Hysteroscopy in postmenopause: from diagnosis to the management of intrauterine pathologies.

With the increase in life expectancy, women now live up to one-third of their life in menopause. Postmenopausal bleeding (PMB) is a common gynecologic complaint encountered by the clinician. Endometrial cancer is present in about 10% of patients with PMB. Nevertheless, many other conditions such as endometrial or cervical polyps, genital atrophy, or non-gynecologic conditions may also be present. Hysteroscopy has replaced blind diagnostic procedures and is now considered the gold-standard technique for the diagnosis and management of intrauterine pathology. Gynecologists in clinical practice should be familiar with the use of hysteroscopy in the diagnosis and treatment of the menopausal patient presenting with gynecologic complaints. The aim of this article is to report the current evidence on the role of hysteroscopy in the evaluation and management of the postmenopausal patient with intrauterine pathology.

Effectiveness of seminal plasma in in vitro fertilisation treatment: a systematic review and meta-analysis.

BACKGROUND: With in vitro fertilization (IVF) techniques, only 20-25% of the transferred embryos lead to a pregnancy. OBJECTIVE: To evaluate the beneficial effects of seminal plasma (SP) or semen applied at the time of oocyte aspiration or embryo transfer. SEARCH STRATEGY: Electronic databases were searched from their inception up to August 2017. SELECTION CRITERIA: We included all randomized controlled trials (RCTs) evaluating the effects of SP or semen in IVF treatment. Trials were considered if women were exposed to any kind of SP or semen (either SP/semen injection or sexual intercourse) around the time of oocyte pickup and embryo transfer. DATA COLLECTION AND ANALYSIS: The primary outcome was clinical pregnancy rate (CPR). MAIN RESULTS: Eight RCTs on women undergoing IVF (2128 in total) were included in the meta-analysis. Women randomized in the intervention group had a significantly higher CPR compared with controls (30.0 versus 25.1%; RR 1.20; 95% CI, 1.04-1.39). No significant differences were found in the secondary outcomes, including livebirth rate, biochemical pregnancy, miscarriage, multiple pregnancies, and birth weight. The subgroup analyses (four RCTs, 780 participants), including only those RCTs in which prepared undiluted SP was injected just after oocyte pickup, conformed with the overall analysis for the primary outcome (46.3 versus 37.2%; RR 1.23; 95% CI, 1.05-1.45). CONCLUSION: Because intravaginal or intracervical SP application around the time of oocyte pickup is associated with higher CPR, local application SP may be considered as a potential treatment to improve implantation. TWEETABLE ABSTRACT: SP at the time of oocyte pickup is associated with higher CPR.

One-step transvaginal three-dimensional hysterosalpingo-foam sonography (3D-HyFoSy) confirmation test for Essure® follow-up: a multicenter study.

OBJECTIVE: To evaluate, in patients who underwent Fallopian-tube sterilization by hysteroscopic insertion of an Essure® device, the feasibility and accuracy of three-dimensional (3D) transvaginal sonography (TVS) to check the position of the device and 3D hysterosalpingo-foam sonography (3D-HyFoSy) using contrast-enhanced gel foam to assess consequent tubal occlusion. METHODS: This was a prospective multicenter study conducted from June 2012 to July 2014 in four Italian centers, which included 50 women who underwent hysteroscopic Essure microinsert placement in a total of 95 Fallopian tubes. Placement of the microinserts was performed in an outpatient setting following standard procedure recommendations. All patients underwent transvaginal 3D-HyFoSy and hysterosalpingography (HSG) approximately 12-14 weeks after the procedure. The position of the devices was first checked on 3D-TVS and classified according to specific criteria (Positions A, B, C and D). Then, 3D-HyFoSy with ExEm® gel foam as the ultrasound contrast agent was performed to confirm tubal occlusion by the absence of contrast agent within the tubes and/or around the ovaries. To evaluate the feasibility of 3D-HyFoSy, consecutive volume acquisitions were performed while injecting the gel foam. After sonographic evaluation, women underwent HSG to assess the success of sterilization, as standard methodology. Side effects and pain evoked during and after 3D-HyFoSy and HSG were evaluated using a numeric pain rating scale. RESULTS: On 3D-TVS, 10 devices (10.5%) were in Position A, two (2.1%) in Position B, 59 (62.1%) in Position C and 24 (25.3%) in Position D. During 3D-HyFoSy, tubal occlusion was observed in 89 of 95 tubes (93.7%). In the six cases in which the passage of the contrast was observed, one device (16.7%) was in Position B, one device (16.7%) in Position D and four devices (66.7%) were found to lie in Position C. Tubal patency was confirmed at HSG with a concordance rate of 100%. The mean pain score associated with 3D-HyFoSy was significantly lower than that on HSG. CONCLUSIONS: 3D-TVS with HyFoSy allows accurate assessment of the position of Essure microinserts and tubal occlusion. It can be considered a safe, reliable, non-invasive alternative to HSG. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.

