[Systematic hysteroscopy prior to in vitro fertilization]. / Hystéroscopie systématique avant fécondation in vitro.

OBJECTIVE: To evaluate the benefits of a diagnostic hysteroscopy prior to in vitro fertilization. PATIENTS AND METHODS: We retrospectively studied 145 patients who underwent ICSI during a period of 6 months. Office hysteroscopy was systematically performed before the first stimulation cycle. If pathological findings were revealed, appropriate medical or surgical treatment was given. RESULTS: Pathological patterns were observed in 45% of hysteroscopies. Endometritis, polyps and myomas and mucosal diseases were the most frequently observed. The patients aged over 38 years didn't show higher rate of pathology (29% vs 27% for the younger patients). The treatment of pathologies gave the same pregnancy rate than the normal cavities. Patients with endometritis were treated with antibiotics and 40% of them became pregnant in the following cycle. DISCUSSION AND CONCLUSION: Systematic hysteroscopy prior to IVF-ICSI showed to be an effective investigation that could improve the pregnancy rate.

[Hysteroplasty for enlargement: apropos of the results]. / L'hystéroplastie d'agrandissement: à propos des résultats.

The DiethylstilBbestrol (DES) is a synthetic estrogen which was prescribed from 1941 onwards for the prevention of miscarriage. As well as a possible risk of cancer, another side effect of this treatment was the possible of abnormality of the genitalia in the female issue of the prescribed user. Apart from possibly having a hypoplasic uterus, the patient is also prone, in the case where she has an undersized uterus, to having a much narrower than normal cavity. Consequently there is a tendency for an excess of muscle tissue on the uterus walls. This can be observed on an RMN. The most significant characteristics of this abnormality are: constriction rings around the proximal uterine segment, a T shaped uterus, uterus with an arched based. The idea of the plastic enlargement operation is to widen the cavity by making careful incisions on the excess muscle tissue located on the uterus wall. The objective of this is to obtain a triangular shaped cavity taking care though not to weaken the walls themselves. 51 patients were treated. We observed 31 pregnancies (49%) after 16 months with 25 ungoing pregnancies. Generally the anatomic results are excellent but it's difficult to measure the functional results or the success rate in future pregnancies. The reason for this is the enlarging of the cavity alone does not guarantee successful fertility. There are other problems to take in to account e.g. implantation, miscarriage and premature labor. There are risks with this operation: placenta percreta, a possible rupture of the uterus, though this can happen at any time with DES patients. This operation can only be recommended once a thorough examination of the patient has been made. It is not advisable with a patient who has a hypoplasic cavity in a hypoplasic uterus (hysterometry < 4 cm). This operation should never be done as a first course of action but it can be recommended above all if the patient has a constriction ring: as a sole reason for infertility; where infertility has been diagnosed and unsuccessfully treated; and an unexplained failure of ART, and where the patient has unexplained repeated miscarriages.

Thermal balloon ablation versus endometrial resection for the treatment of abnormal uterine bleeding.

This study compares the clinical efficacy and safety of a thermal uterine balloon system with hysteroscopic endometrial resection in the treatment of dysfunctional uterine bleeding. In all, 147 women were treated by two experienced gynaecological surgeons: one performed 73 thermal balloon ablations and the other 74 endometrial resections between November 1994 and April 1998. The inclusion criteria were similar in both groups. The operative time was reduced significantly with the uterine balloon technique. There were no intra-operative complications in either group and postoperative morbidities were minimal and not statistically different. Multivariate analysis noted two prognostic factors associated with failures: retroverted uterus with thermal balloon ablation and age under 43 years with endometrial resection. The overall success rate did not differ significantly between the two groups 83.0 +/- 5% for balloon ablation and 76.3 +/- 6% for endometrial resection. Uterine balloon ablation appears to be as efficacious as endometrial resection. The former is much easier to perform, making the technique readily reproducible, especially by those with limited expertise in hysteroscopic surgery, and thus more widely applicable and safer.

