Exploring the knowledge, attitudes, and perceptions of women of reproductive age towards fertility and elective oocyte cryopreservation for age-related fertility decline in the UK: a cross-sectional survey.

STUDY QUESTION: What are the knowledge, perceptions and attitudes towards fertility and elective oocyte cryopreservation (OC) for age-related fertility decline (ARFD) in women in the UK? SUMMARY ANSWER: Awareness of OC for ARFD has reportedly improved compared to studies carried out almost a decade ago, but inconsistencies in knowledge remain regarding the rate of miscarriage amongst specific age groups, the financial costs and optimal age to undergo OC for ARFD. WHAT IS KNOWN ALREADY: The age of first-time motherhood has increased amongst western societies, with many women of reproductive age underestimating the impact of age on fertility. Further understanding of women's awareness of their fertility, the options available to preserve it and the barriers for seeking treatment earlier are required in order to prevent the risk of involuntary childlessness. STUDY DESIGN, SIZE, DURATION: A hyperlink to a cross-sectional survey was posted on social media (Instagram) between 25 February 2021 and 11 March 2021. PARTICIPANTS/MATERIALS, SETTING, METHODS: Women from the general population aged 18-50 years were invited to complete the survey. MAIN RESULTS AND THE ROLE OF CHANCE: In total, 5482 women fulfilled the inclusion criteria and completed the survey. The mean age of participants was 35.0 years (SD 10.25; range 16-52). Three quarters (74.1%; n = 4055) disagreed or strongly disagreed they felt well informed regarding the options available to preserve their fertility, in case of a health-related problem or ARFD. The majority overestimated the risk of miscarriage in women aged ≥30 years old, with 14.5% correctly answering 20%, but underestimated the risks in women ≥40, as 20.1% correctly answered 40-50%. Three quarters (73.2%; n = 4007) reported an awareness of OC for ARFD and 65.8% (n = 3605) reported that they would consider undergoing the procedure. The number of women who considered OC for ARFD across age groups were as follows: 18-25 (8.3%; n = 300), 26-30 (35.8%; n = 1289), 31-35 (45.9%; n = 1654), 36-40 (9.6%; n = 347), 41-45 (0.3%; n = 13), and 46-50 (0.1%; n = 2). The majority of women (81.3%; n = 4443) underestimated the cost of a single cycle of OC for ARFD (<£5000). Furthermore, 10.4% (n = 566) believed a single cycle would be adequate enough to retrieve sufficient oocytes for cryopreservation. Approximately 11.0% (n = 599) believed OC for ARFD may pose significant health risks and affect future fertility. Less than half agreed or strongly agreed that the lack of awareness regarding OC for ARFD has impacted the likelihood of pursuing this method of fertility preservation further (41.4%; n = 2259). LIMITATIONS, REASONS FOR CAUTION: Results from cross-sectional studies are limited as interpretations made are merely associations and not of causal relationships. The online nature of participant recruitment is subject to selection bias, considering women with access to social media are often from higher socioeconomic and education backgrounds, thus limiting generalizability of the findings. WIDER IMPLICATIONS OF THE FINDINGS: Further education regarding the financial costs and optimal age to undergo elective OC to increase the chances of successful livebirth are required. Clinicians should encourage earlier fertility counselling to ensure that OC is deemed a preventative measure of ARFD, rather than an ultimate recourse to saving declining fertility. STUDY FUNDING/COMPETING INTEREST(S): No funding was required for this article. There are no conflicts of interests to declare. TRIAL REGISTRATION NUMBER: N/A.

Euploid blastocysts implant irrespective of their morphology after NGS-(PGT-A) testing in advanced maternal age patients.

