Hormonal support in women with Asherman syndrome does not lead to better outcomes: A randomized trial.

Purpose: The purpose of the study was to investigate if adjuvant hormones after successful adhesiolysis lead to a reduction in spontaneous recurrence of adhesions and influence reproductive outcomes. Methods: A single-blind randomized controlled trial comparing administration of oral estrogen (the usual care group) with not giving estrogen (no estrogen) in women after successful adhesiolysis for Asherman syndrome. Women were included between September 2013 and February 2017, with a follow-up of 3 years to monitor recurrences and reproductive outcomes. Analyses were based on an intention to treat analyses. This study was registered under NL9655. Results: A total of 114 women were included. At 1 year, virtually all patients (except 3) were either having a recurrence or were pregnant. Women who did not receive estrogen did not have more recurrences of adhesions in the first year prior to pregnancy (66.1% in the usual care group, 52.7% in the no-estrogen group, p = 0.15). Of the women in usual care, 89.8% got pregnant within 3 years, and 67.8% got a living child; this was 83.6% and 60.0%, respectively, in the no-estrogen group (p = 0.33 and p = 0.39, respectively). Conclusion: Usual care does not lead to better outcomes as compared with not giving exogenous estrogen but is associated with side effects.

Efficacy of Oral Nifedipine, Naproxen, or Placebo for Pain Relief During Diagnostic Hysteroscopy in an Office Setting: A Randomized Pilot Study.

STUDY OBJECTIVE: To compare nifedipine, naproxen, or placebo for pain relief during diagnostic hysteroscopy. DESIGN: Double-blind, randomized controlled pilot study. SETTING: University hospital. PATIENTS: Women scheduled for office diagnostic hysteroscopy (n = 60). INTERVENTIONS: Women received nifedipine (2 tablets of 10 mg), naproxen (2 tablets of 250 mg), or placebo (2 tablets of 500 mg lactose) 30 to 60 minutes prior to hysteroscopy. MEASUREMENTS AND MAIN RESULTS: Sixty patients were enrolled in the study (21 in the nifedipine group, 19 in the naproxen group, and 20 in the placebo group). The median pain scores during hysteroscope insertion, measured on a Visual Analog Scale (VAS), were 1 (interquartile range (IQR) 0-0), 2 (0-4) and 1 (0-1) in the nifedipine, naproxen and placebo group, respectively (P,14). The median VAS scores during hysteroscopy were 5 (IQR 2-7), 5 (4-8) and 5 (3-7) in the nifedipine, naproxen and placebo group, respectively (P,73). The median VAS scores immediately after hysteroscopy were 2 (IQR 0-4), 3 (0-6) and 3 (1-5) in the nifedipine, naproxen and placebo group, respectively (P,40). The median VAS scores 30 minutes after hysteroscopy were 1 (IQR 0-2), 1 (0-1) and 1 (0-2) in the nifedipine, naproxen and placebo group, respectively (P,63). Hysteroscope insertion failed in 1 case (naproxen group) because of cervica`l stenosis (P,32). Flushes, fatigue and vertigo, 30 minutes after the procedure, were significantly more prevalent in the nifedipine group compared to the naproxen (p < .001, p,03, p,03, respectively) and the placebo group (p < .001, p,01, p,01, respectively). Palpitations occurred only in the nifedipine group (p < .001). The day after the procedure, the headache was most prevalent in the nifedipine group compared to the naproxen group (p,001) and the placebo group (p,001). CONCLUSION: In our pilot study, pain relief and success rates for office diagnostic hysteroscopy were not significantly different between nifedipine, naproxen, and placebo. Nifedipine was associated with more, albeit tolerable, side-effects.

The link between intrauterine adhesions and impaired reproductive performance: a systematic review of the literature.

