Hysteroscopy and female infertility: a fresh look to a busy corner.

Hysteroscopy has evolved from the traditional art of examining the uterine cavity for diagnostic purposes to an invaluable modality to concomitantly diagnose and (see and) treat a multitude of intrauterine pathologies, especially in the field and clinics specialising in female reproduction. This article reviews the literature on the most common cervical, endometrial, uterine and tubal pathologies such as chronic endometritis, endometrial polyps, adenomyosis, endometriosis, endometrial atrophy, adhesions, endometrial hyperplasia, cancer, and uterine malformations. The aim is to determine the efficiency of hysteroscopy compared with other available techniques as a diagnostic and treatment tool and its association with the success of in vitro fertilisation procedures. Although hysteroscopy requires an experienced operator for optimal results and is still an invasive procedure, it has the unique advantage of combining great diagnostic and treatment opportunities before and after ART procedures. In conclusion, hysteroscopy should be recommended as a first-line procedure in all cases with female infertility, and a special effort should be made for its implementation in the development of new high-tech procedures for identification and treatment infertility-associated conditions.

Distension media delivery systems in hysteroscopy: past, present and future.

To examine the uterine cavity and/or to perform hysteroscopic surgery, one has to access the uterine cavity through the cervix, distend the cavity with a fluid (liquid or gas) to visualize it with a telescope and/or a camera system and use energy (mechanical or thermal) to affect and/or remove tissue. Distension of the uterine cavity then is an important component of hysteroscopy, and during the last century, numerous attempts have been made to achieve an undistorted and unobstructed panoramic view of the uterine cavity. In order to achieve this goal, the uterine cavity has been distended with fluids using a variety of techniques, including gravity-assisted systems, pressure cuffed systems, and electronic pumps. Excessive fluid intravasation during hysteroscopy can lead to significant complications, and hence, automated fluid delivery systems have been developed recently to provide a safe and more efficient method of fluid delivery. This review aims to describe the evolution of distension media delivery systems chronologically from the 1900s to the present day.

Classification systems of Asherman's syndrome. An old problem with new directions.

Intrauterine adhesion (IUA) formation and the resulting Asherman's syndrome (AS) is an unfortunate clinical condition that occurs when the endometrium is damaged as a consequence of trauma, such as vigorous curettage, infection, or some Müllerian anomaly. The most frequent symptoms include hypo/amenorrhea, infertility, and adverse reproductive outcomes. Prevention of IUA formation is essential; however, when present, accurate diagnosis and surgical intervention (hysteroscopic adhesiolysis) are required. The outcome of this treatment is based on the technique and the extent of surgery performed which depends on the severity and complexity of the disease. Hence its classification becomes particularly important to determine a standardized therapy for each case and patient counseling regarding the prognosis. In this article, we aim to describe the IUAs classification systems that have been proposed comparing the merits and demerits of each one.

Reproductive outcomes of infertile women undergoing "see and treat" office hysteroscopy: a retrospective observational study.

INTRODUCTION: This study aimed to assess the feasibility and efficacy of office hysteroscopy to diagnose and treat the specific uterine pathologies frequently diagnosed and thought to be associated with female infertility. MATERIAL AND METHODS: Using office hysteroscopy, we examined the uterine cavity in women with primary or secondary infertility and evaluated the reproductive outcomes of those affected by one or more pathologies, including cervico-isthmic adhesions, intrauterine polyps and intrauterine adhesions. Additional patient characteristics considered were age and parity, uterine pathology, pain during hysteroscopy, and outcomes including spontaneous pregnancies achieved and time between treatment and pregnancy. RESULTS: Reproductive outcomes of 200 patients affected by one or more uterine pathologies were evaluated. Cervico-isthmic adhesions were the most frequent findings in older women, with nearly 80% of them achieving pregnancy sooner than the others in our study. Spontaneous pregnancy rates following office hysteroscopy were 76%, 53% and 22% in women with cervico-isthmic adhesions, polyps (< 5 mm) and intrauterine adhesions, respectively. CONCLUSIONS: Office hysteroscopy is a feasible and highly effective diagnostic and therapeutic procedure for cervico-isthmic and intrauterine adhesions, as well as for small polyps, allowing the resolution of female infertility related to these pathologies, without trauma and with only minimal discomfort.

Evaluation and treatment of infertile women with Asherman syndrome: an updated review focusing on the role of hysteroscopy.

Asherman syndrome is a rare acquired clinical condition resulting in the obliteration of the uterine cavity causedby the presence of partial or complete fibrous intrauterine adhesions involving at least two-thirds of the uterine cavity potentially obstructing the internal cervical orifice. Common reported symptoms of the disease are alterations of the menstrual pattern with decreased menstrual bleeding leading up to amenorrhoea and infertility. Hysteroscopy is currently considered the gold standard diagnostic and therapeutic approach for patients with intrauterine adhesions. An integrated approach, including preoperative, intraoperative and postoperative therapeutic measures, however, are warranted owing to the complexity of the syndrome. This review aims to summarize the most recent evidence on the recommended preoperative, intraoperative and postoperative procedures to restore the uterine cavity and a functional endometrium, as well as on the concomitant use of adjuvant therapies to achieve optimal fertility outcomes.

