Laparoscopic-assisted neo-cervico-vaginal anastomosis and neo-vagina creation in congenital atresia: A retrospective study measuring the outcome and success.

Cervico-vaginal agenesis is a developmental disorder classified as a Mullerian duct anomaly. STUDY OBJECTIVE: We aimed to study the surgical outcomes of vaginoplasty and laparoscopic-assisted cervical-vaginoplasty carried out using our set-up from June 2016 to December 2022. Additionally, we measured the success of our modified laparoscopy-assisted neo-cervical creation. DESIGN: A retrospective study. SETTING: The study was conducted in a tertiary care center and included all patients who underwent vaginoplasty and neo-cervico-vaginal creation using the rail-road method. PATIENTS: A total of 33 patients were followed-up meticulously and their outcomes were noted. The study was retrospective and largely depended on patient compliance during follow-up. INTERVENTION: Of the 33 patients, 22 underwent vaginoplasty (McIndoe technique) and 11 underwent neo-cervico-vaginoplasty (rail-road method using both open and laparoscopic methods). MEASUREMENTS AND MAIN RESULTS: The most common presentation was primary amenorrhea (cyclic abdominal pain with primary amenorrhea) and urinary retention. Four patients underwent hysteroscopy-guided hematometra drainage and none underwent hysterectomy. The average vaginal length measured during the follow-up was 5.2 ± 1.90 cm. Significant symptom relief was observed. Longest follow-up duration was 4.7 years with a mean duration of 210 (180) days. CONCLUSION: Although the procedure is strenuous, postoperative results showed satisfactory outcomes in improving the quality of life of patients. With expertise in the technique, the associated comorbidity is reduced, which provides relief for the patients.

Syndrome of inappropriate secretion of thyroid-stimulating hormone in a subject with galactorrhea and menstrual disorder and undergoing infertility treatment: Case report.

RATIONALE: Syndrome of inappropriate secretion of thyroid-stimulating hormone (SITSH) is a rare cause of hyperthyroidism. Thyroid-stimulating hormone (TSH) levels are usually normal or high, and triiodothyronine (FT3) and free thyroxine (FT4) levels are usually high in subjects with SITSH. PATIENT CONCERN: A 37-year-old woman had experienced galactorrhea and menstrual disorder for a couple of years before. She had undergone infertility treatment in 1 year before, hyperthyroidism was detected and she was referred to our institution. DIAGNOSIS: She was suspected of having SITSH and was hospitalized at our institution for further examination. The data on admission were as follows: FT3, 4.62 pg/mL; FT4, 1.86 ng/dL; TSH, 2.55 µIU/mL. Although both FT3 and FT4 levels were high, TSH levels were not suppressed, which is compatible with SITSH. In addition, in brain contrast-enhanced magnetic resonance imaging, nodular lesions were observed in the pituitary gland with a diameter of approximately 10 mm. In the thyrotropin-releasing hormone load test, TSH did not increase at all, which was also compatible with TSH-secreting pituitary adenoma. In the octreotide load test, the TSH levels were suppressed. Based on these findings, we diagnosed this subject as SITSH. INTERVENTIONS: Hardy surgery was performed after the final diagnosis. In TSH staining of the resected pituitary adenoma, many TSH-producing cells were observed. These findings further confirmed the diagnosis of pituitary adenoma producing TSH. OUTCOMES: Approximately 2 months after the operation, TSH, FT3, and FT4 levels were normalized. Approximately 3 months after the operation, she became pregnant without any difficulty. LESSONS: We should consider the possibility of SITSH in subjects with galactorrhea, menstrual disorders, or infertility. In addition, we should recognize that it is very important to repeatedly examine thyroid function in subjects with galactorrhea, menstrual disorder, or infertility.

18-Year-old patient with Klinefelter syndrome (47, XXY) and complete androgen insensitivity syndrome (CAIS) - case report.

