Efficacy of Hysteroscopy in Improving Fertility Outcomes in Women Undergoing Assisted Reproductive Technique: A Systematic Review and Meta-Analysis of Randomized Controlled Trials.

INTRODUCTION: Usefulness of hysteroscopy before assisted reproductive technique (ART) was considered debatable. However, over the last decade, several new trials have been added to available literature. We aimed to assess the impact of diagnostic and operative hysteroscopy on reproductive outcomes of infertile women with and without intrauterine abnormalities. MATERIALS AND METHODS: MEDLINE, Scopus, SciELO, Embase, Cochrane Library at CENTRAL, PROSPERO, CINAHL, grey literature, conference proceedings, and international controlled trials registries were searched without temporal, geographical, or language restrictions. Randomized controlled trials (RCTs) of infertile women comparing hysteroscopy versus no hysteroscopy prior to the first ART or after at least one failed attempt were included. RCTs of infertile women with intrauterine pathology comparing diagnostic versus operative hysteroscopy were included in separate analysis. Random-effect meta-analysis was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Grading of Recommendations, Assessment, Development and Evaluation and Cochrane criteria were used for quality of evidence and risk of bias assessment. Primary outcome was live birth rate (LBR). Secondary outcomes were clinical pregnancy (CPR) and pregnancy loss rate. RESULTS: Fifteen studies (5,038 women) were included. Compared to no hysteroscopy before first or after failed ART attempts, moderate-quality evidence showed that hysteroscopy increased the LBR (relative risk [RR] 1.24, 95% confidence interval [CI] 1.09-1.43, I2 = 21%), confirmed by subgroup analysis for women with failure after one or more ART cycles (RR 1.43, 95% CI: 1.19-1.72, I2 = 0%) but not before the first ART. Moderate-quality evidence showed that it increased the CPR (RR 1.36, 95% CI: 1.18-1.57; I2 = 51%), confirmed in subgroup analysis for both implantation failure (RR 1.40, 95% CI: 1.12-1.74, I2 = 52%) and before first ART (RR 1.32, 95% CI: 1.11-1.57, I2 = 42%). Low-quality data suggest that operative hysteroscopy increases CPR when used to treat intrauterine pathologies (RR 2.13, 95% CI: 1.56-2.92, I2 = 0%). CONCLUSIONS: Although moderate-quality evidence supports performing hysteroscopy before ART in women with history of implantation failure, hysteroscopic evaluation of uterine cavity should be considered a first-line technique in all infertile women undergoing ART. Additional high-quality RCTs are still needed, particularly to assess yield during couple's initial evaluation even before ART is considered.

Risk of endometrial cancer in asymptomatic postmenopausal women in relation to ultrasonographic endometrial thickness: systematic review and diagnostic test accuracy meta-analysis.

