Hysteroscopic endometrial peeling as a different approach to endometrial scratching. Case series report.

STUDY QUESTION: Does hysteroscopic endometrial peeling improve reproductive outcomes in women with implantation failure? DESIGN: In this case series, 66 women underwent an hysteroscopic endometrial peeling and subsequently, a single frozen embryo transfer. RESULTS: After the exclusion of patients with intraoperative incidental findings, pregnancy was achieved in 63% (42/66) of the women who underwent hysteroscopic endometrial peeling and subsequently a single frozen embryo transfer, clinical pregnancy rate was observed in 57% (38/66) of the patients and, clinical pregnancy loss occurred in 10% (4/38). CONCLUSION: this novel surgical technique seems to increase implantation as well as clinical pregnancy rates in women with repeated implantation failure. We can hypothesize that the controlled and subtle degree of endometrial injury generated by the peeling generates an inflammatory cascade that enhances implantation.

Hysteroscopic detection of chronic endometritis: Evaluating proposed hysteroscopic features suggestive of chronic endometritis.

PURPOSE: To evaluate the proposed criteria in a large sample and in additional subgroups in order to test the validity of the hysteroscopic features widely-accepted as suggestive of CE. METHOD(S): All patients (n: 2675) underwent outpatient hysteroscopy, with the vaginoscopic approach technique. Hysteroscopic features such as, stromal oedema, diffuse or focal hyperaemia, "strawberry aspect", micropolyposis and endometrial polyps, are often indicate the presence of chronic endometritis. All hysteroscopic features, alone and in combination were applied in 7 (seven) different subgroups of the sample: total sample, women in reproductive age, women with infertility issues/IVF screening, women with history of recurrent miscarriages, menopausal women, and women with hysteroscopic indication of Abnormal Uterine Bleeding (AUB) in women of reproductive age and postmenopausal bleeding (PMB). From each case, endometrial samples were obtained and immunohistochemistry, identifying CD-138, was applied in order to diagnose CE. RESULT(S): A total of 2675 patients were included of which, 1444 women were found with at least one of the proposed hysteroscopic features mentioned above. Stromal oedema, focal or diffuse hyperaemia and "strawberry aspect" in combination with micropolyposis demonstrated higher rates of diagnostic accuracy in the detection of CE correlated to histologic confirmation. Micropolyposis, stromal oedema, focal or diffuse hyperaemia and "strawberry aspect" offer great diagnostic accuracy in the hysteroscopic detection of Chronic Endometritis, regardless reproductive status and/or clinical presentation. Endometrial polyps are not valid hysteroscopic features in cases of suspected CE. CONCLUSION(S): Diagnostic hysteroscopy can accurately diagnose cases of CE, based on stromal oedema, focal or diffuse hyperaemia and "strawberry aspect", in combination with micropolyposis. In subgroups of infertile women, higher diagnostic accuracy based on the hysteroscopic features mentioned, was more likely to be achieved. Whether endometrial polyps are suggestive of CE, when identified during office hysteroscopy, remains controversial.

Office hysteroscopy before first in vitro fertilization. A randomized controlled trial.

BACKGROUND: Implantation failure remains a mystery since decades. This procedure needs a "top quality embryo" and a "normal" uterine cavity. To assess uterine cavity before first in vitro fertilization (IVF), many diagnostic tools could be used. Hysteroscopy remains the gold standard to diagnose and treat intra-uterine anomalies. However, it is not clearly recommanded to offer an office hysteroscopy before first IVF when transvaginal ultrasound (TVUS) and hysterosalpingography (HSG) were normal. PURPOSE: This study aimed to assess the role of office hysteroscopy before first IVF when no intra-uterine anomalies are suspected. BASIC PROCEDURES: We conducted a randomized controlled trial including 171 women scheduled for their first IVF. Women were assigned to either Group I: office hysteroscopy before IVF or Group II: immediate IVF. We included women aged less than 40 years, having regular cycles, FSH levels less than10UI/l, antral follicular count ≥12, normal TVUS and HSG. Their body mass index (BMI) ranged from 19 to 30 kg/m2. We excluded patients known having severe endometriosis, polycystic ovarian syndrome (PCOS) and oocyte receivers. The primary outcome were livebirth rate and clinical pregnancy rate. MAIN FUNDINGS: Between january 2016 and september 2017, we randomly assigned 171 women to either Group I (n = 84) or Group II (n = 87). Hysteroscopy was done in the mid-follicular phase immediately before IVF. Baseline characteristics and IVF features were comparable between groups except for the IVF protocol. Live birth rate was 23,9% in Group I versus 19,3% in Group II. (p = 0,607). Clinical Pregnancy rate was 32,4% in Group I versus 21,7% in Group II. (p = 0,326). No statistical significance was observed for neither miscarriage rate nor multiple pregnancy rate. Hysteroscopy showed 30% unsuspected intra-uterine anomalies: 11 intra-uterine adhesions, 7 polyps, 7 clinical endometritis and one fibroid print. Therapeutic hysteroscopy was done only for 6 intra-uterine adhesions and 3 polyps. Other anomalies did not require operative hysteroscopy. Visual analog score during hysteroscopy was 4,69 +/-2,892. 5 women (6%) of Group I experienced discomfort during diagnostic hysteroscopy. Only one patient had vagal syncope. No further complications were observed. PRINCIPAL CONCLUSIONS: Office hysteroscopy before first IVF seems not improve IVF results. Minimal intra-uterine anomalies not diagnosed by transvaginal ultrasound and hysterosalpingography do not seem to reduce IVF results.