AIMS: The aims of the presented case report are to emphasize the importance of a proper diagnostics and treatment in the case of the coexistence of Klinefelter syndrome (KS, 47 XXY) and complete androgen insensitivity syndrome (CAIS). Since there is no causal treatment it is necessary to provide the patient with a good quality of life, including psychological and sexological support. MATERIALS AND METHODS: The presented case report is the retrospective analysis of the patient's medical history over the 3 years. RESULTS: At the age of 15, the patient was directed to genetic testing due to primary amenorrhea. The results of the patient showed an incorrect male karyotype with the SRY gene present (47, XXY). A molecular diagnostics revealed a very rare variant of the androgen receptor (AR) mutation responsible for tissue insensitivity to androgens. The detected mutation has not been described in the available databases so far. Following a diagnosis of the presence of Klinefelter syndrome (KS, 47 XXY) together with complete androgen insensitivity syndrome (CAIS), the patient underwent a bilateral gonadectomy. CONCLUSIONS: In women with KS and CAIS physiological reproduction and maintenance of normal sex, hormone levels are not possible. A gonadectomy is performed due to the risk of malignant testicular tumors.

Diagnosis and Surgical Treatment of Uterine Isthmus Atresia: A Case Report and Review of the Literature.

Uterine isthmus atresia is a rare Müllerian duct anomaly occasionally diagnosed in adolescents with primary amenorrhea and cyclic abdominal pain. A case is presented of a 14-year-old female with monthly cyclic lower abdominal pain of a 2-year duration. Magnetic resonance imaging and 3-dimensional ultrasound showed separation of a 10-mm fibrotic tissue between the cervical canal and the endometrial cavity. In an attempt to preserve reproductive ability, an end-to-end anastomosis was laparoscopically performed between the cervical canal and uterine cavity. A platinol stent (WallFlex Biliary RX; Boston Scientific, Boston, MA) was placed by hysteroscopy to avoid stenosis after surgery. Laparoscopic end-to-end anastomosis is proposed to treat congenital uterine isthmus atresia.

Single port laparoscopy combined with vaginal cervicovaginal reconstruction in a patient with congenital atresia of the cervix.

OBJECTIVE: To introduce an innovation that combines single port laparoscopic and Wharton-Sheares-George cervicovaginal reconstruction using a small intestinal submucosa (SIS) graft in a patient with congenital cervical atresia, absence of vagina, and incomplete uterine septum (U2aC4V4). DESIGN: Video article introducing a new surgical technique. SETTING: University hospital. PATIENT(S): A 15-year-old patient with congenital cervical atresia, absence of vagina, and incomplete uterine septum had primary amenorrhea and cyclic lower abdominal pain. The magnetic resonance imaging did not show hematometra and the endometrium was 6 mm when she had lower abdominal pain. INTERVENTION(S): A neovagina (depth, 7 cm; width, 2.5 cm) was created using the Wharton-Sheares-George neovaginoplasty. By single laparoscopy, the bladder was separated from the anterior surface of the uterus. With the mold in the neovagina created by the assistant, the apex of neovagina was opened. Then the lower uterine segment was exposed and incised. A T-shaped intrauterine device was connected to an 8-cm-long catheter scissored from a 14-F Foley catheter and was inserted into the uterus to prevent cervical or vaginal stenosis. The upper end of the graft was applied onto the lower uterine segment with delayed absorbable sutures. The lower end was sutured to the high vaginal or vestibular mucosa. MAIN OUTCOME MEASURE(S): The feasibility and effect of combination single port laparoscopic with vaginal cervicovaginal reconstruction in the congenital atresia of cervix. RESULT(S): The operation was successful. The operating time was 90 minutes. Hospitalization was 3 days. There were no intraoperative and postoperative complications. The patient had resumption of menses at three cycles postoperatively, and she had no dysmenorrhea. No cervical or vaginal stenosis occurred because of the Foley catheter. CONCLUSION(S): Single port laparoscopic combined with vaginal cervicovaginal reconstruction provided a minimally invasive, safe, and effective surgical option for the young patient with congenital atresia of cervix. It was successful and without complications or cervical or vaginal stenosis.

Factors That Impact Fertility after Hysteroscopic Adhesiolysis for Intrauterine Adhesions and Amenorrhea: A Retrospective Cohort Study.