Risk of Cesarean scar defect following single- vs double-layer uterine closure: systematic review and meta-analysis of randomized controlled trials.

OBJECTIVE: There is a growing body of evidence that suggests that the surgical technique for uterine closure following Cesarean delivery influences the healing of the Cesarean scar, but there is still no consensus on the optimal technique. The aim of this systematic review and meta-analysis was to compare the effect of single- vs double-layer uterine closure on the risk of uterine scar defect. METHODS: MEDLINE, Scopus, ClinicalTrials.gov, PROSPERO, EMBASE and the Cochrane Central Register of Controlled Trials were searched from inception of each database until May 2016. All randomized controlled trials (RCTs) evaluating the effect of single- vs double-layer uterine closure following low transverse Cesarean section on the risk of uterine scar defect were included. The primary outcome was the incidence of uterine scar defects detected on ultrasound. Secondary outcomes were residual myometrial thickness evaluated by ultrasound and the incidence of uterine dehiscence and/or rupture in subsequent pregnancy. Summary measures were reported as relative risk (RR) or mean difference (MD), with 95% CIs. Quality of the evidence was assessed using the GRADE approach. RESULTS: Nine RCTs (3969 participants) were included in the meta-analysis. The overall risk of bias of the included trials was low. Statistical heterogeneity within the studies was low, with no inconsistency in the primary and secondary outcomes. Women who received single-layer uterine closure had a similar incidence of uterine scar defects as did women who received double-layer closure (25% vs 43%; RR, 0.77 (95% CI, 0.36-1.64); five trials; 350 participants; low quality of evidence). Compared with double-layer uterine closure, women who received single-layer closure had a significantly thinner residual myometrium on ultrasound (MD, -2.19 mm (95% CI, -2.80 to -1.57 mm); four trials; 374 participants; low quality of evidence). No difference was found in the incidence of uterine dehiscence (0.4% vs 0.2%; RR, 1.34 (95% CI, 0.24-4.82); three trials; 3421 participants; low quality of evidence) or uterine rupture (0.1% vs 0.1%; RR, 0.52 (95% CI, 0.05-5.53); one trial; 3234 participants; low quality of evidence) in a subsequent pregnancy. CONCLUSIONS: Single- and double-layer closure of the uterine incision following Cesarean delivery are associated with a similar incidence of Cesarean scar defects, as well as uterine dehiscence and rupture in a subsequent pregnancy. However, the quality level of summary estimates, as assessed by GRADE, was low, indicating that the true effect may be, or is even likely to be, substantially different from the estimate of the effect. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.

Adhesions and endometriosis: challenges in subfertility management : (An expert opinion of the ANGEL-The ANti-Adhesions in Gynaecology Expert PaneL-group).

There is molecular evidence that endometriosis has a negative impact on the ovaries, although the exact pathophysiology concerning endometriosis-associated subfertility is not known. The negative impact on the tubo-ovarian unit can be directly by distorting the anatomy, indirectly by invoking inflammation or by oxidative damage with poorer-quality oocytes. Endometriosis even seems to have a negative effect on pregnancy outcome after in vitro fertilization.

The comprehensiveness of the ESHRE/ESGE classification of female genital tract congenital anomalies: a systematic review of cases not classified by the AFS system.