PURPOSE: Does blastocyst morphology following euploid elective single embryo transfer (eSET) after preimplantation genetic testing for aneuploidies (PGT-A) via next generation sequencing impact clinical outcome? METHODS: Two hundred ninety-six patients underwent PGT-A. Of 1549 blastocysts, 1410 blastocysts had a conclusive result after PGT-A and were included for analysis. An eSET policy was followed in a frozen embryo replacement cycle. A total of 179 euploid blastocysts were thawed and transferred. Clinical outcomes were categorized in four different embryo quality groups: excellent, good, average and poor. RESULTS: Euploidy rate was 19/36 (52.7%, 95% CI 37-68), 199/470 (42.3%, 95% CI 38-47), 156/676 (23.0%, 95% CI 20-26) and 39/228 (17.1%, 95% CI 13-23) in the excellent, good, average and poor quality blastocyst groups, respectively. Fitted logistic regression analysis taking into account the following covariables: female, age, embryo chromosomal status and day of blastocyst development/biopsy showed that morphology was predictive of the comprehensive chromosome screening result (p < 0.05). A logistic regression analysis was also performed on clinical outcomes taking into account the effect of blastocyst morphology and day of blastocyst development/biopsy. None of the parameters were shown to be significant, suggesting morphology and day of blastocyst development/biopsy do not reduce the competence of euploid embryos (p > 0.05). CONCLUSIONS: After eSET, implantation rate was 80-86%; live birth rate per embryo transfer was 60-73% and clinical miscarriage rate was found to be < 10% and were not significantly affected by the embryo morphology. Results are concordant with those reported when using aCGH and highlights the competence of poor-quality euploid embryos.

Premature ovarian insufficiency: how to improve reproductive outcome?

Premature ovarian insufficiency (POI) is a life-changing condition that affects women in their reproductive age. The condition is not necessarily permanent but is associated with intermittent and unpredictable ovarian activity. Hence, spontaneous pregnancies have been reported to be 5-10%. However, pregnancy in patients with POI is still unlikely and rare. Although, there are reviews on POI in the literature, there is a lack of reports which focus on how to improve the reproductive outcome of these women who wish to conceive spontaneously or use assisted conception with their own oocytes. We found that there is no conclusive evidence of which treatment is optimal for women with POI who wish to conceive using their own gametes. However, one could surmise that it is important to lower gonadotropin levels into the physiological range before embarking on any treatment, even if natural conception is the only choice for the woman/couple. In the future, multi-center, randomized, double-blind, placebo-controlled trials should be carried out, which may entail recruitment of patients from various centers nationally and internationally to increase the sample size and therefore achieve a powered study. This may standardize the treatment of women with POI who wish to conceive and ultimately have their biological child.

Preoperative assessment of submucous fibroids by three-dimensional saline contrast sonohysterography.

OBJECTIVE: Submucous fibroids are a common cause of menstrual disturbance that can be treated by hysteroscopic resection. Preoperative patient selection is critical for the success of surgery and it is usually based on hysteroscopic assessment of fibroid protrusion into the uterine cavity. Three-dimensional saline contrast sonohysterography (3D-SCSH) provides additional information about the size and location of submucous fibroids, but it has not yet been evaluated for its usefulness in preoperative assessment. The aim of this study was to examine the potential value of various demographic and ultrasound variables for the prediction of successful submucous fibroid resection. METHODS: This was a prospective study of symptomatic women diagnosed with submucous fibroids who underwent 3D-SCSH prior to hysteroscopic resection. The women's age and parity and fibroid position, diameter, protrusion ratio, size of the intramural component and distance from the internal cervical os were all recorded. The outcome measure was success of a single hysteroscopic resection in achieving a complete excision of the fibroid. Univariate analysis and multivariate logistic regression analysis using a training set and a testing set were performed to investigate the prediction of successful fibroid resection. RESULTS: A total of 61 women with 67 fibroids were included in the study. There was a statistically significant difference between women who had complete and those who had incomplete resection in the mean protrusion ratio (67.8 (SD 14.5)% vs. 47.0 (SD 17.8)%; P = 0.001), the median maximum fibroid diameter (24.0 (interquartile range (IQR), 19.0-30.5) mm vs. 45.0 (IQR, 28.8-51.3) mm; P = 0.001) and the median size of the intramural component of the fibroid (8.0 (IQR, 4.0-11.5) mm vs. 16.5 (IQR, 12.5-29.3) mm; P = 0.001). Stepwise multivariate logistic regression analysis retained size of intramural component (odds ratio (OR) 0.511), parity (OR 0.002) and fibroid diameter (OR 0.843) as significant independent predictors of a complete fibroid resection. The model had an area under the receiver-operating characteristics curve of 0.975 (SE 0.039) for the training set (n = 39) and 0.864 (SE 0.090) for the testing set (n = 28). CONCLUSION: Submucous fibroid protrusion ratio, fibroid diameter and size of the fibroid's intramural component are significantly associated with the likelihood of successful fibroid resection. A logistic regression model can calculate individual probability of complete resection and may improve preoperative counseling of patients.