STUDY OBJECTIVE: To identify factors that affect reproductive outcomes after hysteroscopic adhesiolysis in patients with severe intrauterine adhesions (IUAs, scored between 9 and 12 according to the American Fertility Society classification) and amenorrhea. DESIGN: A retrospective cohort study. SETTING: A university-affiliated hospital. PATIENTS: One hundred fifty-one patients with severe IUAs and amenorrhea. INTERVENTION: Patients were diagnosed via hysteroscopy and underwent at least 1 hysteroscopic adhesiolysis between May 2012 and January 2016. MEASUREMENTS AND MAIN RESULTS: Of 151 patients, 12 were lost to follow-up, and 139 were included in the study with a follow-up period ranging from 2 to 6 years. Of the 139 evaluable patients, 107 (77%) recovered with a normal uterine cavity (free of IUAs), 28 (20.1%) had improved uterine cavity (fewer IUAs), and 4 (2.9%) showed no improvement. Moreover, 79 patients (56.8%) recovered with normal menstruation, 54 (38.9%) showed increased frequency of menstruation, and 6 (4.3%) had persistent amenorrhea. Seventy-seven (55.4%) became pregnant, of whom 13 had a spontaneous miscarriage, 11 birthed prematurely (at 31-36 gestational weeks), 44 experienced term delivery, and 9 were still pregnant at the end of the study. Age >32 years (p = .002, odds ratio [OR] = 3.442), >2 surgeries (p = .027, OR = 2.969), cervical canal adhesions (p = .047, OR = 2.112), and disease course >6 months (p = .037, OR = 2.335) were risk factors for infertility in patients with severe IUAs and amenorrhea. CONCLUSION: Younger age, earlier treatment within the disease course, fewer cervical canal adhesions, and fewer surgical procedures improve the reproductive outcome in patients with severe IUAs and amenorrhea.

The utility of adrenal and ovarian venous sampling in a progesterone-producing adrenal tumor and review of the literature.

PURPOSE: A clinical case presenting secondary amenorrhea accompanied by an adrenal adenoma and hyperprogesteronemia is described in this study. METHODS: Selective catheterization and sampling of adrenal and ovarian veins were performed. RESULTS: The source of hyperprogesteronemia was located in the right adrenal gland. A progesterone-producing tumor in the right adrenal gland was diagnosed and removed. Twenty-six days after tumor resection, menstruation occurred. CONCLUSIONS: Progesterone-producing tumors should be considered with the presence of an adrenal mass and hyperprogesteronemia. Combined adrenal and ovarian venous sampling may help to identify the source of progesterone secretion.

Successful pregnancy outcome after septum resection and use of amnion graft in patient with high transverse vaginal septum.

A 20-year-old woman recently married presented to the outpatient department of the hospital, with primary amenorrhea and difficulty in having coitus. Her height was 155 cm, breast development was normal for age, and other secondary sexual characters seemed normal. On local examination, external genitalia was normal looking, and there was no vaginal discharge. She had a blind vagina of 2 cm length. The ultrasound showed a normal-sized uterus and ovaries seemingly normal. Hormonal profile comprising serum follicle-stimulating hormone, luteinising hormone, prolactin and thyroid stimulating hormone were all within normal limits. Karyotyping was done, which showed a 46,XX pattern. The patient underwent vaginal surgery during which septum resection was done, and amnion grafting was performed to prevent stricture formation. The patient resumed successful coitus 3 months after surgery. There was no discomfort on coitus. She conceived 7 months later. Following this, the patient delivered a healthy baby boy through caesarean section at term.

Combined Laparoscopic and Vaginal Cervicovaginal Reconstruction Using Acellular Porcine Small Intestinal Submucosa Graft in a Patient with Mayer-Rokitansky-Küster-Hauser Syndrome (U5aC4V4).

