Systematic review and network meta-analysis of hydrosalpinx treatment before in vitro fertilization.

OBJECTIVES: To compare different methods to treat hydrosalpinx, based on both ablative and non-ablative approaches, in infertile patients before undergoing IVF-ET. METHODS: Systematic review and network meta-analysis (NMA) of comparisons between different treatments of hydrosalpinx in infertile patients undergoing IVF. DATA SOURCES: structured searches in common citation databases. Study inclusion criteria: peer-reviewed randomized trials (RCT) or cohort studies comparing effects of salpingectomy, laparoscopic proximal tubal occlusion (LTO), insertion of intratubal device (ITD), sclerotherapy, ultrasound-guided aspiration and no treatment, on live birth, ongoing pregnancy, clinical pregnancy as main outcomes, considering also miscarriage, ectopic pregnancy and complications as secondary outcomes. Principal NMA included RCT, and aggregated NMA of RCT and observational studies was carried out. Pooled effects have been estimated by Odds Ratio (OR) and its 95% confidence interval (CI) for direct and indirect-mixed comparisons, derived from random-effects models. Imprecision and heterogeneity of NMA estimations was assessed by comparison of its 95% CI with predefined intervals for clinically relevant size of effect (OR <0.9 or >1.1). Surface under the cumulative ranking curve (SUCRA) were used to predict treatment rankings for each outcome. RESULTS: Nine RCT were included in main analysis, plus 17 additional observational studies in additional analysis. NMA of RCT did not identify significant differences in the effect of compared treatments on live birth rate, and LTO was the option with the highest value of SUCRA (0.92, mean rank: 1.2). Salpingectomy and US-aspiration associated to a significant increase of ongoing pregnancy rate compared to no treatment, according to NMA results (NMA OR: 4.35; 95% CI: 1.7, 11.14 and 2.8; 95% CI: 1.03, 7.58 respectively). Salpingectomy had the highest SUCRA value (0.88, mean rank: 1.4). NMA estimated significant increase of clinical pregnancy rate for salpingectomy compared with no treatment (NMA OR: 2.24; 95% CI: 1.3, 3.86) as well as for LTO versus no treatment (NMA OR: 2.55; 95% CI: 1.2, 5.41). Both comparisons were affected by a high grade of heterogeneity. For clinical pregnancy, LTO was the intervention with highest SUCRA (0.85; mean rank: 1.6). Regarding secondary outcomes, feasible NMA estimates did not support significant differences between treatments effects. According to aggregated NMA including randomized and observational studies, sclerotherapy showed significant beneficial effects on live birth rate compared to no treatment (NMA (OR: 4.6; 95% CI: 1.21, 17.46). Compared with untreated patients, the aggregated NMA estimates a higher ongoing pregnancy rate in patients treated with salpingectomy (NMA OR: 3.35; 95% CI: 2.12, 5.12), US-aspiration (NMA OR: 2.16; 95% CI: 1.28, 3.65) and LTO (NMA OR: 2.46; 95% CI: 1.11, 5.43). Salpingectomy and LTO produced a higher beneficial effect compared to ITD, based on both direct and indirect comparisons. Salpingectomy obtained the highest SUCRA value in rank of effects on ongoing pregnancy (0.94; mean rank: 1.2). NMA found significant effects on clinical pregnancy for comparisons between the different active management procedures compared with no treatments, with the exception of ITD insertion. LTO had more increasing effect on clinical pregnancy rate compared with US-aspiration (NMA OR: 2.04; 95% CI: 1.05, 3.97), while for the rest of the comparisons between procedures no significant differences were identified. NMA ranked LTO as the treatment with a highest SUCRA value (0.91; mean rank: 1.5). NMA prediction models identified LTO as best intervention to reduce miscarriage (SUCRA value: 0.84; mean rank: 1.8), as sclerotherapy as safer option in terms of ovarian response to IVF stimulation. CONCLUSIONS: The present NMA fails to support the effectiveness of any option to treat hydrosalpinx before IVF in order to improve live birth rates, although the beneficial effect of salpingectomy and US aspirations on ongoing pregnancy rates and of both salpingectomy and LTO on clinical pregnancy rates emerges from our analysis, which reinforces current recommendations. Based on the aggregated analyses, sclerotherapy could be a promising alternative to conventional laparoscopic techniques, combined with a favorable safety profile. This article is protected by copyright. All rights reserved.

Impact of congenital uterine anomalies on obstetric and perinatal outcomes: systematic review and meta-analysis.