Optimal Isthmocele Management: Hysteroscopic, Laparoscopic, or Combination.

OBJECTIVE: To conduct a systematic review of the literature on the hysteroscopic and laparoscopic repair of isthmocele. DATA SOURCES: A thorough search of the PubMed/Medline, Embase, and Cochrane databases was performed. (PROSPERO registration number CRD42020190668). METHODS OF STUDY SELECTION: Studies from the last 20 years that addressed isthmocele repair were collected. Both authors screened for study eligibility and extracted data. All prospective and retrospective studies of more than 10 women were included. TABULATION, INTEGRATION, AND RESULTS: The initial search identified 666 articles (Preferred Reporting Items for Systematic Reviews and Meta-Analyses flow chart) (see Supplemental Fig.). We excluded duplicates, case reports, reviews, video articles, and technique articles. We also excluded studies describing only laparotomy or vaginal repair as these were not in the scope of this review. A total of 31 articles met the inclusion criteria, 21 for hysteroscopic resection and 13 for laparoscopic or combined repair (4 articles tested both modalities and appear in both Tables 1 and 2).For abnormal uterine bleeding, hysteroscopic remodeling relived symptoms in 60% to 100% of cases and laparoscopy in 78% to 94%. Secondary infertility was not evaluated in all studies. After hysteroscopic and laparoscopic treatment, 46% to 100% and 37.5% to 90% of those who wished to conceive became pregnant, after the procedure, respectively. Pain and dysmenorrhea seem to be uncommon. All studies that tested improvement of pain had fewer than 10 women. However, between 66% and 100% of women who complain of pain or dysmenorrhea will note a marked improvement to full resolution. CONCLUSION: Patients with an isthmocele or cesarean scar defect are usually asymptomatic. For symptomatic women, a repair is a valid option. For those with residual myometrial thickness >2 to 3 mm, hysteroscopic remodeling is the modality of choice with an improvement in abnormal uterine bleeding, secondary infertility, and pain. Women with a residual myometrial thickness <2- to 3-mm laparoscopic repair with simultaneous hysteroscopic guidance show similar results. Because available data are limited, no cutoff for the correct choice between hysteroscopy and laparoscopy can be concluded. We recommend 2.5 mm as the cutoff value based on common practice and expert opinion, although no significance between hysteroscopic and laparoscopic treatment was shown.

2020 Hong Kong College of Obstetricians and Gynaecologists guideline on investigations of premenopausal women with abnormal uterine bleeding.

Abnormal uterine bleeding in premenopausal women is a common gynaecological symptom and composes of abnormality in the frequency, duration, regularity, and flow volume of menstruation. It could constitute the presentation of various gynaecological malignancies. An appropriate history and physical examination are mandatory to ascertain the diagnosis. Depending on the clinical condition, a complete blood picture, thyroid function test, clotting profile, chlamydia test, cervical smear, and pregnancy test can be performed. Ultrasound should be performed in cases with a pelvic mass, unsatisfactory physical examination, persistent symptoms, or no response to medical treatment. In women aged ≥40 years, an out-patient endometrial biopsy with Pipelle should be performed. In women aged <40 years with risk factors for endometrial cancer, persistent symptoms, or no response to medical treatment, an endometrial biopsy should be performed to rule out endometrial cancer. Hysteroscopy or saline infusion sonohysterography is more sensitive than ultrasound for diagnosing endometrial pathology. Details of the above recommendations are presented.

