Obstetric outcomes in pregnant COVID-19 women: the imbalance of von Willebrand factor and ADAMTS13 axis.

BACKGROUND: Thrombotic microangiopathy has been invoked as one of the most important mechanisms of damage in COVID-19 patients. Protease ADAMTS13 is a marker of microangiopathy responsible for controlling von Willebrand multimers size. Von Willebrand factor/ADAMTS13 ratio has been found impaired in COVID-19 patients outside pregnancy. METHODS: We prospectively investigated 90 pregnant women admitted to two tertiary academic hospitals in Italy with a laboratory-confirmed diagnosis of SARS-CoV-2 infection. Demographic, clinical information and routine laboratory data were collected at the hospital admission and until discharge. We investigated whether vonWillebrand /ADAMTS13 axis imbalance is a predictor of adverse outcomes. Logistic regression analysis, which controlled for potential confounders, was performed to evaluate the association between laboratory parameters and clinical outcomes. RESULTS: Most women (55.6%) were parae, with median gestational age at admission of 39 weeks. At hospital admission, 63.3% were asymptomatic for COVID-19 and 24.4% showed more than one sign or symptom of infection. Nulliparae with group O showed Willebrand / ADA MTS-13 ratios significantly lower than non-O, whereas in multiparae this difference was not observed. Logistic regression showed that ratio von Willebrand to ADAMTS13 was significantly and independently associated with preterm delivery (OR 1.9, 95%CI 1.1-3.5). CONCLUSION: This study shows an imbalance of vonWillebrand /ADAMTS13 axis in pregnant women with COVID-19, leading to a significantly higher and independent risk of preterm delivery. Monitoring these biomarkers might support decision making process to manage and follow-up pregnancies in this setting.

SARS-CoV-2 and Placenta: New Insights and Perspectives.

The study of SARS-CoV-2 positive pregnant women is of some importance for gynecologists, obstetricians, neonatologists and women themselves. In recent months, new works have tried to clarify what happens at the fetal-placental level in women positive for the virus, and different pathogenesis mechanisms have been proposed. Here, we present the results of a large series of placentas of Coronavirus disease (COVID) positive women, in a reference center for COVID-positive pregnancies, on which we conducted histological, immunohistochemical and electron microscopy investigations. A case-control study was conducted in order to highlight any histopathological alterations attributable to SARS-CoV-2. The prevalence of maternal vascular malperfusion was not significantly different between cases and controls (54.3% vs. 43.7% p = 0.19), whereas the differences with regard to fetal vascular malperfusion (21.1% vs. 4.2% p < 0.001) were significant. More frequent in cases with respect to controls were decidual arteriopathy (40.9% vs. 1.4% p < 0.0001), decidual inflammation (32.4% vs. 0.7% p < 0.0001), perivillous fibrin deposition (36.6% vs. 3.5% p < 0.0001) and fetal vessel thrombi (22.5% vs. 0.7% p < 0.0001). No significant differences in the percentage of terminal villous hyperplasia and chorioamnionitis were observed between the two groups. As the pandemic continues, these studies will become more urgent in order to clarify the possible mechanism of maternal-fetal transmission of the virus.

Comparison of endometrial polyp recurrence in fertile women after office hysteroscopic endometrial polypectomy using two widely spread techniques.

AIM: To compare the recurrence of benign endometrial polyps after office hysteroscopic polypectomy performed with a bipolar electrode (BE) or a small diameter hysteroscopic tissue removal system (HTRs). METHODS: From July 2018 to December 2019 we evaluated the charts of 114 asymptomatic fertile women who underwent office hysteroscopic polypectomy, 1 year before, for a single large benign endometrial polyp (size between 10 and 20 mm) using a 4 mm continuous flow hysteroscope with a BE or a 5 mm HTRs. Patients, divided into two groups according to surgical procedure, each performed exclusively by one expert gynecologist, were scheduled for a 12-month postoperative transvaginal sonography to evaluate the recurrence of endometrial polyps. RESULTS: Forty-eight women of the BE group and 42 of the HTRs group were considered for the 1-year transvaginal sonography follow-up. Five polyps were identified in the BE group and three in the HTRs group (5/48 vs 3/42, P = n.s.). All polyps were removed hysteroscopically (in three out of five and in two out of three cases, respectively, in the same places of the previous polypectomy) and evaluated as 'benign' by the pathologist. CONCLUSION: Office hysteroscopic endometrial polypectomy with small HTRs compared to BE revealed at a 1-year follow-up no difference in terms of complete removal and recurrence of polyps. HTRs polypectomy resulted in less pain and significantly quicker time of procedure compared to BE. This data should be kept in mind for patient comfort any time hysteroscopic polypectomy is planned in an office setting.