BACKGROUND: Intrauterine adhesions (IUAs) are one of the main reproductive system diseases in women worldwide. Fusion between the injured opposing walls leads to partial-to-complete obliteration of the cavity and/or cervical canal. The main clinical manifestations in case of IUAs are menstrual disturbances, cyclic pain and reproductive disorders. The reproductive outcomes of women with IUAs remain limited and inefficient compared to women without IUAs, even after adhesiolysis. An exact understanding of the underlying mechanisms and processes to explain the compromised reproductive performance and outcomes in case of IUAs are lacking. METHODS: A systematic literature review of MEDLINE-PubMed (1966 to January 2022) and EMBASE (1974 to January 2022) was performed following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Studies were included if they reported underlying causes, related mechanisms and processes to explain the association between IUAs and impaired reproductive performance, pregnancy and obstetric complications. RESULTS: After an extensive review of the literature, 58 articles were identified reporting underlying mechanisms to explain the association between IUAs and impaired fertility. Intrauterine scarring influences the process of fertilization, reproductive performance and ultimately reproductive outcome. IUAs can disturb the cervico-utero-tubal sperm transport and result in an avascular and unresponsive endometrium with decreased receptivity and thickness. Abnormal decidualization and abnormal trophoblastic infiltration leads to placental attachment disorders. Moreover, the risk for premature delivery, intrauterine fetal growth restriction and fetal anomalies is increased in case of IUAs. CONCLUSION: The impact of IUAs on reproductive performance, even after adhesiolysis, is becoming more apparent. The postulated mechanisms to explain the association are related to sperm transport, embryo implantation and placentation. Prevention, by preserving the basal layer of the endometrium is essential. Effective and evidence-based strategies for the prevention of endometrial injury and formation of IUAs, are urgently needed.

Live births after Asherman syndrome treatment.

OBJECTIVE: To study the reproductive outcomes after surgical management of women with Asherman syndrome (AS). DESIGN: Cohort study. SETTING: International referral hospital for women with AS. PATIENT(S): A total of 500 women who were diagnosed with and treated for AS between January 2003 and December 2016 and followed for a minimum of 2 years. INTERVENTION(S): Hysteroscopic adhesiolysis using conventional instruments with concomitant fluoroscopy as a guidance method. MAIN OUTCOME MEASURE(S): Live birth rate. RESULT(S): Of the 500 women included in the cohort, 569 pregnancies were achieved within 3 years after surgery. The miscarriage rate was 33.0%, and the live birth rate was 67.4%. Age, the causal procedure, and at least one miscarriage after adhesiolysis strongly predicted the outcome of a live birth. CONCLUSION(S): The overall take-home newborn rate was 67.4% after adhesiolysis in women with AS. Women with AS who are relatively young, with a first-trimester procedure preceding AS, and with low grades of adhesions and no miscarriage after adhesiolysis have the best chance of a newborn delivery.

Clinical Aspects of HyFoSy as Tubal Patency Test in Subfertility Workup.

BACKGROUND: Tubal patency testing is an essential part of female subfertility evaluation. Traditionally, hysterosalpingography (HSG) was the first step to evaluate tubal patency. However, during the past decade Hysterosalpingo-Contrast Sonography (HyCoSy) was introduced in order to avoid radiation exposure and Hysterosalpingo-Foam Sonography (HyFoSy) has been developed as a safe and less painful alternative. OBJECTIVES AND RATIONALE: The aim of this narrative review is to provide an overview of the currently available HyFoSy literature and related clinical aspects. SEARCH METHODS: A literature search was conducted using PubMed and Embase from the introduction of HyFoSy to March 2019. Unfortunately, a meta-analysis was not possible due to a too small number of studies, being mutually incomparable for the various subjects of clinical aspects, even for the reliability as a test for tubal patency. OUTCOMES: Nine small studies concluded that the accuracy and effectiveness as a test for tubal patency of 2D- and 3D-HyFoSy are comparable or even better than HSG or HyCoSy. With or without using Doppler techniques, 3D-HyFoSy does not seem to offer benefits above real-time 2D-HyFoSy. Five studies reported on pain and discomfort during HyFoSy, concluding that HyFoSy is a well-tolerated, less painful procedure compared to HSG, without a need for the use of analgesics. There are suggestions about an increased pregnancy rate in the first three cycles after the procedure but in no studies pregnancy outcome after HyFoSy was compared with other or no intervention. WIDER IMPLICATIONS: HyFoSy is a promising and safe alternative for HSG with regard to accuracy and effectiveness. HyFoSy lacks radiation and iodine exposure and is a well-tolerated and less painful procedure than HSG, without the need for analgesics. However more research is needed to make clear statements regarding a therapeutic effect of HyFoSy.

Hysterectomy for heavy menstrual bleeding.

Hysterectomy is the most frequently performed major surgical intervention in gynecology. Although surgically removing the uterus is invasive, it represents the most definitive treatment option for heavy menstrual bleeding. In this article, we will discuss the indications for hysterectomy as a treatment for heavy menstrual bleeding, the different approaches to perform the hysterectomy, the complications which may occur during and after this procedure and finally the outcomes in comparison with other treatment options.