Cirurgia ginecológica e COVID-19: qual o impacto e como devo conduzir? / Gynecological Surgery and COVID-19: What is the Impact and How Should I Manage it?

Estima-se que cerca de 28 milhões de cirurgias sejam postergadas ou canceladas no mundo em decorrência desta pandemia, causando atraso no diagnóstico e tratamento de mais de 2 milhões de casos oncológicos. No Brasil, tanto a ANS (Agência Nacional de Saúde) como a Anvisa (Agência Nacional de Vigilância Sanitária) orientaram o adiamento das cirurgias eletivas e não essenciais, tendo um impacto considerável no número de procedimentos cirúrgicos, com diminuição de 33,4% neste período no Brasil. No entanto, algumas mulheres necessitam de tratamento para várias doenças ginecológicas, algumas das quais não podem ser adiadas. O objetivo deste artigo é apresentar recomendações sobre o tratamento cirúrgico durante a pandemia de COVID-19.(AU)

To treat or not to treat? An evidence-based practice guide for the management of endometrial polyps.

Endometrial polyps are a common finding, with a prevalence of about 40%, and are usually diagnosed incidentally as most are asymptomatic. Symptomatic polyps usually present with abnormal uterine bleeding and/or sub-fertility. About 25% of polyps resolve spontaneously if managed conservatively. The usual management of endometrial polyps, symptomatic or asymptomatic, is polypectomy, performed primarily to exclude malignancy within the polyp despite the overall risk of malignancy being low (about 3%). The main risk factors for malignancy are menopause and abnormal uterine bleeding, with hypertension, obesity, diabetes mellitus, and tamoxifen use thought to play a lesser role. Transvaginal ultrasonography is the primary diagnostic tool for endometrial polyps although visualization by hysteroscopy is the gold standard for diagnosis. There is no proven preventative or medical treatment, with complete polyp removal under hysteroscopic guidance the recommended surgical treatment. Some women may decline surgical endometrial polyp management due to the small inherent risks. Conservative management is an option for asymptomatic premenopausal and postmenopausal women, whilst polypectomy is recommended for all women with abnormal uterine bleeding. Management should be individualized and made in consultation with the patient.

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.

Hysteroscopic and aspiration biopsies in the histologic evaluation of the endometrium, a comparative study.

This study aimed to compare the quality of histological endometrial samples collected through Pipelle aspiration and hysteroscopic biopsies to assess the agreement between these 2 biopsies in the histological diagnosis of malignancy and to compare the costs of both biopsies.This was a cross-sectional study. Forty-five women were biopsied, first using Pipelle and immediately after using hysteroscopy. The material collected was sent for analysis, and hysteroscopy was considered the gold standard. The results were divided into the following 3 categories: normal (atrophic, proliferative, and secretory endometrium); polyps; and malignancies. We report the agreement between Pipelle and hysteroscopy in the diagnosis of malignancy and compare their costs.The study showed that while analyzing endometrial malignancies, Pipelle sampling had 100% sensitivity and specificity. In the detection of polyps, Pipelle sampling showed 26.1% sensitivity, 88.9% specificity, 75% positive predictive value, 48.5% negative predictive value, and 53.7% accuracy. Agreement with hysteroscopy in the diagnosis of malignancy was 100%. The Pipelle device costs 27 times less than hysteroscopic biopsy for health insurance companies. This cost is 13.7 times lower in the Brazilian Unified Health System.Endometrial biopsies using the Pipelle have a high accuracy for endometrial cancer and a low accuracy for polyps. We detected 100% agreement between the reports of Pipelle and hysteroscopy with regard to malignancy. Pipelle is the most cost-effective method of endometrial biopsy.

Diagnostic accuracy of saline contrast sonohysterography in detecting endometrial polyps in women with postmenopausal bleeding: systematic review and meta-analysis.