STUDY QUESTION: How comprehensive is the recently published European Society of Human Reproduction and Embryology (ESHRE)/European Society for Gynaecological Endoscopy (ESGE) classification system of female genital anomalies? SUMMARY ANSWER: The ESHRE/ESGE classification provides a comprehensive description and categorization of almost all of the currently known anomalies that could not be classified properly with the American Fertility Society (AFS) system. WHAT IS KNOWN ALREADY: Until now, the more accepted classification system, namely that of the AFS, is associated with serious limitations in effective categorization of female genital anomalies. Many cases published in the literature could not be properly classified using the AFS system, yet a clear and accurate classification is a prerequisite for treatment. STUDY DESIGN, SIZE AND DURATION: The CONUTA (CONgenital UTerine Anomalies) ESHRE/ESGE group conducted a systematic review of the literature to examine if those types of anomalies that could not be properly classified with the AFS system could be effectively classified with the use of the new ESHRE/ESGE system. An electronic literature search through Medline, Embase and Cochrane library was carried out from January 1988 to January 2014. Three participants independently screened, selected articles of potential interest and finally extracted data from all the included studies. Any disagreement was discussed and resolved after consultation with a fourth reviewer and the results were assessed independently and approved by all members of the CONUTA group. PARTICIPANTS/MATERIALS, SETTING, METHODS: Among the 143 articles assessed in detail, 120 were finally selected reporting 140 cases that could not properly fit into a specific class of the AFS system. Those 140 cases were clustered in 39 different types of anomalies. MAIN RESULTS AND THE ROLE OF CHANCE: The congenital anomaly involved a single organ in 12 (30.8%) out of the 39 types of anomalies, while multiple organs and/or segments of Müllerian ducts (complex anomaly) were involved in 27 (69.2%) types. Uterus was the organ most frequently involved (30/39: 76.9%), followed by cervix (26/39: 66.7%) and vagina (23/39: 59%). In all 39 types, the ESHRE/ESGE classification system provided a comprehensive description of each single or complex anomaly. A precise categorization was reached in 38 out of 39 types studied. Only one case of a bizarre uterine anomaly, with no clear embryological defect, could not be categorized and thus was placed in Class 6 (un-classified) of the ESHRE/ESGE system. LIMITATIONS, REASONS FOR CAUTION: The review of the literature was thorough but we cannot rule out the possibility that other defects exist which will also require testing in the new ESHRE/ESGE system. These anomalies, however, must be rare. WIDER IMPLICATIONS OF THE FINDINGS: The comprehensiveness of the ESHRE/ESGE classification adds objective scientific validity to its use. This may, therefore, promote its further dissemination and acceptance, which will have a positive outcome in clinical care and research. STUDY FUNDING/COMPETING INTERESTS: None.

Hysteroscopic outpatient metroplasty to expand dysmorphic uteri (HOME-DU technique): a pilot study.

The new classification system of uterine anomalies from the European Society of Human Reproduction and Embryology and the European Society for Gynaecological Endoscopy defines T-shaped and tubular-shaped infantilis uteri as 'dysmorphic'. Such malformations have been proven to be associated with poor reproductive performance. A prospective observational study was conducted with 30 infertile women with dysmorphic uterus who underwent the novel Hysteroscopic Outpatient Metroplasty to Expand Dysmorphic Uteri (HOME-DU ) technique. Incisions are made on the uterine walls with a 5 Fr bipolar electrode. The procedure was conducted in outpatients under conscious sedation, using a 5-mm office hysteroscope. The technique was successful in all cases without complications. A net increase of uterine volume was found, as measured at hysteroscopy and three-dimensional transvaginal ultrasound (P < 0.001). Uterine morphology improved in all patients but one. At mean follow-up of 15 months, clinical pregnancy rate was 57% and term delivery rate 65%. These early data support HOME-DU as safe and effective in expanding the volume and normalizing the appearance of the uterine cavity of dysmorphic uteri. Although the cohort was small, pregnancy and live births outcomes were favourable in this poor-prognosis group, implying desirable benefits, which should be compared with other techniques.

Uterine leiomyosarcoma: report of three cases and review of the literature.