Resectoscopic Metroplasty with Uterine Septum Excision: A Histologic Analysis of the Uterine Septum.

STUDY OBJECTIVE: To evaluate the histology of the uterine septum after its complete hysteroscopic excision. DESIGN: Case series. SETTING: Second Gynecological and Obstetric Unit and Pathological Anatomy Department of the University of Bari, Italy. PATIENTS: Thirty-five patients aged between 25 and 41 years who were diagnosed with uterine septum by 3-dimensional ultrasound per the European Society for Human Reproduction and Embryology/European Society of Gastrointestinal Endoscopy 2013/Salim 2003 criteria. In addition, office hysteroscopy was performed to define the anatomy of the uterine cavity and to exclude the presence of other endometrial pathologic conditions. INTERVENTIONS: Operative hysteroscopic septum resection was performed. The septum was initially incised with an "L-shape" bipolar electrode with a 5-mm bipolar mini-resectoscope (KARL STORZ SE & Co. KG, Tuttlingen, Germany). Then, using the bipolar loop, 2 triangles of the septum were excised in parallel, obtaining uninterrupted entire septum-long strips from the fundus to the apex of the septum. These strips were immediately removed from the uterus and reassembled in vitro to reconstruct a macroscopic, 3-dimensional structure of the septum for complete morphologic and histologic evaluations. MEASUREMENTS AND MAIN RESULTS: Patients presented with an average body mass index of 24.8 kg/m2and were all nulliparous. Histologic evaluation of the uterine septa showed a different conformation of the muscle bundles along the septum. Muscle cells in the apex and edges of the septum were arranged in nodules circumscribed by a thin area of collagen fibers. Medium-sized vessels were distributed in the collagen fibers around the muscle cells. Only few capillary vessels were present in the muscle nodules. This pattern was very similar to the cell arrangement in leiomyomas. In the core of the septa, near the base, the muscle bundles showed a linear course with concurrent collagen fibers and vessels. All the aforementioned characteristics were consistently present in every patient. On high-power histologic fields (200×), the muscle portion accounted for 48.3% ± 1.8% (mean, 6%) area in the apex and borders to 48.5% ± 1.3% (mean, 6%) area in the core. Collagen fibers accounted for 27.1% ± 1.1% (mean, 4%) area in the apex and borders to 26.7% ± 1.3% (mean 5%) area in the core. CONCLUSION: By removing the septum as a whole structure, this study allowed us to redefine the concept of the septum as a complex structure according to the islands of muscle fibers irregularly arranged in vertex, in a context of collagen tissue and similar to the structure of myomas. It appears to deeply involve the anterior and posterior uterine walls, resembling a "reverse letter H."

Human Endometrial Microbiota at Term of Normal Pregnancies.

The endometrium is a challenging site for metagenomic analysis due to difficulties in obtaining uncontaminated samples and the limited abundance of the bacterial population. Indeed, solid correlations between endometrial physio-pathologic conditions and bacteria compositions have not yet been firmly established. Nevertheless, the study of the endometrial microbiota is of great interest due to the close correlations between microbiota profiles, women's health, and successful pregnancies. In this study, we decided to tackle the study of the endometrial microbiota through analysis of bacterial population in women subjected to elective caesarean delivery. As a pilot study, a cohort of 19 Caucasian women at full term of normal pregnancy and with a prospection of elective caesarean delivery was enrolled for endometrium sampling at the time of caesarean section. Sampling was carried out by endometrial biopsy soon after the delivery of the newborn and the discharge of the placenta and fetal membranes from the uterus. Bacterial composition was established by a deep metabarcoding next generation sequencing (NGS) procedure addressing the V5-V6 hypervariable region of the 16S rRNA gene. Amplicon sequences were analysed by bioinformatic procedures for denoising and taxonomic classification. The RDP database was used as 16S rRNA reference collection. Metabarcoding analysis showed the presence of a common bacterial composition, including six genera classifiable within the human microbiota (Cutibacterium, Escherichia, Staphylococcus, Acinetobacter, Streptococcus, Corynebacterium), that could be part of the core endometrial microbiota under the specific conditions examined. These results can provide useful information for future studies on the correlations between bacteria and successful pregnancies.

