Reproductive Outcome of Transcervical Uterine Incision in Unicornuate Uterus.

BACKGROUND: The pregnancy outcome of the unicornuate uterus is associated with an increased risk of miscarriage, cervical incompetence, and a number of obstetric complications. However, at present, there is no accepted treatment method for women with unicornuate uterus, other than expectant measures. The aim of this study was to evaluate the reproductive outcome of transcervical uterine incision (TCUI) in patients with unicornuate uterus. METHODS: Thirty-three patients with unicornuate uterus presented to our tertiary center for infertility or miscarriage. All 33 patients underwent TCUI and were followed up for 10-52 months. The pregnancy outcomes ( first-trimester miscarriage, second-trimester miscarriage, preterm, term, intrauterine death, ongoing pregnancy, and live birth) before and after TCUI were compared by t- test. RESULTS: Among 31 patients who attempted to conceive after TCUI, twenty conceived including one termination of pregnancy, one second-trimester miscarriage, one ectopic pregnancy, five preterm deliveries, 11 term delivery, and one ongoing pregnancy. There were 16 live births in total. There was significant reduction in the first-trimester miscarriage rate (t = 4.890; P< 0.001), increase in term delivery (t = -3.288; P = 0.002), and live birth rates (t = -4.073; P< 0.001) after TCUI. CONCLUSION: TCUI appeared to improve the pregnancy outcome in women with unicornuate uterus presenting with infertility or miscarriage.

Effect of interval after surgery on in vitro fertilization/ intracytoplasmic sperm injection outcomes in patients with stage III/IV endometriosis.

BACKGROUND: For patients with severe endometriosis, the spontaneous pregnancy rates have been reported to be near 0 due to extreme distortion of normal pelvic anatomy. Surgery is one of the treatment options; however, if patients failed to conceive after surgery, in vitro fertilization (IVF) is effective. The objective of this retrospective study was to determine the clinical characteristics of IVF/intracytoplasmic sperm injection (ICSI) in patients with stage III/IV endometriosis, and to determine the impact of the interval from surgery to IVF/ICSI on outcome. METHODS: One hundred and sixty patients who were diagnosed with stage III/IV endometriosis underwent IVF/ICSI cycles between February 2004 and June 2009 were enrolled. The mean interval from surgery to IVF, number of oocytes retrieved, fertilization rate, implantation rate, embryos transferred, and good embryos transferred were compared between two age groups (35 years). RESULTS: The mean interval from surgery to IVF was (37.9+/-28.9) months for the group35 years of age. Twenty-five IVF/ICSI cycles (12.8%) were performed during the first year after surgery, and 34.9% IVF/ICSI cycles were performed 2 years after surgery. No significant differences existed between the two groups with respect to the fertilization rate, implantation rate, number of embryos transferred, number of good embryos, clinical pregnancy rates, live birth rates, and cumulative clinical pregnancy rates (P>0.05). The probability of cumulative clinical pregnancies was 75%, 50%, and 25% ((29.0+/-4.8), (61.0+/-7.6), and (120.0+/-16.9) months after surgery, respectively). CONCLUSIONS: For infertile patients with stage III/IV endometriosis, the optimal time to conceive by IVF/ICSI is <2 years after surgery; nevertheless, most of the patients took a longer time to conceive.

[Polymorphism of estrogen receptor alpha genes Pvu I, Xba I and TA repeat sequence and hypomenorrhea with unknown aetiology].

OBJECTIVE: To study the roles of the polymorphism of the estrogen receptor genes in hypomenorrhea with unknown aetiology. METHODS: A case control study was carried out in south west of China, with 100 patients with hypomenorrhea in the case group and 100 eumenorrhea women in the control group. Molecular biology test was undertaken to test the restriction fragment length polymorphism (RFLP) of the first intron incision enzyme Pvu II, Xba I in ERa gene. Depuration, clone and sequence analysis was performed to the TA repeated sequence in the hypervariable region of estrogen receptor gene. The genotype distribution of ERa gene polymorphism was compard between the case and control groups. RESULTS: The patients with hypomennorrhea had higher P genotypic frequency (47.5%) than the control (30.5%), with an OR of 1. 810 (95% CI = 1.113-2.765, P = 0.012). The patients with hypomennorrhea had lower X genotypic frequency (20.5%) than the control (32.0%), with an OR of 0.641 (95% CI = 0.361-0. 898, P = 0.036). The patients with hypomennorrhea had higher frequency of TA13 allele (P = 0.006) and lower Frequency of TA15 allele frequency (P = 0.033) than the control. CONCLUSION: ERa gene polymorphism is associated with hypomenorrhea with unknown aetiology. P allele and TA13 allele may be risk factors, while X allele and TA15 allele may be protective factors.