Background: Congenital uterine anomalies (CUA) can be associated with impairments of early and late pregnancy events. Objective: To assess the impact of CUA on reproductive outcomes in pregnancies conceived spontaneously or after assisted reproduction. Materials and Methods: Systematic review and meta-analysis of cohort studies comparing patients with CUA versus women with normal uterus. A structured literature search was performed in leading scientific databases to identify prospective and retrospective studies. The Newcastle-Ottawa scale, adapted to AHRQ standards, was used to assess the risk of bias. Pooled odds ratios (OR) were calculated. Publication bias and statistical heterogeneity were assessed, and meta-regression was used to analyse the heterogeneity. Main outcome measures: Miscarriage, ectopic pregnancy, placental abruption, term, and premature rupture of membranes (PROM), malpresentation at delivery, preterm delivery prior to 37, 34 and 32 weeks, caesarean delivery, intrauterine growth restriction/small for gestational age, foetal mortality and perinatal mortality. Results: 32 studies were included. CUAs increased significantly the risk of first/second trimester miscarriage (OR:1.54;95%CI:1.14-2.07), placental abruption (OR:5.04;3.60-7.04), PROM (OR:1.71;1.34-2.18), foetal malpresentation at delivery (OR:21.04;10.95-40.44), preterm birth (adjusted OR:4.34;3.59-5.21), a caesarean delivery (adjusted OR:7.69;4.17-14.29), intrauterine growth restriction/small for gestational age (adjusted OR:50;6.11-424), foetal mortality (OR:2.07;1.56-2.73) and perinatal mortality (OR:3.28;2.01-5.36). Conclusions: CUA increases the risk of complications during pregnancy, delivery, and postpartum. Complications most frequent in CUA patients were preterm delivery, foetal malpresentation, and caesarean delivery. What is new?: Bicornuate uterus was associated with the highest number of adverse outcomes, followed by didelphys, subseptate and septate uterus.

Hysteroscopic laser ablation of symptomatic uterine fibroids: insights from a prospective study.

OBJECTIVE: This study aimed to evaluate the feasibility and efficacy of in-office hysteroscopic ablation of submucous uterine fibroids using a diode laser. METHOD: A pilot study was conducted between January 2018 and January 2019 in a tertiary care university hospital. Patients with at least one symptomatic, class 0-2 FIGO classification, uterine fibroid ≤7 cm in size were eligible for inclusion. Evaluation of the changes in fibroid size and vascularity was performed using three-dimensional Doppler ultrasonography. Vaporization of the fibroid core was conducted using a 980-1470 nm wavelength diode laser inserted through the hysteroscope's working channel. The primary outcome was evaluation of the fibroid volume before and at 2 months after the procedure. RESULTS: Twenty women were enrolled in the study. At 2-month follow-up, the volume of the fibroids was significantly reduced (51.6 ± 22.5 vs. 33.4 ± 17.1 mm3; p < 0.001). A major reduction of three-dimensional sonographic color Doppler vascularity (observed by the same operator and confirmed by four blind reviewers) was also achieved in 12/20 patients (60%; p = 0.03) while a reported symptom of heavy menstrual bleeding decreased from 18/20 (90%) to 2/18 (10%; p < 0.01). CONCLUSION: Hysteroscopic laser ablation represents a feasible and effective alternative for treating women with symptomatic submucous fibroids in the office setting. Further studies with larger sample size and longer follow-up periods are needed to validate this promising technique.Key messageThis pilot study shows that in-office hysteroscopic laser ablation (HLA) could be a feasible alternative to treat symptomatic submucous uterine fibroids by coagulating their core, reducing their size and vascularization.

Diagnosis and management of isthmocele (Cesarean scar defect): a SWOT analysis.

The purpose of this State-of-the-Art Review was to provide a strategic analysis, in terms of strengths, weaknesses, opportunities and threats (SWOT analysis), of the current evidence regarding the management of uterine isthmocele (Cesarean scar defect). Strengths include the fact that isthmocele can be diagnosed on two-dimensional transvaginal ultrasound, and that surgical repair may restore natural fertility potential and prevent secondary infertility, as well as reduce the risk of miscarriage and other obstetric complications. However, there is a lack of high-quality evidence regarding the best diagnostic method and criteria, as well as the potential benefits of surgical repair with respect to fertility. There is a need for experienced surgeons skilled in the various isthmocele repair techniques. Isthmocele repair does not prevent the need for Cesarean delivery in subsequent pregnancies. There is increasing awareness regarding the accuracy of transvaginal ultrasound in diagnosing isthmocele. This may lead to surgical correction and prevention of obstetric and perinatal complications in subsequent pregnancies, including Cesarean scar pregnancy. Regarding threats, the existence of different surgical techniques means that there is a risk of selecting an inadequate approach if the type of isthmocele and the patient's characteristics are not considered. There is a risk of overtreatment when asymptomatic defects are repaired surgically. Finally, there is an absence of cost-effectiveness analyses to justify routine repair. Thus, while there are many data suggesting that isthmocele has an adverse effect on both natural fertility and the outcome of assisted reproduction techniques, high-quality evidence to support surgical isthmocele repair in all asymptomatic patients desiring future fertility are lacking. There is increasing agreement to recommend hysteroscopic repair of isthmocele as a first-line approach as long as the residual myometrial thickness is at least 2.5-3.0 mm. © 2023 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

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.