Endometrial implantation factors in women with submucous uterine fibroids.

Uterine fibroids are benign tumours, which are associated with subfertility and early pregnancy loss. This study was carried out to examine the effect of submucous fibroids on concentrations of glycodelin, insulin-like growth factor binding protein-1 (IGFBP-1), interleukin-6 (IL-6), interleukin-10 (IL-10), tumour necrosis factor α (TNFα) and osteopontin in uterine flushings. Premenopausal women with a certain diagnosis of submucous fibroid confirmed on three-dimensional saline infusion sonohysterography were recruited into the study. The control group included women without ultrasonic evidence of any uterine or endometrial pathology. All women had uterine flushings performed 7days post LH surge. Enzyme linked immunoassays were performed to analyse glycodelin, IL-6, IL-10, TNFα and osteopontin, whilst immunoradiometric assay was used to analyse IGFBP-1. In 23 women with submucous fibroids, the concentrations of glycodelin and IL-10 in uterine flushings were significantly lower compared with 17 women in the control group (P=0.002; P=0.007, respectively). There were no significant differences between the two groups in concentrations of IGFBP-1, IL-6, TNFα and osteopontin. Women with submucous fibroids had significantly lower concentrations of glycodelin and IL-10 in mid-luteal phase uterine flushings. This finding may explain the association with submucous fibroids and adverse reproductive outcomes. Uterine fibroids are small growths from the muscle of the uterus (womb). Submucous fibroids protrude into the cavity of the womb. We do not know what causes fibroids to form and grow. In most women, fibroids cause no symptoms and they are sometimes detected on routine gynaecological examination. In some women, however, fibroids can cause heavier and longer menstrual periods. Another problem associated with fibroids is bleeding between periods. The effect of fibroids on fertility is not clear, but some doctors believe that they may also cause infertility and early miscarriage. This study tried to see whether presence of submucous fibroids has any effect on various substances produced by the lining of the womb to facilitate development of early pregnancy. Women with a confirmed diagnosis of submucous fibroids were asked to attend the clinic and have the uterine cavity flushed with a special solution 7days after ovulation. The fluid, which was taken back from the womb, was then analysed to measure the amounts of substances that favour pregnancy development. Women with a normal uterine cavity were also asked to have the uterine cavity flushed to act as a comparison. The study showed that the uterine cavities of women with submucous fibroids were producing decreasing amount of substances favourable to early pregnancy development. We speculate that this may explain why some women with submucous fibroids have difficulties falling pregnant. Our findings should be helpful to doctors advising women with submucous fibroids who wish to start a family.

The natural history of fibroids.