[The study on the relationship between Rsa I, Alu I polymorphism of the estrogen receptor beta gene and unknown aetiology hypomenorrhea].

OBJECTIVE: To study the relationship between estrogen receptor beta gene (ER beta) polymorphism and unknown aetiology hypomenorrhea in Southwestern China . METHODS: One hundred eumenorrhea women were chosen as control group and another 100 hypomenorrhea patients as case group from Southwestern China. Restriction fragment length polymorphism (RFLP) of the Rsa I and Alu I in ER beta gene was analysed. The ER beta gene polymorphism genotype distribution in case group and control group was compared. RESULTS: R allele frequency in case and control groups was 37.5% and 48.5% respectively, the OR was 0.64 (95%CI: 0.42-0.97), P= 0.026. A allele frequency in case and control groups was 18.0% and 11.5% respectively, the OR was 1.69 (95%CI: 0.93-3.09), P= 0.07. RFLP of Rsa I and Alu I in both groups were distributed with polymorphism. CONCLUSION: ERbeta gene polymorphism has a relation with unknown aetiological hypomenorrhea. R allele may be the guard factor, and A allele may be its risk factor.

[Study on the peritoneal dissemination of endometrial cells during hysteroscopy].

OBJECTIVE: To study prospectively the likelihood and the affecting factors of endometrial cell dissemination into the peritoneal cavity during hysteroscopic procedures. METHODS: A total of 121 patients with benign endometrial pathology underwent hysteroscopy combined with laparoscopy. All the patients had pelvic washings performed just before and after the procedure of hysteroscopy. We collected the peritoneal washings and analyzed the peritoneal cytology changes in both groups pre- and post-hysteroscopy, as well as the dissemination rate related to the time of hysteroscopy, the intrauterine distention pressure, the volume of distention media, and the feature of endometrial conditions. RESULTS: The ratio of positive endometrial cells in the peritoneal washings of post-hysteroscopy group was 51.2% (62/121), which was significantly higher than pre-hysteroscopy group, 38.0% (46/121) (P < 0.01). The mean operation time in the group of positive peritoneal cytology was (38 +/- 16) min, longer than the negative group (P < 0.05). However, there was no significant difference between the two groups with regard to the total volume of distention media, the distention pressure, and the endometrial feature (P > 0.05). CONCLUSIONS: Hysteroscopic procedures may have a risk of disseminating the endometrial cells into peritoneal cavity. Under a certain uterine distention pressure, the rate of dissemination is correlated with hysteroscopic duration.

[Study on mechanism of infertility or sterility caused by uterine septa and reproductive prognosis after hysteroscopic metroplasty].

OBJECTIVE: To study the mechanism of infertility/sterility caused by uterine septa and the reproductive prognosis after transcervical resection of septum (TCRS). METHODS: One hundred and eleven patients with uterine septum including 34 patients of infertility and 77 patients of sterility were performed on TCRS. The patients were followed up of the reproductive outcomes. The process of pregnancies and deliveries were compared with those of 1548 normal uterine pregnancies. We also studied and compared the pathomorphologic and the micro-structure features between the septum and uterine wall in 30 cases (8 cases with infertility and 22 cases with sterility). RESULTS: (1) The amount of the endometrium glands on septum was less than that on the uterine wall or endometrium un-synchronous growth between septum and uterine wall was shown in 7 cases of infertility and 13 cases of sterility. The positive index level of estrogen and progestogen receptors on septum was weaker than that on uterine wall. The densities of the smooth muscle cells were thicker and the collagenous fibers were sparser in the base and middle of septum compared with uterine wall (P < 0.05). The amounts of the small arteries in septum were rarer than in uterine wall (P < 0.05). Ultrastructure characters showed glandular epithelium cells distributed irregularly and poor pili on septum in the sterility patients. (2) Sixteen infertility patients became pregnant (47.1%, 16/34) postoperation, which was much higher than pregnancy rate of preoperation (8.8%, 3/34, P < 0.01). In sterility group, the spontaneous abortion rate decreased from 84.1% (180/214) to 29.0% (18/62, P < 0.01), and the mature delivery rate and live birth rate rose from 3.3% (7/214), 0.9% (2/214) to 56.4% (35/62) and 64.5% (40/62) respectively (P < 0.01). (3) There were no differences between TCRS patients and normal uterine pregnant women in complications, and the mortality of perinatal (P > 0.05). The rate of cesarean section in post-TCRS patients was higher than in normal control group (P < 0.01). CONCLUSIONS: The differences of pathomorphology and ultra-structure between septum and uterine wall are the causation of infertility/sterility in the uterine septum patients. The reproductive prognosis can be improved remarkably by performing TCRS, which does not increase pregnant complications or affect fetus growth. Cesarean section should not be a standard way for delivery.

[Analysis on the complications of hysteroscopic surgeries].