STUDY OBJECTIVE: To introduce a creation that combines laparoscopic and Wharton-Sheares-George cervicovaginal reconstruction using a small intestinal submucosa (SIS) graft in a patient with Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome who had a rudimentary cavity (U5aC4V4) [1]. DESIGN: A video article introducing a new surgical technique. SETTING: A university hospital. PATIENTS: A 24-year-old patient had primary amenorrhea and irregular lower abdominal pain for 9 years. The patient was Tanner stage 3 for pubic hair and Tanner stage 4 for breast development. The physical examination revealed no vagina. A primordial uterus and a uterus with a rudimentary cavity were detected by magnetic resonance imaging [2,3]. However, the rudimentary cavity had no hematometra. Magnetic resonance imaging also found a left solitary kidney. The diagnosis was MRKH syndrome with a rudimentary cavity (U5aC4V4) [4]. The patient desired resumption of menses and possible future fertility. INTERVENTIONS: Combined laparoscopic and Wharton-Sheares-George cervicovaginal reconstruction using an SIS graft was performed. MEASUREMENTS AND MAIN RESULTS: With the Wharton-Sheares-George neovaginoplasty, a vaginal mold with a surrounding SIS graft was inserted into the newly created cavity [5]. Using laparoscopy, the lower uterine segment was incised by shape dissection. The proximal segment of the SIS graft to the lower uterine segment was sutured. A T-shaped intrauterine device with a Foley catheter was fixed in the uterine cavity by the delay of absorbed sutures to prevent cervical or vaginal stenosis. The distal segment of the SIS graft was sutured with the high vaginal or vestibular mucosa vaginally. The operation was successfully completed. The operating time was 2 hours. Hospitalization was 4 days. There were no blood transfusions or complications. The patient had resumption of menses for 2 cycles postoperatively, and she had no dysmenorrhea. The patient did not have sexual intercourse because of the mode in the vagina to prevent vagina stenosis. No cervical stenosis occurred because of the Foley catheter. CONCLUSION: In the past, a uterus with a rudimentary cavity in patients with MRKH was always excised, and patients lost the chance of menstrual onset and fertility. Combined laparoscopic and Wharton-Sheares-George cervicovaginal reconstruction using an SIS graft provided a minimally invasive, safe, and effective surgical option for the young patient with MRKH syndrome with a rudimentary cavity. The technique is not complex, is easy to learn and perform, and provided a result with functional and anatomic satisfaction. No special surgical apparatus is needed with this technique.

Fertility after transsphenoidal surgery in patients with prolactinomas: A meta-analysis.

Pituitary prolactinomas in women often lead to amenorrhea, galactorrhea, or infertility. The purpose of this study was to evaluate the effectiveness of transsphenoidal surgery (TSS) in restoring fertility in women with proloactinomas. A systematic search of the literature was conducted in accordance with PRISMA guidelines through 6/13/2017. PubMed, Embase, and Cochrane databases were utilized to select studies reporting on patients with pituitary prolactinomas removed via TSS. Outcomes extracted included pre- and post-operative rates of menses, lactation, and fertility. Pooled effect estimates were calculated using random-effects. After removal of duplicates, 900 articles remained, of which 14 were meta-analyzed. The mean difference between pre- and post-operative prolactin level was 186.9 (95% CI = 133.7, 240.1; I2 = 69.9%; P-heterogeneity<0.01; 7 studies). The pooled prevalence of pre-operative amenorrhea was 96% (95% CI = 92%, 98%; I2 = 45.8%; P-heterogeneity = 0.09; 11 studies) and significantly larger than post-operative amenorrhea of 40% (95% CI = 27%, 55%; P- I2 = 85%; heterogeneity<0.01; 11 studies); (P-interaction comparing the 2 groups <0.01). The pooled prevalence of pre-operative galactorrhea was 84% (95% CI = 74%, 90%; I2 = 66.9%; P-heterogeneity<0.01; 10 studies) and significantly larger than post-operative galactorrhea of 29% (95% CI = 17%, 44%; I2 = 76.5%; P-heterogeneity<0.01; 7 studies) (P-interaction<0.01). Univariate meta-regression on age, continent, publication year, study design, quality, duration, or timing revealed these covariates were not effect modifiers for any of the 3 outcomes (all P > 0.05). No evidence of publication bias was seen using Begg's and Egger's tests (all P > 0.05). Transsphenoidal surgery appeared to improve fertility measures in women with pituitary prolactinomas.

Amenorrhoea and reversible infertility due to obstructive hydrocephalus: literature review and case report.

BACKGROUND: Endocrine abnormalities are well-recognized consequences of intracranial pathology such as pituitary tumours. Less commonly, hydrocephalus may lead to dysfunction of the endocrine system, presenting as amenorrhoea or precocious puberty. We present a case report and literature review of hydrocephalus causing endocrine abnormalities including reversible infertility. CASE DESCRIPTION: A 34 year-old female presented with amenorrhoea and infertility. MRI showed a third ventricular mass and hydrocephalus. The amenorrhoea resolved within weeks of endoscopic third ventriculostomy and tumour biopsy; pregnancy ensued within 6 months. Thirty-two cases of hydrocephalus-related amenorrhoea were reported between 1915 and 2007. All patients who underwent modern hydrocephalus treatment experienced partial or complete resolution of endocrine dysfunction. Successful pregnancy was reported in three patients, as in our case presentation. While mechanisms of dysfunction have not been completely elucidated, studies point toward loss of GnRH pulsatility due to compression of the medio-basal hypothalamic structures. CONCLUSION: Hydrocephalus can cause endocrine dysfunction, including amenorrhoea, which may reverse with CSF diversion. Therefore, cranial imaging is an important component in the evaluation of such endocrine abnormalities.