This is the report of three cases of unsuspected uterine leiomyosarcoma diagnosed by pathologist after hysteroscopic resection. The literature on this issue has been reviewed. Mesenchymal uterine tumors are rare malignancies, occurring in only 17 per one million women annually. The three most common variants of uterine sarcoma are endometrial stromal sarcoma, leiomyosarcoma, and malignant mixed Müllerian tumour. Less than one percent of women believed to have a leiomyoma actually have a sarcoma at hysterectomy. According to the authors' experience and the available literature reviewed, the removal of the whole myomatosus lesion, even if its appearance suggests a typical submucosal myoma, represents the only method to definitively rule out the presence of sarcomatous tissue.

Use of oral GnRH antagonists combined therapy in the management of symptomatic uterine fibroids.

Uterine fibroids have an impact on women's lives due to their high prevalence, physical symptoms, their consequences on patients' emotional and psychological well-being and loss of work productivity. The choice of therapeutical approaches varies depending on several factors, and therefore should be applied individually. Currently, there is an unmet need for good, reliable, uterine-sparing options. The oral GnRH antagonists (Elagolix, Relugolix, Linzagolix) represent a new alternative for the medical management of hormone-dependent gynaecological diseases such as uterine fibroids or endometriosis. They rapidly bind to the GnRH receptor, block endogenous GnRH activity and directly suppress LH and FSH production, avoiding unwanted flare-up effects. Some GnRH antagonists are marketed in combination with hormone replacement therapy add-back to counteract hypo-oestrogenic side effects. According to the registration trials, once-daily GhRH antagonist combination therapy results in a significant reduction in menstrual bleeding, as compared with placebo, and preserves bone mineral density, for up to 104 weeks. Further studies in the long term are needed to evaluate the whole impact of medical treatment of uterine fibroids on the management of this common women's disease.

Cavernous haemangioma and mid trimester pregnancy loss leading to severe haemorrhage and hysterectomy: a case report and review of literature.

Background: Cavernous haemangiomas are benign vascular tumours that are known to occasionally involve the female genital tract, including the uterus. They are often underdiagnosed during pregnancy, although they can also lead to severe postpartum or antepartum haemorrhage. Objectives: Describe our case of an uncommon second-trimester pregnancy loss in a woman with a diffuse cavernous haemangioma of the uterus and cervix and review the wider literature. Methods: The review was conducted using MEDLINE, Scopus and PubMed electronic databases from beginning of the database to May 2023, using the following keywords: arteriovenous malformation; cavernous haemangioma/hemangioma; uterine neoplasms; pregnancy complications; abnormal vaginal bleeding. Main outcome measures: Description of the characteristics of cavernous haemangioma during pregnancy as well as diagnostic criteria and treatment options. Results: Twenty publications were included in the review, which included English-language case reports over a period from 1959 to 2022. No pathognomonic symptoms for cavernous haemangioma of the uterus in a pregnant woman were noted. Complications including massive secondary postpartum haemorrhage, haemoperitoneum, and severe thrombocytopenia with anaemia after delivery were reported. Conclusions: Diagnosis and management during pregnancy can be challenging and requires considerable attention, with a multidisciplinary approach including gynaecologists, radiologists, and pathologists to avoid major complications. What is new?: An additional case of diffuse cavernous haemangioma of the uterus and cervix is described, that adds to the little existing literature.

ESGO/ESHRE/ESGE Guidelines for the fertility-sparing treatment of patients with endometrial carcinoma.