Office treatment of large endometrial polyps using truclear 5C: Feasibility and acceptability.

AIM: This retrospective multicenter study was carried out to evaluate feasibility, effectiveness and patient acceptability of a small diameter hysteroscopic tissue removal system in the treatment of large endometrial polyps (≥20 mm), usually not removed in an office setting. METHODS: Hundred and forty-six women with a single greater than 10-mm diameter polyp considered for polypectomy between April 2016 and August 2017. Sixty-five of these patients had a polyp size greater than 20 mm. All hysteroscopic polypectomy, using Hysteroscopic Tissue Removal system (TruClear 5C System Medtronic), were performed in an office setting with vaginoscopic approach. RESULTS: Procedural success, time to complete the polypectomy and patient pain scores were evaluated. Polyps less than 20 mm were completely removed in 79/81 cases (97.53%). The completeness of greater than or equal to 20-mm polyp removal was achieved in 63/65 cases (96.92%). The median time for polypectomy was 4.19 ± 1.03 min for polyps less than 20 mm and 4.97 ± 1.30 min for polyps greater than or equal to 20 mm, respectively. Pain was minimal and brief, and the mean pain score measured on a 10-point visual analog scale at the end of polypectomy showed no significant difference between the two groups. In 4/79 (5.06%) cases with polyps less than 20 mm and in 4/63 (6.35%) cases with polyps greater than or equal to 20 mm women reported moderate pain. All specimens were adequate for pathologic measurements. CONCLUSION: Hysteroscopic treatment of polyps greater than or equal to 20 mm in size with TruClear 5C is feasible and well tolerated in an office setting with no significant difference regarding completeness compared to polyps less than 20 mm, but with a minimal increase in procedure times.

Office myomectomy.

Small myomas have a high potential to grow and either to become symptomatic or to cause complications in women of reproductive age. Furthermore, although the risk of malignancy is rare, even the most experienced operator cannot replace the histological analysis to exclude malignancy or premalignant lesions. Such small symptomatic and asymptomatic totally or partially intracavitary myomas may be treated effectively and safety in office setting. The aim of this paper is to describe the currently available hysteroscopic techniques to treat myomas <1.5 cm also with a minimal intramural component without anaesthesia or analgesia in ambulatory setting reducing patient's discomfort.

Challenging the cervix: strategies to overcome the anatomic impediments to hysteroscopy: analysis of 31,052 office hysteroscopies.

OBJECTIVE: To report our experience on 10,156 cases of cervical stenosis (CS) diagnosed at office hysteroscopy. DESIGN: Retrospective study. SETTING: Ambulatory clinics of diagnostic and operative hysteroscopy of two university teaching hospitals (Naples and Bari). PATIENT(S): A total of 31,052 patients undergoing office hysteroscopy. INTERVENTION(S): All of the paper and electronic reports of the office hysteroscopies performed from January 1996 to September 2014 were reviewed. Hysteroscopies were classified as successful (i.e., when access to and visualization of the entire uterine cavity was possible during the same procedure), incomplete (i.e., when access to uterine cavity was possible, but the entire uterine cavity could not be examined), or failed (i.e., when access to uterine cavity was not possible). CS was classified on the basis of localization: stenosis of external cervical ostium (ECO; type I); stenosis of distal third of cervical channel and the internal cervical ostium (ICO; type II); stenosis of the ICO (type III), and combined stenosis of ECO and ICO (type IV). MAIN OUTCOME MEASURE(S): The success rate at overpassing CS (including both successful and incomplete hysteroscopies) was the primary outcome measure. Secondary outcome measures were frequency and localization of CS in fertile and postmenopausal women and the frequency of use of technical maneuvers and/or miniaturized mechanical or bipolar instruments to overcome them. RESULT(S): All hysteroscopies were performed with the use of a 5- or 4-mm rigid continuous-flow office operative hysteroscope by operators with different levels of expertise. The hysteroscopy technique used was standardized between the two centers and among all of the surgeons throughout the years. An access to the uterine cavity with a complete evaluation of the whole endometrial surface was possible in 93.9% of cases (29,152 patients). The main reasons of the 1,320 (4.3%) incomplete and 580 (1.9%) failed hysteroscopies were pain and CS, respectively. CS was identified in 10,156 women (32.7% of all procedures) and was significantly more frequent in postmenopausal than in fertile women (70.1% vs. 29.9%), except for type I stenosis, which was more frequent in fertile than in postmenopausal women. Type IV CS (44.3%) was the most commonly detected. Overall, CS was managed successfully with minimal discomfort in 98.5% of cases with technical maneuvers and miniaturized mechanical and/or bipolar instruments. Adhesiolysis with the distal tip of the hysteroscope by rotating the scope on the endocamera was the significantly more used strategy to overpass all types of CS (39.8% of cases), generally used in combination with miniaturized operative instruments (79.2%). Bipolar electrodes were more used in cases of type I and type IV stenosis (39.7%) compared with the other types of CS. CONCLUSION(S): CS and pain represent the main reasons for failed hysteroscopy. Recent technical and technologic innovations, together with increased operator experience and optimal pain management, have made it possible to overcome even severe CS with the use of office hysterosocpy, thus significantly reducing the rate of failed procedures and the need for operating room and general anesthesia.