OBJECTIVE: This study aimed to evaluate the risk of endometrial carcinoma and atypical endometrial hyperplasia in asymptomatic postmenopausal women concerning the endometrial thickness measured by stratified threshold categories used for performing subsequent endometrial sampling and histologic evaluation. DATA SOURCES: MEDLINE, Scopus, ClinicalTrials.gov, SciELO, Embase, the Cochrane Central Register of Controlled Trials, LILACS, conference proceedings, and international controlled trials registries were searched without temporal, geographic, or language restrictions. STUDY ELIGIBILITY CRITERIA: Studies were selected if they had a crossover design evaluating the risk of atypical endometrial hyperplasia and endometrial carcinoma in postmenopausal asymptomatic women and calculated the diagnostic accuracy of transvaginal ultrasonography thresholds (at least 3.0 mm) confirmed by histopathologic diagnosis. METHODS: This was a systematic review and diagnostic test accuracy meta-analysis according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses of Diagnostic Test Accuracy and Synthesizing Evidence from Diagnostic Accuracy Tests guidelines. Endometrial thickness thresholds were grouped as follows: from 3.0 to 5.9 mm; between 6.0 and 9.9 mm; between 10.0 and 13.9 mm; and ≥14.0 mm. Quality assessment was performed using the Quality Assessment Tool for Diagnostic Accuracy Studies 2 tool. Publication bias was quantified using the Deek funnel plot test. Coprimary outcomes were the risk of atypical endometrial hyperplasia or endometrial carcinoma according to the endometrial thickness and diagnostic accuracy of each threshold group. RESULTS: A total of 18 studies provided the data of 10,334 women who were all included in the final analysis. Overall, at an endometrial thickness threshold of at least 3.0 mm, the risk of atypical endometrial hyperplasia or endometrial carcinoma was increased 3-fold relative to women below the cutoff (relative risk, 3.77; 95% confidence interval, 2.26-6.32; I2=74%). Similar degrees of risk were reported for thresholds between 3.0 and 5.9 mm (relative risk, 5.08; 95% confidence interval, 2.26-11.41; I2=0%), 6.0 and 9.9 mm (relative risk, 4.34; 95% confidence interval, 1.68-11.23; I2=0%), 10.0 and 13.9 mm (relative risk, 4.11; 95% confidence interval, 1.55-10.87; I2=86%), and ≥14.0 mm (relative risk, 2.53; 95% confidence interval, 1.04-6.16; I2=78%) with no significant difference among subgroups (P=.885). Regarding diagnostic accuracy, the pooled sensitivity decreased from thresholds below 5.9 mm (relative risk, 0.81; 95% confidence interval, 0.49-0.85) to above 14.0 mm (relative risk, 0.28; 95% confidence interval, 0.18-0.40). Furthermore, the specificity increased from 0.70 (95% confidence interval, 0.61-0.78) for endometrial thickness between 3.0 and 5.9 mm to 0.86 (95% confidence interval, 0.71-0.94) when the endometrial thickness is ≥14.0 mm. For 3.0 to 5.9 mm and 10.0 to 13.9 mm thresholds, the highest diagnostic odds ratios of 10 (95% confidence interval, 3-41) and 11 (95% confidence interval, 2-49), with areas under the curve of 0.81 (95% confidence interval, 0.77-0.84) and 0.82 (95% confidence interval, 0.79-0.86), respectively, were retrieved. The summary point analysis revealed that the 3.0 to 5.9 mm cutoff point was placed higher in the summary receiver operator curve space than the other subgroups, indicating increased endometrial carcinoma or atypical endometrial hyperplasia diagnosis using these cutoffs. CONCLUSION: Both low and high endometrial thickness thresholds in postmenopausal asymptomatic women seem equally effective in detecting endometrial carcinoma and atypical endometrial hyperplasia. However, although using a 3.0 to 5.9 mm cutoff results in a lower specificity, the offsetting improvement in sensitivity may justify using this cutoff for further endometrial evaluation in patients with suspected endometrial malignancy.

Pain Management during Office Hysteroscopy: An Evidence-Based Approach.

Background and Objectives: Hysteroscopy is a reliable technique which is highly useful for the evaluation and management of intrauterine pathology. Recently, the widespread nature of in-office procedures without the need for anesthesia has been requesting validation of practical approach in order to reduce procedure-related pain. In this regard, we performed a comprehensive review of literature regarding pain management in office hysteroscopic procedures. Materials and Methods: MEDLINE, EMBASE, The Cochrane Library (Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, Cochrane Methodology Register), Global Health, Health Technology Assessment Database and Web of Science, other research registers (for example Clinical Trials database) were searched. We searched for all original articles regarding pain relief strategy during office hysteroscopy, without date restriction. Results have been collected and recommendations have been summarized according to the Appraisal of Guidelines for Research and Evaluation (AGREE) tool. Moreover, the strength of each recommendation was scored following the Grading of Recommendations Assessment (GRADE) system, in order to present the best available evidence. Results: Both pharmacological and non-pharmacological strategies for pain management are feasible and can be applied in office setting for hysteroscopic procedures. The selection of strategy should be modulated according to the characteristics of the patient and difficulty of the procedure. Conclusions: Accumulating evidence support the use of pharmacological and other pharmacological-free strategies for reducing pain during office hysteroscopy. Nevertheless, future research priorities should aim to identify the recommended approach (or combined approaches) according to the characteristics of the patient and difficulty of the procedure.

In-office hysteroscopic removal of retained or fragmented intrauterine device without anesthesia: a cross-sectional analysis of an international survey.