Results of centralized Asherman surgery, 2003-2013.

OBJECTIVE: To study the success rate of hysteroscopic adhesiolysis and the spontaneous recurrence rate of intrauterine adhesions (IUAs) in patients with Asherman syndrome. DESIGN: Cohort study. SETTING: University-affiliated hospitals. PATIENT(S): A total of 638 women with Asherman syndrome were included, all diagnosed using hysteroscopy, and operated on between 2003 and 2013. INTERVENTION(S): Hysteroscopic adhesiolysis. MAIN OUTCOME MEASURE(S): Hysteroscopic adhesiolysis was classified as successful if a normalization of menstrual blood flow occurred, along with a restored, healthy, cavity anatomy, free of adhesions, with hysteroscopic visualization of ≥ 1 tubal ostium. Recurrences of adhesions were diagnosed using hysteroscopy after an initial successful procedure. RESULT(S): A first-trimester procedure preceded Asherman syndrome in 371 women (58.2%) and caused adhesions of grades 1-2A. In 243 (38.1%) women, a postpartum procedure caused IUAs of grades 3-5. The procedure was successful in 606 women (95%), and restoration of menstrual blood flow occurred in 97.8%; IUAs spontaneously recurred in 174 (27.3%) of these cases. High grades of adhesions were predictive of a higher chance of spontaneous recurrence of adhesions. CONCLUSION(S): In 95% of women with Asherman syndrome, a healthy uterine cavity was restored with hysteroscopic adhesiolysis, in 1-3 attempts, with a 28.7% recurrence rate of spontaneous IUAs.

Hysteroscopy and the treatment of uterine fibroids.

Fibroids or (leio)myomas are benign tumours that very commonly derive from smooth muscle cells of the myometrium. They are the most common indication for a hysterectomy. However, in women desirous of preservation of their uterus or of their fertility, a myomectomy may be a more appropriate form of surgical therapy. The submucous variant is often associated with heavy menstrual bleeding or subfertility. It can be removed with hysteroscopic surgery. Refinements of hysteroscopic surgical techniques have resulted in a better ability to remove submucous myomas. The state of the art of such hysteroscopical techniques and instrumentation to treat submucous myomas and what has been proven is discussed.

Safety aspects and side-effects of ExEm-gel and foam for uterine cavity distension and tubal patency testing.

A state-of-the-art overview of the safety and side-effects of ExEm-gel for uterine cavity distension and ExEm-foam for tubal patency testing is presented. A literature search was carried out using PubMed, textbooks, pharmaceutical databases and reports of toxicity tests. Information on clinical use in humans and experiments in animal models was collected and grouped according to the following components: glycerol, hydroxyethyl cellulose and purified water; subjects included toxicity test, influence on sperm cells, oocytes, blastocyst development, uterine cavity distension, tubal patency testing, pain and obstetric applications. No unknown side-effects of gel or foam, or unexpected concerns about safety, were reported. More information than expected was available on the absence of effects of the components on various human tissues. Although it is difficult to prove that the search is complete, and it is possible that side-effects remain unreported, the combination of glycerol, hydroxyethyl cellulose and purified water is considered to be safe for intrauterine application and tubal patency testing, indicating an optimal risk-benefit ratio in clinical use. The safest strategy, however, is to restrict clinical examinations with gel and foam to the pre-ovulatory phase of the menstrual cycle.

Outcomes of pregnancies in women with hysteroscopically placed micro-inserts in situ.

This was a retrospective review of all pregnancies reported after Essure in situ in the Netherlands. Pregnancies included those that were unintentional (resulting from lack of protocol adherence and/or misread confirmation tests) and those that were intentional (resulting from off-label use of Essure micro-inserts for hydrosalpinx closure before in vitro fertilization/intracytoplasmic sperm injection with embryo transfer or in vitro fertilization with embryo transfer after regret of sterilization). The outcomes of 50 pregnancies in women with 1 or 2 micro-inserts in situ were evaluated. Eight unintended pregnancies and 18 intended pregnancies resulted in birth of a full-term healthy baby. Seven infants were delivered via cesarean-section. Two women delivered prematurely by C-section, (singleton after 34 weeks 1 day, twins after 35 weeks 3 days). All babies are healthy and without any congenital anomalies. There were 2 stillbirths after 20 weeks; however, it is unlikely that this was related to the presence of the micro-inserts. In conclusion, it is unlikely that the presence of intratubal micro-inserts interferes with implantation and the developing amniotic sac and fetus.