OBJECTIVES: Fibroids are common, hormone-dependent, benign uterine tumors. They can cause significant morbidity and the symptoms depend largely on their size. The aim of this study was to describe the natural history of fibroids and identify factors that may influence their growth. METHODS: This was a retrospective longitudinal study of premenopausal women who were diagnosed with uterine fibroids on ultrasound examination. All women underwent at least two transvaginal ultrasound scans, which were all performed by a single operator. Fibroids were measured in three perpendicular planes and the mean diameter was calculated. The size and position of every individual fibroid was assessed and recorded on a computerized database. The volume of each fibroid was calculated using the formula for a sphere. RESULTS: A total of 122 women were included in the study. Their median age at the initial examination was 40 (range, 27-45) years. Seventy-two (59.0%) were nulliparous and 74 (60.7%) had multiple fibroids. The median interval between the initial and final examination was 21.5 (range, 8-90) months. The median fibroid volume increased by 35.2% per year. Small fibroids (< 20 mm mean diameter) grew significantly faster than larger fibroids (P = 0.007). The median increase in size was significantly higher in cases of intramural fibroids (53.2 (interquartile range (IQR), 11.2-217)%) than in subserous fibroids (25.1 (IQR, 1.1-87.1)%) and submucous fibroids (22.8 (IQR, - 11.7 to 48.3)%) (P = 0.012). Multivariate analysis retained only fibroid size at presentation as an independent predictor of fibroid growth. CONCLUSION: The growth of fibroids in premenopausal women is influenced by the tumor's size at presentation.

The effect of hysteroscopic polypectomy on the concentrations of endometrial implantation factors in uterine flushings.

Endometrial polyps have been associated with infertility and early pregnancy loss. The aim of this study was to investigate the effect of hysteroscopic polypectomy on the concentrations of endometrial implantation factors in uterine flushings. Pre-menopausal women with a certain diagnosis of endometrial polyp on contrast-enhanced transvaginal ultrasound scan were recruited into this prospective study. In all women, paired samples of uterine flushings were obtained on the same day of the menstrual cycle prior to and post hysteroscopic polypectomy. Enzyme-linked immunoassays were performed to analyse glycodelin, interleukin-6 (IL-6), interleukin-10 (IL-10), tumour necrosis factor alpha (TNFalpha) and osteopontin, whilst immunoradiometric assay was used to analyse insulin-like growth factor binding protein-1 (IGFBP-1). Concentrations of IGFBP-1, TNFalpha and osteopontin in uterine flushings were significantly lower in the mid-secretory phase prior to polypectomy in comparison to the measurements obtained after complete surgical removal of the polyp (P < 0.05). There were no differences in the concentrations of glycodelin, IL-6 and IL-10 in paired samples prior to and post-polypectomy. The presence of endometrial polyps is associated with decreased mid-secretory concentrations of IGFBP-1, TNFalpha and osteopontin, which are reversed following surgical polypectomy.

Deficient lower-segment Cesarean section scars: prevalence and risk factors.

OBJECTIVE: To examine the sonographic features of transverse lower-segment uterine Cesarean section scars in non-pregnant, premenopausal women and to identify factors associated with scar deficiency. METHODS: Non-pregnant, premenopausal women with histories of previous transverse lower-segment Cesarean sections, who were referred for an ultrasound scan for a variety of gynecological indications, were included in this study. An attempt was made to identify the uterine scars on transvaginal ultrasound scan and to describe their locations and morphological features. Various demographic, clinical and ultrasound data were examined in order to identify factors associated with deficient scars. Deficient scars were defined as detectable myometrial thinning at the site of the Cesarean section scar. RESULTS: Lower-segment uterine scars were detected in 321/324 (99.1%; 95% CI, 98.0-100) women with a history of previous Cesarean section. Sixty-three (19.4%; 95% CI, 15.1-23.8) women had evidence of deficient Cesarean scars. Using multivariate analysis, a history of multiple Cesarean sections, uterine retroflexion and the inability to visualize all Cesarean scars in women with previous multiple Cesarean sections were all shown to be significantly associated with deficient scars. CONCLUSION: Deficient uterine scars are a frequent finding in women with a history of previous Cesarean section. The risk of scar deficiency is increased in women with a retroflexed uterus and in those who have undergone multiple Cesarean sections.