Background: The standard surgical treatment of endometrial carcinoma (EC) consisting of total hysterectomy with bilateral salpingo-oophorectomy drastically affects the quality of life of patients and creates a challenge for clinicians. Recent evidence-based guidelines of the European Society of Gynaecological Oncology (ESGO), the European SocieTy for Radiotherapy & Oncology (ESTRO) and the European Society of Pathology (ESP) provide comprehensive guidelines on all relevant issues of diagnosis and treatment in EC in a multidisciplinary setting. While also addressing work-up for fertility preservation treatments and the management and follow-up for fertility preservation, it was considered relevant to further extend the guidance on fertility sparing treatment. Objectives: To define recommendations for fertility-sparing treatment of patients with endometrial carcinoma. Materials and Methods: ESGO/ESHRE/ESGE nominated an international multidisciplinary development group consisting of practicing clinicians and researchers who have demonstrated leadership and expertise in the care and research of EC (11 experts across Europe). To ensure that the guidelines are evidence-based, the literature published since 2016, identified from a systematic search was reviewed and critically appraised. In the absence of any clear scientific evidence, judgment was based on the professional experience and consensus of the development group. The guidelines are thus based on the best available evidence and expert agreement. Prior to publication, the guidelines were reviewed by 95 independent international practitioners in cancer care delivery and patient representatives. Results: The multidisciplinary development group formulated 48 recommendations for fertility-sparing treatment of patients with endometrial carcinoma in four sections: patient selection, tumour clinicopathological characteristics, treatment and special issues. Conclusions: These recommendations provide guidance to professionals caring for women with endometrial carcinoma, including but not limited to professionals in the field of gynaecological oncology, onco-fertility, reproductive surgery, endoscopy, conservative surgery, and histopathology, and will help towards a holistic and multidisciplinary approach for this challenging clinical scenario. What is new?: A collaboration was set up between the ESGO, ESHRE and ESGE, aiming to develop clinically relevant and evidence-based guidelines focusing on key aspects of fertility-sparing treatment in order to improve the quality of care for women with endometrial carcinoma across Europe and worldwide.

ESGO/ESHRE/ESGE Guidelines for the fertility-sparing treatment of patients with endometrial carcinoma.

Background: The standard surgical treatment of endometrial carcinoma (EC) consisting of total hysterectomy with bilateral salpingo-oophorectomy drastically affects the quality of life of patients and creates a challenge for clinicians. Recent evidence-based guidelines of the European Society of Gynaecological Oncology (ESGO), the European SocieTy for Radiotherapy & Oncology (ESTRO) and the European Society of Pathology (ESP) provide comprehensive guidelines on all relevant issues of diagnosis and treatment in EC in a multidisciplinary setting. While also addressing work-up for fertility preservation treatments and the management and follow-up for fertility preservation, it was considered relevant to further extend the guidance on fertility sparing treatment. Objectives: To define recommendations for fertility-sparing treatment of patients with endometrial carcinoma. Materials and Methods: ESGO/ESHRE/ESGE nominated an international multidisciplinary development group consisting of practicing clinicians and researchers who have demonstrated leadership and expertise in the care and research of EC (11 experts across Europe). To ensure that the guidelines are evidence-based, the literature published since 2016, identified from a systematic search was reviewed and critically appraised. In the absence of any clear scientific evidence, judgment was based on the professional experience and consensus of the development group. The guidelines are thus based on the best available evidence and expert agreement. Prior to publication, the guidelines were reviewed by 95 independent international practitioners in cancer care delivery and patient representatives. Results: The multidisciplinary development group formulated 48 recommendations for fertility-sparing treatment of patients with endometrial carcinoma in four sections: patient selection, tumour clinicopathological characteristics, treatment and special issues. Conclusions: These recommendations provide guidance to professionals caring for women with endometrial carcinoma, including but not limited to professionals in the field of gynaecological oncology, onco-fertility, reproductive surgery, endoscopy, conservative surgery, and histopathology, and will help towards a holistic and multidisciplinary approach for this challenging clinical scenario. What is new? A collaboration was set up between the ESGO, ESHRE and ESGE, aiming to develop clinically relevant and evidence-based guidelines focusing on key aspects of fertility-sparing treatment in order to improve the quality of care for women with endometrial carcinoma across Europe and worldwide.

Quality of life, lifestyle behavior and employment experience: a comparison between young and midlife survivors of gynecology early stage cancers.