OBJECTIVE: In women with postmenopausal bleeding, endometrial polyps are a frequent finding and the risk of a focal (pre)malignancy in a polyp is up to 6%. Because of this reported risk, the detection of polyps in these women, preferably by a minimally invasive method, is important. The aim of this systematic review was to assess the accuracy of saline contrast sonohysterography (SCSH) for diagnosis of endometrial polyps in women with postmenopausal bleeding. METHODS: In August 2018, an electronic search was performed of MEDLINE, EMBASE and Web of Science databases to identify all diagnostic studies in which SCSH was used to detect endometrial polyps in postmenopausal women. Studies were included if SCSH was performed to detect endometrial polyps in women with postmenopausal bleeding and if detection of a polyp on hysteroscopy or diagnosis on histopathology was used as a reference standard. Two reviewers assessed methodological quality using the quality assessment of diagnostic accuracy studies (QUADAS-2) tool. Two separate analyses were performed for each reference standard. Pooled sensitivity and specificity were calculated using the hierarchical summary receiver-operating characteristics (HSROC) model and HSROC curves were plotted. RESULTS: After selection and quality assessment, five studies were included. Using 'polyps diagnosed with histopathology' as the reference standard, the pooled sensitivity of SCSH was 86.5% (95% CI, 63.6-100%) and the pooled specificity was 91.1% (95% CI, 63.2-100%). Using 'polyps seen on hysteroscopy' as the reference standard, the pooled sensitivity of SCSH was 85.1% (95% CI, 66.9-100%) and the pooled specificity was 84.5% (95% CI, 68.1-100%). Excluding the one study that included women in whom the SCSH examination was reported to be suboptimal, the pooled sensitivity increased to 90.7% (95% CI, 72.8-100%) using hysteroscopy as the reference standard. The sensitivity of hysteroscopy to detect polyps, as reported in two studies, was 81-98%. CONCLUSIONS: Provided that the SCSH examination is of optimal quality, it can be considered as a method to stratify women with postmenopausal bleeding for further diagnostic workup and treatment with hysteroscopy. In women without suspicion of a polypoid lesion on SCSH, and with a benign endometrial sample, expectant management should be considered. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

Precisión del diagnóstico de la sonohisterografía con contraste salino en la detección de pólipos endometriales en mujeres con hemorragia postmenopáusica: revisión sistemática y metaanálisis OBJETIVO: En las mujeres con hemorragia postmenopáusica, los pólipos endometriales son frecuentes y el riesgo de una (pre)malignidad focal en un pólipo es de hasta el 6%. Debido a este riesgo reportado, es importante la detección de pólipos en estas mujeres, preferiblemente por un método mínimamente invasivo. El objetivo de esta revisión sistemática fue evaluar la precisión de la sonohisterografía con contraste salino (SCSH, por sus siglas en inglés) para el diagnóstico de pólipos endometriales en mujeres con hemorragia postmenopáusica. MÉTODOS: En agosto de 2018 se realizó una búsqueda electrónica en las bases de datos MEDLINE, EMBASE y Web of Science para identificar todos los estudios diagnósticos en los que se utilizó la SCSH para detectar pólipos endometriales en mujeres postmenopáusicas. Los estudios se incluyeron cuando la SCSH se realizó para detectar pólipos endometriales en mujeres con hemorragia postmenopáusica o cuando la detección de un pólipo en la histeroscopia o el diagnóstico sobre la histopatología se utilizó como estándar de referencia. Dos revisores evaluaron la calidad metodológica mediante la evaluación de calidad de la herramienta de estudios de precisión diagnóstica (QUADAS-2). Se realizaron dos análisis separados para cada estándar de referencia. La sensibilidad y especificidad combinadas se calcularon utilizando el modelo jerárquico de resumen de las características operativas del receptor (HSROC, por sus siglas en inglés) y se trazaron las curvas HSROC. RESULTADOS: Después de la selección y la evaluación de calidad, se incluyeron cinco estudios. Utilizando los 'pólipos diagnosticados con histopatología' como estándar de referencia, la sensibilidad combinada de la SCSH fue del 86,5% (IC 95%, 63,6-100%) y la especificidad combinada fue del 91,1% (IC 95%, 63,2-100%). Utilizando como estándar de referencia los 'pólipos observados en la histeroscopia', la sensibilidad combinada de la SCSH fue del 85,1% (IC 95%: 66,9-100%) y la especificidad combinada fue del 84,5% (IC 95%: 68,1-100%). Excluyendo el único estudio que incluyó mujeres en las que se reportó que el examen por SCSH no fue adecuado, la sensibilidad combinada aumentó al 90,7% (IC 95%: 72,8-100%), usando la histeroscopia como estándar de referencia. La sensibilidad de la histeroscopia para detectar pólipos, tal y como se informó en dos estudios, fue del 81-98%. CONCLUSIONES: Siempre que el examen por SCSH sea de calidad óptima, puede considerarse como un método para estratificar a las mujeres con hemorragia postmenopáusica para su posterior diagnóstico y tratamiento con histeroscopia. En mujeres sin sospecha de una lesión polipoide mediante SCSH y con una muestra endometrial benigna, se debe considerar el tratamiento expectante. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