Fertility outcomes following expectant management of tubal ectopic pregnancy.

OBJECTIVES: To evaluate fertility outcome after the expectant management of tubal ectopic pregnancy. METHODS: Our dedicated early pregnancy database was searched for all women diagnosed with a tubal ectopic pregnancy between January 1999 and June 2003 who were either managed expectantly or underwent a salpingectomy. They were contacted to enquire about their ability to conceive following the ectopic pregnancy and about the outcomes of any subsequent pregnancies. RESULTS: Four hundred and forty-four women had a diagnosis of tubal ectopic pregnancy, and 173 (39%) were successfully contacted. A total of 146/173 (84.4%; 95% CI, 79-89.8%) tried for another pregnancy: 49/59 (83.1%; 95% CI, 73.4-92.6%) in the expectant management and 97/114 (85.1%; 95% CI, 78.4-91.6%) in the salpingectomy group (P > 0.05). Spontaneous intrauterine pregnancy occurred in 41/49 (83.7%; 95% CI, 73.3-94.2%) women managed expectantly and in 62/97 (63.9%; 95% CI, 54.4-73.5%) women managed surgically (odds ratio 2.89; 95% CI, 1.22-6.86%). The risk of recurrent ectopic pregnancy was not significantly different between the two management groups. CONCLUSIONS: Fertility outcomes following the expectant management of tubal ectopic pregnancy are comparable to those following salpingectomy.

Value of preoperative ultrasound examination in the selection of women with adnexal masses for laparoscopic surgery.

OBJECTIVES: To assess the value of preoperative ultrasound examination in predicting the feasibility of intermediate-level laparoscopic surgery for benign adnexal masses. METHODS: Symptomatic women with a clinical or ultrasound diagnosis of adnexal mass were offered a detailed transvaginal ultrasound scan in order to assess the feasibility of laparoscopic cystectomy/oophorectomy. In all cases an attempt was made to establish a likely histological diagnosis using the pattern recognition method. The selection criteria for laparoscopic surgery were: no ultrasound features suggestive of ovarian cancer, predominantly cystic lesion with no solid foci > 5 cm in mean diameter, no evidence of severe pelvic endometriosis or severe pelvic adhesions and dermoid cyst < 10 cm in mean diameter. Laparoscopic surgery was classified as successful if the mass was removed completely without resorting to a laparotomy. RESULTS: One hundred and forty-three women were diagnosed with a total of 162 adnexal cysts. The final dataset consisted of 137 women (with 153 lesions), 113 (82.5%) of whom were selected for laparoscopy and 24 (17.5%) for laparotomy. On histological examination 152 (99.3%) cysts were benign and the remaining one (0.7%) was borderline. The operation was successfully completed laparoscopically in 107/113 (94.7%) cases. The preoperative ultrasound assessment predicted the successful outcome of laparoscopic surgery with a sensitivity of 98% (95% CI, 94-99%), specificity of 79% (95% CI, 60-90%), positive predictive value of 95% (95% CI, 89-98%), positive likelihood ratio of 4.58 (95% CI, 2.25-9.32) and negative likelihood ratio of 0.02 (95% CI, 0.01-0.09). CONCLUSIONS: A detailed preoperative transvaginal ultrasound examination is a helpful tool for assessing the feasibility of intermediate-level laparoscopic surgery in women with benign adnexal lesions.

Ultrasound diagnosis of ectopic pregnancy in the non-communicating horn of a unicornuate uterus (cornual pregnancy).

