New hysteroscopic techniques for submucosal uterine fibroids.

PURPOSE OF REVIEW: To review the preoperative preparation, intraoperative equipment and techniques to facilitate hysteroscopic resection of submucous fibroids. RECENT FINDINGS: The use of preoperative ultrasound can guide safe resection of submucous fibroids and should be an integral part of a preoperative workup. The data regarding misoprostol use for cervical dilation prior to hysteroscopy is somewhat conflicting and the decision to preoperatively administer misoprostol should be on a case-by-case basis. Hysteroscopic resection of submucous intrauterine fibroids can now be performed under low-dose spinal anesthesia and with the development of smaller instruments and bipolar technology, in an office-based setting without any anesthesia and, sometimes, analgesia. Although the complete removal of type 1 and 2 submucous fibroids remain a challenge, the development of newer techniques such as office preparation of partially intramural myomas and cold-loop myomectomy can result in better removal of these submucous fibroids with an intramural component. SUMMARY: Hysteroscopic resection of submucous uterine fibroids should be a simple, well tolerated and effective procedure. Innovations to the existing hysteroscopic techniques and the development of the hysteroscopic morcellator will hopefully result in a greater number of gynecologic surgeons being able to safely perform hysteroscopic resection of submucous uterine fibroids.

Effects of embryo transfer catheters on the endometrial surface noted at hysteroscopy.

STUDY OBJECTIVE: To assess the effects on the endometrial surface of embryo transfer catheters using hysteroscopy with ultrasound guidance. DESIGN: Prospective descriptive study (Canadian Task Force classification III). SETTING: University-based clinical practice. PATIENTS: Twenty patients with a documented difficult trial transfer (TT). INTERVENTION: All patients underwent an intraoperative TT using an Edwards-Wallace catheter (n = 10), a Soft-Pass catheter with obturator (n = 2), or an Echosight Patton catheter with a coaxial wire (n = 8), with placement assured using ultrasound. This was followed by hysteroscopy and cervical surgical correction. MEASUREMENTS AND MAIN RESULTS: A 5-mm hysteroscope was used to visualize, assess, and document TT catheter placement and effects on the endometrial cavity. The Wallace catheter caused the least trauma (20%). The Soft-Pass catheter with obturator (100%) resulted in linear grooves in the endometrial surface. The most traumatic effects occurred with use of the coaxial catheter (38%), which caused shaving with petechial bleeding past the point of obstruction. In addition, 3 of the Wallace catheters were improperly placed (cannulation of tubal ostia, n = 2) and coiled back (n =1). CONCLUSION: Despite ultrasound guidance, endometrial disruption and catheter displacement occurs with difficult embryo transfer catheter placement, which may suggest an explanation for lower pregnancy rates in these difficult cases. Greater attention to correction of cervical disease before an in vitro fertilization-embryo transfer cycle may improve clinical outcomes.

The relative proportion of preterm births complicated by premature rupture of membranes in multifetal gestations: a population-based study.

OBJECTIVE: To compare the relative contribution of premature rupture of membranes (PROM) to preterm births in singleton compared with multifetal gestations. STUDY DESIGN: A population-based retrospective cohort study of 291,782 nonanomalous live births in the state of Ohio from January 1, 2006, to December 31, 2007, identified through birth certificate data. Frequency of PROM was compared between singleton and multifetal gestations and then stratified by gestational age at birth. Multivariate regression analysis estimated the risk of PROM by plurality in each gestational age group, accounting for influential risk factors. RESULTS: The frequency of PROM increased with increasing plurality of gestation. The relative proportion of preterm birth < 37 weeks complicated by PROM increased with gestational plurality 13.2% singletons, 16.8% twins, 20.0% triplets, 19.6% quadruplets, and 100% for higher-order multiples (p < 0.001). The frequency of PROM increased with earlier gestational age at birth, regardless of plurality. The increased risk of PROM in multifetal gestation persisted even after adjustment for influential concomitant risk factors. CONCLUSION: The proportion of preterm birth attributable to PROM increases by plurality of gestation, with its most significant contribution in higher-order multiples and at earliest gestational ages when outcomes are the poorest.

Cryopreservation Does Not Affect the Clinical Pregnancy Rate of Blastocysts Derived from Vitrified Oocytes.

