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.

The effect of transcervical resection of submucous fibroids on menstrual blood loss: A prospective cohort study.

OBJECTIVES: Transcervical resection of myoma (TCRM) is a widely implemented treatment for submucous fibroids. The aim of this study is to evaluate the effect of TCRM on menstrual bleeding, fibroid related symptoms and quality of life and hemoglobin (Hb) levels. STUDY DESIGN: A prospective cohort study was conducted in three teaching hospitals and two academic hospitals in the Netherlands. Patients with HMB (PBAC score > 150) and submucous fibroids (type 0, 1, 2, 3, 4 and hybrid type 2-5) scheduled for TCRM were eligible. At baseline and 3 months after TCRM a Trans Vaginal Ultrasound (TVU) was performed and a Hb sample was taken. Patients filled out the Pictorial Blood Assessment Chart (PBAC) and the Uterine Fibroid Symptom and Quality of Life (UFS-QOL) questionnaire at baseline and up to 6 months after surgery. Primary outcome was improvement in PBAC score 6 months after surgery. Secondary outcomes were improvement in PBAC score and Hb level 3 months after surgery and UFS-QOL scores 3 and 6 months after surgery. RESULTS: 126 patients were included and 104 were operated. PBAC were obtained from 98 patients. Six months after surgery, 56.6% of patients went from HMB to normal menstrual bleeding (PBAC < 150). A significant reduction in median PBAC scores of 427 (IQR 198 - 1392) (p <.0001) was found (86% improvement). UFS-QOL scores were obtained from 91 patients. Symptom severity improved from a median of 54 on a scale of 100 (IQR 44-66) at baseline to 22 (IQR 9-41) after 6 months (p <.0001) (59% improvement). Health related quality of life (HRQOL) improved from a median score of 44 on a scale of 100 (IQR 33-62) to 89 (IQR 67-97) 6 months after surgery (p <.0001) (102% improvement). CONCLUSION: TCRM significantly reduces the amount of menstrual bleeding, severity of fibroid related symptoms and improves HRQOL in patients with submucous fibroids.

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.

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.

An alternative approach for removal of placental remnants: hysteroscopic morcellation.

STUDY OBJECTIVE: To evaluate our initial experience with hysteroscopic morcellation for removal of placental remnants. DESIGN: Retrospective case series (Canadian Task Force classification II-3). SETTING: University hospital and 2 teaching hospitals. PATIENTS: Women with histologic confirmation of placental remnants after miscarriage, termination of pregnancy, or delivery. INTERVENTION: From January 2005 to May 2010, hysteroscopic morcellation was used for removal of placental remnants. Retrospective review of medical records was performed. MEASUREMENTS AND MAIN RESULTS: Analysis of 105 procedures was performed. In 99 procedures (94.3%), placental remnants were removed successfully at the first approach, and 90 procedures (85.7%) were without any adverse events. In 6 patients (5.7%), uterine perforation occurred, in 4 during cervical dilation and in 2 during the hysteroscopic procedure. Postoperatively, 3 patients had fever, 1 had hemorrhage, and 1 had abdominal pain. Routine second-look hysteroscopy in 23 patients revealed mild intrauterine adhesions in 1 patient (4.4%). CONCLUSION: Hysteroscopic morcellation seems to be an effective technique for management of placental remnants. Future studies comparing various surgical treatment methods are needed to define factors that influence the ability to obtain the safest and most complete removal of placental remnants because this remains a challenging pregnancy-related condition.

Regional and temporal variation in hysterectomy rates and surgical routes for benign diseases in the Netherlands.

OBJECTIVE: To provide descriptive statistics on hysterectomy for benign gynecological conditions in the Netherlands and to analyze regional and temporal variations in hysterectomy rates and surgical routes. DESIGN: Retrospective cohort study. SETTING: Dutch hospitals. POPULATION: All women with a hysterectomy for benign gynecological conditions in the Netherlands in 1995-2005. METHODS: This study is based on an analysis of the Dutch registry of hospital admissions for 1995-2005. MAIN OUTCOME MEASURES: The age-adjusted hysterectomy rate and age- and diagnosis-adjusted proportion of vaginal hysterectomies for each Dutch healthcare region and time period. RESULTS: The average annual crude hysterectomy rate for benign disease only, was 17.2 per 10,000 women of all ages. The vaginal route was chosen for 50.8% of the patients. During the study period, the number of hysterectomies for bleeding disorders declined almost 25%. Among 27 Dutch healthcare regions, the age-adjusted hysterectomy rates for bleeding disorders and pelvic organ prolapse varied 2.2- and 2.3-fold, respectively. The average annual age- and diagnosis-adjusted proportion of vaginal hysterectomies varied from 43.4 to 63.8%. The regional differences with regard to rate and proportion declined slightly over time. CONCLUSIONS: The Netherlands is among the countries with the lowest hysterectomy rates and the highest proportion of vaginal hysterectomies. The regional differences indicate that a further decrease in the hysterectomy rates and an increase in the proportion of vaginal hysterectomies are possible.