OBJECTIVE: To prospectively evaluate ultrasound criteria for the diagnosis of pregnancy in the rudimentary horn of a unicornuate uterus (cornual pregnancy). METHODS: This was a prospective observational study over a period of 90 months in a tertiary referral center in a London teaching hospital. A diagnosis of cornual pregnancy was made when all the following ultrasound criteria were met: (1) a single interstitial portion of Fallopian tube in the main uterine body; (2) a gestational sac, mobile and separate from the uterus, surrounded by myometrium; and (3) a vascular pedicle joining the gestational sac to the unicornuate uterus. In cases where the ultrasound criteria were met the pregnancy was followed up and the final outcome was recorded, including operative and histological findings. RESULTS: Over the study period eight cases of cornual pregnancy were diagnosed. Six women had a single case of cornual pregnancy. One woman was managed expectantly in her first cornual pregnancy and subsequently suffered a recurrence. Surgical management varied depending on viability of the pregnancy and gestational age at presentation. In all the women who underwent surgery the diagnosis was eventually confirmed at operation and on histological examination. During the study period there were no false positive or false negative results in our unit using the above criteria. CONCLUSION: The proposed ultrasound criteria appear accurate and may be applied in clinical practice to facilitate preoperative diagnosis of cornual ectopic pregnancy.

Efficacy of Shirodkar cervical suture in securing hemostasis following surgical evacuation of Cesarean scar ectopic pregnancy.

OBJECTIVES: To assess the efficacy of a Shirodkar cervical suture in arresting hemorrhage following surgical removal of a Cesarean scar ectopic pregnancy. METHODS: The study included women with an ultrasound diagnosis of Cesarean scar ectopic pregnancy who were scheduled for surgical evacuation. After administration of general anesthetic, a Shirodkar cervical suture was inserted using the standard surgical technique. The suture was left untied and the Cesarean scar pregnancy was evacuated under ultrasound guidance using suction curettage. Once the pregnancy had been successfully removed, the suture was tied and 500 microg ergometrine was administered intravenously to ensure uterine contraction. The patients were prescribed prophylactic antibiotics and the suture was removed 7 days later in the outpatient setting, under local anesthetic. RESULTS: Over a 4-year period a total of 33 Cesarean scar pregnancies were diagnosed, and 28 (85%) had surgical evacuation. A cervical suture was necessary to achieve hemostasis in 22/28 (79%; 95% CI, 64-94) cases. In the remaining 6/28 (21%; 95% CI, 6-36) cases, the bleeding was minimal and the suture was not tied. The median estimated intraoperative blood loss was 50 (range, 50-1500) mL. Six of 28 (21%; 95% CI, 6-36) women suffered blood loss > or = 300 mL and two (7%; 95% CI, 0-17) required blood transfusion. One woman (5%; 95% CI, 0-14) required repeat surgery because of retained products of conception. There were no other significant complications and the uterus was preserved successfully in all cases. CONCLUSIONS: Insertion of a Shirodkar cervical suture during the evacuation of a Cesarean scar pregnancy is an effective method for securing hemostasis; it minimizes the need for blood transfusion and ensures preservation of fertility.

Reproductive outcomes of women with a previous history of Caesarean scar ectopic pregnancies.

BACKGROUND: Caesarean scar ectopic pregnancy is associated with a number of significant complications. In this study, we report on subsequent reproductive outcomes in a group of women following successful treatment of their scar pregnancies. METHODS: The study included those women who received treatment for their Caesarean scar pregnancies between April 1999 and October 2005. Their ability to conceive, the time it took to become pregnant and outcomes of subsequent pregnancies were all recorded. RESULTS: 40 women with Caesarean scar pregnancies were managed in our unit. The uterus was conserved in 38/40 cases. Follow-up data were available in 29/38 (76%) of women. Twenty-four out of 29 (83%) attempted to become pregnant. Twenty-one out of 24 [88%, 95% confidence interval (CI): 75-100] women conceived spontaneously. Twenty out of 21 (95%, 95% CI: 86-100) pregnancies were intrauterine and one woman (5%, 95% CI: 0-14) had a recurrent scar ectopic. Thirteen out of 20 (65%, 95% CI: 44-86) intrauterine pregnancies appeared normal. Nine out of 13 (69%) were delivered by Caesarean section. Seven out of 20 (35%, 95% CI: 14-56) intrauterine pregnancies ended in spontaneous abortions. CONCLUSIONS: Our study shows that reproductive outcomes following treatment of caesarean scar ectopic pregnancies are favourable. The risk of complications including recurrent scar implantation appears to be low.