To investigate about the opinions of gynecologists regarding the in-office hysteroscopic removal of retained or fragmented intrauterine device (IUD) without anesthesia. An online survey was made available to gynecologists who routinely performed in-office hysteroscopy. Five areas of interest were analyzed: average number of hysteroscopic procedures performed without anesthesia, availability on their local market of the different types of hormonal and non-hormonal IUDs, reasons for the hysteroscopic removal of the IUD, types of IUDs that were more commonly found retained or fragmented and, overall difficulty of the hysteroscopic removal. A total of 419 surgeons voluntarily responded the survey, of which 19 were excluded for not performing in-office hysteroscopy. The most commonly available IUD was the Levonorgestrel-based Mirena (Bayer Healthcare, Germany) or similar, (399/400, 99.7%), followed by Copper T (Paragard, CooperSurgical INC, United States) (397/400, 99.2%), Multiload (234/400, 58.5%) and Jaydess (Bayer Healthcare, Germany) (227/400, 56.7%). The intracavitary retention of the IUD with (44.5%, 178/400) and without (42.2%, 169/400) visible strings accounted as the most common reason for undergoing hysteroscopic IUD removal. Copper T IUD was the most common intracavitary retained (297/400, 74.2%) as well as fragmented device (236/400, 59.9%). The in-office hysteroscopic removal of the IUD was considered an easy procedure by almost all the operators (386/400, 96.5%). In-office hysteroscopy without anesthesia is seen as a feasible and easy approach to remove retained or fragmented IUDs inside the uterine cavity or cervical canal. While the Levonorgestrel-based IUD is the most commercialized, Copper T IUDs are the most commonly found retained or fragmented.

Postsurgical barrier strategies to avoid the recurrence of intrauterine adhesion formation after hysteroscopic adhesiolysis: a network meta-analysis of randomized controlled trials.

OBJECTIVE: To assess the efficacy of mechanical strategies to avoid the recurrence of intrauterine adhesions, to evaluate the impact on subsequent fertility after hysteroscopic adhesiolysis and to rank the available antiadhesive options. DATA SOURCES: MEDLINE, Scopus, ClinicalTrials.gov, CINAHL, Scielo, EMBASE, PROSPERO, Cochrane Library, conference proceedings, and international controlled trials registries were searched without temporal, geographic, and language restrictions. STUDY ELIGIBILITY CRITERIA: Randomized trials that analyzed the recurrence, reproductive outcomes, or both in women undergoing hysteroscopic adhesiolysis followed by mechanical prevention of intrauterine adhesions were included. The exclusion criteria included the following: quasi-randomized trials and trials without randomization and studies including patients undergoing hysteroscopic surgery that was different from adhesiolysis. STUDY APPRAISAL AND SYNTHESIS METHODS: The Preferred Reporting Items for Systematic reviews and Meta-Analyses extension statement for network meta-analyses guidelines were followed. We performed a network meta-analysis based on the random effects model for mixed multiple treatment comparisons to rank the antiadhesive strategies by surface under the cumulative ranking curve area. Quality assessment was performed using the criteria outlined in the Cochrane Handbook for Systematic Reviews of Interventions. The primary outcome was the recurrent presence of intrauterine adhesions. RESULTS: Eleven studies with data for 1596 women were identified as applicable. A copper intrauterine device together with an intrauterine balloon (surface under the cumulative ranking curve area=46.4%) or with cross-linked hyaluronic acid gel (surface under the cumulative ranking curve area=21.3%) seemed effective in preventing adhesions recurrence. Regarding the fecundity, hyaluronic acid gel demonstrated the highest pregnancy rates (surface under the cumulative ranking curve area=79.8%). The greatest degrees of change in the mean adhesions scores were found with the use of hyaluronic acid gel plus an intrauterine device (surface under the cumulative ranking curve area=38.9%). For postsurgical adhesion severity, hyaluronic acid gel plus intrauterine device (surface under the cumulative ranking curve area=49.9%) followed by intrauterine device alone (surface under the cumulative ranking curve area=30.8%) was ranked the highest. Dried amnion graft (surface under the cumulative ranking curve area=53.8%) and uterine balloon (surface under the cumulative ranking curve area=45%) showed the greatest menstrual pattern improvement. CONCLUSION: Cross-linked hyaluronic acid gel, with or without insertion of a copper intrauterine device, seems to be the most effective approach. However, the lack of a clear best therapy suggests the need for further studies to draw firm conclusions.

Osseous metaplasia of the endometrium: A multicenter retrospective study.