Hysteroscopic Patterns in Women on Treatment With Ulipristal Acetate 5 mg/day: A Preliminary Study.

STUDY OBJECTIVE: To describe the hysteroscopic findings in women on treatment with ulipristal acetate (UPA) and to define the most common hysteroscopic patterns related to the treatment and compare them with the histologic findings. DESIGN: Preliminary study. SETTING: OB-GYN and Gynecology Oncology Clinic, Military Medical Institute, Ministry of Defense, Warsaw, Poland, and Obstetrics and Gynecology Department, University of Bari, Italy. PATIENTS: Seventy-four premenopausal patients complaining of abnormal uterine bleeding due to uterine myomas and on treatment with UPA 5 mg/day for at least 30 days. INTERVENTIONS: Women received transvaginal sonography (TVS) and then office hysteroscopy and visually guided endometrial biopsies. Video hysteroscopies were recorded in digital format. Pictures were evaluated by 2 authors off-line and compared with histologic results. MEASUREMENTS AND MAIN RESULTS: Hysteroscopic aspects and classification of progesterone receptor modulator-associated endometrial changes were measured. The most common hysteroscopic finding was the combination of a flat subtle epithelium with small glandular openings; large isolated or confluent cysts in the stroma, giving the surface a floating aspect at fluid distention; and well-evident subendometrial vascular network with a "chicken-wire" vascular pattern (44.6%). This finding accounted for 82% of cases with endometrial thickness > 10 mm at TVS. Histology confirmed a combination of epithelial secretory (vacuoles) and hypotrophic effects (small and dilated glands), whereas at stromal level the combination of cysts, dense stroma, and vascular wall thickening was found. At 3 months follow-up echographic, hysteroscopic, and histologic endometrial patterns were normal in all patients. CONCLUSIONS: In most women on UPA and with thickened endometrium at TVS, the hysteroscopy showed benign and characteristics aspects related to the ambivalent effects of UPA on progesterone receptor. These alterations took place just after 1 month of treatment but disappeared within 3 months of stopping treatment.

Ultrasonographic and hysteroscopic outcomes of uterine scar healing after cesarean section: comparison of two types of single-layer suture.

AIM: A common anatomical consequence of low-segment cesarean section is the presence of a pouch on the anterior uterine wall that can be detected by sonography or hysteroscopy. Different suturing techniques have been compared (single vs double layer) and showed no substantial differences. This prospective longitudinal study was aimed at evaluating the outcome of the cesarean scar, comparing two different types of single-layer sutures by transvaginal ultrasound and hysteroscopy. MATERIAL AND METHODS: The study sample consisted of two groups of 30 singleton primiparae at term who delivered by elective low segment cesarean section. In the first group, uterine closure was done with locked continuous single-layer sutures and in the second group, with single-layer interrupted sutures. Patients were assessed by transvaginal ultrasound and hysteroscopy, between the 6th and the 12th month after delivery, and again at the 24th month. Ultrasound measurements were made of the pouch area, if present. RESULTS: A bell-shaped uterine wall defect was seen at ultrasound in 36 (85.71%) of 42 patients who completed the follow up at the 24th month. It was larger in the group of patients with closure by continuous sutures (6.2 [2.1-14.7] mm2) as compared to interrupted sutures (4.6 [1.9-8.2] mm2, P = 0.03). Hysteroscopy confirmed the presence of the wall defect in all 36 cases, but different hysteroscopic outcomes were observed. CONCLUSION: Locked continuous sutures seem to cause a larger defect as compared to interrupted sutures, probably due to a greater ischemic effect exerted on the uterine tissue.