Accuracy of ultrasound subjective 'pattern recognition' for the diagnosis of borderline ovarian tumors.

OBJECTIVES: To assess the value of pattern recognition for the preoperative ultrasound diagnosis of borderline ovarian tumors (BOTs). METHODS: This was a prospective study of women who were referred to our regional cancer center with the diagnosis of an adnexal mass on a Level II (routine) gynecological ultrasound scan. Women with lesions of uncertain nature were referred for a Level III (expert) ultrasound scan in our tertiary center. The tumor pattern recognition method was used to differentiate between various types of ovarian tumors. Morphological features suggestive of BOTs were: unilocular cyst with a positive ovarian crescent sign and extensive papillary projections arising from the inner wall, or a cyst with a well defined multilocular nodule. The ultrasound findings were compared with the final histological diagnosis. RESULTS: A total of 224 women with an adnexal mass of uncertain nature were referred for an expert scan, 166 (74.1%) of whom underwent surgery. In this group of women the final histological diagnoses were: 99 (60%) benign lesions, 32 (19%) invasive ovarian cancer and 35 (21%) BOTs. Using pattern recognition combining the different morphological features, a correct preoperative diagnosis of BOT was made in 24/35 (68.6%) women: area under the receiver-operating characteristics curve 0.812 (standard error 0.049; 95% CI, 0.716-0.908), sensitivity 0.69 (95% CI, 0.52-0.81), specificity 0.94 (95% CI, 0.88-0.97), positive likelihood ratio 11.3 (95% CI, 5.53-22.8) and negative likelihood ratio 0.34 (95% CI, 0.21-0.55). CONCLUSIONS: Ultrasound diagnosis of BOTs is highly specific. However, typical features are absent in one-third of cases, which are typically misdiagnosed as benign lesions.

A new method of transvaginal ultrasound-guided polypectomy: a feasibility study.

OBJECTIVES: A new device has been manufactured (Safe T Choice), which allows attachment of a transvaginal ultrasound probe to a specially adapted cervical tenaculum. This affords the capacity to monitor intrauterine surgical procedures without the need for hysteroscopy. The purpose of this study was to investigate the feasibility of endometrial polypectomy using this device combined with saline contrast sonohysterography (SCSH) to monitor the procedure. METHODS: Women diagnosed with an endometrial polyp on routine B-mode two-dimensional transvaginal ultrasound (TVS) were invited to join the study. Transvaginal ultrasound-guided polypectomies were carried out by a single operator. The procedure was timed from application until removal of the tenaculum. The ultrasound views were rated as satisfactory or poor. Success of the procedure was gauged by complete removal of the polyp without recourse to hysteroscopy. Women also attended for postoperative follow-up ultrasound scans to check for residual disease. RESULTS: Thirty-seven women were recruited to the study. The mean operating time was 8 min (95% CI, 5.9-10.4). The procedure was successful in 32/37 (86.5%) cases (95% CI, 75.5-97.5). In three cases (8.1%) the procedure failed because of an inability to obtain satisfactory images of the uterine cavity, and in two further cases (5.4%) the operator was unable to grasp and remove the polyp. Two patients (5.4%) bled from the tenaculum insertion site, necessitating suture for hemostasis. There were no other complications and none of the patients had evidence of residual polyp tissue at the follow-up visit. CONCLUSION: This study showed that transvaginal ultrasound-guided polypectomy is a feasible technique for the removal of endometrial polyps. Further work is required to compare outcomes and cost-effectiveness of this technique with hysteroscopic polypectomy.