection of fallopian tubal obstruction. DATA SOURCES: An electronic search from inception to March 31, 2020, was performed in Medline, Scopus, EMBASE, and the Cochrane Central Register of Controlled Trials. METHODS OF STUDY SELECTION: This diagnostic accuracy meta-analysis was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses and Synthesizing Evidence from Diagnostic Accuracy Tests recommendations. A combination of the following Medical Subject Headings terms and keywords was included in the search strategy: "hysteroscopy[MeSH]," "tubal obstruction," "tubal patency," "tubal dysfunction," and "tubal blockage." Quality assessment of the included studies was conducted using the Quality Assessment Tool for Diagnostic Accuracy Studies-2 (University of Bristol, Bristol, United Kingdom). Publication bias was evaluated by means of the Deek funnel plot asymmetry test. The following outcomes were analyzed: diagnostic odds ratio, area under hierarchical summary receiver operating characteristic and area under receiver operating characteristic curve, sensitivity, specificity, and positive and negative likelihood ratios. TABULATION, INTEGRATION, AND RESULTS: Six studies comparing hysteroscopy with laparoscopic chromopertubation were included in the meta-analysis. After pooling all the studies, the diagnostic odds ratio was 43. The evaluated area under receiver operating characteristic curve was 0.93, correlating with high diagnostic accuracy for the index test. Sensitivity and specificity were 88% and 85%, respectively. In addition, the positive and negative likelihood ratios were 5.88 and 0.16, respectively. CONCLUSION: Hysteroscopic techniques are highly accurate and sensitive for detecting fallopian tubal obstruction. Interventional assessment enhances diagnostic accuracy compared with observational assessment, as does the office setting compared with the operating room. Additional studies, along with a refinement of the techniques, could facilitate the widespread use of hysteroscopic techniques for the detection of fallopian tube occlusion.

COVID 19 pandemic and minimally invasive gynecology: consequences and future perspectives.

The extent of the 2020 pandemic not only extends to the infected patients but also to patients who have been waiting for medical procedures. Reevaluation of the healthcare system is important in order to help assist the needs of intensive care units. The urgency of the gynaecological cases should be aligned based on surgical interventions and minimally invasive methods should be preferred. This will not endanger professional and other resource demands of ICUs. In acute cases, laparoscopy or hysteroscopy (preferring office hysteroscopy) should be chosen, that require no or only short period of hospitalization. Postponing non-acute surgeries is recommended to the post-pandemic period. Abbreviations: ICU: intensive care unit; COVID-19: coronavirus disease; SARS-CoV-2: severe acute respiratory syndrome Coronaviruses; IgM-IgG: immunoglobulin M; GAGP: aerosol generating procedures; PPE: personal protective equipment; ERAS: early recovery after surgery; mESAS: modified elective surgery acuity scale; RPOC: retained product of concept; PMB: postmenopausal bleeding.

Classification systems of Asherman's syndrome. An old problem with new directions.

Intrauterine adhesion (IUA) formation and the resulting Asherman's syndrome (AS) is an unfortunate clinical condition that occurs when the endometrium is damaged as a consequence of trauma, such as vigorous curettage, infection, or some Müllerian anomaly. The most frequent symptoms include hypo/amenorrhea, infertility, and adverse reproductive outcomes. Prevention of IUA formation is essential; however, when present, accurate diagnosis and surgical intervention (hysteroscopic adhesiolysis) are required. The outcome of this treatment is based on the technique and the extent of surgery performed which depends on the severity and complexity of the disease. Hence its classification becomes particularly important to determine a standardized therapy for each case and patient counseling regarding the prognosis. In this article, we aim to describe the IUAs classification systems that have been proposed comparing the merits and demerits of each one.

Single pixel polarimetric imaging through scattering media.

Polarimetric imaging can provide valuable information about biological samples in a wide range of applications. Detrimental tissue scattering and depolarization however currently hamper in vivo polarization imaging. In this work, single pixel imaging is investigated as a means of reconstructing polarimetric images through scattering media. A theoretical imaging model is presented, and the recovery of the spatially resolved Mueller matrix of a test object behind a scattering phantom is demonstrated experimentally.