OBJECTIVE: To investigate the causations, management and prevention methods on the complications of hysteroscopic procedures. METHODS: Retrospective analysis of 36 cases with hysteroscopic complication, focusing on their characteristics and clinical management as well as prevention methods during the ten years from 1993 to 2004. RESULTS: Among 36 cases, 11 cases with uterine perforation and incomplete perforation, which happened during the complicated procedures, were treated by both laparoscopy and laparotomy. Five cases with heavy bleeding were encountered because of the deeply injury to the uterine wall and Foley catheter was inserted into uterine cavity and it stopped the bleeding successfully except in one case done by hysterectomy. Three cases with fluid overload syndrome were cured by using diuretic agent and saline infusion. There is no serious consequence in one case with air embolism due to prompt diagnosis and treatment. Four cases with postablation-sterilization syndrome were treated effectively by performing hysterectomy plus single or bilateral salpingectomy, dilating cervical canal as well as resecting adhesions. Twelve cases with adhesion inside uterine cavity followed hysteroscopy were also treated by dilating cervical canal, underwent adhesionlysis and hysterectomy. CONCLUSIONS: The potential factors causing complications of hysteroscopy include complicated procedures inside uterine cavity, higher pressure of irrigation, deep injury of endometrium as well as incomplete removal of endometrium during hysteroscopic operations. It is the necessary measures to reduce the complications by performing laparoscopy or B ultrasound monitoring simultaneously, standardizing the procedure and strengthening postoperation management.

[Transcervical resection of myoma in treatment of hysteromyoma, experience in 962 x\cases].

OBJECTIVE: To study the technique and effect of transcervical resection of myoma (TCRM) in treatment of hysteromyoma. METHODS: 962 women suffering type 0 hysteromyoma (n = 281), 316 type 1 hysteromyoma (n = 316), type 2 hysteromyoma (n = 282), submucous and intramural myoma (n = 34), cervical myoma (n = 11), prolapse myoma (n = 23), and adenomyoma (n = 15) underwent TCRM with "five-step technique", monitored by B-ultrasound or laparoscopy, Follow-up lasted more than 6 months. RESULTS: The primary operation successful rate was 99.77%. The mean size and depth of uterus were 7.44 +/- 1.3 gestation weeks and (8.31 +/- 1.43) cm, the diameter of the biggest myoma was 7.2 cm. The mean weight of the resected tissues was (22.63 +/- 31.41) g, and the mean operation time and blood loss during the operation were 32.50 +/- 172.72 minutes and (7.75 +/- 19.49) ml. No transfusion was needed. The complications included postoperative fever (3 cases), uterine bleeding (1 case), uterine perforation (1 case), and TURP syndrome (2 cases). Postoperative scanty menstrual rate was 100% in the type 0 hysteromyoma group, 99.1% in the type I hysteromyoma group, 94.02% in the type II hysteromyoma group, 100% in the cervical myoma and prolapse myoma group, 84% in the multiple myoma and intramural myoma group, and 87% in the adenomyoma group respectively. The alleviation rates of dysmenorrhea and anemia were 78% and 82.95% respectively. Those who have severe complications of internal medicine showed obvious improvement. The residual myoma of 2 cases were resected during the secondary operation 9 days and 3 months after the primary operation. 455 cases (52.17%) resumed their work in 1 month postoperatively. 32 living infants were delivered. CONCLUSION: Safe and highly effective, TCRM can be the first choice in treatment of submucous and intramural hysteromyoma.

[Evaluation on clinical application and long term outcomes of transcervical resection of endometrium].

OBJECTIVE: To evaluate the short term and long term outcomes of abnormal uterine bleeding (AUB) treated by transcervical resection of endometrium (TCRE) as well as the factors which influence the outcomes. METHODS: From May 1990 to September 2002 there were 1431 cases who suffered from menorrhagia. A total of 1468 times of TCRE were performed. Hysteroscopic diagnosis and endometrium biopsy was performed to rule out malignant diseases in 1203 cases. One stage TCRE was performed in 265 cases. Resistance index (RI) and pulse index (PI) of every level uterine artery were measured by ultrasound and serum levels of were 6 steroid sex hormones were measured by laboratory in 32 cases. The mean duration of follow-up was 68.5 months (3 - 148 months). RESULTS: Three cases of uterine perforation were encountered. Smog like echo in the anterior uterine wall was found in 714 cases (49.9%) by B ultrasonography, among them 21 cases (63.6%) were proved adenomyosis by pathological examination. One hundred and fifty nine cases (10.8%) had been treated by drugs, such as homeostasis, analgesic agent, antibiotics, progesterone and endometrium inhibiting agents, etc. Repeat TCRE was performed in 37 cases. Owing to recurrent bleeding, dysmenorrhea or uterine myoma 87 cases (6.1%) were finally received hysterectomy. CONCLUSIONS: (1) The main cause of recurrence was incomplete destruction of or leak from basal layer of endometrium. Shift wire loop with the sheath together to resect endometrium from the fundus to cervix smoothly can solve the problem of incomplete resection. Upon completion of operations, "blind area" and "blind point" should be examined and resected again if there is some endometrium left behind which could solve leak from basal layer of endometrium. (2) The duration of follow-up and adenomyosis are the main factors, which influence the long-term successful rate. (3) TCRE dose not influence the ovarian function obviously.