Fertility-enhancing hysteroscopic surgery.

Uterine abnormalities, including congenital pathologies, polyps, submucous leiomyomata, intrauterine adhesions, and chronic endometritis, have been reported in 21 to 47% of patients undergoing in vitro fertilization cycles. The position of hysteroscopy in current fertility practice is under debate. Although there are many randomized controlled trials on technical feasibility and patient compliance demonstrating that the procedure is well tolerated and effective in the treatment of intrauterine pathologies, there is no consensus on the effectiveness of hysteroscopic surgery in improving the prognosis of subfertile women. However, in patients with at least two failed cycles of assisted reproductive technology, diagnostic hysteroscopy and, if necessary, operative hysteroscopy is mandatory to improve reproductive outcome. Office hysteroscopy is a powerful tool for the diagnosis and treatment of intrauterine benign pathologies. It is a simple, safe, reproducible, effective, quick, well-tolerated, and low-cost surgical procedure, with no need for an operating room.

Diagnosis of colorectal endometriosis: contribution of contrast enhanced MR-colonography.

OBJECTIVE: To investigate the contribution of contrast-enhanced MR-colonography (CE-MR-C) for the diagnosis of intestinal endometriosis. METHODS: One hundred and four women with suspected endometriosis were prospectively enrolled. All patients were subjected to MRI consisting of two phases: pelvic high-resolution MRI (HR-MRI) followed by CE-MR-C after colonic distension using a 1.5-liter water enema and injection of 0.15 ml/kg of 0.5 M gadolinium-DTPA with T1w high-resolution isotropic volume (THRIVE) and balanced turbo field echo (BTFE) images. HR-MRI and CE-MR-C were considered as two datasets, which were independently reviewed by two radiologists with 12 and 2 years' experience respectively. The presence of deep pelvic endometriotic lesions with particular attention to colorectal involvement was recorded. RESULTS: MRI findings correlated with laparoscopy in all cases. Thanks to CE-MR-C images, sensitivity, specificity, PPV, NPV and accuracy for diagnosis of colorectal endometriosis increased from 76%, 96%, 84%, 93% and 91%, to 95%, 97%, 91%, 99% and 97% for the most experienced radiologist and from 62%, 93%, 72%, 89% and 85%, to 86%, 94%, 82%, 96% and 92% for the less experienced radiologist; moreover, the interobserver agreement increased from 0.63 to 0.80 (Cohen's K test). CONCLUSION: CE-MR-C allows easier recognition of colorectal endometriosis and higher interobserver agreement.

A new hysteroscopic technique for the preparation of partially intramural myomas in office setting (OPPIuM technique): A pilot study.

OBJECTIVE: To assess the safety and the effectiveness of a novel hysteroscopic technique for the Office Preparation of Partially Intramural Myomas (OPPIuM), to facilitate the subsequent, already scheduled, resectoscopic myomectomy. DESIGN: Pilot study. SETTING: University of Bari, Naples and Foggia. PATIENTS: Fifty-nine fertile women (age 27-48 years) diagnosed at office hysteroscopy as having symptomatic submucous myomas>1.5 cm with intramural development (G1 and G2), scheduled for resectoscopic surgery. INTERVENTIONS: The OPPIuM technique consisted of an incision of the endometrial mucosa covering the myoma by means of Fr scissors or bipolar Versapoint Twizzle electrode, along its reflection line on the uterine wall, up to the precise identification of the cleavage surface between the myoma and its pseudo-capsule. Such procedure was aimed at triggering the protrusion of the intramural portion of the myoma into the uterine cavity during the following menstrual cycles, thus facilitating the subsequent total removal of the lesion via resectoscopic surgery. All patients underwent follow-up in-patient hysteroscopy after 2 menstrual cycles before resectoscopic surgery were performed. MEASUREMENTS AND MAIN RESULTS: The OPPIuM technique was successfully performed in all cases. The mean diameter of successfully prepared myomas was 2.9+/-0.8 cm. At follow-up hysteroscopy, the conversion of partially intramural myomas into totally or prevalently intracavitary ones was observed in 93.2% (55/59) of cases. In 2 of 3 cases of failure, the myomas' size was>4 cm. One patient was excluded from the study because of the occurrence of total spontaneous expulsion of the myoma at the subsequent menstrual cycle. CONCLUSIONS: Our preliminary findings seem to support the safety and the effectiveness of the OPPIuM procedure by reporting the conversion of myomas with intramural development>1.5 cm into totally or prevalently intracavitary ones in nearly 93% of cases. Such technique may allow surgeons to perform resectoscopic surgery more safely and quickly as dealing with prevalently intracavitary lesions. However, further studies are mandatory to validate its use in daily practice.