Evaluation and treatment of infertile women with Asherman syndrome: an updated review focusing on the role of hysteroscopy.

Asherman syndrome is a rare acquired clinical condition resulting in the obliteration of the uterine cavity causedby the presence of partial or complete fibrous intrauterine adhesions involving at least two-thirds of the uterine cavity potentially obstructing the internal cervical orifice. Common reported symptoms of the disease are alterations of the menstrual pattern with decreased menstrual bleeding leading up to amenorrhoea and infertility. Hysteroscopy is currently considered the gold standard diagnostic and therapeutic approach for patients with intrauterine adhesions. An integrated approach, including preoperative, intraoperative and postoperative therapeutic measures, however, are warranted owing to the complexity of the syndrome. This review aims to summarize the most recent evidence on the recommended preoperative, intraoperative and postoperative procedures to restore the uterine cavity and a functional endometrium, as well as on the concomitant use of adjuvant therapies to achieve optimal fertility outcomes.

Hysteroscopic endometrial resection vs. hysterectomy for abnormal uterine bleeding: impact on quality of life and sexuality. Evidence from a systematic review of randomized controlled trials.

PURPOSE OF REVIEW: The aim of this systematic review is to summarize the current evidence regarding the effectiveness of hysterectomy and hysteroscopic endometrial resection in improving quality of life (QoL), sexual function and psychological wellbeing of women abnormal uterine bleeding. RECENT FINDINGS: We performed a systematic literature search in PubMed/MEDLINE and Embase for original studies written in English (registered in PROSPERO 2019 CRD42019133632), using the terms 'endometrial ablation', 'endometrial destruction', 'endometrial resection', 'hysterectomy', 'menorrhagia', 'dysfunctional uterine bleeding', 'quality of life', 'sexuality' published up to April 2019. Our literature search produced 159 records. After exclusions, nine studies were included showing the following results: both types of treatment significantly improve QoL and psychological wellbeing; hysterectomy is associated with higher rates of satisfaction; hysterectomy is not associated with a significant deterioration in sexual function. SUMMARY: Hysterectomy is currently more advantageous in terms of improving abnormal uterine bleeding and satisfaction rates than hysteroscopic endometrial destruction techniques. Furthermore, there is some evidence of a greater improvement in general health for women undergoing hysterectomy. However, high-quality prospective randomized controlled trials should be implemented to investigate the effectiveness of hysterectomy and endometrial ablation in the improvement of QoL outcomes in larger patient cohorts.

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.

Management of anxiety and pain perception in women undergoing office hysteroscopy: a systematic review.

PURPOSE: The aim of this review is to provide an overview of the literature about the perception and management of anxiety and pain in women undergoing an office hysteroscopic procedure. METHODS: We performed a systematic literature search in Embase, PubMed/MEDLINE, Cochrane Library and Web of Science for original studies written in English (registered in PROSPERO 2019-CRD42019132341), using the terms 'hysteroscopy' AND 'pain' AND 'anxiety' published up to January 2019. Only original articles (randomized, observational and retrospective studies) about management of anxiety and pain related to the hysteroscopic procedure were considered eligible. RESULTS: Our literature search produced 84 records. After exclusions, 11 studies including 2222 patients showed the following results: (a) pain experienced during hysteroscopy is negatively affected by preprocedural anxiety; (b) pharmacological interventions seem to be help in reducing pain during hysteroscopy; (c) waiting time before the procedure is a significant factor affecting patients' anxiety; (d) music during the procedure may be helpful in reducing anxiety. CONCLUSIONS: The utilization of office hysteroscopy is hampered by varying levels of anxiety and pain perceived by women who are candidates for the procedure. For these reasons, it is essential to identify effective pharmacological and non-pharmacological strategies to alleviate these factors. We recommend further studies especially focusing on non-pharmacological interventions to facilitate the dissemination of good clinical practices among hysteroscopists.