New developments in hysteroscopy.

Diagnostic and operative hysteroscopy have become standards in gynaecologic practice. Many hysteroscopic procedures have replaced old, invasive techniques, such as dilatation and curettage. As instruments have reduced in size, office hysteroscopy has begun to replace operating-room procedures. New instruments and techniques continue to emerge, and the prospects for improvement seem unlimited. Discussed are hysteroscopic sterilisation, bipolar electrosurgery, hysteroscopic morcellation, and virtual hysteroscopy. Furthermore, the evidence for supporting the vaginoscopic approach, cervical preparation, pain medication and the use of local anaesthetics is presented. Main hysteroscopic procedures, such as polypectomy, myomectomy, adhesiolysis, metroplasty, and the role of hysteroscopy before embryo transfer, are reviewed, and what has been proven is further discussed.

First experiences with hysterosalpingo-foam sonography (HyFoSy) for office tubal patency testing.

BACKGROUND: This study was conducted to describe the first experiences with hysterosalpingo-foam sonography (HyFoSy) as a first step routine office procedure for tubal patency testing. METHODS: A prospective observational cohort study was started in a university affiliated teaching hospital. In 2010, 73 patients with subfertility and a low risk of tubal pathology were examined. A non-toxic foam containing hydroxymethylcellulose and glycerol was applicated through a cervical applicator for contrast sonography (HyFoSy). Tubal patency was determined by transvaginal ultrasonographic demonstration of echogenic dispersion of foam in the Fallopian tube and/or the peritoneal cavity. Only in case patency could not be demonstrated, a hysterosalpingography (HSG) was performed as a control. RESULTS: In 67 out of 73 (92%) patients, a successful procedure was performed. In 57 out of 73 (78%) cases, there was no further need for a HSG. In five patients (5/73; 7%) tubal occlusion was confirmed by HSG and in five patients (5/73; 7%) there was discordance between HyFoSy and HSG. Of 73 patients, 14 (19%) conceived within a median of 3 months after the procedure. CONCLUSIONS: HyFoSy is a successful procedure to demonstrate tubal patency as a first step office procedure.

Essure® hydrosalpinx occlusion prior to IVF-ET as an alternative to laparoscopic salpingectomy.

OBJECTIVE: To investigate the success rate of proximal tubal occlusion with Essure(®) devices in subfertile women with unilateral or bilateral hydrosalpinx and to observe the results of subsequent treatment with IVF-ET and/or frozen embryo transfer. STUDY DESIGN: Prospective, single-arm, clinical study in 20 women with unilateral or bilateral hydrosalpinges (all visible on transvaginal ultrasound) due to undergo IVF-ET and/or frozen embryo transfer. In all patients, laparoscopy was considered to be contraindicated due to extensive pelvic adhesions. RESULT(S): In all patients the Essure(®) devices were placed in an ambulant setting without any complications. Proximal tubal occlusion was confirmed by hysterosalpingography in 19 out of 20 patients (95%) and in 26 of 27 treated tubes (96%). After 45 embryo transfer procedures in 19 patients, 18 pregnancies with 12 live births, 6 miscarriages and 1 immature delivery (probably related to cervical insufficiency leading to chorioamnionitis and subsequent rupture of the membranes) were observed. CONCLUSION(S): Essure(®) devices are effective in inducing proximal tubal occlusion in subfertile patients with hydrosalpinges. After artificial reproductive treatments a cumulative live birth rate per patient of 63% and a cumulative live birth rate per transfer of 27% were achieved. The latter was related to the large proportion of patients with severe endometriosis.

Essure hysteroscopic tubal occlusion device for the treatment of hydrosalpinx prior to in vitro fertilization-embryo transfer in patients with a contraindication for laparoscopy.

OBJECTIVE: To investigate the success rate of proximal tubal occlusion with Essure devices in subfertile women with hydrosalpinges, and to observe the results of subsequent treatment with IVF. DESIGN: Prospective, single-arm, clinical study. SETTING: University hospital and teaching hospital. PATIENT(S): Ten women with uni- or bilateral hydrosalpinges prior to IVF. In all patients laparoscopy was felt to be contraindicated. INTERVENTION(S): Hysteroscopic placement of Essure devices in an office setting. MAIN OUTCOME MEASURE(S): Placement rate, successful proximal tubal occlusion, and pregnancy rate after IVF. RESULT(S): All patients had successful placement of the Essure devices without any complications. Proximal tubal occlusion was confirmed by hysterosalpingography in 9 out of 10 patients. A 40% ongoing pregnancy rate was achieved with 20% life births after one IVF cycle and/or frozen embryo transfer. CONCLUSION(S): Proximal occlusion of hydrosalpinges with Essure devices before IVF is a successful treatment for patients with a contraindication for salpingectomy.