Management of anxiety and pain perception in women undergoing office hysteroscopy: a systematic review.

PURPOSE: The aim of this review is to provide an overview of the literature about the perception and management of anxiety and pain in women undergoing an office hysteroscopic procedure. METHODS: We performed a systematic literature search in Embase, PubMed/MEDLINE, Cochrane Library and Web of Science for original studies written in English (registered in PROSPERO 2019-CRD42019132341), using the terms 'hysteroscopy' AND 'pain' AND 'anxiety' published up to January 2019. Only original articles (randomized, observational and retrospective studies) about management of anxiety and pain related to the hysteroscopic procedure were considered eligible. RESULTS: Our literature search produced 84 records. After exclusions, 11 studies including 2222 patients showed the following results: (a) pain experienced during hysteroscopy is negatively affected by preprocedural anxiety; (b) pharmacological interventions seem to be help in reducing pain during hysteroscopy; (c) waiting time before the procedure is a significant factor affecting patients' anxiety; (d) music during the procedure may be helpful in reducing anxiety. CONCLUSIONS: The utilization of office hysteroscopy is hampered by varying levels of anxiety and pain perceived by women who are candidates for the procedure. For these reasons, it is essential to identify effective pharmacological and non-pharmacological strategies to alleviate these factors. We recommend further studies especially focusing on non-pharmacological interventions to facilitate the dissemination of good clinical practices among hysteroscopists.

Ulipristal Acetate Before Hysteroscopic Myomectomy: A Systematic Review.

IMPORTANCE: Uterine leiomyomas, also referred to as myomas or fibroids, are the most common benign tumors of the reproductive tract. Ulipristal acetate (UPA) is an active selective progesterone receptor modulator used as preoperative treatment for uterine myomas. PURPOSE: The aim of this review is to provide an overview of the literature about the effects of UPA administration before hysteroscopic myomectomy. The clinical question in "PICO" format was in patients affected by uterine myomas undergoing operative hysteroscopic management, "Does UPA impact the surgical outcomes?" EVIDENCE ACQUISITION: We performed a systematic literature search in PubMed/MEDLINE and Embase for original studies written in English (registered in PROSPERO CRD42018092201), using the terms "hysteroscopy" AND "ulipristal acetate" published up to March 2019. Original articles about UPA treatment before hysteroscopic myomectomy (randomized, observational, retrospective studies) were considered eligible. RESULTS: Our literature search produced 32 records. After exclusions, 4 studies were considered eligible for analysis. Results show that UPA does not worsen the overall technical difficulty of hysteroscopic myomectomy. Moreover, it may increase the chance of complete primary myomectomy in complex hysteroscopic procedures. CONCLUSIONS AND RELEVANCE: Despite the positive results presented in this systematic review, low-quality evidence exists yet on the impact of UPA treatment before hysteroscopic myomectomy. High-quality prospective randomized controlled trials are required to establish the impact of UPA on surgical outcomes of patients treated for uterine myomas by hysteroscopy. Moreover, long-term outcomes of myomectomies after UPA treatment (such as frequency of myoma recurrence, recovery time, and quality of life) should be determined.

From hysteroscopy to laparoendoscopic surgery: what is the best surgical approach for symptomatic isthmocele? A systematic review and meta-analysis.

PURPOSE: To investigate the effectiveness and risks of different surgical therapies for isthmocele in symptomatic women with abnormal uterine bleeding, infertility, or for the prevention of obstetric complications, considering safety and surgical complications. METHODS: PubMed/MEDLINE, Scopus, Embase, Science Direct, and Cochrane Library were systematically searched (n° CRD4201912035) for original articles on the surgical treatment of isthmocele published between 1950 and 2018. Data synthesis was completed using MedCalc 16.4.3. The body of evidence was assessed using the GRADE methodology. RESULTS: We retrieved 33 publications: 28 focused on a single surgical technique, and five comparing different techniques. Meta-analysis showed an improvement of symptoms in 85.00% (75.05-92.76%) of women after hysteroscopic correction, 92.77% (85.53-97.64%) after laparoscopic/robotic correction, and 82.52% (67.53-93.57%) after vaginal correction. Hysteroscopic surgery was associated with the lowest risk of complications (0.76%, 0.20-1.66%). CONCLUSIONS: We found adequate evidence supporting the use of surgery for the treatment of symptomatic isthmocele, as it was found to improve the bleeding symptoms in more than 80% of patients. Differently, we found a lack of evidence regarding the role of surgery with the purpose of improving fertility or reducing the risk of obstetric complications in women with asymptomatic isthmocele. The hysteroscopic correction of isthmocele may be the safest and most effective strategy in those patients with adequate residual myometrial thickness overlying the isthmocele. Laparoscopic and vaginal surgeries may be the preferred options for patients with a thinner residual myometrium over the defect (< 2.5 mm) and when hysteroscopic treatment is inconclusive.