From the dry lab to the operating room: the first transferability study of hysteroscopic skills.

OBJECTIVE: The aim of this study is to prove that a short dry lab training prior to the surgery is efficient to acquire basic hysteroscopic skills and that these skills are transferable directly to the operation theater. METHODS: Thirty-nine gynecologists who never attended a training course or practiced hysteroscopy before were evaluated. Participants were randomly divided into trainees (n = 21) and control (n = 18). Trainees attended a short time dry lab prior the exposure to the OR. The controls went directly to the OR. Participants were asked to identify the different landmarks of the uterine cavity and to perform a punch biopsy under the supervision of a gynecologist expert in hysteroscopy. A video recording for all the exercises was done, and showed independently to two expert surgeons in hysteroscopy for evaluation. The experts were also asked to distinguish between the trainees and the control. RESULTS: For both experts, the trainees' performance was statistically better than that of the controls (p < 0.001) for the identification of the uterus land marks and the punch biopsy. The two experts identified 80.9 and 85.7%, respectively, of the trainees. The participants' subgroup ID and the experts' identification were statistically correlated (p < 0.001). CONCLUSION: A short time dry lab is efficient to acquire basic hysteroscopic skills and these skills are transferable directly to the OR.

Office hysteroscopy for postmenopausal women: Feasibility and correlation with transvaginal ultrasound.

OBJECTIVE: To evaluate feasibility of office hysteroscopy in postmenopausal women and correlation between transvaginal ultrasound (TV-US) and hysteroscopy. METHODS: Postmenopausal women addressed at office hysteroscopy for postmenopausal bleeding or increase endometrial thickness were included. A 3.5-mm rigid hysteroscope was used without cervical dilatation or local anaesthesia. Speculum was never used. Data concerning women's symptoms and TV-US findings were collected. RESULTS: Four-hundred-seventy postmenopausal women referred for office hysteroscopy were included in this descriptive study. Three-hundred-fifty women (74.5%) experienced abnormal uterine bleeding. The success rate of office hysteroscopy was 76.4% and was significantly higher in cases of postmenopausal bleeding (80.9%) than in women without postmenopausal bleeding (63.3%) (p=0.01). Three-hundred-sixteen women had both a successful hysteroscopy and TV-US. The correlation between hysteroscopy and TV-US was 68.5% for the diagnosis of increased endometrial thickness, polyps and submucosal myoma (Kappa=0.28). The rate of endometrial cancer for women with postmenopausal bleeding was 12.6% (n=44) while it was 1.7% (n=2) for asymptomatic women. Two (4.3%) out of these 46 women with endometrial cancer had normal hysteroscopy, while 7 (15.2%) had a normal TV-US (including endometrial thickness below 5mm). Among the 54 women without bleeding and with a thickened endometrium, one (1.8%) had endometrial cancer. CONCLUSION: Office hysteroscopy is successful without anaesthesia for 76.4% of postmenopausal women. The correlation between TV-US and hysteroscopy is low, and we recommend to practice both sonography and hysteroscopy in women with postmenopausal bleeding.

Surgery and out-patient data collection and reporting using Filemaker Pro.

OBJECTIVE: The application of an electronic database in clinical practice is used widespread in every field of medicine. The aim of the present study is to illustrate our experience to use a database software for documentation of two of our clinical activities, outpatient hysteroscopy and inpatient gynaecological surgery. PATIENTS AND METHODS: In 2004, we designed two databases, the first one to document surgical procedures in the operating theatre, the second to document outpatient hysteroscopy procedures using FileMaker v.8.5. The data entry interface contains free text fields for patient demographic data and the description of the surgical procedure, supplemented by drop-down lists for items such as clinical findings, procedures, instrumentation, technique, and complications. Copies were filed in the main hospital notes, sent to General Practitioners, and also given to our patients. RESULTS: Since August 2004, we have used our two databases to document 2766 gynaecological operations and 3777 outpatient hysteroscopies. All users particularly liked the dropdown lists as their use greatly reduced the time taken to enter each patient's data. The databases were regularly used to select patients for audit projects and research data collection for prospective studies. CONCLUSIONS: FileMaker is an user-friendly and easily configured software, extremely valuable in everyday clinical work.