GOALS: To evaluate differences and changes in quality of life (QoL), lifestyle behavior and employment experience of young in comparison to midlife adults in response to early stage gynecologic cancer diagnoses. METHODS: 263 patients, divided into two age groups (Group A: ≤ 45 and Group B: >45 years), were interviewed on their QoL, lifestyle behavior (dietary habits, tobacco and alcohol use, physical activity) and employment experience (employment status and working time) at diagnosis and within 4 years from the treatment. The QoL was evaluated by European Organization for Research and Treatment of Cancer (EORTC) Quality of Life Questionnaire C30 (QLQ-C30) and its specific modules for each cancer type (in particular endometrium, cervix, ovarian and breast). RESULTS: Global health status was significantly different between the two groups. In the younger age group a more relevant cancer interference on family life and social activities and a greater impact on perception of health status have been observed. Young women were more affected by fatigue, constipation, gastrointestinal symptoms, lymphedema, poor body image and impaired sexuality. Cancer diagnosis had a major negative impact on employment of younger patients. Conversely, younger patients had overall better health behavior. They reported a higher daily intake of fruits and vegetables, along with lower alcohol consumption, furthermore they were a little more physically active than midlife adults. CONCLUSIONS: To enhance quality of life and to promote healthy lifestyle behavior of female cancer patients, particularly in younger age, it is essential to assure multidisciplinary approaches with specific medical intervention and psychosocial supports. Indeed, midlife adults seem to have a more rapid adaptive tendency to return towards levels of well-being, following cancer diagnosis and treatment, than younger patients.

'See and treat' outpatient hysteroscopy with novel fibreoptic 'Alphascope'.

This paper describes an experience with the Alphascope, a fibreoptic hysteroscopy system (Gynecare, Ethicon Women's Health and Urology). This prospective observational study was carried out at a tertiary hospital in Naples, Italy. The study population comprised patients undergoing outpatient hysteroscopy with the semi-rigid Versascope Hysteroscopy System using the Alphascope. 7-Fr gauge mechanical instruments and 5-Fr bipolar electrodes (Versapoint, Gynecare, Ethicon Inc., Somerville, NJ) were used for the operative procedures. Outpatient hysteroscopy was successful in 97% of cases. These were diagnostic in 41%, while operative hysteroscopy was performed in 59% of cases. The endoscopic view was subjectively defined by the operator as good/excellent in 95% of procedures. A total of 98% of patients expressed moderate/high degree of satisfaction and only 2% were dissatisfied. The system is successful in the outpatient setting in 95% of attempts.

Incorporating 3D reconstruction in preoperative surgical planning of Multiple Myomectomy.

Background: Medical 3D imaging is a promising emerging technology that allows recreating the details of human anatomy. The use of this innovative technology has resulted in improved surgical efficiency and better clinical outcomes. However, its incorporation in gynaecologic surgery has not been widely adopted. Objectives: To demonstrate the use of Hyper Accuracy 3D reconstruction in a patient with infertility who underwent multiple myomectomy. Materials and Methods: A stepwise approach describing the incorporation of Hyper Accuracy 3D imaging technology into the preoperative surgical planning and intraoperative guidance of a patient with multiple myomas undergoing multiple myomectomy. Main Outcome Measures: Preoperative evaluation of a patient with multiple myoma and infertility who presented to our department seeking surgical management. Hyper Accuracy 3D image was obtained, and a 3D digital image reconstruction of the uterus delineating the exact number, volume, and location of the fibroids was created. The 3D digital image was available during the surgical procedure which helped to plan the surgical steps allowing a systematic surgical approach resulting in an effective surgery with minimal blood loss. Results: The benefits of intraoperative guidance using Hyper Accuracy 3D in a patient with multiple myomas and infertility are demonstrated. Conclusions: The adoption of this promising imaging technology into gynaecologic surgery is feasible and should be further investigated. Additional studies evaluating the clinical impact of using Hyper Accuracy 3D imaging in the preoperative planning of patients with gynaecologic surgical pathology are needed.

Endometrial biopsy under direct hysteroscopic visualisation versus blind endometrial sampling for the diagnosis of endometrial hyperplasia and cancer: Systematic review and meta-analysis.