Hysteroscopy in the management of endometrial hyperplasia and cancer in reproductive aged women: new developments and current perspectives.

Over the last twenty years, the incidence of early endometrial cancer (EC) and atypical endometrial hyperplasia (AEH) among women of reproductive age is increasing rapidly, likely due to a combination of factors including increased prevalence of obesity and delayed of childbirths. Regarding preoperative diagnosis of endometrial neoplasia, it is still debated which is the most accurate and reliable method to obtain endometrial histopathological samples with fractional dilatation and curettage (D&C) having been considered, for a long time, as the method of choice. Nowadays, the advent of in-office endometrial biopsy with or without hysteroscopy has radically changed the approach, giving the opportunity to perform the endometrial biopsy under direct visualization. However, the lack of agreement about its diagnostic accuracy is still relevant. Since a significant number of women with AEH and/or EC are of childbearing age, a fertility-sparing diagnostic and therapeutic approach should be considered in all cases. The feasibility, safety and efficacy of fertility-sparing strategies involving hysteroscopic focal resections in conjunction with hormonal therapies have been evaluated and beneficial effects have been confirmed in several studies and one meta-analysis. Both local and systemic administration of hormonal therapies are currently used. Oral progestin, including medroxyprogesterone acetate (MPA) and megestrol acetate, are the most commonly used therapies. Nowadays, new therapeutic approaches, such as levonorgestrel intrauterine systems (LNG-IUS), gonadotropin-releasing hormone (GnRH) agonists, combined megestrol acetate and metformin, and other combinations of therapies are also used as first line therapies or after the hysteroscopic resection of the lesion. However, it is still unclear which approach provides higher clinical response with lower relapse rate, in addition to preserving fertility in women desiring to conceive. The aim of this narrative review is to summarize the available evidence regarding the evaluation and management with fertility-sparing treatments options of women with AEC and EC.

Fertility and pregnancy outcomes following resectoscopic septum division with and without intrauterine balloon stenting: a randomized pilot study.

BACKGROUND AND OBJECTIVES: Although uterine stenting is performed routinely following hysteroscopic metroplasty, we were unable to find any evidence documenting its value with regards to septum reformation and/or obstetrical performance. To evaluate the benefits of intrauterine Foley catheter/balloon splinting after resectoscopic septum division on septum reformation, fertility, and pregnancy outcomes. DESIGN AND SETTING: Prospective, randomized controlled pilot study (Canadian Task Force Classification I) conducted in university affiliated teaching hospital. PATIENTS AND METHODS: Twenty-eight women with infertility and/or adverse pregnancy outcomes diagnosed with intrauterine septum were randomized into having a No. 14 pediatric Foley catheter/balloon for 5 days (n=13) vs. no balloon (n=15) following resectoscopic septum division. None of the patients received preoperative endometrial thinning, antibiotic prophylaxis or adjuvant postoperative hormone therapy. All uterine septa were divided under general anaesthesia using a 26 F (9 mm) resectoscope with a monopolar electrical knife using glycine irrigant solution (1.5%) and 120 watts of power of low voltage (cut) waveform. RESULTS: The median age (range) was 29 years (23-38) and 32 years (22-40), respectively (P=.59). The groups were comparable by age, past obstetrical performance and comorbidities including endometriosis stage I-IV in 3 and 4 women, in the catheter/balloon and balloon group, respectively, and one in each group of polycystic ovarian syndrome and Crohn disease and one case of tubal obstruction in the balloon group. There were no intra- or postoperative complications. At 3 months, a hysterosalpingogram was done in 10 (77%) and 13 (87%) women, respectively, the results of which were normal. At 12-18 months, 1 woman in the balloon and 3 in the control group were not trying to conceive and 1 in each group had not conceived. Of the remaining women, 11 (92%) in each group had conceived and pregnancy outcomes included spontaneous abortion 3 (25%) and 4 (33.3%), ectopic pregnancy 0 and 1, second trimester loss 1 (8.3%) and 0 and term pregnancy 8 (66.6%) in both groups. Conception through assisted reproductive technology occurred in 2 and 1 woman, respectively. CONCLUSIONS: Following resectoscopic septum division with monopolar knife electrode, splinting the uterine cavity with Foley catheter provided no advantage in septum reformation, clinical pregnancy rate, and pregnancy outcomes.