Vitrified, or "frozen", donor eggs can either be fertilized and cultured for fresh transfer (group 1), or fertilized and cryopreserved for transfer in a "frozen embryo transfer" cycle (group 2). This study compared the pregnancy rates between the two groups. Frozen donor egg cycles (N = 1213) were analyzed at the World Egg Bank. The outcome studied was clinical pregnancy rate. Cycles included only single embryo transfers (ET) without preimplantation genetic testing (PGT). A total of 600 cycles met the inclusion criteria. Group 1 included 409 cycles and group 2 had 191 cycles. There was no statistical significance in clinical pregnancy rate between the two groups (38.63% vs 32.46%, p = 0.14). Mean embryo age was higher in group 2 (5.1 vs. 5.4 days, p < 0.01). The compounding effect of vitrification when applied to two distinct stages (oocyte and embryo), has not been studied. When comparing the two groups, we found no difference in pregnancy rate. However, there was a trend towards fewer pregnancies in group 2. A larger study should be done to determine the validity of this result (Ramadan et al. in Fertil Steril, 2020).

Heavy menstrual bleeding diagnosis and medical management.

Heavy menstrual bleeding (HMB) is a common gynecological problem that has a significant impact on a woman's quality of life and the activities of daily living. Due to the difficulty in accurately describing menstrual bleeding abnormalities using older terminology, the PALM-COEIN classification system of the Federation Internationale de Gynecologie et d'Obstetrique was proposed to describe and identify the etiology of abnormal endometrial bleeding. As there is no single pathway that is associated with HMB, there are several therapeutic interventions involving different molecular pathways to reduce HMB. This article will highlight the current evidence as it relates to the etiology of HMB as well as medical modalities of treatment.

The Effect of Levonorgestrel on Fibrinolytic Factors in Human Endometrial Endothelial Cells.

OBJECTIVE: The levonorgestrel-releasing intrauterine system is considered a highly effective treatment of heavy menstrual bleeding (HMB). While LNG has established effects on the stromal and glandular compartments of the endometrial tissue, its effect on the endometrial endothelial cells has not been investigated. We examined whether LNG regulates fibrinolytic factors, tissue plasminogen activator (tPA), and urokinase plasminogen activator (uPA) secreted by human endometrial endothelial cells (HEECs) and determined the steroid receptor through which LNG exerts its effect on the endothelium. METHODS: The HEECs were treated with LNG or progesterone and levels of tPA and plasminogen activator inhibitor 1 (PAI-1) measured. The HEECs were specifically examined for the presence of androgen receptors through Western blot. Levonorgestrel ± flutamide were added to HEECs and the levels of tPA and uPA were examined. RESULTS: An enzyme-linked immunosorbent assay performed on culture media confirmed a statistically significant decrease in tPA levels in cells treated with LNG (77.80% ± 8.0% of control; n = 5, P < .05 vs control) but not progesterone. The androgen receptor (110 kDa) was detected in HEEC lysates. The decrease in tPA was blocked by the addition of flutamide (101.3% ± 16% of control), a classic nonsteroidal androgen receptor blocker. There was no change in uPA or PAI-1 levels in cells treated with LNG. CONCLUSIONS: Levonorgestrel decreases tPA levels through the androgen receptor in HEECs. Thus, LNG inhibits tPA secretion by the endometrial endothelial cell. This response suggests reduction in HMB with LNG-IUS could reflect an LNG-mediated promotion of hemostasis.

Hysteroscopic enucleation of type II submucosal uterine leiomyomas using a TRUCLEAR hysteroscopic morcellator: case report and review of the literature.

OBJECTIVE: We describe a case of complete enucleation of a Type II leiomyoma using the TRUCLEAR™ (Smith & Nephew Endoscopy, Andover, MA) hysteroscopic morcellator (THM) and demonstrate appropriate preoperative assessment and intraoperative surgical principles during this case. Complete hysteroscopic enucleation of Type II leiomyomas is also systematically reviewed. MATERIALS AND METHODS: In this case report and review, performed in a tertiary-care university setting, the THM was used for hysteroscopic resection of two submucosal leiomyomas. RESULTS: A 41-year-old gravida 1 para 0010 presented with infertility and symptomatic leiomyomas. Preoperative assessment included a hysterosalpingogram, magnetic resonance imaging, and sonohysterography demonstrating several extrinsic impressions on the uterine cavity and two submucosal leiomyomas (Type I and Type II). Diagnostic hysteroscopy confirmed findings. As the THM blade started resecting the Type II leiomyoma, it began to separate from the underlying myometrium. Attempts to release the edge of the leiomyoma, including reverse rotation of the blade, completely enucleated the leiomyoma, which was subsequently removed from the cavity with the THM. Minimal bleeding was encountered; intraoperative ultrasound confirmed normal overlying myometrium. Postoperatively, sonohysterography showed complete closure of the dead space with only a slightly distorted endometrial cavity. CONCLUSIONS: Hysteroscopic uterine leiomyoma enucleation should only be performed in experienced hands. Inadvertent enucleation of a Type II leiomyoma with a THM device is described, with review of key surgical principles that guided safe resection.