Hysteroscopic morcellator for removal of intrauterine polyps and myomas: a randomized controlled pilot study among residents in training.

The purpose of this randomized controlled study was to compare conventional resectoscopy and hysteroscopic morcellation among residents in training (Canadian Task Force classification I). Sixty women with an intrauterine polyp or myoma were randomized to either hysteroscopic removal by conventional resectoscopy or hysteroscopic morcellation performed by 6 residents in training for obstetrics and gynecology (10 procedures per resident). The mean operating time for resectosocpy and morcellation was 17.0 (95% confidence interval [95% CI] 14.1-17.9, standard deviation [SD] 8.4) and 10.6 (95% CI 7.3-14.0, SD 9.5) min, respectively (p = .008). Multiple linear regression analysis showed that operating time increased significantly, for both resectoscopy and morcellator, when volume of intrauterine disorder increased. The use of the hysteroscopic morcellator reduced operating time more than 8 min in comparison to conventional resectoscopy (p < .001) when correction for volume was applied. Subjective surgeon and trainer scores for convenience of technique on a visual analog scale were in favor of the morcellator. No learning curve was observed. In conclusion, the hysteroscopic morcellator for removal of intrauterine polyps and myomas offers a good alternative to conventional resectoscopy for residents in training.

The METEX study: methotrexate versus expectant management in women with ectopic pregnancy: a randomised controlled trial.

BACKGROUND: Patients with ectopic pregnancy (EP) and low serum hCG concentrations and women with a pregnancy of unknown location (PUL) and plateauing serum hCG levels are commonly treated with systemic methotrexate (MTX). However, there is no evidence that treatment in these particular subgroups of women is necessary as many of these early EPs may resolve spontaneously. The aim of this study is whether expectant management in women with EP or PUL and with low but plateauing serum hCG concentrations is an alternative to MTX treatment in terms of treatment success, future pregnancy, health related quality of life and costs. METHODS/DESIGN: A multicentre randomised controlled trial in The Netherlands. Hemodynamically stable patients with an EP visible on transvaginal ultrasound and a plateauing serum hCG concentration < 1,500 IU/L or with a persisting PUL with plateauing serum hCG concentrations < 2,000 IU/L are eligible for the trial. Patients with a viable EP, signs of tubal rupture/abdominal bleeding, or a contra-indication for MTX will not be included. Expectant management is compared with systemic MTX in a single dose intramuscular regimen (1 mg/kg) in an outpatient setting. Serum hCG levels are monitored weekly; in case of inadequately declining, systemic MTX is installed or continued. In case of hemodynamic instability and/or signs of tubal rupture, surgery is performed. The primary outcome measure is an uneventful decline of serum hCG to an undetectable level by the initial intervention. Secondary outcomes are (re)interventions (additional systemic MTX injections and/or surgery), treatment complications, health related quality of life, financial costs, and future fertility. Analysis is performed according to the intention to treat principle. Quality of life is assessed by questionnaires before and at three time points after randomisation. Costs are expressed as direct costs with data on costs and used resources in the participating centres. Fertility is assessed by questionnaires after 6, 12, 18 and 24 months. Patients' preferences will be assessed using a discrete choice experiment. DISCUSSION: This trial will provide guidance on the present management dilemmas in women with EPs and PULs with low and plateauing serum hCG concentrations. TRIAL REGISTRATION: Current Controlled Trials ISRCTN 48210491.

Outcomes for abdominal myomectomies among high-volume surgeons.

OBJECTIVE: To examine the relationship between surgical volume and complications and resource utilization for myomectomy. STUDY DESIGN: This retrospective cross-sectional study in a university hospital setting (Brigham and Women's Hospital) analyzed 527 consecutive women with uterine fibroids who underwent abdominal myomectomy. A multivariate analysis was performed to determine the association between surgical volume and outcomes. RESULTS: There were no significant medical or surgical complications following myomectomy. However, high-volume surgeons did procedures significantly faster, they collected more tissue per time and their patients had less blood loss. CONCLUSION: The surgical volume of the physician does not affect the safety of abdominal myomectomy. However, high-volume surgeons had more efficient resource utilization than did physicians doing fewer cases.