[Uterus and diethylstilbestrol: which examinations, which antecedents for an active management? Which treatments?]. / Utérus et diethylstilbestrol: quelles explorations, quels antécédents pour une prise en charge active? Quels traitements?

Diethylstilbestrol (DES) was widely prescribed to pregnant women from 1946 to 1977. This resulted in multiple abnormalities of the genital tract. Many studies show an increased incidence of infertility, ectopic pregnancy, spontaneous abortions and premature delivery. For women with certain abnormalities such as a construction of the upper uterine cavity, with or without a T configuration of the uterus, hysteroscopic metroplasty is feasible with good anatomic and functional results.

[Hysteroscopic resection of the endometrium: an alternative to hysterectomy?]. / La résection hystéroscopique de l'endomètre: une alternative à l'hystérectomie?

A study carried out on 342 cases of endometrial resection, with a follow up of 3 to 36 months, has allowed us to precise: 1. The indications of this technique: patients more than 40 years, suffering of abnormal uterine bleeding. 2. The endometrial ablation was performed by electrosurgery through an operating channel of the hysteroscopic sheet (9 mm) and with a glycocol distended media (1.5%). The mean time to complete the operation was 35 +/- 10 minutes, the mean length of the hospital stay was 1 day. We had no serious complications. 3. And the rate of success (amenorrhea or hypomenorrhea) was 95% at 3 months but decreased at 90% at 36 months. The rate of secondary hysterectomy was 10%, due to the associated lesions: myoma with adenomyosis in 50% of the cases. There was some evidence of superior health related quality of life among hysterectomy patients. It's the reason why it is necessary to make a serious selection of the patients who are to be treated by this method in order to avoid complications and secondary hysterectomy.

[Uterine rupture during labor following surgical hysteroscopy]. / Ruptures utérines lors d'accouchements après hystéroscopie opératoire.

Two cases of obstetrical uterine rupture after operative hysteroscopy without perforation are described. One was treated for uterus septus, the other one for synechia. However, the uterus could have been fragilized in both cases: one had been perforated by a uterine device, the other case had a past history of repeated curetage. A review of the literature shows 7 other similar cases, published over last ten years, 6 of them having a past history of perforation during the operative hysteroscopy (5 cases) or by an intra-uterine device. These obstetrical complications, although rare, can lead to consider a uterus treated by hysteroscopy as being at risk for obstetrical rupture.

Endometrial ossification: a cause of secondary infertility. Report of two cases.

Two cases of endometrial ossification with secondary infertility are reported; pelvic ultrasonography suggested an intrauterine foreign body in one case. Hysteroscopy was necessary to make the correct diagnosis and to remove the bony fragments from the two cases. One patient conceived naturally after the bony fragments were removed.

Endometrial ablation: principles and technique.

Uterine bleeding may be caused either by benign organic pathology as well as different dysfunctional conditions. Medical treatment with progestins, danazol or GnRH analogues is usually used as the first choice therapy. Where the symptoms persist, hysterectomy is generally proposed; it has been calculated that from 500,000 to 700,000 such operations are performed annually in the United States. The authors review the state of the art of the endometrial ablation as an alternative to hysterectomy and other medical therapy. Endometrial ablation either by means of the YAG-laser or with the resectoscope, would seem to play a role in well-selected cases of dysfunctional uterine bleeding. In the authors opinion a multicenter study on large numbers of patients is needed in order to confirm these preliminary results.

Hysteroscopic detection of heterotopic intrauterine bone formation.

The diagnosis and management of heterotopic intrauterine bone formation was performed hysteroscopically in nine patients. The presenting symptom was secondary infertility in seven, pelvic pain in one and passage of bone fragments in one. All nine patients had a history of spontaneous and therapeutic abortion. Hysteroscopy was more accurate than hysterosalpingography in detecting the condition. Four pregnancies occurred in the seven infertile patients following removal of the bone. In four of nine cases there was clear evidence of remaining bone fragments after the initial removal.

Cervical surgery in infertility.