Hysteroscopic myomectomy and case volume hysteroscopic myomectomy performed by high- and low-volume surgeons.

OBJECTIVE: To determine whether surgical volume influences efficiency of hysteroscopic myomectomy as a treatment for uterine fibroids. STUDY DESIGN: This retrospective cross-sectional study performed at a university teaching hospital included all patients who underwent hysteroscopic myomectomy between 2001 and 2005 by a faculty surgeon. We used 3 outcomes as measures of efficiency: amount of tissue resected per case, operating department time per case and amount of tissue resected per minute. RESULTS: High-volume surgeons resected more tissue than low-volume surgeons (p = 0.01), had shorter operating department times (p = 0.018) and resected more tissue per time (p = 0.015). CONCLUSION: High-volume surgeons have higher efficiency performing hysteroscopic myomectomy as a treatment for uterine fibroids.

The relation of annual surgeon case volume to clinical outcomes and resource utilization in abdominal hysterectomy.

OBJECTIVE: To study the relationship of annual surgeon case volume to surgical outcome following hysterectomy. STUDY DESIGN: We performed a retrospective cohort study of women who underwent hysterectomy between January 1995 and December 2005 and evaluated the relationship of surgeon volume to complications and resource utilization. RESULTS: A total of 214 physicians contributed a total of 8,747 patients to the study. Of these patients, 7,166 women underwent abdominal hysterectomy. Overall, rates of complications in the study population were low. However, compared with patients of low annual surgeon case volume (i.e., who performed <10 hysterectomies per year), high annual surgeon case volume (i.e., who performed > or = 10 hysterectomies per year) had fewer intraoperative complications, fewer postoperative complications and shorter procedure times than surgeons with low annual volume for abdominal hysterectomy. CONCLUSION: Among women undergoing abdominal hysterectomy, physicians who operate on more patients annually have fewer complications and faster procedure times, compared with lower volume surgeons. Both groups have low complication rates, however, confirming the safety of the procedure even in the hands of low-volume surgeons.

Severe complication after termination of a second trimester cervical pregnancy.

OBJECTIVE: To report a supracervical hysterectomy performed after a life-threatening hemorrhage due to an attempted surgical termination at a gestational age of 18 weeks, which appeared to be a cervical pregnancy. DESIGN: Case report. SETTING: Teaching hospital. PATIENT(S): A 36-year-old pregnant woman, with two previous cesarean sections. INTERVENTION(S): Supracervical hysterectomy. MAIN OUTCOME MEASURE(S): Not applicable. RESULT(S): A stable patient. CONCLUSION(S): By missing a cervical pregnancy in the second trimester, a life-threatening hemorrhage occurred after an attempted surgical termination. In case of failure of the conservative therapy this rare diagnosis should be considered. A supracervical hysterectomy at this gestational age is the only therapeutic option.

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.

Focused ultrasound surgery of intramural leiomyomas may facilitate fertility: a case report.

OBJECTIVE: To describe a successful pregnancy after a change in configuration of the endometrial cavity after magnetic resonance imaging-guided focused ultrasound surgery (MRgFUS) for leiomyomas. DESIGN: Case report. SETTING: University hospital. PATIENT: A 40-year-old woman with known leiomyomas and a history of secondary infertility. INTERVENTION: Magnetic resonance imaging-guided focused ultrasound surgery treatment of two intramural myomas, one with a significant submucosal component. MAIN OUTCOME MEASURE: Change in conformation of the uterine cavity. RESULT(S): A viable intrauterine pregnancy, with full-term uneventful labor and vaginal delivery. CONCLUSION(S): Magnetic resonance imaging-guided focused ultrasound surgery changed the configuration of the endometrial cavity, and a subsequent pregnancy resulted in a term delivery.