Background: Endometrial cancer is the most common gynaecological neoplasia in western countries. Diagnosis of endometrial cancer requires an endometrial biopsy. A good quality endometrial biopsy allows not only the identification of the pathology, but also preoperative histologic subtype classification. Endometrial biopsy can be performed under direct hysteroscopic visualisation, but also using blind sampling techniques. Objectives: To compare endometrial biopsy performed under direct hysteroscopic visualisation versus blind sampling for the diagnosis of endometrial hyperplasia and cancer. Materials and Methods: Systematic review and meta-analysis. Electronic databases were searched from their inception until March 2022.We included all studies comparing endometrial biopsy performed under direct hysteroscopic visualisation versus blind endometrial sampling. Main outcome measures: Sample adequacy, failure rate to detect endometrial cancer or endometrial hyperplasia, and rate of detection of endometrial cancer. The summary measures were reported as relative risk (RR) with 95% of confidence interval (CI). Results: Four studies with a total of 1,295 patients were included. Endometrial biopsy under direct hysteroscopic visualisation was associated with a significantly higher rate of sample adequacy (RR 1.13, 95% CI 1.10 to 1.17), and significantly lower risk of failure to detect endometrial cancer or endometrial hyperplasia (RR 0.16, 95% CI 0.03 to 0.92) compared to blind endometrial sampling. However, there was no significant difference between endometrial biopsies taken under direct hysteroscopic visualisation or blindly, with or without a preceding diagnostic hysteroscopy, in the rate of detection of endometrial cancer (RR 0.18, 95% CI 0.03 to 1.06). Conclusion: Hysteroscopic endometrial biopsy under direct visualisation is associated with significantly higher rate of sample adequacy and is comparable to blind endometrial sampling for the diagnosis of endometrial cancer and precancer. What is new?: Hysteroscopic endometrial biopsy under direct visualisation would be expected to reduce diagnostic failure for endometrial cancer compared to blind endometrial sampling.

Hysteroscopic resection vs dilation and evacuation for treatment of caesarean scar pregnancy: study protocol for a randomised controlled trial.

Background: Caesarean scar pregnancy (CSP) is a type of ectopic pregnancy where the fertilised egg is implanted in the muscle or fibrous tissue of the scar after a previous caesarean section. Management options for women who opted for termination of CSP include sharp curettage, dilation and evacuation (D&E), excision of trophoblastic tissues, local or systemic administration of methotrexate, bilateral hypogastric artery ligation, and selective uterine artery embolisation with curettage and/or methotrexate administration. Recently hysteroscopic resection has also been proposed as an alternative option. Objective: To compare the surgical outcome of hysteroscopic resection with dilation and evacuation (D&E) for the treatment of caesarean scar pregnancy (CSP). Methods: Parallel-group, non-blinded, randomised clinical trial conducted at a single centre in Italy. Eligible women are those with singleton gestations at less than 9 weeks of gestation, and with thickness of myometrial layer ≥1 mm at the level of the ectopic. Inclusion criteria are women with CSP with positive embryonic/fetal heart activity who opted for termination of pregnancy. Patients will be randomised 1:1 to receive either hysteroscopic resection (i.e. intervention group) or D&E (i.e. control group). In both groups, 50 mg/m2 (based on DuBois formula for body surface area) of methotrexate (MTX) will be injected intramuscularly at the time of randomisation (day 1) and another dose at day 3. A third dose of MTX is planned in case of persistence of fetal heart activity on day 5. Participants will receive either D&E or hysteroscopic resection from 3 to 7 days after the last dose of MTX. A sample size of 54 women is planned. Main outcome measures: The primary outcome is the success rate of the treatment protocol, defined as no requirement for further treatment until complete resolution of the CSP as demonstrated by negative beta hCG levels and absence of residual gestational material on ultrasound examination.. Study hypothesis: Hysteroscopic surgery is superior to D&E for the treatment of CSP. What is new?: The results of the trial will provide information on the best treatment for CSP.

Fertility sparing management of uterine adenosarcoma: Case report and literature review.

Adenosarcoma is an extremely rare malignancy of the female genital tract composed of stromal sarcoma with a benign epithelial component. Current treatment recommendations include total hysterectomy with bilateral salpingo-oophorectomy, precluding future fertility. Although most frequently diagnosed in postmenopausal women, it is occasionally present in younger women of reproductive age with desire for future fertility. In 2015, we reported the case of a 23-year-old patient diagnosed with uterine adenosarcoma, who having strong desire of future fertility, opted for fertility sparing surgery. At a follow-up five years later, we can now report her case of spontaneous pregnancy and livebirth. A review of the literature concerning fertility outcomes in patients with uterine adenosarcoma undergoing fertility sparing therapeutic options is presented.