OBJECTIVE: To describe clinical and demographic characteristics, ultrasound appearance, and hysteroscopic outcomes of patients with endometrial osseous metaplasia. STUDY DESIGN: We conducted a multicenter retrospective study. We retrospectively reviewed the medical records of all consecutive patients who were referred for hysteroscopy at fourteen institutions in Venezuela, Spain, Morocco, India, Ukraine, Argentina, the United States, and Italy between 1994 and 2018. We identified and included all patients who had a diagnosis of osseous metaplasia at the pathologic report, and data were retrieved from the medical records. RESULTS: Between January 1st, 1994, and December 31st, 2018, 63 patients out of a total of 419,673 women who underwent hysteroscopy had a diagnosis of osseous metaplasia (0.015%). Most patients were 31-40 years old (53.7%), were Caucasian or Hispanic (95.5%), and had at least one previous pregnancy (86.9%). Forty-one out of 63 patients (65.1%) had at least one miscarriage before the index hysteroscopy. Dysmenorrhea, abnormal uterine bleeding, and infertility were reported by 34.9%, 27.0%, and 23.8% of patients. 14.3% of women were asymptomatic. Preoperative transvaginal ultrasound was available and identified a hyperechoic area of variable size with posterior acoustic shadowing in all cases. Hysteroscopy was successful without complications in all 63 cases. Follow-up data were available in 30.2% of patients: 69.2% of patients were infertile, and 44.4% of them conceived and achieved a live birth; all other symptoms improved after hysteroscopic treatment in all patients. CONCLUSIONS: Osseous metaplasia appears associated with multiple unspecific gynecologic symptoms without the predominant role of infertility, as previously suggested. Although endometrial osseous metaplasia is rare, gynecologists should consider this pathologic condition when the characteristic ultrasound appearance is detected, being hysteroscopic treatment effective.

Hysteroscopic endometrial biopsy: from indications to instrumentation and techniques. A call to action.

During the last twenty years, the diagnostic approach to endometrial pathology has radically evolved. For over a century, intrauterine blind biopsy techniques were considered the gold standard procedure for the histopathological diagnosis of intrauterine diseases. The advent of hysteroscopy, which made it possible to directly visualize the uterine cavity, and the subsequent miniaturization of the instruments allowing its use in the office setting without anesthesia are considered game-changers. To date, it is feasible to retrieve a targeted eye specimen of endometrial tissue with little or no discomfort for the patient in the office setting. To pursue this aim, several technological upgrades have improved the diagnostic accuracy of hysteroscopic endometrial biopsy. In this paper we provide an up-to-date review of the latest evidence regarding indications, instrumentations, and techniques for hysteroscopic endometrial biopsy, to help the operator in providing an adequate endometrial sampling for histopathological analysis.

The Rule of 10: a simple 3D ultrasonographic method for the diagnosis of T-shaped uterus.

PURPOSE: To investigate and propose a new simple tridimensional (3D) ultrasonographic method to diagnose a T-shaped uterus (Class U1a). METHODS: A multicenter non-experimental case-control diagnostic accuracy study was conducted between January 2018 and December 2019, including 50 women (cases) diagnosed with T-shaped uterus (U1a class) and 50 women with a "normal uterus" (controls). All the enrolled women underwent 3D ultrasound, drawing four lines and recording the length of three of them as follow: draw and measure the interostial line (R0); draw from the midpoint of R0 a perpendicular line length 20 mm; draw and measure in the uterine cavity a line parallel to R0 at 10 mm below R0 (R10) and a second line parallel to R0 at 20 mm below R0 (R20). The diagnostic performance of all sonographic parameters statistically significantly different between T-shaped and normal uteri was estimated using the receiver operator characteristic (ROC) curve analysis. RESULTS: R10 and R20 were statistically significantly shorter in the T-shaped than the normal uterus. R10 reported the highest diagnostic accuracy with an area under the ROC curve of 0.973 (95% CI 0.940-1.000). R10 length maximizing the Youden's J statistic was 10.5 mm. Assuming R10 length equal to or shorter than 10 mm as the cut off value for defining a woman as having a T-shaped uterus, the new ultrasonographic method following the proposed protocol (R0, R10, and R20) reported sensitivity for T-shaped uterus of 91.1% (95% CI 0.78-0.97%) and a specificity of 100% (95% CI 0.89-100%). The positive likelihood ratio was higher than 30, and the negative likelihood ratio was 0.09 (95% CI 0.04-0.26). CONCLUSIONS: Measuring the length of the intracavitary line parallel to the interostial line at 10 mm from it and using a length ≤ of 10 mm as cut off value (the "Rule of 10") appears a simple and accurate 3D ultrasonographic method for the diagnosis of a T-shaped uterus.