Gel instillation sonohysterography: first experience with a new technique.

OBJECTIVE: A practical attempt to simplify and improve the technique of artificial uterine cavity distension by instilling gel instead of flushing saline. DESIGN: Prospective observational study. SETTING: Teaching hospital. PATIENT(S): One hundred twenty patients with an indication for sonohysterography (abnormal uterine bleeding, exclusion of congenital abnormalities, or preoperative or postoperative evaluation of submucous myomas, polyps, or synechiae). INTERVENTION(S): A hydroxyethylcellulose gel containing anesthetic and antiseptic agents was instilled in the uterine cavity through a plastic intrauterine insemination cannula attached to a flexible plastic tube and a syringe. Transvaginal (3-dimensional) ultrasonography was performed concomitantly. MAIN OUTCOME MEASURE(S): Stable filling of the uterine cavity allowing a high-quality ultrasonographic visualization. RESULT(S): An optimal distension of the uterine cavity could be achieved with an average of only 4 mL (range, 2-10 mL) in 113 patients. As expected, a stable filling of the uterine cavity permitted a precise visualization of the uterine cavity and its linings and offered an optimal presentation for a 3-dimensional ultrasound recording and reconstruction. CONCLUSION(S): Gel instillation is a simple technique with minimal inconvenience for the patient and seems to be an attractive alternative to saline infusion during sonohysterography.

Follow-up after incomplete hysteroscopic removal of uterine fibroids.

BACKGROUND: In this observational study, we analysed whether a period of wait and see was reasonable following incomplete removal of submucous fibroids, with regard to symptoms of abnormal uterine bleeding, and whether factors predicting subsequent surgery could be identified. METHODS: In 3 affiliated hospitals, patients with incomplete removal of submucous fibroids, treated with hysteroscopic myomectomy for abnormal uterine bleeding, between January 1997 and January 2005, were followed over time. Using life-table analysis (Kaplan-Meier method), the cumulative proportion of women having surgery-free survival following incomplete removal of submucous fibroids was calculated. Cox-proportional hazard analyses were used to analyse relationships of variables with recurrence of symptoms. RESULTS: Forty-one consecutive patients met the inclusion criteria, and were followed over time. The mean age was 42.5 years (range 27-55). The majority of patients with incomplete removal of submucous fibroids were diagnosed with type 2 fibroids. Termination of the procedure before complete removal was achieved, was principally caused by reaching the maximum fluid deficit (90.2%). The surgery-free percentages were 70.2% (95%-CI: 55.3-85.1) at 1 year, 54.8% (95%-CI: 38.1-70.7) at 2 years, and 44.2% (95%-CI: 26.9-61.5) at 3 years. Size of fibroid (diameter) pre-operatively turned out to be of statistically significant influence, with a hazard ratio of 1.762 (95%-CI: 1.114-2.787) per cm increase in diameter (p=0.016). CONCLUSIONS: The results indicate that incomplete removal does not always seem to necessitate subsequent surgery. Instead of subsequent surgery immediately post-operatively, a wait and see policy is worth considering after incomplete removal.

The Intra Uterine Morcellator: a new hysteroscopic operating technique to remove intrauterine polyps and myomas.

STUDY OBJECTIVE: A new hysteroscopic operating technique was compared retrospectively with conventional resectoscopy. DESIGN: Retrospective comparison (Canadian Task Force Classification II-2). SETTING: Gynecology department of a university-affiliated teaching hospital. PATIENTS: Fifty-five women, 27 with endometrial polyps and 28 with submucous myomas. INTERVENTION: Patients were treated with a prototype of the Intra Uterine Morcellator (IUM). This cutting device, 35 cm in length, was inserted into a straight working channel of a 90-mm hysteroscope. MEASUREMENTS AND MAIN RESULTS: The major advantages were ease of removal of tissue fragments through the instrument and the use of saline solution instead of electrolyte-free solutions used in monopolar high-frequency resectoscopy. The mean operating time was 8.7 minutes (95% CI: 7.3-10.1) for the removal of endometrial polyps compared with 30.9 minutes (CI: 27.0-34.8) for resectoscopy, and 16.4 minutes (CI: 12.6-20.2) for submucous myomas compared with 42.2 minutes (CI: 39.7-44.7) for resectoscopy. All procedures were uneventful. CONCLUSION: This new technique is faster, and it appears to be easier to perform. Therefore, it can be expected to result in fewer fluid-related complications and to lead to a shorter learning curve when compared with conventional resectoscopy.