We wish to stress three original techniques among the numerous operations which can be performed on the uterine cervix for the treatment of infertility. The first treatment is for cervical dysplasia of the cervix, a conization performed by electrosurgery under local anaesthesia, using a metallic handle of 23 mm, associated with vaporization by a CO2 laser at the edges of the resection. This technique, used for 125 patients, has permitted adequate resection. The rate of incomplete resection is less than 10%. This method has preserved the possibility of pregnancies without abortion. The second technique is the surgical repair of a large post-obstetrical split of the cervix by an abdominal exposure. After dissection of the bladder, the vagina is opened longitudinally, the cervix exposed and repaired carefully. Four patients who had previously had four to six abortions between 4 and 6 months of gestation, succeeded in achieving a full-term pregnancy by this technique. The third technique is the resection of the isthmic septum by microscissors or micro-electrocautery under local or general anaesthesia by hysteroscopy. Twelve cases, five with primary infertility, seven with second infertility and habitual abortions, were operated on by this technique in 1986-87. Four pregnancies have resulted.

Hysteroscopy in perimenopausal and postmenopausal women with abnormal uterine bleeding.

From February 1983 to January 1985, we performed outpatient microhysteroscopic examinations on 618 women 45 years of age or older with abnormal uterine bleeding (AUB). Three hundred thirty-four (54%) had normal and functional or hypoatrophic endometrium, 78 (12.6%) had low-risk hyperplasia, 8 (1.3%) had high-risk hyperplasia, and 66 (10.6%) had adenocarcinoma. Correlation with histologic findings revealed the considerable diagnostic accuracy of the technique: its reliability approaches 100% when one deals with endometrial neoplasia, 87.5% with high-risk hyperplasia and 65.2% with low-risk hyperplasia. The diagnosis cannot rely on hysteroscopic examination only. A biopsy can be performed during the examination or immediately thereafter. In 54.1% of AUB patients, no endometrial changes could be detected on hysteroscopy and biopsy. Curettage, therefore, would have resulted in overtreatment of these patients. Moreover, the usefulness of dilatation and curettage in about half of AUB patients over 45 should be questioned seriously.

Uterine evaluation by microhysteroscopy in IVF candidates.

Over an eight-month period, microhysteroscopy was performed on 180 women, candidates for in-vitro fertilization (IVF). One hundred and two of them were suspected of having uterocervical pathology (group I), and 78 were not (group II). Group I had microhysteroscopic abnormalities in 60.8% and group II in 21.8%. Microhysteroscopy showed 30.6% of 36 positive hysterographies to be false positive and 37.5% of 144 negative hysterographies to be false negative, producing a confirmation rate of 63.9%. Admission to the IVF programme depended on microhysteroscopic normality. One hundred and one women were accepted directly, and 20 refused ('primary decision'). Fifty-nine were deferred with treatable hysteroscopic abnormalities, pending medical (22) and surgical (37) treatment, 14 via the microhysteroscope. Of the 59 women deferred, 51 were finally admitted and 8 rejected after a microhysteroscopic check ('secondary decision'). Finally, 152 of the 180 candidates (84.4%) were admitted. Microhysteroscopy helped to determine the optimal route for embryo transfer in 23 women with cervical pathology. Term pregnancy rates per embryo transfer were similar with hysteroscopic findings primarily normal, or normal after successful treatment (11.2 and 10.8% respectively). Microhysteroscopy seems useful for selection of cases for IVF, accurately determining utero-cervical pathology or normality, aiding in surgical correction of abnormalities and facilitating the process of embryo transfer. We suggest that microhysteroscopy should be performed routinely on all IVF candidates.

In vitro fertilization in tuberculous infertility.

Twenty women, suffering from infertility due to histologically proved genital tuberculosis, were managed by in vitro fertilization (IVF) in 49 attempts. The main histopathological lesions were tuberculous salpingitis in 12 women, tuberculous endometritis in 5, and pelvic peritoneal tuberculosis in 3. A preliminary evaluation including, particularly, a laparoscopy and a hysteroscopy was performed. Five deliveries and one ongoing pregnancy were obtained. The results suggest that IVF nowadays represents the only treatment for tuberculous infertility.

Hysteroscopic treatment of uterine septa.