Are 3D ultrasound and office hysteroscopy useful for the assessment of uterine cavity after late foetal loss?

OBJECTIVE: To assess the efficacy of office hysteroscopy and 3D ultrasound for the diagnostic of uterine anomalies after late foetal loss. METHOD: This retrospective observational study took place in the gynaecologic unit of a teaching hospital from 2009 to 2014. Women with late foetal loss (<22 weeks of gestation) had an office hysteroscopy and 3D ultrasound within three months after delivery. The results of the ultrasound and hysteroscopy were recorded and compared. RESULTS: Eighty women were included with a mean age of 29.8 years (28.2-31.4). Forty-seven women had both hysteroscopy and 3D ultrasound, and a uterine cavity's anomaly (bicornuate uterus, T-Shape uterus and septate uterus) was found in ten women (21%) at 3D sonography and in 13 women (28%) at office hysteroscopy. Concordance between the two exams was very good with a kappa at 0.83. In three cases, a uterine cavity's anomaly was found at hysteroscopy whereas sonography was normal. Anomalies at ultrasound (uterine cavity's anomaly, myometrium anomaly or ovarian anomaly) were found in 27.6% of cases. CONCLUSIONS: Both 3D ultrasound and office hysteroscopy are useful for assessment of the uterine cavity after late foetal loss. The application of these two exams is important, as hysteroscopy is generally used for assessment of the uterine cavity and endometrium, while 3D ultrasound is generally used to identify the precise type of uterine malformation and for the examination of the myometrium and annexes.

Hysteroscopy after repeated implantation failure of assisted reproductive technology: A meta-analysis.

We conducted this meta-analysis to explore the prognostic value of outpatient (or office) hysteroscopy (OH) preceding in vitro fertilization (IVF) or intracytoplasmic sperm injection (ICSI) cycles in women who had experienced repeated implantation failure (RIF), particularly in regard to the conflicting evidence reported by previous studies. Two reviewers independently searched Pubmed, MEDLINE, Web of Science, Cochrane Library and Embase to identify all publications of clinical trials of hysteroscopy with or without endometrial biopsy in RIF patients. The primary outcome measures were clinical pregnancy rate (CPR) and live birth rate (LBR). Pooled relative ratios (RRs) with 95% confidence intervals (CIs) were calculated. Publication bias was detected using funnel plots and Egger's regression tests. Six eligible studies comprising 4143 patients were included. The CPR and LBR were both significantly higher in RIF patients with OH than RIF patients without OH (CPR: RR 1.34, 95% CI 1.14-1.57, P < 0.05; LBR: RR 1.29, 95% CI 1.03-1.62, P < 0.05). Subgroup analysis revealed a significant association between OH and CPR in Asia (CPR: RR 1.49, 95% CI 1.31-1.69; P < 0.05) rather than in Europe (CPR: RR 1.08, 95% CI 0.93-1.26; P = 0.291). However, there was no evidence of a significant difference in either CPR or LBR between the normal and abnormal OH groups (CPR: RR 0.92, 95% CI 0.83-1.02, P = 0.12; LBR: RR 0.76, 95% CI 0.37-1.56, P = 0.450). Hysteroscopy may potentially improve pregnancy outcomes in patients with RIP.

Advanced Hysteroscopic Surgery: Quality Assurance in Teaching Hospitals.

Advanced hysteroscopic surgery (AHS) is a vitally important technique in the armamentarium for the management of many day-to-day clinical problems, such as menorrhagia, surgical excision of uterine myomata and septa in the management of female infertility, hysteroscopic excision of chronically retained products of conception (placenta accreta), and surgical removal of intramural ectopic pregnancy. In today's climate of accountability, it is necessary that gynecologists take a more active role in assuring the quality of their work. In this article, we discuss the quality assurance system from the point of view of the surgical audit meetings in some of the major teaching hospitals affiliated with the University of Queensland (Brisbane, Queensland, Australia).