Laparoscopic Uterovaginal Anastomosis for Cervical Agenesis: A Case Report.

STUDY OBJECTIVE: Isolated cervical agenesis occurs in 1 in 80 000 to 100 000 births. According to the American Fertility Society, cervical agenesis should be classified as a type Ib müllerian anomaly. According to ESHRE/ESGE classification, it is classified in class C4 category. Here we demonstrate the possibility of an innovative surgery for the management of cervical agenesis. DESIGN: Stepwise description of laparoscopic uterovaginal anastomosis (Canadian Task Force classification II-3). SETTING: Video. PATIENT: A 13-year-old girl. INTERVENTION: Laparoscopic uterovaginal anastomosis was performed. Informed consent was taken from the patient for use of video and images. Institutional review board has ruled that approval was not required for this study. MEASUREMENTS AND MAIN RESULTS: This video demonstrates the management of a case of a 13-year-old girl with primary amenorrhea and cyclical lower abdominal pain for 5 months. After complete examination and investigation, a diagnosis of isolated cervical agenesis with hematomata and blind-ending vagina was made. An innovative technique was used to perform laparoscopic uterovaginal anastomosis. Later, a hysteroscopy was done that revealed patency of anastomoses. As a result, the patient is experiencing spontaneous regular menstruation for 48 months. The main steps of the procedure were as follows: A follow-up hysteroscopy was performed at 9 weeks after surgery. It showed patent anastomosis and normal uterine cavity. After 48 months, a repeat hysteroscopy was done and a partial fibrotic septum noted. It was resected using electric energy. CONCLUSION: Uterovaginal anastomosis for isolated cervical agenesis is possible by a minimally invasive approach. It can be offered as a first-line management for such cases over hysterectomy and cervical canalization, which have high complication rates. The surgery should only be performed by a specialized team with required expertise in minimally invasive surgery.

Hysteroscopic Intrauterine Adhesiolysis Using a Blunt Spreading Dissection Technique With Double-action Forceps.

STUDY OBJECTIVE: To demonstrate step-by-step the technique of hysteroscopic adhesiolysis (HA) by means of a blunt spreading technique using double-action forceps to dissect and restore the layer between the anterior and posterior uterine walls in a patient with severe intrauterine adhesions (IUAs), particularly in cases in which the endometrial lining is obscured on ultrasound imaging and the endometrial cavity is completely occluded on hysteroscopy. DESIGN: A step-by-step explanation of the technique using videos and pictures (educative video) (Canadian Task Force Classification III). SETTING: A university-affiliated hospital. PATIENT: A 36-year-old, gravida 3, para 1, abortus 2 woman presenting with amenorrhea for 5 months after surgical termination of a 53-day intrauterine pregnancy. She had no cyclic lower abdominal pain. Ultrasound revealed an obscure endometrial stripe and no obvious hematometra. Both the urine human chorionic gonadotropin test and the progesterone withdrawal test were negative. One month before admission, hysteroscopic adhesiolysis failed because the uterine cavity was inaccessible because of adhesions completely occluding the lower uterine cavity. Additionally, the uterine cavity could not be explored with a probe because the anatomic layer of the endometrial lining could not be easily identified by transabdominal ultrasound. INTERVENTION: HA using a blunt spreading dissection technique with double-action forceps to restore the uterine cavity followed by "ploughing" of the intrauterine scar tissue using cold scissors [1]. MEASUREMENTS AND MAIN RESULTS: An intraoperative technique with commentary highlighting tips for a successful dissection. The uterine cavity was successfully restored using the blunt spreading dissection technique. There were no complications, including false uterine wall passage, uterine perforation, or fluid overload. Postoperative hysteroscopy at 1 month revealed an almost normal uterine cavity. CONCLUSIONS: HA using a blunt spreading dissection technique to restore the uterine cavity is a simple, effective, and safe hysteroscopic skill, especially when the endometrial stripe is obscured on ultrasound imaging and exploring the uterine cavity by means of a probe has failed. Furthermore, this technique may serve as an alternative to resectoscopic techniques because it uses cold forceps and scissors, which provide better protection for the endometrium.