Patients with septate uterus usually undergo reproductive failures with recurrent abortions and premature deliveries. Up till now surgical therapy for such a defect has relied on different abdominal metroplasty procedures reflecting the need to establish normal anatomy and physiology of the uterus. Nowadays, wide experience accumulated in hysteroscopic management of intrauterine adhesions, has allowed the incision of the uterine septa with the hysteroscopic technique. In this report the Authors describe the surgical technique of the hysteroscopic metroplasty in eleven cases. Initial results are encouraging: surgical outcome is good, with no intra- or postoperative morbidity; if the pregnancy outcome rate confirms these results, then the traditional abdominal surgical approach should become an out-moded therapy, so making hysteroscopic metroplasty the treatment of choice for the uterine septa.

Microhysteroscopy: a new approach to the diagnosis of cervical intraepithelial neoplasia.

The recent development of the microhysteroscope permits observation of female genital tract surfaces at different magnifications ranging from 1:1 to contact microscopic examination of vitally stained living cells at a magnification of 150:1. One of the emerging applications of the microhysteroscope is in the diagnosis of cervical intraepithelial neoplasia (CIN). To evaluate the capabilities and reliability of microhysteroscopy, two studies were performed. The first study compared this technique with colposcopy, cytology, and histology in the evaluation of 92 patients with abnormal Papanicolaou smears (CIN II, III). The second study prospectively evaluated 800 patients using microhysteroscopy as a screening tool. Initial results of the two studies suggest that microhysteroscopy is a highly precise method of evaluating cervical precancerous lesions.

Hysteroscopic reversible tubal sterilization.

The Authors describe their experience with a new type of intratubal mechanical device to be inserted under hysteroscopic control. Up to present time, 1471 cycles without any other form of contraception have been observed. Although the promising results of this preliminary report in the field of hysteroscopic reversible tubal sterilization, the Authors underline that this new technique is still evolving and will be improved with further experience.

PIP: Techniques for hysteroscopic tubal sterilization may be divided into 3 categories: destruction of the interstitial of the bube by means of electrocoagulation or cryonecrosis; injection of sclerosing substances or silicone liquid; and mechanical devices which will occlude the interstitial section. Experience with a new type of intratubal mechanical device to be inserted under hysteroscopic control is described. The detailed and enlarged visualization possible with the aid of microhysteroscope, during an atraumatic outpatient examination, led to the invention of a device which is suitable for this method and for the anatomo-physiological conditions of the interstitial section of the tube. The device is made of surgical nylon (1 mm diameter) having an open loop at its distal end with an elastic memory so that it can be opened at varying widths and be fixed in the tube, and preventing its migration into the uterine cavity. A similarly adaptable proximal loop stops it from migrating into the peritoneum and facilitates its removal by means of a simple hook. The middle section of about 28-30 mm in length is supple so that it can be atraumatically inserted in the interstitial section. The 2 devices are placed in a supple inserting catheter (diameter 1.5 mm) and a nylon guide thread enables their progression to be followed under visual control. The microhysteroscopic technique is the same as that used for a diagnostic examination or for surgery. From march 1982 to February 1984, 166 patients who requested permanent sterilization were informed about and accepted this method. The average patient age was 33.5 years, with and average parity of 2.4. Patients less than 30 years of age or who had fewer than 2 living children were excluded. In 149 patients it was possible to effect a bilateral insertion during the 1st microhysteroscopy. In 7 patients it was necessary to make 2 attempts, either because of bleeding or unsatisfactory visualization. There was serious retroversion in 3 cases, atresic tubal orifices in 4, and in 1 case the pain felt by the patient was so violent that an hour's rest was necessary. In these 8 patients the device was not inserted. The discomfort felt during the procedure is equal to that experienced during a diagnostic microhysteroscopic examination. A microhysteroscopic examination performed 1 month after insertion showed 4 expulsions. Up to the present time, 1471 cycles without any other form of contraception have been observed. 1 intrauterine pregnancy occurred 6 months after insertion. The technique is still evolving and will be improved with experience and further study.