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.

Mechanical hysteroscopic tissue removal or hysteroscopic morcellator: understanding the past to predict the future. A narrative review.

BACKGROUND: In recent years, the available evidence revealed that mechanical hysteroscopic tissue removal (mHTR) systems represent a safe and effective alternative to conventional operative resectoscopic hysteroscopy to treat a diverse spectrum of intrauterine pathology including endometrial polyps, uterine myomas, removal of placental remnants and to perform targeted endometrial biopsy under direct visualisation. This innovative technology simultaneously cuts and removes the tissue, allowing one to perform the procedure in a safer, faster and more effective way compared to conventional resectoscopic surgery. OBJECTIVE: To review currently available scientific evidence concerning the use of mechanical hysteroscopic morcellators and highlight relevant aspects of the technology. MATERIAL AND METHODS: A narrative review was conducted analysing the available literature regarding hysteroscopic tissue removal systems. MAIN OUTCOME MEASURES: Characteristics of available mHTR systems, procedures they are used for, their performance including safety aspects and their comparison. RESULTS: A total of 7 hysteroscopic morcellators were identified. The diameter of the external sheet ranged from 5.25 to 9.0 mm, optics ranged from 0.8 to 6.3 mm with 0o angle. The cutter device diameter ranged from 2.9 to 4.5 mm most of them with rotation and reciprocation. CONCLUSION: We conclude that the adoption of mHTR has shown to reduce operating time, simultaneously cutting and suctioning tissue fragments avoiding the need for multiple removal and reinsertions of the device into the uterine cavity as well as reducing the volume of distension media required to complete the procedure compared to using the hysteroscopic resectoscope.

Management of tubal ectopic pregnancy with methotrexate in the setting of symptomatic Coronavirus disease 2019 (COVID-19): A case report.

Background: Coronavirus Disease 2019 (COVID-19) represents a complex therapeutic challenge. As the pandemic progresses, patients are presenting with ectopic pregnancies (EPs) and symptomatic COVID-19. Objective: We present the management of a patient with multiple medical comorbidities and tubal EP in the setting of severe symptomatic COVID-19 infection where all management options were precluded. Methods: Case report with literature review of management of tubal EP in the setting of severe symptomatic COVID-19 infection. Result: After careful consideration of options, the patient underwent successful medical management with methotrexate while receiving supportive care for COVID-19. Conclusions: Methotrexate proved to be the safest therapeutic option in this patient. Management of patients with severe COVID-19 and gynaecologic emergencies should be individualised and carefully reviewed with evolving knowledge of COVID-19.

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.

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.

Clinical management of vaginal bleeding in postmenopausal women.

Menopause is characterized by permanent cessation of menstrual periods and is clinically diagnosed after 12 months of complete amenorrhea. It occurs at a median age of 51 years alongside the physiological process of aging, although it can happen at an earlier age for other medical conditions or after surgery (surgical menopause). Due to reduced circulating estrogens and progesterone, the reproductive organs undergo progressive atrophy. This physiologic process of aging is also present at an endometrial level; without the cyclic hormonal actions of the menstrual cycle, the endometrium during menopause becomes atrophic. 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. Historically, dilation and curettage (D&C) was the main diagnostic procedure in patients with PMB; however, newer methods of investigation have replaced D&C. The aim of this review is to present an up-to-date analysis of the current evidence for the clinical management of vaginal bleeding in postmenopausal women.

Hysteroscopic management of retained products of conception: A single center observational study.

BACKGROUND: Retained products of conception (RPOC) are defined as the presence of tissue inside the uterine cavity after delivery or termination of a pregnancy. Operative hysteroscopy is associated with increased surgical success and decreased postoperative formation of intrauterine adhesions. The aim of this study is to report our experience in hysteroscopic management of RPOC. METHODS: A retrospective chart review identified patients who underwent hysteroscopic removal of retained products of conception at a single center (n=45). Basic demographic data, surgical findings and applied technique were reviewed. Chi Square and independent samples t-tests were performed when appropriate. A significance level of p<0.05 was accounted. RESULTS: Of all cases included, 64% were the result of a spontaneous or elective abortion and 47% were from patients who had failed previous treatment. Previous medical or surgical treatment was observed in 37.9% of patients labeled as type 0-1 versus 62.5% of type 2-3 (p=0.1138). The timing between the end of the preceding pregnancy and hysteroscopic removal was in average 2.62 months in type 0-1 compared to 1.7 months in type 2-3 (p=0.1068). All patients who were classified as type 2-3 required the use of monopolar energy during the surgery, compared to zero patients who were classified as type 0-1 (p < 0.0001). CONCLUSION: Operative hysteroscopy remains a safe and highly effective option for the management of RPOC and should be the preferred method compared to traditional dilatation and suction curettage.