Congenital vaginal atresia: A report of 39 cases in a regional Obstetrics and Gynecology Hospital.

To investigate the clinical course and management of congenital vaginal atresia. This retro-spective analysis included patients with congenital vaginal atresia treated from March 2004 to August 2014 at the Obstetrics and Gynecology Hospital of Fudan University. Thirty-nine patients were included in this study. Their average age was 16.87±2.2 years when they came to our hospital. Totally, 51% of the patients had isolated congenital vaginal atresia with a normal cervix, whereas the others had either cervical atresia or imperforate hymen. The primary presenting signs and symptoms included primary amenorrhea (71.8%), periodic abdominalgia (41.0%), abdominal pain (36.0%), dyspareunia (10.3%), menstrual disorders (5.1%), and pelvic mass (5.1%). Ultrasound and magnetic resonance imaging (MRI) were effective inspection methods for the screening of urogenital tract-associated anomalies. Vagi-noplasty mainly included simple vagina reconstruction with insertion of a mold (n=22) and split-thickness skin grafting (n=4). In 64% of surgical patients, normal menstrual bleeding was achieved. Four of the patients subsequently became pregnant and delivered at term. Primary amenorrhea, periodic abdominalgia and abdominal pain are the main reasons for the post pubertal patients to visit doctors. Surgical methods can successfully provide these patients an opportunity for subsequent conservative management, can result in normal menstrual bleeding, resolve cyclic pelvic pain, and provide some po-tential for fertility.

Case Report: Laparoscopic Uterovaginal Anastomosis for Congenital Isolated Cervical Agenesis.

Management of cervical agenesis is a challenge owing to the complexity of the malformation and the difficulty in restoring and preserving fertility. We propose a minimally invasive fertility-sparing surgery for a 17-year-old woman with congenital cervical agenesis and a normal vagina and uterus confirmed by vaginoscopy. The patient was admitted for primary amenorrhea, hematometra, and cyclic pelvic pain. She had undergone previous laparoscopies for ovarian endometriosis. Our surgical approach involved the creation of an isthmus-vaginal anastomosis with a uterovaginal reconnection. After surgery, the patient experienced regular menstrual cycles without dysmenorrhea. At 12 months postsurgery, she continued to experience normal menstruation, and the uterovaginal connection had not stenosed. Management of congenital cervical agenesis requires accurate diagnosis that includes appropriate classification of the malformation (European Society of Human Reproduction and Embryology/European Society for Gynaecological Endoscopy classification). Surgical treatment is controversial and depends on the patient's age and desire for resolution.

Transverse Vaginal Septum With Secondary Infertility: A Rare Case.

STUDY OBJECTIVE: To demonstrate the technique of laparoscopic vaginal reconstruction in a rare case of mid-vaginal septum with secondary infertility. DESIGN: A step-by-step explanation of the technique using videos and pictures (Canadian Task Force classification IV). SETTING: Transverse vaginal septum is a rare condition, with an incidence of only 1 in 30,000 women. It is usually a congenital mullerian fusion defect; few cases of acquired septum have been reported. Roughly 40% of cases occur in the mid-vagina. Transverse vaginal septum typically presents with primary amenorrhea and hematocolpos. The goal of surgery is to create a patent vagina with restoration of fertility. The laparoscopic approach has proven superiority over the open technique. INTERVENTIONS: Laproscopic vaginal reconstruction was performed in a 24 year female with transverse vaginal septum. Dissection was done laproscopically up to mid vagina. Incision was given on vagina excising the septum followed by reconstruction. CONCLUSION: The laparoscopic approach to vaginal reconstruction avoids the abdominal incision, with its associated pain and possible adhesion formation. It also provides a better view for dissection. In this patient, a patent vagina was created in a single operation, with no postoperative dyspareunia, and fertility was restored.

Endometrial Ablation in Women With Abnormal Uterine Bleeding Related to Ovulatory Dysfunction: A Cohort Study.