Oral Desogestrel as Endometrial Preparation before Operative Hysteroscopy: A Systematic Review.

The pharmacologic preparation of the endometrium before hysteroscopy may be achieved with the use of various drugs. This systematic review aims to summarize the available evidence regarding the use of desogestrel for endometrial preparation before hysteroscopic procedures. A literature search for suitable articles published in English language from inception of the database until August 2019 was performed using the following databases: PubMed/MEDLINE, EMBASE, the Cochrane Library, and Google Scholar. All original articles concerning desogestrel-only pretreatment before hysteroscopic surgery were considered eligible. Reviews, case reports/series, conference papers, studies including the use of combined hormonal preparation, and articles in languages other than English were excluded from the analysis. The literature search retrieved 3 studies that met all the inclusion criteria. The data demonstrated that desogestrel may be considered as a hormonal pretreatment drug before hysteroscopic procedures. The drug was distinctly effective and assessed as helpful by the operating surgeon in numerous patients who were administered the pretreatment of 75 µg daily. Oral desogestrel is a cheap, easily available, safe, and quite efficient alternative for endometrial preparation before hysteroscopic procedures.

Office hysteroscopic myomectomy without myoma extraction: A multicenter prospective study.

OBJECTIVE: To evaluate the feasibility and safety of leaving the submucous myoma (SM) in the uterine cavity after office hysteroscopic enucleation. STUDY DESIGN: Prospective multicenter study including patients who had a single SM diagnosed by transvaginal ultrasounds with surgical indication. Office hysteroscopic enucleation of the SM was performed using a 5 mm continuous flow office hysteroscope with a 2.9 mm rod lens optical system and a 5 Fr operative channel. After the SM was released preserving the pseudo capsule using cold instruments, it was left into the uterine cavity. The primary endpoint was the proportion of patients without evidence of the myoma at the transvaginal ultrasound performed after 90 days from surgery. RESULTS: Between January 1st, 2018, and March 31st, 2020, a total of 204 patients were enrolled. Most patients were nulliparous and reported abnormal uterine bleeding as the leading symptom. 76.5 % of enucleated myomas had a diameter ranging between 1.5 and 2.5 cm, and 81.4 % of SMs were of G0 or G1. Hysteroscopic procedures had a mean duration of 23.2 ± 10.5 min. The operative time was associated with the SM grade and size. All hysteroscopic procedures were completed. A vasovagal reaction was observed in 3 women (1.5 %), and minimal post-operative bleeding was reported after 7 procedures (3.4 %). None reported pelvic pain or vaginal discharges/bleeding during follow-up. The average patient satisfaction from surgery was 4.59 (5-points Likert scale). The level of patient satisfaction was not associated with the grade and the size of the myoma. In 192 (94.12 %; 98 %CI: 89.03-96.93 %) out of 204 patients, the SM was absent at the transvaginal ultrasound performed at the follow-up end. A higher prevalence of G2 SMs and lower prevalence of G1 SMs were observed among patients with evidence of the myoma after 90 days from the surgery. CONCLUSION: Office hysteroscopic myomectomy with SM enucleation without mass extraction appears safe, well-tolerated, and effective in at least 89 % of patients. G2 SMs may be the factor associated with the procedure's failure.

Intrauterine infusion of platelet-rich plasma for severe Asherman syndrome: a cutting-edge approach.

Asherman syndrome (AS) consists of intrauterine adhesions development as a consequence of trauma, radiation, or infection in the endometrium. Clinical symptoms include menstrual alterations, infertility, and pregnancy complications, such as recurrent pregnancy loss or abnormal placentation. In this article, we performed a narrative review of the literature, searching electronic databases (i.e., Medline, Pubmed, and Google Scholar) to summarize the available pieces of evidence about epidemiology, pathophysiology, diagnosis, and treatment of AS. Hysteroscopy is essential for diagnosis and treatment, although adhesions may recur. Different postoperative therapies have been proposed to prevent recurrence and restore impaired endometrial function and promote endometrial regeneration, although these effects are usually temporary. We report a case of AS with adhesion recurrence and endometrial atrophy who was successfully treated with intrauterine autologous platelet-rich plasma (PRP) infusion. This therapy allowed endometrial tissue regeneration, leading to increased vascularity and endometrium thickness, and restoration of endometrial function that led to a successful pregnancy. Though there is limited experience supporting the use of PRP to improve endometrial function, it has been safely used in other fields of medicine; besides, it is easy to obtain, not expensive, and harmless being an autologous source. Future studies are encouraged to further assess this approach to treat AS.