Hysteroscopic removal of gauze packing inadvertently sutured to the uterine cavity: report of 2 cases.

We report on 2 cases of successful hysteroscopic removal of uterovaginal packing, inserted during cesarean sections after uterine hemorrhage resistant to medical therapy. The packing, in both cases, could not be removed vaginally with sponge forceps because the packing had been sutured to the uterine cavity. A hysteroscopic approach enabled identification and cutting with 5F scissors of the stitches fixing the packing to the uterine walls, allowing straightforward removal in an outpatient setting and avoiding a repeated laparotomy. Some useful techniques to handle such a situation are described.

Fibrotic tissue in the endometrioma capsule: surgical and physiopathologic considerations from histologic findings.

Ovarian tissue inadvertently excised along with endometriomas was associated with the presence of pericystic fibrosis and serum levels of CA-125, representing the only clinical parameter for predicting follicle loss before surgery. A consecutive series of 91 ovarian endometriotic cysts were studied, and an inverse relationship between serum CA-125 and the thickness of the fibrotic tissue of the endometrioma capsule was demonstrated.

Office hysteroscopy in an in vitro fertilization program.

OBJECTIVE: In the present paper we evaluate the incidence of intrauterine pathologies in a population undergoing in vitro fertilization (IVF) treatment. Moreover, we compare the IVF outcome between patients with normal and abnormal uterine findings to determine if office hysteroscopy (OH) is of any clinical significance. METHODS: The hysteroscopic findings in 866 consecutive patients were analyzed. The study group included 555 patients at the first IVF attempt and 311 patients with two or more failed IVF cycles. RESULTS: All hysteroscopic parameters were considered normal in 514 cases (59.4%); in 352 cases (40.6%) various pathological conditions were found. Patients were divided into two groups according to the hysteroscopic findings. The implantation and pregnancy rates were similar between the groups. Comparing the clinical outcomes in patients with repeated IVF failure who had hysteroscopy with no pathology and with pathology, we did not find any statistical differences. CONCLUSIONS: This study suggests that hysteroscopy as a routine infertility examination should be performed in all patients, owing to the elevated incidence of hysteroscopic pathological findings (59.4%); hysteroscopy also seems to be the best way to repair the uterine cavity when pathological conditions are present. However, performing OH before IVF-embryo transfer is of no significant value in improving pregnancy outcomes.

The destiny of myomas: should we treat small submucous myomas in women of reproductive age?

OBJECTIVE: To carry out a thorough analysis aimed at demonstrating that a "wait-and-see" approach is no longer acceptable in women of reproductive age with small submucous myomas, even if they are asymptomatic. DESIGN: Review article. SETTING: University hospitals. PATIENT(S): Women of reproductive age with small (<1.5 cm) submucous myomas. INTERVENTION(S): "See-and-treat" hysteroscopy performed in an outpatient setting. MAIN OUTCOME MEASURES(S): a) The real endometrial surface and volume occupied by a submucous myoma; b) the high potential of a small myoma to grow during the reproductive age; c) its negative impact on reproduction through normal or assisted conception; d) the inability to perform a reliable and "safe" diagnosis, with respect to malignancy, without an eye-guided biopsy; and e) the effectiveness of "see-and-treat" hysteroscopy in removing small submucous myomas. RESULT(S): Small myomas, as hormone-dependent benign tumors, have a high potential to grow and either to become symptomatic or to cause complications during natural or assisted conception and pregnancy. Furthermore, not withstanding the risk of malignancy is rare, even the most experienced operator cannot replace the histological analysis to exclude malignancy or premalignant lesions. "See-and-treat" hysteroscopy has been demonstrated to be safe and effective in removing such small submucous myomas. CONCLUSION(S): A "wait-and-see" approach is no longer acceptable in women of reproductive age with small submucous myomas, especially if the lesion could be easily and safely removed in an outpatient setting with minimal patient's discomfort.