STUDY OBJECTIVE: To evaluate the efficacy and safety of endometrial ablation (EA) for the treatment of abnormal uterine bleeding (AUB) associated with ovulatory dysfunction. DESIGN: A retrospective cohort study (Canadian Task Force classification II-2). SETTING: An academic medical center. PATIENTS: Women with AUB who underwent EA during an 8-year period. INTERVENTIONS: EA by radiofrequency or thermal balloon ablation techniques. MEASUREMENTS AND MAIN RESULTS: Women with AUB were divided into 2 groups: irregular bleeding with ovulatory dysfunction (AUB-O) or regular heavy bleeding related to a primary endometrial disorder (AUB-E). Outcome measures included rates of amenorrhea and treatment failure (ie, need for reablation or hysterectomy). Outcomes were compared between groups using survival analyses and chi-square tests. Known confounders were adjusted for using Cox and logistic regression models. Five-year cumulative treatment failure rates were 11.7% (95% confidence interval [CI], 6.5%-16.9%) for AUB-O and 12.3% (95% CI, 8.4%-16.2%) for AUB-E (p = .62). The unadjusted hazard ratio for treatment failure was 0.87 (95% CI, 0.72-1.05, p = .16). After adjusting for known risk factors for failure, the hazard ratio was 1.48 (95% CI, 0.82-2.65, p = .19). The rates of amenorrhea were 11.8% for AUB-O and 13.8% for AUB-E with an unadjusted odds ratio of 0.84 (95% CI, 0.48-1.48, p = .55). After adjusting for factors for amenorrhea after EA, the odds ratio was 1.08 (95% CI, 0.62-1.84, p =.78). No pregnancies or endometrial cancers occurred after EA. CONCLUSION: EA is effective in women with AUB-O and can be used as an alternative to hysterectomy or in patients with contraindications to medical management of AUB-O.

Congenital Atresia of Uterine Isthmus: Successful Diagnosis and End-To-End Anastomosis.

BACKGROUND: Müllerian duct anomalies are rare and occasionally diagnosed in adolescents with primary amenorrhea, abdominal pain, and sexual difficulties. They are present in a variety of forms and sometimes difficult to appropriately classify. The management of malformations remains controversial. CASE: A 15-year-old girl with primary amenorrhea and cyclic lower abdominal pain was found on laparoscopic examination to have an asymmetric ball-shaped uterus with isthmus stenosis suspended in the pelvis. The junction between the lower segment of uterus and the cervix was very thin and stenotic with scar-like tissue changes. Combined with pathologic evaluation, it was finally diagnosed as congenital atresia of uterine isthmus. Thus, an end-to-end anastomosis was performed instead of surgical resection. SUMMARY AND CONCLUSION: Müllerian duct anomalies in a variety of forms can be difficult to diagnosis correctly and treat appropriately. Preservation of reproductive ability is the first objective of all treatments.

Microwave endometrial ablation versus thermal balloon endometrial ablation (MEATBall): 5-year follow up of a randomised controlled trial.

OBJECTIVE: To compare long-term outcomes following microwave endometrial ablation (MEA™) and thermal balloon ablation (TBall). DESIGN: Follow up of a prospective, double-blind randomised controlled trial at 5 years. SETTING: A teaching hospital in the UK. POPULATION: A total of 320 women eligible for and requesting endometrial ablation. METHODS: Eligible women were randomised in a 1:1 ratio to undergo MEA or Tball. Postal questionnaires were sent to participants at a minimum of 5 years postoperatively to determine satisfaction with outcome, menstrual status, bleeding scores and quality of life measurement. Subsequent surgery was ascertained from the women and the hospital operative database. MAIN OUTCOME MEASURES: The primary outcome measure was overall satisfaction with treatment. Secondary outcomes included evaluation of menstrual loss, change in quality of life scores and subsequent surgery. RESULTS: Of the women originally randomised 217/314 (69.1%) returned questionnaires. Nonresponders were assumed to be treatment failures for data analysis. The primary outcome of satisfaction was similar in both groups (58% for MEA™ versus 53% for TBall, difference 5%; 95% CI -6 to 16%). Amenorrhoea rates were high following both techniques (51% versus 45%, difference 6%; 95% CI -5 to 17%). There was no significant difference in the hysterectomy rates between the two arms (9% versus 7%, difference 2%; 95% CI -5 to 9%). CONCLUSIONS: At 5 years post-treatment there were no significant clinical differences in patient satisfaction, menstrual status, quality of life scores or hysterectomy rates between MEA™ and Thermachoice 3, thermal balloon ablation.