Pain management for in-office hysteroscopy. A practical decalogue for the operator.

Hysteroscopy is known to be the gold standard for evaluation of intrauterine pathologies, pre-menopausal and post-menopausal abnormal uterine bleeding and, in addition to this, it is a crucial examination in the infertility work-up. In-office operative hysteroscopy incorporates the outstanding possibility of seeing and treating an intracavitary pathology in the same examination, eliminating all the risk related to anesthesia and reducing procedure-related costs. By now, performing operative procedures in the office setting is recognized as feasible and safe. Over the last 20 years, many efforts have been made to implement the in-office operative approach worldwide. However, for some women, in-office hysteroscopy is still considered a painful experience, with reported discomfort at different steps of the hysteroscopic procedures. Moreover, uneventful and tedious sensations might be increased by a high level of anxiety for such examination. For this reason, despite the feasibility of the in-office approach, many clinicians are still afraid of provoking pain during the procedure and rather not to perform surgical procedures in the office, postponing the removal of the pathology in the operating room. To date, there is no consensus concerning pain management for in-office hysteroscopy and different approaches, pharmacological and non-pharmacological aids, as well as several procedural tips and tricks are utilized. Our purpose is to provide a feasible practical decalogue for the operator, to supply adequate management of pain during in-office hysteroscopic procedures, performing challenging operations, shrinking discomfort, aiming to upgrade both women's and operator's satisfaction.

Hysteroscopic Metroplasty for T-Shaped Uterus: A Systematic Review and Meta-analysis of Reproductive Outcomes.

IMPORTANCE: To date, a comprehensive review on the safety and effectiveness of hysteroscopic metroplasty for T-shaped uterus is still missing. OBJECTIVE: To provide a robust synthesis of the available studies investigating reproductive outcomes after hysteroscopic metroplasty for T-shaped uterus. EVIDENCE ACQUISITION: We performed a systematic review and meta-analysis (CRD42019143291), using the proportion method with 95% confidence interval (CI). Statistical heterogeneity was assessed by Higgins test (I2). RESULTS: We included 11 cohort studies embedding 937 women who underwent hysteroscopic metroplasty. After surgery, the pooled percentage of live birth was 44.54% (95% CI, 36.12%-53.12%; I2 = 46.22%) and 56.88% (95% CI, 46.48%-66.98%; I2 = 36.38%) in women with primary infertility and recurrent miscarriage, respectively. In women with recurrent miscarriage, the pooled proportion of miscarriage was 21.46% (95% CI, 15.09%-28.61%; I2 = 30.18%). The pooled clinical pregnancy proportion in women with primary infertility was 57.19% (95% CI, 43.83%-70.03%; I2 = 77.81%). The pooled rate of surgical complications was 0.65% (95% CI, 0.20%-1.33%; I2 = 11.44%). CONCLUSIONS: The hysteroscopic correction of T-shaped uteri was associated with high live birth rate and low miscarriage rate, both in case of primary infertility and recurrent miscarriage. RELEVANCE: Hysteroscopic metroplasty can be considered a safe and effective strategy to improve reproductive outcomes in case of T-shaped uterus.

Hysteroscopic outpatient metroplasty for T-shaped uterus in women with reproductive failure: Results from a large prospective cohort study.