[Analysis of the efficiency of transcervical resection of endometrium for treating dysfunctional uterine bleeding and factors reducing the efficiency of the operation].

OBJECTIVE: To investigate the efficiency and factors related to the recurrence of transcervical resection of endometrium (TCRE) in treating women with dysfunctional uterine bleeding (DUB). METHODS: Two hundred and twenty women with DUB were selected for TCRE. Specimens from removed endometrium were obtained during the procedures and their menstruation and menorrhagia after the operations were followed up. We also studied the uterine specimens obtained from the recurrent cases undergoing hysterectomies. The specimens were stained by hematoxylin-eosin and immuno-histochemistry respectively to evaluate the depth of removed myometrium and the histopathologic changes in relapsed cases. RESULTS: The follow up period after operation was 24 to 114 months. (1) Overall effective rate was 94.5%, in which amenorrhea rate was 25.9%, menstruation reduction rate was 68.6%. (2) The effective rate of corrective anemia was 97.3% and the satisfaction rate for the operation was 92.3%. (3) Thirty-eight cases required subsequent treatment as a result of recurrence, of which 10 cases underwent hysterectomy and 3 cases underwent repeat TCRE and 25 cases were given medicine treatment. (4) The average depth of myometrium in removed endometrium strip was 2.12 approximately 3.26 mm. (5) Endometrium regrowth was seen in the resected uterine specimens from relapsed cases and adenomyosis was also found in the intra-uterine wall in some cases. CONCLUSIONS: (1) TCRE is a safe and effective alternative treatment for DUB. (2) The main factor reducing the efficiency is either incomplete removal of endometrium or adenomyosis. (3) Standardizing the procedures and strengthening postoperative management are essential requirements for improving the efficiency of TCRE.

[Analysis of 16 cases of uterine perforation during hysteroscopic electro-surgeries].

OBJECTIVE: To analyse the cause, diagnosis, treatment and preventive methods of uterine perforation resulting from hysteroscopic electro-surgeries. METHODS: Data of cases with uterine perforation were collected from 5 hospitals where overall 3,541 hysteroscopic electro-surgeries were done from May 1990 to July 2002. There were 1 468 transcervical resections of endometrium (TCRE), 797 cases of transcervical resection of myoma (TCRM), 783 cases of transcervical resection of endometrial polyp (TCRP), 189 cases of transcervical resection of uterine septa (TCRS), 112 cases of transcervical resection of uterine adhesion (TCRA) and 192 cases of transcervical removal of foreign body (TCRF). All operations were performed under B-ultrasonographic or laparoscopic monitoring. Cervical dilator stick was inserted into cervical canal or 200 micro g of misoprostol put in the posterior fornix the evening before operation. The procedures were done according to different indications and purposes. Cases of uterine perforation were divided into two groups: caused by approaching (entry-related) and by surgical instruments (technique-related). RESULTS: Totally sixteen cases (0.45%) of uterine perforation occurred. Seven cases occurred during cervical dilatation and 1 during hysteroscopy inserting lentry-related. Eight cases were technique-related caused by electrode. The incidences of uterine perforation of different operations were: TCRA 4.46% (5/112), TCRF 3.12% (6/192), TCRE 0.27% (4/1 468), TCRM 0.13% (1/797). TCRP and TCRS none. These 16 cases were all diagnosed during operations. 10 cases (62%) by B ultrasound and (or) laparoscopy, 6 cases (38%) by hysteroscopy and clinical features. 13 cases were complete uterine perforations, among them 2 were diagnosed by laparoscopic monitoring, 5 by B-ultrasonic monitoring, 4 by hysteroscopy and 2 by symptoms and B-ultrasound, 3 cases were incomplete uterine perforations in which 2 were diagnosed by laparoscopic monitoring and one by B-ultrasound monitoring. CONCLUSIONS: Half of uterine perforation cases were entry-related, so attention has to be paid to entry of Hegar or hysteroscopy (i.e., not dilate the cervix as possible and introduce the scope under direct vision). The other half were related to surgeons' experience and type of operation. TCRA and TCRF run more risks. B-ultrasound and (or) laparoscopy monitoring during hysteroscopic electro-surgery may help to prevent but not completely avoid uterine perforation.