OBJECTIVE: To evaluate the effectiveness of hysteroscopic outpatient metroplasty in women with T-shaped uterus and primary reproductive failure. STUDY DESIGN: Prospective cohort study including nulliparous women with primary unexplained infertility, repeated in vitro fertilization (IVF) failure or recurrent spontaneous miscarriage and T-shaped uterus anomaly not diethylstilbestrol-related, diagnosed by 3D ultrasound and diagnostic hysteroscopy. Between January 2015 and December 2017, hysteroscopic metroplasty was performed in outpatient settings with a 5-mm diameter hysteroscope and 5-Fr operative scissors. After 3 months, expectant management was proposed to women with unexplained couple infertility or recurrent spontaneous miscarriages, and IVF treatment was proposed after 6 months without natural conception or immediately to couple with repeated IVF failure. Minimum follow-up was planned for 1 year. RESULTS: A total of 63 women were included, and only 60 tried to conceive after metroplasty. Hysteroscopic procedures were performed without complications. Clinical pregnancy rate after metroplasty was 83.3% (n = 50/60) (p < 0.001), and the live birth rate was 63.3% (n = 38/60) (p < 0.001). Cesarean section rate was 26.3%. No pregnancy complications potentially related to uterine surgery were reported. The abortion rate was 12% (n = 6/50) (p < 0.001). CONCLUSION: In women with primary reproductive failure and T-shaped uterus, hysteroscopic metroplasty seems to be effective to improve reproductive outcomes.

Subtypes of T-shaped uterus.

OBJECTIVE: To present three different subtypes of T-shaped uterus with the use of three-dimensional (3D) ultrasound imaging and hysteroscopy. DESIGN: Video article. SETTING: Fertility center. PATIENT(S): Three cases showing the different subtypes of T-shaped uterus. INTERVENTION(S): 3D ultrasound imaging and hysteroscopy. MAIN OUTCOME MEASURE(S): Distance between the interostial line and external uterine profile at the midcoronal plane of the uterus obtained with the use of transvaginal 3D ultrasound; delineation of the external uterine contour and the length of any existing internal indentation (defined as the distance between the interostial line and the indentation's edge at the cavity). RESULT(S): It is possible to identify three different subtypes of T-shaped uterus: the most common type of T-shaped uterus, with thick lateral walls and normal fundus (without septum or subseptum appereance) and interostial distance; the Y-shaped uterus, with thick lateral walls, fundal septum or subseptum, and reduced interostial distance; and the I-shaped uterus, with very thick lateral walls (even above the isthmus) and severe reduction of the interostial distance (tubular appearance of the whole uterus). CONCLUSION(S): We solicit to investigate the occurrence of different T-shaped uterus subtypes in large cohorts, to evaluate whether they may have different reproductive outcomes and whether they may need different approaches for surgical correction through hysteroscopic metroplasty.

Outcomes after Hysteroscopic Treatment of Symptomatic Isthmoceles in Patients with Abnormal Uterine Bleeding and Pelvic Pain: A Prospective Case Series.

BACKGROUND: Isthmoceles are described as complications associated with caesarean section (CS). Only symptomatic isthmoceles should be treated. The main symptoms are abnormal uterine bleeding (AUB) in the absence of any other causes, pelvic pain and secondary infertility. There are several techniques described for the correction of isthmoceles. Isthmoplasty can be performed by hysteroscopy, laparoscopy or vaginal surgery. The aim of this study was to assess the effectiveness of hysteroscopic surgical treatment of isthmoceles in women with associated symptoms such as pelvic pain and AUB. MATERIALS AND METHODS: A prospective case series study was performed; this study included all women with AUB, pelvic pain and ultrasonographic (US) diagnosis of isthmocele, who had undergone hysteroscopic correction between June 2014 and December 2017 in our Hospital. RESULTS: Thirty eight women underwent surgical hysteroscopy for correction of symptomatic isthmoceles. All patients presented AUB, 42.1% experienced pelvic pain and 28.9% had secondary infertility. US evaluation of isthmoceles was performed using 2D ultrasound. The residual myometrial thickness (RMT) above the isthmocele was measured in women who expected future pregnancy; if it was <2.5 mm the patient was not included in the study because the correction was performed laparoscopically. Follow-up was performed one and two months after the surgery. In all cases, pelvic pain was resolved one month after the surgery. AUB disappeared within the first month in 87.5% of patients and in the second month in 96.8% of subjects; however, one patient needed further surgery to alleviate her symptoms. Secondary infertility was assessed one year after surgical isthmoplasty. Seven women completed the first year of follow up, and three of them (42.8%) reported pregnancy after treatment between six and eight months after the surgery. CONCLUSION: Hysteroscopic correction of symptomatic isthmoceles may constitute a safe and effective technique for patients who present AUB and pelvic pain.